Professional Education

  • MD, Yale School of Medicine, Doctor of Medicine (2020)
  • MHS, Yale School of Medicine, Clinical Research (2020)
  • ScB, Brown University, Neuroscience (2014)

All Publications

  • Teaching Video NeuroImage: Infantile Upbeat Nystagmus as an Isolated Presentation of CACNA1F-Related Retinal Dystrophy. Neurology Silverman, A., Cheronis, C., Beres, S. 2024; 102 (9): e209416

    View details for DOI 10.1212/WNL.0000000000209416

    View details for PubMedID 38579184

  • Eye Toward Stroke Prevention: Central Retinal Artery Occlusion and Tandem Internal Carotid Artery Occlusion. Stroke Cheronis, C., Silverman, A., George, P. M. 2024

    View details for DOI 10.1161/STROKEAHA.123.045957

    View details for PubMedID 38511307

  • Impact of an Interactive, Animation-Based Electroencephalography Curriculum on Learner Confidence and Knowledge. Pediatric neurology Silverman, A., Hilgenberg, S., Shen, S., Spelbrink, E. M., Klotz, J. 2023; 151: 96-103


    BACKGROUND: There is a national need for innovative electroencephalography (EEG) education with efficacy evaluated by rigorous statistical analysis. We created a dynamic, online resource that includes a series of animated videos at a single academic medical center.METHODS: For the animations and interactive module, we used VideoScribe and Articulate, respectively. The module comprised three chapters: (1) Origin & Technical Aspects of EEG, (2) Normal Adult EEG in Wakefulness & Sleep, and (3) Abnormal EEG, with appendices on artifacts, variants, activation procedures, seizure/epilepsy classification, and neonatal/pediatric EEG. The curriculum and knowledge assessments were reviewed independently by two fellowship-trained physicians before distribution. Linear mixed-effects models with bootstrapping were used to compare paired pre- and post-tests as well as Likert scale questionnaires.RESULTS: Forty-nine learners participated in the pretest survey; 38 matched participants completed post-tests (78%). Learners across fields perceived benefit (100% would recommend to colleagues), indicated improved self-efficacy (P<0.0001), and performed better on post-test knowledge assessments (54.1 vs 88.2%, P<0.0001). In the neurology providers subgroup (n=20), pretest scores correlated with years in training (Spearman r=0.52, P=0.039), neurology rotations (r=0.70, P=0.003), epilepsy/EEG rotations (r=0.6, P=0.014), and EEG teaching hours (r=0.62, P=0.01); content knowledge and self-efficacy improvement for neurology providers remained significant in a multivariate model adjusting for these covariates.CONCLUSIONS: This animation-based, interactive EEG module proved effective in elevating learner confidence and knowledge across several medical specialties and training levels. Further study across institutions and subspecialties is needed to substantiate broad applicability, but our data appear promising for early EEG learners.

    View details for DOI 10.1016/j.pediatrneurol.2023.11.015

    View details for PubMedID 38141555

  • Clinical Problem Solving: A 38-year-Old Woman With Systemic Lupus Erythematosus Presenting With Headache, Nausea, and Vomiting. The Neurohospitalist Silverman, A., Dugue, R., George, P. M. 2023; 13 (4): 394-398


    A 38-year-old woman with migraine headaches and systemic lupus erythematosus with recent cessation of her immunosuppressive therapy presents with prolonged headache and hypertensive emergency. Her examination is notable for a peripheral right facial palsy and stable malar rash. There are no signs of systemic infection nor systemic symptoms of a lupus flare. Initial CT head reveals bilateral hypodensities in the basal ganglia. Within 8 hours of presentation, she develops right hemiplegia and becomes encephalopathic. MRI shows multifocal acute infarcts (most notably in the left basal ganglia), enhancement of the right facial nerve, and multifocal vessel wall enhancement in the anterior and posterior circulation. We discuss the differential diagnosis, comprehensive workup, and subsequent treatment decisions in the management of this immunocompromised patient with encephalopathy, headache, and rapidly progressing focal neurologic deficits.

    View details for DOI 10.1177/19418744231182285

    View details for PubMedID 37701245

    View details for PubMedCentralID PMC10494810

  • Images: Benign myoclonus of sleep associated with K-complexes on EEG. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Silverman, A., Miglis, M. G., Gallentine, W. 2023


    In this brief case report on paroxysmal sleep-related movements, we describe an adolescent patient's presentation of brief jerking movements during sleep and the accompanying differential diagnosis. In examining the patient's overnight electroencephalogram (EEG), we utilize hallmark sleep architecture to provide reassurance to the patient and her family.

    View details for DOI 10.5664/jcsm.10822

    View details for PubMedID 37772703

  • Resuscitate but not Intubate? Partial Codes in Pediatrics. Pediatrics Silverman, A., Batten, J., Berkman, E., Fitzgerald, H., Epstein, B., Shearer, E., Diekema, D., Burgart, A. 2023


    The use of partial code status in pediatric medicine presents clinicians with unique ethical challenges. The clinical vignette describes the presentation of a pulseless infant with a limited life expectancy. The infant's parents instruct the emergency medicine providers to resuscitate but not to intubate. In an emergency, without a clear understanding of parents' goals, complying with their request risks an ineffective resuscitation. The first commentary focuses on parental grief and how, in certain circumstances, a partial code best serves their needs. Its authors argue that providers are sometimes obligated to endure moral distress. The second commentary focuses on the healthcare team's moral distress and highlights the implications of a relational ethics framework for the case. The commentators emphasize the importance of honest communication and pain management. The final commentary explores the systems-level and how the design of hospital code status orders may contribute to requests for partial codes. They argue systems should discourage partial codes and prohibit resuscitation without intubation.

    View details for DOI 10.1542/peds.2022-058931

    View details for PubMedID 37435669

  • Teaching NeuroImage: Cutaneous Lesions and Leptomeningeal Carcinomatosis in Gastric Signet-Ring Cell Carcinoma. Neurology Silverman, A., Loube, D., Lovall, M., Cheronis, C., Madill, E., Karch, C. 2023

    View details for DOI 10.1212/WNL.0000000000207448

    View details for PubMedID 37290974

  • Clinical Problem Solving: A 38-year-Old Woman With Systemic Lupus Erythematosus Presenting With Headache, Nausea, and Vomiting NEUROHOSPITALIST Silverman, A., Dugue, R., George, P. M. 2023
  • Bilateral Marcus Gunn jaw-Winking Syndrome in a Neonate with Congenital Neurosyphilis JOURNAL OF PEDIATRICS Johnson, A., Silverman, A., Segal, J., Beres, S. 2023; 252: 223-224
  • Episodic ataxic gait in a healthy toddler: an exemplary case of recurrent vertigo of childhood. The Journal of pediatrics Silverman, A., Barsh, G. R., Jeng, S. 2022

    View details for DOI 10.1016/j.jpeds.2022.12.015

    View details for PubMedID 36549413

  • Child Neurology: Horner Syndrome in an Otherwise Well-Appearing Infant. Neurology Silverman, A., Beres, S. 2022


    We report an exemplary case of acquired Horner syndrome secondary to neuroblastoma in infancy. The patient presented with ptosis, miosis, and heterochromia. In reviewing the patient's laboratory and imaging workup, we highlight key etiologic differences between the pediatric and adult populations. Other important teaching points included in the discussion are a review of sympathetic neuroanatomy and oculosympathetic paresis, the appropriate and evidence-based diagnostic workup in infants and children, and a review of pharmacologic testing using cocaine and apraclonidine drops.

    View details for DOI 10.1212/WNL.0000000000201377

    View details for PubMedID 36130839

  • Bilateral Marcus Gunn Jaw-Winking Syndrome in a Neonate with Congenital Neurosyphilis. The Journal of pediatrics Johnson, A., Silverman, A., Segal, J. B., Beres, S. 2022

    View details for DOI 10.1016/j.jpeds.2022.09.023

    View details for PubMedID 36152687

  • Blood Pressure Trajectory Groups and Outcome After Endovascular Thrombectomy: A Multicenter Study. Stroke Petersen, N. H., Kodali, S., Meng, C., Li, F., Nguyen, C. K., Peshwe, K. U., Strander, S., Silverman, A., Kimmel, A., Wang, A., Anadani, M., Almallouhi, E., Spiotta, A. M., Kim, J. T., Giles, J. A., Keyrouz, S. G., Farooqui, M., Zevallos, C., Maier, I. L., Psychogios, M. N., Liman, J., Riou-Comte, N., Richard, S., Gory, B., Quintero Wolfe, S., Brown, P. A., Fargen, K. M., Mistry, E. A., Fakhri, H., Mistry, A. M., Wong, K. H., de Havenon, A., Nascimento, F. A., Kan, P., Matouk, C., Ortega-Gutiérrez, S., Sheth, K. N. 2022; 53 (4): 1216-1225


    Elevated blood pressure after endovascular thrombectomy (EVT) has been associated with an increased risk of hemorrhagic transformation and poor functional outcomes. However, the optimal hemodynamic management after EVT remains unknown, and the blood pressure course in the acute phase of ischemic stroke has not been well characterized. This study aimed to identify patient subgroups with distinct blood pressure trajectories after EVT and study their association with radiographic and functional outcomes.This multicenter retrospective cohort study included consecutive patients with anterior circulation large-vessel occlusion ischemic stroke who underwent EVT. Repeated time-stamped blood pressure data were recorded for the first 72 hours after thrombectomy. Latent variable mixture modeling was used to separate subjects into five groups with distinct postprocedural systolic blood pressure (SBP) trajectories. The primary outcome was functional status, measured on the modified Rankin Scale 90 days after stroke. Secondary outcomes included hemorrhagic transformation, symptomatic intracranial hemorrhage, and death.Two thousand two hundred sixty-eight patients (mean age [±SD] 69±15, mean National Institutes of Health Stroke Scale 15±7) were included in the analysis. Five distinct SBP trajectories were observed: low (18%), moderate (37%), moderate-to-high (20%), high-to-moderate (18%), and high (6%). SBP trajectory group was independently associated with functional outcome at 90 days (P<0.0001) after adjusting for potential confounders. Patients with high and high-to-moderate SBP trajectories had significantly greater odds of an unfavorable outcome (adjusted odds ratio, 3.5 [95% CI, 1.8-6.7], P=0.0003 and adjusted odds ratio, 2.2 [95% CI, 1.5-3.2], P<0.0001, respectively). Subjects in the high-to-moderate group had an increased risk of symptomatic intracranial hemorrhage (adjusted odds ratio, 1.82 [95% CI, 1-3.2]; P=0.04). No significant association was found between trajectory group and hemorrhagic transformation.Patients with acute ischemic stroke demonstrate distinct SBP trajectories during the first 72 hours after EVT that have differing associations with functional outcome. These findings may help identify potential candidates for future blood pressure modulation trials.

    View details for DOI 10.1161/STROKEAHA.121.034408

    View details for PubMedID 34781705

    View details for PubMedCentralID PMC8960326

  • Human Resources Silverman, A. Anastomosis. 2022
  • Cerebral Autoregulation StatPearls Silverman, A., Petersen, N. H. 2022
  • Furgen Silverman, A. Slate. Future Tense. 2021
  • Catamenial epilepsy Silverman, A. Neurology (e-Pearl). 2021
  • Progressive Tetraparesis in a 57-Year-Old Man With Congenital Absence of an Anterior Spinal Artery: A Case of Anterior Spinal Cord Infarction. The Neurohospitalist Selvadurai, C., Silverman, A., Traner, C., Narula, R., Schindler, J. 2020; 10 (4): 305-308


    A 57-year-old man presented with sudden neck pain radiating down his arms. This pain progressed to bilateral upper and subsequently lower extremity weakness and numbness. His vitals were notable for systolic blood pressures lower than his baseline (down to 90 mm Hg). The patient's neurological examination as well as magnetic resonance imaging of the cervical and thoracic spine localized to a lesion in the anterior spinal cord. The differential diagnosis for such an acute presentation included stroke, demyelination, intramedullary neoplasm, infection, metabolic myelopathy, and a dural arteriovenous fistula. Further imaging with angiography demonstrated that our patient lacked an anterior spinal artery. In its place, collateral flow from cervical artery branches provided sustenance to the anterior spinal cord. In the setting of hemodynamic instability, this variant anatomy likely predisposed the patient to ischemia, leading to the classic presentation of anterior cord syndrome.

    View details for DOI 10.1177/1941874420926759

    View details for PubMedID 32983352

    View details for PubMedCentralID PMC7495689

  • Effects of Collateral Status on Infarct Distribution Following Endovascular Therapy in Large Vessel Occlusion Stroke. Stroke Al-Dasuqi, K., Payabvash, S., Torres-Flores, G. A., Strander, S. M., Nguyen, C. K., Peshwe, K. U., Kodali, S., Silverman, A., Malhotra, A., Johnson, M. H., Matouk, C. C., Schindler, J. L., Sansing, L. H., Falcone, G. J., Sheth, K. N., Petersen, N. H. 2020; 51 (9): e193-e202


    We aim to examine effects of collateral status and post-thrombectomy reperfusion on final infarct distribution and early functional outcome in patients with anterior circulation large vessel occlusion ischemic stroke.Patients with large vessel occlusion who underwent endovascular intervention were included in this study. All patients had baseline computed tomography angiography and follow-up magnetic resonance imaging. Collateral status was graded according to the criteria proposed by Miteff et al and reperfusion was assessed using the modified Thrombolysis in Cerebral Infarction (mTICI) system. We applied a multivariate voxel-wise general linear model to correlate the distribution of final infarction with collateral status and degree of reperfusion. Early favorable outcome was defined as a discharge modified Rankin Scale score ≤2.Of the 283 patients included, 129 (46%) had good, 97 (34%) had moderate, and 57 (20%) had poor collateral status. Successful reperfusion (mTICI 2b/3) was achieved in 206 (73%) patients. Poor collateral status was associated with infarction of middle cerebral artery border zones, whereas worse reperfusion (mTICI scores 0-2a) was associated with infarction of middle cerebral artery territory deep white matter tracts and the posterior limb of the internal capsule. In multivariate regression models, both mTICI (P<0.001) and collateral status (P<0.001) were among independent predictors of final infarct volumes. However, mTICI (P<0.001), but not collateral status (P=0.058), predicted favorable outcome at discharge.In this cohort of patients with large vessel occlusion stroke, both the collateral status and endovascular reperfusion were strongly associated with middle cerebral artery territory final infarct volumes. Our findings suggesting that baseline collateral status predominantly affected middle cerebral artery border zones infarction, whereas higher mTICI preserved deep white matter and internal capsule from infarction; may explain why reperfusion success-but not collateral status-was among the independent predictors of favorable outcome at discharge. Infarction of the lentiform nuclei was observed regardless of collateral status or reperfusion success.

    View details for DOI 10.1161/STROKEAHA.120.029892

    View details for PubMedID 32781941

    View details for PubMedCentralID PMC7484023

  • Direct carotid puncture for mechanical thrombectomy in acute ischemic stroke patients with prohibitive vascular access. Journal of neurosurgery Cord, B. J., Kodali, S., Strander, S., Silverman, A., Wang, A., Chouairi, F., Koo, A. B., Nguyen, C. K., Peshwe, K., Kimmel, A., Porto, C. M., Hebert, R. M., Falcone, G. J., Sheth, K. N., Sansing, L. H., Schindler, J. L., Matouk, C. C., Petersen, N. H. 2020: 1-11


    While the benefit of mechanical thrombectomy (MT) for patients with anterior circulation acute ischemic stroke with large-vessel occlusion (AIS-LVO) has been clearly established, difficult vascular access may make the intervention impossible or unduly prolonged. In this study, the authors evaluated safety as well as radiographic and functional outcomes in stroke patients treated with MT via direct carotid puncture (DCP) for prohibitive vascular access.The authors retrospectively studied patients from their prospective AIS-LVO database who underwent attempted MT between 2015 and 2018. Patients with prohibitive vascular access were divided into two groups: 1) aborted MT (abMT) after failed transfemoral access and 2) attempted MT via DCP. Functional outcome was assessed using the modified Rankin Scale at 3 months. Associations with outcome were analyzed using ordinal logistic regression.Of 352 consecutive patients with anterior circulation AIS-LVO who underwent attempted MT, 37 patients (10.5%) were deemed to have prohibitive vascular access (mean age [± SD] 82 ± 11 years, mean National Institutes of Health Stroke Scale [NIHSS] score 17 ± 5, with females accounting for 75% of the patients). There were 20 patients in the DCP group and 17 in the abMT group. The two groups were well matched for the known predictors of clinical outcome: age, sex, and admission NIHSS score. Direct carotid access was successfully obtained in 19 of 20 patients. Successful reperfusion (thrombolysis in cerebral infarction score 2b or 3) was achieved in 16 (84%) of 19 patients in the DCP group. Carotid access complications included an inability to catheterize the carotid artery in 1 patient, neck hematomas in 4 patients, non-flow-limiting common carotid artery (CCA) dissections in 2 patients, and a delayed, fatal carotid blowout in 1 patient. The neck hematomas and non-flow-limiting CCA dissections did not require any subsequent interventions and remained clinically silent. Compared with the abMT group, patients in the DCP group had smaller infarct volumes (11 vs 48 ml, p = 0.04), a greater reduction in NIHSS score (-4 vs +2.9, p = 0.03), and better functional outcome (shift analysis for 3-month modified Rankin Scale score: adjusted OR 5.2, 95% CI 1.02-24.5; p = 0.048).DCP for emergency MT in patients with anterior circulation AIS-LVO and prohibitive vascular access is safe and effective and is associated with higher recanalization rates, smaller infarct volumes, and improved functional outcome compared with patients with abMT after failed transfemoral access. DCP should be considered in this patient population.

    View details for DOI 10.3171/2020.5.JNS192737

    View details for PubMedID 32796146

    View details for PubMedCentralID PMC9491727

  • Habit NEUROLOGY Silverman, A. 2020; 95 (4): 179
  • Hemodynamics and Hemorrhagic Transformation After Endovascular Therapy for Ischemic Stroke. Frontiers in neurology Silverman, A., Kodali, S., Sheth, K. N., Petersen, N. H. 2020; 11: 728


    Hemorrhagic transformation remains a potentially catastrophic complication of reperfusion therapies for the treatment of large-vessel occlusion ischemic stroke. Observational studies have found an increased risk of hemorrhagic transformation in patients with elevated blood pressure as well as a high degree of blood pressure variability, suggesting a link between hemodynamics and hemorrhagic transformation. Current society-endorsed guidelines recommend maintaining blood pressure below a fixed threshold of 180/105 mmHg regardless of thrombolytic or endovascular intervention. However, given the high recanalization rates with mechanical thrombectomy, it is unclear if the same hemodynamic goals from the pre-thrombectomy era apply. Also, individual patient factors such as the degree of reperfusion, infarct size, and collateral status likely need to be considered. In this review, we will discuss current evidence linking hemodynamics to hemorrhagic transformation after mechanical thrombectomy. In addition, we will review the clinical relevance of cerebral autoregulation in stroke, highlighting recent studies that have harnessed autoregulatory physiology to define and trend individualized limits of autoregulation. This review will go on to emphasize the translatability of this approach to stroke management. Finally, we will discuss novel statistical approaches like trajectory analysis to post-thrombectomy hemodynamics.

    View details for DOI 10.3389/fneur.2020.00728

    View details for PubMedID 32765416

    View details for PubMedCentralID PMC7379334

  • Clinical Reasoning: A 16-year-old girl with ataxia, oscillopsia, and behavioral changes. Neurology Silverman, A., Selvadurai, C., Picard, J., Gluck, L., Fisayo, A., Makhani, N., Benitez, V. 2020; 94 (16): 713-717

    View details for DOI 10.1212/WNL.0000000000009297

    View details for PubMedID 32234821

    View details for PubMedCentralID PMC7282879

  • Fixed Compared With Autoregulation-Oriented Blood Pressure Thresholds After Mechanical Thrombectomy for Ischemic Stroke. Stroke Petersen, N. H., Silverman, A., Strander, S. M., Kodali, S., Wang, A., Sansing, L. H., Schindler, J. L., Falcone, G. J., Gilmore, E. J., Jasne, A. S., Cord, B., Hebert, R. M., Johnson, M., Matouk, C. C., Sheth, K. N. 2020; 51 (3): 914-921


    Background and Purpose- Loss of cerebral autoregulation in the acute phase of ischemic stroke leaves patients vulnerable to blood pressure (BP) changes. Effective BP management after endovascular thrombectomy may protect the brain from hypoperfusion or hyperperfusion. In this observational study, we compared personalized, autoregulation-based BP targets to static systolic BP thresholds. Methods- We prospectively enrolled 90 patients undergoing endovascular thrombectomy for stroke. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy-derived tissue oxygenation (a cerebral blood flow surrogate) in response to changes in mean arterial pressure. The resulting autoregulatory index was used to trend the BP range at which autoregulation was most preserved. Percent time that mean arterial pressure exceeded the upper limit of autoregulation or decreased below the lower limit of autoregulation was calculated for each patient. Time above fixed systolic BP thresholds was computed in a similar fashion. Functional outcome was measured with the modified Rankin Scale at 90 days. Results- Personalized limits of autoregulation were successfully computed in all 90 patients (age 71.6±16.2, 47% female, mean National Institutes of Health Stroke Scale 13.9±5.7, monitoring time 28.0±18.4 hours). Percent time with mean arterial pressure above the upper limit of autoregulation associated with worse 90-day outcomes (odds ratio per 10% 1.84 [95% CI, 1.3-2.7] P=0.002), and patients with hemorrhagic transformation spent more time above the upper limit of autoregulation (10.9% versus 16.0%, P=0.042). Although there appeared to be a nonsignificant trend towards worse outcome with increasing time above systolic BP thresholds of 140 mm Hg and 160 mm Hg, the effect sizes were smaller compared with the personalized approach. Conclusions- Noninvasive determination of personalized BP thresholds for stroke patients is feasible. Deviation from these limits may increase risk of further brain injury and poor functional outcome. This approach may present a better strategy compared with the classical approach of maintaining systolic BP below a predetermined value, though a randomized trial is needed to determine the optimal approach for hemodynamic management.

    View details for DOI 10.1161/STROKEAHA.119.026596

    View details for PubMedID 32078493

    View details for PubMedCentralID PMC7050651

  • Cerebral Autoregulation-guided Parameters for Predicting Midline Shift After Large-vessel Occlusion Ischemic Stroke American Academy of Neurology Silverman, A., Wang, A., Kodali, S., Strander, S., Kimmel, A., Nguyen, C., Peshwe, K., Matouk, C., Sheth, K., Marshall, R., Tan, C., Petersen, N. Wolters Kluwer Health, Inc.. 2020
  • Risk of Worse Outcome in Stroke Patients with High Blood Pressure Variability After Endovascular Thrombectomy May Be Amplified by Impaired Cerebral Autoregulation American Academy of Neurology Nguyen, C., et al 2020
  • An Autoregulation-Derived Prediction Model for Midline Shift After Ischemic Stroke International Stroke Conference Silverman, A., Wang, A., Kodali, S., Strander, S., Kimmel, A., Nguyen, C., Peshwe, K., Matouk, C., Sheth, K., Kimberly, W., Tan, C., Petersen, N. American Heart Association, Inc.. 2020
  • Broca's area Neurology Silverman, A. 2020
  • Seizure Medications StatPearls Subbarao, B. S., Silverman, A., Eapen, B. C. 2020
  • Neuroscientist, in Love. Academic psychiatry : the journal of the American Association of Directors of Psychiatric Residency Training and the Association for Academic Psychiatry Silverman, A. 2019; 43 (6): 648

    View details for DOI 10.1007/s40596-019-01057-3

    View details for PubMedID 30972658

  • Response by Petersen et al to Letter Regarding Article, "Decreases in Blood Pressure During Thrombectomy Are Associated With Larger Infarct Volumes and Worse Functional Outcome". Stroke Petersen, N. H., Silverman, A., Kimmel, A. C., Sheth, K. N. 2019; 50 (11): e321-e322

    View details for DOI 10.1161/STROKEAHA.119.027098

    View details for PubMedID 31623540

    View details for PubMedCentralID PMC6824272

  • Association of Personalized Blood Pressure Targets With Hemorrhagic Transformation and Functional Outcome After Endovascular Stroke Therapy. JAMA neurology Petersen, N. H., Silverman, A., Wang, A., Strander, S., Kodali, S., Matouk, C., Sheth, K. N. 2019; 76 (10): 1256-1258

    View details for DOI 10.1001/jamaneurol.2019.2120

    View details for PubMedID 31355872

    View details for PubMedCentralID PMC6664391

  • Deviation From Personalized Blood Pressure Targets Is Associated With Worse Outcome After Subarachnoid Hemorrhage. Stroke Silverman, A., Kodali, S., Strander, S., Gilmore, E. J., Kimmel, A., Wang, A., Cord, B., Falcone, G., Hebert, R., Matouk, C., Sheth, K. N., Petersen, N. H. 2019; 50 (10): 2729-2737


    Background and Purpose- Optimal blood pressure (BP) management during the early stages of aneurysmal subarachnoid hemorrhage remains uncertain. Observational studies have found worse outcomes in patients with increased hemodynamic variability, suggesting BP optimization as a potential neuroprotective strategy. In this study, we calculated personalized BP targets at which cerebral autoregulation was best preserved. We analyzed how deviation from these limits correlates with functional outcome. Methods- We prospectively enrolled 31 patients with aneurysmal subarachnoid hemorrhage. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy (NIRS)-derived tissue oxygenation-a surrogate for cerebral blood flow-as well as intracranial pressure (ICP) in response to changes in mean arterial pressure using time-correlation analysis. The resulting autoregulatory indices were used to identify the upper and lower limit of autoregulation. Percent time that mean arterial pressure exceeded limits of autoregulation was calculated for each patient. Functional outcome was assessed using the modified Rankin Scale at discharge and 90 days. Associations with outcome were analyzed using ordinal multivariate logistic regression. Results- Personalized limits of autoregulation were computed in all patients (age 57.5±13.4, 23F, mean World Federation of Neurological Surgeons 2±1, monitoring time 67.8±50.8 hours). Optimal BP and limits of autoregulation were calculated on average for 89.5±6.7% of the total monitoring period. ICP- and NIRS-derived optimal pressures strongly correlated with one another (P<0.0001). Percent time that mean arterial pressure deviated from limits of autoregulation significantly associated with worse functional outcome at discharge (NIRS, P=0.001; ICP, P=0.004) and 90 days (NIRS, P=0.002; ICP, P=0.003), adjusting separately for age, World Federation of Neurological Surgeons, vasospasm, and delayed cerebral ischemia. Conclusions- Both invasive (ICP) and noninvasive (NIRS) determination of personalized BP targets after aneurysmal subarachnoid hemorrhage is feasible, and these 2 approaches revealed significant collinearity. Furthermore, exceeding individualized limits of autoregulation was associated with poor functional outcomes.

    View details for DOI 10.1161/STROKEAHA.119.026282

    View details for PubMedID 31495332

    View details for PubMedCentralID PMC6756936

  • Decreases in Blood Pressure During Thrombectomy Are Associated With Larger Infarct Volumes and Worse Functional Outcome. Stroke Petersen, N. H., Ortega-Gutierrez, S., Wang, A., Lopez, G. V., Strander, S., Kodali, S., Silverman, A., Zheng-Lin, B., Dandapat, S., Sansing, L. H., Schindler, J. L., Falcone, G. J., Gilmore, E. J., Amin, H., Cord, B., Hebert, R. M., Matouk, C., Sheth, K. N. 2019; 50 (7): 1797-1804


    Background and Purpose- After large-vessel intracranial occlusion, the fate of the ischemic penumbra, and ultimately final infarct volume, largely depends on tissue perfusion. In this study, we evaluated whether blood pressure reduction and sustained relative hypotension during endovascular thrombectomy are associated with infarct progression and functional outcome. Methods- We identified consecutive patients with large-vessel intracranial occlusion ischemic stroke who underwent mechanical thrombectomy at 2 comprehensive stroke centers. Intraprocedural mean arterial pressure (MAP) was monitored throughout the procedure. ΔMAP was calculated as the difference between admission MAP and lowest MAP during endovascular thrombectomy until recanalization. Sustained hypotension was measured as the area between admission MAP and continuous measurements of intraprocedural MAP (aMAP). Final infarct volume was measured using magnetic resonance imaging at 24 hours, and functional outcome was assessed using the modified Rankin Scale at discharge and 90 days. Associations with outcome were analyzed using linear and ordinal multivariable logistic regression. Results- Three hundred ninety patients (mean age 71±14 years, mean National Institutes of Health Stroke Scale score of 17) were included in the study; of these, 280 (72%) achieved Thrombolysis in Cerebral Infarction 2B/3 reperfusion. Eighty-seven percent of patients experienced MAP reductions during endovascular thrombectomy (mean 31±20 mm Hg). ΔMAP was associated with greater infarct growth ( P=0.036) and final infarct volume ( P=0.035). Mean ΔMAP among patients with favorable outcomes (modified Rankin Scale score, 0-2) was 20±21 mm Hg compared with 30±24 mm Hg among patients with poor outcome ( P=0.002). In the multivariable analysis, ΔMAP was independently associated with higher (worse) modified Rankin Scale scores at discharge (adjusted odds ratio per 10 mm Hg, 1.17; 95% CI, 1.04-1.32; P=0.009) and at 90 days (adjusted odds ratio per 10 mm Hg, 1.22; 95% CI, 1.07-1.38; P=0.003). The association between aMAP and outcome was also significant at discharge ( P=0.002) and 90 days ( P=0.001). Conclusions- Blood pressure reduction before recanalization is associated with larger infarct volumes and worse functional outcomes for patients affected by large-vessel intracranial occlusion stroke. These results underscore the importance of BP management during endovascular thrombectomy and highlight the need for further investigation of blood pressure management after large-vessel intracranial occlusion stroke.

    View details for DOI 10.1161/STROKEAHA.118.024286

    View details for PubMedID 31159701

    View details for PubMedCentralID PMC6787912

  • Persistent connection. Neurology Silverman, A. 2019; 92 (16): 768-769

    View details for DOI 10.1212/WNL.0000000000007304

    View details for PubMedID 30988084

  • Individualized blood pressure management after subarachnoid hemorrhage using real-time autoregulation monitoring: a pilot study using NIRS and ICP-derived limits of autoregulation International Stroke Conference Silverman, A., Wang, A., Kodali, S., Strander, S., Cord, B., Hebert, R., Matouk, C., Gilmore, E., Sheth, K., Petersen, N. American Heart Association, Inc.. 2019
  • Parakinesia brachialis oscitans Silverman, A. Neurology (e-Pearl). 2019
  • Blood Pressure Management Outside Individualized Limits of Autoregulation is Associated with Neurologic Deterioration and Worse Functional Outcomes in Patients with Large-Vessel Occlusion (LVO) Ischemic Stroke American Academy of Neurology Annual Meeting Silverman, A., Wang, A., Strander, S., Kodali, S., Sansing, L., Schindler, J., Hebert, R., Gilmore, E., Sheth, K., Petersen, N. 2019
  • Residency Training: Progressive gait difficulty and incontinence in a 40-year-old man with HIV. Neurology Silverman, A., O'Meara, T., Le, L., Robertson, K., Spudich, S. 2018; 91 (23): 1065-1070

    View details for DOI 10.1212/WNL.0000000000006619

    View details for PubMedID 30510020

    View details for PubMedCentralID PMC6282230

  • Atrial Fibrillation in a Patient With an Accessory Pathway. Journal of investigative medicine high impact case reports Silverman, A., Taneja, S., Benchetrit, L., Makusha, P., McNamara, R. L., Pine, A. B. 2018; 6: 2324709618802870


    A 24-year-old man with history of unspecified arrhythmia presented with palpitations and chest pain. Initial electrocardiogram (ECG) revealed irregular tachycardia with varying QRS width: 150 to 200 beats per minute for narrow complexes and 300 beats per minute for wide complexes. Following cardioversion, ECG revealed sinus tachycardia with a preexcitation pattern of positive delta waves in the anterolateral leads and negative delta waves in inferior leads. The patient remained in sinus rhythm and underwent successful ablation of a right posteroseptal accessory pathway. Subsequent ECG showed upright T waves in the leads I, aVL, and V2-6, large inverted T waves in leads III and aVF, and no delta waves. This case serves as an important reminder that atrial fibrillation (AF) in the presence of an accessory pathway may present with confounding ECG features, potentially leading to incorrect diagnoses and treatments that may be life threatening. Despite 10% to 30% prevalence of AF in the presence of an accessory pathway and the relative awareness of Wolff-Parkinson-White syndrome among general internal medicine providers, the clinical recognition of Wolff-Parkinson-White syndrome may be hindered in the presence of preexcited AF.

    View details for DOI 10.1177/2324709618802870

    View details for PubMedID 30283806

    View details for PubMedCentralID PMC6166305

  • Prominent motor abnormalities in Thai men and women with presumed subtype CRF01_AE HIV-1 infection improve with antiretroviral therapy American Academy of Neurology Annual Meeting Silverman, A., Chan, P., Paul, R., Hellmuth, J., Sithinamsuwan, P., Ananworanich, J., Phanuphak, N., Fletcher, J., Chalermchai, T., Tipsuk, S., Suttichom, D., Valcour, V., Spudich, S. Wolters Kluwer Health, Inc.. 2017
  • Acute Hepatitis with Mixed Pattern in the Setting of Primary Epstein-Barr Virus (EBV) Infection in a 43-Year-Old Woman Society of General Internal Medicine Benchetrit, L., Makusha, P., Silverman, A., Taneja, S., Pine, A. 2017
  • Cortical theta is increased while thalamocortical coherence is decreased in rat models of acute and chronic pain. Pain Leblanc, B. W., Lii, T. R., Silverman, A. E., Alleyne, R. T., Saab, C. Y. 2014; 155 (4): 773–82


    Thalamocortical oscillations are critical for sensory perception. Although pain is known to disrupt synchrony in thalamocortical oscillations, evidence in the literature is controversial. Thalamocortical coherence has been reported to be increased in patients with neurogenic pain but decreased in a rat model of central pain. Moreover, theta (4 to 8 Hz) oscillations in primary somatosensory (S1) cortex are speculated to predict pain in humans. To date, the link between pain and network oscillations in animal models has been understudied. Thus, we tested the hypothesis that pain disrupts thalamocortical coherence and S1 theta power in two rat models of pain. We recorded electrocorticography (ECoG) waveforms over S1 and local field potentials (LFP) within ventral posterolateral thalamus in freely behaving rats under spontaneous (stimulus-independent) pain conditions. Rats received intradermal capsaicin injection (Cap) in the hindpaw, followed hours later by chronic constriction injury (CCI) of the sciatic nerve lasting several days. Our results show that pain decreases coherence between LFP and ECoG waveforms in the 2- to 30-Hz range, and increases ECoG power in the theta range. These changes are short-lasting after Cap and longer-lasting after CCI. These data might be particularly relevant to preclinical correlates of spontaneous pain-like behavior, with potential implications to clinical biomarkers of ongoing pain.

    View details for DOI 10.1016/j.pain.2014.01.013

    View details for PubMedID 24457192

  • Enhancing the learning experience for organic chemistry students at Brown Harriet W. Sheridan Center for Teaching and Learning (25th Anniversary Celebration) Hess, K., Taylor, S., Zimmt, M., Pedersen, L., Levy, S., Silverman, A. 2012