Best Practices in Stroke Quality Improvement

https://scholarlycommons.henryford.com/detstrokeconf2019/1006/thumbnail.jp

Impact of the COVID-19 Pandemic on Acute Stroke Care, Time Metrics, Outcomes, and Racial Disparities in a Southeast Michigan Health System

BACKGROUND: COVID-19 has impacted acute stroke care with several reports showing worldwide drops in stroke caseload during the pandemic. We studied the impact of COVID-19 on acute stroke care in our health system serving Southeast Michigan as we rolled out a policy to limit admissions and transfers. METHODS: in this retrospective study conducted at two stroke centers, we included consecutive patients presenting to the ED for whom a stroke alert was activated during the period extending from 3/20/20 to 5/20/20 and a similar period in 2019. We compared demographics, time metrics, and discharge outcomes between the two groups. RESULTS: of 385 patients presented to the ED during the two time periods, 58% were African American. There was a significant decrease in the number of stroke patients presenting to the ED and admitted to the hospital between the two periods (p \u3c0.001). In 2020, patients had higher presenting NIHSS (median: 2 vs 5, p = 0.012), discharge NIHSS (median: 2 vs 3, p = 0.004), and longer times from LKW to ED arrival (4.8 vs 9.4 h, p = 0.031) and stroke team activation (median: 10 vs 15 min, p = 0.006). In 2020, stroke mimics rates were lower among African Americans. There were fewer hospitalizations (p \u3c0.001), and transfers from outside facilities (p = 0.015). CONCLUSION: a trend toward faster stroke care in the ED was observed during the pandemic along with dramatically reduced numbers of ED visits, hospitalizations and stroke mimics. Delayed ED presentations and higher stroke severity characterized the African American population, highlighting deepening of racial disparities during the pandemic

Rituximab for prevention of strokes in cerebral rheumatoid vasculitis

Rheumatoid arthritis (RA) is an autoimmune disorder which manifests as inflammation of the synovial joints alongside extra-articular involvement. Uncommonly, patients may develop vasculitis of small and medium-sized blood vessels, formally diagnosed as systemic rheumatoid vasculitis (SRV). In particularly rare cases, patients may develop a subtype of SRV known as cerebral rheumatoid vasculitis (CRV) which manifests in patients as stroke. To date, no formal recommendations or guidelines have been established for treatment and prevention of CRV-induced stroke besides experiential therapy with various immunomodulators. Here, we describe the utility of Rituximab in addition to steroids for prevention of stroke in our patient with evidence of multiple CRV-induced strokes with excellent recovery of post-stroke symptoms and remission of new onset cerebral vasculitis processes

What to Look for on Post-stroke Neuroimaging

The most feared complication after acute ischemic stroke is symptomatic or asymptomatic hemorrhagic conversion. Neuroimaging and clinical criteria are used to predict development of hemorrhage. Seizures after acute ischemic stroke or stroke-like symptoms from seizures are not common but may lead to confusion in the peristroke period, especially if seizures are repetitive or evolve into status epilepticus, which could affect neuroimaging findings. Malignant infarction develops when cytotoxic edema is large enough to lead to herniation and death. Post-stroke neuroimaging prognosticators have been described and should be assessed early so that appropriate treatment is offered before herniation leads to additional tissue injury

Predictors of Prolonged Hospital Stay in Status Migrainosus

BACKGROUND: Patients with status migrainosus often need to be admitted due to the severity of their headaches. Their hospitalization is often prolonged due to poor headache control. Large sample studies looking into the factors associated with prolonged length of stay (pLOS) in status migrainosus are lacking. METHODS: We utilized the Nationwide Inpatient Sample database to identify 4325 patients with primary discharge diagnosis of status migrainosus. Length of inpatient stay (LOS) of more than 6 days (90th percentile of LOS) was defined as pLOS. Patient demographics, hospital characteristics, mood disorders, anxiety disorder, and common medical comorbidities were identified. Multivariable logistic regression was used to identify factors associated with pLOS. RESULTS: We found 402 patients with pLOS. Female gender, African American race, mood disorder, obesity, opioid abuse, congestive heart failure, and chronic renal failure were significant independent predictors of pLOS. Median inflation-adjusted cost of hospitalization was USD$3829 (interquartile range: 2419-5809). CONCLUSION: We were able to identify several factors associated with pLOS in status migrainosus. Most of the factors we found were similar to those known to increase the prevalence and severity of migraine in the general population. Knowledge of these factors may help physicians identify high-risk patients to institute early migraine abortive and prophylactic treatment in order to shorten the length of hospital stay

CSF Pressure Change in Relation to Opening Pressure and CSF Volume Removed

BACKGROUND AND PURPOSE: Idiopathic intracranial hypertension is a complex neurologic disorder resulting from increased intracranial pressure. Our aim was to determine whether a correlation exists between the CSF pressure-volume relationship, specifically the craniospinal elastance and pressure-volume index, in patients with idiopathic intracranial hypertension and whether opening pressure affects this relationship. MATERIALS AND METHODS: Lumbar punctures performed for suspected idiopathic intracranial hypertension from 2006 to 2017 were identified. Opening and closing pressures, CSF volume removed, and clinical diagnosis of idiopathic intracranial hypertension were obtained from the medical records. The craniospinal elastance (pressure change per milliliter of CSF removed) and pressure-volume index were calculated, and the Pearson correlation coefficients between both the craniospinal elastance and pressure-volume index and opening pressure were determined. Linear regression models of craniospinal elastance and the pressure-volume index and interaction terms with opening pressure were assessed for covariate influence on this association. RESULTS: One hundred sixteen patients were included in the final analysis. The mean craniospinal elastance according to opening pressure group was 0.52 ± 0.18 forH CONCLUSIONS: As opening pressure increases, the craniospinal elastance increases in a linear fashion while the pressure-volume index decreases. Further studies are needed to determine whether these changes relate to the underlying pathophysiology of idiopathic intracranial hypertension or simply represent established CSF volume pressure dynamics

Safety and Efficacy of Stent Retrievers for the Management of Acute Ischemic Stroke: Comprehensive Review and Meta-Analysis

OBJECTIVES: This study sought to evaluate the safety and efficacy of stent retriever for the management of acute ischemic stroke. BACKGROUND: Stroke is the third leading cause of death and the most common cause of disability in the United States. Early reperfusion has been associated with favorable outcomes. Stent retrievers are novel endovascular devices that provide vessel recanalization via thrombus retrieval mechanical thrombectomy. METHODS: The authors performed a literature search using PubMed, EMBASE, and Cochrane Central Register of Controlled Trials from May 2005 to May 2015. Randomized controlled trails (RCTs) comparing endovascular therapy (ET) with the use of retrievable stents against standard therapy (ST) for the management of acute stroke were included. RESULTS: Five RCTs (the MR CLEAN, ESCAPE, EXTEND-IA, SWIFT-PRIME, and REVASCAT studies) with 634 patients in the ET group and 653 patients in the ST group met inclusion criteria. The frequency of a low 90-day modified Rankin Score (0 to 2) in the intervention group was 42.6% compared with 26.1% in the control group (odds ratio: 2.43; 95% confidence interval [CI]: 1.9 to 3.09; p \u3c 0.0001). The frequency of intracranial bleeding was 4.2% in the ET group compared with 4.3% in the ST group (risk ratio: 1.08; 95% CI: 0.64 to 1.82; p = 0.78). 90-day mortality was 15.1% in the ET group compared with 18.7% in the ST group (risk ratio: 0.81; 95% CI: 0.58 to 1.12; p = 0.19). There was no evidence of significant heterogeneity or publication bias for any of the endpoints. CONCLUSIONS: On the basis of the results of this meta-analysis of RCTs, ET with stent retrievers appears as a safe and effective therapeutic option for acute ischemic stroke due to large vessel occlusion

CSF Pressure Change in Relation to Opening Pressure and CSF Volume Removed

BACKGROUND AND PURPOSE: Idiopathic intracranial hypertension is a complex neurologic disorder resulting from increased intracranial pressure. Our aim was to determine whether a correlation exists between the CSF pressure-volume relationship, specifically the craniospinal elastance and pressure-volume index, in patients with idiopathic intracranial hypertension and whether opening pressure affects this relationship. MATERIALS AND METHODS: Lumbar punctures performed for suspected idiopathic intracranial hypertension from 2006 to 2017 were identified. Opening and closing pressures, CSF volume removed, and clinical diagnosis of idiopathic intracranial hypertension were obtained from the medical records. The craniospinal elastance (pressure change per milliliter of CSF removed) and pressure-volume index were calculated, and the Pearson correlation coefficients between both the craniospinal elastance and pressure-volume index and opening pressure were determined. Linear regression models of craniospinal elastance and the pressure-volume index and interaction terms with opening pressure were assessed for covariate influence on this association. RESULTS: One hundred sixteen patients were included in the final analysis. The mean craniospinal elastance according to opening pressure group was 0.52 ± 0.18 for H2O, 0.57 ± 0.20 for 20-29 cm H2O, 0.91 ± 0.28 for 30-39 cm H2O, and 1.20 ± 0.25 for ≥40 cm H2O. There was a positive linear association between opening pressure and craniospinal elastance with a 0.28 cm H2O/mL increase in craniospinal elastance (standard error = 0.03, P \u3c .001) for every 10 cm H2O increase in opening pressure. Of the covariables analyzed, only age older than 50 years and total volume of CSF removed affected this association. CONCLUSIONS: As opening pressure increases, the craniospinal elastance increases in a linear fashion while the pressure-volume index decreases. Further studies are needed to determine whether these changes relate to the underlying pathophysiology of idiopathic intracranial hypertension or simply represent established CSF volume pressure dynamics

JC Virus Induced Longitudinally Extensive Transverse Myelitis in Immunocompromised Patient

Introduction: John Cunningham virus (JCV) is a human polyomavirus that causes a fatal demyelinating disease of the central nervous system (CNS) called progressive multifocal leukoencephalopathy (PML). Primary JCV infection usually occurs asymptomatically in childhood and may result in a chronic asymptomatic carrier state. It remains usually dormant in the kidneys, lympho-reticular system, or brain tissue. Seventy to ninty percent of adults are seropositive for the JC virus and the viral DNA is detected in the urine of 20%-30% of immunologically intact adults. Reactivation of JCV is seen commonly in the setting of HIV infection, hematologic malignancy, or iatrogenic immunosuppression due to failure of cellular immune surveillance to suppress viral replication. PML lesions are typically multifocal, non-contrast enhancing at the grey white matter junction, usually in the parietooccipital, peri-thalamic regions, cerebellum, and brain stem. We present an immunocompromised patient with PML induced longitudinally extensive transverse myelitis (LETM) and peripheral nerve root involvement. Case report: 62 years old male presented with progressive weakness and difficulty walking for less than a month. The patient was diagnosed with chronic lymphocytic leukemia in 2009. He was managed with monthly intravenous immunoglobulins, as he developed hypogammaglobinemia after only two sessions of chemotherapy with Fludarabine and Rituximab. He remained asymptomatic till August 2018, when he developed left leg weakness that rapidly extended to involve the right leg in a month. Shortly thereafter, he developed urinary and fecal incontinence and became bed ridden. His examination showed bilateral lower extremity hypotonia, absent deep tendon reflexes and prominent fasciculations. Cerebrospinal fluid (CSF )analysis showed 2 WBCs, negative IgG index, no oligoclonal bands, negative viral PCR for HSV 1 and 2, VZV, CMV, and West Nile, and no malignant cells. EMG showed evidence of demyelination and frequent fasciculations with no evidence of denervation. Magnetic resonance imaging (MRI) of the brain and spine showed non-enhancing T2 FLAIR hyper intense signal changes in the ponto-medullary junction and the spinal cord extending from T10 to the conus medullaris. Initial diagnosis was NMO spectrum disease and the patient was started on IV pulse steroids for 5 days, followed by a course of oral prednisone of 60 mg daily. However anti Aquaporin-4 and anti-MOG antibodies were not detected in the serum. His symptoms worsened rapidly, and the weakness extended to both of his upper extremities. Repeat MRI of the brain and spine showed severe progression of the T2/FLAIR hyperintense lesions to the posterior pons, medulla oblongata and entire spinal cord. All parenchymal lesions were non-contrast enhancing. The cauda and conus medullaris had tumefactive appearance. Repeated CSF analysis showed elevated protein of 93, 5 WBCs, negative cultures, and negative viral PCR for CMV, VZV, HSV 1 and 2, but JCV PCR was positive. Follow up EMG showed progression of the disease with evidence of wide spread radiculopathy and anterior horn cell involvement. Prednisone was gradually tapered off. His condition continued to deteriorate with involvement of respiratory and bulbar muscles. Given the extension of the disease and poor prognosis, the family withdrew care after 1 month of hospital stay and declined autopsy. Conclusion: PML is a fatal disease that should be suspected in immunosuppressed patients with rapid neurological decline. Typically, it affects the brain and the cerebellum, however it should be included in the differential diagnosis for patients LETM, particularly if the lesions are non-contrast enhancing. JCV PCR is moderately sensitive but highly specific as a useful tool for diagnosis, however biopsy is remains gold standard for diagnosis. While no effective treatment has been identified reconstitution of the immune state might suppress the viral replication.https://scholarlycommons.henryford.com/merf2019caserpt/1057/thumbnail.jp