Risk of Major Adverse Cardiovascular Events After Emergency Department Visits for Hypertensive Urgency.

BACKGROUND: Chronic hypertension is an established long-term risk factor for major adverse cardiovascular events (MACEs). However, little is known about short-term MACE risk after hypertensive urgency, defined as an episode of acute severe hypertension without evidence of target-organ damage. We sought to evaluate the short-term risk of MACE after an emergency department (ED) visit for hypertensive urgency resulting in discharge to home. METHODS: We performed a case-crossover study using deidentified administrative claims data. Our case periods were 1-week intervals from 0 to 12 weeks before hospitalization for MACE. We compared ED visits for hypertensive urgency during these case periods versus equivalent control periods 1 year earlier. Hypertensive urgency and MACE components were all ascertained using previously validated International Classification of Diseases, Tenth Revision Clinical Modification codes. We used McNemar test for matched data to calculate risk ratios. RESULTS: Among 2 225 722 patients with MACE, 1 893 401 (85.1%) had a prior diagnosis of hypertension. There were 4644 (0.2%) patients who had at least 1 ED visit for hypertensive urgency during the 12 weeks preceding their MACE hospitalization. An ED visit for hypertensive urgency was significantly more common in the first week before MACE compared with the same chronological week 1 year earlier (risk ratio, 3.5 [95% CI, 2.9-4.2]). The association between hypertensive urgency and MACE decreased in magnitude with increasing temporal distance from MACE and was no longer significant by 11 weeks before MACE (risk ratio, 1.2 [95% CI, 0.99-1.6]). CONCLUSIONS: ED visits for hypertensive urgency were associated with a substantially increased short-term risk of subsequent MACE.

Validation of the International Classification of Diseases, Tenth Revision Code for the National Institutes of Health Stroke Scale Score.

BACKGROUND: Administrative data can be useful for stroke research but have historically lacked data on stroke severity. Hospitals increasingly report the National Institutes of Health Stroke Scale (NIHSS) score using an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code, but this code's validity remains unclear. METHODS: We examined the concordance of ICD-10 NIHSS scores versus NIHSS scores recorded in CAESAR (Cornell Acute Stroke Academic Registry). We included all patients with acute ischemic stroke from October 1, 2015, when US hospitals transitioned to ICD-10, through 2018, the latest year in our registry. The NIHSS score (range, 0-42) recorded in our registry served as the reference gold standard. ICD-10 NIHSS scores were derived from hospital discharge diagnosis code R29.7xx, with the latter 2 digits representing the NIHSS score. Multiple logistic regression was used to explore factors associated with availability of ICD-10 NIHSS scores. We used ANOVA to examine the proportion of variation (R2) in the true (registry) NIHSS score that was explained by the ICD-10 NIHSS score. RESULTS: Among 1357 patients, 395 (29.1%) had an ICD-10 NIHSS score recorded. This proportion increased from 0% in 2015 to 46.5% in 2018. In a logistic regression model, only higher registry NIHSS score (odds ratio per point, 1.05 [95% CI, 1.03-1.07]) and cardioembolic stroke (odds ratio, 1.4 [95% CI, 1.0-2.0]) were associated with availability of the ICD-10 NIHSS score. In an ANOVA model, the ICD-10 NIHSS score explained almost all the variation in the registry NIHSS score (R2=0.88). Fewer than 10% of patients had a large discordance (≥4 points) between their ICD-10 and registry NIHSS scores. CONCLUSIONS: When present, ICD-10 codes representing NIHSS scores had excellent agreement with NIHSS scores recorded in our stroke registry. However, ICD-10 NIHSS scores were often missing, especially in less severe strokes, limiting the reliability of these codes for risk adjustment.

Obstructive Sleep Apnea and Positive Airway Pressure Usage in Populations with Neurological Disease.

Obstructive sleep apnea (OSA) is characterized by repetitive episodes of complete or partial upper airway obstruction during sleep, with a worldwide estimate of 936 million sufferers. Treatments of OSA include continuous positive airway pressure (CPAP), weight loss, positional therapy, oral appliances, positive upper airway pressure, oro-maxillofacial surgery, hypoglossal nerve stimulation, and bariatric surgery, and others, with CPAP being the most commonly prescribed treatment. In this review, the neurologic conditions of stroke, cognitive decline, epilepsy, and migraines will be discussed as they relate to OSA. Additionally, the literature regarding improvement in these conditions following treatment with CPAP will be explored.

Short-term stroke risk after emergency department treat-and-release headache visit.

OBJECTIVE: To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke. BACKGROUND: Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error. METHODS: We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities. RESULTS: We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80). CONCLUSION: Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.

Cervical spinal cord infarction associated with coronavirus infectious disease (COVID)-19.

Coronavirus disease (COVID-19) has a number of emerging neurological manifestations in addition to pneumonia and respiratory distress. In what follows, we describe a case of a previously healthy young man with severe COVID-19 who subsequently developed an acute flaccid paralysis. Work up revealed a lesion in his cervical spinal cord concerning for spinal infarction or transverse myelitis. He received empiric pulsed steroids without improvement. Taken together, we felt his presentation was most consistent with spinal cord infarction in the setting of critical illness with COVID-19. We believe this is a rare case of spinal cord stroke associated with COVID-19.

Missed cerebrovascular events during prolonged sedation for COVID-19 pneumonia.

Cerebrovascular complications among critically ill patients with COVID-19 have yet to be fully characterized. In this retrospective case series from a single academic tertiary care referral center in New York City, we present 12 patients with ischemic or hemorrhagic strokes that were found on imaging after a period of prolonged sedation in the setting of COVID-19 pneumonia. This series demonstrates a pattern of cerebrovascular events clinically masked by deep sedation required for management of COVID-19 related acute respiratory distress syndrome (ARDS). Of the 12 patients included, 10 had ischemic stroke, 4 of which had hemorrhagic conversion, and 2 had primary intracerebral hemorrhage. Ten patients were on therapeutic anticoagulation prior to discovery of their stroke, and the remainder received intermediate dose anticoagulation (in a range between prophylactic and therapeutic levels). Additional studies are needed to further characterize the counterbalancing risks of ischemic and hemorrhagic stroke, as well as the optimal management of this patient population.

Posterior reversible encephalopathy syndrome in patients with COVID-19.

OBJECTIVE: To report four patients with coronavirus disease 2019 (COVID-19) who developed posterior reversible encephalopathy syndrome (PRES). METHODS: Patient data was abstracted from medical records at Weill Cornell Medical Center. RESULTS: Four patients with SARS-CoV-2 infection and PRES were identified. The patients' ages ranged from 64 to 74 years, and two were women. All four patients were admitted to the hospital with acute respiratory distress syndrome requiring intensive care unit admission and mechanical ventilation. PRES was diagnosed after persistent confusion, lethargy, new focal neurological deficits, or seizures were noted, with evidence of seizures on electroencephalogram for two of the patients. Imaging confirmed the presence of cerebral vasogenic edema. All four patients had elevated blood pressure and renal injury in the days preceding PRES diagnosis, as well as evidence of systemic inflammation and systemic hypercoagulability. Symptoms of PRES improved with blood pressure control. CONCLUSIONS: Our four cases demonstrate the occurrence of PRES in critically-ill patients with COVID-19. PRES should be considered in the differential for acute neurological deficits and seizures in this setting.

Central retinal artery occlusion occurring 30 years after successful revascularization surgery for moyamoya disease: case report.

We report a case of central retinal artery occlusion (CRAO) leading to unilateral blindness occurring in a moyamoya patient 30 years after successful pial synangiosis when she was 6 years old. Imaging studies at the time of the CRAO revealed total occlusion of the ipsilateral cervical and intracranial internal carotid artery, a vessel shown to be patent on MRI/MRA studies for decades previously. This case demonstrates that long-term follow-up of operated moyamoya patients may reveal late secondary complications, of which physicians, patients, and families need to be aware.

Risk of Ischemic Stroke in Patients With Coronavirus Disease 2019 (COVID-19) vs Patients With Influenza.

IMPORTANCE: It is uncertain whether coronavirus disease 2019 (COVID-19) is associated with a higher risk of ischemic stroke than would be expected from a viral respiratory infection. OBJECTIVE: To compare the rate of ischemic stroke between patients with COVID-19 and patients with influenza, a respiratory viral illness previously associated with stroke. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was conducted at 2 academic hospitals in New York City, New York, and included adult patients with emergency department visits or hospitalizations with COVID-19 from March 4, 2020, through May 2, 2020. The comparison cohort included adults with emergency department visits or hospitalizations with influenza A/B from January 1, 2016, through May 31, 2018 (spanning moderate and severe influenza seasons). EXPOSURES: COVID-19 infection confirmed by evidence of severe acute respiratory syndrome coronavirus 2 in the nasopharynx by polymerase chain reaction and laboratory-confirmed influenza A/B. MAIN OUTCOMES AND MEASURES: A panel of neurologists adjudicated the primary outcome of acute ischemic stroke and its clinical characteristics, mechanisms, and outcomes. We used logistic regression to compare the proportion of patients with COVID-19 with ischemic stroke vs the proportion among patients with influenza. RESULTS: Among 1916 patients with emergency department visits or hospitalizations with COVID-19, 31 (1.6%; 95% CI, 1.1%-2.3%) had an acute ischemic stroke. The median age of patients with stroke was 69 years (interquartile range, 66-78 years); 18 (58%) were men. Stroke was the reason for hospital presentation in 8 cases (26%). In comparison, 3 of 1486 patients with influenza (0.2%; 95% CI, 0.0%-0.6%) had an acute ischemic stroke. After adjustment for age, sex, and race, the likelihood of stroke was higher with COVID-19 infection than with influenza infection (odds ratio, 7.6; 95% CI, 2.3-25.2). The association persisted across sensitivity analyses adjusting for vascular risk factors, viral symptomatology, and intensive care unit admission. CONCLUSIONS AND RELEVANCE: In this retrospective cohort study from 2 New York City academic hospitals, approximately 1.6% of adults with COVID-19 who visited the emergency department or were hospitalized experienced ischemic stroke, a higher rate of stroke compared with a cohort of patients with influenza. Additional studies are needed to confirm these findings and to investigate possible thrombotic mechanisms associated with COVID-19.

Vascular Neurologists' Involvement in the Care of Medicare Patients With Ischemic Stroke.

BACKGROUND AND PURPOSE: We sought to determine the proportion of patients with ischemic stroke evaluated by vascular neurologists in the United States. METHODS: Using 2009 to 2015 claims from a 5% nationally representative sample of Medicare beneficiaries, we identified patients ≥65 years of age who were hospitalized for ischemic stroke. We ascertained the proportion of patients evaluated during the hospitalization or within 90 days of discharge by nonvascular and vascular neurologists. We assessed the relationship between county-level socioeconomic status and the likelihood of neurologist evaluation and between neurologist evaluation and diagnostic testing. RESULTS: Among 66 989 patients with ischemic stroke, 37 820 (56.5%) were evaluated by a nonvascular neurologist and 11 700 (17.5%) by a board-certified vascular neurologist. Across increasing quartiles of county socioeconomic advantage, the proportion of patients evaluated by a vascular neurologist was 12.2%, 16.5%, 19.8%, and 23.0%. Relative to evaluation by a nonvascular neurologist, evaluation by a vascular neurologist was associated with a higher likelihood of postdischarge heart rhythm monitoring (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.6-1.9), echocardiography (OR, 1.4; 95% CI, 1.3-1.4), cervical vessel imaging (OR, 1.3; 95% CI, 1.2-1.3), and intracranial vessel imaging (OR, 2.1; 95% CI, 2.0-2.2). CONCLUSIONS: In a nationally representative cohort of Medicare beneficiaries, we found that about three quarters of patients with ischemic stroke were evaluated by a neurologist, and about one-sixth were evaluated by a vascular neurologist. Patients who were evaluated by a vascular neurologist were significantly more likely to undergo diagnostic testing.

Risk of Ischemic Stroke in Patients with Covid-19 versus Patients with Influenza.

IMPORTANCE: Case series without control groups suggest that Covid-19 may cause ischemic stroke, but whether Covid-19 is associated with a higher risk of ischemic stroke than would be expected from a viral respiratory infection is uncertain. OBJECTIVE: To compare the rate of ischemic stroke between patients with Covid-19 and patients with influenza, a respiratory viral illness previously linked to stroke. DESIGN: A retrospective cohort study. SETTING: Two academic hospitals in New York City. PARTICIPANTS: We included adult patients with emergency department visits or hospitalizations with Covid-19 from March 4, 2020 through May 2, 2020. Our comparison cohort included adult patients with emergency department visits or hospitalizations with influenza A or B from January 1, 2016 through May 31, 2018 (calendar years spanning moderate and severe influenza seasons). Exposures: Covid-19 infection confirmed by evidence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the nasopharynx by polymerase chain reaction, and laboratory-confirmed influenza A or B. Main Outcomes and Measures: A panel of neurologists adjudicated the primary outcome of acute ischemic stroke and its clinical characteristics, etiological mechanisms, and outcomes. We used logistic regression to compare the proportion of Covid-19 patients with ischemic stroke versus the proportion among patients with influenza. RESULTS: Among 2,132 patients with emergency department visits or hospitalizations with Covid-19, 31 patients (1.5%; 95% confidence interval [CI], 1.0%-2.1%) had an acute ischemic stroke. The median age of patients with stroke was 69 years (interquartile range, 66-78) and 58% were men. Stroke was the reason for hospital presentation in 8 (26%) cases. For our comparison cohort, we identified 1,516 patients with influenza, of whom 0.2% (95% CI, 0.0-0.6%) had an acute ischemic stroke. After adjustment for age, sex, and race, the likelihood of stroke was significantly higher with Covid-19 than with influenza infection (odds ratio, 7.5; 95% CI, 2.3-24.9). CONCLUSIONS AND RELEVANCE: Approximately 1.5% of patients with emergency department visits or hospitalizations with Covid-19 experienced ischemic stroke, a rate 7.5-fold higher than in patients with influenza. Future studies should investigate the thrombotic mechanisms in Covid-19 in order to determine optimal strategies to prevent disabling complications like ischemic stroke.

Thrombolysis for Acute Ischemic Stroke Following Transcatheter Aortic Valve Replacement: Case Report and Literature Review.

INTRODUCTION: Intravenous thrombolytic therapy with recombinant tissue type plasminogen activator (IV-tPA) is the first-line treatment option for acute ischemic stroke (AIS). The tPA exclusion criteria, defined decades ago, require updates as new technologies emerge. Transcatheter aortic valve replacement (TAVR), which has begun to replace open surgery, poses a risk for acute stroke and falls outside of prior tPA guidelines. CASE REPORT: Here we describe a post-TAVR patient treated safely with IV-tPA for presumed AIS. CONCLUSION: Previously undescribed, we suggest that tPA should be considered for post-TAVR AIS patients who otherwise satisfy inclusion and exclusion criteria.

Characteristics and anatomic distribution of early vs late stroke after cardiac surgery.

BACKGROUND: The primary objective of this study was to identify the specific predictors of early and late stroke in patients after open heart surgery. Secondary outcomes included (a) risk factors for perioperative stroke, (b) anatomic location of stroke according to time of presentation, and (c) the impact of stroke on operative mortality. METHODS: Adult patients undergoing open cardiac surgery with cardiopulmonary bypass from 2006 to 2016 at the New York Presbyterian Hospital/Weill Cornell Medicine were retrospectively reviewed. In total 7957 patients were included. We compared the demographic and perioperative variables in three groups: no stroke, early stroke, and late stroke using regression analysis. RESULTS: The incidence of perioperative stroke for the entire study period was 1.5% (117 of 7957). Early stroke occurred in 84 (71.8%) patients, whereas late stroke occurred in 33 (28.2%). Early strokes were usually embolic events (64 of 66, 97.0%, P = .66) on the right side (30 of 66, 45.5%, P < .001), in the anterior circulation (38 of 66, 57.6%, P = .001), or in multiple distributions (28 of 66, 42.4%, P = .002). Late strokes were more likely left-sided (16 of 28, 57.1%, P < .001) and uncommonly in both the anterior and posterior hemispheres (1 of 28, 3.6%, P = .001). Stroke, regardless of timing, was a significant predictor of operative mortality (odds ratio, 11.0, confidence interval, 6.1-19.7, P < .001). CONCLUSIONS: Early and late strokes after cardiac surgery have distinct incidence, location, and likely etiology. Both early and late strokes portend a very high incidence of operative mortality.

Sleep Disorders and Stroke: Does Treatment of Obstructive Sleep Apnea Decrease Risk of Ischemic Stroke?

PURPOSE OF REVIEW: This review aims to support obstructive sleep apnea (OSA) as a risk factor for ischemic stroke, review treatment strategies for OSA, provide a comprehensive review of clinical data on OSA treatment and ischemic stroke risk, and to critically assess if treatment of OSA decreases the risk of ischemic stroke and if treatment improves outcomes and subsequent ischemic stroke risk in post-stroke patients. RECENT FINDINGS: Several observational studies, randomized controlled trials (RCTs), and meta-analyses have examined the risk of ischemic stroke and cardiovascular events in patients with OSA and have also examined continuous positive airway pressure (CPAP) treatment in these patients. Observational studies have shown an increased risk of ischemic stroke in patients with untreated OSA when compared with patients treated with CPAP; however, results are not statistically significant. RCTs and meta-analyses have shown no significant ischemic stroke risk reduction in CPAP treated patients with OSA. Several studies have shown improved outcomes in post-stroke patients with OSA treated with CPAP; however, few data is available for subsequent ischemic stroke risk reduction. Further research is needed for surgical treatment of OSA and assessment of ischemic stroke risk. OSA is associated with increased risk of ischemic stroke, and OSA should be treated with the appropriate therapy. While the current data is promising, more studies are necessary to state whether treatment of OSA reduces ischemic stroke risk and subsequent ischemic stroke risk. A practical approach to the sleep disorder evaluation and treatment of patients with cerebrovascular disease is outlined.

Tips and Resources for Medication Reconciliation.

Medication errors occur despite best intentions and are often the result of medication discrepancies. Medication reconciliation reduces the likelihood of errors by addressing medication discrepancies that result from multiple points of care, transitions in care, or patient report. Providers and practices may feel overwhelmed by new record systems and regulatory requirements, but multiple resources are available to assist providers to perform medication reconciliation with their patients. Providers and practices should implement medication reconciliation strategies, such as adoption of a multidisciplinary approach, engagement of patients to track medications, and identification of patients who are at high risk for medication list discrepancies and errors. Medication reconciliation will ultimately improve quality of care.

Blood-Brain Barrier Permeability in Aneurysmal Subarachnoid Hemorrhage: Correlation With Clinical Outcomes.

OBJECTIVE: The current understanding of the utility of blood-brain barrier permeability (BBBP) evaluation with extended-pass perfusion CT in the clinical setting is limited. We assessed whether BBBP parameters evaluated with perfusion CT correlate with unfavorable clinical outcomes in patients with aneurysmal subarachnoid hemorrhage (SAH). MATERIALS AND METHODS: A retrospective cross-sectional analysis was performed of 22 patients who underwent perfusion CT on days 0-3 after SAH. Extended perfusion CT data were postprocessed into BBBP quantitative maps of kep (washout rate constant of contrast agent from the extravascular extracellular space [EES] to the intravascular space), PS (permeability surface area product), Ktrans (volume transfer constant from blood plasma to EES), and Ve (EES volume per unit tissue volume) using Olea Sphere software (version 2.0). Clinical outcomes data regarding the presence of permanent neurologic deficits and modified Rankin scores were collected at discharge. ROC curve analyses and unpaired t tests were performed. RESULTS: The 22 patients were stratified on the basis of their clinical outcomes of permanent neurologic deficit and modified Rankin scores. In patients with unfavorable clinical outcomes (i.e., patients with permanent neurologic deficit and those with modified Rankin scores of 3-6), PS and Ve were significantly increased and kep and Ktrans were significantly decreased. A multiparameter ROC curve analysis combining the four parameters yielded an AUC of 0.80 for permanent neurologic deficit and an AUC of 0.89 for modified Rankin scores of 3-6. CONCLUSION: SAH patients with unfavorable outcomes had significantly elevated PS and Ve and significantly decreased kep, indicating increased BBBP, compared with SAH patients with unfavorable outcomes. Evaluation of BBBP parameters may provide prognostication of unfavorable outcomes in patients with SAH and help guide management.

Circulating protein Z concentration, PROZ variants, and unexplained cerebral infarction in young and middle-aged adults.

Protein Z (PZ) is a vitamin K-dependent plasma protein that exhibits both pro- and anticoagulant properties. Both low and high PZ levels have been linked to ischaemic stroke. Although PZ-lowering gene variants have been found to be less common in ischaemic stroke, the relationship remains unclear. We investigated PZ levels and PROZ variants in a multi-ethnic case-control study of unexplained stroke in participants aged 18 to 64. Plasma PZ was measured in cases (≥2 months post-stroke) and controls. PZ polymorphisms G79A (rs3024735) and A13G (2273971) were genotyped. A combined genetic score (0-4 minor alleles) was created assuming additive effects. A total of 715 individuals (1:1.4 cases:controls) was included. Analyses revealed evidence of a non-linear association. After adjusting for demographic and clinical covariates, PZ levels >2.5 µg/ml (90th %ile) were significantly associated with cryptogenic stroke (OR 2.41 [95 % CI 1.34, 4.34]) as compared with lower levels. Higher genetic score was related to progressively lower levels of PZ, and the presence of four minor alleles was associated with lower odds of stroke (adjusted OR 0.26 [95 % CI 0.07, 0.96]) versus 0 minor alleles. In this multi-ethnic study of young and middle-aged adults, there was evidence of a non-linear positive association between PZ level and unexplained stroke, with a directionally consistent association for genetic variants related to PZ levels and cryptogenic stroke. These findings support elevated PZ levels as a risk factor for cryptogenic stroke.