{2022}

In-hospital predictors of post-stroke depression for targeted initiation of Selective Serotonin Reuptake Inhibitors (SSRIs)

History of depression and a positive inpatient PHQ-9 appear to be most strongly predictive of long-term PSD. Initiating SSRIs only in those individuals at highest risk for PSD may help reduce the burden of stroke recovery in this targeted population while minimizing adverse side effects.

Yi, J., Lu, J., Yang, A., Marsh, E.B. In-hospital predictors of post-stroke depression for targeted initiation of Selective Serotonin Reuptake Inhibitors (SSRIs). BMC Psychiatry 22, 722 (2022). https://doi.org/10.1186/s12888-022-04378-0

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When Less is More: Non-Contrast Head CT Alone to Work-Up Hypertensive Intracerebral Hemorrhage

Hypertensive ICH is associated with several predictive factors. Using deep location and history of hypertension alone correctly identifies the majority of hypertensive ICH without additional work-up. This model may result in more efficient diagnostic testing without sacrificing patient care.

Chen C, Girgenti S, Mallick D, *Marsh EB. When less is more: non-contrast head CT alone to work-up hypertensive intracerebral hemorrhage. J Clin Neurosci, 2022;100:108-112. doi.org/10.1016/j.jocn.2022.04.006

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The Telemedicine Experience: Using Principles of Clinical Excellence to Identify Disparities and Optimize Care

Results showed a lower-than expected number of patients who were black and of lower socioeconomic status followed up virtually, which indicates a potential barrier to patient care access. Those who participated in televists reported to be satisfied with the experience and felt that the care met their medical needs. Older patients were more likely to experience technical difficulties, and majority preferred in-person visits. Overall, telemedicine practices can be an effective model for patient care; however, variables such as age, education, socioeconomic status, and ease of access must be considered when designing.

Khan S, Llinas EJ, Danoff SK, Llinas RH, *Marsh EB. The telemedicine experience: using principles of clinical excellence to identify disparities and optimize care. Medicine, 2022;101(10). doi: 10.1097/MD.0000000000029017

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{2021}

The Routine Follow-Up Head CT: Is it Still a Necessary Step in the Thrombolysis Pathway?

The 24-hour head CT scan does not change management for most stroke patients, particularly those with low National Institutes of Health Stroke Scale scores who do not undergo MT. Consideration should be given to removing routine follow-up imaging from post-thrombolysis protocols in favor of an examination-based approach.

Llinas EJ, Max A, Khan S, *Marsh EB. The routine follow-up head CT: is it still a necessary step in the thrombolysis pathway? Neurocrit Care. 2021; doi: 10.1007/s12028-021-01348-4.

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COVID-19 and Vaccination in the Setting of Neurologic Disease

While vaccination has been associated with potential side effects including AIDP and sinus venous thrombosis, the risk of these complications is incredibly small, much smaller than the risk of infection itself. There are groups, however, for example those on immunosuppressive therapy, who may benefit from further consideration regarding timing of vaccination with respect to their treatment.

Elisabeth B. Marsh, Michael Kornberg, Kevin Kessler, Ihtsham Haq, Anup D. Patel, Avindra Nath, Becky Schierman, Lyell K. Jones Jr. American Academy of Neurology July 2021, DOI: 10.1212/WNL.0000000000012578

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Abnormal Singing Can Identify Patients With Right Hemisphere Cortical Strokes at Risk for Impaired Prosody

When administered a singing screen, patients with RH cortical infarcts are more likely to demonstrate impaired prosody comprehension and production, as well as poor variation of tone when singing compared to patients with subcortical infarcts. This simple screen is able to successfully identify patients with cortical lesions and potential prosodic deficits.

Lin RZ and *Marsh EB. Abnormal singing can identify patients with right hemisphere cortical strokes at risk for impaired prosody. Medicine. 2021;100(23):e26280.

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{2020}

Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of “Drip and Ship” on Effectiveness and Outcomes

Determining the optimal pathways for patient care is important. Advances in the acute treatment of large vessel occlusion with mechanical thrombectomy has raised questions over the utility of bridging with IV tPA. We conducted a large, retrospective review of our cases and found that administration of IV tPA prior to mechanical thrombectomy in patients with large vessel occlusion demonstrated better overall outcomes compared to mechanical thrombectomy alone. This suggests that the use of IV tPA in combination with mechanical thrombectomy should remain as the treatment for large vessel occlusions.

Chang, A., Beheshtian, E., Llinas, E. J., Idowu, O. R., & Marsh, E. B. (2020). Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of "Drip and Ship" on Effectiveness and Outcomes. Frontiers in neurology, 11, 585929. https://doi.org/10.3389/fneur.2020.585929

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{2018}

Shorter ICU Stays? The Majority of Post-IV tPA Symptomatic Hemorrhages Occur Within 12 Hours of Treatment

Patients who receive treatment with intravenous tissue plasminogen activator (IV tPA) are at risk of developing symptomatic intracranial hemorrhage (sICH), a life-threatening complication. The current standard of care requires that these patients are monitored for 24 hours post-treatment, which is resource-intensive. However, given the relatively short half-life of tPA, it was hypothesized that sICH due to IV tPA would develop well before 24 hours.

Results showed that sICH associated with the administration of IV tPA typically occurs within the first 12 hours of treatment. Longer monitoring in an ICU-like setting may be unnecessary for most individuals.

Chang A, Llinas EJ, Chen K, Llinas RH, Marsh EB. Shorter intensive care unit stays?: The majority of post-intravenous tPA (tissue-type plasminogen activator) symptomatic hemorrhages occur within 12 hours of treatment. Stroke 2018;49(6):1521-1524.
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Cerebral microbleeds shouldn't dictate treatment of acute stroke: a retrospective cohort study evaluating risk of intracerebral hemorrhage

Our findings support prior findings that a high cerebral microbleed burden (CMB, >10) in patients with acute stroke treated with IV tPA are associated with a higher risk of symptomatic hemorrhage (sICH). However, the overall rate of sICH in the presence of CMB is very low, indicating that the presence of CMBs by itself should not dictate the decision to treat with thrombolytics.

Chacon-Portillo MA, Llinas RH, Marsh EB. Cerebral microbleeds shouldn't dictate treatment of acute stroke: a retrospective cohort study evaluating risk of intracerebral hemorrhage. BMC Neurology 2018;18(1):33.
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Streamlining the Process for Intravenous Tissue Plasminogen Activator

The use of a stroke nurse and a nursing flow sheet as part of the acute stroke assessment significantly increases the proportion of patients treated with IV tPA within 60 minutes from hospital arrival.

Lawrence E, Merbach D, Thorpe S, Llinas RH, Marsh EB. Streamlining the process for intravenous tissue plasminogen activator. Journal of Neuroscience Nursing 2018;50(1):37-41.
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{2017}

Isolated aphasia in the emergency department: The likelihood of ischemia is low

Strokes affecting language without motor or sensory deficits are uncommon. In the acute setting, isolated “aphasia” is most often due to a stroke mimic; however, it can occur rarely, particularly in those with prior history of ischemia.

Casella G, Llinas RH, Marsh EB. Isolated aphasia in the emergency department: the likelihood of ischemia is low. Clinical Neurology and Neurosurgery 2017;163:24-26.
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In Potential Stroke Patients on Warfarin, the International Normalized Ratio Predicts Ischemia

Sub-therapeutic international normalized ratio (INR) and atrial fibrillation are strongly associated with ischemia in patients on warfarin presenting with acute neurologic symptoms. Ischemia is far less likely in patients with an INR of ≥2 and rare in those with an INR ≥3.6. This study shows that the INR value of a patient on warfarin can help stratify patients' risk for acute ischemic stroke and guide further neurologic imaging and workup.

Cao C, Martinelli A, Spoelhof B, Llinas RH, Marsh EB. In potential stroke patients on warfarin, the international normalized ratio predicts ischemia. Cerebrovascular Diseases EXTRA 2017;7(2):111-119.
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{2016}

Reversible Cerebrovasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) is a reversible vasculopathy, or narrowing of the blood vessels, that is an important cause of stroke in young people and most often affects women. RCVS classically presents with a thunderclap headache that can progress to cause intracranial hemorrhage (ICH) or ischemic stroke. The clinical and imaging characteristics of RCVS have been well-characterized; however, the optimal therapy and best method to monitor treatment effect remains unclear. We published a case series of patients with RCVS treated with calcium channel blockade using transcranial doppler ultrasound (TCD) to monitor their blood vessels and found that longer-acting verapamil, given every 12 hours, is effective in decreasing velocities (opening vessels). We currently follow patients with RCVS in our longitudinal clinic where we are committed to improving outcomes. 

Marsh EB, Ziai W, Llinas RH. The need for a rational approach to vasoconstrictive syndromes: transcranial doppler and calcium channel blockers in RCVS. Case Reports in Neurology 2016;8(2):161-171.
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Keep it simple: vascular risk factors and focal exam findings correctly identify posterior circulation ischemia in “dizzy” patients

The presence of calcification within the cervical and intracranial vessels on computed tomography angiography (CTA) can be associated with posterior circulation ischemia, but in our population did not add significant utility above clinical acumen. A vascular risk assessment and neurological examination are adequate for risk stratification of ischemia in the dizzy patient and should remain the standard evaluation.

Chen K, Schneider ALC, Llinas RH, Marsh EB. Keep it simple: vascular risk factors and focal exam findings correctly identify posterior circulation ischemia in “dizzy” patients. BMC Emergency Medicine 2016;16(1):8-16.
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{2014}

Stuttering Lacunes: An Acute Role for Clopidogrel?

Our experience suggests that acutely loading with clopidogrel may be both effective and well tolerated in the treatment of stuttering lacunes.

Marsh EB, Llinas RH. Stuttering lacunes: an acute role for clopidogrel? Journal of Neurology and Translational Neuroscience 2014;2(1):1035-1038.
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{2012}

Diagnosing CNS Vasculitis: The Case Against Empiric Treatment

We report a case series of 5 patients who were admitted or transferred to the Johns Hopkins Hospital with a clinical history and magnetic resonance imaging findings suggestive of primary central nervous system vasculitis (PCNSV). Four patients had received at least 1 course of immunosuppression with high-dose intravenous (IV) corticosteroids and/or a corticosteroid-sparing agent. Each underwent an extensive workup including 4-vessel cerebral angiography and, in the majority of cases, brain biopsy to evaluate for mimics of PCNSV. In each of the 5 cases, an alternative diagnosis was found.

We propose a cautious, multistep approach to the diagnosis of PCNSV, which takes into account more common diagnoses and avoids the pitfalls of empiric treatment.

Marsh EB, Zeiler SR, Levy M, Llinas RH, Urrutia VC. Diagnosing CNS Vasculitis: the case against empiric treatment. The Neurologist 2012;18(4): 233-238.
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