Before-After Study of an Electronic Order Set for Reversal of Vitamin K Antagonist-Associated Intracerebral Hemorrhage.

BACKGROUND: Vitamin K antagonist (VKA)-associated intracerebral hemorrhages (ICHs) are more likely to expand and are associated with higher mortality than primary ICH. Prompt reversal of anticoagulant effect with prothrombin complex concentrate (PCC) may promote hemostasis and decrease hematoma expansion. The aim of this study was to evaluate the impact of an electronic order set designed to standardize and facilitate more timely reversal of coagulopathy in VKA-associated ICH. METHODS: We identified all adults who received PCC for VKA-associated ICH from June 2012 to June 2015 at University of California San Francisco Medical Center, which included a period before and after an electronic order set became available in 2014. We abstracted baseline demographics and clinical data from electronic health records. The primary outcome was time from radiographic identification of ICH to administration of PCC. RESULTS: Thirty-one patients received PCC for VKA-associated ICH, including 17 patients before and 14 patients after the order set became available. Baseline demographics and clinical features were similar. Order set use was associated with a significant decrease in the time from identification of ICH on imaging to the administration of PCC (median 83 vs 45 minutes; P = .02), more accurate dosing (29.4% vs 92.9%; P < .01), and a shorter time from the PCC order to follow-up international normalized ratio (INR) testing (median 164 vs 85 minutes, P = .001). CONCLUSION: An electronic order set for administering PCC for VKA-associated ICH was associated with significantly faster time to PCC administration and increased dosing accuracy.

Conjugate Eye Deviation on CT Associated With Worse Outcomes Despite IV Thrombolysis.

INTRODUCTION: Rapid stroke management has significant implications in patient outcomes. Ipsilateral computed tomography conjugate eye deviation (CT-CED) has been associated with worse outcomes but has never been evaluated as predictive of vascular occlusion. To test the hypothesis that CT-CED is a marker for vascular occlusion, we evaluated patients treated with intravenous tissue plasminogen activator (IV tPA). METHODS: We performed a retrospective analysis of patients with acute ischemic stroke treated with IV tPA at a large tertiary care hospital over an 18-month period. A waiver of informed consent was granted. Two examiners evaluated baseline brain CTs blinded to the location of infarct to assess the presence of CT-CED and follow-up imaging for the location of infarct and the presence of intracranial large vessel occlusion. Demographics, initial National Institutes of Health Stroke Scale (NIHSS), modified Rankin Scales (mRSs), and hospital length of stay (LOS) were collected. RESULTS: Among 104 patients treated with IV tPA, 36 had CT-CED. Inter-rater reliability for CT-CED was excellent (κ = 0.97; 95% confidence interval: 0.98-1.0). The CT-CED group was older (69.8 vs 64 years; P = .038), had higher initial NIHSS (14.6 vs 11; P = .01), worse mRS (3.2 vs 2.4; P = .03), and longer LOS (8.4 vs 6.4; P = .05) compared with those without CT-CED. A vascular occlusion in the territory of the infarct was seen in 58% of patients with CT-CED versus 32% without CT-CED (P < .01). Atrial fibrillation (AF) was diagnosed in 61% patients with CT-CED versus 22% without (P < .01). CONCLUSION: The CT-CED is associated with higher initial NIHSS, large vessel occlusion, and AF. Prospective studies are needed to ascertain whether CT-CED may be utilized part of a screen for endovascular therapy.

Reducing Cost and Intravenous Duration of Nicardipine in Intracerebral Hemorrhage Patients via an Interdisciplinary Approach.

BACKGROUND: The mainstay of acute management of intracerebral hemorrhage (ICH) is blood pressure reduction. Intravenous (IV) nicardipine is an effective but costly intervention for blood pressure reduction in the intensive care unit (ICU). Earlier transition to oral (PO) antihypertensive agents may reduce ICU length of stay (LOS) and associated costs. We sought to study the effectiveness of an interdisciplinary intervention to start earlier transition to PO antihypertensives. METHODS: From July 2011 to July 2012, patients with ICH who received IV nicardipine were reviewed and screened for eligibility by an interdisciplinary team including physicians and pharmacists. These patients were compared to a control group 1 year prior to this intervention. The duration of nicardipine treatment (median hours), estimated costs, and ICU LOS were measured. RESULTS: A total of 35 patients and 44 controls were studied. The median hours of IV nicardipine use were significantly decreased from a baseline mean of 118 to 30 hours (P < .001); total cost savings per year was $433,566 ($18,475 per patient). The average LOS remained similar (8.4 versus 8.9 days, P < .990). In a follow-up study 1 year later, after the intervention was no longer used, a sample of 21 consecutive patients was reviewed and the duration of IV nicardipine treatment had increased to a mean of 96 hours. CONCLUSION: A physician and pharmacist-led project to initiate oral antihyperintensive medications earlier was successful in reducing the duration of IV nicardipine treatment in patients with ICH while leading to substantial cost savings.

Acute Thyrotoxicosis of Graves Disease Associated with Moyamoya Vasculopathy and Stroke in Latin American Women: A Case Series and Review of the Literature.

OBJECTIVE: Moyamoya disease is a cerebral vasculopathy characterized by stenosis of the terminal internal carotid artery, proximal middle cerebral artery, and anterior cerebral artery. There is an association between moyamoya vasculopathy and Graves disease, primarily in Asian populations. Here, we present the largest series of non-Asian, predominantly Latino patients with moyamoya vasculopathy in the setting of Graves thyrotoxicosis, as well as the largest review of the literature to date. METHODS: We retrospectively analyzed patients presenting with stroke in the setting of clinical Graves disease to our institution from 2004 to 2014. Moyamoya vasculopathy was diagnosed by magnetic resonance angiography in all patients. RESULTS: Eight patients with Graves disease thyrotoxicosis and moyamoya vasculopathy were identified. Six patients were effectively managed with aggressive medical management using antithyroid and antiplatelet medications. No recurrent strokes were noted once thyrotoxicosis was controlled. Intracranial bypass was necessary in 2 patients who failed medical management. Seventy-nine additional cases were reported from the literature. There was no significant difference in clinical improvement between medical therapy alone and medical therapy with neurosurgical prophylaxis (87.0% vs. 88.0%, respectively; P = 0.94). CONCLUSIONS: Moyamoya vasculopathy associated with Graves disease thyrotoxicosis in non-Asian women may be more common than previously thought. In addition, our series suggests that thyrotoxicosis promotes the progression of vasculopathy. Based on our review, there is no significant difference in clinical improvement between proper medical and surgical therapies. Aggressive medical therapy should be considered first-line treatment for moyamoya vasculopathy with Graves thyrotoxicosis, with neurosurgical rescue reserved for medically refractory cases.

Fibroblast Growth Factor 23 Is Associated With Subclinical Cerebrovascular Damage: The Northern Manhattan Study.

BACKGROUND AND PURPOSE: Elevated fibroblast growth factor 23 (FGF23) regulates phosphate homeostasis and is linked with mortality, cardiovascular events, and stroke. However, the role of FGF23 as a risk factor for subclinical cerebrovascular damage is unclear. METHODS: We used multivariable linear and logistic regression to evaluate associations between FGF23, continuously and by quartiles, with white matter hyperintensity volume, expressed as percent intracranial volume (%ICV), and subclinical brain infarction (SBI) in a community-based stroke-free sample. RESULTS: There were 1170 stroke-free Northern Manhattan Study (NOMAS) participants with FGF23 levels and quantitative magnetic resonance imaging data on white matter hyperintensity volume and SBI. Participants with FGF23 levels in the top quartile (range=85-1425 RU/mL) had greater white matter hyperintensity volume (ß=0.19 %ICV; 95% CI, 0.04-0.33 %ICV; P=0.01) compared with those in the lowest quartile (range=15-49 RU/mL), adjusted for demographics, vascular risk factors, and estimated glomerular filtration rate. These findings remained significant in those without evidence of chronic kidney disease (estimated glomerular filtration rate <60 mL/min per 1.73 m(2)). Elevated FGF23 was not associated with SBI overall after adjusting for demographic factors and estimated glomerular filtration rate, but sex modified the effect of FGF23 on odds of SBI (P for interaction=0.03). FGF23 was associated with significantly greater odds of SBI only in men (odds ratio, 1.7; 95% CI, 1.1-2.7; P=0.03) after full adjustment. CONCLUSIONS: These cross-sectional community-based data from a diverse urban sample show an association between elevated FGF23 and small vessel disease and magnetic resonance imaging-defined brain infarction in men, independent of chronic kidney disease. Data on elevated FGF23 and subclinical cerebrovascular damage progression are needed.

Episodic Aphasia Associated With Cortical Spreading Depression After Subdural Hemorrhage Evacuation.

Cortical spreading depression (CSD) has been associated with many pathological entities including migraine, trauma, hemorrhage, and mitochondrial disease. The clinical diagnosis remains challenging without the other concomitant features such as headache because CSD can mimic seizure or acute stroke. Wereport of a 77 year-old right handed man with a left subdural hematoma evacuation that subsequently developed episodic aphasia, slurred speech, right nasolabial fold flattening, and right pronator drift. In this case report, we discuss our multimodal diagnostic approach and treatment in a patient with episodic aphasia and neurological deficits in order to propose the diagnosis of cortical spreading depression. CSD should be considered when focal deficits in brief episodes occur after stroke and seizures have been ruled out. Treatment choices as illustrated by this case report can have an impact on outcome and resolution of episodes.

Fibroblast Growth Factor 23 Is Associated With Carotid Plaque Presence and Area: The Northern Manhattan Study.

OBJECTIVE: Elevated fibroblast growth factor 23 (FGF23), a hormone that regulates phosphate homeostasis, has been associated with mortality, cardiovascular events, and stroke, and to arterial calcification in chronic kidney disease, but its role in atherosclerosis is unclear and population-based studies are lacking. We hypothesized that elevated FGF23 would associate with carotid plaque presence, area, and echogenicity in the race/ethnically diverse community-based Northern Manhattan Study (NOMAS) sample. APPROACH AND RESULTS: There were 1512 stroke-free NOMAS participants with FGF23 and 2-dimensional carotid ultrasound data (mean age, 68±9 years; 61% women; 62% Hispanic, 18% black, and 18% white). We used multivariable linear and logistic regression to evaluate FGF23, continuously and by quintiles, as a correlate of carotid plaque, plaque area (cubic root transformed), and echogenicity adjusting for sociodemographic and vascular risk factors. Participants with FGF23 levels in the top quintile were more likely to have carotid plaque (odds ratio, 1.49; 95% confidence interval, 1.02-2.19; P=0.04) and larger plaque area (ß=0.32 mm(2), 95% confidence interval, 0.10-0.53 mm(2); P=0.004) than those in the lowest quintile, adjusting for estimated glomerular filtration rate, demographics, and vascular risk factors. Linear regression models also showed that log transformed FGF23 (LnFGF23) associated with greater odds of plaque presence (odds ratio, 1.26 per LnFGF23; 95% confidence interval, 1.01-1.58; P=0.04), and plaque area (ß=0.19 mm(2) per LnFGF23; 95% confidence interval, 0.07-0.31 mm(2); P=0.002). CONCLUSIONS: Higher FGF23 associated with greater likelihood and burden of carotid atherosclerosis independent of CKD. Atherosclerosis may be a mechanism through which FGF23 increases cardiovascular events and stroke.

Hyperglycemia presenting as left middle cerebral artery stroke: a case report.

BACKGROUND AND PURPOSE: Hyperglycemia is an important diagnostic differential and has been reported to cause focal neurological deficits masquerading as stroke. Discussion of hyperglycemia as a stroke mimic has been sparse in the era of diffusion weighted imaging, but remains an important mimic. CASE SUMMARY: A 67 year-old right-handed woman with presented with lethargy, global aphasia, left eye deviation and right hemiparesis. She received IV t-PA for left MCA syndrome and transferred for possible intervention. Initial labs showed a glucose 825mg/dL. MRI/MRA brain was negative for acute stroke with patent vessels, but abnormalities on MRperfusion. The patient was admitted and treated with medical resuscitation including IV fluids and an insulin drip. After normoglycemia was achieved the patient's neurological deficits resolved. EEG on day one of hospitalization showed left hemispheric slowing that subsequently normalized on continuous recording. CONCLUSION: We report a case of hyperglycemia clinically mimicking a left MCA syndrome reversed with medical management possibly explained by metabolic demand-blood flow coupling of inactive tissue rather than hypoperfused tissue at risk of infarction.

Awake craniotomy for brain tumor resection: the rule rather than the exception?

OBJECTIVE: Awake craniotomy (AC) has seen an expanded role in brain tumor surgery over the past few decades. AC allows intraoperative cortical mapping and the continuous assessment of neurophysiological parameters, which are otherwise unattainable under general anesthesia (GA). The ability of AC to analyze eloquent brain areas makes it a powerful method for reducing the risks associated with tumor resection, especially in motor and language cortex. We present a review of the literature to examine the benefits and limits of using AC over GA. METHODS: A literature search was performed using the Medline and PubMed databases from 1970 and 2012 that compared craniotomy for tumor resection under GA and AC. Data of interest included length of hospital stay, operating time, extent of resection, and neurological sequelae. RESULTS: A total of 8 studies with 951 patients (411 utilizing AC and 540 utilizing GA) were included in this review. Our interpretation of the literature suggests that AC (4 d, n=110) results in a shorter hospital stay than GA (9 d, n=116). Mean extent of resection was slightly less under awake conditions (41%, n=321) versus GA (44%, n=444), and postoperative deficits were less frequent under awake conditions (7%, n=411) versus GA (23%, n=520). Surgery time was slightly less in the AC group (165 min, n=324) versus GA (168 min, n=477). CONCLUSIONS: Given the effectiveness of AC for resection of eloquent tumors, the data suggests an expanded role for AC in brain tumor surgery regardless of tumor location.

Spinal epidural abscess and paralytic mechanisms.

PURPOSE OF REVIEW: The incidence of spinal epidural abscess is increasing, and the understanding of the pathophysiology is evolving. Better understanding of the pathophysiology, specifically the role of ischemia, warrants a change in therapy. RECENT FINDINGS: Paralysis in spinal epidural abscess may be the result of spinal cord compression, spinal cord arterial and/or venous ischemia and thrombophlebitis or a combination of these. SUMMARY: Recent evidence indicates the following areas of investigation and management can improve outcome in spinal epidural abscess: minimally invasive surgery early versus medical management when there are no significant neurological deficits, neuroradiologic arterial evaluation with therapies directed at vascular ischemia and thrombosis, and aggressive rehabilitation.