1
|
Spears RC, McLouth CJ, Pennypacker KR, Frank JA, Maglinger B, Martha S, Trout AL, Roberts J, Stowe AM, Sheikhi L, Pahwa S, Fraser JF. Alterations in Local Peri-Infarct Blood Gases in Stroke Patients Undergoing Thrombectomy. World Neurosurg 2021; 158:e317-e322. [PMID: 34728392 DOI: 10.1016/j.wneu.2021.10.171] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 10/25/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Ischemic stroke is a prevalent, devastating disease with high morbidity and mortality. Despite extensive research using animal models, significant gaps remain in understanding the pathological processes in human stroke. We previously developed a tissue bank to analyze the blood immediately proximal and distal to an intracranial thrombus in patients undergoing mechanical thrombectomy (ClinicalTrials.gov identifier, NCT03153683). Our goal for the present project was to evaluate the blood gas changes and acid/base balance during stroke and determine how vascular collateralization affects these changes. METHODS We analyzed the blood samples and computed tomography angiography collateral scores from the first 62 patients in the BACTRAC (Blood and Clot Thrombectomy Registry and Collaboration) registry. The bicarbonate, partial pressure of oxygen, and partial pressure of carbon dioxide (pCO2) values of the intracranial (distal) and systemic (proximal) arterial blood relative to the occlusive thrombus were analyzed. Analysis of the group differences in systemic and intracranial blood gas values was also performed. RESULTS The partial pressure of oxygen, pCO2, and bicarbonate levels were all significantly higher in the systemic blood than in the intracranial blood (P < 0.001 for all) at thrombectomy. Collateralization did not significantly affect the distal blood gas values. Compared with the female patients, the male patients had had higher systemic pCO2 values (39.8 vs. 36.6 mm Hg; P = 0.0065) and lower systemic and intracranial pH values (7.351 vs. 7.392; P = 0.0047). CONCLUSIONS The arterial blood gases differed immediately proximal and distal to thrombi in large vessel occlusive stroke. Although vascular collateralization did not appear to affect the blood gas changes, some blood gas values differed between men and women. The changes in bicarbonate and pCO2 suggested a compensatory acid-base process occurring at the time of infarction.
Collapse
Affiliation(s)
| | - Christopher J McLouth
- Department of Behavioral Science, University of Kentucky Hospital, Lexington, Kentucky, USA
| | - Keith R Pennypacker
- Department of Neurology and Neuroscience, University of Kentucky, Lexington, Kentucky, USA
| | - Jacqueline A Frank
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA
| | - Benton Maglinger
- Department of Neurology, University of Kentucky Hospital, Lexington, Kentucky, USA
| | - Sarah Martha
- College of Nursing, University of Kentucky, Lexington, Kentucky, USA; Present address: Sarah Martha, Department of Biobehavioral Nursing Science, College of Nursing, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Amanda L Trout
- Department of Neurology and Neuroscience, University of Kentucky, Lexington, Kentucky, USA
| | - Jill Roberts
- Department of Neurology and Neuroscience, University of Kentucky, Lexington, Kentucky, USA; Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA
| | - Ann M Stowe
- Department of Neurology and Neuroscience, University of Kentucky, Lexington, Kentucky, USA; Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA
| | - Lila Sheikhi
- Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA; Department of Neurology, University of Kentucky, Lexington, Kentucky, USA; Department of Radiology, University of Kentucky, Lexington, Kentucky, USA
| | - Shivani Pahwa
- Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA; Department of Neurology, University of Kentucky, Lexington, Kentucky, USA; Department of Radiology, University of Kentucky, Lexington, Kentucky, USA
| | - Justin F Fraser
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, Kentucky, USA; Department of Neurosurgery, University of Kentucky, Lexington, Kentucky, USA; Department of Neurology, University of Kentucky, Lexington, Kentucky, USA; Department of Radiology, University of Kentucky, Lexington, Kentucky, USA
| |
Collapse
|
2
|
Ogata A, Ebashi R, Koguchi M, Suzuyama K, Liu X, Tanaka T, Masuoka J, Yakushiji Y, Hara H, Abe T. Influence of Microcatheter Position on First-pass Success of Thrombectomy for Acute Ischemic Stroke. World Neurosurg 2020; 146:e708-e713. [PMID: 33171319 DOI: 10.1016/j.wneu.2020.10.173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/30/2020] [Accepted: 10/31/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE In acute ischemic stroke, patient outcomes can be improved by first-pass successful recanalization of the occluded vessel. This study investigated whether microcatheter position could influence the success of first-pass recanalization. METHODS We retrospectively analyzed 59 consecutive acute ischemic stroke patients who underwent intra-arterial thrombectomy with stent retrievers for middle cerebral artery (M1) occlusion. Angiography findings obtained via the first pass of the microcatheter were analyzed. The microcatheter was considered to be inserted into M2 segments that gave rise to parietal arteries (M2P) if the anterior or posterior parietal artery was observed. Recanalization results were compared between patients with and without microcatheter insertion into M2P. The angle and diameter of vessels were measured using post-procedural magnetic resonance angiography. RESULTS The rate of first-pass successful recanalization (modified thrombolysis in cerebral infarction score of ≥2b) was significantly higher in patients with microcatheter insertion into M2P than in those without (56% vs. 22%, P = 0.016). The number of passes was lower in patients with first-pass microcatheter insertion into M2P than in those without (1.8 ± 1.0 vs. 2.5 ± 1.5, P = 0.05). The mean diameter of M2P was significantly larger than that of the other M2 (1.9 ± 0.6 mm vs. 1.7 ± 0.5 mm, P = 0.035). The M1/M2P angle was significantly smaller than that between M1 and the other M2. (49° ± 32° vs. 67° ± 31°, P = 0.006). CONCLUSIONS First-pass microcatheter insertion into M2P may contribute to fast successful recanalization in patients with M1 occlusion who undergo intra-arterial thrombectomy using stent retrievers.
Collapse
Affiliation(s)
- Atsushi Ogata
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan.
| | - Ryo Ebashi
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Motofumi Koguchi
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Kenji Suzuyama
- Department of Neurosurgery, Karatsu Red Cross Hospital, Saga, Japan
| | - Xuan Liu
- Department of Neurosurgery, Imari Arita Kyoritsu Hospital, Saga, Japan
| | - Tatsuya Tanaka
- Department of Neurosurgery, Imari Arita Kyoritsu Hospital, Saga, Japan
| | - Jun Masuoka
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Tatsuya Abe
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| |
Collapse
|
3
|
Evaluation of sex differences in acid/base and electrolyte concentrations in acute large vessel stroke. Exp Neurol 2020; 323:113078. [DOI: 10.1016/j.expneurol.2019.113078] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/26/2019] [Accepted: 10/01/2019] [Indexed: 12/26/2022]
|
4
|
Ospel JM, Kashani N, Goyal M, Menon BK, Campbell BCV, Fischer U, Turjman F, Mitchell P, Yoshimura S, Podlasek A, Rabinstein AA, Wilson AT, Kim BM, Baxter BW, Cherian MP, Heo JH, Foss M, Demchuk AM, Sylaja PN, Hill MD, Saposnik G, Almekhlafi MA. Time of day and endovascular treatment decision in acute stroke with relative endovascular treatment indication: insights from UNMASK EVT international survey. J Neurointerv Surg 2019; 12:122-126. [DOI: 10.1136/neurintsurg-2019-014976] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 05/29/2019] [Accepted: 05/30/2019] [Indexed: 11/03/2022]
Abstract
Background and purposeThe decision to proceed with endovascular thrombectomy should ideally be made independent of inconvenience factors, such as daytime. We assessed the influence of patient presentation time on endovascular therapy decision making under current local resources and assumed ideal conditions in acute ischemic stroke with level 2B evidence for endovascular treatment.Methods and materialsIn an international cross sectional survey, 607 stroke physicians from 38 countries were asked to give their treatment decisions to 10 out of 22 randomly assigned case scenarios. Eleven scenarios had level 2B evidence for endovascular treatment: 7 daytime scenarios (7:00 am–5:00 pm) and four night time cases (5:01 pm– 6:59 am). Participants provided their treatment approach assuming (A) there were no practice constraints and (B) under their current local resources. Endovascular treatment decisions in the 11 scenarios were analyzed according to presentation time with adjustment for patient and physician characteristics.ResultsParticipants selected endovascular therapy in 74.2% under assumed ideal conditions, and 70.7% under their current local resources of night time scenarios, and in 67.2% and 63.8% of daytime scenarios. Night time presentation did not increase the probability of a treatment decision against endovascular therapy under current local resources or assumed ideal conditions.ConclusionPresentation time did not influence endovascular treatment decision making in stroke patients in this international survey.
Collapse
|
5
|
Martha SR, Fraser JF, Pennypacker KR. Acid-Base and Electrolyte Changes Drive Early Pathology in Ischemic Stroke. Neuromolecular Med 2019; 21:540-545. [PMID: 31280473 DOI: 10.1007/s12017-019-08555-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 07/01/2019] [Indexed: 12/19/2022]
Abstract
Emergent large vessel occlusion accounts for 20-40% of ischemic strokes and is the most debilitating form of stroke. Some of the earliest changes in response to ischemic stroke occur in blood gases and electrolytes. These biochemical changes occur within minutes after occlusion in experimental models of stroke and can be utilized to predict stroke outcomes. The majority of ELVO stroke patients are middle-aged to elderly and are of both sexes, revealing that there is an age and sex mismatch between ischemic stroke patients and animal models, since most experimental studies use young male rats. Rethinking of the animal models should be considered, especially in encouraging the use of aged male and female rats with comorbidities to more closely mirror human populations. Mechanical thrombectomy provides a unique opportunity for researchers to further this work by expanding the collection and analysis of blood samples that are adjacent to the thrombus. To understand the complexity of stroke, researchers can analyze these tissues for different molecular targets that occur in response to ischemic stroke. This information may aid in the reduction of symptom burden for individuals diagnosed with ischemic stroke. Investigators should also focus on data from ischemic stroke patients and attempt to discover target molecules and then in animal models to establish mechanism, which will aid in the development of new stroke therapies. This review discusses the translation of these studies to the human patient to develop the capability to predict stroke outcomes. Future studies are needed to identify molecular targets to predict the risk of worsened long-term outcomes and/or increased risk for mortality.
Collapse
Affiliation(s)
- Sarah R Martha
- College of Nursing, University of Kentucky, Lexington, KY, USA
| | - Justin F Fraser
- Department of Neurology, University of Kentucky, Center for Advanced Translational Stroke Science, Building BBSRB, Office B377, Lexington, KY, 40536, USA.,Department of Neurosurgery, University of Kentucky, Lexington, KY, USA.,Department of Neuroscience, University of Kentucky, Lexington, KY, USA.,Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Keith R Pennypacker
- Department of Neurology, University of Kentucky, Center for Advanced Translational Stroke Science, Building BBSRB, Office B377, Lexington, KY, 40536, USA. .,Department of Neuroscience, University of Kentucky, Lexington, KY, USA.
| |
Collapse
|
6
|
Martinez-Gutierrez JC, Leslie-Mazwi T, Chandra RV, Ong KL, Nogueira RG, Goyal M, Albuquerque FC, Hirsch JA. Number needed to treat: A primer for neurointerventionalists. Interv Neuroradiol 2019; 25:613-618. [PMID: 31248312 DOI: 10.1177/1591019919858733] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The number needed to treat is a commonly used statistical term in modern neurointerventional practice. It represents the number of patients that need to be treated for one patient to benefit from an intervention. Given its growing popularity in reflecting study results, understanding the basics behind this statistic is of practical value to the neurointerventionalist. METHODS Here, we review the basic theory and calculation of the number needed to treat, its application to stroke interventions, and its limitations. In addition, we demonstrate several simple methods of calculating the number needed to treat utilizing recent thrombectomy trial results. By presenting the number needed to treat as a universal metric, we provide a comprehensive comparative of the number needed to treat for key stroke therapies, including mechanical thrombectomy, tissue plasminogen activator, carotid endarterectomy, and prevention with antiplatelet and statin drugs. CONCLUSIONS In comparison with available stroke therapies, mechanical thrombectomy stands out as the most effective acute intervention in patients with emergent large-vessel occlusions. Understanding how the number needed to treat is derived and its implications helps provide perspective to clinical trial data, identify health-care resource priorities, and improve communication with patients, health-care providers, and additional key stakeholders.
Collapse
Affiliation(s)
| | - Thabele Leslie-Mazwi
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Ronil V Chandra
- Neuro-Interventional Radiology, Monash Imaging, Monash Health, Monash University, Melbourne, Australia
| | | | - Raul G Nogueira
- Neuroendovascular Service, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, USA
| | - Mayank Goyal
- Diagnostic and Interventional Neuroradiology, Seaman Family MR Research Centre, Foothills Medical Centre, Calgary, Canada
| | | | - Joshua A Hirsch
- Neurointerventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| |
Collapse
|
7
|
The pincer movement of cost and quality in neurointerventional care: resource management as an imperative. J Neurointerv Surg 2019; 11:323-325. [DOI: 10.1136/neurintsurg-2019-014871] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2019] [Indexed: 11/03/2022]
|
8
|
Ebashi R, Ogata A, Nishihara M, Inoue K, Yoshioka F, Takase Y, Masuoka J, Yakushiji Y, Irie H, Hara H, Abe T. Significance of simulated conventional images on dual energy CT after endovascular treatment for ischemic stroke. J Neurointerv Surg 2019; 11:898-902. [PMID: 30670626 DOI: 10.1136/neurintsurg-2018-014486] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 12/20/2018] [Accepted: 12/26/2018] [Indexed: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE CT scans often reveal post-interventional cerebral hyperdensities (PCHDs) immediately after intra-arterial thrombectomy (IAT) for ischemic stroke. Dual energy CT (DE-CT) can indicate whether PCHDs are caused by hemorrhage or iodinated contrast. Hyperdense lesions, detected on DE-CT with the use of iodinated contrast, could be associated with delayed hemorrhagic transformation and poor outcome. However, the quantitative indicators in DE-CT for predicting delayed hemorrhagic transformation remain unclear. We assessed such indicators for predicting delayed hemorrhagic transformation. MATERIAL AND METHODS We retrospectively analyzed 52 consecutive acute ischemic stroke patients who underwent IAT. Simulated conventional CT (sCCT) images were obtained immediately after a DE-CT scan. Virtual, unenhanced, non-contrast (VNC) imaging was performed after reconstruction. Hounsfield units (HU) of the infarct areas observed on the sCCT were measured. The association of HU on sCCT with hemorrhage on VNC and delayed parenchymal hemorrhage (PH) was evaluated. RESULTS The HU of sCCT with hemorrhage on VNC was significantly higher than without it (377.9±385 HU vs 83.5±37.9 HU; P<0.0001). The cut-off index was 80 HU, which displayed 100% sensitivity, 63.8% specificity, 22.3% positive predictive value, and 100% negative predictive value (P=0.0001, area under the curve (AUC)=0.89). The HU with delayed PH was substantially higher than without it (250.8±382.2 HU vs 93.7±64.8 HU; P=0.01). The cut-off index was 78 HU, which showed 100% sensitivity, 61% specificity, 25% positive predictive value, and 100% negative predictive value (P=0.049, AUC=0.76). CONCLUSION sCCT images on DE-CT are useful for excluding intracerebral hemorrhage and delayed PH.
Collapse
Affiliation(s)
- Ryo Ebashi
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Atsushi Ogata
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Masashi Nishihara
- Department of Radiology, Faculty of Medicine, Saga University, Saga, Japan
| | - Kohei Inoue
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Fumitaka Yoshioka
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yukinori Takase
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Jun Masuoka
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Yusuke Yakushiji
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Hiroyuki Irie
- Department of Radiology, Faculty of Medicine, Saga University, Saga, Japan
| | - Hideo Hara
- Division of Neurology, Department of Internal Medicine, Faculty of Medicine, Saga University, Saga, Japan
| | - Tatsuya Abe
- Department of Neurosurgery, Faculty of Medicine, Saga University, Saga, Japan
| |
Collapse
|
9
|
Fargen KM, Hirsch JA. Neurointerventionalists, stroke and burnout. J Neurointerv Surg 2018; 10:811-812. [DOI: 10.1136/neurintsurg-2018-014304] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2018] [Indexed: 11/04/2022]
|
10
|
Hirsch JA. Commentary on 'The POST trial: initial post-market experience of the Penumbra system: revascularization of large vessel occlusion in acute ischemic stroke in the United States and Europe'. J Neurointerv Surg 2018; 10:i33-i34. [PMID: 30037951 DOI: 10.1136/neurintsurg-2018-014096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2018] [Indexed: 11/03/2022]
|
11
|
Jadhav AP, Desai SM, Hirsch JA. Thrombolysis in patients with WAKE-UP or unknown time of stroke onset: ready for prime time? J Neurointerv Surg 2018; 10:1130-1131. [PMID: 29973386 DOI: 10.1136/neurintsurg-2018-014154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 11/04/2022]
Affiliation(s)
- Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shashvat M Desai
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Joshua A Hirsch
- NeuroInterventional Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
12
|
Golding LP, Nicola GN, Ansari SA, Rosenkrantz AB, Silva III E, Manchikanti L, Hirsch JA. MACRA 2.5: the legislation moves forward. J Neurointerv Surg 2018; 10:1224-1228. [DOI: 10.1136/neurintsurg-2018-013910] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 06/08/2018] [Accepted: 06/09/2018] [Indexed: 11/04/2022]
Abstract
The Medicare and CHIP Reauthorization Act of 2015 remains the payment policy law of the land. 2017 was the first year in which performance reporting will tangibly impact future physician payments. The Centers for Medicare & Medicaid Services (CMS) considers 2017 and 2018 transitional years before full implementation in 2019. As such, 2018 increases the reporting requirements over 2017 in the form of a gradual phase-in while introducing several key changes and new elements. Indeed, it is the nature of the transition itself that led to the somewhat unique title of this manuscript, i.e., MACRA 2.5. Stakeholder feedback to the CMS regarding the program has ranged widely from the elimination of core components to expanding reporting to non-government payers. This article explores the potential impact on neurointerventional physicians.
Collapse
|
13
|
Kallmes DF, Hirsch JA, Siddiqui AH. Let's -ectomize thrombectomy, shall we? J Neurointerv Surg 2018; 10:1031-1032. [PMID: 29907574 DOI: 10.1136/neurintsurg-2018-014102] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2018] [Indexed: 11/04/2022]
Affiliation(s)
- David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Joshua A Hirsch
- NeuroInterventional Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, New York, USA
| |
Collapse
|
14
|
Williams MM, Wilson TA, Leslie-Mazwi T, Hirsch JA, Kellogg RT, Spiotta AM, De Leacy R, Mocco J, Albuquerque FC, Ducruet AF, Arthur A, Srinivasan VM, Kan P, Mokin M, Dumont TM, Reeves A, Singh J, Wolfe SQ, Fargen KM. The burden of neurothrombectomy call: a multicenter prospective study. J Neurointerv Surg 2018; 10:1143-1148. [PMID: 29678885 DOI: 10.1136/neurintsurg-2018-013772] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/04/2018] [Accepted: 03/09/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Neurothrombectomy frequency is increasing, and a better understanding of the neurothrombectomy call burden is needed. METHODS Neurointerventional physicians at nine participating stroke centers prospectively recorded time requirements for all neurothrombectomy (NT) consultations over 30 consecutive 24 hour call periods. RESULTS Data were collected from a total of 270 days of call. 214 NT consultations were reported (mean 0.79 per day), including 130 'false positive' consultations that ultimately did not lead to thrombectomy (mean 0.48 per day). 84 NT procedures were performed at the nine centers (0.32 per day, or 1 every 3 days). Most (59.8%) consultations occurred between 5pm and 7am. 30% of thrombectomy procedures resulted in delays in scheduled cases; treating physicians had to emergently travel to the hospital for 51.2% of these cases. A median of 27 min was spent on each false positive consultation and 171 min on each thrombectomy. Overall, the median physician time spent on NT responsibilities per 24 hour call period was 69 min (mean 85 min; IQR 16-135 min). CONCLUSIONS NT consultations are frequent and often disrupt physician schedules, requiring physicians to commute in from home after hours in the majority of cases. As procedural and consultation volumes increase, it is crucial to understand the significant burden of call on neurointerventional physicians and develop strategies that reduce the potential for burnout. Importantly, this study was performed prior to the completion of the DAWN and DEFUSE3 trials; NT consultations are expected to continue to increase in the future.
Collapse
Affiliation(s)
- Michelle M Williams
- Department of Neurological Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| | - Taylor A Wilson
- Department of Neurological Surgery, University of Arkansas, Little Rock, Arkansas, USA
| | - Thabele Leslie-Mazwi
- Departments of Neurosurgery and Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Department of Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Adam Arthur
- Department of Neurosurgery, University of Tennessee/Semmes-Murphy Clinic, Memphis, Tennessee, USA
| | | | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Travis M Dumont
- Department of Neurosurgery, University of Arizona, Tucson, Arizona, USA
| | - Alan Reeves
- Department of Radiology, Neuroendovascular Division, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Jasmeet Singh
- Department of Neurological Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Department of Neurological Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| | - Kyle M Fargen
- Department of Neurological Surgery, Wake Forest University, Winston Salem, North Carolina, USA
| |
Collapse
|
15
|
Fargen KM, West JL, Mocco J. Lifting the veil on stroke outcomes: revisiting stroke centers' transparency through public reporting of metrics. J Neurointerv Surg 2018; 10:839-842. [PMID: 29627793 DOI: 10.1136/neurintsurg-2018-013866] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 03/16/2018] [Accepted: 03/19/2018] [Indexed: 12/18/2022]
Abstract
Public reporting of healthcare metrics provides transparency that allows patients and emergency medical providers to make informed decisions about where patients should receive care. Most previous reports about public reporting of health metrics have demonstrated significant improvements in outcome metrics after implementation. However, no mechanism exists, voluntary or otherwise, for the public reporting of outcomes of stroke care. We review the components of public reporting of health outcomes data and its limited history in stroke outcomes. We summarize the literature on public reporting in cardiovascular interventions, particularly percutaneous coronary interventions, as a close corollary to mechanical neurothrombectomy. The benefits, limitations, and controversies associated with reporting of cardiovascular outcomes are reviewed with a focus on the development of risk-avoidant behaviors. This article serves as a primer for discussion of the potential benefits, limitations, and unintended consequences of public reporting of stroke data.
Collapse
Affiliation(s)
- Kyle M Fargen
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - James L West
- Department of Neurosurgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| |
Collapse
|
16
|
Leslie-Mazwi T, Chandra RV, Baxter BW, Arthur AS, Hussain MS, Singh IP, Frei DF, Klucznik RP, Albuquerque FC, Hirsch JA. ELVO: an operational definition. J Neurointerv Surg 2018; 10:507-509. [DOI: 10.1136/neurintsurg-2018-013792] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2018] [Indexed: 11/04/2022]
|
17
|
Motyer R, Asadi H, Thornton J, Nicholson P, Kok HK. Current evidence for endovascular therapy in stroke and remaining uncertainties. J Intern Med 2018; 283:2-15. [PMID: 28727192 DOI: 10.1111/joim.12653] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Class 1 level A evidence now supports endovascular thrombectomy as best practice in the management of large vessel occlusion acute ischaemic stroke. However, significant questions pertaining to initial imaging, radiological assessment, patient selection and therapeutic limits remain unanswered. A specific cohort of patients who benefit from endovascular thrombectomy has been established, although current uncertainties regarding selection of those not meeting top-tier evidence criteria may potentially deny certain patients the benefit of intervention. This is of particular relevance in patients presenting in a delayed manner. Whilst superior outcomes are achieved with reduced time to endovascular reperfusion, denying patients intervention based on symptom duration alone may not be appropriate. Advanced understanding of ischaemic stroke pathophysiology supports an individualized approach to patient evaluation, given variance in the rate of ischaemic core progression and the extent of salvageable penumbra. Physiological imaging techniques may therefore be utilized to better inform patient selection for endovascular thrombectomy and evidence suggests that a transition from time-based to tissue-based therapeutic thresholds may be of greater value. Multiple ongoing randomized controlled trials aim to further define the benefit of endovascular thrombectomy and it is hoped that these results will advance, and possibly broaden, patient selection criteria to ensure that maximum benefit from the intervention may be achieved.
Collapse
Affiliation(s)
- R Motyer
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin, Ireland.,Faculty of Radiologists, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - H Asadi
- Department of Radiology, Interventional Neuroradiology Service, Austin Hospital, Melbourne, VIC, Australia.,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, VIC, Australia.,Faculty of Health, School of Medicine, Deakin University, Waurn Ponds, VIC, Australia
| | - J Thornton
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin, Ireland.,Faculty of Radiologists, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - P Nicholson
- Department of Radiology, Interventional Neuroradiology Service, Beaumont Hospital, Dublin, Ireland.,Faculty of Radiologists, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - H K Kok
- Faculty of Radiologists, Royal College of Surgeons in Ireland, Dublin, Ireland.,Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|
18
|
|
19
|
|
20
|
Rodrigues FB, Neves JB, Caldeira D, Ferro JM, Ferreira JJ, Costa J. Endovascular treatment versus medical care alone for ischaemic stroke: systematic review and meta-analysis. BMJ 2016; 353:i1754. [PMID: 27091337 PMCID: PMC4834754 DOI: 10.1136/bmj.i1754] [Citation(s) in RCA: 130] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To evaluate the efficacy and safety of endovascular treatment, particularly adjunctive intra-arterial mechanical thrombectomy, in patients with ischaemic stroke. DESIGN Systematic review and meta-analysis. DATA SOURCES Medline, Embase, Cochrane Central Register of Controlled Trials, Web of Science, SciELO, LILACS, and clinical trial registries from inception to December 2015. Reference lists were crosschecked. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Randomised controlled trials in adults aged 18 or more with ischaemic stroke comparing endovascular treatment, including thrombectomy, with medical care alone, including intravenous recombinant tissue plasminogen activator (rt-PA). Trial endpoints were functional outcome (modified Rankin scale scores of ≤2) and mortality at 90 days after onset of symptoms. No language or time restrictions applied. RESULTS 10 randomised controlled trials (n=2925) were included. In pooled analysis endovascular treatment, including thrombectomy, was associated with a higher proportion of patients experiencing good (modified Rankin scale scores ≤2) and excellent (scores ≤1) outcomes 90 days after stroke, without differences in mortality or rates for symptomatic intracranial haemorrhage, compared with patients randomised to medical care alone, including intravenous rt-PA. Heterogeneity was high among studies. The more recent studies (seven randomised controlled trials, published or presented in 2015) proved better suited to evaluate the effect of adjunctive intra-arterial mechanical thrombectomy on its index disease owing to more accurate patient selection, intravenous rt-PA being administered at a higher rate and earlier, and the use of more efficient thrombectomy devices. In most of these studies, more than 86% of the patients were treated with stent retrievers, and rates of recanalisation were higher (>58%) than previously reported. Subgroup analysis of these seven studies yielded a risk ratio of 1.56 (95% confidence interval 1.38 to 1.75) for good functional outcomes and 0.86 (0.69 to 1.06) for mortality, without heterogeneity among the results of the studies. All trials were open label. Risk of bias was moderate across studies. The full results of two trials are yet to be published. CONCLUSIONS Moderate to high quality evidence suggests that compared with medical care alone in a selected group of patients endovascular thrombectomy as add-on to intravenous thrombolysis performed within six to eight hours after large vessel ischaemic stroke in the anterior circulation provides beneficial functional outcomes, without increased detrimental effects. SYSTEMATIC REVIEW REGISTRATION PROSPERO CRD42015019340.
Collapse
Affiliation(s)
- Filipe Brogueira Rodrigues
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal Department of Medicine, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal
| | - Joana Briosa Neves
- Department of Medicine, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal
| | - Daniel Caldeira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal
| | - José M Ferro
- Department of Neurosciences, Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal
| | - Joaquim J Ferreira
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal Department of Neurosciences, Neurology, Hospital de Santa Maria, Centro Hospitalar Lisboa Norte, Portugal
| | - João Costa
- Laboratory of Clinical Pharmacology and Therapeutics, Faculty of Medicine, University of Lisbon, Av Prof Egas Moniz 1649-035, Lisbon, Portugal Clinical Pharmacology Unit, Instituto de Medicina Molecular, Lisbon, Portugal Center for Evidence-Based Medicine, Faculty of Medicine, University of Lisbon, Portugal Portuguese Collaborating Center of the IberoAmerican Cochrane Network, Faculty of Medicine, University of Lisbon, Portugal
| |
Collapse
|
21
|
Tsivgoulis G, Safouris A, Krogias C, Arthur AS, Alexandrov AV. Endovascular reperfusion therapies for acute ischemic stroke: dissecting the evidence. Expert Rev Neurother 2016; 16:527-34. [DOI: 10.1586/14737175.2016.1168297] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
22
|
Chandra RV, Leslie-Mazwi TM, Mehta BP, Derdeyn CP, Demchuk AM, Menon BK, Goyal M, González RG, Hirsch JA. Does the use of IV tPA in the current era of rapid and predictable recanalization by mechanical embolectomy represent good value? J Neurointerv Surg 2016; 8:443-6. [PMID: 26758911 DOI: 10.1136/neurintsurg-2015-012231] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 12/14/2015] [Indexed: 11/03/2022]
Abstract
As healthcare delivery in the USA transforms into a model that at its core requires value-based considerations, ischemic stroke is confronted by intersecting forces. Modern techniques allow rapid revascularization in the majority of patients with large vessel occlusions. Dramatic advances in the evidentiary basis for mechanical embolectomy are increasing the number of patients treated with this therapy. A key part of the therapeutic arsenal in many patients treated with interventional techniques has been concurrent intravenous thrombolysis. We consider whether this paradigm warrants change.
Collapse
Affiliation(s)
- Ronil V Chandra
- Department of Imaging, Monash Imaging, Monash Health, Melbourne, Victoria, Australia Stroke and Ageing Research Centre, Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Thabele M Leslie-Mazwi
- NeuroEndovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Colin P Derdeyn
- Departments of Radiology, Neurology and Neurological Surgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Andrew M Demchuk
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Bijoy K Menon
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Departments of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - R Gilberto González
- Neuroradiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
23
|
Rai AT, Smith MS, Boo S, Tarabishy AR, Hobbs GR, Carpenter JS. The 'pit-crew' model for improving door-to-needle times in endovascular stroke therapy: a Six-Sigma project. J Neurointerv Surg 2016; 8:447-52. [PMID: 26863106 PMCID: PMC4853568 DOI: 10.1136/neurintsurg-2015-012219] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 12/17/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND Delays in delivering endovascular stroke therapy adversely affect outcomes. Time-sensitive treatments such as stroke interventions benefit from methodically developed protocols. Clearly defined roles in these protocols allow for parallel processing of tasks, resulting in consistent delivery of care. OBJECTIVE To present the outcomes of a quality-improvement (QI) process directed at reducing stroke treatment times in a tertiary level academic medical center. METHODS A Six-Sigma-based QI process was developed over a 3-month period. After an initial analysis, procedures were implemented and fine-tuned to identify and address rate-limiting steps in the endovascular care pathway. Prospectively recorded treatment times were then compared in two groups of patients who were treated 'before' (n=64) or 'after' (n=30) the QI process. Three time intervals were measured: emergency room (ER) to arrival for CT scan (ER-CT), CT scan to interventional laboratory arrival (CT-Lab), and interventional laboratory arrival to groin puncture (Lab-puncture). RESULTS The ER-CT time was 40 (±29) min in the 'before' and 26 (±15) min in the 'after' group (p=0.008). The CT-Lab time was 87 (±47) min in the 'before' and 51 (±33) min in the 'after' group (p=0.0002). The Lab-puncture time was 24 (±11) min in the 'before' and 15 (±4) min in the 'after' group (p<0.0001). The overall ER-arrival to groin-puncture time was reduced from 2 h, 31 min (±51) min in the 'before' to 1 h, 33 min (±37) min in the 'after' group, (p<0.0001). The improved times were seen for both working hours and off-hours interventions. CONCLUSIONS A protocol-driven process can significantly improve efficiency of care in time-sensitive stroke interventions.
Collapse
Affiliation(s)
- Ansaar T Rai
- Department of Radiology, Neurology and Neurosurgery, West Virginia University, Morgantown, West Virginia, USA
| | - Matthew S Smith
- Department of Neurology, West Virginia University, Morgantown, West Virginia, USA
| | - SoHyun Boo
- Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA
| | - Abdul R Tarabishy
- Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA
| | - Gerald R Hobbs
- Department of Statistics, West Virginia University, Morgantown, West Virginia, USA
| | - Jeffrey S Carpenter
- Interventional Neuroradiology, West Virginia University, Morgantown, West Virginia, USA
| |
Collapse
|
24
|
Mascitelli JR, Wilson N, Shoirah H, De Leacy RA, Furtado SV, Paramasivam S, Oermann EK, Mack WJ, Tuhrim S, Dangayach NS, Meyer SA, Bederson JB, Mocco J, Fifi JT. The impact of evidence: evolving therapy for acute ischemic stroke in a large healthcare system. J Neurointerv Surg 2016; 8:1129-1135. [PMID: 26747878 DOI: 10.1136/neurintsurg-2015-012117] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Accepted: 11/25/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND With a recent surge of clinical trials, the treatment of ischemic stroke has undergone dramatic changes. OBJECTIVE To evaluate the impact of evidence and a revamped stroke protocol on a large healthcare system. METHODS A retrospective review of 69 patients with ischemic stroke treated with intra-arterial therapy was carried out. Cohort 1 included patients treated before implementation of a new stroke protocol, and cohort 2 after implementation. Angiographic outcome was graded using the Thrombolysis in Cerebral Infarction (TICI) score. Clinical outcomes were assessed using the National Institute of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS). RESULTS Primary outcomes comparing cohorts demonstrated decreased arrival-to-puncture time (cohort 2: 104 vs cohort 1: 181 min, p<0.001), similar TICI 2b/3 rates (86.5% vs 81.3%, p=0.5530), and similar percentage of patients with discharge mRS 0-2 (18.9% vs 21.9%, p=0.7740). Notable secondary outcomes for cohort 2 included decreased puncture-to-first pass time (34 vs 53 min, p <0.001), increased TICI 3 rates (37.8% vs 18.8%, p=0.0290), a trend toward greater improvements in NIHSS on postoperative day 1 (6.8 vs 2.6, p=0.0980) and discharge (9.5 vs 6.7, p=0.1130), and a trend toward increased percentage of patients discharged with mRS 0-3 (48.6% vs 34.4%, p=0.3280 NS). There were similar rates of symptomatic intracerebral hemorrhage (10.8% vs 9.4%, p=0.9570) and death (10.8% vs 15.6%, p=0.5530). CONCLUSIONS An interdisciplinary and rapid response to the emergence of strong clinical evidence can result in dramatic changes in a large healthcare system.
Collapse
Affiliation(s)
- Justin R Mascitelli
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Natalie Wilson
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Hazem Shoirah
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Reade A De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Sunil V Furtado
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Srinivasan Paramasivam
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Eric K Oermann
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - William J Mack
- Department of Neurosurgery, Keck Medicine of USC, Los Angeles, California, USA
| | - Stanley Tuhrim
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Neha S Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stephan A Meyer
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Joshua B Bederson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| |
Collapse
|