Friday, April 24, 2015
Wednesday, April 01, 2015
Sunday, March 29, 2015
Gensicke H1, Zinkstok SM, Roos YB, Seiffge DJ, Ringleb P, Artto V, Putaala J, Haapaniemi E, Leys D, Bordet R, Michel P, Odier C, Berrouschot J, Arnold M, Heldner MR, Zini A, Bigliardi G, Padjen V, Peters N, Pezzini A, Schindler C, Sarikaya H, Bonati LH, Tatlisumak T, Lyrer PA, Nederkoorn PJ, Engelter ST.
OBJECTIVE: To investigate the association of renal impairment on functional outcome and complications in stroke patients treated with IV thrombolysis (IVT).
METHODS: In this observational study, we compared the estimated glomerular filtration rate (GFR) with poor 3-month outcome (modified Rankin Scale scores 3-6), death, and symptomatic intracranial hemorrhage (sICH) based on the criteria of the European Cooperative Acute Stroke Study II trial. Unadjusted and adjusted odds ratios (ORs) with 95% confidence intervals (CIs) were calculated. Patients without IVT treatment served as a comparison group.
RESULTS: Among 4,780 IVT-treated patients, 1,217 (25.5%) had a low GFR (<60 mL/min/1.73 m(2)). A GFR decrease by 10 mL/min/1.73 m(2) increased the risk of poor outcome (OR [95% CI]): (ORunadjusted 1.20 [1.17-1.24]; ORadjusted 1.05 [1.01-1.09]), death (ORunadjusted 1.33 [1.28-1.38]; ORadjusted 1.18 [1.11-1.249]), and sICH (ORunadjusted 1.15 [1.01-1.22]; ORadjusted 1.11 [1.04-1.20]). Low GFR was independently associated with poor 3-month outcome (ORadjusted 1.32 [1.10-1.58]), death (ORadjusted 1.73 [1.39-2.14]), and sICH (ORadjusted 1.64 [1.21-2.23]) compared with normal GFR (60-120 mL/min/1.73 m(2)). Low GFR (ORadjusted 1.64 [1.21-2.23]) and stroke severity (ORadjusted 1.05 [1.03-1.07]) independently determined sICH. Compared with patients who did not receive IVT, treatment with IVT in patients with low GFR was associated with poor outcome (ORadjusted 1.79 [1.41-2.25]), and with favorable outcome in those with normal GFR (ORadjusted 0.77 [0.63-0.94]).
CONCLUSION: Renal function significantly modified outcome and complication rates in IVT-treated stroke patients. Lower GFR might be a better risk indicator for sICH than age. A decrease of GFR by 10 mL/min/1.73 m(2) seems to have a similar impact on the risk of death or sICH as a 1-point-higher NIH Stroke Scale score measuring stroke severity.
Thursday, March 26, 2015
Thursday, February 05, 2015
The Safety of Intravenous Thrombolysis for Ischemic Stroke in Patients With Pre-Existing Cerebral Aneurysms
A Case Series and Review of the Literature
- From the Department of Neurology (N.J.E., S.A.J.), University of California San Francisco, San Francisco, CA; and the Department of Neurology and Neuroscience (H.K.), Weill Cornell Medical College, New York, NY.
- Correspondence to Nancy J. Edwards, MD, University of California San Francisco, Neurovascular Service, 505 Parnassus Avenue, Box 0114, San Francisco, CA 94143-0114. E-mail firstname.lastname@example.org
Please note these are people who were incidentally found to have aneurysms on screening. There is no guideline to say that managing patients with tpa is safe or valid.
Tuesday, January 13, 2015
Sunday, December 07, 2014
Tuesday, December 02, 2014
No history of
cortical infarct 1
total score -- add sum of parts
cut score used in many articles is 7
source Neurology 2013 au Thaler
Variables associated with recurrence in highRoPE score group include history of stroke or TIA, hypermobile interatrial septum, and a small shunt, but not shunt at rest.
Sunday, November 30, 2014
2. Clinical: hemiparesis, hemianopia, cortical blindness; seizures, dementia, migraine, muscle weakness,
4. May be relapsing remitting
5. High lactic/abn muscle biopsy
6. AVOID statins and Depakote
Vision and memory loss
Onset in fourth decade
Death in five to ten years
Retinopathy is neovascularization of disc, retinal hemorrhage a and macular edema.
Half patients have tumor like lesion with cortical sparing resembling malignancy.
Small white matter lesions may resemble MS
Caused by mutations o. TREX1 gene
Inherited as aut dom
Retinopathy may respond to bevacizumab
2. Risk factors include age, female gender, family history
3. Risk of rupture in positive family history patients is 17 x higher than in predicted based on size and location in observational studies (Familial Intracranial Aneurysm study).
4. Associated diseases are Marfan syndrome, Ehler Danlos syndrome type IV, aortic coarctation, FMD, and autosomal dominant PCK (12.4 percent).
5. Modifiable risk factors for aneurysm growth include smoking, alcohol abuse and hypertension
6. MCA bifurcation aneurysms are more readily accessible to surgery.
2. Paroxysmal or stuttering episodes ppt by HV is typical for Moyà Moyà
3. In newborn, consider maternal factors (HTN, DM), perinatal factors, neonatal factors (congenital heart disease, dehydration, infection), and PLACENTAL vasculopathy
4. ACCP recommends against the use of altplace in pediatric stroke outside clinical trials
5. In Toronto, UFH is used for AIS regardless of mechanism
6. The syndrome of transient cerebral arteriopathy of childhood is a well defined unilateral focal arteriopathy presumably of inflammatory origin. Features include irregular stenosis at carotid T junction. Varicella angiopathy is similar and borrelia and bartonella are also reported. Treatment may include antithrombotics, high dose pulse steroids with long taper, and acyclovir. differential includes Moyà Moyà and dissection of the carotid.
2. The most common acquired thrombophilia is the apl syndrome
3. Seven percent of the white population carries the prothrombin gene mutation but it's rare in black and Asian populations
4. Inherited protein S deficiency autosomal dominant and heterozygous; homozygous is incompatible with life.
5. Protein C deficiency can be due to meningococcemia, liver disease, DIC, ARDS, methotrexate, 5FU, and cyclophosphamide.
Saturday, November 29, 2014
2. Mechanism: increases thrombin production
3. Prevalence varies widely by ethnicity: 5.3 percent in whites, 2.2 percent in Hispanics, 1.3 percent in native Americans, 1.2 percent in African Americans, 0.5 percent in Asian Americans.
4. Five to ten percent of heterozygous carriers in their lifetimes; a sevenfold risk over non carriers but homozygous have an 80 fold risk.
5. 90 to 95 percent of patients with protein C resistance have a point mutation of factor V506Q.
6. Other causes of increased protein C resistance include smoking, oral contraceptives, pregnancy, HRT use, cancer, and anti phospholipid syndrome
7. Syndrome is convincingly linked to venous but not arterial thrombotic events
8. Testing in nonwhite populations is low yield
9. Testing in ischemic stroke in absence of a right to left shunt is low yield
10. In presence of a right to left shunt screening for Dvt with leg ultrasound and pelvic venography is useful
Tuesday, November 25, 2014
Background/Aims: It has been questioned whether patients with unruptured intracranial aneurysms (IAs) are at a greater risk for the development of intracerebral hemorrhage (ICH) following thrombolytic therapy. We thus performed a meta-analysis to better quantify the risk of post-thrombolysis ICH in patients with acute ischemic stroke and incidental IAs. Methods: We searched PubMed, Web of Science and EMBASE for studies assessing ICH risk in patients with acute ischemic stroke treated with thrombolysis, in relation to the presence of pretreatment IAs. A fixed-effects model meta-analysis was performed. Results: We identified four studies totaling 707 participants receiving intravenous thrombolysis. The prevalence of unruptured IAs was 6.8%. Pooled analysis demonstrates relative risk (RR) for the presence of unruptured IAs and the development of any ICH to be 1.204 (95% CI 0.709-2.043; p = 0.492; I(2) = 0.0%). The RR for sICH is 1.645 (95% CI 0.453-5.970; p = 0.449; I(2) = 28.1%). Conclusion: Intravenous thrombolysis was safe among patients with acute ischemic stroke and incidental unruptured IAs. Future prospective studies with much larger sample sizes are required to clarify the significance of the association between pre-existing unruptured IAs and the development of post-thrombolysis ICH. © 2014 S. Karger AG, Basel.
Friday, November 14, 2014
Thursday, November 13, 2014
Monday, October 20, 2014
Odds ratio and population attributable risk of 10 factors estimated to acount for 90 % of ischemic stroke risk
Additional points for cardiac surgery-- evidence based
RISK OF HEMORRHAGE
Thursday, October 09, 2014
use of dual antiplatelet therapy more than 12 months among patients who received drug eluting stents was not significantly more effective than aspirin monotherapy.
study of 614 patients showed that among patients with permanent AF, lenient rate control is as effective as strict rate control and is easier to achieve.
Thursday, June 12, 2014
Saturday, May 17, 2014
Friday, April 04, 2014
Studied 4780 ivt treated patients, of whom 25.5 % had a low GFR below 60 mL/min. Low GFR was significantly associated with poor 3 month outcome death and sICH; lower GFR "might be a better risk indicator than age" and a decrease by 10 mL/min/1.73 m@ has a similar impact on death or SIC as one point on the NIHSS
editor note: does not apply to those with known Chagas disease vasculitis, and a small number was studied, and positive serology is different than having severe disease
Saturday, February 08, 2014
Monday, January 06, 2014
Saturday, July 27, 2013
Thursday, July 11, 2013
An infrequent type of stroke with an unusual cause and successful therapy: basilar artery occlusion caused by a cardiac papillary fibroelastoma recanalized 12 hours after onset [In Process Citation]
Intern Med (Japan), 2013, 52(2) p277-9