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Akbik F, Saad H, Grossberg JA, Tong FC, Cawley CM, Howard BM. Aneurysmal recurrence after successful flow-diversion embolization. Interv Neuroradiol 2024; 30:297-301. [PMID: 35635228 PMCID: PMC11095357 DOI: 10.1177/15910199221105175] [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: 03/29/2022] [Revised: 05/15/2022] [Accepted: 05/17/2022] [Indexed: 11/15/2022] Open
Abstract
Aneurysmal recurrence after successful flow-diversion embolization is exceptionally rare. The rarity of recurrence has called into question the yield of interval surveillance imaging. Here we report the case of a recurrent intracranial aneurysm despite complete angiographic resolution after flow-diversion therapy with a Pipeline embolization device (PED). Given the absence of poor wall apposition, endoleak, and device migration, how this aneurysm recurred remains unclear, particularly given the recurrence was at a timepoint at which complete reendothelialization of the device would be expected. The patient ultimately underwent interval treatment with a second device placed across the neck of the aneurysm. Although rare, reports of aneurysmal recurrences support the use of interval non-invasive imaging surveillance to ensure successful embolization in this patient population.
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Affiliation(s)
- Feras Akbik
- Department of Neurology, Division of Neurocritical care, Emory University School of Medicine, Atlanta, GA, USA
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Frank C Tong
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, GA, USA
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2
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Zhao H, Sathialingam E, Cowdrick KR, Urner T, Lee SY, Bai S, Akbik F, Samuels OB, Kandiah P, Sadan O, Buckley EM. Comparison of diffuse correlation spectroscopy analytical models for measuring cerebral blood flow in adults. J Biomed Opt 2023; 28:126005. [PMID: 38107767 PMCID: PMC10723621 DOI: 10.1117/1.jbo.28.12.126005] [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] [Figures] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/30/2023] [Accepted: 11/21/2023] [Indexed: 12/19/2023]
Abstract
Significance Although multilayer analytical models have been proposed to enhance brain sensitivity of diffuse correlation spectroscopy (DCS) measurements of cerebral blood flow, the traditional homogeneous model remains dominant in clinical applications. Rigorous in vivo comparison of these analytical models is lacking. Aim We compare the performance of different analytical models to estimate a cerebral blood flow index (CBFi) with DCS in adults. Approach Resting-state data were obtained on a cohort of 20 adult patients with subarachnoid hemorrhage. Data at 1 and 2.5 cm source-detector separations were analyzed with the homogenous, two-layer, and three-layer models to estimate scalp blood flow index and CBFi. The performance of each model was quantified via fitting convergence, fit stability, brain-to-scalp flow ratio (BSR), and correlation with transcranial Doppler ultrasound (TCD) measurements of cerebral blood flow velocity in the middle cerebral artery (MCA). Results The homogeneous model has the highest pass rate (100%), lowest coefficient of variation (CV) at rest (median [IQR] at 1 Hz of 0.18 [0.13, 0.22]), and most significant correlation with MCA blood flow velocities (R s = 0.59 , p = 0.010 ) compared with both the two- and three-layer models. The multilayer model pass rate was significantly correlated with extracerebral layer thicknesses. Discarding datasets with non-physiological BSRs increased the correlation between DCS measured CBFi and TCD measured MCA velocities for all models. Conclusions We found that the homogeneous model has the highest pass rate, lowest CV at rest, and most significant correlation with MCA blood flow velocities. Results from the multilayer models should be taken with caution because they suffer from lower pass rates and higher coefficients of variation at rest and can converge to non-physiological values for CBFi. Future work is needed to validate these models in vivo, and novel approaches are merited to improve the performance of the multimodel models.
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Affiliation(s)
- Hongting Zhao
- Emory University, Georgia Institute of Technology, Wallace H. Coulter Department of Biomedical Engineering, Atlanta, Georgia, United States
| | - Eashani Sathialingam
- Emory University, Georgia Institute of Technology, Wallace H. Coulter Department of Biomedical Engineering, Atlanta, Georgia, United States
| | - Kyle R. Cowdrick
- Emory University, Georgia Institute of Technology, Wallace H. Coulter Department of Biomedical Engineering, Atlanta, Georgia, United States
| | - Tara Urner
- Emory University, Georgia Institute of Technology, Wallace H. Coulter Department of Biomedical Engineering, Atlanta, Georgia, United States
| | - Seung Yup Lee
- Emory University, Georgia Institute of Technology, Wallace H. Coulter Department of Biomedical Engineering, Atlanta, Georgia, United States
- Kennesaw State University, Department of Electrical and Computer Engineering, Marietta, Georgia, United States
| | - Shasha Bai
- Emory University, School of Medicine, Department of Pediatrics, Atlanta, Georgia, United States
| | - Feras Akbik
- Emory University, School of Medicine, Department of Neurology and Neurosurgery, Division of Neurocritical Care, Atlanta, Georgia, United States
| | - Owen B. Samuels
- Emory University, School of Medicine, Department of Neurology and Neurosurgery, Division of Neurocritical Care, Atlanta, Georgia, United States
| | - Prem Kandiah
- Emory University, School of Medicine, Department of Neurology and Neurosurgery, Division of Neurocritical Care, Atlanta, Georgia, United States
| | - Ofer Sadan
- Emory University, School of Medicine, Department of Neurology and Neurosurgery, Division of Neurocritical Care, Atlanta, Georgia, United States
| | - Erin M. Buckley
- Emory University, Georgia Institute of Technology, Wallace H. Coulter Department of Biomedical Engineering, Atlanta, Georgia, United States
- Emory University, School of Medicine, Department of Pediatrics, Atlanta, Georgia, United States
- Children’s Healthcare of Atlanta, Children’s Research Scholar, Atlanta, Georgia, United States
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3
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Saad H, Eshraghi S, Alawieh AM, Akbik F, Cawley CM, Howard BM, Ash M, Hsu A, Pabaney A, Maier I, Al Kasab S, El Naamani K, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Shaban A, Arthur AS, Yoshimura S, Fragata I, Cuellar-Saenz HH, Polifka AJ, Mascitelli J, Osbun JW, Matouk C, Park MS, Levitt MR, Dumont TM, Williamson R, Spiotta AM, Grossberg JA. Technical and clinical outcomes in concurrent multivessel occlusions treated with mechanical thrombectomy: insights from the STAR collaboration. J Neurointerv Surg 2023; 15:1072-1077. [PMID: 36597932 DOI: 10.1136/jnis-2022-019608] [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: 09/05/2022] [Accepted: 11/05/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has become the mainstay treatment for large vessel occlusion, with favorable safety and efficacy profile. However, the safety and efficacy of EVT in concurrent multi-territory occlusions (MTVOs) remains unclear. OBJECTIVE To investigate the prevalence, clinical and technical outcomes of concurrent EVT for MTVOs. METHODS Data were included from the Stroke Thrombectomy and Aneurysm Registry (STAR) with 32 stroke centers for EVT performed to treat bilateral anterior or concurrent anterior and posterior circulation occlusions between 2017 and 2021. Patients with MTVO were identified, and propensity score matching was used to compare this group with patients with occlusion in a single arterial territory. RESULTS Of a total of 7723 patients who underwent EVT for acute ischemic stroke, 54 (0.7%) underwent EVT for MTVOs (mean age 69±12.5; female 50%). 28% had bilateral and 72% had anterior and posterior circulations occlusions. The rate of successful recanalization (Thrombolysis in Cerebral Infarction 2b/3), complications, modified Rankin score at 90 days, and mortality was not significantly different between the matched cohorts. Multivariate analysis confirmed that MTVOs were not associated with poor functional outcome, symptomatic intracranial hemorrhage, or longer procedure time. CONCLUSION Compared with EVT for single vessel occlusions, EVT in appropriately selected patients with MTVOs has a similar efficacy and safety profile.
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Affiliation(s)
- Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Sheila Eshraghi
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali M Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Feras Akbik
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Makenna Ash
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alice Hsu
- Emory University School of Medicine, Atlanta, Georgia, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joon-Tae Kim
- Chonnam National University, Gwangju, Korea (the Republic of)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar Rai
- Department of Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Robert M Starke
- Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Amir Shaban
- Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | | | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Joshua W Osbun
- Department of Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville, VA, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Richard Williamson
- Department of Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Saad HW, Eshraghi S, Howard BM, Buster BE, Akbik F, Maier I, Goyal N, Starke RM, Rai A, Fargen KM, Psychogios M, Jabbour P, DeLeacy R, Dumont TM, Kan P, Arthur AS, Crosa R, Gory B, Spiotta AM, Alawieh AM, Grossberg JA. 476 Technical and Clinical Outcomes in Concurrent Multivessel Occlusions Treated With Mechanical Thrombectomy: Insights from the STAR Collaboration. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_476] [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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5
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Steed T, Hsu A, Akbik F, Luu K, Samuels OB, Sadan O, Grossberg JA. 383 Artificial Neural Network Modeling of Outcomes in Subarachnoid Hemorrhage. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_383] [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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6
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Sathialingam E, Cowdrick KR, Liew AY, Fang Z, Lee SY, McCracken CE, Akbik F, Samuels OB, Kandiah P, Sadan O, Buckley EM. Microvascular cerebral blood flow response to intrathecal nicardipine is associated with delayed cerebral ischemia. Front Neurol 2023; 14:1052232. [PMID: 37006474 PMCID: PMC10064128 DOI: 10.3389/fneur.2023.1052232] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Accepted: 02/06/2023] [Indexed: 03/19/2023] Open
Abstract
One of the common complications of non-traumatic subarachnoid hemorrhage (SAH) is delayed cerebral ischemia (DCI). Intrathecal (IT) administration of nicardipine, a calcium channel blocker (CCB), upon detection of large-artery cerebral vasospasm holds promise as a treatment that reduces the incidence of DCI. In this observational study, we prospectively employed a non-invasive optical modality called diffuse correlation spectroscopy (DCS) to quantify the acute microvascular cerebral blood flow (CBF) response to IT nicardipine (up to 90 min) in 20 patients with medium-high grade non-traumatic SAH. On average, CBF increased significantly with time post-administration. However, the CBF response was heterogeneous across subjects. A latent class mixture model was able to classify 19 out of 20 patients into two distinct classes of CBF response: patients in Class 1 (n = 6) showed no significant change in CBF, while patients in Class 2 (n = 13) showed a pronounced increase in CBF in response to nicardipine. The incidence of DCI was 5 out of 6 in Class 1 and 1 out of 13 in Class 2 (p < 0.001). These results suggest that the acute (<90 min) DCS-measured CBF response to IT nicardipine is associated with intermediate-term (up to 3 weeks) development of DCI.
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Affiliation(s)
- Eashani Sathialingam
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Kyle R. Cowdrick
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Amanda Y. Liew
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Zhou Fang
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
| | - Seung Yup Lee
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Electrical and Computer Engineering, Kennesaw State University, Marietta, GA, United States
| | - Courtney E. McCracken
- Center for Research and Evaluation, Kaiser Permanente Georgia, Atlanta, GA, United States
| | - Feras Akbik
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Owen B. Samuels
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Prem Kandiah
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Ofer Sadan
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA, United States
| | - Erin M. Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Emory University, Atlanta, GA, United States
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, United States
- Children's Research Scholar, Children's Healthcare of Atlanta, Atlanta, GA, United States
- *Correspondence: Erin M. Buckley
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7
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Sathialingam E, Cowdrick K, Urner T, Liew A, Akbik F, Samuels O, Kandiah P, Buckley E, Sadan O. 528: CEREBRAL BLOOD FLOW MONITORING PREDICTS RESPONSE TO INTRATHECAL NICARDIPINE TREATMENT FOR VASOSPASM. Crit Care Med 2023. [DOI: 10.1097/01.ccm.0000907840.98411.05] [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: 12/23/2022]
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8
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Akbik F, Konan HD, Williams KP, Ermias LM, Shi Y, Takieddin O, Grossberg JA, Howard BM, Tong F, Cawley CM, Mei Y, Samuels OB, Sadan O. Cannabis Use Is Not Associated With Aneurysmal Subarachnoid Hemorrhage Complications or Outcomes. Stroke 2022; 53:e375-e376. [PMID: 35730458 DOI: 10.1161/strokeaha.122.038951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Feras Akbik
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA. (F.A., O.T., O.S.)
| | | | | | | | - Yuyang Shi
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta (Y.S., Y.M.)
| | - Obai Takieddin
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA. (F.A., O.T., O.S.)
| | - Jonathan A Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - Frank Tong
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - Yajun Mei
- H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta (Y.S., Y.M.)
| | - Owen B Samuels
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA. (J.A.G., B.M.H., F.T., C.M.C., O.B.S.)
| | - Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA. (F.A., O.T., O.S.)
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Sadan O, Akbik F. Treating Delayed Cerebral Ischemia: Should We Focus on Blood Pressure or Vasodilatation? Stroke 2022; 53:2617-2619. [DOI: 10.1161/strokeaha.122.039800] [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: 11/16/2022]
Affiliation(s)
- Ofer Sadan
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA
| | - Feras Akbik
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, Emory University School of Medicine, Atlanta, GA
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10
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Akbik F, Yang C, Howard BM, Grossberg JA, Danyluk L, Martin KS, Alawieh A, Rindler RS, Tong FC, Barrow DL, Cawley CM, Samuels OB, Sadan O. Delayed Presentations and Worse Outcomes After Aneurysmal Subarachnoid Hemorrhage in the Early COVID-19 Era. Neurosurgery 2022; 91:66-71. [DOI: 10.1227/neu.0000000000001925] [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] [Received: 06/16/2021] [Accepted: 12/24/2021] [Indexed: 11/19/2022] Open
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11
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Affiliation(s)
- Feras Akbik
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
| | - Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, GA
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12
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Akbik F, Pimentel-Farias C, Press DA, Foster NE, Luu K, Williams MG, Andea SG, Kyei RK, Wetsel GM, Grossberg JA, Howard BM, Tong F, Cawley CM, Samuels OB, Sadan O. Diffuse Angiogram-Negative Subarachnoid Hemorrhage is Associated with an Intermediate Clinical Course. Neurocrit Care 2021; 36:1002-1010. [PMID: 34932193 DOI: 10.1007/s12028-021-01413-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 08/24/2021] [Accepted: 11/23/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The cerebral angiography result is negative for an underlying vascular lesion in 15-20% of patients with nontraumatic subarachnoid hemorrhage (SAH). Patients with angiogram-negative SAH include those with perimesencephalic SAH and diffuse SAH. Consensus suggests that perimesencephalic SAH confers a more favorable prognosis than diffuse SAH. Limited data exist to contextualize the clinical course and prognosis of diffuse SAH in relation to aneurysmal SAH in terms of critical care complications, neurologic complications, and functional outcomes. Here we compare the clinical course and functional outcomes of patients with perimesencephalic SAH, diffuse SAH, and aneurysmal SAH to better characterize the prognostic implications of each SAH subtype. METHODS We conducted a retrospective cohort study that included all patients with nontraumatic SAH admitted to a tertiary care referral center between January 1, 2012, and December 31, 2017. Bleed patterns were radiographically adjudicated, and patients were assigned to three groups: perimesencephalic SAH, diffuse SAH, and aneurysmal SAH. Patient demographics, complications, and clinical outcomes were reported and compared. RESULTS Eighty-six patients with perimesencephalic SAH, 174 with diffuse SAH, and 998 with aneurysmal SAH presented during the study period. Patients with aneurysmal SAH were significantly more likely to be female, White, and active smokers. There were no significant differences between patients with diffuse SAH and perimesencephalic SAH patterns. Critical care complications were compared across all three groups, with significant between-group differences in hypotension and shock (3.5% vs. 16.1% vs. 38.4% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01) and endotracheal intubation (0% vs. 26.4% vs. 48.8% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.01). Similar trends were noted with long-term supportive care with tracheostomy and gastrostomy tubes and length of stay. Cerebrospinal fluid diversion was increasingly required across bleed types (9.3% vs. 54.6% vs. 76.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively, p < 0.001). Vasospasm and delayed cerebral ischemia were comparable between perimesencephalic SAH and diffuse SAH but significantly lower than aneurysmal SAH. Patients with diffuse SAH had intermediate functional outcomes, with significant rates of nonhome discharge (23.0%) and poor functional status on discharge (26.4%), significantly higher than patients with perimesencephalic SAH and lower than patients with aneurysmal SAH. Diffuse SAH similarly conferred an intermediate rate of good functional outcomes at 1-6 months post discharge (92.3% vs. 78.6% vs. 47.3% for perimesencephalic SAH vs. diffuse SAH vs. aneurysmal SAH, respectively; p < 0.016). CONCLUSIONS We confirm the consensus data that perimesencephalic SAH is associated with a more benign clinical course but demonstrate that diffuse SAH confers an intermediate prognosis, more malignant than perimesencephalic SAH but not as morbid as aneurysmal SAH. These results highlight the significant morbidity associated with diffuse SAH and emphasize need for vigilance in the acute care of these patients. These patients will likely benefit from continued high-acuity observation and potential support to avert significant risk of morbidity and neurologic compromise.
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Affiliation(s)
- Feras Akbik
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA. .,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.
| | - Cederic Pimentel-Farias
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Di'Jonai A Press
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Niara E Foster
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Kevin Luu
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Merin G Williams
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Sena G Andea
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Regina K Kyei
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Grace M Wetsel
- Emory University, Atlanta, GA, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - Brian M Howard
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - Frank Tong
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - C Michael Cawley
- Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA.,Department of Neurosurgery, Emory University Hospital and Emory University School of Medicine, Atlanta, GA, USA
| | - Owen B Samuels
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
| | - Ofer Sadan
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, 30322, USA.,Neuroscience Intensive Care Unit, Emory Healthcare, Atlanta, GA, USA
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13
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Akbik F, Alawieh A, Dimisko L, Howard BM, Cawley CM, Tong FC, Nahab F, Samuels OB, Maier I, Feng W, Goyal N, Starke RM, Rai A, Fargen KM, Psychogios MN, Jabbour P, De Leacy R, Keyrouz SG, Dumont TM, Kan P, Liman J, Arthur AS, Wolfe SQ, Mocco J, Crosa RJ, Fox WC, Gory B, Spiotta AM, Grossberg JA. Bridging thrombolysis in atrial fibrillation stroke is associated with increased hemorrhagic complications without improved outcomes. J Neurointerv Surg 2021; 14:979-984. [PMID: 34819345 DOI: 10.1136/neurintsurg-2021-017954] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 09/27/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Atrial fibrillation (AF) associated ischemic stroke is associated with worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Conversely, AF is not associated with hemorrhagic complications or functional outcomes in patients undergoing mechanical thrombectomy (MT). This differential effect of MT and IVT in AF associated stroke raises the question of whether bridging thrombolysis increases hemorrhagic complications in AF patients undergoing MT. METHODS This international cohort study of 22 comprehensive stroke centers analyzed patients with large vessel occlusion (LVO) undergoing MT between June 1, 2015 and December 31, 2020. Patients were divided into four groups based on comorbid AF and IVT exposure. Baseline patient characteristics, complications, and outcomes were reported and compared. RESULTS 6461 patients underwent MT for LVO. 2311 (35.8%) patients had comorbid AF. In non-AF patients, bridging therapy improved the odds of good 90 day functional outcomes (adjusted OR (aOR) 1.29, 95% CI 1.03 to 1.60, p=0.025) and did not increase hemorrhagic complications. In AF patients, bridging therapy led to significant increases in symptomatic intracranial hemorrhage and parenchymal hematoma type 2 (aOR 1.66, 1.07 to 2.57, p=0.024) without any benefit in 90 day functional outcomes. Similar findings were noted in a separate propensity score analysis. CONCLUSION In this large thrombectomy registry, AF patients exposed to IVT before MT had increased hemorrhagic complications without improved functional outcomes, in contrast with non-AF patients. Prospective trials are warranted to assess whether AF patients represent a subgroup of LVO patients who may benefit from a direct to thrombectomy approach at thrombectomy capable centers.
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Affiliation(s)
- Feras Akbik
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.,Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA.,Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Laurie Dimisko
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Frank C Tong
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Fadi Nahab
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Owen B Samuels
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Wuwei Feng
- Neurology, Duke University Medical Center, Durham, North Carolina, USA
| | - Nitin Goyal
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Robert M Starke
- Neurosurgery and Radiology, University of Miami, Miller School of Medicine, Miami, Florida, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Reade De Leacy
- Neurosurgery, The Mount Sinai Health System, New York, New York, USA
| | - Saleh G Keyrouz
- Department of Neurology, Washington University at St. Louis, St Louis, Missouri, USA
| | - Travis M Dumont
- Surgery, Division of Neurosurgery, Banner University of Arizona Medical Center, Tucson, Arizona, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Jan Liman
- Neurology, University Medical Center, Göttingen, Germany
| | - Adam S Arthur
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - J Mocco
- Neurosurgery, The Mount Sinai Health System, New York, New York, USA
| | | | - W Christopher Fox
- Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France.,INSERM, IADI, Université de Lorraine, Nancy, France
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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14
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Akbik F, Waddel H, Jaja BNR, Macdonald RL, Moore R, Samuels OB, Sadan O. Nicardipine Prolonged Release Implants for Prevention of Delayed Cerebral Ischemia after Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis. J Stroke Cerebrovasc Dis 2021; 30:106020. [PMID: 34365121 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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: 04/27/2021] [Revised: 07/12/2021] [Accepted: 07/18/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES A paucity of treatments to prevent delayed cerebral ischemia (DCI) has stymied recovery after aneurysmal subarachnoid hemorrhage (aSAH). Nicardipine has long been recognized as a potent cerebrovascular vasodilator with a history off-label use to prevent vasospasm and DCI. Multiple centers have developed nicardipine prolonged release implants (NPRI) that are directly applied during clip ligation to locally deliver nicardipine throughout the vasospasm window. Here we perform a systematic review and meta-analysis to assess whether NPRI confers protection against DCI and improves functional outcomes after aSAH. MATERIALS AND METHODS A systematic search of PubMed, Ovid Embase, and Cochrane databases was performed for studies reporting the use of NPRI after aSAH published after January 1, 1980. We included all studies assessing the association of NPRI with DCI and or functional outcomes. Findings from studies with control arms were analyzed using a random effects model. A separate network meta-analysis was performed, including controlled NPRI studies, single-arm NPRI reports, and the control-arms of modern aSAH randomized clinical trials as additional comparators. RESULTS The search identified 214 unique citations. Three studies with 284 patients met criteria for the random effects model. The pooled summary odds ratio for the association of NPRI and DCI was 0.21 (95% CI 0.09-0.49, p = 0.0002) with no difference in functional outcomes (OR 1.80, 95% CI 0.63 - 5.16, p = 0.28). 10 studies of 866 patients met criteria for the network meta-analysis. The pooled summary odds ratio for the association of NPRI and DCI was 0.30 (95% CI 0.13-0.89,p = 0.017) with a trend towards improved functional outcomes (OR 1.68, 0.63 - 4.13 95% CI, p = 0.101). CONCLUSIONS In these meta-analyses, NPRI decreases the incidence of DCI with a non-significant trend towards improvement in functional outcomes. Randomized trials on the role of intrathecal calcium channel blockers are warranted to evaluate these observations in a prospective manner.
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Affiliation(s)
- Feras Akbik
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA.
| | - Hannah Waddel
- Department of Biostatistics and Bioinformatics, Biostatistics Collaboration Core, Emory University, Atlanta, GA, USA.
| | | | - R Loch Macdonald
- Department of Neurosurgery, University of California, San Francisco, Fresno, CA, USA.
| | - Renee Moore
- Department of Biostatistics and Bioinformatics, Biostatistics Collaboration Core, Emory University, Atlanta, GA, USA.
| | - Owen B Samuels
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA.
| | - Ofer Sadan
- Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, 1364 Clifton Rd NE, Atlanta, GA, USA
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15
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Akbik F, Xu H, Xian Y, Shah S, Smith EE, Bhatt DL, Matsouaka RA, Fonarow GC, Schwamm LH. Trends in Reperfusion Therapy for In-Hospital Ischemic Stroke in the Endovascular Therapy Era. JAMA Neurol 2021; 77:1486-1495. [PMID: 32955582 DOI: 10.1001/jamaneurol.2020.3362] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance A significant proportion of acute ischemic strokes occur while patients are hospitalized. Limited contemporary data exist on the utilization rates of intravenous thrombolysis or endovascular therapy for in-hospital stroke. Objective To use a national registry to examine temporal trends in the use of intravenous and endovascular reperfusion therapies for treatment of in-hospital stroke. Design, Setting, and Participants This retrospective cohort study analyzed data from 267 956 patients who underwent reperfusion therapy for stroke with in-hospital or out-of-hospital onset reported in the Get With the Guidelines-Stroke national registry from January 2008 to September 2018. Exposures In-hospital onset vs out-of-hospital onset of stroke symptoms. Main Outcomes and Measures Temporal trends in the use of reperfusion therapy, process measures of quality, and the association between functional outcomes and key patient characteristics, comorbidities, and treatments. Results Of 67 493 patients with in-hospital stroke onset, this study observed increased rates of vascular risk factors (standardized mean difference >10%) but no significant differences in age or sex in patients undergoing intravenous thrombolysis only (mean [interquartile range {IQR}] age, 72 [80-62] y; 53.2% female) or those undergoing endovascular therapy (mean [IQR] age, 69 [59-79] y; 49.8% female). Of these patients, 10 481 (15.5%) received intravenous thrombolysis and 2494 (3.7%) underwent endovascular therapy. Compared with 2008, in 2018 the proportion of in-hospital stroke among all stroke hospital discharges was higher (3.5% vs 2.7%; P < .001), as was use of intravenous thrombolysis (19.1% vs 9.1%; P < .001) and endovascular therapy (6.4% vs 2.5%; P < .001) in patients with in-hospital stroke, with a significant increase in endovascular therapy in mid-2015 (P < .001). Compared with patients who received intravenous thrombolysis for out-of-hospital stroke onset, those with in-hospital onset were associated with longer median (IQR) times from stroke recognition to cranial imaging (33 [18-60] vs 16 [9-26] minutes; P < .001) and to thrombolysis bolus (81 [52-125] vs 60 [45-84] minutes; P < .001). In adjusted analyses, patients with in-hospital stroke onset who were treated with intravenous thrombolysis were less likely to ambulate independently at discharge (adjusted odds ratio, 0.78; 95% CI, 0.74-0.82; P < .001) and were more likely to die or to be discharged to hospice (adjusted odds ratio, 1.39; 95% CI, 1.29-1.50; P < .001) than patients with out-of-hospital onset who also received intravenous thrombolysis treatment. Comparisons among patients treated with endovascular therapy yielded similar findings. Conclusions and Relevance In this cohort study, in-hospital stroke onset was increasingly reported and treated with reperfusion therapy. Compared with out-of-hospital stroke onset, in-hospital onset was associated with longer delays to reperfusion and worse functional outcomes, highlighting opportunities to further care for patients with in-hospital stroke onset.
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Affiliation(s)
- Feras Akbik
- Department of Neurology, Neurosurgery, Emory University Hospital, Atlanta, Georgia
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, North Carolina
| | - Ying Xian
- Duke Clinical Research Institute, Durham, North Carolina
| | - Shreyansh Shah
- Duke Clinical Research Institute, Durham, North Carolina
| | - Eric E Smith
- Department of Neurology, University of Calgary, Calgary, Alberta, Canada
| | - Deepak L Bhatt
- Brigham and Women's Hospital Heart & Vascular Center.,Harvard Medical School, Boston, Massachusetts
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Durham, North Carolina.,Department of Neurology, Duke University, Durham, North Carolina
| | - Gregg C Fonarow
- Department of Cardiology, University of California, Los Angeles Medical Center, Los Angeles
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
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16
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Sadan O, Waddel H, Moore R, Feng C, Mei Y, Pearce D, Kraft J, Pimentel C, Mathew S, Akbik F, Ameli P, Taylor A, Danyluk L, Martin KS, Garner K, Kolenda J, Pujari A, Asbury W, Jaja BNR, Macdonald RL, Cawley CM, Barrow DL, Samuels O. Does intrathecal nicardipine for cerebral vasospasm following subarachnoid hemorrhage correlate with reduced delayed cerebral ischemia? A retrospective propensity score-based analysis. J Neurosurg 2021; 136:115-124. [PMID: 34087804 DOI: 10.3171/2020.12.jns203673] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 12/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cerebral vasospasm and delayed cerebral ischemia (DCI) contribute to poor outcome following subarachnoid hemorrhage (SAH). With the paucity of effective treatments, the authors describe their experience with intrathecal (IT) nicardipine for this indication. METHODS Patients admitted to the Emory University Hospital neuroscience ICU between 2012 and 2017 with nontraumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Using a propensity-score model, this patient cohort was compared to patients in the Subarachnoid Hemorrhage International Trialists (SAHIT) repository who did not receive IT nicardipine. The primary outcome was DCI. Secondary outcomes were long-term functional outcome and adverse events. RESULTS The analysis included 1351 patients, 422 of whom were diagnosed with cerebral vasospasm and treated with IT nicardipine. When compared with patients with no vasospasm (n = 859), the treated group was significantly younger (mean age 51.1 ± 12.4 years vs 56.7 ± 14.1 years, p < 0.001), had a higher World Federation of Neurosurgical Societies score and modified Fisher grade, and were more likely to undergo clipping of the ruptured aneurysm as compared to endovascular treatment (30.3% vs 11.3%, p < 0.001). Treatment with IT nicardipine decreased the daily mean transcranial Doppler velocities in 77.3% of the treated patients. When compared to patients not receiving IT nicardipine, treatment was not associated with an increased rate of bacterial ventriculitis (3.1% vs 2.7%, p > 0.1), yet higher rates of ventriculoperitoneal shunting were noted (19.9% vs 8.8%, p < 0.01). In a propensity score comparison to the SAHIT database, the odds ratio (OR) to develop DCI with IT nicardipine treatment was 0.61 (95% confidence interval [CI] 0.44-0.84), and the OR to have a favorable functional outcome (modified Rankin Scale score ≤ 2) was 2.17 (95% CI 1.61-2.91). CONCLUSIONS IT nicardipine was associated with improved outcome and reduced DCI compared with propensity-matched controls. There was an increased need for permanent CSF diversion but no other safety issues. These data should be considered when selecting medications and treatments to study in future randomized controlled clinical trials for SAH.
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Affiliation(s)
- Ofer Sadan
- 1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Hannah Waddel
- 2Department of Biostatistics and Bioinformatics, Biostatistics Collaboration Core, Emory University, Atlanta, Georgia
| | - Reneé Moore
- 2Department of Biostatistics and Bioinformatics, Biostatistics Collaboration Core, Emory University, Atlanta, Georgia
| | - Chen Feng
- 3H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - Yajun Mei
- 3H. Milton Stewart School of Industrial and Systems Engineering, Georgia Institute of Technology, Atlanta, Georgia
| | - David Pearce
- 1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Jacqueline Kraft
- 1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Cederic Pimentel
- 1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Subin Mathew
- 1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Feras Akbik
- 1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Pouya Ameli
- 1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia
| | - Alexis Taylor
- 1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia
| | | | | | | | | | - Amit Pujari
- 5Emory University School of Medicine, Atlanta, Georgia
| | - William Asbury
- 6Department of Clinical Pharmacy, Emory Healthcare, Atlanta, Georgia
| | - Blessing N R Jaja
- 7Department of Genetics and Development, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - R Loch Macdonald
- 8Department of Neurological Surgery, UCSF Fresno, California; and
| | - C Michael Cawley
- 9Department of Neurosurgery, Emory University Hospital and School of Medicine, Atlanta, Georgia
| | - Daniel L Barrow
- 9Department of Neurosurgery, Emory University Hospital and School of Medicine, Atlanta, Georgia
| | - Owen Samuels
- 1Department of Neurology and Neurosurgery, Division of Neurocritical Care, Emory University School of Medicine, Atlanta, Georgia
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17
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Akbik F, Alawieh A, Cawley CM, Howard B, Tong F, Nahab FB, Saad H, Dimisko L, Mustroph CM, Pradilla G, Maier I, Goyal N, Starke R, rai A, Fargen K, Psychogios M, Jabbour PM, De Leacy RA, Keyrouz SG, Dumont T, Kan P, Arthur AS, Crosa R, Gory B, Spiotta AM, Grossberg JA. Abstract P20: Bridging Therapy Increases Hemorrhagic Complications Without Improving Functional Outcomes in Atrial Fibrillation Associated Stroke. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
*
on behalf of the Stroke Thrombectomy and Aneurysm Registry (STAR) Collaborators
Introduction:
Intravenous thrombolysis complications are enriched in AF associated stroke, as these patients have worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications. These data suggest that AF patients may be at particularly high risk for complications of bridging therapy for large vessel occlusions treated with mechanical thrombectomy (MT). Here we determine whether clinical outcomes differ in AF associated stroke treated with MT and bridging therapy.
Methods:
We performed a retrospective cohort study of the Stroke and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4,169 patients who underwent MT for an anterior circulation stroke, 1,517 (36.4 %) of which had comorbid AF. Prospectively defined baseline characteristics and clinical outcomes were compared.
Results:
Hemorrhagic complications after MT were similar in patients with or without AF. In patients without AF, bridging therapy improved 90-day outcomes (aOR 1.32, 1.02-1.74, p<0.05) without increasing hemorrhagic complications. In patients with AF, bridging therapy independently predicted hemorrhagic complications in AF patients (aOR 2.08, 1.06-4.06, p<0.033) without improving functional outcomes.
Conclusions:
Bridging therapy in AF patients undergoing thrombectomy independently increased the odds of intracranial hemorrhage and did not improve functional outcomes. AF patients may represent a high-risk subgroup for thrombolytic complications. Randomized trials are warranted to determine whether patients with AF associated stroke may benefit by deferring bridging therapy at thrombectomy-capable centers.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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18
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Grossberg J, Eshraghi S, Howard B, Buster B, Akbik F, Maier I, Goyal N, Starke R, rai A, Fargen K, Psychogios M, Jabbour PM, De Leacy RA, Keyrouz SG, Dumont T, Kan P, Arthur AS, Crosa R, Gory B, Spiotta AM. Abstract P479: A Tale of Two Clots: A Multicenter Study on Multiple Territory Thrombectomy. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p479] [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 benefit of thrombectomy for large vessel occlusion (LVO) is well proven. There is minimal data on concurrent thrombectomy for multi-territory occlusions.
Methods:
We reviewed the STAR registry from 2015-8 for patients treated with either right and left sided thrombectomy or anterior and posterior circulation thrombectomy at 15 comprehensive stroke centers.
Results:
There were 4966 patients in the study period who had completed outcome data and LVO thrombectomy. 38 (0.8%) underwent endovascular thrombectomy for multi-territory occlusions. 26% had bilateral occlusions and 74% had anterior and posterior circulation occlusions. Among the 38, 50% were female, 49% were white, and 91% had a prestroke mRS<3. 95% had an ASPECT score of >6 and 55% received iv t-pa. 83% of patients had successful recanalization (TICI 2B/3) for both territories. The overall complication rate was 15%. 5% of patients had sICH or PH2. 26% of patients had a 90day mRS<2. When controlling for admission NIHSS, baseline mRS, age, comorbidities, and ASPECT in logistic regression analysis, multiple territory compared to single territory did not predict increased risk of sICH (p=0.73, 95%CI: 0.2-3.3), rate of TICI2B/3 (OR for TICI2B+: 0.93, p=0.88, CI: 0.38 - 2.3), or worse outcome (OR for good outcome: 0.6, p=.212, CI: 0.3-1.3). On linear regression analysis for attempts and procedure time, multiple territory thrombectomy required significantly higher number of attempts (Coefficient +1.8, p=0.001) without a significantly longer procedure time (Coefficient = +10, p=0.244).
Conclusion:
With similar selection to single territory LVOs, good outcome can be achieved in multi-territory infarction with reasonable procedure time and no additional risk of hemorrhage or poor outcome.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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19
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Akbik F, Alawieh A, Cawley CM, Howard BM, Tong FC, Nahab F, Saad H, Dimisko L, Mustroph C, Samuels OB, Pradilla G, Maier I, Goyal N, Starke RM, Rai A, Fargen KM, Psychogios MN, Jabbour P, De Leacy R, Giles J, Dumont TM, Kan P, Arthur AS, Crosa RJ, Gory B, Spiotta AM, Grossberg JA. Differential effect of mechanical thrombectomy and intravenous thrombolysis in atrial fibrillation associated stroke. J Neurointerv Surg 2020; 13:883-888. [PMID: 33318066 DOI: 10.1136/neurintsurg-2020-016720] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/17/2020] [Accepted: 10/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT). OBJECTIVE To determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT. METHODS We performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared. RESULTS AF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (p<0.01). AF had no effect on intracranial hemorrhage (aOR 0.69, 95% CI 0.43 to 1.12) or 90-day functional outcomes (aOR 1.17, 95% CI 0.91 to 1.50) after MT, although patients with AF were less likely to receive IVT (46% vs 54%, p<0.0001). CONCLUSIONS In patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.
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Affiliation(s)
- Feras Akbik
- Department of Neurology, Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Frank C Tong
- Department of Radiology, Emory University, Altanta, Georgia, USA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | | | - Owen B Samuels
- Department of Neurology, Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami Beach, Florida, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Giles
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
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20
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Akbik F, Robertson M, Das AS, Singhal T, Lee JW, Vaitkevicius H. Correction to: The PET Sandwich: Using Serial FDG-PET Scans with Interval Burst Suppression to Assess Ictal Components of Disease. Neurocrit Care 2020; 33:330-331. [DOI: 10.1007/s12028-020-00981-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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21
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Sadan O, Feng C, Pearce DT, Kraft J, Pimentel C, Mathew S, Akbik F, Ameli PA, Taylor AM, Danyluk L, Martin KS, Garner K, Kolenda J, Pujari A, Mei Y, Asbury W, Samuels OB. Abstract 65: Intrathecal Nicardipine for Cerebral Vasospasm Post Subarachnoid Hemorrhage - A Single Center Experience. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.65] [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:
Cerebral vasospasm leading to delayed cerebral ischemia (DCI) is one of the most significant factors impacting functional outcome in patients diagnosed with non-traumatic subarachnoid hemorrhage (SAH). Effective treatment in this setting is lacking. We now report a single center retrospective cohort experience with intrathecal (IT) Nicardipine for this indication.
Methods:
All patients discharged between 2013-2017 diagnosed with non-traumatic SAH, either aneurysmal or idiopathic, were included in the analysis. Demographics, risk factors, clinical courses, radiological DCI, and functional outcomes were analyzed.
Results:
1,085 patients were admitted with aneurysmal (n=796) or idiopathic (n=289) SAH. The mean age was 54.5±14.1 and 67.7% were women. Low grade hemorrhage (WFNS 1) was found in 42.4%, medium (WFNS 2-3) in 26.9%, and high grade (WFNS 4-5) in 30.7%. Cerebral vasospasm was diagnosed in 36.6% of the patients, and 85.4% of those received IT Nicardipine (n=339). Only 8.4% of all patients required angiography to treat vasospasm. TCD data was available for 159 patients who received IT Nicardipine. Treatment reduced mean velocities in all arteries within one day by 15.4% on average (p<0.01). This reduction was sustained for the duration of treatment. Nineteen patients (1.8%) suffered from bacterial ventriculitis, and no statistically significant correlation was noted between IT treatment and infection (OR 1.06 95%CI[0.42-2.7]). The incidence of radiological DCI, identified by blinded assement of imaging, was 9.4% and clinical DCI was 5.7%. In this cohort, 65.5% had a favorable functional outcome (mRS≤2) at 90 days.
Conclusions:
In a retrospective analysis, off-label IT Nicardipine is a safe and potentially effective treatment for cerebral vasospasm and prevention of the subsequent cerebral ischemia. Being the largest of its kind, this cohort could serve as a baseline for future clinical trial designs assessing IT Nicardipine safety and efficacy in a prospective, controlled fashion.
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Affiliation(s)
- Ofer Sadan
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Chen Feng
- H. Milton Stewart Sch of Industrial and Systems Engineering, Georgia Tech, Atlanta, GA
| | - David T Pearce
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Jacqueline Kraft
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Cederic Pimentel
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Subin Mathew
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Feras Akbik
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Pouya A Ameli
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Alexis M Taylor
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Lisa Danyluk
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Kathleen S Martin
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Krista Garner
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | - Jennifer Kolenda
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
| | | | - Yajun Mei
- H. Milton Stewart Sch of Industrial and Systems Engineering, Georgia Tech, Atlanta, GA
| | | | - Owen B Samuels
- Neurology and Neurosurgery, division of Neurocritical care, Emory Univ, Atlanta, GA
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Akbik F, Xu H, Xian Y, Shah S, Smith EE, Bhatt DL, Matsouaka RA, Fonarow GC, Schwamm LH. Abstract WP46: Patient Characteristics, Quality and Outcomes After Endovascular Therapy for In-Hospital Ischemic Stroke. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp46] [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:
A significant number of acute ischemic strokes occur while patients are hospitalized for other reasons. No national data have been reported on endovascular therapy (EVT) for in-hospital onset stroke. Here we compare the patient characteristics, process measures of quality, and outcomes for in-hospital onset vs. community-onset of strokes in a large US national registry.
Methods:
We performed a retrospective cohort study of Get With The Guidelines-Stroke (GTWG-Stroke) from January 2008 to June 2018 from 2,333 participating sites that included 2,428,178 patients with acute ischemic stroke. Among 67,493 in-hospital onset strokes, 2494 (3.7%) underwent EVT. We examined the association between key patient characteristics (in-hospital onset, demographics, comorbidities, treatment with EVT) and functional outcomes using multivariable logistic regression models.
Results:
The rate of EVT increased from 2.5% in 2008 to 6.4% in 2018 (p<0.001), with a significant and sustained increase in EVT after the second quarter of 2015 (p<0.0001). Compared with patients with community-onset strokes, patients with in-hospital onset stroke had longer times to cranial imaging and arterial puncture but similar median NIHSS (16 (9 - 21) vs. 16 (10 - 21) Std Diff 1.9). Patients with in-hospital onset stroke were less likely to undergo EVT within 120 mins of symptom recognition, have symptomatic intracranial hemorrhage, or ambulate independently at discharge. They were more likely to die or be discharged to hospice.
Conclusions:
Though use of EVT in GWTG-Stroke for in-hospital stroke remains low, it more than doubled in the past decade. Compared with community onset stroke, these patients have longer intervals to CT and arterial puncture, with associated worse functional outcomes. While there may be important differences in baseline patient characteristics between the groups, efforts must still be made to shorten time to reperfusion for in-hospital strokes.
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Affiliation(s)
| | - Haolin Xu
- Duke Clinical Rsch Institute, Durham, NC
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23
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Akbik F, Xu H, Xian Y, Shah S, Smith EE, Bhatt DL, Matsouaka RA, Fonarow GC, Schwamm LH. Abstract 103: Intravenous Thrombolysis for In-Hospital Ischemic Stroke in the Endovascular Era: Findings From the National Get With the Guidelines-Stroke Registry. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.103] [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:
A significant proportion of acute ischemic strokes occur while patients are hospitalized for other reasons. Limited data exist on the utilization of intravenous alteplase (IV tPA) for in-hospital stroke, particularly in the endovascular era. We compared temporal trends of IV tPA use, patient characteristics, process measures of quality, and outcomes for in-hospital versus community onset strokes in a national registry.
Methods:
We performed a retrospective cohort study of Get With The Guidelines-Stroke (GTWG-Stroke) from January 2008 to June 2018 from 2,333 participating sites that included 2,428,178 patients with acute ischemic stroke. In-hospital onset was reported in 67,493 patients. We examined the association between stroke onset location, patient characteristics, comorbidities, treatment with IV tPA and unadjusted and adjusted functional outcomes (Table, standardized differences >10% for significance).
Results:
Of 67,493 patients with in-hospital onset stroke, 11,123 received IV tPA. The rate of IV tPA administration steadily increased, from 9.5% in 2008 to 20.7% in 2017 (p<0.001). Compared with patients with community-onset strokes who were treated with IV tPA, patients with in-hospital onset stroke had longer times to cranial imaging and administration of IV tPA. Patients with in-hospital onset stroke were less likely to be treated within 60 minutes of recognition, and at discharge, ambulate independently or go directly home. They were more likely to die or be discharged to hospice after adjusting for patient and hospital characteristics.
Conclusions:
In this national cohort, in-hospital onset strokes are increasingly treated with intravenous tPA in a period that spans the endovascular era. Compared with community-onset stroke, patients with in-hospital onset stroke had longer intervals to thrombolysis and worse outcomes. These data highlight opportunities to improve inpatient systems of stroke care further.
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Affiliation(s)
| | - Haolin Xu
- Duke Clinical Rsch Institute, Durham, NC
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24
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Singhal T, Solomon I, Akbik F, Smirnakis S, Vaitkevicius H. Correction to: Ventral striatal and septal area hypermetabolism on FDG-PET in herpes simplex viral encephalitis. J Neurovirol 2019; 26:121. [PMID: 31515701 DOI: 10.1007/s13365-019-00789-0] [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: 10/26/2022]
Abstract
The word "hypermetabolism" needs to be replaced by "hypometabolism" at only ONE place and NOT throughout the article.So the correction could be stated as:"In the case description section, the sentence "A repeat dedicatedbrain FDG-PET scan performed on day 9, under burst suppression,showed diffuse hypermetabolism with persistent relativehypermetabolism in the left ventral striatum and septalarea (Fig. 1b)."should read as"A repeat dedicatedbrain FDG-PET scan performed on day 9, under burst suppression,showed diffuse hypometabolism with persistent relativehypermetabolism in the left ventral striatum and septalarea (Fig. 1b)." At all other places, the word hypermetabolism is appropriate.
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Affiliation(s)
- T Singhal
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Building for Transformative Medicine, Room 4092, 60 Fenwood Road, Boston, MA, 02115-6128, USA.
| | - I Solomon
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - F Akbik
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Building for Transformative Medicine, Room 4092, 60 Fenwood Road, Boston, MA, 02115-6128, USA
| | - S Smirnakis
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Building for Transformative Medicine, Room 4092, 60 Fenwood Road, Boston, MA, 02115-6128, USA
| | - H Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Building for Transformative Medicine, Room 4092, 60 Fenwood Road, Boston, MA, 02115-6128, USA
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25
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Singhal T, Solomon I, Akbik F, Smirnakis S, Vaitkevicius H. Ventral striatal and septal area hypermetabolism on FDG-PET in herpes simplex viral encephalitis. J Neurovirol 2019; 26:118-120. [PMID: 31286440 DOI: 10.1007/s13365-019-00779-2] [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: 10/05/2018] [Revised: 05/07/2019] [Accepted: 06/18/2019] [Indexed: 12/01/2022]
Abstract
A 71-year-old man presented with sudden onset, generalized tonic-clonic seizures and altered mental status. Initial brain magnetic resonance imaging was normal but a brain FDG-PET scan showed hypermetabolism in the left ventral striatum and septal area. Initial cerebrospinal fluid (CSF) examination showed mildly elevated protein but herpes simplex virus (HSV) polymerase chain reaction (PCR) was negative. A repeat CSF examination performed 9 days later showed a positive HSV PCR. Histopathological and immunohistochemical examination of autopsy specimen confirmed the presence of CD45+ lymphocytes and HSV antigen, suggesting the presence of both inflammation and viral infection corresponding to PET abnormality.
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Affiliation(s)
- T Singhal
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Building for Transformative Medicine, Room 4092, 60 Fenwood Road, Boston, MA, 02115-6128, USA.
| | - I Solomon
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - F Akbik
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Building for Transformative Medicine, Room 4092, 60 Fenwood Road, Boston, MA, 02115-6128, USA
| | - S Smirnakis
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Building for Transformative Medicine, Room 4092, 60 Fenwood Road, Boston, MA, 02115-6128, USA
| | - H Vaitkevicius
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Building for Transformative Medicine, Room 4092, 60 Fenwood Road, Boston, MA, 02115-6128, USA
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26
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Raymond SB, Akbik F, Stapleton CJ, Mehta BP, Chandra RV, Gonzalez RG, Rabinov JD, Schwamm LH, Patel AB, Hirsch JA, Leslie-Mazwi TM. Protocols for Endovascular Stroke Treatment Diminish the Weekend Effect Through Improvements in Off-Hours Care. Front Neurol 2018; 9:1106. [PMID: 30619062 PMCID: PMC6305592 DOI: 10.3389/fneur.2018.01106] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/03/2018] [Indexed: 12/04/2022] Open
Abstract
Introduction: The weekend effect is a well-recognized phenomenon in which patient outcomes worsen for acute strokes presenting outside routine business hours. This is attributed to non-uniform availability of services throughout the week and evenings and, though described for intravenous thrombolysis candidates, is poorly understood for endovascular stroke care. We evaluated the impact of institutional protocols on the weekend effect, and the speed and outcome of endovascular therapy as a function of time of presentation. Method: This study assesses a prospective observational cohort of 129 consecutive patients. Patients were grouped based on the time of presentation during regular work hours (Monday through Friday, 07:00–19:00 h) vs. off-hours (overnight 19:00–07:00 h and weekends) and assessed for treatment latency and outcome. Results: Treatment latencies did not depend on the time of presentation. The door to imaging interval was comparable during regular and off-hours (median time 21 vs. 19 min, respectively, p < 0.50). Imaging to groin puncture was comparable (71 vs. 71 min, p < 1.0), as were angiographic and functional outcomes. Additionally, treatment intervals decreased with increased protocol experience; door-to-puncture interval significantly decreased from the first to the fourth quarters of the study period (115 vs. 94 min, respectively, p < 0.006), with the effect primarily seen during off-hours with a 28% reduction in median door-to-puncture times. Conclusions: Institutional protocols help diminish the weekend effect in endovascular stroke treatment. This is driven largely by improvement in off-hours performance, with protocol adherence leading to further decreases in treatment intervals over time.
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Affiliation(s)
- Scott B Raymond
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, United States.,Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Feras Akbik
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | | | - Brijesh P Mehta
- Department of Neuroendovascular Surgery, Memorial Healthcare System, Hollywood, FL, United States
| | - Ronil V Chandra
- Interventional Neuroradiology, Monash Health, Melbourne, VIC, Australia
| | - Roberto G Gonzalez
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, United States.,Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, United States.,Department of Radiology, Massachusetts General Hospital, Boston, MA, United States.,Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Boston, MA, United States
| | - Thabele M Leslie-Mazwi
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, United States.,Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
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27
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Izzy S, Rubin DB, Ahmed FS, Akbik F, Renault S, Sylvester KW, Vaitkevicius H, Smallwood JA, Givertz MM, Feske SK. Cerebrovascular Accidents During Mechanical Circulatory Support. Stroke 2018; 49:1197-1203. [DOI: 10.1161/strokeaha.117.020002] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Revised: 03/03/2018] [Accepted: 03/12/2018] [Indexed: 12/20/2022]
Affiliation(s)
- Saef Izzy
- From the Department of Neurology, Brigham and Women’s Hospital, Boston, MA (S.I., D.B.R., F.A., H.V., S.K.F.)
| | - Daniel B. Rubin
- From the Department of Neurology, Brigham and Women’s Hospital, Boston, MA (S.I., D.B.R., F.A., H.V., S.K.F.)
- Department of Neurology, Massachusetts General Hospital, Boston (D.B.R., F.A.)
| | - Firas S. Ahmed
- Department of Radiology, Columbia University Medical Center, New York, NY (F.S.A.)
| | - Feras Akbik
- From the Department of Neurology, Brigham and Women’s Hospital, Boston, MA (S.I., D.B.R., F.A., H.V., S.K.F.)
- Department of Neurology, Massachusetts General Hospital, Boston (D.B.R., F.A.)
| | | | - Katelyn W. Sylvester
- Department of Pharmacy Services, Brigham and Women’s Hospital, Boston, MA (K.W.S.)
| | - Henrikas Vaitkevicius
- From the Department of Neurology, Brigham and Women’s Hospital, Boston, MA (S.I., D.B.R., F.A., H.V., S.K.F.)
| | - Jennifer A. Smallwood
- Department of Preventative Medicine & Epidemiology, Boston University School of Medicine, MA (J.A.S.)
| | - Michael M. Givertz
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (M.M.G.)
| | - Steven K. Feske
- From the Department of Neurology, Brigham and Women’s Hospital, Boston, MA (S.I., D.B.R., F.A., H.V., S.K.F.)
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28
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Akbik F, Matiello M, Piquet A, Cho T, Cohen A, Venna N. Bibrachial plegia due to Lyme radiculopoliomyelitis-myelitis. J Neurol Sci 2017; 378:1-2. [PMID: 28566141 DOI: 10.1016/j.jns.2017.04.028] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [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: 10/26/2016] [Revised: 04/11/2017] [Accepted: 04/14/2017] [Indexed: 11/16/2022]
Abstract
Nervous system involvement occurs in up to 15% of patients with Lyme disease, most commonly manifested as cranial neuropathy, lymphocytic meningitis, and or radiculoneuritis. We describe a patient with subacute radiculopoliomyelitis-myelitis matching the selective involvement of the anterior horns and roots of the cervical spinal cord seen on MRI and on electrodiagnostic studies. We demonstrate positive CSF Lyme antibodies and document a near-complete recovery with antibiotics. This case highlights the importance of recognizing an atypical presentation of Lyme disease in the setting of initial radiculitis and or myelitis, particularly given the potential for favorable outcomes with appropriate treatment.
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Affiliation(s)
- Feras Akbik
- Massachusetts General Hospital, United States; Harvard Medical School, United States
| | - Marcelo Matiello
- Massachusetts General Hospital, United States; Harvard Medical School, United States
| | | | - Tracey Cho
- Massachusetts General Hospital, United States; Harvard Medical School, United States
| | - Adam Cohen
- Massachusetts General Hospital, United States; Harvard Medical School, United States
| | - Nagagopal Venna
- Massachusetts General Hospital, United States; Harvard Medical School, United States.
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29
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Raymond SB, Akbik F, Hirsch JA, Stapleton CJ, Gonzalez RG, Mehta BP, Rabinov JD, Patel AB, Chandra RV, Leslie-Mazwi T. Abstract WP330: Protocol Approaches Negate the “Weekend Effect” for Endovascular Stroke Treatment. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp330] [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:
Endovascular management of stroke from acute large vessel occlusion (LVO) requires complex, emergent diagnostic and therapeutic procedures. The “weekend effect” (worsened outcomes from stroke presenting on weekends or evenings) is a recognized phenomenon, attributed to non-uniform availability of services throughout the week. We assessed the impact of institutional protocols for stroke patients undergoing endovascular therapy during off hours.
Methods:
We analyzed a prospective observational stroke database for consecutive patients with anterior circulation stroke undergoing endovascular therapy between 6/2012 and 10/2015. Patients were grouped and analyzed based on day of the week and time of presentation to the emergency department. Off-hours were considered between 1900hrs and 0700hrs on weekdays and 1900hrs on Friday to 0700hrs on Mondays for weekends. Functional outcome was assessed prospectively by 3 month modified Rankin scale (mRS), dichotomized into good (mRS 0-2) versus poor (mRS 3-6).
Results:
In a cohort of 129 patients, 75 (58%) patients were treated off-hours. Patients treated off-hours demonstrated equivalent imaging to groin puncture times (78 vs 72 min, p = 0.4) and procedure durations (75 vs 68 min, p = 0.3). Reperfusion rates (TICI 2b or 3) were 68% off hours and 76% during working hours (p = 0.4). Complication rates were similar between the two groups. Outcome at 90 days was no different in the patients treated off hours, with 35 of 75 treated off-hours achieving a good outcome (mRS 0-2) compared to 22 of 54 treated during working hours (p = 0.6). With protocol adherence, temporal improvement was noted in imaging to groin times.
Discussion/Conclusions:
Following recent evidence of benefit from endovascular therapy for LVOs there is increased attention to care delivery. Our findings demonstrate that under the guidance of protocols, the “weekend effect” was negated. Evaluation and treatment times, and 90 day outcomes were equivalent in patients treated off- vs business hours, with improving treatment times as familiarity with protocols increased. Our findings highlight the importance of establishing institutional and regional protocols in the optimized management of these patients.
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Affiliation(s)
| | - Feras Akbik
- Dept of Neurology, Massachusetts General Hosp, Boston, MA
| | | | | | | | - Brijesh P Mehta
- NeuroInterventional Surgery, Memorial Healthcare System, Hollywood, FL
| | | | - Aman B Patel
- Neurosurgery, Massachusetts General Hosp, Boston, MA
| | - Ronil V Chandra
- Interventional Neuroradiology, Monash Health, Melbourne, Australia
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30
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Akbik F, Hirsch JA, Chandra RV, Frei D, Patel AB, Rabinov JD, Rost N, Schwamm LH, Leslie-Mazwi TM. Telestroke—the promise and the challenge. Part two—expansion and horizons. J Neurointerv Surg 2016; 9:361-365. [DOI: 10.1136/neurintsurg-2016-012340] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Accepted: 02/20/2016] [Indexed: 11/04/2022]
Abstract
Acute ischemic stroke remains a major public health concern, with low national treatment rates for the condition, demonstrating a disconnection between the evidence of treatment benefit and delivery of this treatment. Intravenous thrombolysis and endovascular thrombectomy are both strongly evidence supported and exquisitely time sensitive therapies. The mismatch between the distribution and incidence of stroke presentations and the availability of specialist care significantly affects access to care. Telestroke, the use of telemedicine for stroke, aims to surmount this hurdle by distributing stroke expertise more effectively, through video consultation with and examination of patients in locations removed from specialist care. This is the second of a two part review, and is focused on the challenges telestroke faces for wider adoption. It further details the anticipated evolution of this novel therapeutic platform, and the potential roles it holds in stroke prevention, ambulance based care, rehabilitation, and research.
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31
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Akbik F, Hirsch JA, Chandra RV, Frei D, Patel AB, Rabinov JD, Rost N, Schwamm LH, Leslie-Mazwi TM. Telestroke-the promise and the challenge. Part one: growth and current practice. J Neurointerv Surg 2016; 9:357-360. [PMID: 26984868 DOI: 10.1136/neurintsurg-2016-012291] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [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: 02/14/2016] [Accepted: 02/20/2016] [Indexed: 11/04/2022]
Abstract
Acute ischemic stroke remains a major public health concern, with low national treatment rates for the condition, demonstrating a disconnection between the evidence of treatment benefit and delivery of this treatment. Intravenous thrombolysis and endovascular thrombectomy are both strongly evidence supported and exquisitely time sensitive therapies. The mismatch between the distribution and incidence of stroke presentations and the availability of specialist care significantly affects access to care. Telestroke, the use of telemedicine for stroke, aims to surmount this hurdle by distributing stroke expertise more effectively, through video consultation with and examination of patients in locations removed from specialist care. This is the first of a detailed two part review, and explores the growth and current practice of telestroke, including the specific role it plays in the assessment and management of patients after emergent large vessel occlusion.
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Affiliation(s)
- F Akbik
- Department of Stroke Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - J A Hirsch
- Department of Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neuroendovascular, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - R V Chandra
- Department of Neuroendovascular, Monash University Hospital, Melbourne, Australia
| | - D Frei
- Department of NeuroInterventional Surgery, Radiology Imaging Associates/RIA Neurovascular, Swedish Medical Center, Englewood, Colorado, USA
| | - A B Patel
- Department of Neuroendovascular, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - J D Rabinov
- Department of Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neuroendovascular, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - N Rost
- Department of Stroke Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - L H Schwamm
- Department of Stroke Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - T M Leslie-Mazwi
- Department of Stroke Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Neuroendovascular, Massachusetts General Hospital, Boston, Massachusetts, USA
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32
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Abstract
OPINION STATEMENT The natural history of an acute ischemic stroke from a large vessel occlusion (LVO) is poor and has long challenged stroke therapy. Recently, endovascular therapy has demonstrated superiority to medical management in appropriately selected patients. This advance has revolutionized acute care for LVO and mandates a reevaluation of the entire chain of stroke care delivery, including patient selection, intervention, and post-procedural care. Since endovascular therapy is a therapy specifically targeting LVO, its application should be restricted to those patients only. Clinical and radiologic parameters need to be considered in patient selection. Data supports that all patients over the age of 18 years presenting with a National Institutes of Health Stroke Scale (NIHSS) of 6 or greater within 6 hours of symptom onset should be considered for emergent endovascular therapy. Radiologically, those with a LVO of the internal carotid artery (ICA) or middle cerebral artery (MCA) M1 portion, intermediate or good collaterals and without large established infarct should be considered endovascular candidates. Selection beyond these parameters remains an open question and is being actively evaluated. In all cases, revascularization should be attempted with a new generation device (stentriever or direct aspiration), as these techniques are most likely to deliver adequate reperfusion. Post-revascularization, patients are closely monitored in an intensive care setting followed by discharge to rehabilitation, if required, or directly home. Patients should be evaluated in delayed fashion to assess recovery (typically at 3 months post-treatment). Ultimately, the poor natural history of ischemic stroke from LVO and the potential significant benefit from endovascular therapy over medical management alone necessitate a national response to ensure we identify and treat all eligible patients as rapidly and effectively as possible.
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Affiliation(s)
- Feras Akbik
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua A Hirsch
- Neuroendovascular Service, Massachusetts General Hospital, Boston, MA, 02114, USA
| | - Pedro Telles Cougo-Pinto
- Department of Neurosciences and Behavior Sciences, Ribeirão Preto Medical School, Ribeirão Preto, SP, Brazil
| | - Ronil V Chandra
- Interventional Neuroradiology, Monash Health, Monash University, Melbourne, Australia
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Thabele Leslie-Mazwi
- Neuroendovascular Service, Massachusetts General Hospital, Boston, MA, 02114, USA.
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Akbik F. Dr. David Rimm is interviewed by Feras Akbik. Yale J Biol Med 2007; 80:183-5. [PMID: 18449386 PMCID: PMC2347361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Dr. David Rimm, MD PhD, is a professor of Pathology at the Yale University School of Medicine specializing in developing quantitative, diagnostic techniques. His lab recently engineered a fluorescence-based algorithm, Automated Quantitative Analysis (AQUA), to analyze tissue microarrays in the hope of moving toward personalized medicine and diagnoses.
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Muthuswamy PP, Akbik F, Franklin C, Spigos D, Barker WL. Management of major or massive hemoptysis in active pulmonary tuberculosis by bronchial arterial embolization. Chest 1987; 92:77-82. [PMID: 2439259 DOI: 10.1378/chest.92.1.77] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Management of massive hemoptysis in patients with active pulmonary tuberculosis is complicated. Transcatheter hemostatic embolization of bleeding vessels with absorbable material has been reported to be useful in controlling this problem. Twelve patients with active pulmonary tuberculosis who had major or massive hemoptysis were managed at Cook County Hospital, Chicago, from 1982 to 1986. Various methods of treatment have been evaluated. The technique of angiographic embolization and the criteria for selection of patients for its use constitute the basis of this report.
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