Rajanandini Muralidharan

University of Pennsylvania, Philadelphia, Pennsylvania, United States

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Publications (11)54.37 Total impact

  • R Muralidharan, F J Mateen, A A Rabinstein
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    ABSTRACT: The objective of our study was to identify neurological factors associated with poor outcome in adult patients with fulminant bacterial meningitis. This was a retrospective review of consecutive adult patients with fulminant bacterial meningitis, defined as meningitis causing coma within 24-48 h of hospitalization, at Mayo Clinic Rochester between January 2000 and November 2010. Functional status was assessed at discharge and upon last follow-up using the modified Rankin scale (mRS). The primary end-point was death or new major disability (increase of >2 on the mRS) at last follow-up. Thirty-nine patients were identified. Encephalopathy (44%), coma (28%), focal seizures (3%) or a combination of these (26%) were present on admission. The most common pathogen was Streptococcus pneumoniae (57%). All patients were treated with broad spectrum antibiotics and 51% received steroids. Serious systemic complications were seen in 23 patients. Sixteen patients (41%) died during hospitalization. Median mRS at hospital discharge for surviving patients was 3; four patients had new major disability with a mean follow-up of 11 months. Predictors of death or new major disability included lower Glasgow Coma Scale score at nadir [P = 0.002; age- and sex-adjusted odds ratio (OR) 0.46, 95% confidence interval (CI) 0.28-0.48], longer duration of symptoms before hospitalization (P = 0.045; adjusted OR 2.34, 95% CI 1.02-5.37), abnormal head imaging at presentation (P = 0.008; adjusted OR 9.40, 95% CI 1.78-49.6) and use of intracranial pressure monitoring (P = 0.010, adjusted OR 51.0, 95% CI 2.51-1036). Many adult patients who survive hospitalization are able to regain their pre-morbid level of function. Aggressive management of bacterial meningitis is justified even in comatose adult patients.
    European Journal of Neurology 12/2013; · 4.16 Impact Factor
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    ABSTRACT: Intravenous tissue plasminogen activator is the most effective treatment for acute ischemic stroke, and its use may therefore serve as an indicator of the available level of acute stroke care. The greatest burden of stroke is in low- and middle-income countries, but the extent to which intravenous tissue plasminogen activator is used in these countries is unreported. A systematic review was performed searching each country name AND 'stroke' OR 'tissue plasminogen activator' OR 'thrombolysis' using PubMed, Embase, Global Health, African Index Medicus, and abstracts published in the International Journal of Stroke (Jan. 1, 1996-Oct. 1, 2012). The reported use of intravenous tissue plasminogen activator was then analyzed according to country-level income status, total expenditure on health per capita, and mortality and disability-adjusted life years due to stroke. There were 118 780 citations reviewed. Of 214 countries and independent territories, 64 (30%) reported use of intravenous tissue plasminogen activator for acute ischemic stroke in the medical literature: 3% (1/36) low-income, 19% (10/54) lower-middle-income, 33% (18/54) upper-middle-income, and 50% (35/70) high-income-countries (test for trend, P < 0·001). When considering country-level determinants of reported intravenous tissue plasminogen activator use for acute ischemic stroke, total healthcare expenditure per capita (odds ratio 3·3 per 1000 international dollar increase, 95% confidence interval 1·4-9·9, P = 0·02) and reported mortality rate from cerebrovascular disease (odds ratio 1·02, 95% confidence interval 0·99-1·06, P = 0·02) were significant, but reported disability-adjusted life years from cerebrovascular diseases and gross national income per capita were not (P > 0·05). Of the 10 countries with the highest disability-adjusted life years due to stroke, only one reported intravenous tissue plasminogen activator use. By reported use, intravenous tissue plasminogen activator for acute ischemic stroke is available to some patients in approximately one-third of countries. Access to advanced acute stroke care is most limited where the greatest burden of cerebrovascular disease is reported.
    International Journal of Stroke 11/2013; · 4.03 Impact Factor
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    ABSTRACT: Study Design. Retrospective consecutive case seriesObjective. To determine predictors of outcome in patients undergoing surgical treatment of spinal dural arteriovenous fistula (SDAVF).Summary of Background Data. Most previous studies assessing postoperative outcome in patients with SDAVF have been limited due to small population size, lack of sufficient information on presurgical variables, or short time of postoperative follow up. Consequently, the most reliable predictors of functional outcome after treatment of SDAVF are not yet well established.Methods. Retrospective analysis of consecutive patients with SDAVF treated surgically between June 1985 and March 2008 in our institution. The Aminoff-Logue gait (G) and micturition (M) scores were used to stratify the degree of disability and the G+M score was used as the primary outcome measure. Demographics, clinical presentation, time to diagnosis, fistula level, presurgical motor and sphincter impairment, and MRI findings were assessed as prognosticators for postoperative outcomes.Results. 153 patients were analyzed. Mean follow-up was 31±36.2 months. Most patients were improved (44%) or stable (34%) upon last follow-up. Among preoperative variables, worsening weakness with exertion was associated with better G+M score at last follow-up (p<0.001) and presence of pinprick level was associated with worse G+M score at last follow-up (p = 0.020). On multivariable analysis, worsening weakness with exertion was associated with better outcome at last follow-up, and higher G score at presentation and higher G+M score at discharge were associated with worse outcome at last follow-up. MRI exams performed postoperatively on 104 patients (mean 19.1±22.5 months) showed complete resolution or improvement of the presurgical T2 signal abnormalities in 83.6% of cases. Changes in postoperative MRI and fistula level did not correlate with functional outcomes.Conclusions. The degree of preoperative disability from SDAFV does not determine who will benefit most from surgery and even patients with severe deficits can improve after treatment. Patients with preoperative exertional claudication and absent pinprick level on examination have greater chances of post-surgical improvement.
    Spine 02/2013; · 2.16 Impact Factor
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    ABSTRACT:   There are few clinical studies on the attempted treatments and outcomes in patients with Susac syndrome (SS) (retinocochleocerebral vasculopathy).   A retrospective review was performed of all patients presenting with SS at the Mayo Clinic in Rochester, Minnesota, USA (1 January 1998-1 October 2011).   There were 29 cases of SS (24 women, mean age at presentation, 35 years; range, 19-65; full triad of brain, eye, and ear involvement, n = 16; mean follow-up time, 29 months). Thirty CSF analyses were performed in 27 cases (mean protein 130 mg/dl, range 35-268; mean cell count 14, range 1-86). MRI of the brain showed corpus callosal involvement (79%), T2-weighted hyperintensities (93%), and gadolinium enhancement (50%). Average lowest modified Rankin Scale score was 2.5 (median 2, range 0-5). Most patients (93%) received immunosuppressive treatment, with a mean time to treatment of 2 months following symptomatic onset. Treatments included intravenous methylprednisolone or dexamethasone (n = 23), oral corticosteroids (n = 24), plasma exchange (PLEX) (n = 9), intravenous immunoglobulin (IVIg) (n = 15), cyclophosphamide (n = 6), mycophenolate mofetil (n = 5), azathioprine (n = 2), and rituximab (n = 1). Most patients also received an antiplatelet agent (n = 21). Improvement or stabilization was noted in eight of 11 cases treated with IVIg in the acute period (three experienced at least partial deterioration) and eight of nine cases of PLEX treatment (one lost to follow up).   Susac syndrome may be severe, disabling, and protracted in some patients. PLEX may be an adjunct or alternative therapy for patients who do not experience symptomatic improvement following steroid treatment.
    European Journal of Neurology 01/2012; 19(6):800-11. · 4.16 Impact Factor
  • F J Mateen, A Zubkov, R Muralidharan, G Petty, J Winters
    Neurology 10/2011; 77(17):e103; author reply e103-4. · 8.30 Impact Factor
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    ABSTRACT: Extracorporeal membrane oxygenation (ECMO) may be urgently used as a last resort form of life support when all other treatment options for potentially reversible cardiopulmonary injury have failed. To examine the range and frequency of neurological injury in ECMO-treated adults. Retrospective clinicopathological cohort study. Mayo Clinic, Rochester, Minnesota. A prospectively collected registry of all patients 15 years or older treated with ECMO for 12 or more hours from January 2002 to April 2010. Patients were analyzed for potential risk factors for neurological events and death using logistic regression and Cox proportional hazards models. Neurological diagnosis and/or death. A total of 87 adults were treated (35 female [40%]; median age, 54 years [interquartile range, 31]; mean duration of ECMO, 91 hours [interquartile range, 100]; overall survival >7 days after ECMO, 52%). Neurological events occurred in 42 patients who received ECMO (50%; 95% confidence interval [CI], 39%-61%). Diagnoses included subarachnoid hemorrhage, ischemic watershed infarctions, hypoxic-ischemic encephalopathy, unexplained coma, and brain death. Death in patients who received ECMO who did not require antecedent cardiopulmonary resuscitation was associated with increased age (odds ratio, 1.24 per decade; 95% CI, 1.03-1.50; P = .02) and lower minimum arterial oxygen pressure (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .03). Although stroke was rarely diagnosed clinically, 9 of 10 brains studied at autopsy demonstrated hypoxic-ischemic and hemorrhagic lesions of vascular origin. Severe neurological sequelae occur frequently in adult ECMO-treated patients with otherwise reversible cardiopulmonary injury (conservative estimate, 50%) and include a range of potentially fatal neurological diagnoses that may be due to the precipitating event and/or ECMO treatment.
    Archives of neurology 08/2011; 68(12):1543-9. · 7.58 Impact Factor
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    ABSTRACT: Transplant recipients are at risk of developing progressive multifocal leukoencephalopathy (PML), a rare demyelinating disorder caused by oligodendrocyte destruction by JC virus. Reports of PML following transplantation were found using PubMed Entrez (1958-July 2010). A multicenter, retrospective cohort study also identified all cases of PML among transplant recipients diagnosed at Mayo Clinic, Johns Hopkins University, Washington University, and Amsterdam Academic Medical Center. At 1 institution, the incidence of posttransplantation PML was calculated. A total of 69 cases (44 solid organ, 25 bone marrow) of posttransplantation PML were found including 15 from the 4 medical centers and another 54 from the literature. The median time to development of first symptoms of PML following transplantation was longer in solid organ vs bone marrow recipients (27 vs 11 months, p = 0.0005, range of <1 to >240). Median survival following symptom onset was 6.4 months in solid organ vs 19.5 months in bone marrow recipients (p = 0.068). Case fatality was 84% (95% confidence interval [CI], 70.3-92.4%) and survival beyond 1 year was 55.7% (95% CI, 41.2-67.2%). The incidence of PML among heart and/or lung transplant recipients at 1 institution was 1.24 per 1,000 posttransplantation person-years (95% CI, 0.25-3.61). No clear association was found with any 1 immunosuppressant agent. No treatment provided demonstrable therapeutic benefit. The risk of PML exists throughout the posttransplantation period. Bone marrow recipients survive longer than solid organ recipients but may have a lower median time to first symptoms of PML. Posttransplantation PML has a higher case fatality and may have a higher incidence than reported in human immunodeficiency virus (HIV) patients on highly-active antiretroviral therapy (HAART) or multiple sclerosis patients treated with natalizumab.
    Annals of Neurology 08/2011; 70(2):305-22. · 11.19 Impact Factor
  • RajaNandini Muralidharan, Alejandro A Rabinstein, Eelco F M Wijdicks
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    ABSTRACT: To demonstrate a rare but potential mechanism of quadriplegia in a patient with fulminant pneumococcal meningitis complicated by severe intracranial hypertension. Case report. Intensive care unit. A 21-year-old man who presented with 3 days of headache, combativeness, and fever. Antibiotics and steroids were initiated after lumbar puncture yielded purulent cerebrospinal fluid and streptococcus pneumoniae. The patient's course was complicated by severe cerebral edema necessitating intracranial pressure monitoring and intracranial pressure-targeted therapy. Within 5 days he developed quadriplegia and areflexia. Brain and cervical spine magnetic resonance imaging revealed patchy areas of T2 signal hyperintensity with associated gadolinium enhancement in the superior cervical spinal cord, cerebellar tonsils, and medulla. Quadriplegia secondary to tonsillar herniation in fulminant meningitis is rare but should be considered in patients with acute quadriparesis after treatment of increased intracranial pressure. Magnetic resonance imaging signal changes and gadolinium enhancement may be demonstrated. Significant improvement of cord symptoms can be expected.
    Archives of neurology 04/2011; 68(4):513-6. · 7.58 Impact Factor
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    ABSTRACT: To identify a reliable method of performing apnea testing as part of brain death determination in adult patients who develop loss of brainstem reflexes while receiving extracorporeal membrane oxygenation (ECMO). ECMO provides extracirculatory support to patients in cardiorespiratory failure who would otherwise be expected to die. Many studies have reported brain death as a potential complication of adult ECMO, but none have cited how apnea testing was performed in these patients. This retrospective review identified adults 15 years or older treated with ECMO at our institution (2002-2010) and the method of determination of brain death when complete loss of brainstem reflexes occurred. Loss of all brainstem reflexes was identified in three cases (3/87, 3.4%). The apnea test was not performed since it was deemed "difficult," leading to withdrawal of ECMO and intensive care. Ancillary tests such as cerebral flow studies were not used because they may not document absent cerebral arterial flow due to the ischemic nature of the injury. We propose the use of an oxygenated apnea test on ECMO using continuous positive airway pressure (CPAP) through the ventilator or anesthesia bag, with an inline manometer and an end tidal CO(2) device. Apnea testing is essential in the determination of brain death, but may not be employed in ECMO-treated adult patients. Apnea testing using the above protocol may assist in better decision making for adult ECMO patients at risk of brain death.
    Neurocritical Care 02/2011; 14(3):423-6. · 3.04 Impact Factor
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    ABSTRACT: Retrospective consecutive case series. To assess the symptoms, neurologic signs, and radiologic findings in a large series of patients with myelopathy due to spinal dural arteriovenous fistula (SDAVF). The clinical diagnosis of SDAVF is difficult because presenting symptoms and signs can be similar to those seen with spinal canal stenosis or peripheral nerve or root disorders. We reviewed 153 consecutive patients with SDAVF treated surgically at our institution between 1985 and 2008. Before surgery, all patients had detailed neurologic examination, 147 patients had spinal magnetic resonance imaging (MRI) and all but one, had spinal angiography. We evaluated associations between symptoms, physical signs, spinal cord T2 signal abnormality on MRI, and fistula level on angiogram. Mean age was 63.5 years and 119 (77.8%) were men. Weakness and sensory changes are usually symmetric and ascend from the lower extremities. Presenting symptoms included leg weakness (74 patients, 48.4%), leg sensory disturbances (41 patients, 26.8%), pain involving back or legs (31 patients, 20.3%), and sphincter disturbances (6 patients, 3.9%). Worsening weakness with exertion was present in 66 (43.1%) patients and correlated with thoracic fistula location (P=0.04). Pinprick level was identified in 57 (37.3%) patients; L1 level (22.8%) was the most common, followed by T10 (19.3%). Fistula level (±2 levels) corresponded to pinprick level in only 40% of these patients. T2 signal abnormality involved the conus in 95% of our patients. Highest cord level of T2 signal hyperintensity (±2 levels) corresponded to pinprick level in 25% of cases. Leg weakness exacerbated by exercise, likely due to worsening hypertension in the arterialized draining vein, is a common manifestation of thoracic SDAVF. Although a sensory level is often found, it cannot reliably guide the level of imaging. Thus, the entire spine should be examined with MRI when an SDAVF is suspected.
    Spine 02/2011; 36(25):E1641-7. · 2.16 Impact Factor
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    ABSTRACT: OBJECTIVE: Transplant recipients are at risk of developing progressive multifocal leukoencephalopathy (PML), a rare demyelinating disorder caused by oligodendrocyte destruction by JC virus. METHODS: Reports of PML following transplantation were found using PubMed Entrez (1958-July 2010). A multicenter, retrospective cohort study also identified all cases of PML among transplant recipients diagnosed at Mayo Clinic, Johns Hopkins University, Washington University, and Amsterdam Academic Medical Center. At 1 institution, the incidence of posttransplantation PML was calculated. RESULTS: A total of 69 cases (44 solid organ, 25 bone marrow) of posttransplantation PML were found including 15 from the 4 medical centers and another 54 from the literature. The median time to development of first symptoms of PML following transplantation was longer in solid organ vs bone marrow recipients (27 vs 11 months, p = 0.0005, range of <1 to >240). Median survival following symptom onset was 6.4 months in solid organ vs 1
    Ann.Neurol. 70(2):305-322.

Publication Stats

117 Citations
54.37 Total Impact Points

Institutions

  • 2013
    • University of Pennsylvania
      • Department of Neurology
      Philadelphia, Pennsylvania, United States
  • 2011–2013
    • Mayo Clinic - Rochester
      • Department of Neurology
      Rochester, Minnesota, United States
    • Mayo Foundation for Medical Education and Research
      • Department of Neurology
      Scottsdale, AZ, United States