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Diestro JDB, Adeeb N, Musmar B, Salim H, Aslan A, Cancelliere NM, McLellan RM, Algin O, Ghozy S, Lay SV, Guenego A, Renieri L, Carnevale J, Saliou G, Mastorakos P, El Naamani K, Shotar E, Premat K, Möhlenbruch M, Kral M, Bernstock JD, Doron O, Chung C, Salem MM, Lylyk I, Foreman PM, Vachhani JA, Shaikh H, Župančić V, Hafeez MU, Catapano J, Waqas M, Ibrahim MK, Mohammed MA, Imamoglu C, Bayrak A, Rabinov JD, Ren Y, Schirmer CM, Piano M, Kühn AL, Michelozzi C, Elens S, Starke RM, Hassan AE, Ogilvie M, Nguyen A, Jones J, Brinjikji W, Nawka MT, Psychogios M, Ulfert C, Pukenas B, Burkhardt JK, Huynh T, Martinez-Gutierrez JC, Essibayi MA, Sheth SA, Spiegel G, Tawk RG, Lubicz B, Panni P, Puri AS, Pero G, Nossek E, Raz E, Killer-Oberpfalzer M, Griessenauer CJ, Asadi H, Siddiqui A, Brook AL, Altschul D, Spears J, Marotta TR, Ducruet AF, Albuquerque FC, Regenhardt RW, Stapleton CJ, Kan P, Kalousek V, Lylyk P, Boddu S, Knopman J, Aziz-Sultan MA, Tjoumakaris SI, Jabbour PM, Clarençon F, Limbucci N, Cuellar-Saenz HH, Mendes Pereira V, Patel AB, Dmytriw AA. Association of preprocedural antiplatelet use with decreased thromboembolic complications for intracranial aneurysms undergoing intrasaccular flow disruption. J Neurosurg 2024:1-8. [PMID: 38701528 DOI: 10.3171/2024.2.jns232918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 02/23/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE This study was conducted to investigate the impact of antiplatelet administration in the periprocedural period on the occurrence of thromboembolic complications (TECs) in patients undergoing treatment using the Woven EndoBridge (WEB) device for intracranial wide-necked bifurcation aneurysms. The primary objective was to assess whether the use of antiplatelets in the pre- and postprocedural phases reduces the likelihood of developing TECs, considering various covariates. METHODS A retrospective multicenter observational study was conducted within the WorldWideWEB Consortium and comprised 38 academic centers with endovascular treatment capabilities. Univariable and multivariable logistic regression analyses were performed to determine the association between antiplatelet use and TECs, adjusting for covariates. Missing predictor data were addressed using multiple imputation. RESULTS The study comprised two cohorts: one addressing general thromboembolic events and consisting of 1412 patients, among whom 103 experienced TECs, and another focusing on symptomatic thromboembolic events and comprising 1395 patients, of whom 50 experienced symptomatic TECs. Preprocedural antiplatelet use was associated with a reduced likelihood of overall TECs (OR 0.32, 95% CI 0.19-0.53, p < 0.001) and symptomatic TECs (OR 0.49, 95% CI 0.25-0.95, p = 0.036), whereas postprocedural antiplatelet use showed no significant association with TECs. The study also revealed additional predictors of TECs, including stent use (overall: OR 4.96, 95% CI 2.38-10.3, p < 0.001; symptomatic: OR 3.24, 95% CI 1.26-8.36, p = 0.015), WEB single-layer sphere (SLS) type (overall: OR 0.18, 95% CI 0.04-0.74, p = 0.017), and posterior circulation aneurysm location (symptomatic: OR 18.43, 95% CI 1.48-230, p = 0.024). CONCLUSIONS The findings of this study suggest that the preprocedural administration of antiplatelets is associated with a reduced likelihood of TECs in patients undergoing treatment with the WEB device for wide-necked bifurcation aneurysms. However, postprocedural antiplatelet use did not show a significant impact on TEC occurrence.
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Affiliation(s)
- Jose Danilo Bengzon Diestro
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Nimer Adeeb
- 2Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana
| | - Basel Musmar
- 2Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana
| | - Hamza Salim
- 2Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana
| | - Assala Aslan
- 2Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana
| | - Nicole M Cancelliere
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Rachel M McLellan
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Oktay Algin
- 4Ankara University, Medical Faculty, Department of Radiology, Ankara, Turkey
| | | | - Sovann V Lay
- 6Service de Neuroradiologie Diagnostique et Thérapeutique, Centre Hospitalier de Toulouse, Hôpital Purpan, Toulouse, France
| | - Adrien Guenego
- 7Service de Neuroradiologie Interventionnelle, Hôpital Universitaire Erasme, Bruxelles, Belgique
| | - Leonardo Renieri
- 8Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Joseph Carnevale
- 9Neurosurgery & Interventional Neuroradiology, NewYork-Presbyterian Hospital, Weill Cornell School of Medicine, New York, New York
| | - Guillaume Saliou
- 10Service de radiodiagnostic et radiologie interventionnelle, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Panagiotis Mastorakos
- 11Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Kareem El Naamani
- 11Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Eimad Shotar
- 12Département de Neuroradiologie, Hôpital Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Kevin Premat
- 12Département de Neuroradiologie, Hôpital Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Markus Möhlenbruch
- 13Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Germany
| | - Michael Kral
- 14Department of Neurosurgery, Christian Doppler University Hospital and Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Joshua D Bernstock
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Omer Doron
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Charlotte Chung
- Departments of15Radiology and
- 39Neurosurgery, NYU Langone Health Center, New York, New York
| | - Mohamed M Salem
- 16Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Ivan Lylyk
- 17Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Paul M Foreman
- 18Department of Neurosurgery, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, Florida
| | - Jay A Vachhani
- 18Department of Neurosurgery, Orlando Health Neuroscience and Rehabilitation Institute, Orlando, Florida
| | - Hamza Shaikh
- Departments of19Radiology and
- 40Neurosurgery, Cooper University Health Care, Cooper Medical School of Rowan University, Camden, New Jersey
| | - Vedran Župančić
- 20Department of Radiology, Subdivision of Interventional Neuroradiology, Clinical Hospital Center Sisters of Mercy, Zagreb, Croatia
| | - Muhammad U Hafeez
- 21Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, Texas
| | - Joshua Catapano
- 22Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Muhammad Waqas
- 23Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Mohamed K Ibrahim
- Departments of5Radiology and
- 38Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Marwa A Mohammed
- Departments of5Radiology and
- 38Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Cetin Imamoglu
- 37Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital of the Ministry of Health, Ankara, Turkey
| | - Ahmet Bayrak
- 37Dr. Abdurrahman Yurtaslan Oncology Training and Research Hospital of the Ministry of Health, Ankara, Turkey
| | - James D Rabinov
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Yifan Ren
- 24Department of Radiology, Interventional Radiology and Neurointerventional Services, Austin Health, Melbourne, Victoria, Australia
| | - Clemens M Schirmer
- Departments of25Neurosurgery and
- 41Radiology, Geisinger Hospital, Danville, Pennsylvania
| | - Mariangela Piano
- 26Interventistica Neurovascolare, Ospedale Niguarda Cà Granda, Milano, Italy
| | - Anna L Kühn
- 27Department of Neurointerventional Radiology, UMass Memorial Hospital, Worcester, Massachusetts
| | | | - Stéphanie Elens
- 8Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | | | - Ameer E Hassan
- 30Department of Neuroscience, Valley Baptist Neuroscience Institute, Harlingen, Texas
| | - Mark Ogilvie
- Departments of31Neurosurgery and
- 42Radiology, University of Alabama at Birmingham, Alabama
| | - Anh Nguyen
- 32Department of Neuroradiology, University Hospital of Basel, Switzerland
| | - Jesse Jones
- Departments of31Neurosurgery and
- 42Radiology, University of Alabama at Birmingham, Alabama
| | - Waleed Brinjikji
- Departments of5Radiology and
- 38Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Marie T Nawka
- 33Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios Psychogios
- 32Department of Neuroradiology, University Hospital of Basel, Switzerland
| | - Christian Ulfert
- 13Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Germany
| | - Bryan Pukenas
- 16Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Jan-Karl Burkhardt
- 16Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania
| | - Thien Huynh
- Departments of34Radiology and
- 43Neurosurgery, Mayo Clinic, Jacksonville, Florida
| | | | - Muhammed Amir Essibayi
- 36Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; and
| | - Sunil A Sheth
- Departments of35Radiology
- 44Neurology, and
- 45Neurosurgery, University of Texas Health Science Center at Houston, Texas
| | - Gary Spiegel
- Departments of35Radiology
- 44Neurology, and
- 45Neurosurgery, University of Texas Health Science Center at Houston, Texas
| | - Rabih G Tawk
- Departments of34Radiology and
- 43Neurosurgery, Mayo Clinic, Jacksonville, Florida
| | - Boris Lubicz
- 8Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Pietro Panni
- 28Interventistica Neurovascolare, Ospedale San Raffaele, Milano, Italy
| | - Ajit S Puri
- 27Department of Neurointerventional Radiology, UMass Memorial Hospital, Worcester, Massachusetts
| | - Guglielmo Pero
- 26Interventistica Neurovascolare, Ospedale Niguarda Cà Granda, Milano, Italy
| | - Erez Nossek
- Departments of15Radiology and
- 39Neurosurgery, NYU Langone Health Center, New York, New York
| | - Eytan Raz
- Departments of15Radiology and
- 39Neurosurgery, NYU Langone Health Center, New York, New York
| | - Monika Killer-Oberpfalzer
- 14Department of Neurosurgery, Christian Doppler University Hospital and Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- 14Department of Neurosurgery, Christian Doppler University Hospital and Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Hamed Asadi
- Departments of15Radiology and
- 39Neurosurgery, NYU Langone Health Center, New York, New York
| | - Adnan Siddiqui
- 23Department of Neurosurgery, State University of New York at Buffalo, New York
| | - Allan L Brook
- 36Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; and
| | - David Altschul
- 36Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York; and
| | - Julian Spears
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Thomas R Marotta
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Andrew F Ducruet
- 22Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | | | - Robert W Regenhardt
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Christopher J Stapleton
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Peter Kan
- 21Department of Neurosurgery, UTMB and Baylor School of Medicine, Houston, Texas
| | - Vladimir Kalousek
- 20Department of Radiology, Subdivision of Interventional Neuroradiology, Clinical Hospital Center Sisters of Mercy, Zagreb, Croatia
| | - Pedro Lylyk
- 17Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Srikanth Boddu
- 10Service de radiodiagnostic et radiologie interventionnelle, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Jared Knopman
- 9Neurosurgery & Interventional Neuroradiology, NewYork-Presbyterian Hospital, Weill Cornell School of Medicine, New York, New York
| | - Mohammad A Aziz-Sultan
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | | | - Pascal M Jabbour
- 11Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Frédéric Clarençon
- 12Département de Neuroradiologie, Hôpital Pitié-Salpêtrière, Université Sorbonne, Paris, France
| | - Nicola Limbucci
- 9Neurosurgery & Interventional Neuroradiology, NewYork-Presbyterian Hospital, Weill Cornell School of Medicine, New York, New York
| | - Hugo H Cuellar-Saenz
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Vitor Mendes Pereira
- 1Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Ontario, Canada
| | - Aman B Patel
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
| | - Adam A Dmytriw
- 3Neuroendovascular Program, Massachusetts General Hospital and Brigham and Women's Hospital, Harvard University, Boston, Massachusetts
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Chebib FT, Tawk RG. All Patients with ADPKD Should Undergo Screening for Intracranial Aneurysms: CON. Kidney360 2024; 5:495-498. [PMID: 37990377 DOI: 10.34067/kid.0000000000000322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 11/15/2023] [Indexed: 11/23/2023]
Affiliation(s)
- Fouad T Chebib
- Division of Nephrology and Hypertension, Mayo Clinic, Jacksonville, Florida
- Mayo Clinic Florida PKD Center of Excellence, Jacksonville, Florida
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
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Ghaith AK, El-Hajj VG, Atallah E, Rios Zermeno J, Ravindran K, Gharios M, Hoang H, Bydon M, Ohlsson M, Elmi-Terander A, Tawk RG, Jabbour P. Impact of the pandemic and concomitant COVID-19 on the management and outcomes of middle cerebral artery strokes: a nationwide registry-based study. BMJ Open 2024; 14:e080738. [PMID: 38417967 PMCID: PMC10900352 DOI: 10.1136/bmjopen-2023-080738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 02/19/2024] [Indexed: 03/01/2024] Open
Abstract
OBJECTIVES To investigate the impact of the COVID-19 pandemic as well as concomitant COVID-19 itself on stroke care, focusing on middle cerebral artery (MCA) territory infarctions. DESIGN Registry-based study. SETTING We used the National Inpatient Sample (NIS) database, which covers a wide range of hospitals within the USA. PARTICIPANTS The NIS was queried for patients with MCA strokes between 2016 and 2020. In total, 35 231 patients were included. OUTCOME MEASURES Outcome measures were postprocedural complications, length of stays (LOSs), in-hospital mortality and non-routine discharge. Propensity score matching using all available baseline variables was performed to reduce confounders when comparing patients with and without concomitant COVID-19. RESULTS Mechanical thrombectomy (MT) was performed in 48.4%, intravenous thrombolysis (IVT) in 38.2%, and both MT and IVT (MT+IVT) in 13.4% of patients. A gradual increase in the use of MT and an opposite decrease in the use of IVT (p<0.001) was detected during the study period. Overall, 25.0% of all patients were admitted for MCA strokes during the pandemic period (2020), of these 209 (2.4%) were concomitantly diagnosed with COVID-19. Patients with MCA strokes and concomitant COVID-19 were significantly younger (64.9 vs 70.0; p<0.001), had significantly worse NIH Stroke Severity scores, and worse outcomes in terms of LOS (12.3 vs 8.2; p<0.001), in-hospital mortality (26.3% vs 9.8%; p<0.001) and non-routine discharge (84.2% vs 76.9%; p=0.013), as compared with those without COVID-19. After matching, only in-hospital mortality rates remained significantly higher in patients with COVID-19 (26.7% vs 8.5%; p<0.001). Additionally, patients with COVID-19 had higher rates of thromboembolic (12.3% vs 7.6%; p=0.035) and respiratory (11.3% vs 6.6%; p=0.029) complications. CONCLUSIONS Among patients with MCA stroke, those with concomitant COVID-19 were significantly younger and had higher stroke severity scores. They were more likely to experience thromboembolic and respiratory complications and in-hospital mortality compared with matched controls.
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Affiliation(s)
| | | | - Elias Atallah
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | | | | | - Maria Gharios
- Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | | | | | - Marcus Ohlsson
- Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | | | - Rabih G Tawk
- Mayo Clinic in Florida, Jacksonville, Florida, USA
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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Erben Y, Li Y, Da Rocha-Franco JA, Tawk RG, Barrett KM, Freeman WD, Lin M, Huang JF, Miller D, Farres H, Brott TG, Meschia JF, Hakaim AG. Asymptomatic Females Are at Higher Risk for Perioperative TIA/Stroke and Males Are at Higher Risk for Long-Term Mortality after Carotid Artery Stenting: A Vascular Quality Initiative Analysis. Int J Angiol 2024; 33:36-45. [PMID: 38352638 PMCID: PMC10861297 DOI: 10.1055/s-0040-1712506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
Abstract
The study aims to review the sex differences with respect to transient ischemic attack (TIA)/stroke and death in the perioperative period and on long-term follow-up among asymptomatic patients treated with carotid stenting (CAS) in the vascular quality initiative (VQI). All cases reported to VQI of asymptomatic CAS (ACAS) patients were reviewed. The primary end point was risk of TIA/stroke and death in the in-hospital perioperative period and in the long-term follow-up. The secondary end point was to evaluate predictors of in-hospital perioperative TIA/stroke and mortality on long-term follow-up after CAS. There were 22,079 CAS procedures captured from January 2005 to April 2019. There were 5,785 (62.7%) patients in the ACAS group. The rate of in-hospital TIA/stroke was higher in female patients (2.7 vs. 1.87%, p = 0.005) and the rate of death was not significant (0.03 vs. 0.07%, p = 0.66). On multivariable logistic regression analysis, prior/current smoking history (odds ratio = 0.58 [95% confidence interval or CI = 0.39-0.87]; p = 0.008) is a predictor of in-hospital TIA/stroke in females. The long-term all-cause mortality is significantly higher in male patients (26.9 vs. 15.7%, p < 0.001). On multivariable Cox-regression analysis, prior/current smoking history (hazard ratio or HR = 1.17 [95% CI = 1.01-1.34]; p = 0.03), coronary artery disease or CAD (HR = 1.15 [95% CI = 1.03-1.28]; p = 0.009), chronic obstructive pulmonary disease or COPD (HR = 1.73 [95% CI = 1.55-1.93]; p < 0.001), threat to life American Society of Anesthesiologists (ASA) class (HR = 2.3 [95% CI = 1.43-3.70]; p = 0.0006), moribund ASA class (HR = 5.66 [95% CI = 2.24-14.29]; p = 0.0003), and low hemoglobin levels (HR = 0.84 [95% CI = 0.82-0.86]; p < 0.001) are the predictors of long-term mortality. In asymptomatic carotid disease patients, women had higher rates of in-hospital perioperative TIA/stroke and a predictor of TIA/stroke is a prior/current history of smoking. Meanwhile, long-term all-cause mortality is higher for male patients compared with their female counterparts. Predictors of long-term mortality are prior/current smoking history, CAD, COPD, higher ASA classification of physical status, and low hemoglobin level. These data should be considered prior to offering CAS to asymptomatic female and male patients and careful risks versus benefits discussion should be offered to each individual patient.
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Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | - Yupeng Li
- Department of Political Science and Economics, Rowan University, Glassboro, New Jersey
| | | | - Rabih G. Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
| | | | - William D. Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | - Michelle Lin
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | | | - David Miller
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | | | | | - Albert G. Hakaim
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
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Rios-Zermeno J, Ghaith AK, El Hajj VG, Soltan F, Greco E, Michaelides L, Lin MP, Meschia JF, Akinduro OO, Bydon M, Bendok BR, Tawk RG. Extracranial-Intracranial Bypass for Moyamoya Disease: The Influence of Racial and Socioeconomic Disparities on Outcomes - A National Inpatient Sample Analysis. World Neurosurg 2024; 182:e624-e634. [PMID: 38061545 DOI: 10.1016/j.wneu.2023.12.005] [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: 10/19/2023] [Accepted: 12/03/2023] [Indexed: 12/31/2023]
Abstract
BACKGROUND Extracranial-intracranial (EC-IC) bypass is an established therapeutic option for Moyamoya disease (MMD). However, little is known about the effects of racial and ethnic disparities on outcomes. This study assessed trends in EC-IC bypass outcomes among MMD patients stratified by race and ethnicity. METHODS Utilizing the US National Inpatient Sample, we identified MMD patients undergoing EC-IC bypass between 2002 and 2020. Demographic and hospital-level data were collected. Multivariable analysis was conducted to identify independent factors associated with outcomes. Trend analysis was performed using piecewise joinpoint regression. RESULTS Out of 14,062 patients with MMD, 1771 underwent EC-IC bypass. Of these, 60.59% were White, 17.56% were Black, 12.36% were Asians, 8.47% were Hispanic, and 1.02% were Native Americans. Nonhome discharge was noted in 21.7% of cases, with a 6.7% death and 3.8% postoperative neurologic complications rates. EC-IC bypass was more commonly performed in Native Americans (23.38%) and Asians (17.76%). Hispanics had the longest mean length of stay (8.4 days) and lower odds of nonhome discharge compared to Whites (odds ratio: 0.64; 95% confidence interval: 0.40-1.03; P = 0.04). Patients with Medicaid, private insurance, self-payers, and insurance paid by other governments had lower odds of nonhome discharge than those with Medicare. CONCLUSION This study highlights racial and socioeconomic disparities in EC-IC bypass for patients with MMD. Despite these disparities, we did not find any significant difference in the quality of care. Addressing these disparities is essential for optimizing MMD outcomes.
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Affiliation(s)
- Jorge Rios-Zermeno
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Abdul Karim Ghaith
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Fatima Soltan
- School of Public Health, Imperial College London, London, UK
| | - Elena Greco
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Loizos Michaelides
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Michelle P Lin
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota, USA; Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA.
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Greco E, Ghaith AKA, Rios-Zermeno J, Ghanem M, Perez-Vega C, Kashyap S, Freeman WD, Miller DA, Huynh TJ, Bydon M, Middlebrooks EH, Sandhu SJS, Tawk RG. Long-Term Safety and Efficacy of Pipeline Embolization Device in Anterior and Posterior Circulation Aneurysms: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 185:103-112. [PMID: 38307200 DOI: 10.1016/j.wneu.2024.01.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Flow diversion using the pipeline embolization device (PED) has been a paradigm shift for anterior circulation (AC) aneurysms. However, only a few studies report the long-term (≥1 year) angiographic and clinical outcomes for posterior circulation (PC) aneurysms. This study aims to compare the long-term safety and efficacy of treatment of AC and PC aneurysms with PED. METHODS The databases included Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane, and Scopus. Studies with at least 10 patients and 1-year follow-up were included. Twenty-four studies met our inclusion criteria. A random effect meta-analysis was performed to estimate the ischemic and hemorrhagic complications. A meta-analysis of proportions was performed to estimate the pooled rates of long-term complete aneurysmal occlusion, symptomatic stroke, aneurysmal rupture, and intracranial hemorrhage. RESULTS There were 1952 aneurysms, of which 1547 (79.25%) were in the AC and 405 (20.75%) in the PC. The 1-year occlusion rate was 78% in AC compared to 73% in PC aneurysms (P < 0.01). The symptomatic infarct rate was 5% in AC compared to 13% in PC (P < 0.01). While the rupture rate was 1% in AC compared to 4% in PC (P = 0.01), the rate of intracranial hemorrhage was 2% for both (P = 0.99). CONCLUSIONS The long-term occlusion rate after PED was higher in AC aneurysms, and the cumulative incidence of stroke and aneurysm rupture was higher in PC aneurysms.
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Affiliation(s)
- Elena Greco
- Research Fellow in the Department of Radiology, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA; Research Fellow in the Department of Neurologic Surgery, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Abdul Karim A Ghaith
- Research Fellow in the Neuro-Informatics Laboratory, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Jorge Rios-Zermeno
- Research Fellow in the Department of Neurologic Surgery, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Marc Ghanem
- Gilbert and Rose-Marie Chagoury School of Medicine, Lebanese American University, Beirut, Lebanon
| | - Carlos Perez-Vega
- Resident in the Department of Neurologic Surgery, Mayo Clinic School of Graduate Medical Education, Mayo Clinic College of Medicine and Science, Jacksonville, Florida, USA
| | - Samir Kashyap
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - W David Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Neurology, and Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - David A Miller
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Thien J Huynh
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Mohamad Bydon
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Erik H Middlebrooks
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA.
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Durand NC, Kim HG, Patel VN, Turnbull MT, Siegel JL, Hodge DO, Tawk RG, Meschia JF, Freeman WD, Zubair AC. Mesenchymal Stem Cell Therapy in Acute Intracerebral Hemorrhage: A Dose-Escalation Safety and Tolerability Trial. Neurocrit Care 2023:10.1007/s12028-023-01897-w. [PMID: 38114796 DOI: 10.1007/s12028-023-01897-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 11/15/2023] [Indexed: 12/21/2023]
Abstract
BACKGROUND We conducted a preliminary phase I, dose-escalating, safety, and tolerability trial in the population of patients with acute intracerebral hemorrhage (ICH) by using human allogeneic bone marrow-derived mesenchymal stem/stromal cells. METHODS Eligibility criteria included nontraumatic supratentorial hematoma less than 60 mL and Glasgow Coma Scale score greater than 5. All patients were monitored in the neurosciences intensive care unit for safety and tolerability of mesenchymal stem/stromal cell infusion and adverse events. We also explored the use of cytokines as biomarkers to assess responsiveness to the cell therapy. We screened 140 patients, enrolling 9 who met eligibility criteria into three dose groups: 0.5 million cells/kg, 1 million cells/kg, and 2 million cells/kg. RESULTS Intravenous administration of allogeneic bone marrow-derived mesenchymal stem/stromal cells to treat patients with acute ICH is feasible and safe. CONCLUSIONS Future larger randomized, placebo-controlled ICH studies are necessary to validate this study and establish the effectiveness of this therapeutic approach in the treatment of patients with ICH.
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Affiliation(s)
- Nisha C Durand
- Center for Regenerative Biotherapeutics, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
- Human Cellular Therapy Laboratory, Mayo Clinic, Jacksonville, FL, USA.
| | - H G Kim
- Clinical Research Intern Scholar Program, Mayo Clinic, Jacksonville, FL, USA
| | - Vishal N Patel
- Division of Neuroradiology, Mayo Clinic, Jacksonville, FL, USA
| | - Marion T Turnbull
- Research Collaborator in the Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Jason L Siegel
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - David O Hodge
- Biostatistics Unit, Mayo Clinic, Jacksonville, FL, USA
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - W David Freeman
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL, USA
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA
- Department of Neurology, Mayo Clinic, Jacksonville, FL, USA
| | - Abba C Zubair
- Center for Regenerative Biotherapeutics, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Department of Laboratory Medicine and Pathology, Center for Regenerative Biotherapeutics, Mayo Clinic, Jacksonville, FL, USA
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Ghaith AK, Greco E, Rios-Zermeno J, El-Hajj VG, Perez-Vega C, Ghanem M, Kashyap S, Fox WC, Huynh TJ, Sandhu SS, Ohlsson M, Elmi-Terander A, Bendok BR, Bydon M, Tawk RG. Safety and efficacy of the pipeline embolization device for treatment of small vs. large aneurysms: a systematic review and meta-analysis. Neurosurg Rev 2023; 46:284. [PMID: 37882896 DOI: 10.1007/s10143-023-02192-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 10/27/2023]
Abstract
Flow diversion with the pipeline embolization device (PED) is increasingly used to treat intracranial aneurysms with high obliteration rates and low morbidity. However, long-term (≥ 1 year) angiographic and clinical outcomes still require further investigation. The aim of this study was to compare the occlusion and complication rates for small (< 10 mm) versus large (10-25 mm) aneurysms at long-term following treatment with PED. A systematic review and meta-analysis were performed in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. We conducted a comprehensive search of English language databases including Ovid MEDLINE and Epub Ahead of Print, In-Process, and Daily, Ovid EMBASE, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus. Our studies included a minimum of 10 patients treated with PED for small vs. large aneurysms and with at least 12 months of follow-up. The primary safety endpoint was the rate of clinical complications measured by the occurrence of symptomatic stroke (confirmed clinically and radiographically), intracranial hemorrhage, or aneurysmal rupture. The primary efficacy endpoint was the complete aneurysm occlusion rate. Our analysis included 19 studies with 1277 patients and 1493 aneurysms. Of those, 1378 aneurysms met our inclusion criteria. The mean age was 53.9 years, and most aneurysms were small (89.75%; N = 1340) in women (79.1%; N = 1010). The long-term occlusion rate was 73% (95%, CI 65 to 80%) in small compared to 84% (95%, CI 76 to 90%) in large aneurysms (p < 0.01). The symptomatic thromboembolic complication rate was 5% (95%, CI 3 to 9%) in small compared to 7% (95%, CI 4 to 13%) in large aneurysms (p = 0.01). The rupture rate was 2% vs. 4% (p = 0.92), and the rate of intracranial hemorrhage was 2% vs. 4% (p = 0.96) for small vs. large aneurysms, respectively; however, these differences were not statistically significant. The long-term occlusion rate after PED treatment is higher in large vs. small aneurysms. Symptomatic thromboembolic rates with stroke are also higher in large vs. small aneurysms. The difference in the rates of aneurysm rupture and intracranial hemorrhage was insignificant. Although the PED seems a safe and effective treatment for small and large aneurysms, further studies are required to clarify how occlusion rate and morbidity are affected by aneurysm size.
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Affiliation(s)
- Abdul Karim Ghaith
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Elena Greco
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Victor Gabriel El-Hajj
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Carlos Perez-Vega
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Marc Ghanem
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Samir Kashyap
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - W Christopher Fox
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | - Thien J Huynh
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA
| | | | - Marcus Ohlsson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Bernard R Bendok
- Department of Neurological Surgery, Mayo Clinic, Phoenix, AZ, USA
| | - Mohamad Bydon
- Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, MN, USA
- Department of Neurological Surgery, Mayo Clinic, Rochester, MN, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, USA.
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Rios-Zermeno J, Tawk RG. Commentary: Simultaneous Clipping of an Ophthalmic Aneurysm and a Laterally Projecting Paraclinoid Aneurysm Through the Endoscopic Endonasal Approach: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2023; 25:e242-e243. [PMID: 37534907 DOI: 10.1227/ons.0000000000000840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/06/2023] [Indexed: 08/04/2023] Open
Affiliation(s)
- Jorge Rios-Zermeno
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Bhatia S, Riccobono G, Lima NJ, Cruz JT, Prusener DW, Domingo R, Ghaith AK, Rios-Zermeno J, Kashyap S, Tawk RG. Percutaneous Closure Device for the Carotid artery: An integrated review and design analysis. J Neurointerv Surg 2023:jnis-2023-020702. [PMID: 37739794 DOI: 10.1136/jnis-2023-020702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 08/11/2023] [Indexed: 09/24/2023]
Abstract
Endovascular thrombectomies (EVTs) are the current standard of care therapy for treating acute ischemic strokes. While access through the femoral or radial arteries is routine, up to 20% of EVTs through these sites are unable to access the cerebral vasculature on the first pass. These shortcomings are commonly due to tortuous vasculature, atherosclerotic arteries, and type III aortic arch, seen especially in the elderly population. Recent studies have shown the benefits of accessing the cerebral vasculature through a percutaneous direct carotid puncture (DCP), which can reduce the time of the procedure by half. However, current vascular closure devices (VCDs) designed for the femoral artery are not suited to close the carotid artery due to the anatomical differences. This unmet clinical need further limits a DCP approach. Thus, to foster safe adoption of this potential approach, a VCD designed specifically for the carotid artery is needed. In this review, we outline the major biomechanical properties and shortcomings of current VCDs and propose the requirements necessary to effectively design and develop a carotid closure device.
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Affiliation(s)
- Shovan Bhatia
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | | | - Nicholas J Lima
- Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Joshua T Cruz
- The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Derek W Prusener
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Georgia, USA
| | - Ricardo Domingo
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Jorge Rios-Zermeno
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Samir Kashyap
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
| | - Rabih G Tawk
- Department of Neurosurgery, Mayo Clinic Florida, Jacksonville, Florida, USA
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Lin MP, Demirer M, Middlebrooks EH, Tawk RG, Erben YM, Mateti NR, Youssef H, Anisetti B, Elkhair AM, Gupta V, Erdal BS, Barrett KM, Brott TG, Meschia JF. Greater burden of white matter lesions and silent infarcts ipsilateral to carotid stenosis. J Stroke Cerebrovasc Dis 2023; 32:107287. [PMID: 37531723 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107287] [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: 05/05/2023] [Revised: 07/25/2023] [Accepted: 07/29/2023] [Indexed: 08/04/2023] Open
Abstract
OBJECTIVES Carotid stenosis may cause silent cerebrovascular disease (CVD) through atheroembolism and hypoperfusion. If so, revascularization may slow progression of silent CVD. We aimed to compare the presence and severity of silent CVD to the degree of carotid bifurcation stenosis by cerebral hemisphere. MATERIALS AND METHODS Patients age ≥40 years with carotid stenosis >50% by carotid ultrasound who underwent MRI brain from 2011-2015 at Mayo Clinic were included. Severity of carotid stenosis was classified by carotid duplex ultrasound as 50-69% (moderate), 70-99% (severe), or occluded. White matter lesion (WML) volume was quantified using an automated deep-learning algorithm applied to axial T2 FLAIR images. Differences in WML volume and prevalent silent infarcts were compared across hemispheres and severity of carotid stenosis. RESULTS Of the 183 patients, mean age was 71±10 years, and 39.3% were female. Moderate stenosis was present in 35.5%, severe stenosis in 46.5% and occlusion in 18.0%. Patients with carotid stenosis had greater WML volume ipsilateral to the side of carotid stenosis than the contralateral side (mean difference, 0.42±0.21cc, p=0.046). Higher degrees of stenosis were associated with greater hemispheric difference in WML volume (moderate vs. severe; 0.16±0.27cc vs 0.74±0.31cc, p=0.009). Prevalence of silent infarct was 23.5% and was greater on the side of carotid stenosis than the contralateral side (hemispheric difference 8.8%±3.2%, p=0.006). Higher degrees of stenosis were associated with higher burden of silent infarcts (moderate vs severe, 10.8% vs 31.8%; p=0.002). CONCLUSIONS WML and silent infarcts were greater on the side of severe carotid stenosis.
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Affiliation(s)
| | - Mutlu Demirer
- Department of Radiology, Mayo Clinic, Jacksonville, FL
| | | | - Rabih G Tawk
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL
| | - Young M Erben
- Department of Vascular Surgery, Mayo Clinic, Jacksonville, FL
| | | | | | | | | | - Vikash Gupta
- Department of Radiology, Mayo Clinic, Jacksonville, FL
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Greco E, Rios-Zermeno J, Ghaith AK, Faisal UH, Goyal A, Akinduro OO, Kashyap S, Miller DA, Graepel SP, Bydon M, Middlebrooks EH, Sandhu SS, Tawk RG. Flow diversion using the Pipeline embolization device for intracranial and extracranial pseudoaneurysms: a systematic review and meta-analysis of the literature. Neurosurg Focus 2023; 54:E5. [PMID: 37127035 DOI: 10.3171/2023.2.focus22644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/13/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE Pseudoaneurysms (PSAs) are complex vascular lesions. Flow diversion has been proposed as an alternative treatment to parent artery occlusion that preserves laminar flow. The authors of the present study investigated the safety and short-term (< 1 year) and long-term (≥ 1 year) aneurysm occlusion rates following the treatment of intracranial and extracranial PSAs using the Pipeline embolization device (PED). METHODS An electronic database search for full-text English-language articles in Ovid MEDLINE and Epub Ahead of Print, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus was conducted following the PRISMA guidelines. Studies of any design including at least 4 patients with intracranial or extracranial PSAs treated using a PED were included in this analysis. The primary outcome of interest was the rate of peri- and postprocedural complications. Secondarily, the authors analyzed the incidence of complete aneurysm occlusion. RESULTS A total of 90 patients with 96 PSAs across 9 studies were included. The mean age was 38.2 (SD 15.14) years, and 37.8% of the patients were women. The mean PSA size was 4.9 mm. Most PSAs were unruptured, and the most common etiology was trauma (n = 32, 35.5%), followed by spontaneous formation (n = 21, 23.3%) and iatrogenic injury (n = 19, 21.1%). Among the 51 (53.1%) intracranial and 45 (46.9%) extracranial PSAs were 19 (19.8%) dissecting PSAs. Sixty-six (77.6%) PSAs were in the internal carotid artery and 10 (11.8%) in the vertebral artery. Thirty-three (34.4%) PSAs were treated with ≥ 2 devices, and 8 (8.3%) underwent adjunctive coiling. The mean clinical and angiographic follow-up durations were 10.7 and 12.9 months, respectively. The short-term (< 1 year) and long-term (≥ 1 year) complete occlusion rates were 79% (95% CI 66%-88%, p = 0.82) and 84% (95% CI 70%-92%, p = 0.95), respectively. Complication rates were 8% for iatrogenic dissection (95% CI 3%-16%, p = 0.94), 10% for silent thromboembolism (95% CI 5%-21%, p = 0.77), and 12% for symptomatic thromboembolism (95% CI 6%-23%, p = 0.48). No treatment-related hemorrhage was observed. The overall mortality rate at the last follow-up was 14%. CONCLUSIONS The complete occlusion rate for PSAs treated with the PED was high and increased over time. Although postprocedural complications and mortality were not insignificant, flow diversion represents a reasonably safe option for managing these complex lesions.
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Affiliation(s)
- Elena Greco
- Departments of1Neurological Surgery and
- 2Radiology, Mayo Clinic, Jacksonville, Florida
| | - Jorge Rios-Zermeno
- 3Department of Neurological Surgery, Instituto Nacional de Neurología y Neurocirugía, Mexico City, Mexico
| | - Abdul Karim Ghaith
- 4Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 5Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Umme Habiba Faisal
- 6All India Institute of Medical Sciences, Kalyani, West Bengal, India; and
| | | | | | | | - David A Miller
- Departments of1Neurological Surgery and
- 2Radiology, Mayo Clinic, Jacksonville, Florida
| | - Stephen P Graepel
- 7Department of Education, Division of Biomedical and Scientific Visualization, Mayo Foundation for Medical Education and Research, Mayo Clinic, Rochester, Minnesota
| | - Mohamad Bydon
- 4Mayo Clinic Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
- 5Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota
| | - Erik H Middlebrooks
- Departments of1Neurological Surgery and
- 2Radiology, Mayo Clinic, Jacksonville, Florida
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Valero-Moreno F, Pullen MW, Navarro-Martínez G, Ruiz-Garcia H, Domingo RA, Martínez JL, Suarez-Meade P, Damon A, Quiñones-Hinojosa A, Sandhu SJ, Tawk RG, Fox WC. Absence of the torcular, review of venous sinus anatomy, and the simplified dural sinus classification. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05559-w. [PMID: 37014451 DOI: 10.1007/s00701-023-05559-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 03/08/2023] [Indexed: 04/05/2023]
Abstract
BACKGROUND Classically, the torcular Herophili is described as the symmetric junction between the superior sagittal sinus (SSS), transverse sinuses (TSs), and straight sinus (SS). However, finding this pattern in practice is not standard. Anatomical variations are common, and different drainage patterns should be expected. Existing literature proposes highly detailed descriptions and classifications of this region. Still, a simplified and practical categorization is not available. METHODS We present an anatomical finding of the torcular Herophili discovered on a cadaveric dissection. Then, we conducted a retrospective study examining the 100 most recent cranial magnetic resonance venographies (MRVs) from the Mayo Clinic, labeling them with a new proposed dural sinus classification system. Images were initially classified by two authors and further validated by a board-certified neurosurgeon and a board-certified neuroradiologist from our institution. To measure consistency in image identification, two additional international neurosurgeons were asked to classify a subset of the same MRV images, and their answers were compared. RESULTS Of the MRV cohort, 33 patients were male and 67 were female. Their ages ranged from 18 to 86 years, with a mean of 47.35 years and a median of 49 years. Upon examination, 53 patients presented as confluent (53%), 9 as SSS divergent (9%), 25 as SS divergent (25%), 11 as circular (11%), and 2 as trifurcated (2%). The inter-rater reliability ranked very good; agreement between the two neurosurgeons was 83% (κ = 0.830, p < 0.0005). CONCLUSION The confluence of the venous sinuses is a highly variable anatomical area that is rarely evaluated with neuroimaging before surgery. The classic textbook configuration is not the rule. Using a simplified classification system may increase awareness and hopefully patient safety by preparing the physician for anatomical variations that they will encounter in a surgical or clinical scenario.
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Affiliation(s)
- Fidel Valero-Moreno
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Michael W Pullen
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Henry Ruiz-Garcia
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Ricardo A Domingo
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | | | - Paola Suarez-Meade
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - Aaron Damon
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | | | - Sukhwinder Js Sandhu
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
- Department of Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA
| | - W Christopher Fox
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL, 32224, USA.
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Domingo R, Tripathi S, Abello-Vaamode J, Singh R, Perez-Vega C, Ramos-Fresnedo A, Tawk RG. 397 Direct Carotid Puncture for Mechanical Thrombectomy After Failed Peripheral Access: A Systematic Review and Meta-Analysis. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_397] [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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Tatit RT, Ogilvy CS, Shutran MS, Tawk RG, Yasuda TA, Baccin CE. Plasticity of the adult circle of Willis in response to flow diversion stents. Surg Neurol Int 2023; 14:49. [PMID: 36895205 PMCID: PMC9990810 DOI: 10.25259/sni_1139_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Accepted: 01/28/2023] [Indexed: 02/12/2023] Open
Abstract
Background We present five patients with remodeling of the adult circle of Willis in response to flow diverter stents (FDSs) at the anterior communicating artery (AComA) and the posterior communicating artery (PComA). The observed changes provide a paradigm of how flow change can institute anatomic changes in the adult circle of Willis vasculature. Case Description In the first two cases, after placement of the FDS covering the AComA, there was an increase in size and flow of the contralateral A1-anterior cerebral artery which had previously been hypoplastic. In one of the cases, this led to the filling of the aneurysm and required placement of coils within the lesion which was curative. In case three, the FDS effect led to asymptomatic occlusion of the PComA and associated aneurysm without change of the ipsilateral P1-segement of posterior-cerebral-artery (P1-PCA) caliber. In the fourth case, the FDS covering an aneurysm with a fetal PCA arising from its neck resulted in significant reduction of the aneurysm size, persistent flow and caliber of the fetal PCA, and the hypoplastic ipsilateral P1-PCA. Finally, in the fifth case, after FDS occlusion of the PComA and aneurysm there was increasement in diameter of the ipsilateral P1-PCA that was previously hypoplastic. Conclusion The use of FDS can affect vessels covered by the device and other arteries of the circle of Willis adjacent to the FDS. The phenomena illustrated in the hypoplastic branches appear to be a compensatory response to the hemodynamic changes induced by the divertor and to the altered flow in the circle of Willis.
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Affiliation(s)
- Rafael Trindade Tatit
- Department of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo, Brazil
| | - Christopher S Ogilvy
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Max S Shutran
- Neurosurgical Service, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Rabih G Tawk
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, United States
| | - Thomas A Yasuda
- Department of Interventional Neuroradiology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
| | - Carlos Eduardo Baccin
- Department of Interventional Neuroradiology, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil
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Perez-Vega C, Domingo RA, Tripathi S, Ramos-Fresnedo A, Martínez Santos JL, Rahme RJ, Freeman WD, Sandhu SS, Miller DA, Bendok BR, Brinjikji W, Quinones-Hinojosa A, Meyer FB, Tawk RG, Fox WC. Intracranial Aneurysms in Loeys-Dietz Syndrome: A Multicenter Propensity-Matched Analysis. Neurosurgery 2022; 91:541-546. [PMID: 35876667 DOI: 10.1227/neu.0000000000002070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Accepted: 04/26/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Loeys-Dietz syndrome (LDS) is an autosomal dominant connective tissue disorder characterized by a classic triad of hypertelorism, bifid uvula and/or cleft palate, and generalized arterial tortuosity. There are limited data on the prevalence and rupture risk of intracranial aneurysms (IAs) in the setting of LDS, with no established guidelines. OBJECTIVE To analyze the prevalence and rupture risk of IA in LDS. METHODS Electronic medical records of patients with a confirmed diagnosis of LDS and available cerebrovascular imaging were reviewed. Patients were divided into 2 groups based on the presence of IA. Unmatched and propensity-matched analyses were used to identify potential risk factors for aneurysm formation. RESULTS Records of 1111 patients were screened yielding a total of 60 patients with a diagnosis of LDS. Eighteen (30%) patients had IA, 4 (22.2%) of whom had multiple aneurysms for a total of 24 IAs. Twenty-three (95.8%) aneurysms were located in the anterior circulation; none of them were ruptured. On unmatched analysis, age ( P = .015), smoking history ( P = .034), hypertension ( P = .035), and number of extracranial aneurysms ( P < .001) were significantly higher in patients with IA. After matching for age, sex, race, stroke history, family history, and extracranial aneurysms, smoking history ( P = .009) remained significant. CONCLUSION Patients with LDS have an increased risk of IAs, especially with a history of smoking. The prevalence rate of IAs in our series was 30%. Screening imaging should be considered at diagnosis, and patients should be encouraged to abstain from smoking. Further studies are needed to elucidate the risk of IA rupture and treatment considerations in this unique population.
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Affiliation(s)
- Carlos Perez-Vega
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Shashwat Tripathi
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.,Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | | | - Jaime L Martínez Santos
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.,Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Rudy J Rahme
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | | | - David A Miller
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Bernard R Bendok
- Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona, USA
| | | | | | - Fredric B Meyer
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - W Christopher Fox
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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17
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Raymond J, Gentric JC, Magro E, Nico L, Bacchus E, Klink R, Cognard C, Januel AC, Sabatier JF, Iancu D, Weill A, Roy D, Bojanowski MW, Chaalala C, Barreau X, Jecko V, Papagiannaki C, Derrey S, Shotar E, Cornu P, Eker OF, Pelissou-Guyotat I, Piotin M, Aldea S, Beaujeux R, Proust F, Anxionnat R, Costalat V, Corre ML, Gauvrit JY, Morandi X, Brunel H, Roche PH, Graillon T, Chabert E, Herbreteau D, Desal H, Trystram D, Barbier C, Gaberel T, Nguyen TN, Viard G, Gevry G, Darsaut TE, _ _, _ _, Raymond J, Roy D, Weill A, Iancu D, Bojanowski MW, Chaalala C, Darsaut TE, O’Kelly CJ, Chow MMC, Findlay JM, Rempel JL, Fahed R, Lesiuk H, Drake B, Santos MD, Gentric JC, Nonent M, Ognard J, El-Aouni MC, Magro E, Seizeur R, Timsit S, Pradier O, Desal H, Boursier R, Thillays F, Roualdes V, Piotin M, Blanc R, Aldea S, Cognard C, Januel AC, Sabatier JF, Calviere L, Gauvrit JY, Raoult H, Eugene F, Bras AL, Ferre JC, Paya C, Morandi X, Lecouillard I, Nouhaud E, Ronziere T, Trystram D, Naggara O, Rodriguez-Regent C, Kerleroux B, Barbier C, Gaberel T, Emery E, Touze E, Papagiannaki C, Derrey S, Eker OF, Riva R, Pellisou-Guyotat I, Guyotat J, Berhouma M, Dumot C, Biondi A, Thines L, Bougaci N, Charbonnier G, Bracard S, Anxionnat R, Gory B, Civit T, Bernier-Chastagner V, Barreau X, Marnat G, Jecko V, Penchet G, Gimbert E, Huchet A, Herbreteau D, Boulouis G, Bibi R, Ifergan H, Janot K, Velut S, Brunel H, Roche PH, Graillon T, Peyriere H, Kaya JM, Touta A, Troude L, Boissonneau S, Clarençon F, Shotar E, Sourour N, Lenck S, Premat K, Boch AL, Cornu P, Nouet A, Costalat V, Bonafe A, Dargazanli C, Gascou G, Lefevre PH, Riquelme C, Corre ML, Beaujeux R, Pop R, Proust F, Cebula H, Ollivier I, Spatola G, Spell L, Chalumeau V, Gallas S, Ikka L, Mihalea C, Ozanne A, Caroff J, Chabert E, Mounayer C, Rouchaud A, Caire F, Ricolfi F, Thouant P, Cao C, Mourier KL, Farah W, Nguyen TN, Abdalkader M, Huynh T, Tawk RG, Carlson AP, Silva LAO, Froio NDL, Silva GS, Mont’Alverne FJA, Martins JL, Mendes GN, Miranda RR. Endovascular treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial. J Neurosurg 2022; 138:1393-1402. [PMID: 37132535 DOI: 10.3171/2022.9.jns22987] [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: 05/05/2022] [Accepted: 09/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The role of endovascular treatment in the management of patients with brain arteriovenous malformations (AVMs) remains uncertain. AVM embolization can be offered as stand-alone curative therapy or prior to surgery or stereotactic radiosurgery (SRS) (pre-embolization). The Treatment of Brain AVMs Study (TOBAS) is an all-inclusive pragmatic study that comprises two randomized trials and multiple registries.
METHODS
Results from the TOBAS curative and pre-embolization registries are reported. The primary outcome for this report is death or dependency (modified Rankin Scale [mRS] score > 2) at last follow-up. Secondary outcomes include angiographic results, perioperative serious adverse events (SAEs), and permanent treatment-related complications leading to an mRS score > 2.
RESULTS
From June 2014 to May 2021, 1010 patients were recruited in TOBAS. Embolization was chosen as the primary curative treatment for 116 patients and pre-embolization prior to surgery or SRS for 92 patients. Clinical and angiographic outcomes were available in 106 (91%) of 116 and 77 (84%) of 92 patients, respectively. In the curative embolization registry, 70% of AVMs were ruptured, and 62% were low-grade AVMs (Spetzler-Martin grade I or II), while the pre-embolization registry had 70% ruptured AVMs and 58% low-grade AVMs. The primary outcome of death or disability (mRS score > 2) occurred in 15 (14%, 95% CI 8%–22%) of the 106 patients in the curative embolization registry (4 [12%, 95% CI 5%–28%] of 32 unruptured AVMs and 11 [15%, 95% CI 8%–25%] of 74 ruptured AVMs) and 9 (12%, 95% CI 6%–21%) of the 77 patients in the pre-embolization registry (4 [17%, 95% CI 7%–37%] of 23 unruptured AVMs and 5 [9%, 95% CI 4%–20%] of 54 ruptured AVMs) at 2 years. Embolization alone was confirmed to occlude the AVM in 32 (30%, 95% CI 21%–40%) of the 106 curative attempts and in 9 (12%, 95% CI 6%–21%) of 77 patients in the pre-embolization registry. SAEs occurred in 28 of the 106 attempted curative patients (26%, 95% CI 18%–35%, including 21 new symptomatic hemorrhages [20%, 95% CI 13%–29%]). Five of the new hemorrhages were in previously unruptured AVMs (n = 32; 16%, 95% CI 5%–33%). Of the 77 pre-embolization patients, 18 had SAEs (23%, 95% CI 15%–34%), including 12 new symptomatic hemorrhages [16%, 95% CI 9%–26%]). Three of the hemorrhages were in previously unruptured AVMs (3/23; 13%, 95% CI 3%–34%).
CONCLUSIONS
Embolization as a curative treatment for brain AVMs was often incomplete. Hemorrhagic complications were frequent, even when the specified intent was pre-embolization before surgery or SRS. Because the role of endovascular treatment remains uncertain, it should preferably, when possible, be offered in the context of a randomized trial.
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Affiliation(s)
- Jean Raymond
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | | | - Elsa Magro
- Department of Neurosurgery, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | - Lorena Nico
- Department of Radiology, CHU Saint-Etienne, France
| | - Emma Bacchus
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Ruby Klink
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | | | | | - Jean-François Sabatier
- Neurosurgery, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Daniela Iancu
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Alain Weill
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Daniel Roy
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Michel W. Bojanowski
- Department of Surgery, Division of Neurosurgery, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Chiraz Chaalala
- Department of Surgery, Division of Neurosurgery, Centre hospitalier de l’Université de Montréal (CHUM), Montréal, Québec, Canada
| | - Xavier Barreau
- Neuroradiology Department, Pellegrin Hospital Group, CHU Bordeaux, France
| | - Vincent Jecko
- Neurosurgery Department A, Pellegrin Hospital Group, CHU Bordeaux, France
| | | | - Stéphane Derrey
- Neurosurgery, Charles Nicolle Hospital, Rouen Normandy University Hospital, Rouen, France
| | | | - Philippe Cornu
- Neurosurgery, Mercy Salpetriere Hospital AP-HP, Paris, France
| | | | | | | | - Sorin Aldea
- Neurosurgery, Adolphe de Rothschild Foundation Hospital, Paris, France
| | | | - François Proust
- Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
| | - René Anxionnat
- Interventional Neuroradiology Department, University of Lorraine, Laboratory IADI INSERM U1254, CHRU Nancy, France
| | | | | | | | | | - Hervé Brunel
- Departments of Interventional Neuroradiology and
| | | | | | - Emmanuel Chabert
- Interventional Neuroradiology Department, CHU Clermont-Ferrand, France
| | - Denis Herbreteau
- Interventional Neuroradiology Department, Bretonneau Hospital, Tours, France
| | - Hubert Desal
- Interventional Neuroradiology Department, CHU de Nantes, France
| | - Denis Trystram
- Interventional Neuroradiology Department, University of Paris, INSERM U1266, IPNP, GHU Paris, France
- Psychiatry and Neurosciences, Sainte-Anne Hospital, Paris, France
| | | | | | - Thanh N. Nguyen
- Departments of Radiology,
- Neurology, and
- Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts; and
| | | | - Guylaine Gevry
- Department of Radiology, Service of Neuroradiology, Centre hospitalier de l’Université de Montréal (CHUM), and CHUM Research Centre, Montréal, Québec, Canada
| | - Tim E. Darsaut
- Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
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18
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Darsaut TE, Magro E, Bojanowski MW, Chaalala C, Nico L, Bacchus E, Klink R, Iancu D, Weill A, Roy D, Sabatier JF, Cognard C, Januel AC, Pelissou-Guyotat I, Eker O, Roche PH, Graillon T, Brunel H, Proust F, Beaujeux R, Aldea S, Piotin M, Cornu P, Shotar E, Gaberel T, Barbier C, Corre ML, Costalat V, Jecko V, Barreau X, Morandi X, Gauvrit JY, Derrey S, Papagiannaki C, Nguyen TN, Abdalkader M, Tawk RG, Huynh T, Viard G, Gevry G, Gentric JC, Raymond J. Surgical treatment of brain arteriovenous malformations: clinical outcomes of patients included in the registry of a pragmatic randomized trial. J Neurosurg 2022; 138:891-899. [PMID: 36087316 DOI: 10.3171/2022.7.jns22813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 07/15/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The Treatment of Brain Arteriovenous Malformations Study (TOBAS) is a pragmatic study that includes 2 randomized trials and registries of treated or conservatively managed patients. The authors report the results of the surgical registry. METHODS TOBAS patients are managed according to an algorithm that combines clinical judgment and randomized allocation. For patients considered for curative treatment, clinicians selected from surgery, endovascular therapy, or radiation therapy as the primary curative method, and whether observation was a reasonable alternative. When surgery was selected and observation was deemed unreasonable, the patient was not included in the randomized controlled trial but placed in the surgical registry. The primary outcome of the trial was mRS score > 2 at 10 years (at last follow-up for the current report). Secondary outcomes include angiographic results, perioperative serious adverse events, and permanent treatment-related complications leading to mRS score > 2. RESULTS From June 2014 to May 2021, 1010 patients were recruited at 30 TOBAS centers. Surgery was selected for 229/512 patients (44%) considered for curative treatment; 77 (34%) were included in the surgery versus observation randomized trial and 152 (66%) were placed in the surgical registry. Surgical registry patients had 124/152 (82%) ruptured and 28/152 (18%) unruptured arteriovenous malformations (AVMs), with the majority categorized as low-grade Spetzler-Martin grade I-II AVM (118/152 [78%]). Thirteen patients were excluded, leaving 139 patients for analysis. Embolization was performed prior to surgery in 78/139 (56%) patients. Surgical angiographic cure was obtained in 123/139 all-grade (89%, 95% CI 82%-93%) and 105/110 low-grade (95%, 95% CI 90%-98%) AVM patients. At the mean follow-up of 18.1 months, 16 patients (12%, 95% CI 7%-18%) had reached the primary safety outcome of mRS score > 2, including 11/16 who had a baseline mRS score ≥ 3 due to previous AVM rupture. Serious adverse events occurred in 29 patients (21%, 95% CI 15%-28%). Permanent treatment-related complications leading to mRS score > 2 occurred in 6/139 patients (4%, 95% CI 2%-9%), 5 (83%) of whom had complications due to preoperative embolization. CONCLUSIONS The surgical treatment of brain AVMs in the TOBAS registry was curative in 88% of patients. The participation of more patients, surgeons, and centers in randomized trials is needed to definitively establish the role of surgery in the treatment of unruptured brain AVMs. Clinical trial registration no.: NCT02098252 (ClinicalTrials.gov).
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Affiliation(s)
- Tim E Darsaut
- 1Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Elsa Magro
- 2Department of Neurosurgery, CHU Cavale Blanche, INSERM UMR 1101 LaTIM, Brest, France
| | - Michel W Bojanowski
- 3Department of Surgery, Division of Neurosurgery, University of Montreal Health Centre (CHUM), Montreal, Quebec, Canada
| | - Chiraz Chaalala
- 3Department of Surgery, Division of Neurosurgery, University of Montreal Health Centre (CHUM), Montreal, Quebec, Canada
| | - Lorena Nico
- 4Division of Interventional Neuroradiology, Department of Radiology, CHU Saint-Etienne, North Hospital, Saint-Etienne, France
| | - Emma Bacchus
- 1Division of Neurosurgery, Department of Surgery, University of Alberta Hospital, Mackenzie Health Sciences Centre, Edmonton, Alberta, Canada
| | - Ruby Klink
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada
| | - Daniela Iancu
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Alain Weill
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Daniel Roy
- 6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
| | - Jean-Francois Sabatier
- 7Department of Neurosurgery, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Christophe Cognard
- 8Diagnostic and Therapeutic Neuroradiology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | - Anne-Christine Januel
- 8Diagnostic and Therapeutic Neuroradiology Department, Pierre-Paul Riquet Hospital, Toulouse University Hospital, Toulouse, France
| | | | - Omer Eker
- 10Diagnostic and Interventional Neurological Imaging, Pierre Wertheimer Neurological Hospital, Hospices Civils de Lyon, Lyon, France
| | | | - Thomas Graillon
- 12Department of Neurosurgery, Aix Marseille University, INSERM, AP-HM, MMG, UMR1251, Marmara Institute, La Timone Hospital, Marseille, France
| | - Hervé Brunel
- 13Department of Neuroradiology, La Timone Hospital, AP-HM, Marseille, France
| | - Francois Proust
- 14Department of Neurosurgery, Strasbourg University Hospitals, Strasbourg, France
| | - Rémy Beaujeux
- 15Department of Interventional Neuroradiology, University Hospital of Strasbourg, Strasbourg, France
| | | | - Michel Piotin
- 17Interventional Radiology, Adolphe de Rothschild Foundation Hospital, Paris, France
| | | | - Eimad Shotar
- 19Neuroradiology, Mercy Salpetriere Hospital AP-HP, Paris, France
| | | | - Charlotte Barbier
- 21Vascular and Interventional Imaging, CHU Caen Normandie, Caen, France
| | | | | | - Vincent Jecko
- 24Neurosurgery Department A, Pellegrin Hospital Group, CHU Bordeaux, Bordeaux, France
| | - Xavier Barreau
- 25Diagnostic and Therapeutic Neuroradiology Department, Pellegrin Hospital Group, CHU Bordeaux, Bordeaux, France
| | | | - Jean-Yves Gauvrit
- 27Neuroradiology, Pontchaillou Hospital, Rennes University Hospital, Rennes, France
| | | | | | - Thanh N Nguyen
- Departments of30Radiology.,31Neurology, and.,32Neurosurgery, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | | | | | - Thien Huynh
- 34Radiology, Mayo Clinic, Jacksonville, Florida
| | - Geraldine Viard
- 35Clinical Investigation Center, CHU Brest, Brest, France; and
| | - Guylaine Gevry
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada
| | - Jean-Christophe Gentric
- 36Department of Interventional Neuroradiology, Cavale Blanche Hospital, Brest University Hospital, Brest, France
| | - Jean Raymond
- 5Research Centre of the University of Montreal Hospital Centre, Interventional Neuroradiology Research Laboratory (NRI), Montreal, Quebec, Canada.,6Department of Radiology, Service of Neuroradiology, Hospital Centre of the University of Montreal (CHUM), Montreal, Quebec, Canada
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Perez AF, Fox WC, Huynh T, Abello-Vaamonde JA, Farres H, Miller DA, Tawk RG, Sandhu SJS, Meschia JF, Erben Y. Imaging Characteristics and Reintervention in Patients After Radiation Induced Carotid Artery Stenting. Ann Vasc Surg 2022; 87:369-379. [PMID: 35817386 DOI: 10.1016/j.avsg.2022.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Revised: 05/29/2022] [Accepted: 06/14/2022] [Indexed: 11/01/2022]
Abstract
OBJECTIVE To evaluate and describe the radiographic imaging findings in a series of patients who underwent re-intervention after radiation-induced carotid artery stenting (RICAS). METHODS Retrospective review of patients with prior RICAS and subsequent re-intervention. RESULTS We describe ten patients including eight male and two female patients with twelve re-interventions due to prior diagnosed radiation induced carotid artery stenosis (RICS) and subsequent stenting during the period 2000-2019. The rate of re-intervention was found to be 10%. The pattern of stenosis is unique to this patient population including specifically long-segment stenosis, proximal and distal to the stent location, which tends not to occur in the atherosclerotic patient population. CONCLUSION Careful surveillance after RICAS is necessary to assess for the risk and the unusual pattern of stenosis to offer re-intervention in this high-risk patient population.
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Affiliation(s)
- Ana Fuentes Perez
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Thien Huynh
- Department of Radiology, Mayo Clinic, Jacksonville, FL
| | | | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Rabih G Tawk
- Department of Neurosurgery, Mayo Clinic, Jacksonville, FL
| | | | | | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
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Domingo RA, Ramos-Fresnedo A, Perez-Vega C, Tripathi S, Pullen MW, Martinez JL, Erben YM, Meschia J, Tawk RG. Cerebral venous thrombosis during the COVID-19 Pandemic: A multi-center experience. Clin Neurol Neurosurg 2022; 217:107256. [PMID: 35462303 PMCID: PMC9017058 DOI: 10.1016/j.clineuro.2022.107256] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 04/07/2022] [Accepted: 04/17/2022] [Indexed: 11/29/2022]
Abstract
Objective To describe the clinical characteristics and outcomes of CVT in patients with history of recent COVID-19 infection or vaccination. Methods We reviewed demographic, clinical, and radiographic characteristics of non-pyrogenic, non-traumatic CVT cases at our multi-center institution between March 2020 and December 2021. Patients were grouped according to their history of recent COVID-19 infection or vaccination into group-I (+COVID-19 association) and group-II (-COVID-19 association). Results Fifty-one patients with CVT were included, of which 14 (27.4%) had a positive COVID-19 association: 10 with infection and 4 with mRNA-COVID-vaccine. Nine patients in group-I had COVID-19 infection or vaccine within 30 days of CVT diagnosis, including 3 patients with active infection at the time of CVT diagnosis. Half of the patients in group-I (n = 7,50.0%) and 32.4% (n = 12) of group-II were male, and mean age was 52.6 years in group-I and 51.4 years in group-II. Fever at presentation was noted in one patient who had active COVID infection (I=1 (7.1%), II= 0 (0%)). Higher rates of comorbidities were observed in group-II: hypertension (I= 2 (14.3%), II= 13 (35.1%)), deep venous thrombosis(I=1(7.1%), II= 10 (27.0%)), pulmonary emboli (I=1(7.1%), II= 8(21.6%)), or stroke(I=0(0%), II= 6(16.4%)). Three patients had thrombocytopenia at the time of CVT diagnosis (5.4%) and most patients (n = 37, 72.5%) were treated medically with anticoagulation. Complication rate during hospitalization was 17.6% (n = 6), and no mortality was noted. Conclusion Twenty-seven percent of CVT patients were associated with COVID-19 infection or vaccination, and the majority presented within 30 days of infection/vaccination.
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Affiliation(s)
- Ricardo A Domingo
- Neurologic Surgery Department, Mayo Clinic, Jacksonville, Florida, USA
| | | | - Carlos Perez-Vega
- Neurologic Surgery Department, Mayo Clinic, Jacksonville, Florida, USA
| | - Shashwat Tripathi
- Neurologic Surgery Department, Mayo Clinic, Jacksonville, Florida, USA; Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Michael W Pullen
- Neurologic Surgery Department, Mayo Clinic, Jacksonville, Florida, USA
| | - Jaime L Martinez
- Neurologic Surgery Department, Mayo Clinic, Jacksonville, Florida, USA
| | - Young M Erben
- Neurology Department, Mayo Clinic, Jacksonville, Florida, USA
| | - James Meschia
- Neurology Department, Mayo Clinic, Jacksonville, Florida, USA
| | - Rabih G Tawk
- Neurologic Surgery Department, Mayo Clinic, Jacksonville, Florida, USA.
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Domingo RA, Ramos-Fresnedo A, Ravindran K, Tawk RG. Combined anterior and posterior circulation approach for stent-assisted coiling of a recurrent basilar tip aneurysm. J Neurointerv Surg 2022; 15:512. [PMID: 35595408 DOI: 10.1136/neurintsurg-2022-019002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 05/03/2022] [Indexed: 11/04/2022]
Abstract
Endovascular treatment of recurrent basilar aneurysms is challenging due to significant changes in the configuration of the aneurysm and adjacent vessels from prior interventions.1 Coil compaction is a common cause of recurrence and alters the aneurysm morphology significantly.2-4 Stenting of the basilar artery into a posterior cerebral artery modifies the angles between these vessels.5 In this video, we discuss a combined approach via the anterior and posterior circulation for stent-assisted coiling of a recurrent basilar tip aneurysm (Video 1) . A patient in their 40s with a history of ruptured aneurysm underwent multiple endovascular interventions including coiling, stent-assisted coiling, and Woven Endobridge (WEB) device. The patient presented with worsening headaches and underwent treatment with stent-assisted coiling for recurrence. After encountering challenges with direct access from the basilar artery, a combined anterior and posterior circulation approach was used.6 The stent was deployed through the posterior communicating artery and a snare was used to navigate the complex anatomy.neurintsurg;neurintsurg-2022-019002v1/V1F1V1Video 1Disclaimer: this video summarises a scientific article published by BMJ Publishing Group Limited (BMJ). The content of this video has not been peer-reviewed and does not constitute medical advice. Any opinions expressed are solely those of the contributors. Viewers should be aware that professionals in the field may have different opinions. BMJ does not endorse any opinions expressed or recommendations discussed. Viewers should not use the content of the video as the basis for any medical treatment. BMJ disclaims all liability and responsibility arising from any reliance placed on the content.
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Affiliation(s)
| | | | | | - Rabih G Tawk
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA
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22
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Erben Y, Lin M, Franco-Mesa C, Huang JF, Sandhu SS, Miller D, Tawk RG. Through-and-Through Brachio/Radio-Femoral Access Technique for Endovascular Recanalization of the Left Subclavian Artery. Aorta (Stamford) 2022; 10:38-40. [PMID: 35640587 PMCID: PMC9179226 DOI: 10.1055/s-0042-1743198] [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] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
The authors illustrate the use of through-and-through brachio/radio-femoral access technique in two patients who presented with subclavian steal syndrome. This is an additional tool in the armamentarium of the endovascular specialist to improve management of complex cases with subclavian steal syndrome. This technique provides several advantages to improve efficiency and precision of the procedure while reserving the open surgical bypass option if needed.
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Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | - Michelle Lin
- Department of Neurology, Mayo Clinic, Jacksonville, Florida
| | - Camila Franco-Mesa
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, Florida
| | | | | | - David Miller
- Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Rabih G. Tawk
- Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida
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Akinduro OO, Gopal N, Hasan TF, Nourollah-Zadeh E, Vakharia K, De Leacy R, Burkhardt JK, Yamamoto J, Mocco J, Castilla LR, Kan PTM, Boulos A, Levy E, Tawk RG. Pipeline Embolization Device for Treatment of Extracranial Internal Carotid Artery Pseudoaneurysms: A Multicenter Evaluation of Safety and Efficacy. Neurosurgery 2021. [DOI: 10.1093/neuros/nyz548_s025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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24
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Domingo RA, Tripathi S, Perez-Vega C, Martinez J, Suarez Meade P, Ramos-Fresnedo A, English SW, Huynh T, Lin MP, Fox WC, Tawk RG. Influence of Platelet Count on Procedure-Related Outcomes After Mechanical Thrombectomy for Large Vessel Occlusion: A Systematic Review and Meta-Analysis. World Neurosurg 2021; 157:187-192.e1. [PMID: 34653708 DOI: 10.1016/j.wneu.2021.10.080] [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: 08/19/2021] [Revised: 10/04/2021] [Accepted: 10/05/2021] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To compare outcomes between patients who underwent mechanical thrombectomy for large vessel occlusion based on platelet count: low versus normal. METHODS Three studies were included with a pooled cohort of 1125 patients. Data points were collected and pooled by meta-analysis of proportions via a logit transformation to provide a summary statistic. Both fixed-effect and random-effects models were recruited for the analysis. In this meta-analysis, risk of developing symptomatic intracranial hemorrhage, unfavorable clinical outcomes (modified Rankin Scale score >3), and mortality of patients with low platelet counts were compared with patients with normal platelet counts according to the criteria for inclusion used by each study. RESULTS Of patients, 50 (4.7%) had low platelet count, and 1075 (95.3%) had normal platelet count. Patients in the low platelet count group had a substantially higher risk of mortality (risk ratio 1.93, 95% confidence interval 1.43-2.60, P < 0.0001, I2 = 0%), but no differences in clinical outcomes (risk ratio 0.66, 95% confidence interval 0.40-1.11, P = 0.12, I2 = 0%) or symptomatic intracranial hemorrhage (risk ratio 2.03, 95% confidence interval 0.87-4.70, P = 0.10, I2 = 15%) were noted. CONCLUSIONS Patients with low platelet counts had increased mortality compared with patients with normal platelet counts following mechanical thrombectomy for large vessel occlusion.
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Affiliation(s)
- Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Shashwat Tripathi
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA; Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Carlos Perez-Vega
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Jaime Martinez
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Paola Suarez Meade
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | | | | | - Thien Huynh
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, USA
| | - Michelle P Lin
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - W Christopher Fox
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.
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25
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Domingo RA, De Biase G, Navarro R, Santos JLM, Rivas GA, Gupta V, Miller D, Bendok BR, Brinjikji W, Fox WC, Huynh TJ, Tawk RG. Clinical and radiographic characteristics of sacral arteriovenous fistulas: a multicenter experience. J Neurosurg Spine 2021:1-11. [PMID: 34624835 DOI: 10.3171/2021.5.spine21119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 05/17/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Available data on management of sacral arteriovenous fistulas (sAVFs) are limited to individual case reports and small series. Management includes observation, endovascular embolization, or surgical ligation, with no clear guidelines on the optimal treatment modality. The authors' objective was to report their multiinstitutional experience with management of sAVF patients, including clinical and radiographic characteristics and postprocedural outcomes. METHODS The electronic medical records of patients with a diagnosis of spinal arteriovenous fistula treated from January 2004 to December 2019 at the authors' institutions were reviewed, and data were summarized using descriptive statistics, including percentage and count for categorical data, median as a measure of central tendency for continuous variables, and interquartile range (IQR) as a measure of dispersion. RESULTS A total of 26 patients with sAVFs were included. The median (IQR) age was 65 (57-73) years, and 73% (n = 19) of patients were male. Lower-extremity weakness was the most common presenting symptom (n = 24 [92%]), and half the patients (n = 13 [50%]) reported bowel and bladder sphincter dysfunction. The median (IQR) time from symptom onset to treatment was 12 (5.25-26.25) months. Radiographically, all patients had T2 hyperintensity at the level of the conus medullaris (CM) (n = 26 [100%]). Intradural flow voids were identified in 85% (n = 22) of patients. The majority of the lesions had a single identifiable arterial feeder (n = 19 [73%]). The fistula was located most commonly at the S1 level (n = 13 [50%]). The site where the draining vein connects to the pial venous plexus was seen predominantly at the lumbar level (n = 16 [62%]). In total, 29 procedures were performed: 10 open surgeries and 19 endovascular embolization procedures. Complete occlusion was achieved in 90% (n = 9) of patients after open surgery and 79% (n = 15) after endovascular embolization. Motor improvement was seen in 68% of patients (n = 15), and bladder and bowel function improved in 9 patients (41%). At last follow-up, 73% (n = 16) of patients had either resolution or improvement of the pretreatment intramedullary T2 signal hyperintensity. CONCLUSIONS T2 hyperintensity of the CM and a dilated filum terminale vein are consistent radiographic signs of sAVF, and delayed presentation is common. Complete occlusion was achieved in almost all patients after surgery, and endovascular embolization was effective in 70% of the patients. Further studies are needed to determine the best treatment modality based on case-specific characteristics.
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Affiliation(s)
- Ricardo A Domingo
- 1Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Gaetano De Biase
- 1Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Ramon Navarro
- 2Department of Neurologic Surgery, Cleveland Clinic, Abu Dhabi, United Arab Emirates
| | - Jaime L Martinez Santos
- 1Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida.,3Department of Neurologic Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Gabriella A Rivas
- 4School of Medicine, Saint George's University, Great River, New York
| | - Vivek Gupta
- 5Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - David Miller
- 5Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Bernard R Bendok
- 6Department of Neurologic Surgery, Mayo Clinic, Phoenix, Arizona; and
| | | | - W Christopher Fox
- 1Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Thien J Huynh
- 5Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - Rabih G Tawk
- 1Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
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Perez-Vega C, Domingo RA, Tripathi S, Ramos-Fresnedo A, Kashyap S, Quinones-Hinojosa A, Lin MP, Fox WC, Tawk RG. Influence of glucose levels on clinical outcome after mechanical thrombectomy for large-vessel occlusion: a systematic review and meta-analysis. J Neurointerv Surg 2021; 14:neurintsurg-2021-017771. [PMID: 34362794 DOI: 10.1136/neurintsurg-2021-017771] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 06/16/2021] [Indexed: 12/29/2022]
Abstract
Mechanical thrombectomy (MT) represents the mainstay of treatment for patients with acute ischemic stroke due to large-vessel occlusion (LVO). Intravenous thrombolysis has been associated with worse clinical outcome in patients presenting with high blood glucose levels at admission; to date the true effect of hyperglycemia in the setting of MT has not been fully elucidated. In this meta-analysis, we analyzed the influence of high blood glucose levels at admission on clinical outcome after MT. Ovid EMBASE, PubMed, Scopus, and Cochrane Library databases were searched from their dates of inception up to March 2021. An initial search identified 2118 articles representing 1235 unique studies. After applying selection criteria, three prospective and five retrospective studies were analyzed, yielding a pooled cohort of 5861 patients (2041 who presented with hyperglycemia, and 3820 who presented with normal blood glucose levels). Patients in the hyperglycemia group were less likely to have a modified Ranking Scale (mRS) score <3 (risk ratio (RR): 0.65; 95% CI 0.59 to 0.72; p<0.0001; I 2=13%), and had an increased risk of symptomatic intracranial hemorrhage (sICH) (RR: 2.07; 95% CI 1.65 to 2.60; p<0.0001; I 2=0%) and mortality (RR: 1.73; 95% CI 1.57 to 1.91; p<0.0001; I 2=0%). Patients who present with hyperglycemia and undergo MT for treatment of LVO have an increased risk of unfavorable clinical outcome, sICH, and mortality. Glucose levels at admission appear to be a prognostic factor in this subset of patients. Further studies should focus on evaluating control of the glucose level at admission as a modifiable risk factor in patients undergoing MT for LVO.
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Affiliation(s)
- Carlos Perez-Vega
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Shashwat Tripathi
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.,Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | | | - Samir Kashyap
- Department of Neurosurgery, Riverside University Health System, Riverside, California, USA
| | | | - Michelle P Lin
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, USA
| | - W Christopher Fox
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Domingo RA, Ravindran K, Tawk RG. Carotid Stenting: Flow Reversal Technique: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E111-E112. [PMID: 33929024 DOI: 10.1093/ons/opab119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 02/21/2021] [Indexed: 11/14/2022] Open
Abstract
Management options for carotid stenosis include medical management, carotid endarterectomy, carotid stenting with distal filter protection, or stenting with either flow arrest or flow reversal techniques.1 Flow reversal with transcarotid artery revascularization (TCAR) technique represents a hybrid approach with surgical access to the common carotid for endovascular placement of a stent in the internal carotid artery. This direct access to the carotid artery avoids navigating the challenging anatomy of the aortic arch with endovascular devices.2 Compared to transfemoral stenting, TCAR possesses lower risk of transient ischemic attack and stroke, and compared to carotid endarterectomy, there is less risk of cranial neuropathy.3,4 We present the case of an 87-yr-old man with recurrent severe stenosis (85%) of the right internal carotid artery. The patient had a remote history of bilateral endarterectomies for asymptomatic stenosis and was found with recurrence and progression of right internal carotid artery stenosis. Options were discussed and decision was made to proceed with TCAR after he consented for the procedure. The patient tolerated the procedure well with satisfactory revascularization. Exam remained unremarkable prior to discharge on postoperative day 1 and during follow-up at 1 mo. Patient consented to the publication of their image.
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Affiliation(s)
- Ricardo A Domingo
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Krishnan Ravindran
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Domingo RA, Ravindran K, Kulakova K, Tawk RG. Intracranial Access: Dural Venous Sinus Stenting: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E113-E114. [PMID: 33891009 DOI: 10.1093/ons/opab120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Accepted: 02/21/2021] [Indexed: 11/13/2022] Open
Abstract
Cerebral venous sinus stenting has gained popularity in recent years as a safe and efficacious treatment of selected patients with idiopathic intracranial hypertension (IIH) and focal venous sinus stenosis.1-3 The main goal of treatment is to prevent visual loss, and often patients report resolution of headache and visual symptoms within 21 mo of mean follow-up.4-8 We present the case of a 57-yr-old woman with medically refractory IIH, bilateral sinus stenosis, and a mass lesion causing stenosis on the left. Venous angiogram with pressure monitoring was completed with the patient awake, which showed a significant pressure gradient on the right (19 mm Hg) and borderline gradient on the left (8 mm Hg). Options were reviewed and decision was made to proceed with the treatment of the right-sided stenosis with stenting and continue with the observation of the lesion on the left to prevent further visual deterioration. The patient consented for the procedure, and she tolerated the procedure well. Neurological exam remained at baseline, and she was discharged home on post-operative day #1. At 2 mo's follow-up, the patient reported improvement in headaches and remained intact neurologically.
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Affiliation(s)
- Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Krishnan Ravindran
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Katya Kulakova
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.,Sechenov First Moscow State Medical University, Moscow, Russia
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Tawk RG, Hasan TF, D'Souza CE, Peel JB, Freeman WD. Diagnosis and Treatment of Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage. Mayo Clin Proc 2021; 96:1970-2000. [PMID: 33992453 DOI: 10.1016/j.mayocp.2021.01.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/27/2020] [Accepted: 01/12/2021] [Indexed: 12/11/2022]
Abstract
Unruptured intracranial aneurysms (UIAs) are commonly acquired vascular lesions that form an outpouching of the arterial wall due to wall thinning. The prevalence of UIAs in the general population is 3.2%. In contrast, an intracranial aneurysm may be manifested after rupture with classic presentation of a thunderclap headache suggesting aneurysmal subarachnoid hemorrhage (SAH). Previous consensus suggests that although small intracranial aneurysms (<7 mm) are less susceptible to rupture, aneurysms larger than 7 mm should be treated on a case-by-case basis with consideration of additional risk factors of aneurysmal growth and rupture. However, this distinction is outdated. The PHASES score, which comprises data pooled from several prospective studies, provides precise estimates by considering not only the aneurysm size but also other variables, such as the aneurysm location. The International Study of Unruptured Intracranial Aneurysms is the largest observational study on the natural history of UIAs, providing the foundation to the current guidelines for the management of UIAs. Although SAH accounts for only 3% of all stroke subtypes, it is associated with considerable burden of morbidity and mortality. The initial management is focused on stabilizing the patient in the intensive care unit with close hemodynamic and serial neurologic monitoring with endovascular or open surgical aneurysm treatment to prevent rebleeding. Since the results of the International Subarachnoid Aneurysm Trial, treatment of aneurysmal SAH has shifted from surgical clipping to endovascular coiling, which demonstrated higher odds of survival free of disability at 1 year after SAH. Nonetheless, aneurysmal SAH remains a public health hazard and is associated with high rates of disability and death.
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Affiliation(s)
- Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport
| | | | | | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL; Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Critical Care, Mayo Clinic, Jacksonville, FL
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30
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Domingo RA, Martinez Santos JL, Ravindran K, Tawk RG. Management of Thromboembolic Complications During Aneurysm Coiling: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 20:E348-E349. [PMID: 33571364 DOI: 10.1093/ons/opaa480] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 11/27/2020] [Indexed: 11/14/2022] Open
Abstract
Thromboembolic complications during aneurysm coiling are rare, with higher rates noted in ruptured aneurysms as patients are not usually premedicated with dual antiplatelet therapy.1,2 Management includes a series of escalating strategies, including medical therapy and intra-arterial thrombolysis.3-6 Additional strategies include mechanical thrombectomy with suction aspiration and stent retrievers.3 Intracranial stenting can be used as a last resource, especially in ruptured cases given the need for dual antiplatelets to prevent stent thrombosis.2 We present the case of a 42-yr-old man with a ruptured left internal carotid artery aneurysm with associated intracranial and intraventricular hemorrhage. The patient was initially presented to an outside facility after he was found in bed unable to speak and with right hemiparesis. The patient consented for surgery and underwent external ventricular drain (EVD) placement for the treatment of obstructive hydrocephalus, followed by diagnostic cerebral angiogram and aneurysm coiling. After the deployment of the last coil, control angiogram showed a small filling defect at the interface between the aneurysm neck and the distal vessel. The patient received intravenous heparin for therapeutic ACT and aspirin load. After progressive enlargement of the thrombus, the patient received intra-arterial glycoprotein (GP) IIB/IIIA inhibitors with a microcatheter positioned proximal to the thrombus. As the thrombus mass continued to enlarge, mechanical thrombectomy with an aspiration catheter was performed twice. Follow-up angiogram 20 min after the second aspiration demonstrated near-complete resolution of the thrombus. The patient recovered from his right hemiparesis, and he was discharged to rehabilitation on POD #21.
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Affiliation(s)
- Ricardo A Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
| | - Jaime L Martinez Santos
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida.,Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | | | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida
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Domingo RA, Ravindran K, Tawk RG. Carotid In-Stent Stenosis: Cutting Balloon Angioplasty: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2021; 21:E240-E241. [PMID: 34097735 DOI: 10.1093/ons/opab194] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 04/04/2021] [Indexed: 11/14/2022] Open
Abstract
In-stent stenosis has a reported prevalence of 14% to 19% at 1-yr follow-up after carotid stenting and is associated with an increased risk of acute ischemic stroke.1,2 Risk factors include female sex, diabetes, and dyslipidemia. Cutting balloon angioplasty is a safe and effective treatment modality for the treatment of carotid in-stent stenosis, and alternative treatment options include observation with medical management and placement of another stent.3,4 The authors present the case of a 61-yr-old man with carotid in-stent restenosis and progressive worsening on serial imaging with ultrasound. The patient had a history of carotid stenting for symptomatic stenosis 6 mo prior and was maintained on aspirin and clopidogrel. In light of the progressive worsening, the in-stent stenosis was confirmed on computed tomography (CT) angiogram. The options were discussed with the patient and he consented for treatment with cutting balloon angioplasty. Final angiogram showed improvement of the luminal diameter with a residual stenosis of 15%. The patient tolerated the procedure well and was discharged home on postoperative day 1. Follow-up ultrasound demonstrated moderate improvement in peak systolic velocities, and the plan is to continue observation with a clinical follow-up and repeat carotid Dopplers at 3 mo.
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Affiliation(s)
- Ricardo A Domingo
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Krishnan Ravindran
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Heemskerk JL, Domingo RA, Tawk RG, Vivas-Buitrago TG, Huang JF, Rogers A, Quinones-Hinojosa A, Abode-Iyamah K, Freeman WD. Time Is Brain: Prehospital Emergency Medical Services Response Times for Suspected Stroke and Effects of Prehospital Interventions. Mayo Clin Proc 2021; 96:1446-1457. [PMID: 33714603 DOI: 10.1016/j.mayocp.2020.08.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 08/17/2020] [Accepted: 08/24/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To compare prehospital time for patients with suspected stroke in Florida with the American Stroke Association (ASA) time benchmarks, and to investigate the effects of dispatch notification and stroke assessment scales on prehospital time. PATIENTS AND METHODS A retrospective analysis was performed using data from Florida's Emergency Medical Services Tracking and Reporting System database. All patients with suspected stroke transported to a treatment center from January 1, 2018, through December 31, 2018, were analyzed. Time intervals from 911 call to hospital arrival were evaluated and compared with ASA benchmarks. RESULTS In 2018, 11,577 patients with suspected stroke were transported to a hospital (mean age, 71.5±15.7 years; 51.5% women). The median alarm-to-hospital time was 33.98 minutes (27.8 to 41.4), with a total emergency medical services (EMS) time of 32.30 minutes (26.5 to 39.478). The on-scene time was the largest time interval with a median of 13.28 minutes (10.0 to 17.4). Emergency medical services encounters met the ASA benchmarks for time in 58% to 62% of the EMS encounters in Florida (recommended 90%; P<.001). The total EMS time was reduced when a stroke notification was reported by the dispatch center (32.00 minutes vs 32.62 minutes; P=.006) or when a stroke assessment scale was used by the EMS personnel (31.88 minutes vs 32.96 minutes; P=.005). CONCLUSION This study reveals a substantial opportunity for improvement in stroke care in Florida. Two prehospital EMS stroke interventions seem to reduce prehospital time for patients with suspected stroke. Adoption of these interventions might improve the stroke systems of care.
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Affiliation(s)
| | | | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL
| | | | | | - Ashley Rogers
- Department of Neurology, Mayo Clinic, Jacksonville, FL
| | | | | | - William D Freeman
- Department of Neurological Surgery, Neurology, and Critical Care Medicine, Mayo Clinic, Jacksonville, FL.
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Reddy V, Todnem N, Franco-Mesa C, Erben Y, Tawk RG, Ritchie C. Endovascular repair of a common femoral artery puncture after losing access using a vascular closure device. J Vasc Surg Cases Innov Tech 2021; 7:466-468. [PMID: 34258485 PMCID: PMC8259393 DOI: 10.1016/j.jvscit.2021.04.026] [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] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/30/2021] [Indexed: 11/02/2022]
Abstract
We present a case of a common femoral artery repair after losing access to the vessel in a 67-year-old woman using a Mynx-Grip vascular closure device. The hematoma over the right common femoral artery was accessed under fluoroscopic guidance. Then, the balloon of the closure device was inflated inside the artery and pulled back against the origin of the puncture site into the common femoral artery. Finally, the collagen plug was deployed and pressed against the outside of the vessel to occlude the puncture site.
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Affiliation(s)
- Vamsi Reddy
- School of Medicine, Medical College of Georgia, Augusta, Ga
| | - Nathan Todnem
- Department of Neurosurgery, Baptist Health Medical Group, Louisville, Ky
| | - Camila Franco-Mesa
- Division of Vascular and Endovascular Surgery, Mayo Clinic Florida, Jacksonville, Fla
| | - Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic Florida, Jacksonville, Fla
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, Fla
| | - Charles Ritchie
- Division of Vascular and Interventional Radiology, Mayo Clinic Florida, Jacksonville, Fla
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Binning MJ, Maxwell CR, McAree M, Veznedaroglu E, Felbaum DR, Arthur A, Goyal N, Wolfe SQ, Tschoe C, Crowley RW, Levy E, Vakharia K, Rai HH, Pandey AS, Daou BJ, Tawk RG, Ringer AJ, Liebman KM. The Use of Antiplatelet Agents and Heparin in the 24-Hour Postintravenous Alteplase Window for Neurointervention. Neurosurgery 2021; 88:746-750. [PMID: 33442725 DOI: 10.1093/neuros/nyaa530] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 09/26/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Intravenous (IV) alteplase with mechanical thrombectomy has been found to be superior to alteplase alone in select patients with intracranial large vessel occlusion. Current guidelines discourage the use of antiplatelet agents or heparin for 24 h following alteplase. However, their use is often necessary in certain circumstances during thrombectomy procedures. OBJECTIVE To study the safety and outcomes in patients who received blood thinning medications for thrombectomy after IV Tissue-Type plasminogen activator (tPA). METHODS This is a multicenter retrospective review of the use of antiplatelet agents and/or heparin in patients within 24 h following tPA administration. Patient demographics, comorbidities, bleeding complications, and discharge outcomes were collected. RESULTS A series of 88 patients at 9 centers received antiplatelet medications and/or heparin anticoagulation following IV alteplase for revascularization procedures requiring stenting. The mean National Institutes of Health Stroke Scale (NIHSS) on admission was 14.6. Reasons for use of a stent included internal carotid artery occlusion in 74% of patients. Thrombolysis in cerebral infarction (TICI) 2b-3 revascularization was accomplished in 90% of patients. The rate of symptomatic intracranial hemorrhage (sICH) was 8%; this was not significantly different than the sICH rate for a matched group of patients not receiving antiplatelets or heparin during the same time frame. Functional independence at 90 d (modified Rankin Scale 0-2) was seen in 57.8% of patients. All-cause mortality was 12%. CONCLUSION The use of antiplatelet agents and heparin for stroke interventions following IV alteplase appears to be safe without significant increased risk of hemorrhagic complications in this group of patients when compared to control data and randomized controlled trials.
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Affiliation(s)
| | | | - Michael McAree
- Global Neurosciences Institute, Lawrenceville, New Jersey
| | | | - Daniel R Felbaum
- Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Adam Arthur
- University of Tennessee, Memphis-Semmes-Murphey Clinic, Memphis, Tennessee
| | - Nitin Goyal
- University of Tennessee, Memphis-Semmes-Murphey Clinic, Memphis, Tennessee
| | | | | | | | - Elad Levy
- University at Buffalo Neurosurgery, Williamsville, New York
| | - Kunal Vakharia
- University at Buffalo Neurosurgery, Williamsville, New York
| | - Hamid H Rai
- University at Buffalo Neurosurgery, Williamsville, New York
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Munner MS, Ritchie CA, Elkhidir IH, Mohammadat DT, Ahmed HJ, Altayeb KA, Yassin RZ, Hassan RM, Hamad SA, Nimir M, Hamid OS, Johnson MM, Narula T, Erben Y, Tawk RG, Miller DA, Gupta V, Devcic Z, Freeman WD, Toskich BB. Incidence of acute pulmonary embolism among patients hospitalized with COVID-19: a systematic review and meta-analysis. F1000Res 2021. [DOI: 10.12688/f1000research.27425.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19) is a global pandemic, which is associated with venous thromboembolism and pulmonary embolism (PE). This study aimed to estimate the pooled incidence of PE among patients hospitalized with COVID-19 within the published literature. Methods: This systematic review and meta-analysis was performed according to PRISMA guidelines. An electronic search using MEDLINE /PubMed, ScienceDirect, Cochrane, and OpenGray databases was conducted May 19th, 2020. Eligible studies included sufficient data to calculate the incidence of PE diagnosed during hospitalization in patients with COVID-19. Case reports were excluded. Quality was assessed using the Newcastle-Ottawa scale (observational cohort and case-control), AXIS tool (cross-sectional), and quality assessment tool (case series). Demographics and PE incidence data were extracted from the included studies and analyzed with R language. The pooled incidence of PE in patients hospitalized with COVID-19 was calculated. Results: The database search identified 128 records. Ten observational studies were eligible and were included in the meta-analysis with a total of 1722 patients (mean age= 63.36). .The incidence of PE was noted to be higher in males. The D-dimer levels were specified between PE group and non-PE group in only three studies, while the remaining either reported it improperly or had missing data.The pooled PE incidence in patients hospitalized with COVID-19 was 17% (95% CI: 0.1-0.26). There was a high degree of study heterogeneity (I2 = 94%, p<0.01). Conclusion: The pooled PE incidence in patients hospitalized with COVID-19 is 17%. This increased incidence is greater than that previously reported in the general population of non-COVID-19. Attention and further investigation of this risk is warranted.
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Erben Y, Franco-Mesa C, Miller D, Lanzino G, Bendok BR, Li Y, Sandhu SJS, Barrett KM, Freeman WD, Lin M, Huang JF, Huynh T, Farres H, Brott TG, Hakaim AG, Brigham TJ, Todnem ND, Tawk RG, Meschia JF. Higher Risk for Reintervention in Patients after Stenting for Radiation-Induced Internal Carotid Artery Stenosis: A Single-Center Analysis and Systematic Review. Ann Vasc Surg 2020; 73:1-14. [PMID: 33373766 DOI: 10.1016/j.avsg.2020.11.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 10/11/2020] [Accepted: 11/16/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study aimed to review short- and long-term outcomes of all carotid artery stenting (CAS) in patients with radiation-induced (RI) internal carotid artery (ICA) stenosis compared with patients with atherosclerotic stenosis (AS). METHODS We performed a single-center, multisite case-control study of transfemoral carotid artery intervention in patients stented for RI or AS. Cases of stented RI carotid arteries were identified using a CAS database covering January 2000 to December 2019. These patients were randomly matched 2:1 with stented patients because of AS by age, sex, and year of CAS. A conditional logistic regression model was performed to estimate the odds of reintervention in the RI group. Finally, a systematic review was performed to assess the outcomes of RI stenosis treated with CAS. RESULTS There were 120 CAS in 113 patients because of RI ICA stenosis. Eighty-nine patients (78.8%) were male, and 68 patients (60.2%) were symptomatic. The reasons for radiation included most commonly treatment for diverse malignancies of the head and neck in 109 patients (96.5%). The mean radiation dose was 58.9 ± 15.6 Gy, and the time from radiation to CAS was 175.3 ± 140.4 months. Symptoms included 31 transient ischemic attacks (TIAs), 21 strokes (7 acute and 14 subacute), and 17 amaurosis fugax. The mean National Institutes of Health Stroke Scale in acute strokes was 8.7 ± 11.2. In asymptomatic patients, the indication for CAS was high-grade stenosis determined by duplex ultrasound. All CAS were successfully completed. Reinterventions were more frequent in the RI ICA stenosis cohort compared with the AS cohort (10.1% vs. 1.4%). Reinterventions occurred in 14 vessels, and causes for reintervention were restenosis in 12 followed by TIA/stroke in two vessels. On conditional regression modeling, patients with RI ICA stenosis were at a higher risk for reintervention (odds ratio = 7.1, 95% confidence interval = 2.1-32.8; P = 0.004). The mean follow-up was 33.7 ± 36.9 months, and the mortality across groups was no different (P = 0.12). CONCLUSIONS In our single-center, multisite cohort study, patients who underwent CAS for RI ICA stenosis experienced a higher rate of restenosis and a higher number of reinterventions compared with CAS for AS. Although CAS is safe and effective for this RI ICA stenosis cohort, further data are needed to reduce the risk of restenosis, and close patient surveillance is warranted. In our systematic review, CAS was considered an excellent alternative option for the treatment of patients with RI ICA stenosis. However, careful patient selection is warranted because of the increased risk of restenosis on long-term follow-up.
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Affiliation(s)
- Young Erben
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL.
| | - Camila Franco-Mesa
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | - David Miller
- Department of Radiology, Mayo Clinic, Jacksonville, FL
| | | | | | - Yupeng Li
- Department of Political Science and Economics, Rowan University, Glassboro, NJ
| | | | | | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, FL; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Michelle Lin
- Department of Neurology, Mayo Clinic, Jacksonville, FL
| | | | - Thien Huynh
- Department of Radiology, Mayo Clinic, Jacksonville, FL
| | - Houssam Farres
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Albert G Hakaim
- Division of Vascular and Endovascular Surgery, Mayo Clinic, Jacksonville, FL
| | | | - Nathan D Todnem
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
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Heemskerk J, Domingo R, Vivas-Buitrago TG, Quiñones-Hinojosa A, Huang J, Tawk RG, Abode-Iyamah K, Freeman W. Time is Brain. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_252] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Ravindran K, Tawk RG. In Reply: Pipeline Embolization Device for Treatment of Extracranial Internal Carotid Artery Pseudoaneurysms: A Multicenter Evaluation of Safety and Efficacy. Neurosurgery 2020; 87:E706. [DOI: 10.1093/neuros/nyaa387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Accepted: 06/27/2020] [Indexed: 11/14/2022] Open
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Domingo R, Tripathi S, Perez-Vega C, Vivas-Buitrago TG, Lu V, Todnem N, Quinones-Hinojosa A, Tawk RG. Treatment of Posterior Circulation Fusiform Aneurysms with Flow Diversion vs Stent-Assisted Coiling. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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40
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Toskich BB, Muneer MS, Gopal N, Akinduro OO, Marenco-Hillembrand L, Ritchie C, Miller DA, Middlebrooks EH, Tawk RG. Mapping angiography and transarterial technetium macroaggregated albumin particle simulation of recurrent atypical intracranial meningioma: feasibility for potential vascular brachytherapy. Radiol Case Rep 2020; 15:2278-2281. [PMID: 32983300 PMCID: PMC7494606 DOI: 10.1016/j.radcr.2020.07.051] [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] [Received: 05/01/2020] [Revised: 07/17/2020] [Accepted: 07/18/2020] [Indexed: 11/17/2022] Open
Abstract
Atypical meningioma (AM) (WHO-II) has a recurrence rate of 28% after gross total resection (GTR) with limited salvage options. Transarterial therapies may provide treatment opportunities in AM patients who exhausted standard-of-care therapy. In cases where favorable tumor vasculature and particle simulation demonstrate acceptable target dose, Yttrium-90 trans-arterial radioemobilization (TARE) could theoretically provide salvage therapy. A 67-year-old man presented with recurrent AM post gross total resection with adjuvant radiotherapy in 2012, 2014, and 2016. The patient was deemed a poor candidate for additional therapies. Tumor vasculature mapping was performed to determine TARE candidacy. Super-selective angiography and contrast-enhanced cone-beam computed tomography angiosomes demonstrated predominant pial collaterals and minor supply from a middle meningeal artery branch. Particle simulation was performed by infusing 0.3 mCi of 99mTc-macroaggregated albumin (99mTc-MAA). SPECT/CT-MRI fusion demonstrated conformal activity solely within the tumor volume perfused by the middle meningeal artery branch with a lung shunt fraction of 54.7%. The patient subsequently received off-label Nivolumab (PD-1 inhibitor). Mapping angiography for AM using 99mTc-MAA is feasible. It may identify candidates for TARE and potential AM patients with favorable blood supply. The potential for conformal intracranial vascular brachytherapy is intriguing, however, altered arterial supply in recurrent tumors is challenging.
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Affiliation(s)
- Beau B. Toskich
- Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - Mohamed S. Muneer
- Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL, USA
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
- Division of Neuroradiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville 32224, FL, USA
| | - Neethu Gopal
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | - Oluwaseun O. Akinduro
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
| | | | - Charles Ritchie
- Division of Interventional Radiology, Mayo Clinic, Jacksonville, FL, USA
| | - David A. Miller
- Division of Neuroradiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville 32224, FL, USA
| | - Erik H. Middlebrooks
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
- Division of Neuroradiology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville 32224, FL, USA
| | - Rabih G. Tawk
- Department of Neurological Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, USA
- Corresponding author.
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Domingo RA, Tripathi S, Perez-Vega C, Vivas-Buitrago T, Lu VM, Todnem ND, Quinones-Hinojosa A, Tawk RG. Treatment of posterior circulation non-saccular aneurysms with flow diversion versus stent-assisted coiling: a systematic review and meta-analysis. J Neurointerv Surg 2020; 13:159-163. [PMID: 32651184 DOI: 10.1136/neurintsurg-2020-016294] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [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: 05/05/2020] [Revised: 06/09/2020] [Accepted: 06/14/2020] [Indexed: 11/03/2022]
Abstract
Treatment of non-saccular aneurysms of the posterior circulation poses a great challenge with unpredictable outcomes due to the absence of a true aneurysm neck and the presence of perforating vessels. In this article, we aim to compare endovascular treatment of unruptured posterior circulation non-saccular aneurysms with stent-assisted coiling (SAC) and flow diversion (FD) in terms of occlusion rate and clinical outcomes. A systematic search of electronic databases from inception to August 2019 identified 484 articles for screening. After proper inclusion/exclusion criteria, 15 articles were included and data were extracted and analyzed using meta-analysis of proportions. The pooled cohort consisted of 430 aneurysms: 128 (29.7%) treated with SAC in 5 studies and 302 (70.3%) treated with FD in 11 studies. Complete/near-complete occlusion was achieved in 83% after FD (95% CI 0.75 to 0.90; I2=45%) and 84% after SAC (95% CI 0.72 to 0.91; I2=22%), with no significant difference between techniques (p=0.95). Periprocedural complications were observed in 18% after FD (95% CI 0.14 to 0.23; I2=0%) and 6% after SAC (95% CI 0.02 to 0.13; I2=0%); the subgroup analysis was statistically significant (p=0.008). Furthermore, no statistically significant difference was observed in favorable clinical outcomes between groups. These results suggest similar efficacy in occlusion rate and favorable clinical outcome for posterior circulation non-saccular aneurysms treated with SAC and FD. Stroke was the most common complication regardless of treatment modality, and a lower periprocedural complication rate was noted with SAC. Further studies are needed with the primary focus of reducing the risk of stroke with either modality.
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Affiliation(s)
- Ricardo A Domingo
- Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | | | - Carlos Perez-Vega
- School of Medicine, Monterrey Institute of Technology and Higher Education - Mexico State Campus, Guadalajara, Mexico
| | | | - Victor M Lu
- Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Nathan D Todnem
- Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
| | | | - Rabih G Tawk
- Neurosurgery, Mayo Clinic Hospital Jacksonville, Jacksonville, Florida, USA
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Schirmer CM, Ringer AJ, Arthur AS, Binning MJ, Fox WC, James RF, Levitt MR, Tawk RG, Veznedaroglu E, Walker M, Spiotta AM. Delayed presentation of acute ischemic strokes during the COVID-19 crisis. J Neurointerv Surg 2020; 12:639-642. [PMID: 32467244 PMCID: PMC7295853 DOI: 10.1136/neurintsurg-2020-016299] [Citation(s) in RCA: 98] [Impact Index Per Article: 24.5] [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: 05/05/2020] [Revised: 05/13/2020] [Accepted: 05/15/2020] [Indexed: 01/13/2023]
Abstract
BACKGROUND The COVID-19 pandemic has disrupted established care paths worldwide. Patient awareness of the pandemic and executive limitations imposed on public life have changed the perception of when to seek care for acute conditions in some cases. We sought to study whether there is a delay in presentation for acute ischemic stroke patients in the first month of the pandemic in the US. METHODS The interval between last-known-well (LKW) time and presentation of 710 consecutive patients presenting with acute ischemic strokes to 12 stroke centers across the US were extracted from a prospectively maintained quality database. We analyzed the timing and severity of the presentation in the baseline period from February to March 2019 and compared results with the timeframe of February and March 2020. RESULTS There were 320 patients in the 2-month baseline period in 2019, there was a marked decrease in patients from February to March of 2020 (227 patients in February, and 163 patients in March). There was no difference in the severity of the presentation between groups and no difference in age between the baseline and the COVID period. The mean interval from LKW to the presentation was significantly longer in the COVID period (603±1035 min) compared with the baseline period (442±435 min, P<0.02). CONCLUSION We present data supporting an association between public awareness and limitations imposed on public life during the COVID-19 pandemic in the US and a delay in presentation for acute ischemic stroke patients to a stroke center.
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Affiliation(s)
- Clemens M Schirmer
- Department of Neurosurgery and Neuroscience Institute, Geisinger Health System, Wilkes-Barre, PA, United States
- Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Scranton, PA, United States
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | | | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Mandy J Binning
- Global Neurosciences Institute, Pennington, NJ, United States
| | - W Christopher Fox
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, United States
| | - Robert F James
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Michael R Levitt
- Neurological Surgery, Radiology and Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL, United States
| | | | - Melanie Walker
- Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Collins CI, Hasan TF, Mooney LH, Talbot JL, Fouraker AL, Nelson KF, Ohanian M, Bonnett SL, Tawk RG, Nordan LM, Hodge DO, Kaplan RS, Thiemann BL, Karney M, Freeman WD. Subarachnoid Hemorrhage "Fast Track": A Health Economics and Health Care Redesign Approach for Early Selected Hospital Discharge. Mayo Clin Proc Innov Qual Outcomes 2020; 4:238-248. [PMID: 32542215 PMCID: PMC7283927 DOI: 10.1016/j.mayocpiqo.2020.04.001] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objective To determine whether earlier hospital discharge is feasible and safe in selected patients with subarachnoid hemorrhage (SAH) using an outpatient “fast-track” protocol. Patients and Methods We conducted a prospective quality improvement cohort study with the primary feasibility end point of patients with SAH deemed safe for discharge by treating team consensus. All patients received detailed education and outpatient transcranial Doppler monitoring; caregivers could contact the on-call team 24-7. Primary safety end points were adverse events after discharge and hospital readmission. Results From January 1, 2010, to January 1, 2015, our center had 377 SAH diagnoses, of which 200 were included in the final cohort, 36 qualifying for fast-track early discharge. The 30-day readmission rate for fast-track patients was 11.0% (4 of 36) compared with 11.4% (18 of 164) for non–fast-track patients. The rate of delayed cerebral ischemia and stroke was 3% (1 of 36) in the fast-track group vs 25.0% (41 of 164) for the non–fast-track group. Adverse events occurred in 11.0% (4 of 36) of the fast-track group compared with 26.0% (43 of 164) in the non–fast-track group. The mean length of stay was reduced 60% from 15 days to 6.6 days in the fast-track group. Conclusion Although our fast-track group was relatively small, data suggested early feasibility and safety in a carefully selected group of patients with SAH. Direct and indirect financial benefits of early discharge over a 5-year period were an estimated savings at least $864,000 in overall costs. A comparative effectiveness study is planned to replicate and validate these results using a larger multicenter design.
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Key Words
- DCI, delayed cerebral ischemia
- ICU, intensive care unit
- LOS, length of stay
- MCA, middle cerebral artery
- QI, quality improvement
- SAH, subarachnoid hemorrhage
- TCD, transcranial Doppler ultrasonography
- TDABC, time-driven activity-based cost
- WFNS, World Federation of Neurological Surgeons
- mFS, modified Fisher scale
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Affiliation(s)
| | - Tasneem F Hasan
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | | | | | | | - Katherine F Nelson
- Department of Physical Medicine and Rehabilitation, Mayo Clinic, Jacksonville, FL
| | | | | | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL
| | - Lisa M Nordan
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Jacksonville, FL
| | - David O Hodge
- Division of Biomedical Statistics and Informatics, Mayo Clinic, Jacksonville, FL
| | - Robert S Kaplan
- Accounting and Management, Harvard Business School, Boston, MA
| | - Benjamin L Thiemann
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL
| | | | - William D Freeman
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL.,Department of Neurology, Mayo Clinic, Jacksonville, FL.,Department of Critical Care and Multidisciplinary Program, Mayo Clinic, Jacksonville, FL
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Zahra K, Turnbull MT, Zubair AC, Siegel JL, Venegas-Borsellino CP, Tawk RG, Freeman WD. A Combined Approach to Intracerebral Hemorrhage: Intravenous Mesenchymal Stem Cell Therapy with Minimally Invasive Hematoma Evacuation. J Stroke Cerebrovasc Dis 2020; 29:104931. [PMID: 32689636 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104931] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 04/08/2020] [Accepted: 05/03/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Mesenchymal stem cells (MSCs) are multipotent stromal cells currently being tested as therapy for a variety of diseases. MSC therapy and hematoma evacuation using a minimally invasive approach are being studied separately to improve clinical outcomes after stroke. We report the first case of a patient with intracerebral hemorrhage (ICH) treated with combination MSC therapy and endoscopic hematoma evacuation. CASE REPORT A 36-year-old woman with a past medical history of essential chronic hypertension and right lung bronchial atresia presented to the emergency department with acute neurologic decline (National Institute of Health Stroke Scale [NIHSS] score, 22). Computed tomography showed a 4.4 × 3.5 × 3.5 cm right basal ganglia hemorrhage with intraventricular extension. An external ventricular drain was placed, and she was enrolled in a Phase I clinical trial investigating intravenous MSC therapy for acute ICH. Continued neurologic deterioration due to increased intracranial pressure led to minimally invasive hematoma evacuation using the Artemis Neuro Evacuation Device (Penumbra, Inc.) on hospital day 4. Follow-up scans showed decreased density and extent of hemorrhage. She was discharged on day 41 with improved neurologic function scores (NIHSS score, 2). At 3-month follow-up, she was walking on her own, but had residual left arm and hand weakness (modified Rankin Score, 2). CONCLUSIONS This case report suggests that the combination of MSC therapy and minimally invasive hematoma evacuation may be safe and well tolerated. Further larger randomized clinical trials are required to identify whether MSC therapy in combination with minimally invasive hematoma evacuation is safe, tolerable, and potentially improves outcomes than either alone.
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Affiliation(s)
- Kaneez Zahra
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States.
| | - Marion T Turnbull
- Department of Neurology, Mayo Clinic, Jacksonville, FL, United States.
| | - Abba C Zubair
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Jacksonville, FL, United States.
| | - Jason L Siegel
- Department of Neurology, Department of Critical Care Medicine, and Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, United States.
| | | | - Rabih G Tawk
- Department of Neurologic Surgery and Department of Radiology, Mayo Clinic, Jacksonville, FL, United States.
| | - William D Freeman
- Department of Neurology, Department of Critical Care Medicine, and Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224, United States.
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Al Shaikh RH, Hasan TF, Becker TL, Ng Tucker LK, Meschia JF, Tawk RG, Ayala E, Freeman WD. Rapidly Resolving and Recurrent Contralateral Subdural Hematoma From Disseminated Intravascular Coagulation. J Stroke Cerebrovasc Dis 2020; 29:104872. [PMID: 32434727 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/20/2020] [Accepted: 04/05/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Acute, recurrent subdural hematoma (SDH) is a rare entity in the absence of trauma. Atraumatic SDH may be due to vascular disorders, coagulopathies, or intracranial hypotension. It is a rare complication of disseminated intravascular coagulation (DIC), with no prior reports in patients with intracranial metastatic colon cancer (MCC). Rapid resolution of the initial acute SDH with contralateral recurrence has not yet been reported in the literature. We present a case of rapidly resolving and recurrent, contralateral acute SDH from DIC secondary to MCC. CASE DESCRIPTION A 77-year-old woman with MCC presented with severe, acute onset headache. She progressed to unresponsiveness, dilated right pupil, and Glasgow Coma Scale (GCS) score of 4T. Initial computed tomography (CT) of the head demonstrated a right, 17-mm SDH with a right-to-left midline shift. Repeat CT head 8 hours later revealed resolution of the right SDH. She was extubated with notable clinical improvement. Laboratory examination showed international normalized ratio of 3.4, leukocytosis, and thrombocytopenia. The next morning, she became lethargic, GCS score of 3, with bilateral fixed pupils and dilated to 5-mm, and she was then reintubated. Repeat CT head demonstrated a new left SDH with bilateral uncal herniation. A small hyperdense focus in the left parietal region was suspicious for intraparenchymal hematoma versus a hemorrhagic metastatic focus. Shortly after, she was extubated due to do not resuscitate status, and she then passed away. CONCLUSIONS To our knowledge, this is the first case illustrating rapidly resolving and recurrent, contralateral acute SDH from DIC in a patient with MCC. Clinical recognition of this phenotypic pattern should raise the question of an underlying coagulopathy.
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Affiliation(s)
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport 71103, Louisiana, United States.
| | - Tara L Becker
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States.
| | - Lauren K Ng Tucker
- Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States.
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States.
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, United States.
| | - Ernesto Ayala
- Department of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida, United States.
| | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida, United States; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, United States.
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Haranhalli N, Mbabuike N, Grewal SS, Hasan TF, Heckman MG, Freeman WD, Gupta V, Vibhute P, Brown BL, Miller DA, Jahromi BS, Tawk RG. Topographic correlation of infarct area on CT perfusion with functional outcome in acute ischemic stroke. J Neurosurg 2020; 132:33-41. [PMID: 30641833 DOI: 10.3171/2018.8.jns181095] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2018] [Accepted: 08/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The role of CT perfusion (CTP) in the management of patients with acute ischemic stroke (AIS) remains a matter of debate. The primary aim of this study was to evaluate the correlation between the areas of infarction and penumbra on CTP scans and functional outcome in patients with AIS. METHODS This was a retrospective review of 100 consecutively treated patients with acute anterior circulation ischemic stroke who underwent CT angiography (CTA) and CTP at admission between February 2011 and October 2014. On CTP, the volume of ischemic core and penumbra was measured using the Alberta Stroke Program Early CT Score (ASPECTS). CTA findings were also noted, including the site of occlusion and regional leptomeningeal collateral (rLMC) score. Functional outcome was defined by modified Rankin Scale (mRS) score obtained at discharge. Associations of CTP and CTA parameters with mRS scores at discharge were assessed using multivariable proportional odds logistic regression models. RESULTS The median age was 67 years (range 19-95 years), and the median NIH Stroke Scale score was 16 (range 2-35). In a multivariable analysis adjusting for potential confounding variables, having an infarct on CTP scans in the following regions was associated with a worse mRS score at discharge: insula ribbon (p = 0.043), perisylvian fissure (p < 0.001), motor strip (p = 0.007), M2 (p < 0.001), and M5 (p = 0.023). A worse mRS score at discharge was more common in patients with a greater volume of infarct core (p = 0.024) and less common in patients with a greater rLMC score (p = 0.004). CONCLUSIONS The results of this study provide evidence that several CTP parameters are independent predictors of functional outcome in patients with AIS and have potential to identify those patients most likely to benefit from reperfusion therapy in the treatment of AIS.
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Affiliation(s)
| | | | | | | | | | | | - Vivek Gupta
- 4Department of Radiology, Mayo Clinic, Jacksonville, Florida; and
| | - Prasanna Vibhute
- 4Department of Radiology, Mayo Clinic, Jacksonville, Florida; and
| | | | | | - Babak S Jahromi
- 5Departments of Neurologic Surgery and Radiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Donaldson AM, Martinez-Paredes J, Domingo R, Tawk RG. Nasal Packing Causing Occlusion of Contralateral Internal Carotid Artery During Control of Pseudoaneurysm Bleed. World Neurosurg 2020; 138:262-268. [PMID: 32142945 DOI: 10.1016/j.wneu.2020.02.132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 02/20/2020] [Accepted: 02/21/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND Carotid pseudoaneurysm is a rare complication of pituitary surgery and can present with epistaxis. Nasal packing is considered first-line treatment for the control of carotid bleeding. We describe a case of complete occlusion of the contralateral cavernous carotid artery because of nasal packing placed to control hemorrhage from a cavernous carotid pseudoaneurysm. CASE DESCRIPTION A 55-year-old man presented with a history of recurrent epistaxis requiring multiple hospital visits and nasal packing over a 9-month period. Nasal endoscopies failed to show a source of bleeding; therefore, the patient underwent bilateral sphenopalatine artery ligations. Postoperative computed tomography angiogram showed no evidence of aneurysm, but did report indistinctness of the lateral sphenoid walls. Symptoms remained controlled for 4 months, but ultimately, he presented to the emergency department with massive epistaxis. A magnetic resonance angiogram noted a 2- to 3-mm left cavernous carotid pseudoaneurysm, and the patient underwent endovascular embolization of bilateral internal maxillary arteries. Significant epistaxis was noted immediately thereafter and he was taken to the operating room to control bleeding. A 4-cm absorbable nasal packing was placed into each sphenoid cavity after profuse bleeding from the left sphenoid sinus was noted. After control of bleeding, cerebral angiogram showed complete occlusion of bilateral internal carotid arteries (ICAs). The right-sided packing was adjusted, and the ICA profusion improved. CONCLUSIONS To our knowledge, this is the only report that describes complete occlusion of the contralateral cavernous carotid artery because of extrinsic compression of the lateral sphenoid wall, in the setting of a symptomatic pseudoaneurysm.
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Affiliation(s)
- Angela M Donaldson
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Jacksonville, Florida, USA.
| | - Jhon Martinez-Paredes
- Department of Otolaryngology-Head & Neck Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Ricardo Domingo
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA
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Tawk RG, Akinduro OO, Grewal SS, Brasiliense L, Grand W, Grotenhuis A. Endoscopic Transforaminal Transchoroidal Approach to the Third Ventricle for Cystic and Solid Tumors. World Neurosurg 2020; 134:e453-e459. [DOI: 10.1016/j.wneu.2019.10.099] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2019] [Revised: 10/15/2019] [Accepted: 10/16/2019] [Indexed: 01/31/2023]
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49
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Akinduro OO, Gopal N, Hasan TF, Nourollah-Zadeh E, Vakharia K, De Leacy R, Burkhardt JK, Yamamoto J, Mocco J, Castilla LR, Tze Man Kan P, Boulos A, Levy E, Tawk RG. Pipeline Embolization Device for Treatment of Extracranial Internal Carotid Artery Pseudoaneurysms: A Multicenter Evaluation of Safety and Efficacy. Neurosurgery 2020; 87:770-778. [DOI: 10.1093/neuros/nyz548] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 11/04/2019] [Indexed: 12/20/2022] Open
Abstract
Abstract
BACKGROUND
There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series.
OBJECTIVE
To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms.
METHODS
This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up.
RESULTS
A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (>90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients.
CONCLUSION
The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.
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Affiliation(s)
| | - Neethu Gopal
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
| | - Tasneem F Hasan
- Department of Neurology, Ochsner Louisiana State University Health Sciences Center, Shreveport, Louisiana
| | | | - Kunal Vakharia
- Department of Neurological Surgery, University at Buffalo, Buffalo, New York
| | - Reade De Leacy
- Department of Neurological Surgery, Mount Sinai, New York, New York
| | - Jan-Karl Burkhardt
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas
| | - Junichi Yamamoto
- Department of Neurological Surgery, Albany Medical Center, Albany, New York
| | - J Mocco
- Department of Neurological Surgery, Mount Sinai, New York, New York
| | | | - Peter Tze Man Kan
- Department of Neurological Surgery, Baylor College of Medicine, Houston, Texas
| | - Alan Boulos
- Department of Neurological Surgery, Albany Medical Center, Albany, New York
| | - Elad Levy
- Department of Neurological Surgery, University at Buffalo, Buffalo, New York
| | - Rabih G Tawk
- Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida
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50
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Jamali SA, Turnbull MT, Kanekiyo T, Vishnu P, Zubair AC, Raper CC, Tawk RG, Freeman WD. Elevated Neutrophil-Lymphocyte Ratio is Predictive of Poor Outcomes Following Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:104631. [PMID: 31964576 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104631] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Accepted: 12/22/2019] [Indexed: 02/09/2023] Open
Abstract
Background Recent studies of patients with intracerebral hemorrhage suggest an association between peripheral blood neutrophil-lymphocyte ratio and neurologic deterioration. We aimed to study the prognostic utility of neutrophil-lymphocyte ratio in predicting inpatient mortality in aneurysmal subarachnoid hemorrhage. Methods We conducted a retrospective electronic medical record review of the clinical, laboratory, and radiographic data of patients with aneurysmal subarachnoid hemorrhage 18 years of age or older presenting to the neuroscience intensive care unit from January 1, 2011, to December 31, 2017. Patients with aneurysmal subarachnoid hemorrhage were divided into 2 groups (group 1, alive at discharge; group 2, deceased prior to discharge), and neutrophil-lymphocyte ratio laboratory mean values were recorded for each patient. Our primary outcome measure was inpatient mortality, and our secondary measure was incidence of pneumonia with hospitalization. Results We identified 403 patients with aneurysmal subarachnoid hemorrhage for the study. After exclusion criteria, 44 eligible patients were divided into the 2 groups (group 1, n = 32; group 2, n = 12). Mean neutrophil-lymphocyte ratio for group 1 was 11.53, and for group 2, 17.85 (P < .01). The mean neutrophil-lymphocyte ratio of those who developed pneumonia compared to those who did not was 15.28 versus 12.81, respectively (P = .39). A Kaplan-Meier plot demonstrated increased mortality among patients with a neutrophil-lymphocyte ratio equal to or greater than 12.5 compared to those with a neutrophil-lymphocyte ratio less than 12.5. Conclusions These preliminary data demonstrate that a neutrophil-lymphocyte ratio equal to or greater than 12.5 at admission predict higher inpatient mortality in patients with aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
| | | | | | - Prakash Vishnu
- Division of Hematology and Medical Oncology, Mayo Clinic, Jacksonville, Florida
| | - Abba C Zubair
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Jacksonville, Florida
| | - Carol C Raper
- Quality Management Services, Mayo Clinic, Jacksonville, Florida
| | - Rabih G Tawk
- Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida; Department of Radiology, Mayo Clinic, Jacksonville, Florida
| | - William D Freeman
- Department of Neurology, Mayo Clinic, Jacksonville, Florida; Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, Florida.
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