1
|
Harrington WB, Fugler PR, Midkiff T, Christensen SJ, Miller E. Exploring Choke Holds in Brazilian Jiujitsu Athletes: A Demographic Study. Cureus 2024; 16:e60618. [PMID: 38894780 PMCID: PMC11182763 DOI: 10.7759/cureus.60618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 05/19/2024] [Indexed: 06/21/2024] Open
Abstract
Introduction Brazilian jiujitsu is a relatively new sport that has grown exponentially in popularity along with the growth of the Ultimate Fighting Championship (UFC). In jiujitsu, there are a variety of submissions with a choke hold being one of the most popular. There is a subset of athletes in jiujitsu who believes chokes are safe. However, there have been case reports of relatively young athletes suffering strokes secondary to internal carotid or vertebral artery dissections after being placed in choke holds. There have been manuscripts describing the injury profile in jiujitsu, but none mention stroke or dissections. This study evaluated how frequently chokes happen in jiujitsu and if athletes have ever experienced symptoms consistent with cervical artery dissection (CAD). Additionally, this study aimed to describe the training frequency and baseline demographics of jiujitsu athletes. Methods A survey was distributed throughout social media platforms which asked both quantitative and qualitative questions regarding athlete training. The survey consisted of 28 questions which collected largely baseline grappling information about the participants such as how long they trained, how often they spar, favorite submission, how frequently they are choked, etc. This data was then analyzed using odds ratio and one sample t-test to evaluate for statistical differences. Results A total of 521 participants were included in the analysis. The participants were mostly male (84.7%), trained for four years, four times per week; 99.8% (520) participated in sparring, with an average age of 37; and 55.7% (290) have experienced symptoms consistent with CAD. Descriptive statistics revealed that individuals who were 37 years of age or younger were more likely to experience symptoms consistent with CAD (odds ratio: 1.5337 (95% confidence interval (CI): 1.0827-2.1727). Athletes that were 37 years of age or younger have been training for fewer years (4.7 years vs 8.8 years) but train more days per week (4.03 times per week vs 3.76 time per week), drill for a longer amount of time (46.8 minutes per class vs 38.3 minutes per class), attend longer classes (81.12 minutes vs 72.3 minutes), and train for a longer period of time per week (338.5 minutes vs 274.6 minutes) than athletes over 37 years. All previously mentioned variables were analyzed using a one sample t-test and were significant at the α = 0.05 level. The lone qualitative question regarding the term "train brain" revealed that of those who experienced it, 84.1% (58) described it as a cognitive/physical impairing event. Conclusion Jiujitsu athletes train multiple times per week and are frequently exposed to choke holds. There is no literature to examine the long-term effects of these chokes on the athlete's cervical vasculature. Additional studies should be conducted to evaluate the effects of the repetitive stress placed on these vessels.
Collapse
Affiliation(s)
- William B Harrington
- Medical School, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| | - Patrick R Fugler
- Emergency Medicine, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| | - Tatiana Midkiff
- Physiology, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| | | | - Eric Miller
- Surgery, Centra Bedford Memorial Hospital, Bedford, USA
- Surgery, Liberty University College of Osteopathic Medicine, Lynchburg, USA
| |
Collapse
|
2
|
Yaghi S, Engelter S, Del Brutto VJ, Field TS, Jadhav AP, Kicielinski K, Madsen TE, Mistry EA, Salehi Omran S, Pandey A, Raz E. Treatment and Outcomes of Cervical Artery Dissection in Adults: A Scientific Statement From the American Heart Association. Stroke 2024; 55:e91-e106. [PMID: 38299330 DOI: 10.1161/str.0000000000000457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2024]
Abstract
Cervical artery dissection is an important cause of stroke, particularly in young adults. Data conflict on the diagnostic evaluation and treatment of patients with suspected cervical artery dissection, leading to variability in practice. We aim to provide an overview of cervical artery dissection in the setting of minor or no reported mechanical trigger with a focus on summarizing the available evidence and providing suggestions on the diagnostic evaluation, treatment approaches, and outcomes. Writing group members drafted their sections using a literature search focused on publications between January 1, 1990, and December 31, 2022, and included randomized controlled trials, prospective and retrospective observational studies, meta-analyses, opinion papers, case series, and case reports. The writing group chair and vice chair compiled the manuscript and obtained writing group members' approval. Cervical artery dissection occurs as a result of the interplay among risk factors, minor trauma, anatomic and congenital abnormalities, and genetic predisposition. The diagnosis can be challenging both clinically and radiologically. In patients with acute ischemic stroke attributable to cervical artery dissection, acute treatment strategies such as thrombolysis and mechanical thrombectomy are reasonable in otherwise eligible patients. We suggest that the antithrombotic therapy choice be individualized and continued for at least 3 to 6 months. The risk of recurrent dissection is low, and preventive measures may be considered early after the diagnosis and continued in high-risk patients. Ongoing longitudinal and population-based observational studies are needed to close the present gaps on preferred antithrombotic regimens considering clinical and radiographic prognosticators of cervical artery dissection.
Collapse
|
3
|
Lin X, Guo W, She D, Kang Y, Xing Z, Cao D. Initial and follow-up high-resolution vessel wall MRI study of spontaneous cervicocranial artery dissection. Eur Radiol 2024; 34:1704-1715. [PMID: 37670185 DOI: 10.1007/s00330-023-10207-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 07/01/2023] [Accepted: 07/12/2023] [Indexed: 09/07/2023]
Abstract
OBJECTIVES To explore the factors associated with ischemic stroke secondary to spontaneous cervicocranial artery dissection (sCCAD) and evaluate the initial imaging markers related to outcomes. METHODS Initial and follow-up high-resolution vessel wall MRI (VW-MRI) in consecutive patients with sCCAD were retrospectively analyzed. The associations of clinical and imaging factors and variants of the circle of Willis (COW) with ischemic stroke were evaluated using binary logistic regression analyses. The anatomical outcomes were categorized as complete, partial, and no remodeling based on changes of the vessel wall and lumen. Ordinal logistic regression analysis was used to assess associations between initial features and outcomes. RESULTS A total of 115 dissected arteries (79 strokes, 36 non-strokes) were detected in 103 patients. Follow-up VW-MRI was available in 46 patients (44.7%, with 51 vessels), with a median interval of 8.5 months. Pseudoaneurysm (odd ratio [OR], 0.178; 95% confidence interval [CI], 0.039-0.810; p = 0.026) tended to rarely cause ischemic stroke, while intraluminal thrombus (OR, 5.558; 95% CI, 1.739-17.765; p = 0.004), incomplete COW (OR, 9.309; 95% CI, 2.122-40.840; p = 0.003), and partial complete COW (OR, 4.463; 95% CI, 1.211-16.453; p = 0.025) were independently associated with stroke occurrence. Furthermore, the presence of double lumen (OR, 5.749; 95% CI, 1.358-24.361; p = 0.018) and occlusion (OR, 12.975; 95% CI, 3.022-55.645; p = 0.001) were associated with no remodeling of sCCAD. CONCLUSIONS Multiple initial factors were found to be related to stroke occurrence and anatomical outcomes of sCCAD. High-resolution VW-MRI may provide valuable insights into the pathophysiology and evolution of sCCAD. CLINICAL RELEVANCE STATEMENT Initial and follow-up high-resolution vessel wall MRI may help elucidate the pathophysiology of spontaneous cervicocranial artery dissection and provide important insights into the evolution and further facilitate the optimal management of patients with spontaneous cervicocranial artery dissection. KEY POINTS • Clinical and imaging factors, as well as the status of primary collateral circulation, are associated with ischemic stroke secondary to spontaneous cervicocranial artery dissection. • The follow-up high-resolution vessel wall MRI provides valuable insights into the long-term evolution and anatomical outcomes of spontaneous cervicocranial artery dissection. • The high-resolution vessel wall MRI features related to ischemic stroke and anatomical outcomes may further facilitate the optimal management of patients with spontaneous cervicocranial artery dissection.
Collapse
Affiliation(s)
- Xuehua Lin
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, 20 Cha-Zhong Road, Fuzhou, 350005, Fujian, China
| | - Wei Guo
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, 20 Cha-Zhong Road, Fuzhou, 350005, Fujian, China
| | - Dejun She
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, 20 Cha-Zhong Road, Fuzhou, 350005, Fujian, China
| | - Yaqing Kang
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, 20 Cha-Zhong Road, Fuzhou, 350005, Fujian, China
| | - Zhen Xing
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, 20 Cha-Zhong Road, Fuzhou, 350005, Fujian, China
| | - Dairong Cao
- Department of Radiology, The First Affiliated Hospital of Fujian Medical University, 20 Cha-Zhong Road, Fuzhou, 350005, Fujian, China.
- Department of Radiology, Fujian Key Laboratory of Precision Medicine for Cancer, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, Fujian, China.
- Key Laboratory of Radiation Biology of Fujian Higher Education Institutions, the First Affiliated Hospital, Fujian Medical University, Fuzhou, 350005, Fujian, China.
| |
Collapse
|
4
|
Keser Z, Diehn FE, Lanzino G. Photon-Counting Detector CT Angiography in Cervical Artery Dissection. Stroke 2024; 55:e48-e49. [PMID: 38293798 DOI: 10.1161/strokeaha.123.046174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Affiliation(s)
- Zafer Keser
- Departments of Neurology (Z.K.), Mayo Clinic, Rochester, MN
| | | | | |
Collapse
|
5
|
Liberman AL, Zhang C, Parikh NS, Salehi Omran S, Navi BB, Lappin RI, Merkler AE, Kaiser JH, Kamel H. Misdiagnosis of Posterior Reversible Encephalopathy Syndrome and Reversible Cerebral Vasoconstriction Syndrome in the Emergency Department. J Am Heart Assoc 2023; 12:e030009. [PMID: 37750568 PMCID: PMC10727253 DOI: 10.1161/jaha.123.030009] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 08/24/2023] [Indexed: 09/27/2023]
Abstract
Background Cerebrovascular dysregulation syndromes, posterior reversible encephalopathy syndrome (PRES) and reversible cerebral vasoconstriction syndrome (RCVS), are challenging to diagnose because they are rare and require advanced neuroimaging for confirmation. We sought to estimate PRES/RCVS misdiagnosis in the emergency department and its associated factors. Methods and Results We conducted a retrospective cohort study of PRES/RCVS patients using administrative claims data from 11 states (2016-2018). We defined patients with a probable PRES/RCVS misdiagnosis as those with an emergency department visit for a neurological symptom resulting in discharge to home that occurred ≤14 days before PRES/RCVS hospitalization. Proportions of patients with probable misdiagnosis were calculated, characteristics of patients with and without probable misdiagnosis were compared, and regression analyses adjusted for demographics and comorbidities were performed to identify factors affecting probable misdiagnosis. We identified 4633 patients with PRES/RCVS. A total of 210 patients (4.53% [95% CI, 3.97-5.17]) had a probable preceding emergency department misdiagnosis; these patients were younger (mean age, 48 versus 54 years; P<0.001) and more often female (80.4% versus 69.3%; P<0.001). Misdiagnosed patients had fewer vascular risk factors except prior stroke (36.3% versus 24.2%; P<0.001) and more often had comorbid headache (84% versus 21.4%; P<0.001) and substance use disorder (48.8% versus 37.9%; P<0.001). Facility-level factors associated with probable misdiagnosis included smaller facility, lacking a residency program (62.2% versus 73.7%; P<0.001), and not having on-site neurological services (75.7% versus 84.3%; P<0.001). Probable misdiagnosis was not associated with higher likelihood of stroke or subarachnoid hemorrhage during PRES/RCVS hospitalization. Conclusions Probable emergency department misdiagnosis occurred in ≈1 of every 20 patients with PRES/RCVS in a large, multistate cohort.
Collapse
Affiliation(s)
- Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Neal S. Parikh
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | | | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | | | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Jed H. Kaiser
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of NeurologyFeil Family Brain and Mind Research Institute, Weill Cornell MedicineNew YorkNY
| |
Collapse
|
6
|
Salehi Omran S. Cervical Artery Dissection. Continuum (Minneap Minn) 2023; 29:540-565. [PMID: 37039409 DOI: 10.1212/con.0000000000001233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Cervical artery dissection is a common cause of stroke in young adults. This article reviews the pathophysiology, etiology and risk factors, evaluation, management, and outcomes of spontaneous cervical artery dissection. LATEST DEVELOPMENTS Cervical artery dissection is believed to be a multifactorial disease, with environmental factors serving as possible triggers in patients who have a genetic predisposition to dissection formation. Cervical artery dissection can cause local symptoms or ischemic events, such as ischemic stroke or transient ischemic attack. Neuroimaging is used to confirm the diagnosis; classic findings include a long tapered arterial stenosis or occlusion, dissecting aneurysm, intimal flap, double lumen, or intramural hematoma. Patients with cervical artery dissection who present with an acute ischemic stroke should be evaluated for IV thrombolysis, endovascular therapy eligibility, or both. Antithrombotic therapy with either anticoagulation or antiplatelet treatment is used to prevent stroke from cervical artery dissection. The risk of recurrent ischemia appears low and is mostly limited to the first two weeks after symptom onset. ESSENTIAL POINTS Cervical artery dissection is a known cause of ischemic strokes. Current data show no difference between the benefits and risks of anticoagulation versus antiplatelet therapy in the acute phase of symptomatic extracranial cervical artery dissection, thereby supporting the recommendation that clinicians can prescribe either treatment. Further research is warranted to better understand the pathophysiology and long-term outcomes of cervical artery dissection.
Collapse
|
7
|
Deen R, Austin C, Bullen A. Review article: Non-penetrating neck artery dissection in young adults: Not to be missed! Emerg Med Australas 2023; 35:384-389. [PMID: 36948224 DOI: 10.1111/1742-6723.14202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 02/10/2023] [Accepted: 03/09/2023] [Indexed: 03/24/2023]
Abstract
Young adults who present to the ED with neck pain following non-penetrating, seemingly trivial trauma to the neck, are at risk of neck artery dissection and subsequent stroke. Sport-related neck injury is the chief cause. Physical examination may often be unremarkable, and although there may be reluctance to expose young patients to radiation, radiological imaging is central to making a diagnosis of arterial wall disruption. A comprehensive literature search was performed in relation to neck artery dissection, and the evidence was scrutinised. We discuss the typical mechanism of injury, symptoms, anatomical considerations and clinical aids in diagnosis of neck artery dissection. Although the incidence is low, neck artery dissection has a mortality of 7%. As such, it is important for front-line physicians to have a high suspicion of the diagnosis and a low threshold to organise radiological examinations, specifically computerised tomography. Early detection of neck artery dissection will trigger clinical protocols that call for multi-disciplinary team management of this condition. In general, guideline-based recommendation for the management of neck artery dissection involving an intimal flap is by anti-platelet therapy while treatment of neck artery dissection that results in a pseudo-aneurysm or thrombosis is managed by surgical intervention or endovascular techniques. Close follow up combined with antithrombotic treatment is recommended in these individuals, the goal being prevention of stroke.
Collapse
Affiliation(s)
- Raeed Deen
- Department of Vascular Surgery, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Calyb Austin
- Department of Vascular Surgery, Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Andrew Bullen
- Department of Vascular Surgery, Wollongong Hospital, Wollongong, New South Wales, Australia
| |
Collapse
|
8
|
Hashimoto Y, Matsushige T, Kawano R, Yoshiyama M, Hara T, Kobayashi S, Ono C, Sakamoto S, Horie N. Headache characteristics to screen for cervicocerebral artery dissection in patients with acute onset unusual headache. Headache 2023; 63:283-289. [PMID: 36748124 DOI: 10.1111/head.14454] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 10/12/2022] [Accepted: 10/17/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES The aim of this preplanned primary analysis was to investigate the clinical manifestations of headache to screen for CAD patients with acute onset headache only. BACKGROUND Spontaneous cervicocerebral artery dissection (CAD) with acute onset headache is not rare in clinical practice; however, it is underdiagnosed. On the other hand, subsequent infarction or subarachnoid hemorrhage mainly occurs within 1 week of headache onset. METHODS Between April 2017 and January 2022, we conducted a single-center, cross-sectional retrospective study on 197 consecutive referred patients from neurosurgical outpatient clinics with acute onset unusual headache (stronger or longer headache than usual). All patients underwent magnetic resonance imaging to screen for secondary headache and were diagnosed based on the diagnostic protocol. We examined patient background data and the following headache characteristics: distribution, condition at the onset of headache, accompanying vomiting or nausea, worsening headache, and analgesic effects against headache. These factors were analyzed to identify independent diagnostic predictors of CAD. In this study, the rate of missing data was 41% for improvement of headache by analgesia and multiple imputation by chained equations was performed. RESULTS A total of 93 patients (46 men and 47 women; mean age: 48 years, range: 25-73 years) were diagnosed with CAD. Univariate logistic regression analysis showed CAD was associated with current smoking, systolic blood pressure >140 mmHg, unilateral headache, worsening headache, and no headache improvement by analgesia. Unilateral, worsening headache and no headache improvement by analgesia remained independent diagnostic predictors in multivariable logistic regression after multiple imputation. No headache improvement by analgesia had the highest sensitivity (86%), while worsening headache had the highest specificity (84%). CONCLUSIONS CAD needs to be considered in patients with unilateral, worsening headache and no headache improvement by analgesia.
Collapse
Affiliation(s)
- Yukishige Hashimoto
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Toshinori Matsushige
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Reo Kawano
- Innovation Center for Translational Research, National Center for Geriatrics and Gerontology, Obu, Japan
| | - Michitsura Yoshiyama
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Takeshi Hara
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Shohei Kobayashi
- Department of Neurosurgery and Interventional Neuroradiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Chiaki Ono
- Department of Radiology, Hiroshima City North Medical Center Asa Citizens Hospital, Hiroshima, Japan
| | - Shigeyuki Sakamoto
- Department of Neurosurgery Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Nobutaka Horie
- Department of Neurosurgery Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| |
Collapse
|
9
|
Liberman AL, Zhang C, Lipton RB, Kamel H, Parikh NS, Navi BB, Segal AZ, Razzak J, Newman-Toker DE, Merkler AE. Short-term stroke risk after emergency department treat-and-release headache visit. Headache 2022; 62:1198-1206. [PMID: 36073865 PMCID: PMC10041409 DOI: 10.1111/head.14387] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 08/02/2022] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To evaluate whether patients discharged to home after an emergency department (ED) visit for headache face a heightened short-term risk of stroke. BACKGROUND Stroke hospitalizations that occur soon after ED visits for headache complaints may reflect diagnostic error. METHODS We conducted a retrospective cohort study using statewide administrative claims data for all ED visits and admissions at nonfederal hospitals in Florida 2005-2018 and New York 2005-2016. Using standard International Classification of Diseases (ICD) codes, we identified adult patients discharged to home from the ED (treat-and-release visit) with a benign headache diagnosis (cohort of interest) as well as those with a diagnosis of renal colic or back pain (negative controls). The primary study outcome was hospitalization within 30 days for stroke (ischemic or hemorrhagic) defined using validated ICD codes. We assess the relationship between index ED visit discharge diagnosis and stroke hospitalization adjusting for patient demographics and vascular comorbidities. RESULTS We identified 1,502,831 patients with an ED treat-and-release headache visit; mean age was 41 (standard deviation: 17) years and 1,044,520 (70%) were female. A total of 2150 (0.14%) patients with headache were hospitalized for stroke within 30 days. In adjusted analysis, stroke risk was higher after headache compared to renal colic (hazard ratio [HR]: 2.69; 95% confidence interval [CI]: 2.29-3.16) or back pain (HR: 4.0; 95% CI: 3.74-4.3). In the subgroup of 26,714 (1.78%) patients with headache who received brain magnetic resonance imaging at index ED visit, stroke risk was only slightly elevated compared to renal colic (HR: 1.47; 95% CI: 1.22-1.78) or back pain (HR: 1.49; 95% CI: 1.24-1.80). CONCLUSION Approximately 1 in 700 patients discharged to home from the ED with a headache diagnosis had a stroke in the following month. Stroke risk was three to four times higher after an ED visit for headache compared to renal colic or back pain.
Collapse
Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Junaid Razzak
- Department of Emergency Medicine, Weill Cornell Medicine, New York, New York, USA
| | - David E Newman-Toker
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Epidemiology and Health Policy & Management, The Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA.,Department of Otolaryngology and Emergency Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| |
Collapse
|
10
|
Ebrahimzadeh SA, Manzoor K, Edlow JA, Selim M, Chang YM, Bhadelia RA, Mehta P. Diagnostic yield of CT angiography performed for suspected cervical artery dissection in the emergency department. Emerg Radiol 2022; 29:825-832. [DOI: 10.1007/s10140-022-02065-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 05/22/2022] [Indexed: 11/24/2022]
|
11
|
Witsch J, Mir SA, Parikh NS, Murthy SB, Kamel H, Navi BB, Segal AZ, Fink ME, Rutrick SB, Safford MM, Narula N, Goyal P, Gaudino M, Girardi LN, Devereux RB, Roman MJ, Zhang C, Merkler AE. Association Between Cervical Artery Dissection and Aortic Dissection. Circulation 2021; 144:840-842. [PMID: 34491775 DOI: 10.1161/circulationaha.121.055274] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jens Witsch
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Saad A Mir
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Matthew E Fink
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Stephanie B Rutrick
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Monika M Safford
- Division of Cardiology, Department of Medicine (M.M.S., N.N., P.G., R.B.D., M.J.R.), Weill Cornell Medical College, New York
| | - Nupoor Narula
- Division of Cardiology, Department of Medicine (M.M.S., N.N., P.G., R.B.D., M.J.R.), Weill Cornell Medical College, New York
| | - Parag Goyal
- Division of Cardiology, Department of Medicine (M.M.S., N.N., P.G., R.B.D., M.J.R.), Weill Cornell Medical College, New York
| | - Mario Gaudino
- Department of Cardiothoracic Surgery (M.G., L.N.G.), Weill Cornell Medical College, New York
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery (M.G., L.N.G.), Weill Cornell Medical College, New York
| | - Richard B Devereux
- Division of Cardiology, Department of Medicine (M.M.S., N.N., P.G., R.B.D., M.J.R.), Weill Cornell Medical College, New York
| | - Mary J Roman
- Division of Cardiology, Department of Medicine (M.M.S., N.N., P.G., R.B.D., M.J.R.), Weill Cornell Medical College, New York
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.A.M., N.S.P., S.B.M., H.K., B.B.N., A.Z.S., M.E.F., S.B.R., C.Z., A.E.M.), Weill Cornell Medical College, New York
| |
Collapse
|
12
|
Liberman AL, Lu J, Wang C, Cheng NT, Moncrieffe K, Lipton RB. Factors associated with hospitalization for ischemic stroke and TIA following an emergency department headache visit. Am J Emerg Med 2020; 46:503-507. [PMID: 33191047 DOI: 10.1016/j.ajem.2020.10.082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 10/06/2020] [Accepted: 10/31/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Misdiagnosis of cerebrovascular disease among Emergency Department (ED) patients with headache has been reported. We hypothesized that markers of substandard diagnostic processes would be associated with subsequent ischemic cerebrovascular events among patients discharged from the ED with a headache diagnosis even after adjusting for demographic variables and medical history. METHODS We conducted a case-control study of adult ED patients diagnosed with a primary headache disorder at Montefiore Medical Center from 9/1/2013-9/1/2018. Cases were defined as patients hospitalized for an ischemic stroke or TIA within 365 days of their index ED visit. Control patients were defined as those who lacked a subsequent hospitalization for cerebrovascular disease. Pre-specified demographic, clinical, and diagnostic process factors were compared between groups; conditional logistic regression was used to assess the separate and joint influence of baseline features on risk of cerebral ischemia. RESULTS A total of 93 consecutive headache patients with a subsequent ischemic stroke/TIA hospitalization were matched to 93 controls (n = 186). Cases were older than controls and more likely to have traditional cerebrovascular risk factors. Neurological consultation was obtained more often for cases (13% vs. 4%; P = 0.03), cases were in the ED for longer (6 vs. 5 h, P = 0.03), and more frequently received neuroimaging (80% vs. 48%; P < 0.0001). Rates of neurological examination, documented differential diagnoses, and clear discharge follow up plans were similar between cases and controls. In our conditional logistic regression model, only history of prior stroke/TIA was associated with increased odds of subsequent cerebral ischemia. CONCLUSION Factors associated with diagnostic process failures did not increase the odds of subsequent ischemic stroke/TIA hospitalization following ED headache visit in our study.
Collapse
Affiliation(s)
- Ava L Liberman
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Jenny Lu
- Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY, United States of America.
| | - Cuiling Wang
- Department of Biostatistics, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Natalie T Cheng
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Khadean Moncrieffe
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| | - Richard B Lipton
- Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America.
| |
Collapse
|