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Samaniego EA, Dabus G, Meyers PM, Kan PT, Frösen J, Lanzino G, Welch BG, Volovici V, Gonzalez F, Fifi J, Charbel FT, Hoh BL, Khalessi A, Marks MP, Berenstein A, Pereira VM, Bain M, Colby GP, Narayanan S, Tateshima S, Siddiqui AH, Wakhloo AK, Arthur AS, Lawton MT. Most Promising Approaches to Improve Brain AVM Management: ARISE I Consensus Recommendations. Stroke 2024; 55:1449-1463. [PMID: 38648282 DOI: 10.1161/strokeaha.124.046725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Accepted: 03/01/2024] [Indexed: 04/25/2024]
Abstract
Brain arteriovenous malformations (bAVMs) are complex, and rare arteriovenous shunts that present with a wide range of signs and symptoms, with intracerebral hemorrhage being the most severe. Despite prior societal position statements, there is no consensus on the management of these lesions. ARISE (Aneurysm/bAVM/cSDH Roundtable Discussion With Industry and Stroke Experts) was convened to discuss evidence-based approaches and enhance our understanding of these complex lesions. ARISE identified the need to develop scales to predict the risk of rupture of bAVMs, and the use of common data elements to perform prospective registries and clinical studies. Additionally, the group underscored the need for comprehensive patient management with specialized centers with expertise in cranial and spinal microsurgery, neurological endovascular surgery, and stereotactic radiosurgery. The collection of prospective multicenter data and gross specimens was deemed essential for improving bAVM characterization, genetic evaluation, and phenotyping. Finally, bAVMs should be managed within a multidisciplinary framework, with clinical studies and research conducted collaboratively across multiple centers, harnessing the collective expertise and centralization of resources.
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Affiliation(s)
- Edgar A Samaniego
- Department of Neurology, Neurosurgery and Radiology, University of Iowa (E.A.S.)
| | - Guilherme Dabus
- Department of Neurosurgery, Baptist Health, Miami, FL (G.D.)
| | - Philip M Meyers
- Department of Radiology and Neurological Surgery, Columbia University, New York (P.M.M.)
| | - Peter T Kan
- Department of Neurological Surgery, University of Texas Medical Branch Galveston (P.T.K.)
| | - Juhana Frösen
- Department of Rehabilitation, Tampere University Hospital, Finland (J.F.)
| | | | - Babu G Welch
- Departments of Neurological Surgery and Radiology; The University of Texas Southwestern, Dallas (B.G.W.)
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC University Medical Centre, Rotterdam, the Netherlands (V.V.)
| | - Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD (F.G.)
| | - Johana Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York (J.F., A.B.)
| | - Fady T Charbel
- Department of Neurosurgery, University of Illinois at Chicago (F.T.C.)
| | - Brian L Hoh
- Department of Neurosurgery, College of Medicine, University of Florida, Gainesville (B.L.H.)
| | | | - Michael P Marks
- Interventional Neuroradiology Division, Stanford University Medical Center, Palo Alto, CA (M.P.M.)
| | - Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York (J.F., A.B.)
| | - Victor M Pereira
- Department of Neurosurgery, St. Michael's Hospital, Toronto, Canada (V.M.P.)
| | - Mark Bain
- Department of Neurological Surgery, Cleveland Clinic, OH (M.B.)
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles (G.P.C.)
| | - Sandra Narayanan
- Neurointerventional Program and Comprehensive Stroke Program, Pacific Neuroscience Institute, Santa Monica, CA (S.N.)
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles (S.T.)
| | - Adnan H Siddiqui
- Department of Neurosurgery, Gates Vascular Institute, Buffalo, New York (A.H.S.)
| | - Ajay K Wakhloo
- Department of Radiology, Tufts University School of Medicine, Boston, MA (A.K.W.)
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Clinic, University of Tennessee Health Science Center, Memphis (A.S.A.)
| | - Michael T Lawton
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (M.T.L.)
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Kan P, Fiorella D, Dabus G, Samaniego EA, Lanzino G, Siddiqui AH, Chen H, Khalessi AA, Pereira VM, Fifi JT, Bain MD, Colby GP, Wakhloo AK, Arthur AS. ARISE I Consensus Statement on the Management of Chronic Subdural Hematoma. Stroke 2024; 55:1438-1448. [PMID: 38648281 DOI: 10.1161/strokeaha.123.044129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 01/10/2024] [Indexed: 04/25/2024]
Abstract
ARISE (Aneurysm/AVM/cSDH Roundtable Discussion With Industry and Stroke Experts) organized a one-and-a-half day meeting and workshop and brought together representatives from academia, industry, and government to discuss the most promising approaches to improve outcomes for patients with chronic subdural hematoma (cSDH). The emerging role of middle meningeal artery embolization in clinical practice and the design of current and potential future trials were the primary focuses of discussion. Existing evidence for imaging, indications, agents, and techniques was reviewed, and areas of priority for study and key questions surrounding the development of new and existing treatments for cSDH were identified. Multiple randomized, controlled trials have met their primary efficacy end points, providing high-level evidence that middle meningeal artery embolization is a potent adjunctive therapy to the standard (surgical and nonsurgical) management of neurologically stable cSDH patients in terms of reducing rates of disease recurrence. Pooled data analyses following the formal conclusion and publication of these trials will form a robust foundation upon which guidelines can be strengthened for cSDH treatment modalities and optimal patient selection, as well as delineate future lines of investigation.
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Affiliation(s)
- Peter Kan
- Department of Neurosurgery, The University of Texas Medical Branch, Galveston (P.K.)
| | - David Fiorella
- Department of Neurosurgery, Stony Brook University, NY (D.F.)
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, FL (G.D.)
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics (E.A.S.)
| | | | - Adnan H Siddiqui
- Department of Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, NY (A.H.S.)
| | - Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD (H.C.)
| | - Alexander A Khalessi
- Department of Neurological Surgery, University of California, San Diego, La Jolla (A.A.K.)
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, University Health Network, Toronto Western Hospital, ON, Canada (V.M.P.)
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (J.T.F.)
| | - Mark D Bain
- Cerebrovascular Center, Departments of Neurology and Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, OH (M.D.B.)
| | - Geoffrey P Colby
- Department of Neurosurgery, University of California Los Angeles David Geffen School of Medicine (G.P.C.)
| | - Ajay K Wakhloo
- Department of Interventional Neuroradiology, Lahey Hospital & Medical Center, Burlington, MA (A.K.W.)
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis (A.S.A.)
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Hetts SW, Al-Mufti F, Dabus G, Fifi JT, Mocco J, Jayaraman MV. Focused update to guidelines for endovascular therapy for emergent large vessel occlusion: large core and basilar artery occlusion patients. J Neurointerv Surg 2024; 16:113-114. [PMID: 37479479 DOI: 10.1136/jnis-2023-020763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/07/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Steven W Hetts
- Radiology, University of California San Francisco (UCSF), Biomedical Imaging and Neurological Surgery, San Francisco, California, USA
| | - Fawaz Al-Mufti
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | | | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - J Mocco
- Mount Sinai Health System, New York, New York, USA
| | - Mahesh V Jayaraman
- Diagnostic Imaging, Brown University Warren Alpert Medical School, Providence, Rhode Island, USA
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4
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Fargen KM, Kittel C, Curry BP, Hile CW, Wolfe SQ, Brown P, Mokin M, Rai AT, Chen M, Starke RM, Albuquerque FC, Ansari SA, Kan P, Spiotta AM, Dabus G, Leslie-Mazwi TM, Hirsch JA. Mechanical thrombectomy decision making and prognostication: Stroke treatment Assessments prior to Thrombectomy In Neurointervention (SATIN) study. J Neurointerv Surg 2023; 15:e381-e387. [PMID: 36609542 DOI: 10.1136/jnis-2022-019741] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 12/28/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard-of-care treatment for stroke patients with emergent large vessel occlusions. Despite this, little is known about physician decision making regarding MT and prognostic accuracy. METHODS A prospective multicenter cohort study of patients undergoing MT was performed at 11 comprehensive stroke centers. The attending neurointerventionalist completed a preprocedure survey prior to arterial access and identified key decision factors and the most likely radiographic and clinical outcome at 90 days. Post hoc review was subsequently performed to document hospital course and outcome. RESULTS 299 patients were enrolled. Good clinical outcome (modified Rankin Scale (mRS) score of 0-2) was obtained in 38% of patients. The most frequently identified factors influencing the decision to proceed with thrombectomy were site of occlusion (81%), National Institutes of Health Stroke Scale score (74%), and perfusion imaging mismatch (43%). Premorbid mRS score determination in the hyperacute setting accurately matched retrospectively collected data from the hospital admission in only 140 patients (46.8%). Physicians correctly predicted the patient's 90 day mRS tertile (0-2, 3-4, or 5-6) and final modified Thrombolysis in Ischemic Cerebral Infarction score preprocedure in only 44.2% and 44.3% of patients, respectively. Clinicians tended to overestimate the influence of occlusion site and perfusion imaging on outcomes, while underestimating the importance of pre-morbid mRS. CONCLUSIONS This is the first prospective study to evaluate neurointerventionalists' ability to accurately predict clinical outcome after MT. Overall, neurointerventionalists performed poorly in prognosticating patient 90 day outcomes, raising ethical questions regarding whether MT should be withheld in patients with emergent large vessel occlusions thought to have a poor prognosis.
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Affiliation(s)
- Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Carol Kittel
- Division of Public Health Sciences, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Brian P Curry
- Neurological Surgery, Walter Reed Army Medical Center, Bethesda, Maryland, USA
| | - Connor W Hile
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Patrick Brown
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | - Robert M Starke
- Department of Neurosurgery and Radiology, University of Miami School of Medicine, Miami, Florida, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, Miami, Florida, USA
| | | | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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Desai H, Al-Salihi MM, Morsi RZ, Vayani OR, Kothari SA, Thind S, Carrión-Penagos J, Baskaran A, Tarabichi A, Bonderski VA, Siegler JE, Hahn M, Coleman ER, Brorson JR, Mendelson SJ, Mansour A, Dabus G, Hurley M, Prabhakaran S, Linfante I, Kass-Hout T. Intravenous cangrelor use for neuroendovascular procedures: a two-center experience and updated systematic review. Front Neurol 2023; 14:1304599. [PMID: 38116108 PMCID: PMC10728671 DOI: 10.3389/fneur.2023.1304599] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 11/10/2023] [Indexed: 12/21/2023] Open
Abstract
Background The optimal antiplatelet therapy regimen for certain neuroendovascular procedures remains unclear. This study investigates the safety and feasibility of intravenous dose-adjusted cangrelor in patients undergoing acute neuroendovascular interventions. Methods We conducted a retrospective chart review of all consecutive patients on intravenous cangrelor for neuroendovascular procedures between September 1, 2020, and March 13, 2022. We also conducted an updated systematic review and meta-analysis using PubMed, Scopus, Web of Science, Embase and the Cochrane Library up to February 22, 2023. Results In our cohort, a total of 76 patients were included [mean age (years): 57.2 ± 18.2, males: 39 (51.3), Black: 49 (64.5)]. Cangrelor was most used for embolization and intracranial stent placement (n = 24, 32%). Approximately 44% of our patients had a favorable outcome with a modified Rankin Scale (mRS) score of 0 to 2 at 90 days (n = 25/57); within 1 year, 8% of patients had recurrent or new strokes (n = 5/59), 6% had symptomatic intracranial hemorrhage [sICH] (4/64), 3% had major extracranial bleeding events (2/64), and 3% had a gastrointestinal bleed (2/64). In our meta-analysis, 11 studies with 298 patients were included. The pooled proportion of sICH and intraprocedural thromboembolic complication events were 0.07 [95% CI 0.04 to 1.13] and 0.08 [95% CI 0.05 to 0.15], respectively. Conclusion Our study found that intravenous cangrelor appears to be safe and effective in neuroendovascular procedures, with low rates of bleeding and ischemic events. However, further research is needed to compare different dosing and titration protocols of cangrelor and other intravenous agents.
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Affiliation(s)
- Harsh Desai
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | - Mohammed Maan Al-Salihi
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, WI, United States
| | - Rami Z. Morsi
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | - Omar R. Vayani
- Pritzker School of Medicine, University of Chicago, Chicago, IL, United States
| | - Sachin A. Kothari
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | - Sonam Thind
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | | | - Archit Baskaran
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | - Ammar Tarabichi
- Department of Neurology, DENT Neurologic Institute, Amherst, NY, United States
| | | | - James E. Siegler
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | - Mary Hahn
- Department of Neurology, Stony Brook University Hospital, Stony Brook, NY, United States
| | | | - James R. Brorson
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | - Scott J. Mendelson
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | - Guilherme Dabus
- Department of Neurology, Baptist Cardiac and Vascular Institute, Miami, FL, United States
| | - Michael Hurley
- Department of Radiology, University of Chicago, Chicago, IL, United States
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, IL, United States
| | - Italo Linfante
- Department of Neurology, Baptist Cardiac and Vascular Institute, Miami, FL, United States
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, IL, United States
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6
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Benalia VHC, Cortez GM, Mounayer C, Saatci I, Cekirge HS, Kocer N, Islak C, Dabus G, Brinjikji W, Baltacioglu F, Pereira VM, Nishi H, Siddiqui AH, Monteiro A, Lopes DK, Aghaebrahim A, Sauvageau E, Hanel RA. Safety and Efficacy of Flow Diverters for Treatment of Unruptured Anterior Communicating Artery Aneurysms: Retrospective Multicenter Study. J Neurointerv Surg 2023; 15:1181-1186. [PMID: 37845019 DOI: 10.1136/jnis-2023-020673] [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: 06/12/2023] [Accepted: 08/16/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND The anterior communicating artery (AComm) region is the most common site of intracranial aneurysms, with increased rupture risk compared with other locations. Overall, flow diverters present as a safe and efficacious treatment for intracranial aneurysms, but there is paucity of data for their use in the treatment of unruptured AComm aneurysms. We present the largest multicentric analysis evaluating the outcomes of flow diverters in AComm aneurysm treatment. METHODS Databases from 10 centers were retrospectively reviewed for unruptured AComm aneurysms treated with flow diverters. Demographics, clinical presentation, radiographic characteristics, procedural complications, and outcomes were assessed. RESULTS A total of 144 patients harboring 147 AComm aneurysms were treated between January 2012 and December 2021. Seventy-four were women (51.4%) and median age was 60 (IQR 50-67) years. All were unruptured AComm aneurysms. Half of the cohort had similar anterior cerebral artery sizes (51.4%). The most common morphology was saccular (94.6%), with a branch involvement in 32.7% of cases. Median vessel diameter was 2.4 mm, and the Pipeline Flex was the most prevalent device (32.7%). Median follow-up time was 17 months, with complete occlusion in 86.4% at the last follow-up. Functional independence (modified Rankin Scale score 0-2) was reported in 95.1%. Intraprocedural complications occurred in 5.6%, and postoperative complications were noted in 9.7% of cases. Combined major complication and mortality rate was 2.1%. CONCLUSIONS Our study suggests that flow diverters are a useful treatment for AComm aneurysms. Mid-term results indicated favorable aneurysm occlusion with a good safety profile. Additional prospective studies with longer follow-up periods and independent adjudication are warranted to better assess these results.
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Affiliation(s)
- Victor H C Benalia
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Gustavo M Cortez
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Charbel Mounayer
- Interventional Neuroradiology Department, University Hospital Centre of Limoges, Limoges, France
| | - Isil Saatci
- Interventional Neuroradiology Department, Koru Health Group, Ankara, Turkey
| | - H Saruhan Cekirge
- Interventional Neuroradiology Department, Koru Health Group, Ankara, Turkey
| | - Naci Kocer
- Department of Radiology, Istanbul University-Cerrahpasa Cerrahpasa Faculty of Medicine, Fatih, Istanbul, Turkey
| | - Civan Islak
- Department of Radiology, Istanbul University-Cerrahpasa Cerrahpasa Faculty of Medicine, Fatih, Istanbul, Turkey
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac and Vascular Institute-Baptist Hospital, Miami, Florida, USA
| | - Waleed Brinjikji
- Department of Neurosurgery and Neuroradiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Feyyaz Baltacioglu
- Department of Radiology, Division of Interventional Radiology/Neuroradiology, VKV Amerikan Hastanesi, Istanbul, Turkey
| | - Vitor M Pereira
- Department of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Hidehisa Nishi
- Department of Neuroradiology, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Andre Monteiro
- Departments of Neurosurgery and Radiology, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Demetrius K Lopes
- Neurosurgery, Brain and Spine Institute-Advocate Aurora Health, Chicago, Illinois, USA
| | - Amin Aghaebrahim
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
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7
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Nguyen TN, Qureshi MM, Strambo D, Strbian D, Räty S, Herweh C, Abdalkader M, Olive-Gadea M, Ribo M, Psychogios M, Fischer U, Nguyen A, Kuramatsu JB, Haupenthal D, Köhrmann M, Deuschl C, Kühne Escola J, Yaghi S, Shu L, Puetz V, Kaiser DPO, Kaesmacher J, Mujanovic A, Marterstock DC, Engelhorn T, Klein P, Haussen DC, Mohammaden MH, Abdelhamid H, Souza Viana L, Cunha B, Fragata I, Romoli M, Diana F, Virtanen P, Lappalainen K, Clark J, Matsoukas S, Fifi JT, Sheth SA, Salazar-Marioni S, Marto JP, Ramos JN, Miszczuk M, Riegler C, Jadhav AP, Desai SM, Maus V, Kaeder M, Siddiqui AH, Monteiro A, Masoud HE, Suryadevara N, Mokin M, Thanki S, Siegler JE, Khalife J, Linfante I, Dabus G, Asdaghi N, Saini V, Nolte CH, Siebert E, Meinel TR, Finitsis S, Möhlenbruch MA, Ringleb PA, Berberich A, Nogueira RG, Hanning U, Meyer L, Michel P, Nagel S. Endovascular Versus Medical Management of Posterior Cerebral Artery Occlusion Stroke: The PLATO Study. Stroke 2023. [PMID: 37222709 DOI: 10.1161/strokeaha.123.042674] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
BACKGROUND The optimal management of patients with isolated posterior cerebral artery occlusion is uncertain. We compared clinical outcomes for endovascular therapy (EVT) versus medical management (MM) in patients with isolated posterior cerebral artery occlusion. METHODS This multinational case-control study conducted at 27 sites in Europe and North America included consecutive patients with isolated posterior cerebral artery occlusion presenting within 24 hours of time last well from January 2015 to August 2022. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The coprimary outcomes were the 90-day modified Rankin Scale ordinal shift and ≥2-point decrease in the National Institutes of Health Stroke Scale. RESULTS Of 1023 patients, 589 (57.6%) were male with median (interquartile range) age of 74 (64-82) years. The median (interquartile range) National Institutes of Health Stroke Scale was 6 (3-10). The occlusion segments were P1 (41.2%), P2 (49.2%), and P3 (7.1%). Overall, intravenous thrombolysis was administered in 43% and EVT in 37%. There was no difference between the EVT and MM groups in the 90-day modified Rankin Scale shift (aOR, 1.13 [95% CI, 0.85-1.50]; P=0.41). There were higher odds of a decrease in the National Institutes of Health Stroke Scale by ≥2 points with EVT (aOR, 1.84 [95% CI, 1.35-2.52]; P=0.0001). Compared with MM, EVT was associated with a higher likelihood of excellent outcome (aOR, 1.50 [95% CI, 1.07-2.09]; P=0.018), complete vision recovery, and similar rates of functional independence (modified Rankin Scale score, 0-2), despite a higher rate of SICH and mortality (symptomatic intracranial hemorrhage, 6.2% versus 1.7%; P=0.0001; mortality, 10.1% versus 5.0%; P=0.002). CONCLUSIONS In patients with isolated posterior cerebral artery occlusion, EVT was associated with similar odds of disability by ordinal modified Rankin Scale, higher odds of early National Institutes of Health stroke scale improvement, and complete vision recovery compared with MM. There was a higher likelihood of excellent outcome in the EVT group despite a higher rate of symptomatic intracranial hemorrhage and mortality. Continued enrollment into ongoing distal vessel occlusion randomized trials is warranted.
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Affiliation(s)
- Thanh N Nguyen
- Neurology, Boston Medical Center, MA. (T.N.N., J.C.)
- Radiology, Boston Medical Center, MA. (T.N.N., M.M.Q., M.A., P.K.)
| | - Muhammad M Qureshi
- Radiology, Boston Medical Center, MA. (T.N.N., M.M.Q., M.A., P.K.)
- Radiation Oncology, Boston Medical Center, MA. (M.M.Q.)
| | - Davide Strambo
- Neurology Service, Lausanne University Hospital, University of Lausanne, Switzerland (D. Strambo, P.M.)
| | - Daniel Strbian
- Neurology, Helsinki University Hospital, Finland. (D. Strbian, S.R.)
| | - Silja Räty
- Neurology, Helsinki University Hospital, Finland. (D. Strbian, S.R.)
| | - Christian Herweh
- Neuroradiology, Heidelberg University Hospital, Germany. (C.H., M. Moehlenbruch)
| | | | - Marta Olive-Gadea
- Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain. (M.O.-G., M. Ribo)
| | - Marc Ribo
- Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain. (M.O.-G., M. Ribo)
| | - Marios Psychogios
- Neurology Service, Lausanne University Hospital, University of Lausanne, Switzerland (D. Strambo, P.M.)
| | - Urs Fischer
- Neurology, Basel University Hospital, University of Basel, Switzerland. (U.F.)
- Neurology, Bern University Hospital, University of Bern, Switzerland (T.R.M., U.F.)
| | - Anh Nguyen
- Radiology, Basel University Hospital, University of Basel, Switzerland. (A.N, M.P.)
| | - Joji B Kuramatsu
- Neurology, University of Erlangen-Nuremberg, Germany. (J.B.K., D.H.)
| | - David Haupenthal
- Neurology, University of Erlangen-Nuremberg, Germany. (J.B.K., D.H.)
| | - Martin Köhrmann
- Neurology, Universitätsklinikum Essen, Germany. (M. Köhrmann, J.K.E.)
| | | | | | - Shadi Yaghi
- Neurology, Rhode Island Hospital, Brown University Medical School, Providence, RI (S.Y., L.S.)
| | - Liqi Shu
- Neurology, Rhode Island Hospital, Brown University Medical School, Providence, RI (S.Y., L.S.)
| | - Volker Puetz
- Radiology, Helsinki University Hospital, Finland. (P.V., K.L.)
- Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany. (V.P.)
| | - Daniel P O Kaiser
- Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany. (D.P.O.K.)
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Switzerland (J. Kaesmacher, A. Mujanovic)
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Switzerland (J. Kaesmacher, A. Mujanovic)
| | | | - Tobias Engelhorn
- Neuroradiology, University of Erlangen-Nuremberg, Germany. (D.C.M., T.E.)
| | - Piers Klein
- Radiology, Boston Medical Center, MA. (T.N.N., M.M.Q., M.A., P.K.)
| | - Diogo C Haussen
- Neurology, Grady Memorial Hospital, Atlanta, GA (D.C.H., M.H.M., H.A., L.S.V.)
| | | | - Hend Abdelhamid
- Neurology, Grady Memorial Hospital, Atlanta, GA (D.C.H., M.H.M., H.A., L.S.V.)
| | - Lorena Souza Viana
- Neurology, Grady Memorial Hospital, Atlanta, GA (D.C.H., M.H.M., H.A., L.S.V.)
| | - Bruno Cunha
- Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Portugal (B.C., I.F.)
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Portugal (B.C., I.F.)
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy (M. Romoli)
| | - Francesco Diana
- Interventional Neuroradiology, Hospital Universitario Vall d'Hebron, Barcelona, Spain. (F.D.)
| | - Pekka Virtanen
- Radiology, Helsinki University Hospital, University of Helsinki, Finland (P.V., K.L.)
| | - Kimmo Lappalainen
- Radiology, Helsinki University Hospital, Finland. (P.V., K.L.)
- Radiology, Helsinki University Hospital, University of Helsinki, Finland (P.V., K.L.)
| | - Judith Clark
- Neurology, Boston Medical Center, MA. (T.N.N., J.C.)
| | - Stavros Matsoukas
- Neurosurgery, Mount Sinai Health System, New York City, NY (S.M., J.T.F.)
| | - Johanna T Fifi
- Neurosurgery, Mount Sinai Health System, New York City, NY (S.M., J.T.F.)
| | - Sunil A Sheth
- Neurology, McGovern Medical School at UTHealth, TX (S.A.S., S.S.-M.)
| | | | - João Pedro Marto
- Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal. (J.P.M.)
| | - João Nuno Ramos
- Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Portugal. (J.N.R.)
| | - Milena Miszczuk
- Neuroradiology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Germany. (M. Miszczuk, E.S.)
| | - Christoph Riegler
- Neurology, Experimental Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Germany. (C.R., C.H.N.)
| | - Ashutosh P Jadhav
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J., S.M.D.)
| | - Shashvat M Desai
- Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J., S.M.D.)
| | - Volker Maus
- Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Germany (V.M., M. Kaeder)
| | - Maximilian Kaeder
- Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Germany (V.M., M. Kaeder)
| | | | - Andre Monteiro
- Neurosurgery, University of Buffalo, NY (A.H.S., A. Monteiro)
| | - Hesham E Masoud
- Neurology, New York Upstate Medical University, Syracuse, NY (H.E.M.)
| | | | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa (M. Mokin, S.T.)
| | - Shail Thanki
- Neurosurgery, University of South Florida, Tampa (M. Mokin, S.T.)
| | - James E Siegler
- Cooper Neurological Institute, Camden, NJ (J.E.S., J. Khalife)
| | - Jane Khalife
- Cooper Neurological Institute, Camden, NJ (J.E.S., J. Khalife)
| | | | | | - Negar Asdaghi
- Neurology, University of Miami Miller School of Medicine, FL (N.A., V.S.)
| | - Vasu Saini
- Neurology, University of Miami Miller School of Medicine, FL (N.A., V.S.)
| | - Christian H Nolte
- Neurology, Experimental Neurology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Germany. (C.R., C.H.N.)
| | - Eberhard Siebert
- Neuroradiology, Freie Universität Berlin and Humboldt-Universität zu Berlin, Charité-Universitätsmedizin Berlin, Germany. (M. Miszczuk, E.S.)
| | - Thomas R Meinel
- Neurology, Bern University Hospital, University of Bern, Switzerland (T.R.M., U.F.)
| | | | - Markus A Möhlenbruch
- Neuroradiology, Heidelberg University Hospital, Germany. (C.H., M. Moehlenbruch)
| | - Peter A Ringleb
- Neurology, Heidelberg University Hospital, Germany. (P.A.R., S.N.)
| | | | - Raul G Nogueira
- Neurology, University of Pittsburgh Medical Center, PA (R.G.N., N.S.)
| | - Uta Hanning
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (U.H., L.M.)
| | - Lukas Meyer
- Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (U.H., L.M.)
| | - Patrik Michel
- Radiology, Basel University Hospital, University of Basel, Switzerland. (A.N, M.P.)
| | - Simon Nagel
- Neurology, Heidelberg University Hospital, Germany. (P.A.R., S.N.)
- Neurology, University of Pittsburgh Medical Center, PA (R.G.N., N.S.)
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8
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Benalia V, Cortez G, Mounayer C, Saatci I, Cekirge S, Koçer N, Islak C, Dabus G, Brinjikji W, Baltacıoğlu F, Pereira VM, Nishi H, Siddiqui A, Lopes DK, Aghaebrahim A, Sauvageau E, Hanel RA. 315 Use of Flow Diverter in the Treatment of Anterior Communicating Artery Aneurysms: A Multicenter Experience (FEAR ME study). Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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9
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Patra DP, Syal A, Rahme RJ, Abi-Aad KR, Singh R, Turcotte EL, Jones BA, Meyer J, Hudson M, Chong BW, Dabus G, James RF, Krishna C, Bendok BR. A comparison of treating physician versus independent core lab assessments of post-aneurysm treatment imaging outcomes: an analysis of prospectively collected data from a randomized trial. J Neurosurg 2022:1-9. [PMID: 36681980 DOI: 10.3171/2022.10.jns22841] [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: 05/18/2022] [Accepted: 10/25/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Aneurysm occlusion has been used as surrogate marker of aneurysm treatment efficacy. Aneurysm occlusion scales are used to evaluate the outcome of endovascular aneurysm treatment and to monitor recurrence. These scales, however, require subjective interpretation of imaging data, which can reduce the utility and reliability of these scales and the validity of clinical studies regarding aneurysm occlusion rates. Use of a core lab with independent blinded reviewers has been implemented to enhance the validity of occlusion rate assessments in clinical trials. The degree of agreement between core labs and treating physicians has not been well studied with prospectively collected data. METHODS In this study, the authors analyzed data from the Hydrogel Endovascular Aneurysm Treatment (HEAT) trial to assess the interrater agreement between the treating physician and the blinded core lab. The HEAT trial included 600 patients across 46 sites with intracranial aneurysms treated with coiling. The treating site and the core lab independently reviewed immediate postoperative and follow-up imaging (3-12 and 18-24 months, respectively) using the Raymond-Roy occlusion classification (RROC) scale, Meyer scale, and recanalization survey. A post hoc analysis was performed to calculate interrater reliability using Cohen's kappa. Further analysis was performed to assess whether degree of agreement varied on the basis of various factors, including scale used, timing of imaging, size of the aneurysm, imaging modality, location of the aneurysm, dome-to-neck ratio, and rupture status. RESULTS Minimal interrater agreement was noted between the core lab reviewers and the treating physicians for assessing aneurysm occlusion using the RROC grading scale (k = 0.39, 95% CI 0.38-0.40) and Meyer scale (k = 0.23, 95% CI 0.14-0.38). The degree of agreement between groups was slightly better but still weak for assessing recanalization (k = 0.45, 95% CI 0.38-0.52). Factors that significantly improved degree of agreement were scales with fewer variables, greater time to follow-up, imaging modality (digital subtraction angiography), and wide-neck aneurysms. CONCLUSIONS Assessment of aneurysm treatment outcome with commonly used aneurysm occlusion scales suffers from risk of poor interrater agreement. This supports the use of independent core labs for validation of outcome data to minimize reporting bias. Use of outcome tools with fewer point categories is likely to provide better interrater reliability. Therefore, the outcome assessment tools are ideal for clinical outcome assessment provided that they are sensitive enough to detect a clinically significant change.
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Affiliation(s)
- Devi P Patra
- 1Department of Neurological Surgery, Mayo Clinic, Phoenix.,2Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix.,3Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Arjun Syal
- 4New York Medical College, Valhalla, New York
| | - Rudy J Rahme
- 5Department of Neurosurgery, Global Neuroscience Institute, Philadelphia, Pennsylvania
| | | | - Rohin Singh
- 7Mayo Clinic Alix School of Medicine, Scottsdale, Arizona
| | - Evelyn L Turcotte
- 1Department of Neurological Surgery, Mayo Clinic, Phoenix.,2Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix.,3Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Breck A Jones
- 3Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona.,8Division of Neurosurgery, Southern Illinois University School of Medicine, Springfield, Illinois
| | - Jenna Meyer
- 1Department of Neurological Surgery, Mayo Clinic, Phoenix.,2Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix.,3Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Miles Hudson
- 1Department of Neurological Surgery, Mayo Clinic, Phoenix.,2Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix.,3Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Brian W Chong
- 12Department of Radiology, Mayo Clinic, Phoenix, Arizona
| | - Guilherme Dabus
- 9Department of Neuroradiology, Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida
| | - Robert F James
- 10Department of Neurosurgery, IU Health Physicians Neurosurgery, Indianapolis, Indiana
| | - Chandan Krishna
- 1Department of Neurological Surgery, Mayo Clinic, Phoenix.,2Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix.,3Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Bernard R Bendok
- 1Department of Neurological Surgery, Mayo Clinic, Phoenix.,2Precision Neurotherapeutics Innovation Lab, Mayo Clinic, Phoenix.,3Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona.,11Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Phoenix.,12Department of Radiology, Mayo Clinic, Phoenix, Arizona
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10
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Dmytriw AA, Ghozy S, Sweid A, Piotin M, Bekelis K, Sourour N, Raz E, Vela-Duarte D, Linfante I, Dabus G, Kole M, Martínez-Galdámez M, Nimjee SM, Lopes DK, Hassan AE, Kan P, Ghorbani M, Levitt MR, Escalard S, Missios S, Shapiro M, Clarençon F, Elhorany M, Tahir RA, Youssef PP, Pandey AS, Starke RM, El Naamani K, Abbas R, Mansour OY, Galvan J, Billingsley JT, Mortazavi A, Walker M, Dibas M, Settecase F, Heran MKS, Kuhn AL, Puri AS, Menon BK, Sivakumar S, Mowla A, D'Amato S, Zha AM, Cooke D, Vranic JE, Regenhardt RW, Rabinov JD, Stapleton CJ, Goyal M, Wu H, Cohen J, Turkel-Parella D, Xavier A, Waqas M, Tutino V, Siddiqui A, Gupta G, Nanda A, Khandelwal P, Tiu C, Portela PC, Perez de la Ossa N, Urra X, de Lera M, Arenillas JF, Ribo M, Requena M, Piano M, Pero G, De Sousa K, Al-Mufti F, Hashim Z, Nayak S, Renieri L, Du R, Aziz-Sultan MA, Liebeskind D, Nogueira RG, Abdalkader M, Nguyen TN, Vigilante N, Siegler JE, Grossberg JA, Saad H, Gooch MR, Herial NA, Rosenwasser RH, Tjoumakaris S, Patel AB, Tiwari A, Jabbour P. International Controlled Study of Revascularization and Outcomes Following COVID-Positive Mechanical Thrombectomy. Eur J Neurol 2022; 29:3273-3287. [PMID: 35818781 PMCID: PMC9349405 DOI: 10.1111/ene.15493] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Revised: 06/24/2022] [Accepted: 06/29/2022] [Indexed: 11/29/2022]
Abstract
Background and purpose Previous studies suggest that mechanisms and outcomes in patients with COVID‐19‐associated stroke differ from those in patients with non‐COVID‐19‐associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID‐19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. Methods A cross‐sectional, international multicenter retrospective study was conducted in consecutively admitted COVID‐19 patients with concomitant acute LVO, compared to a control group without COVID‐19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable‐adjusted analysis was conducted. Results In this cohort of 697 patients with acute LVO, 302 had COVID‐19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID‐19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID‐19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23–0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12–0.77; p = 0.012). Moreover, endovascular complications, in‐hospital mortality, and length of hospital stay were significantly higher among COVID‐19 patients (p < 0.001). Conclusion COVID‐19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID‐19 patients with LVO were more often younger and had higher morbidity/mortality rates.
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Affiliation(s)
- Adam A Dmytriw
- Neuroendovascular Program, Mass General Brigham Partners, Harvard Medical School, Boston, MA, USA.,Neuroradiology & Neurosurgery Services, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sherief Ghozy
- Neuroradiology & Neurosurgery Services, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Kimon Bekelis
- Department of Neurosurgery, Good Samaritan Hospital Medical Center, West Islip, New York, USA
| | - Nader Sourour
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Eytan Raz
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Daniel Vela-Duarte
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Florida, USA
| | - Italo Linfante
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Florida, USA
| | - Guilherme Dabus
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Florida, USA
| | - Max Kole
- Department of Neurosurgery, Henry Ford Hospital, Michigan, USA
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology, Hospital Clinico Universitario de Valladolid, Spain
| | - Shahid M Nimjee
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Demetrius K Lopes
- Department of Neurosurgery, Advocate Aurora Health, Chicago, Illinois, USA
| | - Ameer E Hassan
- Department of Neuroscience, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, UTMB, Houston, Texas, USA
| | | | - Michael R Levitt
- Departments of Neurological Surgery, Radiology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - Simon Escalard
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
| | - Symeon Missios
- Department of Neurosurgery, Good Samaritan Hospital Medical Center, West Islip, New York, USA
| | - Maksim Shapiro
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Fréderic Clarençon
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Mahmoud Elhorany
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Rizwan A Tahir
- Department of Neurosurgery, Henry Ford Hospital, Michigan, USA
| | - Patrick P Youssef
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert M Starke
- Department of Neurosurgery & Neuroradiology, University of Miami & Jackson Memorial Hospital, Miami, Florida, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | - Jorge Galvan
- Department of Interventional Neuroradiology, Hospital Clinico Universitario de Valladolid, Spain
| | | | - Abolghasem Mortazavi
- Department of Neuroscience, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Melanie Walker
- Departments of Neurological Surgery, Radiology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA
| | - Mahmoud Dibas
- Neuroradiology & Neurosurgery Services, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Fabio Settecase
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Manraj K S Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Anna L Kuhn
- Division of Neurointerventional Radiology, Department of Radiology, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, Department of Radiology, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Bijoy K Menon
- Calgary Stroke Program, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Sanjeev Sivakumar
- Department of Medicine (Neurology), Prisma Health Upstate, USC, Greenville, South Carolina, USA
| | - Ashkan Mowla
- Department of Neurological Surgery, University of Southern California, Los Angeles, California, USA
| | - Salvatore D'Amato
- Neuroendovascular Program, Mass General Brigham Partners, Harvard Medical School, Boston, MA, USA
| | - Alicia M Zha
- Department of Neurology, UT Health Science Center, Houston, Texas, USA
| | - Daniel Cooke
- Department of Neurointerventional Radiology, San Francisco General Hospital, San Francisco, California, USA
| | - Justin E Vranic
- Neuroendovascular Program, Mass General Brigham Partners, Harvard Medical School, Boston, MA, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Mass General Brigham Partners, Harvard Medical School, Boston, MA, USA
| | - James D Rabinov
- Neuroendovascular Program, Mass General Brigham Partners, Harvard Medical School, Boston, MA, USA
| | - Christopher J Stapleton
- Neuroendovascular Program, Mass General Brigham Partners, Harvard Medical School, Boston, MA, USA
| | - Mayank Goyal
- Calgary Stroke Program, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hannah Wu
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA.,Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA.,Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - Jake Cohen
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA.,Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA.,Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - David Turkel-Parella
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA.,Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA.,Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - Andrew Xavier
- Department of Neurology, Sinai Grace Hospital, Detroit, Michigan, USA.,Department of Neurology, St. Joseph Mercy Health, Ann Arbor, Michigan, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA
| | - Vincent Tutino
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA
| | - Gaurav Gupta
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Anil Nanda
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Priyank Khandelwal
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Cristina Tiu
- Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania; "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania
| | - Pere C Portela
- Department of Neurology, Hospital Universitari, Bellvitge, Barcelona, Spain
| | - Natalia Perez de la Ossa
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Xabier Urra
- Department of Neurology, Hospital Clínic, Barcelona, Spain
| | - Mercedes de Lera
- Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain
| | - Juan F Arenillas
- Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain; Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain; Departament de Medicina, Universitat Autónoma de Barcelona, Barcelona, Spain
| | - Mariangela Piano
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Guglielmo Pero
- Department of Neuroradiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Keith De Sousa
- Department of Neurology, Eastern Region, Northwell Health, Long Island, New York, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Radiology, and Neurosurgery, Westchester Medical Center at NY Medical College, Valhalla, New York, USA
| | - Zafar Hashim
- Department of Radiology, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom
| | - Sanjeev Nayak
- Department of Radiology, University Hospital of North Midlands, Stoke-on-Trent, United Kingdom
| | - Leonardo Renieri
- Department of Radiology, Neurovascular Unit, Careggi University Hospital, Florence, Italy
| | - Rose Du
- Neuroradiology & Neurosurgery Services, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mohamed A Aziz-Sultan
- Neuroradiology & Neurosurgery Services, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - David Liebeskind
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, USA
| | - Raul G Nogueira
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Mohamad Abdalkader
- Departments of Neurology and Radiology, Boston Medical Center, Boston University School of Medicine, Massachusetts, USA
| | - Thanh N Nguyen
- Departments of Neurology and Radiology, Boston Medical Center, Boston University School of Medicine, Massachusetts, USA
| | - Nicholas Vigilante
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | | | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Aman B Patel
- Neuroendovascular Program, Mass General Brigham Partners, Harvard Medical School, Boston, MA, USA
| | - Ambooj Tiwari
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA.,Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA.,Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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11
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Massari F, Dabus G, Cortez GM, Singh J, Kuhn AL, Naragum V, Anagnostakou V, Hanel RA, Gounis MJ, Puri AS. Super large-bore ingestion of clot (SLIC) leads to high first pass effect in thrombectomy for large vessel occlusion. J Neurointerv Surg 2022:neurintsurg-2022-018806. [PMID: 35732483 DOI: 10.1136/neurintsurg-2022-018806] [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: 02/14/2022] [Accepted: 05/21/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Super large-bore aspiration (SLBA) has shown high rates of complete clot ingestion. OBJECTIVE To report the initial clinical feasibility, safety, and efficacy of this novel SLBA insert combination-super large-bore ingestion of clot (SLIC) technique for stroke. METHODS We performed a retrospective review of three comprehensive stroke center databases. The SLIC technique entails a triaxial assembly of an 8 Fr 0.106″ Base Camp catheter, 0.088″ catheter extender (HiPoint), and an insert catheter (Tenzing 8) that completely consumes the inner diameter of the 0.088″ SLBA catheter. The HiPoint catheter is delivered over the Tenzing 8 to the face of the embolus, which is withdrawn, while aspirating through the Base Camp and HiPoint catheters as a single assembly. RESULTS Thirty-three consecutive patients with large vessel occlusion were treated with SLIC. The median age was 70 years (30-91) and 17 were male (51.5%). The median presenting National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT score was 21 (1-34) and 8 (5-10), respectively. There was 100% success in delivering the 0.088″ catheter to the site of the occlusion. The successful revascularization rate (modified Thrombolysis in Cerebral Infarction (mTICI) score ≥2B) was 100% within a single pass in most cases (82%). Final mTICI ≥2C was achieved in 94.1% of occlusions, with 73.5% mTICI 3 recanalization. The rate of first pass effect in achieving excellent reperfusion (mTICI ≥2C) was 70.5%. There were no adverse events or postprocedural symptomatic hemorrhages. CONCLUSIONS Our initial experience with the SLIC technique resulted in achieving a first pass effect (mTICI ≥2C) in 70.5%. Navigation of the SLBA catheter extender over the Tenzing insert was successful and safe in this early experience.
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Affiliation(s)
- Francesco Massari
- Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA.,Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Guilherme Dabus
- Department of Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac & Vascular Institute - Baptist Hospital, Miami, Florida, USA
| | - Gustavo M Cortez
- Department of Neurosurgery, Lyerly Neurosurgery, Jacksonville, Florida, USA
| | - Jasmeet Singh
- Department of Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA.,Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
| | - Anna Luisa Kuhn
- Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA.,Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Varun Naragum
- Department of Radiology, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Vania Anagnostakou
- New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Medical Center Downtown, Jacksonville, Florida, USA
| | - Matthew J Gounis
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, University of Massachusetts Medical Center, Worcester, Massachusetts, USA
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Abrams K, Dabus G. Perfusion Scotoma: A Potential Core Underestimation in CT Perfusion in the Delayed Time Window in Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2022; 43:813-816. [PMID: 35618426 DOI: 10.3174/ajnr.a7524] [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: 02/15/2022] [Accepted: 04/07/2022] [Indexed: 11/07/2022]
Abstract
With the growing rise in utilization of CT perfusion for selecting patients for thrombectomy in acute ischemic stroke from large vessel occlusion, some potential pitfalls are becoming more commonly seen particularly when it comes to estimating the core infarct size on CT perfusion. Ghost infarct core has been described to account for overestimating core infarct size in the early time period (<3 hours). Herein, we describe the phenomenon of underestimating core infarct size on CT perfusion in the later time period (>6 hours), which we have termed perfusion scotoma.
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Affiliation(s)
- K Abrams
- From the Department of Radiology (K.A.), Baptist Hospital of Miami, Miami Neuroscience Institute, Miami, Florida
| | - G Dabus
- Department of Neuroendovascular Surgery (G.D.), Miami Cardiac and Vascular Institute, Miami Neuroscience Institute, Miami, Florida
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13
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Jabbour P, Dmytriw AA, Sweid A, Piotin M, Bekelis K, Sourour N, Raz E, Linfante I, Dabus G, Kole M, Martínez-Galdámez M, Nimjee SM, Lopes DK, Hassan AE, Kan P, Ghorbani M, Levitt MR, Escalard S, Missios S, Shapiro M, Clarençon F, Elhorany M, Vela-Duarte D, Tahir RA, Youssef PP, Pandey AS, Starke RM, El Naamani K, Abbas R, Hammoud B, Mansour OY, Galvan J, Billingsley JT, Mortazavi A, Walker M, Dibas M, Settecase F, Heran MKS, Kuhn AL, Puri AS, Menon BK, Sivakumar S, Mowla A, D'Amato S, Zha AM, Cooke D, Goyal M, Wu H, Cohen J, Turkel-Parrella D, Xavier A, Waqas M, Tutino VM, Siddiqui A, Gupta G, Nanda A, Khandelwal P, Tiu C, Portela PC, Perez de la Ossa N, Urra X, de Lera M, Arenillas JF, Ribo M, Requena M, Piano M, Pero G, De Sousa K, Al-Mufti F, Hashim Z, Nayak S, Renieri L, Aziz-Sultan MA, Nguyen TN, Feineigle P, Patel AB, Siegler JE, Badih K, Grossberg JA, Saad H, Gooch MR, Herial NA, Rosenwasser RH, Tjoumakaris S, Tiwari A. Characteristics of a COVID-19 Cohort With Large Vessel Occlusion: A Multicenter International Study. Neurosurgery 2022; 90:725-733. [PMID: 35238817 PMCID: PMC9514728 DOI: 10.1227/neu.0000000000001902] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 12/06/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND The mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke. OBJECTIVE To describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort. METHODS We conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020. RESULTS The total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002). CONCLUSION COVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.
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Affiliation(s)
- Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Adam A. Dmytriw
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France;
| | - Kimon Bekelis
- Department of Neurosurgery, Good Samaritan Hospital Medical Center, West Islip, New York, USA
| | - Nader Sourour
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Eytan Raz
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Italo Linfante
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida, USA
| | - Guilherme Dabus
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida, USA
| | - Max Kole
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA;
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain;
| | - Shahid M. Nimjee
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA;
| | - Demetrius K. Lopes
- Department of Neurosurgery, Advocate Aurora Health, Chicago, Illinois, USA
| | - Ameer E. Hassan
- Department of Neuroscience, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, Texas, USA
| | | | - Michael R. Levitt
- Departments of Neurological Surgery, Radiology, Mechanical Engineering, and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA;
| | - Simon Escalard
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France;
| | - Symeon Missios
- Department of Neurosurgery, Good Samaritan Hospital Medical Center, West Islip, New York, USA
| | - Maksim Shapiro
- Department of Radiology, New York University Langone Medical Center, New York, New York, USA
| | - Frédéric Clarençon
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Mahmoud Elhorany
- Department of Interventional Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Daniel Vela-Duarte
- Department of Interventional Neuroradiology & Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Baptist Hospital of Miami, Miami, Florida, USA
| | - Rizwan A. Tahir
- Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan, USA;
| | - Patrick P. Youssef
- Department of Neurosurgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA;
| | - Aditya S. Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Robert M. Starke
- Department of Neurosurgery & Neuroradiology, University of Miami & Jackson Memorial Hospital, Miami, Florida, USA;
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Bassel Hammoud
- Department of Biomedical Engineering, American University of Beirut, Beirut, Lebanon;
| | - Ossama Y. Mansour
- Department of Neurology and Neuroradiology, Alexandria University Hospital, Al Attarin, Egypt;
| | - Jorge Galvan
- Department of Interventional Neuroradiology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain;
| | | | - Abolghasem Mortazavi
- Department of Neuroscience, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Melanie Walker
- Departments of Neurological Surgery and Stroke & Applied Neuroscience Center, University of Washington, Seattle, Washington, USA;
| | - Mahmoud Dibas
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - Fabio Settecase
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, USA
| | - Manraj K. S. Heran
- Division of Neuroradiology, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, USA
| | - Anna L. Kuhn
- Division of Neurointerventional Radiology, Department of Radiology, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Ajit S. Puri
- Division of Neurointerventional Radiology, Department of Radiology, UMass Memorial Medical Center, Worcester, Massachusetts, USA
| | - Bijoy K. Menon
- Calgary Stroke Program, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Sanjeev Sivakumar
- Department of Neurosurgery & Neuroradiology, University of Miami & Jackson Memorial Hospital, Miami, Florida, USA;
| | - Ashkan Mowla
- Department of Neurological Surgery, University of Southern California, Los Angeles, California, USA
| | - Salvatore D'Amato
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - Alicia M. Zha
- Department of Neurology, UT Health Science Center, Houston, Texas, USA
| | - Daniel Cooke
- Department of Neurointerventional Radiology, San Francisco General Hospital, San Francisco, California, USA
| | - Mayank Goyal
- Calgary Stroke Program, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Hannah Wu
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA
- Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA
- Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - Jake Cohen
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA
- Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA
- Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - David Turkel-Parrella
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA
- Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA
- Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
| | - Andrew Xavier
- Department of Neurology, Sinai Grace Hospital, Detroit, Michigan, USA
- Department of Neurology, St. Joseph Mercy Health, Ann Arbor, Michigan, USA
| | - Muhammad Waqas
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA
| | - Vincent M. Tutino
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA
| | - Adnan Siddiqui
- Department of Neurosurgery, University of New York at Buffalo, Buffalo, New York, USA
| | - Gaurav Gupta
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Anil Nanda
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Priyank Khandelwal
- Department of Neurology, Robert Wood Johnson University Hospital, New Brunswick, New Jersey, USA
| | - Cristina Tiu
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | - Pere C. Portela
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Natalia Perez de la Ossa
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain;
| | - Xabier Urra
- Department of Neurology, Hospital Clínic, Barcelona, Spain;
| | - Mercedes de Lera
- Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain;
| | - Juan F. Arenillas
- Department of Neurology, Hospital Clínico Universitario, Valladolid, Spain;
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain;
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA;
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Vall d'Hebron Research Institute, Barcelona, Spain;
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA;
| | - Mariangela Piano
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | - Guglielmo Pero
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | - Keith De Sousa
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Fawaz Al-Mufti
- Stroke Unit, Neuroscience Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain;
| | - Zafar Hashim
- Department of Radiology, University Hospital of North Midlands, Stoke-on-Trent, UK
| | - Sanjeev Nayak
- Department of Neurology, Hospital Clínic, Barcelona, Spain;
| | - Leonardo Renieri
- Department of Radiology, Neurovascular Unit, Careggi University Hospital, Florence, Italy
| | - Mohamed A. Aziz-Sultan
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - Thanh N. Nguyen
- Departments of Neurology and Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA;
| | - Patricia Feineigle
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA;
| | - Aman B. Patel
- Interventional Neuroradiology & Endovascular Neurosurgery Service, Mass General Brigham Partners, Harvard Medical School, Boston, Massachusetts, USA
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA;
| | - Khodr Badih
- Department of Physics, University of Toronto, Toronto, Ontario, Canada;
| | | | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - M. Reid Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Nabeel A. Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Robert H. Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA;
| | - Ambooj Tiwari
- Department of Neurology, Brookdale University Hospital, Brooklyn, New York, USA
- Department of Neurology, Jamaica Medical Center, Richmond Hill, New York, USA
- Department of Neurology, NYU Lutheran Hospital, Brooklyn, New York, USA
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Dabus G, Kotecha R, Linfante I, Wieczorek DJ, Gutierrez AN, Candela JG, McDermott MW. Analysis of potential time saving in brain arteriovenous malformation stereotactic radiosurgery planning using a new software platform. Med Dosim 2021; 47:38-42. [PMID: 34481717 DOI: 10.1016/j.meddos.2021.07.004] [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: 03/21/2021] [Revised: 05/31/2021] [Accepted: 07/24/2021] [Indexed: 11/15/2022]
Abstract
To evaluate the utility of integrating a 3D vessel tree co-registration software platform into the stereotactic radiosurgery (SRS) workflow and its time saving for brain arteriovenous malformation (bAVM) treatment in adults compared to the conventional stereotactic head frame workflow. Eight consecutive adult bAVM cases were selected and retrospectively reviewed. Total number of angiograms and SRS procedures were 8. The electronic medical records were analyzed by time stamps to determine the length of time for each component of the set-up, transport, and frame removal. Times were averaged and the start of sedation by anesthesia used as a surrogate for the start of the frame application process. Reductions in workflow times were then modeled assuming cerebral angiography as a separate procedure. There were 8 adult bAVM cases included. Six were female. All patients had a single treatment session. Average age was 51.5 years (Range: 36-71). All patients were treated under monitored anesthesia care. In 6 patients, the AVM was deeply located (basal ganglia, midbrain, brainstem); in 2 cases, the lesion was frontal. Spetzler-Martin grades were 4 (50%) Grade 2 and 4 (50%) Grade 3. The average prescription isodose volume (PIV) and 12 Gy volumes (V12Gy) were 0.85 cc and 1.74 cc, respectively. The mean time from frame application to arrival in the angiography room was 111.5 minutes (range 40 to 171 min; median 107 min; SD 35.3 min); transport from angiography room to SRS was 47.5 minutes (range 15 to 107 min; median 36 min; SD 31.1 min), and frame removal after SRS was 20.5 minutes (range 10 to 47 min; median 16 min; SD 11.6 min). The average total additional time for the entire process of frame application, patient transportation, and frame removal was 132 minutes (range 87 to 181 min; median 127.5 min; SD 28.4 min). Therefore, assuming a non-frame based workflow and with angiography performed ahead of the actual radiosurgical treatment, the total time savings on the day of treatment was estimated at 132 minutes (range 87 to 181 min; median 127.5 min; SD 28.4 min). The ability to perform angiography, image fusion, and treatment planning for the actual day-of-delivery using 3-dimensional vessel tree co-registration could result in significant time savings over traditional workflow practices. Further experience with this system will evaluate its accuracy, reproducibility, and potential broader use in SRS workflow paradigms for the treatment of vascular pathologies. For bAVMs, the benefits of this time savings might allow for streamlined workflows on the day of SRS.
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Affiliation(s)
- Guilherme Dabus
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL; Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL; Herbert Wertheim College of Medicine, Florida International University, Miami, FL.
| | - Rupesh Kotecha
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Italo Linfante
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL; Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, FL; Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - D Jay Wieczorek
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - Alonso N Gutierrez
- Department of Radiation Oncology, Miami Cancer Institute, Baptist Health South Florida, Miami, FL; Herbert Wertheim College of Medicine, Florida International University, Miami, FL
| | - John G Candela
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL; Herbert Wertheim College of Medicine, Florida International University, Miami, FL
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15
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Dmytriw AA, Dibas M, Schirmer CM, Settecase F, Heran MKS, Efendizade A, Kühn AL, Puri AS, Ospel J, Menon B, Sivakumar S, Mowla A, Vela‐Duarte D, Linfante I, Dabus G, Regenhardt RW, Patel AB, Leslie‐Mazwi T, D’Amato S, Rosenthal J, Zha A, Talukder N, Sheth S, Cooke D, Leung LY, Malek A, Voetsch B, Sehgal S, Wakhloo AK, Wu H, Cohen J, Turkel‐Parella D, Xavier A, Tiwari A. Age and Acute Ischemic Stroke Outcome in North American Patients With COVID-19. J Am Heart Assoc 2021; 10:e021046. [PMID: 34219466 PMCID: PMC8483479 DOI: 10.1161/jaha.121.021046] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background Acute ischemic stroke (AIS) in the context of COVID‐19 has received considerable attention for its propensity to affect patients of all ages. We aimed to evaluate the effect of age on functional outcome and mortality following an acute ischemic event. Methods and Results A prospectively maintained database from comprehensive stroke centers in Canada and the United States was analyzed for patients with AIS from March 14 to September 30, 2020 who tested positive for SARS‐CoV‐2. The primary outcome was Modified Rankin Scale score at discharge, and the secondary outcome was mortality. Baseline characteristics, laboratory values, imaging, and thrombectomy workflow process times were assessed. Among all 126 patients with COVID‐19 who were diagnosed with AIS, the median age was 63 years (range, 27–94). There were 35 (27.8%) patients with AIS in the aged ≤55 years group, 47 (37.3%) in the aged 56 to 70 group, and 44 (34.9%) in the aged >70 group. Intravenous tissue plasminogen activator and thrombectomy rates were comparable across these groups, (P=0.331 and 0.212, respectively). There was a significantly lower rate of mortality between each group favoring younger age (21.9% versus 45.0% versus 48.8%, P=0.047). After multivariable adjustment for possible confounders, a 1‐year increase in age was significantly associated with fewer instances of a favorable outcome of Modified Rankin Scale 0 to 2 (odds ratio [OR], 0.95; 95 CI%, 0.90–0.99; P=0.048) and higher mortality (OR, 1.06; 95 CI%, 1.02–1.10; P=0.007). Conclusions AIS in the context of COVID‐19 affects young patients at much greater rates than pre‐pandemic controls. Nevertheless, instances of poor functional outcome and mortality are closely tied to increasing age.
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16
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Greenwood J, Belnap S, Dabus G, Linfante I, De Los Rios La Rosa F. Risk of contracting SARS-CoV-2 (COVID-19) from hospital admission and the impact of protection efforts on acute stroke treatment. Clin Neurol Neurosurg 2021; 207:106793. [PMID: 34225003 PMCID: PMC8241578 DOI: 10.1016/j.clineuro.2021.106793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/24/2021] [Accepted: 06/26/2021] [Indexed: 11/16/2022]
Abstract
Background It is unclear how interventions designed to restrict community and in-hospital exposure to the SARS-CoV-2 (COVID-19) virus influenced stroke care for patients seeking acute treatment. Therefore, we aimed to determine how these COVID-19 interventions impacted acute stroke treatment times and to assess the risk of contracting COVID-19 due to their stay in our medical center. Methods Retrospective, single center, two-phase study evaluating hospital and community trends from 12/2019 – 04/2020 compared to the previous year and pre/post (n = 156/93) intervention implementation. Phase I assessed stroke treatment times, delay to hospital arrival, and witnessed stroke volume. Phase II, a post-implementation telephone survey, assessed risk of developing symptoms or testing positive for COVID-19. Results Stroke volume declined by 29% (p < .05) from April to March compared to the previous year. However, no significant delays in seeking medical care (pre Mdn=112, post Mdn=95, p = .34) was observed. Witnessed stroke volume decreased 11% (p < .001) compared to the pre-implementation group, but no significant delay in IV alteplase (pre Mdn=22 mins; post Mdn=26 mins, p = .08) nor endovascular treatment (pre Mdn=60 mins; post Mdn=80 mins, p = .45) was observed. In Phase II, 63 patients participated, two tested (3%) COVID-19 positive during admission and four (6%) within two weeks of discharge. COVID-19 contraction risk during and after hospitalization remained similar to the general population (RR=1.75, 95%CI: 0.79–3.63). Overall results indicated a marked decrease in stroke volume, no significant delays to either seek or provide acute stroke care were evident, and COVID-19 contraction risk was low. Conclusions Seeking acute stroke medical care outweighs the risk of COVID-19 exposure.
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Affiliation(s)
- Jessica Greenwood
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Starlie Belnap
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Guilherme Dabus
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
| | - Italo Linfante
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, FL, USA
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Yoo AJ, Soomro J, Andersson T, Saver JL, Ribo M, Bozorgchami H, Dabus G, Liebeskind DS, Jadhav A, Mattle H, Zaidat OO. Benchmarking the Extent and Speed of Reperfusion: First Pass TICI 2c-3 Is a Preferred Endovascular Reperfusion Endpoint. Front Neurol 2021; 12:669934. [PMID: 34046008 PMCID: PMC8144635 DOI: 10.3389/fneur.2021.669934] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: End-of-procedure substantial reperfusion [modified Treatment in Cerebral Ischemia (mTICI) 2b-3], the leading endpoint for thrombectomy studies, has several limitations including a ceiling effect, with recent achieved rates of ~90%. We aimed to identify a more optimal definition of angiographic success along two dimensions: (1) the extent of tissue reperfusion, and (2) the speed of revascularization. Methods: Core-lab adjudicated TICI scores for the first three passes of EmboTrap and the final all-procedures result were analyzed in the ARISE II multicenter study. The clinical impact of extent of reperfusion and speed of reperfusion (first-pass vs. later-pass) were evaluated. Clinical outcomes included 90-day functional independence [modified Rankin Scale (mRS) 0–2], 90-day freedom-from-disability (mRS 0–1), and dramatic early improvement [24-h National Institutes of Health Stroke Scale (NIHSS) improvement ≥ 8 points]. Results: Among 161 ARISE II subjects with ICA or MCA M1 occlusions, reperfusion results at procedure end showed substantial reperfusion in 149 (92.5%), excellent reperfusion in 121 (75.2%), and complete reperfusion in 79 (49.1%). Reperfusion rates on first pass were substantial in 81 (50.3%), excellent reperfusion in 62 (38.5%), and complete reperfusion in 44 (27.3%). First-pass excellent reperfusion (first-pass TICI 2c-3) had the greatest nominal predictive value for 90-day mRS 0–2 (sensitivity 58.5%, specificity 68.6%). There was a progressive worsening of outcomes with each additional pass required to achieve TICI 2c-3. Conclusions: First-pass excellent reperfusion (TICI 2c-3), reflecting rapid achievement of extensive reperfusion, is the technical revascularization endpoint that best predicted functional independence in this international multicenter trial and is an attractive candidate for a lead angiographic endpoint for future trials. Clinical Trial Registration:http://www.clinicaltrials.gov, identifier NCT02488915.
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Affiliation(s)
- Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Fort Worth, TX, United States
| | - Jazba Soomro
- Department of Neurointervention, Texas Stroke Institute, Fort Worth, TX, United States
| | - Tommy Andersson
- Neuroradiology, Karolinska University Hospital, Clinical Neuroscience Karolinska Institutet, Stockholm, Sweden.,Medical Imaging, Allgemeine Ziekenhuis Groeninge, Kortrijk, Belgium
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Vall D'Hebron University Hospital, Barcelona, Spain
| | - Hormozd Bozorgchami
- Department of Neurology, Oregon Health and Science University Hospital, Portland, OR, United States
| | - Guilherme Dabus
- Department of Interventional Neuroradiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, FL, United States
| | - David S Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core and Stroke Center, University of California, Los Angeles, Los Angeles, CA, United States
| | - Ashutosh Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Heinrich Mattle
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Osama O Zaidat
- Mercy St. Vincent Medical Center, Toledo, OH, United States
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18
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Gupta R, Saver JL, Levy E, Zaidat OO, Yavagal D, Liebeskind DS, Khaldi A, Gross B, Lang M, Narayanan S, Jankowitz B, Snyder K, Siddiqui A, Davies J, Lin E, Hassan A, Hanel R, Aghaebrahim A, Kaushal R, Malek A, Mueller-Kronast N, Starke R, Bozorgchami H, Nesbit G, Horikawa M, Priest R, Liu J, Budzik RF, Pema P, Vora N, Taqi MA, Samaniego E, Wang QT, Nossek E, Dabus G, Linfante I, Puri A, Abergel E, Starkman S, Tateshima S, Jadhav AP. New Class of Radially Adjustable Stentrievers for Acute Ischemic Stroke: Primary Results of the Multicenter TIGER Trial. Stroke 2021; 52:1534-1544. [PMID: 33739136 PMCID: PMC8078128 DOI: 10.1161/strokeaha.121.034436] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: The Tigertriever is a novel, radially adjustable, fully visible, stentriever that permits the operator to align radial expansion with target vessel diameters. This multicenter trial compared the Tigertriever’s effectiveness and safety compared with established stent retrievers. Methods: Single arm, prospective, multicenter trial comparing the Tigertriever to efficacy and safety performance goals derived from outcomes in 6 recent pivotal studies evaluating the Solitaire and Trevo stent-retriever devices with a lead-in and a main-study phase. Patients were enrolled if they had acute ischemic stroke with National Institutes of Health Stroke Scale score ≥8 due to large vessel occlusion within 8 hours of onset. The primary efficacy end point was successful reperfusion, defined as core laboratory-adjudicated modified Thrombolysis in Cerebral Ischemia score 2b-3 within 3 passes of the Tigertriever. The primary safety end point was a composite of 90-day all-cause mortality and symptomatic intracranial hemorrhage. Secondary efficacy end points included 3-month good clinical outcome (modified Rankin Scale score 0–2) and first-pass successful reperfusion. Results: Between May 2018 and March 2020, 160 patients (43 lead-in, 117 main phase) at 17 centers were enrolled and treated with the Tigertriever. The primary efficacy end point was achieved in 84.6% in the main-study phase group compared with the 63.4% performance goal and the 73.4% historical rate (noninferiority P<0.0001; superiority P<0.01). The first pass successful reperfusion rate was 57.8%. After all interventions, successful reperfusion (modified Thrombolysis in Cerebral Ischemia score ≥2b) was achieved in 95.7% and excellent reperfusion (modified Thrombolysis in Cerebral Ischemia score 2c-3) in 71.8%. The primary safety composite end point rate of mortality and symptomatic intracranial hemorrhage was 18.1% compared with the 30.4% performance goal and the 20.4% historical rate (noninferiority P=0.004; superiority P=0.57). Good clinical outcome was achieved in 58% at 90 days. Conclusions: The Tigertriever device was shown to be highly effective and safe compared with Trevo and Solitaire devices to remove thrombus in patients with large-vessel occlusive stroke eligible for mechanical thrombectomy. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03474549.
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Affiliation(s)
- Rishi Gupta
- Wellstar Medical Group, Department of Neurosurgery, Wellstar Health System Kennestone Hospital Marietta, GA (R.G., A.K.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles (J.L.S., D.S.L.)
| | - Elad Levy
- Departments of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, OH (E.L., O.O.Z.)
| | - Osama O Zaidat
- Departments of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, OH (E.L., O.O.Z.)
| | - Dileep Yavagal
- Department of Neurology (D.Y.), University of Miami School of Medicine, FL
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles (J.L.S., D.S.L.)
| | - Ahmad Khaldi
- Wellstar Medical Group, Department of Neurosurgery, Wellstar Health System Kennestone Hospital Marietta, GA (R.G., A.K.)
| | - Bradley Gross
- Department of Neurosurgery, Stroke Institute, University of Pittsburgh Medical Center, PA (B.G., M.L.)
| | - Michael Lang
- Wellstar Medical Group, Department of Neurosurgery, Wellstar Health System Kennestone Hospital Marietta, GA (R.G., A.K.)
| | | | - Brian Jankowitz
- Department of Neurosurgery, Cooper University Health Care, Camden, NJ (B.J.)
| | - Kenneth Snyder
- Department of Neurosurgery, State University of New York at Buffalo (K.S., A.S.. J.D.)
| | - Adnan Siddiqui
- Department of Neurosurgery, State University of New York at Buffalo (K.S., A.S.. J.D.)
| | - Jason Davies
- Department of Neurosurgery, State University of New York at Buffalo (K.S., A.S.. J.D.)
| | - Eugene Lin
- Departments of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, OH (E.L., O.O.Z.)
| | - Ameer Hassan
- Department of Neurology, Valley Baptist Medical Center, Harlingen, TX (A.H.)
| | - Ricardo Hanel
- Stroke and Cerebrovascular Surgery, Lyerly Neurosurgery/Baptist Neurological Institute, Jacksonville, FL (R.H., A.A.)
| | - Amin Aghaebrahim
- Stroke and Cerebrovascular Surgery, Lyerly Neurosurgery/Baptist Neurological Institute, Jacksonville, FL (R.H., A.A.)
| | - Ritesh Kaushal
- Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., A.M., N.M.-K.)
| | - Ali Malek
- Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., A.M., N.M.-K.)
| | - Nils Mueller-Kronast
- Advanced Neuroscience Network/Tenet South Florida, Delray Beach (R.K., A.M., N.M.-K.)
| | - Robert Starke
- Department of Neurosurgery (R.S.), University of Miami School of Medicine, FL
| | - Hormozd Bozorgchami
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Gary Nesbit
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Masahiro Horikawa
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Ryan Priest
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Jesse Liu
- Oregon Health and Science University, Portland (H.B., G.N., M.H., R.P., J.L.)
| | - Ronald F Budzik
- Department of Radiology, Riverside Radiology and Interventional Associates, Columbus, OH (R.F.B., P.P., N.V.)
| | - Peter Pema
- Department of Radiology, Riverside Radiology and Interventional Associates, Columbus, OH (R.F.B., P.P., N.V.)
| | - Nirav Vora
- Department of Radiology, Riverside Radiology and Interventional Associates, Columbus, OH (R.F.B., P.P., N.V.)
| | - M Asif Taqi
- Vascular Neurology of Southern California, Los Robles Hospital, Thousand Oaks (M.A.T.)
| | - Edgar Samaniego
- Departments of Neurology, Neurosurgery and Radiology University of Iowa Hospitals and Clinics, Iowa City (E.S.)
| | - Qingliang Tony Wang
- Departments of Neurology, Surgery/Neurosurgery, and Comprehensive Stroke Center, Maimonides Medical Center/SUNY Downstate Health Sciences University, Brooklyn, NY (Q.T.W.)
| | - Erez Nossek
- Department of Neurosurgery, New York University Medical School (E.N.)
| | - Guilherme Dabus
- Department of Neurointerventional Surgery, Baptist Cardiac and Vascular Institute, Miami, FL (G.D., I.L.)
| | - Italo Linfante
- Department of Neurointerventional Surgery, Baptist Cardiac and Vascular Institute, Miami, FL (G.D., I.L.)
| | - Ajit Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester (A.P.)
| | - Eitan Abergel
- Department of Neuroradiology, Rambam Health Care, Haifa, Israel (E.A.)
| | - Sidney Starkman
- Department of Emergency Medicine (S.S.), University of California Los Angeles
| | - Satoshi Tateshima
- Department of Radiology and Neurosurgery (S.T.), University of California Los Angeles
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J.)
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19
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Greenwood J, Belnap S, Bedgio R, Dabus G, Linfante I, De Los Rios La Rosa F. Abstract P153: SARS-CoV-2 (COVID-19) Protection Efforts on Acute Stroke Treatment. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
It is unclear how the interventions designed to restrict community and in-hospital exposure to the SARS-CoV-2 virus affected the care for stroke patients seeking acute treatment. The objective of the following study was to determine the impact COVID-19 has had on the treatment times for patients evaluated as acute stroke alerts at Baptist Hospital of Miami (BHM). A co-primary objective of the study was to assess the risk of contracting SARS-CoV-2 within 2 weeks from hospital discharge.
Methods:
This retrospective, two phase study was conducted between December 2019 and April 2020. In phase one, we assessed time from symptom onset to hospital arrival, number of strokes with witnessed onset, and in-hospital treatment times pre & post implementation of Covid-19 preventive exposure measures. In phase two of the study, a telephone survey was conducted on the post implementation group to assess the risk of patients developing symptoms or testing positive for SARS-CoV-2 from hospital admission up to two weeks post discharge.
Results:
Phase I demonstrated there was a 40% decline in stroke volume, but no significant delay to seek medical attention post implementation of the SARS prevention strategies. On average individuals in the pre-group (n=155) waited approximately 260 minutes (SE=24) to seek medical attention vs. 203 minutes (SE=27) minutes for the post-group (n=87). However, there was nearly a six-fold increase in the percentage of cases with unknown symptom onset post implementation of COVID-19 safety precautions. There was significant delay in administering IV alteplase, increasing from 24 mins (n=16) to 33 mins (n=21) post implementation; delays observed for endovascular treatment were not significant (pre, n=13 mean= 73 mins, post n=12 mean= 82 mins). The volume of patients treated with either IV alteplase and/or endovascular treatment remained similar. Phase II of the study is on-going, results will be available for the ISC.
Discussion:
The COVID-19 crisis in our community was associated with a six-fold increase in the percentage of cases with unknown stroke onset time. Besides a marked decrease in stroke volume, we did not evidence significant delays to either seek or provide acute stroke care outside a modest increase in door to needle time.
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20
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Bendok BR, Abi-Aad KR, Ward JD, Kniss JF, Kwasny MJ, Rahme RJ, Aoun SG, El Ahmadieh TY, El Tecle NE, Zammar SG, Aoun RJN, Patra DP, Ansari SA, Raymond J, Woo HH, Fiorella D, Dabus G, Milot G, Delgado Almandoz JE, Scott JA, DeNardo AJ, Dashti SR. The Hydrogel Endovascular Aneurysm Treatment Trial (HEAT): A Randomized Controlled Trial of the Second-Generation Hydrogel Coil. Neurosurgery 2020; 86:615-624. [PMID: 32078692 PMCID: PMC7534546 DOI: 10.1093/neuros/nyaa006] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Accepted: 12/12/2019] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Aneurysm recurrence after coiling has been associated with aneurysm growth, (re)hemorrhage, and a greater need for follow-up. The second-generation HydroCoil Embolic System (HES; MicroVention, Inc) consists of a platinum core with integrated hydrogel and was developed to reduce recurrence through enhancing packing density and healing within the aneurysm. OBJECTIVE To compare recurrence between the second-generation HES and bare platinum coil (BPC) in the new-generation Hydrogel Endovascular Aneurysm Treatment Trial (HEAT). METHODS HEAT is a randomized, controlled trial that enrolled subjects with ruptured or unruptured 3- to 14-mm intracranial aneurysms amenable to coiling. The primary endpoint was aneurysm recurrence using the Raymond-Roy scale. Secondary endpoints included minor and major recurrence, packing density, adverse events related to the procedure and/or device, mortality, initial complete occlusion, aneurysm retreatment, hemorrhage from target aneurysm during follow-up, aneurysm occlusion stability, and clinical outcome at final follow-up. RESULTS A total of 600 patients were randomized (HES, n = 297 and BPC, n = 303), including 28% with ruptured aneurysms. Recurrence occurred in 11 (4.4%) subjects in the HES arm and 44 (15.4%) subjects in the BPC arm (P = .002). While the initial occlusion rate was higher with BPC, the packing density and both major and minor recurrence rates were in favor of HES. Secondary endpoints including adverse events, retreatment, hemorrhage, mortality, and clinical outcome did not differ between arms. CONCLUSION Coiling of small-to-medium aneurysms with second-generation HES resulted in less recurrence when compared to BPC, without increased harm. These data further support the use of the second-generation HES for the embolization of intracranial aneurysms. VIDEO ABSTRACT
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Affiliation(s)
- Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Department of Otolaryngology, Mayo Clinic, Phoenix, Arizona.,Department of Radiology, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Karl R Abi-Aad
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Jennifer D Ward
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Jason F Kniss
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Mary J Kwasny
- Department of Preventive Medicine, Feinberg School of Medicine, Chicago, Illinois
| | - Rudy J Rahme
- Department of Neurological Surgery, Northwestern University, Chicago, Illinois
| | - Salah G Aoun
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Tarek Y El Ahmadieh
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Najib E El Tecle
- Department of Neurological Surgery, Saint Louis University Hospital, St. Louis, Missouri
| | - Samer G Zammar
- Department of Neurological Surgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Rami James N Aoun
- Department of General Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Devi P Patra
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona.,Precision Neuro-therapeutics Innovation Lab, Mayo Clinic, Phoenix, Arizona.,Neurosurgery Simulation and Innovation Lab, Mayo Clinic, Phoenix, Arizona
| | - Sameer A Ansari
- Department of Radiology, Northwestern University, Chicago, Illinois
| | - Jean Raymond
- Laboratoire de Neuroradiologie Interventionnelle, Université de Montréal, Montreal, Canada
| | - Henry H Woo
- Department of Neurological Surgery, North Shore University Hospital, Manhasset, New York
| | - David Fiorella
- Department of Radiology, Stony Brook University Hospital, Stony Brook, New York
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Cardiac and Vascular Institute, Miami, Florida
| | - Genevieve Milot
- Département de Chirurgie, CHU de Quebec, Quebec City, Canada
| | | | - John A Scott
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Andrew J DeNardo
- Department of Neurological Surgery, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Shervin R Dashti
- Department of Neurological Surgery Norton Neuroscience Institute, Norton Healthcare, Louisville, Kentucky
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21
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Fargen KM, Leslie-Mazwi TM, Klucznik RP, Wolfe SQ, Brown P, Ansari SA, Dabus G, Spiotta AM, Mokin M, Hassan AE, Liebeskind D, Welch BG, Siddiqui AH, Hirsch JA. The professional and personal impact of the coronavirus pandemic on US neurointerventional practices: a nationwide survey. J Neurointerv Surg 2020; 12:927-931. [PMID: 32788389 PMCID: PMC7421723 DOI: 10.1136/neurintsurg-2020-016513] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 07/28/2020] [Accepted: 07/29/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Little is currently known about the effects of the coronavirus (COVID-19) pandemic on neurointerventional (NI) procedural volumes or its toll on physician wellness. METHODS A 37-question online survey was designed and distributed to physician members of three NI physician organizations. RESULTS A total of 151 individual survey responses were obtained. Reduced mechanical thrombectomy procedures compared with pre-pandemic were observed with 32% reporting a greater than 50% reduction in thrombectomy volumes. In concert with most (76%) reporting at least a 25% reduction in non-mechanical thrombectomy urgent NI procedures and a nearly unanimous (96%) cessation of non-urgent elective cases, 68% of physicians reported dramatic reductions (>50%) in overall NI procedural volume compared with pre-pandemic. Increased door-to-puncture times were reported by 79%. COVID-19-positive infections occurred in 1% of physician respondents: an additional 8% quarantined for suspected infection. Sixty-six percent of respondents reported increased career stress, 56% increased personal life/family stress, and 35% increased career burnout. Stress was significantly increased in physicians with COVID-positive family members (P<0.05). CONCLUSIONS This is the first study designed to understand the effects of the COVID-19 pandemic on NI physician practices, case volumes, compensation, personal/family stresses, and work-related burnout. Future studies examining these factors following the resumption of elective cases and relaxing of social distancing measures will be necessary to better understand these phenomena.
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Affiliation(s)
- Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | | | | | - Stacey Q Wolfe
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Patrick Brown
- Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac & Vascular Institute - Baptist Hospital, Miami, Florida, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Treasure Hills, Harlingen, Texas, USA
| | | | - Babu G Welch
- Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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22
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Rai AT, Leslie-Mazwi TM, Fargen KM, Pandey AS, Dabus G, Hassan AE, Fraser JF, Hirsch JA, Gupta R, Hanel R, Yoo AJ, Bozorgchami H, Fiorella D, Mocco J, Arthur AS, Zaidat O, Siddiqui AH. Neuroendovascular clinical trials disruptions due to COVID-19. Potential future challenges and opportunities. J Neurointerv Surg 2020; 12:831-835. [PMID: 32606103 PMCID: PMC7371488 DOI: 10.1136/neurintsurg-2020-016502] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 06/17/2020] [Accepted: 06/20/2020] [Indexed: 12/15/2022]
Abstract
To assess the impact of COVID-19 on neurovascular research and deal with the challenges imposed by the pandemic. METHODS A survey-based study focused on randomized controlled trials (RCTs) and single-arm studies for acute ischemic stroke and cerebral aneurysms was developed by a group of senior neurointerventionalists and sent to sites identified through the clinical trials website (https://clinicaltrials.gov/), study sponsors, and physician investigators. RESULTS The survey was sent to 101 institutions, with 65 responding (64%). Stroke RCTs were being conducted at 40 (62%) sites, aneurysm RCTs at 22 (34%) sites, stroke single-arm studies at 37 (57%) sites, and aneurysm single-arm studies at 43 (66%) sites. Following COVID-19, enrollment was suspended at 51 (78%) sites-completely at 21 (32%) and partially at 30 (46%) sites. Missed trial-related clinics and imaging follow-ups and protocol deviations were reported by 27 (42%), 24 (37%), and 27 (42%) sites, respectively. Negative reimbursements were reported at 17 (26%) sites. The majority of sites, 49 (75%), had put new trials on hold. Of the coordinators, 41 (63%) worked from home and 20 (31%) reported a personal financial impact. Remote consent was possible for some studies at 34 (52%) sites and for all studies at 5 (8%) sites. At sites with suspended trials (n=51), endovascular treatment without enrollment occurred at 31 (61%) sites for stroke and 23 (45%) sites for aneurysms. A total of 277 patients with acute ischemic stroke and 184 with cerebral aneurysms were treated without consideration for trial enrollment. CONCLUSION Widespread disruption of neuroendovascular trials occurred because of COVID-19. As sites resume clinical research, steps to mitigate similar challenges in the future should be considered.
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Affiliation(s)
- Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | | | - Kyle M Fargen
- Department of Neurological Surgery and Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Guilherme Dabus
- Department of Interventional Neuroradiology and Neuroendovascular Surgery, Miami Neuroscience Institute and Miami Cardiac & Vascular Institute - Baptist Hospital, Miami, Florida, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA
| | - Justin F Fraser
- Department of Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Rishi Gupta
- Department of Neurosurgery, WellStar Health System, Marietta, Georgia, USA
| | - Ricardo Hanel
- Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Albert J Yoo
- Department of Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | | | - David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
| | - J Mocco
- The Mount Sinai Health System, New York, New York, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Osama Zaidat
- Department of Neuroscience, St Vincent Mercy Hospital, Toledo, Ohio, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York, USA
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23
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Dabus G, Kan P, Diaz C, Pabon B, Andres-Mejia J, Linfante I, Grossberg JA, Howard BM, Islak C, Kocer N, Kizilkilic O, Puri AS, Kuhn AL, Moholkar V, Ortega-Gutierrez S, Samaniego EA, McDermott MW. Endovascular treatment of anterior cranial fossa dural arteriovenous fistula: a multicenter series. Neuroradiology 2020; 63:259-266. [PMID: 32840681 DOI: 10.1007/s00234-020-02536-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/20/2020] [Indexed: 11/26/2022]
Abstract
PURPOSE We report a multicenter experience using endovascular embolization as the first line approach for treatment of anterior cranial fossa (ACF) dural arteriovenous fistula (DAVF). METHODS All patients with DAVFs located in the anterior cranial fossa who were treated with endovascular technique as a first line approach were included. Demographics, clinical presentation, angioarchitecture, strategy, complications, immediate angiographic, and follow-up results were included in the analysis. RESULTS Twenty-three patients met the inclusion criteria (18 male and 5 female). Age ranged from 14 to 79 years (mean 53 years). Twelve patients presented with hemorrhage. Twenty-eight endovascular procedures were performed. The overall immediate angiographic cure rate after endovascular treatment was 82.6% (19/23 patients). The angiographic cure rate of the transvenous strategy was significantly superior to the transarterial strategy (p ≤ 0.001). There was 1 complication in 28 total procedures (3.6%). Angiographic follow-up was available in 21 out of the 23 patients with a mean of 25 months (range 2 to 108 months). In these 21 patients, the DAVF was completely cured in 20 (95%). At last follow-up, all patients had a modified Rankin scale (mRS) 0 to 2. CONCLUSION Our experience suggests that endovascular treatment for ACF DAVFs has an acceptable safety profile with high rates of complete occlusion, particularly with transvenous approach. Whenever possible, transvenous approach should be preferred over transarterial approach as first line strategy.
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Affiliation(s)
- Guilherme Dabus
- Division of Interventional Neuroradiology/NeuroEndovascular Surgery, Miami Neuroscience Institute - Baptist Hospital, Miami, FL, USA.
- Miami Cardiac & Vascular Institute, 8900 N. Kendall Drive, Miami, FL, 33176, USA.
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
| | - Carlos Diaz
- Interventional Neuroradiology at Incare, Universidad de Antioquia, Medellin, Colombia
| | - Boris Pabon
- Interventional Neuroradiology at Angioteam, Medellin, Colombia
| | | | - Italo Linfante
- Division of Interventional Neuroradiology/NeuroEndovascular Surgery, Miami Neuroscience Institute - Baptist Hospital, Miami, FL, USA
| | | | - Brian M Howard
- Department of Neurosurgery, Emory University, Atlanta, GA, USA
| | - Civan Islak
- Department of Neuroradiology, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Naci Kocer
- Department of Neuroradiology, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Osman Kizilkilic
- Department of Neuroradiology, Cerrahpaşa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts, Worcester, MA, USA
| | - Anna L Kuhn
- Department of Radiology, University of Massachusetts, Worcester, MA, USA
| | - Viraj Moholkar
- Department of Radiology, University of Massachusetts, Worcester, MA, USA
| | | | - Edgar A Samaniego
- Department of Neurology and Radiology, University of Iowa, Iowa City, IA, USA
| | - Michael W McDermott
- Division of Interventional Neuroradiology/NeuroEndovascular Surgery, Miami Neuroscience Institute - Baptist Hospital, Miami, FL, USA
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Linfante I, Andreone V, Ravelo N, Starosciak AK, Arif B, Shallwani H, Tze Man Kan P, McDermott MW, Dabus G. Endovascular Treatment of Giant Intracranial Aneurysms. Cureus 2020; 12:e8290. [PMID: 32601564 PMCID: PMC7317134 DOI: 10.7759/cureus.8290] [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: 12/01/2022] Open
Abstract
Objective Giant intracranial aneurysms (GIAs) are associated with a high risk of rupture and have a high mortality rate when they rupture (65-100%). The traditional microsurgical approach to secure these lesions is challenging, and as such endovascular embolization has been increasingly selected as a treatment option. Methods We performed a retrospective analysis of consecutive patients with ruptured and unruptured GIAs at three medical centers from October 2008 to April 2016. Clinical follow-up and digital subtraction angiography were conducted at six months post-treatment. Chi-square analysis was used to determine differences in outcomes between anterior and posterior circulation aneurysms and if a pipeline embolization device (PED) provided favorable outcomes in unruptured GIAs. Results A total of 45 consecutive patients (mean/median age = 57/59; range: 16-82 years) were included. The mean/median aneurysm size was 29.9/28.3 mm (range: 25-50 mm). Eight (18%) patients presented with aneurysmal subarachnoid hemorrhage and 37 (82%) with unruptured GIAs. Twenty-eight (62%) were treated with a PED: 11 (24.4%) with one PED, 1 (2.2%) with PED + coils, 11 (24.4%) with more than one PED, and 5 (13.5%) with multiple PED + coils. The overall mortality rate was 3/45 (6.7%). No deaths were procedure-related. Five (11.1%) patients experienced ischemic stroke but only 2 had a 90-day modified Rankin Scale (mRS) score of ≥3. Of 33 patients available for six-month angiography, Raymond scale (RS) scores were 1, 2, and 3 for 23/45 (70%), 7/45 (20.9%), and 3/45 (9.1%), respectively. Chi-square test demonstrated that overall, anterior circulation GIAs had better clinical (mRS score) and radiographic (RS score) outcomes than posterior GIAs. PED alone provided similar clinical mRS outcomes but had a higher rate of complete occlusion at six months compared with PED + coils and coils alone in unruptured GIAs (p < 0.05). Conclusions Endovascular embolization using PED or PED + coils appears to be a moderately safe and effective treatment option for patients with GIAs.
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Affiliation(s)
- Italo Linfante
- Neurology, Miami Cardiac & Vascular Institute/Miami Neuroscience Institute, Baptist Health South Florida, Miami, USA
| | | | - Natalia Ravelo
- Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Amy K Starosciak
- Neurology, Miami Neuroscience Institute, Baptist Health South Florida, Miami, USA
| | - Bilal Arif
- Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, USA
| | - Hussain Shallwani
- Neurosurgery, University at Buffalo - The State University of New York, Buffalo, USA
| | | | | | - Guilherme Dabus
- Radiology, Miami Cardiac & Vascular Institute/Miami Neuroscience Institute, Miami, USA
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Lal BK, Roubin GS, Rosenfield K, Heck D, Jones M, Jankowitz B, Jovin T, Chaturvedi S, Dabus G, White CJ, Gray W, Matsumura J, Katzen BT, Hopkins LN, Mayorga-Carlin M, Sorkin JD, Howard G, Meschia JF, Brott TG. Quality Assurance for Carotid Stenting in the CREST-2 Registry. J Am Coll Cardiol 2020; 74:3071-3079. [PMID: 31856962 DOI: 10.1016/j.jacc.2019.10.032] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/03/2019] [Accepted: 10/15/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND The CREST-2 Registry (C2R) was approved by National Institute of Neurological Disorders and Stroke-National Institutes of Health in September 2014 with Centers for Medicare & Medicaid Services, U.S. Food and Drug Administration, and industry collaboration to enroll patients undergoing CAS. The registry credentials interventionists and promotes optimal patient selection, procedural-technique, and outcomes. OBJECTIVES This study reports periprocedural outcomes in a cohort of carotid artery stenting (CAS) performed for asymptomatic and symptomatic carotid stenosis. METHODS Asymptomatic patients with ≥70% and symptomatic patients with ≥50% carotid stenosis, ≤80 years of age, and at standard or high risk for carotid endarterectomy are eligible for enrollment. Interventionists are credentialed by a multispecialty committee that reviews experience, lesion selection, technique, and outcomes. The primary endpoint was a composite of stroke and death (S/D) in the 30-day periprocedural period. Myocardial infarction and access-site complications were assessed as secondary outcomes. RESULTS As of December 2018, 187 interventionists from 98 sites in the United States performed 2,219 CAS procedures in 2,141 patients with primary atherosclerosis (78 were bilateral). The mean age of the cohort was 68 years, 65% were male, and 92% were white; 1,180 (55%) were for asymptomatic disease, and 961 (45%) were for symptomatic disease. All U.S. Food and Drug Administration-approved stents and embolic protection devices were represented. The 30-day rate of S/D was 1.4% for asymptomatic, 2.8% for symptomatic, and 2.0% for all patients. CONCLUSIONS C2R is the first national registry for CAS cosponsored by federal and industry partners. CAS was performed by experienced operators using appropriate patient selection and optimal technique. In that setting, a broad group of interventionists achieved very low periprocedural S/D rates for asymptomatic and symptomatic patients.
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Affiliation(s)
- Brajesh K Lal
- Department of Vascular Surgery, University of Maryland, Baltimore, Maryland.
| | - Gary S Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/Brookwood Baptist Medical Center, Birmingham, Alabama
| | - Kenneth Rosenfield
- Department of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Donald Heck
- Department of Radiology, Novant Health Clinical Research, Winston-Salem, North Carolina
| | - Michael Jones
- Department of Cardiology, Baptist Health Lexington, Lexington, Kentucky
| | - Brian Jankowitz
- Department of Neurosurgery, UPMC Presbyterian University Hospital, Pittsburgh, Pennsylvania
| | - Tudor Jovin
- Department of Neurology, UPMC Presbyterian University Hospital, Pittsburgh, Pennsylvania
| | | | - Guilherme Dabus
- Department of Interventional Neuroradiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, Florida
| | | | - William Gray
- Department of Cardiology, Lankenau Medical Center, Wynnewood, Pennsylvania
| | - Jon Matsumura
- Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Barry T Katzen
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute, Miami, Florida
| | | | | | - John D Sorkin
- Department of Biostatistics and Informatics, Baltimore VA Medical Center, Baltimore, Maryland
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Thomas G Brott
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
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Linfante I, Ravipati K, Starosciak AK, Reyes D, Dabus G. Intravenous cangrelor and oral ticagrelor as an alternative to clopidogrel in acute intervention. J Neurointerv Surg 2020; 13:30-32. [PMID: 32414891 DOI: 10.1136/neurintsurg-2020-015841] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 04/07/2020] [Accepted: 04/10/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Dual antiplatelet therapy (DAP) is necessary to prevent thromboembolic events during carotid stenting, stent-assisted coil embolization, and implant of flow diverters (FD). However, DAP in the acute phase may be challenging. An intravenous alternative, cangrelor, has rapid onset, short plasma half-life, and more reliable antiplatelet action for acute interventions. The study objective was to evaluate feasibility and safety of IV cangrelor during acute neuroendovascular surgery procedures. METHODS We performed a retrospective analysis of our database of patients treated with stent-assisted coil embolization, FD placement for aneurysmal subarachnoid hemorrhage (aSAH), or stenting for acute internal carotid artery (ICA) occlusion where IV cangrelor was used. Morbidity, mortality, incidence of thromboembolic events, hemorrhages, and 90-day outcomes were reported. RESULTS Ten patients were found in our database from June 2018 through January 2019. Four patients had aSAH, four had middle cerebral artery strokes with tandem lesions, one had an ICA occlusion, and one had a vertebral artery aneurysm. One of the ten patients experienced a thrombotic event. One patient developed new post-procedural bleeding and two had worsening intracranial hemorrhage. Five patients were discharged home in stable condition, two to acute rehabilitation, one to a nursing facility, and two others expired (likely the result of the severe and evolving strokes). Of the eight who were discharged, six (75%) had a good 90-day functional outcome (modified Rankin Scale 0-2). CONCLUSION Acute administration of IV cangrelor with or without oral ticagrelor is a feasible antiplatelet treatment option for acute neuroendovascular procedures.
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Affiliation(s)
- Italo Linfante
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, USA .,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Kaushik Ravipati
- Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, Florida, USA
| | - Amy Kathryn Starosciak
- Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA.,Translational Medicine, Florida International University Herbert Wertheim College of Medicine, Miami, Florida, USA
| | - Dennys Reyes
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, USA.,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
| | - Guilherme Dabus
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida, USA.,Miami Neuroscience Institute, Baptist Health South Florida, Miami, Florida, USA
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27
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Roa JA, Maud A, Jabbour P, Dabus G, Pazour A, Dandapat S, Ortega-Gutierrez S, Paez-Granda D, Kalousek V, Hasan DM, Samaniego EA. Transcirculation Approach for Mechanical Thrombectomy in Acute Ischemic Stroke: A Multicenter Study and Review of the Literature. Front Neurol 2020; 11:347. [PMID: 32457691 PMCID: PMC7221059 DOI: 10.3389/fneur.2020.00347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/08/2020] [Indexed: 12/03/2022] Open
Abstract
Background: Transcirculation approaches, which consist of primary catheterization of a target artery from the contralateral side or opposite cerebral circulation, provide alternate endovascular routes when anterograde interventions are not feasible. We aimed to assess the safety and efficacy of mechanical thrombectomy (MT) through a transcirculation route. Methods: Six centers provided retrospective data on acute ischemic stroke (AIS) patients who underwent MT via transcirculation approaches. Demographics and technical details of the endovascular intervention were collected. Recanalization rates, peri-procedural complications and clinical/angiographic outcomes immediately after the procedure and at last available follow-up were assessed. A review of the literature reporting on AIS patients whom underwent transcirculation MT was also performed. Results: Our multicenter study included 14 AIS patients treated through transcirculation routes. Mean age was 57.8 ± 11.9 years, and 10 (71.4%) were men. Mean NIHSS at admission was 18.4 (range 8–27). TICI 2b-3 recanalization was achieved in 10/14 (71.4%) patients. Three patients died after intervention: one due to late recanalization, one due to acute in-stent thrombosis, and one due to a procedure-related thromboembolic brainstem infarct. Of 11 surviving patients with follow-up available (mean 9.7 months), mRS 0–2 was achieved in 6 (54.5%) cases. Our review of the literature pooled a total of 37 transcirculation MT cases. Most common occlusions were tandem lesions (ICA + MCA = 64.9%) and BA + bilateral VA (18.9%). ACOM and PCOM were crossed in 18 (48.6%) cases each; one patient required a combined ACOM-PCOM approach. Primary recanalization technique included intra-arterial (IA) thrombolytics alone in 10 (27%), angioplasty ± stenting in 6 (16.2%), stent-retriever in 8 (21.6%), contact aspiration in 6, and combined (MT ± IA-thrombolytics) in 6 cases. Twenty-eight (75.7%) AIS patients achieved successful TIMI 2-3/TICI 2b-3 recanalization. After a mean follow-up of 6.7 months, 23/31 (74.2%) patients achieved a favorable functional outcome. Conclusions: Transcirculation approaches may be used to access the target lesion when the parent artery cannot be crossed through conventional antegrade routes. These techniques are feasible but should be reserved as a bailout maneuver when anterograde MT is not possible. Newer endovascular devices have improved neurological and angiographic outcomes in transcirculation cases.
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Affiliation(s)
- Jorge A Roa
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia, PA, United States
| | - Guilherme Dabus
- Department of Radiology, Miami Cardiac and Vascular Institute, Miami, FL, United States
| | - Avery Pazour
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Santiago Ortega-Gutierrez
- Departments of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Diego Paez-Granda
- Department of Radiology, Virgen de la Arrixaca University Hospital, Murcia, Spain
| | - Vladimir Kalousek
- Department of Neurology, University Clinical Hospital Center "Sestre Milosrdnice", Zagreb, Croatia
| | - David M Hasan
- Departments of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
| | - Edgar A Samaniego
- Departments of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, United States
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28
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Fraser JF, Arthur AS, Chen M, Levitt M, Mocco J, Albuquerque FC, Ansari SA, Dabus G, Jayaraman MV, Mack WJ, Milburn J, Mokin M, Narayanan S, Puri AS, Siddiqui AH, Tsai JP, Klucznik RP. Society of NeuroInterventional Surgery recommendations for the care of emergent neurointerventional patients in the setting of COVID-19. J Neurointerv Surg 2020; 12:539-541. [DOI: 10.1136/neurintsurg-2020-016098] [Citation(s) in RCA: 79] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 11/03/2022]
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Brasiliense LBC, Aguilar-Salinas P, Lopes DK, Nogueira D, DeSousa K, Nelson PK, Moran CJ, Mazur MD, Taussky P, Park MS, Dabus G, Linfante I, Chaudry I, Turner RD, Spiotta AM, Turk AS, Siddiqui AH, Levy EI, Hopkins LN, Arthur AS, Nickele C, Gonsales D, Sauvageau E, Hanel RA. Multicenter Study of Pipeline Flex for Intracranial Aneurysms. Neurosurgery 2020; 84:E402-E409. [PMID: 30239959 DOI: 10.1093/neuros/nyy422] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 09/11/2017] [Accepted: 08/10/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The Pipeline Flex (PED Flex; Medtronic, Dublin, Ireland) was designed to facilitate deployment and navigation compared to its previous iteration to reduce the rate of technical events and complications. OBJECTIVE To assess the neurological morbidity and mortality rates of the PED Flex at 30 d. METHODS Information from 9 neurovascular centers was retrospectively obtained between July 2014 and March 2016. Data included patient/aneurysm characteristics, periprocedural events, clinical, and angiographic outcomes. Multivariate logistic regression was performed to determine predictors of unfavorable clinical outcome (modified Rankin Scale [mRS] > 2). RESULTS A total of 205 patients harboring 223 aneurysms were analyzed. The 30-d neurological morbidity and mortality rates were 1.9% (4/205) and 0.5% (1/205), respectively. The rate of intraprocedural events without neurological morbidity was 6.8% (14/205), consisting of intraprocedural ischemic events in 9 patients (4.5%) and hemorrhage in 5 (2.4%). Other technical events included difficulty capturing the delivery wire in 1 case (0.5%) and device migration after deployment in another case (0.5%). Favorable clinical outcome (mRS 0-2) was achieved in 186 patients (94.4%) at discharge and in 140 patients (94.5%) at 30 d. We did not find predictors of clinical outcomes on multivariate analysis. CONCLUSION The 30-d rates of neurological morbidity and mortality in this multicenter cohort using the PED Flex for the treatment of intracranial aneurysms were low, 1.9% (4/205) and 0.5% (1/205), respectively. In addition, technical events related to device deployment were also low, most likely due to the latest modifications in the delivery system.
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Affiliation(s)
| | - Pedro Aguilar-Salinas
- Baptist Neurological Institute, Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida
| | - Demetrius K Lopes
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Danilo Nogueira
- Department of Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | - Keith DeSousa
- Department of Radiology and Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Peter K Nelson
- Department of Radiology and Neurosurgery, NYU Langone Medical Center, New York, New York
| | - Christopher J Moran
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Marcus D Mazur
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Philipp Taussky
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Min S Park
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Guilherme Dabus
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Italo Linfante
- Miami Cardiac & Vascular Institute, Baptist Health South Florida, Miami, Florida
| | - Imran Chaudry
- Department of Neurosurgery and Radiology, MUSC, Charleston, South Carolina
| | - Ray D Turner
- Department of Neurosurgery and Radiology, MUSC, Charleston, South Carolina
| | - Alex M Spiotta
- Department of Neurosurgery and Radiology, MUSC, Charleston, South Carolina
| | - Aquilla S Turk
- Department of Neurosurgery and Radiology, MUSC, Charleston, South Carolina
| | - Adnan H Siddiqui
- Department of Neurosurgery and Toshiba Stroke Research Center, University at Buffalo, Buffalo, New York
| | - Elad I Levy
- Department of Neurosurgery and Toshiba Stroke Research Center, University at Buffalo, Buffalo, New York
| | - L Nelson Hopkins
- Department of Neurosurgery and Toshiba Stroke Research Center, University at Buffalo, Buffalo, New York
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Christopher Nickele
- Department of Neurosurgery, University of Tennessee Health Sciences Center, Memphis, Tennessee
| | - Douglas Gonsales
- Baptist Neurological Institute, Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida
| | - Eric Sauvageau
- Baptist Neurological Institute, Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida
| | - Ricardo A Hanel
- Baptist Neurological Institute, Lyerly Neurosurgery, Baptist Health, Jacksonville, Florida
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30
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Fargen KM, Ansari SA, Spiotta A, Dabus G, Mokin M, Brown P, Wolfe SQ, Kittel C, Kan P, Baxter BW, De Leacy R, Milburn J, Munich SA, Ducruet AF, Reeves A, Fraser JF, Starke RM, Jadhav AP, Mack WJ, Arthur AS, Pride L, Sheth SA, Rai AT, Leslie-Mazwi T, Hirsch JA. Influence of thrombectomy volume on non-physician staff burnout and attrition in neurointerventional teams. J Neurointerv Surg 2020; 12:1199-1204. [PMID: 32245843 DOI: 10.1136/neurintsurg-2020-015825] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 03/09/2020] [Accepted: 03/16/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Burnout takes a heavy toll on healthcare providers. We sought to assess the prevalence and risk factors for burnout among neurointerventional (NI) non-physician procedural staff (nurses and technologists) given increasing thrombectomy demands. METHODS A 41-question online survey containing questions including the Maslach Burnout Inventory-Human Services Survey for Medical Personnel was distributed to NI nurses and radiology technologists at 20 US endovascular capable stroke centers. RESULTS 244 responses were received (64% response rate). Median (IQR) composite scores for emotional exhaustion were 25 (15-35), depersonalization 6 (2-11), and personal accomplishment 39 (35-43). Fifty-one percent of respondents met established criteria for burnout. There was no significant relationship between hospital thrombectomy volume, call frequency, call cases covered, or length of commute. On multiple logistic regression analysis, feeling under-appreciated by hospital leadership (OR 4.1; P<0.001) and working with difficult/unpleasant physicians (OR 1.2; P=0.05) were strongly associated with burnout. At participating centers, nurse and technologist attrition was 25% over the previous year. Over 50% of respondents indicated they had strongly considered leaving their position over the last 2 years. CONCLUSIONS This survey of US NI non-physician procedural staff demonstrates a self-reported burnout prevalence of 51%. This was driven more by interaction with leadership and physician staff than by thrombectomy procedural volume and stroke call. Attrition among NI non-physician procedural staff is high.
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Affiliation(s)
- Kyle M Fargen
- Neurological Surgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Sameer A Ansari
- Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alejandro Spiotta
- Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascularl Surgery, Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Patrick Brown
- Radiology, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Carol Kittel
- Neurological Surgery, Winston Salem, North Carolina, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - James Milburn
- Radiology, Ochsner Medical System, New Orleans, Louisiana, USA
| | - Stephan A Munich
- Department of Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Alan Reeves
- Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Justin F Fraser
- Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
| | - Robert M Starke
- Department of Neurosurgery & Neuroradiology, University of Miami & Jackson Memorial Hospital, Miami, Florida, USA
| | | | - William J Mack
- Neurosurgery, University of Southern California, Los Angeles, California, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lee Pride
- Neuroradiology, UT Southwestern, Dallas, Texas, USA
| | - Sunil A Sheth
- Neurology, University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
| | | | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
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Mokin M, Primiani CT, Castonguay AC, Nogueira RG, Haussen DC, English JD, Satti SR, Chen J, Farid H, Borders C, Veznedaroglu E, Binning MJ, Puri A, Vora NA, Budzik RF, Dabus G, Linfante I, Janardhan V, Alshekhlee A, Abraham MG, Edgell R, Taqi MA, Khoury RE, Majjhoo AQ, Kabbani MR, Froehler MT, Finch I, Ansari SA, Novakovic R, Nguyen TN, Zaidat OO. First Pass Effect in Patients Treated With the Trevo Stent-Retriever: A TRACK Registry Study Analysis. Front Neurol 2020; 11:83. [PMID: 32132966 PMCID: PMC7040359 DOI: 10.3389/fneur.2020.00083] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 01/23/2020] [Indexed: 11/23/2022] Open
Abstract
Background and Objective: The first pass effect (FPE; achieving complete recanalization with a single thrombectomy device pass) has been shown to be associated with higher rates of good clinical outcomes in patients with acute ischemic stroke. Here, we investigate clinical and radiographic factors associated with FPE in a large U.S. post-marketing registry (TRACK, Trevo Stent-Retriever Acute Stroke). Methods: We analyzed the TRACK database (multicenter registry of 634 patients from 23 centers from March 2013 through August 2015), which 609 patients were included in the final analysis. FPE was defined as a single pass/use of device, TICI 2c/3 recanalization, and no use of rescue therapy. Analysis of individual patient data from TRACK were performed to analyze clinical and radiographic characteristics associated with FPE as well-compared clinical outcomes defined as modified Rankin Scale (mRS) score at 30 and 90 days from hospital discharge to the non-FPE group. Results: The rate of FPE in TRACK was 23% (140/609). There was no association between patient demographics and FPE, including age (p = 0.36), sex (p = 0.50), race (p = 0.50), location of occlusion (p = 0.26), baseline NIHSS (p = 0.62), or past medical history. There was no difference in the use of a balloon-guide catheter or general anesthesia (49 and 57% with FPE vs. 47 and 64%, p = 0.63 and p = 0.14, respectively). Clinical outcomes were significantly associated with FPE; 63 vs. 44% in non-FPE patients achieved mRS 0–2 at 90 days (p = 0.0004). Conclusion: Our study showed that achieving complete recanalization with a single thrombectomy pass using the Trevo device was highly beneficial. The most common clinical factors that are used to determine eligibility for endovascular therapy, such as NIHSS severity, location of occlusion or patient age were not predictive of the ability to achieve FPE.
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Affiliation(s)
- Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
| | - Christopher T Primiani
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, United States
| | | | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, GA, United States
| | - Joey D English
- Department of Neurology, California Pacific Medical Center, San Francisco, CA, United States
| | - Sudhakar R Satti
- Department of Neurointerventional Surgery, Christiana Care Health Center, Newark, DE, United States
| | - Jennifer Chen
- Department of Radiology, Sidney Kimmel Medical College, Philadelphia, PA, United States
| | - Hamed Farid
- Department of Neurointerventional Radiology, St. Jude Medical Center, Fullerton, CA, United States
| | - Candace Borders
- Department of Neurosurgery, Irvine School of Medicine, University of California, Irvine, Irvine, CA, United States
| | - Erol Veznedaroglu
- Department of Neurosurgery, Drexel Neurosciences Institute, Philadelphia, PA, United States
| | - Mandy J Binning
- Department of Neurosurgery, Drexel Neurosciences Institute, Philadelphia, PA, United States
| | - Ajit Puri
- Department of Radiology, University of Massachusetts Medical School, Worcester, MA, United States
| | - Nirav A Vora
- Department of Radiology, Riverside Radiology and Interventional Associates, Columbus, OH, United States
| | - Ron F Budzik
- Department of Radiology, Riverside Radiology and Interventional Associates, Columbus, OH, United States
| | - Guilherme Dabus
- Department of Neurointerventional Surgery, Baptist Cardiac and Vascular Institute, Miami, FL, United States
| | - Italo Linfante
- Department of Neurointerventional Surgery, Baptist Cardiac and Vascular Institute, Miami, FL, United States
| | - Vallabh Janardhan
- Comprehensive Stroke Program and Neurointerventional, Texas Stroke Institute, Plano, TX, United States
| | - Amer Alshekhlee
- Department of Vascular and Interventional Neurology, DePaul Stroke Center-SSM Neuroscience Institutes, St. Louis, MO, United States
| | - Michael G Abraham
- Neurology and Interventional Radiology, University of Kansas Medical Center, Kansas City, KS, United States
| | - Randall Edgell
- Department of Neurology, St. Louis University, St. Louis, MO, United States
| | - Muhammad Asif Taqi
- Department of Neurology and Neurosurgery, Los Robles Hospital and Medical Center, Thousand Oaks, CA, United States
| | - Ramy El Khoury
- Department of Neurology, Tulane University, New Orleans, LA, United States
| | - Aniel Q Majjhoo
- Department of Neurology, Wayne State School of Medicine, Detroit, MI, United States
| | - Mouhammed R Kabbani
- Department of Neurosurgery, Gundersen Health System, La Crosse, WI, United States
| | - Michael T Froehler
- Department of Neurology, Neurosurgery, and Radiology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ira Finch
- Interventional Radiology, John Muir Health, Walnut Creek, CA, United States
| | - Sameer A Ansari
- Department of Radiology, Neurology, and Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | - Roberta Novakovic
- Department of Radiology, Neurology, and Neurotherapeutics, UT Southwestern Medical Center, Dallas, TX, United States
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery, and Radiology, Boston Medical Center, Boston, MA, United States
| | - Osama O Zaidat
- Department of Endovascular Neurosurgery and Stroke, St. Vincent Mercy Medical Center, Toledo, OH, United States
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Pontes-Neto OM, Abud DG, Castro-Afonso L, Martins-Filho RK, Nakiri G, Montalverne FJ, Rebello L, Silva GS, Lima FO, Frudit M, de Souza AC, Fiorot JA, Faria M, Liebeskind D, Bezerra D, Dabus G, de Freitas GR, Wagner M, Broderick J, Molina C, Oliveira-Filho J, Nogueira R, Martins S. Abstract WP9: Impact of Sex Differences on the Treatment Effect of Mechanical Thrombectomy: A Subgroup Analysis of the RESILIENT Trial. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Despite evidence supporting the overall efficacy of mechanical thrombectomy (MT) in acute ischemic stroke (AIS) due to large vessel occlusion (LVO) of the anterior circulation, it is unclear whether the treatment effect of MT differs by sex in different populations. We assessed the impact of sex differences in the treatment effect of MT in the RESILIENT trial.
Methods:
RESILIENT was a prospective, multicenter, randomized phase III trial that was designed to assess the safety, efficacy, and cost-effectiveness of mechanical thrombectomy as compared to medical treatment alone in patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country.
Results:
Among 221 patients enrolled in the trial, 104 (47,1%) were female. Baseline characteristics were well balanced between sexes, except for a higher prevalence of hypertension (76% vs. 57.4%; p=0.004) and diabetes (34.3% vs. 21.7%; p=0.039) and a lower frequency of alcohol abuse (4% vs. 28.9%; p=0.001) in females. After adjustment for baseline characteristics, we found a significant interaction (p=0.026) between sex and the effect of MT with a lower efficacy of MT for functional independency at 90 days among women (aOR=1.13;95%CI:0.42-3.02) compared to men (aOR=4.78; 95%CI:1.88-12.15).
Conclusions:
In our study population of patients with AIS caused by LVO of the anterior circulation, women were less likely to benefit from MT than men. Further studies are necessary to investigate these findings.
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Affiliation(s)
| | | | | | | | | | | | | | - Gisele S Silva
- Neurology and Neurosurgery Dept, Federal Univ of Sao Paulo, Sao Paulo, Brazil
| | | | | | | | | | - Mario Faria
- Hosp de Clinicas de Porto Alegre, Porto Alegre, Brazil
| | | | | | - Guilherme Dabus
- Miami Cardiac and Vascular Institute and Baptist Neuroscience Cntr, Miami, FL
| | | | - Mario Wagner
- Federal Univ of Rio Grande do Sul, Porto ALegre, Brazil
| | | | | | | | - Raul Nogueira
- Dept of Neurology, Marcus Stroke & Neuroscience Cntr, Grady Memorial Hosp,, Atlanta, GA
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Roa JA, Ortega-Gutierrez S, Martinez-Galdamez M, Maud A, Dabus G, Pazour A, Dandapat S, Arteaga MS, Fernandez JG, Paez-Granda D, Kalousek V, Pons RB, Mowla A, Duckwiler G, Szeder V, Jabbour P, Hasan DM, Samaniego EA. Transcirculation Approach for Endovascular Embolization of Intracranial Aneurysms, Arteriovenous Malformations, and Dural Fistulas: A Multicenter Study. World Neurosurg 2020; 134:e1015-e1027. [DOI: 10.1016/j.wneu.2019.11.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 11/12/2019] [Accepted: 11/13/2019] [Indexed: 11/25/2022]
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Roa JA, Dabus G, Dandapat S, Hasan D, Samaniego EA. Ethmoidal dural arteriovenous fistulas: endovascular transvenous embolization technique. J Neurointerv Surg 2020; 12:610. [DOI: 10.1136/neurintsurg-2019-015691] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 01/07/2020] [Accepted: 01/09/2020] [Indexed: 11/03/2022]
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35
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Dabus G, Linfante I, McDermott MW. Angiography and embolization of meningiomas. Handb Clin Neurol 2020; 169:193-202. [PMID: 32553290 DOI: 10.1016/b978-0-12-804280-9.00013-5] [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] [Subscribe] [Scholar Register] [Indexed: 03/26/2023]
Abstract
The preoperative embolization of meningiomas has been part of the surgical treatment of large meningiomas for over 45 years. During that time there have been huge advances in the field of endovascular surgery with respect to techniques and instrumentation. Angiography and embolization are usually reserved for the largest tumors where there are concerns over potential blood loss with surgical excision. In this chapter, we discuss the technical aspects of angiography and embolization as well as results and complications.
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Affiliation(s)
- Guilherme Dabus
- Miami Neuroscience Institute, Baptist Health of South Florida, Miami, FL, United States; Miami Cardiac & Vascular Institute, Baptist Health of South Florida, Miami, FL, United States.
| | - Italo Linfante
- Miami Neuroscience Institute, Baptist Health of South Florida, Miami, FL, United States; Miami Cardiac & Vascular Institute, Baptist Health of South Florida, Miami, FL, United States
| | - Michael W McDermott
- Miami Neuroscience Institute, Baptist Health of South Florida, Miami, FL, United States; Division of Neuroscience, Herbert Wertheim College of Medicine, Florida International University, Miami, FL, United States
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36
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Starke RM, Snelling B, Al-Mufti F, Gandhi CD, Lee SK, Dabus G, Fraser JF. Transarterial and transvenous access for neurointerventional surgery: report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg 2019; 12:733-741. [PMID: 31818970 DOI: 10.1136/neurintsurg-2019-015573] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/07/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
The purpose of this publication is to provide a comprehensive review on the techniques and tools used for vascular access in neurointerventional procedures. Using published literature, we reviewed data on access methods, sites, tools, and techniques for neurointerventions. Recommendations are provided based on quality of data/levels of evidence and, where appropriate, expert consensus. While tools and techniques continue to be developed, current literature and experience supports certain principles regarding vascular access for neurointerventional procedures.
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Affiliation(s)
- Robert M Starke
- Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Brian Snelling
- Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Chirag D Gandhi
- Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Seon-Kyu Lee
- Radiology, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Justin F Fraser
- Neurological Surgery, University of Kentucky, Lexington, Kentucky, USA
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37
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Nogueira RG, Lima FO, Pontes-Neto OM, S Silva G, José Mont'Alverne F, Abud DG, Frudit M, Passos P, Haussen DC, Dabus G, de Freitas GR, Oliveira-Filho J, Bezerra DC, Liebeskind DS, Wagner MB, Passos JE, Molina CA, Broderick J, Saver JL, Martins SO. Randomization of endovascular treatment with stent-retriever and/or thromboaspiration versus best medical therapy in acute ischemic stroke due to large vessel occlusion trial: Rationale and design. Int J Stroke 2019; 16:100-109. [PMID: 31793395 DOI: 10.1177/1747493019890700] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND RESILIENT is a prospective, multicenter, randomized phase III trial to test the safety, efficacy, and cost-effectiveness of mechanical thrombectomy as compared to medical treatment alone in patients treated under the less than ideal conditions typically found in the public healthcare system of a developing country. METHODS Subjects must fulfill the following main inclusion criteria: symptom onset ≤8 h, age ≥18 years, baseline NIHSS ≥8, evidence of intracranial ICA or proximal MCA (M1 segment) occlusion, ASPECTS ≥6 on CT or >5 on DWI-MRI and be either ineligible for or unresponsive to intravenous alteplase. The primary end-point is the distribution of disability levels (on the modified Rankin Scale, mRS) at 90 days under the intention-to-treat principle. RANDOMIZATION Randomization is performed under a minimization process using age, baseline NIHSS, intravenous alteplase use, occlusion site and center. DESIGN The trial is designed with an expectation of a 10% difference in the proportion of favorable outcome (mRS 0-2 at 90 days) common odds ratio of 1.615. PRIMARY OUTCOME Projected sample size is 690 subjects with pre-planned interim analyses at 174, 346, and 518 subjects. SECONDARY OUTCOMES Secondary end-points include: 90-day functional independence (mRS ≤2), mRS shift stratified for treatment with IV rt-PA at 90 days, infarct volume on 24 h CT or MRI, early dramatic response (NIHSS 0-2 or improvement ≥8 points) at 24 h, vessel recanalization evaluated by CTA or MRA at 24 h, and the post-procedure rate of successful reperfusion (defined as a modified Treatment in Cerebral Infarction 2b or greater). Safety variables are mortality at 90 days, symptomatic intracranial hemorrhage at 24 h and procedure-related complications.
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Affiliation(s)
- Raul G Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Fabricio O Lima
- Neurology Service, 365090Hospital Geral de Fortaleza, Fortaleza-CE, Brazil.,Department of Neurology, 28128Universidade de Fortaleza, Fortaleza-CE, Brazil
| | - Octávio M Pontes-Neto
- Stroke Service-Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | - Gisele S Silva
- Neurology and Neurosurgery Department, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.,Academic Research Organization, 37896Hospital Israelita Albert Einstein São Paulo, São Paulo, Brazil
| | | | - Daniel G Abud
- Department of Internal Medicine, Radiology Division, Hospital das Clínicas-Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Michel Frudit
- Neurointerventional Radiology Service, Federal University of São Paulo, São Paulo, Brazil
| | - Paulo Passos
- 156417Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Diogo C Haussen
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, 12239Emory University School of Medicine, Atlanta, GA, USA
| | - Guilherme Dabus
- Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, FL, USA
| | - Gabriel R de Freitas
- 519983D'Or Institute for Research and Education, 28110Universidade Federal Fluminense, Rio de Janeiro, Brazil
| | - Jamary Oliveira-Filho
- Postgraduate Program in Health Sciences, 28111Federal University of Bahia School of Medicine, Salvador, BA, Brazil
| | - Daniel C Bezerra
- Department of Neurology, Hospital Pró-Cardíaco, Rio de Janeiro, Brazil
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, 8783University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Mario B Wagner
- School of Medicine, 28124Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - José Ef Passos
- Administrative Director of the National Council of Municipal Health Secretariats, Bauru, São Paulo
| | - Carlos A Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Autonomous University of Barcelona, Barcelona, Spain
| | - Joseph Broderick
- Department of Neurology and Rehabilitation Medicine, 12303University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, 8783University of California Los Angeles David Geffen School of Medicine, Los Angeles, CA, USA
| | - Sheila O Martins
- 156417Hospital Moinhos de Vento, Porto Alegre, Brazil.,Neurology Service, Hospital de Clínicas de Porto Alegre, 28124Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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38
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De Macedo Rodrigues K, Kühn AL, Tamura T, Dabus G, Kan P, Marosfoi MG, Lozano JD, Perras M, Brooks C, Howk MC, Hou SY, Rex DE, Massari F, Gounis MJ, Wakhloo AK, Puri AS. Pipeline Embolization Device for Pericallosal Artery Aneurysms: A Retrospective Single Center Safety and Efficacy Study. Oper Neurosurg (Hagerstown) 2019; 14:351-358. [PMID: 28521024 DOI: 10.1093/ons/opx111] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 04/11/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Pericallosal artery aneurysm treatment may be challenging using traditional endovascular techniques. OBJECTIVE To demonstrate the feasibility, efficacy, and safety of endovascular treatment of pericallosal artery aneurysm using flow diverters. METHODS We performed a retrospective review of our institutional database from July 2013 through July 2016 and identified 7 subjects with a pericallosal artery aneurysm treated with the Pipeline embolization device (ev3 Neurovascular, Medtronic, Dublin, Ireland) and at least 1 follow-up angiogram. Technical feasibility, procedural complication, angiographic results, and clinical outcome were evaluated. RESULTS Placement of the Pipeline embolization device was successful in all cases without evidence of procedural complication. Five out of 7 subjects showed a complete aneurysm occlusion at 6- to 12-mo follow-up angiogram. The 2 subjects with persistent aneurysm filling showed decreased aneurysm sac volume on follow-up angiograms (96% and 60%). There was no evidence of in-implant stenosis or intimal hyperplasia. No thromboembolic or hemorrhagic complications were seen during the follow-up period. Only 1 patient had a transient change in Modified Rankin scale score from baseline as a result of different unrelated procedure. CONCLUSION Our preliminary results demonstrate feasibility of the use of flow diverter stent for treatment of aneurysms of the pericallosal artery with rate of aneurysm occlusion comparable to literature and without evidence of increased procedural or short-term morbidity. A long-term and larger cohort study is needed to validate our findings.
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Affiliation(s)
- Katyucia De Macedo Rodrigues
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Anna Luisa Kühn
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Takamitsu Tamura
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | | | - Peter Kan
- Depa-rtment of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Miklos G Marosfoi
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - J Diego Lozano
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Mary Perras
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Christopher Brooks
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Mary C Howk
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Samuel Y Hou
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - David E Rex
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Francesco Massari
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Matthew J Gounis
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Ajay K Wakhloo
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Ajit S Puri
- Division of Neuroimaging and Interve-ntion and New England Center for Stroke Research, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
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Lal BK, Meschia JF, Roubin GS, Jankowitz B, Heck D, Jovin T, White CJ, Rosenfield K, Katzen B, Dabus G, Gray W, Matsumura J, Hopkins LN, Luke S, Sharma J, Voeks JH, Howard G, Brott TG. Factors influencing credentialing of interventionists in the CREST-2 trial. J Vasc Surg 2019; 71:854-861. [PMID: 31353274 DOI: 10.1016/j.jvs.2019.05.035] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/01/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial (CREST-2) is a pair of randomized trials assessing the relative efficacy of carotid revascularization in the setting of intensive medical management (IMM) in patients with asymptomatic high-grade atherosclerotic stenosis. One of the trials assesses IMM with or without carotid artery stenting (CAS). Given the low risk of stroke in nonrevascularized patients receiving IMM, it is essential that there be low periprocedural risk of stroke for CAS if it is to show incremental benefit. Thus, credentialing of interventionists to ensure excellence is vital. This analysis describes the protocol-driven approach to credentialing of CAS interventionists for CREST-2 and its outcomes. METHODS To be eligible to perform stenting in CREST-2, interventionists needed to be credentialed on the basis of a detailed Interventional Management Committee (IMC) review of data from their last 25 consecutive cases during the past 24 months along with self-reported lifetime experience case numbers. When necessary, additional prospective cases performed in a companion registry were requested after webinar training. Here we review the IMC experience from the first formal meeting on March 21, 2014 through October 14, 2017. RESULTS The IMC had 102 meetings, and 8311 cases submitted by 334 interventionists were evaluated. Most were either cardiologists or vascular surgeons, although no single specialty made up the majority of applicants. The median total experience was 130 cases (interquartile range [IQR], 75-266; range, 25-2500). Only 9% (30/334) of interventionists were approved at initial review; approval increased to 46% (153/334) after submission of new cases with added training and re-review. The median self-reported lifetime case experience for those approved was 211.5 (IQR, 100-350), and the median number of cases submitted for review was 30 (IQR, 27-35). The number of CAS procedures performed per month (case rate) was the only factor associated with approval during the initial cycle of review (P < .00001). CONCLUSIONS Identification of interventionists who were deemed sufficiently skilled for CREST-2 has required substantial oversight and a controlled system to judge current skill level that controls for specialty-based practice variability, procedural experience, and periprocedural outcomes. High-volume interventionists, particularly those with more recent experience, were more likely to be approved to participate in CREST-2. Primary approval was not affected by operator specialty.
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Affiliation(s)
- Brajesh K Lal
- Department of Surgery, University of Maryland, Baltimore, Md.
| | | | - Gary S Roubin
- Department of Cardiology, Cardiovascular Associates of the Southeast/Brookwood, Baptist Medical Center, Birmingham, Ala
| | - Brian Jankowitz
- Department of Neurosurgery, UPMC Presbyterian University Hospital, Pittsburgh, Pa
| | - Donald Heck
- Department of Radiology, Novant Health Clinical Research, Winston-Salem, NC
| | - Tudor Jovin
- Department of Neurology, UPMC Presbyterian University Hospital, Pittsburgh, Pa
| | | | | | - Barry Katzen
- Department of Interventional Radiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, Fla
| | - Guilherme Dabus
- Department of Interventional Neuroradiology, Miami Cardiac and Vascular Institute at Baptist Hospital of Miami, Miami, Fla
| | - William Gray
- Department of Cardiology, Lankenau Medical Center, Wynnewood, Pa
| | - Jon Matsumura
- Department of Surgery, University of Wisconsin Hospital and Clinics, Madison, Wisc
| | | | - Sothear Luke
- Department of Neurology, Mayo Clinic, Jacksonville, Fla
| | - Jashank Sharma
- Department of Surgery, University of Maryland, Baltimore, Md
| | - Jenifer H Voeks
- Department of Neurology, Medical University of South Carolina, Charleston, SC
| | - George Howard
- Department of Biostatistics, University of Alabama at Birmingham, Birmingham, Ala
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Martínez-Galdámez M, Orlov K, Kadziolka K, Puthuran M, Kalousek V, Pabón B, Escartín J, Rodríguez C, Chandran A, Kislitsin D, Berestov V, Vega P, Diaz C, Dabus G. Safety and efficacy of intracranial aneurysm embolization using the “combined remodeling technique”: low-profile stents delivered through double lumen balloons: a multicenter experience. Neuroradiology 2019; 61:1067-1072. [DOI: 10.1007/s00234-019-02240-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Accepted: 06/04/2019] [Indexed: 12/22/2022]
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Fargen KM, Arthur AS, Leslie-Mazwi T, Garner RM, Aschenbrenner CA, Wolfe SQ, Ansari SA, Dabus G, Spiotta A, Mokin M, Linfante I, Mocco J, Hirsch JA. A survey of burnout and professional satisfaction among United States neurointerventionalists. J Neurointerv Surg 2019; 11:1100-1104. [PMID: 30975735 DOI: 10.1136/neurintsurg-2019-014833] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [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: 02/12/2019] [Revised: 03/11/2019] [Accepted: 03/14/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND The toll of burnout on healthcare is significant and associated with physician depression and medical errors. OBJECTIVE To assess the prevalence and risk factors for burnout among neurointerventionalists. METHODS A 39-question online survey containing questions about neurointerventional practice and the Maslach Burnout Inventory-Human Services Survey for medical personnel was distributed to members of major US neurointerventional physician societies. RESULTS 320 responses were received. Median (interquartile range) composite scores for emotional exhaustion were 25 (16-35), depersonalization 7 (4-12), and personal accomplishment 39 (35-44). 164/293 respondents (56%) met established criteria for burnout. There was no significant relationship between training background, practice setting, call frequency, or presence of a senior partner on burnout prevalence. Multiple logistic regression analysis showed that feeling underappreciated by hospital leadership (OR=3.71; p<0.001) and covering more than one hospital on call (OR=1.96; p=0.01) were strongly associated with burnout. Receiving additional compensation for a call was independently protective against burnout (OR= 0.70; p=0.005). CONCLUSIONS This survey of United States neurointerventional physicians demonstrated a self-reported burnout prevalence of 56%, which is similar to the national average among physicians across other specialties. Additional compensation for a call was a significant protective factor against burnout. In addition, feeling underappreciated by departmental or hospital leadership and covering more than one hospital while on call were associated with greater odds of burnout.
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Affiliation(s)
- Kyle M Fargen
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam S Arthur
- UT Department of Neurosurgery/Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | | | - Rebecca M Garner
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Carol A Aschenbrenner
- Biostatistics, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Sameer A Ansari
- Radiology, Neurology, and Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Guilherme Dabus
- Interventional Neuroradiology and Neuroendovascular Surgery, Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Alejandro Spiotta
- Neurosciences, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Italo Linfante
- Baptist Cardiac and Vascular Institute, Miami, Florida, USA
| | - J Mocco
- The Mount Sinai Health System, New York, New York, USA
| | - Joshua A Hirsch
- Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Zaidi SF, Castonguay AC, Jumaa MA, Malisch TW, Linfante I, Marden FA, Abraham MG, Chebl AB, Novakovic R, Taqi MA, Nogueira RG, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Dabus G, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Yoo AJ, Shaltoni H, Janardhan V, Chen PR, Britz GW, Kaushal R, Nanda A, Gupta R, Zaidat OO. Intraarterial Thrombolysis as Rescue Therapy for Large Vessel Occlusions. Stroke 2019; 50:1003-1006. [DOI: 10.1161/strokeaha.118.024442] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Mechanical thrombectomy (MT) devices have led to improved reperfusion and clinical outcomes in acute ischemic stroke patients with emergent large vessel occlusions; however, less than one-third of patients achieve complete reperfusion. Use of intraarterial thrombolysis in the context of MT may provide an opportunity to enhance these results. Here, we evaluate the use of intraarterial rtPA (recombinant tissue-type plasminogen activator) as rescue therapy (RT) after failed MT in the North American Solitaire Stent-Retriever Acute Stroke registry.
Methods—
The North American Solitaire Stent-Retriever Acute Stroke registry recruited sites within North America to submit data on acute ischemic stroke patients treated with the Solitaire device. After restricting the population of 354 patients to use of RT and anterior emergent large vessel occlusions, we compared patients who were treated with and without intraarterial rtPA after failed MT.
Results—
A total of 37 and 44 patients was in the intraarterial rtPA RT and the no intraarterial rtPA RT groups, respectively. Revascularization success (modified Thrombolysis in Cerebral Infarction ≥2b) was achieved in more intraarterial rtPA RT patients (61.2% versus 46.6%;
P
=0.13) with faster times to recanalization (100±85 versus 164±235 minutes;
P
=0.36) but was not statistically significant. The rate of symptomatic intracranial hemorrhage (13.9% versus 6.8%;
P
=0.29) and mortality (42.9% versus 44.7%;
P
=0.87) were similar between the groups. Good functional outcome (modified Rankin Scale score of ≤2) was numerically higher in intraarterial rtPA patients (22.9% versus 18.4%;
P
=0.64). Further restriction of the RT population to M1 occlusions only and time of onset to groin puncture ≤8 hours, resulted in significantly higher successful revascularization rates in the intraarterial rtPA RT cohort (77.8% versus 38.9%;
P
=0.02).
Conclusions—
Intraarterial rtPA as RT demonstrated a similar safety and clinical outcome profile, with higher reperfusion rates achieved in patients with M1 occlusions. Prospective studies are needed to delineate the role of intraarterial thrombolysis in MT.
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Affiliation(s)
- Syed F. Zaidi
- From the University of Toledo Health Science Campus, OH (S.F.Z., A.C.C., M.A.J.)
| | - Alicia C. Castonguay
- From the University of Toledo Health Science Campus, OH (S.F.Z., A.C.C., M.A.J.)
| | - Mouhammad A. Jumaa
- From the University of Toledo Health Science Campus, OH (S.F.Z., A.C.C., M.A.J.)
| | - Tim W. Malisch
- AMITA Alexian Brothers, Elk Grove Village, IL (T.W.M., F.A.M.)
| | - Italo Linfante
- Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.)
| | | | | | | | | | - M. Asif Taqi
- Los Robles Medical Center, Thousand Oaks, CA (M.A.T.)
| | | | | | | | | | | | - Guilherme Dabus
- Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.)
| | | | | | - Ansaar T. Rai
- West Virginia University Medicine, Morgantown (A.T.R.)
| | | | | | | | | | | | | | - Peng R. Chen
- University of Texas Medical School at Houston (P.R.C.)
| | | | | | | | - Rishi Gupta
- Wellstar Health Systems, Marietta, GA (R.G.)
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Nguyen TN, Castonguay AC, Nogueira RG, Haussen DC, English JD, Satti SR, Chen J, Farid H, Borders C, Veznedaroglu E, Binning MJ, Puri AS, Vora NA, Budzik RF, Dabus G, Linfante I, Janardhan V, Alshekhlee A, Abraham MG, Edgell RC, Taqi MA, El Khoury R, Mokin M, Majjhoo AQ, Kabbani MR, Froehler MT, Finch I, Ansari SA, Novakovic R, Abdalkader M, Zaidat OO. Effect of balloon guide catheter on clinical outcomes and reperfusion in Trevo thrombectomy. J Neurointerv Surg 2019; 11:861-865. [DOI: 10.1136/neurintsurg-2018-014452] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 12/19/2018] [Accepted: 12/26/2018] [Indexed: 11/03/2022]
Abstract
IntroductionThe Solitaire stent retriever registry showed improved reperfusion, faster procedure times, and better outcome in acute stroke patients with large vessel occlusion treated with a balloon guide catheter (BGC) and Solitaire stent retriever compared with a conventional guide catheter. The goal of this study was to evaluate whether use of a BGC with the Trevo stent retriever improves outcomes compared with a conventional guide catheter.MethodsThe TRACK registry recruited 23 sites to submit demographic, clinical, and site adjudicated angiographic and outcome data on consecutive patients treated with the Trevo stent retriever. BGC use was at the discretion of the physician.Results536 anterior circulation patients (of whom 279 (52.1%) had BGC placement) were included in this analysis. Baseline characteristics were notable for younger patients in the BGC group (65.4±15.3 vs 68.1±13.6, P=0.03) and lower rate of hypertension (72% vs 79%, P=0.06). Mean time from symptom onset to groin puncture was longer in the BGC group (357 vs 319 min, P=0.06).Thrombolysis in Cerebral Infarction 2b/3 scores were higher in the BGC cohort (84% vs 75.5%, P=0.01). There was no difference in reperfusion time, first pass effect, number of passes, or rescue therapy. Good clinical outcome at 3 months was superior in patients with BGC (57% vs 40%; P=0.0004) with a lower mortality rate (13% vs 23%, P=0.008). Multivariate analysis demonstrated that BGC use was an independent predictor of good clinical outcome (OR 2; 95% CI 1.3 to 3.1, P=0.001).ConclusionsIn acute stroke patients presenting with anterior circulation large vessel occlusion, use of a BGC with the Trevo stent retriever resulted in improved reperfusion, improved clinical outcome, and lower mortality.
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Zaidat OO, Castonguay AC, Gupta R, Sun CHJ, Martin C, Holloway WE, Mueller-Kronast N, English JD, Linfante I, Dabus G, Malisch TW, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Taqi MA, Abraham MG, Janardhan V, Shaltoni H, Novakovic R, Yoo AJ, Abou-Chebl A, Chen PR, Britz GW, Kaushal R, Nanda A, Issa MA, Nogueira RG. North American Solitaire Stent Retriever Acute Stroke registry: post-marketing revascularization and clinical outcome results. J Neurointerv Surg 2018; 10:i45-i49. [DOI: 10.1136/neurintsurg-2013-010895.rep] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2013] [Revised: 08/19/2013] [Accepted: 08/26/2013] [Indexed: 11/04/2022]
Abstract
BackgroundLimited post-marketing data exist on the use of the Solitaire FR device in clinical practice. The North American Solitaire Stent Retriever Acute Stroke (NASA) registry aimed to assess the real world performance of the Solitaire FR device in contrast with the results from the SWIFT (Solitaire with the Intention for Thrombectomy) and TREVO 2 (Trevo versus Merci retrievers for thrombectomy revascularization of large vessel occlusions in acute ischemic stroke) trials.MethodsThe investigator initiated NASA registry recruited North American sites to submit retrospective angiographic and clinical outcome data on consecutive acute ischemic stroke (AIS) patients treated with the Solitaire FR between March 2012 and February 2013. The primary outcome was a Thrombolysis in Myocardial Ischemia (TIMI) score of ≥2 or a Treatment in Cerebral Infarction (TICI) score of ≥2a. Secondary outcomes were 90 day modified Rankin Scale (mRS) score, mortality, and symptomatic intracranial hemorrhage.Results354 patients underwent treatment for AIS using the Solitaire FR device in 24 centers. Mean time from onset to groin puncture was 363.4±239 min, mean fluoroscopy time was 32.9±25.7 min, and mean procedure time was 100.9±57.8 min. Recanalization outcome: TIMI ≥2 rate of 83.3% (315/354) and TICI ≥2a rate of 87.5% (310/354) compared with the operator reported TIMI ≥2 rate of 83% in SWIFT and TICI ≥2a rate of 85% in TREVO 2. Clinical outcome: 42% (132/315) of NASA patients demonstrated a 90 day mRS ≤2 compared with 37% (SWIFT) and 40% (TREVO 2). 90 day mortality was 30.2% (95/315) versus 17.2% (SWIFT) and 29% (TREVO 2).ConclusionsThe NASA registry demonstrated that the Solitaire FR device performance in clinical practice is comparable with the SWIFT and TREVO 2 trial results.
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Reyes D, Becerra V, Alcala I, Linfante I, Dabus G. Usefulness of Cone Beam Intra-Arterial CTA for Evaluation of Flow Diverters: A Practical Approach for Daily Use. Interv Neurol 2018; 7:457-463. [PMID: 30410525 DOI: 10.1159/000490577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 06/02/2018] [Indexed: 11/19/2022]
Abstract
Cone beam computed tomography (CBCT), initially used for evaluation of intraprocedural complications such as hemorrhage, has evolved to provide details of implanted devices such as flow diverters. The study aim is to present our experience in using CBCT with intra-arterial injection and provide a step-by-step approach for postprocessing in a practical protocol for daily use. IRB approval was obtained, and the neurointerventional database was retrospectively reviewed from July 2012 to June 2017. Patients who underwent cone beam intra-arterial CT angiography for evaluation of implanted flow diverter devices were reviewed. Patient demographics, aneurysm location (internal carotid artery [ICA]-cavernous, ICA-paraclinoid, and ICA-distal; middle cerebral artery [MCA], anterior cerebral artery [ACA]-acom, ACA-pericallosal, vertebral artery [VA]), type (saccular, dissecting fusiform, or blister) and size, device, injection technique (contrast dilution, rate, and volume), and reconstruction protocol were recorded. Acquired images were postprocessed using a Philips Xtravision workstation. Eighty patients (63 women and 17 men) met the inclusion criteria of our study. Age range was 25-80 years old. Treated aneurysms were located in the ICA-paraclinoid in 48 cases (60%), ICA-distal in 12 cases, ICA-cavernous in 8 cases, MCA in 4 cases, VA in 4 cases, ACA-acom in 2 cases, ACA-pericallosal in 2 cases; 69 were saccular, 8 fusiform, and 3 ruptured blister aneurysms. There were 52 small, 20 large, and 8 giant aneurysms. Pipeline (Medtronic, MN, USA) was the predominant device used in 77 procedures. Two injection techniques were used: 2.5 mL/s for a total volume of 55 mL with a 2-s imaging delay or 3 mL/s for a total volume of 70 mL with a 3-s imaging delay; contrast (Ioxilan 300 mgI/mL) dilution was 10-20% in all cases. The device's landing zones, conformability, presence of deformities, and wall apposition were successfully visualized in all cases. Metal artifact reduction program was applied in 9 coiled aneurysms, and this was satisfactory as well.
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Affiliation(s)
- Dennys Reyes
- Division of Neurointerventional Surgery, Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Victor Becerra
- Division of Neurointerventional Surgery, Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Indiana Alcala
- Division of Neurointerventional Surgery, Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Italo Linfante
- Division of Neurointerventional Surgery, Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Guilherme Dabus
- Division of Neurointerventional Surgery, Miami Cardiac & Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
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Fifi JT, Dabus G, Mack WJ, Mocco J, Pride L, Arthur AS, Albuquerque FC. In the thrombectomy era, triage in the field improves care. J Neurointerv Surg 2018; 10:607-608. [DOI: 10.1136/neurintsurg-2018-014136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2018] [Indexed: 11/04/2022]
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Zaidat OO, Bozorgchami H, Ribó M, Saver JL, Mattle HP, Chapot R, Narata AP, Francois O, Jadhav AP, Grossberg JA, Riedel CH, Tomasello A, Clark WM, Nordmeyer H, Lin E, Nogueira RG, Yoo AJ, Jovin TG, Siddiqui AH, Bernard T, Claffey M, Andersson T, Ribo M, Hetts S, Hacke W, Mehta B, Hacein-Bey L, Kim A, Abou-Chebl A, Shabe P, Hetts S, Hacein-Bey L, Kim A, Abou-Chebl A, Dix J, Gurian J, Zink W, Dabus G, O’Leary, N, Reilly A, Lee K, Foley J, Dolan M, Hartley E, Clark T, Nadeau K, Shama J, Hull L, Brown B, Priest R, Nesbit G, Horikawa M, Hoak D, Petersen B, Beadell N, Herrick K, White C, Stacey M, Ford S, Liu J, Ribó M, Sanjuan, E, Sanchis M, Molina C, Rodríguez-Luna, D, Boned Riera S, Pagola J, Rubiera M, Juega J, Rodríguez N, Muller N, Stauder M, Stracke P, Heddier M, Charron V, Decock A, Herbreteau D, Bibi R, De Sloovere A, Doutreloigne I, Pieters D, Dewaele T, Bourgeois P, Vanhee F, Vanderdouckt P, Vancaster E, Baxendell L, Gilchrist V, Cannon Y, Graves C, Armbruster K, Jovin T, Jankowitz B, Ducruet A, Aghaebrahim A, Kenmuir C, Shoirah H, Molyneaux B, Tadi P, Walker G, Starr M, Doppelheuer S, Schindler K, Craft L, Schultz M, Perez H, Park J, Hall A, Mitchell A, Webb L, Haussen D, Frankel M, Bianchi N, Belagaje S, Mahdi N, Lahoti S, Katema A, Winningham M, Anderson A, Tilley D, Steinhauser T, Scott D, Thacker A, Calderon V, Lin E, Becke S, Krieter S, Jansen O, Wodarg F, Larsen N, Binder A, Wiesen C, Hartney M, Bookhagan L, Ross H, Gay J, Snyder K, Levy E, Davies J, Sonig A, Rangel-Castilla L, Mowla A, Shakir H, Fennell V, Atwal G, Natarajan S, Beecher J, Thornton J, Cullen A, Brennan P, O’Hare A, Asadi H, Budzik R, Taylor M, Jennings M, Laube F, Jackson J, Gatrell R, Reebel L, Albon A, Gerniak J, Groezinger K, Lauf M, Voraco N, Pema P, Davis T, Hicks W, Mejilla J, Teleb M, Sunenshine P, Russo E, Flynn R, Twyford J, Ver Hage A, Smith E, Apolinar L, Blythe S, Maxan J, Carter J, Taschner T, Bergmann U, Meckel S, Elsheik S, Urbach H, Maurer C, Egger K, Niesen W, Baxter B, Knox, A, Hazelwood B, Quarfordt S, Calvert J, Hawk H, Malek, R, Padidar A, Tolley U, Gutierrez A, Mordasini P, Seip T, Balasubramaniam R, Gralla J, Fischer U, Zibold F, Piechowiak E, DeLeacy R, Apruzzeses R, Alfonso C, Haslett J, Fifi J, Mocco J, Starkman S, Guzy, J, Grunberg N, Szeder V, Tateshima S, Duckwiler G, Nour M, Liebeskind D, Tang X, Hinman J, Tipirneni A, Yavagal D, Guada L, Bates K, Balladeras S, Bokka S, Suir S, Caplan J, Kandewall P, Peterson E, Starke R, Puri A, Hawk M, Brooks C, L’Heurex J, Ty K, Rex D, Massari F, Wakhloo A, Lozano D, Rodrigua K, Pierot L, Fabienne M, Sebastien S, Emmoinoli M. Primary Results of the Multicenter ARISE II Study (Analysis of Revascularization in Ischemic Stroke With EmboTrap). Stroke 2018; 49:1107-1115. [DOI: 10.1161/strokeaha.117.020125] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 02/05/2018] [Accepted: 02/26/2018] [Indexed: 02/04/2023]
Affiliation(s)
- Osama O. Zaidat
- From the Department of Neuroscience, Mercy St. Vincent Medical Center, Toledo, OH (O.O.Z., E.L.)
| | | | - Marc Ribó
- Department of Neuroradiology, Vall d’Hebron University Hospital, Barcelona, Spain (M.R., A.T.)
| | - Jeffrey L. Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, University of Bern, Switzerland (H.P.M.)
| | - René Chapot
- Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus, Essen, Germany (R.C., H.N.)
| | - Ana Paula Narata
- Centre Hospitalier Régional Universitaire, Hôpitaux de Tours, France (A.P.N.)
| | | | - Ashutosh P. Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., T.G.J.)
| | - Jonathan A. Grossberg
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA (J.A.G., R.G.N.)
| | | | - Alejandro Tomasello
- Department of Neuroradiology, Karolinska University Hospital, Karolinska Institute, Stockholm, Sweden (T.A.)
| | - Wayne M. Clark
- Oregon Health and Science University Hospital, Portland (H.B., W.M.C.)
| | - Hannes Nordmeyer
- Department of Radiology and Neuroradiology, Alfried Krupp Krankenhaus, Essen, Germany (R.C., H.N.)
| | - Eugene Lin
- From the Department of Neuroscience, Mercy St. Vincent Medical Center, Toledo, OH (O.O.Z., E.L.)
| | - Raul G. Nogueira
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, GA (J.A.G., R.G.N.)
| | - Albert J. Yoo
- Department of Interventional Radiology, Texas Stroke Institute, Dallas–Fort Worth (A.J.Y.)
| | - Tudor G. Jovin
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., T.G.J.)
| | | | | | | | - Tommy Andersson
- Department of Neuroradiology, Vall d’Hebron University Hospital, Barcelona, Spain (M.R., A.T.)
- AZ Groeninge, Kortrijk, Belgium (O.F., T.A.)
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Samaniego EA, Mendez AA, Nguyen TN, Kalousek V, Guerrero WR, Dandapat S, Dabus G, Linfante I, Hassan AE, Drofa A, Kouznetsov E, Leedahl D, Hasan D, Maud A, Ortega-Gutierrez S. LVIS Jr Device for Y-Stent-Assisted Coil Embolization of Wide-Neck Intracranial Aneurysms: A Multicenter Experience. Interv Neurol 2018; 7:271-283. [PMID: 29765397 DOI: 10.1159/000487545] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Accepted: 02/09/2018] [Indexed: 01/19/2023]
Abstract
Background and Purpose Complex wide-neck intracranial aneurysms are challenging to treat. We report a multicenter experience using the LVIS Jr stent for "Y-stent"-assisted coiling embolization of wide-neck bifurcation aneurysms. Methods Seven centers provided retrospective data on patients who underwent Y-stenting. Technical complications, immediate posttreatment angiographic results, clinical outcomes, and imaging follow-up were assessed. Results Thirty patients/aneurysms were treated: 15 basilar tip, 8 middle cerebral artery, 4 anterior communicating artery, 1 pericallosal, and 2 posterior inferior cerebellar artery aneurysms. The mean aneurysm size was 11 mm and the mean dome-to-neck ratio was 1.3 mm. Twenty-four aneurysms were unruptured and treated electively, and 6 were acutely ruptured. Fifty-eight LVIS Jr stents were successfully deployed without any technical issue. One pro-cedural and transient in-stent thrombosis resolved with the intravenous infusion of a glycoprotein IIb/IIIa inhibitor. Five periprocedural complications (within 30 days) occurred: 2 periprocedural neurological complications (1 small temporal stroke that presented with transient aphasia and 1 posterior cerebral artery infarct) and 3 nonneurological periprocedural complications (2 retroperitoneal hematomas, and 1 patient developed a disseminated intravascular coagulopathy). One permanent complication (3.3%) directly related to Y-stenting was reported in the patient who suffered the posterior cerebral artery infarct. Immediate complete obliteration (Raymond-Roy Occlusion Classification [RROC] I-II) was achieved in 26 cases (89.6%). Twenty-four patients had clinical and imaging follow-up (mean 5.2 months). Complete angiographic occlusion (RROC I-II) was observed in 23 patients (96%). A good functional outcome with a modified Rankin Scale score ≤2 was achieved in 26 cases. Conclusions In this multicenter case series, Y-stent-assisted coiling of wide-neck aneurysms with the LVIS Jr device was feasible and relatively safe. Follow-up imaging demonstrated very low recanalization rates.
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Affiliation(s)
- Edgar A Samaniego
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Aldo A Mendez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Thanh N Nguyen
- Department of Neurology, Neurosurgery and Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Vladimir Kalousek
- Department of Radiology, Clinical Hospital Center "Sestre Milosrdnice,", Zagreb, Croatia
| | - Waldo R Guerrero
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Sudeepta Dandapat
- Department of Neurology, Neurosurgery and Radiology, University of Iowa, Iowa, Iowa, USA
| | - Guilherme Dabus
- Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | - Italo Linfante
- Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| | | | - Alexander Drofa
- Department of Neurosurgery, Sanford Brain & Spine Center, Fargo, North Dakota, USA
| | - Evgueni Kouznetsov
- Department of Neurosurgery, Sanford Brain & Spine Center, Fargo, North Dakota, USA
| | - David Leedahl
- Pharmacy Services, Sanford Medical Center, Fargo, North Dakota, USA
| | - David Hasan
- Department of Neurosurgery, University of Iowa, Iowa, Iowa, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, Texas, USA
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Zaidat OO, Castonguay AC, Linfante I, Gupta R, Martin CO, Holloway WE, Mueller-Kronast N, English JD, Dabus G, Malisch TW, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Taqi MA, Abraham MG, Yoo AJ, Janardhan V, Shaltoni H, Novakovic R, Abou-Chebl A, Chen PR, Britz GW, Sun CHJ, Bansal V, Kaushal R, Nanda A, Nogueira RG. First Pass Effect. Stroke 2018; 49:660-666. [PMID: 29459390 DOI: 10.1161/strokeaha.117.020315] [Citation(s) in RCA: 404] [Impact Index Per Article: 67.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 12/01/2017] [Accepted: 01/16/2018] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In acute ischemic stroke, fast and complete recanalization of the occluded vessel is associated with improved outcomes. We describe a novel measure for newer generation devices: the first pass effect (FPE). FPE is defined as achieving a complete recanalization with a single thrombectomy device pass.
Methods—
The North American Solitaire Acute Stroke Registry database was used to identify a FPE subgroup. Their baseline features and clinical outcomes were compared with non-FPE patients. Clinical outcome measures included 90-days modified Rankin Scale score, National Institutes of Health Stroke Scale score, mortality, and symptomatic intracranial hemorrhage. Multivariate analyses were performed to determine whether FPE independently resulted in improved outcomes and to identify predictors of FPE.
Results—
A total of 354 acute ischemic stroke patients underwent thrombectomy in the North American Solitaire Acute Stroke registry. FPE was achieved in 89 out of 354 (25.1%). More middle cerebral artery occlusions (64% versus 52.5%) and fewer internal carotid artery occlusions (10.1% versus 27.7%) were present in the FPE group. Balloon guide catheters were used more frequently with FPE (64.0% versus 34.7%). Median time to revascularization was significantly faster in the FPE group (median 34 versus 60 minutes;
P
=0.0003). FPE was an independent predictor of good clinical outcome (modified Rankin Scale score ≤2 was seen in 61.3% in FPE versus 35.3% in non-FPE cohort;
P
=0.013; odds ratio, 1.7; 95% confidence interval, 1.1–2.7). The independent predictors of achieving FPE were use of balloon guide catheters and non-internal carotid artery terminus occlusion.
Conclusions—
The achievement of complete revascularization from a single Solitaire thrombectomy device pass (FPE) is associated with significantly higher rates of good clinical outcome. The FPE is more frequently associated with the use of balloon guide catheters and less likely to be achieved with internal carotid artery terminus occlusion.
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Affiliation(s)
- Osama O. Zaidat
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Alicia C. Castonguay
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Italo Linfante
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Rishi Gupta
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Coleman O. Martin
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - William E. Holloway
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Nils Mueller-Kronast
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Joey D. English
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Guilherme Dabus
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Tim W. Malisch
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Franklin A. Marden
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Hormozd Bozorgchami
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Andrew Xavier
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Ansaar T. Rai
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Michael T. Froehler
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Aamir Badruddin
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Thanh N. Nguyen
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - M. Asif Taqi
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Michael G. Abraham
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Albert J. Yoo
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Vallabh Janardhan
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Hashem Shaltoni
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Roberta Novakovic
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Alex Abou-Chebl
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Peng R. Chen
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Gavin W. Britz
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Chung-Huan J. Sun
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Vibhav Bansal
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Ritesh Kaushal
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Ashish Nanda
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
| | - Raul G. Nogueira
- From the Neuroscience Institute, Mercy Health St. Vincent Medical Center, Toledo, OH (O.O.Z.); Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, FL (I.L., G.D.); Neuroscience Center, Wellstar Health System, Atlanta, GA (R.G.); Neurointerventional and Diagnostic Associates, Saint Luke’s Hospital, Kansas City, MO (C.O.M, W.E.H.); Department of Neurology, Delray Medical Center, Delray Beach, FL (N.M.-K., R.K.); California Pacific Medical Center, San Francisco (J
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50
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Mokin M, Chinea A, Primiani CT, Ren Z, Kan P, Srinivasan VM, Hanel R, Aguilar-Salinas P, Turk AS, Turner RD, Chaudry MI, Ringer AJ, Welch BG, Mendes Pereira V, Renieri L, Piano M, Elijovich L, Arthur AS, Cheema A, Lopes DK, Saied A, Baxter BW, Hawk H, Puri AS, Wakhloo AK, Shallwani H, Levy EI, Siddiqui AH, Dabus G, Linfante I. Treatment of blood blister aneurysms of the internal carotid artery with flow diversion. J Neurointerv Surg 2018; 10:1074-1078. [DOI: 10.1136/neurintsurg-2017-013701] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 02/07/2018] [Accepted: 02/08/2018] [Indexed: 11/03/2022]
Abstract
BackgroundBlood blister aneurysms (BBA) are a rare subset of intracranial aneurysms that represent a therapeutic challenge from both a surgical and endovascular perspective.ObjectiveTo report multicenter experience with flow diversion exclusively for BBA, located at non-branching segments along the anteromedial wall of the supraclinoidal internal carotid artery (ICA).MethodsConsecutive cases of BBA located at non-branching segments along the anteromedial wall of the supraclinoidal ICA treated with flow diversion were included in the final analysis.Results49 patients with 51 BBA of the ICA treated with devices to achieve the flow diversion effect were identified. 43 patients with 45 BBA of the ICA were treated with the pipeline embolization device and were included in the final analysis. Angiographic follow-up data were available for 30 patients (32 aneurysms in total); 87.5% of aneurysms (28/32) showed complete obliteration, 9.4% (3/32) showed reduced filling, and 3.1% (1/32) persistent filling. There was no difference between the size of aneurysm (≤2 mm vs >2 mm) or the use of adjunct coiling and complete occlusion of the aneurysm on follow-up (P=0.354 and P=0.865, respectively). Clinical follow-up data were available for 38 of 43 patients. 68% of patients (26/38) had a good clinical outcome (modified Rankin scale score of 0–2) at 3 months. There were 7 (16%) immediate procedural and 2 (5%) delayed complications, with 1 case of fatal delayed re-rupture after the initial treatment.ConclusionsOur data support the use of a flow diversion technique as a safe and effective therapeutic modality for BBA of the supraclinoid ICA.
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