Outcomes of COVID-19 Complications and their Possibilities as Potential Triggers of Stroke.

INTRODUCTION: There is limited literature on coronavirus disease 2019 (COVID -19) complications such as thromboembolism, cardiac complications etc. as possible trigger for stroke. Hence, we aim to evaluate the prevalence and outcomes of COVID-19 related cardiovascular complications and secondary infection and their possibility as potential triggers for the stroke. METHODS: Data from observational studies describing the complications [acute cardiac injury (ACI), cardiac arrhythmias (CA), disseminated intravascular coagulation (DIC), septic shock, secondary infection] and outcomes of COVID-19 hospitalized patients from December 1, 2019 to June 30, 2020, were extracted following PRISMA guidelines. Adverse outcomes defined as intensive care units, oxygen saturation less than 90%, invasive mechanical ventilation, severe disease, and in-hospital mortality. The odds ratio and 95% confidence interval were obtained, and forest plots were created using random-effects models. A short review of these complications as triggers of stroke was conducted. RESULTS: 16 studies with 3480 confirmed COVID-19 patients, prevalence of ACI [38%vs5.9%], CA [26%vs5.3%], DIC [4%vs0.74%], septic shock [18%vs0.36%], and infection [30%vs12.5%] was higher among patients with poor outcomes. In meta-analysis, ACI [aOR:9.93(95%CI:3.95-25.00], CA [7.52(3.29-17.18)], DIC [7.36(1.24-43.73)], septic shock [30.12(7.56-120.10)], and infection [10.41(4.47-24.27)] had higher odds of adverse outcomes. Patients hospitalized with acute ischemic stroke and intracerebral hemorrhage, had complications like pulmonary embolism, venous thromboembolism, DIC, etc. and had poor outcomes CONCLUSION: The complications like acute cardiac injury, cardiac arrhythmias, DIC, septic shock, and secondary infection had poor outcomes. Patients with stroke were having history of these complications. Long term monitoring is required in such patients to prevent stroke and mitigate adverse outcomes.

Stroke and HIV-associated neurological complications: A retrospective nationwide study.

There is an increased risk of stroke and other neurological complications in human immunodeficiency virus (HIV) infected patients with no large population-based studies in the literature. We aim to evaluate the prevalence of stroke, HIV-associated neurological complications, and identify risk factors associated with poor outcomes of stroke among HIV admissions in the United States. In the nationwide inpatient sample with adult HIV hospitalizations, patients with primary cerebrovascular disease (CeVDs) and HIV-associated neurological complications were identified by ICD-9-CM codes. We performed a retrospective study with weighted analysis to evaluate the prevalence of stroke and neurological complications and outcomes of stroke among HIV patients. We included 1,559,351 HIV admissions from 2003 to 2014, of which 22470 (1.4%) patients had CeVDs (transient ischemic attack [TIA]: 3240 [0.2%], acute ischemic stroke [AIS]: 14895 [0.93%], and hemorrhagic stroke [HS]: 4334 [0.27%]), 7781 (0.49%) had neurosyphilis, 29,925 (1.87%) meningitis, 39,190 (2.45%) cytomegalovirus encephalitis, 4699 (0.29%) toxoplasmosis, 9964 (0.62%) progressive multifocal leukoencephalopathy, and 142,910 (8.94%) epilepsy. There is increased overall prevalence trend for CeVDs (TIA: 0.17%-0.24%; AIS: 0.62%-1.29%; HS: 0.26%-0.31%; pTrend < .0001) from 2003 to 2014. Among HIV admissions, variables associated with AIS were neurosyphilis (odds ratio: 4.38; 95% confidence interval: 3.21-5.97), meningitis (4.87 [4.10-5.79]), and central nervous system tuberculosis (6.72 [3.85-11.71]). Toxoplasmosis [4.27 [2.34-7.76]), meningitis (2.91 [2.09-4.06)], and cytomegalovirus encephalitis (1.62 [1.11-2.37]) were associated with higher odds of HS compared to patients without HS. There was an increasing trend of CeVDs over time among HIV hospitalizations. HIV-associated neurological complications were associated with the risk of stroke, together with increased mortality, morbidity, disability, and discharge to long-term care facilities. Further research would clarify stroke risk factors in HIV patients to mitigate adverse outcomes.

Chronic Periodontitis is Associated With Cerebral Atherosclerosis -A Nationwide Study.

Introduction Chronic periodontitis and atherosclerosis share common risk factors and produce the same inflammatory markers. Many studies found a high prevalence of chronic periodontitis in patients with atherosclerosis but there is no strong evidence to support a specific association of chronic periodontitis with cerebral atherosclerosis. We aimed to study the concurrent prevalence and association of chronic periodontitis with cerebral atherosclerosis and cerebrovascular diseases among the US population. Methods We performed a cross-sectional analysis of a Nationwide Inpatient Sample with adult hospitalizations to identify the primary diagnosis of cerebrovascular diseases [acute ischemic stroke (AIS), hemorrhagic stroke (HS), and transient ischemic attack (TIA)] with concurrent cerebral atherosclerosis and chronic periodontitis. Multivariate survey logistic regression models were fitted to evaluate the linkage of chronic periodontitis with cerebral atherosclerosis and cerebrovascular diseases. Results Of total 56,499,788 hospitalizations, 0.01% had chronic periodontitis. Prevalence of chronic periodontitis was higher in 50-64 years (36.18% vs. 23.91%), males (59.19% vs. 41.06% in females), Afro-Americans (25.93% vs. 15.21%), and 0-25th percentile median-household-income-category (38.31% vs. 30.15%) compared to non-chronic periodontitis. There was significantly higher prevalence of cerebral atherosclerosis (0.71% vs. 0.41%; p<0.0001) with weak evidence of high prevalence of cerebrovascular diseases (AIS:2.21% vs. 1.97%; p=0.1563; HS:0.57% vs. 0.46%; p=0.1560) among chronic periodontitis compared to non-chronic periodontitis. In regression analysis, odds of having cerebral atherosclerosis were 2.48-folds higher in patients with chronic periodontitis compared to that without-chronic periodontitis, and cerebral atherosclerosis patients were associated with higher odds of TIA (aOR:2.40; p<0.0001), AIS (aOR:3.35; p<0.0001), and HS (aOR:1.51; p<0.0001) compared to without-cerebral atherosclerosis. No significant relationship between chronic periodontitis and cerebrovascular diseases was observed. Conclusion Although chronic periodontitis may not directly increase the risk of cerebrovascular diseases, it increases the burden of cerebrovascular diseases by evidently increasing the risk of cerebral atherosclerosis. Early identification of chronic periodontitis and atherosclerotic risk factors may help to mitigate the risk of cerebrovascular diseases.

Stroke-like migraine attacks after radiation therapy (SMART) syndrome-a case series and review.

INTRODUCTION: Cranial irradiation is used both prophylactically and for the treatment of brain tumors. There are various complications associated with it. The rare complication of stroke-like migraine attacks after radiation therapy (SMART) syndrome usually occurs several years after radiation therapy but is a reversible phenomenon. It usually presents with headaches, seizures, or other focal neurological deficits concerning stroke or recurrence of the underlying disease. OBJECTIVES: We aim to present two cases of SMART syndrome highlighting the typical presentation, imaging findings, and differential diagnosis. We also conducted the literature review since the early recognition of this rare delayed onset complication is crucial, given its self-limited course and to avoid misinterpretations of the cases. CONCLUSION: Our extensive review favors MRI, CT, and prolonged EEG monitoring to rule out other differentials and showed that initiation of corticosteroid therapy and antiepileptic treatment were helpful in the resolution of symptoms and prevent recurrences. Therefore, future studies should be focused on early identification and management guidelines for SMART syndrome.

Stroke-Associated Pneumonia: A Retrospective Study of Risk Factors and Outcomes.

INTRODUCTION: Pneumonia is the most common complication after stroke, but our knowledge on risk factors and predictors of stroke-associated pneumonia (SAP) is limited. We sought to evaluate the predictors and outcomes of SAP among acute ischemic stroke (AIS) hospitalizations. METHODS: This is a cross-sectional study of the Nationwide Inpatient Sample database from the year 2003 to 2014. We identified adult hospitalizations with AIS using International Classification of Diseases, ninth revision, clinical modification (ICD-9-CM) codes. The SAP was identified by the presence of a secondary diagnosis of hospital-acquired pneumonia and ventilator-associated pneumonia. Multivariable survey logistic regression models were utilized to evaluate the predictors of SAP. RESULTS: Overall, 4,224,924 AIS hospitalizations were identified, of which 149,169 (3.53%) had SAP. The prevalence of SAP decreased from 3.72% in 2003 to 3.17% in 2014 (P<0.0001). Mortality [17.12% vs. 4.77%; adjusted odds ratio (aOR): 1.71; P<0.0001] and morbidity (22.53% vs. 3.28%; aOR: 1.86; P<0.0001) were markedly elevated in SAP group compare to non-SAP group. The significant risk factors of pneumonia among AIS hospitalization were nasogastric tube (aOR: 1.21; P=0.0179), noninvasive mechanical ventilation (aOR: 1.65; P<0.0001), invasive mechanical ventilation (aOR: 4.09; P<0.0001), length of stay between 1 to 2 weeks (aOR: 1.99; P<0.0001), >2 weeks (aOR: 3.90; P<0.0001), hemorrhagic conversion (aOR: 1.17; P=0.0002), and epilepsy (aOR: 1.09; P=0.0009). Other concurrent comorbidities which increased the risk of SAP among AIS patients were acquired immune deficiency syndrome (aOR: 1.88; P<0.0001), alcohol abuse (aOR: 1.60; P=0.0006), deficiency anemia (aOR: 1.26; P<0.0001), heart failure (aOR: 1.62; P<0.0001), pulmonary disease (aOR: 1.73; P<0.0001), diabetes (aOR: 1.29; P=0.0288), electrolyte disorders (aOR: 1.50; P<0.0001), paralysis (aOR: 1.22; P<0.0001), pulmonary circulation disorders (aOR: 1.22; P<0.0001), renal failure (aOR: 1.12; P<0.0001), coagulopathy (aOR: 1.13; P=0.0006), and weight loss (aOR: 1.39; P<0.0001). CONCLUSION: Our data underline the considerable epidemiological and prognostic impact of SAP in patients with AIS leading to higher mortality, morbidity, length of stay, and hospital cost despite advancements in care.

Recommended Strategies for Physician Burnout, a Well-Recognized Escalating Global Crisis Among Neurologists.

Several indexes are used to classify physician burnout, with the Maslach Burnout Inventory currently being the most widely accepted. This index measures physician burnout based on emotional exhaustion, detachment from work, and lack of personal achievement. The overall percentage of physicians with burnout is estimated to be around 40%, but the proportion varies between specialties. Neurology currently has the second-highest rate of burnout and is projected to eventually take the top position. The purpose of this review is to provide a comprehensive overview focusing on the causes and ramifications of burnout and possible strategies for addressing the crisis. Several factors contribute to burnout among neurologist, including psychological trauma associated with patient care and a lack of respect compared to other specialties. Various interventions have been proposed for reducing burnout, and this article explores the feasibility of some of them. Burnout not only impacts the physician but also has adverse effects on the overall quality of patient care and places a strain on the health-care system. Burnout has only recently been recognized and accepted as a health crisis globally, and hence most of the proposed action plans have not been validated. More studies are needed to evaluate the long-term effects of such interventions.

Hypertension is a Leading Cause of Nontraumatic Intracerebral Hemorrhage in Young Adults.

OBJECTIVE: To evaluate the etiology and discharge outcome of nontraumatic intracerebral hemorrhage (ICH) in young adults admitted to a comprehensive stroke center. METHODS: A retrospective chart review was performed on patients with a discharge diagnosis of nontraumatic ICH admitted from 7/1/2011 to 6/30/2016. Data was collected on demographics, clinical history, ICH score, hemorrhage location, do-not-resuscitate (DNR) orders, likely etiology, and discharge disposition. Categorical data was reported as percentage. Chi-squared test was performed to evaluate association of location of ICH, etiology of ICH, and ICH score with the discharge outcome. RESULTS: Sixty-three patients met the study criteria, with mean age 35.4 ± 6.4 years including 26 (41%) women and 40 (64%) whites. Headache (65%) and change in mental status (48%) were the most common presenting symptoms. Hemorrhage was most commonly seen in the deep structures in 29 (46%) patients followed by lobar ICH in 14 (22%) patients. The most common etiology of ICH was hypertension in 23 (37%) patients, followed by vascular abnormalities in 18 (29%) patients. Forty-two (67%) had good outcome defined as discharge to home (n = 25) or acute inpatient rehabilitation (n = 17). Twenty-one (33%) patients had bad outcome with discharge to skilled nursing facility (n = 6), hospice (n = 1) or died in the hospital (n = 14). Hospital DNR orders were noted in 11 (18%) patients. Higher ICH score (P < .0001) and use of DNR orders (P < .0001) were associated with bad outcome. All 11 patients with DNR orders died in the hospital. Location or etiology of hemorrhage were not associated with discharge outcome. CONCLUSIONS: Hypertension, a modifiable risk factor, is a major cause of nontraumatic ICH in young adults. Aggressive management of hypertension is essential to halt the recent increased trends of ICH due to hypertension. Early DNR orders may need to be cautiously used in the hospital.

The Lipid Paradox Among Acute Ischemic Stroke Patients-A Retrospective Study of Outcomes and Complications.

BACKGROUND AND OBJECTIVES: The Studies have suggested hypercholesterolemia is a risk factor for cerebrovascular disease. However, few of the studies with a small number of patients had tested the effect of hypercholesterolemia on the outcomes and complications among acute ischemic stroke (AIS) patients. We hypothesized that lipid disorders (LDs), though risk factors for AIS, were associated with better outcomes and fewer post-stroke complications. MATERIALS AND METHOD: We performed a retrospective analysis of the Nationwide Inpatient Sample (years 2003-2014) in adult hospitalizations for AIS to determine the outcomes and complications associated with LDs, using ICD-9-CM codes. In 2014, we also aimed to estimate adjusted odds of AIS in patients with LDs compared to patients without LDs. The multivariable survey logistic regression models, weighted to account for sampling strategy, were fitted to evaluate relationship of LDs with AIS among 2014 hospitalizations, and outcomes and complications amongst AIS patients from2003-2014. RESULTS AND CONCLUSIONS: In 2014, there were 28,212,820 (2.02% AIS and 5.50% LDs) hospitalizations. LDs patients had higher prevalence and odds of having AIS compared with non-LDs. Between 2003-2014, of the total 4,224,924 AIS hospitalizations, 451,645 (10.69%) had LDs. Patients with LDs had lower percentages and odds of mortality, risk of death, major/extreme disability, discharge to nursing facility, and complications including epilepsy, stroke-associated pneumonia, GI-bleeding and hemorrhagic-transformation compared to non-LDs. Although LDs are risk factors for AIS, concurrent LDs in AIS is not only associated with lower mortality and disability but also lower post-stroke complications and higher chance of discharge to home.

Multidisciplinary Approach and Outcomes of Tele-neurology: A Review.

In rural and underserved areas, there are restrictions in healthcare due to the lack of availability of neurologists; patients have to travel long distances to receive the required care. Considering the fact that neurological conditions have large mortality and disability rates, there is a need for innovative services like tele-neurology. It is an important tool in improving the health and quality of life by using different ways of communication between neurologists and patients, or neurologists and other providers. We examine the current types of facilities available in tele-neurology, as well as outcomes, barriers, limitations, legal litigations, and the multidisciplinary nature based on prior studies. We have also suggested recommendations for the future of tele-neurology including effective-accessibility and inexpensive-utilization in developing countries. There are various tele-health programs created by The Veterans Health Administration including a clinical video tele-health (CVT) system. This system allows direct patient care of veterans by neurologists. The University of South Carolina implemented a web-based tele-stroke program in which acute ischemic stroke patients were treated in the Emergency Department (ED) of rural hospitals by neurologists, after consulting with rural ED physicians. With growing technology and popularity of tele-neurology, there are now international collaborative efforts in tele-medicine that are looking to be adapted to tele-neurology. Thus, tele-neurology can provide quality neurological care with patient satisfaction, as well as time and cost savings. The tele-stroke group established by TRUST-tPA trial (Therapeutic Trial Evaluating Efficacy of Telemedicine (TELESTROKE) of Patients With Acute Stroke) has 10 community hospital-emergency rooms that were connected to a stroke center. It was found that tele-stroke is appropriate in places where there is no way for a patient to access a stroke unit within a 4.5-hour time window. Like other tele-neurology subtypes, tele-epilepsy and pediatric tele-neurology also offer more follow-up care to people of remote areas which have limited access. There are other subtypes like mental health, chronic neurological care, and hospitalist which are very effective in improving outcome and quality of life of people living in remote areas. Tele-neurology has effectively reduced travel costs and times; there is high patient satisfaction and reduced disparity for general and specialized neurological care. But there are certain limitations like large equipment costs, certain bandwidth requirement, and trained staff to use the equipment. Transmission of patient information using public internet raises the concern of legality. There should be sufficient encryption to satisfy the Health Insurance Portability and Accountability Act (HIPAA) requirements to ensure patient confidentiality and safety of personal data. The adaptation of tele-neurology is a powerful and innovative way to enhance healthcare in areas with a shortage of specialists. Implementation of this tool is limited due to cost burden, lack of expertise to implement necessary technology, legal litigations, and suitable financial and professional incentives for the users. This review focuses on the trajectory of utilization and the issues to be addressed in order to provide the full benefits of tele-neurology to undeserved communities in the future.

Safety of Transesophageal Echocardiography in Patients with Thrombocytopenia.

BACKGROUND: According to current literature and guidelines, thrombocytopenia is considered a relative contraindication for performing transesophageal echocardiogram (TEE). In cancer patients, thrombocytopenia is frequently present. No prior studies have assessed the safety and complications of TEE in a thrombocytopenic population. METHODS: From January 2002 to December 2017, all patients who underwent TEE at MD Anderson Cancer Center in the nonoperative setting were included in the study. Patient characteristics, laboratory data, indications, and complications of TEE were obtained from medical records. Thrombocytopenia was defined as platelet count <100,000/µL prior to procedure. In this retrospective study, medical records were reviewed up to 30 days after procedure to search for possible complications related to TEE. RESULTS: During the study period, 2,345 TEE studies were performed. The mean age was 58.2 ± 15.3 years and 58.8% of patients were male. Thrombocytopenia was found in 814 patients (34.7%). More thrombocytopenic patients had hematologic malignancy, when compared with patients with normal platelet level (79.7% vs 30.2%; P < .001). The most common indication for TEE study was to evaluate for suspected endocarditis (48.0%) and was found more frequently in thrombocytopenic patients compared with those with normal platelet count (69.5% vs 36.5%; P < .001). Overall, 10 patients (0.4%) had complications related to TEE: eight minor oropharyngeal bleeding that did not require transfusion, one transient atrial fibrillation, and one esophageal perforation. There was no major bleeding, respiratory failure, or death related to TEE examination during the study period. Minor oropharyngeal bleeding was the only complication seen in thrombocytopenic patients (seven patients, 0.3%). CONCLUSIONS: Thrombocytopenia is common in cancer patients undergoing TEE. TEE-related complications are minimal in patients with both normal or low platelet count. With appropriate patient preparation and careful probe manipulation, TEE can be safely performed in thrombocytopenic patients.

Temporal Arteritis Presenting as an Isolated Bilateral Abducens Nerve Palsy: A Rare Case of a 65-year-old Male.

Giant cell arteritis (GCA) or temporal arteritis (TA) is a granulomatous inflammation of medium to large-sized arteries. It may have a diverse presentation. The most common presenting symptoms of GCA are fever, malaise, unilateral headache, jaw claudication, polymyalgia rheumatica (PMR) and ophthalmoplegia. Most severe sequelae of GCA could be blindness. We report a case of a 65-year-old Caucasian male who presented for the third time with recurrent episodes of diplopia. Neurologic exam showed bilateral cranial nerve (CN) VI palsy, slightly worse on the right than the left side. Other focal neurological deficits were absent. GCA was considered and biopsy of the temporal artery was performed which showed necrotizing pan-arteritis, consistent with GCA. The patient was empirically treated with intravenous (IV) methylprednisolone while awaiting the biopsy results which resulted in the resolution of the symptoms. As far as we know, this is the second case in the literature about the bilateral sixth CN involvement in the background of GCA.

Burden of Arrhythmias in Epilepsy Patients: A Nationwide Inpatient Analysis of 1.4 Million Hospitalizations in the United States.

Arrhythmias have been one of the common complications in epilepsy patients and have also been the reason for death. However, limited data exist about the burden and outcomes of arrhythmias by subtypes in epilepsy. Our study aims at evaluating the burden and differences in outcomes of various subtypes of arrhythmias in epilepsy patient population. The Nationwide Inpatient Sample (NIS) database from 2014 was examined for epilepsy and arrhythmias related discharges using appropriate International Classification of Disease, Ninth Revision Clinical Modification (ICD-9-CM) codes. The frequency of arrhythmias, gender differences in arrhythmia by subtypes, in-hospital outcomes and mortality predictors was analyzed. A total of 1,424,320 weighted epilepsy patients was determined and included in this study. Around 23.9% (n =277,230) patients had cardiac arrhythmias. The most frequent arrhythmias in the descending frequency were: atrial fibrillation (AFib) 9.7%, other unspecified causes 7.3%, sudden cardiac arrest (SCA) 1.4%, bundle branch block (BBB) 1.2%, ventricular tachycardia (VT) 1%. Males were more predisposed to cardiac arrhythmias compared to females (OR [odds ratio]: 1.1, p <0.001). The prevalence of most subtypes arrhythmias was higher in males. Arrhythmias were present in nearly a quarter of patients with epilepsy. Life threatening arrhythmias were more common in male patients. The length of stay (LOS) and mortality were significantly higher in epilepsy patients with arrhythmia. It is imperative to develop early diagnosis and prompt therapeutic measures to reduce this burden and poor outcomes due to concomitant arrhythmias in epilepsy patients.