Monmouth Neuroscience at the 2014 NJ Stroke Conference

We are happy to report that Monmouth’s stoke program was well represented at the 2014 New Jersey Stroke Conference earlier this month.

Two department of medicine residents, Drs Amor and Chan, presented our TIA center data in the poster session:

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Dr Holland gave a talk on the role of telemedicine in stroke rehabilitation.

Dr Holland and Monmouth Neuroscience Institute’s TIA Rapid Evaluation Center Honored at the 2013 Heart Ball

The American Heart Association and American Stroke Association gathered to recognize Dr. Neil Holland and Dr. June Duck as this year’s medical honorees at the annual Heart Ball on June 21 at the Ocean Place Resort and Spa in Long Branch.

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Drs Holland and Duck with their awards.

Dr. Holland was recognized for excellence in stroke care. Commended for his role in developing a TIA and Minor Stroke Rapid Evaluation Center, Dr. Holland has focused care to optimize stroke prevention without the need for hospitalization in high-risk patients.

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The Monmouth TIA Center Team – L to R – Neuroscience ARNP Florence Armour, Hospital VP Shirley Hwang, Program Director Dr Holland, Neuroscience Coordinator Felesia Swanson & Dept of Medicine Chairman Dr Allan Tunkel

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Dr Holland with his partners – L to R – Drs Gennaro, Anayiotos, Gilson, Holland, Herman, Davis, Mendelson & Ponce.
The success of the TIA Center is the result of close cooperation between hospital administration, all of the doctors in the practice, the Emergency Room, and many many other members of the hospitals medical and technical staff.

Find out about Monmouth’s Stroke Service and TIA Center.

Monmouth Stroke Awareness Month Event, May 15 2013, 12pm

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Join us for a FREE education event

WHEN – Wednesday May 15, 2013 12-1pm

WHERE – Long Branch Senior Center

Dr Neil Holland, Medical Director of the Stroke Program and Neuroscience Institute, Monmouth Medical Center

Nanette DeLeon, Registered Dietician, Monmouth Medical Center

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Learn about:

The warning signs and symptoms of a stroke,

How urgent care is crucial in saving lives and preventing disability,

The telltale symptoms of transient ischemic attack, sometimes referred to as “mini-stroke”,

Nutrition for stroke prevention.

CALL 732 571 6542 To Register!

Click here for directions.

Find out more about: the Monmouth Stroke Center, Monmouth TIA center, Strokes and TIAs.

So you have carotid stenosis, should you have surgery?

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Carotid endarterectomy is surgery to remove atheroma (plaque build up) that causes narrowing (stenosis) in the artery to lower the risk for future TIA (transient ischemic attack) and stroke.

So, it seems simple, you’ve been found to have carotid artery disease, you have surgery to “fix it” and reduce your future stroke risk, right?

Well, you guessed it, it’s not that easy.

First, some facts about carotid artery disease and stroke:

Each carotid endarterectomy surgery costs about $15,000.

When you undergo surgery, there is a surgical risk (of stroke or death) which you pay up front, in exchange for a cumulative annual stroke rate reduction (%/yr) for the remainder of your life.

A good analogy is taking out a mortgage.  Doing surgery can be compared to paying points on your new mortgage to lower the future interest rate.  Your more likely to do it for a 20y that for a 5y mortgage.

Whether the benefits of surgery exceed the risk, whether it is worth paying points on your mortgage, and will depend on:
1. The actual risk of surgical complications at your center
2. Your age (i.e. future life expectancy),
3. The degree of carotid stenosis,
4. Most importantly, if you have had a TIA or stroke in the vascular territory of the affected artery within the previous 6-months – referred to as a symptomatic carotid stenosis.

This is how the degree of carotid stenosis is calculated, 1-a/c * 100:
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FOR A SYMPTOMATIC CAROTID STENOSIS ≥70%
Surgery will reduce the risk of stroke from 26 to 9% over 2yrs
That’s a “relative risk reduction of 60%”
You have to treat 6 pts to prevent 1 stroke/2yr
Or, treat 2.4 pts to prevent 1 stroke/5yrs

FOR A SYMPTOMATIC CAROTID STENOSIS 50-70%
Surgery will reduce the risk of stroke from 22 to 16% over 5 yrs
That’s a “relative risk reduction of 30%”
You have to treat 16 pts to prevent 1 stroke/5yrs

FOR AN ASYMPTOMATIC CAROTID STENOSIS ≥ 60%
Surgery will reduce the Risk of stroke from 10 to 5% over 5yr
That’s a “relative risk reduction of 50%”
But, you have to treat 20 pts to prevent 1 stroke/5yrs

FOR AN ASYMPTOMATIC CAROTID STENOSIS <60%
There is no benefit from surgery

The above data is abstracted from the NASCET and ACAS studies, and are based on a surgical complication rate of <6% for symptomatic and <3% for asymptmatic cases. Complication rates can be as high as 10% at some centers. Click here to find your hospital, and look up the complication rate from carotid surgery.

All patients with symptomatic carotid stenoses >70% are probably going to benefit from surgery, even more so if they get to surgery within 2 weeks of their TIA or stroke.

Most patients with symptomatic carotid stenoses in the 50-70% range will benefit from surgery, if it is done at a center where the surgical complication rate is <6%, and they have a life expectancy of >5 years.

The benefits of surgery for an asymptomatic carotid stenosis identified on a routine screening study are much less certain. You can bet the surgeon will tell you that he/she can reduce your future stroke risk by 50%, but all they are really doing is increasing your chance of not having a stroke from 90 to 95% over the next 5 years, so if you are in your 80s or at a center where the complication rate from surgery is >5%, you’re probably not going to break even, and would do better to stick with medical therapy.

Remember to ask these questions before signing up for surgery.

Radiation from unnessary CT scans

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CT or CAT (Computed axial tomography) scans use computer processed rotating x-ray images to create a detailed cross-sectional image (tomograph) of an organ or body part.

The use of CT has increased exponentially over the last 20 years, and more than 72 million scans were performed in the United States in 2007 compared to only 3 million in 1980.

The use of CT scanning only continues to grow. Doctors are increasing using chest CT to screen for lung cancer, CT based “virtual” colonoscopies to check for colon cancer, CT angiography of the coronary arteries in place of simple exercise stress tests, and CT angiography of the carotid arteries in place of safer duplex ultrasound and MR (magnetic resonance) angiography.

The radiation exposure from a sigle CT scan is equivalent to about 750 chest x-rays.

It is estimated that 0.4% of current cancers in the United States may be from exposure to radiation from CTs performed in the past, and that this may increase to 2% (or 29000 future cancers) as a consequence of 2007 rates of CT usage.

Click here to link Dr Eric Topol’s recent Medscape commentary on the runaway use of CTs.

Click here for a recent Washington Post article on the risk of repeated CT scans in children.

Click here for a statement from the American Academy of Neurology on unnecessary diagnostic testing.

CT can still have some advantages over MR imaging of the brain – it is more readily available and faster in the emergency setting, and can be done in patients who have a contraindication to MR imaging like a pacemaker or other metal implant.

However, it is one of our goals at Monmouth Neuroscience Institute to reduce unnecessary diagnostic testing wherever possible. We strive to avoid doing both CT and MR scans on neurological patients by seeing TIA patients  in our outpatient TIA Rapid Evaluation Center(TREC).  TREC patients can avoid an emergency room visit and CT scan in favor of an elective MR scan, which not only gives  more information, but also avoids an unnecessary dose of radiation.