Publications by authors named "Alejandro A Rabinstein"

542 Publications

Predictive modeling in neurocritical care using causal artificial intelligence.

World J Crit Care Med 2021 Jul 9;10(4):112-119. Epub 2021 Jul 9.

Department of Medicine, Department of Neurology, Mayo Clinic College of Medicine, Rochester, MN 55905, United States.

Artificial intelligence (AI) and digital twin models of various systems have long been used in industry to test products quickly and efficiently. Use of digital twins in clinical medicine caught attention with the development of Archimedes, an AI model of diabetes, in 2003. More recently, AI models have been applied to the fields of cardiology, endocrinology, and undergraduate medical education. The use of digital twins and AI thus far has focused mainly on chronic disease management, their application in the field of critical care medicine remains much less explored. In neurocritical care, current AI technology focuses on interpreting electroencephalography, monitoring intracranial pressure, and prognosticating outcomes. AI models have been developed to interpret electroencephalograms by helping to annotate the tracings, detecting seizures, and identifying brain activation in unresponsive patients. In this mini-review we describe the challenges and opportunities in building an actionable AI model pertinent to neurocritical care that can be used to educate the newer generation of clinicians and augment clinical decision making.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5492/wjccm.v10.i4.112DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8291004PMC
July 2021

Artificial Intelligence-Enabled ECG to Identify Silent Atrial Fibrillation in Embolic Stroke of Unknown Source.

J Stroke Cerebrovasc Dis 2021 Jul 21;30(9):105998. Epub 2021 Jul 21.

Cardiovascular Diseases, Mayo Clinic, Rochester, MN 55905, USA. Electronic address:

Objectives: Embolic strokes of unknown source (ESUS) are common and often suspected to be caused by unrecognized paroxysmal atrial fibrillation (AF). An AI-enabled ECG (AI-ECG) during sinus rhythm has been shown to identify patients with unrecognized AF. We pursued this study to determine if the AI-ECG model differentiates between patients with ESUS and those with known causes of stroke, and to evaluate whether the AF prediction by AI-ECG among patients with ESUS was associated with the results of prolonged ambulatory cardiac rhythm monitoring.

Materials And Methods: We reviewed consecutive patients admitted with acute ischemic stroke to a comprehensive stroke center between January 2018 and August 2019 and employed the TOAST classification to categorize the mechanisms of ischemia. Use and results of ambulatory cardiac rhythm monitoring after discharge were gathered. We ran the AI-ECG model to obtain AF probabilities from all ECGs acquired during the hospitalization and compared those probabilities in patients with ESUS versus those with known stroke causes (apart from AF), and between patients with and without AF detected by ambulatory cardiac rhythm monitoring.

Results: The study cohort had 930 patients, including 263 patients (28.3%) with known AF or AF diagnosed during the index hospitalization and 265 cases (28.5%) categorized as ESUS. Ambulatory cardiac rhythm monitoring was performed in 226 (85.3%) patients with ESUS. AF probability by AI-ECG was not associated with ESUS. However, among patients with ESUS, the probability of AF by AI-ECG was associated with a higher likelihood of AF detection by ambulatory monitoring (P = 0.004). A probability of AF by AI-ECG greater than 0.20 was associated with AF detection by ambulatory cardiac rhythm monitoring with an OR of 5.47 (95% CI 1.51-22.51).

Conclusions: AI-ECG may help guide the use of prolonged ambulatory cardiac rhythm monitoring in patients with ESUS to identify those who might benefit from anticoagulation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105998DOI Listing
July 2021

Subarachnoid hemorrhage from sudden gravitational changes.

Neuroradiol J 2021 Jul 8:19714009211030540. Epub 2021 Jul 8.

Department of Neurology, 6915Mayo Clinic, Mayo Clinic, USA.

Diffuse subarachnoid hemorrhage is commonly attributed to the rupture of intracranial aneurysms or other vascular malformations. Non-aneurysmal hemorrhages often have a characteristic pattern or clear mechanism (e.g. trauma) with an often more benign clinical course. We report the case of a diffuse non-aneurysmal subarachnoid hemorrhage due to sudden gravitational changes encountered during complex airflight maneuvers, complicated by hydrocephalus and cerebral vasospasm. This case illustrates a rare phenomenon that may again be encountered in the future with the advent and advancement of civilian spaceflight.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/19714009211030540DOI Listing
July 2021

Repeat Catheter Angiography in Patients with Aneurysmal-Pattern Angiographically Negative Subarachnoid Hemorrhage.

Neurocrit Care 2021 Jun 28. Epub 2021 Jun 28.

Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.

Background: A significant proportion of patients with subarachnoid hemorrhage have a normal cerebral angiogram. Patients with angiographically negative subarachnoid hemorrhage (anSAH) with either perimesencephalic- (panSAH) or aneurysmal-pattern hemorrhage (aanSAH, also known as diffuse anSAH) have an excellent prognosis, but only if underlying vascular abnormalities are completely excluded. The rate of occult aneurysms in patients with aanSAH varies widely across studies. The purpose of this study was to quantify the value of repeat DSA in these patients.

Methods: We reviewed the records of all patients initially diagnosed with aanSAH after a screening DSA at a single tertiary neurovascular referral center from January 2006-April 2018. Patients with panSAH and traumatic SAH were excluded. We also performed a systematic review and meta-analysis of positive second DSAs in previously published case series of patients with aanSAH who underwent two serial DSAs. For meta-analysis, PubMed Central, MEDLINE and Cochrane Library databases were searched for pertinent studies up to November 2019. The rate of aneurysm detection on repeat angiography was extracted from each study. Pooled rates for positive second angiogram were calculated as untransformed proportions in a binary random-effects model meta-analysis. Inter-study heterogeneity was calculated using an I statistic.

Results: Three of 27 patients (11.1%) with aanSAH and at least two DSAs were subsequently found to have a cerebral aneurysm in our institutional dataset. Twenty-six studies in our systematic review met inclusion criteria, and the pooled rate of positive second angiogram was 10.4% (95% CI 7.3%-13.5%, P < 0.001). Substantial inter-study heterogeneity was observed in the meta-analysis (I = 61.7%, P < 0.001).

Conclusions: One in 10 patients with aanSAH has an occult ruptured aneurysm. A second-look DSA should be strongly considered in these cases.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-021-01247-8DOI Listing
June 2021

Good Recovery Is Possible in Young Patients With Posttraumatic Coma and Brainstem Microbleeds.

Neurology 2021 07 28;97(2):53-54. Epub 2021 May 28.

From the Department of Neurology, Mayo Clinic, Rochester, MN.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000012197DOI Listing
July 2021

Batch enrollment for an artificial intelligence-guided intervention to lower neurologic events in patients with undiagnosed atrial fibrillation: rationale and design of a digital clinical trial.

Am Heart J 2021 Sep 24;239:73-79. Epub 2021 May 24.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN.

Background: Clinical trials are a fundamental tool to evaluate medical interventions but are time-consuming and resource-intensive.

Objectives: To build infrastructure for digital trials to improve efficiency and generalizability and test it using a study to validate an artificial intelligence algorithm to detect atrial fibrillation (AF).

Design: We will prospectively enroll 1,000 patients who underwent an electrocardiogram for any clinical reason in routine practice, do not have a previous diagnosis of AF or atrial flutter and would be eligible for anticoagulation if AF is detected. Eligible patients will be identified using digital phenotyping algorithms, including natural language processing that runs on the electronic health records. Study invitations will be sent in batches via patient portal or letter, which will direct patients to a website to verify eligibility, learn about the study (including video-based informed consent), and consent electronically. The method aims to enroll participants representative of the general patient population, rather than a convenience sample of patients presenting to clinic. A device will be mailed to patients to continuously monitor for up to 30 days. The primary outcome is AF diagnosis and burden; secondary outcomes include patients' experience with the trial conduct methods and the monitoring device. The enrollment, intervention, and follow-up will be conducted remotely, ie, a patient-centered site-less trial.

Summary: This is among the first wave of trials to adopt digital technologies, artificial intelligence, and other pragmatic features to create efficiencies, which will pave the way for future trials in a broad range of disease and treatment areas. Clinicaltrials.gov: NCT04208971.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ahj.2021.05.006DOI Listing
September 2021

Acute Hypertensive Response in Patients With Acute Intracerebral Hemorrhage: A Narrative Review.

Neurology 2021 May 24. Epub 2021 May 24.

Department of Neurology, Mayo Clinic, Rochester, MN, USA.

ObjectiveTo review the role of the acute hypertensive response in patients with intracerebral hemorrhage, current treatment options and areas for further research.MethodsReview of the literature to assess 1) Frequency of acute hypertensive response in intracerebral hemorrhage 2) Consequences of acute hypertensive response in clinical outcomes 3) Acute hypertensive response and secondary brain injury: hematoma expansion and perihematomal edema 4) Vascular autoregulation, safety data side effects of acute antihypertensive treatment, and 5) Randomized clinical trials and meta-analyses.ResultsAn acute hypertensive response is highly frequent in patients with acute intracerebral hemorrhage, and it is associated with poor clinical outcomes. However, it is not clear whether high blood pressure is a cause poor clinical outcome, or it solely represents a marker of severity. Although current guidelines recommend intensive blood pressure treatment (<140 mmHg) in patients with intracerebral hemorrhage, two randomized clinical trials have failed to demonstrate a consistent clinical benefit from this approach, and new data suggest that intensive blood pressure treatment could be beneficial for some patients, but detrimental for others.ConclusionsIntracerebral hemorrhage is a heterogenous disease, thus, a one-fit-all approach for blood pressure treatment may be suboptimal. Further research should concentrate on finding subgroups of patients more likely to benefit from aggressive BP lowering, considering ICH etiology, ultra-early randomization and risk markers of hematoma expansion on brain imaging.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000012276DOI Listing
May 2021

Antiseizure Medication use in Gastric Bypass Patients and Other Post-Surgical Malabsorptive States.

Epilepsy Behav Rep 2021 22;16:100439. Epub 2021 Mar 22.

Department of Neurology, Mayo Clinic, Rochester, MN, United States.

Healthcare professionals are encountering an increasing number of patients who have undergone bariatric surgeries. Antiseizure medications (ASM) have a narrow therapeutic window, and patients with malabsorptive states receiving ASM present a complex situation as the pharmacokinetics of these drugs have only been studied in patients with a normal functioning gastrointestinal tract. Patients with malabsorptive states may have altered pharmacokinetics, and there is limited literature to guide drug selection and dosage adjustment in patients with malabsorptive states. This review highlights pharmacokinetic parameters of common ASM, and considerations when managing patients on them. The effect of pH, lipophilicity, absorption, and metabolism should be taken into account when selecting and managing ASMs in this patient population. Based on these parameters, levetiracetam, and topiramate have fewer issues referable to absorption related to bariatric surgery while oral formulations of phenytoin, carbamazepine, oxcarbamazepine and valproic acid have reduced absorption due to effects of bariatric surgery based on the pharmacokinetic properties of these medications. Extended formulations should be avoided and ASM serum concentrations should be checked before and after surgery. The care of patients with epilepsy who are scheduled to undergo bariatric surgery should be guided by a multidisciplinary team including a pharmacist and a neurologist who should be involved in the adjustment of the ASMs throughout the pre-surgical and post-surgical periods.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ebr.2021.100439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8093413PMC
March 2021

Acute Coma.

Neurol Clin 2021 05;39(2):257-272

Department of Neurology, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA. Electronic address:

An acutely comatose patient constitutes a medical emergency until proved otherwise. Managing these emergencies requires organized teamwork to recognize and treat life-threatening situations and reversible causes of coma. Once vital functions have been stabilized, information from the history and physical examination should be used to rationally guide subsequent testing. Identifying causes of coma for which emergency treatment is possible should be the priority. The treatment and prognosis depend on the cause.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ncl.2021.01.001DOI Listing
May 2021

The authors reply.

Crit Care Med 2021 May;49(5):e560-e561

Intensive Care Unit, Hospital Carlos G. Malbran, Catamarca, Argentina.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004958DOI Listing
May 2021

Neurological Complications in Patients with Heart Transplantation.

Semin Neurol 2021 Apr 13. Epub 2021 Apr 13.

Department of Neurology, Mayo Clinic, Rochester, Minnesota.

Neurological complications after heart transplantation are common and include cerebrovascular events (ischemic strokes, hemorrhagic strokes, and transient ischemic attacks), seizures, encephalopathy, central nervous system (CNS) infections, malignancies, and peripheral nervous system complications. Although most neurological complications are transient, strokes and CNS infections can result in high mortality and morbidity. Early recognition and timely management of these serious complications are crucial to improve survival and recovery. Diagnosing CNS infections can be challenging because their clinical presentation can be subtle in the setting of immunosuppression. Immunosuppressive medications themselves can cause a broad spectrum of neurological complications including seizures and posterior reversible encephalopathy syndrome. This article provides a review of the diagnosis and management of neurological complications after cardiac transplantation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0041-1726285DOI Listing
April 2021

Thromboelastography is a Marker for Clinically Significant Progressive Hemorrhagic Injury in Severe Traumatic Brain Injury.

Neurocrit Care 2021 Apr 12. Epub 2021 Apr 12.

Department of Pharmacy, Mayo Clinic, Rochester, MN, USA.

Background: Coagulopathy in traumatic brain injury (TBI) is associated with increased risk of poor outcomes, but accurate prediction of clinically significant progressive hemorrhagic injury (PHI) in patients with severe TBI remains a challenge. Thromboelastography (TEG) is a real-time test of whole blood coagulation that provides dynamic information about global hemostasis. This study aimed to identify differences in TEG values between patients with severe TBI who did or did not experience clinically significant PHI.

Methods: This was a single-center retrospective cohort study of adult patients with severe TBI. Patients were eligible for inclusion if initial Glasgow coma scale (GCS) was ≤ 8 and baseline head computed tomography (CT) imaging and TEG were available. Exclusion criteria included receipt of hemostatic agents prior to TEG. PHI was defined as bleeding expansion on CT within 24 h associated with 2-point drop in GCS, neurosurgical intervention, or mortality within 24 h. The primary endpoint was TEG value differences between patients with and without PHI. Secondary endpoints included differences in conventional coagulation tests (CCTs) between groups.

Results: Of the 526 patients evaluated, 141 met inclusion criteria. The most common reason for exclusion was lack of baseline TEG and receipt of reversal product prior to TEG. Sixty-four patients experienced PHI in the first 24 h after presentation. K time (2.03 min vs. 1.33 min, P = 0.035) and alpha angle (65° vs. 69°, P = 0.015) were found to be significantly different in patients experiencing PHI. R time (5.25 min vs. 4.71 min), maximum amplitude (61 mm vs. 63 mm), and clot lysis at 30 min after maximum clot strength (3.5% vs. 1.7%) were not significantly different between groups. Of the CCTs, only activated partial thromboplastin time (30.3 s vs. 27.6 s, P = 0.014) was found to be different in patients with PHI.

Conclusions: Prolonged K time and narrower alpha angle were found to be associated with developing clinically significant PHI in patients with severe TBI. Despite differences detected in alpha angle, median values in both groups were within normal reference ranges. These abnormalities may reflect pathologic hypoactivity of fibrinogen, and further study is warranted to evaluate TEG-guided cryoprecipitate administration in this patient population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-021-01217-0DOI Listing
April 2021

Use of Remdesivir in Myasthenia gravis and COVID-19.

Pharmacotherapy 2021 06 27;41(6):546-550. Epub 2021 Apr 27.

Division of Pulmonary & Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Myasthenia gravis and the associated pharmacologic management options could place patients at higher risk of contracting severe acute respiratory syndrome coronavirus 2 and exhibiting more severe manifestations of the novel coronavirus disease 2019 (COVID-19). Multiple agents have been studied for the management of the COVID-19, including remdesivir. To date, no published reports have evaluated the utilization of the antiviral remdesivir in patients with myasthenia gravis. We describe the first reported clinical course of three patients with myasthenia gravis who safely received remdesivir in combination with dexamethasone for the management of COVID-19.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/phar.2524DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8251297PMC
June 2021

Neurological manifestations of thrombotic microangiopathy syndromes in adult patients.

J Thromb Thrombolysis 2021 May 23;51(4):1163-1169. Epub 2021 Mar 23.

Department of Neurology, Mayo Clinic, 200 1st Street SW, Rochester, MN, 55905, USA.

The objective of this study was to compare the frequency and severity of neurologic manifestations in adult patients diagnosed with thrombotic thrombocytopenic purpura (TTP), hemolytic uremic syndrome (HUS) and atypical HUS (aHUS). This is a retrospective cohort study of adult patients diagnosed with TTP, HUS and atypical HUS hospitalized at a tertiary center between January 2004 and October 2016. A total of 42 TTP, 16 HUS and 20 aHUS episodes were reviewed to collect clinical, laboratory and radiographic data, as well as information regarding long-term functional outcome. Neurologic symptoms are more common in patients with TTP and HUS as compared to aHUS (p < 0.001 and p = 0.002, respectively). Encephalopathy occurred in 29 TTP (69%) and 11 HUS (68%) episodes. Focal deficits were only observed in patients with TTP (n = 8 [19%]). Seizures were most commonly seen in HUS patients (n = 8 [50%]). Posterior reversible encephalopathy syndrome (PRES) was the most common neuroimaging finding in these syndromes; ischemic infarcts and hemorrhages occurred uncommonly. There was no correlation between presence of neurologic symptoms or neuroimaging abnormalities and poor outcome. Patients with TTP and HUS appear to have a similar spectrum of neurologic manifestations, whereas neurologic involvement is less common in aHUS. PRES is the most common imaging abnormality, and may present atypically. Despite presence of neurologic symptoms or neuroimaging abnormalities, patients with thrombotic microangiopathy (TMA) tend to have favorable long-term outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11239-021-02431-5DOI Listing
May 2021

Cerebral Amyloid Angiopathy Burden and Cerebral Microbleeds: Pathological Evidence for Distinct Phenotypes.

J Alzheimers Dis 2021 ;81(1):113-122

Department of Pathology and Laboratory Medicine, Mayo Clinic, Rochester, MN, USA.

Background: The relationship between cerebral microbleeds (CMBs) on hemosiderin-sensitive MRI sequences and cerebral amyloid angiopathy (CAA) remains unclear in population-based participants or in individuals with dementia.

Objective: To determine whether CMBs on antemortem MRI correlate with CAA.

Methods: We reviewed 54 consecutive participants with antemortem T2*GRE-MRI sequences and subsequent autopsy. CMBs were quantified on MRIs closest to death. Autopsy CAA burden was quantified in each region including leptomeningeal/cortical and capillary CAA. By a clustering approach, we examined the relationship among CAA variables and performed principal component analysis (PCA) for dimension reduction to produce two scores from these 15 interrelated predictors. Hurdle models assessed relationships between principal components and lobar CMBs.

Results: MRI-based CMBs appeared in 20/54 (37%). 10 participants had ≥2 lobar-only CMBs. The first two components of the PCA analysis of the CAA variables explained 74% variability. The first rotated component (RPC1) consisted of leptomeningeal and cortical CAA and the second rotated component of capillary CAA (RPC2). Both the leptomeningeal and cortical component and the capillary component correlated with lobar-only CMBs. The capillary CAA component outperformed the leptomeningeal and cortical CAA component in predicting lobar CMBs. Both capillary and the leptomeningeal/cortical components correlated with number of lobar CMBs.

Conclusion: Capillary and leptomeningeal/cortical scores correlated with lobar CMBs on MRI but lobar CMBs were more closely associated with the capillary component. The capillary component correlated with APOEɛ4, highlighting lobar CMBs as one aspect of CAA phenotypic diversity. More CMBs also increase the probability of underlying CAA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3233/JAD-201536DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8113155PMC
January 2021

Spinal cord transient ischemic attack: Insights from a series of spontaneous spinal cord infarction.

Neurol Clin Pract 2020 Dec;10(6):480-483

Department of Neurology (SWE), Emory University, Atlanta, GA; and Department of Neurology (AAR, EPF, NLZ), Mayo Clinic, Rochester, MN.

Objective: To define the prevalence and characteristics of spinal cord transient ischemic attack (sTIA) in a large retrospective series of patients who met diagnostic criteria for spontaneous spinal cord infarction (SCI).

Methods: An institution-based search tool was used to identify patients evaluated at the Mayo Clinic in Rochester, MN, from 1997 to 2017 with spontaneous SCI (n = 133). Cases were subsequently reviewed for transient myelopathic symptoms preceding infarction that were suspected ischemic in nature. We performed a descriptive analysis of patients with sTIA before SCI.

Results: Of 133 patients with a diagnosis of spontaneous SCI, we identified 4 patients (3%) who experienced sTIA before SCI. The median age at presentation was 61.5 years (range 46-75 years), 2 (50%) were women, and 3 (75%) had traditional vascular risk factors. Localization was cervical cord in 2 cases (50%) and thoracic cord in 2 cases (50%); all patients developed SCI in the same distribution as their preceding sTIA symptoms. All patients experienced recurrent sTIA before SCI. Symptoms ranged from seconds to a few minutes before returning to baseline. No patients had pain as a feature of sTIA.

Conclusions: sTIAs are possible but rare in patients who subsequently have a SCI. Clinical features are similar to those of SCI, with rapid onset of severe myelopathic deficits, followed by prompt resolution. Vascular risk factors are common in these patients. Thus, recognition of a sTIA may represent a valuable opportunity for vascular risk factor modification and stroke prevention. However, given the rarity, physicians should explore other possible explanations when sTIA is considered.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/CPJ.0000000000000778DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837427PMC
December 2020

Frequency of intracranial aneurysms and sub-arachnoid hemorrhage is significantly lesser in bicuspid aortic valve than aortic coarctation.

Int J Cardiol 2021 05 28;330:229-231. Epub 2021 Jan 28.

Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA. Electronic address:

Background: Bicuspid aortic valve(BAV) is common. Some studies suggest that all BAV patients require screening for intracranial aneurysm(IA) in order to prevent sub-arachnoid hemorrhage(SAH). Aortic coarctation(CoA) carries high-risk of both IA and SAH. Using a nationally-representative population, we assessed the frequency of IA and SAH in admissions with BAV-without-CoA versus admissions with CoA(with or without BAV).

Methods: Between 2000 and 2016, adult admissions with a primary/secondary diagnosis of BAV and/or CoA were identified using the National Inpatient Sample. Admissions with traumatic SAH and inter-hospital transfers were excluded. Outcomes were frequency of IA and SAH, and in-hospital mortality in BAV-without-CoA versus CoA.

Results: In this 17-year period, 254,675 admissions met inclusion criteria and 236,930(93.0%) had BAV-without-CoA. BAV-with-CoA was present in 2846(1.1%) and isolated-CoA in 14,899(5.9%), for a total of 17,745(7%) with CoA. IA was noted in 405 admissions(0.2%) overall, BAV-without-CoA versus CoA having 293(0.1%) versus 112(0.6%), p < 0.001. SAH was noted in 910 admissions(0.4%) overall, with BAV-without-CoA versus CoA having 760(0.3%) versus 150(0.9%), p < 0.001.

Conclusions: In this study, BAV-without-CoA admissions had 0.1%(6-times lower than CoA) and 0.3%(3-times lower that CoA) IA and SAH, respectively, which is comparable to the general population. This suggests that BAV-without-CoA patients likely do not require routine surveillance for IA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijcard.2021.01.045DOI Listing
May 2021

Serum Neurofilament to Magnetic Resonance Imaging Lesion Area Ratio Differentiates Spinal Cord Infarction From Acute Myelitis.

Stroke 2021 Jan 11;52(2):645-654. Epub 2021 Jan 11.

Departments of Neurology (E.S., A.M., S.J.P., E.P.F., A.A.R., D.M.N., N.L.Z.), Mayo Clinic, Rochester.

Background And Purpose: The diagnosis of spontaneous spinal cord infarction (SCI) is limited by the lack of diagnostic biomarkers and MRI features that often overlap with those of other myelopathies, especially acute myelitis. We investigated whether the ratio between serum neurofilament light chain levels and MRI T2-lesion area (neurofilament light chain/area ratio-NAR) differentiates SCI from acute myelitis of similar severity.

Methods: We retrospectively identified Mayo Clinic patients (January 1, 2000-December 31, 2019) with (1) SCI, (2) AQP4 (aquaporin 4)-IgG or MOG (myelin oligodendrocyte glycoprotein)-IgG-associated myelitis at disease clinical presentation, or (3) idiopathic transverse myelitis from a previously identified population-based cohort of patients seronegative for AQP4-IgG and MOG-IgG. Serum neurofilament light chain levels (pg/mL) were assessed at the Verona University (SIMOA, Quanterix) in a blinded fashion on available stored samples obtained ≤3 months from myelopathy presentation. For each patient, the largest spinal cord lesion area (mm) was manually outlined by 2 independent raters on sagittal T2-weighted MRI images, and the mean value was used to determine NAR (pg/[mL·mm]).

Results: Forty-eight patients were included SCI, 20 (definite, 11; probable, 6; possible, 3); acute myelitis, 28 (AQP4-IgG-associated, 17; MOG-IgG-associated, 5; idiopathic transverse myelitis, 6). The median expanded disability status scale score (range) at myelopathy nadir were 7.75 (2-8.5) and 5.5 (2-8), respectively. Serum neurofilament light chain levels (median [range] pg/mL) in patients with SCI (188 [14.3-2793.4]) were significantly higher compared with patients with AQP4-IgG-associated myelitis (37 [0.8-6942.9]), MOG-IgG-associated myelitis (45.8 [4-283.8]), and idiopathic transverse myelitis (15.6 [0.9-217.8]); =0.01. NAR showed the highest accuracy for identification of SCI versus acute myelitis with values ≥0.35 pg/(mL·mm) yielding 86% specificity and 95% sensitivity (area under the curve=0.93). The positive and negative likelihood ratios were 6.67 and 0.06, respectively. NAR remained independently associated with SCI after adjusting for age, gender, immunotherapy before sampling, and days from myelopathy symptoms onset to sampling (=0.0007).

Conclusions: NAR is a novel and promising clinical biomarker for differentiation of SCI from acute myelitis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.120.031482DOI Listing
January 2021

Temporal Trends, Predictors, and Outcomes of Acute Ischemic Stroke in Acute Myocardial Infarction in the United States.

J Am Heart Assoc 2021 01 5;10(2):e017693. Epub 2021 Jan 5.

Department of Cardiovascular Medicine Mayo Clinic Rochester MN.

Background There are limited contemporary data prevalence and outcomes of acute ischemic stroke (AIS) complicating acute myocardial infarction (AMI). Methods and Results Adult (>18 years) AMI admissions using the National Inpatient Sample database (2000-2017) were evaluated for in-hospital AIS. Outcomes of interest included in-hospital mortality, hospitalization costs, length of stay, discharge disposition, and use of tracheostomy and percutaneous endoscopic gastrostomy. The discharge destination was used to classify survivors into good and poor outcomes. Of a total 11 622 528 AMI admissions, 183 896 (1.6%) had concomitant AIS. As compared with 2000, in 2017, AIS rates increased slightly among ST-segment-elevation AMI (adjusted odds ratio, 1.10 [95% CI, 1.04-1.15]) and decreased in non-ST-segment-elevation AMI (adjusted odds ratio, 0.47 [95% CI, 0.46-0.49]) admissions (<0.001). Compared with those without, the AIS cohort was on average older, female, of non-White race, with greater comorbidities, and higher rates of arrhythmias. The AMI-AIS admissions received less frequent coronary angiography (46.9% versus 63.8%) and percutaneous coronary intervention (22.7% versus 41.8%) (<0.001). The AIS cohort had higher in-hospital mortality (16.4% versus 6.0%; adjusted odds ratio, 1.75 [95% CI, 1.72-1.78]; <0.001), longer hospital length of stay, higher hospitalization costs, greater use of tracheostomy and percutaneous endoscopic gastrostomy, and less frequent discharges to home (all <0.001). Among AMI-AIS survivors (N=153 318), 57.3% had a poor functional outcome at discharge with relatively stable temporal trends. Conclusions AIS is associated with significantly higher in-hospital mortality and poor functional outcomes in AMI admissions.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/JAHA.120.017693DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955313PMC
January 2021

Antifibrinolytics in subarachnoid haemorrhage.

Lancet 2021 01 23;397(10269):74-75. Epub 2020 Dec 23.

Department of Neurology, Mayo Clinic, Rochester, MN 55905, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S0140-6736(20)32636-2DOI Listing
January 2021

The authors reply.

Crit Care Med 2021 01;49(1):e113-e114

Department of Neurology, Division of Critical Care Neurology, Mayo Clinic, Rochester, MN.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1097/CCM.0000000000004718DOI Listing
January 2021

Subarachnoid hemorrhage rebleeding in the first 24 h is associated with external ventricular drain placement and higher grade on presentation: Cohort study.

J Clin Neurosci 2020 Nov 12;81:180-185. Epub 2020 Oct 12.

Department of Neurology, Mayo Clinic, Rochester, MN, United States.

Background: Rebleeding after aneurysmal subarachnoid hemorrhage (aSAH) confers a poor prognosis; however, risk factors and differential outcomes associated with early rebleeding in the first 24 h after symptom presentation are incompletely understood.

Methods: A retrospective cohort study of all aSAH presenting to our institution between 2001 and 2016 was performed. Early rebleeding events were defined as clinical neurologic decline with radiographically confirmed acute intracranial hemorrhage within 24 h after symptom presentation. Univariate and multivariate logistic regression analyses were used to assess clinical associations, with a specific focus on baseline Glasgow Coma Score (GCS), World Federation of Neurosurgical Societies (WFNS), and modified Fisher scores.

Results: Of 471 aSAH cases, 33 (7%) experienced early rebleeding. Multivariate regression identified extraventricular drain (EVD) placement (OR = 2.16, P = 0.04) and WFNS 3-5 (OR = 2.69, P = 0.02) as significant predictors of early rebleeding. Good functional outcomes were observed in 8 patients with early rebleeding (24%), all of whom underwent aneurysm treatment. Higher SAH grade prior to rebleeding (WFNS 3-5) was significantly associated with increased odds of an unfavorable functional outcome (OR = 8.09, P < 0.01). Anticoagulation, aneurysm size and location were not significantly associated with either early rebleeding incidence or functional outcome.

Conclusions: Early rebleeding in aSAH is associated with unfavorable functional outcomes. EVD placement and higher SAH grade on presentation appear to be significantly and independently associated with increased risk of rebleeding within first 24 h, as well as unfavorable long-term functional outcome; however, the clinical benefit of hyper-acute aneurysm treatment requires further investigation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2020.09.064DOI Listing
November 2020

Artificial Intelligence-Electrocardiography to Predict Incident Atrial Fibrillation: A Population-Based Study.

Circ Arrhythm Electrophysiol 2020 12 13;13(12):e009355. Epub 2020 Nov 13.

Department of Cardiovascular Medicine (G.C., X.Y., Z.I.A., K.C.S., P.A.F., P.A.N.), Mayo Clinic, Rochester, MN.

Background: An artificial intelligence (AI) algorithm applied to electrocardiography during sinus rhythm has recently been shown to detect concurrent episodic atrial fibrillation (AF). We sought to characterize the value of AI-enabled electrocardiography (AI-ECG) as a predictor of future AF and assess its performance compared with the CHARGE-AF score (Cohorts for Aging and Research in Genomic Epidemiology-AF) in a population-based sample.

Methods: We calculated the probability of AF using AI-ECG, among participants in the population-based Mayo Clinic Study of Aging who had no history of AF at the time of the baseline study visit. Cox proportional hazards models were fit to assess the independent prognostic value and interaction between AI-ECG AF model output and CHARGE-AF score. C statistics were calculated for AI-ECG AF model output, CHARGE-AF score, and combined AI-ECG and CHARGE-AF score.

Results: A total of 1936 participants with median age 75.8 (interquartile range, 70.4-81.8) years and median CHARGE-AF score 14.0 (IQR, 13.2-14.7) were included in the analysis. Participants with AI-ECG AF model output of >0.5 at the baseline visit had cumulative incidence of AF 21.5% at 2 years and 52.2% at 10 years. When included in the same model, both AI-ECG AF model output (hazard ratio, 1.76 per SD after logit transformation [95% CI, 1.51-2.04]) and CHARGE-AF score (hazard ratio, 1.90 per SD [95% CI, 1.58-2.28]) independently predicted future AF without significant interaction (=0.54). C statistics were 0.69 (95% CI, 0.66-0.72) for AI-ECG AF model output, 0.69 (95% CI, 0.66-0.71) for CHARGE-AF, and 0.72 (95% CI, 0.69-0.75) for combined AI-ECG and CHARGE-AF score.

Conclusions: In the present study, both the AI-ECG AF model output and CHARGE-AF score independently predicted incident AF. The AI-ECG may offer a means to assess risk with a single test and without requiring manual or automated clinical data abstraction.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/CIRCEP.120.009355DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8127001PMC
December 2020

Mechanical ventilation in patients with acute brain injury: recommendations of the European Society of Intensive Care Medicine consensus.

Intensive Care Med 2020 12 11;46(12):2397-2410. Epub 2020 Nov 11.

School of Medicine and Surgery, University of Milano - Bicocca, Milan, Italy.

Purpose: To provide clinical practice recommendations and generate a research agenda on mechanical ventilation and respiratory support in patients with acute brain injury (ABI).

Methods: An international consensus panel was convened including 29 clinician-scientists in intensive care medicine with expertise in acute respiratory failure, neurointensive care, or both, and two non-voting methodologists. The panel was divided into seven subgroups, each addressing a predefined clinical practice domain relevant to patients admitted to the intensive care unit (ICU) with ABI, defined as acute traumatic brain or cerebrovascular injury. The panel conducted systematic searches and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method was used to evaluate evidence and formulate questions. A modified Delphi process was implemented with four rounds of voting in which panellists were asked to respond to questions (rounds 1-3) and then recommendation statements (final round). Strong recommendation, weak recommendation, or no recommendation were defined when > 85%, 75-85%, and < 75% of panellists, respectively, agreed with a statement.

Results: The GRADE rating was low, very low, or absent across domains. The consensus produced 36 statements (19 strong recommendations, 6 weak recommendations, 11 no recommendation) regarding airway management, non-invasive respiratory support, strategies for mechanical ventilation, rescue interventions for respiratory failure, ventilator liberation, and tracheostomy in brain-injured patients. Several knowledge gaps were identified to inform future research efforts.

Conclusions: This consensus provides guidance for the care of patients admitted to the ICU with ABI. Evidence was generally insufficient or lacking, and research is needed to demonstrate the feasibility, safety, and efficacy of different management approaches.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00134-020-06283-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7655906PMC
December 2020

SMART syndrome: retrospective review of a rare delayed complication of radiation.

Eur J Neurol 2021 Apr 3;28(4):1316-1323. Epub 2020 Dec 3.

Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.

Background: SMART (stroke-like migraine attacks after radiation therapy) is a rare, delayed complication of brain radiation. In this study, we wanted to review the spectrum of symptoms, neuroradiological findings, autoimmune status, and outcomes in SMART syndrome patients.

Methods: We conducted a retrospective cohort study of all consecutive adult patients (≥18 years) diagnosed with SMART syndrome at Mayo Clinic, Rochester between January 1995 and December 2018.

Results: We identified 25 unique patients with SMART syndrome and a total of 31 episodes and 15 (60%) patients were male. The median age at onset was 46 (interquartile range [IQR] 43-55) years and the median latency of onset after the initial radiation was 21.6 (IQR 14.4-28.2) years. Magnetic resonance imaging (MRI) showed gyral edema and enhancement in all cases with the temporal (25, 80.6%) and parietal (23, 74.2%) lobes being the most commonly affected. The median follow-up of the patients in our cohort was 10 (IQR 6-32) weeks. On univariate analysis, factors associated with an increased risk of recurrent SMART episodes were female gender (odds ratio [OR] 8.1, 95% confidence interval [95% CI] 1.1-52.6, p = 0.019) and absence of electrographic seizure discharges during initial symptoms (OR 7.4, 95% CI 1.1-45.9, p = 0.032). We could not identify an autoimmune etiology. Longer duration of symptoms (>10 weeks) correlated with an older age (p = 0.049), temporal lobe involvement (p < 0.001), and diffusion restriction (p = 0.043).

Conclusions: SMART is a syndrome with characteristic imaging findings and clinical features. Incomplete recovery by 10 weeks occurred in one-third of individuals and was associated with older age, temporal lobe involvement, and restricted diffusion on MRI.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/ene.14632DOI Listing
April 2021

Looking Twice the Wrong Way: The Challenge of Diagnosing Acute Basilar Artery Occlusion.

Neurocrit Care 2021 06 9;34(3):1094-1098. Epub 2020 Oct 9.

Departments of Neurology, Mayo Clinic, 200 First Street SW, Rochester, MN, 55905, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-020-01116-wDOI Listing
June 2021

Functional outcome after critical illness in older patients: a population-based study.

Neurol Res 2021 Feb 4;43(2):103-109. Epub 2020 Oct 4.

Departments of Neurology, Mayo Clinic , Rochester, MN, USA.

Purpose: To determine the prevalence of disability among ICU survivors one year after admission, and which factors influence functional outcome.

Methods: We examined consecutive patients enrolled in the population-based Mayo Clinic Olmsted Study of Aging and then admitted to medical or surgical adult ICUs at Mayo Clinic, Rochester between January 1, 2006, and December 31, 2014 to determine one-year functional outcomes.

Results: 831cases were included. Mean age was 84 years (IQR 79-88). 569 (68.5%) patients were alive one year after ICU admission. Of them, 546 patients had functional assessment at one year and 367 (67.2%) had good functional outcome. On multivariable analysis, poor one-year functional outcome (death or disability) was more common among women, older patients, and patients with baseline cognitive impairment (mild cognitive impairment or dementia), higher Carlson scores, and longer ICU stay (all P <.01). After excluding deceased patients, these associations remained unchanged. In addition, 120 (32.3%) of 372 patients who had post-ICU cognitive evaluation experienced cognitive decline after the ICU admission.

Conclusions: On a population-based cohort of older, predominantly elderly patients, approximately two-thirds of survivors maintained or regained good functional status 1 year after ICU hospitalization. However, older age, female sex, greater comorbidities, abnormal baseline cognition, and longer ICU stay were associated with poor functional recovery and cognitive decline was common.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/01616412.2020.1831302DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8220866PMC
February 2021

Proceedings from the Neurotherapeutics Symposium on Neurological Emergencies: Shaping the Future of Neurocritical Care.

Neurocrit Care 2020 12 21;33(3):636-645. Epub 2020 Sep 21.

Department of Neurology, McKnight Brain Institute, University of Florida College of Medicine, Room L3-100, 1149 Newell Drive, Gainesville, FL, 32611, USA.

Effective treatment options for patients with life-threatening neurological disorders are limited. To address this unmet need, high-impact translational research is essential for the advancement and development of novel therapeutic approaches in neurocritical care. "The Neurotherapeutics Symposium 2019-Neurological Emergencies" conference, held in Rochester, New York, in June 2019, was designed to accelerate translation of neurocritical care research via transdisciplinary team science and diversity enhancement. Diversity excellence in the neuroscience workforce brings innovative and creative perspectives, and team science broadens the scientific approach by incorporating views from multiple stakeholders. Both are essential components needed to address complex scientific questions. Under represented minorities and women were involved in the organization of the conference and accounted for 30-40% of speakers, moderators, and attendees. Participants represented a diverse group of stakeholders committed to translational research. Topics discussed at the conference included acute ischemic and hemorrhagic strokes, neurogenic respiratory dysregulation, seizures and status epilepticus, brain telemetry, neuroprognostication, disorders of consciousness, and multimodal monitoring. In these proceedings, we summarize the topics covered at the conference and suggest the groundwork for future high-yield research in neurologic emergencies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-020-01085-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7736003PMC
December 2020

Paroxysmal Sympathetic Hyperactivity.

Semin Neurol 2020 Oct 9;40(5):485-491. Epub 2020 Sep 9.

Department of Neurology, Mayo Clinic, Rochester, Minnesota.

Paroxysmal sympathetic hyperactivity (PSH) is a relatively common, but often unrecognized, complication of acute diffuse or multifocal brain diseases, most frequently encountered in young comatose patients with severe traumatic brain injury. It is presumed to be caused by loss of cortical inhibitory modulation of diencephalic and brain stem centers and possible additional maladaptive changes in the spinal cord that combine to produce exaggerated sympathetic responses to stimulation. The syndrome consists of repeated sudden episodes of tachycardia, tachypnea, hypertension, sweating, and sometimes fever and dystonic posturing. The diagnosis is clinical. Treatment includes reducing any external stimulation that can trigger the episodes, and starting abortive (e.g., intravenous morphine) and preventive medications (e.g., gabapentin, propranolol, clonidine). Prompt and adequate treatment of PSH may reduce the likelihood of secondary complications, such as dehydration, weight loss and malnutrition, and muscle contractures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0040-1713845DOI Listing
October 2020
-->