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Brazel M, Harris J, Carroll D, Davidson J, Levchak PJ, Malhotra A, LaBuzetta JN. Reporting on Neurological Decline as Identified by Hourly Neuroassessments. J Neurosci Nurs 2024; 56:118-122. [PMID: 38833429 PMCID: PMC11419944 DOI: 10.1097/jnn.0000000000000765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2024]
Abstract
ABSTRACT BACKGROUND: Hourly neurological examinations (neuro exam) have been widely used to monitor for a decline in neurological status, allowing for timely intervention. There are, however, limited data behind this common practice. The objective of this study was to identify how frequently neurological decline occurred across various diagnoses and whether that decline (1) was identified by a scheduled neurocheck and (2) altered management. METHODS: A cross-sectional survey was performed in a neurological intensive care unit at a tertiary care academic medical center. Clinical neuroscience nurses caring for patients with hourly neurological assessments completed a brief survey at 12-hour shift completion. RESULTS: Data were collected from 212 nurse's shifts. Neurological changes were identified by nurses in 14% (n = 30) of shifts. The neurological change was identified during a scheduled neurocheck 67% of the time, with the detection of changes more likely to occur during a scheduled neuro exam than at other times ( P < .05). There was no change to the care plan in 55% of the cases of neurological decline. Patients with subarachnoid hemorrhage were more likely to have a decline detected. CONCLUSION: Findings suggest that many patients undergo hourly neurological exams without ever identifying a neurological deterioration. In many instances of neurodeterioration, there was no change to the treatment plan pursued. Primary diagnoses and neurological changes may not be entirely independent, and therefore, hourly neuro exams may have greater yield in some diagnoses than others. Replication is warranted with a larger sample to evaluate the risks and benefits of neuroassessments.
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Affiliation(s)
- Marcus Brazel
- Division of Nursing, University of California San Diego Health
| | - Jennifer Harris
- Division of Nursing, University of California San Diego Health
| | - Dawn Carroll
- Division of Nursing, University of California San Diego Health
| | - Judy Davidson
- Division of Nursing, University of California San Diego Health
- Department of Psychiatry, School of Medicine, University of California San Diego
| | - Philip J. Levchak
- Department of Sociology and Criminal Justice, University of Hartford, West Hartford, CT 06117
| | - Atul Malhotra
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, UC San Diego Health, University of California, San Diego, La Jolla, CA, USA
| | - Jamie Nicole LaBuzetta
- Department of Neurosciences, Division of Neurocritical Care, UC San Diego Health, University of California, San Diego, La Jolla, CA, USA
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Santos D, Maillie L, Dhamoon MS. Patterns and Outcomes of Intensive Care on Acute Ischemic Stroke Patients in the US. Circ Cardiovasc Qual Outcomes 2023; 16:e008961. [PMID: 36734862 DOI: 10.1161/circoutcomes.122.008961] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Up to 20% of acute ischemic stroke (AIS) patients may benefit from intensive care unit (ICU)-level care; however, there are few studies evaluating ICU availability for AIS. We aim to summarize the proportion of elderly AIS patients in the United States who are admitted to an ICU and assess the national availability of ICU-level care in AIS. METHODS We performed a retrospective cohort study using de-identified Medicare inpatient datasets from January 1, 2016 through December 31, 2019 for US individuals aged ≥65 years. We used validated International Classification of Diseases, Tenth Revision, Clinical Modification codes to identify AIS admission and interventions. ICU-level care was identified by revenue center code. AIS patient characteristics and interventions were stratified by receipt of ICU-level care, comparing differences through calculated standardized mean difference score due to large sample sizes. RESULTS From 2016 through 2019, a total of 952 400 admissions by 850 055 individuals met criteria for hospital admission for AIS with 19.9% involving ICU-level care. Individuals were predominantly >75 years of age (58.5%) and identified as white (80.0%). Hospitals on average admitted 11.4% (SD 14.6) of AIS patients to the ICU, with the median hospital admitting 7.7% of AIS patients to the ICU. The ICU admissions were younger and more likely to receive reperfusion therapy but had more comorbid conditions and neurologic complications. Of the 5084 hospitals included, 1971 (38.8%) reported no ICU-level AIS care. Teaching hospitals (36.9% versus 1.6%, P<0.0001) with larger AIS volume (P<0.0001) or in larger metropolitan areas (P<0.0001) were more likely to have an ICU available. CONCLUSIONS We found evidence of national variation in the availability of ICU-level care for AIS admissions. Since ICUs may provide comprehensive care for the most severe AIS patients, continued effort is needed to examine ICU accessibility and utility among AIS.
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Affiliation(s)
- Daniel Santos
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (D.S.)
| | - Luke Maillie
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (L.M., M.S.D.)
| | - Mandip S Dhamoon
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY (L.M., M.S.D.)
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Anaesthetic and peri-operative management for thrombectomy procedures in stroke patients. Anaesth Crit Care Pain Med 2023; 42:101188. [PMID: 36599377 DOI: 10.1016/j.accpm.2022.101188] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Accepted: 12/15/2022] [Indexed: 01/02/2023]
Abstract
PURPOSE To provide recommendations for the anaesthetic and peri-operative management for thrombectomy procedure in stroke patients DESIGN: A consensus committee of 15 experts issued from the French Society of Anaesthesia and Intensive Care Medicine (Société Française d'Anesthésie et Réanimation, SFAR), the Association of French-language Neuro-Anaesthetists (Association des Neuro-Anesthésistes Réanimateurs de Langue Francaise, ANARLF), the French Neuro-Vascular Society (Société Francaise de Neuro-Vasculaire, SFNV), the French Neuro-Radiology Society (Société Francaise de Neuro-Radiologie, SFNR) and the French Study Group on Haemostasis and Thrombosis (Groupe Français d'Études sur l'Hémostase et la Thrombose, GFHT) was convened, under the supervision of two expert coordinators from the SFAR and the ANARLF. A formal conflict-of-interest policy was developed at the outset of the process and enforced throughout. The entire guideline elaboration process was conducted independently of any industry funding. The authors were required to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of quality of evidence. METHODS Four fields were defined prior to the literature search: (1) Peri-procedural management, (2) Prevention and management of secondary brain injuries, (3) Management of antiplatelet and anticoagulant treatments, (4) Post-procedural management and orientation of the patient. Questions were formulated using the PICO format (Population, Intervention, Comparison, and Outcomes) and updated as needed. Analysis of the literature was then conducted and the recommendations were formulated according to the GRADE methodology. RESULTS The SFAR/ANARLF/SFNV/SFNR/GFHT guideline panel drew up 18 recommendations regarding anaesthetic management of mechanical thrombectomy procedures. Due to a lack of data in the literature allowing to conclude with high certainty on relevant clinical outcomes, the experts decided to formulate these guidelines as "Professional Practice Recommendations" (PPR) rather than "Formalized Expert Recommendations". After two rounds of rating and several amendments, a strong agreement was reached on 100% of the recommendations. No recommendation could be formulated for two questions. CONCLUSIONS Strong agreement among experts was reached to provide a sizable number of recommendations aimed at optimising anaesthetic management for thrombectomy in patients suffering from stroke.
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Cencer S, Tubergen T, Packard L, Gritters D, LaCroix H, Frye A, Wills N, Zachariah J, Wees N, Khan N, Min J, Dejesus M, Combs J, Khan M. Shorter Intensive Care Unit Stay (12 Hours) Post Thrombolysis Is Safe and Reduces Length of Stay for Minor Stroke Patients. Neurohospitalist 2022; 12:504-507. [DOI: 10.1177/19418744211048014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The current standard of practice for patients with acute ischemic stroke treated with intravenous tissue-type plasminogen activator (tPA) requires critical monitoring for 24-hours post-treatment due to the risk of symptomatic intracranial hemorrhage (sICH). This is a costly and resource intensive practice. In this study, we evaluated the safety and efficacy of this standard 24-hour ICU monitoring period compared with a shorter 12-hour ICU monitoring period for minor stroke patients (NIHSS 0-5) treated with tPA only. Stroke mimics and those who underwent thrombectomy were excluded. The primary outcome was length of hospital stay. Secondary outcome measures included sICH, deep venous thrombosis (DVT), pulmonary embolism (PE), pneumonia, favorable discharge to home or acute rehabilitation, readmission within 30 days, and favorable functional outcome defined as modified Rankin scale (mRS) of 0-2 at 90 days. Of the 122 patients identified, 77 were in the 24-hour protocol and 45 were in 12-hour protocol. There was significant difference in length of hospital stay for the 24-hour ICU protocol (2.8 days) compared with the 12-hour ICU protocol (1.8 days) ( P < 0.001). Although not statistically significant, the 12-hour group had favorable rates of sICH, 30-day readmission rates, favorable discharge disposition and favorable functional outcome. Rates of DVT, PE and aspiration pneumonia were identical between the groups. Compared with 24-hour ICU monitoring, 12-hour ICU monitoring after thrombolysis for minor acute ischemic stroke was not associated with any increase in adverse outcomes. A randomized trial is needed to verify these findings.
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Affiliation(s)
- Samantha Cencer
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Tricia Tubergen
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Laurel Packard
- Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
| | | | - Hattie LaCroix
- Office of Research, Spectrum Health, Grand Rapids, MI, USA
| | - Angela Frye
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Nicole Wills
- Nursing Administration, Spectrum Health, Grand Rapids, MI, USA
| | - Joseph Zachariah
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nabil Wees
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Nadeem Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jiangyong Min
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Michelle Dejesus
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Jordan Combs
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
| | - Muhib Khan
- Division of Neurology, Neuroscience Institute, Spectrum Health, Grand Rapids, MI, USA
- Michigan State University, Michigan, MI, USA
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Daneshvari NO, Johansen MC. Associations between cerebral magnetic resonance imaging infarct volume and acute ischemic stroke etiology. PLoS One 2021; 16:e0256458. [PMID: 34424914 PMCID: PMC8382190 DOI: 10.1371/journal.pone.0256458] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 08/08/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Identifying ischemic stroke etiology is necessary for proper treatment and secondary prevention. We sought to define associations between infarct volume and stroke subtypes. MATERIALS AND METHODS Inclusion criteria necessitated a Johns Hopkins Hospital inpatient admission (2017-2019) for ischemic stroke with confirmatory brain magnetic resonance imaging. Infarct volume was calculated using MRIcron© by a masked reviewer. Ischemic strokes were adjudicated using TOAST classification. Multivariable/multinomial logistic regression determined associations between infarct volume and stroke subtypes with interaction terms for infarct number and location. Stepwise adjustment accounted for potential confounders. RESULTS Patients (N = 150) were on average 61 years old, male (58%), and black (57%). Each 5mL increase in infarct volume was associated with cardioembolic (OR 1.07, 95%CI 1.01-1.14) and large-artery occlusions (OR 1.10, 95%CI 1.02-1.18), but lower odds of lacunar stroke (OR 0.18, 95%CI 0.06-0.55). There was no difference in risk of cardioembolic (base) and large-artery atherosclerotic strokes with increasing infarct volume (RRR 1.01, 95%CI 0.94-1.09), but risk of lacunar stroke was decreased (RRR 0.17, 95%CI 0.06-0.53). Infarct number (single vs multiple) modified the association between volume and subtype for large-artery occlusions (p-interaction 0.09). CONCLUSIONS In this study, larger volume infarcts were significantly associated with both cardioembolic and large-artery atherosclerotic strokes (no difference in the degree of association) and decreased odds of lacunar stroke. A single, large-volume stroke was associated with large-artery atherosclerosis, while multiple infarcts were associated with cardioembolism. Given the differential associations between volume, number of lesions, and stroke etiology, defining stroke subtypes in light of infarct volume might aid in clinical practice.
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Affiliation(s)
- Nicholas Omid Daneshvari
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
| | - Michelle Christina Johansen
- Department of Neurology, Cerebrovascular Division, The Johns Hopkins University School of Medicine, Baltimore, Maryland, United States of America
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LaBuzetta JN, Hirshman BR, Malhotra A, Owens RL, Kamdar BB. Practices and Patterns of Hourly Neurochecks: Analysis of 8,936 Patients With Neurological Injury. J Intensive Care Med 2021; 37:784-792. [PMID: 34219542 DOI: 10.1177/08850666211029220] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Patients experiencing acute neurological injury often receive hourly neurological assessments ("neurochecks") to capture signs of deterioration. While commonly utilized in the intensive care unit (ICU) setting, little is known regarding practices (i.e., variations by age and ordering services) and patterns (i.e., duration and post-discontinuation plans) of hourly neurochecks. To inform future quality improvement intervention efforts, we performed an analysis of hourly neurochecks using an electronic health record-based dataset. STUDY DESIGN AND METHODS Our 75-month retrospective dataset consisted of all health system ICU patients who received hourly neurochecks. Variables included age, admission diagnosis category, ordering provider, post-discontinuation order, and discharge destination. Multivariable Cox regression was used to evaluate factors associated with hourly neurocheck duration. RESULTS We evaluated 9,513 first admission hourly neurocheck orders in 8,936 patients. The trauma, neurosurgery, and neurocritical care services were responsible for 4,067 (43%), 2,071 (22%) and 1,697 (18%) hourly neurocheck orders, respectively. Median (interquartile range) hourly neurocheck duration was 1.09 (0.69, 2.35) days, and was greater than 3 and 7 days, respectively, for 1,773 (19%) and 640 (7%) patients. Median hourly neurocheck duration ranged from 0.87 (0.65, 1.68) to 1.60 (0.83, 2.97) days for neurosurgical and non-neurological ICU services, respectively. Upon discontinuation, 2,225 (23%) of hourly neurochecks were transitioned to no neurochecks. CONCLUSION Substantial differences exist between ICU services and practice patterns surrounding hourly neurochecks. Understanding these differences will help inform intervention efforts aimed at streamlining hourly neurocheck practices and outcomes for patients with acute neurological injury.
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Affiliation(s)
- Jamie Nicole LaBuzetta
- Division of Neurocritical Care, Department of Neurosciences, UC San Diego Health, La Jolla, CA, USA
| | - Brian R Hirshman
- Department of Neurosurgery, UC San Diego Health, La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, UC San Diego Health, La Jolla, CA, USA
| | - Robert L Owens
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, UC San Diego Health, La Jolla, CA, USA
| | - Biren B Kamdar
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, UC San Diego Health, La Jolla, CA, USA
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Faigle R, Chen BJ, Krieger R, Marsh EB, Alkhachroum A, Xiong W, Urrutia VC, Gottesman RF. Novel Score for Stratifying Risk of Critical Care Needs in Patients With Intracerebral Hemorrhage. Neurology 2021; 96:e2458-e2468. [PMID: 33790039 PMCID: PMC8205477 DOI: 10.1212/wnl.0000000000011927] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 02/19/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To develop a risk prediction score identifying patients with intracerebral hemorrhage (ICH) at low risk for critical care. METHODS We retrospectively analyzed data of 451 patients with ICH between 2010 and 2018. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting independent predictors of intensive care unit (ICU) needs according to strength of association. The risk score was tested in the validation cohort and externally validated in a dataset from another institution. RESULTS The rate of ICU interventions was 80.3%. Systolic blood pressure (SBP), Glasgow Coma Scale (GCS) score, intraventricular hemorrhage (IVH), and ICH volume were independent predictors of critical care, resulting in the following point assignments for the Intensive Care Triaging in Spontaneous Intracerebral Hemorrhage (INTRINSIC) score: SBP 160 to 190 mm Hg (1 point), SBP >190 mm Hg (3 points); GCS 8 to 13 (1 point), GCS <8 (3 points); ICH volume 16 to 40 cm3 (1 point), ICH volume >40 cm3 (2 points); and presence of IVH (1 point), with values ranging between 0 and 9. Among patients with a score of 0 and no ICU needs during their emergency department stay, 93.6% remained without critical care needs. In an external validation cohort of patients with ICH, the INTRINSIC score achieved an area under the receiver operating characteristic curve of 0.823 (95% confidence interval 0.782-0.863). A score <2 predicted the absence of critical care needs with 48.5% sensitivity and 88.5% specificity, and a score <3 predicted the absence of critical care needs with 61.7% sensitivity and 83.0% specificity. CONCLUSION The INTRINSIC score identifies patients with ICH who are at low risk for critical care interventions. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that the INTRINSIC score identifies patients with ICH at low risk for critical care interventions.
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Affiliation(s)
- Roland Faigle
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH.
| | - Bridget J Chen
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Rachel Krieger
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Elisabeth B Marsh
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Ayham Alkhachroum
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Wei Xiong
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Victor C Urrutia
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
| | - Rebecca F Gottesman
- From the Department of Neurology (R.F., B.J.C., R.K., E.B.M., V.C.U., R.F.G.), Johns Hopkins University School of Medicine, Baltimore, MD; Department of Neurology (A.A.), University of Miami, Miller School of Medicine, Jackson Memorial Health System, FL; and Department of Neurology (W.X.), Case Western Reserve University School of Medicine, University Hospitals Cleveland Medical Center, OH
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Wang Z, Han Y, Tian S, Bao J, Wang Y, Jiao J. Lupeol Alleviates Cerebral Ischemia-Reperfusion Injury in Correlation with Modulation of PI3K/Akt Pathway. Neuropsychiatr Dis Treat 2020; 16:1381-1390. [PMID: 32581541 PMCID: PMC7276199 DOI: 10.2147/ndt.s237406] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 04/08/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND/AIM This study aimed to investigate the effect and mechanism of lupeol on cerebral ischemia-reperfusion injury in rats. METHODS The effects of lupeol on cerebral infarction, cerebral water content, neurological symptoms and cerebral blood flow in rats were evaluated. Nissl staining was carried out to assess the neuronal damage of ischemic brain after I/R in rats. Apoptosis of ischemic brain neurons after I/R was detected by TUNEL staining. Western blotting was carried out to detect the effects of lupeol on the expression of p-PDK1, p-Akt, pc-Raf, p-BAD, cleaved caspase-3 and p-PTEN. RESULTS Lupeol significantly increased cerebral blood flow after I/R in rats, reduced brain water content and infarct volume, and decreased neurological function scores. It significantly reduced neuronal damage after I/R in rats, and significantly reduced neuronal cell loss. PI3K inhibitor (LY294002) can eliminate the effect of lupeol on I/R in rats. In addition, lupeol significantly increased the protein expression of p-PDK1, p-Akt, pc-Raf, p-BAD, and down-regulated the expression of cleaved caspase-3. LY294002 reversed the effects of lupeol on the expression of PI3K/Akt signaling pathway-related proteins and cleaved caspase-3 after I/R in rats. CONCLUSION Lupeol had significant neuroprotective effects on brain I/R injury and neuronal apoptosis, and its mechanism may be related to the activation of PI3K/Akt signaling pathway.
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Affiliation(s)
- Zhiwei Wang
- Department of Internal Medicine-Neurology, The First Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province 050031, People's Republic of China
| | - Yanfen Han
- Department of Internal Medicine-Neurology, The Affiliated Hospital of Sergeant School of Army Medical University, Shijiazhuang City, Hebei Province 050000, People's Republic of China
| | - Shujuan Tian
- Department of Internal Medicine-Neurology, The First Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province 050031, People's Republic of China
| | - Junqiang Bao
- Department of Internal Medicine-Neurology, The First Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province 050031, People's Republic of China
| | - Yahui Wang
- Department of Rehabilitation, The First Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province 050031, People's Republic of China
| | - Junping Jiao
- Department of Internal Medicine-Neurology, The First Hospital of Hebei Medical University, Shijiazhuang City, Hebei Province 050031, People's Republic of China
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Yeo LLL, Tan BYQ, Andersson T. Review of Post Ischemic Stroke Imaging and Its Clinical Relevance. Eur J Radiol 2017; 96:145-152. [PMID: 28237773 DOI: 10.1016/j.ejrad.2017.02.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 02/09/2017] [Accepted: 02/11/2017] [Indexed: 10/20/2022]
Abstract
In this day and age, multiple imaging modalities are available to the stroke physician in the post-treatment phase.The practical challenge for physicians who treat stroke is to evaluate the pros and cons of each technique and select the best choice for the situation. The choice of imaging modality remains contentious at best and varies among different institutions and centres. This is no simple task an there are many factors to consider, including the differential diagnosis which need to be evaluated, the availability and reliability of the imaging technique and time and expertise required to perform and interpret the scanning. Other ancillary competing interest also come into play such as the financial cost of the modality, the requirement for patient monitoring during the imaging procedure and patient comfort. In an effort to clear some of the ambiguity surrounding this topic we present some of the current techniques in use and others, which are still in the realm of research and have not yet transitioned into clinical practice.
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Affiliation(s)
- Leonard L L Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
| | - Benjamin Y Q Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden; Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
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McDermott M, Jacobs T, Morgenstern L. Critical care in acute ischemic stroke. HANDBOOK OF CLINICAL NEUROLOGY 2017; 140:153-176. [PMID: 28187798 DOI: 10.1016/b978-0-444-63600-3.00010-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Most ischemic strokes are managed on the ward or on designated stroke units. A significant proportion of patients with ischemic stroke require more specialized care. Several studies have shown improved outcomes for patients with acute ischemic stroke when neurocritical care services are available. Features of acute ischemic stroke patients requiring intensive care unit-level care include airway or respiratory compromise; large cerebral or cerebellar hemisphere infarction with swelling; infarction with symptomatic hemorrhagic transformation; infarction complicated by seizures; and a large proportion of patients require close management of blood pressure after thrombolytics. In this chapter, we discuss aspects of acute ischemic stroke care that are of particular relevance to a neurointensivist, covering neuropathology, neurodiagnostics and imaging, blood pressure management, glycemic control, temperature management, and the selection and timing of antithrombotics. We also focus on the care of patients who have received intravenous thrombolysis or mechanical thrombectomy. Complex clinical decision making in decompressive hemicraniectomy for hemispheric infarction and urgent management of basilar artery thrombosis are specifically addressed.
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Affiliation(s)
- M McDermott
- Stroke Program, University of Michigan, Ann Arbor, MI, USA.
| | - T Jacobs
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - L Morgenstern
- Stroke Program, University of Michigan, Ann Arbor, MI, USA
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Faigle R, Marsh EB, Llinas RH, Urrutia VC, Gottesman RF. ICAT: a simple score predicting critical care needs after thrombolysis in stroke patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:26. [PMID: 26818069 PMCID: PMC4730614 DOI: 10.1186/s13054-016-1195-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/15/2016] [Indexed: 12/20/2022]
Abstract
Background Patients receiving intravenous thrombolysis (IVT) for acute ischemic stroke are at risk of developing complications, commonly necessitating admission to an intensive care unit (ICU). At present, most IVT is administered in the Emergency Department or in dedicated stroke units, but no evidence-based criteria exist that allow for early identification of patients at increased risk of developing ICU needs. The present study describes a novel prediction score aiming to identify a subpopulation of post-IVT patients at high risk for critical care interventions. Methods We retrospectively analyzed data from 301 patients undergoing IVT at our institutions during a 5-year period. Two hundred and ninety patients met inclusion criteria. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of critical care needs based on strength of association. Results Seventy-two patients (24.8 %) required critical care interventions. Black race (odds ratio [OR] 3.81, p =0.006), male sex (OR 3.79, p =0.008), systolic blood pressure (SBP; OR 1.45 per 10 mm Hg increase in SBP, p <0.001), and NIH stroke scale (NIHSS; OR 1.09 per 1 point increase in NIHSS, p =0.071) were independent predictors of critical care needs. The optimal model for score development, predicting critical care needs, achieved an AUC of 0.782 in the validation group. The score was named the ICAT (Intensive Care After Thrombolysis) score, assigning the following points: black race (1 point), male sex (1 point), SBP (2 points if 160–200 mm Hg; 4 points if >200 mm Hg), and NIHSS (1 point if 7–12; 2 points if >12). Each 1-point increase in the score was associated with 2.22-fold increased odds for critical care needs (95 % CI 1.78–2.76, p <0.001). A score ≥2 was associated with over 13 times higher odds of critical care needs compared to a score <2 (OR 13.60, 95 % CI 3.23–57.19), predicting critical care with 97.2 % sensitivity and 28.0 % specificity. Conclusion The ICAT score, combining information about race, sex, SBP, and NIHSS, predicts critical care needs in post-IVT patients and may be helpful when triaging post-IVT patients to the appropriate monitoring environment. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1195-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA.
| | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| | - Rafael H Llinas
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
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