Publications by authors named "Michelle C Johansen"

17 Publications

  • Page 1 of 1

Thoracic Aortic Calcium for the Prediction of Stroke Mortality (from the Coronary Artery Calcium Consortium).

Am J Cardiol 2021 Mar 3. Epub 2021 Mar 3.

Johns Hopkins University School of Medicine, Baltimore, Maryland. Electronic address:

Thoracic aortic calcium(TAC) is an important marker of extracoronary atherosclerosis with established predictive value for all-cause mortality. We sought to explore the predictive value of TAC for stroke mortality, independent of the more established coronary artery calcium (CAC) score. The CAC Consortium is a retrospectively assembled database of 66,636 patients aged ≥18 years with no previous history of cardiovascular disease, baseline CAC scans for risk stratification, and follow-up for 12 ± 4 years. CAC scans capture the adjacent thoracic aorta, enabling assessment of TAC from the same images. TAC was available in 41,066 (62%), and was primarily analyzed as present or not present. To account for competing risks for nonstroke death, we utilized multivariable-adjusted Fine and Gray competing risk regression models adjusted for traditional cardiovascular risk factors and CAC score. The mean age of participants was 53.8 ± 10.3 years, with 34.4% female. There were 110 stroke deaths during follow-up. The unadjusted subdistribution hazard ratio (SHR) for stroke mortality in those who had TAC present compared with those who did not was 8.80 (95% confidence interval [CI]: 5.97, 12.98). After adjusting for traditional risk factors and CAC score, the SHR was 2.21 (95% CI:1.39,3.49). In sex-stratified analyses, the fully adjusted SHR for females was 3.42 (95% CI: 1.74, 6.73) while for males it was 1.55 (95% CI: 0.83, 2.90). TAC was associated with stroke mortality independent of CAC and traditional risk factors, more so in women. The presence of TAC appears to be an independent risk marker for stroke mortality.
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http://dx.doi.org/10.1016/j.amjcard.2021.02.038DOI Listing
March 2021

Intersegmental artery dissection resulting in spinal infarction.

Neurol Clin Pract 2020 Dec;10(6):535-537

Division of Interventional Neuroradiology (PG, GD, MSP) and Department of Neurology (MK, MCJ), The Johns Hopkins Hospital, Baltimore, MD.

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http://dx.doi.org/10.1212/CPJ.0000000000000766DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7837433PMC
December 2020

The Investigation of Left Atrial Structure and Stroke Etiology: The I-LASER Study.

J Am Heart Assoc 2021 Jan 14;10(2):e018766. Epub 2021 Jan 14.

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

Background Left atrial (LA) function is important in stroke, but often poorly characterized. We evaluated the association of 2-dimensional speckle tracking echocardiography LA variables with stroke subtype (cardioembolic stroke [CS] cryptogenic stroke versus other). The hypothesis is worse LA active function is associated with CS, but not cryptogenic strokes. Methods and Results In this prospective cohort (2017-2019), left ventricular/LA structure and function were quantified by 2-dimensional and speckle tracking echocardiography in 151 patients with stroke. Strain/strain rate curves for the 3 components of the LA cycle, ie, (1) Reservoir (global longitudinal strain [Srmax]), (2) Conductive (early LA Sr [Sre]), and (3) Active (late LA strain [Sra]) were evaluated, masked to stroke subtype. Associations of cardiac features with stroke subtype were tested using multivariable logistic regressions. Odds of CS were increased in patients with a larger LA systolic diameter (odds ratio [OR], 2.96, 95% CI, 1.14-7.69) but reduced in patients with a higher Srmax (better reservoir) (OR, 0.80, 95% CI, 0.67-0.97). Lower Sra (worse function) was associated with an increased odds of CS (OR, 1.72, 95% CI, 1.07-2.76) but not independent of atrial fibrillation. Higher active LA emptying fraction (better active phase) was associated with reduced odds of CS (OR, 0.74, 95% CI, 0.57-0.95) or cryptogenic stroke (OR, 0.82, 95% CI, 0.68-0.98) versus other subtypes; other associations between cryptogenic stroke and speckle tracking echocardiography were not found. Conclusions Markers of LA structure and function were associated with CS. Similar associations were not found for cryptogenic stroke, which might suggest different underlying mechanisms, given study limitations. Further understanding could aid stroke diagnosis and secondary stroke prevention research.
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http://dx.doi.org/10.1161/JAHA.120.018766DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955322PMC
January 2021

ANA Webinars: Clinical and basic research resilience during COVID-19.

Ann Clin Transl Neurol 2021 01 15;8(1):302-304. Epub 2020 Dec 15.

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

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http://dx.doi.org/10.1002/acn3.51230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7818117PMC
January 2021

Associations Between Atrial Cardiopathy and Cerebral Amyloid: The ARIC-PET Study.

J Am Heart Assoc 2020 12 8;9(24):e018399. Epub 2020 Dec 8.

The Johns Hopkins University School of Medicine Baltimore MD.

Background Atrial fibrillation (AF) is a risk factor for cognitive decline, possibly from silent brain infarction. Left atrial changes in structure or function (atrial cardiopathy) can lead to AF but may impact cognition independently. It is unknown if AF or atrial cardiopathy also acts on Alzheimer disease-specific mechanisms, such as deposition of β-amyloid. Methods and Results A total of 316 dementia-free participants from the ARIC (Atherosclerosis Risk in Communities) study underwent florbetapir positron emission tomography, electrocardiography, and 2-dimensional echocardiography. Atrial cardiopathy was defined as ≥1: (1) left atrial volume index >34 mL/m; (2) P-wave terminal force >5000 µV×ms; and (3) serum NT-proBNP (N-terminal pro-B-type natriuretic peptide) >250 pg/mL. Cross-sectional associations between global cortical β-amyloid (>1.2 standardized uptake value ratio) and adjudicated history of AF and atrial cardiopathy, each, were evaluated using multivariable logistic regression. Participants (mean age, 76 years) were 56% women and 42% Black individuals. Odds of elevated florbetapir standardized uptake value ratio were significantly increased among those with atrial cardiopathy (odds ratio, 1.81; 95% CI, 1.02-3.22) and doubled for those with enlarged left atrial volume index after adjustment for demographics/risk factors (95% CI, 1.04-4.61). There was no association between P-wave terminal force or NT-proBNP and elevated florbetapir standardized uptake value ratio, nor between AF and elevated standardized uptake value ratio. Conclusions Among healthy, nondemented community-dwelling older individuals, we report an association between atrial cardiopathy, left atrial volume index, and elevated brain amyloid, by positron emission tomography, without a similar association in individuals with AF. Potential limitations include reverse causation and survival bias. Ongoing work will help determine if changes in cardiac structure and function precede or occur simultaneously with amyloid deposition.
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http://dx.doi.org/10.1161/JAHA.120.018399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7955392PMC
December 2020

Embolic Stroke of Unknown Source Clinical Trials and Advances in Research.

Ann Neurol 2020 09 17;88(3):462-463. Epub 2020 Jul 17.

Department of Neurology, Weill Cornell Medicine, New York, NY, USA.

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http://dx.doi.org/10.1002/ana.25825DOI Listing
September 2020

Cardiorespiratory Fitness and Incident Stroke Types: The FIT (Henry Ford ExercIse Testing) Project.

Mayo Clin Proc 2020 07;95(7):1379-1389

Department of Cardiac Imaging, Houston Methodist DeBakey Heart & Vascular Center, TX. Electronic address:

Objective: To study the association between cardiorespiratory fitness (CRF) and incident stroke types.

Patients And Methods: We studied a retrospective cohort of patients referred for treadmill stress testing in the Henry Ford Health System (Henry Ford ExercIse Testing Project) without history of stroke. CRF was expressed by metabolic equivalents of task (METs). Using appropriate International Classification of Diseases, Ninth Revision codes, incident stroke was ascertained through linkage with administrative claims files and classified as ischemic, hemorrhagic, and subarachnoid hemorrhage (SAH). Multivariable-adjusted Cox proportional hazards models examined the association between CRF and incident stroke.

Results: Among 67,550 patients, mean ± SD age was 54±13 years, 46% (n=31,089) were women, and 64% (n=43,274) were white. After a median follow-up of 5.4 (interquartile range 2.7-8.5) years, a total of 7512 incident strokes occurred (6320 ischemic, 2481 hemorrhagic, and 275 SAH). Overall, there was a graded lower incidence of stroke with higher MET categories. Patients with METs of 12 or more had lower risk of overall stroke [0.42 (95% CI, 0.36-0.49)], ischemic stroke [0.69 (95% CI, 0.58-0.82)], and hemorrhagic stroke [0.71 (95% CI, 0.52-0.95)].

Conclusion: In a large ethnically diverse cohort of patients referred for treadmill stress testing, CRF is inversely associated with risk for ischemic and hemorrhagic stroke.
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http://dx.doi.org/10.1016/j.mayocp.2019.11.027DOI Listing
July 2020

Cerebral venous thrombosis: Associations between disease severity and cardiac markers.

Neurol Clin Pract 2020 Apr;10(2):115-121

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

Background: Plasma cardiac troponin (cTn) elevation occurs in acute ischemic stroke and intracranial hemorrhage and can suggest a poor prognosis. Because acute cerebral venous thrombosis (CVT) might lead to venous stasis, which could result in cardiac stress, it is important to evaluate whether cTn elevation occurs in patients with CVT.

Methods: Inpatients at Johns Hopkins Hospital from 2005 to 2015 meeting the following criteria were included: CVT ( codes with radiologic confirmation) and available admission electrocardiogram (ECG) and cTn level. In regression models, presence of ECG abnormalities and cTn elevation (>0.06 ng/mL) were evaluated as dependent variables in separate models, with location and severity of CVT involvement as independent variables, adjusted for age, sex, and hypertension.

Results: Of 81 patients with CVST, 53 (66%) met the inclusion criteria. Participants were, on average, aged 42 years, white (71%), and female (66%). The left transverse sinus was most commonly thrombosed (47%), with 66% having >2 veins thrombosed. Twenty-two (41%) had cTn elevation. Odds of cTn elevation increased per each additional vein thrombosed (adjusted OR 2.79, 95% CI [1.08-7.23]). Of those with deep venous involvement, 37.5% had cTn elevation compared with 4.4% without deep clots ( = 0.02). Venous infarction (n = 15) was associated with a higher mean cTn (0.14 vs 0.02 ng/mL, = 0.009) and was predictive of a higher cTn in adjusted models (β = 0.15, 95% CI [0.06-0.25]).

Conclusions: In this single-center cohort study, markers of CVT severity were associated with increased odds of cTn elevation; further investigation is needed to elucidate causality and significance.
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http://dx.doi.org/10.1212/CPJ.0000000000000670DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156205PMC
April 2020

Is incident stroke associated with increased risk of major adverse cardiovascular events?

Neurology 2020 04 10;94(15):644-645. Epub 2020 Mar 10.

From the Cerebrovascular Division, Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1212/WNL.0000000000009235DOI Listing
April 2020

Associations Between Left Ventricular Structure, Function, and Cerebral Amyloid: The ARIC-PET Study.

Stroke 2019 12 10;50(12):3622-3624. Epub 2019 Oct 10.

From the The Johns Hopkins University School of Medicine, Baltimore, MD (M.C.J., D.F.W., R.F.G.).

Background and Purpose- Cardiovascular disease is a known risk factor for cognitive decline, although the mechanisms remain unclear. We hypothesize that Aβ (β-amyloid), a core pathology of Alzheimer's disease, will be associated with subclinical cardiac structure and function echocardiogram indices. Methods- Three hundred six nondemented participants from the ARIC study (Atherosclerosis Risk in Communities Study) underwent florbetapir positron emission tomography and 2D echocardiography (echo). Cross-sectional associations between echo markers of left ventricular structure and function and global cortical Aβ (≥1.2 standardized uptake value ratio were evaluated using multivariable logistic regression with interaction terms when appropriate. Results- Participants ranged in age from 67 to 88 years, were 57% female and 42% black. Per 1 cm increase in end-diastolic left ventricular diameter, the odds of elevated florbetapir standardized uptake value ratio doubled (odds ratio, 2.04 [95% CI, 1.10-3.77]), with similar findings when excluding mild cognitive impairment (odds ratio, 2.61 [95% CI, 1.22-5.59]). Conclusions- We have demonstrated a significant association between a marker of left ventricular structure and elevated florbetapir standardized uptake value ratio, identified using positron emission tomography. Ongoing prospective work will help determine if changes in cardiac structure and function either precede, or occur simultaneously with deposition of amyloid.
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http://dx.doi.org/10.1161/STROKEAHA.119.027220DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6878182PMC
December 2019

Understanding Atrial Cardiopathy: an Under-Recognized Contributor to Cardioembolic Stroke.

Curr Treat Options Neurol 2019 Jun 25;21(7):32. Epub 2019 Jun 25.

Department of Neurology, The Johns Hopkins University School of Medicine, 600 N. Wolfe Street, Phipps 4 Suite 446, Baltimore, MD, 21287, USA.

Purpose Of Review: Ischemic stroke is the fifth leading cause of death in the world with cardioembolic stroke (CES) causing a disproportional amount of the morbidity and mortality associated with stroke. Atrial fibrillation (AF) is the leading cause of CES, and as the population ages, the incidence of CES is anticipated to rise. The importance of proper diagnosis and treatment of patients with embolic-appearing stroke is significant due to the burden of disease and the severity of the illness.

Recent Findings: The past decade has seen an explosion of treatment options for patients with CES related to AF as well as better mechanisms by which to monitor and diagnose patients with AF. While optimal secondary prevention of stroke with anticoagulation in the setting of AF is known, what remains to be defined is the appropriate treatment of other types of strokes that appear embolic, but no source of the embolism is discovered. In this article, we will review what is known about the diagnosis and treatment of CES, discuss the emergence of novel therapeutics and emphasize what must be investigated in the future to move the field forward, such as the emerging concept of atrial cardiopathy.
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http://dx.doi.org/10.1007/s11940-019-0571-4DOI Listing
June 2019

Associations of echocardiographic features with stroke in those without atrial fibrillation.

Neurology 2019 02 23;92(9):e924-e932. Epub 2019 Jan 23.

From the Department of Neurology (M.C.J., M.L., R.F.G.), The Johns Hopkins University School of Medicine, Baltimore, MD; and the Department of Cardiology (S.N.), The University of Pennsylvania Perelman School of Medicine, Philadelphia.

Objective: To determine the associations between transthoracic echocardiogram (TTE) cardiac structure/function measures and cardioembolic stroke (CES) and new-onset atrial fibrillation (AF) in patients without known AF.

Methods: Inpatients at a single institution (2013-2015) with imaging-confirmed ischemic stroke, no AF, and TTE within the 1st week were included. TTE structure/function variables were abstracted. Stroke subtype (CES vs other) was defined according to Trial of Org 10172 in Acute Stroke Treatment, blinded to TTE results. New AF was defined as any duration of AF on ECG, telemetry, or event monitor. Separate multivariable logistic regression models defined associations between CES or new-onset AF and TTE measures, adjusting for demographic and vascular risk factors.

Results: Of 322 participants (mean age 60 years), 55% were male and 56% African American. In adjusted models (odds ratio, 95% confidence interval), odds of CES increased per 0.1 cm increase in left atrial (LA) systolic diameter (1.06, 1.02-1.11), 1 cm/s in mitral E point velocity (1.03, 1.02-1.05), with presence of mitral valve dysfunction (3.78, 1.42-10.02), and with wall motion abnormality (2.00, 1.13-3.55). As ejection fraction increased (per 10%), odds of CES decreased (0.65, 0.53-0.79). New-onset AF was also associated with increasing LA systolic diameter (1.13, 1.04-1.22).

Conclusions: Cardiac structural changes independent of AF and detectable on TTE may be on the CES causal pathway. Confirming these results could have implications for future use of TTE and decisions about antithrombotic vs anticoagulant treatment.
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http://dx.doi.org/10.1212/WNL.0000000000007002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987865PMC
February 2019

Associations of Echocardiography Markers and Vascular Brain Lesions: The ARIC Study.

J Am Heart Assoc 2018 12;7(24):e008992

1 Johns Hopkins University School of Medicine Baltimore MD.

Background Associations between subtle changes in cardiac and cerebral structure and function are not well understood, with some studies suggesting that subclinical cardiac changes may be associated with markers of vascular brain insult. Methods and Results Data from the ARIC (Atherosclerosis Risk in Communities) Study (5th ARIC visit; 2011-2013; N=1974) were used to explore relationships between abnormalities of cardiac structure/function and subclinical brain disease and to test specific associations between those cardiac and vascular brain changes that share a common mechanism. In adjusted models white matter hyperintensities were 0.66 cm greater (95% confidence interval [CI] 0.08-1.25) for every 1-mm increase in left ventricular LV wall thickness and 0.64 cm greater (95% CI 0.19-1.08) for every 10 g/m increase in LV mass index, both markers of LV structure. Odds of brain infarction also increased with greater LV wall thickness (odds ratio 1.11, 95% CI 1.01-1.23 per 1 mm) and larger LV mass (odds ratio 1.08, 95% CI 1.00-1.17 per 10 g/m). Higher ejection fraction (per 5%), a marker of systolic function, was significantly associated with decreased odds of overall infarct (odds ratio 0.85, 95% CI 0.77-0.95), but not with cortical infarction (odds ratio 0.92, 95% CI 0.78-1.08). Conclusions Among elderly participants in a large cohort study, subclinical markers of LV structure and LV systolic dysfunction were associated with increased odds of brain infarction and more white matter hyperintensities, independent of other vascular risk factors. This suggests end-organ dysfunction occurs in the heart and brain in parallel, with further studies needed to determine causality.
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http://dx.doi.org/10.1161/JAHA.118.008992DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6405621PMC
December 2018

Risk of recurrent cervical artery dissection.

Neurology 2018 04 16;90(16):719-720. Epub 2018 Mar 16.

From the Department of Neurology (J.W.C.), Maryland Stroke Center, Baltimore VA Medical Center and University of Maryland School of Medicine; and Cerebrovascular Division (M.C.J.), Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD.

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http://dx.doi.org/10.1212/WNL.0000000000005322DOI Listing
April 2018

: A Validated Scoring System for Early Stratification of Neurologic Outcome After Out-of-Hospital Cardiac Arrest Treated With Targeted Temperature Management.

J Am Heart Assoc 2017 May 20;6(5). Epub 2017 May 20.

Department of Cardiovascular Medicine, University of Virginia, Charlottesville, VA

Background: Out-of-hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post-OHCA remains difficult in patients receiving targeted temperature management.

Methods And Results: Retrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32-34°C) for 24 hours at a tertiary-care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3-5). Patient demographics, pre-OHCA diagnoses, and initial laboratory studies post-resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system (). The score ranges 0 to 5 using equally weighted variables: (): coronary artery disease, known pre-OHCA; (): glucose ≥200 mg/dL; (): rhythm of arrest not ventricular tachycardia/fibrillation; (): age >45; (): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary-care health system (n=272) from 2012 to 2014. The c-statistic for predicting neurologic outcome was 0.82 (0.74-0.90, <0.001) in the development cohort and 0.81 (0.76-0.87, <0.001) in the validation cohort. When subdivided by score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0-1, n=60), 22% versus 19% for medium (2-3, n=307), and 0% versus 2% for high (4-5, n=99) scores in the development and validation cohorts, respectively.

Conclusions: stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32-34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable ( ≤1) and poor ( ≥4) prognoses.
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http://dx.doi.org/10.1161/JAHA.116.003821DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5524053PMC
May 2017

Current perspectives on the use of intravenous recombinant tissue plasminogen activator (tPA) for treatment of acute ischemic stroke.

Vasc Health Risk Manag 2014 24;10:75-87. Epub 2014 Feb 24.

Department of Neurology, University of Virginia, Charlottesville, VA, USA ; Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.

In 1995, the NINDS (National Institute of Neurological Disorders and Stroke) tPA (tissue plasminogen activator) Stroke Study Group published the results of a large multicenter clinical trial demonstrating efficacy of intravenous tPA by revealing a 30% relative risk reduction (absolute risk reduction 11%-15%) compared with placebo at 90 days in the likelihood of having minimal or no disability. Since approval in 1996, tPA remains the only drug treatment for acute ischemic stroke approved by the US Food and Drug Administration. Over the years, an abundance of research and clinical data has supported the safe and efficacious use of intravenous tPA in all eligible patients. Despite such supporting data, it remains substantially underutilized. Challenges to the utilization of tPA include narrow eligibility and treatment windows, risk of symptomatic intracerebral hemorrhage, perceived lack of efficacy in certain high-risk subgroups, and a limited pool of neurological and stroke expertise in the community. With recent US census data suggesting annual stroke incidence will more than double by 2050, better education and consensus among both the medical and lay public are necessary to optimize the use of tPA for all eligible stroke patients. Ongoing and future research should continue to improve upon the efficacy of tPA through more rapid stroke diagnosis and treatment, refinement of advanced neuroimaging and stroke biomarkers, and successful demonstration of alternative means of reperfusion.
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http://dx.doi.org/10.2147/VHRM.S39213DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3938499PMC
September 2014