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1.
J Stroke Cerebrovasc Dis ; 29(2): 104479, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31784379

RESUMO

OBJECTIVE: To examine the association of a comorbid seizure diagnosis with early hospital readmission rates following an index hospitalization for stroke in the United States. METHODS: Retrospective analysis of the 2014 National Readmission Database. The study population included adult patients (age >18 years old) with stroke, identified using the International Classification of Disease Ninth Revision, Clinical Modification (ICD-9-CM) codes 433.X1, 434.X1, and 436 for ischemic stroke as well as 430, 431, 432.0, 432.1, and 432.9 for hemorrhagic stroke. A subgroup of patients with a secondary discharge diagnosis of seizures was identified using the ICD-9-CM codes 780.39 and 345.X. We computed all-cause 30-day readmission rates for all strokes and by stroke type (ischemic versus hemorrhagic). Finally, we used a multivariable logistic regression model to examine the independent association between seizure and readmission by stroke type. RESULTS: Of 271,148 stroke patients, 6.3% (16,970) had a secondary discharge diagnosis of seizures including 5.0% (11,562) of patients with ischemic stroke and 13.4% (5,409) with hemorrhagic stroke. Overall readmission rate for stroke patients was 11.9% (hemorrhagic stroke: 14.2% versus ischemic strokes: 11.6%). Thirty-day readmission rate was higher in patients with seizures for all strokes (15.6% versus 11.7%, P value <.001), ischemic strokes (15.0% versus11.4%, P value <.001), and hemorrhagic strokes (16.7% versus 13.8%, P value <.001). After adjusting for several patient-specific and healthcare system-specific confounders, hospitalized stroke patients with comorbid seizure diagnosis were more likely than those without seizures to be readmitted within 30 days (OR: 1.20, 95% CI: 1.14-1.25). CONCLUSION: The presence of a comorbid diagnosis of seizure disorder in a hospitalized stroke patient significantly raises the occurrence of early hospital readmission in the United States.


Assuntos
Isquemia Encefálica/diagnóstico , Hemorragias Intracranianas/diagnóstico , Readmissão do Paciente , Convulsões/diagnóstico , Acidente Vascular Cerebral/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/terapia , Comorbidade , Bases de Dados Factuais , Feminino , Humanos , Hemorragias Intracranianas/epidemiologia , Hemorragias Intracranianas/terapia , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Convulsões/epidemiologia , Convulsões/terapia , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Estados Unidos/epidemiologia , Adulto Jovem
2.
Neurology ; 93(16): e1507-e1513, 2019 10 15.
Artigo em Inglês | MEDLINE | ID: mdl-31519779

RESUMO

OBJECTIVE: Treatment of patients with stroke presenting with minor deficits remains controversial, and the recent Potential of rtPA for Ischemic Strokes with Mild Symptoms (PRISMS) trial, which randomized patients to thrombolysis vs aspirin, did not show benefit. We studied the safety and efficacy of thrombolysis in a population of patients with acute stroke presenting with low NIH Stroke Scale (NIHSS) scores screened using MRI. METHODS: The NIH Natural History of Stroke database was reviewed from January 2006 to December 2016 to identify all patients with an initial NIHSS score ≤5 who received thrombolysis within 4.5 hours of symptom onset after being screened with MRI. The 24-hour postthrombolysis MRIs were reviewed for hemorrhagic transformation. Primary outcomes were symptomatic intracranial hemorrhage (sICH) and favorable 90-day outcome modified Rankin Scale score 0-1. Subgroup analysis was performed on patients who would have been eligible for the PRISMS trial, which enrolled patients with a nondisabling neurologic deficit. RESULTS: A total of 121 patients were included in the study with a median age of 65 and an NIHSS score of 3; 63% were women. The rate of any hemorrhagic transformation was 13%, with 11% of them being limited to petechial hemorrhage. The rate of sICH was <1%. Sixty-six patients had 90-day outcome data; of those, 74% had a favorable outcome. For the subgroup of 81 PRISMS-eligible patients, none experienced sICH. Fifty of these patients had 90-day outcome data; of these, 84% had a favorable outcome. CONCLUSIONS: Thrombolytic therapy was safe in our patients with stroke with minor deficits who were initially evaluated by MRI. Future studies of this population may benefit from MRI selection. CLASSIFICATION OF EVIDENCE: This study provides Class IV evidence that for patients with acute ischemic stroke and NIHSS ≤5 screened with MRI, IV tissue plasminogen activator is safe.


Assuntos
Isquemia Encefálica/terapia , Imagem por Ressonância Magnética , Acidente Vascular Cerebral/terapia , Ativador de Plasminogênio Tecidual/uso terapêutico , Idoso , Aspirina/uso terapêutico , Isquemia Encefálica/diagnóstico , Feminino , Fibrinolíticos/uso terapêutico , Humanos , Hemorragias Intracranianas/terapia , Imagem por Ressonância Magnética/métodos , Masculino , Pessoa de Meia-Idade , Acidente Vascular Cerebral/diagnóstico , Terapia Trombolítica/efeitos adversos
3.
J Stroke Cerebrovasc Dis ; 28(11): 104342, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31521517

RESUMO

GOAL: Cerebral amyloid angiopathy (CAA) is the second-most common cause of nontraumatic intracerebral hemorrhages (ICH), surpassed only by uncontrolled hypertension. We characterized the percentage, risk factors, and comorbidities of patients suffering from CAA-related ICH in relation to long-term outcomes. MATERIAL AND METHODS: We performed retrospective analyses and clinical follow-ups of individuals suffering from ICH who were directly admitted to neurosurgery between 2002 and 2016. FINDINGS: Seventy-four of 174 (42%) spontaneous nontraumatic lobar ICH cases leastwise satisfied the modified Boston criteria definition for at least "possible CAA." Females suffered a higher risk of CAA-caused ICH (42 of 74, 56.8%, P= .035). Atrial fibrillation as a major comorbidity was observed in 19 patients (25.7%). Recovery (decrease of modified Rankin scale [mRS]) was highest during hospitalization in the acute clinic. One-year mortality was as follows: 14 of 25 patients (56%) with probable CAA without supporting pathology, 6 of 18, and 8 of 31 patients with supporting pathology and possible CAA, respectively. Only 10 of 74 (13.6%) had favorable long-term outcomes (mRS ≤2). Increasing numbers of lobar hemorrhages, low initial Glasgow Coma Scale, and subarachnoid hemorrhage were significantly associated with poor survivability, whereas statins, antithrombotic agents, an intraventricular hemorrhage, and midline shift played seemingly minor roles. CONCLUSIONS: Symptomatic ICH is a serious stage in CAA progression with high mortality. The high incidence of concurrent atrial fibrillation in these patients may support data on more widespread vascular pathology in CAA.


Assuntos
Fibrilação Atrial/epidemiologia , Angiopatia Amiloide Cerebral/epidemiologia , Hemorragias Intracranianas/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Fibrilação Atrial/terapia , Angiopatia Amiloide Cerebral/diagnóstico por imagem , Angiopatia Amiloide Cerebral/mortalidade , Angiopatia Amiloide Cerebral/terapia , Comorbidade , Progressão da Doença , Feminino , Alemanha/epidemiologia , Humanos , Incidência , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/mortalidade , Hemorragias Intracranianas/terapia , Masculino , Pessoa de Meia-Idade , Prevalência , Prognóstico , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo
4.
Am Surg ; 85(8): 821-829, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-31560301

RESUMO

Anticoagulated older adults suffering ground-level falls are a specialty trauma population at risk for intracranial hemorrhage (ICH). Delays in diagnosis or initiation of anticoagulation reversal can lead to increased morbidity/mortality. A novel "Headstrike" protocol was implemented to improve the treatment efficacy and disposition of these patients. The study objective was to determine effectiveness of the "Headstrike" protocol in providing these patients with timely treatment and disposition, while maintaining positive outcomes. A trauma performance improvement database was queried for all "Headstrike" activations for a 12-month period after implementation. Demographics, patient care, and health data were collected. Descriptive statistics were used for cohort analysis. Five hundred fifteen patients were activated as a "Headstrike" during the study period. Thirty eight patients were diagnosed with ICH (7.4%), 35 of whom were identified on initial imaging. Anticoagulation reversal was ordered for 84.6 per cent of these patients. Of the patients with negative initial CT, only three patients (0.8%) were found to have a delayed ICH on routine follow-up imaging. No anticoagulant/antiplatelet agent was associated with a significantly higher risk of ICH. Implementation of the "Headstrike" protocol resulted in trauma service line resources being used more efficiently, while ensuring high-quality, expeditious care to this population.


Assuntos
Acidentes por Quedas/estatística & dados numéricos , Anticoagulantes/administração & dosagem , Protocolos Clínicos , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/terapia , Idoso , Feminino , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Masculino , Melhoria de Qualidade , Estudos Retrospectivos , Centros de Traumatologia , Resultado do Tratamento
5.
J Stroke Cerebrovasc Dis ; 28(11): 104395, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31540781

RESUMO

BACKGROUND AND PURPOSE: We investigated the associations between alcohol-related emergency department visits and hospitalizations and vascular events including acute ischemic stroke, intracerebral hemorrhage (ICH), and subarachnoid hemorrhage. METHODS: The New York State Inpatient and Emergency Department Databases were examined (2006-2013). Validated International Classification of Diseases 9th edition definitions identified index vascular hospitalizations and alcohol abuse encounters. We used case cross-over analysis with conditional logistic regression to estimate odds ratios (OR) for the association between alcohol-related encounters during 6 case periods (7, 14, 30, 60, 90, and 120 days before index event) compared to control periods (1 year before). Multivariate logistic regression was used to examine the association between an alcohol-related encounter within 6 months before index admission and 30-day readmission after discharge. RESULTS: An alcohol encounter before index admission was associated with acute ischemic stroke (OR = 1.765 within 60 days, 1.418 within 90 days, and 1.287 within 120 days) and subarachnoid hemorrhage (OR = 2.375 within 90 days), but not ICH. Alcohol-related encounters within 6 months before index vascular events increased the likelihood of 30-day readmission after index admission. CONCLUSION: We found that a recent alcohol-related counter was associated with occurrence of vascular events, but not ICH, as well as worse outcomes after index admission.


Assuntos
Consumo de Bebidas Alcoólicas/efeitos adversos , Alcoolismo/epidemiologia , Serviço Hospitalar de Emergência , Hemorragias Intracranianas/epidemiologia , Trombose Intracraniana/epidemiologia , Acidente Vascular Cerebral/epidemiologia , Tromboembolia Venosa/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Consumo de Bebidas Alcoólicas/epidemiologia , Alcoolismo/diagnóstico , Bases de Dados Factuais , Feminino , Hospitalização , Humanos , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/terapia , Trombose Intracraniana/diagnóstico , Trombose Intracraniana/terapia , Masculino , Pessoa de Meia-Idade , New York/epidemiologia , Prognóstico , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/terapia , Fatores de Tempo , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/terapia
6.
World Neurosurg ; 132: 390-396, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31394356

RESUMO

OBJECTIVE: Kitab al-Dhakhira fi 'Ilm al-Tibb is one of Thabit b. Qurra's most noteworthy books on medicine in Arabic in the ninth century. This study aims to present and discuss the section subtitled "wounds in the head" in the 24th chapter of Kitab al-Dhakhira considering the information in the literature. MATERIALS AND METHODS: This study is primarily based on a copy of Kitab al-Dhakhira edited by Dr. G. Sobhy and printed in al-Matba'at al-Amiriyya, Cairo in 1928. It is compared with the manuscript, which is in the Sehit Ali Pasa Collection, nr. 2028, in the Süleymaniye Manuscript Library in Istanbul, Turkey. The 24th chapter was first translated into English and then examined. The acquired knowledge from the chapter is discussed in this study by comparing it with that on this subject from the literature regarding the history of medicine. RESULTS: The 24th chapter, entitled "On Wounds and Wounds in the Head and Hemorrhage from Them and from Other Wounds and on Gently Drawing Arrowhead/Spearhead and Thorn," includes a section subtitled "wounds in the head." This section provides information regarding steps to be taken if the head is simply wounded or if there is an accompanying swelling, how to control hemorrhage, which medicines should be used for treatment, and how to bandage wounds in the head, but unfortunately, it specifies no details regarding surgical interventions for such wounds. CONCLUSIONS: Kitab al-Dhakhira presents interesting knowledge regarding wounds in the head, reflecting the medical paradigm of that era.


Assuntos
Traumatismos Craniocerebrais/terapia , Medicina Arábica/história , Neurocirurgia/história , Livros/história , História Medieval , Humanos , Hemorragias Intracranianas/terapia , Turquia
7.
World Neurosurg ; 131: e606-e613, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31408751

RESUMO

OBJECTIVE: In the present study, we sought to evaluate the timing and outcomes in patients with hemorrhagic stroke who received tracheostomy. METHODS: A retrospective database search was undertaken to identify patients with hemorrhagic stroke between January 2010 and December 2018. Clinical data on basic demographics, clinical features, and outcomes were extracted. The primary outcome was in-hospital mortality and secondary outcomes were hospital stays and hospital costs. Univariate and multivariate analyses were used to compare the characteristics and outcomes between patients with hemorrhagic stroke who underwent tracheostomy early (days 1-6) and late (days 7 or later). RESULTS: A total of 425 patients were identified, 74.4% (n = 316) received an early tracheostomy during the hospitalization. Patients with hemorrhagic stroke who received early tracheostomy had a higher rate of neurosurgical operation (odds ratio, 2.77; 95% confidence interval, 1.54-4.99; P = 0.001) and different types of hemorrhagic stroke (P = 0.001) in comparison with the late tracheostomy patients. In addition, early tracheostomy was associated with shorter hospital stays (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P = 0.003) and reduced hospital costs (P < 0.001) than with late tracheostomy. However, no significant difference was observed with regard to in-hospital mortality between early and late tracheostomy groups (P = 0.744). CONCLUSIONS: In our cohort, early tracheostomy in patients with hemorrhagic stroke may help reduce hospital stays and hospital costs, but not in-hospital mortality. Future prospective multicenter studies are warranted to validate these findings.


Assuntos
Mortalidade Hospitalar , Hemorragias Intracranianas/terapia , Acidente Vascular Cerebral/terapia , Traqueostomia/métodos , Idoso , Feminino , Custos Hospitalares/estatística & dados numéricos , Humanos , Hemorragias Intracranianas/economia , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos , Respiração Artificial/economia , Respiração Artificial/métodos , Estudos Retrospectivos , Acidente Vascular Cerebral/economia , Fatores de Tempo , Traqueostomia/economia , Resultado do Tratamento
8.
BMJ Case Rep ; 12(8)2019 Aug 26.
Artigo em Inglês | MEDLINE | ID: mdl-31451452

RESUMO

A 5-year-old girl presented to paediatric emergency with fever and seizures for a short duration. At first, meningitis was suspected and management was started empirically. There was no improvement in the clinical condition of the patient and investigations revealed spontaneous intracranial haemorrhage (ICH) secondary to factor XIII deficiency. The child was transfused cryoprecipitate and managed conservatively for ICH. She became asymptomatic and was kept on monthly cryoprecipitate transfusions. This case report summarises factor XIII deficiency in ICH which was not suspected initially, but diagnosed later on after CT scan head and factor XIII assay. This report also highlights events occurring during its management.


Assuntos
Deficiência do Fator XIII , Hemorragias Intracranianas , Plasma , Convulsões , Testes de Coagulação Sanguínea/métodos , Pré-Escolar , Serviços Médicos de Emergência/métodos , Deficiência do Fator XIII/complicações , Deficiência do Fator XIII/diagnóstico , Deficiência do Fator XIII/terapia , Fator XIIIa/análise , Feminino , Febre/diagnóstico , Febre/etiologia , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/fisiopatologia , Hemorragias Intracranianas/terapia , Pediatria/métodos , Convulsões/diagnóstico , Convulsões/etiologia , Tomografia Computadorizada por Raios X/métodos , Resultado do Tratamento
10.
Emerg Med Clin North Am ; 37(3): 529-544, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31262419

RESUMO

Central nervous system hemorrhage has multiple pathophysiologic etiologies, including intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH), and traumatic brain injury (TBI). Given the nuances intrinsic to each of these etiologies and pathophysiologic processes, optimal blood pressure varies significantly and depends on type of hemorrhage and individual characteristics. This article reviews the most current evidence regarding blood pressure targets and provides guidance on reversal of anticoagulation for TBI, ICH, and SAH. It also describes the assessment, optimal therapeutic targets, and interventions to treat intracranial hypertension that can result from TBI, ICH, or SAH.


Assuntos
Hemorragias Intracranianas/terapia , Hipertensão Intracraniana/terapia , Anti-Hipertensivos/uso terapêutico , Antitrombinas/uso terapêutico , Pressão Sanguínea , Lesões Encefálicas Traumáticas/complicações , Lesões Encefálicas Traumáticas/terapia , Medicina de Emergência , Hemostáticos/uso terapêutico , Humanos , Hemorragias Intracranianas/diagnóstico , Hipertensão Intracraniana/diagnóstico , Hipertensão Intracraniana/etiologia , Transfusão de Plaquetas , Vasodilatadores/uso terapêutico
11.
Wilderness Environ Med ; 30(3): 295-301, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31229367

RESUMO

The West African carpet viper (Echis ocellatus) causes more deaths than any other snake in sub-Saharan Africa. Carpet viper envenomations are characterized by a venom-induced consumption coagulopathy and systemic bleeding syndrome, in addition to local symptoms of painful progressive swelling and tissue destruction. The highest mortality rate is seen in the final stages of the syndrome, which typically ends with fatal internal bleeding or hemorrhagic shock. We present 2 cases of E ocellatus envenomation with intracranial hemorrhage seen at a rural hospital in Bembèrèkè, Benin, and describe the successful management of these patients in a limited-resource setting. In one case the patient was treated with an ineffective Indian-made antivenom before evaluation by the authors and continued to deteriorate until she was treated with effective antivenom 10 d after the bite. In both cases lumbar puncture was performed for diagnostic or therapeutic purposes with good effect, and both patients made full recoveries without sequelae. These cases demonstrate the remarkable ability of high-quality antivenoms to reverse life-threatening envenomations even in the final stages of the hemorrhagic syndrome and illustrate the dangers posed by low-quality antivenoms that have flooded the market in the developing world.


Assuntos
Antivenenos/uso terapêutico , Fatores Imunológicos/uso terapêutico , Hemorragias Intracranianas/terapia , Mordeduras de Serpentes/terapia , Venenos de Víboras/antagonistas & inibidores , Viperidae , Animais , Benin , Criança , Feminino , Humanos , Hemorragias Intracranianas/etiologia , Masculino , Resultado do Tratamento
12.
World Neurosurg ; 130: e583-e587, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31254696

RESUMO

OBJECTIVE: Endovascular treatment (EVT) is a promising clinical technology. However, some patients with posterior circulation stroke might not experience neurological function recovery after EVT. We reviewed the recent experience with EVT to clarify the clinical and radiographic factors that contribute to optimal neurological outcomes. METHODS: We analyzed the data from 108 consecutive patients with acute posterior circulation stroke who had undergone EVT from January 2016 to December 2018. A favorable outcome was defined as a modified Rankin scale score of 0-3 at 3 months. We evaluated the association and predictive value of the clinical and radiographic factors that contribute to good neurological outcomes. RESULTS: Of the 108 included patients, 43 had a favorable clinical outcome at day 90. Univariate analysis revealed a significant association between the 90-day favorable outcome and the baseline values of systolic blood pressure, time of stroke onset, contrast extravasation, symptomatic intracranial hemorrhage, general anesthesia, Alberta stroke program early computed tomography score for the posterior circulation, and the National Institutes of Health stroke scale (NIHSS) score. Contrast extravasation (odds ratio [OR], 5.094; 95% confidence interval [CI], 1.22-21.261), symptomatic intracranial hemorrhage (OR, 11.24; 95% CI, 1.309-96.517), general anesthesia (OR, 5.094; 95% CI, 1.22-21.26), and baseline NIHSS score (OR, 1.087; 95% CI, 1.023-1.309) were found to be independent predictors of a favorable outcome at day 90. Contrast extravasation alone predicted for unfavorable clinical outcomes and mortality with high specificity. CONCLUSION: In the present retrospective case series, contrast extravasation, symptomatic intracranial hemorrhage, the use of general anesthesia, and baseline NIHSS score were related to a favorable prognosis for patients with posterior circulation stroke after EVT. Contrast extravasation was an independent and strong predictor of unfavorable clinical outcomes.


Assuntos
Isquemia Encefálica/terapia , Procedimentos Endovasculares/efeitos adversos , Extravasamento de Materiais Terapêuticos e Diagnósticos/etiologia , Hemorragias Intracranianas/terapia , Acidente Vascular Cerebral/terapia , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Resultado do Tratamento
13.
Stroke ; 50(7): 1641-1647, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31177986

RESUMO

Background and Purpose- Do-not-resuscitate (DNR) orders are common after stroke, though there are limited data on trends over time. We investigated time trends in DNR orders in a community with a large minority population. Methods- Cases of ischemic stroke (IS) or intracerebral hemorrhage (ICH) were identified from the BASIC study (Brain Attack Surveillance in Corpus Christi) from June 2007 through October 2016. Cox proportional hazards models were used to assess time to DNR orders, with an interaction term added to allow separate hazard ratios for early (≤24 hours) and late (>24 hours) DNR. Stroke type-specific calendar trends were assessed with an interaction term between calendar year (linear) and stroke type. Results- Two thousand six hundred seventy-two cases were included (ICH, 14%). Mean age was 69, 50% were female, and race-ethnicity was Mexican American (58%), non-Hispanic white (37%), and African American (5%). Overall, 16% had a DNR order during the hospitalization. For ICH, DNR orders (early and late) were stable over the study period. However, early DNR orders became more common over time after ischemic stroke (hazard ratio for 2016 versus 2007: 1.89; 95% CI, 1.06-3.39), with no change over time for late DNR orders after ischemic stroke. Mexican Americans (hazard ratio, 0.65; 95% CI, 0.50-0.86) and African Americans (hazard ratio, 0.17; 95% CI, 0.04-0.71) were less likely than non-Hispanic whites to have early DNR orders, though there were no race-ethnic differences in late DNR orders. There was no change in race-ethnic difference in DNR orders over the time of the study (interaction P>0.60). Conclusions- Despite revised national guidelines cautioning against early DNR orders in ICH, presence of DNR orders after ICH was stable between 2007 and 2016, with only slight increases in early DNR orders after ischemic stroke. Mexican Americans and African Americans remain less likely than non-Hispanic whites to have early DNR orders after stroke.


Assuntos
Grupos Étnicos/estatística & dados numéricos , Ordens quanto à Conduta (Ética Médica)/ética , Acidente Vascular Cerebral/terapia , Adulto , Afro-Americanos/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/terapia , Feminino , Hispano-Americanos/estatística & dados numéricos , Humanos , Hemorragias Intracranianas/terapia , Masculino , Americanos Mexicanos/estatística & dados numéricos , Pessoa de Meia-Idade
14.
Stroke ; 50(7): 1703-1710, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-31167618

RESUMO

Background and Purpose- The management of unruptured brain arteriovenous malformations remains unclear. Using a large cohort to determine risk factors predictive of hemorrhagic presentation of arteriovenous malformations, this study aims to develop a predictive tool that could guide hemorrhage risk stratification. Methods- A database of 789 arteriovenous malformation patients presenting to our institution between 1990 and 2017 was used. A hold-out method of model validation was used, whereby the data was randomly split in half into training and validation data sets. Factors significant at the univariable level in the training data set were used to construct a model based on multivariable logistic regression. Model performance was assessed using receiver operating curves on the training, validation, and complete data sets. The predictors and the complete data set were then used to derive a risk prediction formula and a practical scoring system, where every risk factor was worth 1 point except race, which was worth 2 points (total score varies from 0 to 6). The factors are summarized by R2eD arteriovenous malformation (acronym: R2eD AVM). Results- In 755 patients with complete data, 272 (36%) presented with hemorrhage. From the training data set, a model was derived containing the following risk factors: nonwhite race (odds ratio [OR]=1.8; P=0.02), small nidus size (OR=1.47; P=0.14), deep location (OR=2.3; P<0.01), single arterial feeder (OR=2.24; P<0.01), and exclusive deep venous drainage (OR=2.07; P=0.02). Area under the curve from receiver operating curve analysis was 0.702, 0.698, and 0.685 for the training, validation, and complete data sets, respectively. In the entire study population, the predicted probability of hemorrhagic presentation increased in a stepwise manner from 16% for patients with no risk factors (score of 0) to 78% for patients having all the risk factors (score of 6). Conclusions- The final model derived from this study can be used as a predictive tool that supplements clinical judgment and aids in patient counseling.


Assuntos
Bases de Dados Factuais , Malformações Arteriovenosas Intracranianas , Hemorragias Intracranianas , Modelos Cardiovasculares , Adolescente , Adulto , Feminino , Humanos , Malformações Arteriovenosas Intracranianas/complicações , Malformações Arteriovenosas Intracranianas/diagnóstico , Malformações Arteriovenosas Intracranianas/fisiopatologia , Malformações Arteriovenosas Intracranianas/terapia , Hemorragias Intracranianas/diagnóstico , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/fisiopatologia , Hemorragias Intracranianas/terapia , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Fatores de Risco
15.
J Stroke Cerebrovasc Dis ; 28(8): 2109-2114, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31133484

RESUMO

BACKGROUND: Overall, 75.2% of deaths from stroke occur in low- and middle-income countries. Mexico is a middle-income country with little information about the prognosis of early and late postischemic and hemorrhagic stroke. OBJECTIVE: To evaluate the factors associated with post-stroke survival in the Mexican population. METHODS: Observational study of consecutive stroke cases involving a first-ever hemorrhagic or ischemic stroke, with patients who received care at the National Institute of Neurology and Neurosurgery, in Mexico City, between 2009 and 2012. Patients were followed for up to 4 years after the index event. Exploratory analysis of survival was carried out with Kaplan-Meier and log-rank tests. Factors associated with survival time were determined using Cox models. RESULTS: A total of 300 out of 544 (55.15%) patients had a hemorrhagic stroke, 135 of 544 (24.82%) patients died during the entire follow-up period, and 56 of 544 (10.29%) died in the first 30 days post-stroke (early mortality). Early mortality after stroke was associated with age ≥ 65 years (Adjusted Hazard Ratio - AHR = 2.07, P = .02) and ≥ 2 in-hospital medical complications (AHR = 46.13, P < .01). Late mortality was associated with age ≥ 65 years (AHR = 3.43, P < .01), ≥2 in-hospital medical complications (AHR = 2.55, P < .01), high comorbidity (AHR = 5.43, P < .01), and recurrence (AHR = 1.90, P = .01). CONCLUSIONS: Patients with hemorrhagic and ischemic stroke who presented in-hospital medical complications, high comorbidity, and were over 65 years old had higher rates of early and late mortality.


Assuntos
Isquemia Encefálica/mortalidade , Isquemia Encefálica/terapia , Hemorragias Intracranianas/mortalidade , Hemorragias Intracranianas/terapia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/terapia , Adulto , Fatores Etários , Idoso , Isquemia Encefálica/diagnóstico , Comorbidade , Feminino , Seguimentos , Humanos , Hemorragias Intracranianas/diagnóstico , Masculino , México/epidemiologia , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Análise de Sobrevida , Fatores de Tempo , Resultado do Tratamento
16.
Clin Interv Aging ; 14: 565-570, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30936686

RESUMO

Chronic cerebral circulation insufficiency (CCCI) is viewed as an alarming state induced by long-term reduction in cerebral perfusion, which is associated with neurological deficits and high risk of stroke occurrence or recurrence. CCCI accounts for a large proportion of both outpatients and inpatients with cerebrovascular diseases, while management of CCCI remains a formidable challenge to clinicians. Normobaric oxygen (NBO) is an adjuvant hyperoxygenation intervention supplied with one atmosphere pressure (1 ATA =101.325 kPa). A plethora of studies have demonstrated the efficacy of NBO on the penumbra in acute stroke. NBO has been shown to increase the oxygen pressure, raise the intracranial blood flow, protect blood-brain barrier and enhance neuroprotective effects. As similar underlying mechanisms are shared by the penumbra in stroke and the ischemic-hypoxic brain tissues in CCCI, we speculate that NBO may serve as a promising therapeutic strategy for attenuating short-term symptoms or improving long-term clinical outcomes among patients with CCCI. Due to the scant research exploring the efficacy and safety of NBO for treating CCCI so far, both experimental and clinical studies are warranted to verify our hypothesis in the future.


Assuntos
Isquemia Encefálica/terapia , Oxigênio/uso terapêutico , Acidente Vascular Cerebral/terapia , Animais , Circulação Cerebrovascular/fisiologia , Transtornos Cerebrovasculares/terapia , Hemodinâmica/fisiologia , Humanos , Hemorragias Intracranianas/terapia , Fármacos Neuroprotetores/uso terapêutico
18.
J Stroke Cerebrovasc Dis ; 28(6): 1759-1766, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30879712

RESUMO

GOAL: Interhospital transfer (IHT) facilitates access to specialized neurocritical care but may also introduce unique risk. Our goal was to describe providers' perceptions of safety threats during IHT for patients with nontraumatic intracranial hemorrhage. MATERIALS AND METHODS: We employed qualitative, semi-structured interviews at an academic medical center receiving critically-ill neurologic transfers, and 5 referring hospitals. Interviewees included physicians, nurses, and allied health professionals with experience caring for patients transferred between hospitals for nontraumatic intracranial hemorrhage. Interviews continued until data saturation was reached. Coding occurred concurrently with interviews. Analysis was inductive, using the constant comparative method. FINDINGS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. Insufficient communication highlights the unique communication challenges specific to IHT, which overlay and compound known intrahospital communication barriers. Gaps in clinical practice revolve primarily around the provision of neurocritical care for this patient population, often subject to resource availability, by receiving hospital emergency medicine providers. Lack of structure outlines providers' questions that emerge when institutions fail to identify process channels, expectations, and accountability during complex neurocritical care transitions. CONCLUSIONS: The predominant impediments to safe, high-quality neurocritical care transitions between hospitals are insufficient communication, gaps in clinical practice, and lack of IHT structure. These themes serve as fundamental targets for quality improvement initiatives. To our knowledge, this is the first description of challenges to quality and safety in high-risk neurocritical care transitions through clinicians' voices.


Assuntos
Prestação Integrada de Cuidados de Saúde/organização & administração , Hemorragias Intracranianas/terapia , Segurança do Paciente , Transferência de Pacientes/organização & administração , Atitude do Pessoal de Saúde , Comportamento Cooperativo , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Comunicação Interdisciplinar , Entrevistas como Assunto , Hemorragias Intracranianas/diagnóstico , Equipe de Assistência ao Paciente/organização & administração , Lacunas da Prática Profissional , Prognóstico , Pesquisa Qualitativa , Medição de Risco , Fatores de Risco , Fatores de Tempo
19.
Artif Organs ; 43(8): 736-744, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30868618

RESUMO

Continuous-flow left ventricular assist device (LVAD) placement has become a standard of care in advanced heart failure treatment. Bleeding is the most frequently reported adverse event after LVAD implantation and may be increased by antithrombotic agents used for prevention of pump thrombosis. This retrospective cohort included 85 adult patients implanted with a Heartmate II LVAD. Major bleeding was defined as occurring >7 days after implant and included intracranial hemorrhage, events requiring 2 units of packed red blood cells within a 24-h period, and death from bleeding. Primary outcome was intensity of anticoagulation between patients with or without at least one incidence of nonsurgical major bleeding. Major bleeding occurred in 35 (41%) patients with 0.48 events per patient year and a median (IQR) time to first bleed of 134.5 (39.3, 368.5) days. The median (IQR) INR at time of bleed was 1.7 (1.4, 2.5). Median INR during follow-up did not differ between groups and patients with major bleeding were not more likely to have a supra-therapeutic INR. Patients who bled were more likely to have received LVAD for destination therapy, to have lower weight, worse renal function, and lower hemoglobin at baseline. Duration of LVAD support and survival were similar between groups with no difference in occurrence of thrombosis. Incidence of nonsurgical major bleeding was not significantly associated with degree of anticoagulation. Certain baseline characteristics may be more important than anticoagulation intensity to identify patients at risk for bleeding after LVAD implant. Modification of anticoagulation alone is not a sufficient management strategy and early intervention may be required to mitigate bleeding impact.


Assuntos
Anticoagulantes/uso terapêutico , Coração Auxiliar/efeitos adversos , Hemorragia/etiologia , Trombose/prevenção & controle , Idoso , Anticoagulantes/efeitos adversos , Coagulação Sanguínea/efeitos dos fármacos , Feminino , Hemorragia/terapia , Humanos , Hemorragias Intracranianas/etiologia , Hemorragias Intracranianas/terapia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
20.
Acta Haematol ; 141(3): 158-163, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30799408

RESUMO

TAFRO syndrome, a rare systemic inflammatory disease, can lead to multiorgan failure without appropriate treatment. Although thrombocytopenia is frequently seen in patients with TAFRO syndrome, little is known about its pathogenesis. Moreover, while recent studies have reported the presence of an anterior mediastinal mass in some patients, the pathological status of this remains unclear. Here, we report a case of fatal bleeding in a patient with TAFRO syndrome accompanied by an anterior mediastinal mass. A 55-year-old female was transferred to our hospital with a 2-week history of fever, epistaxis, and dyspnea. Laboratory tests revealed severe thrombocytopenia, computed tomography (CT) showed pleural effusions, and bone marrow biopsy revealed reticulin myelofibrosis. We suspected TAFRO syndrome, but the CT scan showed an anterior mediastinal mass that required a biopsy to exclude malignancy. She soon developed severe hemorrhagic diathesis and died of intracranial hemorrhage despite intensive treatment. She had multiple autoantibodies against platelets, which caused platelet destruction. An autopsy of the mediastinal mass revealed fibrous thymus tissues with infiltration by plasma cells. Our case suggests that thrombocytopenia could be attributed to antibody-mediated destruction and could be lethal. Hence, immediate treatment is imperative in cases of severe thrombocytopenia, even when accompanied by an anterior mediastinal mass.


Assuntos
Autoanticorpos , Hiperplasia do Linfonodo Gigante , Doenças do Mediastino , Púrpura Trombocitopênica Idiopática , Tomografia Computadorizada por Raios X , Autopsia , Hiperplasia do Linfonodo Gigante/sangue , Hiperplasia do Linfonodo Gigante/diagnóstico por imagem , Hiperplasia do Linfonodo Gigante/patologia , Hiperplasia do Linfonodo Gigante/terapia , Evolução Fatal , Feminino , Humanos , Hemorragias Intracranianas/sangue , Hemorragias Intracranianas/diagnóstico por imagem , Hemorragias Intracranianas/patologia , Hemorragias Intracranianas/terapia , Doenças do Mediastino/sangue , Doenças do Mediastino/diagnóstico por imagem , Doenças do Mediastino/patologia , Doenças do Mediastino/terapia , Pessoa de Meia-Idade , Derrame Pleural/sangue , Derrame Pleural/diagnóstico , Derrame Pleural/patologia , Derrame Pleural/terapia , Mielofibrose Primária/sangue , Mielofibrose Primária/diagnóstico por imagem , Mielofibrose Primária/patologia , Mielofibrose Primária/terapia , Púrpura Trombocitopênica Idiopática/sangue , Púrpura Trombocitopênica Idiopática/diagnóstico por imagem , Púrpura Trombocitopênica Idiopática/patologia , Púrpura Trombocitopênica Idiopática/terapia
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