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T Tomsick

Publications and source records attributed to T Tomsick.

At least 19 recordsLinked to original sources
PubMed2005

Combined IV and intra-arterial thrombolysis for acute ischemic stroke.

Combined IV and intra-arterial (IA) thrombolysis for acute ischemic stroke may offer advantages over either technique alone. Sixty-two nonrandomized patients with NIH Stroke Scale scores of > or =10 who met standard criteria for IV thrombolysis were treated with an IV/IA approach. Three-month modified Rankin Scale scores were 0 to 2 for 50% of patients, mortality was 18%, and symptomatic intracerebral hemorrhage occurred in 8%. IV/IA thrombolysis appeared safe and effective in this group.

Adult↗
PubMed2001

Greater Cincinnati/Northern Kentucky Stroke Study: volume of first-ever ischemic stroke among blacks in a population-based study.

BACKGROUND AND PURPOSE: The volume of ischemic stroke on CT scans has been studied in a standardized fashion in acute stroke therapy trials with median volumes between 10.5 to 55 cm(3). The volume of first-ever ischemic stroke in the population is not known. METHODS: The first phase of the population-based Greater Cincinnati/Northern Kentucky Stroke Study identified all ischemic strokes occurring in blacks in the greater Cincinnati region between January and June of 1993. The patients in this phase of the study who had a first-ever ischemic clinical stroke were identified, and the volume of ischemic stroke was measured. RESULTS: There were 257 verified clinical cases of ischemic stroke, of which 181 had a first-ever ischemic infarct. Imaging was available for 150 of these patients, and 79 had an infarct on the CT or MRI study that was definitely or possibly related to the clinical symptoms. For these patients, volumetric measurements were performed by means of the modified ellipsoid method. The median volume of first-ever ischemic stroke for the 79 patients was 2.5 cm(3) (interquartile range, 0.5 to 8.8 cm(3)). There was a significant relation between location of lesion and infarct size (P<0.001) and between volume and mechanism of stroke (P=0.001). CONCLUSIONS: The volume of first-ever ischemic stroke among blacks in our population-based study is smaller than has been previously reported in acute stroke therapy trials. The large proportion of small, mild strokes in blacks may be an important reason for the low percentage of patients who meet the inclusion criteria for tissue plasminogen activator. Further study is necessary to see if these results are generalizable to a multiracial population.

Acute Disease↗
PubMed2000

Combined intravenous and intra-arterial recombinant tissue plasminogen activator in acute ischemic stroke.

BACKGROUND AND PURPOSE: A retrospective analysis was performed on 20 consecutive patients who presented with severe acute ischemic stroke and were evaluated for a combined intravenous (IV) and local intra-arterial (IA) recombinant tissue plasminogen activator (rtPA) thrombolytic approach within 3 hours of onset. METHODS: Twenty consecutive patients with carotid artery distribution strokes were evaluated and treated using a combined IV and IA rtPA approach over a 14-month period (September 1998 to October 1999). rtPA (0.6 mg/kg) was given intravenously (maximum dose 60 mg); 15% of the IV dose was given as bolus, followed by a continuous infusion over 30 minutes. A maximal IA dose, up to 0.3 mg/kg or 24 mg, whichever was less, was given over a maximum of 2 hours. IV treatment was initiated within 3 hours in 19 of 20 patients. All 20 patients underwent angiography, and 16 of 20 patients received local IA rtPA. RESULTS: The median baseline National Institutes of Health Stroke Scale (NIHSS) score for the 20 patients was 21 (range 11 to 31). The median time from stroke onset to IV treatment was 2 hours and 2 minutes, and median time to initiation of IA treatment was 3 hours and 30 minutes. Ten patients (50%) recovered to a modified Rankin Scale (mRS) of 0 or 1; 3 patients (15%), to an mRS of 2; and 5 patients (25%), to an mRS of 4 or 5. One patient (5%) developed a symptomatic intracerebral hemorrhage and eventually died. One other patient (5%) expired because of complications from the stroke. CONCLUSIONS: We believe that the greater-than-expected proportion of favorable outcomes in these patients with severe ischemic stroke reflects the short time to initiation of both IV and IA thrombolysis.

Acute Disease↗
PubMed1999

Early surgical treatment for supratentorial intracerebral hemorrhage: a randomized feasibility study.

BACKGROUND AND PURPOSE: The safety and the effectiveness of the surgical treatment of spontaneous intracerebral hemorrhage (ICH) remain controversial. To investigate the feasibility of urgent surgical evacuation of ICH, we conducted a small, randomized feasibility study of early surgical treatment versus current nonoperative management in patients with spontaneous supratentorial ICH. METHODS: Patients with spontaneous supratentorial ICH who presented to 1 university and 2 community hospitals were randomized to surgical treatment or best medical treatment. Principal eligibility criteria were ICH volume >10 cm(3) on baseline CT scan with a focal neurological deficit, Glasgow Coma Scale score >4 at the time of enrollment, randomization and therapy within 24 hours of symptom onset, surgery within 3 hours of randomization, and no evidence for ruptured aneurysm or arteriovenous malformation. The primary end point was the 3-month Glasgow Outcome Scale (GOS). A good outcome was defined as a 3-month GOS score >3. RESULTS: Twenty patients were randomized over 24 months, 9 to surgical intervention and 11 to medical treatment. The median time from onset of symptoms to presentation at the treating hospitals was 3 hours and 17 minutes, the time from randomization to surgery was 1 hour and 20 minutes, and the time from onset of symptoms to surgery was 8 hours and 35 minutes. The likelihood of a good outcome (primary outcome measure: GOS score >3) for the surgical treatment group (56%) did not differ significantly from the medical treatment group (36%). There was no significant difference in mortality at 3 months. Analysis of the secondary 3-month outcome measures showed a nonsignificant trend toward a better outcome in the surgical treatment group versus the medical treatment group for the median GOS, Barthel Index, and Rankin Scale and a significant difference in the National Institutes of Health Stroke Scale score (4 versus 14; P=0.04). CONCLUSIONS: Very early surgical treatment for acute ICH is difficult to achieve but feasible at academic medical centers and community hospitals. The trend toward less 3-month morbidity with surgical intervention in patients with spontaneous supratentorial ICH warrants further investigation of very early clot removal in larger randomized clinical trials.

Cerebellar Diseases↗
PubMed1999

Utility, safety, and accuracy of intraoperative angiography in the surgical treatment of aneurysms and arteriovenous malformations.

BACKGROUND AND PURPOSE: The role of intraoperative angiography in the treatment of neurovascular lesions has remained extremely controversial. We retrospectively reviewed the utility, safety, and accuracy of intraoperative angiography to ascertain its effect on the treatment of patients with neurovascular lesions. METHODS: We reviewed the results of intraoperative angiography in 91 patients treated surgically for intracranial aneurysms and in 98 patients treated surgically for arteriovenous malformations (AVMs). All treatments were completed at two major teaching hospitals between October 1987 and March 1995. RESULTS: The initial angiographic findings caused the surgical procedure to be modified in 24 (26%) of the patients with aneurysms and in 28 (29%) of the patients with AVMs. Analysis of the final angiographic sequence showed residual lesions in nine (10%) of the aneurysm cases and in eight (8%) of the AVM cases. The imperfect angiographic results were deemed acceptable because there was either evidence of collateral flow when the parent vessel was occluded or the risk of further surgical modification was considered more dangerous than the abnormality itself. Seven patients suffered complications, of which only one had permanent neurologic sequelae: a CNS complication rate of 0.5%. Comparison of the intraoperative angiographic findings with those of postoperative studies revealed four false-negative results (5.2%). CONCLUSION: Intraoperative angiography is an important component in the treatment of patients with intracranial vascular lesions. It is effective and can be carried out with low risk in this patient population.

Cerebral Angiography↗
PubMed1997

Early hemorrhage growth in patients with intracerebral hemorrhage.

BACKGROUND AND PURPOSE: The goal of the present study was to prospectively determine how frequently early growth of intracerebral hemorrhage occurs and whether this early growth is related to early neurological deterioration. METHODS: We performed a prospective observational study of patients with intracerebral hemorrhage within 3 hours of onset. Patients had a neurological evaluation and CT scan performed at baseline, 1 hour after baseline, and 20 hours after baseline. RESULTS: Substantial growth in the volume of parenchymal hemorrhage occurred in 26% of the 103 study patients between the baseline and 1-hour CT scans. An additional 12% of patients had substantial growth between the 1- and 20-hour CT scans. Hemorrhage growth between the baseline and 1-hour CT scans was significantly associated with clinical deterioration, as measured by the change between the baseline and 1-hour Glasgow Coma Scale and National Institutes of Health Stroke Scale scores. No baseline clinical or CT prediction of hemorrhage growth was identified. CONCLUSIONS: Substantial early hemorrhage growth in patients with intracerebral hemorrhage is common and is associated with neurological deterioration. Randomized treatment trials are needed to determine whether this early natural history of ongoing bleeding and frequent neurological deterioration can be improved.

Adult↗
PubMed1996

Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy.

PURPOSE: To determine the relationship between the hyperdense middle cerebral artery sign (HMCAS) and neurologic deficit, as evidenced by the National Institutes of Health (NIH) stroke scale score, and to determine the relationship of the HMCAS and the NIH stroke scale score to arteriographic findings after thrombolytic therapy. METHODS: Fifty-five patients with acute ischemic stroke were rated on the NIH stroke scale, were examined with CT, and were treated with intravenous alteplase within 90 minutes of symptom onset. Presence of the HMCAS was determined on the baseline CT scan by a neuroradiologist blinded to the patient's neurologic deficit. Patients with the HMCAS were compared with those without HMCAS with regard to baseline NIH stroke scale score, 2-hour NIH stroke scale score, findings at posttreatment arteriography, 3-month residual neurologic deficit, and 3-month ischemia volumes as evidenced on CT scans. RESULTS: Eighteen patients (33%) had the HMCAS. These patients had a median baseline NIH stroke scale score of 19.5 compared with a median score of 10 for the patients lacking the HMCAS sign. At 3 months, one (6%) of the HMCAS-positive patients was completely improved neurologically compared with 17 (47%) of the HMCAS-negative patients. Restricting analysis to those patients with a stroke scale score of 10 or greater (n = 37), 18 HMCAS-positive patients showed less early neurologic improvement, were less likely to be completely improved at 3 months, and had larger infarcts compared with the 19 HMCAS-negative patients. Compared with the HMCAS-positive and HMCAS-negative patients with a stroke scale score of 10 or greater, patients with a stroke scale score of less than 10 had fewer occlusive changes of the internal carotid and middle cerebral arteries on posttreatment arteriograms and had a better neurologic recovery at 3 months. CONCLUSION: The presence of the HMCAS on CT scans obtained within 90 minutes of stroke onset is associated with a major neurologic deficit, and in this study it predicted a poor clinical and radiologic outcome after intravenous thrombolytic therapy. However, a major neurologic deficit, defined as a stroke scale score of 10 or more, was better than a positive HMCAS as a predictor of poor neurologic outcome after thrombolytic therapy. Patients with a low stroke scale score (< 10) may benefit from ultraearly intravenous alteplase therapy.

Adult↗
PubMed1995

Hyperglycemia and hemorrhagic transformation of cerebral infarcts.

BACKGROUND: Identification of factors that predispose to bleeding into ischemic brain could lead to safer use of thrombolytic agents in the setting of ischemic stroke. Recently de Courten-Meyers and colleagues reported that occluding the middle cerebral artery of markedly hyperglycemic cats was associated with 5-fold more frequent and 25-fold more extensive hemorrhage into infarcts than in normoglycemic animals. Hemorrhage associated with hyperglycemia in cats was much more pronounced with reperfusion than with permanent middle cerebral artery occlusion. CASE DESCRIPTION: We describe two patients with a unique presentation of diffuse hemorrhagic infarction of the caudate and lentiform nuclei associated with initially marked hyperglycemia and the subsequent development of hemichorea. CONCLUSIONS: We hypothesize that the marked hyperglycemia due to poor control of diabetes contributed to the hemorrhagic change of the caudate and lenticular nuclei. Because the hemorrhage in hyperglycemic cats was more pronounced in the setting of reperfusion, hemorrhagic risk associated with hyperglycemia should be investigated, particularly in ongoing thrombolytic treatment trials for acute ischemic stroke. We encourage other acute stroke investigators to prospectively look at the risk of brain hemorrhage in stroke patients with marked hyperglycemia.

Aged↗
PubMed1994

Baseline silent cerebral infarction in the Asymptomatic Carotid Atherosclerosis Study.

BACKGROUND AND PURPOSE: In a group of patients with high-grade asymptomatic carotid artery stenosis, we prospectively determined the prevalence and radiological characteristics of clinically asymptomatic brain infarction evident on computed tomography. Risk factors and extent of carotid disease were also determined. METHODS: Patients randomized into the Asymptomatic Carotid Atherosclerosis Study (ACAS) underwent a neurological history, a detailed stroke/transient ischemic attack questionnaire, and a detailed neurological examination. Computed tomography scans were examined by standardized criteria developed as part of a quality-control program supervised by a neuroradiologist. The presence, location, and size of all cerebral infarctions evident by computed tomography were determined. RESULTS: Among 1132 patients, 848 had no history of stroke or transient ischemic attack. One hundred twenty-six patients (15%) had a silent infarct; 95 (11%) had one, 24 (3%) had two, and 7 (1%) had three or more infarcts. The infarct size was small and deep for 117 patients (72%), less than one-half lobe for 45 (28%), and one-half to less than one lobe for 1 (0.5%). The silent infarcts were evenly distributed ipsilaterally and contralaterally to the study artery but were significantly more frequent in the right hemisphere (P < .05). Factors associated with silent infarction were abnormal gait (P < .001), abnormal deep tendon reflexes or plantar responses (P = .038), but not degree of carotid stenosis. Silent infarction was less frequent among this totally asymptomatic cohort (15%) compared with those with transient ischemic attacks (34/139, 25%; P < .001). CONCLUSIONS: Silent infarction in the setting of asymptomatic carotid stenosis is not uncommon, but silent infarctions are rarely sizable. The clinical significance of silent cerebral infarction in patients with asymptomatic carotid artery stenosis has yet to be established.

Adult↗
PubMed1994

Initial and recurrent bleeding are the major causes of death following subarachnoid hemorrhage.

BACKGROUND AND PURPOSE: The goal of this study was to determine the causes of mortality and morbidity after subarachnoid hemorrhage. METHODS: We identified all first-ever spontaneous subarachnoid hemorrhages that occurred in the nearly 1.3 million population of greater Cincinnati during 1988. RESULTS: Thirty-day mortality for subarachnoid hemorrhage was 45% (36 of 80 cases). Of the 36 deaths, 22 (61%) died within 2 days of onset; 21 of these deaths were due to the initial hemorrhage, and one death was due to rebleeding documented by computer tomography. Nine of the remaining 14 deaths after day 2 were caused by the initial hemorrhage (2 cases) or rebleeding (7 cases). Volume of subarachnoid hemorrhage was a powerful predictor of 30-day morality (P = .0001). Only 3 of the 29 patients with a volume of subarachnoid hemorrhage of 15 cm3 or less died before 30 days. Two of these 3 patients died from documented rebleeding; the third had 87 cm3 of additional intraventricular hemorrhage. Delayed arterial vasospasm contributed to only 2 of all 36 deaths. CONCLUSIONS: Most deaths after subarachnoid hemorrhage occur very rapidly and are due to the initial hemorrhage. Rebleeding is the most important preventable cause of death in hospitalized patients. In a large representative metropolitan population, delayed arterial vasospasm plays a very minor role in mortality caused by subarachnoid hemorrhage.

Aged↗
PubMed1994

Management of intracerebral hemorrhage in a large metropolitan population.

The management of all patients with spontaneous, nonaneurysmal intracerebral hemorrhages that occurred in the 1.26 million population of Greater Cincinnati during 1988 was reviewed. Of the 188 patients with intracerebral hemorrhage, 26 had operative removal of their intracerebral hemorrhage, and 8 had removal of their intracerebral hemorrhage and an arteriovenous malformation. In 15 of the 34 patients, the operation was performed within 12 hours of onset. The operative removal of parenchymal hemorrhages was performed in 29% of cerebellar, 24% of lobar, 13% of deep, and 10% of pontine hemorrhages. Admission Glasgow Coma Scale scores were similar for operated and nonoperated patients (11 +/- 3 versus 11 +/- 3), but operated patients were significantly younger (58 +/- 17 versus 72 +/- 15 yr), were more likely to have a lobar hemorrhage (64 versus 43%) or a cerebellar hemorrhage (29 versus 7%), and had larger parenchymal hemorrhages (50 +/- 31 versus 37 +/- 38 ml). Operated patients had a borderline lower 30-day mortality (25%) than nonoperated patients (46%), but the overall morbidity and mortality for the two groups did not differ significantly. Patients undergoing an early operation were more critically ill preoperatively and had a greater 30-day mortality (45%) than did those patients undergoing a late operation (12%). Half of the 43% mortality for all hospitalized cases occurred during the first 2 days after onset, and two-thirds occurred during the first 4 days. Only 12% of all patients had a minor handicap or better at 30 days. Neurosurgeons in our community performed operative removal of parenchymal hemorrhage in nearly one fifth of all patients with intracerebral hemorrhage.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1994

Use of a coil introducer to shape microcatheters.

We have found that an angled tip with a 40-degree angle and a distal length of 1 to 3 mm can be useful in subselecting intracranial vessels whose origins are otherwise difficult to catheterize. In addition, curves can be introduced by shaping the coil introducer as needed. These shapes can be safely formed using a coil introducer inserted in a retrograde fashion and fixed in boiling water.

Catheterization↗
PubMed1993

Lobar hemorrhage in the elderly. The undiminishing importance of hypertension.

BACKGROUND AND PURPOSE: We sought to determine whether hypertension is less common in primary lobar hemorrhage than intracerebral hemorrhage in other locations and whether the frequency of hypertension in lobar hemorrhage diminishes with advancing age. METHODS: We identified all cases of intracerebral hemorrhage in Greater Cincinnati during 1988 by review of hospital and autopsy records as well as computed tomographic and magnetic resonance scans. RESULTS: During 1988, 66 primary lobar hemorrhages occurred, constituting 46% of all intracerebral hemorrhages in those under 75 years of age and 34% in those age 75 and older. A history of hypertension was present in 67% of patients with lobar, 73% of those with deep, 73% of those with cerebellar, and 78% of those with pontine hemorrhages. Left ventricular hypertrophy was present in 21% of patients with lobar, 27% of those with deep, and 47% of those with pontine/cerebellar hemorrhages. The frequency of hypertension in patients with lobar hemorrhage did not decrease with advancing age. CONCLUSIONS: The proportion of all intracerebral hemorrhages that are lobar does not increase with advancing age. Hypertension is nearly as common in primary lobar hemorrhage as in deep, cerebellar, and pontine hemorrhages, and its importance as an associated condition for lobar hemorrhage does not diminish with advancing age.

Adult↗
PubMed1993

Volume of intracerebral hemorrhage. A powerful and easy-to-use predictor of 30-day mortality.

BACKGROUND AND PURPOSE: The aim of this study was to determine the 30-day mortality and morbidity of intracerebral hemorrhage in a large metropolitan population and to determine the most important predictors of 30-day outcome. METHODS: We reviewed the medical records and computed tomographic films for all cases of spontaneous intracerebral hemorrhage in Greater Cincinnati during 1988. Independent predictors of 30-day mortality were determined using univariate and multivariate statistical analyses. RESULTS: The 30-day mortality for the 188 cases of intracerebral hemorrhage was 44%, with half of deaths occurring within the first 2 days of onset. Volume of intracerebral hemorrhage was the strongest predictor of 30-day mortality for all locations of intracerebral hemorrhage. Using three categories of parenchymal hemorrhage volume (0 to 29 cm3, 30 to 60 cm3, and 61 cm3 or more), calculated by a quick and easy-to-use ellipsoid method, and two categories of the Glasgow Coma Scale (9 or more and 8 or less), 30-day mortality was predicted correctly with a sensitivity of 96% and a specificity of 98%. Patients with a parenchymal hemorrhage volume of 60 cm3 or more on their initial computed tomogram and a Glasgow Coma Scale score of 8 or less had a predicted 30-day mortality of 91%. Patients with a volume of less than 30 cm3 and a Glasgow Coma Scale score of 9 or more had a predicted 30-day mortality of 19%. Only one of the 71 patients with a volume of parenchymal hemorrhage of 30 cm3 or more could function independently at 30 days. CONCLUSIONS: Volume of intracerebral hemorrhage, in combination with the initial Glasgow Coma Scale score, is a powerful and easy-to-use predictor of 30-day mortality and morbidity in patients with spontaneous intracerebral hemorrhage.

Adult↗
PubMed1993

Intracerebral hemorrhage more than twice as common as subarachnoid hemorrhage.

The authors report a study of all instances of spontaneous intracerebral hemorrhage (ICH) (188 cases) and subarachnoid hemorrhage (SAH) (80 cases) that occurred in the Greater Cincinnati area during 1988. Adjusted for age, sex, and race, the annual incidence of ICH was 15 per 100,000 population (95% confidence interval 13 to 17) versus six per 100,000 for SAH (95% confidence interval 5 to 8). The incidence of ICH was at least double that of SAH for women, men, and whites and approximately 1 1/2 times that for blacks. The 30-day mortality rate of 44% for ICH was not significantly different from the 46% mortality rate for SAH. Despite the evidence that ICH is more than twice as common and the disorder just as deadly as SAH, clinical and laboratory research continues to focus primarily on SAH.

Adolescent↗
PubMed1992

The risk of subarachnoid and intracerebral hemorrhages in blacks as compared with whites.

BACKGROUND: Stroke is an important cause of death among blacks, and intracerebral and subarachnoid hemorrhages account for nearly half of all early deaths from stroke. The present study investigates whether blacks and whites differ in their risk of having either intracerebral or subarachnoid hemorrhage. METHODS: We reviewed the medical records, autopsy reports, and CT scans of all patients suspected of having had an intracerebral or subarachnoid hemorrhage during 1988 among the nearly 1.3 million people in the Greater Cincinnati metropolitan area. RESULTS: There were 221 cases of first spontaneous intracranial hemorrhage among 1,086,462 whites (159 intracerebral and 62 subarachnoid hemorrhages), and 45 cases among 171,718 blacks (27 intracerebral and 18 subarachnoid hemorrhages). Blacks had 2.1 times the risk of subarachnoid hemorrhage of whites (95 percent confidence interval, 1.3 to 3.6) and 1.4 times the risk of intracerebral hemorrhage (95 percent confidence interval, 0.9 to 2.1). In those under the age of 75, the risk of intracerebral hemorrhage among blacks was 2.3 times that of whites (95 percent confidence interval, 1.5 to 3.6), whereas the risk among blacks 75 or older was one fourth that of whites (95 percent confidence interval, 0.1 to 0.8). Deaths within 30 days of intracerebral or subarachnoid hemorrhage accounted for 1.9 years of life lost per 1000 blacks under 65 years of age, as compared with 0.5 year per 1000 whites. CONCLUSIONS: Young and middle-aged blacks have a substantially higher risk of subarachnoid or intracerebral hemorrhage than whites of similar age. These types of stroke are important causes of excess mortality among young and middle-aged blacks.

Adult↗
PubMed1990

Radiation-induced cerebral aneurysms.

The association between vasculopathy and radiation is well recognized. Generalized arterial disruption and subsequent stenosis and occlusion is most often described. Additional vascular phenomenon, such as pseudoaneurysm formation, aneurysmal dilatation and aneurysmal rupture, are less common. We document a case of a cerebral aneurysm formation and rupture in the field radiated for cerebral neoplasm.

Astrocytoma↗