Symptomatic Intracerebral Hemorrhage after Intravenous Thrombolysis: Predictive Factors and Validation of Prediction Models.

OBJECTIVE: Thrombolytic therapy with intravenous alteplase (IV-rtPA) has a known risk of symptomatic intracerebral hemorrhage (sICH). We aim to identify factors with a significant association with the development of sICH post-IV-rtPA. We also aim to perform an external validation of sICH predicting scores in our patient population. MATERIAL AND METHODS: We performed a retrospective chart review of patients who received IV-rtPA at our tertiary care hospital. We excluded patients who underwent mechanical thrombectomy. We analyzed various factors recorded at presentation such as presenting mean arterial pressure (MAP), blood glucose, National Institutes of Health Stroke Scale (NIHSS) score, verify Aspirin, verify Plavix, age, sex, platelet count, international normalized ratio, prothrombin time, partial thromboplastin time, hemoglobin A1c, low-density lipoprotein, onset to treatment time, weight, sex, and early infarct signs on computed tomography (CT) head and compared them between sICH and non-sICH groups. For validation of sICH scores, we used documented variables to calculate the following scores for each patient: stroke prognostication using age and NIH stroke scale-100 (SPAN-100), DRAGON, CUCCHIARA, hemorrhage after thrombolysis (HAT), SEDAN, totaled health risks in vascular events, and safe implementation of thrombolysis in stroke-symptomatic intracerebral hemorrhage. RESULTS: sICH rate in our cohort of 89 patients was 5.62% according to the European-Australasian Cooperative Acute Stroke Study-II (ECASS-II) criteria and 7.86% according to the National Institute of Neurological Disorders and Stroke (NINDS) criteria. In the multivariate regression analysis, MAP (95% CI, .001-.01; P .002), blood glucose greater than or equal to 185 mg/dL (95% CI, .12-.45; P .001) and presence of early infarct signs (95% CI, .06-.25; P .002) had a significant association with the development of sICH with the ECASS-II definition of sICH post-IV-rtPA, whereas, only MAP (95% CI, 1.01-1.18; P .025) and verify Aspirin less than 500 (95% CI, .01-.80; P .032) had a significant association with the development of sICH with the NINDS definition of sICH post-IV-rtPA. Our study found that HAT (95% CI, .58-.96; P .044) and DRAGON (95% CI, .61-.96; P .012) scores had the highest area under the curve (AUC) with respect to ECASS-II and NINDS criteria of sICH, respectively. CONCLUSIONS: We found that presenting MAP, presence of early infarct signs on CT Head and blood glucose greater than or equal to 185 mg/dL upon a patient's presentation have a significant association with sICH post-IV-rtPA when the ECASS-II definition was used, while presenting MAP and verify Aspirin less than 500 upon a patient's presentation have a significant association with sICH post-IV-rtPA when the NINDS definition was used. Our study found that HAT and DRAGON scores had the highest AUC, and they were the most valid in predicting the development of sICH in our independent cohort. Patients with these risk factors should receive more intensive neurological monitoring.

Cerebral Ischemia due to Aortic Arch Thrombosis Secondary to Iron Deficiency Anemia.

Thrombocytosis, hypercoagulable state, and hypoxia secondary to anemia are some of the mechanisms that are thought to cause strokes in patients with iron deficiency anemia (IDA). Several cases of middle-aged females with IDA who had embolic strokes due to aortic arch thrombosis have been reported. Majority of the cases were treated with anticoagulation. We report another case of embolic strokes in a patient with IDA treated with anticoagulation and iron replacement without recurrence of further episodes. We concluded that embolic phenomenon in middle-aged females with IDA warrants transesophageal echocardiogram with an evaluation of aortic arch.

An occult finding in heparin drip order set.

BACKGROUND: In 1998, the Institute of Medicine (IOM) noted that the American healthcare system had many problems. A major concern was the pervasiveness of medical errors. Electronic medical records (EMR) were introduced for myriad of reasons, one being to reduce these errors. Within the EMR, order sets have been shown to reduce variation in clinical practice and improve the quality of care. However, the lack of standardization in these sets enables peculiar orders, such as fecal occult blood test (FOBT) in the heparin drip order set at our hospital, to be surprisingly included. Our study was conducted to evaluate the consequences associated with having FOBT in this order set. METHODS: A retrospective study of 898 adult hospitalized patients over a 6-month period, who had a heparin drip ordered at a single academic center, was conducted. The main focus of our study was the 130 patients for whom the FOBT was sent. RESULTS: Fifteen percent (n=130) of patients started on IV heparin had FOBT sent, of which 33 (25%) came back positive. Approximately one-third (36%) of the positive results were documented by a provider, either in a progress note or discharge summary. In eight instances of a positive FOBT (24%), the heparin drip was stopped. For 10 patients with a positive test (30%), gastroenterology was consulted, and 4 (12%) patients had inpatient endoscopy. Five patients with positive FOBT died while in the hospital (15%) as compared to seven patients (7%) in the negative FOBT group, p<0.05. CONCLUSIONS: Most patients started on heparin did not have FOBT tested, and the results changed management infrequently, even when positive. The regular review of all order sets is imperative to ensure that they remain evidenced-based and sensible.