Can emergency department physicians safely and effectively initiate thrombolysis for acute ischemic stroke?

OBJECTIVE: To review the clinical outcomes of stroke patients treated with IV tissue plasminogen activator (tPA; alteplase) in a community setting and to compare outcomes when treatment was initiated by a neurologist or an emergency department (ED) physician in telephone consultation with a neurologist and radiologist. METHODS: Clinical information was prospectively collected for 43 stroke patients treated with IV tPA (alteplase) within a five-hospital network of affiliated community hospitals. Blinded 3-month outcomes were obtained with telephone interview or patient visit. RESULTS: Excellent functional recovery measured by a Modified Rankin score of 0 to 1 (42%), symptomatic intracerebral hemorrhages (7%), and mortality (16.3%) were similar to those reported by National Institute of Neurological Disorders and Stroke (39%, 7.7%, 17.3%). After initial screening by an ED physician, 20 patients were directly examined by a stroke neurologist who then prescribed tPA. Twenty-three patients received tPA prescribed by an ED physician after telephone consultation with a neurologist and review of the head CT by a radiologist. Functional outcome, symptomatic intracerebral bleeding rate, and mortality rate were similar between these groups. Door-to-needle time was similar. Protocol deviations were much higher when ED physicians prescribed the tPA compared to when neurologists did (30% versus 5%). These protocol deviations were reduced with staff education. CONCLUSIONS: The clinical results of the National Institute of Neurological Disorders and Stroke tPA Stroke Trial were replicated in this small series of patients treated in a community setting. Outcomes were similar whether the prescribing physician was a neurologist or an ED physician.

Forensic evaluation of the sexually abused child.

Results of a 16-year forensic study of 162 cases are presented. A forensic examination protocol is delineated, laboratory specimens/evidence collection methods given, and an anatomical chart of the prepubescent female genitalia with a pictorial atlas of female abuse trauma provided. The number of child victims per 100,000 at-risk population was static v the population increase and increased v victim's age. More than 80% of all cases and 82.1% of positive cases involved girls. Of all victims, approximately 40% were positive based on history, physical evidence, laboratory evidence, and/or eyewitness deposition. Alleged incestual perpetrators accounted for 21.97% of female and 3.3% of male cases reported and 20% of female and 0% of positive for findings of sexual abuse.

Primary malignant nerve sheath tumor of the gasserian ganglion: a report of two cases.

Primary tumors of the gasserian ganglion are usually benign, and secondary tumors are malignant. We report two cases of a malignant primary tumor of the gasserian ganglion, bringing the total in the world literature to five. The presentation, etiological features, and treatment of these cases are reviewed, together with a review of the literature. Preoperative differentiation from a benign tumor is not possible with certainty. A combination of operation and radiation therapy seems to be the best treatment at present.

Neurological assessment.

Neurological assessment of certain movement disorders is described with emphasis on Parkinson's disease. In addition, abnormal behavior and changes in affect are given. Changes in neurological status, i.e., Bradykinesia, rigidity, gait changes, hand-writing irregularity, postural reflexes are outlined. The differential diagnosis of the disease is also indicated in addition to prognosis and to the biochemical correlates of Parkinson's disease.

alpha 2-Adrenergic receptor binding in human platelets: alterations during the menstrual cycle.

We studied the effect of several clinically important variables on the characteristics of alpha 2-adrenergic receptors in human platelet membranes. The number and affinity of the receptor binding sites were determined from radioligand binding experiments, with [3H]yohimbine being the radioligand of choice. Platelets from female subjects had a cyclic variation in the number of alpha 2-adrenergic receptors that coincided with their menstrual cycles. The number of alpha 2-receptors was highest at the onset of menses and dropped to 74% to 79% of that value during the middle of the cycle. In concurrent experiments we did not observe comparable cyclic changes in receptor binding sites in platelets from male subjects. There was no age-dependent alteration in receptor number in a sample of 39 subjects ranging in age from 8 to 80 yr, but the number of alpha 2-receptors in platelets from male and female subjects differed. We also tested the possibility of a circadian rhythm in alpha 2-receptor number but found no cyclic changes as a function of time of day. There was no alteration in alpha 2-adrenergic receptor binding in the platelets from five subjects with Parkinson's disease. Finally, there was no change in receptor affinity as a function of any of the variables tested. These data should apply to the design of further studies on the clinical importance of platelet alpha 2-adrenergic receptors.

Occurrence and implications of seizures in subarachnoid hemorrhage due to ruptured intracranial aneurysms.

The records of 100 consecutive cases of subarachnoid hemorrhage due to ruptured aneurysm were reviewed to determine the incidence and the prognostic implications of seizures during the acute phase. Seizures occurred in 26% of the patients. Sixty-three per cent of the seizures occurred near the onset of the initial hemorrhage. The occurrence of these early seizures did not correlate with the location of the aneurysm or the prognosis. Most of the remaining seizures occurred immediately after rebleeding, with no greater morbidity or mortality compared to all patients who rebled. Pathogenic mechanisms of seizures associated with subarachnoid hemorrhage are proposed and discussed.

Therapy of ischemic cerebrovascular disease.

Major advances are being made in our understanding of the pathophysiology of ischemic stroke. In the past 25 years anticoagulation, carotid endarterectomy, and antiplatelet aggregation agents, along with less well-accepted therapies, have been introduced for the management of this complex disorder. Also, noninvasive diagnostic methods have been developed for evaluating these patients. This article reviews the pathophysiology of cerebral ischemia and the data on the effectiveness of the various therapies advocated for its management.

Musical performance during transient global amnesia.

An organist had an episode of transient global amnesia during a recital. Despite a severe immediate-memory deficit, he performed complex organ music. This case suggests that the localization of the cerebral deficit in transient global amnesia is distinct from the cerebral centers necessary for performance of instrumental music.

Correlation of intraoperative electroencephalography with neurologic deficit after carotid endarterectomy.

In an attempt to prevent morbidity and mortality in carotid endarterectomy, we monitored 47 operations with intraoperative EEG to determine which patients should have a shunt during endarterectomy. The EEG was recorded for up to five minutes during test carotid cross-clamping. When EEG asymmetry between the cerebral hemispheres occurred, the clamp was immediately removed. A shunt was used in all patients who had EEG asymmetry. In the absence of EEG asymmetry, no shunt was used. Of the 38 patients with no EEG asymmetry intraoperatively, one patient had transient deficits postoperatively. Electroencephalographic asymmetry occurred in nine patients during test carotid cross-clamping. Postoperatively, five of these shunted patients awakened neurologically intact and four patients had transient deficit. When the EEG was normal and no shunt was used, patients did well; when the EEG was abnormal and a shunt was used, there was a high incidence of transient neurologic deficit.