Objectives:
To present a patient with acute hemorrhagic leukoencephalitis (AHLE) and a systematic review of the literature analyzing diagnostic procedures, treatment, and outcomes of AHLE.
Methods:
...PubMed and Cochrane databases were screened. Papers published since 01/01/2000 describing adult patients are reported according to the PRISMA-guidelines.
Results:
A 59-year old male with rapidly developing coma and cerebral biopsy changes compatible with AHLE is presented followed by 43 case reports from the literature including males in 67% and a mean age of 38 years. Mortality was 47%. Infectious pathogens were reported in 35%, preexisting autoimmune diseases were identified in 12%. Neuroimaging revealed uni- or bihemispheric lesions in 65% and isolated lesions of the cerebellum, pons, medulla oblongata or the spinal cord without concomitant hemispheric involvement in 16%. Analysis of the cerebrospinal fluid showed an increased protein level in 87%, elevated white blood cells in 65%, and erythrocytes in 39%. Histology (reported in 58%) supported the diagnosis of AHLE in all cases. Glucocorticoids were used most commonly (97%), followed by plasmapheresis (26%), and intravenous immunoglobulins (12%), without a clear temporal relationship between treatment and the patients' clinical course.
Conclusions:
Although mortality was lower than previously reported, AHLE remains a life-threatening neurologic emergency with high mortality. Diagnosis is challenging as the level of evidence regarding the diagnostic yield of clinical, neuroimaging and laboratory characteristics remains low. Hence, clinicians are urged to heighten their awareness and to prompt cerebral biopsies in the context of rapidly progressive neurologic decline of unknown origin with the concurrence of the compiled characteristics. Future studies need to focus on treatment characteristics and their effects on course and outcome.
Objective
Information about rivaroxaban plasma level (RivLev) may guide treatment decisions in patients with acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH) taking rivaroxaban.
Methods
...In a multicenter registry‐based study (Novel Oral Anticoagulants in Stroke Patients collaboration; ClinicalTrials.gov: NCT02353585) of patients with stroke while taking rivaroxaban, we compared RivLev in patients with AIS and ICH. We determined how many AIS patients had RivLev ≤ 100ng/ml, indicating possible eligibility for thrombolysis, and how many ICH patients had RivLev ≥ 75ng/ml, making them possibly eligible for the use of specific reversal agents. We explored factors associated with RivLev (Spearman correlation, regression models) and studied the sensitivity and specificity of international normalized ratio (INR) thresholds to substitute RivLev using cross tables and receiver operating characteristic curves.
Results
Among 241 patients (median age = 80 years, interquartile range IQR = 73–84; median time from onset to admission = 2 hours, IQR = 1–4.5 hours; median RivLev = 89ng/ml, IQR = 31–194), 190 had AIS and 51 had ICH. RivLev was similar in AIS patients (82ng/ml, IQR = 30–202) and ICH patients (102ng/ml, IQR = 51–165; p = 0.24). Trough RivLev(≤137ng/ml) occurred in 126/190 (66.3%) AIS and 34/51 (66.7%) ICH patients. Among AIS patients, 108/190 (56.8%) had RivLev ≤ 100ng/ml. In ICH patients, 33/51 (64.7%) had RivLev ≥ 75ng/ml. RivLev was associated with rivaroxaban dosage, and inversely with renal function and time since last intake (each p < 0.05). INR ≤ 1.0 had a specificity of 98.9% and a sensitivity of 25.7% to predict RivLev ≤ 100ng/ml. INR ≥ 1.4 had a sensitivity of 59.3% and specificity of 90.1% to predict RivLev ≥ 75ng/ml.
Interpretation
RivLev did not differ between patients with AIS and ICH. Half of the patients with AIS under rivaroxaban had a RivLev low enough to consider thrombolysis. In ICH patients, two‐thirds had a RivLev high enough to meet the eligibility for the use of a specific reversal agent. INR thresholds perform poorly to inform treatment decisions in individual patients. Ann Neurol 2018;83:451–459
Background
Most case series of patients with ischemic stroke (IS) and COVID‐19 are limited to selected centers or lack 3‐month outcomes. The aim of this study was to describe the frequency, clinical ...and radiological features, and 3‐month outcomes of patients with IS and COVID‐19 in a nationwide stroke registry.
Methods
From the Swiss Stroke Registry (SSR), we included all consecutive IS patients ≥18 years admitted to Swiss Stroke Centers or Stroke Units during the first wave of COVID‐19 (25 February to 8 June 2020). We compared baseline features, etiology, and 3‐month outcome of SARS‐CoV‐2 polymerase chain reaction‐positive (PCR+) IS patients to SARS‐CoV‐2 PCR− and/or asymptomatic non‐tested IS patients.
Results
Of the 2341 IS patients registered in the SSR during the study period, 36 (1.5%) had confirmed COVID‐19 infection, of which 33 were within 1 month before or after stroke onset. In multivariate analysis, COVID+ patients had more lesions in multiple vascular territories (OR 2.35, 95% CI 1.08–5.14, p = 0.032) and fewer cryptogenic strokes (OR 0.37, 95% CI 0.14–0.99, p = 0.049). COVID‐19 was judged the likely principal cause of stroke in 8 patients (24%), a contributing/triggering factor in 12 (36%), and likely not contributing to stroke in 13 patients (40%).
There was a strong trend towards worse functional outcome in COVID+ patients after propensity score (PS) adjustment for age, stroke severity, and revascularization treatments (PS‐adjusted common OR for shift towards higher modified Rankin Scale (mRS) = 1.85, 95% CI 0.96–3.58, p = 0.07).
Conclusions
In this nationwide analysis of consecutive ischemic strokes, concomitant COVID‐19 was relatively rare. COVID+ patients more often had multi‐territory stroke and less often cryptogenic stroke, and their 3‐month functional outcome tended to be worse.
In a nationwide Swiss analysis of consecutive ischemic strokes, concomitant COVID‐19 was relatively rare. COVID+ patients more often had multi‐territory stroke and less often cryptogenic stroke, and their 3‐month functional outcome tended to be worse.
Since their market approval, direct oral anticoagulants (DOACs) are being increasingly used for stroke prevention in patients with atrial fibrillation. However, the management of DOAC-treated ...patients with stroke poses several challenges for physicians in everyday clinical practice, both in the acute setting and in long-term care. This has spurred extensive research activity in the field over the past few years, which we review here.
Adverse events (AEs)-healthcare caused events leading to patient harm or even death-are common in healthcare. Although it is a frequently investigated topic, systematic knowledge on this phenomenon ...in stroke patients is limited. To determine cumulative incidence of no-harm incidents and AEs, including their severity and preventability, a cohort study using trigger tool methodology for retrospective record review was designed. The study was carried out in a stroke center at a university hospital in the German speaking part of Switzerland. Electronic records from 150 randomly selected patient admissions for transient ischemic attack (TIA) or ischemic stroke, with or without acute recanalization therapy, were used. In total, 170 events (108 AEs and 62 no-harm incidents) were identified, affecting 83 patients (55.3%; 95% CI 47 to 63.4), corresponding to an event rate of 113 events/100 admissions or 142 events/1000 patient days. The three most frequent AEs were ischemic strokes (
= 12, 7.1%), urinary tract infections (
= 11, 6.5%) and phlebitis (
= 10, 5.9%). The most frequent no-harm incidents were medication events (
= 37, 21.8%). Preventability ranged from 12.5% for allergic reactions to 100% for medication events and pressure ulcers. Most of the events found (142; 83.5%; 95% CI 76.9 to 88.6) occurred throughout the whole stroke care. The remaining 28 events (16.5%; 95% CI 11.4 to 23.1) were detected during stroke care but were related to care outside the stroke pathway. Trigger tool methodology allows detection of AEs and no-harm incidents, showing a frequent occurrence of both event types in stroke and TIA patients. Further investigations into events' relationships with organizational systems and processes will be needed, first to achieve a better understanding of these events' underlying mechanisms and risk factors, then to determine efforts needed to improve patient safety.
Summary
Objectives
Periodic social events may influence the incidence and course of status epilepticus (SE), likely explained by patients’ behavioral changes regarding alcohol intake, sleep, and ...compliance with antiseizure medication. However, data regarding the association between such events and SE are lacking. The aim of this study was to identify and quantify associations between periodic social events and the incidence, etiology, and outcome of SE.
Methods
Adult patients who were admitted to a tertiary academic medical care center with SE from 2005 to 2015 were included. Associations between periodic social events (including birthday, Christmas, New Year's Eve, carnival, national holiday) and the number and etiologies of SE over time were calculated using linear and Poisson regression. Logistic regression was applied to identify associations between time from social events and outcome.
Results
Four hundred nine patients with a median age of 66 years (interquartile range 52‐76) were analyzed. The number of total SE events and SE in patients with known epilepsy peaked within 2 weeks following social events and then decreased with each additional day (incidence rate ratio IRRper day 0.99, 95% confidence interval CI 0.98‐0.99; P < .001 and IRRper day 0.99, 95% CI 0.98‐0.99; P < .001, respectively) and week (IRRper week 0.94, 95% CI 0.93‐0.95; P < .001 and IRRper week 0.94, 95% CI 0.92‐0.96; P < .001, respectively). The highest proportion of epilepsy patients not taking antiseizure medication was seen closest to social events and decreased thereafter (IRRper day 0.99, 95% CI 0.98‐0.99; P = .003). There was no association between time from social events and outcome.
Significance
Our findings support the hypothesis that periodic social events in adults may be associated with an increase in SE and should heighten awareness for SE in this context. Clinicians are urged to inform epilepsy patients regarding this association and to instruct them on preventive measures around such events.
Lipoprotein (a) Lp(a) serum levels are highly genetically determined and promote atherogenesis. High Lp(a) levels are associated with increased cardiovascular morbidity. Serum Lp(a) levels have ...recently been associated with large artery atherosclerosis (LAA) stroke. We aimed to externally validate this association in an independent cohort.
This study stems from the prospective multicentre CoRisk study (CoPeptin for Risk Stratification in Acute Stroke patients NCT00878813), conducted at the University Hospital Bern, Switzerland, between 2009 and 2011, in which Lp(a) plasma levels were measured within the first 24 hours after stroke onset. We assessed the association of Lp(a) with LAA stroke using multivariable logistic regression and performed interaction analyses to identify potential effect modifiers.
Of 743 patients with ischaemic stroke, 105 (14%) had LAA stroke aetiology. Lp(a) levels were higher for LAA stroke than non-LAA stroke patients (23.0 nmol/l vs 16.3 nmol/l, p = 0.01). Multivariable regression revealed an independent association of log10and#xA0;Lp(a) with LAA stroke aetiology (aOR 1.47 95% CI 1.03and#x2013;2.09, p = 0.03). The interaction analyses showed that Lp(a) was not associated with LAA stroke aetiology among patients with diabetes.
In a well-characterised cohort of patients with ischaemic stroke, we validated the association of higher Lp(a) levels with LAA stroke aetiology, independent of traditional cardiovascular risk factors. These findings may inform randomised clinical trials investigating the effect of Lp(a) lowering agents on cardiovascular outcomes. The CoRisk (CoPeptin for Risk Stratification in Acute Patients) study is registered on ClinicalTrials.gov.
NCT00878813.
Inflammation is an established pathway in the formation, growth, and rupture of atherosclerotic plaques. Inflammation is thus essential to the pathogenesis of coronary heart disease and some types of ...ischemic stroke.
The benefit of anti-inflammatory therapies, such as colchicine
and the anti-IL1β canakinumab,
is proven in patients with coronary heart disease, yet it remains unproven for patients with ischemic stroke. Compared with coronary heart disease, the etiology of stroke is more heterogeneous. Besides arterio-arterial atherogenic embolism, possible etiologies are penetrator artery occlusion, cardioembolism, and other mechanisms. Finding a stroke etiology remains elusive in up to 30%-40% of patients despite a full evaluation. Understanding whether the stroke etiology modifies the association between inflammatory markers and recurrence risk is an important step to improve selection of patients for randomized trials on anti-inflammatory agents. IL-6 and high-sensitive CRP (hs-CRP) have been implicated in a higher recurrence risk after ischemic stroke by both an individual participant data meta-analysis
and a Mendelian randomization study,
but granular, in vivo results stratified by stroke etiology are lacking.
Standard operating procedures (SOP) incorporating plasma levels of rivaroxaban might be helpful in selecting patients with acute ischemic stroke taking rivaroxaban suitable for IVthrombolysis (IVT) ...or endovascular treatment (EVT).
This was a single-center explorative analysis using data from the Novel-Oral-Anticoagulants-in-Stroke-Patients-registry (clinicaltrials.gov:NCT02353585) including acute stroke patients taking rivaroxaban (September 2012 to November 2016). The SOP included recommendation, consideration, and avoidance of IVT if rivaroxaban plasma levels were <20 ng/mL, 20‒100 ng/mL, and >100 ng/mL, respectively, measured with a calibrated anti-factor Xa assay. Patients with intracranial artery occlusion were recommended IVT+EVT or EVT alone if plasma levels were ≤100 ng/mL or >100 ng/mL, respectively. We evaluated the frequency of IVT/EVT, door-to-needle-time (DNT), and symptomatic intracranial or major extracranial hemorrhage.
Among 114 acute stroke patients taking rivaroxaban, 68 were otherwise eligible for IVT/EVT of whom 63 had plasma levels measured (median age 81 years, median baseline National Institutes of Health Stroke Scale 6). Median rivaroxaban plasma level was 96 ng/mL (inter quartile range IQR 18‒259 ng/mL) and time since last intake 11 hours (IQR 4.5‒18.5 hours). Twenty-two patients (35%) received IVT/EVT (IVT n=15, IVT+EVT n=3, EVT n=4) based on SOP. Median DNT was 37 (IQR 30‒60) minutes. None of the 31 patients with plasma levels >100 ng/mL received IVT. Among 14 patients with plasma levels ≤100 ng/mL, the main reason to withhold IVT was minor stroke (n=10). No symptomatic intracranial or major extracranial bleeding occurred after treatment.
Determination of rivaroxaban plasma levels enabled IVT or EVT in one-third of patients taking rivaroxaban who would otherwise be ineligible for acute treatment. The absence of major bleeding in our pilot series justifies future studies of this approach.
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