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Corriveau RA, Koroshetz WJ, Gladman JT, Jeon S, Babcock D, Bennett DA, Carmichael ST, Dickinson SLJ, Dickson DW, Emr M, Fillit H, Greenberg SM, Hutton ML, Knopman DS, Manly JJ, Marder KS, Moy CS, Phelps CH, Scott PA, Seeley WW, Sieber BA, Silverberg NB, Sutherland ML, Taylor A, Torborg CL, Waddy SP, Gubitz AK, Holtzman DM. Alzheimer's Disease-Related Dementias Summit 2016: National research priorities. Neurology 2017; 89:2381-2391. [PMID: 29117955 DOI: 10.1212/wnl.0000000000004717] [Citation(s) in RCA: 93] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/05/2017] [Indexed: 01/02/2023] Open
Abstract
Goal 1 of the National Plan to Address Alzheimer's Disease is to prevent and effectively treat Alzheimer disease and Alzheimer disease-related dementias by 2025. To help inform the research agenda toward achieving this goal, the NIH hosts periodic summits that set and refine relevant research priorities for the subsequent 5 to 10 years. This proceedings article summarizes the 2016 Alzheimer's Disease-Related Dementias Summit, including discussion of scientific progress, challenges, and opportunities in major areas of dementia research, including mixed-etiology dementias, Lewy body dementia, frontotemporal degeneration, vascular contributions to cognitive impairment and dementia, dementia disparities, and dementia nomenclature.
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Volkow ND, Koob GF, Croyle RT, Bianchi DW, Gordon JA, Koroshetz WJ, Pérez-Stable EJ, Riley WT, Bloch MH, Conway K, Deeds BG, Dowling GJ, Grant S, Howlett KD, Matochik JA, Morgan GD, Murray MM, Noronha A, Spong CY, Wargo EM, Warren KR, Weiss SRB. The conception of the ABCD study: From substance use to a broad NIH collaboration. Dev Cogn Neurosci 2017; 32:4-7. [PMID: 29051027 PMCID: PMC5893417 DOI: 10.1016/j.dcn.2017.10.002] [Citation(s) in RCA: 429] [Impact Index Per Article: 61.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Revised: 08/24/2017] [Accepted: 10/07/2017] [Indexed: 11/18/2022] Open
Abstract
Adolescence is a time of dramatic changes in brain structure and function, and the adolescent brain is highly susceptible to being altered by experiences like substance use. However, there is much we have yet to learn about how these experiences influence brain development, how they promote or interfere with later health outcomes, or even what healthy brain development looks like. A large longitudinal study beginning in early adolescence could help us understand the normal variability in adolescent brain and cognitive development and tease apart the many factors that influence it. Recent advances in neuroimaging, informatics, and genetics technologies have made it feasible to conduct a study of sufficient size and scope to answer many outstanding questions. At the same time, several Institutes across the NIH recognized the value of collaborating in such a project because of its ability to address the role of biological, environmental, and behavioral factors like gender, pubertal hormones, sports participation, and social/economic disparities on brain development as well as their association with the emergence and progression of substance use and mental illness including suicide risk. Thus, the Adolescent Brain Cognitive Development study was created to answer the most pressing public health questions of our day.
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Ramos KM, Rommelfanger KS, Greely HT, Koroshetz WJ. Neuroethics and the NIH BRAIN Initiative. JOURNAL OF RESPONSIBLE INNOVATION 2017; 5:122-130. [PMID: 30854409 PMCID: PMC6405257 DOI: 10.1080/23299460.2017.1319035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
The Brain Research through Advancing Innovative Neurotechnologies® (BRAIN) Initiative is focused on developing new tools and neurotechnologies to revolutionize our understanding of how the brain functions in health and disease, in large part to address the growing societal impact of neurological, mental health, and substance abuse disorders. Recent advances in neurotechnology are delivering unprecedented ways to interrogate and modulate brain function, and the BRAIN Initiative is focused on translation for human medical uses over the next decade. Since its inception, the NIH component of the BRAIN Initiative has utilized an iterative model of integrating ethics into the scientific trajectory of the Initiative, most recently with the creation of a Neuroethics Division of the NIH BRAIN Initiative Multi-Council Working Group. The Division serves as a resource of expertise, to help the BRAIN Initiative navigate issues involving ethics. Here we discuss the BRAIN Initiative, and its implications and aspirations for neuroethics. We also discuss new opportunities for collaboration and for integrating stakeholder voices.
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Lima FO, Silva GS, Furie KL, Frankel MR, Lev MH, Camargo ÉCS, Haussen DC, Singhal AB, Koroshetz WJ, Smith WS, Nogueira RG. Field Assessment Stroke Triage for Emergency Destination: A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes. Stroke 2016; 47:1997-2002. [PMID: 27364531 DOI: 10.1161/strokeaha.116.013301] [Citation(s) in RCA: 178] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2016] [Accepted: 05/23/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Patients with large vessel occlusion strokes (LVOS) may be better served by direct transfer to endovascular capable centers avoiding hazardous delays between primary and comprehensive stroke centers. However, accurate stroke field triage remains challenging. We aimed to develop a simple field scale to identify LVOS. METHODS The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale was based on items of the National Institutes of Health Stroke Scale (NIHSS) with higher predictive value for LVOS and tested in the Screening Technology and Outcomes Project in Stroke (STOPStroke) cohort, in which patients underwent computed tomographic angiography within the first 24 hours of stroke onset. LVOS were defined by total occlusions involving the intracranial internal carotid artery, middle cerebral artery-M1, middle cerebral artery-2, or basilar arteries. Patients with partial, bihemispheric, and anterior+posterior circulation occlusions were excluded. Receiver operating characteristic curve, sensitivity, specificity, positive predictive value, and negative predictive value of FAST-ED were compared with the NIHSS, Rapid Arterial Occlusion Evaluation (RACE) scale, and Cincinnati Prehospital Stroke Severity (CPSS) scale. RESULTS LVO was detected in 240 of the 727 qualifying patients (33%). FAST-ED had comparable accuracy to predict LVO to the NIHSS and higher accuracy than RACE and CPSS (area under the receiver operating characteristic curve: FAST-ED=0.81 as reference; NIHSS=0.80, P=0.28; RACE=0.77, P=0.02; and CPSS=0.75, P=0.002). A FAST-ED ≥4 had sensitivity of 0.60, specificity of 0.89, positive predictive value of 0.72, and negative predictive value of 0.82 versus RACE ≥5 of 0.55, 0.87, 0.68, and 0.79, and CPSS ≥2 of 0.56, 0.85, 0.65, and 0.78, respectively. CONCLUSIONS FAST-ED is a simple scale that if successfully validated in the field, it may be used by medical emergency professionals to identify LVOS in the prehospital setting enabling rapid triage of patients.
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Collins FS, Anderson JM, Austin CP, Battey JF, Birnbaum LS, Briggs JP, Clayton JA, Cuthbert B, Eisinger RW, Fauci AS, Gallin JI, Gibbons GH, Glass RI, Gottesman MM, Gray PA, Green ED, Greider FB, Hodes R, Hudson KL, Humphreys B, Katz SI, Koob GF, Koroshetz WJ, Lauer MS, Lorsch JR, Lowy DR, McGowan JJ, Murray DM, Nakamura R, Norris A, Perez-Stable EJ, Pettigrew RI, Riley WT, Rodgers GP, Sieving PA, Somerman MJ, Spong CY, Tabak LA, Volkow ND, Wilder EL. Basic science: Bedrock of progress. Science 2016; 351:1405. [PMID: 27013720 DOI: 10.1126/science.351.6280.1405-a] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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Mott M, Janis S, Koroshetz WJ. StrokeNet Takes Off: National Institute of Neurological Disorders and Stroke Organizational Update. Stroke 2016; 47:e51-2. [PMID: 26814236 DOI: 10.1161/strokeaha.115.012063] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Koroshetz WJ, Landis S. Neurology's stake in foundational neuroscience research. Neurology 2014; 83:670-1. [PMID: 24991032 DOI: 10.1212/wnl.0000000000000681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Montine TJ, Koroshetz WJ, Babcock D, Dickson DW, Galpern WR, Glymour MM, Greenberg SM, Hutton ML, Knopman DS, Kuzmichev AN, Manly JJ, Marder KS, Miller BL, Phelps CH, Seeley WW, Sieber BA, Silverberg NB, Sutherland M, Torborg CL, Waddy SP, Zlokovic BV, Corriveau RA. Recommendations of the Alzheimer's disease-related dementias conference. Neurology 2014; 83:851-60. [PMID: 25080517 DOI: 10.1212/wnl.0000000000000733] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
The National Alzheimer's Project Act, signed into law in 2011, mandates a National Plan to Address Alzheimer's Disease that is updated annually. In the Plan, the term Alzheimer disease includes not only Alzheimer disease (AD) proper, but also several specified related dementias, namely, frontotemporal, Lewy body, vascular, and mixed dementia. In response to a specific action item in the 2012 National Plan, the National Institute of Neurological Disorders and Stroke, in collaboration with the National Institute on Aging, convened panels of experts and conducted a 2-day public conference to develop research priorities and timelines for addressing Alzheimer disease-related dementias (ADRD) in 5 topic areas: multiple etiology dementias, health disparities, Lewy body dementias including dementia with Lewy bodies and Parkinson disease dementia, frontotemporal dementia and related tauopathies, and vascular contributions to ADRD. By design, the product was up to 8 prioritized research recommendations in each topic area including estimated timelines from when work on a recommendation is started to completion or to full implementation of an ongoing activity, and recognition of shared research themes across recommendations. These included increased education and training of both researchers and health care professionals, addressing health disparities, fundamental neurobiology research, advanced diagnostics, collaborative biosample repositories, and a focus on developing effective interventions to prevent or treat ADRD by the year 2025 as targeted by the National Plan.
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Koroshetz WJ, Landis S. Neurology's stake in foundational neuroscience research. Ann Neurol 2014; 75:621-2. [PMID: 24756692 DOI: 10.1002/ana.24161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2014] [Revised: 04/20/2014] [Accepted: 04/20/2014] [Indexed: 11/09/2022]
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Koroshetz WJ. Review of Alfalfa to Ivy: Memoir of a Harvard Medical School Dean. JAMA Neurol 2014. [DOI: 10.1001/jamaneurol.2013.5169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Lima FO, Furie KL, Silva GS, Lev MH, Camargo ECS, Singhal AB, Harris GJ, Halpern EF, Koroshetz WJ, Smith WS, Nogueira RG. Prognosis of untreated strokes due to anterior circulation proximal intracranial arterial occlusions detected by use of computed tomography angiography. JAMA Neurol 2013; 71:151-7. [PMID: 24323077 DOI: 10.1001/jamaneurol.2013.5007] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Limited data exist regarding the natural history of proximal intracranial arterial occlusions. OBJECTIVE To investigate the outcomes of patients who had an acute ischemic stroke attributed to an anterior circulation proximal intracranial arterial occlusion. DESIGN, SETTING, AND PARTICIPANTS A prospective cohort study at 2 university-based hospitals from 2003 to 2005 in which nonenhanced computed tomography scans and computed tomography angiograms were obtained at admission of all adult patients suspected of having an ischemic stroke in the first 24 hours of symptom onset. EXPOSURE Anterior circulation proximal intracranial arterial occlusion. MAIN OUTCOMES AND MEASURES Frequency of good outcome (defined as a modified Rankin Scale score of ≤ 2) and mortality at 6 months. RESULTS A total of 126 patients with a unilateral complete occlusion of the intracranial internal carotid artery (ICA; 26 patients: median National Institutes of Health Stroke Scale [NIHSS] score, 11 [interquartile range, 5-17]), of the M1 segment of the middle cerebral artery (MCA; 52 patients: median NIHSS score, 13 [interquartile range, 6-16]), or of the M2 segment of the MCA (48 patients: median NIHSS score, 7 [interquartile range, 4-15]) were included. Of these 3 groups of patients, 10 (38.5%), 20 (38.5%), and 26 (54.2%) with ICA, MCA-M1, and MCA-M2 occlusions, respectively, achieved a modified Rankin Scale score of 2 or less, and 6 (23.1%), 12 (23.1%), and 10 (20.8%) were dead at 6 months. Worse outcomes were seen in patients with a baseline NIHSS score of 10 or higher, with a modified Rankin Scale score of 2 or less achieved in only 7.1% (1 of 14), 23.5% (8 of 34), and 22.7% (5 of 22) of patients and mortality rates of 35.7% (5 of 14), 32.4% (11 of 34), and 40.9% (9 of 22) among patients with ICA, MCA-M1, and MCA-M2 occlusions, respectively. Age (odds ratio, 0.94 [95% CI, 0.91-0.98]), NIHSS score (odds ratio, 0.73 [95% CI, 0.64-0.83]), and strength of leptomeningeal collaterals (odds ratio, 2.37 [95% CI, 1.08-5.20]) were independently associated with outcome, whereas the level of proximal intracranial arterial occlusion (ICA vs MCA-M1 vs MCA-M2) was not. CONCLUSIONS AND RELEVANCE The natural history of proximal intracranial arterial occlusion is variable, with poor outcomes overall. Stroke severity and collateral flow appear to be more important than the level of proximal intracranial arterial occlusion in determining outcomes. Our results provide useful data for proper patient selection and sample size calculations in the design of new clinical trials aimed at recanalization therapies.
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Koroshetz WJ, Brown J. NIH: Developing And Funding Research In Emergency Care And Training The Next Generation Of Emergency Care Researchers. Health Aff (Millwood) 2013; 32:2186-92. [DOI: 10.1377/hlthaff.2013.0833] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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González RG, Furie KL, Goldmacher GV, Smith WS, Kamalian S, Payabvash S, Harris GJ, Halpern EF, Koroshetz WJ, Camargo ECS, Dillon WP, Lev MH. Good outcome rate of 35% in IV-tPA-treated patients with computed tomography angiography confirmed severe anterior circulation occlusive stroke. Stroke 2013; 44:3109-13. [PMID: 24003051 DOI: 10.1161/strokeaha.113.001938] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE To determine the effect of intravenous tissue plasminogen activator (IV-tPA) on outcomes in patients with severe major anterior circulation ischemic stroke. METHODS Prospectively, 649 patients with acute stroke had admission National Institutes of Health stroke scale (NIHSS) scores, noncontrast computed tomography (CT), CT angiography (CTA), and 6-month outcome assessed using modified Rankin scale. IV-tPA treatment decisions were made before CTA, at the time of noncontrast CT scanning, as per routine clinical protocol. Severe symptoms were defined as NIHSS>10. Poor outcome was defined as modified Rankin scale >2. Major occlusions were identified on CTA. Univariate and multivariate stepwise-forward logistic regression analyses of the full cohort were performed. RESULTS Of 649 patients, 188 (29%) patients presented with NIHSS>10, and 64 out of 188 (34%) patients received IV-tPA. Admission NIHSS, large artery occlusion, and IV-tPA all independently predicted good outcomes; however, a significant interaction existed between IV-tPA and occlusion (P<0.001). Of the patients who presented with NIHSS>10 with anterior circulation occlusion, twice the percentage had good outcomes if they received IV-tPA (17 out of 49 patients, 35%) than if they did not (13 out of 77 patients, 17%; P=0.031). The number needed to treat was 7 (95% confidence interval, 3-60). CONCLUSIONS IV-tPA treatment resulted in significantly better outcomes in patients with severely symptomatic stroke with major anterior circulation occlusions. The 35% good outcome rate was similar to rates found in endovascular therapy trials. Vascular imaging may help in patient selection and stratification for trials of IV-thrombolytic and endovascular therapies.
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Moskowitz MA, Grotta JC, Koroshetz WJ. The NINDS Stroke Progress Review Group final analysis and recommendations. Stroke 2013; 44:2343-50. [PMID: 23821230 DOI: 10.1161/strokeaha.113.001192] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bleck TP, Nowinski CJ, Gershon R, Koroshetz WJ. What is the NIH toolbox, and what will it mean to neurology? Neurology 2013; 80:874-5. [PMID: 23460616 DOI: 10.1212/wnl.0b013e3182872ea0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Soares HD, Potter WZ, Pickering E, Kuhn M, Immermann FW, Shera DM, Ferm M, Dean RA, Simon AJ, Swenson F, Siuciak JA, Kaplow J, Thambisetty M, Zagouras P, Koroshetz WJ, Wan HI, Trojanowski JQ, Shaw LM. Plasma biomarkers associated with the apolipoprotein E genotype and Alzheimer disease. ACTA ACUST UNITED AC 2013; 69:1310-7. [PMID: 22801723 DOI: 10.1001/archneurol.2012.1070] [Citation(s) in RCA: 162] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND A blood-based test that could be used as a screen for Alzheimer disease (AD) may enable early intervention and better access to treatment. OBJECTIVE To apply a multiplex immunoassay panel to identify plasma biomarkers of AD using plasma samples from the Alzheimer's Disease Neuroimaging Initiative cohort. DESIGN Cohort study. SETTING The Biomarkers Consortium Alzheimer's Disease Plasma Proteomics Project. PARTICIPANTS Plasma samples at baseline and at 1 year were analyzed from 396 (345 at 1 year) patients with mild cognitive impairment, 112 (97 at 1 year) patients with AD, and 58 (54 at 1 year) healthy control subjects. MAIN OUTCOME MEASURES Multivariate and univariate statistical analyses were used to examine differences across diagnostic groups and relative to the apolipoprotein E (ApoE) genotype. RESULTS Increased levels of eotaxin 3, pancreatic polypeptide, and N-terminal protein B-type brain natriuretic peptide were observed in patients, confirming similar changes reported in cerebrospinal fluid samples of patients with AD and MCI. Increases in tenascin C levels and decreases in IgM and ApoE levels were also observed. All participants with Apo ε3/ε4 or ε4/ε4 alleles showed a distinct biochemical profile characterized by low C-reactive protein and ApoE levels and by high cortisol, interleukin 13, apolipoprotein B, and gamma interferon levels. The use of plasma biomarkers improved specificity in differentiating patients with AD from controls, and ApoE plasma levels were lowest in patients whose mild cognitive impairment had progressed to dementia. CONCLUSIONS Plasma biomarker results confirm cerebrospinal fluid studies reporting increased levels of pancreatic polypeptide and N-terminal protein B-type brain natriuretic peptide in patients with AD and mild cognitive impairment. Incorporation of plasma biomarkers yielded high sensitivity with improved specificity, supporting their usefulness as a screening tool. The ApoE genotype was associated with a unique biochemical profile irrespective of diagnosis, highlighting the importance of genotype on blood protein profiles.
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Geocadin RG, Bleck TP, Koroshetz WJ, Robertson CS, Zaidat OO, LeRoux PD, Wijman CAC, Suarez JI. Research priorities in neurocritical care. Neurocrit Care 2012; 16:35-41. [PMID: 21792752 DOI: 10.1007/s12028-011-9611-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This summary of the last session of the First Neurocritical Care Research Conference reviews the discussions about research priorities in neurocritical care. The first presentation reviewed current projects funded by the National Institute of Neurological Disorders and Stroke at the National Institutes of Health and potential models to follow including an independent Neurocritical Care Network or the creation of such a network with the goal of collaborating with already existing ones. Experienced neurointensivists then presented their views on the most common and important research questions that need to be answered and investigated in the field. Finally, utility of clinical registries was discussed emphasizing their importance as hypothesis generators. During the group discussion, interests in comparative effectiveness research, the use of physiological endpoints from monitoring and alternate trial design were expressed.
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González RG, Lev MH, Goldmacher GV, Smith WS, Payabvash S, Harris GJ, Halpern EF, Koroshetz WJ, Camargo ECS, Dillon WP, Furie KL. Improved outcome prediction using CT angiography in addition to standard ischemic stroke assessment: results from the STOPStroke study. PLoS One 2012; 7:e30352. [PMID: 22276182 PMCID: PMC3262833 DOI: 10.1371/journal.pone.0030352] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2011] [Accepted: 12/14/2011] [Indexed: 11/19/2022] Open
Abstract
PURPOSE To improve ischemic stroke outcome prediction using imaging information from a prospective cohort who received admission CT angiography (CTA). METHODS In a prospectively designed study, 649 stroke patients diagnosed with acute ischemic stroke had admission NIH stroke scale scores, noncontrast CT (NCCT), CTA, and 6-month outcome assessed using the modified Rankin scale (mRS) scores. Poor outcome was defined as mRS>2. Strokes were classified as "major" by the (1) Alberta Stroke Program Early CT Score (ASPECTS+) if NCCT ASPECTS was ≤7; (2) Boston Acute Stroke Imaging Scale (BASIS+) if they were ASPECTS+ or CTA showed occlusion of the distal internal carotid, proximal middle cerebral, or basilar arteries; and (3) NIHSS for scores >10. RESULTS Of 649 patients, 253 (39.0%) had poor outcomes. NIHSS, BASIS, and age, but not ASPECTS, were independent predictors of outcome. BASIS and NIHSS had similar sensitivities, both superior to ASPECTS (p<0.0001). Combining NIHSS with BASIS was highly predictive: 77.6% (114/147) classified as NIHSS>10/BASIS+ had poor outcomes, versus 21.5% (77/358) with NIHSS≤10/BASIS- (p<0.0001), regardless of treatment. The odds ratios for poor outcome is 12.6 (95% CI: 7.9 to 20.0) in patients who are NIHSS>10/BASIS+ compared to patients who are NIHSS≤10/BASIS-; the odds ratio is 5.4 (95% CI: 3.5 to 8.5) when compared to patients who are only NIHSS>10 or BASIS+. CONCLUSIONS BASIS and NIHSS are independent outcome predictors. Their combination is stronger than either instrument alone in predicting outcomes. The findings suggest that CTA is a significant clinical tool in routine acute stroke assessment.
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Nogueira RG, Ferreira R, Grant PE, Maier SE, Koroshetz WJ, Gonzalez RG, Sheth KN. Restricted diffusion in spinal cord infarction demonstrated by magnetic resonance line scan diffusion imaging. Stroke 2011; 43:532-5. [PMID: 22033988 DOI: 10.1161/strokeaha.111.624023] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We report on the use of line scan diffusion magnetic resonance imaging in the evaluation of spinal cord infarctions. METHODS Data on 19 patients with clinical findings consistent with spinal cord infarctions and abnormal findings on line scan diffusion imaging were reviewed. The Apparent Diffusion Coefficient (ADC) measurements for the normal spinal cord and for the areas of abnormality were calculated from trace ADC maps. RESULTS Restricted diffusion was found in all 19 patients. Absolute ADC values in the ischemic area ranged between 395.4 and 575.8 × 10(-6) mm(2)/s, with ADC ratios ranging between 39.4% and 57.4%. CONCLUSIONS Line scan diffusion imaging is technically feasible and appears to be a reliable method to diagnose spinal cord infarction in the acute setting.
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McKhann GM, Knopman DS, Chertkow H, Hyman BT, Jack CR, Kawas CH, Klunk WE, Koroshetz WJ, Manly JJ, Mayeux R, Mohs RC, Morris JC, Rossor MN, Scheltens P, Carrillo MC, Thies B, Weintraub S, Phelps CH. The diagnosis of dementia due to Alzheimer's disease: recommendations from the National Institute on Aging-Alzheimer's Association workgroups on diagnostic guidelines for Alzheimer's disease. Alzheimers Dement 2011; 7:263-9. [PMID: 21514250 DOI: 10.1016/j.jalz.2011.03.005] [Citation(s) in RCA: 9810] [Impact Index Per Article: 754.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The National Institute on Aging and the Alzheimer's Association charged a workgroup with the task of revising the 1984 criteria for Alzheimer's disease (AD) dementia. The workgroup sought to ensure that the revised criteria would be flexible enough to be used by both general healthcare providers without access to neuropsychological testing, advanced imaging, and cerebrospinal fluid measures, and specialized investigators involved in research or in clinical trial studies who would have these tools available. We present criteria for all-cause dementia and for AD dementia. We retained the general framework of probable AD dementia from the 1984 criteria. On the basis of the past 27 years of experience, we made several changes in the clinical criteria for the diagnosis. We also retained the term possible AD dementia, but redefined it in a manner more focused than before. Biomarker evidence was also integrated into the diagnostic formulations for probable and possible AD dementia for use in research settings. The core clinical criteria for AD dementia will continue to be the cornerstone of the diagnosis in clinical practice, but biomarker evidence is expected to enhance the pathophysiological specificity of the diagnosis of AD dementia. Much work lies ahead for validating the biomarker diagnosis of AD dementia.
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Maas MB, Lev MH, Ay H, Singhal AB, Greer DM, Smith WS, Harris GJ, Halpern EF, Koroshetz WJ, Furie KL. The prognosis for aphasia in stroke. J Stroke Cerebrovasc Dis 2010; 21:350-7. [PMID: 21185744 DOI: 10.1016/j.jstrokecerebrovasdis.2010.09.009] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Revised: 09/29/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Aphasia is a disabling chronic stroke symptom, but the prognosis for patients presenting with aphasia in the hyperacute window has not been well characterized. The purpose of this study is to assess the prognosis for recovery of language function in subjects presenting with aphasia caused by ischemic stroke within 12 hours of symptom onset. METHODS Subjects presenting with aphasia were identified from a prospective cohort study of 669 subjects presenting emergently with acute stroke. Subjects were characterized by demographics, serial clinical examinations, unenhanced computed tomography, and computed tomographic angiography. Aphasia severity was assessed by National Institutes of Health Stroke Scale (NIHSS) examinations performed at baseline, discharge, and 6 months. Demographic, clinical, and imaging factors were assessed for prognostic impact. RESULTS Aphasia was present in 30% of subjects (n = 204). Of the 166 aphasic patients alive at discharge (median 5 days), aphasia improved in 57% and resolved in 38%. In the 102 aphasic subjects evaluated at 6 months, aphasia improved in 86% and completely resolved in 74% of subjects. Among aphasic subjects with "mild" stroke (initial NIHSS <5), aphasia resolved in 90% of subjects by 6 months. Factors significantly associated with better outcome included clinically and radiographically smaller strokes and lower prestroke disability. CONCLUSIONS The prognosis for full recovery of aphasia present in the hyperacute window is good. Radiographic and clinical markers indicating lesser extent of ischemia correlated to greater recovery. Given the excellent prognosis for language recovery in mild stroke, the net benefit of thrombolysis in such cases is uncertain.
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Lima FO, Furie KL, Silva GS, Lev MH, Camargo ECS, Singhal AB, Harris GJ, Halpern EF, Koroshetz WJ, Smith WS, Yoo AJ, Nogueira RG. The pattern of leptomeningeal collaterals on CT angiography is a strong predictor of long-term functional outcome in stroke patients with large vessel intracranial occlusion. Stroke 2010; 41:2316-22. [PMID: 20829514 DOI: 10.1161/strokeaha.110.592303] [Citation(s) in RCA: 248] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The role of noninvasive methods in the evaluation of collateral circulation has yet to be defined. We hypothesized that a favorable pattern of leptomeningeal collaterals, as identified by CT angiography, correlates with improved outcomes. METHODS Data from a prospective cohort study at 2 university-based hospitals where CT angiography was systematically performed in the acute phase of ischemic stroke were analyzed. Patients with complete occlusion of the intracranial internal carotid artery and/or the middle cerebral artery (M1 or M2 segments) were selected. The leptomeningeal collateral pattern was graded as a 3-category ordinal variable (less, equal, or greater than the unaffected contralateral hemisphere). Univariate and multivariate analyses were performed to define the independent predictors of good outcome at 6 months (modified Rankin Scale score ≤2). RESULTS One hundred ninety-six patients were selected. The mean age was 69±17 years and the median National Institute of Health Stroke Scale score was 13 (interquartile range, 6 to 17). In the univariate analysis, age, baseline National Institute of Health Stroke Scale score, prestroke modified Rankin Scale score, Alberta Stroke Programme Early CT score, admission blood glucose, history of hypertension, coronary artery disease, congestive heart failure, atrial fibrillation, site of occlusion, and collateral pattern were predictors of outcome. In the multivariate analysis, age (OR, 0.95; 95% CI, 0.93 to 0.98; P=0.001), baseline National Institute of Health Stroke Scale (OR, 0.75; 0.69 to 0.83; P<0.001), prestroke modified Rankin Scale score (OR, 0.41; 0.22 to 0.76; P=0.01), intravenous recombinant tissue plasminogen activator (OR, 4.92; 1.83 to 13.25; P=0.01), diabetes (OR, 0.31; 0.01 to 0.98; P=0.046), and leptomeningeal collaterals (OR, 1.93; 1.06 to 3.34; P=0.03) were identified as independent predictors of good outcome. CONCLUSIONS Consistent with angiographic studies, leptomeningeal collaterals on CT angiography are also a reliable marker of good outcome in ischemic stroke.
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Ay H, Koroshetz WJ. Transient ischemic attack: are there different types or classes? Risk of stroke and treatment options. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2010; 8:193-200. [PMID: 16635438 DOI: 10.1007/s11936-006-0012-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Recent advances in neuroimaging have revolutionized the evaluation of the clinical syndrome of transient ischemic attack (TIA). Diffusion-weighted imaging demonstrates microinfarctions (< 1 cm(3)) in approximately 50% of patients with TIA, establishing that not all clinically transient spells are transient at the tissue level. The clinical syndrome of TIA that is associated with ischemic brain injury is called "transient symptoms with infarction" (TSI). TSI appears to be a different subset because it harbors higher risk of imminent stroke than "TIA with no infarction." Armed with the evidence of ischemia as the cause of transient spell, clinicians can pursue the most appropriate therapy for stroke prevention by targeting the underlying etiology of brain ischemia.
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Anderson HV, Rosenfield KA, White CJ, Ho KKL, Spertus JA, Jones PG, Tang F, Cates CU, Jaff MR, Koroshetz WJ, Katzan IL, Hopkins LN, Rumsfeld JS, Brindis RG. Clinical features and outcomes of carotid artery stenting by clinical expert consensus criteria: a report from the CARE registry. Catheter Cardiovasc Interv 2010; 75:519-25. [PMID: 20088016 DOI: 10.1002/ccd.22333] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND In 2007, a multispecialty society task force published a clinical expert consensus document (CECD) on carotid stenting (CAS), containing recommendations for appropriate patient selection and quality of care. The CECD also inspired creation of a large, national registry of carotid revascularization, the Carotid Artery Revascularization and Endarterectomy (CARE) registry. Our goal here was to investigate whether initial CAS procedures submitted to CARE conformed to CECD recommendations, and examine their clinical outcomes. METHODS We analyzed CAS procedures for the period January 1, 2005 through December 31, 2008. These were grouped into those that conformed to CECD recommendations [CECD(+), n = 4,636, 79.8%] and those that did not [CECD(-), n = 1,168, 20.2%]. RESULTS The CECD(+) patients were older than CECD(-) patients (71.5 +/- 10.3 vs. 67.6 +/- 10.3 years, P = 0.001, respectively), and more frequently had chronic kidney disease (46.9% vs. 17.8%, P = 0.001), chronic lung disease (33.0% vs. 12.4%, P = 0.001), ejection fraction <or= 0.30 (13.5% vs. 5.5%, P = 0.001) and contralateral carotid artery occlusion (12.7% vs. 4.6%, P = 0.001). Clinical outcomes at 30 days were similar, including death (1.24% vs. 0.76%, P = 0.184), stroke (5.32% vs. 5.34%, P = 0.954), and death, stroke, or MI (7.04% vs. 6.95%, P = 0.944). CONCLUSIONS Most CAS procedures submitted to CARE conformed to CECD recommendations for patient selection. For reported data, clinical outcomes at 30 days were similar for procedures meeting and those not meeting recommendations, and were similar to outcomes reported by other large registries. These findings suggest that acceptable patient selection criteria for CAS are employed as it expands beyond investigators into more widespread clinical practice.
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