Citations

Background and Purpose— Postpartum angiopathy (PPA), a rare cause of stroke in the puerperium, is heralded by severe headaches within 1–2 weeks after delivery. Angiography demonstrates segmental vasoconstriction that often resolves spontaneously. PPA is generally regarded as benign. We aimed to define clinical presentations, radiological findings, and outcomes of patients with PPA. Methods— We retrospectively reviewed patients from 3 centers with acute neurological symptoms and angiography showing vasoconstriction in the postpartum period. Patients without neuroimaging and with diagnoses of cerebral venous sinus thrombosis and aneurysmal hemorrhage were excluded. Patient characteristics, clinical symptoms, neuroimaging findings, and clinical condition at hospital discharge were collected. Results— Eighteen patients (mean age, 31 years; range, 15–41) were identified. Median gestation was 38 weeks. Twelve (67%) had a history of prior uneventful pregnancy. Neurological symptoms began on median day 5 postpartum and included headache (n=16, 89%), focal deficit (n=9, 50%), visual disturbance (n=8, 44%), encephalopathy (n=6, 33%), and seizure (n=5, 28%), often in combination. Brain imaging was abnormal in most (n=13, 72%). The most common abnormalities were intracranial hemorrhage (n=7, 39%), vasogenic edema (n=6, 35%), and infarction (n=6, 35%). Clinical outcomes were markedly variable with full recovery seen in 9 (50%), death after a fulminant course in 4 (22%), and residual deficits in 5 (28%). Conclusions— In contrast to prior reports, this group of patients with PPA had a higher proportion of nonbenign outcomes. Most patients who undergo neuroimaging have parenchymal abnormalities, which are most often stroke (hemorrhagic or ischemic) or reversible vasogenic edema.

Background and Purpose— Patients with aneurysmal subarachnoid hemorrhage are typically kept in the intensive care unit to be monitored for signs of delayed cerebral ischemia (DCI). Identifying patients at lower risk for DCI could have a positive financial impact by allowing earlier transfer from the intensive care unit. Methods— We analyzed 307 consecutive patients admitted to the intensive care unit. Demographic, clinical, and neuroimaging data were recorded. The relationship with absent DCI was analyzed using univariate and multivariate logistic regression models. Results— DCI did not develop in 169 patients (57.9%). Among factors at admission, age 68 years or older ( P =0.0003; OR, 3.16; 95% CI, 1.66–6.39), World Federation of Neurological Surgeons (WFNS) I to III at presentation ( P =0.0003; OR, 2.73; 95% CI, 1.57–4.79), WFNS I to III at worst ( P =0.0003; OR, 2.39; 95% CI, 1.48–3.87), WFNS I to III after resuscitation ( P =0.0006; OR, 2.85; 95% CI, 1.56–5.32), modified Fisher grade 1 to 2 ( P =0.0021; OR, 2.43; 95% CI, 1.37–4.47), absence of intracranial hematoma ( P =0.0042; OR, 2.26; 95% CI, 1.29–4.01), and aneurysm in the posterior circulation ( P =0.025; OR, 1.74; 95% CI, 1.07–2.87) were associated with absence of DCI. On multivariate analysis, a model including age 68 years or older, WFNS I to III at presentation and a modified Fisher grade 1 to 2 were independently predictive of the absence of DCI, with a specificity of 100% and a positive predictive value of 100%. Conclusions— We propose a new model that can reliably identify patients with aneurysmal subarachnoid hemorrhage who are at very low risk for DCI. These patients could be candidates for early transfer to the general ward.

Background and Purpose— It is important to know the costs for hospitalization for ischemic stroke patients treated with intravenous thrombolysis so that comparisons can be made with payments to hospitals. Methods— Using the National Inpatient Sample, we evaluated hospitalization costs for patients treated with intravenous thrombolysis for acute ischemic stroke in the United States from 2001 to 2008. Cost data were correlated with demographics and clinical outcome. Results— Intravenous thrombolysis for acute ischemic stroke was received by 63 472 patients; 24 094 patients were younger than age 65 years and 40 780 patients were 65 years or older. Median hospital costs in 2008 dollars were $14 102 (interquartile range, $9987–$20 819) for patients with good outcome, $18 856 (interquartile range, $13 145–$30 423) for patients with severe disability, and $19 129 (interquartile range, $11 966–$30 781) for patients with in-hospital mortality. Average 2008 Medicare payments were $10 098 for intravenous thrombolysis without complication and $13 835 for intravenous thrombolysis with major complication. Conclusions— Hospitalization costs for patients treated with intravenous thrombolysis are substantially higher than Medicare payments.

Background and Purpose— Helicopter transportation of patients with acute stroke who have received recombinant tissue-type plasminogen activator is commonly considered the best option. We evaluated if transportation by helicopter can reduce complications and improve clinical outcomes in patients with acute stroke. Methods— We conducted a review of consecutive patients with acute ischemic stroke transferred to our hospital after intravenous thrombolysis initiated at a referral center. Results— A total of 122 patient transportations were analyzed, 94 by air and 28 by ground. Time from activation of the transport system to arrival at our hospital was significantly shorter with air transportation (53 versus 68 minutes, P =0.04). Two complications were noted in the air group and no complications were noted in the ground group ( P =1.0). All other outcome measures were not significantly different between groups. Conclusions— Air transfer of patients with acute ischemic stroke treated with thrombolysis does not seem to impart any benefit to patient outcomes when compared with ground transport. Therefore, ground transport should be considered for these patients unless they are being considered for emergency endovascular rescue therapy.