No abstract

In this study, patients with stroke and TIA who were young and black were more likely to have urine toxicology screening. Eleven percent of all tested patients (and 9% of patients 50 years or older) were positive for cocaine. To avoid disparities, we suggest that all stroke and TIA patients be tested.

No abstract

Background:The 2010 American Academy of Neurology guideline for the diagnosis of acute ischemic stroke recommends MRI with diffusion weighted imaging (DWI) over noncontrast head CT. No studies have evaluated the influence of imaging choice on patient outcome. We sought to evaluate the variables that influenced one-year outcomes of stroke and TIA patients, including the type of imaging utilized.Methods:Patients were identified from a prospectively collected stroke and TIA database at a single primary stroke center during a one-year period. Data were abstracted from patient electronic medical records. The primary outcome measure was death, myocardial infarction, or recurrent stroke within the following year. Secondary outcome measures included predictors of getting an MRI study.Results:727 consecutive patients with a discharge diagnosis of stroke or TIA were identified (616 and 111 respectively); 536 had CT and MRI, 161 had CT alone, 29 had MRI alone, and one had no neuroimaging. On multiple logistic regression analysis, there were no differences in primary or secondary outcome measures among different imaging strategies. Predictors of the primary outcome measure included age and NIHSS, while performance of a CT angiogram (CTA) predicted a decreased odds of death, stroke, or MI. The strongest predictor of having an MRI was admission to a stroke unit.Conclusions:These results suggest that long-term (one-year) patient outcomes may not be influenced by imaging strategy. Performance of a CTA was protective in this cohort. A randomized trial of different imaging modalities should be considered.

Introduction: Myocardial injury is often encountered in acute ischemic stroke (AIS). Specific infarct locations have been considered as involved in its pathophysiology but there has been no systematic study involving MRI volumetric analyses. We aimed to define the imaging factors related to elevated troponin levels in AIS. Hypothesis: Specific infarct locations would be associated with AIS-related myocardial injury. Methods: We analyzed prospectively collected stroke registry data of patients with AIS admitted in one calendar year and included all patients with clinical and diffusion-weighted imaging (DWI) proven diagnosis of AIS, serum troponin measured within 24 hours of onset, and DWI studies of sufficient quality to permit analyses. Serum troponin ≥ 0.04 was considered elevated. A brain atlas was co-registered to each DWI volume by affine transform with 12 parameters representing pre-specified brain regions, including temporal, parietal, frontal, occipital lobes, insula and brainstem. Lesion volumes were calculated and the percent of total lesion volume within each region was computed. The relationship between troponin status (elevated vs. normal) and presence of ischemic lesion in a brain region was assessed using χ2 test. Multivariate logistic regression models with stepwise selection were done to determine which combination of brain regions were associated with elevated troponin levels. Results: We included 266 patients; 138 (52%) were men, mean age was 66(±14) years. Elevated troponin level was found in 72 (27%) and normal in 194 (73%) patients. There was no age difference between the two groups. Patients with elevated troponin levels had larger infarct volumes than those with normal levels [21,446(±35,414) mm3 vs. 13,058 (±38,100) mm3, p=0.001). Patients with elevated troponin levels were more likely to have left parietal (OR=2.74, 95%CI=1.48 to 5.07, p=0.001) and right frontal (OR=2.05, 95%CI=1.06 to 3.94, p=0.032) infarct location. Conclusions: Myocardial injury is often encountered in AIS, especially in patients with larger infarct volumes. Left parietal and right frontal infarct locations are independent predictors of myocardial injury. Further study will help define the clinical and prognostic significance of our findings.

Background: Administration of intravenous (IV) t-PA for acute ischemic stroke (AIS) improves outcomes. The most dreaded complication is intracerebral hemorrhage (ICH). Some patients have symptoms that impersonate an AIS but are later found to have an alternate diagnosis; these are termed stroke mimics (SM). SM treated with IV t-PA are exposed to hemorrhagic complications without benefit. Objectives: To describe the characteristics, safety, and outcomes of SM patients treated with t-PA under 4.5 hours. Methods: We reviewed all patients hospitalized after IV t-PA treatment at a tertiary care hospital and primary stroke center from January 2008 through December 2011. SMs were determined by review of clinical and imaging findings. SM are described and compared to t-PA treated patients with AIS for demographics, ICH, bleeding complications, and outcomes. Results: We identified 38 SM (12%) and 285 AIS (88%) t-PA treated patients. Compared to AIS, SM patients were younger (55.1 vs. 67.0 yrs, p<.001), more often women (68% vs.49%, p=.025), and reported a history of stroke more often (45% v 14%, p<.001). There were no differences in race, baseline stroke scale (9.4 v 10.9, p=.26), or onset to treatment time (164 min v 159 min, p=.63); 12 SM were in the 3-4.5 hour window. There were no ICHs or deaths in SM patients. There were two (5.2%) SM systemic hemorrhages; a femoral artery bleed post cardiac catheterization requiring transfusion, and an UGI bleed after a nasogastric tube not requiring transfusion. The average SM length of stay was 3.4 +/- 2.2 days. The mean discharge NIHSS score was 1.3 +/-2.5 in the SM v 4.6+/-5.7 in the AIS patients (p<.001). SM discharges were: home (84%), rehab center (12%), Nursing home 3%, and other (3%). The most common cause of SM was conversion disorder (47%) seizures (32 %) and migraine (8%). Conclusion: SM are not uncommon. Treatment of SM with IV t-PA appears to be safe in this cohort. The most common etiologies of stroke mimics were conversion disorder, seizures, and migraine. These results are consistent with existing published data on use of IV t-PA in SMs. Until more specific diagnostics are available, suspected SM should not be a reason to withhold t-PA treatment.

No abstract