Akhil Patel - Academia.edu (original) (raw)

Papers by Akhil Patel

International Journal of Emergency Medicine, 2012

Posterior reversible encephalopathy syndrome (PRES) can present with focal neurologic deficits, m... more Posterior reversible encephalopathy syndrome (PRES) can present with focal neurologic deficits, mimicking a stroke and can often represent a diagnostic challenge when presenting atypically. A high degree of suspicion is required in the clinical setting in order to yield the diagnosis. Cerebral CT perfusion (CTP) is utilized in many institutions as the first line in acute stroke imaging. CTP has proved to be a very sensitive measure of cerebral blood flow dynamics, most commonly employed to delineate the infarcted tissue from penumbra (at-risk tissue) in ischemic strokes. But abnormal CTP is also seen in stroke mimics such as seizures, hypoglycemia, tumors, migraines and PRES. In this article we describe a case of PRES in an elderly bone marrow transplant recipient who presented with focal neurological deficits concerning for a cerebrovascular accident. CTP played a pivotal role in the diagnosis and initiation of appropriate management. We also briefly discuss the pathophysiology of PRES.

Surgical Neurology International, 2012

Background: Takayasu's arteritis (TA) is a rare and potentially devastating condition leading to ... more Background: Takayasu's arteritis (TA) is a rare and potentially devastating condition leading to prolonged morbidity and even death. Case Description: We report an 18-year-old female presenting with an acute ischemic stroke treated with intravenous thrombolysis and subsequent endovascular therapy (ET) with excellent results followed by chronic treatment with immunosuppressants after a formal diagnosis of TA. Following immunosupression, improvement was noted in critical stenoses of the extracranial large vessels. Conclusion: These observations underscore the importance of early initiation of therapy to halt or even reverse vascular pathology, though frequent follow up is mandatory as relapse is common. In this article we provide brief review of the current literature on TA related to pathophysiology, criterion for diagnosis, therapy, and follow up.

Neurology, 2012

ABSTRACT Objective: To determine if admission medical research council(MRC) motor strength grade ... more ABSTRACT Objective: To determine if admission medical research council(MRC) motor strength grade and presence of vascular collateralization are predictors of outcome after endovascular intervention(EI) for acute stroke. Background Large vessel ischemia constitute 30-50% of all cerebrovascular events and EI are gaining importance in the management. There are few clinical indicators of poor outcome like NIH stroke scale, age, extent of territory, infarct volume among others. Design/Methods: Retrospective analysis of 62 patients who underwent EI (MERCI,penumbra,alligator,balloon angioplasty,stents or combination of these procedures) with or without concurrent t-PA for acute stroke from 2007-2011. All patients had head and neck CTA with perfusion and EI. Admission MRC motor grade and collateralization on CTA were independent variables. Modified collateral flow(CS) grading 0-3 for absent, ≤50%,>50% but <100% and 100% collateral supply of the occluded MCA territory was used. Disposition served as primary outcome measure: home,acute rehabilitation,skilled nursing facility(SNF),hospice or death. Results: Median age=75; median motor grade=2,with an interquartile range0-3. 53% were discharged to acute rehab or home(good outcome). SNF placement was 16%(intermediate outcome). Hospice disposition and death was 30%(poor outcome). In the poor outcome category,100% had MRC grade 0-1. The motor grade was significantly associated with death/SNF;as well as worse functional outcome(p<0.001). In the good and intermediate outcome group almost all of them had MRC grade ≥2. Collaterals did not significantly affected outcome or modified Rankin scale at discharge; Age vs Collaterals(p=0.3784);Gender vs Collaterals(p=0.5066) and Collaterals vs disposition(p=0.3541). Conclusions: This preliminary data suggest Motor grade assessment serve as a robust predictor of outcome after acute stroke intervention. Limitations:Severe neglect,intubated/sedated patients,and previous stroke.Modified collateral flow score grading needs revision as there is a disparity between different grades especially grade 1 & 2. For example person with minimal collaterals (eg: 5%)is in the same category of CS 1 as the person with 49% collaterals, which has a huge bearing on clinical outcome.

Journal of Cardiovascular Disease Research, 2012

Cardiac embolism, primarily from atrial fibrillation (AF), is implicated in a quarter of all isch... more Cardiac embolism, primarily from atrial fibrillation (AF), is implicated in a quarter of all ischemic strokes. In the setting of AF, contraindications to traditional therapies can create a clinical dilemma when choosing an agent for secondary stroke prophylaxis. Newer horizons in the medical and surgical management of AF have helped us choose from a wide variety of available therapies, the best possible management. In this article, we review the current trends in AF management including newer oral anticoagulants as well as surgical devices from a neurologist's view.

International Journal of Emergency Medicine, 2012

Posterior reversible encephalopathy syndrome (PRES) can present with focal neurologic deficits, m... more Posterior reversible encephalopathy syndrome (PRES) can present with focal neurologic deficits, mimicking a stroke and can often represent a diagnostic challenge when presenting atypically. A high degree of suspicion is required in the clinical setting in order to yield the diagnosis. Cerebral CT perfusion (CTP) is utilized in many institutions as the first line in acute stroke imaging. CTP has proved to be a very sensitive measure of cerebral blood flow dynamics, most commonly employed to delineate the infarcted tissue from penumbra (at-risk tissue) in ischemic strokes. But abnormal CTP is also seen in stroke mimics such as seizures, hypoglycemia, tumors, migraines and PRES. In this article we describe a case of PRES in an elderly bone marrow transplant recipient who presented with focal neurological deficits concerning for a cerebrovascular accident. CTP played a pivotal role in the diagnosis and initiation of appropriate management. We also briefly discuss the pathophysiology of PRES.

Surgical Neurology International, 2012

Background: Takayasu's arteritis (TA) is a rare and potentially devastating condition leading to ... more Background: Takayasu's arteritis (TA) is a rare and potentially devastating condition leading to prolonged morbidity and even death. Case Description: We report an 18-year-old female presenting with an acute ischemic stroke treated with intravenous thrombolysis and subsequent endovascular therapy (ET) with excellent results followed by chronic treatment with immunosuppressants after a formal diagnosis of TA. Following immunosupression, improvement was noted in critical stenoses of the extracranial large vessels. Conclusion: These observations underscore the importance of early initiation of therapy to halt or even reverse vascular pathology, though frequent follow up is mandatory as relapse is common. In this article we provide brief review of the current literature on TA related to pathophysiology, criterion for diagnosis, therapy, and follow up.

Neurology, 2012

ABSTRACT Objective: To determine if admission medical research council(MRC) motor strength grade ... more ABSTRACT Objective: To determine if admission medical research council(MRC) motor strength grade and presence of vascular collateralization are predictors of outcome after endovascular intervention(EI) for acute stroke. Background Large vessel ischemia constitute 30-50% of all cerebrovascular events and EI are gaining importance in the management. There are few clinical indicators of poor outcome like NIH stroke scale, age, extent of territory, infarct volume among others. Design/Methods: Retrospective analysis of 62 patients who underwent EI (MERCI,penumbra,alligator,balloon angioplasty,stents or combination of these procedures) with or without concurrent t-PA for acute stroke from 2007-2011. All patients had head and neck CTA with perfusion and EI. Admission MRC motor grade and collateralization on CTA were independent variables. Modified collateral flow(CS) grading 0-3 for absent, ≤50%,>50% but <100% and 100% collateral supply of the occluded MCA territory was used. Disposition served as primary outcome measure: home,acute rehabilitation,skilled nursing facility(SNF),hospice or death. Results: Median age=75; median motor grade=2,with an interquartile range0-3. 53% were discharged to acute rehab or home(good outcome). SNF placement was 16%(intermediate outcome). Hospice disposition and death was 30%(poor outcome). In the poor outcome category,100% had MRC grade 0-1. The motor grade was significantly associated with death/SNF;as well as worse functional outcome(p<0.001). In the good and intermediate outcome group almost all of them had MRC grade ≥2. Collaterals did not significantly affected outcome or modified Rankin scale at discharge; Age vs Collaterals(p=0.3784);Gender vs Collaterals(p=0.5066) and Collaterals vs disposition(p=0.3541). Conclusions: This preliminary data suggest Motor grade assessment serve as a robust predictor of outcome after acute stroke intervention. Limitations:Severe neglect,intubated/sedated patients,and previous stroke.Modified collateral flow score grading needs revision as there is a disparity between different grades especially grade 1 & 2. For example person with minimal collaterals (eg: 5%)is in the same category of CS 1 as the person with 49% collaterals, which has a huge bearing on clinical outcome.

Journal of Cardiovascular Disease Research, 2012

Cardiac embolism, primarily from atrial fibrillation (AF), is implicated in a quarter of all isch... more Cardiac embolism, primarily from atrial fibrillation (AF), is implicated in a quarter of all ischemic strokes. In the setting of AF, contraindications to traditional therapies can create a clinical dilemma when choosing an agent for secondary stroke prophylaxis. Newer horizons in the medical and surgical management of AF have helped us choose from a wide variety of available therapies, the best possible management. In this article, we review the current trends in AF management including newer oral anticoagulants as well as surgical devices from a neurologist's view.