Faculty Bibliography

Background: Stroke code activations are a valuable tool in providing prompt care to stroke patients who may be eligible for treatments such as tPA and endovascular interventions. However, stroke codes involve the immediate attention of many members of the healthcare team and significant hospital resources. The National Institutes of Health Stroke Scale (NIHSS) is commonly used to evaluate stroke severity; however, even patients with an NIHSS score of zero can have ongoing neurologic symptoms and disability. Confusion over the goals of stroke codes and the appropriate situations for their use may contribute to unnecessary activations.
Objective(s): The purpose of this analysis was to evaluate the frequency of stroke code activations in situations where activating a stroke code provides little potential benefit in terms of therapeutic options over a non-emergent neurology consult.
Method(s): We reviewed the records for all emergency department (ED) stroke code activations over the first five months of 2018, looking specifically at cases with an NIHSS score of zero. Within this pool, we identified cases where the patient was documented as being asymptomatic during initial ED evaluation as their symptoms had resolved (transient ischemic attack), as well as those who had been symptomatic for over 24 hours and were outside the therapeutic window. These patients were not eligible for emergent therapeutic intervention. Thus, these were cases in which a stroke code activation was avoidable.
Result(s): Of the 120 stroke codes with an NIHSS of zero, 39 (32.5%) involved patients whose symptoms had completely resolved prior to arrival. Another three cases involved patients who had been symptomatic for over 24 hours and were outside the therapeutic window. Thus, of the stroke code activations with an NIHSS of zero in this time period, 42 (35%) were avoidable as these patients would not have been considered candidates for emergent treatment.
Conclusion(s): Clarification and reinforcement of appropriate criteria for stroke code activation have the potential to reduce overutilization of resources in situations unlikely to affect acute therapeutic management. Addressing this would allow for a reduction in the burden on healthcare professionals and ED resources

Objectives: To demonstrate the development and use of an acute imaging protocol for the metabolic assessment of tissue viability during acute stroke.
Method(s): The DAWN and DEFUSE 3 trials (1,2) have demonstrated that there is much to gain from the use of physiologically based guidelines to extend the use of mechanical recanalization. Literature reports provide strong data supporting the use of brain tissue sodium concentration (TSC) as a biomarker for identifying physiologically non-viable tissue during evolving brain ischemia (3,4). Testing this hypothesis in vivo, in humans, have been previously hampered by acquisition times that were long for routine clinical use. Recent developments in MRI data acquisition and hardware make it possible to acquire the data to provide the aforementioned assessment in under 5 minutes at a level of signal-to-noise ratio (SNR) and spatial resolution compatible with physiologically driven MRI scans such as diffusion weighted imaging and perfusion imaging. This was achieved using an Ultra-Short-Echo Time sequence with optimal acquisition throughput (TPI, TE/TR 0.3/100 ms, p 0.2). Signal excitation/reception was performed using a patient-friendly double-tuned (¹H/²³Na) birdcage coil (Quality Electrodynamics Inc., Mayfield Heights, Ohio). The protocol was implemented on a MAGNETOM Skyra 3 Tesla scanner at NYU's Tisch hospital. The scanner is located adjacent (20 feet) to the neuro interventional suite where patients are recanalized. Subject's anesthesia was maintained (FabiusMRI, DraegerInc., Telford, PA) and physiological status continuously monitored using MRI-compatible equipment (Expression MR400, Phillips Healthcare, Andover, MA).
Result(s): After phantom validation and healthy volunteer studies to determine the quantitative performance of the data acquisition techniques the protocol was used on post-endovascular thrombectomy subjects (n 3), immediately upon procedure completion and under its own IRB approved protocol. During these studies, the use of the proposed methodology was found to be compatible with the clinical care of the subjects. Specifically, performing the required scans was not found to interfere with the subject's post-recanalization care. Tissue sodium concentration data were, likewise, found to meet the required levels of SNR to provide the quantitative assessment mentioned above. A representative data set from one of these sessions is shown in figure 1. This mechanically-recanalized patient had an area of non-salvaged tissue in the left parietal lobe that is clearly depicted on the ²³Na MRI scan. The TSC in this area was 76 mM at the time of the scan. (Figure presented)
Conclusion(s): This work demonstrates that state-of-the-art MRI methodology can be used to provide a clinically viable imaging protocol for evaluating the use of sodium MRI as a quantitative biomarker for identifying physiologically viable tissue during evolving brain ischemia

Background and Aims: Contemplating the use of N-acetylcysteine as a neuroprotectant, with dextran as an antithrombotic for patients with NIHSS less than or equal to 5, we quantified treatment-relevant clinical characteristics of a sample of this patient population at a single stroke center over one year.
Method(s): Patients with NIHSSResult(s): One-hundred twenty-eight of 310 (41%) patients with ischemic stroke had NIHSSConclusion(s): Minor stroke symptoms may not be captured by the current NIHSS. This population rarely had renal or hepatic failure, making them good candidates for combination N-acetylcysteine and dextran

BACKGROUND AND PURPOSE/OBJECTIVE:Patients with intracerebral hemorrhage (ICH) frequently present with hypertension, but it is unclear if this is due to pre-existing hypertension (prHTN) or to the bleed itself or associated pain. We sought to assess the relationship between prHTN and admission systolic blood pressure (aBP) and bleed severity. METHODS:We retrospectively assessed the relationship between prHTN and aBP and NIHSS in patients with ICH at 3 institutions. RESULTS:Of 251 patients, 170 (68%) had prHTN based on history of hypertension/antihypertensive use. Median aBP was significantly higher in those with prHTN (155 mm Hg (IQR 135-181) versus 139 mm Hg (IQR 124-158), P < .001). Patients with left ventricular hypertrophy (LVH) on electrocardiogram (ECG) or transthoracic echocardiogram (TTE) had significantly higher aBP than those without LVH (median aBP 195 mm Hg (IQR 155-216) for patients with LVH on ECG versus 147 mm Hg (IQR 129-163) for patients with no LVH on ECG, P < .001; median aBP 181 mm Hg (IQR 153-214) for patients with LVH on TTE versus 152 mm Hg (IQR 137-169) for patients with no LVH on TTE, P = .01). prHTN was associated with a higher median NIHSS (11 (IQR 3-20) for patients with history of hypertension/antihypertensive use versus 6 (IQR 1-14) for patients without this history (P = .02); 9 (IQR 3-19) versus 5 (IQR 2-13) for patients with/without LVH on ECG (P = .085); and 10 (IQR 5-18) versus 5 (IQR 1-13) for patients with/without LVH on TTE (P = .046). CONCLUSIONS:Patients with ICH who have prHTN have higher aBP and NIHSS, suggesting that prHTN may worsen reactive hypertension in the setting of ICH.

Introduction The 5 seminal mechanical thrombectomy (MT) trials had a median age of 68 years. Though some of these trials included nonagenarians, there is little data on their outcomes. We aimed to compare the procedural, discharge outcomes and complications, of MT for acute ischemic stroke (AIS) in nonagenarians versus younger patients(<=69) Methods Patients with AIS admitted to two comprehensive stroke centers were enrolled prospectively in a registry. Rates of MT were compared between nonagenarians vs <=69. Among those who underwent MT, procedural outcomes, complications, and discharge disposition were compared in propensity scorematched groups (matched for NIHSS, pre-stroke mRS, IV-tPA administration and T IG grade>=2b) of nonagenarians to patients<=69. Good discharge disposition was defined as a discharge to home/acute rehabilitation. Results Of the 3010 AIS patients, 46/297 (16%) nonagenarians underwent MT compared to 159/1337 (12%) patients <=69 (P=0.091) with TICI>=2b of 89% vs 94%; p=0.238 respectively. 78 patients (N=39 >=90, N=39 <69) were propensity score-matched with a median admission NIHSS of 22 and 19, and median ASPECTS of 9 and 9, respectively (both P>0.05). Those <69 more often had Ml occlusions than nonagenarians (84% vs 50%, P=0.035), whereas ICA (10% vs 13%, p=0.76), and M2 (21% vs 43%, p=0.19) occlusions were similar between the two groups. Time to groin puncture (100+/-65 vs 76+/-34; p=0.124), revascularization time (134+/-72 vs 110+/-54; p=0.145), complication rates (0 vs 5.1%; p=0.494) and inhospital deaths (11% vs 24%; p=0.155) were similar among the two groups. 44% of nonagenarians had good discharge disposition, compared to 51% of patients <69 years (p=0.650) Conclusions We present one of the largest series of MT among nonagenarians with 89% successful recanalization rates. In propensity score analysis almost half of nonagenarians (44%) were discharged to home/rehab, which is comparable to a younger cohort (51%). Aggressive management is warranted in the oldest of the old

BACKGROUND AND PURPOSE/OBJECTIVE:The relationship between in-hospital hyperglycemia and neurological outcome after intracerebral hemorrhage (ICH) is not well studied. METHODS:We analyzed the relationships between pre-hospital and hospital variables including highest in-hospital glucose (HIHGLC) and discharge Glasgow Coma Scale (GCS), discharge Modified Rankin Scale (MRS) and 3-month MRS using a single-institution cohort of ICH patients between 2013 and 2015. RESULTS:There were 106 patients in our sample. Mean HIHGLC was 154 ± 58mg/dL for patients with discharge GCS of 15 and 180 ± 57mg/dL for patients with GCS < 15; 146 ± 55mg/dL for patients with discharge MRS 0-3 and 175 ± 58mg/dL for patients with discharge MRS 4-6; and 149 ± 52mg/dL for patients with 3-month MRS of 0-3 and 166 ± 61mg/dL for patients with 3-month MRS of 4-6. On univariate analysis, discharge GCS was associated with HIHGLC (P = .01), age (P = .006), ICH volume (P = .008), and length of stay (LOS) (P = .01); discharge MRS was associated with HIHGLC (P < .001), age (P < .001), premorbid MRS (P = .046), ICH volume (P < .001), and LOS (P < .001); and 3-month MRS was associated with HIHGLC (P = .006), discharge MRS (P < .001), age (P = .001), sex (P = .002), ICH volume (P = .03), and length of stay (P = .004). On multivariate analysis, discharge GCS only had a significant relationship with ICH volume (odds ratio [OR] .949, .927-.971); discharge MRS had a significant relationship with age (OR 1.043, 1.009-1.079), premorbid MRS (OR 2.622, 1.144-6.011), and ICH volume (OR 1.047, 1.003-1.093); and 3-month MRS only had a significant relationship with age (OR 1.039, 1.010-1.069). CONCLUSIONS:The relationship between in-hospital hyperglycemia and neurological outcomes in ICH patients was meaningful on univariate, but not multivariate, analysis. Glucose control after ICH is important.