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Thon JM, Sharkus R, Thakkar R, Hunter K, Siegler JE, Thon OR. Utilization of FDA approved treatments for neuromyelitis optica spectrum disorder in clinical practice: A survey study of academic neuroimmunologists. Mult Scler Relat Disord 2023; 80:105076. [PMID: 37866024 DOI: 10.1016/j.msard.2023.105076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 09/28/2023] [Accepted: 10/12/2023] [Indexed: 10/24/2023]
Abstract
Neuromyelitis optica spectrum disorder (NMOSD) is a rare autoimmune condition for which three treatments have been approved since 2019: eculizumab, inebilizumab, and satralizumab. We conducted a survey of U.S. academic neuroimmunologists to assess adoption of these therapies and barriers to use. Thirty-three neuroimmunologists from 18 states completed the survey. Nearly all (88 %) reported using the novel NMOSD treatments (NNTs). They uncommonly switched clinically stable patients to NNTs (69 % switched none, 22 % switched 1-25 % of their patients). For newly diagnosed patients, NNT initiation rates varied. Following relapse, respondents were dichotomized, either switching 75-100 % of patients (60 %) or 0-25 % (40 %). Insurance and cost-related barriers were common.
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Affiliation(s)
- Jesse M Thon
- Cooper Neurological Institute, Cooper University Healthcare, Camden NJ, United States; Cooper Medical School of Rowan University, Camden NJ, United States
| | - Robert Sharkus
- Cooper Neurological Institute, Cooper University Healthcare, Camden NJ, United States
| | - Richa Thakkar
- Cooper Neurological Institute, Cooper University Healthcare, Camden NJ, United States
| | - Krystal Hunter
- Cooper Research Institute, Cooper University Hospital, Camden NJ, United States
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Healthcare, Camden NJ, United States; Cooper Medical School of Rowan University, Camden NJ, United States
| | - Olga R Thon
- Cooper Neurological Institute, Cooper University Healthcare, Camden NJ, United States; Cooper Medical School of Rowan University, Camden NJ, United States.
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Patel K, Taneja K, Obusan MB, Yaghi S, Nguyen TN, Thon JM, Kass-Hout T, Brorson JR, Prabhakaran S, Siegler JE. Real-World Outcomes for Basilar Artery Occlusion Thrombectomy With Mild Deficits: The National Inpatient Sample. Stroke 2023; 54:2031-2039. [PMID: 37350272 DOI: 10.1161/strokeaha.123.043487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 06/06/2023] [Indexed: 06/24/2023]
Abstract
BACKGROUND Thrombectomy for basilar artery occlusion (BAO) has proven efficacy in patients with moderate-to-severe deficits, but has unclear benefits for those with mild symptoms. METHODS Using an observational cohort design, the US National Inpatient Sample (2018-2020) was queried for adult patients with basilar artery occlusion and National Institutes of Health Stroke Scale (NIHSS) <10 for patients treated with thrombectomy versus medical management. The primary outcome of routine discharge (to home or self-care) was evaluated using multivariable logistic regression and propensity score matching, adjusted for baseline characteristics, stroke severity, and treatment with thrombolysis. RESULTS Of 17 019 with basilar artery occlusion, 5795 patients met the criteria for inclusion criteria for our study, and 880 (15.4%) were treated with endovascular thrombectomy. In the propensity score-matched cohort, 880 patients were treated with medical management and endovascular thrombectomy, respectively. In multivariable regression, endovascular thrombectomy was associated with both an increased odds of routine discharge (odds ratio, 1.95 [95% CI, 1.31-2.90]; P=0.001) and a decreased length of hospital stay (B, -0.74 [95% CI, -1.36 to -0.11]; P=0.02) compared with medical management. In the propensity score matched cohort, endovascular thrombectomy remained associated with greater odds of routine discharge (2.01 [95% CI, 1.21-3.34]; P=0.007) but no difference in length of hospital stay (B, -0.22 [95% CI, -0.90 to 0.46]; P=0.53). CONCLUSIONS Routine discharge was more common in this representative US cohort of patients with basilar artery occlusion and National Institutes of Health Stroke Scale <10 who underwent thrombectomy compared to conventional medical management. These findings suggest thrombectomy may be associated with better functional outcomes despite lower National Institutes of Health Stroke Scale and should be validated in a clinical trial setting.
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Affiliation(s)
- Karan Patel
- Cooper Medical School of Rowan University, Camden, NJ (K.P., J.M.T., J.E.S.)
| | - Kamil Taneja
- Renaissance School of Medicine at Stony Brook University, NY (K.T., M.B.O.)
| | - Matthew B Obusan
- Renaissance School of Medicine at Stony Brook University, NY (K.T., M.B.O.)
| | - Shadi Yaghi
- Warren Alpert School of Medicine at Brown University, Providence, RI (S.Y.)
- Department of Neurology, Rhode Island Hospital, Providence (S.Y.)
| | - Thanh N Nguyen
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, MA (T.N.N.)
| | - Jesse M Thon
- Cooper Medical School of Rowan University, Camden, NJ (K.P., J.M.T., J.E.S.)
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.M.T., J.E.S.)
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, IL (T.K.-H., J.R.B., S.P.)
| | - James R Brorson
- Department of Neurology, University of Chicago, IL (T.K.-H., J.R.B., S.P.)
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, IL (T.K.-H., J.R.B., S.P.)
| | - James E Siegler
- Cooper Medical School of Rowan University, Camden, NJ (K.P., J.M.T., J.E.S.)
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.M.T., J.E.S.)
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Mason Sharma A, Birnhak A, Sanborn E, Bhana N, Kazmi K, Thon JM, Thon OR, Siegler JE. Neuroimaging mimics of anoxic brain injury: A review. J Neuroimaging 2023. [PMID: 37070435 DOI: 10.1111/jon.13106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 04/19/2023] Open
Abstract
Diffuse cortical diffusion changes on magnetic resonance imaging (MRI) are characteristically ascribed to global cerebral anoxia, typically after cardiac arrest. Far from being pathognomonic, however, this neuroimaging finding is relatively nonspecific, and can manifest in a myriad of disease states including hypoxia, metabolic derangements, infections, seizure, toxic exposures, and neuroinflammation. While these various conditions can all produce a neuroimaging pattern of widespread cortical diffusion restriction, many of these underlying causes do have subtly unique imaging features that are appreciable on MRI and can be of clinical and diagnostic utility. Specific populations of neurons are variably sensitive to certain types of injury, whether due to differences in perfusion, receptor type density, or the unique tropisms of infectious organisms. In this narrative review, we discuss a number of distinct etiologies of diffuse cortical diffusion restriction on MRI, the unique pathophysiologies responsible for tissue injury, and the resulting neuroimaging characteristics that can be of assistance in differentiating them. As widespread cortical injury from any cause often presents with altered mental status or coma, the differential diagnosis can be enhanced with rapid acquisition of MRI when clinical history or detailed physical examination is limited. In such settings, the distinct imaging features discussed in this article are of interest to both the clinician and the radiologist.
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Affiliation(s)
| | - Alana Birnhak
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
| | - Emma Sanborn
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Nikhil Bhana
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
| | - Khuram Kazmi
- Department of Diagnostic Radiology, Cooper University Hospital, Camden, New Jersey, USA
| | - Jesse M Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
| | - Olga R Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
- Cooper Medical School, Rowan University, Camden, New Jersey, USA
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Vigilante N, Patel K, Oak S, Butler M, Thon JM, Siegler JE. Abstract TP106: Outcomes Following Off-label Glyburide In Large Hemispheric Infarction: A Single-center Experience. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
One in 10 ischemic strokes are large hemispheric infarctions (LHI), half of which cause cerebral edema that can lead to significant mortality. Our center implemented a protocol using acute glyburide in patients with LHI to determine its safety and efficacy in reducing formation of cerebral edema.
Methods:
Consecutive adult patients at our center (10/2019-08/2021) with LHI who met criteria for the CHARM trial were treated with glyburide per an institutional protocol (2.5mg per nasogastric tube twice daily for 3 days) with multi-disciplinary oversight. Unadjusted logistic regression was used to estimate odds of a favorable shift in 90-day modified Rankin Scale (mRS), with adjustment for age, pre-stroke mRS, National Institutes of Health Stroke Scale (NIHSS) and large vessel occlusion (LVO). Propensity-score matching was used to model shift in 90-day mRS. Safety events were also assessed.
Results:
Of 1684 stroke patients treated at our center, 95 met criteria for CHARM and were included, among whom 21 completed the glyburide protocol (28 attempted) and 67 received standard-of-care (SOC); 34 patients were propensity-matched (nglyburide=17). Compared to SOC (n=67), patients treated with glyburide (n=21) had similar pre-stroke mRS, NIHSS, and LVOs, but were younger (median 61y vs. 67y, p<0.01). Glyburide was not associated with a favorable shift in 90-day mRS in unadjusted (OR 1.40, 95%CI 0.51-3.88) or adjusted regression (OR 0.71, 95%CI 0.17-2.94), or following propensity score matching (OR 1.39, 95%CI 0.32-6.07). There was no significant reduction in midline shift in unadjusted, adjusted, or propensity score-matched models (p>0.05). Two patients required D50 rescue, and 1 did not complete the protocol due to recurrent hypoglycemia.
Conclusions:
In this single center analysis, glyburide was found to have a low risk of hypoglycemic events. Despite the small sample size, there was no signal of better clinical or imaging outcomes in treated patients.
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Affiliation(s)
| | | | | | | | - Jesse M Thon
- Cooper Neurological Institute, Cooper Univ Hosp, Camden, NJ
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Patel P, Tiongson J, Chen A, Siegal T, Oak S, Golla A, Kamen S, Thon JM, Vigilante N, Rana A, Hester T, Siegler JE. Outcomes associated with antithrombotic strategies in heart failure with reduced ejection fraction and sinus rhythm following acute ischemic stroke. Front Neurol 2022; 13:1041806. [PMID: 36588887 PMCID: PMC9797677 DOI: 10.3389/fneur.2022.1041806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 11/24/2022] [Indexed: 12/23/2022] Open
Abstract
Purpose Insufficient data exist regarding the benefit of long-term antiplatelet vs. anticoagulant therapy in the prevention of recurrent ischemic stroke in patients with ischemic stroke and heart failure with reduced ejection fraction (HFrEF). Therefore, this study aimed to compare longitudinal outcomes associated with antiplatelet vs. anticoagulant use in a cohort of patients with stroke and with an ejection fraction of ≤40%. Methods We retrospectively analyzed single-center registry data (2015-2021) of patients with ischemic stroke, HFrEF, and sinus rhythm. Time to the primary outcome of recurrent ischemic stroke, major bleeding, or death was assessed using the adjusted Cox proportional hazards model and was compared between patients treated using anticoagulation (±antiplatelet) vs. antiplatelet therapy alone after propensity score matching using an intention-to-treat (ITT) approach, with adjustment for residual measurable confounders. Sensitivity analyses included the multivariable Cox proportional hazards model using ITT and as-treated approaches without propensity score matching. Results Of 2,974 screened patients, 217 were included in the secondary analyses, with 130 patients matched according to the propensity score for receiving anticoagulation treatment for the primary analysis, spanning 143 patient-years of follow-up. After propensity score matching, there was no significant association between anticoagulation and the primary outcome [hazard ratio (HR) 1.10, 95% confidence interval (CI): 0.56-2.17]. Non-White race (HR 2.26, 95% CI: 1.16-4.41) and the presence of intracranial occlusion (HR 2.86, 95% CI: 1.40-5.83) were independently associated with the primary outcome, while hypertension was inversely associated (HR 0.42, 95% CI: 0.21-0.84). There remained no significant association between anticoagulation and the primary outcome in sensitivity analyses. Conclusion In HFrEF patients with an acute stroke, there was no difference in outcomes of antithrombotic strategies. While this study was limited by non-randomized treatment allocation, the results support future trials of stroke patients with HFrEF which may randomize patients to anticoagulation or antiplatelet.
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Affiliation(s)
- Parth Patel
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Justin Tiongson
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Austin Chen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Taylor Siegal
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Solomon Oak
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Akhil Golla
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Jesse M. Thon
- Cooper Medical School of Rowan University, Camden, NJ, United States,Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | | | - Ameena Rana
- Department of Neurology, Sinai Beth Israel Hospital, New York, NY, United States
| | - Taryn Hester
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - James E. Siegler
- Cooper Medical School of Rowan University, Camden, NJ, United States,Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States,*Correspondence: James E. Siegler
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DePolo D, Gillen S, Marden K, Rajagopalan S, Thon OR, Siegler JE, Thon JM. Severe Wernicke's Encephalopathy Associated with Cortical Ribboning and Intracranial Hemorrhage. Neurohospitalist 2022; 12:702-705. [PMID: 36147752 PMCID: PMC9485700 DOI: 10.1177/19418744221098385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/03/2023] Open
Abstract
Wernicke's encephalopathy (WE) is a neurological emergency that results from thiamine deficiency. It is most commonly associated with chronic alcohol consumption but can result from any cause of impaired thiamine absorption or dietary intake. The classic triad of ophthalmoparesis, ataxia, and altered sensorium is rarely seen in toto, and while certain radiographic findings strongly correlate with the disease, one should have a low threshold to suspect (and promptly treat) patients in order to mitigate the risk of morbidity and mortality. However, atypical presentations can result in delayed or missed diagnoses. In this report, we describe a case of severe non-alcoholic WE associated with atypical brain Magnetic resonance imaging (MRI) manifestations of both cortical diffusion restriction and intracranial hemorrhage, which have previously been associated with poor outcomes. Early treatment with high-dose parenteral thiamine resulted in rapid improvement in ocular motility and reversal of MRI abnormalities, and on long-term follow up, the patient had made a marked functional improvement. This case highlights the importance of recognizing these unusual imaging features of WE in a patient with a compatible clinical syndrome in order to make a timely diagnosis and initiate treatment, as there is potential for a good clinical outcome despite these imaging findings.
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Affiliation(s)
- Daniel DePolo
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Stefan Gillen
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Kyle Marden
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Swarna Rajagopalan
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Olga R. Thon
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - James E. Siegler
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jesse M. Thon
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
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Rana A, Yu S, Reid-Herrera S, Kamen S, Hunter K, Shaikh H, Jovin T, Thon OR, Patel P, Siegler JE, Thon JM. Eptifibatide use in ischemic stroke patients undergoing endovascular thrombectomy: A matched cohort analysis. Front Neurol 2022; 13:939215. [PMID: 36237613 PMCID: PMC9551346 DOI: 10.3389/fneur.2022.939215] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
IntroductionSmall studies have suggested that eptifibatide (EPT) may be safe in acute ischemic stroke (AIS) following intravenous thrombolysis or during endovascular therapy (EVT) for large vessel occlusion (LVO). However, studies are called upon to better delineate the safety of EPT use during EVT.MethodsA comprehensive stroke center registry (09/2015-12/2020) of consecutive adults who had undergone EVT for anterior LVO was queried. Patients treated with EPT were matched with 2 control groups based on known factors associated with intracranial hemorrhage (ICH) risk - age, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and number of thrombectomy passes. Safety outcomes (intracranial hemorrhage [ICH], parenchymal hematoma [PH-2] grade hemorrhagic transformation, symptomatic ICH [sICH]) and efficacy outcomes (TICI 2B/3 recanalization, 24-h National Institutes of Health Stroke Scale [NIHSS] score), were compared between matched groups using descriptive statistics. In addition, multivariable logistic regression was used to assess for an association between EPT and PH-1/PH-2 grade hemorrhages.ResultsA total of 162 patients were included, 54 of whom (33%) received EPT. The rate of ICH was similar between groups (p = 0.62), while PH-2 was significantly more frequent with EPT (16.7% EPT vs. 3.7 vs. 1.9%; p = 0.009), but without significant differences in sICH (5.6% EPT vs. 7.4 vs. 3.7%; p = 0.72). Rates of TICI Score ≥ 2B were nominally higher with EPT use (83.3 vs. 77.8 vs. 77.8%, p = 0.70). Between the EPT and control groups, there were no differences in 24-h NIHSS (p = 0.09) or 90-day mortality (p = 0.58). Our adjusted multivariate analysis identified that the number of passes (p < 0.01), EPT use (p < 0.01), and tandem occlusion (p = 0.03) were independent predictors of PH1/PH2 grade hemorrhage. Additionally, every unit increase in number of passes resulted in a 1.5 times greater odds of a high-grade hemorrhagic transformation in EPT-treated patients (adjusted OR = 1.594).ConclusionIn this single-center analysis, EPT use during EVT was associated with a significantly higher rate of PH1/PH2 grade hemorrhages, but not with differences in sICH, 24-h NIHSS, or 90-day mortality. Randomized prospective trials are needed to determine the safety and efficacy of EPT in this population.
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Affiliation(s)
- Ameena Rana
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Siyuan Yu
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | | | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - Krystal Hunter
- Cooper Research Institute, Cooper University Hospital, Camden, NJ, United States
| | - Hamza Shaikh
- Department of Radiology, Cooper University Hospital, Camden, NJ, United States
| | - Tudor Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Olga R. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Parth Patel
- Cooper Medical School of Rowan University, Camden, NJ, United States
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
| | - Jesse M. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, United States
- *Correspondence: Jesse M. Thon
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Vigilante N, Kamen S, Shannon R, Thau L, Butler M, Oak S, Zhang L, Hester T, Thon JM, Siegler JE. Functional Recovery in Patients with Acute Stroke and Pre-Existing Disability: A Natural History Study. J Stroke Cerebrovasc Dis 2022; 31:106508. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Revised: 03/18/2022] [Accepted: 04/02/2022] [Indexed: 10/18/2022] Open
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Zhang L, Kamen S, Niles J, Goss J, Heslin ME, Vigilante N, Thau L, Edwards C, Marden KR, Thon JM, Yeager T, Siegler JE. Resident-Driven Dysphagia Screening Protocol for Expedited Antithrombotic Delivery in Acute Ischemic Stroke. Neurohospitalist 2022; 12:467-475. [DOI: 10.1177/19418744221098384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background We implemented a multi-disciplinary process improvement intervention at our Comprehensive Stroke Center with speech/language pathologists to expedite oral medication delivery in stroke patients. Following a failed nursing dysphagia screen, trained neurology physicians screened dysphagia further to approve use of oral medications. We analyzed the safety and efficacy of this intervention. Methods We analyzed retrospectively collected data for hospital course, timing of first screen, first oral medication use, and complications (e.g., aspiration pneumonia) in consecutive ischemic stroke patients (9/2019-07/2021). Patients were included if they passed a dysphagia assessment by physicians (Ph), nurses (RN), or speech/language pathologists (SLP). Arrival-to-dysphagia screen and arrival-to-antithrombotic were assessed using restricted mean survival time (RMST). Results Of the 789 included patients, 673 were passed by RN, 104 by SLP, and 12 by Ph. Compared to patients passed by SLP, those passed by Ph were younger and had less severe deficits ( P < .01 for both). Patients were screened more quickly by Ph than RN or SLP (median 38 vs 182 vs 1330-min post-arrival, P = .0001; 299-min RMST difference vs RN [95%CI 22-575, P = .03]; 470-min RMST difference vs SLP [95%CI 175-765, P = .002]). This translated to faster oral antithrombotic use for Ph-passed patients (138-min RMST difference vs RN [95%CI 59-216]; 332-min RMST difference vs SLP [95%CI 253-411]). No patients passed by Ph experienced aspiration pneumonia (0%). Conclusions We safely conducted a physician-driven dysphagia screening paradigm which led to faster oral antithrombotic delivery without signal of patient harm. Physician availability to complete dysphagia screens in acute stroke patients was a limitation.
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Affiliation(s)
| | | | - Jennifer Niles
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jessica Goss
- Department of Speech and Language Pathology, Cooper University Hospital, Camden, NJ, USA
| | | | | | | | | | - Kyle R. Marden
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jesse M. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Terri Yeager
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
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Oak S, Cucchiara BL, Thau L, Nguyen TN, Sathya A, Reyes-Esteves S, Vigilante N, Kamen S, Hall J, Patel P, Garg R, Abdalkader M, Thon JM, Siegler JE. Age Alters Prevalence of Left Atrial Enlargement and Nonstenotic Carotid Plaque in Embolic Stroke of Undetermined Source. Stroke 2022; 53:2260-2267. [PMID: 35354301 DOI: 10.1161/strokeaha.121.037522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Nonstenotic carotid plaque and undetected atrial fibrillation are potential mechanisms of embolic stroke of undetermined source (ESUS), but it is unclear which is more likely to be the contributing stroke mechanism. We explored the relationship between left atrial enlargement (LAE) and nonstenotic carotid plaque across age ranges in an ESUS population. METHODS A retrospective multicenter cohort of consecutive patients with unilateral, anterior circulation ESUS was queried (2015 to 2021). LAE and plaque thickness were determined by transthoracic echocardiography and computed tomography angiography, respectively. Descriptive statistics were used to compare plaque features in relation to age and left atrial dimensions. RESULTS Among the 4155 patients screened, 273 (7%) met the inclusion criteria. The median age was 65 years (interquartile range [IQR] 54-74), 133 (48.7%) were female, and the median left atrial diameter was 3.5 cm (IQR 3.1-4.1). Patients with any LAE more frequently had hypertension (85.9% versus 67.2%, P<0.01), diabetes (41.0% versus 25.6%, P=0.01), dyslipidemia (56.4% versus 40.0%, P=0.01), and coronary artery disease (22.8% versus 11.3%, P=0.02). Carotid plaque thickness was greater ipsilateral versus contralateral to the stroke hemisphere in the overall cohort (median 1.9 mm [IQR 0-3] versus 1.5 mm [IQR 0-2.6], P<0.01); however, this was largely driven by the subgroup of patients without any LAE (median 1.8 mm [IQR 0-2.9] versus 1.5 mm [IQR 0-2.5], P<0.01). Compared with patients ≥70 years, younger patients had more carotid plaque ipsilateral versus contralateral (mean difference 0.42 mm±1.24 versus 0.08 mm±1.54, P=0.047) and less moderate-to-severe LAE (6.3% versus 15.3%, P=0.02). CONCLUSIONS Younger patients with ESUS had greater prevalence of ipsilateral nonstenotic plaque, while the elderly had more LAE. The differential effect of age on the probability of specific mechanisms underlying ESUS should be considered in future studies.
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Affiliation(s)
- Solomon Oak
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Brett L Cucchiara
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (B.L.C., S.R.-E.)
| | - Lauren Thau
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Division of Interventional Neuroradiology, Boston Medical Center, MA (T.N.N., A.S., M.A.)
| | - Anvitha Sathya
- Department of Neurology, Radiology, Division of Interventional Neuroradiology, Boston Medical Center, MA (T.N.N., A.S., M.A.)
| | - Sahily Reyes-Esteves
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia (B.L.C., S.R.-E.)
| | - Nicholas Vigilante
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Jillian Hall
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Parth Patel
- Cooper Medical School of Rowan University, Camden, NJ (S.O, L.T., N.V., S.K., J.H., P.P.)
| | - Rahul Garg
- Department of Neurology, Cooper University Hospital, Camden, NJ (R.G., J.M.T., J.E.S.)
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Division of Interventional Neuroradiology, Boston Medical Center, MA (T.N.N., A.S., M.A.)
| | - Jesse M Thon
- Department of Neurology, Cooper University Hospital, Camden, NJ (R.G., J.M.T., J.E.S.)
| | - James E Siegler
- Department of Neurology, Cooper University Hospital, Camden, NJ (R.G., J.M.T., J.E.S.)
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11
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Oak S, Thau L, Nguyen TN, Sathya A, Reyes-Esteves S, Cucchiara BL, Vigilante N, Kamen S, Hall J, Patel P, Thon JM, Siegler JE. Abstract WP155: Relationship Between Nonstenotic Plaque, Left Atrial Enlargement, And Age In Patients With Embolic Stroke Of Undetermined Source: A Multi-center Observational Cohort Study. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wp155] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Nonstenotic internal carotid artery (ICA) plaque as a mechanism of embolic stroke of undetermined source (ESUS) is controversial. Studies show an inverse relationship between cardioembolic stroke risk and nonstenotic plaque in ESUS patients. We explored this relationship using left atrial enlargement (LAE) as a marker of cardioembolic stroke predisposition.
Methods:
A retrospective multicenter cohort of consecutive patients with unilateral, anterior circulation ESUS was queried. ESUS diagnosis was based on an embolic stroke pattern without an identifiable source on imaging and ≥24hrs of telemetry. Descriptive statistics were used to differentiate clinical, laboratory, and imaging predictors of sex adjusted LAE.
Results:
Of the 4155 patients screened, 273 (7%) met the inclusion criteria. Compared to patients without LAE, those with LAE were older (68y vs 62y, p<0.01), and had more frequent hypertension (83.7% vs 66.9%, p<0.01) and coronary artery disease (22.8% vs 11.3%, p=0.02). All had greater ipsilateral than contralateral ICA plaque (median 1.9cm [IQR 0-3] vs 1.5cm [IQR 0-2.6], p<0.01) without any difference in stenosis (median 0% [IQR 0-0] vs. 0% [IQR 0-0], p=0.19). Patients under 70 had greater plaque ipsilateral versus contralateral than patients 70 or older (mean difference 0.42cm [±1.24] vs 0.08cm [±1.54], p=0.047), and were less likely to have any LAE (28.6% vs 42.9%, p=0.02) or moderate-to-severe LAE (6.3% vs 15.3%, p=0.02). The probability of finding more ipsilateral than contralateral plaque in ESUS patients exceeded chance (50%) for patients under 70 (Figure).
Discussion:
Clinically relevant ipsilateral ICA plaque was more frequent in this ESUS cohort, regardless of LAE. When stratified by age, younger patients had greater ipsilateral ICA plaque burden and less LAE. While nonstenotic plaque and LAE frequently co-exist, younger ESUS patients were at greater risk of nonstenotic plaque than the elderly, who were at greater risk of LAE.
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12
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Czap AL, Zha AM, Sebaugh J, Hassan AE, Shulman JG, Abdalkader M, Nguyen TN, Linfante I, Starosciak AK, Ortega-Gutierrez S, Farooqui M, Quispe-Orozco D, Vora NA, Rai V, Nogueira RG, Haussen DC, Jillella DV, Rana A, Yu S, Thon JM, Zaidat OO, Khandelwal P, Bach I, Sheth SA, Jadhav AP, Desai SM, Jovin TG, Liebeskind DS, Siegler JE. Endovascular thrombectomy time metrics in the era of COVID-19: observations from the Society of Vascular and Interventional Neurology Multicenter Collaboration. J Neurointerv Surg 2022; 14:neurintsurg-2020-017205. [PMID: 33558439 PMCID: PMC7871225 DOI: 10.1136/neurintsurg-2020-017205] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 01/23/2021] [Accepted: 01/25/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Unprecedented workflow shifts during the coronavirus disease 2019 (COVID-19) pandemic have contributed to delays in acute care delivery, but whether it adversely affected endovascular thrombectomy metrics in acute large vessel occlusion (LVO) is unknown. METHODS We performed a retrospective review of observational data from 14 comprehensive stroke centers in nine US states with acute LVO. EVT metrics were compared between March to July 2019 against March to July 2020 (primary analysis), and between state-specific pre-peak and peak COVID-19 months (secondary analysis), with multivariable adjustment. RESULTS Of the 1364 patients included in the primary analysis (51% female, median NIHSS 14 [IQR 7-21], and 74% of whom underwent EVT), there was no difference in the primary outcome of door-to-puncture (DTP) time between the 2019 control period and the COVID-19 period (median 71 vs 67 min, P=0.10). After adjustment for variables associated with faster DTP, and clustering by site, there remained a trend toward shorter DTP during the pandemic (βadj=-73.2, 95% CI -153.8-7.4, Pp=0.07). There was no difference in DTP times according to local COVID-19 peaks vs pre-peak months in unadjusted or adjusted multivariable regression (βadj=-3.85, 95% CI -36.9-29.2, P=0.80). In this final multivariable model (secondary analysis), faster DTP times were significantly associated with transfer from an outside institution (βadj=-46.44, 95% CI -62.8 to - -30.0, P<0.01) and higher NIHSS (βadj=-2.15, 95% CI -4.2to - -0.1, P=0.05). CONCLUSIONS In this multi-center study, there was no delay in EVT among patients treated for intracranial occlusion during the COVID-19 era compared with the pre-COVID era.
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Affiliation(s)
- Alexandra L Czap
- Neurology, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Alicia M Zha
- Neurology, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Jacob Sebaugh
- Neurology, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
- Clinical Neuroscience Research, Valley Baptist Medical Center, Harlingen, Texas, USA
| | - Julie G Shulman
- Neurology, Boston Medical Center, Boston, Massachusetts, USA
| | | | - Thanh N Nguyen
- Neurology, Boston Medical Center, Boston, Massachusetts, USA
- Radiology, Boston Medical Center, Boston, Massachusetts, USA
- Interventional Neuroradiology and Endovascular Neurosurgery, Boston Medical Center, Boston, Massachusetts, USA
| | - Italo Linfante
- Department of Interventional Neuroradiology and Endovascular Neurosurgery, Baptist Health South Florida, Coral Gables, Florida, USA
| | | | - Santiago Ortega-Gutierrez
- Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Darko Quispe-Orozco
- Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Nirav A Vora
- Neuroscience Center, Riverside Methodist Hospital, Columbus, Ohio, USA
| | - Vivek Rai
- Neuroscience Center, Riverside Methodist Hospital, Columbus, Ohio, USA
| | | | | | | | - Ameena Rana
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Siyuan Yu
- Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Jesse M Thon
- Cooper Neurological Institute, Cooper University Health Care, Camden, New Jersey, USA
| | - Osama O Zaidat
- Neuroscience Institute, Bons Secours Mercy Health St. Vincent Hospital, Toledo, Ohio, USA
| | | | - Ivo Bach
- Neurology, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Sunil A Sheth
- Neurology, McGovern Medical School at the University of Texas Health Science Center, Houston, Texas, USA
| | - Ashutosh P Jadhav
- Neurology, University of Pittsburgh Medical Center Mercy Hospital, Pittsburgh, Pennsylvania, USA
- Neurology, University of Pittsburgh Medical Center Presbyterian Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shashvat M Desai
- Neurology, University of Pittsburgh Medical Center Mercy Hospital, Pittsburgh, Pennsylvania, USA
- Neurology, University of Pittsburgh Medical Center Presbyterian Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Health Care, Camden, New Jersey, USA
| | - David S Liebeskind
- Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Health Care, Camden, New Jersey, USA
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13
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Heslin ME, Thon JM, Caruso E, Romiyo P, Rana A, Yu S, Thau L, Rana A, Kamen S, Siegler JE. Utility of transesophageal echocardiography in the identification and treatment of occult mechanisms of cerebral infarction. J Clin Neurosci 2021; 95:31-37. [PMID: 34929648 DOI: 10.1016/j.jocn.2021.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/11/2021] [Accepted: 10/18/2021] [Indexed: 11/25/2022]
Abstract
Cryptogenic stroke comprises approximately 25% of all cases of ischemic stroke. The diagnostic evaluation of these patients remains a challenge in clinical practice. Transesophageal echocardiography (TEE) has been shown to have superior diagnostic accuracy in identifying potential cardioembolic sources of ischemic stroke when compared to transthoracic echocardiography (TTE). However, there has been inconsistent data on the management implications of these new cardiac findings. The addition of TEE to the comprehensive stroke evaluation will better identify potential cardiac sources of embolism (CSE) and will result in significant management changes. A prospective registry of consecutively admitted patients with acute ischemic stroke (1/1/2015-8/10/2020) was retrospectively queried. Patients 18 to 60 years of age with stroke due to mechanisms other than large or small vessel disease, or atrial fibrillation were eligible for inclusion. The primary outcome was any high-risk CSE identified on TEE following unrevealing TTE. Of the 2,404 consecutive stroke patients evaluated during the study period, 263 (11%) met inclusion criteria and the median age was 53 (IQR 46-57). TEE was performed in 108 patients (41%). A high-risk CSE was identified in 36 patients (33%), the majority of which were PFOs (n = 29). TEE led to a clinical management change in 14 patients (39%) after identification of a high-risk CSE; 6 underwent PFO closure and 8 had adjustment to their antithrombotic therapy. The addition of TEE to the comprehensive stroke evaluation led to the identification of a high-risk CSE in one in three patients resulting in significant management changes.
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Affiliation(s)
- Mark E Heslin
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA.
| | - Jesse M Thon
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| | - Evan Caruso
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
| | - Prasanth Romiyo
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Ankit Rana
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Siyuan Yu
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Lauren Thau
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Ameena Rana
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Scott Kamen
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - James E Siegler
- Cooper Neurological Institute, Department of Internal Medicine, Cooper University Hospital, Camden, NJ 08103, USA
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14
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Abstract
Large vessel occlusion (LVO) stroke represents a stroke subset associated with the highest morbidity and mortality. Multiple prospective randomized trials have shown that thrombectomy, alone or in conjunction with IV thrombolysis, is highly effective in reestablishing cerebral perfusion and improving clinical outcomes. In unselected patients and especially in patients with poor collaterals, the benefit of reperfusion therapy is exquisitely time sensitive; the earlier thrombectomy is started, the lower the likelihood of disability or death. Understanding both the pathophysiologic underpinnings and the modifying factors of this strong time-to-treatment effect demonstrated in numerous randomized clinical trials is important for implementation of intrahospital workflow measures to maximize time efficiency of thrombectomy. Reducing delays in reperfusion therapy initiation has become a priority in acute stroke care, and therefore a thorough understanding of the main systems-based factors responsible for these delays is critical. Because the time spent evaluating the patient in the emergency department, which typically includes neuroimaging studies performed in scanners remote from the angiography suite, represents the main source of delays in thrombectomy initiation, the direct to angiography (DTA) model has emerged as a means to substantially reduce treatment times and is being instituted at an increasing number of thrombectomy centers across the world. The aim of this report is to introduce DTA as an emerging stroke care paradigm for patients with suspicion of LVO stroke, review results from studies evaluating its feasibility and impact on outcomes, describe current barriers to its more widespread adoption, and propose potential solutions to overcoming these barriers.
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Affiliation(s)
- Jesse M Thon
- From Cooper Neurological Institute and Cooper Medical School of Rowan University, Camden, NJ
| | - Tudor G Jovin
- From Cooper Neurological Institute and Cooper Medical School of Rowan University, Camden, NJ.
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15
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Piantadosi A, Mukerji SS, Ye S, Leone MJ, Freimark LM, Park D, Adams G, Lemieux J, Kanjilal S, Solomon IH, Ahmed AA, Goldstein R, Ganesh V, Ostrem B, Cummins KC, Thon JM, Kinsella CM, Rosenberg E, Frosch MP, Goldberg MB, Cho TA, Sabeti P. Enhanced Virus Detection and Metagenomic Sequencing in Patients with Meningitis and Encephalitis. mBio 2021; 12:e0114321. [PMID: 34465023 PMCID: PMC8406231 DOI: 10.1128/mbio.01143-21] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 07/02/2021] [Indexed: 01/21/2023] Open
Abstract
Meningitis and encephalitis are leading causes of central nervous system (CNS) disease and often result in severe neurological compromise or death. Traditional diagnostic workflows largely rely on pathogen-specific tests, sometimes over days to weeks, whereas metagenomic next-generation sequencing (mNGS) profiles all nucleic acid in a sample. In this single-center, prospective study, 68 hospitalized patients with known (n = 44) or suspected (n = 24) CNS infections underwent mNGS from RNA and DNA to identify potential pathogens and also targeted sequencing of viruses using hybrid capture. Using a computational metagenomic classification pipeline based on KrakenUniq and BLAST, we detected pathogen nucleic acid in cerebrospinal fluid (CSF) from 22 subjects, 3 of whom had no clinical diagnosis by routine workup. Among subjects diagnosed with infection by serology and/or peripheral samples, we demonstrated the utility of mNGS to detect pathogen nucleic acid in CSF, importantly for the Ixodes scapularis tick-borne pathogens Powassan virus, Borrelia burgdorferi, and Anaplasma phagocytophilum. We also evaluated two methods to enhance the detection of viral nucleic acid, hybrid capture and methylated DNA depletion. Hybrid capture nearly universally increased viral read recovery. Although results for methylated DNA depletion were mixed, it allowed the detection of varicella-zoster virus DNA in two samples that were negative by standard mNGS. Overall, mNGS is a promising approach that can test for multiple pathogens simultaneously, with efficacy similar to that of pathogen-specific tests, and can uncover geographically relevant infectious CNS disease, such as tick-borne infections in New England. With further laboratory and computational enhancements, mNGS may become a mainstay of workup for encephalitis and meningitis. IMPORTANCE Meningitis and encephalitis are leading global causes of central nervous system (CNS) disability and mortality. Current diagnostic workflows remain inefficient, requiring costly pathogen-specific assays and sometimes invasive surgical procedures. Despite intensive diagnostic efforts, 40 to 60% of people with meningitis or encephalitis have no clear cause of CNS disease identified. As diagnostic uncertainty often leads to costly inappropriate therapies, the need for novel pathogen detection methods is paramount. Metagenomic next-generation sequencing (mNGS) offers the unique opportunity to circumvent these challenges using unbiased laboratory and computational methods. Here, we performed comprehensive mNGS from 68 prospectively enrolled patients with known (n = 44) or suspected (n = 24) CNS viral infection from a single center in New England and evaluated enhanced methods to improve the detection of CNS pathogens, including those not traditionally identified in the CNS by nucleic acid detection. Overall, our work helps elucidate how mNGS can become integrated into the diagnostic toolkit for CNS infections.
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Affiliation(s)
- Anne Piantadosi
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Shibani S. Mukerji
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Simon Ye
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard-MIT Program of Health Sciences and Technology, Cambridge, Massachusetts, USA
| | - Michael J. Leone
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lisa M. Freimark
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Daniel Park
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Gordon Adams
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jacob Lemieux
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Sanjat Kanjilal
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Isaac H. Solomon
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Asim A. Ahmed
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pediatrics, Harvard Medical School, Children’s Hospital, Boston, Massachusetts, USA
| | - Robert Goldstein
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Vijay Ganesh
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Neurology, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Bridget Ostrem
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Kaelyn C. Cummins
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, Massachusetts, USA
| | - Jesse M. Thon
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Cormac M. Kinsella
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, Massachusetts, USA
| | - Eric Rosenberg
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Matthew P. Frosch
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marcia B. Goldberg
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Tracey A. Cho
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- University of Iowa, Department of Neurology, Iowa City, Iowa, USA
| | - Pardis Sabeti
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Department of Organismic and Evolutionary Biology, Harvard University, Cambridge, Massachusetts, USA
- Department of Immunology and Infectious Disease, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
- Howard Hughes Medical Institute, Chevy Chase, Maryland, USA
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16
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17
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Siegler JE, Cardona P, Arenillas JF, Talavera B, Guillen AN, Chavarría-Miranda A, de Lera M, Khandelwal P, Bach I, Patel P, Singla A, Requena M, Ribo M, Jillella DV, Rangaraju S, Nogueira RG, Haussen DC, Vazquez AR, Urra X, Chamorro Á, Román LS, Thon JM, Then R, Sanborn E, de la Ossa NP, Millàn M, Ruiz IN, Mansour OY, Megahed M, Tiu C, Terecoasa EO, Radu RA, Nguyen TN, Curiale G, Kaliaev A, Czap AL, Sebaugh J, Zha AM, Liebeskind DS, Ortega-Gutierrez S, Farooqui M, Hassan AE, Preston L, Patterson MS, Bushnaq S, Zaidat O, Jovin TG. Cerebrovascular events and outcomes in hospitalized patients with COVID-19: The SVIN COVID-19 Multinational Registry. Int J Stroke 2021; 16:437-447. [PMID: 32852257 PMCID: PMC7533468 DOI: 10.1177/1747493020959216] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/20/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients. AIM To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease. METHODS Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in four countries (1 February 2020-16 June 2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST). RESULTS Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) were female and 96/172 (55.8%) were between the ages 60 and 79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130-280/100,000), and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p < 0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p < 0.01), older age (aOR 1.78, 95%CI 1.07-2.94, p = 0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34-0.98, p = 0.04) were the only independent predictors of mortality among patients with stroke and COVID-19. CONCLUSIONS COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19-associated cerebrovascular complications; therefore, aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.
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Affiliation(s)
- James E Siegler
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden NJ, USA
| | - Pere Cardona
- Department of Neurology, Hospital Universitari, Bellvitge, Barcelona, Spain
| | - Juan F Arenillas
- Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain
- Neurovascular Research Laboratory, Instituto de Biología y Genética Molecular, Universidad de Valladolid, Consejo Superior de Investigaciones Científicas, Madrid, Spain
| | - Blanca Talavera
- Department of Neurology, Hospital Universitari, Bellvitge, Barcelona, Spain
| | - Ana N Guillen
- Department of Neurology, Hospital Universitari, Bellvitge, Barcelona, Spain
| | | | - Mercedes de Lera
- Department of Neurology, Hospital Universitari, Bellvitge, Barcelona, Spain
| | - Priyank Khandelwal
- Neurovascular Research Laboratory, Instituto de Biología y Genética Molecular, Universidad de Valladolid, Consejo Superior de Investigaciones Científicas, Madrid, Spain
| | - Ivo Bach
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
| | - Pratit Patel
- Neurovascular Research Laboratory, Instituto de Biología y Genética Molecular, Universidad de Valladolid, Consejo Superior de Investigaciones Científicas, Madrid, Spain
| | | | - Manuel Requena
- Department of Neurosurgery, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Marc Ribo
- Department of Neurosurgery, Robert Wood Johnson University Hospital, New Brunswick, NJ, USA
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain
| | - Dinesh V Jillella
- Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Srikant Rangaraju
- Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Raul G Nogueira
- Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Diogo C Haussen
- Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | | | - Xabier Urra
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Ángel Chamorro
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Luis S Román
- Area of Neuroscience, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Jesse M Thon
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden NJ, USA
| | - Ryna Then
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden NJ, USA
| | - Emma Sanborn
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden NJ, USA
| | | | - Mònica Millàn
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | - Isaac N Ruiz
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | - Ossama Y Mansour
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Carretera Canyet s/n, Badalona, Barcelona, Spain
| | - Mohammed Megahed
- Department of Neurology, Stroke and Neurointervention division, Alexandria University, Alexandria, Egypt
| | - Cristina Tiu
- Department of Critical Care Medicine, Alexandria University, Alexandria, Egypt
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
| | - Elena O Terecoasa
- Department of Critical Care Medicine, Alexandria University, Alexandria, Egypt
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
| | - Răzvan A Radu
- Department of Critical Care Medicine, Alexandria University, Alexandria, Egypt
| | - Thanh N Nguyen
- “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, MA, USA
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, MA, USA
| | | | - Artem Kaliaev
- Department of Neurology, Boston Medical Center, Boston University School of Medicine, MA, USA
| | - Alexandra L Czap
- Department of Neurosurgery, Boston Medical Center, Boston University School of Medicine, MA, USA
| | - Jacob Sebaugh
- Department of Neurosurgery, Boston Medical Center, Boston University School of Medicine, MA, USA
| | - Alicia M Zha
- Department of Neurosurgery, Boston Medical Center, Boston University School of Medicine, MA, USA
| | - David S Liebeskind
- Department of Neurology, McGovern Medical School, University of Texas Health Science Center, Houston, TX, USA
| | | | - Mudassir Farooqui
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Ameer E Hassan
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Department of Clinical Neuroscience Research, Valley Baptist Medical Center, Harlingen, TX, USA
| | - Laurie Preston
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Mary S Patterson
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Saif Bushnaq
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Osama Zaidat
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Tudor G Jovin
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden NJ, USA
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18
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Abstract
Background We examined sex differences in nonstenotic carotid plaque composition in patients with embolic stroke of undetermined source (ESUS). Methods and Results Patients with anterior circulation ischemic stroke imaged with neck computed tomographic angiography who met criteria for ESUS or had atrial fibrillation were identified. Patients with atrial fibrillation were included as a negative control. Semiautomated plaque quantification software analyzed carotid artery bifurcations. Plaque subcomponent (calcium, intraplaque hemorrhage [IPH], and lipid rich necrotic core) volumes were compared by sex and in paired analyses of plaque ipsilateral versus contralateral to stroke. Multivariate linear regressions tested for associations. Ninety‐four patients with ESUS (55% women) and 95 patients with atrial fibrillation (47% women) were identified. Men with ESUS showed significantly higher volumes of calcified plaque (63.9 versus 19.6 mm3, P<0.001), IPH (9.4 versus 3.3 mm3, P=0.008) and a IPH/lipid rich necrotic core ratio (0.17 versus 0.07, P=0.03) in carotid plaque ipsilateral to stroke side than women. The atrial fibrillation cohort showed no significant sex differences in plaque volumes ipsilateral to stroke. Multivariate analyses of the ESUS cohort showed male sex was associated with IPHipsi (β=0.49; 95% CI, 0.11–0.87) and calciumipsi (β=0.78; 95% CI, 0.33–1.23). Paired plaque analyses in men with ESUS showed significantly higher calcified plaque (63.9 versus 34.1 mm3, P=0.03) and a trend of higher IPHipsi (9.4 versus 7.5 mm3, P=0.73) and lipid rich necrotic coreipsi (59.0 versus 48.4 mm3, P=0.94) volumes. Conclusions Sex differences in carotid plaque composition in ESUS suggest the possibility of a differential contribution of nonstenosing carotid plaque as a stroke mechanism in men versus women.
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Affiliation(s)
- Jae W Song
- Department of Radiology University of Pennsylvania Philadelphia PA
| | - Quy Cao
- Department of Biostatistics University of Pennsylvania Philadelphia PA
| | - James E Siegler
- Cooper Neurologic Institute Cooper University Hospital Camden NJ
| | - Jesse M Thon
- Cooper Neurologic Institute Cooper University Hospital Camden NJ
| | - John H Woo
- Department of Radiology University of Pennsylvania Philadelphia PA
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19
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Siegler JE, Patel P, Romiyo P, Thau L, Heslin M, Smith A, Chen A, Little D, Thon JM. Abstract P152: Missed Treatment Opportunities and Earlier Stroke Detection Among Hospitalized Patients With Acute Cerebral Infarction. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
In preparation for a quality improvement study, we queried our prospective stroke registry for patients who might benefit from prophylactic monitoring in order to estimate the time advantage to monitoring.
Methods:
A prospective, single center registry of adult patients (9/20/19-6/30/20) was queried for in-hospital acute anterior circulation strokes. Indications for hospitalization as well as delays from last known well (LKW) to symptom recognition, imaging, and treatment were explored.
Results:
Of 540 consecutively evaluated adults with acute stroke, 68 (12.6%) developed an anterior circulation infarction while hospitalized, 32 (47.1%) of whom were female with a median age of 66 years (IQR 60-77) and median NIHSS of 14 (IQR 4-22). Four patients (5.9%) received intravenous thrombolysis although another 20 (29.4%) would have been eligible for thrombolysis if not for a delay in symptom recognition. An internal carotid, M1, or M2 occlusion was observed in 13 patients (19.1%), 8 of whom were treated at a median of 198 minutes after LKW (IQR 102-670; Figure). In patients treated endovascularly or with thrombolytics, the delay from LKW to symptom recognition accounted for 55.5% of the delay in care.
Conclusions:
One-third of patients in this single-center cohort would have been eligible for thrombolysis were it not for delays in symptom recognition. The delay to groin puncture exceeded 3 hours for over half of patients with proximal anterior occlusions. Earlier detection using prophylactic monitoring devices has the potential to reduce this major impedance to stroke care and ultimately improve outcomes.
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Affiliation(s)
| | | | | | | | | | - Ainsley Smith
- Cooper Neurologic Institute, Cooper Univ Hosp, Camden, NJ
| | | | - Dena Little
- Cooper Neurologic Institute, Cooper Univ Hosp, Camden, NJ
| | - Jesse M Thon
- Cooper Neurologic Institute, Cooper Univ Hosp, Camden, NJ
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20
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Siegler JE, Portela P, Arenillas JF, Chavarria-Miranda A, Guillen A, de Lera M, Khandelwal P, Bach I, Patel P, Singla A, Requena M, Ribo M, Jillella DV, Nogueira RG, Haussen DC, Vazquez AR, Urra X, San Roman L, Thon JM, Then R, Perez de la Ossa N, Millan M, Mansour O, Tiu C, Nguyen T, Kaliaev A, Czap AL, Zha A, Liebeskind DS, Ortega-Gutierrez S, Farooqui M, Hassan AE, Bushnaq S, Zaidat OO, Jovin TG. Abstract P75: Cerebrovascular Events and Outcomes in Hospitalized Patients With Covid-19: The Society of Vascular and Interventional Neurology Multinational Registry. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p75] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients.
Aims:
To summarize the findings of a multinational observational cohort of patients with SARS-CoV-2 and cerebrovascular disease.
Methods:
Retrospective observational cohort of consecutive adults evaluated in the emergency department and/or admitted with coronavirus disease 2019 (COVID-19) across 31 hospitals in 4 countries (2/1/2020 - 06/16/2020). The primary outcome was the incidence rate of cerebrovascular events, inclusive of acute ischemic stroke, intracranial hemorrhages (ICH), and cortical vein and/or sinus thrombosis (CVST).
Results:
Of the 14,483 patients with laboratory-confirmed SARS-CoV-2, 172 were diagnosed with an acute cerebrovascular event (1.13% of cohort; 1130/100,000 patients, 95%CI 970-1320/100,000), 68/171 (40.5%) of whom were female and 96/172 (55.8%) were between the ages 60-79 years. Of these, 156 had acute ischemic stroke (1.08%; 1080/100,000 95%CI 920-1260/100,000), 28 ICH (0.19%; 190/100,000 95%CI 130 - 280/100,000) and 3 with CVST (0.02%; 20/100,000, 95%CI 4-60/100,000). The in-hospital mortality rate for SARS-CoV-2-associated stroke was 38.1% and for ICH 58.3%. After adjusting for clustering by site and age, baseline stroke severity, and all predictors of in-hospital mortality found in univariate regression (p<0.1: male sex, tobacco use, arrival by emergency medical services, lower platelet and lymphocyte counts, and intracranial occlusion), cryptogenic stroke mechanism (aOR 5.01, 95%CI 1.63-15.44, p<0.01), older age (aOR 1.78, 95%CI 1.07-2.94, p=0.03), and lower lymphocyte count on admission (aOR 0.58, 95%CI 0.34-0.98 p=0.04) were the only independent predictors of mortality among patients with stroke and COVID-19.
Conclusions:
COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke. The mortality rate is high for COVID-19 associated cerebrovascular complications, therefore aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.
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Affiliation(s)
| | - Pere Portela
- Dept of Neurology, Hosp Universitari, Bellvitge, Barcelona, Spain
| | | | | | - Ana Guillen
- Dept of Neurology, Hosp Universitari, Bellvitge, Barcelona, Spain
| | - Mercedes de Lera
- Dept of Neurology, Hosp Clínico Universitario, Valladolid, Spain
| | | | - Ivo Bach
- Dept of Neurology, Robert Wood Johnson Univ Hosp, New Brunswick, NJ
| | - Pratit Patel
- Dept of Neurology, Robert Wood Johnson Univ Hosp, New Brunswick, NJ
| | - Amit Singla
- Dept of Neurosurgery, Robert Wood Johnson Univ Hosp, New Brunswick, NJ
| | - Manuel Requena
- Stroke Unit, Dept of Neurology, Vall d’Hebron Rsch Institute; Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | | | | | | | | | - Alejandro R Vazquez
- Dept of Neurology, Hosp Clínic; Area of Neuroscience, Institut d’Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Xabier Urra
- Dept of Neurology, Hosp Clínic, Barcelona, Spain
| | | | - Jesse M Thon
- Cooper Neurologic Institute, Cooper Univ Hosp, Camden, NJ
| | - Ryna Then
- Cooper Neurologic Institute, Cooper Univ Hosp, Camden, NJ
| | - Natalia Perez de la Ossa
- Stroke Unit, Neuroscience Dept, Hosp Universitari Germans Trias i Pujol, Carretera Canyet s/n, 08916 Badalona, Barcelona, Spain
| | | | | | - Cristina Tiu
- Dept of Neurology, Univ Emergency Hosp Bucharest; "Carol Davila" Univ of Medicine and Pharmacy, Bucharest, Romania
| | - Thanh Nguyen
- Dept of Neurology, Boston Med Cntr, Boston Univ Sch of Medicine, MA 02118, USA; Dept of Radiology, Dept of Neurosurgery, Dept of Neurology, Boston Med Cntr, Boston, MA
| | - Artem Kaliaev
- Dept of Radiology, Boston Med Cntr, Boston Univ Sch of Medicine, MA 02118, USA, Boston, MA
| | | | - Alicia Zha
- UT Health Science Cntr Houston, Houston, TX
| | | | | | | | | | - Saif Bushnaq
- Neuroscience Institute, Bon Secours Mercy Health St. Vincent Hosp, Toledo, OH
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21
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Siegler JE, Zha A, Czap AL, Ortega-Gutierrez S, Farooqui M, Liebeskind DS, Desai S, Hassan AE, Starosciak AK, Linfante I, Rai V, Thon JM, Then R, Heslin M, Thau L, Khandelwal P, Mohammaden M, Haussen DC, Nogueira RG, Jillella DV, Kaliaev A, Nguyen T, Zaidat OO, Jovin TG, Jadhav A. Abstract 2: Acute Stroke Care During The Covid-19 Pandemic: The Society Of Vascular And Interventional Neurology Collaboration. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
We sought to evaluate whether the coronavirus disease 2019 (COVID-19) pandemic may have contributed to delays in acute stroke management at Comprehensive Stroke Centers (CSCs).
Methods:
Pooled clinical data of consecutive adult stroke patients from 12 U.S. CSCs (1/1/2019-5/31/2020) were queried. The rate of thrombolysis for non-transferred patients within the Target: Stroke goal of 60min was compared between patients admitted 3/1/2019-5/31/2019 (pre-COVID-19) and 3/1/2020-5/31/2020 (COVID-19). The time from arrival to imaging and treatment with thrombolysis or thrombectomy, as continuous variables, were also assessed.
Results:
Of the 7906 patients included, 1319 were admitted pre-COVID-19 and 933 were admitted during COVID-19, 15% of whom underwent intravenous thrombolysis. There was no difference in the rate of thrombolysis within 60min during COVID-19 (OR 0.88, 95%CI 0.42-1.86, p=0.74), despite adjustment for variables associated with earlier treatment (adjusted OR 0.82, 95%CI 0.38-1.76, p=0.61). There was no significant overall delay to thrombolysis during the COVID-19 period vs. pe-COVID-19 (p=0.42), even after multivariable adjustment (p=0.63) or after comparison across months leading to COVID-19 (Figure). The only independent predictor of delayed treatment time between periods was the use of emergency medical services (adjusted β=-6.93, 95%CI -12.83 - -1.04, p=0.03). There was no significant delay from hospital arrival to imaging in all patients, or imaging to skin puncture in patients who underwent thrombectomy.
Conclusions:
There was no independent effect of the COVID-19 period on delays in acute care with respect to thrombolysis or thrombectomy in this multicenter observational cohort. Further studies are warranted to externally validate these findings, and determine if site volume or center accreditation may mediate a collateral effect of the pandemic on stroke care paradigms.
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Affiliation(s)
| | - Alicia Zha
- UT Health Science Cntr Houston, Houston, TX
| | | | | | | | | | | | | | | | | | - Vivek Rai
- OhioHealth Neuroscience Cntr, Riverside Methodist Hosp, Columbus, OH
| | - Jesse M Thon
- Cooper Neurologic Institute, Cooper Univ Hosp, Camden, NJ
| | - Ryna Then
- Cooper Neurologic Institute, Cooper Univ Hosp, Camden, NJ
| | | | - Lauren Thau
- Cooper Neurologic Institute, Cooper Med Sch of Rowan Univ, Camden, NJ
| | - Priyank Khandelwal
- Dept of Endovascular Neurological Surgery & Neurology, Robert Wood Johnson Univ Hosp, New Brunswick, NJ
| | | | - Diogo C Haussen
- Marcus Stroke & Neuroscience Cntr, Grady Memorial Hosp, Atlanta, GA
| | | | | | - Artem Kaliaev
- Dept of Interventional Neurology and Neuroradiology, Boston Med Cntr,, Boston, MA
| | - Thanh Nguyen
- Dept of Neurology, Neurosurgery and Radiology, Boston Med Cntr, Boston, MA
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22
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Ramos-Araque ME, Siegler JE, Ribo M, Requena M, López C, de Lera M, Arenillas JF, Pérez IH, Gómez-Vicente B, Talavera B, Portela PC, Guillen AN, Urra X, Llull L, Renú A, Nguyen TN, Jillella D, Nahab F, Nogueira R, Haussen D, Then R, Thon JM, Esparragoza LR, Hernández-Pérez M, Bustamante A, Mansour OY, Megahed M, Hassan T, Liebeskind DS, Hassan A, Bushnaq S, Osman M, Vazquez AR. Stroke etiologies in patients with COVID-19: the SVIN COVID-19 multinational registry. BMC Neurol 2021; 21:43. [PMID: 33514335 PMCID: PMC7846488 DOI: 10.1186/s12883-021-02075-1] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 01/19/2021] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Coronavirus disease 2019 (COVID-19) is associated with a small but clinically significant risk of stroke, the cause of which is frequently cryptogenic. In a large multinational cohort of consecutive COVID-19 patients with stroke, we evaluated clinical predictors of cryptogenic stroke, short-term functional outcomes and in-hospital mortality among patients according to stroke etiology. METHODS We explored clinical characteristics and short-term outcomes of consecutively evaluated patients 18 years of age or older with acute ischemic stroke (AIS) and laboratory-confirmed COVID-19 from 31 hospitals in 4 countries (3/1/20-6/16/20). RESULTS Of the 14.483 laboratory-confirmed patients with COVID-19, 156 (1.1%) were diagnosed with AIS. Sixty-one (39.4%) were female, 84 (67.2%) white, and 88 (61.5%) were between 60 and 79 years of age. The most frequently reported etiology of AIS was cryptogenic (55/129, 42.6%), which was associated with significantly higher white blood cell count, c-reactive protein, and D-dimer levels than non-cryptogenic AIS patients (p=0.05 for all comparisons). In a multivariable backward stepwise regression model estimating the odds of in-hospital mortality, cryptogenic stroke mechanism was associated with a fivefold greater odds in-hospital mortality than strokes due to any other mechanism (adjusted OR 5.16, 95%CI 1.41-18.87, p = 0.01). In that model, older age (aOR 2.05 per decade, 95%CI 1.35-3.11, p < 0.01) and higher baseline NIHSS (aOR 1.12, 95%CI 1.02-1.21, p = 0.01) were also independently predictive of mortality. CONCLUSIONS Our findings suggest that cryptogenic stroke among COVID-19 patients carries a significant risk of early mortality.
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Affiliation(s)
- María E Ramos-Araque
- Institute of Biomedical Research of Salamanca, Department of Neurology, Hospital Universitario de Salamanca, Salamanca, Spain
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - James E Siegler
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA.
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain
- Departament of Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain
- Departament of Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Cristina López
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Mercedes de Lera
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Juan F Arenillas
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Isabel Hernández Pérez
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Beatriz Gómez-Vicente
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Blanca Talavera
- Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Ana Nuñez Guillen
- Department of Neurology, Hospital Universitari, Bellvitge, Barcelona, Spain
| | - Xabier Urra
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Laura Llull
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Arturo Renú
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Thanh N Nguyen
- Department of Neurology, Department of Radiology, Department of Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA
| | - Dinesh Jillella
- Department of Neurology, Emory University School of Medicine, Atlanta, USA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, USA
| | - Raul Nogueira
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | - Diogo Haussen
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | - Ryna Then
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jesse M Thon
- Cooper Neurologic Institute, Cooper University Hospital, Camden, NJ, USA
| | - Luis Rodríguez Esparragoza
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Maria Hernández-Pérez
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Alejandro Bustamante
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Ossama Yassin Mansour
- Neurology Department, Stroke and neurointervention unit, Alexandria University, Alexandria, Egypt
| | - Mohammed Megahed
- Critical care Department, Alexandria University, Alexandria, Egypt
| | - Tamer Hassan
- Neurosurgery Department, Stroke and Neurointervention unit, Alexandria University, Alexandria, Egypt
| | - David S Liebeskind
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, USA
| | - Ameer Hassan
- Department of Clinical Neuroscience Research, Valley Baptist Medical Center, Harlingen, TX, USA
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Saif Bushnaq
- Neuroscience Institute, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH, USA
| | - Mohamed Osman
- Neuroscience Institute, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH, USA
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23
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Siegler JE, Zha AM, Czap AL, Ortega-Gutierrez S, Farooqui M, Liebeskind DS, Desai SM, Hassan AE, Starosciak AK, Linfante I, Rai V, Thon JM, Then R, Heslin ME, Thau L, Khandelwal P, Mohammaden MH, Haussen DC, Nogueira RG, Jillella DV, Nahab F, Kaliaev A, Nguyen TN, Zaidat O, Jovin TG, Jadhav AP. Influence of the COVID-19 Pandemic on Treatment Times for Acute Ischemic Stroke: The Society of Vascular and Interventional Neurology Multicenter Collaboration. Stroke 2021; 52:40-47. [PMID: 33250041 PMCID: PMC7934334 DOI: 10.1161/strokeaha.120.032789] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 10/15/2020] [Accepted: 11/05/2020] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE The pandemic caused by the novel coronavirus disease 2019 (COVID-19) has led to an unprecedented paradigm shift in medical care. We sought to evaluate whether the COVID-19 pandemic may have contributed to delays in acute stroke management at comprehensive stroke centers. METHODS Pooled clinical data of consecutive adult stroke patients from 14 US comprehensive stroke centers (January 1, 2019, to July 31, 2020) were queried. The rate of thrombolysis for nontransferred patients within the Target: Stroke goal of 60 minutes was compared between patients admitted from March 1, 2019, and July 31, 2019 (pre-COVID-19), and March 1, 2020, to July 31, 2020 (COVID-19). The time from arrival to imaging and treatment with thrombolysis or thrombectomy, as continuous variables, were also assessed. RESULTS Of the 2955 patients who met inclusion criteria, 1491 were admitted during the pre-COVID-19 period and 1464 were admitted during COVID-19, 15% of whom underwent intravenous thrombolysis. Patients treated during COVID-19 were at lower odds of receiving thrombolysis within 60 minutes of arrival (odds ratio, 0.61 [95% CI, 0.38-0.98]; P=0.04), with a median delay in door-to-needle time of 4 minutes (P=0.03). The lower odds of achieving treatment in the Target: Stroke goal persisted after adjustment for all variables associated with earlier treatment (adjusted odds ratio, 0.55 [95% CI, 0.35-0.85]; P<0.01). The delay in thrombolysis appeared driven by the longer delay from imaging to bolus (median, 29 [interquartile range, 18-41] versus 22 [interquartile range, 13-37] minutes; P=0.02). There was no significant delay in door-to-groin puncture for patients who underwent thrombectomy (median, 83 [interquartile range, 63-133] versus 90 [interquartile range, 73-129] minutes; P=0.30). Delays in thrombolysis were observed in the months of June and July. CONCLUSIONS Evaluation for acute ischemic stroke during the COVID-19 period was associated with a small but significant delay in intravenous thrombolysis but no significant delay in thrombectomy time metrics. Taking steps to reduce delays from imaging to bolus time has the potential to attenuate this collateral effect of the pandemic.
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Affiliation(s)
- James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Alicia M. Zha
- Department of Neurology, University of Texas Health Science Center at Houston, TX (A.M.Z., A.L.C.)
| | - Alexandra L. Czap
- Department of Neurology, University of Texas Health Science Center at Houston, TX (A.M.Z., A.L.C.)
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics (S.O.-G., M.F.)
| | - Mudassir Farooqui
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics (S.O.-G., M.F.)
| | - David S. Liebeskind
- Department of Neurology, Ronald Reagan University of California at Los Angeles (D.S.L.)
| | - Shashvat M. Desai
- Department of Neurology, University of Pittsburgh Medical Center Mercy Hospital, PA (S.M.D., A.P.J.)
- Department of Neurology, University of Pittsburgh Medical Center Presbyterian Medical Center, PA (S.M.D., A.P.J.)
| | - Ameer E. Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center, Harlingen, TX (A.E.H.)
| | - Amy K. Starosciak
- Center for Research (A.K.S.), Baptist Health South Florida, Coral Gables
| | - Italo Linfante
- Department of Interventional Neuroradiology and Endovascular Neurosurgery (I.L.), Baptist Health South Florida, Coral Gables
| | - Vivek Rai
- OhioHealth Neuroscience Center, Riverside Methodist Hospital, Columbus (V.R.)
| | - Jesse M. Thon
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Ryna Then
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Mark E. Heslin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Lauren Thau
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Priyank Khandelwal
- Department of Endovascular Neurological Surgery and Neurology, Robert Wood Johnson University Hospital, New Brunswick, NJ (P.K.)
| | - Mahmoud H. Mohammaden
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (M.H.M., D.C.H., R.G.N.)
| | - Diogo C. Haussen
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (M.H.M., D.C.H., R.G.N.)
| | - Raul G. Nogueira
- Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (M.H.M., D.C.H., R.G.N.)
| | - Dinesh V. Jillella
- Department of Neurology, Emory University Hospital, Atlanta, GA (D.V.J., F.N.)
| | - Fadi Nahab
- Department of Neurology, Emory University Hospital, Atlanta, GA (D.V.J., F.N.)
| | - Artem Kaliaev
- Department of Interventional Neurology and Neuroradiology, Boston Medical Center, MA (A.K., T.N.N.)
| | - Thanh N. Nguyen
- Department of Interventional Neurology and Neuroradiology, Boston Medical Center, MA (A.K., T.N.N.)
| | - Osama Zaidat
- Department of Neurology, Mercy Health St. Vincent Hospital, Toledo, OH (O.Z.)
| | - Tudor G. Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ (J.E.S., J.M.T., R.T., M.E.H., L.T., T.G.J.)
| | - Ashutosh P. Jadhav
- Department of Neurology, University of Pittsburgh Medical Center Mercy Hospital, PA (S.M.D., A.P.J.)
- Department of Neurology, University of Pittsburgh Medical Center Presbyterian Medical Center, PA (S.M.D., A.P.J.)
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24
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Regenhardt RW, Thon JM, Das AS, Thon OR, Charidimou A, Viswanathan A, Gurol ME, Chwalisz BK, Frosch MP, Cho TA, Greenberg SM. Association Between Immunosuppressive Treatment and Outcomes of Cerebral Amyloid Angiopathy-Related Inflammation. JAMA Neurol 2020; 77:1261-1269. [PMID: 32568365 PMCID: PMC7309570 DOI: 10.1001/jamaneurol.2020.1782] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 03/20/2020] [Indexed: 07/27/2023]
Abstract
IMPORTANCE Cerebral amyloid angiopathy-related inflammation (CAA-ri), a distinct subtype of cerebral amyloid angiopathy, is characterized by an autoimmune reaction to cerebrovascular β-amyloid deposits. Outcomes and response to immunosuppressive therapy for CAA-ri are poorly understood. OBJECTIVE To identify clinical, neuroimaging, laboratory, pathologic, or treatment-related associations with outcomes after an episode of CAA-ri. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study of prospectively identified individuals who presented from July 3, 1998, to November 27, 2017, with a median follow-up of 2.7 years (interquartile range, 1.0-5.5 years). The study included 48 consecutive patients with CAA-ri meeting diagnostic criteria who had at least 1 disease episode and subsequent outcome data. No patients refused or were excluded. EXPOSURES Prespecified candidate variables were immunosuppressive therapies, cerebrospinal fluid pleocytosis, magnetic resonance imaging findings of recent infarcts or contrast enhancement, and histopathologic evidence of vessel wall inflammation. MAIN OUTCOMES AND MEASURES Clinical improvement and worsening were defined by persistent changes in signs or symptoms, radiographic improvement by decreased subcortical foci of T2 hyperintensity or T1 enhancement, and radiographic worsening by increased subcortical T2 hyperintensity, T1 enhancement, or infarcts. Disease recurrence was defined as new-onset clinical symptoms associated with new imaging findings. RESULTS The 48 individuals in the study included 29 women and had a mean (SD) age of 68.9 (9.9) years. Results of presenting magnetic resonance imaging revealed that 10 of 29 patients with CAA-ri (34%) had T1 contrast enhancement, 30 of 32 (94%) had subcortical T2 hyperintensity (22 of 30 [73%] asymmetric), 7 of 32 (22%) had acute or subacute punctate infarcts, and 27 of 31 (87%) had microbleeds. Immunosuppressive treatments after first episodes included corticosteroids (33 [69%]), cyclophosphamide (6 [13%]), and mycophenolate (2 [4%]); 14 patients (29%) received no treatment. Clinical improvement and radiographic improvement were each more likely in individuals treated with an immunosuppressive agent than with no treatment (clinical improvement: 32 of 34 [94%] vs 7 of 14 [50%]; odds ratio, 16.0; 95% CI, 2.72-94.1; radiographic improvement: 24 of 28 [86%] vs 4 of 14 [29%]; odds ratio, 15.0; 95% CI, 3.12-72.1). Recurrence was less likely if CAA-ri was treated with any immunosuppressant agent than not (9 of 34 [26%] vs 10 of 14 [71%]; hazard ratio, 0.19; 95% CI, 0.07-0.48). When controlling for treatment, no variables were associated with outcomes aside from an association between APOE ɛ4 and radiographic improvement (odds ratio, 4.49; 95% CI, 1.11-18.2). CONCLUSIONS AND RELEVANCE These results from a relatively large series of patients with CAA-ri support the effectiveness of immunosuppressive treatment and suggest that early treatment may both improve the initial disease course and reduce the likelihood of recurrence. These results raise the possibility that early blunting of CAA-ri and the autoimmune response may have long-term benefits for the subsequent disease course.
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Affiliation(s)
- Robert W. Regenhardt
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Jesse M. Thon
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alvin S. Das
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Olga R. Thon
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Andreas Charidimou
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Anand Viswanathan
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - M. Edip Gurol
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Bart K. Chwalisz
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Matthew P. Frosch
- Neuropathology Service, C. S. Kubik Laboratory for Neuropathology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Tracey A. Cho
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Steven M. Greenberg
- J. Philip Kistler Stroke Research Center, Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
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25
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Kakadia B, Ahmed J, Siegal T, Jovin TG, Thon JM. Mild encephalopathy with reversible splenium lesion (MERS) in a patient with COVID-19. J Clin Neurosci 2020; 79:272-274. [PMID: 33070911 PMCID: PMC7340073 DOI: 10.1016/j.jocn.2020.07.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 07/05/2020] [Indexed: 01/19/2023]
Abstract
Neurological complications of coronavirus 2019 (COVID-19) are common, and novel manifestations are increasingly being recognized. Mild encephalopathy with reversible splenium lesion (MERS) is a syndrome that has been associated with viral infections, but not previously with COVID-19. In this report, we describe the case of a 69 year-old man who presented with fever and encephalopathy in the setting of a diffusion-restricting splenium lesion, initially mimicking an ischemic stroke. A comprehensive infectious workup revealed positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies, and a pro-inflammatory laboratory profile characteristic of COVID-19 infection. His symptoms resolved and the brain MRI findings completely normalized on repeat imaging, consistent with MERS. This case suggests that MERS may manifest as an autoimmune response to SARS-CoV-2 infection and should be considered in a patient with evidence of recent COVID-19 infection and the characteristic MERS clinico-radiological syndrome.
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Affiliation(s)
- Bhavika Kakadia
- Cooper Neurological Institute, Cooper University Hospital, and Cooper Medical School of Rowan University, Camden, NJ 08103, United States
| | - Jaffer Ahmed
- Cooper Neurological Institute, Cooper University Hospital, and Cooper Medical School of Rowan University, Camden, NJ 08103, United States
| | - Todd Siegal
- Department of Radiology, Cooper University Hospital, Camden, NJ 08103, United States
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Hospital, and Cooper Medical School of Rowan University, Camden, NJ 08103, United States
| | - Jesse M Thon
- Cooper Neurological Institute, Cooper University Hospital, and Cooper Medical School of Rowan University, Camden, NJ 08103, United States.
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26
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Thon JM, Regenhardt RW, Thon OR, Charidimou A, Viswanathan A, Gurol ME, Chwalisz BK, Frosch M, Cho TA, Greenberg SM. Abstract WP426: Cerebral Amyloid Angiopathy-related Inflammation: Immunosuppressive Treatment and Outcome. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Cerebral amyloid angiopathy-related inflammation (CAAri) is characterized by altered cognition, headaches, and seizures and is associated with vasogenic edema and an anti-amyloid immune response on imaging and histology. Optimal treatments are poorly understood. Our objective was to analyze clinical features and treatment strategies in CAAri to identify predictors of outcome.
Methods:
We retrospectively reviewed the records of 56 consecutive patients with pathologically or radiographically diagnosed CAAri at Massachusetts General Hospital. Clinical, laboratory, pathology, and treatment data were collected for analysis. Inflammatory events were defined by previously described clinical and radiographic parameters. Chi-Square analyses were used to determine if treatment with immunotherapy was associated with outcomes.
Results:
Of the 56 subjects, 8 had vessel wall inflammation on pathology, 21 had perivascular inflammation on pathology, and 48 had probable CAAri by validated imaging criteria. Thirty-five were female, 49 presented with an inflammatory event, and the mean age at first event was 69.3+/-10.2 years. First events included headache (n=21), cognitive/behavioral change (29), focal deficit (9), seizure (20), and other (6). CSF was examined in 26 subjects after first event (6 with WBC>5, 24 with protein>45, 1 without abnormality). Treatments included steroids (33), cyclophosphamide (6), mycophenolate (2), and no treatment (14). After first event, clinical improvement (n=39) was more likely if treated with any immunotherapy than not (32/34 vs 7/14, p=0.001). Radiographic improvement (28) was more likely if treated than not (24/28 vs 4/14, p<0.0001). Radiographic worsening (13) was less likely if treated than if not treated (3/28 vs. 10/14, p<0.0001). Only 3 had clinical worsening and 0 were unchanged. At least 1 recurrent event (19) was more likely if not treated than if treated (10/13 vs 9/31, p=0.005); 10 had multiple recurrences and 1 died during an event.
Conclusion:
This study of the largest CAAri patient population to-date suggests treatment with immunosuppression is associated with improved clinical and radiographic outcomes and decreased recurrence of events.
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Affiliation(s)
- Jesse M Thon
- Neurology, Hosp of the Univ of Pennsylvania, Philadelphia, PA
| | | | - Olga R Thon
- Neurology, Drexel Univ College of Medicine, Philadelphia, PA
| | | | | | | | | | | | - Tracey A Cho
- Neurology, Univ of Iowa Carver College of Medicine, Iowa City, IA
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27
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Abstract
A 78-year-old man with a history of benign prostatic hyperplasia presented with double vision, facial pain, altered taste and headache for 7 weeks. Neurological exam was notable for palsies of the right V, VI, VII and XII cranial nerves. An expansive clival mass and multiple lesions in the vertebra were found on MRI. Radionuclide studies showed extensive tumour burden in his liver and peritoneum. His serologies showed normal carcinoembryonic antigen and carbohydrate antigen 19-9 levels and modestly elevated prostate-specific antigen, which was a red herring. Biopsy of his omentum was consistent with metastatic adenocarcinoma with immunostaining indicating an upper gastrointestinal primary tumour. The patient underwent several cycles of radiation therapy, but ultimately elected to pursue hospice care. This case demonstrates the presentation of multiple cranial neuropathies from a clival mass and an unusual primary source from an upper gastrointestinal tumour.
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Affiliation(s)
| | - Jesse M Thon
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Amar Dhand
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
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28
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Thon JM, Grossmann L, Bhattacharyya S. Teaching Video NeuroImages: Apraxia of eyelid closure following right hemispheric infarction. Neurology 2017; 89:e15. [DOI: 10.1212/wnl.0000000000004091] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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