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Schartz D, Finkelstein A, Zhong J, Brinjikji W, Bender MT. Improved Cerebral Glymphatic Flow after Transvenous Embolization of CSF-Venous Fistula. AJNR Am J Neuroradiol 2024:ajnr.A8229. [PMID: 38697791 DOI: 10.3174/ajnr.a8229] [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: 01/08/2024] [Accepted: 02/06/2024] [Indexed: 05/05/2024]
Abstract
Spontaneous intracranial hypotension is characterized by symptoms of low intracranial CSF volume due to various mechanisms of CSF leakage. One such mechanism is a CSF-venous fistula, treatable with transvenous embolization resulting in substantial radiographic and clinical improvement. However, the exact mechanisms underlying these improvements, including the potential involvement of the glymphatic system, remain unclear. To noninvasively assess glymphatic clearance in spontaneous intracranial hypotension, we used an advanced MR imaging technique called the DTI along the perivascular spaces in 3 patients with CSF-venous fistula before and after embolization. All 3 patients with spontaneous intracranial hypotension initially had low glymphatic flow, which improved postembolization. Two patients with symptomatic improvement exhibited a more substantial increase in glymphatic flow compared with a patient with minimal improvement. These findings suggest a possible link between cerebral glymphatics in spontaneous intracranial hypotension pathophysiology and symptomatic improvement, warranting larger studies to explore the role of the glymphatic system in spontaneous intracranial hypotension.
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Affiliation(s)
- Derrek Schartz
- From the Department of Imaging Sciences (D.S. A.F., J.Z.), University of Rochester Medical Center, Rochester, New York
| | - Alan Finkelstein
- From the Department of Imaging Sciences (D.S. A.F., J.Z.), University of Rochester Medical Center, Rochester, New York
| | - Jianhui Zhong
- From the Department of Imaging Sciences (D.S. A.F., J.Z.), University of Rochester Medical Center, Rochester, New York
| | - Waleed Brinjikji
- Department of Radiology (W.B.), Mayo Clinic, Rochester, Minnesota
| | - Matthew T Bender
- Department of Neurosurgery (M.T.B.), University of Rochester Medical Center, Rochester, New York
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Schartz D, Rahmani R, Gunturi A, Kohli GS, Akkipeddi SMK, Ellens NR, Romiyo P, Kessler A, Bhalla T, Mattingly TK, Bender MT. Observation versus intervention for Borden type I intracranial dural arteriovenous fistula: A pooled analysis of 469 patients. Interv Neuroradiol 2024; 30:175-182. [PMID: 36113111 DOI: 10.1177/15910199221127070] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024] Open
Abstract
BACKGROUND While it is thought that Borden Type I intracranial dural arteriovenous fistula (dAVF) have a benign clinical course, their management remains controversial. METHODS A comparative meta-analysis was completed to evaluate the outcomes of intervention verses observation of Borden Type I intracranial dAVF. Outcome measures included: grade progression, worsening symptoms, death due to dAVF, permanent complications other than death, functional independence (mRS 0-2), and rate of death combined with permanent complication, were evaluated. Risk differences (RD) were determined using a random effects model. RESULTS Three comparative studies combined with the authors' institutional experience resulted in a total of 469 patients, with 279 patients who underwent intervention and 190 who were observed. There was no significant difference in dAVF grade progression between the intervention and observation arms, 1.8% vs. 0.7%, respectively (RD: 0.01, 95% CI: -0.02 to 0.04, P = 0.49), or in symptom progression occurring in 31/279 (11.1%) intervention patients and 11/190 (5.8%) observation patients (RD: 0.03, CI: -0.02 to 0.09, P = 0.28). There was also no significant difference in functional independence on follow up. However, there was a significantly higher risk of dAVF related death, permanent complication from either intervention or dAVF related ICH or stroke in the intervention group (11/279, 3.9%) compared to the observation group (0/190, 0%) (RD: 0.04, CI: 0.1 to 0.06, P = 0.007). CONCLUSION Intervention of Borden Type I dAVF results in a higher risk of death or permanent complication, which should be strongly considered when deciding on management of these lesions.
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Affiliation(s)
- Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Aditya Gunturi
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Gurkirat Singh Kohli
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Nathaniel R Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Prasanth Romiyo
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
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Ellens NR, Schartz D, Kohli G, Rahmani R, Akkipeddi SMK, Mattingly TK, Bhalla T, Bender MT. Safety and efficacy comparison of embolic agents for middle meningeal artery embolization for chronic subdural hematoma. J Cerebrovasc Endovasc Neurosurg 2024; 26:11-22. [PMID: 37828746 PMCID: PMC10995466 DOI: 10.7461/jcen.2023.e2023.04.002] [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: 04/14/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 10/14/2023] Open
Abstract
OBJECTIVE To perform a systematic review and meta-analysis evaluating the efficacy of middle meningeal artery embolization in terms of both clinical and radiographic outcomes, when performed with different embolic agents. METHODS A systematic literature review and meta-analysis was performed to evaluate the impact of embolic agents on outcomes for middle meningeal artery (MMA) embolization. The use of polyvinyl alcohol (PVA) with or without (±) coils, N-butyl cyanoacrylate (n-BCA) ± coils, and Onyx alone were separately evaluated. Primary outcome measures were recurrence, the need for surgical rescue and in-hospital periprocedural complications. RESULTS Thirty-one studies were identified with a total of 1,134 patients, with 786 receiving PVA, 167 receiving n-BCA, and 181 patients receiving Onyx. There was no difference in the recurrence rate (5.5% for PVA, 4.5% for n-BCA, and 6.5% for Onyx, with P=0.71) or need for surgical rescue (5.0% for PVA, 4.0% for n-BCA, and 6.9% for Onyx, with P=0.89) based on the embolic agent. Procedural complications also did not differ between embolic agents (1.8% for PVA, 3.6% for n-BCA, and 1.6% for Onyx, with P=0.48). CONCLUSIONS Rates of recurrence, need for surgical rescue, and periprocedural complication following MMA embolization are not impacted by the type of embolic agent utilized. Ongoing clinical trials may be used to further investigate these findings.
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Affiliation(s)
- Nathaniel R. Ellens
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, New York, USA
| | - Gurkirat Kohli
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | | | - Thomas K. Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, New York, USA
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Schartz D, Finkelstein A, Hoang N, Bender MT, Schifitto G, Zhong J. Diffusion-Weighted Imaging Reveals Impaired Glymphatic Clearance in Idiopathic Intracranial Hypertension. AJNR Am J Neuroradiol 2024; 45:149-154. [PMID: 38238097 DOI: 10.3174/ajnr.a8088] [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: 08/14/2023] [Accepted: 11/02/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND AND PURPOSE The pathophysiology underlying idiopathic intracranial hypertension (IIH) remains incompletely understood. While one theory postulates impaired cerebral glymphatic clearance in IIH, there is a paucity of methods to quantify glymphatic activity in human brains. The purpose of this study was to use advanced diffusion-weighed imaging to evaluate the glymphatic clearance of IIH patients and how it may relate to clinical severity. MATERIALS AND METHODS DWI was used to separately evaluate the diffusivity along the cerebral perivascular spaces and lateral association and projection fibers, with the degree of diffusivity used as a surrogate for glymphatic function (diffusion tensor image analysis along the perivascular space. Patients with IIH were compared with normal controls. Glymphatic clearance was correlated with several clinical metrics, including lumbar puncture opening pressure and Frisen papilledema grade (low grade: 0-2; high grade: 3-5). RESULTS In total, 99 patients with IIH were identified and compared with 6 healthy controls. Overall, patients with IIH had significantly lower glymphatic clearance based on DWI-derived diffusivity compared with controls (P = .005). Additionally, in patients with IIH, there was a significant association between declining glymphatic clearance and increasing Frisen papilledema grade (P = .046) but no correlation between opening pressure and glymphatic clearance (P = .27). Furthermore, healthy controls had significantly higher glymphatic clearance compared with patients with IIH and low-grade papilledema (P = .015) and high-grade papilledema (P = .002). Lastly, patients with IIH and high-grade papilledema had lower glymphatic clearance compared with patients with IIH and low-grade papilledema (P = .005). CONCLUSIONS Patients with IIH possess impaired glymphatic clearance, which is directly related to the extent of clinical severity. The DWI-derived parameters can be used for clinical diagnosis or to assess response to treatment.
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Affiliation(s)
- Derrek Schartz
- From the Department of Imaging Sciences (D.S., A.F., N.H., G.S., J.Z.), University of Rochester Medical Center, Rochester, New York
| | - Alan Finkelstein
- From the Department of Imaging Sciences (D.S., A.F., N.H., G.S., J.Z.), University of Rochester Medical Center, Rochester, New York
| | - Nhat Hoang
- From the Department of Imaging Sciences (D.S., A.F., N.H., G.S., J.Z.), University of Rochester Medical Center, Rochester, New York
| | - Matthew T Bender
- Department of Neurosurgery (M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Giovanni Schifitto
- From the Department of Imaging Sciences (D.S., A.F., N.H., G.S., J.Z.), University of Rochester Medical Center, Rochester, New York
- Department of Neurology (G.S.), University of Rochester Medical Center, Rochester, New York
| | - Jianhui Zhong
- From the Department of Imaging Sciences (D.S., A.F., N.H., G.S., J.Z.), University of Rochester Medical Center, Rochester, New York
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Akkipeddi SMK, Rahmani R, Schartz D, Chittaranjan S, Ellens NR, Kohli GS, Bhalla T, Mattingly TK, Welle K, Morrell CN, Bender MT. Stroke emboli from patients with atrial fibrillation enriched with neutrophil extracellular traps. Res Pract Thromb Haemost 2024; 8:102347. [PMID: 38496712 PMCID: PMC10943055 DOI: 10.1016/j.rpth.2024.102347] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 01/19/2024] [Accepted: 02/01/2024] [Indexed: 03/19/2024] Open
Abstract
Background Recent literature has demonstrated remarkable heterogeneity in the composition of acute ischemic stroke (AIS) emboli, which may impact susceptibility to therapy. Objectives In this study, we explored differences in proteomic composition of retrieved embolic material from patients with stroke with and without atrial fibrillation (AF) (AF+ and AF-, respectively). Methods The full proteome of retrieved thromboembolic material from 24 patients with AIS was obtained by mass spectrometry. Known marker proteins were assigned groups representing broad classes of embolus components: red blood cells, platelets, neutrophils, eosinophils, histones, complement, and other clotting-associated proteins (eg, fibrinogen). Relative protein abundances were compared between AF+ and AF- samples. Functional implications of differences were explored with gene set enrichment analysis and Gene Ontology enrichment analysis and visualization tool. Results One hundred sixty-six proteins were differentially expressed between AF+ and AF- specimens. Eight out of the 15 neutrophil proteins (P < .05; fold change, >2) and 4 of the 14 histone proteins were significantly enriched in AF+ emboli (P < .05; fold change, >2). Gene set enrichment analysis revealed a significant representation of proteins from published neutrophil extracellular trap (NET) proteomic gene sets. The most significantly represented functional Gene Ontology pathways in patients with AF involved neutrophil activation and degranulation (P < 1 × 10-7). Conclusion The present analysis suggests enrichment of NETs in emboli of patients with stroke and AF. NETs are a significant though understudied structural component of thrombi. This work suggests not only unique stroke biology in AF but also potential therapeutic targets for AIS in this population.
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Affiliation(s)
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Siddharth Chittaranjan
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Nathaniel R. Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Gurkirat S. Kohli
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas K. Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Kevin Welle
- Mass Spectrometry Research Laboratory, University of Rochester Medical Center, Rochester, New York, USA
| | - Craig N. Morrell
- Aab Cardiovascular Research Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Schartz D, Akkipeddi SMK, Rahmani R, Ellens N, Houk C, Kohli GS, Worley L, Welle K, Bhalla T, Mattingly T, Morrell C, Bender MT. Ischemic Stroke Thrombus Perviousness Is Associated with Distinguishable Proteomic Features and Susceptibility to ADAMTS13-Augmented Thrombolysis. AJNR Am J Neuroradiol 2023; 45:22-29. [PMID: 38123915 PMCID: PMC10756583 DOI: 10.3174/ajnr.a8069] [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: 07/13/2023] [Accepted: 10/20/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND AND PURPOSE Perviousness is the differential attenuation on CT of an intracranial arterial occlusive thrombus before and after IV contrast administration. While perviousness/permeability has been shown to be related to various clinical outcomes and reflects histopathologic composition, it remains unclear whether perviousness is also associated with differences in proteomic composition. MATERIALS AND METHODS Retrieved clots from 59 patients were evaluated with quantitative mass spectrometry. Proteomic differences between high-perviousness (≥11 HU) and low-perviousness (<11 HU) clots were investigated. Perviousness as a continuous variable was also correlated with protein abundance. Last, an ex vivo lysis assay was performed to investigate the differential susceptibility to tPA, deoxyribonuclease, and ADAMTS13 thrombolysis as a function of perviousness. RESULTS In total, 2790 distinct proteins were identified. Thrombus perviousness was associated with distinct proteomic features, including depletion of the macrophage marker CD14 (P = .039, z = 1.176) and hemoglobin subunit ζ (P = .046, z = 1.68) in pervious clots. Additionally, proteins involved in platelet cytoskeleton remodeling (tropomyosin α-3-chain) and granule secretion/aggregation (synaptotagmin-like protein 4/FC region receptor II-a) were associated with increasing perviousness (P < .006), among numerous other proteins. Monocyte/macrophage-associated proteins (apoptosis-associated specklike protein containing a CARD/SAMHD1) were also depleted in pervious emboli (P < .002). Ex vivo lysis indicated that pervious clots were more susceptible to ADAMTS13-augmented tPA thrombolysis compared with impervious clots (P < .05), though without differences in deoxyribonuclease digestion. CONCLUSIONS Thrombus perviousness is associated with complex proteomic features, including differential abundance of platelet-related proteins in highly permeable clots with monocyte/macrophage depletion. This association may help to explain why highly pervious thrombi were also found more susceptible to ADAMTS13-augmented thrombolysis.
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Affiliation(s)
- Derrek Schartz
- From the Department of Imaging Sciences (D.S., L.W.), University of Rochester Medical Center, Rochester, New York
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Sajal Medha K Akkipeddi
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Redi Rahmani
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Nathaniel Ellens
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Clifton Houk
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Gurkirat Singh Kohli
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Logan Worley
- From the Department of Imaging Sciences (D.S., L.W.), University of Rochester Medical Center, Rochester, New York
| | - Kevin Welle
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Tarun Bhalla
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Thomas Mattingly
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
| | - Craig Morrell
- Aab Cardiovascular Research Institute (C.M.), University of Rochester Medical Center, Rochester, New York
| | - Matthew T Bender
- Department of Neurosurgery (D.S., S.M.K.A., R.R., N.E., C.H., G.S.K., K.W., T.B., T.M., M.T.B.), University of Rochester Medical Center, Rochester, New York
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Ellens NR, Schartz D, Ismail R, Kessler A, Ellika S, Akkipeddi SMK, Rahmani R, Bender MT. Efficacy of transvenous embolization of CSF-venous fistula in spontaneous intracranial hypotension: Case-series. Interv Neuroradiol 2023:15910199231221449. [PMID: 38130106 DOI: 10.1177/15910199231221449] [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: 12/23/2023] Open
Abstract
BACKGROUND Spontaneous intracranial hypotension is a debilitating neurological condition which can be caused by a cerebrospinal fluid-venous fistula. Transvenous embolization is a promising technique to provide minimally invasive yet durable treatment. METHODS A retrospective single-center case series was performed on all patients who underwent transvenous embolization of a cerebrospinal fluid (CSF)-venous fistula. Clinical and radiographic parameters, including Bern score, were reported preoperatively and at 3-month follow-up. RESULTS Six patients underwent embolization of a CSF-venous fistula. All fistulae were located in the thoracic spine and technical success was achieved in all cases. Three patients had symptom resolution, two had significant improvement, and one had stable symptoms on follow-up. The mean Bern score was 6.83 (SD = 1.47) preoperatively and 1.83 (SD = 1.64) postoperatively with a mean improvement in Bern score of 5.0 (SD = 1.9, p = 0.0013). CONCLUSIONS CSF-venous fistulas are an increasingly recognized clinical entity which may be treated with transvenous embolization. This case series serves to further validate this technique and suggests it can be performed with similar outcomes in lower volume centers.
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Affiliation(s)
- Nathaniel R Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Shehenaz Ellika
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Redi Rahmani
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
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Schartz D, Akkipeddi SMK, Chittaranjan S, Rahmani R, Gunturi A, Ellens N, Kohli GS, Kessler A, Mattingly T, Morrell C, Bhalla T, Bender MT. CT hyperdense cerebral artery sign reflects distinct proteomic composition in acute ischemic stroke thrombus. J Neurointerv Surg 2023; 15:1264-1268. [PMID: 36878687 DOI: 10.1136/jnis-2022-019937] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Hyperdense cerebral artery sign (HCAS) is an imaging biomarker in acute ischemic stroke (AIS) that has been shown to be associated with various clinical outcomes and stroke etiology. While prior studies have correlated HCAS with histopathological composition of cerebral thrombus, it is unknown whether and to what extent HCAS is also associated with distinct clot protein composition. METHODS Thromboembolic material from 24 patients with AIS were retrieved via mechanical thrombectomy and evaluated with mass spectrometry in order to characterize their proteomic composition. Presence (+) or absence (-) of HCAS on preintervention non-contrast head CT was then determined and correlated with thrombus protein signature with abundance of individual proteins calculated as a function HCAS status. RESULTS 24 clots with 1797 distinct proteins in total were identified. 14 patients were HCAS(+) and 10 were HCAS(-). HCAS(+) were most significantly differentially abundant in actin cytoskeletal protein (P=0.002, Z=2.82), bleomycin hydrolase (P=0.007, Z=2.44), arachidonate 12-lipoxygenase (P=0.004, Z=2.60), and lysophospholipase D (P=0.007, Z=2.44), among other proteins; HCAS(-) clots were differentially enriched in soluble N-ethylmaleimide-sensitive factor (NSF) attachment protein (P=0.0009, Z=3.11), tyrosine-protein kinase Fyn (P=0.002, Z=2.84), and several complement proteins (P<0.05, Z>1.71 for all), among numerous other proteins. Additionally, HCAS(-) thrombi were enriched in biological processes involved with plasma lipoprotein and protein-lipid remodeling/assembling, and lipoprotein metabolic processes (P<0.001), as well as cellular components including mitochondria (P<0.001). CONCLUSIONS HCAS is reflective of distinct proteomic composition in AIS thrombus. These findings suggest that imaging can be used to identify mechanisms of clot formation or maintenance at the protein level, and might inform future research on thrombus biology and imaging characterization.
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Affiliation(s)
- Derrek Schartz
- Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Sajal Medha K Akkipeddi
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Siddharth Chittaranjan
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Aditya Gunturi
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Nathaniel Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Gurkirat Singh Kohli
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Alex Kessler
- Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Craig Morrell
- Aab Cardiovascular Research Institute, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Schartz D, Ellens N, Ismail R, Houk C, Kessler A, Ellika S, Bender MT. Prevalence of SLEC-negative spontaneous intracranial hypotension in patients with spinal nerve root sleeve diverticula on MRI. Neuroradiol J 2023; 36:736-739. [PMID: 37589060 PMCID: PMC10649535 DOI: 10.1177/19714009231196467] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023] Open
Abstract
PURPOSE While there is thought to be an association between spinal nerve root diverticula (NRD) and spontaneous intracranial hypotension (SIH) without a spinal longitudinal epidural collection (SLEC), it remains unclear what the overall prevalence of SLEC-negative SIH is in patients with NRD on MRI. METHODS Spine MRI imaging reports from our single institution were electronically screened for instances of NRD over a 9-year period (2016-2023). From these cases, patients with brain MRIs consistent with SIH were also identified. Subsequently, the overall proportion of SLEC-negative SIH was determined as a function of total cases with NRD based on spinal level. RESULTS In total, 83,843 patients with spinal MRIs were screened which identified 4174 (4.97%) with NRD. From these, there were 1203 cervical, 622 thoracic, and 2979 lumbosacral spine MRIs. In total, 16 patients (0.38%; Standard Error [SE]: 0.48%-0.28%) had a brain MRI compatible with SLEC-negative SIH and met ICHD-3 criteria. Patients with cervical NRD had SIH in 2 cases (0.16%; SE: 0.27%-0.05%). SLEC-negative SIH was present in 11 patients with lumbosacral NRD (0.34%; SE: 0.44%-0.24%). In patients with diverticula in the thoracic spine, 14 (2.3%; SE: 2.8%-1.8%) had SLEC-negative SIH. SLEC-negative SIH was significantly more prevalent in patients with thoracic diverticula compared to those with cervical (p<.0001) or lumbosacral NRD (p<.0001). CONCLUSION In patients with spinal NRD, concurrent SLEC-negative SIH is present in approximately 0.38% of patients, suggesting that in the vast majority of cases, they are an incidental finding. However, SIH is present in approximately 2.3% of patients with thoracic NRD and may be more specific for leak localization.
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Affiliation(s)
- Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, USA
- Department of Neurosurgery, University of Rochester Medical Center, USA
| | - Nathaniel Ellens
- Department of Neurosurgery, University of Rochester Medical Center, USA
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, USA
| | - Clifton Houk
- Department of Neurosurgery, University of Rochester Medical Center, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, USA
| | - Shehanaz Ellika
- Department of Imaging Sciences, University of Rochester Medical Center, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, USA
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Schartz D, Susa S, Ellens N, Akkipeddi SMK, Houk C, Bhalla T, Mattingly T, Hasan D, Bender MT. Symptomatic carotid artery intraluminal thrombus: risk of medical management failure and distal embolization. J Neurointerv Surg 2023:jnis-2023-021044. [PMID: 38041660 DOI: 10.1136/jnis-2023-021044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 11/11/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Carotid artery intraluminal thrombus (ILT), or free-floating thrombus, is an uncommon cerebrovascular entity with considerable equipoise regarding its clinical management. Likewise, in patients treated with medical management (MM), distal embolization and/or intracranial hemorrhage (ICH) may still occur. METHODS All patients with symptomatic ILT from 2016 to 2023 were identified from our tertiary care institution. Patients with MM failure (recurrent cerebral ischemia and/or symptomatic ICH) were compared with patients with MM non-failure. Differences in ILT volume and length were calculated. Receiver operator characteristic (ROC) curve analysis was used to identify the cut-off volume and length for risk of MM failure. RESULTS In total, 45 patients with ILT were identified with 41 treated with frontline MM. Of these 41 patients treated with MM, seven (17%) had MM failure with six (14.6%) having new embolic stroke and one (2.3%) with symptomatic ICH. Patients with MM failure had a significantly higher mean thrombus volume than MM non-failure patients (257 mm3 vs 59.6 mm3, P=0.0006). Likewise, patients with MM failure had significantly longer thrombus on average (21 mm vs 6.6 mm, P=0.0009). ROC curve analysis showed that an ILT volume of 90 mm3 resulted in a sensitivity of 71.4% and specificity of 85.3% for MM failure (AUC 0.775; CI 0.55 to 1.0, P=0.023). CONCLUSIONS Carotid ILTs that fail MM are significantly larger and longer. These findings suggest that a thrombus volume of 90 mm3 may serve as a guide for intervention with good sensitivity and specificity for risk of MM failure.
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Affiliation(s)
- Derrek Schartz
- Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Stephen Susa
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Nathaniel Ellens
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Clifton Houk
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas Mattingly
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - David Hasan
- Neurosurgery, Duke University, Durham, North Carolina, USA
| | - Matthew T Bender
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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11
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Ismail R, Schartz D, Hoang T, Kessler A. Middle meningeal artery pseudoaneurysm and pterygoid plexus fistula following percutaneous radiofrequency rhizotomy: illustrative case. J Neurosurg Case Lessons 2023; 6:CASE23237. [PMID: 37931246 PMCID: PMC10631543 DOI: 10.3171/case23237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 09/28/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Percutaneous treatment for trigeminal neuralgia is a safe and effective therapeutic methodology and can be accomplished in the form of balloon compression, glycerol rhizotomy, and radiofrequency thermocoagulation. These procedures are generally well tolerated and demonstrate minimal associated morbidity. Moreover, vascular complications of these procedures are exceedingly rare. OBSERVATIONS We present the case of a 64-year-old female with prior microvascular decompression and balloon rhizotomy who presented after symptom recurrence and underwent a second balloon rhizotomy at our institution. Soon thereafter, she presented with pulsatile tinnitus and a right preauricular bruit on physical examination. Subsequent imaging revealed a middle meningeal artery (MMA) to pterygoid plexus fistula and an MMA pseudoaneurysm. Coil and Onxy embolization were used to manage the pseudoaneurysm and fistula. LESSONS This case illustrates the potential for MMA pseudoaneurysm formation as a complication of percutaneous trigeminal balloon rhizotomy, which has not been seen in the literature. Concurrent MMA-pterygoid plexus fistula is also a rarity demonstrated in this case.
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12
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Schartz D, Ellens N, Kohli GS, Rahmani R, Akkipeddi SMK, Colby GP, Hui F, Bhalla T, Mattingly T, Bender MT. Impact of aspiration catheter size on clinical outcomes in aspiration thrombectomy. J Neurointerv Surg 2023; 15:e111-e116. [PMID: 35918126 DOI: 10.1136/jnis-2022-019246] [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] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 07/19/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Direct aspiration thrombectomy is a well-established method for mechanical thrombectomy in acute ischemic stroke. Yet, the influence of aspiration catheter internal diameter (ID) on aspiration thrombectomy efficacy is incompletely understood. METHODS A systematic literature review and meta-regression analysis was completed to evaluate the impact of primary aspiration thrombectomy outcomes based on the ID of the aspiration catheter. Primary outcome measures were: final recanalization of modified Thrombolysis In Cerebral Ischemia (mTICI) 2b-3 with aspiration only and with rescue modalities, first pass effect (FPE), need for rescue modalities, intracranial hemorrhagic complication rates, and functional outcomes of 90-day modified Rankin Scale (mRS) of 0-2. RESULTS 30 studies were identified with 3228 patients. Meta-regression analysis revealed a significant association between increasing aspiration catheter ID and FPE (p=0.032), between ID and final recanalization with aspiration only (p=0.05), and between ID size and recanalization including cases with rescue modalities (p=0.002). Further, subgroup analysis indicated that catheters with an ID ≥0.064 inch had a lower rate of need for rescue than smaller catheters (p=0.013). Additionally, catheters with an ID ≥0.068 inch had a higher rate of intracranial bleeding complications (p=0.025). Lastly, no significant association was found in functional outcomes overall. CONCLUSIONS Larger aspiration catheters are associated with a higher rate of FPE, final recanalization with only an aspiration catheter, and in cases with rescue modalities, though with a higher rate of hemorrhagic complications. These findings confirm that aspiration catheter size functions as a variable in aspiration thrombectomy, which should be considered in future study and trial design.
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Affiliation(s)
- Derrek Schartz
- Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Nathaniel Ellens
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Redi Rahmani
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Geoffrey P Colby
- Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Ferdinand Hui
- Neuroscience Institute, Division of Neurointerventional Surgery, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Tarun Bhalla
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas Mattingly
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew T Bender
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Schartz D, Furst T, Ellens N, Kohli GS, Rahmani R, Akkipeddi SMK, Schmidt T, Bhalla T, Mattingly T, Bender MT. Preoperative Embolization of Meningiomas Facilitates Reduced Surgical Complications and Improved Clinical Outcomes : A Meta-analysis of Matched Cohort Studies. Clin Neuroradiol 2023; 33:755-762. [PMID: 36854814 DOI: 10.1007/s00062-023-01272-4] [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: 11/07/2022] [Accepted: 01/24/2023] [Indexed: 03/02/2023]
Abstract
PURPOSE The utility of preoperative embolization (PE) of intracranial meningiomas is unclear and controversial. The aim of this study was to investigate the effect of PE on meningioma surgical resection by completing a meta-analysis of matched cohort studies. METHODS A systematic review and meta-analysis of matched cohort studies was completed to evaluate the effect of PE on meningioma resection and outcomes. Outcome measures included: intraoperative blood loss, major surgical complications, total surgical complications including minor ones, total major complications including major surgical and embolization complications, total overall complications, and postoperative functional independence defined as modified Rankin Score (mRS) of 0-2. Pooled odds ratios (OR) were determined via a fixed effects model. RESULTS A total of 6 matched cohort studies were identified with 219 embolized and 215 non-embolized meningiomas. There was no significant difference in intraoperative blood loss between the two groups (P = 0.87); however, the embolization group had a significantly lower odds ratio of major surgically related complications (OR: 0.37, 95% confidence interval, CI: 0.21-0.67, P = 0.0009, I2 = 0%), but no difference in minor surgical complications (P = 0.86). While there was a significantly lower odds ratio of total overall surgical and PE-related complications in PE cases (OR: 0.64, CI: 0.41-1.0, P = 0.05, I2 = 66%), there was no difference in total combined major complications between the groups (OR: 0.57, CI: 0.27-1.18, P = 0.13, I2 = 33%). Lastly, PE was associated with a higher odds ratio of functional independence on postoperative follow-up (OR: 2.3, CI: 1.06-5.02, P = 0.04, I2 = 0%). CONCLUSION For certain meningiomas, PE facilitates lower overall complications, lower major surgical complications, and improved functional independence. Further research is required to identify the particular subset of meningiomas that benefit from PE.
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Affiliation(s)
- Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA.
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA.
| | - Taylor Furst
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Nathaniel Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Gurkirat Singh Kohli
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | | | - Tyler Schmidt
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Thomas Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
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Schartz D, Manganaro M, Szekeres D, Ismail R, Hoang T, Worley L, Finkelstein A, Schartz C, Akkipeddi SMK, Bender MT, Kessler A. Direct percutaneous puncture versus transarterial embolization for head and neck paragangliomas: A systematic review and meta-analysis. Interv Neuroradiol 2023:15910199231188859. [PMID: 37455341 DOI: 10.1177/15910199231188859] [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] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Embolization of head and neck paragangliomas (HNPs) is a well-established treatment strategy and adjunctive therapy. However, the optimal mode of intervention, whether by direct percutaneous puncture (DP) or via transarterial embolization (TAE), remains unclear. METHODS The aim of this study was to complete a systematic literature review and meta-analysis to compare the safety and efficacy of DP versus TAE for HNP embolization. The Cochrane Library and MEDLINE databases were used to identify studies describing the clinical outcomes of either DP or TAE for HNP embolization. Outcome measures included: complete angiographic devascularization, major complications, and minor complications. Pooled rates were calculated for each variable which were then compared with meta-regression using a random effects model. RESULTS Thirty-one retrospective studies met inclusion criteria, detailing 394 patients with 411 HNPs. Overall, DP was associated with a higher rate of complete devascularization (91.5%, 95% confidence interval [CI]: 85.6% to 97.4%; I2 = 0%) when compared to TAE technique (40.1%, CI: 27.2% to 58.9%; I2 = 93%). However, there was no difference regarding major complication rates between DP (6%, CI:1.3% to 10.8%; I2 = 0%) and TAE for HNP embolization (3.3%, CI: 1.4% to 5.3%; I2 = 0%) (p = 0.370), nor in minor complications between the techniques (p = 0.211). Subgroup analysis of TAE embolic agents revealed that particle embolics were associated with a significantly lower rate of major complications (2.5%; 0.4% to 4.6%; I2 = 0%) when compared to liquid embolics (10.6%, CI:4% to 17.3%; I2 = 48%; p = 0.022). CONCLUSIONS A DP approach for HNP embolization results in a higher rate of complete devascularization and with a similar complication profile when compared to TAE. These findings also suggest that particle embolics are associated with fewer major complications compared to liquid embolics when TAE is utilized.
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Affiliation(s)
- Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Mark Manganaro
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Denes Szekeres
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Rahim Ismail
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Timothy Hoang
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Logan Worley
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Alan Finkelstein
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
| | - Chelsey Schartz
- University of Kansas School of Medicine, Kansas City, KS, USA
| | | | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, USA
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Ismail R, Manganaro M, Schartz D, Worley L, Kessler A. A pictorial review of imaging findings associated with upper cervical trauma. Emerg Radiol 2023:10.1007/s10140-023-02141-w. [PMID: 37254028 DOI: 10.1007/s10140-023-02141-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 05/02/2023] [Indexed: 06/01/2023]
Abstract
The diagnosis of cervical spine injury in the emergency department remains a critical skill of emergency room physicians as well as radiologists. Such diagnoses are often associated with high morbidity and mortality unless readily identified and treated appropriately. Both computed tomography (CT) and magnetic resonance imaging (MRI) often are crucial in the workup of spinal injury and play a key role in arriving at a diagnosis. Unfortunately, missed cervical spine injuries are not necessarily uncommon and often precede detrimental neurologic sequalae. With the increase in whole-body imaging ordered from the emergency department, it is critical for radiologists to be acutely aware of key imaging features associated with upper cervical trauma, possible mimics, and radiographic clues suggesting potential high-risk patient populations. This pictorial review will cover key imaging features from several different imaging modalities associated with upper cervical spine trauma, explore patient epidemiology, mechanism, and presentation, as well as identify confounding radiographic signs to aid in confident and accurate diagnoses.
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Affiliation(s)
- Rahim Ismail
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Mark Manganaro
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Derrek Schartz
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Logan Worley
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA.
| | - Alexander Kessler
- Department of Imaging Science, University of Rochester, 601 Elmwood Ave, Rochester, NY, 14642, USA
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Akkipeddi SM, Rahmani R, Schartz D, Chittaranjan S, Gunturi A, Bhalla T, Mattingly T, Morrell C, Bender MT. 312 Neutrophil Extracellular Trap (NET) Proteins Enriched in Emboli Retrieved from Stroke Patients with Atrial Fibrillation. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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17
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Ellens NR, Schartz D, Kohli GS, Rahmani R, Medha Akkipeddi S, Mattingly T, Bhalla T, Bender MT. 551 Middle Meningeal Artery Embolization Embolic Agents – A Systematic Review & Meta-Analysis. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
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18
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Kohli G, George DD, Grenga A, Santangelo G, Gosev I, Schartz D, Kessler A, Khan I, Barrus B, Gu Y, Bhalla T, Mattingly TK, Bender MT. Mechanical Thrombectomy for Ischemic Stroke Secondary to Large Vessel Occlusions in Patients on Extracorporeal Membrane Oxygenation. Cerebrovasc Dis 2023; 52:532-538. [PMID: 36716722 DOI: 10.1159/000528218] [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: 07/03/2022] [Accepted: 10/20/2022] [Indexed: 02/01/2023] Open
Abstract
INTRODUCTION The use of short-term mechanical circulatory support (MCS) devices and procedures for function- and life-sustaining therapy is becoming a routine practice at many centers. Concomitant with the increasing use of MCS is the increasing recognition of acute brain injuries, including acute ischemic stroke, which may be caused by a myriad of MCS-driven factors. The aim of this case series was to document our experience with mechanical thrombectomy (MT) for ischemic stroke in extracorporeal membrane oxygenation (ECMO) patients. METHODS We retrospectively reviewed a prospectively maintained database of patients undergoing endovascular thrombectomy for large vessel occlusion at our institution. We identified patients that were on ECMO and underwent thrombectomy. Baseline demographics and procedural and functional outcomes were collected. RESULTS Three patients on ECMO were identified to have a large vessel occlusion and underwent thrombectomy. Two patients had an internal carotid artery terminus occlusion and one had a basilar artery occlusion. An mTICI 3 recanalization was achieved in all patients without postoperative hemorrhagic complications. Two patients achieved a 3-month mRS of 1, while one had mRS 4. CONCLUSION Ischemic stroke can be associated with significant morbidity in MCS patients. We demonstrate that MT can be safely performed in this patient population with good outcomes.
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Affiliation(s)
- Gurkirat Kohli
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Derek D George
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Audrey Grenga
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Gabrielle Santangelo
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Igor Gosev
- Division of Cardiac Surgery, Department of Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Alex Kessler
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | - Imad Khan
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Bryan Barrus
- Baptist Health Cardiothoracic Surgery Clinic, Little Rock, Arkansas, USA
| | - Yang Gu
- Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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Kohli GS, Schartz D, Whyte R, Akkipeddi SM, Ellens NR, Bhalla T, Mattingly TK, Bender MT. Endovascular thrombectomy with or without intravenous thrombolysis in acute basilar artery occlusion ischemic stroke: A meta-analysis. J Stroke Cerebrovasc Dis 2022; 31:106847. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
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Kohli GS, Whyte R, Schartz D, Rahmani R, Ellens NR, Susa ST, Bhalla T, Mattingly TK, Bender MT. Approaches to and outcomes of intra-arterial tPA in embolectomy for large vessel occlusion. J Stroke Cerebrovasc Dis 2022; 31:106717. [PMID: 35994881 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 08/03/2022] [Accepted: 08/08/2022] [Indexed: 10/15/2022] Open
Abstract
INTRODUCTION Intra-arterial tissue plasminogen activator (IA tPA) is sometimes used in conjunction with aspiration catheters and stentrievers to achieve recanalization in endovascular thrombectomy (ET) for large vessel occlusion (LVO). Reports of safety and efficacy of this approach are limited by technical heterogeneity and sample size. METHODS We retrospectively reviewed a data set of patients undergoing ET for LVO between August 2017 and September 2020 to identify those that received IA tPA. IA tPA usage, timing and dosage was at the discretion of the operative neurosurgeon. We identified three broad categories of IA tPA administration: (1) adjunctive with the first pass; (2) salvage with subsequent passes after first pass achieved incomplete revascularization; and (3) post-thrombectomy residual distal occlusions. Univariate and multivariate logistic regression were performed to test associations with recanalization, hemorrhage, and functional independence. RESULTS Among 271 patients, 158 (58%) patients had IA tPA, of which 83 received adjuvant IA tPA, 60 received salvage IA tPA, and 15 received post-thrombectomy IA tPA for distal occlusions. There were no differences in demographics, stroke etiology and premorbid medications between these groups. Patients receiving salvage IA tPA had longer times from groin access to recanalization and more passes, as expected. On multivariate analysis neither adjunctive nor salvage IA tPA was significantly associated with recanalization, post-operative hemorrhage, or functional outcomes. On univariate analysis, patients receiving salvage IA tPA had lower rates of TICI 3 or 2b revascularization (80% vs. 89% adjunctive and 92% no IA tPA, p = 0.003) and higher rates of any postoperative hemorrhage (33% vs. 22% adjunctive and 19% no IA tPA, p = 0.003). CONCLUSIONS In this retrospective, single-institution series, IA tPA used adjunctively or as salvage therapy in ET for LVO was not associated with recanalization, post-operative hemorrhage, or functional outcomes, suggesting IA tPA is an available modality that can be utilized in cases of recalcitrant clots.
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Affiliation(s)
- Gurkirat Singh Kohli
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States.
| | - Racquel Whyte
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Derrek Schartz
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Nathaniel R Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Stephen T Susa
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Thomas K Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
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Ellens NR, Schartz D, Rahmani R, Akkipeddi SMK, Kelly AG, Benesch CG, Parker SA, Burgett JL, Proper D, Pilcher WH, Mattingly TK, Grotta JC, Bhalla T, Bender MT. Mobile Stroke Unit Operational Metrics: Institutional Experience, Systematic Review and Meta-Analysis. Front Neurol 2022; 13:868051. [PMID: 35614916 PMCID: PMC9124821 DOI: 10.3389/fneur.2022.868051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/19/2022] [Indexed: 11/26/2022] Open
Abstract
Background The available literature on mobile stroke units (MSU) has focused on clinical outcomes, rather than operational performance. Our objective was to establish normalized metrics and to conduct a meta-analysis of the current literature on MSU performance. Methods Our MSU in upstate New York serves 741,000 people. We present prospectively collected, retrospectively analyzed data from the inception of our MSU in October of 2018, through March of 2021. Rates of transportation/dispatch and MSU utilization were reported. We also performed a meta-analysis using MEDLINE, SCOPUS, and Cochrane Library databases, calculating rates of tPA/dispatch, tPA-per-24-operational-hours (“per day”), mechanical thrombectomy (MT)/dispatch and MT/day. Results Our MSU was dispatched 1,719 times in 606 days (8.5 dispatches/24-operational-hours) and transported 324 patients (18.8%) to the hospital. Intravenous tPA was administered in 64 patients (3.7% of dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150–0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074–0.163). The MSU was in use for 38,742 minutes out of 290,760 total available minutes (13.3% utilization rate). Our meta-analysis included 14 articles. Eight studies were included in the analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8–9.5%, I2 = 92%) and 11 were included in the analysis of tPA/day (1,858/4,961) for a rate of 0.358 (95% CI 0.215–0.502, I2 = 99%). Seven studies were included for MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2–2.8%, I2 = 67%) and MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046–0.138, I2 = 91%). Conclusions In this single institution retrospective study and meta-analysis, we outline the following operational metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and utilization rate. These metrics are useful for internal and external comparison for institutions with or considering developing mobile stroke programs.
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Affiliation(s)
- Nathaniel R. Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, United States
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Sajal Medha K. Akkipeddi
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Adam G. Kelly
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Curtis G. Benesch
- Department of Neurology, University of Rochester Medical Center, Rochester, NY, United States
| | - Stephanie A. Parker
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX, United States
| | - Jason L. Burgett
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Diana Proper
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Webster H. Pilcher
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Thomas K. Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - James C. Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital—Texas Medical Center, Houston, TX, United States
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Matthew T. Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
- *Correspondence: Matthew T. Bender
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Schartz D, Porter M, Schartz E, Kallas J, Gupta A, Butani D, Cantos A. Transarterial yrittrium-90 radioembolization for unresectable intrahepatic cholangiocarcinoma: a systematic review and meta-analysis. J Vasc Interv Radiol 2022; 33:679-686. [PMID: 35219834 DOI: 10.1016/j.jvir.2022.02.016] [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: 11/20/2021] [Revised: 01/06/2022] [Accepted: 02/13/2022] [Indexed: 12/01/2022] Open
Abstract
PURPOSE To investigate the overall efficacy and survival profile of Yrittrium-90 (Y-90) radioembolization for unresectable intrahepatic cholangiocarcinoma (ICC). MATERIALS AND METHODS A systematic literature review and meta-analysis was completed using a random effects model. Studies describing the use of Y-90 for unresectable ICC were included. Disease control rate (DCR), downstaged to resectable rate, CA19-9 response rate, pooled overall median survival (OS), pooled median progression free survival (PFS), and mean reported survival rates ranging from 3 to 36 months (mo) were evaluated. RESULTS Twenty-one studies detailing a total of 921 patients were included. The overall DCR was 82.3% [95% Confidence Interval (CI): 76.7% to 87.8%, I2 = 81%). In 11% of cases, patients were downstaged to being surgically resectable (CI: 6.1% to 15.9%, I2 = 78%). The CA19-9 response rate was 67.2% (CI: 54.5% to 79,8%, I2 = 60%). From point of radioembolization, PFS was 7.8 months (CI: 4.2 mo to 11.3 mo, I2 = 94%), and overall median survival was 12.7 months (CI: 10.6 mo to 14.8 mo, I2 = 62%). Lastly, the overall mean reported survival proportions were at 3 mo (84% survival, SD: 10%), 6 mo (69%, SD:16%), 12 mo (47%, SD: 19%), 18 mo (31%, SD: 21%), 24 mo (30%, SD 19%), 30 mo (21% (SD: 27%), and at 36 mo (5%, SD 7%). CONCLUSIONS Radioembolization with Y-90 for unresectable ICC remains beneficial for both disease control and survival. Data from ongoing projects will continue to help optimize treatment and patient selection resulting in improved patient outcomes.
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Affiliation(s)
- Derrek Schartz
- University of Rochester Medical Center, Department of Imaging Sciences, Rochester, NY, USA.
| | - Marc Porter
- University of Rochester Medical Center, Department of Imaging Sciences, Rochester, NY, USA
| | - Emily Schartz
- University of Rochester Medical Center, Department of Imaging Sciences, Rochester, NY, USA
| | - Jeffrey Kallas
- University of Rochester Medical Center, Department of Imaging Sciences, Rochester, NY, USA
| | - Akshya Gupta
- University of Rochester Medical Center, Department of Imaging Sciences, Rochester, NY, USA
| | - Devang Butani
- University of Rochester Medical Center, Department of Imaging Sciences, Rochester, NY, USA
| | - Andrew Cantos
- University of Rochester Medical Center, Department of Imaging Sciences, Rochester, NY, USA
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Ellens NR, Schartz D, Rahmani R, Akkipeddi SM, Kelly AG, Benesch C, Burgett J, Lesperance J, Proper D, Mattingly T, Pilcher W, Bhalla T, Bender M. Abstract WP41: Mobile Stroke Unit Operational Performance: A Retrospective Single Institution Analysis And Meta-Analysis. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.wp41] [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:
Mobile stroke units (MSU) have become increasingly common and now span a diverse range of communities. Reporting has previously focused on clinical outcomes, and metrics reporting the operational performance of MSUs have not been standardized. The aim of this study was to establish normalized metrics to evaluate MSUs and to a complete a meta-analysis of the current literature on MSU performance.
Methods:
Our MSU serves a population of 741,000 people in upstate New York. Data was prospectively collected and retrospectively analyzed from its inception in October of 2018 through March of 2021. We report rates of transportation/dispatch and MSU utilization rates. MEDLINE and Cochrane Library databases were utilized to perform a meta-analysis. Pooled rates of tPA/dispatch, tPA/day, mechanical thrombectomy (MT)/dispatch and MT/day were calculated. An assessment of inter-study heterogeneity was also completed.
Results:
In 606 days, our MSU was dispatched 1,719 times for an average rate of 2.8 dispatches/day. 324 patients (18.8%) were transported to the hospital by the MSU. Intravenous tPA was administered in 64 patients (3.7% of all dispatches) and the rate of tPA/day was 0.317 (95% CI 0.150 to 0.567). MT was performed in 24 patients (1.4% of dispatches) for a MT/day rate of 0.119 (95% CI 0.074 to 0.163). Of the 290,760 total minutes the MSU was available, it was in use for 38,742 minutes (13.3% utilization rate). Our meta-analysis included 18 total articles. Eight studies were included in the pooled analysis of tPA/dispatch (342/5,862) for a rate of 7.2% (95% CI 4.8% to 9.5%, I2 = 92%) and nine were included in the analysis of tPA/day (785/1,998) for a rate of 0.359 (95% CI 0.150 to 0.567, I2 = 99%). Seven studies met criteria for analysis of MT/dispatch (102/5,335) for a rate of 2.0% (95% CI 1.2% to 2.8%, I2 = 67%) and for MT/day (103/1,249) for a rate of 0.092 (95% CI 0.046 to 0.138, I2 = 91%).
Conclusions:
Future studies investigating MSUs should focus on the following normalized metrics: tPA/dispatch, tPA/day, MT/dispatch, MT/day, and the newly described utilization rate. These normalized metrics are also useful at an institutional level when evaluating the overall utilization and efficacy of an MSU.
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Affiliation(s)
| | - Derrek Schartz
- Imaging Sciences, Univ of Rochester Med Cntr, Rochester, NY
| | | | | | - Adam G Kelly
- Neurology, Univ of Rochester Med Cntr, Rochester, NY
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Akkipeddi SMK, Ellens NR, Schartz D, Rahmani R, Kelly AG, Benesch CG, Burgett JL, Lesperance J, Proper D, Mattingly TK, Pilcher WH, Bhalla T, Bender MT. Abstract TMP28: Decision For Tpa Administration, Not Drive Time, Contributes Most To Variance In Thrombolysis Times Onboard Mobile Stroke Unit. Stroke 2022. [DOI: 10.1161/str.53.suppl_1.tmp28] [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:
Hospitals have improved stroke thrombolysis times through rigorous assessment of care delays. While mobile stroke units (MSU) expedite intravenous thrombolysis for acute ischemic stroke, the same rigor has not been applied to this novel setting.
Methods:
We reviewed all cases of intravenous tissue plasminogen activator (tPA) administration onboard our mobile stroke unit in Rochester, NY since its inception in 2019. The dispatch timeline was divided into six intervals: (1) drive time, (2) onboarding time, (3) HCT collection, (4) HCT reading, (5) decision time, and (6) tPA administration. Cases in which tPA was delayed due to medical contraindications or inability to obtain consent were not included in the analysis.
Results:
The mean ± SD total time between MSU dispatch and tPA was 42 ± 8.4 min (range: 26-60 min; N = 53). The longest interval was (1) drive time (between dispatch and arrival, 12.0 ± 4.7 min). However, the inter-case variation was greatest in (5) decision time (between HCT reading and treatment decision, 6.3 ± 6.2 min). After ranking cases by total time, the interval that had the widest variance between the first and fourth quartiles was decision time (2.45x). The other intervals varied by a factor of 1.50x for (6) tPA administration and less than 1.00x for the other four intervals. Decision time was the interval most closely correlated with total time (Spearman’s ρ = 0.46; p = 0.00051), which was reduced in our second year of operation (38.8 from 44.6 minutes; Mann-Whitney, Z = 2.38, p = 0.02). Decision time was negatively correlated with time since inception of the MSU (Spearman’s ρ = -0.29, p = 0.037), suggesting that improvements in decision time drove improvements in overall thrombolysis time.
Conclusion:
The largest driver of variation in total time from emergency alert to tPA administration is provider decision time in our MSU program. This observation should be investigated in other settings but may ultimately inform MSU training and staffing.
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Affiliation(s)
| | | | - Derrek Schartz
- Dept of Imaging Sciences, Univ of Rochester Med Cntr, Rochester, NY
| | - Redi Rahmani
- Dept of Neurosurgery, Univ of Rochester Med Cntr, Rochester, NY
| | - Adam G Kelly
- Dept of Neurology, Univ of Rochester Med Cntr, Rochester, NY
| | | | - Jason L Burgett
- Dept of Neurosurgery, Univ of Rochester Med Cntr, Rochester, NY
| | | | - Diana Proper
- Dept of Neurosurgery, Univ of Rochester Med Cntr, Rochester, NY
| | | | | | - Tarun Bhalla
- Dept of Neurosurgery, Univ of Rochester Med Cntr, Rochester, NY
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25
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Schartz E, Manganaro M, Schartz D. Declining Medicare Reimbursement for Diagnostic Radiology: A 10-Year Analysis Across 50 Imaging Studies. Curr Probl Diagn Radiol 2022; 51:693-698. [DOI: 10.1067/j.cpradiol.2022.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 01/05/2022] [Accepted: 01/06/2022] [Indexed: 11/22/2022]
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26
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Schartz D, Mattingly TK, Rahmani R, Ellens N, Akkipeddi SMK, Bhalla T, Bender MT. Noncurative microsurgery for cerebral aneurysms: a systematic review and meta-analysis of wrapping, residual, and recurrence rates. J Neurosurg 2021; 137:1-11. [PMID: 34798602 DOI: 10.3171/2021.9.jns211698] [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: 07/10/2021] [Accepted: 09/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Microsurgery for cerebral aneurysms is called definitive, yet some patients undergo a craniotomy that results in noncurative treatment. Furthermore, the overall rate of noncurative microsurgery for cerebral aneurysms is unclear. The objective of this study was to complete a systematic review and meta-analysis to quantify three scenarios of noncurative treatment: aneurysm wrapping, postclipping remnants, and late regrowth of completely obliterated aneurysms. METHODS A PRISMA-guided systematic literature review of the MEDLINE and Cochrane Library databases and meta-analysis was completed. Studies were included that detailed rates of aneurysm wrapping, residua confirmed with imaging, and regrowth after confirmed total occlusion. Pooled rates were subsequently calculated using a random-effects model. An assessment of statistical heterogeneity and publication bias among the included studies was also completed for each analysis, with resultant I2 values and p values determined with Egger's test. RESULTS Sixty-four studies met the inclusion criteria for final analysis. In 41 studies, 573/15,715 aneurysms were wrapped, for a rate of 3.5% (95% CI 2.7%-4.2%, I2 = 88%). In 43 studies, 906/13,902 aneurysms had residual neck or dome filling, for a rate of 6.4% (95% CI 5.2%-7.6%, I2 = 93%). In 15 studies, 71/2568 originally fully occluded aneurysms showed regrowth, for a rate of 2.1% (95% CI 1.2%-3.1%, I2 = 58%). Together, there was a total rate of noncurative surgery of 12.0% (95% CI 11.5%-12.5%). Egger's test suggested no significant publication bias among the studies. Meta-regression analysis revealed that the reported rate of aneurysm wrapping has significantly declined over time, whereas the rates of aneurysm residua and recurrence have not significantly changed. CONCLUSIONS Open microsurgery for cerebral aneurysm results in noncurative treatment approximately 12% of the time. This metric may be used to counsel patients and as a benchmark for other treatment modalities. This investigation is limited by the high degree of heterogeneity among the included studies.
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Affiliation(s)
- Derrek Schartz
- 1Department of Imaging Sciences, University of Rochester Medical Center, Rochester, New York; and
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Thomas K Mattingly
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Redi Rahmani
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Nathaniel Ellens
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | | | - Tarun Bhalla
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
| | - Matthew T Bender
- 2Department of Neurosurgery, University of Rochester Medical Center, Rochester, New York
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27
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Schartz D, Akkipeddi SMK, Ellens N, Rahmani R, Kohli GS, Bruckel J, Caplan JM, Mattingly TK, Bhalla T, Bender MT. Complications of transradial versus transfemoral access for neuroendovascular procedures: a meta-analysis. J Neurointerv Surg 2021; 14:820-825. [PMID: 34479985 DOI: 10.1136/neurintsurg-2021-018032] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 08/23/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Transradial access (TRA) has gained increased usage among neurointerventionalists. However, the overall safety profile of access site complications (ASCs) and non-access site complications (NASCs) of TRA versus transfemoral access (TFA) for neuroendovascular procedures remains unclear. METHODS A systematic literature review and meta-analysis using a random effects model was conducted to investigate the pooled odds ratios (OR) of ASCs and NASCs. Randomized, case-control, and cohort studies comparing access-related complications were analyzed. An assessment of study heterogeneity and publication bias was also completed. RESULTS Seventeen comparative studies met the inclusion criteria for final analysis. Overall, there was a composite ASC rate of 1.8% (49/2767) versus 3.2% (168/5222) for TRA and TFA, respectively (P<0.001). TRA was associated with a lower odds of ASC compared with TFA (OR 0.42; 95% CI 0.25 to 0.68, P<0.001, I2=31%). There was significantly lower odds of complications within the intervention and diagnostic subgroups. For NASC, TRA had a lower composite incidence of complications than TFA at 1.2% (31/2586) versus 4.2% (207/4909), P<0.001). However, on meta-analysis, we found no significant difference overall between TRA and TFA for NASCs (OR 0.79; 95% CI 0.51 to 1.22, P=0.28, I2=0%), which was also the case on subgroup analysis. CONCLUSION On meta-analysis, the current literature indicates that TRA is associated with a lower incidence of ASCs compared with TFA, but is not associated with a lower rate of NASCs.
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Affiliation(s)
- Derrek Schartz
- Imaging Sciences, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Nathaniel Ellens
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Redi Rahmani
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | | | - Jeffrey Bruckel
- Cardiology, University of Rochester Medical Center, Rochester, New York, USA
| | - Justin M Caplan
- Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Thomas K Mattingly
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Tarun Bhalla
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Matthew T Bender
- Neurosurgery, University of Rochester Medical Center, Rochester, New York, USA
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28
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Schartz D, Young E. Medicare Reimbursement Trends for Interventional Radiology Procedures: 2012 to 2020. J Vasc Interv Radiol 2021; 32:447-452. [PMID: 33454179 DOI: 10.1016/j.jvir.2020.12.007] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 12/02/2020] [Accepted: 12/05/2020] [Indexed: 11/18/2022] Open
Abstract
PURPOSE To investigate the reimbursement trends for interventional radiology (IR) procedures from 2012 to 2020. MATERIALS AND METHODS Reimbursement data from the Physician Fee Schedule look-up tool from the Centers for Medicare and Medicaid Services was compiled for 20 common IR procedures. The authors then investigated compensation trends after adjusting for inflation and from the unadjusted data between 2012 and 2020. RESULTS From 2012 to 2020, the mean unadjusted reimbursement for procedures decreased by -6.9% (95% confidence interval [CI], -13.5% to -0.34%). This trend was even more profound after inflation was taken into account, with a mean decline in adjusted reimbursement of -18.7% (95% CI, -24.4% to -12.9%) during the study period, with a mean yearly decline of -2.8%. The difference between the mean unadjusted and adjusted payment amounts was significant (P = .012). Similarly, linear regression analysis of the adjusted average reimbursement across all procedures revealed an overall decline from 2012 to 2020 (R2 = 0.97), indicating a steady decline in reimbursement over time. CONCLUSIONS In just under a decade, IR has experienced significant reimbursement cuts by Medicare, as demonstrated by both the unadjusted and inflation-adjusted payment trends. Knowledge of these trends is critically important for practicing interventional radiologists, leaders within the field, and legislators, who may play a role in formulating future reimbursement schedules for IR. These data may be used to help support more amenable reimbursement plans to sustain and facilitate the growth of the specialty.
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Affiliation(s)
- Derrek Schartz
- University of Rochester Medical Center, Department of Imaging Sciences, 601 Elmwood Avenue, Rochester, NY, 14642.
| | - Emily Young
- University of Rochester Medical Center, Department of Imaging Sciences, 601 Elmwood Avenue, Rochester, NY, 14642
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Schartz D, Young E, Guerin S. Transradial approach for pediatric interventions: A review and analysis of the literature. J Vasc Access 2020; 22:438-443. [PMID: 32781881 DOI: 10.1177/1129729820948688] [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: 11/15/2022] Open
Abstract
BACKGROUND Transradial access for interventions has been well studied in the adult population, but there is a paucity of literature of its use in the pediatric population. METHODS We conducted a systematic literature review and gathered and synthesized all of the available data into a cohesive resource for review and analysis of the topic. RESULTS Pooled analysis of the available data shows that transradial access in pediatric patients has a success rate of 91%, a vasospasm rate of 11.4%, and loss of pulse rate of 3.0% for a total complication rate of 14%. No permanent complications, or complications requiring surgery, were observed in any study. After stratifying for indication of intervention, neurological indications were associated with a lower complication rate compared to cardiac indications (0.1 vs 0.43, respectively, p = 0.004). In addition, studies published after 2013 were associated with a lower complication rate compared to those published during or before 2013 (0.11 vs 0.33, respectively, p = 0.01). CONCLUSION Compared to prior studies on pediatric transfemoral access, transradial access has a higher complication rate. But there may be a lower rate of complications that require surgical intervention. Further studies are needed to clarify any advantages that transradial access may have over transfemoral access for pediatric patients.
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Affiliation(s)
- Derrek Schartz
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.,Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Emily Young
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.,Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Stephen Guerin
- Geisel School of Medicine at Dartmouth College, Hanover, NH, USA.,Department of Radiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
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30
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Schartz D, Divakar P, Tafe L, Paydarfar J. Primary Ewing's sarcoma of the petroclival bone: A case report and literature review. Surg Neurol Int 2020; 11:6. [PMID: 31966925 PMCID: PMC6969381 DOI: 10.25259/sni_415_2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Accepted: 12/19/2019] [Indexed: 11/09/2022] Open
Abstract
Background: Primary Ewing’s sarcoma (ES) is typically seen within the long bones, vertebrae, or pelvis. Uncommonly, it can be found within the cranium among the rarest locations for primary ES are the skull base, in particular, the petroclival bone. Case Description: The patient is a 68-year-old female with past medical history of Stage III breast cancer who presented with severe retro-orbital headache and diplopia due to a cranial nerve VI palsy. Magnetic resonance imaging (MRI) revealed a mass at the left petroclival bone with extension into the adjacent left petrous apex and into the posterior aspect of the left cavernous sinus proximal to the carotid artery. The patient subsequently underwent an endoscopic transsphenoidal biopsy. Pathological and molecular analysis supported a diagnosis of ES. The patient then underwent neoadjuvant chemotherapy and radiotherapy. At 12 month-follow-up, her petroclival ES demonstrated significant interval decrease in size on MRI surveillance imaging. Conclusions: This is the third case of primary ES of the petroclival bone to be reported in the literature. In this patient, management consisted of surgical incisional biopsy followed by adjuvant radiation and chemotherapy. Knowledge and awareness of this type of tumor is important for the skull base surgeon.
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Affiliation(s)
- Derrek Schartz
- Department of Surgery, Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
| | | | - Laura Tafe
- Department of Pathology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Joseph Paydarfar
- Department of Surgery, Section of Otolaryngology- Head and Neck Surgery
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31
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Schartz D, D'Agostino E, Makler V, Hickey WF, Bauer DF. Third ventricle World Health Organization Grade II meningioma presenting with intraventricular hemorrhage and obstructive hydrocephalus: A case report and literature review. Surg Neurol Int 2019; 10:73. [PMID: 31528411 PMCID: PMC6744824 DOI: 10.25259/sni-90-2019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2018] [Accepted: 01/07/2019] [Indexed: 11/22/2022] Open
Abstract
Background: Third ventricular meningiomas are exceedingly rare intracranial tumors that may present with intraventricular hemorrhage. Case Description: The patient is 46-year-old who initially presented with obstructive hydrocephalus from a presumed vascular lesion and who was treated with endoscopic third ventriculostomy. He presented 3 years later with acute intraventricular hemorrhage and hydrocephalus. The hemorrhage was evacuated and the third ventricular tumor was resected, and the patient made an excellent recovery. Histopathological analysis identified the tumor as the World Health Organization Grade II meningioma. Conclusion: Third ventricular meningioma is a rare tumor that may present with hemorrhage and obstructive hydrocephalus. Surgical resection can be helpful for this rare presentation of intracranial meningioma.
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Affiliation(s)
- Derrek Schartz
- Geisel School of Medicine, Section of Neurological Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Erin D'Agostino
- Geisel School of Medicine, Section of Neurological Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - Vyacheslav Makler
- Departement of Surgery, Section of Neurological Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - William F Hickey
- Departement of Pathology, Section of Neurological Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
| | - David F Bauer
- Departement of Surgery, Section of Neurological Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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Grommes C, Pastore A, Palaskas N, Tang SS, Campos C, Schartz D, Codega P, Nichol D, Clark O, Hsieh WY, Rohle D, Rosenblum M, Viale A, Tabar VS, Brennan CW, Gavrilovic IT, Kaley TJ, Nolan CP, Omuro A, Pentsova E, Thomas AA, Tsyvkin E, Noy A, Palomba ML, Hamlin P, Sauter CS, Moskowitz CH, Wolfe J, Dogan A, Won M, Glass J, Peak S, Lallana EC, Hatzoglou V, Reiner AS, Gutin PH, Huse JT, Panageas KS, Graeber TG, Schultz N, DeAngelis LM, Mellinghoff IK. Ibrutinib Unmasks Critical Role of Bruton Tyrosine Kinase in Primary CNS Lymphoma. Cancer Discov 2017; 7:1018-1029. [PMID: 28619981 DOI: 10.1158/2159-8290.cd-17-0613] [Citation(s) in RCA: 263] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 06/13/2017] [Accepted: 06/15/2017] [Indexed: 12/22/2022]
Abstract
Bruton tyrosine kinase (BTK) links the B-cell antigen receptor (BCR) and Toll-like receptors with NF-κB. The role of BTK in primary central nervous system (CNS) lymphoma (PCNSL) is unknown. We performed a phase I clinical trial with ibrutinib, the first-in-class BTK inhibitor, for patients with relapsed or refractory CNS lymphoma. Clinical responses to ibrutinib occurred in 10 of 13 (77%) patients with PCNSL, including five complete responses. The only PCNSL with complete ibrutinib resistance harbored a mutation within the coiled-coil domain of CARD11, a known ibrutinib resistance mechanism. Incomplete tumor responses were associated with mutations in the B-cell antigen receptor-associated protein CD79B. CD79B-mutant PCNSLs showed enrichment of mammalian target of rapamycin (mTOR)-related gene sets and increased staining with PI3K/mTOR activation markers. Inhibition of the PI3K isoforms p110α/p110δ or mTOR synergized with ibrutinib to induce cell death in CD79B-mutant PCNSL cells.Significance: Ibrutinib has substantial activity in patients with relapsed or refractory B-cell lymphoma of the CNS. Response rates in PCNSL were considerably higher than reported for diffuse large B-cell lymphoma outside the CNS, suggesting a divergent molecular pathogenesis. Combined inhibition of BTK and PI3K/mTOR may augment the ibrutinib response in CD79B-mutant human PCNSLs. Cancer Discov; 7(9); 1018-29. ©2017 AACR.See related commentary by Lakshmanan and Byrd, p. 940This article is highlighted in the In This Issue feature, p. 920.
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Affiliation(s)
- Christian Grommes
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.,Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Alessandro Pastore
- Department of Computational Biology Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Nicolaos Palaskas
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sarah S Tang
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Carl Campos
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Derrek Schartz
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Paolo Codega
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Donna Nichol
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Owen Clark
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Wan-Ying Hsieh
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Dan Rohle
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Marc Rosenblum
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Agnes Viale
- Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Viviane S Tabar
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cameron W Brennan
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Igor T Gavrilovic
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Thomas J Kaley
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Craig P Nolan
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Antonio Omuro
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Elena Pentsova
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Alissa A Thomas
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Elina Tsyvkin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Ariela Noy
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - M Lia Palomba
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Paul Hamlin
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Craig S Sauter
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Craig H Moskowitz
- Department of Medicine, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Julia Wolfe
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Ahmet Dogan
- Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Minhee Won
- NRG Oncology Statistics and Data Management Center, Philadelphia, Pennsylvania
| | - Jon Glass
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Scott Peak
- Department of Neurosurgery, The Permanente Medical Group, Sacramento, California
| | - Enrico C Lallana
- Department of Neuro-Oncology, The Permanente Medical Group, Redwood City, California
| | - Vaios Hatzoglou
- Department of Radiology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Anne S Reiner
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Philip H Gutin
- Department of Neurosurgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Jason T Huse
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Pathology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Katherine S Panageas
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Thomas G Graeber
- Department of Molecular and Medical Pharmacology, Crump Institute for Molecular Imaging, University of California, Los Angeles, California
| | - Nikolaus Schultz
- Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York. .,Marie-Josée and Henry R. Kravis Center for Molecular Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Lisa M DeAngelis
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York. .,Department of Neurology, Weill Cornell Medical College, New York, New York
| | - Ingo K Mellinghoff
- Department of Neurology, Memorial Sloan Kettering Cancer Center, New York, New York. .,Human Oncology and Pathogenesis Program, Memorial Sloan Kettering Cancer Center, New York, New York.,Department of Neurology, Weill Cornell Medical College, New York, New York.,Department of Pharmacology, Weill Cornell Medical College, New York, New York
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