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Vasospasm after aneurysmal subarachnoid hemorrhage was noted in some studies to be less frequent and less severe in older age. One hypothesis is that atherosclerosis makes arteries too stiff to spasm. The objective of this study was to assess the association between intracranial calcification, a marker for atherosclerosis, and vasospasm. Charts and nonenhanced computed tomography scans of patients with subarachnoid hemorrhage were retrospectively reviewed. Transcranial Doppler studies were used to categorize vasospasm using mean flow velocity: mild vasospasm 120-199 cm/second and severe ≥ 200 cm/second. Calcification of the intracranial internal carotid artery was quantified by calculating the volume and density of the calcified lesions. A total of 172 patients met study criteria (mean age, 54 ± 13 years; 88 women). Patients who had calcification (n = 90; 52%) were significantly older (61 ± 12 years vs. 46 ± 10 years; P < .0001). Mean calcification score was 532 ± 853. Calcification score was directly associated with age (P < .0001) and inversely associated with mean flow velocity (P = .0027). Only the highest tertile was independently associated with less vasospasm (odds ratio, .34; 95% confidence interval, .12-.93). There was an interaction between calcification score and age in which age greater than 65 years was only protective of vasospasm when combined with the highest calcification tertile. We conclude that intracranial calcification is associated with lower rates of vasospasm. The amount of visualized calcification inversely influences the severity of vasospasm. Calcification, and the underlying presumed atherosclerosis, maybe 1 mechanism by which vasospasm has lower frequency and severity in older age.
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Arteria Carótida Interna/fisiopatología , Aneurisma Intracraneal/complicaciones , Hemorragia Subaracnoidea/etiología , Calcificación Vascular/fisiopatología , Vasoespasmo Intracraneal/fisiopatología , Adulto , Anciano , Anciano de 80 o más Años , Velocidad del Flujo Sanguíneo , Arteria Carótida Interna/diagnóstico por imagen , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Hemorragia Subaracnoidea/diagnóstico por imagen , Tomógrafos Computarizados por Rayos X , Ultrasonografía Doppler Transcraneal , Calcificación Vascular/diagnóstico por imagen , Vasoespasmo Intracraneal/diagnóstico por imagenRESUMEN
OBJECTIVE: The objective was to determine the long-term outcome of patients with severe persistent neurological deficits without a large infarction on computed tomographic (CT) scan. METHODS: We analyzed the prospectively collected data as part of the randomized, placebo controlled trial in patients with ischemic stroke presenting within 3 hours of symptom onset. Volume of infarction was measured from CT scan acquired at 3 months. Favorable outcome defined by no significant or slight disability on a modified Rankin scale at 12 months. We determined the outcome of patients with National Institutes of Health Stroke Scale score (NIHSS score) ≥ 10 at 24 hours. RESULTS: Of the 277 patients with NIHSS score ≥ 10 at 24 hours, 88 (32%) met the criteria of clinical-radiological severity mismatch. Compared with patients with NIHSS score ≥ 10 with infarct volume ≥ 20 cc, the patients with NIHSS score ≥ 10 and infarct volume <20 cc were older but there were no differences in the gender, race or vascular risk factors. Patients with clinical-radiological severity mismatch were more likely to have a favorable outcome at 12 months compared with those without mismatch (odd ratio 4.3, 95% confidence interval 1.5-12.6, P = .0063) after adjusting for potential confounders. CONCLUSIONS: We observed that approximately one-fourth of patients with severe neurological deficits have clinical-radiological severity mismatch. Such patients appear to have a high rate of favorable outcomes at 1 year.
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Infarto Cerebral/diagnóstico , Infarto Cerebral/terapia , Enfermedades del Sistema Nervioso/diagnóstico , Enfermedades del Sistema Nervioso/prevención & control , Activador de Tejido Plasminógeno/uso terapéutico , Tomografía Computarizada por Rayos X/estadística & datos numéricos , Adulto , Anciano , Anciano de 80 o más Años , Infarto Cerebral/epidemiología , Método Doble Ciego , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Enfermedades del Sistema Nervioso/epidemiología , Efecto Placebo , Prevalencia , Pronóstico , Factores de Riesgo , Índice de Severidad de la Enfermedad , Resultado del Tratamiento , Estados Unidos/epidemiología , Adulto JovenAsunto(s)
Hipertensión/diagnóstico , Imagen por Resonancia Magnética/métodos , Daño por Reperfusión/diagnóstico , Accidente Cerebrovascular/diagnóstico , Enfermedad Aguda , Anciano de 80 o más Años , Presión Sanguínea/fisiología , Humanos , Hipertensión/complicaciones , Masculino , Reperfusión/efectos adversos , Daño por Reperfusión/complicaciones , Accidente Cerebrovascular/complicacionesRESUMEN
BACKGROUND: The 'drip-and-ship' paradigm denotes a treatment regimen in patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated at the emergency department (ED) of a community hospital, followed by transfer within 24 h to a comprehensive stroke center. Although the drip-and-ship paradigm has the potential to increase the number of patients who receive IV rt-PA, comparative outcomes have not been assessed at a population-based level. METHODS: Statewide estimates of thrombolysis, associated in-hospital outcomes, and hospitalization charges were obtained from 2008-2009 Minnesota Hospital Association data for all patients hospitalized with a primary diagnosis of ischemic stroke. Patients who were assigned the drip-and-ship code [International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) V45.88] were classified under the drip-and-ship paradigm. Patients who underwent thrombolysis (ICD-9-CM code 99.10) without drip-and-ship code were classified as primary ED arrival. Patient outcomes were analyzed after stratification into patients treated with IV rt-PA through primary ED arrival or drip-and-ship paradigm. RESULTS: Of the 21,024 admissions, 602 (2.86%) received IV rt-PA either through primary ED arrival (n = 473) or the drip-and-ship paradigm (n = 129). IV rt-PA was administered in 30 hospitals, of which 13 hospitals used the drip-and-ship paradigm; the number of patients treated with the drip-and-ship paradigm varied from 1 to 40 between the 13 hospitals. The rates of secondary intracerebral or subarachnoid hemorrhage were higher in patients treated with IV rt-PA through primary ED arrival compared with those treated with the drip-and-ship paradigm (8.5 vs. 3.1%, respectively; p = 0.038). The in-hospital mortality rate was similar among ischemic stroke patients receiving IV rt-PA through primary ED arrival or the drip-and-ship paradigm (5.9 vs. 7.0%, respectively). The mean hospital charges were USD 65,669 for primary ED arrival and USD 47,850 for drip-and-ship-treated patients (p < 0.001). The rate of admission to a certified stroke center as final destination for acute hospitalization was higher in patients treated by drip-and-ship paradigm compared with those treated by primary ED arrival mode (p = 0.015). CONCLUSIONS: The results of the drip-and-ship paradigm compare favorably with IV rt-PA treatment through primary ED arrival in this statewide study. Our results support the recommendations of various professional organizations that the drip-and-ship method of IV rt-PA administration for stroke may be an effective option for increasing the utilization of IV rt-PA on a large scale.
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BACKGROUND: To evaluate the agreement in patient selection based on computed tomography (CT) and CT-perfusion (CT-P) imaging interpretation between stroke specialists in stroke patients considered for endovascular treatment. METHODS: All endovascular-treated acute ischemic stroke patients were identified through a prospective database from two comprehensive stroke centers; 25 consecutively treated patients were used for this analysis. Initial CT images and CT-P data were independently interpreted by five board eligible/certified vascular neurologists with additional endovascular training to decide whether or not to select the patient for endovascular treatment. The CT/CT-P images were evaluated separately and used as the sole imaging decision making criteria, 2 weeks apart from each other (memory wash-out period). For each set of imaging data inter-rater and intra-rater agreement scores were obtained using Cohen's kappa statistic to assess the proportion of agreement beyond chance. RESULTS: Kappa values for the treatment decisions based on CT images was 0.43 (range 0.14-0.8) (moderate agreement), and for the decisions based on CTP images was 0.29 (range 0.07-0.67) (fair agreement) among the five subjects. There was substantial variability within the group and between images interpretation. Observed agreement on decision to treat with endovascular therapy was found to be 75% with CT images and 59% with CT-P images (with no adjustment for chance). Kappa values for intra-rater agreement were -0.14 (ranged -0.27-0.27) (poor agreement). CONCLUSIONS: There is considerable lack of agreement, even among stroke specialists, in selecting acute ischemic stroke patients for endovascular treatment based on CT-P changes. This mandates a careful evaluation of CT-P for patient selection before widespread adoption.
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Isquemia Encefálica/tratamiento farmacológico , Procedimientos Endovasculares/métodos , Selección de Paciente , Accidente Cerebrovascular/tratamiento farmacológico , Terapia Trombolítica/métodos , Anciano , Femenino , Fibrinolíticos/uso terapéutico , Humanos , Masculino , Persona de Mediana Edad , Imagen de Perfusión , Estudios Prospectivos , Tomografía Computarizada por Rayos XRESUMEN
OBJECTIVES: The aim of this study was to compare the clinical outcomes of acute ischemic stroke patients 80 years or older treated with intravenous recombinant tissue plasminogen activator (i.v. rt-PA), or endovascular intervention with or without i.v. rt-PA, or nonthrombolytic medical treatment. METHODS: This study was a retrospective, nonrandomized, observational study of patients, admitted within 9 hours of symptom onset, at 3 academic, university-affiliated hospitals. The main outcome measures were neurologic improvement, defined by improvement in National Institutes of Health Stroke Scale score at 7 days or discharge of 4 or more, or achieving a score of 0; symptomatic and asymptomatic intracerebral hemorrhage; favorable outcome (discharge modified Rankin score 0-2); and in-hospital mortality. RESULTS: A total of 44 patients received i.v. rt-PA, 46 received endovascular intervention with or without i.v. rt-PA, and 66 received nonthrombolytic medical treatment. I.v. rt-PA-treated patients had a significantly clinically higher chance of favorable outcome (odds ratio [OR], 5.6; 95% confidence interval [CI], 1.8-17.5), when compared with nonthrombolytic medical treatment. A significantly higher rate of neurologic improvement was observed among the i.v. rt-PA (7.2; 95% CI, 2.7-19.5) and endovascularly treated patients (5.8; 95% CI, 2-16.8) when compared with nonthrombolytic medical treatment. CONCLUSIONS: A prominently higher rate of neurologic improvement and favorable clinical outcome was observed among acute ischemic stroke patients 80 years or older treated with i.v. rt-PA or endovascular intervention when compared with nonthrombolytic medical treatment, supporting the use of acute thrombolytic therapies in this patient population when contraindications are not present.
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Infarto Encefálico/terapia , Fibrinolíticos/uso terapéutico , Terapia Trombolítica , Activador de Tejido Plasminógeno/uso terapéutico , Anciano de 80 o más Años , Infarto Encefálico/tratamiento farmacológico , Infarto Encefálico/cirugía , Distribución de Chi-Cuadrado , Procedimientos Endovasculares , Femenino , Humanos , Modelos Logísticos , Masculino , Proteínas Recombinantes/uso terapéutico , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Evaluating transient impairment of consciousness is critical to diagnose epileptic seizures, syncope, parasomnias, organic encephalopathies, and psychogenic nonepileptic seizures. Effective evaluation of episodic unconscious events demands interactive interviewing of the patient and witnesses of the events, with judgment as to historians' observational abilities. When generalized tonic-clonic seizures have been witnessed by medical staff or other reliable observers, a search for concomitant nonconvulsive events and for comorbid illnesses often elucidates diagnoses unsuspected by the referring physician. Consultation for stupor-coma should not miss a potentially reversible acute severe encephalopathy, particularly when reversibility requires timely therapy. Perspicacious analyses of complex cognitive-motor phenomena support judicious application of diagnostic procedures, including brief or prolonged EEG and video-EEG, EKG tilt-table testing, EKG loop monitoring, and brain imaging.
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OBJECTIVE: To determine the outcomes related to thrombolytic treatment of an acute ischemic stroke secondary to an arterial dissection in a large national cohort. DESIGN: Retrospective database study. SETTING: Nationwide Inpatient Sample data files from 2005 to 2008. PATIENTS: We determined the frequency of underlying arterial dissection among patients with acute ischemic stroke treated with thrombolytic treatment and associated in-hospital outcomes. MAIN OUTCOME MEASURES: All the in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis. RESULTS: Of the 47,899 patients with ischemic stroke who received thrombolytic treatment, 488 (1%) had an underlying dissection. The intracranial hemorrhage rates did not differ between patients with ischemic stroke with or without underlying dissection who received thrombolytic treatment (6.9% vs 6.4%). After adjusting for age, sex, hypertension, diabetes mellitus, renal failure, congestive heart failure, and hospital teaching status, presence of dissection was associated with higher rates of moderate disability (odds ratio, 2.8; 95% confidence interval, 1.7-4.6; P < .001) at discharge. The interaction terms between dissection and thrombolytic treatment among all patients with ischemic stroke for predicting in-hospital mortality (P = .84) and minimal disability (P = .13) were not statistically significant. CONCLUSIONS: The adjusted rate of favorable outcomes is lower among patients with ischemic stroke with underlying arterial dissection following thrombolytic treatment compared with those without underlying dissections. However, the observed lower rates are not influenced by thrombolytic treatment.
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Disección Aórtica/complicaciones , Isquemia Encefálica/terapia , Enfermedades Arteriales Intracraneales/complicaciones , Accidente Cerebrovascular/terapia , Terapia Trombolítica , Enfermedad Aguda , Anciano , Isquemia Encefálica/complicaciones , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Terapia Trombolítica/efectos adversos , Resultado del Tratamiento , Estados UnidosRESUMEN
BACKGROUND: There is some evidence that hyperglycemia increases the rate of poor outcomes in patients with intracerebral hemorrhage (ICH). We explored the relationship between various parameters of serum glucose concentrations measured during acute hospitalization and hematoma expansion, perihematomal edema, and three month outcome among subjects with ICH. METHODS: A post-hoc analysis of a multicenter prospective study recruiting subjects with ICH and elevated systolic blood pressure (SBP) ≥170 mmHg who presented within 6 h of symptom onset was performed. The serum glucose concentration was measured repeatedly up to 5 times over 3 days after admission and change over time was characterized using a summary statistic by fitting the linear regression model for each subject. The admission glucose, glucose change between admission and 24 hour glucose concentration, and estimated parameters (slope and intercept) were entered in the logistic regression model separately to predict the functional outcome as measured by modified Rankin scale (mRS) at 90 days (0-3 vs. 4-6); hematoma expansion at 24 h (≤33 vs. >33%); and relative perihematomal edema expansion at 24 h (≤40 vs. >40%). RESULTS: A total of 60 subjects were recruited (aged 62.0 ±15.1 years; 56.7% men). The mean of initial glucose concentration (±standard deviation) was 136.7 mg/dl (±58.1). Thirty-five out of 60 (58%) subjects had a declining glucose over time (negative slope). The risk of poor outcome (mRS 4-6) in those with increasing serum glucose levels was over two-fold relative to those who had declining serum glucose levels (RR = 2.64, 95% confidence interval [CI]: 1.03, 6.75). The RRs were 2.59 (95% CI: 1.27, 5.30) for hematoma expansion >33%; and 1.25 (95% CI: 0.73, 2.13) for relative edema expansion >40%. CONCLUSIONS: Decline in serum glucose concentration correlated with reduction in proportion of subjects with hematoma expansion and poor clinical outcome. These results provide a justification for a randomized controlled clinical trial to evaluate the efficacy of aggressive serum glucose reduction in reducing death and disability among patients with ICH.
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Glucemia/metabolismo , Edema Encefálico/sangre , Hemorragia Cerebral/sangre , Hematoma/sangre , Hospitalización , Hiperglucemia/sangre , Anciano , Anciano de 80 o más Años , Antihipertensivos/administración & dosificación , Edema Encefálico/diagnóstico , Edema Encefálico/mortalidad , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/mortalidad , Progresión de la Enfermedad , Femenino , Escala de Coma de Glasgow , Hematoma/diagnóstico , Hematoma/mortalidad , Humanos , Hiperglucemia/diagnóstico , Hiperglucemia/mortalidad , Hipertensión/sangre , Hipertensión/diagnóstico , Hipertensión/mortalidad , Hipoglucemiantes/administración & dosificación , Infusiones Intravenosas , Insulina/administración & dosificación , Masculino , Persona de Mediana Edad , Examen Neurológico , Nicardipino/administración & dosificación , Proyectos Piloto , Pronóstico , Estudios Prospectivos , Estadística como Asunto , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Percutaneous transluminal angioplasty (PTA) has been introduced for treatment of symptomatic cerebral vasospasm in patients with subarachnoid hemorrhage (SAH). While angiographic improvement is consistently reported, clinical improvement following the procedure varies, and limited data is available regarding overall impact on outcome. METHODS: The authors performed a retrospective analysis of all hospital admissions with aneurysmal SAH over a 6 year period. The length of stay, discharge outcomes (measured by modified Rankin scale [mRS] at discharge), and 1-year mortality among patients with SAH before (4 year period) and after (2 year period) institution of PTA for cerebral vasospasm were compared. Embolization for intracranial aneurysm was used as a therapeutic option throughout the study duration. The effect of institution of PTA for vasospasm after adjusting for age, clinical severity, and use of aneurysm embolization on both discharge outcomes and 1-year mortality in multivariate analysis was evaluated. RESULTS: A total of 146 patients with aneurysmal SAH were admitted during the study duration. There was no difference between the 89 patients admitted in pre-angioplasty period and 57 patients admitted in post-angioplasty period in regards to age, medical co-morbidities, and admission clinical severity of patients (measured by Hunt and Hess grade and Glasgow coma scale). A total of 18 (32%) patients underwent PTA with or without intra-arterial vasodilator treatment in the second period of the study. There was a non significant decrease in rates of severe disability and death (mRS 5-6) at discharge (45 vs. 33%, P = 0.09) and 1-year mortality (32 vs. 22%, P = 0.26) after introduction of PTA for cerebral vasospasm after adjusting for potential confounders. There was no significant difference between the two time periods in regards to length of stay. CONCLUSION: A non significant trend was noted with reduced rate of severe disability and mortality at discharge and 1-year mortality after the introduction of PTA for cerebral vasospasm associated with SAH without increasing the length of hospital stay.
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Angioplastia , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/terapia , Vasoespasmo Intracraneal/terapia , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Embolización Terapéutica , Femenino , Humanos , Tiempo de Internación , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Hemorragia Subaracnoidea/mortalidad , Tasa de Supervivencia , Resultado del Tratamiento , Vasoespasmo Intracraneal/diagnóstico , Vasoespasmo Intracraneal/etiología , Adulto JovenRESUMEN
BACKGROUND: Primary angioplasty has been introduced for the treatment of symptomatic cerebral vasospasm in patients with subarachnoid hemorrhage (SAH). The data regarding the therapeutic benefit of angioplasty in improving patient outcomes are limited, hence its utilization at hospitals remains controversial and currently is not reimbursed by Medicare or major insurance companies. METHODS: We analyzed the data from Nationwide Inpatient Sample (NIS), a nationally representative dataset of all admissions in the United States from 2005 to 2007. We analyzed the prevalence of angioplasty procedure for cerebral vasospasm at the national level. In-hospital mortality, discharge status, length of stay, and cost of hospitalization were compared between hospitals performing angioplasty with those not performing angioplasty in multivariable model, adjusted for patient's age, utilization of endovascular aneurysm obliteration, and disease severity. RESULTS: Of the 74,356 estimated patients with nontraumatic SAH, 47% (n = 35,172) were admitted to hospitals that perform angioplasty for cerebral vasospasm and only 1307 patients (3.8%) were treated with angioplasty for vasospasm. In multivariable analysis, after adjustment for patient and hospital characteristics, we found that patients admitted to hospitals performing angioplasty had higher rates of discharge to home without supervision (OR 1.3, 95% CI: 1.1-1.6). There was no difference in in-hospital mortality, length of stay, or cost of hospitalization. CONCLUSIONS: Our analysis suggests that the odds of a patient being discharged to home are better at hospitals performing angioplasty for cerebral vasospasm. Provision of angioplasty may be used as a surrogate marker of model of care in management of patients with SAH.
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Angioplastia , Hospitalización , Hemorragia Subaracnoidea/complicaciones , Hemorragia Subaracnoidea/terapia , Vasoespasmo Intracraneal/terapia , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Hemorragia Subaracnoidea/mortalidad , Tasa de Supervivencia , Resultado del Tratamiento , Estados Unidos , Vasoespasmo Intracraneal/etiología , Vasoespasmo Intracraneal/mortalidadRESUMEN
OBJECTIVE: To identify the relationship between the magnitude of leptomeningeal collaterals (LMC) on digital subtraction angiography (DSA) and regional cerebral blood volume (rCBV)/regional cerebral blood flow (rCBF) mismatch on computed tomography perfusion (CTP) in patients with acute middle cerebral artery (MCA) occlusion. DESIGN/METHODS: We reviewed the clinical records, and neuroimaging studies in consecutive patients with proximal MCA (M1-segment) and proximal branch (M2-segment) occlusion undergoing endovascular treatment following the demonstration of mismatch on CTP. DSA images acquired prior to the treatment were used to grade collateral flow from the anterior cerebral artery to the MCA on a scale ranging from 1 to 5, based on retrograde reconstitution of MCA segments in the late arterial phase. CTP images were reviewed and rCBV/rCBF mismatch was categorized as minor (≤ 1/3 of MCA territory), moderate (1/3-2/3 of MCA territory), or severe (> 2/3 to complete territory). Statistical association was assessed using Pearson exact test. RESULTS: A total of sixteen patients were studied (10 were men; mean age of 69 years). Mean time from symptom onset to CTP was 146 minutes. Patients with M1-segment occlusion (n=10) had more severe rCBV/rCBF mismatch compared to patients with M2-segment occlusion (p=0.016). There was no association between the magnitude of LMC and severity of rCBV/rCBF mismatch on CTP. CONCLUSIONS/RELEVANCE: The magnitude of LMC on DSA does not correlate with the severity of rCBV/rCBF mismatch in patients with MCA occlusion. This result suggests that additional factors, such as micro vascular failure, may contribute to altered cerebral perfusion.
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BACKGROUND: Intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is used to treat acute ischemic stroke (AIS) within 4.5 hours of symptom onset. Endovascular treatment (ET) may provide higher rates of recanalization, but longer time to treatment may limit comparative clinical benefit and widespread applicability. OBJECTIVE: This retrospective study compares symptom onset to treatment times in patients who received both IV rt-PA and ET for AIS and its effect on clinical outcome. METHODS: AIS patients presenting to our facility who received both IV rt-PA and ET were reviewed using them as case and control to match other factors contributing to time to treatment. Good outcome was defined as modified Rankin Scale score 0 to 2 at discharge. RESULTS: Fifty patients received both treatments with significantly shorter mean symptom onset to time to IV rt-PA compared with symptom onset to time to ET (96.8 ± 39.3 minutes versus 255.3 ± 92.2 minutes, p < 0.001). Patients receiving ET in less time than the mean time had a higher rate of favorable outcome at discharge (45.5% versus 11.8%, p = 0.017) and a significantly lower rate of mortality at three months (15.2% versus 52.9%, p = 0.017) than those receiving it after the mean time. The symptom onset to times to ET was significantly longer in transferred patients compared to primary emergency department patients (299.3 minutes versus 230.5 minutes, p = 0.01) CONCLUSION: A considerable difference in symptom onset to treatment times between IV and ET was observed among patients with AIS, especially those who were transferred from another facility. Reducing the time to treatment for ET has the potential to improve outcomes among ischemic stroke patients.
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BACKGROUND: Evidence indicates that systolic blood pressure (SBP) reduction may reduce hematoma expansion in patients with intracerebral hemorrhage (ICH) who are initially seen with acute hypertensive response. OBJECTIVE: To explore the relationship between different variables of SBP reduction and hematoma expansion, perihematomal edema, and 3-month outcome among patients with ICH. DESIGN: Post hoc analysis of a traditional phase 1 dose-escalation multicenter prospective study. SETTING: Emergency departments and intensive care units. PATIENTS: Patients having ICH with an elevated SBP of at least 170 mm Hg who were seen within 6 hours of symptom onset. INTERVENTION: Systolic blood pressure reduction using intravenous nicardipine hydrochloride targeting 3 tiers of sequentially escalating SBP reduction goals (170-199, 140-169, or 110-139 mm Hg). MAIN OUTCOME MEASURES: We evaluated the effect of SBP reduction (relative to initial SBP) on the following: hematoma expansion (defined as an increased intraparenchymal hemorrhage volume >33% on 24-hour vs baseline computed tomographic [CT] images), higher perihematomal edema ratio (defined as a >40% increased ratio of edema volume to hematoma volume on 24-hour vs baseline CT images), and poor 3-month outcome (defined as a modified Rankin scale score of 4-6). RESULTS: Sixty patients (mean [SD] age, 62.0 [15.1] years; 34 men) were recruited (18, 20, and 22 patients in each of the 3 SBP reduction goal tiers). The median area under the curve (AUC) (calculated as the area between the hourly SBP measurements over 24 hours and the baseline SBP) was 1360 (minimum, 3643; maximum, 45) U. Comparing patients having less vs more aggressive SBP reduction based on 24-hour AUC analysis, frequencies were 32% vs 17% for hematoma expansion, 61% vs 40% for higher perihematomal edema ratio, and 46% vs 38% for poor 3-month outcome (P > .05 for all). The median SBP reductions were 54 mm Hg at 6 hours and 62 mm Hg at 6 hours from treatment initiation. Comparing patients having equal to or less vs more than the median SBP reduction at 2 hours, frequencies were 21% vs 31% for hematoma expansion, 42% vs 57% for higher perihematomal edema ratio, and 35% vs 48% for poor 3-month outcome (P > .05 for all). CONCLUSIONS: We found no significant relationship between SBP reduction and any of the outcomes measured herein; however, the Antihypertensive Treatment of Acute Cerebral Hemorrhage study was primarily a safety study and was not powered for such end points. The consistent favorable direction of these associations supports further studies with an adequately powered randomized controlled design to evaluate the efficacy of aggressive pharmacologic SBP reduction.
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Antihipertensivos/administración & dosificación , Presión Sanguínea/efectos de los fármacos , Hipertensión/complicaciones , Hipertensión/tratamiento farmacológico , Hemorragia Intracraneal Hipertensiva/tratamiento farmacológico , Hemorragia Intracraneal Hipertensiva/etiología , Adulto , Anciano , Antihipertensivos/efectos adversos , Presión Sanguínea/fisiología , Encéfalo/irrigación sanguínea , Encéfalo/metabolismo , Encéfalo/patología , Edema Encefálico/etiología , Edema Encefálico/fisiopatología , Edema Encefálico/prevención & control , Arterias Cerebrales/efectos de los fármacos , Arterias Cerebrales/fisiopatología , Relación Dosis-Respuesta a Droga , Servicios Médicos de Urgencia/métodos , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Humanos , Hipertensión/fisiopatología , Hemorragia Intracraneal Hipertensiva/fisiopatología , Masculino , Persona de Mediana Edad , Nicardipino/administración & dosificación , Nicardipino/efectos adversos , Evaluación de Resultado en la Atención de Salud , Estudios Prospectivos , Factores de Tiempo , Resultado del TratamientoRESUMEN
Treatment of high-grade symptomatic carotid stenosis via carotid endarterectomy has been shown to be superior to medical management alone in several studies. Carotid angioplasty and stenting (CAS) has emerged as an alternative approach to endarterectomy to reduce the associated perioperative risks. Several anatomic and physiologic factors that increase the risk of stroke and/or death associated with endarterectomy have been identified. The alternative approach of CAS has been found to be noninferior to endarterectomy for high surgical risk patients with severe symptomatic carotid stenosis and the use of this procedure is supported by the current widely accepted guidelines. In patients with standard surgical risk, the differential benefit of CAS compared with endarterectomy is not clear. Several advantages of CAS have been identified in previous studies in selected patients. The results of CAS will undoubtedly continue to improve with advances in device designs, technological expertise, and appropriate patient selection.
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Angioplastia de Balón , Arterias Carótidas/patología , Estenosis Carotídea/terapia , Stents , Endarterectomía Carotidea , Humanos , Medición de Riesgo , Accidente Cerebrovascular/prevención & control , Accidente Cerebrovascular/terapiaRESUMEN
INTRODUCTION: No clinical data exist to compare outcomes between patients with intracerebral hemorrhage (ICH) treated with different intravenous antihypertensive agents. This study was performed to compare outcomes among patients with ICH who were treated with intravenous infusion of different antihypertensive medications during the first 24 hours after admission. METHODS: We analyzed one-year data (2005-2006) from the Premier database which is a nationally representative hospital discharge database containing data pertaining to admissions in the United States. We compared discharge outcomes, length of stay, and cost of hospitalization between groups of patients who were treated using either intravenous nicardipine or nitroprusside infusion. Chi-square and ANOVA were used for univariate analysis. Logistic and linear regression analyses were performed to adjust for baseline risk of mortality between the two groups. RESULTS: A total of 12,767 admissions with primary diagnosis of ICH were identified. Nicardipine was administered in 926 patients (7.3%) and nitroprusside was administered in 530 (4.3%) patients. There was no difference in baseline disease severity or risk of mortality among patients who were administered nicardipine or nitroprusside. After adjustment for baseline risk of mortality, the risk of in-hospital mortality (odds ratio [OR] 1.7, 95% confidence interval [95% CI] 1.3-2.2) was higher among patients treated with nitroprusside compared with nicardipine. The risk of in-hospital mortality was also higher after adjustment for baseline risk of mortality and hospital characteristics in patients treated with nitroprusside (OR 1.6, 95% CI 1.2-2.1). After exclusion of patients who died during hospitalization, there was no difference in length of stay and total hospital cost in the multivariate analysis. CONCLUSION: Use of nicardipine compared with nitroprusside infusion during the first 24 h after ICH may be associated with reduced risk of in-hospital mortality without any increase in the hospitalization cost or length of stay.
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Antihipertensivos/administración & dosificación , Hemorragia Cerebral/tratamiento farmacológico , Hemorragia Cerebral/mortalidad , Nicardipino/administración & dosificación , Nitroprusiato/administración & dosificación , Anciano , Antihipertensivos/economía , Hemorragia Cerebral/economía , Bases de Datos Factuales , Costos de los Medicamentos , Femenino , Costos de Hospital , Mortalidad Hospitalaria , Humanos , Infusiones Intravenosas , Tiempo de Internación/economía , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Nicardipino/economía , Nitroprusiato/economía , Factores de RiesgoRESUMEN
BACKGROUND: As clopidogrel is being increasingly used, intracerebral hemorrhage (ICH) associated with clopidogrel are expected to increase. We assessed the prevalence and clinical characteristics of of ICH with clopidogrel in a consecutive series of patients in two hospitals. METHODS: We retrospectively reviewed the medication history of 204 patients (112 in one hospital and 92 in another - both individually consecutive) admitted with ICH. We identified the patients who were using clopidogrel prior to ICH occurrence. The etiology of the ICH was categorized on the basis of clinical history and diagnostic imaging, and outcome was subsequently evaluated. RESULTS: A total of 8 (4%) of the 204 patients were using clopidogrel prior to onset of ICH. Clopidogrel was the only medication in 3 patients and was used with aspirin or warfarin in 3 and 2 patients, respectively. Aspirin or warfarin was the only medication in 23 (%) and 14 (%) patients associated with ICH, respectively. The hematoma was located in the basal ganglia (n=2), lobes (n=2), thalamus (n=1), intraventricular (n=2), and cerebellar (n=2). One patient had secondary intraventricular extension. All patients using a combination of clopidogrel and warfarin prior to ICH died. CONCLUSION: The prevalence of ICH associated with clopidogrel is approximating the prevalence of aspirin- or warfarin-associated ICH. The mortality with clopidogrel related ICH appears to be high particularly when in combination with another antithrombotic agent.
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INTRODUCTION: To assess the impact of new therapeutic strategies on outcome and cost of hospitalization among patients with myasthenia gravis (MG) who are mechanically ventilated in United States. METHODS: Using a retrospective analysis of cross sectional survey, we determined the rates of occurrence, in-hospital outcomes, and mean hospital charges for patients hospitalized with MG requiring mechanical ventilation in 1991-1992 using the Nationwide Inpatient Survey (NIS) and compared these outcomes with homologous data from 2001-2002. NIS is the largest all-payer inpatient care database in the United States. RESULTS: When comparing data from 2001-2002 with data from 1991-1992, we found a higher number of admissions for MG that required mechanical ventilation (994 vs. 652). The proportion of women was similar (53% vs. 60%). The average age (in years ± standard deviation) was significantly higher (65 ± 17 vs. 58 ± 18, p=0.0002). The length of hospitalization (in days ± standard deviation) was not different (22 ± 19 vs. 21 ± 16). Discharge to home occurred less frequently (29% vs. 60%, p=0.0001) and in hospital mortality minimally lower (13% vs. 15%). There was a significant increase in mean hospital charges ($118,000 vs. $84,100 adjusted for inflation, p=0.0001). In hospital mortality was higher among urban teaching hospitals compared with urban non teaching hospitals in 2001-2002. CONCLUSIONS: Despite improvement in therapeutic strategies from 1991 to 2002, there was only a modest reduction in mortality and no substantial reduction of length of hospitalization for patients with MG requiring mechanical ventilation.
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OBJECTIVE: There is a decreased sensation of thirst and often dehydration among the elderly population. It is unclear whether it represents a contributing factor for cerebral ischemic events. DESIGN: Consecutive patients presenting to a University Hospital within 24 h of symptom onset, and a discharge diagnosis of acute ischemic stroke or transient ischemic attack in the year 2005, were identified. Healthy controls matched to gender, age, and presence of diabetes mellitus were obtained from the National Health and Nutrition Examination Survey (NHANES) 1999-2004. Calculated plasma osmolality of patients and healthy controls was compared in groups defined by age; > or =65 years and <65 years, before and after adjustment for possible confounders. Plasma osmolality comparisons were also made between subjects with and without diabetes mellitus or diuretic use. Within the patients group, comparisons were made according to stroke subtypes and time from symptom onset; < or =6 h vs. >6 h. RESULTS: Plasma osmolality of patients > or =65 years was significantly higher than that of matched healthy controls, and the difference remained significant when we adjusted for potential confounders (295.4 vs. 292.3 mOsm/kg, difference 3.1, standard error (SE) 1.13, P = 0.006). Patients taking diuretics had higher plasma osmolality than patients not taking diuretics (296.0 +/- 8.0 vs. 292.4 +/- 8.0 mOsm/kg, P = 0.0026). Among patients, there was no difference between subgroups defined by stroke subtypes or time from symptom onset. CONCLUSIONS: Elderly patients presenting with acute ischemic stroke or transient ischemic attack have high plasma osmolality levels, suggestive of volume depletion. This seems to be an early phenomenon and possibly a contributing factor to cerebral ischemia.