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  1. Article ; Online: Spinal Decerebrate-Like Posturing After Brain Death: A Case Report and Review of the Literature.

    Kumar, Abhay / Tummala, Pavan / Feen, Eliahu S / Dhar, Rajat

    Journal of intensive care medicine

    2016  Volume 31, Issue 9, Page(s) 622–624

    Abstract: Introduction: Criteria for establishing brain death (BD) require absence of all brainstem-mediated reflexes including motor (ie, decerebrate or decorticate) posturing. A number of spinal cord automatisms may emerge after BD, but occurrence of ... ...

    Abstract Introduction: Criteria for establishing brain death (BD) require absence of all brainstem-mediated reflexes including motor (ie, decerebrate or decorticate) posturing. A number of spinal cord automatisms may emerge after BD, but occurrence of decerebrate-like spinal reflexes may be particularly problematic; confusion of such stereotypic extension-pronation movements with brain stem reflexes may confound or delay definitive diagnosis of BD. We present a case in which we verified the noncerebral (ie, likely spinal) origin of such decerebrate-like reflexes.
    Methods: Case report and systematic review of literature.
    Results: A 63-year-old woman presented with large pontine hemorrhage and complete loss of cerebral function, including no motor response to pain. Apnea testing confirmed death by neurologic criteria. Thirty-six hours after BD declaration, during assessment for organ donation, she began to exhibit spontaneous and stimulus-induced stereotypic extension-pronation of the upper extremities. The similarity of these movements to decerebrate posturing prompted concern for retained brain stem function, but repeat neurological examination of cranial nerves and apnea testing did not reveal any cerebral responses. Electrocerebral silence on electroencephalogram and absent perfusion on nuclear medicine brain imaging further confirmed BD. Review of PubMed yielded 5 additional case reports and 4 cohorts describing cases of decerebrate-like extension-pronation movements presenting in a delayed fashion after BD.
    Conclusion: Extension-pronation movements that mimic decerebrate posturing may be seen in a delayed fashion after BD. Verification of lack of any brain activity (by both examination and multiple ancillary tests) in this case and others prompts us to attribute these movements as spinal cord reflexes and propose they be recognized within the rubric of accepted post-BD automatisms that should not delay diagnosis or necessitate confirmatory testing.
    MeSH term(s) Brain Death/physiopathology ; Brain Stem/physiopathology ; Decerebrate State/diagnosis ; Decerebrate State/physiopathology ; Electroencephalography ; Female ; Humans ; Middle Aged ; Muscle Contraction ; Neurologic Examination/methods ; Spinal Nerves/physiopathology ; Tissue and Organ Procurement
    Language English
    Publishing date 2016-10
    Publishing country United States
    Document type Case Reports ; Journal Article ; Review
    ZDB-ID 632828-3
    ISSN 1525-1489 ; 0885-0666
    ISSN (online) 1525-1489
    ISSN 0885-0666
    DOI 10.1177/0885066616646076
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  2. Article: Raised Intracranial Pressure.

    Feen, Eliahu S / Suarez, Jose I

    Current treatment options in neurology

    2004  Volume 7, Issue 2, Page(s) 109–117

    Abstract: Raised intracranial pressure is a relatively common problem facing the clinician treating neurocritically ill patients. It is a leading cause of death in patients with intracranial pathology. There is a lack of controlled clinical trials evaluating most ... ...

    Abstract Raised intracranial pressure is a relatively common problem facing the clinician treating neurocritically ill patients. It is a leading cause of death in patients with intracranial pathology. There is a lack of controlled clinical trials evaluating most of the therapies currently available for raised intracranial pressure. The basic pathophysiologic and clinical principles of raised intracranial pressure are discussed and the major treatment options are presented. Patients with raised intracranial pressure should be evaluated immediately with particular attention to airway and hemodynamic status. Controlled hyperventilation and hyperosmolality (using mannitol or hypertonic saline solutions) frequently are administered simultaneously. In patients with refractory elevation of intracranial pressure other therapies such as barbiturate coma and surgical interventions are available.
    Language English
    Publishing date 2004-12-31
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2057342-X
    ISSN 1534-3138 ; 1092-8480
    ISSN (online) 1534-3138
    ISSN 1092-8480
    DOI 10.1007/s11940-005-0020-4
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  3. Article ; Online: Status epilepticus.

    Feen, Eliahu S / Bershad, Eric M / Suarez, Jose I

    Southern medical journal

    2008  Volume 101, Issue 4, Page(s) 400–406

    Abstract: Status epilepticus (SE) in adults is a state of continuous seizures lasting more than 5 minutes, or rapidly recurrent seizures without regaining consciousness. The overall US and European estimated crude incidence rate of SE ranges from 6.8 to 41/100,000/ ...

    Abstract Status epilepticus (SE) in adults is a state of continuous seizures lasting more than 5 minutes, or rapidly recurrent seizures without regaining consciousness. The overall US and European estimated crude incidence rate of SE ranges from 6.8 to 41/100,000/yr. The etiologies of SE include primary central nervous system pathologies and systemic disorders. The two basic mechanisms involved in the genesis of SE are an excess of excitatory activity and a loss of normal inhibitory neurotransmission. Mortality associated with SE can be as high as 26% for the average adult. Early recognition and treatment are important for improving the chances for a good outcome. The first line of treatment is an intravenous benzodiazepine, with lorazepam being the current preferred agent. All patients with SE who remain with altered awareness 20 to 30 minutes after cessation of clinical seizures should undergo electroencephalographic studies, because up to 20% of patients without clinical evidence of seizures after initial treatment can have nonconvulsive SE.
    MeSH term(s) Algorithms ; Benzodiazepines/therapeutic use ; Electroencephalography ; Humans ; Incidence ; Prognosis ; Risk Factors ; Status Epilepticus/diagnosis ; Status Epilepticus/epidemiology ; Status Epilepticus/physiopathology ; Status Epilepticus/therapy
    Chemical Substances Benzodiazepines (12794-10-4)
    Language English
    Publishing date 2008-04
    Publishing country United States
    Document type Journal Article ; Review
    ZDB-ID 185329-6
    ISSN 1541-8243 ; 0038-4348
    ISSN (online) 1541-8243
    ISSN 0038-4348
    DOI 10.1097/SMJ.0b013e31816852b0
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  4. Article ; Online: Myasthenia gravis crisis.

    Bershad, Eric M / Feen, Eliahu S / Suarez, Jose I

    Southern medical journal

    2008  Volume 101, Issue 1, Page(s) 63–69

    Abstract: Myasthenia gravis (MG) is an autoimmune disorder resulting from the production of antibodies against acetylcholine receptors leading to the destruction of the postsynaptic membrane at the neuromuscular junction. In the US there are about 18,000 people ... ...

    Abstract Myasthenia gravis (MG) is an autoimmune disorder resulting from the production of antibodies against acetylcholine receptors leading to the destruction of the postsynaptic membrane at the neuromuscular junction. In the US there are about 18,000 people with MG. Myasthenia gravis crisis (MGC) is defined as any MG exacerbation necessitating mechanical ventilation. Most patients presenting with MGC have an identifiable risk factor. The diagnosis of MGC should be suspected in all patients with respiratory failure, particularly those with unclear etiology. Acute management of MGC requires supportive general and ventilatory therapy and institution of measures to improve the neuromuscular blockade. The latter includes plasma exchange or i.v. immunoglobulin, and removal of the offending trigger. The outcome of patients with MGC has improved significantly and the current mortality rate is about 4 to 8%.
    MeSH term(s) Blood Gas Analysis ; Cholinesterase Inhibitors/therapeutic use ; Diagnosis, Differential ; Disease Progression ; Humans ; Immunoglobulins, Intravenous/therapeutic use ; Muscle, Skeletal/immunology ; Myasthenia Gravis/complications ; Myasthenia Gravis/diagnosis ; Myasthenia Gravis/immunology ; Myasthenia Gravis/therapy ; Plasma Exchange ; Pyridostigmine Bromide/therapeutic use ; Receptors, Cholinergic/immunology ; Respiration, Artificial ; Respiratory Insufficiency/etiology ; Respiratory Insufficiency/physiopathology ; Respiratory Insufficiency/therapy ; Risk Factors
    Chemical Substances Cholinesterase Inhibitors ; Immunoglobulins, Intravenous ; Receptors, Cholinergic ; Pyridostigmine Bromide (KVI301NA53)
    Language English
    Publishing date 2008-01
    Publishing country United States
    Document type Journal Article ; Review
    ZDB-ID 185329-6
    ISSN 1541-8243 ; 0038-4348
    ISSN (online) 1541-8243
    ISSN 0038-4348
    DOI 10.1097/SMJ.0b013e31815d4398
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  5. Article: Impact of a specialized neurointensive care team on outcomes of critically ill acute ischemic stroke patients.

    Bershad, Eric M / Feen, Eliahu S / Hernandez, Olga H / Suri, M Fareed K / Suarez, Jose I

    Neurocritical care

    2008  Volume 9, Issue 3, Page(s) 287–292

    Abstract: Background and purpose: Dedicated stroke units are associated with improved patient outcomes after acute ischemic stroke in general. However, it is unknown whether the population of critically ill ischemic stroke patients admitted to the neurocritical ... ...

    Abstract Background and purpose: Dedicated stroke units are associated with improved patient outcomes after acute ischemic stroke in general. However, it is unknown whether the population of critically ill ischemic stroke patients admitted to the neurocritical care unit (NCCU) benefit from primary management by a specialized neurocritical care team (NCT). This study is intended to investigate such benefit.
    Methods: A retrospective chart review in a large academic university hospital identified 400 patients with acute ischemic stroke admitted to the NCCU, from January 1997 to April 2000, aged 65 +/- 14 years. We examined the short- and long-term outcomes of these patients before and after institution of a specialized NCT. We used logistic regression models to determine independent association between outcome and availability of NCT.
    Results: The presence of a NCT was associated with a decreased length of NCCU stay (2.9 +/- 2.0 vs. 3.7 +/- 2.9 days, P < 0.01), decreased length of hospital stay (7.5 +/- 4.7 vs. 9.9 +/- 7.6, P < 0.001), and increased proportion of home discharges (47% vs. 36%, P < 0.05). The only independent predictor of in-hospital and long-term mortality was the underlying severity of disease as determined by the APACHE III score.
    Conclusions: In critically ill acute ischemic stroke patients, institution of a dedicated NCT was associated with a reduction in resource utilization and improved patient outcomes at hospital discharge. Several factors including improved patient care protocols may explain this association.
    MeSH term(s) APACHE ; Aged ; Aged, 80 and over ; Brain Ischemia/complications ; Brain Ischemia/mortality ; Brain Ischemia/therapy ; Cohort Studies ; Critical Care/organization & administration ; Female ; Hospital Mortality ; Humans ; Length of Stay ; Male ; Middle Aged ; Outcome and Process Assessment (Health Care) ; Patient Care Team/organization & administration ; Retrospective Studies ; Stroke/etiology ; Stroke/mortality ; Stroke/therapy
    Language English
    Publishing date 2008
    Publishing country United States
    Document type Journal Article
    ZDB-ID 2381896-7
    ISSN 1556-0961 ; 1541-6933
    ISSN (online) 1556-0961
    ISSN 1541-6933
    DOI 10.1007/s12028-008-9051-5
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  6. Article ; Online: Ischemic Stroke with Troponin Elevation: Patient Characteristics, Resource Utilization, and In-Hospital Outcomes.

    Peddada, Krishi / Cruz-Flores, Salvador / Goldstein, Larry B / Feen, Eliahu / Kennedy, Kevin F / Heuring, Timothy / Stolker, Joshua M

    Cerebrovascular diseases (Basel, Switzerland)

    2016  Volume 42, Issue 3-4, Page(s) 213–223

    Abstract: Background: Among patients hospitalized for acute ischemic stroke, abnormal serum troponins are associated with higher risk of short-term mortality. However, most findings have been reported from European hospitals. Whether troponin elevation after ... ...

    Abstract Background: Among patients hospitalized for acute ischemic stroke, abnormal serum troponins are associated with higher risk of short-term mortality. However, most findings have been reported from European hospitals. Whether troponin elevation after stroke is independently associated with death among a more heterogeneous US population remains unclear. Furthermore, only a few studies have evaluated the association between the magnitude of troponin elevation and subsequent mortality, patterns of dynamic troponin changes over time, or whether troponin elevation is related to specific causes of death.
    Methods: Using data collected in the American Heart Association's 'Get With The Guidelines' stroke registry between 2008 and 2012 at a tertiary care US hospital, we used logistic regression to evaluate the independent relationship between troponin elevation and mortality after adjusting for demographic and clinical characteristics. We then assessed whether the magnitude of troponin elevation was related to in-hospital mortality by calculating mortality rates according to tertiles of peak troponin levels. Dynamic troponin changes over time were evaluated as well. To better understand whether troponin elevation identified patients most likely to die due to a specific cause of death, investigators blinded from troponin values reviewed all in-hospital deaths, and the association between troponin elevation and mortality was evaluated among patients with cardiac, neurologic, or other causes of death.
    Results: Of 1,145 ischemic stroke patients, 199 (17%) had elevated troponin levels. Troponin-positive patients had more cardiovascular risk factors, more intensive medical therapy, and greater use of cardiac procedures. These individuals had higher in-hospital mortality rates than troponin-negative patients (27 vs. 8%, p < 0.001), and this association persisted after adjustment for 13 clinical and management variables (OR 4.28, 95% CI 2.40-7.63). Any troponin elevation was associated with higher mortality, even at very low peak troponin levels (mortality rates 24-29% across tertiles of troponin). Patients with persistently rising troponin levels had fewer anticoagulant and antiatherosclerotic therapies, with markedly worse outcomes. Furthermore, troponin-positive patients had higher rates of all categories of death: neurologic (17 vs. 7%), cardiac (5 vs. <1%), and other causes of death (5 vs. <1%; p < 0.001 for all comparisons).
    Conclusions: Ischemic stroke patients with abnormal troponin levels are at higher risk of in-hospital death, even after accounting for demographic and clinical characteristics, and any degree of troponin elevation identifies this higher level of risk. Troponins that continue to rise during the hospitalization identify stroke patients at markedly higher risk of mortality, and both neurologic and non-neurologically mediated mortality rates are higher when troponin is elevated.
    MeSH term(s) Aged ; Aged, 80 and over ; Biomarkers/blood ; Brain Ischemia/blood ; Brain Ischemia/diagnosis ; Brain Ischemia/mortality ; Brain Ischemia/therapy ; Chi-Square Distribution ; Female ; Health Resources/utilization ; Hospital Mortality ; Humans ; Logistic Models ; Male ; Middle Aged ; Multivariate Analysis ; Odds Ratio ; Registries ; Retrospective Studies ; Risk Assessment ; Risk Factors ; Stroke/blood ; Stroke/diagnosis ; Stroke/mortality ; Stroke/therapy ; Tertiary Care Centers ; Time Factors ; Treatment Outcome ; Troponin/blood ; United States/epidemiology ; Up-Regulation
    Chemical Substances Biomarkers ; Troponin
    Language English
    Publishing date 2016-05-03
    Publishing country Switzerland
    Document type Journal Article ; Observational Study
    ZDB-ID 1069462-6
    ISSN 1421-9786 ; 1015-9770
    ISSN (online) 1421-9786
    ISSN 1015-9770
    DOI 10.1159/000445526
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  7. Article: Coagulopathy and inhospital deaths in patients with acute subdural hematoma.

    Bershad, Eric M / Farhadi, Saeid / Suri, M Fareed K / Feen, Eliahu S / Hernandez, Olga H / Selman, Warren R / Suarez, Jose I

    Journal of neurosurgery

    2008  Volume 109, Issue 4, Page(s) 664–669

    Abstract: Object: Acute subdural hematoma (SDH) is one of the most lethal forms of intracranial injury; several risk factors predictive of a worse outcome have been identified. Emerging research suggests that patients with coagulopathy and intracerebral ... ...

    Abstract Object: Acute subdural hematoma (SDH) is one of the most lethal forms of intracranial injury; several risk factors predictive of a worse outcome have been identified. Emerging research suggests that patients with coagulopathy and intracerebral hemorrhage have a worse outcome than patients without coagulopathy but with intracerebral hemorrhage. The authors sought to determine if such a relationship exists for patients with acute SDH.
    Methods: The authors conducted a retrospective analysis of consecutive patients admitted to a neurosciences intensive care unit with acute SDH over a 4-year period (January 1997-December 2001). Demographic data, laboratory values, admission source, prior functional status, medical comorbidities, treatments received, and discharge disposition were recorded, as were scores on the Acute Physiology, Age, and Chronic Health Evaluation III (APACHE III). Coagulopathy was defined as an internal normalized ratio>1.2 or a prothrombin time>or=12.7 seconds. Univariate and multivariate analyses were performed on 244 patients to determine factors associated with worse short-term outcomes.
    Results: The authors identified 248 patients with acute SDH admitted to the neurointensive care unit during the study period, of which 244 had complete data. Most were male (61%), and the mean age of the study population was 71.3+/-15 years (range 20-95 years). Fifty-three patients (22%) had coagulopathy. The median APACHE III score was 43 (range 11-119). Twenty-nine patients (12%) died in the hospital. Independent predictors of inhospital death included APACHE III score (odds ratio [OR] 4.4, 95% confidence interval [CI] 1.4-13.4, p=0.011) and coagulopathy (OR 2.7, 95% CI 1.1-7.1, p=0.037). Surgical evacuation of acute SDH was associated with reduced inhospital deaths (OR 0.2, 95% CI 0.1-0.6, p=0.003).
    Conclusions: Coagulopathy is independently associated with inhospital death in patients with acute SDH. Time to treatment to correct coagulopathy using fresh frozen plasma and/or vitamin K was prolonged.
    MeSH term(s) APACHE ; Adult ; Aged ; Aged, 80 and over ; Blood Coagulation Disorders/drug therapy ; Blood Coagulation Disorders/mortality ; Female ; Hematoma, Subdural, Acute/drug therapy ; Hematoma, Subdural, Acute/mortality ; Hospital Mortality ; Humans ; Inpatients/statistics & numerical data ; Intensive Care Units/statistics & numerical data ; Male ; Middle Aged ; Plasma ; Retrospective Studies ; Vitamin K/therapeutic use ; Vitamins/therapeutic use
    Chemical Substances Vitamins ; Vitamin K (12001-79-5)
    Language English
    Publishing date 2008-10
    Publishing country United States
    Document type Journal Article
    ZDB-ID 3089-2
    ISSN 1933-0693 ; 0022-3085
    ISSN (online) 1933-0693
    ISSN 0022-3085
    DOI 10.3171/JNS/2008/109/10/0664
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  8. Article: Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team.

    Suarez, Jose I / Zaidat, Osama O / Suri, Muhammad F / Feen, Eliahu S / Lynch, Gwendolyn / Hickman, Janice / Georgiadis, Alexandros / Selman, Warren R

    Critical care medicine

    2004  Volume 32, Issue 11, Page(s) 2311–2317

    Abstract: Objective: To determine predictors of in-hospital and long-term mortality and length of stay in patients admitted to the neurosciences critical care unit.: Design: Retrospective analysis of a prospectively collected database.: Setting: ... ...

    Abstract Objective: To determine predictors of in-hospital and long-term mortality and length of stay in patients admitted to the neurosciences critical care unit.
    Design: Retrospective analysis of a prospectively collected database.
    Setting: Neurosciences critical care unit of a large academic tertiary care hospital.
    Patients: Adult patients (n = 2381) admitted to our neurosciences critical care unit from January 1997 to April 2000.
    Interventions: Introduction of a specialized neurocritical care team.
    Measurements and main results: Data obtained from the database included demographics, admission source, length of stay, neurosciences critical care unit and hospital disposition, admission Acute Physiology and Chronic Health Evaluation (APACHE) III score, and principal and secondary diagnoses. The introduction of a neurocritical care team in September 1998 was also collected, as was death at 1 yr after admission. Univariate analysis was carried out using Student's t-test, Mann-Whitney U test, or chi-square test (significance, p < .05). A logistic regression model was used to create a prediction model for in-hospital and long-term mortality. A general linear model was used to determine predictors of length of stay (after log transformation). Independent predictors of in-hospital mortality included APACHE III (odds ratio, 1.07 [1.06-1.08]) and admission from another intensive care unit (odds ratio, 2.9 [1.4-6.2]). The presence of a neurocritical care team was an independent predictor of decreased mortality (odds ratio, 0.7 [0.5-1.0], p = .044). Admission after the neurocritical care team was implemented was associated with reduced length of stay in both the neurosciences critical care unit (4.2 +/- 4.0 vs. 3.7 +/- 3.4, p < .001) and the hospital (9.9 +/- 8.0 vs. 8.4 +/- 6.9, p < .0001). There was no difference in readmission rates to the intensive care unit or discharge disposition to home before and after the neurocritical care team was established. The availability of the neurocritical care team was not associated with significant changes in long-term mortality. Factors independently associated with long-term mortality included female gender, admission from another intensive care unit, APACHE III score, and being moderately disabled before admission.
    Conclusion: Introduction of a neurocritical care team, including a full-time neurointensivist who coordinated care, was associated with significantly reduced in-hospital mortality and length of stay without changes in readmission rates or long-term mortality.
    MeSH term(s) APACHE ; Academic Medical Centers ; Adult ; Aged ; Analysis of Variance ; Critical Illness/mortality ; Critical Illness/therapy ; Female ; Health Services Research ; Hospital Mortality ; Humans ; Intensive Care Units/organization & administration ; Length of Stay/statistics & numerical data ; Linear Models ; Logistic Models ; Male ; Middle Aged ; Neurology/organization & administration ; Neurosurgery/organization & administration ; Ohio/epidemiology ; Organizational Innovation ; Outcome Assessment (Health Care) ; Patient Care Team/organization & administration ; Patient Readmission/statistics & numerical data ; Predictive Value of Tests ; Program Evaluation ; Prospective Studies ; Retrospective Studies ; Risk Factors
    Language English
    Publishing date 2004-11
    Publishing country United States
    Document type Evaluation Studies ; Journal Article
    ZDB-ID 197890-1
    ISSN 1530-0293 ; 0090-3493
    ISSN (online) 1530-0293
    ISSN 0090-3493
    DOI 10.1097/01.ccm.0000146132.29042.4c
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  9. Article: Ischemic Stroke with Troponin Elevation: Patient Characteristics, Resource Utilization, and In-Hospital Outcomes

    Peddada, Krishi / Cruz-Flores, Salvador / Goldstein, Larry B. / Feen, Eliahu / Kennedy, Kevin F. / Heuring, Timothy / Stolker, Joshua M.

    Cerebrovascular Diseases

    2016  Volume 42, Issue 3-4, Page(s) 213–223

    Abstract: Background: Among patients hospitalized for acute ischemic stroke, abnormal serum troponins are associated with higher risk of short-term mortality. However, most findings have been reported from European hospitals. Whether troponin elevation after ... ...

    Institution Cardiology, Saint Louis University, St. Louis, Mo Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, Tex Neurology, Duke University and Durham VA Medical Centers, Durham, N.C Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Mo., and Cardiology, Mercy Heart and Vascular, Washington, Mo., USA
    Abstract Background: Among patients hospitalized for acute ischemic stroke, abnormal serum troponins are associated with higher risk of short-term mortality. However, most findings have been reported from European hospitals. Whether troponin elevation after stroke is independently associated with death among a more heterogeneous US population remains unclear. Furthermore, only a few studies have evaluated the association between the magnitude of troponin elevation and subsequent mortality, patterns of dynamic troponin changes over time, or whether troponin elevation is related to specific causes of death. Methods: Using data collected in the American Heart Association's ‘Get With The Guidelines' stroke registry between 2008 and 2012 at a tertiary care US hospital, we used logistic regression to evaluate the independent relationship between troponin elevation and mortality after adjusting for demographic and clinical characteristics. We then assessed whether the magnitude of troponin elevation was related to in-hospital mortality by calculating mortality rates according to tertiles of peak troponin levels. Dynamic troponin changes over time were evaluated as well. To better understand whether troponin elevation identified patients most likely to die due to a specific cause of death, investigators blinded from troponin values reviewed all in-hospital deaths, and the association between troponin elevation and mortality was evaluated among patients with cardiac, neurologic, or other causes of death. Results: Of 1,145 ischemic stroke patients, 199 (17%) had elevated troponin levels. Troponin-positive patients had more cardiovascular risk factors, more intensive medical therapy, and greater use of cardiac procedures. These individuals had higher in-hospital mortality rates than troponin-negative patients (27 vs. 8%, p < 0.001), and this association persisted after adjustment for 13 clinical and management variables (OR 4.28, 95% CI 2.40-7.63). Any troponin elevation was associated with higher mortality, even at very low peak troponin levels (mortality rates 24-29% across tertiles of troponin). Patients with persistently rising troponin levels had fewer anticoagulant and antiatherosclerotic therapies, with markedly worse outcomes. Furthermore, troponin-positive patients had higher rates of all categories of death: neurologic (17 vs. 7%), cardiac (5 vs. <1%), and other causes of death (5 vs. <1%; p < 0.001 for all comparisons). Conclusions: Ischemic stroke patients with abnormal troponin levels are at higher risk of in-hospital death, even after accounting for demographic and clinical characteristics, and any degree of troponin elevation identifies this higher level of risk. Troponins that continue to rise during the hospitalization identify stroke patients at markedly higher risk of mortality, and both neurologic and non-neurologically mediated mortality rates are higher when troponin is elevated.
    Keywords Stroke ; Biomarkers ; Cardiac disorders and stroke ; Troponin ; Clinical outcome ; Clinical research ; Diagnosis and treatment of acute stroke (ischemia) ; Epidemiology ; Mortality ; Cause of death
    Language English
    Publishing date 2016-05-03
    Publisher S. Karger AG
    Publishing place Basel, Switzerland
    Document type Article
    Note Original Paper
    ZDB-ID 1069462-6
    ISSN 1421-9786 ; 1015-9770
    ISSN (online) 1421-9786
    ISSN 1015-9770
    DOI 10.1159/000445526
    Database Karger publisher's database

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  10. Article ; Online: Stroke mimics under the drip-and-ship paradigm.

    Mehta, Sonal / Vora, Nirav / Edgell, Randall C / Allam, Hesham / Alawi, Aws / Koehne, Jennifer / Kumar, Abhay / Feen, Eliahu / Cruz-Flores, Salvador / Alshekhlee, Amer

    Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association

    2014  Volume 23, Issue 5, Page(s) 844–849

    Abstract: Background: Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized ... ...

    Abstract Background: Recent reports suggested better outcomes associated with the drip-and-ship paradigm for acute ischemic stroke (AIS) treated with thrombolysis. We hypothesized that a higher rate of stroke mimics (SM) among AIS treated in nonspecialized stroke centers that are transferred to comprehensive centers is responsible for such outcomes.
    Methods: Consecutive patients treated with thrombolysis according to the admission criteria were reviewed in a single comprehensive stroke center over 1 academic year (July 1, 2011 to June 30, 2012). Information on the basic demographic, hospital complications, psychiatric diagnoses, and discharge disposition was collected. We identified those patients who were treated at a facility and then transferred to the tertiary center (ie, drip-and-ship paradigm). In addition to comparative and adjusted analysis to identify predictors for SM, a stratified analysis by the drip-and-ship status was performed.
    Results: One hundred twenty patients were treated with thrombolysis for AIS included in this analysis; 20 (16.7%) were discharged with the final diagnosis of SM; 14 of those had conversion syndrome and 6 patients had other syndromes (seizures, migraine, and hypoglycemia). Patients with SM were younger (55.6 ± 15.0 versus 69.4 ± 14.9, P = .0003) and more likely to harbor psychiatric diagnoses (45% versus 9%; P ≤ .0001). Eighteen of 20 SM patients (90%) had the drip-and-ship treatment paradigm compared with 65% of those with AIS (P = .02). None of the SM had hemorrhagic complications, and all were discharged to home. Predictors of SM on adjusted analysis included the drip-and-ship paradigm (odds ratio [OR] 12.8, 95% confidence interval [CI] 1.78, 92.1) and history of any psychiatric illness (OR 12.08; 95% CI 3.14, 46.4). Eighteen of 83 drip-and-ship patients (21.7%) were diagnosed with SM compared with 2 of 37 patients (5.4%) presented directly to the hub hospital (P = .02).
    Conclusion: The drip-and-ship paradigm and any psychiatric history predict the diagnosis of SM. None of the SM had thrombolysis-related complications, and all were discharged to home. These findings may explain the superior outcomes associated with the drip-and-ship paradigm in the treatment for AIS.
    MeSH term(s) Adult ; Aged ; Aged, 80 and over ; Diagnosis, Differential ; Female ; Fibrinolytic Agents/administration & dosage ; Fibrinolytic Agents/adverse effects ; Humans ; Male ; Middle Aged ; Missouri ; Patient Discharge ; Patient Transfer ; Predictive Value of Tests ; Risk Factors ; Stroke/diagnosis ; Stroke/drug therapy ; Tertiary Care Centers ; Thrombolytic Therapy/adverse effects ; Treatment Outcome ; Unnecessary Procedures/adverse effects
    Chemical Substances Fibrinolytic Agents
    Language English
    Publishing date 2014-05
    Publishing country United States
    Document type Journal Article
    ZDB-ID 1131675-5
    ISSN 1532-8511 ; 1052-3057
    ISSN (online) 1532-8511
    ISSN 1052-3057
    DOI 10.1016/j.jstrokecerebrovasdis.2013.07.012
    Database MEDical Literature Analysis and Retrieval System OnLINE

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