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Stroke from basilar artery occlusion is associated with a poor natural history with high rates of death and disability. Intravenous thrombolysis administered within 4.5 hours of last known well time improves the odds of a good neurological outcome after ischemic stroke, including in patients with basilar artery occlusion. Thrombectomy for basilar artery occlusion has had mixed outcomes. The WAKE-UP randomized clinical trial demonstrated that administration of intravenous thrombolysis can benefit select patients with wake-up strokes whose brain MRI shows restricted diffusion but no accompanying T2 FLAIR change. We report a case of a wake-up acute ischemic stroke presenting with acute vertigo followed by progressive brainstem dysfunction from a basilar artery occlusion. The patient was successfully treated with intravenous thrombolysis beyond 4.5 hours of last known well and symptom discovery time according to an MRI tissue-based approach resulting in partial recanalization of her basilar artery and recovery to near normal. This case suggests that hyperacute MRI can serve as a tissue clock to select patients with wake-up stroke for acute reperfusion therapy even if they do not meet standard trial inclusion criteria, including patients with basilar artery occlusion.

ObjectiveHypertensive urgency, defined as acutely elevated BP without target organ damage, is associated with an increased risk of adverse cardiovascular events and accounts for a substantial proportion of national emergency department (ED) visits. To advance research in this space, we sought to validate the newICD-10-CMdiagnostic code for hypertensive urgency within a single healthcare system.MethodsWe performed a retrospective chart-review study of ED encounters at Weill Cornell Medicine from 2016 – 2021. We randomly selected 25 encounters with theICD-10-CMcode I16.0 as the primary discharge diagnosis and 25 encounters with primaryICD-10-CMdischarge diagnosis codes for benign headache disorders. A single board-certified vascular neurologist reviewed all 50 encounters while blinded to the assignedICD-10-CMcodes to identify cases of hypertensive urgency. We calculated the sensitivity, specificity, and positive predictive values of theICD-10-CMcode I16.0 with 95% confidence intervals (CI).ResultsOut of 50 randomly selected ED encounters, 24 were adjudicated as hypertensive urgency. All encounters adjudicated as hypertensive urgency had been assigned theICD-10-CMdischarge diagnosis code of I16.0. All 25 of the encounters adjudicated as headache were assigned anICD-10-CMdischarge diagnosis code for a benign headache disorder. TheICD-10-CMcode for hypertensive urgency, I16.0, was thus found to have a sensitivity of 100% (95% CI: 86-100%), specificity of 96% (95% CI: 80-100%), and positive predictive value of 96% (95% CI: 78-99%).ConclusionWe found that the newICD-10-CMcode for hypertensive urgency, I16.0, can reliably identify patients with this condition.

Background Recent literature suggests that acute rises in blood pressure may precede intracerebral hemorrhage. We therefore hypothesized that patients discharged from the emergency department with hypertension face an increased risk of intracerebral hemorrhage in subsequent weeks. Methods Using administrative claims data from California, New York, and Florida, we identified all patients discharged from the emergency department from 2005 to 2011 with a primary diagnosis of hypertension ( ICD-9-CM codes 401-405). We excluded patients if they were hospitalized from the emergency department or had prior histories of cerebrovascular disease at the index visit with hypertension. We used the Mantel–Haenszel estimator for matched data to compare each patient's odds of intracerebral hemorrhage during days 8-38 after emergency department discharge to the same patient's odds during days 373-403 after discharge. This cohort-crossover design with a 1-week washout period enabled individual patients to serve as their own controls, thereby minimizing confounding bias. Results Among the 552,569 patients discharged from the emergency department with a primary diagnosis of hypertension, 93 (.017%) were diagnosed with intracerebral hemorrhage during days 8-38 after discharge compared to 70 (.013%) during days 373-403 (odds ratio 1.33, 95% confidence interval .96-1.84). The odds of intracerebral hemorrhage were increased in certain subgroups of patients (≥60 years of age and those with secondary discharge diagnoses besides hypertension), but absolute risks were low in all subgroups. Conclusions Patients with emergency department discharges for hypertension do not face a substantially increased short-term risk of intracerebral hemorrhage after discharge.

Intro: Elevated SBP is common after ICH. Continuous infusions of IV antihypertensive agents are often utilized to quickly correct SBP requiring ICU level care. It is difficult to predict SBP response to these treatments and subsequent medication weaning strategies, as SBP elevation can be the result or etiology of ICH. Identifying patients with a history of uncontrolled hypertension may help tailor SBP treatment. Left ventricular hypertrophy (LVH) on echocardiogram (echo) is a tool to assess for uncontrolled hypertension. Hypothesis: ICH patients with LVH require longer times of continuous infusions of antihypertensive medications (labetalol/nicardipine) compared to those without LVH. Methods: Admission demographics, medical history, continuous infusions of anti-hypertensives, echo data, ICH characteristics and medical/surgical interventions were prospectively collected for primary-ICH patients between 2009-2015. Patients without admission echo were excluded. LVH presence was evaluated as a binary variable and intergroup differences were evaluated using Mann-Whitney U or Student’s t- test for continuous variables and χ2 or Fisher exact test for categorical variables. Association of LVH presence and total duration of labetalol/nicardipine (in hours) within 72 h of ICU admission was evaluated using linear regression analysis after adjusting for age, race, ICH score and surgical intervention. Results: 370 primary-ICH patients with admission echo were identified. Of these patients, 252 (68%) patients had LVH. ICH patients with LVH were significantly younger (64 vs 69yo), had higher prevalence of pre-morbid hypertension (84 vs 64%), and higher ED and NICU admission SBP (189 vs 174mmHg; 158 vs 147mmHg). No intergroup differences in ICH score, surgical interventions or standing oral anti-hypertensive medication use was seen. Linear regression revealed ICH patients with LVH had longer times on continuous anti-hypertensive infusions compared to those without (20 vs 10h; β=0.11; p=0.04) after adjusting for aforementioned covariates. Conclusions: Our findings suggest that ICH patients with LVH on echo present with elevated SBP that is difficult to control. Early identification of this group may allow for earlier, tailored treatments.

Introduction: Although common, severe hypertension in the emergency department (ED) has not been well studied. Current guidelines recommend against aggressive treatment of acutely hypertensive ED patients without end-organ failure and instead recommend initiation of oral antihypertensive agents and outpatient follow-up. However, recent data suggests that intracerebral hemorrhage (ICH) often occurs shortly after an acute rise in blood pressure. Hypothesis: We hypothesized that patients discharged from the ED with hypertension face an increased risk of ICH in subsequent weeks. Methods: Using administrative claims data from CA, NY, and FL, we identified all patients discharged from the ED from 2005 through 2011 with a primary diagnosis of hypertension (ICD-9-CM codes 401-405). Patients were excluded if they were hospitalized from the ED or had prior histories of cerebrovascular disease at the index visit with hypertension. Using the Mantel-Haenszel estimator for matched data, we compared each patient’s odds of ICH during days 8-38 after ED discharge to the same patient’s odds during days 373-403 after discharge. This cohort-crossover design with a one-week washout period enabled individual patients to serve as their own controls, thereby minimizing confounding bias. Results: Among 552,569 patients discharged from the ED with a primary diagnosis of hypertension, 93 (0.017%) were diagnosed with ICH during days 8-38 after discharge compared to 70 (0.013%) during days 373-403 (OR 1.33, 95% CI 0.96-1.84). The odds of ICH were increased in certain subgroups of patients (≥60 years of age and those with secondary discharge diagnoses besides hypertension), but absolute risks were low in all subgroups. Conclusions: Contrary to our hypothesis, patients with ED visits for hypertension did not face an increased short-term risk of ICH after discharge. These findings support current guidelines for the ED management of patients with acute hypertension.

Elevated plasma renin activity (PRA) is associated with increased risk of future myocardial infarction (MI) in ambulatory hypertensive patients. The present study evaluated the relationship of PRA to the diagnosis of acute MI in patients presenting to an emergency department with suspected acute MI. PRA was measured upon entry to the emergency department, before any acute treatment, as part of the standard evaluation of 349 consecutive patients who were hospitalized for suspected MI. Diagnosis of acute MI was confirmed in 73 patients, and ruled out in 276. They did not differ in age (65.9 +/- 2 v 66.1 +/- 1 years), systolic (143 +/- 4 v 140 +/- 2 mm Hg), or diastolic (81 +/- 2 v 81 +/- 1 mm Hg) pressures. Median PRA was 2.7-fold higher in acute MI (0.89 v 0.33 ng/L/s; P < .001). In a multivariate analysis controlling for other cardiac risk factors and prior drug therapy, PRA as a continuous variable was the predominant independent factor associated with acute MI (P < .0001), followed by white race (P = .002) and history of hypertension (P = .047). The height of the PRA level upon entry to the emergency department was directly and independently associated with the diagnosis of acute MI. These new findings extend earlier reports because they encompass acute MI patients, include both hypertensive and normotensive patients, and control for potentially confounding variables. Based on these observations, a randomized clinical trial is warranted to determine whether measurement of PRA in acute MI could refine the process by which treatments are applied.

Staphylococcus aureus bacteremia is a frequent occurrence in patients with indwelling catheters. Endocarditis, osteomyelitis, and septic arthritis are common metastatic complications. A hemodialysis patient developed fever, headache, neck pain, sore throat, and dysphagia in the setting of S. aureus bacteremia. Contrast computed tomography scan of the neck revealed a retropharyngeal phlegmon. Recurrent bacteremia led to the identification of the access graft as the infectious source. We present this case to increase awareness among emergency physicians that retropharyngeal infection by S. aureus can arise by hematogenous spread and should be considered in the differential diagnosis of a bacteremic patient with sore throat or neck pain.

To the Editor: The serotonin syndrome consists of behavioral, neuromuscular, and autonomic changes that result from increased activity of serotonin (5-hydroxytryptamine) in the central nervous syst...

Xenopus adult muscle, whole Xenopus embryos, and cultured embryonic myocytes together contain five acetylcholinesterase forms which can be resolved by sucrose density gradient centrifugation. These are identified as the collagenase-sensitive asymmetric forms A12 and A8, and the globular forms G4, G2, and G1. Asymmetric forms rise in whole embryos during the period of neuromuscular synapse formation, but their rise is not prevented by tricaine methanesulfonate, which abolishes motor activity. Aneural myocyte cultures synthesize primarily asymmetric acetylcholinesterase, much of which is extracellular. Prior nerve contact is not required for its expression. The proportion of asymmetric forms is neither decreased by tetrodotoxin, nor enhanced by veratridine and aconitine. We conclude that muscle activity does not modulate the expression of asymmetric acetylcholinesterase in Xenopus.

Errors in translation have been measured in cell-free protein synthesising extracts derived from cultured MRC-5 human diploid fibroblasts of limited lifespan. Using polyuridylic acid as messenger, the error frequency for the misincorporation of leucine was 1–2%. It was found that varying the concentration of leucine increased the error frequency for leucine misincorporation. No difference could be detected in the accuracy of translation with increasing cell age, from passage 25 to 55. The aminoglycoside antibiotic, paromomycin, was shown to have a profound effect on the leucine misincorporation, increasing the error frequency of this amino acid twenty- to fortyfold. However, there was no difference in the paromomycin-induced errors with increasing cell age. Another effect of this antibiotic is that it inhibits the incorporation of the cognate amino acid phenylalanine. It was found that passage 55 cell extracts were less inhibited by paromomycin than similar extracts made from lower passage cells (passages 25 and 40). When the accuracy of translation of cell extracts made from human transformed cells (HeLa) and untransformed cells (MRC-5) was compared, no detectable difference could be found. Paromomycin increased the leucine errors in extracts made from HeLa cells to a similar degree to that observed for MRC-5 fibroblasts.

The assembly of the collagen tailed A12 form of acetylcholinesterase (AChE) is regulated by muscle contraction. To begin to study this regulation, we derived antibody probes for the three subunits (100 kd, catalytic, and collagen tail) of AChE purified from Torpedo californica electric tissue. These included a polyclonal antiserum that recognizes all 3 subunits and 19 monoclonal antibodies; 16 of the monoclonals recognized the catalytic subunit, 2 recognized the tail subunit, and 1 recognized the 100 kd subunit on Western blots. We used immunohistochemical procedures to show that several of the anticatalytic and one of the antitail monoclonals cross-reacted with frog muscle AChE and Western blotting to show that several of the anticatalytic monoclonals cross-react with rat brain AChE. These antibodies were then used to immunoprecipitate AChE precursors from a cell-free translation system. There were generally three primary translation products, corresponding to the three enzyme subunits. Therefore, each subunit is probably derived from a separate mRNA. Occasionally there were two translation products corresponding to the catalytic subunit alone. The catalytic subunit was glycosylated following addition of canine microsomal membranes to the translation mix. The mRNA coding for this subunit appeared to be present in the poly(A)- RNA pool.