Cortical Laminar Necrosis After Severe Hydrocephalus: Case Report and Review of the Literature.

Objectives: We present a case of cortical laminar necrosis after severe hydrocephalus to highlight considerations for multimodal cerebral autoregulation monitoring to determine mean arterial pressure (MAP) thresholds during neurological emergencies, as well as postoperative head imaging for patients with ventriculoperitoneal shunts (VPS). Methods: A 40-year-old woman with a history of Chiari II malformation and non-communicating hydrocephalus with VPS presented in septic shock from a sacral wound. One week after colostomy for fecal diversion, the patient became comatose and had progressive slowing to full suppression on electroencephalogram (EEG). Results: CT imaging revealed hydrocephalus, most likely due to VPS distal obstruction from intraperitoneal surgery. Despite neurosurgical and neurocritical care management, MRI confirmed diffuse cortical hypoxic ischemic injury. Discussion: The Neurocritical Care Society's Emergency Neurological Life Support (ENLS) protocol for neurological emergencies focuses on managing increased intracranial pressure (ICP) but does not set MAP goals. As ICP may be very high during brain herniation, our case demonstrates that higher MAP may be required to maintain adequate circulation. To determine the optimal MAP target, bedside multimodality monitoring, including ICP monitors, transcranial doppler, and near infrared spectroscopy, can help establish individualized cerebral autoregulation guided thresholds. Outside of a neurological intensive care unit, EEG can monitor cerebral blood flow and indicate windows for intervention before exam or imaging changes. Additionally, our case demonstrates how a post-operative surveillance CT head should be considered for patients with VPS.

Cerebral Microbleeds and Acute Hematoma Characteristics in the ATACH-2 and MISTIE III Trials.

BACKGROUND AND OBJECTIVES: To study the relationship between the presence of cerebral microbleeds (CMBs) and acute hematoma characteristics among patients with primary intracerebral hemorrhage (ICH). METHODS: We pooled individual patient data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 (MISTIE III) trial. We included individuals with a brain MRI scan. Exposure was the presence of a CMB. The coprimary outcomes were admission ICH volume and hematoma expansion. Mixed-effects linear and logistic regression models were used, with demographics and comorbid conditions considered fixed effects and the study cohort treated as a random effect. Additional analyses assessed the relationship between CMB topography and number and hematoma characteristics. RESULTS: Of the 1,499 patients with ICH enrolled in the parent trials, 466 (31.1%) were included in this analysis, and 231 (49.6%) patients had CMBs. In adjusted models, presence of CMBs was associated with smaller ICH volume (ß = -0.26, 95% confidence interval [CI] -0.44 to -0.08) and lower odds of hematoma expansion (odds ratio 0.65, 95% CI 0.40-0.95; p = 0.04). The strength of association between CMBs and hematoma characteristics increased with increasing number of CMBs. The location of the CMBs and the severity of leukoaraiosis did not modify these results. DISCUSSION: In a pooled cohort of patients with ICH, our results are consistent with the hypothesis that more severe underlying small vessel disease, as represented by CMBs, leads to smaller baseline hematoma volumes and reduced hematoma expansion. Underlying cerebral small vessel disease may be of prognostic significance after ICH. TRIAL REGISTRATION INFORMATION: ClinicalTrials.gov Identifier: NCT01176565 and NCT01827046. CLASSIFICATION OF EVIDENCE: This study provides Class II evidence that the presence of microbleeds on MRI is associated with a smaller ICH volume at presentation and a lower rate of hematoma expansion on follow-up imaging.

Prognostic Value of a Structural Brain MRI Score in the Acute Phase of Aneurysmal Subarachnoid Hemorrhage: A Pilot Study.

BACKGROUND/OBJECTIVE: Aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality despite advances in management. We evaluated the prognostic significance of a qualitative score using brain magnetic resonance imaging (MRI) features obtained early after aSAH. METHODS: Patients with aSAH were enrolled in a prospective observational cohort and underwent brain MRI during their acute hospitalization. MRIs were rated using a scoring system that considers the anatomical location of signal intensity changes on diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) sequences. The relationship between MRI scores and functional outcome defined by modified Rankin scale (mRS) at 6 months was evaluated in uni- and multivariable models. RESULTS: The cohort included 45 aSAH patients (median World Federation of Neurologic Surgeons (IQR) 2 (1-4)) who underwent brain MRI a mean (SD) of 9.0 ± 8.0 days after aSAH. At 6 months after aSAH, 26 patients had achieved a favorable outcome (mRS ≤ 2) while 15 had an unfavorable outcome (mRS > 2). Deep gray nuclei (DGN) score (p = 0.016), cortex + DGN score (p = 0.015), FLAIR score (p = 0.016), DWI score (p = 0.0045), and overall score (p = 0.0081) were significantly lower in patients with favorable outcome compared to those with unfavorable outcome. However, MRI scores were not independent predictors of outcome in multivariable models adjusting for admission Hunt and Hess, Glasgow Coma Scale, or World Federation of Neurologic Surgeons scales. CONCLUSIONS: In this pilot study, a qualitative scoring system using anatomically defined MRI FLAIR and DWI signal abnormalities identified in the acute phase of aSAH was linked to 6-month functional outcome. However, these scores did not add prognostic value to established indices of neurological severity.

Lung-protective ventilation and adjunctive strategies to manage respiratory failure: are they safe in the neurological patient?

PURPOSE OF REVIEW: The coexistence of neurological injury and respiratory failure is common in intensive care. This article provides a contemporary overview of the safety and efficacy of different strategies for mechanical ventilation and adjunctive respiratory approaches in patients with acute brain injury. RECENT FINDINGS: Available evidence indicates that lung-protective ventilation (LPV) can be implemented safely in a range of patients with concurrent respiratory failure and brain injury of different etiologies; however, the clinical efficacy of LPV in this setting needs to be established. In patients who have severe acute respiratory distress syndrome (ARDS) and brain injury, adjunctive measures (neuromuscular blocker drug infusions, prone positioning, extracorporeal membrane oxygenation) may be considered, although the neurophysiological impact and safety of these techniques need further investigation. Intracranial pressure and other neuromonitoring techniques may be of value to ensure optimal management of mechanical ventilation and adjunctive measures in this population. SUMMARY: Research is needed to determine the safety, feasibility, and efficacy of LPV and adjunctive approaches for managing patients with concurrent brain injury and respiratory failure.

Prevalence of Cervical Artery Dissection Among Hospitalized Patients With Stroke by Age in a Nationally Representative Sample From the United States.

OBJECTIVE: To test the hypothesis that the prevalence of cervical artery dissection remains constant across age groups, we evaluated the relationship between age and cervical artery dissection in patients with stroke using a nationally representative sample from the United States. METHODS: We used inpatient claims data included in the 2012-2015 releases of the National Inpatient Sample (NIS). We used validated ICD-9-CM codes to identify adults hospitalized with ischemic stroke and a concomitant diagnosis of carotid or vertebral artery dissection. Survey weights provided by the NIS and population estimates from the US census were used to calculate nationally representative estimates. The χ2 test for trend was used to compare the prevalence of concomitant dissection among stroke hospitalizations across patient subgroups defined by age. Poisson regression and the Wald test for trend were used to evaluate whether the prevalence of hospitalizations for stroke and concomitant dissection per million person-years varied by age groups. RESULTS: There were 17,320 (95% confidence interval [CI], 15,614-19,026) hospitalizations involving ischemic stroke and a concomitant dissection. The prevalence of dissection among stroke hospitalizations decreased across 10-year age groups from 7.2% (95% CI, 6.2%-8.1%) among persons younger than 30 years to 0.2% (95% CI, 0.1%-0.2%) among persons older than 80 years (p value for trend <0.001). However, the prevalence of hospitalizations for stroke and concomitant dissection increased from 5.4 (95% CI, 4.6-6.2) hospitalizations per million person-years among adults younger than 30 to 24.4 (95% CI, 21.0-27.9) hospitalizations per million person-years among adults older than age 80 (p value for trend <0.01). CONCLUSION: In a nationally representative sample, the prevalence of hospitalizations for dissection-related stroke increased with age.

Relationship between Presence of Visceral Infarction and Functional Outcome among Patients with Acute Ischemic Stroke.

INTRODUCTION: Evidence of visceral infarction is often found in patients with acute ischemic stroke. It remains uncertain whether there exists a relationship between visceral infarction and functional outcomes among patients with stroke. OBJECTIVE: The aim of this study was to evaluate whether evidence of visceral infarction is associated with functional outcomes among patients with stroke. METHODS: Among patients with acute ischemic stroke enrolled in the Cornell AcutE Stroke Academic Registry (CAESAR) from 2011 through 2016, we included those with a contrast-enhanced abdominal computed tomographic scan within 1 year of admission. Our outcome was ambulatory status at discharge from acute stroke hospitalization, categorized as walking without assistance, walking with assistance, and unable to walk. We used ordinal logistic regression to examine the association between visceral infarction and discharge ambulatory status after adjustment for demographics, stroke risk factors, stroke severity (NIH Stroke Scale), and stroke subtype. RESULTS: Among 2,116 ischemic stroke patients registered in CAESAR from 2011 to 2016, 259 had contrast-enhanced abdominal computed tomographic imaging, of whom 48 (19%) had evidence of visceral infarction. After adjustment for demographics, stroke risk factors, stroke severity, and stroke subtype, the presence of visceral infarction was associated with a worse ambulatory status at discharge (global OR for better ambulatory status, 0.4; 95% CI, 0.2-1.0, p = 0.046). CONCLUSIONS: We found that the presence of visceral infarction was associated with poor functional outcomes at the time of hospital discharge. These findings suggest that such findings are not necessarily benign and are at the least a marker of poor outcomes.

Differences in Admission Blood Pressure Among Causes of Intracerebral Hemorrhage.

Background and Purpose- It is unknown whether admission systolic blood pressure (SBP) differs among causes of intracerebral hemorrhage (ICH). We sought to elucidate an association between admission BP and ICH cause. Methods- We compared admission SBP across ICH causes among patients in the Cornell Acute Stroke Academic Registry, which includes all adults with ICH at our center from 2011 through 2017. Trained analysts prospectively collected demographics, comorbidities, and admission SBP, defined as the first recorded value in the emergency department or on transfer from another hospital. ICH cause was adjudicated by a panel of neurologists using the SMASH-U criteria. We used ANOVA to compare mean admission SBP among ICH causes. We used multiple linear regression to adjust for age, sex, race, Glasgow Coma Scale score, and hematoma size. In secondary analyses, we compared hourly SBP measurements during the first 72 hours after admission, using mixed-effects linear models adjusted for the covariates above plus antihypertensive agents. Results- Among 484 patients with ICH, admission SBP varied significantly across ICH causes, ranging from 138 (±24) mm Hg in those with structural vascular lesions to 167 (±35) mm Hg in those with hypertensive ICH (P<0.001). The mean admission SBP in hypertensive ICH was 17 (95% CI, 11-24) mm Hg higher than in ICH of all other causes combined. These differences remained significant after adjustment for age, sex, race, Glasgow Coma Scale score, and hematoma size (P<0.001), and this persisted throughout the first 72 hours of hospitalization (P<0.001). Conclusions- In a single-center ICH registry, SBP varied significantly among ICH causes, both on admission and during hospitalization. Our results suggest that BP in the acute post-ICH setting is at least partly associated with ICH cause rather than simply representing a physiological reaction to the ICH itself.

Medical Mobile Applications for Stroke Survivors and Caregivers.

BACKGROUND: Recent studies estimate nearly half of the US population can access mobile medical applications (apps) on their smartphones. The are no systematic data available on apps focused on stroke survivors/caregivers. OBJECTIVE: To identify apps (a) designed for stroke survivors/caregivers, (b) dealing with a modifiable stroke risk factor (SRF), or (c) were developed for other purposes but could potentially be used by stroke survivors/caregivers. METHODS: A systematic review of the medical apps in the US Apple iTunes store was conducted between August 2013 and January 2016 using 18 predefined inclusion/exclusion criteria. SRFs considered were: diabetes, hypertension, smoking, obesity, atrial fibrillation, and dyslipidemia. RESULTS: Out of 30,132 medical apps available, 843 (2.7%) eligible apps were identified. Of these apps, (n = 74, 8.7%) apps were specifically designed for stroke survivors/caregivers use and provided the following services: language/speech therapy (n = 28, 37%), communication with aphasic patients (n = 19, 25%), stroke risk calculation (n = 11, 14%), assistance in spotting an acute stroke (n = 8, 10%), detection of atrial fibrillation (n = 3, 4%), direction to nearby emergency room (n = 3, 4%), physical rehabilitation (n = 3, 4%), direction to the nearest certified stroke center (n = 1, < 2%), and visual attention therapy (n = 1, <2%). 769 apps identified that were developed for purposes other than stroke. Of these, the majority (n = 526, 68%) addressed SRFs. CONCLUSIONS: Over 70 medical apps exist to specifically support stroke survivors/caregivers and primarily targeted language and communication difficulties. Apps encompassing most stroke survivor/caregiver needs could be developed and tested to ensure the issues faced by these populations are being adequately addressed.

Does the Magnitude of the Electrocardiogram QT Interval Dispersion Predict Stroke Outcome?

BACKGROUND: QT dispersion, maximal interlead difference in QT interval on 12-lead electrocardiogram (ECG), measures cardiac repolarization abnormalities. Data are conflicting whether QT dispersion predicts adverse outcome in acute ischemic stroke (AIS) patients. Our objective is to determine if QT dispersion predicts: (1) short-term clinical outcome in AIS, and (2) stroke location (insular versus noninsular cortex). METHODS: Admission ECGs from 412 consecutive patients with acute stroke symptoms from 2 university-based stroke centers were reviewed. QT dispersion was measured. A neuroradiologist reviewed brain imaging for insular cortex involvement. Favorable clinical outcomes at discharge were modified Rankin Scale (mRS) score of 0-1, discharge National Institutes of Health Stroke Scale (NIHSS) score less than 2, and discharge to home. Multiple logistic regressions were performed for each outcome measure and to determine the association between insular infarct and QT dispersion. RESULTS: Of 145 subjects in the final analysis, median age was 65 years (interquartile range [IQR] 56-75), male patients were 38%, black patients were 68%, median QT dispersion was 78 milliseconds (IQR 59-98), and median admission NIHSS score was 4 (IQR 2-6). QT dispersion did not predict short-term clinical outcome for mRS score (odds ratio [OR] = 1.001, 95% confidence interval [CI] .99-1.01, P = .85), NIHSS at discharge (OR = .994, 95% CI .98-1.01, P = .30), or discharge disposition (OR = 1.001, 95% CI .99-1.01, P = .81). Insular cortex involvement did not correlate with QT dispersion magnitude (OR = 1.009, 95% CI .99-1.02, P = .45). CONCLUSIONS: We could not demonstrate that QT dispersion is useful in predicting short-term clinical outcome at discharge in AIS. Further, the magnitude of QT dispersion did not predict insular cortical stroke location.

Stroke and Etonogestrel/Ethinyl Estradiol Ring (NuvaRing): Clinical, Radiological, and Prognostic Features.

BACKGROUND: A recent study found that NuvaRing (a vaginal contraceptive ring containing 15 µg ethinyl estradiol and 120 µg etonogestrel) has 2.5 times increased relative risk of thrombotic stroke compared to nonuse. OBJECTIVE: We studied a case series of 19 such patients as well as prior published case reports to clarify clinical, radiological, and prognostic features. METHODS: Medical records and imaging for 18 cases were initially systematically reviewed for consultation in a class action lawsuit. One case was seen personally outside of litigation. All 19 cases were entered into a database detailing clinical, radiological, and prognostic features as well as other potential risk factors. A literature search identified 8 additional cases. RESULTS: Average age at stroke was 31.7 ± 9.8 years; average duration of NuvaRing use prior to stroke was 11.2 months. Arterial stroke occurred in 10 of 19 (52%); 1 of 10 (10%) was hemorrhagic. Venous sinus thrombosis was present in 11 of 19 (58%) on initial imaging; 6 of 11 (54%) were hemorrhagic. The most common presenting symptom was headache (7 of 19 [37%]) and motor weakness (7 of 19 [37%]). A hypercoagulable condition was present in 3 of 19 (16%); 3 of 19 (16%) had history of hypercoagulable disease in a first-degree relative. Mortality was .5%; 8 of 19 (42%) fully recovered and 3 of 19 (15%) were discharged to rehabilitation. CONCLUSIONS: In this largest case series of NuvaRing-associated stroke to date, approximately half of the strokes are venous and half are arterial. Stroke typically occurred within the first year of use, and as soon as 2 weeks after NuvaRing initiation.

The Rapid Initiation, Titration, and Transition from Intravenous to Oral Treprostinil in a Patient with Severe Pulmonary Arterial Hypertension.

In patients who require urgent initiation of pulmonary arterial hypertension medications due to disease progression, it is customary to start intravenous prostacyclin therapy, typically during a hospital admission. If there are complicating factors or relative contraindications to intravenous and subcutaneous prostanoids, oral treprostinil provides another pathway to prostanoid therapy, but this usually requires a prolonged titration. We describe the case of a thirty-six-year-old male with severe pulmonary arterial hypertension and contraindication to intravenous and subcutaneous prostanoid therapy due to congenital deafness and the risk of not hearing the intravenous pump alarms. Intravenous treprostinil was initiated, titrated to high dose, and then rapidly transitioned to oral treprostinil. A rapid initiation, titration, and transition from intravenous to oral treprostinil can be safely performed under watchful supervision in order to achieve higher and more efficacious doses of oral treprostinil in a timely manner.

Obesity and urologic complications after renal transplantation.

Although obesity has been associated with improved survival on dialysis, its short-and long-term effects on renal transplantation outcomes remain unclear. Herein, we evaluate the short-term and intermediate long-term effects of obesity on first-time renal transplant patients. A retrospective analysis was performed on 180 consecutive renal transplant recipients from living unrelated donors during 2006-2008 in a major transplantation center in Tehran, Iran. Among these, 34 (18%) patients were found to be obese (body mass index ≥30 kg/m 2 ). Obese patients were more likely to develop post-transplant renal artery stenosis (RAS) (17.6% vs. 2.8%, P <0.001), hematoma (47.9% vs. 17.6, P = 0.009), surgical wound complications (64.7% vs. 9.6%, P <0.001) and renal vein thrombosis (2% vs. 0%, P <0.001). However, the incidence of delayed graft function, lymphocele, urologic complications of ureterovesical junction stenosis or urinary leakage, surgical complications of excessive bleeding or renal artery thrombosis and duration of hospitalization were similar between the two groups. The two-year patient and graft survival were also statistically not different. Renal transplantation in obese recipients is associated with a higher incidence of post-transplant RAS, hematoma, surgical wound complications and renal vein thrombosis, but similar two-year patient and graft survival.

Efficacy of oral metronidazole in treatment of cutaneous and mucosal lichen planus.

INTRODUCTION: Response to different antimicrobial agents supports the infection hypothesis for lichen planus (LP). There are individual case reports describing the improvement of LP with oral metronidazole treatment in patients with concomitant intestinal amebiasis or giardiasis. There are two small studies that reported metronidazole might be effective in some patients with idiopathic LP who did not have concomitant protozoal infections of the intestinal or genital tracts. The authors performed an open trial to evaluate the effectiveness of metronidazole, as a single treatment, on different forms of LP. PATIENTS AND METHODS: A total of 49 patients, 24 male and 25 female, were selected from the dermatology outpatient clinic with a diagnosis of LP in one of its forms. Metronidazole was administered at 250 mg every eight hours daily without any concomitant therapy. Patients were examined at baseline and at days 21, 42, 63, 84 of treatment, and the follow-up period was three months. The authors used SPSS software (Version 15) for data analysis. RESULTS: A total of 20 (40.82%) skin lesions had complete response (CR) to treatment by metronidazole, 16 (32.65%) had relative healing (PR) and 13 (26.53%) did not improve (NR). The overall treatment response (CR + PR) of LP skin lesions was 73.47 percent in this study. In mucosal involvement, the overall treatment response was 66.6 percent, and finally the overall treatment response for itching was obtained in 75 percent of the cases. CONCLUSION: Based on the authors' findings, metronidazole can be an alternative therapy in treatment of LP, and is a safe agent to be considered.