Bio


Dr. Nirali Vora is a Clinical Associate Professor of Neurology and Neurological sciences at Stanford University. She is board certified in Adult Neurology and Vascular Neurology after completing her residency and advanced fellowship training at Stanford. She provides comprehensive care for all stroke patients, as well as hospitalized adults with acute or undiagnosed neurological conditions. She specializes in treating vascular disorders including TIA, vasculitis, dissection, venous thrombosis, and undetermined or “cryptogenic” causes of stroke.

Dr. Vora directs the Stanford Global Health Neurology program, through which she started the first stroke unit in Zimbabwe and gained experience in HIV neurology and other neuro-infectious diseases. Additional research interests include stroke prevention, TIA triage, eliminating disparities in health care, and neurology education. She is also the Director of the Stanford Adult Neurology Residency Program.

Clinical Focus


  • Global Health Neurology Education
  • Stroke
  • TIA (Transient Ischemic Attack)
  • Neurology

Academic Appointments


Administrative Appointments


  • Residency Program Director, Adult Neurology (2018 - Present)
  • Director, Global Health Neurology (2014 - Present)
  • Associate Residency Director, Adult Neurology (2016 - 2018)
  • Associate Fellowship Director, Vascular Neurology (2014 - 2016)

Honors & Awards


  • Teaching Award, Neurology Clerkship (2016-2017)
  • Christine Wijman Humanism in Medicine Award, Stanford University (2013)
  • Resident Scholar, American Academy of Neurology (2013)
  • Chief Resident, Stanford Neurology Residency Program (2012-2013)
  • Teaching Award, Neurology Clerkship (2013)

Boards, Advisory Committees, Professional Organizations


  • Member, American Academy of Neurology (2009 - Present)
  • Member, American Heart/Stroke Association (2012 - Present)
  • Executive Education Committee, World Federation of Neurology (2013 - 2014)

Professional Education


  • Fellowship:Stanford University Vascular Neurology Fellowship (2014) CA
  • Residency:Stanford University Neurology Residency (2013) CA
  • Internship:Santa Clara Valley Medical Center Internal Medicine Residency (2010) CA
  • Medical Education:Rosalind Franklin University The Chicago Medical School (2009) IL
  • Board Certification: Vascular Neurology, American Board of Psychiatry and Neurology (2014)
  • Board Certification: Neurology, American Board of Psychiatry and Neurology (2013)

Community and International Work


  • Global Health Neurology, Ghana, Kumasi, Ghana

    Topic

    Stroke systems of care, education

    Partnering Organization(s)

    KNUST, KATH

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    Yes

  • Global Health Neurology, Zimbabwe

    Topic

    Stroke care

    Partnering Organization(s)

    Center for Innovation in Global Health

    Populations Served

    Underserved

    Location

    International

    Ongoing Project

    Yes

    Opportunities for Student Involvement

    Yes

  • Arbor Free Clinic

    Populations Served

    Underserved

    Location

    International

    Ongoing Project

    No

    Opportunities for Student Involvement

    No

Clinical Trials


  • AtRial Cardiopathy and Antithrombotic Drugs In Prevention After Cryptogenic Stroke Recruiting

    Objectives - Primary: To test the hypothesis that apixaban is superior to aspirin for the prevention of recurrent stroke in patients with cryptogenic ischemic stroke and atrial cardiopathy. - Secondary: To test the hypothesis that the relative efficacy of apixaban over aspirin increases with the severity of atrial cardiopathy.

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  • Imaging Collaterals in Acute Stroke (iCAS) Recruiting

    Stroke is caused by a sudden blockage of a blood vessel that delivers blood to the brain. Unblocking the blood vessel with a blood clot removal device restores blood flow and if done quickly may prevent the disability that can be caused by a stroke. However, not all stroke patients benefit from having their blood vessel unblocked. The aim of this study is to determine if special brain imaging, called MRI, can be used to identify which stroke patients are most likely to benefit from attempts to unblock their blood vessel with a special blood clot removal device. In particular, we will assess in this trial whether a noncontrast MR imaging sequence, arterial spin labeling (ASL), can demonstrate the presence of collateral blood flow (compared with a gold standard of the angiogram) and whether it is useful to predict who will benefit from treatment.

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  • Platelet-Oriented Inhibition in New TIA and Minor Ischemic Stroke (POINT) Trial Not Recruiting

    A transient ischemic attack (TIA) is a transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction. An ischemic stroke is a cerebral infarction. In POINT, eligibility is limited to brain TIAs and to minor ischemic strokes (with an NIH Stroke Scale [NIHSS] score less than or equal to 3). TIAs are common [25], and are often harbingers of disabling strokes. Approximately 250,000-350,000 TIAs are diagnosed each year in the US. Given median survival of more than 8 years [32], there are approximately 2.4 million TIA survivors. In a national survey, one in fifteen of those over 65 years old reported a history of TIA [33], which is equivalent to a prevalence of 2.3 million in older Americans. Based on the prevalence of undiagnosed transient neurological events, the true incidence of TIA may be twice as high as the rates of diagnosis [33]. Based on our review of the National Inpatient Sample for 1997-2003, there were an average of 200,000 hospital admissions for TIA each year, with annual charges climbing quickly in the period to $2.6 billion in 2003. Composite endpoint of new ischemic vascular events: ischemic stroke, myocardial infarction or ischemic vascular death at 90 days.

    Stanford is currently not accepting patients for this trial. For more information, please contact Rosen Mann, (650) 721-2645.

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  • Rivaroxaban Versus Aspirin in Secondary Prevention of Stroke and Prevention of Systemic Embolism in Patients With Recent Embolic Stroke of Undetermined Source (ESUS) Not Recruiting

    This is a study in patients who recently had a brain attack (stroke) and in whom no clear cause of the stroke could be identified. These strokes are likely due to a blood clot and therefore, can be called embolic stroke of undetermined source. The abbreviation is ESUS. The study will compare 2 blood thinners. Patients will be randomly assigned to either Rivaroxaban 15 mg or Aspirin 100 mg and the study is intended to show, if patients given rivaroxaban have fewer blood clots in the brain (stroke) or in other blood vessels.

    Stanford is currently not accepting patients for this trial. For more information, please contact Madelleine Garcia , stroke center.

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  • Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial Not Recruiting

    The Stroke Hyperglycemia Insulin Network Effort (SHINE) Trial is a multicenter, randomized, controlled clinical trial of 1400 patients that will include approximately 60 enrolling sites. The study hypotheses are that treatment of hyperglycemic acute ischemic stroke patients with targeted glucose concentration (80mg/dL - 130 mg/dL) will be safe and result in improved 3 month outcome after stroke. Eligible subjects must be randomized within 12 hours of stroke symptom onset and either have type 2 diabetes and glucose concentrations of over 110 mg/dL or no history of diabetes and glucose concentrations of 150 mg/dL or higher on initial evaluation. The enrolling sites will include the Neurological Emergencies Treatment Trials (NETT) sites as well as non NETT sites from all over the United States. The study will evaluate the safety and efficacy of targeted glucose control (treatment group - IV insulin with target 80-130 mg/dl) verses control therapy of sub q insulin plus basal insulin with target glucose less than 180 mg/ dL. The primary outcome will be functional outcome at 3 months as measured by the modified Rankin Scale (mRS) Score. The primary safety outcome will be severe hypoglycemia defined as <40 mg/dL. Enrollment will occur over 5-7 years.

    Stanford is currently not accepting patients for this trial. For more information, please contact Rosen Mann, (650) 721-2645.

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  • Study to Examine the Effects of MultiStem in Ischemic Stroke Not Recruiting

    A study to examine the safety and potential effectiveness of the adult stem cell investigational product, MultiStem, in adults who have suffered an ischemic stroke. The hypothesis is that MultiStem will be safe and provide benefit following an ischemic stroke.

    Stanford is currently not accepting patients for this trial. For more information, please contact Neil Schwartz , (650) 723 - 7193.

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  • Transient Ischemic Attack (TIA) Triage and Evaluation of Stroke Risk Not Recruiting

    Transient ischemic attack (TIA) is a transient neurological deficit (speech disturbance, weakness…), caused by temporary occlusion of a brain vessel by a blood clot that leaves no lasting effect. TIA diagnosis can be challenging and an expert stroke evaluation combined with magnetic resonance imaging (MRI) could improve the diagnosis accuracy. The risk of a debilitating stroke can be as high as 5% during the first 72 hrs after TIA. TIA characteristics (duration, type of symptoms, age of the patient), the presence of a significant narrowing of the neck vessels responsible for the patient's symptoms (symptomatic stenosis), and an abnormal MRI are associated with an increased risk of stroke. An emergent evaluation and treatment of TIA patients by a stroke specialist could reduce the risk of stroke to 2%. Stanford has implemented an expedited triage pathway for TIA patients combining a clinical evaluation by a stroke neurologist, an acute MRI of the brain and the vessels and a sampling of biomarkers (Lp-PLA2). The investigators are investigating the yield of this unique approach to improve TIA diagnosis, prognosis and secondary stroke prevention. The objective of this prospective cohort study is to determine which factors will help the physician to confirm the diagnosis of TIA and to define the risk of stroke after a TIA.

    Stanford is currently not accepting patients for this trial. For more information, please contact Stephanie Kemp, BS, 650-723-4481.

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All Publications


  • Decreasing Stroke Code to CT Time in Patients Presenting with Stroke Symptoms. Radiographics : a review publication of the Radiological Society of North America, Inc Kalnins, A., Mickelsen, L. J., Marsh, D., Zorich, C., Casal, S., Tai, W. A., Vora, N., Olalia, G., Wintermark, M., Larson, D. B. ; 37 (5): 1559–68

    Abstract

    Guided quality improvement (QI) programs present an effective means to streamline stroke code to computed tomography (CT) times in a comprehensive stroke center. Applying QI methods and a multidisciplinary team approach may decrease the stroke code to CT time in non-prenotified emergency department (ED) patients presenting with symptoms of stroke. The aim of this project was to decrease this time for non-prenotified stroke code patients from a baseline mean of 20 minutes to one less than 15 minutes during an 18-week period by applying QI methods in the context of a structured QI program. By reducing this time, it was expected that the door-to-CT time guideline of 25 minutes could be met more consistently. Through the structured QI program, we gained an understanding of the process that enabled us to effectively identify key drivers of performance to guide project interventions. As a result of these interventions, the stroke code to CT time for non-prenotified stroke code patients decreased to a mean of less than 14 minutes. This article reports these methods and results so that others can similarly improve the time it takes to perform nonenhanced CT studies in non-prenotified stroke code patients in the ED. (©)RSNA, 2017.

    View details for DOI 10.1148/rg.2017160190

    View details for PubMedID 28820652

  • Clopidogrel and Aspirin in Acute Ischemic Stroke and High-Risk TIA. The New England journal of medicine Johnston, S. C., Easton, J. D., Farrant, M., Barsan, W., Conwit, R. A., Elm, J. J., Kim, A. S., Lindblad, A. S., Palesch, Y. Y. 2018

    Abstract

    Background Combination antiplatelet therapy with clopidogrel and aspirin may reduce the rate of recurrent stroke during the first 3 months after a minor ischemic stroke or transient ischemic attack (TIA). A trial of combination antiplatelet therapy in a Chinese population has shown a reduction in the risk of recurrent stroke. We tested this combination in an international population. Methods In a randomized trial, we assigned patients with minor ischemic stroke or high-risk TIA to receive either clopidogrel at a loading dose of 600 mg on day 1, followed by 75 mg per day, plus aspirin (at a dose of 50 to 325 mg per day) or the same range of doses of aspirin alone. The dose of aspirin in each group was selected by the site investigator. The primary efficacy outcome in a time-to-event analysis was the risk of a composite of major ischemic events, which was defined as ischemic stroke, myocardial infarction, or death from an ischemic vascular event, at 90 days. Results A total of 4881 patients were enrolled at 269 international sites. The trial was halted after 84% of the anticipated number of patients had been enrolled because the data and safety monitoring board had determined that the combination of clopidogrel and aspirin was associated with both a lower risk of major ischemic events and a higher risk of major hemorrhage than aspirin alone at 90 days. Major ischemic events occurred in 121 of 2432 patients (5.0%) receiving clopidogrel plus aspirin and in 160 of 2449 patients (6.5%) receiving aspirin plus placebo (hazard ratio, 0.75; 95% confidence interval [CI], 0.59 to 0.95; P=0.02), with most events occurring during the first week after the initial event. Major hemorrhage occurred in 23 patients (0.9%) receiving clopidogrel plus aspirin and in 10 patients (0.4%) receiving aspirin plus placebo (hazard ratio, 2.32; 95% CI, 1.10 to 4.87; P=0.02). Conclusions In patients with minor ischemic stroke or high-risk TIA, those who received a combination of clopidogrel and aspirin had a lower risk of major ischemic events but a higher risk of major hemorrhage at 90 days than those who received aspirin alone. (Funded by the National Institute of Neurological Disorders and Stroke; POINT ClinicalTrials.gov number, NCT00991029 .).

    View details for DOI 10.1056/NEJMoa1800410

    View details for PubMedID 29766750

  • Rivaroxaban or aspirin for patent foramen ovale and embolic stroke of undetermined source: a prespecified subgroup analysis from the NAVIGATE ESUS trial. The Lancet. Neurology Kasner, S. E., Swaminathan, B., Lavados, P., Sharma, M., Muir, K., Veltkamp, R., Ameriso, S. F., Endres, M., Lutsep, H., Messé, S. R., Spence, J. D., Nedeltechev, K., Perera, K., Santo, G., Olavarria, V., Lindgren, A., Bangdiwala, S., Shoamanesh, A., Berkowitz, S. D., Mundl, H., Connolly, S. J., Hart, R. G. 2018

    Abstract

    Patent foramen ovale (PFO) is a contributor to embolic stroke of undetermined source (ESUS). Subgroup analyses from previous studies suggest that anticoagulation could reduce recurrent stroke compared with antiplatelet therapy. We hypothesised that anticoagulant treatment with rivaroxaban, an oral factor Xa inhibitor, would reduce the risk of recurrent ischaemic stroke compared with aspirin among patients with PFO enrolled in the NAVIGATE ESUS trial.NAVIGATE ESUS was a double-blinded, randomised, phase 3 trial done at 459 centres in 31 countries that assessed the efficacy and safety of rivaroxaban versus aspirin for secondary stroke prevention in patients with ESUS. For this prespecified subgroup analysis, cohorts with and without PFO were defined on the basis of transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE). The primary efficacy outcome was time to recurrent ischaemic stroke between treatment groups. The primary safety outcome was major bleeding, according to the criteria of the International Society of Thrombosis and Haemostasis. The primary analyses were based on the intention-to-treat population. Additionally, we did a systematic review and random-effects meta-analysis of studies in which patients with cryptogenic stroke and PFO were randomly assigned to receive anticoagulant or antiplatelet therapy.Between Dec 23, 2014, and Sept 20, 2017, 7213 participants were enrolled and assigned to receive rivaroxaban (n=3609) or aspirin (n=3604). Patients were followed up for a mean of 11 months because of early trial termination. PFO was reported as present in 534 (7·4%) patients on the basis of either TTE or TOE. Patients with PFO assigned to receive aspirin had a recurrent ischaemic stroke rate of 4·8 events per 100 person-years compared with 2·6 events per 100 person-years in those treated with rivaroxaban. Among patients with known PFO, there was insufficient evidence to support a difference in risk of recurrent ischaemic stroke between rivaroxaban and aspirin (hazard ratio [HR] 0·54; 95% CI 0·22-1·36), and the risk was similar for those without known PFO (1·06; 0·84-1·33; pinteraction=0·18). The risks of major bleeding with rivaroxaban versus aspirin were similar in patients with PFO detected (HR 2·05; 95% CI 0·51-8·18) and in those without PFO detected (HR 2·82; 95% CI 1·69-4·70; pinteraction=0·68). The random-effects meta-analysis combined data from NAVIGATE ESUS with data from two previous trials (PICSS and CLOSE) and yielded a summary odds ratio of 0·48 (95% CI 0·24-0·96; p=0·04) for ischaemic stroke in favour of anticoagulation, without evidence of heterogeneity.Among patients with ESUS who have PFO, anticoagulation might reduce the risk of recurrent stroke by about half, although substantial imprecision remains. Dedicated trials of anticoagulation versus antiplatelet therapy or PFO closure, or both, are warranted.Bayer and Janssen.

    View details for DOI 10.1016/S1474-4422(18)30319-3

    View details for PubMedID 30274772

  • The Sound of Silence: How Much Noise Should We Make About Postablation Silent Strokes? CIRCULATION Zei, P. C., Vora, N. 2017; 135 (9): 878-880
  • Inter-rater agreement analysis of the Precise Diagnostic Score for suspected transient ischemic attack. International journal of stroke Cereda, C. W., George, P. M., Inoue, M., Vora, N., Olivot, J., Schwartz, N., Lansberg, M. G., Kemp, S., Mlynash, M., Albers, G. W. 2016; 11 (1): 85-92

    Abstract

    No definitive criteria are available to confirm the diagnosis of transient ischemic attack. Inter-rater agreement between physicians regarding the diagnosis of transient ischemic attack is low, even among vascular neurologists. We developed the Precise Diagnostic Score, a diagnostic score that consists of discrete and well-defined clinical and imaging parameters, and investigated inter-rater agreement in patients with suspected transient ischemic attack.Fellowship-trained vascular neurologists, blinded to final diagnosis, independently reviewed retrospectively identical history, physical examination, routine diagnostic studies, and brain magnetic resonance imaging (diffusion and perfusion images) from consecutive patients with suspected transient ischemic attack. Each patient was rated using the 8-point Precise Diagnostic Score score, composed of a clinical score (0-4 points) and an imaging score (0-4 points). The composite Precise Diagnostic Score determines a Precise Diagnostic Score Likelihood of Brain Ischemia Scale: 0-1 = unlikely, 2 = possible, 3 = probable, 4-8 = very likely.Three raters reviewed data from 114 patients. Using Precise Diagnostic Score, all three raters scored a similar percentage of the clinical events as being "probable" or "very likely" caused by brain ischemia: 57, 55, and 58%. Agreement was high for both total Precise Diagnostic Score (intraclass correlation coefficient of 0.94) and for the Likelihood of Brain Ischemia Scale (agreement coefficient of 0.84).Compared with prior studies, inter-rater agreement for the diagnosis of transient brain ischemia appears substantially improved with the Precise Diagnostic Score scoring system. This score is the first to include specific criteria to assess the clinical relevance of diffusion-weighted imaging and perfusion lesions and supports the added value of magnetic resonance imaging for assessing patients with suspected transient ischemic attack.

    View details for DOI 10.1177/1747493015607507

    View details for PubMedID 26763024

  • TIA triage in emergency department using acute MRI (TIA-TEAM): A feasibility and safety study. International journal of stroke Vora, N., Tung, C. E., Mlynash, M., Garcia, M., Kemp, S., Kleinman, J., Zaharchuk, G., Albers, G., Olivot, J. 2015; 10 (3): 343-347

    Abstract

    Positive diffusion weighted imaging (DWI) on MRI is associated with increased recurrent stroke risk in TIA patients. Acute MRI aids in TIA risk stratification and diagnosis.To evaluate the feasibility and safety of TIA triage directly from the emergency department (ED) with acute MRI and neurological consultation.Consecutive ED TIA patients assessed by a neurologist underwent acute MRI/MRA of head/neck per protocol and were hospitalized if positive DWI, symptomatic vessel stenosis, or per clinical judgment. Stroke neurologist adjudicated the final TIA diagnosis as definite, possible, or not a cerebrovascular event. Stroke recurrence rates were calculated at 7, 90, 365 days and compared with predicted stroke rates derived from historical DWI and ABCD(2) score data.One hundred twenty-nine enrolled patients had a mean age of 69 years (±17) and median ABCD(2) score of 3 (interquartile range [IQR] 3-4). During triage, 112 (87%) patients underwent acute MRI after a median of 16 h (IQR 10-23) from symptom onset. No patients experienced a recurrent event before imaging. Twenty-four (21%) had positive DWI and 8 (7%) had symptomatic vessel stenosis. Of the total cohort, 83 (64%) were discharged and 46 (36%) were hospitalized. By one-year follow-up, one patient in each group had experienced a stroke. Of 92 patients with MRI and index cerebrovascular event, recurrent stroke rates were 1·1% at 7 and 90 days. These were similar to predicted recurrence rates.TIA triage in the ED using a protocol with neurological consultation and acute MRI is feasible and safe. The majority of patients were discharged without hospitalization and rates of recurrent stroke were not higher than predicted.

    View details for DOI 10.1111/ijs.12390

    View details for PubMedID 25367837

  • The global burden of neurologic diseases. Neurology Chin, J. H., Vora, N. 2014; 83 (4): 349-351

    View details for DOI 10.1212/WNL.0000000000000610

    View details for PubMedID 25049303

  • A student-initiated and student-facilitated international health elective for preclinical medical students. Medical education online Vora, N., Chang, M., Pandya, H., Hasham, A., Lazarus, C. 2010; 15

    Abstract

    Global health education is becoming more important for developing well-rounded physicians and may encourage students toward a career in primary care. Many medical schools, however, lack adequate and structured opportunities for students beginning the curriculum.Second-year medical students initiated, designed, and facilitated a pass-fail international health elective, providing a curricular framework for preclinical medical students wishing to gain exposure to the clinical and cultural practices of a developing country.All course participants (N=30) completed a post-travel questionnaire within one week of sharing their experiences. Screening reflection essays for common themes that fulfill university core competencies yielded specific global health learning outcomes, including analysis of health care determinants.Medical students successfully implemented a sustainable global health curriculum for preclinical student peers. Financial constraints, language, and organizational burdens limit student participation. In future, long-term studies should analyze career impact and benefits to the host country.

    View details for DOI 10.3402/meo.v15i0.4896

    View details for PubMedID 20186283