Bilateral Stroke: A Case Report.

We present the case of a 74-year-old woman, functionally independent in her daily activities, with a medical history notable for hypertension and dyslipidemia. She presented to the emergency room with an altered level of consciousness, opening her eyes only to pain, no verbal response, and flexion withdrawal from pain coupled with a Glasgow Coma Scale of 7. The intensive care unit was promptly summoned, and the patient was intubated and admitted to intensive care. Comprehensive laboratory assessments revealed no abnormalities and an initial cerebral CT scan showed no acute changes. A subsequent CT scan performed 24 hours post-event disclosed bilateral ischemia affecting the territories of the anterior and middle cerebral arteries. Regrettably, this catastrophic event precluded any potential for recovery. Consequently, the decision was made not to pursue further investigations to determine the underlying cause. The medical team opted for supportive treatment and comfort measures. Tragically, the patient died on the 37th day of hospital admission.

Etiology and clinical characteristics of pediatric non-neoplastic posterior reversible encephalopathy: systematic review.

Although more commonly seen in adult population, posterior reversible encephalopathy syndrome (PRES) can also be observed in pediatric patients. The etiopathogenesis of pediatric PRES is poorly understood, and the available evidence comes mostly from childhood cancer. Analysis of the sociodemographic and clinical characteristics of the different noncancer-related types can improve the understanding of pediatric PRES. Methods: Systematic review of characteristics and outcome of noncancer pediatric PRES. Primary sources of investigation were identified and selected through Pubmed and Scopus databases. The research was complemented by reference search in relevant publications. Study protocol was registered (Prospero CRD42020165798). Results: We identified 449 cases of noncancer pediatric PRES from 272 studies, median age 10 (newborn to 17 years), 49.9% girls. The 4 most common groups of conditions were renal 165 (36.7%), hematologic 84 (18.7%), autoimmune 64 (14.3%), and cardiovascular 28 (6.2%) disorders. The 4 most prevalent precipitants identified were hypertensive crisis 119 (26.5%), corticosteroids 56 (12.5%), immunosuppression drugs 44 (9.8%), and biologic drugs 14 (3.1%). Clinical presentations included seizures 100 (22.3%), headaches 22 (4.9%), encephalopathy 17 (3.8%), visual disturbances 6 (1.3%), and focal deficit 3 (0.7%). The distribution of lesions was (n = 380): combined anterior/posterior circulation (40.8%), isolated posterior circulation (24.1%), anterior circulation (6.2%), and deep structures (1.6%). Residual neurological deficits occurred in about 1 out 10 cases. Conclusion: Pediatric PRES differs from the adult in etiology, precipitants, and clinical manifestations. Renal diseases predominate, acute raised blood pressure is less frequent, and cortical deficits are rarer. In addition, the proportion of patients with combined anterior/posterior circulation was higher. Permanent neurological sequels can occur.

A Case Report of an Emergency Hypertensive Episode During Trastuzumab Therapy.

Human epidermal growth factor receptor 2 (HER2+) targeted therapies, such as trastuzumab emtansine, has been shown to have a significant positive effect on the outcome of breast cancer. Rarely, this therapy can cause adverse cardiovascular effects such as cardiac dysfunction, arrhythmias and hypertension. We report a case of a 60-year-old woman who presented to the emergency department with an episode of hypertensive emergency. She had been recently diagnosed with hypertension which was found to be poorly controlled. The recent administration of trastuzumab together with this hypertensive episode led us to suspect trastuzumab as the cause for this rise in her blood pressure. With this case we intend to raise awareness of hypertension, a potentially preventable condition, as an adverse effect of human epidermal growth factor receptor 2 targeted therapies such as trastuzumab. Additionally we propose an appropriate and careful management of arterial hypertension among those receiving this first-in-class drug.

Tongue Hematoma With Necrosis.

Spontaneous tongue hematoma is a known rare adverse side effect associated with warfarin therapy. There is a long list of drug-to-drug interactions with warfarin that may contribute to a rise in international normalized ratio (INR) levels, increasing the risk of bleeding. We present a case of an elderly female patient who presented with oral dysphagia and spontaneous oral cavity bleeding while on warfarin therapy. She was found to have tongue hematoma and necrosis. A week prior she started treatment with topical miconazole for oral candidiasis and a few days later topical clarithromycin was added. Treatment given was mainly supportive with intravenous vitamin K, fresh frozen plasma, and aminocaproic acid. Full recovery was achieved. It is our intention to raise awareness of a rare adverse side effect related to warfarin therapy that may have been precipitated with the use of medications known to contribute to INR elevation. As learning points, we emphasize close monitoring of INR levels when using known drug-to-drug interactions with warfarin and also consider replacing warfarin for a direct oral anticoagulant if no contraindication is present.

Poor intensive stroke care is associated with short-term death after spontaneous intracerebral hemorrhage.

OBJECTIVES: The case fatality from spontaneous ICH (SICH) remains high. The quality and intensity of early treatment is one of the determinants of the outcome. We aimed to study the association of early intensive care, using the Intracerebral Hemorrhage-Specific Intensity of Care Quality Metrics (IHSICQM) with the 30-day in-hospital mortality in Algarve, Portugal. PATIENTS AND METHODS: analysis of prospective collected data of 157 consecutive SICH patients (2014-2016). Logistic regression was performed to assess the role of IHSICQM on the 30-day in-hospital mortality controlling for the most common clinical and radiological predictors of death. Receiver operating characteristic (ROC) curve was developed to evaluate the prediction accuracy of the IHSICQM score (C-statistics). RESULTS: forty-five (29 %) patients died. The group of deceased patients had lower intensity of care (lower IHSICQM score) and higher proportion of poor prognosis associated factors (pre-ICH functional dependency, intraventricular dissection/glycaemia). On the multivariate analysis, higher IHSICQM was associated with reduction of the odds of death, 0.27 (0.14-0.50) per each increasing point. The ROC curve showed a high discriminating ability of isolated IHSICQM in predicting the 30-day mortality (AUC = 0,95; 95 % CI = [0,86; 0,95]). CONCLUSION: the early intensity of quality of care independently predicts the 30-day in-hospital mortality. Quantification of the intensity of SICH is a valid tool to persuade improvement of SICH care, as well to help comparison of performances within and between hospitals.

Fine particulate air pollution and occurrence of spontaneous intracerebral hemorrhage in an area of low air pollution.

OBJECTIVES: The association between short-term ambient particulate matter ≤ 2.5 µm diameter (PM2.5) and spontaneous intracerebral hemorrhage (SICH) occurrence is unclear. We aimed to study the association of ambient PM2.5 with occurrence of SICH in an area of low air pollution in southern Portugal. PATIENTS AND METHODS: PM2.5 levels from the 3 days before the SICH event (Lag 1, 2, 3) was compared with one control period (Lag 15-17) using a case-crossover analysis. Conditional logistic regression was used to estimate the odds ratio (OR) with 95% confidence interval (CI). Analysis was stratified by gender, age, functional neurological status, type of SICH, environmental factors (temperature, humidity, time of day and season). RESULTS: Three-hundred and eight patients were included (2010-2015); mean age 70.8 years, 62.8% were males. The mean values (µg/l) of PM2.5 were higher on the case days (Lag1 = 7.76, Lag2 = 7.64, Lag3 = 7.74) compared to control period (Lag14-17 = 6.77). For each 10 µg/l increase, the likelihood of SICH increased 5.7% (95% CI = 1.020-1.095. P = .002). The strength of the association was higher in patients younger than 70 years (OR = 1.064, 95% CI = 1.009-1.122); without prior to SICH neurological disability (OR = 1.061, 95% CI 1.022-1.101); with non-lobar type (OR = 1.054, 95% CI = 1.012-1.099). A circadian and circannual pattern was present with increased strength of the association when SICH occurred in the morning time (OR = 1,067, 95% CI = 1.012-1.125), in the fall (OR = 1.118, 95% CI = 1.031-1.213) and the in the winter (OR = 1.064, 95% CI = 1.002-1.129). The association was also potentiated at lower temperature values. CONCLUSION: Short-term increases of PM2.5 are associated with occurrence of SICH in Algarve, a region of low ambient pollution. Patient and ambient level factors can influence the strength of this association.

Frequent Emergency Department Visits After Spontaneous Intracerebral Hemorrhage: Who Is at Risk?

BACKGROUND: The long-term prognosis of spontaneous intracerebral hemorrhage (SICH) is poor. Frequent emergency department (ED) visits can signal increased risk of hospitalization and death. There are no studies describing the risk of frequent ED visits after SICH. METHODS: Retrospective cohort study of a community representative consecutive SICH survivors (2009-2015) from southern Portugal. Logistic regression analysis was performed to identify sociodemographic and clinical factors associated with frequent ED visits (≥4 visits) within the first year after hospital discharge. RESULTS: A total of 360 SICH survivors were identified, 358 (98.6%) of whom were followed. The median age was 72; 64% were males. The majority of survivors (n = 194, 54.2%) had at least 1 ED visit. Reasons for ED visits included infections, falls with trauma, and isolated neurological symptoms. Forty-four (12.3%) SICH survivors became frequent ED visitors. Frequent ED visitors were older and had more hospitalizations (P < .001) and ED visits (P < .001) prior to the SICH, unhealthy alcohol use (P = .049), longer period of index SICH hospitalization (P = .032), pneumonia during hospitalization (P = .001), and severe neurological impairment at discharge (P = .001). Pneumonia during index hospitalization (odds ratio [OR]: 3.08; confidence interval [CI]: 1.39-6.76; P = .005) and history of ED visits prior to SICH (OR: 1.64; CI: 1.19-2.26, P = .003) increased the likelihood of becoming a frequent ED visitor. CONCLUSIONS: Predictors of frequent ED visits are identifiable at hospital discharge and during any ED visit. Improvement of transitional care and identification of at-risk patients may help reduce multiple ED visits.

Complications Associated With Nasogastric Tube Placement in the Acute Phase of Stroke: A Systematic Review.

This systematic review explores the frequency of complications associated with nasogastric tube (NGT) placement in patients with acute stroke. The unique condition of the dysphasic, immobile, confused immunosuppressed patient who has had an acute stroke hampers any consistent inference from other neurological or nonneurological condition in which NGT placement is used. Twelve studies including 921 patients fed by NGT in the acute phase (first 4 weeks) were included in the analysis. The overall quality of the included studies was good. The main limitation was the heterogeneity and small size of most studies. The occurrence of NGT placement failure and malposition, hypoxemia, and regurgitation was addressed in the selected studies. Recurrent NGT dislodgement and a combination of tube dislodgement and blockage of the tube were the main reasons for NGT placement failure. In the absence of chronic hypoxemic pulmonary or cardiac disorders, NGT feeding was not associated with clinically significant hypoxemia in patients who have had an acute stroke. Data are scarce on the topic. Research about the frequency of local and systemic NGT complications and strategies for prevention will certainly contribute to enhance evidence-based management of dysphagia in acute stroke.

Hospital readmissions after spontaneous intracerebral hemorrhage in Southern Portugal.

OBJECTIVES: Spontaneous intracerebral hemorrhage (SICH) survivors are at risk of hospital readmissions. Data on readmissions after SICH is scarce. We aimed to study the frequency and predictors of readmissions after SICH in Algarve, Portugal. PATIENTS AND METHODS: Retrospective study of a community representative cohort of SICH survivors (2009-2015). The first unplanned readmission in the first year after discharge was the outcome. Cox regression analysis was performed to identify predictors of 1-year readmission. RESULTS: Of the 357 SICH survivors followed, 116 (32.5%) were readmitted within the first-year. Sixty-seven (18.8%) of the survivors were early readmitted (<90 days), corresponding to 57.8% or all readmissions. Common causes were pneumonia, endocrine/nutritional/metabolic and cardiovascular complications. The risk of readmission was increased by prior to index SICH history of ≥ 3 previous emergency department visits (hazards ratio (HR) = 2.663 (1.770-4.007); P < 0.001), pneumonia during index hospitalization (HR = 2.910 (1.844-4.592); P < 0.001) and reduced in patients discharge home (HR = 0.681 (0.366-0.976); P = 0.048). CONCLUSIONS: The rate of readmissions after SICH is high, predictors are identifiable and causes are potentially preventable. Improvement of care can potentially reduce this burden.

Short-Term Outcome of Spontaneous Intracerebral Hemorrhage in Algarve, Portugal: Retrospective Hospital-Based Study.

BACKGROUND: The short-term outcome from spontaneous intracerebral hemorrhage (SICH) is influenced by local quality of care and population specificities. There are no studies about the SICH mortality in southern Portugal. The objective of this study was to describe the predictors of 30-day in-hospital SICH mortality in Algarve, the southernmost region of Portugal. METHODS: Logistic regression was used to identify predictors of in-hospital death. Kaplan-Meier analysis was used to estimate survival over time based on SICH severity. RESULTS: Of the 549 cases, 349 (63.6%) were men; the mean age was 71.4 years. Two hundred seventeen patients (39.5%) did not receive stroke unit (SU) care. The 30-day mortality was 34.4%. Independent predictors of death were older age (odds ratio [OR] = 1.096, 95% confidence interval [CI] = 1.031-2.062, P = .022) per additional year, vitamin K antagonists use (OR = 5.464, 95% CI = 2.088-25.714, P = .043), admission Glasgow Coma Scale (GCS) score of 8 or lower (OR = 20.511, 95% CI = 7.862-62.168, P < .0001) or GCS score of 9-12 (OR = 12.709, 95% CI = 3.078-44.113, P < .0001), hematoma volume (OR = 1.037, 95% CI = 1.004-1.071, P = .028) per additional milliliter, intraventricular dissection (OR = 1.916, 95% CI = 1.105-4.566, P = .046), and pneumonia (OR 12.918, 95% CI = 4.603-24.683, P < .0001). SU care was independently associated with reduction of death (OR .395, 95% CI = .126-.635, P = .004). Severity correlated with short time to death (P < .0001). Sixty-five of the patients (39.2%) died after the seventh day of SICH ("non-neurological deaths"). CONCLUSIONS: The in-hospital 30-day mortality is high in the region. Admitting more patients to the SU and implementation of preventive strategies of complications can reduce mortality.

Intracerebral hemorrhage as a manifestation of cerebral hyperperfusion syndrome after carotid revascularization: systematic review and meta-analysis.

BACKGROUND: Intracerebral hemorrhage (ICH) in the context of cerebral hyperperfusion syndrome (CHS) is an uncommon but potentially lethal complication after carotid revascularization for carotid occlusive disease. Information about its incidence, risk factors and fatality is scarce. Therefore, we aimed to perform a systematic review and meta-analysis focusing on the incidence, risk factors and outcomes of ICH in the context of CHS after carotid revascularization. METHODS: We searched the PubMed and EBSCO hosts for all studies published in English about CHS in the context of carotid revascularization. Two reviewers independently assessed each study for eligibility based on predefined criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the PROSPERO register was made (register no. CRD42016033190), including the pre-specified protocol. RESULTS: Forty-one studies involving 28,956 participants were deemed eligible and included in our analysis. The overall quality of the included studies was fair. The pooled frequency of ICH in the context of CHS was 38% (95% CI: 26% to 51%, I2 = 84%, 24 studies), and the pooled case fatality of ICH after CHS was 51% (95% CI: 32% to 71%, I2 = 77%, 17 studies). When comparing carotid angioplasty with stenting (CAS) with carotid endarterectomy (CEA), post-procedural ICH in the context of CHS was less frequent in CEA. ICH following CHS occurred less often in large series and was rare in asymptomatic patients. The most common risk factors were periprocedural hypertension and ipsilateral severe stenosis. CONCLUSIONS: ICH as a manifestation of CHS is rare, more frequent after CAS and associated with poor prognosis. Periprocedural control of hypertension can reduce its occurrence.

Incidence and case-fatality from spontaneous intracerebral hemorrhage in a southern region of Portugal.

BACKGROUND: There is scarce information on incidence and case fatality of spontaneous intracerebral hemorrhage (SICH) in certain regions of the world, including in Europe. There is no community-based data on SICH in Southern Portugal. AIM: To determine the incidence and early case-fatality from SICH in Algarve, the southernmost region of Portugal. METHODS: The recommended criteria for stroke incidence studies was used to identify cases of incident first-ever SICH from January 1st to December 31st 2015 in a subregion with 280,081 inhabitants. Crude incidence rates per age group and gender; standardized rates to the European population; and age adjusted case fatality rates were calculated. RESULTS: Eighty-two first-ever cases of SICH (64.6% men) occurred. The mean age was 72.3 years (SD±12.1); women were 3 years older than men on average and had more frequently lobar SICH. The crude annual incidence rate was 29.2/100,000 (95% CI 23.4- 38.6; p<0.001); higher in men (39.7/100,000) than women (19.8/100,000). The standardized to the European population incidence was 15.1/100,000 (95% CI 3.6-18.9; p<0.05); 26.9 and 10.9/100,000 for men and women respectively. The 30-day case-fatality was 40 % (95% CI 29-51) and increased steeply with age CONCLUSION: The incidence of SICH in Southern Portugal was high, but within the figures found in some parts of Europe. However, a marked predominance of males was found and the case-fatality rate was amongst the highest reported in western countries.