Posterior Reversible Encephalopathy Syndrome: A Comparative Study of Pediatric Versus Adult Patients

BACKGROUND

Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that, although characteristically reversible, can result in long-term disability. Our aim was to identify the clinical and radiological factors that are unique to children with PRES compared with adults with the syndrome in a single center.

METHODS

We retrospectively reviewed the clinical and radiological records of all patients with PRES admitted at a tertiary care medical center from 2007 to 2014. All patients who met the clinical and radiological criteria for PRES were dichotomized into children (less than 18 years) and adults (18 years or older) based on their age groups, and comparison of their baseline variables, clinical, laboratory, and imaging features was performed.

RESULTS

During this study period, 19 pediatric patients and 100 adult patients with PRES were identified. On univariate analysis, factors significantly associated with pediatric patients with the syndrome were multiorgan failure (84.2% vs 50%, P = 0.006), temporal lobe involvement (63.3% vs 39%, P = 0.04), restricted diffusion (42.1% vs 18%, P = 0.02), and less likelihood of cerebellar involvement (21.1% vs 57%, P = 0.004). On bivariate logistic regression analysis, all these factors remained significantly associated with pediatric PRES; multiorgan failure (odds ratio: 5.80, 95% confidence interval: 1.45 to 29.41, P = 0.03), temporal lobe involvement (odds ratio: 5.08, 95% confidence interval: 1.17 to 22.17, P = 0.03), restricted diffusion (odds ratio: 2.48, 95% confidence interval: 1.61 to 10.10, P = 0.02), and less likely to have cerebellar involvement (odds ratio: 0.08, 95% confidence interval: 0.002 to 0.39, P = 0.002).

CONCLUSIONS

Factors unique to PRES in children compared with adults include a greater propensity with multi-organ failure, involvement of the temporal lobe, and restricted diffusion on imaging.

Spectrum of Cerebrovascular Disease in Patients with Multiple Myeloma Undergoing Chemotherapy-Results of a Case Control Study

Objectives

Patients with multiple myeloma (MM) are at increased risk of arterial thrombosis. Our aim was to determine the risk factors, mechanisms and outcome of strokes in these patients.

Methods

We conducted a retrospective matched case–control study from our database of MM patients enrolled in Total Therapy (TT) 2, TT3a and TT3b protocols who developed a vascular event (transient ischemic attack, ischemic stroke, or intracerebral hemorrhage) from October 1998 to January 2014. Cases were matched for age-matched selected controls. Baseline demographics, risk factors, MM characteristics, laboratory values, and mortality of cases were compared to those of controls. Multivariate logistic regression analysis identified risk factors associated with stroke. Ischemic strokes (IS) were classified with modified Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria.

Results

Of 1,148 patients, 46 developed a vascular event (ischemic stroke, 33; transient ischemic attack, 11; hypertensive intracerebral hemorrhage, 2). Multivariate logistic regression analysis determined renal insufficiency (odds Ratio, 3.528; 95% CI, 1.36–9.14; P = 0.0094) and MM Stages I and II (odds Ratio, 2.770, 95% CI, 1.31–5.81; p = 0.0073) were independent predictors of stroke. In our study, strokes attributable to hypercoagulability, atrial fibrillation and small-vessel occlusion were common mechanisms. After a stroke, 78% of patients were discharged to home or a rehabilitation facility and 4% to a long-term nursing facility; in-hospital mortality was 15%. Despite suffering a stroke no significant differences in survival were observed.

Conclusion

In our cohort of multiple myeloma patients, renal failure and MM Stages I and II had increased risk of stroke.

Predictors of poor outcome in patients with posterior reversible encephalopathy syndrome

PURPOSE

Posterior reversible encephalopathy syndrome (PRES) is an acute neurotoxic syndrome that, although characteristically reversible, can be fatal or result in long-term disability in a subset of patients. Our aim was to identify factors associated with poor discharge outcome in PRES patients.

MATERIALS AND METHODS

We retrospectively reviewed the clinical and radiological records of all patients with PRES admitted at our tertiary care medical center from 2007 to 2014. They were divided based their modified Rankin Score at discharge and compared for their baseline variables, clinical, laboratory and imaging features. Poor outcome was defined by a modified Rankin scale 2-6 and was subdivided based on the primary mechanism that led to poor outcome.

RESULTS

Out of 100 PRES subjects, 36% had poor discharge outcomes. Factors associated with poor outcomes on univariate analysis were history of diabetes mellitus, coma, high Charlson comorbidity index, post-transplantation, autoimmune condition, lack of systolic or diastolic hypertension, elevated blood urea nitrogen and involvement of the corpus callosum. On multivariate analysis, only prior diabetes mellitus odd ratio (OR) = 6.8 (95% CI 1.1-42.1, p = 0.04), corpus callosum involvement (OR = 11.7; 95% CI 2.4-57.4, p = 0.00) were associated with poor outcome. Poor outcome also correlated with increased length of hospital stay (OR = 7.9; 95% CI 1.3-49.7, p = 0.03).

CONCLUSION

Large prospective studies incorporating serial blood glucose values and advanced imaging studies are required to validate these findings.

Post t-PA transfer to hub improves outcome of moderate to severe ischemic stroke patients

Background and Purpose

Telemedicine offers rural hospitals the ability to treat acute ischemic stroke on site with intravenous tissue plasminogen activator (t-PA). Most patients are subsequently transferred to a hub hospital with a primary stroke center for post t-PA care. There is little evidence that such transfer is beneficial. The purpose of our study is to determine whether the transfer of patients to hub hospitals is beneficial.

Methods

We retrospectively analyzed data from our prospectively collected cohort in the AR SAVES (Stroke Assistance through Virtual Emergency Support) telestroke network from November 2008 till January 2012. We compared the outcome of patients who were transferred to a “hub” with those who remained at the “spoke” hospital where thrombolysis took place. We stratified patients according to stroke severity using admission NIHSS scores into two groups: patients with mild stroke (NIHSS <8) and those with moderate to severe stroke (NIHSS ≥8). We defined good outcome as a modified Rankin Scale (mRS) score ≤2. Statistical analysis was performed using Fisher’s exact test, two-tailed, and significance was considered at p < 0.05.

Results

Out of 894 telestroke consultations, 206 patients received thrombolytic therapy; 134 patients had moderate to severe strokes and 160 patients (78%) were transferred to the hub after thrombolytic therapy. The percentage of patients with good outcome at 3 months was similar between patients transferred to hub and those who stayed at the spoke (61% vs. 55%, p = NS). However, when only patients with moderate to severe strokes were analyzed, patients transferred to the hub were more likely to have good outcomes at three months post t-PA (50% versus 24%, p = 0.026).

Conclusions

Patients with moderate to severe ischemic strokes who were treated with t-PA in a telestroke network may potentially benefit from expert care at a primary stroke center.

Nosocomial infections in patients with spontaneous intracerebral hemorrhage

BACKGROUND

Nosocomial infections are frequent complications in patients with intracerebral hemorrhage.

OBJECTIVES

To determine the prevalence, risk factors, and outcomes of nosocomial infections in patients with intracerebral hemorrhage.

METHODS

Prospectively collected data on patients with spontaneous intracerebral hemorrhage between January 2009 and June 2012 were retrospectively reviewed. Patients who had nosocomial infection during the hospital stay were compared with patients who did not. Poor outcome was defined as death or discharge to a long-term nursing facility.

RESULTS

At least 1 nosocomial infection developed in 26% of 202 patients with intracerebral hemorrhage. The most common infections were pneumonia (18%), urinary tract infection (12%), meningitis or ventriculitis (3%), and bacteremia (1%). On univariate analysis, independent predictors of nosocomial infection were intraventricular hemorrhage, hydrocephalus, low score on the Glasgow Coma Scale at admission, hyperglycemia at admission, and treatment with mechanical ventilation. On multivariate regression analysis, the only significant predictor of nosocomial infection was intraventricular hemorrhage (odds ratio, 5.4; 95% CI, 1.2-11.4; P = .02). Patients with nosocomial infection were more likely than those without to require a percutaneous gastrostomy tube (odds ratio, 33.1, 95% CI, 23.3-604.4; P < .001) and to have a longer stay in the intensive care unit or hospital without a significant increase in mortality. Patients with nosocomial pneumonia were also more likely to have a poor outcome (P < .001).

CONCLUSION

Pneumonia was the most common infection among patients with intracerebral hemorrhage.

Abstract W MP105: Regionalization of Care and Increased Burden on Specialized Stroke Centers

Introduction: Many patients are transferred to specialized stroke centers for advanced ischemic stroke (AIS) care, especially after tPA. We sought to determine differences in the baseline characteristics and outcomes between AIS cases presenting directly to our academic stroke center as compared to those transferred from outside facilities (OSH).

Methods: Using our institutional GWTG stroke registry, we analyzed 1,726 AIS cases (01/09 - 02/14). Univariate and multivariable models explored differences in patients presenting directly at our center as compared to transferred from OSH.

Results: 46% percent of all AIS were transferred patients. Compared to those presenting directly at our center, transferred patients were older, more often Caucasian, with more vascular risk factors. They had worse median NIHSS, more often had limb weakness or aphasia and received IV tPA. In-hospital mortality was nearly double in transferred patients. Transfer-in patients had a longer hospital length of stay and were more often discharged to inpatient rehab. Independent predictors of in-hospital mortality were increasing age, A. fib, coronary artery disease and initial NIHSS. Transfer status was not independently associated with in-hospital mortality.

Conclusions: Transferred patients differed significantly from those presenting directly, they have more stroke risk factors and present with severe strokes. Accepting such patients increase the burden at specialized stroke centers. Despite having more severe strokes on arrival, transfer patients had similar in-hospital mortality after adjusting for stroke severity (NIHSS) lending support to the concept of regionalized stroke care.

Abstract T P306: The Association Between Treatments and Hematoma Expansion in Thrombolysis Related Hemorrhage: A Multicenter Retrospective Study

Background: Symptomatic intracerebral hemorrhage (sICH) is the most feared complication of thrombolytic therapy in acute ischemic stroke. There is limited data on efficacy of treatments to prevent hematoma expansion (HE). We hypothesized that treatment for sICH would reduce HE.

Methods: This study was a collaboration from 5 stroke centers (Columbia University, Massachusetts General Hospital, University of Arkansas, Washington University, and UCLA). Outcome was HE, defined as 33% increase in hematoma volume in the first 24 hours.

Results: We identified 87 patients with sICH between 1/2009-4/2014 and analyzed the 70 patients (80%) with follow up scans after sICH; those without a follow-up scan were all made comfort care in the first 24 hours and expired. HE occurred in 18 patients (26%); mean duration to diagnosis of sICH was 13±10 hours and mean duration to treatment after detection was 2.4±1.8 hours. On univariate analysis, the only factor associated with increased risk of HE was platelet transfusion (50% vs. 15%,p<0.008). Providing any treatment for sICH vs. none was not associated with reduced HE. There was a trend towards HE with cryoprecipitate treatment (44% vs 23%,p=0.1), time to sICH < 12 hours (42% vs. 19%,p=0.1), and post-thrombolysis fibrinogen < 150 mg/dL (75% vs. 31%,p=0.1). After adjusting for code status, the odds of a patient being treated was increased if the time to diagnosis was <12 hours (OR 5.73, 95%CI 1.46-22.6). After adjusting for time to sICH diagnosis, there was no longer an association between HE and cryoprecipitate use (OR 0.94, 95%CI 0.20-4.46), however, there remained a non-significant association between platelet transfusion and HE(OR 2.93, 95%CI 0.56-15.3). In multi-variable models, none of the treatments given or pretreatment characteristics were associated with reduced HE.

Conclusion: Although our study is underpowered to detect treatment effect, the treatments used to reverse coagulopathy in sICH were not associated with reduced rate of HE across multiple centers. Larger studies are needed to establish an algorithm to diagnose and treat sICH early enough to prevent HE.

Abstract T MP95: Treatment and Outcome of Thrombolysis Related Hemorrhage: A Multi-center Retrospective Study

Background: The most feared complication from thrombolysis is symptomatic intracerebral hemorrhage (sICH). Current treatments for sICH are based on limited data. We aim to the efficacy of treatments utilized.

Methods: We conducted a collaborative study from 5 academic stroke centers (Columbia University, Massachusetts General Hospital, University of Arkansas, Washington University, and UCLA) on acute post-thrombolysis sICH treatment. The definition of sICH was based on the Safe Implementation of Thrombolysis in Stroke criteria. The primary outcome was in-hospital mortality. Analysis was performed using Fisher’s test and independent t-test, followed by multivariable regression; p<0.05 was statistically significant.

Results: We identified 87 patients with sICH from 1/09 to 4/14. Mean time from rtPA infusion to sICH diagnosis was 12±10 hours and mean time to treatment after diagnosis 2.5 ± 2.3 hours. 91% were diagnosed more than 2 hours from initiation of rtPA. The median NIHSS was lower in patients diagnosed in the first 3 hours versus after 3 hours (10 vs. 18, p=0.01). We found no association between receiving any treatment versus none with in-hospital mortality (37% vs 52%, p = 0.1). Factors associated with higher mortality were code status change within 24 hours (56% vs. 13%, p<0.001), endovascular treatment (27% vs. 9%, p=0.04), and pre-thrombolysis warfarin (10% vs. 0%, p = 0.04). There was trend towards lower mortality with neurosurgical treatment (13% vs. 2%, p = 0.1), and hematoma volume less than 30 cc (30% vs. 53%, p = 0.1). In multivariable models, code status change (OR = 6.2, CI 2.0-20), hematoma volume more than 30 ml (OR = 4.9, CI 1.2-19.6), and endovascular treatment (OR = 4.8, CI 1.1-20.2) were associated with increased in-hospital mortality.

Conclusion: The treatment of post-thrombolysis sICH did not reduce mortality. Possible explanations include perception of futility, prolonged time to diagnosis, and endovascular treatment. More aggressive neurological monitoring beyond two hours from rtPA and screening high risk patients, especially those with high NIHSS score may potentially reduce time to diagnosis/treatment. Innovative treatment with high efficacy and short onset of action should be studied to improve the outcome of sICH.

Predictors of major improvement after intravenous thrombolysis in acute ischemic stroke

BACKGROUND

Intravenous thrombolysis improves outcomes of stroke patients. The immediate response to thrombolysis is variable and few studies attempted to identify predictors of major neurological improvement (MNI) 24 h following thrombolysis. Our objective is to determine predictors of MNI 24 h following thrombolysis.

METHODS

We reviewed the prospective database of patients treated through our telestroke network and at our institution between November 2008 and June 2012. We included all patients who received IV t-PA and had a 24-h NIHSS score available. Similar to previous studies, we defined MNI as a reduction in NIHSS score by ≥8 points, or a score of 0 or 1 at 24 h. Demographics, risk factors, time to treatment, and clinical and laboratory data, were compared between MNI present or absent. Baseline predictors were compared using t- and Fisher's exact tests, and outcomes using multivariate logistic regression analysis.

RESULTS

Out of 316 patients, 306 had 24-h NIHSS scores and 38% of them experienced MNI. Patients with MNI were less likely to be older than 80 years (16% vs. 29%, p = 0.008) and to have atrial fibrillation (9% vs. 24%, p = 0.001) compared to those without; we found no other predictors of MNI. After adjusting for baseline demographics and risk factors, age less than 80 years (OR = 1.9, 95% CI 1.1-3.6) and absence of atrial fibrillation (OR = 3.0, 95% CI: 1.4-6.2) predicted MNI.

CONCLUSION

Major neurological improvement within 24 h after thrombolysis is more likely in younger patients and those without atrial fibrillation.

Thrombolysis in ischemic stroke without arterial occlusion at presentation

BACKGROUND AND PURPOSE

None of the randomized trials of intravenous tissue-type plasminogen activator reported vascular imaging acquired before thrombolysis. Efficacy of tissue-type plasminogen activator in stroke without arterial occlusion on vascular imaging remains unknown and speculative.

METHODS

We performed a retrospective, multicenter study to collect data of patients who presented to participating centers during a 5-year period with ischemic stroke diagnosed by clinical examination and MRI and with imaging evidence of no vascular occlusion. These patients were divided into 2 groups: those who received thrombolytic therapy and those who did not. Primary outcome measure of the study was excellent clinical outcome defined as modified Rankin Scale of 0 to 1 at 90 days from stroke onset. Secondary outcome measures were good clinical outcome (modified Rankin Scale, 0-2) and perfect outcome (modified Rankin Scale, 0). Safety outcome measures were incidence of symptomatic intracerebral hemorrhage and poor outcome (modified Rankin Scale, 4-6).

RESULTS

A total of 256 patients met study criteria, 103 with thrombolysis and 153 without. Logistic regression analysis showed that patients who received thrombolysis had more frequent excellent outcomes with odds ratio of 3.79 (P<0.01). Symptomatic intracerebral hemorrhage was more frequent in thrombolysis group (4.9 versus 0.7%; P=0.04). Thrombolysis led to more frequent excellent outcome in nonlacunar group with odds ratio 4.90 (P<0.01) and more frequent perfect outcome in lacunar group with odds ratio 8.25 (P<0.01).

CONCLUSIONS

This study provides crucial data that patients with ischemic stroke who do not have visible arterial occlusion at presentation may benefit from thrombolysis.

Imaging predictors of outcome following intravenous thrombolysis in acute stroke

Intravenous tissue plasminogen activator is the only approved medical treatment for patients with acute ischemic stroke. While it is associated with excellent clinical outcome in about 30 %, even with timely thrombolysis administration, certain strokes continue to evolve and lead to poor outcomes. Several studies have attempted to identify predictors of outcome despite timely thrombolysis. Persistence of a proximal clot burden and large vessel occlusion following thrombolysis are markers for patients who may potentially benefit from advanced treatment modalities like intra-arterial thrombolysis and thrombectomy. Timely brain imaging and interpretation play a crucial role in providing these treatment decisions. In this review, various imaging predictors of poor outcome among patients with acute ischemic stroke treated with intravenous thrombolysis are outlined. Despite identification of these imaging predictors, thrombolysis should not be withheld, as it may still be beneficial in a subset of patients. Knowledge of these predictors may set benchmarks for selecting candidates who may potentially benefit from advanced management strategies in future trials.

ASPECTS is a predictor of favorable CT perfusion in acute ischemic stroke

BACKGROUND AND PURPOSE

Computed tomography perfusion (CTP) is used by some stroke centers to stratify stroke patients who may potentially benefit from endovascular treatment. Our aim is to identify predictors of a favorable CTP in acute ischemic stroke patients evaluated within 8h from symptoms onset for possible endovascular treatment.

MATERIALS AND METHODS

We reviewed records of patients who had CTP studies between August 2010 and September 2012. We included all patients with anterior circulation strokes with evidence of large vessel disease. All patients had CT head and CT angiography head and neck as part of our protocol. Favorable CTP was defined as core infarct size less than one third the middle cerebral artery distribution and penumbra>20% of infarct size. The patients were divided into two groups based on favorable CTP or not. Baseline characteristics, time parameters, laboratory data and radiological data were compared between both groups. For statistical analysis, we used independent and Fisher's exact tests and a multivariate logistic regression model.

RESULTS

During this period, 60 patients met the inclusion criteria. Patients with favorable CTP were likely to be ≥ 80 years (33% vs 9%, P = 0.026), have Alberta Stroke Program early CT score (ASPECTS) > 7 (81% v. 21%, P ≤ 0.001) and lower mean time from symptom onset to CTP (234 ± 91 vs 305 ± 122, P = 0.015). On regression analysis, ASPECTS was the only independent predictor of a favorable CTP (OR = 16.2, CI: 4.3-62.2, P < 0.001).

CONCLUSION

ASPECT score may be used as a tool to predict a favorable CTP. Larger studies are needed to confirm our findings.

Autopsy proven causes of in hospital mortality in acute stroke

To characterize discrepancies between the causes of death as determined by the clinician and autopsy findings in patients admitted with stroke, we retrospectively reviewed all autopsies on patients died with a diagnosis of stroke. Fifty-eight patients with a diagnosis of stroke died after admission to our tertiary medical center in the past ten years were autopsied. Strokes included ischemic strokes, hemorrhagic strokes and subarachnoid hemorrhages. Thirty-five had complete autopsy and twenty-three patients had autopsy limited to brain only examination. We reviewed the autopsy findings and correlated them to the clinical diagnoses that were extracted from the clinical records. We looked particularly for major discrepancies that could have altered treatment strategies. Discrepancies between clinical diagnoses and autopsy findings were classified into major and minor using the Goldman et al. criteria. Only in three instances there were major discrepancies and therapy may have altered medical management in one of these.

Primary antiphospholipid syndrome manifesting as partial status epilepticus

Primary antiphospholipid syndrome (APS) is an autoimmune disease defined by vascular thrombosis, pregnancy complications, and persistent antiphospholipid antibodies. Neurological manifestations include stroke, seizures, and chorea among others. Seizures are often precipitated by an acute ischemic event, but occasionally, structural abnormalities are absent. We present a 61-year-old man who developed partial seizures that progressed into partial status epilepticus. His seizures were intractable and required aggressive treatment with multiple anti-epileptic medications. He was diagnosed with primary APS and treated with anticoagulation. Head imaging did not reveal any acute ischemic events. This case demonstrates that primary APS may present as a refractory status epilepticus unrelated to acute cerebral ischemia.

Thrombolysis to stroke mimics in telestroke

Stroke mimics are patients diagnosed initially with stroke who finally receive a different diagnosis, such as seizure, conversion disorder or encephelopathy. We compared the number of stroke mimics receiving thrombolytic therapy via a telestroke network and via a conventional primary stroke centre. We reviewed the data on all patients who received intravenous t-PA through the ARSAVES statewide telestroke network or at the University of Arkansas for Medical Sciences (UAMS) stroke centre between November 2008 and January 2012. During the study period there were 252 patients (46 UAMS, 206 ARSAVES). Of the 206 telestroke patients, 141 patients (68%) were transferred to the UAMS and were examined there by a vascular neurologist where a diagnosis of stroke or stroke mimic was made; 65 patients (32%) stayed at the peripheral site and were excluded from the present study. Of the 189 study patients, 3-month outcome data were available on 166 (89%), 43 from UAMS (94%) and 123 from ARSAVES (87%). The mean door to needle time was significantly shorter at the UAMS (72 min vs. 91 min, P = 0.001). However, the percentage of good outcomes was similar in both groups (70% vs. 58%, P = 0.21) and both groups had similar total time from symptom onset to treatment (154 min vs. 156 min, P = 0.81) and similar baseline characteristics. The percentage of stroke mimics was similar in the two groups: UAMS 4.3% and ARSAVES 7.8% (P = 0.53). Although making a diagnosis of stroke mimic may be challenging on face-to-face encounter, our study shows that this challenge does not increase if telemedicine is used instead. Larger prospective studies are now required to confirm the findings of our study.