Publications by authors named "Sara K Rostanski"

18 Publications

  • Page 1 of 1

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

Large Subcortical Intracerebral Hemorrhage Because of Reversible Cerebral Vasoconstriction Syndrome: A Case Study.

Stroke 2020 11 1;51(11):e305-e309. Epub 2020 Sep 1.

Department of Neurology (A.A., S.K.R.), New York University School of Medicine.

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http://dx.doi.org/10.1161/STROKEAHA.120.029363DOI Listing
November 2020

Education Research: Teaching and assessing communication and professionalism in neurology residency with simulation.

Neurology 2020 02 20;94(5):229-232. Epub 2020 Jan 20.

From the Departments of Neurology (A.M.K., A.L., P.P., S.K.R., A.N., C.Z., K.I., L.J.B.), Neurosurgery (A.L.), Medicine (S.Z.), Ophthalmology (L.J.B., S.L.G.), and Population Health (L.J.B.), New York University School of Medicine.

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http://dx.doi.org/10.1212/WNL.0000000000008895DOI Listing
February 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

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

Impact of Patient Language on Emergency Medical Service Use and Prenotification for Acute Ischemic Stroke.

Neurohospitalist 2019 Jan 27;9(1):5-8. Epub 2018 Sep 27.

Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY, USA.

Background And Purpose: Use of emergency medical services (EMS) is associated with decreased door-to-needle time in acute ischemic stroke (AIS). Whether patient language affects EMS utilization and prenotification in AIS has been understudied. We sought to characterize EMS use and prenotification by patient language among intravenous tissue plasminogen activator (IV-tPA) tissue plasminogen (IV-tPA) treated patients at a single center with a large Spanish-speaking patient population.

Methods: We performed a retrospective analysis of all patients who received IV-tPA in our emergency department between July 2011 and June 2016. Baseline characteristics, EMS use, and prenotification were compared between English- and Spanish-speaking patients. Logistic regression was used to measure the association between patient language and EMS use.

Results: Of 391 patients who received IV-tPA, 208 (53%) primarily spoke English and 174 (45%) primarily spoke Spanish. Demographic and clinical factors including National Institutes of Health Stroke Scale (NIHSS) did not differ between language groups. Emergency medical services use was higher among Spanish-speaking patients (82% vs 70%; < .01). Prenotification did not differ by language (61% vs 63%; = .8). In a multivariable model adjusted for age, sex, and NIHSS, Spanish speakers remained more likely to use EMS (odds ratio: 1.8, 95% confidence interval: 1.1-3.0).

Conclusion: Emergency medical services usage was higher in Spanish speakers compared to English speakers among AIS patients treated with IV-tPA; however, prenotification rates did not differ. Future studies should evaluate differences in EMS utilization according to primary language and ethnicity.
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http://dx.doi.org/10.1177/1941874418801429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6327237PMC
January 2019

Education Research: Simulation training for neurology residents on acquiring tPA consent: An educational initiative.

Neurology 2018 12;91(24):e2276-e2279

From the Departments of Neurology (S.K.R., A.M.K., L.J.B., K.I., S.L.G., A.L.) and Medicine (S.Z.), New York University School of Medicine, New York.

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http://dx.doi.org/10.1212/WNL.0000000000006651DOI Listing
December 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

Perfusion imaging and recurrent cerebrovascular events in intracranial atherosclerotic disease or carotid occlusion.

Int J Stroke 2018 08 5;13(6):592-599. Epub 2018 Mar 5.

1 Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, USA.

Background Large vessel disease stroke subtype carries the highest risk of early recurrent stroke. In this study we aim to look at the association between impaired perfusion and early stroke recurrence in patients with intracranial atherosclerotic disease or total cervical carotid occlusion. Methods This is a retrospective study from a comprehensive stroke center where we included consecutive patients 18 years or older with intracranial atherosclerotic disease or total cervical carotid occlusion admitted with a diagnosis of ischemic stroke within 24 h from symptom onset with National Institute Health Stroke Scale < 15, between 1 December 2016 and 30 June 2017. Patients with (1) evidence of ≥ 50% stenosis of a large intracranial artery or total carotid artery occlusion, (2) symptoms referable to the territory of the affected artery, and (3) perfusion imaging data using the RAPID processing software were included. The primary predictor was unfavorable perfusion imaging defined as T > 6 s mismatch volume (penumbra volume-infarct volume) of 15 ml or more. The outcome was recurrent cerebrovascular events at 90 days defined as worsening or new neurological symptoms in the absence of a nonvascular cause attributable to the decline, or new infarct or infarct extension in the territory of the affected artery. We used Cox proportional hazards models to determine the association between impaired perfusion and recurrent cerebrovascular events. Results Sixty-two patients met our inclusion criteria; mean age 66.4 ± 13.1 years, 64.5% male (40/62) and 50.0% (31/62) with intracranial atherosclerotic disease. When compared to patients with favorable perfusion pattern, patients with unfavorable perfusion pattern were more likely to have recurrent cerebrovascular events (55.6% (10/18) versus 9.1% (4/44), p < 0.001). This association persisted after adjusting for potential confounders (adjusted hazard ratio 10.44, 95% confidence interval 2.30-47.42, p = 0.002). Conclusion Perfusion mismatch predicts recurrent cerebrovascular events in patients with ischemic stroke due to intracranial atherosclerotic disease or total cervical carotid occlusion. Studies are needed to determine the utility of revascularization strategies in this patient population.
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http://dx.doi.org/10.1177/1747493018764075DOI Listing
August 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

Developing a Stroke Center.

Stroke 2017 07 13;48(7):e155-e156. Epub 2017 Jun 13.

From the Department of Neurology, Columbia University Medical Center, New York, NY (E.C.M.); Department of Neurology, Brown University, Miriam Hospital, Providence, RI (C.B.); Department of Neurology, New York University School of Medicine, NY (S.K.R.); and Department of Neurology, Bellevue Hospital Center, New York, NY (S.K.R.).

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http://dx.doi.org/10.1161/STROKEAHA.117.017745DOI Listing
July 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

The Association between Diffusion MRI-Defined Infarct Volume and NIHSS Score in Patients with Minor Acute Stroke.

J Neuroimaging 2017 07 9;27(4):388-391. Epub 2017 Jan 9.

Division of Social Epidemiology, Department of Neurology, Global Institute of Public Health, NYU Langone Medical Center and Department of Epidemiology, College of Dentistry, New York University, New York, NY.

Background: Prior studies have shown a correlation between the National Institutes of Health Stroke Scale (NIHSS) and stroke volume on diffusion weighted imaging (DWI); data are more limited in patients with minor stroke. We sought to determine the association between DWI lesion(s) volume and the (1) total NIHSS score and (2) NIHSS component scores in patients with minor stroke.

Methods: We included all patients with minor stroke (NIHSS 0-5) enrolled in the Stroke Warning Information and Faster Treatment study. We calculated lesion(s) volume (cm ) on the DWI sequence using Medical Image Processing, Analysis, and Visualization (MIPAV, NIH, Version 7.1.1). We used nonparametric tests to study the association between the primary outcome, DWI lesion(s) volume, and the predictors (NIHSS score and its components).

Results: We identified 894 patients with a discharge diagnosis of minor stroke; 709 underwent magnetic resonance imaging and 510 were DWI positive. There was a graded relationship between the NIHSS score and median DWI lesion volume in cm : (NIHSS 0: 7.1, NIHSS 1: 8.0, NIHSS 2: 17.1, NIHSS 3: 11.6, NIHSS 4: 19.0, and NIHSS 5: 23.6, P < .01). The median lesion volume was significantly higher in patients with neglect (105.6 vs. 12.5, P = .025), language disorder (34.6 vs. 11.9, P < .001), and visual field impairment (185.6 vs. 11.6, P < .001). Other components of the NIHSS were not associated with lesion volume.

Conclusion: In patients with minor stroke, the nature of deficit when used with the NIHSS score can improve prediction of infarct volume. This may have clinical and therapeutic implications.
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http://dx.doi.org/10.1111/jon.12423DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5518742PMC
July 2017

Language barriers between physicians and patients are not associated with thrombolysis of stroke mimics.

Neurol Clin Pract 2016 Oct;6(5):389-396

Departments of Neurology (SKR, OW, RSM, JZW) and Emergency Medicine (JIS), Columbia University Medical Center, New York, NY.

Background: Acute stroke is a time-sensitive condition in which rapid diagnosis must be made in order for thrombolytic treatment to be administered. A certain proportion of patients who receive thrombolysis will be found on further evaluation to have a diagnosis other than stroke, so-called "stroke mimics." Little is known about the role of language discordance in the emergency department diagnosis of acute ischemic stroke.

Methods: This is a retrospective analysis of all acute ischemic stroke patients who received IV tissue plasminogen activator (tPA) in our emergency department between July 2011 and December 2015. Baseline characteristics, patient language, and final diagnosis were compared between encounters in which the treating neurologist and patient spoke the same language (concordant cases) and encounters in which they did not (discordant cases).

Results: A total of 350 patients received IV tPA during the study period. English was the primary language for 52.6%, Spanish for 44.9%, and other languages for 2.6%; 60.3% of cases were classified as language concordant and 39.7% as discordant. We found no significant difference in the proportion of stroke mimics in the language concordant compared to discordant groups (16.6% vs 9.4%, = 0.06). Similarly, the proportion of stroke mimics did not differ between English- and Spanish-speaking patients (15.8% vs 11.5%, = 0.27).

Conclusions: Language discordance was not associated with acute stroke misdiagnosis among patients treated with IV tPA. Prospective evaluation of communication during acute stroke encounters is needed to gain clarity on the role of language discordance in acute stroke misdiagnosis.
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http://dx.doi.org/10.1212/CPJ.0000000000000287DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5100703PMC
October 2016

The Influence of Language Discordance Between Patient and Physician on Time-to-Thrombolysis in Acute Ischemic Stroke.

Neurohospitalist 2016 Jul 14;6(3):107-10. Epub 2016 Apr 14.

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

Background And Purpose: Reducing door-to-imaging (DIT) time is a major focus of acute stroke quality improvement initiatives to promote rapid thrombolysis. However, recent data suggest that the imaging-to-needle (ITN) time is a greater source of treatment delay. We hypothesized that language discordance between physician and patient would contribute to prolonged ITN time, as rapidly taking a history and confirming last known well require facile communication between physician and patient.

Methods: This is a retrospective analysis of all patients who received tissue plasminogen activator (tPA) in our emergency department between July 2011 and December 2014. Baseline characteristics and relevant time intervals were compared between encounters where the treating neurologist and patient spoke the same language (concordant cases) and where they did not (discordant cases).

Results: A total of 279 patients received tPA during the study period. English was the primary language for 51%, Spanish for 46%, and other languages for 3%; 59% of cases were classified as language concordant and 41% as discordant. We found no differences in median DIT (24 vs 25, P = .5), ITN time (33 vs 30, P = .3), or door-to-needle time (DTN; 58 vs 55, P = .1) between concordant and discordant groups. Similarly, among patients with the fastest and slowest ITN times, there were no differences.

Conclusion: In a high-volume stroke center with a large proportion of Spanish speakers, language discordance was not associated with changes in DIT, ITN time, or DTN time.
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http://dx.doi.org/10.1177/1941874416637405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4906557PMC
July 2016

Precision Medicine for Ischemic Stroke.

JAMA Neurol 2016 07;73(7):773-4

Columbia University Medical Center, New York, New York.

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http://dx.doi.org/10.1001/jamaneurol.2016.0087DOI Listing
July 2016

Sleep Disordered Breathing and White Matter Hyperintensities in Community-Dwelling Elders.

Sleep 2016 Apr 1;39(4):785-91. Epub 2016 Apr 1.

Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, NY.

Study Objectives: To examine the association between markers of sleep-disordered breathing (SDB) and white matter hyperintensity (WMH) volume in an elderly, multiethnic, community-dwelling cohort.

Methods: This is a cross-sectional analysis from the Washington Heights-Inwood Columbia Aging Project (WHICAP), a community-based epidemiological study of older adults. Structural magnetic resonance imaging was obtained starting in 2004; the Medical Outcomes Study-Sleep Scale (MOS-SS) was administered to participants starting in 2007. Linear regression models were used to assess the relationship between the two MOS-SS questions that measure respiratory dysfunction during sleep and quantified WMH volume among WHICAP participants with brain imaging.

Results: A total of 483 older adults had both structural magnetic resonance imaging and sleep assessment. Self-reported SDB was associated with WMH. After adjusting for demographic and vascular risk factors, WMH volumes were larger in individuals with frequent snoring (β = 2.113, P = 0.004) and among those who reported waking short of breath or with headache (β = 1.862, P = 0.048).

Conclusions: In community-dwelling older adults, self-reported measures of SDB are associated with larger WMH volumes. The cognitive effects of SDB that are increasingly being recognized may be mediated at the small vessel level.
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http://dx.doi.org/10.5665/sleep.5628DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4791612PMC
April 2016

Imaging Parameters and Recurrent Cerebrovascular Events in Patients With Minor Stroke or Transient Ischemic Attack.

JAMA Neurol 2016 May;73(5):572-8

Department of Neurology, College of Physicians and Surgeons, Columbia University, New York, New York.

Importance: Neurological worsening and recurrent stroke contribute substantially to morbidity associated with transient ischemic attacks and strokes (TIA-S).

Objective: To determine predictors of early recurrent cerebrovascular events (RCVEs) among patients with TIA-S and National Institutes of Health Stroke Scale scores of 0 to 3.

Design, Setting, And Participants: A retrospective cohort study was conducted at 2 tertiary care centers (Columbia University Medical Center, New York, New York, and Tulane University Medical Center, New Orleans, Louisiana) between January 1, 2010, and December 31, 2014. All patients with neurologist-diagnosed TIA-S with a National Institutes of Health Stroke Scale score of 0 to 3 who presented to the emergency department were included.

Main Outcomes And Measures: The primary outcome (adjudicated by 3 vascular neurologists) was RCVE: neurological deterioration in the absence of a medical explanation or recurrent TIA-S during hospitalization.

Results: Of the 1258 total patients, 1187 had no RCVEs and 71 had RCVEs; of this group, 750 patients (63.2%) and 39 patients (54.9%), respectively, were aged 60 years or older. There were 505 patients with TIA-S at Columbia University; 31 (6.1%) had RCVEs (15 patients had neurological deterioration only, 11 had recurrent TIA-S only, and 5 had both). The validation cohort at Tulane University consisted of 753 patients; 40 (5.3%) had RCVEs (24 patients had neurological deterioration only and 16 had both). Predictors of RCVE in multivariate models in both cohorts were infarct on neuroimaging (computed tomographic scan or diffusion-weighted imaging sequences on magnetic resonance imaging) (Columbia University: not applicable and Tulane University: odds ratio, 1.75; 95% CI, 0.82-3.74; P = .15) and large-vessel disease etiology (Columbia University: odds ratio, 6.69; 95% CI, 3.10-14.50 and Tulane University: odds ratio, 8.13; 95% CI, 3.86-17.12; P < .001). There was an increase in the percentage of patients with RCVEs when both predictors were present. When neither predictor was present, the rate of RCVE was extremely low (up to 2%). Patients with RCVEs were less likely to be discharged home in both cohorts.

Conclusions And Relevance: In patients with minor stroke, vessel imaging and perhaps neuroimaging parameters, but not clinical scores, were associated with RCVEs in 2 independent data sets. Prospective studies are needed to validate these predictors.
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http://dx.doi.org/10.1001/jamaneurol.2015.4906DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5022560PMC
May 2016