Insulin for glycaemic control in acute ischaemic stroke.

BACKGROUND: People with hyperglycaemia concomitant with an acute stroke have greater mortality, stroke severity, and functional impairment when compared with those with normoglycaemia at stroke presentation. This is an update of a Cochrane Review first published in 2011. OBJECTIVES: To determine whether intensively monitoring insulin therapy aimed at maintaining serum glucose within a specific normal range (4 to 7.5 mmol/L) in the first 24 hours of acute ischaemic stroke influences outcome. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (September 2013), CENTRAL (The Cochrane Library 2013, Issue 8), MEDLINE (1950 to September 2013), EMBASE (1980 to September 2013), CINAHL (1982 to September 2013), Science Citation Index (1900 to September 2013), and Web of Science (ISI Web of Knowledge) (1993 to September 2013). We also searched ongoing trials registers and SCOPUS. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing intensively monitored insulin therapy versus usual care in adults with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS: We obtained a total of 1565 titles through the literature search. Two review authors independently selected the included articles and extracted the study characteristics, study quality, and data to estimate the odds ratio (OR) and 95% confidence interval (CI), mean difference (MD) and standardised mean difference (SMD) of outcome measures. We resolved disagreements by discussion. MAIN RESULTS: We included 11 RCTs involving 1583 participants (791 participants in the intervention group and 792 in the control group). We found that there was no difference between the treatment and control groups in the outcomes of death or dependency (OR 0.99, 95% CI 0.79 to 1.23) or final neurological deficit (SMD -0.09, 95% CI -0.19 to 0.01). The rate of symptomatic hypoglycaemia was higher in the intervention group (OR 14.6, 95% CI 6.6 to 32.2). In the subgroup analyses of diabetes mellitus (DM) versus non-DM, we found no difference for the outcomes of death and disability or neurological deficit. The number needed to treat was not significant for the outcomes of death and final neurological deficit. The number needed to harm was nine for symptomatic hypoglycaemia. AUTHORS' CONCLUSIONS: After updating the results of our previous review, we found that the administration of intravenous insulin with the objective of maintaining serum glucose within a specific range in the first hours of acute ischaemic stroke does not provide benefit in terms of functional outcome, death, or improvement in final neurological deficit and significantly increased the number of hypoglycaemic episodes. Specifically, those people whose glucose levels were maintained within a tighter range with intravenous insulin experienced a greater risk of symptomatic and asymptomatic hypoglycaemia than those people in the control group.

Efficacy and safety of outpatient fludarabine, cyclophosphamide, and rituximab based allogeneic hematopoietic cell transplantation in adults with severe aplastic anemia.

The age effect in severe aplastic anemia (SAA) following allogeneic hematopoietic cell transplantation (HCT) favors the use of reduced intensity conditioning (RIC) regimens in older adults. We implemented a non-myeloablative regimen consisting of fludarabine, cyclophosphamide, and rituximab (FCR) to improve HCT outcomes in SAA. Patients who underwent first HCT for SAA utilizing an FCR regimen between January 2016 and May 2022 were included. Outcomes analyzed included time to engraftment, incidence of graft failure, GVHD, viral reactivation, disease recurrence, and GVHD-free, relapse-free survival (GRFS). Among 24 patients included, median age was 43.5 years (22-62) and a variety of donor types and stem cell sources were represented. At median follow-up of 26.9 months (2.4-72.7), no cases of grade III-IV acute (aGVHD) or severe chronic GVHD (cGVHD) were recorded. Viral reactivation was minimal, and there were no cases of graft failure or PTLD, with 100% disease-free and overall survival at last follow up. The estimate of 1-year GRFS was 86.3% (95% CI: 72.8-100%), with moderate cGVHD accounting for all events. The FCR regimen in SAA was well tolerated, even in older adults, with 100% disease-free survival with low GVHD and infection rates. These encouraging findings should be validated in larger prospective trials.

Spontaneous retroperitoneal hematoma: etiology, characteristics, management, and outcome.

BACKGROUND: Spontaneous retroperitoneal hematoma (SRH) can be fatal, requiring immediate recognition and intervention. Current literature is limited, providing little direction in patient care. OBJECTIVE: To describe clinical characteristics of patients with SRH during an 8-year period. METHODS: Observational cohort study of all consecutive patients 18 years and older with SRH from January 2000 to December 2007. SRH was defined as unrelated to invasive procedures, surgery, trauma, or abdominal aortic aneurysm. RESULTS: Of 346 patients screened, 89 were eligible. Median age was 72 years; 56.2% were male. Overall, 66.3% were anticoagulated: 41.6% on warfarin, 30.3% heparin, and 11.2% low-molecular-weight heparin; 30.3% were on antiplatelet therapy; 16.5% were taking both anticoagulant and antiplatelet medications; 15.3% were taking neither. Primary presentation to the Emergency Department was seen in 36%; 64% developed SRH during inpatient anticoagulation therapy. The most common symptom was pain: abdominal (67.5%), leg (23.8%), hip (22.5%), and back (21.3%); 10.1% were misdiagnosed upon their initial encounter. Computed tomography (CT) was performed in 98.8%, ultrasound in 22.1%, and magnetic resonance imaging in 3.5%. Of all subjects, 40.4% were managed in an intensive care unit; 24.7% underwent interventional radiology (IR) procedures and 6.7% surgical evacuation; 75.3% received blood transfusion. Mortality was 5.6% within 7 days, 10.1% within 30 days, and 19.1% within 6 months. CONCLUSIONS: SRH is uncommon but potentially lethal, with a non-specific presentation that can lead to misdiagnosis. One-third of the cohort was not taking anticoagulants. CT was effective at identification. Most patients received aggressive management with transfusion or IR procedures.

An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack.

STUDY OBJECTIVE: We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack. METHODS: This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days. RESULTS: The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days. CONCLUSION: The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification.

Insulin for glycaemic control in acute ischaemic stroke.

BACKGROUND: Patients with hyperglycaemia concomitant with an acute stroke have greater stroke severity and greater functional impairment when compared to those with normoglycaemia at stroke presentation. OBJECTIVES: To determine whether maintaining serum glucose within a specific normal range (4 to 7.5 mmol/L) in the first 24 hours of acute ischaemic stroke influences outcome. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (June 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE (1950 to June 2010), EMBASE (1980 to June 2010), CINAHL (1982 to June 2010), Science Citation Index (1900 to June 2010), and Web of Science (ISI Web of Knowledge) (1993 to June 2010). In an effort to identify further published, unpublished and ongoing trials we searched ongoing trials registers and SCOPUS. SELECTION CRITERIA: Eligible studies were randomised controlled trials comparing intensively monitored insulin therapy versus usual care in adult patients with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the study characteristics, study quality, and data to estimate the odds ratio (OR) and 95% confidence interval (CI), mean difference (MD) and standardised mean difference (SMD) of outcome measures. MAIN RESULTS: We included seven trials involving 1296 participants (639 participants in the intervention group and 657 in the control group). We found that there was no difference between treatment and control groups in the outcome of death or disability and dependence (OR 1.00, 95% CI 0.78 to 1.28) or final neurological deficit (SMD -0.12, 95% CI -0.23 to 0.00). The rate of symptomatic hypoglycaemia was higher in the intervention group (OR 25.9, 95% CI 9.2 to 72.7). In the subgroup analyses of diabetes mellitus (DM) versus non-DM, we found no difference for the outcomes of death and dependency or neurological deficit. AUTHORS' CONCLUSIONS: With the current evidence, we found that the administration of intravenous insulin with the objective of maintaining serum glucose within a specific range in the first hours of acute ischaemic stroke does not provide benefit in terms of functional outcome, death, or improvement in final neurological deficit and significantly increased the number of hypoglycaemic episodes. Specifically, those who were maintained within a more tight range of glycaemia with intravenous insulin experienced a greater risk of symptomatic and asymptomatic hypoglycaemia than those individuals in the control group.

Emergency Department hyperglycemia as a predictor of early mortality and worse functional outcome after intracerebral hemorrhage.

BACKGROUND: We have previously reported the association of hyperglycemia and mortality after ischemic stroke. This study attempts to answer the hypothesis, if hyperglycemia at arrival, is associated with early mortality and functional outcome in patients with acute non-traumatic intracerebral hemorrhage (ICH). METHODS: The study cohort consisted of 237 patients who presented to the ED with ICH and had blood glucose measured on ED presentation. The presence of hyperglycemia on presentation was correlated with outcome measures including volume of hematoma, intraventricular extension of hematoma (IVE), stroke severity, functional outcome at discharge, and date of death. RESULTS: Of the cohort of 237 patients, a total of 47 patients had prior history of Diabetes Mellitus (DM). Median blood glucose at presentation was 140 mg/dl (Inter-quartile range 112-181 mg/dl). DM patients had higher glucose levels on arrival (median 202 mg/dl for DM vs. 132.5 mg/dl for non-DM, P < 0.0001). Higher blood glucose at ED arrival was associated with early mortality in both non-diabetics and diabetics (P < 0.0001). Higher blood glucose was associated with poor functional outcome in non-DM patients(P < 0.0001) but not in DM patients (P = 0.268). In the logistic regression model, after adjustment for stroke severity, hematoma volume, and IVE of hemorrhage, higher initial blood glucose was a significant predictor of death (P = 0.0031); as well as bad outcome in non-DM patients (P = 0.004). CONCLUSIONS: Hyperglycemia on presentation in non-diabetic patients is an independent predictor of early mortality and worse functional outcome in patients with intracerebral hemorrhage.

Prolonged QTc as a predictor of mortality in acute ischemic stroke.

OBJECTIVE: We sought to examine the relationship of the QTc interval with mortality and functional outcome after acute ischemic stroke, and determine whether a threshold cutoff is present beyond which risk of death increases. METHODS: The QTc interval was measured for all patients presenting to the emergency department. The outcomes were mortality at 90 days and functional outcome at hospital discharge. The cutoffs were determined plotting martingale residuals. RESULTS: Patients with a prolonged QTc interval were more likely to die within 90 days compared with patients without a prolonged interval (relative risk [RR] 2.5; 95% confidence interval [CI] 1.5-4.1; P < .001). The estimated survival at 90 days was 70.5% and 87.1%, respectively. This association retained statistical significance after adjusting for age and National Institutes of Health Stroke Scale score (RR 1.7; 95% CI 1.0-2.9; P = .043). Patients with a prolonged QTc interval were also more likely to have poor functional status compared with patients without a prolonged interval (odds ratio 1.8; 95% CI 1.2-3.0; P = .006). This association was not statistically significant after adjusting for age and National Institutes of Health Stroke Scale score (odds ratio 1.2; 95% CI 0.7-2.4). The identified threshold cutoffs for increased risk of death at 90 days were 440 milliseconds for women and 438 milliseconds for men. CONCLUSION: There appears to be an increased risk of early death in patients with acute ischemic stroke and a prolonged QTc interval at the time of emergency department presentation. Prognosis appears to be worse with QTc intervals longer than 440 milliseconds in women and longer than 438 milliseconds in men.

Statins in ischemic stroke: just low-density lipoprotein lowering or more?

BACKGROUND: Statins have been shown to improve the functional outcome of patients after an ischemic stroke. We hypothesized that daily statin intake improves functional outcome after an acute ischemic stroke in patients with low-density lipoprotein (LDL) less than or equal to 100 mg/dL. METHODS: This was a prospective cohort study during a 22-month period of patients presenting with an acute ischemic stroke and lipid profiles measured. The functional disability was determined using modified Rankin scale score (0-2 good outcome, 3-6 bad outcome) at discharge. Chi-square test for binary data and nonparametric tests for nonnormally distributed variables were used for analysis. RESULTS: Of 508 patients, 207 presented with an LDL of 100 mg/dL or less and were included in the analysis. There was no significant difference in admission stroke severity (National Institutes of Health Stroke Scale [NIHSS]; P = .18), age (P = .31), and sex (P = .06) between those taking statins and not taking statins. Patients with LDL less than or equal to 100 mg/dL and taking statins (n = 100) were significantly more likely to have a good functional outcome (odds ratio 1.91; 95% confidence interval 1.05-3.47) when compared with those not on the medication. After adjusting for age, sex, and NIHSS, statin intake still predicted a better functional outcome (P < .0001). CONCLUSION: Daily statin intake appears to result in a better functional outcome after an ischemic stroke in patients with ideal LDL levels (

Electrocardiographic intervals in the healthy geriatric population--what are the "normals"?

The authors compared the average electrocardiographic (ECG) intervals in a population of patients 80 years and older with published "normal" values. The medical records of patients who presented to the Mayo Clinic for health maintenance examinations and who had a routine ECG performed (N=702) were selected. Age; sex; rhythm; PR, QRS, and QTc intervals; incidence of cardiac disease; and presence of interval-prolonging medication were recorded. Reference ranges were estimated from the data and compared with standard cutoffs for prolonged intervals. Interval values were significantly higher in men. Reference ranges were established separately for both sexes based on the subset of 578 patients without a history of cardiac disease and not taking interval-prolonging medication. In all instances, the ranges were higher than the recommended cutoffs. The upper limits for prolonged PR, QRS, and QTc intervals were found to be significantly higher in a population of patients older than 80 years.

Severe hypertension in the emergency department patient.

Severely elevated blood pressure is a common clinical problem en-countered in the Emergency Department. It is often difficult for physicians to differentiate between patients who need emergent blood pressure reduction, requiring the use of intravenous agents and in-tensive monitoring, and those for whom careful, slow reduction in BP is more appropriate. The optimal assessment and management of these patients is reviewed here, with an emphasis on clinical strategies that will most efficiently identify those at greatest risk.

Female gender remains an independent risk factor for poor outcome after acute nontraumatic intracerebral hemorrhage.

Objective. To study whether gender influences outcome after intracerebral hemorrhage (ICH). Methods. Cohort study of 245 consecutive adults presenting to the emergency department with spontaneous ICH from January 2006 to December 2008. Patients with subarachnoid hemorrhage, extradural hemorrhage, and recurrence of hemorrhage were excluded. Results. There were no differences noted between genders in stroke severity (NIHSS) at presentation, ICH volume, or intraventricular extension (IVE) of hemorrhage. Despite this, females had 1.94 times higher odds of having a bad outcome (modified Rankin score (mRs) ≥3) as compared to males (95% CI 1.12 to 3.3) and 1.84 times higher odds of early mortality (95% CI 1.02-3.33). analyzing known variables influencing mortality in ICH, the authors found that females did have higher serum glucose levels on arrival (P = 0.0096) and 4.2 times higher odds for a cerebellar involvement than males (95% CI 1.63-10.75). After adjusting for age, NIHSS, glucose levels, hemorrhage volume, and IVE, female gender remained an independent predictor of early mortality (P = 0.0127). Conclusions. Female gender may be an independent predictor of early mortality in ICH patients, even after adjustment for stroke severity, hemorrhage volume, IVE, serum glucose levels, and age.

The impact of blood pressure hemodynamics in acute ischemic stroke: a prospective cohort study.

OBJECTIVE: To assess relationships between blood pressure hemodynamic measures and outcomes after acute ischemic stroke, including stroke severity, disability and death. METHODS: The study cohort consisted of 189 patients who presented to our emergency department with ischemic stroke of less than 24 hours onset who had hemodynamic parameters recorded and available for review. Blood pressure (BP) was non-invasively measured at 5 minute intervals for the length of the patient's emergency department stay. Systolic BP (sBP) and diastolic BP (dBP) were measured for each patient and a differential (the maximum minus the minimum BP) calculated. Three outcomes were studied: stroke severity, disability at hospital discharge, and death at 90 days. Statistical tests used included Spearman correlations (for stroke severity), Wilcoxon test (for disability) and Cox models (for death). RESULTS: Larger differentials of either dBP (p = 0.003) or sBP (p < 0.001) were significantly associated with more severe strokes. A greater dBP (p = 0.019) or sBP (p = 0.036) differential was associated with a significantly worse functional outcome at hospital discharge. Those patients with larger differentials of either dBP (p = 0.008) or sBP (0.007) were also significantly more likely to be dead at 90 days, independently of the basal BP. CONCLUSION: A large differential in either systolic or diastolic blood pressure within 24 hours of symptom onset in acute ischemic stroke appears to be associated with more severe strokes, worse functional outcome and early death.

Cardioembolic but not other stroke subtypes predict mortality independent of stroke severity at presentation.

Introduction. Etiology of acute ischemic stroke (AIS) is known to significantly influence management, prognosis, and risk of recurrence. Objective. To determine if ischemic stroke subtype based on TOAST criteria influences mortality. Methods. We conducted an observational study of a consecutive cohort of patients presenting with AIS to a single tertiary academic center. Results. The study population consisted of 500 patients who resided in the local county or the surrounding nine-county area. No patients were lost to followup. Two hundred and sixty one (52.2%) were male, and the mean age at presentation was 73.7 years (standard deviation, SD = 14.3). Subtypes were as follows: large artery atherosclerosis 97 (19.4%), cardioembolic 144 (28.8%), small vessel disease 75 (15%), other causes 19 (3.8%), and unknown 165 (33%). One hundred and sixty patients died: 69 within the first 30 days, 27 within 31-90 days, 29 within 91-365 days, and 35 after 1 year. Low 90-, 180-, and 360-day survival was seen in cardioembolic strokes (67.1%, 65.5%, and 58.2%, resp.), followed for cryptogenic strokes (78.0%, 75.3%, and 71.1%). Interestingly, when looking into the cryptogenic category, those with insufficient information to assign a stroke subtype had the lowest survival estimate (57.7% at 90 days, 56.1% at 180 days, and 51.2% at 1 year). Conclusion. Cardioembolic ischemic stroke subtype determined by TOAST criteria predicts long-term mortality, even after adjusting for age and stroke severity.

Effect of anticoagulant and antiplatelet therapy in patients with spontaneous intra-cerebral hemorrhage: Does medication use predict worse outcome?

OBJECTIVES: To assess the impact of anticoagulants and antiplatelet agents on the severity and outcome of spontaneous non-traumatic intra-cerebral hemorrhage (ICH). To evaluate associations between reversal of anticoagulation and mortality/morbidity in these patients. METHODS: Data was collected on a consecutive cohort of adults presenting with ICH to an academic Emergency Department over a 3-year period starting January 2006. RESULTS: The final cohort of 245 patients consisted of 125 females (51.1%). The median age of the cohort was 73 years [inter-quartile (IQR) range of 59-82 years]. Antiplatelet (AP) use was seen in 32.6%, 18.4% were using anticoagulant (AC) and 8.9% patients were on both drugs (AC+AP). Patients on AC had significantly higher INR (median 2.3) and aPTT (median 31 s) when compared to patients not on AP/AC (median INR 1.0, median aPTT 24s; p<0.001). Similarly patients on AC+AP also had higher INR (median 1.9) and aPTT (median 30s) when compared to those not on AC/AP (p<0.001). Hemorrhage volumes were significantly higher for patients on AC alone (median 64.7 cm(3)) when compared to those not on either AC/AP (median 27.2 cm(3); p=0.05). The same was not found for patients using AP (median volume 20.5 cm(3); p=0.813), or both AC+AP (median volume 27.7 cm(3); p=0.619). Patients on AC were 1.43 times higher at risk to have intra-ventricular extension of hemorrhage (IVE) as compared to patients not on AC/AP (95% CI 1.04-1.98; p=0.035). There was no relationship between the use of AC/AP/AC+AP and functional outcome of patients. Patients on AC were 1.74 times more likely to die within 7 days (95% CI 1.0-3.03; p=0.05). No relationship was found between use of AP or AC+AP use and mortality. Of the 82 patients with INR>1.0, 52 patients were given reversal (minimum INR 1.4, median 2.3). Therapy was heterogeneous, with fresh frozen plasma (FFP) being the most commonly used agent (86.5% patients, median dose 4U). Vitamin K, activated factor VIIa and platelets were the other agents used. Post reversal, INR normalized within 24h (median 1.2, IQR 1.1-1.3). There was no association between reversal and volume of hemorrhage, IVE, early mortality (death<7 days) or functional outcome. CONCLUSIONS: Anticoagulated patients were at 1.7 times higher risk of early mortality after ICH. Reversal of INR to normal did not influence mortality or functional outcome.

Evaluation of transient ischemic attack in an emergency department observation unit.

OBJECTIVE: To evaluate the feasibility of a protocol for evaluation of transient ischemic attack (TIA) in an Emergency Department Observation Unit (EDOU), and assess the risk of early stroke after such an evaluation. METHODS: All adult patients presenting to the Emergency Department (ED) with signs and symptoms consistent with TIA were prospectively enrolled in this observational study over a period of 3 years. Patients underwent a standardized TIA evaluation per protocol. Risk of subsequent stroke at 48 h, 1 week, 1 month, and 3 months was prospectively assessed. RESULTS: In total, 418 patients were seen during the study period, and all were evaluated per the EDOU TIA protocol. The mean age was 73.1 (+/-13.3) years and 53.8% were males. Comorbidities included hypertension in 71.5%, diabetes mellitus in 20.1%, prior TIA in 19.6%, and prior ischemic stroke in 19.6% of the cohort. Brain CT, neurology consult, electrocardiogram, carotid ultrasound, and additional tests were performed, and education was given. A total of 30.4% of the patients were dismissed directly from the EDOU. The risk of stroke at 2 days was 0.96%, at 7 days 1.2%, at 30 days 1.9%, and 2.4% at 90 days. CONCLUSION: An Emergency Department Observation Unit Protocol for TIA is a feasible option for expedited evaluation of these patients.

Hyperglycemia as an independent predictor of worse outcome in non-diabetic patients presenting with acute ischemic stroke.

OBJECTIVE: To determine if differences in outcome exist between diabetic and non-diabetic patients who present to the Emergency Department (ED) with acute ischemic stoke (AIS) and elevated blood glucose. METHODS: The study population consisted of 447 consecutive patients who presented to the ED with AIS within 24 h of symptom onset and had blood glucose measured on presentation. Hyperglycemia was defined as >130 mg/dl. Outcomes studied included infarct volume, stroke severity (NIH Stroke Scale), functional impairment (modified Rankin Score), and 90-day mortality. Patients with hyperglycemia were then stratified into those with and without a prior history of diabetes mellitus (DM) for the purposes of analysis. RESULTS: Patients with hyperglycemia exhibited significantly greater stroke severity (P = 0.002) and greater functional impairment (P = 0.004) than those with normoglycemia. Patients with hyperglycemia were 2.3 times more likely to be dead at 90 days compared to those with normal glucose (P < 0.001). Stroke severity (P < 0.001) and functional impairment (P < 0.001) were both significantly worse in patients with hyperglycemia and no prior history of DM, when compared to patients with hyperglycemia and previously diagnosed DM. Among the patients without a prior history of DM, patients with hyperglycemia were 3.4 times more likely to die within 90 days (P < 0.001) when compared with patients with normoglycemia. In contrast, the hazard ratio was 1.6 among the patients with DM (P = 0.66). CONCLUSION: Hyperglycemia on presentation is associated with significantly poorer outcomes following AIS. Patients with hyperglycemia and no prior history of DM have a particularly poor prognosis, worse than that for patients with known diabetes and hyperglycemia.

Pharmacologic elevation of blood pressure for acute brain ischemia.

INTRODUCTION: Several studies demonstrated that patients with low blood pressure upon presentation with acute ischemic stroke have worse outcomes. Elevated mean arterial pressure (MAP) directly improves cerebral perfusion. Phenylephrine is a selective alpha-1 agonist with peripheral vasoconstrictive effect, raising the blood pressure without constricting brain vessels. METHODS: We report a 63-year-old lady presenting with an acute high carotid T occlusion causing hemispheric ischemia that was completely reversed by implementing blood pressure augmentation with fluids and intravenous phenylephrine. RESULTS: She arrived 4 h after symptoms onset. At its nadir, the NIHSS was 17. Head CT did not reveal hemorrhage or acute ischemic changes. CT angiogram confirmed the presence of a right internal carotid artery occlusion at the level of the neck. Hemodynamic support in the form of IV normal saline was initiated, followed by a bolus of phenylephrine. The patient responded to blood pressure augmentation with marked improvement in her level of consciousness, therefore an infusion of phenylephrine at 140 mcg/min titrated to a MAP of 110-120 mmHg was begun. There was complete resolution of the left hemiparesis less than an hour later. CONCLUSION: This case lends support to the growing body of literature that sustains the use of pharmacological blood pressure augmentation to treat acute brain ischemia. Patients with cervical carotid occlusion represent the ideal candidates for hemodynamic augmentation treatment, as collateral flow can recruited from multiple pathways.

Percutaneous clot removal devices in acute ischemic stroke: a systematic review and meta-analysis.

We conducted a systematic review and meta-analysis of mechanical thrombectomy in the treatment of ischemic stroke and assessed factors for technical and clinical success and survival. We searched the literature using MEDLINE and EMBASE for January 1, 2000, through March 1, 2006. Studies were limited to those in human beings; there were no language or study design restrictions. Validity assessment was performed using the Newcastle-Ottawa Scale. The pooled cohort was compared with a historical cohort matched for sex, age, and National Institutes of Health Stroke Survey score. The search yielded 114 publications. Two authors determined inclusibility (interrater agreement, kappa = 0.94). Mean preprocedure National Institutes of Health Stroke Survey score was 20.4. The middle cerebral artery (36%) and the posterior circulation (38%) were the most frequently occluded areas. The clot was accessible in 85% of the patients. Hemorrhage occurred in 22% of the patients. Of 81 patients with concurrent thrombolysis, 18.5% had hemorrhage compared with 27.3% of 66 patients without thrombolysis (P = .21). Of the 126 patients with accessible clots, 36% had a good modified Rankin score (

The role of hyperglycemia in acute ischemic stroke.

Stroke remains a leading cause of death and long-term disability in the developed world. Reperfusion and anti-thrombotic therapies are of limited benefit for the majority of patients following acute ischemic stroke, and increasing interest has focused on therapeutic approaches that seek to modulate infarct evolution. Animal and human studies have linked hyperglycemia in the acute phase of ischemic stroke to worse clinical outcomes regardless of the presence of pre-existing diabetes mellitus. Experimental data suggest that elevated blood glucose may directly contribute to infarct expansion through a number of maladaptive metabolic pathways, and that treatment with insulin may attenuate these adverse effects. In this review, we analyze the relationship between elevated serum glucose and acute cerebrovascular ischemia, and critically appraise the potential of a clinical strategy that targets euglycemia in all acute stroke patients.

A sinister cause of nausea and vomiting.

A 30-year-old intellectually challenged woman with recent travel history to Texas presented with intractable nausea and nonprojectile vomiting for 3 weeks. She had diffuse abdominal pain with no change in her bowel movements. Her family noted that she had recently become more withdrawn. On presentation, she was afebrile with a normal abdominal exam. Physical examination was remarkable for subtle bilateral end-gaze nystagmus. An extensive workup at an outside hospital over 2 weeks included upper endoscopy with small bowel follow-through, pelvic sonogram, and a head computed tomography (CT), all of which were reportedly unremarkable. No outside films were accessible at the time. At our facility, laboratory examination was obtained that ruled out an infectious etiology. Abdominal CT showed no gastrointestinal or hepatobiliary abnormalities. Because of reported personality changes and nystagmus on physical exam, magnetic resonance imaging (MRI) of the head was obtained to rule out cerebellar or vestibular pathology.