Citations

Background and purposeThe objective of our study was to identify neurological factors associated with poor outcome in adult patients with fulminant bacterial meningitis.MethodsThis was a retrospective review of consecutive adult patients with fulminant bacterial meningitis, defined as meningitis causing coma within 24–48 h of hospitalization, at Mayo Clinic Rochester between January 2000 and November 2010. Functional status was assessed at discharge and upon last follow‐up using the modified Rankin scale (mRS). The primary end‐point was death or new major disability (increase of >2 on the mRS) at last follow‐up.ResultsThirty‐nine patients were identified. Encephalopathy (44%), coma (28%), focal seizures (3%) or a combination of these (26%) were present on admission. The most common pathogen was Streptococcus pneumoniae (57%). All patients were treated with broad spectrum antibiotics and 51% received steroids. Serious systemic complications were seen in 23 patients. Sixteen patients (41%) died during hospitalization. Median mRS at hospital discharge for surviving patients was 3; four patients had new major disability with a mean follow‐up of 11 months. Predictors of death or new major disability included lower Glasgow Coma Scale score at nadir [P = 0.002; age‐ and sex‐adjusted odds ratio (OR) 0.46, 95% confidence interval (CI) 0.28–0.48], longer duration of symptoms before hospitalization (P = 0.045; adjusted OR 2.34, 95% CI 1.02–5.37), abnormal head imaging at presentation (P = 0.008; adjusted OR 9.40, 95% CI 1.78−49.6) and use of intracranial pressure monitoring (P = 0.010, adjusted OR 51.0, 95% CI 2.51−1036).ConclusionMany adult patients who survive hospitalization are able to regain their pre‐morbid level of function. Aggressive management of bacterial meningitis is justified even in comatose adult patients.

Background Limited information is available on the frequency of pulmonary embolism ( PE ) in patients with an acute ischemic stroke ( AIS ). We evaluated clinical characteristics, predisposing factors, and outcomes in AIS patients with PE . Methods and Results We included all AIS patients admitted to participating institutions in the R egistry of the C anadian S troke N etwork. Clinically PE was documented by a physician and confirmed by computed tomography pulmonary angiography within 30 days of the stroke case index. The primary outcome was death or disability at discharge. Secondary outcomes included disposition, length of hospital stay, mortality at 3 months and 1 year. Among 11 287 patients with AIS , PE was found in 89 (0.78%) patients. History of cancer, deep vein thrombosis ( DVT )/ PE , and DVT during the hospitalization were associated with PE . PE was associated with higher risk of death at 30 days (25.8% versus 13.6%; P <0.001), at 1 year (47.2% versus 24.6%; P <0.001), and disability at discharge (85.4% versus 63.6%; P <0.001). Mean length of stay was longer in stroke patients with PE (36 versus 16 days; P =0.001). After adjusting for age, sex, and stroke severity, PE remained associated with lower survival at 30 days and 1 year, and death or disability at discharge ( OR 3.02; 95% CI 1.56 to 5.83). Conclusions In this large cohort study, PE occurred in nearly 1% of AIS patients. PE was more common in patients with severe stroke, history of cancer, previous DVT / PE or acute DVT and associated with lower short‐ and long‐term survival, greater disability, and longer length of stay.

Background and Purpose— The prognostic significance of subarachnoid extension of intracerebral hemorrhage was determined in the INTEnsive blood pressure Reduction in Acute Cerebral hemorrhage Trial (INTERACT2) study. Methods— INTERACT2 was an open randomized controlled trial of early intensive compared with guideline-recommended blood pressure lowering in patients with elevated systolic blood pressure within 6 hours of intracerebral hemorrhage. Independent predictors of death or major disability (scores 3–6 on the modified Rankin Scale) at 90 days were analyzed in logistic regression models. Results— Of 2582 participants, 192 (7%) had subarachnoid extension, which was associated with larger hematoma volumes ( P <0.0001) and higher National Institute of Health Stroke Scale score ( P <0.0001). Subarachnoid extension predicted death or major disability at 90 days (71% versus 53%; unadjusted odds ratio, 2.25; 95% confidence interval, 1.63–3.10; P <0.0001). The association remained significant after adjusting for age, region, lipid-lowering therapy, systolic blood pressure, glucose, location of hematoma, intraventricular extension, and randomized treatment (odds ratio, 2.17; 95% confidence interval, 1.50–3.14; P <0.0001), but not after further adjustment for baseline hematoma volume ( P =0.62). Conclusions— Subarachnoid extension of intracerebral hemorrhage is associated with poor prognosis, which is determined by a larger volume of the underlying intraparenchymal hematoma. Clinical Trial Registration— URL: http://www.clinicaltrials.gov . Unique identifier: NCT00716079.

The availability of population-based epidemiological data on the incident risk of stroke is very scarce in Argentina and other Latin American countries. In response to the priorities established by the World Health Organization and the United Nations, PREVISTA was envisaged as a population-based program to determine the risk of first-ever and recurrent stroke and transient ischemic attack incidence and mortality in Tandil, Buenos Aires, Argentina. The study will be conducted according to Standardized Tools for Stroke Surveillance (STEPS Stroke) methodology and will enroll all new (incident) and recurrent consecutive cases of stroke and transient ischemic attack in the City of Tandil between May 1st, 2013 and April 30, 2015. The study will include patients with ischemic stroke, non-traumatic primary intracerebral hemorrhage, subarachnoid hemorrhage, and transient ischemic attack. To ensure the inclusion of every cerebrovascular event during an observation period of two years, we will instrument an ‘intensive screening program’, consisting of a comprehensive daily tracking of every potential event of stroke or transient ischemic attack using multiple overlapping sources. Mortality would be determined during follow-up for every enrolled patient. Also, fatal community events would be screened daily through revision of death certificates at funeral homes and local offices of vital statistics. All causes of death will be adjudicated by an ad-hoc committee. The close population of Tandil is representative of a large proportion of Latin-American countries with low- and middle-income economies. The findings and conclusions of PREVISTA may provide data that could support future health policy decision-making in the region.

Background— A patent foramen ovale (PFO) may permit arterial embolization of thrombi that accumulate on the leads of cardiac implantable electronic devices in the right-sided cardiac chambers. We sought to determine whether a PFO increases the risk of stroke/transient ischemic attack (TIA) in patients with endocardial leads. Methods and Results— We retrospectively evaluated all patients who had endocardial leads implanted between January 1, 2000, and October 25, 2010, at Mayo Clinic Rochester. Echocardiography was used to establish definite PFO and non-PFO cohorts. The primary end point of stroke/TIA consistent with a cardioembolic etiology and the secondary end point of mortality during postimplantation follow-up were compared in PFO versus non-PFO patients with the use of Cox proportional hazards models. We analyzed 6075 patients (364 with PFO) followed for a mean 4.7±3.1 years. The primary end point of stroke/TIA was met in 30/364 (8.2%) PFO versus 117/5711 (2.0%) non-PFO patients (hazard ratio, 3.49; 95% confidence interval, 2.33–5.25; P <0.0001). The association of PFO with stroke/TIA remained significant after multivariable adjustment for age, sex, history of stroke/TIA, atrial fibrillation, and baseline aspirin/warfarin use (hazard ratio, 3.30; 95% confidence interval, 2.19–4.96; P <0.0001). There was no significant difference in all-cause mortality between PFO and non-PFO patients (hazard ratio, 0.91; 95% confidence interval, 0.77–1.07; P =0.25). Conclusions— In patients with endocardial leads, the presence of a PFO on routine echocardiography is associated with a substantially increased risk of embolic stroke/TIA. This finding suggests a role of screening for PFOs in patients who require cardiac implantable electronic devices; if a PFO is detected, PFO closure, anticoagulation, or nonvascular lead placement may be considered.