1
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Yoo AJ, Geyik S, Froehler MT, Maurer CJ, Kass-Hout T, Zaidat OO, Nogueira RG, Hanel RA, Pierot L, Spelle L, Lopes D, Hassan A, Širvinskas A, Lin E, Ribo M, Blasco J, Taqi MA, Badruddin A, Siddiqui AH, Miller TR, Hussain SM, Haussen DC, Woodward K, Groden C, Consoli A, Chaudry MI, Ramsey C, Maud A, Bentley J, Bajrami A, Sahnoun M, Fiehler J, Gupta R. Primary results from the CLEAR study of a novel stent retriever with drop zone technology. J Neurointerv Surg 2023:jnis-2023-020960. [PMID: 38050090 DOI: 10.1136/jnis-2023-020960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 10/29/2023] [Indexed: 12/06/2023]
Abstract
BACKGROUND Challenges to revascularization of large vessel occlusions (LVOs) persist. Current stent retrievers have limited effectiveness for removing organized thrombi. The NeVa device is a novel stent retriever designed to capture organized thrombi within the scaffold during retrieval. OBJECTIVE To evaluate the safety and effectiveness of revascularization of acute LVOs with the NeVa device. METHODS Prospective, international, multicenter, single-arm, Investigational Device Exemption study to evaluate the performance of the NeVa device in recanalizing LVOs including internal carotid artery, M1/M2 middle cerebral artery, and vertebrobasilar arteries, within 8 hours of onset. Primary endpoint was rate of expanded Treatment in Cerebral Ischemia (eTICI) score 2b-3 within 3 NeVa passes, tested for non-inferiority against a performance goal of 72% with a -10% margin. Additional endpoints included first pass success and 90-day modified Rankin Scale (mRS) score 0-2. Primary composite safety endpoint was 90-day mortality and/or 24-hour symptomatic intracranial hemorrhage (sICH). RESULTS From April 2021 to April 2022, 139 subjects were enrolled at 25 centers. Median National Institutes of Health Stroke Scale (NIHSS) score was 16 (IQR 12-20). In the primary analysis population (n=107), eTICI 2b-3 within 3 NeVa passes occurred in 90.7% (97/107; non-inferiority P<0.0001; post hoc superiority P<0.0001). First pass eTICI 2b-3 was observed in 73.8% (79/107), with first pass eTICI 2b67-3 in 69.2% (74/107) and eTICI 2c-3 in 48.6% (52/107). Median number of passes was 1 (IQR 1-2). Final eTICI 2b-3 rate was 99.1% (106/107); final eTICI 2b67-3 rate was 91.6% (98/107); final eTICI 2c-3 rate was 72.9% (78/107). Good outcome (90-day mRS score 0-2) was seen in 65.1% (69/106). Mortality was 9.4% (13/138) with sICH in 5.0% (7/139). CONCLUSIONS The NeVa device is highly effective and safe for revascularization of LVO strokes and demonstrates superior first pass success compared with a predicate performance goal. TRIAL REGISTRATION NUMBER NCT04514562.
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Affiliation(s)
- Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Serdar Geyik
- Department of Radiology, Istanbul Aydin Universitesi, Istanbul, Turkey
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Christoph Johannes Maurer
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Bayern, Germany
| | - Tareq Kass-Hout
- Department of Medicine, University of Chicago, Chicago, Illinois, USA
| | - Osama O Zaidat
- Department of Neuroscience, Mercy Health Saint Vincent Medical Center, Toledo, Ohio, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Ricardo A Hanel
- Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Laurent Pierot
- Department of Radiology, University Hospital Reims, Reims, France
| | - Laurent Spelle
- NEURI The Brain Vascular Center, Bicetre Hospital Interventional Neuroradiology, Le Kremlin-Bicetre, France
- Paris-Saclay University Faculty of Medicine, Le Kremlin-Bicetre, France
| | | | - Ameer Hassan
- Department of Neurology, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | | | - Eugene Lin
- Department of Neuroscience, Mercy Health Saint Vincent Medical Center, Toledo, Ohio, USA
| | - Marc Ribo
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
- Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jordi Blasco
- Department of Neurology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Muhammad Asif Taqi
- Department of Neurosurgery and Neurointervention, Vascular Neurology of Southern California, Thousand Oaks, California, USA
| | | | - Adnan H Siddiqui
- Department of Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Timothy R Miller
- Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Shazam M Hussain
- Cleveland Clinic Stroke Program, Cleveland Clinic, Cleveland, Ohio, USA
| | - Diogo C Haussen
- Department of Neurology and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Keith Woodward
- Fort Sanders Regional Medical Center, Knoxville, Tennessee, USA
| | | | | | - M Imran Chaudry
- Department of Neurosurgery, Prisma Health, Greenville, South Carolina, USA
| | | | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | | | - Arsida Bajrami
- Department of Neurology, Istanbul Aydin Universitesi, Istanbul, Turkey
| | | | - Jens Fiehler
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Eppdata GmbH, Hamburg, Germany
| | - Rishi Gupta
- Wellstar Health System Inc, Marietta, Georgia, USA
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2
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Sheriff FG, Ahmad A, Inam ME, Khatri R, Maud A, Rodriguez GJ. A systematic review on the assessment of cerebral autoregulation in patients with Large Vessel Occlusion. Front Neurol 2023; 14:1287873. [PMID: 38046584 PMCID: PMC10693431 DOI: 10.3389/fneur.2023.1287873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
As the majority of large vessel occlusion (LVO) patients are not treated with revascularization therapies or efficiently revascularized, complementary management strategies are needed. In this article we explore the importance of cerebral autoregulation (CA) assessment in the prediction and/or modification of infarct growth and hemorrhagic transformation. In patients with LVO, these are important factors that affect prognosis. A systematic search of the PubMed, EMBASE databases and a targeted Google search was conducted, resulting in the inclusion of 34 relevant articles. There is an agreement that CA is impaired in patients with LVO; several factors have been identified such as time course, revascularization status, laterality, disease subtype and location, some of which may be potentially modifiable and affect outcomes. The personalized CA assessment of these patients suggests potential for better understanding of the inter-individual variability. Further research is needed for the development of more accurate, noninvasive techniques for continuous monitoring and personalized thresholds for CA.
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Affiliation(s)
- Faheem G. Sheriff
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | | | - Mehmet E. Inam
- University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rakesh Khatri
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Alberto Maud
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Gustavo J. Rodriguez
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
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3
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Sheriff F, Lavezo J, Floresca R, Chaudhury MR, Colina G, Regenhardt R, Gupta V, Rodriguez G, Maud A. Clinicopathologic Analysis of COVID‐19 Associated Thrombi in the Setting of Large Vessel Occlusion: A Prospective Case–Control Study. SVIN 2023. [DOI: 10.1161/svin.123.000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/12/2023] [Indexed: 07/19/2023]
Abstract
BACKGROUND
Acute ischemic stroke secondary to large vessel occlusion is among the most serious complications associated with COVID‐19 infection resulting in worse morbidity and mortality. We sought to study the association between COVID‐19 infection and large vessel occlusion thrombus pathology to better define the etiopathogenesis of this atypical cause of stroke.
METHODS
Thrombi were collected during mechanical thrombectomy and stained using hematoxylin and eosin. Blinded analysis of pathology was prospectively performed by a board‐certified neuropathologist. Red blood cell, fibrin, and white blood cell predominance was ascertained. Concomitant peripheral blood counts and clinical and imaging data were collected and analyzed. All samples underwent performance of reverse transcription polymerase chain reaction for SARS‐CoV2.
RESULTS
Between January 2020 and February 2022, a total of 952 acute ischemic stroke admissions were seen at the University Medical Center of El Paso, TX. Of these, 195 patients (20.5%) had large vessel occlusions and underwent mechanical thrombectomy and 53 patients had thrombus collected and analyzed. Seven patients (3.6%) tested positive for SARS‐CoV2. COVID‐19 positive patients were more likely to be younger (mean 57.4 years;
P
=0.07), male (85.7%;
P
=0.03), and have red blood cell predominant thrombi (85.7%;
P
=0.03). There was a statistically significant association between peripheral neutrophil count and white blood cell lysis in the overall cohort (
P
=0.015), who did not differ according to COVID‐19 status.
CONCLUSION
Thrombi retrieved from patients who were COVID‐19 positive and had stroke demonstrated red blood cell predominance. This finding requires further investigation using appropriate immunohistochemical techniques in a larger cohort of patients.
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Affiliation(s)
- Faheem Sheriff
- Department of Neurology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Jonathan Lavezo
- Department of Pathology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Ryan Floresca
- Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Mohammad Rauf Chaudhury
- Department of Neurology University of Texas at Houston Health Sciences Center McGovern Medical School Houston TX
| | - Gabriela Colina
- Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Robert Regenhardt
- Department of Neurosurgery Massachusetts General Hospital Harvard Medical School Boston MA
| | - Vikas Gupta
- Department of Neurology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Gustavo Rodriguez
- Department of Neurology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
| | - Alberto Maud
- Department of Neurology Texas Tech University Health Sciences Center El Paso Paul L. Foster School of Medicine El Paso TX
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4
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Yoo AJ, Geyik S, Froehler M, Maurer C, Kass-Hout T, Zaidat O, Nogueira RG, Hanel R, Pierot L, Spelle L, Lopes D, Hassan AE, Sirvinskas A, Lin E, Ribo M, Blasco J, Taqi M, Badruddin A, Siddiqui AH, Miller TR, Hussain M, Haussen DC, Woodward K, Groden C, Consoli A, Chaudry I, Ramsey C, Maud A, Bentley J, Brinjikji W, Bajrami A, Sahnoun M, Fiehler J, Gupta R. Abstract WMP87: Primary Results From The CLEAR Study Of The Safety And Effectiveness Of The Neva Stent Retriever For Large Vessel Thrombectomy. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wmp87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Despite the proven benefit of stent retrievers, challenges to rapid revascularization of large vessel occlusions (LVO) persist. Current stent retrievers have limited effectiveness for removing organized thrombi. The NeVa device is a novel stent retriever designed with openings in the basket cell structure (“drop zones”) intended to capture organized thrombi within the central scaffold during retrieval. Prospective, multicenter, open label, single arm, FDA-regulated IDE study to evaluate the performance of the NeVa device for recanalizing occluded intracranial vessels including ICA, M1/M2 MCA, and vertebrobasilar arteries, within 8 hours of onset. Primary endpoint was rate of eTICI 2b-3 within 3 NeVa passes, tested for non-inferiority against a performance goal of 72% with a margin of -10%. Additional efficacy endpoints included first pass effect to eTICI 2b-3 (FPE) and 90-day mRS 0-2. Primary safety endpoint was 90-day mortality. (ClinicalTrials.gov NCT04514562) (Site-adjudicated revascularization results are reported here. Final core lab results will be presented at the conference.) From April 1, 2021 to April 28, 2022, 139 subjects were enrolled at 25 centers in the US and Europe. Mean age was 67 ± 13 years; 47% were female. Median NIHSS score was 16 (IQR: 12-20). Occlusions were 14 (10%) ICA, 85 (61%) M1, 38 (27%) M2, 1 (1%) Basilar and 1 (1%) PCA. Mean time to first pass was 19 ± 12 minutes. eTICI 2b-3 within 3 NeVa passes occurred in 87.8% (122/139; CI 81.1%,92.7%; non-inferiority p<0.0001; post hoc superiority p=0.002, tested against performance goal of 72%). FPE (to eTICI 2b-3) was observed in 67.6% (94/139), with first pass to eTICI 2b67-3 in 61.2% (85/139) and to eTICI 2c-3 in 43.9% (61/139). Median number of passes was 1 (IQR 1-2). Final eTICI 2b-3 rate was 94.2% (131/139); final eTICI 2c-3 rate was 65.5% (91/139). Good outcome (90-day mRS 0-2) was seen in 62.6% (87/139) and was 74.4% in patients with FPE (70/94 vs. 17/45 (37.8%) without FPE; p<0.0001). Mortality was 9.4% (13/139) with sICH in 8 (5.8%) subjects. The NeVa device is effective and safe for revascularization of LVO strokes and demonstrates high first pass success in this international multicenter study. First pass reperfusion (eTICI 2b-3) was strongly associated with functional independence.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Muhammad Taqi
- Vascular Neurology of Southern California, Thousand Oaks, CA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jens Fiehler
- Univ Med Cntr Hamburg-Eppendorf, Hamburg, Germany
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5
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Matuja SS, Ahmed RA, Munseri P, Khanbhai K, Tessua K, Lyimo F, Rodriguez GJ, Gupta V, Maud A, Chaudhury MR, Manji M, Sheriff F. Ischemic Stroke at a Tertiary Academic Hospital in Tanzania: A Prospective Cohort Study With a Focus on Presumed Large Vessel Occlusion. Front Neurol 2022; 13:882928. [PMID: 35911912 PMCID: PMC9330741 DOI: 10.3389/fneur.2022.882928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background Large vessel ischemic strokes account for more than one-third of all strokes associated with substantial morbidity and mortality without early intervention. The incidence of large vessel occlusion (LVO) is not known in sub-Saharan Africa (SSA). Definitive vessel imaging is not routinely available in resource-limited settings. Aims We aimed to investigate the burden and outcomes of presumed LVO among patients with ischemic stroke admitted to a large tertiary academic hospital in Tanzania. Methods This cohort study recruited all consenting first-ever ischemic stroke participants admitted at a tertiary hospital in Tanzania. Demographic data were recorded, and participants were followed up to 1 year using the modified Rankin Scale (mRS). A diagnosis of presumed LVO was made by a diagnostic neuroradiologist and interventional neurologist based on contiguous ischemic changes in a pattern consistent with proximal LVO on a non-contrast computed tomography head. We examined factors associated with presumed LVO using logistic regression analysis. Inter-observer Kappa was calculated. Results We enrolled 158 first-ever ischemic strokes over 8 months with a mean age of 59.7 years. Presumed LVO accounted for 39.2% [95% confidence interval (CI) 31.6–47.3%] and an overall meantime from the onset of stroke symptoms to hospital arrival was 1.74 days. Participants with presumed LVO were more likely to involve the middle cerebral artery (MCA) territory (70.9%), p < 0.0001. Independent factors on multivariate analysis associated with presumed LVO were hypertension [adjusted odds ratio (aOR) 5.74 (95% CI: 1.74–18.9)] and increased waist-hip ratio [aOR 7.20 (95% CI: 1.83–28.2)]. One-year mortality in presumed LVO was 80% when compared with 73.1% in participants without presumed LVO. The Cohen's Kappa inter-observer reliability between the diagnostic neuroradiologist and interventional neurologist was 0.847. Conclusion There is a high burden of presumed LVO associated with high rates of 1-year morbidity and mortality at a tertiary academic hospital in Tanzania. Efforts are needed to confirm these findings with definitive vessel imaging, promoting cost-effective preventive strategies to reduce the burden of non-communicable diseases (NCDs), and a call for adopting endovascular therapies to reduce morbidity and mortality.
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Affiliation(s)
- Sarah Shali Matuja
- Department of Internal Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- *Correspondence: Sarah Shali Matuja
| | - Rashid Ali Ahmed
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Patricia Munseri
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Khuzeima Khanbhai
- Department of Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Kezia Tessua
- Department of Internal Medicine, Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Frederick Lyimo
- Department of Radiology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Gustavo J. Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Vikas Gupta
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Mohammad Rauf Chaudhury
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Mohamed Manji
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Faheem Sheriff
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
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6
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Sheriff F, Xu H, Maud A, Gupta V, Vellipuram A, Fonarow GC, Matsouaka RA, Xian Y, Reeves M, Smith EE, Saver J, Rodriguez G, Cruz-Flores S, Schwamm LH. Temporal Trends in Racial and Ethnic Disparities in Endovascular Therapy in Acute Ischemic Stroke. J Am Heart Assoc 2022; 11:e023212. [PMID: 35229659 PMCID: PMC9075329 DOI: 10.1161/jaha.121.023212] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Introduction Endovascular therapy (EVT) use increased following clinical trials publication in 2015, but limited data suggest there may be persistent race and ethnicity differences. Methods and Results We included all patients with acute ischemic stroke arriving within 6 hours of last known well and with National Institute of Health Stroke Scale (NIHSS) score ≥6 between April 2012 and June 2019 in the Get With The Guidelines‐Stroke database and evaluated the association between race and ethnicity and EVT use and outcomes, comparing the era before versus after 2015. Of 302 965 potentially eligible patients; 42 422 (14%) underwent EVT. Although EVT use increased over time in all racial and ethnic groups, Black patients had reduced odds of EVT use compared with non‐Hispanic White (NHW) patients (adjusted odds ratio [aOR] before 2015, 0.68 [0.58‒0.78]; aOR after 2015, 0.83 [0.76‒0.90]). In‐hospital mortality/discharge to hospice was less frequent in Black, Hispanic, and Asian patients compared with NHW. Conversely discharge home was more frequent in Hispanic (29.7%; aOR, 1.28 [1.16‒1.42]), Asian (28.2%; aOR, 1.23 [1.05‒1.44]), and Black (29.1%; aOR, 1.08 [1.00‒1.18]) patients compared with NHW (24%). However, at 3 months, functional independence (modified Rankin Scale, 0–2) occurred less frequently in Black (37.5%; aOR, 0.84 [0.75‒0.95]) and Asian (33%; aOR, 0.79 [0.65‒0.98]) patients compared with NHW patients (38.1%). Conclusions In a large cohort of patients treated with EVT, Black versus NHW patient disparities in EVT use have narrowed over time but still exist. Discharge related outcomes were slightly more favorable in racial and ethnic underrepresented groups; 3‐month functional outcomes were worse but improved across all groups with time.
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Affiliation(s)
| | - Haolin Xu
- Duke Clinical Res Inst Durham Durham NC
| | - Alberto Maud
- Texas Tech University Health Sciences Center El Paso TX
| | - Vikas Gupta
- Texas Tech University Health Sciences Center El Paso TX
| | | | - Gregg C Fonarow
- UCLA Division of CardiologyRonald Reagan-UCLA Medical Center Los Angeles CA
| | | | - Ying Xian
- University of Texas Southwestern Medical Center Dallas TX
| | - Mathew Reeves
- College of Human Medicine Michigan State University East Lansing MI
| | | | | | | | | | - Lee H Schwamm
- Mass General HospitalHarvard Medical School Boston MA
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7
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Chaudhry MR, Kherani D, Fadah K, Chaudhry SA, Singh B, Kausar N, Moreno J, Ghatali M, Vellipuram AR, Maud A, Piriyawat P, Sheriff F, Rodriguez G, Cruz-Flores S. Abstract TP112: Racial Differences In Palliative Care Utilization And Impact On Inpatient Mortality Length Stay And Costs Among Patients With Ischemic Stroke. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tp112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Palliative is increasingly used in critically ill patients which has lead to shorter length of stays, higher inpatient mortality and lower utilization of aggressive treatment. We performed analysis to evaluate trends in utilization of palliative care among patients with Ischemic Stroke and its effect on in-hospital outcomes over a 10-year period.
Methods:
We obtained data for patients admitted to hospitals in the United States from 2009 to 2018 with a primary diagnosis of Ischemic stroke (IS) using a large national database. We determined the overall and among different races, rate of utilization of palliative care in patients with IS and associated in-hospital outcomes consisting of mean hospital charges, mean length of stay and in-hospital mortality.
Results:
Out of 5525248 patients admitted with primary diagnosis of IS, palliative care was used in 150301 (2.72%). There was a 1.05-fold utilization of PC (1.69% in 2009 vs 1.78% in 2018; p<0.001) from 2009 till 2018. Similarly, there were 1.003, 1.4, 1.04 and 1.05-folds increase in utilization of PC among different races: whites, blacks, hispanics and others respectively, p<0.001. Overall rates of PC utilization among different races: whites, blacks, hispanics and others were: 3.0%, 1.6%, 2.03% and 2.69%, p<0.001 respectively. The length of hospitalization remained significantly higher (6.0±7.4 versus 3.8±5.2, p<0.001) in patients undergoing PC compared those who did not. The cost of hospitalization remained significantly higher ($55068 ± 84630 versus $ 40148 ± 53479, p<0.001) in patients undergoing PC compared with those who did not. Patients with PC utilization had significantly higher (42.9% versus 1.56%, p<0.001) in-hospital mortality compared ones with out.
Conclusions:
Between 2009 and 2018, there has been a significant increase in utilization of PC among patients with IS along with longer length of stay and higher hospital charges. Patients with PC had significantly in-hospital morality. The findings in this IS population are paradoxical to what has been seen in other critical illnesses which may be related to differences in natural history.
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Affiliation(s)
| | | | - Kahtan Fadah
- Internal Medicine, Texas Tech Univ El Paso, El Paso, TX
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8
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Chaudhry MR, Fadah K, Kherani D, Chaudhry SA, Singh B, Kausar N, Moreno J, Ghatali M, Vellipuram AR, Piriyawat P, Gupta V, Sheriff F, Maud A, Rodriguez G, Cruz-Flores S. Abstract TP130: Racial Differences In Palliative Care Utilization And Impact On Inpatient Mortality Length Stay And Costs Among Patients With Intracerebral Hemorrhage. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tp130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Palliative is increasingly used in critically ill patients which has lead to shorter length of stays, higher inpatient mortality and lower utilization of aggressive treatment. We performed analysis to evaluate trends in utilization of palliative care among patients with subarachnoid hemorrhage and its effect on in-hospital outcomes over a 10-year period.
Methods:
We obtained data for patients admitted to hospitals in the United States from 2009 to 2018 with a primary diagnosis of intracerebral hemorrhage (ICH) using a large national database. We determined the overall and among different races, rate of utilization of palliative care in patients with ICH and associated in-hospital outcomes consisting of mean hospital charges, mean length of stay and in-hospital mortality.
Results:
Out of 711787 patients admitted with primary diagnosis of ICH, palliative care was used in 105354 (14.8%). There was a 2.5-fold increase in utilization of PC (8.9% in 2009 vs 22.9% in 2018; p<0.001). Similarly, there were 2.4, 2.6, 3.7 and 2.4-folds increase in utilization of PC among different races: whites, blacks, hispanics and others respectively, p<0.001. Overall rates of PC utilization among different races: whites, blacks, hispanics and others were: 17.4%, 9.8%, 10.1% and 12.2%, p<0.001 respectively. The length of hospitalization remained significantly lower (4.8±7.8 versus 7.7±10.8, p<0.001) in patients undergoing PC compared with those who did not. The cost of hospitalization remained significantly lower ($54736 ± 94502 versus $ 79426 ± 124617, p<0.001) in patients undergoing PC compared with those who did not. Patients with PC utilization had significantly higher (64.9% versus 13.7%, p<0.001) in-hospital mortality compared ones with out.
Conclusions:
Between 2009 and 2018, there has been a significant increase in utilization of PC among patients with ICH along with shorter length of stay and lower hospital charges. ICH patients with PC had significantly higher in-hospital mortality.
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Affiliation(s)
| | - Kahtan Fadah
- Internal Medicine, Texas Tech Univ El Paso, El Paso, TX
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Chaudhry MR, Kherani D, Fadah K, Chaudhry SA, Singh B, Kausar N, Ghatali M, Vellipuram ARR, Piriyawat P, Maud A, Sheriff F, Rodriguez G, Cruz-Flores S, Qureshi AI. Abstract WP132: National Trends In Utilization And Outcomes Of Acute Ischemic Stroke And Intracerebral Hemorrhage Patients Undergoing Gastrostomy Tube Placement. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wp132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Persistent dysphagia requiring gastrostomy tube placement continues to be a major issue for stroke patients. We performed analysis to evaluate trends in utilization of gastrostomy tube placement and associated rates of death among acute ischemic stroke (IS) and intracerebral hemorrhage (ICH) patients over a 10-year period.
Methods:
We obtained data for patients admitted to hospitals in United States from 2009 to 2018 with a primary diagnosis of IS or ICH using a large national database. We determined rate and pattern of utilization and associated in-hospital outcomes of gastrostomy tube placement among IS and ICH patients.
Results:
A total of 50551 (7.05%) and 136922 (2.45%) patients underwent gastrostomy tube placement among the 716777and 5567538patients admitted with ICH and IS, respectively. There was a 3.2-fold decrease in patients who gastrostomy tube placement among patients with IS (2.3% in 2009 vs 0.7% in 2018; P<0.001), and by a 1.5-fold decrease for those with ICH (7.8% in 2009 vs 5.3% in 2018; P<0.001). The rates of in-hospital mortality among patients undergoing gastrostomy tube placement remained unchanged throughout the 10 years for patients with IS (5.2% in 2009 vs 4.9% in 2018; p = 0.54) but decreased by fold for those with ICH (7.58% in 2009 vs 2.7% in 2010; p = 0.01). The length of hospitalization remained significantly higher in patients undergoing gastrostomy tube placement compared with those who did not for both patients with IS (16.2 ±15.7versus 3.6±4.3, p<.0001) and those with ICH (24.4±22.1 versus 6.0±7.5, p<.0001). The cost of hospitalization remained significantly higher in patients undergoing gastrostomy tube placement compared with those who did not for both patients with IS ($140563± 172413 versus $ 37950.2± 45101.6, p<.0001) and those with ICH ($254519± 251973 versus $ 62133.3± 90833.9, p<.0001).
Conclusions:
Between 2009 and 2018, there has been a significant reduction in the proportion of IS and ICH patients who underwent gastrostomy tube placement. However, the length and cost of hospitalization remained significantly higher among patients who underwent gastrostomy tube placement.
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Affiliation(s)
| | | | - Kahtan Fadah
- Internal Medicine, Texas Tech Univ El Paso, El Paso, TX
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10
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Chaudhry MR, Fadah K, Kherani D, Chaudhry SA, Singh B, Kausar N, Moreno J, Ghatali M, Vellipuram AR, Gupta V, Maud A, Piriyawat P, Sheriff F, Rodriguez G, Cruz-Flores S. Abstract TMP7: Racial Differences In Palliative Care Utilization And Impact On Inpatient Mortality Length Stay And Costs Among Patients With Subarachnoid Hemorrhage. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tmp7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Palliative is increasingly used in critically ill patients which has lead to shorter length of stays, higher inpatient mortality and lower utilization of aggressive treatment. We performed analysis to evaluate trends in utilization of palliative care among patients with subarachnoid hemorrhage and its effect on in-hospital outcomes over a 10-year period.
Methods:
We obtained data for patients admitted to hospitals in the United States from 2009 to 2018 with a primary diagnosis of subarachnoid hemorrhage (SAH) using a large national database. We determined the overall and sub racial rate of utilization of palliative care in patients with SAH and associated in-hospital outcomes consisting of mean hospital charges, mean length of stay and in-hospital mortality.
Results:
Out of 199928 patients admitted with primary diagnosis of SAH, palliative care was used in 20490 (10.2%). There was a 2.2-fold increase in utilization of PC (6.5%% in 2009 vs 14.4% in 2018; p<0.001). Similarly, there were 1.7, 2.9, 3.2- and 4.6-folds increase in utilization of PC among different races: whites, blacks, hispanics and others respectively, p<0.001. Overall rates of PC utilization among among different races: whites, blacks, hispanics and others were: 11.8%, 6.9%, 7.5% and 10.0%, p<0.001 respectively. The length of hospitalization remained significantly lower in patients undergoing PC compared with those who did not. (6.5±9.9 versus 11.6±12.6, p<0.001). The cost of hospitalization remained significantly lower in patients undergoing PC compared with those who did not. ($120526 ± 193412 versus $ 185116 ± 219434, p<0.001). Patients with PC utilization had significantly higher (72.7% versus 13.6%, p<0.001) in-hospital mortality compared ones with out.
Conclusions:
Between 2009 and 2018, there has been a significant increase in utilization of PC among patients with SAH along with shorter length of stay and lower hospital charges. SAH patients with PC had significantly higher in-hospital mortality.
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Affiliation(s)
| | - Kahtan Fadah
- Internal Medicine, Texas Tech Univ El Paso, El Paso, TX
| | | | | | | | | | | | | | | | - Vikas Gupta
- Neurology, Texas Tech Univ El Paso, El Paso, TX
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11
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Gupta R, Woodward K, Fiorella D, Woo HH, Liebeskind D, Frei D, Siddiqui A, De Leacy R, Hanel R, Elijovich L, Maud A. Primary results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following Aneurysm Subarachnoid Hemorrhage (VITAL) Study. J Neurointerv Surg 2021; 14:815-819. [PMID: 34493577 DOI: 10.1136/neurintsurg-2021-017859] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/03/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Cerebral vasospasm (CV) after aneurysmal subarachnoid hemorrhage (aSAH) is linked to worse neurological outcomes. The NeVa VS is a novel cerebral dilation device based on predicate stent retrievers. We report the results of the Vesalio NeVa VS for the Treatment of Symptomatic Cerebral Vasospasm following aSAH (VITAL) Study. METHODS This was a single-arm prospective multicenter trial to assess the safety and probable benefit of the NeVa VS device to treat CV. Patients were screened and treated if they had CV >50% on non-invasive imaging confirmed by cerebral angiography. The vessel diameters were measured before and after treatment by an independent core laboratory. The primary endpoint was ≥50% vessel diameter immediately after treatment with the NeVa VS device. RESULTS Thirty patients with a mean age of 52±11 years and mean Hunt-Hess grade of 3.1±0.9 were enrolled. A total of 74 vessels were treated with an average of 1.3 deployments per vessel (95 deployments total). The mean pre-treatment narrowing of the target vessel (n=74) was 65.6% with reduction of the narrowing to 29.4% after treatment. The primary endpoint was achieved in 64 of 74 vessels (86.5%). In three of 95 total deployments (3.2%), thrombus at the site of deployment was observed during the procedure without apparent neurological sequelae. CONCLUSIONS The NeVa VS device appears to be a safe treatment to regain vessel diameter in severely narrowed intracranial arteries secondary to CV associated with aSAH. This treatment offers a new tool that allows for controlled vessel expansion to treat CV.
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Affiliation(s)
- Rishi Gupta
- Neurosurgery, WellStar Health System, Marietta, Georgia, USA
| | - Keith Woodward
- Department of Radiology, Fort Sanders Regional Medical Center, Knoxville, Tennessee, USA
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA.,Neurosurgery, SUNY Stony Brook, Stony Brook, New York, USA
| | - Henry H Woo
- Neurosurgery, Northwell Health, Manhasset, New York, USA
| | | | - Donald Frei
- Interventional Neuroradiology, Radiology Imaging Associates, Englewood, Colorado, USA
| | - Adnan Siddiqui
- Neurosurgery, University at Buffalo School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA
| | - Ricardo Hanel
- Neurosurgery, Lyerly Neurosurgery Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Lucas Elijovich
- Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Alberto Maud
- Neurology, Texas Tech University Health Sciences Center - El Paso, El Paso, Texas, USA
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12
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Mohammaden MH, Nogueira RG, Tekle W, Ortega-Gutierrez S, Farooqui M, Zevallos CB, Hanel RA, Cortez GM, Aghaebrahim A, Starke RM, Aref H, Elbassiouny A, Gamea A, Alaraj A, Sadeh M, Grigoryan M, Kuybu O, Haussen DC, Sheth SA, Maud A, Cordina SM, Tanweer O, Kan P, Burkhardt JK, Grandhi R, Siddiq F, Hassan AE. Safety and efficacy of balloon-mounted stent in the treatment of symptomatic intracranial atherosclerotic disease: a multicenter experience. J Neurointerv Surg 2021; 14:756-761. [PMID: 34349013 DOI: 10.1136/neurintsurg-2021-017818] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/26/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Randomized clinical trials have failed to prove that the safety and efficacy of endovascular treatment for symptomatic intracranial atherosclerotic disease (ICAD) is better than that of medical management. A recent study using a self-expandable stent showed acceptable lower rates of periprocedural complications. OBJECTIVE To study the safety and efficacy of a balloon-mounted stent (BMS) in the treatment of symptomatic ICAD. METHODS Prospectively maintained databases from 15 neuroendovascular centers between 2010 and 2020 were reviewed. Patients were included if they had severe symptomatic intracranial stenosis in the target artery, medical management had failed, and they underwent intracranial stenting with BMS after 24 hours of the qualifying event. The primary outcome was the occurrence of stroke and mortality within 72 hours after the procedure. Secondary outcomes were the occurrence of stroke, transient ischemic attacks (TIAs), and mortality on long-term follow-up. RESULTS A total of 232 patients were eligible for the analysis (mean age 62.8 years, 34.1% female). The intracranial stenotic lesions were located in the anterior circulation in 135 (58.2%) cases. Recurrent stroke was the qualifying event in 165 (71.1%) while recurrent TIA was identified in 67 (28.9%) cases. The median (IQR) time from the qualifying event to stenting was 5 (2-20.75) days. Strokes were reported in 13 (5.6%) patients within 72 hours of the procedure; 9 (3.9%) ischemic and 4 (1.7%) hemorrhagic, and mortality in 2 (0.9%) cases. Among 189 patients with median follow-up time 6 (3-14.5) months, 12 (6.3%) had TIA and 7 (3.7%) had strokes. Three patients (1.6%) died from causes not related to stroke. CONCLUSION Our study has shown that BMS may be a safe and effective treatment for medically refractory symptomatic ICAD. Additional prospective randomized clinical trials are warranted.
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Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA.,Department of Neurology, South Valley University Faculty of Medicine, Qena, Egypt
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Wondwossen Tekle
- Department of Neurology, UTRGV School of Medicine, Harlingen, Texas, USA.,Department of Neurology, Valley Baptist Medical Center, Harlingen, Texas, USA
| | - Santiago Ortega-Gutierrez
- Department of Neuroloy, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Cynthia B Zevallos
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Robert M Starke
- Department of Neurosurgery and Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Hany Aref
- Department of Neurology, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Ahmed Elbassiouny
- Department of Neurology, Ain Shams University Faculty of Medicine, Cairo, Egypt
| | - Ayman Gamea
- Department of Neurology, South Valley University Faculty of Medicine, Qena, Egypt
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | - Morteza Sadeh
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA
| | | | - Okkes Kuybu
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA.,Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Sunil A Sheth
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, Texas, USA
| | - Steve M Cordina
- Department of Neurology, University of South Alabama Health System, Mobile, Alabama, USA
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor Health Care System, Dallas, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri System, Columbia, Missouri, USA
| | - Ameer E Hassan
- Department of Neurology, UTRGV School of Medicine, Harlingen, Texas, USA .,Department of Neurology, Valley Baptist Medical Center, Harlingen, Texas, USA
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13
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Khandelwal P, Majmundar N, Rodriguez GJ, Patel P, Dodson V, Singla A, Khatri R, Gupta V, Sheriff F, Vellipuram A, Cruz-Flores S, Maud A. Dual-center study comparing transradial and transfemoral approaches for flow diversion treatment of intracranial aneurysms. Brain Circ 2021; 7:65-70. [PMID: 34189348 PMCID: PMC8191526 DOI: 10.4103/bc.bc_38_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/30/2020] [Accepted: 01/26/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The transfemoral approach (TFA) has been the traditional approach for neurointerventional cases. While the TFA allows for triaxial support in flow diverting stent cases, it is associated with access site complications. Recently, the transradial approach (TRA) has emerged as a safer alternative to the TFA. To the best of our knowledge, there have only been single-center studies comparing outcomes in flow diverter cases for these approaches. We demonstrate the safety and feasibility of the TRA for placement of flow diverting stents in the treatment of unruptured intracranial aneurysms at two high-volume centers. MATERIALS AND METHODS We performed a retrospective review of prospectively collected institutional databases at two high-volume neuroendovascular centers. Cases from 2016 to 2018 of unruptured intracranial aneurysms treated by flow diverting stenting accessed through either the TRA or the TFA were compared. Patient demographics, procedural and radiographic metrics including location and size of the aneurysm, size, and length of the flow diverter implant, and fluoroscopic time were recorded. Puncture site complications and length of hospital stay were also included in the data analysis. RESULTS There were three out of 29 TRA cases which were converted to the TFA. None of the TRA patients experienced site complications, whereas three TFA patients experienced site complications. While TRA and TFA patients did not differ significantly in their exposure to radiation, TRA patients experienced shorter hospital stays. CONCLUSIONS While long-term studies are still lacking regarding this approach, we demonstrate that the TRA is a safe and feasible approach for flow diverter stent placement.
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Affiliation(s)
- Priyank Khandelwal
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Neil Majmundar
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Pratit Patel
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Vincent Dodson
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Amit Singla
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Vikas Gupta
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Faheem Sheriff
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Anantha Vellipuram
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
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Abstract
PURPOSE OF REVIEW To summarize evidence for the feasibility and the efficacy of mobile stroke units (MSUs) and telemedicine in the field to reduce time delays in offering acute stroke interventions. RECENT FINDINGS A mobile stroke unit is a modified ambulance and includes sophisticated equipment, either trained personnel on board, or connection with skilled physicians via telemedicine. Stroke assessment and treatment agreeability between the on board and remote neurologist is high in MSUs. MSUs are the promising option to reduce stroke symptom onset to treatment time; telemedicine platform has a satisfactory audiovisual quality, high inter-rater reliability for remote stroke symptom assessment, diagnosis, and decision to treat. Use of MSU also avoids the need for inter-hospital transfers. MSUs improve prehospital stroke care and reduce delays in access to intravenous thrombolytic and mechanical thrombectomy in selective markets. Advancement in telecommunication and modern technology has the potential to make MSU telemedicine-aided management more cost-effective. Further research is needed before its widespread implementation.
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Affiliation(s)
- Jithendhar Kandimalla
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, 79905, USA
| | - Anantha R Vellipuram
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, 79905, USA
| | - Gustavo Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, 79905, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, 79905, USA
| | - Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, 79905, USA
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, 79905, USA.
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15
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Sheriff FG, Rodriguez GJ, Gupta V, Maud A. Letter regarding 'Radial first or patient first : a case series and meta-analysis of transradial (TRA) versus transfemoral (TFA) access for acute ischemic stroke intervention'. J Neurointerv Surg 2021; 13:e16. [PMID: 33906939 DOI: 10.1136/neurintsurg-2021-017655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Faheem G Sheriff
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA.,Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA.,Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Vikas Gupta
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA.,Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA .,Paul L Foster School of Medicine, El Paso, Texas, USA
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16
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Sheriff F, Inam ME, Thanh Truong VT, Lopez-Rivera V, Lekka E, Kermali K, Sheth S, Maud A, Gupta V, Rodriguez G, Pedroza C, Chen PR. Dual Antiplatelet Therapy Duration After Venous Sinus Stenting for Idiopathic Intracranial Hypertension and Stent Survival-Is Longer Necessarily Better? A Meta-Regression. World Neurosurg 2021; 151:e86-e93. [PMID: 33819705 DOI: 10.1016/j.wneu.2021.03.134] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 03/24/2021] [Accepted: 03/25/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND Venous stenting (VS) for venous sinus stenosis in the setting of idiopathic intracranial hypertension has been increasing in acceptance by neurointerventionalists. Stent-adjacent stenosis (SAS) and in-stent stenosis leading to symptom recurrence and the need for retreatment are known delayed complications. However, the effect of the dual antiplatelet therapy (DAPT) duration on these complications has remained poorly characterized. METHODS An extensive literature search was performed to identify reports of VS for patients with idiopathic intracranial hypertension from 2000 to 2020. The primary outcome was the occurrence of SAS. The secondary outcomes included the occurrence of composite stenosis (in-stent stenosis and SAS) and stent survival, defined as the need for retreatment or other surgical management. Generalized linear mixed models were used to explore the effects of DAPT duration (3 vs ≥6 months) on the primary and secondary outcomes. RESULTS A total of 325 patients met the inclusion criteria and were included in our analysis. SAS occurred in 9% (95% confidence interval, 6%-15%) of the patients, and stent survival was 90% (95% confidence interval, 84%-93%) in the cohort. With every 1-mm Hg increase in the venous pressure gradient, an 8% decrease was found in the odds of stent survival (P = 0.043). The meta-regression revealed no association between the DAPT duration and the primary outcome or the odds of composite stenosis and stent survival. CONCLUSIONS We found no differences between 3 and ≥6 months of DAPT in terms of the risk of stent stenosis or stent survival. However, patients with a higher venous pressure gradient before VS had a greater risk of stent failure.
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Affiliation(s)
- Faheem Sheriff
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA; Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Mehmet Enes Inam
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Van Thi Thanh Truong
- Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Victor Lopez-Rivera
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Elvira Lekka
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Kumail Kermali
- Department of Medicine, Kilimanjaro Christian Medical Center, Moshi, Tanzania
| | - Sunil Sheth
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Vikas Gupta
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Gustavo Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA
| | - Claudia Pedroza
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Peng Roc Chen
- Department of Neurosurgery, University of Texas Health Science Center at Houston, Houston, Texas, USA.
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17
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Kandimalla J, Hussain Z, Piriyawat P, Rodriguez G, Maud A, Khatri R, Cruz-Flores S, Vellipuram AR. Stroke Rates Following Surgical Versus Percutaneous Revascularization for Ischemic Heart Disease. Curr Cardiol Rep 2021; 23:45. [PMID: 33721116 DOI: 10.1007/s11886-021-01471-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/11/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE OF REVIEW Coronary revascularization is a commonly performed major procedure in the hospitals. Stroke is one of the dreaded complications after coronary revascularization procedures. The focus of this review is to understand the stroke risk in percutaneous cutaneous intervention (PCI) and coronary artery bypass grafting (CABG) procedures. RECENT FINDINGS Available data show that PCI offers less procedural stroke risk compared to CABG although the survival benefits of CABG are better in certain scenarios. Innovative advancements in techniques, pre-procedural optimum medical therapy (OMT), intraoperative neuro-monitoring, and multidisciplinary post procedural care are the few strategies in early detection and reduce stroke risk. Despite several innovations and strategies, it is evident that there is not enough data available to make concrete conclusions related to stroke risk after coronary revascularization, which warrants further investigation.
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Affiliation(s)
- Jithendhar Kandimalla
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Zain Hussain
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Paisith Piriyawat
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Gustavo Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Rakesh Khatri
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA
| | - Anantha R Vellipuram
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX, 79905, USA.
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Chaudhry MRA, Gill H, Chaudhry S, Singh B, Bandaru H, Vellipuram AR, Piriyawat P, Maud A, Rodriguez G, Cruz-Flores S. Abstract P454: Do Not Resuscitate Orders in Intracerebral Hemorrhage Patients. Impact on Mortality. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction/background:
Do not resuscitate (DNR) orders have been associated with higher mortality in hospitalized patients which the question if they these patients are victims of the self-fulfilling prophecy; that the odds of their survival is made worse by withholding aggressive treatment. In addition, previous reports show that racial and ethnic minorities tend to opt for more aggressive and lifesaving procedures as compared to Whites.
Methods:
We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all intracerebral hemorrhage (ICH) patients. DNR code status was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, length of stay) were compared between the two groups. DNR code status was compared between different racial groups.
Results:
Of the 884379 patients with ICH, 81968 (9.26%%) had DNR order. ICH patients with DNR order had higher proportion of females (55.1% versus 49.1%, P <.0001) and were older (74.2 years versus 66 years, P <.0001) compared to ICH patients without DNR. The in-hospital mortality was also higher (53.4% versus 23.3%, p≤.0001) among patients with DNR both univariate and multivariate analysis (OR = 3.24 (3.07 -3.41), p<.0001) after adjusting for potential confounders. Whites have a higher rate (11.5% versus 8.08%) of DNR order as compared to other racial/ethnic groups
Conclusions:
While there may be other explanations at play, the higher mortality and shorter LOS suggest that early DNR orders do lead to the self-fulfilling prophecy. The lower proportion of DNR orders among minorities suggest a sociocultural aspect in accepting the concept of DNR. These two facts raise concerns about what the real vs perceived meaning of DNR orders.
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Affiliation(s)
| | - Hussan Gill
- College of Medicine, Univ of Oklahoma, Tulsa, OK
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19
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Chaudhry MR, Gill H, Chaudhry S, Singh B, Bandaru H, Vellipuram AR, Piriyawat P, Maud A, Rodriguez GJ, Cruz-Flores S. Abstract P399: Do Not Resuscitate Orders in Subarachnoid Hemorrhage Patients. Impact on Mortality. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction/background:
Do not resuscitate (DNR) orders have been associated with higher mortality in hospitalized patients which the question if they these patients are victims of the self-fulfilling prophecy; that the odds of their survival is made worse by withholding aggressive treatment. In addition, previous reports show that racial and ethnic minorities tend to opt for more aggressive and lifesaving procedures as compared to Whites.
Methods:
We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all subarachnoid hemorrhage (ICH) patients. DNR code status was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, length of stay) were compared between the two groups. DNR code status was compared between different racial groups.
Results:
Of the 325923 patients with SAH, 20127 (6.17%%) had DNR order. SAH patients with DNR order had higher proportion of females (61.7% versus 59.4%, P=0.0048) and were older (70.9 years versus 58.4 years, P <.0001) compared to SAH patients without DNR. The in-hospital mortality was also higher (66.4% versus 22.4%, p≤.0001) among patients with DNR both univariate and multivariate analysis (OR = 5.05 (4.58 -5.56), p<.0001) after adjusting for potential confounders. Whites have a higher rate (7.59% versus 5.84%, P <.0001) of DNR order as compared to other racial/ethnic groups
Conclusions:
While there may be other explanations at play, the higher mortality and shorter LOS suggest that early DNR orders do lead to the self-fulfilling prophecy. The lower proportion of DNR orders among minorities suggest a sociocultural aspect in accepting the concept of DNR. These two facts raise concerns about what the real vs perceived meaning of DNR orders.
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Affiliation(s)
| | - Hussan Gill
- College of Medicine, Univ of Oklahoma, Tulsa, OK
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20
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Chaudhry MR, Gill H, Chaudhry S, Singh B, Bandaru H, Vellipuram AR, Piriyawat P, Maud A, Rodriguez GJ, Cruz-Flores S. Abstract P456: Myocardial Infarction in Patients With Intracerebral Hemorrhage. Prevalence and Impact on Outcome. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction/background:
Comorbidities can potentially affect outcome of patients with intracerebral hemorrhage (ICH). It is unclear what the prevalence of acute myocardial infarction (AMI) and its impact on outcome are in patients with intracerebral hemorrhage.
Methods:
We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all intracerebral hemorrhage (ICH) patients. AMI was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, discharge disposition, length of stay and in-hospital charges) were compared between the two groups.
Results:
Of the 884379 patients with ICH, 27692 (3.13%) had in-hospital myocardial infraction. ICH patients with AMI order had lower proportion of females (47.8% versus 49.7%, P= 0.0028) and were older (69.7 years versus 67.2 years, P <.0001) compared to ICH patients without MI. The in-hospital mortality was higher (40.9% versus 25.5%, p≤.0001) among ICH patients with AMI in both univariate and multivariate analysis (OR = 1.22 (1.14 -1.31), P<.0001) after adjusting for potential confounders. ICH patients with MI had higher (72.4% versus 58.8%, P <.0001) proportion of moderate to severe disability at discharge compared to ones without. Similarly, mean length of in-hospital stay (12.4 days versus 8.94 days, P <.0001) and mean hospital charges ($129328 versus $ 81984.0, P <.0001) were also higher in ICH patients with MI
Conclusions:
While only 3.13% of patients with ICH have an AMI, there is a 22% increase in worse outcome among those patients with AMI and ICH.
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Affiliation(s)
| | - Hussan Gill
- College of Medicine, Univ of Oklahoma, Broken Arrow, OK
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21
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Chaudhry MR, Gill H, Chaudhry S, Singh B, Bandaru H, Vellipuram AR, Piriyawat P, Maud A, Rodriguez G, Cruz-Flores S. Abstract P444: Myocardial Infarction and Subarachnoid Hemorrhage. Frequency and Impact on Outcome. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction/background:
Subarachnoid hemorrhage is known to be associated with systemic complications including neurogenic pulmonary edema and Talkotsubo cardiomyopathy. We set to establish the frequency of myocardial infarction (MI) and its impact on outcome among patients with subarachnoid hemorrhage (SAH)
Methods:
We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all subarachnoid hemorrhage (ICH) patients. Myocardial infraction (MI) was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, moderate to severe disability at dischagre, length of stay and in-hospital charges) were compared between the two groups.
Results:
Of the 325923 patients with SAH, 12720 (3.90%) had in-hospital myocardial infraction. SAH patients with MI were older (64.6 years versus 59.0 years, P <.0001) compared to SAH patients without MI but there was no difference in-term of proportion of females between the two groups. The in-hospital mortality was also higher (49.8% versus 23.9%, p≤.0001) among patients with MI in both univariate and multivariate analysis (OR = 1.75 (1.59 -1.93), P<.0001) after adjusting for potential confounders. SAH patients with MI had higher (68.5% versus 40.9%, P <.0001) proportion of moderate to severe disability at discharge compared to ones without. Similarly, mean length of in-hospital stay (13.2 days versus 11.8 days, P <.0001) and mean hospital charges ($188845 versus $150062, P <.0001) were also higher in SAH patients with MI
Conclusions:
While MI was reported in only 3.9% of SAH cases it had a significant impact on outcome with a one fold increase in morality and about 75% increase risk of severe disability.
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Affiliation(s)
| | - Hussan Gill
- College of Medicine, Univ of Oklahoma, Tulsa, OK
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22
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Chaudhry MRA, Gill H, Chaudhry S, Singh B, Bandaru H, Vellipuram AR, Maud A, Rodriguez GJ, Cruz-Flores S, Qureshi AI. Abstract P437: Trends in Outcomes, and Length and Costs of Hospitalization in Patients With Intracerebral Hemorrhage in United States. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
It remains unclear whether there is any improvement in outcomes of patients with intracerebral hemorrhage over the last decade.
Objective:
To determine trends pertaining in-hospital outcomes in patients with intracerebral hemorrhage using nationally representative data.
Methods:
We determined the national estimates of intracerebral hemorrhage admissions from 2005 to 2014 and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data. The NIS is the largest all-payer inpatient care database in the US and contains data from 986 hospitals approximating a 20% stratified sample of US hospitals. Outcome was classified as none to minimal disability, moderate to severe disability, and death based on discharge destination.
Results:
In the 10-year period, there were 70,637 admissions for intracerebral hemorrhage (annual estimate 80804 in 2005 to 109930 in 2014). There was a significant reduction in in-hospital mortality in patients with intracerebral hemorrhage from 30% to 23% (trend test, p < 0.0001). There was a trend towards increase in proportion of patients with moderate to severe disability (trend test, p < 0.097). The mean length of hospitalization increased from 8.58 days to 9.23 days (trend test, p < 0.0001) and cost of hospitalization increased from $50532.1 to $110932.1 (trend test, p < 0.0001).
Conclusions:
The mortality in patients with intracerebral hemorrhage has decreased but there is increased rates of moderate to severe disability, length of hospitalization, and hospitalization cost over the last decade.
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Affiliation(s)
| | - Hussan Gill
- College of Medicine Univ of Oklahoma, Tulsa, OK
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23
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Mohammaden M, Nogueira RG, TEKLE WONDWOSSEN, siddiq F, Haussen DC, Elbassiouny A, Aref H, Grigoryan M, Hanel R, Cortez G, Ortega S, Zevallos C, Mudassir F, Maud A, Sheth S, Spiegel GR, Kan PTM, Burkhardt JK, Hassan AE. Abstract P476: Safety and Efficacy of Balloon Mounted Drug-Eluting Stent in the Treatment of Symptomatic Intracranial Atherosclerotic Disease Multicenter International Experience. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Intracranial atherosclerotic disease (ICAD) is a common cause of refractory stroke. Randomized clinical trials failed to prove the safety and efficacy of the endovascular treatment options of symptomatic ICAD (sICAD). However, there are many concerns regarding inclusion criteria in these trials which made them less effective than standard medical management. Herein, we aim to study the safety and efficacy of drug-eluting balloon mounted stents (DES) in the treatment of sICAD.
Methods:
A retrospective review of endovascular database from 10 comprehensive stroke centers inside and outside the USA from January 2017 to January 2020 was reviewed. Patients were included if they had symptomatic intracranial stenosis ≥70% in the target vessel, failed best medical management, and underwent intracranial stenting with DES. The primary outcome was the occurrence of ischemic stroke, hemorrhage, or mortality within 72 hours of the procedure. Secondary outcomes included rates of symptomatic and angiographic recurrence within 6 months of the procedure.
Results:
There was a total of 129 patients, the median age was 65 [58-72] years, 40 (31%) were females. The intracranial stenotic lesions were located in anterior circulation in 74 (57.4%) of cases [24 (18.6%) supraclinoid ICA, 5 (3.9%) cavernous ICA, 17 (13.2%) petrous ICA, 5 (19.4%) MCA-M1, and 3 (2.3%) M2] and in posterior circulation in 55 (42.6%) of cases [36 (27.9) vertebral artery V4 segment, 18 (14%) basilar and 1 (0.7%) PCA]. Recurrent stroke was the qualifying event in 101 (78.3%) while transient ischemic attacks (TIA) were identified in 28 (21.7%) of cases. The median time from the qualifying event to stenting was 6 [2-24] days. Strokes were reported within 72 hours of the procedure; 2 (1.6%) ischemic, 2 (1.6%) hemorrhagic strokes and 2 (1.6%) patients suffered inpatient mortality. The median follow-up time was 6 [3-6.75] months. Among 99 patients who had clinical follow up 2 (2%) had TIA and 6 (6.1%) had strokes. Fifty-one patients had follow-up imaging of whom symptomatic ISR was reported in 8 (15.7%).
Conclusion:
Our study has shown that in appropriately selected patients with sICAD, endovascular treatment using DES is safe and effective. Prospective randomized clinical trials are warranted.
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Qureshi AI, Agunbiade S, Huang W, Akhtar IN, Abraham MG, Akhtar N, Al-Mufti F, Aytac E, Balgetir F, Grigoryan M, Gomez CR, Hassan AE, Jani V, Janjua NA, Jiao L, Khatri R, Kirmani JF, Kobayashi A, Kozak O, Lee J, Lobanova I, Mansour OY, Maud A, Mazighi M, Piotin M, Rodriguez GJ, Siddiq F, Suri MFK, Tekle WG. Changes in Neuroendovascular Procedural Volume During the COVID-19 Pandemic: An International Multicenter Study. J Neuroimaging 2020; 31:171-179. [PMID: 33227167 PMCID: PMC7753603 DOI: 10.1111/jon.12803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE The effect of coronavirus disease 2019 (COVID‐19) pandemic on performance of neuroendovascular procedures has not been quantified. METHODS We performed an audit of performance of neuroendovascular procedures at 18 institutions (seven countries) for two periods; January‐April 2019 and 2020, to identify changes in various core procedures. We divided the region where the hospital was located based on the median value of total number of COVID‐19 cases per 100,00 population‐into high and low prevalent regions. RESULTS Between 2019 and 2020, there was a reduction in number of cerebral angiograms (30.9% reduction), mechanical thrombectomy (8% reduction), carotid artery stent placement for symptomatic (22.7% reduction) and asymptomatic (43.4% reduction) stenoses, intracranial angioplasty and/or stent placement (45% reduction), and endovascular treatment of unruptured intracranial aneurysms (44.6% reduction) and ruptured (22.9% reduction) and unruptured brain arteriovenous malformations (66.4% reduction). There was an increase in the treatment of ruptured intracranial aneurysms (10% increase) and other neuroendovascular procedures (34.9% increase). There was no relationship between procedural volume change and intuitional location in high or low COVID‐19 prevalent regions. The procedural volume reduction was mainly observed in March‐April 2020. CONCLUSIONS We provided an international multicenter view of changes in neuroendovascular practices to better understand the gaps in provision of care and identify individual procedures, which are susceptible to change.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Samiat Agunbiade
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO.,Division of Neurological Surgery, University of Missouri, Columbia, MO
| | - Wei Huang
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Iqra N Akhtar
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Michael G Abraham
- Departments of Neurology and Radiology, University of Kansas Medical Center, Kansas City, KS
| | - Naveed Akhtar
- Department of Neurointervention, Marion Bloch Neuroscience Institute/Saint Luke's Hospital, Kansas City, MO
| | - Fawaz Al-Mufti
- Departments of Neurology, Neurosurgery and Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Emrah Aytac
- Zeenat Qureshi Stroke Institute, Department of Neurology, University of FIRAT, Elazig, Turkey
| | - Ferhat Balgetir
- Zeenat Qureshi Stroke Institute, Department of Neurology, University of FIRAT, Elazig, Turkey
| | - Mikayel Grigoryan
- Adventist Health Glendale Comprehensive Stroke Center, Los Angeles, CA
| | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley - Valley Baptist Medical Center, Harlingen, TX
| | - Vishal Jani
- Department of Neurology, Creighton University Medical Center/CHI Health, Omaha, NE
| | | | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Jawad F Kirmani
- Stroke and Neurovascular Center, Hackensack Meridian Health-JFK University Medical Center, Hackensack, NJ
| | - Adam Kobayashi
- Department of Neurology and Interventional Stroke Treatment Centre, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Osman Kozak
- Department of Neurology, Jefferson Health Abington, Philadelphia, PA
| | - Jun Lee
- Department of Neurology, Yeungnam University School of Medicine, Daegu, Korea
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Ossama Yassin Mansour
- Department of Neurology, Stroke and Neurointervention Section, Alexandria University Hospital, Faculty of medicine, Alexandria, Egypt
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Farhan Siddiq
- Division of Neurological Surgery, University of Missouri, Columbia, MO
| | | | - Wondwossen G Tekle
- Department of Neurology, University of Texas Rio Grande Valley - Valley Baptist Medical Center, Harlingen, TX
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25
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Khatri R, Qureshi MA, Chaudhry MRA, Maud A, Vellipuram AR, Cruz-Flores S, Rodriguez GJ. The Angiographic Anatomy of the Sphenoidal Segment of the Middle Cerebral Artery and Its Relevance in Mechanical Thrombectomy. Interv Neurol 2020; 8:231-241. [PMID: 32508905 DOI: 10.1159/000502545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 08/01/2019] [Indexed: 11/19/2022]
Abstract
Objective The middle cerebral artery (MCA) is the most commonly treated artery in mechanical thrombectomy stroke trials; however, there is no pragmatic agreement about the segmental anatomy and nomenclature utilized. It results in significant clinical-radiological dissociation and introduces bias in research trials. The purpose of the study is to review and compare angiographic anatomy with microsurgical anatomy literature of the MCA with emphasis on the discrepancy. Methodology Consecutive cerebral angiograms between January 2011 and March 2014 were retrospectively reviewed by endovascular surgical neuroradiologists. Information about the anatomy of the sphenoidal segment of the MCA classified as classic and non-classic pattern, the lenticulostriate artery takeoff pattern, and the course angulation of the sphenoidal segment were studied. Results A total of 500 patients, 886 cerebral angiograms, were reviewed. We found the classic pattern of the main trunk MCA bifurcation and a straight angulation course in less than half of the cases. The lenticulostriate arteries arose not only from the main trunk but also from its divisions in more than half of the cases. Conclusion It is important to corroborate our findings and to develop a pragmatic classification to accurately assess MCA occlusions from the radiological and clinical perspective.
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Affiliation(s)
- Rakesh Khatri
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
| | | | | | - Alberto Maud
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
| | | | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
| | - Gustavo Jose Rodriguez
- Department of Neurology, Texas Tech University of Health Sciences Center, El Paso, Texas, USA
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26
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Abootalebi S, Aertker BM, Andalibi MS, Asdaghi N, Aykac O, Azarpazhooh MR, Bahit MC, Barlinn K, Basri H, Shahripour RB, Bersano A, Biller J, Borhani-Haghighi A, Brown RD, Campbell BC, Cruz-Flores S, De Silva DA, Di Napoli M, Divani AA, Edgell RC, Fifi JT, Ghoreishi A, Hirano T, Hong KS, Hsu CY, Huang JF, Inoue M, Jagolino AL, Kapral M, Kee HF, Keser Z, Khatri R, Koga M, Krupinski J, Liebeskind DS, Liu L, Ma H, Maud A, McCullough LD, Meyer DM, Mifsud V, Morovatdar N, Nilanont Y, Oxley TJ, Özdemir AÖ, Pandian J, Pantoni L, Papamitsakis NIH, Parry-Jones A, Phan T, Rodriguez G, Romano JG, Sabaa-Ayoun Z, Saber H, Sasannezhad P, Saver JL, Scharf E, Shuaib A, Silver B, Singhal S, Smith CJ, Stranges S, Sylaja PN, Torbey M, Toyoda K, Tsivgoulis G, Wasay M, Yassi N, Yoshimoto T, Zamani B, Zand R. Call to Action: SARS-CoV-2 and CerebrovAscular DisordErs (CASCADE). J Stroke Cerebrovasc Dis 2020; 29:104938. [PMID: 32807412 PMCID: PMC7205703 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104938] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/01/2020] [Accepted: 05/02/2020] [Indexed: 12/31/2022] Open
Abstract
Background and purpose The novel severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2), now named coronavirus disease 2019 (COVID-19), may change the risk of stroke through an enhanced systemic inflammatory response, hypercoagulable state, and endothelial damage in the cerebrovascular system. Moreover, due to the current pandemic, some countries have prioritized health resources towards COVID-19 management, making it more challenging to appropriately care for other potentially disabling and fatal diseases such as stroke. The aim of this study is to identify and describe changes in stroke epidemiological trends before, during, and after the COVID-19 pandemic. Methods This is an international, multicenter, hospital-based study on stroke incidence and outcomes during the COVID-19 pandemic. We will describe patterns in stroke management, stroke hospitalization rate, and stroke severity, subtype (ischemic/hemorrhagic), and outcomes (including in-hospital mortality) in 2020 during COVID-19 pandemic, comparing them with the corresponding data from 2018 and 2019, and subsequently 2021. We will also use an interrupted time series (ITS) analysis to assess the change in stroke hospitalization rates before, during, and after COVID-19, in each participating center. Conclusion The proposed study will potentially enable us to better understand the changes in stroke care protocols, differential hospitalization rate, and severity of stroke, as it pertains to the COVID-19 pandemic. Ultimately, this will help guide clinical-based policies surrounding COVID-19 and other similar global pandemics to ensure that management of cerebrovascular comorbidity is appropriately prioritized during the global crisis. It will also guide public health guidelines for at-risk populations to reduce risks of complications from such comorbidities.
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Affiliation(s)
- Shahram Abootalebi
- Dr. Everett Chalmers Regional Hospital, Dalhousie University, New Brunswick, Canada.
| | - Benjamin M Aertker
- Department of Neurology, UTHealth McGovern Medical School, The University of Texas at Houston, Houston, Texas, USA.
| | - Mohammad Sobhan Andalibi
- International UNESCO Center for Health-Related Basic Sciences and Human Nutrition, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Negar Asdaghi
- Department of Neurology, University of Miami, Miami, Florida, USA.
| | - Ozlem Aykac
- Department of Neurology and Neurocritical Care, Eskisehir Osmangazi University, Eskişehir, Turkey
| | - M Reza Azarpazhooh
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada; Department of Clinical Neurological Sciences, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Neurology, School of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - M Cecilia Bahit
- Chief of Cardiology, INECO Neurociencias, Rosario, Argentina
| | - Kristian Barlinn
- Department of Neurology, Carl Gustav Carus University Hospital, Technische Universität Dresden, Dresden, Germany.
| | - Hamidon Basri
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Malaysia.
| | | | - Anna Bersano
- Fondazione Istituto Neurologico 'Carlo Besta', Milan, Italy.
| | - Jose Biller
- Department of Neurology, Loyola University Health System, Stritch School of Medicine, Chicago, USA.
| | | | - Robert D Brown
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Bruce Cv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia.
| | | | | | - Mario Di Napoli
- Department of Neurology and Stroke Unit, San Camillo de' Lellis General District Hospital, Rieti, Italy; Neurological Section, Neuro-epidemiology Unit, SMDN-Centre for Cardiovascular Medicine and Cerebrovascular Disease Prevention, Sulmona, L'Aquila, Italy.
| | - Afshin A Divani
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Randall C Edgell
- Department of Neurology, Souers Stroke Institute, Saint Louis University, USA
| | - Johanna T Fifi
- Departments of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Abdoreza Ghoreishi
- Department of Neurology, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Japan.
| | - Keun-Sik Hong
- Department of Neurology, Inje University, Ilsan Paik Hospital, Goyang, Republic of Korea
| | - Chung Y Hsu
- Graduate Institute of Clinical Medical Science, China Medical University, Taipei, Taichung.
| | | | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Amanda L Jagolino
- Department of Neurology, UTHealth McGovern Medical School, The University of Texas at Houston, Houston, Texas, USA.
| | - Moira Kapral
- Department of Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada; Institute for Clinical Evaluative Sciences, Toronto, Canada.
| | - Hoo Fan Kee
- Department of Medicine, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Zafer Keser
- Department of Neurology, UTHealth McGovern Medical School, The University of Texas at Houston, Houston, Texas, USA.
| | - Rakesh Khatri
- Neurology Department, Texas Tech Health University, El Paso, Texas, USA.
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Jerzy Krupinski
- Department of Neurology, Hospital Universitari MutuaTerrassa, Terrassa (Barcelona), Spain; Department of Life Sciences, CBS, Manchester Metropolitan University, Manchester, UK.
| | | | - Liping Liu
- Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Henry Ma
- Department of Neurology, Monash Health and Department of Medicine, School of Clinical Sciences Monash University, Australia
| | - Alberto Maud
- Neurology Department, Texas Tech Health University, El Paso, Texas, USA
| | - Louise D McCullough
- Department of Neurology, UTHealth McGovern Medical School, The University of Texas at Houston, Houston, Texas, USA.
| | | | | | - Negar Morovatdar
- Clinical Research Development Unit, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Yongchai Nilanont
- Siriraj Stroke Center, Department of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thomas J Oxley
- Department of Neurosurgery, Mount Sinai Hospital, New York, USA.
| | - Atilla Özcan Özdemir
- Department of Neurology and Neurocritical Care, Eskisehir Osmangazi University, Eskişehir, Turkey
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College, Ludhiana, India
| | - Leonardo Pantoni
- Department of Biomedical and Clinical Sciences Luigi Sacco, University of Milan, Milan, Italy.
| | | | - Adrian Parry-Jones
- Manchester Centre for Clinical Neurosciences, Salford Royal National Health Service Foundation Trust, Manchester Academic Health Science Centre, Salford, UK.
| | - Thanh Phan
- Department of Neurology, Monash Health and Department of Medicine, School of Clinical Sciences Monash University, Australia.
| | - Gustavo Rodriguez
- Neurology Department, Texas Tech Health University, El Paso, Texas, USA
| | - Jose G Romano
- Department of Neurology, University of Miami, Miami, Florida, USA.
| | - Ziad Sabaa-Ayoun
- Stroke Prevention and Atherosclerosis Research Centre, Robarts Research Institute, Western University, London, Ontario, Canada; Schulich School of Medicine and Dentistry, Western University, London, Ontario Canada.
| | - Hamidreza Saber
- David Geffen School of Medicine, Comprehensive Stroke Center, Department of Neurology, University of California, Los Angeles, USA.
| | - Payam Sasannezhad
- Department of Neurology, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Jeffrey L Saver
- Department of Neurology, Geffen School of Medicine, UCLA, USA.
| | - Eugene Scharf
- Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA.
| | - Ashfaq Shuaib
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Brian Silver
- Department of Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA.
| | - Shaloo Singhal
- Department of Neurology, Monash Health and Department of Medicine, School of Clinical Sciences Monash University, Australia
| | - Craig J Smith
- Division of Cardiovascular Sciences, Lydia Becker Institute of Immunology and Inflammation, University of Manchester, UK; Manchester Centre for Clinical Neurosciences, Manchester Academic Health Science Centre, Salford Royal NHS Foundation Trust, Salford, UK.
| | - Saverio Stranges
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Family Medicine, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada; Department of Population Health, Luxembourg Institute of Health, Strassen, Luxembourg.
| | - P N Sylaja
- Comprehensive Stroke Care Program, Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST), Trivandrum 695 011, Kerala, India
| | - Michel Torbey
- Department of Neurology, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA.
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
| | | | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne; Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia.
| | - Takeshi Yoshimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan.
| | - Babak Zamani
- Neurology department of Iran University of Medical Sciences, Tehran, Iran
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, Danville, Pennsylvania, USA
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Roa JA, Maud A, Jabbour P, Dabus G, Pazour A, Dandapat S, Ortega-Gutierrez S, Paez-Granda D, Kalousek V, Hasan DM, Samaniego EA. Transcirculation Approach for Mechanical Thrombectomy in Acute Ischemic Stroke: A Multicenter Study and Review of the Literature. Front Neurol 2020; 11:347. [PMID: 32457691 PMCID: PMC7221059 DOI: 10.3389/fneur.2020.00347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/08/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, provide alternate endovascular routes when anterograde interventions are not feasible. We aimed to assess the safety and efficacy of mechanical thrombectomy (MT) through a transcirculation route. Methods: Six centers provided retrospective data on acute ischemic stroke (AIS) patients who underwent MT via transcirculation approaches. Demographics and technical details of the endovascular intervention were collected. Recanalization rates, peri-procedural complications and clinical/angiographic outcomes immediately after the procedure and at last available follow-up were assessed. A review of the literature reporting on AIS patients whom underwent transcirculation MT was also performed. Results: Our multicenter study included 14 AIS patients treated through transcirculation routes. Mean age was 57.8 ± 11.9 years, and 10 (71.4%) were men. Mean NIHSS at admission was 18.4 (range 8–27). TICI 2b-3 recanalization was achieved in 10/14 (71.4%) patients. Three patients died after intervention: one due to late recanalization, one due to acute in-stent thrombosis, and one due to a procedure-related thromboembolic brainstem infarct. Of 11 surviving patients with follow-up available (mean 9.7 months), mRS 0–2 was achieved in 6 (54.5%) cases. Our review of the literature pooled a total of 37 transcirculation MT cases. Most common occlusions were tandem lesions (ICA + MCA = 64.9%) and BA + bilateral VA (18.9%). ACOM and PCOM were crossed in 18 (48.6%) cases each; one patient required a combined ACOM-PCOM approach. Primary recanalization technique included intra-arterial (IA) thrombolytics alone in 10 (27%), angioplasty ± stenting in 6 (16.2%), stent-retriever in 8 (21.6%), contact aspiration in 6, and combined (MT ± IA-thrombolytics) in 6 cases. Twenty-eight (75.7%) AIS patients achieved successful TIMI 2-3/TICI 2b-3 recanalization. After a mean follow-up of 6.7 months, 23/31 (74.2%) patients achieved a favorable functional outcome. Conclusions: Transcirculation approaches may be used to access the target lesion when the parent artery cannot be crossed through conventional antegrade routes. These techniques are feasible but should be reserved as a bailout maneuver when anterograde MT is not possible. Newer endovascular devices have improved neurological and angiographic outcomes in transcirculation cases.
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Affiliation(s)
- Jorge A Roa
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Guilherme Dabus
- Department of Radiology, Miami Cardiac and Vascular Institute, Miami, FL, United States
| | - Avery Pazour
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Santiago Ortega-Gutierrez
- Departments of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Diego Paez-Granda
- Department of Radiology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Vladimir Kalousek
- Department of Neurology, University Clinical Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - David M Hasan
- Departments of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Edgar A Samaniego
- Departments of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
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Roa JA, Ortega-Gutierrez S, Martinez-Galdamez M, Maud A, Dabus G, Pazour A, Dandapat S, Arteaga MS, Fernandez JG, Paez-Granda D, Kalousek V, Pons RB, Mowla A, Duckwiler G, Szeder V, Jabbour P, Hasan DM, Samaniego EA. Transcirculation Approach for Endovascular Embolization of Intracranial Aneurysms, Arteriovenous Malformations, and Dural Fistulas: A Multicenter Study. World Neurosurg 2020; 134:e1015-e1027. [DOI: 10.1016/j.wneu.2019.11.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 11/25/2022]
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Khatri R, Afzal MR, Qureshi MA, Maud A, Huanyu D, Rodriguez GJ. Response to “Letter to the Editor” by Bhattacharyya et al. J Stroke Cerebrovasc Dis 2019; 28:2361. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Vellipuram AR, Cruz-Flores S, Chaudhry MRA, Rawla P, Maud A, Rodriguez GJ, Kassar D, Piriyawat P, Qureshi MA, Khatri R. Comparative Outcomes of Respiratory Failure Associated with Common Neuromuscular Emergencies: Myasthenia Gravis versus Guillain-Barré Syndrome. Medicina (Kaunas) 2019; 55:E375. [PMID: 31311172 PMCID: PMC6681261 DOI: 10.3390/medicina55070375] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/09/2019] [Accepted: 07/11/2019] [Indexed: 01/05/2023]
Abstract
Background and objectives: Myasthenia gravis (MG) and Guillain-Barré Syndrome (GBS) are autoimmune neuromuscular disorders that may present as neuromuscular emergencies requiring mechanical ventilation and critical care. Comparative outcomes of these disease processes, once severe enough to require mechanical ventilation, are not known. In this study, we compared the patients requiring mechanical ventilation in terms of in-hospital complications, length of stay, disability, and mortality between these two disease entities at a national level. Materials and Methods: Mechanically ventilated patients with primary diagnosis of MG (n = 6684) and GBS (n = 5834) were identified through retrospective analysis of Nationwide Inpatient Sample (NIS) database for the years 2006 to 2014. Results: Even though mechanically ventilated MG patients were older (61.0 ± 19.1 versus 54.9 ± 20.1 years) and presented with more medical comorbidities, they had lower disease severity on admission, as well as lower in-hospital complications sepsis, pneumonia, and urinary tract infections as compared with GBS patients. In the multivariate analysis, after adjusting for confounders including treatment, GBS patients had significantly higher disability (odds ratio (OR) 15.6, 95% confidence interval (CI) 10.9-22.2) and a longer length of stay (OR 3.48, 95% CI 2.22-5.48). There was no significant difference in mortality between the groups (8.45% MG vs. 10.0% GBS, p = 0.16). Conclusion: Mechanically ventilated GBS patients have higher disease severity at admission along with more in-hospital complications, length of stay, and disability compared with MG patients. Potential explanations for these findings include delay in the diagnosis, poor response to immunotherapy particularly in patients with axonal GBS variant, or longer recovery time after nerve damage.
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Affiliation(s)
- Anantha R Vellipuram
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA.
| | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Mohammad Rauf A Chaudhry
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Prashanth Rawla
- Department of Internal Medicine, Hospitalist Sovah Health, Martinsville, VA 24112, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Darine Kassar
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Paisith Piriyawat
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Mohtashim A Qureshi
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Rakesh Khatri
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
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Maud A, Khatri R, Chaudhry M, Vellipuram A, Cruz-Flores S, Rodriguez G. Transradial Access Results in Faster Skin Puncture to Reperfusion Time than Transfemoral Access in Posterior Circulation Mechanical Thrombectomy. J Vasc Interv Neurol 2019; 10:53-57. [PMID: 31308872 PMCID: PMC6613485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Successful mechanical embolectomy for acute embolic arterial occlusion in the posterior cerebral circulation can potentially result in less neurologic disability and mortality. The transradial approach can potentially offer more direct navigation into the posterior circulation than the transfemoral approach and can result in faster recanalization time. OBJECTIVE To compare procedural metrics and the technical and clinical outcomes of transradial versus transfemoral access for mechanical embolectomy in the posterior cerebral circulation. MATERIAL AND METHODS Single-center retrospective review of a prospectively maintained neurointerventional database from a large volume neurointerventional service in a tertiary academic center. Patients presenting with acute disabling symptoms due to embolic occlusion of a large intracranial artery in the posterior that underwent to endovascular treatment in our institution from January 2017 to January 2019 were included in the present study. RESULTS Between January 2018 and January 2019 a total of 10 subjects underwent a mechanical embolectomy for acute embolic occlusion on the posterior circulation via transradial access; and between January 2017 and January 2018 a total of 10 subjects underwent a mechanical embolectomy for acute embolic occlusion on the posterior circulation via transfemoral access. Subjects in the transradial access group had a shorter skin puncture to recanalization time compared to the transfemoral group (29.2 ± 17.6 in the transradial group vs. 63.9 ± 56.7 in the transfemoral group respectively). CONCLUSIONS This is the first study comparing transradial versus transfemoral access for mechanical embolectomy in patients with acute embolic occlusion in the posterior cerebral circulation. Transradial access resulted in a safe, effective, and faster endovascular route for recanalization in the acute embolic occlusion of the posterior circulation.
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Affiliation(s)
- A. Maud
- Corresponding Author: Alberto Maud MD, Department of Neurology, Texas Tech University Health Sciences Center, 4800 Alberta Avenue El Paso, TX, 79905, USA. Tel.: (915) 929-8587.
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Cruz-Flores S, Rodriguez GJ, Chaudhry MRA, Qureshi IA, Qureshi MA, Piriyawat P, Vellipuram AR, Khatri R, Kassar D, Maud A. Racial/ethnic disparities in hospital utilization in intracerebral hemorrhage. Int J Stroke 2019; 14:686-695. [DOI: 10.1177/1747493019835335] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and purpose There is evidence that racial and ethnic differences among intracerebral hemorrhage (ICH) patients exist. We sought to establish the occurrence of disparities in hospital utilization in the United States. Methods We identified ICH patients from United States Nationwide Inpatient Sample database for years 2006–2014 using codes (DX1 = 431, 432.0) from the International Classification of Diseases, 9th edition. We compared five race/ethnic categories: White, Black, Hispanic, Asian or Pacific Islander, and Others ( Native American and other) with regard to demographics, comorbidities, disease severity, in-hospital complications, in-hospital procedures, length of stay (LOS), total hospital charges, in-hospital mortality, palliative care, (PC) and do not resuscitate (DNR). We categorized procedures as lifesaving (i.e. ventriculostomy, craniotomy, craniectomy, and ventriculoperitoneal (VP) shunt), life sustaining (i.e. mechanical ventilation, tracheostomy, transfusions, and gastrostomy). White race/ethnicity was set as the reference group. Results Out of 710,293 hospitalized patients with ICH 470,539 (66.2%), 114,821 (16.2%), 66,451 (9.3%), 30,297 (4.3%) and 28,185 (3.9%) were White, Black, Hispanic, Asian or Pacific Islander, and Others, respectively. Minorities (Black, Hispanic, Asian or Pacific Islander, and Others) had a higher rate of in-hospital complications, in-hospital procedures, mean LOS, and hospital charges compared to Whites. In contrast, Whites had a higher rate of in-hospital mortality, PC, and DNR. In multivariable analysis, all minorities had higher rate of MV, tracheostomy, transfusions, and gastrostomy compared to Whites, while Hispanics had higher rate of craniectomy and VP shunt; and Asian or Pacific Islander and Others had higher rate of craniectomy. Whites had a higher rate of in-hospital mortality, palliative care, and DNR compared to minorities. In mediation analysis, in-hospital mortality for whites remained high after adjusting with PC and DNR. Conclusion Minorities had greater utilization of lifesaving and life sustaining procedures, and longer LOS. Whites had greater utilization of palliative care, hospice, and higher in-hospital mortality. These results may reflect differences in culture or access to care and deserve further study.
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Affiliation(s)
- Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Mohammad Rauf A Chaudhry
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Ihtesham A Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Mohtashim A Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Paisith Piriyawat
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Anantha R Vellipuram
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Darine Kassar
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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Rawla P, Vellipuram A, Khatri R, Maud A, Rodriguez GJ, Cruz-Flores S. Abstract WP212: Trends in Acute Ischemic Stroke Hospitalizations by Age Groups, Length of Stay, Mortality and Hospital Costs in the United States From 2000-2014. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Acute Ischemic Stroke (AIS) is a significant cause of long term disability. The primary objective of our study was to analyze the trends in AIS hospitalizations by age groups, Length of Stay (LOS), Mortality and hospital costs in the United States over a 15-year period from the years 2000 to 2014.
Methods:
Nationwide inpatient sample (NIS) database was used to identify AIS admissions in all patients from 2000 to 2014 using ICD-9-CM codes 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, and 436 as the principal discharge diagnosis. NIS is the largest all-payer inpatient care database in the United States, containing data on more than 7 million hospital stays. It has a large sample size which is ideal for developing national and regional estimates.
Results:
A total of 554,226,249 discharges with a diagnosis of AIS were analyzed from 2000 to 2014 from the NIS database. Hospitalization rates for AIS increased significantly from years 2000 to 2014 for ages 18-44 (relative percentage change (RPC): +33.75%) and ages 45-64(RPC: +41.21%). Hospitalization rates for AIS have significantly decreased in the age group 65-84 (RPC: -16.69%). In-hospital mortality decreased from 6.97% in 2000 to 4.4% in 2014. Mean LOS has decreased from 6.19 days to 4.2 days during the same period. Mean hospital costs have gone up from $6,975 to $12,322.
Conclusion:
Overall in-hospital mortality and LOS associated with AIS has decreased over the years. AIS US hospitalizations have significantly increased in the age groups from 18-64 while there was a significant decrease in the rate of hospitalizations in the age groups 65-84. Further research needs to be done to identify the risk factors contributing to a substantial rise in AIS hospitalizations in young to middle age adults.
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Affiliation(s)
| | | | - Rakesh Khatri
- Neurology, Texas Tech Univ Health Sciences Cntr El Paso, El Paso, TX
| | - Alberto Maud
- Neurology, Texas Tech Univ Health Sciences Cntr El Paso, El Paso, TX
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Khatri R, Afzal MR, Vellipuram A, Maud A, Cruz-Flores S, Rodriguez G. Abstract TP49: Trends of Patent Foramen Ovale (pfo) Closure From 2008 to 2014 at National Level: Us Experience. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Evidence for patent foramen ovale (PFO) closure has been controversial, as was reflected in the guidelines published by AHA/ASA in 2014. Prior to 2014, three randomized controlled trials compared PFO closure and medical management. Evidence of PFO closure was lacking however PFO closure was being performed in both trial settings and non-trial settings.
Methods:
We analyzed the Nationwide Inpatient sample (NIS) from 2008 to 2014. Ischemic stroke (IS) patients with primary diagnosis using ICD 9 codes were selected along with secondary diagnosis of PFO/ ASD (ICD 9 code: 745.5). Further we selected the patients who underwent the PFO closure procedure using ICD 9 procedure codes: 35.51 and 35.52. We evaluated the rate of PFO closure, characteristics of patients receiving closure and evolution of trend during that time period at the national level.
Results:
Total number of patients admitted over 7 years in US with Ischemic stroke associated with PFO was 77964. Only a minority of patients [n=1487 (1.9%)] received PFO closure and about half were females (50.2%). Majority of treatments (70%) were performed in teaching hospital setting. Patients who underwent PFO closure were younger, mean age 55.3 years (± SD 16.6) years versus 61.4 years (± SD 16.7) (p< 0.001) in patent who did not receive closure. Medical comorbidities were significantly lower in group receiving treatment (Congestive heart failure 0.9% vs. 7.6%, hypertension 55% vs. 64.6%, atrial fibrillation 6.9% vs. 11.6%) but no difference was noted in deep venous thrombosis, pulmonary embolism and diabetes mellitus. We noted a significant downward trend of PFO closure at the national level and at teaching hospitals over 7 years (see graph 1)
Conclusion:
National database demonstrated that only a minority of patients received PFO closure in setting of ischemic stroke and overall a downward trend was noted over the years in setting of negative randomized trials.
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Maud A, Khatri R, Lin LM, Diaz OM, Vellipuram AR, Cruz-Flores S, Rodriguez GJ. Internal Carotid Artery Dilatation Induced by General Anesthesia: Technical Observation. J Vasc Interv Neurol 2018; 10:52-55. [PMID: 30746011 PMCID: PMC6350873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- A Maud
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
| | - R Khatri
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
| | - L M Lin
- Department of Neurosurgery, University of California Irvine Medical Center, Orange, CA, USA
| | - O M Diaz
- Interventional Neuroradiology, Methodist Hospital, Houston, TX, USA
| | - A R Vellipuram
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
- Department of Neurosurgery, University of California Irvine Medical Center, Orange, CA, USA
- Interventional Neuroradiology, Methodist Hospital, Houston, TX, USA
| | - S Cruz-Flores
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
| | - G J Rodriguez
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
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Qureshi IA, Rodriguez GJ, Cruz-Flores S, Maud A. Persistent focal enhancement of the cisternal segment of oculomotor nerve in ophthalmoplegic migraine. Neurol Clin Pract 2018; 7:381-383. [PMID: 29620088 DOI: 10.1212/cpj.0000000000000303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/04/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Ihtesham A Qureshi
- Neurology Department, Texas Tech University of Health Sciences Center, El Paso
| | - Gustavo J Rodriguez
- Neurology Department, Texas Tech University of Health Sciences Center, El Paso
| | | | - Alberto Maud
- Neurology Department, Texas Tech University of Health Sciences Center, El Paso
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Samaniego EA, Mendez AA, Nguyen TN, Kalousek V, Guerrero WR, Dandapat S, Dabus G, Linfante I, Hassan AE, Drofa A, Kouznetsov E, Leedahl D, Hasan D, Maud A, Ortega-Gutierrez S. LVIS Jr Device for Y-Stent-Assisted Coil Embolization of Wide-Neck Intracranial Aneurysms: A Multicenter Experience. Interv Neurol 2018; 7:271-283. [PMID: 29765397 DOI: 10.1159/000487545] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/09/2018] [Indexed: 01/19/2023]
Abstract
Background and Purpose Complex wide-neck intracranial aneurysms are challenging to treat. We report a multicenter experience using the LVIS Jr stent for "Y-stent"-assisted coiling embolization of wide-neck bifurcation aneurysms. Methods Seven centers provided retrospective data on patients who underwent Y-stenting. Technical complications, immediate posttreatment angiographic results, clinical outcomes, and imaging follow-up were assessed. Results Thirty patients/aneurysms were treated: 15 basilar tip, 8 middle cerebral artery, 4 anterior communicating artery, 1 pericallosal, and 2 posterior inferior cerebellar artery aneurysms. The mean aneurysm size was 11 mm and the mean dome-to-neck ratio was 1.3 mm. Twenty-four aneurysms were unruptured and treated electively, and 6 were acutely ruptured. Fifty-eight LVIS Jr stents were successfully deployed without any technical issue. One pro-cedural and transient in-stent thrombosis resolved with the intravenous infusion of a glycoprotein IIb/IIIa inhibitor. Five periprocedural complications (within 30 days) occurred: 2 periprocedural neurological complications (1 small temporal stroke that presented with transient aphasia and 1 posterior cerebral artery infarct) and 3 nonneurological periprocedural complications (2 retroperitoneal hematomas, and 1 patient developed a disseminated intravascular coagulopathy). One permanent complication (3.3%) directly related to Y-stenting was reported in the patient who suffered the posterior cerebral artery infarct. Immediate complete obliteration (Raymond-Roy Occlusion Classification [RROC] I-II) was achieved in 26 cases (89.6%). Twenty-four patients had clinical and imaging follow-up (mean 5.2 months). Complete angiographic occlusion (RROC I-II) was observed in 23 patients (96%). A good functional outcome with a modified Rankin Scale score ≤2 was achieved in 26 cases. Conclusions In this multicenter case series, Y-stent-assisted coiling of wide-neck aneurysms with the LVIS Jr device was feasible and relatively safe. Follow-up imaging demonstrated very low recanalization rates.
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Affiliation(s)
- Edgar A Samaniego
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Aldo A Mendez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Vladimir Kalousek
- Department of Radiology, Clinical Hospital Center "Sestre Milosrdnice,", Zagreb, Croatia
| | - Waldo R Guerrero
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Sudeepta Dandapat
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Guilherme Dabus
- Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Italo Linfante
- Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | | | - Alexander Drofa
- Department of Neurosurgery, Sanford Brain & Spine Center, Fargo, North Dakota, USA
| | - Evgueni Kouznetsov
- Department of Neurosurgery, Sanford Brain & Spine Center, Fargo, North Dakota, USA
| | - David Leedahl
- Pharmacy Services, Sanford Medical Center, Fargo, North Dakota, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa, Iowa, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
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Khatri R, Vellipuram AR, Maud A, Afzal MR, Qureshi MA, Qureshi IA, Piriyawat P, Cruz-Flores S, Rodriguez GJ. Abstract TP166: Frequency of Brain Death in Acute Cerebrovascular Disease Related Mortality. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp166] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Despite the frequent occurrence of brain death in intensive care unit, the prevalence rate of brain death in ischemic stroke (IS), intracranial hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is not known at national level. In addition the prevalence of cardiac arrest in these patients is not established.
Methods:
From 2012, ICD-9-CM includes a specific code for brain death (348.82). Brain death patients were identified from the nationwide in-patient sample database for the years 2012 to 2014. Associated in-hospital cardiac arrest patients were also identified under each category. Demographics, medical comorbidities, in-hospital complications, procedures, length of stay and hospital charges were compared.
Results:
Rate of brain death was highest in SAH related mortality (22%, 3255 brain deaths/ 14620 in-hospital mortality), followed by ICH, (12.5%, 5760 brain deaths/ 45945 in-hospital mortality) and ischemic stroke (3%, 1840 brain death/62285 in-hospital mortality). Majority of the patients had brain death secondary to neurological insult (ICH n=5260, 91.3%; SAH n= 2625 (80.6%) and IS n=1640, 89.1%) without any secondary diagnosis of in-hospital cardiac arrest. Length of stay was shorter in patients with SAH and ICH (mean 2.92±4.13 days and 2.53±3.56 days respectively) compared to IS patients (mean 4.93 ± 10.2 days, p < 0.001) suggesting brain death is an early event in hemorrhagic stroke.
Conclusion:
Brain death in the majority of cerebrovascular patients occurs as a result of primary neurological insult without associated cardiac arrest. It occurs much earlier in hemorrhagic stroke compared to ischemic stroke.
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Affiliation(s)
- Rakesh Khatri
- Texas Tech Univ Health Sciences Cntr El Paso, El Paso, TX
| | | | - Alberto Maud
- Texas Tech Univ Health Sciences Cntr El Paso, El Paso, TX
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Afzal MR, Maud A, Cruz-Flores S, Qureshi MA, Qureshi IA, Vellipuram AR, Piriyawat P, Rodriguez GJ, Khatri R. Abstract WP319: Continued Nationwide Decline in Stroke Related In-hospital Mortality in United States. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Previously a downward trend in stroke related in-hospital mortality was noted from 1996 to 2006 reflecting advancements in acute stroke care. Given ongoing improvement in acute stroke care models and therapies, our study assessed nationwide patterns in in-hospital mortality related to acute stroke for next decade.
Methods:
Patients with acute stroke were identified from the nationwide in-patient sample database for the years 2007 to 2014 using International Classification of Diseases, Ninth Revision procedure codes. Time trends in the proportion of stroke hospitalizations that resulted in death were assessed.
Results:
Between 2007 and 2014, overall stroke hospitalizations increased from 1017 414 in 2007 to 2008 to 1114 960 in 2013 to 2014, whereas percentage stroke hospitalizations that resulted in death decreased from 8.98% in 2007-2008 to 7.34% in 2013-2014 (P<0.0001). Unadjusted Odds of mortality decreased regardless of stroke type: ischemic stroke (IS) (OR 0.798, 95% CI 0.762 to 0.835), subarachnoid hemorrhage (SAH) (OR 0.885, 95% CI 0.810 to 0.968), and intracerebral hemorrhage (ICH) (OR 0.865, 95% CI 0.824 to 0.908). In multivariate analysis these odds remained significant (IS: OR 0.813, 95% CI 0.770 to 0.859), SAH: OR 0.680, 95% CI 0.611 to 0.757, ICH: OR 0.707, 95% CI 0.664to 0.754) after adjusting with age, gender, race, medical comorbidities, in-hospital complications, insurance status and APRDRG Severity scale).
Conclusions:
There is continued decline in Nationwide In-Hospital Mortality among hospitalized acute stroke patients. This reflects ongoing improvement in stroke care models and advancement in therapies.
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Gavito-Higuera J, Khatri R, Qureshi IA, Maud A, Rodriguez GJ. Aggressive blood pressure treatment of hypertensive intracerebral hemorrhage may lead to global cerebral hypoperfusion: Case report and imaging perspective. World J Radiol 2017; 9:448-453. [PMID: 29354210 PMCID: PMC5746648 DOI: 10.4329/wjr.v9.i12.448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Revised: 08/22/2017] [Accepted: 11/30/2017] [Indexed: 02/06/2023] Open
Abstract
Hypoperfusion injury related to blood pressure decrease in acute hypertensive intracerebral hemorrhage continues to be a controversial topic. Aggressive treatment is provided with the intent to stop the ongoing bleeding. However, there may be additional factors, including autoregulation and increased intracranial pressure, that may limit this approach. We present here a case of acute hypertensive intracerebral hemorrhage, in which aggressive blood pressure management to levels within the normal range led to global cerebral ischemia within multiple border zones. Global cerebral ischemia may be of concern in the management of hypertensive hemorrhage in the presence of premorbid poorly controlled blood pressure and increased intracranial pressure.
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Affiliation(s)
- Jose Gavito-Higuera
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Ihtesham A Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
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Afzal MR, Qureshi MA, Miran MS, Rodriguez GJ, Maud A, Khatri R. Delayed Coil Migration: Uncommon Cause of Ischemic Stroke and Retrieval Technique. J Vasc Interv Neurol 2017; 9:36-37. [PMID: 29445437 PMCID: PMC5805907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Mohammad Rauf Afzal
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Mohtashim Arbaab Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | | | - Gustavo J. Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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43
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Qureshi IA, Rodriguez GJ, Chacon-Quesada T, Jose GH, Cruz-Flores S, Maud A. Cervical Arterial Fibromuscular Dysplasia in a Biethnic Population: A Retrospective Study in the U.S.-Mexican Border. Int J Angiol 2017; 26:253-258. [PMID: 29142493 DOI: 10.1055/s-0036-1593773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
Background There have been studies trying to characterize Fibromuscular Dysplasia (FMD); however, most of them are based in mainly non-Hispanic sample. The objective of this study is to better understand the epidemiology and clinical characteristics of craniocervical FMD in the Hispanic population. Methods We retrospectively reviewed the cerebral angiograms performed in our center in a period of 3.5 years under any indication looking for angiographic patterns of FMD. Exclusion criteria consisted of cases in which the first angiogram was done when the patients were younger than 18 years. Patients were subdivided based on those with FMD and those without it for baseline characteristics and were looked for any associations. We further compared the same baseline characteristics among Hispanic FMD and non-Hispanic FMD population. A chart review was conducted looking for clinical features and vascular events. Results We analyzed 448 angiograms among patients younger than 18 years. We identified 47 patients with evidence of FMD involving the cervical arteries and 401 patients without FMD. Of the 47 patients with FMD in our neuroendovascular registry, we found that 76.6% were women and 57.4% were Hispanics. There was no statistical significant difference when comparing the variables across ethnicities, except history of cigarette smoking and dyslipidemia. The most common associated supra-aortic arterial lesions seen in the FMD group were intracranial aneurysm and arterial dissections. We then used same variables to compare Hispanic FMD with non-Hispanic FMD. We have found that there has been a positive association of cigarette smoking and dyslipidemia with FMD ( p ≤ 0.05). Conclusion Our study suggests that FMD affecting the carotid and vertebral arteries has similar demographic pattern across ethnicities in the United States. In Hispanics, the disease appears to have a predilection for women and history of cigarette smoking. Intracranial aneurysm and arterial dissection were the most commonly associated arterial lesions.
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Affiliation(s)
- Ihtesham A Qureshi
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas
| | | | - Gavito-Higuera Jose
- Department of Radiology, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas
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Lapid D, Qureshi MA, Quresh IA, Afzal MR, Maud A, Rodriguez GJ, Khatri R. Possible Reversible Cerebral Vasoconstriction Syndrome Associated with Eucalyptus: Case Report. J Vasc Interv Neurol 2017; 9:17-20. [PMID: 29163745 PMCID: PMC5683022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Reversible cerebral vasoconstrictive syndrome (RCVS) has characteristic clinical features, brain imaging and Angiographic features. The majority of RCVS cases are associated with the use of antidepressants, polysubstance abuse, and nasal decongestants. We here present a case that highlights the use of eucalyptus herbs as a possible precipitant factor for RCVS formation. CASE PRESENTATION A 42-year-old woman presented to the emergency department with a tingling sensation on the right-hand side of her body and a two-week progressive throbbing severe holocranial headache radiating to the neck, with associated nausea, photophobia, and phonophobia. She denied any seizures and recent trauma or fevers. She was not taking scheduled medications, but she had used inhaling vapors obtained from boiling eucalyptus leaves to alleviate sinus congestion. Initial imaging revealed subarachnoid hemorrhage at bilateral posterior parietal convexity leading to her admission into the intensive care unit. Further work up disclosed the presence of findings consistent with RCVS. CONCLUSION In conclusion, we hereby postulate that some herbal remedies used in alternative medicine, including eucalyptus, could play a role in causing serotonergic symptoms including dizziness, diarrhea, and cerebral vasoconstriction. Understanding that eucalyptus has the potential to contribute to RCVS due to its serotoninergic activity may be of importance in the diagnosis and management of these patients.
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Affiliation(s)
| | | | - Ihtesham Aatif Quresh
- Corresponding Author: Ihtesham Aatif Qureshi MD, Department of Neurology, Texas Tech University of Health Sciences Center, 4800 Alberta Avenue, El Paso, TX, USA. Tel.: (312) 888-6929; fax: (915) 215-5900.
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45
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Qureshi IA, Qureshi MA, Maud A. A 72-year-old with eyelid opening apraxia in Steele-Richardson-Olszewski syndrome. Clin Case Rep 2017; 5:1054-1055. [PMID: 28588873 PMCID: PMC5458046 DOI: 10.1002/ccr3.958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Revised: 01/13/2017] [Accepted: 03/10/2017] [Indexed: 11/11/2022] Open
Abstract
In our patient with Steele–Richardson–Olszewski syndrome presenting with apraxia of eyelid opening, there is a possibility to be readily confused with conditions presenting in similar pattern such as blepharospasm and eyelid ptosis. Therefore, it is essential to correlate the clinical findings with electromyographic recordings and dopamine transporter scan (DaT).
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Affiliation(s)
- Ihtesham A. Qureshi
- Neurology Department; Texas Tech University Health Sciences Center; 4800 Alberta Avenue El Paso 79905 Texas
| | - Mohtashim A. Qureshi
- Neurology Department; Texas Tech University Health Sciences Center; 4800 Alberta Avenue El Paso 79905 Texas
| | - Alberto Maud
- Neurology Department; Texas Tech University Health Sciences Center; 4800 Alberta Avenue El Paso 79905 Texas
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Chompoopong P, Rostambeigi N, Kassar D, Maud A, Qureshi IA, Cruz-Flores S, Rodriguez GJ. Are We Overlooking Stroke Chameleons? A Retrospective Study on the Delayed Recognition of Stroke Patients. Cerebrovasc Dis 2017; 44:83-87. [PMID: 28511184 DOI: 10.1159/000471929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/22/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE New effective recanalization therapies are currently available for acute ischemic stroke; yet a vast majority of stroke patients are left untreated. The lack of early recognition may be because often times, stroke patients present with atypical manifestations that resemble other conditions (which are referred to as "stroke chameleons"). We set to study the proportion of patients with delayed stroke recognition in a single center. METHODS We performed a retrospective analysis of a prospectively collected data over a 9-year period. All adult patients discharged with the diagnosis of ischemic stroke or transient ischemic attack (TIA) were identified and traced for their diagnosis on admission. Those cases with a diagnosis other than ischemic stroke or TIA on admission were identified as possible stroke chameleons and categorized into different groups according to the occurrence of neurological or non-neurological manifestations at presentation. RESULTS Of 2,303 cases with discharge diagnosis of ischemic stroke or TIA, 919 (39.9%) were found to be possible stroke chameleons. More than half of these patients (58.4%) presented with neurological manifestations including disorders of the somatic sensation (33%), alteration of consciousness (30%), and disorders of speech/language (11%). The remaining possible stroke chameleons had manifestations pertaining to other organ systems such as cardiopulmonary, gastrointestinal, systemic infection, trauma, and thromboembolic events elsewhere. CONCLUSIONS In our cohort, a surprisingly large percentage of possible stroke chameleons was observed. It is important to confirm our findings, study the impact on clinical outcome, and develop strategies for early stroke patient recognition.
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Khatri R, Afzal MR, Rodriguez GJ, Maud A, Miran MS, Qureshi MA, Cruz-Flores S, Qureshi AI. Albumin-Induced Neuroprotection in Focal Cerebral Ischemia in the ALIAS Trial: Does Severity, Mechanism, and Time of Infusion Matter? Neurocrit Care 2017; 28:60-64. [DOI: 10.1007/s12028-017-0400-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Qureshi MA, Afzal MR, Qureshi IA, Ghatali M, Piriyawat P, Maud A, Cruz-Flores S, Rodriguez GJ. Abstract WP24: The Middle Cerebral Artery Occlusion, Anatomy Study and Pitfalls in the Design and Classification of Its Segment Occlusions in the Clinical Trials. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
The middle cerebral artery (MCA) occlusion is the most commonly treated vessel with mechanical thrombectomy. The MCA is defined in segments. The M1 segment is classically defined as the horizontal segment extending from the internal carotid artery bifurcation to the Sylvian fissure. It is assumed that the MCA bifurcation occurs in the M1-2 junction, and terms M2 occlusion and division occlusion are used indistinctly, however it is not known how often the MCA bifurcation occurs within the M1 segment.
Methodology:
Consecutive patients undergoing cerebral angiograms were selected between 2011 and 2015. The anatomy of the MCA was classified as classical, when the bifurcation occurs at the M1-2 junction and non-classical when the bifurcation occurs within the M1 segment, having the M1 segment a pre-bifurcation (main trunk) and a post-bifurcation (division) occlusion. Demographics and vascular risk factors were also collected.
Results:
A total of 500 patients underwent a cerebral angiogram and were studied. The classical pattern was found in 47.5% patients on the left and 53.5% patients on the right. There were no differences between the classical and non-classical anatomical pattern when demographics or vascular risk factors were compared.
Conclusion:
In our series of patients the non-classical pattern was found in almost 50.0% of the patients undergoing a cerebral angiogram. In the endovascular treatment of acute ischemic stroke, it is necessary to develop a new classification as an M1 occlusion could relate to a post-bifurcation (division) or a pre-bifurcation (main trunk) occlusion and comparison of these groups may lead to confounding results.
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Afzal MR, Qureshi MA, Qureshi IA, Piriyawat P, Maud A, Cruz-Flores S, Rodriguez GJ. Abstract WP22: Endovascular Treatment for Distal Middle cerebral Artery Occlusions in Patients with Acute Ischemic Stroke From Interventional Management of Stroke Trial (IMS III). Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Currently, endovascular treatment is advocated for middle cerebral artery (MCA) occlusions, however not much is known about the natural history of an M1 compared to an M2 occlusion.
Objective:
To compare the clinical outcome in endovascularly treated patients with proximal vessel occlusion (M1) versus a more distal occlusion (M2) among patients with ischemic stokes in a negative trial.
Methods:
Data from Interventional Management of Stroke trial (IMS-III) for patients with acute ischemic stroke with distal MCA (mainly M2 and beyond) occlusions diagnosed by either computed tomographic angiography (CTA) or catheter angiography were analyzed. NIHSS at admission, baseline characteristics, infarct volume at baseline and outcome at 90 days (mRS score) were compared between the two groups. Favorable outcome was defined by discharge modified Rankin scale (mRS) score of 0-2, at 3 months. Multivariate logistical regression was performed to compare the outcomes after adjusting for potential confounders.
Results:
Of the
434
from the endovascular therapy group,
215 (49.5%)
and
98 (22.5%)
patients had M1 and M2 occlusion respectively. Patients with M1 occlusion had higher mean NIHSS at admission
(18.76± 4.94 versus 17.37± 5.72, P-value = 0.029)
and higher infarct volume
(105.92 ± 113.23
versus 49.67 ± 63.42, P-value = 0.000)
. Rate of favorable outcome defined by mRS at discharge was lower among patients with M1
(31.53%vs.46.67%p-value = 0.0128)
. After adjusting for age, sex, total NIHSS score at admission, hepato-biliary disorders, anticoagulants, antiplatelet, NSAIDS, patients with M1 occlusion had higher rates of poor outcomes; odds ratio
(OR) 1.819
(confidence interval
[CI] 1.032- 3.205, P=0.03860).
Conclusions:
In patients enrolled in IMS-III trial, an M1 occlusion demonstrated a larger tissue infarct size and a lower rate of favorable outcome than an M2 occlusion, given the negative results of the trial, these findings reflect the natural history of these two occlusion sites.
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