As part of our research, we are interested in higher level cognitive processes such as attention and multi-tasking. Even after small strokes, these activities can become impaired. This results in the inability for previously high-functioning individuals (school teachers, musicians, CEOs) to re-integrate into their prior home and workplace environments. It results in divorce, loss of jobs, and poor quality of life. The cognitive difficulties seem to occur regardless of the location of the stroke, and the underlying cause is poorly understood. It may be because the brain functions as a network (in other words, 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 the University of Maryland and the National Institutes of Health to determine what is happening in the brain to impair cognition. Eligible patients with small strokes and difficulty with cognition on testing in our clinic travel to our partnering institutes 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. Our preliminary data are exciting! A 42-year-old executive presented to clinic with a small stroke, slow processing speed, and poor executive functioning that prohibited him from returning to work and leading meetings. The stroke itself did not explain his symptoms, but MEG showed diffuse abnormal activation within the frontal lobes, an important area for higher level processing (see left figure). These findings indicate that our hypotheses may be correct, but larger studies are needed. If we can determine the brain changes responsible for post-stroke cognitive impairment, we will be able to predict who is most likely to recover, devise better treatment strategies, and promote faster and fuller recovery after stroke.
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.
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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