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Ospel JM, Diprose WK, Ganesh A, Martins S, Nguyen T, Psychogios M, Mansour O, Al-Ajlan F, Yang P, Pandian J, Gopinathan A, Sandset EC, Kennedy J, Volders D, Fahed R, Tjoumakaris S, Bhogal P, Kurz M, Yavagal D, Inoa V, Hill MD, Goyal M. Challenges to Widespread Implementation of Stroke Thrombectomy. Stroke 2024; 55:2173-2183. [PMID: 38979609 DOI: 10.1161/strokeaha.124.045889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Abstract
Endovascular treatment (EVT) for acute ischemic stroke is one of the most efficacious and effective treatments in medicine, yet globally, its implementation remains limited. Patterns of EVT underutilization exist in virtually any health care system and range from a complete lack of access to selective undertreatment of certain patient subgroups. In this review, we outline different patterns of EVT underutilization and possible causes. We discuss common challenges and bottlenecks that are encountered by physicians, patients, and other stakeholders when trying to establish and expand EVT services in different scenarios and possible pathways to overcome these challenges. Lastly, we discuss the importance of implementation research studies, strategic partnerships, and advocacy efforts to mitigate EVT underutilization.
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Affiliation(s)
- Johanna Maria Ospel
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - William K Diprose
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Sheila Martins
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil (S.M.)
| | - Thanh Nguyen
- Departments of Radiology and Neurology, Boston Medical Center, MA (T.N.)
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Switzerland (M.P.)
| | - Ossama Mansour
- Alexandria Faculty of Medicine, Department of Neurology, Alexandria University, Egypt (O.M.)
| | - Fahad Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia (F.A.-A.)
| | - Pengfei Yang
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (P.Y.)
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Vellore, India (J.P.)
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore (A. Gopinathan)
| | | | - James Kennedy
- Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom (J.K.)
| | - David Volders
- Department of Radiology, Dalhousie University, Halifax, Canada (D.V.)
| | - Robert Fahed
- Division Neurology, Department of Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada (R.F.)
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA (S.T.)
| | - Pervinder Bhogal
- Department of Neuroradiology, The Royal London Hospital, Barts NHS Trust, United Kingdom (P.B.)
| | - Martin Kurz
- Department of Neurology, Stavanger University Hospital, Norway (M.K.)
| | - Dileep Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, FL (D.Y.)
| | - Violiza Inoa
- Department of Neurology, University of Tennessee Health Science Center, Memphis (V.I.)
| | - Michael D Hill
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
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Hussein HM, Yang MK, Ramezani S, Sharma R, Lodhi OUH, Owens-Pochinka Y, Lu J, Elbokl A. Racial Impact on Inpatient Stroke Quality of Care in Two Community Hospitals. J Clin Med 2023; 12:7654. [PMID: 38137723 PMCID: PMC10743521 DOI: 10.3390/jcm12247654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2023] [Revised: 12/08/2023] [Accepted: 12/09/2023] [Indexed: 12/24/2023] Open
Abstract
INTRODUCTION This analysis was conducted as a part of a quality improvement project aiming at identifying racial disparity in inpatient stroke quality of care. METHODS The Get With The Guidelines (GWTG) database was used to identify all patients discharged with any stroke diagnosis between January and December 2021. An additional chart review was conducted to ensure the accuracy of racial/ethnic categorization. The sample was dichotomized into white vs. non-white groups and compared with univariate analysis. RESULTS The study sample comprised 1408 encounters (1347 patients) with Mean age of 71 ± 15 years, 51% women, 82% white patients, 15% non-white patients, 72% acute ischemic stroke (AIS); 15% transient ischemic attack (TIA), 9% intracerebral hemorrhage (ICH), 3% subarachnoid hemorrhage (SAH), and 1% stroke not otherwise specified. Non-white patients were younger and had fewer concomitant diagnoses, a lower proportion of TIA, and a higher proportion of ICH (p = 0.004). In the AIS cohort, compared to white patients, non-white patients had less frequent ambulance (p = 0.009), arrived at the hospital later than white patients (7.7 h longer; p < 0.001), had more severe strokes, and had less frequent IV thrombolysis utilization (7% vs. 13%; p = 0.042). Similarly, in the TIA cohort, non-white patients' utilization of EMS was lower than that of white patients, and their hospital arrival was delayed. In the ICH cohort, non-white patients were younger and had a lower frequency of atrial fibrillation and a non-significant trend toward higher disease severity. The SAH cohort had only eight non-white patients, six of whom were transferred to a higher level of hospital care within a few hours of arrival. Importantly, the hospital-based quality metrics, such as door-to-CT time, door-to-needle time, and the Joint Commission stroke quality metrics, were similar between the two groups. CONCLUSIONS There is a racial disparity in the pre-hospital phase of the stroke chain of survival of non-white patients, impacting IV thrombolysis utilization. The younger age and worse lipid profile and hemoglobin A1c of non-white patients suggest the need for better preventative care starting at a young age.
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Affiliation(s)
- Haitham M. Hussein
- Department of Neurology, University of Minnesota, MMC 295, 420 Delaware Street SE, Minneapolis, MN 55455, USA (S.R.); (R.S.); (O.u.h.L.); (Y.O.-P.); (J.L.)
| | - Mai-Kau Yang
- Department of Neurology, University of Minnesota, MMC 295, 420 Delaware Street SE, Minneapolis, MN 55455, USA (S.R.); (R.S.); (O.u.h.L.); (Y.O.-P.); (J.L.)
| | - Solmaz Ramezani
- Department of Neurology, University of Minnesota, MMC 295, 420 Delaware Street SE, Minneapolis, MN 55455, USA (S.R.); (R.S.); (O.u.h.L.); (Y.O.-P.); (J.L.)
| | - Rishi Sharma
- Department of Neurology, University of Minnesota, MMC 295, 420 Delaware Street SE, Minneapolis, MN 55455, USA (S.R.); (R.S.); (O.u.h.L.); (Y.O.-P.); (J.L.)
| | - Omair ul haq Lodhi
- Department of Neurology, University of Minnesota, MMC 295, 420 Delaware Street SE, Minneapolis, MN 55455, USA (S.R.); (R.S.); (O.u.h.L.); (Y.O.-P.); (J.L.)
| | - Yaroslav Owens-Pochinka
- Department of Neurology, University of Minnesota, MMC 295, 420 Delaware Street SE, Minneapolis, MN 55455, USA (S.R.); (R.S.); (O.u.h.L.); (Y.O.-P.); (J.L.)
| | - Jinci Lu
- Department of Neurology, University of Minnesota, MMC 295, 420 Delaware Street SE, Minneapolis, MN 55455, USA (S.R.); (R.S.); (O.u.h.L.); (Y.O.-P.); (J.L.)
| | - Ahmed Elbokl
- Institute of Health Informatics, University of Minnesota, Minneapolis, MN 55455, USA;
- Department of Neurology, Ain Shams University, Cairo 11517, Egypt
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Naqvi IA, Cohen AS, Kim Y, Harris J, Denny MC, Strobino K, Bicher N, Leite RA, Sadowsky D, Adegboye C, Okpala N, Okpala M, Savitz SI, Marshall RS, Sharrief A. Inequities in Telemedicine Use Among Patients With Stroke and Cerebrovascular Diseases. Neurol Clin Pract 2023; 13:e200148. [PMID: 37064589 PMCID: PMC10101710 DOI: 10.1212/cpj.0000000000200148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 01/26/2023] [Indexed: 03/18/2023]
Abstract
Background and ObjectivesIn response to the COVID-19 pandemic, outpatient stroke care delivery was rapidly transformed to outpatient evaluation through video (VTM) and telephone (TPH) telemedicine (TM) visits around the world. We sought to evaluate the sociodemographic differences in outpatient TM use among stroke patients.MethodsWe conducted a retrospective chart review of outpatients evaluated at 3 tertiary stroke centers in the early period of the pandemic, 3/16/2020 through 7/31/2020. We compared the use of TM by patient characteristics including age, sex, race/ethnicity, insurance status, stroke type, patient type, and site. The association between TM use and patient characteristics was measured using the relative risk (RR) from a modified Poisson regression, and site-specific effects were controlled using a multilevel analysis.ResultsA total of 2,024 visits were included from UTHealth (n = 878), MedStar Health (n = 269), and Columbia (n = 877). The median age was 64 [IQR 52–74] years, and 53% were female. Approximately half of the patients had private insurance, 36% had Medicare, and 15% had Medicaid. Two-thirds of the visits were established patients. TM accounted for 90% of total visits, and the use of TM over office visits was primarily associated with site, not patient characteristics. TM utilization was associated with Asian and other/unknown race. Among TM users, older age, Black race, Hispanic ethnicity, and Medicaid insurance were associated with lower VTM use. Black (aRR 0.88, 95% CI 0.86–0.91,p< 0.001) and Hispanic patients (aRR 0.92, 95% CI 0.87–0.98,p= 0.005) had approximately 10% lower VTM use, while Asian patients (aRR 0.98, 95% CI 0.89–1.07,p= 0.59) had similar VTM use compared with White patients. Patients with Medicaid were less likely to use VTM compared with those with private insurance (aRR 0.86, 95% CI 0.81–0.91,p< 0.001).DiscussionIn our diverse cohort across 3 centers, we found differences in TM visit type by race and insurance early during the COVID-19 pandemic. These findings suggest disparities in VTM access across different stroke populations. As VTM remains an integral part of outpatient neurology practice, steps to ensure equitable access are essential.
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Affiliation(s)
- Imama A Naqvi
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Audrey S Cohen
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Youngran Kim
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Jennifer Harris
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Mary Carter Denny
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Kevin Strobino
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Nathan Bicher
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Ryan A Leite
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Dylan Sadowsky
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Comfort Adegboye
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Nnedinma Okpala
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Munachi Okpala
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Sean I Savitz
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Randolph S Marshall
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
| | - Anjail Sharrief
- Department of Neurology (IAN, KS, RSM), Division of Stroke and Cerebrovascular Diseases, Vagelos College of Physicians and Surgeons, Columbia University, New York City, NY; Department of Neurology (ASC, YK, NO, MO, SIS, AS) and Institute for Stroke and Cerebrovascular Disease, McGovern Medical School, The University of Texas Health Science Center at Houston, TX; Department of Neurology (JH), Division of Stroke and Cerebrovascular Disease, Cedar-Sinai Medical Center, Los Angeles, CA; Department of Neurology (MCD, NB, RAL, DS), Georgetown University Medical Center and MedStar Georgetown University Hospital, Washington, DC; Howard University (CA), Washington, DC
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Levy EI, Monteiro A, Waqas M, Siddiqui AH. Access to Mechanical Thrombectomy for Stroke: Center Qualifications, Prehospital Management, and Geographic Disparities. Neurosurgery 2023; 92:3-9. [PMID: 36519855 DOI: 10.1227/neu.0000000000002206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/25/2022] [Indexed: 12/23/2022] Open
Abstract
Mechanical thrombectomy (MT) became the "gold-standard" treatment for most patients with acute ischemic stroke due to anterior circulation large vessel occlusion. With such a remarkable paradigm shift, it is important that this modality of treatment becomes widely and homogeneously available throughout the United States and other countries. Although the time window for MT is large (24 hours in selected patients), time is still a major determinant of outcome. Several variables are involved in achieving timely access of MT for the majority of the population: prehospital management systems, transportation models, in-hospital workflow organization, accreditation and infrastructure of centers, training of neurointervention professionals, and geographic distribution of centers. The current situation in the United States regarding MT access is marked by geographic and socioeconomic disparities. We provide an overview of current challenges and solutions in achieving more universal access to MT for the population.
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Affiliation(s)
- Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA.,Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA.,Jacobs Institute, Buffalo, New York, USA
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