1
|
Calixte A, Lartigue S, McGaugh S, Mathelier M, Patel A, Siyanaki MRH, Pierre K, Lucke-Wold B. Neurointerventional Radiology: History, Present and Future. JOURNAL OF RADIOLOGY AND ONCOLOGY 2023; 7:26-32. [PMID: 37795208 PMCID: PMC10550195 DOI: 10.29328/journal.jro.1001049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/06/2023]
Abstract
Neurointerventional Radiology (NIR), encompassing neuroendovascular surgery, endovascular neurosurgery, and interventional neurology, is an innovative and rapidly evolving multidisciplinary specialty focused on minimally invasive therapies for a wide range of neurological disorders. This review provides a comprehensive overview of NIR, discussing the three routes into the field, highlighting their distinct training paradigms, and emphasizing the importance of unified approaches through organizations like the Society of Neurointerventional Surgery (SNIS). The paper explores the benefits of co-managed care and its potential to improve patient outcomes, as well as the role of interdisciplinary collaboration and cross-disciplinary integration in advancing the field. We discuss the various contributions of neurosurgery, radiology, and neurology to cerebrovascular surgery, aiming to inform and educate those interested in pursuing a career in neurointervention. Additionally, the review examines the adoption of innovative technologies such as robotic-assisted techniques and artificial intelligence in NIR, and their implications for patient care and the future of the specialty. By presenting a comprehensive analysis of the field of neurointervention, we hope to inspire those considering a career in this exciting and rapidly advancing specialty, and underscore the importance of interdisciplinary collaboration in shaping its future.
Collapse
Affiliation(s)
- Andre Calixte
- New York Medical College, Valhalla, New York, 10595, USA
| | - Schan Lartigue
- New York Medical College, Valhalla, New York, 10595, USA
| | - Scott McGaugh
- University of Florida College of Medicine, Gainesville, Florida, 32608, USA
| | - Michael Mathelier
- University of Florida College of Medicine, Gainesville, Florida, 32608, USA
| | - Anjali Patel
- University of Florida College of Medicine, Gainesville, Florida, 32608, USA
| | | | - Kevin Pierre
- University of Florida Department of Radiology, Gainesville, Florida, 32608, USA
| | - Brandon Lucke-Wold
- University of Florida Department of Neurosurgery, Gainesville, Florida, 32608, USA
| |
Collapse
|
2
|
Farooqui M, Ikram A, Suriya S, Qeadan F, Bzdyra P, Quadri SA, Zafar A. Patterns of Care in Patients with Basilar Artery Occlusion (BAO): A Population-Based Study. Life (Basel) 2023; 13:life13030829. [PMID: 36983984 PMCID: PMC10053211 DOI: 10.3390/life13030829] [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: 01/18/2023] [Revised: 03/06/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Basilar artery occlusion (BAO) is associated with high morbidity and mortality. Endovascular therapy (EVT) has been shown to be beneficial in acute BAO patients. This retrospective observational study used the National Inpatient Sample (NIS) database to identify BAO patients using the International Classification of Diseases (ICD). Multivariable models were used to evaluate the association of risk factors, comorbidities, length of stay (LOS) in hospital, total cost, disposition, and transfer status. A total of 1120 (447 females, 39.95%) patients were identified, with a higher proportion of White individuals (66.8% vs. 57.6%), atrial fibrillation (31.5% vs. 17.2%; p < 0.0001), and peripheral vascular disease (21.2% vs. 13.7%; p = 0.009). A lower proportion of individuals with diabetes mellitus (32.1% vs. 39.5%; p = 0.05) was found in the EVT group. Majority of the patients (924/1120, 82.5%) were treated at the urban teaching facility, which also performed most of the EVT procedures (164, 89.13%), followed by non-academic urban (166, 14.8%) and rural (30, 2.7%) hospitals. Most patients (19/30, 63%) admitted to rural hospitals were transferred to other facilities. Urban academic hospitals also had the highest median LOS (8.9 days), cost of hospitalization (USD 117,261), and disposition to home (32.6%). This study observed distinct patterns and geographical disparities in the acute treatment of BAO patients. There is a need for national- and state-level strategies to improve access to stroke care.
Collapse
Affiliation(s)
- Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
| | - Asad Ikram
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
| | - Sajid Suriya
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM 87106, USA
| | - Fares Qeadan
- Department of Family and Preventive Medicine, University of Utah, Salt Lake City, UT 84112, USA
| | - Piotr Bzdyra
- Department of Neurology, St. Bernardine Medical Center, San Bernadino, CA 92404, USA
| | - Syed A Quadri
- Department of Neurology, University of Cincinnati, Cincinnati, OH 45221, USA
| | - Atif Zafar
- Department of Neurology, St. Michael Hospital, University of Toronto, Toronto, ON M5B 1W8, Canada
| |
Collapse
|
3
|
Farooqui M, Suriya S, Quadri S, Baig A, Khalil MH, Liaquat A, Taqi A. Reduction in Door-to-Groin Puncture Time for Endovascular Treatment in Acute Ischemic Stroke Patients With Large Vessel Occlusion. Cureus 2022; 14:e28348. [PMID: 36168340 PMCID: PMC9506579 DOI: 10.7759/cureus.28348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2022] [Indexed: 11/27/2022] Open
Abstract
Background The outcome of mechanical thrombectomy for large vessel occlusion (LVO) in patients with acute ischemic stroke (AIS) is time-dependent. In the current stroke workflow, the pre-hospital delay is one of the most common reasons for an increase in door-to-groin puncture time (DGPT). In the present study, we sought to compare the difference in (DGPT) before and after the implementation of the Ventura Emergent Large Vessel Occlusion Score (VES) protocol for LVO. Methods VES was implemented in the Ventura County of California by Emergency Medical Services (EMS). We performed a retrospective analysis to compare DGPT of patients undergoing endovascular treatment (EVT) pre- and post-VES implementation. Mean and standard deviation was reported for the continuous variable ‘time for intra-arterial (IA) treatment’ in minutes. The Mann-Whitney test was used for the comparison of the variable between the two groups. analyses were performed using SAS v9.4 (SAS Institute Inc., Cary, NC) with a significant p-value of ≤0.05. Results A total of 304 (males: 142 and females: 162) patients were alerted of the stroke code by the EMS. VES was positive in 139 patients. Of these, 64 (46%) were males and 75 (54%) were females. VES score of 1, 2, 3, and 4 were recorded in 57 (41%), 44 (31.6%), 31 (22.3%), and 7 (5%) patients, respectively. A total of 48 VES-positive patients underwent EVT. There were 62 patients who underwent EVT before the implementation of the VES protocol. The mean DGPT for the EVT among post-VES patients was 65 minutes, which was significantly (p=0.0009) shorter than the mean DGPT of 109 minutes among pre-VES patients. Conclusion VES is a simplified and effective tool for identifying LVO in the field. Implementation of VES showed significantly reduced DGPT in LVO patients.
Collapse
|
4
|
Morihara R, Yamashita T, Osakada Y, Feng T, Hu X, Fukui Y, Tadokoro K, Takemoto M, Abe K. Efficacy and safety of spot heating and ultrasound irradiation on in vitro and in vivo thrombolysis models. J Cereb Blood Flow Metab 2022; 42:1322-1334. [PMID: 35130767 PMCID: PMC9207486 DOI: 10.1177/0271678x221079127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The feasibility of transcranial sonothrombolysis has been demonstrated, although little is known about the relationships between thermal or mechanical mechanisms and thrombolytic outcomes. Therefore, the present study aims to reveal the effect and safety of temperature and ultrasound through in vitro and in vivo thrombolysis models. Artificial clots in microtubes were heated in a water bath or sonicated by ultrasound irradiation, and then clots weight decrease with rising temperature and sonication time was confirmed. In the in vitro thrombotic occlusion model, based on spot heating, clot volume was reduced and clots moved to the distal side, followed by recanalization of the occlusion. In the in vivo study, the common carotid artery of rats was exposed to a spot heater or to sonication. No brain infarct or brain blood barrier disruption was shown, but endothelial junctional dysintegrity and an inflammatory response in the carotid artery were detected. The present spot heating and ultrasound irradiation models seem to be effective for disintegrating clots in vitro, but the safety of the in vivo model was not fully supported by the data. However, the data indicates that a shorter time exposure could be less invasive than a longer exposure.
Collapse
Affiliation(s)
- Ryuta Morihara
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Toru Yamashita
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yosuke Osakada
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Tian Feng
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Xinran Hu
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Yusuke Fukui
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koh Tadokoro
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Mami Takemoto
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Koji Abe
- Department of Neurology, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| |
Collapse
|
5
|
Nogueira RC, Aries M, Minhas JS, H Petersen N, Xiong L, Kainerstorfer JM, Castro P. Review of studies on dynamic cerebral autoregulation in the acute phase of stroke and the relationship with clinical outcome. J Cereb Blood Flow Metab 2022; 42:430-453. [PMID: 34515547 PMCID: PMC8985432 DOI: 10.1177/0271678x211045222] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute stroke is associated with high morbidity and mortality. In the last decades, new therapies have been investigated with the aim of improving clinical outcomes in the acute phase post stroke onset. However, despite such advances, a large number of patients do not demonstrate improvement, furthermore, some unfortunately deteriorate. Thus, there is a need for additional treatments targeted to the individual patient. A potential therapeutic target is interventions to optimize cerebral perfusion guided by cerebral hemodynamic parameters such as dynamic cerebral autoregulation (dCA). This narrative led to the development of the INFOMATAS (Identifying New targets FOr Management And Therapy in Acute Stroke) project, designed to foster interventions directed towards understanding and improving hemodynamic aspects of the cerebral circulation in acute cerebrovascular disease states. This comprehensive review aims to summarize relevant studies on assessing dCA in patients suffering acute ischemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage. The review will provide to the reader the most consistent findings, the inconsistent findings which still need to be explored further and discuss the main limitations of these studies. This will allow for the creation of a research agenda for the use of bedside dCA information for prognostication and targeted perfusion interventions.
Collapse
Affiliation(s)
- Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Department of Neurology, Hospital Nove de Julho, São Paulo, Brazil
| | - Marcel Aries
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center+, School for Mental Health and Neuroscience (MHeNS), Maastricht, The Netherlands
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, USA
| | - Li Xiong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jana M Kainerstorfer
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, USA.,Neuroscience Institute, Carnegie Mellon University, Pittsburgh, USA
| | - Pedro Castro
- Department of Neurology, Faculty of Medicine of University of Porto, Centro Hospitalar Universitário de São João, Porto, Portugal
| |
Collapse
|
6
|
Sacks D, Dhand S, Hegg R, Hirsch K, McCollom V, Sarin S, Vadlamudi V, Wasser T, Zylak C. Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists vs Neurointerventional Physicians. J Vasc Interv Radiol 2022; 33:619-626.e1. [PMID: 35150837 DOI: 10.1016/j.jvir.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/04/2021] [Accepted: 11/25/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To test the hypothesis that interventional radiologists (IR) have outcomes for endovascular stroke thrombectomy (EVT) similar to Neurointerventional (NI) physicians and could be used to improve availability of thrombectomy. MATERIALS AND METHODS Eight hospitals providing EVT performed by IR and NI in the same institution submitted sequential retrospective data limited to the era of modern devices. Good clinical outcome (90 day modified Rankin score 0-2) and successful revascularization (modified Thrombolysis in Cerebral Infarction score > 2b) were compared between specialties, adjusted for treating hospital, patient age, stroke severity, Alberta Stroke Program Early CT Score (ASPECTS), time from symptom onset to door, and clot location. Propensity score matching was used to compare outcomes. A total of 1009 patients were entered (622 treated by IR and 387 treated by NI). RESULTS Median stroke onset to puncture was 245 vs 253 minutes (p=.49), technically successful revascularization was 81.8% vs 82.4% (p=.81), and good clinical outcome was 45.5% vs 50.1% (p=.16), respectively. After adjusting, physician specialty was not a significant predictor of good clinical outcome (odds ratio 1.028 [95% CI 0.760-1.390]; p=.86). After matching, mRS 0-2 was 47.7% for IR and 51.1% for NI (p=0.366). CONCLUSION There was no significant difference in successful revascularization and good clinical outcomes between IR and NI physicians. Outcomes by IR were similar to NI outcomes from previously published trials and registries. This may be useful to address coverage and access to stroke interventions.
Collapse
Affiliation(s)
| | | | - Ryan Hegg
- Research Medical Center, Kansas City, MO
| | | | | | - Shawn Sarin
- George Washington University Hospital, Washington, DC
| | | | | | | |
Collapse
|
7
|
Radvany MG, Sacks D, Brown A, Wojak JC, Gemmete JJ, Wang EA, Vadlamudi V. Survey of Interventional Radiologists Providing Endovascular Stroke Therapy in the United States. J Vasc Interv Radiol 2021; 32:1492-1494. [PMID: 34325004 DOI: 10.1016/j.jvir.2021.07.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Revised: 06/30/2021] [Accepted: 07/04/2021] [Indexed: 11/28/2022] Open
Affiliation(s)
- Martin G Radvany
- Department of Radiology, University of Arkansas for Medical Sciences, Little Rock, Arkansas; Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - David Sacks
- Department of Interventional Radiology, Tower Health, Reading Hospital, West Reading, Pennsylvania
| | - Aliza Brown
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR 72205
| | - Joan C Wojak
- Department of Radiology, Our Lady of Lourdes Regional Medical Center, Lafayette, Louisiana
| | - Joseph J Gemmete
- Department of Radiology and Department of Neurosurgery, University of Michigan Hospitals, Ann Arbor, Michigan
| | - Eric A Wang
- Charlotte Radiology, Carolinas Medical Center, Charlotte, North Carolina
| | - Venu Vadlamudi
- Department of CardioVascular and Interventional Radiology, Inova Alexandria Hospital, Alexandria, Virginia
| |
Collapse
|
8
|
Zhou MH, Kansagra AP. Changes in Patient Volumes and Outcomes After Adding Thrombectomy Capability. Stroke 2021; 52:2143-2149. [PMID: 33866819 DOI: 10.1161/strokeaha.120.032389] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE With the rising demand for endovascular thrombectomy (EVT) and introduction of thrombectomy-capable stroke centers (TSC), there is interest among existing stroke hospitals to add EVT capability to attract and retain stroke patient referrals. In this work, we quantify changes in patient volumes and outcomes when adding EVT capability to an existing stroke center. METHODS In MATLAB 2017a Simulink, we simulate a 3-center system comprising an EVT-capable comprehensive stroke center, an EVT-incapable primary stroke center, and an EVT-incapable primary stroke center that gains EVT capability (TSC). We model these changes in 2 geographic settings (urban and rural) using 2 routing paradigms (Nearest Center and Bypass). In Nearest Center, patients are sent to the nearest center regardless of EVT capability. In Bypass, patients with severe strokes are sent to the nearest EVT-capable center, and all others are sent to the nearest center. Probability of good clinical outcome is determined by type and timing of treatment using outcomes reported in clinical trials. RESULTS Adding EVT capability in the Bypass model produced an absolute increase of 40.1% in total volume of patients with stroke and 31.2% to 31.9% in total volume of acute stroke treatments at the TSC. In the Nearest Center model, the total volume of patients with stroke did not change, but total volume of acute stroke treatment at the TSC had an absolute increase of 9.3% to 9.5%. Good clinical outcomes saw an absolute increase of 0.2% to 0.6% in the whole population and 0.3% to 1.8% in the TSC population. CONCLUSIONS Adding EVT capability shifts patient and treatment volume to the TSC. However, these changes produce modest improvement in overall population health. Health systems should weigh relative hospital and patient benefits when considering adding EVT capability.
Collapse
Affiliation(s)
- Minerva H Zhou
- School of Medicine (M.H.Z.), Washington University, St. Louis, MO
| | - Akash P Kansagra
- Mallinckrodt Institute of Radiology (A.P.K.), Washington University, St. Louis, MO.,Department of Neurological Surgery (A.P.K.), Washington University, St. Louis, MO.,Department of Neurology (A.P.K.), Washington University, St. Louis, MO
| |
Collapse
|
9
|
Beharry J, Fink J, Colgan F, Laing A, Mann D, Collecutt W, Krauss M, Wu T. Endovascular Therapy for Ischemic Stroke Can Be Successfully Performed by Peripheral Vascular Interventionalists. J Vasc Interv Radiol 2020; 31:1978-1983. [PMID: 33187862 DOI: 10.1016/j.jvir.2020.08.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/17/2020] [Accepted: 08/27/2020] [Indexed: 11/30/2022] Open
Abstract
PURPOSE To describe interventionalist and workflow characteristics of an acute stroke endovascular thrombectomy (EVT) center without a dedicated interventional neuroradiology service and report clinical and radiologic outcomes. MATERIALS AND METHODS Retrospective review was performed of all patients receiving EVT at Christchurch Hospital, New Zealand, from June 2014 to the end of December 2019 from a prospective reperfusion registry. During the study period, 5 peripheral vascular interventional radiologists, 2 of whom had experience in other neuroendovascular procedures, performed 210 EVT procedures. Median age of patients was 76 years (interquartile range: 64-83 y), and 107 (51%) were men. RESULTS The most commonly occluded vessel was the M1 middle cerebral artery (n = 114; 54%). Successful reperfusion (Modified Treatment In Cerebral Ischemia score 2b-3) was achieved in 180 (86%) procedures. Favorable 90-day outcome (modified Rankin Scale score 0-2) was achieved in 102 (54%) patients with no disability before stroke. Symptomatic intracranial hemorrhage occurred in 3 (1.4%) patients. Treatment rates in the local catchment area increased from 6 per 100,000 population in 2017 to 15 per 100,000 in 2019. CONCLUSIONS The results of this study suggest peripheral vascular interventional radiologists with specific training can successfully perform EVT resulting in a significant increase in EVT provision.
Collapse
Affiliation(s)
- James Beharry
- Department of Neurology, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand.
| | - John Fink
- Department of Neurology, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand
| | - Frances Colgan
- Department of Interventional Radiology, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand
| | - Andrew Laing
- Department of Interventional Radiology, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand
| | - Dana Mann
- Central Oregon Radiology Associates, Bend, Oregon
| | - Wayne Collecutt
- Department of Interventional Radiology, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand
| | - Martin Krauss
- Department of Interventional Radiology, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand
| | - Teddy Wu
- Department of Neurology, Christchurch Hospital, Private Bag 4710, Christchurch 8140, New Zealand; New Zealand Brain Research Institute, Christchurch, New Zealand
| |
Collapse
|
10
|
Yeo LL, Bhogal P, Tan BY. Short Cuts to Improve Stroke Outcomes by Prehospital Triage. Stroke 2020; 51:3192-3194. [DOI: 10.1161/strokeaha.120.032486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Leonard L.L. Yeo
- Division of neurology, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.)
- Yong Loo Lin School of Medicine, National University of Singapore (L.L.L.Y., B.Y.Q.T.)
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, St. Bartholomew’s and The Royal London Hospital, United Kingdom (P.B.)
| | - Benjamin Y.Q. Tan
- Division of neurology, National University Health System, Singapore (L.L.L.Y., B.Y.Q.T.)
- Yong Loo Lin School of Medicine, National University of Singapore (L.L.L.Y., B.Y.Q.T.)
| |
Collapse
|
11
|
Nogueira RC, Lam MY, Llwyd O, Salinet ASM, Bor-Seng-Shu E, Panerai RB, Robinson TG. Cerebral autoregulation and response to intravenous thrombolysis for acute ischemic stroke. Sci Rep 2020; 10:10554. [PMID: 32601359 PMCID: PMC7324382 DOI: 10.1038/s41598-020-67404-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 06/02/2020] [Indexed: 11/20/2022] Open
Abstract
We hypothesized that knowledge of cerebral autoregulation (CA) status during recanalization therapies could guide further studies aimed at neuroprotection targeting penumbral tissue, especially in patients that do not respond to therapy. Thus, we assessed CA status of patients with acute ischemic stroke (AIS) during intravenous r-tPA therapy and associated CA with response to therapy. AIS patients eligible for intravenous r-tPA therapy were recruited. Cerebral blood flow velocities (transcranial Doppler) from middle cerebral artery and blood pressure (Finometer) were recorded to calculate the autoregulation index (ARI, as surrogate for CA). National Institute of Health Stroke Score was assessed and used to define responders to therapy (improvement of ≥ 4 points on NIHSS measured 24–48 h after therapy). CA was considered impaired if ARI < 4. In 38 patients studied, compared to responders, non-responders had significantly lower ARI values (affected hemisphere: 5.0 vs. 3.6; unaffected hemisphere: 5.4 vs. 4.4, p = 0.03) and more likely to have impaired CA (32% vs. 62%, p = 0.02) during thrombolysis. In conclusion, CA during thrombolysis was impaired in patients who did not respond to therapy. This variable should be investigated as a predictor of the response to therapy and to subsequent neurological outcome.
Collapse
Affiliation(s)
- Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, 01246-904, Brazil. .,Department of Neurology, Hospital Nove de Julho, São Paulo, Brazil.
| | - Man Y Lam
- Department of Cardiovascular Sciences, Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, University of Leicester, Leicester, LE2 7LX, UK
| | - Osian Llwyd
- Department of Cardiovascular Sciences, Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, University of Leicester, Leicester, LE2 7LX, UK
| | - Angela S M Salinet
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, 01246-904, Brazil
| | - Edson Bor-Seng-Shu
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, 01246-904, Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, University of Leicester, Leicester, LE2 7LX, UK.,NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, LE3 9QP, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, Cerebral Haemodynamics in Ageing and Stroke Medicine Research Group, University of Leicester, Leicester, LE2 7LX, UK.,NIHR Leicester Biomedical Research Centre, University of Leicester, Leicester, LE3 9QP, UK
| |
Collapse
|
12
|
Safety of inter-hospital transfer of patients with acute ischemic stroke for evaluation of endovascular thrombectomy. Sci Rep 2020; 10:5655. [PMID: 32221353 PMCID: PMC7101346 DOI: 10.1038/s41598-020-62528-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Accepted: 03/15/2020] [Indexed: 11/09/2022] Open
Abstract
Stroke networks facilitate access to endovascular treatment (EVT) for patients with ischemic stroke due to large vessel occlusion. In this study we aimed to determine the safety of inter-hospital transfer and included all patients with acute ischemic stroke who were transferred within our stroke network for evaluation of EVT between 06/2016 and 12/2018. Data were derived from our prospective EVT database and transfer protocols. We analyzed major complications and medical interventions associated with inter-hospital transfer. Among 615 transferred patients, 377 patients (61.3%) were transferred within our telestroke network and had transfer protocols available (median age 76 years [interquartile range, IQR 17], 190 [50.4%] male, median baseline NIHSS score 17 [IQR 8], 246 [65.3%] drip-and-ship i.v.-thrombolysis). No patient suffered from cardio-respiratory failure or required emergency intubation or cardiopulmonary resuscitation during the transfer. Among 343 patients who were not intubated prior departure, 35 patients (10.2%) required medical interventions during the transfer. The performance of medical interventions was associated with a lower EVT rate and higher mortality at three months. In conclusion, the transfer of acute stroke patients for evaluation of EVT was not associated with major complications and transfer-related medical interventions were required in a minority of patients.
Collapse
|
13
|
Sacks D, AbuAwad MK, Ahn SH, Baerlocher MO, Brady PS, Cole JW, Dhand S, Fox BD, Gemmete JJ, Kee-Sampson JW, McCollom V, Patel PJ, Radvany MG, Tomalty RD, Vadlamudi V, Webb MS, Wojak JC. Society of Interventional Radiology Training Guidelines for Endovascular Stroke Treatment. J Vasc Interv Radiol 2019; 30:1523-1531. [DOI: 10.1016/j.jvir.2019.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 08/13/2019] [Accepted: 08/13/2019] [Indexed: 01/19/2023] Open
|
14
|
Schwamm LH. Optimizing Prehospital Triage for Patients With Stroke Involving Large Vessel Occlusion: The Road Less Traveled. JAMA Neurol 2019; 75:1467-1469. [PMID: 30193286 DOI: 10.1001/jamaneurol.2018.2323] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Lee H Schwamm
- Comprehensive Stroke Center, Massachusetts General Hospital, Harvard Medical School, Boston
| |
Collapse
|
15
|
Patel TM, Shah SC, Pancholy SB. Long Distance Tele-Robotic-Assisted Percutaneous Coronary Intervention: A Report of First-in-Human Experience. EClinicalMedicine 2019; 14:53-58. [PMID: 31709402 PMCID: PMC6833466 DOI: 10.1016/j.eclinm.2019.07.017] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2019] [Revised: 07/05/2019] [Accepted: 07/30/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Robotic-assisted percutaneous coronary intervention (R-PCI) has been successfully employed in the United States since 2011. Performing R-PCI from a remote location has never been reported but if feasible would extend availability of treatment to many patients with coronary artery disease (CAD) who would otherwise go without. OBJECTIVE To assess the feasibility of remote tele-R-PCI with the operator 20 miles away from the patients. METHODS Five patients with single, type A coronary artery lesions treatable by PCI consented to participate. The primary endpoint was procedural success with no major adverse cardiac events (MACE) before discharge. Procedural success was defined as achieving < 10% diametric stenosis of the occluded target vessel utilizing tele-R-PCI balloon angioplasty and stent deployment (CorPath GRX®, Corindus Vascular Robotics, USA) without converting to in-lab manual PCI by an on-site standby team. Procedural, angiographic, and safety data were collected as were questionnaire scores from the remote operator evaluating the robot-network composite, image clarity, and overall confidence in the procedure. RESULTS The primary endpoint was achieved in 100% of patients. No procedural complications or adverse events occurred, and all patients were discharged the following day without MACE. The operator scores were favorable with the operators rating the procedure as equivalent to an in-lab procedure. CONCLUSIONS Performing long distance tele-R-PCI in patients with CAD is feasible with predictably successful outcomes if reliable network connectivity and local cardiac catheterization facilities are available.
Collapse
Affiliation(s)
- Tejas M. Patel
- Apex Heart Institute, Ahmedabad, India
- Corresponding author at: Apex Heart Institute, Ahmedabad, India.
| | | | - Samir B. Pancholy
- The Wright Center for Graduate Medical Education, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| |
Collapse
|
16
|
Kicielinski KP, Ogilvy CS. Role of the Neurosurgeon in Acute Ischemic Stroke Treatment From Triage to Intensive Care Unit. Neurosurgery 2019; 85:S47-S51. [DOI: 10.1093/neuros/nyz013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/07/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
As ischemic stroke care advances with more patients eligible for mechanical thrombectomy, so too does the role of the neurosurgeon in these patients. Neurosurgeons are an important member of the team from triage through the intensive care unit. This paper explores current research and insights on the contributions of neurosurgeons in care of acute ischemic stroke patients in the acute setting.
Collapse
Affiliation(s)
| | - Christopher S Ogilvy
- Beth Israel Deaconess Medical Center, Brain Aneurysm Institute, Boston, Massachusetts
| |
Collapse
|
17
|
Saber H, Navi BB, Grotta JC, Kamel H, Bambhroliya A, Vahidy FS, Chen PR, Blackburn S, Savitz SI, McCullough L, Sheth SA. Real-World Treatment Trends in Endovascular Stroke Therapy. Stroke 2019; 50:683-689. [PMID: 30726185 PMCID: PMC6407696 DOI: 10.1161/strokeaha.118.023967] [Citation(s) in RCA: 71] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and Purpose- Recent landmark trials provided overwhelming evidence for effectiveness of endovascular stroke therapy (EST). Yet, the impact of these trials on clinical practice and effectiveness of EST among lower volume centers remains poorly characterized. Here, we determine population-level patterns in EST performance in US hospitals and compare EST outcomes from higher versus lower volume centers. Methods- Using validated diagnosis codes from data on all discharges from hospitals and Emergency Rooms in Florida (2006-2016) and the National Inpatient Sample (2012-2016) we identified patients with acute ischemic stroke treated with EST. The primary end point was good discharge outcome defined as discharge to home or acute rehabilitation facility. Multivariate regressions adjusted for medical comorbidities, intravenous tPA (tissue-type plasminogen activator) usage and annual hospital stroke volume were used to evaluate the likelihood of good outcome over time and by annual hospital EST volume. Results- A total of 3890 patients (median age, 73 [61-82] years, 51% female) with EST were identified in the Florida cohort and 42 505 (median age, 69 [58-79], 50% female) in the National Inpatient Sample. In both Florida and the National Inpatient Sample, the number of hospitals performing EST increased continuously. Increasing numbers of EST procedures were performed at lower annual EST volume hospitals over the studied time period. In adjusted multivariate regression, there was a continuous increase in the likelihood of good outcomes among patients treated in hospitals with increasing annual EST procedures per year (odds ratio, 1.1; 95% CI, 1.1-1.2 in Florida and odds ratio, 1.3; 95% CI, 1.2-1.4 in National Inpatient Sample). Conclusions- Analysis of population-level datasets of patients treated with EST from 2006 to 2016 demonstrated an increase in the number of centers performing EST, resulting in a greater number of procedures performed at lower volume centers. There was a positive association between EST volume and favorable discharge outcomes in EST-performing hospitals.
Collapse
Affiliation(s)
- Hamidreza Saber
- From the Department of Neurology, Wayne State University School of Medicine, Detroit, MI (H.S.)
| | - Babak B Navi
- Department of Neurology (B.B.N., H.K.), Weill Cornell Medical College, New York, NY
- Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Houston, TX (J.G.)
| | - Hooman Kamel
- Department of Neurology (B.B.N., H.K.), Weill Cornell Medical College, New York, NY
- Feil Family Brain and Mind Research Institute (B.B.N., H.K.), Weill Cornell Medical College, New York, NY
| | - Arvind Bambhroliya
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
| | - Farhaan S Vahidy
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
| | - Peng Roc Chen
- Department of Neurosurgery (P.R.C., S.B.), UT Health McGovern School of Medicine, Houston, TX
| | - Spiros Blackburn
- Department of Neurosurgery (P.R.C., S.B.), UT Health McGovern School of Medicine, Houston, TX
| | - Sean I Savitz
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
| | - Louise McCullough
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
| | - Sunil A Sheth
- Department of Neurology, Institute for Stroke and Cerebrovascular Disease (A.B., F.S.V., S.I.S., L.M., S.A.S.), UT Health McGovern School of Medicine, Houston, TX
| |
Collapse
|
18
|
The Role of Interventional Radiologists in Acute Ischemic Stroke Interventions: A Joint Position Statement from the Society of Interventional Radiology, the Cardiovascular and Interventional Radiology Society of Europe, and the Interventional Radiology Society of Australasia. J Vasc Interv Radiol 2019; 30:131-133. [DOI: 10.1016/j.jvir.2018.09.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2018] [Accepted: 09/29/2018] [Indexed: 11/18/2022] Open
|
19
|
Pallesen LP, Barlinn K, Puetz V. Role of Decompressive Craniectomy in Ischemic Stroke. Front Neurol 2019; 9:1119. [PMID: 30687210 PMCID: PMC6333741 DOI: 10.3389/fneur.2018.01119] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 12/06/2018] [Indexed: 12/12/2022] Open
Abstract
Ischemic stroke is one of the leading causes for death and disability worldwide. In patients with large space-occupying infarction, the subsequent edema complicated by transtentorial herniation poses a lethal threat. Especially in patients with malignant middle cerebral artery infarction, brain swelling secondary to the vessel occlusion is associated with high mortality. By decompressive craniectomy, a significant proportion of the skull is surgically removed, allowing the ischemic tissue to shift through the surgical defect rather than to the unaffected regions of the brain, thus avoiding secondary damage due to increased intracranial pressure. Several studies have shown that decompressive craniectomy reduces the mortality rate in patients with malignant cerebral artery infarction. However, this is done for the cost of a higher proportion of patients who survive with severe disability. In this review, we will describe the clinical and radiological features of malignant middle cerebral artery infarction and the role of decompressive craniectomy and additional therapies in this condition. We will also discuss large cerebellar stroke and the possibilities of suboccipital craniectomy.
Collapse
Affiliation(s)
- Lars-Peder Pallesen
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| | - Volker Puetz
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany
| |
Collapse
|
20
|
|
21
|
Shakir HJ, Shallwani H, Rangel-Castilla L, Bregy A, Davies JM, Sonig A, Ogilvy CS, Snyder KV, Hopkins LN, Siddiqui AH, Levy EI. Neuroendovascular Fellowship Training: Self-Assessment of a Program Accredited by the Committee on Advanced Subspecialty Training. Neurosurgery 2018; 82:407-413. [PMID: 29351626 DOI: 10.1093/neuros/nyx593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 11/21/2017] [Indexed: 11/15/2022] Open
Abstract
The University at Buffalo's neuroendovascular fellowship is one of the longest running fellowship programs in North America. The burgeoning neurointerventional workforce and the rapid growth in the neurointerventional space on the heels of groundbreaking clinical trials prompted us to assess the fellowship's academic impact and its graduates' perceptions and productivity. An anonymized web-based survey was sent to all former neuroendovascular fellows with specific questions pertaining to current practice, research and funding, and perceptions about the fellowship's impact on their skills, competitiveness, and compensation. Additionally, the h-index was calculated to assess the academic productivity of each graduated fellow. Among 50 former fellows, 42 (84%) completed the survey. The fellows came from various countries, ethnic backgrounds, and specialties including neurosurgery (n = 39, 93%), neurology (n = 2, 5%), and neuroradiology (n = 1, 2%). Twenty (48%) respondents were currently chairs or directors of their practice. Most (n = 30, 71%) spent at least 10% of their time on research activities, with 27 (64%) receiving research funding. The median h-index of all 50 former fellows was 14. The biggest gains from the fellowship were reported to be improvement in endovascular skills (median = 10 on a scale of 0-10 [highest]) and increase in competitiveness for jobs in vascular neurosurgery (median = 10), followed by increase in academic productivity (median = 8), and knowledge of vascular disease (median = 8). In an era with open calls for moratoriums on endovascular fellowships, concerns over market saturation, and pleas to improve training, fellowship programs perhaps merit a more objective assessment. The effectiveness of a fellowship program may best be measured by the academic impact and leadership roles of former fellows.
Collapse
Affiliation(s)
- Hakeem J Shakir
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Hussain Shallwani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Leonardo Rangel-Castilla
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Amade Bregy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Biomedical Informatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York
| | - L Nelson Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Jacobs Institute, Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York.,Jacobs Institute, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York.,Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York.,Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York
| |
Collapse
|
22
|
Froehler MT, Saver JL, Zaidat OO, Jahan R, Aziz-Sultan MA, Klucznik RP, Haussen DC, Hellinger FR, Yavagal DR, Yao TL, Liebeskind DS, Jadhav AP, Gupta R, Hassan AE, Martin CO, Bozorgchami H, Kaushal R, Nogueira RG, Gandhi RH, Peterson EC, Dashti SR, Given CA, Mehta BP, Deshmukh V, Starkman S, Linfante I, McPherson SH, Kvamme P, Grobelny TJ, Hussain MS, Thacker I, Vora N, Chen PR, Monteith SJ, Ecker RD, Schirmer CM, Sauvageau E, Abou-Chebl A, Derdeyn CP, Maidan L, Badruddin A, Siddiqui AH, Dumont TM, Alhajeri A, Taqi MA, Asi K, Carpenter J, Boulos A, Jindal G, Puri AS, Chitale R, Deshaies EM, Robinson DH, Kallmes DF, Baxter BW, Jumaa MA, Sunenshine P, Majjhoo A, English JD, Suzuki S, Fessler RD, Delgado Almandoz JE, Martin JC, Mueller-Kronast NH. Interhospital Transfer Before Thrombectomy Is Associated With Delayed Treatment and Worse Outcome in the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke). Circulation 2017; 136:2311-2321. [PMID: 28943516 PMCID: PMC5732640 DOI: 10.1161/circulationaha.117.028920] [Citation(s) in RCA: 289] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2017] [Accepted: 09/08/2017] [Indexed: 11/17/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Endovascular treatment with mechanical thrombectomy (MT) is beneficial for patients with acute stroke suffering a large-vessel occlusion, although treatment efficacy is highly time-dependent. We hypothesized that interhospital transfer to endovascular-capable centers would result in treatment delays and worse clinical outcomes compared with direct presentation. Methods: STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) was a prospective, multicenter, observational, single-arm study of real-world MT for acute stroke because of anterior-circulation large-vessel occlusion performed at 55 sites over 2 years, including 1000 patients with severe stroke and treated within 8 hours. Patients underwent MT with or without intravenous tissue plasminogen activator and were admitted to endovascular-capable centers via either interhospital transfer or direct presentation. The primary clinical outcome was functional independence (modified Rankin Score 0–2) at 90 days. We assessed (1) real-world time metrics of stroke care delivery, (2) outcome differences between direct and transfer patients undergoing MT, and (3) the potential impact of local hospital bypass. Results: A total of 984 patients were analyzed. Median onset-to-revascularization time was 202.0 minutes for direct versus 311.5 minutes for transfer patients (P<0.001). Clinical outcomes were better in the direct group, with 60.0% (299/498) achieving functional independence compared with 52.2% (213/408) in the transfer group (odds ratio, 1.38; 95% confidence interval, 1.06–1.79; P=0.02). Likewise, excellent outcome (modified Rankin Score 0–1) was achieved in 47.4% (236/498) of direct patients versus 38.0% (155/408) of transfer patients (odds ratio, 1.47; 95% confidence interval, 1.13–1.92; P=0.005). Mortality did not differ between the 2 groups (15.1% for direct, 13.7% for transfer; P=0.55). Intravenous tissue plasminogen activator did not impact outcomes. Hypothetical bypass modeling for all transferred patients suggested that intravenous tissue plasminogen activator would be delayed by 12 minutes, but MT would be performed 91 minutes sooner if patients were routed directly to endovascular-capable centers. If bypass is limited to a 20-mile radius from onset, then intravenous tissue plasminogen activator would be delayed by 7 minutes and MT performed 94 minutes earlier. Conclusions: In this large, real-world study, interhospital transfer was associated with significant treatment delays and lower chance of good outcome. Strategies to facilitate more rapid identification of large-vessel occlusion and direct routing to endovascular-capable centers for patients with severe stroke may improve outcomes. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02239640.
Collapse
Affiliation(s)
| | - Jeffrey L Saver
- University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.)
| | | | - Reza Jahan
- University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.)
| | | | | | - Diogo C Haussen
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.)
| | - Frank R Hellinger
- Florida Hospital Neuroscience Institute, Winter Park (F.R.H., R.H.G.)
| | - Dileep R Yavagal
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, FL (D.R.Y., E.C.P.)
| | - Tom L Yao
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y., S.R.D.)
| | | | | | - Rishi Gupta
- WellStar Neurosciences Network, WellStar Kennestone Regional Medical Center, Marietta, GA (R.G.)
| | | | | | | | - Ritesh Kaushal
- Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., N.H.M.-K.)
| | - Raul G Nogueira
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA (D.C.H., R.G.N.)
| | - Ravi H Gandhi
- Florida Hospital Neuroscience Institute, Winter Park (F.R.H., R.H.G.)
| | - Eric C Peterson
- University of Miami Miller School of Medicine/Jackson Memorial Hospital, FL (D.R.Y., E.C.P.)
| | - Shervin R Dashti
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y., S.R.D.)
| | | | | | - Vivek Deshmukh
- Providence St Vincent Medical Center, Portland, OR (V.D.)
| | - Sidney Starkman
- University of California, Los Angeles (J.L.S., R.J., D.S.L., S.S.)
| | | | | | - Peter Kvamme
- University of Tennessee Medical Center, Knoxville (P.K.)
| | | | | | - Ike Thacker
- Baylor University Medical Center, Dallas, TX (I.T.)
| | - Nirav Vora
- OhioHealth Riverside Methodist Hospital, Columbus (N.V.)
| | - Peng Roc Chen
- Memorial Hermann Texas Medical Center, Houston (P.R.C.)
| | | | | | | | | | | | | | - Lucian Maidan
- Mercy San Juan Medical Center and Mercy General, Carmichael, CA (L.M.)
| | | | | | | | | | - M Asif Taqi
- Los Robles Medical Center, Thousand Oaks, CA (M.A.T.)
| | | | | | | | - Gaurav Jindal
- University of Maryland Medical Center, Baltimore (G.J.)
| | - Ajit S Puri
- University of Massachusetts Memorial Medical Center, Worcester (A.S.P.)
| | - Rohan Chitale
- Vanderbilt University Medical Center, Nashville, TN (M.T.F., R.C.)
| | | | | | | | | | | | | | | | - Joey D English
- California Pacific Medical Center, San Francisco, CA (J.D.E.)
| | | | | | | | | | | | | |
Collapse
|