Implementation and Analysis of a Free Water Protocol in Acute Trauma and Stroke Patients.

BACKGROUND: Free water protocols allow patients who aspirate thin liquids and meet eligibility criteria to have access to water or ice according to specific guidelines. Limited research is available concerning free water protocols in acute care settings. OBJECTIVES: To compare rates of positive clinical outcomes and negative clinical indicators of a free water protocol in the acute care setting and to continue monitoring participants discharged into the hospital system's rehabilitation setting. Positive clinical outcomes were diet upgrade, fewer days to diet upgrade, and fewer days in the study. Negative clinical indicators were pneumonia, intubation, and diet downgrade. METHODS: A multidisciplinary team developed and implemented a free water protocol. All eligible stroke and trauma patients (n = 104) treated over a 3-year period were randomly assigned to an experimental group with access to water and ice or a control group without such access. Trained study staff recorded data on positive outcomes and negative indicators; statistical analyses were conducted with blinding. RESULTS: No significant group differences in positive outcomes were found (all P values were > .40). Negative clinical indicators were too infrequent to allow for statistical comparison of the 2 groups. Statistical analyses could not be conducted on the small number (n = 15) of patients followed into rehabilitation, but no negative clinical indicators occurred in these patients. CONCLUSIONS: Larger-scale studies are needed to reach decisive conclusions on the positive outcomes and negative indicators of a free water protocol in the acute care setting.

Endovascular Thrombectomy for Mild Strokes: How Low Should We Go?

Background and Purpose- Endovascular thrombectomy (EVT) is effective for acute ischemic stroke with large vessel occlusion and National Institutes of Health Stroke Scale (NIHSS) ≥6. However, EVT benefit for mild deficits large vessel occlusions (NIHSS, <6) is uncertain. We evaluated EVT efficacy and safety in mild strokes with large vessel occlusion. Methods- A retrospective cohort of patients with anterior circulation large vessel occlusion and NIHSS <6 presenting within 24 hours from last seen normal were pooled. Patients were divided into 2 groups: EVT or medical management. Ninety-day mRS of 0 to 1 was the primary outcome, mRS of 0 to 2 was the secondary. Symptomatic intracerebral hemorrhage was the safety outcome. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, presentation NIHSS, time last seen normal to presentation, center, IV alteplase, Alberta Stroke Program early computed tomographic score, and thrombus location. We then performed propensity score matching as a sensitivity analysis. Results were also stratified by thrombus location. Results- Two hundred fourteen patients (EVT, 124; medical management, 90) were included from 8 US and Spain centers between January 2012 and March 2017. The groups were similar in age, Alberta Stroke Program early computed tomographic score, IV alteplase rate and time last seen normal to presentation. There was no difference in mRS of 0 to 1 between EVT and medical management (55.7% versus 54.4%, respectively; adjusted odds ratio, 1.3; 95% CI, 0.64-2.64; P=0.47). Similar results were seen for mRS of 0 to 2 (63.3% EVT versus 67.8% medical management; adjusted odds ratio, 0.9; 95% CI, 0.43-1.88; P=0.77). In a propensity matching analysis, there was no treatment effect in 62 matched pairs (53.5% EVT, 48.4% medical management; odds ratio, 1.17; 95% CI, 0.54-2.52; P=0.69). There was no statistically significant difference when stratified by any thrombus location; M1 approached significance ( P=0.07). Symptomatic intracerebral hemorrhage rates were higher with thrombectomy (5.8% EVT versus 0% medical management; P=0.02). Conclusions- Our retrospective multicenter cohort study showed no improvement in excellent and independent functional outcomes in mild strokes (NIHSS, <6) receiving thrombectomy irrespective of thrombus location, with increased symptomatic intracerebral hemorrhage rates, consistent with the guidelines recommending the treatment for NIHSS ≥6. There was a signal toward benefit with EVT only in M1 occlusions; however, this needs to be further evaluated in future randomized control trials.

Successful reperfusion of bilateral middle cerebral artery embolic occlusions using stent retriever thrombectomy.

A 40-year-old woman presented to our stroke center for a left middle cerebral artery embolic occlusion. This was successfully treated with mechanical thrombectomy using a stent retriever and balloon guide catheter aspiration. The patient was discharged home in good condition on clopidogrel but returned 2 months later with a contralateral right middle cerebral artery embolic occlusion. This was also successfully treated, this time with a stent retriever and local aspiration (Sol-Arc technique). She was once again discharged in good condition but with warfarin and an implanted loop recorder. This case demonstrates the feasibility of short-term bilateral mechanical thrombectomy for embolic middle cerebral artery occlusions.

Critical Event Intervals in Determining Candidacy for Intravenous Thrombolysis in Acute Stroke.

BACKGROUND: The aim of the study was to determine the optimal set point for the critical event benchmarks described in stroke guidelines and validate the ability of these goals to predict successful administration of intravenous thrombolysis within 60 min of hospital arrival. METHODS: This was a retrospective cohort analysis of patients with acute ischemic stroke who received intravenous thrombolysis following presentation to the emergency department. The national benchmarks for time intervals associated with the completion of critical events required to determine candidacy for thrombolysis were evaluated for the ability to predict successful administration of thrombolysis within 60 min of hospital arrival. Optimal time interval cut points were then estimated using regression and receiver-operator characteristic curve analysis and compared to guidelines. RESULTS: Of the 523 patients included in the analysis, 229 (43.8%) received intravenous thrombolysis within 60 min of hospital arrival. Of the patients who met the critical event interval goals described in guidelines, only 51.6% received thrombolysis within 60 min. The optimized cut points suggested by the regression analysis aligned with the guideline benchmarks with the only substantial difference being a shortened goal of arrival to neuroimaging start time of 19 min. This difference did not impact the overall predictive value. CONCLUSION: The critical event benchmarks proposed in this study by logistic regression closely correlate with the critical event benchmarks described in the AHA/ASA acute stroke guidelines.

Validation of clinical prediction scores in patients with primary intracerebral hemorrhage.

BACKGROUND: Initial reports of the FUNC score suggest that it may accurately identify those patients suffering from intracerebral hemorrhage (ICH) with an ultra low chance of functional neurologic recovery. This study's aim is to validate the FUNC score and determine if it accurately identifies the cohort of patients with an ultra low chance of survival with good neurologic recovery. METHODS: Retrospective review of 501 consecutive primary ICH patients admitted from the Emergency Department to a large healthcare system. Performance of the FUNC, ICH-GS, and oICH scores was determined by calculating areas under the receiver-operator-characteristic curves. Patients with a predicted 100 % chance of poor neurologic outcome (PNO) (FUNC <4 and ICH-GS >10) scores were evaluated to determine if DNR impacted 90 day survival or rate of survival with a Glasgow Outcome Score of <3. RESULTS: In 366 cases of primary ICH who presented during the study period, 222(61 %) survived to discharge. Both the FUNC (AUC: 0.873) and ICH-GS (AUC: 0.888) outperformed the oICH (AUC: 0.743) in predicting 90-day mortality (p = <0.001). Of 68 patients with a FUNC score <4, 67 (98.5 %) had PNO at discharge. The presence of DNR was not associated with a significant difference in the rate of PNO at discharge (40/40 = 100 % vs. 27/28 = 96.4 % p = 0.42) or 90-day mortality (40/40 = 100 % vs. 21/28 = 75 %, p = 0.06). CONCLUSION: The FUNC and ICH-GS appear superior to the oICH in predicting outcome in patients with primary ICH. In addition, the FUNC score appears to accurately identify patients with low chance of functional neurologic recovery at discharge.

Extent of intra-arterial calcification on head CT is predictive of the degree of intracranial atherosclerosis on digital subtraction angiography.

BACKGROUND: Intracranial intra-arterial calcifications (ICAC) are a common finding on head CT examinations, but their significance is not known. The aim of this study is to determine if a relationship exists between ICAC on head CT and the presence of a high-grade atherosclerotic stenosis on cerebral angiography. METHODS: This was a retrospective study of 108 consecutive patients admitted to the stroke service at Parkland Hospital in Dallas, Tex., USA. Each patient had undergone a head CT and catheter-based angiographic study to meet the inclusion criteria. Demographic information was recorded along with CT imaging data in regards to the amount of calcification. Angiographic images were reviewed independently, and a comparison was made to determine if calcification was predictive of finding a high-grade stenosis on angiography. RESULTS: A total of 108 consecutive patients with a mean age of 56 +/- 12 years were studied. Of the 540 vessels studied, 65 (12%) were found to have a stenosis of >or=50% on angiography, and 71 (13.1%) were found to have a calcium grade of 3 or 4 on head CT. ICAC appeared to be more common in the anterior circulation compared to the posterior circulation. Patients with grade 3 or 4 calcification of an intracranial vessel on head CT were more likely to have a stenosis of >or=50% on cerebral angiography. CONCLUSIONS: The presence of ICAC on head CT appears to correlate with the presence of an underlying intracranial stenosis on angiography. Further study is required to validate these preliminary findings.

An echocardiographic-confirmed case of atrial myxoma causing cerebral embolic ischemic stroke: a case report.

A myxoma is the most common primary tumor of the heart. It has been reported as the source of a cardiogenic embolism. Therefore, it is important for clinicians to detect the myxoma early via echocardiography to prevent complications, such as syncope, sudden death, and cerebral embolic ischemic stroke. This report presents the case of a 54-year-old female whose clinical manifestation of atrial myxoma was an ischemic stroke. Atrial myxoma was later confirmed as the cause of her symptoms via transesophageal echocardiography.

Transcranial Doppler: an introduction for primary care physicians.

Transcranial Doppler (TCD) is a diagnostic tool that can be used at bedside to assess the cerebral vasculature noninvasively. It is inexpensive, safe, and reliable when compared with other techniques. It can be repeated multiple times and can be used for continuous monitoring if needed. Screening of children with sickle cell disease to assess and prevent ischemic strokes and monitoring for vasospasm after subarachnoid hemorrhage are well established, evidenced based utilizations of TCD. It is useful for the evaluation of occlusive intracranial vascular lesions with many emerging indications in the management of ischemic stroke. TCD with micro-bubble enhancement has comparable sensitivity to transesophageal echocardiogram in detecting right-to-left atrial cardiac shunts. TCD is underused as a clinical tool despite well established indications. The pressure to contain increasing medical cost will likely result in increased utilization of this test in future.

Biochemical and stone-risk profiles with topiramate treatment.

BACKGROUND: Topiramate is a novel neuromodulatory agent commonly prescribed for the treatment of seizure disorders and for migraine headache prophylaxis. Calcium phosphate kidney stones have been observed with topiramate treatment, but a comprehensive elucidation of stone-risk profile was not reported previously. This study explores the relationship between topiramate treatment and propensity for kidney stone formation. METHODS: Thirty-two topiramate-treated subjects and 50 healthy volunteers participated in a cross-sectional study in which serum chemistry test and 24-hour urine collection results were evaluated for stone risk. Furthermore, a short-term longitudinal study was conducted in 7 patients to assess stone risk before and 3 months after topiramate treatment. RESULTS: Serum bicarbonate levels were lower with topiramate treatment. Urinary pH, urinary bicarbonate excretion, and fractional excretion of bicarbonate increased, whereas urinary citrate excretion was significantly lower (737 +/- 329 versus 278 +/- 226 mg/d; P < 0.001). Net acid excretion did not change. The relative saturation ratio for brushite increased with topiramate treatment (3.14 +/- 1.69 versus 1.27 +/- 1.26; P < 0.001) because of urinary alkalinization and decreased urinary citrate levels. Urinary saturation of undissociated uric acid decreased (41 +/- 52 versus 76 +/- 60 mg/d; P < 0.001). CONCLUSION: Treatment with topiramate causes systemic metabolic acidosis, markedly lower urinary citrate excretion, and increased urinary pH. These changes increase the propensity to form calcium phosphate stones.