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  • 1
    Online Resource
    Online Resource
    Risk of Mortality After an Arterial Ischemic Event Among Intracerebral Hemorrhage Survivors
    SAGE Publications ; 2022
    In:  The Neurohospitalist Vol. 12, No. 1 ( 2022-01), p. 19-23
    Details
    In: The Neurohospitalist, SAGE Publications, Vol. 12, No. 1 ( 2022-01), p. 19-23
    Abstract: The impact of arterial ischemic events after intracerebral hemorrhage (ICH) on outcomes is unclear. This study aimed to evaluate the risk of death among ICH survivors with and without an incident arterial ischemic event. Methods: We performed a retrospective cohort study using claims data from Medicare beneficiaries with a non-traumatic ICH from January 2008 to October 2015. Our exposure was an arterial ischemic event, a composite of acute ischemic stroke or myocardial infarction (MI), identified using validated ICD-9-CM diagnosis codes. The outcome was mortality. We used marginal structural models to analyze the risk of death among ICH patients with and without an arterial ischemic event, after adjusting for confounders as time-varying covariates. Results: Among 8,804 Medicare beneficiaries with ICH, 2,371 (26.9%) had an arterial ischemic event. During a median follow-up time of 1.9 years (interquartile range, 0.7-3.9), ICH patients with an arterial ischemic event had a mortality rate of 21.7 (95% confidence interval [CI], 20.4-23.0) per 100 person-years compared to a rate of 15.0 (95% CI, 14.4-15.6) per 100 person-years in those without. In the marginal structural model, an arterial ischemic event was associated with an increased risk of death (hazard ratio [HR] , 1.8; 95% confidence interval [CI], 1.6-1.9). In secondary analyses, the mortality risk was elevated after an ischemic stroke (HR, 1.7; 95% CI, 1.5-1.8), and MI (HR, 3.0; 95% CI, 2.4-3.8). Conclusions: We found that elderly patients who survived an ICH had an increased risk of death after a subsequent ischemic stroke or MI.
    Type of Medium: Online Resource
    ISSN: 1941-8744 , 1941-8752
    URL: Article
    DOI: 10.1177/19418744211026709
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2022
    detail.hit.zdb_id: 2629083-2
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  • 2
    Online Resource
    Online Resource
    Association between elevated fibrosis-4 index of liver fibrosis and risk of hemorrhagic stroke
    SAGE Publications ; 2024
    In:  European Stroke Journal
    Details
    In: European Stroke Journal, SAGE Publications
    Abstract: Cirrhosis is associated with an increased risk of hemorrhagic stroke. Liver fibrosis, typically a silent condition, is antecedent to cirrhosis. The objective of this study was to test the hypothesis that elevated Fibrosis-4 (FIB-4) index, indicating a high probability of liver fibrosis, is associated with an increased risk of hemorrhagic stroke. Methods: We performed a cohort analysis of the prospective United Kingdom Biobank cohort study. Participants 40–69 years old were enrolled between 2007 and 2010 and had available follow-up data until March 1, 2018. We excluded participants with prevalent hemorrhagic stroke or thrombocytopenia. High probability of liver fibrosis was defined as having a value 〉 2.67 of the validated FIB-4 index. The primary outcome was hemorrhagic stroke (intracerebral or subarachnoid hemorrhage), defined based on hospitalization and death registry data. Secondary outcomes were intracerebral and subarachnoid hemorrhage, separately. We used Cox proportional hazards models to evaluate the association of FIB-4 index 〉 2.67 with hemorrhagic stroke while adjusting for potential confounders including hypertension, alcohol use, and antithrombotic use. Results: Among 452,994 participants (mean age, 57 years; 54% women), approximately 2% had FIB-4 index 〉 2.67, and 1241 developed hemorrhagic stroke. In adjusted models, FIB-4 index 〉 2.67 was associated with an increased risk of hemorrhagic stroke (HR, 2.0; 95% CI, 1.6–2.6). Results were similar for intracerebral hemorrhage (HR, 2.0; 95% CI, 1.5–2.7) and subarachnoid hemorrhage (HR, 2.2; 95% CI, 1.5–3.5) individually. Conclusions: Elevated FIB-4 index was associated with an increased risk of hemorrhagic stroke.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/23969873241259561
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2024
    detail.hit.zdb_id: 2851287-X
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  • 3
    Online Resource
    Online Resource
    Long-Term Risk of Hip Fracture After Ischemic Stroke
    SAGE Publications ; 2020
    In:  The Neurohospitalist Vol. 10, No. 2 ( 2020-04), p. 95-99
    Details
    In: The Neurohospitalist, SAGE Publications, Vol. 10, No. 2 ( 2020-04), p. 95-99
    Abstract: Data are lacking on the long-term risk of hip fracture among patients with ischemic stroke. A better understanding of the contemporary incidence of hip fracture after ischemic stroke could benefit patient care by promoting strategies to prevent this disabling complication in stroke survivors. Methods: We performed a retrospective cohort study using inpatient and outpatient claims between 2008 and 2015 from a nationally representative 5% sample of Medicare beneficiaries. We included patients ≥66 years of age who were hospitalized with acute ischemic stroke, defined through a validated diagnostic code algorithm. We excluded patients who had a prior or concurrent hip fracture diagnosis at the time of ischemic stroke. The primary outcome was hip fracture requiring hospitalization. Survival statistics were used to calculate crude incidence rates, and the Kaplan-Meier method was used to calculate cumulative rates. Results: Among the 1 772 550 beneficiaries in our sample, 60 099 were diagnosed with an acute ischemic stroke without prior or concomitant hip fracture. During 4.5 (±2.2) years of follow-up, the incidence of hip fracture was 1.6 (95% confidence interval [CI]: 1.5-1.6) per 100 person-years in patients with acute ischemic stroke versus 0.6 (95% CI: 0.6-0.6) per 100 person-years in patients without acute ischemic stroke. The cumulative 5-year rate of hip fracture was 7.6% (95% CI: 7.2%-8.0%) among patients with acute ischemic stroke versus 2.8% (95% CI: 2.8%-2.9%) among the remaining Medicare beneficiaries. Conclusion: We found that among elderly Medicare beneficiaries with acute ischemic stroke, nearly 1 in 12 developed a hip fracture over the next 5 years.
    Type of Medium: Online Resource
    ISSN: 1941-8744 , 1941-8752
    URL: Article
    DOI: 10.1177/1941874419859755
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2020
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  • 4
    Online Resource
    Online Resource
    The Use of Neuroimaging Studies and Neurological Consultation to Evaluate Dizzy Patients in the Emergency Department
    SAGE Publications ; 2013
    In:  The Neurohospitalist Vol. 3, No. 1 ( 2013-01), p. 7-14
    Details
    In: The Neurohospitalist, SAGE Publications, Vol. 3, No. 1 ( 2013-01), p. 7-14
    Abstract: Dizziness is a frequent reason for neuroimaging and neurological consultation, but little is known about the utility of either practice. We sought to characterize the patterns and yield of neuroimaging and neurological consultation for dizziness in the emergency department (ED). Methods: We retrospectively identified consecutive adults presenting to an academic ED from 2007 to 2009, with a primary complaint of dizziness, vertigo, or imbalance. Neurologists reviewed medical records to determine clinical characteristics, whether a neuroimaging study (head computed tomography [CT] or brain magnetic resonance imaging [MRI] ) or neurology consultation was obtained in the ED, and to identify relevant findings on neuroimaging studies. Two neurologists assigned a final diagnosis for the cause of dizziness. Logistic regression was used to evaluate bivariate and multivariate predictors of neuroimaging and consultation. Results: Of 907 dizzy patients (mean age 59 years; 58% women), 321 (35%) had a neuroimaging study (28% CT, 11% MRI, and 4% both) and 180 (20%) had neurological consultation. Serious neurological disease was ultimately diagnosed in 13% of patients with neuroimaging and 21% of patients with neurological consultation, compared to 5% of the overall cohort. Headache and focal neurological deficits were associated with both neuroimaging and neurological consultation, while age ≥60 years and prior stroke predicted neuroimaging but not consultation, and positional symptoms predicted consultation but not neuroimaging. Conclusion: In a tertiary care ED, neuroimaging and neurological consultation were frequently utilized to evaluate dizzy patients, and their diagnostic yield was substantial.
    Type of Medium: Online Resource
    ISSN: 1941-8744 , 1941-8752
    URL: Article
    DOI: 10.1177/1941874412458677
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2013
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  • 5
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    Online Resource
    Tissue-Based Thrombolysis for Wake-Up Stroke With Basilar Artery Occlusion: A Case Report
    SAGE Publications ; 2023
    In:  The Neurohospitalist Vol. 13, No. 1 ( 2023-01), p. 86-89
    Details
    In: The Neurohospitalist, SAGE Publications, Vol. 13, No. 1 ( 2023-01), p. 86-89
    Abstract: Stroke from basilar artery occlusion is associated with a poor natural history with high rates of death and disability. Intravenous thrombolysis administered within 4.5 hours of last known well time improves the odds of a good neurological outcome after ischemic stroke, including in patients with basilar artery occlusion. Thrombectomy for basilar artery occlusion has had mixed outcomes. The WAKE-UP randomized clinical trial demonstrated that administration of intravenous thrombolysis can benefit select patients with wake-up strokes whose brain MRI shows restricted diffusion but no accompanying T2 FLAIR change. We report a case of a wake-up acute ischemic stroke presenting with acute vertigo followed by progressive brainstem dysfunction from a basilar artery occlusion. The patient was successfully treated with intravenous thrombolysis beyond 4.5 hours of last known well and symptom discovery time according to an MRI tissue-based approach resulting in partial recanalization of her basilar artery and recovery to near normal. This case suggests that hyperacute MRI can serve as a tissue clock to select patients with wake-up stroke for acute reperfusion therapy even if they do not meet standard trial inclusion criteria, including patients with basilar artery occlusion.
    Type of Medium: Online Resource
    ISSN: 1941-8744 , 1941-8752
    URL: Article
    DOI: 10.1177/19418744221119597
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2023
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  • 6
    Online Resource
    Online Resource
    Evaluation of Transient Ischemic Attack and Minor Stroke: A Rapid Outpatient Model for the COVID-19 Pandemic and Beyond
    SAGE Publications ; 2022
    In:  The Neurohospitalist Vol. 12, No. 1 ( 2022-01), p. 38-47
    Details
    In: The Neurohospitalist, SAGE Publications, Vol. 12, No. 1 ( 2022-01), p. 38-47
    Abstract: The grim circumstances of the COVID-19 pandemic have highlighted the need to refine and adapt stroke systems of care. Patients’ care-seeking behaviors have changed due to perceived risks of in-hospital treatment during the pandemic. In response to these challenges, we optimized a recently implemented, novel outpatient approach for the evaluation and management of minor stroke and transient ischemic attack, entitled RESCUE-TIA. This modified approach incorporated telemedicine visits and remote testing, and proved valuable during the pandemic. In this review article, we provide the evidence-based rationale for our approach, describe its operationalization, and provide data from our initial experience.
    Type of Medium: Online Resource
    ISSN: 1941-8744 , 1941-8752
    URL: Article
    DOI: 10.1177/19418744211000508
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2022
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  • 7
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    Online Resource
    Relationship between Lambl’s excrescences and embolic strokes of undetermined source
    SAGE Publications ; 2020
    In:  European Stroke Journal Vol. 5, No. 2 ( 2020-06), p. 169-173
    Details
    In: European Stroke Journal, SAGE Publications, Vol. 5, No. 2 ( 2020-06), p. 169-173
    Abstract: About one-fourth of ischaemic strokes are classified as embolic strokes of undetermined source. Lambl’s excrescences are commonly seen on cardiac valves, and data are limited on whether they may be a source of embolization. We examined the relationship between Lambl’s excrescences and embolic stroke of undetermined source. Patients and Methods We performed a case-control study of patients in the Cornell AcutE Stroke Academic Registry. Stroke aetiologies were adjudicated using the Trial of Org 10172 in Acute Stroke Treatment and embolic stroke of undetermined source criteria. We included patients with acute ischaemic stroke between 2011 and 2016 who underwent transthoracic or transoesophageal echocardiography within six months of hospitalisation. Cases were embolic stroke of undetermined source patients and controls were patients with an identified, non-cardioembolic stroke aetiology (i.e. small- or large-vessel strokes). Multiple logistic regression was used to evaluate the association between Lambl’s excrescences and embolic stroke of undetermined source after adjustment for demographics, comorbidities and mode of echocardiography. Results A total of 923 patients met the criteria for this analysis, including 530 with embolic stroke of undetermined source and 393 with small- or large-vessel strokes. Lambl’s excrescences were identified in 47 (8.9%) patients with embolic stroke of undetermined source and 11 (2.8%) patients with small- or large-artery strokes, but the majority (54/58) of Lambl’s excrescences were visualised on transoesophageal echocardiogram and embolic stroke of undetermined source patients were more likely to undergo transoesophageal echocardiogram. After adjustment for demographics, comorbidities and mode of echocardiography, we found no association between the presence of Lambl’s excrescences and embolic stroke of undetermined source (odds ratio 0.9; 95% confidence interval 0.4–2.3). Conclusion We found no association between Lambl’s excrescences and embolic stroke of undetermined source. These results do not support the hypothesis that Lambl’s excrescences are an occult cause of embolic stroke of undetermined source.
    Type of Medium: Online Resource
    ISSN: 2396-9873 , 2396-9881
    URL: Article
    DOI: 10.1177/2396987319901201
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2020
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  • 8
    Online Resource
    Online Resource
    Outcomes of patients with pre-existing disability managed by mobile stroke units: A sub-analysis of the BEST-MSU study
    SAGE Publications ; 2023
    In:  International Journal of Stroke
    Details
    In: International Journal of Stroke, SAGE Publications
    Abstract: Few data exist on acute stroke treatment in patients with pre-existing disability (PD) since they are usually excluded from clinical trials. A recent trial of mobile stroke units (MSUs) demonstrated faster treatment and improved outcomes, and included PD patients. Aim: To determine outcomes with tissue plasminogen activator (tPA), and benefit of MSU versus management by emergency medical services (EMS), for PD patients. Methods: Primary outcomes were utility-weighted modified Rankin Scale (uw-mRS). Linear and logistic regression models compared outcomes in patients with versus without PD, and PD patients treated by MSU versus standard management by EMS. Time metrics, safety, quality of life, and health-care utilization were compared. Results: Of the 1047 tPA-eligible ischemic stroke patients, 254 were with PD (baseline mRS 2–5) and 793 were without PD (baseline mRS 0–1). Although PD patients had worse 90-day uw-mRS, higher mortality, more health-care utilization, and worse quality of life than non-disabled patients, 53% returned to at least their baseline mRS, those treated faster had better outcome, and there was no increased bleeding risk. Comparing PD patients treated by MSU versus EMS, 90-day uw-mRS was 0.42 versus 0.36 (p = 0.07) and 57% versus 46% returned to at least their baseline mRS. There was no interaction between disability status and MSU versus EMS group assignment (p = 0.67) for 90-day uw-mRS. Conclusion: PD did not prevent the benefit of faster treatment with tPA in the BEST-MSU study. Our data support inclusion of PD patients in the MSU management paradigm.
    Type of Medium: Online Resource
    ISSN: 1747-4930 , 1747-4949
    URL: Article
    DOI: 10.1177/17474930231185471
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2023
    detail.hit.zdb_id: 2211666-7
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  • 9
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    Online Resource
    Amyloid β-Related Central Nervous System Angiitis Presenting With an Isolated Seizure
    SAGE Publications ; 2014
    In:  The Neurohospitalist Vol. 4, No. 2 ( 2014-04), p. 86-89
    Details
    In: The Neurohospitalist, SAGE Publications, Vol. 4, No. 2 ( 2014-04), p. 86-89
    Abstract: Amyloid beta-related angiitis (ABRA) of the central nervous system (CNS) is a very rare inflammatory disorder that causes destruction of CNS arteries and subsequent neuronal injury. Most patients with ABRA are old and present with cognitive dysfunction and stroke; however, some patients may present atypically. In this article, we report a 44-year-old man who presented with a first-time seizure but was otherwise neurologically intact and denied any headache. Brain MRI showed right hemispheric and bilateral medial frontal lobe hyperintensities and microhemorrhages that were most suspicious for a mass lesion. An extensive diagnostic evaluation including CSF analysis and catheter angiography was unremarkable. A brain biopsy with specific stains for amyloid surprisingly demonstrated ABRA and led to immunosuppressive treatment. The patient has remained neurologically intact and seizure-free 1 year after presentation. This case demonstrates that ABRA can occur in young patients without headache or neurologic deficits, and should be considered in patients with new-onset seizures and mass lesions. It also reinforces the need to consider a brain biopsy in patients with idiopathic brain lesions and negative non-invasive testing, as it is virtually impossible to confirm the diagnosis of ABRA otherwise.
    Type of Medium: Online Resource
    ISSN: 1941-8744 , 1941-8752
    URL: Article
    DOI: 10.1177/1941874413502796
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2014
    detail.hit.zdb_id: 2629083-2
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  • 10
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    Online Resource
    Endovascular Therapy for Acute Stroke in Patients With Cancer
    SAGE Publications ; 2014
    In:  The Neurohospitalist Vol. 4, No. 3 ( 2014-07), p. 133-135
    Details
    In: The Neurohospitalist, SAGE Publications, Vol. 4, No. 3 ( 2014-07), p. 133-135
    Abstract: Intravenous thrombolysis is the standard treatment for acute ischemic stroke (AIS). However, patients with cancer who have stroke are often precluded from therapy because of coagulopathy or recent surgery. Endovascular therapy may be a more suitable recanalization strategy for some patients with cancer and stroke, but no prior detailed reports documenting its use in this population exist. We present a case series from a tertiary care referral center of 2 patients with active systemic cancer who were successfully treated with endovascular therapy for AIS. Both patients had active lung cancer with excellent premorbid functional status and presented with severe AIS from left middle cerebral artery occlusions. Intravenous thrombolysis was deferred because of absolute contraindications. Mechanical embolectomy was performed instead and revascularization was achieved within 5 hours in both patients, resulting in dramatic neurological recoveries— National Institutes of Health Stroke Scale improved from 14 to 0 and from 23 to 3 from admission to discharge, respectively. In conclusion, endovascular therapy may be beneficial for select patients with cancer and AIS who are ineligible for intravenous thrombolysis. However, further studies are needed to determine the safety and efficacy of endovascular therapy in the population with cancer.
    Type of Medium: Online Resource
    ISSN: 1941-8744 , 1941-8752
    URL: Article
    DOI: 10.1177/1941874413520509
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2014
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