Hemispheric differences in ischemic stroke: is left-hemisphere stroke more common?

BACKGROUND AND PURPOSE: Understanding the mechanisms underlying stroke can aid the development of therapies and improve the final outcome. The purposes of this study were to establish whether there are characteristic mechanistic differences in the frequency, severity, functional outcome, and mortality between left- and right-hemisphere ischemic stroke and, given the velocity differences in the carotid circulation and direct branching of the left common carotid artery from the aorta, whether large-vessel ischemia (including cardioembolism) is more common in the territory of the left middle cerebral artery. METHODS: Trial cohorts were combined into a data set of 476 samples. Using Trial of Org 10172 in Acute Stroke Treatment criteria, ischemic strokes in a total 317 patients were included in the analysis. Hemorrhagic stroke, stroke of undetermined etiology, cryptogenic stroke, and bilateral ischemic strokes were excluded. Laterality and vascular distribution were correlated with outcomes using a logistic regression model. The etiologies of the large-vessel strokes were atherosclerosis and cardioembolism. RESULTS: The overall event frequency, mortality, National Institutes of Health Stroke Scale (NIHSS) score, Glasgow Coma Scale score, and rate of mechanical thrombectomy interventions differed significantly between the hemispheres. Left-hemispheric strokes (54%) were more common than right-hemispheric strokes (46%; p=0.0073), and had higher admission NIHSS scores (p=0.011), increased mortality (p=0.0339), and higher endovascular intervention rates (p≤0.0001). ischemic strokes were more frequent in the distribution of the left middle cerebral artery (122 vs. 97; p=0.0003) due to the higher incidence of large-vessel ischemic stroke in this area (p=0.0011). CONCLUSIONS: Left-hemispheric ischemic strokes appear to be more frequent and often have a worse outcome than their right-hemispheric counterparts. The incidence of large-vessel ischemic strokes is higher in the left middle cerebral artery distribution, contributing to these hemispheric differences. The hemispheric differences exhibit a nonsignificant trend when strokes in the middle cerebral artery distribution are excluded from the analysis.

TBI surveillance using the common data elements for traumatic brain injury: a population study.

BACKGROUND: To characterize the patterns of presentation of adults with head injury to the Emergency Department. METHODS: This is a cohort study that sought to collect injury and outcome variables with the goal of characterizing the very early natural history of traumatic brain injury in adults. This IRB-approved project was conducted in collaboration with our Institution's Center for Translational Science Institute. Data were entered in REDCap, a secure database. Statistical analyses were performed using JMP 10.0 pro for Windows. RESULTS: The cohort consisted of 2,394 adults, with 40% being women and 79% Caucasian. The most common mechanism was fall (47%) followed by motor vehicle collision (MVC) (36%). Patients sustaining an MVC were significantly younger than those whose head injury was secondary to a fall (P < 0.0001). Ninety-one percent had CT imaging; hemorrhage was significantly more likely with worse severity as measured by the Glasgow Coma Score (chi-square, P < 0.0001). Forty-four percent were admitted to the hospital, with half requiring ICU admission. In-hospital death was observed in 5.4%, while neurosurgical intervention was required in 8%. For all outcomes, worse TBI severity per GCS was significantly associated with worse outcomes (logistic regression, P < 0.0001, adjusted for age). CONCLUSION: These cohort data highlight the burden of TBI in the Emergency Department and provide important demographic trends for further research.

Aortic dissection and thrombosis diagnosed by emergency ultrasound in a patient with leg pain and paralysis.

The authors present a case of aortic dissection and abdominal aortic aneurysm thrombosis in a 78-year-old male who presented to the emergency department (ED) complaining of lower extremity and paralysis for the past 1.5 hours. The initial vital signs in the ED were as follows: blood pressure (BP) 132/88 mmHg, heart rate (HR) 96, respiratory rate (RR) 14, and an oxygen saturation of 94% at room air. Physical exam was notable for pale and cold left leg. The ED physician was unable to palpate or detect a Doppler signal in the left femoral artery. Bedside ultrasound was performed which showed non-pulsatile left femoral artery and limited flow on color Doppler. Abdominal aortic aneurysm screening ultrasound was performed showing a 4.99 cm infrarenal abdominal aortic aneurysm and an intra-aortic thrombus with an intimal flap. Vascular surgery was promptly contacted and the patient underwent emergent aorto-bi-femoral bypass, bilateral four compartment fasciotomy, right common femoral artery endarterectomy with profundoplasty, and subsequent left leg amputation. Emergency physicians should utilize bedside ultrasound in patients who present with risk factors or threatening signs and symptoms that may suggest aortic dissection or aneurysm. Bedside ultrasound decreases time to definitive treatment and the mortality of the patients.

Fibroelastoma as a culprit of syncope.

We present a case of a valvular mass diagnosed by emergency department bedside ultrasonography in a young patient with syncope. Bedside ultrasound has become a valuable tool in the evaluation of patients with syncope in the emergency department. This patient was believed to have a fibroelastoma on ultrasound that was confirmed by magnetic resonance and ultimately by postsurgical pathological evaluation. The indications and findings of using ultrasonography as part of the workup of syncope in the emergency department are discussed.

The Triglyceride Paradox in Stroke Survivors: A Prospective Study.

Objective. The purpose of our study was to understand the association between serum triglycerides and outcomes in acute ischemic stroke (AIS) patients. Methods. A cohort of all adult patients presenting to the Emergency Department (ED) with an AIS from March 2004 to December 2005 were selected. The lipid profile levels were measured within 24 hours of stroke onset. Demographics, admission stroke severity (NIHSS), functional outcome at discharge (modified Rankin Scale (mRS)), and mortality at 3 months were recorded. Results. The final cohort consisted of 334 subjects. A lower level of triglycerides at presentation was found to be significantly associated with worse National Institutes of Health Stroke Scale (NIHSS) (P = 0.004), worse mRS (P = 0.02), and death at 3 months (P = 0.0035). After adjusting for age and gender and NIHSS, the association between triglyceride and mortality at 3 months was not significant (P = 0.26). Conclusion. Lower triglyceride levels seem to be associated with a worse prognosis in AIS.

Posterior reversible encephalopathy syndrome (PRES) and CT perfusion changes.

Posterior reversible encephalopathy syndrome (PRES) can present with focal neurologic deficits, mimicking a stroke and can often represent a diagnostic challenge when presenting atypically. A high degree of suspicion is required in the clinical setting in order to yield the diagnosis. Cerebral CT perfusion (CTP) is utilized in many institutions as the first line in acute stroke imaging. CTP has proved to be a very sensitive measure of cerebral blood flow dynamics, most commonly employed to delineate the infarcted tissue from penumbra (at-risk tissue) in ischemic strokes. But abnormal CTP is also seen in stroke mimics such as seizures, hypoglycemia, tumors, migraines and PRES. In this article we describe a case of PRES in an elderly bone marrow transplant recipient who presented with focal neurological deficits concerning for a cerebrovascular accident. CTP played a pivotal role in the diagnosis and initiation of appropriate management. We also briefly discuss the pathophysiology of PRES.

The impact of blood pressure hemodynamics in acute ischemic stroke: a prospective cohort study.

OBJECTIVE: To assess relationships between blood pressure hemodynamic measures and outcomes after acute ischemic stroke, including stroke severity, disability and death. METHODS: The study cohort consisted of 189 patients who presented to our emergency department with ischemic stroke of less than 24 hours onset who had hemodynamic parameters recorded and available for review. Blood pressure (BP) was non-invasively measured at 5 minute intervals for the length of the patient's emergency department stay. Systolic BP (sBP) and diastolic BP (dBP) were measured for each patient and a differential (the maximum minus the minimum BP) calculated. Three outcomes were studied: stroke severity, disability at hospital discharge, and death at 90 days. Statistical tests used included Spearman correlations (for stroke severity), Wilcoxon test (for disability) and Cox models (for death). RESULTS: Larger differentials of either dBP (p = 0.003) or sBP (p < 0.001) were significantly associated with more severe strokes. A greater dBP (p = 0.019) or sBP (p = 0.036) differential was associated with a significantly worse functional outcome at hospital discharge. Those patients with larger differentials of either dBP (p = 0.008) or sBP (0.007) were also significantly more likely to be dead at 90 days, independently of the basal BP. CONCLUSION: A large differential in either systolic or diastolic blood pressure within 24 hours of symptom onset in acute ischemic stroke appears to be associated with more severe strokes, worse functional outcome and early death.

Role of bedside ultrasound in CMV retinitis: a case report.

We present a case of retinal detachment diagnosed by emergency department bedside ultrasonography in a patient with CMV retinitis. The indications and findings of ocular ultrasonography are discussed.

Trimethoprim-sulfamethoxazole-induced hyperkalemia in a patient with normal renal function.

The authors present a case of Trimethoprim-sulfamethoxazole-induced hyperkalemia in a patient with normal renal function. While toxicity of this drug has been reported in patients with renal insufficiency, this case highlights the toxicity associated with normal kidney function. Due to its popularity in the medical field and to the largely unrecognized effect of hyperkalemia, it is important to consider such adverse effects when prescribing TMX-SMX. One must be reminded of the possibility of the development of life-threatening hyperkalemia in relatively healthy patients.

Cardioembolic but not other stroke subtypes predict mortality independent of stroke severity at presentation.

Introduction. Etiology of acute ischemic stroke (AIS) is known to significantly influence management, prognosis, and risk of recurrence. Objective. To determine if ischemic stroke subtype based on TOAST criteria influences mortality. Methods. We conducted an observational study of a consecutive cohort of patients presenting with AIS to a single tertiary academic center. Results. The study population consisted of 500 patients who resided in the local county or the surrounding nine-county area. No patients were lost to followup. Two hundred and sixty one (52.2%) were male, and the mean age at presentation was 73.7 years (standard deviation, SD = 14.3). Subtypes were as follows: large artery atherosclerosis 97 (19.4%), cardioembolic 144 (28.8%), small vessel disease 75 (15%), other causes 19 (3.8%), and unknown 165 (33%). One hundred and sixty patients died: 69 within the first 30 days, 27 within 31-90 days, 29 within 91-365 days, and 35 after 1 year. Low 90-, 180-, and 360-day survival was seen in cardioembolic strokes (67.1%, 65.5%, and 58.2%, resp.), followed for cryptogenic strokes (78.0%, 75.3%, and 71.1%). Interestingly, when looking into the cryptogenic category, those with insufficient information to assign a stroke subtype had the lowest survival estimate (57.7% at 90 days, 56.1% at 180 days, and 51.2% at 1 year). Conclusion. Cardioembolic ischemic stroke subtype determined by TOAST criteria predicts long-term mortality, even after adjusting for age and stroke severity.

Insulin for glycaemic control in acute ischaemic stroke.

BACKGROUND: Patients with hyperglycaemia concomitant with an acute stroke have greater stroke severity and greater functional impairment when compared to those with normoglycaemia at stroke presentation. OBJECTIVES: To determine whether maintaining serum glucose within a specific normal range (4 to 7.5 mmol/L) in the first 24 hours of acute ischaemic stroke influences outcome. SEARCH STRATEGY: We searched the Cochrane Stroke Group Trials Register (June 2010), CENTRAL (The Cochrane Library 2010, Issue 2), MEDLINE (1950 to June 2010), EMBASE (1980 to June 2010), CINAHL (1982 to June 2010), Science Citation Index (1900 to June 2010), and Web of Science (ISI Web of Knowledge) (1993 to June 2010). In an effort to identify further published, unpublished and ongoing trials we searched ongoing trials registers and SCOPUS. SELECTION CRITERIA: Eligible studies were randomised controlled trials comparing intensively monitored insulin therapy versus usual care in adult patients with acute ischaemic stroke. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted the study characteristics, study quality, and data to estimate the odds ratio (OR) and 95% confidence interval (CI), mean difference (MD) and standardised mean difference (SMD) of outcome measures. MAIN RESULTS: We included seven trials involving 1296 participants (639 participants in the intervention group and 657 in the control group). We found that there was no difference between treatment and control groups in the outcome of death or disability and dependence (OR 1.00, 95% CI 0.78 to 1.28) or final neurological deficit (SMD -0.12, 95% CI -0.23 to 0.00). The rate of symptomatic hypoglycaemia was higher in the intervention group (OR 25.9, 95% CI 9.2 to 72.7). In the subgroup analyses of diabetes mellitus (DM) versus non-DM, we found no difference for the outcomes of death and dependency or neurological deficit. AUTHORS' CONCLUSIONS: With the current evidence, we found that the administration of intravenous insulin with the objective of maintaining serum glucose within a specific range in the first hours of acute ischaemic stroke does not provide benefit in terms of functional outcome, death, or improvement in final neurological deficit and significantly increased the number of hypoglycaemic episodes. Specifically, those who were maintained within a more tight range of glycaemia with intravenous insulin experienced a greater risk of symptomatic and asymptomatic hypoglycaemia than those individuals in the control group.

Prescriptions for self-injectable epinephrine in emergency department angioedema management.

BACKGROUND: Angioedema is often treated in the emergency department (ED). Few studies have evaluated self-injectable epinephrine (SIE) prescribing patterns for angioedema. OBJECTIVES: To describe presentation and management of ED patients with angioedema and determine factors associated with epinephrine administration, hospital admission and SIE prescription. METHODS: We conducted a retrospective cohort study of all ED patients with angioedema between January 2005 and December 2006. RESULTS: Of 63 patients, 39 (61.9%) were female. Median age was 49 years. Precipitating factors were identified in 36 (57.1%) patients. History of other allergic conditions was seen in 37 (58.7%) patients. Seventeen (27.0%) patients received epinephrine, 55 (87.3%) received antihistamines, and 51 (81.0%) received steroids. Epinephrine was administered more commonly in patients with edema of the tongue (risk ratio [RR], 5.28, 95% confidence interval [CI] 1.95-14.33, P = .0003), tightness/fullness of throat (RR, 3.31, 95% CI 1.62-6.76, P = .006), and dyspnea/wheeze (RR, 3.04, 95% CI 1.41-6.59, P = .005). Hospitalization was more common in patients with dyspnea/wheeze (P = .028) and allergic history (P = .006). Thirteen patients (22.0%) were discharged with SIE. An SIE prescription was associated with younger patients (median age, 26 years [interquartile range (IQR) 15-50] vs a median age 57.5 years [IQR 43-68], P = .004) and patients with throat tightness/fullness (RR, 4.2, 95% CI 1.8-9.8, P = .005). CONCLUSION: Patients with respiratory symptoms and allergic history were likely to be admitted. Epinephrine use was more frequent in patients with signs and symptoms of oropharyngeal edema. Younger patients and those with tightness/fullness of throat were likely to be prescribed SIE. Further studies are needed to determine who would benefit from epinephrine use and SIE prescription.

Incidence and predictors of myocardial infarction after transient ischemic attack: a population-based study.

BACKGROUND AND PURPOSE: Coronary artery disease is the leading cause of death after TIA. Reliable estimates of the risk of MI after TIA, however, are lacking. METHODS: Our purpose was to determine the incidence of and risk factors for MI after TIA. We cross-referenced preexisting incidence cohorts from the Rochester Epidemiology Project for TIA (1985-1994) and MI (1979-2006) to identify all community residents with incident MI after incident TIA. Incidence of MI after TIA was determined using Kaplan-Meier life-table methods. This was compared to the age-, sex-, and period-specific MI incidences in the general population. Proportional hazards regression analysis was used to examine associations between clinical variables and the occurrence of MI after TIA. RESULTS: Average annual incidence of MI after TIA was 0.95%. Relative risk for incident MI in the TIA cohort compared to the general population was 2.09 (95% CI, 1.52-2.81). This was highest in patients younger than 60 years old (relative risk, 15.1; 95% CI, 4.11-38.6). Increasing age (hazard ratio, 1.51 per 10 years; 95% CI, 1.14-2.01), male sex (hazard ratio, 2.19; 95% CI, 1.18-4.06), and the use of lipid-lowering therapy at the time of TIA (hazard ratio, 3.10; 95% CI, 1.20-8.00) were independent risk factors for MI after TIA. CONCLUSIONS: Average annual incidence of MI after TIA is ≈1%, approximately double that of the general population. The relative risk increase is especially high in patients younger than 60 years old. These data are useful for identifying subgroups of patients with TIA at highest risk for subsequent MI.

An assessment of the incremental value of the ABCD2 score in the emergency department evaluation of transient ischemic attack.

STUDY OBJECTIVE: We study the incremental value of the ABCD2 score in predicting short-term risk of ischemic stroke after thorough emergency department (ED) evaluation of transient ischemic attack. METHODS: This was a prospective observational study of consecutive patients presenting to the ED with a transient ischemic attack. Patients underwent a full ED evaluation, including central nervous system and carotid artery imaging, after which ABCD2 scores and risk category were assigned. We evaluated correlations between risk categories and occurrence of subsequent ischemic stroke at 7 and 90 days. RESULTS: The cohort consisted of 637 patients (47% women; mean age 73 years; SD 13 years). There were 15 strokes within 90 days after the index transient ischemic attack. At 7 days, the rate of stroke according to ABCD2 category in our cohort was 1.1% in the low-risk group, 0.3% in the intermediate-risk group, and 2.7% in the high-risk group. At 90 days, the rate of stroke in our ED cohort was 2.1% in the low-risk group, 2.1% in the intermediate-risk group, and 3.6% in the high-risk group. There was no relationship between ABCD2 score at presentation and subsequent stroke after transient ischemic attack at 7 or 90 days. CONCLUSION: The ABCD2 score did not add incremental value beyond an ED evaluation that includes central nervous system and carotid artery imaging in the ability to risk-stratify patients with transient ischemic attack in our cohort. Practice approaches that include brain and carotid artery imaging do not benefit by the incremental addition of the ABCD2 score. In this population of transient ischemic attack patients, selected by emergency physicians for a rapid ED-based outpatient protocol that included early carotid imaging and treatment when appropriate, the rate of stroke was independent of ABCD2 stratification.

Worse outcome after stroke in patients with obstructive sleep apnea: an observational cohort study.

To evaluate the risk and presence of obstructive sleep apnea (OSA) in patients presenting with acute ischemic stroke, and examine the correlation of OSA with age, sex, ischemic stroke subtype, disability, and death, a prospective cohort study was conducted in all consecutive patients presenting with acute ischemic stroke between June 2007 and March 2008. Exclusion criteria were age < 18 years, refusal of consent for the study, and incomplete questionnaire. The Berlin Sleep Questionnaire was used to identify patients at high risk for OSA. A total of 174 patients with acute ischemic stroke were included; 130 (74.7%) had a modified Rankin Scale (mRS) score ≥ 3 at dismissal, and 11 patients (6.3%) died within 1 month. The Berlin Sleep Questionnaire identified 105 patients (60.4%) at high risk for OSA, along with 7 patients (4%) with a previous diagnosis of OSA. Those with a previous diagnosis of OSA were more likely to die within the first month after stroke (relative risk, 5.3; 95% confidence interval, 1.4-20.1) compared with those without OSA. Patients at high risk for OSA did not demonstrate increased mortality at 30 days (P = 1.0). In multivariate analysis, after adjusting for age and National Institutes of Health Stroke Scale score, previous diagnosis of OSA was an independent predictor of worse functional outcome, that is, worse mRS score at hospital discharge (P = .004). The mRS score was 1.2 points higher (adjusted R², 40%) in those with OSA. Our findings suggest that patients considered at high risk for ischemic stroke should be screened for OSA, the prevalence of which may be as high as 60%. Those with definitive diagnosis of OSA before stroke are at increased risk of death within the first month after an acute ischemic stroke.

Matrix metalloproteinase-9 as a marker for acute ischemic stroke: a systematic review.

Matrix metalloproteinase-9 (MMP-9) is a possible marker for acute ischemic stroke (AIS). In animal models of cerebral ischemia, MMP expression was significantly increased and was related to blood-brain barrier disruption, vasogenic edema formation, and hemorrhagic transformation. The definition of the exact role of MMPs after ischemic stroke will have important diagnostic implications for stroke and for the development of therapeutic strategies aimed at modulating MMPs. The objectives of the present study were to determine (1) whether MMP-9 is a possible marker for AIS; (2) whether MMP-9 levels correlate with infarct volume, stroke severity, or functional outcome; and (3) whether MMP-9 levels correlate with the development of hemorrhagic transformation after tissue plasminogen activator (t-PA) administration. The literature was searched using MEDLINE and EMBASE with no year restriction. All relevant reports were included. A total of 22 studies (3,289 patients) satisfied the inclusion criteria. Our review revealed that higher MMP-9 values were significantly correlated with larger infarct volume, severity of stroke, and worse functional outcome. There were significant differences in MMP-9 levels between patients with AIS and healthy control subjects. Moreover, MMP-9 was a predictor of the development of intracerebral hemorrhage in patients treated with thrombolytic therapy. MMP-9 level was significantly increased after stroke onset, with the level correlating with infarct volume, stroke severity, and functional outcome. MMP-9 is a possible marker for ongoing brain ischemia, as well as a predictor of hemorrhage in patients treated with t-PA.

Altered mental status and a not-so-benign rash.

Introduction. The authors are presenting a case of Thrombotic Thrombocytopenic Purpura (TTP) that presented with complaints of altered mental status and found to have petechiae. Case Presentation. An 81-year-old female patient presented to the Emergency Department (ED) of a tertiary care hospital with chief complains of dizziness, slurred speech, and weakness. She was found to have lower extremity petechiae on physical examination. On blood exam, she had thrombocytopenia, and her peripheral blood smear showed schistocytes. Her renal function was also impaired. The CT scan of head was without any abnormality. She was finally diagnosed as having TTP and transferred to ICU but ultimately passed away. Conclusion. TTP is a rare syndrome with preventable mortality if diagnosed early and managed appropriately with plasmapheresis. The Emergency Department physicians should be aware of the presenting symptoms and signs of TTP.

Abdominal trauma: never underestimate it.

Introduction. We present a case of a sports injury. The initial presentation and clinical examination belied serious intra-abdominal injuries. Case Presentation. A 16-year-old male patient came to emergency department after a sports-related blunt abdominal injury. Though on clinical examination the injury did not seem to be serious, FAST revealed an obscured splenorenal window. The CT scan revealed a large left renal laceration and a splenic laceration that were managed with Cook coil embolization. Patient remained tachycardic though and had to undergo splenectomy, left nephrectomy, and a repair of left diaphragmatic rent. Patient had no complication and had normal renal function at 6-month followup. Conclusion. The case report indicates that management of blunt intra-abdominal injury is complicated and there is a role for minimally invasive procedures in management of certain patients. A great deal of caution is required in monitoring these patients, and surgical intervention is inevitable in deteriorating patients.

Seizures in pregnancy/eclampsia.

The physical and emotional stress of pregnancy can precipitate new-onset seizures in a woman. In these cases, emergency department evaluations must rule out underlying pathology. Careful consideration of antiepileptic drug use must be considered in the first trimester as all antiepileptic drugs have been linked to some teratogenic effect. Eclampsia must always be considered in the pregnant woman who is more than 20 weeks gestation; 25% of eclamptic seizures occur in the postpartum period. Magnesium is the recommended treatment for eclamptic seizures when delivery is not possible.