Julio A Chalela

Medical University of South Carolina, Charleston, South Carolina, United States

Are you Julio A Chalela?

Claim your profile

Publications (82)431.76 Total impact

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Objective: To determine the prevalence, type, and significance of brain damage in critically ill patients with a primary non-neurological diagnosis developing acute brain dysfunction. Methods: This retrospective cohort study was performed at the Johns Hopkins University School of Medicine, an academic tertiary care hospital. Medical records were reviewed of 479 consecutive ICU patients who underwent brain MRI over a 2-year period. Patients were selected for analysis if MRI was obtained to evaluate an acute onset of brain dysfunction (altered mental status, seizures, and/or focal neurological deficit). Subjects with a history of a central nervous system disorder were excluded. The principal clinical endpoint was Glasgow Outcome Scale (GOS) assessed at discharge. MRI-defined brain abnormalities were classified according to type and location. Factors associated with MRI-defined abnormalities were assessed in uni- and multivariable models. Results: 146 patients met inclusion criteria (mean age 54±7years). Brain damage was detected in 130 patients (89%). The most prevalent lesions were white matter hyperintensities (104/146, 71%) and acute cerebral infarcts (59/146, 40%). In a multivariable model, lesions on brain MRI were independently associated with unfavorable outcome (GOS1-3 in 71% of patients with lesions vs. 44% in those without, p=0.007). No adverse events occurred in relation to transport and MRI scanning. Conclusions: In critically ill patients without known neurological disease who have brain dysfunction, MRI reveals an unexpectedly high burden of underlying brain damage, which is associated with unfavorable outcome. The results indicate that brain damage could be an important and under-recognized factor contributing to critical illness brain dysfunction.
    Neurocritical Care 02/2015; DOI:10.1007/s12028-015-0110-4 · 3.04 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The use of mechanical thrombectomy for the treatment of acute ischemic stroke has significantly advanced over the last 5 years. Few data are available comparing the cost and clinical and angiographic outcomes associated with available techniques. The aim of this study is to compare the cost and efficacy of current endovascular stroke therapies.
    Journal of Neurointerventional Surgery 07/2014; DOI:10.1136/neurintsurg-2014-011282 · 2.50 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Novel oral anticoagulants present challenges and uncertainties in the management of hemorrhagic emergencies. An 84-year-old man taking dabigatran presented with a subdural hematoma requiring neurosurgical intervention. Routine coagulation assays were prolonged at admission and following administration of Factor VIII Inhibitor Bypassing Activity (FEIBA). Thromboelastography (TEG(®)) was utilized to assess clot dynamics prior to placement of a subdural drain, which was safely inserted despite a prolonged thrombin time (TT). Exclusive reliance on the TT may delay necessary interventions. TEG(®) may be a valuable tool to investigate hemostasis in patients on dabigatran requiring emergent procedures.
    Journal of Thrombosis and Thrombolysis 05/2013; DOI:10.1007/s11239-013-0933-9 · 1.99 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: The "white cerebellum" sign is a rare imaging finding described mainly in children with hypoxic brain injury. MATERIALS AND METHODS: Single case report and review of the literature. FINDINGS: We describe a child with acute bacterial meningitis in whom plain CT and MRI showed the white cerebellum sign. The subtle imagings findings were not recognized and a lumbar puncture was performed. Markedly increased intracranial pressure was documented by lumbar puncture and by placement of an intraparenchymal monitor. Contrary to most prior descriptions the patient made a very good recovery. CONCLUSIONS: The white cerebellum sign is a subtle imaging finding seen in patients with diffuse cerebral edema, such finding may not be as ominous as previously thought.
    Neurocritical Care 04/2013; 18(3). DOI:10.1007/s12028-013-9836-z · 3.04 Impact Factor
  • Jill Blandford, Julio A Chalela
    [Show abstract] [Hide abstract]
    ABSTRACT: INTRODUCTION: Perimesencephalic subarachnoid hemorrhage is a rare neurologic condition of unclear etiology. Multiple mechanisms have been postulated as potential triggers, but none are universally accepted. METHODS: Single observational case report and review of the literature. RESULTS: We describe a patient who developed perimesencephalic subarachnoid hemorrhage in the setting of "hypoxic training" (breath-holding while swimming). We describe the plausible pathophysiologic events that caused the hemorrhage. CONCLUSION: The occurrence of perimesencephalic subarachnoid hemorrhage during hypoxic training suggests that acute venous congestion may be a triggering factor. The increasing popularity of hypoxic training demands vigilance from health care providers.
    Neurocritical Care 03/2013; 18(3). DOI:10.1007/s12028-013-9827-0 · 3.04 Impact Factor
  • J Ivan Lopez, Ashley Holdridge, Julio Chalela
    [Show abstract] [Hide abstract]
    ABSTRACT: Although headaches are common in the general population and have many causes, headaches secondary to inflammatory processes in the blood vessels in the Central Nervous System (CNS) are not so common. The most common types of vasculitis that are associated with headaches include primary CNS vasculitis, systemic necrotizing arteritis, granulomatous vasculitis, and systemic collagen diseases. It is important to differentiate between "true" vasculitides and a condition known and reversible cerebral vasoconstriction syndrome (RCVS). While treatment for many of the vasculitides consists of anti-inflammatory medications, this approach may produce significant complications in RCVS. It is up to the clinician to judiciously use imaging and laboratory data to reach the proper diagnosis and therefore offer the correct treatment to these patients.
    Current Pain and Headache Reports 03/2013; 17(3):320. DOI:10.1007/s11916-012-0320-9 · 2.26 Impact Factor
  • Julio A Chalela, J Ivan Lopez
    [Show abstract] [Hide abstract]
    ABSTRACT: Hunger strikes are not infrequent occurrences in military and civilian prisons. Although practicing clinicians are familiar with the management of patients who have limited oral intake, managing hunger strikers is unfamiliar to most. The psychological, physiological, and social events that surround hunger strikes are very complex and need to be understood by those caring for hunger strike patients. To provide adequate medical care to hunger strike patients, clinicians most understand the physiological events that ensue after prolonged starvation. Careful vigilance for development of refeeding syndrome is of key importance. A multidisciplinary approach to hunger strikes is of utmost importance, and involvement of a multidisciplinary clinical team as well as prison officials is essential.
    Nutrition in Clinical Practice 10/2012; 28(1). DOI:10.1177/0884533612462896 · 2.06 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Patient selection for acute ischemic stroke has been largely driven by time-based criteria, although emerging data suggest that image-based criteria may be useful. The purpose of this study was to directly compare outcomes of patients treated within a traditional time window with those treated beyond this benchmark when CT perfusion (CTP) imaging was used as the primary selection tool. METHODS: A prospectively collected database of all patients with acute ischemic stroke who received intra-arterial therapy at the Medical University of South Carolina was retrospectively analyzed, regardless of time from symptom onset. At presentation, CTP maps were qualitatively assessed. Selected patients underwent intra-arterial therapy. Functional outcome according to the modified Rankin scale (mRS) score at about 90 days was documented. RESULTS: 140 patients were included in the study. The median time from symptom onset to groin access was 7.0 h. Overall, 28 patients (20%) had bleeding complications, but only 10 (7.1%) were symptomatic. The average National Institute of Health Stroke Scale (NIHSS) score for patients treated ≤7 h from symptom onset was 17.3 and 30.2% had a mRS score of 0-2 at 90 days. Patients treated >7 h from symptom onset had an average NIHSS score of 15.1 and 45.5% achieved a mRS score of 0-2 at 90 days (p=0.104). Patients in the two groups had similar rates of symptomatic intracerebral hemorrhage (8.5% and 5.8%, respectively; p=0.745). CONCLUSIONS: No difference was found in the rates of good functional outcome between patients treated ≤7 h and those treated >7 h from symptom onset. These data suggest that imaging-based patient selection is a safe and viable methodology.
    Journal of Neurointerventional Surgery 08/2012; 5(6). DOI:10.1136/neurintsurg-2012-010452 · 2.50 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: Recent evidence indicates that multidisciplinary care improves patient outcomes in cerebrovascular (CV) disease. A multidisciplinary integrated CV program was recently instituted at a high-volume tertiary referral center, providing the opportunity to evaluate patient outcomes before and after its introduction. OBJECTIVE: To evaluate outcomes after treatment of patients with intracranial aneurysm in relation to the introduction of a CV program at our institution. METHODOLOGY: A retrospective chart review was performed on all new patient encounters for a 6-month period each before and immediately after the introduction of the CV program, as well as at a more recent 6-month period to evaluate long-term results. Data were collected on demographic variables, rupture status, medical comorbidities, hospital complications, in-hospital procedures, hospital course and modified Rankin score at discharge and follow up. RESULTS: The total number of patients treated increased from 55 in the 6-month period before the introduction of the CV program to 112 in the most recent time period (p<0.05). Both the surgical clipping and endovascular coiling procedures increased (p<0.05). A significant increase occurred in patients with multiple comorbidities (30.5% vs 34.7%, p=0.035). The mean length of stay decreased from 12.22±13.26 days before the program to 9.23±12.04 days in the most current data (p<0.05). CONCLUSIONS: Creation of an integrated CV program at a large-volume tertiary referral center resulted in better outcomes for an increased number of more medically complicated patients with intracranial aneurysms. This study provides preliminary data for developing an integrated model of multidisciplinary care for the management of CV disease.
    Journal of Neurointerventional Surgery 04/2012; 5(3). DOI:10.1136/neurintsurg-2012-010309 · 2.50 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: REACH Medical University of South Carolina (MUSC) provides stroke consults via the internet in South Carolina. From May 2008 to April 2011 231 patients were treated with intravenous (IV) thrombolysis and 369 were transferred to MUSC including 42 for intra-arterial revascularization [with or without IV tissue plasminogen activator (tPA)]. Medical outcomes and hemorrhage rates, reported elsewhere, were good (Lazaridis et al., 2011). Here we report operational features of REACH MUSC which covers 15 sites with 2,482 beds and 471,875 Emergency Department (ED) visits per year. Eight Academic Faculty from MUSC worked with 165 different physicians and 325 different nurses in the conduct of 1085 consults. For the 231 who received tPA, time milestones (in minutes) were: Onset to Door: 62 (mean), 50 (median); Door to REACH Consult: 43 and 33, Consult Request to Consult Start: was 9 and 7, Consult Start to tPA Decision: 31 and 25; Decision to Infusion: 20 and 14, and total Door to Needle: 98 and 87. The comparable times for the 854 not receiving tPA were: Onset to Door: 140 and 75; Door to REACH Consult: 61 and 41; Consult Request to Consult Start: 9 and 7, Consult Start to tPA Decision: 27 and 23. While the consultants respond to consult requests in <10, there is a long delay between arrival and Consult request. Tracking of operations indicates if we target shortening Door to Call time and time from tPA decision to start of drug infusion we may be able to improve Door to Needle times to target of <60. The large number of individuals involved in the care of these patients, most of whom had no training in REACH usage, will require novel approaches to staff education in ED based operations where turnover is high. Despite these challenges, this robust system delivered tPA safely and in a high fraction of patients evaluated using the REACH MUSC system.
    Frontiers in Neurology 03/2012; 3:33. DOI:10.3389/fneur.2012.00033
    This article is viewable in ResearchGate's enriched format
  • Clinical Neurology and Neurosurgery 03/2012; · 1.25 Impact Factor
  • Clinical neurology and neurosurgery 03/2012; 114(7):1030-2. DOI:10.1016/j.clineuro.2012.01.037 · 1.30 Impact Factor
  • Julio A Chalela, J Ivan Lopez
    Neurology 01/2012; 78(3):218-20. DOI:10.1212/WNL.0b013e31823fcdca · 8.30 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Traditional treatment in acute ischemic stroke is based on time criteria when administering intravenous and intra-arterial therapies. However, recent evidence suggests that image-based criteria may be useful for selecting patients for intra-arterial interventions. The use of CT perfusion (CTP)-based criteria, regardless of time from symptom onset, in patient selection for intra-arterial treatment of ischemic stroke was assessed. Patients with ischemic stroke who presented to the emergency department at the Medical University of South Carolina with a National Institute of Health Stroke Scale score of ≥ 8, regardless of time from symptom onset, were assessed retrospectively. CTP maps were qualitatively assessed for the presence of penumbra and infarction. Selected patients underwent mechanical aspiration of their occlusion using the Penumbra system. Functional outcome was then recorded using the modified Rankin scale (mRS) at 90 days or the closest follow-up to 90 days. 53 patients were included in the study. The median time from symptom onset to groin vascular access was 6.3 h. Eight patients (15%) had bleeding complications including subarachnoid hemorrhage, parenchymal hemorrhage and intraventricular hemorrhage. After CTP-based selection, the patients were divided into two groups for analysis: ≤6 h and >6 h from symptom onset to endovascular procedure. No difference was found in functional outcome between the two groups (38.5% and 40.7% achieved 90-day mRS ≤2, respectively (p=1.0) and 57.7% and 51.9% achieved 90-day mRS ≤3, respectively (p=0.785)). There was no difference in the rate of intracranial hemorrhage between the two groups (11.5 vs 18.5, p=0.704). This study demonstrated similar rates of good functional outcome and intracranial hemorrhage in patients with ischemic stroke when endovascular treatment was performed based on CTP selection rather than time-guided selection. These findings suggest that endovascular reperfusion in ischemic stroke may be effective and safe, and may allow patient selection not solely based on time from symptom onset.
    Journal of Neurointerventional Surgery 09/2011; 4(4):261-5. DOI:10.1136/neurintsurg-2011-010067 · 2.50 Impact Factor
  • Source
    Neurological Sciences 06/2011; 33(1):215-6. DOI:10.1007/s10072-011-0652-y · 1.50 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Family history is a recognized risk factor in aneurysmal subarachnoid hemorrhage (SAH). The genetic and environmental contributions are actively researched. The authors of this report present a case series of 3 first-degree siblings affected by nontraumatic, angiographically negative SAH. Data in this study suggest that familial predisposition may also apply to spontaneous, nonaneurysmal SAH and that family history should be actively investigated in all such patients. The identification of families with multiple affected members could lead to an improved understanding of the genetic and environmental factors associated with this condition.
    Journal of Neurosurgery 06/2011; 115(3):621-3. DOI:10.3171/2011.5.JNS1119 · 3.15 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Cerebral edema and raised intracranial pressure are common problems in neurological intensive care. Osmotherapy, typically using mannitol or hypertonic saline (HTS), has become one of the first-line interventions. However, the literature on the use of these agents is heterogeneous and lacking in class I studies. The authors hypothesized that clinical practice would reflect this heterogeneity with respect to choice of agent, dosing strategy, and methods for monitoring therapy. An on-line survey was administered by e-mail to members of the Neurocritical Care Society. Multiple-choice questions regarding use of mannitol and HTS were employed to gain insight into clinician practices. A total of 295 responses were received, 79.7% of which were from physicians. The majority (89.9%) reported using osmotherapy as needed for intracranial hypertension, though a minority reported initiating treatment prophylactically. Practitioners were fairly evenly split between those who preferred HTS (54.9%) and those who preferred mannitol (45.1%), with some respondents reserving HTS for patients with refractory intracranial hypertension. Respondents who preferred HTS were more likely to endorse prophylactic administration. Preferred dosing regimens for both agents varied considerably, as did monitoring parameters. Treatment of cerebral edema using osmotically active substances varies considerably between practitioners. This variation could hamper efforts to design and implement multicenter trials in neurocritical care.
    Neurocritical Care 12/2010; 14(2):222-8. DOI:10.1007/s12028-010-9477-4 · 3.04 Impact Factor
  • Julio A Chalela, Leo Bonillha, Ron Neyens, Angela Hays
    [Show abstract] [Hide abstract]
    ABSTRACT: Manganese encephalopathy is a potential complication of parenteral nutrition. Lack of early recognition leads to unnecessary testing and to continued exposure to manganese. Case report and review of the literature. We describe the clinical and imaging findings of a patient with manganese encephalopathy in whom the diagnosis was delayed due to lack of recognition of the characteristic imaging findings. Manganese encephalopathy has protean clinical and imaging findings that can easily be overlooked.
    Neurocritical Care 12/2010; 14(3):456-8. DOI:10.1007/s12028-010-9476-5 · 3.04 Impact Factor
  • Angela Hays, Julio A. Chalela
    [Show abstract] [Hide abstract]
    ABSTRACT: Acute myelopathy is a broad term used to describe spinal cord dysfunction of sudden, recent onset Diagnostic possibilities are ample, but practicing neurointensivists deal mainly with traumatic and inflammatory myelopathies Main objective in the initial management is to differentiate those patients who could benefit from acute surgical intervention (compressive myelopathies) from those patients who require medical management KeywordsMyelopathies-TM-Traumatic SCI
    12/2009: pages 323-339;
  • [Show abstract] [Hide abstract]
    ABSTRACT: The M2-360 degrees is a recent class of aneurysm coil. This device combines the second generation of bioactive copolymer coating, which is intended to promote aneurysm fibrosis, with the "360 degrees " design, which is meant to improve uniformity and density of packing. This study evaluates the safety and angiographic stability of these devices. This was a retrospective review of 86 consecutive patients with 100 intracranial aneurysms that were treated using M2-360 degrees s. Follow-up was done at 6 and 12 months. Seventy-eight aneurysms were coiled solely with M2-360 degrees s, and 22 aneurysms were treated with a combination of coils. In mixed-coil cases, the average percentage of coil volume consisting of M2-360 degrees coils was 78%. Procedure-related neurologic complications occurred in 6 patients (7%). Initial complete occlusion was obtained in 80 aneurysms. Of 76 aneurysms with 6-month angiographic follow-up, 4 (5.3%) revealed further occlusion, 54 (71.1%) were unchanged, and 18 (23.7%) showed recanalization. Of 38 aneurysms with 12-month follow-up, 1 (2.6%) revealed further occlusion, 23 (60.5%) were unchanged, and 14 (36.8%) showed recanalization. Six- and 12-month angiograms showed major recanalization (requiring further coiling) in 3.9% and 15.8% of cases, respectively. The risk of complications with M2-360 degrees -treated aneurysms is comparable with reports of other coils, indicating that M2-360 degrees s are relatively safe. Although the initial occlusion rate is higher than that in other coiling series, recanalization rates were similar to those obtained with other coil designs. This study does not demonstrate an advantage with M2-360 degrees s.
    Surgical Neurology 08/2009; 72(1):41-7. DOI:10.1016/j.surneu.2009.02.014 · 1.67 Impact Factor

Publication Stats

3k Citations
431.76 Total Impact Points

Top Journals


  • 2006–2014
    • Medical University of South Carolina
      • • Division of Neuroradiology
      • • Department of Neurosciences (College of Medicine)
      • • Department of Radiology
      Charleston, South Carolina, United States
  • 2012
    • University of South Carolina
      Columbia, South Carolina, United States
  • 2005–2008
    • Johns Hopkins University
      • Department of Anesthesiology and Critical Care Medicine
      Baltimore, MD, United States
    • University of Ulsan
      Urusan, Ulsan, South Korea
  • 2007
    • Georgetown University
      Washington, Washington, D.C., United States
    • The University of Calgary
      Calgary, Alberta, Canada
  • 2001–2005
    • National Institutes of Health
      • Branch of Stroke and Ischemia
      Maryland, United States
  • 2004
    • University of California, Los Angeles
      Los Ángeles, California, United States
  • 2000–2003
    • University of Pennsylvania
      • Department of Neurology
      Filadelfia, Pennsylvania, United States
  • 1999–2003
    • Hospital of the University of Pennsylvania
      • Department of Neurology
      Philadelphia, Pennsylvania, United States