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Rodriguez Calienes A, Galecio-Castillo M, Petersen NH, Ribo M, Farooqui M, Hassan AE, Jumaa MA, Divani AA, Abraham MG, Fifi JT, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Sheth S, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Lu Y, Vivanco-Suarez J, Dibas M, Mokin M, Yavagal DR, Jovin TG, Ortega-Gutierrez S. Mediation Analysis of Acute Carotid Stenting in Tandem Lesions: Effect on Functional Outcome in a Multicenter Registry. Neurology 2024; 103:e209617. [PMID: 38959444 DOI: 10.1212/wnl.0000000000209617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Current evidence suggests that acute carotid artery stenting (CAS) for cervical lesions is associated with better functional outcomes in patients with acute stroke with tandem lesions (TLs) treated with endovascular therapy (EVT). However, the underlying causal pathophysiologic mechanism of this relationship compared with a non-CAS strategy remains unclear. We aimed to determine whether, and to what degree, reperfusion mediates the relationship between acute CAS and functional outcome in patients with TLs. METHODS This subanalysis stems from a multicenter retrospective cohort study across 16 stroke centers from January 2015 to December 2020. Patients with anterior circulation TLs who underwent EVT were included. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale ≥2B by the local team at each participating center. Mediation analysis was conducted to examine the potential causal pathway in which the relationship between acute CAS and functional outcome (90-day modified Rankin Scale) is mediated by successful reperfusion. RESULTS A total of 570 patients were included, with a median age (interquartile range) of 68 (59-76), among whom 180 (31.6%) were female. Among these patients, 354 (62.1%) underwent acute CAS and 244 (47.4%) had a favorable functional outcome. The remaining 216 (37.9%) patients were in the non-CAS group. The CAS group had significantly higher rates of successful reperfusion (91.2% vs 85.1%; p = 0.025) and favorable functional outcomes (52% vs 29%; p = 0.003) compared with the non-CAS group. Successful reperfusion was a strong predictor of functional outcome (adjusted common odds ratio [acOR] 4.88; 95% CI 2.91-8.17; p < 0.001). Successful reperfusion partially mediated the relationship between acute CAS and functional outcome, as acute CAS remained significantly associated with functional outcome after adjustment for successful reperfusion (acOR 1.89; 95% CI 1.27-2.83; p = 0.002). Successful reperfusion explained 25% (95% CI 3%-67%) of the relationship between acute CAS and functional outcome. DISCUSSION In patients with TL undergoing EVT, successful reperfusion predicted favorable functional outcomes when CAS was performed compared with non-CAS. A considerable proportion (25%) of the treatment effect of acute CAS on functional outcome was found to be mediated by improvement of successful reperfusion rates.
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Affiliation(s)
- Aaron Rodriguez Calienes
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Milagros Galecio-Castillo
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Nils H Petersen
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Marc Ribo
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Mudassir Farooqui
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Ameer E Hassan
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Mouhammad A Jumaa
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Afshin A Divani
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Michael G Abraham
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Johanna T Fifi
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Waldo R Guerrero
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Amer M Malik
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - James E Siegler
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Thanh N Nguyen
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Sunil Sheth
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Albert J Yoo
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Guillermo Linares
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Nazli Janjua
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Darko Quispe-Orozco
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Yujing Lu
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Juan Vivanco-Suarez
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Mahmoud Dibas
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Maxim Mokin
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Dileep R Yavagal
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Tudor G Jovin
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Santiago Ortega-Gutierrez
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
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