The Bayview Stroke Intervention Clinic (BaSIC)
Dr. Marsh is the Medical Director of Bayview Medical Center’s Stroke Program and, along with Dr. Rafael Llinas, runs The Bayview Stroke Intervention Clinic (BaSIC). BaSIC is a multidisciplinary outpatient clinic. Patients are seen within 4-6 weeks of their discharge from the Bayview Neurology Service so that key follow-up issues including post-stroke depression and fatigue can be addressed; persistent symptoms managed; and medications reconciled. Patients and families have the opportunity to see their stroke on neuroimaging, with the goal of truly understanding why the stroke occurred and the best way to decrease the chance of a future event. Our multidisciplinary approach allows for those with continued needs to be directly linked to our rehabilitation services. The program has already led to higher post-discharge follow-up rates, better adherence to risk factor modification strategies, and decreased rates of re-hospitalization.
In addition to patient care, BaSIC also serves as a clinical research environment focused on stroke outcomes. Together, we are identifying critical gaps in the knowledge of stroke recovery. Our long-term goal is to enhance post-stroke care by improving both symptomatic recovery and patient-centered outcomes. We are currently investigating factors related to cognitive decline post-stroke, and the influence of post-stroke depression, fatigue, and persistent symptoms on long-term recovery and quality of life for both patients and their families.
Magnetoencephalography- As part of our research, we are interested in higher level cognitive processes, such as attention and multi-tasking. After even small strokes these activities can become impaired. It may be because the brain functions as a network and you require all of your brain to be functioning normally to be at your best. In order to determine if this is the case and how connections change after stroke, we are partnering with New York University. Eligible patients with small strokes and difficulty with cognition on testing in our clinic travel to NYU where they undergo magnetoencephalography (MEG). Similar to an MRI, the MEG records which areas of the brain are active during various activities. Testing is performed about 1 month after stroke and repeated at 6 months. If we can determine the brain changes responsible for post-stroke cognitive impairment, we may be able to devise better treatment strategies to promote recovery.
Predicting Intracranial Hemorrhage: The HeRS score
Intracranial hemorrhage (ICH) is a devastating neurologic event. One form of ICH is hemorrhagic transformation of ischemic stroke (HT), which typically occurs in the days immediately following the infarct. HT often results in neurologic deficits, long-term disability, or death. It is unknown whether all types of ICH share common risk factors. The ability to predict who is at highest risk for HT and ICH is important to clinicians, particularly when considering treatment with anticoagulation, a common occurrence given the increasing frequency of patients with atrial fibrillation, blood clots, and mechanical valves. Anticoagulation itself likely increases risk of HT, making this group a potentially high-risk patient population. Until recently, no clinical tool existed to accurately estimate risk. Using a retrospective cohort of inpatients with acute stroke with an indication for anticoagulation, we found that age, infarct volume, and renal impairment are important predictors of HT. We created a Hemorrhage Risk Stratification (HeRS) score using these factors, specifically for the inpatient population, to allow physicians to quickly and accurately predict their patient’s individual risk of hemorrhagic conversion. This is useful not only to inform the clinical team and the patient of the expected risk, but also to guide treatment decisions. The HeRS score has been prospectively validated in a unique prospectively recruited inpatient cohort.
In collaboration with information technologist Peter Dziedzic, we have created an application available on iTunes that allows for quick and easy calculation of a patient’s HeRS score. The score provides a clinically useful and quantifiable risk estimate for hemorrhagic transformation in patients warranting anticoagulation, and may be used to guide treatment decisions when the need for anticoagulation is less clear.
Clinical Trial Keywords
Reversible Cerebral Vasoconstriction Syndrome (RCVS)
Reversible Cerebrovasoconstriction Syndrome: A Clinical Trial
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. Patients presenting to Johns Hopkins Hospital and Bayview Medical Center with signs and symptoms consistent with RCVS are currently being enrolled in a clinical trial comparing two standard treatments: short acting nimodipine given every 4 hours, and longer acting verapamil given every 12 hours. They undergo monitoring of the blood vessels using transcranial doppler ultrasound (TCD) and monitoring with neurological evaluations and pain scales. After discharge they return to the clinic at 90 days for a repeat evaluation including neuroimaging and assessment. We will evaluate which medication is most effective at reducing symptoms and preventing complications such as stroke or ICH and hope that results will lead to a standardized treatment for RCVS that optimizes good outcomes.