Joanna Ramiro | Saint Louis University (original) (raw)

Papers by Joanna Ramiro

Research Square (Research Square), Dec 21, 2023

OBJECTIVE: This retrospective study explores whether neurointensivist’s prognostication impacts t... more OBJECTIVE: This retrospective study explores whether neurointensivist’s prognostication impacts treatment decisions in anoxic brain injury (ABI) patients after cardiac arrest (CA). BACKGROUND: The neurointensivist is often responsible for prognostication of ABI patients after CA. It is unclear if the neurointensivist9s involvement and input affect decision-making. METHODS: Medical records of 165 patients with a diagnosis of CA between 04/01/2008 - 04/30/2015 at our institution were reviewed. Details of patients with ABI after CA including interventions such as hypothermia, sedation, ancillary testing, neurointensivist’s examinations and prognostication were reviewed along with final discharge outcomes. Prognostications were based on the Practice Parameters of American Academy of Neurology published in 2006. Comparative analyses were done for continuous as well as categorical variables. RESULTS: 26 patients were diagnosed with ABI following CA. Neurointensivists were involved in prognostication in 80[percnt] (n= 21) cases. Six (29[percnt]) patients underwent hypothermia protocol; prognostication was delayed until ≥ 3 days after normothermia was achieved. Patients were deemed to have “good” outcome in 24[percnt] (n=5) cases whereas remaining were suggested to have “indeterminate” or “poor” outcomes in similar proportions (38[percnt], n= 8). Prognostication by the neurointensivist significantly influenced treatment decisions (regarding withdrawal vs continuation of care) as care was withdrawn the most in patients predicted to have “poor” outcomes (87[percnt]) as opposed to the “indeterminate” (50[percnt]) or “good” outcome patients (20[percnt]), p=0.050. Discussions with family members (whether led by neurointensivist vs other specialists) did not significantly influence treatment decisions. There was no significant difference in treatment decisions based on patient’s wishes (verbal or advanced directives) vs “consensus” of next of the kin. CONCLUSIONS: Prognostication by the neurointensivist significantly influences treatment plans (withdrawal of care vs supportive care) in ABI patients following CA. Larger, prospective studies would be needed to elucidate what other factors influence decisions regarding treatment in this patient population. Disclosure: Dr. Prakash has nothing to disclose. Dr. Ramiro has nothing to disclose. Dr. Feen has nothing to disclose. Dr. Kumar has nothing to disclose.

Current Clinical Neurology

Stroke: Vascular and Interventional Neurology

Introduction : Obtaining serial head computed tomography (CTH) imaging for patients with spontane... more Introduction : Obtaining serial head computed tomography (CTH) imaging for patients with spontaneous intracerebral hemorrhage (sICH) is commonly utilized to monitor for hematoma expansion (HE), defined as an increase in ICH volume by 33%. Obtaining recurrent CTH in the ICU setting may burden nursing and transport staff, expose patients to radiation, and inflate healthcare costs. It remains unclear whether utilizing scheduled CTH for sICH patients is more advantageous than targeted CTH, which is prompted by a decline in neurological status. We reviewed clinical factors and imaging studies in patients with and without HE. Methods : This retrospective cohort study conducted over two years identified 171 sICH patients. Patient demographics, clinical and neuroimaging data were recorded (including the reason for repeat imaging). These variables were then compared and analyzed in relation to HE using SPSS version 26, chi‐square tests for categorical variables, and independent‐samples t‐tes...

Neurology, 2015

OBJECTIVE: We investigated factors associated with in-hospital mortality in a cohort of patients ... more OBJECTIVE: We investigated factors associated with in-hospital mortality in a cohort of patients with large hemispheric infarction (LHI) who underwent decompressive hemicraniectomy (DHC). BACKGROUND: It remains uncertain which patients with malignant edema after LHI remain at risk of death despite DHC. DESIGN/METHODS: This retrospective cohort study conducted over a five-year period identified 24 LHI patients who underwent DHC. Patient demographics, pre- and post-DHC clinical and neuro-imaging data, were recorded. These variables were analyzed in relation to in-hospital mortality. RESULTS: Patients were predominantly male (17/24), with a mean age of 55±15 years and a baseline NIHSS score of 18.5± 4. Despite DHC, performed at a median of 52 hours, mortality still occurred in 9 patients (38[percnt]), with 11 (46[percnt]) going to acute rehabilitation and remainder to long-term care facility (LTC). Patients had a mean pre-operative mid-line shift (MLS) of 11 ± 3 mm. When compared with ...

Missouri medicine, 2015

Brain injury is a leading cause of mortality and morbidity among cardiac arrest survivors. Manage... more Brain injury is a leading cause of mortality and morbidity among cardiac arrest survivors. Management of these patients in the acute phase is challenging as is predicting their outcomes especially with the application of hypothermia. Therapeutic hypothermia has been proven beneficial but target temperature, timing, and duration that produce the best outcome are unclear and the subject of ongoing research. We review the recent advances in therapy and update the guidelines for management of these patients.

Cureus

Reversible cerebral vasoconstriction syndrome (RCVS) manifests with a thunderclap headache and re... more Reversible cerebral vasoconstriction syndrome (RCVS) manifests with a thunderclap headache and reversible vascular abnormalities. Red blood cell transfusions have not been well identified as a risk factor for RCVS. We report a rare case of acute brain injury resulting from RCVS after a packed red blood cell (PRBC) transfusion. A 49-year-old female with a history of menorrhagia initially presented with generalized weakness. She was found to have a hemoglobin (Hgb) of 1.7 g/dL in the setting of a fundal fibroid for which she received five units of PRBCs. Post transfusion, she complained of several days of thunderclap headache and later returned with new-onset seizures. She was admitted to the neurocritical care unit for the treatment of status epilepticus. Metabolic, infectious and toxic work-up were unremarkable except for an elevated lactate. MRI of the brain with contrast showed extensive bilateral hemispheric and cerebellar white matter T2-weighted fluid-attenuated inversion recovery (T2/FLAIR) hyperintensities with areas of enhancement. A diagnostic cerebral angiogram was performed to evaluate for a vascular etiology and revealed focal segmental stenoses in bilateral A1 segments of the anterior cerebral arteries and in branches of the bilateral middle cerebral arteries. These findings were suggestive of RCVS. Clinicians should have a high degree of suspicion for RCVS in patients presenting with neurological manifestations, such as thunderclap headache or seizures after recent transfusion. The window for injury may be longer than that seen in other organs, such as in transfusion-related acute lung injury (TRALI).

Journal of Stroke and Cerebrovascular Diseases

OBJECTIVE Central nervous system (CNS) ischemic events caused by fungal infections are rare, and ... more OBJECTIVE Central nervous system (CNS) ischemic events caused by fungal infections are rare, and clinical characteristics of these ischemic events are largely unknown. The objective of this manuscript is to highlight characteristics of fungal-related strokes and describe possible mechanistic differences between CNS mold and yeast infection-related strokes. METHODS We report a single-center retrospective case series of all adult patients who presented with concurrent CNS fungal infection and stroke between 2010 and 2018. Patients believed to have a stroke etiology due to cardioembolic, atheroembolic, or strokes nontemporally associated with a CNS fungal infection and those with incomplete stroke workups were excluded from analysis. RESULTS Fourteen patients were identified with ischemic stroke and concurrent CNS fungal infection without other known ischemic stroke etiology. Eight patients had a CNS yeast infection, and 6 had a CNS mold infection. All patients presented with recurrent or progressive stroke symptoms. Six patients were immune-compromised. Four patients admitted to intravenous drug use. All yeast infections were identified by cerebrospinal fluid culture or immunologic studies while all but one of the mold infections required identification by tissue biopsy. Leptomeningeal enhancement was only associated with CNS yeast infections, while basal ganglia stroke was only associated with CNS mold infections. CONCLUSION Ischemic stroke secondary to CNS fungal infections should be considered in patients with recurrent or progressive cryptogenic stroke, regardless of immune status and cerebrospinal fluid profile. CNS yeast and mold infections have slightly different stroke and laboratory characteristics and should have a distinct diagnostic method. Depending on clinical suspicion, a thorough diagnostic approach including spinal fluid analysis and biopsy should be considered.

Neurocritical care, Oct 26, 2016

Pneumothorax is an under-recognized complication of apnea testing performed as part of the neurol... more Pneumothorax is an under-recognized complication of apnea testing performed as part of the neurological determination of death. It may result in hemodynamic instability or even cardiac arrest, compromising ability to declare brain death (BD) and viability of organs for transplantation. We report three cases of pneumothorax with apnea testing (PAT) and review the available literature of this phenomenon. Series of three cases supplemented with a systematic review of literature (including discussion of apnea testing in major brain death guidelines). Two patients were diagnosed with PAT due to immediate hemodynamic compromise, while the third was diagnosed many hours after BD. An additional nine cases of PAT were found in the literature. Information regarding oxygen cannula diameter was available for nine patients (range 2.3-5.3 mm), and flow rate was available for ten patients (mean 11 L/min). Pneumothorax was treated to resolution in the majority of patients (n = 8), although only six...

Neurology, Apr 8, 2014

OBJECTIVE: To describe the clinical features of task specific writing tremor as a presenting symp... more OBJECTIVE: To describe the clinical features of task specific writing tremor as a presenting symptom in Parkinson9s disease BACKGROUND: Writing tremor (WT) is defined as tremor isolated to the act of writing and is the most common type of task-specific tremor. WT may occur as a primary distinct condition or be related to essential tremor or dystonia (as in writer’s cramp). In a prospective study done by Ondo et al, two of forty-one patients with WT fulfilled criteria for Parkinson’s disease. We describe the occurrence of task-specific WT as a first symptom in five cases who later developed Parkinson’s disease (PD). DESIGN/METHODS: This is a clinical case series of five patients who presented with task specific writing tremor with progression to Parkinson’s disease. RESULTS: The patients were all Caucasian males. The age of onset ranged from 46-76 years. The duration from the onset of WT to the diagnosis of PD was 1-5 years. In all the patients, a pronounced high amplitude action tremor occurred with the act of writing but not with the finger nose test. Bradykinesia, rigidity and a less pronounced rest tremor were seen in the hand affected by the WT. The WT in these cases was refractory to Propranalol/Primidone but responded to Carbidopa-Levodopa. The dopamine transporter (DaT) scan done in 3 patients showed asymmetric bilateral dopaminergic deficits with greater loss in the putamen contralateral to the hand affected by WT. CONCLUSIONS: The pathophysiology of WT is not well characterized, and the published data on the occurrence of WT in PD is limited. WT can occur as the initial symptom of PD. Patients with WT should be screened carefully for clinical features of PD. The DaT scan can help to confirm the diagnosis of PD in patients with WT. Disclosure: Dr. Smith has nothing to disclose. Dr. Alawi has nothing to disclose. Dr. Ramiro has nothing to disclose. Dr. Chand has received personal compensation for activities with Teva Neuroscience and Allergan Inc. as a speaker. Dr Chand has received research support from Andante Medical Devices.

Missouri medicine

Neurointervention in the Medical Specialties, 2014

The post-procedure intensive care of neuroinventional patients is integral to patient good outcom... more The post-procedure intensive care of neuroinventional patients is integral to patient good outcomes. Neurointerventional patients may present either electively or emergently. In situations, the neurointensivist should be prepared and anticipate patient needs. The “time is brain” principle is highly relevant in the neurointensive care unit, with perioperative complications requiring rapid diagnosis and quick intervention. Communication between physicians taking care of the patient is also key. This chapter summarizes the neurocritical care needs after neurointerventional procedures. These procedures include aneurysm coiling, carotid stenting, intracranial embolization procedures, and acute stroke interventions, among others.

Stroke

Background and Purpose: It remains uncertain which patients with malignant edema after large hemi... more Background and Purpose: It remains uncertain which patients with malignant edema after large hemispheric infarction (LHI) remain at risk of death despite decompressive hemicraniectomy (DHC). We investigated factors associated with in-hospital mortality in a cohort of patients with LHI who underwent DHC. Methodology: This retrospective cohort study conducted over a five-year period identified 24 LHI patients who underwent DHC. Patient demographics, pre- and post-DHC clinical and neuro-imaging data were recorded (including midline shift [MLS] at the level of lateral ventricles). These variables were then analyzed in relation to in-hospital mortality. Results: Patients were predominantly male (17/24), with mean age of 55±15 years and baseline NIHSS score of 18.5± 4. Despite DHC, performed at a median of 52 hours, mortality still occurred in 9 patients (38%), with 11 (46%) going to acute rehabilitation and remainder to long-term care facility (LTC). Patients had a mean pre-operative MLS...