The role of admission timing in the outcome of intracerebral hemorrhage patients at a specialized stroke center.

INTRODUCTION: Admission at 'off times' has been suggested to result in increased risk of poor outcome. The utilization of high volume centers may be a potential remedy to this variability in care. OBJECTIVE: To assess the ability of a high volume center to mitigate variability in care due to timing of admission in a post hoc analysis of an observational study. METHODS: The medical records of 200 hypertensive intracerebral hemorrhage (ICH) patients admitted to the Neurological Intensive Care Unit (NICU) from 12 January 2009 to 4 April 2013 were identified and examined for variable outcome based on admission timing using the modified Rankin Scale (mRS). Multiple logistic regression was used to assess predictors of poor outcome, correcting severity of admission. RESULTS: Seventy-five admissions were recorded to have occurred on the weekend. The 3-month follow-up mRS of surviving patients was 3·78 in weekend admissions and 3·63 in weekday admissions (P  =  0·62). One hundred and seven night admissions occurred. The average mRS at 3 months of surviving patients was 3·56 in night admissions and 3·84 in daytime admissions (P  =  0·36). Thirteen patients were admitted in July. The 3-month mRS of surviving patients was 3·71 for July admissions and 3·38 for non-July admissions (P  =  0·58). Only ICH score was found to be a predictor of outcome on multivariate analysis (P < 0·001). CONCLUSIONS: No significant difference in the outcome of patients was identified regardless of time of admission. High volume centers may be less prone to temporal variability in care, though the existence of temporal variability in care at low volume centers is controversial.

Delay in surgical treatment of patients with hilar cholangiocarcinoma: does time impact outcomes?

BACKGROUND: Substantial time elapses before patients with hilar cholangiocarcinoma (HCC) receive surgical treatment because of time-consuming preoperative staging and other interventions, including biliary drainage and portal vein embolization. Prolonged times potentially lead to unresectability and the formation of metastases, yet these issues have not been investigated previously in HCC. This study aimed to evaluate the time between onset of symptoms and the provision of ultimate treatment in patients with HCC and the impact of the length of time on outcomes. METHODS: Delays in the treatment of consecutive patients with HCC were evaluated by contacting general practitioners (GPs) and extracting data from hospital files. Time periods were correlated with resectability, occurrence of metastasis, tumour stage and survival using logistic and Cox regression analyses. RESULTS: Treatment times in 209 consecutive HCC patients were evaluated. The median time from first GP visit until presentation at the tertiary centre was 35 days. Time until treatment was longer when initial symptoms did not include jaundice (non-specific symptoms, P < 0.001). Duration of workup and preoperative biliary drainage at the tertiary centre prior to final surgical treatment resulted in an additional median time of 74 days. No correlation was found between treatment time in weeks and resectability [odds ratio (OR) 1.010, 95% confidence interval (CI) 0.985-1.036], metastasis (OR = 0.947, 95% CI 0.897-1.000), tumour stage (OR = 1.006, 95% CI 0.981-1.031) or survival in resected patients (hazard ratio = 0.996, 95% CI 0.975-1.018). CONCLUSIONS: The time that elapses between the presentation of symptoms and final treatment in patients with HCC is substantial, especially in patients with non-specific symptoms. This time, however, does not affect resectability, metastasis, tumour stage or survival, which suggests that preoperative optimization should not be omitted because of potential delays in treatment.

Alpha-7 nicotinic acetylcholine receptor agonists in intracerebral hemorrhage: an evaluation of the current evidence for a novel therapeutic agent.

Intracerebral hemorrhage (ICH) is the most deadly and least treatable subtype of stroke, and at the present time there are no evidence-based therapeutic interventions for patients with this disease. Secondary injury mechanisms are known to cause substantial rates of morbidity and mortality following ICH, and the inflammatory cascade is a major contributor to this post-ICH secondary injury. The alpha-7 nicotinic acetylcholine receptor (α7-nAChR) agonists have a well-established antiinflammatory effect and have been shown to attenuate perihematomal edema volume and to improve functional outcome in experimental ICH. The authors evaluate the current evidence for the use of an α7-nAChR agonist as a novel therapeutic agent in patients with ICH.

Decompressive hemicraniectomy without clot evacuation in dominant-sided intracerebral hemorrhage with ICP crisis.

OBJECT: Large intracerebral hemorrhage (ICH), compounded by perihematomal edema, can produce severe elevations of intracranial pressure (ICP). Decompressive hemicraniectomy (DHC) with or without clot evacuation has been considered a part of the armamentarium of treatment options for these patients. The authors sought to assess the preliminary utility of DHC without evacuation for ICH in patients with supratentorial, dominant-sided lesions. METHODS: From September 2009 to May 2012, patients with ICH who were admitted to the neurological ICU at Columbia University Medical Center were prospectively enrolled in that institution's ICH Outcomes Project (ICHOP). Five patients with spontaneous supratentorial dominant-sided ICH underwent DHC without clot evacuation for recalcitrant elevated ICP. Data pertaining to the patients' characteristics and outcomes of treatment were prospectively collected. RESULTS: The patients' median age was 43 years (range 30-55 years) and the ICH etiology was hypertension in 4 of 5 patients, and systemic lupus erythematosus vasculitis in 1 patient. On admission, the median Glasgow Coma Scale (GCS) score was 7 (range 5-9). The median ICH volume was 53 cm(3) (range 28-79 cm(3)), and the median midline shift was 7.6 mm (range 3.0-11.3 mm). One day after surgery, the median decrease in midline shift was 2.7 mm (range 1.5-4.6 mm), and the median change in GCS score was +1 (range -3 to +5). At discharge, all patients were still alive, and the median GCS score was 10 (range 9-11), the median modified Rankin Scale (mRS) score was 5 (range 5-5), and the median NIHSS (National Institutes of Health Stroke Scale) score was 22 (range 17-27). Six months after hemorrhage, 1 patient had died, 2 were functionally dependent (mRS Score 4-5), and 2 were functionally independent (mRS Score 0-3). Outcomes for the patients treated with DHC were good compared with 1) outcomes for all patients with spontaneous supratentorial ICH admitted during the same period (n = 144) and 2) outcomes for matched patients (dominant ICH, GCS Score 5-9, ICH volume 28-79 cm(3), age < 60 years) whose cases were managed nonoperatively (n = 5). CONCLUSIONS: Decompressive hemicraniectomy without clot evacuation appears feasible in patients with large ICH and deserves further investigation, preferably in a randomized controlled setting.

The role of advanced neuroimaging in intracerebral hemorrhage.

In this report, the authors sought to summarize existing literature to provide an overview of the currently available techniques and to critically assess the evidence for or against their application in intracerebral hemorrhage (ICH) for management, prognostication, and research. Functional imaging in ICH represents a potential major step forward in the ability of physicians to assess patients suffering from this devastating illness due to the advantages over standing imaging modalities focused on general tissue structure alone, but its use is highly controversial due to the relative paucity of literature and the lack of consolidation of the predominantly small data sets that are currently in existence. Current data support that diffusion tensor imaging and tractography, diffusion-perfusion weighted MRI techniques, and functional MRI all possess major potential in the areas of highlighting motor deficits, motor recovery, and network reorganization. Novel clinical studies designed to objectively assess the value of each of these modalities on a wider scale in conjunction with other methods of investigation and management will allow for their rapid incorporation into standard practice.