Friday, April 24, 2015

from: Daniel Jacobs

Hi! How are you?
Have you seen this ? It was shown on the Oprah's show! 
Best wishes, 
Daniel Jacobs

From: Daniel Jacobs

Hi! How are you? 

Have you seen this before? 
Oprah had been using it for over a year! 

Wednesday, April 01, 2015

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Sunday, March 29, 2015

renal function and tpa

IV thrombolysis and renal function.

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


ESCAPE trial  (" Endovascular treatment for small core and anterior circulation proximal occlusion with emphasis on minimizing CT to recanalization times")
120 patients with proximal anterior circulation occlusion were randomized to alteplase v. alteplase + embolectomy.  Study was stopped early due to positive results.  Outcome measure was mrs at 90 days.  The study used CT and CT-A and multiphase CT angiogram. mrs of 0-2 was achieved in 53 % v. 29.2 % (p<0.001).
SWIFT PRIME ("Solitaire with the intention for thrombectomy as primary endocascular treatment"). 98 patienrs were randomized in each arm within 4.5 hours to tpa and 6 hours of symptom onset to Solitaire.  Outcome was mrs 0-2 at 90 days 60.2 % with endovascular treatment v. 35.5 % without (p= 0.0002)
For every 100 patients treated, 39 would have a better outcome with endovascular than with just tpa, and an additional 25 % would reach functional independence. Study was led by Dr. Saver.  He notes that whether to perform the procedure after six hours is not answered.
For MRS of 0, 17 % of patients achieved who got alteplase + procedure v. 8.6 % of alteplase only
For MRS of 1, 25.5 % v. 10.8 % 
For MRS of 2, numbers wwere 17.3 % v. 17.2 %
Overall good outcome occurred in 60.1 % of patients with embolectomy v. 35.5 % of patients with T-pa alone.
EXTEND 1A: ("Extending the time for thrombolysis in emergency neurological deficits-intraarterial").  35 patients were randomized to tpa alone, 33 to embolectomy but only 27 underwent embolectomy.  37 % of tpa patients achieved early reperfusion v. 100 % of embolectomy patients (p<0.0001).  37 % of patients on tpa achieved early neurological recovery v. 80 % of patients receiving embolectomy (p=0.0002).  They used the Solitaire stent and a 4.5 hour tpa window.  Endovascular was initiated within 210 minutes after onset of stroke.  Study was led by Dr. Bruce Campbell in Austrailia. 

Thursday, February 05, 2015

Stroke.43: 412-416

The Safety of Intravenous Thrombolysis for Ischemic Stroke in Patients With Pre-Existing Cerebral Aneurysms

A Case Series and Review of the Literature

  1. S. Andrew Josephson, MD
+ Author Affiliations
  1. 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.
  1. 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


Background and Purpose—Unruptured cerebral aneurysms are currently considered a contraindication to intravenous tissue-type plasminogen activator for acute ischemic stroke. This is due to a theoretical increase in the risk of hemorrhage from aneurysm rupture, although it is unknown whether this risk is a significant one. We sought to determine the safety of intravenous tissue-type plasminogen activator administration in a cohort of patients with pre-existing aneurysms.
Methods—We reviewed the medical records of patients treated for acute ischemic stroke with intravenous tissue-type plasminogen activator during an 11-year period at 2 academic medical centers. We identified a subset of patients with unruptured cerebral aneurysms present on prethrombolysis vascular imaging. Our outcomes of interest were any intracranial hemorrhage, symptomatic intracranial hemorrhage, and subarachnoid hemorrhage. Fisher exact test was used to compare the rates of hemorrhage among patients with and without aneurysms.
Results—We identified 236 eligible patients, of whom 22 had unruptured cerebral aneurysms. The rate of intracranial hemorrhage among patients with aneurysms (14%; 95% CI, 3%–35%) did not significantly differ from the rate among patients without aneurysms (19%; 95% CI, 14%–25%). None of the patients with aneurysms developed symptomatic intracranial hemorrhage (0%; 95% CI, 0%–15%) compared with 10 of 214 patients without aneurysms (5%; 95% CI, 2%–8%). Similar proportions of patients developed subarachnoid hemorrhage (5%; 95% CI, 0%–23% versus 6%; 95% CI, 3%–10%).
Conclusions—Our findings suggest that intravenous tissue-type plasminogen activator for acute ischemic stroke is safe to administer in patients with pre-existing cerebral aneurysms because the risk of aneurysm rupture and symptomatic intracranial hemorrhage is low.

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

Effects of Glden Hour Thrombolysis

Ebinger M, Kunz Am Wendt M et al  Effects of golden hour thrombolysis: a prehospital acute neurological treatment and optimizatyion of medical care in stroke (Phantom S ) Study.  JAMA Neurol 2015; 72: 25-30 with accompaning editorial
German study with stroke emergency mobile units, ie ambulances with CT scanner, POC lab, and telemedicine connection.  It also is staffed with a neurologist.
Rates of thrombolysis in golden hour 22 v. 32 % with deployment of STEMO, rate of golden hour thrombolysis is higher and were more likely to be discharged home with no increased risks to patient. The future?
Comment-- watch what happens in Germany and try to apply it to the United States
Our ambulances have cited short drive times to OH

Sunday, December 07, 2014

Pearls on strokes associated with hematologic diseases

This is based on an OLD article by Martin Samuels, so newer drugs for condition are not included
Samuels MA, Thalinger K.  Cerebrovascular manifestations of selected hematologic diseases.  Seminars in Neurology 11:4 1991.
1.  Anemia-- examine the EYE.  First sign is pallor, then spindle shaped retinal hemorrages with cotton wool spots. 
2.  Blood transfusions can trigger stroke in patients with Beta thallasemia (cites Logothetis J. et al. Neurology 1972;22:294-304.
3. In thrombocytopenia, intracranial hemorrhages occurs as small ring shaped hemorrhages in the gray and white matter due to capillary bleeding.Subdural, subarachnoid and epidural hemorrhages are rare inthis condition.  Peripheral nerve and spinal cord hemorrhage also are rare.
4. In thrombotic thrombocytic purpura (TTP), consists of triad of thrombotic purpura, hemolytic anemia and neurologic manifestations.  Fever and renal disease are "invariably" present.  Diagnosis depends on tissue of skin, lymph node, bone marrow or spleen that show hyalinization of arterioles and platelet thrombi with small foci of parenchymal necrosis and petecchiae."Gray matter" symptoms include headache, confusion, aphasia, hemiparesis,visual changes, dysarthria, seizures, coma, vertigo. Exchange transfusion helps dramatically. Other treatments are heparin, steroids, splenectomy.
5.  In hemolytic uremic syndrome, similar to TTP, caused by immune deposits, exchange transfusion can result in dramatic improvement.  FFP without albumen also helps. 
6.  Henoch-Schoenlein purpura (anaphylactoid purpura) is characterized by serosanguineous effusions into subcutaneous, submucous, and subserous tissues, esp in young adults.  Treatment is supportive.  ICH and SAH occur rarely.
7.  Ischemic strokes occur in 15-32 percent of patients with polycythemia vera.  The annual incidence of TIA/ stroke is 4-5 percent even in those treated with phlebotomy.  Conversely, risk of stroke is rare in secondary polycythmia.  For example, someone with congenitally cyanotic heart disease and Hct of 60 has very low risk, none occurred in a small series cited with> 200 patient years of followup.
8.  Hyperviscosity syndrome is a major cause of stroke in patients with myeloma.  Clinical presentation is stupor, coma, drowsiness, inattention,delirium.  Fundoscopic changes include "sausage veins,"  retinal hemorrhages and exudates.  Focal events can occur in Waldenstrom's macroglobulinemia.  Plasma exchange can dramatically improve symptoms due to heavy proteins.

Tuesday, December 02, 2014

PFO and attributable risk with RoPE score

                        cryptogenic stroke, CS (n= 3,023)                                           
RoPE score          No patients   Prevalence PFO   PFO attributable   
0-3                         613               23(19-26)             0                          
4                            511               35(31-39)             38 (25-48)              
5                            516               34 (30-38)            34 (21-45)             
6                            482               47(42-51)             62 (54-68)         
7                            434               54(49-59)             72 (66-76)            
8                            287               67(62-73)             84 (79-87)         
9-10                       180                73(66-79)             88(83-91)         
                       cryptogenic stroke (CS) with PFO (N=1,324)
                            No CS+PFO    est 2 yr TIA/CVA (Kaplan-Meier) 
0-3                         108                20(12-28)
4                            148                12(6-18)
5                            186                  7 (6-18)
6                            236                  8 (4-12)
7                            263                  6 (2-10)
8                            233                  6 (2-10)
9-10                       150                   2(0-4)

attributable risk PFO based on Bayes' theorem

derivation of data used to make RoPE database

RoPE score for PFO

RoPE score for PFO (Risk of Paradoxical Embolus)

Characteristic    Points

No history of
DM                         1
stroke/TIA              1
HTN                       1
nonsmoker             1
cortical infarct        1

18-29                      5
30-39                      4
40-49                      3
50-59                      2
60-69                      1

total score  -- add sum of parts
cut score used in many articles is 7

source Neurology 2013 au Thaler

RoPE score, PFO and CS

Thaler DE, Ruthazer R, Weimar C., et al.  Recurrent stroke predictors differ in medically treated patients with pathogenic v. other PFO's.  Neurology 2014; 83: 221-226.
The RoPE score, "Risk of Paradoxical Embolism" score estimates the probability that a PFO discovered in a cryptogenic stroke (CS) patient is incidental or pathogenic, based on Bayes theorem.  Patients with high RoPE score (younger, no vascular risk factors, and a superficial infarct) are more likely to have pathogenic PFO's while patients with low RoPE scores (older, vascular risk factors) are probably incidental.  Authors hypothesized that predictors of recurrent stroke should differ among high and low RoPE score patients and PFO characteristics should be les important in low RoPE score individuals. 
Risk factors for recurrence with 1-2.2 yrs of followup  included LOW RoPE scores (one year followup, 7 v. 4 %; two year followup 10 v. 5 %) with 4/5 recurrences being in low score subgroup 
Patients with TIA had more recurrent events (HR 1.69) but there was no interaction with RoPE score.
Variable associated with risk in low RoPE group include older age, those treated with antiplatelet drugs after initial event.

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. 
Comment of blogger
The article confirms / validates the RoPE score to some extent.  However, the point of closure is to prevent lifetime risk of paradoxical embolus, not 2 year risk.  As such, I am skeptical of the claim that risk of recurrence is lower in high RoPE score group

Sunday, November 30, 2014

MELAS pearls

1. Onset before 40
2. Clinical: hemiparesis, hemianopia, cortical blindness; seizures, dementia, migraine, muscle weakness,
3. Associated
Short stature
Hearing loss
Recurrent vomiting
4. May be relapsing remitting
5. High lactic/abn muscle biopsy
6. AVOID statins and Depakote


Retinal vasculopathy with cerebral leukodystrophy aka cerebroretinal vasculopathy sysndrome aka hereditary endotheliopathy, retinopathy, nephropathy and stroke.

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

CARASIL pearls

1.  Onset decades 3 to 5
2.  Premature alopecia occurs in teen years
3.  Cervical and lumbar spondylitis occurs in 2d and 3d decades
4.  Mutations in A serine peptides 1 on chromosome 10 q is implicated

Cadasil pearls

1. Strokes are subcortical many with classic lacunae syndromes
2. False negative genetic tests should prompt skin biopsy for granular osmiophic material in the vascular basal lsmina which is a specific finding
3. MRI finding occur in anterior temporal poles (o'Sullivan sign seen in 90 percent) but also extreme capsule and corpus callosum also are distinctive
4.  Other MRI findings are microbleeds and brain atrophy
5.  80 plus NOTCH3 mutations are identified
6.  Migraine with aura occurs in 30 percent, often in 3rd decade long before strokes

Unruptured aneurysm pearls

1. High risk patients who require screening are those with at least two first degree relatives with aneurysm or autosomal dominant polycystic kidney disease

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.

Pearls pediatric stroke

1. Stroke may present with seizures in newborns and even older kids

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.

Hypercoagulable misc

1. Homocystinuria, anti phospholipid syndrome, and thrombin deficiency are some of the only syndromes associated with arterial thrombosis

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

Pearls on factor V (Leiden) mutation

1. By far the most common genetic risk factor for thrombophilia

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

thrombolysis and aneurysms

Post-Thrombolysis Hemorrhage Risk of Unruptured Intracranial Aneurysms; Chen F, Yan S, Jin X, Lin C, Cao J; European Neurology 73 (1-2), 37-43 (Nov 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

Subarachnoid hemorhage and growth hormone treatment in childhood

Poidvin A, et al.  GH treatment for childhood short stature and risk of stroke in early adulthood. Neurology; 2013; 83: 780-6.
6874 children with idiopathic GH deficiency or short stature who stated GH treatment had  rate of hemorrhage from 3.5 to 7.0 compared registry rates. from 1985-96 
Editorial (Ichord R) outlines ramifications on screening adults exposed to GH and counselling kids considering GH about risks, which are small but not negligible.

Small strokes causing severe vertigo. Frequency of false negative MRI's and

nonlacunar mechanisms.
Tehrani ASS, Kattah JC, Mantokoudis G, et al. Neurololgy 2014; 83: 169=173
Out of acute vestibular syndrome (AVS)  25 % have stroke
80 % of patients with stroke have isolated dizziness/vertigo and 20 % have focal neurologic signs
35 % of strokes are missed, often with negative MRI's. 
Out of 190 high risk  AVS presentations, 105 strokes
15  "small strokes" who underwent repeat imaging and found lesion < 10 mm in axial diameter
Location of stroke: lateral medulla (60 %)
Etiology Many dissections of vertebral artery, less commonly small vessel, cardiac embolus 
"HINTS PLUS" with the plus being a "hearing battery" bedside finger rub picks up the AICA strokes more accurately than MRI
My comment-
Lateral medullary infarctions have expected neurologic signs and symptoms that may be missed by physicians who do not know what to look for.  These include decreased gag/phonation, and crossed sensory symptoms (loss of st tract on one foot, dorsal column function on the other) that will pick up many or most of those. I would guess that in AVS with HINTS plus hearing eval plus careful gag/sensory exam some if not most of the strokes could be diagnosed clinically and localized accurately.  MRI is a poor test in this disease, but diagnosis is possible.

Thursday, November 13, 2014

Blood pressure variability after thrombolysis: prognostic signficance

Delgado-Mederos E, Ribo M, Rovira A, et al.  Prognostic significance of blood pressure variability after thrombolysis in acute stroke.  Neurology 2008; 71: 552=558.
80 stroke patients were prospectively studies who had MCA occlusion treated with t-pa.Multiple BP measurements were obtained.  Recanalization was assessed with TCD at six hours.  NIHSS was done at baseline and 24 hours, MRS at 3 months. 
55 % were recanalized.  Both SBP and DBP variability were highly associated with DWI growth (done before and 36 hours after thrombolysis) and outcome, but only in patients who failed to recanalize
Notes-- There was a significant decline in overall SBP and DBP in recanalized but not unrecanalized patients. However BP variability was the only factor corresponding to DWI growth.  Authors speculate that treating the swings is as important as treating the outlying numbers.
Blogger comment-- this observational study is interesting but not powerful enough to be determinant 

Monday, October 20, 2014

Infarction in the anterior choroidal artery territory: clinical progression and prognosis factors

Chausson N, et al.  JSCD; 2014; 23:8: 2012-7.
Authors describe the phenotypes of  anterior choroidal stroke in heretofore unappreciated ways.  They prospectively enrolled patients with AChA disease
*One hundred patients were found out of 1234 total (8.1 %) who had AChA strokes
*  Main risk factors found were hypertension and (79 %) and diabetes (31 %). 
*  88 % had "lacunar" (motor syndrome in 51, sensorimotor in 23, ataxic hemiparesis in 14, isolated ataxia in 4, other 7)
*  only four patients had hemianopia
*  cardioembolic and atherothrombotic causes wee rare
*  3 % mortality but 26 % poor outcomes, invariably due to residual motor deficit and/or spasticity
* Progressive strokes were seen in 46, and 16 with fluctuations, wiht progressions over a mean of 56 hours and being almost exclusively motor
* Use of iv tpa did nto help prevent progression (tpa was used in 12/46 progressors and 9/54 nonprogressors)
* predictor of poor outcome was those who reached an NIHSS of 6 or greater, clinical progression, and infarct size > 15 mm
* Progression was nearly always due to infarct expansion on DWI
* Authors suggest new treatments are needed for this disease.

Recurrence in Intracranial atherosclerotic disease (ICAD): a stenosis based analysis

Gouvela a, et al.  JSCD, 2014: 23:8:2080-4.
Authors confirmed prior work showing extremely high recurrence rate of stroke in this type of disease:  12.3 per 100 patient years, with mean time to recurrence being 1.7 months among symptomatic intracranial stenosis (SIS) and 0.88 per 100 patient years among asymptomatic intracranial stenosis (AIS). 
They investigated 1302 patients retrospectively, with 218 strokes in 158 patients, of which 77 were symptomatic and 141 asymptomatic.  Patients with AIS were older, had more AF
blogger note-- interesting article that splits ICAD ina new way, to AIS and SIS that has very different clinical outcomes.

Odds ratio and population attributable risk of 10 factors estimated to acount for 90 % of ischemic stroke risk

Risk factor            OR              PAR    (confidence intervals available elsewhere)
hypertension          2.64            34.6
current smoking     2.09            18.9
waist to hip ratio    1.65             26.5
Diet risk score       1.35             18.8
Regular exercise    0.69             28.5
Diabetes mellitus   1.36             5.0
ETOH (> 30/mo)     1.51             3.8
Stress/depression   1.30            4.6
Cardiac causes       2.38            6.7
ratio apo B/A1        1.89             24.9
Spouses of smokers have double risk of stroke.  Much benefit of cessation occurs in first 6 months.  Cessation leads to return to baseline risk within five years.
Fives risk factors  related to lifestyle and risk
1. Absent current smoking
2. 30 + minutes per day of exercise
3. healthy diet
4.  moderate ETOh consumption
5.  BMI < 25
If all five risk factors are favorable,   RR is -.2, PAR is -53.
Cretan Mediterranean diet is the best one; those randomized to it had 70 % less CV events within 27 months
This diet contains more fat esp olive oil.  Its much lower in meat and dairy products and uses fruit as desert. It has high levels of canola nad olive oil, high fruit/vegetable/lentils/beans and nuts.  Avoid trans fats and egg yolks; meat every other day.
Ottawa Model of Smoking Cessation
Identify smoking status-- have you used any form of tobacco in the past six months? The past seven days?
Document-- smoking history (pack years); previous quit attempts, time to first cigarette
Advise--- "There is nothing more important that cessation. We can help you with that"
Pharmacotherapy-- readily available medicine, prescribed appropriately
Followup-- FP; telephone calls; community resources.

ACC/AHA Guisdelines for postcardiac surgery atrial fibrillation; and CABG in general

* patients with pre-existing AF receiving antiarrhythmics or rate controlling agents should be continued ont hese in postop period.
*  Oral beta blocker is recommended to prevent post op AF in patients undergoing cardiac surgery-- unless contraindicated
*  An AV nodal blocking agent is recommended for postop rate control in patients who develop postop AF
* Preop amiodarone decreases the incidence of AF in patients undergoing cardiac surgery  and represents appropriate prophylactic therapy for patients at high risk of AF
*  Its reasonable to restore sinus rhythm pharmacologically or through cardioversion among patients who develop postoperative AF
*  It is reasonable to administer anti-arrhytmics to maintain SR in patients with postop refractory or recurrent AF
*  Antithrombotic medication is reasonable to administer in patients who develop postop AF
*  Prophylactic sotalol may be considered in high risk patients. 

Additional points for cardiac surgery-- evidence based
*Matching preop and postop BP may reduce the risk of perioperative stroke or death  III/B
* Preop statins reduce the perioperative stroke risk in cardiac surgery  IB/A
*  Antiplatelet therapy eg ASA reduces the postop stroke risk without increasing the risk of bleeding complications  Ia/A
*  Discontinuing warfarin or antiplatelet agents in anticipation of surgery increases the risk of perioperative stroke, with the highest risk in patients with CAD

Benefit of CEA in different conditions

Degree of stensois         Studies        Recc           Risk reduction
Symptomatic stenosis
   70-99%                       NASCET     CEA LEVEL A       16.5 % at two years
   >60 %                         ECST               "                     11.6 % at 3 years
   50-69 %                       NASCET           "                    10.1 % at 5 years
Asymptomatic stenosis
>60 %                            ACAS, ACST     "                     6.3 % at five years

-- some literature favors early surgery for patients without early ICH on CT scans
-- of those who hemorrhaged, hemorhhage occured 3-6 days after surgery when patients were improving or ambulatory.  They occurred in 6/900 patients studied
-- Dosick et al. reported 9.5 % restroke incidence with six week waiting period before CEA
--In NASCET 4.9 % of 103 patients  (5 patients) had restroke within 30 days of trial entry if treated medically
-- In a variety of studies patients operated within 3 weeks had 3 % stroke risk, those operated beyong 3 weeks had a 5.3 % stroke risk

Timing of tpa; outcomes

0-90 minites  odds ratio for favorable outcome at 3 months based on 4 point decline of NIHSS is 2.11
90-180 minutes-- odds ratio is 1.69
In NINDS trials, poor outcomes as defined by MRS >3 at 24 hours were predicted by NIHSS>22
NIHSS>17 plus AF

Thursday, October 09, 2014

Duration of dual antiplatelet therapy after implantation of drug eluting stents

Park et al. NEJM 2010; 362: 1374-82. 
use of dual antiplatelet therapy more than 12 months among patients who received drug eluting stents was not significantly more effective than aspirin monotherapy. 

Lenient v. strict rate control in patients with atrial fibrillation

Gelder et al.  NEJM 2010; 362: 1363-73

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.

Saturday, May 17, 2014

Fingolimod and atrial fibrillation

Rolf et al.  Paroxysmal atrial fibrillation after initiation of fingolimod for multiple sclerosis treatment
42 year old male had PAF on initiation, resolution on withdrawal of, recurrence on reinitiation and reresolution permanently on discontinuation of fingolimod.  Extensive cardiac testing was negative.   This is different than the bradycardia that is known to occur with fingolimod which requires initiation with cardiac monitoring. 
Authors note that fingolimod is an agonist of S1P-R1,2,3 in cardiovascuklar system.  In atrial myocytes, binding of the receptors causes activation of the potassium channels leading to an inward K current and decreased firing rate.  Therefore drug causes bradycardia or AV conduction blockade.  There is in animal models, S1P induced reperfusion tachyarrythmias. 

Friday, April 04, 2014

IV thrombolysis and renal disease

Neurology 2013; 81: 1780-8.

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

IV tpa is safe in Chagas disease related strokes

Neurology 2013;81:1773-5.  Out of a series of 240 patients in Brazil, 24 (13.8%) had positive serologic testing for Chagas disease.  They more likely had heart failure and higher NIHSS but did NOT have more symptomatic intracranial hemorrhage or in hospital death than patients without.  Conclusion:  Chagas disease diagnosis does not preclude use of tpa.
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

Monday, January 06, 2014

Syndrome of the trephined

Skin "sinks" weeks to months after a craniectomy.  It can have minor or major presentations, rarely coma, and be relieved with placing patient in trendelenberg position and using a titanium mesh.  

Thursday, July 11, 2013

Cardiac papillary fibroelastoma: A comprehensive

Cardiac papillary fibroelastoma: A comprehensive
analysis of 725 cases
Ramesh M. Gowda, MD,a Ijaz A. Khan, MD, FACP, FACC,b Chandra K. Nair, MD, FACP, FACC,b
Nirav J. Mehta, MD,b Balendu C. Vasavada, MD, FACC,a and Terrence J. Sacchi, MD, FACCa Omaha, Neb, and
Brooklyn, NY
(Am Heart J 2003;146:404–10.)
Seven hundred twenty-five cases of CPF were identified. Males comprised 55% of
patients. Highest prevalence was in the 8th decade of life. The valvular surface was the predominant locations of tumor.
The most commonly involved valve was the aortic valve, followed by the mitral valve. The left ventricle was the predominant
nonvalvular site involved. No clear risk factor for development of CPF has been reported. Size of the tumor varied
from 2 mm to 70 mm. Clinically, CPFs have presented with transient ischemic attack, stroke, myocardial infarction, sudden
death, heart failure, presyncope, syncope, pulmonary embolism, blindness, and peripheral embolism. Tumor mobility
was the only independent predictor of CPF-related death or nonfatal embolization. Symptomatic patients should be
treated surgically because the successful complete resection of CPF is curative and the long-term postoperative prognosis
is excellent. The symptomatic patients who are not surgical candidates could be offered long-term oral anticoagulation,
although no randomized controlled data are available on its efficacy. Asymptomatic patients could be treated surgically if
the tumor is mobile, as the tumor mobility is the independent predictor of death or nonfatal embolization. Asymptomatic
patients with nonmobile CPF could be followed-up closely with periodic clinical evaluation and echocardiography, and
receive surgical intervention when symptoms develop or the tumor becomes mobile.
Additional pearls from this review:
papillary fibroelastomas (CPF), the second most
common primary cardiac tumors, are benign endocardial
papillomas predominantly affecting the cardiac
valves, and account for three fourths of all cardiac valvular
tumors. They consist of a small, highly papillary,
pedunculated and avascular tumor, covered by a single
layer of endothelium, containing variable amounts of
fine elastic fibrils arranged in whorls in a hyaline
Although CPF are rare and histologically benign
tumors, they may result in life-threatening complications,
such as stroke, acute valve dysfunction, embolism,
and sudden death.
The most common clinical presentation was of transient
ischemic attack or stroke (n 120 patients). The
other manifestations were angina (n 49 patients),
myocardial infarction (n 28 patients), sudden death
(n 21 patients), heart failure (n 24 patients), presyncope
or syncope (n 12 patients), pulmonary
embolism (n 3 patients), blindness (n 7 patients),
mesenteric ischemia (n 2 patients), peripheral emboli
(n 3 patients), and renal infarction (n 1 patient).
In patients with mitral valve tumors, stroke was
the most common clinical presentation, but in patients
with aortic valve tumors, sudden death and myocardial
infarction were the 2 most common presentations. In
a large number of patients, tumors were identified as
incidental findings at autopsy (n 209 patients) or at
surgery for other cardiac reasons (n 9 patients).
The major immunophenotypic
difference between CPF and cardiac myxoma was the
frequent presence of muscle-specific actin in the stellate
cells of the stroma in cardiac myxoma but not in
Because most CPF are located in the left heart (95%),
systemic embolism in particular is frequent. In a majority
of CPF cases with embolism, the cerebral arteries,
including retinal arteries, are affected, and transient
ischemic attack, stroke, and sudden visual loss have
been reported
The classic
diastolic tumor plop, which is heard in one third of
patients with atrial myxoma, has not been described
with CPF, except in 1 case where a tricuspid valve
CPF was associated with a tumor plop.46
7. Diferential diagnostic analysis:
Cardiac myxoma
is a predominant left atrial tumor, and is usually attached
to the atrial septum by a stalk. Histologically,
myxoma differs from CPF by presence of polygonal
myxoma cells and blood vessels within papillae.125
The papillae of CPF are devoid of blood vessels. Calretinin
staining may be a useful way to distinguish between
myxoma and CPF.218 Cardiac fibroma, which is
a separate entity, frequently demonstrates calcification
and cystic degeneration. Cardiac rhabdomyomas are
predominant myocardial neoplasms seen in infants and
children.214 Metastatic tumors of the heart are more
frequent than the primary tumors.1 Unlike CPF, malignant
tumors commonly involve the pericardium and
myocardium, and are usually accompanied by systemic
symptoms. However, with both primary and metastatic
tumors, the clinical course may be complicated by emboli.
Ljevak J, Mismas A, Bazina A, et al.
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
take home points: Again, BA can be recanalized later than other vessels; this tumor type is very sensitive to lysis

Etiology and treatment of ischaemic stroke in patients with (sup)-thalassemia major.

Eur J Neurol 2011 Dec;18(12):1426-8    (ISSN: 1468-1331)
BACKGROUND AND PURPOSE: Although hypercoagulability-induced thromboembolism is generally accepted as cause of cerebral ischaemia in thalassemic patients, cardiogenic embolism has been recently suggested as another possible stroke etiology. METHODS: We present four adult (sup)-thalassemia major patients with manifest cardiac involvement who suffered territorial strokes. RESULTS: In the presence of siderotoxic cardiomyopathy and arrhythmia, we assumed cardiogenic embolism as etiology of stroke and initiated oral anticoagulation as preventive medication. Two of our patients were the first (sup)-thalassemia major patients who underwent successful thrombolysis with rtPA. CONCLUSIONS: Cardioembolism seems to be the cause of stroke in cases of (sup)-thalassemia major. Thrombolysis can be applied in the setting of acute brain ischaemia in such high risk patients. [ 2011 The Author(s). European Journal of Neurology 2011 EFNS.].
Comment:  Take home points
1.  Thal cases can be cardioembolic not just hypercoagulable and may benefit from anticoagulation
2.  Thrombolysis might help in some cases

Friday, June 07, 2013

anticoagulation in acute stroke

Lancet Neurology 2013 published a metaanalysis of studies showing no benefit of anticoagulation in acute stroke.  However, like Freddy Krueger, the debate will not die.  Below is an excerpt from the editorial by Hart et al.  that lays out some of the remaining points of contention.
A meta-analysis of 24 trials involving 23 748 patients with acute stroke found that early anticoagulation compared with no anticoagulation reduced recurrent ischaemic stroke and venous thromboembolism at the cost of increased intracranial and extracranial haemorrhage, with no overall reduction in death or disability.2 Consequently, guidelines for stroke management now recommend that anticoagulants should not be used for the management of acute stroke caused by common cerebrovascular disorders (including atrial fibrillation).3 Nonetheless, the question remains: are there acute stroke patients at high risk of thrombotic events and low risk of bleeding who might yet benefit from early anticoagulant therapy?
In this issue of The Lancet Neurology, William Whiteley and colleagues4 report the results of a pooled individual patient-level analysis of the five largest randomised trials that have tested heparins in patients with acute ischaemic stroke. The authors developed risk prediction models to identify acute stroke patients The analyses by Whiteley and colleagues provide no support for the use of anticoagulants in the management of patients with acute stroke, but the results must be interpreted with caution. First, despite careful efforts by the investigators to derive the best risk-prediction models, they were only modestly predictive of thromboembolic and bleeding events (C-statistics in the order of 0·6), thereby reducing the quality of the evidence and limiting the strength of the conclusions. Second, the conclusion must necessarily be restricted to the subgroups common to the trial databases; for example, the presence of large artery atherosclerosis was not considered.5 Third, uncertainty remains regarding the role of heparins in patients with uncommon conditions resulting in acute brain ischaemia. These include patients with acute cerebral venous thrombosis, small-to-moderate brain infarcts due to cerebral arterial dissection, aseptic embolism from prosthetic cardiac valves, mobile left ventricular thrombi, and aortic arch plaque with protruding overlying thrombi.
The balance between risks and benefits of heparins also remains unclear for patients with acute transient ischaemic attack or minor ischaemic strokes who were poorly represented in the randomised trials. These patients have a low risk of secondary haemorrhagic transformation because they do not have substantial areas of acute brain necrosis. A randomised trial that assessed the combination of clopidogrel plus aspirin in patients with acute transient ischaemic attack found a benefit of the intensive antiplatelet therapy,6 and other trials testing dual antiplatelet therapy in patients with acute ischaemic attack or minor ischaemic stroke are ongoing.7 Whether early anticoagulation provides benefit for these patients needs to be assessed.
Recently introduced novel oral anticoagulants that selectively target thrombin (dabigatran etexilate) or factor Xa (rivaroxaban, apixaban) are attractive candidates for acute stroke treatment because they work rapidly (within 2–3 h) after oral administration. The most important advantage of the novel oral anticoagulants over warfarin is the sharply decreased risk of intracerebral haemorrhage seen during long-term treatment in patients with atrial fibrillation.8 If the novel oral agents are associated with a similarly low risk of secondary brain haemorrhage after acute stroke, the balance between risks and benefits of early anticoagulation might be altered in favour of treatment, making this a priority for future research.
Despite multiple randomised trials testing heparins in patients with acute ischaemic stroke, and also the rigorous efforts by Whiteley and colleagues to identify subsets of patients defined by thromboembolic and bleeding risk that might benefit from early anticoagulation, the value of this approach has not been established for any patient group.4 However, promising early data with the use of combined antiplatelet therapy and the emergence of novel oral anticoagulants with a rapid onset of action and low risk of intracranial haemorrhage means that anticoagulant therapies for patients with acute brain ischaemia remains a fruitful area for future clinical research.