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Kristian Barlinn,
Andrew D Barreto,
April Sisson,
David S Liebeskind,
Mark E Schafer,
John Alleman,
Limin Zhao,
Loren Shen,
Luis F Cava,
Mohammad H Rahbar, James C Grotta,
Andrei V Alexandrov
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ABSTRACT: BACKGROUND AND PURPOSE: We aimed to evaluate safety and tolerability of a novel operator-independent ultrasound device among stroke-free volunteers. METHODS: A headframe containing 18 ultrasound transducers (each operating at 2 MHz, pulsed-wave) was used to expose both temporal windows and the suboccipital window. The transmission characteristics were set to emulate the acoustic characteristics of the exposure levels in the Combined Lysis of Thrombus in Brain Ischemia using Transcranial Ultrasound and Systemic tPA trial and to never exceed Food and Drug Administration-mandated diagnostic ultrasound exposure limits. Volunteers underwent 2 hours of insonation with transducer activation one at a time. Safety was captured using serial neurological examinations and pre- and postinsonation MRI for detection of the blood brain barrier permeability. RESULTS: A total of 15 volunteers (40% men; 49±16 years; 27% black; all pre-exposure National Institutes of Health Stroke Scale scores 0) were enrolled. Five volunteers received pulsed-wave ultrasound via the best pair temporal transducers, 5 via sequential activation of the suboccipital transducers, and 5 via sequential activation of all bilateral temporal and suboccipital transducers. All subjects were safely insonated with no adverse effects as indicated by the neurological examinations during, immediately after the exposure, and at 24 hours, and no abnormality of the blood brain barrier was found on any of the MRIs. CONCLUSIONS: Our novel device was well tolerated by stroke-free volunteers and did not cause any neurological dysfunction nor did it affect blood brain barrier integrity. The safety and efficacy of the device are now being tested in stroke patients receiving intravenous tissue-type plasminogen activator in phase II-III clinical trials.
Stroke 04/2013; · 5.73 Impact Factor
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ABSTRACT: BACKGROUND: Lack of recognition of early symptoms of acute posterior circulation ischaemic stroke might delay timely diagnosis and treatment with tissue plasminogen activator. AIMS AND HYPOTHESIS: We hypothesized that patients with posterior circulation stroke receive delayed thrombolytic treatment in comparison to anterior circulation stroke. We investigated the differences in times to evaluation or treatment between patients with anterior circulation ischaemic stroke and posterior circulation stroke in our aim to understand the barriers that might have caused these delays. METHODS: A cross-sectional study was conducted using consecutive patients presenting to our tertiary academic centre with acute ischaemic stroke who were treated with intravenous tissue plasminogen activator within 4·5 h from symptom onset. We compared demographics, stroke severity, symptoms and signs, and time intervals among onset, emergency department arrival, emergency department physician evaluation, neurologist evaluation, brain imaging, and tissue plasminogen activator treatment in patients with anterior circulation stroke and posterior circulation stroke. RESULTS: Among 252 patients treated with intravenous tissue plasminogen activator, 12% had posterior circulation stroke. Patients with posterior circulation stroke had significantly lower median baseline the National Institutes of Health and Stroke Scale (NIHSS) score (P = 0·01), higher frequency of nausea (P < 0·01), vomiting (P < 0·01), dizziness (P < 0·01), and lower frequency of aphasia (P = 0·002) or neglect (P = 0·048). The emergency department physician evaluation-to-neurologist evaluation and door-to-needle intervals were significantly longer for posterior circulation stroke patients compared with anterior circulation stroke patients. The neurologist-to-needle time, however, was similar in the two groups. The presence of nausea and vomiting was associated with a longer time from emergency department evaluation to neurology evaluation and had a significant association with delayed treatment. CONCLUSIONS: Posterior circulation stroke patients had a delay in neurology evaluation after initial emergency department evaluation and a delay in intravenous tissue plasminogen activator administration compared with anterior circulation stroke patients. There may be difficulties in rapidly recognizing the symptoms of posterior circulation stroke, in contrast to anterior circulation stroke, in the emergency department.
International Journal of Stroke 03/2013; · 2.38 Impact Factor
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ABSTRACT: Ischaemic stroke is one of the leading causes of death and disability worldwide, and intravenous alteplase is the only proven effective treatment in the acute setting. Hypothermia has been shown to improve neurological outcomes after global ischaemia-hypoxia in comatose patients who have had cardiac arrest, and is one of the most extensively studied and powerful therapeutic strategies in acute ischaemic stroke. The protective mechanisms of therapeutic hypothermia affect the ischaemic cascade across several parallel pathways and, when coupled with reperfusion strategies, might yield synergistic benefits for patients who have had a stroke. Technological advances have allowed hypothermia to be induced rapidly, and the treatment has been used safely in acute stroke patients. Conclusive efficacy trials assessing therapeutic hypothermia combined with reperfusion therapies in acute ischaemic stroke are ongoing.
The Lancet Neurology 03/2013; 12(3):275-84. · 23.46 Impact Factor
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ABSTRACT: Background-The creation of The Joint Commission primary stroke centers (PSCs) has increased access to acute stroke care in metropolitan areas. We hypothesized that the rise in PSCs in the Houston area was associated with demographic changes and decreased trial enrollment at our comprehensive stroke center. METHODS: Consecutive admissions to the UT Houston stroke team from January 2005 to June 2011 were reviewed for demographic and clinical information. Patient characteristics were compared across years. Logistic regression was performed to assess the odds of admission per year. RESULTS: During the 6.5-year study period, there were 6623 admissions. Admissions increased each year. The proportion of patients transferred from other hospitals to our Comprehensive Stroke Center increased from 24.6% in 2005 to 45.5% in 2011. The number of The Joint Commission PSCs in the greater Houston area increased from 2 to 15. The percentage of large artery occlusions fell from 32.9% in 2005 to a low of 16.4% in 2010, whereas minor strokes (National Institutes of Health Stroke Scale, 0-5) increased from 37.4% in 2005 to 48.6% in 2011. Among stroke patients presenting within 3 hours, study enrollment fell from 45.8% in 2005 to 19.3% in 2011. CONCLUSIONS: We observed a temporal association between the changes in our patient demographics and the number of The Joint Commission PSCs in Houston. The number of large artery occlusions decreased over time, whereas the number of mild strokes increased. In addition, the number of patients enrolled into clinical trials substantially decreased. Increased access to stroke care at PSCs may be associated with changes in patient demographics and clinical trial enrollment at our center.
Stroke 02/2013; · 5.73 Impact Factor
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Benedikt Frank, James C Grotta,
Andrei V Alexandrov,
Erich Bluhmki,
Patrick Lyden,
Atte Meretoja,
Nishant K Mishra,
Ashfaq Shuaib,
Nils G Wahlgren,
Christian Weimar,
Kennedy R Lees
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ABSTRACT: BACKGROUND AND PURPOSE: Intravenous thrombolysis with alteplase is approved for acute ischemic stroke, but its use is limited by numerous contraindications and warnings arising from trial selection criteria or expert opinions. We examined outcomes from alteplase-treated versus untreated patients, registered in a trials archive, according to presence or absence of specified contraindications and warnings. METHODS: We analyzed 90-day modified Rankin Scale across the whole distribution of scores using the Cochran-Mantel-Haenszel test, with adjustment for age and baseline National Institutes of Health Stroke Score, followed by proportional odds logistic regression analysis to estimate the odds ratios for preferred outcome. RESULTS: We used data from 9613 ischemic stroke patients of whom 2755 were treated with thrombolysis. Adjusted odds ratios showed a broad trend of more favorable 3-month outcome associated with alteplase treatment versus no treatment in various subgroups of patients with contraindications and warnings; for example, 1.40 (95% confidence interval [CI], 1.14-1.70) in patients aged >80 (n=1805), 1.50 (95% CI, 1.03-2.18) in patients with combined history of prior stroke and diabetes mellitus (n=672), 1.42 (95% CI, 1.19-1.70) in patients on prior single antiplatelet agent (n=1626), 2.20 (95% CI, 1.12-4.32) in patients on oral anticoagulation, and International Normalized Ratio≤1.7 (n=157), 1.50 (95% CI, 1.15-1.97) in patients with baseline glucose >180 (n=879), and 1.57 (95% CI, 1.12-2.18) in patients with pretreatment National Institutes of Health Stroke Score >22 (n=620).Conclusions
This comprehensive retrospective analysis of various contraindications and warnings provides reassurance about benefits and risks of intravenous alteplase treatment in common clinical situations.
Stroke 02/2013; · 5.73 Impact Factor
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Rachael L Fulton,
Kennedy R Lees,
Erich Bluhmki,
Gabriele Biegert,
Gregory W Albers,
Stephen M Davis,
Geoffrey A Donnan, James C Grotta,
Werner Hacke,
Markku Kaste, [......],
M G Hennerici,
M Hommel,
P Lyden,
J Marler,
K Muir,
R Sacco,
P Teal,
N G Wahlgren,
S Warach,
C Weimar
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ABSTRACT: BACKGROUND AND PURPOSE: Approved use of intravenous alteplase for ischemic stroke offers net benefit. Pooled randomized controlled trial analysis suggests additional patients could benefit but others be harmed with treatment initiated beyond 4·5 h after stroke onset. We proposed prognostic scoring methods to identify a strategy for patient selection. METHODS: We selected 500 patients treated by intravenous alteplase and 500 controls from Virtual International Stroke Trials Archive, matching modified Rankin score outcomes to those from pooled randomized controlled trial 4·5-6 h data. We ranked patients by prognostic score. We chose limits to optimize our sample for a net treatment benefit significant at P = 0·01 by Cochran-Mantel-Haenszel test and by ordinal regression. For validation, we had these applied to the pooled randomized controlled trial data for 4·5-6 h, testing for net benefit by Cochran-Mantel-Haenszel test, ordinal regression, and also by dichotomized outcomes: modified Rankin score 0-1, mortality and parenchymal hemorrhage type 2 bleeds. All analyses were adjusted for age and National Institutes of Health Stroke Scale. RESULTS: In the training dataset, limits of 56-95 on a prognostic score retained 714 patients in whom there was net benefit significant at P = 0·01. When applied to the 1120 patients in the pooled randomized controlled trial 4·5-6 h dataset, score limits of 56-95 retained 711 patients and gave odds ratio for improved modified Rankin score distribution of 1·13, 95% confidence interval 0·87-1·47, Cochran-Mantel-Haenszel P = 0·89. More patients achieved modified Rankin score 0-1 (odds ratio 1·44, 1·02-2·05, P = 0·04) but mortality and parenchymal hemorrhage type 2 bleeds were increased: odds ratio 1·56, 1·01-2·40, P = 0·04; odds ratio 15·6, 3·7-65·8, P = 0·0002, respectively. CONCLUSION: Selection of patients between 4·5 and 6 h based on simple clinical measures failed to deliver a population in whom the alteplase effect would be safe and effective.
International Journal of Stroke 01/2013; · 2.38 Impact Factor
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Stroke 01/2013; · 5.73 Impact Factor
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Preeti Sahota,
Farhaan Vahidy,
Claude Nguyen,
Thanh-Tung Bui,
Bing Yang,
Kaushik Parsha,
Jennifer Garrett,
Arvind Bambhroliya,
Andrew Barreto, James C Grotta,
Jaroslaw Aronowski,
Mohammad H Rahbar,
Sean Savitz
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ABSTRACT: BACKGROUND: In animal models, the spleen contracts after acute ischemic stroke, followed by release of inflammatory cells leading to secondary brain injury. AIMS: We aim to characterize splenic responses in patients with acute ischemic stroke. METHODS: In this prospective observational study, we measured daily spleen sizes with abdominal ultrasound in 30 patients with suspected acute ischemic stroke. Splenic ultrasounds were also performed in 20 healthy individuals. RESULTS: A generalized estimating equation, longitudinal regression model for adjusted spleen measurements showed the difference between baseline spleen volume (within six-hours of stroke onset) and the volume at the last measured time point (up to seven-days) to be statistically significant (volume difference of 51·9 cm(3) , P = 0·04). Healthy controls had significantly smaller day-to-day variations; the maximum observed difference in mean spleen volume between any two time points was 9·5 cm(3) , with the average change over the period of observation being 1·24 cm(3) . A statistically significant negative association was also observed between the pattern of change of total white blood cell count and spleen volume (P = 0·01). An analysis of individual cases demonstrated possible associations between daily spleen volume changes and clinical course. CONCLUSIONS: We hypothesize that the spleen may initially contract after ischemic stroke followed by a re-expansion and that it contributes to ischemic brain injury mediated via cellular components. Characterization of the splenic response after stroke and its contribution to cerebral ischemic injury has the potential to provide new opportunities for the development of novel stroke therapies.
International Journal of Stroke 12/2012; · 2.38 Impact Factor
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ABSTRACT: OBJECTIVE: To test the role of hospital-acquired symptomatic urinary tract infection (SUTI) as an independent predictor of discharge disposition in the acute stroke patient. STUDY DESIGN: A retrospective observational study of prospectively collected data from patients admitted to the stroke service at a single university-based hospital between July 2004 and October 2009, with discharge disposition of home, inpatient rehabilitation, skilled nursing facility, or long-term acute care. SETTING: A single university-based hospital. PARTICIPANTS: After institutional review board approval was obtained, we performed a data query of the fields of interest from our university-based stroke registry, a collection of 200 variables collected prospectively for each patient admitted to the stroke service. The registry is maintained by the Specialized Programs of Translational Research in Acute Stroke Data Core. The Specialized Programs of Translational Research in Acute Stroke is a national network of 8 centers that perform early phase clinical projects, share data, and promote new approaches to therapy for acute stroke. MAIN OUTCOME MEASURES: Baseline demographics, including age, gender, ethnicity, and National Institutes of Health Stroke Scale (NIHSS) score, were collected. Cerebrovascular disease risk factors were used for independent risk assessment. Interaction terms were created between SUTI and known covariates, such as age, NIHSS, serum creatinine level, history of stroke, and urinary incontinence. Because patients who share discharge disposition tend to have similar length of hospitalization, we analyzed the effect of SUTI on the median length of stay for a correlation. Days in the intensive care unit and death were used to evaluate morbidity and mortality. By using multivariate logistic regression, the data were analyzed for differences in poststroke disposition among patients with SUTI. RESULTS: Of 4971 patients admitted to the University of Texas at Houston Stroke Service, 2089 were discharged to home, 1029 to inpatient rehabilitation, 659 to a skilled nursing facility, and 226 to a long-term acute care facility. Patients with an SUTI were 57% less likely to be discharged home compared with the other levels of care (P < .0001; odds ratio 0.430 [95% confidence interval 0.303-0.609]). When considering inpatient rehabilitation versus skilled nursing facility, patients with SUTI were 38% less likely to be discharged to inpatient rehabilitation (P < .0058; odds ratio 0.626 [95% confidence interval, 0.449-0.873]). We performed interaction analyses for SUTI and age, NIHSS, urinary incontinence, serum creatinine level, and history of stroke. We noted an interaction between SUTI and NIHSS for discharge disposition to a skilled nursing facility versus a long-term acute care facility. For patients with SUTI, a 1-unit increase in NIHSS results in a 10.6% increase in the likelihood of stroke rehabilitation in a long-term acute care facility compared with 5.6% increased likelihood for patients without SUTI (P = .0370). CONCLUSIONS: Acute stroke patients with hospital-acquired SUTI are less likely to be discharged home. In our analysis, if poststroke care is necessary, then patients with SUTI are more likely to receive inpatient stroke rehabilitation at the level of care suggestive of lower functional status. For every point increase in NIHSS, stroke patients with SUTI are 10.6% more likely to require continued rehabilitation care in a long-term acute care facility versus a skilled nursing facility compared with 5.6% for patients without SUTI. The combination of premorbid urinary incontinence and urinary tract infection has no additional impact on discharge disposition. This study is limited by its retrospective nature and the undetermined role of psychosocial factors related to discharge. Prospective studies are warranted on the efficacy of early catheter discontinuation, identification of new-onset urinary incontinence, use of genitourinary barriers, and catheter care every shift as variables that can decrease the risk of infection. The information obtained from prospective studies will have an impact on resource use that is of prime importance in the current health care climate.
Der Notarzt 10/2012; · 0.28 Impact Factor
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Andrea Elliott,
Jeremy Wetzel,
Tiffany Roper,
Evan Pivalizza,
James McCarthy,
Cristina Wallace,
Mary Jane Hess,
Hui Peng,
Mohammad H Rahbar,
Navdeep Sangha, James C Grotta
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ABSTRACT: BACKGROUND: Thromboelastography measures the dynamics of coagulation. There are limited data about thromboelastography in acute ischemic stroke other than a single study from 1974 suggesting that acute ischemic stroke patients are hypercoagulable. There have been no studies of thromboelastography in the thrombolytic era despite its potential usefulness as a measure of clot lysis. This study was designed to provide initial thromboelastography data in stroke patients before and after tissue plasminogen activator therapy and to provide the necessary preliminary data for further study of thromboelastography's ability to identify clot subtype and predict response to tissue plasminogen activator therapy. METHODS: All acute ischemic stroke patients presenting between 11/2009 and 2/2011 eligible for tissue plasminogen activator therapy were screened and 56 enrolled. Blood was drawn before (52 patients) and 10 mins after tissue plasminogen activator bolus (30 patients). Demographics, vitals, labs, 24 h National Institutes of Health Stroke Scale, and computed tomography scan results were collected. Patients were compared with normal controls. RESULTS: Acute ischemic stroke patients had shorter R (4·8 ± 1·5 vs. 6·0 ± 1·7 min, P = 0·0004), greater α Angle (65·0 ± 7·6 vs. 61·5 ± 5·9°, P = 0·01), and shorter K (1·7 ± 0·7 vs. 2·1 ± 0·7 min, P = 0·002) indicating faster clotting. Additionally, a subset formed clots with stronger platelet-fibrin matrices. Treatment with tissue plasminogen activator resulted in reduction in all indices of clot strength (LY30 = 0 (0-0·4) vs. 94·4 (15·2-95·3) P < 0·0001); however, there was considerable variability in response. CONCLUSIONS: Thromboelastography demonstrates that many acute ischemic stroke patients are hypercoaguable. Thromboelastography values reflect variable clot subtype and response to tissue plasminogen activator. Further study based on these data will determine if thromboelastography is useful for measuring the dynamic aspects of clot formation and monitoring lytic therapy.
International Journal of Stroke 09/2012; · 2.38 Impact Factor
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Neurology 06/2012; 78(24):1907-8. · 8.31 Impact Factor
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ABSTRACT: Introduction: Up to 40% of primary intracerebral hemorrhages (ICHs) expand within the first 24 hours (natural history). The authors aimed
to study the safety and preliminary efficacy of ɛ-aminocaproic acid (EACA) in halting ICH enlargement.
Methods: Consecutive patients with hematoma volumes ranging from 5 to 80 mL were recruited within 12 hours of ICH onset. A total of
5 g EACA was infused during 1 hour and then 1 g/hour for 23 hours. Hematoma volume was compared onbaseline, and 24–48-hour
brain imaging. Consecutive untreated patients underwent the same imaging protocol.
Results: Three of the first five patients treated had HE>33% of their baseline volume. HE occurred in two of the nine untreated patients.
The 80% confidence interval for HE in the treated patients was 32–88%. No thrombotic or other serious adverse events were
attributed to EACA.
Conclusion: It is unlikely that the rate of HE in patients given EACA within 12 hours of ICH is less than the natural history rate, although
this treatment appears to be safe.
Neurocritical Care 04/2012; 1(1):47-51. · 2.47 Impact Factor
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ABSTRACT: There is a great need for new treatments for acute ischemic stroke that will achieve greater rates of arterial recanalization and increase the population of patients who may benefit. Of several approaches under investigation, intra-arterial therapy (IAT) is the farthest along in clinical development, but experience has shown that the increased rates of recanalization achieved are not always translated to improved patient outcomes. Proper patient selection, allied to efficient strategies aiming at faster recanalization and reperfusion, may result in better clinical outcomes and more rational use of therapeutic resources. While high-tech multimodal imaging has the great promise of identifying hypoperfused but still viable brain tissue, a number of clues suggest that relatively low-tech approaches similar to those that were used to demonstrate the efficacy of systemic thrombolysis, and which have emphasized the key role of time and clinical factors such as age, glucose, stroke severity, and infarct on noncontrast CT scan, deserve greater study as an efficient way to optimize IAT. Eventually it will be a combination of predictors that will enable us to most precisely identify the best patients for IAT and any other new revascularization therapies.
Neurology 03/2012; 78(10):755-61. · 8.31 Impact Factor
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Andrew D Barreto,
Andrei V Alexandrov,
Pat Lyden,
Jessica Lee,
Sheryl Martin-Schild,
Loren Shen,
Tzu-Ching Wu,
April Sisson,
Renganayaki Pandurengan,
Zhongxue Chen, [......],
Clotilde Balucani,
Kristian Barlinn,
Rebecca M Sugg,
Zsolt Garami,
Georgios Tsivgoulis,
Nicole R Gonzales,
Sean I Savitz,
Robert Mikulik,
Andrew M Demchuk, James C Grotta
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ABSTRACT: Argatroban is a direct thrombin inhibitor that safely augments recanalization achieved by tissue-type plasminogen activator (tPA) in animal stroke models. The Argatroban tPA Stroke Study was an open-label, pilot safety study of tPA plus Argatroban in patients with ischemic stroke due to proximal intracranial occlusion.
During standard-dose intravenous tPA, a 100-μg/kg bolus of Argatroban and infusion for 48 hours was adjusted to a target partial thromboplastin time of 1.75× baseline. The primary outcome was incidence of significant intracerebral hemorrhage defined as either symptomatic intracerebral hemorrhage or Parenchymal Hematoma Type 2. Recanalization was measured at 2 and 24 hours by transcranial Doppler or CT angiography.
Sixty-five patients were enrolled (45% men, mean age 63±14 years, median National Institutes of Health Stroke Scale=13). The median (interquartile range) time tPA to Argatroban bolus was 51 (38-60) minutes. Target anticoagulation was reached at a median (interquartile range) of 3 (2-7) hours. Significant intracerebral hemorrhage occurred in 4 patients (6.2%; 95% CI, 1.7-15.0). Of these, 3 were symptomatic (4.6%; 95% CI, 0.9-12.9). Seven patients (10%) died in the first 7 days. Within the 2-hour monitoring period, transcranial Doppler recanalization (n=47) occurred in 29 (61%) patients: complete in 19 (40%) and partial in another 10 (21%).
The combination of Argatroban and intravenous tPA is potentially safe in patients with moderate neurological deficits due to proximal intracranial arterial occlusions and may produce more complete recanalization than tPA alone. Continued evaluation of this treatment combination is warranted.
URL: www.clinicaltrials.gov. Unique identifier: NCT00268762.
Stroke 03/2012; 43(3):770-5. · 5.73 Impact Factor
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Nicole R Gonzales,
Jharna Shah,
Navdeep Sangha,
Lenis Sosa,
Rebecca Martinez,
Loren Shen,
Mallikarjunarao Kasam,
Miriam M Morales,
M Monir Hossain,
Andrew D Barreto, [......],
Ramy El Khoury,
Amrou Sarraj,
Preeti Sahota,
William Hicks,
Indrani Acosta,
M Rick Sline,
Mohammad H Rahbar,
Xiurong Zhao,
Jaroslaw Aronowski, James C Grotta
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ABSTRACT: RATIONALE : Preclinical work demonstrates that the transcription factor peroxisome proliferator-activated receptor gamma plays an important role in augmenting phagocytosis while modulating oxidative stress and inflammation. We propose that targeted stimulation of phagocytosis to promote efficient removal of the hematoma without harming surrounding brain cells may be a therapeutic option for intracerebral hemorrhage. AIMS : The primary objective is to assess the safety of the peroxisome proliferator-activated receptor gamma agonist, pioglitazone, in increasing doses for three-days followed by a maintenance dose, when administered to patients with spontaneous intracerebral hemorrhage within 24 h of symptom onset compared with standard care. We will determine the maximum tolerated dose of pioglitazone. STUDY DESIGN : This is a prospective, randomized, blinded, placebo-controlled, dose-escalation safety trial in which patients with spontaneous intracerebral hemorrhage are randomly allocated to placebo or treatment. The Continual Reassessment Method for dose finding is used to determine the maximum tolerated dose of pioglitazone. Hematoma and edema resolution is evaluated with serial magnetic resonance imaging (MRI) at specified time points. Functional outcome will be evaluated at three- and six-months. OUTCOMES : The primary safety outcome is mortality at discharge. Secondary safety outcomes include mortality at three-months and six-months, symptomatic cerebral edema, clinically significant congestive heart failure, edema, hypoglycemia, anemia, and hepatotoxicity. Radiographic outcomes will explore the time frame for resolution of 25%, 50%, and 75% of the hematoma. Clinical outcomes are measured by the National Institutes of Health Stroke Scale (NIHSS), the Barthel Index, modified Rankin Scale, Stroke Impact Scale-16, and EuroQol at three- and six-months.
International Journal of Stroke 02/2012; · 2.38 Impact Factor
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ABSTRACT: This study aimed to evaluate factors that help determine the post-acute level of care for stroke patients with aspiration pneumonia (ASPNA).
This was a retrospective observational study of patients admitted to the University of Texas at Houston Medical School Stroke Service between July 2004 and October 2009 with discharge dispositions of home, inpatient rehabilitation, skilled nursing facility, or subacute care (n = 3511). Demographics, stroke risk factors, and National Institutes of Health Stroke Scale (NIHSS) values were collected. Interactions were evaluated between ASPNA and aging, ASPNA and NIHSS, ASPNA and use of tube feeding, and ASPNA and history of stroke. Using multivariable logistic regression, the data were analyzed for differences in disposition among patients with ASPNA.
There were significant correlations between ASPNA and an NIHSSvalue of 7.44 or greater for discharge to inpatient rehabilitation, skilled nursing facility, or subacute care compared with discharge to home (P = 0.0138); between ASPNA and an NIHSS value of 10.93 or greater for discharge to skilled nursing facility or subacute care compared with inpatient rehabilitation (P < 0.0001); and between ASPNA and age greater than 69.30 yrs for discharge to subacute care compared with a skilled nursing facility (P G 0.0001).
Patients with ASPNA and an NIHSS value of 7.44 or greater are more likely to require additional postacute care. ASPNA and an NIHSS value of 10.93 or greater increased the chance of postacute care at a level suggestive of lower functional status (skilled nursing facility or subacute care compared with inpatient rehabilitation). Age greater than 69.30 yrs plus ASPNA increased the likelihood of placement in subacute care vs. a skilled nursing facility.
American journal of physical medicine & rehabilitation / Association of Academic Physiatrists 02/2012; 91(2):141-7. · 1.56 Impact Factor
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Maurizio Paciaroni,
Clotilde Balucani,
Giancarlo Agnelli,
Valeria Caso,
Giorgio Silvestrelli, James C Grotta,
Andrew M Demchuk,
Sung-Il Sohn,
Giovanni Orlandi,
Didier Leys, [......],
Claudia Trentini,
Giuseppe Martini,
Charitomeni Piperidou,
Ioannis Heliopoulos,
Sebastiano D'Anna,
Manuel Cappellari,
Edoardo Donati,
Giorgio Bono,
Elisabetta Traverso,
Danilo Toni
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ABSTRACT: The beneficial effect of intravenous thrombolytic therapy in patients with acute ischemic stroke attributable to internal carotid artery (ICA) occlusion remains unclear. The aim of this study was to evaluate the efficacy and safety of intravenous recombinant tissue-type plasminogen activator in these patients.
ICARO was a case-control multicenter study on prospectively collected data. Patients with acute ischemic stroke and ICA occlusion treated with intravenous recombinant tissue-type plasminogen activator within 4.5 hours from symptom onset (cases) were compared to matched patients with acute stroke and ICA occlusion not treated with recombinant tissue-type plasminogen activator (controls). Cases and controls were matched for age, gender, and stroke severity. The efficacy outcome was disability at 90 days assessed by the modified Rankin Scale, dichotomized as favorable (score of 0-2) or unfavorable (score of 3-6). Safety outcomes were death and any intracranial bleeding.
Included in the analysis were 253 cases and 253 controls. Seventy-three cases (28.9%) had a favorable outcome as compared with 52 controls (20.6%; adjusted odds ratio (OR), 1.80; 95% confidence interval [CI], 1.03-3.15; P=0.037). A total of 104 patients died, 65 cases (25.7%) and 39 controls (15.4%; adjusted OR, 2.28; 95% CI, 1.36-3.22; P=0.001). There were more fatal bleedings (2.8% versus 0.4%; OR, 7.17; 95% CI, 0.87-58.71; P=0.068) in the cases than in the controls.
In patients with stroke attributable to ICA occlusion, thrombolytic therapy results in a significant reduction in the proportion of patients dependent in activities of daily living. Increases in death and any intracranial bleeding were the trade-offs for this clinical benefit.
Stroke 01/2012; 43(1):125-30. · 5.73 Impact Factor
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ABSTRACT: Bone marrow mononuclear cells (MNC) represent an investigational treatment for stroke. The objective of this study was to determine the relevance of vasoactive mediators, generated in response to MNC injection, as factors regulating cerebral perfusion (CP), the biodistribution of MNC, and outcome in stroke.
Long Evans rats underwent transient middle cerebral artery occlusion. MNC were extracted from the bone marrow at 22 hrs and injected via the internal carotid artery or the femoral vein 2 hours later. CP was measured with MRI or continuous laser Doppler flowmetry. Serum samples were collected to measure vasoactive mediators. Animals were treated with the Nitric Oxide (NO) inhibitor, L-NAME, to establish the relevance of NO-signaling to the effect of MNC. Lesion size, MNC biodistribution, and neurological deficits were assessed.
CP transiently increased in the peri-infarct region within 30 min after injecting MNC compared to saline or fibroblast control. This CP increase corresponded temporarily to serum NO elevation and was abolished by L-NAME. Pre-treatment with L-NAME reduced brain penetration of MNC and prevented MNC from reducing infarct lesion size and neurological deficits.
NO generation in response to MNC may represent a mechanism underlying how MNC enter the brain, reduce lesion size, and improve outcome in ischemic stroke.
PLoS ONE 01/2012; 7(3):e32793. · 4.09 Impact Factor
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ABSTRACT: OBJECTIVE: This study aimed to evaluate factors that help determine the postacute level of care for stroke patients with aspiration pneumonia (ASPNA). DESIGN: This was a retrospective observational study of patients admitted to the University of Texas at Houston Medical School Stroke Service between July 2004 and October 2009 with discharge dispositions of home, inpatient rehabilitation, skilled nursing facility, or subacute care (n = 3511). Demographics, stroke risk factors, and National Institutes of Health Stroke Scale (NIHSS) values were collected. Interactions were evaluated between ASPNA and aging, ASPNA and NIHSS, ASPNA and use of tube feeding, and ASPNA and history of stroke. Using multivariable logistic regression, the data were analyzed for differences in disposition among patients with ASPNA. RESULTS: There were significant correlations between ASPNA and an NIHSS value of 7.44 or greater for discharge to inpatient rehabilitation, skilled nursing facility, or subacute care compared with discharge to home (P = 0.0138); between ASPNA and an NIHSS value of 10.93 or greater for discharge to skilled nursing facility or subacute care compared with inpatient rehabilitation (P < 0.0001); and between ASPNA and age greater than 69.30 yrs for discharge to subacute care compared with a skilled nursing facility (P < 0.0001). CONCLUSIONS: Patients with ASPNA and an NIHSS value of 7.44 or greater are more likely to require additional postacute care. ASPNA and an NIHSS value of 10.93 or greater increased the chance of postacute care at a level suggestive of lower functional status (skilled nursing facility or subacute care compared with inpatient rehabilitation). Age greater than 69.30 yrs plus ASPNA increased the likelihood of placement in subacute care vs. a skilled nursing facility.
American journal of physical medicine & rehabilitation / Association of Academic Physiatrists 12/2011; · 1.56 Impact Factor
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ABSTRACT: Progression of neurological deficit (PND) is a frequent complication of acute subcortical ischemic stroke (SCS). The role of intracranial atherosclerosis (IAS) in PND is controversial. Our goal was to evaluate IAS on admission, as predictor of PND in SCS patients.
SCS patients were identified from our prospective database from 2004 to 2008. Clinical and laboratory data were collected from charts, and radiographic data from original radiographs. The proximal intracranial arteries were graded as patent, irregular, stenotic, or occlusion. IAS was defined as irregularity or stenosis. PND was defined as a change in the National Institutes of Health Stroke Scale >1 point.
Two hundred and two SCS patients were identified. In 14%, PND occurred at a median of 2 days from onset. Univariate analysis by infarct location showed the following to be associated with PND: for anterior circulation infarcts (centrum semiovale/basal ganglia), M1 atherosclerosis (p = 0.042); for posterior circulation infarcts, vertebral artery atherosclerosis (p = 0.018). For both groups, we found a non-significant association with age (p = 0.2) and HbA1c levels (p = 0.095). No association was found with admission glucose levels. Multivariate analysis showed the following association with PND: for anterior circulation infarcts, M1 atherosclerosis (OR 4.7; 95% CI 1.2-18.8; p = 0.03); for pontine infarcts, vertebral artery atherosclerosis (OR 5.8; 95% CI 1.1-29.4; p = 0.033). There was an increase in PND likelihood with an increasing number of atherosclerotic vessels.
In our cohort of SCS patients, PND was associated with IAS of the responsible vessels. These results suggest a role for IAS in the pathogenesis of PNF in SCS patients.
Cerebrovascular Diseases 12/2011; 33(1):64-8. · 2.72 Impact Factor
