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Elfil M, Morsi RZ, Ghozy S, Elmashad A, Siddiqui A, Al-Bayati AR, Alaraj A, Brook A, Kam AW, Chatterjee AR, Patsalides A, Waldau B, Prestigiacomo CJ, Matouk C, Schirmer CM, Altschul D, Parrella DT, Toth G, Jindal G, Shaikh HA, Dolia JN, Fifi JT, Fraser JF, DO JT, Amuluru K, Kim LJ, Harrigan M, Amans MR, Kole M, Mokin M, Abraham M, Jumaa M, Janjua N, Zaidat O, Youssef PP, Khandelwal P, Wang QT, Grandhi R, Hanel R, Kellogg RT, Ortega-Gutierrez S, Sheth S, Nguyen TN, Szeder V, Hu YC, Yoo AJ, Tanweer O, Jankowitz B, Heit JJ, Williamson R, Kass-Hout T, Crowley RW, El-Ghanem M, Al-Mufti F. Factors Affecting Selection of TraineE for Neurointervention (FASTEN). Interv Neuroradiol 2024:15910199241232726. [PMID: 38389309 DOI: 10.1177/15910199241232726] [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] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND IMPORTANCE Neurointervention is a very competitive specialty in the United States due to the limited number of training spots and the larger pool of applicants. The training standards are continuously updated to ensure solid training experiences. Factors affecting candidate(s) selection have not been fully established yet. Our study aims to investigate the factors influencing the selection process. METHODS A 52-question survey was distributed to 93 program directors (PDs). The survey consisted of six categories: (a) Program characteristics, (b) Candidate demographics, (c) Educational credentials, (d) Personal traits, (e) Research and extracurricular activities, and (f) Overall final set of characteristics. The response rate was 59.1%. As per the programs' characteristics, neurosurgery was the most involved specialty in running the training programs (69%). Regarding demographics, the need for visa sponsorship held the greatest prominence with a mean score of 5.9 [standard deviation (SD) 2.9]. For the educational credentials, being a graduate from a neurosurgical residency and the institution where the candidate's residency training is/was scored the highest [5.4 (SD = 2.9), 5.4 (SD = 2.5), respectively]. Regarding the personal traits, assessment by faculty members achieved the highest score [8.9 (SD = 1)]. In terms of research/extracurricular activities, fluency in English had the highest score [7.2 (SD = 1.9)] followed by peer-reviewed/PubMed-indexed publications [6.4 (SD = 2.2)]. CONCLUSION Our survey investigated the factors influencing the final decision when choosing the future neurointerventional trainee, including demographic, educational, research, and extracurricular activities, which might serve as valuable guidance for both applicants and programs to refine the selection process.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Elmashad
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Adnan Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University of Buffalo, Buffalo, NY, USA
| | - Alhamza R Al-Bayati
- Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, Pittsburg, PA, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois, Chicago, IL, USA
| | - Allan Brook
- Department of Neurosurgery, Montefiore Medical Center and Children's Hospital at Montefiore (CHAM), Bronx, NY, USA
| | - Anthony W Kam
- Department of Radiology, Loyola University Medical Center, Stritch School of Medicine, Maywood, IL, USA
| | - Arindam Rano Chatterjee
- Interventional Neuroradiology, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO, USA
| | - Athos Patsalides
- Department of Neurosurgery, North Shore University Hospital, Donald and Barbara Zucker School of Medicine, Manhasset, NY, USA
| | - Ben Waldau
- Neurosurgery, University of California Davis, Sacramento, CA, USA
| | - Charles J Prestigiacomo
- Department of Neurological Surgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | | | - David Altschul
- Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David T Parrella
- Interventional Neurology, Ascension Saint Thomas Hospital West, Nashville, TN, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Gaurav Jindal
- Division of Interventional Neuroradiology, Department of Radiology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Hamza A Shaikh
- Department of Radiology, Cooper University Hospital, Camden, NJ, USA
| | | | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Justin F Fraser
- Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA
| | - Justin Thomas DO
- Department of Neurosurgery, McLaren Northern Hospital, Petoskey, MI, USA
| | - Krishna Amuluru
- Interventional Neuroradiology, Goodman Campbell Brain and Spine, Indianapolis, IN, USA
| | - Louis J Kim
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
| | - Mark Harrigan
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Matthew R Amans
- Departments of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Max Kole
- Department of Neurosurgery, Henry Ford Hospital, Detroit, MI, USA
| | - Max Mokin
- Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Osama Zaidat
- Department of Endovascular Neurosurgery, Mercy Health St Vincent Medical Center, Toledo, OH, USA
| | - Patrick P Youssef
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Priyank Khandelwal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Qingliang Tony Wang
- Departments of Neurology/Neurosurgery, Maimonides Medical Center/SUNY Downstate Health Sciences University, Brooklyn, NY, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, UT, USA
| | - Ricardo Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, FL, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | | | - Sunil Sheth
- Department of Neurology, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Viktor Szeder
- Department of Radiological Sciences, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Yin C Hu
- Department of Neurosurgery, UH Cleveland Medical Center, Cleveland, OH, USA
| | - Albert J Yoo
- Department of Radiology/Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | - Omar Tanweer
- Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | | | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA
| | - Richard Williamson
- Department of Neurological Surgery, Allegheny Health Network, Pittsburgh, PA, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Richard W Crowley
- Department of Neurological Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Mohammad El-Ghanem
- Neuroendovascular Surgery, HCA Houston Northwest/University of Houston College of Medicine, Houston, TX, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
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2
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Dicpinigaitis AJ, Fortunato MP, Goyal A, Syed SA, Patel R, Subah G, Rosenberg JB, Bowers CA, Mayer SA, Jankowitz B, Gandhi CD, Al-Mufti F. Mapping geographic disparities in treatment and clinical outcomes of high-grade aneurysmal subarachnoid hemorrhage in the United States. J Neurointerv Surg 2024:jnis-2023-021330. [PMID: 38378239 DOI: 10.1136/jnis-2023-021330] [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: 11/30/2023] [Accepted: 02/03/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND AND OBJECTIVE Although high-grade (Hunt and Hess 4 and 5) aneurysmal subarachnoid hemorrhage (aSAH) typically portends a poor prognosis, early and aggressive treatment has previously been demonstrated to confer a significant survival advantage. This study aims to evaluate geographic, demographic, and socioeconomic determinants of high-grade aSAH treatment in the United States. METHODS The National Inpatient Sample (NIS) was queried to identify adult high-grade aSAH hospitalizations during the period of 2015 to 2019 using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD) codes. The primary clinical endpoint of this analysis was aneurysm treatment by surgical or endovascular intervention (SEI), while the exposure of interest was geographic region by census division. Favorable functional outcome (assessed by the dichotomous NIS-SAH Outcome Measure, or NIS-SOM) and in-hospital mortality were evaluated as secondary endpoints in treated and conservatively managed groups. RESULTS Among 99 460 aSAH patients identified, 36 795 (37.0%) were high-grade, and 9210 (25.0%) of these were treated by SEI. Following multivariable logistic regression analysis, determinants of treatment by SEI included female sex (adjusted OR (aOR) 1.42, 95% CI 1.35 to 1.51), transfer admission (aOR 1.18, 95% CI 1.12 to 1.25), private insurance (ref: government-sponsored insurance) (aOR 1.21, 95% CI 1.14 to 1.28), and government hospital ownership (ref: private ownership) (aOR 1.17, 95% CI 1.09 to 1.25), while increasing age (by decade) (aOR 0.93, 95% CI 0.91 to 0.95), increasing mortality risk (aOR 0.60, 95% CI 0.57 to 0.63), urban non-teaching hospital status (aOR 0.66, 95% CI 0.59 to 0.73), rural hospital location (aOR 0.13, 95% CI 0.7 to 0.25), small hospital bedsize (aOR 0.68, 95% CI 0.60 to 0.76), and geographic region (South Atlantic (aOR 0.72, 95% CI 0.63 to 0.83), East South Central (aOR 0.75, 95% CI 0.64 to 0.88), and Mountain (aOR 0.72, 95% CI 0.61 to 0.85)) were associated with a lower likelihood of treatment. High-grade aSAH patients treated by SEI experienced significantly greater rates of favorable functional outcomes (20.1% vs 17.3%; OR 1.20, 95% CI 1.13 to 1.28, P<0.001) and lower rates of mortality (25.8% vs 49.1%; OR 0.36, 95% CI 0.34 to 0.38, P<0.001) in comparison to those conservatively managed. CONCLUSION A complex interplay of demographic, socioeconomic, and geographic factors influence treatment patterns of high-grade aSAH in the United States.
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Affiliation(s)
| | | | - Anjali Goyal
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Shoaib A Syed
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Rohan Patel
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Jon B Rosenberg
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, Utah, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Brian Jankowitz
- Hackensack Meridian Neuroscience Institute, JFK University Medical Center, Hackensack, New Jersey, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- School of Medicine, New York Medical College, Valhalla, New York, USA
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
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3
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Chen H, Salem MM, Colasurdo M, Sioutas GS, Khalife J, Kuybu O, Carroll KT, Hoang AN, Baig AA, Salih M, Khorasanizadeh M, Baker C, Mendez Ruiz A, Cortez GM, Abecassis Z, Ruiz Rodríguez JF, Davies JM, Narayanan S, Cawley CM, Riina H, Moore J, Spiotta AM, Khalessi A, Howard BM, Hanel RA, Tanweer O, Tonetti D, Siddiqui AH, Lang M, Levy EI, Jovin TG, Grandhi R, Srinivasan VM, Levitt MR, Ogilvy CS, Jankowitz B, Thomas AJ, Gross BA, Burkhardt JK, Kan P. Standalone middle meningeal artery embolization versus middle meningeal artery embolization with concurrent surgical evacuation for chronic subdural hematomas: a multicenter propensity score matched analysis of clinical and radiographic outcomes. J Neurointerv Surg 2023:jnis-2023-020907. [PMID: 37932033 DOI: 10.1136/jnis-2023-020907] [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: 08/12/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Middle meningeal artery embolization (MMAE) has emerged as a promising therapy for chronic subdural hematomas (cSDHs). The efficacy of standalone MMAE compared with MMAE with concurrent surgery is largely unknown. METHODS cSDH patients who underwent successful MMAE from 14 high volume centers with at least 30 days of follow-up were included. Clinical and radiographic variables were recorded and used to perform propensity score matching (PSM) of patients treated with standalone MMAE or MMAE with concurrent surgery. Multivariable logistic regression models were used for additional covariate adjustments. The primary outcome was recurrence requiring surgical rescue, and the secondary outcome was radiographic failure defined as <50% reduction of cSDH thickness. RESULTS 722 MMAE procedures in 588 cSDH patients were identified. After PSM, 230 MMAE procedures remained (115 in each group). Median age was 73 years, 22.6% of patients were receiving anticoagulation medication, and 47.9% had no preoperative functional disability. Median midline shift was 4 mm and cSDH thickness was 16 mm, representing modestly sized cSDHs. Standalone MMAE and MMAE with surgery resulted in similar rates of surgical rescue (7.8% vs 13.0%, respectively, P=0.28; adjusted OR (aOR 0.73 (95% CI 0.20 to 2.40), P=0.60) and radiographic failure (15.5% vs 13.7%, respectively, P=0.84; aOR 1.08 (95% CI 0.37 to 2.19), P=0.88) with a median follow-up duration of 105 days. These results were similar across subgroup analyses and follow-up durations. CONCLUSIONS Standalone MMAE led to similar and durable clinical and radiographic outcomes as MMAE combined with surgery in select patients with moderately sized cSDHs and mild clinical disease.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
- Neurology, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marco Colasurdo
- Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Georgios S Sioutas
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Khalife
- Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Okkes Kuybu
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA
| | - Kate T Carroll
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Alex Nguyen Hoang
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Ammad A Baig
- Neurosurgery, Buffalo State, The State University of New York, Buffalo, New York, USA
| | - Mira Salih
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | - Cordell Baker
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Aldo Mendez Ruiz
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, Kansas, USA
| | | | - Zack Abecassis
- Department of Neurosurgery, University of Washington, Seattle, Washington, USA
| | | | - Jason M Davies
- Neurosurgery and Biomedical Engineering, Toshiba Stroke and Vascular Research Institute, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Sandra Narayanan
- Department of Neurology, Neurosurgery, UPMC, Pittsburgh, Pennsylvania, USA
| | | | | | - Justin Moore
- Department of Neurosurgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alexander Khalessi
- Department of Neurological Surgery, University of California San Diego, La Jolla, California, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - Daniel Tonetti
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Michael Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | | | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Brian Jankowitz
- Neurosurgery, University of Pennsylvania, Camden, Pennsylvania, USA
| | - Ajith J Thomas
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey, USA
| | - Bradley A Gross
- Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Peter Kan
- Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
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4
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Vivanco-Suarez J, Mendez-Ruiz A, Farooqui M, Bekelis K, Singer JA, Javed K, Altschul DJ, Fifi JT, Matsoukas S, Cooper J, Al-Mufti F, Gross B, Jankowitz B, Kan PT, Hafeez M, Orru E, Dajles A, Galecio-Castillo M, Zevallos CB, Wakhloo AK, Ortega-Gutierrez S. Safety and efficacy of the surpass streamline for intracranial aneurysms (SESSIA): A multi-center US experience pooled analysis. Interv Neuroradiol 2023; 29:589-598. [PMID: 35934939 PMCID: PMC10549718 DOI: 10.1177/15910199221118148] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Revised: 07/09/2022] [Accepted: 07/17/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND PURPOSE Flow diversion has established as standard treatment for intracranial aneurysms, the Surpass Streamline is the only FDA-approved braided cobalt/chromium alloy implant with 72-96 wires. We aimed to determine the safety and efficacy of the Surpass in a post-marketing large United States cohort. MATERIALS AND METHODS This is a retrospective multicenter study of consecutive patients treated with the Surpass for intracranial aneurysms between 2018 and 2021. Baseline demographics, comorbidities, and aneurysm characteristics were collected. Efficacy endpoint included aneurysm occlusion on radiographic follow-up. Safety endpoints were major ipsilateral ischemic stroke or treatment-related death. RESULTS A total of 277 patients with 314 aneurysms were included. Median age was 60 years, 202 (73%) patients were females. Hypertension was the most common comorbidity in 156 (56%) patients. The most common location of the aneurysms was the anterior circulation in 89% (279/314). Mean aneurysm dome width was 5.77 ± 4.75 mm, neck width was 4.22 ± 3.83 mm, and dome/neck ratio was 1.63 ± 1.26. Small-sized aneurysms were 185 (59%). Single device was used in 94% of the patients, mean number of devices per patient was 1.06. At final follow-up, complete obliteration rate was 81% (194/239). Major stroke and death were encountered in 7 (3%) and 6 (2%) cases, respectively. CONCLUSION This is the largest cohort study using a 72-96 wire flow diverter. The Surpass Streamline demonstrated a favorable safety and efficacy profile, making it a valuable option for treating not only large but also wide-necked small and medium-sized intracranial aneurysms.
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Affiliation(s)
- Juan Vivanco-Suarez
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Alan Mendez-Ruiz
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Mudassir Farooqui
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Kimon Bekelis
- Department of Neurological Surgery, Good Samaritan Hospital Medical Center, West Islip, NY, United States
| | - Justin A Singer
- Department of Neurological Surgery, Spectrum Health, Grand Rapids, MI, United States
| | - Kainaat Javed
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY, United States
| | - David J Altschul
- Department of Neurological Surgery, Montefiore Medical Center, Bronx, NY, United States
| | - Johanna T Fifi
- Department of Neurological Surgery, The Mount Sinai Hospital, New York, NY, United States
| | - Stavros Matsoukas
- Department of Neurological Surgery, The Mount Sinai Hospital, New York, NY, United States
| | - Jared Cooper
- Department of Neurology, Neurosurgery & Radiology, Westchester Medical Center and New York Medical College, Valhalla, NY, United States
| | - Fawaz Al-Mufti
- Department of Neurology, Neurosurgery & Radiology, Westchester Medical Center and New York Medical College, Valhalla, NY, United States
| | - Bradley Gross
- Department of Endovascular Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Brian Jankowitz
- Department of Endovascular Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Peter T Kan
- Department of Neurological Surgery, University of Texas Medical Branch, Galveston, TX, United States
| | - Muhammad Hafeez
- Department of Neurological Surgery, University of Texas Medical Branch, Galveston, TX, United States
| | - Emanuele Orru
- Department of Interventional Neuroradiology, Lahey Hospital & Medical Center, Burlington, MA, United States
| | - Andres Dajles
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Milagros Galecio-Castillo
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Cynthia B Zevallos
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Ajay K Wakhloo
- Department of Interventional Neuroradiology, Lahey Hospital & Medical Center, Burlington, MA, United States
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, The University of Iowa Hospitals and Clinics, Iowa City, IA, United States
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5
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Pabon B, Torres V, Woodward K, Cardozo M, Tan B, Chaubal V, Badruddin A, Wolfe T, Pereira E, Jankowitz B, Costalat V, Altschul D, Langerford CA, Zaidat OO. Treatment of a ruptured shallow trilobed cerebral aneurysm with the novel saccular endovascular aneurysm lattice (SEAL) device: A case report with one year follow-up. Interv Neuroradiol 2023:15910199231187048. [PMID: 37455501 PMCID: PMC10399503 DOI: 10.1177/15910199231187048] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Intrasaccular flow disruption is a viable alternative to other endovascular treatments for saccular or wide-necked bifurcation intracranial aneurysms; however, wide neck aneurysms with irregular shapes or shallow depth may not be amenable to treatment currently available intrasaccular devices. Here, we present the first ever case report of the novel Saccular Endovascular Aneurysm Lattice Embolization System (SEAL™). The versatile utility of the SEAL™ device is demonstrated in a patient with acute subarachnoid hemorrhage (SAH) from a ruptured, complex, left middle cerebral artery (MCA) trilobed shallow wide-necked bifurcation aneurysm. Deployment and implantation of the SEAL device were technically feasible, safe, and conformed well to the irregular shape of the complex, ruptured aneurysm. Immediate total aneurysm occlusion was observed after implantation. Importantly, 1-year angiographic follow-up demonstrated durable, complete occlusion with no safety concerns. The SEAL device is a promising new novel technology which has the potential to treat very shallow aneurysms with limited height and irregular, multilobulated aneurysms.
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Affiliation(s)
- Boris Pabon
- Department of Neurosurgery, Universidad De Antioquia, Medellin, Colombia
| | - Victor Torres
- Department of Neurosurgery, Universidad De Antioquia, Medellin, Colombia
| | - Keith Woodward
- Department of Neurointerventional Radiology, Covenant Health, Knoxville, TN, USA
| | - Margarita Cardozo
- Department of Neurosurgery, Universidad De Antioquia, Medellin, Colombia
| | - Benedict Tan
- Department of Neurosciences, St. Vincent Mercy Medical Center, Toledo, OH, USA
| | - Varun Chaubal
- Department of Neurosciences, St. Vincent Mercy Medical Center, Toledo, OH, USA
| | | | | | | | - Brian Jankowitz
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac University Hospital of Montpellier, Montpellier, France
| | - David Altschul
- Department of Neurosurgery, Montefiore Medical Center-Albert Einstein College of Medicine, Bronx, NY, USA
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6
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Mohamed GA, Nogueira RG, Essibayi MA, Aboul-Nour H, Mohammaden M, Haussen DC, Ruiz AM, Gross BA, Kuybu O, Salem MM, Burkhardt JK, Jankowitz B, Siegler JE, Patel P, Hester T, Ortega-Gutierrez S, Farooqui M, Galecio-Castillo M, Nguyen TN, Abdalkader M, Klein P, Charles JH, Saini V, Yavagal DR, Jumah A, Alaraj A, Peng S, Hafeez M, Tanweer O, Kan P, Scaggiante J, Matsoukas S, Fifi JT, Mayer SA, Chebl AB. Tissue Clock Beyond Time Clock: Endovascular Thrombectomy for Patients With Large Vessel Occlusion Stroke Beyond 24 Hours. J Stroke 2023; 25:282-290. [PMID: 37282375 DOI: 10.5853/jos.2023.00017] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 01/02/2023] [Accepted: 03/10/2023] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Randomized trials proved the benefits of mechanical thrombectomy (MT) for select patients with large vessel occlusion (LVO) within 24 hours of last-known-well (LKW). Recent data suggest that LVO patients may benefit from MT beyond 24 hours. This study reports the safety and outcomes of MT beyond 24 hours of LKW compared to standard medical therapy (SMT). METHODS This is a retrospective analysis of LVO patients presented to 11 comprehensive stroke centers in the United States beyond 24 hours from LKW between January 2015 and December 2021. We assessed 90-day outcomes using the modified Rankin Scale (mRS). RESULTS Of 334 patients presented with LVO beyond 24 hours, 64% received MT and 36% received SMT only. Patients who received MT were older (67±15 vs. 64±15 years, P=0.047) and had a higher baseline National Institutes of Health Stroke Scale (NIHSS; 16±7 vs.10±9, P<0.001). Successful recanalization (modified thrombolysis in cerebral infarction score 2b-3) was achieved in 83%, and 5.6% had symptomatic intracranial hemorrhage compared to 2.5% in the SMT group (P=0.19). MT was associated with mRS 0-2 at 90 days (adjusted odds ratio [aOR] 5.73, P=0.026), less mortality (34% vs. 63%, P<0.001), and better discharge NIHSS (P<0.001) compared to SMT in patients with baseline NIHSS ≥6. This treatment benefit remained after matching both groups. Age (aOR 0.94, P<0.001), baseline NIHSS (aOR 0.91, P=0.017), Alberta Stroke Program Early Computed Tomography (ASPECTS) score ≥8 (aOR 3.06, P=0.041), and collaterals scores (aOR 1.41, P=0.027) were associated with 90-day functional independence. CONCLUSION In patients with salvageable brain tissue, MT for LVO beyond 24 hours appears to improve outcomes compared to SMT, especially in patients with severe strokes. Patients' age, ASPECTS, collaterals, and baseline NIHSS score should be considered before discounting MT merely based on LKW.
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Affiliation(s)
- Ghada A Mohamed
- Department of Neurology, Medical University of South Carolina (MUSC), Charleston, SC, USA
| | - Raul G Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Muhammed Amir Essibayi
- Department of Neurosurgery, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Hassan Aboul-Nour
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, USA
| | - Aldo Mendez Ruiz
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bradley A Gross
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Okkes Kuybu
- Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - Brian Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, PA, USA
| | - James E Siegler
- Department of Neurology, Cooper University Medical Center, Camden, NJ, USA
| | - Pratit Patel
- Department of Neurology, Cooper University Medical Center, Camden, NJ, USA
| | - Taryn Hester
- Department of Neurology, Cooper University Medical Center, Camden, NJ, USA
| | | | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Thanh N Nguyen
- Departments of Neurology and Radiology, Boston University School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Departments of Neurology and Radiology, Boston University School of Medicine, Boston, MA, USA
| | - Piers Klein
- Departments of Neurology and Radiology, Boston University School of Medicine, Boston, MA, USA
| | - Jude H Charles
- Departments of Neurology and Radiology, Boston University School of Medicine, Boston, MA, USA
| | - Vasu Saini
- Department of Neurology, University of Miami, Miami, FL, USA
| | | | - Ammar Jumah
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Sophia Peng
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Muhammad Hafeez
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Omar Tanweer
- Department of Neurosurgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX, USA
| | - Jacopo Scaggiante
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX, USA
| | - Stavros Matsoukas
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NYC, NY, USA
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, Westchester Medical Center, Westchester, NY, USA
| | - Alex B Chebl
- Department of Neurology, Henry Ford Health, Detroit, MI, USA
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7
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Jankowitz B, Swanson T, Zaidat OO. 563 Post-Approval Three Year Outcomes Study of the Neuroform Atlas Stent for Treatment of Wide-Neck Intracranial Aneurysms. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_563] [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: 03/18/2023] Open
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8
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Lipski M, Pasciolla S, Wojcik K, Jankowitz B, A Igneri L. Comparison of 4-factor prothrombin complex concentrate and andexanet alfa for reversal of apixaban and rivaroxaban in the setting of intracranial hemorrhage. J Thromb Thrombolysis 2022; 55:519-526. [PMID: 36566473 DOI: 10.1007/s11239-022-02752-z] [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: 12/05/2022] [Indexed: 12/26/2022]
Abstract
The purpose of this study was to evaluate and compare clinical outcomes in patients who experienced intracranial hemorrhage (ICH) while taking apixaban or rivaroxaban and were reversed with four-factor prothrombin complex concentrates (4F-PCC) or andexanet alfa (AA). This retrospective cohort included adult patients that received 4F-PCC or AA for the initial management of an apixaban- or rivaroxaban-associated ICH. A primary outcome of excellent or good hemostatic efficacy at 12 h post-reversal was assessed. Secondary outcomes evaluated were change in hematoma volume size at 12 h, functional status at discharge, need for surgical intervention or additional hemostatic agents post-reversal, new thrombotic event within 28 days, 28-day all-cause mortality, discharge disposition, and hospital and intensive care unit lengths of stay. A total of 70 patients were included (4F-PCC, n = 47; AA, n = 23). For the primary outcome analysis, 21 patients were included in the 4F-PCC group and 12 in the AA group. The rate of effective hemostasis was similar between the 4F-PCC and AA groups (66.7% vs 75%, p = 0.62). There were no statistically significant differences between the groups for secondary outcomes, including 28-day mortality (40.4% vs 39.1%, p = 0.92) and thrombotic complications within 28 days of reversal (17.0% vs 21.7%, p = 0.63). In patients who experienced an ICH while taking apixaban or rivaroxaban, 4F-PCC and AA were found to have similar rates of excellent or good hemostatic efficacy.
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Affiliation(s)
- Michelle Lipski
- Department of Pharmacy, University of Pittsburgh Medical Center Hamot, Erie, PA, 16506, USA.
| | - Stacy Pasciolla
- Department of Pharmacy, Philadelphia College of Pharmacy, Saint Joseph's University, Philadelphia, PA, USA.,Department of Pharmacy, Cooper University Health Care, Camden, NJ, USA
| | - Kevin Wojcik
- Department of Neurosurgery, Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA.,Department of Neurosurgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Brian Jankowitz
- Department of Neurosurgery, Perelman School of Medicine at the Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Lauren A Igneri
- Department of Pharmacy, Cooper University Health Care, Camden, NJ, USA
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9
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Song R, Ali M, Smith C, Jankowitz B, Hom D, Mocco J, Kellner CP. Initial Experience With the NICO Myriad Device for Minimally Invasive Endoscopic Evacuation of Intracerebral Hemorrhage. Oper Neurosurg (Hagerstown) 2022; 23:194-199. [PMID: 35972081 PMCID: PMC10593260 DOI: 10.1227/ons.0000000000000304] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 04/03/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) is a devastating form of stroke for which there is no consensus treatment. Although open craniotomy has been explored as a surgical treatment option, multiple minimally invasive (MIS) techniques have been developed including endoscopic evacuation. An adjunctive aspiration device can be used through the working channel to provide an additional degree of freedom and increased functionality regarding clot manipulation and morcellation. OBJECTIVE To report our single-center technical experience with the Myriad device used as an adjunctive aspiration device during endoscopic ICH evacuation in an exploratory case series. METHODS Demographic, clinical, and radiographic data were collected on patients who underwent MIS endoscopic ICH evacuation using the Myriad aspiration device from December 2018 to March 2019. RESULTS Eight patients underwent ICH evacuation with the Myriad aspiration device. Bleeding was confined to the cortex in 4 patients, subcortical region in 2 patients, and the cerebellum in 2 patients. One of the cerebellar cases also underwent suboccipital craniotomy. The mean preoperative hematoma volume was 65.1 ± 68.9 mL, and the median postoperative volume was 7.6 ± 9.0 mL, for an average evacuation percentage of 88.1% ± 12.1%. In 75% of the cases, a bleeding vessel was identified and treated with either cautery or irrigation alone. There was no hemorrhagic recurrence or mortality within 30 days. CONCLUSION Data from this initial experience suggest that MIS endoscopic ICH evacuation with the NICO Myriad aspiration device is feasible and technically effective. Multicenter exposure is necessary to verify broader applicability.
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Affiliation(s)
- Rui Song
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Muhammad Ali
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Colton Smith
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Brian Jankowitz
- Department of Neurosurgery, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Danny Hom
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Christopher P. Kellner
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
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10
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Pease M, Zaher M, Lopez AJ, Yu S, Egodage T, Semroc S, Arefan D, Jankowitz B. Multicenter and prospective trial of anti-epileptics for early seizure prevention in mild traumatic brain injury with a positive computed tomography scan. Surg Neurol Int 2022; 13:241. [PMID: 35855176 PMCID: PMC9282794 DOI: 10.25259/sni_38_2022] [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: 01/10/2022] [Accepted: 05/04/2022] [Indexed: 11/24/2022] Open
Abstract
Background: Posttraumatic seizures (PTSs) are a major source of disability after traumatic brain injury (TBI). The Brain Trauma Foundation Guidelines recommend prophylactic anti-epileptics (AEDs) for early PTS in severe TBI, but high-quality evidence is lacking in mild TBI. Methods: To determine the benefit of administering prophylactic AEDs, we performed a prospective and multicenter study evaluating consecutive patients who presented to a Level 1 trauma center from January 2017 to December 2020. We included all patients with mild TBI defined as Glasgow Coma Scale (GCS) 13–15 and a positive head computed tomography (CT). Patients were excluded for previous seizure history, current AED use, or a neurosurgical procedure. Patients were given a prophylactic 7-day course of AEDs on a week-on versus week-off basis and followed with in-person clinic visits, in-hospital evaluation, or a validated phone questionnaire. Results: Four hundred and ninety patients were enrolled, 349 (71.2%) had follow-up, and 139 (39.8%) were given prophylactic AEDs. There was no difference between seizure rates for the prophylactic AED group (0.7%) and those without (2.9%; P = 0.25). Patients who had a PTS were on average older (81.4 years) than patients without a seizure (64.8 years; P = 0.02). Seizure rate increased linearly by age groups: <60 years old (0%); 60–70 years old (1.7%); 70–80 years old (2.3%); and >80 years old (4.6%). Conclusion: Prophylactic AEDs did not provide a benefit for PTS reduction in mild TBI patients with a positive CT head scan.
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Affiliation(s)
- Matthew Pease
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Mazen Zaher
- Department of Neurosurgery, Medical School, Cooper University, Camden, United States
| | - Alejandro J. Lopez
- Department of Neurosurgery, Medical School, Cooper University, Camden, United States
| | - Siyuan Yu
- Department of Neurosurgery, Medical School, Cooper University, Camden, United States
| | - Tanya Egodage
- Department of General Surgery, Cooper University Hospital, Camden, United States
| | - Suzan Semroc
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States
| | - Dooman Arefan
- Department of Radiology, University of Pittsburgh, Pittsburgh, United States
| | - Brian Jankowitz
- Department of Neurosurgery, Medical School, Cooper University, Camden, United States
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11
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Zakeri A, Schreiber C, Shah V, VonEnde E, Granger J, Minnema AJ, Constable M, Shujaat T, Youssef P, Powers C, Jankowitz B, Nimjee SM. Utility of the novel guide catheter in mechanical thrombectomy for emergent large vessel occlusion stroke. Interv Neuroradiol 2022:15910199221084483. [PMID: 35642272 DOI: 10.1177/15910199221084483] [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] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND A number of large bore guide catheters are currently available for use in neuroendovascular surgery. This study represents a multi-institutional retrospective series of patients undergoing mechanical thrombectomy with the use of a TracStar Large Distal Platform (LDP) guide catheter and assessed its performance in vivo in 107 patients. OBJECTIVE To review a multi-institutional initial experience with the TracStar LDP guide catheter during mechanical thrombectomy for emergent large vessel occlusion (ELVO). METHODS A retrospective review was performed at two level one stroke centres to include all patients who underwent mechanical thrombectomy and had the TracStar LDP guide catheter used during the intervention. RESULTS The TracStar LDP guide catheter was successfully used in 107 mechanical thrombectomies. In anterior circulation ELVO, the guide catheter advanced into the cavernous segment of the internal carotid artery in 62.6% (62/99) of cases. In posterior circulation cases, the guide catheter advanced to the basilar artery in 87.5% (7/8) of cases. A thrombolysis in cerebral infarction 2b or greater reperfusion was obtained in 90.7% (97/107). No complications occurred related to the TracStar LDP guide catheter. Three complications occurred with aspiration catheters including a small dissection that did not require further intervention and fracturing of the AXS Catalyst 6 catheter tip in two cases. No thromboembolic events occurred. CONCLUSIONS The TracStar LDP large bore guide catheter is safe and effective at navigating the tortuous vascular anatomy often encountered during mechanical thrombectomy for stroke. The flexible distal and stiffer proximal components provide a good combination of navigability and support for use in neuroendovascular interventions.
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Affiliation(s)
- Amanda Zakeri
- Department of Neurosurgery, 12306The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
| | - Craig Schreiber
- Department of Neurosurgery, 2202Cooper University Hospital, 1 Cooper Plaza, Camden, New Jersey 08103
| | - Varun Shah
- Department of Neurosurgery, 12306The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
| | - Elizabeth VonEnde
- Department of Radiology, 174218The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
| | - Jessica Granger
- Department of Neuroendovascular Imaging and Perioperative Services, 189465The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
| | - Amy J Minnema
- Department of Neurosurgery, 12306The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
| | - Mark Constable
- Department of Neurosurgery, 12306The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
| | - Taimur Shujaat
- Department of Radiology, 174218The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
| | - Patrick Youssef
- Department of Neurosurgery, 12306The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
| | - Ciarán Powers
- Department of Neurosurgery, 12306The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
| | - Brian Jankowitz
- Department of Neurosurgery, 2202Cooper University Hospital, 1 Cooper Plaza, Camden, New Jersey 08103
| | - Shahid M Nimjee
- Department of Neurosurgery, 12306The Ohio State University Medical Center, 410 W 10th Ave., Columbus, Ohio 43210
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12
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Pasciolla S, Wojcik K, Kavi T, Green D, Shaikh H, Jankowitz B, Igneri LA. Comparison of 4-factor PCC reversal of apixaban and rivaroxaban versus warfarin for intracranial hemorrhage. J Thromb Thrombolysis 2021; 54:74-81. [PMID: 34837144 DOI: 10.1007/s11239-021-02613-1] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/14/2021] [Indexed: 11/30/2022]
Abstract
The purpose of this study is to assess efficacy of 4-factor prothrombin complex concentrates (4F-PCC) for direct oral anticoagulant (DOAC)-associated intracranial hemorrhage (ICH) as compared to its use in warfarin-associated ICH. A retrospective cohort study was performed to compare the efficacy of 4F-PCC for reversal of apixaban and rivaroxaban versus warfarin for ICH at Cooper University Health Care from January 2015 to December 2019. Patients included were ≥ 18 years of age who developed an ICH while on apixaban, rivaroxaban, or warfarin. The primary outcome was to compare the percentage of patients with Excellent or Good hemostatic efficacy after 4F-PCC administration. Secondary outcomes were to describe functional outcomes at discharge, in-hospital mortality, and thrombotic complications after 4F-PCC administration. A total of 159 patients were included; 115 patients received warfarin and 44 patients received a DOAC (apixaban, n = 22; rivaroxaban, n = 22). 70 patients were evaluable for the primary endpoint. Thirty-four (66.7%) patients in the warfarin group versus 14 (73.7%) patients in the DOAC group were determined to have excellent or good hemostatic efficacy (p = 0.57). In-hospital mortality (30.4% vs. 40.9%, p = 0.21) and thrombotic complications (9.6% vs. 11.4%, p = 0.67) were comparable between the warfarin vs. DOAC groups, respectively. This small, retrospective study found no difference in patients with excellent/good hemostatic efficacy after reversal with 4F-PCC for DOAC-associated ICH compared to warfarin-associated ICH. This study is limited by its retrospective nature and sample size. Larger, prospective studies are needed to further determine the efficacy of 4F-PCC in reversing DOAC-associated ICH.
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Affiliation(s)
- Stacy Pasciolla
- Philadelphia College of Pharmacy, University of the Sciences, Philadelphia, PA, USA. .,Department of Pharmacy, Cooper University Health Care, Camden, NJ, USA.
| | - Kevin Wojcik
- Department of Neurosurgery, Cooper University Health Care, Camden, NJ, USA
| | - Tapan Kavi
- Neurocritical Care, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | - Danielle Green
- Department of Pharmacy, Doylestown Health, Doylestown, PA, USA
| | - Hamza Shaikh
- Director of Neurointerventional Surgery, Cooper University Health Care, Camden, NJ, USA
| | - Brian Jankowitz
- Department of Neurosurgery, Penn Neuroscience Center, Philadelphia, PA, USA
| | - Lauren A Igneri
- Department of Pharmacy, Cooper University Health Care, Camden, NJ, USA
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13
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Mayer SA, Frontera JA, Jankowitz B, Kellner CP, Kuppermann N, Naik BI, Nishijima DK, Steiner T, Goldstein JN. Recommended Primary Outcomes for Clinical Trials Evaluating Hemostatic Agents in Patients With Intracranial Hemorrhage: A Consensus Statement. JAMA Netw Open 2021; 4:e2123629. [PMID: 34473266 DOI: 10.1001/jamanetworkopen.2021.23629] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE In patients with acute spontaneous or traumatic intracranial hemorrhage, early hemostasis is thought to be critical to minimize ongoing bleeding. However, research evaluating hemostatic therapies has been hampered by a lack of standardized clinical trial outcome measures. OBJECTIVE To identify appropriate primary outcomes for phase 2 and 3 clinical trials of therapies aimed at reducing acute intracranial bleeding. EVIDENCE REVIEW A comprehensive review of all previous clinical trials of hemostatic therapy for intracranial bleeding was performed, and studies measuring the frequency, risk factors, and association of intracranial bleeding with outcome of hemorrhage growth were included. FINDINGS A hierarchy of 3 outcome measures is recommended, with the first choice being a global patient-centered clinical outcome scale measured 30 to 180 days after the event; the second, a combined clinical and radiographic end point associating hemorrhage expansion with a poor patient-centered outcome at 24 hours or later; and the third, a radiographic measure of hemorrhage expansion at 24 hours alone. Additional recommendations stress the importance of separating various subtypes of bleeding when possible, early treatment within a standardized treatment window, and the routine use of computerized planimetry comparing continuous measures of absolute and relative hemorrhage growth as either a primary or secondary end point. CONCLUSIONS AND RELEVANCE Standardization of outcome measures in studies of intracranial bleeding and hemostatic therapy will support comparative effectiveness research and meta-analysis, with the goal of accelerating the translation of research into clinical practice. The 3 outcome measures proposed in this consensus statement could help this process.
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Affiliation(s)
- Stephan A Mayer
- Departments of Neurology and Neurosurgery, Westchester Medical Center Health, New York Medical College, Valhalla
| | | | - Brian Jankowitz
- Department of Neurosurgery, Cooper University Health Care, Camden, New Jersey
| | | | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California, Davis School of Medicine, UC Davis Health, Sacramento
| | - Bhiken I Naik
- Department of Anesthesiology and Neurological Surgery, University of Virginia, Charlottesville
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California, Davis School of Medicine, UC Davis Health, Sacramento
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Joshua N Goldstein
- Department of Emergency Medicine, Massachusetts General Hospital, Boston
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14
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Gupta R, Saver JL, Levy E, Zaidat OO, Yavagal D, Liebeskind DS, Khaldi A, Gross B, Lang M, Narayanan S, Jankowitz B, Snyder K, Siddiqui A, Davies J, Lin E, Hassan A, Hanel R, Aghaebrahim A, Kaushal R, Malek A, Mueller-Kronast N, Starke R, Bozorgchami H, Nesbit G, Horikawa M, Priest R, Liu J, Budzik RF, Pema P, Vora N, Taqi MA, Samaniego E, Wang QT, Nossek E, Dabus G, Linfante I, Puri A, Abergel E, Starkman S, Tateshima S, Jadhav AP. New Class of Radially Adjustable Stentrievers for Acute Ischemic Stroke: Primary Results of the Multicenter TIGER Trial. Stroke 2021; 52:1534-1544. [PMID: 33739136 PMCID: PMC8078128 DOI: 10.1161/strokeaha.121.034436] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: The Tigertriever is a novel, radially adjustable, fully visible, stentriever that permits the operator to align radial expansion with target vessel diameters. This multicenter trial compared the Tigertriever’s effectiveness and safety compared with established stent retrievers. Methods: Single arm, prospective, multicenter trial comparing the Tigertriever to efficacy and safety performance goals derived from outcomes in 6 recent pivotal studies evaluating the Solitaire and Trevo stent-retriever devices with a lead-in and a main-study phase. Patients were enrolled if they had acute ischemic stroke with National Institutes of Health Stroke Scale score ≥8 due to large vessel occlusion within 8 hours of onset. The primary efficacy end point was successful reperfusion, defined as core laboratory-adjudicated modified Thrombolysis in Cerebral Ischemia score 2b-3 within 3 passes of the Tigertriever. The primary safety end point was a composite of 90-day all-cause mortality and symptomatic intracranial hemorrhage. Secondary efficacy end points included 3-month good clinical outcome (modified Rankin Scale score 0–2) and first-pass successful reperfusion. Results: Between May 2018 and March 2020, 160 patients (43 lead-in, 117 main phase) at 17 centers were enrolled and treated with the Tigertriever. The primary efficacy end point was achieved in 84.6% in the main-study phase group compared with the 63.4% performance goal and the 73.4% historical rate (noninferiority P<0.0001; superiority P<0.01). The first pass successful reperfusion rate was 57.8%. After all interventions, successful reperfusion (modified Thrombolysis in Cerebral Ischemia score ≥2b) was achieved in 95.7% and excellent reperfusion (modified Thrombolysis in Cerebral Ischemia score 2c-3) in 71.8%. The primary safety composite end point rate of mortality and symptomatic intracranial hemorrhage was 18.1% compared with the 30.4% performance goal and the 20.4% historical rate (noninferiority P=0.004; superiority P=0.57). Good clinical outcome was achieved in 58% at 90 days. Conclusions: The Tigertriever device was shown to be highly effective and safe compared with Trevo and Solitaire devices to remove thrombus in patients with large-vessel occlusive stroke eligible for mechanical thrombectomy. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03474549.
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Affiliation(s)
- Rishi Gupta
- Wellstar Medical Group, Department of Neurosurgery, Wellstar Health System Kennestone Hospital Marietta, GA (R.G., A.K.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles (J.L.S., D.S.L.)
| | - Elad Levy
- Departments of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, OH (E.L., O.O.Z.)
| | - Osama O Zaidat
- Departments of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, OH (E.L., O.O.Z.)
| | - Dileep Yavagal
- Department of Neurology (D.Y.), University of Miami School of Medicine, FL
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles (J.L.S., D.S.L.)
| | - Ahmad Khaldi
- Wellstar Medical Group, Department of Neurosurgery, Wellstar Health System Kennestone Hospital Marietta, GA (R.G., A.K.)
| | - Bradley Gross
- Department of Neurosurgery, Stroke Institute, University of Pittsburgh Medical Center, PA (B.G., M.L.)
| | - Michael Lang
- Wellstar Medical Group, Department of Neurosurgery, Wellstar Health System Kennestone Hospital Marietta, GA (R.G., A.K.)
| | | | - Brian Jankowitz
- Department of Neurosurgery, Cooper University Health Care, Camden, NJ (B.J.)
| | - Kenneth Snyder
- Department of Neurosurgery, State University of New York at Buffalo (K.S., A.S.. J.D.)
| | - Adnan Siddiqui
- Department of Neurosurgery, State University of New York at Buffalo (K.S., A.S.. J.D.)
| | - Jason Davies
- Department of Neurosurgery, State University of New York at Buffalo (K.S., A.S.. J.D.)
| | - Eugene Lin
- Departments of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, OH (E.L., O.O.Z.)
| | - Ameer Hassan
- Department of Neurology, Valley Baptist Medical Center, Harlingen, TX (A.H.)
| | - Ricardo Hanel
- Stroke and Cerebrovascular Surgery, Lyerly Neurosurgery/Baptist Neurological Institute, Jacksonville, FL (R.H., A.A.)
| | - Amin Aghaebrahim
- Stroke and Cerebrovascular Surgery, Lyerly Neurosurgery/Baptist Neurological Institute, Jacksonville, FL (R.H., A.A.)
| | - Ritesh Kaushal
- Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., A.M., N.M.-K.)
| | - Ali Malek
- Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., A.M., N.M.-K.)
| | - Nils Mueller-Kronast
- Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., A.M., N.M.-K.)
| | - Robert Starke
- Department of Neurosurgery (R.S.), University of Miami School of Medicine, FL
| | - Hormozd Bozorgchami
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Gary Nesbit
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Masahiro Horikawa
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Ryan Priest
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Jesse Liu
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Ronald F Budzik
- Department of Radiology, Riverside Radiology and Interventional Associates, Columbus, OH (R.F.B., P.P., N.V.)
| | - Peter Pema
- Department of Radiology, Riverside Radiology and Interventional Associates, Columbus, OH (R.F.B., P.P., N.V.)
| | - Nirav Vora
- Department of Radiology, Riverside Radiology and Interventional Associates, Columbus, OH (R.F.B., P.P., N.V.)
| | - M Asif Taqi
- Vascular Neurology of Southern California, Los Robles Hospital, Thousand Oaks (M.A.T.)
| | - Edgar Samaniego
- Departments of Neurology, Neurosurgery and Radiology University of Iowa Hospitals and Clinics, Iowa City (E.S.)
| | - Qingliang Tony Wang
- Departments of Neurology, Surgery/Neurosurgery, and Comprehensive Stroke Center, Maimonides Medical Center/SUNY Downstate Health Sciences University, Brooklyn, NY (Q.T.W.)
| | - Erez Nossek
- Department of Neurosurgery, New York University Medical School (E.N.)
| | - Guilherme Dabus
- Department of Neurointerventional Surgery, Baptist Cardiac and Vascular Institute, Miami, FL (G.D., I.L.)
| | - Italo Linfante
- Department of Neurointerventional Surgery, Baptist Cardiac and Vascular Institute, Miami, FL (G.D., I.L.)
| | - Ajit Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester (A.P.)
| | - Eitan Abergel
- Department of Neuroradiology, Rambam Health Care, Haifa, Israel (E.A.)
| | - Sidney Starkman
- Department of Emergency Medicine (S.S.), University of California Los Angeles
| | - Satoshi Tateshima
- Department of Radiology and Neurosurgery (S.T.), University of California Los Angeles
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J.)
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15
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Mascitelli JR, Levitt MR, Griessenauer CJ, Kim LJ, Gross B, Abla A, Winkler E, Jankowitz B, Grandhi R, Goren O, Schirmer CM. Transcirculation approach for stent-assisted coiling of intracranial aneurysms: a multicenter study. J Neurointerv Surg 2020; 13:711-715. [PMID: 33203763 DOI: 10.1136/neurintsurg-2020-016899] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 09/20/2020] [Revised: 10/27/2020] [Accepted: 11/02/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND The transcirculation approach (TCA) for stent-assisted coiling (SAC) of intracranial aneurysms may be useful for certain wide-neck bifurcation aneurysms as well as those with acute-angle efferent branches. OBJECTIVE To describe a multicenter experience using the TCA for SAC. METHODS A multicenter, retrospective study (2016-2020) of aneurysm treatment using SAC via the TCA. Angiographic outcome was scored using the Raymond Scale (adequate occlusion 1 and 2), and clinical outcome was scored using a modified Rankin Scale (good outcome 0-2) RESULTS: Twenty-nine patients with 29 aneurysms were included (62.1% female; average age 61; 89.7% unruptured; 13.8% previously treated; average dome size 6.4 mm; average neck 4.4 mm). Aneurysm locations included internal carotid artery-fetal posterior cerebral artery (n=4), internal carotid artery terminus (n=4), anterior communicating artery (n=8), vertebral artery-posterior inferior cerebellar artery (n=2), and basilar tip (n=11). The TCA used communicating arteries (93.1%; average 1.6 mm), intermediate catheters (51.7%), jailing technique (62.1%), and staged procedures (10.3%). The most common stent was the Neuroform Atlas (Stryker; 69%). Immediate adequate occlusion was obtained in 75.9%, and five patients with inadequate occlusion progressed to adequate occlusion at follow-up. One (3.4%) procedural complication occurred: a watershed stroke in the setting of baseline four-vessel extracranial disease. Two patients had a poor outcome unrelated to the TCA. The majority of patients (86.4%) had a good clinical outcome. One case of in-stent stenosis due to non-compliance with medication was seen, which resolved with medication resumption. CONCLUSIONS The TCA for SAC can be performed for a variety of aneurysms with a low complication rate and good clinical outcomes.
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Affiliation(s)
- Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Louis J Kim
- Department of Neurosurgery, University of Washington School of Medicine, Seattle, WA, USA
| | - Bradley Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Adib Abla
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Ethan Winkler
- Department of Neurosurgery, University of California, San Francisco, San Francisco, CA, USA
| | - Brian Jankowitz
- Department of Neurosurgery, Cooper University Health Care, Camden, NJ, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Oded Goren
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Danville, PA, USA.,Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
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16
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Rao RR, Desai SM, Tonetti DA, Manners J, Gross BA, Jankowitz B, Jovin TG, Jadhav AP. Thrombectomy after in-house stroke in the transfer population. J Stroke Cerebrovasc Dis 2020; 29:105049. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105049] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/05/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022] Open
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17
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Desai SM, Tonetti DA, Morrison AA, Molyneaux BJ, Starr M, Rocha M, Gross BA, Jankowitz B, Jovin TG, Jadhav AP. Delayed functional independence after thrombectomy: temporal characteristics and predictors. J Neurointerv Surg 2020; 12:837-841. [DOI: 10.1136/neurintsurg-2020-016111] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 11/03/2022]
Abstract
BackgroundVariability in early neurological improvement after endovascular thrombectomy (EVT) for large vessel occlusion (LVO) stroke is well documented. Understanding the temporal progression of functional independence after EVT, especially delayed functional independence in patients who do not experience early improvement, is essential for prognostication and rehabilitation.ObjectiveTo determine the incidence of early and delayed functional independence and identify associated predictors after EVT.MethodsA retrospective analysis of prospectively collected data on patients undergoing EVT in the setting of anterior circulation LVO was performed. Demographic, clinical, radiological, treatment, and procedural information were analyzed. Incidence and predictors of early functional independence (EFI, modified Rankin Scale (mRS) score 0–2 at discharge) and delayed functional independence (DFI, mRS score 0–2 at 90 days in non-EFI patients) were analyzed.ResultsThree hundred and fifty-five patients met the study criteria. 55% were women and mean age was 71±15. Mean National Institutes of Health Stroke Scale (NIHSS) score was 17±6 and median Alberta Stroke Program Early CT Score was 9 (8-10). EFI was observed in 21% (73) of patients. Among non-EFI patients (282), DFI was observed in 30% (85) of patients. Shorter time to treatment (p=0.03), lower 24 hours NIHSS score (p<0.001), and smaller follow-up infarct volume (p=0.003) were independent predictors of EFI. Younger age (p=0.011), lower 24 hours NIHSS score (p=0.001), and absence of parenchymal hemorrhage (PH2; p=0.039) were independent predictors of DFI.ConclusionApproximately one-fifth of patients experience EFI and one-third of non-early improvers experience DFI. Younger age, lower 24 hours NIHSS score, and absence of parenchymal hemorrhage were independent predictors of DFI among non-early improvers. Further studies are required to improve our understanding of DFI.
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18
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Lal BK, Roubin GS, Rosenfield K, Heck D, Jones M, Jankowitz B, Jovin T, Chaturvedi S, Dabus G, White CJ, Gray W, Matsumura J, Katzen BT, Hopkins LN, Mayorga-Carlin M, Sorkin JD, Howard G, Meschia JF, Brott TG. Quality Assurance for Carotid Stenting in the CREST-2 Registry. J Am Coll Cardiol 2020; 74:3071-3079. [PMID: 31856962 DOI: 10.1016/j.jacc.2019.10.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [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] [Received: 06/17/2019] [Revised: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The CREST-2 Registry (C2R) was approved by National Institute of Neurological Disorders and Stroke-National Institutes of Health in September 2014 with Centers for Medicare & Medicaid Services, U.S. Food and Drug Administration, and industry collaboration to enroll patients undergoing CAS. The registry credentials interventionists and promotes optimal patient selection, procedural-technique, and outcomes. OBJECTIVES This study reports periprocedural outcomes in a cohort of carotid artery stenting (CAS) performed for asymptomatic and symptomatic carotid stenosis. METHODS Asymptomatic patients with ≥70% and symptomatic patients with ≥50% carotid stenosis, ≤80 years of age, and at standard or high risk for carotid endarterectomy are eligible for enrollment. Interventionists are credentialed by a multispecialty committee that reviews experience, lesion selection, technique, and outcomes. The primary endpoint was a composite of stroke and death (S/D) in the 30-day periprocedural period. Myocardial infarction and access-site complications were assessed as secondary outcomes. RESULTS As of December 2018, 187 interventionists from 98 sites in the United States performed 2,219 CAS procedures in 2,141 patients with primary atherosclerosis (78 were bilateral). The mean age of the cohort was 68 years, 65% were male, and 92% were white; 1,180 (55%) were for asymptomatic disease, and 961 (45%) were for symptomatic disease. All U.S. Food and Drug Administration-approved stents and embolic protection devices were represented. The 30-day rate of S/D was 1.4% for asymptomatic, 2.8% for symptomatic, and 2.0% for all patients. CONCLUSIONS C2R is the first national registry for CAS cosponsored by federal and industry partners. CAS was performed by experienced operators using appropriate patient selection and optimal technique. In that setting, a broad group of interventionists achieved very low periprocedural S/D rates for asymptomatic and symptomatic patients.
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Affiliation(s)
- Brajesh K Lal
- Department of Vascular Surgery, University of Maryland, Baltimore, Maryland.
| | - Gary S Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/Brookwood Baptist Medical Center, Birmingham, Alabama
| | - Kenneth Rosenfield
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Donald Heck
- Department of Radiology, Novant Health Clinical Research, Winston-Salem, North Carolina
| | - Michael Jones
- Department of Cardiology, Baptist Health Lexington, Lexington, Kentucky
| | - Brian Jankowitz
- Department of Neurosurgery, UPMC Presbyterian University Hospital, Pittsburgh, Pennsylvania
| | - Tudor Jovin
- Department of Neurology, UPMC Presbyterian University Hospital, Pittsburgh, Pennsylvania
| | | | - Guilherme Dabus
- Department of Interventional Neuroradiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, Florida
| | | | - William Gray
- Department of Cardiology, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Jon Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Barry T Katzen
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, Florida
| | | | | | - John D Sorkin
- Department of Biostatistics and Informatics, Baltimore VA Medical Center, Baltimore, Maryland
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
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19
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Tonetti D, Jankowitz B, Cynthia K, Zussman B, Rao R, Stone J, Gardner P, Friedlander R, Gross B, Jadhav A, Jovin T. Abstract TP135: Urgent Treatment for Symptomatic Carotid Stenosis: The Pittsburgh Revascularization and Treatment Emergently After Stroke Protocol. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tp135] [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:
Patients with symptomatic carotid stenosis remain at high risk of early recurrent stroke without revascularization. The aim of this report is to analyze prospectively-recorded data from an institutional protocol that standardized the urgent (<48 hours) treatment of patients presenting with symptomatic carotid stenosis and underwent either carotid stenting (CAS) or carotid endarterectomy (CEA).
Methods:
All patients presenting over 28 months to a comprehensive stroke center with symptomatic carotid stenosis within 48 hours of index event were screened for inclusion. All patients were given dual antiplatelet therapy. If there was clinical equipoise between CEA and CAS, patients underwent angiography and subsequently revascularization if DSA demonstrated ≥50% stenosis. The primary outcome was a composite of stroke or death within 30 days.
Results:
178 patients with a diagnosis of recently symptomatic carotid stenosis were included; 120 patients (67%) met criteria. 59 patients underwent CEA and 61 patients underwent CAS. There were not significant differences in the primary outcome; 3 patients (5.1%) in the CEA arm and 3 patients (4.9%) in the CAS arm met the primary outcome.
Conclusion:
In this prospective analysis, urgent revascularization for symptomatic carotid stenosis can be done with equivalently low rates of stroke or death, regardless of revascularization strategy.
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20
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Affiliation(s)
- Alejandro J Lopez
- Department of Neurological Surgery, Cooper University Hospital, Camden, New Jersey, USA
| | - Brian Jankowitz
- Department of Neurological Surgery, Cooper University Hospital, Camden, New Jersey, USA
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21
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Stone JG, Zussman BM, Tonetti DA, Brown M, Desai SM, Gross BA, Jadhav A, Jovin TG, Jankowitz B. Transradial versus transfemoral approaches for diagnostic cerebral angiography: a prospective, single-center, non-inferiority comparative effectiveness study. J Neurointerv Surg 2020; 12:993-998. [DOI: 10.1136/neurintsurg-2019-015642] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/19/2019] [Accepted: 12/22/2019] [Indexed: 12/27/2022]
Abstract
BackgroundInterventional cardiology produced level 1 evidence recommending radial artery-first for coronary angiography given lower vascular complications. Neuroendovascular surgeons have not widely adopted the transradial approach. This prospective, single center, non-inferiority comparative effectiveness study aims to compare the transradial and transfemoral approaches for diagnostic cerebral angiography with respect to efficacy, safety and patient satisfaction.MethodsConsecutive patients presenting for diagnostic cerebral angiography were selected to undergo right radial or femoral access based on date of presentation. Primary outcome was ability to answer the predefined diagnostic goal of the cerebral angiogram using the initial access site and was assessed with a non-inferiority design. Secondary outcomes included technical success per vessel, complications, procedure times and patient satisfaction.ResultsA total of 312 patients were enrolled, 158 and 154 for right radial and femoral access, respectively. The diagnostic goal of the angiogram was achieved in 152 of 154 (99%) patients who underwent attempted femoral access compared with 153 of 158 (97%) patients who underwent radial access, confirming non-inferiority of the transradial approach. Secondary outcomes showed equivalent technical success by vessel, no major complications, and similar frequency of minor complications between the two approaches. In-room time was similar between approaches, though post-procedure recovery room time was significantly shorter for transradial patients. Patient satisfaction results significantly favored the radial approach.ConclusionsIn patients undergoing diagnostic cerebral angiography, transfemoral and transradial access achieve procedural goals with similar effectiveness and safety, though patients strongly prefer the radial approach. Findings support consideration of adopting a radial-first strategy for diagnostic cerebral angiography.
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22
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Tonetti DA, Desai SM, Casillo S, Stone J, Brown M, Jankowitz B, Jovin TG, Gross BA, Jadhav A. Successful reperfusion, rather than number of passes, predicts clinical outcome after mechanical thrombectomy. J Neurointerv Surg 2019; 12:548-551. [DOI: 10.1136/neurintsurg-2019-015330] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Revised: 10/09/2019] [Accepted: 10/10/2019] [Indexed: 11/03/2022]
Abstract
IntroductionFor patients undergoing mechanical thrombectomy, numerous (>3) thrombectomy passes may be harmful. However, non-recanalization leads to poor outcomes. For patients requiring multiple thrombectomy passes to achieve reperfusion, it remains unclear if the risk/benefit ratio favors recanalization.ObjectiveTo test the hypothesis that the benefits afforded by successful reperfusion outweigh the risk conveyed by the numerous passes required.MethodsWe retrospectively reviewed prospectively collected data for patients presenting to a comprehensive stroke center with anterior circulation large vessel occlusion (ACLVO) and undergoing thrombectomy requiring more than one pass over 24 months. We stratified patients into three groups: group 1 (successful reperfusion in 2–3 passes), group 2 (successful reperfusion in ≥4 passes), and group 3 (unsuccessful reperfusion).Results250 patients with ACLVO constituted the study cohort. Despite similar demographics, group 2 patients had better clinical outcomes than those in group 3 at 24 hours (National Institutes of Health Stroke Scale (NIHSS) score 13.5 vs 19.1, p<0.001) and at 90 days (modified Rankin Scale score 0–2 rates of 31.1% vs 0.0%, p=0.006) On multivariate logistic regression analysis, age (p=0.034), Alberta Stroke Program Early CT Score (p<0.01), NIHSS score (p=0.02), and parenchymal
hematoma type 2 (p=0.015) were significant predictors of functional independence among those who achieved successful reperfusion, but the number of passes required did not predict outcome for these patients (p=0.74).ConclusionPatients who achieve successful reperfusion after many passes have better clinical outcomes than those who do not, despite the number of passes and procedural time required. The number of passes required to achieve successful reperfusion beyond the first pass is not a predictor of functional independence.
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23
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Lal BK, Meschia JF, Roubin GS, Jankowitz B, Heck D, Jovin T, White CJ, Rosenfield K, Katzen B, Dabus G, Gray W, Matsumura J, Hopkins LN, Luke S, Sharma J, Voeks JH, Howard G, Brott TG. Factors influencing credentialing of interventionists in the CREST-2 trial. J Vasc Surg 2019; 71:854-861. [PMID: 31353274 DOI: 10.1016/j.jvs.2019.05.035] [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] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/01/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is a pair of randomized trials assessing the relative efficacy of carotid revascularization in the setting of intensive medical management (IMM) in patients with asymptomatic high-grade atherosclerotic stenosis. One of the trials assesses IMM with or without carotid artery stenting (CAS). Given the low risk of stroke in nonrevascularized patients receiving IMM, it is essential that there be low periprocedural risk of stroke for CAS if it is to show incremental benefit. Thus, credentialing of interventionists to ensure excellence is vital. This analysis describes the protocol-driven approach to credentialing of CAS interventionists for CREST-2 and its outcomes. METHODS To be eligible to perform stenting in CREST-2, interventionists needed to be credentialed on the basis of a detailed Interventional Management Committee (IMC) review of data from their last 25 consecutive cases during the past 24 months along with self-reported lifetime experience case numbers. When necessary, additional prospective cases performed in a companion registry were requested after webinar training. Here we review the IMC experience from the first formal meeting on March 21, 2014 through October 14, 2017. RESULTS The IMC had 102 meetings, and 8311 cases submitted by 334 interventionists were evaluated. Most were either cardiologists or vascular surgeons, although no single specialty made up the majority of applicants. The median total experience was 130 cases (interquartile range [IQR], 75-266; range, 25-2500). Only 9% (30/334) of interventionists were approved at initial review; approval increased to 46% (153/334) after submission of new cases with added training and re-review. The median self-reported lifetime case experience for those approved was 211.5 (IQR, 100-350), and the median number of cases submitted for review was 30 (IQR, 27-35). The number of CAS procedures performed per month (case rate) was the only factor associated with approval during the initial cycle of review (P < .00001). CONCLUSIONS Identification of interventionists who were deemed sufficiently skilled for CREST-2 has required substantial oversight and a controlled system to judge current skill level that controls for specialty-based practice variability, procedural experience, and periprocedural outcomes. High-volume interventionists, particularly those with more recent experience, were more likely to be approved to participate in CREST-2. Primary approval was not affected by operator specialty.
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Affiliation(s)
- Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, Md.
| | | | - Gary S Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/Brookwood, Baptist Medical Center, Birmingham, Ala
| | - Brian Jankowitz
- Department of Neurosurgery, UPMC Presbyterian University Hospital, Pittsburgh, Pa
| | - Donald Heck
- Department of Radiology, Novant Health Clinical Research, Winston-Salem, NC
| | - Tudor Jovin
- Department of Neurology, UPMC Presbyterian University Hospital, Pittsburgh, Pa
| | | | | | - Barry Katzen
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, Fla
| | - Guilherme Dabus
- Department of Interventional Neuroradiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, Fla
| | - William Gray
- Department of Cardiology, Lankenau Medical Center, Wynnewood, Pa
| | - Jon Matsumura
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisc
| | | | - Sothear Luke
- Department of Neurology, Mayo Clinic, Jacksonville, Fla
| | - Jashank Sharma
- Department of Surgery, University of Maryland, Baltimore, Md
| | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Ala
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Pichamuthu J, Feroze R, Chung T, Jankowitz B, Vorp DA. CEREBRAL ANEURYSM WALL STRESS AFTER COILING DEPENDS ON MORPHOLOGY AND COIL PACKING DENSITY. J Biomech Eng 2019; 141:2738328. [PMID: 31294748 DOI: 10.1115/1.4044214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 11/08/2022]
Abstract
Endovascular coil embolization is widely used to treat cerebral aneurysms as an alternative to surgical clipping. It involves filling the aneurysmal sac with metallic coils to promote the formation of a coil/thrombus mass (CTM) to protect the aneurysm wall from hemodynamic forces and prevents rupture. A significant number of aneurysms are incompletely coiled leading to aneurysm regrowth and/or recanalization. Porcine blood and platinum coils were used to construct an in-vitro CTM for uniaxial compression testing with coil packing densities (CPDs) of 10%, 20%, and 30%. Mechanical properties for each case were derived and used in finite element simulations of patient specific 3D reconstructions of aneurysms with simple or complex geometries. Reproducible stress/strain curves were obtained from compression testing of CTM and predicted by a polynomial mechanical response function. An exponential increase in the CTM stiffness was observed with increasing CPD. Elevated wall stresses were found throughout the aneurysm dome, neck, and parent artery in simulations of the aneurysms with no filling. Complete, 100% filling of the aneurysms with whole blood clot and CPDs of 10%, 20%, and 30% significantly reduced mean wall stress (MWS) in simple and complex geometry aneurysms. Sequential increases in CPD resulted in significantly greater increases in MWS in simple but not complex geometry aneurysms. These results provide a quantitative measure of the degree to which CPD impacts wall stress and suggest that complex aneurysmal geometries may be more resistant to coil embolization treatment.
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Affiliation(s)
- Joseph Pichamuthu
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, PA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Rafey Feroze
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA
| | - Timothy Chung
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA
| | - Brian Jankowitz
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, PA
| | - David A Vorp
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA; Center for Vascular Remodeling and Regeneration, University of Pittsburgh, Pittsburgh, PA; Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, PA; Department of Surgery, University of Pittsburgh, Pittsburgh, PA; McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA; Department of Chemical & Petroleum Engineering, University of Pittsburgh, Pittsburgh, PA; Clinical and Translational Sciences Institute, University of Pittsburgh, Pittsburgh, PA
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Hawkes C, Desai S, Son J, Panczykowski D, Tememe D, Shah K, Gross B, Jankowitz B, Jovin T, Jadhav AP. Abstract WP39: Radiographic Classification of ICA Occlusions Predicts Clinical Fluctuation and Post-Stenting Hemorrhage Risk. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp39] [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:
The optimal treatment strategy for symptomatic extra-cranial internal carotid artery (ICA) occlusion remains unknown. A radiographic classification of ICA occlusions has been proposed to help predict technical feasibility and the risk of complications with revascularization. The classification includes 4 main types (A-D) based on the morphology of the ICA stump (A having a tapered stump, B having a non-tapered stump, C and D having no stump) as well as the presence of reconstitution of flow in the intracranial ICA (C having reconstitution of the ICA within the cavernous and/or petrous segment and D having no reconstitution). In this study, we assess the predictive value of this classification scheme in understanding clinical phenotype and post-stenting complications.
Methods:
A retrospective review of a prospectively maintained database was conducted of clinical and radiological data from patients undergoing attempted angioplasty and stenting of complete symptomatic cervical ICA occlusion without tandem intracranial occlusion.
Results:
Seventy-two patients were included in the study, with a mean age of 63 years and 36% female gender. Classification type was as follows: 36% (type A), 25% (type B), 32% (type C) and 7% (type D). Revascularization was successful in 66/72 (92%) of patients. Clinical fluctuation prior to revascularization was most frequent in type A occlusions (p=0.02) and least frequent in type B occlusion (p=0.02). Only 8% of patients had peri-procedural intracerebral hemorrhage and the highest frequency occurred in group D (p=0.05). In a multivariate analysis, lower age, lower pre-treatment NIH Stroke Scale and favorable Alberta Stroke Program Early CT Score were predictors of higher modified Rankin Scale at 3 months (p=0.025, 0.004, 0.049, respectively).
Conclusions:
Radiographic classification of ICA occlusions can help classify patient phenotypes and potentially predict the technical safety of angioplasty and stenting. Prospective studies are warranted to confirm these findings.
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Affiliation(s)
| | | | - Ji Son
- Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | | | | | - Kavit Shah
- Univ of Pittsburgh Med Cntr, Pittsburgh, PA
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M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D. Imaging features and safety and efficacy of endovascular stroke treatment: a meta-analysis of individual patient-level data. Lancet Neurol 2018; 17:895-904. [DOI: 10.1016/s1474-4422(18)30242-4] [Citation(s) in RCA: 213] [Impact Index Per Article: 35.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 06/11/2018] [Accepted: 06/12/2018] [Indexed: 11/29/2022]
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Zaidat OO, Bozorgchami H, Ribó M, Saver JL, Mattle HP, Chapot R, Narata AP, Francois O, Jadhav AP, Grossberg JA, Riedel CH, Tomasello A, Clark WM, Nordmeyer H, Lin E, Nogueira RG, Yoo AJ, Jovin TG, Siddiqui AH, Bernard T, Claffey M, Andersson T, Ribo M, Hetts S, Hacke W, Mehta B, Hacein-Bey L, Kim A, Abou-Chebl A, Shabe P, Hetts S, Hacein-Bey L, Kim A, Abou-Chebl A, Dix J, Gurian J, Zink W, Dabus G, O’Leary, N, Reilly A, Lee K, Foley J, Dolan M, Hartley E, Clark T, Nadeau K, Shama J, Hull L, Brown B, Priest R, Nesbit G, Horikawa M, Hoak D, Petersen B, Beadell N, Herrick K, White C, Stacey M, Ford S, Liu J, Ribó M, Sanjuan, E, Sanchis M, Molina C, Rodríguez-Luna, D, Boned Riera S, Pagola J, Rubiera M, Juega J, Rodríguez N, Muller N, Stauder M, Stracke P, Heddier M, Charron V, Decock A, Herbreteau D, Bibi R, De Sloovere A, Doutreloigne I, Pieters D, Dewaele T, Bourgeois P, Vanhee F, Vanderdouckt P, Vancaster E, Baxendell L, Gilchrist V, Cannon Y, Graves C, Armbruster K, Jovin T, Jankowitz B, Ducruet A, Aghaebrahim A, Kenmuir C, Shoirah H, Molyneaux B, Tadi P, Walker G, Starr M, Doppelheuer S, Schindler K, Craft L, Schultz M, Perez H, Park J, Hall A, Mitchell A, Webb L, Haussen D, Frankel M, Bianchi N, Belagaje S, Mahdi N, Lahoti S, Katema A, Winningham M, Anderson A, Tilley D, Steinhauser T, Scott D, Thacker A, Calderon V, Lin E, Becke S, Krieter S, Jansen O, Wodarg F, Larsen N, Binder A, Wiesen C, Hartney M, Bookhagan L, Ross H, Gay J, Snyder K, Levy E, Davies J, Sonig A, Rangel-Castilla L, Mowla A, Shakir H, Fennell V, Atwal G, Natarajan S, Beecher J, Thornton J, Cullen A, Brennan P, O’Hare A, Asadi H, Budzik R, Taylor M, Jennings M, Laube F, Jackson J, Gatrell R, Reebel L, Albon A, Gerniak J, Groezinger K, Lauf M, Voraco N, Pema P, Davis T, Hicks W, Mejilla J, Teleb M, Sunenshine P, Russo E, Flynn R, Twyford J, Ver Hage A, Smith E, Apolinar L, Blythe S, Maxan J, Carter J, Taschner T, Bergmann U, Meckel S, Elsheik S, Urbach H, Maurer C, Egger K, Niesen W, Baxter B, Knox, A, Hazelwood B, Quarfordt S, Calvert J, Hawk H, Malek, R, Padidar A, Tolley U, Gutierrez A, Mordasini P, Seip T, Balasubramaniam R, Gralla J, Fischer U, Zibold F, Piechowiak E, DeLeacy R, Apruzzeses R, Alfonso C, Haslett J, Fifi J, Mocco J, Starkman S, Guzy, J, Grunberg N, Szeder V, Tateshima S, Duckwiler G, Nour M, Liebeskind D, Tang X, Hinman J, Tipirneni A, Yavagal D, Guada L, Bates K, Balladeras S, Bokka S, Suir S, Caplan J, Kandewall P, Peterson E, Starke R, Puri A, Hawk M, Brooks C, L’Heurex J, Ty K, Rex D, Massari F, Wakhloo A, Lozano D, Rodrigua K, Pierot L, Fabienne M, Sebastien S, Emmoinoli M. Primary Results of the Multicenter ARISE II Study (Analysis of Revascularization in Ischemic Stroke With EmboTrap). Stroke 2018; 49:1107-1115. [DOI: 10.1161/strokeaha.117.020125] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/05/2018] [Accepted: 02/26/2018] [Indexed: 02/04/2023]
Affiliation(s)
- Osama O. Zaidat
- From the Department of Neuroscience, Mercy St. Vincent Medical Center, Toledo, OH (O.O.Z., E.L.)
| | | | - Marc Ribó
- Department of Neuroradiology, Vall d’Hebron University Hospital, Barcelona, Spain (M.R., A.T.)
| | - Jeffrey L. Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.)
| | - René Chapot
- Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus, Essen, Germany (R.C., H.N.)
| | - Ana Paula Narata
- Centre Hospitalier Régional Universitaire, Hôpitaux de Tours, France (A.P.N.)
| | | | - Ashutosh P. Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., T.G.J.)
| | - Jonathan A. Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA (J.A.G., R.G.N.)
| | | | - Alejandro Tomasello
- Department of Neuroradiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden (T.A.)
| | - Wayne M. Clark
- Oregon Health and Science University Hospital, Portland (H.B., W.M.C.)
| | - Hannes Nordmeyer
- Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus, Essen, Germany (R.C., H.N.)
| | - Eugene Lin
- From the Department of Neuroscience, Mercy St. Vincent Medical Center, Toledo, OH (O.O.Z., E.L.)
| | - Raul G. Nogueira
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA (J.A.G., R.G.N.)
| | - Albert J. Yoo
- Department of Interventional Radiology, Texas Stroke Institute, Dallas–Fort Worth (A.J.Y.)
| | - Tudor G. Jovin
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., T.G.J.)
| | | | | | | | - Tommy Andersson
- Department of Neuroradiology, Vall d’Hebron University Hospital, Barcelona, Spain (M.R., A.T.)
- AZ Groeninge, Kortrijk, Belgium (O.F., T.A.)
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A, Sanossian N, Loh Y, Devlin T, Baxter B, Hawk H, Sapkota B, Quarfordt S, Sirelkhatim A, Dellinger C, Barton K, Reddy VK, Ducruet A, Jadhav A, Horev A, Giurgiutiu DV, Totoraitis V, Hammer M, Jankowitz B, Wechsler L, Rocha M, Gulati D, Campbell D, Star M, Baxendell L, Oakley J, Siddiqui A, Hopkins LN, Snyder K, Sawyer R, Hall S, Costalat V, Riquelme C, Machi P, Omer E, Arquizan C, Mourand I, Charif M, Ayrignac X, Menjot de Champfleur N, Leboucq N, Gascou G, Moynier M, du Mesnil de Rochemont R, Singer O, Berkefeld J, Foerch C, Lorenz M, Pfeilschifer W, Hattingen E, Wagner M, You SJ, Lescher S, Braun H, Dehkharghani S, Belagaje SR, Anderson A, Lima A, Obideen M, Haussen D, Dharia R, Frankel M, Patel V, Owada K, Saad A, Amerson L, Horn C, Doppelheuer S, Schindler K, Lopes DK, Chen M, Moftakhar R, Anton C, Smreczak M, Carpenter JS, Boo S, Rai A, Roberts T, Tarabishy A, Gutmann L, Brooks C, Brick J, Domico J, Reimann G, Hinrichs K, Becker M, Heiss E, Selle C, Witteler A, Al-Boutros S, Danch MJ, Ranft A, Rohde S, Burg K, Weimar C, Zegarac V, Hartmann C, Schlamann M, Göricke S, Ringlestein A, Wanke I, Mönninghoff C, Dietzold M, Budzik R, Davis T, Eubank G, Hicks WJ, Pema P, Vora N, Mejilla J, Taylor M, Clark W, Rontal A, Fields J, Peterson B, Nesbit G, Lutsep H, Bozorgchami H, Priest R, Ologuntoye O, Barnwell S, Dogan A, Herrick K, Takahasi C, Beadell N, Brown B, Jamieson S, Hussain MS, Russman A, Hui F, Wisco D, Uchino K, Khawaja Z, Katzan I, Toth G, Cheng-Ching E, Bain M, Man S, Farrag A, George P, John S, Shankar L, Drofa A, Dahlgren R, Bauer A, Itreat A, Taqui A, Cerejo R, Richmond A, Ringleb P, Bendszus M, Möhlenbruch M, Reiff T, Amiri H, Purrucker J, Herweh C, Pham M, Menn O, Ludwig I, Acosta I, Villar C, Morgan W, Sombutmai C, Hellinger F, Allen E, Bellew M, Gandhi R, Bonwit E, Aly J, Ecker RD, Seder D, Morris J, Skaletsky M, Belden J, Baker C, Connolly LS, Papanagiotou P, Roth C, Kastrup A, Politi M, Brunner F, Alexandrou M, Merdivan H, Ramsey C, Given II C, Renfrow S, Deshmukh V, Sasadeusz K, Vincent F, Thiesing JT, Putnam J, Bhatt A, Kansara A, Caceves D, Lowenkopf T, Yanase L, Zurasky J, Dancer S, Freeman B, Scheibe-Mirek T, Robison J, Rontal A, Roll J, Clark D, Rodriguez M, Fitzsimmons BFM, Zaidat O, Lynch JR, Lazzaro M, Larson T, Padmore L, Das E, Farrow-Schmidt A, Hassan A, Tekle W, Cate C, Jansen O, Cnyrim C, Wodarg F, Wiese C, Binder A, Riedel C, Rohr A, Lang N, Laufs H, Krieter S, Remonda L, Diepers M, Añon J, Nedeltchev K, Kahles T, Biethahn S, Lindner M, Chang V, Gächter C, Esperon C, Guglielmetti M, Arenillas Lara JF, Martínez Galdámez M, Calleja Sanz AI, Cortijo Garcia E, Garcia Bermejo P, Perez S, Mulero Carrillo P, Crespo Vallejo E, Ruiz Piñero M, Lopez Mesonero L, Reyes Muñoz FJ, Brekenfeld C, Buhk JH, Krützelmann A, Thomalla G, Cheng B, Beck C, Hoppe J, Goebell E, Holst B, Grzyska U, Wortmann G, Starkman S, Duckwiler G, Jahan R, Rao N, Sheth S, Ng K, Noorian A, Szeder V, Nour M, McManus M, Huang J, Tarpley J, Tateshima S, Gonzalez N, Ali L, Liebeskind D, Hinman J, Calderon-Arnulphi M, Liang C, Guzy J, Koch S, DeSousa K, Gordon-Perue G, Haussen D, Elhammady M, Peterson E, Pandey V, Dharmadhikari S, Khandelwal P, Malik A, Pafford R, Gonzalez P, Ramdas K, Andersen G, Damgaard D, Von Weitzel-Mudersbach P, Simonsen C, Ruiz de Morales Ayudarte N, Poulsen M, Sørensen L, Karabegovich S, Hjørringgaard M, Hjort N, Harbo T, Sørensen K, Deshaies E, Padalino D, Swarnkar A, Latorre JG, Elnour E, El-Zammar Z, Villwock M, Farid H, Balgude A, Cross L, Hansen K, Holtmannspötter M, Kondziella D, Hoejgaard J, Taudorf S, Soendergaard H, Wagner A, Cronquist M, Stavngaard T, Cortsen M, Krarup LH, Hyldal T, Haring HP, Guggenberger S, Hamberger M, Trenkler J, Sonnberger M, Nussbaumer K, Dominger C, Bach E, Jagadeesan BD, Taylor R, Kim J, Shea K, Tummala R, Zacharatos H, Sandhu D, Ezzeddine M, Grande A, Hildebrandt D, Miller K, Scherber J, Hendrickson A, Jumaa M, Zaidi S, Hendrickson T, Snyder V, Killer-Oberpfalzer M, Mutzenbach J, Weymayr F, Broussalis E, Stadler K, Jedlitschka A, Malek A, Mueller-Kronast N, Beck P, Martin C, Summers D, Day J, Bettinger I, Holloway W, Olds K, Arkin S, Akhtar N, Boutwell C, Crandall S, Schwartzman M, Weinstein C, Brion B, Prothmann S, Kleine J, Kreiser K, Boeckh-Behrens T, Poppert H, Wunderlich S, Koch ML, Biberacher V, Huberle A, Gora-Stahlberg G, Knier B, Meindl T, Utpadel-Fischler D, Zech M, Kowarik M, Seifert C, Schwaiger B, Puri A, Hou S. Effect of general anaesthesia on functional outcome in patients with anterior circulation ischaemic stroke having endovascular thrombectomy versus standard care: a meta-analysis of individual patient data. Lancet Neurol 2018; 17:47-53. [DOI: 10.1016/s1474-4422(17)30407-6] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Revised: 10/05/2017] [Accepted: 10/11/2017] [Indexed: 10/18/2022]
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Dávalos A, Cobo E, Molina CA, Chamorro A, de Miquel MA, Román LS, Serena J, López-Cancio E, Ribó M, Millán M, Urra X, Cardona P, Tomasello A, Castaño C, Blasco J, Aja L, Rubiera M, Gomis M, Renú A, Lara B, Martí-Fàbregas J, Jankowitz B, Cerdà N, Jovin TG. Safety and efficacy of thrombectomy in acute ischaemic stroke (REVASCAT): 1-year follow-up of a randomised open-label trial. Lancet Neurol 2017; 16:369-376. [PMID: 28318984 DOI: 10.1016/s1474-4422(17)30047-9] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2016] [Revised: 01/25/2017] [Accepted: 02/13/2017] [Indexed: 11/15/2022]
Abstract
BACKGROUND The REVASCAT trial and other studies have shown that the neurovascular thrombectomy improves outcomes at 90 days post stroke. However, whether the observed benefit is sustained in the long term remains unknown. We report the results of the prespecified 12-month analysis of the REVASCAT trial. METHODS Patients with acute ischaemic stroke who could be treated within 8 h of symptom onset were randomly assigned to medical therapy (including intravenous alteplase when eligible) and neurovascular thrombectomy with Solitaire FR or medical therapy alone. The main secondary outcome measure at 1 year follow-up was disability, measured using the modified Rankin Scale (mRS), ranging from 0 (no symptoms) to 6 (death) with categories 5 (severe disability) and 6 (death) collapsed into one category (severe disability or death), analysed as the distribution of the mRS. Additional prespecified secondary outcome measures included health-related quality of life measured with the EuroQol five dimensions questionnaire (EQ-5D) utility index (ranging from -0·3 to 1, higher values indicate better quality of life), the rate of functional independence (mRS 0-2), and cognitive function measured with the Trail Making Test (reported elsewhere). Treatment allocation was open label but endpoints at 12 months were assessed by masked investigators. The trial was registered at ClinicalTrials.gov, number NCT01692379. FINDINGS From Nov 24, 2012, to Dec 12, 2014, 206 patients were randomly assigned to medical therapy plus endovascular treatment (n=103) or medical treatment alone (n=103), at four centres in Catalonia, Spain. At 12 months post randomisation, based on 205 of 206 outcomes available at 12 months, thrombectomy reduced disability over the range of the mRS (common adjusted odds ratio [aOR] 1·80, 95% CI 1·09-2·99), and improved functional independence (mRS=0-2; 45 [44%] of 103 patients vs 31 [30%] of 103 patients; aOR 1·86, 95% CI 1·01-3·44). Health-related quality of life was superior in the thrombectomy group (mean EQ-5D utility index score, 0·46 [SD 0·38] in the thrombectomy group vs 0·33 [0·33] in the control group, difference 0·12 [95% CI 0·03-0·22]; p=0·01). 1-year mortality was 23% (24 of 103 patients) in the thrombectomy group versus 24% (25 of 103 patients) in the control group. INTERPRETATION At 12 months follow-up, neurovascular thrombectomy reduced post-stroke disability and improved health-related quality of life, indicating sustained benefit. These findings have important clinical and public health implications for evaluating the cost-effectiveness of the intervention in the long term. FUNDING Fundació Ictus Malaltia Vascular through an unrestricted grant from Medtronic.
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Affiliation(s)
- Antoni Dávalos
- Department of Neuroscience, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Erik Cobo
- Department of Statistics and Operations Research, Barcelona-Tech, Barcelona, Spain
| | | | | | - M Angeles de Miquel
- Department of Radiology, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Luis San Román
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | | | - Elena López-Cancio
- Trial Office Coordination, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Marc Ribó
- Stroke Unit, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Mónica Millán
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Xabier Urra
- Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Pere Cardona
- Stroke Unit, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Carlos Castaño
- Section of Interventional Neuroradiology, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Jordi Blasco
- Department of Radiology, Hospital Clínic, Barcelona, Spain
| | - Lucía Aja
- Department of Radiology, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Marta Rubiera
- Stroke Unit, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Meritxell Gomis
- Stroke Unit, Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Arturo Renú
- Stroke Unit, Hospital Clínic, Barcelona, Spain
| | - Blanca Lara
- Stroke Unit, Hospital de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Brian Jankowitz
- Department of Neurosurgery, Stroke Institute, UPMC, Pittsburgh, PA, USA
| | - Neus Cerdà
- Biostatistics Unit, Bioclever CRO, Barcelona, Spain
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, UPMC, Pittsburgh, PA, USA.
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Streib C, Rangaraju S, Winger DG, Campbell DT, Paolini S, Jankowitz B, Jadhav A, Jovin T. Abstract 132: Final Infarct Volume is a Critical Determinant of Hospitalization Cost in Anterior Circulation Large Vessel Occlusion Stroke. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.132] [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:
Anterior circulation large vessel occlusion (ACLVO) stroke, one of the most devastating stroke subtypes, is associated with substantial economic burden. Identifying predictors of increased ACLVO stroke hospitalization cost is essential to developing cost-effective treatment strategies.
Methods:
We utilized comprehensive patient-level cost-tracking software to calculate hospitalization costs for ACLVO stroke patients at our institution between July 2012-October 2014. Patient demographics and neuroimaging findings were analyzed. Predictors of hospitalization cost were determined using multivariable linear regression. In addition to our primary analysis (all eligible ACLVO patients), we conducted subgroup analyses by treatment (endovascular, IV tPA-only, and no reperfusion therapy) and sensitivity analyses.
Results:
341 patients (median age 69 [IQR 57-80], median NIHSS 16 [IQR 13-21], median hospitalization cost $16,446 [IQR $9823-$27,165]) were included in our primary analysis; final infarct volume (FIV), parenchymal hematoma, age, obstructive sleep apnea, and baseline NIHSS were significant predictors of hospitalization cost (Figure). FIV alone accounted for 20.51% of the total variance in hospitalization cost. Notably, FIV was consistently the most robust predictor of increased cost across primary, subgroup, and sensitivity analyses. Over the observed range of FIVs in our cohort, each additional 1cc of infarcted brain tissue increased hospitalization cost by $122.35.
Conclusion:
FIV is a critical determinant of increased hospitalization cost in ACLVO stroke. Therapies resulting in reduced FIV may not only improve clinical outcomes, but prove cost-effective.
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Affiliation(s)
| | | | - Daniel G Winger
- Univ of Pittsburgh Clinical Translational Science Institute, Pittsburgh, PA
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Jadhav AP, Aghaebrahim A, Horev A, Giurgiutiu DV, Ducruet AF, Jankowitz B, Jovin TG. Stent Retriever-Mediated Manual Aspiration Thrombectomy for Acute Ischemic Stroke. Interv Neurol 2016; 6:16-24. [PMID: 28611829 DOI: 10.1159/000449321] [Citation(s) in RCA: 14] [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] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE Stent retriever thrombectomy and manual aspiration thrombectomy (MAT) have each been shown to lead to high rates of recanalization as single-modality endovascular stroke therapy. We sought to describe the safety and efficacy of a multimodal approach combining these two techniques termed 'stent retriever-mediated manual aspiration thrombectomy' (SMAT) and compared them to MAT alone. METHODS Retrospective review of a prospectively acquired acute endovascular stroke database. RESULTS 195 consecutive patients with large-vessel occlusion were identified between July 2013 and April 2015. Occlusion distribution was as follows: 52% middle cerebral artery segment 1 (M1), 6% M2, 29% internal carotid artery, and 13% vertebrobasilar. Median onset to treatment time was 278 min. Intravenous rtPA was administered in 33% of cases, whereas 34% of cases had symptom onset beyond 8 h. Effective recanalization (TICI 2b/3) was achieved in 91% of patients and in 49% of patients, only a single pass was necessary. Median groin puncture to recanalization time was 40 min. Symptomatic intracerebral hemorrhage occurred in 5% of patients. Favorable outcomes defined as a modified Rankin Scale score of 0-2 were noted in 42% of patients. Compared with MAT alone, SMAT achieved a similar rate of effective recanalization (91 vs. 88%, p = n.s.) but was associated with faster access to reperfusion times (49 vs. 77 min, p < 0.00001). CONCLUSIONS SMAT is a safe and efficacious method to achieve rapid revascularization that leads to faster recanalization compared to manual aspiration alone. Future prospective comparisons are necessary to establish the most clinically effective therapy for acute thrombectomy.
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Affiliation(s)
- Ashutosh P Jadhav
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Winchester, Va., USA.,Department of Neurological Surgery, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Winchester, Va., USA
| | - Amin Aghaebrahim
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Winchester, Va., USA
| | - Anat Horev
- Department of Soroka Medical Center, Beersheba, Israel
| | | | - Andrew F Ducruet
- Department of Neurological Surgery, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Winchester, Va., USA
| | - Brian Jankowitz
- Department of Neurological Surgery, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Winchester, Va., USA
| | - Tudor G Jovin
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Winchester, Va., USA.,Department of Neurological Surgery, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pa. Winchester, Va., USA
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Jankowitz B, Iannaccone F, De Santis G, De Beule M, Gounis M, Van Der Marel K, Puri A. E-064 Adjunctive Stent are Not Flow Diverters: A Computational Flow Dynamics Study Comparing Flow Diverters to Adjunctive Stents. J Neurointerv Surg 2016. [DOI: 10.1136/neurintsurg-2016-012589.136] [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: 11/04/2022]
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Panczykowski D, Pease M, Zhao Y, Weiner G, Ares W, Crago E, Jankowitz B, Ducruet AF. Prophylactic Antiepileptics and Seizure Incidence Following Subarachnoid Hemorrhage: A Propensity Score-Matched Analysis. Stroke 2016; 47:1754-60. [PMID: 27301932 DOI: 10.1161/strokeaha.116.013766] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 04/28/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE The utility of prophylactic antiepileptic drug (AED) administration after spontaneous subarachnoid hemorrhage remains controversial. AEDs have not clearly been associated with a reduction in seizure incidence and have been associated with both neurological worsening and delayed functional recovery in this setting. METHODS We retrospectively analyzed a prospectively collected database of subarachnoid hemorrhage patients admitted to our institution between 2005 and 2010. Between 2005 and 2007, all patients received prophylactic AEDs upon admission. After 2007, no patients received prophylactic AEDs or had AEDs immediately discontinued if initiated at an outside hospital. A propensity score-matched analysis was then performed to compare the development of clinical and electrographic seizures in these 2 populations. RESULTS Three hundred and fifty three patients with spontaneous subarachnoid hemorrhage were analyzed, 43% of whom were treated with prophylactic AEDs upon admission. Overall, 10% of patients suffered clinical and electrographic seizures, most frequently occurring within 24 hours of ictus (47%). The incidence of seizures did not vary significantly based on the use of prophylactic AEDs (11 versus 8%; P=0.33). Propensity score-matched analyses suggest that patients receiving prophylactic AEDs had a similar likelihood of suffering seizures as those who did not (P=0.49). CONCLUSIONS Propensity score-matched analysis suggests that prophylactic AEDs do not significantly reduce the risk of seizure occurrence in patients with spontaneous subarachnoid hemorrhage.
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Affiliation(s)
- David Panczykowski
- From the Department of Neurological Surgery, University of Pittsburgh Medical Center, PA (D.P., M.P., Y.Z., G.W., W.A., B.J., A.F.D.); and School of Nursing, University of Pittsburgh, PA (E.C.)
| | - Matthew Pease
- From the Department of Neurological Surgery, University of Pittsburgh Medical Center, PA (D.P., M.P., Y.Z., G.W., W.A., B.J., A.F.D.); and School of Nursing, University of Pittsburgh, PA (E.C.)
| | - Yin Zhao
- From the Department of Neurological Surgery, University of Pittsburgh Medical Center, PA (D.P., M.P., Y.Z., G.W., W.A., B.J., A.F.D.); and School of Nursing, University of Pittsburgh, PA (E.C.)
| | - Gregory Weiner
- From the Department of Neurological Surgery, University of Pittsburgh Medical Center, PA (D.P., M.P., Y.Z., G.W., W.A., B.J., A.F.D.); and School of Nursing, University of Pittsburgh, PA (E.C.)
| | - William Ares
- From the Department of Neurological Surgery, University of Pittsburgh Medical Center, PA (D.P., M.P., Y.Z., G.W., W.A., B.J., A.F.D.); and School of Nursing, University of Pittsburgh, PA (E.C.)
| | - Elizabeth Crago
- From the Department of Neurological Surgery, University of Pittsburgh Medical Center, PA (D.P., M.P., Y.Z., G.W., W.A., B.J., A.F.D.); and School of Nursing, University of Pittsburgh, PA (E.C.)
| | - Brian Jankowitz
- From the Department of Neurological Surgery, University of Pittsburgh Medical Center, PA (D.P., M.P., Y.Z., G.W., W.A., B.J., A.F.D.); and School of Nursing, University of Pittsburgh, PA (E.C.)
| | - Andrew F Ducruet
- From the Department of Neurological Surgery, University of Pittsburgh Medical Center, PA (D.P., M.P., Y.Z., G.W., W.A., B.J., A.F.D.); and School of Nursing, University of Pittsburgh, PA (E.C.).
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Ribo M, Molina CA, Cobo E, Cerdà N, Tomasello A, Quesada H, De Miquel MA, Millan M, Castaño C, Urra X, Sanroman L, Dàvalos A, Jovin T, Sanjuan E, Rubiera M, Pagola J, Flores A, Muchada M, Meler P, Huerga E, Gelabert S, Coscojuela P, Rodriguez D, Santamarina E, Maisterra O, Boned S, Seró L, Rovira A, Muñoz L, Pérez de la Ossa N, Gomis M, Dorado L, López-Cancio E, Palomeras E, Munuera J, García Bermejo P, Remollo S, García-Sort R, Cuadras P, Puyalto P, Hernández-Pérez M, Jiménez M, Martínez-Piñeiro A, Lucente G, Chamorro A, Obach V, Cervera A, Amaro S, Llull L, Codas J, Balasa M, Navarro J, Ariño H, Aceituno A, Rudilosso S, Renu A, Macho JM, Blasco J, López A, Macías N, Cardona P, Rubio F, Cano L, Lara B, Aja L, Chamorro A, Serena J, Rovira A, Albers G, Lees K, Arenillas J, Roberts R, Goyal M, Demchuk A, Minhas P, Al-Ajlan F, Salluzzi M, Zimmel L, Patel S, Eesa M, von Kummer R, Martí-Fàbregas J, Jankowitz B, Serena J, Salvat-Plana M, López-Cancio E, Hernandez-Pérez M. Association Between Time to Reperfusion and Outcome Is Primarily Driven by the Time From Imaging to Reperfusion. Stroke 2016; 47:999-1004. [DOI: 10.1161/strokeaha.115.011721] [Citation(s) in RCA: 96] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Accepted: 02/04/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
A progressive decline in the odds of favorable outcome as time to reperfusion increases is well known. However, the impact of specific workflow intervals is not clear.
Methods—
We studied the mechanical thrombectomy group (n=103) of the prospective, randomized REVASCAT (Randomized Trial of Revascularization With Solitaire FR Device Versus Best Medical Therapy in the Treatment of Acute Stroke due to Anterior Circulation Large Vessel Occlusion Presenting Within Eight Hours of Symptom Onset) trial. We defined 3 workflow metrics: time from symptom onset to reperfusion (OTR), time from symptom onset to computed tomography, and time from computed tomography (CT) to reperfusion. Clinical characteristics, core laboratory-evaluated Alberta Stroke Program Early CT Scores (ASPECTS) and 90-day outcome data were analyzed. The effect of time on favorable outcome (modified Rankin scale, 0–2) was described via adjusted odds ratios (ORs) for every 30-minute delay.
Results—
Median admission National Institutes of Health Stroke Scale was 17.0 (14.0–20.0), reperfusion rate was 66%, and rate of favorable outcome was 43.7%. Mean (SD) workflow times were as follows: OTR: 342 (107) minute, onset to CT: 204 (93) minute, and CT to reperfusion: 138 (56) minute. Longer OTR time was associated with a reduced likelihood of good outcome (OR for 30-minute delay, 0.74; 95% confidence interval [CI], 0.59–0.93). The onset to CT time did not show a significant association with clinical outcome (OR, 0.87; 95% CI, 0.67–1.12), whereas the CT to reperfusion interval showed a negative association with favorable outcome (OR, 0.72; 95% CI, 0.54–0.95). A similar subgroup analysis according to admission ASPECTS showed this relationship for OTR time in ASPECTS<8 patients (OR, 0.56; 95% CI, 0.35–0.9) but not in ASPECTS≥8 (OR, 0.99; 95% CI, 0.68–1.44).
Conclusions—
Time to reperfusion is negatively associated with favorable outcome, being CT to reperfusion, as opposed to onset to CT, the main determinant of this association. In addition, OTR was strongly associated to outcome in patients with low ASPECTS scores but not in patients with high ASPECTS scores.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01692379.
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Affiliation(s)
- Marc Ribo
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Carlos A. Molina
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Erik Cobo
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Neus Cerdà
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Alejandro Tomasello
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Helena Quesada
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Maria Angeles De Miquel
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Mónica Millan
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Carlos Castaño
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Xabier Urra
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Luis Sanroman
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Antoni Dàvalos
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Tudor Jovin
- From the Stroke Unit, Department of Neurology, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain (M.R., C.A.M.); Statistics and Operations Research, Barcelona-Tech, Universitat Politecnica de Catalunya, Barcelona, Spain (E.C.); Bioclever, Barcelona, Spain (N.C.); Department of Radiology, Hospital Vall d’Hebron, Barcelona, Spain (A.T.); Stroke Unit, Departments of Neurology (H.Q.) and Radiology (M.A.D.M.), Hospital de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
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- Data and Safety Monitoring Board
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - J. Serena
- Central blinded evaluation of Modified Rankin Scale
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Al-ajlan F, Goyal M, Menon BK, Demchuk AM, Eesa M, Rempel JL, Thornton J, Roy D, Roy D, Jovin TG, Willinsky RA, Sapkota B, Lum C, Frei DF, Montanera WJ, Poppe AY, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Hill MD. Abstract TP14: Final Infarct Volume as an Early Indicator the Clinical Outcome: Insight from ESCAPE Trial. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.tp14] [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:
The goal of reperfusion therapy in acute ischemic stroke is to limit the extension of the ischemic core. The objectives of the present study were to assess the relationship between endovascular treatment and final infarct volume.
Methods and Results:
ESCAPE is a multicenter prospective randomized open-label trial with blinded outcome evaluation that enrolled 315 patients (endovascular treatment n=165; control n=150). Of these, 314 patient infarct volumes at 24 hours on CT or MRI were measured blinded to clinical data. Because infarct volumes were non-normally distributed, final infarct volumes were analysed by quartiles. Final infarct volumes were compared by treatment assignment and recanalization/reperfusion status measured by 2-8h CT angiogram in the control group and by formal angiography in the intervention arm.
Results:
Median final infarct volume among all study participants was 21 mL (IQR: 7 to 72). Median final infarct volume in endovascular treatment arm at 15.5 mL (IQR: 5 to 46.5) was significantly lower than median final infarct volume in control arm 33.5 mL (IQR: 11 to 95; P=0.0004). Small infarcts, defined as 1st quartile of infarct volumes were more common in the endovascular group compared to control (relative risk [RR] 1.5, CI95 1.02-2.3). Successful recanalization and reperfusion was highly associated with small infarcts (RR 2.2, CI95 1.4-3.4). The proportion of large hemispheric stroke (defined as an infarct volume in the 4th quartile) was much less frequent in the endovascular treatment arm (RR 0.6, CI95 0.3-0.8).
Conclusions:
This analysis supports the primary results of ESCAPE trial as endovascular treatment was associated with significantly smaller final infarct volumes. Recanalization/reperfusion was associated with smaller final infarct volume.
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Affiliation(s)
- Fahad Al-ajlan
- Clinical Neurosciences, Univ of Calgary, Calgary, Canada
| | | | - Bijoy K Menon
- Clinical Neurosciences, Univ of Calgary, Calgary, Canada
| | | | | | | | | | - Daniel Roy
- Universite de Montreal, Montreal, Canada
| | - Daniel Roy
- Universite de Montreal, Montreal, Canada
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Hana Choe
- Abington Memorial Hosp, Abington, PA
| | | | | | | | | | | | - Michael D Hill
- Clinical Neurosciences, Univ of Calgary, Calgary, Canada
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Lin R, Jankowitz B, Aleu A, Kostov D, Kanaan H, Lee K, Bartynski W, Huen A, Jovin T, Horowitz M, Gehris R. Sinus pericranii: A case report. J Pediatr Neuroradiol 2015. [DOI: 10.3233/pnr-2012-008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Ridwan Lin
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brian Jankowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Aitziber Aleu
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Dean Kostov
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hilal Kanaan
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kim Lee
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Walter Bartynski
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Arthur Huen
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tudor Jovin
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael Horowitz
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robin Gehris
- Department of Dermatology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Gardner PA, Vaz-Guimaraes F, Jankowitz B, Koutourousiou M, Fernandez-Miranda JC, Wang EW, Snyderman CH. Endoscopic Endonasal Clipping of Intracranial Aneurysms: Surgical Technique and Results. World Neurosurg 2015; 84:1380-93. [PMID: 26117084 DOI: 10.1016/j.wneu.2015.06.032] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [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: 05/01/2015] [Revised: 06/15/2015] [Accepted: 06/16/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Microsurgical clipping of intracranial aneurysms requires meticulous technique and is usually performed through open approaches. Endoscopic endonasal clipping of intracranial aneurysms may use the same techniques through an alternative corridor. The aim of this article is to report a series of patients who underwent an endoscopic endonasal approach (EEA) for microsurgical clipping of intracranial aneurysms. METHODS We conducted a retrospective chart review. Surgical outcome and complications were noted. The conceptual application and the technical nuances of these procedures are discussed. RESULTS Ten patients underwent EEA for clipping of 11 intracranial aneurysms arising from the paraclinoidal internal carotid artery (n = 9) and vertebrobasilar system (n = 2). The internal carotid artery aneurysms projected medially, whereas the vertebrobasilar artery aneurysms were directly ventral to the brainstem with low-lying basilar apices. One patient required craniotomy for distal control given the size and thrombosed nature of the aneurysm. Proximal and distal vascular control with direct visualization of the aneurysm was obtained in all patients. In all cases, aneurysms were completely occluded. Among complications, 3 patients had postoperative cerebrospinal fluid leakage and 2 other patients had meningitis. Two patients suffered lacunar strokes. One recovered completely and the other remains with mild disabling symptoms. CONCLUSIONS EEAs can provide direct access for microsurgical clipping of rare and carefully selected intracranial aneurysms. The basic principles of cerebrovascular surgery have to be followed throughout the procedure. These surgeries require a skull base team with a neurosurgeon well versed in both endoscopic endonasal and cerebrovascular surgery, working in concert with an otolaryngologist experienced in skull base endoscopy and reconstruction.
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Affiliation(s)
- Paul A Gardner
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Francisco Vaz-Guimaraes
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Maria Koutourousiou
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Juan C Fernandez-Miranda
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Eric W Wang
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Carl H Snyderman
- Department of Otolaryngology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Grandhi R, Zhang X, Panczykowski D, Choi P, Hunnicutt CT, Jadhav AP, Ducruet AF, Jovin T, Jankowitz B. Incidence of delayed angiographic femoral artery complications using the EXOSEAL vascular closure device. Interv Neuroradiol 2015; 21:401-6. [PMID: 26015532 DOI: 10.1177/1591019915581776] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [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: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Femoral artery injuries are known complications of percutaneous vascular closure devices (VCDs). We studied the incidence of delayed femoral artery angiographic irregularities after neurointerventional procedures in which the EXOSEAL extravascular closure device was used for femoral arterial puncture closure. METHODS Adult patients who underwent femoral arterial puncture closures with an EXOSEAL VCD and had a follow-up femoral artery angiogram from June 2012 through August 2013 were reviewed. A blinded radiologist compared pre-deployment and follow-up femoral arteriograms for the presence of femoral artery stenosis, dissection, pseudoaneurysm, or development of an arteriovenous fistula. Hospital records were reviewed for major or minor complications of the groin site or femoral artery. RESULTS The EXOSEAL VCD achieved hemostasis, without evidence of a groin hematoma or requiring subsequent prolonged manual compression, in 400 of 441 closures following transfemoral arterial access, representing a device success rate of 90.7%. A total of 98 patients underwent 102 repeat angiograms following closure with the EXOSEAL VCD. The average time to the repeat angiogram was 73.5 days (range 0-488, median 28). Follow-up femoral arteriography demonstrated an irregularity in seven cases, all of which were vessel stenoses of <50%. There were no dissections, pseudoaneurysms, infections, or ischemic events in the study population. CONCLUSIONS Angiographic irregularities were seen in 6.86% of cases after closure with the EXOSEAL VCD. There were no clinically significant vascular complications. Thus, femoral artery closure with EXOSEAL carries a low risk of clinically significant delayed angiographic findings.
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Affiliation(s)
- Ramesh Grandhi
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Xiaoran Zhang
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - David Panczykowski
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Phillip Choi
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Ashutosh P Jadhav
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Andrew F Ducruet
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tudor Jovin
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA UPMC Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Brian Jankowitz
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Goyal M, Demchuk AM, Menon BK, Eesa M, Rempel JL, Thornton J, Roy D, Jovin TG, Willinsky RA, Sapkota BL, Dowlatshahi D, Frei DF, Kamal NR, Montanera WJ, Poppe AY, Ryckborst KJ, Silver FL, Shuaib A, Tampieri D, Williams D, Bang OY, Baxter BW, Burns PA, Choe H, Heo JH, Holmstedt CA, Jankowitz B, Kelly M, Linares G, Mandzia JL, Shankar J, Sohn SI, Swartz RH, Barber PA, Coutts SB, Smith EE, Morrish WF, Weill A, Subramaniam S, Mitha AP, Wong JH, Lowerison MW, Sajobi TT, Hill MD. Randomized assessment of rapid endovascular treatment of ischemic stroke. N Engl J Med 2015; 372:1019-30. [PMID: 25671798 DOI: 10.1056/nejmoa1414905] [Citation(s) in RCA: 4189] [Impact Index Per Article: 465.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation. METHODS We randomly assigned participants to receive standard care (control group) or standard care plus endovascular treatment with the use of available thrombectomy devices (intervention group). Patients with a proximal intracranial occlusion in the anterior circulation were included up to 12 hours after symptom onset. Patients with a large infarct core or poor collateral circulation on computed tomography (CT) and CT angiography were excluded. Workflow times were measured against predetermined targets. The primary outcome was the score on the modified Rankin scale (range, 0 [no symptoms] to 6 [death]) at 90 days. A proportional odds model was used to calculate the common odds ratio as a measure of the likelihood that the intervention would lead to lower scores on the modified Rankin scale than would control care (shift analysis). RESULTS The trial was stopped early because of efficacy. At 22 centers worldwide, 316 participants were enrolled, of whom 238 received intravenous alteplase (120 in the intervention group and 118 in the control group). In the intervention group, the median time from study CT of the head to first reperfusion was 84 minutes. The rate of functional independence (90-day modified Rankin score of 0 to 2) was increased with the intervention (53.0%, vs. 29.3% in the control group; P<0.001). The primary outcome favored the intervention (common odds ratio, 2.6; 95% confidence interval, 1.7 to 3.8; P<0.001), and the intervention was associated with reduced mortality (10.4%, vs. 19.0% in the control group; P=0.04). Symptomatic intracerebral hemorrhage occurred in 3.6% of participants in intervention group and 2.7% of participants in control group (P=0.75). CONCLUSIONS Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality. (Funded by Covidien and others; ESCAPE ClinicalTrials.gov number, NCT01778335.).
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Affiliation(s)
- Mayank Goyal
- The authors' affiliations are listed in the Appendix
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Jadhav AP, Aghaebrahim N, Horev A, Giurgiutiu DV, Ducruet A, Jankowitz B, Jovin T. Abstract W MP4: Stentriever Mediated Manual Aspiration Thrombectomy (SMAT) for Acute Ischemic Stroke in 93 Consecutive Patients. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.wmp4] [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:
Both stentriever technology and manual aspiration thrombectomy have been demonstrated to independently lead to high rates of recanalization in acute ischemic strokes presenting with large vessel occlusions. We sought to describe the safety and efficacy of a multimodal approach combining the two techniques.
Methods:
Retrospective review of a prospectively acquired acute endovascular stroke database.
Results:
93 consecutive patients were identified presenting between July 2013 and July 2014. Median age: 67. Median NIHSS: 17. Patients had the following baseline features: 48% female gender, 72% hypertension, 12% diabetes, 39% atrial fibrillation, 29% CAD. Occlusion distribution included 71% M1, 13% M2, 13% ICAT, 16% VB. On presentation, 28% received IV tpa and 34% presented beyond 8 hours. High quality recanalization (TICI2b/3) was achieved in 88% of patients. Recanalization required an average of 2.36 passes. The Solitaire stentriever was used in 81% of cases and the Trevo device was used in the remainder of cases. The aspiration catheter employed was the 072/058 Navien in 74% of cases, 043 DAC in 4% of cases and 5Max ACE in 27% of cases. Median door to groin puncture time was 69 minutes and median groin puncture to recanalization time was 47 minutes. Symptomatic hemorrhage occurred in 5% of patients. Good outcomes were noted in 42% of patients. In anterior circulation stroke patients who received IV tpa prior to IA therapy, good outcomes were noted in 50% of patients.
Conclusions:
SMAT is a safe and efficacious method of achieving rapid revascularization in acute stroke patients. Future prospective comparisons of MAT, stentreiver alone and SMAT are necessary to establish the most clinical effective therapy for acute thrombectomy.
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Affiliation(s)
| | | | - Anat Horev
- Neurology, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | | | | | | | - Tudor Jovin
- Neurology, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
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Gulati D, Ducruet A, Aghaebrahim A, Jankowitz B, Jadhav A, Jovin T. Abstract W MP22: Impact of Difference in Definitions of M1 and M2 segment of Middle Cerebral Artery on Acute Stroke Endovascular Therapy. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.wmp22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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:
The involvement of the different segment of middle cerebral artery has different implications in terms of acute stroke endovascular therapy as learnt from recent trials. It has been suggested in prior trials that M1 segment occlusion might benefit more from acute endovascular therapy as compared to M2 segment. Ongoing trials have different definitions for segments of middle cerebral artery.
METHODS:
Retrospective review of latest 71 cases of either M1/M2 confirmed on Digital Subtraction Angiography (DSA) in prospectively maintained database of acute stroke interventions at our institute is performed. Of these, 49 cases have CTA performed prior to DSA (69%). Stroke Neurologist has blindly reviewed CTA angiogram. Conventional angiogram findings are considered accurate for the exact site of occlusion. Two definitions from REVASCAT trial and SWIFT PRIME trial are then scored based on CTA and assessed in respect to findings in DSA
RESULTS:
As per RESVASCAT defintion, 34 out of 49 cases on CTA/MRA (69%) have M1 occlusion on CTA. Of these 34 cases, 32 are then found to have M1 occlusion on DSA as well. The number of M2 occlusions were 9 out of 49 (18%) on CTA and all of them were found to have M2 occlusion of DSA as well. The accuracy of RESVASCAT definition of M1 and M2 were 32/34 (94%) are 9/9 (100%) respectively.
As per SWIFT PRIME definition, 27 out of 49 cases (58%) on CTA/MRA have M1 occlusions on CTA. Of these 27 cases, all cases were found to have M1 occlusions on DSA as well. The number of M2 occlusions were 15 out of 49 (31%) on CTA and 9 were found to have M2 occlusions on DSA. The accuracy of SWIFT PRIME definition of M1 and M2 were 27/27 (100%) and 9/15(60%).
6 cases (12%) with M1 occlusions on CTA as per REVASCAT definition were defined as M2 occlusions as per SWIFT PRIME.
CONCLUSIONS:
The examination of angiographic data found discrepancies between these two definitions. The accuracy of REVASCAT definition was better for M2 whereas the accuracy of SWIFT PRIME definition was better for M1. The different definition of middle cerebral artery segments could potentially lead to discrepancies in the eligibility criteria for acute endovascular interventions. The criteria used in determining the M1 and M2 segments should be consistent across the field.
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Affiliation(s)
- Deepak Gulati
- Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Andrew Ducruet
- Neurosurgical Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | | | - Brian Jankowitz
- Neurosurgical Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Ashutosh Jadhav
- Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Tudor Jovin
- Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
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Gulati D, Aghaebrahim, A, Malik A, Ducruet A, Jankowitz B, Jovin T, Jadhav A. Abstract T P18: Incidence and Management of Intracranial Wire Perforation During Acute Stroke Endovascular Therapy. Stroke 2015. [DOI: 10.1161/str.46.suppl_1.tp18] [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:
Wire perforation during endovascular thrombectomy for acute stroke is a rare but devastating complication. Understanding the incidence and mechanism of this adverse event may further identify preventive strategies and improvements in management during perforation.
METHODS:
Retrospective review of a prospectively maintained database of acute stroke interventions at our institute identified 1035 patients. Of these, 46 patients were noted to have contrast extravastion during the procedure concerning for wire perforation (4%).
RESULTS:
A majority of the cases involved the anterior circulation (76%). Sites of perforation included: ICA (12), MCA (23), ophthalmic (1), anterior choroidal (2), PCA (4), PICA (1), SCA (1) and vertebral artery (2). Successful hemostasis was achieved with onyx embolization (39%), coil embolization (13%), onyx/coil combined embolization (5%), microcatheter occlusion (2%) and balloon inflation (7%). Thirty one percentage of the cases occurred during intracranial stenting or angioplasty. Despite high rates of mortality (72%), rapid recognition of extravasation and hemostasis led to good outcomes in 9% of patient.
CONCLUSION:
Intra-procedural wire perforation with leakage of contrast is associated with catheterization of small caliber vessels such as distal MCA branches (M3), anterior choroidal artery and diminutive posterior circulation vessels as well as intracranial angioplasty/stenting. Devastating outcomes can potentially be averted with appropriate hemostatic control.
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Affiliation(s)
- Deepak Gulati
- Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | | | - Amer Malik
- Stroke Div, Univ of Miami Miller Sch of Medicine, Miami, FL
| | - Andrew Ducruet
- Neurosurgical Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Brian Jankowitz
- Neurosurgical Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Tudor Jovin
- Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Ashutosh Jadhav
- Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
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Kooshkabadi A, Jankowitz B, Choi PA, Weiner GM, Greene S. Thrombosis and spontaneous recanalization of a giant intracranial aneurysm: diagnostic and management pearls in a pediatric patient. J Neurosurg Pediatr 2015; 15:78-81. [PMID: 25380175 DOI: 10.3171/2014.10.peds13588] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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] [Indexed: 11/06/2022]
Abstract
The authors present the case of a boy who was successfully managed through the spontaneous thrombosis of a cavernous internal carotid artery (ICA) aneurysm, the subsequent occlusion of the ICA, its recanalization, and ultimate endovascular sacrifice, using only two angiograms because of the diagnostic capability of CT angiography. Spontaneous recanalization of the ICA following occlusion in the setting of a giant aneurysm has not been previously reported.
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Affiliation(s)
- Ali Kooshkabadi
- Department of Neurosurgery, University of Pittsburgh Medical Center, and
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Aghaebrahim A, Leiva-Salinas C, Jadhav AP, Jankowitz B, Zaidi S, Jumaa M, Urra X, Amorim E, Zhu G, Giurgiutiu DV, Horev A, Reddy V, Hammer M, Wechsler L, Wintermark M, Jovin T. Outcomes after endovascular treatment for anterior circulation stroke presenting as wake-up strokes are not different than those with witnessed onset beyond 8 hours. J Neurointerv Surg 2014; 7:875-80. [DOI: 10.1136/neurintsurg-2014-011316] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 09/25/2014] [Indexed: 11/04/2022]
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Streib C, Aghaebrahim A, Rangarauju S, Jankowitz B, Amorim E, Paolini S, Wintermark M, Zhu G, Leiva-Salinas C, Jadhav A, Jovin T. Abstract W P10: Endovascular Treatment for Anterior Circulation Stroke Leads to Similar Outcomes in Very Early (within 3 hours) versus Selected Late (Beyond 8 Hours) Presenting Patients. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.wp10] [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:
Endovascular therapy for acute ischemic stroke (AIS) is thought to have a higher chance of good outcome in patients presenting early than in those presenting late. However, a subgroup of late presenting patients, identifiable through advanced neuroimaging methods, has favorable physiology and can still experience good outcomes following reperfusion. We sought to compare outcomes in patients treated very early (within 3 hours) vs. late (beyond 8 hours) at our institution.
Methods:
Via retrospective analysis of a prospectively collected database of 961 consecutive patients treated at our center (2001-2013), we identified patients with anterior circulation stroke who underwent endovascular treatment < 3 hours from time last seen well (with or without prior IV thrombolysis), and patients who underwent endovascular treatment > 8 hours from time last seen well, selected with advanced neuroimaging. Baseline characteristics and outcomes including MRI derived final infarct volumes (FIV) for each group were analyzed. [Table]
Results:
We identified 108 patients treated < 3 hours and 177 patients treated > 8 hours from time last seen well. Baseline characteristics were not significantly different between the two groups except for differences in atrial fibrillation, baseline ASPECTS, and baseline NIHSS. All outcome measures were not significantly different between the two treatment groups. [Table]
Conclusion:
Despite larger baseline infarcts in the > 8 hour group compared to the < 3 hour group, rates of good outcomes, FIV, and mortality did not differ between the two groups. These findings may be explained by differences in the rate of infarct growth from presentation to reperfusion in the two patient populations.
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Affiliation(s)
- Christopher Streib
- Dept of Neurology, Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Amin Aghaebrahim
- Dept of Neurology, Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Srikant Rangarauju
- Dept of Neurology, Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Brian Jankowitz
- Dept of Neurosurgery, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | | | | | - Max Wintermark
- Dept of Radiology, Neuroradiology Div, Univ of Virginia, Charlottesville, VA
| | - Guangming Zhu
- Dept of Radiology, Neuroradiology Div, Univ of Virgina, Charlottesville, VA
| | | | - Ashutosh Jadhav
- Dept of Neurology, Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Tudor Jovin
- Dept of Neurology, Stroke Institute, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
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Jadhav AP, Starr M, Juuma M, Syed Z, Hammer M, Reddy V, Jankowitz B, Wechsler L, Jovin T. Abstract T P24: Endovascular Thrombectomy in Non-Intubated Patients for Basilar Artery Occlusive Disease is Associated With Improved Outcomes. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.tp24] [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:
Basilar artery occlusive disease is associated with poor outcomes and high rates of mortality in the absence of recanalization. Intra-arterial thrombectomy can lead to improved outcomes in a subset of patients, but the determinants of these outcomes are poorly understood. Patients are often routinely intubated prior to thrombectomy for concern of poor mental status and potential procedural complication risk in an uncooperative patient, however intubation itself carries an associated complication profile. We sought to understand the outcomes in patients undergoing thrombectomy with intravenous conscious sedation (IVCS) versus general anesthesia (GA).
Methods:
A review of our prospectively maintained endovascular stroke database identified 103 patients presenting with basilar occlusion.
Results:
79 patients underwent GA and 24 patients underwent IVCS. There were no significant differences in age, gender or stroke risk factors between the two groups. The average NIHSS was higher in the GA group versus the IVCS group (21 vs. 14, p=0.006)- this variable was also controlled for as a potential confounder in the multivariate analysis. Rates of TICI 2b/3 recanalization had a trend towards being slightly higher in the IVCS group (92% vs 84%, p=0.26). In the GA group, there was a trend towards higher rates of wire perforation (9% vs 0%, p=0.14) and hemorrhage (11% vs 0%, p=0.08), and there was a significantly higher incidence of in-hospital death (47% vs 17%, p=0.008). In the IVCS group, there was a higher rate of good outcomes (mRS 0-2 at 3 months, 63% vs 23%, p=0.00045). In multivariate analysis, the following variables were significantly associated with good outcomes: lower age (p 0.010), TICI 2b/3 recanalization (p=0.040) and IVCS (p=0.0035).
Conclusions:
In addition to age and TICI 2b/3 quality recanalization, the use of IVCS is associated with improved outcomes in patients with basilar artery occlusive disease undergoing thrombectomy. These data also suggest the safety and efficacy of endovascular thrombectomy in non-intubated patients. Routine and elective intubation of patients undergoing IA therapy should be avoided if possible as it may be associated with higher complication rates and poor outcomes.
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Affiliation(s)
| | - Matthew Starr
- Neurology, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | | | - Zaidi Syed
- Neurology, Univ of Toledo Med Cntr, Toledo, OH
| | - Maxim Hammer
- Neurology, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | - Vivek Reddy
- Neurology, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
| | | | | | - Tudor Jovin
- Neurology, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
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Jovin T, Jankowitz B, Jadhav AP. Abstract T P13: Reversed Ischemic Attack (Ria): Proposal for a New Terminology in the Era of Thrombolytic Therapy. Stroke 2014. [DOI: 10.1161/str.45.suppl_1.tp13] [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:
Cerebral ischemic attacks are classically known to cause either permanent injury in the case of ‘stroke’ or transient dysfunction without permanent injury in the case of ‘TIA’. The latter occurs due to timely restoration of cerebral blood flow and implies a spontaneous process. With thrombolytic therapy (intravenous or intra-arterial) complete reperfusion is possible and can lead in some patients to complete reversal of the ischemic insult both clinically and radiographically. This entity is inadequately characterized by the current stroke terminology.
Methods:
A retrospective review of a prospectively maintained database identified 800 patients who underwent acute endovascular reperfusion therapy. Inclusion criteria were: complete clinical recovery without evidence of infarction on follow up MRI (DWI sequence).
Results:
We identified 8 patients. Intravenous alteplase followed by intra-arterial therapy was administered in 37.5% of cases. Admission NIHSS ranged from 8-21 and recanalization occurred between 45-490 minutes of symptom onset. The site of occlusion was as follows: left internal carotid artery terminus (2, 25%), middle cerebral artery M1 segment (5, 62.5%) and middle cerebral artery M2 segment (1, 12.5%).
Conclusions:
A hitherto unreported condition of complete clinical and radiographic recovery after reperfusion therapy for large vessel intracranial occlusion is being described. Review of an endovascular database comprising 800 consecutive cases, revealed that the incidence of this entity is 1%. We postulate that in parallel to an increase in efficacy and utilization of revascularization modalities along with an increase in assessment of vessel patency prior to intravenous thrombolysis, recognition of this phenomenon will increase and propose the term ‘Reversed’ Ischemic Attack (RIA) to address a deficiency in terminology currently associated with this condition.
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Affiliation(s)
- Tudor Jovin
- Neurology, Univ of Pittsburgh Med Cntr, Pittsburgh, PA
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Jankowitz B, Grandhi R, Horev A, Aghaebrahim A, Jadhav A, Linares G, Jovin T. Primary manual aspiration thrombectomy (MAT) for acute ischemic stroke: safety, feasibility and outcomes in 112 consecutive patients: Table 1. J Neurointerv Surg 2014; 7:27-31. [DOI: 10.1136/neurintsurg-2013-011024] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Grandhi R, Kanaan H, Shah A, Harrison G, Bonfield C, Jovin T, Jankowitz B, Horowitz M. Safety and efficacy of percutaneous femoral artery access followed by Mynx closure in cerebral neurovascular procedures: a single center analysis. J Neurointerv Surg 2013; 6:445-50. [DOI: 10.1136/neurintsurg-2013-010749] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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Ribo M, Molina CA, Jankowitz B, Tomasello A, Zaidi S, Jumaa M, Coscojuela P, Oakley J, Alvarez-Sabín J, Jovin T. Stentrievers versus other endovascular treatment methods for acute stroke: comparison of procedural results and their relationship to outcomes. J Neurointerv Surg 2013; 6:265-9. [PMID: 23716720 DOI: 10.1136/neurintsurg-2013-010748] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [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: 11/03/2022]
Abstract
BACKGROUND AND PURPOSE The use of stentrievers (ST) is rapidly growing due to several potential benefits over other available treatments. ST potentially restore flow before clot retrieval and reduce procedural time. We aimed to study the impact of these potential benefits. METHODS Patients with acute stroke treated with endovascular procedures in two stroke centers were studied. According to device availability, patients were treated either with intra-arterial tissue plasminogen activator (IAT), Merci or ST. We defined time to initial flow restoration as time from symptom onset to first pass of contrast to previously occluded arteries either through the deployed device or after recanalization. Complete recanalization (Thrombolysis In Cerebral Infarction >2b), day 5 National Institute of Health Stroke Scale (NIHSS) score and favorable outcome at 3 months (modified Rankin Scale score≤2) were recorded. RESULTS A total of 315 patients were studied: 127 IAT, 119 Merci, 69 ST (26 Trevo, 43 Solitaire). No major differences were observed in baseline characteristics between the treatment groups. The rate of complete recanalization was higher with ST (67.2%) than with IAT (50.8%) or Merci (57.3%) (p=0.05). Time from groin puncture to final recanalization was lower with ST (88±46 min) than with IAT (103±70 min) or Merci (128±62 min) (p<0.01) and time from groin puncture to initial flow restoration was shorter with ST (36±18 min) than with IAT (92±67 min) or Merci (114±57 min) (p<0.01). Discharge NIHSS was lower in the ST group (7, IQR 1-26) than in the IAT (14, 2-30) or Merci (12, 5-30) groups (p=0.05) and the rate of favorable outcome was higher: ST (52.9%) vs IAT (33.9%) and Merci (40%) (p=0.03). The use of a ST increased the odds of a favorable outcome (OR 1.9, 95% CI 1.04 to 3.39; p=0.037). CONCLUSIONS In acute endovascular treatment of stroke, the use of ST may increase recanalization and reduce time to flow restoration leading to improved outcomes.
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Affiliation(s)
- Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
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