Severe hemiparesis as a prehospital tool to triage stroke severity: a pilot study to assess diagnostic accuracy and treatment times.

INTRODUCTION: With the publication of the recent trials showing the tremendous benefits of mechanical thrombectomy, opportunities exist to refine prehospital processes to identify patients with larger stroke syndromes. MATERIALS AND METHODS: We retrospectively reviewed consecutive patients who were brought via scene flight from rural parts of the region to our institution, from December 1, 2014 to June 5, 2015, with severe hemiparesis or hemiplegia. We assessed the accuracy of the diagnosis of stroke and the number of patients requiring endovascular therapy. Moreover, we reviewed the times along the pathway of patients who were treated with endovascular therapy. RESULTS: 45 patients were brought via helicopter from the field to our institution. 27 (60%) patients were diagnosed with an ischemic stroke. Of these, 12 (26.7%) were treated with mechanical thrombectomy and 6 (13.3%) with intravenous tissue plasminogen activator alone. An additional three patients required embolization procedures for either a dural arteriovenous fistula or cerebral aneurysm. Thus a total of 15 (33%) patients received an endovascular procedure and 21/45 (46.7%) received an acute treatment. For patients treated with thrombectomy, the median time from first medical contact to groin puncture was 101 min, with 8 of the 12 patients (66.7%) being discharged to home. CONCLUSIONS: We have presented a pilot study showing that severe hemiparesis or hemiplegia may be a reasonable prehospital tool in recognizing patients requiring endovascular treatment. Patients being identified earlier may be treated faster and potentially improve outcomes. Further prospective controlled studies are required to assess the impact on outcomes and cost effectiveness using this methodology.

CODE FAST: a quality improvement initiative to reduce door-to-needle times.

BACKGROUND: Rapid delivery of IV tissue plasminogen activator (tPA) in qualifying patients leads to better clinical outcomes. The American Heart Association has reduced target door-to-needle (DTN) times from 60 to 45 min in the hopes of continued process improvements across institutions. OBJECTIVE: To start a quality improvement project called CODE FAST in order to reduce DTN times at our institution. MATERIALS AND METHODS: We retrospectively reviewed data from our internally maintained database of patients treated with intravenous tPA before and after implementation of the CODE FAST protocol. We assessed demographic information, time of day and times of arrival to first image and delivery of tPA in patients from February 2014 to February 2015. Outcomes were assessed based on discharge to home. Univariate analysis was performed to assess for improvement in DTN times before and after implementation of the protocol. RESULTS: A total of 93 patients (41 pre-CODE FAST and 52 post-CODE FAST) received IV tPA during the study period. Patients were equally matched between the two groups except that in the pre-CODE FAST era patients receiving tPA were younger and more likely to be men. There was a substantial reduction in door-to-imaging time from a median of 16 to 8 min (p<0.0001) and DTN time with a reduction in the median from 62 to 25 min (p<0.0001). In logistic regression modeling, there was a trend towards more discharges to home in patients treated during the CODE FAST era. CONCLUSIONS: We present a quality improvement project that has been overwhelmingly successful in reducing DTN time to <30 min. The template we present may be helpful to other institutions looking to reduce their DTN times and may also reduce costs as we note a trend towards more discharges to home.

Increased levels of interleukins 2 and 17 in the cerebrospinal fluid of patients with idiopathic intracranial hypertension.

IIH is a condition of raised intracranial pressure of unknown pathogenesis, which is most commonly seen in young overweight women. This study was designed to confirm and extend previous reports by our and other groups showing increased inflammatory cytokine expression in patients with IIH. We analyzed the concentrations of 14 cytokines (IL-1ß, IL-2, IL-4, IL-6, IL-8, IL-10, IL-12p70, IL-17, IL-22, IL-23, IFNγ, TNFα, TGFß, and osteopontin) in the serum and cerebrospinal fluid (CSF) of 17 patients with IIH and 53 patients with other neurological conditions. Patients with IIH had highly elevated IL-2, IL-4, IL-10, IL-17 and IFNγ in the CSF compared to patients with multiple sclerosis or non-organic/non-inflammatory neurological conditions. No significant differences were seen between serum cytokine levels in four patient groups (IIH - multiple sclerosis - inflammatory neurological conditions - non-organic/non-inflammatory neurological conditions) and there were no correlations between serum and CSF cytokine levels. In IIH, levels of IL-2, IL-8 and IL-17 were significantly higher in CSF than serum; levels of IL-1ß, IL-4, IL-22, IFNγ and TNFα were significantly higher in serum than CSF. For most cytokines, the CSF/serum cytokine ratio was significantly higher than the CSF/serum albumin ratio, indicating intrathecal synthesis of these cytokines in IIH. We conclude that IIH is associated with elevated levels of IL-17 and IL-2 in the CSF, suggesting the involvement of these cytokines in disease pathogenesis.

Yips and other movement disorders in golfers.

Golf is a sport that requires perfect motor coordination and a balance between mobility and stability. Golfer's "yips," an intermittent motor disturbance manifested as transient tremor, jerk, or spasm that primarily occurs when the player is trying to chip or make a putt, is a movement disorder frequently encountered in both amateur and professional golfers. In addition, other movement disorders, such as tremors and dystonia, also can interfere with playing golf. Although the pathophysiology of the yips remains poorly understood, recent studies suggest that it may be a form of a task-specific, focal dystonia involving the hand and arm. Because task-specific dystonias and tremors are best treated by botulinum toxin injections, this also may be an effective therapy for the yips. The aim of this article is to systematically review the literature and our own experience with the yips and other movement disorders in golfers.

Cytokines and chemokines in idiopathic intracranial hypertension.

BACKGROUND: The pathogenesis of idiopathic intracranial hypertension (IIH) remains unclear and as such it remains a diagnosis of exclusion. OBJECTIVES: To identify cerebrospinal fluid (CSF) and serum cytokine and chemokine profiles associated with IIH. METHOD: Semiquantitative assessment with cytokine antibody arrays was used to detect the relative expression of 42 different cytokines and chemokines in the CSF and serum of 8 IIH patients and 8 controls. Subsequently, quantitative assay with enzyme linked immunosorbent assay was performed for chemokine CCL2, interleukin-1 alpha (IL-1alpha), and leptin. RESULTS: Cytokine antibody array showed elevated levels of CCL2 in the CSF and CCL7, CCL8, IL-1alpha, and leptin levels in serum in IIH patients compared with controls. Subsequent quantitative assessment with enzyme linked immunosorbent assay showed significantly elevated CSF CCL2 in IIH patients compared with controls (P < .01) but there was no significant difference in leptin and IL-1alpha levels between the groups. CONCLUSION: This is the first report demonstrating differences in cytokine expression in the serum and CSF in IIH patients compared with controls. Since the pathogenesis of IIH is unclear, the heterogeneity of the cytokine expression reported here may help understand the pathogenesis of this condition.