Sex-dependent outcomes of recanalization-treated acute ischemic stroke patients at Shamir (Assaf Harofeh) medical center, Israel, 2011-2020.

BACKGROUND/OBJECTIVES: Sex-based differences in incidence, etiologies, severity and recanalization treatment outcomes of patients with acute ischemic stroke (AIS) have been studied extensively. We set out to determine if there were sex-based differences in outcomes among AIS patients who received recanalization treatments at Shamir (Assaf Harofeh) Medical Center (SMC), Israel, between 2011 and 2020. METHODS: This was a single-center, retrospective chart review. The primary analysis compared outcomes for men and women, overall and stratifying by disease severity. We compared also demographics, risk factors and workflow data. RESULTS: Eight hundred and eleven patients received recanalization treatment between 2011 and 2020: 472 (58.1%) men and 339 (41.8%) women. Mean age, NIHSS score and proportion with an NIHSS score ≥ 6 were higher for women. Cerebrovascular risk factors were more prevalent in women, particularly atrial fibrillation, except that current smoking was more prevalent in men. Six hundred and twenty patients (78.1%) were treated with TPA alone, 89 (11.2%) with TPA and endovascular treatment (EVT), and 85 (10.7%) with EVT alone. Fifty percent of patients were discharged home, 41% to a rehabilitation hospital or nursing home, and 9% did not survive. Twenty-four patients (3%) sustained symptomatic bleeds. Outcomes were worse in patients with NIHSS score ≥ 6. Outcomes did not differ by sex. CONCLUSIONS: While treated women presented with more severe AIS and more risk factors, we did not find significant sex-related differences in outcomes. Meticulous adherence to risk factor modification remains the best strategy to reduce stroke incidence, morbidity, and mortality in women and in men.

CT-guided thrombolytic treatment of patients with wake-up strokes.

BACKGROUND: Observational studies of thrombolysis outcomes in wake-up acute ischemic stroke patients selected based on non-contrast brain CT criteria suggested that treated patients did as well as or better than those not treated, after adjustment for baseline characteristics. We began offering thrombolytic treatment (IVTPA) to patients presenting with wake-up strokes and normal non-contrast brain CTs, who could be treated within 4.5 h of being found. DESIGN/METHODS: A retrospective chart review was performed in patients presenting with AIS between November 2014 and December 2017 who received IVTPA. A planned subgroup analysis compared patients with wake-up strokes and normal non-contrast brain CTs to patients with witnessed stroke treated within 4.5 h of being found, or of witnessed onset, respectively. RESULTS: Three hundred and six patients were treated, 279 with witnessed-onset and 27 with wake-up strokes. The latter were not candidates for endovascular intervention. Efficacy and safety were similar in both groups. Discharges home, respectively, were 143(53%) and 13(48%); facility discharges were 112(40.1%) and 11(40.7%) and in-hospital mortality was 19 (6.8%) and 3 (11%). Treatment-related symptomatic bleeds were: 5(1.8%) and 1 (3.7%), respectively. CONCLUSIONS: The findings affirm, in a new clinical series reflecting routine practice, that it is safe to treat with IVTPA patients with wake-up strokes and a normal brain CT scan, who are not candidates for endovascular intervention. We hypothesize, that when the non-contrast brain CT scan is normal, it may be safe to extend beyond 4.5 h the IVTPA treatment eligibility window in similar patients with witnessed-onset stroke.

Effect of the 2013 AHA/ASA guidelines on TPA use in acute ischemic stroke at Assaf Harofeh Medical Center in Israel.

BACKGROUND: Use of TPA to treat patients with acute ischemic stroke was introduced in Assaf Harofeh Medical Center (AHMC) in Israel in November 2007 initially with strict adherence to the inclusion/exclusion criteria of the pivotal NINDS TPA studies published in 1995. The treatment window was expanded in 2010 to 4.5h following the results of ECASS-III. Application of the 2013 AHA/ASA Guidelines resulted in further expanded inclusion and relaxed exclusion criteria. DESIGN/METHODS: A retrospective chart review was conducted of patients who received TPA at AHMC to evaluate the additional impact of applying the 2013 guidelines. Number of patients treated, outcomes at discharge, and safety were compared between two periods: May 2011-January 2013 (the 21months preceding the 2013 Guidelines); and February 2013-October 2014 (the 21months after publication of the 2013 Guidelines). Statistical analysis was done using z-tests for differences between proportions, and t-tests to compare means. RESULTS: 63 patients were treated during the immediate pre-2013 Guideline period (36/year, or approximately 5% of patients with ischemic stroke), and 105 during the post-2013 Guidelines period (60/year, approximately 8.3% of patients with ischemic stroke) (p<0.001). During the two periods, respectively: discharges home were 22(34%) and 55(52%) (p<0.05); facility discharges were 29(46%) and 33(31%); and inter-hospital transfers were 6(9%), and 11(10% of treated patients). Most transfers were for endovascular treatment. Total treatment-related symptomatic bleeds in the two periods, respectively, was: 4(6%) and 4(4%), and the number of in-hospital deaths was 6 (9%) and 6 (6%) (unchanged). CONCLUSIONS: Application of the 2013 AHA/ASA Guidelines resulted in a 64% increase in the number of acute ischemic stroke patients treated with TPA at AHMC with no worsening of aggregate outcomes and no increase in bleeds or deaths.

Multimodal treatment of hemorrhagic pituitary metastasis as first manifestation of renal cell carcinoma.

BACKGROUND: Metastatic tumors involving the pituitary gland are very rare, with only few cases reported so far in the literature. CASE DESCRIPTION: We report a case of a man who presented with an extremely vascular hemorrhagic pituitary metastasis as the first manifestation of renal cell carcinoma. The patient was successfully treated with staged procedures, including preoperative tumor vasculature embolization followed by transsphenoidal tumor resection. CONCLUSIONS: This is the first report describing multimodality treatment of a patient with pituitary metastasis of unknown origin requiring presurgical embolization before successful tumor removal.

Treatment of intra-cranial aneurysms with the SILK flow diverter: 2 years' experience with 28 patients at a single center.

BACKGROUND: Flow diverters are recently developed stent-like endovascular devices developed to treat complex and non-coilable aneurysms. SILK is a type of flow diverter that has been used for nearly 3 years. Only sparse data about it are available. We would like to share our experience with this device. METHODS: Twenty-eight patients were treated with SILK from October 2008 to October 2010. Thirty-one treatment sessions were performed for 32 aneurysms using 31 SILKs. Twenty have been treated with SILK only and eight with SILK and adjuvant stents. Twenty-six (86%) patients performed cross-sectional imaging (MRA/CTA) for follow-up. Eighteen (64%) patients had follow-up brain angiography. RESULTS: In all patients the SILK could be deployed. No case of early or late aneurysmal rupture was noted. Five patients (17.8%) developed immediate clinical complications, which were permanent in three (10.7%). All the complications occurred in patients harboring aneurysms larger than 15 mm. In two other patients, occlusion of the SILK was noted with no clinical deficit. A complete or near-complete aneurysmal occlusion was found in brain angiography or cross-sectional imaging follow-up in 83.3% of the patients. CONCLUSIONS: SILK is a relatively simple device to use, with a low rate of technical and clinical complications and a high short-term aneurysmal occlusion rate. In aneurysms smaller than 15 mm, the results are excellent. Results are also encouraging in the larger aneurysms, taking into consideration their complexity. The device characteristics and mainly its drawbacks must be well known by the users.

Return to flight with multiple sclerosis: aeromedical considerations.

Multiple sclerosis (MS) is the most frequent demyelinating disease of the central nervous system, with versatile manifestations--relapsing-remitting or progressive--and an unpredictable course, with prognoses ranging from minimal neurological impairment to severely disabled. Disease modifying agents can minimize relapse rate and slow disease progression. Yet most patients suffer relapses and progression despite use of these agents. Several of the manifestations of MS may cause overall decrease in the performance of the aviator. These include cognitive impairment, fatigue, and depression. Episodes of spasms, dysarthria, ataxia, parasthesias, diplopia, and hemiplegia, as well as drug side effects may also affect flight. Seizures and episodes of vertigo may occur suddenly and result in in-flight incapacitation. We present our experience with two aviators with definite MS and a navigator with probable MS. The various manifestations of MS are specifically addressed with an emphasis on the aeromedical implications.

Myasthenia gravis and return to flying status.

INTRODUCTION: Myasthenia gravis (MG) is a common primary disorder of neuromuscular transmission. Although MG was once a fatal disease, today treatment with immunomodulating agents and cholinomimetic medications with good supportive care have improved the prognosis and the ability of patients to adapt to their workplaces, including the flight environment. CASES: The diagnosis of MG in two aircrew members illustrates the range of severity for MG from isolated ocular symptoms to relentlessly progressive generalized disease, as well as the unpredictability of the disease and difficulty in treatment. Nevertheless, both patients were returned to limited flying status. DISCUSSION: MG presents the potential for subtle progression with resulting effects on flight performance. In addition to the disease itself, flight surgeons must also consider problems related to treatment and its side effects. Progression and exacerbations of MG can develop during the course of the disease, requiring careful adjustments to treatment regimens. Taking all these factors into consideration, including the unpredictability of this disease, pilots with apparently stabilized MG should nevertheless be assigned only to duties during which the patient would be able to maintain and use his flying capabilities without risking the mission, himself, and other crewmembers.

Tuberous sclerosis in a military pilot.

Tuberous sclerosis (TS) is a multisystem disorder characterized by hamartomas in various organs. It usually manifests itself during infancy or childhood with neurological features, including mental retardation and seizures. We present the case of a military pilot who was diagnosed with TS at 22 yr. of age after he had completed flight training. Suspicion of TS arose from evaluation of a chronic rash around the pilot's nose, and diagnosis was confirmed based on the presence of multiple calcified nodules on CT imaging of the brain. No neurological abnormalities were found. The primary aeromedical concerns were the risk of seizures or development of tumors at sites that might lead to sudden incapacitation. Hamartomas can be reliably detected at an early stage by means of annual history, physical examination, and imaging of tumor-prone organs. After review of the literature and consultation with medical specialists, we assessed the risk of adult-onset seizures in a TS patient without preexisting neurological findings as scarce. The pilot was therefore granted a waiver limited to flying a two-pilot helicopter with a program of tight medical follow-up.

Is intraocular pressure in myotonic dystrophy patients spuriously low?

BACKGROUND: Ocular hypotony is a common unexplained feature of myotonic dystrophy type 1. Spuriously low applanation tonometric readings can be caused by thin corneas, flat corneal curvature and corneal edema. OBJECTIVES: To determine whether structure abnormalities of the cornea cause spuriously low readings in applanation tonometry. METHODS: We utilized a TMS-2N corneal topographer, a NonconRobo SP-6000 Specular microscope and a Corneo-Gage Plus 1A Pachymeter to examine seven patients with DM1 and eight healthy controls. Intraocular pressure, central corneal thickness, and endothelial cell density were measured, and simulated keratometry readings were made. Cornea guttata and irregularity of corneal topography patterns were also sought. RESULTS: The mean intraocular pressure was 9.86 +/- 1.29 mmHg for all patients (intraocular operated and non-operated eyes) and 12.88 +/- 1.89 mmHg for the controls (P=0.000021, two-tailed t-test). Central corneal thickness was 530.57 +/- 35.30 micron for all patients and 535.00 +/- 39.62 micron for the controls (P=0.75, two-tailed t-test). Endothelial cell density was 3164 +/- 761 cells/ mm2 for all patients and 3148 +/- 395 cells/mm2 for the controls (P=0.94, two-tailed t-test). Simulated keratometry readings were similar in both groups when the operated eyes were excluded. Cornea guttata and irregularity of corneal topography patterns were also noted in the study group. CONCLUSIONS: Corneal thickness, corneal curvature and corneal hydration were within normal limits and thus were not the cause for the low applanation tonometry reading in DM1. The presence of cornea guttata and irregularity of corneal topography patterns in DM1 warrants further investigation.

Mechanisms of vestibulo-ocular reflex (VOR) cancellation in spinocerebellar ataxia type 3 (SCA-3) and episodic ataxia type 2 (EA-2).

The vestibulo-ocular reflex (VOR) mechanism triggers eye movements as a result of head motion in order to keep gaze stationary relative to the world. However, in order to shift the direction of the gaze along with head motion, the VOR mechanism must be overridden ("cancelled"). Two mechanisms have been proposed to explain this cancellation: a reduction of the VOR gain or activation of smooth pursuit (SP) eye movements in the opposite direction. We studied VOR cancellation using the magnetic search coil in six spinocerebellar ataxia type 3 (SCA-3) and four episodic ataxia type 2 (EA-2) patients, conditions that are known to have degraded SP but different degrees of VOR impairment. Abnormal VOR was found in two of the four EA-2 patients and all of the SCA-3 patients. All subjects possessed residual VOR, although when tested using head thrusts it was almost negligible in the SCA-3 patients. The EA-2 patients showed essentially no SP and the SCA-3 patients had poor SP. However, for all patients, the gain during VOR cancellation was comparable to normals. These results provide additional evidence that SP cancellation of the VOR cannot be the sole mechanism utilized in overriding the VOR in these patients.

Physician versus paramedic in the setting of ground forces operations: are they interchangeable?

BACKGROUND: The setting of military ground force operations can be demanding and requires a matched medical assistance plan. A major consideration is the type of medical caregiver that is assigned to the mission. We studied the similarities, differences, advantages, and disadvantages of physicians versus paramedics in this scenario. METHODS: We interviewed 20 ground force physicians, highly experienced in this setting. We summarized their responses and formulated quantitative decision-making tables regarding two sorts of missions: a long-duration mission, far from friendly definitive care, and a short-duration mission, close to friendly hospitals. RESULTS: The major areas in which physicians and paramedics differ, pertinent to a ground force operation are: formal education, on-job training, knowledge base, ability to treat a wide variety of medical conditions, ability to perform manual lifesaving procedures, social and moral impact, availability, physical fitness, combat skills, and cost. Of a maximum score of 100 points, for a long-term mission a physician scores 77.7 points while a paramedic scores 63.6 points. The scores for a short-term mission are 72.7 and 67.9, respectively. DISCUSSION: Physicians and paramedics are distinct groups of medical caregivers and this is also true for the setting of ground force operations. They are not interchangeable. Our data show that a physician has a relative advantage over a paramedic, especially in long-term missions, far from friendly facilities. CONCLUSION: A physician is the first choice for all kinds of military ground force missions while a paramedic can be a reasonable substitute for missions of short duration, close to definitive care.

Is posttraumatic benign paroxysmal positional vertigo different from the idiopathic form?

BACKGROUND: Although head trauma is considered a common cause of benign paroxysmal positional vertigo (BPPV), clinical presentation and outcome of traumatic BPPV (t-BPPV) have not been systematically evaluated. OBJECTIVES: To compare the clinical presentation, patient's response to physical treatment, and outcome of patients with t-BPPV with those with the idiopathic form (i-BBPV). SETTING: Tertiary referral neuro-otology outpatient clinic. METHODS: We reviewed the clinical records of 247 consecutive patients with posterior canal BPPV during the years 1997 to 2000. All patients were diagnosed using the Dix-Hallpike test and treated using the particle repositioning maneuver. Patients with an onset of positional vertigo within 3 days of well-documented head trauma were included in the t-BPPV group. The outcome was compared with the outcome of 42 patients with i-BPPV who were similarly treated and followed up. RESULTS: Twenty-one (8.5%) of the 247 patients with BPPV fulfilled the diagnostic criteria for t-BPPV. The most common cause of head trauma was motor vehicle crash, documented in 57% of the cases; half of the patients additionally suffered from a whiplash injury. While the other causes were diverse, common falls were predominant. Only 2 of the patients involved in motor vehicle crashes experienced brief loss of consciousness. Sixty-seven percent of patients with t-BPPV required repeated physical treatments for complete resolution of signs and symptoms in comparison to 14% of patients with i-BPPV (P<.001). During a mean +/-SD follow-up of 21.7 +/- 9.7 months, 57% of t-BPPV patients and 19% of i-BPPV controls had recurrent attacks (P<.004). CONCLUSIONS: The nature and severity of the traumas causing t-BPPV are diverse, ranging from minor head injuries to more severe head and neck trauma with brief loss of consciousness. It appears that t-BPPV is more difficult to treat than i-BPPV, and also has a greater tendency to recur.

[Traumatic benign paroxysmal positional vertigo: diagnosis and treatment].

Although head trauma is the cause of Benign Paroxysmal Positional Vertigo (BPPV) in about 15% of cases, the clinical features and response to treatment in this particular group of patients was not previously evaluated. We present 20 cases of traumatic BPPV: 12 cases identified from 150 consecutive BPPV patients diagnosed in our Dizziness Clinic; and 8 cases diagnosed from 75 consecutive head trauma patients seen in the Emergency Room. In all patients the clinical diagnosis was confirmed by the Dix-Hallpike maneuver and all were treated by the Epley procedure. Treatment results were compared to those of 40 consecutive patients with idiopathic BPPV. There was a wide spectrum and severity of head trauma including road accident (7), different falls (5), blow to the head (5) and miscellaneous (3). Two patients experienced brief loss of consciousness. Only two patients were diagnosed as BPPV before referral to our clinic. When presented to our Dizziness Clinic the patients were diagnosed as follows: unspecified dizziness (7), cervical vertigo (4) and transient ischemic attack (1). Five patients (25%) had bilateral BPPV. Eight patients (40%) had complete resolution of symptoms and signs following a single treatment while 12 patients (60%) required additional physical treatments until complete resolution of BPPV was achieved. During follow-up, 11 patients (55%) had recurrent attacks of BPPV. Thirty-four patients with idiopathic BPPV (85%) had a single successful treatment session while the others required repeated physical treatments until complete resolution of BPPV. We conclude that traumatic BPPV is probably under-recognized or misdiagnosed in clinical practice. Response to a single physical treatment seems to be less favorable than in idiopathic BPPV. The Dix-Hallpike maneuver is mandatory in all patients with dizziness and vertigo following head trauma.