Publications

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.

A 72-year-old woman was admitted for elective L4/L5 laminectomy. The operative procedure was extradural, and a Jackson-Pratt (JP) drain was placed in the tissue bed and set to wall suction during skin closure. During closure, the patient developed a 15 s period of asystole. The patient was haemodynamically stable, but was comatose for 3 days postoperatively. Cardiac enzymes and EEG were unrevealing. Head CT showed traces of subarachnoid haemorrhage and signs suggestive of cerebral anoxia. JP drain at the incision produced 170-210 mL/day of fluid, positive for β-2 transferrin, indicating cerebrospinal fluid (CSF). The patient fully returned to baseline on hospital day 10. MRI on hospital day 8 normalised. The reversible coma and radiographic findings were most consistent with acute intracranial hypotension relating to acute loss of CSF. Because radiographic findings can mimic hypoxic-ischaemic injury, acute intracranial hypotension should be considered in the differential diagnosis of postoperative coma after cranial or spinal surgery.

Previous studies of cocaine use and stroke have focused on acute effects of cocaine in perceived high-risk populations. We characterized mechanisms and risk factors for cocaine use among ischemic stroke patients from a broad range of socioeconomic backgrounds to inform medical management decisions and prevention efforts. We studied consecutive adults admitted with acute ischemic stroke to our institution between January 2007 and December 2010 with a history or laboratory confirmation of cocaine use. Age, sex, and race-matched cocaine-negative controls were derived from the same study population. Demographics, risk factors, clinical and imaging data were compared between groups. Among 4073 acute ischemic stroke patients, 91 (2.2%) had a history of cocaine use and/or a positive toxicology screen (cases). Cocaine abusers did not differ from controls by occupation, income, or educational level (P > 0.5). Active tobacco use independently increased the odds of cocaine use among stroke patients (odds ratio 3.9, 95% confidence interval 2.0-7.5), as did the history of migraine (odds ratio 2.5, 95% confidence interval 1.1-5.9). Stroke subtype also predicted cocaine use among stroke patients (odds ratio 0.73, 95% confidence interval 0.58-0.93). Stroke patients with current or past cocaine use could not be distinguished from non-users by socioeconomic factors. Liberal use of toxicology screening among a much broader population of patients is needed for proper identification and management. Further study of causal mechanisms for cardioembolism in cocaine-associated stroke is warranted.

Severe traumatic brain injury is associated with both acute and delayed neuro- logical injury. Cerebral vasospasm is commonly associated with delayed neurological decline in aneurysmal subarachnoid hemorrhage patients. However, the role played by vasospasm in traumatic brain injury is less clear. Vasospasm occurs earlier, for a shorter duration, and often without significant neurological consequence among traumatic brain injury patients. Detection and management strategies for vasospasm in aneurysmal subarachnoid hemorrhage are not easily transferrable to traumatic brain injury patients. We present a patient with a severe traumatic brain injury who had dramatic improvement following emergent decompressive hemicraniectomy. Two weeks after initial presentation he suffered a precipitous decline despite intensive surveillance. This case illustrates the distinct challenges of diagnosing cerebral vasospasm in the setting of severe traumatic brain injury.

BACKGROUND: Transcranial Doppler ultrasound (TCD) has been used as a confirmatory test for the diagnosis of brain death (BD), but may be inaccurate in patients with a skull defect or extraventricular drain (EVD).

METHODS AND RESULTS: We report three cases of patients with a skull defect or EVD in whom TCD supported a diagnosis of BD but in which the clinical examination later refuted the diagnosis.

CONCLUSION: We caution against the use of TCD to confirm the diagnosis of BD in the presence of a skull defect or EVD.

BACKGROUND: Whether brain imaging can identify patients who are most likely to benefit from therapies for acute ischemic stroke and whether endovascular thrombectomy improves clinical outcomes in such patients remains unclear.

METHODS: In this study, we randomly assigned patients within 8 hours after the onset of large-vessel, anterior-circulation strokes to undergo mechanical embolectomy (Merci Retriever or Penumbra System) or receive standard care. All patients underwent pretreatment computed tomography or magnetic resonance imaging of the brain. Randomization was stratified according to whether the patient had a favorable penumbral pattern (substantial salvageable tissue and small infarct core) or a nonpenumbral pattern (large core or small or absent penumbra). We assessed outcomes using the 90-day modified Rankin scale, ranging from 0 (no symptoms) to 6 (dead).

RESULTS: Among 118 eligible patients, the mean age was 65.5 years, the mean time to enrollment was 5.5 hours, and 58% had a favorable penumbral pattern. Revascularization in the embolectomy group was achieved in 67% of the patients. Ninety-day mortality was 21%, and the rate of symptomatic intracranial hemorrhage was 4%; neither rate differed across groups. Among all patients, mean scores on the modified Rankin scale did not differ between embolectomy and standard care (3.9 vs. 3.9, P=0.99). Embolectomy was not superior to standard care in patients with either a favorable penumbral pattern (mean score, 3.9 vs. 3.4; P=0.23) or a nonpenumbral pattern (mean score, 4.0 vs. 4.4; P=0.32). In the primary analysis of scores on the 90-day modified Rankin scale, there was no interaction between the pretreatment imaging pattern and treatment assignment (P=0.14).

CONCLUSIONS: A favorable penumbral pattern on neuroimaging did not identify patients who would differentially benefit from endovascular therapy for acute ischemic stroke, nor was embolectomy shown to be superior to standard care. (Funded by the National Institute of Neurological Disorders and Stroke; MR RESCUE ClinicalTrials.gov number, NCT00389467.).