Publications

OBJECTIVE: Data evaluating the long-term outcomes, particularly with regard to treatment modality, of aneurysmal subarachnoid hemorrhage (SAH) in octogenarians are limited. The primary objectives were to evaluate the disposition (living at home vs institutional settings) and analyze the predictors of long-term survival and return to home for octogenarians after SAH.

METHODS: Data pertaining to patients age 80 and older who underwent microsurgical clipping or endovascular coiling for SAH were extracted from 100% nationwide Medicare inpatient claims and linked with the Minimum Data Set (2008-2011). Patient disposition was tracked for 2 years after index SAH admission. Multivariable logistic regression stratified by aneurysm treatment modality, and adjusted for patient factors including SAH severity, evaluated predictors of return to home at 60 and 365 days after SAH. Survival 365 days after SAH was analyzed with a multivariable Cox proportional hazards model.

RESULTS: A total of 1298 cases were included in the analysis. One year following SAH, 56% of the patients had died or were in hospice care, 8% were in an institutional post-acute care setting, and 36% had returned home. Open microsurgical clipping (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.54-0.81), male sex (aHR 0.70, 95% CI 0.57-0.87), tracheostomy (aHR 0.63, 95% CI 0.47-0.85), gastrostomy (aHR 0.60, 95% CI 0.48-0.76), and worse SAH severity (aHR 0.94, 95% CI 0.92-0.97) were associated with reduced likelihood of patients ever returning home. Older age (aHR 1.09, 95% CI 1.05-1.13), tracheostomy (aHR 2.06, 95% CI 1.46-2.91), gastrostomy (aHR 1.55, 95% CI 1.14-2.10), male sex (aHR 1.66, 95% CI 1.20-2.23), and worse SAH severity 1.51 (95% CI 1.04-2.18) were associated with reduced survival.

CONCLUSIONS: In this national analysis, 56% of octogenarians with SAH died, and 36% returned home within 1 year of SAH. Coil embolization predicted returning to home, which may suggest a benefit to endovascular treatment in this patient population.

Stroke is a leading cause of death and disability, and while preferences for cardiopulmonary resuscitation (CPR) are frequently discussed, there is limited evidence detailing outcomes after CPR among acute cerebrovascular neurology (inclusive of stroke, subarachnoid hemorrhage (SAH)) patients. Systematic review and meta-analysis of PubMed and Cochrane libraries from January 1990 to December 2016 was conducted among stroke patients undergoing in-hospital CPR. Primary data from studies meeting inclusion criteria at two levels were extracted: 1) studies reporting survival to hospital discharge after CPR with cerebrovascular primary admitting diagnosis, and 2) studies reporting survival to hospital discharge after CPR with cerebrovascular comorbidity. Meta-analysis generated weighted, pooled survival estimates for each population. Of 818 articles screened, there were 176 articles (22%) that underwent full review. Three articles met primary inclusion criteria, with an estimated 8% (95% Confidence Interval (CI) 0.01, 0.14) rate of survival to hospital discharge from a pooled sample of 561 cerebrovascular patients after in-hospital CPR. Twenty articles met secondary inclusion criteria, listing a cerebrovascular comorbidity, with an estimated rate of survival to hospital discharge of 16% (95% CI 0.14, 0.19). All studies demonstrated wide variability in adherence to Utstein guidelines, and neurological outcomes were detailed in only 6 (26%) studies. Among the few studies reporting survival to hospital discharge after CPR among acute cerebrovascular patients, survival is lower than general inpatient populations. These findings synthesize the limited empirical basis for discussions about resuscitation among stroke patients, and highlight the need for more disease stratified reporting of outcomes after inpatient CPR.

BACKGROUND: Intracerebral hemorrhage (ICH) volumes are frequently used for prognostication and inclusion of patients in clinical trials. We sought to compare the original ABC/2 method and sABC/2, a simplified version with the planimetric method.

METHODS: We retrospectively reviewed admission head CT scans of consecutive ICH patients admitted to a single academic center from July 2012 to April 2013. We assessed ICH volume on the admission. In ABC/2 method, A = greatest hemorrhage diameter by CT, B = diameter perpendicular to A, C = the approximate number of CT slices with hemorrhage multiplied by the slice thickness. C is weighted by area as < 25%, 25-50%, or > 75%. However, in the sABC/2 method, C is the total number of cuts with ICH without any weighting. Bland-Altman plots were generated for both the ABC/2 and sABC/2 methods in comparison to the planimetric method.

RESULTS: One hundred thirty-five patients with spontaneous ICH were included in the final analysis. Bland-Altman analysis illustrated that both ABC/2 and sABC/2 were concordant with the planimetric method. ABC/2 had more bias than sABC/2 (47% vs. 5%, respectively) with no evidence of a linear trend. For differentiating a volume threshold of 30 mL, ABC/2 was less sensitive but more specific than sABC/2 (P < .0001). Concordance between planimetry, ABC/2, and sABC/2 was high, evidenced by most coefficients exceeding .90.

CONCLUSION: Simplified ABC/2 (sABC/2) method performs better than ABC/2 in calculating ICH volumes. Moreover, it is better in differentiating a volume threshold of 30 mL. These findings may have implications for outcomes prediction and clinical trials inclusion.

Subdural hematoma (SDH) is among the most common conditions managed by neurologists and neurosurgeons. As SDH incidence rates increase, a wider spectrum of SDH related complications have become evident. We prospectively identified a series of three patients with similar patterns of ipsilateral insular diffusion weighted imaging (DWI) hyperintensity associated with subdural hematoma. Detailed chart review was performed, and cases are described in relation to anatomy and proposed pathophysiology of venous hypertension and arterial vasospasm. The DWI changes were evident in all cases where clinical deficits following SDH evacuation were out of proportion to computed tomography findings. Therefore SDH-associated insular infarction may be a marker of greater disease severity, and further study of management and outcomes is needed.

Pazopanib is a tyrosine kinase receptor antagonist used for renal cell carcinoma and soft tissue sarcoma that inhibits tumour growth and angiogenesis. A common side effect of pazopanib is hypertension. We report a case of a 69-year-old woman with clear cell renal cell carcinoma who developed a large right occipital intracerebral haemorrhage 3 weeks after initiating pazopanib. Although this was initially suspected to be a haemorrhagic metastasis, MRI revealed bi-occipital oedema, supporting a diagnosis of posterior reversible encephalopathy syndrome (PRES). A craniectomy was required. Immunohistochemical stains for renal cell carcinoma antigen, CA IX and PAX8 were negative. This case suggests that PRES and intracerebral haemorrhage may result from pazopanib use and are important complications to consider prior to initiating this agent.

BACKGROUND: While clinical trial data support decompressive hemicraniectomy (DHC) as improving survival among patients with severe ischemic stroke, quality of life outcomes among older persons remain controversial.

AIMS: To aid decision-making and understand practice variation, we measured long-term outcomes and patterns of regional variation for a nationwide cohort of ischemic stroke patients after DHC.

METHODS: Medicare fee-for-service ischemic stroke cases over age 65 during the year 2008 were used to create a cohort followed for 2 years (2009-2010) after stroke and DHC procedure. Rates of mortality, acute hospital readmission, and long-term care (LTC) utilization were calculated. Multiple logistic regression was used to identify individual predictors of institutional LTC. Regional variation in DHC was calculated through aggregation and merging with the state-level data.

RESULTS: Among 397,503 acute ischemic stroke patients, 130 (0.03 %) underwent DHC. Mean age was 72 years, and 75 % were between the ages of 65 and 74. Mortality was highest (38 %) within the first 30 days. At 2 years, 59 % of the original cohort had died. The 30-day rate of acute hospital readmission was 25 %. Among survivors, 75 % returned home 1 year after index stroke admission. States with higher per capita health expenditures were associated with wider variation in utilization of DHC.

CONCLUSIONS: There is a high rate of mortality among older stroke patients undergoing DHC. Although most survivors of DHC are not permanently institutionalized, there is wide variation in utilization of DHC across the USA.

BACKGROUND: Fever is a common occurrence in the Neurocritical Care Unit (NCCU). It is reported that up to 50 % of these fevers are associated with a non-infectious source. As this is a diagnosis of exclusion, a complete fever evaluation must be done to rule out infection. Procalcitonin (PCT) has been identified as a possible biomarker to distinguish infectious from non-infectious etiologies of fever. We hypothesized that PCT could be used as a predictor of infectious fever in febrile patients with intracranial hemorrhage admitted to the NCCU.

METHODS: A prospective observational cohort of patients admitted to a 12-bed NCCU in a tertiary-care university hospital from January 1, 2014, to October 1, 2014, was studied. Patients with intracranial hemorrhage (aneurismal subarachnoid hemorrhage, traumatic brain injury, intracerebral hemorrhage, or non-traumatic subdural hemorrhage) and fever defined as ≥101.4 °F were included. All patients had a urinalysis, chest X-ray, two sets of blood cultures, and PCT as part of their fever evaluation. Patients also had urine, sputum, CSF cultures, and Clostridium difficile toxin PCR as clinically indicated. Patients with incomplete fever evaluations were excluded.

RESULTS: Seventy-three patients met inclusion criteria: 36 had infections identified and 37 did not. Type of intracranial hemorrhage was similar between groups. For those with identified infection, median PCT was 0.15 ng/mL (IQR 0.06-0.5 ng/mL). For those without identified infection, median PCT was 0.09 ng/mL (IQR 0.05-0.45 ng/mL), p = 0.30. Analyzing subgroups of intracranial hemorrhage patients revealed no group with a significant difference in PCT values. Patients with identified infection did have higher white blood cell counts (median 14.1 × 109/L (11.6-17.4 × 109/L) compared to those without identified infection 12 × 109/L (9.9-14.1 × 109/L), p = 0.02.

CONCLUSION: Among patients with intracranial hemorrhage, PCT did not differentiate infectious fever from non-infectious fever.

BACKGROUND: Older patients with aneurysmal subarachnoid hemorrhage (aSAH) are unique, and determinants of post-acute care outcomes are not well elucidated. The primary objective was to identify hospital characteristics associated with 30-day readmission and mortality rates after hospital discharge among older patients with aSAH.

METHODS AND RESULTS: This cohort study used Medicare patients ≥65 years discharged from US hospitals from January 1, 2008, to November 30, 2010, after aSAH. Medicare data were linked to American Hospital Association data to describe characteristics of hospitals treating these patients. Using multivariable logistic regression to adjust for patient characteristics, hospital factors associated with (1) hospital readmission and (2) mortality within 30 days after discharge were identified. A total of 5515 patients ≥65 years underwent surgical repair for aSAH in 431 hospitals. Readmission rate was 17%, and 8.5% of patients died within 30 days of discharge. In multivariable analyses, patients treated in hospitals with lower annualized aSAH volumes were more likely to be readmitted 30 days after discharge (lowest versus highest quintile, 1-2 versus 16-30 cases; adjusted odds ratio, 2.10; 95% confidence interval, 1.56-2.84). Patients treated in hospitals with lower annualized aSAH volumes (lowest versus highest quintile: adjusted odds ratio, 1.52; 95% confidence interval, 1.05-2.19) had a greater likelihood of dying 30 days after discharge.

CONCLUSIONS: Older patients with aSAH discharged from hospitals treating lower volumes of such cases are at greater risk of readmission and dying within 30 days. These findings may guide clinician referrals, practice guidelines, and regulatory policies influencing which hospitals should care for older patients with aSAH.

BACKGROUND: Healthcare-associated infections (HAIs) are seen in 17% of critically ill patients. Probiotics, live nonpathogenic microorganisms, may aid in reducing the incidence of infection in critically ill patients. We hypothesized that administration of probiotics would be safe and reduce the incidence of HAIs among mechanically ventilated neurocritical care patients.

METHODS: We assembled 2 retrospective cohorts of mechanically ventilated neurocritical care patients. In the preintervention cohort from July 1, 2011, to December 31, 2011, probiotics were not used. In the postintervention group from July 1, 2012, to December 31, 2012, 1 g of a combination of Lactobacillus acidophilus and Lactobacillus helveticus was administered twice daily to all patients who were mechanically ventilated for more than 24 hours.

RESULTS: There were a total of 167 patients included, 80 patients in the preintervention group and 87 patients in the postintervention group. No patients in the preintervention group received probiotics. Eighty-five (98%) patients in the postintervention group received probiotics for a median of 10 days (interquartile range, 4-20 days). There were 14 (18%) HAIs in the preintervention group and 8 (9%) HAIs in the postintervention group (P = .17). Ventilator days, lengths of stay, in-hospital mortality, and discharge disposition were similar between the pre- and postintervention groups. There were no cases of Lactobacillus bacteremia or other adverse events associated with probiotics use.

CONCLUSION: Probiotics are safe to administer in neurocritical care patients; however, this study failed to demonstrate a significant decrease in HAIs or secondary outcomes associated with probiotics.

BACKGROUND: Reducing hospital readmissions is a key component of reforms for stroke care. Current readmission prediction models lack accuracy and are limited by data being from only acute hospitalizations. We hypothesized that patient-level factors from a nationwide post-acute care database would improve prediction modeling.

METHODS AND RESULTS: Medicare inpatient claims for the year 2008 that used International Classification of Diseases, Ninth Revision codes were used to identify ischemic stroke patients older than age 65. Unique individuals were linked to comprehensive post-acute care assessments through use of the Minimum Data Set (MDS). Logistic regression was used to construct risk-adjusted readmission models. Covariates were derived from MDS variables. Among 39 178 patients directly admitted to nursing homes after hospitalization due to acute stroke, there were 29 338 (75%) with complete MDS assessments. Crude rates of readmission and death at 30 days were 8448 (21%) and 2791 (7%), respectively. Risk-adjusted models identified multiple independent predictors of all-cause 30-day readmission. Model performance of the readmission model using MDS data had a c-statistic of 0.65 (95% CI 0.64 to 0.66). Higher levels of social engagement, a marker of nursing home quality, were associated with progressively lower odds of readmission (odds ratio 0.71, 95% CI 0.55 to 0.92).

CONCLUSIONS: Individual clinical characteristics from the post-acute care setting resulted in only modest improvement in the c-statistic relative to previous models that used only Medicare Part A data. Individual-level characteristics do not sufficiently account for the risk of acute hospital readmission.