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Using administrative claims data, the authors found significantly increased risks for primary thrombotic events beyond the 6-week postpartum period, when the risk is well recognized to be high. However, absolute increases in risk from 7 to 12 weeks after delivery were small. Pregnancy significantly increases the risk of thrombosis. This heightened thrombotic risk rises further during the postpartum period, which is conventionally defined as the 6 weeks after delivery. 1 As compared with the nonpregnant state, the 6-week postpartum period is associated with increases by a factor of 3 to 9 in the risk of stroke, by a factor of 3 to 6 in the risk of myocardial infarction, and by a factor of 9 to 22 in the risk of venous thromboembolism. 2 – 8 It is unknown whether these risks remain increased after the conventionally defined 6-week postpartum period. Guidelines for the treatment . . .

Background and purpose Demographics, clinical characteristics, stroke mechanisms and long‐term outcomes were compared between acute ischaemic stroke (AIS) patients with active cancer (AC) versus non‐cancer patients. Methods Using data from 2003 to 2021 in the Acute STroke Registry and Analysis of Lausanne, a retrospective cohort study was performed comparing patients with AC, including previously known and newly diagnosed cancers, with non‐cancer patients. Patients with inactive cancer were excluded. Outcomes were the modified Rankin Scale (mRS) score at 3 months, death and cerebrovascular recurrences at 12 months before and after propensity score matching. Results Amongst 6686 patients with AIS, 1065 (15.9%) had a history of cancer. After excluding 700 (10.4%) patients with inactive cancer, there were 365 (5.5%) patients with AC and 5621 (84%) non‐cancer AIS patients. Amongst AC patients, 154 (42.2%) strokes were classified as cancer related. In multivariable analysis, patients with AC were older (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.00–1.03), had fewer vascular risk factors and were 48% less likely to receive reperfusion therapies (aOR 0.52, 95% CI 0.35–0.76). Three‐month mRS scores were not different in AC patients (aOR 2.18, 95% CI 0.96–5.00). At 12 months, death (adjusted hazard ratio 1.91, 95% CI 1.50–2.43) and risk of cerebrovascular recurrence (sub‐distribution hazard ratio 1.68, 95% CI 1.22–2.31) before and after propensity score matching were higher in AC patients. Conclusions In a large institutional registry spanning nearly two decades, AIS patients with AC had less past cerebrovascular disease but a higher 1‐year risk of subsequent death and cerebrovascular recurrence compared to non‐cancer patients. Antithrombotic medications at discharge may reduce this risk in AC patients.

To describe the rate and predictors of central nervous system (CNS) disease in emergency department (ED) patients with dizziness in the modern era of neuroimaging. We retrospectively reviewed the medical records of all adults presenting between January 1, 2007, and December 31, 2009, to an academic ED for a primary triage complaint of dizziness, vertigo, or imbalance. The final diagnosis for the cause of dizziness was independently assigned by 2 neurologists, with a third neurologist resolving any disagreements. The primary outcome was a composite of ischemic stroke, intracranial hemorrhage, transient ischemic attack, seizure, brain tumor, demyelinating disease, and CNS infection. Univariate and multivariate logistic regression were used to assess the association between clinical variables and serious CNS causes of dizziness. Of 907 patients experiencing dizziness (mean age, 59 years; 58% women [n=529]), 49 (5%) had a serious neurologic diagnosis, including 37 cerebrovascular events. Dizziness was often caused by benign conditions, such as peripheral vertigo (294 patients [32%]) or orthostatic hypotension (121 patients [13%]). Age 60 years or older (odds ratio [OR], 5.7; 95% confidence interval [CI], 2.5-11.2), a chief complaint of imbalance (OR, 5.9; 95% CI, 2.3-15.2), and any focal examination abnormality (OR, 5.9; 95% CI, 3.1-11.2) were independently associated with serious neurologic diagnoses, whereas isolated dizziness symptoms were inversely associated (OR, 0.2; 95% CI, 0.0-0.7). Dizziness in the ED is generally benign, although a substantial fraction of patients harbor serious neurologic disease. Clinical suspicion should be heightened for patients with advanced age, imbalance, or focal deficits.

Altered mental status (AMS) is a frequent reason to visit the emergency department (ED), and it carries a broad differential diagnosis. There is a lack of nationally representative data on the clinical characteristics and diagnostic patterns of ED visits for AMS. We performed a cross-sectional analysis of adult ED visits for AMS using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2022. Visits for AMS were identified using the primary reason for visit variable recorded in the survey instrument. We evaluated demographics, clinical features, and discharge diagnoses (identified using ICD-10-CM codes). We applied survey visit weights to obtain nationally representative estimates and report 95 % confidence intervals (CI). Visits for AMS accounted for 3.1 % (95 % CI, 2.9–3.4) of all ED visits during the study period representing approximately 4.5 million annual visits. Among all ED visits for AMS, mean age was 50 years (SD: 21.0), 43.6 % were women, and 60.3 % arrived via ambulance. Diagnostic testing in the ED was common, with head CT performed in 29.2 % (95 % CI, 26.4 %–32.1 %) of visits, and specialist consultation sought in 22.3 % (95 % CI, 18.9 %–26.1 %). The most common ED discharge diagnoses were nonspecific symptoms or signs (e.g., syncope, nausea and vomiting, unspecified abdominal pain) in 27.1 % (95 % CI, 24.3 %–30.2 %) of visits, psychiatric diagnoses in 26.0 % (95 % CI, 23.5 %–28.7 %) of visits, injuries in 13 % (95 % CI, 11.4 %–14.8 %) of visits, alcohol or drug-related disorders in 9.3 % (95 % CI, 7.6 %–11.4 %) of visits, and neurological diseases in 4.9 % (95 % CI, 3.8 %–6.4 %) of visits. Patients were discharged to home from the ED in 38 % (95 % CI, 34.4 %–41.7 %) of visits. In a contemporary, nationally representative sample of visits for AMS to U.S. EDs, the most common discharge diagnoses were nonspecific symptoms or signs (syndromic), suggesting potential opportunities to improve diagnostic accuracy for these patients.

Severe hypertension can accompany neurological symptoms without obvious signs of target organ damage. However, acute cerebrovascular events can also be a cause and consequence of severe hypertension. We therefore use US population-level data to determine prevalence and clinical characteristics of patients with severe hypertension and neurological complaints. We used nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) collected in 2016–2019 to identify adult ED patients with severely elevated blood pressure (BP) defined as systolic BP ≥ 180 mmHg and/or diastolic BP ≥120 mmHg. We used ED reason for visit data fields to define neurological complaints and used diagnosis data fields to define acute target organ damage. We applied survey visit weights to obtain national estimates. Based on 5083 observations, an estimated 40.4 million patients (95% CI: 37.5–43.0 million) in EDs nationwide from 2016 to 2019 had severe hypertension, equating to 6.1% (95% CI: 5.7–6.5%) of all ED visits. Only 2.8% (95% CI: 2.0–3.9%) of ED patients with severe hypertension were diagnosed with acute cerebrovascular disease; hypertensive urgency was diagnosed in 92.0% (95% CI: 90.3–93.4%). Neurological complaints were frequent in both patients with (75.6%) and without (19.9%) cerebrovascular diagnoses. Hypertensive urgency patients with neurological complaints were more often older, female, had prior stroke/TIA, and had neuroimaging than patients without these complaints. Non-migraine headache and vertigo were the most common neurological complaints recorded. In a nationally representative survey, one-in-sixteen ED patients had severely elevated BP and one-fifth of those patients had neurological complaints.

We aimed to estimate the risk of ischemic stroke after intracranial hemorrhage in patients with atrial fibrillation. Using discharge data from all nonfederal acute care hospitals and emergency departments in California, Florida, and New York from 2005 to 2012, we identified patients at the time of a first-recorded encounter with a diagnosis of atrial fibrillation. Ischemic stroke and intracranial hemorrhage were identified using validated diagnosis codes. Kaplan-Meier survival statistics and Cox proportional hazard analyses were used to evaluate cumulative rates of ischemic stroke and the relationship between incident intracranial hemorrhage and subsequent stroke. Among 2,084,735 patients with atrial fibrillation, 50,468 (2.4%) developed intracranial hemorrhage and 89,594 (4.3%) developed ischemic stroke during a mean follow-up period of 3.2 years. The 1-year cumulative rate of stroke was 8.1% (95% CI, 7.5-8.7%) after intracerebral hemorrhage, 3.9% (95% CI, 3.5-4.3%) after subdural hemorrhage, and 2.0% (95% CI, 2.0-2.1%) in those without intracranial hemorrhage. After adjustment for the CHA2DS2-VASc score, stroke risk was elevated after both intracerebral hemorrhage (hazard ratio [HR], 2.8; 95% CI, 2.6-2.9) and subdural hemorrhage (HR, 1.6; 95% CI, 1.5-1.7). Cumulative 1-year rates of stroke ranged from 0.9% in those with subdural hemorrhage and a CHA2DS2-VASc score of 0, to 33.3% in those with intracerebral hemorrhage and a CHA2DS2-VASc score of 9. In a large, heterogeneous cohort, patients with atrial fibrillation faced a substantially heightened risk of ischemic stroke after intracranial hemorrhage. The risk was most marked in those with intracerebral hemorrhage and high CHA2DS2-VASc scores.

ObjectiveTransesophageal echocardiography (TEE) is sometimes used to search for cardioembolic sources after ischemic stroke or transient ischemic attack (TIA). TEE visualizes some sources better than transthoracic echocardiography, but TEE is invasive and may cause aspiration. Few data exist on the risk of respiratory complications after TEE in patients who had stroke or TIA. Our objective was to determine whether TEE was associated with increased risk of respiratory failure in patients who had ischemic stroke or TIA.DesignThis is a retrospective cohort study using administrative data from inpatient and outpatient insurance claims collected by the US federal government’s Centers for Medicare and Medicaid Services.SettingHospitals and outpatient clinics throughout the USA.Participants99 081 patients ≥65 years old hospitalized for out-of-hospital ischemic stroke or TIA, defined by validated International Classification of Disease-9/10 diagnosis codes and present-on-admission codes, using claims data from 2008 to 2018 in a random 5% sample of Medicare beneficiaries.Main outcome measuresAcute respiratory failure, defined as endotracheal intubation and/or mechanical ventilation, starting on the first day after admission through 28 days afterward.ResultsOf 99 081 patients included in this analysis, 73 733 (74.4%) had an ischemic stroke and 25 348 (25.6%) a TIA. TEE was performed in 4677 (4.7%) patients and intubation and/or mechanical ventilation in 1403 (1.4%) patients. The 28-day cumulative risk of respiratory failure after TEE (1.4%; 95% CI 0.8% to 2.7%) was similar to that seen in those without TEE (1.4%; 95% CI 1.4% to 1.5%) (p=0.84). After adjustment for age, sex, race, Charlson comorbidities, diagnosis of stroke versus TIA, intravenous thrombolysis, and mechanical thrombectomy, TEE was not associated with an increased risk of respiratory failure (HR, 0.9; 95% CI 0.6 to 1.2).ConclusionsIn a cohort of older patients who had ischemic stroke or TIA, TEE was not associated with an increased risk of subsequent respiratory failure.

Objective Patients with posterior reversible encephalopathy syndrome (PRES) can develop seizures during the acute phase. We sought to determine the long‐term risk of seizure after PRES. Methods We performed a retrospective cohort study using statewide all‐payer claims data from 2016–2018 from nonfederal hospitals in 11 US states. Adults admitted with PRES were compared to adults admitted with stroke, an acute cerebrovascular disorder associated with long‐term risk of seizure. The primary outcome was seizure diagnosed during an emergency room visit or hospital admission after the index hospitalization. The secondary outcome was status epilepticus. Diagnoses were determined using previously validated ICD‐10‐CM codes. Patients with seizure diagnoses before or during the index admission were excluded. We used Cox regression to evaluate the association of PRES with seizure, adjusting for demographics and potential confounders. Results We identified 2095 patients hospitalized with PRES and 341,809 with stroke. Median follow‐up was 0.9 years (IQR, 0.3–1.7) in the PRES group and 1.0 years (IQR, 0.4–1.8) in the stroke group. Crude seizure incidence per 100 person‐years was 9.5 after PRES and 2.5 after stroke. After adjustment for demographics and comorbidities, patients with PRES had a higher risk of seizure than patients with stroke (HR, 2.9; 95% CI, 2.6–3.4). Results were unchanged in a sensitivity analysis that applied a two‐week washout period to mitigate detection bias. A similar relationship was observed for the secondary outcome of status epilepticus. Interpretation PRES was associated with an increased long‐term risk of subsequent acute care utilization for seizure compared to stroke.

Objective Atrial cardiopathy without atrial fibrillation (AF) may be a potential cardiac source of embolic strokes of undetermined source (ESUS). Atrial volume is a feature of atrial cardiopathy, but the relationship between atrial volume and ESUS remains unclear. Methods We compared left atrial volume among ischemic stroke subtypes in the Cornell Acute Stroke Academic Registry (CAESAR), which includes all patients with acute ischemic stroke at our hospital since 2011. Stroke subtype was determined by neurologists per the TOAST classification and consensus ESUS definition. Left atrial volume index (LAVI) was obtained directly from our echocardiography image system (Xcelera, Philips Healthcare). We used t‐tests and analysis of variance for unadjusted comparisons and targeted minimum loss‐based estimation for comparisons adjusted for demographics and comorbidities. Results Among 2116 patients in CAESAR from 2011 to 2016, 1293 had LAVI measurements. LAVI varied across subtypes (P < 0.001) from 48.8 (±30.0) mL/m2 in cardioembolic strokes to 30.3 (±10.5) mL/m2 in small‐vessel strokes. LAVI was larger in ESUS (33.3 ± 13.6 mL/m2) than in small‐ or large‐vessel stroke (30.9 ± 10.7 mL/m2) (P = 0.01). The association between LAVI and ESUS persisted after the adjustment for demographics and comorbidities: a 10 mL/m2 increase in LAVI was associated with a 4.4% increase in ESUS probability (95% CI, 2.3%–6.4%). Results were similar after excluding patients with AF during post‐discharge heart‐rhythm monitoring. Interpretation We found larger left atria among patients with ESUS versus non‐cardioembolic stroke. There was significant overlap in left atrial size between ESUS and non‐cardioembolic stroke, highlighting that many ESUS cases are not cardioembolic.

Retrospective studies have reported an association between cancer and arterial thromboembolic event (ATE) risk. We sought to confirm this in a prospective cohort with adjudicated outcomes. We evaluated participants enrolled in the REGARDS (REasons for Geographic and Racial Differences in Stroke) study with Medicare coverage for 365 days before their baseline visit (2003‐2007). Medicare claims were used to identify new cancer diagnoses during follow‐up. Using incidence‐density sampling, participants who developed cancer were matched by age, sex, race, and education 1:4 to control participants who had not developed cancer. Participants were prospectively followed through 2015 for an expert‐adjudicated ATE, defined as acute myocardial infarction or ischemic stroke. Cox regression was performed to evaluate the association between incident cancer and subsequent ATE. In this analysis, 836 REGARDS participants with incident cancer were matched to 3339 control participants without cancer. In the 30 days after cancer diagnosis, 0.60% (n = 5) of the participants had an ATE; most of these events occurred near the time of cancer diagnosis. After adjustment for demographics, geographic region, and cardiovascular risk factors, compared to the noncancer controls, participants with incident cancer had an increased risk of ATE in the first 30 days after diagnosis (hazard ratio, 5.8; 95% confidence interval, 2.1‐15.9). There was no association between cancer diagnosis and ATE beyond 30 days. Cancers with known metastases and types considered high risk for venous thromboembolism had the strongest associations with ATE. Incident cancer is associated with an increased short‐term risk of ATE independent of vascular risk factors.