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Ntaios G, Baumgartner H, Doehner W, Donal E, Edvardsen T, Healey JS, Iung B, Kamel H, Kasner SE, Korompoki E, Navi BB, Pristipino C, Saba L, Schnabel RB, Svennberg E, Lip GYH. Embolic strokes of undetermined source: a clinical consensus statement of the ESC Council on Stroke, the European Association of Cardiovascular Imaging and the European Heart Rhythm Association of the ESC. Eur Heart J 2024; 45:1701-1715. [PMID: 38685132 DOI: 10.1093/eurheartj/ehae150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2024] Open
Abstract
One in six ischaemic stroke patients has an embolic stroke of undetermined source (ESUS), defined as a stroke with unclear aetiology despite recommended diagnostic evaluation. The overall cardiovascular risk of ESUS is high and it is important to optimize strategies to prevent recurrent stroke and other cardiovascular events. The aim of clinicians when confronted with a patient not only with ESUS but also with any other medical condition of unclear aetiology is to identify the actual cause amongst a list of potential differential diagnoses, in order to optimize secondary prevention. However, specifically in ESUS, this may be challenging as multiple potential thromboembolic sources frequently coexist. Also, it can be delusively reassuring because despite the implementation of specific treatments for the individual pathology presumed to be the actual thromboembolic source, patients can still be vulnerable to stroke and other cardiovascular events caused by other pathologies already identified during the index diagnostic evaluation but whose thromboembolic potential was underestimated. Therefore, rather than trying to presume which particular mechanism is the actual embolic source in an ESUS patient, it is important to assess the overall thromboembolic risk of the patient through synthesis of the individual risks linked to all pathologies present, regardless if presumed causally associated or not. In this paper, a multi-disciplinary panel of clinicians/researchers from various backgrounds of expertise and specialties (cardiology, internal medicine, neurology, radiology and vascular surgery) proposes a comprehensive multi-dimensional assessment of the overall thromboembolic risk in ESUS patients through the composition of individual risks associated with all prevalent pathologies.
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Affiliation(s)
- George Ntaios
- Department of Internal Medicine, School of Health Sciences, University of Thessaly, Larissa University Hospital, Larissa 41132, Greece
| | - Helmut Baumgartner
- Department of Cardiology III: Adult Congenital and Valvular Heart Disease, University Hospital Muenster, Muenster, Germany
| | - Wolfram Doehner
- Department of Cardiology (Campus Virchow), Center of Stroke Research Berlin, German Centre for Cardiovascular Research (DZHK) partner site Berlin, Berlin Institute of Health-Center for Regenerative Therapies, Deutsches Herzzentrum der Charité, Charité, Berlin, Germany
| | - Erwan Donal
- Service de Cardiologie et CIC-IT 1414, CHU Rennes, Rennes, France
| | - Thor Edvardsen
- Department of Cardiology, Faculty of Medicine, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Jeff S Healey
- Cardiology Division, McMaster University, Hamilton, Canada
| | - Bernard Iung
- Bichat Hospital, APHP and Université Paris-Cité, INSERM LVTS U1148, Paris, France
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Scott E Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Eleni Korompoki
- Department of Clinical Therapeutics, Alexandra Hospital, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Christian Pristipino
- Interventional and Intensive Cardiology Unit, San Filippo Neri Hospital, ASL Roma 1, Rome, Italy
| | - Luca Saba
- Department of Radiology, Azienda Ospedaliero Universitaria (A.O.U.), di Cagliari-Polo di Monserrato, Cagliari, Italy
| | - Renate B Schnabel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- DZHK (German Center for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Germany
| | - Emma Svennberg
- Department of Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University, Liverpool Heart & Chest Hospital, Liverpool, UK
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
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Lee HJ, Schwamm LH, Sansing LH, Kamel H, de Havenon A, Turner AC, Sheth KN, Krishnaswamy S, Brandt C, Zhao H, Krumholz H, Sharma R. StrokeClassifier: ischemic stroke etiology classification by ensemble consensus modeling using electronic health records. NPJ Digit Med 2024; 7:130. [PMID: 38760474 PMCID: PMC11101464 DOI: 10.1038/s41746-024-01120-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 04/23/2024] [Indexed: 05/19/2024] Open
Abstract
Determining acute ischemic stroke (AIS) etiology is fundamental to secondary stroke prevention efforts but can be diagnostically challenging. We trained and validated an automated classification tool, StrokeClassifier, using electronic health record (EHR) text from 2039 non-cryptogenic AIS patients at 2 academic hospitals to predict the 4-level outcome of stroke etiology adjudicated by agreement of at least 2 board-certified vascular neurologists' review of the EHR. StrokeClassifier is an ensemble consensus meta-model of 9 machine learning classifiers applied to features extracted from discharge summary texts by natural language processing. StrokeClassifier was externally validated in 406 discharge summaries from the MIMIC-III dataset reviewed by a vascular neurologist to ascertain stroke etiology. Compared with vascular neurologists' diagnoses, StrokeClassifier achieved the mean cross-validated accuracy of 0.74 and weighted F1 of 0.74 for multi-class classification. In MIMIC-III, its accuracy and weighted F1 were 0.70 and 0.71, respectively. In binary classification, the two metrics ranged from 0.77 to 0.96. The top 5 features contributing to stroke etiology prediction were atrial fibrillation, age, middle cerebral artery occlusion, internal carotid artery occlusion, and frontal stroke location. We designed a certainty heuristic to grade the confidence of StrokeClassifier's diagnosis as non-cryptogenic by the degree of consensus among the 9 classifiers and applied it to 788 cryptogenic patients, reducing cryptogenic diagnoses from 25.2% to 7.2%. StrokeClassifier is a validated artificial intelligence tool that rivals the performance of vascular neurologists in classifying ischemic stroke etiology. With further training, StrokeClassifier may have downstream applications including its use as a clinical decision support system.
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Affiliation(s)
- Ho-Joon Lee
- Department of Genetics and Yale Center for Genome Analysis, Yale School of Medicine, New Haven, CT, USA.
| | - Lee H Schwamm
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital and Harvard Medical School Boston, Boston, MA, USA
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Lauren H Sansing
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York City, NY, USA
| | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Ashby C Turner
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital and Harvard Medical School Boston, Boston, MA, USA
| | - Kevin N Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Smita Krishnaswamy
- Departments of Genetics and Computer Science, Yale School of Medicine, New Haven, CT, USA
| | - Cynthia Brandt
- Department of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT, USA
| | - Hongyu Zhao
- Departments of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Harlan Krumholz
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
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Kamel H, Tirschwell DL, Elkind MSV. Apixaban to Prevent Recurrence After Cryptogenic Stroke-Reply. JAMA 2024:2818625. [PMID: 38739409 DOI: 10.1001/jama.2024.6855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/14/2024]
Affiliation(s)
- Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York
| | | | - Mitchell S V Elkind
- Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York, New York
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Liberman AL, Razzak J, Lappin RI, Navi BB, Bruce SS, Liao V, Kaiser JH, Ng C, Segal AZ, Kamel H. Risk of Major Adverse Cardiovascular Events After Emergency Department Visits for Hypertensive Urgency. Hypertension 2024. [PMID: 38660784 DOI: 10.1161/hypertensionaha.124.22885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/28/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Chronic hypertension is an established long-term risk factor for major adverse cardiovascular events (MACEs). However, little is known about short-term MACE risk after hypertensive urgency, defined as an episode of acute severe hypertension without evidence of target-organ damage. We sought to evaluate the short-term risk of MACE after an emergency department (ED) visit for hypertensive urgency resulting in discharge to home. METHODS We performed a case-crossover study using deidentified administrative claims data. Our case periods were 1-week intervals from 0 to 12 weeks before hospitalization for MACE. We compared ED visits for hypertensive urgency during these case periods versus equivalent control periods 1 year earlier. Hypertensive urgency and MACE components were all ascertained using previously validated International Classification of Diseases, Tenth Revision Clinical Modification codes. We used McNemar test for matched data to calculate risk ratios. RESULTS Among 2 225 722 patients with MACE, 1 893 401 (85.1%) had a prior diagnosis of hypertension. There were 4644 (0.2%) patients who had at least 1 ED visit for hypertensive urgency during the 12 weeks preceding their MACE hospitalization. An ED visit for hypertensive urgency was significantly more common in the first week before MACE compared with the same chronological week 1 year earlier (risk ratio, 3.5 [95% CI, 2.9-4.2]). The association between hypertensive urgency and MACE decreased in magnitude with increasing temporal distance from MACE and was no longer significant by 11 weeks before MACE (risk ratio, 1.2 [95% CI, 0.99-1.6]). CONCLUSIONS ED visits for hypertensive urgency were associated with a substantially increased short-term risk of subsequent MACE.
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Affiliation(s)
- Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | | | | | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Samuel S Bruce
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Vanessa Liao
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Jed H Kaiser
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Catherine Ng
- Information Technologies and Services Department, Weill Cornell Medicine, New York (C.N.)
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute (A.L.L., B.B.N., S.S.B., V.L., J.H.K., A.Z.S., H.K.)
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Wechsler PM, Pandya A, Parikh NS, Razzak JA, White H, Navi BB, Kamel H, Liberman AL. Cost-Effectiveness of Increased Use of Dual Antiplatelet Therapy After High-Risk Transient Ischemic Attack or Minor Stroke. J Am Heart Assoc 2024; 13:e032808. [PMID: 38533952 DOI: 10.1161/jaha.123.032808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/14/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Rates of dual antiplatelet therapy (DAPT) after high-risk transient ischemic attack or minor ischemic stroke (TIAMIS) are suboptimal. We performed a cost-effectiveness analysis to characterize the parameters of a quality improvement (QI) intervention designed to increase DAPT use after TIAMIS. METHODS AND RESULTS We constructed a decision tree model that compared current national rates of DAPT use after TIAMIS with rates after implementing a theoretical QI intervention designed to increase appropriate DAPT use. The base case assumed that a QI intervention increased the rate of DAPT use to 65% from 45%. Costs (payer and societal) and outcomes (stroke, myocardial infarction, major bleed, or death) were modeled using a lifetime horizon. An incremental cost-effectiveness ratio <$100 000 per quality-adjusted life year was considered cost-effective. Deterministic and probabilistic sensitivity analyses were performed. From the payer perspective, a QI intervention was associated with $9657 in lifetime cost savings and 0.18 more quality-adjusted life years compared with current national treatment rates. A QI intervention was cost-effective in 73% of probabilistic sensitivity analysis iterations. Results were similar from the societal perspective. The maximum acceptable, initial, 1-time payer cost of a QI intervention was $28 032 per patient. A QI intervention that increased DAPT use to at least 51% was cost-effective in the base case. CONCLUSIONS Increasing DAPT use after TIAMIS with a QI intervention is cost-effective over a wide range of costs and proportion of patients with TIAMIS treated with DAPT after implementation of a QI intervention. Our results support the development of future interventions focused on increasing DAPT use after TIAMIS.
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Affiliation(s)
- Paul M Wechsler
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Ankur Pandya
- Department of Health Policy and Management Harvard T.H. Chan School of Public Health Boston MA
| | - Neal S Parikh
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Junaid A Razzak
- Department of Emergency Medicine Weill Cornell Medicine New York NY
| | - Halina White
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Babak B Navi
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Hooman Kamel
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
| | - Ava L Liberman
- Department of Neurology, Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute, Weill Cornell Medicine New York NY
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Kaleem S, Zhang C, Gusdon AM, Oh S, Merkler AE, Avadhani R, Awad I, Hanley DF, Kamel H, Ziai WC, Murthy SB. Association Between Neutrophil-Lymphocyte Ratio and 30-Day Infection and Thrombotic Outcomes After Intraventricular Hemorrhage: A CLEAR III Analysis. Neurocrit Care 2024; 40:529-537. [PMID: 37349600 DOI: 10.1007/s12028-023-01774-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 06/02/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Serum neutrophil-lymphocyte ratio (NLR) is a surrogate marker for the inflammatory response after intracerebral hemorrhage (ICH) and is associated with perihematomal edema and long-term functional outcomes. Whether NLR is associated with short-term ICH complications is poorly understood. We hypothesized that NLR is associated with 30-day infection and thrombotic events after ICH. METHODS We performed a post hoc exploratory analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial. The study exposure was the serum NLR obtained at baseline and on days 3 and 5. The coprimary outcomes, ascertained at 30 days, were any infection and a thrombotic event, defined as composite of cerebral infarction, myocardial infarction, or venous thromboembolism; both infection and thrombotic event were determined through adjudicated adverse event reporting. Binary logistic regression was used to study the relationship between NLR and outcomes, after adjustment for demographics, ICH severity and location, and treatment randomization. RESULTS Among the 500 patients enrolled in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage III trial, we included 303 (60.6%) without missing data on differential white blood cell counts at baseline. There were no differences in demographics, comorbidities, or ICH severity between patients with and without data on NLR. In adjusted logistic regression models, NLR ascertained at baseline (odds ratio [OR] 1.03; 95% confidence interval [CI] 1.01-1.07, p = 0.03) and NLR ascertained at day 3 were associated with infection (OR 1.15; 95% CI 1.05-1.20, p = 0.001) but not with thrombotic events. Conversely, NLR at day 5 was associated with thrombotic events (OR 1.07, 95% CI 1.01-1.13, p = 0.03) but not with infection (OR 1.13; 95% CI 0.76-1.70, p = 0.56). NLR at baseline was not associated with either outcome. CONCLUSIONS Serum NLR ascertained at baseline and on day 3 after randomization was associated with 30-day infection, whereas NLR obtained on day 5 was associated with thrombotic events after ICH, suggesting that NLR could be a potential early biomarker for ICH-related complications.
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Affiliation(s)
- Safa Kaleem
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Aaron M Gusdon
- Department of Neurological Surgery, University of Texas Health Science Center, Houston, TX, USA
| | - Stephanie Oh
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Isaam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL, USA
| | - Daniel F Hanley
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Wendy C Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago, IL, USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA.
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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Bruce SS, Murthy S, Kamel H. Validation of International Classification of Diseases, 10thEdition, Clinical Modification (ICD-10-CM) Code I68.0 for Cerebral Amyloid Angiopathy. medRxiv 2024:2024.01.16.24301394. [PMID: 38293044 PMCID: PMC10827277 DOI: 10.1101/2024.01.16.24301394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Introduction Cerebral amyloid angiopathy (CAA) is a common cause of intracerebral hemorrhage and cognitive impairment in the elderly. Though definitive diagnosis requires post-mortem pathological analysis, clinical and radiographic criteria allow for noninvasive, in vivo diagnosis. We sought to validate the new ICD-10-CM diagnostic code for CAA with respect to the recently updated Boston criteria, version 2.0. Methods We conducted a retrospective study of inpatient and outpatient encounters at a single hospital center, Weill Cornell Medicine (WCM), from 10/1/2015 to 12/31/2018. We randomly selected 25 encounters with the ICD-10-CM code I68.0 and 25 encounters with a primary diagnosis of intracerebral hemorrhage or ischemic stroke, without code I68.0. A single board-certified neurologist, blinded to ICD codes, reviewed detailed medical records and images from brain MRI and CT scans from all 50 selected encounters and identified subjects with possible or probable CAA by Boston criteria 2.0. Sensitivity and specificity of ICD-10-CM code I68.0 was calculated. Results Of the 50 selected encounters, 21 (42%) met criteria for possible or probable CAA: 18 (36%) met criteria for probable CAA, 2 (4%) met criteria for probable CAA with supporting pathology, and 1 (2%) met criteria for possible CAA. The ICD-10-CM code I68.0 was found to have a sensitivity of 81% (95% CI, 58-95%) and specificity of 72% (95% CI, 53-87%) for identifying possible or probable CAA. Conclusion The ICD-10-CM code I68.0 was found to have good sensitivity and moderate specificity for CAA as defined by current clinical and radiographic diagnostic criteria. Based on our results, this code may be useful for identifying patients with CAA in future research using administrative claims data.
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Affiliation(s)
- Samuel S. Bruce
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
| | - Santosh Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine
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Mears J, Kaleem S, Panchamia R, Kamel H, Tam C, Thalappillil R, Murthy S, Merkler AE, Zhang C, Ch'ang JH. Leveraging the Capabilities of AI: Novice Neurology-Trained Operators Performing Cardiac POCUS in Patients with Acute Brain Injury. Neurocrit Care 2024:10.1007/s12028-024-01953-z. [PMID: 38506968 DOI: 10.1007/s12028-024-01953-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 02/01/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Cardiac point-of-care ultrasound (cPOCUS) can aid in the diagnosis and treatment of cardiac disorders. Such disorders can arise as complications of acute brain injury, but most neurologic intensive care unit (NICU) providers do not receive formal training in cPOCUS. Caption artificial intelligence (AI) uses a novel deep learning (DL) algorithm to guide novice cPOCUS users in obtaining diagnostic-quality cardiac images. The primary objective of this study was to determine how often NICU providers with minimal cPOCUS experience capture quality images using DL-guided cPOCUS as well as the association between DL-guided cPOCUS and change in management and time to formal echocardiograms in the NICU. METHODS From September 2020 to November 2021, neurology-trained physician assistants, residents, and fellows used DL software to perform clinically indicated cPOCUS scans in an academic tertiary NICU. Certified echocardiographers evaluated each scan independently to assess the quality of images and global interpretability of left ventricular function, right ventricular function, inferior vena cava size, and presence of pericardial effusion. Descriptive statistics with exact confidence intervals were used to calculate proportions of obtained images that were of adequate quality and that changed management. Time to first adequate cardiac images (either cPOCUS or formal echocardiography) was compared using a similar population from 2018. RESULTS In 153 patients, 184 scans were performed for a total of 943 image views. Three certified echocardiographers deemed 63.4% of scans as interpretable for a qualitative assessment of left ventricular size and function, 52.6% of scans as interpretable for right ventricular size and function, 34.8% of scans as interpretable for inferior vena cava size and variability, and 47.2% of scans as interpretable for the presence of pericardial effusion. Thirty-seven percent of screening scans changed management, most commonly adjusting fluid goals (81.2%). Time to first adequate cardiac images decreased significantly from 3.1 to 1.7 days (p < 0.001). CONCLUSIONS With DL guidance, neurology providers with minimal to no cPOCUS training were often able to obtain diagnostic-quality cardiac images, which informed management changes and significantly decreased time to cardiac imaging.
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Affiliation(s)
- Jennifer Mears
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Safa Kaleem
- Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Rohan Panchamia
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, F610, New York, NY, 10065, USA
| | - Chris Tam
- Department of Anesthesiology, Weill Cornell Medicine, New York, NY, USA
| | | | - Santosh Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, F610, New York, NY, 10065, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, F610, New York, NY, 10065, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, F610, New York, NY, 10065, USA
| | - Judy H Ch'ang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, 525 East 68th Street, F610, New York, NY, 10065, USA.
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Harris W, Kaiser JH, Liao V, Avadhani R, Iadecola C, Falcone GJ, Sheth KN, Qureshi AI, Goldstein JN, Awad I, Hanley DF, Kamel H, Ziai WC, Murthy SB. Association Between Hematoma Volume and Risk of Subsequent Ischemic Stroke: A MISTIE III and ATACH-2 Analysis. Stroke 2024; 55:541-547. [PMID: 38299346 PMCID: PMC10932908 DOI: 10.1161/strokeaha.123.045859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 01/17/2024] [Indexed: 02/02/2024]
Abstract
BACKGROUND Nontraumatic intracerebral hemorrhage (ICH) is independently associated with a long-term increased risk of major arterial ischemic events. While the relationship between ICH location and ischemic risk has been studied, whether hematoma volume influences this risk is poorly understood. METHODS We pooled individual patient data from the MISTIE III (Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation Phase 3) and the ATACH-2 (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) trials. The exposure was hematoma volume, treated as a continuous measure in the primary analysis, and dichotomized by the median in the secondary analyses. The outcome was a symptomatic, clinically overt ischemic stroke, adjudicated centrally within each trial. We evaluated the association between hematoma volume and the risk of an ischemic stroke using Cox regression analyses after adjustment for demographics, vascular comorbidities, and ICH characteristics. RESULTS Of 1470 patients with ICH, the mean age was 61.7 (SD, 12.8) years, and 574 (38.3%) were female. The median hematoma volume was 17.3 mL (interquartile range, 7.2-35.7). During a median follow-up of 107 days (interquartile range, 91-140), a total of 30 ischemic strokes occurred, of which 22 were in patients with a median ICH volume of ≥17.3 mL and a cumulative incidence of 4.6% (95% CI, 3.1-7.1). Among patients with a median ICH volume <17.3 mL, there were 8 ischemic strokes with a cumulative incidence of 3.1% (95% CI, 1.7-6.0). In primary analyses using adjusted Cox regression models, ICH volume was associated with an increased risk of ischemic stroke (hazard ratio, 1.02 per mL increase [95% CI, 1.01-1.04]). In secondary analyses, ICH volume of ≥17.3 mL was associated with an increased risk of ischemic stroke (hazard ratio, 2.5 [95% CI, 1.1-7.2]), compared with those with an ICH volume <17.3 mL. CONCLUSIONS In a heterogeneous cohort of patients with ICH, initial hematoma volume was associated with a heightened short-term risk of ischemic stroke.
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Affiliation(s)
- William Harris
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Jed H. Kaiser
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Vanessa Liao
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Radhika Avadhani
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Guido J. Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Institutes and Department of Neurology, University of Missouri, Columbia, MO
| | - Joshua N. Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago, IL
| | - Daniel F. Hanley
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Wendy C. Ziai
- Brain Injury Outcomes Center, Johns Hopkins University, Baltimore, MD
- Division of Neurosciences Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
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10
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de Havenon A, Zhou LW, Koo AB, Matouk C, Falcone GJ, Sharma R, Ney J, Shu L, Yaghi S, Kamel H, Sheth KN. Endovascular Treatment of Acute Ischemic Stroke After Cardiac Interventions in the United States. JAMA Neurol 2024; 81:264-272. [PMID: 38285452 PMCID: PMC10825786 DOI: 10.1001/jamaneurol.2023.5416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/25/2023] [Indexed: 01/30/2024]
Abstract
Importance Ischemic stroke is a serious complication of cardiac intervention, including surgery and percutaneous procedures. Endovascular thrombectomy (EVT) is an effective treatment for ischemic stroke and may be particularly important for cardiac intervention patients who often cannot receive intravenous thrombolysis. Objective To examine trends in EVT for ischemic stroke during hospitalization of patients with cardiac interventions vs those without in the United States. Design, Setting, and Participants This cohort study involved a retrospective analysis using data for 4888 US hospitals from the 2016-2020 National Inpatient Sample database. Participants included adults (age ≥18 years) with ischemic stroke (per codes from the International Statistical Classification of Diseases, Tenth Revision, Clinical Modification), who were organized into study groups of hospitalized patients with cardiac interventions vs without. Individuals were excluded from the study if they had either procedure prior to admission, EVT prior to cardiac intervention, EVT more than 3 days after admission or cardiac intervention, or endocarditis. Data were analyzed from April 2023 to October 2023. Exposures Cardiac intervention during admission. Main Outcomes and Measures The odds of undergoing EVT by cardiac intervention status were calculated using multivariable logistic regression. Adjustments were made for stroke severity in the subgroup of patients who had a National Institutes of Health Stroke Scale (NIHSS) score documented. As a secondary outcome, the odds of discharge home by EVT status after cardiac intervention were modeled. Results Among 634 407 hospitalizations, the mean (SD) age of the patients was 69.8 (14.1) years, 318 363 patients (50.2%) were male, and 316 044 (49.8%) were female. A total of 12 093 had a cardiac intervention. An NIHSS score was reported in 218 576 admissions, 216 035 (34.7%) without cardiac intervention and 2541 (21.0%) with cardiac intervention (P < .001). EVT was performed in 23 660 patients (3.8%) without cardiac intervention vs 194 (1.6%) of those with cardiac intervention (P < .001). After adjustment for potential confounders, EVT was less likely to be performed in stroke patients with cardiac intervention vs those without (adjusted odds ratio [aOR], 0.27; 95% CI, 0.23-0.31), which remained consistent after adjusting for NIHSS score (aOR, 0.28; 95% CI, 0.22-0.35). Among individuals with a cardiac intervention, receiving EVT was associated with a 2-fold higher chance of discharge home (aOR, 2.21; 95% CI, 1.14-4.29). Conclusions and Relevance In this study, patients hospitalized with ischemic stroke and cardiac intervention may be less than half as likely to receive EVT as those without cardiac intervention. Given the known benefit of EVT, there is a need to better understand the reasons for lower rates of EVT in this patient population.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - Lily W. Zhou
- Department of Neurology, The University of British Columbia, Vancouver, Canada
| | - Andrew B. Koo
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut
| | - Guido J. Falcone
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - Richa Sharma
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - John Ney
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York
- Deputy Editor, JAMA Neurology
| | - Kevin N. Sheth
- Department of Neurology, Center for Brain and Mind Health, Yale University, New Haven, Connecticut
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11
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Mistry AM, Saver J, Mack W, Kamel H, Elm J, Beall J. Subarachnoid Hemorrhage Trials: Cutting, Sliding, or Keeping mRS Scores and WFNS Grades. Stroke 2024; 55:779-784. [PMID: 38235584 DOI: 10.1161/strokeaha.123.044790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Rigorous evidence generation with randomized controlled trials has lagged for aneurysmal subarachnoid hemorrhage (SAH) compared with other forms of acute stroke. Besides its lower incidence compared with other stroke subtypes, the presentation and outcome of patients with SAH also differ. This must be considered and adjusted for in designing pivotal randomized controlled trials of patients with SAH. Here, we show the effect of the unique expected distribution of the SAH severity at presentation (World Federation of Neurological Surgeons grade) on the outcome most used in pivotal stroke randomized controlled trials (modified Rankin Scale) and, consequently, on the sample size. Furthermore, we discuss the advantages and disadvantages of different options to analyze the outcome and control the expected distribution of the World Federation of Neurological Surgeons grades in addition to showing their effects on the sample size. Finally, we offer methods that investigators can adapt to more precisely understand the effect of common modified Rankin Scale analysis methods and trial eligibility pertaining to the World Federation of Neurological Surgeons grade in designing their large-scale SAH randomized controlled trials.
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Affiliation(s)
| | - Jeffrey Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (J.S.)
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles (W.M.)
| | - Hooman Kamel
- Department of Neurology, Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY (H.K.)
| | - Jordan Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., J.B.)
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston (J.E., J.B.)
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12
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Kamel H, Longstreth WT, Tirschwell DL, Kronmal RA, Marshall RS, Broderick JP, Aragón García R, Plummer P, Sabagha N, Pauls Q, Cassarly C, Dillon CR, Di Tullio MR, Hod EA, Soliman EZ, Gladstone DJ, Healey JS, Sharma M, Chaturvedi S, Janis LS, Krishnaiah B, Nahab F, Kasner SE, Stanton RJ, Kleindorfer DO, Starr M, Winder TR, Clark WM, Miller BR, Elkind MSV. Apixaban to Prevent Recurrence After Cryptogenic Stroke in Patients With Atrial Cardiopathy: The ARCADIA Randomized Clinical Trial. JAMA 2024; 331:573-581. [PMID: 38324415 PMCID: PMC10851142 DOI: 10.1001/jama.2023.27188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Accepted: 12/13/2023] [Indexed: 02/09/2024]
Abstract
Importance Atrial cardiopathy is associated with stroke in the absence of clinically apparent atrial fibrillation. It is unknown whether anticoagulation, which has proven benefit in atrial fibrillation, prevents stroke in patients with atrial cardiopathy and no atrial fibrillation. Objective To compare anticoagulation vs antiplatelet therapy for secondary stroke prevention in patients with cryptogenic stroke and evidence of atrial cardiopathy. Design, Setting, and Participants Multicenter, double-blind, phase 3 randomized clinical trial of 1015 participants with cryptogenic stroke and evidence of atrial cardiopathy, defined as P-wave terminal force greater than 5000 μV × ms in electrocardiogram lead V1, serum N-terminal pro-B-type natriuretic peptide level greater than 250 pg/mL, or left atrial diameter index of 3 cm/m2 or greater on echocardiogram. Participants had no evidence of atrial fibrillation at the time of randomization. Enrollment and follow-up occurred from February 1, 2018, through February 28, 2023, at 185 sites in the National Institutes of Health StrokeNet and the Canadian Stroke Consortium. Interventions Apixaban, 5 mg or 2.5 mg, twice daily (n = 507) vs aspirin, 81 mg, once daily (n = 508). Main Outcomes and Measures The primary efficacy outcome in a time-to-event analysis was recurrent stroke. All participants, including those diagnosed with atrial fibrillation after randomization, were analyzed according to the groups to which they were randomized. The primary safety outcomes were symptomatic intracranial hemorrhage and other major hemorrhage. Results With 1015 of the target 1100 participants enrolled and mean follow-up of 1.8 years, the trial was stopped for futility after a planned interim analysis. The mean (SD) age of participants was 68.0 (11.0) years, 54.3% were female, and 87.5% completed the full duration of follow-up. Recurrent stroke occurred in 40 patients in the apixaban group (annualized rate, 4.4%) and 40 patients in the aspirin group (annualized rate, 4.4%) (hazard ratio, 1.00 [95% CI, 0.64-1.55]). Symptomatic intracranial hemorrhage occurred in 0 patients taking apixaban and 7 patients taking aspirin (annualized rate, 1.1%). Other major hemorrhages occurred in 5 patients taking apixaban (annualized rate, 0.7%) and 5 patients taking aspirin (annualized rate, 0.8%) (hazard ratio, 1.02 [95% CI, 0.29-3.52]). Conclusions and Relevance In patients with cryptogenic stroke and evidence of atrial cardiopathy without atrial fibrillation, apixaban did not significantly reduce recurrent stroke risk compared with aspirin. Trial Registration ClinicalTrials.gov Identifier: NCT03192215.
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - W. T. Longstreth
- Department of Neurology, University of Washington, Seattle
- Department of Medicine, University of Washington, Seattle
- Department of Epidemiology, University of Washington, Seattle
| | | | | | - Randolph S. Marshall
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Joseph P. Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Rebeca Aragón García
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Pamela Plummer
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Noor Sabagha
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Qi Pauls
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Christy Cassarly
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Catherine R. Dillon
- Department of Public Health Sciences, Medical University of South Carolina, Charleston
| | - Marco R. Di Tullio
- Division of Cardiology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Eldad A. Hod
- Department of Pathology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
| | - Elsayed Z. Soliman
- Epidemiological Cardiology Research Center, Department of Internal Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - David J. Gladstone
- Sunnybrook Research Institute, Hurvitz Brain Sciences Program, Sunnybrook Health Sciences Centre, and Division of Neurology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jeff S. Healey
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Mukul Sharma
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland, and Baltimore VA Hospital, Baltimore
| | - L. Scott Janis
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Balaji Krishnaiah
- Department of Neurology, University of Tennessee Health Sciences Center, Memphis
| | - Fadi Nahab
- Departments of Neurology and Pediatrics, Emory University, Atlanta, Georgia
| | - Scott E. Kasner
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Robert J. Stanton
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Matthew Starr
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Wayne M. Clark
- Department of Neurology, Oregon Health & Science University, Portland
| | | | - Mitchell S. V. Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
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13
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Giantini-Larsen A, Zhang C, Stieg P, Kamel H. Trends in AVM-Associated Intracranial Hemorrhage in the United States, 2000-2019. JAMA Neurol 2024:2814785. [PMID: 38345797 PMCID: PMC10862264 DOI: 10.1001/jamaneurol.2023.5663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Accepted: 11/22/2023] [Indexed: 02/15/2024]
Abstract
This cross-sectional study examines whether there has been a significant change in the annual incidence of arteriovenous malformation (AVM)–associated intracranial hemorrhage among US adults over the past 2 decades.
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Affiliation(s)
- Alexandra Giantini-Larsen
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York
| | - Cenai Zhang
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York
| | - Philip Stieg
- Department of Neurological Surgery, Weill Cornell Medicine, New York Presbyterian Hospital, New York
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, New York
- Deputy Editor, JAMA Neurology
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14
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Dicpinigaitis AJ, Seitz A, Berkin J, Al-Mufti F, Kamel H, Navi BB, Pawar A, White H, Liberman AL. Association of Assisted Reproductive Technology and Stroke During Hospitalization for Delivery in the United States. Stroke 2024. [PMID: 38299332 DOI: 10.1161/strokeaha.124.046419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/31/2024] [Indexed: 02/02/2024]
Abstract
Background: Infertility treatment with assisted reproductive technologies (ART) has been associated with adverse vascular events in some, but not all previous studies. Endothelial damage, prothrombotic factor release, and a higher prevalence of cardiovascular risk factors in those receiving ART have been invoked to explain this association. We sought to explore the relationship between ART and stroke risk using population-level data. Methods: We conducted a retrospective cohort study using data from the National Inpatient Sample (NIS) registry from 2015-2020, including all delivery hospitalizations for patients aged 15-55 years. The study exposure was use of ART. The primary endpoint was any stroke defined as ischemic stroke (IS), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), or cerebral venous thrombosis (CVT) during index delivery hospitalization. Individual stroke subtypes (IS, SAH, ICH, and CVT) were evaluated as secondary endpoints. Standard International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) algorithms were used to define study exposure, comorbidities, and prespecified endpoints. In addition to reporting population-level estimates, propensity score (PS) adjustment by inverse probability weighting (IPW) was used to mimic the effects of randomization by balancing baseline clinical characteristics associated with stroke between ART and non-ART users. Results: Among 19,123,125 delivery hospitalizations identified, patients with prior ART (n = 202,815, 1.1%) experienced significantly higher rates of any stroke (27.1/100,000 vs. 9.1/100,000), IS (9.9/100,000 vs. 3.3/100,000), SAH (7.4/100,000 vs. 1.6/100,000), ICH (7.4/100,000 vs. 2.0/100,000), and CVT (7.4/100,000 vs. 2.7/100,000) in comparison to non-ART users (all p < 0.001 for all unadjusted comparisons). Following IPW analysis, ART was associated with increased odds of any stroke (aOR 2.14 [95% CI 2.02-2.26]; p < 0.001). Conclusion: Using population-level data among patients hospitalized for delivery in the United States, we found an association between ART and stroke after adjustment for measured confounders.
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Affiliation(s)
| | - Alison Seitz
- Neurology, New York Presbyterian Hospital - Weill Cornell Medical College, UNITED STATES
| | | | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, UNITED STATES
| | - Hooman Kamel
- Neurology, Weill Cornell Medical College, UNITED STATES
| | - Babak Benjamin Navi
- Neurology and Brain and Mind Research Institute, Weill Cornell Medicine, UNITED STATES
| | | | - Halina White
- Neurology, Weill Cornell Medicine, UNITED STATES
| | - Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, UNITED STATES
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15
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Garton ALA, Oh SE, Müller A, Avadhani R, Zhang C, Merkler AE, Awad I, Hanley D, Kamel H, Ziai WC, Murthy SB. Catheter Tract Hemorrhages and Intracerebral Hemorrhage Outcomes in the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage Trial. Neurosurgery 2024; 94:334-339. [PMID: 37721435 DOI: 10.1227/neu.0000000000002687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/27/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Factors associated with external ventricular catheter tract hemorrhage (CTH) are well studied; whether CTH adversely influence outcomes after intracerebral hemorrhage (sICH), however, is poorly understood. We therefore sought to evaluate the association between CTH and sICH outcomes. METHODS We performed a post hoc analysis of the Clot Lysis: Evaluating Accelerated Resolution of Intraventricular Hemorrhage trial. The exposure was CTH and evaluated on serial computed tomography scans between admission and randomization (approximately 72 hours). The primary outcomes were a composite of death or major disability (modified Rankin Score >3) and mortality alone, both assessed at 6 months. Secondary outcomes were functional outcomes at 30 days, permanent cerebrospinal fluid (CSF) shunt placement, any infection, and ventriculitis. We performed logistic regression adjusted for demographics, comorbidities, sICH characteristics, and treatment assignment, for all analyses. RESULTS Of the 500 patients included, the mean age was 59 (SD, ±11) years and 222 (44%) were female. CTH occurred in 112 (22.4%) patients and was more common in minority patients, those on prior antiplatelet therapy, and patients who had more than 1 external ventricular drain placed. The end of treatment intraventricular hemorrhage volume was higher among patients with CTH (11.7 vs 7.9 mL, P = .01), but there were no differences in other sICH characteristics or the total duration of external ventricular drain. In multivariable regression models, CTH was not associated with death or major disability (odds ratio, 0.7; 95% CI: 0.4-1.2) or death alone (odds ratio, 0.8; 95% CI, 0.5-1.4). There were no relationships between CTH and secondary outcomes including 30-day functional outcomes, permanent CSF shunt placement, any infection, or ventriculitis. CONCLUSION Among patients with sICH and large intraventricular hemorrhage, CTH was not associated with poor sICH outcomes, permanent CSF shunt placement, or infections. A more detailed cognitive evaluation is needed to inform about the role of CTH in sICH prognosis.
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Affiliation(s)
- Andrew L A Garton
- Department of Neurological Surgery, Weill Cornell Medicine, New York , New York , USA
| | - Stephanie E Oh
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Achim Müller
- Department of Neurology, Clinical Neuroscience Center, University Hospital Zurich and University of Zurich, Zurich , Switzerland
| | - Radhika Avadhani
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Issam Awad
- Department of Neurological Surgery, University of Chicago School of Medicine, Chicago , Illinois , USA
| | - Daniel Hanley
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
| | - Wendy C Ziai
- Brain Injury Outcomes Division, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
- Division of Neurosciences Critical Care, Department of Neurology, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit and Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York , New York , USA
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16
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Rivier CA, Kamel H, Sheth KN, Iadecola C, Gupta A, de Leon MJ, Ross E, Falcone GJ, Murthy SB. Cerebral Amyloid Angiopathy and Risk of Isolated Nontraumatic Subdural Hemorrhage. JAMA Neurol 2024; 81:163-169. [PMID: 38147345 PMCID: PMC10751656 DOI: 10.1001/jamaneurol.2023.4918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 10/29/2023] [Indexed: 12/27/2023]
Abstract
Importance Cerebral amyloid angiopathy (CAA) is a common cause of spontaneous intracerebral hemorrhage in older patients. Although other types of intracranial hemorrhage can occur in conjunction with CAA-related intracerebral hemorrhage, the association between CAA and other subtypes of intracranial hemorrhage, particularly in the absence of intracerebral hemorrhage, remains poorly understood. Objective To determine whether CAA is an independent risk factor for isolated nontraumatic subdural hemorrhage (SDH). Design, Setting, and Participants A population-based cohort study was performed using a 2-stage analysis of prospectively collected data in the UK Biobank cohort (discovery phase, 2006-2022) and the All of Us Research Program cohort (replication phase, 2018-2022). Participants included those who contributed at least 1 year of data while they were older than 50 years, in accordance with the diagnostic criteria for CAA. Participants with prevalent intracranial hemorrhage were excluded. Data were analyzed from October 2022 to October 2023. Exposure A diagnosis of CAA, identified using the International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) diagnosis code. Main Outcomes and Measures The outcome was an isolated nontraumatic SDH, identified using ICD-10-CM codes. Two identical analyses were performed separately in the 2 cohorts. First, the risk of SDH in patients with and without CAA was assessed using Cox proportional hazards models, adjusting for demographic characteristics, cardiovascular comorbidities, and antithrombotic medication use. Second, multivariable logistic regression was used to study the association between CAA and SDH. Results The final analytical sample comprised 487 223 of the total 502 480 individuals in the UK Biobank cohort and 158 008 of the total 372 082 individuals in the All of Us cohort. Among the 487 223 participants in the discovery phase of the UK Biobank, the mean (SD) age was 56.5 (8.1) years, and 264 195 (54.2%) were female. There were 649 cases of incident SDH. Of the 126 participants diagnosed with CAA, 3 (2.4%) developed SDH. In adjusted Cox regression analyses, participants with CAA had an increased risk of having an SDH compared with those without CAA (hazard ratio [HR], 8.0; 95% CI, 2.6-24.8). Multivariable logistic regression analysis yielded higher odds of SDH among participants with CAA (odds ratio [OR], 7.6; 95% CI, 1.8-20.4). Among the 158 008 participants in the All of Us cohort, the mean (SD) age was 63.0 (9.5) years, and 89 639 (56.7%) were female. The findings were replicated in All of Us, in which 52 participants had CAA and 320 had an SDH. All of Us participants with CAA had an increased risk of having an SDH compared with those without CAA (HR, 4.9; 95% CI, 1.2-19.8). In adjusted multivariable logistic regression analysis, CAA was associated with higher odds of SDH (OR, 5.2; 95% CI, 0.8-17.6). Conclusions and Relevance In 2 large, heterogeneous cohorts, CAA was associated with increased risk of SDH. These findings suggest that CAA may be a novel risk factor for isolated nontraumatic SDH.
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Affiliation(s)
- Cyprien A. Rivier
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
- Yale Center for Brain and Mind Health, Yale School of Medicine, New Haven, Connecticut
| | - Hooman Kamel
- Deputy Editor, JAMA Neurology
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Kevin N. Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
- Yale Center for Brain and Mind Health, Yale School of Medicine, New Haven, Connecticut
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Ajay Gupta
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Mony J. de Leon
- Brain Health Imaging Institute, Department of Radiology, Weill Cornell Medicine, New York, New York
| | - Elizabeth Ross
- Center for Neurogenetics, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
| | - Guido J. Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
- Yale Center for Brain and Mind Health, Yale School of Medicine, New Haven, Connecticut
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York
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Parikh NS, Wahbeh F, Tapia C, Ianelli M, Liao V, Jaywant A, Kamel H, Kumar S, Iadecola C. Cognitive impairment and liver fibrosis in non-alcoholic fatty liver disease. BMJ Neurol Open 2024; 6:e000543. [PMID: 38268753 PMCID: PMC10806883 DOI: 10.1136/bmjno-2023-000543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/20/2023] [Indexed: 01/26/2024] Open
Abstract
Background Data regarding the prevalence and phenotype of cognitive impairment in non-alcoholic fatty liver disease (NAFLD) are limited. Objective We assessed the prevalence and nature of cognitive deficits in people with NAFLD and assessed whether liver fibrosis, an important determinant of outcomes in NAFLD, is associated with worse cognitive performance. Methods We performed a prospective cross-sectional study. Patients with NAFLD underwent liver fibrosis assessment with transient elastography and the following assessments: Cognitive Change Index, Eight-Item Informant Interview to Differentiate Aging and Dementia Questionnaire (AD8), Montreal Cognitive Assessment (MoCA), EncephalApp minimal hepatic encephalopathy test and a limited National Institutes of Health Toolbox battery (Flanker Inhibitory Control and Attention Test, Pattern Comparison Test and Auditory Verbal Learning Test). We used multiple linear regression models to examine the association between liver fibrosis and cognitive measures while adjusting for relevant covariates. Results We included 69 participants with mean age 50.4 years (SD 14.4); 62% were women. The median liver stiffness was 5.0 kilopascals (IQR 4.0-6.9), and 25% had liver fibrosis (≥7.0 kilopascals). Cognitive deficits were common in people with NAFLD; 41% had subjective cognitive impairment, 13% had an AD8 >2, 32% had MoCA <26 and 12% had encephalopathy detected on the EncephalApp test. In adjusted models, people with liver fibrosis had modestly worse performance only on the Flanker Inhibitory Control and Attention Task (β=-0.3; 95% CI -0.6 to -0.1). Conclusion Cognitive deficits are common in people with NAFLD, among whom liver fibrosis was modestly associated with worse inhibitory control and attention.
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Affiliation(s)
- Neal S Parikh
- Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Farah Wahbeh
- Neurology, Weill Cornell Medicine, New York, New York, USA
| | | | | | - Vanessa Liao
- Neurology, Weill Cornell Medicine, New York, New York, USA
| | | | - Hooman Kamel
- Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Sonal Kumar
- Medicine, Weill Cornell Medicine, New York, New York, USA
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18
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Otite FO, Patel SD, Aneni E, Lamikanra O, Wee C, Albright KC, Burke D, Latorre JG, Morris NA, Anikpezie N, Singla A, Sonig A, Kamel H, Khandelwal P, Chaturvedi S. Plateauing atrial fibrillation burden in acute ischemic stroke admissions in the United States from 2010 to 2020. Int J Stroke 2024:17474930231222163. [PMID: 38086764 DOI: 10.1177/17474930231222163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2024]
Abstract
BACKGROUND Utilization of oral anticoagulants for acute ischemic stroke (AIS) prevention in patients with atrial fibrillation (AF) increased in the United States over the last decade. Whether this increase has been accompanied by any change in AF prevalence in AIS at the population level remains unknown. The aim of this study is to evaluate trends in AF prevalence in AIS hospitalizations in various age, sex, and racial subgroups over the last decade. METHODS We used data contained in the 2010-2020 National Inpatient Sample to conduct a serial cross-sectional study. Primary AIS hospitalizations with and without comorbid AF were identified using International Classification of Diseases Codes. Joinpoint regression was used to compute annualized percentage change (APC) in prevalence and to identify points of change in prevalence over time. RESULTS Of 5,190,148 weighted primary AIS hospitalizations over the study period, 25.1% had comorbid AF. The age- and sex-standardized prevalence of AF in AIS hospitalizations increased across the entire study period 2010-2020 (average APC: 1.3%, 95% confidence interval (CI): 0.8-1.7%). Joinpoint regression showed that prevalence increased in the period 2010-2015 (APC: 2.8%, 95% CI: 1.9-3.9%) but remained stable in the period 2015-2020 (APC: -0.3%, 95% CI: -1.0 to 1.9%). Upon stratification by age and sex, prevalence increased in all age/sex groups from 2010 to 2015 and continued to increase throughout the entire study period in hospitalizations in men 18-39 years (APC: 4.0%, 95% CI: 0.2-7.9%), men 40-59 years (APC: 3.4%, 95% CI: 1.9-4.9%) and women 40-59 years (APC: 4.4%, 95% CI: 2.0-6.8%). In contrast, prevalence declined in hospitalizations in women 60-79 (APC: -1.0%, 95% CI: -0.5 to -1.5%) and women ⩾ 80 years over the period 2015-2020 but plateaued in hospitalizations in similar-aged men over the same period. CONCLUSION AF prevalence in AIS hospitalizations in the United States increased over the period 2010-2015, then plateaued over the period 2015-2020 due to declining prevalence in hospitalizations in women ⩾ 60 years and plateauing prevalence in hospitalizations in men ⩾ 60 years.
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Affiliation(s)
- Fadar Oliver Otite
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Smit D Patel
- Department of Neurosurgery, University of Connecticut, Hartford, CT, USA
| | - Ehimen Aneni
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | | | - Claribel Wee
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Karen C Albright
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Devin Burke
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Julius Gene Latorre
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Nicholas Allen Morris
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nnabuchi Anikpezie
- Department of Population Health, University of Mississippi Medical Center, Jackson, MS, USA
| | - Amit Singla
- Department of Neurosurgery, Rutgers University, Newark, NJ, USA
| | - Ashish Sonig
- Department of Neurosurgery, Rutgers University, Newark, NJ, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | | | - Seemant Chaturvedi
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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19
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Sposato LA, Albin CSW, Elkind MSV, Kamel H, Saver JL. Patent Foramen Ovale Management for Secondary Stroke Prevention: State-of-the-Art Appraisal of Current Evidence. Stroke 2024; 55:236-247. [PMID: 38134261 DOI: 10.1161/strokeaha.123.040546] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2023]
Abstract
Patent foramen ovale (PFO) is frequently identified in young patients with ischemic stroke. Randomized controlled trials provide robust evidence supporting PFO closure in selected patients with cryptogenic ischemic stroke; however, several questions remain unanswered. This report summarizes current knowledge on the epidemiology of PFO-associated stroke, the role of PFO as a cause of stroke, and anatomic high-risk features. We also comment on breakthrough developments in patient selection algorithms for PFO closure in relation to the PFO-associated stroke causal likelihood risk stratification system. We further highlight areas for future research in PFO-associated stroke including the efficacy and safety of PFO closure in the elderly population, incidence, and long-term consequences of atrial fibrillation post-PFO closure, generalizability of the results of clinical trials in the real world, and the need for assessing the effect of neurocardiology teams on adherence to international recommendations. Other important knowledge gaps such as sex, race/ethnicity, and regional disparities in access to diagnostic technologies, PFO closure devices, and clinical outcomes in the real world are also discussed as priority research topics.
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Affiliation(s)
- Luciano A Sposato
- Departments of Clinical Neurological Sciences, Epidemiology and Biostatistics, and Anatomy and Cell Biology, Schulich School of Medicine and Dentistry (L.A.S.), Western University, London, ON, Canada
- Heart & Brain Laboratory (L.A.S.), Western University, London, ON, Canada
- Robarts Research Institute and Lawson Health Research Institute, London, ON, Canada (L.A.S.)
| | - Catherine S W Albin
- Department of Neurology & Neurosurgery, Emory University School of Medicine, Atlanta, GA (C.S.W.A.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons (M.S.V.E.), Columbia University, New York
- Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York (H.K.)
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles (J.L.S.)
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20
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Kamel H. Reassessing the implications of atrial fibrillation detected after stroke. Lancet Neurol 2024; 23:9-11. [PMID: 37839433 DOI: 10.1016/s1474-4422(23)00406-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 10/06/2023] [Indexed: 10/17/2023]
Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY 10021, USA.
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21
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Zolin A, Zhang C, Ooi H, Sarva H, Kamel H, Parikh NS. Association of liver fibrosis with cognitive decline in Parkinson's disease. J Clin Neurosci 2024; 119:10-16. [PMID: 37976909 DOI: 10.1016/j.jocn.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 10/23/2023] [Accepted: 11/10/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Cognitive decline is a common but variable non-motor manifestation of Parkinson's disease. Chronic liver disease contributes to dementia, but its impact on cognitive performance in Parkinson's disease is unknown. We assessed the effect of liver fibrosis on cognition in Parkinson's disease. METHODS We conducted a retrospective cohort study using data from the Parkinson's Progression Markers Initiative. Our exposure was liver fibrosis at baseline, based on the validated Fibrosis-4 score. Our primary outcome was the Montreal Cognitive Assessment, and additional outcome measures were the Symbol Digit Modalities Test, the Benton Judgement of Line Orientation, the Letter-Number Sequencing Test, and the Modified Semantic Fluency Test. We used linear regression models to assess the relationship between liver fibrosis and scores on cognitive assessments at baseline and linear mixed models to evaluate the association between baseline Fibrosis-4 score with changes in each cognitive test over five years. Models were adjusted for demographics, comorbidities, and alcohol use. RESULTS We included 409 participants (mean age 61, 40 % women). There was no significant association between liver fibrosis and baseline performance on any of the cognitive assessments in adjusted models. However, over the subsequent five year period, liver fibrosis was associated with more rapid decline in scores on the Montreal Cognitive Assessment (interaction coefficient, -0.07; 95 % CI, -0.12, -0.02), the Symbol Digit Modalities Test, the Benton Judgement of Line Orientation, and the Modified Semantic Fluency Test. CONCLUSION In people with Parkinson's disease, the presence of comorbid liver fibrosis was associated with more rapid decline across multiple cognitive domains.
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Affiliation(s)
- Aryeh Zolin
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hwai Ooi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA; Parkinson's Disease and Movement Disorders Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Harini Sarva
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA; Parkinson's Disease and Movement Disorders Institute, Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA.
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22
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Mistry AM, Naidugari J, Craven J, Williams L, Beall J, Khatri P, Broderick JP, Rice TW, Kamel H, Mack W. Usage of mineralocorticoids and isotonic crystalloids in subarachnoid hemorrhage patients in the United States. J Stroke Cerebrovasc Dis 2024; 33:107449. [PMID: 37995500 PMCID: PMC10841607 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/23/2023] [Accepted: 10/26/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. METHODS We surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites in 2023, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters from 2010 to 2020 in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20 % of all acute inpatient care in the United States. RESULTS Although mineralocorticoids are used by 70 % of the NINDS StrokeNet sites, it is used in less than 20 % of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41 and 45 %, respectively. CONCLUSIONS The use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.
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Affiliation(s)
- Akshitkumar M Mistry
- Department of Neurosurgery, University of Louisville, 220 Abraham Flexner Way, 15th Floor, Louisville, KY 40202, USA.
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jocelyn Craven
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Logan Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Joseph P Broderick
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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23
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Shipes VB, Meinzer C, Wolf BJ, Li H, Carpenter MJ, Kamel H, Martin RH. Designing a phase-III time-to-event clinical trial using a modified sample size formula and Poisson-Gamma model for subject accrual that accounts for the lag in site initiation using the PERT distribution. Stat Med 2023; 42:5694-5707. [PMID: 37926516 PMCID: PMC10847961 DOI: 10.1002/sim.9935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 07/01/2023] [Accepted: 10/03/2023] [Indexed: 11/07/2023]
Abstract
A priori estimation of sample size and subject accrual in multi-site, time-to-event clinical trials is often challenging. Such trials are powered based on the number of events needed to detect a clinically significant difference. Sample size based on number of events relates to the expected duration of observation time for each subject. Temporal patterns in site initiation and subject enrollment ultimately affect when subjects can be accrued into the study. Lag times are common as the site start-up process optimizes, resulting in delays that may curtail observational follow-up and therefore undermine power. The proposed method introduces a Program Evaluation and Review Technique (PERT) model into the sample size estimation which accounts for the lag in site start-up. Additionally, a PERT model is introduced into a Poisson-Gamma subject accrual model to predict the quantity of study sites needed. The introduction of the PERT model provides greater flexibility in both a priori power assessment and planning the number of sites, as it specifically allows for the inclusion of anticipated delays in site start-up time. This model results in minimal power loss even when PERT distribution inputs are misspecified compared to the traditional assumption of simultaneous start-up for all sites. Together these updated formulations for sample size and subject accrual models offer an improved method for designing a multi-site time-to-event clinical trial that accounts for a flexible site start-up process.
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Affiliation(s)
- Virginia B Shipes
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Biostatistics, The Emmes Company, Rockville, Maryland, USA
| | - Caitlyn Meinzer
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Bethany J Wolf
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hong Li
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Mathew J Carpenter
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
- Hollings Cancer Center, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York City, New York, USA
| | - Renee H Martin
- Division of Biostatistics, Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina, USA
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24
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Garton ALA, Berger K, Merkler AE, Kamel H, Knopman J, Zhang C, Murthy SB. Antiplatelet therapy and outcomes after aneurysmal subarachnoid hemorrhage: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 235:108025. [PMID: 37925994 PMCID: PMC10841860 DOI: 10.1016/j.clineuro.2023.108025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 09/04/2023] [Accepted: 10/25/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The efficacy of antiplatelet therapy (APT) after aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. We performed a systematic review and meta-analysis to summarize the associations of APT use after aSAH with outcomes. METHODS We searched published medical literature to identify cohort studies involving adults with aSAH. The exposure was APT use after aSAH. Outcome measures were good functional outcome (modified Rankin Score 0-2 or Glasgow Outcome Scale 4-5), delayed cerebral ischemia (infarcts on neuroimaging), and intracranial hemorrhage. After assessing study heterogeneity and publication bias, we performed a meta-analysis using random-effects models to assess the strength of association between APT and SAH outcomes. RESULTS A total of 14 studies with 4228 aSAH patients were included. APT after aSAH was associated with good functional outcome (pooled relative risk, 1.08; 95% confidence interval, [CI], 1.02-1.15; I2 = 45%, p for heterogeneity = 0.04), but there was no relationship with delayed cerebral ischemia (pooled relative risk, 0.80; 95% confidence interval, [CI], 0.63-1.02; I2 = 61%, p for heterogeneity <0.01) or intracranial hemorrhage (pooled relative risk, 1.50; 95% confidence interval, [CI], 0.98-2.31; I2 = 0, p for heterogeneity =0.71). In additional analyses, APT resulted in good functional outcomes in endovascularly-treated patients. When stratified by type of medication, aspirin, clopidogrel, and ticlopidine were associated with good functional outcomes. CONCLUSIONS APT after aSAH was associated with a modest improvement in functional outcome, but there was no relationship with delayed cerebral ischemia or intracranial hemorrhage.
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Affiliation(s)
- Andrew L A Garton
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Karen Berger
- Department of Pharmacy, NewYork-Presbyterian Hospital/Weill Cornell Medical Center, USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Jared Knopman
- Department of Neurological Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA.
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25
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Murthy SB, Zhang C, Shah S, Schwamm LH, Fonarow GC, Smith EE, Bhatt DL, Ziai WC, Kamel H, Sheth KN. Antithrombotic and Statin Prescription After Intracerebral Hemorrhage in the Get With The Guidelines-Stroke Registry. Stroke 2023; 54:2972-2980. [PMID: 37942641 PMCID: PMC10842167 DOI: 10.1161/strokeaha.123.043194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 10/17/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Survivors of intracerebral hemorrhage (ICH) face an increased risk of ischemic cardiovascular events. Current ICH guidelines do not provide definitive recommendations regarding the use of antithrombotic and statin therapies. We, therefore, sought to study practice patterns and factors associated with the use of such medications after ICH. METHODS This was a cross-sectional study of patients with ICH in the Get With The Guidelines-Stroke registry, between 2011 and 2021. Patients transferred to another hospital, those who died during hospitalization, and those with missing information on discharge medications were excluded. The study exposure was the proportion of patients who were prescribed antithrombotic or statin medications. We first ascertained the proportion of patients prescribed antithrombotic and lipid-lowering medications at discharge overall and across strata defined by pre-ICH use and history of previous ischemic vascular disease or atrial fibrillation. We then studied factors associated with the discharge prescription of these medications after ICH, using multiple logistic regressions. RESULTS In the final cohort, 50 416 (10.4%) of 486 586 patients with ICH were prescribed antiplatelet medications, 173 322 (35.1%) of 493 491 patients with ICH were prescribed statins, and 27 085 (5.4%) of 486 585 patients with ICH were prescribed anticoagulation therapy at discharge. The proportion of patients with antiplatelet therapy was 16.6% with pre-ICH use and 15.6% in those with previous ischemic vascular disease. Statins were prescribed to 41.1% and 43.7% of patients on previous lipid-lowering therapy and ischemic vascular disease, respectively. Anticoagulation therapy was restarted in 11.1% of patients. In logistic regression analysis, factors associated with higher use of antithrombotic or statin therapies after ICH were younger age, male sex, pre-ICH medication use, previous ischemic vascular disease, atrial fibrillation, lower admission National Institutes of Health Stroke Scale, longer length of stay, and favorable discharge outcome. CONCLUSIONS Few patients with ICH are prescribed antithrombotic or statin therapies at hospital discharge. Given the emerging association between ICH and future major cardiovascular events, trials examining the net benefit of antiplatelet and lipid-lowering therapy after ICH are warranted.
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Affiliation(s)
- Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
- Department of Neurology (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
- Department of Neurology (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
| | - Shreyansh Shah
- Department of Neurology, Duke University Hospital, Durham, NC (S.S.)
| | - Lee H Schwamm
- Department of Biomedical Informatics and Data Sciences (L.H.S.), Yale School of Medicine, New Haven, CT
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan University of California, Los Angeles Medical Center (G.C.F.)
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, AB, Canada (E.E.S.)
| | - Deepak L Bhatt
- Department of Cardiovascular Medicine, Icahn School of Medicine at Mount Sinai Health System, New York, NY (D.L.B.)
| | - Wendy C Ziai
- Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (W.C.Z.)
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
- Department of Neurology (S.B.M., C.Z., H.K.), Weill Cornell Medicine, New York, NY
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Departments of Neurology and Neurosurgery, The Yale Center for Brain and Mind Health (K.N.S.), Yale School of Medicine, New Haven, CT
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Wechsler LR, Adeoye O, Alemseged F, Bahr-Hosseini M, Deljkich E, Favilla C, Fisher M, Grotta J, Hill MD, Kamel H, Khatri P, Lyden P, Mirza M, Nguyen TN, Samaniego E, Schwamm L, Selim M, Silva G, Yavagal DR, Yenari MA, Zachrison KS, Boltze J, Yaghi S. Most Promising Approaches to Improve Stroke Outcomes: The Stroke Treatment Academic Industry Roundtable XII Workshop. Stroke 2023; 54:3202-3213. [PMID: 37886850 DOI: 10.1161/strokeaha.123.044279] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/20/2023] [Indexed: 10/28/2023]
Abstract
The Stroke Treatment Academic Industry Roundtable XII included a workshop to discuss the most promising approaches to improve outcome from acute stroke. The workshop brought together representatives from academia, industry, and government representatives. The discussion examined approaches in 4 epochs: pre-reperfusion, reperfusion, post-reperfusion, and access to acute stroke interventions. The participants identified areas of priority for developing new and existing treatments and approaches to improve stroke outcomes. Although many advances in acute stroke therapy have been achieved, more work is necessary for reperfusion therapies to benefit the most possible patients. Prioritization of promising approaches should help guide the use of resources and investigator efforts.
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Affiliation(s)
- Lawrence R Wechsler
- University of Pittsburgh School of Medicine and University of Pittsburgh Medical Center, PA (L.R.W.)
| | - Opeolu Adeoye
- Washington University School of Medicine, St. Louis, MO (O.A.)
| | | | | | | | | | - Marc Fisher
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | | | | | - Hooman Kamel
- Weill Cornel School of Medicine, New York, NY (H.K.)
| | - Pooja Khatri
- University of Cincinnati Medical Center, OH (P.K.)
| | - Patrick Lyden
- University of Southern California, Los Angeles, CA (P.L.)
| | | | | | | | - Lee Schwamm
- Massachusetts General Hospital, Boston (L.S.)
| | - Magdy Selim
- Beth Israel Deaconess Medical Center, Boston, MA (M.S.)
| | | | | | | | | | - Johannes Boltze
- School of Life Sciences, University of Warwick, Coventry, United Kingdom (J.B.)
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Al-Shahi Salman R, Stephen J, Tierney JF, Lewis SC, Newby DE, Parry-Jones AR, White PM, Connolly SJ, Benavente OR, Dowlatshahi D, Cordonnier C, Viscoli CM, Sheth KN, Kamel H, Veltkamp R, Larsen KT, Hofmeijer J, Kerkhoff H, Schreuder FHBM, Shoamanesh A, Klijn CJM, van der Worp HB. Effects of oral anticoagulation in people with atrial fibrillation after spontaneous intracranial haemorrhage (COCROACH): prospective, individual participant data meta-analysis of randomised trials. Lancet Neurol 2023; 22:1140-1149. [PMID: 37839434 DOI: 10.1016/s1474-4422(23)00315-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 08/09/2023] [Accepted: 08/15/2023] [Indexed: 10/17/2023]
Abstract
BACKGROUND The safety and efficacy of oral anticoagulation for prevention of major adverse cardiovascular events in people with atrial fibrillation and spontaneous intracranial haemorrhage are uncertain. We planned to estimate the effects of starting versus avoiding oral anticoagulation in people with spontaneous intracranial haemorrhage and atrial fibrillation. METHODS In this prospective meta-analysis, we searched bibliographic databases and trial registries using the strategies of a Cochrane systematic review (CD012144) on June 23, 2023. We included clinical trials if they were registered, randomised, and included participants with spontaneous intracranial haemorrhage and atrial fibrillation who were assigned to either start long-term use of any oral anticoagulant agent or avoid oral anticoagulation (ie, placebo, open control, another antithrombotic agent, or another intervention for the prevention of major adverse cardiovascular events). We assessed eligible trials using the Cochrane Risk of Bias tool. We sought data for individual participants who had not opted out of data sharing from chief investigators of completed trials, pending completion of ongoing trials in 2028. The primary outcome was any stroke or cardiovascular death. We used individual participant data to construct a Cox regression model of the time to the first occurrence of outcome events during follow-up in the intention-to-treat dataset supplied by each trial, followed by meta-analysis using a fixed-effect inverse-variance model to generate a pooled estimate of the hazard ratio (HR) with 95% CI. This study is registered with PROSPERO, CRD42021246133. FINDINGS We identified four eligible trials; three were restricted to participants with atrial fibrillation and intracranial haemorrhage (SoSTART [NCT03153150], with 203 participants) or intracerebral haemorrhage (APACHE-AF [NCT02565693], with 101 participants, and NASPAF-ICH [NCT02998905], with 30 participants), and one included a subgroup of participants with previous intracranial haemorrhage (ELDERCARE-AF [NCT02801669], with 80 participants). After excluding two participants who opted out of data sharing, we included 412 participants (310 [75%] aged 75 years or older, 249 [60%] with CHA2DS2-VASc score ≤4, and 163 [40%] with CHA2DS2-VASc score >4). The intervention was a direct oral anticoagulant in 209 (99%) of 212 participants who were assigned to start oral anticoagulation, and the comparator was antiplatelet monotherapy in 67 (33%) of 200 participants assigned to avoid oral anticoagulation. The primary outcome of any stroke or cardiovascular death occurred in 29 (14%) of 212 participants who started oral anticoagulation versus 43 (22%) of 200 who avoided oral anticoagulation (pooled HR 0·68 [95% CI 0·42-1·10]; I2=0%). Oral anticoagulation reduced the risk of ischaemic major adverse cardiovascular events (nine [4%] of 212 vs 38 [19%] of 200; pooled HR 0·27 [95% CI 0·13-0·56]; I2=0%). There was no significant increase in haemorrhagic major adverse cardiovascular events (15 [7%] of 212 vs nine [5%] of 200; pooled HR 1·80 [95% CI 0·77-4·21]; I2=0%), death from any cause (38 [18%] of 212 vs 29 [15%] of 200; 1·29 [0·78-2·11]; I2=50%), or death or dependence after 1 year (78 [53%] of 147 vs 74 [51%] of 145; pooled odds ratio 1·12 [95% CI 0·70-1·79]; I2=0%). INTERPRETATION For people with atrial fibrillation and intracranial haemorrhage, oral anticoagulation had uncertain effects on the risk of any stroke or cardiovascular death (both overall and in subgroups), haemorrhagic major adverse cardiovascular events, and functional outcome. Oral anticoagulation reduced the risk of ischaemic major adverse cardiovascular events, which can inform clinical practice. These findings should encourage recruitment to, and completion of, ongoing trials. FUNDING British Heart Foundation.
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Affiliation(s)
- Rustam Al-Shahi Salman
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK; Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK.
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Jayne F Tierney
- MRC Clinical Trials Unit at UCL, Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Steff C Lewis
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | | | - Philip M White
- Department of Neuroradiology, Newcastle-upon-Tyne Hospitals National Health Service Trust, Newcastle upon Tyne, UK; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Stuart J Connolly
- Department of Medicine (Neurology), Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Oscar R Benavente
- Department of Medicine (Neurology), University of British Columbia, Vancouver, BC, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa and Hospital Research Institute, Ottawa, ON, Canada
| | - Charlotte Cordonnier
- University of Lille, INSERM, CHU Lille, U1172-Lille Neuroscience & Cognition, Lille, France
| | - Catherine M Viscoli
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Department of Neurology and Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
| | - Roland Veltkamp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Kristin T Larsen
- Department of Geriatric Medicine, Oslo University Hospital, Oslo, Norway; Department of Neurology, Akershus University Hospital, Lørenskog, Norway
| | - Jeannette Hofmeijer
- Department of Neurology and Clinical Neurophysiology, Rijnstate Hospital, and University of Twente, Arnhem, Netherlands
| | - Henk Kerkhoff
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Floris H B M Schreuder
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, ON, Canada
| | - Catharina J M Klijn
- Department of Neurology, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Centre, Nijmegen, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
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28
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Bernstein RA, Kamel H, Granger CB, Piccini JP, Katz JM, Sethi PP, Pouliot E, Franco N, Ziegler PD, Schwamm LH. Atrial Fibrillation In Patients With Stroke Attributed to Large- or Small-Vessel Disease: 3-Year Results From the STROKE AF Randomized Clinical Trial. JAMA Neurol 2023; 80:1277-1283. [PMID: 37902733 PMCID: PMC10616765 DOI: 10.1001/jamaneurol.2023.3931] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/03/2023] [Indexed: 10/31/2023]
Abstract
Importance The STROKE AF study found that in patients with prior ischemic stroke attributed to large-artery atherosclerotic disease (LAD) or small-vessel occlusive disease (SVD), 12% developed AF over 1 year when monitored with an insertable cardiac monitor (ICM). The occurrence over subsequent years is unknown. Objectives To compare the rates of AF detection through 3 years of follow-up between an ICM vs site-specific usual care in patients with prior ischemic stroke attributed to LAD or SVD. Design, Setting, and Participants This multicenter, randomized (1:1) clinical trial took place at 33 sites in the US with enrollment between April 2016 and July 2019 and 3-year follow-up through July 2022. Eligible patients were aged 60 years or older, or aged 50 to 59 years with at least 1 additional stroke risk factor and had an index ischemic stroke attributed to LAD or SVD within 10 days prior to ICM insertion. Of the 496 patients enrolled, 492 were randomized and 4 were excluded. Interventions ICM monitoring vs site-specific usual care. Main Outcomes and Measures The prespecified long-term outcome of the trial was AF detection through study follow-up (up to 3 years). AF was defined as an episode lasting more than 30 seconds, adjudicated by an expert committee. Results In total, 492 patients were randomized and included in the analyses (median [IQR] age, 66 [60-74] years; 307 men [62.4%] and 185 women [37.6%]), of whom 314 completed 3-year follow-up (63.8%). The incidence rate of AF at 3 years was 21.7% (46 patients) in the ICM group vs 2.4% (5 patients) in the control group (hazard ratio, 10.0; 95% CI, 4.0-25.2; P < .001). Conclusions and Relevance Patients with ischemic stroke attributed to LAD or SVD face an increasing risk of AF over time and most of the AF occurrences are not reliably detected by standard medical monitoring methods. One year of negative monitoring should not reassure clinicians that patients who have experienced stroke will not develop AF over the next 2 years. Trial Registration ClinicalTrials.gov Identifier: NCT02700945.
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Affiliation(s)
- Richard A. Bernstein
- Davee Department of Neurology, Feinberg School of Medicine of Northwestern University, Chicago, Illinois
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, New York
- Deputy Editor, JAMA Neurology
| | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P. Piccini
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey M. Katz
- Department of Neurology and Radiology, North Shore University Hospital, Manhasset, New York
| | - Pramod P. Sethi
- Guilford Neurology Associates, Moses H. Cone Hospital, Greensboro, North Carolina
| | - Erika Pouliot
- Cardiac Rhythm Management, Clinical Department, Medtronic, Minneapolis, Minnesota
| | - Noreli Franco
- Cardiac Rhythm Management, Clinical Department, Medtronic, Minneapolis, Minnesota
| | - Paul D. Ziegler
- Cardiac Rhythm Management, Research Department, Medtronic, Minneapolis, Minnesota
| | - Lee H. Schwamm
- Department of Digital Strategy and Transformation, Yale School of Medicine, New Haven, Connecticut
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29
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Homssi M, Balaji V, Zhang C, Shin J, Gupta A, Kamel H. Association between left atrial volume index and infarct volume in patients with ischemic stroke. Front Neurol 2023; 14:1265037. [PMID: 38053799 PMCID: PMC10694187 DOI: 10.3389/fneur.2023.1265037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 10/30/2023] [Indexed: 12/07/2023] Open
Abstract
Background Left atrial volume index (LAVI) is one marker of atrial myopathy, which is increasingly being recognized as a cause of cardioembolic stroke even in the absence of atrial fibrillation. Cardiac embolism is associated with larger strokes than other stroke mechanisms. The purpose of this study was to examine the association between LAVI and total brain infarct volume in patients with ischemic stroke. Methods This was a retrospective study of 545 patients prospectively enrolled in the Cornell ActuE Stroke Academic Registry (CAESAR), which includes all acute ischemic stroke patients admitted to our hospital since 2011. LAVI measurements were obtained from our echocardiography image store system (Xclera, Philips Healthcare). Brain infarcts on diffusion-weighted images (DWI) were manually segmented and infarct volume was obtained on 3D Slicer. We used multiple linear regression models adjusted for age, sex, race, and vascular comorbidities including atrial fibrillation. Results Among 2,945 CAESAR patients, 545 patients had both total infarct volume and LAVI measured. We found an association between LAVI and log-transformed total brain infarct volume in both unadjusted (β = 0.018; p = 0.002) and adjusted (β = 0.024; p = 0.001) models. Conclusion We found that larger left atrial volume was associated with larger brain infarcts. This association was independent of known cardioembolic risk factors such as atrial fibrillation and heart failure. These findings support the concept that atrial myopathy may be a source of cardiac embolism even in the absence of traditionally recognized mechanisms such as atrial fibrillation.
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Affiliation(s)
- Moayad Homssi
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Venkatesh Balaji
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, United States
| | - James Shin
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, United States
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, United States
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, United States
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30
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Kahan J, Ong H, Elnaas H, Ch'ang JH, Murthy SB, Merkler AE, Sabuncu MR, Gupta A, Kamel H. Optic Nerve Diameter on Non-Contrast Computed Tomography and Intracranial Hypertension in Patients With Acute Brain Injury: A Validation Study. J Neurotrauma 2023; 40:2282-2288. [PMID: 37212270 PMCID: PMC10775921 DOI: 10.1089/neu.2023.0051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023] Open
Abstract
Intracranial hypertension is a feared complication of acute brain injury that can cause ischemic stroke, herniation, and death. Identifying those at risk is difficult, and the physical examination is often confounded. Given the widespread availability and use of computed tomography (CT) in patients with acute brain injury, prior work has attempted to use optic nerve diameter measurements to identify those at risk of intracranial hypertension. We aimed to validate the use of optic nerve diameter measurements on CT as a screening tool for intracranial hypertension in a large cohort of brain-injured patients. We performed a retrospective observational cohort study in a single tertiary referral Neuroscience Intensive Care Unit. We identified patients with documented intracranial pressure (ICP) measures as part of their routine clinical care who had non-contrast CT head scans collected within 24 h, and then measured the optic nerve diameters and explored the relationship and test characteristics of these measures to identify those at risk of intracranial hypertension. In a cohort of 314 patients, optic nerve diameter on CT was linearly but weakly associated with ICP. When used to identify those with intracranial hypertension (> 20 mm Hg), the area under the receiver operator curve (AUROC) was 0.68. Using a previously proposed threshold of 0.6 cm, the sensitivity was 81%, specificity 43%, positive likelihood ratio 1.4, and negative likelihood ratio 0.45. CT-derived optic nerve diameter using a threshold of 0.6 cm is sensitive but not specific for intracranial hypertension, and the overall correlation is weak.
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Affiliation(s)
- Joshua Kahan
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Hanley Ong
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Hailan Elnaas
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Judy H. Ch'ang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Santosh B. Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Mert R. Sabuncu
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
- School of Electrical and Computer Engineering, Cornell University and Cornell Tech, New York, New York, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
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Lee HJ, Schwamm LH, Sansing L, Kamel H, de Havenon A, Turner AC, Sheth KN, Krishnaswamy S, Brandt C, Zhao H, Krumholz H, Sharma R. StrokeClassifier: Ischemic Stroke Etiology Classification by Ensemble Consensus Modeling Using Electronic Health Records. Res Sq 2023:rs.3.rs-3367169. [PMID: 37961532 PMCID: PMC10635373 DOI: 10.21203/rs.3.rs-3367169/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Determining the etiology of an acute ischemic stroke (AIS) is fundamental to secondary stroke prevention efforts but can be diagnostically challenging. We trained and validated an automated classification machine intelligence tool, StrokeClassifier, using electronic health record (EHR) text data from 2,039 non-cryptogenic AIS patients at 2 academic hospitals to predict the 4-level outcome of stroke etiology determined by agreement of at least 2 board-certified vascular neurologists' review of the stroke hospitalization EHR. StrokeClassifier is an ensemble consensus meta-model of 9 machine learning classifiers applied to features extracted from discharge summary texts by natural language processing. StrokeClassifier was externally validated in 406 discharge summaries from the MIMIC-III dataset reviewed by a vascular neurologist to ascertain stroke etiology. Compared with stroke etiologies adjudicated by vascular neurologists, StrokeClassifier achieved the mean cross-validated accuracy of 0.74 (±0.01) and weighted F1 of 0.74 (±0.01). In the MIMIC-III cohort, the accuracy and weighted F1 of StrokeClassifier were 0.70 and 0.71, respectively. SHapley Additive exPlanation analysis elucidated that the top 5 features contributing to stroke etiology prediction were atrial fibrillation, age, middle cerebral artery occlusion, internal carotid artery occlusion, and frontal stroke location. We then designed a certainty heuristic to deem a StrokeClassifier diagnosis as confidently non-cryptogenic by the degree of consensus among the 9 classifiers, and applied it to 788 cryptogenic patients. This reduced the percentage of the cryptogenic strokes from 25.2% to 7.2% of all ischemic strokes. StrokeClassifier is a validated artificial intelligence tool that rivals the performance of vascular neurologists in classifying ischemic stroke etiology for individual patients. With further training, StrokeClassifier may have downstream applications including its use as a clinical decision support system.
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Affiliation(s)
- Ho-Joon Lee
- Department of Genetics and Yale Center for Genome Analysis, Yale School of Medicine, New Haven, CT
| | - Lee H. Schwamm
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital and Harvard Medical School Boston, MA
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Lauren Sansing
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York City, NY
| | - Adam de Havenon
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Ashby C. Turner
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital and Harvard Medical School Boston, MA
| | - Kevin N. Sheth
- Department of Neurology, Yale School of Medicine, New Haven, CT
| | - Smita Krishnaswamy
- Departments of Genetics and Computer Science, Yale School of Medicine, New Haven, CT
| | - Cynthia Brandt
- Department of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT
| | - Hongyu Zhao
- Departments of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Harlan Krumholz
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Richa Sharma
- Department of Neurology, Yale School of Medicine, New Haven, CT
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32
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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] [What about the content of this article? (0)] [Affiliation(s)] [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.
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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
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Mistry AM, Saver J, Mack W, Kamel H, Elm J, Beall J. Subarachnoid Hemorrhage Trials: Cutting, Sliding, or Keeping mRS Scores and WFNS Grades. medRxiv 2023:2023.09.28.23296257. [PMID: 37873354 PMCID: PMC10593043 DOI: 10.1101/2023.09.28.23296257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
Abstract
Rigorous evidence generation with randomized controlled trials (RCTs) has lagged for aneurysmal subarachnoid hemorrhage (SAH) compared to other forms of acute stroke. Besides its lower incidence compared to other stroke subtypes, the presentation and outcome of SAH patients also differ. This must be considered and adjusted for in designing pivotal RCTs of SAH patients. Here, we show the effect of the unique expected distribution of the SAH severity at presentation (World Federation of Neurological Surgeons, WFNS, grade) on the outcome most used in pivotal stroke RCTs (modified Rankin Scale, mRS) and consequently on the sample size. Further, we discuss the advantages and disadvantages of different options to analyze the outcome and control the expected distribution of WFNS grades in addition to showing their effects on the sample size. Last, we offer methods that investigators can adapt to more precisely understand the effect of common mRS analysis methods and trial eligibility pertaining to the WFNS grade in designing their large-scale SAH RCTs.
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Affiliation(s)
| | - Jeffrey Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Jordan Elm
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
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Broderick JP, Silva GS, Selim M, Kasner SE, Aziz Y, Sutherland J, Jauch EC, Adeoye OM, Hill MD, Mistry EA, Lyden PD, Mocco J, Smith EM, Hernandez-Jimenez M, Deljkich E, Kamel H. Enhancing Enrollment in Acute Stroke Trials: Current State and Consensus Recommendations. Stroke 2023; 54:2698-2707. [PMID: 37694403 PMCID: PMC10542906 DOI: 10.1161/strokeaha.123.044149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
The Stroke Treatment Academic Industry Roundtable (STAIR) convened a session and workshop regarding enrollment in acute stroke trials during the STAIR XII meeting on March 22, 2023. This forum brought together stroke physicians and researchers, members of the National Institute of Neurological Disorders and Stroke, industry representatives, and members of the US Food and Drug Administration to discuss the current status and opportunities for improving enrollment in acute stroke trials. The workshop identified the most relevant issues impacting enrollment in acute stroke trials and addressed potential action items for each. Focus areas included emergency consent in the United States and other countries; careful consideration of eligibility criteria to maximize enrollment and representativeness; investigator, study coordinator, and pharmacist availability outside of business hours; trial enthusiasm/equipoise; site start-up including contractual issues; site champions; incorporation of study procedures into standard workflow as much as possible; centralized enrollment at remote sites by study teams using telemedicine; global trials; and coenrollment in trials when feasible. In conclusion, enrollment of participants is the lifeblood of acute stroke trials and is the rate-limiting step for testing an exciting array of new approaches to improve patient outcomes. In particular, efforts should be undertaken to broaden the medical community's understanding and implementation of emergency consent procedures and to adopt designs and processes that are easily incorporated into standard workflow and that improve trials' efficiencies and execution. Research and actions to improve enrollment in ongoing and future trials will improve stroke outcomes more broadly than any single therapy under consideration.
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Affiliation(s)
- Joseph P. Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio
| | - Gisele Sampaio Silva
- Federal University of São Paulo, Clinical Trialist/Neurology ,Albert Einstein Hospital, São Paulo, Brazil
| | - Magdy Selim
- Dept. of Neurology, Division of Stroke & Cerebrovascular Disease. Harvard Medical School / Beth Israel Deaconess Med. Ctr
| | - Scott E. Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Yasmin Aziz
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio
| | | | - Edward C. Jauch
- Chair, Department of Research and Evaluation Sciences, University of North Carolina at MAHEC
| | - Opeolu M. Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, Emergency Physician-in-Chief, Barnes-Jewish Hospital, St. Louis, MO
| | - Michael D. Hill
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Eva A. Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio
| | - Patrick D. Lyden
- Professor of Physiology and Neuroscience, Professor of Neurology, Zilkha Neurogenetic Institute, Keck School of Medicine of USC
| | - J Mocco
- Department of Neurological Surgery, Mount Sinai Health System. Mount Sinai Health System. New York, New York, United States
| | | | - Macarena Hernandez-Jimenez
- Scientific Director, aptaTargets S.L., Av. Cardenal Herrera Oria 298, Madrid, Spain. Pharmacology and Toxicology Department, Complutense University, Av. Complutense s/n, Madrid, Spain
| | | | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY
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Homssi M, Saha A, Delgado D, RoyChoudhury A, Thomas C, Lin M, Baradaran H, Kamel H, Gupta A. Extracranial Carotid Plaque Calcification and Cerebrovascular Ischemia: A Systematic Review and Meta-Analysis. Stroke 2023; 54:2621-2628. [PMID: 37638399 PMCID: PMC10530110 DOI: 10.1161/strokeaha.123.042807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/17/2023] [Indexed: 08/29/2023]
Abstract
BACKGROUND Although coronary calcification quantification is an established approach for cardiovascular risk assessment, the value of quantifying carotid calcification is less clear. As a result, we performed a systematic review and meta-analysis to evaluate the association between extracranial carotid artery plaque calcification burden and ipsilateral cerebrovascular ischemic events. METHODS A comprehensive literature search was performed in the following databases: Ovid MEDLINE(R) 1946 to July 6, 2022; OVID Embase 1974 to July 6, 2022; and The Cochrane Library (Wiley). We performed meta-analyses including studies in which investigators performed a computed tomography assessment of calcification volume, percentage, or other total calcium burden summarizable in a single continuous imaging biomarker and determined the association of these features with the occurrence of ipsilateral stroke or transient ischemic attack. RESULTS Our overall meta-analysis consisted of 2239 carotid arteries and 9 studies. The presence of calcification in carotid arteries ipsilateral to ischemic stroke or in stroke patients compared with asymptomatic patients did not demonstrate a significant association with ischemic cerebrovascular events (relative risk of 0.75 [95% CI, 0.44-1.28]; P=0.29). When restricted to studies of significant carotid artery stenosis (>50%), the presence of calcification was associated with a reduced risk of ischemic stroke (relative risk of 0.56 [95% CI, 0.38-0.85]; P=0.006). When the analysis was limited to studies of patients with mainly nonstenotic plaques, there was an increased relative risk of ipsilateral ischemic stroke of 1.72 ([95% CI, 1.01-2.91]; P=0.04). Subgroup meta-analyses of total calcium burden and morphological features of calcium showed wide variability in their strength of association with ischemic stroke and demonstrated significant heterogeneity. CONCLUSIONS The presence of calcification in carotid plaque confers a reduced association with ipsilateral ischemic events, although these results seem to be limited among carotid arteries with higher degrees of stenosis. Adoption of carotid calcification measures in clinical decision-making will require additional studies providing more reproducible and standardized methods of calcium characterization and testing these imaging strategies in prospective studies.
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Affiliation(s)
- Moayad Homssi
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Atin Saha
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Diana Delgado
- Samuel J. Wood Library and C.V. Starr Biomedical Information Center, Weill Cornell Medicine, New York, NY, USA
| | - Arindam RoyChoudhury
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Charlene Thomas
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY, USA
| | - Matthew Lin
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Hediyeh Baradaran
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY, USA
- Feil Family Brain Mind Institute, Weill Cornell Medicine, New York, NY, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
- Feil Family Brain Mind Institute, Weill Cornell Medicine, New York, NY, USA
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Mistry AM, Naidugari J, Craven J, Williams L, Beall J, Khatri P, Broderick JP, Rice TW, Kamel H, Mack W. Usage of Mineralocorticoids and Isotonic Crystalloids in Subarachnoid Hemorrhage Patients in the United States. medRxiv 2023:2023.09.28.23296245. [PMID: 37808838 PMCID: PMC10557832 DOI: 10.1101/2023.09.28.23296245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Background The usage rates of mineralocorticoids (fludrocortisone) to treat hyponatremia and isotonic crystalloids (saline and balanced crystalloids) to maintain intravascular volume in patients with aneurysmal subarachnoid hemorrhage (aSAH) patients across the United States are unknown. Methods We surveyed National Institute of Neurologic Disorders and Stroke (NINDS) StrokeNet sites, which are mostly large, tertiary, academic centers, and analyzed subarachnoid hemorrhage encounters in the Premier Healthcare Database that is representative of all types of hospitals and captures about 20% of all acute inpatient care in the United States. Results Although mineralocorticoids are used by 70% of the NINDS StrokeNet sites in aSAH patients, it is used in less than 25% of the aSAH encounters in the Premier Database. Although saline is ubiquitously used, balanced crystalloids are increasingly used for fluid therapy in aSAH patients. Its use in the NINDS StrokeNet sites and the Premier Healthcare Database is 41% and 45%, respectively. Conclusions The use of mineralocorticoids remains low, and balanced crystalloids are increasingly used as fluid therapy in aSAH patients. The effectiveness of mineralocorticoids and balanced crystalloids in improving outcomes for aSAH patients must be rigorously tested in randomized clinical trials.
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Affiliation(s)
| | - Janki Naidugari
- School of Medicine, University of Louisville, Louisville, KY, USA
| | - Jocelyn Craven
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Logan Williams
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Jonathan Beall
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Joseph P. Broderick
- Departments of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, OH, USA
| | - Todd W. Rice
- Department of Medicine, Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - William Mack
- Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
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Navi BB, Zhang C, Kaiser JH, Liao V, Cushman M, Kasner SE, Elkind MSV, Tagawa ST, Guntupalli SR, Gaudino MFL, Lee AYY, Khorana AA, Kamel H. Cancer and the Risk of Perioperative Arterial Ischemic Events. Eur Heart J Qual Care Clin Outcomes 2023:qcad057. [PMID: 37757472 DOI: 10.1093/ehjqcco/qcad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
BACKGROUND AND AIMS Most cancer patients require surgery for diagnosis and treatment. This study evaluated whether cancer is a risk factor for perioperative arterial ischemic events. METHODS The primary cohort included patients registered in the National Surgical Quality Improvement Program (NSQIP) between 2006-2016. The secondary cohort included Healthcare Cost and Utilization Project (HCUP) claims data from 11 U.S. states between 2016-2018. Study populations comprised patients who underwent inpatient (NSQIP, HCUP) or outpatient (NSQIP) surgery. Study exposures were disseminated cancer (NSQIP) and all cancers (HCUP). The primary outcome was a perioperative arterial ischemic event, defined as myocardial infarction or stroke diagnosed within 30 days after surgery. RESULTS Among 5,609,675 NSQIP surgeries, 2.2% involved patients with disseminated cancer. The perioperative arterial ischemic event rate was 0.96% among patients with disseminated cancer versus 0.48% among patients without (HR, 2.01; 95% CI, 1.90-2.13). In Cox analyses adjusting for demographics, functional status, comorbidities, surgical specialty, anesthesia type, and clinical factors, disseminated cancer remained associated with higher risk of perioperative arterial ischemic events (HR, 1.37; 95% CI, 1.28-1.46). Among 1,341,658 surgical patients in the HCUP cohort, 11.8% had a diagnosis of cancer. A perioperative arterial ischemic event was diagnosed in 0.74% of patients with cancer versus 0.54% of patients without cancer (HR, 1.35; 95% CI, 1.27-1.43). In Cox analyses adjusted for demographics, insurance, comorbidities, and surgery type, cancer remained associated with higher risk of perioperative arterial ischemic events (HR, 1.31; 95% CI, 1.21-1.42). CONCLUSIONS Cancer is an independent risk factor for perioperative arterial ischemic events.
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Affiliation(s)
- Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Jed H Kaiser
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Vanessa Liao
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Mary Cushman
- Division of Hematology and Oncology, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, VT
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY
| | - Scott T Tagawa
- Division of Hematology and Oncology, Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Saketh R Guntupalli
- Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, University of Colorado School of Medicine at Denver, Aurora, CO
| | - Mario F L Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Agnes Y Y Lee
- Division of Hematology, Department of Medicine, University of British Columbia, BC Cancer, Vancouver, BC
| | - Alok A Khorana
- Department of Hematology and Oncology, Taussig Cancer Institute and Case Comprehensive Cancer Center, Cleveland Clinic, Cleveland, OH
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
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Parikh NS, Basu E, Hwang MJ, Rosenblatt R, VanWagner LB, Lim HI, Murthy SB, Kamel H. Management of Stroke in Patients With Chronic Liver Disease: A Practical Review. Stroke 2023; 54:2461-2471. [PMID: 37417238 PMCID: PMC10527812 DOI: 10.1161/strokeaha.123.043011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
Chronic liver disease (CLD) is a highly prevalent condition. There is burgeoning recognition that there are many people with subclinical liver disease that may nonetheless be clinically significant. CLD has a variety of systemic aberrations relevant to stroke, including thrombocytopenia, coagulopathy, elevated liver enzymes, and altered drug metabolism. There is a growing body of literature on the intersection of CLD and stroke. Despite this, there have been few efforts to synthesize these data, and stroke guidelines provide scant guidance on this topic. To fill this gap, this multidisciplinary review provides a contemporary overview of CLD for the vascular neurologist while appraising data regarding the impact of CLD on stroke risk, mechanisms, and outcomes. Finally, the review addresses acute and chronic treatment considerations for patients with stroke-ischemic and hemorrhagic-and CLD.
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Affiliation(s)
- Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
| | | | - Mu Ji Hwang
- Department of Neurology, Brown University, Providence, RI (M.J.H.)
| | - Russel Rosenblatt
- Division of Gastroenterology and Hepatology, Department of Internal Medicine (R.R.), Weill Cornell Medicine, New York, NY
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, Department of Internal Medicine, University of Texas Southwestern, Dallas (L.B.V.)
| | - Hana I Lim
- Division of Hematology and Oncology, Department of Internal Medicine.(H.I.L.), Weill Cornell Medicine, New York, NY
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (N.S.P., E.B., S.B.M., H.K.), Weill Cornell Medicine, New York, NY
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Ahmad MI, Chen LY, Singh S, Luqman-Arafath TK, Kamel H, Soliman EZ. Interrelations between albuminuria, electrocardiographic left atrial abnormality, and incident atrial fibrillation in the Multi-Ethnic Study of Atherosclerosis (MESA) cohort. Int J Cardiol 2023; 383:102-109. [PMID: 37100232 DOI: 10.1016/j.ijcard.2023.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/13/2023] [Accepted: 04/18/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND The objective of the study was to examine the joint associations of albuminuria and electrocardiographic left atrial abnormality (ECG-LAA) with incident atrial fibrillation (AF) and whether this relationship varies by race. METHODS This analysis included 6670 participants free of clinical cardiovascular disease (CVD), including atrial fibrillation (AF), from the Multi-Ethnic Study of Atherosclerosis. ECG-LAA was defined as P-wave terminal force in V1 [PTFV1] >5000 μV × ms. Albuminuria was defined as urine albumin-creatinine ratio (UACR) ≥30 mg/g. Incident AF events through 2015 were ascertained from hospital discharge records and study-scheduled electrocardiograms. Cox proportional hazard models were used to examine the association of "no albuminuria + no ECG-LAA (reference)", "isolated albuminuria", "isolated ECG-LAA" and "albuminuria + ECG-LAA" with incident AF. RESULTS Over a median follow-up of 13.8 years, 979 incident cases of AF occurred. In adjusted models, the concomitant presence of ECG-LAA and albuminuria was associated with a higher risk of AF than either ECG-LAA or albuminuria in isolation (HR (95% CI): 2.43 (1.65-3.58), 1.33 (1.05-1.69), and 1.55 (1.27-1.88), respectively (interaction p-value = 0.50). Effect modification by race was observed with a 4-fold greater AF risk in Black participants with albuminuria + ECG-LAA (HR (95%CI): 4.37 (2.38-8.01) but no significant association in White participants (HR (95% CI) 0.60 (0.19-1.92) respectively; (interaction p-value for race x albuminuria-ECG-LAA combination = 0.05). CONCLUSIONS Concomitant presence of ECG-LAA and albuminuria confers a higher risk of AF compared to either one in isolation with a stronger association in Blacks than Whites.
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Affiliation(s)
- Muhammad Imtiaz Ahmad
- Department of Internal Medicine, Section on Hospital Medicine, Medical College of Wisconsin, Wauwatosa, WI, United States of America.
| | - Lin Y Chen
- Lillehei Heart Institute and Cardiovascular Division, University of Minnesota Medical School, Minneapolis, United States of America
| | - Sanjay Singh
- Department of Internal Medicine, Section on Hospital Medicine, Medical College of Wisconsin, Wauwatosa, WI, United States of America
| | - T K Luqman-Arafath
- Department of Internal Medicine, Section on Hospital Medicine, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, United States of America
| | - Elsayed Z Soliman
- Epidemiological Cardiology Research Center (EPICARE), Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC, United States of America
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Kamel H, Elkind MSV. Genetics and the Quest to Define Sources of Cardiac Embolism. Stroke 2023; 54:1786-1788. [PMID: 37363943 DOI: 10.1161/strokeaha.123.043488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/28/2023]
Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, NY (H.K.)
| | - Mitchell S V Elkind
- Department of Neurology, Vagelos College of Physicians and Surgeons, and Department of Epidemiology, Mailman School of Public Health, Columbia University, NY (M.S.V.E.)
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Scholtz LC, Rosenberg J, Robbins MS, Wong T, Mints G, Kaplan A, Leung D, Kamel H, Ch'ang JH. Ultrasonography in neurology: A comprehensive analysis and review. J Neuroimaging 2023. [PMID: 37204265 DOI: 10.1111/jon.13124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/09/2023] [Accepted: 05/10/2023] [Indexed: 05/20/2023] Open
Abstract
Neurologists in both the inpatient and outpatient settings are increasingly using ultrasound to diagnose and manage common neurological diseases. Advantages include cost-effectiveness, the lack of exposure to ionizing radiation, and the ability to perform at the bedside to provide real-time data. There is a growing body of literature that supports using ultrasonography to improve diagnostic accuracy and aid in performing procedures. Despite the increasing utilization of this imaging modality in medicine, there has been no comprehensive review of the clinical applications of ultrasound in the field of neurology. We discuss the current uses and limitations of ultrasound for various neurological conditions. We review the role for ultrasound in commonly performed neurologic procedures including lumbar puncture, botulinum toxin injections, nerve blocks, and trigger point injections. We specifically discuss the technique for ultrasound-assisted lumbar puncture and occipital nerve block as these are commonly performed. We then focus on the utility of ultrasound in the diagnosis of neurologic conditions. This includes neuromuscular diseases such as motor neuron disorders, focal neuropathies, and muscular dystrophy as well as vascular conditions such as stroke and vasospasm in subarachnoid hemorrhage. We also address ultrasound's use in critically ill patients to aid in identifying increased intracranial pressure, hemodynamics, and arterial and/or venous catheterization. Finally, we address the importance of standardized ultrasound curricula in trainee education and make recommendations for the future directions of research and competency guidelines within our specialty.
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Affiliation(s)
- Laura C Scholtz
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Jon Rosenberg
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Matthew S Robbins
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Tanping Wong
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Gregory Mints
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Aaron Kaplan
- Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Dora Leung
- Department of Neurology, Hospital for Special Surgery, New York, New York, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Judy H Ch'ang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
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Homssi M, Vora A, Zhang C, Baradaran H, Kamel H, Gupta A. Association Between Spotty Calcification in Nonstenosing Extracranial Carotid Artery Plaque and Ipsilateral Ischemic Stroke. J Am Heart Assoc 2023; 12:e028525. [PMID: 37183863 PMCID: PMC10227294 DOI: 10.1161/jaha.122.028525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 04/04/2023] [Indexed: 05/16/2023]
Abstract
Background Small spotty calcifications in the coronary arteries are associated with an increased risk of myocardial infarction. We examined the association between spotty calcifications near the carotid bifurcations and ipsilateral ischemic stroke in patients with <50% luminal stenosis of the extracranial carotid arteries. Methods and Results We used data from the CAESAR (Cornell Acute Stroke Academic Registry), a prospective registry of all patients with acute ischemic stroke admitted to our institution. We included patients who met criteria for cryptogenic stroke and underwent computed tomography angiography and brain magnetic resonance imaging. Patients with extracranial carotid artery stenosis ≥50% and patients with posterior or bilateral anterior circulation infarcts were excluded. We examined the carotid bifurcations for spotty calcifications, defined as ≥1 contiguous regions of luminal calcification ≤3 mm along the long axis of the vessel. We also measured low-density plaque and maximum plaque thickness. The eligible cohort consisted of 117 patients with a mean age of 66.7±1.65 years with a median National Institute of Health Stroke Scale stroke at the time of arrival of 6 (range, 3-13). The number of spotty calcifications present within a low-density plaque was significantly associated with ipsilateral infarction (0.3±0.8 versus 0.1±0.4, P=0.02). Maximum plaque thickness was also significantly associated with ipsilateral infarction (1.4 mm ±1.5 versus 1.0 mm ±1.1, P=0.004). Conclusions Spotty calcifications associated with low-density plaque and maximum plaque thickness were associated with ipsilateral ischemic stroke in patients with nonstenotic carotid atherosclerosis, suggesting a role as imaging markers of high-risk plaque.
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Affiliation(s)
- Moayad Homssi
- Department of Radiology, Weill Cornell MedicineNew YorkNYUSA
| | - Amar Vora
- Department of Radiology, Weill Cornell MedicineNew YorkNYUSA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell MedicineNew YorkNYUSA
| | - Hediyeh Baradaran
- Department of Radiology and Imaging SciencesUniversity of UtahSalt Lake CityUTUSA
| | - Hooman Kamel
- Brain Mind Institute, Weill Cornell MedicineNew YorkNYUSA
- Department of Neurology, Weill Cornell MedicineNew YorkNYUSA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell MedicineNew YorkNYUSA
- Brain Mind Institute, Weill Cornell MedicineNew YorkNYUSA
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Zhu J, Kamel H, Gupta A, Mushlin AI, Menzies NA, Gaziano TA, Rosenthal MB, Pandya A. Prioritizing Quality Measures in Acute Stroke Care : A Cost-Effectiveness Analysis. Ann Intern Med 2023; 176:649-657. [PMID: 37126821 PMCID: PMC10211083 DOI: 10.7326/m22-3186] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND The American Heart Association and American Stroke Association (AHA/ASA) endorsed 15 process measures for acute ischemic stroke (AIS) to improve the quality of care. Identifying the highest-value measures could reduce the administrative burden of quality measure adoption while retaining much of the value of quality improvement. OBJECTIVE To prioritize AHA/ASA-endorsed quality measures for AIS on the basis of health impact and cost-effectiveness. DESIGN Individual-based stroke simulation model. DATA SOURCES Published literature. TARGET POPULATION U.S. patients with incident AIS. TIME HORIZON Lifetime. PERSPECTIVE Health care sector. INTERVENTION Current versus complete (100%) implementation at the population level of quality measures endorsed by the AHA/ASA with sufficient clinical evidence (10 of 15). OUTCOME MEASURES Life-years, quality-adjusted life-years (QALYs), incremental cost-effectiveness ratios, and incremental net health benefits. RESULTS OF BASE-CASE ANALYSIS Discounted life-years gained from complete implementation would range from 472 (tobacco use counseling) to 34 688 (early carotid imaging) for an annual AIS patient cohort. All AIS quality measures were cost-saving or highly cost-effective by AHA standards (<$50 000 per QALY for high-value care). Early carotid imaging and intravenous tissue plasminogen activator contributed the largest fraction of the total potential value of quality improvement (measured as incremental net health benefit), accounting for 72% of the total value. The top 5 quality measures accounted for 92% of the total potential value. RESULTS OF SENSITIVITY ANALYSIS A web-based user interface allows for context-specific sensitivity and scenario analyses. LIMITATION Correlations between quality measures were not incorporated. CONCLUSION Substantial variation exists in the potential net benefit of quality improvement across AIS quality measures. Benefits were highly concentrated among 5 of 10 measures assessed. Our results can help providers and payers set priorities for quality improvement efforts and value-based payments in AIS care. PRIMARY FUNDING SOURCE National Institute of Neurological Disorders and Stroke.
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Affiliation(s)
- Jinyi Zhu
- Department of Health Policy, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, NY, USA
| | - Alvin I Mushlin
- Departments of Population Health Sciences and Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Nicolas A Menzies
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Thomas A Gaziano
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Meredith B Rosenthal
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ankur Pandya
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Savelieva I, Fumagalli S, Kenny RA, Anker S, Benetos A, Boriani G, Bunch J, Dagres N, Dubner S, Fauchier L, Ferrucci L, Israel C, Kamel H, Lane DA, Lip GYH, Marchionni N, Obel I, Okumura K, Olshansky B, Potpara T, Stiles MK, Tamargo J, Ungar A. EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA). Europace 2023; 25:1249-1276. [PMID: 37061780 PMCID: PMC10105859 DOI: 10.1093/europace/euac123] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 06/27/2022] [Indexed: 04/17/2023] Open
Abstract
There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.
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Affiliation(s)
- Irina Savelieva
- Cardiovascular Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - Stefano Fumagalli
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
| | - Rose Anne Kenny
- Mercer’s Institute for Successful Ageing, Department of Medical Gerontology, St James’s Hospital, Dublin, Ireland
| | - Stefan Anker
- Department of Cardiology (CVK), Germany
- Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Germany
- German Centre for Cardiovascular Research (DZHK) partner site Berlin, Germany
- Charité Universitätsmedizin Berlin, Germany
| | - Athanase Benetos
- Department of Geriatric Medicine CHRU de Nancy and INSERM U1116, Université de Lorraine, Nancy, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | - Jared Bunch
- (HRS representative): Intermountain Medical Center, Cardiology Department, Salt Lake City,Utah, USA
- Stanford University, Department of Internal Medicine, Palo Alto, CA, USA
| | - Nikolaos Dagres
- Heart Center Leipzig, Department of Electrophysiology, Leipzig, Germany
| | - Sergio Dubner
- (LAHRS representative): Clinica Suizo Argentina, Cardiology Department, Buenos Aires Capital Federal, Argentina
| | - Laurent Fauchier
- Centre Hospitalier Universitaire Trousseau et Université François Rabelais, Tours, France
| | | | - Carsten Israel
- Evangelisches Krankenhaus Bielefeld GmbH, Bielefeld, Germany
| | - Hooman Kamel
- Department of Neurology, Weill Cornell Medical College, New York, NY, USA
| | - Deirdre A Lane
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, United Kingdom
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, United Kingdom
- Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
- Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, General Cardiology Division, University of Florence and AOU Careggi, Florence, Italy
| | - Israel Obel
- (CASSA representative): Milpark Hospital, Cardiology Unit, Johannesburg, South Africa
| | - Ken Okumura
- (APHRS representative): Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Brian Olshansky
- University of Iowa Hospitals and Clinics, Iowa CityIowa, USA
- Covenant Hospital, Waterloo, Iowa, USA
- Mercy Hospital Mason City, Iowa, USA
| | - Tatjana Potpara
- School of Medicine, Belgrade University, Serbia
- Cardiology Clinic, Clinical Center of Serbia, Serbia
| | - Martin K Stiles
- (APHRS representative): Waikato Clinical School, University of Auckland and Waikato Hospital, Hamilton, New Zealand
| | - Juan Tamargo
- Department of Pharmacology, School of Medicine, CIBERCV, Universidad Complutense, Madrid, Spain
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, Geriatric Intensive Care Unit and Geriatric Arrhythmia Unit, University of Florence and AOU Careggi, Florence, Italy
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Parikh NS, Kamel H, Zhang C, Gupta A, Cohen DE, de Leon MJ, Gottesman RF, Iadecola C. Association of liver fibrosis with cognitive test performance and brain imaging parameters in the UK Biobank study. Alzheimers Dement 2023; 19:1518-1528. [PMID: 36149265 PMCID: PMC10033462 DOI: 10.1002/alz.12795] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 08/05/2022] [Accepted: 08/09/2022] [Indexed: 11/11/2022]
Abstract
INTRODUCTION We hypothesized that liver fibrosis is associated with worse cognitive performance and corresponding brain imaging changes. METHODS We examined the association of liver fibrosis with cognition and brain imaging parameters in the UK Biobank study. Liver fibrosis was assessed using the Fibrosis-4 (FIB-4) score. The primary cognitive outcome was the digit symbol substitution test (DSST); secondary outcomes were additional executive function/processing speed and memory tests. Imaging outcomes were hippocampal, total brain, and white matter hyperintensity (WMH) volumes. RESULTS We included 105,313 participants with cognitive test data, and 41,982 with magnetic resonance imaging (MRI). In adjusted models, liver fibrosis was associated with worse performance on the DSST and tests of executive function but not memory. Liver fibrosis was associated with lower hippocampal and total brain volumes, without compelling association with WMH volume. DISCUSSION Liver fibrosis is associated with worse performance on select cognitive tests and lower hippocampal and total brain volumes. HIGHLIGHTS It is increasingly recognized that chronic liver conditions impact brain health. We performed an analysis of data from the UK Biobank prospective cohort study. Liver fibrosis was associated with worse performance on executive function tests. Liver fibrosis was not associated with memory impairment. Liver fibrosis was associated with lower hippocampal and total brain volumes.
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Affiliation(s)
- Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
| | - Ajay Gupta
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - David E Cohen
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mony J de Leon
- Department of Radiology, Weill Cornell Medicine, New York, New York, USA
| | - Rebecca F Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Research Program, Bethesda, Maryland, USA
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, New York, USA
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46
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Wechsler PM, Liberman AL, Restifo D, Abramson EL, Navi BB, Kamel H, Parikh NS. Cost-Effectiveness of Smoking Cessation Interventions in Patients With Ischemic Stroke and Transient Ischemic Attack. Stroke 2023; 54:992-1000. [PMID: 36866670 PMCID: PMC10050136 DOI: 10.1161/strokeaha.122.040356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 02/17/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Smoking cessation rates after stroke and transient ischemic attack are suboptimal, and smoking cessation interventions are underutilized. We performed a cost-effectiveness analysis of smoking cessation interventions in this population. METHODS We constructed a decision tree and used Markov models that aimed to assess the cost-effectiveness of varenicline, any pharmacotherapy with intensive counseling, and monetary incentives, compared with brief counseling alone in the secondary stroke prevention setting. Payer and societal costs of interventions and outcomes were modeled. The outcomes were recurrent stroke, myocardial infarction, and death using a lifetime horizon. Estimates and variance for the base case (35% cessation), costs and effectiveness of interventions, and outcome rates were imputed from the stroke literature. We calculated incremental cost-effectiveness ratios and incremental net monetary benefits. An intervention was considered cost-effective if the incremental cost-effectiveness ratio was less than the willingness-to-pay threshold of $100 000 per quality-adjusted life-year (QALY) or when the incremental net monetary benefit was positive. Probabilistic Monte Carlo simulations modeled the impact of parameter uncertainty. RESULTS From the payer perspective, varenicline and pharmacotherapy with intensive counseling were associated with more QALYs (0.67 and 1.00, respectively) at less total lifetime costs compared with brief counseling alone. Monetary incentives were associated with 0.71 more QALYs at an additional cost of $120 compared with brief counseling alone, yielding an incremental cost-effectiveness ratio of $168/QALY. From the societal perspective, all 3 interventions provided more QALYs at less total costs compared with brief counseling alone. In 10 000 Monte Carlo simulations, all 3 smoking cessation interventions were cost-effective in >89% of runs. CONCLUSIONS For secondary stroke prevention, it is cost-effective and potentially cost-saving to deliver smoking cessation therapy beyond brief counseling alone.
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Affiliation(s)
- Paul M Wechsler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Ava L Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Daniel Restifo
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Erika L Abramson
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, USA
| | - Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY, USA
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Burke DJ, Baig T, Goyal P, Kamel H, Sharma R, Parikh NS, McCullough SA, Zhang C, Merkler AE. Duration of Heightened Risk of Acute Ischemic Stroke After Hospitalization for Acute Systolic Heart Failure. J Am Heart Assoc 2023; 12:e027179. [PMID: 36926994 PMCID: PMC10111517 DOI: 10.1161/jaha.122.027179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/18/2023]
Abstract
Background The duration and magnitude of increased stroke risk after a hospitalization for acute systolic heart failure (HF) remains uncertain. Methods and Results The authors performed a retrospective cohort study using claims (2008-2018) from a nationally representative 5% sample of Medicare beneficiaries aged ≥66 years. Cox regression models were fitted separately for the groups with and without acute systolic HF to examine its association with the incidence of ischemic stroke after adjustment for demographics, stroke risk factors, and Charlson comorbidities. Corresponding survival probabilities were used to compute the hazard ratio (HR) in each 30-day interval after discharge. The authors stratified patients by the presence of atrial fibrillation (AF) before or during the hospitalization for acute systolic HF. Among 2 077 501 eligible beneficiaries, 94 641 were hospitalized with acute systolic HF. After adjusting for demographics, stroke risk factors, and Charlson comorbidities, the risk of ischemic stroke was highest in the first 30 days after discharge from an acute systolic HF hospitalization for patients with AF (HR, 2.4 [95% CI, 2.1-2.7]) and without AF (HR, 4.6 [95% CI, 4.0-5.3]). The risk of stroke remained elevated for 60 days in patients with AF (HR, 1.4 [95% CI, 1.2-1.6]) and was not significantly elevated afterward. The risk of stroke remained significantly elevated through 330 days in patients without AF (HR, 2.1 [95% CI, 1.7-2.7]) and was no longer significantly elevated afterward. Conclusions A hospitalization for acute systolic HF is associated with an increased risk of ischemic stroke up to 330 days in patients without concomitant AF.
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Affiliation(s)
- Devin J Burke
- Division of Neurocritical Care Weill Cornell Medicine New York NY USA
| | - Tehniyat Baig
- Weill Cornell Medicine - Qatar Doha Qatar
- Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute New York NY USA
- Department of Neurology Weill Cornell Medicine New York NY USA
| | - Parag Goyal
- Department of Medicine Weill Cornell Medicine New York NY USA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute New York NY USA
- Department of Neurology Weill Cornell Medicine New York NY USA
| | - Richa Sharma
- Department of Neurology Yale School of Medicine New Haven CT USA
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute New York NY USA
- Department of Neurology Weill Cornell Medicine New York NY USA
| | | | - Cenai Zhang
- Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute New York NY USA
- Department of Neurology Weill Cornell Medicine New York NY USA
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit Feil Family Brain and Mind Research Institute New York NY USA
- Department of Neurology Weill Cornell Medicine New York NY USA
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48
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Parikh NS, Zhang C, Omran SS, Restifo D, Carpenter MJ, Schwamm L, Kamel H. Smoking-Cessation Pharmacotherapy After Stroke and Transient Ischemic Attack: A Get With The Guidelines-Stroke Analysis. Stroke 2023; 54:e63-e65. [PMID: 36727507 PMCID: PMC9992306 DOI: 10.1161/strokeaha.122.041532] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Neal S Parikh
- Clinical and Translational Neuroscience Unit, Weill Cornell Medicine, New York, NY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Weill Cornell Medicine, New York, NY
| | | | - Daniel Restifo
- Clinical and Translational Neuroscience Unit, Weill Cornell Medicine, New York, NY
| | - Matthew J. Carpenter
- Department of Psychiatry and Behavioral Sciences, Hollings Cancer Center, Medical University of South Carolina, Charleston, SC
| | - Lee Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Weill Cornell Medicine, New York, NY
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Kamel H, Liberman AL, Merkler AE, Parikh NS, Mir SA, Segal AZ, Zhang C, Díaz I, Navi BB. Validation of the International Classification of Diseases, Tenth Revision Code for the National Institutes of Health Stroke Scale Score. Circ Cardiovasc Qual Outcomes 2023; 16:e009215. [PMID: 36862375 PMCID: PMC10237010 DOI: 10.1161/circoutcomes.122.009215] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Accepted: 10/24/2022] [Indexed: 03/03/2023]
Abstract
BACKGROUND Administrative data can be useful for stroke research but have historically lacked data on stroke severity. Hospitals increasingly report the National Institutes of Health Stroke Scale (NIHSS) score using an International Classification of Diseases, Tenth Revision (ICD-10) diagnosis code, but this code's validity remains unclear. METHODS We examined the concordance of ICD-10 NIHSS scores versus NIHSS scores recorded in CAESAR (Cornell Acute Stroke Academic Registry). We included all patients with acute ischemic stroke from October 1, 2015, when US hospitals transitioned to ICD-10, through 2018, the latest year in our registry. The NIHSS score (range, 0-42) recorded in our registry served as the reference gold standard. ICD-10 NIHSS scores were derived from hospital discharge diagnosis code R29.7xx, with the latter 2 digits representing the NIHSS score. Multiple logistic regression was used to explore factors associated with availability of ICD-10 NIHSS scores. We used ANOVA to examine the proportion of variation (R2) in the true (registry) NIHSS score that was explained by the ICD-10 NIHSS score. RESULTS Among 1357 patients, 395 (29.1%) had an ICD-10 NIHSS score recorded. This proportion increased from 0% in 2015 to 46.5% in 2018. In a logistic regression model, only higher registry NIHSS score (odds ratio per point, 1.05 [95% CI, 1.03-1.07]) and cardioembolic stroke (odds ratio, 1.4 [95% CI, 1.0-2.0]) were associated with availability of the ICD-10 NIHSS score. In an ANOVA model, the ICD-10 NIHSS score explained almost all the variation in the registry NIHSS score (R2=0.88). Fewer than 10% of patients had a large discordance (≥4 points) between their ICD-10 and registry NIHSS scores. CONCLUSIONS When present, ICD-10 codes representing NIHSS scores had excellent agreement with NIHSS scores recorded in our stroke registry. However, ICD-10 NIHSS scores were often missing, especially in less severe strokes, limiting the reliability of these codes for risk adjustment.
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Affiliation(s)
- Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Ava L. Liberman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Alexander E. Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Neal S. Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Saad A. Mir
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Alan Z. Segal
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Iván Díaz
- Department of Population Health Sciences, Weill Cornell Medicine, New York, NY
| | - Babak B. Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
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50
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Witsch J, Rutrick SB, Lansdale KN, Seitz A, Kamel H, Parikh NS, Segal AZ, Mir SA, Murthy SB, Niogi SN, Gaudino M, Girardi LN, Kim J, Devereux RB, Roman MJ, Iadecola C, Kasner SE, Zhang C, Merkler AE. Influenza-Like Illness as a Short-Term Risk Factor for Arterial Dissection. Stroke 2023; 54:e66-e68. [PMID: 36779339 DOI: 10.1161/strokeaha.122.042367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/14/2023]
Affiliation(s)
- Jens Witsch
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (J.W., S.E.K.).,Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Stephanie B Rutrick
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Kelsey N Lansdale
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Alison Seitz
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Hooman Kamel
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Neal S Parikh
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Alan Z Segal
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Saad A Mir
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Santosh B Murthy
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Sumit N Niogi
- Department of Radiology (S.N.N.), Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery (M.G., L.N.G.), Weill Cornell Medicine, New York, NY
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery (M.G., L.N.G.), Weill Cornell Medicine, New York, NY
| | - Jiwon Kim
- Division of Cardiology (J.K., R.B.D., M.J.R.), Weill Cornell Medicine, New York, NY
| | - Richard B Devereux
- Division of Cardiology (J.K., R.B.D., M.J.R.), Weill Cornell Medicine, New York, NY
| | - Mary J Roman
- Division of Cardiology (J.K., R.B.D., M.J.R.), Weill Cornell Medicine, New York, NY
| | - Costantino Iadecola
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania School of Medicine, Philadelphia (J.W., S.E.K.)
| | - Cenai Zhang
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
| | - Alexander E Merkler
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology (J.W., S.B.R., K.N.L., A.S., H.K., N.S.P., A.Z.S., S.A.M., S.B.M., C.I., C.Z., A.E.M.), Weill Cornell Medicine, New York, NY
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