Bio

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

Publications

All Publications


  • Time Course for Benefit and Risk of Clopidogrel and Aspirin after Acute Transient Ischemic Attack and Minor Ischemic Stroke: A Secondary Analysis from the POINT Randomized Trial. Circulation Johnston, S. C., Elm, J. J., Easton, J. D., Farrant, M., Barsan, W. G., Kim, A. S., Lindblad, A. S., Palesch, Y. Y., Zurita, K. G., Albers, G. W., Cucchiara, B. L., Kleindorfer, D. O., Lutsep, H. L., Pearson, C., Sethi, P., Vora, N., POINT and Neurological Emergencies Treatment Trials Network Investigators 2019

    Abstract

    BACKGROUND: In patients with acute minor ischemic stroke or high-risk transient ischemic attack enrolled in the POINT trial, the combination of clopidogrel and aspirin for 90 days reduced major ischemic events but increased major hemorrhage compared to aspirin alone.METHODS: In a secondary analysis of POINT (N=4,881), we assessed the time course for benefit and risk from the combination of clopidogrel and aspirin. The primary efficacy outcome was a composite of ischemic stroke, myocardial infarction, or ischemic vascular death. The primary safety outcome was major hemorrhage. Risks and benefits were estimated for delayed times of treatment initiation using left-truncated models.RESULTS: Through 90 days, the rate of major ischemic events was initially high then decreased markedly, while the rate of major hemorrhage remained low but relatively constant throughout. Using a model-based approach, the optimal change-point for major ischemic events was 21 days (0-21 days HR 0.65 for clopidogrel-aspirin vs. aspirin, 95% CI 0.50-0.85, p=0.0015, compared to 22-90 days HR 1.38, 95% CI 0.81-2.35, p=0.24). Models showed benefits of clopidogrel-aspirin for treatment delayed as long as 3 days after symptom onset.CONCLUSIONS: The benefit of clopidogrel-aspirin occurs predominantly within the first 21 days, and outweighs the low, but ongoing risk of major hemorrhage. When considered with the results of CHANCE, a similar trial treating with clopidogrel-aspirin for 21 days and showing no increase in major hemorrhage, these results suggest limiting clopidogrel-aspirin use to 21 days may maximize benefit and reduce risk after high-risk TIA or minor ischemic stroke.CLINICAL TRIAL REGISTRATION: URL: https://clinicaltrials.gov Unique Identifier: NCT00991029.

    View details for DOI 10.1161/CIRCULATIONAHA.119.040713

    View details for PubMedID 31238700

  • 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 PubMedID 28820652

  • NEUROLOGY RESIDENT EDUCATION WITH ACUTE STROKE SIMULATION IMPROVES CODE READINESS Legault, C., Vora, N. SAGE PUBLICATIONS LTD. 2018: 72
  • Stroke Code Simulation Has Sustained Benefit on Neurology Resident Education and Preparedness for Stroke Call Legault, C., Vora, N. LIPPINCOTT WILLIAMS & WILKINS. 2018
  • Design and Implementation of a Novel Acute Stroke Code for the Extended Window of Endovascular Treatment Legault, C., Dujari, S., Shen, S. H., Wagner, A. M., Albers, G., Bernier, E., Callagy, P., Vora, N. LIPPINCOTT WILLIAMS & WILKINS. 2018
  • 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 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 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

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