Timing of symptomatic hemorrhage after intravenous tPA (tissue-type plasminogen activator).

Timing of symptomatic hemorrhage after intravenous tPA (tissue-type plasminogen activator).

Shorter ICU Stays? The Majority of Post-IV tPA Symptomatic Hemorrhages Occur Within 12 Hours of Treatment

Patients who receive treatment with intravenous tissue plasminogen activator (IV tPA) are at risk of developing symptomatic intracranial hemorrhage (sICH), a life-threatening complication. The current standard of care requires that these patients are monitored for 24 hours post-treatment, which is resource-intensive. However, given the relatively short half-life of tPA, it was hypothesized that sICH due to IV tPA would develop well before 24 hours.

Results showed that sICH associated with the administration of IV tPA typically occurs within the first 12 hours of treatment. Longer monitoring in an ICU-like setting may be unnecessary for most individuals.

Chang A, Llinas EJ, Chen K, Llinas RH, Marsh EB. Shorter intensive care unit stays?: The majority of post-intravenous tPA (tissue-type plasminogen activator) symptomatic hemorrhages occur within 12 hours of treatment. Stroke 2018;49(6):1521-1524.
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Collaterals Predict Outcome Regardless of Time Last Known Normal

When imaging is favorable, the modified Rankin Scale score at follow-up is comparable regardless of time last known well. Functional outcomes appear to be driven most significantly by the presence of collaterals.

Sharma R, Llinas R, Urrutia V, Marsh EB. Collaterals predict outcome regardless of time last known normal. Journal of Stroke and Cerebrovascular Diseases 2018;27(4):971-977.
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Cerebral microbleeds shouldn't dictate treatment of acute stroke: a retrospective cohort study evaluating risk of intracerebral hemorrhage

Our findings support prior findings that a high cerebral microbleed burden (CMB, >10) in patients with acute stroke treated with IV tPA are associated with a higher risk of symptomatic hemorrhage (sICH). However, the overall rate of sICH in the presence of CMB is very low, indicating that the presence of CMBs by itself should not dictate the decision to treat with thrombolytics.

Chacon-Portillo MA, Llinas RH, Marsh EB. Cerebral microbleeds shouldn't dictate treatment of acute stroke: a retrospective cohort study evaluating risk of intracerebral hemorrhage. BMC Neurology 2018;18(1):33.
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Streamlining the Process for Intravenous Tissue Plasminogen Activator

The use of a stroke nurse and a nursing flow sheet as part of the acute stroke assessment significantly increases the proportion of patients treated with IV tPA within 60 minutes from hospital arrival.

Lawrence E, Merbach D, Thorpe S, Llinas RH, Marsh EB. Streamlining the process for intravenous tissue plasminogen activator. Journal of Neuroscience Nursing 2018;50(1):37-41.
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Isolated aphasia in the emergency department: The likelihood of ischemia is low

Strokes affecting language without motor or sensory deficits are uncommon. In the acute setting, isolated “aphasia” is most often due to a stroke mimic; however, it can occur rarely, particularly in those with prior history of ischemia.

Casella G, Llinas RH, Marsh EB. Isolated aphasia in the emergency department: the likelihood of ischemia is low. Clinical Neurology and Neurosurgery 2017;163:24-26.
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In Potential Stroke Patients on Warfarin, the International Normalized Ratio Predicts Ischemia

Sub-therapeutic international normalized ratio (INR) and atrial fibrillation are strongly associated with ischemia in patients on warfarin presenting with acute neurologic symptoms. Ischemia is far less likely in patients with an INR of ≥2 and rare in those with an INR ≥3.6. This study shows that the INR value of a patient on warfarin can help stratify patients' risk for acute ischemic stroke and guide further neurologic imaging and workup.

Cao C, Martinelli A, Spoelhof B, Llinas RH, Marsh EB. In potential stroke patients on warfarin, the international normalized ratio predicts ischemia. Cerebrovascular Diseases EXTRA 2017;7(2):111-119.
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Keep it simple: vascular risk factors and focal exam findings correctly identify posterior circulation ischemia in “dizzy” patients

The presence of calcification within the cervical and intracranial vessels on computed tomography angiography (CTA) can be associated with posterior circulation ischemia, but in our population did not add significant utility above clinical acumen. A vascular risk assessment and neurological examination are adequate for risk stratification of ischemia in the dizzy patient and should remain the standard evaluation.

Chen K, Schneider ALC, Llinas RH, Marsh EB. Keep it simple: vascular risk factors and focal exam findings correctly identify posterior circulation ischemia in “dizzy” patients. BMC Emergency Medicine 2016;16(1):8-16.
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Stuttering Lacunes: An Acute Role for Clopidogrel?

Our experience suggests that acutely loading with clopidogrel may be both effective and well tolerated in the treatment of stuttering lacunes.

Marsh EB, Llinas RH. Stuttering lacunes: an acute role for clopidogrel? Journal of Neurology and Translational Neuroscience 2014;2(1):1035-1038.
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Diagnosing CNS Vasculitis: The Case Against Empiric Treatment

We report a case series of 5 patients who were admitted or transferred to the Johns Hopkins Hospital with a clinical history and magnetic resonance imaging findings suggestive of primary central nervous system vasculitis (PCNSV). Four patients had received at least 1 course of immunosuppression with high-dose intravenous (IV) corticosteroids and/or a corticosteroid-sparing agent. Each underwent an extensive workup including 4-vessel cerebral angiography and, in the majority of cases, brain biopsy to evaluate for mimics of PCNSV. In each of the 5 cases, an alternative diagnosis was found.

We propose a cautious, multistep approach to the diagnosis of PCNSV, which takes into account more common diagnoses and avoids the pitfalls of empiric treatment.

Marsh EB, Zeiler SR, Levy M, Llinas RH, Urrutia VC. Diagnosing CNS Vasculitis: the case against empiric treatment. The Neurologist 2012;18(4): 233-238.
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