Publications by authors named "Shashank Agarwal"

52 Publications

Surprising simplicity in the modeling of dynamic granular intrusion.

Sci Adv 2021 Apr 23;7(17). Epub 2021 Apr 23.

Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.

Granular intrusions, such as dynamic impact or wheel locomotion, are complex multiphase phenomena where the grains exhibit solid-like and fluid-like characteristics together with an ejected gas-like phase. Despite decades of modeling efforts, a unified description of the physics in such intrusions is as yet unknown. Here, we show that a continuum model based on the simple notions of frictional flow and tension-free separation describes complex granular intrusions near free surfaces. This model captures dynamics in a variety of experiments including wheel locomotion, plate intrusions, and running legged robots. The model reveals that one static and two dynamic effects primarily give rise to intrusion forces in such scenarios. We merge these effects into a further reduced-order technique (dynamic resistive force theory) for rapid modeling of granular locomotion of arbitrarily shaped intruders. The continuum-motivated strategy we propose for identifying physical mechanisms and corresponding reduced-order relations has potential use for a variety of other materials.
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http://dx.doi.org/10.1126/sciadv.abe0631DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8064642PMC
April 2021

Increase in Ventricle Size and the Evolution of White Matter Changes on Serial Imaging in Critically Ill Patients with COVID-19.

Neurocrit Care 2021 Mar 5. Epub 2021 Mar 5.

Department of Neurology, NYU Langone Medical Center, New York, NY, 10016, USA.

Background: Evolution of brain magnetic resonance imaging (MRI) findings in critically ill patients with coronavirus disease 2019 (COVID-19) is unknown.

Methods: We retrospectively reviewed 4530 critically ill patients with COVID-19 admitted to three tertiary care hospitals in New York City from March 1 to June 30, 2020 to identify patients who had more than one brain MRI. We reviewed the initial and final MRI for each patient to (1) measure the percent change in the bicaudate index and third ventricular diameter and (2) evaluate changes in the presence and severity of white matter changes.

Results: Twenty-one patients had two MRIs separated by a median of 22 [Interquartile range (IQR) 14-30] days. Ventricle size increased for 15 patients (71%) between scans [median bicaudate index 0.16 (IQR 0.126-0.181) initially and 0.167 (IQR 0.138-0.203) on final imaging (p < 0.001); median third ventricular diameter 6.9 mm (IQR 5.4-10.3) initially and 7.2 mm (IQR 6.4-10.8) on final imaging (p < 0.001)]. Every patient had white matter changes on the initial and final MRI; between images, they worsened for seven patients (33%) and improved for three (14%).

Conclusions: On serial imaging of critically ill patients with COVID-19, ventricle size frequently increased over several weeks. White matter changes were often unchanged, but in some cases they worsened or improved, demonstrating there is likely a spectrum of pathophysiological processes responsible for these changes.
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http://dx.doi.org/10.1007/s12028-021-01207-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935478PMC
March 2021

Hypertrophic Olivary Degeneration and Movement Disorder in a Patient with Familial Creutzfeldt-Jakob Disease.

Cureus 2020 Oct 8;12(10):e10854. Epub 2020 Oct 8.

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

A 38-year-old male presented with a three-week history of bilateral lower extremity choreiform movements. History included sleep abnormalities, rushed and unintelligible speech, with delusions two to six months prior to presentation. He also developed mild dysphagia, staring spells, and anterograde amnesia. On examination, he had pressured speech, asynchronous cycling movements of the bilateral lower extremities persisting during sleep, occasional ballistic movements of the upper extremities, and ataxia. Magnetic resonance imaging (MRI) of the brain showed high cortical signal change in bilateral parieto-occipital cortices with evidence of medullary olive hypertrophy bilaterally. Electroencephalography showed generalized slowing without periodic spikes. Cerebrospinal fluid was positive for protein 14-3-3 and real-time quaking-induced conversion. Genetic testing was positive for autosomal dominant prion protein gene (PRNP) genetic mutation. The patient passed away three months after discharge. This case provides previously undescribed imaging and movement abnormalities in a patient with familial Creutzfeldt-Jakob disease (CJD), and suggests that CJD should not be removed from the differential in patients with these atypical findings.
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http://dx.doi.org/10.7759/cureus.10854DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7652026PMC
October 2020

Etiologic Subtypes of Ischemic Stroke in SARS-CoV-2 Patients in a Cohort of New York City Hospitals.

Front Neurol 2020 17;11:1004. Epub 2020 Sep 17.

Neuroradiology & Neurointervention Service, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, United States.

To describe the ischemic stroke subtypes related to coronavirus disease 2019 (COVID-19) in a cohort of New York City hospitals and explore their etiopathogenesis. Most neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology. Data were collected prospectively April 1-April 15, 2020 from two centers in New York City to review possible ischemic stroke types seen in COVID-19-positive patients. Patient presentation, demographics, related vascular risk factors, associated laboratory markers, as well as imaging and outcomes were collected. The age of patients ranged between 27 and 82 years. Approximately 81% of patients had known vascular risk factors, the commonest being hypertension (75%) followed by diabetes (50%) coronary disease or atrial fibrillation. Eight patients presented with large vessel occlusion (LVO) with median age 55 years (27-82) and all were male. Eight patients presented with non-LVO syndromes, with median age 65.5 years (59-82) and most were female (62.5%). Both groups were 50% African Americans and 37.5% South Asian. Both groups had similar D-dimer levels although other acute phase reactants/disease severity markers (Ferritin, CRP, procalcitonin) were higher in the LVO group. The LVO group also had a significantly higher mortality compared to the non-LVO group. The most common etiology was cryptogenic (6 patients) followed by small vessel occlusion (3 patients) and undetermined-unclassified (3 patients). For the remaining 4 patients, 2 were identified as cardioembolic and 2 with large artery atherosclerosis. COVID-19-related ischemic events can present as small vessel occlusions, branch emboli or large vessel occlusions. The most common etiology is cryptogenic. Patients with LVO syndromes tend to be younger, male and may have elevated acute inflammatory markers.
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http://dx.doi.org/10.3389/fneur.2020.01004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7527497PMC
September 2020

A Prospective Study of Neurologic Disorders in Hospitalized Patients With COVID-19 in New York City.

Neurology 2021 01 5;96(4):e575-e586. Epub 2020 Oct 5.

From the New York University Grossman School of Medicine (J.A.F., S.S., R.L., T.F., B.F., P.M.-V., T.S., S.B., D.Y., A.G., N.M., P.P., J.G., K.M., S.A., M.B., A.A., E.V., M.O., A.K., K.L., Daniel Friedman, David Friedman, M.H., J.H., S.T., J.H., N.A.-F., P.K., A.L., A.S.L., T.Z., D.E.K., B.M.C., J.T., S.Y., K.I., E.S., D.P., M.L., T.W., A.B.T., L.B., S.G.), New YorkUniversity of Pittsburgh School of Medicine (S.H.-Y.C., E.L.F.), PAThe Ohio State University (M.M., S.M.), ColumbusMedical University of Innsbruck (R.H.), AustriaThe Johns Hopkins University School of Medicine (C.R., J.I.S., W.Z.), Baltimore, MDUniversity of Utah School of Medicine (M.S., A.d.H.), Salt Lake CityUniversity of Cambridge (D.M.), UK.

Objective: To determine the prevalence and associated mortality of well-defined neurologic diagnoses among patients with coronavirus disease 2019 (COVID-19), we prospectively followed hospitalized severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-positive patients and recorded new neurologic disorders and hospital outcomes.

Methods: We conducted a prospective, multicenter, observational study of consecutive hospitalized adults in the New York City metropolitan area with laboratory-confirmed SARS-CoV-2 infection. The prevalence of new neurologic disorders (as diagnosed by a neurologist) was recorded and in-hospital mortality and discharge disposition were compared between patients with COVID-19 with and without neurologic disorders.

Results: Of 4,491 patients with COVID-19 hospitalized during the study timeframe, 606 (13.5%) developed a new neurologic disorder in a median of 2 days from COVID-19 symptom onset. The most common diagnoses were toxic/metabolic encephalopathy (6.8%), seizure (1.6%), stroke (1.9%), and hypoxic/ischemic injury (1.4%). No patient had meningitis/encephalitis or myelopathy/myelitis referable to SARS-CoV-2 infection and 18/18 CSF specimens were reverse transcriptase PCR negative for SARS-CoV-2. Patients with neurologic disorders were more often older, male, white, hypertensive, diabetic, intubated, and had higher sequential organ failure assessment (SOFA) scores (all < 0.05). After adjusting for age, sex, SOFA scores, intubation, history, medical complications, medications, and comfort care status, patients with COVID-19 with neurologic disorders had increased risk of in-hospital mortality (hazard ratio [HR] 1.38, 95% confidence interval [CI] 1.17-1.62, < 0.001) and decreased likelihood of discharge home (HR 0.72, 95% CI 0.63-0.85, < 0.001).

Conclusions: Neurologic disorders were detected in 13.5% of patients with COVID-19 and were associated with increased risk of in-hospital mortality and decreased likelihood of discharge home. Many observed neurologic disorders may be sequelae of severe systemic illness.
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http://dx.doi.org/10.1212/WNL.0000000000010979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7905791PMC
January 2021

Acute stroke care in a New York City comprehensive stroke center during the COVID-19 pandemic.

J Stroke Cerebrovasc Dis 2020 Sep 20;29(9):105068. Epub 2020 Jun 20.

Department of Neurology, New York Langone Health, New York, NY, United States. Electronic address:

Background And Purpose: The coronavirus disease-2019 (COVID-19) pandemic caused unprecedented demand and burden on emergency health care services in New York City. We aim to describe our experience providing acute stroke care at a comprehensive stroke center (CSC) and the impact of the pandemic on the quality of care for patients presenting with acute ischemic stroke (AIS).

Methods: We retrospectively analyzed data from a quality improvement registry of consecutive AIS patients at New York University Langone Health's CSC between 06/01/2019-05/15/2020. During the early stages of the pandemic, the acute stroke process was modified to incorporate COVID-19 screening, testing, and other precautionary measures. We compared stroke quality metrics including treatment times and discharge outcomes of AIS patients during the pandemic (03/012020-05/152020) compared with a historical pre-pandemic group (6/1/2019-2/29/2020).

Results: A total of 754 patients (pandemic-120; pre-pandemic-634) were admitted with a principal diagnosis of AIS; 198 (26.3%) received alteplase and/or mechanical thrombectomy. Despite longer median door to head CT times (16 vs 12 minutes; p = 0.05) and a trend towards longer door to groin puncture times (79.5 vs. 71 min, p = 0.06), the time to alteplase administration (36 vs 35 min; p = 0.83), door to reperfusion times (103 vs 97 min, p = 0.18) and defect-free care (95.2% vs 94.7%; p = 0.84) were similar in the pandemic and pre-pandemic groups. Successful recanalization rates (TICI≥2b) were also similar (82.6% vs. 86.7%, p = 0.48). After adjusting for stroke severity, age and a prior history of transient ischemic attack/stroke, pandemic patients had increased discharge mortality (adjusted OR 2.90 95% CI 1.77 - 7.17, p = 0.021) CONCLUSION: Despite unprecedented demands on emergency healthcare services, early multidisciplinary efforts to adapt the acute stroke treatment process resulted in keeping the stroke quality time metrics close to pre-pandemic levels. Future studies will be needed with a larger cohort comparing discharge and long-term outcomes between pre-pandemic and pandemic AIS patients.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105068DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7305900PMC
September 2020

Special considerations in the assessment of catastrophic brain injury and determination of brain death in patients with SARS-CoV-2.

J Neurol Sci 2020 10 8;417:117087. Epub 2020 Aug 8.

NYU Langone Medical Center, Department of Neurology, New York, NY 10016, United States of America; NYU Langone Medical Center, Department of Neurosurgery, New York, NY 10016, United States of America.

Introduction: The coronavirus disease 2019 (Covid-19) pandemic has led to challenges in provision of care, clinical assessment and communication with families. The unique considerations associated with evaluation of catastrophic brain injury and death by neurologic criteria in patients with Covid-19 infection have not been examined.

Methods: We describe the evaluation of six patients hospitalized at a health network in New York City in April 2020 who had Covid-19, were comatose and had absent brainstem reflexes.

Results: Four males and two females with a median age of 58.5 (IQR 47-68) were evaluated for catastrophic brain injury due to stroke and/or global anoxic injury at a median of 14 days (IQR 13-18) after admission for acute respiratory failure due to Covid-19. All patients had hypotension requiring vasopressors and had been treated with sedative/narcotic drips for ventilator dyssynchrony. Among these patients, 5 had received paralytics. Apnea testing was performed for 1 patient due to the decision to withdraw treatment (n = 2), concern for inability to tolerate testing (n = 2) and observation of spontaneous respirations (n = 1). The apnea test was aborted due to hypoxia and hypotension. After ancillary testing, death was declared in three patients based on neurologic criteria and in three patients based on cardiopulmonary criteria (after withdrawal of support (n = 2) or cardiopulmonary arrest (n = 1)). A family member was able to visit 5/6 patients prior to cardiopulmonary arrest/discontinuation of organ support.

Conclusion: It is feasible to evaluate patients with catastrophic brain injury and declare brain death despite the Covid-19 pandemic, but this requires unique considerations.
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http://dx.doi.org/10.1016/j.jns.2020.117087DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7414304PMC
October 2020

Cerebral Microbleeds and Leukoencephalopathy in Critically Ill Patients With COVID-19.

Stroke 2020 09 5;51(9):2649-2655. Epub 2020 Aug 5.

Department of Neurology (S.A., A.L., K.M., S.G.), NYU Langone Health, New York, NY.

Background And Purpose: We conducted this study to investigate the prevalence and distribution of cerebral microbleeds and leukoencephalopathy in hospitalized patients with coronavirus disease 2019 (COVID-19) and correlate with clinical, laboratory, and functional outcomes.

Methods: We performed a retrospective chart review of 4131 COVID-19 positive adult patients who were admitted to 3 tertiary care hospitals of an academic medical center at the epicenter of the COVID-19 pandemic in New York City from March 1, 2020, to May 10, 2020, to identify patients who had magnetic resonance imaging (MRI) of the brain. We evaluated the MRIs in detail, and identified a subset of patients with leukoencephalopathy and/or cerebral microbleeds. We compared clinical, laboratory, and functional outcomes for these patients to patients who had a brain MRI that did not show these findings.

Results: Of 115 patients who had an MRI of the brain performed, 35 (30.4%) patients had leukoencephalopathy and/or cerebral microbleeds. Patients with leukoencephalopathy and/or cerebral microbleeds had neuroimaging performed later during the hospitalization course (27 versus 10.6 days; <0.001), were clinically sicker at the time of brain MRI (median GCS 6 versus 14; <0.001), and had higher peak D-dimer levels (8018±6677 versus 3183±3482; <0.001), lower nadir platelet count (116.9±62.2 versus 158.3±76.2; =0.03), higher peak international normalized ratio (2.2 versus 1.57; <0.001) values when compared with patients who had a brain MRI that did not show these findings. They required longer ventilator support (34.6 versus 9.1 days; <0.001) and were more likely to have moderate and severe acute respiratory distress syndrome score (88.6% versus 23.8%, <0.001). These patients had longer hospitalizations (42.1 versus 20.9 days; <0.001), overall worse functional status on discharge (mRS 5 versus 4; =0.001), and higher mortality (20% versus 9%; =0.144).

Conclusions: The presence of leukoencephalopathy and/or cerebral microbleeds is associated with a critical illness, increased mortality, and worse functional outcome in patients with COVID-19.
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http://dx.doi.org/10.1161/STROKEAHA.120.030940DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434006PMC
September 2020

Stroke Treatment Delay Limits Outcome After Mechanical Thrombectomy: Stratification by Arrival Time and ASPECTS.

J Neuroimaging 2020 09 27;30(5):625-630. Epub 2020 Jun 27.

Department of Neurology, New York Langone Medical Center, New York, NY.

Background And Purpose: Mechanical thrombectomy (MT) has helped many patients achieve functional independence. The effect of time-to-treatment based in specific epochs and as related to Alberta Stroke Program Early CT Score (ASPECTS) has not been established. The goal of the study was to evaluate the association between last known normal (LKN)-to-puncture time and good functional outcome.

Methods: We conducted a retrospective cohort study of prospectively collected acute ischemic stroke patients undergoing MT for large vessel occlusion. We used binary logistic regression models adjusted for age, Modified Treatment in Cerebral Ischemia score, initial National Institutes of Health Stroke Scale, and noncontrast CT ASPECTS to assess the association between LKN-to-puncture time and favorable outcome defined as Modified Rankin Score 0-2 on discharge.

Results: Among 421 patients, 328 were included in analysis. Increased LKN-to-puncture time was associated with decreased probability of good functional outcome (adjusted odds ratio [aOR] ratio per 15-minute delay = .98; 95% confidence interval [CI], .97-.99; P = .001). This was especially true when LKN-puncture time was 0-6 hours (aOR per 15-minute delay = .94; 95% CI, .89-.99; P = .05) or ASPECTS 8-10 (aOR = .98; 95% CI, .97-.99; P = .002) as opposed to when LKN-puncture time was 6-24 hours (aOR per 15-minute delay = .99; 95% CI, .97-1.00; P = .16) and ASPECTS <8 (aOR = .98; 95% CI, .93-1.03; P = .37).

Conclusion: Decreased LKN-groin puncture time improves outcome particularly in those with good ASPECTS presenting within 6 hours. Strategies to decrease reperfusion times should be investigated, particularly in those in the early time window and with good ASPECTS.
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http://dx.doi.org/10.1111/jon.12729DOI Listing
September 2020

Mitigating memory effects during undulatory locomotion on hysteretic materials.

Elife 2020 06 24;9. Epub 2020 Jun 24.

Department of Physics, Georgia Institute of Technology, Atlanta, United States.

While terrestrial locomotors often contend with permanently deformable substrates like sand, soil, and mud, principles of motion on such materials are lacking. We study the desert-specialist shovel-nosed snake traversing a model sand and find body inertia is negligible despite rapid transit and speed dependent granular reaction forces. New surface resistive force theory (RFT) calculation reveals how wave shape in these snakes minimizes material memory effects and optimizes escape performance given physiological power limitations. RFT explains the morphology and waveform-dependent performance of a diversity of non-sand-specialist snakes but overestimates the capability of those snakes which suffer high lateral slipping of the body. Robophysical experiments recapitulate aspects of these failure-prone snakes and elucidate how re-encountering previously deformed material hinders performance. This study reveals how memory effects stymied the locomotion of a diversity of snakes in our previous studies (Marvi et al., 2014) and indicates avenues to improve all-terrain robots.
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http://dx.doi.org/10.7554/eLife.51412DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314545PMC
June 2020

Response by Agarwal et al to Letter Regarding Article, "Redefined Measure of Early Neurological Improvement Shows Treatment Benefit of Alteplase Over Placebo".

Stroke 2020 07 17;51(7):e136-e137. Epub 2020 Jun 17.

Department of Neurology, Vanderbilt University Medical Center, Nashville, TN (E.M.).

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http://dx.doi.org/10.1161/STROKEAHA.120.030262DOI Listing
July 2020

Mechanical Thrombectomy in Nonagenarians: A Propensity Score Matched Analysis.

J Stroke Cerebrovasc Dis 2020 Jul 13;29(7):104870. Epub 2020 May 13.

Department of Neurology, NYU School of Medicine, New York, NY, USA. Electronic address:

Background: Little data exists on outcomes of mechanical thrombectomy (MT) in nonagenarians. We aimed to compare the procedural and discharge outcomes of MT for acute ischemic stroke (AIS) in nonagenarians versus younger patients.

Methods: Procedural outcomes and discharge disposition were compared in propensity score-matched groups of nonagenarians versus patients aged≤69 with AIS who underwent MT. Patients aged 70-89 were excluded in order to compare nonagenarians to a younger cohort that most closely approximates the age of patients in the seminal MT trials. Good discharge disposition was defined as a discharge to home or acute rehabilitation.

Results: Of 3010 AIS patients, 46/297(16%) nonagenarians underwent MT compared to 159/1337(12%) aged≤69 (P = 0.091). Of 78 propensity score-matched patients (N = 39 ≥90, N = 39 ≤69), the median admission NIHSS was 22 versus 20, median ASPECTS was 9 versus 9, pre-stroke mRS<4 was 82% versus 87%, 18% versus 8% received IV tPA, and mTICI≥2b was 90% versus 90%, respectively (all P>0.05). Revascularization time (569 versus 372 min), door to groin puncture time (82 versus 71 min) and groin puncture to revascularization times (39 versus 24 min) were similar in between nonagenarians and ≤69, respectively (both P>0.05). Symptomatic ICH (2.6% versus 10.3%; p = 0.165) and in-hospital death rates (10% vs 26%; p = 0.077) trended lower among nonagenarians versus aged≤69. Good discharge disposition occurred in 44% of nonagenarians versus 51% aged≤69 years (p = 0.496).

Conclusions: In propensity score analysis, 90% of nonagenarians achieved successful recanalization and almost half (44%) were discharged to home/acute rehabilitation, which was similar to a younger (aged≤69 years) cohort.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104870DOI Listing
July 2020

Training in neurology: Flexibility and adaptability of a neurology training program at the epicenter of COVID-19.

Neurology 2020 06 8;94(24):e2608-e2614. Epub 2020 May 8.

From the Departments of Neurology (S.A., S.S., N.A.-F., A.K., L.J.B., S.L.G.), Population Health (L.J.B.), and Ophthalmology (L.J.B., S.L.G.), New York University Grossman School of Medicine, New York.

Objective: To outline changes made to a neurology residency program in response to coronavirus disease 2019 (COVID-19).

Methods: In early March 2020, the first cases of COVID-19 were announced in the United States. New York City quickly became the epicenter of a global pandemic, and our training program needed to rapidly adapt to the increasing number of inpatient cases while being mindful of protecting providers and continuing education. Many of these changes unfolded over days, including removing residents from outpatient services, minimizing the number of residents on inpatient services, deploying residents to medicine services and medical intensive care units, converting continuity clinic patient visits to virtual options, transforming didactics to online platforms only, and maintaining connectedness in an era of social distancing. We have been able to accomplish this through daily virtual meetings among leadership, faculty, and residents.

Results: Over time, our program has successfully rolled out initiatives to service the growing number of COVID-related inpatients while maintaining neurologic care for those in need and continuing our neurologic education curriculum.

Conclusion: It has been necessary and feasible for our residency training program to undergo rapid structural changes to adapt to a medical crisis. The key ingredients in doing this successfully have been flexibility and teamwork. We suspect that many of the implemented changes will persist long after the COVID-19 crisis has passed and will change the approach to neurologic and medical training.
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http://dx.doi.org/10.1212/WNL.0000000000009675DOI Listing
June 2020

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

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

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

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

Carotid intimal sarcoma causing stroke and intracranial metastasis via tumor embolization.

Neurology 2020 03 16;94(11):e1122-e1125. Epub 2020 Jan 16.

From the Departments of Neurology (S.A., K.A., S.Y., M.S., S.K., S.G.), Radiology (A.D., E.R.), and Pathology (S.T.H.), NYU Langone Health, New York, NY.

Objective: To present the clinical, radiologic, and pathologic findings of a patient with carotid intimal sarcoma.

Methods: Detailed medical interview, neurologic examination, and diagnostic evaluation including CT angiography head and neck, MRI brain and neck, digital subtraction angiography, and biopsy of the mass were performed.

Results: We report a patient who presented with symptoms of multifocal, bilateral strokes over weeks caused by an enlarging tumor thrombus associated with an intimal sarcoma of the carotid artery. The presence of a carotid space mass encasing the left internal carotid artery was initially not recognized on imaging and was mistakenly attributed to soft atheromatous plaque rather than tumor thrombus. Rapid disease progression resulted in multiple intracranial metastases from tumor embolization.

Conclusion: Clinical and radiologic findings of intimal sarcoma may be similar to those of thrombotic disease. However, patients with sarcoma may show an associated perivascular soft tissue mass and an unusual distribution of vessel stenosis. Reevaluation of imaging should be considered in patients presenting with initial imaging findings suggestive of rapidly progressive thrombotic disease who have a poor response to antithrombotic therapy and do not follow an expected clinical course.
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http://dx.doi.org/10.1212/WNL.0000000000008980DOI Listing
March 2020

Redefining Early Neurological Improvement After Reperfusion Therapy in Stroke.

J Stroke Cerebrovasc Dis 2020 Feb 11;29(2):104526. Epub 2019 Dec 11.

Department of Neurology, New York Langone Health, New York, New York; Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island. Electronic address:

Background And Purpose: Early neurologic improvement (ENI) in patients treated with alteplase has been shown to correlate with functional outcome. However, the definition of ENI remains controversial and has varied across studies. We hypothesized that ENI defined as a percentage change in the National Institute of Health Stroke Scale (NIHSS) score (percent change NIHSS score) at 24-hours would better correlate with favorable outcomes at 3 months than ENI defined as the change in NIHSS score (delta NIHSS score) at 24 hours.

Methods: Retrospective analysis of prospectively collected single-center quality improvement data was performed of all acute ischemic stroke (AIS) patients treated with alteplase. We examined delta NIHSS score and percent change NIHSS score in unadjusted and adjusted logistic regression models as predictors of a favorable outcome at 3 months (defined as mRS 0-1).

Results: Among 586 patients who met the inclusion criteria, 194 (33.1%) had a favorable outcome at 3 months. In fully adjusted models, both delta NIHSS score (OR per point decrease 1.27; 95% confidence interval [CI] 1.19-1.36) and percent change NIHSS score (OR per 10 percent decrease 1.17; 95% CI 1.12-1.22) were associated with favorable functional outcome at 3 months. Receiver operating characteristic (ROC) curve comparison showed that the area under the ROC curve for percent change NIHSS score (.755) was greater than delta NIHSS score (.613) or admission NIHSS (.694).

Conclusions: Percentage change in NIHSS score may be a better surrogate marker of ENI and functional outcome in AIS patients after receiving acute thrombolytic therapy. More studies are needed to confirm our findings.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2019.104526DOI Listing
February 2020

Transcranial magnetic stimulation therapy for focal leg dystonia: a case report.

J Clin Mov Disord 2019 8;6. Epub 2019 Mar 8.

1The Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, NYU School of Medicine, 222 E 41st Street, 13th Floor, New York, NY 10017 USA.

Background: Dystonia is a debilitating disease that causes abnormal, often repetitive, movements, postures or both. The pathophysiology is unknown but related to loss of neuronal inhibition, aberrant sensorimotor integration, and/or derangements of synaptic plasticity. Current treatments include pharmacotherapy, botulinum toxin injections and deep brain stimulation (DBS). The response to these treatments are often limited and carry the risk of side effects requiring alternative therapies such as non-invasive brain stimulation.

Case Presentation: We present a case report of a 65-year -old man with refractory focal 'task-specific' dystonia. The treatment plan included 10-daily sessions of 1 Hz, 2600 pulses of repetitive transcranial magnetic stimulation (rTMS) targeting the primary motor cortex.

Conclusion: There were no clinical benefits noticed. Currently, there are no rTMS protocol treatments for dystonia. Publication of negative results will help in refining the optimal stimulation parameters, thus maximizing the effectiveness and reproducibility of future therapeutic protocols.
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http://dx.doi.org/10.1186/s40734-019-0076-zDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6408853PMC
March 2019

Tele-monitored tDCS rehabilitation: feasibility, challenges and future perspectives in Parkinson's disease.

J Neuroeng Rehabil 2019 01 31;16(1):20. Epub 2019 Jan 31.

The Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, Department of Neurology, NYU School of Medicine, 222 East 41st Street, New York, NY, 10017, USA.

Transcranial direct current stimulation (tDCS) is a modality of non-invasive brain stimulation involving the application of low amplitude direct current via surface electrodes on the scalp. tDCS has been studied in healthy populations and in multiple brain disorders and has the potential to be a treatment for several neuropsychiatric conditions by virtue of its capability of influencing cognitive, motor and behavioral processes. tDCS is a generally safe technique when performed within standardized protocols in research or clinical settings. Furthermore, tDCS portability, high acceptability and user-friendly interface makes it highly appealing for telemedicine practices. The term "telemedicine" refers to the procedures, educational strategies, and care services that are remotely administered by means of different communication technologies, with the final goal of increasing access to care for individuals and for improving public health. The use of telemedicine combined with tDCS protocols is increasing, although the safety of this approach in different clinical settings awaits further assessment. While "do-it-yourself" tDCS should be discouraged due to the unknown risk of adverse events, the implementation of tele-monitored tDCS (tele-tDCS) within standardized frameworks ensuring safety, tolerability, and reproducibility may allow this technology to reach larger clinical populations and bypass some of the common barriers preventing access to health services and clinical trials. This review will discuss the current evidence supporting the feasibility of tele-tDCS paradigms and their therapeutic potential, with particular emphasis on the implications for patients with Parkinson's disease.
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http://dx.doi.org/10.1186/s12984-019-0481-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6357497PMC
January 2019

Subclavian steal syndrome due to dialysis fistula corrected with subclavian artery stenting.

Neurol Clin Pract 2018 Oct;8(5):e23-e25

Departments of Neurology (SA, PK, GS, JF, KA, AT) and Internal Medicine (LS), NYU Langone Health-Brooklyn, NY.

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http://dx.doi.org/10.1212/CPJ.0000000000000510DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6276325PMC
October 2018

Isolated end-stage renal disease in Sjögren's syndrome due to immune complex mediated glomerulonephritis.

Oxf Med Case Reports 2018 Dec 4;2018(12):omy109. Epub 2018 Dec 4.

Department of Nephrology, NYU Langone Health, Brooklyn, NY, USA.

Renal involvement is an uncommon extra-glandular manifestation in Sjogren's syndrome (SS). We present the case of a young male who presented with nephrotic range proteinuria and advanced irreversible renal disease, with positive anti-Ro antibody (Ab) and antineutrophil cytoplasmic antibody (ANCA) with myeloperoxidase (MPO) specificity. He was initially treated with steroids for suspected ANCA vasculitis but treatment was discontinued as there was no response and renal biopsy revealed interstitial lymphocytic infiltrates, advanced glomerular disease with immune complex mediated glomerulonephritis more suspicious for SS. SS usually affects exocrine glands and patients rarely have renal involvement in which cases it is commonly tubulo-interstitial nephritis. This report describes a rare case of anti-Ro Ab and MPO-ANCA positive patient with advanced irreversible renal disease due to immune-complex mediated glomerulonephritis felt to be due to SS and without any classic sicca symptoms.
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http://dx.doi.org/10.1093/omcr/omy109DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6277814PMC
December 2018

Generalizing remotely supervised transcranial direct current stimulation (tDCS): feasibility and benefit in Parkinson's disease.

J Neuroeng Rehabil 2018 12 7;15(1):114. Epub 2018 Dec 7.

New York University Langone Health, New York, USA.

Background: Transcranial direct current stimulation (tDCS) is a non-invasive brain stimulation technique that has been shown to improve common symptoms of neurological disorders like depressed mood, fatigue, motor deficits and cognitive dysfunction. tDCS requires daily treatment sessions in order to be effective. We developed a remotely supervised tDCS (RS-tDCS) protocol for participants with multiple sclerosis (MS) to increase accessibility of tDCS, reducing clinician, patient, and caregiver burden. The goal of this protocol is to facilitate home use for larger trials with extended treatment periods. In this study we determine the generalizability of RS-tDCS paired with cognitive training (CT) by testing its feasibility in participants with Parkinson's disease (PD).

Methods: Following the methods in our MS protocol development, we enrolled sixteen participants (n = 12 male, n = 4 female; mean age 66 years) with PD to complete ten open-label sessions of RS-tDCS paired with CT (2.0 mA × 20 min) at home under the remote supervision of a trained study technician. Tolerability data were collected before, during, and after each individual session. Baseline and follow-up measures included symptom inventories (fatigue and sleep) and cognitive assessments.

Results: RS-tDCS was feasible and tolerable for patients with PD, with at-home access leading to high protocol compliance. Side effects were mostly limited to mild sensations of transient itching and burning under the electrode sites. Similar to prior finding sin MS, we found preliminary efficacy for improvement of fatigue and cognitive processing speed in PD.

Conclusions: RS-tDCS paired with CT is feasible for participants with PD to receive at home treatment. Signals of benefit for reduced fatigue and improved cognitive processing speed are consistent across the PD and MS samples. RS-tDCS can be generalized to provide tDCS to a range of patients with neurologic disorders for at-home rehabilitation.

Trial Registration: ClinicalTrials.gov Identifier: NCT02746705 . Registered April 21st 2016.
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http://dx.doi.org/10.1186/s12984-018-0457-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6284269PMC
December 2018

Clinical-radiographic correlates of Artery of Percheron infarcts in a case series of 6 patients.

J Clin Neurosci 2019 Mar 22;61:266-268. Epub 2018 Nov 22.

Department of Neurology, NYU Langone Medical Center, NY, United States.

Bilateral thalamic strokes due to Artery of Percheron (AOP) occlusion are rare but have been previously reported in the literature. It is due to a rare anatomic variant where a solitary arterial trunk from the proximal segment of either posterior cerebral artery (PCA) supplies bilateral thalami and midbrain. Despite its description in the literature, these strokes are usually missed and patient's symptoms are not thought to be secondary to a vascular etiology. Through this report we aim to describe the clinical and radiographic features seen in these patients. We describe a series of 6 patients who present with varying levels of somnolence and oculomotor nerve palsies who had an occlusion of the AOP with bilateral thalamic infarcts with midbrain involvement. These clinical presentations, combined with the "V" sign on MRI are important in making the diagnosis.
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http://dx.doi.org/10.1016/j.jocn.2018.11.030DOI Listing
March 2019

Remotely-supervised transcranial direct current stimulation paired with cognitive training in Parkinson's disease: An open-label study.

J Clin Neurosci 2018 Nov 5;57:51-57. Epub 2018 Sep 5.

Marlene and Paolo Fresco Institute for Parkinson's and Movement Disorders, NYU School of Medicine, New York, NY 10016, USA. Electronic address:

Background: Transcranial direct current stimulation (tDCS) has been explored as a potential intervention in Parkinson's disease (PD) and recent studies have shown promising results in cognitive, gait and motor function. However, evidence of efficacy is limited due to small size studies, short treatment periods, lack of standardization of methodologies and other study design limitations. Remotely supervised-tDCS (RS-tDCS) allows "at-home" study participation, potentially easing recruitment, compliance and overall feasibility for clinical studies.

Objective: Here, we aim to explore preliminary effects of RS-tDCS paired with cognitive training in PD by delivering RS-tDCS neuromodulation at participant's home while still maintaining clinical trial standards.

Methods: This was a prospective, open-label study using RS-tDCS paired with cognitive training. Each PD participant completed 10 tDCS sessions (20-min, 1.5-2.0-mA, bi-hemispheric DLPFC montage, left anodal), over a span of two weeks. All tDCS sessions were supervised in real-time through videoconferencing. Outcomes included the Unified Parkinson's Disease Rating Scale (UPDRS) and Grooved Pegboard Test.

Results: All RS-tDCS sessions were well tolerated and completed successfully. Total UPDRS and motor UPDRS-III scores decreased significantly. Pegboard completion time improved significantly for the non-dominant hand. There was a strong positive correlation between the time of the sessions, and motor improvements in UPDRS part-III.

Conclusion: RS-tDCS paradigm through a 'telemedicine protocol' holds therapeutic potential for motor symptoms in PD while maximizing compliance and ease of recruitment. Conducting afternoon sessions might be more effective than during the morning. Our paradigm may be influential in designing future studies and facilitating larger and longer duration clinical trials.
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http://dx.doi.org/10.1016/j.jocn.2018.08.037DOI Listing
November 2018

Position change during colonoscopy improves caecal intubation rate, mucosal visibility, and adenoma detection in patients with suboptimal caecal preparation.

Prz Gastroenterol 2017 14;12(4):296-302. Epub 2017 Dec 14.

Department of Gastroenterology, Metrowell Health Center, NY, USA.

Introduction: Most colonoscopies are completed in the left lateral (LL) position but in cases of suboptimal caecal preparation, changing the patient's position to supine (S) and, if needed, to right lateral (RL) improves caecal intubation rate, mucosal visibility, and adenoma detection.

Aim: To determine if position change during colonoscopy facilitates optimal visualisation of the caecum.

Material And Methods: A total of 359 patients were grouped into three categories based on the initial caecal intubation position. After caecal intubation, caecal visibility was scored on a four-point scale depending on the number of imaginary quadrants of the caecum completely visualized - Arya Caecal Prep Score. A score of 1 or 2 was unsatisfactory, while 3 or 4 was considered satisfactory. In patients with unsatisfactory score, position was changed from LL to S and then RL and visibility was scored again.

Results: The initial caecal intubation in the LL position was achieved in 66.8% of patients, S in 28.5%, and RL in 4.8% of patients. 84.5% (300/355) of patients had an acceptable visualisation score at the initial caecal intubation position. Of the 55 patients with unsatisfactory caecum visualisation scores in the initial intubation position, 30 (8.5%) had satisfactory scores after the first position change (95% CI: 5.77-11.84). Twenty-five (7.04%) subjects required two position changes (95% CI: 4.61-10.22%). An additional 9.3% (11/118) of adenomas were detected in caecum and ascending colon following position change.

Conclusions: Changing patient position improves caecal intubation rate, mucosal visibility, and adenoma detection.
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http://dx.doi.org/10.5114/pg.2017.72106DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5771455PMC
December 2017

Are we missing non-motor seizures in Parkinson's disease? Two case reports.

J Clin Mov Disord 2017 5;4:14. Epub 2017 Sep 5.

The Marlene and Paolo Fresco Institute for Parkinson's & Movement Disorders, NYU Langone Medical Center - New York University School of Medicine, New York, NY USA.

Background: Parkinson's disease (PD) is predominantly recognized for its motor symptoms, but patients struggle from a morbid and heterogeneous collection of non-motor symptoms (NMS-PD) that can affect their quality of life even more. NMS-PD is a rather generalized term and the heterogeneity and non-specific nature of many symptoms poses a clinical challenge when a PD patient presents with non-motor complaints that may not be NMS-PD.

Case Presentation: We report two patients with idiopathic PD who presented with acute episodes of cognitive changes. Structural brain images, cardiovascular and laboratory assessment were unremarkable. Both patients experienced a considerable delay before receiving an epilepsy-evaluation, at which point electroencephalogram abnormalities supported the diagnosis of focal non-motor seizures with alteration of awareness. Antiepileptic therapy was implemented and was effective in both cases.

Conclusions: Diagnosing non-motor seizures can be challenging. However, PD patients pose an even greater challenge given their eclectic non-motor clinical manifestations and other disease-related complications that could confound and mislead adequate clinical interpretation. Our two cases provide examples of non-motor seizures that may mimic non-motor symptoms of PD. Treating physicians should always consider other possible causes of non-motor symptoms that may coexist in PD patients. Epilepsy work-up should be contemplated in the differential of acute changes in cognition, behavior, or alertness.
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http://dx.doi.org/10.1186/s40734-017-0061-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5583992PMC
September 2017

Resolution of constipation, anal stricture, and iron deficiency anemia after iron infusion: an analogy with Plummer Vinson syndrome.

Springerplus 2016 15;5(1):1976. Epub 2016 Nov 15.

Vijaypal Arya Physician P.C., 7554 Metropolitan Avenue, New York, NY USA.

Background: Anal stricture is a disabling condition which is often unresponsive to conservative medical management. The complications of surgical procedures such as dilatations and anoplasty make it a formidable treatment challenge. Through this case, we report and explore a new medical treatment for ano-rectal strictures with an analogy to Plummer Vinson syndrome. A 69-year-old male presented with chronic constipation, rectal pain, and easy fatigability. The physical exam was negative for anal fissure and a digital rectal examination could not be completed because an index finger could not be advanced through the narrowed anus. Laboratory reports revealed microcytic hypochromic anemia with iron deficiency. A colonoscopy performed with a GIF XQ180 OLYMPUS scope, confirmed anal stricture with non-specific colitis. Conservative management with laxatives, high fiber diet, local anesthetics with a trial of mesalamine was initiated but the patient continued to have symptoms. He was referred to a hematologist for an evaluation of anemia and was started on intravenous (IV) iron infusion.

Findings: The patient's symptoms of constipation, anal stricture and iron deficiency anemia resolved with iron infusion over 3 months. A repeat rectal exam was painless and confirmed resolution of anal stricture.

Conclusion: IV iron supplementation combined with conventional anal dilatation presents as a promising approach toward the treatment of anal strictures.
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http://dx.doi.org/10.1186/s40064-016-3629-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5108749PMC
November 2016