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Diestro JDB, Adeeb N, Musmar B, Salim H, Aslan A, Cancelliere NM, McLellan RM, Algin O, Ghozy S, Lay SV, Guenego A, Renieri L, Carnevale J, Saliou G, Mastorakos P, El Naamani K, Shotar E, Premat K, Möhlenbruch M, Kral M, Bernstock JD, Doron O, Chung C, Salem MM, Lylyk I, Foreman PM, Vachhani JA, Shaikh H, Župančić V, Hafeez MU, Catapano J, Waqas M, Ibrahim MK, Mohammed MA, Imamoglu C, Bayrak A, Rabinov JD, Ren Y, Schirmer CM, Piano M, Kühn AL, Michelozzi C, Elens S, Starke RM, Hassan AE, Ogilvie M, Nguyen A, Jones J, Brinjikji W, Nawka MT, Psychogios M, Ulfert C, Pukenas B, Burkhardt JK, Huynh T, Martinez-Gutierrez JC, Essibayi MA, Sheth SA, Spiegel G, Tawk RG, Lubicz B, Panni P, Puri AS, Pero G, Nossek E, Raz E, Killer-Oberpfalzer M, Griessenauer CJ, Asadi H, Siddiqui A, Brook AL, Altschul D, Spears J, Marotta TR, Ducruet AF, Albuquerque FC, Regenhardt RW, Stapleton CJ, Kan P, Kalousek V, Lylyk P, Boddu S, Knopman J, Aziz-Sultan MA, Tjoumakaris SI, Jabbour PM, Clarençon F, Limbucci N, Cuellar-Saenz HH, Mendes Pereira V, Patel AB, Dmytriw AA. Association of preprocedural antiplatelet use with decreased thromboembolic complications for intracranial aneurysms undergoing intrasaccular flow disruption. J Neurosurg 2024:1-8. [PMID: 38701528 DOI: 10.3171/2024.2.jns232918] [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: 12/20/2023] [Accepted: 02/23/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE This study was conducted to investigate the impact of antiplatelet administration in the periprocedural period on the occurrence of thromboembolic complications (TECs) in patients undergoing treatment using the Woven EndoBridge (WEB) device for intracranial wide-necked bifurcation aneurysms. The primary objective was to assess whether the use of antiplatelets in the pre- and postprocedural phases reduces the likelihood of developing TECs, considering various covariates. METHODS A retrospective multicenter observational study was conducted within the WorldWideWEB Consortium and comprised 38 academic centers with endovascular treatment capabilities. Univariable and multivariable logistic regression analyses were performed to determine the association between antiplatelet use and TECs, adjusting for covariates. Missing predictor data were addressed using multiple imputation. RESULTS The study comprised two cohorts: one addressing general thromboembolic events and consisting of 1412 patients, among whom 103 experienced TECs, and another focusing on symptomatic thromboembolic events and comprising 1395 patients, of whom 50 experienced symptomatic TECs. Preprocedural antiplatelet use was associated with a reduced likelihood of overall TECs (OR 0.32, 95% CI 0.19-0.53, p < 0.001) and symptomatic TECs (OR 0.49, 95% CI 0.25-0.95, p = 0.036), whereas postprocedural antiplatelet use showed no significant association with TECs. The study also revealed additional predictors of TECs, including stent use (overall: OR 4.96, 95% CI 2.38-10.3, p < 0.001; symptomatic: OR 3.24, 95% CI 1.26-8.36, p = 0.015), WEB single-layer sphere (SLS) type (overall: OR 0.18, 95% CI 0.04-0.74, p = 0.017), and posterior circulation aneurysm location (symptomatic: OR 18.43, 95% CI 1.48-230, p = 0.024). CONCLUSIONS The findings of this study suggest that the preprocedural administration of antiplatelets is associated with a reduced likelihood of TECs in patients undergoing treatment with the WEB device for wide-necked bifurcation aneurysms. However, postprocedural antiplatelet use did not show a significant impact on TEC occurrence.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Nimer Adeeb
- 2Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana
| | - Basel Musmar
- 2Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana
| | - Hamza Salim
- 2Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana
| | - Assala Aslan
- 2Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana
| | - Nicole M Cancelliere
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Rachel M McLellan
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Oktay Algin
- 4Ankara University, Medical Faculty, Department of Radiology, Ankara, Turkey
| | | | - Sovann V Lay
- 6Service de Neuroradiologie Diagnostique et Thérapeutique, Centre Hospitalier de Toulouse, Hôpital Purpan, Toulouse, France
| | - Adrien Guenego
- 7Service de Neuroradiologie Interventionnelle, Hôpital Universitaire Erasme, Bruxelles, Belgique
| | - Leonardo Renieri
- 8Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Joseph Carnevale
- 9Neurosurgery & Interventional Neuroradiology, NewYork-Presbyterian Hospital, Weill Cornell School of Medicine, New York, New York
| | - Guillaume Saliou
- 10Service de radiodiagnostic et radiologie interventionnelle, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Panagiotis Mastorakos
- 11Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kareem El Naamani
- 11Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Eimad Shotar
- 12Département de Neuroradiologie, Hôpital Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Kevin Premat
- 12Département de Neuroradiologie, Hôpital Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Markus Möhlenbruch
- 13Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Germany
| | - Michael Kral
- 14Department of Neurosurgery, Christian Doppler University Hospital and Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Joshua D Bernstock
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Omer Doron
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Charlotte Chung
- Departments of15Radiology and
- 39Neurosurgery, NYU Langone Health Center, New York, New York
| | - Mohamed M Salem
- 16Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Ivan Lylyk
- 17Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Paul M Foreman
- 18Department of Neurosurgery, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, Florida
| | - Jay A Vachhani
- 18Department of Neurosurgery, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, Florida
| | - Hamza Shaikh
- Departments of19Radiology and
- 40Neurosurgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Vedran Župančić
- 20Department of Radiology, Subdivision of Interventional Neuroradiology, Clinical Hospital Center Sisters of Mercy, Zagreb, Croatia
| | - Muhammad U Hafeez
- 21Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, Texas
| | - Joshua Catapano
- 22Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Muhammad Waqas
- 23Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Mohamed K Ibrahim
- Departments of5Radiology and
- 38Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Marwa A Mohammed
- Departments of5Radiology and
- 38Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Cetin Imamoglu
- 37Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital of the Ministry of Health, Ankara, Turkey
| | - Ahmet Bayrak
- 37Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital of the Ministry of Health, Ankara, Turkey
| | - James D Rabinov
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Yifan Ren
- 24Department of Radiology, Interventional Radiology and Neurointerventional Services, Austin Health, Melbourne, Victoria, Australia
| | - Clemens M Schirmer
- Departments of25Neurosurgery and
- 41Radiology, Geisinger Hospital, Danville, Pennsylvania
| | - Mariangela Piano
- 26Interventistica Neurovascolare, Ospedale Niguarda Cà Granda, Milano, Italy
| | - Anna L Kühn
- 27Department of Neurointerventional Radiology, UMass Memorial Hospital, Worcester, Massachusetts
| | | | - Stéphanie Elens
- 8Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | | | - Ameer E Hassan
- 30Department of Neuroscience, Valley Baptist Neuroscience Institute, Harlingen, Texas
| | - Mark Ogilvie
- Departments of31Neurosurgery and
- 42Radiology, University of Alabama at Birmingham, Alabama
| | - Anh Nguyen
- 32Department of Neuroradiology, University Hospital of Basel, Switzerland
| | - Jesse Jones
- Departments of31Neurosurgery and
- 42Radiology, University of Alabama at Birmingham, Alabama
| | - Waleed Brinjikji
- Departments of5Radiology and
- 38Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Marie T Nawka
- 33Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios Psychogios
- 32Department of Neuroradiology, University Hospital of Basel, Switzerland
| | - Christian Ulfert
- 13Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Germany
| | - Bryan Pukenas
- 16Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Jan-Karl Burkhardt
- 16Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Thien Huynh
- Departments of34Radiology and
- 43Neurosurgery, Mayo Clinic, Jacksonville, Florida
| | | | - Muhammed Amir Essibayi
- 36Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; and
| | - Sunil A Sheth
- Departments of35Radiology
- 44Neurology, and
- 45Neurosurgery, University of Texas Health Science Center at Houston, Texas
| | - Gary Spiegel
- Departments of35Radiology
- 44Neurology, and
- 45Neurosurgery, University of Texas Health Science Center at Houston, Texas
| | - Rabih G Tawk
- Departments of34Radiology and
- 43Neurosurgery, Mayo Clinic, Jacksonville, Florida
| | - Boris Lubicz
- 8Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Pietro Panni
- 28Interventistica Neurovascolare, Ospedale San Raffaele, Milano, Italy
| | - Ajit S Puri
- 27Department of Neurointerventional Radiology, UMass Memorial Hospital, Worcester, Massachusetts
| | - Guglielmo Pero
- 26Interventistica Neurovascolare, Ospedale Niguarda Cà Granda, Milano, Italy
| | - Erez Nossek
- Departments of15Radiology and
- 39Neurosurgery, NYU Langone Health Center, New York, New York
| | - Eytan Raz
- Departments of15Radiology and
- 39Neurosurgery, NYU Langone Health Center, New York, New York
| | - Monika Killer-Oberpfalzer
- 14Department of Neurosurgery, Christian Doppler University Hospital and Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- 14Department of Neurosurgery, Christian Doppler University Hospital and Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Hamed Asadi
- Departments of15Radiology and
- 39Neurosurgery, NYU Langone Health Center, New York, New York
| | - Adnan Siddiqui
- 23Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Allan L Brook
- 36Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; and
| | - David Altschul
- 36Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; and
| | - Julian Spears
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Thomas R Marotta
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Andrew F Ducruet
- 22Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Robert W Regenhardt
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Christopher J Stapleton
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Peter Kan
- 21Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, Texas
| | - Vladimir Kalousek
- 20Department of Radiology, Subdivision of Interventional Neuroradiology, Clinical Hospital Center Sisters of Mercy, Zagreb, Croatia
| | - Pedro Lylyk
- 17Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Srikanth Boddu
- 10Service de radiodiagnostic et radiologie interventionnelle, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jared Knopman
- 9Neurosurgery & Interventional Neuroradiology, NewYork-Presbyterian Hospital, Weill Cornell School of Medicine, New York, New York
| | - Mohammad A Aziz-Sultan
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | | | - Pascal M Jabbour
- 11Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Frédéric Clarençon
- 12Département de Neuroradiologie, Hôpital Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Nicola Limbucci
- 9Neurosurgery & Interventional Neuroradiology, NewYork-Presbyterian Hospital, Weill Cornell School of Medicine, New York, New York
| | - Hugo H Cuellar-Saenz
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Vitor Mendes Pereira
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Aman B Patel
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Adam A Dmytriw
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
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El Naamani K, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. The 30-Day Readmission Rate in Neurosurgery: A New Metric for Reimbursement. World Neurosurg 2024; 185:440-441. [PMID: 38494354 DOI: 10.1016/j.wneu.2024.02.116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/19/2024]
Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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El Naamani K, Musmar B, Gupta N, Ikhdour O, Abdelrazeq H, Ghanem M, Wali MH, El-Hajj J, Alhussein A, Alhussein R, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM, Herial NA. The Artificial Intelligence Revolution in Stroke Care: A Decade of Scientific Evidence in Review. World Neurosurg 2024; 184:15-22. [PMID: 38185459 DOI: 10.1016/j.wneu.2024.01.012] [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: 08/14/2023] [Revised: 01/01/2024] [Accepted: 01/02/2024] [Indexed: 01/09/2024]
Abstract
BACKGROUND The emergence of artificial intelligence (AI) has significantly influenced the diagnostic evaluation of stroke and has revolutionized acute stroke care delivery. The scientific evidence evaluating the role of AI, especially in areas of stroke treatment and rehabilitation is limited but continues to accumulate. We performed a systemic review of current scientific evidence evaluating the use of AI in stroke evaluation and care and examined the publication trends during the past decade. METHODS A systematic search of electronic databases was conducted to identify all studies published from 2012 to 2022 that incorporated AI in any aspect of stroke care. Studies not directly relevant to stroke care in the context of AI and duplicate studies were excluded. The level of evidence and publication trends were examined. RESULTS A total of 623 studies were examined, including 101 reviews (16.2%), 9 meta-analyses (1.4%), 140 original articles on AI methodology (22.5%), 2 case reports (0.3%), 2 case series (0.3%), 31 case-control studies (5%), 277 cohort studies (44.5%), 16 cross-sectional studies (2.6%), and 45 experimental studies (7.2%). The highest published area of AI in stroke was diagnosis (44.1%) and the lowest was rehabilitation (12%). A 10-year trend analysis revealed a significant increase in AI literature in stroke care. CONCLUSIONS Most research on AI is in the diagnostic area of stroke care, with a recent noteworthy trend of increased research focus on stroke treatment and rehabilitation.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Basel Musmar
- School of Medicine, An-Najah National University, Nablus, Palestine
| | - Nithin Gupta
- Jerry M. Wallace School of Osteopathic Medicine, Campbell University, Lillington, North Carolina, USA
| | - Osama Ikhdour
- School of Medicine, An-Najah National University, Nablus, Palestine
| | | | - Marc Ghanem
- Gilbert and Rose-Marie Chaghoury School of Medicine, Lebanese American University, Byblos, Lebanon
| | - Murad H Wali
- College of Public Health, Temple University, Philadelphia, Pennsylvania, USA
| | - Jad El-Hajj
- School of Medicine, St. George's University, St. George, Grenada
| | - Abdulaziz Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Reyoof Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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Musmar B, Salim H, Abdelgadir J, Spellicy S, Adeeb N, Zomorodi A, Friedman A, Awad I, Jabbour PM, Hasan DM. Antithrombotic Therapy in Cerebral Cavernous Malformations: A Systematic Review, Meta-Analysis, and Network Meta-Analysis. J Am Heart Assoc 2024; 13:e032910. [PMID: 38471833 PMCID: PMC11010038 DOI: 10.1161/jaha.123.032910] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 01/04/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Cerebral cavernous malformations are complex vascular anomalies in the central nervous system associated with a risk of intracranial hemorrhage. Traditional guidelines have been cautious about the use of antithrombotic therapy in this patient group, citing concerns about potential bleeding risk. However, recent research posits that antithrombotic therapy may actually be beneficial. This study aims to clarify the association between antithrombotic therapy, including antiplatelet and anticoagulant medications, and the risk of intracranial hemorrhage in patients with cerebral cavernous malformations. METHODS AND RESULTS A comprehensive literature search was conducted in PubMed, Web of Science, and Scopus databases, following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Nine single-center, nonrandomized cohort studies involving 2709 patients were included. Outcomes were analyzed using random-effects model, and a network meta-analysis was conducted for further insight. Of the 2709 patients studied, 388 were on antithrombotic therapy. Patients on antithrombotic therapy had a lower risk of presenting with intracranial hemorrhage (odds ratio [OR], 0.56 [95% CI, 0.45-0.7]; P<0.0001). In addition, the use of antithrombotic therapy was associated with lower risk of intracranial hemorrhage from a cerebral cavernous malformation on follow-up (OR, 0.21 [95% CI, 0.13-0.35]; P<0.0001). A network meta-analysis revealed a nonsignificant OR of 0.73 (95% CI, 0.23-2.56) when antiplatelet therapy was compared with anticoagulant therapy. CONCLUSIONS Our study explores the potential benefits of antithrombotic therapy in cerebral cavernous malformations. Although the analysis suggests a possible role for antithrombotic agents, it is critical to note that the evidence remains preliminary. Fundamental biases in study design, such as ascertainment and assignment bias, limit the weight of our conclusions. Therefore, our findings should be considered hypothesis-generating and not definitive for clinical practice change.
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Affiliation(s)
- Basel Musmar
- Department of NeurosurgeryDuke University HospitalDurhamNCUSA
| | - Hamza Salim
- Department of NeurosurgeryLouisiana State University HospitalShreveportLAUSA
| | | | | | - Nimer Adeeb
- Department of NeurosurgeryLouisiana State University HospitalShreveportLAUSA
| | - Ali Zomorodi
- Department of NeurosurgeryDuke University HospitalDurhamNCUSA
| | - Allan Friedman
- Department of NeurosurgeryDuke University HospitalDurhamNCUSA
| | - Issam Awad
- Department of NeurosurgeryThe University of Chicago MedicineChicagoILUSA
| | - Pascal M. Jabbour
- Department of NeurosurgeryThomas Jefferson University HospitalPhiladelphiaPAUSA
| | - David M. Hasan
- Department of NeurosurgeryDuke University HospitalDurhamNCUSA
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5
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Dmytriw AA, Salim H, Musmar B, Aslan A, Cancelliere NM, McLellan RM, Algin O, Ghozy S, Dibas M, Lay SV, Guenego A, Renieri L, Carnevale J, Saliou G, Mastorakos P, Naamani KE, Shotar E, Premat K, Möhlenbruch M, Kral M, Doron O, Chung C, Salem MM, Lylyk I, Foreman PM, Vachhani JA, Shaikh H, Župančić V, Hafeez MU, Catapano J, Waqas M, Tutino VM, Ibrahim MK, Mohammed MA, Imamoglu C, Bayrak A, Rabinov JD, Ren Y, Schirmer CM, Piano M, Kühn AL, Michelozzi C, Elens S, Starke RM, Hassan AE, Ogilvie M, Sporns P, Jones J, Brinjikji W, Nawka MT, Psychogios M, Ulfert C, Diestro JDB, Pukenas B, Burkhardt JK, Huynh T, Martinez-Gutierrez JC, Essibayi MA, Sheth SA, Spiegel G, Tawk R, Lubicz B, Panni P, Puri AS, Pero G, Nossek E, Raz E, Killer-Oberfalzer M, Griessenauer CJ, Asadi H, Siddiqui A, Brook AL, Altschul D, Ducruet AF, Albuquerque FC, Regenhardt RW, Stapleton CJ, Kan P, Kalousek V, Lylyk P, Boddu S, Knopman J, Aziz-Sultan MA, Tjoumakaris SI, Clarençon F, Limbucci N, Cuellar-Saenz HH, Jabbour PM, Pereira VM, Patel AB, Adeeb N. Dual Layer vs Single Layer Woven EndoBridge Device in the Treatment of Intracranial Aneurysms: A Propensity Score-Matched Analysis. Neurosurg Rev 2024; 47:116. [PMID: 38483647 DOI: 10.1007/s10143-024-02341-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 02/26/2024] [Accepted: 03/03/2024] [Indexed: 03/19/2024]
Abstract
BACKGROUND The Woven EndoBridge (WEB) devices have been used for treating wide neck bifurcation aneurysms (WNBAs) with several generational enhancements to improve clinical outcomes. The original device dual-layer (WEB DL) was replaced by a single-layer (WEB SL) device in 2013. This study aimed to compare the effectiveness and safety of these devices in managing intracranial aneurysms. METHODS A multicenter cohort study was conducted, and data from 1,289 patients with intracranial aneurysms treated with either the WEB SL or WEB DL devices were retrospectively analyzed. Propensity score matching was utilized to balance the baseline characteristics between the two groups. Outcomes assessed included immediate occlusion rate, complete occlusion at last follow-up, retreatment rate, device compaction, and aneurysmal rupture. RESULTS Before propensity score matching, patients treated with the WEB SL had a significantly higher rate of complete occlusion at the last follow-up and a lower rate of retreatment. After matching, there was no significant difference in immediate occlusion rate, retreatment rate, or device compaction between the WEB SL and DL groups. However, the SL group maintained a higher rate of complete occlusion at the final follow-up. Regression analysis showed that SL was associated with higher rates of complete occlusion (OR: 0.19; CI: 0.04 to 0.8, p = 0.029) and lower rates of retreatment (OR: 0.12; CI: 0 to 4.12, p = 0.23). CONCLUSION The WEB SL and DL devices demonstrated similar performances in immediate occlusion rates and retreatment requirements for intracranial aneurysms. The SL device showed a higher rate of complete occlusion at the final follow-up.
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Affiliation(s)
- Adam A Dmytriw
- Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, MA, 02114, USA.
| | - Hamza Salim
- Departement of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, LA, USA
| | - Basel Musmar
- Departement of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, LA, USA
| | - Assala Aslan
- Departement of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, LA, USA
| | - Nicole M Cancelliere
- Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Rachel M McLellan
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, MA, 02114, USA
| | - Oktay Algin
- Medical Faculty, Department of Radiology, Ankara University, Ankara, Turkey
| | - Sherief Ghozy
- Departments of Radiology and Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Mahmoud Dibas
- Departement of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, LA, USA
| | - Sovann V Lay
- Service de Neuroradiologie Diagnostique Et Thérapeutique, Centre Hospitalier de Toulouse, Hôpital Purpan, Toulouse, France
| | - Adrien Guenego
- Service de Neuroradiologie Interventionnelle, Hôpital Universitaire Erasme, Brussels, Belgique
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Joseph Carnevale
- Neurosurgery & Interventional Neuroradiology, Weill Cornell School of Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Guillaume Saliou
- Service de Radiodiagnostic Et Radiologie Interventionnelle, Centre Hospitalier Vaudois de Lausanne, Lausanne, Switzerland
| | | | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Eimad Shotar
- Department de Neuroradiologie, Hôpital Pitié-Salpêtrière. Université Sorbonne, Paris, France
| | - Kevin Premat
- Department de Neuroradiologie, Hôpital Pitié-Salpêtrière. Université Sorbonne, Paris, France
| | - Markus Möhlenbruch
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Michael Kral
- Department of Neurosurgery, Christian Doppler University Hospital & Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Omer Doron
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, MA, 02114, USA
| | - Charlotte Chung
- Departments of Radiology & Neurosurgery, NYU Langone Health Center, New York, NY, USA
| | - Mohamed M Salem
- Department of Neurosurgery, University of Pennsylvania Medical Center, Pennsylvania, PA, USA
| | - Ivan Lylyk
- Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Paul M Foreman
- Neurosurgery Department, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, FL, USA
| | - Jay A Vachhani
- Neurosurgery Department, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, FL, USA
| | - Hamza Shaikh
- Departments of Radiology & Neurosurgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Vedran Župančić
- Subdivision of Interventional Neuroradiology, Department of Radiology, Clinical Hospital Center 'Sisters of Mercy', Zagreb, Croatia
| | - Muhammad U Hafeez
- Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, TX, USA
| | - Joshua Catapano
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Muhammad Waqas
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, USA
| | - Vincent M Tutino
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, USA
| | - Mohamed K Ibrahim
- Departments of Radiology and Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Marwa A Mohammed
- Departments of Radiology and Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Cetin Imamoglu
- Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital of the Ministry of Health, Ankara, Turkey
| | - Ahmet Bayrak
- Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital of the Ministry of Health, Ankara, Turkey
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, MA, 02114, USA
| | - Yifan Ren
- Interventional Radiology and Neurointerventional Services, Department of Radiology, Austin Health, Melbourne, VIC, Australia
| | - Clemens M Schirmer
- Department of Neurosurgery and Radiology, Geisinger Health System, Danville, PA, USA
| | - Mariangela Piano
- Interventistica Neurovascolare, Ospedale Niguarda Cà Granda, Milan, Italy
| | - Anna L Kühn
- Department of Neurointerventional Radiology, UMass Memorial Hospital, Worcester, MA, USA
| | | | - Stéphanie Elens
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Robert M Starke
- Deparment of Neurosurgery, University of Miami, Miami, FL, USA
| | - Ameer E Hassan
- Deparment of Neuroscience, Valley Baptist Neuroscience Institute, Harlingen, TX, USA
| | - Mark Ogilvie
- Deparments of Neurosurgery and Radiology, University of Alabama, Birmingham, AL, USA
| | - Peter Sporns
- Department of Interventional Neuroradiology, Interventional Neuroradiology, University Hospital of Basel, Basel, Switzerland
| | - Jesse Jones
- Deparments of Neurosurgery and Radiology, University of Alabama, Birmingham, AL, USA
| | - Waleed Brinjikji
- Departments of Radiology and Neurosurgery, Mayo Clinic, Rochester, MN, USA
| | - Marie T Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios Psychogios
- Department of Interventional Neuroradiology, Interventional Neuroradiology, University Hospital of Basel, Basel, Switzerland
| | - Christian Ulfert
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jose Danilo Bengzon Diestro
- Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Bryan Pukenas
- Department of Neurosurgery, University of Pennsylvania Medical Center, Pennsylvania, PA, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania Medical Center, Pennsylvania, PA, USA
| | - Thien Huynh
- Departments of Radiology and Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Juan Carlos Martinez-Gutierrez
- Departments of Radiology, Neurology, and Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Muhammed Amir Essibayi
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Sunil A Sheth
- Departments of Radiology, Neurology, and Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Gary Spiegel
- Departments of Radiology, Neurology, and Neurosurgery, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Rabih Tawk
- Departments of Radiology and Neurosurgery, Mayo Clinic, Jacksonville, FL, USA
| | - Boris Lubicz
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Pietro Panni
- Interventistica Neurovascolare, Ospedale San Raffaele Milano, Milan, Italy
| | - Ajit S Puri
- Department of Neurointerventional Radiology, UMass Memorial Hospital, Worcester, MA, USA
| | - Guglielmo Pero
- Interventistica Neurovascolare, Ospedale Niguarda Cà Granda, Milan, Italy
| | - Erez Nossek
- Departments of Radiology & Neurosurgery, NYU Langone Health Center, New York, NY, USA
| | - Eytan Raz
- Departments of Radiology & Neurosurgery, NYU Langone Health Center, New York, NY, USA
| | - Monika Killer-Oberfalzer
- Department of Neurosurgery, Christian Doppler University Hospital & Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler University Hospital & Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Hamed Asadi
- Departments of Radiology & Neurosurgery, NYU Langone Health Center, New York, NY, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, State University of New York at Buffalo, Buffalo, NY, USA
| | - Allan L Brook
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David Altschul
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, MA, 02114, USA
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, MA, 02114, USA
| | - Peter Kan
- Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, TX, USA
| | - Vladimir Kalousek
- Subdivision of Interventional Neuroradiology, Department of Radiology, Clinical Hospital Center 'Sisters of Mercy', Zagreb, Croatia
| | - Pedro Lylyk
- Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Srikanth Boddu
- Service de Radiodiagnostic Et Radiologie Interventionnelle, Centre Hospitalier Vaudois de Lausanne, Lausanne, Switzerland
| | - Jared Knopman
- Neurosurgery & Interventional Neuroradiology, Weill Cornell School of Medicine, New York Presbyterian Hospital, New York, NY, USA
| | | | | | - Frédéric Clarençon
- Department de Neuroradiologie, Hôpital Pitié-Salpêtrière. Université Sorbonne, Paris, France
| | - Nicola Limbucci
- Neurosurgery & Interventional Neuroradiology, Weill Cornell School of Medicine, New York Presbyterian Hospital, New York, NY, USA
| | - Hugo H Cuellar-Saenz
- Departement of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, LA, USA
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Vitor Mendes Pereira
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, MA, 02114, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard University, Boston, MA, 02114, USA
| | - Nimer Adeeb
- Departement of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, LA, USA
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El Naamani K, Mastorakos P, Yudkoff CJ, Abbas R, Tjoumakaris SI, Gooch MR, Herial NA, Rosenwasser RH, Zarzour H, Schmidt RF, Jabbour PM. Comparison of PED/PED Flex and PED Shield in the treatment of unruptured intracerebral aneurysms. J Neurosurg 2024; 140:436-440. [PMID: 37877979 DOI: 10.3171/2023.7.jns23981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 07/11/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE The object of this study was to compare the efficacy and safety profile of the Pipeline embolization device (PED)/Pipeline Flex embolization device (PED Flex) with that of the Pipeline Flex embolization device with Shield Technology (PED Shield). After introducing the first-generation PED and the second-generation PED Flex with its updated delivery system, the PED Shield was launched with a synthetic layer of phosphorylcholine surface modification to reduce thrombogenicity. METHODS This is a retrospective review of unruptured aneurysms treated with PED/PED Flex versus PED Shield between 2017 and 2022 at the authors' institution. Patients with ruptured aneurysms, adjunctive treatment, failed flow diverter deployment, and prior treatment of the target aneurysm were excluded. Baseline characteristics were collected for all patients, including age, sex, past medical history (hypertension, hyperlipidemia, diabetes mellitus), smoking status, aneurysm location, and aneurysm dimensions (neck, width, height) and morphology (saccular, nonsaccular). The primary outcome was procedural and periprocedural complication rates. RESULTS The study cohort comprised 200 patients with 200 aneurysms, including 150 aneurysms treated with the PED/PED Flex and 50 treated with the PED Shield. With respect to intraprocedural and periprocedural complications, length of stay, length of follow-up, and functional outcome at discharge, there was no significant difference between the two cohorts. At the midterm follow-up, the rate of in-stent stenosis (PED/PED Flex: 14.2% vs PED Shield: 14.6%, p = 0.927), aneurysm occlusion (complete occlusion: 79.5% vs 80.5%, respectively; neck remnant: 4.7% vs 12.2%; dome remnant: 15.7% vs 7.3%; p = 0.119), and the need for retreatment (5.3% vs 0%, p = 0.097) were comparable between the two cohorts. CONCLUSIONS This study suggests that, as compared to first- and second-generation PED and PED Flex, the third-generation PED Shield offers similar rates of complications, aneurysm occlusion, and in-stent stenosis at the midterm follow-up.
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El Naamani K, Momin AA, Hunt A, Jain P, Oghli YS, Ghanem M, Musmar B, El Fadel O, Alhussein A, Alhussein R, Pedapati V, Muharremi E, El-Hajj J, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. Causes and Predictors of 30-Day Readmission in Patients With Stroke Undergoing Mechanical Thrombectomy: A Large Single-Center Experience. Neurosurgery 2024:00006123-990000000-01021. [PMID: 38224235 DOI: 10.1227/neu.0000000000002826] [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] [Received: 10/12/2023] [Accepted: 11/29/2023] [Indexed: 01/16/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The 30-day readmission rate has emerged as a metric of quality care and is associated with increased health care expenditure. We aim to identify the rate and causes of 30-day readmission after mechanical thrombectomy and provide the risk factors of readmission to highlight high-risk patients who may require closer care. METHODS This is a retrospective study from a prospectively maintained database of 703 patients presenting for mechanical thrombectomy between 2017 and 2023. All patients who presented with a stroke and underwent a mechanical thrombectomy were included in this study. Patients who were deceased on discharge were excluded from this study. RESULTS Our study comprised 703 patients, mostly female (n = 402, 57.2%) with a mean age of 70.2 years ±15.4. The most common causes of readmission were cerebrovascular events (stroke [n = 21, 36.2%], intracranial hemorrhage [n = 9, 15.5%], and transient ischemic attack [n = 1, 1.7%]).Other causes of readmission included cardiovascular events (cardiac arrest [n = 4, 6.9%] and bradycardia [n = 1, 1.7%]), infection (wound infection postcraniectomy [n = 3, 5.2%], and pneumonia [n = 1, 1.7%]). On multivariate analysis, independent predictors of 30-day readmission were history of smoking (odds ratio [OR]: 2.2, 95% CI: 1.1-4.2) P = .01), distal embolization (OR: 3.2, 95% CI: 1.1-8.7, P = .03), decompressive hemicraniectomy (OR: 9.3, 95% CI: 3.2-27.6, P < .01), and intracranial stent placement (OR: 4.6, 95% CI: 2.4-8.7) P < .01). CONCLUSION In our study, the rate of 30-day readmission was 8.3%, and the most common cause of readmission was recurrent strokes. We identified a history of smoking, distal embolization, decompressive hemicraniectomy, and intracranial stenting as independent predictors of 30-day readmission in patients with stroke undergoing mechanical thrombectomy.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Arbaz A Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Yazan Shamli Oghli
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Marc Ghanem
- School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Basel Musmar
- School of Medicine, An-Najah National University, Nablus, Palestine
| | - Omar El Fadel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdulaziz Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Reyoof Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Vinay Pedapati
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Eti Muharremi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jad El-Hajj
- Saint George's University School of Medicine, Saint George, Grenada
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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8
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El Naamani K, Abbas R, Ghanem M, Mounzer M, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. Resuming Anticoagulants in Patients With Intracranial Hemorrhage: A Meta-Analysis and Literature Review. Neurosurgery 2024; 94:14-19. [PMID: 37459580 DOI: 10.1227/neu.0000000000002625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/24/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Intracerebral hemorrhage (ICH) is one of the most disabling cerebrovascular events. Several studies have discussed oral anticoagulant (OAC)-related ICH; however, the optimal timing of resuming OAC in patients with ICH is still a dilemma. In this literature review/meta-analysis, we will summarize, discuss, and provide the results of studies pertaining to OAC resumption in patients with ICH. METHODS Using PubMed, Ovid Medline, and Web science, a systemic literature review was performed in accordance with the Preferred Reporting Items for Systemic Reviews and Meta-Analyses statement on December 20, 2022. Inclusion criteria for the meta-analysis were all studies reporting mean, median, and standard deviation for the duration of anticoagulants resumption after ICH. Thirteen studies met the above criteria and were included in the meta-analysis. RESULTS Of the 271 articles found in the literature, pooled analysis was performed in 13 studies that included timing of OAC resumption after ICH. The pooled mean duration to OAC resumption after the index ICH was 31 days (95% CI: 13.7-48.3). There was significant variation among the mean duration to OAC resumption reported by the studies as observed in the heterogeneity test ( P -value ≈0). CONCLUSION Based on our meta-analysis, the average time of resuming OAC in patients with ICH is around 30 days. Several factors including the type of intracranial hemorrhage, the type of OAC, and the indication for OACs should be taken into consideration for future studies to try and identify the best time to resume OAC in patients with ICH.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Marc Ghanem
- The Lebanese American University Gilbert and Rose-Marie Chaghoury School of Medicine, Beirut, Lebanon
| | - Marc Mounzer
- Drexel University, Philadelphia , Pennsylvania , USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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9
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El Naamani K, Hunt A, Jain P, Lawall CL, Yudkoff CJ, El Fadel O, Ghanem M, Mastorakos P, Momin AA, Alhussein A, Alhussein R, Atallah E, Abbas R, Zakar R, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. The Rate and Predictors of 30-Day Readmission in Patients Treated for Unruptured Cerebral Aneurysms: A Large Single-Center Study. Neurosurgery 2023; 93:1415-1424. [PMID: 37681971 DOI: 10.1227/neu.0000000000002663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 07/09/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Numerous studies of various populations and diseases have shown that unplanned 30-day readmission rates are positively correlated with increased morbidity and all-cause mortality. In this study, we aim to provide the rate and predictors of 30-day readmission in patients undergoing treatment for unruptured intracranial aneurysms. METHODS This is a retrospective study of 525 patients presenting for aneurysm treatment between 2017 and 2022. All patients who were admitted and underwent a successful treatment of their unruptured intracerebral aneurysms were included in the study. The primary outcome was the rate and predictors of 30-day readmission. RESULTS The rate of 30-day readmission was 6.3%, and the mean duration to readmission was 7.8 days ± 6.9. On univariate analysis, factors associated with 30-day readmission were antiplatelet use on admission (odds ratio [OR]: 0.4, P = .009), peri-procedural rupture (OR: 15.8, P = .007), surgical treatment of aneurysms (OR: 2.2, P = .035), disposition to rehabilitation (OR: 9.5, P < .001), and increasing length of stay (OR: 1.1, P = .0008). On multivariate analysis, antiplatelet use on admission was inversely correlated with readmission (OR: 0.4, P = .045), whereas peri-procedural rupture (OR: 9.5, P = .04) and discharge to rehabilitation (OR: 4.5, P = .029) were independent predictors of 30-day readmission. CONCLUSION In our study, risk factors for 30-day readmission were aneurysm rupture during the hospital stay and disposition to rehabilitation, whereas the use of antiplatelet on admission was inversely correlated with 30-day readmission. Although aneurysm rupture is a nonmodifiable risk factor, more studies are encouraged to focus on the correlation of antiplatelet use and rehabilitation disposition with 30-day readmission rates.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Charles L Lawall
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Clifford J Yudkoff
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Omar El Fadel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Marc Ghanem
- Gilbert and Rose-Marie Chaghoury School of Medicine, Lebanese American University, Byblos , Lebanon
| | - Panagiotis Mastorakos
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Arbaz A Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Abdulaziz Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Reyoof Alhussein
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Elias Atallah
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Rida Zakar
- School of Medicine, Saint Joseph University, Beirut , Lebanon
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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10
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Ghanem M, El Naamani K, Rawad A, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. Transverse Sinus Stenting for the Treatment of Idiopathic Intracranial Hypertension With a Pressure Gradient of 70 mm Hg: A Technical Note and Systematic Review. Oper Neurosurg (Hagerstown) 2023; 25:e338-e344. [PMID: 37589472 DOI: 10.1227/ons.0000000000000858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/05/2023] [Indexed: 08/18/2023] Open
Abstract
BACKGROUND AND IMPORTANCE Venous sinus stenosis is believed to play a role in the pathogenesis of idiopathic intracranial hypertension (IIH). Venous stenting has emerged as a promising treatment option for patients with IIH because of venous sinus stenosis refractory to medical management or unsuitable for shunt placement. In this technical note, we present a case of IIH with the highest recorded pressure gradient to date. CLINICAL PRESENTATION This technical note presents the successful use of intracranial venous stenting in a patient with IIH because of severe venous sinus stenosis, leading to significant improvement in vision and reduction in intracranial pressure. A meticulous review of the literature revealed that our patient exhibited the highest recorded pressure gradient (70 mm Hg). This remarkable finding underscores the potential effectiveness of venous stenting as a viable treatment approach. The procedure involved the placement of a Zilver stent (Cook Medical) and balloon angioplasty after stenting of the right transverse sinus stenosis, resulting in a substantial decrease in pressure gradient. Following the procedure, another venous manometry showed no more gradient with a uniform pressure in the whole venous system at 18 mm Hg. CONCLUSION To our knowledge, this case presents the highest pressure gradient reported in the literature and contributes to the growing evidence supporting venous stenting in patients with IIH and venous sinus stenosis.
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Affiliation(s)
- Marc Ghanem
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
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11
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El Naamani K, Abbas R, Tjoumakaris SI, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM, Evans J, Gooch MR. Venous sinus stenting for idiopathic intracranial hypertension patients with functioning ventriculoperitoneal shunts: A case series. Clin Neurol Neurosurg 2023; 233:107894. [PMID: 37499303 DOI: 10.1016/j.clineuro.2023.107894] [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: 06/04/2023] [Revised: 07/10/2023] [Accepted: 07/11/2023] [Indexed: 07/29/2023]
Abstract
Idiopathic intracranial hypertension (IIH) is a disease defined by increased intracranial pressure and associated with a variety of symptoms ranging from headaches to tinnitus. Ventricular peritoneal shunting has been the mainstay treatment for patients with IIH. Although VPS's have shown efficacy in treating IIH, some patients complain of refractory symptoms even with functioning VPS's. Venus stenting has emerged as a new technique for treating these refractory symptoms. Despite the scarce literature pertaining its efficacy and safety profile, several small studies have shown promising results. In this case series, four patients with IIH complained of refractory symptoms despite functioning VPS's and were treated with venous stenting.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | | | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - James Evans
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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12
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Sanchez S, Essibayi MA, Hickerson M, Ojeda DJ, Kasab SA, Yoshimura S, Jabbour PM, Mascitelli J, Levitt MR, Cuellar-Saenz HH, Brinjikji W, Spiotta AM, Shaban A, Samaniego EA. Morphological characteristics of brain aneurysms among age groups. Interv Neuroradiol 2023:15910199231201520. [PMID: 37715650 DOI: 10.1177/15910199231201520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/18/2023] Open
Abstract
BACKGROUND Patient's age is an important factor in determining the risk of aneurysm rupture. However, there is limited data on how aneurysm morphology differs among age groups. We studied morphological characteristics of brain aneurysms among age groups in a large cohort. METHODS Aneurysms from the Stroke Thrombectomy and Aneurysm Registry (STAR) were analyzed. The following parameters were included: location, size, neck, width, height, aspect ratio, and regular versus irregular morphology. The risk of rupture presentation was estimated using logistic regression. RESULTS A total of 1407 unruptured and 607 ruptured saccular aneurysms were included. The most common locations of ruptured aneurysms in patients younger than 70 years-old were the middle cerebral artery (MCA) and the anterior communicating artery (ACOM). The most common location of ruptured aneurysms in patients older than 70 years-old were the posterior communicating artery (PCOM) and ACOM. The size of unruptured aneurysms increased with age (p < .001). Conversely, the size of ruptured aneurysms was similar among age groups (p = .142). Unruptured and ruptured aneurysms became more irregular at presentation with older age (p < .001 and p .025, respectively). Irregular morphology and location were associated with rupture status across all age groups in multivariate regression. CONCLUSIONS Younger patients have small unruptured and ruptured aneurysms, and ruptured aneurysms are mostly located in the MCA and ACOM. Older patients have larger and more irregular unruptured aneurysms, and ruptured aneurysms are mostly located in the PCOM and ACOM. An irregular morphology increases the risk of rupture in all age groups.
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Affiliation(s)
| | | | | | | | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, USA
| | | | | | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, USA
| | | | | | | | | | - Amir Shaban
- Department of Neurology, University of Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa, USA
- Department of Neurosurgery, University of Iowa, USA
- Department of Radiology, University of Iowa, USA
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13
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Amllay A, Becerril-Gaitan A, Hunt A, Jain P, Chen CJ, El Naamani K, Abbas R, Rudick L, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. Safety of Mechanical Thrombectomy in Patients on Antiplatelet/Anticoagulation. World Neurosurg 2023; 176:e476-e484. [PMID: 37257646 DOI: 10.1016/j.wneu.2023.05.084] [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: 03/13/2023] [Accepted: 05/22/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is performed in patients who are already on anticoagulation (AC)/antiplatelet therapy (AP). However, data are insufficient regarding MT's safety and efficacy profiles in these patients. OBJECTIVE Investigate the outcome of stroke patients already on anticoagulation/antiplatelet receiving MT. METHODS We included consecutive acute ischemic stroke patients treated with MT for 10 years (2012-2022) in a comprehensive stroke center. Baseline variables, efficacy (recanalization [Thrombolysis in Cerebral Infraction] ≥ 2b), good functional outcome (modified Ranking Scale ≤ 2 at 3 months), and safety (symptomatic intracranial hemorrhage [sICH], mortality rates) were evaluated. Additionally, we conducted a subgroup analysis of patients with prior single-AP versus DAPT. RESULTS Six hundred forty-six patients were included (54.5% women, median age 71 years), 84 (13%) were on AC, 196 (30.3%) on AP, and 366 (56.7%) in the control group. The AC and AP groups were older and had more comorbidities. sICH occurred in 7.3% of cases. There was no significant difference in sICH incidence across the groups. The AC group had a lower rate of intravenous thrombolysis (15.9%; P < 0.001), a higher rate of sICH (11.9% vs. AP 7.7% and control 6%; P = 0.172), and higher mortality at discharge (17.9% vs. AP 8.7% and control 10.4%; P = 0.07). However, the groups had similar functional outcomes and mortality rates at 3 months. Successful recanalization was achieved in 92.7% and was similar across groups. Multivariable logistic regression and the subgroup analysis (single-AP vs. dual AP) did not reveal statistically significant associations. CONCLUSIONS MT in patients with prior anticoagulation and AP presenting with acute ischemic strokeis feasible, effective, and safe.
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Affiliation(s)
- Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Levi Rudick
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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14
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El Naamani K, Khanna O, Syal A, Momin AA, Abbas R, Amllay A, Sambangi A, Hunt A, Dougherty J, Lawall CL, Tjoumakaris SI, Gooch MR, Herial NA, Rosenwasser RH, Zarzour H, Schmidt RF, Jabbour PM. A Comparison of Outcomes Between Transfemoral Versus Transradial Access for Carotid Stenting. Neurosurgery 2023; 93:445-452. [PMID: 36861988 DOI: 10.1227/neu.0000000000002437] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 01/04/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND The transradial (TR) approach has emerged as an alternative to the transfemoral (TF) approach in carotid artery stenting (CAS) because of its perceived benefits in access site complications and overall patient experience. OBJECTIVE To assess outcomes of TF vs TR approach for CAS. METHODS This is a retrospective single-center review of patients receiving CAS through the TR or TF route between 2017 and 2022. All patients with symptomatic and asymptomatic carotid disease who underwent attempted CAS were included in our study. RESULTS A total of 342 patients were included in this study: 232 underwent CAS through TF approach vs 110 through the TR route. On univariate analysis, the rate of overall complications was more than double for the TF vs TR cohort; however, this did not achieve statistical significance (6.5% vs 2.7%, odds ratio [OR] = 0.59 P = .36). The rate of cross-over from TR to TF was significantly higher on univariate analysis (14.6 % vs 2.6%, OR = 4.77, P = .005) and on inverse probability treatment weighting analysis (OR = 6.11, P < .001). The rate of in-stent stenosis (TR: 3.6% vs TF: 2.2%, OR = 1.71, P = .43) and strokes at follow-up (TF: 2.2% vs TR: 1.8%, OR = 0.84, P = .84) was not significantly different. Finally, median length of stay was comparable between both cohorts. CONCLUSION The TR approach is safe, feasible, and provides similar rates of complications and high rates of successful stent deployment compared with the TF route. Neurointerventionalists adopting the radial first approach should carefully assess the preprocedural computed tomography angiography to identify patients amenable to TR approach for carotid stenting.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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15
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Siddiq F, Nunna RS, Beall JM, Khan I, Khan M, Tekle WG, Ezzeldin M, Tanweer O, Burkhardt JK, Jabbour PM, Tjoumakaris SI, Herial NA, Siddiqui AH, Grandhi R, Martin RL, Qureshi AI, Hassan AE. Thirty-Day Outcomes of Resolute Onyx Stent for Symptomatic Intracranial Stenosis: A Multicenter Propensity Score-Matched Comparison With Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis Trial. Neurosurgery 2023; 92:1155-1162. [PMID: 36700730 PMCID: PMC10553131 DOI: 10.1227/neu.0000000000002338] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 07/15/2022] [Accepted: 11/02/2022] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Symptomatic intracranial atherosclerotic disease (sICAD) is estimated to cause 10% of strokes annually in the United States. However, treatment remains a challenge with several different stenting options studied in the past with unfavorable results. OBJECTIVE To report the 30-day stroke and/or death rate associated with intracranial stent placement for sICAD using Resolute Onyx Zotarolimus-Eluting Stent (RO-ZES) and provide a comparison with the results of Stenting Versus Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS) trial. METHODS Prospectively maintained databases across 8 stroke centers were used to identify adult patients treated with RO-ZES for sICAD between January 2019 and December 2021. Primary end point was composite of 30-day stroke, intracerebral hemorrhage, and/or death. Propensity score matching was performed using age, hypertension, lipid disorder, cigarette smoking, and symptomatic target vessel to create a matched group for comparison between RO-ZES and the SAMMPRIS medical management and treatment groups (SAMMPRIS percutaneous angioplasty and stenting [S-PTAS]). RESULTS A total of 132 patients met the inclusion criteria for analysis (mean age: 64.2 years). Mean severity of stenosis was 81.4% (±11.4%). A total of 4 (3.03%) stroke and/or deaths were reported within 30 days of treatment in the RO-ZES group compared with 6.6% in the SAMMPRIS medical management group (OR [odds ratio] 2.26, 95% CI 0.7-9.56, P = .22) and 15.6% in the S-PTAS group (OR 5.9, 95% CI 2.04-23.4, P < .001). Propensity score match analysis of 115 patients in each group demonstrated 30-day stroke and/or death rate of 2.6% in the RO-ZES group and 15.6% in the S-PTAS group (OR 6.88, 95% CI 1.92-37.54, P < .001). CONCLUSION Patients treated with RO-ZES had a relatively low 30-day stroke and/or death rate compared with the S-PTAS group. Further large-scale prospective studies are warranted to evaluate the safety and efficacy of RO-ZES for the treatment of sICAD.
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Affiliation(s)
- Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Ravi S. Nunna
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Jonathan M. Beall
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Inamullah Khan
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Musharaf Khan
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, USA
| | - Wondwossen G. Tekle
- Department of Neurology, Valley Baptist—University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Mohamad Ezzeldin
- Department of Clinical Science, University of Houston, HCA Houston, Houston, Texas, USA
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Pascal M. Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Nabeel A. Herial
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Adnan H. Siddiqui
- Department of Neurosurgery, University of Buffalo, Buffalo, New York, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Renee L. Martin
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri, USA
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist—University of Texas Rio Grande Valley, Harlingen, Texas, USA
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16
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Patel PD, Khanna O, Gooch MR, Glener SR, Mouchtouris N, Momin AA, Sioutas G, Amllay A, Barsouk A, El Naamani K, Yudkoff C, Wyler DA, Jallo JI, Tjoumakaris S, Jabbour PM, Harrop JS. Clinical Outcomes After Ultra-Early Cranioplasty Using Craniectomy Contour Classification as a Patient Selection Criterion. Oper Neurosurg (Hagerstown) 2023:01787389-990000000-00661. [PMID: 37166197 DOI: 10.1227/ons.0000000000000689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/20/2023] [Indexed: 05/12/2023] Open
Abstract
BACKGROUND Although not a technically difficult operation, cranioplasty is associated with high rates of complications. The optimal timing of cranioplasty to mitigate complications remains the subject of debate. OBJECTIVE To report outcomes between patients undergoing cranioplasty at ultra-early (0-6 weeks), intermediate (6 weeks to 6 months), and late (>6 months) time frames. We report a novel craniectomy contour classification (CCC) as a radiographic parameter to assess readiness for cranioplasty. METHODS A single-institution retrospective analysis of patients undergoing cranioplasty was performed. Patients were stratified into ultra-early (within 6 weeks of index craniectomy), intermediate (6 weeks to 6 months), and late (>6 months) cranioplasty cohorts. We have devised CCC scores, A, B, and C, based on radiographic criteria, where A represents those with a sunken brain/flap, B with a normal parenchymal contour, and C with "full" parenchyma. RESULTS A total of 119 patients were included. There was no significant difference in postcranioplasty complications, including return to operating room (P = .212), seizures (P = .556), infection (P = .140), need for shunting (P = .204), and deep venous thrombosis (P = .066), between the cohorts. Univariate logistic regression revealed that ultra-early cranioplasty was significantly associated with higher rate of functional independence at >6 months (odds ratio 4.32, 95% CI 1.39-15.13, P = .015) although this did not persist when adjusting for patient selection features (odds ratio 2.90, 95% CI 0.53-19.03, P = .234). CONCLUSION In appropriately selected patients, ultra-early cranioplasty is not associated with increased rate of postoperative complications and is a viable option. The CCC may help guide decision-making on timing of cranioplasty.
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Affiliation(s)
- Pious D Patel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Steven R Glener
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Arbaz A Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georgios Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Barsouk
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Clifford Yudkoff
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David A Wyler
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jack I Jallo
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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17
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Essibayi MA, Anadani M, Almallouhi E, Yaghi S, Maier I, Jabbour PM, Kim JT, Wolfe SQ, Rai A, Starke R, Psychogios M, Shaban A, Arthur AS, Yoshimura S, Howard B, Alawieh A, Fragata I, Cuellar H, Polifka A, Mascitelli J, Osbun J, Matouk C, Park MS, Levitt M, Dumont T, Williamson R, Altschul D, Spiotta AM, Al Kasab S. Abstract WP164: Acute Carotid Stenting Versus Conservative Management For Tandem Carotid Occlusions: Insights From STAR. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Management of anterior circulation emergent large vessel occlusion with tandem carotid occlusion (TCO) remains a challenge during mechanical thrombectomy (MT). To day, there is no consensus regarding emergent carotid stenting (ECS) in the setting of MT with TCO. We aimed to compare the outcomes of ECS versus conservative management (MT alone) among patients with TCO.
Methods:
Data from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 was interrogated. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the ICA or MCA were included in the analyses. We compared baseline, procedural charecteristics, successful reperfusion (mTICI 2b-3), favorable 90-day good outcomes (mRS 0-2), intravenous tPA administration and symptomatic ICH between patients who did or did not undergo ECS. Multivariate regression was performed adjusting for variables of clinical importance. Propensity score matching for IV tPA use was performed to explore its safety with stenting.
Results:
Among 9812 thrombectomy patients, 688 patients had TCO; 132 underwent emergent stenting and 444 had MT alone. Patients who did not undergo ECS had a higher prevalence of atrial fibrillation (33.9% Vs 9.2%, P<.001), higher admission NIHSS scores (18 Vs 14, P<.001), shorter time from symptom onset to puncture (275 minutes Vs 333 minutes, P=0.029), and were predominantly women (59.2% Vs 33.6%, P<0.001).Patients with stenting had lower mortality rates ( 17.5% Vs 29.6%, P=0.009), and higher rates of successful reperfusion (83% Vs 95%, P=0.001). No difference in mRS 0-2 (37.5% Vs 30.4%, P=0.178) or sICH were seen (11.1% Vs 15.4%, P=0.219). Propensity score matching analysis (n=129 in each group) demonstrated better rates of reperfusion (94.8 Vs 84.4%, P=0.011) in the stenting group. Advanced age, higher admission NIHSS and lower ASPECT scores were associated with worse clinical outcomes.
Conclusion:
ECS during MT for TCO appears to be safe and is associated with better clinical and angiographic outcomes compared to conservative management.
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Affiliation(s)
| | | | | | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
| | | | | | | | | | | | | | | | | | | | - Isabel Fragata
- Cntr Hospar Universitário de Lisboa Central, Lisbon, Portugal
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18
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Almallouhi E, Al Kasab S, Maier I, Jabbour PM, Kim JT, Quintero Wolfe SC, rai A, Starke R, Psychogios M, Samaniego EA, Arthur AS, Yoshimura S, Grossberg JA, Alawieh A, Fragata I, Cuellar H, Polifka A, Mascitelli J, Osbun J, Matouk C, Park MS, Levitt M, Dumont T, Williamson R, Spiotta AM, Grandhi R. Abstract 48: Outcomes And Risk Of Hemorrhagic Transformation Following Mechanical Thrombectomy In Primary Distal Posterior Cerebral Artery Occlusions-subgroup Analysis From STAR. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
While mechanical thrombectomy (MT) has become the standard of care for acute stroke patients presenting with large vessel occlusion (LVO) and salvageable brain tissue, limited data is currently available regarding the benefits of MT in patents with medium vessel occlusions (MeVO) especially in the posterior circulation (P2 occlusions).
Methods:
We used the Stroke Thrombectomy and Aneurysm registry (STAR) which included data from 35 stroke centers in North America, Europe, Asia, and South America. We included patients who presented with MeVO in the M2, M3 or P2 segments and underwent MT. We used a Generalized Linear Model to assess the relationship between location of occlusion and outcomes.
Results:
9812 patients were included in STAR at the time of this analysis; 43 underwent MT for P2 occlusion, 130 underwent MT for M3 occlusion; and 1273 underwent MT for M2 occlusion. There was no difference in age, sex, race, rate of IV-tPA and stroke severity between patients in all 3 groups (Table 1). There was a trend toward lower rate of atrial fibrillation in patients with P2 and M3 occlusions. Patients with P2 occlusions were less likely to achieve successful recanalization (modified treatment in cerebral infarction score≥2b); intraarterial thrombolysis was used less in P2 occlusions (4.7% compared to 16.2% in M3 occlusions and 10.1% in M2 occlusions). However, there was no difference in the rate of successful first pass. On multivariable analysis, P2 occlusions were not associated with hemorrhagic transformation (OR 2.0, 95% CI 0.7-5.7, P 0.186), 90-day mortality (OR 0.5, 95% CI 0.2-1.4, P 0.183), or 90-day favorable outcome (OR 2.0, 95% CI 0.9-4.4, P 0.084).
Conclusions:
In this multicenter study, there was no significant difference in safety and efficacy of MT in patients with MeVOs in posterior circulation (P2 occlusions) compared to M2 and M3 occlusions. Improved techniques for successful recanalization are needed for posterior circulation MeVOs.
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Affiliation(s)
| | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
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19
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Andersson T, Nogueira RG, Yoo AJ, Hanel R, Zaidat OO, Hacke W, Jovin T, Fiehler J, De Meyer SF, Brinjikji W, Doyle K, Liebeskind DS, Haussen DC, Inoa V, Humphries WE, Woodward KB, Jabbour PM, Francois O, Bozorgchami H, Levy EI, Boor S, Cohen J, Dashti SR, Taqi MA, Budzik RF, Schirmer CM, Hussain MS, Estrade L, De Leacy RA, Puri AS, Chitale RV, Brekenfeld C, Siddiqui AH. Abstract 28: First Pass Outcomes And Associated Clot Characteristics: Secondary Analysis Of The Excellent Registry. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
EXCELLENT (NCT03685578) is a global prospective, multicenter, real-world registry of mechanical thrombectomy for stroke with the EmboTrap device as first line treatment which includes clot collection and analysis.
Aim of the study:
To report the rates of clinical outcomes and clot characteristics associated with first pass reperfusion in EXCELLENT.
Methods:
Per pass angiographic outcomes assessed by an independent core lab were available in 984 subjects Analysis of clot from 538 cases was performed by independent central labs blinded to clinical data. 90-day mRS assessment was blinded to subject data.
Results:
First pass reperfusion of mTICI 2b-3 (63.2%) and 2c-3 (38.3%) was significantly predictive of mRS 0-2 or ≤pre-stroke (p=0.011 and p=0.016) but not all-cause mortality at 90 days (p=0.080 and p=0.123, respectively). Further, mTICI 2c-3 in one pass was associated with a higher rate of mRS 0-2 or ≤pre-stroke vs. mTICI 2c-3 reperfusion in >1 pass, (55.5% and 45.1%, respectively, p=0.013) and a rate of all-cause mortality at 90 days of 14.6% vs. 19.8% (p=0.097). Full patient characteristics and clinical outcomes are shown in Table 1. Notable clot composition findings included: RBC (%, mean±SD): mTICI 2c-3, 1 pass 47.69±22.25, mTICI 2c-3, >1 pass 43.86±19.05, (p=0.088); fibrin: mTICI 2c-3, 1 pass 23.20±13.80, mTICI 2c-3 >1 pass 25.40 ± 13.52 (p=0.131); von Willebrand factor (VWF): mTICI2c-3, 1 pass 16.09±14.62, mTICI 2c-3, >1 pass 19.42±17.15 (p=0.038).
Conclusions:
First pass reperfusion in the EXCELLENT registry was associated with better clinical outcomes at 90 days. Clots retrieved with first pass reperfusion had higher RBC and lower fibrin and VWF content compared to those who achieved reperfusion at greater than one pass.
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Affiliation(s)
- Tommy Andersson
- Karolinska Univ Hosp and Karolinska Institute, Stockholm, Sweden
| | | | | | | | | | | | | | - Jens Fiehler
- Univ Med Cntr Hamburg Eppendorf, Hamburg, Germany
| | | | | | | | | | | | - Violiza Inoa
- Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | | | | | | | | | - Elad I Levy
- Univ at Buffalo, State Univ of New York, Williamsville, NY
| | - Stephan Boor
- Univ Med Cntr of the Johannes Gutenberg Univ Mainz, Mainz, Germany
| | - Jose Cohen
- Hadassah Univ Med Cntr, Jerusalem, Israel
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20
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Almallouhi E, Anadani M, Al Kasab S, Maier I, Jabbour PM, Kim JT, Quintero Wolfe SC, rai A, Starke R, Psychogios M, Samaniego EA, Arthur AS, Yoshimura S, Grossberg JA, Alawieh A, Fragata I, Cuellar H, Polifka A, Mascitelli J, Osbun J, Matouk C, Park MS, Levitt M, Dumont T, Williamson R, Spiotta AM. Abstract 98: The Impact Of Aspiration Catheter Size On Thrombectomy Outcomes Using Adapt Technique-analysis From The STAR Registry. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.98] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introductions:
Clinical trials have shown that aspiration thrombectomy is as safe and effective as stent-retriever thrombectomy. Multiple improvements have been made to the aspiration technique over the last few years. In this study, we aim to assess the effect of aspiration catheter bore size on the outcomes of A direct aspiration first pass technique (ADAPT) thrombectomy.
Methods:
We included patients who underwent ADAPT thrombectomy for M1 or internal carotid artery terminus (ICA-T) occlusions in the Stroke Thrombectomy and Aneurysm (STAR) database. Patients included between July 2016 and July 2022. We compared baseline characteristics, procedural metrics and outcomes between patients who underwent thrombectomy using small bore (0.035”-0.060”), medium bore (0.062”-0.068”) and large bore (0.070”-0.074”) catheters.
Results:
A total of 1158 patients were included; 576 (49.7%) females, 645 (70%) White, and 464 (40.6%) received IV-tPA. No difference was noticed in age, sex, and vascular risk factors between the 3 different groups. There was higher rate of IV-tPA in the small-bore catheter group (48.8%) compared to the medium and large bore catheter groups (38.4% and 36.7%, respectively) (P=0.03). Procedure duration was shorter when using medium (20 min) and large (18 min) compared to small bore catheters (30 min) (P=0.01). Both medium and large bore catheters were associated with higher rate of successful recanalization (88.9% and 87.9%, respectively) compared to small bore catheters (81.6%) (P=0.010). However, the difference in successful recanalization or procedure duration between medium and large bore catheters was not significant. No difference was noted in the rate of symptomatic hemorrhagic transformation (sICH) (4.7%, 5.3%, and 7.1%; P=0.345), 90-day favorable outcome (modified Rankin Scale 0-2) (41.8%, 39.3%, 40.8%; P=0.766) or 90-day mortality (18.1%, 23.5%, 24.4%; P=0.111) between the groups.
Conclusions:
Higher rate of successful recanalization and shorter procedure duration were observed when using medium and large bore aspiration catheters compared with small bore catheters in ADAPT technique. However, these procedural benefits were not observed when comparing large bore to medium bore catheters.
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Affiliation(s)
| | | | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
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21
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El Naamani K, Amllay A, Chen CJ, Capone S, Abbas R, Sioutas GS, Munoz A, Yudkoff CJ, Carreras A, Sambangi A, Hunt A, Jain P, Stine EA, Sathe A, Smit R, Yazbeck F, Tjoumakaris SI, Gooch MR, Herial NA, Rosenwasser RH, Zarzour H, Schmidt RF, El-Ghanem M, Jabbour PM. The Effect of COVID-19 Vaccines on Stroke Outcomes: A Single-Center Study. World Neurosurg 2023; 170:e834-e839. [PMID: 36494068 PMCID: PMC9726206 DOI: 10.1016/j.wneu.2022.11.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 11/28/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND One of the defining narratives of the COVID-19 pandemic has been the acceptance and distribution of vaccine. To compare the outcomes of COVID-19 positive vaccinated and unvaccinated stroke patients. METHODS This is a single-center retrospective study of COVID-19-vaccinated and unvaccinated stroke patients between April 2020 and March 2022. All patients presenting with stroke regardless of treatment modalities were included. National Institutes of Health Stroke Scale was used to assess stroke severity. The primary outcome was functional capacity of the patients at discharge. RESULTS The study cohort comprised 203 COVID-19 positive stroke patients divided into 139 unvaccinated and 64 fully vaccinated patients. At discharge, the modified Rankin scale score was significantly lower in the vaccinated cohort (3[1-4] vs. 4[2-5], odds ratio = 0.508, P = 0.011). At 3 months of follow-up, the median modified Rankin scale score was comparable between both cohorts. CONCLUSIONS Although vaccination did not show any significant difference in stroke patient outcomes on follow-up, vaccines were associated with lower rates of morbidity and mortality at discharge among stroke patients during the pandemic.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center, Houston, Texas, USA
| | - Stephen Capone
- Department of Neurology, Virginia Tech Carilion Clinic, Roanoke, Virginia, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georgios S. Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alfredo Munoz
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Clifford J. Yudkoff
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Angeleah Carreras
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abhijeet Sambangi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Emily A. Stine
- Psychology Department, College of Arts and Sciences, Arcadia University, Glenside, Pennsylvania, USA
| | - Anish Sathe
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rupert Smit
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fouad Yazbeck
- School of Medicine, University of Washington, Seattle, Washington, USA
| | - Stavropoula I. Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael R. Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A. Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H. Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F. Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Mohammad El-Ghanem
- Department of Neurology, HCA-Houston, University of Houston, Houston, Texas, USA
| | - Pascal M. Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA,To whom correspondence should be addressed: Pascal M. Jabbour, M.D
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22
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Essibayi MA, Anadani M, Almallouhi E, Yaghi S, Lajthia O, Maier I, Jabbour PM, Kim JT, Quintero Wolfe S, rai A, Starke R, Psychogios M, Shaban A, Arthur AS, Yoshimura S, Howard B, Alawieh A, Fragata I, Cuellar H, Polifka A, Mascitelli J, Osbun J, Matouk C, Park MS, Levitt M, Dumont T, Williamson R, Altschul D, Spiotta AM, Al Kasab S. Abstract TP154: Outcomes Of Acute Carotid Stenting With Or Without Intravenous Thrombolysis Among Patients With Acute Tandem Occlusion: Insights From STAR. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Introduction:
Emergency carotid artery stenting during mechanical thrombectomy has emerged as an effective emergent treatment for tandem carotid occlusions. Nevertheless, scarce evidence is available about the safety of this procedure in patients who received intravenous tPA before thrombectomy. Herein, we investigate the safety of acute carotid stenting among patients who received intravenous tPA in a large international multicenter registry.
Methods:
Patients from the Stroke Thrombectomy and Aneurysm Registry between 2010 and 2022 were analyzed. Only patients with concomitant occlusions of cervical carotid and proximal ipsilateral intracranial segments of the internal carotid or middle cerebral artery were included in the final analyses. Patients were divided into two groups, depending on tPA administration. The primary outcome was 90-day good clinical outcome (mRS 0-2), and the primary safety outcome was symptomatic intracranial hemorrhage. Univariate and multivariate regressions were performed adjusting for variables of clinical importance.
Results:
Among 9812 with acute ischemic stroke in the registry, 132 patients had acute tandem occlusion and underwent carotid stenting; of those, 60 patients received IV tPA. Compared to non-intravenous thrombolytics, patients with IV tPA had a higher male prevalence (78.3% Vs 54.4%, P=0.005) and better ASPECT scores (9 Vs 8, P=0.022) with a shorter time from onset to puncture (241 Vs 672 minutes, P<0.001). There was no difference in rates of successful revascularization (94% Vs 95.5%, P=NS), good clinical outcome (50.8% Vs 61.4%, P=NS), symptomatic intracranial hemorrhage (15.3% Vs 14.5%, P=NS) or procedural complications (15% Vs 11.6%, P=NS) between the tPA and non-tPA groups.
Conclusion:
The use of IV tPA did not affect the safety or efficacy of emergent carotid stenting in the setting of acute tandem occlusion.
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Affiliation(s)
| | | | | | | | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
| | | | | | | | | | | | | | | | | | | | - Isabel Fragata
- Cntr Hospar Universitário de Lisboa Central, Lisbon, Portugal
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23
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El Naamani K, Saad H, Chen CJ, Abbas R, Sioutas GS, Amllay A, Yudkoff CJ, Carreras A, Sambangi A, Hunt A, Jain P, Dougherty J, Tjoumakaris SI, Gooch MR, Herial NA, Rosenwasser RH, Zarzour H, Schmidt RF, Jabbour PM. Comparison of Flow-Redirection Endoluminal Device and Pipeline Embolization Device in the Treatment of Intracerebral Aneurysms. Neurosurgery 2023; 92:118-124. [PMID: 36170173 DOI: 10.1227/neu.0000000000002148] [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] [Received: 04/13/2022] [Accepted: 07/14/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The use of flow diverters for treating intracranial aneurysms has been widely used in the past decade; however, data comparing pipeline embolization device (PED; Medtronic Inc) and flow-redirection endoluminal device (FRED; MicroVention) in the treatment of intracranial aneurysms remain scarce. OBJECTIVE To compare the outcomes of PED and FRED in the treatment of intracranial aneurysms. METHODS This is a single-center retrospective review of aneurysms treated with PED and FRED devices. Patients treated with PED or FRED were included. Cases requiring multiple or adjunctive devices were excluded. Primary outcome was complete aneurysm occlusion at 6 months. Secondary outcomes included good functional outcome, need for retreatment, and any complication. RESULTS The study cohort comprised 150 patients, including 35 aneurysms treated with FRED and 115 treated with PED. Aneurysm characteristics including location and size were comparable between the 2 cohorts. 6-month complete occlusion rate was significantly higher in the PED cohort (74.7% vs 51.5%; P = .017) but lost significance after inverse probability weights. Patients in the PED cohort were associated with higher rates of periprocedural complications (3.5% vs 0%; P = .573), and the rate of in-stent stenosis was approximately double in the FRED cohort (15.2% vs 6.9%; P = .172). CONCLUSION Compared with PED, FRED offers modest 6-month occlusion rates, which may be due to aneurysmal and baseline patient characteristics differences between both cohorts. Although not significant, FRED was associated with a higher complication rate mostly because of in-stent stenosis. Additional studies with longer follow-up durations should be conducted to further evaluate FRED thrombogenicity.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Georgios S Sioutas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Clifford J Yudkoff
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Angeleah Carreras
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Abhijeet Sambangi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jaime Dougherty
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Hekmat Zarzour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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24
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Khanna O, Al Saiegh F, Mouchtouris N, Sajja K, Baldassari MP, El Naamani K, Tjoumakaris S, Gooch MR, Rosenwasser RH, Starke RM, Jabbour PM. Coil Embolization with Subsequent Subacute Flow Diversion Before Hospital Discharge as a Treatment Paradigm for Ruptured Aneurysms. World Neurosurg 2022; 167:e583-e589. [PMID: 35987457 DOI: 10.1016/j.wneu.2022.08.052] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 08/09/2022] [Accepted: 08/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Subtotal coil embolization followed by subsequent flow diversion is often pursued for treatment of acutely ruptured aneurysms. Owing to the need for anti-platelet therapy, the optimal time of safely pursuing flow diversion treatment has not been fully elucidated. In this study, we aim to demonstrate the safety and feasibility of staged treatment of acutely ruptured aneurysms with early coil embolization followed by flow diversion prior to discharge. METHODS A retrospective study to evaluate clinical outcomes of patients who presented with aneurysmal subarachnoid hemorrhage and underwent coil embolization followed by subacute flow diversion treatment during the same hospitalization. RESULTS A total of 18 patients are included in our case series. Eight patients presented with Hunt-Hess (H-H) grade 2 bleed, 6 patients with H-H grade 3, and 2 patients each with H-H grade 4 and H-H grade 1. Eight patients required placement of an external ventricular drain on admission. After initial coil embolization, 12 achieved Raymond-Roy grade 2 occlusion, and 6 attained grade 3a/b occlusion. The mean duration between coil embolization and subsequent flow diversion was 9.83 days (range: 1-30). There were no instances of re-hemorrhage between initial coil embolization and subsequent flow diversion treatment. Sixteen patients had a minimum of 6-month follow-up, of which 15 were found to have complete occlusion, and 1 required subsequent clipping. CONCLUSIONS Subtotal coil embolization followed by definitive treatment using flow diversion during the same hospitalization is feasible and achieves excellent aneurysm occlusion rates while avoiding dual anti-platelet therapy during the initial hemorrhage period.
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Affiliation(s)
- Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kalyan Sajja
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael P Baldassari
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA.
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25
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Lu VM, Luther EM, Silva MA, Elarjani T, Abdelsalam A, Maier I, Al Kasab S, Jabbour PM, Kim JT, Wolfe SQ, Rai AT, Psychogios MN, Samaniego EA, Arthur AS, Yoshimura S, Grossberg JA, Alawieh A, Fragata I, Polifka A, Mascitelli J, Osbun J, Park MS, Levitt MR, Dumont T, Cuellar H, Williamson RW, Romano DG, Crosa R, Gory B, Mokin M, Moss M, Limaye K, Kan P, Yavagal DR, Spiotta AM, Starke RM. Prognostic significance of age within the adolescent and young adult acute ischemic stroke population after mechanical thrombectomy: insights from STAR. J Neurosurg Pediatr 2022; 30:448-454. [PMID: 35986724 DOI: 10.3171/2022.7.peds22250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/06/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although younger adults have been shown to have better functional outcomes after mechanical thrombectomy (MT) for acute ischemic stroke (AIS), the significance of this relationship in the adolescent and young adult (AYA) population is not well defined given its undefined rarity. Correspondingly, the goal of this study was to determine the prognostic significance of age in this specific demographic following MT for large-vessel occlusions. METHODS A prospectively maintained international multi-institutional database, STAR (Stroke Thrombectomy and Aneurysm Registry), was reviewed for all patients aged 12-18 (adolescent) and 19-25 (young adult) years. Parameters were compared using chi-square and t-test analyses, and associations were interrogated using regression analyses. RESULTS Of 7192 patients in the registry, 41 (0.6%) satisfied all criteria, with a mean age of 19.7 ± 3.3 years. The majority were male (59%) and young adults (61%) versus adolescents (39%). The median prestroke modified Rankin Scale (mRS) score was 0 (range 0-2). Strokes were most common in the anterior circulation (88%), with the middle cerebral artery being the most common vessel (59%). The mean onset-to-groin puncture and groin puncture-to-reperfusion times were 327 ± 229 and 52 ± 42 minutes, respectively. The mean number of passes was 2.2 ± 1.2, with 61% of the cohort achieving successful reperfusion. There were only 3 (7%) cases of reocclusion. The median mRS score at 90 days was 2 (range 0-6). Between the adolescent and young adult subgroups, the median mRS score at last follow-up was statistically lower in the adolescent subgroup (1 vs 2, p = 0.03), and older age was significantly associated with a higher mRS at 90 days (coefficient 0.33, p < 0.01). CONCLUSIONS Although rare, MT for AIS in the AYA demographic is both safe and effective. Even within this relatively young demographic, age remains significantly associated with improved functional outcomes. The implication of age-dependent stroke outcomes after MT within the AYA demographic needs greater validation to develop effective age-specific protocols for long-term care across both pediatric and adult centers.
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Affiliation(s)
- Victor M Lu
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Evan M Luther
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Michael A Silva
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Turki Elarjani
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Ahmed Abdelsalam
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Ilko Maier
- 2Department of Neurology, University Medical Center Gottingen, Gottingen, Germany
| | - Sami Al Kasab
- 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Pascal M Jabbour
- 4Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Joon-Tae Kim
- 5Department of Neurosurgery, Chonnam National University Hospital, Gwangju, South Korea
| | - Stacey Q Wolfe
- 6Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Ansaar T Rai
- 7Department of Neuroradiology, University of West Virginia, Morgantown, West Virginia
| | | | | | - Adam S Arthur
- 10Department of Neurosurgery, Semmes Murphey Neurologic and Spine Clinic, Memphis, Tennessee
| | - Shinichi Yoshimura
- 11Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | | | - Ali Alawieh
- 12Department of Neurosurgery, Emory University, Atlanta, Georgia
| | - Isabel Fragata
- 13Department of Neuroradiology, Hospital Sao Jose Centro Hospitalar Lisboa Central, Lisboa, Portugal
| | - Adam Polifka
- 14Department of Neurosurgery, University of Florida, Gainesville, Florida
| | - Justin Mascitelli
- 15Department of Neurosurgery, University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Joshua Osbun
- 16Department of Neurosurgery, Washington University in St. Louis, St. Louis, Missouri
| | - Min S Park
- 17Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Michael R Levitt
- 18Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Travis Dumont
- 19Department of Neurosurgery, University of Arizona, Tucson, Arizona
| | - Hugo Cuellar
- 20Department of Radiology, Louisiana State University Health Shreveport, Shreveport, Louisiana
| | - Richard W Williamson
- 21Department of Neurosurgery, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Daniele G Romano
- 22Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Salerna, Italy
| | - Roberto Crosa
- 23Department of Neurosurgery, Neurological Endovascular Center, Medica Uruguaya, Montevideo, Uruguay
| | - Benjamin Gory
- 24Department of Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Maxim Mokin
- 25Department of Neurosurgery, University of South Florida, Tampa, Florida
| | - Mark Moss
- 26Department of Interventional Neuroradiology, Washington Regional Medical, Fayetteville, Arkansas
| | - Kaustubh Limaye
- 27Department of Interventional Neuroradiology, Indiana University, Indianapolis, Indiana; and
| | - Peter Kan
- 28Department of Neurosurgery, University of Texas Medical Branch-Galveston, Galveston, Texas
| | - Dileep R Yavagal
- 1Department of Neurosurgery, University of Miami, Miami, Florida
| | - Alejandro M Spiotta
- 3Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Robert M Starke
- 1Department of Neurosurgery, University of Miami, Miami, Florida
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26
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Ilyas A, Chen CJ, Abecassis IJ, Al-Saiegh F, Ironside N, Jabbour PM, Tjoumakaris S, Gooch MR, Lee CC, Sheehan JP, Ding D. Stereotactic Radiosurgery for A Randomized Trial of Unruptured Brain Arteriovenous Malformations-Eligible Patients: A Meta-Analysis. Neurosurgery 2022; 91:684-692. [PMID: 36001787 DOI: 10.1227/neu.0000000000002115] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 06/12/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The outcomes of A Randomized Trial of Unruptured Brain Arteriovenous Malformations (ARUBA) were controversial, and they suggested that intervention is inferior to medical management for unruptured brain arteriovenous malformations (AVMs). However, several studies have shown that stereotactic radiosurgery (SRS) is an acceptable therapy for unruptured AVMs. OBJECTIVE To test the hypothesis that ARUBA intervention arm's SRS results are meaningfully inferior to those from similar populations reported by other studies. METHODS We performed a literature review to identify SRS studies of patients who met the eligibility criteria for ARUBA. Patient, AVM, treatment, and outcome data were extracted for statistical analysis. Regression analyses were pooled to identify factors associated with post-SRS obliteration and hemorrhage. RESULTS The study cohort included 8 studies comprising 1620 ARUBA-eligible patients who underwent SRS. At the time of AVM diagnosis, 36% of patients were asymptomatic. The mean follow-up duration was 80 months. Rates of radiologic, symptomatic, and permanent radiation-induced changes were 45%, 11%, and 2%, respectively. The obliteration rate was 68% at last follow-up. The post-SRS hemorrhage and mortality rates were 8%, and 2%, respectively. Lower Spetzler-Martin grade (odds ratios [OR] = 0.84 [0.74-0.95], P = .005), lower radiosurgery-based AVM score (OR = 0.75 [0.64-0.95], P = .011), lower Virginia Radiosurgery AVM Scale (OR = 0.86 [0.78-0.95], P = .003), and higher margin dose (OR = 1.13 [1.02-1.25], P = .025) were associated with obliteration. CONCLUSION SRS carries a favorable risk to benefit profile for appropriately selected ARUBA-eligible patients, particularly those with smaller volume AVMs. Our findings suggest that the results of ARUBA do not reflect the real-world safety and efficacy of SRS for unruptured AVMs.
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Affiliation(s)
- Adeel Ilyas
- Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Isaac Josh Abecassis
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
| | - Fadi Al-Saiegh
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Natasha Ironside
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Cheng-Chia Lee
- Department of Neurosurgery, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jason P Sheehan
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Dale Ding
- Department of Neurological Surgery, University of Louisville, Louisville, Kentucky, USA
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27
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Schmidt RF, Sweid A, Mouchtouris N, Velagapudi L, Chalouhi N, Gooch MR, Rosenwasser RH, Jabbour PM, Tjoumakaris SI. Predictors of first-pass reperfusion for mechanical thrombectomy in acute ischemic stroke. Clin Neurol Neurosurg 2022; 219:107314. [PMID: 35662056 DOI: 10.1016/j.clineuro.2022.107314] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 05/26/2022] [Accepted: 05/28/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Rapid reperfusion of ischemic penumbra in patients with acute stroke is critical to neurological recovery. Achieving reperfusion after first-pass mechanical thrombectomy has been associated with improved patient outcomes. However, the predictors for obtaining first-pass reperfusion are not well known. METHODS A single-institution retrospective study of all patients who underwent mechanical thrombectomy at a tertiary care center from January 2010 until March 2019 was conducted to assess for predictors of first-pass reperfusion. RESULTS A total of 257 patients were reviewed. Successful reperfusion was obtained in 63.4% of patients, and in 38% of patients on the first pass. On multivariate analysis, increasing door-to-puncture time was a negative predictor of FPR (OR 0.989, 95% CI = 0.980-0.997) and use of combined thrombectomy technique with stent-retriever and aspiration was a positive predictor of FPR compared to aspiration or stent-retriever alone (OR 4.441, 95% CI = 1.001-19.699). CONCLUSIONS Combination therapy using stent-retriever and aspiration may increase the chance of obtaining FPR, whereas delays in starting the procedure after patient arrival may decrease the odds of FPR. Rapid thrombectomy initiation and procedural technique may play in optimizing rates of FPR and ultimately patient outcomes, however, randomized controlled trials assessing these variables are necessary to determine optimal treatment strategies.
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Affiliation(s)
- Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lohit Velagapudi
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, University of Florida, Gainesville, FL, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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Ghaith AK, El Naamani K, Mualem W, Ghanem M, Rajjoub R, Sweid A, Yolcu YU, Onyedimma C, Tjoumakaris SI, Bydon M, Jabbour PM. Transradial versus Transfemoral Approaches in Diagnostic and Therapeutic Neuroendovascular Interventions: A Meta-Analysis of Current Literature. World Neurosurg 2022; 164:e694-e705. [PMID: 35580777 DOI: 10.1016/j.wneu.2022.05.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 05/07/2022] [Accepted: 05/09/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND The adoption of the transradial approach (TRA) has been increasing in popularity as a primary method to conduct both diagnostic and therapeutic interventions. As this technique gains broader acceptance and use within the neuroendovascular community, comparing its complication profile with a better-established alternative technique, the transfemoral approach (TFA), becomes more important. This study aimed to evaluate the safety of TRA compared with TFA in patients undergoing diagnostic, therapeutic, and combined neuroendovascular procedures. METHODS A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A literature search of PubMed and other databases was conducted for studies from all available dates. To compare TRA and TFA, we performed an indirect meta-analysis between studies that mentioned the complications of the procedures. RESULTS Our search yielded 532 studies, of which 108 met full inclusion criteria. A total of 54,083 patients (9137 undergoing TRA and 44,946 undergoing TFA) were included. Access site complication rate was lower in TRA (1.62%) compared with TFA (3.31%) (P < 0.01). Neurological complication rate was lower in TRA (1.64%) compared with TFA (3.82%) (P = 0.02 and P < 0.01, respectively). Vascular spasm rate was higher in TRA (3.65%) compared with TFA (0.88%) (P < 0.01). Wound infection complication rate was higher in TRA (0.32%) compared with TFA (0.2%) (P < 0.01). CONCLUSIONS Patients undergoing TFA are significantly more likely to experience access site complications and neurological complications compared with patients undergoing TRA. Patients undergoing TRA are more likely to experience complications such as wound infections and vascular spasm.
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Affiliation(s)
- Abdul Karim Ghaith
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - William Mualem
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Marc Ghanem
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Rami Rajjoub
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Yagiz U Yolcu
- Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Chiduziem Onyedimma
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Mohamad Bydon
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA.
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
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Naamani KE, Chen CJ, Abbas R, Sweid A, Sioutas GS, Badih K, Ramesh S, Tjoumakaris SI, Gooch MR, Herial NA, Zarzour H, Schmidt RF, Rosenwasser RH, Jabbour PM. Woven EndoBridge versus stent-assisted coil embolization of cerebral bifurcation aneurysms. J Neurosurg 2022; 137:1786-1793. [PMID: 35535832 DOI: 10.3171/2022.3.jns2217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/08/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Stent-assisted coil (SAC) embolization has been the mainstay endovascular treatment for bifurcation aneurysms. The recent introduction of the Woven EndoBridge (WEB) device has presented an alternative endovascular treatment modality for these aneurysms. Direct comparisons of outcomes between these two modalities are limited in the literature. Here, the authors compared the outcomes of bifurcation aneurysms treated with SAC and WEB devices. METHODS This retrospective single-center study comprised 148 bifurcation aneurysms that were treated endovascularly with SAC or WEB devices between 2011 and 2019. The primary outcome was complete occlusion of the aneurysm at 6 months on catheter angiography. RESULTS The SAC and WEB cohorts comprised 85 and 63 aneurysms, respectively. The baseline characteristics were well balanced after inverse probability weight (IPW) adjustment, except for smoking status. The 6-month complete occlusion rate was higher in the WEB cohort than the SAC cohort (67.4% vs 40.6%; unadjusted OR [95% CI] 3.014 [1.385-6.563], p = 0.005). However, this difference in complete occlusion rates did not remain significant after IPW adjustment and multiple imputations. The neck remnant rate was lower in the WEB cohort than the SAC cohort (20% vs 50%; OR [95% CI] 0.250 [0.107-0.584], p = 0.001), and this difference remained significant after IPW adjustment (OR [95% CI] 0.304 [0.116-0.795], p = 0.015) and multiple imputations. CONCLUSIONS Use of SAC and WEB demonstrated comparable 6-month complete occlusion rates for bifurcation aneurysms. WEB appeared to be associated with a lower rate of neck remnant at 6 and 12 months compared with SAC. WEB was also associated with fewer complications and decreased retreatment rates compared with SAC.
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Affiliation(s)
- Kareem El Naamani
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Ching-Jen Chen
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Rawad Abbas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Ahmad Sweid
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Georgios S Sioutas
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Khodr Badih
- 2Department of Physics, University of Toronto, Ontario, Canada
| | - Sunidhi Ramesh
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Stavropoula I Tjoumakaris
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - M Reid Gooch
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Nabeel A Herial
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Hekmat Zarzour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Richard F Schmidt
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Robert H Rosenwasser
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
| | - Pascal M Jabbour
- 1Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania; and
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Munoz A, Jabre R, Orenday-Barraza JM, Eldin MS, Chen CJ, Al-Saiegh F, Abbas R, El Naamani K, Gooch MR, Jabbour PM, Tjoumakaris S, Rosenwasser RH, Herial NA. A review of mechanical thrombectomy techniques for acute ischemic stroke. Interv Neuroradiol 2022:15910199221084481. [PMID: 35238227 PMCID: PMC10399505 DOI: 10.1177/15910199221084481] [Citation(s) in RCA: 4] [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] [Indexed: 02/04/2023] Open
Abstract
Mechanical thrombectomy is established as standard of care in the management of acute ischemic stroke due to large vessel occlusion and evidence-based guidelines for mechanical thrombectomy have been defined. As research continues to further expand the eligibility criteria for thrombectomy and the number of thrombectomy procedures increase worldwide, there is also growing focus on innovation of thrombectomy devices, procedural techniques, and related outcomes. Thrombectomy primarily involves use of stent retrievers and distal aspiration techniques, but variations and different combinations of techniques have been reported. As this is a rapidly evolving area in stroke management, there is debate as to which, if any, of these techniques leads to improved clinical outcomes over another and there is a lack of data comparing them. In this review, currently published and distinct techniques of mechanical thrombectomy are described methodically along with illustrations to aid in understanding the subtle differences between the techniques. The perceived benefits of each variation are discussed.
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Affiliation(s)
- Alfredo Munoz
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Roland Jabre
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jose M Orenday-Barraza
- Department of Neurosurgery, 42283University of Arizona College of Medicine, Phoenix, Arizona, USA
| | - Mohamed Shehab Eldin
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ching-Jen Chen
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Fadi Al-Saiegh
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michael Reid Gooch
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Sidney Kimmel College of Medicine, 23217Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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El Naamani K, Abbas R, Sioutas GS, Tjoumakaris SI, Gooch MR, Herial NA, Rosenwasser RH, Jabbour PM. Endovascular Robotic Interventions. Neurosurg Clin N Am 2022; 33:225-231. [DOI: 10.1016/j.nec.2021.11.008] [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: 10/19/2022]
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Almallouhi E, Al Kasab S, Hubbard Z, Bass EC, Porto G, Alawieh A, Chalhoub R, Jabbour PM, Starke RM, Wolfe SQ, Arthur AS, Samaniego E, Maier I, Howard BM, Rai A, Park MS, Mascitelli J, Psychogios M, De Leacy R, Dumont T, Levitt MR, Polifka A, Osbun J, Crosa R, Kim JT, Casagrande W, Yoshimura S, Matouk C, Kan PT, Williamson RW, Gory B, Mokin M, Fragata I, Zaidat O, Yoo AJ, Spiotta AM. Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in the Early and Extended Window. JAMA Netw Open 2021; 4:e2137708. [PMID: 34878550 PMCID: PMC8655598 DOI: 10.1001/jamanetworkopen.2021.37708] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
IMPORTANCE Limited data are available about the outcomes of mechanical thrombectomy (MT) for real-world patients with stroke presenting with a large core infarct. OBJECTIVE To investigate the safety and effectiveness of MT for patients with large vessel occlusion and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of 2 to 5. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used data from the Stroke Thrombectomy and Aneurysm Registry (STAR), which combines the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. The study included 2345 patients presenting with an occlusion in the internal carotid artery or M1 segment of the middle cerebral artery from January 1, 2016, to December 31, 2020. Patients were followed up for 90 days after intervention. The ASPECTS is a 10-point scoring system based on the extent of early ischemic changes on the baseline noncontrasted computed tomography scan, with a score of 10 indicating normal and a score of 0 indicating ischemic changes in all of the regions included in the score. EXPOSURE All patients underwent MT in one of the included centers. MAIN OUTCOMES AND MEASURES A multivariable regression model was used to assess factors associated with a favorable 90-day outcome (modified Rankin Scale score of 0-2), including interaction terms between an ASPECTS of 2 to 5 and receiving MT in the extended window (6-24 hours from symptom onset). RESULTS A total of 2345 patients who underwent MT were included (1175 women [50.1%]; median age, 72 years [IQR, 60-80 years]; 2132 patients [90.9%] had an ASPECTS of ≥6, and 213 patients [9.1%] had an ASPECTS of 2-5). At 90 days, 47 of the 213 patients (22.1%) with an ASPECTS of 2 to 5 had a modified Rankin Scale score of 0 to 2 (25.6% [45 of 176] of patients who underwent successful recanalization [modified Thrombolysis in Cerebral Ischemia score ≥2B] vs 5.4% [2 of 37] of patients who underwent unsuccessful recanalization; P = .007). Having a low ASPECTS (odds ratio, 0.60; 95% CI, 0.38-0.85; P = .002) and presenting in the extended window (odds ratio, 0.69; 95% CI, 0.55-0.88; P = .001) were associated with worse 90-day outcome after controlling for potential confounders, without significant interaction between these 2 factors (P = .64). CONCLUSIONS AND RELEVANCE In this cohort study, more than 1 in 5 patients presenting with an ASPECTS of 2 to 5 achieved 90-day functional independence after MT. A favorable outcome was nearly 5 times more likely for patients with low ASPECTS who had successful recanalization. The association of a low ASPECTS with 90-day outcomes did not differ for patients presenting in the early vs extended MT window.
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Affiliation(s)
- Eyad Almallouhi
- Department of Neurosurgery, Medical University of South Carolina, Charleston
- Department of Neurology, Medical University of South Carolina, Charleston
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston
- Department of Neurology, Medical University of South Carolina, Charleston
| | - Zachary Hubbard
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Eric C. Bass
- Department of Radiology, Medical University of South Carolina, Charleston
| | - Guilherme Porto
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Reda Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Pascal M. Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Robert M. Starke
- Department of Neurosurgery, University of Miami Health System, Miami, Florida
| | - Stacey Q. Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Adam S. Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis
| | - Edgar Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Brian M. Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia
| | - Ansaar Rai
- Department of Radiology, West Virginia School of Medicine, Morgantown
| | - Min S. Park
- Department of Neurosurgery, University of Virginia, Charlottesville
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio
| | | | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Health System, New York, New York
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tuscon
| | | | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University, St Louis, Missouri
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo, Uruguay
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Korea
| | - Walter Casagrande
- Department of Cerebrovascular and Endovascular Neurosurgery, Hospital Juan Fernandez, Buenos Aires, Argentina
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston
| | | | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa
| | - Isabel Fragata
- Neuroradiology Department, Hospital São José Centro Hospitalar, Lisboa, Portugal
| | - Osama Zaidat
- Neuroscience Department, Bon Secours Mercy Health St Vincent Medical Center, Toledo, Ohio
| | - Albert J. Yoo
- Department of Radiology, Texas Stroke Institute, Dallas–Fort Worth
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Burks JD, Chen SH, Luther EM, Almallouhi E, Al Kasab S, Jabbour PM, Wolfe SQ, Fargen KM, Arthur AS, Goyal N, Fragata I, Maier I, Matouk C, Grossberg J, Kan P, Schirmer C, Crowley RW, Ares W, Ogilvy CS, Rai AT, Levitt MR, Mokin M, Guerrero W, Park MS, Mascitelli J, Yoo A, Williamson RW, Grande A, Crosa R, Webb S, Psychogios M, Peterson EC, Yavagal DR, Spiotta AM, Starke RM. Effect of Hispanic Status in Mechanical Thrombectomy Outcomes After Ischemic Stroke: Insights From STAR. Stroke 2021; 52:e715-e719. [PMID: 34517765 DOI: 10.1161/strokeaha.120.033326] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race. Methods Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days. Results Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72–84), compared with 63 years (54–74) for NHB, and 71 years (60–80) for NHW patients (P<0.001). Hispanic patients had a higher incidence of diabetes (41%; P<0.001) and hypertension (82%; P<0.001) compared with NHW and NHB patients. Median procedure time was shorter in Hispanics (36 minutes) compared to NHB (39 minutes) and NHW (44 minutes) patients (P<0.001). In multivariate analysis, Hispanic patients were less likely to have favorable outcome (odds ratio, 0.502 [95% CI, 0.263–0.959]), controlling for other significant predictors (age, admission National Institutes Health Stroke Scale, onset to groin time, number of attempts, procedure time). Conclusions Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.
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Affiliation(s)
- Joshua D Burks
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Stephanie H Chen
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Evan M Luther
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Eyad Almallouhi
- Department of Neurosurgery, Medical University of South Carolina, Charleston (E.A., S.A.K., A.M.S.)
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston (E.A., S.A.K., A.M.S.)
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA (P.M.J.)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forrest School of Medicine, Winston-Salem, NC (S.Q.W., K.M.F.)
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forrest School of Medicine, Winston-Salem, NC (S.Q.W., K.M.F.)
| | - Adam S Arthur
- Department of Neurosurgery (A.S.A., N.G.), Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN
| | - Nitin Goyal
- Department of Neurosurgery (A.S.A., N.G.), Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN.,Neurology (N.G.), Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN
| | - Isabel Fragata
- Department of Neuroradiology, Hospital Sao Jose Centro Hospitalar Lisboa Central, Lisboa, Portugal (I.F.)
| | - Ilko Maier
- Department of Neurology, University Medical Center Gottingen, Germany (I.M.)
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, CT (C.M.)
| | | | - Peter Kan
- Department of Neurosurgery, Baylor School of Medicine, Houston, TX (P.K.)
| | - Clemens Schirmer
- Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, PA (C.S.)
| | | | - William Ares
- Department of Neurosurgery, NorthShore University Health System, Evanston, IL (W.A.)
| | | | - Ansaar T Rai
- Department of Neuroradiology, University of West Virginia, Morgantown (A.T.R.)
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle (M.R.L.)
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa (M.M., W.G.)
| | - Waldo Guerrero
- Department of Neurosurgery, University of South Florida, Tampa (M.M., W.G.)
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville (M.S.P.)
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Sciences Center at San Antonio (J.M.)
| | - Albert Yoo
- Texas Stroke Institute, Fort Worth (A.Y.)
| | | | - Andrew Grande
- Department of Neurosurgery, University of Minnesota, Minneapolis (A.G.)
| | - Roberto Crosa
- Department of Neurosurgery Centro Endovascular Neurologico Medica Uruguaya Montevideo, Uruguay (R.C.)
| | - Sharon Webb
- Department of Neurosurgery, Bon Secours Health System, Greenville, SC (S.W.)
| | - Marios Psychogios
- Department of Radiology, University Hospital Basel, Switzerland (M.P.)
| | - Eric C Peterson
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Dileep R Yavagal
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston (E.A., S.A.K., A.M.S.)
| | - Robert M Starke
- Department of Neurosurgery, University of Miami, FL (J.D.B., S.H.C., E.M.L., E.C.P., D.R.Y., R.M.S.)
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Schmidt RF, Vibbert MD, Vernick CA, Mendelson AM, Harley C, Labella G, Houser J, Becher P, Simko E, Jabbour PM, Tjoumakaris SI, Gooch MR, Sharan AD, Farrell CJ, Harrop JS, Rosenwasser RH, Jaffe RC, Jallo J. Standardizing postoperative handoffs using the evidence-based IPASS framework through a multidisciplinary initiative improves handoff communication for neurosurgical patients in the neuro-intensive care unit. J Clin Neurosci 2021; 92:67-74. [PMID: 34509265 DOI: 10.1016/j.jocn.2021.07.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 07/13/2021] [Accepted: 07/25/2021] [Indexed: 11/25/2022]
Abstract
Errors in communication are a major source of preventable medical errors. Neurosurgical patients frequently present to the neuro-intensive care unit (NICU) postoperatively, where handoffs occur to coordinate care within a large multidisciplinary team. A multidisciplinary working group at our institution started an initiative to improve postoperative neurosurgical handoffs using validated quality improvement methodology. Baseline handoff practices were evaluated through staff surveys and serial observations. A formalized handoff protocol was implemented using the evidence based IPASS format (Illness severity, Patient summary, Action list, Situational awareness and contingency planning, Synthesis by receiver). Cycles of objective observations and surveys were employed to track practice improvements and guide iterative process changes over one year. Surveys demonstrated improved perceptions of handoffs as organized (17.1% vs 69.7%, p < 0.001), efficient (27.0% vs. 72.7%, p < 0.001), comprehensive (17.1% vs. 66.7%, p < 0.001), and safe (18.0% vs. 66.7%, p < 0.001), noting improved teamwork (31.5% vs. 69.7%, p < 0.001). Direct observations demonstrated improved communication of airway concerns (47.1% observed vs. 92.3% observed, p < 0.001), hemodynamic concerns (70.6% vs. 97.1%, p = 0.001), intraoperative events (52.9% vs. 100%, p < 0.001), neurological examination (76.5% vs. 100%, p < 0.001), vital sign goals (70.6% vs. 100%, p < 0.001), and required postoperative studies (76.5% vs. 100%, p < 0.001). Receiving teams demonstrating improved rates of summarization (47.1% vs. 94.2%, p = 0.005) and asking questions (76.5% vs 98.1%, p = 0.004). The mean handoff time during long-term follow-up was 4.4 min (95% confidence interval = 3.9-5.0 min). Standardization of handoff practices yields improvements in communication practices for postoperative neurosurgical patients.
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Affiliation(s)
- Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States.
| | - Matthew D Vibbert
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Coleen A Vernick
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Andrew M Mendelson
- Department of Anesthesiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Caitlin Harley
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Giuliana Labella
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jessica Houser
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Patrick Becher
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Erin Simko
- Department of Nursing, Thomas Jefferson University, Philadelphia, PA, United States
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | | | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Ashwini D Sharan
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Christopher J Farrell
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - James S Harrop
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
| | - Rebecca C Jaffe
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jack Jallo
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, PA, United States
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Dodd WS, Laurent D, Dumont AS, Hasan DM, Jabbour PM, Starke RM, Hosaka K, Polifka AJ, Hoh BL, Chalouhi N. Pathophysiology of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage: A Review. J Am Heart Assoc 2021; 10:e021845. [PMID: 34325514 PMCID: PMC8475656 DOI: 10.1161/jaha.121.021845] [Citation(s) in RCA: 92] [Impact Index Per Article: 30.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 06/09/2021] [Indexed: 01/23/2023]
Abstract
Delayed cerebral ischemia is a major predictor of poor outcomes in patients who suffer subarachnoid hemorrhage. Treatment options are limited and often ineffective despite many years of investigation and clinical trials. Modern advances in basic science have produced a much more complex, multifactorial framework in which delayed cerebral ischemia is better understood and novel treatments can be developed. Leveraging this knowledge to improve outcomes, however, depends on a holistic understanding of the disease process. We conducted a review of the literature to analyze the current state of investigation into delayed cerebral ischemia with emphasis on the major themes that have emerged over the past decades. Specifically, we discuss microcirculatory dysfunction, glymphatic impairment, inflammation, and neuroelectric disruption as pathological factors in addition to the canonical focus on cerebral vasospasm. This review intends to give clinicians and researchers a summary of the foundations of delayed cerebral ischemia pathophysiology while also underscoring the interactions and interdependencies between pathological factors. Through this overview, we also highlight the advances in translational studies and potential future therapeutic opportunities.
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Affiliation(s)
- William S. Dodd
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Dimitri Laurent
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Aaron S. Dumont
- Department of Neurological SurgerySchool of MedicineTulane UniversityNew OrleansLA
| | - David M. Hasan
- Department of NeurosurgeryCarver College of MedicineUniversity of IowaIowa CityIA
| | - Pascal M. Jabbour
- Department of Neurological SurgerySidney Kimmel Medical CollegeThomas Jefferson UniversityPhiladelphiaPA
| | - Robert M. Starke
- Department of Neurological SurgeryMiller School of MedicineUniversity of MiamiFL
| | - Koji Hosaka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Adam J. Polifka
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Brian L. Hoh
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
| | - Nohra Chalouhi
- Department of NeurosurgeryCollege of MedicineUniversity of FloridaGainesvilleFL
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Dodd WS, Jabbour PM, Sweid A, Tjoumakaris S, Gooch MR, Al Saiegh F, Hasan DM, Starke RM, Kan PT, Polifka AJ, Laurent D, Busl KM, Ghosh R, Hoh BL, Chalouhi N. Aneurysmal Subarachnoid Hemorrhage in Patients with Coronavirus Disease 2019 (COVID-19): A Case Series. World Neurosurg 2021; 153:e259-e264. [PMID: 34242830 PMCID: PMC8260497 DOI: 10.1016/j.wneu.2021.06.092] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/17/2021] [Accepted: 06/18/2021] [Indexed: 02/07/2023]
Abstract
Objective The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a pressing public health issue. Although most cases do not result in severe illness requiring hospitalization, there is increasing evidence that SARS-CoV-2–induced inflammation can exacerbate pre-existing diseases. We sought to describe the characteristics of patients with aneurysmal subarachnoid hemorrhage who were actively or very recently infected with SARS-CoV-2. Methods We reviewed subarachnoid hemorrhage cases of patients who also were positive for SARS-CoV-2 at 5 high-volume cerebrovascular centers in the United States from March 2020 to January 2021. Cases of aneurysmal subarachnoid hemorrhage were analyzed. Results A total of 10 patients were identified, consisting of 5 women (50%) and 5 men (50%). Median age was 38.5 years. Four of the 10 patients (40%) were asymptomatic with respect to SARS-CoV-2–related symptoms, 3 patients (30%) had mild-to-moderate symptoms, and 3 patients (30%) had severe coronavirus disease 2019 (COVID-19), with pneumonia and sepsis. Of the 10 cases, 4 had dissecting pseudoaneurysms (40%), 3 in the posterior circulation and 1 in the anterior circulation. Among 6 saccular/blister aneurysms, 4 (67%) were ≤4 mm in largest diameter. Conclusions Our experience with aneurysmal subarachnoid hemorrhage in patients positive for COVID-19 reveals a possibly distinct pattern compared with traditional aneurysmal subarachnoid hemorrhage, namely a high frequency of small aneurysms, dissecting pseudoaneurysms, and young patients.
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Affiliation(s)
- William S Dodd
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David M Hasan
- Department of Neurosurgery, Carver College of Medicine, University of Iowa, Iowa City, Iowa, USA
| | - Robert M Starke
- Department of Neurological Surgery, Miller School of Medicine, University of Miami, Miami, Florida, USA
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | - Adam J Polifka
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Dimitri Laurent
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Katharina M Busl
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida, USA; Department of Neurology, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Ritam Ghosh
- Department of Neurological Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Brian L Hoh
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Nohra Chalouhi
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville, Florida, USA.
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El Naamani K, Carrasco J, Ramesh S, Milman T, Abbas R, Sweid A, Zhou S, El Hajjar R, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. Preoperative Ultrasound-Guided Percutaneous Embolization of Orbital Lymphaticovenous Malformations Using Onyx. World Neurosurg 2021; 154:13-20. [PMID: 34245882 DOI: 10.1016/j.wneu.2021.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 11/28/2022]
Abstract
The treatment of orbital lymphaticovenous malformations (OLVMs) has evolved from simple surgical resection to a multimodal approach consisting of sclerosing agents, embolization, and resection depending on the specific components that compose the lesion. Here we present a representative case series of 5 nonconsecutive patients who underwent percutaneous embolization of OLVMs with the Onyx Liquid Embolic System (Medtronic, Dublin, Ireland) before surgical resection between 2019 and 2021. OLVMs are rare, benign, congenital lesions that grow with age and can become symptomatic and disabling. Treatment can be conservative or invasive; depending on the clinical presentation and characteristics of the lesions, treatment modalities can vary. Preoperative percutaneous embolization of OLVMs with the Onyx system is a promising technique, as demonstrated in this case series.
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Affiliation(s)
- Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Jacqueline Carrasco
- Oculoplastic and Orbital Surgery Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | | | - Tatyana Milman
- Occular Pathology Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Siwei Zhou
- Oculoplastic and Orbital Surgery Service, Wills Eye Hospital, Philadelphia, Pennsylvania, USA
| | - Rayan El Hajjar
- Department of Pathology, Anatomy, and Cell Biology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Michael R Gooch
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania, USA.
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38
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Khanna O, Hafazalla K, Saiegh FA, Tahir R, Schunemann V, Theofanis TN, Mouchtouris N, Gooch MR, Tjoumakaris S, Rosenwasser RH, Jabbour PM. Simultaneous bilateral mechanical thrombectomy in a patient with COVID-19. Clin Neurol Neurosurg 2021; 206:106677. [PMID: 34020326 PMCID: PMC8117485 DOI: 10.1016/j.clineuro.2021.106677] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 02/07/2023]
Abstract
Owing to systemic inflammation and widespread vessel endotheliopathy, SARS-CoV-2 has been shown to confer an increased risk of cryptogenic stroke, particularly in patients without any traditional risk factors. In this report, we present a case of a 67-year-old female who presented with acute stroke from bilateral anterior circulation large vessel occlusions, and was incidentally found to be COVID-positive on routine hospital admission screening. The patient had a large area of penumbra bilaterally, and the decision was made to pursue bilateral simultaneous thrombectomy, with two endovascular neurosurgeons working on each side to achieve a faster time to recanalization. Our study highlights the utility and efficacy of simultaneous bilateral thrombectomy, and this treatment paradigm should be considered for use in patients who present with multifocal large vessel occlusions.
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Affiliation(s)
- Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Karim Hafazalla
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rizwan Tahir
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Victoria Schunemann
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Thana N Theofanis
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Hines K, Mouchtouris N, Al Saiegh F, Hafazalla K, Mazza J, Phan P, Gooch MR, Tjoumakaris S, Rosenwasser RH, Jabbour PM. Prediction of hematoma expansion in spontaneous intracerebral hemorrhage: Our institutional experience. J Clin Neurosci 2021; 86:271-275. [PMID: 33775341 DOI: 10.1016/j.jocn.2021.01.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2020] [Revised: 12/30/2020] [Accepted: 01/28/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Spontaneous intracerebral hemorrhage (sICH) is a disease process with high morbidity and mortality. In particular, hematoma expansion (HE) is a feared complication of sICH. With 15-40% of patients experiencing HE, it has become increasingly important to predict which sICH will remain stable and which will expand. OBJECTIVE With new treatment options being developed, it is becoming increasingly important to be able to predict which hemorrhages are at high versus low risk for expansion. The authors of this study hope to reexamine variables associated with hematoma expansion in hopes of generating newer data on risk factors for expansion. METHODS A retrospective analysis identified 334 patients who presented with sICH. The primary outcome was HE on follow up head CT. HE was defined as a greater than 33% increase or an absolute increase in 6 mL or more in overall volume between the two sets of CT images. Analysis was performed using unpaired t-test, Chi-square, and Fisher's exact tests, as appropriate. RESULTS Of the 334 patients, 247 (74.0%) did not experience an expansion of their ICH while 87 (26.0%) did. Multivariable logistic regression was performed demonstrating ICH score of 3 or greater (4.76 (95% CI 2.60-8.72, p < 0.001) , cortical location of the sICH (1.77 (95% CI 1.03-3.04, p = 0.038), and presence of a fluid level (6.46 (95% CI 2.28-18.3, p < 0.001) as significant predictors of HE. CONCLUSIONS Our study found that fluid-fluid levels on non-contrast CT, an ICH score 3 or greater, and lobar sICH were all more likely to expand.
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Affiliation(s)
- Kevin Hines
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Nikolaos Mouchtouris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Fadi Al Saiegh
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Karim Hafazalla
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Jacob Mazza
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Phillip Phan
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - M Reid Gooch
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Stavropoula Tjoumakaris
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Robert H Rosenwasser
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States
| | - Pascal M Jabbour
- Department of Neurosurgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, PA, United States.
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Almallouhi E, Al Kasab S, Alawieh A, Al-Kawaz M, Starke R, Grossberg JA, Jabbour PM, Wolfe S, Fargen K, Levitt M, Arthur AS, De Leacy RA, Park MS, Raper D, Polifka A, Crowley RW, Dumont T, Osbun J, Crosa R, Maier I, Kim JT, Casagrande W, Rai A, Chowdhry S, Mokin M, Matouk C, Fragata I, Williamson R, Yoo AJ, Mascitelli J, Kan P, Psychogios M, Hui FK, Spiotta AM. Abstract P504: Outcomes and Predictors of Successful First Pass in MCA Occlusions Using ADAPT Thrombectomy Technique - Insights From STAR. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p504] [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:
Successful first pass (SFP) has been identified as a key benchmark of the success of mechanical thrombectomy (MT). However, studies that evaluate the predictors and outcomes of SFP using ADAPT (A Direct Aspiration first Pass Technique) are limied by the small number of patients or single center design.
Methods:
We used data from the prospectively collected data from 28 stroke centers that are included in the Stroke Thrombectomy and Aneurysm Registry (STAR). Patients with middle cerebral artery (MCA) occlusions at the level of M1 or M2 segments were included. SFP was defined by achieving modified Thrombolysis in Cerebral Infarction (mTICI) score≥2b with a single aspiration attempt. A multivariable logistic regression analysis was used to assess the predictors of SFP and evaluate the relationship between SFP and favorable 90-day outcome (90-day modified Rankin scale ≤2).
Results:
Out of 6123 patients included in STAR, 1002 (16.4%) underwent MT of M1 or M2 occlusion using ADAPT technique. SFP was achieved in 390 (38.9%) patients. SFP patients were older (72 vs. 69, P=0.007), had higher Alberta Stroke Program Early CT Score (ASPECTS) on presentation (9 vs. 8, P=0.018) (Table 1). On multivariable analysis, neither age (aOR 1.006, 95% CI 0.996-1.016, P=0.252) nor ASPECTS (aOR 1.055, 95% CI 0.976-1.141, P=0.179) were independent predictor of SFP. Importantly, SFP was independently associated with favorable 90-day outcome (aOR 2.769, 95% CI 1.988-3.858, P<0.001) after controlling for age, sex, ASPECTS, history of atrial fibrillation, NIHSS on presentation, onset to groin time and IV-tPA.
Conclusion:
In this cohort of patients with M1 or M2 occlsuion undergoing MT using ADAPT technique, patients who had SFP were older and had better ASPECTS. However, both age and ASPECTS were not independently associated with SFP. Also, patients who had SFP were almost 3 times more likely to achieve favorable 90-day outcome.
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Affiliation(s)
| | | | - Ali Alawieh
- Med Univ of South Carolina, MOUNT PLEASANT, SC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joon-tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
| | - Walter Casagrande
- Sanatorio Goemes and Hosp of Agudos Juan A Fernadez, Argentina, Argentina
| | | | | | | | | | | | | | | | | | - Peter Kan
- The Univ of Texas Med Branch, Galveston, TX
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Almallouhi E, Al Kasab S, Alawieh A, Chen S, BURKS JOSHUA, Wolfe S, Jabbour PM, Levitt M, Arthur AS, De Leacy RA, Grossberg JA, Ogilvy CS, Park MS, Raper D, Polifka A, Crowley RW, Dumont T, Osbun J, Crossa R, Maier I, Kim JT, Casagrande W, Rai A, Chowdhry S, Mokin M, Matouk C, Fragata I, Williamson R, Yoo AJ, Mascitelli J, Kan P, Psychogios M, Fargen K, Starke R, Spiotta AM. Abstract P6: Impact of Ethnicity on the Outcomes of Mechanical Thrombectomy- Insights From Star. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p6] [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:
Previous studies have reported that Hispanic stroke patients have limited access to mechanical thrombectomy (MT) compared to other ethnic groups. This has resulted in worse stroke outcomes in this group. However, limited data is available about the outcomes of MT in Hispanic patients.
Methods:
We used data from the Stroke Thrombectomy and Aneurysm Registry (STAR) that combined the prospectively maintained databases of 28 thrombectomy-capable stroke centers in the US, Europe, and Asia. Consecutive patients who underwent MT were included in these analyses and patients were divided into 2 groups (Hispanics vs. non-Hispanics). Baseline features, time from symptom onset, thrombolysis receipt, final thrombolysis in cerebral infarction (TICI) score, symptomatic hemorrhage, and 90-day functional outcomes (measured by modified Rankin scale-mRS) were compared between Hispanic and non-Hispanics patients. A generalized linear model with logit link was used to assess the relationship between ethnicity and favorable outcomes at 90-day (mRS 0-2) controlling for confounders.
Results:
We included 2015 patients in these analyses. Of those, 285 (14.1%) were Hispanic. As shown in table 1, Hispanic patients were older (72 vs. 70, p=0.007), more likely to have diabetes (41.1% vs. 26.5%, p<0.001), and more likely to have hypertension (81.8% vs. 73.7%, p=0.004). Importantly, Hispanics had a shorter procedure duration with a similar rate of successful recanalization (TICI≥2B). On multivariable analysis, Hispanic ethnicity was associated with a lower probability of favorable 90-day outcome (aOR 0.659, 95% CI 0.494-0.879, P=0.005) after controlling for age, stroke risk factors and location of occlusion.
Conclusion:
Hispanic patients receiving MT have higher rate of stroke risk factors including diabetes and hypertension. Moreover, Hispanic ethnicity was independently associated with lower probability of favorable 90-day outcome.
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Affiliation(s)
| | | | - Ali Alawieh
- Med Univ of South Carolina, MOUNT PLEASANT, SC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Gwangju, Korea, Republic of
| | - Walter Casagrande
- Sanatorio Goemes and Hosp of Agudos Juan A Fernadez, Argentina, Argentina
| | | | | | | | | | | | | | | | | | - Peter Kan
- The Univ of Texas Med Branch, Galveston, TX
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Hubbard Z, Porto GB, Al Kasab S, Almallouhi E, Spiotta AM, De Leacy RA, Raper D, rai A, Dumont T, Wolfe S, Jabbour PM, Ogilvy CS, Park MS, Levitt M, Polifka A, Crowley R, Arthur AS, Osbun J, Crosa R, Maier I, Kim JT, Casagrande W, Grossberg JA, Chowdhry SA, Mokin M, Matouk C, Fragata I, Williamson R, Yoo AJ, Mascitelli J, Kan P, Psychogios MN, Starke R. Abstract P500: Outcomes of Mechanical Thrombectomy in Patients With Low Aspects: Insights From Star. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p500] [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:
Patients with poor baseline images were excluded from most clinical trials so the data about whether these patients could benefit from MT remains unknown. In this study, we aim to investigate the safety and efficacy of MT in patients with large vessel occlusion (LVO) and large core infarct (LCI).
Methods:
The Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We included thrombectomy patients presenting with LVO within 24 hours and with a LCI as defined by Alberta Stroke Program Early CT Score (ASPECTS) < 6. Patients presenting within 6 hours of last known normal (LKN) were considered in the early window and patients presenting after 6 hours were considered in the late window. 90-day outcomes were assessed. We used a logistic regression model to assess the factors associated with good 90-day outcome in patients in the early and late windows.
Results:
144 patients were included in this study (table). Median age was 69 and 92 (64%) patients were treated in the early MT window. ICA was the most common site of occlusion (48.6%) and ADAPT was used in 34.7%. Admission NIHSS was 17.5. Successful recanalization (TICI>2b) was achieved in 84.7% and median procedure time was 54 minutes. sICH hemorrhage was observed in 22 (15.3%). Median mRS was 4 at 90 days. Favorable outcome was observed in 41 patients (28.5%) and mortality occurred in in 59 (41%). There was no difference in 90-day functional outcome between patients in early and late windows. In patients presenting in the early window, age (aOR=0.905, p=0.0002) and baseline NIHSS (aOR=0.909, p=0.0423) were independently associated with 90-day outcome. In patients presenting in the late window, only age (aOR=0.934, p=0.0069) was independently associated with good outcome.
Conclusion:
More than one in four patients presenting with ASPECTS<6 may achieve functional independence at 90-day following MT. Patient age remains the main predictor of 90-day outcome in patients with low ASPECTS in both late and early windows.
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Affiliation(s)
- Zachary Hubbard
- Dept of Neurosurgery, Med Univ of South Carolina, Charleston, SC
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Ilko Maier
- Dept of Neurosurgery, Universitätsmedizin Göttingen, Göttingen, Germany
| | | | | | | | | | | | | | | | | | | | | | - Peter Kan
- Baylor College of Medicine, Houston, TX
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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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Nogueira R, Siddiqui AH, De Meyer SF, Doyle K, Fiehler J, Hacke W, Hanel R, Liebeskind DS, Zaidat OO, Haussen DC, Humphries W, Woodward KB, Jabbour PM, Dashti SR, Bozorgchami H, Levy E, Schirmer CM, Taqi MA, De Leacy RA, Boor S, Hussain MS, Puri AS, Estrade L, Andersson T. Abstract P496: Clot Characteristics in Mechanical Thrombectomy: Interim Analysis of the EXCELLENT Registry. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p496] [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:
Red blood cell (RBC) rich vs fibrin rich clots have different mechanical properties and greater knowledge about clot composition in the context of clinical, imaging, and procedural factors in mechanical thrombectomy (MT) may help with procedural optimization. The EXCELLENT Registry (NCT03685578) is a prospective, global, multi-center, observational registry of EmboTrap as the first line MT device for large vessel occlusion (LVO). We present an interim analysis of clot collected per pass in the registry.
Methods:
Five hundred thirty-three clot specimens from 376 subjects were collected by 20 sites and sent for analysis by independent Central Labs under standardized protocol. Analysis was interrupted by COVID-19, but the labs were fully operational as of June 2020 and on track to deliver results for 300 subjects in Q4. At the time of abstract submission, composition data for 234 clots from 163 subjects was available. All available data will be presented at the time of the conference.
Results:
Cardioembolic etiology (n=100) was associated with lower RBC (40.2 vs 47.2%) and higher fibrin content (31.7 vs 26.7%) compared to large artery disease (n=12). Hyperdense/vessel susceptibility sign (78+, 24-, per independent imaging core lab) corresponded to higher mean RBC content (44.4 vs 34.9%). Treatment with IV tPA (60+, 91-) had no clear impact on clot composition (42.3 vs 40.6% RBC; 30.4 vs 30.0% fibrin). Notably, clots retrieved with the first 2 passes of were more RBC rich (42.1 vs 28.0%) and clots retrieved in higher passes had a higher average fibrin content (35.5 vs 29.6%) suggesting that higher fibrin content leads to greater refractoriness.
Conclusions:
Clot density/susceptibility on baseline imaging, stroke etiology and number of thrombectomy passes were associated with differential clot composition. These findings may have potential implications for the development of better MT strategies.
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Affiliation(s)
- Raul Nogueira
- Neurosurgery, Emory Univ Sch of Medicine, Atlanta, GA
| | | | - Simon F De Meyer
- Laboratory for Thrombosis Rsch, KU Leuven, Campus Kulak Kortrijk, Kortrijk, Belgium
| | | | | | | | | | | | | | | | | | - Keith B Woodward
- Dept of Radiology, TNVI Knoxville/ Fort Sanders Regional Med Cntr, Knoxville, TN
| | | | | | | | | | | | - Muhammad A Taqi
- Dept of Neurology, Los Robles Med Cntr, Vascular Neurology of Southern California, Thousand Oaks, CA
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45
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Siddiqui AH, Waqas M, Andersson T, De Meyers SF, Fiehler J, Hacke W, Hanel R, Jovin T, Liebeskind DS, Yoo AJ, Zaidat OO, Haussen DC, Inoa V, Woodward K, Humphries WE, Jabbour PM, Francois O, Dashti SR, Bozorgchami H, Levy E, Budzik R, Schirmer C, Taqi MA, Estrade L, De Leacy RA, Boor S, Hussain S, Puri AS, Estrade L, Nogueira RG. Abstract P14: Per Pass Clot Retrieval Technique: Interim Analysis of the Excellent Registry. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p14] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
EXCELLENT (NCT03685578) is a large, prospective, single-arm, multicenter, international registry of mechanical thrombectomy (MT) with EmboTrap as the first attempted device in routine clinical practice. The study collects per pass data on procedural and technical details that are based on interventionalists’ preference, providing an opportunity to assess current practices in MT across multiple international high-volume stroke centers.
Methods:
Subjects treated according to standard of care were eligible for inclusion in the study if EmboTrap was used in the first MT pass. Interim analysis focusing on procedural details and per pass clot retrieval technique was performed based on 689 subjects enrolled by 79 physicians across 26 international sites (US, Belgium, Germany, France) between Sept 2018 and Jul 2020.
Results:
Mean #passes was 2.1 (median=1, max=10), 50.3% subjects had only 1 pass and 84.8% had 3 or fewer. Per pass use of stent retriever, aspiration, balloon guide, intermediate catheter and long sheath catheter, along with technique details (e.g. incubation time, device positioning, co-aspiration) are summarized in Table 1. Rates and reasons for device changes are also given.
Conclusion:
Interim analysis of the ongoing EXCELLENT registry informs on current practice patterns in MT. This is the first report of detailed per pass clot retrieval strategies in a large international multicenter cohort.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | - Keith Woodward
- Radiology, TNVI Knoxville/ Fort Sanders Regional Med Cntr, Knoxville, NY
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46
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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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47
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Murchison AP, Sweid A, Dharia R, Theofanis TN, Tjoumakaris SI, Jabbour PM, Bilyk JR. Monocular visual loss as the presenting symptom of COVID-19 infection. Clin Neurol Neurosurg 2020; 201:106440. [PMID: 33383464 PMCID: PMC7831816 DOI: 10.1016/j.clineuro.2020.106440] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 12/06/2020] [Accepted: 12/10/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND IMPORTANCE Additional time is needed to determine the exact impact of COVID-19 on acute cerebrovascular disease incidence, but recently published data has correlated COVID-19 to large vessel occlusion strokes. CLINICAL PRESENTATION We report the first case of central retinal artery occlusion (CRAO) as the initial manifestation of COVID-19 infection. Subsequent neuroimaging revealed a large thrombus extending into the internal carotid artery. CONCLUSION This case illustrates the need to suspect COVID-19 infection in patients presenting with retinal arterial occlusion, including individuals who are asymptomatic or minimally symptomatic for COVID-19 infection.
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Affiliation(s)
- Ann P Murchison
- Eye Emergency Room, Wills Eye Hospital & Associate Professor, Department of Emergency Medicine, Thomas Jefferson University Hospital, Philadelphia, PA, United States; Oculoplastic and Orbital Surgery Service, Wills Eye Hospital, Philadelphia, PA, United States.
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Robin Dharia
- Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Thana N Theofanis
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
| | - Jurij R Bilyk
- Oculoplastic and Orbital Surgery Service, Wills Eye Hospital, Philadelphia, PA, United States.
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48
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Ghosh R, Chalouhi N, Sweid A, Saiegh FA, Khanna O, Mouchtouris N, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour PM. Carotid cutdown for mechanical thrombectomy in the setting of intravenous tissue plasminogen activator: A technical report. J Clin Neurosci 2020; 81:302-305. [PMID: 33222934 DOI: 10.1016/j.jocn.2020.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 09/16/2020] [Accepted: 10/03/2020] [Indexed: 01/16/2023]
Abstract
Acute ischemic stroke (AIS) is a leading cause of mortality and morbidity in the world. Patients are usually treated with endovascular methods and access is often gained trans-femoral or trans-radial. In patients with difficult anatomy, in rare cases the approach must be done trans-cervical. Our case illustrates a patient who received IVTPA prior to attempted endovascular treatment, leading to a direct carotid cutdown for mechanical thrombectomy. Our patient presented with a left M1 occlusion and had received intravenous thrombolytic at the presentation of his symptoms. Due to unfavorable anatomy and tortuous aortic arch, conventional access could not be obtained. In order to achieve reperfusion while maintaining hemostasis, a decision was made to perform an open carotid cutdown to catherize the left internal carotid artery to successfully retrieve the thrombus. This resulted in a TICI2B revascularization. This is the first reported case of direct carotid access in the setting of acute ischemic stroke with IVTPA. Open technique allowed us to maintain hemostasis while bypassing the tortuous arch and achieving reperfusion and give the patient the best chance for a functional recovery.
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Affiliation(s)
- Ritam Ghosh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Fadi Al Saiegh
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Nikolaos Mouchtouris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Michael Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, United States.
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49
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Khanna O, Velagapudi L, Das S, Sweid A, Mouchtouris N, Al Saiegh F, Avery MB, Chalouhi N, Schmidt RF, Sajja K, Gooch MR, Tjoumakaris S, Rosenwasser RH, Jabbour PM. A comparison of radial versus femoral artery access for acute stroke interventions. J Neurosurg 2020; 135:727-732. [PMID: 33186909 DOI: 10.3171/2020.7.jns201174] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 07/02/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE In this study, the authors aimed to investigate procedural and clinical outcomes between radial and femoral artery access in patients undergoing thrombectomy for acute stroke. METHODS The authors conducted a single-institution retrospective analysis of 104 patients who underwent mechanical thrombectomy, 52 via transradial access and 52 via traditional transfemoral access. They analyzed various procedural and clinical metrics between the two patient cohorts. RESULTS There was no difference between patient demographics or presenting symptoms of stroke severity between patients treated via transradial or transfemoral access. The mean procedural time was similar between the two treatment cohorts: 60.35 ± 36.81 minutes for the transradial group versus 65.50 ± 29.92 minutes for the transfemoral group (p = 0.451). The mean total fluoroscopy time for the procedure was similar between the two patient cohorts (20.31 ± 11.68 for radial vs 18.49 ± 11.78 minutes for femoral, p = 0.898). The majority of patients underwent thrombolysis in cerebral infarction score 2b/3 revascularization, regardless of access site (92.3% for radial vs 94.2% for femoral, p = 0.696). There was no significant difference in the incidence of access site or periprocedural complications between the transradial and transfemoral cohorts. CONCLUSIONS Acute stroke intervention performed via transradial access is feasible and effective, with no significant difference in procedural and clinical outcomes compared with traditional transfemoral access. Larger studies are required to further validate the efficacy and limitations of transradial access for neurointerventional procedures.
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50
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Schmidt RF, Sweid A, Chalouhi N, Avery MB, Sajja KC, Al-Saiegh F, Weinberg JH, Asada A, Joffe D, Zarzour HK, Gooch MR, Rosenwasser RH, Jabbour PM, Tjoumakaris SI. Endovascular Management of Complex Fenestration-Associated Aneurysms: A Single-Institution Retrospective Study and Review of Existing Techniques. World Neurosurg 2020; 146:e607-e617. [PMID: 33130285 DOI: 10.1016/j.wneu.2020.10.131] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 10/24/2020] [Accepted: 10/26/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Aneurysms associated with fenestrations of intracranial arteries are exceptionally rare findings. Management strategies for these aneurysms are not well-defined, especially regarding endovascular treatment. We sought to investigate the strategies and feasibility of endovascular treatment approaches for various fenestration-associated intracranial aneurysms. METHODS We performed a retrospective chart review of 2000 aneurysms treated endovascularly, identifying 8 aneurysms located at arterial fenestrations. The technical details and procedural outcomes were reviewed to identify common management approaches, technical nuances, and treatment outcomes. RESULTS There were 3 (37.5%) aneurysms associated with fenestrations of the basilar artery or vertebrobasilar junction. All 3 were successfully treated with a previously undescribed coil-assisted flow-diversion technique, resulting in complete obliteration. Three (37.5%) aneurysms were associated with fenestrations of the anterior communicating artery. Of those, 2 were successfully treated with stent-assisted coil embolization and 1 with coil embolization alone. One (12.5%) aneurysm was associated with a fenestration of the paraclinoid internal carotid artery and 1 (12.5%) aneurysm found was at the takeoff of the posterior inferior cerebellar artery at a fenestration of the vertebral artery. Both were successfully treated with coil-assisted flow diversion. There were no permanent procedural complications. Major considerations for endovascular management of these aneurysms were the dominance of fenestration trunks, aneurysms arising from the fenestration apex or a fenestration limb, amenability to flow diversion, and anticipation of vascular remodeling. CONCLUSIONS Fenestration-associated aneurysms are very rare. We have identified common factors to help guide decision-making for endovascular approaches and demonstrate successful aneurysm treatment using these methods.
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Affiliation(s)
- Richard F Schmidt
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Nohra Chalouhi
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael B Avery
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kalyan C Sajja
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Fadi Al-Saiegh
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Joshua H Weinberg
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Ashlee Asada
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Joffe
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Hekmat K Zarzour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - M Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pascal M Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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