Publications by authors named "Seemant Chaturvedi"

168 Publications

Global Impact of COVID-19 on Stroke Care and Intravenous Thrombolysis.

Neurology 2021 Mar 25. Epub 2021 Mar 25.

Department of Neurology, University of North Carolina at Chapel Hill, North Carolina, USA.

Objective: The objectives of this study were to measure the global impact of the pandemic on the volumes for intravenous thrombolysis (IVT), IVT transfers, and stroke hospitalizations over 4 months at the height of the pandemic (March 1 to June 30, 2020) compared with two control 4-month periods.

Methods: We conducted a cross-sectional, observational, retrospective study across 6 continents, 70 countries, and 457 stroke centers. Diagnoses were identified by their ICD-10 codes and/or classifications in stroke databases.

Results: There were 91,373 stroke admissions in the 4 months immediately before compared to 80,894 admissions during the pandemic months, representing an 11.5% (95%CI, -11.7 to - 11.3, p<0.0001) decline. There were 13,334 IVT therapies in the 4 months preceding compared to 11,570 procedures during the pandemic, representing a 13.2% (95%CI, -13.8 to -12.7, p<0.0001) drop. Interfacility IVT transfers decreased from 1,337 to 1,178, or an 11.9% decrease (95%CI, -13.7 to -10.3, p=0.001). Recovery of stroke hospitalization volume (9.5%, 95%CI 9.2-9.8, p<0.0001) was noted over the two later (May, June) versus the two earlier (March, April) pandemic months. There was a 1.48% stroke rate across 119,967 COVID-19 hospitalizations. SARS-CoV-2 infection was noted in 3.3% (1,722/52,026) of all stroke admissions.

Conclusions: The COVID-19 pandemic was associated with a global decline in the volume of stroke hospitalizations, IVT, and interfacility IVT transfers. Primary stroke centers and centers with higher COVID19 inpatient volumes experienced steeper declines. Recovery of stroke hospitalization was noted in the later pandemic months.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000011885DOI Listing
March 2021

New Avenues for Optimal Treatment of Atrial Fibrillation and Stroke Prevention.

Stroke 2021 Apr 25;52(4):1490-1499. Epub 2021 Feb 25.

Department of Neurology, University of Maryland School of Medicine, Baltimore (S.C.).

One in 3 individuals free of atrial fibrillation (AF) at index age 55 years is estimated to develop AF later in life. AF increases not only the risk of ischemic stroke but also of dementia, even in stroke-free patients. In this review, we address recent advances in the heart-brain interaction with focus on AF. Issues discussed are (1) the timing of direct oral anticoagulants start following an ischemic stroke; (2) the comparison of direct oral anticoagulants versus vitamin K antagonists in early secondary stroke prevention; (3) harms of bridging with heparin before direct oral anticoagulants; (4) importance of appropriate direct oral anticoagulants dosing; (5) screening for AF in high-risk populations, including the role of wearables; (6) left atrial appendage occlusion as an alternative to oral anticoagulation; (7) the role of early rhythm-control therapy; (8) effect of lifestyle interventions on AF; (9) AF as a risk factor for dementia. An interdisciplinary approach seems appropriate to address the complex challenges posed by AF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.120.032060DOI Listing
April 2021

The Proportion of Preventable Thrombectomy Procedures with Improved Atrial Fibrillation Stroke Prevention.

J Stroke Cerebrovasc Dis 2021 Apr 3;30(4):105599. Epub 2021 Feb 3.

University of Maryland Department of Neurology, Baltimore, MD, USA.

Background: Large vessel occlusion (LVO) strokes can in part be prevented with better atrial fibrillation (AF) stroke prevention strategies; thus we evaluated the rate of AF in patients presenting with acute LVO strokes undergoing mechanical thrombectomy (MT) and assessed patterns of oral anticoagulant (OAC) use prior to the index stroke.

Methods And Results: We identified 347 MT cases from February 2015 to September 2018. A retrospective chart review was conducted to identify patient sociodemographics, presence of AF, use of anticoagulation, stroke severity, CHADS-VASc scores, and functional outcomes. AF was present in 161 (46%) cases. Patients with AF were older (mean 76 ± 11 years vs. 66 ± 15 years) and more likely to be female (56% vs. 46%) with higher rates of hypertension, dyslipidemia, heart failure and smoking. Of the 100 patients with known AF, 59 were not on anticoagulation prior to the index stroke. Of 39 patients with known AF on OAC, 57% were not therapeutic on warfarin and 20% were not taking prescribed direct OACs. A total of 72 (21%) thrombectomy cases were performed on patients with known AF who were not effectively anticoagulated. After multivariate adjustments, there was no significant difference in modified Rankin Scale score at discharge, in-hospital mortality, or symptomatic intracranial hemorrhage between the AF and non-AF groups.

Conclusion: In our study, 21% of patients with LVO stroke had known AF and were not effectively anticoagulated. Improved stroke preventive measures could potentially reduce the occurrence of stroke and avoid unnecessary procedures for patients with AF.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105599DOI Listing
April 2021

To Screen or Not to Screen for Carotid Stenosis: Is That the Question?

JAMA Neurol 2021 Apr;78(4):383-384

Department of Neurology & Stroke Program, University of Maryland School of Medicine, Baltimore.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaneurol.2020.5382DOI Listing
April 2021

Age differences in utilization and outcomes of tissue-plasminogen activator and mechanical thrombectomy in acute ischemic stroke.

J Neurol Sci 2021 01 7;420:117262. Epub 2020 Dec 7.

Department of Neurology, University of Maryland Medical Center, Baltimore, MD, USA.

Background And Purpose: U.S. demographics is shifting towards older population. Older stroke patients likely receive less tissue-plasminogen activator (t-PA) and mechanical thrombectomy (MT) compared to younger patients. The objective of this study is to evaluate extent of difference in utilization of t-PA and MT and outcomes of stroke between three age groups -18-45 (young adults), 46-80 (middle/old), and > 80 (oldest old) years.

Methods: It is a retrospective cross-sectional observational study. Primary outcomes were rates of stroke intervention and effect of age on stroke intervention. Secondary outcomes were in-hospital mortality, discharge to home, and prolonged length of stay. Multivariate survey-logistic regression was performed to evaluate outcomes.

Results: Among 487,105 patients in the study 4.8% were young adults, 66.6% middle/old, and 28.6% oldest old. Compared to young adults, middle/old received 19% (OR = 0.81; 95%CI = 0.72-0.91) less t-PA alone; and 33% (OR = 0.67; 95%CI = 0.53-0.83) less MT alone; oldest old received 25% less t-PA alone (OR = 0.75; 95%CI = 0.66-0.86) and 51% (OR = 0.49; 95%CI = 0.38-0.63) less MT alone. Compared to young adults, in-hospital mortality was three-fold higher among middle/old (OR = 3.5; 95%CI = 1.3-9.6), and seven-fold higher among oldest old (OR = 7.5; 95%CI = 2.8-20.5) for t-PA alone; discharge to home reduced by 40% in middle/old (OR = 0.6; 95%CI = 0.4-0.7) and by 80% in oldest old (OR = 0.2; 95%CI = 0.1-0.2) for t-PA alone and similarly for MT alone.

Conclusions: Oldest old receive one-fourth less t-PA and half less MT compared to young adults. Oldest old patients who received t-PA alone or MT alone had remarkably worse outcomes for in-hospital mortality and discharge to home than young adults did.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jns.2020.117262DOI Listing
January 2021

Emergency Medicine Physician Attitudes toward Anticoagulant Initiation for Patients with Atrial Fibrillation.

J Stroke Cerebrovasc Dis 2021 Feb 23;30(2):105474. Epub 2020 Nov 23.

Department of Neurology, University of Maryland, Baltimore, MD 410-328-4723, United States.

Background And Aim: Guidelines for the primary prevention of stroke recognize the emergency department as a location for physicians to identify atrial fibrillation and to initiate oral anticoagulants. Numerous studies have shown low anticoagulant prescription rates-approximately 18%-in OAC-naïve patients with atrial fibrillation discharged from the emergency department. We sought to obtain the opinions of Emergency Medicine physicians regarding anticoagulant decision-making for patients with atrial fibrillation seen in the emergency department.

Methods: 14-item paper surveys were distributed to emergency department physicians within a single hospital system. The survey consisted of single-, multi- answer and open-ended questions regarding knowledge and usage frequency of the CHADS-VASc score, knowledge of anticoagulant options and reasons for why an anticoagulant was not initiated.

Results: 55 emergency department physicians completed the survey (overall response rate 59%). 89% (49/55) agreed the emergency department is an important location to initiate anticoagulation depending on comorbidities. A lower proportion reported ever starting a patient in the emergency department on a new anticoagulant prescription upon discharge (55% (30/55) p <.0001). The belief that a new anticoagulant prescription is the responsibility of the PCP/ Cardiologist/ Neurologist (52%; 15/29), not wanting to be held responsible in the event of a life-threatening bleeding event (41%; 12/29), and concerns about inadequate follow-up and/or lack of insurance (24%; 7/29) were the most commonly cited reasons for not starting an appropriate patient with atrial fibrillation on an anticoagulant.

Conclusion: Emergency Medicine physicians support initiating oral anticoagulants in the ED for patients with atrial fibrillation; however, discrepancies exist between their intentions and actual practice.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105474DOI Listing
February 2021

Increased Mortality in Women Following Stroke: A Complex Issue.

J Womens Health (Larchmt) 2021 Mar 21;30(3):287-288. Epub 2020 Sep 21.

Department of Neurology and Stroke Program, University of Maryland, Baltimore, Maryland, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/jwh.2020.8791DOI Listing
March 2021

Rationale, Design, and Implementation of Intensive Risk Factor Treatment in the CREST2 Trial.

Stroke 2020 10 21;51(10):2960-2971. Epub 2020 Sep 21.

Neurology, Mayo Clinic, Jacksonville, FL (J.F.M., T.G.B.).

Background And Purpose: The CREST2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis) is comparing intensive medical management (IMM) alone to IMM plus revascularization with carotid endarterectomy or transfemoral carotid artery stenting for preventing stroke or death within 44 days after randomization or ipsilateral ischemic stroke thereafter. There are extensive clinical trial data on outcomes after revascularization of asymptomatic carotid stenosis, but not for IMM. As such, the experimental treatment in CREST2 is IMM, which is described in this article.

Methods: IMM consists of aspirin 325 mg/day and intensive risk factor management, primarily targeting systolic blood pressure <130 mm Hg (initially systolic blood pressure <140 mm Hg) and LDL (low-density lipoprotein) cholesterol <70 mg/dL. Secondary risk factor targets focus on tobacco smoking, non-HDL (high-density lipoprotein), HbA1c (hemoglobin A1c), physical activity, and weight. Risk factor management is performed by site personnel and a lifestyle coaching program delivered by telephone. We report interim risk factor data on 1618 patients at baseline and last follow-up through 24 months.

Results: The mean baseline LDL of 80.5 mg/dL improved to 66.7 mg/dL. The mean baseline systolic blood pressure of 139.7 mm Hg improved to 130.3 mm Hg. The proportion of patients in-target improved from 43% to 61% for systolic blood pressure <130 mm Hg and from 45% to 67% for LDL<70 mg/dL (both changes <0.001).

Conclusions: The rigorous multimodal approach to intensive stroke risk factor management in CREST2 has resulted in significant improvements in risk factor control that will enable a comparison of cutting-edge medical care to revascularization in patients with asymptomatic carotid stenosis. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02089217.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.120.030730DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7530035PMC
October 2020

Trends in incidence and epidemiologic characteristics of cerebral venous thrombosis in the United States.

Neurology 2020 10 26;95(16):e2200-e2213. Epub 2020 Aug 26.

From the Department of Neurology (F.O.O., J.G.L.), State University of New York Upstate Medical University, Syracuse; Department of Neurology (S.P.), University of Connecticut, Hartford; Department of Neurology (R.S.), Yale University, New Haven, CT; Department of Internal Medicine (P. Khandwala, D.D.), Crozier Chester Medical Center, Chester, PA; Molecular Neuropharmacology Unit (E.O.A.), National Institute of Neurological Disorders and Stroke, Bethesda, MD; Department of Healthcare Transformation Initiative (N.A.), University of Texas Health Science Center at Houston; Department of Neurology (S.I.), Brigham and Women's Hospital/Harvard Medical School, Boston, MA; Department of Neurology (A.M.M., D.Y.), University of Miami Miller School of Medicine, FL; Department of Neurology (P. Khandelwal), Rutgers New Jersey Medical School, Newark; and Department of Neurology (S.C.), University of Maryland, Baltimore.

Objective: To test the hypothesis that race-, age-, and sex-specific incidence of cerebral venous thrombosis (CVT) has increased in the United States over the last decade.

Methods: In this retrospective cohort study, validated ICD codes were used to identify all new cases of CVT (n = 5,567) in the State Inpatients Databases (SIDs) of New York and Florida (2006-2016). A new CVT case was defined as first hospitalization for CVT in the SID without prior CVT hospitalization. CVT counts were combined with annual Census data to compute incidence. Joinpoint regression was used to evaluate trends in incidence over time.

Results: From 2006 to 2016, annual age- and sex-standardized incidence of CVT in cases per 1 million population ranged from 13.9 to 20.2, but incidence varied significantly by sex (women 20.3-26.9, men 6.8-16.8) and by age/sex (women 18-44 years of age 24.0-32.6, men 18-44 years of age 5.3-12.8). Incidence also differed by race (Blacks: 18.6-27.2; Whites: 14.3-18.5; Asians: 5.1-13.8). On joinpoint regression, incidence increased across 2006 to 2016, but most of this increase was driven by an increase in all age groups of men (combined annualized percentage change [APC] 9.2%, < 0.001), women 45 to 64 years of age (APC 7.8%, < 0.001), and women ≥65 years of age (APC 7.4%, < 0.001). Incidence in women 18 to 44 years of age remained unchanged over time.

Conclusion: CVT incidence is disproportionately higher in Blacks compared to other races. New CVT hospitalizations increased significantly over the last decade mainly in men and older women. Further studies are needed to determine whether this increase represents a true increase from changing risk factors or an artifactual increase from improved detection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000010598DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7713788PMC
October 2020

Trends and controversies in carotid artery stenosis treatment.

F1000Res 2020 7;9. Epub 2020 Aug 7.

Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.

Despite the completion of several multi-center trials, the management of carotid stenosis remains in flux. Key questions include the role of intensive medical management in the treatment of asymptomatic carotid stenosis. In addition, identification of patients with symptomatic stenosis who will most benefit from carotid revascularization remains a priority. The role of newer imaging techniques such as carotid plaque analysis with magnetic resonance imaging is also challenging current treatment paradigms. These topics are explored in this topical update.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.12688/f1000research.25922.1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416573PMC
October 2020

The interplay between COVID 19 and non-communicable diseases.

J Stroke Cerebrovasc Dis 2020 09 1;29(9):105104. Epub 2020 Jul 1.

Davee Department of Neurology and Stroke and Neurocritical Care Program, Northwestern University Feinberg School of Medicine.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328547PMC
September 2020

Current Status of Dyslipidemia Treatment for Stroke Prevention.

Curr Neurol Neurosci Rep 2020 06 22;20(8):31. Epub 2020 Jun 22.

Stroke Division and Department of Neurology, University of Maryland School of Medicine, 110 S. Paca St., Baltimore, MD, 21201, USA.

Purpose Of Review: Elevated cholesterol is an established risk factor for ischemic stroke. The value of statins for stroke prevention has been clear for more than a decade.

Recent Findings: However, the use of new medication combinations such as ezetimibe or proprotein convertase subtilisin-kexin type 9 inhibitors plus statins is increasing and the value for reducing stroke has been shown for these combination therapies. Recent data also support the strategy of lowering triglycerides for stroke prevention. A modern approach to dyslipidemia treatment and its relation to stroke prevention is summarized in this paper.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11910-020-01052-4DOI Listing
June 2020

Carotid Revascularization Options in the Elderly Patients.

Angiology 2020 11 17;71(10):873-875. Epub 2020 Jun 17.

Department of Neurology, 12264University of Maryland, Baltimore, MD, USA.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0003319720933428DOI Listing
November 2020

Thrombectomy Outcomes in Acute Ischemic Stroke due to Middle Cerebral Artery M2 Occlusion with Stent Retriever versus Aspiration: A Multicenter Experience.

Interv Neurol 2020 Jan 18;8(2-6):180-186. Epub 2019 Jun 18.

Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.

Objective: To examine outcomes for thrombectomy devices used for treatment of acute ischemic stroke (AIS) with middle cerebral artery (MCA) M2 segment emergent large vessel occlusion (ELVO) as the optimal device for such reperfusion is not clearly defined.

Methods: A retrospective cohort study of consecutive AIS patients with MCA M2 ELVO undergoing thrombectomy from 3 academic medical centers was conducted from October 1999 through June 2016. The patients were divided based on the device utilized. Multivariate analysis of associations between devices (stent retriever or aspiration only [manual or pump aspiration system]) was performed. Primary outcomes were good recanalization (i.e., modified thrombolysis in cerebral infarction score ≥2b) and a favorable modified Rankin scale (mRS) score (i.e. ≤2). The secondary outcome was symptomatic intracerebral hemorrhage (sICH).

Results: A total of 197 AIS patients underwent MCA M2 ELVO thrombectomy with either a stent retriever ( = 120) or aspiration only ( = 77). The aspiration-only group utilized either manual ( = 38) or pump aspiration ( = 39). Utilization of a stent retriever over manual aspiration is independently associated with higher odds of a favorable mRS score (OR = 3.2; 95% CI 1.02-9.7) and lower odds of sICH (OR = 0.09; 95% CI 0.03-0.31). Utilization of a stent retriever over a pump aspiration system is independently associated with higher odds of good recanalization (OR = 3.8; 95% CI 1.5-9.6). Utilization of a newer-generation pump aspiration catheter compared to a stent retriever resulted in similar rates of favorable mRS scores, sICH, successful recanalization, and mortality.

Conclusion: Utilization of a newer-generation pump aspiration catheter compared to a stent retriever resulted in similar outcomes, but worse outcomes were seen with the manual aspiration technique. These findings need to be confirmed with a large randomized trial utilizing stent retrievers and newer-generation pump aspiration systems.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1159/000500198DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253853PMC
January 2020

Asymptomatic Intracranial Artery Stenosis-One Less Thing to Worry About.

JAMA Neurol 2020 08;77(8):935-936

University of Maryland School of Medicine, Department of Neurology and Stroke Program, Baltimore, Maryland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamaneurol.2020.0878DOI Listing
August 2020

Rural-Urban Disparities in Intracerebral Hemorrhage Mortality in the USA: Preliminary Findings from the National Inpatient Sample.

Neurocrit Care 2020 06;32(3):715-724

Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.

Objectives: To compare in-hospital mortality between intracerebral hemorrhage (ICH) patients in rural hospitals to those in urban hospitals of the USA.

Methods: We used the National Inpatient Sample to retrospectively identify all cases of ICH in the USA over the period 2004-2014. We used multivariable-adjusted models to compare odds of mortality between rural and urban hospitals. Joinpoint regression was used to evaluate trends in age- and sex-adjusted mortality in rural and urban hospitals over time.

Results: From 2004 to 2014, 5.8% of ICH patients were admitted in rural hospitals. Rural patients were older (mean [SE] 76.0 [0.44] years vs. 68.8 [0.11] years in urban), more likely to be white and have Medicare insurance. Age- and sex-adjusted mortality was greater in rural hospitals (32.2%) compared to urban patients (26.5%) (p value < 0.001). After multivariable adjustment, patients hospitalized in rural hospitals had two times the odds of in-hospital death compared to patients in urban hospitals (OR 2.07, 95% CI 1.77-2.41. p value < 0.001). After joinpoint regression, mortality declined in urban hospitals by an average of 2.8% per year (average annual percentage change, [AAPC] - 2.8%, 95% CI - 3.7 to - 1.8%), but rates in rural hospitals remained unchanged (AAPC - 0.54%, 95% CI - 1.66 to 0.58%).

Conclusions: Despite current efforts to reduce disparity in stroke care, ICH patients hospitalized in rural hospitals had two times the odds of dying compared to those in urban hospitals. In addition, the ICH mortality gap between rural and urban centers is increasing. Further studies are needed to identify and reverse the causes of this disparity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12028-020-00950-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7223184PMC
June 2020

Tracking the Development of Cerebrovascular Risk Factors Following Pregnancy With Preeclampsia.

J Stroke Cerebrovasc Dis 2020 Jun 24;29(6):104720. Epub 2020 Mar 24.

University of Maryland Medical System, Miami, Florida.

Objective: To evaluate the development and management of cerebrovascular risk factors following a pregnancy with preeclampsia.

Methods: This is a retrospective chart review including women diagnosed with preeclampsia between 2012 and 2013 with later encounters within 2014-2016. For each subject that met inclusion criteria, the development of cerebrovascular risk factors was determined using ICD codes within the 2014-2016 electronic medical record (EMR). For subjects who developed risk factors, current treatment was determined from the EMR. Demographic data was also documented. Differences in the development and treatment of risk factors were compared among racial groups and age. Descriptive statistics were calculated using SAS statistical software.

Results: Compared to prepregnancy health status, the incidence of hypertension increased by 1.7 times (P < .05), hyperlipidemia increased by 4.5 (P < .05), migraines increased by 2.2 (P < .05), and diabetes mellitus increased by 2 (P < .05) after a pregnancy with preeclampsia. Black non-Hispanics had highest rates of hypertension, obesity, and migraines (20.5%, 9.1%, and 6.8%, respectively.) Of hypertensives, 73.6% (42/57) were prescribed medication. Of diabetics, 88.9% (16/18) were prescribed medication. No patients with hyperlipidemia were prescribed a statin. Black non-Hispanics had higher rates of risk factor management (74.3% of hypertensives and 100% of diabetics treated) than white Hispanics (55% and 77.8%, respectively).

Conclusions: This study shows a significant increased risk of the development of cerebrovascular risk factors such as hypertension, hyperlipidemia, migraines, and diabetes following a diagnosis of preeclampsia. Opportunities exist for the early treatment of these risk factors, which could reduce the long-term rate of stroke in these women.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104720DOI Listing
June 2020

Early Anticoagulation for Minor Non-Cardioembolic Stroke and Transient Ischemic Attack: Too Early to Call.

Stroke 2020 04 26;51(4):1051-1052. Epub 2020 Feb 26.

From the Department of Neurology and Stroke Program, University of Maryland, Baltimore.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.119.028583DOI Listing
April 2020

The Use of Oral Anticoagulants in Patients with Atrial Fibrillation in the Emergency Department.

J Stroke Cerebrovasc Dis 2020 Apr 27;29(4):104599. Epub 2020 Jan 27.

Department of Neurology, University of Maryland, Baltimore, MD.

Background And Aim: Atrial Fibrillation is the leading cause of embolic stroke, yet less than half of high-risk patients with atrial fibrillation are on adequate stroke prevention with oral anticoagulants. Guidelines for the primary prevention of stroke recognize the emergency department as a location for physicians to identify atrial fibrillation and initiate anticoagulants. We sought to compare anticoagulant prescription rates in patients with atrial fibrillation in various provider settings to identify opportunities for improvement in cardioembolic stroke prevention.

Methods: A retrospective cohort study of 436 patients with atrial fibrillation presenting to the emergency department from 2014 to 2018 was performed. Baseline characteristics, stroke risk, and rates of anticoagulant prescription were compared across 3 groups: (1) patients discharged from the emergency department, (2) patients admitted under observation status, and (3) patients admitted to inpatient hospital service.

Results: Among 436 patients (47% women, 51% Hispanic), we identified 105 in the emergency department cohort, 131 in the observation cohort and 200 in the inpatient cohort. The average CHADS-VASc score was 2.5 in the emergency department cohort, 2.6 in the observation cohort and 3.3 in the inpatient cohort. Anticoagulants were prescribed for high-risk patients (CHADS-VASc score ≥ 2) in 17.5% (7/40) of the emergency department cohort compared to 73% (38/52, P< .0001) of the observation cohort and 80% (82/103 P< .0001) of the inpatient cohort.

Conclusion: Patients with atrial fibrillation are more likely to be prescribed anticoagulants if admitted to inpatient or under observation status compared to the emergency department.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.104599DOI Listing
April 2020

Quality Assurance for Carotid Stenting in the CREST-2 Registry.

J Am Coll Cardiol 2019 12;74(25):3071-3079

Department of Neurology, Mayo Clinic, Jacksonville, Florida.

Background: The CREST-2 Registry (C2R) was approved by National Institute of Neurological Disorders and Stroke-National Institutes of Health in September 2014 with Centers for Medicare & Medicaid Services, U.S. Food and Drug Administration, and industry collaboration to enroll patients undergoing CAS. The registry credentials interventionists and promotes optimal patient selection, procedural-technique, and outcomes.

Objectives: This study reports periprocedural outcomes in a cohort of carotid artery stenting (CAS) performed for asymptomatic and symptomatic carotid stenosis.

Methods: Asymptomatic patients with ≥70% and symptomatic patients with ≥50% carotid stenosis, ≤80 years of age, and at standard or high risk for carotid endarterectomy are eligible for enrollment. Interventionists are credentialed by a multispecialty committee that reviews experience, lesion selection, technique, and outcomes. The primary endpoint was a composite of stroke and death (S/D) in the 30-day periprocedural period. Myocardial infarction and access-site complications were assessed as secondary outcomes.

Results: As of December 2018, 187 interventionists from 98 sites in the United States performed 2,219 CAS procedures in 2,141 patients with primary atherosclerosis (78 were bilateral). The mean age of the cohort was 68 years, 65% were male, and 92% were white; 1,180 (55%) were for asymptomatic disease, and 961 (45%) were for symptomatic disease. All U.S. Food and Drug Administration-approved stents and embolic protection devices were represented. The 30-day rate of S/D was 1.4% for asymptomatic, 2.8% for symptomatic, and 2.0% for all patients.

Conclusions: C2R is the first national registry for CAS cosponsored by federal and industry partners. CAS was performed by experienced operators using appropriate patient selection and optimal technique. In that setting, a broad group of interventionists achieved very low periprocedural S/D rates for asymptomatic and symptomatic patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2019.10.032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7012370PMC
December 2019

Alcohol withdrawal is associated with poorer outcome in acute ischemic stroke.

Neurology 2019 11 25;93(21):e1944-e1954. Epub 2019 Oct 25.

From the Molecular Neuropharmacology Unit (E.O.A.), National Institutes of Neurologic Disorders and Stroke, NIH, Bethesda, MD; Division of Neurocritical Care (F.O.O.), Department of Neurology, Massachusetts General Hospital/Harvard Medical School, Boston; and Department of Neurology (S.C.), University of Maryland School of Medicine, Baltimore.

Objective: To determine the association between alcohol abuse (AA) and alcohol withdrawal (AW) with acute ischemic stroke (AIS) outcomes.

Methods: All adult AIS admissions in the United States from 2004 to 2014 were identified from the National Inpatient Sample (weighted n = 4,438,968). Multivariable-adjusted models were used to evaluate the association of AW with in-hospital medical complications, mortality, cost, and length of stay in patients with AIS.

Results: Of the AA admissions, 10.6% of patients, representing 0.4% of all AIS, developed AW. The prevalence of AA and AW in AIS increased by 45.2% and 40.0%, respectively, over time ( for trend <0.001). Patients with AA were predominantly men (80.2%), white (65.9%), and in the 40- to 59-year (44.6%) and 60- to 79-year (45.6%) age groups. After multivariable adjustment, AIS admissions with AW had >50% increased odds of urinary tract infection, pneumonia, sepsis, gastrointestinal bleeding, deep venous thrombosis, and acute renal failure compared to those without AW. Patients with AW were also 32% more likely to die during their AIS hospitalization compared to those without AW (odds ratio 1.32, 95% confidence interval 1.11-1.58). AW was associated with ≈15-day increase in length of stay and ≈$5,000 increase in hospitalization cost ( < 0.001).

Conclusion: AW is associated with increased cost, longer hospitalizations, and higher odds of medical complications and in-hospital mortality after AIS. Proactive surveillance and management of AW may be important in improving outcomes in these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000008518DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6885576PMC
November 2019

A clinical decision rule for timing of carotid endarterectomy.

J Vasc Surg 2019 11;70(5):1723

Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore, Md.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jvs.2019.06.181DOI Listing
November 2019

BIIB093 (IV glibenclamide): an investigational compound for the prevention and treatment of severe cerebral edema.

Expert Opin Investig Drugs 2019 Dec 24;28(12):1031-1040. Epub 2019 Oct 24.

Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD, USA.

: Brain swelling due to edema formation is a major cause of neurological deterioration and death in patients with large hemispheric infarction (LHI) and severe traumatic brain injury (TBI), especially contusion-TBI. Preclinical studies have shown that SUR1-TRPM4 channels play a critical role in edema formation and brain swelling in LHI and TBI. Glibenclamide, a sulfonylurea drug and potent inhibitor of SUR1-TRPM4, was reformulated for intravenous injection, known as BIIB093.: We discuss the findings from Phase 2 clinical trials of BIIB093 in patients with LHI (GAMES-Pilot and GAMES-RP) and from a small Phase 2 clinical trial in patients with TBI. For the GAMES trials, we review data on objective biological variables, adjudicated edema-related endpoints, functional outcomes, and mortality which, despite missing the primary endpoint, supported the initiation of a Phase 3 trial in LHI (CHARM). For the TBI trial, we review data on MRI measures of edema and the initiation of a Phase 2 trial in contusion-TBI (ASTRAL).: Emerging clinical data show that BIIB093 has the potential to transform our management of patients with LHI, contusion-TBI and other conditions in which swelling leads to neurological deterioration and death.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/13543784.2019.1681967DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6893098PMC
December 2019

Antithrombotic Therapy to Prevent Recurrent Strokes in Ischemic Cerebrovascular Disease: JACC Scientific Expert Panel.

J Am Coll Cardiol 2019 08;74(6):786-803

Department of Neurology, University of Miami, Miller School of Medicine, Miami, Florida. Electronic address:

Stroke survivors carry a high risk of recurrence. Antithrombotic medications are paramount for secondary prevention and thus crucial to reduce the overall stroke burden. Appropriate antithrombotic agent selection should be based on the best understanding of the physiopathological mechanism that led to the initial ischemic injury. Antiplatelet therapy is preferred for lesions characterized by atherosclerosis and endothelial injury, whereas anticoagulant agents are favored for cardiogenic embolism and highly thrombophilic conditions. Large randomized controlled trials have provided new data to support recommendations for the evidence-based use of antiplatelet agents and anticoagulant agents after stroke. In this review, the authors cover recent trials that have altered clinical practice, cite systematic reviews and meta-analyses, review evidence-based recommendations based on older landmark trials, and indicate where there are still evidence-gaps and new trials being conducted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jacc.2019.06.039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7291776PMC
August 2019

Obstructive Sleep Apnea in Adults.

N Engl J Med 2019 07;381(3):e7

University of Michigan Medical School, Ann Arbor, MI.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1056/NEJMc1906527DOI Listing
July 2019

Processes of Care Associated With Risk of Mortality and Recurrent Stroke Among Patients With Transient Ischemic Attack and Nonsevere Ischemic Stroke.

JAMA Netw Open 2019 07 3;2(7):e196716. Epub 2019 Jul 3.

Veterans Affairs Health Services Research and Development, Precision Monitoring to Transform Care, Quality Enhancement Research Initiative, Department of Veterans Affairs, Indianapolis, Indiana.

Importance: Early evaluation and management of patients with transient ischemic attack (TIA) and nonsevere ischemic stroke improves outcomes.

Objective: To identify processes of care associated with reduced risk of death or recurrent stroke among patients with TIA or nonsevere ischemic stroke.

Design, Setting, And Participants: This cohort study included all patients with TIA or nonsevere ischemic stroke at Department of Veterans Affairs emergency department or inpatient settings from October 2010 to September 2011. Multivariable logistic regression was used to model associations of processes of care and without-fail care, defined as receiving all guideline-concordant processes of care for which patients are eligible, with risk of death and recurrent stroke. Data were analyzed from March 2018 to April 2019.

Main Outcomes And Measures: Risk of all-cause mortality and recurrent ischemic stroke at 90 days and 1 year was calculated. Overall, 28 processes of care were examined. Without-fail care was assessed for 6 processes: brain imaging, carotid artery imaging, hypertension medication intensification, high- or moderate-potency statin therapy, antithrombotics, and anticoagulation for atrial fibrillation.

Results: Among 8076 patients, the mean (SD) age was 67.8 (11.6) years, 7752 patients (96.0%) were men, 5929 (73.4%) were white, 474 (6.1%) had a recurrent ischemic stroke within 90 days, 793 (10.7%) had a recurrent ischemic stroke within 1 year, 320 (4.0%) died within 90 days, and 814 (10.1%) died within 1 year. Overall, 9 processes were independently associated with lower odds of both 90-day and 1-year mortality after adjustment for multiple comparisons: carotid artery imaging (90-day adjusted odds ratio [aOR], 0.49; 95% CI, 0.38-0.63; 1-year aOR, 0.61; 95% CI, 0.52-0.72), antihypertensive medication class (90-day aOR, 0.58; 95% CI, 0.45-0.74; 1-year aOR, 0.70; 95% CI, 0.60-0.83), lipid measurement (90-day aOR, 0.68; 95% CI, 0.51-0.90; 1-year aOR, 0.64; 95% CI, 0.53-0.78), lipid management (90-day aOR, 0.46; 95% CI, 0.33-0.65; 1-year aOR, 0.67; 95% CI, 0.53-0.85), discharged receiving statin medication (90-day aOR, 0.51; 95% CI, 0.36-0.73; 1-year aOR, 0.70; 95% CI, 0.55-0.88), cholesterol-lowering medication intensification (90-day aOR, 0.47; 95% CI, 0.26-0.83; 1-year aOR, 0.56; 95% CI, 0.41-0.77), antithrombotics by day 2 (90-day aOR, 0.56; 95% CI, 0.40-0.79; 1-year aOR, 0.69; 95% CI, 0.55-0.87) or at discharge (90-day aOR, 0.59; 95% CI, 0.41-0.86; 1-year aOR, 0.69; 95% CI, 0.54-0.88), and neurology consultation (90-day aOR, 0.67; 95% CI, 0.52-0.87; 1-year aOR, 0.74; 95% CI, 0.63-0.87). Anticoagulation for atrial fibrillation was associated with lower odds of 1-year mortality only (aOR, 0.59; 95% CI, 0.40-0.85). No processes were associated with reduced risk of recurrent stroke after adjustment for multiple comparisons. The rate of without-fail care was 15.3%; 1216 patients received all guideline-concordant processes of care for which they were eligible. Without-fail care was associated with a 31.2% lower odds of 1-year mortality (aOR, 0.69; 95% CI, 0.55-0.87) but was not independently associated with stroke risk.

Conclusions And Relevance: Patients who received 6 readily available processes of care had lower adjusted mortality 1 year after TIA or nonsevere ischemic stroke. Clinicians caring for patients with TIA and nonsevere ischemic stroke should seek to ensure that patients receive all guideline-concordant processes of care for which they are eligible.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1001/jamanetworkopen.2019.6716DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6613337PMC
July 2019

Letter by Chaturvedi Regarding Article, "WEAVE Trial: Final Results in 152 On-Label Patients".

Stroke 2019 07 11;50(7):e222. Epub 2019 Jun 11.

Department of Neurology and Stroke Program, University of Maryland School of Medicine, Baltimore.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1161/STROKEAHA.119.025852DOI Listing
July 2019

Vertebral artery stenting: lifting the therapeutic fog.

Lancet Neurol 2019 07 23;18(7):620-621. Epub 2019 May 23.

Stroke Program and Department of Neurology, University of Maryland School of Medicine, Baltimore, MD 21201, USA. Electronic address:

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/S1474-4422(19)30191-7DOI Listing
July 2019

Stroke in young adults: Five new things.

Neurol Clin Pract 2018 Dec;8(6):501-506

Division of Vascular Neurology (NB, AMM, SC), Department of Neurology, University of Miami Miller School of Medicine, and Miami VA Hospital (SC), FL.

Purpose Of Review: The incidence of stroke in young adults is increasing, mainly driven by an increasing incidence of ischemic stroke in this population. We provide new information that has been recently presented regarding the risk factor prevalence, some specific etiologic causes, and management strategies in ischemic stroke in this population.

Recent Findings: Recent studies indicate a rapid increase in traditional risk factors in young adults. New information regarding the management of patent foramen ovale in cryptogenic stroke and cervical artery dissection is available.

Summary: Stroke in young adults is a rapidly growing problem with deep public health implications. There are many areas in this field, which require further research.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/CPJ.0000000000000522DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6294527PMC
December 2018

Treatment of a hot carotid: More fuel is needed to clarify the best treatments.

Neurol Clin Pract 2018 Dec;8(6):466-467

Department of Neurology, University of Miami Miller School of Medicine, FL.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/CPJ.0000000000000561DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6294528PMC
December 2018