Patient refusal of thrombolytic therapy for suspected acute ischemic stroke.

OBJECTIVE: To determine factors associated with patients refusing IV t-PA for suspected acute ischemic stroke (AIS), and to compare the outcomes of patients who refused t-PA (RT) with those treated with t-PA. METHODS: Patients who were treated with and refused t-PA at our stroke center were identified retrospectively. Demographics, clinical presentation, and outcome measures were collected and compared. Clinical outcome was defined as excellent (mRS: 0-1), good (mRS: 0-2), and poor (mRS: 3-6). RESULTS: Over 7·5 years, 30 (4·2%) patients refused t-PA. There were no demographic differences between the treated and RT groups. The rate of RT decreased over time (OR 0·63, 95% CI 0·50-0·79). Factors associated with refusal included a later symptom onset to emergency department presentation time (OR 1·02, 95% CI 1·01-1·03), lower NIHSS (OR 1·11, 95% CI 1·03-1·18), a higher proportion of stroke mimics (OR 17·61, 95% CI 6·20-50·02) and shorter hospital stay (OR 1·32, 95% CI 1·09-1·61). Among patients who were subsequently diagnosed with ischemic stroke, only length of stay was significantly shorter for refusal patients (OR 1·37, 95% CI 1·06-1·78). After controlling for mild strokes and stroke mimics, clinical outcome was not different between the groups (OR 1·61, 95% CI 0·69-3·73). CONCLUSION: The incidence of patients refusing t-PA has decreased over time, yet it may be a cause for t-PA under-utilization. Patients with milder symptoms were more likely to refuse t-PA. Refusal patients presented later to the hospital and had shorter hospital stays. One out of six refusal patients (16·6%) had a stroke mimic.

Safety of high doses of urokinase and reteplase for acute ischemic stroke.

BACKGROUND AND PURPOSE: ET is considered in selected patients with AIS with persistent arterial occlusion after receiving IVT. Limited data exist on the safety of IA high doses of UK and RT for ET. We investigated any correlation between IA doses of UK or RT and safety outcomes in patients who underwent ET. MATERIALS AND METHODS: We identified all patients from our stroke registry who received UK or RT for ET from 1998 to 2008. Demographics, baseline National Institutes of Health Stroke Scale scores, recanalization rates, rates of attempted MT, mortality, SICH, and discharge modified Rankin Scale scores were collected. RESULTS: Of 197 patients; 72 received UK and 125 received RT. More than 90% of patients in both groups had received prior IVT. The median IA dose of UK was 200,000 U (range, 25,000-1,500,000 U) and of RT was 2 mg (range, 1-8 mg). Concurrent MT was attempted in 59.7% of UK-treated patients and 72.0% of RT-treated patients, with SICH rates of 4.2% and 8.0%, respectively. Logistic regression adjusting for prior IVT and MT revealed no correlation between SICH and doses of UK (OR, 1.00; 95% CI, 0.99-1.00; P = .94) or RT (OR, 0.803; 95% CI, 0.48-1.33; P = .39). There was no correlation between mortality and doses of UK (OR, 1.00; 95% CI, 0.99-1.00; P = .51) or RT (OR, 1.048; 95% CI, 0.77-1.42; P = .75). CONCLUSIONS: High IA doses of UK and RT may be safe when given with or without MT in patients with AIS despite receiving a full dose of intravenous recombinant tissue plasminogen activator. These results need prospective validation.

The effect of transcatheter injections on cell viability and cytokine release of mononuclear cells.

BACKGROUND AND PURPOSE: Several studies suggest that various types of cellular therapies enhance recovery after stroke in animal models. IA-based delivery of cells to the brain is under investigation for stroke, but it is unknown whether cells are injured as a result of being injected through a catheter or exposed to iodinated contrast medium or solutions containing heparin. MATERIALS AND METHODS: We assessed the effect of catheterization with the Excelsior SL-10 catheter or exposure to heparin or iodine contrast on human bone marrow MNCs. Viability and cell injury were assessed by trypan blue exclusion, caspase-3 activity, and lipid peroxidation. Cellular function of MNCs was assessed by their production and release of VEGF, IL-10, and IGF-1. RESULTS: Flow rates of 10 million cells from 0.5 to 2 mL/min did not alter MNC viability; however, 5 mL/min of MNCs did reduce viability by 19%. Iodine and low-dose heparin exposure did not affect cell viability; however, high-dose heparin was cytotoxic. Catheter delivery at 2 mL/min did not affect levels of VEGF, IL-10, or IGF-1. CONCLUSIONS: MNCs do not appear to be damaged by heparin, iodine contrast, and the Excelsior SL-10 catheter at flow rates up to 2 mL/min. However, higher flow rates did reduce viability, and high-dose heparin did cause cell death.

Safety of tPA in stroke mimics and neuroimaging-negative cerebral ischemia.

BACKGROUND: Patients with acute neurologic symptoms may have other causes simulating ischemic stroke, called stroke mimics (SM), but they may also have averted strokes that do not appear as infarcts on neuroimaging, which we call neuroimaging-negative cerebral ischemia (NNCI). We determined the safety and outcome of IV thrombolysis within 3 hours of symptom onset in patients with SM and NNCI. METHODS: Patients treated with IV tissue plasminogen activator (tPA) within 3 hours of symptom onset were identified from our stroke registry from June 2004 to October 2008. We collected admission NIH Stroke Scale (NIHSS) score, modified Rankin score (mRS), length of stay (LOS), symptomatic intracerebral hemorrhage (sICH), and discharge diagnosis. RESULTS: Among 512 treated patients, 21% were found not to have an infarct on follow-up imaging. In the SM group (14%), average age was 55 years, median admission NIHSS was 7, median discharge NIHSS was 0, median LOS was 3 days, and there were no instances of sICH. The most common etiologies were seizure, complicated migraine, and conversion disorder. In the NNCI group (7%), average age was 61 years, median admission NIHSS was 7, median discharge NIHSS was 0, median LOS was 3 days, and there were no instances of sICH. Nearly all SM (87%) and NNCI (91%) patients were functionally independent on discharge (mRS 0-1). CONCLUSIONS: Our data support the safety of administering IV tissue plasminogen activator to patients with suspected acute cerebral ischemia within 3 hours of symptom onset, even when the diagnosis ultimately is found not to be stroke or imaging does not show an infarct.

The ethics of prophylactic antibiotics for neurosurgical procedures.

The prophylactic use of antibiotics has become a routine procedure in many areas of medicine. In neurosurgery, however, there is considerable debate over their use in the prevention of postoperative infection. We pose several ethical questions about antibiotic prophylaxis in a neurosurgical setting. These questions are discussed under the following categories: responsible usage of antibiotics; the ethical dilemmas of controlled, antibiotic clinical trials, and some problems inherent in not using prophylactic antibiotics.

Cushing's contributions to neuroscience, part 2: Cushing and several dwarfs.

Harvey Cushing revolutionized modern neurosurgery and pioneered the field of neuroendocrinology. This second of a two-part series on Harvey Cushing's contributions to neuroscience discusses his pivotal discoveries of the function and clinical disorders of the anterior pituitary. A review of his 20-year obsession with the pituitary reveals Cushing's ingenuity, keen sense of observation, and persistent stubborness. His enthusiasm to test his ideas, however, led to risky experimentation. Despite his foibles, his work opened up new frontiers of research for a number of investigators, whose efforts resulted in the identification of specific pituitary hormones, the hypothalamic regulation of the pituitary, and the practical applications of endocrinology.

Cell-specific caspase expression by different neuronal phenotypes in transient retinal ischemia.

Emerging evidence supports an important role for caspases in neuronal death following ischemia-reperfusion injury. This study assessed whether cell specific caspases participate in neuronal degeneration and whether caspase inhibition provides neuroprotection following transient retinal ischemia. We utilized a model of transient global retinal ischemia. The spatial and temporal pattern of the active forms of caspase 1, 2 and 3 expression was determined in retinal neurons following ischemic injury. Double-labeling with cell-specific markers identified which cells were expressing different caspases. In separate experiments, animals received various caspase inhibitors before the induction of ischemia. Sixty minutes of ischemia resulted in a delayed, selective neuronal death of the inner retinal layers at 7 days. Expression of caspase 1 was not detected at any time point. Maximal expression of caspase 2 was found at 24 h primarily in the inner nuclear and ganglion cell layers of the retina and localized to ganglion and amacrine neurons. Caspase 3 also peaked at 24 h in both the inner nuclear and outer nuclear layers and was predominantly expressed in photoreceptor cells and to a lesser extent in amacrine neurons. The pan caspase inhibitor, Boc-aspartyl fmk, or an antisense oligonucleotide inhibitor of caspase 2 led to significant histopathologic and functional improvement (electroretinogram) at 7 days. No protection was found with the caspase 1 selective inhibitor, Y-vad fmk. These observations suggest that ischemia-reperfusion injury activates different caspases depending on the neuronal phenotype in the retina and caspase inhibition leads to both histologic preservation and functional improvement. Caspases 2 and 3 may act in parallel in amacrine neurons following ischemia-reperfusion. These results in the retina may shed light on differential caspase specificity in global cerebral ischemia.

Antithrombotic and thrombolytic therapy for ischemic stroke.

Antithrombotic and thrombolytic agents form the cornerstone of stroke prevention and treatment. Large, randomized trials have also highlighted the effectiveness and safety of early and continuous antiplatelet therapy in reducing atherothrombotic stroke recurrence. Aspirin is the antiplatelet treatment standard against which several other antiplatelet agents (ticlopidine, clopidogrel, aspirin-dipyridamole) have been shown to be more effective. The prevention of cardioembolic stroke is best accomplished with oral anticoagulation, barring any contraindications. The thrombolytic agent, rt-PA, improves outcome in ischemic stroke patients treated within 3 hours of onset. The risk-benefit ratio is narrow because of an increased risk for bleeding but studies do not support a higher risk in the geriatric population.

The novel beta-blocker, carvedilol, provides neuroprotection in transient focal stroke.

Increasing evidence supports a role for oxidative stress, proinflammatory cytokines, and apoptosis in the pathophysiology of focal ischemic stroke. Previous studies have found that the multi-action drug, carvedilol, is a mixed adrenergic antagonist, and that it behaves as an antioxidant and inhibits apoptosis. In the current study, the authors investigated whether carvedilol provides protection in focal cerebral ischemia and whether this protection is associated with reduced apoptosis and the downregulation of the inflammatory cytokines, tumor necrosis factor-alpha (TNF-alpha) and interleukin- 1beta (IL-1beta). Male Sprague-Dawley rats were subjected to transient middle cerebral artery occlusion (MCAO) by an intraluminal filament technique. Carvedilol (1, 3, and 10 mg/kg) was injected daily subcutaneously 2 or 4 days before the induction of ischemia. Neurologic scores, infarct volumes, TUNEL staining, and mRNA levels of TNF-alpha and IL-1beta were assessed at 24 hours reperfusion. The effect of carvedilol on microvascular cortical perfusion was studied with continuous laser-Doppler flowmetry. Twenty-four hours after MCAO, carvedilol at all three doses reduced infarct volumes by at least 40% and reduced neurologic deficits on average by 40% compared with vehicle-treated controls when given 2 or 4 days before the induction of ischemia. This protection was not mediated by changes in temperature or blood flow. Treatment with all three dose regimens resulted in fewer TUNEL positive cells compared with controls. At 24 hours reperfusion, carvedilol decreased TNF-alpha and IL-1beta expression by 40% to 50% in the ipsilateral ischemic cortex compared with the contralateral controls. The results of the current study indicate that carvedilol is neuroprotective in focal cerebral ischemia and may protect the ischemic brain by inhibiting apoptosis and attenuating the expression of TNF-alpha and IL-1beta.

Leukemia inhibitory factor requires concurrent p75LNTR signaling to induce apoptosis of cultured sympathetic neurons.

Apoptosis may result either from positive induction by ligand binding to a plasma membrane receptor or from negative induction attributable to loss of a suppressor signal. For example, apoptosis of developing sympathetic neurons may be induced in culture either by exposure to leukemia inhibitory factor (LIF) or by deprivation of nerve growth factor. This study compared the cell death pathways activated in sympathetic neurons by these two different stimuli. Both types of cell death were developmentally regulated; both were maximal in the immediate postnatal period and disappeared over the next 2 weeks. Both types of cell death were reduced by genetic deletion of Bax or by virally mediated overexpression of Bcl-2. Similarly both were reduced by inhibition of caspase activity or by inhibition of Nedd-2 synthesis with antisense oligonucleotides. Finally, both involved activation of c-Jun N-terminal kinase (JNK) signaling. Nedd-2 expression by sympathetic neurons declined in parallel with the developmental loss of LIF-mediated cell death, suggesting that downregulation of the caspase during development may underlie the loss of cytokine-mediated apoptosis. Treatment of sympathetic neurons with an antibody that blocks the function of the low-affinity neurotrophin receptor (p75(LNTR)) prevented LIF-induced cell death. Similarly genetic deletion of p75(LNTR) prevented apoptosis after LIF treatment. These observations suggest that concurrent p75(LNTR) signaling is necessary for LIF-induced cell death and that cytokine-mediated cell death and growth factor deprivation appear to activate the same intracellular pathways involving JNK signaling.

Topical irrigation with polymyxin and bacitracin for spinal surgery.

BACKGROUND: The purpose of the present study was to evaluate constant irrigation with saline containing 50,000 units each of polymyxin and bacitracin in a regimen of antimicrobial prophylaxis for clean spinal surgery at two community hospitals with a zero infection rate. METHODS: The focus was on the bactericidal effects of prophylactic topical antibiotics by assessing random contamination in neurosurgical wounds from: 1) the flora of the integument and nares of the operating team, 2) the surgical apparel, 3) the patient's skin, 4) air-borne organisms in the operating theater, and 5) the surgeon's gloves. RESULTS: Based on individual biotyping of bacteria and antimicrobial sensitivity testing, no consistent source or pattern could be uncovered for the organisms recovered from the operative site. Relying on longitudinal data, the incidence of intraoperative bacterial growth with continuous saline lavage was reduced from 64 to 4% when the combination of topical polymyxin and bacitracin was added. CONCLUSIONS: Although the virtual elimination of bacterial growth in the surgical site was accomplished, the efficacy of topical antibiotics in the prevention of wound infection remains unproven.

Apoptosis in neurological disease.

Enormous interest in cell death in the past several years has moved apoptosis to the forefront of scientific research. Apoptosis has been found to mediate cell deletion in tissue homeostasis, embryological development, and immunological functioning. It also occurs in pathological conditions, including cancer and acquired immunodeficiency syndrome, and is implicated in neurodegenerative diseases. Claims of neuronal apoptosis induced by various agents and conditions are published regularly, but in many instances the data are questionable because they are incomplete. This review presents a brief history of apoptosis and describes the evidence required before claims of apoptosis are made. Summaries and critiques of important investigations concerning the genetic and biochemical regulation of neuronal apoptosis are presented, as are other studies describing connections between apoptosis and neuronal cell death in physiological and pathological situations. There is a realization that apoptosis can be programmed and is distinguishable from necrotic cell death. Combining apoptosis with programmed cell death produces misleading terminology and confusion over these two forms of cell degeneration. Further investigations into neuronal apoptosis should focus on all of the criteria that the original investigators outlined 25 years ago, to clarify whether apoptosis and/or another form of cell death mediates neuronal degeneration in physiological settings and in neurological diseases such as Alzheimer's disease, Parkinson's disease, epilepsy, and ischemia/stroke.

Leonard I. Malis and prophylactic antibiotics.

Leonard I. Malis introduced important changes in the antimicrobial regimen for neurosurgical procedures at The Mount Sinai Hospital. Among Dr. Malis' innovations, intraoperative administration of a single dose each of vancomycin and gentamicin or tobramicin and constant irrigation of the surgical site with a bactericidal antibiotic (streptomycin) led to the elimination of primary wound infections during a 20-year period. In a study to locate potential sources of microbial contamination in his operating room, this combination of parenteral antibiotics was justified, because 36% of patients were at risk for exposure to methicillin-resistant Staphylococcus aureus and Gram-negative bacteria. Streptomycin as a topical agent was found to be highly efficacious in preventing intraoperative growth of potential pathogens cultured from the surgical wound and the operating room environment.

Apoptosis in the retina.

An enormous interest in cell death over the past several years has catapulted apoptosis to the forefront of scientific research. Apoptosis has been found to mediate cell deletion in tissue homeostasis, embryological development and immunologic function. It also occurs in pathological situations including cancer and AIDS, and is implicated in a variety of ocular diseases. This review presents a brief history of apoptosis and the proper evidence needed in order to claim that apoptosis is taking place. A summary and critique of important investigations concerning the genetic and biochemical regulation of apoptosis is presented, as well as a focus on other studies drawing a connection between apoptosis and cell death in physiological and pathological situations.

Investigations of the bacteriologic factors in cervical disk surgery.

A study was undertaken to evaluate the potential risk of wound infection in cervical disk disease, the appropriateness of the current prophylactic regimen of intravenous cefazolin at Good Samaritan Hospital, and the increasing resistance of coagulase-negative staphylococci in nosocomial infections. In addition, the methodology used in three prior studies was used to verify that double-gloving is a more effective barrier to bacterial contamination than single-gloving and that topical streptomycin lavage is superior to constant irrigation with plain saline. No wound infections were documented in the 40 patients who underwent cervical disk surgery in a 12-month period. Coagulase-negative Staphylococcus species were the most common bacterial isolate, but only 20% were resistant to cefazolin. Of the 11 S. aureus isolates, 9 were sensitive to cefazolin and 2 were methicillin resistant. A remarkable 95% (114/120) of the intraoperative wound cultures were free of bacteria. In only 2 cases was there a serial increase in colonies of the same organism over the course of the operation. There was one positive glove culture--coagulase-negative Staphylococcus sensitive to cefazolin. The patient's skin was identified as the source of contamination in 3 intraoperative cultures of the wound and 2 cultures of the ambient operating room air. Neither individual biotyping of bacteria nor antimicrobial susceptibility testing uncovered any consistent source or pattern to account for the organisms in the surgical wound or ambient operating room air. Bacteria resistant to cefazolin were found in 36% of the intraoperative environmental cultures but in only 16% of the isolates from patients' skin.(ABSTRACT TRUNCATED AT 250 WORDS)

Investigations of the bacteriological factors in clean neurosurgical wounds.

A number of questions remained unanswered by the empirical success of antimicrobial prophylaxis for neurosurgical patients at The Mount Sinai Hospital during a 15-year period. Vancomycin (1 g intravenously) and tobramycin (80 mg intramuscularly) were administered in the induction room. Streptomycin (50 mg) was mixed into each liter of saline used to irrigate the surgical incision. A series of 45 consecutive clean neurosurgical operations were investigated. The potential sources of random contamination of the surgical wound that were studied included the following: 1) the patient's skin; 2) the flora of the skin and nares of the operating team; 3) the surgical apparel; 4) the surgeons' gloves; and 5) the airborne organisms in the operating theater. No wound infections were documented during a 4-month period between June and September of 1991. A remarkable 98% of the intraoperative cultures of the surgical wounds were free of bacteria. Positive cultures of glove imprints were found in 29% of the operations, and the bacterial source was traced to four different surgeons in four operations (9%). The surgeons' gloves were also a source of potential pathogens (Staphylococcus aureus) in two instances, but the bacterial species were also recovered from cultures of the environment. Based on individual biotyping of bacteria and antibiotic susceptibility testing, no consistent source or pattern could be uncovered for the bacteria in the surgical wound or the operating room air.(ABSTRACT TRUNCATED AT 250 WORDS)