Contemporary Approach to the Diagnosis and Management of Cerebrospinal Fluid Rhinorrhea.

BACKGROUND: Cerebrospinal fluid (CSF) rhinorrhea, when left untreated, can lead to meningitis and other serious complications. Treatment traditionally has entailed an open craniotomy, although the paradigm has now evolved to encompass endoscopic procedures. Trauma, both accidental and iatrogenic, causes the majority of leaks, and trauma involving skull base and facial fractures is most likely to cause CSF rhinorrhea. Diagnosis is aided by biochemical assay and imaging studies. METHODS: We reviewed the literature and summarized current practice regarding the diagnosis and management of CSF rhinorrhea. RESULTS: Management of CSF leaks is dictated by the nature of the fistula, its location, and flow volume. Control of elevated intracranial pressure may require medical therapy or shunt procedures. Surgical reconstruction utilizes a graduated approach involving vascularized, nonvascularized, and adjunctive techniques to achieve closure of the CSF leak. Endoscopic techniques have an important role in select cases. CONCLUSION: An active surgical approach to closing CSF leaks may provide better long-term outcomes in some patients compared to more conservative management.

The Impact of Myocardial Infarction vs. Pneumonia on Outcome in Acute Ischemic Stroke.

The aim of this study was to examine the association between MI and PNA in the setting of acute ischemic stroke and patient outcome. Eligible patients were identified from a prospectively collected stroke registry and included if transthoracic echocardiography (TTE) was performed during their inpatient stay. 426 patients met inclusion criteria (mean age 64, 73% Black, 48% female). Twenty-one patients (4.9%) experienced an MI. Patients who later suffered a MI initially presented with more severe strokes (median NIHSS 7 vs. 5, p=0.014). More patients in the MI group experienced pneumonia (26% vs. 9%, p=0.004). After adjusting for age, baseline glucose and NIHSS, the odds of in-hospital mortality for patients with MI was 3 times that of those without MI (OR 3.2 95% CI 1.1-9.7, p=0.036). When adjustment was made for pneumonia, age, baseline glucose and NIHSS, MI was no longer significantly related to in-hospital mortality (OR 2.5 95% CI 0.8-8.2, p=0.131). In our sample, while MI was significantly associated with in-hospital mortality, this association was attenuated after adjusting for presence of pneumonia. Our findings raise the question as to whether the prevention of pneumonia could improve in-hospital mortality among patients who experience MI in the setting of ischemic stroke.

Cardiac Function and Short-Term Outcome in Patients with Acute Ischemic Stroke: A Cross-Sectional Study.

Few studies have investigated the relationship between left ventricular ejection fraction (LVEF) and functional outcome in ischemic stroke patients. The purpose of this study was to determine if a low LVEF in ischemic stroke was associated with functional outcome. A cross-sectional study was performed on ischemic stroke patients admitted to a single academic stroke center from June 2008 to December 2010. LVEF was determined using transthoracic or transesophageal echocardiography. Patients were categorized into three LVEF groups: severely low (<30%), moderately low (30-49%), and normal (>50%). Baseline demographics, in-hospital complications, and early outcomes were compared among LVEF groups using Chi-square, Wilcoxon rank sum, and logistic regression.590 patients met inclusion criteria (median age 65, 74% African American, 48% female). LVEF was normal in 79.8%, moderately low in 10.8%, and severely low in 9.3%. A smaller proportion of patients with severely low LVEF appeared to have good functional outcome compared to other groups (26% vs. 40% vs. 45%, p=0.028); however, this relationship was not significant after adjusting for age, baseline National Institute of Health Stroke Scale score and admission glucose (OR 0.6, 95% CI 0.3-1.3, p=0.216). Low LVEF was not an independent, significant predictor of short-term functional outcomes in ischemic stroke patients.

24-Hour ICH Score Is a Better Predictor of Outcome than Admission ICH Score.

BACKGROUND: The ICH score is a validated tool for predicting 30-day morbidity and mortality in patients with intracerebral hemorrhage. AIMS AND/OR HYPOTHESIS: The aim of this study is to determine if the ICH score calculated 24 hours after admission is a better predictor of mortality than the ICH score calculated on admission. METHODS: Patients presenting to our center with ICH from 7/08-12/10 were retrospectively identified from our prospective stroke registry. ICH scores were calculated based on initial Glasgow coma scale (GCS) and emergent head computed tomography (CT) on initial presentation and were recalculated after 24 hours. RESULTS: A total of 91 patients out of 121 had complete data for admission and 24-hour ICH score. The ICH score changed in 38% from baseline to 24 hours. After adjusting for age, NIHSS on admission, and glucose, ICH score at 24 hours was a significant, independent predictor of mortality (OR = 2.71, 95% CI 1-19-6.20, and P = 0.018), but ICH score on admission was not (OR = 2.14, 95% CI 0.88-5.24, and P = 0.095). CONCLUSION: Early determination of the ICH score may incorrectly estimate the severity and expected outcome after ICH. Calculations of the ICH score 24 hours after admission will better predict early outcomes.