Biomedical subjects

Isaac E Silverman

Publications and source records attributed to Isaac E Silverman.

7 recordsLinked to original sources

PubMed2006

Acute stroke management in the elderly.

BACKGROUND AND PURPOSE: Though the proportion of elderly stroke patients is increasing, patients >80 years are often excluded from clinical stroke trials. We reviewed the management of older patients presenting with acute ischemic stroke (AIS) and assessed the safety and efficacy of recombinant tissue plasminogen activator (rtPA) administration in a community-based setting. METHODS: A retrospective review of patients >80 years (n = 341) admitted to a community stroke center with AIS were compared to their younger counterparts (n = 690) using the stroke center database from April 2003 to December 2005. Parameters that were measured included admission and discharge NIH Stroke Scale (NIHSS), rate of thrombolytic treatment, the frequency and etiology of thrombolytic exclusion criteria and complications from rtPA for the different aged populations. Additional data were collected for Barthel Index at 12 months. RESULTS: A total of 166 patients underwent thrombolysis. Older patients were not delayed in reaching the hospital within 3 h of stroke onset (182/690, 26%, in the <80 cohort vs. 98/341, 29%, in the > or = 80 cohort). Although the overall rates of tPA use were similar in both the young and aged cohort, older patients were less likely to be treated with rtPA because of reasons not listed as exclusion criteria (17% in the <80 cohort vs. 32% in the > or = 80 cohort). The older group did not have an excess risk of intracranial hemorrhage following rtPA infusion despite equivalent NIHSS on admission (13.5 in the <80 cohort vs. 12.4 in the > or = 80 cohort). Both groups showed improvement in NIHSS following thrombolytic treatment with a drop of 7.7 points in the younger age group and 5.6 points in the older group. Elderly patients treated with rtPA had a comparable 12-month modified Barthel Index score to younger cohorts. CONCLUSIONS: Early treatment with rtPA in patients >80 years appears to be both safe and efficacious. Treated patients showed improvements both acutely (a decrease in NIHSS at 72 h) and chronically, as shown by a sustained improvement in the Barthel Index. A large number of elderly patients were excluded from rtPA treatment despite arriving within the time frame of treatment for reasons not considered as traditional exclusion criteria. Older patients with AIS can be treated safely with thrombolytic therapy in a community setting. This therapy should not be withheld on the basis of age.

Acute Disease↗

PubMed2005

Safety and efficacy of mechanical embolectomy in acute ischemic stroke: results of the MERCI trial.

BACKGROUND AND PURPOSE: The only Food and Drug Administration (FDA)-approved treatment for acute ischemic stroke is tissue plasminogen activator (tPA) given intravenously within 3 hours of symptom onset. An alternative strategy for opening intracranial vessels during stroke is mechanical embolectomy, especially for patients ineligible for intravenous tPA. METHODS: We investigated the safety and efficacy of a novel embolectomy device (Merci Retriever) to open occluded intracranial large vessels within 8 hours of the onset of stroke symptoms in a prospective, nonrandomized, multicenter trial. All patients were ineligible for intravenous tPA. Primary outcomes were recanalization and safety, and secondary outcomes were neurological outcome at 90 days in recanalized versus nonrecanalized patients. RESULTS: Recanalization was achieved in 46% (69/151) of patients on intention to treat analysis, and in 48% (68/141) of patients in whom the device was deployed. This rate is significantly higher than that expected using an historical control of 18% (P<0.0001). Clinically significant procedural complications occurred in 10 of 141 (7.1%) patients. Symptomatic intracranial hemorrhages was observed in 11 of 141 (7.8%) patients. Good neurological outcomes (modified Rankin score < or =2) were more frequent at 90 days in patients with successful recanalization compared with patients with unsuccessful recanalization (46% versus 10%; relative risk [RR], 4.4; 95% CI, 2.1 to 9.3; P<0.0001), and mortality was less (32% versus 54%; RR, 0.59; 95% CI, 0.39 to 0.89; P=0.01). CONCLUSIONS: A novel endovascular embolectomy device can significantly restore vascular patency during acute ischemic stroke within 8 hours of stroke symptom onset and provides an alternative intervention for patients who are otherwise ineligible for thrombolytics.

Angiography↗

PubMed2005

Cerebral edema during treatment of diabetic ketoacidosis in an adult with new onset diabetes.

INTRODUCTION: Diabetic ketoacidosis (DKA) continues to be a medical emergency, in part because of a rare and devastating complication associated with its treatment, cerebral edema. In children, cerebral edema is the principal cause of mortality, but clinically significant cerebral edema in adults is rare. METHODS AND RESULTS: We report the case of a 27-year-old male (not previously known to be diabetic) who presented with a first episode of DKA complicated by the development of fatal cerebral edema despite medical treatment. CONCLUSION: The pathophysiological mechanisms for cerebral edema associated with DKA occurring in children and adults are believed to be similar and are discussed in this report. However, patients who develop cerebral edema may deteriorate rapidly, and experience with successful treatment has been limited.

Adult↗

PubMed2004

Expanding the range of therapies for acute ischemic stroke: the early experience of the Regional Stroke Center at Hartford Hospital.

PURPOSE: Three to four percent of all patients with acute ischemic stroke (AIS) receive the only FDA-approved therapy, intravenous tissue plasminogen activator. We sought to assess the impact of a regional stroke program, the Stroke Center at Hartford Hospital, in facilitating various therapies for patients with AIS, and their early outcomes. METHODS: For a 34-month period (May 2001 to February, 2004), 113 patients received either i.v. and/or intra-arterial thrombolysis, or an experimental protocol as a therapy for AIS. The Hartford Hospital and Stroke Center databases were queried for the diagnosis of AIS using ICD-9 codes, site of patient presentation, transportation modality, stroke severity, and clinical outcome. RESULTS: The percentage of patients with AIS treated has increased each of the past five fiscal years, to 15.4% for fiscal year 2004 to date. This growth is paralleled by increases in mean annual stroke severity of all stroke patients admitted to Hartford Hospital and in the numbers of patients transferred with AIS from other hospitals in southern New England. Symptomatic hemorrhage rate for the 113 patients was 5.3%. In-hospital mortality rate was 25.7%. Most patients (56.6%) were discharged from Hartford Hospital either to home or to acute rehabilitation. CONCLUSIONS: A regional stroke program greatly facilitated acute stroke treatment interventions. We attribute this growth to widespread educational programming, an Acute Stroke Team, catheter-based therapies with a dedicated Interventional Neuroradiology service, a 1800 Acute Stroke Hotline, and clinical trials.

Algorithms↗

PubMed2003

Initial experience with a transcatheter septal closure system for secondary stroke prevention in patients with interatrial septal defects.

BACKGROUND: Percutaneous transcatheter closure of a patent foramen ovale (PFO) has been utilized over the last several years to prevent thromboembolic events in selected patients with a prior cryptogenic stroke. We describe our initial experience at Hartford Hospital with a transcatheter PFO closure system and our multidisciplinary approach. METHODS: From March to November 2002, we performed percutaneous transcatheter closure of a PFO in 16 patients with a prior history of cryptogenic stroke(s) and/or transient ischemic attack using the CardioSEAL Septal Occluder system. All 16 patients had a PFO visualized on their transesophageal echocardiogram (TEE) study, and 15 patients also had an atrial septal aneurysm. PFO closure was performed with a CardioSEAL Septal Occluder in the cardiac catheterization laboratory under general anesthesia with TEE guidance. Following device placement, all patients were discharged on a regimen of aspirin and clopidigrel, with follow-up in the Stroke Clinic. RESULTS: Successful deployment of the septal occluder and effective PFO closure was achieved in all 16 patients with no major procedural or in-hospital complications. Short-term clinical follow-up has demonstrated no recurrent neurologic thromboembolic events, but one patient was rehospitalized for de novo atrial fibrillation. Follow-up transthoracic echocardiographic assessment at three to six months postprocedure, obtained in eight patients thus far, has demonstrated no residual interatrial shunting. CONCLUSION: Our early results suggest that percutaneous PFO closure with the CardioSEAL Septal Occluder system is a safe option for secondary stroke prevention in carefully selected patients with interatrial septal defects and a history of cryptogenic stroke or TIA. Patient selection and the long-term effectiveness and safety of this approach require further assessment.

Adult↗

PubMed2002

Poststroke seizures.

Stroke is the most common cause of seizures in the elderly, and seizures are among the most common neurologic sequelae of stroke. About 10% of all stroke patients experience seizures, from stroke onset until several years later. This review discusses current understanding of the epidemiology, pathogenesis, classification, clinical manifestations, diagnostic studies, differential diagnosis, and management issues of seizures associated with various cerebrovascular lesions, with a focus on anticonvulsant use in the elderly.

Aged↗

PubMedDate not supplied

The "drip-and-ship" approach: starting IV t-PA for acute ischemic stroke at outside hospitals prior to transfer to a regional stroke center.

PURPOSE: Acute stroke therapy with intravenous (IV) tissue plasminogen activator (t-PA) is vastly underutilized. Increasingly, patients are being started on IV t-PA and being transferred to regional Stroke Center programs, where additional therapies can be offered in a multimodal format. We describe our experience at the Stroke Center at Hartford Hospital with interhospital patient transfers who received IV t-PA prior to transfer to our medical center. METHODS: A retrospective analysis of our Acute Stroke Therapies database was undertaken, encompassing the intial four-year period of our Stroke Center program (May 1, 2001 to April 30, 2005). We evaluated the patient characteristics, clinical outcomes, and adjunctive therapies of patients who were started on IV t-PA at referring hospitals prior to their emergent transfer to our Stroke Center. RESULTS: From a total of 229 patients who received IV and/or IA thrombolysis and newer catheter-delivered devices or clinical trials at our Stroke Center, a total of 33 (14.4%) were started on IV t-PA at an outside hospital prior to transfer. Symptomatic hemorrhage occurred in one of the 33 patients (3.0%), and in-hospital mortality rate for these patients was 6.1%. A total of 26 patients (78.8%) had a positive outcome in that they were discharged either to home or to acute rehabilitation. CONCLUSIONS: Use of IV t-PA in a "drip-and-ship" approach is growing at the regional Stroke Center at Hartford Hospital. This protocol is safe and offers several advances for the care of patients with AIS: (a) empowering emergency physicians and neurologists at outside hospitals, via access to a 24/7 Acute Stroke Hotline, to treat patients with AIS; (b) facilitating the early initiation of IV t-PA; and (c) offering adjunctive therapeutic approaches, following arrival at our facility, for patients not sufficiently improving with IV t-PA alone.

Acute Disease↗