Pregnancy in advanced age and the risk of stroke in postmenopausal women: analysis of Women's Health Initiative Study.

BACKGROUND: The incidence of pregnancy in advanced age among women is increasing because of the availability of assisted reproduction, although the long-term health consequences are not known. OBJECTIVE: The purpose of this study was to determine the effect of pregnancy in advanced age on the occurrence of cardiovascular events in a large cohort of postmenopausal women. STUDY DESIGN: We analyzed the data for 72,221 women aged 50-79 years who were enrolled in the observational arm of the Women's Health Initiative study. We determined the effect of pregnancy in advanced age (last pregnancy at age ≥40 year) on the risk of ischemic stroke, hemorrhagic stroke, myocardial infarction, and cardiovascular death over a mean period (±standard deviation) of 12±1 years using Cox Proportional Hazards analysis after adjusting for potential confounders. RESULTS: A total of 3306 of the 72,221 participants (4.6%) reported pregnancy in advanced age. Compared with pregnancy in normal age, the rates of ischemic stroke (3.8% vs 2.4%), hemorrhagic stroke (1.0% vs 0.5%), and cardiovascular death (3.9% vs 2.3%) were significantly higher among women with pregnancy in advanced age. In multivariate analysis, women with pregnancy in advanced age were 50% more likely to experience a hemorrhagic stroke (hazard ratio, 1.5; 95% confidence interval, 1.0-2.1) after adjustment for age, race/ethnicity, congestive heart failure, systolic blood pressure, atrial fibrillation, alcohol use, and cigarette smoking. There was no significant difference in the risk of ischemic stroke, myocardial infarction, and cardiovascular death among women with pregnancy in advanced age after adjustment for potential confounders. CONCLUSION: Women with pregnancy at an advanced age have a higher risk for hemorrhagic stroke in the postmenopausal period.

Risk of Ischemic Stroke in High Risk Atrial Fibrillation Patients during Periods of Warfarin Discontinuation for Surgical Procedures.

IMPORTANCE: The risk of ischemic stroke during periods of warfarin discontinuation for surgical procedures is recognized but not well characterized. OBJECTIVE: The study aimed to quantitate the risk of ischemic stroke associated with high risk atrial fibrillation during periods of warfarin discontinuation. DESIGN, SETTING AND PARTICIPANTS: A cohort of 4,060 patients (mean follow-up period of 3.5 ± 1.3 years) were randomized into the Atrial Fibrillation Follow-Up Investigation of Rhythm Management study. Patients enrolled in the study had atrial fibrillation plus at least one other risk factor for stroke or death: age ≥65 years', systemic hypertension, diabetes mellitus, congestive heart failure, transient ischemic attack, prior stroke, left atrium >50 mm, left ventricular fractional shortening <25% or left ventricular ejection fraction <40%. EXPOSURE: Warfarin discontinuation for procedure. MAIN OUTCOME AND MEASURES: The association of warfarin discontinuation with the incidence of ischemic stroke using pooled repeated measures and Cox proportional hazards analyses during follow-up after adjusting for age, gender, obesity, diabetes mellitus, hypercholesterolemia, cigarette smoking and study period. RESULTS: Warfarin discontinuation for procedure occurred in 265 (0.4%) of the 71,355 person observations. Compared with those without warfarin discontinuation, the rate of ischemic stroke was higher among participants with surgery-related warfarin discontinuation (1.1% of 265 person observations vs. 0.2% of 71,090 person observations, p = 0.001). Warfarin discontinuation was associated with an increased risk for ischemic stroke (relative risk 5.8; 95% CI 1.8-18.4) after adjusting for potential confounders. The population-attributable risk associated with surgery-related warfarin discontinuation was estimated to be 23.1% (95% CI 15.2-30.9%) for ischemic stroke. CONCLUSIONS AND RELEVANCE: The 6-fold higher risk of ischemic stroke associated with discontinuation of warfarin for surgical procedures must be recognized in high risk atrial fibrillation patients and considered in the risk-benefit analysis of any procedure.

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Maintenance Dialysis Patients.

Outcomes of cardiopulmonary resuscitation (CPR) in hospitalized patients with ESRD requiring maintenance dialysis are unknown. Outcomes of in-hospital CPR in these patients were compared with outcomes in the general population using data from the Nationwide Inpatient Sample (NIS; 2005-2011). The study population included all adults (≥ 18 years old) from the general population and those with a history of ESRD. Baseline characteristics, in-hospital complications, and discharge outcomes were compared between the two groups. The effects of in-hospital CPR on mortality, length of stay, hospitalization charges, and discharge destination were analyzed. Yearly national trends in survival, discharge to home, and length of stay were also examined using the Cochran-Armitage trend test. During the study period, 56,069 patients with ESRD underwent in-hospital CPR compared with 323,620 patients from the general population. Unadjusted in-hospital mortality rates were higher in patients with ESRD (73.9% versus 71.8%, P<0.001) on univariate analysis. After adjusting for age, gender, and potential confounders, patients with ESRD had higher odds of mortality (odds ratio, 1.24; 95% confidence interval, 1.11 to 1.3; P<0.001). Survival after CPR improved in the year 2011 compared with 2005 (31% versus 21%, P<0.001). Multivariate analysis also revealed that a greater proportion of patients with ESRD who survived were discharged to skilled nursing facilities. In conclusion, outcomes after in-hospital CPR are improving in patients with ESRD but remain worse than outcomes in the general population. Patients with ESRD who survive are more likely to be discharged to nursing homes.

Incident cancer in a cohort of 3,247 cancer diagnosis free ischemic stroke patients.

BACKGROUND: Subclinical cancer can manifest as a thromboembolic event and may be detected at a later interval in ischemic stroke survivors. We determined the rate of incident cancer and effect on cardiovascular endpoints in a large cohort of ischemic stroke survivors. METHODS: An analysis of 3,680 adults with nondisabling cerebral infarction who were followed for two years within the randomized, double-blinded VISP trial was performed. The primary intervention was best medical/surgical management plus a daily supplementation of vitamin B6, vitamin B12, and folic acid. We calculated age-adjusted rates of incidence of cancer among ischemic stroke survivors and standardized incidence ratios (SIR) with 95% confidence intervals (CI) based on comparison with age-adjusted rates in the general population. The significant variables from univariate analysis were entered in a Cox Proportional Hazards analysis to identify the association between various baseline factors and incident cancer after adjusting age, gender, and race/ethnicity. A logistic regression analysis evaluated the association between incident cancer and various endpoints including stroke, coronary heart disease, myocardial infarction, and death after adjusting age, gender, and race/ethnicity. RESULTS: A total of 3,247 patients (mean age ± SD of 66 ± 11; 2,013 were men) were cancer free at the time of enrollment. The incidence of new cancer was 0.15, 0.80, 1.2, and 2.0 per 100 patients at 1 month, 6 months, 1 year, and 2 years, respectively. The age-adjusted annual rate of cancer in patients with ischemic stroke was higher than in persons in the general population at 1 year (581.8/100,000 persons vs. 486.5/100,000 persons, SIR 1.2, 95% CI 1.16-1.24) and 2 years (1,301.7/100,000 vs. 911.5/100,000, SIR 1.4, 95% CI 1.2-1.6) after recruitment. There was a higher risk for death (odds ratio (OR) 3.1, 95% CI 1.8-5.4), and composite endpoint of stroke, coronary heart disease, and/or death (OR 1.4, 95% CI 1.0-2.2) among participants who developed incident cancer compared with those who were cancer free after adjusting for potential confounders. CONCLUSIONS: The annual rate of age-adjusted cancer incidence was higher among ischemic stroke patients compared with those in the general population. The odds of mortality were three folds higher among stroke survivors who developed incident cancer.

Readministration of intravenous alteplase in acute ischemic stroke patients: case series and systematic review.

BACKGROUND: Because of a high risk of recurrence of ischemic events, some patients may be candidates for readministration of intravenous (IV) alteplase. METHODS: We performed a single-center review and performed a search on PubMed from January 1966 to April 2014 for cases of readministration of alteplase. Favorable outcome was defined by a modified Rankin scale of 0 to 2 at discharge or at 1 to 3 months, improvement of greater than or equal to 4 points within 24 hours in the National Institutes of Health Stroke Scale score, or as a major improvement in the 72-hour National Institutes of Health Stroke Scale score. RESULTS: Four ischemic stroke patients underwent readministration of IV alteplase in our single-center review. None of the patients had symptomatic or asymptomatic intracerebral hemorrhage.In 2 patients, IV alteplase had been administered for a previous acute ischemic stroke, 6 and 49 days before the index ischemic stroke.At discharge, both patients had a favorable outcome. A total of 22 cases of readministration of alteplase for ischemic stroke have been reported in literature. The mean interval between the 2 administrations of alteplase was 428 days (range, 3 hours to 2280 days).Asymptomatic post thrombolytic intracerebral hemorrhages were seen in 2 patients. Favorable outcome was seen in 16 patients. A total of 9 underwent readministration of IV alteplase within 3 months for recurrent ischemic stroke. Favorable outcome was seen in 5 of these 9 patients. CONCLUSIONS: We observed a relatively high rate of favorable outcomes and a small rate of adverse events after readministration of IV alteplase in ischemic stroke patients.

A population-based study of the incidence and case fatality of non-aneurysmal subarachnoid hemorrhage.

BACKGROUND: There is a paucity of reliable and recent data regarding epidemiology of non-aneurysmal subarachnoid hemorrhage (SAH) in population-based studies. OBJECTIVES: To determine the incidence and case fatality of non-aneurysmal SAH using a population-based design. METHODS: Medical records and angiographic data of all patients from Stearns and Benton Counties, Minnesota, admitted with SAH were reviewed to identify incident case of non-aneurysmal SAH. Patients with a first-time diagnosis of non-aneurysmal SAH (based on two negative cerebral angiograms performed ≥7 days apart) between June 1st, 2012 and June 30th, 2014 were considered incident cases. We calculated the incidences of non-aneurysmal and aneurysmal SAH adjusted for age and sex based on the 2010 US census. RESULTS: Of the 18 identified SAH among 189,093 resident populations, five were true incident cases of non-aneurysmal SAH in this population-based study. The age- and sex-adjusted incidence of non-aneurysmal SAH were 2.8 [95 % confidence interval (CI) 2.7-2·9] per 100,000 person-years which was lower than aneurysmal SAH incidence of 7.2 [95 % CI 7.1-7.4] per 100,000 person-years. The age-adjusted incidence of non-aneurysmal SAH was similar (compared with aneurysmal SAH) among men; 3.2 [95 % CI 3.1-3.3] per 100,000 person-years versus 2.2 [95 % CI 2.1-2.3] per 100,000 person-years, respectively. The age-adjusted case fatality rate at 3 months was 4.46 and 0.0 per 100,000 persons for aneurysmal and non-aneurysmal SAH, respectively. CONCLUSIONS: The incidence of non-aneurysmal SAH was higher than previously reported particularly among men.

Incidental asymptomatic intracerebral hemorrhages and risk of subsequent cardiovascular events and cognitive decline in elderly persons.

BACKGROUND: The long-term prognostic significance of incidental asymptomatic intracerebral hemorrhages (aICHs) detected on brain magnetic resonance imaging (MRI) is unknown. METHODS: We analyzed clinical and baseline MRI data from the cohort of 5888 study participants aged 65 years and older recruited in the Cardiovascular Health Study from 4 US communities. We identified participants who had aICHs on MRI and selected 3 age- and gender-matched controls without aICHs. We compared the rates of cardiovascular events using logistic regression analysis including incident myocardial infarction, stroke, and death between those with and without aICHs. RESULTS: A total of 23 participants had aICHs classified as acute (n = 3), subacute (n = 4), and chronic (n = 16). During 14 years of follow-up, the risk of incident stroke (relative risk [RR], .6; 95% confidence interval [CI], .2-2.0), myocardial infarction (RR, .3; 95% CI, .06-1.4), and death (RR, .6; 95% CI, .2-1.7) was not different between participants with aICHs compared with controls (n = 69). There was no difference between the 2 groups with regard to time to ischemic stroke or time to death by Kaplan-Meier analysis. CONCLUSIONS: The risks of stroke, myocardial infarction, and death were similar between persons with aICHs detected on MRI compared with age- and gender-matched controls.

Worse in-hospital outcomes in patients with transient ischemic attack in association with acute kidney injury: analysis of nationwide in-patient sample.

OBJECTIVES: The effect of acute kidney injury (AKI) on outcomes of transient ischemic attack (TIA) is largely unknown. We wanted to determine the impact of AKI on the outcomes of patients admitted with TIA. METHODS: Data from all adult patients admitted to the U.S. hospitals between 2005 and 2011 with a primary discharge diagnosis of TIA and secondary diagnosis of AKI were included, using the nationwide in-patient dataset. The association of AKI with TIA-related mortality and discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. RESULTS: Of the 1,173,340 patients admitted with TIA, 45,974 (3.8%) had AKI. Dialysis was required in 29 (0.06%) patients. TIA patients with AKI had higher rates of moderate-to-severe disability (21.2 vs. 13.7%, p ≤ 0.0001), and in-hospital mortality (0.6 vs. 0.1%, p ≤ 0.0001) compared with those without AKI. After adjusting for age, sex, and potential confounders; TIA patients with AKI had higher odds of moderate-to-severe disability [OR 1.3, 95% CI 1.2-1.4, p < 0.0001] and death (OR 4.2, 95% CI 3.0-6.1, p < 0.0001). CONCLUSIONS: AKI in patients with TIA is associated with significantly higher rates of moderate-to-severe disability at discharge and in-hospital mortality compared with those without AKI.

Increased incidence and treatment of intracranial atherosclerotic disease during mechanical thrombectomy is safe, even with an increased number of passes.

BACKGROUND: The incidence of intracranial atherosclerotic disease (ICAD) in acute ischemic stroke treated with mechanical thrombectomy (MT) is not well defined, and its description may lead to improved stroke devices and rates of first pass success. METHODS: A retrospective study was performed on MT patients from 2012 to 2019 at a comprehensive stroke center using chart review and angiogram analysis. Angiograms at the time of MT were reviewed for ICAD, and location and severity were recorded. Patients with ICAD were divided according to ICAD location relative to the large vessel occlusion (LVO) site. Statistical analyses were performed on baseline demographics, comorbidities, MT procedure variables, outcome variables, and their association with ICAD. RESULTS: Of the 533 patients (mean age 70.4 (SD 13.20) years, 43.5% women), 131 (24.6%) had ICAD. There was no significant difference in favorable discharge outcomes (modified Rankin Scale score of 0-2; 23.8% ICAD vs 27.0% non-ICAD; p=0.82) or groin puncture to recanalization times (average 43.5 (range 8-181) min for ICAD vs 40.2 (4-204) min for non-ICAD; p=0.42). Patients with ICAD experienced a significantly higher number of passes (average 1.8 (range 1-7) passes for ICAD vs 1.6 (1-5) passes for non-ICAD; p=0.0059). Adjusting for age, ≥3 device passes, baseline National Institutes of Health Stroke Scale, rates of angioplasty only, rates of concurrent angioplasty and stenting, coronary artery disease and atrial fibrillation incidences, and time from emergency department arrival to recanalization, yielded no significant difference in rates of favorable outcomes between the two groups. CONCLUSION: Patients who underwent MT with underlying ICAD had similar rates of favorable outcomes as those without, but required a higher number of device passes.

The Effect of Diagnostic Catheter Angiography on Outcomes of Acute Ischemic Stroke Patients Being Considered for Endovascular Treatment.

BACKGROUND: The risk of catheter-based angiograms alone (non-therapeutic angiogram that does not lead to therapeutic intervention) in acute ischemic stroke patients who are considered for endovascular treatment is not well studied. METHODS: We compared the rates of neurological deterioration within 24 h; symptomatic intracranial hemorrhage (ICH) within 30 h; acute kidney injury (AKI) and major non-ICH within five days; and functional independence (defined by modified Rankin scale of 0-2) at three months among subjects who underwent a non-therapeutic catheter-based angiogram with subjects who did not undergo catheter-based angiogram in a multicenter clinical trial. Logistic regression analyses was performed to adjust for age, baseline Alberta stroke program early CT score (ASPECTS) strata (0-7 and 8-10), and baseline National Institutes of Health Stroke Scale (NIHSS) score strata (≤9, 10-19, and ≥20). RESULTS: Compared with subjects who did not undergo any catheter-based angiogram (n = 222), 89 subjects who underwent a non-therapeutic catheter-based angiogram had similar adjusted rates of neurological deterioration [odds ratio (OR) = 1; 95% confidence interval (CI) 0.4-2.3; p = 1] and symptomatic ICH (OR = 0.4; 95% CI 0.1-1.8; p = 0.2). There was no difference in the adjusted rates of AKI, or non-ICH between the two groups. The rate of functional independence at three months was significantly higher among the patients who received a catheter-based angiogram (OR = 2; 95% CI 1.1-3.5; p = 0.016) after adjusting for potential confounders. CONCLUSION: Non-therapeutic catheter-based angiograms in acute ischemic stroke patients who are being considered for endovascular treatment do not adversely affect patient outcomes.

Occurrence of Femoral Nerve Injury among Patients Undergoing Transfemoral Percutaneous Catheterization Procedures in the United States.

BACKGROUND: The proximity of the femoral nerve to the femoral artery renders it vulnerable to injury during transfemoral percutaneous catheterization (TPC) procedures. OBJECTIVE: To determine the incidence of femoral nerve injury in patients undergoing cardiac catheterization in a nationally representative inpatient database. METHODS: We analyzed data released annually from the Nationwide Inpatient Sample. We pooled data from 2002 to 2010 and, using the ICD-9-CM procedure codes, identified patients who underwent TPC. We subsequently identified occurrences of femoral nerve injury in this cohort. Baseline characteristics, comorbid conditions, in-hospital complications, and discharge outcomes-including mortality, mild disability, and moderate-to-severe disability-were compared between patients with femoral neuralgia and those without. RESULTS: Of the 15,894,201 patients who underwent percutaneous catheterization procedures, 597 (3.8 per 100,000 procedures) developed femoral nerve injury. The incidence of femoral nerve injury was higher in women: 57% versus 39%, p < 0.004. Patients with coexisting congestive heart failure or coagulopathy had a non-significant increase in the incidence of femoral nerve injury. There was no in-hospital mortality among patients who developed femoral nerve injury, but the rate of discharge to nursing facilities was higher in this cohort: 17% versus 6%, p < 0.001. After adjusting for age, gender, presence of congestive heart failure, and coagulopathy, femoral nerve injury during percutaneous catheterization procedures was independently associated with moderate-to-severe disability at discharge (odds ratio 2.3; 95% confidence interval 1.4-3.8; p < 0.001). CONCLUSION: Femoral nerve injury is a rare complication of percutaneous catheterization procedures that may increase the likelihood of moderate-to-severe disability at patient's discharge.

Are Hispanic patients with subarachnoid hemorrhage treated differently in border states than in nonborder states?

OBJECTIVE Recent studies have found an underutilization of in-hospital procedures in treatments of Hispanic patients admitted with coronary artery disease in states along the US-Mexico border ("border states"). The purpose of this study was to determine any treatment disparities between patients treated for subarachnoid hemorrhage (SAH) in border and nonborder states and whether this disparity was associated with differential hospital charges. METHODS Using the National (Nationwide) Inpatient Sample, the authors retrieved data of Hispanic and non-Hispanic patients who were admitted in 2011 for SAH in a border state (California, Arizona, New Mexico, and Texas) or nonborder state (the remaining 46 US states). The authors determined the rates of use of endovascular coiling and surgical clipping treatments, hospital charges, and outcomes according to the patients' demographics and treatment in border or nonborder states. RESULTS In total, 18,368 patients were admitted with SAH in the selected time period, including 2310 Hispanic patients (12.6%). Of these patients, 1525 were admitted in a border state and 785 in a nonborder state. In border states, rates of surgical treatment significantly differed between patients of Hispanic (21.9%) and non-Hispanic (14.0%) origin (p = 0.02). In particular, Hispanic patients were more likely to undergo surgical clipping than were non-Hispanic patients. In the nonborder states, the rates of surgical treatment were similar for Hispanic and non-Hispanic patients (14.0% vs 15.6%, p = 0.6). Hispanic patients with SAH were billed significantly higher in-hospital charges in border states than in nonborder states ($219,260 and $192,418 [US dollars], respectively, p < 0.001). CONCLUSIONS Use of surgical treatments for Hispanic patients with SAH residing in border states has a unique pattern, which significantly increases in-hospital charges in this patient population.

Analysis of Spinal Cord Infarction Associated with Aortic Stent Graft Placement Using Nationwide Inpatient Sample (2002-2011).

PURPOSE: We performed this study to identify the rate and determinants of and associated outcomes with spinal cord infarction among patients treated with aortic stent graft placement at a national level. METHODS: We analyzed the data files from Nationwide Inpatient Sample (NIS) from 2002 to 2011. We performed multivariate logistic regression analysis to assess the rates of moderate to severe disability or death in patients with and without spinal cord infarction after adjusting for age, gender, and comorbidities that were significant in univariate analysis. We also determined change in annual rates of spinal cord infarction associated with aortic stent graft placement from 2002 through 2011. RESULTS: Spinal cord infarction occurred in 761 (0.2%) of 305,788 patients who underwent aortic stent graft placement. There was an increase in the annual rate of spinal cord infarction among patients who underwent aortic stent graft placement from 2002 (0.03%) to 2011 (0.4%) (p <0.001). The patients who developed spinal cord infarction had significantly higher odds of in hospital mortality ([odd ratio] OR: 3.0; 95% confidence interval [CI]: 2.4-3.8) after adjusting for age, gender, race/ethnicity, aortic aneurysms, thoracic graft, hypertension, ischemic strokes or transient ischemic attacks, coagulopathy, congestive heart failure, deficiency or chronic blood loss anemia, atrial fibrillation, renal failure, elective admission, and teaching hospital status. Among those who were discharged alive, patients who developed spinal cord infarction had significantly higher odds of moderate to severe disability (OR: 2.8; 95% CI: 2.5-3.2). CONCLUSIONS: The occurrence of spinal cord infarction in patients undergoing aortic stent graft placement appears to be increasing. Spinal cord infarction is associated with prominently higher rates of death and moderate to severe disability.

Hormone replacement therapy and the risk of subarachnoid hemorrhage in postmenopausal women.

OBJECT The incidence of subarachnoid hemorrhage (SAH) increases after menopause. Anecdotal data suggest that hormone replacement therapy (HRT) may reduce the rate of SAH and aneurysm formation in women. The goal of this study was to determine the effect of HRT on occurrence of SAH in a large prospective cohort of postmenopausal women. METHODS The data were analyzed for 93, 676 women 50-79 years of age who were enrolled in the observational arm of the Women's Health Initiative Study. The effect of HRT on risk of SAH was determined over a period of 12 ± 1 years (mean ± SD) using Cox proportional hazards analysis after adjusting for potential confounders. Additional analysis was performed to identify the risk associated with "estrogen only" and "estrogen and progesterone" HRT among women. RESULTS Of the 93, 676 participants, 114 (0.1%) developed SAH during the follow-up period. The rate of SAH was higher among women on active HRT compared with those without HRT used (0.14% vs 0.11%, absolute difference 0.03%, p < 0.0001). In unadjusted analysis, participants who reported active use of HRT were 60% more likely to suffer an SAH (RR 1.6, 95% CI 1.1-2.3). Compared with women without HRT use, the risk of SAH continued to be higher among women reporting active use of HRT (RR 1.5, 95% CI 1.0-2.2) after adjusting for age, systolic blood pressure, cigarette smoking, alcohol consumption, body mass index, race/ethnicity, diabetes, and cardiovascular disease. The risk of SAH was nonsignificantly higher among women on "estrogen only" HRT (RR 1.4, 95% CI 0.91-2.0) than "estrogen and progesterone" HRT(RR 1.2, 95% CI 0.8-2.1) after adjusting for the above-mentioned confounders. CONCLUSIONS Postmenopausal women, particularly those at risk for SAH due to presence of unruptured aneurysms, family history, or cardiovascular risk factors, should be counseled against use of HRT.

Hypertension is Associated With Increased Mortality in Children Hospitalized With Arterial Ischemic Stroke.

BACKGROUND: Recently a single-center study suggested that hypertension after stroke in children was a risk factor for mortality. Our goal was to assess the association between hypertension and outcome after arterial ischemic stroke in children from a large national sample. METHODS: Using the Healthcare Cost and Utilization Project Kids' Inpatient Database, children (1-18 years) with a primary diagnosis of ischemic stroke (International Classification of Diseases, Ninth Revision [ICD-9] codes 433-437.1) who also had a diagnosis of elevated blood pressure (ICD-9 code 796.2) or hypertension (ICD-9 codes 401 and 405) from 2003, 2006, and 2009 were identified. Clinical characteristics, discharge outcomes, and length of stay were assessed. Multivariable logistic regression was used to assess the relationship between hypertension and in-hospital mortality or discharge outcomes. RESULTS: Of 2590 children admitted with arterial ischemic stroke, 156 (6%) also had a diagnosis of hypertension. Ten percent of children with hypertension also had renal failure. Among patients with arterial ischemic stroke, hypertension was associated with increased mortality (7.4% vs. 2.8%; P = 0.01) and increased length of stay (mean 11 ± 17 vs. 7 ± 12 days; P = 0.004) compared with those without hypertension. After adjusting for age, sex, intubation, presence of a fluid and electrolyte disorder, and renal failure, children with hypertension had an increased odds of in-hospital death (odds ratio 1.2, 95% confidence interval [1.1-3.3, P = 0.04]). CONCLUSION: Hypertension was associated with an increased risk of in-hospital death for children presenting with arterial ischemic stroke. Further prospective study of blood pressure in children with stroke is needed.

Lumbar Catheter Placement Using Paramedian Approach Under Fluoroscopic Guidance.

BACKGROUND: Lumbar catheter placement under fluoroscopic guidance may reduce the rate of technical failures and associated complications seen with insertion guided by manually palpable landmarks. METHODS: We reviewed our experience with 43 attempted lumbar catheter placements using paramedian approach under fluoroscopic guidance and ascertained rates of technical success, and clinical events. RESULTS: Among the 43 patients, 18, 1, and 1 patients were on aspirin (with dipyrimadole in 2), clopidogrel, and combination of both, respectively. Lumbar catheter placement was successful in 42 of 43 attempted placements. Floroscopic guidance was critical in three patients; one patient had severe cerebrospinal fluid (CSF) depletion (empty thecal sac phenomenon) following pituitary surgery leading to no cerebrospinal fluid return despite correct placement confirmation under fluoroscopy. Two patients had spinal needle placement at the junction between epidural and cerebrospinal fluid spaces (junctional position) leading to cerebrospinal fluid return but inability to introduce the lumbar catheter. After confirmation of position by the injection of contrast or radiographic landmarks the needle was advanced by indenting the subcutaneous tissue or reinserting at a spinal level above the first insertion. The lumbar catheter remained in position over a mean period (±standard deviation) of 4.1(±2.3) days. Improvement in hydrocephalus was seen in two patients with intracranial mass lesions. One patient developed cerebrospinal fluid leakage through the insertion track following removal of catheter and required skin suturing at the site of insertion. CONCLUSIONS: We observed a high technical success rate with low rate of complications even in patients with intracranial mass lesions, those on ongoing antiplatelet medications or in whom insertion would not be possible guided by manually palpable landmarks.

Does Hospitalist Directed Care for Acute Ischemic Stroke Patients Improve Adherence to "Get with the Guidelines"?

BACKGROUND AND PURPOSE: Hospitalist directed care is associated with improved outcomes in several medical conditions. The hospitalist effect has not been studied in acute ischemic stroke (AIS) patients. We compare length of stay (LOS), outcome, and adherence to "Get with the Guidelines" (GWTG) stroke quality measures among AIS patients admitted under a hospitalist with three other specialties (internist, family practice, or specialist). METHODS: We collected demographics, risk factors and discharge outcomes (modified Rankin Scale (mRS)) for consecutive AIS patients over 4-year period (2010-2014). We categorized all stroke admissions according to admitting physicians. We compared rates of adherence with all of the GWTG Stroke inpatient quality measures between the four groups. RESULTS: A total of 1584 patients [mean age ( ± SD) 68.6 ± 13.7 years; 55.6% men] were admitted with AIS. There was no statistically significant difference in LOS between the four groups (p=0.4). There was significant difference in the GWTG inpatient quality measures with the hospitalist group having lowest rates of any nonadherence observed in 5% of admissions (p=0.03), and the internists had the highest rate of nonadherence observed in 16% of admissions (p=0.01). The most common deficiency was not prescribing statin at discharge (56% of total fallouts). There was no difference in rates of poor outcomes on discharge (mRS 3-6) (p=0.2). CONCLUSIONS: There was a significantly higher rate of adherence to GWTG inpatient stroke measures when AIS patients were admitted under the care of a hospitalist. Prospective studies are required to evaluate if higher rates of adherence lead to better long term outcomes.

Risk of In-Hospital Cardiac Arrest Among Medicare Beneficiaries Undergoing Video Electroencephalographic Monitoring.

PURPOSE: Sudden cardiac death is the dominant reason of sudden unexpected death in epilepsy (SUDEP). Anecdotal reports have documented cardiac arrest during video electroencephalographic (EEG) monitoring. We performed this study to determine the rate of cardiac arrest and need for cardiac resuscitation during video EEG monitoring. METHODS: We used inpatient data from the Centers for Medicare and Medicaid Services (CMS)'s Linkable 2008-2010 Medicare Data Entrepreneur's Synthetic Public Use File. Using the International Classification of Diseases 9th revision (ICD-9) primary diagnosis codes, we identified patients with epilepsy. We used the primary or secondary ICD-9 procedure codes to identify patients who underwent video EEG during admission. For primary endpoints, we identified patients who suffered cardiac arrest and those who underwent cardiorespiratory resuscitation (CPR). RESULTS: A total of 6,087 patients (mean age 76±12 years; 3,354 women) were included; 5,597 patients had a primary diagnosis of epilepsy and no video EEG, 240 patients had a primary diagnosis of epilepsy and underwent video EEG, and 250 patients underwent a video EEG without any diagnosis of epilepsy. A total of 12 patients (0.2%, 95% CI: 0.7-0.8) suffered a cardiac arrest during their admission. Three patients (0.1%) underwent CPR during their admission. There was no in-hospital mortality. None of the patients in those undergoing video EEG suffered cardiac arrest or underwent CPR. CONCLUSION: While the risk of cardiac arrest during video EEG monitoring may exist, the rate of such events was negligible in our study comprising of elderly Medicare patients.

Factors Associated With Increased In-Hospital Mortality Among Children With Intracerebral Hemorrhage.

We assessed factors associated with mortality and potential targets for intervention in a large national sample of children with nontraumatic intracerebral hemorrhage. Using Healthcare Cost and Utilization Project Kids' Inpatient Database ICD-9-CM code 431 identified children aged 1 to 18 years with nontraumatic intracerebral hemorrhage in 2003, 2006 and 2009. Intracerebral hemorrhage was the primary diagnosis for 1172 children (ages 1-18 years) over the 3-year sample. Factors associated with mortality based on multivariable logistic regression included Hispanic ethnicity (odds ratio 1.9, 95% confidence interval 1.1-3.3), older age (11-18 vs 1-10 years, odds ratio 2.5, 95% confidence interval 1.3-5.0), coagulopathy (odds ratio 3.0, 95% confidence interval 1.6-6.0), and coma (odds ratio 9.0, 95% confidence interval 3.2-24.6). From 2003 to 2009, there was a non-significant decrease in mortality with a significant increase in length of stay from 9 to 11 days (P < .003). In children with intracerebral hemorrhage, coma and coagulopathy had the strongest association with mortality; coagulopathy is a potentially modifiable risk factor.

Catheter-Based Trans-Epidural Approach to Aspirate Cervical and Thoracic Epidural Abscesses: A Cadaveric Feasibility Study.

BACKGROUND: Approaching and aspirating cervical and high thoracic epidural abscesses through a trans-epidural route from the lumbar region access represents an alternative method for selected patients. OBJECTIVE: We determined the feasibility of catheter-based manipulation and aspiration using the trans-epidural route. MATERIAL AND METHODS: A custom designed infusion-suction catheter system that includes an outer suction catheter and inner infusion catheter in concentric relation with radio-opaque marker bands was tested in a cadaveric preparation to determine (1) the ability to place an aspiration catheter over a guidewire using a percutaneous approach within the posterior lumbar epidural space; (2) the highest vertebral level a catheter can be advanced within the epidural space; and (3) the ability to aspirate artificial purulent-like material placed in the cervical and thoracic level epidural space. RESULTS: We were able to advance two infusion-suction catheter systems from a 14G Touhy spinal needle inserted via an oblique parasagittal approach at the L2-L3 intervertebral space. The infusion-suction catheter was advanced up to the level of the cervical vertebral level of C2 within the epidural space under fluoroscopic guidance. We were able to aspirate artificial purulent-like material directly injected with a 22G Quincke spinal needle at vertebral levels C4-C5 and at vertebral levels T10-T11 by aspiration and manipulation of the outer catheter within the epidural space at levels C3-C7 and T9-L1, respectively. CONCLUSIONS: Our observations support the further exploration of a percutaneous catheter-based trans-epidural approach to treat epidural abscesses. The trans-epidural approach may be used alone or as a staged or concurrent approach with open surgical treatment.