Successful Thrombectomy of the Posterior Cerebral Artery P2 Segment in a 61-Year-Old Man with Acute Ischaemic Stroke: A Case Report.

BACKGROUND Acute ischemic stroke in the posterior cerebral artery (PCA) territory can lead to persistent disabling deficits. The PCA is divided into 4 segments. The P2 segment begins at the posterior communicating artery and curves around the midbrain and above the tentorium cerebelli. This report is of a 61-year-old man with acute ischemic stroke involving the left hippocampus treated with direct thrombectomy of the P2 segment of the PCA. CASE REPORT A 61-year-old white man presented with transient amnesia, aphasia, right-sided hemianopia, dizziness, and persistent acute memory deficits. Magnetic resonance imaging (MRI) showed a left hippocampal acute ischemic stroke with left PCA occlusion in the P2 segment. Despite a low National Institutes of Health Stroke Scale (NIHSS) score and the already-formed lesion in the hippocampus, successful stent retriever thrombectomy was performed due to a considerable perfusion-diffusion mismatch and a persistent potentially disabling neurocognitive deficit. Due to partial thrombus dislocation, occlusion of the common origin of the right posterior inferior cerebellar artery (PICA) and anterior inferior cerebellar artery (AICA) occurred and was immediately treated by thrombectomy to prevent severe cerebellar infarction. His clinical symptoms completely resolved and a neuropsychological exam showed no residual deficits. CONCLUSIONS Thrombectomy of the P2 segment of the PCA is feasible and can be considered to treat patients with acute occlusion at risk for persistent disabling deficits, based on clinical estimation of the impact of such deficits and the presence of potentially salvageable brain tissue. Potential procedural complications should be sought out and immediately treated, if technically feasible.

Relevance of National Institutes of Health Stroke Scale subitems for best revascularization therapy in minor stroke patients with large vessel occlusion: An observational multicentric study.

BACKGROUND AND PURPOSE: The best management of acute ischemic stroke patients with a minor stroke and large vessel occlusion is still uncertain. Specific clinical and radiological data may help to select patients who would benefit from endovascular therapy (EVT). We aimed to evaluate the relevance of National Institutes of Health Stroke Scale (NIHSS) subitems for predicting the potential benefit of providing EVT after intravenous thrombolysis (IVT; "bridging treatment") versus IVT alone. METHODS: We extracted demographic, clinical, risk factor, radiological, revascularization and outcome data of consecutive patients with M1 or proximal M2 middle cerebral artery occlusion and admission NIHSS scores of 0-5 points, treated with IVT ± EVT between May 2005 and March 2021, from nine prospectively constructed stroke registries at seven French and two Swiss comprehensive stroke centers. Adjusted interaction analyses were performed between admission NIHSS subitems and revascularization modality for two primary outcomes at 3 months: non-excellent functional outcome (modified Rankin Scale score 2-6) and difference in NIHSS score between 3 months and admission. RESULTS: Of the 533 patients included (median age 68.2 years, 46% women, median admission NIHSS score 3), 136 (25.5%) initially received bridging therapy and 397 (74.5%) received IVT alone. Adjusted interaction analysis revealed that only facial palsy on admission was more frequently associated with excellent outcome in patients treated by IVT alone versus bridging therapy (odds ratio 0.47, 95% confidence interval 0.24-0.91; p = 0.013). Regarding NIHSS difference at 3 months, no single NIHSS subitem interacted with type of revascularization. CONCLUSIONS: This retrospective multicenter analysis found that NIHSS subitems at admission had little value in predicting patients who might benefit from bridging therapy as opposed to IVT alone. Further research is needed to identify better markers for selecting EVT responders with minor strokes.

From damage control surgery to complex abdominal wall reconstruction It is possible even in the elderly in a Spoke Center?

AIM: To describe our Spoke Center experience in Damage Control Surgery (DCS) in a non traumatic patient and the possibility of delayed abdominal wall reconstruction (AWR). Material of Study The case of a 73 years old Caucasian male treated with DCS for a septic shock due to a duodenal perforation and his clinical course till the abdominal wall reconstruction. RESULTS: We made DCS with abbreviated laparotomy, suture of the ulcer and duodenostomy with a foley placed in right hypochondrium. Patiens was discharged with a low-flow fistula and with TPN. After 18 months we made an open cholecystectomy and a complete abdominal wall reconstruction with Fasciotens Hernia System® adding a biological mesh. DISCUSSION AND COMMENTS: Periodic training in emergency settings and in complex abdominal wall procedures is the right way to manage critic clinical case. Like Niebuhr's abbreviated laparotomy experience also in our case this procedure allows primary closure of complex hernias and is potentially less prone to complications than component separation methods. Unlike Fung's experience we didn' t use negative pressure wound therapy system (NPWT) equally achieving good results. CONCLUSIONS: Elective repair of abdominal wall disaster is possible even in elderly patients who have been treated by abbreviated laparotomy and DCS surgery. In order to obtain good results is fundamental to have a trained staff. KEY WORDS: Damage Control Surgery (DCS), Giant incisional Hernia, Abdominal Wall Repair.

Effect of the mode of delivery on the risk of endometriosis recurrence: a retrospective cohort study.

OBJECTIVE: To evaluate the risk of endometriosis recurrence according to the mode of delivery (cesarean section vs. vaginal birth) in patients who had become pregnant with a live birth after surgery for endometriosis. DESIGN: A retrospective cohort study. A Cox proportional-hazards regression was performed to evaluate the risk factors for endometriosis recurrence at 36 months of follow-up after the last pregnancy. SETTING: Academic hospital. PATIENT(S): Patients who have had ≥1 pregnancy with a live birth following conservative surgery for ovarian endometriosis performed from January 2009 to December 2016 at our institution. INTERVENTION(S): Patients who underwent ≥1 cesarean section after surgery for endometriosis. MAIN OUTCOME MEASURES: The recurrence rate of endometriosis after live-birth pregnancies obtained after the first surgery for endometriosis. RESULTS: Patients with a history of ≥1 cesarean section after surgery for endometriosis have a higher risk of endometriosis recurrence than the patients who have had a vaginal birth, with an adjusted hazard ratio of 2.25 (95% confidence interval, 1.27-3.96). CONCLUSION: A cesarean section after surgery for endometriosis is associated with a twofold high risk of endometriosis recurrence with respect to vaginal birth. A different follow-up approach may be needed in those patients, and avoiding inappropriate indications for cesarean sections in pregnant patients with a history of surgery for endometriosis is necessary.

Emergency Surgery in a "No-Covid-19 Spoke Center" during the pandemic. One year of experience and a new organizational model.

AIM: We analysed our one-year surgical activity in a spoke 'COVID-19 free' centre during the pandemic in South Italy. MATERIAL OF STUDY: From Feb 2020 to Feb 2021 we performed 800 operations (40% in emergency and 60% of major surgery). We applied restrictive measures for the access of patients in our department from 15/2/2020 after several cases of unclear fever. Visitors were not allowed to stay in the ward. RESULTS: In the first period of lockdown, from March to June 2020, in our Region, biomolecular test was indicated only for symptomatic people. We organized the hospitalization with a sealed compartment system (that we defined "boing system") in which the patient stationed in an 'isolation room' for at least 48 hours upon the entry. From July 2020 molecular test were made to all patients before hospitalization. The boing system remains for emergency recovery. DISCUSSION: In the first phase of pandemia we chose to subject patients to serological examination based on the IgM assay to consider them negative. We organized the hospitalization with a sealed compartment system (that we defined "boing system") CONCLUSION: In the first phase of the pandemic the serological examination has shown high specificity in identifying positive patients for COVID 19. In that period we supposed that patients with negative serology could be considered non-contagious Neither patients or staff has been resulted positive to SarS CoV2 test. KEY WORDS: Covid 19, Emercency Surgery, Spoke Center, Pandemia, Serological Tests.

Carotid Artery Plaque Progression: Proposal of a New Predictive Score and Role of Carotid Intima-Media Thickness.

BACKGROUND: We aimed to investigate if the carotid intima-media thickness (IMT) at baseline and the HAD2S score, composed of the sum of single risk factors (hypertension, age ≥ 75 years, diabetes, dyslipidemia, smoking), were predictive of plaque progression. METHODS: We performed a retrospective analysis on real-life prospectively collected data from patients with any detectable carotid plaque at follow up. The plaque score, calculated at baseline (T0) and at a median follow up of 36.6 months (IQR 39.6-34.3) (T3), was defined as 0: no plaque or stenosis < 30%; 1: stenosis in the range 30-49%; 2: in the range 50-69%; 3: in the range 70-99% and 4: occlusion. Carotid IMT was measured at T0 and T3; HAD2S score was calculated at baseline. RESULTS: We included 340 patients with a mean age of 69.9 (9.1) years and 25.3% subjects had plaque progression. Individuals with progression had a median HAD2S score of 3 (1) while those without progression had 2 (1). Patients with progression had a mean baseline IMT of 0.86 (0.17) while those without progression had 0.77 (0.18) (p < 0.0001). A correlation between progression and baseline IMT was found (p = 0.002). CONCLUSION: Baseline IMT could be considered a predictor of progression. Patients with progression had an HAD2S score higher than those without evolution.

Predictors of Early Stroke or Death in Patients Undergoing Transcatheter Aortic Valve Implantation.

BACKGROUND/OBJECTIVE: While postoperative stroke is a known complication of Transcatheter Aortic Valve Implantation (TAVI), predictors of early stroke occurrence have not been specifically reviewed. The objective of this study was to estimate the predictors and incidence of stroke during the first 30 days post-TAVI. METHODS: A cohort of 506 consecutive patients having undergone TAVI between January 2017 and June 2019 was extracted from a prospective database. Preoperative, intraoperative and postoperative characteristics were analyzed by univariate analysis followed by logistic regression to find predictors of the occurrence of stroke or death within the first 30 days after the procedure. RESULTS: Incidence of stroke within 30 days post-TAVI was 4.9%, [CI 95% 3.3-7.2], i.e., 25 strokes. Four out of the 25 patients (16%) with a stroke died within 30 days post-TAVI. After logistic regression analysis, the predictors of early stroke related to TAVI were: CHA2Ds2VASc score ≥ 5 (odds ratio [OR] 2.62; 95% CI: 1.06-6.49; p = .037), supra-aortic access vs. femoral access (OR: 9.00, 95%CI: 2.95-27.44; p = .001) and introduction post-TAVI of a single vs. two or three antithrombotic agents (OR: 5.13; CI 95%: 1.99 to 13.19; p = .001). Over the 30-day period, bleeding occurred in 28 patients (5.5%), in 25 of whom, it was associated with femoral or iliac artery access injury. Anti-thrombotic regimen was not associated with bleeding; two patients out of 48 (4.1%) bled with a single anti-thrombotic regimen vs. 26 patients out of 458 (5.6%) with a dual or triple anti-thrombotic regimen (p = 0.94). The overall 30-day mortality rate was 3.9%, [95% CI 2.5-6.0]. Patients with a single post-TAVI antithrombotic agent (OR: 44.07 [CI 95% 13.45-144.39]; p < .0001) and patients with previous coronary artery bypass surgery or coronary artery stenting (OR: 6.16, [CI 95% 1.99-21.29]; p = .002) were at significantly higher risk of death within the 30-day period. CONCLUSION: In this large-scale single-center retrospective study, a single post-TAVI antithrombotic regimen independently predicted occurrence of early stroke or death. Dual or triple antithrombotic regimen was not associated with a higher risk of bleeding and should be considered as an option in patients undergoing TAVI.

Chlorhexidine plus alcohol versus povidone iodine plus alcohol, combined or not with innovative devices, for prevention of short-term peripheral venous catheter infection and failure (CLEAN 3 study): an investigator-initiated, open-label, single centre, randomised-controlled, two-by-two factorial trial.

BACKGROUND: Two billion peripheral venous catheters are sold globally each year, but the optimal skin disinfection and types of devices are not well established. We aimed to show the superiority of disinfection with 2% chlorhexidine plus alcohol over 5% povidone iodine plus alcohol in preventing infectious complications, and of closed integrated catheters, positive displacement needleless-connectors, disinfecting caps, and single-use prefilled flush syringes used in combination (innovation group) over open catheters and three-way stopcocks for treatment administration (standard group) in preventing catheter failure. METHODS: We did an open-label, randomised-controlled trial with a two-by-two factorial design, for which we enrolled adults (age ≥18 years) visiting the emergency department at the Poitiers University Hospital, France, and requiring one peripheral venous catheter before admission to the medical wards. Before catheter insertion, patients were randomly assigned (1:1:1:1) using a secure web-based random-number generator to one of four treatment groups based on skin preparation and type of devices (innovative devices or standard devices; 2% chlorhexidine plus alcohol or 5% povidone iodine plus alcohol). Primary outcomes were the incidence of infectious complications (local infection, catheter colonisation, or bloodstream infections) and time between catheter insertion and catheter failure (occlusion, dislodgment, infiltration, phlebitis, or infection). This study is registered with ClinicalTrials.gov, NCT03757143. FINDINGS: 1000 patients were recruited between Jan 7, and Sept 6, 2019, of whom 500 were assigned to the chlorhexidine plus alcohol group and 500 to the povidone iodine plus alcohol group (250 with innovative solutions and 250 with standard devices in each antiseptic group). No significant interaction was found between the two study interventions. Local infections occurred less frequently with chlorhexidine plus alcohol than with povidone iodine plus alcohol (0 [0%] of 496 patients vs six [1%] of 493 patients) and the same was observed for catheter colonisation (4/431 [1%] vs 70/415 [17%] catheters among the catheters cultured; adjusted subdistribution hazard ratio 0·08 [95% CI 0·02-0·18]). Median time between catheter insertion and catheter failure was longer in the innovation group compared with the standard group (50·4 [IQR 29·6-69·4] h vs 30·0 [16·6-52·6] h; p=0·0017). Minor skin reactions occurred in nine (2%) patients in the chlorhexidine plus alcohol group and seven (1%) patients in the povidone iodine plus alcohol group. INTERPRETATION: For skin antisepsis, chlorhexidine plus alcohol provides greater protection of peripheral venous catheter-related infectious complications than does povidone iodine plus alcohol. Use of innovative devices extends the catheter complication-free dwell time. FUNDING: Becton Dickinson.

SiPP (Stroke in Pregnancy and Postpartum): A prospective, observational, international, multicentre study on pathophysiological mechanisms, clinical profile, management and outcome of cerebrovascular diseases in pregnant and postpartum women.

RATIONALE: Cerebrovascular diseases associated with pregnancy and postpartum period are uncommon; however, they can have an important impact on health of both women and foetus or newborn. AIMS: To evaluate the frequency, characteristics and management of cerebrovascular events in pregnant/postpartum women, to clarify pathophysiological mechanisms underlying the occurrence of these events including biomolecular aspects, and to assess the short- and long-term cerebrovascular and global cardiovascular outcome of these patients, their predictors and infant outcome. METHODS AND DESIGN: This is an observational, prospective, multicentre, international case-control study. The study will include patients with cerebrovascular events during pregnancy and/or within six months after delivery. For each included case, two controls will be prospectively recruited: one pregnant or puerperal subject without any history of cerebrovascular event and one non-pregnant or non-puerperal subject with a recent cerebrovascular event. All controls will be matched by age, ethnicity and type of cerebrovascular event with their assigned cases. The pregnant controls will be matched also by pregnancy weeks/trimester. Follow-up will last 24 months for the mother and 12 months for the infant. SUMMARY: To better understand causes and outcomes of uncommon conditions like pregnancy/postpartum-related cerebrovascular events, the development of multisite, multidisciplinary registry-based studies, such as the Stroke in Pregnancy and Postpartum study, is needed in order to collect an adequate number of patients, draw reliable conclusions and give definite recommendations on their management.

Transcranial Doppler to detect right-to-left shunt in cryptogenic acute ischemic stroke.

OBJECTIVES: We aimed to confirm the sensitivity and specificity of contrast transcranial Doppler (cTCD) in the detection of right-to-left shunt (RLS) compared to the current reference standard (i.e., transesophageal echocardiography-TEE) in patients aged <55 years with a cryptogenic acute ischemic stroke (AIS) or high-risk (ABCD2 score ≥4) transient ischemic attack (TIA), and to calculate the real life delay in detecting RLS by cTCD versus TEE in a tertiary care academic stroke center. METHODS: Consecutive 16- to 54-year-old patients with AIS or high-risk TIA underwent complete diagnostic workup which included, in case of undetermined etiology, cTCD and TEE. Sensitivity and specificity of cTCD, RLS characteristics, and median delay between the two tests were calculated. RESULTS: Of the 98 included patients, 52 (53%) had a cryptogenic cerebrovascular ischemic event, which displayed a 56% prevalence of RLS related to a patent foramen ovale (PFO) mainly with a high-grade shunt. When comparing TCD with "bubble test" to TEE, sensitivity and specificity were both 100%. Median delays from symptom onset to examination were 2 (min-max 1-10) and 21 (min-max 1-60) days, respectively, for cTCD and TEE. No adverse event occurred during or after cTDC examination. CONCLUSIONS: Transcranial Doppler with "bubble test" appears as the best screening test for the detection of RLS in young and middle-aged adults with cryptogenic acute cerebral ischemic events to select patients potentially suitable for closure procedure after TEE confirmation.

Back to Basics: Adherence With Guidelines for Glucose and Temperature Control in an American Comprehensive Stroke Center Sample.

BACKGROUND: Variance from guideline-directed care for glucose and temperature control remains unknown in the United States at a time when priorities have shifted to ensure rapid diagnosis and treatment of acute stroke patients. However, protocol-driven nursing surveillance for control of hyperglycemia and hyperthermia has been shown to improve patient outcomes. METHODS: We conducted an observational pilot study to assess compliance with American guidelines for glucose and temperature control and association with discharge outcomes in consecutive acute stroke patients admitted to 5 US comprehensive stroke centers. Data for the first 5 days of stroke admission were collected from electronic medical records and entered and analyzed in SPSS using descriptive statistics, Mann-Whitney U test, Student t tests, and logistic regression. RESULTS: A total of 1669 consecutive glucose and 3782 consecutive temperature measurements were taken from a sample of 235 acute stroke patients; the sample was 87% ischemic and 13% intracerebral hemorrhage. Poor glucose control was found in 33% of patients, and the most frequent control method ordered (35%) was regular insulin sliding scale without basal dosing. Poor temperature control was noted in 10%, and 39% did not have temperature recorded in the emergency department. Lower admission National Institutes of Health Stroke Scale score and well-controlled glucose were independent predictors of favorable outcome (discharge modified Rankin Scale score, 0-2) in reperfusion patients. CONCLUSION: Glucose and temperature control may be overlooked in this era of rapid stroke diagnosis and treatment. Acute stroke nurses are well positioned to assume leadership of glucose and temperature monitoring and treatment.

Should We Screen for Janus Kinase 2 V617F Mutation in Cerebral Venous Thrombosis?

BACKGROUND: The presence of Janus Kinase 2 (JAK2) V617F mutation represents a major diagnostic criterion for detecting myeloproliferative neoplasms (MPN) and even in the absence of overt MPN, JAK2 V617F mutation is associated with splanchnic vein thrombosis. However, the actual prevalence and diagnostic value of the JAK2 V617F mutation in patients with cerebral venous thrombosis (CVT) are not known. The aims of this study were to assess the prevalence of JAK2 V617F mutation in a large group of consecutive CVT patients, to detect clinical, biological, and radiological features associated with the mutation, and to determine the long-term venous thrombosis recurrence rate in CVT patients with JAK2 mutation but without overt MPN in order to recommend the best preventive treatment. METHODS: This was a prospective study conducted on consecutive patients with a first-ever radiologically confirmed CVT. JAK2 V617F mutation analysis was assessed in all the study subjects. JAK2 V617F-positive patients were followed up to detect new venous thrombotic events. RESULTS: Of the 125 included subjects, 7 were found to have JAK2 V617F mutation (5.6%; 95% CI 2.3-11.2). Older age (p = 0.039) and higher platelet count (p = 0.004) were independently associated with JAK2 V617F positivity in patients without overt MPN. During a mean follow-up period of 59 (SD 46) months, 2 JAK2 V617F-positive patients presented with 4 new venous thromboembolic events. CONCLUSIONS: Screening for the JAK2 V617F mutation in CVT patients seems to be useful even in the absence of overt MPN and/or in the presence of other risk factors for CVT because of its relatively high prevalence and the risk of thrombosis recurrence.

Posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome after bilateral carotid paraganglioma resection: A case report.

Background Paraganglioma is a rare neuroendocrine tumour arising anywhere along the paravertebral sympathetic and parasympathetic chains. In the neck, paraganglioma may affect the carotid body (carotid body tumour). Case report We describe a 43-year-old woman who presented with a reversible vasoconstriction syndrome associated with a posterior reversible encephalopathy syndrome following a surgery for a left carotid paraganglioma (with a past medical history of surgery for a right carotid paraganglioma a few months before). Conclusion A consequence of a baroreflex modification is discussed in order to explain the rare occurrence of such symptoms.

Venous Thrombotic Recurrence After Cerebral Venous Thrombosis: A Long-Term Follow-Up Study.

BACKGROUND AND PURPOSE: After cerebral venous thrombosis (CVT), the risk of venous thrombotic events was estimated at 2% to 3% for a new CVT and 3% to 8% for extracranial events. However, because of the paucity of prospective studies, the clinical course of CVT is still largely unknown. We aimed to prospectively evaluate the rate of thrombosis recurrence in a cohort of CVT patients with a long-term follow-up and to detect predisposing factors for recurrence. METHODS: Consecutive CVT patients with complete clinical, radiological, biological, and genetic data were systematically followed up. New venous thrombotic events were detected after hospital readmission and imaging confirmation. RESULTS: One-hundred eighty-seven patients (mean age 45±18 years, 67% women) with angiographically confirmed CVT were included. Cause was found in 73% of patients. Coagulation abnormality and JAK2 gene mutation were detected in 20% and 9%, respectively. Median follow-up length was 73 months (range 1-247 months). Mean duration of the oral anticoagulant treatment was 14 months. Mortality rate was 2.5% per year, with 2% in-hospital mortality. During follow-up, CVT reoccurred in 6 patients, whereas 19 subjects had a symptomatic extracranial venous thrombotic event, with cumulative venous thrombotic recurrence rates of 3% at 1 year, 8% at 2 years, 12% at 5 years, and 18% at 10 years. A previous venous thrombotic event (hazard ratio, 2.8; P=0.018), presence of cancer or malignant hemopathies (hazard ratio, 3.2; P=0.039), and unknown CVT causes (hazard ratio, 2.81; P=0.024) were independently associated with recurrence. CONCLUSIONS: In our cohort of CVT patients followed on average for >6 years, subjects with a previous venous thrombotic event, cancer/malignant hemopathies, and unknown CVT causes were found to be at higher risk of recurrence.

Long-term outcome of basilar stenosis in Erdheim-Chester disease: A case report.

BACKGROUND: Erdheim-Chester disease (ECD) is a rare form of non-Langerhans cell histiocytosis. This inflammatory myeloid neoplasm is frequently complicated by neurological symptoms, but stroke is an exceptional manifestation of this disease. METHODS: We report the case of a 59-year-old woman who presented a vertebrobasilar stroke secondary to infiltration and severe stenosis of the basilar artery, improved after interferon-alpha therapy. We performed a review of the relevant literature and reported the few other cases described. RESULTS: With our patient, we have found only 7 observations of cerebrovascular disorder in ECD. Most of them had supravascular arteries involvement. CONCLUSION: Stroke is a rare treatable and potentially reversible complication of ECD. The pathophysiological processes explaining stroke in this disease are uncertain, but periarterial stenosis of cerebral arteries may be a mechanism.

Direct stroke unit admission of intravenous tissue plasminogen activator: safety, clinical outcome, and hospital cost savings.

BACKGROUND: In the USA, stable intravenous tissue plasminogen activator (IV tPA) patients have traditionally been cared for in an intensive care unit (ICU). We examined the safety of using an acuity-adaptable stroke unit (SU) to manage IV tPA patients. METHODS: We conducted an observational study of consecutive patients admitted to our acuity-adaptable SU over the first 3 years of operation. Safety was assessed by symptomatic intracerebral hemorrhage (sICH) rates, systemic hemorrhage (SH) rates, tPA-related deaths, and transfers from SU to ICU; cost savings and length of stay (LOS) were determined. RESULTS: We admitted 333 IV tPA patients, of which 302 were admitted directly to the SU. A total of 31 (10%) patients had concurrent systemic hemodynamic or pulmonary compromise warranting direct ICU admission. There were no differences in admission National Institutes of Health Stroke Scale scores between SU and ICU patients (9.0 versus 9.5, respectively). Overall sICH rate was 3.3% (n = 10) and SH rate was 2.9 (n = 9), with no difference between SU and ICU patients. No tPA-related deaths occurred, and no SU patients required transfer to the ICU. Estimated hospital cost savings were US$362,400 for 'avoided' ICU days, and hospital LOS decreased significantly (p = 0.001) from 9.8 ± 15.6 days (median 5) in year 1, to 5.2 ± 4.8 days (median 3) by year 3. CONCLUSIONS: IV tPA patients may be safely cared for in a SU when nurses undergo extensive education to ensure clinical competence. Use of the ICU solely for monitoring may constitute significant overuse of system resources at an expense that is not associated with additional safety benefit.

Emerging Risk Factors for Dementia: The Role of Blood Pressure Variability.

In the recent years, classical vascular risk factors have been suggested to play a role also in the development of degenerative dementia. Arterial hypertension has been implicated in the pathogenesis of dementia but no conclusive results have been produced yet; more recently, blood pressure variability (BPV) has been suggested as a more important risk factor for both silent brain vascular lesions and the development of dementia. Blood pressure variability is defined as the variation in blood pressure over time, measured on different time spans and in different ways. We reviewed current scientific literature about the role of BPV in the pathogenesis of dementia, and about the association of abnormal BPV patterns and different forms of dementia. We also suggested some hypothetical pathogenic mechanisms.

Risk of pneumonia associated with zero-degree head positioning in acute ischemic stroke patients treated with intravenous tissue plasminogen activator.

INTRODUCTION: In the hyperacute phase of ischemic stroke, a 0° position is recommended to increase cerebral perfusion in nonhypoxic patients able to tolerate lying flat. However, use of 0° positioning is not uniformly applied in clinical practice, most likely due to concerns of aspiration pneumonia. We aimed to determine the risk of pneumonia associated with 0° head of bed positioning in acute stroke patients treated with thrombolytic therapy. METHODS: A retrospective descriptive study was conducted using prospectively collected, consecutive acute ischemic stroke patients treated with IVtPA whose head of bed was positioned at 0° for the first 24 h. Rates of hospital-acquired pneumonia were determined using a strict adjudication process to insure accuracy of pneumonia diagnoses. Quantitative characteristics were analyzed in SPSS to compare differences between "true" pneumonia cases and nonpneumonia cases. RESULTS: Twenty-four of 333 (7.2%) patients had mention the diagnosis of pneumonia in the registry and/or medical record. Of these cases, only 15 (4.5%) met evidence-based diagnostic criteria for hospital-acquired pneumonia. The 15 adjudicated cases had similar median admission NIHSS scores to nonpneumonia cases (10 vs. 9, respectively; P = ns), but were older (74 ± 15 vs. 64 ± 17 years; mean difference 9.889, 95 CI = 1.2-18.6; P = 0.026). A total of eight patients with pneumonia were intubated and mechanically ventilated, and one patient received bilevel positive airway pressure ventilation during the 0° positioning period. Pneumonia cases had significantly longer hospitalizations (14.5 ± 12 vs. 6.6 ± 9 days; mean difference 7.97, 95% CI = 1.1-14.8; P = 0.026) and higher median discharge mRS score (4 vs. 3: P = 0.003). CONCLUSIONS: Zero-degree head of bed positioning in the first 24 h following an acute ischemic stroke treated with IV-tPA was associated with acceptable rates of pneumonia. Rates for pneumonia may be further reduced by eliminating use of a 0° protocol in intubated/mechanically ventilated patients.

Elevation of Plasma 2-Arachidonoylglycerol Levels in Alzheimer's Disease Patients as a Potential Protective Mechanism against Neurodegenerative Decline.

BACKGROUND: Growing evidence suggests that the endocannabinoid system is involved in the pathogenesis of Alzheimer's disease (AD) and atherosclerosis. OBJECTIVE: The purpose of this study was to investigate the activation of the endocannabinoid system in AD in vivo and the possible intermediate role of atherosclerosis. METHODS: We enrolled 41 patients with probable AD, and 30 age- and gender-matched controls. All subjects underwent: ultrasound examination of cerebral and neck vessels (including intima-media thickness and plaque stenosis evaluation); blood sampling to measure levels of endocannabinoid [anandamide (AEA), 2-arachidonoylglycerol (2-AG)] and endogenous AEA analogues [N-palmitoyl-ethanolamide (PEA); N-oleoyl-ethanolamide]; neuropsychological evaluation and brain MRI (atrophy, white matter hyperintensity volume). RESULTS: 2-AG levels were higher in AD patients compared to controls (Mann-Whitney test p = 0.021). In the AD group, 2-AG correlated to white matter hyperintensity volume (r = 0.415, p = 0.015) and was higher in patients with chronic heart ischemic disease (p = 0.023). In AD patients, 2-AG was also positively related to memory (r = 0.334, p = 0.05) and attention (r = 0.423, p = 0.018) performances. Constructional praxia test scores were lower in patients with higher levels of PEA (r =-0.389, p = 0.019). CONCLUSION: AD patients present high plasma 2-AG levels, also in relation to heart ischemic disease and cerebral leukoaraiosis. This may be a protective mechanism hindering neurodegeneration, but it may also play an ambivalent role on cerebrovascular circulation. The increase in 2-AG and PEA levels observed with ongoing pathological processes may differently modulate cognitive performances.

Do billing codes accurately capture intravenous tissue plasminogen activator treatment rates? Justified concern for clinical performance measures based on billing code assignment.

BACKGROUND: International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes are commonly used to determine US national stroke volume and intravenous (IV) tissue plasminogen activator (tPA) treatment rates; however, this method is often criticized because of assumed poor validity and reliability of coding assignment. We sought to understand the validity of IV tPA ICD-9-CM code assignments within a comprehensive stroke center in the southeastern United States. METHODS: Confirmed stroke registry IV tPA cases were retrieved from 2009 to 2011; tPA drip and ship cases were eliminated from the analysis. Retained clinical data included admission National Institutes of Health Stroke Scale (NIHSS) scores, hemorrhagic transformation, diffusion positive magnetic resonance imaging (MRI) results, and discharge modified Rankin Scale (mRS) score. RESULTS: A total of 247 IV tPA cases were assembled, of which 78% were appropriately assigned the IV tPA billing code. ICD-9 code 434.91 (cerebral artery occlusion with infarct) was used for 72% of the sample, 434.11 (cerebral emboli with infarct) was used for 9% of cases, and 433.11 (carotid occlusion with infarct) was assigned to 2% of cases. Interestingly, 435 (transient cerebral ischemia) was assigned to 2% (n = 7) with all of these cases having NIHSS score more than 2 at time of treatment, diffusion MRI documentation of infarction in 29%, and 43% having a discharge mRS score more than 2. CONCLUSIONS: Our findings support the concern that billing codes may significantly underestimate actual IV tPA treatment volume in the United States and suggest the need for regular audit of billing codes by Stroke Center leaders, with provision of feedback and education to coders, aimed at improving code assignment.