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Imeh-Nathaniel E, Imeh-Nathaniel S, Imeh-Nathaniel A, Coker-Ayo O, Kulkarni N, Nathaniel TI. Sex Differences in Severity and Risk Factors for Ischemic Stroke in Patients With Hyperlipidemia. Neurosci Insights 2024; 19:26331055241246745. [PMID: 38706531 PMCID: PMC11069268 DOI: 10.1177/26331055241246745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 03/27/2024] [Indexed: 05/07/2024] Open
Abstract
Objective This study aims to determine sex differences in poststroke hypertriglyceridemia (serum triglyceride levels ⩾ 200 mg/dl) and high stroke severity in ischemic stroke patients. Method Our study analyzed data from 392 males and 373 females with hypertriglyceridemia. Stroke severity on admission was measured using the National Institute of Health Stroke Scale (NIHSS) with a value ⩽7 indicating a more favorable post-stroke prognosis while a score of >7 indicates poorer post-stroke outcomes. Logistic regression models adjusted for demographic and risk factors. The adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for each clinical risk factor were used to predict the increasing odds of an association of a specific clinical baseline risk factor with the male or female AIS with hypertriglyceridemia. Results In the adjusted analysis, male patients with hypertriglyceridemia, diastolic blood pressure (OR = 1.100, 95% CI, 1.034-1.171, P = .002), and Ischemic stroke mortality (OR = 6.474, 95% CI, 3.262-12.847, P < .001) were significantly associated with increased stroke severity. In female patients with hypertriglyceridemia, age (OR = 0.920, 95% CI, 0.866-0.978, P = .008) was associated with reduced stroke severity, while ischemic stroke mortality score (OR = 37.477, 95% CI, 9.636-145.756, P < .001) was associated with increased stroke severity. Conclusion Increased ischemic stroke mortality risk score was associated with increased severity in both male and female AIS patients with hypertriglyceridemia. Our findings provide information about sex differences in specific risk factors that can be managed to improve the care of male and female ischemic stroke patients with hypertriglyceridemia.
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Affiliation(s)
| | | | | | | | | | - Thomas I Nathaniel
- School of Medicine Greenville, University of South Carolina, Greenville, SC, USA
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2
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Brown C, Terrell K, Goodwin R, Nathaniel T. Stroke Severity in Ischemic Stroke Patients with a History of Diastolic Blood Pressure Treated in a Telestroke Network. J Cardiovasc Dev Dis 2022; 9:jcdd9100345. [PMID: 36286297 PMCID: PMC9604184 DOI: 10.3390/jcdd9100345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/26/2022] [Accepted: 10/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background: The relationship between diastolic blood pressure (DBP), risk factors, and stroke severity in acute ischemic stroke (AIS) patients treated in a telestroke network is not fully understood. The present study aims to determine the effect of risk factors on stroke severity in AIS patients with a history of elevated DBP. Material and Methods: We retrospectively analyzed data on stroke severity for AIS patients treated between January 2014 and June 2016 treated in the PRISMA Health telestroke network. Data on the severity of stroke on admission were evaluated using NIHSS scores ≤7 for reduced, and >7 for increased, stroke severity. DBP was stratified as ≤80 mmHg for reduced DBP and >80 mmHg for elevated DBP. The study’s primary outcomes were risk factors associated with improving neurologic functions or reduced stroke severity and deteriorating neurologic functions or increased stroke severity. The associations between risk factors and stroke severity for AIS with elevated DBP were determined using multi-level logistic and regression models. Results: In the adjusted analysis, AIS patients with a DBP ≤ 80 mmHg, obesity (OR = 0.388, 95% Cl, 0.182−0.828, p = 0.014) was associated with reduced stroke severity, while an increased heart rate (OR = 1.025, 95% Cl, 1.001−1.050, p = 0.042) was associated with higher stroke severity. For AIS patients with a DBP > 80 mmHg, hypertension (OR = 3.453, 95% Cl, 1.137−10.491, p = 0.029), history of smoking (OR = 2.55, 95% Cl, 1.06−6.132, p = 0.037), and heart rate (OR = 1.036, 95% Cl, 1.009−1.064, p = 0.009) were associated with higher stroke severity. Caucasians (OR = 0.294, 95% Cl, 0.090−0.964, p = 0.002) and obesity (OR = 0.455, 95% Cl, 0.207−1.002, p = 0.05) were more likely to be associated with reduced stroke severity. Conclusions: Our findings reveal specific risk factors that can be managed to improve the care of AIS patients with elevated DBP treated in the telestroke network.
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Affiliation(s)
- Christina Brown
- Department of Biology, College of Charleston, Charleston, SC 29424, USA
| | - Kameron Terrell
- Department of Biology, College of Charleston, Charleston, SC 29424, USA
| | - Richard Goodwin
- Department of Biology, College of Charleston, Charleston, SC 29424, USA
- School of Medicine Greenville, University of South Carolina, Greenville, SC 29605, USA
| | - Thomas Nathaniel
- School of Medicine Greenville, University of South Carolina, Greenville, SC 29605, USA
- Correspondence:
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3
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Molecular mechanisms underlying some major common risk factors of stroke. Heliyon 2022; 8:e10218. [PMID: 36060992 PMCID: PMC9433609 DOI: 10.1016/j.heliyon.2022.e10218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/10/2022] [Accepted: 08/04/2022] [Indexed: 11/25/2022] Open
Abstract
Ischemic and hemorrhagic strokes are the most common known cerebrovascular disease which can be induced by modifiable and non-modifiable risk factors. Age and race are the most common non-modifiable risk factors of stroke. However, hypertension, diabetes, obesity, dyslipidemia, physical inactivity, and cardiovascular disorders are major modifiable risk factors. Understanding the molecular mechanism mediating each of these risk factors is expected to contribute significantly to reducing the risk of stroke, preventing neural damage, enhancing rehabilitation, and designing suitable treatments. Abnormalities in the structure of the blood-brain barrier and blood vessels, thrombosis, vasoconstriction, atherosclerosis, reduced cerebral blood flow, neural oxidative stress, inflammation, and apoptosis, impaired synaptic transmission, excitotoxicity, altered expression/activities of many channels and signaling proteins are the most knows mechanisms responsible for stroke induction. However, the molecular role of risk factors in each of these mechanisms is not well understood and requires a lot of search and reading. This review was designed to provide the reader with a single source of information that discusses the current update of the prevalence, pathophysiology, and all possible molecular mechanisms underlying some major risk factors of stroke namely, hypertension, diabetes mellitus, dyslipidemia, and lipid fraction, and physical inactivity. This provides a full resource for understanding the molecular effect of each of these risk factors in stroke.
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Rech MA, Donahey E, DeMott JM, Coles LL, Peksa GD. The impact of antihypertensive use in the treatment of acute ischemic stroke in patients receiving alteplase. Am J Emerg Med 2021; 50:93-96. [PMID: 34329955 DOI: 10.1016/j.ajem.2021.07.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 06/30/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND Treatment of acute ischemic stroke (AIS) with intravenous alteplase within 4.5 h of symptom onset is associated with neurologic improvement. High baseline blood pressure (BP) and BP variability during the first 24 h of AIS is associated with increased early adverse events and death. The purpose of this study is to characterize the incidence of poor neurologic outcome in patients treated with alteplase for AIS who received antihypertensive medications prior to and within the first 24 h following alteplase administration compared with patients who did not. METHODS This was a multicenter, retrospective cohort of patients >18 years diagnosed with AIS from January 1, 2011 through December 31, 2015 who received one or more antihypertensive medication in the first 24 h of AIS in patients receiving alteplase compared to controls. The primary endpoint was poor neurologic outcome at 90 days, according to modified Rankin Scale ≥3. Univariate analysis was conducted using Chi-square, Fisher's exact test, or Mann-Whitney U test. Multivariable logistic regression was conducted to determine independent predictors of poor outcome. RESULTS Of the 587 patients evaluated, 351 (59.7%) were included, of which 127 (36.2%) received antihypertensive(s). More patients in the antihypertensive treatment group had a history of hypertension (88.2% vs. 69.6%, p < 0.01), diabetes (37% vs. 25.5%, p = 0.03) and chronic kidney disease (19.7% vs. 8.5%, p < 0.01). Intravenous push labetalol was most commonly administered (81.2%), followed by nicardipine (44.1%), and hydralazine (22%). More patients in the antihypertensive treatment group experienced poor neurologic outcome at 90 days (53.5% vs. 38.8%, p < 0.01), however, this finding was not observed after multivariable logistic regression. CONCLUSION Antihypertensive treatment in the first 24 h of AIS was associated with poor neurologic outcomes at 90 days. However, after controlling for other clinical factors in a multivariable logistic regression, this association was no longer observed.
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Affiliation(s)
- Megan A Rech
- Department of Emergency Medicine, Stritch School of Medicine, Loyola University Chicago, 2160 S 1st Ave, Maywood, IL 60153, United States of America.
| | - Elisabeth Donahey
- Department of Pharmacy, Loyola University Medical Center, 2160 S 1st Ave, Maywood, IL 60153, United States of America.
| | - Joshua M DeMott
- Rush University Medical Center, Chicago IL, 1653 W Congress Pkwy, Chicago, IL 60612, United States of America.
| | - Laura L Coles
- Novant Health Forsyth Medical Center, 3333 Silas Creek Pkwy, Winston-Salem, NC 27103, United States of America
| | - Gary D Peksa
- Rush University Medical Center, Chicago IL, 1653 W Congress Pkwy, Chicago, IL 60612, United States of America.
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5
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Thomson J, New PW. Pharmacological management of stroke in older people. JOURNAL OF PHARMACY PRACTICE AND RESEARCH 2021. [DOI: 10.1002/jppr.1703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Julia Thomson
- Department of Medicine Rehabilitation and Aged Services Program, Kingston Centre Monash Health Clayton Australia
| | - Peter Wayne New
- Department of Medicine Rehabilitation and Aged Services Program, Kingston Centre Monash Health Clayton Australia
- Rehabilitation Services Caulfield Hospital Alfred Health Victoria Australia
- Epworth‐Monash Rehabilitation Medicine Unit Monash Medical School Monash University Parkville Australia
- Department of Epidemiology and Preventive Medicine School of Public Health and Preventive Medicine Monash University Parkville Australia
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Li G, Zhang B, Zhang M, Liu Q, Luo J, Liao Q, Tan M, Bai Z, Xu J, Sun J, Chen M. A non-invasive real-time monitoring system for cytotoxic brain edema in post ischemic stroke based on near-field coupling. Technol Health Care 2021; 29:963-978. [PMID: 33427707 DOI: 10.3233/thc-202685] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND As a common secondary pathophysiological process in postischemic stroke (IS), cytotoxic brain edema (CBE) is an independent factor leading to poor prognosis of patients. Near-field coupling (NFC) technology has some advantages such as non-invasive, non-contact, and unimpeded penetration of the skull. In theory, it can reflect the difference between normal and edema tissues through the near-field coupling phase shift (NFCPS) in the electromagnetic wave transmission trait. METHODS Combining NFC detection principle and computer programming, we established a high-performance real-time monitoring system with functions such as automatic setting of measurement parameters, data acquisition, real-time filtering and dynamic waveform display. To investigate the feasibility of this system to detect CBE, a saline simulation experiment and a 24-hour real-time monitoring experiment after middle cerebral artery occlusion (MCAO) in rats were carried out. RESULTS The results of the saline simulation experiment showed that the change of NFCPS was proportional to the increase of the simulated edema solution, and the variation range of NFCPS was more than 9∘ after 5 ml injection. In the 24-hour monitoring after MCAO, the NFCPS of the experimental group showed an overall downward trend over time an average change of -17.7868 ± 1.6325∘ and the change rate gradually decreased. The 24-hour NFCPS in the control group fluctuates slightly around the initial value, which has no obvious upward or downward trend. CONCLUSION The intragroup and intergroup difference statistical analysis shows that NFCPS can effectively distinguish different intracranial pathophysiological states after IS. This work provides sufficient evidence and a technical basis for using NFCPS to monitor CBE in the future.
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Affiliation(s)
- Gen Li
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Bo Zhang
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Maoting Zhang
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Qi Liu
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Jie Luo
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Qi Liao
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Mei Tan
- Department of Biomedical Engineering, Chongqing University of Technology, Chongqing, China
| | - Zelin Bai
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Jia Xu
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Jian Sun
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Mingsheng Chen
- College of Biomedical Engineering, Army Medical University, Chongqing, China
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7
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Chu YM, Choi KS. Effectiveness of patient education in acute stroke: a comparison between a customised computer system and a pictorial information booklet. BMJ Health Care Inform 2020; 27:bmjhci-2020-100144. [PMID: 32816839 PMCID: PMC7430415 DOI: 10.1136/bmjhci-2020-100144] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 07/07/2020] [Accepted: 07/08/2020] [Indexed: 11/03/2022] Open
Abstract
BackgroundPatients who develop acute stroke are at high risk for deterioration in the first 48–72 hours after admission. An effective educational intervention is needed.ObjectiveThis study aimed to examine the applicability of the customised interactive computer education system (CICS) in patients who had a stroke in the early acute phase in order to determine the efficacy of the education system in (1) information satisfaction and (2) physiological related management compliance.MethodsThe prospective non-blinded randomised controlled study was conducted in an acute stroke unit of a local hospital in Hong Kong from March to August 2019. Chinese participants were selected if they were at least 18 years of age, experienced a minor stroke within 3 days. The exclusion criteria were communication problem and comorbidity with another acute disease. On the first day of admission, participants were allocated to the CICS and booklet groups, with each group comprising 50 participants. On the third day, the primary outcome, Modified Information Satisfaction Questionnaire for Acute Stroke (MISQ-S), was assessed.ResultsThere was a significant difference in ‘the need to improve information measures’ of the MISQ-S (p=0.04) between the CICS and booklet groups. The management compliance of these two groups did not have difference, but the CICS group had better clinical outcome, though not significant (p=0.387).ConclusionPatient education was needed and feasible in the early acute phase, and the CICS was more efficacious than the booklet. The positive results provided insights into and give a direction to the use of information technology in patient education.
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Affiliation(s)
- Yin Man Chu
- Department of Medicine, Tseung Kwan O Hospital, Tseung Kwan O, Hong Kong
| | - Kup Sze Choi
- School of Nursing, Hong Kong Polytechnic University, Kowloon, Hong Kong
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8
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Saladini F, Mancusi C, Bertacchini F, Spannella F, Maloberti A, Giavarini A, Rosticci M, Bruno RM, Pucci G, Grassi D, Pengo M, Muiesan ML. Diagnosis and treatment of hypertensive emergencies and urgencies among Italian emergency and intensive care departments. Results from an Italian survey: Progetto GEAR (Gestione dell'Emergenza e urgenza in ARea critica). Eur J Intern Med 2020; 71:50-56. [PMID: 31690479 DOI: 10.1016/j.ejim.2019.10.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/26/2019] [Accepted: 10/05/2019] [Indexed: 10/25/2022]
Abstract
Hypertensive emergencies (HE) and urgencies (HU) are frequent causes of patients referral to Emergency Department (ED) and the approach may be different according to local clinical practice. Our aim was to explore awareness, management, treatment and counselling after discharge of HE and HU in Italy, by mean of an on-line survey. The young investigator research group of the Italian Society of Hypertension developed a 23-item questionnaire spread by e-mail invitation to the members of Italian Scientific societies in the field of Hypertension. 665 questionnaires were collected from EDs, Emergency and Urgency Medicine, Cardiology or Coronary Units, Internal Medicines, Intensive care, Stroke units. Symptoms considered suspicious of acute organ damage were: chest pain (89.0%), visual disturbances (89.8%), dyspnoea (82.7%), headache (82.1%), dizziness (52.0%), conjunctival haemorrhages (41.5%), tinnitus (38.2%) and epistaxis (34.4%). Exams more frequent prescribed were: electrocardiogram (97.2%), serum creatinine (91.4%), markers of cardiomyocyte necrosis (66.2%), echocardiography (65.1%). The use of intravenous or oral medications to treat HEs was 94.7% and 3.5%, while for HUs 24.4% and 70.8% respectively. Of note, a surprisingly high percentage of physicians (22 % overall, 24.5% in North Italy) used to prescribe sublingual nifedipine. After discharge, home blood pressure monitoring and general practitioner re-evaluation were more frequently suggested, while ambulatory blood pressure monitoring and hypertension specialist examination were less prescribed. The differences observed across the different macro-areas, regarded prescription of diagnostic test and drug administration. This survey depicts a complex situation of shades and lights in the real-life management of HE and HU in Italy.
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Affiliation(s)
- F Saladini
- Department of Medicine, University of Padova, Italy; Cardiology Unit, Cittadella Town Hospital, Padova, Italy.
| | - C Mancusi
- Hypertension Research Center, Department of Advanced Biomedical Science, Federico II University of Naples, Italy
| | - F Bertacchini
- Internal Medicine, University of Brescia-ASST Spedali Civili di Brescia, Italy
| | - F Spannella
- Internal Medicine and Geriatrics, IRCCS-INRCA, Ancona, Italy; Department of Clinical and Molecular Sciences, University "Politecnica delle Marche", Ancona, Italy
| | - A Maloberti
- Cardiology 4, ASST Niguarda Hospital, Milan, Italy; School of Medicine and Surgery, Milano-Bicocca University, Milan, Italy
| | - A Giavarini
- Cardiology Unit, Luigi Sacco Hospital, ASST Fatebenefratelli Sacco, Milano, Italy
| | - M Rosticci
- Medicine and Surgery Sciences Department, Alma Mater Studiorum University of Bologna, Italy
| | - R M Bruno
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - G Pucci
- Internal Medicine, Department of Medicine, University of Perugia, Terni University Hospital, Italy
| | - D Grassi
- Department of Internal medicine and Public Health, University of Aquila, Italy
| | - M Pengo
- Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milano, Italy
| | - M L Muiesan
- Internal Medicine, University of Brescia-ASST Spedali Civili di Brescia, Italy
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Amatangelo MP, Thomas SB. Priority Nursing Interventions Caring for the Stroke Patient. Crit Care Nurs Clin North Am 2019; 32:67-84. [PMID: 32014162 DOI: 10.1016/j.cnc.2019.11.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Nearly 20% of all patients with ischemic stroke will require care in an intensive care unit (ICU), particularly those who have received intravenous alteplase or endovascular therapy. Prioritizing nursing intervention and intensive care monitoring can improve patient outcomes and reduce disability. A collaborative interdisciplinary team approach best facilitates the ICU care of an acute stroke patient.
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Affiliation(s)
- Mary P Amatangelo
- Neurology, Stroke, Neurocritical Care, Brigham and Women's Hospital, 15 Francis Street, BB 335, Boston, MA 02115, USA.
| | - Sarah Beth Thomas
- Neuroscience/Critical Care, Brigham Health/Brigham and Women's Hospital, 75 Francis Street, Tower 10-65, Boston, MA 02115, USA
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10
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Brandler ES, Baksh N. Emergency management of stroke in the era of mechanical thrombectomy. Clin Exp Emerg Med 2019; 6:273-287. [PMID: 31910498 PMCID: PMC6952636 DOI: 10.15441/ceem.18.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 10/13/2018] [Accepted: 10/24/2018] [Indexed: 01/01/2023] Open
Abstract
Emergency management of stroke has been directed at the delivery of recombinant tissue plasminogen activator (tPA) in a timely fashion. Because of the many limitations attached to the delivery of tPA and the perceived benefits accrued to tPA, its use has been limited. Mechanical thrombectomy, a far superior therapy for the largest and most disabling strokes, large vessel occlusions (LVOs), has changed the way acute strokes are managed. Aside from the rush to deliver tPA, there is now a need to identify LVO and refer those patients with LVO to physicians and facilities capable of delivering urgent thrombectomy. Other parts of emergency department management of stroke are directed at identifying and mitigating risk factors for future strokes and at preventing further damage from occurring. We review here the most recent literature supporting these advances in stroke care and present a framework for understanding the role that emergency physicians play in acute stroke care.
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Affiliation(s)
- Ethan S. Brandler
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
| | - Nayeem Baksh
- Department of Emergency Medicine, State University of New York at Stony Brook, Stony Brook, NY, USA
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11
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Liu Y, Manners J, Bittar Y, Chou SHY, Gopalakrishnan V. Towards precision critical care management of blood pressure in hemorrhagic stroke patients using dynamic linear models. PLoS One 2019; 14:e0220283. [PMID: 31381589 PMCID: PMC6681940 DOI: 10.1371/journal.pone.0220283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 07/14/2019] [Indexed: 11/18/2022] Open
Abstract
Finding optimal blood pressure (BP) target and BP treatment after acute ischemic or hemorrhagic strokes is an area of controversy and a significant unmet need in the critical care of stroke victims. Numerous large prospective clinical trials have been done to address this question but have generated neutral or conflicting results. One major limitation that may have contributed to so many neutral or conflicting clinical trial results is the "one-size fit all" approach to BP targets, while the optimal BP target likely varies between individuals. We address this problem with the Acute Intervention Model of Blood Pressure (AIM-BP) framework: an individualized, human interpretable model of BP and its control in the acute care setting. The framework consists of two components: one, a model of BP homeostasis and the various effects that perturb it; and two, a parameter estimator that can learn clinically important model parameters on a patient by patient basis. By estimating the parameters of the AIM-BP model for a given patient, the effectiveness of antihypertensive medication can be quantified separately from the patient's spontaneous BP trends. We hypothesize that the AIM-BP is a sufficient framework for estimating parameters of a homeostasis perturbation model of a stroke patient's BP time course and the AIM-BP parameter estimator can do so as accurately and consistently as a state-of-the-art maximum likelihood estimation method. We demonstrate that this is the case in a proof of concept of the AIM-BP framework, using simulated clinical scenarios modeled on stroke patients from real world intensive care datasets.
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Affiliation(s)
- Yuzhe Liu
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
| | - Jody Manners
- Department of Neurology, Naval Medical Center Portsmouth, Portsmouth, VA, United States of America
| | - Yazan Bittar
- Lewis Katz School of Medicine, Temple University, Philadelphia, PA, United States of America
| | - Sherry H-Y. Chou
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
- Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States of America
| | - Vanathi Gopalakrishnan
- Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, PA, United States of America
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12
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Chronopoulos A, Schutz JS. Central retinal artery occlusion-A new, provisional treatment approach. Surv Ophthalmol 2019; 64:443-451. [PMID: 30707925 DOI: 10.1016/j.survophthal.2019.01.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 01/13/2019] [Accepted: 01/17/2019] [Indexed: 10/27/2022]
Abstract
The retinal ganglion cells infarcted in central retinal artery occlusion (CRAO) are the somata of the optic nerve axons, part of the central nervous system. Consequently, CRAO with inner retinal infarction is a small vessel stroke, usually with the devastating consequence of severe visual loss in the affected eye. At present, there is no generally accepted, evidence-based therapy of nonarteritic CRAO in contrast to ischemic cerebral stroke that has well-accepted treatment protocols. Widely divergent and controversial therapeutic options for CRAO reflect the desperation of treating physicians and disparate conflicting studies. We examine reasons why treatment of nonarteritic CRAO remains problematic and then suggest a provisional new approach to treatment based on updated understanding of CRAO pathophysiology and analysis of current therapeutic options and their rationales.
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Affiliation(s)
- Argyrios Chronopoulos
- Department of Ophthalmology, Hospital of Ludwigshafen, Teaching Hospital of the University of Johannes Gutenberg-University Mainz, Mainz, Germany; Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland.
| | - James S Schutz
- Department of Ophthalmology, University Hospitals and School of Medicine, Geneva, Switzerland
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Sweid A, Atallah E, Saad H, Bekelis K, Chalouhi N, Dang S, Li J, Kumar A, Turpin J, Barsoom R, Tjoumakaris S, Hasan D, DePrince M, Labella G, Rosenwasser RH, Jabbour P. Correlation between pre-admission blood pressure and outcome in a large telestroke cohort. J Clin Neurosci 2019; 62:33-37. [PMID: 30660477 DOI: 10.1016/j.jocn.2019.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 01/03/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Telemedicine rapidly connects patients, with acute ischemic stroke symptoms, with neurovascular specialists for assessment to reduce chemical thrombolysis delivery times. Management of AIS includes maintaining target systolic blood pressures (SBP). In this retrospective study, we assess the efficacy of the telestroke (TS) system at a primary stroke center and the prognostic value of SBP throughout the transportation process. METHODS Patients presenting with acute-onset neurological symptoms to the TS hospitals network, over a 5-year period, were assessed. Those with a confirmed diagnosis of AIS were included. We examined demographics, presenting-NIHSS, last SBP before transfer from the network hospital and continuous BP during transport, stroke risk factors, hospital-course, door-to-needle (DTN) time, treatments, and modified Rankin Scale(mRS). Multivariate analysis was conducted to evaluate the prognostic value of SBP on stroke outcome. RESULTS Of 2,928 patients identified, 1,353 were diagnosed with AIS. Mean age was 66.6 years (SD = 15.4), 47.6% female. Most cases affected the MCA(44.5%). Mean presenting-NIHSS was 8.67(SD = 8.38) and mean SBP was 148 mmHg(SD = 25.39). 73.2% treated using a standard protocol, 23.7% given IVrt-PA, and 6.8% received mechanical thrombectomy(MT). Mean DTN was 96 min(SD = 46; 27.3% <60 min). Age, presenting-NIHSS and pre-existing hypertension were associated with higher mortality and/or higher mRS. SBP was not associated with higher mortality and morbidity. CONCLUSIONS This study displays better clinical outcomes at latest follow-up when compared to current international TS studies. SBP during transportation to the hub hospital did not prove to be a useful prognostic metric. However, future studies should address the limitations of this study to confirm these findings.
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Affiliation(s)
- Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Hassan Saad
- Department of Neurological Surgery, Arkansas Neurosciences Institute, Little Rock, AR, United States
| | - Kimon Bekelis
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Sophia Dang
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Jonathan Li
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Ayan Kumar
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Justin Turpin
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Randa Barsoom
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - David Hasan
- Department of Neurological Surgery, University of Iowa, Department of Neurosurgery, Iowa City, IA, United States.
| | - Maureen DePrince
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Giuliana Labella
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
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Managing high blood pressure during acute ischemic stroke and intracerebral hemorrhage. Curr Opin Neurol 2018; 31:8-13. [DOI: 10.1097/wco.0000000000000508] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Darger B, Gonzales N, Banuelos RC, Peng H, Radecki RP, Doshi PB. Outcomes of Patients Requiring Blood Pressure Control Before Thrombolysis with tPA for Acute Ischemic Stroke. West J Emerg Med 2015; 16:1002-6. [PMID: 26759644 PMCID: PMC4703175 DOI: 10.5811/westjem.2015.8.27859] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 08/26/2015] [Indexed: 11/30/2022] Open
Abstract
Introduction The purpose of this study was to assess safety and efficacy of thrombolysis in the setting of aggressive blood pressure (BP) control as it compares to standard BP control or no BP control prior to thrombolysis. Methods We performed a retrospective review of patients treated with tissue plasminogen activator (tPA) for acute ischemic stroke (AIS) between 2004–2011. We compared the outcomes of patients treated with tPA for AIS who required aggressive BP control prior to thrombolysis to those requiring standard or no BP control prior to thrombolysis. The primary outcome of interest was safety, defined by all grades of hemorrhagic transformation and neurologic deterioration. The secondary outcome was efficacy, determined by functional status at discharge, and in-hospital deaths. Results Of 427 patients included in the analysis, 89 received aggressive BP control prior to thrombolysis, 65 received standard BP control, and 273 required no BP control prior to thrombolysis. Patients requiring BP control had more severe strokes, with median arrival National Institutes of Health Stroke Scale of 10 (IQR [6–17]) in patients not requiring BP control versus 11 (IQR [5–16]) and 13 (IQR [7–20]) in patients requiring standard and aggressive BP lowering therapies, respectively (p=0.048). In a multiple logistic regression model adjusting for baseline differences, there were no statistically significant differences in adverse events between the three groups (P>0.10). Conclusion We observed no association between BP control and adverse outcomes in ischemic stroke patients undergoing thrombolysis. However, additional study is necessary to confirm or refute the safety of aggressive BP control prior to thrombolysis.
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Affiliation(s)
- Bryan Darger
- University of Texas Medical School at Houston, Houston, Texas
| | - Nicole Gonzales
- University of Texas Health Science Center at Houston, Department of Neurology, Houston, Texas
| | - Rosa C Banuelos
- University of Texas Medical School at Houston, Houston, Texas
| | - Hui Peng
- University of Texas Health Science Center at Houston, Department of Neurology, Houston, Texas
| | - Ryan P Radecki
- University of Texas Health Science Center at Houston, Department of Emergency Medicine, Houston, Texas
| | - Pratik B Doshi
- University of Texas Health Science Center at Houston, Department of Emergency Medicine, Houston, Texas
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16
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Hill CE, Varma P, Lenrow D, Price RS, Kasner SE. Reducing Errors in Transition from Acute Stroke Hospitalization to Inpatient Rehabilitation. Front Neurol 2015; 6:227. [PMID: 26579070 PMCID: PMC4621425 DOI: 10.3389/fneur.2015.00227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 10/12/2015] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE Effective stroke care does not end with acute treatment during hospitalization, but extends through rehabilitation and secondary stroke prevention. In transitions across care environments, stroke patients are vulnerable to errors in communication of diagnosis and treatment. This study aimed to demonstrate that formalized communication between the neurology team and the rehabilitation medicine team would promote secondary stroke prevention and minimize interruptions during rehabilitation. METHODS The intervention was a standardized verbal handoff by phone between the discharging neurology resident and the admitting rehabilitation resident regarding each patient at transfer. This retrospective cohort study compared a pre-intervention control group (September 2012 to February 2013) and a post-intervention group transferred with the handoff (September 2013 to January 2014). The outcomes measured included errors in communication of stroke severity, stroke mechanism, medications, and recommended follow-up (appointments and tests) as well as emergent brain imaging, return to the acute care facility, and readmission. RESULTS The pre- and post-intervention groups were similar with respect to number of patients (50 vs. 52) and demographics including gender (52 vs. 54% female), age (65.8 vs. 64.0 years), severity of illness as measured by the National Institutes of Health Stroke Scale (NIHSS) (10 vs. 6.5), and stroke type (84 vs. 77% ischemic). Implementation of the handoff decreased errors in communication of diagnosis (NIHSS 92 vs. 74%, p = 0.02; stroke mechanism 54 vs. 30%, p = 0.02). Furthermore, the handoff decreased the proportion with errors in reconciliation of critical medications (42 vs. 23%, p = 0.04). However, the intervention did not significantly reduce interruptions of the rehabilitation program, such as emergent brain imaging (8 vs. 12%, p = 0.55), or transfers back to the acute care hospital (26 vs. 21%, p = 0.56). CONCLUSION Standardized handoffs decreased errors in communication of diagnosis and critical medications for secondary stroke prevention.
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Affiliation(s)
- Chloé E Hill
- Department of Neurology, University of Pennsylvania , Philadelphia, PA , USA
| | - Priya Varma
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania , Philadelphia, PA , USA
| | - David Lenrow
- Department of Physical Medicine and Rehabilitation, University of Pennsylvania , Philadelphia, PA , USA
| | - Raymond S Price
- Department of Neurology, University of Pennsylvania , Philadelphia, PA , USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania , Philadelphia, PA , USA
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18
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Affiliation(s)
- José G Merino
- Department of Neurology, Johns Hopkins Community Physicians, Bethesda, MD
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