Improving Transfer Times for Acute Ischemic Stroke Patients to a Comprehensive Stroke Center.

BACKGROUND AND OBJECTIVE: The transfer of acute ischemic stroke (AIS) patients to a comprehensive stroke center (CSC) must be rapid. Delays pose an obstacle to time-sensitive stroke treatments and, therefore, increase the likelihood of exclusion from endovascular stroke therapy. This study aims to evaluate the impact of the Stroke Rescue Program, with its goal of minimizing interfacility transfer delays and increasing the number of transport times completed within 60 minutes. METHODS: The Stroke Rescue Program was initiated to facilitate the rapid transfer of AIS patients from regional primary stroke centers (PSCs) to the network's CSC. The transfer process was divided into 3 time elements: transport 1 time (initial phone call from the PSC until emergency medical service [EMS] arrival at the PSC), emergency department (ED) time (EMS PSC arrival to PSC departure), and transport 2 time (PSC departure to CSC arrival). The total transport time target was set at less than 60 minutes. Protocols and procedures were implemented with a focus on decreasing the ED time. RESULTS: Comparing baseline (preimplementation) quarter (n = 21) to postproject quarter (1 year later, n = 31), the percent transported within 60 minutes increased from 62% to 81%. A statistically significant improvement was seen for both median ED time (23 minutes versus 14 minutes; U = 171, P < .01) and median total transport time (56 minutes versus 44 minutes; U = 199, P < .05). CONCLUSION: Interfacility transfer protocols minimizing the time paramedics spend in a PSC ED can significantly reduce total transfer time to a comprehensive stroke center.

Recurrent Stroke due to Patent Foramen Ovale Closure Device Thrombus Eight Years after Implantation.

Patent foramen ovale (PFO) is a common heart defect and is found in about 25% of the general population. Although randomized trials have failed to show the superiority of percutaneous closure of PFO over medical management, the number of patients with closure device placement has grown over the years. Delayed complications from PFO closure are rare. We present a case of cardioembolic stroke secondary to a mobile thrombus on a PFO closure device 8 years after implantation.

Poor Hypertension Control and Longer Transport Times Are Associated with Worse Outcome in Drip-and-Ship Stroke Patients.

BACKGROUND: The "drip-and-ship" paradigm is an important treatment modality for acute ischemic stroke (AIS) patients who do not have immediate access to a comprehensive stroke center (CSC). Intravenous thrombolysis is initiated at a primary stroke center followed by expeditious transfer to a CSC. We sought to determine factors associated with poor outcomes in drip-and-ship AIS patients transferred to a CSC. METHODS: This study is a retrospective analysis of 130 consecutive drip-and-ship patients transferred by ambulance to a single CSC between July 2012 and June 2014. Multiple patient and transport factors were analyzed. Transport blood pressure (BP) control was considered inadequate if the systolic BP was greater than 180 mmHg and/or diastolic BP was greater than 105 mmHg upon CSC arrival. Poor patient outcome was defined as discharge to hospice or expiry, a discharge modified Rankin Scale (mRS) score higher than 2, or symptomatic intracerebral hemorrhage (ICH). RESULTS: There was a significant association between inadequate BP control upon CSC arrival and in-hospital mortality or discharge to hospice (P < .0007). Arrival BP was not associated with the risk of post-thrombolysis symptomatic ICH. Longer transport time was significantly associated with a poorer mRS score at discharge (P < .0174) and death (P < .0351). CONCLUSIONS: Post-thrombolysis BP guideline violations and longer transport times during drip-and-ship transfers were significantly associated with poor outcome. Guidelines for strict transport BP management and alternative modes of transfer for longer-distance transports may be warranted.

Delayed Thrombus on Carotid Web: Case Report With Escalation of Treatment.

Carotid artery web is an underrecognized source and is found in about 1-2% of patients with acute ischemic stroke. Although, first described four decades ago, optimal therapy for carotid web is not yet known. Carotid stenting and endarterectomy are increasingly used for carotid web treatment, given its definitive treatment and avoiding the complications associated with anticoagulation. The case reported here is of an ischemic stroke secondary to a mobile thrombus on a carotid web evident on CT angiography and successful definitive treatment with delayed carotid wall stent placement. In young patients who have a diagnosis of ischemic stroke, the carotid web should be on the differential and adequate neuroimaging with either CTA or DSA should be pursued.

Delayed Presentation of Posterior Reversible Encephalopathy Syndrome in the Setting of Serotonin-Norepinephrine Reuptake Inhibitors.

Posterior reversible encephalopathy syndrome (PRES) is a complex process that has been implicated in the setting of many chronic diseases (i.e., hypertension, chronic kidney disease, autoimmune diseases, infections, transplant treatments, etc.). The exact pathogenesis of PRES is still unclear; however, it has been suggested to involve endothelial injury leading to immune system activation and cytokine release. This case report examines an atypical presentation of PRES caused by serotonin-norepinephrine reuptake inhibitors (SNRIs).

Clinical Vignette of Bacterial Meningitis Complicated by a Cerebrovascular Event.

Community-acquired bacterial meningitis is a life-threatening illness that is commonly caused by Streptococcus pneumoniae. Often, it can be associated with high mortality and morbidity rates especially due to the frequency of added neurological complications like hydrocephalus, seizures, stroke, and cerebrovascular events. Here we present an unusual case of cerebrovascular infarction complicating the outcome of a patient who suffered from community-acquired bacterial meningitis.

Clinical Manifestations of Severe Untreated Hypothyroidism.

Thyroid hormones play a crucial role in maintaining homeostasis throughout the human body. Hypothyroidism is a result of insufficient circulating levels of thyroid hormone. In a hypothyroid state, not only do all metabolic processes tend to slow down but so do neurological processes. Here, we present an interesting case of a woman with a history of severe hypothyroidism that was untreated for the past 10 years.

Subpial Hemorrhage in an Adult Male.

Subpial hemorrhage (SPH) is a rare entity that may often be overlooked in favor of more common intercranial bleeds, especially in adults. Our case demonstrates classical imaging findings seen in SPH in an adult male. SPH is poorly understood, with no identified clinical syndrome or symptomology, and further identification and classification of SPH are necessary to develop a more thorough understanding of its pathophysiology and potential treatment protocols.

Use of Arterial Spin-Labeling in Patients with Aneurysmal Sub-arachnoid hemorrhage.

Delayed cerebral ischemia (DCI) due to cerebral vasospasm following aneurysmal subarachnoid hemorrhage (aSAH) has long been recognized as a major source of morbidity and mortality. Early detection of cerebral vasospasm and identification of patients who are likely to become symptomatic is crucial to guide aggressive medical and/or endovascular interventions. Magnetic resonance imaging using arterial spin-label (ASL) is a noninvasive mean for assessing cerebral blood flow and is based on direct magnetic labeling of arterial blood water protons. The diagnostic role of ASL in acute ischemic stroke, epilepsy, and neurodegenerative disorders has been explained in multiple studies but its ability to predict vasospasm in aSAH has not been published before. The purpose of this study is to highlight the diagnostic implications of different perfusion patterns of ASL in patients with aSAH which can be utilized to prevent DCI in such patients when other commonly used modalities are not available, contraindicated, or fail to detect vasospasm.

Seizure Prophylaxis in the Immediate Post-Hemorrhagic Period in Patients with Aneurysmal Subarachnoid Hemorrhage.

INTRODUCTION: Seizures are a well-known complication of aneurysmal subarachnoid hemorrhage (aSAH) and occur most commonly in the immediate posthemorrhagic period. Most commonly used antiepileptic drugs (AEDs) for seizure prophylaxis in aSAH include phenytoin and levetiracetam. There is no reliable data available on the safety and efficacy of restricting AED prophylaxis only till the aneurysm is secured. METHODS: We retrospectively chart reviewed patients admitted to our neurosciences intensive care unit (NICU) with aSAH during the past two years. Seizure incidence was studied in patients treated with phenytoin versus levetiracetam and in patients treated for 3-7 days vs. those where AED was discontinued immediately after aneurysm was secured. RESULTS: In 28 patients, AED prophylaxis was discontinued immediately after the aneurysm was secured, and in 21 patients, it was continued for 3-7 days. Of the 28 patients who received AED prophylaxis for less than or equal to two days, phenytoin was used in 20 patients and levetiracetam was used in eight patients. In patients receiving AED prophylaxis for 3-7 days, phenytoin was used in eight cases and levetiracetam was used in 13 cases. None of these patients had seizures reported during hospitalization or at three-month follow-up. CONCLUSION: Stopping the AED prophylaxis immediately after aneurysm coiling is not associated with increased risk of seizures. Seizures at presentation in patients with aSAH are not associated with development of epilepsy at three months. Both phenytoin and levetiracetam are well tolerated in patients with aSAH when limited to the immediate posthemorrhagic period.