Temporal Trends in Racial and Ethnic Disparities in Endovascular Therapy in Acute Ischemic Stroke.

Introduction Endovascular therapy (EVT) use increased following clinical trials publication in 2015, but limited data suggest there may be persistent race and ethnicity differences. Methods and Results We included all patients with acute ischemic stroke arriving within 6 hours of last known well and with National Institute of Health Stroke Scale (NIHSS) score ≥6 between April 2012 and June 2019 in the Get With The Guidelines-Stroke database and evaluated the association between race and ethnicity and EVT use and outcomes, comparing the era before versus after 2015. Of 302 965 potentially eligible patients; 42 422 (14%) underwent EVT. Although EVT use increased over time in all racial and ethnic groups, Black patients had reduced odds of EVT use compared with non-Hispanic White (NHW) patients (adjusted odds ratio [aOR] before 2015, 0.68 [0.58‒0.78]; aOR after 2015, 0.83 [0.76‒0.90]). In-hospital mortality/discharge to hospice was less frequent in Black, Hispanic, and Asian patients compared with NHW. Conversely discharge home was more frequent in Hispanic (29.7%; aOR, 1.28 [1.16‒1.42]), Asian (28.2%; aOR, 1.23 [1.05‒1.44]), and Black (29.1%; aOR, 1.08 [1.00‒1.18]) patients compared with NHW (24%). However, at 3 months, functional independence (modified Rankin Scale, 0-2) occurred less frequently in Black (37.5%; aOR, 0.84 [0.75‒0.95]) and Asian (33%; aOR, 0.79 [0.65‒0.98]) patients compared with NHW patients (38.1%). Conclusions In a large cohort of patients treated with EVT, Black versus NHW patient disparities in EVT use have narrowed over time but still exist. Discharge related outcomes were slightly more favorable in racial and ethnic underrepresented groups; 3-month functional outcomes were worse but improved across all groups with time.

Dual-center study comparing transradial and transfemoral approaches for flow diversion treatment of intracranial aneurysms.

BACKGROUND: The transfemoral approach (TFA) has been the traditional approach for neurointerventional cases. While the TFA allows for triaxial support in flow diverting stent cases, it is associated with access site complications. Recently, the transradial approach (TRA) has emerged as a safer alternative to the TFA. To the best of our knowledge, there have only been single-center studies comparing outcomes in flow diverter cases for these approaches. We demonstrate the safety and feasibility of the TRA for placement of flow diverting stents in the treatment of unruptured intracranial aneurysms at two high-volume centers. MATERIALS AND METHODS: We performed a retrospective review of prospectively collected institutional databases at two high-volume neuroendovascular centers. Cases from 2016 to 2018 of unruptured intracranial aneurysms treated by flow diverting stenting accessed through either the TRA or the TFA were compared. Patient demographics, procedural and radiographic metrics including location and size of the aneurysm, size, and length of the flow diverter implant, and fluoroscopic time were recorded. Puncture site complications and length of hospital stay were also included in the data analysis. RESULTS: There were three out of 29 TRA cases which were converted to the TFA. None of the TRA patients experienced site complications, whereas three TFA patients experienced site complications. While TRA and TFA patients did not differ significantly in their exposure to radiation, TRA patients experienced shorter hospital stays. CONCLUSIONS: While long-term studies are still lacking regarding this approach, we demonstrate that the TRA is a safe and feasible approach for flow diverter stent placement.

Role of Telemedicine in Prehospital Stroke Care.

PURPOSE OF REVIEW: To summarize evidence for the feasibility and the efficacy of mobile stroke units (MSUs) and telemedicine in the field to reduce time delays in offering acute stroke interventions. RECENT FINDINGS: A mobile stroke unit is a modified ambulance and includes sophisticated equipment, either trained personnel on board, or connection with skilled physicians via telemedicine. Stroke assessment and treatment agreeability between the on board and remote neurologist is high in MSUs. MSUs are the promising option to reduce stroke symptom onset to treatment time; telemedicine platform has a satisfactory audiovisual quality, high inter-rater reliability for remote stroke symptom assessment, diagnosis, and decision to treat. Use of MSU also avoids the need for inter-hospital transfers. MSUs improve prehospital stroke care and reduce delays in access to intravenous thrombolytic and mechanical thrombectomy in selective markets. Advancement in telecommunication and modern technology has the potential to make MSU telemedicine-aided management more cost-effective. Further research is needed before its widespread implementation.

Stroke Rates Following Surgical Versus Percutaneous Revascularization for Ischemic Heart Disease.

PURPOSE OF REVIEW: Coronary revascularization is a commonly performed major procedure in the hospitals. Stroke is one of the dreaded complications after coronary revascularization procedures. The focus of this review is to understand the stroke risk in percutaneous cutaneous intervention (PCI) and coronary artery bypass grafting (CABG) procedures. RECENT FINDINGS: Available data show that PCI offers less procedural stroke risk compared to CABG although the survival benefits of CABG are better in certain scenarios. Innovative advancements in techniques, pre-procedural optimum medical therapy (OMT), intraoperative neuro-monitoring, and multidisciplinary post procedural care are the few strategies in early detection and reduce stroke risk. Despite several innovations and strategies, it is evident that there is not enough data available to make concrete conclusions related to stroke risk after coronary revascularization, which warrants further investigation.

The Angiographic Anatomy of the Sphenoidal Segment of the Middle Cerebral Artery and Its Relevance in Mechanical Thrombectomy.

OBJECTIVE: The middle cerebral artery (MCA) is the most commonly treated artery in mechanical thrombectomy stroke trials; however, there is no pragmatic agreement about the segmental anatomy and nomenclature utilized. It results in significant clinical-radiological dissociation and introduces bias in research trials. The purpose of the study is to review and compare angiographic anatomy with microsurgical anatomy literature of the MCA with emphasis on the discrepancy. METHODOLOGY: Consecutive cerebral angiograms between January 2011 and March 2014 were retrospectively reviewed by endovascular surgical neuroradiologists. Information about the anatomy of the sphenoidal segment of the MCA classified as classic and non-classic pattern, the lenticulostriate artery takeoff pattern, and the course angulation of the sphenoidal segment were studied. RESULTS: A total of 500 patients, 886 cerebral angiograms, were reviewed. We found the classic pattern of the main trunk MCA bifurcation and a straight angulation course in less than half of the cases. The lenticulostriate arteries arose not only from the main trunk but also from its divisions in more than half of the cases. CONCLUSION: It is important to corroborate our findings and to develop a pragmatic classification to accurately assess MCA occlusions from the radiological and clinical perspective.

Use of a Discharge Educational Strategy Versus Standard Discharge Care on Reduction of Vascular Risk in Patients with Stroke and Transient Ischemic Attack.

PURPOSE OF THE REVIEW: The burden of ischemic stroke is disproportionally distributed between ethnic and racial subgroups in the USA, minority populations with lower socioeconomic status being at higher risk. These discrepancies are mirrored in susceptibility, primary care, and post-discharge procedures. Post-discharge strategies are of particular importance as their primary goal is to prevent recurrent stroke, which makes up about 25% of stroke cases per year in US. As disadvantaged minorities have faster growing populations, recurrent stroke poses a significant challenge not only for caretakers but also for the health care system as the whole. A number of educational strategies were employed to inform the general public of major symptoms, risk factors, and preventive measures for recurrent stroke. However, over affected subgroups did not prove responsive to such measures as these did not conform to their cultural and sociological specificities. RECENT FINDINGS: The Discharge Educational Strategies for Reduction of Vascular Events Intervention (DESERVE) is a randomized control trial with a one year follow up, set out to investigate the possibility that culturally tailored, community-centered post-discharge strategies would improve compliance to therapy and prevention against secondary stroke. The trial targeted African Americans, Hispanic, and non-Hispanic whites, adapting discharge strategies for each individual group. DESERVE accomplished a significant reduction in blood pressure in the Hispanic intervention group by 9.9 mm Hg compared with usual care. The remaining two groups were not susceptible to these measures. DESERVE holds promise for culturally tailored interventions in the future in a battle against stroke and other chronic diseases.

Comparative Outcomes of Respiratory Failure Associated with Common Neuromuscular Emergencies: Myasthenia Gravis versus Guillain-Barré Syndrome.

Background and objectives: Myasthenia gravis (MG) and Guillain-Barré Syndrome (GBS) are autoimmune neuromuscular disorders that may present as neuromuscular emergencies requiring mechanical ventilation and critical care. Comparative outcomes of these disease processes, once severe enough to require mechanical ventilation, are not known. In this study, we compared the patients requiring mechanical ventilation in terms of in-hospital complications, length of stay, disability, and mortality between these two disease entities at a national level. Materials and Methods: Mechanically ventilated patients with primary diagnosis of MG (n = 6684) and GBS (n = 5834) were identified through retrospective analysis of Nationwide Inpatient Sample (NIS) database for the years 2006 to 2014. Results: Even though mechanically ventilated MG patients were older (61.0 ± 19.1 versus 54.9 ± 20.1 years) and presented with more medical comorbidities, they had lower disease severity on admission, as well as lower in-hospital complications sepsis, pneumonia, and urinary tract infections as compared with GBS patients. In the multivariate analysis, after adjusting for confounders including treatment, GBS patients had significantly higher disability (odds ratio (OR) 15.6, 95% confidence interval (CI) 10.9-22.2) and a longer length of stay (OR 3.48, 95% CI 2.22-5.48). There was no significant difference in mortality between the groups (8.45% MG vs. 10.0% GBS, p = 0.16). Conclusion: Mechanically ventilated GBS patients have higher disease severity at admission along with more in-hospital complications, length of stay, and disability compared with MG patients. Potential explanations for these findings include delay in the diagnosis, poor response to immunotherapy particularly in patients with axonal GBS variant, or longer recovery time after nerve damage.

A Rare Adverse Event of Rhabdomyolysis Caused by Sacubitril/Valsartan.

Rhabdomyolysis is caused by extensive damage to skeletal muscles resulting in elevated creatine phosphokinase (CPK), Lactate dehydrogenase (LDH), and aspartate aminotransferase (AST), leading to life-threatening consequences like acute renal failure, cardiac arrhythmias, and hyperthermia. A variety of causes for muscle damage are known, and one of the most common is drug-induced. Statins and many other agents are known to induce muscle damage, but here we report Entresto™ (Sacubitril/Valsartan) induced rhabdomyolysis which has not been previously reported as solely responsible in the literature.

Fluoroquinolones and the Risk of Aortic Aneurysm or Aortic Dissection: A Systematic Review and Meta-Analysis.

OBJECTIVES: We performed a systematic review and meta-analysis to explore the risk of an aortic aneurysm or aortic dissection following fluoroquinolone administration. METHODS: PubMed, Cochrane library, ClinicalTrials.gov, Embase and Google Scholar were systematically reviewed for controlled studies including adult patients exposed to fluoroquinolones with a primary outcome of aortic aneurysm or aortic dissection. RESULTS: The meta-analysis was conducted by pooling the effect estimates of four controlled observational studies (one case-control, one case-crossover and two cohort studies). Fluoroquinolone administration more than doubled the risk to develop aortic aneurysm or aortic dissection within 60 days following fluoroquinolone exposure (adjusted Relative Risk [RR] (95% confidence interval [CI]) = 2.14 (1.93 - 2.36); I2 = 15.8%). The quality of the finding was rated as moderate. The risk increase for aortic aneurysm alone was found to be significant (adjusted RR (95% CI) = 2.23 (2.01 - 2.45); I2 = 0%) while the risk increase for aortic dissection alone was not found to be significant (adjusted RR = 1.88 (0.11 - 3.65); I2 = 74%). In subgroup analysis, the risk increase for aortic aneurysm or aortic dissection appeared to be higher in females compared to males (RR = 1.87 (1.24 - 2.51); I2 = 0% versus RR = 1.58 (1.25 - 1.92); I2 = 0%, respectively) and higher in older patients compared to younger patients (RR = 1.72 (1.37 - 2.07); I2 = 0% versus RR = 1.47 (0.91 - 2.04); I2 = 0%, respectively). Subgroup analysis of two studies which measured the duration-response analysis found that as the duration of fluoroquinolone therapy increased from 3 to 14 days to greater than 14 days, there was an increased risk of aortic aneurysm or dissection. CONCLUSION: The findings of this meta-analysis confirm the positive association between fluoroquinolones and the development of aortic aneurysm or dissection. The data tend to show that this association may be majorly driven by aortic aneurysm. Additionally, some risk factors appear to prevail including prolonged fluoroquinolone treatment and older age.

Lifestyle Interventions to Prevent Cardiovascular Events After Stroke and Transient Ischemic Attack.

PURPOSE OF REVIEW: To summarize lifestyle interventions including pharmacological and non-pharmacological methods targeting modifiable risk factors and their impact on the future cardiovascular events in patients who have suffered transient ischemic attack (TIA) and/or ischemic stroke (IS). RECENT FINDINGS: The latest research indicates that secondary prevention measures can decrease the risk of recurrent stroke, cardiovascular events, and even death. Modifiable risk factors also require behavioral change which can be challenging. There is limited data demonstrating the impact of lifestyle interventions, alone or as part of an integrated care pathway, based on cardiovascular events. There is some support for lifestyle interventions such as increased exercise participation that when delivered as part of a comprehensive care package post stroke leads to minor reductions in blood pressure. High-quality, robust trials are required with longer-term follow-up and clear documentation of mortality, morbidity, and cardiovascular risk profile outcomes.

Racial/ethnic disparities in hospital utilization in intracerebral hemorrhage.

BACKGROUND AND PURPOSE: There is evidence that racial and ethnic differences among intracerebral hemorrhage (ICH) patients exist. We sought to establish the occurrence of disparities in hospital utilization in the United States. METHODS: We identified ICH patients from United States Nationwide Inpatient Sample database for years 2006-2014 using codes (DX1 = 431, 432.0) from the International Classification of Diseases, 9th edition. We compared five race/ethnic categories: White, Black, Hispanic, Asian or Pacific Islander, and Others ( Native American and other) with regard to demographics, comorbidities, disease severity, in-hospital complications, in-hospital procedures, length of stay (LOS), total hospital charges, in-hospital mortality, palliative care, (PC) and do not resuscitate (DNR). We categorized procedures as lifesaving (i.e. ventriculostomy, craniotomy, craniectomy, and ventriculoperitoneal (VP) shunt), life sustaining (i.e. mechanical ventilation, tracheostomy, transfusions, and gastrostomy). White race/ethnicity was set as the reference group. RESULTS: Out of 710,293 hospitalized patients with ICH 470,539 (66.2%), 114,821 (16.2%), 66,451 (9.3%), 30,297 (4.3%) and 28,185 (3.9%) were White, Black, Hispanic, Asian or Pacific Islander, and Others, respectively. Minorities (Black, Hispanic, Asian or Pacific Islander, and Others) had a higher rate of in-hospital complications, in-hospital procedures, mean LOS, and hospital charges compared to Whites. In contrast, Whites had a higher rate of in-hospital mortality, PC, and DNR. In multivariable analysis, all minorities had higher rate of MV, tracheostomy, transfusions, and gastrostomy compared to Whites, while Hispanics had higher rate of craniectomy and VP shunt; and Asian or Pacific Islander and Others had higher rate of craniectomy. Whites had a higher rate of in-hospital mortality, palliative care, and DNR compared to minorities. In mediation analysis, in-hospital mortality for whites remained high after adjusting with PC and DNR. CONCLUSION: Minorities had greater utilization of lifesaving and life sustaining procedures, and longer LOS. Whites had greater utilization of palliative care, hospice, and higher in-hospital mortality. These results may reflect differences in culture or access to care and deserve further study.

Is black tar heroin use associated with wound botulism? A report of two Hispanic patients.

Wound botulism is a potentially lethal condition that can cause paralysis. Its association with black tar heroin is a well-established fact. It is essential to alert clinicians in recognizing the patients with history of injection drug abuse presenting with clinical features of botulism early on admission for prompt diagnosis and treatment.

Somatosensory Evoked Potentials as a Tool to Evaluate Brainstem Herniation in the Neuroscience Intensive Care Unit.

Somatosensory evoked potentials (SSEPs) are a sensitive, minimally invasive technique used to localize dysfunction of myelinated peripheral and central axons in the nervous system. The utility of SSEPs in acutely assessing central nervous system function in brainstem herniation in the neuroscience intensive care unit (NICU) has not been well established. We discuss a case of an 18-year-old, postpartum female who presented with intermittent headache, diplopia, nausea/vomiting and cachexia following delivery two months prior. Shortly after arrival to the emergency department, she developed flaccid quadriparesis and complete ophthalmoplegia. Computed tomography (CT) of the head showed effacement of the basal cisterns along with 2 cm cerebellar tonsillar herniation into the foramen magnum concerning for intracranial hypotension. Raising the head of bed caused hemodynamic instability necessitating prolonged Trendelenburg positioning. The patient was evaluated with serial SSEPs which initially showed a bilateral low amplitude N20 response and normal N13 response. Subsequent SSEP testing showed increased N20 amplitude which correlated with clinical improvement in the patient. SSEP is a minimally invasive and sensitive method used to assess the integrity of the somatosensory nervous system pathway; SSEPs may be a useful monitoring adjunct to assess the evolution of posterior fossa lesions leading to brainstem compression.

Current Endovascular Approach to the Management of Acute Ischemic Stroke.

PURPOSE OF REVIEW: The review provides an overview of current endovascular management of patients with acute ischemic stroke in the light of recent landmark trials proving unequivocal benefit of the intervention. RECENT FINDINGS: Several randomized trials looking at selective groups of patients presenting after an acute ischemic stroke due to large vessel occlusion in the anterior circulation demonstrated an overwhelming benefit of the endovascular treatment compared to intravenous thrombolysis, leading to expedited changes in the American Heart Association/American Stroke Association guidelines. Nonetheless, there are a relative large number of patients that were not included in those trials that might still benefit from endovascular treatment (acute posterior circulation-related strokes or acute embolic occlusion of middle cerebral artery beyond the main trunk for instances) and in which further studies are needed. We also briefly discuss endovascular techniques, post-procedure care, and endovascular treatment delivery models to expedite stroke patient assessment and rapid transport using updated and improved workflow protocols to provide timely recanalization. Endovascular treatment of acute occlusion of a proximal large artery in the anterior circulation is currently the standard of care. Time and quality of recanalization are the most important variables that determine the outcome. The indication for endovascular therapy in different scenarios (acute embolic occlusion in the posterior circulation or more distal branch occlusions) has to be individualized according to each patient's particular characteristics until new evidence is provided.

Efficacy and safety of megestrol in the management of hepatocellular carcinoma: a systematic review of the literature.

INTRODUCTION: Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death worldwide. There is as yet no standard therapy for inoperable HCC. We aimed to systematically review all health-related evidence regarding the effectiveness and safety of megestrol in HCC patients. MATERIAL AND METHODS: We conducted a systematic computerised search in PubMed, Scopus, Web of Science, Embase, and Cochrane CENTRAL. All original human studies reporting the efficacy of megestrol in HCC patients were included in our review. RESULTS: Six studies including 357 patients were finally eligible. The overall mean survival time of 87 megestrol-treated patients, was 9.187 (95% CI 1.134-17.239) months. Eight patients had tumour size enlargement, and eight patients had tumour size reduction. From three studies including 76 patients, 42 patients reported having improvement of appetite and food intake after receiving megestrol. Diverse adverse events were noticed between studies; however, they were tolerable in most of the studies. CONCLUSIONS: To summarise, no conclusive evidence should be declared regarding the effectiveness of megestrol in patients with inoperable HCC. However, previous studies have shown promising results at the level of prolonging the survival rate, tumour size reduction, and improving the quality of life. Therefore, we recommend that future research studies must examine the role of megestrol in large-population, randomised studies.

Splenic Infarct and Pulmonary Embolism as a Rare Manifestation of Cytomegalovirus Infection.

Cytomegalovirus (CMV) is a type of herpes infection that has a characteristic feature of maintaining lifelong latency within the host cell. CMV manifestations can cover a broad spectrum from fever to as severe as pancytopenia, hepatitis, retinitis, meningoencephalitis, Guillain-Barre syndrome, pneumonia, and thrombosis. Multiple case reports of thrombosis associated with CMV have been reported. Deep vein thrombosis or pulmonary embolism is more common in immunocompetent patients while splenic infarct is more common in immunocompromised patients. However, here we report a female patient on low-dose methotrexate for rheumatoid arthritis who presented with both pulmonary embolism and splenic infarct.

Euglycemic diabetic ketoacidosis: a diagnostic and therapeutic dilemma.

Euglycemic diabetic ketoacidosis (EDKA) is a clinical triad comprising increased anion gap metabolic acidosis, ketonemia or ketonuria and normal blood glucose levels <200 mg/dL. This condition is a diagnostic challenge as euglycemia masquerades the underlying diabetic ketoacidosis. Thus, a high clinical suspicion is warranted, and other diagnosis ruled out. Here, we present two patients on regular insulin treatment who were admitted with a diagnosis of EDKA. The first patient had insulin pump failure and the second patient had urinary tract infection and nausea, thereby resulting in starvation. Both of them were aggressively treated with intravenous fluids and insulin drip as per the protocol for the blood glucose levels till the anion gap normalized, and the metabolic acidosis reversed. This case series summarizes, in brief, the etiology, pathophysiology and treatment of EDKA. LEARNING POINTS: Euglycemic diabetic ketoacidosis is rare.Consider ketosis in patients with DKA even if their serum glucose levels are normal.High clinical suspicion is required to diagnose EDKA as normal blood sugar levels masquerade the underlying DKA and cause a diagnostic and therapeutic dilemma.Blood pH and blood or urine ketones should be checked in ill patients with diabetes regardless of blood glucose levels.

Review of Infectious Etiology of Acute Pancreatitis.

While gallstones and alcoholism are widely known to be the most common causative agents of acute pancreatitis, about 10% of cases are thought to be caused by infectious microorganisms. These microorganisms include viruses (e.g. mumps, Coxsackie B, and hepatitis), bacteria (e.g. Mycoplasma pneumoniae and leptospirosis), and parasites (e.g. Ascaris lumbricoides, Fasciola hepatica, and hydatid disease). Each organism causes acute pancreatitis through diverse mechanisms. The review is primarily conducted in an attempt to provide a better understanding of the possibility of acute pancreatitis presenting as a complication relating to these organisms, and the aim is to guide future diagnoses, management, and predictions of complications.

Colon Carcinoma Presenting as Streptococcus anginosus Bacteremia and Liver Abscess.

A collection of dead white blood cells within the liver is called a liver abscess, and pyogenic liver abscess (PLA) is the most common type. PLA is commonly associated with biliary tract infections. However, in this case report, we present a rare cause of Streptococcus anginosus bacteremia and PLA which is associated with a carcinoma of the colon at the splenic flexure. The presentation mimicked a cholecystitis clinically, but the radio-imaging revealed a liver abscess. Blood cultures revealed an uncommon etiological agent, S. anginosus group which is otherwise a commensal in the human gut. In this case report, we aimed to summarize the microbiological aspects of S. anginosus group of organisms, the relevant clinicopathological considerations and the management.

Medical Decision Making: Hyposphagma Prior to Intravenous Tissue Plasminogen Activator in Acute Ischemic Stroke.

The decision to administer intravenous tissue plasminogen activator (IV tPA) is based on standard exclusion and inclusion criteria, which include laboratories, imaging, and time of last known well. When patients present with a clinical scenario that is not addressed in these standards, the decision to administer IV tPA is more complex. We present a case of a patient with an acute stroke syndrome that also included acute subconjunctival hemorrhage (i.e., hyposphagma). We provide the medical decision making that occurred prior to the administration. Ultimately, the finding of hyposphagma should not disqualify eligible patients from receiving IV tPA.