Intracerebral hemorrhage specific intensity of care quality metrics.

Background: Intracerebral hemorrhage (ICH) care can vary among centers and previous studies have demonstrated differences in ICH outcome based on variations in patient care in various settings. The purpose of this paper is to present the design of an evidence-based dataset of elements of a new ICH specific intensity of care quality metrics.

Methods: The articles were identified based on personal knowledge of the subject supplemented by data derived from multi-center randomized trials, and selected non-randomized or observational clinical studies.

Balloon angioplasty for intracranial atherosclerotic disease: periprocedural risks and short-term outcomes in a multicenter study.

Background And Purpose: whether stenting is superior to angioplasty in the treatment of intracranial atherosclerotic disease is unknown. Dissections, vessel rupture, and lesion recoil observed with primary angioplasty using balloon catheters designed for coronary arteries have undermined the role of primary angioplasty as a preferred treatment for intracranial atherosclerotic disease. The goal of this study is to report the immediate and 3-month outcomes of treating patients with intracranial atherosclerotic disease with angioplasty balloon catheters in a multicenter study.

Low risk of intracranial and systemic hemorrhages in patients on dual antiplatelet treatment beyond 1 month following neuroendovascular angioplasty and/or stent placement.

Background: Aspirin and clopidogrel treatment beyond 1 month in patients undergoing angioplasty and/or stent placement within the extra- and/or intracranial arteries is not defined.

Objective: To determine the incidence of intracranial and systemic bleeding events, recurrent ischemic stroke, and death in patients treated with dual antiplatelets for greater than 1 month.

Methods: We determined rates of hemorrhage, stroke, or death in consecutive patients with extra- or intracranial lesions, treated with dual antiplatelets after angioplasty and/or stent procedures.

Guillain-Barré syndrome after Gardasil vaccination: data from Vaccine Adverse Event Reporting System 2006-2009.

Using data from Vaccine Adverse Event Reporting System, we identified 69 reports of Guillain-Barré Syndrome (GBS) after Gardasil vaccination that occurred in the United States between 2006 and 2009. The onset of symptoms was within 6 weeks after vaccination in 70% of the patients in whom the date of vaccination was known. The estimated weekly reporting rate of post-Gardasil GBS within the first 6 weeks (6.

Accuracy of the new ICD-9-CM code for "drip-and-ship" thrombolytic treatment in patients with ischemic stroke.

A new International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) diagnosis code, V45.88, was approved by the Centers for Medicare and Medicaid Services (CMS) on October 1, 2008. This code identifies patients in whom intravenous (IV) recombinant tissue plasminogen activator (rt-PA) is initiated in one hospital's emergency department, followed by transfer within 24 hours to a comprehensive stroke center, a paradigm commonly referred to as "drip-and-ship.

Outcomes after nontraumatic subarachnoid hemorrhage at hospitals offering angioplasty for cerebral vasospasm: a national level analysis in the United States.

Background: Primary angioplasty has been introduced for the treatment of symptomatic cerebral vasospasm in patients with subarachnoid hemorrhage (SAH). The data regarding the therapeutic benefit of angioplasty in improving patient outcomes are limited, hence its utilization at hospitals remains controversial and currently is not reimbursed by Medicare or major insurance companies.

Methods: We analyzed the data from Nationwide Inpatient Sample (NIS), a nationally representative dataset of all admissions in the United States from 2005 to 2007.

Safety and tolerability of high-intensity anticoagulation with bivalirudin during neuroendovascular procedures.

Background: Bivalirudin (Angiomax) is a direct thrombin inhibitor used in interventional cardiology due to its several distinct advantages over heparin, most notably a shorter half-life and a potentially superior safety profile. Bivalirudin is also safe to use in patients with active or remote heparin-induced thrombocytopenia. Our objective was to evaluate the safety and tolerability of high-intensity anticoagulation using bivalirudin during neuroendovascular procedures.

Low patient enrollment sites in multicenter randomized clinical trials of cerebrovascular diseases: associated factors and impact on trial outcomes.

Wide variability in patient enrollment among participating sites is a common phenomenon in multicenter trials. We examined stroke trial-related factors associated with the proportion of sites with low patient enrollment and the effect of these low-enrollment sites on trial outcome. We identified efficacy clinical trials enrolling patients with cerebrovascular diseases between 1980 and 2008 using an electronic database.

Impact of International Subarachnoid Aneurysm Trial results on treatment of ruptured intracranial aneurysms in the United States. Clinical article.

Object: The utilization of endovascular treatment for ruptured intracranial aneurysms is expected to change since the publication of the International Subarachnoid Aneurysm Trial (ISAT) in 2002. The authors performed this analysis to determine the impact of ISAT results on treatment selection for ruptured intracranial aneurysms and associated in-hospital outcomes using nationally representative data.

Methods: We determined the national estimates of treatments used for ruptured intracranial aneurysms and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data.

Occurrence of post-acute recanalization and collateral formation in patients with cerebral venous and sinus thrombosis. A serial venographic study.

Background: The underlying mechanism for symptomatic recovery in patients with cerebral venous and sinus thrombosis (CVST) is not clear, although post-acute recanalization and collateral formation have been proposed as possible mechanisms. To identify the occurrence of recanalization and collateral formation among survivors of CVST and explore its association with symptomatic recovery.

Methods: We identified all the patients admitted with CVST over a 5-year period and who underwent initial magnetic resonance (MR) or computed tomographic (CT) venography and a follow-up CT or MR venography between 3 and 12 months after onset.

Repeated-measures analysis of the National Institute of Neurological Disorders and Stroke rt-PA stroke trial.

Previous analyses, including the National Institute of Neurological Disorders and Stroke (NINDS) rt-PA Stoke Trial, have assessed the clinical treatment efficacy only at single study point, but did not assess efficacy using outcomes collected at multiple time points and incorporate within-patient correlation. The data from the NINDS rt-PA Stroke Trial was analyzed with repeated-measures analysis with generalized estimating equations (GEE) approach using dichotomized outcomes (modified Rankin Scale [mRS], National Institutes of Health Stroke Scale [NIHSS], Barthel Index [BI], and Glasgow Outcome Scale [GOS]). The results were compared with data from previous analyses.

A comparison of Computed Tomography perfusion-guided and time-guided endovascular treatments for patients with acute ischemic stroke.

Background And Purpose: The role of CT perfusion (CT-P) imaging for the selection of patients with acute ischemic stroke who may benefit from endovascular treatment is not defined. The objective of this study was to determine whether CT-P-guided endovascular treatment improves clinical outcomes compared with standard endovascular treatment based on the time interval between symptom onset and presentation and noncontrast cranial CT imaging.

Methods: A retrospective study was performed comparing the clinical characteristics, complications, and clinical outcomes of patients with acute ischemic stroke who were treated using endovascular modalities based on either CT-P imaging (CT-P-guided) or time interval between symptom onset and presentation and absence of intracerebral hemorrhage or extensive ischemic changes on noncontrast cranial CT scan (time-guided).

Intracranial angioplasty and/or stent placement in octogenarians is associated with a threefold greater risk of periprocedural stroke or death.

Purpose: To compare the clinical and angiographic outcomes of endovascular treatment of symptomatic intracranial stenosis between octogenarian and younger patients.

Methods: Data for 244 consecutive patients (173 men; mean age 61.6 years) who underwent angioplasty and/or stenting for intracranial atherosclerotic disease at 5 specialized centers were pooled.

Effect of systolic blood pressure reduction on hematoma expansion, perihematomal edema, and 3-month outcome among patients with intracerebral hemorrhage: results from the antihypertensive treatment of acute cerebral hemorrhage study.

Background: Evidence indicates that systolic blood pressure (SBP) reduction may reduce hematoma expansion in patients with intracerebral hemorrhage (ICH) who are initially seen with acute hypertensive response.

Objective: To explore the relationship between different variables of SBP reduction and hematoma expansion, perihematomal edema, and 3-month outcome among patients with ICH.

Design: Post hoc analysis of a traditional phase 1 dose-escalation multicenter prospective study.

Dabigatran etexilate, a new oral direct thrombin inhibitor, for stroke prevention in patients with atrial fibrillation.

Importance Of The Field: Warfarin is the only oral anticoagulant recommended for the prevention of ischemic stroke in atrial fibrillation. A newer and safer anticoagulant is needed because of increased hemorrhagic risks with warfarin, difficult-to-maintain therapeutic levels, and higher drug to drug and food interactions.

Areas Covered In This Review: Dabigatran etexilate is a new, effective, reversible, rapid-acting, oral direct inhibitor of thrombin.

Cost-effectiveness analysis of protected carotid artery stent placement versus endarterectomy in high-risk patients.

Purpose: To determine the cost-effectiveness of carotid angioplasty with stent placement (CAS) under emboli protection versus carotid endarterectomy (CEA) in patients with severe carotid stenosis considered to be at high surgical risk for CEA.

Methods: The probabilities of various outcomes were adopted from the SAPPHIRE trial results. The quality-adjusted life year (QALYs) associated with each treatment modality were estimated by using the frequencies of various quality-adjusted outcomes (QALY weights of ipsilateral stroke, myocardial infarction, and death).

Indications and applications for extracranial carotid artery stent placement.

Treatment of high-grade symptomatic carotid stenosis via carotid endarterectomy has been shown to be superior to medical management alone in several studies. Carotid angioplasty and stenting (CAS) has emerged as an alternative approach to endarterectomy to reduce the associated perioperative risks. Several anatomic and physiologic factors that increase the risk of stroke and/or death associated with endarterectomy have been identified.

Intracranial atherosclerotic disease: an update.

The consensus conference on intracranial atherosclerosis provides a comprehensive review of the existing literature relevant to the epidemiology, diagnosis, prevention, and treatment of intracranial atherosclerosis, and identifies principles of management and research priorities. Patients who have suffered a stroke or transient ischemic attack attributed to stenosis (50-99%) of a major intracranial artery face a 12 to 14% risk for subsequent stroke during the 2-year period after the initial ischemic event, despite treatment with antithrombotic medications. The annual risk for subsequent stroke may exceed 20% in high-risk groups.

Comparison between primary angioplasty and stent placement for symptomatic intracranial atherosclerotic disease: meta-analysis of case series.

Objective: To compare the short- and long-term rates of stroke-and/or-death associated with primary angioplasty alone and angioplasty with stent placement using a meta-analysis of published studies. Both primary angioplasty alone and angioplasty with stent placement have been proposed as treatment strategies for symptomatic intracranial atherosclerotic disease to reduce the risk of stroke-and/or-death with best medical treatment alone. However, it remains unclear which of these endovascular techniques offers the best risk reduction.

Comparison of partial (.6 mg/kg) versus full-dose (.9 mg/kg) intravenous recombinant tissue plasminogen activator followed by endovascular treatment for acute ischemic stroke: a meta-analysis.

Background: In the treatment of acute ischemic stroke, intravenous (IV) recombinant tissue plasminogen (rt-PA) and intraarterial (IA) interventions are often combined. However, the optimal dose of IV rt-PA preceding endovascular treatment has not been established.

Methods: Studies that used combined IV and IA thrombolysis were identified from a search of the MEDLINE, PubMed, and Cochrane databases.