The Neurohospitalist

Management of carotid stenosis remains controversial despite several trials evaluating carotid endarterectomy (CEA) and carotid angioplasty/stenting (CAS). We compared attitudes in the management of carotid stenosis between selected experts within Europe and North America.

A 3-phase Delphi survey was e-mailed to select stroke experts from Europe (n = 390) and North America (n = 289). Those completing the initial survey were shown all responses after each survey round. Consensus was defined as ≥80% agreement.

For phases 1, 2, and 3, response rates were 32%, 62%, and 73%, respectively. Overall, 100 (15%) of 679 participated in all 3 phases, 19% Europeans versus 9% North Americans (P = .0007). The European group reached consensus in 6 of 15 statements; The North American group reached consensus in 4 of 15. Ninety percentage of Europeans versus 70% of North Americans (P = .017) stated CEA is superior to CAS for symptomatic carotid stenosis. This difference was not significant in the final model (adjusted odds ratio: 3.72 [95% confidence interval: 0.95-14.5]). Sixty-nine percentage of North Americans agreed there is a stronger indication for CAS over CEA in patients younger than 65 years for symptomatic carotid stenosis, whereas 55% of Europeans (P = .023) disagreed. For asymptomatic carotid stenosis, when asked how likely they would recommend CAS, 62% North Americans said “sometimes” versus 60% of Europeans said “never” (P = .06).

The majority of North American and European respondents did not consider the 2 procedures equivalent and seemed to indicate that CEA was preferred for the management of carotid stenosis. These findings need to be further explored to help establish evidence-based guidelines.

We examined neurologic consultations for altered mental status in perioperative liver transplant patients to determine the overall incidence, to assess the presumed etiology and the data reviewed to determine that etiology, and to assess outcomes.

Retrospective chart review conducted for all 728 adult patients receiving orthotopic liver transplantation (OLT) between January 01, 2010, to June 30, 2014, with identification of 218 receiving neurology consults between 30 days pre-OLT and 90 days post-OLT, with review of all records necessary to determine initial findings and follow-up examination.

Seventy-three consults for 69 patients were identified, with 27 felt to be altered since a procedure, 20 with sudden-onset altered mentation, and 26 with gradual or waxing–waning course. A single underlying etiology was identified in only 19 cases, with multiple factors involved in all others, with metabolic, toxic, infectious, and structural etiologies most often implicated. There was no statistically significant difference in outcome for those with altered mental status consults versus the total OLT population, though the sudden-onset presentation group did show significantly increased mortality rates.

This systematic study illustrates the variety of potential causes of altered mentation within the perioperative setting of liver transplantation. Workup including neuroimaging (preferably magnetic resonance imaging), infectious cultures, and expanded metabolic laboratory tests should be undertaken.

Numerous medical society guidelines recommend discontinuation of antibiotics at a maximum of 24 hours after noninstrumented spinal surgery, even when a drain is left in place. As a result of these recommendations, our institution’s Neurosurgery Quality Improvement Committee decided to stop administering prolonged prophylactic systemic antibiotics (PPSAs) to patients with drains after noninstrumented spinal surgery.

We retrospectively reviewed data for patients who had noninstrumented spinal surgery performed by a neurosurgeon at our institution between December 2012 and July 2014 (PPSA period) and December 2014 and July 2016 (non-PPSA period) and had a drain left in place postoperatively. In the PPSA period, patients received antibiotics until drain removal. In the non-PPSA period, patients received antibiotics for a maximum of 24 hours.

We identified 58 patients in the PPSA period and 55 in the non-PPSA period. Discontinuation of PPSAs resulted in a nonsignificant increase in the frequency of surgical site infections (SSIs; 0% in the PPSA period vs 4% in the non-PPSA period; P = .24).

After discontinuing PPSAs for patients with noninstrumented spinal procedures, as is recommended for quality improvement, we saw a nonsignificant increase in our rate of SSIs. Further monitoring of this population is warranted.

The significance of transient neurological attack (TNA) symptoms is unclear. We sought to determine the risk of ischemic stroke after discharge from the emergency department (ED) with a diagnosis consistent with symptoms of TNA.

Using administrative claims data, we identified patients discharged from EDs in New York between 2006 and 2012 with a primary discharge diagnosis of a TNA symptom, defined as altered mental status, generalized weakness, and sensory changes. The primary outcome was ischemic stroke. We used Kaplan-Meier survival statistics to calculate cumulative rates, and Cox regression to compare stroke risk after TNA versus after transient ischemic attack (TIA; positive control) or renal colic (negative control) while adjusting for demographics and vascular risk factors.

Of 499 369 patients diagnosed with a TNA symptom and discharged from the ED, 7756 were hospitalized for ischemic stroke over a period of 4.7 (±1.9) years. At 90 days, the cumulative stroke rate was 0.29% (95% confidence interval [CI]: 0.28%-0.31%) after TNA symptoms versus 2.08% (95% CI: 1.89%-2.28%) after TIA and 0.03% (95% CI: 0.02%-0.04%) after renal colic. The hazard ratio (HR) of stroke was higher after TNA than after renal colic (HR: 2.13; 95% CI: 1.90-2.40) but significantly lower than after TIA (HR: 0.47; 95% CI: 0.44-0.50). Compared to TIA, TNA was less strongly associated with stroke among patients under 60 years of age compared to those over 60.

Patients discharged from the ED with TNA symptoms faced a higher risk of ischemic stroke than patients with renal colic, but the magnitude of stroke risk was low, particularly compared to TIA.