Contrast-associated acute kidney injury in acute ischemic stroke patients following multi-dose iodinated contrast.

BACKGROUND AND OBJECTIVE: lthough intravenous contrast in neuroimaging has become increasingly important in selecting patients for stroke treatment, clinical concerns remain regarding contrast-associated acute kidney injury (CA-AKI). Given the increasing utilization of CT angiography and/or perfusion coupled with cerebral angiography, the purpose of this study was to assess the association of CA-AKI and multi-dose iodinated contrast in acute ischemic stroke (AIS) patients. MATERIALS AND METHODS: etrospective review of AIS patients at a comprehensive stroke center was performed from January 2018 to December 2019. Data collection included patient demographics, stroke risk factors, stroke severity, discharge disposition, modified Rankin Scale, contrast type/volume, and creatinine levels (baseline, 48-72 h). CA-AKI was defined as creatinine increase ≥ 25 % from baseline. Bivariate analyses and multivariable logistic regression models were implemented to compare AIS patients with multi-dose and single-dose contrast. RESULTS: Of 440 AIS patients, 215 (48.9 %) were exposed to a single-dose contrast, and 225 (51.1 %) received multi-dose. In single-dose patients, CA-AKI at 48/72 h was 9.7 %/10.2 % compared to 8.0 %/8.9 % in multi-dose patients. Multi-dose patients were significantly more likely to receive a higher volume of contrast (mean 142.1 mL versus 80.8 mL; p < 0.001), but there was no significant difference in their creatinine levels or CA-AKI. NIHSS score (OR=1.08, 95 % CI=[1.04,1.13]), and patient transfer from another hospital (OR=3.84, 95 % CI=[1.94,7.62]) were significantly associated with multi-dose contrast. CONCLUSIONS: No significant association between multi-dose iodinated contrast and CA-AKI was seen in AIS patients. Concerns of CA-AKI should not deter physicians from pursuing timely and appropriate contrast-enhanced neuroimaging that may optimize treatment outcomes in AIS patients.

Neuroimaging in acute ischemic stroke: Trends, disparities, and clinical impact.

INTRODUCTION: Clinical studies over the past decade expanded the eligibility criteria for endovascular therapy, with advanced imaging selection and new devices leading to higher rates of good outcomes. Herein, we explore the current trends in neuroimaging, associated factors, and impact on treatment and clinical outcomes. MATERIALS AND METHODS: This is a retrospective study of consecutive acute ischemic stroke patients, admitted to a comprehensive stroke center from 2016 to 2020. Patient characteristics, including age, sex, race, arrival method, admission National Institutes of Health Stroke Scale score and last known well to arrival time; imaging and treatment utilization; and discharge outcome by modified Rankin Scale and disposition were extracted from medical records. Trend and multivariable logistic regression analyses were performed, and trends were stratified by patient characteristics. RESULTS: Of 4,125 acute ischemic stroke episodes, 15.1% received intravenous thrombolysis only, and 7.5% received endovascular thrombectomy from 2016 to 2020. Neuroimaging utilization trends significantly increased for computed tomography angiography (CTA) (48.7% to 75.2%, p < 0.001) and computed tomography perfusion (CTP) (0.26% to 32.9%, p < 0.001), and decreased for magnetic resonance angiography (MRA) (43.2% to 24.7%, p < 0.001). These trends held after adjusting for patient characteristics. Endovascular thrombectomy and intravenous thrombolysis were significantly more common in patients with CTA and CTP (p < 0.0001), and these treatments were associated with good clinical outcomes after controlling for patient characteristics. CONCLUSION: We found significantly increased trends in CTA and CTP imaging, which were associated with endovascular thrombectomy and intravenous thrombolysis utilization, in acute ischemic stroke patients from 2016 to 2020.

Clinical Outcomes and Costs of Recurrent Ischemic Stroke: A Systematic Review.

OBJECTIVE: Recurrent stroke patients suffer significant morbidity and mortality, representing almost 30% of the stroke population. Our objective was to determine the clinical outcomes and costs of recurrent ischemic stroke (recurrent-IS). METHODS: Our study protocol was registered with the International Prospective Register of Systematic Reviews (CRD42020192709). Following PRISMA guidelines, our medical librarian conducted a search in EMBASE, PubMed, Web-of-Science, Scopus, and CINAHL (last performed on August 25, 2020). INCLUSION CRITERIA: (1) Studies reporting clinical outcomes and/or costs of recurrent-IS; (2) Original research published in English in year 2010 or later; (3) Study participants aged ≥18 years. EXCLUSION CRITERIA: (1) Case reports/studies, abstracts/posters, Editorial letters/reviews; (2) Studies analyzing interventions other than intravenous thrombolysis and thrombectomy. Four independent reviewers selected studies with review of titles/abstracts and full-text, and performed data extraction. Discrepancies were resolved by a senior independent arbitrator. Risk-of-bias was assessed using the Mixed Methods Appraisal Tool. RESULTS: Initial search yielded 20,428 studies. Based on inclusion/exclusion criteria, 9 studies were selected, consisting of 24,499 recurrent-IS patients. In 5 studies, recurrent-IS ranged from 4.4-56.8% of the ischemic stroke cohorts at 3 or 12 months, or undefined follow-up. Mean age was 60-80 years and female proportions were 38.5-61.1%. Clinical outcomes included mortality 11.6-25.9% for in-hospital, 30-days, or 4-years (3 studies). In one study from the U.S., mean in-hospital costs were $17,121(SD-$53,693) and 1-year disability costs were $34,639(SD-$76,586) per patient. CONCLUSIONS: Our study highlights the paucity of data on clinical outcomes and costs of recurrent-IS and identifies gaps in existing literature to direct future research.

Striving for Socioeconomic Equity in Ischemic Stroke Care: Imaging and Acute Treatment Utilization From a Comprehensive Stroke Center.

PURPOSE: Prior studies have shown socioeconomic disparities in advanced neuroimaging and acute treatment utilization in patients with ischemic stroke. The authors analyzed whether socioeconomic factors were associated with stroke neuroimaging and acute treatment utilization at a comprehensive stroke center. METHODS: A retrospective study of consecutive acute ischemic stroke discharges from 2012 to 2020 at a comprehensive stroke center was performed. Differences in neuroimaging (CT angiography [CTA], CT perfusion, MRI, and MR angiography [MRA]) and acute treatment (intravenous thrombolysis [IVT] and endovascular thrombectomy [EVT]) utilization were evaluated on the basis of socioeconomic factors of age, sex, race, insurance type, and neighborhood-level median household income. Chi-square tests were used for bivariate analyses. Multivariable logistic regression analyses were performed to determine associations between socioeconomic factors and neuroimaging or treatment utilization while controlling for stroke-specific factors and comorbidities. RESULTS: Among 6,140 ischemic stroke discharges, race and insurance type were not significantly associated with lower utilization of neuroimaging (CTA, CT perfusion, MRI, and MRA) or acute stroke treatment (IVT and EVT) after controlling for stroke-specific factors and comorbidities. However, median household income < $80,000/year was associated with lower IVT use (odds ratio [OR], 0.74; 95% confidence interval [CI], 0.63-0.87). In addition, age ≥ 80 years had lower CTA (OR, 0.62; 95% CI, 0.51-0.75) and EVT (OR, 0.53; 95% CI, 0.39-0.73) utilization, and female sex had lower CTA (OR, 0.78; 95% CI, 0.65-0.93) utilization. Significantly higher utilization was observed for MRI in Asian (OR, 1.33; 95% CI, 1.04-1.69) and uninsured (OR, 1.64; 95% CI, 1.07-2.50) patients and for MRA (OR, 1.24; 95% CI, 1.04-1.49) and EVT (OR, 1.62; 95% CI, 1.20-2.20) in privately insured patients. CONCLUSIONS: Once access to a comprehensive stroke center is achieved, socioeconomic disparities in the utilization of health care resources, particularly advanced neuroimaging and acute treatment, may be improved in patients with ischemic stroke.

Pulmonary haemorrhage in neonates: Systematic review of management.

AIM: Pulmonary haemorrhage (PH) is an acute catastrophic event with low incidence yet high mortality among neonates. We aimed to systematically review the management of PH. METHODS: A search was carried out of the PubMed, EMBASE and Cochrane databases according to the PRISMA guidelines. Data were extracted on study design and size, patient demographics, primary and adjunctive treatment methods, and treatment outcomes. RESULTS: Sixteen studies with 385 newborn infants were included and were significantly heterogeneous regarding treatment methods. Primary treatments included surfactant, high-frequency oscillatory ventilation (HFOV), epinephrine, coagulopathy management, intermittent positive pressure ventilation, cocaine and tolazoline. Adjunctive treatment methods included blood products, HFOV, increased positive end-expiratory pressure, vitamin K, surfactant, adrenaline, vasopressors and inotropes. All five studies using surfactant as primary treatment were effective in improving oxygenation index measures and preventing recurrence of PH, and three studies found no association between surfactant and death or long-term disability. Ventilatory support, epinephrine, management of coagulopathy and tolazoline were all found to be effective primary treatments for PH. CONCLUSION: There are several effective methods of managing PH in neonates. Further understanding of the aetiology of PH and ongoing research will allow future prevention and improvements in management of PH.

Strychnine overdose following ingestion of gopher bait.

A 52-year-old male was discovered supine on his bed in a state of early decomposition. Commercial strychnine-treated gopher pellets were found in the home, and suicide notes were present at the scene. Biological fluids and tissues were tested for basic, acidic, and neutral drugs using gas chromatography-mass spectrometry. Concentrations of strychnine in heart and femoral blood were 0.96 and 0.31 mg/L, respectively. Vitreous fluid, bile, urine, liver, and brain specimens contained 0.36 mg/L, 1.17 mg/L, 2.92 mg/L, 4.59 mg/kg, and 0.86 mg/kg strychnine, respectively. No other drugs were detected in any of the samples. The cause of death was attributed to rodenticide poisoning, and the manner of death was suicide.