Outcomes of Homeless Ischemic Stroke Patients Receiving Intravenous Thrombolysis in the United States.

BACKGROUND: Morbidity and mortality among homeless people with cardiovascular diseases and stroke in the United States is high. Adverse outcomes within the homeless population may be the result of seeking care too late to receive time-sensitive interventions. We sought to investigate the impact of homelessness on ischemic stroke patients who received intravenous thrombolysis (IVT). METHODS: We determined rates of post-thrombolytic intracranial hemorrhage (ICH), in-hospital death, and development of moderate to severe disability among homeless ischemic stroke patients treated with IVT. Patients were identified using the Nationwide (National) Inpatient Sample between 2002 and 2017. We compared rates of the various outcomes to non-homeless ischemic stroke patients treated with IVT. RESULTS: There were 514 homeless (mean age 54.7 ± 10.2 years, 20.4% women) and 364,408 non-homeless (mean age 68.6 ± 14.7 years, 49.7% women) ischemic stroke patients who received IVT. There was no difference in post-thrombolytic ICH rates between the two groups (6.6% homeless versus 8.8% non-homeless, p = 0.09). Homeless patients were more frequently discharged to self-care (p = 0.003). Homeless patients were less likely than non-homeless patients to suffer in-hospital death (AOR 0.499 [95% CI 0.30-0.84], p = 0.009) and moderate to severe disability (AOR 0.423 [95% CI 0.29 - 0.62], p < 0.001). CONCLUSION: Homeless ischemic stroke patients who receive IVT are not at an increased risk of developing post-thrombolytic ICH or in-hospital death. Efforts are needed to encourage this unique population to seek medical attention as soon as possible for time-sensitive interventions that may decrease the risk of permanent disability or death associated with ischemic stroke.

The Role of T-box Transcription Factor in a Pituitary Adenoma Diagnostic Algorithm.

CONTEXT.­: We previously examined pituitary adenomas with immunohistochemical (IHC) stains for steroidogenic factor 1, Pit-1, anterior pituitary hormones, cytokeratin CAM 5.2, and the α-subunit of human chorionic gonadotropin and found that a screening panel comprising stains for steroidogenic factor 1, Pit-1, and adrenocorticotropic hormone successfully classified most cases and reduced the overall number of stains required. OBJECTIVES.­: To examine the potential role of IHC stain for T-box transcription factor (Tpit) in the classification of our series of pituitary adenomas and to update our screening panel as necessary. DESIGN.­: We collected 157 pituitary adenomas from 2 institutions and included these in tissue microarrays. Immunostains for Tpit were scored in a blinded fashion using the Allred system. Adenomas were assigned to a gold standard class based on IHC pattern followed by application of available clinical and serologic information. Test characteristics were calculated. Correlation analyses, cluster analyses, and classification tree analyses were used to see whether IHC staining patterns reliably reflected adenoma class. RESULTS.­: Of the cases collected, 147 (93.6%) had sufficient material for Tpit analysis. IHC stain for Tpit identified 8 null cell adenomas (all nonfunctioning clinically) as silent corticotrophs; Tpit stains showed better sensitivity, specificity, positive predictive value, and negative predictive value than IHC for adrenocorticotropic hormone and cytokeratin CAM 5.2. Correlation analyses continued to show the expected relationships among IHC stains. Cluster analyses showed grouping of adenomas into clinically consistent groups. Classification tree analysis underscored the central role of transcription factor IHC stains, including Tpit, in adenoma classification. CONCLUSIONS.­: Substitution of Tpit stain for the adrenocorticotropic hormone stain improves our prior algorithm by reducing the number of false-negatives and false-positives. As a result, fewer adenomas are classified as null cell adenoma, and more adenomas are classified as silent corticotroph adenoma.

Weekday Versus Weekend Presentation in the Acute Management of Ischemic Stroke Through Telemedicine.

A "weekend effect" resulting in higher mortality rates for patients with stroke admitted on weekends has been reported. We examine this phenomenon for patients with acute ischemic stroke (AIS) presenting to telestroke (TS) sites to determine its effect on stroke alert process times and outcomes. From October 2015 to June 2017, we reviewed patients with AIS receiving intravenous alteplase within our TS network. We compared patients presenting to TS sites on weekdays (Monday 07:00 to Friday 18:59) to those presenting on weekends (Friday 19:00 to Monday 06:59). We analyzed door-to-alert activation, alert activation-to-TS evaluation, door-to-imaging, and door-to-needle times. Rates of favorable outcome (modified Rankin Scale score ≤2) and death at 90 days were compared. We identified 89 (54 weekday and 35 weekend) patients (mean age: 71.8 ± 13.3 years, 47.2% women) during the study period. Median door-to-alert activation (P = .01) and door-to-needle (P = .004) times were significantly longer for patients presenting on weekends compared to weekdays. There were no significant differences in median door-to-imaging (P = .1) and alert activation-to-TS evaluation (P = .07) times. Rates of favorable outcome (P = .19) and death (P = .56) at 90 days did not differ. While there were no significant differences in outcomes, patients presenting on weekends had longer door-to-alert activation and door-to-needle times. Efforts to improve methods in efficiency of care on weekends should be considered.

Conivaptan for the Reduction of Cerebral Edema in Intracerebral Hemorrhage: A Safety and Tolerability Study.

BACKGROUND: Perihematomal edema (PHE) growth in intracranial hemorrhage (ICH) is a biomarker for worse outcomes. Although the management of PHE is potentially beneficial for ICH patients, there is currently no proven clinical therapy that both reduces PHE and improves outcomes in this population. OBJECTIVE: To examine the safety and tolerability of conivaptan, a non-peptide vasopressin (AVP) receptor antagonist, for the management of PHE in ICH patients. METHODS: We performed a single-center, open-label, phase I study in seven patients with ICH at risk for developing PHE. Conivaptan (20 mg) was administered every 12 h for 2 days, along with the standard ICH management. Electrolyte levels, renal and cardiac function, and vital signs were monitored throughout treatment. Neurological status, ICH, and PHE volumes were assessed at study baseline, 24 h, 72 h, and 7 days from the first conivaptan administration, as well as at the 3-month follow-up. RESULTS: Conivaptan was well tolerated in our patients. We observed the expected increase in sodium levels following conivaptan administration (p = 0.01), with no change in cardiac or renal function. All patients survived to follow-up, and adverse event rates were comparable with those of the neurocritical care unit overall. CONCLUSIONS: These data indicate that conivaptan can be safely administered to ICH patients and support further clinical investigation into the efficacy of this drug for ICH treatment. CLINICAL TRIAL REGISTRATION: clinicaltrials.gov; NCT03000283, 22 December 2016.

Utility of procalcitonin for diagnosis of bacterial infection-related systemic inflammatory response in the acute neurologic injury population.

OBJECTIVE: Inflammation and bacterial infection are common complicating factors in the treatment of patients with stroke. Inflammatory responses can manifest as systemic inflammatory response syndrome (SIRS), a condition with both infectious and non-infectious etiologies. Accurately identifying patients with infection-related SIRS is important for determining the correct treatment plan. Here, we investigated the use of the glycopeptide procalcitonin (PCT) as a potential biomarker for identifying patients with bacterial infections in the setting of SIRS. PATIENTS AND METHODS: A retrospective chart review was performed for adult patients admitted to United Hospital with an admission or discharge diagnosis of stroke for whom PCT testing was ordered between January 2011 and December 2014. Medical records were searched for the timing of PCT tests, and the previous 24 h was assessed for markers of SIRS, inflammation, and disease severity. RESULTS: PCT levels were negatively correlated with Glasgow Coma Scale scores (ρ=-0.27, p < 0.0001) and glomerular filtration rates (ρ=-0.22, p < 0.001), but demonstrated a positive correlation with white blood cell (WBC) count (ρ = 0.13, p = 0.031) and creatinine levels (ρ = 0.33, p < 0.0001). PCT levels were significantly higher in samples that corresponded to the presence of at least one infection (p < 0.0001) and in SIRS + samples (p < 0.001). However, even with the addition of a SIRS + diagnosis, the predictive value of PCT did not reach levels that would indicate clinical utility for the identification of patients with bacterial infections. CONCLUSIONS: PCT was not a viable biomarker for distinguishing between infectious and non-infections etiologies of SIRS in acute brain injury in this population. However, our results do indicate potential utility for PCT as an indicator for the cessation of antibiotic use in acute brain injury patients with bacterial infections.

Prevalence of atrial fibrillation with insertable cardiac monitors in cryptogenic stroke: A single-center experience.

BACKGROUND: The use of insertable cardiac monitors (ICM) has increased the rate of detection of atrial fibrillation (AF) among cryptogenic stroke (CS) patients. We describe a single-center experience for AF detection among CS patients receiving ICMs upon discharge after the index stroke event and attempt to identify predictors for AF detection. METHODS: From April 2014 to October 2017, patients receiving ICMs for CS who underwent >60 days of monitoring were reviewed. Chronic underlying medical illnesses, presence of left atrial enlargement (LAE) on echocardiography, and PR interval on admission electrocardiogram were assessed as predictors of AF detection. RESULTS: A total of 234 patients (median age 72 [61, 78] years, 45% women) met inclusion criteria and were followed for a median of 536 [282, 848] days. Among studied patients, 68 patients (29%) were found to have AF at a median of 94.5 [16, 239] days from ICM placement. CS patients with AF were significantly older (p < 0.001), and there was a significantly higher proportion of women (p = 0.003) when compared to CS patients without AF. Neither presence of LAE nor prolonged PR interval was predictive of AF detection. CONCLUSION: Almost one-third of CS patients monitored with an ICM were found to have previously undiagnosed AF. CS patients found to have AF were older and more commonly women. Prospective studies are needed to better identify predictors for early AF among the broader population of all CS patients.

Real-world treatment of large vessel occlusions: combined outcomes of directly presenting and transferred-in patients to a stroke center.

Background Stroke patients transferred in for endovascular treatment (ET) may have lower chances for favorable outcomes compared to those who presented directly to a ET-capable hospital. We describe our real-world experience of ET in AIS, especially among patients transferred in. Materials and methods AIS patients receiving ET from January 2015 to November 2016 were reviewed. We calculated median onset to groin puncture (OTP) and groin puncture to recanalization times (PTR), location of target vessel treated, rate of concurrent intravenous (IV) alteplase use, and rate of successful recanalization as defined by TICI ≥ 2b. Outcomes included discharge disposition to nursing home (NH) and 90-day modified Rankin Scale (mRS) scores. Results We identified 174 patients (50.6% women, mean age 69.5 ± 15.7 years, 49.4% transfer-ins) undergoing ET (20.5% terminal internal carotid artery, 47.7% M1, 17% M2, 9.2% basilar artery, 5.7% other). Median OTP and PTR times were 257 [158, 375] and 30 [22, 48] minutes, respectively. Rate of TICI ≥ 2b was 82.9%, and 55.7% received adjunctive IV alteplase. Rate of discharge to NH was 17.2% 90-day mRS ≤ 2 was 41.7%. Discharge to NH (P = 0.32) and 90-day mRS ≤ 2 (P = 0.75) were not significantly different between transferred in versus direct presentation patients. Conclusion High rates of favorable angiographic and clinical outcomes were found among AIS patients receiving ET in our single-center experience, particularly among transferred in patients. The establishment of a stroke network may help in the efficient transfer and assembly of appropriate resources for eligible patients that are transferred in for ET.

The Door to Needle Time Metric Can Be Achieved via Telestroke.

The administration of intravenous (IV) alteplase to patients with stroke via telestroke (TS) can be safe and effective. It remains unclear how quickly IV alteplase occurs during TS evaluations. We sought to compare door to needle times (DNTs) between patients receiving IV alteplase who present directly to our comprehensive stroke center (CSC) and those presenting to community hospitals in our TS network. Consecutive patients with acute ischemic stroke (AIS) who presented to emergency departments and received IV alteplase between August 2014 and June 2015 were identified at our CSC and TS network. Median DNTs with interquartile ranges were calculated in each cohort. During the study period, 117 patients with AIS (mean age 71 ± 15 years, 47% women) receiving IV alteplase were included in the analysis (65 CSC and 52 TS). Median DNT at our CSC was significantly shorter compared to TS sites (CSC: 43 [35-55] minutes vs TS: 54 [41-71] minutes, P < .01). The proportion of patients receiving IV alteplase ≤60 minutes of presentation was significantly higher at our CSC compared to our TS network (CSC 84.6% vs TS 63.5%, P = .02). Differences in favorable discharge to home were not significant (CSC 60% vs TS 46%, P = .14). Guideline-recommended DNTs ≤60 minutes can be achieved in community hospitals with TS guidance. Initiatives are required to better resemble DNTs found at stroke centers.

Thrombolytic treatment to stroke mimic patients via telestroke.

OBJECTIVE: The safety and outcomes of intravenous thrombolysis (IVT) to stroke patients via telestroke (TS) is similar to those presenting to stroke centers. Little is known on the accuracy of TS diagnosis among those receiving IVT. We sought to compare the rate of patients receiving IVT with diagnosis of ischemic stroke as opposed to stroke mimic (SM) in our TS network to those who presented to our comprehensive stroke center (CSC). MATERIALS AND METHODS: Consecutive patients receiving IVT between August 2014 and June 2015 were identified at our CSC and TS network. We compared rates of SM, post-IVT symptomatic intracerebral hemorrhage (sICH), in-hospital mortality, and discharge destination. RESULTS: We evaluated 131 receiving IVT were included in the analysis. Rates of SM receiving IVT were similar (CSC 12% versus 7% TS, p=0.33). Four stroke patients experienced sICH or in-hospital mortality; neither were found among SM patients. Discharge destination was similar between stroke and SM patients (p=0.9). SM patients had higher diagnoses of migraine (p=0.05) and psychiatric illness (p<0.01). CONCLUSION: The accuracy of diagnosing stroke in IVT-eligible patients evaluated via TS is similar to evaluations at our CSC. Continued efforts should be made to minimize exposure of SM patients to IVT in both settings.

Steroidogenic Factor 1, Pit-1, and Adrenocorticotropic Hormone: A Rational Starting Place for the Immunohistochemical Characterization of Pituitary Adenoma.

CONTEXT: -Pituitary adenoma classification is complex, and diagnostic strategies vary greatly from laboratory to laboratory. No optimal diagnostic algorithm has been defined. OBJECTIVE: -To develop a panel of immunohistochemical (IHC) stains that provides the optimal combination of cost, accuracy, and ease of use. DESIGN: -We examined 136 pituitary adenomas with stains of steroidogenic factor 1 (SF-1), Pit-1, anterior pituitary hormones, cytokeratin CAM5.2, and α subunit of human chorionic gonadotropin. Immunohistochemical staining was scored using the Allred system. Adenomas were assigned to a gold standard class based on IHC results and available clinical and serologic information. Correlation and cluster analyses were used to develop an algorithm for parsimoniously classifying adenomas. RESULTS: -The algorithm entailed a 1- or 2-step process: (1) a screening step consisting of IHC stains for SF-1, Pit-1, and adrenocorticotropic hormone; and (2) when screening IHC pattern and clinical history were not clearly gonadotrophic (SF-1 positive only), corticotrophic (adrenocorticotropic hormone positive only), or IHC null cell (negative-screening IHC), we subsequently used IHC for prolactin, growth hormone, thyroid-stimulating hormone, and cytokeratin CAM5.2. CONCLUSIONS: -Comparison between diagnoses generated by our algorithm and the gold standard diagnoses showed excellent agreement. When compared with a commonly used panel using 6 IHC for anterior pituitary hormones plus IHC for a low-molecular-weight cytokeratin in certain tumors, our algorithm uses approximately one-third fewer IHC stains and detects gonadotroph adenomas with greater sensitivity.