J N Goldstein

Publications (7)36.28 Total impact

• Article: Warfarin-related intraventricular hemorrhage: imaging and outcome.

  A Biffi, T W K Battey, A M Ayres, L Cortellini, K Schwab, A J Gilson, N S Rost, A Viswanathan, J N Goldstein, S M Greenberg, J Rosand
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  ABSTRACT: Oral anticoagulation therapy (OAT) with warfarin increases mortality and disability after intracerebral hemorrhage (ICH), the result of increased ICH volume and risk of hematoma expansion. We investigated whether OAT also influences risk of development of intraventricular hemorrhage (IVH), the volume of IVH and IVH expansion, and whether IVH is a substantive mediator of the overall effect of OAT on ICH outcome. We performed a retrospective analysis of a prospectively collected single-center cohort of 1,879 consecutive ICH cases (796 lobar, 865 deep, 153 cerebellar, 15 multiple location, 50 primary IVH) from 1999 to 2009. ICH and IVH volumes at presentation, as well as hematoma expansion (>33% or >6 mL increase) and IVH expansion (>2 mL increase), were determined using established semiautomated methods. Outcome was assessed at 90 days using either the modified Rankin Scale or Glasgow Outcome Scale. Warfarin use was associated with IVH risk, IVH volume at presentation, and IVH expansion in both lobar and deep ICH (all p < 0.05) in a dose-response relationship with international normalized ratio. Warfarin was associated with poor outcome in both lobar and deep ICH (p < 0.01), and >95% of this effect was accounted for by baseline ICH and IVH volumes, as well as ICH and IVH expansion. Warfarin increases IVH volume and risk of IVH expansion in lobar and deep ICH. These findings (along with effects on ICH volume and expansion) likely represent the mechanisms by which anticoagulation worsens ICH functional outcome.
  Neurology 11/2011; 77(20):1840-6. · 8.31 Impact Factor
• Article: Statin use and outcome after intracerebral hemorrhage: case-control study and meta-analysis.

  A Biffi, W J Devan, C D Anderson, A M Ayres, K Schwab, L Cortellini, A Viswanathan, N S Rost, E E Smith, J N Goldstein, S M Greenberg, J Rosand
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  ABSTRACT: Intracerebral hemorrhage (ICH) is a highly lethal disease of the elderly. Use of statins is increasingly widespread among the elderly, and therefore common in patients who develop ICH. Accumulating data suggests that statins have neuroprotective effects, but their association with ICH outcome has been inconsistent. We therefore performed a meta-analysis of all available evidence, including unpublished data from our own institution, to determine whether statin exposure is protective for patients who develop ICH. In our prospectively ascertained cohort, we compared 90-day functional outcome in 238 pre-ICH statin cases and 461 statin-free ICH cases. We then meta-analyzed results from our cohort along with previously published studies using a random effects model, for a total of 698 ICH statin cases and 1,823 non-statin-exposed subjects. Data from our center demonstrated an association between statin use before ICH and increased probability of favorable outcome (odds ratio [OR] = 2.08, 95% confidence interval [CI] 1.37-3.17) and reduced mortality (OR = 0.47, 95% CI 0.32-0.70) at 90 days. No compound-specific statin effect was identified. Meta-analysis of all published evidence confirmed the effect of statin use on good outcome (OR = 1.91, 95% CI 1.38-2.65) and mortality (OR = 0.55, 95% CI 0.42-0.72) after ICH. Antecedent use of statins prior to ICH is associated with favorable outcome and reduced mortality after ICH. This phenomenon appears to be a class effect of statins. Further studies are required to clarify the biological mechanisms underlying these observations.
  Neurology 03/2011; 76(18):1581-8. · 8.31 Impact Factor
• Article: Frequency of adequate contrast opacification of the major intracranial venous structures with CT angiography in the setting of intracerebral hemorrhage: comparison of 16- and 64-section CT angiography techniques.

  J E Delgado Almandoz, H S Su, P W Schaefer, J N Goldstein, S R Pomerantz, M H Lev, R G González, J M Romero
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  ABSTRACT: DVST is an important cause of ICH because its treatment may require anticoagulation or mechanical thrombectomy. We aimed to determine the frequency of adequate contrast opacification of the major intracranial venous structures in CTAs performed for ICH evaluation, which is an essential factor in excluding DVST as the ICH etiology. Two readers retrospectively reviewed CTAs performed in 170 consecutive patients with ICH who presented to our emergency department during a 1-year period to determine by consensus whether qualitatively, contrast opacification in each of the major intracranial venous structures was adequate to exclude DVST. "Adequate contrast opacification" was defined as homogeneous opacification of the venous structure examined. "Inadequate contrast opacification" was defined as either inhomogeneous opacification or nonopacification of the venous structure examined. Delayed scans, if obtained, were reviewed by the same readers blinded to the first-pass CTAs to determine the adequacy of contrast opacification in the venous structures according to the same criteria. In patients who did not have an arterial ICH etiology, the same readers determined if thrombosis of an inadequately opacified intracranial venous structure could have potentially explained the ICH by correlating the presumed venous drainage path of the ICH with the presence of inadequate contrast opacification within the venous structure draining the venous territory of the ICH. CTAs were performed in 16- or 64-section CT scanners with bolus-tracking, scanning from C1 to the vertex. Patients with a final diagnosis of DVST were excluded. We used the Pearson χ(2) test to determine the significance of the differences in the frequency of adequate contrast opacification within each of the major intracranial venous structures in scans obtained using either a 16- or 64-section MDCTA technique. Fifty-eight patients were evaluated with a 16-section MDCTA technique (34.1%) and 112 with a 64-section technique (65.9%). Adequate contrast opacification within all major noncavernous intracranial venous structures was significantly less frequent in first-pass CTAs performed with a 64-section technique (33%) than in those performed with a 16-section technique (60%, P value < .0001). Delayed scans were obtained in 50 patients, all of which demonstrated adequate contrast opacification in the major noncavernous intracranial venous structures. In 142 patients with supratentorial or cerebellar ICH without an underlying arterial etiology, we found that thrombosis of an inadequately opacified major intracranial venous structure could have potentially explained the ICH in 38 patients (26.8%), most examined with a 64-section technique (86.8%). Inadequate contrast opacification of the major intracranial venous structures is common in first-pass CTAs performed for ICH evaluation, particularly if performed with a 64-section technique. Acquiring delayed scans appears necessary to confidently exclude DVST when there is strong clinical or radiologic suspicion.
  American Journal of Neuroradiology 02/2011; 32(5):839-45. · 2.93 Impact Factor
• Article: Practical scoring system for the identification of patients with intracerebral hemorrhage at highest risk of harboring an underlying vascular etiology: the Secondary Intracerebral Hemorrhage Score.

  J E Delgado Almandoz, P W Schaefer, J N Goldstein, J Rosand, M H Lev, R G González, J M Romero
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  ABSTRACT: An ICH patient's risk of harboring an underlying vascular etiology varies according to baseline clinical and NCCT characteristics. Our aim was to develop a practical scoring system to stratify patients with ICH according to their risk of harboring a vascular etiology. Using a data base of 623 patients with ICH evaluated with MDCTA during a 9-year period, we developed a scoring system based on baseline clinical characteristics (age group [0-2 points], sex [0-1 point], neither known HTN nor impaired coagulation [0-1 point]), and NCCT categorization (0-2 points) to predict the risk of harboring a vascular lesion as the ICH etiology (SICH score). We subsequently applied the SICH score to a prospective cohort of 222 patients with ICH who presented to our emergency department during a 13-month period. Using ROC analysis, we calculated the AUC and MOP for the SICH score in both the retrospective and prospective patient cohorts separately and the entire patient population. Patients with SAH in the basal cisterns were excluded. A vascular etiology was found in 120 of 845 patients with ICH evaluated with MDCTA (14.2%), most commonly AVMs (45.8%), aneurysms with purely intraparenchymal rupture (21.7%), and DVSTs (16.7%). The MOP was reached at a SICH score of >2, with the highest incidence of vascular ICH etiologies in patients with SICH scores of 3 (18.5%), 4 (39%), 5 (84.2%), and 6 (100%). There was no significant difference in the AUC between both patient cohorts (0.86-0.87). The SICH score successfully predicts a given ICH patient's risk of harboring an underlying vascular etiology and could be used as a guide to select patients with ICH for neurovascular evaluation to exclude the presence of a vascular abnormality.
  American Journal of Neuroradiology 10/2010; 31(9):1653-60. · 2.93 Impact Factor
• Article: Validation of the Quick Confusion Scale for mental status screening in the emergency department.

  T O Stair, J Morrissey, I Jaradeh, T X Zhou, J N Goldstein
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  ABSTRACT: The Mini-Mental Status Exam (MMSE) is a commonly used assessment of cognitive status; however, it has been considered somewhat unwieldy for use in the emergency department (ED). An alternate test, the Quick Confusion Scale (QCS), has been compared against the MMSE in a single centre. We hypothesised that the QCS would strongly correlate with the MMSE in the ED, but could be administered more quickly. Trained research assistants administered both the QCS and the MMSE to a convenience sample of 666 patients and visitors in an urban academic ED. Patients were randomised as to which test would be administered first. The QCS required less time to complete than the MMSE (2.7+/-1.3 vs. 5.1+/-1.9 min, p<0.0001). Nine patients could not complete the MMSE because they could not use their hands to write and four because of vision impairment. Correlation of QCS and MMSE scores was fair, with Pearson's r=0.61 (95% CI, 0.56-0.66). The QCS can be administered more quickly than the MMSE, and is easier to administer in the ED because it does not require the subject to read, write or draw. There is a fair correlation between QCS and MMSE scores.
  Internal and Emergency Medicine 07/2007; 2(2):130-2. · 2.06 Impact Factor
• Article: Contrast extravasation on CT angiography predicts hematoma expansion in intracerebral hemorrhage.

  J N Goldstein, L E Fazen, R Snider, K Schwab, S M Greenberg, E E Smith, M H Lev, J Rosand
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  ABSTRACT: Patients with acute intracerebral hemorrhage (ICH) presenting within 3 hours of symptom onset are known to be at increased risk of expansion. However, only a minority arrive within this time frame. Therefore, alternative markers for expansion risk are needed. To examine whether contrast extravasation on CT angiography (CTA) at presentation predicts subsequent hematoma expansion. Consecutive patients with primary ICH presenting to an urban tertiary care hospital were prospectively captured in a database. We retrospectively reviewed images for all patients receiving a CTA and at least one further CT scan within 48 hours. Complete data were available for 104 patients. Contrast extravasation at the time of CTA was present in 56% of patients, and associated with an increased risk of hematoma expansion (22% vs 2%, p = 0.003). Patients who received a baseline CTA within 3 hours were more likely to have subsequent expansion (27%, vs 13% for those presenting later, p = 0.1). However, after multivariable analysis, contrast extravasation was the only significant predictor of hematoma expansion (OR 18, 95% CI 2.1 to 162). This effect was independent of time to presentation. Contrast extravasation is independently associated with hematoma expansion. Patients presenting within the first few hours after symptom onset have traditionally been considered those at highest risk of expansion. However, for those presenting later, the presence of contrast may be a useful marker to guide therapies aimed at decreasing this risk.
  Neurology 04/2007; 68(12):889-94. · 8.31 Impact Factor
• Article: Headache in United States emergency departments: demographics, work-up and frequency of pathological diagnoses.

  J N Goldstein, C A Camargo, A J Pelletier, J A Edlow
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  ABSTRACT: Headache is a common complaint in the emergency department (ED). In order to examine headache work-ups and diagnoses across the USA, we queried a representative sample of adult ED visits (the National Hospital Ambulatory Medical Care Survey) for the years 1992-2001. Headache accounted for 2.1 million ED visits per year (2.2% of visits). Of the 14% of patients who underwent neuroimaging, 5.5% received a pathological diagnosis. Of the 2% of patients who underwent lumbar puncture, 11% received a pathological diagnosis. On multivariable analysis, a decreased rate of imaging was noted for patients without private insurance [odds ratio (OR) 0.61, confidence interval (CI) 0.44, 0.86] and for those presenting off-hours (OR 0.55, CI 0.39, 0.77). Patients over 50 were more likely to receive a pathological diagnosis (OR 3.3, CI 1.2, 9.3). In conclusion, clinicians should ensure that appropriate work-ups are performed regardless of presentation time or insurance status, and be vigilant in the evaluation of older patients.
  Cephalalgia 07/2006; 26(6):684-90. · 3.43 Impact Factor