Publications by authors named "Ava L Liberman"

42 Publications

Ischaemic stroke on anticoagulation therapy and early recurrence in acute cardioembolic stroke: the IAC study.

J Neurol Neurosurg Psychiatry 2021 Apr 26. Epub 2021 Apr 26.

Neuroscience Institute, Spectrum Health, Grand Rapids, Michigan, USA.

Background And Purpose: A subset of ischaemic stroke patients with atrial fibrillation (AF) have ischaemic stroke despite anticoagulation. We sought to determine the association between prestroke anticoagulant therapy and recurrent ischaemic events and symptomatic intracranial haemorrhage (sICH).

Methods: We included consecutive patients with acute ischaemic stroke and AF from the Initiation of Anticoagulation after Cardioembolic stroke (IAC) study from eight comprehensive stroke centres in the USA. We compared recurrent ischaemic events and delayed sICH risk using adjusted Cox regression analyses between patients who were prescribed anticoagulation (ACp) versus patients who were naïve to anticoagulation therapy prior to the ischaemic stroke (anticoagulation naïve).

Results: Among 2084 patients in IAC, 1518 had prior anticoagulation status recorded and were followed for 90 days. In adjusted Cox hazard models, ACp was associated with some evidence of a higher risk higher risk of 90-day recurrent ischaemic events only in the fully adjusted model (adjusted HR 1.50, 95% CI 0.99 to 2.28, p=0.058) but not increased risk of 90-day sICH (adjusted HR 1.08, 95% CI 0.46 to 2.51, p=0.862). In addition, switching anticoagulation class was not associated with reduced risk of recurrent ischaemic events (adjusted HR 0.41, 95% CI 0.12 to 1.33, p=0.136) nor sICH (adjusted HR 1.47, 95% CI 0.29 to 7.50, p=0.641).

Conclusion: AF patients with ischaemic stroke despite anticoagulation may have higher recurrent ischaemic event risk compared with anticoagulation-naïve patients. This suggests differing underlying pathomechanisms requiring different stroke prevention measures and identifying these mechanisms may improve secondary prevention strategies.
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http://dx.doi.org/10.1136/jnnp-2021-326166DOI Listing
April 2021

Associating cryptogenic ischemic stroke in the young with cardiovascular risk factor phenotypes.

Sci Rep 2021 Jan 11;11(1):275. Epub 2021 Jan 11.

Department of Neurology, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA.

Acute Ischemic Stroke (AIS) in the young is increasing in prevalence and the largest subtype within this cohort is cryptogenic. To curb this trend, new ways of defining cryptogenic stroke and associated risk factors are needed. We aimed to gain insights into the presence or absence of cardiovascular risk factors in cases of cryptogenic stroke. We conducted a retrospective cohort study of patients aged 18-49 who presented to an urban tertiary care center with AIS. We manually collected predefined demographic, clinical, laboratory and radiological variables. Clinical risk phenotypes were determined using these variables through multivariate analysis of patients with the small and large vessel disease subtypes (vascular phenotype) and cardioembolic subtype (cardiac phenotype). The resultant phenotype models were applied to cases deemed cryptogenic. Within the 449 patients who met criteria, patients with small and large vessel disease (vascular phenotype) had higher rates of hypertension, intracranial atherosclerosis, and diabetes mellitus, and higher admission glucose, HbA1c, admission blood pressure, and cholesterol compared to the patients with cardioembolic AIS. The cardioembolic subgroup (cardiac phenotype) had significantly higher rates of congestive heart failure (CHF), rheumatic heart disease, atrial fibrillation, clotting disorders, left ventricular hypertrophy, larger left atrial sizes, lower ejection fractions, and higher B-type natriuretic peptide and troponin levels. Adjusted multivariate analysis produced six variables independently associated with the vascular phenotype (age, male sex, hemoglobin A1c, ejection fraction (EF), low-density lipoprotein (LDL) cholesterol, and family history of AIS) and five independently associated with the cardiac phenotype (age, female sex, decreased EF, CHF, and absence of intracranial atherosclerosis). Applying these models to cryptogenic stroke cases yielded that 51.5% fit the vascular phenotype and 3.1% fit the cardiac phenotype. In our cohort, half of young patients with cryptogenic stroke fit the risk factor phenotype of small and large vessel strokes.
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http://dx.doi.org/10.1038/s41598-020-79499-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7801422PMC
January 2021

Prevalence of Cervical Artery Dissection Among Hospitalized Patients With Stroke by Age in a Nationally Representative Sample From the United States.

Neurology 2021 02 4;96(7):e1005-e1011. Epub 2021 Jan 4.

From the Clinical and Translational Neuroscience Unit (Y.B.A., P.P., A.C., S.M., B.B.N., C.Z., H.K., A.E.M.), Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medical College; and Department of Neurology (A.L.L., J.D.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

Objective: To test the hypothesis that the prevalence of cervical artery dissection remains constant across age groups, we evaluated the relationship between age and cervical artery dissection in patients with stroke using a nationally representative sample from the United States.

Methods: We used inpatient claims data included in the 2012-2015 releases of the National Inpatient Sample (NIS). We used validated ICD-9-CM codes to identify adults hospitalized with ischemic stroke and a concomitant diagnosis of carotid or vertebral artery dissection. Survey weights provided by the NIS and population estimates from the US census were used to calculate nationally representative estimates. The χ test for trend was used to compare the prevalence of concomitant dissection among stroke hospitalizations across patient subgroups defined by age. Poisson regression and the Wald test for trend were used to evaluate whether the prevalence of hospitalizations for stroke and concomitant dissection per million person-years varied by age groups.

Results: There were 17,320 (95% confidence interval [CI], 15,614-19,026) hospitalizations involving ischemic stroke and a concomitant dissection. The prevalence of dissection among stroke hospitalizations decreased across 10-year age groups from 7.2% (95% CI, 6.2%-8.1%) among persons younger than 30 years to 0.2% (95% CI, 0.1%-0.2%) among persons older than 80 years ( value for trend <0.001). However, the prevalence of hospitalizations for stroke and concomitant dissection increased from 5.4 (95% CI, 4.6-6.2) hospitalizations per million person-years among adults younger than 30 to 24.4 (95% CI, 21.0-27.9) hospitalizations per million person-years among adults older than age 80 ( value for trend <0.01).

Conclusion: In a nationally representative sample, the prevalence of hospitalizations for dissection-related stroke increased with age.
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http://dx.doi.org/10.1212/WNL.0000000000011420DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8055335PMC
February 2021

Factors associated with hospitalization for ischemic stroke and TIA following an emergency department headache visit.

Am J Emerg Med 2020 Nov 7. Epub 2020 Nov 7.

Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, United States of America. Electronic address:

Background: Misdiagnosis of cerebrovascular disease among Emergency Department (ED) patients with headache has been reported. We hypothesized that markers of substandard diagnostic processes would be associated with subsequent ischemic cerebrovascular events among patients discharged from the ED with a headache diagnosis even after adjusting for demographic variables and medical history.

Methods: We conducted a case-control study of adult ED patients diagnosed with a primary headache disorder at Montefiore Medical Center from 9/1/2013-9/1/2018. Cases were defined as patients hospitalized for an ischemic stroke or TIA within 365 days of their index ED visit. Control patients were defined as those who lacked a subsequent hospitalization for cerebrovascular disease. Pre-specified demographic, clinical, and diagnostic process factors were compared between groups; conditional logistic regression was used to assess the separate and joint influence of baseline features on risk of cerebral ischemia.

Results: A total of 93 consecutive headache patients with a subsequent ischemic stroke/TIA hospitalization were matched to 93 controls (n = 186). Cases were older than controls and more likely to have traditional cerebrovascular risk factors. Neurological consultation was obtained more often for cases (13% vs. 4%; P = 0.03), cases were in the ED for longer (6 vs. 5 h, P = 0.03), and more frequently received neuroimaging (80% vs. 48%; P < 0.0001). Rates of neurological examination, documented differential diagnoses, and clear discharge follow up plans were similar between cases and controls. In our conditional logistic regression model, only history of prior stroke/TIA was associated with increased odds of subsequent cerebral ischemia.

Conclusion: Factors associated with diagnostic process failures did not increase the odds of subsequent ischemic stroke/TIA hospitalization following ED headache visit in our study.
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http://dx.doi.org/10.1016/j.ajem.2020.10.082DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8102647PMC
November 2020

Head Computed tomography during emergency department treat-and-release visit for headache is associated with increased risk of subsequent cerebrovascular disease hospitalization.

Diagnosis (Berl) 2021 May 5;8(2):199-208. Epub 2020 Oct 5.

Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

Objectives: The occurrence of head computed tomography (HCT) at emergency department (ED) visit for non-specific neurological symptoms has been associated with increased subsequent stroke risk and may be a marker of diagnostic error. We evaluate whether HCT occurrence among ED headache patients is associated with increased subsequent cerebrovascular disease risk.

Methods: We conducted a retrospective cohort study of consecutive adult patients with headache who were discharged home from the ED (ED treat-and-release visit) at one multicenter institution. Patients with headache were defined as those with primary discharge diagnoses codes for benign headache from 9/1/2013-9/1/2018. The primary outcome of cerebrovascular disease hospitalization was identified using codes and confirmed via chart review. We matched headache patients who had a HCT (exposed) to those who did not have a HCT (unexposed) in the ED in a one-to-one fashion using propensity score methods.

Results: Among the 28,121 adult patients with ED treat-and-release headache visit, 45.6% (n=12,811) underwent HCT. A total of 0.4% (n=111) had a cerebrovascular hospitalization within 365 days of index visit. Using propensity score matching, 80.4% (n=10,296) of exposed patients were matched to unexposed. Exposed patients had increased risk of cerebrovascular hospitalization at 365 days (RR: 1.65: 95% CI: 1.18-2.31) and 180 days (RR: 1.62; 95% CI: 1.06-2.49); risk of cerebrovascular hospitalization was not increased at 90 or 30 days.

Conclusions: Having a HCT performed at ED treat-and-release headache visit is associated with increased risk of subsequent cerebrovascular disease. Future work to improve cerebrovascular disease prevention strategies in this subset of headache patients is warranted.
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http://dx.doi.org/10.1515/dx-2020-0082DOI Listing
May 2021

Anticoagulation Type and Early Recurrence in Cardioembolic Stroke: The IAC Study.

Stroke 2020 09 6;51(9):2724-2732. Epub 2020 Aug 6.

Department of Neurology, Spectrum Health, Grand Rapids, MI (H.P., H.M., J.T., M.V., M.K.).

Background And Purpose: In patients with acute ischemic stroke and atrial fibrillation, treatment with low molecular weight heparin increases early hemorrhagic risk without reducing early recurrence, and there is limited data comparing warfarin to direct oral anticoagulant (DOAC) therapy. We aim to compare the effects of the treatments above on the risk of 90-day recurrent ischemic events and delayed symptomatic intracranial hemorrhage.

Methods: We included consecutive patients with acute ischemic stroke and atrial fibrillation from the IAC (Initiation of Anticoagulation after Cardioembolic) stroke study pooling data from stroke registries of 8 comprehensive stroke centers across the United States. We compared recurrent ischemic events and delayed symptomatic intracranial hemorrhage between each of the following groups in separate Cox-regression analyses: (1) DOAC versus warfarin and (2) bridging with heparin/low molecular weight heparin versus no bridging, adjusting for pertinent confounders to test these associations.

Results: We identified 1289 patients who met the bridging versus no bridging analysis inclusion criteria and 1251 patients who met the DOAC versus warfarin analysis inclusion criteria. In adjusted Cox-regression models, bridging (versus no bridging) treatment was associated with a high risk of delayed symptomatic intracranial hemorrhage (hazard ratio, 2.74 [95% CI, 1.01-7.42]) but a similar rate of recurrent ischemic events (hazard ratio, 1.23 [95% CI, 0.63-2.40]). Furthermore, DOAC (versus warfarin) treatment was associated with a lower risk of recurrent ischemic events (hazard ratio, 0.51 [95% CI, 0.29-0.87]) but not delayed symptomatic intracranial hemorrhage (hazard ratio, 0.57 [95% CI, 0.22-1.48]).

Conclusions: Our study suggests that patients with ischemic stroke and atrial fibrillation would benefit from the initiation of a DOAC without bridging therapy. Due to our study limitations, these findings should be interpreted with caution pending confirmation from large prospective studies.
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http://dx.doi.org/10.1161/STROKEAHA.120.028867DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7484360PMC
September 2020

WITHDRAWN: Neurological examination, rather than vascular risk factor assessment, serves to distinguish strokes from stroke mimics in a population with high prevalence of vascular risk factors.

World Neurosurg 2020 Jul 18. Epub 2020 Jul 18.

Department of Radiology, Albert Einstein College of Medicine.

This article has been withdrawn at the request of the author(s) and/or editor. The Publisher apologizes for any inconvenience this may cause. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/our-business/policies/article-withdrawal.
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http://dx.doi.org/10.1016/j.wneu.2020.07.075DOI Listing
July 2020

Anticoagulation Timing in Cardioembolic Stroke and Recurrent Event Risk.

Ann Neurol 2020 10 5;88(4):807-816. Epub 2020 Aug 5.

Department of Neurology, Brown University, Providence, Rhode Island, USA.

Objective: Guidelines recommend initiating anticoagulation within 4 to 14 days after cardioembolic stroke. Data supporting this did not account for key factors potentially affecting the decision to initiate anticoagulation, such as infarct size, hemorrhagic transformation, or high-risk features on echocardiography.

Methods: We pooled data from stroke registries of 8 comprehensive stroke centers across the United States. We included consecutive patients admitted with ischemic stroke and atrial fibrillation. The primary predictor was timing of initiating anticoagulation (0-3 days, 4-14 days, or >14 days), and outcomes were recurrent stroke/transient ischemic attack/systemic embolism, symptomatic intracerebral hemorrhage (sICH), and major extracranial hemorrhage (ECH) within 90 days.

Results: Among 2,084 patients, 1,289 met the inclusion criteria. The combined endpoint occurred in 10.1% (n = 130) subjects (87 ischemic events, 20 sICH, and 29 ECH). Overall, there was no significant difference in the composite endpoint between the 3 groups (0-3 days: 10.3%, 64/617; 4-14 days: 9.7%, 52/535; >14 days: 10.2%, 14/137; p = 0.933). In adjusted models, patients started on anticoagulation between 4 and 14 days did not have a lower rate of sICH (vs 0-3 days; odds ratio [OR] = 1.49, 95% confidence interval [CI] = 0.50-4.43), nor did they have a lower rate of recurrent ischemic events (vs >14 days; OR = 0.76, 95% CI = 0.36-1.62, p = 0.482).

Interpretation: In this multicenter real-world cohort, the recommended (4-14 days) time frame to start oral anticoagulation was not associated with reduced ischemic and hemorrhagic outcomes. Randomized trials are required to determine the optimal timing of anticoagulation initiation. ANN NEUROL 2020;88:807-816.
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http://dx.doi.org/10.1002/ana.25844DOI Listing
October 2020

Factors associated with therapeutic anticoagulation status in patients with ischemic stroke and atrial fibrillation.

J Stroke Cerebrovasc Dis 2020 Jul 13;29(7):104888. Epub 2020 May 13.

Department of Neurology, University of Utah, Salt Lake City, UT, USA.

Background And Purpose: Understanding factors associated with ischemic stroke despite therapeutic anticoagulation is an important goal to improve stroke prevention strategies in patients with atrial fibrillation (AF). We aim to determine factors associated with therapeutic or supratherapeutic anticoagulation status at the time of ischemic stroke in patients with AF.

Methods: The Initiation of Anticoagulation after Cardioembolic stroke (IAC) study is a multicenter study pooling data from stroke registries of eight comprehensive stroke centers across the United States. Consecutive patients hospitalized with acute ischemic stroke in the setting of AF were included in the IAC cohort. For this study, we only included patients who reported taking warfarin at the time of the ischemic stroke. Patients not on anticoagulation and patients who reported use of a direct oral anticoagulant were excluded. Analyses were stratified based on therapeutic (INR ≥2) versus subtherapeutic (INR <2) anticoagulation status. We used binary logistic regression models to determine factors independently associated with anticoagulation status after adjustment for pertinent confounders. In particular, we sought to determine whether atherosclerosis with 50% or more luminal narrowing in an artery supplying the infarct (a marker for a competing atherosclerotic mechanism) and small stroke size (≤ 10 mL; implying a competing small vessel disease mechanism) related to anticoagulant status.

Results: Of the 2084 patients enrolled in the IAC study, 382 patients met the inclusion criteria. The mean age was 77.4 ± 10.9 years and 52.4% (200/382) were women. A total of 222 (58.1%) subjects presented with subtherapeutic INR. In adjusted models, small stroke size (OR 1.74 95% CI 1.10-2.76, p = 0.019) and atherosclerosis with 50% or more narrowing in an artery supplying the infarct (OR 1.96 95% CI 1.06-3.63, p = 0.031) were independently associated with INR ≥2 at the time of their index stroke.

Conclusion: Small stroke size (≤ 10 ml) and ipsilateral atherosclerosis with 50% or more narrowing may indicate a competing stroke mechanism. There may be important opportunities to improve stroke prevention strategies for patients with AF by targeting additional ischemic stroke mechanisms to improve patient outcomes.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104888DOI Listing
July 2020

Early ischaemic and haemorrhagic complications after atrial fibrillation-related ischaemic stroke: analysis of the IAC study.

J Neurol Neurosurg Psychiatry 2020 07 13;91(7):750-755. Epub 2020 May 13.

Department of Neurology, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA.

Introduction: Predictors of long-term ischaemic and haemorrhagic complications in atrial fibrillation (AF) have been studied, but there are limited data on predictors of early ischaemic and haemorrhagic complications after AF-associated ischaemic stroke. We sought to determine these predictors.

Methods: The Initiation of Anticoagulation after Cardioembolic stroke study is a multicentre retrospective study across that pooled data from consecutive patients with ischaemic stroke in the setting of AF from stroke registries across eight comprehensive stroke centres in the USA. The coprimary outcomes were recurrent ischaemic event (stroke/TIA/systemic arterial embolism) and delayed symptomatic intracranial haemorrhage (d-sICH) within 90 days. We performed univariate analyses and Cox regression analyses including important predictors on univariate analyses to determine independent predictors of early ischaemic events (stroke/TIA/systemic embolism) and d-sICH.

Results: Out of 2084 patients, 1520 patients qualified; 104 patients (6.8%) had recurrent ischaemic events and 23 patients (1.5%) had d-sICH within 90 days from the index event. In Cox regression models, factors associated with a trend for recurrent ischaemic events were prior stroke or transient ischemic attack (TIA) (HR 1.42, 95% CI 0.96 to 2.10) and ipsilateral arterial stenosis with 50%-99% narrowing (HR 1.54, 95% CI 0.98 to 2.43). Those associated with sICH were male sex (HR 2.68, 95% CI 1.06 to 6.83), history of hyperlipidaemia (HR 2.91, 95% CI 1.08 to 7.84) and early haemorrhagic transformation (HR 5.35, 95% CI 2.22 to 12.92).

Conclusion: In patients with ischaemic stroke and AF, predictors of d-sICH are different than those of recurrent ischaemic events; therefore, recognising these predictors may help inform early stroke versus d-sICH prevention strategies.
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http://dx.doi.org/10.1136/jnnp-2020-323041DOI Listing
July 2020

Misdiagnosis of Cervicocephalic Artery Dissection in the Emergency Department.

Stroke 2020 06 16;51(6):1876-1878. Epub 2020 Apr 16.

Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY (B.B.N., C.Z., H.K., A.E.M.).

Background and Purpose- Cervicocephalic artery dissection is an important cause of stroke. The clinical presentation of dissection can resemble that of benign neurological conditions leading to delayed or missed diagnosis. Methods- We performed a retrospective cohort study using statewide administrative claims data from all Emergency Department visits and admissions at nonfederal hospitals in Florida from 2005 to 2015 and New York from 2006 to 2015. Using validated , we identified adult patients hospitalized for cervicocephalic artery dissection. We defined probable misdiagnosis of dissection as having an Emergency Department treat-and-release visit for symptoms or signs of dissection, including headache, neck pain, and focal neurological deficits in the 14 days before dissection diagnosis. Multivariable logistic regression was used to compare adverse clinical outcomes in patients with and without probable misdiagnosis. Results- Among 7090 patients diagnosed with a dissection (mean age 52.7 years, 44.9% women), 218 (3.1% [95% CI, 2.7%-3.5%]) had a preceding probable Emergency Department misdiagnosis. After adjustment for demographics and vascular risk factors, there were no differences in rates of stroke (odds ratio, 0.82 [95% CI, 0.62-1.09]) or in-hospital death (odds ratio, 0.26 [95% CI, 0.07-1.08]) between dissection patients with and without a probable misdiagnosis at index hospitalization. Conclusions- We found that ≈1 in 30 dissection patients was probably misdiagnosed in the 2 weeks before their diagnosis.
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http://dx.doi.org/10.1161/STROKEAHA.120.029390DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253341PMC
June 2020

Redefined Measure of Early Neurological Improvement Shows Treatment Benefit of Alteplase Over Placebo.

Stroke 2020 04 27;51(4):1226-1230. Epub 2020 Feb 27.

From the Department of Neurology, New York Langone Health (S.A., E.S., A.L., J.F., K.I., J.T., S.R., S.Y.).

Background and Purpose- The first of the 2 NINDS (National Institute of Neurological Disorders and Stroke) Study trials did not show a significant increase in early neurological improvement, defined as National Institutes of Health Stroke Scale (NIHSS) improvement by ≥4, with alteplase treatment. We hypothesized that early neurological improvement defined as a percentage change in NIHSS (percent change NIHSS) at 24 hours is superior to other definitions in predicting 3-month functional outcomes and using this definition there would be treatment benefit of alteplase over placebo at 24 hours. Methods- We analyzed the NINDS rt-PA Stroke Study (Parts 1 and 2) trial data. Percent change NIHSS was defined as ([admission NIHSS score-24-hour NIHSS score]×100/admission NIHSS score] and delta NIHSS as (admission NIHSS score-24-hour NIHSS score). We compared early neurological improvement using these definitions between alteplase versus placebo patients. We also used receiver operating characteristic curve to determine the predictive association of early neurological improvement with excellent 3-month functional outcomes (Barthel Index score of 95-100 and modified Rankin Scale score of 0-1), good 3-month functional outcome (modified Rankin Scale score of 0-2), and 3-month infarct volume. Results- There was a significantly greater improvement in the 24-hour median percent change NIHSS among patients treated with alteplase compared with the placebo group (28% versus 15%; =0.045) but not median delta NIHSS (3 versus 2; =0.471). Receiver operating characteristic curve comparison showed that percent change NIHSS (ROC) was better than delta NIHSS (ROC) and admission NIHSS (ROC) with regards to excellent 3-month Barthel Index (ROC, 0.83; ROC, 0.76; ROC, 0.75), excellent 3-month modified Rankin Scale (ROC, 0.83; ROC, 0.74; ROC, 0.78), and good 3-month modified Rankin Scale (ROC, 0.83; ROC, 0.76; ROC, 0.78). Conclusions- In the NINDS rt-PA trial, alteplase was associated with a significant percent change improvement in NIHSS at 24 hours. Percent change in NIHSS may be a better surrogate marker of thrombolytic activity and 3-month outcomes.
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http://dx.doi.org/10.1161/STROKEAHA.119.027476DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7101071PMC
April 2020

Multiple Administrations of Intravenous Thrombolytic Therapy to a Stroke Mimic.

J Emerg Med 2020 Mar 3;58(3):e133-e136. Epub 2019 Dec 3.

Department of Neurology, New York University School of Medicine, New York, New York.

Background: Patients who present emergently with focal neurological deficits concerning for acute ischemic stroke can be extremely challenging to diagnose and treat. Unnecessary administration of thrombolytics to potential stroke patients whose symptoms are not caused by an acute ischemic stroke-stroke mimics-may result in patient harm, although the overall risk of hemorrhagic complications among stroke mimics is low.

Case Report: We present a case of a stroke mimic patient with underlying psychiatric disease who was treated with intravenous alteplase on four separate occasions in four different emergency departments in the same city. Although he did not suffer hemorrhagic complications, this case highlights the importance of rapid exchange of health information across institutions to improve diagnostic quality and safety. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Increased awareness of stroke mimics by emergency physicians may improve diagnostic safety for a subset of high-risk patients. Establishing rapid cross-institutional communication pathways that are integrated into provider's workflows to convey essential patient health information has potential to improve stroke diagnostic decision-making and thus represents an important topic for health systems research in emergency medicine.
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http://dx.doi.org/10.1016/j.jemermed.2019.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7200287PMC
March 2020

Breakdowns in the initial patient-provider encounter are a frequent source of diagnostic error among ischemic stroke cases included in a large medical malpractice claims database.

Diagnosis (Berl) 2020 01;7(1):37-43

CRICO Strategies, Boston, MA, USA.

Background Misdiagnosis of dangerous cerebrovascular disease is a substantial public health problem. We sought to identify and describe breakdowns in the diagnostic process among patients with ischemic stroke to facilitate future improvements in diagnostic accuracy. Methods We performed a retrospective, descriptive study of medical malpractice claims housed in the Controlled Risk Insurance Company (CRICO) Strategies Comparative Benchmarking System (CBS) database from 1/1/2006 to 1/1/2016 involving ischemic stroke patients. Baseline claimant demographics, clinical setting, primary allegation category, and outcomes were abstracted. Among cases with a primary diagnosis-related allegation, we detail presenting symptoms and diagnostic breakdowns using CRICO's proprietary taxonomy. Results A total of 478 claims met inclusion criteria; 235 (49.2%) with diagnostic error. Diagnostic errors originated in the emergency department (ED) in 46.4% (n = 109) of cases, outpatient clinic in 27.7% (n = 65), and inpatient setting in 25.1% (n = 59). Across care-settings, the most frequent process breakdown was in the initial patient-provider encounter [76.2% (n = 179 cases)]. Failure to assess, communicate, and respond to ongoing symptoms was the component of the patient-provider encounter most frequently identified as a source of misdiagnosis in the ED. Exclusively non-traditional presenting symptoms occurred in 35.7% (n = 84), mixed traditional and non-traditional symptoms in 30.6% (n = 72), and exclusively traditional in 23.8% (n = 56) of diagnostic error cases. Conclusions Among ischemic stroke patients, breakdowns in the initial patient-provider encounter were the most frequent source of diagnostic error. Targeted interventions should focus on the initial diagnostic encounter, particularly for ischemic stroke patients with atypical symptoms.
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http://dx.doi.org/10.1515/dx-2019-0031DOI Listing
January 2020

Varicella Zoster Virus Vasculitis and Adult Cerebrovascular Disease.

Neurohospitalist 2019 Oct 28;9(4):203-208. Epub 2019 Apr 28.

Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.

The role of Varicella zoster virus (VZV) in neurological illness, particularly cerebrovascular disease, has been increasingly recognized. Primary infection by VZV causes varicella (chickenpox), after which the virus remains latent in neuronal ganglia. Later, during aging or immunosuppression, the virus can reactivate causing zoster (shingles). Virus reactivation can also spread to cerebral arteries causing vasculitis and stroke. Zoster is a recognized risk factor for stroke, but stroke can occur without preceding zoster rash. The diagnosis of VZV cerebral vasculitis is established by abnormal brain imaging and confirmed by presence of viral DNA or anti-VZV antibodies in cerebrospinal fluid. Treatment with acyclovir with or without prednisone is usually recommended. VZV vasculitis is a unique and uncommon stroke mechanism that has been under recognized. Careful diagnostic investigation may be warranted in a subgroup of patients with ischemic stroke to detect VZV vasculitis and initiate appropriate therapy. In the following review, we detail the clinical presentation of VZV vasculitis, diagnostic challenges in VZV detection, and suggest the ways to enhance recognition and treatment of this uncommon disease.
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http://dx.doi.org/10.1177/1941874419845732DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6739663PMC
October 2019

Acute Lateral Medullary Infarct due to Giant Cell Arteritis: A Case Study.

Stroke 2019 10 9;50(10):e290-e293. Epub 2019 Sep 9.

Saul R. Korey Department of Neurology (C.C.E., K.F.K.-T., A.L.L.), Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.

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http://dx.doi.org/10.1161/STROKEAHA.119.026566DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6756979PMC
October 2019

Migraine as a Stroke Mimic and as a Stroke Chameleon.

Curr Pain Headache Rep 2019 Jul 29;23(9):63. Epub 2019 Jul 29.

Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, 3316 Rochambeau Avenue, Bronx, NY, 10467, USA.

Purpose Of Review: This review details the frequency of and ways in which migraine can be both an ischemic stroke/transient ischemic attack mimic (false positive) and chameleon (false negative). We additionally seek to clarify the complex relationships between migraine and cerebrovascular diseases with regard to diagnostic error.

Recent Findings: Nearly 2% of all patients evaluated emergently for possible stroke have an ultimate diagnosis of migraine; approximately 18% of all stroke mimic patients treated with intravenous thrombolysis have a final diagnosis of migraine. Though the treatment of a patient with migraine with thrombolytics confers a low risk of complication, symptomatic intracerebral hemorrhage may occur. Three clinical prediction scores with high sensitivity and specificity exist that can aid in the diagnosis of acute cerebral ischemia. Differentiating between migraine aura and transient ischemic attacks remains challenging. On the other hand, migraine is a common incorrect diagnosis initially given to patients with stroke. Among patients discharged from an emergency visit to home with a diagnosis of a non-specific headache disorder, 0.5% were misdiagnosed. Further development of tools to quantify and understand sources of stroke misdiagnosis among patients who present with headache is warranted. Both failure to identify cerebral ischemia among patients with headache and overdiagnosis of ischemia can lead to patient harms. While some tools exist to help with acute diagnostic decision-making, additional strategies to improve diagnostic safety among patients with migraine and/or cerebral ischemia are needed.
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http://dx.doi.org/10.1007/s11916-019-0801-1DOI Listing
July 2019

Assessing diagnostic error in cerebral venous thrombosis via detailed chart review.

Diagnosis (Berl) 2019 11;6(4):361-367

Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, USA.

Background Diagnostic error in cerebral venous thrombosis (CVT) has been understudied despite the harm associated with misdiagnosis of other cerebrovascular diseases as well as the known challenges of evaluating non-specific neurological symptoms in clinical practice. Methods We conducted a retrospective cohort study of CVT patients hospitalized at a single center. Two independent reviewers used a medical record review tool, the Safer Dx Instrument, to identify diagnostic errors. Demographic and clinical factors were abstracted. We compared subjects with and without a diagnostic error using the t-test for continuous variables and the chi-square (χ2) test or Fisher's exact test for categorical variables; an alpha of 0.05 was the cutoff for significance. Results A total of 72 CVT patients initially met study inclusion criteria; 19 were excluded due to incomplete medical records. Of the 53 patients included in the final analysis, the mean age was 48 years and 32 (60.4%) were women. Diagnostic error occurred in 11 cases [20.8%; 95% confidence interval (CI) 11.8-33.6%]. Subjects with diagnostic errors were younger (42 vs. 49 years, p = 0.13), more often women (81.8% vs. 54.8%, p = 0.17), and were significantly more likely to have a past medical history of a headache disorder prior to the index CVT visit (7.1% vs. 36.4%, p = 0.03). Conclusions Nearly one in five patients with complete medical records experienced a diagnostic error. Prior history of headache was the only evaluated clinical factor that was more common among those with an error in diagnosis. Future work on distinguishing primary from secondary headaches to improve diagnostic accuracy in acute neurological disease is warranted.
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http://dx.doi.org/10.1515/dx-2019-0003DOI Listing
November 2019

Clinical Decision-Making for Thrombolysis of Acute Minor Stroke Using Adaptive Conjoint Analysis.

Neurohospitalist 2019 Jan 13;9(1):9-14. Epub 2018 Sep 13.

Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Introduction: There is practice variability in the treatment of patients with minor ischemic stroke with thrombolysis. We sought to determine which clinical factors physicians prioritize in thrombolysis decision-making for minor stroke using adaptive conjoint analysis.

Methods: We conducted our conjoint analysis using the Potentially All Pairwise RanKings of all possible Alternatives methodology via the 1000Minds platform to design an online preference survey and circulated it to US physicians involved in stroke care. We evaluated 6 clinical attributes: language/speech deficits, motor deficits, other neurological deficits, history suggestive of increased risk of complication from thrombolysis, age, and premorbid disability. Survey participants were asked to choose between pairs of treatment scenarios with various clinical attributes; scenarios automatically adapted based on participants' prior responses. Preference weights representing the relative importance of each attribute were compared using unadjusted paired tests. Statistical significance was set at α = .05.

Results: Fifty-four participants completed the survey; 61% were vascular neurologists and 93% worked in academic centers. All neurological deficits were ranked higher than age, premorbid status, or potential contraindications to thrombolysis. Differences between each successive mean preference weight were significant: motor (31.7%, standard deviation [SD]: 9.5), language/speech (24.1%, SD: 9.6), other neurological deficits (16.6%, SD: 6.4), premorbid status (12.9%, SD: 6.6), age (10.1%, SD: 6.3), and potential thrombolysis contraindication (4.7%, SD: 4.4).

Conclusion: In a conjoint analysis, surveyed US physicians in academic practice assigned greater weight to motor and speech/language deficits than other neurological deficits, patient age, relative contraindications to thrombolysis, and premorbid disability when deciding to thrombolyse patients with minor stroke.
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http://dx.doi.org/10.1177/1941874418799563DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327243PMC
January 2019

Is the Cost-Effectiveness of Stroke Thrombolysis Affected by Proportion of Stroke Mimics?

Stroke 2019 02;50(2):463-468

Department of Neurology (S.P.), Feinberg School of Medicine, Northwestern University, Chicago, IL.

Background and Purpose- Differentiating ischemic stroke patients from stroke mimics (SM), nonvascular conditions which simulate stroke, can be challenging in the acute setting. We sought to model the cost-effectiveness of treating suspected acute ischemic stroke patients before a definitive diagnosis could be made. We hypothesized that we would identify threshold proportions of SM among suspected stroke patients arriving to an emergency department above which administration of intravenous thrombolysis was no longer cost-effective. Methods- We constructed a decision-analytic model to examine various emergency department thrombolytic treatment scenarios. The main variables were proportion of SM to true stroke patients, time from symptom onset to treatment, and complication rates. Costs, reimbursement rates, and expected clinical outcomes of ischemic stroke and SM patients were estimated from published data. We report the 90-day incremental cost-effectiveness ratio of administering intravenous thrombolysis compared with no acute treatment from a healthcare sector perspective, as well as the cost-reimbursement ratio from a hospital-level perspective. Cost-effectiveness was defined as a willingness to pay <$100 000 USD per quality adjusted life year gained and high cost-reimbursement ratio was defined as >1.5. Results- There was an increase in incremental cost-effectiveness ratios as the proportion of SM cases increased in the 3-hour time window. The threshold proportion of SM above which the decision to administer thrombolysis was no longer cost-effective was 30%. The threshold proportion of SM above which the decision to administer thrombolysis resulted in high cost-reimbursement ratio was 75%. Results were similar for patients arriving within 0 to 90 minutes of symptom onset as compared with 91 to 180 minutes but were significantly affected by cost of alteplase in sensitivity analyses. Conclusions- We identified thresholds of SM above which thrombolysis was no longer cost-effective from 2 analytic perspectives. Hospitals should monitor SM rates and establish performance metrics to prevent rising acute stroke care costs and avoid potential patient harms.
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http://dx.doi.org/10.1161/STROKEAHA.118.022857DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6349501PMC
February 2019

Response by Liberman et al to Letter Regarding Article, "Misdiagnosis of Cerebral Vein Thrombosis in the Emergency Department".

Stroke 2018 08;49(8):e280

Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY.

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http://dx.doi.org/10.1161/STROKEAHA.118.022219DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6202240PMC
August 2018

Inter-rater Agreement for the Diagnosis of Stroke Versus Stroke Mimic.

Neurologist 2018 Jul;23(4):118-121

Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL.

Background And Purpose: Patients who present emergently with acute neurological signs and symptoms represent unique diagnostic challenges for clinicians. We sought to characterize the reliability of physician diagnosis in differentiating aborted or imaging-negative acute ischemic stroke from stroke mimic.

Methods: We constructed 10 case-vignettes of patients treated with thrombolysis with subsequent clinical improvement who lacked radiographic evidence of infarction. Using an online survey, we asked physicians to select a most likely final diagnosis after reading each case-vignette. Inter-rater agreement was evaluated using percent agreement and κ statistic for multiple raters with 95% confidence intervals reported.

Results: Sixty-five physicians participated in the survey. Most participants were in practice for ≥5 years and over half were vascular neurologists. Physicians agreed on the most likely final diagnosis 71% of the time, κ of 0.21 (95% confidence interval, 0.06-0.54). Percent agreement was similar across participant practice locations, years of experience, subspecialty training, and personal experience with thrombolysis.

Conclusions: We found modest agreement among surveyed physicians in distinguishing ischemic stroke syndromes from stroke mimics in patients without radiographic evidence of infarction and clinical improvement after thrombolysis. Methods to improve diagnostic consensus after thrombolysis are needed to assure acute ischemic stroke patients and stroke mimics are treated safely and accurately.
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http://dx.doi.org/10.1097/NRL.0000000000000187DOI Listing
July 2018

Misdiagnosis of Cerebral Vein Thrombosis in the Emergency Department.

Stroke 2018 06 25;49(6):1504-1506. Epub 2018 Apr 25.

Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, New York, NY (G.G., A.C., H.K., A.E.M.).

Background And Purpose: Rates of cerebral venous thrombosis (CVT) misdiagnosis in the emergency department and outcomes associated with misdiagnosis have been underexplored.

Methods: Using administrative data, we identified adults with CVT at New York, California, and Florida hospitals from 2005 to 2013. Our primary outcome was probable misdiagnosis of CVT, defined as a treat-and-release emergency department visit for headache or seizure within 14 days before CVT. In addition, logistic regression was used to compare rates of clinical outcomes in patients with and without probable CVT misdiagnosis. We performed a confirmatory study at 2 tertiary care centers.

Results: We identified 5966 patients with CVT in whom 216 (3.6%; 95% confidence interval [CI], 1.1%-4.1%) had a probable misdiagnosis of CVT. After adjusting for demographics, risk factors for CVT, and the Elixhauser comorbidity index, probable CVT misdiagnosis was not associated with in-hospital mortality (odds ratio, 0.14; 95% CI, 0.02-1.05), intracerebral hemorrhage (odds ratio, 0.97; 95% CI, 0.57-1.65), or unfavorable discharge disposition (odds ratio, 0.90; 95% CI, 0.61-1.32); a longer length of hospital stay was seen among misdiagnosed patients with CVT (odds ratio, 1.62; 95% CI, 1.04-2.50). In our confirmatory cohort, probable CVT misdiagnosis occurred in 8 of 134 patients with CVT (6.0%; 95% CI, 2.6%-11.4%).

Conclusions: In a large, heterogeneous multistate cohort, probable misdiagnosis of CVT occurred in 1 of 30 patients but was not associated with the adverse clinical outcomes included in our study.
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http://dx.doi.org/10.1161/STROKEAHA.118.021058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5970977PMC
June 2018

Diagnostic Error in Stroke-Reasons and Proposed Solutions.

Curr Atheroscler Rep 2018 02 13;20(2):11. Epub 2018 Feb 13.

The Saul R. Korey Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, 3316 Rochambeau Avenue, 4th Floor, Bronx, NY, 10467, USA.

Purpose Of Review: We discuss the frequency of stroke misdiagnosis and identify subgroups of stroke at high risk for specific diagnostic errors. In addition, we review common reasons for misdiagnosis and propose solutions to decrease error.

Recent Findings: According to a recent report by the National Academy of Medicine, most people in the USA are likely to experience a diagnostic error during their lifetimes. Nearly half of such errors result in serious disability and death. Stroke misdiagnosis is a major health care concern, with initial misdiagnosis estimated to occur in 9% of all stroke patients in the emergency setting. Under- or missed diagnosis (false negative) of stroke can result in adverse patient outcomes due to the preclusion of acute treatments and failure to initiate secondary prevention strategies. On the other hand, the overdiagnosis of stroke can result in inappropriate treatment, delayed identification of actual underlying disease, and increased health care costs. Young patients, women, minorities, and patients presenting with non-specific, transient, or posterior circulation stroke symptoms are at increased risk of misdiagnosis. Strategies to decrease diagnostic error in stroke have largely focused on early stroke detection via bedside examination strategies and a clinical decision rules. Targeted interventions to improve the diagnostic accuracy of stroke diagnosis among high-risk groups as well as symptom-specific clinical decision supports are needed. There are a number of open questions in the study of stroke misdiagnosis. To improve patient outcomes, existing strategies to improve stroke diagnostic accuracy should be more broadly adopted and novel interventions devised and tested to reduce diagnostic errors.
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http://dx.doi.org/10.1007/s11883-018-0712-3DOI Listing
February 2018

Symptom-Disease Pair Analysis of Diagnostic Error (SPADE): a conceptual framework and methodological approach for unearthing misdiagnosis-related harms using big data.

BMJ Qual Saf 2018 07 22;27(7):557-566. Epub 2018 Jan 22.

Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: The public health burden associated with diagnostic errors is likely enormous, with some estimates suggesting millions of individuals are harmed each year in the USA, and presumably many more worldwide. According to the US National Academy of Medicine, improving diagnosis in healthcare is now considered 'a moral, professional, and public health imperative.' Unfortunately, well-established, valid and readily available operational measures of diagnostic performance and misdiagnosis-related harms are lacking, hampering progress. Existing methods often rely on judging errors through labour-intensive human reviews of medical records that are constrained by poor clinical documentation, low reliability and hindsight bias.

Methods: Key gaps in operational measurement might be filled via thoughtful statistical analysis of existing large clinical, billing, administrative claims or similar data sets. In this manuscript, we describe a method to quantify and monitor diagnostic errors using an approach we call 'Symptom-Disease Pair Analysis of Diagnostic Error' (SPADE).

Results: We first offer a conceptual framework for establishing valid symptom-disease pairs illustrated using the well-known diagnostic error dyad of dizziness-stroke. We then describe analytical methods for both look-back (case-control) and look-forward (cohort) measures of diagnostic error and misdiagnosis-related harms using 'big data'. After discussing the strengths and limitations of the SPADE approach by comparing it to other strategies for detecting diagnostic errors, we identify the sources of validity and reliability that undergird our approach.

Conclusion: SPADE-derived metrics could eventually be used for operational diagnostic performance dashboards and national benchmarking. This approach has the potential to transform diagnostic quality and safety across a broad range of clinical problems and settings.
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http://dx.doi.org/10.1136/bmjqs-2017-007032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6049698PMC
July 2018

E-Mail Is an Effective Tool for Rapid Feedback in Acute Stroke.

Neurohospitalist 2017 Oct 17;7(4):159-163. Epub 2017 Jan 17.

Department of Neurology, Columbia University Medical Center, New York, NY, USA.

Objective: To determine whether e-mail is a useful mechanism to provide prompt, case-specific data feedback and improve door-to-needle (DTN) time for acute ischemic stroke treated with intravenous tissue plasminogen activator (IV-tPA) in the emergency department (ED) at a high-volume academic stroke center.

Methods: We instituted a quality improvement project at Columbia University Medical Center where clinical details are shared via e-mail with the entire treatment team after every case of IV-tPA administration in the ED. Door-to-needle and component times were compared between the prefeedback (January 2013 to March 2015) and postfeedback intervention (April 2015 to June 2016) periods.

Results: A total of 273 cases were included in this analysis, 102 (37%) in the postintervention period. Median door-to-stroke code activation (2 vs 0 minutes, < .01), door-to-CT Scan (21 vs 18 minutes, < .01), and DTN (54 vs 49 minutes, = .17) times were shorter in the postintervention period, although the latter did not reach statistical significance. The proportion of cases with the fastest DTN (≤45 minutes) was higher in the postintervention period (29.2% vs 42.2%, = .03).

Conclusion: E-mail is a simple and effective tool to provide rapid feedback and promote interdisciplinary communication to improve acute stroke care in the ED.
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http://dx.doi.org/10.1177/1941874416689358DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5613867PMC
October 2017

Letter by Liberman et al Regarding Article, "Psychiatric Hospitalization Increases Short-Term Risk of Stroke".

Stroke 2017 09 3;48(9):e260. Epub 2017 Aug 3.

Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1161/STROKEAHA.117.018391DOI Listing
September 2017

A resident boot camp for reducing door-to-needle times at academic medical centers.

Neurol Clin Pract 2017 Jun;7(3):237-245

Northwestern University (IMR, FZC, MBM, SJM, FAS, DB, RAB, YC, SP), Evanston, IL; and Albert Einstein College of Medicine (ALL), Bronx, NY.

Background: We sought to determine if a structured educational program for neurology residents can lower door-to-needle (DTN) times at an academic institution.

Methods: A neurology resident educational stroke boot camp was developed and implemented in April 2013. Using a prospective database of 170 consecutive acute ischemic stroke (AIS) patients treated with IV tissue plasminogen activator (tPA) in our emergency department (ED), we evaluated the effect of the intervention on DTN times. We compared DTN times and other process measures preintervention and postintervention. Values < 0.05 were considered significant.

Results: The proportion of AIS patients treated with tPA within 60 minutes of arrival to our ED tripled from 18.1% preintervention to 61.2% postintervention ( < 0.001) with concomitant reduction in DTN time (median 79 minutes vs 58 minutes, < 0.001). The resident-delegated task (stroke code to tPA) was reduced (75 minutes vs 44 minutes, < 0.001), while there was no difference in ED-delegated tasks (door to stroke code [7 minutes vs 6 minutes, = 0.631], door to CT [18 minutes in both groups, = 0.547]). There was an increase in stroke mimics treated (6.9% vs 18.4%, = 0.031), which did not lead to an increase in adverse outcomes.

Conclusions: DTN times were reduced after the implementation of a stroke boot camp and were driven primarily by efficient resident stroke code management. Educational programs should be developed for health care providers involved in acute stroke patient care to improve rapid access to IV tPA at academic institutions.
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http://dx.doi.org/10.1212/CPJ.0000000000000367DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5490385PMC
June 2017

Door-to-Needle Delays in Minor Stroke: A Causal Inference Approach.

Stroke 2017 07 23;48(7):1980-1982. Epub 2017 May 23.

From the Department of Neurology, New York University School of Medicine (S.K.R.); Department of Epidemiology, Harvard University School of Public Health, Boston, MA (Z.S.); Department of Neurology (M.S.V.E., R.S.M., O.W., J.Z.W.) and Department of Medicine (J.I.S.), College of Physicians and Surgeons and Department of Epidemiology, Mailman School of Public Health (M.S.V.E.), Columbia University, New York, NY; and Department of Neurology, Albert Einstein College of Medicine, Bronx, NY (A.L.L.).

Background And Purpose: Thrombolysis rates among minor stroke (MS) patients are increasing because of increased recognition of disability in this group and guideline changes regarding treatment indications. We examined the association of delays in door-to-needle (DTN) time with stroke severity.

Methods: We performed a retrospective analysis of all stroke patients who received intravenous tissue-type plasminogen activator in our emergency department between July 1, 2011, and February 29, 2016. Baseline characteristics and DTN were compared between MS (National Institutes of Health Stroke Scale score ≤5) and nonminor strokes (National Institutes of Health Stroke Scale score >5). We applied causal inference methodology to estimate the magnitude and mechanisms of the causal effect of stroke severity on DTN.

Results: Of 315 patients, 133 patients (42.2%) had National Institutes of Health Stroke Scale score ≤5. Median DTN was longer in MS than nonminor strokes (58 versus 53 minutes; =0.01); fewer MS patients had DTN ≤45 minutes (19.5% versus 32.4%; =0.01). MS patients were less likely to use emergency medical services (EMS; 62.6% versus 89.6%, <0.01) and to receive EMS prenotification (43.9% versus 72.4%; <0.01). Causal analyses estimated MS increased average DTN by 6 minutes, partly through mode of arrival. EMS prenotification decreased average DTN by 10 minutes in MS patients.

Conclusions: MS had longer DTN times, an effect partly explained by patterns of EMS prenotification. Interventions to improve EMS recognition of MS may accelerate care.
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http://dx.doi.org/10.1161/STROKEAHA.117.017386DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5708142PMC
July 2017