Stroke center certification: a beginning, not an end.
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Certification↗
Biomedical subjects
Joseph Haymore
Publications and source records attributed to Joseph Haymore.
Comparison of MRI and CT for detection of acute intracerebral hemorrhage.
CONTEXT: Noncontrast computed tomography (CT) is the standard brain imaging study for the initial evaluation of patients with acute stroke symptoms. Multimodal magnetic resonance imaging (MRI) has been proposed as an alternative to CT in the emergency stroke setting. However, the accuracy of MRI relative to CT for the detection of hyperacute intracerebral hemorrhage has not been demonstrated. OBJECTIVE: To compare the accuracy of MRI and CT for detection of acute intracerebral hemorrhage in patients presenting with acute focal stroke symptoms. DESIGN, SETTING, AND PATIENTS: A prospective, multicenter study was performed at 2 stroke centers (UCLA Medical Center and Suburban Hospital, Bethesda, Md), between October 2000 and February 2003. Patients presenting with focal stroke symptoms within 6 hours of onset underwent brain MRI followed by noncontrast CT. MAIN OUTCOME MEASURES: Acute intracerebral hemorrhage and any intracerebral hemorrhage diagnosed on gradient recalled echo (GRE) MRI and CT scans by a consensus of 4 blinded readers. RESULTS: The study was stopped early, after 200 patients were enrolled, when it became apparent at the time of an unplanned interim analysis that MRI was detecting cases of hemorrhagic transformation not detected by CT. For the diagnosis of any hemorrhage, MRI was positive in 71 patients with CT positive in 29 (P<.001). For the diagnosis of acute hemorrhage, MRI and CT were equivalent (96% concordance). Acute hemorrhage was diagnosed in 25 patients on both MRI and CT. In 4 other patients, acute hemorrhage was present on MRI but not on the corresponding CT--each of these 4 cases was interpreted as hemorrhagic transformation of an ischemic infarct. In 3 patients, regions interpreted as acute hemorrhage on CT were interpreted as chronic hemorrhage on MRI. In 1 patient, subarachnoid hemorrhage was diagnosed on CT but not on MRI. In 49 patients, chronic hemorrhage, most often microbleeds, was visualized on MRI but not on CT. CONCLUSION: MRI may be as accurate as CT for the detection of acute hemorrhage in patients presenting with acute focal stroke symptoms and is more accurate than CT for the detection of chronic intracerebral hemorrhage.
Acute Disease↗
Rising statin use and effect on ischemic stroke outcome.
BACKGROUND: Statins (3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors) have neuroprotective effects in experimental stroke models and are commonly prescribed in clinical practice. The aim of this study was to determine if patients taking statins before hospital admission for stroke had an improved clinical outcome. METHODS: This was an observational study of 436 patients admitted to the National Institutes of Health Suburban Hospital Stroke Program between July 2000 and December 2002. Self-reported risk factors for stroke were obtained on admission. Stroke severity was determined by the admission National Institutes of Health Stroke Scale score. Good outcome was defined as a Rankin score < 2 at discharge. Statistical analyses used univariate and multivariate logistic regression models. RESULTS: There were 436 patients with a final diagnosis of ischemic stroke; statin data were available for 433 of them. A total of 95/433 (22%) of patients were taking a statin when they were admitted, rising from 16% in 2000 to 26% in 2002. Fifty-one percent of patients taking statins had a good outcome compared to 38% of patients not taking statins (p = 0.03). After adjustment for confounding factors, statin pretreatment was associated with a 2.9 odds (95% CI: 1.2-6.7) of a good outcome at the time of hospital discharge. CONCLUSIONS: The proportion of patients taking statins when they are admitted with stroke is rising rapidly. Statin pretreatment was significantly associated with an improved functional outcome at discharge. This finding could support the early initiation of statin therapy after stroke.
Aged↗
Acute stroke patients are being underfed: a nitrogen balance study.
INTRODUCTION: Patients with acute neurological illness may be hypercatabolic. The Harris-Benedict Equation (HBE) is used to estimate energy needs in acute stroke. A "stress factor" for stroke does not exist, and it is not known if the HBE accurately estimates the energy expenditure needs in acute ischemic or hemorrhagic stroke. We sought to assess nitrogen balance in patients with acute stroke and to determine the variables associated with negative nitrogen balance. MATERIALS AND METHODS: This was a case series, single-center study. Eligibility criteria included acute stroke requiring enteral nutrition, tolerating tube feedings at goal, normal urine output, and no underlying catabolic illness. Enteral feeding was adjusted to meet HBE requirements. After 24 hours of goal feeding, a 12-hour urine collection for nitrogen excretion was done. We determined if any of the following variables were associated with negative nitrogen balance: gender, glucose 6.6 mmol/L or more, age 80 years or older, National Institutes of Health Stroke Scale (NIHSS) 20 or higher, mechanical ventilation, and diabetes mellitus. RESULTS: We studied 27 patients (10 with intracranial hemorrhages and 17 with ischemic strokes) during an 18-month period. The median age was 80 (range: 48-90), and the median NIHSS was 19 (range: 4-38). The median time to feeding was 2 days (range: 1-8), the median time from onset to nitrogen balance was 5 days (range: 2-11), and the median interval between initiation of feeding and nitrogen collection was 2 days (range: 1-5)Negative nitrogen balance was seen in 12 of 27 (44%) patients. There was no relation between age, NIHSS, stroke type, admission glucose, history of diabetes, and mechanical ventilation use and nitrogen balance. Only 11 of 27 patients were anabolic. CONCLUSION: Critically ill stroke patients are being underfed using the current methods to estimate caloric needs. Hypercatabolism is common in acute stroke; clinical variables do not seem to allow prediction of this catabolic state.
Aged↗
Impact of establishing a primary stroke center at a community hospital on the use of thrombolytic therapy: the NINDS Suburban Hospital Stroke Center experience.
BACKGROUND AND PURPOSE: To increase the proportion of ischemic stroke patients treated with thrombolytic therapy, the establishment of primary stroke centers in community hospitals has been advocated. We evaluated the use of thrombolytic therapy before and after institution of a primary stroke center in a community hospital. METHODS: The availability of an on-call stroke emergency response team was the only significant additional resource required for this hospital. All eligible patients were treated with intravenous tissue plasminogen activator (tPA). The number of patients with cerebrovascular disease, number and proportion of patients treated with tPA, times to treatment, and patient outcomes were recorded during the first 2 years of the stroke center. RESULTS: During the 12 months before institution of the stroke center, 3 ischemic stroke patients (1.5%) were treated with tPA. During the 2-year period of around-the-clock coverage, 44 of 420 ischemic stroke patients (10.5%) were treated with intravenous tPA, a significant increase in tPA use (P<0.0001). CONCLUSIONS: Establishment of a primary stroke center at a community hospital resulted in a substantial increase in the proportion of patients receiving thrombolytic therapy for ischemic stroke. If this experience is generalized, the beneficial impact of primary stroke centers on stroke outcomes and costs to the healthcare system may be substantial.
Adult↗
A neuron in a haystack: advanced neurologic assessment.
An advanced practice nurse (APN) often encounters patients with alterations in neurologic functioning, regardless of the practice setting. In many situations, the APN will be asked to perform the initial evaluation and determine if additional testing and consultation are indicated. For the APN who does not routinely encounter these patients, the experience may be challenging. This article presents an organized approach to the examination of patients with alterations in mentation and level of consciousness and considerations for differential diagnosis.
Brain Death↗