Incidence of Atrial Fibrillation in Large Vessel Occlusion and Large Embolic Stroke of Undetermined Source.

INTRODUCTION: Large vessel occlusion (LVO) stroke is a common presentation of acute ischemic stroke and is often unknown or cryptogenic in etiology. There is a strong association between atrial fibrillation (AF) and cryptogenic LVO stroke, making it a unique stroke subgroup. Therefore, we propose that any LVO stroke meeting the criteria for an embolic stroke of an undetermined source (ESUS) be classified as large ESUS (LESUS). The purpose of this retrospective cohort study was to report the etiology of anterior LVO strokes that underwent endovascular thrombectomy. METHODS: This was a single-center retrospective cohort study characterizing the etiology of acute anterior circulation LVO strokes that received emergent endovascular thrombectomy from 2011 to 2018. Patients with LESUS designation at hospital discharge were changed to cardioembolic etiology if AF was discovered during the two-year follow-up period.  Results: Overall, 155 (45%) of 307 patients in the study were found to have AF. New onset AF was discovered in 12 (23%) of 53 LESUS patients after hospitalization. Furthermore, eight (35%) of 23 LESUS patients who received extended cardiac monitoring were found to have AF. CONCLUSION: Nearly half the patients with LVO stroke who received endovascular thrombectomy were found to have AF. With the use of extended cardiac monitoring devices after hospitalization, AF is frequently discovered in patients with LESUS and may change the secondary stroke prevention strategy.

Expanding Acute Stroke Care in Rural America: A Model for Statewide Success.

Background: The state of West Virginia (WV) is often seen as a health care desert with a scarcity of hospitals and resources. The prevalence of cerebrovascular disease and associated comorbidities are also some of the highest in the nation. Introduction: Ischemic stroke is a time-sensitive diagnosis. Prompt treatment in WV is difficult due to limited and isolated stroke-ready hospitals. Adoption of telestroke has helped to bypass these obstacles and improve access to care. Materials and Methods: Retrospective analyses; using data from the American Heart Association's Get With The Guidelines Stroke Data Registry, and other statewide agencies, we looked for trends in the volume of patients treated with intravenous-tissue plasminogen activator (tPA) in WV. We also reviewed data from West Virginia University's (WVU) telestroke database to assess trends in consult volumes and quality metrics. Results: Since the establishment of WVU telestroke, the total number of stroke patients receiving tPA across the state increased by 173% from 2015 (259 patients) to 2018 (448 patients) (p < 0.0001). Telestroke consults made up 24% (107/448) of total statewide tPA administrations for 2018. Between 2016 and 2018, the total symptomatic hemorrhage rate for tPA treated patients through telestroke was 1% (3/292). Telestroke also facilitated local care by avoiding patient transfer on average 65% of the time.Conclusion: Not only has telestroke increased the quantity of treated acute ischemic strokes, but it has also done so safely and effectively even in resource-poor areas. These findings demonstrate that telestroke is a useful tool for treating strokes, particularly those that happen far from stroke centers.

Comparison of Intraoperative Aminophylline Versus Furosemide in Treatment of Oliguria During Pediatric Cardiac Surgery.

OBJECTIVES: To determine if intraoperative aminophylline was superior to furosemide to prevent or attenuate postoperative cardiac surgery-associated acute kidney injury. DESIGN: Single-center, historical control, retrospective cohort study. SETTING: PICU, university-affiliated children's hospital. PATIENTS: Children with congenital heart disease in PICU who received furosemide or aminophylline to treat intraoperative oliguria. INTERVENTIONS: Intraoperative oliguria was treated either with furosemide (September 2007 to February 2012) or with aminophylline (February 2012 to June 2013). The postoperative 48 hours renal outcomes of the aminophylline group were compared with the furosemide group. The primary outcomes were acute kidney injury and renal replacement therapy use at 48 hours postoperatively. Surgical complexity was accounted for by the use of Risk Adjustment for Congenital Heart Surgery-1 score. MEASUREMENTS AND MAIN RESULTS: The study involves 69 months of observation. There were 200 cases younger than 21 years old reviewed for this study. Eighty-five cases (42.5%) developed acute kidney injury. The aminophylline group patients produced significantly more urine (mL/kg/hr) during the first 8 hours postoperatively than furosemide patients (5.1 vs 3.4 mL/kg/hr; p = 0.01). The urine output at 48 hours postoperatively was similar between the two groups. There was no difference in acute kidney injury incidence at 48 hours between the aminophylline and furosemide groups (38% vs 47%, respectively; p = 0.29). Fewer aminophylline group subjects required renal replacement therapy compared to the furosemide group subjects (n = 1 vs 7, respectively; p = 0.03). In the multi-variant predictive model, intraoperative aminophylline infusion was noted as a negative predictive factor for renal replacement therapy, but not for cardiac surgery-associated acute kidney injury. CONCLUSION: The intraoperative use of aminophylline was more effective than furosemide in reversal of oliguria in the early postoperative period. There were less renal replacement therapy-requiring acute kidney injury in children in the aminophylline group. Future prospective studies of intraoperative aminophylline to prevent cardiac surgery-associated acute kidney injury may be warranted.