Extracranial internal carotid artery dissection with unusual gadolinium enhancement.
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Carotid Artery, Internal, Dissection↗
Biomedical subjects
Shyam Prabhakaran
Publications and source records attributed to Shyam Prabhakaran.
Comparison of warfarin versus aspirin for the prevention of recurrent stroke or death: subgroup analyses from the Warfarin-Aspirin Recurrent Stroke Study.
BACKGROUND AND PURPOSE: We performed a combination of prespecified and exploratory subgroup analyses to detect any treatment differences among various baseline subgroups in the Warfarin-Aspirin Recurrent Stroke Study (WARSS) cohort. METHODS: The WARSS compared the efficacy of adjusted-dose warfarin (INR 1.4-2.8) to aspirin (325 mg/day) for recurrent ischemic stroke or death within 2 years. The effect of warfarin and aspirin was compared among prespecified and exploratory subgroups with respect to sociodemographic and vascular risk factors, stroke subtype, arterial territory, and infarct topography. Hazard ratios and 95% confidence intervals comparing warfarin to aspirin were calculated using Cox proportional hazards models. Differences in hazard ratios were tested using interaction terms. RESULTS: No treatment differences between warfarin and aspirin were found across multiple prespecified subgroups. In a multivariate model, warfarin was associated with greater hazard among patients with moderate stroke severity (HR 1.63, 95% CI 1.005-2.64, p = 0.047) and a greater benefit among those with posterior circulation location without brainstem infarction (HR 0.54, 95% CI 0.33-0.88, p = 0.013). In post-hoc analyses of the cryptogenic subgroup, warfarin was associated with worse outcomes among patients with moderate stroke severity and better outcomes among those without baseline hypertension or with posterior circulation infarcts sparing the brainstem. CONCLUSIONS: In the WARSS, the majority of subgroup analyses showed no benefit of warfarin over aspirin. Warfarin benefit was limited to brainstem-sparing posterior circulation infarcts and select cryptogenic stroke subgroups. Pending future clinical trial evidence to the contrary, antiplatelets are recommended for survivors of noncardioembolic stroke.
Aged↗
Hypertensive encephalopathy with prominent bulbar presentation.
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Aged↗
Multiple reversible episodes of subcortical ischemia following postcoital middle cerebral artery dissection.
BACKGROUND: Subcortical transient ischemic attacks are usually seen in individuals with small-vessel disease. They are often refractory to medical treatment and progress to infarction in many cases. PATIENT: We describe a young man with an unusual and protracted case of recurrent capsular ischemia due to postcoital middle cerebral artery dissection. CONCLUSION: Spontaneous middle cerebral artery dissection should be considered in young patients presenting with subcortical transient ischemic attacks.
Adult↗
Endovascular recanalization therapy in acute ischemic stroke.
BACKGROUND AND PURPOSE: To assess the outcome in acute ischemic stroke patients not eligible for systemic thrombolysis (outside the 3-hour time window, after surgery, or on anticoagulant) undergoing endovascular recanalization therapy (ERT) at the Columbia University Medical Center (CUMC) and to determine US nationwide usage and outcome of ERT in acute ischemic stroke. METHODS: Patients treated at CUMC from 2001 to 2004 and the Nationwide Inpatient Sample (NIS) comprising 20% of all admissions in the United States from 1999 to 2002 were analyzed retrospectively. RESULTS: Thirty-one patients underwent ERT. Mean age was 68+/-14 years, 68% were female, and 45% nonwhite (occlusion sites: internal carotid artery 29%; middle cerebral artery 39%; posterior circulation 32%). Pharmacological or mechanical ERT was initiated beyond 3 hours after symptom onset (median time 4.4 hours) in 61%, 29% had surgery, and 39% were on anticoagulant medication. At discharge, 32% had modified Rankin Scale scores of 0 to 2 (52% discharged home or to rehabilitation facilities); overall mortality was 29%, of which 19% were fatal intracerebral hemorrhages. From the NIS cohort, 477 patients (0.17% of all strokes and 14% of all thrombolysis cases) underwent ERT. Fifteen percent died, and approximately 50% were discharged home or to rehabilitation facilities. Intracerebral hemorrhage occurred in 6%. Fewer good outcomes of the CUMC cohort may be explained by more unfavorable premorbid patient characteristics compared with the NIS cohort. CONCLUSIONS: Despite significant variability in patient characteristics and treatment methods among 2 sources of data analyzed, ERT in stroke patients not eligible for intravenous thrombolysis appears to be a relatively safe and effective treatment alternative that is being used increasingly nationwide.
Acute Disease↗
Isolated primary intracerebral mycetoma: presenting as a mass lesion in a patient with prostate cancer and multiple myeloma.
We report a patient with a history of prostate cancer and multiple myeloma, with a solitary indolent intracerebral mass lesion without any constitutional symptoms and minimal neurologic symptoms. The radiographic appearance of the lesion was that of a tumor but resection revealed a mycetoma, consistent with Aspergillus. A brief review of the literature discusses the rarity, presentation, diagnosis, and management of primary intracerebral mycetomas.
Aged↗
Evolving concepts regarding transient ischemic attacks.
Transient ischemic attack (TIA) represents one end of the spectrum of focal brain ischemia, the other being completed infarction or ischemic stroke. The evolving technologic advancements in neuroimaging continue to change and sharpen the definition, epidemiology, and management of TIA. As a powerful risk factor for ischemic stroke, TIA deserves widespread public and physician education, urgent attention and investigation, and rapid management. The recognition and treatment of TIA provides an excellent opportunity for stroke prevention that is often missed or poorly recognized among physicians.
Animals↗
Overwhelming leukoencephalopathy as the only sign of neuropsychiatric lupus.
We describe a patient with diffuse leukoencephalopathy, a rare central nervous system complication of systemic lupus erythematosus, who died of brain herniation despite aggressive management. Brain magnetic resonance imaging revealed diffuse white matter hyperintensities consistent with vasogenic edema. Autopsy revealed only widespread cerebral edema. Early recognition and persistent, aggressive treatment will be required to avoid this fatal and rare manifestation of neuropsychiatric lupus.
Adult↗