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Berdalin AB, Namestnikova DD, Cherkashova EA, Golovin DA, Gubskiy IL, Lelyuk VG. Arterial Hypertension and Its Consequences Are the Main Predictors of Embolic Stroke of Undetermined Source. DISEASE MARKERS 2023; 2023:3469755. [PMID: 38025665 PMCID: PMC10667056 DOI: 10.1155/2023/3469755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Revised: 10/09/2023] [Accepted: 10/28/2023] [Indexed: 12/01/2023]
Abstract
Methods We performed a hospital-based prospective cohort study with 1,317 enrolled participants. We compared patients and healthy volunteers according to the main demographic, anthropometric parameters, stroke risk factors, comorbidities, and data of clinical and instrumental examination. In order to balance the study and the control groups for age and sex, the propensity score matching was performed. In order to generate the overall predictive model, a multivariate analysis was performed using the binary logistic regression method. Results The following predictors of ESUS were identified in current study: arterial hypertension (AH); increased heart rate and pulmonary arterial systolic pressure (PASP); the presence of conduction disturbance; the enlargement of left, right atrium, and left ventricle end-systolic length; increased intima-media thickness (IMT) in right and left common carotid artery (CCA); lowered Montreal Cognitive Assessment (MoСA) cognitive scale score; the presence of subcortical microbleeds; central brain atrophy; the larger size of third ventricle; and the higher medial temporal lobe atrophy (MTA) score. The following risk factors were included in the final predictive model: the presence of AH (p < 0.0005; OR = 12.98 (95% CI: 4.53-37.21)) and PASP (p=0.018; OR = 1.13 (95% CI: 1.02-1.25)) and male sex (p=0.046; OR = 2.771 (95% CI: 1.017-7.555)). The Nagelkerke's pseudo-R-squared value was 0.404 and the significance of the Hosmer-Lemeshow test was 0.733, which indicate the goodness of the final logistic regression model. Conclusions We propose that AH and its consequences are the main predictors of ESUS. The results of this study emphasize the importance of AH control for primary and secondary prevention of ESUS.
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Affiliation(s)
- Alexander B. Berdalin
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
| | - Daria D. Namestnikova
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Elvira A. Cherkashova
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Denis A. Golovin
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
| | - Ilya L. Gubskiy
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
- Pirogov Russian National Research Medical University, Ministry of Healthcare of the Russian Federation, Moscow 117977, Russia
| | - Vladimir G. Lelyuk
- Federal Center of Brain Research and Neurotechnologies, Federal Medical Biological Agency, Moscow 117513, Russia
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Zhuang J, Zhang X, Liu Q, Zhu M, Huang X. Targeted delivery of nanomedicines for promoting vascular regeneration in ischemic diseases. Am J Cancer Res 2022; 12:6223-6241. [PMID: 36168632 PMCID: PMC9475455 DOI: 10.7150/thno.73421] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 08/15/2022] [Indexed: 11/24/2022] Open
Abstract
Ischemic diseases, the leading cause of disability and death, are caused by the restriction or blockage of blood flow in specific tissues, including ischemic cardiac, ischemic cerebrovascular and ischemic peripheral vascular diseases. The regeneration of functional vasculature network in ischemic tissues is essential for treatment of ischemic diseases. Direct delivery of pro-angiogenesis factors, such as VEGF, has demonstrated the effectiveness in ischemic disease therapy but suffering from several obstacles, such as low delivery efficacy in disease sites and uncontrolled modulation. In this review, we summarize the molecular mechanisms of inducing vascular regeneration, providing the guidance for designing the desired nanomedicines. We also introduce the delivery of various nanomedicines to ischemic tissues by passive or active targeting manner. To achieve the efficient delivery of nanomedicines in various ischemic diseases, we highlight targeted delivery of nanomedicines and controllable modulation of disease microenvironment using nanomedicines.
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Affiliation(s)
- Jie Zhuang
- School of Medicine, Nankai University, Tianjin 300071, China.,Key Laboratory of Bioactive Materials for the Ministry of Education, College of Life Sciences, State Key Laboratory of Medicinal Chemical Biology, and Frontiers Science Center for Cell Responses, Nankai University, Tianjin 300071, China.,Joint Laboratory of Nanozymes, College of Life Sciences, Nankai University, Tianjin 300071, China
| | - Xiangyun Zhang
- Key Laboratory of Bioactive Materials for the Ministry of Education, College of Life Sciences, State Key Laboratory of Medicinal Chemical Biology, and Frontiers Science Center for Cell Responses, Nankai University, Tianjin 300071, China.,Joint Laboratory of Nanozymes, College of Life Sciences, Nankai University, Tianjin 300071, China
| | - Qiqi Liu
- Key Laboratory of Bioactive Materials for the Ministry of Education, College of Life Sciences, State Key Laboratory of Medicinal Chemical Biology, and Frontiers Science Center for Cell Responses, Nankai University, Tianjin 300071, China.,Joint Laboratory of Nanozymes, College of Life Sciences, Nankai University, Tianjin 300071, China
| | - Mingsheng Zhu
- Key Laboratory of Bioactive Materials for the Ministry of Education, College of Life Sciences, State Key Laboratory of Medicinal Chemical Biology, and Frontiers Science Center for Cell Responses, Nankai University, Tianjin 300071, China.,Joint Laboratory of Nanozymes, College of Life Sciences, Nankai University, Tianjin 300071, China
| | - Xinglu Huang
- Key Laboratory of Bioactive Materials for the Ministry of Education, College of Life Sciences, State Key Laboratory of Medicinal Chemical Biology, and Frontiers Science Center for Cell Responses, Nankai University, Tianjin 300071, China.,Joint Laboratory of Nanozymes, College of Life Sciences, Nankai University, Tianjin 300071, China
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3
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Monlezun DJ, Sinyavskiy O, Peters N, Steigner L, Aksamit T, Girault MI, Garcia A, Gallagher C, Iliescu C. Artificial Intelligence-Augmented Propensity Score, Cost Effectiveness and Computational Ethical Analysis of Cardiac Arrest and Active Cancer with Novel Mortality Predictive Score. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58081039. [PMID: 36013506 PMCID: PMC9412828 DOI: 10.3390/medicina58081039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 07/27/2022] [Accepted: 07/29/2022] [Indexed: 11/08/2022]
Abstract
Background and objectives: Little is known about outcome improvements and disparities in cardiac arrest and active cancer. We performed the first known AI and propensity score (PS)-augmented clinical, cost-effectiveness, and computational ethical analysis of cardio-oncology cardiac arrests including left heart catheterization (LHC)-related mortality reduction and related disparities. Materials and methods: A nationally representative cohort analysis was performed for mortality and cost by active cancer using the largest United States all-payer inpatient dataset, the National Inpatient Sample, from 2016 to 2018, using deep learning and machine learning augmented propensity score-adjusted (ML-PS) multivariable regression which informed cost-effectiveness and ethical analyses. The Cardiac Arrest Cardio-Oncology Score (CACOS) was then created for the above population and validated. The results informed the computational ethical analysis to determine ethical and related policy recommendations. Results: Of the 101,521,656 hospitalizations, 6,656,883 (6.56%) suffered cardiac arrest of whom 61,300 (0.92%) had active cancer. Patients with versus without active cancer were significantly less likely to receive an inpatient LHC (7.42% versus 20.79%, p < 0.001). In ML-PS regression in active cancer, post-arrest LHC significantly reduced mortality (OR 0.18, 95%CI 0.14−0.24, p < 0.001) which PS matching confirmed by up to 42.87% (95%CI 35.56−50.18, p < 0.001). The CACOS model included the predictors of no inpatient LHC, PEA initial rhythm, metastatic malignancy, and high-risk malignancy (leukemia, pancreas, liver, biliary, and lung). Cost-benefit analysis indicated 292 racial minorities and $2.16 billion could be saved annually by reducing racial disparities in LHC. Ethical analysis indicated the convergent consensus across diverse belief systems that such disparities should be eliminated to optimize just and equitable outcomes. Conclusions: This AI-guided empirical and ethical analysis provides a novel demonstration of LHC mortality reductions in cardio-oncology cardiac arrest and related disparities, along with an innovative predictive model that can be integrated within the digital ecosystem of modern healthcare systems to improve equitable clinical and public health outcomes.
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Affiliation(s)
- Dominique J. Monlezun
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
- UNESCO Chair in Bioethics & Human Rights, 00163 Rome, Italy; (A.G.); (C.G.)
- School of Bioethics, Universidad Anahuac México, Mexico City 52786, Mexico;
- Center for Artificial Intelligence and Health Equities, Global System Analytics & Structures, New Orleans, LA 70112, USA; (N.P.); (L.S.)
- Correspondence: or or
| | - Oleg Sinyavskiy
- Department of Public Health, Asfendiyarov Kazakh National Medical University, Almaty 050000, Kazakhstan;
| | - Nathaniel Peters
- Center for Artificial Intelligence and Health Equities, Global System Analytics & Structures, New Orleans, LA 70112, USA; (N.P.); (L.S.)
| | - Lorraine Steigner
- Center for Artificial Intelligence and Health Equities, Global System Analytics & Structures, New Orleans, LA 70112, USA; (N.P.); (L.S.)
| | - Timothy Aksamit
- Department of Pulmonary Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Maria Ines Girault
- School of Bioethics, Universidad Anahuac México, Mexico City 52786, Mexico;
| | - Alberto Garcia
- UNESCO Chair in Bioethics & Human Rights, 00163 Rome, Italy; (A.G.); (C.G.)
- School of Bioethics, Universidad Anahuac México, Mexico City 52786, Mexico;
| | - Colleen Gallagher
- UNESCO Chair in Bioethics & Human Rights, 00163 Rome, Italy; (A.G.); (C.G.)
- Pontifical Academy for Life, 00193 Rome, Italy
- Section of Integrated Ethics, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Cezar Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA;
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Wan Kim J, Monlezun D, Kun Park J, Chauhan S, Balanescu D, Koutroumpakis E, Palaskas N, Kim P, Hassan S, Botz G, Crommett J, Reddy D, Cilingiroglu M, Marmagkiolis K, Iliescu C. Post-Cardiac Arrest PCI is Underutilized Among Cancer Patients: Machine Learning Augmented Nationally Representative Case-Control Study of 30 Million Hospitalizations. Resuscitation 2022; 179:43-49. [PMID: 35933056 DOI: 10.1016/j.resuscitation.2022.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/05/2022] [Accepted: 07/25/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Cancer patients are less likely to undergo percutaneous coronary intervention (PCI) after cardiac arrest, although they demonstrate improved mortality benefit from the procedure. We produced the largest nationally representative analysis of mortality of cardiac arrest and PCI for patients with cancer versus non-cancer. METHODS Propensity score adjusted multivariable regression for mortality was performed in this case-control study of the United States' largest all-payer hospitalized dataset, the 2016 National Inpatient Sample. Regression models of mortality and PCI weighted by the complex survey design were fully adjusted for age, race, income, cancer metastases, NIS-calculated mortality risk by Diagnosis Related Group (DRG), acute coronary syndrome, and likelihood of undergoing PCI RESULTS: Of the 30,195,722 hospitalized adult patients, 15.43% had cancer, and 0.79% of the whole sample presented with cardiac arrest (of whom 20.57% underwent PCI). In fully adjusted regression analysis among patients with cardiac arrest, PCI significantly reduced mortality (OR 0.15, 95%CI 0.13-0.19; p<0.001) among patients with cancer greater than those without it (OR 0.21, 95%CI 0.20-0.23; p<0.001). CONCLUSIONS This nationally representative study suggests that post-cardiac arrest PCI is underutilized among patients with cancer despite its significant mortality reduction for such patients (independent of clinical acuity).
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Affiliation(s)
- Jin Wan Kim
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA.
| | - Dominique Monlezun
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jong Kun Park
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Siddharth Chauhan
- Department of Internal Medicine, The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Dinu Balanescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Nicolas Palaskas
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Peter Kim
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Saamir Hassan
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gregory Botz
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - John Crommett
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dereddi Reddy
- Department of Critical Care Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mehmet Cilingiroglu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Cezar Iliescu
- Department of Cardiology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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Fractional Flow Reserve Cardio-Oncology Effects on Inpatient Mortality, Length of Stay, and Cost Based on Malignancy Type: Machine Learning Supported Nationally Representative Case-Control Study of 30 Million Hospitalizations. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58070859. [PMID: 35888578 PMCID: PMC9320131 DOI: 10.3390/medicina58070859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 06/23/2022] [Accepted: 06/25/2022] [Indexed: 11/16/2022]
Abstract
Background and Objectives: There are no nationally representative studies of mortality and cost effectiveness for fractional flow reserve (FFR) guided percutaneous coronary interventions (PCI) in patients with cancer. Our study aims to show how this patient population may benefit from FFR-guided PCI. Materials and Methods: Propensity score matched analysis and backward propagation neural network machine learning supported multivariable regression was performed for inpatient mortality in this case-control study of the 2016 National Inpatient Sample (NIS). Regression results were adjusted for age, race, income, geographic region, metastases, mortality risk, and the likelihood of undergoing FFR versus non-FFR PCI. All analyses were adjusted for the complex survey design to produce nationally representative estimates. Results: Of the 30,195,722 hospitalized patients meeting criteria, 3.37% of the PCIs performed included FFR. In propensity score adjusted multivariable regression, FFR versus non-FFR PCI significantly reduced inpatient mortality (OR 0.47, 95%CI 0.35−0.63; p < 0.001) and length of stay (LOS) (in days; beta −0.23, 95%CI −0.37−−0.09; p = 0.001) while increasing cost (in USD; beta $5708.63, 95%CI, 3042.70−8374.57; p < 0.001), without significantly increasing complications overall. FFR versus non-FFR PCI did not specifically change cancer patients’ inpatient mortality, LOS, or cost. However, FFR versus non-FFR PCI significantly increased inpatient mortality for Hodgkin’s lymphoma (OR 52.48, 95%CI 7.16−384.53; p < 0.001) and rectal cancer (OR 24.38, 95%CI 2.24−265.73; p = 0.009). Conclusions: FFR-guided PCI may be safely utilized in patients with cancer as it does not significantly increase inpatient mortality, complications, and LOS. These findings support the need for an increased utilization of FFR-guided PCI and further studies to evaluate its long-term impact.
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Thomason N, Monlezun DJ, Javaid A, Filipescu A, Koutroumpakis E, Shobayo F, Kim P, Lopez-Mattei J, Cilingiroglu M, Iliescu G, Marmagkiolis K, Ramirez PT, Iliescu C. Percutaneous Coronary Intervention in Patients With Gynecological Cancer: Machine Learning-Augmented Propensity Score Mortality and Cost Analysis for 383,760 Patients. Front Cardiovasc Med 2022; 8:793877. [PMID: 35237670 PMCID: PMC8882615 DOI: 10.3389/fcvm.2021.793877] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/20/2021] [Indexed: 12/26/2022] Open
Abstract
BackgroundDespite the growing number of patients with both coronary artery disease and gynecological cancer, there are no nationally representative studies of mortality and cost effectiveness for percutaneous coronary interventions (PCI) and this cancer type.MethodsBackward propagation neural network machine learning supported and propensity score adjusted multivariable regression was conducted for the above outcomes in this case-control study of the 2016 National Inpatient Sample (NIS), the United States' largest all-payer hospitalized dataset. Regression models were fully adjusted for age, race, income, geographic region, cancer metastases, mortality risk, and the likelihood of undergoing PCI (and also with length of stay [LOS] for cost). Analyses were also adjusted for the complex survey design to produce nationally representative estimates. Centers for Disease Control and Prevention (CDC)-based cost effectiveness ratio (CER) analysis was performed.ResultsOf the 30,195,722 hospitalized patients meeting criteria, 1.27% had gynecological cancer of whom 0.02% underwent PCI including 0.04% with metastases. In propensity score adjusted regression among all patients, the interaction of PCI and gynecological cancer (vs. not having PCI) significantly reduced mortality (OR 0.53, 95%CI 0.36–0.77; p = 0.001) while increasing LOS (Beta 1.16 days, 95%CI 0.57–1.75; p < 0.001) and total cost (Beta $31,035.46, 95%CI 26758.86–35312.06; p < 0.001). Among gynecological cancer patients, mortality was significantly reduced by PCI (OR 0.58, 95%CI 0.39–0.85; p = 0.006) and being in East North Central, West North Central, South Atlantic, and Mountain regions (all p < 0.03) compared to New England. PCI reduced mortality but not significantly for metastatic patients (OR 0.74, 95%CI 0.32–1.71; p = 0.481). Eighteen extra gynecological cancer patients' lives were saved with PCI for a net national cost of $3.18 billion and a CER of $176.50 million per averted death.ConclusionThis large propensity score analysis suggests that PCI may cost inefficiently reduce mortality for gynecological cancer patients, amid income and geographic disparities in outcomes.
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Affiliation(s)
- Nicole Thomason
- Division of Cardiology, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Dominique J. Monlezun
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
- Center for Artificial Intelligence & Health Equities, Global System Analytics & Structures, New Orleans, LA, United States
| | - Awad Javaid
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, United States
| | - Alexandru Filipescu
- Division of Cardiology, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Efstratios Koutroumpakis
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Fisayomi Shobayo
- Division of Cardiology, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Peter Kim
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Juan Lopez-Mattei
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
| | - Mehmet Cilingiroglu
- Department of Internal Medicine, University of Nevada Las Vegas School of Medicine, Las Vegas, NV, United States
| | - Gloria Iliescu
- Department of Internal Medicine, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Kostas Marmagkiolis
- Division of Cardiovascular Disease, University of Arkansas for Medical Sciences, Little Rock, AR, United States
| | - Pedro T. Ramirez
- Department of GynOnc and Reproductive Medicine, The University of Texas Health Sciences Center at Houston, Houston, TX, United States
| | - Cezar Iliescu
- Department of Cardiology, The University of Texas M.D. Anderson Cancer Center, Houston, TX, United States
- *Correspondence: Cezar Iliescu
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Racial and Socioeconomic Disparities in Out-Of-Hospital Cardiac Arrest Outcomes: Artificial Intelligence-Augmented Propensity Score and Geospatial Cohort Analysis of 3,952 Patients. Cardiol Res Pract 2021; 2021:3180987. [PMID: 34868674 PMCID: PMC8635948 DOI: 10.1155/2021/3180987] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/13/2021] [Accepted: 10/29/2021] [Indexed: 12/30/2022] Open
Abstract
Introduction Social disparities in out-of-hospital cardiac arrest (OHCA) outcomes are preventable, costly, and unjust. We sought to perform the first large artificial intelligence- (AI-) guided statistical and geographic information system (GIS) analysis of a multiyear and multisite cohort for OHCA outcomes (incidence and poor neurological disposition). Method We conducted a retrospective cohort analysis of a prospectively collected multicenter dataset of adult patients who sequentially presented to Houston metro area hospitals from 01/01/07-01/01/16. Then AI-based machine learning (backward propagation neural network) augmented multivariable regression and GIS heat mapping were performed. Results Of 3,952 OHCA patients across 38 hospitals, African Americans were the most likely to suffer OHCA despite representing a significantly lower percentage of the population (42.6 versus 22.8%; p < 0.001). Compared to Caucasians, they were significantly more likely to have poor neurological disposition (OR 2.21, 95%CI 1.25–3.92; p=0.006) and be discharged to a facility instead of home (OR 1.39, 95%CI 1.05–1.85; p=0.023). Compared to the safety net hospital system primarily serving poorer African Americans, the university hospital serving primarily higher income commercially and Medicare insured patients had the lowest odds of death (OR 0.45, p < 0.001). Each additional $10,000 above median household income was associated with a decrease in the total number of cardiac arrests per zip code by 2.86 (95%CI -4.26- -1.46; p < 0.001); zip codes with a median income above $54,600 versus the federal poverty level had 14.62 fewer arrests (p < 0.001). GIS maps showed convergence of the greater density of poor neurologic outcome cases and greater density of poorer African American residences. Conclusion This large, longitudinal AI-guided analysis statistically and geographically identifies racial and socioeconomic disparities in OHCA outcomes in a way that may allow targeted medical and public health coordinated efforts to improve clinical, cost, and social equity outcomes.
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Mac Grory B, Emmer BJ, Roosendaal SD, Zagzag D, Yaghi S, Nossek E. Carotid web: an occult mechanism of embolic stroke. J Neurol Neurosurg Psychiatry 2020; 91:1283-1289. [PMID: 33004431 DOI: 10.1136/jnnp-2020-323938] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/20/2020] [Accepted: 08/19/2020] [Indexed: 12/26/2022]
Abstract
The carotid web is a proposed stroke mechanism that may underlie cryptogenic stroke, particularly in younger patients without vascular risk factors. The web appears as a shelf-like projection into the lumen of the proximal cervical internal carotid artery without evidence of calcification. It is pathologically defined as intimal fibromuscular dysplasia. Altered haemodynamics distal to the web cause flow stagnation and remote embolisation of fibrin-based clots. It is best demonstrated and diagnosed on CT angiography (CTA) of the neck because of its ability to resolve calcium and create multiplanar reconstructions. Although they can be readily visualised on CTA, carotid webs may be missed or misinterpreted because they do not typically cause haemodynamically significant stenosis and can mimic arterial dissection, non-calcified atherosclerotic plaque and intraluminal thrombus. Options for management include antiplatelet therapy, carotid endarterectomy and carotid artery stenting. Modern management strategies for cryptogenic stroke include long-term cardiac monitoring, further investigation for structural cardiac disease and a diagnostic workup for arterial hypercoagulability, however, these strategies are not likely to capture the possibility of a carotid web. Carotid webs should be suspected in a young patient presenting with recurrent unihemispheric strokes particularly when conventional vascular risk factors are not present.
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Affiliation(s)
- Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bart J Emmer
- Department of Radiology, Amsterdam University Medical Centres, Duivendrecht, Noord-Holland, The Netherlands
| | - Stefan D Roosendaal
- Department of Radiology, Amsterdam University Medical Centres, Duivendrecht, Noord-Holland, The Netherlands
| | - David Zagzag
- Department of Pathology, NYU Langone Health, New York, New York, USA
| | - Shadi Yaghi
- Department of Neurology, NYU Langone Medical Center, New York, New York, USA
| | - Erez Nossek
- Department of Neurosurgery, New York University School of Medicine, New York, New York, USA
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Modolo GP, Souza JTD, Winckler FC, Ferreira NC, Lange MC, Avelar WM, Minicucci MF, Freitas CCMD, Azevedo PS, Luvizutto GJ, Zornoff LAM, Bazan SGZ, Bazan R. Embolic stroke of undetermined source (ESUS) cohort of Brazilian patients in a university hospital. ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:315-320. [PMID: 31188994 DOI: 10.1590/0004-282x20190045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 01/20/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Embolic stroke of undetermined source (ESUS) is an important group of cryptogenic strokes that are in evidence due recent ongoing trials. We reviewed medical records at discharge from the stroke unit of all patients who met ESUS criteria and attended our institution between February 2016 and July 2017. Among 550 stroke patients, 51 had ESUS. We found that hypertension (60%), diabetes mellitus (34%), and smoking (36%) were the most prevalent risk factors. The mean National Institutes of Health Stroke Scale (NIHSS) scores were 7 at admission and 4 at discharge, while median scores on the modified Rankin scale were 0 and 2 at admission and discharge, respectively. Our sample had similar ages, risk factors prevalence and NIHSS scores at admission and discharge when compared with European and North American cohorts. Although a small cohort, our study suggests that the ESUS population is similar in countries with different health financing.
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Affiliation(s)
- Gabriel Pinheiro Modolo
- Neurology, Psychiatry and Psycology Department, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, São Paulo, Brazil
| | - Juli Thomaz De Souza
- Neurology, Psychiatry and Psycology Department, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, São Paulo, Brazil
| | - Fernanda Cristina Winckler
- Neurology, Psychiatry and Psycology Department, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, São Paulo, Brazil
| | | | - Marcos Cristiano Lange
- Neurology Division, Internal Medicine Department, Hospital de Clínicas, Federal University of Paraná, Curitiba PR, Brazil
| | | | - Marcos Ferreira Minicucci
- Internal Medicine Department, Medical School, São Paulo State University (Unesp), Botucatu, São Paulo, Brazil
| | - Carlos Clayton Macedo de Freitas
- Neurology, Psychiatry and Psycology Department, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, São Paulo, Brazil
| | - Paula Schmidt Azevedo
- Internal Medicine Department, Medical School, São Paulo State University (Unesp), Botucatu, São Paulo, Brazil
| | - Gustavo José Luvizutto
- Department of Applied Physical Therapy, Federal University of Tri^angulo Mineiro (UFTM), Uberaba, Brazil
| | | | - Silméia Garcia Zanati Bazan
- Internal Medicine Department, Medical School, São Paulo State University (Unesp), Botucatu, São Paulo, Brazil
| | - Rodrigo Bazan
- Neurology, Psychiatry and Psycology Department, Botucatu Medical School, São Paulo State University (Unesp), Botucatu, São Paulo, Brazil
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Sommer CJ. Ischemic stroke: experimental models and reality. Acta Neuropathol 2017; 133:245-261. [PMID: 28064357 PMCID: PMC5250659 DOI: 10.1007/s00401-017-1667-0] [Citation(s) in RCA: 344] [Impact Index Per Article: 49.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/31/2016] [Accepted: 01/01/2017] [Indexed: 12/11/2022]
Abstract
The vast majority of cerebral stroke cases are caused by transient or permanent occlusion of a cerebral blood vessel (“ischemic stroke”) eventually leading to brain infarction. The final infarct size and the neurological outcome depend on a multitude of factors such as the duration and severity of ischemia, the existence of collateral systems and an adequate systemic blood pressure, etiology and localization of the infarct, but also on age, sex, comorbidities with the respective multimedication and genetic background. Thus, ischemic stroke is a highly complex and heterogeneous disorder. It is immediately obvious that experimental models of stroke can cover only individual specific aspects of this multifaceted disease. A basic understanding of the principal molecular pathways induced by ischemia-like conditions comes already from in vitro studies. One of the most frequently used in vivo models in stroke research is the endovascular suture or filament model in rodents with occlusion of the middle cerebral artery (MCA), which causes reproducible infarcts in the MCA territory. It does not require craniectomy and allows reperfusion by withdrawal of the occluding filament. Although promptly restored blood flow is far from the pathophysiology of spontaneous human stroke, it more closely mimics the therapeutic situation of mechanical thrombectomy which is expected to be increasingly applied to stroke patients. Direct transient or permanent occlusion of cerebral arteries represents an alternative approach but requires craniectomy. Application of endothelin-1, a potent vasoconstrictor, allows induction of transient focal ischemia in nearly any brain region and is frequently used to model lacunar stroke. Circumscribed and highly reproducible cortical lesions are characteristic of photothrombotic stroke where infarcts are induced by photoactivation of a systemically given dye through the intact skull. The major shortcoming of this model is near complete lack of a penumbra. The two models mimicking human stroke most closely are various embolic stroke models and spontaneous stroke models. Closeness to reality has its price and goes along with higher variability of infarct size and location as well as unpredictable stroke onset in spontaneous models versus unpredictable reperfusion in embolic clot models.
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Affiliation(s)
- Clemens J Sommer
- Institute of Neuropathology, University Medical Center of the Johannes Gutenberg-University Mainz; Focus Program Translational Neuroscience (FTN) and Rhine Main Neuroscience Network (rmn2), Langenbeckstrasse 1, 55131, Mainz, Germany.
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Fibrilación auricular paroxística en ataque cerebro-vascular criptogénico. REVISTA COLOMBIANA DE CARDIOLOGÍA 2016. [DOI: 10.1016/j.rccar.2016.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Pikija S, Magdic J, Trkulja V, Unterkreuter P, Mutzenbach JS, Novak HF, Weymayr F, Hauer L, Sellner J. Intracranial Thrombus Morphology and Composition Undergoes Time-Dependent Changes in Acute Ischemic Stroke: A CT Densitometry Study. Int J Mol Sci 2016; 17:ijms17111959. [PMID: 27886084 PMCID: PMC5133953 DOI: 10.3390/ijms17111959] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2016] [Revised: 11/13/2016] [Accepted: 11/18/2016] [Indexed: 11/16/2022] Open
Abstract
The aim of our study was to assess whether cerebral artery clots undergo time-dependent morphological and compositional changes in acute ischemic stroke. We performed a retrospective chart review of patients admitted within 5 h from symptom onset to three European stroke centers and evaluated non-contrast-enhanced CT (NECT) for hyperdense artery signs (HAS) in 2565 scans. The occlusion site, density of HAS expressed in Hounsfield units (HU), area of HAS, and relative density (rHU) (HU clot/HU non-affected artery) were studied and related to time from symptom onset, clinical severity, stroke etiology, and laboratory parameters. A HAS was present in the middle cerebral artery (MCA) in 185 (7.2%) and further explored. The mean time from symptom onset to CT was 100 min (range 17–300). We found a time-dependent loss of density in the occluded M1 segment within the first 5 h (N = 118, 95% CI [−15, −2], p = 0.01). Further, the thrombus area in the M2 segment decreased with time (cubic trend N = 67, 95% CI [−63, −8], p = 0.02). Overall, and especially in the M2 segment, a lower clot area was associated with higher fibrinogen (−21.7%, 95% CI [−34.8, −5.8], p = 0.009). In conclusion, our results disclosed time-dependent changes of intracranial thrombi with regard to occlusion site, density and area.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Jozef Magdic
- Department of Neurology, Univerzitetni Klinični Center, 2000 Maribor, Slovenia.
| | - Vladimir Trkulja
- Department for Pharmacology, School of Medicine, University of Zagreb, 10000 Zagreb, Croatia.
| | | | | | - Helmut F Novak
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Friedrich Weymayr
- Division of Neuroradiology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Larissa Hauer
- Department of Psychiatry, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, 5020 Salzburg, Austria.
- Department of Neurology, Klinikum rechts der Isar, Technische Universität, 81675 München, Germany.
- Institute of Linguistics, University of Salzburg, 5020 Salzburg, Austria.
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Siegler JE, Samai A, Semmes E, Martin-Schild S. Early Neurologic Deterioration after Stroke Depends on Vascular Territory and Stroke Etiology. J Stroke 2016; 18:203-10. [PMID: 27283280 PMCID: PMC4901951 DOI: 10.5853/jos.2016.00073] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/08/2016] [Accepted: 05/09/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND PURPOSE Early neurologic deterioration (END) occurs in up to one-third of patients with ischemic stroke and is associated with poor outcomes. The purpose of the present study was to determine which stroke etiologies and vascular distributions pose a greater threat of END in stroke patients. METHODS Using a single-center registry of prospectively maintained clinical data, adult ischemic stroke patients admitted (July 2008 to June 2014) within 48 hours of symptom onset were evaluated according to stroke etiology and vascular distribution using diffusion-weighted MRI. Major stroke etiologies were divided into cardioembolic, large vessel, small vessel, other, unknown source, and multiple possible etiologies. END was defined as a worsening of 2 or more points on the National Institutes of Health Stroke Scale during a 24-hour period of hospitalization. Crude and backward stepwise regression models were generated to associate stroke etiology and vascular distribution with END. RESULTS Of the included 961 patients (median age 65 years, 47% female, 72% non-White), 323 (34%) experienced END. Strokes involving the internal carotid artery (ICA) were associated with a threefold higher odds of END in stepwise regression models (OR 3.0, 95% CI 1.4-6.6, P=0.006). Among stroke etiologies, those with unclear mechanisms had the lowest odds of END in the fully adjusted model (OR 0.6, 95% CI 0.4-1.0, P=0.029). CONCLUSIONS In our single-center cohort of patients, ICA infarctions were independently associated with END whereas strokes of unknown etiology were least often associated with END. Larger cohorts are necessary to determine which steps, if any, can be taken to prevent END in these vulnerable populations.
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Affiliation(s)
- Jeffrey L Saver
- From the Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles (UCLA), Los Angeles
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