Clinical Study Influence of Fever and Hospital-Acquired Infection on the Incidence of Delayed Neurological Deficit and Poor Outcome after Aneurysmal Subarachnoid Hemorrhage

Although fever and infection have been implicated in the causation of delayed neurological deficits (DND) and poor outcome after aneurysmal subarachnoid hemorrhage (SAH), the relationship between these two often related events has not been extensively studied. We reviewed these events through of our retrospective database of patients with SAH. Multivariate logistic regression was used to determine independent predictors of DND and poor outcome. A total of 186 patients were analyzed. DND was noted in 76 patients (45%). Fever was recorded in 102 patients (55%); infection was noted in 87 patients (47%). A patient with one infection was more likely to experience DND compared to a patient with no infections (adjusted OR 3.73, 95% CI 1.62, 8.59). For those with more than two infections the likelihood of DND was even greater (adjusted OR 4.24, 95% CI 1.55, 11.56). Patients with 1-2 days of fever were less likely to have a favorable outcome when compared to their counterparts with no fever (adjusted OR 0.19, 95% CI 0.06, 0.62). This trend worsened as the number of days febrile increased. These data suggest that the presence of infection is associated with DND, but that fever may have a stronger independent association with overall outcome

EFFECTS OF TOBACCO DOSE AND LENGTH OF EXPOSURE ON DELAYED NEUROLOGICAL DETERIORATION AND OVERALL CLINICAL OUTCOME AFTER ANEURYSMAL SUBARACHNOID HEMORRHAGE

Abstract OBJECTIVE The association between smoking and intracranial aneurysms is now well recognized. However, the relationship between tobacco use and outcome after aneurysmal subarachnoid hemorrhage (SAH) is not as well understood and published results are contradictory. The purpose of this study is to examine the degree to which the amount of tobacco exposure/dose impacts delayed neurological deterioration and overall clinical outcome after aneurysmal SAH. METHODS We reviewed our retrospective database of patients with aneurysmal SAH. We assessed the impact of four independent tobacco variables: smoker (ever smoked), current smoker (actively smoking within the past yr and with at least a 10 pack per yr history of smoking), long-term smoker (at least a 20 pack per yr history), and salient (combination of current and long-term) smoker as well as tobacco dose (categorized according to number of packs per yr) on two outcome variables, delayed neurological deterioration and dichotomized Glasgow Outcome Scale score. Covariates included in the analysis were age, sex, Hunt and Hess grade, Fisher grade, and medical comorbidities. Stepwise elimination with logistic regression was used to arrive at a final multivariate model for each outcome and independent tobacco variable in the presence of covariates. RESULTS A total of 320 patients were analyzed. As expected, Hunt and Hess grade was a significant predictor of both delayed neurological deterioration and clinical outcome. Tobacco use (smoker variable) showed an independent association with the development of delayed neurological deterioration (P = 0.0409; odds ratio, 1.78; 95% confidence interval, 1.02–3.08). In addition, patients who were long-term or current smokers (salient smoker variable) showed a trend toward a slightly stronger association with the occurrence of delayed neurological deterioration (P = 0.0229; odds ratio, 1.85; 95% confidence interval, 1.09–3.14). No tobacco use variable was associated with clinical outcome (Glasgow Outcome Scale) in the multivariate analysis. CONCLUSION The duration and timing of tobacco use, rather than the dose of tobacco per se, seem to be risk factors for delayed neurological deterioration after aneurysmal SAH. Although we did not find an association between tobacco use and overall clinical outcome after aneurysmal SAH, these results suggest that the distribution of various patterns of tobacco use within a given data set may influence the overall results

Intra-Arterial Lidocaine Blunts the Trigeminocardiac Reflex during Endovascular Treatment of a Carotid-Cavernous Fistula

Carotid-cavernous fistulas (CCFs) are vascular shunts that allow blood to flow from the carotid artery or its branches into the cavernous sinus. Endovascular embolization is the treatment modality of choice. The trigeminocardiac reflex (TCR) is a vagally mediated reflex that can lead to hemodynamic instability. It can be activated during embolization procedures due to the proximity of vagal efferent neurovascular structures within the cavernous sinus. This case report describes the intraoperative management of recurrent, profound bradycardia due to TCR during endovascular CCF embolization

Influence of Fever and Hospital-Acquired Infection on the Incidence of Delayed Neurological Deficit and Poor Outcome after Aneurysmal Subarachnoid Hemorrhage

Although fever and infection have been implicated in the causation of delayed neurological deficits (DND) and poor outcome after aneurysmal subarachnoid hemorrhage (SAH), the relationship between these two often related events has not been extensively studied. We reviewed these events through of our retrospective database of patients with SAH. Multivariate logistic regression was used to determine independent predictors of DND and poor outcome. A total of 186 patients were analyzed. DND was noted in 76 patients (45%). Fever was recorded in 102 patients (55%); infection was noted in 87 patients (47%). A patient with one infection was more likely to experience DND compared to a patient with no infections (adjusted OR 3.73, 95% CI 1.62, 8.59). For those with more than two infections the likelihood of DND was even greater (adjusted OR 4.24, 95% CI 1.55, 11.56). Patients with 1-2 days of fever were less likely to have a favorable outcome when compared to their counterparts with no fever (adjusted OR 0.19, 95% CI 0.06, 0.62). This trend worsened as the number of days febrile increased. These data suggest that the presence of infection is associated with DND, but that fever may have a stronger independent association with overall outcome

Impact of COVID-19 Pandemic on the Incidence, Prehospital Evaluation, and Presentation of Ischemic Stroke at a Nonurban Comprehensive Stroke Center

Introduction. Many reports have described a decrease in the numbers of patients seeking medical attention for typical emergencies during the COVID-19 pandemic. These reports primarily relate to urban areas with widespread community transmission. The impact of COVID-19 on nonurban areas with minimal community transmission is less well understood. Methods. Using a prospectively maintained prehospital quality improvement database, we reviewed our hospital EMS transports with a diagnosis of stroke from January to April 2019 (baseline) and January to April 2020 (pandemic). We compared the volume of patients, transport/presentation times, severity of presenting symptoms, and final diagnosis. Results. In January, February, March, and April 2019, 10, 11, 17, and 19 patients, respectively, were transported in comparison to 19, 14, 10, and 8 during the same months in 2020. From January through April 2019, there was a 53% increase in transports, compared to a 42% decrease during the same months in 2020, constituting significantly different trend-line slopes (3.30; 95% CI 0.48–6.12 versus -3.70; 95% CI -5.76–-1.64, p=0.001). Patient demographics, comorbidities, and symptom severity were mostly similar over the two time periods, and the number of patients with a final diagnosis of stroke was also similar. However, the median interval from EMS dispatch to ED arrival for patients with a final diagnosis of stroke was significantly longer in January to April 2020 (50±11.7 min) compared to the same time period in 2019 (42±8.2 min, p=0.01). Discussion/Conclusion. Our data indicate a decrease in patient transport volumes and longer intervals to EMS activation for suspected stroke care. These results suggest that even in a nonurban location without widespread community transmission, patients may be delaying or avoiding care for severe illnesses such as stroke. Clinicians and public health officials should not ignore the potential impact of pandemic-like illnesses even in areas of relatively low disease prevalence

Variation in Carotid Artery Stenosis Measurements Among Facilities Seeking Carotid Stenting Facility Accreditation.

BACKGROUND: Based on the inclusion criteria of clinical trials, the degree of cervical carotid artery stenosis is often used as an indication for stent placement in the setting of extracranial carotid atherosclerotic disease. However, the rigor and consistency with which stenosis is measured outside of clinical trials are unclear. In an agreement study using a cross-sectional sample, we compared the percent stenosis as measured by real-world physician operators to that measured by independent expert reviewers. METHODS: As part of the carotid stenting facility accreditation review, images were obtained from 68 cases of patients who underwent carotid stent placement. Data collected included demographics, stroke severity measures, and the documented degree of stenosis, termed operator-reported stenosis (ORS), by 34 operators from 14 clinical sites. The ORS was compared with reviewer-measured stenosis (RMS) as assessed by 5 clinicians experienced in treating carotid artery disease. RESULTS: The median ORS was 90.0% (interquartile range, 80.0%-90.0%) versus a median RMS of 61.1% (interquartile range, 49.8%-73.6%), with a median difference of 21.8% (interquartile range, 13.7%-34.4%), CONCLUSIONS: Real-world operators tend to overestimate carotid artery stenosis compared with external expert reviewers. Measurements from facilities granted initial accreditation were closer to expert measurements than those from facilities whose accreditation was delayed. Since decisions regarding carotid revascularization are often based on percent stenosis, such measuring discrepancies likely lead to increased procedural utilization