Is periprocedural sedation during acute stroke therapy associated with poorer functional outcomes?

BACKGROUND: To safely perform acute intra-arterial revascularization procedures, use of sedative medications and paralytics is often necessary. During the conduct of the Interventional Management of Stroke trials (I and II), the level of sedation used periprocedurally varied. At some institutions, patients were paralyzed and intubated as part of the procedural standard of care while at other institutions no routine sedation protocol was followed. The aim of this study was to identify patient characteristics that would correlate with the need for deeper sedation and to explore whether levels of sedation relate to patient outcome. METHODS: 75 of 81 patients in the Interventional Management of Stroke II Study were studied. Patients had anterior circulation strokes and underwent angiography and/or intervention. Four sedation categories were defined and tested for factors potentially associated with the level of sedation. Clinical outcomes were also analyzed, including successful angiographic reperfusion and the occurrence of clinical complications. RESULTS: Only baseline National Institutes of Health Stroke Scale varied significantly by sedation category (p=0.01). Patients that were in the lower sedation category fared better, having a higher rate of good outcomes (p<0.01), lower death rates (p=0.02) and higher successful angiographic reperfusion rates (p=0.01). There was a significantly higher infection rate in patients receiving heavy sedation or pharmacologic paralysis (p=0.02) and a trend towards fewer groin related complications. CONCLUSION: In this small sample, patients not receiving sedation fared better, had higher rates of successful angiographic reperfusion and had fewer complications. Further examination of the indications for procedural sedation or paralysis and their effect on outcome is warranted.

Endovascular Therapy of M2 Occlusion in IMS III: Role of M2 Segment Definition and Location on Clinical and Revascularization Outcomes.

BACKGROUND AND PURPOSE: Uncertainty persists regarding the safety and efficacy of endovascular therapy of M2 occlusions following IV tPA. We reviewed the impact of revascularization on clinical outcomes in 83 patients with M2 occlusions in the Interventional Management of Stroke III trial according to specific M1-M2 segment anatomic features. MATERIALS AND METHODS: Perfusion of any M2 branch distinguished M2-versus-M1 occlusion. Prespecified modified TICI and arterial occlusive lesion revascularization and clinical mRS 0-2 end points at 90 days for endovascular therapy-treated M2 occlusions were analyzed. Post hoc analyses of the relationship of outcomes to multiple baseline angiographic M2 and M1 subgroup characteristics were performed. RESULTS: Of 83 participants with M2 occlusion who underwent endovascular therapy, 41.0% achieved mRS 0-2 at 90 days, including 46.6% with modified TICI 2-3 reperfusion compared with 26.1% with modified TICI 0-1 reperfusion (risk difference, 20.6%; 95% CI, -1.4%-42.5%). mRS 0-2 outcome was associated with reperfusion for M2 trunk (n = 9) or M2 division (n = 42) occlusions, but not for M2 branch occlusions (n = 28). Of participants with trunk and division occlusions, 63.2% with modified TICI 2a and 42.9% with modified TICI 2b reperfusion achieved mRS 0-2 outcomes; mRS 0-2 outcomes for M2 trunk occlusions (33%) did not differ from distal (38.2%) and proximal (26.9%) M1 occlusions. CONCLUSIONS: mRS 0-2 at 90 days was dependent on reperfusion for M2 trunk but not for M2 branch occlusions. For M2 division occlusions, good outcome with modified TICI 2b reperfusion did not differ from that in modified TICI 2a. M2 segment definition and occlusion location may contribute to differences in revascularization and good outcome between Interventional Management of Stroke III and other endovascular therapy studies.

Combined intravenous and intra-arterial recombinant tissue plasminogen activator in acute ischemic stroke.

BACKGROUND AND PURPOSE: A retrospective analysis was performed on 20 consecutive patients who presented with severe acute ischemic stroke and were evaluated for a combined intravenous (IV) and local intra-arterial (IA) recombinant tissue plasminogen activator (rtPA) thrombolytic approach within 3 hours of onset. METHODS: Twenty consecutive patients with carotid artery distribution strokes were evaluated and treated using a combined IV and IA rtPA approach over a 14-month period (September 1998 to October 1999). rtPA (0.6 mg/kg) was given intravenously (maximum dose 60 mg); 15% of the IV dose was given as bolus, followed by a continuous infusion over 30 minutes. A maximal IA dose, up to 0.3 mg/kg or 24 mg, whichever was less, was given over a maximum of 2 hours. IV treatment was initiated within 3 hours in 19 of 20 patients. All 20 patients underwent angiography, and 16 of 20 patients received local IA rtPA. RESULTS: The median baseline National Institutes of Health Stroke Scale (NIHSS) score for the 20 patients was 21 (range 11 to 31). The median time from stroke onset to IV treatment was 2 hours and 2 minutes, and median time to initiation of IA treatment was 3 hours and 30 minutes. Ten patients (50%) recovered to a modified Rankin Scale (mRS) of 0 or 1; 3 patients (15%), to an mRS of 2; and 5 patients (25%), to an mRS of 4 or 5. One patient (5%) developed a symptomatic intracerebral hemorrhage and eventually died. One other patient (5%) expired because of complications from the stroke. CONCLUSIONS: We believe that the greater-than-expected proportion of favorable outcomes in these patients with severe ischemic stroke reflects the short time to initiation of both IV and IA thrombolysis.

Early carotid endarterectomy for critical carotid artery stenosis after thrombolysis therapy in acute ischemic stroke in the middle cerebral artery.

BACKGROUND AND PURPOSE: Tissue plasminogen activator (tPA) has been shown to be effective for acute ischemic stroke. However, if a high-grade cervical carotid stenosis remains despite tPA therapy, patients are at risk for recurrent stroke. Carotid endarterectomy (CEA) has been shown to be effective in symptomatic patients with high-grade cervical carotid stenosis in reducing the risk of stroke, but it is unknown whether CEA can be performed safely after tPA thrombolysis. We describe our experience with 5 patients who underwent early (<48 hours) CEA for residual high-grade cervical carotid stenosis after thrombolytic therapy for acute ischemic stroke in the middle cerebral artery territory. METHODS: All patients had a critical (>99%) carotid artery stenosis on the symptomatic side after tPA therapy. All patients received intravenous tPA; 3 patients also received intra-aortic tPA. Three patients received intravenous heparin infusion immediately after administration of tPA. All patients showed marked improvement in their National Institutes for Health Stroke Scale scores after treatment with tPA. CEA was then performed within 45 hours (6 hours in 1 patient, 23 hours in 2, 26 hours in 1, and 45 hours in 1). RESULTS: All 5 patients underwent successful CEA. There were no complications related to surgery. At discharge, 2 patients had a normal examination, and the remaining patients had mild deficits. In a long-term follow-up of 5 to 22 months, no patient had a recurrent cerebrovascular event. CONCLUSIONS: Early CEA can be performed safely and successfully in patients after tPA treatment for acute ischemic stroke in appropriately selected patients.

Treatment of comminuted distal radius fractures with pins and plaster.

Based on this review, it is evident that the anatomic results obtained by the use of pins and plaster for the treatment of comminuted distal radial fractures is insufficient to yield a high percentage of satisfactory functional end results. In addition, the high complication and reoperation rate noted in our series makes us question whether the technique of pins and plaster should remain a treatment option for these difficult fractures. Perhaps a combination of internal fixation with bone grafting combined with external fixation will provide a solution to this fracture, particularly in young, active patients.

Is periprocedural sedation during acute stroke therapy associated with poorer functional outcomes?

BACKGROUND: To safely perform acute intra-arterial revascularization procedures, use of sedative medications and paralytics is often necessary. During the conduct of the Interventional Management of Stroke trials (I and II), the level of sedation used periprocedurally varied. At some institutions, patients were paralyzed and intubated as part of the procedural standard of care while at other institutions no routine sedation protocol was followed. The aim of this study was to identify patient characteristics that would correlate with the need for deeper sedation and to explore whether levels of sedation relate to patient outcome. METHODS: 75 of 81 patients in the Interventional Management of Stroke II Study were studied. Patients had anterior circulation strokes and underwent angiography and/or intervention. Four sedation categories were defined and tested for factors potentially associated with the level of sedation. Clinical outcomes were also analyzed, including successful angiographic reperfusion and the occurrence of clinical complications. RESULTS: Only baseline National Institutes of Health Stroke Scale varied significantly by sedation category (p=0.01). Patients that were in the lower sedation category fared better, having a higher rate of good outcomes (p<0.01), lower death rates (p=0.02) and higher successful angiographic reperfusion rates (p=0.01). There was a significantly higher infection rate in patients receiving heavy sedation or pharmacologic paralysis (p=0.02) and a trend towards fewer groin related complications. CONCLUSION: In this small sample, patients not receiving sedation fared better, had higher rates of successful angiographic reperfusion and had fewer complications. Further examination of the indications for procedural sedation or paralysis and their effect on outcome is warranted.

Combined IV and intra-arterial thrombolysis for acute ischemic stroke.

Combined IV and intra-arterial (IA) thrombolysis for acute ischemic stroke may offer advantages over either technique alone. Sixty-two nonrandomized patients with NIH Stroke Scale scores of > or =10 who met standard criteria for IV thrombolysis were treated with an IV/IA approach. Three-month modified Rankin Scale scores were 0 to 2 for 50% of patients, mortality was 18%, and symptomatic intracerebral hemorrhage occurred in 8%. IV/IA thrombolysis appeared safe and effective in this group.

Transection of radial digital nerve of the thumb during trigger release.

Iatrogenic laceration of the radial digital nerve of the thumb during trigger release occurred in four patients. Histologic cross sections through the thumb in cadaveric specimens at the level of the metacarpophalangeal crease showed the radial digital nerve to be 2.19 mm beneath the dermis and 1.15 mm directly anterior to the radial sesamoid bone. In this position the nerve is vulnerable to transection when it is trapped between the sesamoid and the knife blade.

The fate of failed bone graft surgery for scaphoid nonunions.

Twenty patients with scaphoid nonunions had bone grafting procedures that failed to achieve union. Nineteen had persistent wrist pain. Electrical stimulation after bone grafting proved useless in obtaining union in five patients. Sixteen patients had additional surgery. Ten had repeat bone grafting. Six scaphoids united after a second grafting and one united after a third graft. However, at follow-up only three of these seven patients had no pain in their wrists. The rate of union was not affected by fracture location, the presence of proximal pole avascular necrosis, or instability. The three patients with nonunion after two bone grafts remain symptomatic. Six patients had salvage procedures; silicone replacement arthroplasty (3), wrist fusion (1), proximal pole excision (1), intercarpal fusion (1). Four were asymptomatic after one of these procedures and two (silicone arthroplasty and intercarpal fusion) became asymptomatic after wrist fusions. Five fractures, believed to be united on the basis of plain radiographs, later demonstrated persistent nonunions. We recommend adequate radiologic follow-up, including tomography, to determine whether or not fracture union has occurred.

In vitro therapy with dobutamine, isoprenaline and sodium nitroprusside protects vascular smooth muscle metabolism from subarachnoid haemorrhage induced cerebral vasospasm.

BACKGROUND: The cerebrospinal fluid (CSF) from subarachnoid haemorrhage (SAH) patients with cerebral vasospasm stimulates vasoconstriction and oxygen consumption in the porcine carotid artery in vitro. Stimulation of oxygen consumption has been used as an in vitro model of vasospasm to assess the relative benefits of nimodipine, isoprenaline, dobutamine, and sodium nitroprusside (SNP). METHOD: Samples of human CSF were obtained from SAH patients and applied to de-endothelialised porcine carotid artery. Stimulation of oxygen consumption (as an in vitro marker for a stimulation of the vessels) was monitored and the effects of SNP, isoprenaline, dobutamine or nimodipine were measured. FINDINGS: The CSF from SAH patients with evidence of vasospasm stimulated oxygen consumption to 0.91 +/- 0.17 (microM O2/min/g dry wt, +/- SD p < or = 0.01) and CSF from SAH patients without vasospasm did not significantly stimulate oxygen consumption 0.27 +/- 0.02, with 0.23 +/- 0.03 (microM O2/min/g dry wt) being an unstimulated rate of respiration for the porcine carotid artery. SNP, isoprenaline or dobutamine significantly (p < or = 0.01) decreased the stimulation of oxygen consumption of the porcine carotid artery whereas nimodipine did not. In a cohort of 41 SAH patients who received nimodipine alone or nimodipine and dobutamine, the in hospital mortality rate of the patients who received only nimodipine was 42% as compared to an in hospital mortality rate of 17% in the nimodipine plus dobutamine group P < or = 0.076). INTERPRETATION: The in vivo data on the 41 patients is not statistically significant, so further studies are required to determine if the differences are important. SNP, isoprenaline and dobutamine significantly decreased oxygen consumption of the porcine carotid arteries exposed to CSF from SAH patients who had vasospasm whereas nimodipine did not. Our in vitro results suggest that these compounds require further study in patients with SAH who are at risk for vasospasm because they may have a direct benefit for the vasospastic arteries.