Although EORTC-QLQ-C30 scores and GIQLI scores from patients undergoing elective colorectal cancer surgery did correlate well, the level of agreement between the two instruments was quite low. Perioperative QoL data from the two instruments cannot be compared with each other.
BACKGROUND AND PURPOSE: New-onset refractory status epilepticus is a clinical condition characterized by acute and prolonged pharmacoresistant seizures without a pre-existing relevant neurologic disorder, prior epilepsy, or clear structural, toxic, or metabolic cause. New-onset refractory status epilepticus is often associated with antineuronal antibodies and may respond to early immunosuppressive therapy, reflecting an inflammatory element of the condition. FDG-PET is a useful diagnostic tool in inflammatory and noninflammatory encephalitis. We report here FDG-PET findings in new-onset refractory status epilepticus and their correlation to disease activity, other imaging findings, and outcomes. MATERIALS AND METHODS:Twelve patients who met the criteria for new-onset refractory status epilepticus and who had FDG-PET and MR imaging scans and electroencephalography at a single academic medical center between 2008 and 2017 were retrospectively identified. Images were independently reviewed by 2 radiologists specialized in nuclear imaging. Clinical characteristics and outcome measures were collected through chart review. RESULTS:Twelve patients underwent 21 FDG-PET scans and 50 MR imaging scans. Nine (75%) patients were positive for autoantibodies. All patients had identifiable abnormalities on the initial FDG-PET in the form of hypermetabolism (83%) and/or hypometabolism (42%). Eight (67%) had medial temporal involvement. All patients (n ϭ 3) with N-methyl-D-aspartic acid receptor antibodies had profound bilateral occipital hypometabolism. Initial MR imaging findings were normal in 6 (50%) patients. Most patients had some degree of persistent hyper-(73%) or hypometabolism (45%) after immunosuppressive therapy. FDG-PET hypometabolism was predictive of poor outcome (mRS 4 -6) at hospital discharge (P ϭ .028). CONCLUSIONS:Both FDG-PET hypometabolism and hypermetabolism are seen in the setting of new-onset refractory status epilepticus and may represent markers of disease activity. ABBREVIATIONS: ALE ϭ autoimmune limbic encephalitis; EEG ϭ electroencephalography; GABA-B ϭ ␥-aminobutyric acid B; LGI1 ϭ leucine-rich glioma inactivated 1; NMDA ϭ N-methyl-D-aspartate; NMDA-R ϭ N-methyl-D-aspartate receptor; NORSE ϭ new-onset refractory status epilepticus; VGKC ϭ voltage-gated potassium channel
The objective of this manuscript is to describe the challenges of Cardio-Cerebral Infarction (CCI) treatment and to highlight the variable approaches in management. CCI is a rare clinical presentation of simultaneous acute ischemic stroke (AIS) and acute myocardial infarction (AMI) and poses a therapeutic challenge for practitioners. Each disease requires timely intervention to prevent irreversible damage; however, optimal management remains unclear. We describe three cases of CCI. All three patients presented with symptomatic left MCA (M1) occlusion, with ST elevation myocardial infarction (STEMI) and left ventricular apical thrombus. Fibrinolysis and mechanical thrombectomy (MT) were discussed in all cases, but only one patient received alteplase (0.9 mg/kg) and none underwent MT. Percutaneous intervention (PCI) was done in only one case. The two patients that did not receive thrombolysis were treated with modified therapeutic heparin (no bolus), and all received antiplatelet therapy. Ultimately, all three patients passed away. CCI poses a clinical challenge for physicians including (1) optimal strategies to enable swift mechanical reperfusion to both the brain and myocardium; (2) difference in dosage of thrombolytics for AIS versus AMI; (3) risk of symptomatic intracerebral hemorrhage following administration of anticoagulation and/or antiplatelet therapy; and (4) caution with use of thrombolytics in the setting of acute STEMI due to the risk of myocardial rupture. In the absence of high quality evidence and clinical guidelines, treatment of CCI is highly individualized.
Background Approach to acute cerebrovascular disease management has evolved in the past few months to accommodate the rising needs of the 2019 novel coronavirus (COVID-19) pandemic. In this study, we investigated the changes in practices and policies related to stroke care through an online survey. Methods A 12 question, cross-sectional survey targeting practitioners involved in acute stroke care in the US was distributed electronically through national society surveys, social media and personal communication. Results Respondants from 39 states completed 206 surveys with the majority (82.5%) from comprehensive stroke centers. Approximately half stated some change in transport practices with 14 (7%) reporting significant reduction in transfers. Common strategies to limit healthcare provider exposure included using personal protective equipment (PPE) for all patients (127; 63.5%) as well as limiting the number of practitioners in the room (129; 64.5%). Most respondents (81%) noted an overall decrease in stroke volume. Many (34%) felt that the outcome or care of acute stroke patients had been impacted by COVID-19. This was associated with a change in hospital transport guidelines (OR 1.325, P = 0.047, 95% CI: 1.004–1.748), change in eligibility criteria for IV-tPA or mechanical thrombectomy (MT) (OR 3.146, P = 0.052, 95% CI: 0.988–10.017), and modified admission practices for post IV-tPA or MT patients (OR 2.141, P = 0.023, 95% CI: 1.110–4.132). Conclusion Our study highlights a change in practices and polices related to acute stroke management in response to COVID-19 which are variable among institutions. There is also a reported reduction in stroke volume across hospitals. Amongst these changes, updates in hospital transport guidelines and practices related to IV-tPA and MT may affect the perceived care and outcome of acute stroke patients.
BACKGROUND AND PURPOSEWe sought to validate ultrasound as a reliable means of assessing vessel stenosis of vertebral artery origins.METHODSWe reviewed 1,135 patient charts with ultrasound of the posterior circulation performed in 2008‐2015 in a single hospital. Inclusion criteria for native vessels consisted of ultrasound and digital subtraction angiography (DSA) performed within 3 months. Patients with indwelling stents were analyzed separately from native vessels. Using DSA as the gold standard, we determined sensitivity and specificity of ultrasound in detecting occlusion at vertebral artery origin. All patients with nonoccluded native vertebral artery origins were evaluated for degree of stenosis on DSA, and compared to mean flow velocity (MFV), peak systolic velocity (PSV), and end‐diastolic velocity (EDV) on ultrasound.RESULTSAmong 218 vertebral artery origins in 139 patients evaluated, ultrasound showed sensitivity of 85.7% (95% confidence interval (CI): 69.7‐95.2%) for occlusion and specificity of 99.5% (95%CI: 96.9‐99.9%). Among 126 arteries without occlusion, <50% stenosis had average MFV (39 ± 19 cm/s), 50‐69% stenosis had average MFV (68 ± 35 cm/s), and severe (70‐99%) stenosis had average MFV (120 ± 93 cm/s) (P < .001). MFV cutoff value of 44 cm/s corresponded to 77% sensitivity and 70% specificity to detect vertebral artery origin stenosis >50% (C‐statistic: .81). PSV value of 97 cm/s corresponded with 72% sensitivity and 70% specificity to detect >50% stenosis (C‐statistic: .77). MFV cutoff value of 60 cm/s corresponded with 70% sensitivity and 82% specificity to predict 70‐99% stenosis (C‐statistic: .83). PSV cutoff value of 110 cm/s corresponded with 80% sensitivity and 72% specificity to predict 70‐99% stenosis (C‐statistic: .84).CONCLUSIONUltrasound has good sensitivity and excellent specificity for detecting vertebral origin occlusion. Flow velocity can be used to screen for severe stenosis of vertebral artery at origin.
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