1
|
Subah G, Zeller S, Damodara N, Fortunato M, Garrett J, Syed S, Uddin A, Pak I, Feldstein E, Mayer S, Gandhi CD, Al-Mufti F. Outcomes of heparin-induced thrombocytopenia type II in aneurysmal subarachnoid hemorrhage patients: A US nationwide analysis. J Neurointerv Surg 2024:jnis-2023-021438. [PMID: 38631904 DOI: 10.1136/jnis-2023-021438] [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: 01/02/2024] [Accepted: 03/20/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Despite the widespread use of heparin during and following endovascular procedures in the management of aneurysmal subarachnoid hemorrhage (SAH) patients, limited research has explored the incidence and impact of heparin-induced thrombocytopenia (HIT) on SAH. METHODS Descriptive statistics, multivariate regressions, and propensity score-matching were employed to compare clinical characteristics, comorbidities, interventions, complications, and outcomes of HIT in SAH patients identified within the US National Inpatient Sample database from 2010 to 2019. RESULTS Among 76 387 SAH patients from 2010 to 2019, 166 (0.22%) developed HIT. HIT was identified as a significant predictor of prolonged length of stay (OR 6.799, 95% CI 3.985 to 11.6, P<0.01) and poor functional outcomes (OR 2.541, 95% CI 1.628 to 3.966, P<0.01) after adjusting for relevant factors. HIT incidence was higher in patients with elevated SAH severity scores (1.42 vs 1.06, P<0.01), younger patients (58.04 vs 61.39 years, P=0.01), overweight individuals (0.4% vs 0.2%, P<0.01), those on long-term anticoagulants (10.84% vs 5.72%, P<0.01), or with a cerebrospinal fluid drainage device (external ventricular drain, ventriculoperitoneal shunt; P<0.01). HIT patients showed increased rates of endovascular coiling, ventricular drain placement, shunt placement, deep vein thrombosis, urinary tract infection, acute kidney injury, pulmonary embolism, venous sinus thrombosis, pneumonia, and cerebral vasospasm (all P<0.01). CONCLUSION SAH patients with HIT exhibited various comorbidities and increased rates of complications, which may contribute to extended hospital stays. This nationwide study aids clinical suspicion and highlights HIT's impact on SAH patients.
Collapse
Affiliation(s)
- Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
- School of Medicine, New York Medical College, Valhalla, New York, USA
- Department of Neurology, New York Westchester Square Medical Center, Bronx, New York, USA
| | - Sabrina Zeller
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Nitesh Damodara
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Michael Fortunato
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jenna Garrett
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Shoaib Syed
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Anaz Uddin
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Issac Pak
- Department of Nephrology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Stephan Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
- Department of Neurology, New York Westchester Square Medical Center, Bronx, New York, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
- Department of Neurology, New York Westchester Square Medical Center, Bronx, New York, USA
| |
Collapse
|
2
|
Li B, Kim MG, Dominguez JF, Feldstein E, Kleinman G, Al-Mufti F, Kim M, Hanft S. Intrasellar hemorrhagic chordoma masquerading as pituitary apoplexy: case report and review of the literature. Br J Neurosurg 2023; 37:1685-1688. [PMID: 34148480 DOI: 10.1080/02688697.2021.1941761] [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: 04/01/2021] [Accepted: 06/07/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND IMPORTANCE Chordomas are centrally located, expansile soft tissue neoplasms that arise from the remnants of the embryological notochord. Hemorrhagic presentation is exceedingly rare and can resemble pituitary apoplexy. Moreover, a purely intrasellar location of a chordoma is extremely uncommon. We report a case of a hemorrhagic intrasellar chordoma in an adult male, which presented similarly to pituitary apoplexy and was resolved with surgical resection. CLINICAL PRESENTATION A 69-year-old male presented with a 4 week history of acute onset headache and concurrent diplopia, with significantly reduced testosterone and slightly reduced cortisol. His left eye demonstrated a sixth cranial nerve palsy. Magnetic resonance imaging of the brain showed a large hemorrhagic mass in the pituitary region with significant compression of the left cavernous sinus and superior displacement of the pituitary gland. The patient underwent an endoscopic endonasal transsphenoidal approach for the resection of the lesion. Near total resection was achieved. Final pathology revealed chordoma with evidence of intratumoral hemorrhage, further confirmed by immunopositive stain for brachyury. Post-operatively, the patient had improved diplopia and was discharged home on low dose hydrocortisone. At 3-month follow-up, his diplopia was resolved and new MRI showed stable small residual disease. CONCLUSIONS Apoplectic chordomas are uncommon given chordoma's characteristic lack of intralesional vascularity and represent a diagnostic challenge in the sellar region. Our unique case demonstrates that despite our initial impression of pituitary apoplexy, this was ultimately a case of apoplectic chordoma that responded well to endoscopic endonasal surgery.
Collapse
Affiliation(s)
- Boyi Li
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - Michael G Kim
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Eric Feldstein
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - George Kleinman
- Department of Pathology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Matthew Kim
- Department of Otolaryngology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| |
Collapse
|
3
|
Heide SK, Gnanaprakasam R, Bornovski Y, Feldstein E, Keller M, Rosenberg J. Clinical Reasoning: An Older Woman With Headaches and Lethargy After a Fall. Neurology 2023; 101:863-868. [PMID: 37604660 PMCID: PMC10662998 DOI: 10.1212/wnl.0000000000207828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 07/19/2023] [Indexed: 08/23/2023] Open
Abstract
In this case, a 77-year-old woman presented with generalized weakness, difficulty ambulating, lethargy, loss of appetite, and headaches after a mechanical fall. This case discusses the management of acute neurologic emergencies such as subdural hematoma, status epilepticus, and bacterial meningitis. Potential etiologies for stroke and CNS infection are highlighted. Readers are led through the diagnostic approach to a patient presenting with a complex array of neurologic symptoms causing rapid clinical decompensation.
Collapse
Affiliation(s)
- Sara K Heide
- From the Department of Neurology (S.K.H.), Mount Sinai Beth Israel Medical Center, New York; Department of Infectious Disease (R.G., M.K.), Department of Neurology (Y.B., J.R.), and Department of Neurosurgery (E.F.), Westchester Medical Center, Valhalla, NY.
| | - Rachel Gnanaprakasam
- From the Department of Neurology (S.K.H.), Mount Sinai Beth Israel Medical Center, New York; Department of Infectious Disease (R.G., M.K.), Department of Neurology (Y.B., J.R.), and Department of Neurosurgery (E.F.), Westchester Medical Center, Valhalla, NY
| | - Yarden Bornovski
- From the Department of Neurology (S.K.H.), Mount Sinai Beth Israel Medical Center, New York; Department of Infectious Disease (R.G., M.K.), Department of Neurology (Y.B., J.R.), and Department of Neurosurgery (E.F.), Westchester Medical Center, Valhalla, NY
| | - Eric Feldstein
- From the Department of Neurology (S.K.H.), Mount Sinai Beth Israel Medical Center, New York; Department of Infectious Disease (R.G., M.K.), Department of Neurology (Y.B., J.R.), and Department of Neurosurgery (E.F.), Westchester Medical Center, Valhalla, NY
| | - Marina Keller
- From the Department of Neurology (S.K.H.), Mount Sinai Beth Israel Medical Center, New York; Department of Infectious Disease (R.G., M.K.), Department of Neurology (Y.B., J.R.), and Department of Neurosurgery (E.F.), Westchester Medical Center, Valhalla, NY
| | - Jon Rosenberg
- From the Department of Neurology (S.K.H.), Mount Sinai Beth Israel Medical Center, New York; Department of Infectious Disease (R.G., M.K.), Department of Neurology (Y.B., J.R.), and Department of Neurosurgery (E.F.), Westchester Medical Center, Valhalla, NY
| |
Collapse
|
4
|
Gomez F, El-Ghanem M, Feldstein E, Jagdeo M, Koul P, Nuoman R, Gupta G, Gandhi CD, Amuluru K, Al-Mufti F. Cerebral Ischemic Reperfusion Injury: Preventative and Therapeutic Strategies. Cardiol Rev 2023; 31:287-292. [PMID: 36129330 DOI: 10.1097/crd.0000000000000467] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Acute ischemic stroke is a leading cause of morbidity and mortality in the United States. Treatment goals remain focused on restoring blood flow to compromised areas. However, a major concern arises after reperfusion occurs. Cerebral ischemic reperfusion injury is defined as damage to otherwise salvageable brain tissue occurring with the reestablishment of the vascular supply to that region. The pool of eligible patients for revascularization continues to grow, especially with the recently expanded endovascular therapeutic window. Neurointensivists should understand and manage complications of successful recanalization. In this review, we examine the pathophysiology, diagnosis, and potential management strategies in cerebral ischemic reperfusion injury.
Collapse
Affiliation(s)
- Francisco Gomez
- From the Department of Neurology, University of Missouri School of Medicine, Columbia, MO
| | - Mohammad El-Ghanem
- Department of Neuroendovascular Surgery, HCA Houston Healthcare, Houston, TX
| | - Eric Feldstein
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
| | - Matt Jagdeo
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
| | - Prateeka Koul
- Department of Neurology, Northshore-Long Island Jewish Medical Center, Manhasset, NY
| | - Rolla Nuoman
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Chirag D Gandhi
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
| | - Krishna Amuluru
- Department of Neurological Surgery, University of Indiana, Indianapolis, IN
| | - Fawaz Al-Mufti
- Westchester Medical Center, Maria Fareri Children's Hospital, Valhalla, NY
| |
Collapse
|
5
|
Fortunato M, Lin F, Uddin A, Subah G, Patel R, Feldstein E, Lui A, Dominguez J, Merckling M, Xu P, McIntyre M, Gandhi C, Al-Mufti F. Frailty as a Predictor of Outcomes in Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Brain Sci 2023; 13:1498. [PMID: 37891864 PMCID: PMC10605612 DOI: 10.3390/brainsci13101498] [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: 09/15/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
Frailty is an emerging concept in clinical practice used to predict outcomes and dictate treatment algorithms. Frail patients, especially older adults, are at higher risk for adverse outcomes. Aneurysmal subarachnoid hemorrhage (aSAH) is a neurosurgical emergency associated with high morbidity and mortality rates that have previously been shown to correlate with frailty. However, the relationship between treatment selection and post-treatment outcomes in frail aSAH patients is not established. We conducted a meta-analysis of the relevant literature in accordance with PRISMA guidelines. We searched PubMed, Embase, Web of Science, and Google Scholar using "Subarachnoid hemorrhage AND frailty" and "subarachnoid hemorrhage AND frail" as search terms. Data on cohort age, frailty measurements, clinical grading systems, and post-treatment outcomes were extracted. Of 74 studies identified, four studies were included, with a total of 64,668 patients. Percent frailty was 30.4% under a random-effects model in all aSAH patients (p < 0.001). Overall mortality rate of aSAH patients was 11.7% when using a random-effects model (p < 0.001). There was no significant difference in mortality rate between frail and non-frail aSAH patients, but this analysis only included two studies and should be interpreted cautiously. Age and clinical grading, rather than frailty, independently predicted outcomes and mortality in aSAH patients.
Collapse
Affiliation(s)
- Michael Fortunato
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Fangyi Lin
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Anaz Uddin
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Galadu Subah
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Rohan Patel
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Eric Feldstein
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Aiden Lui
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Jose Dominguez
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Matthew Merckling
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Patricia Xu
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Matthew McIntyre
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Chirag Gandhi
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| |
Collapse
|
6
|
Lui A, Feldstein E, Clare K, Dicpinigaitis AJ, Reddy M, Khan F, Semaan R, Galluzzo D, Shapiro S, Kamal H, Yaghi S, Pisapia J, Muh C, Nuoman R, Overby P, Etienne M, Chong J, Mayer S, Gandhi CD, Al-Mufti F. Acute ischemic strokes in patients with developmental disabilities: A cross-sectional analysis. Interv Neuroradiol 2023; 29:555-560. [PMID: 35786031 PMCID: PMC10549715 DOI: 10.1177/15910199221110327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Patients with developmental disabilities (DD) are frequently excluded from acute ischemic stroke (AIS) randomized control trials. We sought to evaluate the impact of having DD on this patient cohort. METHODS The National Inpatient Sample was analyzed to explore the impact of AIS and treatment on discharge dispositions in patients with DD. Clinical characteristics, treatments, and outcomes were compared to fully-abled patients with AIS. RESULTS 1,605,723 patients with AIS were identified from 2010-2019, of whom 4094 (0.30%) had a DD. AIS patients with DD were younger (60.31 vs 70.93 years, p < 0.01), less likely to be Caucasian (66.37%vs 68.09%, p = 0.01), and had higher AIS severity (0.63 vs 0.58, p < 0.01). Tissue plasminogen activator (tPA) was administered in 99,739 (6.2%) fully-abled patients and 196 (4.79%) of patients with DD (p < 0.01). Endovascular thrombectomy (EVT) was performed in 21,066 (1.31%) of fully-abled patients and 35 (0.85%) of patients with DD (p < 0.01). The presence of developmental disabilities were predictive of lower rates of tPA (OR:0.71,CI:0.56-0.87,p < 0.01) and EVT (OR:0.24,CI:0.16-0.36,p < 0.01). In a propensity score-matched cohort of all AIS patients who underwent EVT, there was no difference in functional outcome (p = 0.41), in-hospital mortality (0.10), and LOS (p = 0.79). CONCLUSION AIS patients with DD were less likely to receive tPA and EVT compared to fully-abled patients. Individuals with DD had higher mortality and worse discharge disposition. There was no significant difference in post-EVT outcomes between fully-abled patients and patients with developmental disabilities. In the absence of prospective clinical trials, population based cross-sectional analyses such as the present study provide valuable clinical insight.
Collapse
Affiliation(s)
- Aiden Lui
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Kevin Clare
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Medha Reddy
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Farzana Khan
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Rosa Semaan
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Daniela Galluzzo
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Steve Shapiro
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Carrie Muh
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Philip Overby
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Mill Etienne
- School of Medicine, New York Medical College, Valhalla, NY, USA
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Stephan Mayer
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| |
Collapse
|
7
|
Khan F, Peyvandi F, Clare K, Nolan B, Patel S, Feldstein E, Ogulnick JV, Said A, Zeller S, Bornovski Y, Wong S, Medicherla CB, Rosenberg J, Miller D, Coritsidis G, Prabhakaran K, Mayer SA, Gandhi CD, Al-Mufti F. Aneurysmal Subarachnoid Hemorrhage and Cardiac Related Fatality: Who Dies and Why? Cardiol Rev 2023:00045415-990000000-00129. [PMID: 37432015 DOI: 10.1097/crd.0000000000000568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
Medical complications are a notable source of in-hospital death following aneurysmal subarachnoid hemorrhage (aSAH). However, there is a paucity of literature examining medical complications on a national scale. This study uses a national dataset to analyze the incidence rates, case fatality rates, and risk factors for in-hospital complications and mortality following aSAH. We found that the most common complications in aSAH patients (N = 170, 869) were hydrocephalus (29.3%) and hyponatremia (17.3%). Cardiac arrest was the most common cardiac complication (3.2%) and was associated with the highest case fatality rate overall (82%). Patients with cardiac arrest also had the highest odds of in-hospital mortality [odds ratio (OR), 22.92; 95% confidence interval (CI), 19.24-27.30; P < 0.0001], followed by patients with cardiogenic shock (OR, 2.96; 95% CI, 2.146-4.07; P < 0.0001). Advanced age and National Inpatient Sample-SAH Severity Score were found to be associated with an increased risk of in-hospital mortality (OR, 1.03; 95% CI, 1.03-1.03; P < 0.0001 and OR, 1.70; 95% CI, 1.65-1.75; P < 0.0001, respectively). Renal and cardiac complications are significant factors to consider in aSAH management, with cardiac arrest being the strongest indicator of case fatality and in-hospital mortality. Further research is needed to characterize factors that have contributed to the decreasing trend in case fatality rates identified for certain complications.
Collapse
Affiliation(s)
- Farzana Khan
- From the School of Medicine, New York Medical College, Valhalla, NY
| | | | - Kevin Clare
- From the School of Medicine, New York Medical College, Valhalla, NY
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | - Bridget Nolan
- From the School of Medicine, New York Medical College, Valhalla, NY
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | - Smit Patel
- Division of Neurosurgery, University of Connecticut, Farmington CT
| | - Eric Feldstein
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | | | - Azhar Said
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | - Sabrina Zeller
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | - Yarden Bornovski
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | - Serena Wong
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | | | - Jon Rosenberg
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | - Daniel Miller
- Department of eICU and Telehealth, Westchester Medical Center, Valhalla, NY
| | - George Coritsidis
- Department of Critical Care Nephrology, Westchester Medical Center, Valhalla, NY
| | | | - Stephan A Mayer
- From the School of Medicine, New York Medical College, Valhalla, NY
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | - Chirag D Gandhi
- From the School of Medicine, New York Medical College, Valhalla, NY
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| | - Fawaz Al-Mufti
- From the School of Medicine, New York Medical College, Valhalla, NY
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY
| |
Collapse
|
8
|
Sursal T, Gandhi CD, Clare K, Feldstein E, Frid I, Kefina M, Galluzzo D, Kamal H, Nuoman R, Amuluru K, Muh CR, Pisapia JM, Gulko E, Overby P, Chandy D, Etienne M, Kurian C, Kaur G, Dakay K, AlHamid M, Al-Jehani H, Mayer SA, Al-Mufti F. Significant Mortality Associated With COVID-19 and Comorbid Cerebrovascular Disease: A Quantitative Systematic Review. Cardiol Rev 2023; 31:199-206. [PMID: 36576377 DOI: 10.1097/crd.0000000000000480] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
We report the first quantitative systematic review of cerebrovascular disease in coronavirus disease 2019 (COVID-19) to provide occurrence rates and associated mortality. Through a comprehensive search of PubMed we identified 8 cohort studies, 5 case series, and 2 case reports of acute cerebrovascular disease in patients with confirmed COVID-19 diagnosis. Our first meta-analysis utilizing the identified publications focused on comorbid cerebrovascular disease in recovered and deceased patients with COVID-19. We performed 3 additional meta-analyses of proportions to produce point estimates of the mortality and incidence of acute cerebrovascular disease in COVID-19 patients. Patient's with COVID-19 who died were 12.6 times more likely to have a history of cerebrovascular disease. We estimated an occurrence rate of 2.6% (95% confidence interval, 1.2-5.4%) for acute cerebrovascular disease among consecutively admitted patients with COVID-19. While for those with severe COVID-19' we estimated an occurrence rate of 6.5% (95% confidence interval, 4.4-9.6%). Our analysis estimated a rate of 35.5% for in-hospital mortality among COVID-19 patients with concomitant acute cerebrovascular disease. This was consistent with a mortality rate of 34.0% which we obtained through an individual patient analysis of 47 patients derived from all available case reports and case series. COVID-19 patients with either acute or chronic cerebrovascular disease have a high mortality rate with higher occurrence of cerebrovascular disease in patients with severe COVID-19.
Collapse
Affiliation(s)
- Tolga Sursal
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Chirag D Gandhi
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | | | - Eric Feldstein
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Ilya Frid
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Martin Kefina
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Daniela Galluzzo
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Haris Kamal
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Rolla Nuoman
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Krishna Amuluru
- Neurointerventional Radiology, Goodman Campbell Brain and Spine at Ascension St. Vincent, Indianapolis, IN
| | - Carrie R Muh
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Jared M Pisapia
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Edwin Gulko
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Philip Overby
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Dipak Chandy
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Mill Etienne
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Christeena Kurian
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Gurmeen Kaur
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Katarina Dakay
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - May AlHamid
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Hosam Al-Jehani
- Department of Neurology and Neurosurgery, Montreal Neurological Institute and Hospital, McGill University, Montreal, QC, Canada
| | - Stephan A Mayer
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| | - Fawaz Al-Mufti
- From the Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595
| |
Collapse
|
9
|
Naftchi AF, Vazquez S, Spirollari E, Carpenter AB, Ng C, Zeller S, Feldstein E, Rawanduzy C, Das A, Gabriele C, Gandhi R, Stein A, Frid I, Dominguez JF, Hanft SJ, Houten JK, Kinon MD. Adult Trauma Patients With Thoracolumbar Injury Classification and Severity Score of 4: A Systematic Review. Clin Spine Surg 2023; 36:237-242. [PMID: 35994034 DOI: 10.1097/bsd.0000000000001380] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 06/29/2022] [Indexed: 11/26/2022]
Abstract
STUDY DESIGN Systematic review. OBJECTIVE Evaluate characteristics of patients with thoracolumbar injury classification and severity (TLICS) score of 4 (To4) severity traumatic thoracolumbar injury. SUMMARY OF BACKGROUND DATA The TLICS score is used to predict the need for operative versus nonoperative management in adult patients with traumatic thoracolumbar injury. Ambiguity exists in its application and score categorization. METHODS A systematic review of the literature was performed. The databases of MEDLINE, Embase, Web of Science, and Cochrane Review were queried. Studies included adults with traumatic thoracolumbar injury with assigned TLICS score and description of management strategy. RESULTS A total of 16 studies met inclusion criteria representing 1911 adult patients with traumatic thoracolumbar injury. There were 503 (26.32%) patients with To4, of which 298 (59.24%) were operative. Studies focusing on the thoracolumbar junction and AO Type A fracture morphology had To4 patient incidences of 11.15% and 52.94%, respectively. Multiple studies describe better quality of life, pain scores, and radiographic outcomes in To4 who underwent operative treatment patients. CONCLUSION To4 injuries are more commonly AO Type A and located in the thoracolumbar junction in adult patients with traumatic thoracolumbar injury. Despite ambiguous recommendations regarding treatment provided by TLICS, outcomes favor operative intervention in this subset of traumatic thoracolumbar injury patients.
Collapse
Affiliation(s)
| | | | | | | | | | - Sabrina Zeller
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | | | - Ankita Das
- School of Medicine, New York Medical College
| | | | - Ronan Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Alan Stein
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Ilya Frid
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - Simon J Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| | - John K Houten
- Department of Neurosurgery, Maimonides Medical Center, New York, NY
| | - Merritt D Kinon
- Department of Neurosurgery, Westchester Medical Center, Valhalla
| |
Collapse
|
10
|
Lui AK, Lin F, Uddin A, Nolan B, Clare K, Nguyen T, Spirollari E, Feldstein E, Bornovski Y, Dominguez J, Coritsidis G, Gandhi CD, Al-Mufti F. A double-hit: End-stage renal disease patients suffer worse outcomes in intracerebral hemorrhage. Brain Circ 2023; 9:172-177. [PMID: 38020947 PMCID: PMC10679629 DOI: 10.4103/bc.bc_24_23] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/05/2023] [Accepted: 06/13/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Intracerebral hemorrhage (ICH) carries significant morbidity and mortality. Previous single-center retrospective analysis suggests that end-stage renal disease (ESRD) is a risk factor for severe ICH and worse outcomes. This investigation aims to examine the impact of ESRD on ICH severity, complications, and outcomes using a multicenter national database. METHODS The International Classification of Disease, Ninth and Tenth Revision Clinical Modification codes were used to query the National Inpatient Sample for patients with ICH and ESRD between 2010 and 2019. Primary endpoints were the functional outcome, length of stay (LOS), and in-hospital mortality. Multivariate variable regression models and a propensity-score matched analysis were established to analyze patient outcomes associated with baseline patient characteristics. RESULTS We identified 211,266 patients with ICH, and among them, 7,864 (3.77%) patients had a concurrent diagnosis of ESRD. Patients with ESRD were younger (60.85 vs. 67.64, P < 0.01) and demonstrated increased ICH severity (0.78 vs. 0.77, P < 0.01). ESRD patients experienced higher rates of sepsis (15.9% vs. 6.15%, P < 0.01), acute myocardial infarction (8.05% vs. 3.65%, P < 0.01), and cardiac arrest (5.94% vs. 2.4%, P < 0.01). In addition, ESRD predicted poor discharge disposition (odds ratio [OR]: 2.385, 95% confidence interval [CI]: 2.227-2.555, P < 0.01), longer hospital LOS (OR: 1.629, 95% CI: 1.553-1.709, P < 0.01), and in-hospital mortality (OR: 2.786, 95% CI: 2.647-2.932, P < 0.01). CONCLUSIONS This study utilizes a multicenter database to analyze the effect of ESRD on ICH outcomes. ESRD is a significant predictor of poor functional outcomes, in-hospital mortality, and prolonged stay in the ICH population.
Collapse
Affiliation(s)
- Aiden K. Lui
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Fangyi Lin
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Anaz Uddin
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Bridget Nolan
- School of Medicine at New York Medical College, Valhalla, New York USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Kevin Clare
- School of Medicine at New York Medical College, Valhalla, New York USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Terry Nguyen
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Eris Spirollari
- School of Medicine at New York Medical College, Valhalla, New York USA
| | - Eric Feldstein
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Yarden Bornovski
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Jose Dominguez
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - George Coritsidis
- Department of Nephrology at Westchester Medical Center, Valhalla, New York USA
| | - Chirag D. Gandhi
- School of Medicine at New York Medical College, Valhalla, New York USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| | - Fawaz Al-Mufti
- School of Medicine at New York Medical College, Valhalla, New York USA
- Brain and Spine Institute at Westchester Medical Center, Valhalla, New York USA
| |
Collapse
|
11
|
Sursal T, Clare K, Feldstein E, Ogulnick J, Nolan B, Karimov Z, Nazarenko A, Ye L, Bornovski Y, Wong S, Goldberg J, Mayer SA, Bauerschmidt A, El Khoury MY, Al-Jehani H, Gandhi CD, Al-Mufti F. Significant increase in mortality and risk of acute ischemic stroke in infective endocarditis patients with subarachnoid hemorrhage secondary to mycotic aneurysms. J Neurol Sci 2023; 451:120670. [PMID: 37392505 DOI: 10.1016/j.jns.2023.120670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Revised: 04/13/2023] [Accepted: 05/01/2023] [Indexed: 07/03/2023]
Abstract
Infective Endocarditis (IE) patients are known to have a variety of complications with one of the rarest, but serious being cerebral mycotic aneurysm, which can result in subarachnoid hemorrhage (SAH). Using the National In-Patient Sample database, we sought to determine the rate of acute ischemic stroke (AIS) and outcomes in IE- patients with and without SAH. In total, we identified 82,844 IE-patients from 2010 to 2016, of which 641 had a concurrent diagnosis of SAH. IE patients with SAH had a more complicated course, higher mortality rate (OR 4.65 CI 95% 3.9-5.5, P < 0.001), and worse outcomes. This patient population also had a significantly higher rate of AIS (OR 6.3 CI 95% 5.4-7.4, P < 0.001). Overall, 41.5% of IE-patients with SAH had AIS during their hospitalization as compared to 10.1% of IE only patients. IE-patients with SAH were more likely to undergo endovascular treatment (3.6%) with 0.8% of the IE patients with AIS undergoing mechanical thrombectomy. While IE-patients are at risk for various complications, our study suggests a significant increase in the mortality and risk of AIS in those with SAH.
Collapse
Affiliation(s)
- Tolga Sursal
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595, USA
| | - Kevin Clare
- New York Medical College School of Medicine, Valhalla, NY 10595, USA
| | - Eric Feldstein
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595, USA
| | - Jonathan Ogulnick
- New York Medical College School of Medicine, Valhalla, NY 10595, USA
| | - Bridget Nolan
- New York Medical College School of Medicine, Valhalla, NY 10595, USA
| | - Zafar Karimov
- New York Medical College School of Medicine, Valhalla, NY 10595, USA
| | - Andrew Nazarenko
- New York Medical College School of Medicine, Valhalla, NY 10595, USA
| | - Linda Ye
- New York Medical College School of Medicine, Valhalla, NY 10595, USA
| | - Yarden Bornovski
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595, USA
| | - Serena Wong
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595, USA
| | - Joshua Goldberg
- Section of Cardiothoracic Surgery, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA
| | - Stephan A Mayer
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595, USA
| | - Andrew Bauerschmidt
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595, USA
| | - Marc Y El Khoury
- Department of Medicine, Division of Infectious Diseases, Westchester Medical Center, New York Medical College School of Medicine, Valhalla, NY 10595, USA
| | - Hosam Al-Jehani
- Neurosurgery, Imam Abdulrahman Bin Faisal University King Fahd Hospital of the University, Alkhobar, Saudi Arabia
| | - Chirag D Gandhi
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595, USA; New York Medical College School of Medicine, Valhalla, NY 10595, USA
| | - Fawaz Al-Mufti
- Brain and Spine Institute at Westchester Medical Center, Valhalla, NY 10595, USA; New York Medical College School of Medicine, Valhalla, NY 10595, USA.
| |
Collapse
|
12
|
Feldstein E, Zhong A, Clare K, Nolan B, Patel S, Lavi-Romer N, Stadlan Z, Dicpinigaitis A, Dominguez J, Kamal H, Shapiro SD, Biswas A, Tanweer O, Bulsara K, Muh C, Pisapia J, Hanft S, Mayer S, Gandhi CD, Al-Mufti F. Ruptured arteriovenous malformation mortality: Incidence, risk factors, and inpatient outcome score. Interv Neuroradiol 2023:15910199231173458. [PMID: 37157828 DOI: 10.1177/15910199231173458] [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: 05/10/2023] Open
Abstract
BACKGROUND Limited literature exists on the morbidity and mortality of AVM associated intracerebral hemorrhage (ICH) compared with non-AVM ICH. OBJECTIVE We examine morbidity and mortality in cAVM in a large nationwide inpatient sample to create a prognostic inpatient ruptured AVM mortality score. METHODS This retrospective cohort study from 2008 to 2014 compares outcomes in cAVM related hemorrhages and ICH utilizing the National Inpatient Sample database. Diagnostic codes for ICH and AVM underlying ICH were identified. We compared case fatality according to medical complications. Multivariate analysis was used to derive hazard ratios and 95% confidence intervals to assess odds of mortality. RESULTS We identified 6496 patients with ruptured AVMs comparing them to 627,185 admitted with ICH. Mortality was lower for ruptured AVMs (11%) compared to ICH (22%) [p < 0.01]. Mortality associated factors were liver disease (OR 2.64, CI 1.81-3.85, p < .001), diabetes mellitus (OR 2.42, CI 1.38-4.22, p = 0.002), alcohol abuse (OR 1.81, CI 1.31-2.49, p = 0.001), hydrocephalus (OR 3.35 CI 2.81-4.00, p < 0.001), cerebral edema (OR 1.5, 1.25-1.85, p < 0.001), cardiac arrest (OR 15, CI 7.9-30, p < 0.001), and pneumonia (OR 1.93, CI 1.51-2.47, p < 0.001). A 0-5 ruptured AVM mortality score was developed: Cardiac arrest (=3), age >60 (=1), Black race (=1), chronic liver failure (=1) diabetes mellitus (=1), pneumonia (=1), alcohol abuse (=1) and cerebral edema (=1). Mortality increased with score. No patient with 5 or more points survived. CONCLUSION The Ruptured AVM Mortality Score allows for risk stratification on patients with ICH due to ruptured AVM. This scale could prove useful in prognostication and patient education.
Collapse
Affiliation(s)
- Eric Feldstein
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Allison Zhong
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Kevin Clare
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Bridget Nolan
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Smit Patel
- Division of Neurosurgery, University of Connecticut, Farmington, CT, USA
| | - Nir Lavi-Romer
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Zehavya Stadlan
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | | | - Jose Dominguez
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Haris Kamal
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Steven D Shapiro
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Arundhati Biswas
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | | | - Ketan Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, CT, USA
| | - Carrie Muh
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jared Pisapia
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Simon Hanft
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Stephan Mayer
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Chirag D Gandhi
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| |
Collapse
|
13
|
Feldstein E, Ali S, Patel S, Raghavendran K, Martinez E, Blowes L, Ogulnick J, Bravo M, Dominguez J, Li B, Urhie O, Rosenberg J, Bowers C, Prabhakaran K, Bauershmidt A, Mayer SA, Gandhi CD, Al-Mufti F. Acute Respiratory Distress Syndrome in Patients with Subarachnoid Hemorrhage: Incidence, Predictive Factors, and Impact on Mortality. Interv Neuroradiol 2023; 29:189-195. [PMID: 35234070 PMCID: PMC10152822 DOI: 10.1177/15910199221082457] [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: 12/13/2021] [Accepted: 02/04/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Acute respiratory distress syndrome (ARDS) is a known predictor of poor outcomes in critically ill patients. We sought to examine the role ARDS plays in outcomes in subarachnoid hemorrhage (SAH) patients. Prior studies investigating the incidence of ARDS in SAH patients did not control for SAH severity. Hence, we sought to determine the incidence ARDS in patients diagnosed with aneurysmal SAH and investigate the predisposing risk factors and impact upon outcomes. METHODS A retrospective cohort study was conducted using the National Inpatient Sample (NIS) database for the years 2008 to 2014. Multivariate stepwise regression analysis was performed to identify the risk factors and outcome associated with developing ARDS in the setting of SAH. RESULTS We identified 170,869 patients with non-traumatic subarachnoid hemorrhage, of whom 6962 were diagnosed with ARDS and of those 4829 required mechanical ventilation. ARDS more frequently developed in high grade SAH patients (1.97 ± 0.05 vs. 1.15 ± 0.01; p < 0.0001). Neurologic predictors of ARDS included cerebral edema (OR 1.892, CI 1.180-3.034, p = 0.0035) and medical predictors included cardiac arrest (OR 4.642, CI 2.273-9.482, p < 0.0001) and cardiogenic shock (OR 2.984, CI 1.157-7.696, p = 0.0239). ARDS was associated with significantly worse outcomes (15.5% vs. 52.9% discharged home, 63.0% vs. 40.8% discharged to rehabilitation facility and 21.5% vs. 6.3% in-hospital mortality). CONCLUSION Patients with SAH who developed ARDS were less likely to be discharged home, more likely to need rehabilitation and had a significantly higher risk of mortality. The identification of risk factors contributing to ARDS is helpful for improving outcomes and resource utilization.
Collapse
Affiliation(s)
- Eric Feldstein
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Syed Ali
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Smit Patel
- UCLA Medical Center, Los Angeles, CA,
USA
| | | | - Erick Martinez
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Leah Blowes
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jonathan Ogulnick
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Michelle Bravo
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jose Dominguez
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Boyi Li
- University of North Carolina, Chapel
Hill, NC, USA
| | - Ogaga Urhie
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Jon Rosenberg
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | | | | | | | - Stephan A. Mayer
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Chirag D. Gandhi
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Westchester Medical Center/New York Medical College, Valhalla, NY, USA
| |
Collapse
|
14
|
Ng C, Dominguez JF, Hosein-Woodley R, Feldstein E, Naftchi A, Lui A, Dicpinigaitis AJ, McIntyre MK, Kaur G, Santarelli J, Bauerschmidt A, Mayer SA, Bowers CA, Gandhi CD, Al-Mufti F. Utility of frailty as a predictor of acute kidney injury in patients with aneurysmal subarachnoid hemorrhage. Interv Neuroradiol 2023; 29:114-120. [PMID: 35109710 PMCID: PMC9893237 DOI: 10.1177/15910199221076626] [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: 12/08/2021] [Revised: 12/31/2021] [Accepted: 01/11/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is associated with poor outcome in aneurysmal subarachnoid hemorrhage patients (aSAH). Frailty has recently been demonstrated to correlate with elevated mortality and morbidity; its impact on predicting AKI and mortality in aSAH patients has not been investigated. OBJECTIVE Evaluating risk factors and predictors for AKI in aSAH patients. METHODS aSAH patients from a single-center's prospectively maintained database were retrospectively evaluated for development of AKI within 14 days of admission. Baseline demographic and clinical characteristics were collected. The effect of frailty and other risk factors were evaluated. RESULTS Of 213 aSAH patients, 53 (33.1%) were frail and 12 (5.6%) developed AKI. Admission serum creatinine (sCr) and peak sCr within 48 h were higher in frail patients. AKI patients showed a trend towards higher frailty. Mortality was significantly higher in AKI than non-AKI aSAH patients. Frailty was a poor predictor of AKI when controlling for Hunt and Hess (HH) grade or age. HH grade ≥ 4 strongly predicted AKI when controlling for frailty. CONCLUSION AKI in aSAH patients carries a poor prognosis. The HH grade appears to have superior utility as a predictor of AKI in aSAH patients than mFI.
Collapse
Affiliation(s)
- Christina Ng
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | | | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | | | - Aiden Lui
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Matthew K McIntyre
- Department of Neurological Surgery, Oregon Health & Science
University, Portland, OR, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Andrew Bauerschmidt
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico School of
Medicine, Albuquerque, NM, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| |
Collapse
|
15
|
Vazquez S, Stadlan Z, Lapow JM, Feldstein E, Shah S, Das A, Naftchi AF, Spirollari E, Thaker A, Kazim SF, Dominguez JF, Patel N, Kurian C, Chong J, Mayer SA, Kaur G, Gandhi CD, Bowers CA, Al-Mufti F. Frailty and outcomes in lacunar stroke. J Stroke Cerebrovasc Dis 2023; 32:106942. [PMID: 36525849 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106942] [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: 09/20/2022] [Revised: 12/06/2022] [Accepted: 12/09/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Lacunar strokes (LS) are ischemic strokes of the small perforating arteries of deep gray and white matter of the brain. Frailty has been associated with greater mortality and attenuated response to treatment after stroke. However, the effect of frailty on patients with LS has not been previously described. OBJECTIVE To analyze the association between frailty and outcomes in LS. METHODS Patients with LS were selected from the National Inpatient Sample (NIS) 2016-2019 using the International Classification of Disease, 10th edition (ICD-10) diagnosis codes. The 11-point modified frailty scale (mFI-11) was used to group patients into severely frail and non-severely frail cohorts. Demographics, clinical characteristics, and complications were defined. Health care resource utilization (HRU) was evaluated by comparing total hospital charges and length of stay (LOS). Other outcomes studied were discharge disposition and inpatient death. RESULTS Of 48,980 patients with LS, 10,830 (22.1%) were severely frail. Severely frail patients were more likely to be older, have comorbidities, and pertain to lower socioeconomic status categories. Severely frail patients with LS had worse clinical stroke severity and increased rates of complications such as urinary tract infection (UTI) and pneumonia (PNA). Additionally, severe frailty was associated with unfavorable outcomes and increased HRU. CONCLUSION Severe frailty in LS patients is associated with higher rates of complications and increased HRU. Risk stratification based on frailty may allow for individualized treatments to help mitigate adverse outcomes in the setting of LS.
Collapse
Affiliation(s)
- Sima Vazquez
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Zehavya Stadlan
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Justin M Lapow
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Smit Shah
- Department of Neurology, University of South Carolina/PRISMA Health Richland, Columbia, SC, United States
| | - Ankita Das
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | | | - Eris Spirollari
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Akash Thaker
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, United States
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Neisha Patel
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Christeena Kurian
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Stephan A Mayer
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Gurmeen Kaur
- Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| | - Chirag D Gandhi
- School of Medicine, New York Medical College, Valhalla, NY, United States; Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, United States
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, United States
| | - Fawaz Al-Mufti
- School of Medicine, New York Medical College, Valhalla, NY, United States; Department of Neurology, Westchester Medical Center, Valhalla, NY, United States
| |
Collapse
|
16
|
Ng C, Feldstein E, Spirollari E, Vazquez S, Naftchi A, Graifman G, Das A, Rawanduzy C, Gabriele C, Gandhi R, Zeller S, Dominguez JF, Krystal JD, Houten JK, Kinon MD. Management and outcomes of adult traumatic cervical spondyloptosis: A case report and systematic review. J Clin Neurosci 2022; 103:34-40. [DOI: 10.1016/j.jocn.2022.06.026] [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: 12/09/2021] [Revised: 06/03/2022] [Accepted: 06/28/2022] [Indexed: 10/17/2022]
|
17
|
Spirollari E, Vazquez S, Das A, Wang R, Ampie L, Carpenter AB, Zeller S, Naftchi AF, Beaudreault C, Ming T, Thaker A, Vaserman G, Feldstein E, Dominguez JF, Kazim SF, Al-Mufti F, Houten JK, Kinon MD. Characteristics of Patients Selected for Surgical Treatment of Spinal Meningioma. World Neurosurg 2022; 165:e680-e688. [PMID: 35779754 DOI: 10.1016/j.wneu.2022.06.121] [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: 04/19/2022] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Spinal meningiomas are benign extra-axial tumors that can present with neurological deficits. Treatment partly depends on the degree of disability as there is no agreed-upon patient selection algorithm at present. We aimed to elucidate general patient selection patterns in patients undergoing surgery for spinal meningioma. METHODS Data for patients with spinal tumors admitted between 2016 and 2019 were extracted from the U.S. Nationwide Inpatient Sample. We identified patients with a primary diagnosis of spinal meningioma (using International Classification of Disease, 10th revision codes) and divided them into surgical and nonsurgical treatment groups. Patient characteristics were evaluated for intergroup differences. RESULTS Of 6395 patients with spinal meningioma, 5845 (91.4%) underwent surgery. Advanced age, nonwhite race, obesity, diabetes mellitus, chronic renal failure, and anticoagulant/antiplatelet use were less prevalent in the surgical group (all P < 0.001). The only positive predictor of surgical treatment was elective admission status (odds ratio, 3.166; P < 0.001); negative predictors were low income, Medicaid insurance, anxiety, obesity, and plegia. Patients with bowel-bladder dysfunction, plegia, or radiculopathy were less likely to undergo surgical treatment. The surgery group was less likely to experience certain complications (deep vein thrombosis, P < 0.001; pulmonary embolism, P = 0.002). Increased total hospital charges were associated with nonwhite race, diabetes, depression, obesity, myelopathy, plegia, and surgery. CONCLUSIONS Patients treated surgically had a decreased incidence of complications, comorbidities, and Medicaid payer status. A pattern of increased utilization of health care resources and spending was also observed in the surgery group. The results indicate a potentially underserved population of patients with spinal meningioma.
Collapse
Affiliation(s)
| | - Sima Vazquez
- New York Medical College, Valhalla, New York, USA
| | - Ankita Das
- New York Medical College, Valhalla, New York, USA
| | - Richard Wang
- New York Medical College, Valhalla, New York, USA
| | - Leonel Ampie
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Austin B Carpenter
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Sabrina Zeller
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | | | | | - Tiffany Ming
- New York Medical College, Valhalla, New York, USA
| | - Akash Thaker
- New York Medical College, Valhalla, New York, USA
| | | | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - John K Houten
- Department of Neurosurgery, Maimonides Medical Center, Northwell School of Medicine, Brooklyn, New York, USA
| | - Merritt D Kinon
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| |
Collapse
|
18
|
Dicpinigaitis AJ, Feldstein E, Shapiro SD, Kamal H, Bauerschmidt A, Rosenberg J, Amuluru K, Pisapia J, Dangayach NS, Liang JW, Bowers CA, Mayer SA, Gandhi CD, Al-Mufti F. Cerebral vasospasm following arteriovenous malformation rupture: a population-based cross-sectional study. Neurosurg Focus 2022; 53:E15. [DOI: 10.3171/2022.4.focus2277] [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: 03/01/2022] [Accepted: 04/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Studies examining the risk factors and clinical outcomes of arterial vasospasm secondary to cerebral arteriovenous malformation (cAVM) rupture are scarce in the literature. The authors used a population-based national registry to investigate this largely unexamined clinical entity.
METHODS
Admissions for adult patients with cAVM ruptures were identified in the National Inpatient Sample during the period from 2015 to 2019. Complex samples multivariable logistic regression and chi-square automatic interaction detection (CHAID) decision tree analyses were performed to identify significant associations between clinical covariates and the development of vasospasm, and a cAVM–vasospasm predictive model (cAVM-VPM) was generated based on the effect sizes of these parameters.
RESULTS
Among 7215 cAVM patients identified, 935 developed vasospasm, corresponding to an incidence rate of 13.0%; 110 of these patients (11.8%) subsequently progressed to delayed cerebral ischemia (DCI). Multivariable adjusted modeling identified the following baseline clinical covariates: decreasing age by decade (adjusted odds ratio [aOR] 0.87, 95% CI 0.83–0.92; p < 0.001), female sex (aOR 1.68, 95% CI 1.45–1.95; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.34, 95% CI 1.01–1.79; p = 0.045), intraventricular hemorrhage (aOR 1.87, 95% CI 1.17–2.98; p = 0.009), hypertension (aOR 1.77, 95% CI 1.50–2.08; p < 0.001), obesity (aOR 0.68, 95% CI 0.55–0.84; p < 0.001), congestive heart failure (aOR 1.34, 95% CI 1.01–1.78; p = 0.043), tobacco smoking (aOR 1.48, 95% CI 1.23–1.78; p < 0.019), and hospitalization events (leukocytosis [aOR 1.64, 95% CI 1.32–2.04; p < 0.001], hyponatremia [aOR 1.66, 95% CI 1.39–1.98; p < 0.001], and acute hypotension [aOR 1.67, 95% CI 1.31–2.11; p < 0.001]) independently associated with the development of vasospasm. Intraparenchymal and subarachnoid hemorrhage were not associated with the development of vasospasm following multivariable adjustment. Among significant associations, a CHAID decision tree algorithm identified age 50–59 years (parent node), hyponatremia, and leukocytosis as important determinants of vasospasm development. The cAVM-VPM achieved an area under the curve of 0.65 (sensitivity 0.70, specificity 0.53). Progression to DCI, but not vasospasm alone, was independently associated with in-hospital mortality (aOR 2.35, 95% CI 1.29–4.31; p = 0.016) and lower likelihood of routine discharge (aOR 0.62, 95% CI 0.41–0.96; p = 0.031).
CONCLUSIONS
This large-scale assessment of vasospasm in cAVM identifies common clinical risk factors and establishes progression to DCI as a predictor of poor neurological outcomes.
Collapse
Affiliation(s)
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Steven D. Shapiro
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | | | - Jon Rosenberg
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Carmel, Indiana
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Neha S. Dangayach
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York; and
| | - John W. Liang
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York; and
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico
| | - Stephan A. Mayer
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Chirag D. Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| |
Collapse
|
19
|
Feldstein E, Wainwright J, Hanft S. Resection of a C6 Motor Nerve Root Schwannoma Through a Posterior Midline Approach: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 23:e70-e71. [PMID: 35726949 DOI: 10.1227/ons.0000000000000224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 01/27/2022] [Indexed: 11/19/2022] Open
Affiliation(s)
- Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | | | | |
Collapse
|
20
|
Dicpinigaitis AJ, Galea VP, Sursal T, Al-Shammari H, Feldstein E, Ali S, Wong S, Bowers C, Becker C, Pisapia J, Muh C, Hanft S, Tyagi R, Mayer SA, Gandhi CD, Al-Mufti F. Low serum albumin as a risk factor for delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage: eICU collaborative research database analysis. J Neurosurg Sci 2022:S0390-5616.22.05604-1. [PMID: 35766203 DOI: 10.23736/s0390-5616.22.05604-1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) represents a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH) and is a significant predictor of morbidity and mortality. Recent studies have implicated inflammatory processes in the pathogenesis of DCI. METHODS aSAH patient data were retrospectively obtained from the eICU Collaborative Research Database (eICU CRD). Multivariable logistic regression models and receiver operating characteristic (ROC) curve analyses were employed to assess the association between low serum albumin (< 3.4 g/dL) and clinical endpoints: DCI and in-hospital mortality. RESULTS Among 276 aSAH patients included in the analysis, 35.5% (n=98) presented with low serum albumin levels and demonstrated a higher incidence of DCI (18.4% vs. 8.4%, OR=2.45, 95% CI 1.17, 5.10; p=0.017) and in-hospital mortality (27.6% vs. 16.3%, OR=1.95, 95% CI 1.08, 3.54; p=0.027) compared to patients with normal admission albumin values. In a multivariable model controlling for age and World Federation of Neurosurgical Societies grade, low serum albumin remained significantly associated with DCI (OR=2.52, 95% CI 1.18, 5.36; p=0.017), but not with in-hospital mortality. A combined model for prediction of DCI, encompassing known risk factors in addition to low serum albumin, achieved an area under the curve of 0.65 (sensitivity=0.55, specificity=0.75). CONCLUSIONS Serum albumin, a routine and inexpensive laboratory measurement, can may potentially aid in the identification of patients with aSAH at risk for the development of DCI.
Collapse
Affiliation(s)
| | - Vincent P Galea
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Tolga Sursal
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | | | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Syed Ali
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Serena Wong
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Christian Becker
- Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Carrie Muh
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Rachana Tyagi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Stephan A Mayer
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA -
| |
Collapse
|
21
|
Dicpinigaitis AJ, Feldstein E, Gandhi CD, Hanft S. Letter: Early Experience Using Omniscient Neurotechnology Fiber Tracking Software for Resection of Intra-Axial Brain Tumors. Oper Neurosurg (Hagerstown) 2022; 22:e306-e308. [DOI: 10.1227/ons.0000000000000239] [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: 02/10/2022] [Accepted: 02/16/2022] [Indexed: 11/19/2022] Open
|
22
|
Dominguez JF, Sursal T, Kazim SF, Ng C, Vazquez S, DAS A, Naftchi A, Spirollari E, Elkun Y, Gatzoflias S, Ampie L, Feldstein E, Uddin A, Damodara N, Hanft SJ, Gandhi CD, Bowers CA. Frailty is a risk factor for intracranial abscess and is associated with longer length of stay: a retrospective single institution case-control study. J Neurosurg Sci 2022:S0390-5616.22.05720-4. [PMID: 35416458 DOI: 10.23736/s0390-5616.22.05720-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intracranial abscess (IA) causes significant morbidity and mortality. The impact of baseline frailty status on post-operative outcomes of IA patients remains largely unknown. The present study evaluated if frailty status can be used to prognosticate outcomes in IA patients. METHODS We retrospectively reviewed all IA patients undergoing craniotomy at our institution from 2011 to 2018 (n =18). These IA patients were age and gender matched with patients undergoing craniotomy for intracranial tumor (IT), an internal control for comparison. Demographic and clinical data were collected to measure frailty, using the modified frailty index-11 (mFI-11), pre-operative American Society of Anesthesiologists Physical Status Classification System (ASA), and study their association with post-operative complications, as measured by the Clavien-Dindo Grade (CDG). RESULTS No significant difference in mFI-11 or ASA score was observed between the IA and IT groups (p = 0.058 and p = 0.131, respectively). IA patients had significantly higher CDG as compared with the control IT patients (p < 0.001). There was a trend towards increasing LOS in the IA group as compared to the IT group (p = 0.053). Increasing mFI and ASA were significant predictors of LOS by multiple linear regression in the IA group (p = 0.006 and p = 0.001, respectively), but not in the control IT group. Neither mFI-11 nor ASA were found to be predictors for CDG in either group. Within this case-control group of patients, we found an increase for odds of having IA with increasing mFI (OR 1.838, CI 95% 1.016-3.362, p = 0.044). CONCLUSIONS Frail IA patients tend to have more severe postoperative complications. The mFI-11 seems to predict increased resource utilization in the form of LOS. This study provides the initial retrospective data of another neurosurgical pathology where frailty leads to significantly worse outcomes. We also found that mFI may serve as a potential risk factor for severe disease.
Collapse
Affiliation(s)
- Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA -
| | - Tolga Sursal
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Syed F Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | | | | | - Ankita DAS
- New York Medical College, Valhalla, NY, USA
| | | | | | | | | | - Leonel Ampie
- Department of Neurosurgery, University of Virginia-National Institute of Health, Bethesda, MD, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Anaz Uddin
- New York Medical College, Valhalla, NY, USA
| | - Nitesh Damodara
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Simon J Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| |
Collapse
|
23
|
Al-Mufti F, Khandelwal P, Sursal T, Cooper JB, Feldstein E, Amuluru K, Moré JM, Tiwari A, Singla A, Dmytriw AA, Piano M, Quilici L, Pero G, Renieri L, Limbucci N, Martínez-Galdámez M, Schüller-Arteaga M, Galván J, Arenillas-Lara JF, Hashim Z, Nayak S, Desousa K, Sun H, Agarwalla PK, Sudipta Roychowdhury J, Nourollahzadeh E, Prakash T, Xavier AR, Diego Lozano J, Gupta G, Yavagal DR, Elghanem M, Gandhi CD, Mayer SA. Neutrophil-Lymphocyte ratio is associated with poor clinical outcome after mechanical thrombectomy in stroke in patients with COVID-19. Interv Neuroradiol 2022:15910199221093896. [PMID: 35404161 PMCID: PMC9006085 DOI: 10.1177/15910199221093896] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background The neutrophil–lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19. Objective We sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke. Methods We analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated. Results Incidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27–87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p = .003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2–38.6, p = .03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2–52.4, p = .03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p = .043, TICI p = .070). Conclusions We show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.
Collapse
Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurosurgery, New York Medical College, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Priyank Khandelwal
- Department of Neurological Surgery, University Hospital Newark, 12286New Jersey Medical School, Rutgers, New Jersey, USA
| | - Tolga Sursal
- Department of Neurosurgery, New York Medical College, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Jared B Cooper
- Department of Neurosurgery, New York Medical College, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Eric Feldstein
- Department of Neurosurgery, New York Medical College, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, 178242Goodman Campbell Brain and Spine, Indianapolis, Indiana, USA
| | - Jayaji M Moré
- Department of Neurosurgery, New York Medical College, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Ambooj Tiwari
- Department of Neurology, Brookdale and Jamaica Hospital Center, 12297NYU School of Medicine, Brooklyn, New York, USA
| | - Amit Singla
- Department of Neurological Surgery, University Hospital Newark, 12286New Jersey Medical School, Rutgers, New Jersey, USA
| | - Adam A Dmytriw
- Neuroradiology and Neurointervention Service, 1861Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mariangela Piano
- Department of Neuroradiology, 9338ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Luca Quilici
- Department of Neuroradiology, 9338ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Guglielmo Pero
- Department of Neuroradiology, 9338ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Leonardo Renieri
- Department of Radiology, Neurovascular Unit, Careggi University Hospital, Florence, Italy
| | - Nicola Limbucci
- Department of Radiology, Neurovascular Unit, Careggi University Hospital, Florence, Italy
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology, 16238Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Miguel Schüller-Arteaga
- Department of Interventional Neuroradiology, 16238Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Jorge Galván
- Department of Interventional Neuroradiology, 16238Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | | | - Zafar Hashim
- Department of Radiology, University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Sanjeev Nayak
- Department of Radiology, University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Keith Desousa
- Department of Neurology, 5799Northwell Health, Long Island, New York, New York, USA
| | - Hai Sun
- Department of Neurological Surgery, Rutgers Robert Wood Johnson Medical School, New Jersey Medical School, New Brunswick, New Jersey, USA
| | - Pankaj K Agarwalla
- Department of Neurological Surgery, University Hospital Newark, 12286New Jersey Medical School, Rutgers, New Jersey, USA
| | - J Sudipta Roychowdhury
- Department of Neurology & Radiology, 25044Robert Wood Johnson University Hospital, Rutgers, New Jersey, USA
| | - Emad Nourollahzadeh
- Department of Neurology & Radiology, 25044Robert Wood Johnson University Hospital, Rutgers, New Jersey, USA
| | - Tannavi Prakash
- Department of Neurological Surgery, University Hospital Newark, 12286New Jersey Medical School, Rutgers, New Jersey, USA
| | - Andrew R Xavier
- Department of Neurology, Saint Joseph Health, 2956Detroit Medical Center, Detroit, Michigan, USA
| | - J Diego Lozano
- Department of Radiology, 8790University of California Riverside, Riverside, California, USA
| | - Gaurav Gupta
- Department of Neurological Surgery, Rutgers Robert Wood Johnson Medical School, New Jersey Medical School, New Brunswick, New Jersey, USA
| | - Dileep R Yavagal
- Department of Neurology, Miller School of Medicine, Miami, Florida, USA
| | - Mohammad Elghanem
- Department of Neurology, 12216University of Arizona-Tucson, Tucson, Arizona, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, New York Medical College, 8138Westchester Medical Center, Valhalla, New York, USA
| | - Stephan A Mayer
- Department of Neurosurgery, New York Medical College, 8138Westchester Medical Center, Valhalla, New York, USA
| |
Collapse
|
24
|
Li B, Sursal T, Martinez E, Karimov Z, Feldstein E, Stein A, Cooper J, Hosein-Woodley R, Liu A, McIntyre M, Bowers C, Hanft S, Hafeez Z, Pisapia J, Muh C, Tyagi R, Mayer SA, Gandhi CD, Al-Mufti F. An institutional report of heparin induced thrombocytopenia type II in aneurysmal subarachnoid hemorrhage patients. Interv Neuroradiol 2022:15910199221091643. [PMID: 35354315 PMCID: PMC10399499 DOI: 10.1177/15910199221091643] [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 Heparin induced thrombocytopenia Type II (HIT-II) is a dangerous thromboembolic complication of heparin therapy. The current literature on incidence and outcomes of HIT-II in aneurysmal subarachnoid hemorrhage (aSAH) patients remains sparse. OBJECTIVE We report our institution's incidence and outcomes of HIT-II in aSAH patients. METHODS We performed a retrospective cohort study at an academic medical center between June 2014 and July 2018. All patients had aSAH confirmed by digital subtraction angiography. Diagnosis of HIT-II was determined by positive results on both heparin PF4-platelet antibody ELISA (anti-PF4) and serotonin release assay (SRA). RESULTS 204 patients met inclusion criteria. Seven patients (7/204, 3.5%) underwent laboratory testing, three of whom met clinical criteria. HIT-II incidence was confirmed in two of these seven patients (2/204, 0.98%), who had high BMI and T4 scores. CONCLUSION Our institution's report of HIT-II incidence in aSAH patients is lower than previously reported in this population and more closely parallels HIT-II incidence in the general and surgical ICU setting. Widely-accepted American College of Chest Physicians (ACCP) clinical diagnostic criteria in conjunction with anti-PF4 and SRA testing is the gold standard of clinical diagnosis of HIT-II in aSAH patients.
Collapse
Affiliation(s)
- Boyi Li
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Tolga Sursal
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Erick Martinez
- School of Medicine, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Zafar Karimov
- School of Medicine, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Alan Stein
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | | | - Aiden Liu
- School of Medicine, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Matthew McIntyre
- Department of Neurosurgery, 89020Oregon Health and Sciences University, Portland, Oregon 97239, United States
| | - Christian Bowers
- Department of Neurosurgery, 8137University of New Mexico, Albuquerque, New Mexico 87131, United States
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Zeeshan Hafeez
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Carrie Muh
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Rachana Tyagi
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, 8137New York Medical College, Valhalla, NY 10595, United States
| |
Collapse
|
25
|
Zhong AJ, Kamal H, Uddin A, Feldstein E, Shapiro SD, Chung JY, Ogarro M, Friedman R, Simmons J, Graifman G, Kurian C, Kaur G, Mayer SA, Chong J, Gandhi CD, Al-Mufti F. Transcarotid Access for Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis and Systematic Review. J Stroke Cerebrovasc Dis 2022; 31:106428. [PMID: 35279005 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/14/2022] [Accepted: 02/20/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Despite the success of mechanical thrombectomy in large vessel acute ischemic stroke, recanalization may fail due to difficult anatomic access or peripheral arterial occlusive disease. In these cases, transcarotid access may be used as an alternative, but it has not gained prominence due to safety concerns. Our objective was to assess the efficacy and safety of transcarotid access for mechanical thrombectomy. MATERIALS AND METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform a systematic review with articles published from 2010 to 2020 summarizing pre-intervention characteristics, techniques utilized, and outcomes of patients undergoing mechanical thrombectomy via trans-carotid puncture. We performed a meta-analysis of clinical outcomes, reperfusion times and overall complications rates of trans-carotid approach. RESULTS Six studies describing 80 total attempts at carotid access, 72 of which were successful (90% success rate), were included. Direct carotid puncture was most often used as a rescue technique (87% of patients) secondary to failed femoral access. Successful recanalization was achieved in 76% of patients. 90 day modified Rankin Scale ≤ 2 was achieved in 28% of patients. Carotid puncture-reperfusion time was 32 min (CI = 24-40, p < 0.001). Cervical complications occurred at a rate of 26.5% (95% CI = 17%-38%). Only 1.3% (1/80 patients) had a fatal outcome and 96% of complications required no intervention. CONCLUSIONS Our results on the safety and efficacy of transcarotid access suggests that this approach is a viable alternative to failed thrombectomy when transfemoral or trans-radial access may be impractical.
Collapse
Affiliation(s)
- Allison J Zhong
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
| | - Anaz Uddin
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
| | - Steven D Shapiro
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Joon Yong Chung
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - Maziyah Ogarro
- New York Medical College School of Medicine, Valhalla, NY, USA
| | | | - Josh Simmons
- New York Medical College School of Medicine, Valhalla, NY, USA
| | | | - Christeena Kurian
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Ji Chong
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
| |
Collapse
|
26
|
Feldstein E, Dominguez JF, Kaur G, Patel SD, Dicpinigaitis AJ, Semaan R, Fuentes LE, Ogulnick J, Ng C, Rawanduzy C, Kamal H, Pisapia J, Hanft S, Amuluru K, Naidu SS, Cooper HA, Prabhakaran K, Mayer SA, Gandhi CD, Al-Mufti F. Cardiac arrest in spontaneous subarachnoid hemorrhage and associated outcomes. Neurosurg Focus 2022; 52:E6. [DOI: 10.3171/2021.12.focus21650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The authors sought to analyze a large, publicly available, nationwide hospital database to further elucidate the impact of cardiopulmonary arrest (CA) in association with subarachnoid hemorrhage (SAH) on short-term outcomes of mortality and discharge disposition.
METHODS
This retrospective cohort study was conducted by analyzing de-identified data from the National (Nationwide) Inpatient Sample (NIS). The publicly available NIS database represents a 20% stratified sample of all discharges and is powered to estimate 95% of all inpatient care delivered across hospitals in the US. A total of 170,869 patients were identified as having been hospitalized due to nontraumatic SAH from 2008 to 2014.
RESULTS
A total of 5415 patients (3.2%) were hospitalized with an admission diagnosis of CA in association with SAH. Independent risk factors for CA included a higher Charlson Comorbidity Index score, hospitalization in a small or nonteaching hospital, and a Medicaid or self-pay payor status. Compared with patients with SAH and not CA, patients with CA-SAH had a higher mean NIS Subarachnoid Severity Score (SSS) ± SD (1.67 ± 0.03 vs 1.13 ± 0.01, p < 0.0001) and a vastly higher mortality rate (82.1% vs 18.4%, p < 0.0001). In a multivariable model, age, NIS-SSS, and CA all remained significant independent predictors of mortality. Approximately 18% of patients with CA-SAH survived and were discharged to a rehabilitation facility or home with health services, outcomes that were most predicted by chronic disease processes and large teaching hospital status.
CONCLUSIONS
In the largest study of its kind, CA at onset was found to complicate roughly 3% of spontaneous SAH cases and was associated with extremely high mortality. Despite this, survival can still be expected in approximately 18% of patients.
Collapse
Affiliation(s)
- Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Jose F. Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Gurkamal Kaur
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Smit D. Patel
- Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California; and
| | - Alis J. Dicpinigaitis
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Rosa Semaan
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Leanne E. Fuentes
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Jonathan Ogulnick
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Christina Ng
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Cameron Rawanduzy
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Srihari S. Naidu
- Department of Medicine, Westchester Medical Center, New York Medical College of Medicine
| | - Howard A. Cooper
- Department of Cardiology, Westchester Medical Center, New York Medical College of Medicine
| | - Kartik Prabhakaran
- Department of Surgery, Westchester Medical Center, New York Medical College of Medicine, Valhalla, New York
| | - Stephan A. Mayer
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Chirag D. Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| |
Collapse
|
27
|
Dicpinigaitis AJ, Feldstein E, Damodara N, Cooper JB, Shapiro SD, Kamal H, Kinon MD, Pisapia J, Rosenberg J, Gandhi CD, Al-Mufti F. Development of cerebral vasospasm following traumatic intracranial hemorrhage: incidence, risk factors, and clinical outcomes. Neurosurg Focus 2022; 52:E14. [DOI: 10.3171/2021.12.focus21668] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Limited evidence exists characterizing the incidence, risk factors, and clinical associations of cerebral vasospasm following traumatic intracranial hemorrhage (tICH) on a large scale. Therefore, the authors sought to use data from a national inpatient registry to investigate these aspects of posttraumatic vasospasm (PTV) to further elucidate potential causes of neurological morbidity and mortality subsequent to the initial insult.
METHODS
Weighted discharge data from the National (Nationwide) Inpatient Sample from 2015 to 2018 were queried to identify patients with tICH who underwent diagnostic angiography in the same admission and, subsequently, those who developed angiographically confirmed cerebral vasospasm. Multivariable logistic regression analysis was performed to identify significant associations between clinical covariates and the development of vasospasm, and a tICH vasospasm predictive model (tICH-VPM) was generated based on the effect sizes of these parameters.
RESULTS
Among 5880 identified patients with tICH, 375 developed PTV corresponding to an incidence of 6.4%. Multivariable adjusted modeling determined that the following clinical covariates were independently associated with the development of PTV, among others: age (adjusted odds ratio [aOR] 0.98, 95% CI 0.97–0.99; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.80, 95% CI 1.12–2.90; p = 0.015), intraventricular hemorrhage (aOR 6.27, 95% CI 3.49–11.26; p < 0.001), tobacco smoking (aOR 1.36, 95% CI 1.02–1.80; p = 0.035), cocaine use (aOR 3.62, 95% CI 1.97–6.63; p < 0.001), fever (aOR 2.09, 95% CI 1.34–3.27; p = 0.001), and hypokalemia (aOR 1.62, 95% CI 1.26–2.08; p < 0.001). The tICH-VPM achieved moderately high discrimination, with an area under the curve of 0.75 (sensitivity = 0.61 and specificity = 0.81). Development of vasospasm was independently associated with a lower likelihood of routine discharge (aOR 0.60, 95% CI 0.45–0.78; p < 0.001) and an extended hospital length of stay (aOR 3.53, 95% CI 2.78–4.48; p < 0.001), but not with mortality.
CONCLUSIONS
This population-based analysis of vasospasm in tICH has identified common clinical risk factors for its development, and has established an independent association between the development of vasospasm and poorer neurological outcomes.
Collapse
Affiliation(s)
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, and
| | | | | | | | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, and
| | | | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, and
| | - Jon Rosenberg
- Department of Neurology, Westchester Medical Center, Valhalla, New York
| | | | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, and
| |
Collapse
|
28
|
Dicpinigaitis AJ, Palumbo KE, Gandhi CD, Cooper JB, Hanft S, Kamal H, Shapiro SD, Feldstein E, Kafina M, Kurian C, Chong JY, Mayer SA, Al-Mufti F. Association of Elevated Body Mass Index with Functional Outcome and Mortality following Acute Ischemic Stroke: The Obesity Paradox Revisited. Cerebrovasc Dis 2022; 51:565-569. [PMID: 35158366 DOI: 10.1159/000521513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 12/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous literature has identified a survival advantage in acute ischemic stroke (AIS) patients with elevated body mass indices (BMIs), a phenomenon termed the "obesity paradox." OBJECTIVE The aim of this study was to evaluate the independent association between obesity and clinical outcomes following AIS. METHODS Weighted discharge data from the National Inpatient Sample were queried to identify AIS patients from 2015 to 2018. Multivariable logistic regression and Cox proportional hazards modeling were performed to evaluate associations between obesity (BMI ≥ 30) and clinical endpoints following adjustment for acute stroke severity and comorbidity burden. RESULTS Among 1,687,805 AIS patients, 216,775 (12.8%) were obese. Compared to nonobese individuals, these patients were younger (64 vs. 72 mean years), had lower baseline NIHSS scores (6.9 vs. 7.9 mean score), and a higher comorbidity burden. Multivariable analysis demonstrated independent associations between obesity and lower likelihood of mortality (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI]: 0.71, 0.82, p < 0.001; hazard ratio 0.84, 95% CI: 0.73, 0.97, p = 0.015), intracranial hemorrhage (aOR 0.87, 95% CI: 0.82, 0.93, p < 0.001), and routine discharge to home (aOR 0.97, 95% CI: 0.95, 0.99; p = 0.015). Mortality rates between obese and nonobese patients were significantly lower across stroke severity thresholds, but this difference was attenuated among high severity (NIHSS > 20) strokes (21.6% vs. 23.2%, p = 0.358). Further stratification of the cohort into BMI categories demonstrated a "U-shaped" association with mortality (underweight aOR 1.58, 95% CI: 1.39, 1.79; p < 0.001, overweight aOR 0.64, 95% CI: 0.42, 0.99; p = 0.046, obese aOR 0.77, 95% CI: 0.71, 0.83; p < 0.001, severely obese aOR 1.18, 95% CI: 0.74, 1.87; p = 0.485). Sub-cohort assessment of thrombectomy-treated patients demonstrated an independent association of obesity (BMI 30-40) with lower mortality (aOR 0.79, 95% CI: 0.65, 0.96; p = 0.015), but not with routine discharge. CONCLUSION This cross-sectional analysis demonstrates a lower likelihood of discharge to home as well as in-hospital mortality in obese patients following AIS, suggestive of a protective effect of obesity against mortality but not against all poststroke neurological deficits in the short term which would necessitate placement in acute rehabilitation and long-term care facilities.
Collapse
Affiliation(s)
| | - Kieran E Palumbo
- Chicago Medical School at Rosalind Franklin University, North Chicago, Illinois, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Steven D Shapiro
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Martin Kafina
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Christeena Kurian
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Ji Y Chong
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.,Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| |
Collapse
|
29
|
Li B, Kim MG, Dominguez J, Feldstein E, Kleinman G, Hanft S. Intraventricular Choroid Plexus Cavernoma Resection Using Tubular Retractor System and Exoscope Visualization: A Technical Case Report. Oper Neurosurg (Hagerstown) 2022; 22:e134-e137. [PMID: 35030141 DOI: 10.1227/ons.0000000000000075] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 09/29/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Cavernous malformations (CMs) account for approximately 5% to 10% of all CNS vascular malformations, and intraventricular CMs (IVCMs) are a rare subtype, accounting for 2.5% to 10.8% of all intracranial CMs. IVCMs can expand rapidly, leading to compression of adjacent structures, intraventricular hemorrhage, and obstructive hydrocephalus. Diagnosis is challenging because it can mimic a variety of other lesions. CLINICAL PRESENTATION A 71-year-old man presented after a fall because of imbalance. MRI of the head showed a homogenously enhancing 2-cm mass in the posterior aspect of the right lateral ventricle, with blood layering in the right occipital horn and adjacent parietal edema and leptomeningeal enhancement, as well as a pituitary lesion. DISCUSSION The patient underwent a right parietal craniotomy for resection of the mass. The ventricle was accessed through a transsulcal approach through the intraparietal sulcus using a tubular retractor system. The mass was arising from the choroid plexus and dissected free in a piecemeal fashion. Postoperative imaging confirmed gross total resection, and the patient had an uneventful recovery. CONCLUSION Here, we present the first case of a choroid plexus IVCM removed using a tubular retractor system. We demonstrate that this is a safe and effective approach for this rare lesion given the minimal traction on brain parenchyma and enhanced visualization of a deep-seated cavernoma in the lateral ventricle.
Collapse
Affiliation(s)
- Boyi Li
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA
| | - Michael G Kim
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Jose Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Eric Feldstein
- Department of Neurosurgery, New York Medical College, Valhalla, New York, USA
| | - George Kleinman
- Department of Pathology, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| |
Collapse
|
30
|
Kurian C, Mayer S, Kaur G, Sahni R, Feldstein E, Samaan M, Viswanathan D, Sami T, Ali S, Al-Shammari H, Bloomfield J, Bravo M, Nuoman R, Gulko E, Gandhi C, Al-Mufti F. Bihemispheric ischemic strokes in patients with COVID-19. Brain Circ 2022; 8:10-16. [PMID: 35372732 PMCID: PMC8973449 DOI: 10.4103/bc.bc_65_21] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/29/2021] [Accepted: 02/06/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND: There is emerging evidence that COVID-19 can trigger thrombosis because of a hypercoagulable state, including large-vessel occlusion ischemic strokes. Bihemispheric ischemic stroke is uncommon and is thought to indicate an embolic source. Here, we examine the findings and outcomes of patients with bihemispheric stroke in the setting of COVID-19. METHODS: We performed a retrospective cohort study at a quaternary academic medical center between March 1, 2020, and April 30, 2020. We identified all patients with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection who presented with simultaneous bihemispheric ischemic strokes. RESULTS: Of 637 COVID-19 admissions during the 2-month period, 13 had a diagnosis of acute ischemic stroke, including 5 who developed bihemispheric cerebral infarction. Three of those 5 (60%) were female, median age was 54 (range 41–67), and all five were being managed for severe COVID-19-related pneumonia complicated by acute kidney injury and liver failure before the diagnosis of cerebral infarction was established. Five presented with elevated ferritin, lactate dehydrogenase, and interleukin-6 (IL-6) levels, and four had lymphopenia and elevated D-dimer levels. All patients underwent neuroimaging with computed tomography for persistent depressed mentation, with or without a focal neurologic deficit, demonstrating multifocal ischemic strokes with bihemispheric involvement. Outcome was poor in all patients: two were discharged to a rehabilitation facility with moderate-to-severe disability and three (60%) patients died. CONCLUSIONS: Stroke is implicated in SARS-CoV-2 infection. Although causality cannot be established, we present the imaging and clinical findings of patients with COVID-19 and simultaneous bihemispheric ischemic strokes. Multifocal ischemic strokes with bihemispheric involvement should be considered in COVID-19 patients with severe infection and poor neurologic status and may be associated with poor outcomes.
Collapse
|
31
|
Dicpinigaitis AJ, Gandhi CD, Shah SP, Galea VP, Cooper JB, Feldstein E, Shapiro SD, Kamal H, Kurian C, Kaur G, Tyagi R, Biswas A, Rosenberg J, Bauerschmidt A, Bowers CA, Mayer SA, Al-Mufti F. Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients. J Neurol Sci 2022; 434:120168. [DOI: 10.1016/j.jns.2022.120168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/28/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
|
32
|
Lapow JM, Dicpinigaitis AJ, Pammal RS, Coghill GA, Rechester O, Feldstein E, Nuoman R, Maselli K, Kodi S, Bauerschmidt A, Rosenberg JB, Yaghi S, Kaur G, Kurian C, Chong JY, Mayer SA, Gandhi CD, Al-Mufti F. Obstructive sleep apnea confers lower mortality risk in acute ischemic stroke patients treated with endovascular thrombectomy: National Inpatient Sample analysis 2010-2018. J Neurointerv Surg 2021; 14:1195-1199. [PMID: 34930802 DOI: 10.1136/neurintsurg-2021-018161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 11/04/2022]
Abstract
BackgroundObstructive sleep apnea (OSA) portends increased morbidity and mortality following acute ischemic stroke (AIS). Evaluation of OSA in the setting of AIS treated with endovascular mechanical thrombectomy (MT) has not yet been evaluated in the literature. METHODS The National Inpatient Sample from 2010 to 2018 was utilized to identify adult AIS patients treated with MT. Those with and without OSA were compared for clinical characteristics, complications, and discharge disposition. Multivariable logistic regression analysis and propensity score adjustment (PA) were employed to evaluate independent associations between OSA and clinical outcome. RESULTS Among 101 093 AIS patients treated with MT, 6412 (6%) had OSA. Those without OSA were older (68.5 vs 65.6 years old, p<0.001), female (50.5% vs 33.5%, p<0.001), and non-caucasian (29.7% vs 23.7%, p<0.001). The OSA group had significantly higher rates of obesity (41.4% vs 10.5%, p<0.001), atrial fibrillation (47.1% vs 42.2%, p=0.001), hypertension (87.4% vs 78.5%, p<0.001), and diabetes mellitus (41.2% vs 26.9%, p<0.001). OSA patients treated with MT demonstrated lower rates of intracranial hemorrhage (19.1% vs 21.8%, p=0.017), treatment of hydrocephalus (0.3% vs 1.1%, p=0.009), and in-hospital mortality (9.7% vs 13.5%, p<0.001). OSA was independently associated with lower rate of in-hospital mortality (aOR 0.76, 95% CI 0.69 to 0.83; p<0.001), intracranial hemorrhage (aOR 0.88, 95% CI 0.83 to 0.95; p<0.001), and hydrocephalus (aOR 0.51, 95% CI 0.37 to 0.71; p<0.001). Results were confirmed by PA. CONCLUSIONS Our findings suggest that MT is a viable and safe treatment option for AIS patients with OSA.
Collapse
Affiliation(s)
- Justin M Lapow
- New York Medical College School of Medicine, Valhalla, New York, USA
| | | | - Rajkumar S Pammal
- New York Medical College School of Medicine, Valhalla, New York, USA
| | - Griffin A Coghill
- New York Medical College School of Medicine, Valhalla, New York, USA
| | | | - Eric Feldstein
- Neurosurgery, New York Medical College Department of Neurosurgery, Valhalla, New York, USA
| | - Rolla Nuoman
- Neurology, Westchester Medical Center, Valhalla, New York, USA
| | | | - Shyla Kodi
- New York Medical College School of Medicine, Valhalla, New York, USA.,Westchester Medical Center, Valhalla, New York, USA
| | - Andrew Bauerschmidt
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Jon B Rosenberg
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Gurmeen Kaur
- Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | | | - Ji Y Chong
- Neurology, Westchester Medical Center, Valhalla, New York, USA.,Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Stephan A Mayer
- Neurology, Westchester Medical Center, Valhalla, New York, USA
| | - Chirag D Gandhi
- Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| |
Collapse
|
33
|
Li B, Ng C, Feldstein E, Muh C, Mohan A, Tobias M. Non-Operative Management of a Pediatric Patient With Bilateral Subdural Hematomas in the Setting of Ruptured Arachnoid Cyst. Cureus 2021; 13:e20099. [PMID: 34873561 PMCID: PMC8637768 DOI: 10.7759/cureus.20099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2021] [Indexed: 11/11/2022] Open
Abstract
Pediatric subdural hematomas (SDH) are associated with arachnoid cysts (AC), particularly in the middle cranial fossa (MCF). Operative management of these hemorrhages is a mainstay of treatment. Conservative management may be an option if there is minimal mass effect and the patient is mildly symptomatic. A 14-year-old male presented with right frontal headaches that worsened with activity. He was found to have a large right MCF AC. Scheduled routine outpatient follow-up CT of the head demonstrated bilateral SDH. There was no history of significant head trauma. He was admitted for close observation and his inpatient scans remained stable. Outpatient follow-up imaging over the course of three and a half years demonstrated resolution of SDH and decreased AC size. He denied headaches and continued doing well in school. ACs are a risk factor for the development of SDH in young male patients after minor trauma. Development of intracranial hypotension secondary to AC rupture may have contributed to the development of bilateral SDH in our patient. We demonstrate here that close clinical follow up with serial imaging may be considered a management strategy in these patients.
Collapse
Affiliation(s)
- Boyi Li
- Neurological Surgery, University of North Carolina at Chapel Hill School of Medicine, Valhalla, USA
| | - Christina Ng
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| | - Eric Feldstein
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| | - Carrie Muh
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| | - Avinash Mohan
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| | - Michael Tobias
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| |
Collapse
|
34
|
Kaur G, Damodara N, Feldstein E, Dominguez J, Huang KT, Ogulnick JV, Nuoman R, Khandelwal P, El-Ghanem M, Gupta G, Mayer SA, Amuluru K, Gandhi CD, Al-Mufti F. Relation between brain natriuretic peptide and delayed cerebral ischemia in patients with aneurysmalsubarachnoid hemorrhage. Clin Neurol Neurosurg 2021; 211:107031. [PMID: 34837820 DOI: 10.1016/j.clineuro.2021.107031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 10/31/2021] [Accepted: 11/06/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Brain natriuretic peptide (BNP), often used to evaluate degree of heart failure, has been implicated in fluid dysregulation and inflammation in critically-ill patients. Twenty to 30% of patients with aneurysmal subarachnoid hemorrhage (aSAH) will develop some degree of neurogenic stress cardiomyopathy (NSC) and in turn elevation of BNP levels. We sought to explore the association between BNP levels and development of delayed cerebral ischemia (DCI) in patients with aSAH. METHODS We retrospectively evaluated the records of 149 patients admitted to the Neurological Intensive Care Unit between 2006 and 2015 and enrolled in an existing prospectively maintained aSAH database. Demographic data, treatment and outcomes, and BNP levels at admission and throughout the hospital admission were noted. RESULTS Of the 149 patients included in the analysis, 79 developed DCI during their hospital course. We found a statistically significant association between DCI and the highest recorded BNP (OR 1.001, 95% CI-1.001-1.002, p = 0.002). The ROC curve analysis for DCI based on BNP showed that the highest BNP level during hospital admission (AUC 0.78) was the strongest predictor of DCI compared to the change in BNP over time (AUC 0.776) or the admission BNP (AUC 0.632). CONCLUSION Our study shows that DCI is associated not only with higher baseline BNP values (admission BNP), but also with the highest BNP level attained during the hospital course and the rapidity of change or increase in BNP over time. Prospective studies are needed to evaluate whether routine measurement of BNP may help identify SAH patients at high risk of DCI.
Collapse
Affiliation(s)
- Gurmeen Kaur
- Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Nitesh Damodara
- Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Eric Feldstein
- Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Jose Dominguez
- Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Kristen T Huang
- Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Jonathan V Ogulnick
- Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Rolla Nuoman
- Department of Neurology, Maria Fareri Children's Hospital - Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Priyank Khandelwal
- Department of Neurosurgery and Neurology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Mohammad El-Ghanem
- Department of Neurology and Medical Imaging, University of Arizona, Banner University Medical Center, Tucson, AZ, USA
| | - Gaurav Gupta
- Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Stephan A Mayer
- Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | | | - Chirag D Gandhi
- Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
| |
Collapse
|
35
|
Feldstein E, Riccardello G, Amuluru K, Al-Mufti F, Gandhi C. Spontaneous Regression of Cerebral Arteriovenous Malformation Following Onyx Embolization. Cureus 2021; 13:e19533. [PMID: 34804748 PMCID: PMC8592311 DOI: 10.7759/cureus.19533] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2021] [Indexed: 11/24/2022] Open
Abstract
Little is known about the natural history of arteriovenous malformations (AVM) and less is known about their potential for spontaneous regression. The advent of endovascular treatment for embolization or pre-surgical embolization of cerebral arteriovenous malformations (cAVM) has seen several reports of spontaneous regression of partial embolization of cAVMs surface in the literature. A 66-year-old patient had an initial diagnostic cerebral angiogram revealing a left frontoparietal region Spetzler-Martin (SM) grading 4 cAVM. The patient underwent three stages of embolization over eight months leading to a 90% reduction in nidal volume, before being lost to follow up for six years. A six-vessel diagnostic cerebral angiogram was performed at that time to assess for any interval changes and surprisingly, the previously visualized left frontoparietal AVM had regressed. There was evidence of prior onyx embolization with no residual filling or recurrence. Spontaneous regression after partial embolization may be under-reported or the natural history is simply unable to temporally unfold because the typical treatment course results in surgery following partial embolization. Given the potential to forgo the risks of an open procedure, we believe this topic deserves further attention.
Collapse
Affiliation(s)
- Eric Feldstein
- Neurological Surgery, Westchester Medical Center, Valhalla, USA
| | | | | | | | - Chirag Gandhi
- Neurosurgery, Westchester Medical Center, Valhalla, USA
| |
Collapse
|
36
|
Al-Mufti F, Ogulnick J, Feldstein E, Damodara N, Bravo M, Alshammari H, Dominguez J, Cooper J, Huang KT, Marikunte S, Ali S, Patel V, Khandelwal P, Mayer SA, Amuluru K, Gandhi CD. Impact of pre-ictal antiplatelet therapy use in aneurysmal subarachnoid hemorrhage. Clin Neurol Neurosurg 2021; 211:107022. [PMID: 34781219 DOI: 10.1016/j.clineuro.2021.107022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 11/01/2021] [Accepted: 11/02/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE There is limited evidence on the use of antiplatelet therapy (APT) to reduce the risk and morbidity of cerebral aneurysmal rupture. This analysis retrospectively assessed APT use in patients presenting to our institution with aneurysmal subarachnoid hemorrhage (aSAH). METHODS We evaluated the records of 186 patients over 7 years of retrospective data from our tertiary care center and an existing database of patients with aSAH. A total of 18 cases with patients on APT and 168 patients not on APT (controls) were identified. Primary outcomes measured were clinical grade (Hunt and Hess score), radiographic grade (Fisher score), and presence of delayed cerebral ischemia (DCI). Secondary outcomes were modified Rankin score at discharge and at 3 months. DCI from cerebral vasospasm was defined as the occurrence of focal neurological impairment or a decrease in at least 2 points on the Glasgow Coma Scale. Logistic regression models were generated. RESULTS We found that APT use did not appear to lead to statistically significant differences in initial presentation, including Hunt-Hess score and Fisher grade (2.91 vs 3.06, p = 0.66, and 3.23 vs 3.22, p = 0.96 respectively). In addition, APT use was not associated with increased rates of delayed cerebral ischemia (DCI) (OR 0.27 p = 0.12). Our analysis showed that increased Hunt Hess score and the presence of DCI are both associated with increased mRS at 90 days (OR 2.32 p < 0.001; OR 2.91 p = 0.002). CONCLUSION The patients in this retrospective observational study did not demonstrate worse outcomes from their aSAH despite APT therapy. Larger prospective studies should be performed to see if this relationship holds and if decreased rates of DCI can be observed.
Collapse
Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States; Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, United States.
| | - Jonathan Ogulnick
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Nitesh Damodara
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Michelle Bravo
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Hussein Alshammari
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Jose Dominguez
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Kristen T Huang
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Sanjana Marikunte
- School of Medicine, New York Medical College, Valhalla, NY, United States
| | - Syed Ali
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Vikas Patel
- Mohawk Valley Health System, Utica, NY, United States
| | - Priyank Khandelwal
- Department of Neurosurgery and Neurology, Rutgers New Jersey Medical School, Newark, NJ, United States
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Indianapolis, IN, United States
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| |
Collapse
|
37
|
Dominguez JF, Shah S, Feldstein E, Ng C, Li B, Kim M, Santarelli J, Gandhi CD, Tyagi R, Tobias M. Treatment of an Elusive Symptomatic Sinus Pericranii: Case Report and Review of the Literature. J Neurol Surg A Cent Eur Neurosurg 2021; 84:386-389. [PMID: 34781402 DOI: 10.1055/s-0041-1735862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Sinus pericranii (SP) are abnormal vascular connections between extracranial scalp venous channels and intracranial dural sinuses. This vascular abnormality rarely results in significant sequelae, but in select cases, it can be symptomatic. We describe the case of a 7-year-old girl with an SP who experienced intermittent visual, motor, and sensory symptoms not previously described in the literature. Her symptoms resolved after surgical treatment of the SP. We propose a mechanism for her symptoms and the rationale for the role of neurosurgical intervention along with a review of the literature.
Collapse
Affiliation(s)
- Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, United States
| | - Smit Shah
- Department of Neurology, University South Carolina School of Medicine, Columbia, South Carolina, United States
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, United States
| | - Christina Ng
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, United States
| | - Boyi Li
- Department of Neurosurgery, New York Medical College, Valhalla, New York, United States
| | - Michael Kim
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, United States
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, United States
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, United States
| | - Rachana Tyagi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, United States
| | - Michael Tobias
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, United States
| |
Collapse
|
38
|
Gonzalez-Buendia E, Zhao J, Wang L, Mukherjee S, Zhang D, Arrieta VA, Feldstein E, Kane JR, Kang SJ, Lee-Chang C, Mahajan A, Chen L, Realubit R, Karan C, Magnuson L, Horbinski C, Marshall SA, Sarkaria JN, Mohyeldin A, Nakano I, Bansal M, James CD, Brat DJ, Ahmed A, Canoll P, Rabadan R, Shilatifard A, Sonabend AM. TOP2B Enzymatic Activity on Promoters and Introns Modulates Multiple Oncogenes in Human Gliomas. Clin Cancer Res 2021; 27:5669-5680. [PMID: 34433651 PMCID: PMC8818263 DOI: 10.1158/1078-0432.ccr-21-0312] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 05/07/2021] [Accepted: 07/28/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE The epigenetic mechanisms involved in transcriptional regulation leading to malignant phenotype in gliomas remains poorly understood. Topoisomerase IIB (TOP2B), an enzyme that decoils and releases torsional forces in DNA, is overexpressed in a subset of gliomas. Therefore, we investigated its role in epigenetic regulation in these tumors. EXPERIMENTAL DESIGN To investigate the role of TOP2B in epigenetic regulation in gliomas, we performed paired chromatin immunoprecipitation sequencing for TOP2B and RNA-sequencing analysis of glioma cell lines with and without TOP2B inhibition and in human glioma specimens. These experiments were complemented with assay for transposase-accessible chromatin using sequencing, gene silencing, and mouse xenograft experiments to investigate the function of TOP2B and its role in glioma phenotypes. RESULTS We discovered that TOP2B modulates transcription of multiple oncogenes in human gliomas. TOP2B regulated transcription only at sites where it was enzymatically active, but not at all native binding sites. In particular, TOP2B activity localized in enhancers, promoters, and introns of PDGFRA and MYC, facilitating their expression. TOP2B levels and genomic localization was associated with PDGFRA and MYC expression across glioma specimens, which was not seen in nontumoral human brain tissue. In vivo, TOP2B knockdown of human glioma intracranial implants prolonged survival and downregulated PDGFRA. CONCLUSIONS Our results indicate that TOP2B activity exerts a pleiotropic role in transcriptional regulation of oncogenes in a subset of gliomas promoting a proliferative phenotype.
Collapse
Affiliation(s)
- Edgar Gonzalez-Buendia
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Junfei Zhao
- Department of Systems Biology, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Lu Wang
- Department of Biochemistry and Molecular Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Subhas Mukherjee
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Zhang
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Víctor A Arrieta
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- PECEM, Facultad de Medicina, Universidad Nacional Autónoma de México, México
| | - Eric Feldstein
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - J Robert Kane
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Seong Jae Kang
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Catalina Lee-Chang
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Aayushi Mahajan
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | - Li Chen
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Ronald Realubit
- High-Throughput Screening Genome Center, Columbia University, New York, New York
| | - Charles Karan
- High-Throughput Screening Genome Center, Columbia University, New York, New York
| | - Lisa Magnuson
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Craig Horbinski
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Stacy A Marshall
- Department of Biochemistry and Molecular Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jann N Sarkaria
- Department of Radiation Oncology, Mayo Clinic, Rochester, Minnesota
| | - Ahmed Mohyeldin
- Department of Neurosurgery, Ohio State University, Columbus, Ohio
| | - Ichiro Nakano
- Department of Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Mukesh Bansal
- Department of Systems Biology, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Charles D James
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel J Brat
- Department of Pathology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Atique Ahmed
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University, New York, New York
| | - Raul Rabadan
- Department of Systems Biology, Herbert Irving Comprehensive Cancer Center, Columbia University, New York, New York
| | - Ali Shilatifard
- Department of Biochemistry and Molecular Genetics, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Adam M Sonabend
- Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.
| |
Collapse
|
39
|
Lui A, Feldstein E, Clare K, Dicpinigaitis A, Reddy M, Al-Mufti F. Management of acute ischemic strokes in patients with developmental disorders the national inpatient sample. J Neurol Sci 2021. [DOI: 10.1016/j.jns.2021.117817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
40
|
Spirollari E, Feldstein E, Ng C, Vazquez S, Kinon MD, Gandhi C, Tyagi R. Correction of Sagittal Balance With Resection of Kissing Spines. Cureus 2021; 13:e16874. [PMID: 34513449 PMCID: PMC8415043 DOI: 10.7759/cureus.16874] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 11/25/2022] Open
Abstract
Kissing spines syndrome, also known as Baastrup’s disease, is a common yet underdiagnosed disorder involving close approximation of adjacent spinous processes. These painful pseudoarticulations may be secondary to the compensatory mechanisms that result from sagittal imbalance. Conventional operative correction of sagittal balance includes a wide range of procedures from facetectomies to vertebral column resection. Resection of kissing spines for the operative management of sagittal imbalance is a treatment modality not extensively discussed in the literature but may offer improved patient outcomes with shorter operative times, lower risk, and reduced length of stay. A 67-year old male with a history of degenerative disk disease and scoliosis presented with neurogenic claudication and severe back pain that worsened with walking and improved with sitting. X-ray imaging of the lumbar spine revealed straightening of the normal lumbar lordotic curvature with mild rotoscoliosis. There was also evidence of retrolisthesis of L2 on L3 that worsened with flexion. The patient had Baastrup’s disease at the L3-4 and L4, 5 levels that contributed to his reduced range of motion on extension imaging. Operative treatments including long-segment fusion with interbody cages to correct sagittal balance were considered with a discussion of possible debilitating and high-risk post-surgical outcomes. Instead, the patient underwent a simple decompression surgery involving laminectomies and resection of kissing spines to correct his sagittal imbalance. Postoperative follow-up imaging demonstrated significant improvement in sagittal balance, and the patient expressed relief of back and leg pain. Although underdiagnosed, consideration of kissing spines syndrome in the surgical correction of sagittal imbalance may offer an improvement over conventional operations. Our case presents a unique surgical perspective on the treatment of spinal stenosis with kissing spines with particular regard to correcting the sagittal imbalance, avoiding debilitating procedures, and providing better immediate postoperative outcomes.
Collapse
Affiliation(s)
| | | | - Christina Ng
- Neurosurgery, Westchester Medical Center, Valhalla, USA
| | - Sima Vazquez
- Neurosurgery, Westchester Medical Center, Valhalla, USA
| | | | - Chirag Gandhi
- Neurosurgery, Westchester Medical Center, Valhalla, USA
| | - Rachana Tyagi
- Neurosurgery, Westchester Medical Center, Valhalla, USA
| |
Collapse
|
41
|
Dominguez JF, Shah S, Ampie L, Chen X, Li B, Ng C, Feldstein E, Wainwright JV, Schmidt M, Cole C, Koo DC, Chadha B, Lee J, Yarrabothula A, Rao N, Adkoli A, Miller I, Gandhi CD, Al-Mufti F, Santarelli J, Bowers C. Spinal Epidural Abscess Patients Have Higher Modified Frailty Indexes Than Back Pain Patients on Emergency Room Presentation: A Single-Center Retrospective Case-Control Study. World Neurosurg 2021; 152:e610-e616. [PMID: 34129981 DOI: 10.1016/j.wneu.2021.06.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Spinal epidural abscess (SEA) patients have increased medical comorbidities and risk factors for infection compared with those without SEA. However, the association between frailty and SEA patients has not been documented. METHODS A total of 46 SEA patients were randomly paired and matched by age and sex with a control group of patients with back pain who had presented to our emergency department from 2012 to 2017. Statistical analysis identified the risk factors associated with SEA and frailty using the modified frailty index (mFI), and the patients were stratified into robust, prefrail, and frail groups. We examined the value of the mFI as a prognostic predictor and evaluated the classic risk factors (CRFs). RESULTS The SEA patients had higher mFIs and CRFs (P = 0.023 and P < 0.001, respectively) and a longer length of stay (22.89 days vs. 1.72 days; P < 0.001). Of the mFI variables, only diabetes had a significant association with SEA (odds ratio [OR], 3.60; P = 0.012). Among the stratified mFI subgroups, a frail ranking (mFI >2) was the strongest risk factor for SEA (OR, 5.18; P = 0.003). A robust ranking (mFI, 0-1) was a weak negative predictor for SEA (OR, 0.41; P = 0.058). The robust patients were also more likely to be discharged to home (OR, 7.58; P = 0.002). Of the CRF variables, only intravenous drug use had a statistically significant association with SEA (OR, 10.72; P = 0.015). CONCLUSIONS Patients with SEA were more frail compared with the control back pain patients. Frailty was determined to be an independent risk factor for SEA, outside of the CRFs. The use of the mFI could be potentially useful in predicting the diagnosis, prognosticating, and guiding SEA treatment.
Collapse
Affiliation(s)
- Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.
| | - Smit Shah
- Department of Neurology, University of South Carolina, Columbia, South Carolina, USA
| | - Leonel Ampie
- Department of Neurosurgery, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Xintong Chen
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Boyi Li
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Christina Ng
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Eric Feldstein
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - John V Wainwright
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Meic Schmidt
- Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Chad Cole
- Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| | - Donna C Koo
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Bhawneet Chadha
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Joo Lee
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | | | - Naina Rao
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Anusha Adkoli
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Ivan Miller
- Department of Emergency Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA
| | - Christian Bowers
- Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA
| |
Collapse
|
42
|
Awah CU, Chen L, Bansal M, Mahajan A, Winter J, Lad M, Warnke L, Gonzalez-Buendia E, Park C, Zhang D, Feldstein E, Yu D, Zannikou M, Balyasnikova IV, Martuscello R, Konerman S, Győrffy B, Burdett KB, Scholtens DM, Stupp R, Ahmed A, Hsu P, Sonabend AM. Ribosomal protein S11 influences glioma response to TOP2 poisons. Oncogene 2020; 39:5068-5081. [PMID: 32528131 PMCID: PMC7646677 DOI: 10.1038/s41388-020-1342-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 06/11/2019] [Revised: 05/22/2020] [Accepted: 05/29/2020] [Indexed: 12/26/2022]
Abstract
Topoisomerase II poisons are one of the most common class of chemotherapeutics used in cancer. We and others had shown that a subset of glioblastomas (GBM), the most malignant of all primary brain tumors in adults, are responsive to TOP2 poisons. To identify genes that confer susceptibility to this drug in gliomas, we performed a genome-scale CRISPR knockout screen with etoposide. Genes involved in protein synthesis and DNA damage were implicated in etoposide susceptibility. To define potential biomarkers for TOP2 poisons, CRISPR hits were overlapped with genes whose expression correlates with susceptibility to this drug across glioma cell lines, revealing ribosomal protein subunit RPS11, 16, 18 as putative biomarkers for response to TOP2 poisons. Loss of RPS11 led to resistance to etoposide and doxorubicin and impaired the induction of pro-apoptotic gene APAF1 following treatment. The expression of these ribosomal subunits was also associated with susceptibility to TOP2 poisons across cell lines from gliomas and multiple other cancers.
Collapse
Affiliation(s)
- Chidiebere U Awah
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Li Chen
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | | | - Aayushi Mahajan
- Department of Neurological Surgery, Columbia University Medical Center, Columbia University, New York City, NY, USA
| | - Jan Winter
- Functional Genomics and Signaling, German Center for Cancer Research, Heidelberg, Germany
| | - Meeki Lad
- Mailman School of Public Health, Columbia University, New York City, NY, USA
| | - Louisa Warnke
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Edgar Gonzalez-Buendia
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Cheol Park
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Daniel Zhang
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Eric Feldstein
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Dou Yu
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Markella Zannikou
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Irina V Balyasnikova
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Regina Martuscello
- Department of Pathology, Columbia University Medical Centre, Columbia University, New York City, NY, USA
| | | | - Balázs Győrffy
- MTA TTK Lendület Cancer Biomarker Research Group, Institute of Enzymology, Hungarian Academy of Sciences, Budapest, Hungary.,2nd Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Kirsten B Burdett
- Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - Denise M Scholtens
- Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - Roger Stupp
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Atique Ahmed
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States
| | - Patrick Hsu
- Molecular and Cell Biology, Salk Institute, La Jolla, CA, USA
| | - Adam M Sonabend
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States.
| |
Collapse
|
43
|
Ishida W, McCormick KL, Mahajan A, Feldstein E, Lim M, Bruce JN, Canoll PD, Lo SFL. Abstract B165: Investigating in vivo synergistic effect of checkpoint blockade and radiation therapy against chordomas in a humanized mouse model. Cancer Immunol Res 2019. [DOI: 10.1158/2326-6074.cricimteatiaacr18-b165] [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
Abstract
Introduction: With the advent of immunotherapy (IT) against various cancers, its applications to other cancers have been extensively investigated. However, it has been a challenge to apply IT to chordomas, due to lack of clinically translatable in vivo models. Currently, there are no well-established murine chordoma cell lines that can be injected to syngeneic mice or no transgenic mouse models that develop chordomas spontaneously, which would allow us to study the interaction between murine chordomas and murine immune cells. Hence, we aimed to develop a humanized mouse model, where human immune cells are engrafted into immunodeficient mice, to study the interaction between human immune system and human chordomas. We also sought to utilize it to investigate synergistic effect between IT and radiation therapy (RT) against chordoma. Materials and Methods: Fifteen 10-12-week-old NSG mice, which lack mouse T-cells, B cells, and NK cells as well as functional mouse macrophages, were sublethally (1.5Gy) irradiated and then implanted with fetal thymic tissue and CD34+ stem cells that had been harvested from a fetus, whose HLA-types were partially-matched with those of the U-CH1 chordoma cell line. Reconstitution of immune cells in NSG mice was confirmed eight weeks post-transplantation, and then each animal (15 humanized NSG mice and 12 naïve NSG mice) was injected with U-CH1 cell suspension bilaterally and subcutaneously. Next, they were treated for 4 weeks as follows: A) control, isotype antibodies (Abs) injection (n=3), B) anti-human-PD-1 Abs (n=4, 10 mg/kg, 3 times/week for 4 weeks), C) RT + isotype Abs (n=3, unilaterally to the left-sided tumor, 8Gy x 4), D) anti-human-PD-1 Abs and RT (n=5), E) naïve NSG mice (n=6, without the engraftment of human immune cells) + isotype, and F) naïve NSG mice (n=6) + anti-human-PD-1 Abs. During and after the treatment, anti-tumor activities were monitored via tumor size, flow cytometry, qRT-PCR, and immunohistochemistry. Results: Eight weeks after stem cell engraftment, human peripheral blood mononuclear cells (PBMCs) of 43.8% among all PBMCs (human + mouse), human T-cells of 23.4% among human PBMCs, human CD8+ T-cells of 24.3% among human T-cells, and other lymphocytes such as B cells, macrophages, and NK cells were observed in peripheral blood of humanized mice via flow cytometry, which confirmed humanization. One week after the treatment, on the irradiated side, (D) demonstrated lowest tumor volume, highest number of human PBMCs, highest % of CD8+ human (cytotoxic) T-cells, highest % of CD45RO+CD4+ human (memory) T-cells, and lowest % of PD-1+CD8+ human (exhausted) T-cells in the tumors via flow cytometry, highest IFN-gamma in the tumors via qRT-PCR, and highest CD8+ human (cytotoxic) T-cells via immunohistochemistry, compared to the other five groups with statistical significance. Of note, on the nonirradiated side, a similar trend was observed with D) harboring the smallest tumor compared to the others (P=0.09), suggesting the abscopal effect. Finally, there were no statistically significant differences amongst (A) humanized NSG mice with isotype-control antibodies, (E) naïve NSG mice with isotype-control antibodies, and (F) naïve NSG mice with anti-PD-1 antibodies on either sides, indicating that HLA-partially-mismatched immune cells derived from the fetus donor were not able to eradicate U-CH1 chordoma cells. Conclusions: We demonstrated that this humanized mouse model could be a revolutionary platform to investigate IT against rare cancers such as chordomas, where murine equivalent cell lines are not available to date, which hinders us from utilizing syngeneic or transgenic mouse models to study IT. The direct synergistic effect between IT and RT against chordoma as well as the potential abscopal effect was observed, evidenced by lowest tumor volume and highest cytotoxic T-cells and memory T-cells.
Citation Format: Wataru Ishida, Kyle L. McCormick, Aayushi Mahajan, Eric Feldstein, Michael Lim, Jeffrey N. Bruce, Peter D. Canoll, Sheng-fu L Lo. Investigating in vivo synergistic effect of checkpoint blockade and radiation therapy against chordomas in a humanized mouse model [abstract]. In: Proceedings of the Fourth CRI-CIMT-EATI-AACR International Cancer Immunotherapy Conference: Translating Science into Survival; Sept 30-Oct 3, 2018; New York, NY. Philadelphia (PA): AACR; Cancer Immunol Res 2019;7(2 Suppl):Abstract nr B165.
Collapse
Affiliation(s)
- Wataru Ishida
- Johns Hopkins University, Baltimore, MD; Columbia University Medical Center, New York, NY
| | - Kyle L. McCormick
- Johns Hopkins University, Baltimore, MD; Columbia University Medical Center, New York, NY
| | - Aayushi Mahajan
- Johns Hopkins University, Baltimore, MD; Columbia University Medical Center, New York, NY
| | - Eric Feldstein
- Johns Hopkins University, Baltimore, MD; Columbia University Medical Center, New York, NY
| | - Michael Lim
- Johns Hopkins University, Baltimore, MD; Columbia University Medical Center, New York, NY
| | - Jeffrey N. Bruce
- Johns Hopkins University, Baltimore, MD; Columbia University Medical Center, New York, NY
| | - Peter D. Canoll
- Johns Hopkins University, Baltimore, MD; Columbia University Medical Center, New York, NY
| | - Sheng-fu L Lo
- Johns Hopkins University, Baltimore, MD; Columbia University Medical Center, New York, NY
| |
Collapse
|
44
|
Gonzalez-Buendia E, Zhao J, Chen L, Feldstein E, Mahajan A, Rabadan R, James CD, Sonabend A. GENE-17. TOP2B REGULATES CDK4 SPLICE VARIANTS IN GLIOMAS. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Junfei Zhao
- Department of Systems Biology, Columbia University, New York, NY, USA
| | - Li Chen
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | - Raul Rabadan
- Department of Biomedical Informatics and Department of Systems Biology, Columbia University, New York, NY, USA
| | - C David James
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Adam Sonabend
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| |
Collapse
|
45
|
Awah C, Gonzalez-Buendía E, Zhao J, Feldstein E, Chen L, Mahajan A, Warnke L, Wang L, Park C, Winter J, Konermann S, Shilatifard A, James CD, Rabadan R, Hsu P, Bansal M, Ahmed A, Sonabend A. DDIS-13. UNDERSTANDING GLIOBLASTOMA SUSCEPTIBILITY TO TOP2-TARGETING DRUGS FOR PERSONALIZED THERAPY. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Chidiebere Awah
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Edgar Gonzalez-Buendía
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Junfei Zhao
- Department of Systems Biology, Columbia University, New York, NY, USA
| | | | - Li Chen
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | - Louisa Warnke
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lu Wang
- Department of Biochemistry and Molecular Genomics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Cheol Park
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jan Winter
- German Cancer Research Center, Heildelberg, Baden-Wurttemberg, Germany
| | | | - Ali Shilatifard
- Department of Biochemistry and Molecular Genetics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - C David James
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Raul Rabadan
- Department of Biomedical Informatics and Department of Systems Biology, Columbia University, New York, NY, USA
| | | | | | - Atique Ahmed
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Adam Sonabend
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| |
Collapse
|
46
|
Ishida W, McCormick K, Mahajan A, Feldstein E, Lim M, Bruce J, Canoll P, Lo SF. TMOD-37. IN VIVO SYNERGISTIC EFFECT OF CHECKPOINT BLOCKADE AND RADIATION THERAPY AGAINST CHORDOMAS IN A HUMANIZED MOUSE MODEL. Neuro Oncol 2018. [DOI: 10.1093/neuonc/noy148.1149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Wataru Ishida
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | | | - Peter Canoll
- Columbia University Medical Center, Department of Pathology and Cell Biology, New York, NY, USA
| | - Sheng-fu Lo
- Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
47
|
Ishida W, Wang H, McCormick K, Mahajan A, Feldstein E, Lim M, Canoll PD, Bruce JN, Yang YG, Lo SFL. 144 In Vivo Synergistic Effect of Checkpoint Blockade and Radiation Therapy Against Chordomas in a Humanized Mouse Model. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
48
|
Gonzalez-Buendia E, Feldstein E, Zhao J, Mahajan A, Realubit R, Karan C, Rabadan R, Sonabend AM. GENE-08. PHARMACOLOGIC MODULATION OF MYC AND PDGFRA BY TARGETING TOPOISOMERASE II ON GLIOMAS. Neuro Oncol 2017. [DOI: 10.1093/neuonc/nox168.383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
|
49
|
Velasco M, Hurt E, Silva H, Urbina-Quintana A, Hernández-Pieretti O, Feldstein E, Camejo G. Effects of prazosin and propranolol on blood lipids and lipoproteins in hypertensive patients. Am J Med 1986; 80:109-13. [PMID: 3080882 DOI: 10.1016/0002-9343(86)90169-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Prazosin and propranolol were compared in an open, crossover study to determine their effects on plasma lipids and lipoproteins. After a four-week placebo period, 10 hypertensive patients were randomly assigned to prazosin treatment (Group I) and another 10 to propranolol treatment (Group II) for eight weeks. After a second four-week placebo period, treatment in each group was switched to the alternative drug for eight weeks. The mean blood pressure was reduced to normal levels (diastolic blood pressure less than or equal to 90 mm Hg) by both drugs--prazosin (1 to 8 mg per day) and propranolol (40 to 240 mg per day). The results of the study indicate that prazosin decreases serum cholesterol levels. In contrast, propranolol not only increases serum triglyceride levels and very-low-density lipoprotein cholesterol, but decreases total high-density lipoprotein cholesterol, high-density lipoprotein2 cholesterol, high-density lipoprotein2, and apoprotein A-I. The data suggest that propranolol may induce significant, potentially atherogenic changes in lipid metabolism, whereas prazosin may represent an advantageous alternative as an antihypertensive agent, especially in subjects with an already atherogenic lipoprotein profile.
Collapse
|
50
|
Velasco M, Silva H, Feldstein E, Pellicer R, Morillo J, Urbina-Quintana A, Hernández-Pieretti O. Effects of prazosin and alphamethyldopa on blood lipids and lipoproteins in hypertensive patients. Eur J Clin Pharmacol 1985; 28:513-6. [PMID: 3899672 DOI: 10.1007/bf00544060] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The effects of prazosin and alphamethyldopa on blood lipids and lipoproteins were assessed in 20 patients with mild or moderate arterial hypertension. Parameters measured included serum cholesterol (CHO), triglycerides (TG), high density lipoprotein-cholesterol (HDL-CHO), insulin (I), glucose (G), and non-esterified fatty acids (NEFA). Prazosin -4 mg/day for 6 weeks in hydrochlorothiazide-treated patients lowered blood pressure by 18.6/17.2 (systolic/diastolic pressure) mmHg. There was a significant decrease in CHO (-5.8%), in I (-16.5%), and in NEFA (-3.0%), and a significant increase in HDL-CHO (+15.5%). Alphamethyldopa 250-750 mg/day for 6 weeks in hydrochlorothiazide-treated patients lowered blood pressure by 18.8/14.6 (systolic/diastolic pressure) mmHg, accompanied by a non-significant decrease in CHO and TG, and significant increases in HDL-CHO (+10.3%), G (+8.5%) and NEFA (+6.4%). Thus, prazosin appears to have a more beneficial effect on blood lipids and lipoproteins than alphamethyldopa.
Collapse
|