Stroke Network of Wisconsin (SNOW) Scale Predicts Large Vessel Occlusion Stroke in the Prehospital Setting.

Purpose: In previous trials, the Stroke Network of Wisconsin (SNOW) scale accurately predicted large vessel occlusion (LVO) stroke in the hospital setting. This study evaluated SNOW scale performance in the prehospital setting and its ability to predict LVO or distal medium vessel occlusion (DMVO) in patients suspected of having acute ischemic stroke (AIS), a scenario in which transport time to an endovascular treatment-capable facility (ECSC) is critical. Methods: All potential AIS patients with last-known-well time of ≤24 hours were assessed by Milwaukee County Emergency Medical Services for LVO using SNOW. Patients with a positive SNOW score were transferred to the nearest ECSC. One such facility, Aurora St. Luke's Medical Center (ASLMC), was the source of all patient data analyzed in this study. LVO was defined as occlusion of the intracranial carotid artery, middle cerebral artery (M1) segment, or basilar artery. Results: From March 2018 to February 2019, 345 AIS-suspected patients were transported to ASLMC; 19 patients were excluded because no vascular imaging was performed. Of 326 patients, 32 had confirmed LVO and 21 DMVO. For identifying LVO, SNOW scale sensitivity was 0.88, specificity 0.40, positive predictive value (PPV) 0.14, negative predictive value (NPV) 0.97, and area under the curve (AUC) 0.64. Ability to predict DMVO was similar. Overall, the SNOW scale showed sensitivity of 0.83, specificity of 0.39, PPV of 0.10, NPV of 0.97, and AUC of 0.60 in identifying candidates for endovascular thrombectomy. Conclusions: In a prehospital setting, the SNOW scale has high sensitivity in identifying candidates for endovascular thrombectomy and proved highly reliable in ruling out stroke due to LVO.

Cerebral Venous Sinus Thrombosis Associated With Coronavirus Disease 2019: Case Report and Review of the Literature.

INTRODUCTION: Coronavirus disease 2019 (COVID-19) is associated with significant risk of acute thrombosis. We present a case report of a patient with cerebral venous sinus thrombosis (CVST) associated with COVID-19 and performed a literature review of CVST associated with COVID-19 cases. CASE REPORT: A 38-year-old woman was admitted with severe headache and acute altered mental status a week after confirmed diagnosis of COVID-19. Magnetic resonance imaging brain showed diffuse venous sinus thrombosis involving the superficial and deep veins, and diffuse edema of bilateral thalami, basal ganglia and hippocampi because of venous infarction. Her neurological exam improved with anticoagulation (AC) and was subsequently discharged home. We identified 43 patients presenting with CVST associated with COVID-19 infection. 56% were male with mean age of 51.8±18.2 years old. The mean time of CVST diagnosis was 15.6±23.7 days after onset of COVID-19 symptoms. Most patients (87%) had thrombosis of multiple dural sinuses and parenchymal changes (79%). Almost 40% had deep cerebral venous system thrombosis. Laboratory findings revealed elevated mean D-dimer level (7.14/mL±12.23 mg/L) and mean fibrinogen level (4.71±1.93 g/L). Less than half of patients had prior thrombotic risk factors. Seventeen patients (52%) had good outcomes (mRS <=2). The mortality rate was 39% (13 patients). CONCLUSION: CVST should be in the differential diagnosis when patients present with acute neurological symptoms in this COVID pandemic. The mortality rate of CVST associated with COVID-19 can be very high, therefore, early diagnosis and prompt treatment are crucial to the outcomes of these patients.

Thrombolysis After Protamine Reversal of Heparin for Acute Ischemic Stroke After Cardiac Catheterization: Case Report and Literature Review.

BACKGROUND: Patients with an acute ischemic stroke (AIS) following cardiac catheterization (CC) generally do not receive intravenous thrombolysis [intravenous tissue plasminogen activator (IV-tPA)] as it is contraindicated due to the coagulopathy related to the heparin used during the procedure. We report a case of AIS successfully treated with IV thrombolysis following protamine reversal of heparin effect. CASE REPORT: An 87-year-old man with diabetes mellitus, hypertension, neurofibromatosis, and hyperlipidemia underwent elective transradial CC following an abnormal stress test. He had 2 drug-eluting stents for severe stenosis of mid-circumflex and right coronary arteries and received heparin 13,000 IU during procedure. He developed acute left hemiparesis with initial NIH stroke scale (NIHSS) of 4. Computed tomographic scan of the brain and computed tomographic angiogram of head and neck were unremarkable. Bedside activated clotting time was 181. Protamine 40 mg was administered and 30 minutes later, the activated clotting time level was normalized. IV-tPA was administered at 4 hours 25 minutes from his last known well. Within 15 minutes, his NIHSS was 0. Magnetic resonance imaging of brain showed no acute infarction 24 hours after stroke. CONCLUSIONS: There are limited reports of protamine reversal of heparin before IV-tPA administration. To our knowledge, there are only 6 AIS cases including ours. Three cases received 0.6 mg/kg of tPA dose. All have favorable outcomes and no intracranial hemorrhage was reported. Protamine reversal of heparin for AIS after CC seems to be safe. Further studies are needed to confirm the therapeutic safety and efficacy of this strategy.

Pomona Large Vessel Occlusion Screening Tool for Prehospital and Emergency Room Settings.

BACKGROUND: Early identification of patients with acute ischemic strokes due to large vessel occlusions (LVO) is critical. We propose a simple risk score model to predict LVO. METHOD: The proposed scale (Pomona Scale) ranges from 0 to 3 and includes 3 items: gaze deviation, expressive aphasia, and neglect. We reviewed a cohort of all acute stroke activation patients between February 2014 and January 2016. The predictive performance of the Pomona Scale was determined and compared with several National Institutes of Health Stroke Scale (NIHSS) cutoffs (≥4, ≥6, ≥8, and ≥10), the Los Angeles Motor Scale (LAMS), the Cincinnati Prehospital Stroke Severity (CPSS) scale, the Vision Aphasia and Neglect Scale (VAN), and the Prehospital Acute Stroke Severity Scale (PASS). RESULTS: LVO was detected in 94 of 776 acute stroke activations (12%). A Pomona Scale ≥2 had comparable accuracy to predict LVO as the VAN and CPSS scales and higher accuracy than Pomona Scale ≥1, LAMS, PASS, and NIHSS. A Pomona Scale ≥2 had an accuracy (area under the curve) of 0.79, a sensitivity of 0.86, a specificity of 0.70, a positive predictive value of 0.71, and a negative predictive value of 0.97 for the detection of LVO. We also found that the presence of either neglect or gaze deviation alone had comparable accuracy of 0.79 as Pomona Scale ≥2 to detect LVO. CONCLUSION: The Pomona Scale is a simple and accurate scale to predict LVO. In addition, the presence of either gaze deviation or neglect also suggests the possibility of LVO.

Validation of Stroke Network of Wisconsin Scale at Aurora Health Care System.

BACKGROUND: The Stroke Network of Wisconsin (SNOW) scale, previously called the Pomona scale, was developed to predict large-vessel occlusions (LVOs) in patients with acute ischemic stroke (AIS). The original study showed a high accuracy of this scale. We sought to externally validate the SNOW scale in an independent cohort. METHODS: We retrospectively reviewed and calculated the SNOW scale, the Vision Aphasia and Neglect Scale (VAN), the Cincinnati Prehospital Stroke Severity (CPSS), the Los Angeles Motor Scale (LAMS), and the Prehospital Acute Stroke Severity Scale (PASS) for all patients who were presented within 24 hours after onset at AHCS (14 hospitals) between January 2015 and December 2016. The predictive performance of all scales and several National Institute of Health Stroke Scale cutoffs (≥6) were determined and compared. LVO was defined by total occlusions involving the intracranial internal carotid artery, middle cerebral artery (MCA; M1), or basilar arteries. RESULTS: Among 2183 AIS patients, 1381 had vascular imaging and were included in the analysis. LVO was detected in 169 (12%). A positive SNOW scale had comparable accuracy to predict LVO and showed a sensitivity of 0.80, specificity of 0.76, the positive predictive value (PPV) of 0.31, and negative predictive value of 0.96 for the detection of LVO versus CPSS ≥ 2 of 0.64, 0.87, 0.41, and 0.95. A positive SNOW scale had higher accuracy than VAN, LAMS, and PASS. CONCLUSION: In our large stroke network cohort, the SNOW scale has promising sensitivity, specificity and accuracy to predict LVO. Future prospective studies in both prehospital and emergency room settings are warranted.

Relationship and Characteristics of Falling at Temples among the Elderly Group in Nakhon Ratchasima, Thailand.

Background: Falls and their consequences are serious health problems among the elderly. In Thailand, temples are where the elderly often visit to pray and socialize with others. However, studies related to characteristics and severity of falls within temples are limited. Objective: To study characteristics of falls (falls, near falls, and fall-related injuries) and severity of falls among the elderly in temples. Material and Method: A cross-sectional analytic study. Subject is elderly population group (aged 60 and above) in the province of Nakhon Ratchasima (17 districts) who attend temples at least once a week (22 temples). The survey was conducted by questionnaires that required personal information, medical condition, frequency of fall, fall description, fall location, time of fall, and severity after a fall. Results: Total 742 subjects aged adult were screened through questionnaires. A number of 451 persons were reported to have fallen in temples, which was 60.8% of the population, whereas 76.1% of the population was said to have fallen or nearly fell. Most of the subjects have fallen only once in the past year by tripping (55%) and slipping (28.7%). Most of the falls occur outdoors (48.0%) rather than indoors (30.4%) and in the bathroom (21.6%). Some adults do not have any fall-related injuries (33.5%), though most of them experience muscle pain (27.3%). The rate of fractures among the elderly was 7.1%. A total of 117 subjects required hospitalization (25.9%). Upon being discharged from the hospital, 24.8% of the subjects were required to continue recovery at home. Conclusion: The number of near falls and falls among Thai older adults in temples are quite high and very concerning. Such numbers are alarming and indicate that the elderly attending services and activities in temples require appropriate facilities and close attention from accompanying and surrounding persons. This study presented fundamental yet beneficial information which is useful for the architectural, engineering, and public health development for the elderly.

Salvage of distal non-target coil embolization with stent placement and intravenous eptifibatide in a ruptured, unsecured, atypical aneurysm.

INTRODUCTION: Small aneurysms may be challenging to embolize. In cases of subarachnoid hemorrhage (SAH) where treatment is delayed, physicians may have to balance the risks of certain required therapies (antiplatelet agents) with the risk of rerupture. We describe a case of a technically challenging anterior cerebral artery aneurysm requiring eptifibatide infusion prior to definitive aneurysm treatment. CASE REPORT: A 57-year-old woman with SAH, underwent coil embolization of a small fenestrated A1-A2 junction aneurysm. The procedure was complicated by downstream coil migration which was then treated with Enterprise stent placement in the pericallosal artery. This required subsequent infusion of a glycoprotein IIb/IIIa inhibitor until the aneurysm could be repaired surgically. CONCLUSIONS: Revascularization with a stent in a distal cerebral vessel may salvage inadvertent coil migration. Although it is undesirable to administer antiplatelet agents to patients with SAH, in these circumstances short acting agents may be used.

Salvage of distal non-target coil embolization with stent placement and intravenous eptifibatide in a ruptured, unsecured, atypical aneurysm.

INTRODUCTION: Small aneurysms may be challenging to embolize. In cases of subarachnoid hemorrhage (SAH) where treatment is delayed, physicians may have to balance the risks of certain required therapies (antiplatelet agents) with the risk of rerupture. We describe a case of a technically challenging anterior cerebral artery aneurysm requiring eptifibatide infusion prior to definitive aneurysm treatment. CASE REPORT: A 57-year-old woman with SAH, underwent coil embolization of a small fenestrated A1-A2 junction aneurysm. The procedure was complicated by downstream coil migration which was then treated with Enterprise stent placement in the pericallosal artery. This required subsequent infusion of a glycoprotein IIb/IIIa inhibitor until the aneurysm could be repaired surgically. CONCLUSIONS: Revascularization with a stent in a distal cerebral vessel may salvage inadvertent coil migration. Although it is undesirable to administer antiplatelet agents to patients with SAH, in these circumstances short acting agents may be used.

Contrast-Induced Neurotoxicity following Cardiac Catheterization.

We report a case of probable contrast-induced neurotoxicity that followed a technically challenging cardiac catheterization in a 69-year-old woman. The procedure had involved the administration of a large cumulative dose of an iodinated, nonionic contrast medium into the innominate artery: twelve hours following the catheterization, the patient developed a seizure followed by a left hemiplegia, and an initial computed tomography (CT) scan showed sulcal effacement in the right cerebral hemisphere due to cerebral swelling. The patient's clinical symptoms resolved within 24 hours, and magnetic resonance imaging at 32 hours showed resolution of swelling. Contrast-induced neurotoxicity should be found in the differential diagnosis of acute neurological deficits occurring after radiological procedures involving iodinated contrast media, whether ionic or nonionic.

Gentamicin-induced myoclonus: a case report and literature review of antibiotics-induced myoclonus.

INTRODUCTION: Drug-induced myoclonus is a diagnosis of exclusion. Various drugs have been reported to induce myoclonus. Antibiotic-induced myoclonus (AIM) is very rare. We describe a case of multifocal myoclonus secondary to gentamicin toxicity and review the literature of AIM. CASE REPORT: A 59-year-old woman with end-stage renal disease developed generalized multifocal myoclonus within 1 hour after receiving only 1 supratherapeutic dose of gentamicin for a potential hemodialysis catheter infection. Myoclonus was completely resolved after 2 sessions of hemodialysis. We identified 22 patients of AIM in the literature. The median age of patients was 63 years. More than half of patients (12/22, 55%) had underlying chronic kidney disease. Cephalosporins were the most common drug class associated with AIM (12/22 patients; 55%). About two third of patients (15/22, 68%) received overdoses of antibiotics. Fifteen patients (71%) completely recovered after discontinuing or decreasing the dose of antibiotics. Five patients (24%) died of underlying medical conditions or of unknown etiology. Only 1 had persistent myoclonus. The potential mechanisms of AIM are discussed. CONCLUSIONS: AIM, although rare, should be considered as a potential cause of multifocal myoclonus in patients with advanced age or renal insufficiency. The prognosis of AIM appears favorable, with several cases resolving after withdrawal of the antibiotic.

The management of stroke in antiphospholipid syndrome.

Ischemic stroke is one of the most common complications of the antiphospholipid syndrome (APS). Because of the relative lack of definitive prospective studies, there is still some debate as to whether the persistent presence of antiphospholipid antibodies (aPLs) increases the risk of recurrent stroke. There is more evidence for aPLs as a risk factor for first stroke. The mechanisms of ischemic stroke are considered to be thrombotic and embolic. APS patients with thrombotic stroke frequently have other, often conventional vascular risk factors. Transesophageal echocardiogram is strongly recommended in APS patients with ischemic stroke because of the high yield of valvular abnormalities. The appropriate management of thrombosis in patients with APS is still controversial because of limited randomized clinical trial data. This review discusses the current evidence for antithrombotic therapy in patients who are aPL positive but do not fulfill criteria for APS, and in APS patients. Alternative and emerging therapies including low molecular weight heparin, new oral anticoagulants (including direct thrombin inhibitors), hydroxychloroquine, statins, and rituximab, are also addressed.

Acute quadriplegia from hyperkalemia: a case report and literature review.

BACKGROUND: Hyperkalemia has been described as a rare and under recognized cause of acute quadriplegia. CASE REPORT: A 52-year-old man with end-stage renal disease presented with ascending quadriplegia and dyspnea for 2 days. He had life-threatening hyperkalemia (9.0 mEq/L). His electrocardiogram showed typical features of hyperkalemia. His symptoms improved in 30 minutes and completely resolved in 5 hours after emergent treatment of hyperkalemia. He admitted eating large amounts of high potassium foods and taking ibuprofen in uncertain quantities. We reviewed 62 articles and identified 73 patients with secondary hyperkalemic paralysis. Common presentations were diminished reflexes, quadriparesis/paralysis, respiratory involvement, and sensory loss. Almost half of all patients had potassium levels higher than 9 mEq/L. Complete recovery, achieved in 89% of patients, did not correlate either with the absolute potassium level or the degree to which it was corrected. CONCLUSIONS: Hyperkalemia is a rare but treatable cause of acute flaccid paralysis that requires immediate treatment. Late diagnosis can delay appropriate treatment leading to cardiac arrhythmias and arrest.

Acute massive cerebral infarctions treated with hemodialysis.

We report here a 19-year-old woman with Down syndrome and end-stage renal disease who presented with left-sided weakness and fever. She had a massive pericardial effusion of unclear origin that required daily hemodialysis (HD) and cardiac intervention. She developed an acute right middle cerebral artery infarction with severe edema; her cerebral edema significantly improved with daily HD. Later in her hospitalization, she developed seizures and new onset of multiple acute embolic infarctions in left middle cerebral artery, left anterior cerebral artery (ACA), and right posterior cerebral artery (PCA) distributions with midline shift. However, we again noticed a dramatic decrease in cerebral edema with frequent HD. Although there is controversy about the use of dialysis in patients with stroke, our case suggests that daily HD may provide an alternate strategy for treating massive cerebral infarction. More studies are needed in these patients.

Cisplatin nephrotoxicity: a review.

BACKGROUND: Cisplatin is a major antineoplastic drug for the treatment of solid tumors, but it has dose-dependent renal toxicity. METHODS: We reviewed clinical and experimental literature on cisplatin nephrotoxicity to identify new information on the mechanism of injury and potential approaches to prevention and/or treatment. RESULTS: Unbound cisplatin is freely filtered at the glomerulus and taken up into renal tubular cells mainly by a transport-mediated process. The drug is at least partially metabolized into toxic species. Cisplatin has multiple intracellular effects, including regulating genes, causing direct cytotoxicity with reactive oxygen species, activating mitogen-activated protein kinases, inducing apoptosis, and stimulating inflammation and fibrogenesis. These events cause tubular damage and tubular dysfunction with sodium, potassium, and magnesium wasting. Most patients have a reversible decrease in glomerular filtration, but some have an irreversible decrease in glomerular filtration. Volume expansion and saline diuresis remain the most effective preventive strategies. CONCLUSIONS: Understanding the mechanisms of injury has led to multiple approaches to prevention. Furthermore, the experimental approaches in these studies with cisplatin are potentially applicable to other drugs causing renal dysfunction.

Gitelman-like syndrome after cisplatin therapy: a case report and literature review.

BACKGROUND: Cisplatin is a well-known nephrotoxic antineoplastic drug. Chronic hypokalemic metabolic alkalosis with hypomagnesemia and hypocalciuria is one of the rare complications associated with its use. CASE PRESENTATION: A 42-year-old woman presented with a 20 year-history of hypokalemic metabolic alkalosis with hypomagnesemia and hypocalciuria after cisplatin-based chemotherapy for ovarian cancer. This patient has had chronic muscle aches and fatigue and has had episodic seizure-like activity and periodic paralysis. Only thirteen other patients with similar electrolyte abnormalities have been described in the literature. This case has the longest follow-up. CONCLUSION: Cisplatin can cause permanent nephrotoxicity, including Gitelman-like syndrome. This drug should be considered among the possible causes of chronic unexplained electrolyte disorders.

Central nervous system pseudallescheriasis after near-drowning.

BACKGROUND: Clinical characteristics of central nervous system (CNS) pseudallescheriasis after near-drowning have not been systematically analyzed. METHODS: Review of cases reported in the English-language literature. RESULTS: Sixteen patients were identified. The average period between the near-drowning episode and onset of clinical manifestations was 37 days. Common manifestations included fever, altered mental status, headache, seizures, and hemiparesis. All patients developed brain abscesses; however, imaging studies were normal at presentation in 6 patients. Cerebrospinal fluid neutrophilic pleocytosis, elevated protein, and decreased glucose were commonly observed. Most patients were treated with surgical resection and systemic amphotericin B or miconazole. Voriconazole was used in 2 patients. Twelve patients (75%) died. The average time between the near-drowning episode and death was 12 weeks. Four survivors received prompt treatment. CONCLUSIONS: CNS pseudallescheriasis after near-drowning is highly lethal. Early diagnosis and aggressive medical and surgical interventions may improve survival.