tPA: a rural network experience.
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Acute Disease↗
Biomedical subjects
M Ramirez-Lassepas
Publications and source records attributed to M Ramirez-Lassepas.
Stroke and the aging of the brain and the arteries.
Stroke continues to be the third most common cause of death and a major cause of disability among those aged 70 years and older. The risk of stroke doubles for every decade after age 55. It is 25% higher in men. Age, cardiovascular disease, and hypertension are major determinants of cerebral blood flow; all have a negative impact on cerebral reperfusion. The risk of stroke can be reduced at any age by treating and correcting concomitant risk factors: hypertension; heart disease and cardiac arrhythmias (treatment with anticoagulants); transient ischemic attacks (treatment by platelet inhibitors or anticoagulants); and carotid stenosis (by endarterectomy). Cessation of smoking, control of diabetes, reduction of serum lipids, and control of obesity can reduce the risk of stroke. When stroke occurs, early treatment with rt-PA and aggressive patient care results in reduced mortality and morbidity and makes for better neurologic outcomes. Finally, prevention of stroke reduces risk of vascular dementia and makes a better functioning advanced age.
Aging↗
Predictors of intracranial pathologic findings in patients who seek emergency care because of headache.
BACKGROUND: Clinical criteria to select patients with headache in whom structural diagnostic studies (computed tomography) have a high yield disclosing intracranial pathologic findings, independent of abnormal findings on neurologic examination, have not been defined. OBJECTIVE: To determine which clinical characteristics predict the presence of intracranial pathologic findings, independently of neurologic examination, in patients with headache. DESIGN: Case-control, consecutive sample. SETTING: Major metropolitan trauma center emergency department. PATIENTS AND MATERIALS: Hospital records of 139 hospitalized and 329 randomly selected patients from 1720 nonhospitalized adult patients, consecutively evaluated for headache in the emergency department, were reviewed. Demographic data, clinical characteristics of the headache, results of neurologic and physical examinations, and diagnostic radiologic and laboratory results were correlated with final diagnosis and outcome at 6 months after emergency department visit. DATA ANALYSIS: Nonparametric statistical analysis. RESULTS: Intracranial pathologic findings were found in 18 (3.8%) of 468 patients. Acute onset and occipitonuchal location of headache, presence of associated symptoms, and patient age of 55 years or older were significantly associated with the finding of intracranial pathology, independently of the findings from neurologic examination. Abnormal findings on neurologic examination alone, whether focal or nonfocal, had a highly significant association and a positive predictive value for intracranial pathology of 39%. CONCLUSIONS: Abnormal results from neurologic examination are the best clinical parameters to predict structural intracranial pathology; however, in patients 55 years or older with headache of acute onset located in the occipitonuchal region that has associated symptoms, computed tomographic scan of the head is justified as part of their clinical evaluation independently of the findings of the neurologic examination.
Adult↗
A new model of experimental cerebral infarction in New Zealand white rabbits.
To develop an easy, reproducible experimental model of cerebral infarction (CI) without craniotomy in New Zealand white rabbits, a silicone rubber cylinder embedded in a nylon suture was delivered to the middle cerebral arteries through the internal carotid artery in anesthetized animals. Rabbits were sacrificed 0.5-5 h after embolization. CI size and location were ascertained by the triphenyl-2H-tetrazolium chloride (TTC) staining method; cerebral blood flow (CBF) was measured prior to and after embolization. PCO2, temperature and blood pressure were monitored and kept constant. CI occurred in all rabbits after 4 h of ischemia, in 50% after 3 h and only in 33% after 2.5 h. CI did not occur within less than 2.5 h of ischemia. No correlation was found between size and location of CI and occlusion time. CBF was maximally reduced in the right MCA territory but was also reduced in both anterior cerebral arteries and left MCA territories. This model is technically easy and the retrievable embolus allows the study of reperfusion by pulling on the nylon suture. It is suitable for studying chemical and molecular changes of the ischemic cells and/or for studying neuroimage changes after ischemic stroke.
Animals↗
Acute radicular pain as a presenting symptom in multiple sclerosis.
From December 1973 through November 1988, we cared for 11 patients who presented with acute radicular pain and in whom radicular compression was ruled out by imaging techniques. Eventually, multiple sclerosis was diagnosed and judged to be responsible for the acute radiculopathy. The patients (seven women, aged 18 to 40 years; median, 32 years) and four men (aged 23 to 34 years; median, 29 years) were followed up from 6 months to 15 years (mean, 4 years 11 months). They represent 3.9% of 282 newly diagnosed cases of multiple sclerosis during the same 15 years. A retrospective analysis of the characteristics of their illness and its evolution was conducted. Six had lumbosacral radiculopathies; three, cervical and two, thoracic. In six of the 11 patients, symptoms occurred in close relationship to trauma; seven had recurrent radicular pain; four had other pain syndromes; and three others, paroxysmal symptoms. One patient died of complications from multiple sclerosis 3 years after diagnosis. Three others were rated five or greater in the extended Kurtzke disability status scale during follow-up.
Adolescent↗
Medical treatment of transient ischemic attacks: does it influence mortality?
All randomized studies published on the medical treatment of transient ischemic attacks in which controls received no treatment or placebo and in which mortality was reported were reviewed. Using the odds ratio method, we analyzed the results to determine if treatment had an effect on expected mortality. Studies were analyzed separately according to the treatment modality used. Chronic anticoagulation was used in four studies and platelet inhibitors in 12 (14 trials). This meta-analysis showed that neither treatment modality significantly reduces mortality. Chronic anticoagulation may have an adverse effect, and even though platelet inhibitors appeared to reduce mortality, no significance can be demonstrated, and the 95% confidence intervals did not allow us to rule out the possibility, albeit small, of an adverse effect or no effect at all.
Anticoagulants↗
Can embolic stroke be diagnosed on the basis of neurologic clinical criteria?
Diagnosis of embolic stroke is based on identification of a source of embolus (SOE) and on neurologic symptoms acknowledged as "clinical criteria." To test the validity of these criteria, we analyzed the symptoms at onset in 193 patients hospitalized after acute cerebral infarction. Patients were grouped according to identification of a cardiac SOE (106 patients), an arterial SOE (38 patients), or no SOE (49 patients). Cross-tabulations demonstrated that only rapidity and loss of consciousness at onset were associated with the presence of a cardiac SOE to a significant degree. Although these symptoms were highly specific for cardiac SOE, they were not sensitive. A distinct clinical neurologic profile from the symptoms and mode of onset was not identified.
Adult↗
Aneurysmal subarachnoid hemorrhage presenting as cardiorespiratory arrest.
Three cases of subarachnoid hemorrhage (SAH) due to ruptured developmental (berry) aneurysm are reported. Two patients presented with cardiac arrest and were successfully resuscitated, but the diagnosis of SAH was delayed and this most likely influenced poor final outcome. The third patient presented with irreversible respiratory arrest. The possible mechanisms responsible for SAH-triggered cardiac arrhythmia and/or respiratory arrest are discussed. Absence of previous cardiac history, persistent headache, focal neurologic findings (especially papilledema or subhyaloid hemorrhages) should warn the clinician of the possibility of SAH and warrant further neurologic investigation.
Arrhythmias, Cardiac↗
Treatment of acute ischemic stroke. Open trial with continuous intravenous heparinization.
To determine safety of early anticoagulation in patients with acute ischemic stroke, 150 consecutive patients were treated with continuous intravenous heparinization for one to 17 days (median, seven days) in an open trial. Fourteen patients had transient ischemic attacks and 136 patients had acute cerebral infarctions (Cls). None of the patients with transient ischemic attacks experienced untoward events. Of those with acute Cl, four patients (3%) suffered a new, or extension of, Cl; six patients (4.4%) suffered hemorrhagic complications, four patients (3%) died during treatment, and six patients (4%) died afterwards. Three of the deaths were related to treatment complications. Only 13 patients (8.6%) experienced fluctuation of deficit. Median hospitalization was 25.5 days. Recovery of function was good to excellent in 81% of the patients with acute Cl; 75% of the survivors were ambulatory, and about 66% of the patients had either a mild or a minimal neurologic deficit at discharge. The incidence of untoward events in patients with acute Cl was high enough (7.4%) for us to conclude that the efficacy of continuous intravenous heparinization in acute ischemic stroke should be established with controlled studies before its routine use can be recommended.
Acute Disease↗
Value of computed tomographic scan in the evaluation of adult patients after their first seizure.
The role of the computed tomographic (CT) scan in evaluating adults after their first seizure(s) was determined by reviewing the hospital records of 148 patients studied within 30 days of their ictus. Patients with alcohol or drug intoxication or withdrawal or with known brain tumor, craniotomy, or open skull fracture were excluded. Type of seizure; neurological, CT, and electroencephalographic findings; final diagnosis; and hospital outcome were cross correlated. The cause of seizure was established in 71 patients (48%); a structural lesion was identified by CT in 55 (37%), and 16 (11%) had metabolic seizures. CT findings agreed with the results of neurological examination 82% of the time. Structural lesions (including three tumors) were found by CT in 14 patients (15%) with nonfocal findings and in 12 (22%) of those with generalized electroencephalographic abnormalities. Our findings are similar to those reported in adult epileptics and lead us to conclude that the CT scan is a valuable aid in establishing the cause of seizures and in disclosing early lesions.
Adolescent↗
Platelet inhibitors for TIAs. A review of prospective drug trial results.
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Aged↗
Heparin therapy for stroke: hemorrhagic complications and risk factors for intracerebral hemorrhage.
Hemorrhages occurred in 16 (3.1%) of 510 patients treated with continuous intravenous heparin for acute cerebral infarction (269), reversible ischemic neurologic deficit (81), or transient ischemic attack (160). Three patients (0.6%) had intracerebral hematomas. Risk factors included abnormal CT within 24 hours of onset of symptoms (3.2%), severe neurologic deficit (2.8%), two acute infarcts by CT (2.1%), known source of embolus (1.3%), and final diagnosis of cerebral infarction (1.1%). The only identifiable risk factor for systemic hemorrhage (GI 1.0%, GU 0.8%, muscle 0.4%, skin 0.1%) was age over 60 years. The incidence of intraspinal hematoma was 0.6%. Two of the intracerebral hematomas were fatal, and mortality was 31% in patients with hemorrhagic complications; however, the risk of CNS hemorrhage was only 0.8%.
Adult↗
Heparin-induced thrombocytopenia in patients with cerebrovascular ischemic disease.
We studied 137 patients who were treated with heparin for cerebral infarction (73), partially reversible ischemic neurologic deficit (22), or transient ischemic attack (42). Platelet counts were performed before therapy, twice weekly, and at cessation of therapy. Platelets decreased in 118 patients (86%). In 21 (15.3%), platelets dropped greater than or equal to 40%; 9 of 14 new ischemic events and three of six deaths occurred in this group of patients. Because there was a significant association between poor outcome and platelet drop greater than or equal to 40% (p less than 0.001), we believe that platelets should be monitored frequently when patients are treated with heparin for ischemic cerebrovascular disease.
Adult↗
Heparin-associated thrombocytopenia: a prospective evaluation of 211 patients.
Two hundred eleven consecutive patients treated for acute thromboembolic disease were evaluated prospectively for the incidence of thrombocytopenia while receiving heparin treatment. One hundred patients received beef lung heparin and 111 patients received porcine intestinal mucosal heparin. All patients received a minimum of 4 consecutive days of continuous intravenous heparin, and platelet counts were determined prior to, at least twice weekly, and at the cessation of heparin therapy. Heparin-associated thrombocytopenia was defined as a decline from a normal platelet count (100,000-400,000/mm3) to less than 100,000/mm3 with a return to above 100,000/mm3 after the discontinuation of heparin. Heparin-associated thrombocytopenia developed in 11 patients (5.2% incidence). Ten of the thrombocytopenic patients had received beef lung heparin and one received porcine mucosal heparin. Chi-square analysis of these data was significant (p = 0.007). Plasma from seven of nine thrombocytopenic patients demonstrated a plasma factor compatible with a heparin-sensitive antiplatelet antibody. Heparin-associated thrombocytopenia appeared on days 2 to 10 of therapy. Cessation of heparin resulted in remission of thrombocytopenia within 4 days in all patients. Serial quantitative platelet count determinations are indicated in all patients receiving therapeutic heparinization for the early recognition and resolution of heparin-associated thrombocytopenia.
Adolescent↗
Antifibrinolytic therapy in subarachnoid hemorrhage caused by ruptured intracranial aneurysm.
There are 25 published studies on the treatment with antifibrinolytic agents of subarachnoid hemorrhage (SAH) caused by ruptured intracranial aneurysm. Twelve of these studies were uncontrolled and, except for one, all reported reduced incidence of rebleeding. Of 13 controlled studies, 9 were randomized, and 3 were also double-blind. In 7, reported decrease in rebleeding was reported, but only 4 showed decreased mortality. Three studies showed no effect, and three reported a higher incidence of rebleeding in treated patients. Discrepancies may be due to the multiple clinical variables of SAH and to flaws in methodology; nevertheless, the data fail to demonstrate that antifibrinolytic therapy alters the natural history of the disease.
Aminocaproates↗
Neurologic prognosis after cardiopulmonary arrest: IV. Brainstem reflexes.
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Adult↗
Seasonal (circannual) periodicity of spontaneous intracerebral hemorrhage in Minnesota.
Seasonal periodicity in the onset of spontaneous intracerebral hemorrhage was studied in 118 consecutive cases occurring during a six-year span. The patients were urban residents of eastern Minnesota, a region characterized by wide seasonal fluctuations in daylight and temperature. The greatest number of cases consistently occurred each year during January and February. Circannual (about one year) periodicity was demonstrated by statistical analysis using rhythmometric techniques. This periodicity coincided with that reported for mortality from cerebrovascular and cardiovascular diseases in the United States and elsewhere. Available information suggests that in populations at high risk for vascular diseases, climatic conditions might act as synchronizers to endogenous rhythms influencing the periodic occurrence of pathological vascular events.
Adult↗