Citations

Background: The influence of high body mass index (BMI) in acute stroke patients treated with intravenous thrombolysis has not been extensively studied. Previous studies have observed an “obesity paradox” among stroke patients, where better outcomes were observed among overweight and obese patients. The purpose of this study is to determine the influence of obesity and risk components of metabolic syndrome to stroke recovery in patients undergoing intravenous recombinant tissue plasminogen activator (rtPA) treatment. Methods: Patients with acute ischemic stroke who received intravenous rtPA within three-hour from symptom onset at St. Marys Hospital, Mayo Clinic, Rochester, between April 2006 and January 2011, were included in this study. Information on vascular risk factors, stroke severity, and baseline hemodynamic and laboratory indices, were collected. Study outcomes, consisting symptomatic intracerebral hemorrhage (sICH) and poor functional recovery (modified Rankin scale >2), were compared between obese (body mass index, BMI >30 kg/m 2 ), overweight (BMI 25-30 kg/m 2 ) and normal weight (BMI <25 kg/m 2 ) patients. The association between BMI, risk components of the metabolic syndrome and dose of rtPA per kg body weight to stroke outcomes were assessed in a multivariable model. Results: A total of 158 patients (mean age, 75 years; baseline NIHSS, 11), frequency-matched by age and baseline stroke severity, were included in this study. No differences in the frequency of SICH and poor functional recovery were observed among obese, overweight and normal weight patients, before and after adjusting for their baseline characteristics. A linear trend towards worse stroke recovery was observed in patients with a greater number of metabolic risk components (p-trend=0.043). By contrast, there were no significant associations between the number of risk components of metabolic syndrome with respect to sICH. Using stepwise regression analyses, age, baseline stroke severity and the number of risk components of the metabolic syndrome accounted for 52% variation in functional recovery following rtPA treatment. Conclusions: Acute stroke outcomes do not differ between obese and overweight patients. The presence of metabolic risk factors contributes significantly to functional outcomes following rtPA treatment. These results suggest that decreasing the prevalence of metabolic syndrome in the community could reduce the societal burden of stroke-related disability.

Background and Purpose: Leukoaraiosis is a poor prognostic marker for patients with acute ischemic stroke (AIS). This study sought to assess if severity of leukoaraiosis is associated with outcome in patients with AIS following endovascular thrombectomy, and to propose a leukoaraiosis-related modification to the ASPECTS score to improve its predictive value for good outcome. Methods: We analyzed consecutive patients with AIS that underwent mechanical thrombectomy for anterior circulation large vessel occlusion at our comprehensive stroke center. Leukoaraiosis burden was graded using the Fazekas scale (combined scores from two locations categorically divided into no leukoaraiosis (score = 0), mild (1-2), moderate (3-4) and severe (5-6)). The primary outcome measure was 90-day mRS. A proposed Leukoaraiosis-ASPECTS (“L-ASPECTS”) was calculated by subtracting values from the traditional ASPECT based on leukoaraiosis severity (1 point subtracted if mild, 2 if moderate, 3 if severe). Results: Of 174 included patients, 89 (51.2%) were female; average age was 68.0±9.1. 28 (16.1%) had no leukoaraiosis, 66 (37.9%) had mild, 62 (35.6%) had moderate, and 18 (10.3%) had severe. Leukoaraiosis severity was associated with worse 90-day mRS among all patients (p=0.0005) as well as those that were successfully revascularized (p=0.0002). A multivariate analysis confirmed that leukoaraiosis burden was associated with worse 90-day mRS among all patients (mild: p=0.006; moderate: p=0.002; severe: p=0.03), as well as those that underwent successful thrombectomies (p=0.005). Both L-ASPECTS and ASPECTS were associated with poor outcomes, but the association was stronger with L-ASPECTS (p<0.0001 and AUC=0.7 for L-ASPECTS; p=0.04 and AUC=0.59 for ASPECTS). Conclusion: Leukoaraiosis severity on pre-mechanical thrombectomy NCCT is associated with worse 90-day outcome in patients with AIS following endovascular recanalization, and is an independent risk factor for worse outcomes. A proposed L-ASPECTS score had stronger association with outcome than the traditional ASPECTS score.

Introduction: Cortical superficial siderosis (cSS) refers to deposition of blood breakdown products along the cerebral cortex, causing characteristic staining patterns seen with iron-sensitive MRI techniques. Cortical superficial siderosis is a relatively rare disorder, but has been linked to cerebral amyloid angiopathy and Alzheimer’s disease. The objective of this study was to determine the frequency and natural history of cSS in the general elderly population. Methods: MRI scans from the Mayo Clinic Study of Aging (MCSA), an ongoing population-based study of elderly residents in Olmsted County, Minnesota, were reviewed by neuroradiologists. Participants with cSS were identified based on linear pattern of hypointensity on gradient recalled echo imaging consistent with cSS. Exclusion criteria were: 1) MRI findings not consistent with cSS or 2) alternative explanation for MRI findings (such as aneurysmal subarachnoid hemorrhage, intracranial surgery, or trauma). Additional data abstracted included extent of cSS, presence of cerebral microbleeds, and clinical outcome. Results: Eleven out of 1,441 participants had MRI scans showing cSS (0.8%). When stratified by age, the frequency was 0.4% in those 50 to 70 years old and 1.1% in those over 70 years old. Six participants had only focal involvement of cSS (restricted to three or fewer sulci) and five had disseminated involvement (affecting more than three sulci). Microbleeds were seen in four of five (80%) participants with disseminated cSS, but none with focal cSS. Five participants (2 focal, 3 disseminated cSS) had follow up MRI scans, with an average follow up of 25 months. There was no further hemorrhage in those with focal cSS. However, all three participants with disseminated cSS experienced additional hemorrhage: one with new microbleeds, one with new microbleeds and lobar hemorrhage, and one with sulcal subarachnoid hemorrhage and lobar hemorrhage. Conclusion: Although rare, cSS may be encountered in the general elderly population. Extent of involvement of cSS and concomitant microbleeds may be important risk factors for progression of disease and intracerebral hemorrhage. The clinical significance of focal cSS occurring in the absence of microbleeds requires further investigation.

Introduction: Acute stroke pre-arrival notification by emergency medical services (EMS) allows hospital personnel to mobilize resources in advance, thereby improving treatment times and outcomes. However, criteria for pre-arrival notification vary by institution. In developing our own pre-arrival notification system, we aimed to determine whether objective measures, EMS clinical impression, or a combination of both best predicted accurate stroke team activation. Methods: Retrospective review of consecutive patients presenting to our institution via EMS with suspicion of acute stroke from 2014-2015. Data recorded included age, gender, time of symptom onset, glucose, Cincinnati Prehospital Stroke Scale (CPSS), Glasgow Coma Scale (GCS), and EMS impression. Univariate logistic regression was performed with acute stroke team activation in the emergency department (ED) as the endpoint. Results: 130 patients met inclusion criteria. Of these, 88 prompted the ED provider to activate the acute stroke team. Of variables analyzed, CPSS was clinically and statistically significant (OR. 1.7, 95% CI 1.2-2.5, p=0.0035) on univariate analysis, with arm weakness being the most predictive component (OR 2.9, 95% CI 1.04-8.1, p=0.04). EMS impression was not statistically significant (p>0.05). We then performed sensitivity and specificity analyses of CPSS, EMS impression, and CPSS combined with EMS impression (Table). A CPSS score of 3 had the highest specificity, and CPSS score of 1 combined with EMS impression the highest sensitivity. Conclusion: CPSS was the key significant predictor of ED acute stroke team activation, and more specific than EMS clinical impression. By combining CPSS and EMS impression, sensitivity improved, but at the expense of specificity. This suggests that reproducible measurements and scores, such as CPSS, should be the main driver for stroke pre-notification systems and should be integrated systematically into EMS education programs.

Background: Spontaneous spinal subarachnoid hemorrhage (SSAH) is a rare but serious condition that can lead to a variety of medical complications. Methods: Using the Mayo Clinic Rochester database, patients admitted to the Mayo Clinic Rochester, MN hospital with spontaneous SSAH (not iatrogenic or traumatic) between January 2000 and December 2015 were retrospectively reviewed. Demographic and clinical data and functional outcomes as described by the modified Rankin Scale (mRS) score at the time of discharge and at post-admission follow-up were assessed. Results: Eight consecutive patients (median age 70 years, range 51-87) were identified. Seven patients presented with acute onset back pain or headache. Seven patients had poorly controlled chronic hypertension. Two patients had vasculitis, and one had an arteriovenous malformation (AVM). An increase in blood pressure was observed in all patients during their acute presentation as compared to their baseline outpatient readings. Complications included cord compression (n = 4), hyponatremia (n = 5), sulcal subarachnoid hemorrhage (n = 2), chronic arachnoiditis (n=1), vasospasm (n=1), and late cord ischemia (n = 1). All eight patients were managed medically including blood pressure control and repeat imaging. One patient had an aneurysm which was embolized, and two received steroids for vasculitis. One patient died during hospitalization, one died within a week of discharge, five had improved mRS score at post-hospitalization follow-up and had unchanged mRS of 1 at discharge and follow-up. Conclusions: To our knowledge this is the first compilation of cases of spontaneous SSAH. Risk factors for spontaneous SSAH are hypertension, AVM, vasculitis, coarctation of the aorta, and malignancy. Symptomatic cord compression is not uncommon, but can be managed conservatively.

Introduction: An artificial intelligence (AI) algorithm applied to electrocardiography (ECG) during normal sinus rhythm (NSR) has been shown to predict concomitant atrial fibrillation (AF). We sought to characterize the value of AI-ECG as a predictor of future AF and assess its performance compared to other clinical prediction scores in a population-based sample. Methods: We calculated the AI-ECG probability during NSR in patients who enrolled in the population-based Mayo Clinic Study of Aging with at least one ECG in NSR within two years prior and no history of AF at the time of the baseline study visit. The cumulative incidence of AF was estimated for strata defined by AI-ECG probability and CHARGE-AF score. Cox proportional hazards were fit to assess the independent prognostic value and interaction of AI-ECG probability and CHARGE-AF score. Concordance (c) statistics were calculated for AI-ECG probability, CHARGE-AF score and combined AI-ECG and CHARGE-AF score. Results: A total of 1,936 patients with a median age 75.8 (quartile range [QR] 70.4, 81.8) years, median CHARGE-AF score 14.0 (QR 13.2, 14.7) and median CHADS2VASC score 3 (QR 2, 4) were included in the analysis. The cumulative incidence of AF increased in a stepwise fashion across quartiles of AI-ECG probability and CHARGE-AF score (Figure 1). When compared in the same model, both AI-ECG probability (hazard ratio [HR] 1.76, 95% confidence interval [CI] 1.51-2.04) and CHARGE-AF score (HR 1.90, 95% CI 1.58-2.28) independently predicted AF without significant interaction (p=0.54). C statistics were 0.69 (95% CI 0.66-0.72) for AI-ECG probability, 0.69 (95% CI 0.66-0.71) for CHARGE-AF and 0.72 (95% CI 0.69-0.75) for combined AI-ECG and CHARGE-AF score. Conclusions: In the Mayo Clinic Study of Aging, both the AI-ECG probability and CHARGE-AF score independently predicted time to AF. The AI-ECG may offer a means to assess risk with a single test without requiring manual or automated clinical data abstraction.

Background and Purpose: Cerebral microbleeds (CMBs) are represented by small areas of hemosiderin deposition, detected on brain magnetic resonance imaging (MRI), and found in ≈23% of the cognitively normal population over age of 60 years. CMBs predict risk of hemorrhagic and ischemic stroke. They correlate with increased cardiovascular mortality. In this article, we sought to determine in a population-based study whether antithrombotic medications correlate with CMBs and, if present, whether the association was direct or mediated by another variable. Methods: The study consisted of 1253 participants from the population-based Mayo Clinic Study of Aging who underwent T2* gradient-recalled echo magnetic resonance imaging. We tested the relationship between antithrombotic medications and CMB presence and location, using multivariable logistic-regression models. Ordinal logistic models tested the relationship between antithrombotics and CMB frequency. Using structural equation models, we assessed the effect of antithrombotic medications on presence/absence of CMBs and count of CMBs in the CMB-positive group, after considering the effects of age, sex, vascular risk factors, amyloid load by positron emission tomography, and apoE. Results: Two hundred ninety-five participants (26.3%) had CMBs. Among 678 participants taking only antiplatelet medications, 185 (27.3%) had CMBs. Among 95 participants taking only an anticoagulant, 43 (45.3%) had CMBs. Among 44 participants taking an anticoagulant and antiplatelet therapy, 21 (48.8%) had CMBs. Anticoagulants correlated with the presence and frequency of CMBs, whereas antiplatelet agents were not. Structural equation models showed that predictors for presence/absence of CMBs included older age at magnetic resonance imaging, male sex, and anticoagulant use. Predictors of CMB count in the CMB-positive group were male sex and amyloid load. Conclusions: Anticoagulant use correlated with presence of CMBs in the general population. Amyloid positron emission tomography correlated with the count of CMBs in the CMB-positive group.

AbstractNeurological complications after heart transplantation are common and include cerebrovascular events (ischemic strokes, hemorrhagic strokes, and transient ischemic attacks), seizures, encephalopathy, central nervous system (CNS) infections, malignancies, and peripheral nervous system complications. Although most neurological complications are transient, strokes and CNS infections can result in high mortality and morbidity. Early recognition and timely management of these serious complications are crucial to improve survival and recovery. Diagnosing CNS infections can be challenging because their clinical presentation can be subtle in the setting of immunosuppression. Immunosuppressive medications themselves can cause a broad spectrum of neurological complications including seizures and posterior reversible encephalopathy syndrome. This article provides a review of the diagnosis and management of neurological complications after cardiac transplantation.