Papers by Angela Shapshak
Diffuse axonal injury (DAI) is a type of traumatic brain injury (TBI) that results from a blunt i... more Diffuse axonal injury (DAI) is a type of traumatic brain injury (TBI) that results from a blunt injury to the brain . In the United States, traumatic brain injury is a leading cause of death and disability among children and young adults. The Center for Disease Control and Prevention (CDC) estimates that there are over 1.5 million reported cases of traumatic brain injury every year in the United States. Traumatic brain injury is classified as mild, moderate, and severe based on the Glasgow coma scale (GCS). Traumatic brain injury patients with GCS of 13 to 15 are classified to be mild, which includes the majority of traumatic brain injury patients. Patients with a GCS of nine to 12 are considered to have a moderate traumatic brain injury, while patients with GCS below eight are classified as having a severe traumatic brain injury.The GCS measures the following three functions:Diffuse axonal injury (DAI) primarily affects the white matter tracts in the brain. Clinically, patients wit...
Springer eBooks, 2010
ABSTRACT Acute myelopathy is a broad term used to describe spinal cord dysfunction of sudden, rec... more ABSTRACT Acute myelopathy is a broad term used to describe spinal cord dysfunction of sudden, recent onset Diagnostic possibilities are ample, but practicing neurointensivists deal mainly with traumatic and inflammatory myelopathies Main objective in the initial management is to differentiate those patients who could benefit from acute surgical intervention (compressive myelopathies) from those patients who require medical management KeywordsMyelopathies-TM-Traumatic SCI
Stroke, 2017
Background and Purpose: Cerebral edema is known to contribute to clinical decline in patients wit... more Background and Purpose: Cerebral edema is known to contribute to clinical decline in patients with spontaneous ICH. We sought to evaluate the significance of cerebral edema on outcome in young patients with primary ICH. Methods: We performed a retrospective review of patients presenting to our CSC center from 2014-2015 with primary ICH, excluding patients with lobar ICH and age 55 and above. Patients were grouped according to functional outcome at discharge (mRS 0-3 vs. 4-6). Imaging characteristics of those with poor short-term functional outcome (mRS 4-6) were compared to those with mRS 0-3. Receiver Operating Characteristics curves were used to evaluate the discriminatory ability of imaging characteristics with regards to poor functional outcome. Results: A total of 38 patients met inclusion criteria (mean age 47, 42% black, 55% male). On presentation, patients with poor functional outcome had larger mean ICH volume (26 vs 9cc; p=0.020), higher ICH volume to edema volume ratios (...
Neurology, Apr 10, 2018
Objective: To evaluate the trends and predictors of utilization of intra-arterial thrombectomy (I... more Objective: To evaluate the trends and predictors of utilization of intra-arterial thrombectomy (IAT) over an 8 year period. Background: IAT has recently been approved for acute treatment of ischemic strokes (IS). With the advent of several new devices for IAT, this procedure has become more widely utilized with better outcomes. Design/Methods: Analysis of Nationwide Inpatient Sample data (2006–2013) showed a total of 850,997 patients discharged with primary diagnosis of IS, ICD-9 Code 433.xx and 434.xx. IAT was ascertained by ICD-9 procedure code 39.74. Independent predictors of IAT were studied using binary logistic regression. The predictors included in the model were age, sex, race, teaching status, and insurance type. Results: 4903 or 0.6% of IS patients received IAT. Mean age of patients receiving thrombolysis was 71.01 years. Percentage of IS patients receiving IAT has consistently increased from 0.037% in 2006 to 1% in 2013. We also observed significant year to year decrease in mortality among patients receiving IAT. In 2006, 26.2% of IAT patients died as compared to 15.8% in 2013. Using binary logistic regression, the statistically significant independent predictors of IAT utilization were Age (OR= 0.978, p=0.000), Female gender (OR=1.120, p=0.019), Insurance type as compared to Medicare (Private insurance OR=1.199 p=0.006, and self-pay OR=0.778 p=0.05). As compared to Caucasians, African Americans were less likely to receive treatment (OR=0.531 p=0.000). Also, a teaching hospital was found to be more likely to administer IAT as compared to a non-teaching hospital (OR = 5.941, p=0.000). Conclusions: IS patients with younger age, female gender, private insurance and patients admitted to teaching hospitals are more likely and African Americans are less likely to receive IAT. This study showed that IAT utilization has increased significantly since 2006 with a steep decline in the in-hospital mortality. This may point to improved IAT devices and better patients’ selection. Disclosure: Dr. Hamer has nothing to disclose. Dr. Gupta has nothing to disclose. Dr. Lobbous has nothing to disclose. Dr. Benesh has nothing to disclose. Dr. Hays Shapshak has nothing to disclose.
Neuro-oncology, Nov 1, 2018
NEURO-ONCOLOGY • NOVEMBER 2018 models. RESULTS: 949 adult patients were included. Median follow-u... more NEURO-ONCOLOGY • NOVEMBER 2018 models. RESULTS: 949 adult patients were included. Median follow-up was 43 months (range: 3-78 months). Gross total resection (GTR) was achieved in 719 (75.8%) patients, adjuvant radiotherapy was applied in 91 (9.9%) patients. Brain invasion was diagnosed by histology in 24 (2.5%) patients. Patients with/without brain invasion did not differ in terms of age and extent of resection. Patients with histologically proven brain invasion received more often adjuvant radiotherapy (p=0.02). 88 patients experienced tumor recurrence, overall survival was not reached in the majority of patients. The overall median PFS for patients with (without) brain invasion was 22 (23) months (p=0.48). In Subtotal resection and history of another malignancy were associated with shorter PFS in univariate and multivariate models (p<0.001), but neither brain invasion nor radiotherapy. CONCLUSION: Among meningiomas classified as grade I according to the WHO 2007 grading system, histological proven brain invasion is rare and was not associated with worse prognosis in contrast to extent of resection and history of another malignancy. However, whether postoperative radiotherapy might have been beneficial for these patients has to be analysed prospectively.
Neurology, Apr 10, 2018
Objective: This study seeks to evaluate predictors of thrombolysis utilization in patients with I... more Objective: This study seeks to evaluate predictors of thrombolysis utilization in patients with IS. Background: Ischemic stroke (IS) is a highly prevalent condition associated with high rates of death and disability. Thrombolytic treatment is one of the few FDA approved treatments for this devastating condition. Design/Methods: Analysis of the Nationwide Inpatient Sample data (2003–2013) showed a total of 1,168,847 patients discharged with a primary diagnosis of IS, ICD-9 Code 433.xx and 434.xx. Thrombolytic infusion was ascertained by ICD-9 procedure code 99.10. Independent predictors of thrombolytic treatment were studied using binary logistic regression. The predictors included in the model were age, sex, race, teaching status, and insurance type. Results: 3.2% of patients with IS received thrombolytic treatment. Mean age of patients receiving thrombolysis was 69.21 years. Using binary logistic regression, the statistically significant independent predictors were Age (OR= 0.996, p=0.000), Female gender (OR=1.036, p=0.041), Insurance type as compared to Medicare (Medicaid OR =1.128 p=0.002, private insurance OR=1.216 p=0.000, and self-pay OR=1.162 p=0.001). As compared to Caucasians, African Americans were less likely to receive treatment (OR=0.884 p=0.000). Also, teaching hospitals were found to be more likely to administer thrombolysis as compared to a non-teaching hospitals (OR = 1.685, p=0.000). Conclusions: In this representative national sample, African-American race, advanced age, male gender and Medicare insurance status were associated with lower odds of receiving thrombolysis for acute IS. Patients presenting to teaching hospitals, as compared to those treated at non-teaching hospitals, were more likely to receive thrombolytic therapy. Further prospective studies are warranted to better understand the disparities in treatment utilization for these patient cohorts. Disclosure: Dr. Benesh has nothing to disclose. Dr. Gupta has nothing to disclose. Dr. Lobbous has nothing to disclose. Dr. Hays Shapshak has nothing to disclose.
Journal of the South Carolina Medical Association (1975)
Stroke, 2016
Introduction: The 2015 AHA guidelines for ICH management state that initial care of ICH patients ... more Introduction: The 2015 AHA guidelines for ICH management state that initial care of ICH patients should take place in an “ICU or a dedicated stroke unit with physician and nursing neuroscience acute care expertise”. This approach entails transferring ICH patients from community hospitals to centers with stroke expertise. Hypothesis: We explored national trends in transfer of ICH patients to teaching hospitals, and evaluated the differences in demographic, co-morbidity, resource utilization factors, and outcomes for transferred patients (TP) vs. directly admitted patients (DAP). Methods: From the National Inpatient Sample data for years 2006 to 2011, we identified patients with primary diagnosis of ICH (ICD-9 431). We assessed linear trends in the proportion of patients transferred over time using logistic regression. We constructed multivariate logistic regression models to explore the association of transfer status with inpatient mortality after controlling for significant factors....
Stroke, 2015
Background&Purpose: Low serum albumin is associated with poor outcomes in ischemic stroke. Albumi... more Background&Purpose: Low serum albumin is associated with poor outcomes in ischemic stroke. Albumin levels are a marker of nutritional status; albumin also has neuro-protective effects. The role of serum albumin in outcomes in patients with ICH has not been investigated. We examined the association between initial admission albumin and functional outcome at discharge. Subjects&Methods: Consecutive patients (2008 - 2013) diagnosed with primary ICH at our academic stroke center in the Southeast US were retrospectively analyzed. Demographics, initial lab values, and ICH scores were recorded. A poor outcome was defined as mRS 4-6 at discharge. Eligible patients were divided into two groups based on ICH score (0-2 and 3-6). Statistical significance was determined using logistic regression. Results: A total of 103 patients met inclusion criteria (mean age 63, 45% women, 49% black). In patients with an ICH score of 0-2 (n=85), higher albumin was associated with lower odds of poor functional...
Stroke, 2012
Objectives: The Neuroscience stroke telemedicine program of the Medical University of South Carol... more Objectives: The Neuroscience stroke telemedicine program of the Medical University of South Carolina (REACH MUSC) is a robust network of 15 sites served by an academic hub in Charleston. South Carolina’s Health Information Exchange (SCHIEx) collects and displays data from all hospital discharges and emergency room visits. At present, our REACH MUSC stroke consults, like most, are not connected to a central electronic medical record or Health Information Exchange (HIE) like SCHIEx. We used our first 250 REACH MUSC consults to estimate the value to a stroke telemedicine consult of a hypothetical “real time” connection to an HIE. Methods: After IRB approval, names and identifying information of the first 250 consecutive REACH MUSC stroke consults were provided to the SC Office of Research and Statistics for analysis, along with 10 prespecified questions of interest based on their presumed value in the stroke setting (e.g. “can a history of atrial fibrillation be found?”). A retrospecti...
Stroke, 2015
Background and Purpose: In patients with primary ICH, RBC transfusion (RBCT) may be detrimental a... more Background and Purpose: In patients with primary ICH, RBC transfusion (RBCT) may be detrimental and platelet transfusion effects are controversial. Different transfusion thresholds have been suggested in patients with coronary artery disease (CAD). We examined the relationship between transfusion and outcomes in ICH patients with and without CAD. Methods: A retrospective review of consecutive patients with primary ICH admitted to two academic stroke centers from 2008-2013 was conducted. Patients age<18 years, in-hospital strokes and outside hospital transfers were excluded. Primary outcome was discharge mRS of 5-6. Logistic regression was used to assess the association with outcomes. Results: Out of 456 patients identified, 50 (11.2%) had CAD on admission. CAD patients were older (68 vs. 61; p=0.001). There was no significant difference in frequency of RBCT between patients who had CAD compared to those without (6% vs. 9%; p=0.53). The frequency of platelet transfusion was higher...
Stroke, 2016
Background and Objective: Transcranial Doppler (TCD) is endorsed by the American Heart Associatio... more Background and Objective: Transcranial Doppler (TCD) is endorsed by the American Heart Association/American Stroke Association, the American Academy of Neurology, and the Neurocritical Care Society for use in aneurysmal subarachnoid hemorrhage (aSAH) for surveillance of cerebral vasospasm (CV). However, data on utilization of TCD for CV detection and monitoring in aSAH are lacking. We estimated the proportion of patients with aSAH receiving TCD monitoring using the Nationwide Inpatient Sample (NIS). Methods: Data from 2002-2011 NIS were used to calculate the number of discharges with a primary diagnosis of aSAH per 100,000 discharges. Descriptive analysis of nationwide trends in TCD prevalence was performed. Teaching hospitals were examined separately for TCD utilization rates and this was done biennially to prevent small numbers. Results: Between 2002 and 2011, a total of 256,089 patients were discharged with a diagnosis of aSAH of which 3,850 underwent TCD monitoring. aSAH account...
Stroke, 2016
Background and Objective: Transcranial Doppler (TCD) is endorsed by the American Heart Associatio... more Background and Objective: Transcranial Doppler (TCD) is endorsed by the American Heart Association/American Stroke Association, the American Academy of Neurology, and the Neurocritical Care Society for use in aneurysmal subarachnoid hemorrhage (aSAH) for surveillance of cerebral vasospasm (CV). However, data on utilization of TCD for CV detection and monitoring in aSAH are lacking. We estimated the proportion of patients with aSAH receiving TCD monitoring using the Nationwide Inpatient Sample (NIS). Methods: Data from 2002-2011 NIS were used to calculate the number of discharges with a primary diagnosis of aSAH per 100,000 discharges. Descriptive analysis of nationwide trends in TCD prevalence was performed. Teaching hospitals were examined separately for TCD utilization rates and this was done biennially to prevent small numbers. Results: Between 2002 and 2011, a total of 256,089 patients were discharged with a diagnosis of aSAH of which 3,850 underwent TCD monitoring. aSAH account...
Molecular and Cellular Endocrinology, 2001
The regulation of glucocorticoid receptor gene expression by members of the AP-1 family was exami... more The regulation of glucocorticoid receptor gene expression by members of the AP-1 family was examined in glucocorticoid-free NIH3T3 cells transfected with the human glucocorticoid receptor gene promoter driving expression of a CAT reporter gene. c-Jun inhibited the promoter activity by 80% and JunB by 30%, whereas c-Fos and JunD had no inhibitory effect. Electrophoretic mobility shift assays showed that c-Jun is unable to efficiently interact with the AP-1-like site present in the human glucocorticoid receptor promoter. Moreover, c-Jun was still able to repress promoter mutants in which the region containing the AP-1-like site was deleted. NIH3T3 cell clones overexpressing c-Jun exhibited lower glucocorticoid receptor mRNA levels, which suggests that the murine glucocorticoid receptor gene can also be regulated by AP-1. These results provide a new mechanism for cross-talk between the glucocorticoid receptor and the AP-1 family of transcription factors in the absence of glucocorticoid ligands.
Neurocritical Care, 2010
Cerebral edema and raised intracranial pressure are common problems in neurological intensive car... more Cerebral edema and raised intracranial pressure are common problems in neurological intensive care. Osmotherapy, typically using mannitol or hypertonic saline (HTS), has become one of the first-line interventions. However, the literature on the use of these agents is heterogeneous and lacking in class I studies. The authors hypothesized that clinical practice would reflect this heterogeneity with respect to choice of agent, dosing strategy, and methods for monitoring therapy. An on-line survey was administered by e-mail to members of the Neurocritical Care Society. Multiple-choice questions regarding use of mannitol and HTS were employed to gain insight into clinician practices. A total of 295 responses were received, 79.7% of which were from physicians. The majority (89.9%) reported using osmotherapy as needed for intracranial hypertension, though a minority reported initiating treatment prophylactically. Practitioners were fairly evenly split between those who preferred HTS (54.9%) and those who preferred mannitol (45.1%), with some respondents reserving HTS for patients with refractory intracranial hypertension. Respondents who preferred HTS were more likely to endorse prophylactic administration. Preferred dosing regimens for both agents varied considerably, as did monitoring parameters. Treatment of cerebral edema using osmotically active substances varies considerably between practitioners. This variation could hamper efforts to design and implement multicenter trials in neurocritical care.
Critical Care Medicine, 2009
Neurocritical Care, 2010
Manganese encephalopathy is a potential complication of parenteral nutrition. Lack of early recog... more Manganese encephalopathy is a potential complication of parenteral nutrition. Lack of early recognition leads to unnecessary testing and to continued exposure to manganese. Case report and review of the literature. We describe the clinical and imaging findings of a patient with manganese encephalopathy in whom the diagnosis was delayed due to lack of recognition of the characteristic imaging findings. Manganese encephalopathy has protean clinical and imaging findings that can easily be overlooked.
Journal of Neurosurgery, 2011
Family history is a recognized risk factor in aneurysmal subarachnoid hemorrhage (SAH). The genet... more Family history is a recognized risk factor in aneurysmal subarachnoid hemorrhage (SAH). The genetic and environmental contributions are actively researched. The authors of this report present a case series of 3 first-degree siblings affected by nontraumatic, angiographically negative SAH. Data in this study suggest that familial predisposition may also apply to spontaneous, nonaneurysmal SAH and that family history should be actively investigated in all such patients. The identification of families with multiple affected members could lead to an improved understanding of the genetic and environmental factors associated with this condition.
The American surgeon, 2003
Synchronous malignancies are rare occurrences for which there may be a genetic link between two c... more Synchronous malignancies are rare occurrences for which there may be a genetic link between two cancers or which may be simply coincidental. Although glioblastoma multiforme and esophageal adenocarcinoma have few clinical similarities there are no known biochemical or genetic links between the two malignancies. This case discussion details the synchronous occurrences of these two lesions and highlights possible clinical, biochemical, and genetic commonalities.
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Papers by Angela Shapshak