Background
Our aim was to determine whether patients with embolic strokes of undetermined source (ESUS) have higher rates of elevated troponin than patients with noncardioembolic strokes.
Methods and ...Results
CAESAR (The Cornell Acute Stroke Academic Registry) prospectively enrolled all adults with acute stroke from 2011 to 2014. Two neurologists used standard definitions to retrospectively ascertain the etiology of stroke, with a third resolving disagreements. In this analysis we included patients with ESUS and, as controls, patients with small‐ and large‐artery strokes; only patients with a troponin measured within 24 hours of stroke onset were included. A troponin elevation was defined as a value exceeding our laboratory's upper limit (0.04 ng/mL) without a clinically recognized acute ST‐segment elevation myocardial infarction. Multiple logistic regression was used to evaluate the association between troponin elevation and ESUS after adjustment for demographics, stroke severity, insular infarction, and vascular risk factors. In a sensitivity analysis we excluded patients diagnosed with atrial fibrillation after discharge. Among 512 patients, 243 (47.5%) had ESUS, and 269 (52.5%) had small‐ or large‐artery stroke. In multivariable analysis an elevated troponin was independently associated with ESUS (odds ratio 3.3; 95% confidence interval 1.2, 8.8). This result was unchanged after excluding patients diagnosed with atrial fibrillation after discharge (odds ratio 3.4; 95% confidence interval 1.3, 9.1), and the association remained significant when troponin was considered a continuous variable (odds ratio for logtroponin, 1.4; 95% confidence interval 1.1, 1.7).
Conclusions
Elevations in cardiac troponin are more common in patients with ESUS than in those with noncardioembolic strokes.
Objective: We evaluated the ability of genetic and serological testing to diagnose clinically relevant thrombophilias in young adults with ischemic stroke. Methods: We performed a retrospective ...cohort study of patients aged 18-65 years diagnosed with acute ischemic stroke at a comprehensive stroke center between 2011 and 2015 with laboratory testing for thrombophilia. The primary outcome was any positive thrombophilia screening test. The secondary outcome was a change in clinical management based on thrombophilia testing results. Logistic regression was used to assess whether the prespecified risk factors of age, sex, prior venous thromboembolism, family history of stroke, stroke subtype, and presence of patent foramen ovale were associated with outcomes. Results: Among 196 young ischemic stroke patients, at least 1 positive thrombophilia test was identified in 85 patients (43%; 95% CI, 36%-51%) and 16 (8%; 95% CI, 5%-13%) had a resultant change in management. Among 111 patients with cryptogenic strokes, 49 (44%) had an abnormal thrombophilia test and 9 (8%) had a change in management. After excluding cases of isolated hyperhomocysteinemia or methylenetetrahydrofolate reductase or Factor V Leiden gene mutation heterozygosity, the proportion of patients with an abnormal thrombophilia screen decreased to 24%. Prespecified risk factors were not significantly associated with positive thrombophilia testing or a change in management. Conclusions: Two-of-five young patients with ischemic stroke who underwent thrombophilia screening at our institution had at least 1 positive test but only one-in-twelve had a resultant change in clinical management. Neither cryptogenic stroke subtype nor other studied clinical factors were associated with a prothrombotic state.
Cerebral vein thrombosis (CVT) is a type of venous thromboembolism. Whether the risk of pulmonary embolism (PE) after CVT is similar to the risk after deep venous thrombosis (DVT) is unknown.
We ...performed a retrospective cohort study using administrative data from all emergency department visits and hospitalizations in California, New York, and Florida from 2005 to 2013. We identified patients with CVT or DVT and the outcome of PE using previously validated
codes. Kaplan-Meier survival statistics and Cox proportional hazards models were used to compare the risk of PE after CVT versus PE after DVT.
We identified 4754 patients with CVT and 241 276 with DVT. During a mean follow-up of 3.4 (±2.4) years, 138 patients with CVT and 23 063 with DVT developed PE. CVT patients were younger, more often female, and had fewer risk factors for thromboembolism than patients with DVT. During the index hospitalization, the rate of PE was 1.4% (95% confidence interval CI, 1.1%-1.8%) in patients with CVT and 6.6% (95% CI, 6.5%-6.7%) in patients with DVT. By 5 years, the cumulative rate of PE after CVT was 3.4% (95% CI, 2.9%-4.0%) compared with 10.9% (95% CI, 10.8%-11.0%;
<0.001) after DVT. CVT was associated with a lower adjusted hazard of PE than DVT (hazard ratio, 0.26; 95% CI, 0.22-0.31).
The risk of PE after CVT was significantly lower than the risk after DVT. Among patients with CVT, the greatest risk for PE was during the index hospitalization.
Objective Because some cryptogenic strokes may result from large-artery atherosclerosis that goes unrecognized as it causes <50% luminal stenosis, we compared the prevalence of nonstenosing ...intracranial atherosclerotic plaques ipsilateral to cryptogenic cerebral infarcts versus the unaffected side using imaging biomarkers of calcium burden. Methods In a prospective stroke registry, we identified patients with cerebral infarction limited to the territory of one internal carotid artery (ICA). We included patients with stroke of undetermined etiology and, as controls, patients with cardioembolic stroke. We used noncontrast computed tomography to measure calcification in both intracranial ICAs, including qualitative calcium scoring and quantitative scoring utilizing the Agatston–Janowitz (AJ) calcium scoring. Within subjects, the Wilcoxon signed-rank sum test for nonparametric paired data was used to compare the calcium burden in the ICA upstream of the infarction versus the ICA on the unaffected side. Results We obtained 440 calcium measures from 110 ICAs in 55 patients. Among 34 patients with stroke of undetermined etiology, we found greater calcium in the ICA ipsilateral to the infarction (mean Modified Woodcock Visual Scale score, 6.7 ± 4.6) compared with the contralateral side (5.4 ± 4.1) ( P = .005). Among 21 patients with cardioembolic stroke, we found no difference in calcium burden ipsilateral to the infarction (6.7 ± 5.9) versus the contralateral side (7.3 ± 6.3) ( P = .13). The results were similar using quantitative calcium measurements, including the AJ calcium scores. Conclusion In patients with strokes of undetermined etiology, the burden of calcified intracranial large-artery plaque was associated with downstream cerebral infarction.
Although chronic hypertension is a well-established risk factor for stroke, little is known about stroke risk after hypertensive encephalopathy (HE), when neurologic sequelae of hypertension become ...evident. Therefore, we evaluated the risk of stroke after a diagnosis of HE.
We identified all patients discharged from California, New York, and Florida emergency departments and acute care hospitals between 2005 and 2012 with a primary International Classification of Diseases, Ninth Edition, Clinical Modification discharge diagnosis of HE (437.2). Patients discharged with a primary diagnosis of seizure (345.x) served as negative controls, whereas patients with a primary diagnosis of transient ischemic attack (435.x) were positive controls. Our primary outcome was the composite of subsequent ischemic stroke or intracerebral hemorrhage. Kaplan-Meier survival statistics were used to calculate cumulative outcome rates, and Cox proportional hazard analysis was used to examine the association between index disease types and outcomes while adjusting for vascular risk factors.
We identified 8233 patients with HE, 191 091 with seizure, and 308 680 with transient ischemic attack. The 1-year cumulative rate of ischemic stroke or intracerebral hemorrhage after HE was 4.90% (95% confidence interval CI, 4.45-5.40) when compared with 0.92% (95% CI, 0.88-0.97) after seizure and 4.49% (95% CI, 4.42-4.57) after transient ischemic attack. The risk of intracerebral hemorrhage was significantly elevated in those with HE (hazard ratio, 2.0; 95% CI, 1.7-2.5) but not in those with transient ischemic attack (hazard ratio, 1.0; 95% CI, 0.9-1.1), when compared with seizure patients.
Patients discharged with a diagnosis of HE face a high risk of future cerebrovascular events, particularly intracerebral hemorrhage.
Cardiac biomarkers may help identify stroke mechanisms and may aid in improving stroke prevention strategies. There is limited data on the association between these biomarkers and acute ischemic ...stroke (AIS) caused by large vessel occlusion (LVO). We hypothesized that cardiac biomarkers (cardiac troponin and left atrial diameter LAD) would be associated with the presence of LVO.
Data were abstracted from a single center prospective AIS database over 18 months and included all patients with AIS with CT angiography of the head and neck. The presence of LVO was defined as proximal LVO of the internal carotid artery terminus, middle cerebral artery (M1 or proximal M2), or basilar artery. Univariate analyses and predefined multivariable models were performed to determine the association between cardiac biomarkers (positive troponin troponin ≥0.1 ng/mL and LAD on transthoracic echocardiogram) and LVO adjusting for demographic factors (age and sex), risk factors (hypertension, diabetes, hyperlipidemia, history of stroke, congestive heart failure, coronary heart disease, and smoking), and atrial fibrillation (AF).
We identified 1234 patients admitted with AIS; 886 patients (71.8%) had vascular imaging to detect LVO. Of those with imaging available, 374 patients (42.2%) had LVO and 207 patients (23.4%) underwent thrombectomy. There was an association between positive troponin and LVO after adjusting for age, sex and other risk factors (adjusted OR 1.69 1.08-2.63, P = .022) and this association persisted after including AF in the model (adjusted OR 1.60 1.02-2.53, P = 0.043). There was an association between LAD and LVO after adjusting for age, sex, and risk factors (adjusted OR per mm 1.03 1.01-1.05, P = 0.013) but this association was not present when AF was added to the model (adjusted OR 1.01 0.99-1.04, P = .346). Sensitivity analyses using thrombectomy as an outcome yielded similar findings.
Cardiac biomarkers, particularly serum troponin levels, are associated with acute LVO in patients with ischemic stroke. Prospective studies are ongoing to confirm this association and to test whether anticoagulation reduces the risk of recurrent embolism in this patient population.
It is uncertain whether previous ischemic stroke within 3 months of receiving intravenous thrombolysis (tPA tissue-type plasminogen activator) for acute ischemic stroke (AIS) is associated with an ...increased risk of adverse outcomes.
Using administrative claims data, we identified adults with AIS who received intravenous tPA at California, New York, and Florida hospitals from 2005 to 2013. Our primary outcome was intracerebral hemorrhage, and our secondary outcomes were unfavorable discharge disposition and inpatient mortality. We used logistic regression to compare rates of outcomes in patients with and without previous ischemic stroke within 3 months of intravenous tPA for AIS.
We identified 36 599 AIS patients treated with intravenous tPA, of whom 568 (1.6%) had a previous ischemic stroke in the past 3 months. Of all patients who received intravenous tPA, the rate of intracerebral hemorrhage was 4.9% (95% confidence interval CI, 4.7%-5.1%), and death occurred in 10.7% (95% CI, 10.4%-11.0%). After adjusting for demographics, vascular risk factors, and the Elixhauser Comorbidity Index, previous ischemic stroke within 3 months of thrombolysis for AIS was not associated with an increased risk of intracerebral hemorrhage (odds ratio, 0.9; 95% CI, 0.6-1.4;
=0.62), but was associated with an increased risk of death (odds ratio, 1.5; 95% CI, 1.2-1.9;
=0.001) and unfavorable discharge disposition (odds ratio, 1.3; 95% CI, 1.0-1.7;
=0.04).
Among patients who receive intravenous tPA for AIS, recent ischemic stroke is not associated with an increased risk of intracerebral hemorrhage but is associated with a higher risk of death and unfavorable discharge disposition.
Background and Purpose- Transthoracic echocardiography (TTE) is widely used in the ischemic stroke setting. In this study, we aim to investigate the yield of TTE in patients with ischemic stroke and ...known subtype and whether the admission troponin level improves the yield of TTE. Methods- Data were abstracted from a single-center prospective ischemic stroke database for 18 months and included all patients with ischemic stroke whose etiologic subtype could be obtained without the need of TTE. Unadjusted and adjusted regression models were built to determine whether positive cardiac troponin levels (≥0.1 ng/mL) improve the yield of TTE, adjusting for demographic and clinical characteristics. Results- We identified 578 patients who met the inclusion criteria. TTE changed clinical management in 64 patients (11.1%), but intracardiac thrombus was detected in only 4 patients (0.7%). In multivariable models, there was an association between TTE changing management and positive serum troponin level (adjusted odds ratio, 4.26; 95% CI, 2.17-8.34; P<0.001). Conclusions- In patients with ischemic stroke, TTE might lead to a change in clinical management in ≈1 of 10 patients with known stroke subtype before TTE but changed acute treatment decisions in <1 percent of patients. Serum troponin levels improved the yield of TTE in these patients.
Abstract
Background
Mobile stroke units (MSUs) reduce time to thrombolytic therapy in acute ischemic stroke. These units are widely used, but the clinical information systems underlying MSU ...operations are understudied.
Objective
The first MSU on the East Coast of the United States was established at New York Presbyterian Hospital (NYP) in October 2016. We describe our program's 7-month pilot, focusing on the integration of our hospital's clinical information systems into our MSU to support patient care and research efforts.
Methods
NYP's MSU was staffed by two paramedics, one radiology technologist, and a vascular neurologist. The unit was equipped with four laptop computers and networking infrastructure enabling all staff to access the hospital intranet and clinical applications during operating hours. A telephone-based registration procedure registered patients from the field into our admit/discharge/transfer system, which interfaced with the institutional electronic health record (EHR). We developed and implemented a computerized physician order entry set in our EHR with prefilled values to permit quick ordering of medications, imaging, and laboratory testing. We also developed and implemented a structured clinician note to facilitate care documentation and clinical data extraction.
Results
Our MSU began operating on October 3, 2016. As of April 27, 2017, the MSU transported 49 patients, of whom 16 received tissue plasminogen activator (t-PA). Zero technical problems impacting patient care were reported around registration, order entry, or intranet access. Two onboard network failures occurred, resulting in computed tomography scanner malfunctions, although no patients became ineligible for time-sensitive treatment as a result. Thirteen (26.5%) clinical notes contained at least one incomplete time field.
Conclusion
The main technical challenges encountered during the integration of our hospital's clinical information systems into our MSU were onboard network failures and incomplete clinical documentation. Future studies are necessary to determine whether such integrative efforts improve MSU care quality, and which enhancements to information systems will optimize clinical care and research efforts.
Locked-in syndrome is defined as quadriplegia and anarthria with the preservation of consciousness. Typically, locked-in syndrome is caused by an insult to the ventral pons secondary to trauma or ...vascular disease. Presented herein is a case of a locked-in syndrome with an initial MRI with no restricted diffusion and clinical deterioration over the course of four days. Repeat interval MRI demonstrated bilateral pontine ischemia.
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