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Pandhi A, Chandra R, Abdulrazzak MA, Alrohimi A, Mahapatra A, Bain M, Moore N, Hussain MS, Bullen J, Toth G. Mechanical thrombectomy for acute large vessel occlusion stroke beyond 24 h. J Neurol Sci 2023; 447:120594. [PMID: 36893513 DOI: 10.1016/j.jns.2023.120594] [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: 10/04/2022] [Revised: 01/20/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Multiple trials have shown that mechanical thrombectomy (MT) is superior to medical therapy. However, no robust evidence is available regarding MT beyond 24 h. In this study, we aimed to determine the safety and efficacy of endovascular stroke therapy in this late window. METHODS We conducted a retrospective study of prospectively collected data of patients who met extended window trial criteria, but underwent MT beyond 24 h. Safety and efficacy outcomes included symptomatic intracerebral hemorrhage (sICH), procedural complications, number of passes, successful recanalization (mTICI 2b - 3), delta (Δ) NIHSS (baseline-discharge), and favorable outcomes (mRS 0-2 at 90 days). RESULTS A total of 39 patients were included with a median age of 69 years (IQR 61.5, 73.5); 54% were females. Hypertension was present in 76% of patients; 23% were smokers. Half of the patients had M1 occlusion (48.7%). Median preprocedural NIHSS was 11 (IQR 7.0, 19.5). Successful revascularization was achieved in 87%; median number of passes was 2 (IQR 1.0, 3.0). Median ΔNIHSS was 3.0 (IQR -1.5, 8.0). Favorable outcome was achieved in 49% (95% CI: 34%-64%), and 95% were free of complications. A total of 3 patients (7.7%) had sICH. In an exploratory analysis, posterior circulation occlusion was associated with higher mRS at 90 days (OR: 14.7, p = 0.016). Favorable discharge facility was associated with lower mRS at 90 days (OR: 0.11, p = 0.004). CONCLUSIONS Our study showed comparable clinical outcomes of MT beyond 24 h compared to MT trials within 24 h in patients with favorable imaging profile, especially in anterior circulation occlusions.
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Affiliation(s)
- Abhi Pandhi
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rahul Chandra
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Anas Alrohimi
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ashutosh Mahapatra
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Bain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nina Moore
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M Shazam Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jennifer Bullen
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
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2
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Pandhi A, Chandra R, Abdulrazzak M, Alrohimi A, Bain M, Moore N, Hussain M, Wadden D, Bullen J, Toth G. Abstract TP145: Mechanical Thrombectomy Beyond 24 Hours. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.tp145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Multiple randomized controlled trials have shown that mechanical thrombectomy (MT) is superior to medical therapy. However, no robust evidence is available to assess the effectiveness of MT beyond the 24-hour window. In this study, we aimed to determine the safety and efficacy of MT in patients undergoing MT for stroke beyond 24 hours from last known normal (LKN).
Methods:
Retrospective review of a prospectively collected database for subjects who met extended window trial criteria, but underwent MT beyond 24 hours. Recorded variables included age, sex, NIHSS at baseline and at discharge, risk factors, level of occlusion, access site, thrombectomy method. Safety and efficacy outcomes included symptomatic intracerebral hemorrhage (sICH), procedural complications, number of passes, successful recanalization (TICI 2b-3), Δ NIHSS (baseline-discharge), favorable outcomes (mRS 0-2) at 90 days.
Results:
A total of 39 patients were included with a median age of 69 (IQR 61.5, 73.5); 54% were females. Hypertension was the most frequent risk factor in 76% of patients; 23 % of patients were smokers. Half of the patients had M1 occlusion (48.7%). Median preprocedural NIHSS was 11 (IQR 7.0, 19.5). Successful revascularization was achieved in 87%; median number of passes was 2 (IQR 1.0,3.0). Median ΔNIHSS was 3.0 (IQR -1.5, 8.0). Favorable outcome was achieved in 49% (95% CI: 34%-64%), and 95% were free of complications. A total of 3 patients (7.7%) had sICH. In an exploratory analysis, posterior circulation occlusion was associated with higher risk of poor mRS at 90 days (OR: 14.7, p = 0.016). Additionally, favorable discharge facility (home, home health, or rehab) was associated with a much lower risk of poor mRS at 90 days (OR: 0.11, p = 0.004).
Conclusions:
Our single center study of MT beyond 24 hours showed comparable clinical outcomes and safety profile to large MT trials within 24 hours, especially in anterior circulation occlusions. Posterior circulation occlusions were associated with worse outcomes, which warrants further investigation.
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Krishnaiah B, Dawkins D, Nguyen VN, Ishfaq MF, Pandhi A, Krishnan R, Tsivgoulis G, Elangovan C, Rubin M, Nearing K, Alexandrov AW, Arthur AS, Alexandrov AV, Goyal N. Yield of ASPECTS and collateral CTA Selection for mechanical thrombectomy within 6-24 hours from symptom onset in a hub and spoke system. J Stroke Cerebrovasc Dis 2022; 31:106602. [PMID: 35724490 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 05/31/2022] [Accepted: 06/10/2022] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Recent extended window trials support the benefit of mechanical thrombectomy in anterior circulation large vessel occlusions with clinical-radiographic dissociation. Using trial imaging criteria, 6% were found eligible for MT in the EW in a hub-and-spoke system. We examined the eligibility and outcomes in consecutive extended window-mechanical thrombectomy patients using more pragmatic selection criteria. METHODS We retrospectively analyzed single-institution data of anterior circulation large vessel occlusions patients presenting between 6-24 h who underwent mechanical thrombectomy based on a priori determined criteria including non-contrast CT head ASPECTS ≥ 6 and/or CTA collateral scores ASITN/SIR 2-4. Primary outcomes consisted of post-mechanical thrombectomy TICI 2b-3 and 3-month modified Rankin scores; safety outcomes consisted of in-hospital mortality and symptomatic intracerebral hemorrhage. RESULTS 767 consecutive acute ischemic strokes patients presented within the 6-24 hour window, and of these 48 (6%) anterior circulation large vessel occlusions patients underwent mechanical thrombectomy. In this cohort the mean age was 63±17 years, 56% were male, the median NIHSS was 16 [IQR 10-19], the median ASPECTS was 9 (IQR 8-10), and 79% (n=38) had good CTA collaterals. Occlusions were primarily M1 MCA (46%), with 29% tandem occlusions. Successful recanalization (mTICI 2b or 3) was achieved in 73% (n=35), while 6% (n=3) of patients developed symptomatic intracerebral hemorrhage. In-hospital mortality was 25% (n=12) while 40% (n=19) achieved 3-month modified Rankin Scores 0-2. CONCLUSIONS Our data suggest the use of pragmatic imaging approach of ASPECTS ≥6 with CTA collateral grade in extended time window which is already established in most hospitals.
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Affiliation(s)
- Balaji Krishnaiah
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
| | - Demi Dawkins
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis USA.
| | - Vincent N Nguyen
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis USA.
| | - Muhammad F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
| | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
| | - Rashi Krishnan
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA; Second Department of Neurology, Attikon University General Hospital, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece.
| | - Cheran Elangovan
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
| | - Mark Rubin
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
| | - Katherine Nearing
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis USA.
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA.
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN USA; Department of Neurosurgery, University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis USA.
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Chang JJ, Dowlati E, Triano M, Kalegha E, Krishnan R, Kasturiarachi BM, Gachechiladze L, Pandhi A, Themistocleous M, Katsanos AH, Felbaum DR, Mai JC, Armonda RA, Aulisi EF, Elijovich L, Arthur AS, Tsivgoulis G, Goyal N. Admission Neutrophil to Lymphocyte Ratio for Predicting Outcome in Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 30:105936. [PMID: 34174515 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105936] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 05/31/2021] [Accepted: 06/02/2021] [Indexed: 01/02/2023] Open
Abstract
PURPOSE We sought to evaluate the relationship between admission neutrophil-to-lymphocyte ratio (NLR) and functional outcome in aneurysmal subarachnoid hemorrhage (aSAH) patients. MATERIAL AND METHODS Consecutive patients with aSAH were treated at two tertiary stroke centers during a five-year period. Functional outcome was defined as discharge modified Rankin score dichotomized at scores 0-2 (good) vs. 3-6 (poor). RESULTS 474 aSAH patients were evaluated with a mean NLR 8.6 (SD 8.3). In multivariable logistic regression analysis, poor functional outcome was independently associated with higher NLR, older age, poorer clinical status on admission, prehospital statin use, and vasospasm. Increasing NLR analyzed as a continuous variable was independently associated with higher odds of poor functional outcome (OR 1.03, 95%CI 1.00-1.07, p=0.05) after adjustment for potential confounders. When dichotomized using ROC curve analysis, a threshold NLR value of greater than 6.48 was independently associated with higher odds of poor functional outcome (OR 1.71, 95%CI 1.07-2.74, p=0.03) after adjustment for potential confounders. CONCLUSIONS Higher admission NLR is an independent predictor for poor functional outcome at discharge in aSAH patients. The evaluation of anti-inflammatory targets in the future may allow for improved functional outcome after aSAH.
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Affiliation(s)
- Jason J Chang
- Department of Critical Care Medicine. MedStar Washington Hospital Center. Washington, DC, USA; Department of Neurology. Georgetown University Medical Center. Washington, DC, USA.
| | - Ehsan Dowlati
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA
| | - Matthew Triano
- Department of Critical Care Medicine. MedStar Washington Hospital Center. Washington, DC, USA.
| | - Enite Kalegha
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA.
| | - Rashi Krishnan
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA.
| | | | - Leila Gachechiladze
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA.
| | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA.
| | - Marios Themistocleous
- Department of Neurosurgery, Pediatric Hospital of Athens, Agia Sophia. Athens, Greece
| | - Aristeidis H Katsanos
- Department of Neurology, National and Kapodistrian University of Athens. Athens, Greece; Division of Neurology, McMaster University and Population Health Research Institute. Hamilton, ON, Canada
| | - Daniel R Felbaum
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA
| | - Edward F Aulisi
- Department of Neurosurgery. Georgetown University and MedStar Washington Hospital Center. Washington, DC, USA.
| | - Lucas Elijovich
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes Murphey Neurologic and Spine Clinic. Memphis, TN, USA.
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes Murphey Neurologic and Spine Clinic. Memphis, TN, USA.
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA; Department of Neurology, National and Kapodistrian University of Athens. Athens, Greece
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center. Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center and Semmes Murphey Neurologic and Spine Clinic. Memphis, TN, USA.
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5
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Shahjouei S, Tsivgoulis G, Farahmand G, Koza E, Mowla A, Vafaei Sadr A, Kia A, Vaghefi Far A, Mondello S, Cernigliaro A, Ranta A, Punter M, Khodadadi F, Naderi S, Sabra M, Ramezani M, Amini Harandi A, Olulana O, Chaudhary D, Lyoubi A, Campbell BCV, Arenillas JF, Bock D, Montaner J, Aghayari Sheikh Neshin S, Aguiar de Sousa D, Tenser MS, Aires A, Alfonso MDL, Alizada O, Azevedo E, Goyal N, Babaeepour Z, Banihashemi G, Bonati LH, Cereda CW, Chang JJ, Crnjakovic M, De Marchis GM, Del Sette M, Ebrahimzadeh SA, Farhoudi M, Gandoglia I, Gonçalves B, Griessenauer CJ, Murat Hanci M, Katsanos AH, Krogias C, Leker RR, Lotman L, Mai J, Male S, Malhotra K, Malojcic B, Mesquita T, Mir Ghasemi A, Mohamed Aref H, Mohseni Afshar Z, Moon J, Niemelä M, Rezai Jahromi B, Nolan L, Pandhi A, Park JH, Marto JP, Purroy F, Ranji-Burachaloo S, Carreira NR, Requena M, Rubiera M, Sajedi SA, Sargento-Freitas J, Sharma VK, Steiner T, Tempro K, Turc G, Ahmadzadeh Y, Almasi-Dooghaee M, Assarzadegan F, Babazadeh A, Baharvahdat H, Cardoso FB, Dev A, Ghorbani M, Hamidi A, Hasheminejad ZS, Hojjat-Anasri Komachali S, Khorvash F, Kobeissy F, Mirkarimi H, Mohammadi-Vosough E, Misra D, Noorian AR, Nowrouzi-Sohrabi P, Paybast S, Poorsaadat L, Roozbeh M, Sabayan B, Salehizadeh S, Saberi A, Sepehrnia M, Vahabizad F, Yasuda TA, Ghabaee M, Rahimian N, Harirchian MH, Borhani-Haghighi A, Azarpazhooh MR, Arora R, Ansari S, Avula V, Li J, Abedi V, Zand R. SARS-CoV-2 and Stroke Characteristics: A Report From the Multinational COVID-19 Stroke Study Group. Stroke 2021; 52:e117-e130. [PMID: 33878892 PMCID: PMC8078130 DOI: 10.1161/strokeaha.120.032927] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Stroke is reported as a consequence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection in several reports. However, data are sparse regarding the details of these patients in a multinational and large scale. Methods: We conducted a multinational observational study on features of consecutive acute ischemic stroke, intracranial hemorrhage, and cerebral venous or sinus thrombosis among SARS-CoV-2–infected patients. We further investigated the risk of large vessel occlusion, stroke severity as measured by the National Institutes of Health Stroke Scale, and stroke subtype as measured by the TOAST (Trial of ORG 10172 in Acute Stroke Treatment) criteria among patients with acute ischemic stroke. In addition, we explored the neuroimaging findings, features of patients who were asymptomatic for SARS-CoV-2 infection at stroke onset, and the impact of geographic regions and countries’ health expenditure on outcomes. Results: Among the 136 tertiary centers of 32 countries who participated in this study, 71 centers from 17 countries had at least 1 eligible stroke patient. Of 432 patients included, 323 (74.8%) had acute ischemic stroke, 91 (21.1%) intracranial hemorrhage, and 18 (4.2%) cerebral venous or sinus thrombosis. A total of 183 (42.4%) patients were women, 104 (24.1%) patients were <55 years of age, and 105 (24.4%) patients had no identifiable vascular risk factors. Among acute ischemic stroke patients, 44.5% (126 of 283 patients) had large vessel occlusion; 10% had small artery occlusion according to the TOAST criteria. We observed a lower median National Institutes of Health Stroke Scale (8 [3–17] versus 11 [5–17]; P=0.02) and higher rate of mechanical thrombectomy (12.4% versus 2%; P<0.001) in countries with middle-to-high health expenditure when compared with countries with lower health expenditure. Among 380 patients who had known interval onset of the SARS-CoV-2 and stroke, 144 (37.8%) were asymptomatic at the time of admission for SARS-CoV-2 infection. Conclusions: We observed a considerably higher rate of large vessel occlusions, a much lower rate of small vessel occlusion and lacunar infarction, and a considerable number of young stroke when compared with the population studies before the pandemic. The rate of mechanical thrombectomy was significantly lower in countries with lower health expenditures.
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Affiliation(s)
- Shima Shahjouei
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA (S. Shahjouei, A. Mowla, D.C., C.J.G., R.Z.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Greece (G. Tsivgoulis, A.H.K.)
| | - Ghasem Farahmand
- Iranian Center of Neurological Research, Neuroscience Institute (G.F., S.R.-B., M. Ghabaee, M.H.H.), Tehran University of Medical Sciences, Iran.,Neurology Department (G.F., A.V.F., M. Ghabaee), Tehran University of Medical Sciences, Iran
| | - Eric Koza
- Geisinger Commonwealth School of Medicine, Scranton, PA (E.K., O.O.)
| | - Ashkan Mowla
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA (S. Shahjouei, A. Mowla, D.C., C.J.G., R.Z.).,Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, CA (A. Mowla, M.S.T.)
| | - Alireza Vafaei Sadr
- Department de Physique Theorique and Center for Astroparticle Physics, University Geneva, Switzerland (A.V.S.)
| | - Arash Kia
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, Institute for Healthcare Delivery Science, New York City, NY (A.K.)
| | - Alaleh Vaghefi Far
- Neurology Department (G.F., A.V.F., M. Ghabaee), Tehran University of Medical Sciences, Iran
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Italy (S. Mondello)
| | | | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, New Zealand and Department of Medicine, University of Otago, New Zealand (A.R., M.P.)
| | - Martin Punter
- Department of Neurology, Wellington Hospital, New Zealand and Department of Medicine, University of Otago, New Zealand (A.R., M.P.)
| | - Faezeh Khodadadi
- PES University, Bangaluru, Karnataka, India (F. Khodadadi, A.D.)
| | - Soheil Naderi
- Department of Neurosurgery (S.N.), Tehran University of Medical Sciences, Iran
| | - Mirna Sabra
- Neurosciences Research Center, Lebanese University/Medical School, Beirut, Lebanon (M. Sabra, F. Kobeissy)
| | - Mahtab Ramezani
- Neurology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran (M. Ramezani, A.A.H.)
| | - Ali Amini Harandi
- Neurology Department, Shahid Beheshti University of Medical Sciences, Tehran, Iran (M. Ramezani, A.A.H.)
| | - Oluwaseyi Olulana
- Geisinger Commonwealth School of Medicine, Scranton, PA (E.K., O.O.)
| | - Durgesh Chaudhary
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA (S. Shahjouei, A. Mowla, D.C., C.J.G., R.Z.)
| | - Aicha Lyoubi
- Neurology Department, Delafontaine Hospital, Saint-Denis, France (A.L.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (B.C.V.C.)
| | - Juan F Arenillas
- Department of Neurology, University of Valladolid, Spain (J.F.A., M.D.L.A.)
| | - Daniel Bock
- Department of Cardiology, Klinikum Frankfurt Höchst, Germany (D.B.)
| | - Joan Montaner
- Department of Neurology, Hospital Universitario Virgen Macarena, Sevilla, Spain (J. Montaner)
| | | | - Diana Aguiar de Sousa
- Department of Neurology (D.A.d.S.), Hospital de Santa Maria, University of Lisbon, Portugal.,Department of Neurology, Hospital de Santa Maria, University of Lisbon, Portugal (D.A.d.S.)
| | - Matthew S Tenser
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, CA (A. Mowla, M.S.T.)
| | - Ana Aires
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal (A.A., E.A.).,Department of Medicine, University of Porto, Portugal (A.A., E.A.)
| | | | - Orkhan Alizada
- Neurosurgery Department, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Turkey (O.A., M.M.H.)
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal (A.A., E.A.).,Department of Medicine, University of Porto, Portugal (A.A., E.A.)
| | - Nitin Goyal
- Department of Neurology, University of Tennessee (N.G., A.P., S.A.)
| | | | - Gelareh Banihashemi
- Imam Khomeini Hospital, and Neurology Department, Sina Hospital (G.B., F.V.), Tehran University of Medical Sciences, Iran
| | - Leo H Bonati
- Department of Neurology and Stroke Unit, University Hospital Basel, Switzerland (L.H.B.)
| | - Carlo W Cereda
- Stroke Center, Neurocenter of Southern Switzerland, Lugano (C.W.C.)
| | - Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC (J.J.C.)
| | - Miljenko Crnjakovic
- Intensive Care Unit, Department of Neurology, Clinical Hospital Dubrava, Zagreb, Croatia (M.C.)
| | - Gian Marco De Marchis
- Neurorehabilitation Unit, University Center for Medicine of Aging and Rehabilitation Basel, Felix Platter Hospital, University of Basel, Switzerland (G.D.M.)
| | | | | | - Mehdi Farhoudi
- Neurosciences Research Center, Tabriz University of Medical Sciences, Iran (M.F.)
| | | | - Bruno Gonçalves
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, France (B.G., G. Turc)
| | - Christoph J Griessenauer
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA (S. Shahjouei, A. Mowla, D.C., C.J.G., R.Z.)
| | - Mehmet Murat Hanci
- Neurosurgery Department, Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Turkey (O.A., M.M.H.)
| | - Aristeidis H Katsanos
- Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, "Attikon" University Hospital, Greece (G. Tsivgoulis, A.H.K.).,Division of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada (A.H.K.)
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Germany (C.K.)
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel (R.R.L.)
| | - Lev Lotman
- Department of Neurology, Albany Medical Center, NY (L.L., L.N., K.T.)
| | - Jeffrey Mai
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, DC (J. Mai)
| | - Shailesh Male
- Department of Neurosurgery, Vidant Medical Center, Greenville, NC (S. Male)
| | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, PA (K.M.)
| | - Branko Malojcic
- Department of Neurology, TIA Clinic, University Hospital Centre Zagreb, Zagreb School of Medicine, University of Zagreb, Croatia (B.M.)
| | - Teresa Mesquita
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (T.M., J.P.M.)
| | | | - Hany Mohamed Aref
- Department of Neurology, Ain Shams University, Cairo, Egypt (H.M.A.)
| | - Zeinab Mohseni Afshar
- Infection Disease Research Center, Kermanshah University of Medical Sciences, Iran (Z.M.A.)
| | - Jusun Moon
- Department of Neurology, National Medical Center, Seoul, South Korea (J. Moon)
| | - Mika Niemelä
- Department of Neurosurgery, Helsinki University and Helsinki University Hospital, Finland (M.N., B.R.J.)
| | - Behnam Rezai Jahromi
- Department of Neurosurgery, Helsinki University and Helsinki University Hospital, Finland (M.N., B.R.J.)
| | - Lawrence Nolan
- Department of Neurology, Albany Medical Center, NY (L.L., L.N., K.T.)
| | - Abhi Pandhi
- Department of Neurology, University of Tennessee (N.G., A.P., S.A.)
| | - Jong-Ho Park
- Department of Neurology, Myongji Hospital, Hanyang University College of Medicine, South Korea (J.-H.P.)
| | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal (T.M., J.P.M.)
| | - Francisco Purroy
- Department of Neurology, Hospital Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida, Universitat de Lleida, Spain (F.P., N.R.C.)
| | - Sakineh Ranji-Burachaloo
- Iranian Center of Neurological Research, Neuroscience Institute (G.F., S.R.-B., M. Ghabaee, M.H.H.), Tehran University of Medical Sciences, Iran
| | - Nuno Reis Carreira
- Department of Internal Medicine (N.E.C.), Hospital de Santa Maria, University of Lisbon, Portugal.,Department of Neurology, Hospital Arnau de Vilanova, Institut de Recerca Biomèdica de Lleida, Universitat de Lleida, Spain (F.P., N.R.C.)
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron Barcelona, Spain (M. Requena, M. Rubiera).,Department de Medicina, Universitat Autònoma de Barcelona, Spain (M. Requena, M. Rubiera)
| | - Marta Rubiera
- Stroke Unit, Department of Neurology, Hospital Vall d'Hebron Barcelona, Spain (M. Requena, M. Rubiera).,Department de Medicina, Universitat Autònoma de Barcelona, Spain (M. Requena, M. Rubiera)
| | - Seyed Aidin Sajedi
- Department of Neurology, Neuroscience Research Center, Golestan University of Medical Sciences, Iran (S.A.S.)
| | - João Sargento-Freitas
- Department of Neurology, Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal (J.S.-F.)
| | - Vijay K Sharma
- Division of Neurology, University Medicine Cluster, National University Health System, Singapore (V.K.S.)
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Germany (T.S.).,Department of Neurology, Heidelberg University Hospital, Germany (T.S.)
| | - Kristi Tempro
- Department of Neurology, Albany Medical Center, NY (L.L., L.N., K.T.)
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, France (B.G., G. Turc)
| | | | - Mostafa Almasi-Dooghaee
- Divisions of Vascular and Endovascular Neurosurgery (M.A.-D., M. Ghorbani), Firoozgar Hospital, Iran University of Medical Sciences, Tehran.,Neurology (M.A.-D.), Firoozgar Hospital, Iran University of Medical Sciences, Tehran.,Divisions of Vascular and Endovascular Neurosurgery (M.A.-D.), Rasoul-Akram Hospital, Iran University of Medical Sciences, Tehran.,Neurology (M.A.-D.), Rasoul-Akram Hospital, Iran University of Medical Sciences, Tehran
| | | | - Arefeh Babazadeh
- Infectious Diseases and Tropical Medicine Research Center, Health Research Institute, Babol University of Medical Sciences, Iran (A.B.)
| | - Humain Baharvahdat
- Neurosurgical Department, Ghaem Hospital, Mashhad University of Medical Sciences, Iran (H.B.)
| | | | - Apoorva Dev
- PES University, Bangaluru, Karnataka, India (F. Khodadadi, A.D.)
| | - Mohammad Ghorbani
- Divisions of Vascular and Endovascular Neurosurgery (M.A.-D., M. Ghorbani), Firoozgar Hospital, Iran University of Medical Sciences, Tehran
| | - Ava Hamidi
- Neurology Ward, Gheshm Hospital, Iran (A.H.)
| | - Zeynab Sadat Hasheminejad
- Department of Neurology, Imam Hosein Hospital, Shahid Beheshti Medical University, Tehran, Iran (Z.S.H., M. Sepehrnia)
| | | | - Fariborz Khorvash
- Neurology Department, Isfahan University of Medical Sciences, Iran (F. Khorvash)
| | - Firas Kobeissy
- Neurosciences Research Center, Lebanese University/Medical School, Beirut, Lebanon (M. Sabra, F. Kobeissy).,Program of Neurotrauma, Neuroproteomics and Biomarker Research, University of Florida (F. Kobeissy)
| | | | | | - Debdipto Misra
- Steele Institute of Health and Innovation, Geisinger Health System, PA (D.M.)
| | - Ali Reza Noorian
- Department of Neurology, Southern California Permanente Medical Group, Irvine, CA (A.R.N.)
| | | | - Sepideh Paybast
- Department of Neurology, Bou Ali Hospital, Qazvin University of Medical Sciences, Iran (S.P.)
| | - Leila Poorsaadat
- Department of Neurology, Arak University of Medical Sciences, Iran (L.P.)
| | - Mehrdad Roozbeh
- Brain Mapping Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran (M. Roozbeh)
| | - Behnam Sabayan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston (B.S.)
| | - Saeideh Salehizadeh
- Neurology Department, Salahadin Ayubi Hospital, Baneh, Iran (S. Salehizadeh)
| | - Alia Saberi
- Neurology Department, Poursina Hospital, Rasht, Guilan, Iran (S.A.S.N., A.S.)
| | - Mercedeh Sepehrnia
- Department of Neurology, Imam Hosein Hospital, Shahid Beheshti Medical University, Tehran, Iran (Z.S.H., M. Sepehrnia)
| | - Fahimeh Vahabizad
- Imam Khomeini Hospital, and Neurology Department, Sina Hospital (G.B., F.V.), Tehran University of Medical Sciences, Iran
| | | | - Mojdeh Ghabaee
- Iranian Center of Neurological Research, Neuroscience Institute (G.F., S.R.-B., M. Ghabaee, M.H.H.), Tehran University of Medical Sciences, Iran.,Neurology Department (G.F., A.V.F., M. Ghabaee), Tehran University of Medical Sciences, Iran
| | - Nasrin Rahimian
- Department of Neurology, Yasrebi Hospital, Kashan, Iran (N.R.)
| | - Mohammad Hossein Harirchian
- Iranian Center of Neurological Research, Neuroscience Institute (G.F., S.R.-B., M. Ghabaee, M.H.H.), Tehran University of Medical Sciences, Iran
| | | | | | - Rohan Arora
- Department of Neurology, Long Island Jewish Forest Hills, Queens, NY (R.A.)
| | - Saeed Ansari
- Department of Neurology, University of Tennessee (N.G., A.P., S.A.)
| | - Venkatesh Avula
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA (V. Avula, V. Abedi, J.L.)
| | - Jiang Li
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA (V. Avula, V. Abedi, J.L.).,Biocomplexity Institute, Virginia Tech, Blacksburg, VA (J.L., V. Abedi)
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger Health System, Danville, PA (V. Avula, V. Abedi, J.L.).,Biocomplexity Institute, Virginia Tech, Blacksburg, VA (J.L., V. Abedi)
| | - Ramin Zand
- Neurology Department, Neuroscience Institute, Geisinger Health System, PA (S. Shahjouei, A. Mowla, D.C., C.J.G., R.Z.)
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6
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Al Kasab S, Almallouhi E, Alawieh A, Jabbour P, Sweid A, Starke RM, Saini V, Wolfe SQ, Fargen KM, Arthur AS, Goyal N, Pandhi A, Maier I, Grossberg JA, Howard BM, Tjoumakaris SI, Rai A, Park MS, Mascitelli JR, Psychogios MN, Spiotta AM. Alarming downtrend in mechanical thrombectomy rates in African American patients during the COVID-19 pandemic-Insights from STAR. J Neurointerv Surg 2021; 13:304-307. [PMID: 33408256 PMCID: PMC8895862 DOI: 10.1136/neurintsurg-2020-016946] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 12/11/2020] [Accepted: 12/12/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND The coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT). METHODS We used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020). RESULTS We identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004). CONCLUSION The COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.
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Affiliation(s)
- Sami Al Kasab
- Neurosurgery, Medical University of South
Carolina, Charleston, SC, USA
- Neurology,
Medical University of South Carolina, Charleston, SC, USA
| | | | - Eyad Almallouhi
- Neurosurgery, Medical University of South
Carolina, Charleston, SC, USA
- Neurology,
Medical University of South Carolina, Charleston, SC, USA
| | - Ali Alawieh
- Neurosurgery, Emory University, Atlanta, GA,
USA
- Microbiology and
Immunology, Medical University of South Carolina,
Charleston, SC, USA
| | - Pascal Jabbour
- Neurological
Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
| | - Ahmad Sweid
- Neurological
Surgery, Thomas Jefferson University Hospital,
Philadelphia, PA, USA
| | - Robert M Starke
- Neurological
Surgery, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Vasu Saini
- Neurological
Surgery, University of Miami Miller School of
Medicine, Miami, FL, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine,
Winston-Salem, NC, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, NC, USA
| | - Adam S Arthur
- Neurosurgery, Semmes-Murphey Neurologic and Spine
Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science
Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Neurosurgery, University of Tennessee Health Science
Center, Memphis, Tennessee, USA
| | - Abhi Pandhi
- Neurology, University of Tennessee Health Science Center
College of Medicine, Memphis,
Tennessee, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen,
Goettingen, NS, Germany
| | - Jonathan A Grossberg
- Neurosurgery and
Radiology, Emory University School of Medicine,
Atlanta, Georgia, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of
Medicine, Atlanta, Georgia, USA
- Radiology and Imaging
Sciences, Emory University School of Medicine,
Atlanta, Georgia, USA
| | | | - Ansaar Rai
- Radiology, West Virginia University Hospitals,
Morgantown, West Virginia, USA
| | - Min S Park
- Neurosurgery, Barrow Neurological Institute,
Phoenix, Arizona, USA
| | - Justin R Mascitelli
- Neurosurgery, University of Texas Health Science Center at San
Antonio, San Antonio, Texas, USA
| | - Marios N Psychogios
- Department of
Neuroradiology, Clinic of Radiology and Nuclear Medicine,
University Hospital Basel, Basel, Switzerland
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7
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Goyal N, Tsivgoulis G, Malhotra K, Ishfaq MF, Pandhi A, Frohler MT, Spiotta AM, Anadani M, Psychogios M, Maus V, Siddiqui A, Waqas M, Schellinger PD, Groen M, Krogias C, Richter D, Saqqur M, Garcia-Bermejo P, Mokin M, Leker R, Cohen JE, Katsanos AH, Magoufis G, Psychogios K, Lioutas V, VanNostrand M, Sharma VK, Paciaroni M, Rentzos A, Shoirah H, Mocco J, Nickele C, Inoa V, Hoit D, Elijovich L, Alexandrov AV, Arthur AS. Medical Management vs Mechanical Thrombectomy for Mild Strokes: An International Multicenter Study and Systematic Review and Meta-analysis. JAMA Neurol 2020; 77:16-24. [PMID: 31545353 DOI: 10.1001/jamaneurol.2019.3112] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Importance The benefit of mechanical thrombectomy (MT) in patients with stroke presenting with mild deficits (National Institutes of Health Stroke Scale [NIHSS] score <6) owing to emergency large-vessel occlusion (ELVO) remains uncertain. Objective To assess the outcomes of patients with mild-deficits ELVO (mELVO) treated with MT vs best medical management (bMM). Data Sources We retrospectively pooled patients with mELVO during a 5-year period from 16 centers. A meta-analysis of studies reporting efficacy and safety outcomes with MT or bMM among patients with mELVO was also conducted. Data were analyzed between 2013 and 2017. Study Selection We identified studies that enrolled patients with stroke (within 24 hours of symptom onset) with mELVO treated with MT or bMM. Main Outcomes and Measures Efficacy outcomes included 3-month favorable functional outcome and 3-month functional independence that were defined as modified Rankin Scale scores of 0 to 1 and 0 to 2, respectively. Safety outcomes included 3-month mortality and symptomatic and asymptomatic intracranial hemorrhage (ICH). Results We evaluated a total of 251 patients with mELVO who were treated with MT (n = 138; 65 women; mean age, 65.2 years; median NIHSS score, 4; interquartile range [IQR], 3-5) or bMM (n = 113; 51 women; mean age, 64.8; median NIHSS score, 3; interquartile range [IQR], 2-4). The rate of asymptomatic ICH was lower in bMM (4.6% vs 17.5%; P = .002), while the rate of 3-month FI (after imputation of missing follow-up evaluations) was lower in MT (77.4% vs 88.5%; P = .02). The 2 groups did not differ in any other efficacy or safety outcomes. In multivariable analyses, MT was associated with higher odds of asymptomatic ICH (odds ratio [OR], 11.07; 95% CI, 1.31-93.53; P = .03). In the meta-analysis of 4 studies (843 patients), MT was associated with higher odds of symptomatic ICH in unadjusted analyses (OR, 5.52; 95% CI, 1.91-15.49; P = .002; I2 = 0%). This association did not retain its significance in adjusted analyses including 2 studies (OR, 2.06; 95% CI, 0.49-8.63; P = .32; I2 = 0%). The meta-analysis did not document any other independent associations between treatment groups and safety or efficacy outcomes. Conclusions and Relevance Our multicenter study coupled with the meta-analysis suggests similar outcomes of MT and bMM in patients with stroke with mELVO, but no conclusions about treatment effect can be made. The clinical equipoise can further be resolved by a randomized clinical trial.
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Affiliation(s)
- Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis.,Semmes-Murphey Neurologic and Spine Clinic, Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis.,Second Department of Neurology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece
| | - Konark Malhotra
- Department of Neurology, West Virginia University Charleston Division, Charleston
| | - Muhammad F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Michael T Frohler
- Cerebrovascular Program, Vanderbilt University, Nashville, Tennessee
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston
| | - Mohammad Anadani
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Marios Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Volker Maus
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Adnan Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, New York
| | - Muhammad Waqas
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, New York
| | - Peter D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - Marcel Groen
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - Christos Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Daniel Richter
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Maher Saqqur
- Department of Neurology, Hamad General Hospital, Doha, Qatar
| | | | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jose E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Aristeidis H Katsanos
- Second Department of Neurology, National and Kapodistrian University of Athens, "Attikon" University Hospital, Athens, Greece.,Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | | | | | - Vasileios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Meg VanNostrand
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Vijay K Sharma
- Yong Loo Lin School of Medicine, Division of Neurology, National University Hospital, National University of Singapore, Singapore
| | - Maurizio Paciaroni
- Stroke Unit, Divisione di Medicina Cardiovascolare, Università di Perugia, Perugia, Italy
| | - Alexandros Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Gothenburg, Sweden
| | - Hazem Shoirah
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, New York
| | - Christopher Nickele
- Semmes-Murphey Neurologic and Spine Clinic, Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
| | - Violiza Inoa
- Semmes-Murphey Neurologic and Spine Clinic, Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
| | - Daniel Hoit
- Semmes-Murphey Neurologic and Spine Clinic, Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis.,Semmes-Murphey Neurologic and Spine Clinic, Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Clinic, Department of Neurosurgery, University of Tennessee Health Science Center, Memphis
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8
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Pryweller JR, Baughman BC, Frasier SD, O'Conor EC, Pandhi A, Wang J, Morrison AA, Tsao JW. Performance on the DANA Brief Cognitive Test Correlates With MACE Cognitive Score and May Be a New Tool to Diagnose Concussion. Front Neurol 2020; 11:839. [PMID: 32982908 PMCID: PMC7492197 DOI: 10.3389/fneur.2020.00839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/06/2020] [Indexed: 12/02/2022] Open
Abstract
Nearly 380,000 U.S. service members between 2000 and 2017 were, and at least 300,000 athletes annually are, diagnosed with concussion. It is imperative to establish a gold-standard diagnostic test to quickly and accurately diagnose concussion. In this non-randomized, prospective study, we examined the reliability and validity of a novel neurocognitive assessment tool, the Defense Automated Neurobehavioral Assessment (DANA), designed to be a more sensitive, yet efficient, measure of concussion symptomatology. In this study, the DANA Brief version was compared to an established measure of concussion screening, the Military Acute Concussion Evaluation (MACE), in a group of non-concussed service members. DANA Brief subtests demonstrated low to moderate reliability, as measured by intra-class correlation coefficient (ICC; values range: 0.28–0.58), which is comparable to other computerized neurocognitive tests that are widely-implemented to diagnose concussion. Statistically significant associations were found between learning and memory components of the DANA Brief and the diagnostic MACE cognitive test score (DANA Brief subtests: CDD: R2 = 0.05, p = 0.023; CDS: R2 = 0.10, p = 0.010). However, a more robust relationship was found between DANA Brief components involving attention and working memory, including immediate memory, and the MACE cognitive test score (DANA Brief subtests: GNG: R2 = 0.08, p = 0.003; PRO: R2 = 0.08, p = 0.002). These results provide evidence that the DANA Rapid version, a 5-min assessment self-administered on a hand-held portable device, based on the DANA Brief version, may serve as a clinically useful and improved neurocognitive concussion screen to minimize the time between injury and diagnosis in settings where professional medical evaluation may be unavailable or delayed. The DANA's portability, durability, shorter test time and lack of need for a medical professional to diagnose concussion overcome these critical limitations of the MACE.
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Affiliation(s)
- Jennifer R Pryweller
- Department of Neurology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Brandon C Baughman
- Department of Neurology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States.,Semmes Murphey Clinic, Memphis, TN, United States
| | - Samuel D Frasier
- Department of Otolaryngology - Head and Neck Surgery, Naval Medical Center Portsmouth, Portsmouth, VA, United States
| | - Ellen C O'Conor
- Department of Neurology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Abhi Pandhi
- Department of Neurology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Jiajing Wang
- Division of Biostatistics, Department of Preventative Medicine, University of Tennessee Health Science Center, Memphis, TN, United States
| | - Aimee A Morrison
- Department of Obstetrics and Gynecology, Hospital of the University of Pennsylvania, Philadelphia, PA, United States
| | - Jack W Tsao
- Department of Neurology, College of Medicine, University of Tennessee Health Science Center, Memphis, TN, United States.,Memphis Veterans Affairs Medical Center, Memphis, TN, United States.,Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN, United States
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9
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Al Kasab S, Almallouhi E, Alawieh A, Levitt MR, Jabbour P, Sweid A, Starke RM, Saini V, Wolfe SQ, Fargen KM, Arthur AS, Goyal N, Pandhi A, Fragata I, Maier I, Matouk C, Grossberg JA, Howard BM, Kan P, Hafeez M, Schirmer CM, Crowley RW, Joshi KC, Tjoumakaris SI, Chowdry S, Ares W, Ogilvy C, Gomez-Paz S, Rai AT, Mokin M, Guerrero W, Park MS, Mascitelli JR, Yoo A, Williamson R, Grande AW, Crosa RJ, Webb S, Psychogios MN, Ducruet AF, Holmstedt CA, Ringer AJ, Spiotta AM. International experience of mechanical thrombectomy during the COVID-19 pandemic: insights from STAR and ENRG. J Neurointerv Surg 2020; 12:1039-1044. [PMID: 32843359 PMCID: PMC7453763 DOI: 10.1136/neurintsurg-2020-016671] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2020] [Revised: 08/07/2020] [Accepted: 08/10/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied. METHODS A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders. RESULTS 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015). CONCLUSION We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.
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Affiliation(s)
- Sami Al Kasab
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.,Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eyad Almallouhi
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ali Alawieh
- Neurosurgery, Emory University, Atlanta, Georgia, USA.,Microbiology and Immunology, Medical University of South Carolina, South Carolina, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Pascal Jabbour
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ahmad Sweid
- Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Robert M Starke
- Neurological Surgery, University of Miami Miller School of Medicine, Miami Beach, Florida, USA.,University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Vasu Saini
- University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Abhi Pandhi
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Jonathan A Grossberg
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Brian M Howard
- Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Muhammad Hafeez
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | | | | | - Krishna C Joshi
- Neurological Surgery, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Shakeel Chowdry
- North Shore University Health System, Evanston, Illinois, USA
| | - William Ares
- Neurosurgery, North Shore University Health System, Evanston, Illinois, USA
| | | | | | - Ansaar T Rai
- Department of Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Waldo Guerrero
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Min S Park
- Neurosurgery, University of Virginia, Charlottesville, Virginia, USA
| | - Justin R Mascitelli
- Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Albert Yoo
- Texas Stroke Institute, Fort Worth, Texas, USA
| | - Richard Williamson
- Stroke & Cerebrovascular Center, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Andrew Walker Grande
- Neurosurgery, Radiology and Neurology, University of Minnesota, Mendota Heights, Minnesota, USA
| | | | - Sharon Webb
- Neurosurgery, Bon Secours St Francis Hospital, Greenville, South Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Andrew F Ducruet
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Andrew J Ringer
- Neurosurgery, Mayfield Clinic, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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10
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Tsivgoulis G, Goyal N, Katsanos AH, Malhotra K, Ishfaq MF, Pandhi A, Frohler MT, Spiotta AM, Anadani M, Psychogios M, Maus V, Siddiqui A, Waqas M, Schellinger PD, Groen M, Krogias C, Richter D, Saqqur M, Garcia-Bermejo P, Mokin M, Leker R, Cohen JE, Magoufis G, Psychogios K, Lioutas VA, Van Nostrand M, Sharma VK, Paciaroni M, Rentzos A, Shoirah H, Mocco J, Nickele C, Mitsias PD, Inoa V, Hoit D, Elijovich L, Arthur AS, Alexandrov AV. Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity. Eur J Neurol 2020; 27:1039-1047. [PMID: 32149450 DOI: 10.1111/ene.14199] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2019] [Accepted: 02/29/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points. METHODS The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding. RESULTS We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy. CONCLUSIONS Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.
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Affiliation(s)
- G Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - N Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A H Katsanos
- Second Department of Neurology, National and Kapodistrian University of Athens, 'Attikon' University Hospital, Athens, Greece
| | - K Malhotra
- Charleston Division, Department of Neurology, West Virginia University, Charleston, WV, USA
| | - M F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - A Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - M T Frohler
- Cerebrovascular Program, Vanderbilt University, Nashville, TN, USA
| | - A M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Anadani
- Department of Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - M Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - V Maus
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - A Siddiqui
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - M Waqas
- Departments of Neurosurgery and Radiology, University at Buffalo, Buffalo, NY, USA
| | - P D Schellinger
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - M Groen
- Department of Neurology and Neurogeriatry, Johannes Wesling Medical Center Minden, University Clinic RUB, Minden, Germany
| | - C Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - D Richter
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - M Saqqur
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada.,Department of Neurology, Hamad General Hospital, Doha, Qatar
| | - P Garcia-Bermejo
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - M Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - J E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - G Magoufis
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - K Psychogios
- Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - V A Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - M Van Nostrand
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - V K Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore.,Division of Neurology, National University Hospital, Singapore, Singapore
| | - M Paciaroni
- Stroke Unit, Divisione di Medicina Cardiovascolare, Università di Perugia, Perugia, Italy
| | - A Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - H Shoirah
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - J Mocco
- Department of Neurosurgery, Mount Sinai Medical Center, New York, NY, USA
| | - C Nickele
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - P D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.,Department of Neurology, School of Medicine, University of Crete, Herakleion, Greece
| | - V Inoa
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - D Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - L Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN, USA
| | - A V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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11
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Jasne AS, Alsherbini KA, Smith MS, Kuohn LR, Pandhi A, Vagal A, Kanter DS. Response to "Malignant cerebella edema in three-year-old girl following accidental opioid ingestion and fentanyl administration". Neuroradiol J 2020; 33:158. [PMID: 32013696 DOI: 10.1177/1971400920903106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Adam S Jasne
- Department of Neurology, Yale School of Medicine, USA
| | - Khalid A Alsherbini
- Department of Neurology and Neurosurgery, University of Tennessee Health Sciences Center, USA
| | - Matthew S Smith
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, USA
| | | | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science, USA
| | - Achala Vagal
- Department of Radiology, University of Cincinnati, USA
| | - Daniel S Kanter
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, USA
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12
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Kodali S, Meng C, Strander S, Nguyen CK, Silverman A, Kimmel A, Peshwe KU, Wang A, Anadani M, Spiotta AM, de Havenon A, Wong KH, Holcombe A, Ortega-Gutiérrez S, Zevallos C, Mistry EA, Fakhri H, Mistry A, Tarasaria K, Nouh A, Maier IL, Psychogios MN, Liman J, Goyal N, Arthur AS, Pandhi A, Wolfe SQ, Nascimento FA, Kan P, Riou-Comte N, Gory B, Kim JT, Sheth KN, Petersen N. Abstract 120: Systolic Blood Pressure Trajectories 72 Hours After Mechanical Thrombectomy Are Associated With Poor Functional Outcome: A Multicenter Analysis of Individual Patient Blood Pressure Data. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Blood pressure (BP) is an important modifiable parameter after endovascular thrombectomy (EVT). Observational studies have found associations between elevated BP after EVT with hemorrhagic transformation and poor functional outcome. However, blood pressure course after EVT has not been well characterized and optimal hemodynamic management in the immediate post-stroke period remains unresolved. We utilized blood pressure data up to 72 hours after EVT to identify distinct systolic BP (SBP) trajectories and studied their associations with functional outcome.
Methods:
We retrospectively studied a multicenter cohort of 1060 patients with large-vessel occlusion stroke who underwent EVT. BP was recorded non-invasively recorded at least hourly for the first 72 hours. Functional outcome was assessed using the modified Rankin scale (mRS). Favorable functional outcome was defined as mRS <. Latent variable mixture modeling was applied to identify patient subgroups that have comparable SBP trajectories. All analyses were adjusted for age, admission NIHSS, and recanalization status.
Results:
One thousand sixty patients (mean age 70±15, mean NIHSS 16) were included in the analysis. Five distinct SBP trajectories were identified: (1) low (17%), (2) moderate (38%), (3) moderate-to-high (21%), (4) high-to-moderate (17%), and (5) high (7%) (Figure 1A). SBP trajectory group was an independent predictor of functional outcome at discharge (p=0.001) and 90 days (p=0.010, Figure 1B). Patients with high and high-to-moderate SBP trajectories had a significantly higher odds of an unfavorable outcome at 90 days (adjusted OR 2.3, 95%CI 1.2 - 4.3, p=0.01 and adjusted OR 4, 95% CI 1.5-10.7, p=0.06, respectively)
Conclusions:
During the first 72 hours after EVT, acute ischemic stroke patients show distinct SBP trajectories, which differ in relation to functional outcome. The findings may help recognize potential candidates for future blood pressure control trials.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Jan Liman
- Dept of Neurology, Univ Medicine Göttingen, Göttingen, Germany
| | | | | | | | | | | | - Peter Kan
- Dept of Neurosurgery, Baylor College of Medicine, Houston, TX
| | | | | | - Joon-Tae Kim
- Chonnam National Univ Hosp, Kwangju, Korea, Republic of
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13
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Lioutas VA, Katsanos A, Goyal N, Krogias C, Zand R, Sharma V, Varelas P, Malhotra K, Paciaroni M, Karapanayiotides T, Sharaf A, Chang J, Pandhi A, Palaiodimou L, Schroeder C, Tsantes A, Kargiotis O, Boviatsis E, Mehta C, Serdari A, Vadikolias K, Mitsias P, Selim MH, Alexandrov AV, Tsivgoulis G. Abstract WP421: Optimization of Risk Stratification for Anticoagulation-Associated Intracerebral Hemorrhage. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wp421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
With more widespread anticoagulant use, anticoagulation-associated intracerebral hemorrhage (ICH) represents an increasing proportion of all ICH. We hypothesized that
c
ombining ischemic and hemorrhagic stroke risk estimation can guide treatment decisions, with more precision than ischemic risk estimation alone.
Methods:
We enrolled consecutive patients with anticoagulation-associated ICH in 15 centers in USA, Europe and Asia from 2015-2017. Each patient was assigned annual baseline ischemic stroke and hemorrhage risk based on their CHA
2
DS
2
-VASc and HAS-BLED scores without and with index ICH taken into account. We computed a net risk by subtracting the hemorrhagic from the ischemic risk. If the sum was positive the patient was assigned a “Favorable” indication for anticoagulation; if negative an “Unfavorable”. We compared clinical and neuroimaging characteristics between the two groups.
Results:
Our cohort comprised 357 patients (59% male, median age 76 [68-82] years). 69% used vitamin-K antagonists (VKA), 31 % Non vitamin K antagonist (NOAC). 191 (53.5%) of patients had a favorable indication for anticoagulation prior to their ICH event; the rest 166 (46.5%) had an unfavorable indication. Those with an unfavorable indication were younger (72[66-80] vs 78[73-84] years, p=0.001, had a lower CHA
2
DS
2
-VASc score (3[3-4] vs 5[4-6], p<0.001) and higher HAS-BLED score (3[2-4] vs 2[2-3], p=0.025). Those with favorable indication had a significantly higher prevalence of all major cardiovascular risk factors and were more likely to use NOAC (35% vs 25%, p=0.045). After including ICH into the HAS-BLED score estimation, 77 of the 191 patients with favorable profile were rendered unfavorable; leaving 114 patients (32% of the cohort) with favorable profile.
Conclusions:
In this anticoagulation-associated ICH cohort, baseline hemorrhage risk exceeded ischemic risk in ~50% of patients. This finding highlights the need for careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining ~ 50% suffered an ICH although their baseline risk of ischemia exceeded that of hemorrhage which stresses the need for imaging, serum or other biomarkers to allow more precise estimation of hemorrhagic complication risk.
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Affiliation(s)
| | - Aristeidis Katsanos
- Neurology, McMaster Univ / Population Health Rsch Institute, Hamilton, Canada
| | - Nitin Goyal
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | | | - Vijay Sharma
- Neurology, Yong Loo Lin Sch of Medicine, Singapore, Singapore
| | | | | | - Maurizio Paciaroni
- Stroke Unit and Div of Cardiovascular Medicine, Univ of Perugia, Perugia, Italy
| | | | | | - Jason Chang
- Critical Care Medicine, MedStar Washington Hosp Cntr, Washington DC, DC
| | - Abhi Pandhi
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Lina Palaiodimou
- Neurology, Sch of Medicine, National & Kapodistrian Univ of Athens, Athens, Greece
| | | | - Argyrios Tsantes
- Laboratory of Haematology and Blood Bank Unit, Sch of Medicine, National and Kapodistrian Univ of Athens, Athens, Greece
| | | | | | | | | | | | | | | | | | - Georgios Tsivgoulis
- Neurology, Sch of Medicine, National & Kapodistrian Univ of Athens, Athens, Greece
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14
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Lioutas VA, Goyal N, Katsanos AH, Krogias C, Zand R, Sharma VK, Varelas P, Malhotra K, Paciaroni M, Karapanayiotides T, Sharaf A, Chang J, Kargiotis O, Pandhi A, Palaiodimou L, Schroeder C, Tsantes A, Boviatsis E, Mehta C, Serdari A, Vadikolias K, Mitsias PD, Selim MH, Alexandrov AV, Tsivgoulis G. Optimization of risk stratification for anticoagulation-associated intracerebral hemorrhage: net risk estimation. J Neurol 2019; 267:1053-1062. [PMID: 31848737 DOI: 10.1007/s00415-019-09678-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Every anticoagulation decision has in inherent risk of hemorrhage; intracerebral hemorrhage (ICH) is the most devastating hemorrhagic complication. We examined whether combining ischemic and hemorrhagic stroke risk in individual patients might provide a meaningful paradigm for risk stratification. METHODS We enrolled consecutive patients with anticoagulation-associated ICH in 15 tertiary centers in the USA, Europe and Asia between 2015 and 2017. Each patient was assigned baseline ischemic stroke and hemorrhage risk based on their CHA2DS2-VASc and HAS-BLED scores. We computed a net risk by subtracting hemorrhagic from ischemic risk. If the sum was positive the patient was assigned a "Favorable" indication for anticoagulation; if negative, "Unfavorable". RESULTS We enrolled 357 patients [59% men, median age 76 (68-82) years]. 31% used non-vitamin K antagonist (NOAC). 191 (53.5%) patients had a favorable indication for anticoagulation prior to their ICH; 166 (46.5%) unfavorable. Those with unfavorable indication were younger [72 (66-80) vs 78 (73-84) years, p = 0.001], with lower CHA2DS2-VASc score [3(3-4) vs 5(4-6), p < 0.001]. Those with favorable indication had a significantly higher prevalence of most cardiovascular risk factors and were more likely to use a NOAC (35% vs 25%, p = 0.045). Both groups had similar prevalence of hypertension and chronic kidney disease. CONCLUSIONS In this anticoagulation-associated ICH cohort, baseline hemorrhagic risk exceeded ischemic risk in approximately 50%, highlighting the importance of careful consideration of risk/benefit ratio prior to anticoagulation decisions. The remaining 50% suffered an ICH despite excess baseline ischemic risk, stressing the need for biomarkers to allow more precise estimation of hemorrhagic complication risk.
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Affiliation(s)
- Vasileios-Arsenios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA.
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aristeidis H Katsanos
- Department of Neurology, McMaster University/Population Health Research Institute, Hamilton, ON, Canada
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Ramin Zand
- Department of Neurology, Geisinger Medical Center, Danville, PA, USA
| | - Vijay K Sharma
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Konark Malhotra
- Department of Neurology, Allegheny Health Network, Pittsburgh, PA, USA
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of Medicine, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Aboubakar Sharaf
- Department of Neurology, Essentia Health-Duluth Clinic, Duluth, MN, USA
| | - Jason Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | | | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Lina Palaiodimou
- Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Christoph Schroeder
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Argyrios Tsantes
- Laboratory of Haematology and Blood Bank Unit (A.T.), School of Medicine, "Attikon" Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Boviatsis
- Second Department of Neurosurgery, School of Medicine, "Attikon University Hospital", National and Kapodistrian University of Athens, Athens, Greece
| | - Chandan Mehta
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA
| | - Aspasia Serdari
- Department of Child and Adolescent Psychiatry, Democritus University of Thrace, University Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Konstantinos Vadikolias
- Department of Neurology, School of Medicine, University Hospital of Alexandroupolis, Democritus University of Thrace, Alexandroupolis, Greece
| | - Panayiotis D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI, USA.,Department of Neurology, School of Medicine, University of Crete, Crete, Greece
| | - Magdy H Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA, 02215, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA.,Second Department of Neurology, School of Medicine, "Attikon" University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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15
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Anadani M, Arthur AS, Alawieh A, Orabi Y, Alexandrov A, Goyal N, Psychogios MN, Maier I, Kim JT, Keyrouz SG, de Havenon A, Petersen NH, Pandhi A, Swisher CB, Inamullah O, Liman J, Kodali S, Giles JA, Allen M, Wolfe SQ, Tsivgoulis G, Cagle BA, Oravec CS, Gory B, De Marini P, Kan P, Rahman S, Richard S, Nascimento FA, Spiotta A. Blood pressure reduction and outcome after endovascular therapy with successful reperfusion: a multicenter study. J Neurointerv Surg 2019; 12:932-936. [PMID: 31806668 DOI: 10.1136/neurintsurg-2019-015561] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [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: 10/19/2019] [Revised: 11/19/2019] [Accepted: 11/20/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Elevated systolic blood pressure (SBP) after mechanical thrombectomy (MT) correlates with worse outcome. However, the association between SBP reduction (SBPr) and outcome after successful reperfusion with MT is not well established. OBJECTIVE To investigate the association between SBPr in the first 24 hours after successful reperfusion and the functional and safety outcomes of MT. METHODS A multicenter retrospective study, which included 10 comprehensive stroke centers, was carried out. Patients with acute ischemic stroke and anterior circulation large vessel occlusions who achieved successful reperfusion via MT were included. SBPr was calculated using the formula 100×([admission SBP-mean SBP]/admission SBP). Poor outcome was defined as a modified Rankin Scale (mRS) score of 3-6 at 90 days. Safety endpoints included symptomatic intracerebral hemorrhage, mortality, and requirement for hemicraniectomy during admission. A generalized mixed linear model was used to study the association between SBPr and outcomes. RESULTS A total of 1361 patients were included in the final analysis. SBPr as a continuous variable was inversely associated with poor outcome (OR=0.97; 95% CI 0.95 to 0.98; p<0.001) but not with the safety outcomes. Subanalysis based on reperfusion status showed that SBPr was associated with lower odds of poor outcome only in patients with complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI 3)) but not in patients with incomplete reperfusion (mTICI 2b). When SBPr was divided into categories (<1%, 1%-10%, 11%-20%, >20%), the rate of poor outcome was highest in the first group. CONCLUSION SBPr in the first 24 hours after successful reperfusion was inversely associated with poor outcome. No association between SBPr and safety outcome was found.
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Affiliation(s)
- Mohammad Anadani
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Adam S Arthur
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Memphis, USA
| | - Ali Alawieh
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Yser Orabi
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Andrei Alexandrov
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Joon-Tae Kim
- Chonnam, Korea (the Democratic People's Republic of)
| | - Saleh G Keyrouz
- Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | | | - Abhi Pandhi
- Neurology, University of Tennessee Health Science Center College of Medicine, Memphis, Tennessee, USA
| | | | | | - Jan Liman
- Department of Neurology, Universitatsklinikum Gottingen, Gottingen, Niedersachsen, Germany
| | | | - James A Giles
- Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Michelle Allen
- Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Bradley A Cagle
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Chesney S Oravec
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Pierre De Marini
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | | | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Fábio A Nascimento
- Department of Neurology, Baylor College of Medicine, Houston, Texas, USA
| | - Alejandro Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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16
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Lioutas VA, Goyal N, Katsanos AH, Krogias C, Zand R, Sharma VK, Varelas P, Malhotra K, Paciaroni M, Sharaf A, Chang J, Karapanayiotides T, Kargiotis O, Pappa A, Mai J, Pandhi A, Schroeder C, Tsantes A, Mehta C, Kerro A, Khan A, Mitsias PD, Selim MH, Alexandrov AV, Tsivgoulis G. Clinical Outcomes and Neuroimaging Profiles in Nondisabled Patients With Anticoagulant-Related Intracerebral Hemorrhage. Stroke 2019; 49:2309-2316. [PMID: 30355114 DOI: 10.1161/strokeaha.118.021979] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background and Purpose- The aim of this study was to prospectively validate our prior findings of smaller hematoma volume and lesser neurological deficit in nonvitamin K oral anticoagulant (NOAC) compared with Vitamin K antagonist (VKA)-related intracerebral hemorrhage (ICH). Methods- Prospective 12-month observational study in 15 tertiary stroke centers in the United States, Europe, and Asia. Consecutive patients with premorbid modified Rankin Scale score of <2 with acute nontraumatic anticoagulant-related ICH divided into 2 groups according to the type of anticoagulant: NOAC versus VKA. We recorded baseline ICH volume, significant hematoma expansion (absolute [12.5 mL] or relative [>33%] increase), neurological severity measured by National Institutes of Health Stroke Scale score, 90-day mortality, and functional status (modified Rankin Scale score). Results- Our cohort comprised 196 patients, 62 NOAC related (mean age, 75.0±11.4 years; 54.8% men) and 134 VKA related (mean age, 72.3±10.5; 73.1% men). There were no differences in vascular comorbidities, antiplatelet, and statin use; NOAC-related ICH patients had lower median baseline hematoma volume (13.8 [2.5-37.6] versus 19.5 [6.6-52.0] mL; P=0.026) and were less likely to have severe neurological deficits (National Institutes of Health Stroke Scale score of >10 points) on admission (37% versus 55.3%, P=0.025). VKA-ICH were more likely to have significant hematoma expansion (37.4% versus 17%, P=0.008). NOAC pretreatment was independently associated with smaller baseline hematoma volume (standardized linear regression coefficient:-0.415 [95% CI, -0.780 to -0.051]) resulting in lower likelihood of severe neurological deficit (odds ratio, 0.44; 95% CI, 0.22-0.85) in multivariable-adjusted models. Conclusions- Patients with NOAC-related ICH have smaller baseline hematoma volumes and lower odds of severe neurological deficit compared with VKA-related ICH. These findings are important for practicing clinicians making anticoagulation choices.
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Affiliation(s)
- Vasileios-Arsenios Lioutas
- From the Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (V.-A.L., M.H.S.)
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.P., A.K., A.V.A., G.T.)
| | - Aristeidis H Katsanos
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.H.K., G.T.).,Department of Neurology, University of Ioannina School of Medicine, Greece (A.H.K.)
| | - Christos Krogias
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Germany (C.K., C.S.)
| | - Ramin Zand
- Department of Neurology, Geisinger Medical Center, Danville, PA (R.Z., A.K.)
| | - Vijay K Sharma
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore (V.K.S.)
| | - Panayiotis Varelas
- Department of Neurology, Henry Ford Hospital, Detroit, MI (P.V., C.M., P.D.M.)
| | - Konark Malhotra
- Department of Neurology, West Virginia University Charleston Division (K.M.)
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Italy (M.P.)
| | - Aboubakar Sharaf
- Department of Neurology, Essentia Health-Duluth Clinic, MN (A.S.)
| | - Jason Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, DC (J.C.)
| | - Theodore Karapanayiotides
- Second Department of Neurology, AHEPA University Hospital, Aristotelian University of Thessaloniki, Greece (T.K.)
| | | | - Alexandra Pappa
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.P., A.K., A.V.A., G.T.).,Department of Neurology, University of Thessaly, Larissa, Greece (A.P.)
| | - Jeffrey Mai
- Department of Neurosurgery Georgetown University, Washington, DC (J.M.)
| | | | - Christoph Schroeder
- Department of Neurology, St Josef-Hospital, Ruhr University of Bochum, Germany (C.K., C.S.)
| | - Argyrios Tsantes
- Laboratory of Haematology and Blood Bank Unit, "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.T.)
| | - Chandan Mehta
- Department of Neurology, Henry Ford Hospital, Detroit, MI (P.V., C.M., P.D.M.)
| | - Ali Kerro
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.P., A.K., A.V.A., G.T.)
| | - Ayesha Khan
- Department of Neurology, Geisinger Medical Center, Danville, PA (R.Z., A.K.)
| | - Panayiotis D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, MI (P.V., C.M., P.D.M.).,Department of Neurology, School of Medicine, University of Crete, Greece (P.D.M.)
| | - Magdy H Selim
- From the Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (V.-A.L., M.H.S.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.P., A.K., A.V.A., G.T.)
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.P., A.K., A.V.A., G.T.).,Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A.H.K., G.T.)
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17
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Anadani M, Orabi MY, Alawieh A, Goyal N, Alexandrov AV, Petersen N, Kodali S, Maier IL, Psychogios MN, Swisher CB, Inamullah O, Kansagra AP, Giles JA, Wolfe SQ, Singh J, Gory B, De Marini P, Kan P, Nascimento FA, Freire LI, Pandhi A, Mitchell H, Kim JT, Fargen KM, Al Kasab S, Liman J, Rahman S, Allen M, Richard S, Spiotta AM. Blood Pressure and Outcome After Mechanical Thrombectomy With Successful Revascularization. Stroke 2019; 50:2448-2454. [PMID: 31318633 DOI: 10.1161/strokeaha.118.024687] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background and Purpose- Successful reperfusion can be achieved in more than two-thirds of patients treated with mechanical thrombectomy. Therefore, it is important to understand the effect of blood pressure (BP) on clinical outcomes after successful reperfusion. In this study, we investigated the relationship between BP on admission and during the first 24 hours after successful reperfusion with clinical outcomes. Methods- This was a multicenter study from 10 comprehensive stroke centers. To ensure homogeneity of the studied cohort, we included only patients with anterior circulation who achieved successful recanalization at the end of procedure. Clinical outcomes included 90-day modified Rankin Scale, symptomatic intracerebral hemorrhage (sICH), mortality, and hemicraniectomy. Results- A total of 1245 patients were included in the study. Mean age was 69±14 years, and 51% of patients were female. Forty-nine percent of patients had good functional outcome at 90-days, and 4.7% suffered sICH. Admission systolic BP (SBP), mean SBP, maximum SBP, SBP SD, and SBP range were associated with higher risk of sICH. In addition, patients in the higher mean SBP groups had higher rates of sICH. Similar results were found for hemicraniectomy. With respect to functional outcome, mean SBP, maximum SBP, and SBP range were inversely associated with the good outcome (modified Rankin Scale score, 0-2). However, the difference in SBP parameters between the poor and good outcome groups was modest. Conclusions- Higher BP within the first 24 hours after successful mechanical thrombectomy was associated with a higher likelihood of sICH, mortality, and requiring hemicraniectomy.
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Affiliation(s)
- Mohammad Anadani
- From the Department of Neurology, Medical University of South Carolina, Charleston (M.A, Y.O, S.A).,Department of Neurology, Washington University School of Medicine, Saint Louis, MO (S.K, J.G, M.A)
| | - Mohamad Y Orabi
- From the Department of Neurology, Medical University of South Carolina, Charleston (M.A, Y.O, S.A)
| | - Ali Alawieh
- Department of Neurosurgery, Medical University of South Carolina, Charleston (A.A, A.S)
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G, A.V.A, A.P, H.M)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G, A.V.A, A.P, H.M)
| | - Nils Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT (N.P, S.K)
| | - Sreeja Kodali
- Department of Neurology, Yale University School of Medicine, New Haven, CT (N.P, S.K).,Department of Neurology, Washington University School of Medicine, Saint Louis, MO (S.K, J.G, M.A)
| | - Ilko L Maier
- Department of Neurology, University Medical Center Göttingen, Germany (I.M, J.L)
| | | | - Christa B Swisher
- Department of Neurology, Duke University Hospital, Durham, NC(O.I, S.R, C.S)
| | - Ovais Inamullah
- Department of Neurology, Duke University Hospital, Durham, NC(O.I, S.R, C.S)
| | - Akash P Kansagra
- Department of Radiology, Washington University School of Medicine, Saint Louis, MO (A.P.K)
| | - James A Giles
- Department of Neurology, Washington University School of Medicine, Saint Louis, MO (S.K, J.G, M.A)
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest University, Winston-Salem, NC (S.W, K.M.F)
| | - Jasmeet Singh
- Department of Radiology, Wake Forest University, Winston-Salem, NC (J.S)
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, University Hospital of Nancy, France (B.G, P.D.M., S.R.)
| | - Pierre De Marini
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, University Hospital of Nancy, France (B.G, P.D.M., S.R.)
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX (P.K)
| | | | - Luis Idrovo Freire
- Department of Neurology, Leeds General Infirmary, University of Leeds, United Kingdom (L.I.F)
| | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G, A.V.A, A.P, H.M)
| | - Hunter Mitchell
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G, A.V.A, A.P, H.M)
| | - Joon-Tae Kim
- Department of Neurology (J-T. K), Chonnam National University Hospital Gwangju, South Korea
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest University, Winston-Salem, NC (S.W, K.M.F)
| | - Sami Al Kasab
- From the Department of Neurology, Medical University of South Carolina, Charleston (M.A, Y.O, S.A)
| | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Germany (I.M, J.L)
| | - Shareena Rahman
- Department of Neurology, Duke University Hospital, Durham, NC(O.I, S.R, C.S).,Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, University Hospital of Nancy, France (B.G, P.D.M., S.R.)
| | | | - Sébastien Richard
- Department of Neurology, Stroke Unit, CIC-P 1433, INSERM U1116, University Hospital of Nancy, France (S.R.)
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston (A.A, A.S)
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18
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Lioutas VA, Goyal N, Katsanos AH, Krogias C, Zand R, Sharma VK, Varelas P, Malhotra K, Paciaroni M, Sharaf A, Chang J, Kargiotis O, Pandhi A, Schroeder C, Tsantes A, Boviatsis E, Mehta C, Mitsias PD, Selim MH, Alexandrov AV, Tsivgoulis G. Microbleed prevalence and burden in anticoagulant-associated intracerebral bleed. Ann Clin Transl Neurol 2019; 6:1546-1551. [PMID: 31402613 PMCID: PMC6689674 DOI: 10.1002/acn3.50834] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/21/2019] [Accepted: 06/06/2019] [Indexed: 11/06/2022] Open
Abstract
Prior studies suggest an association between Vitamin K antagonists (VKA) and cerebral microbleeds (CMBs); less is known about nonvitamin K oral anticoagulants (NOACs). In this observational study we describe CMB profiles in a multicenter cohort of 89 anticoagulation‐related intracerebral hemorrhage (ICH) patients. CMB prevalence was 51% (52% in VKA‐ICH, 48% in NOAC‐ICH). NOAC‐ICH patients had lower median CMB count [2(IQR:1–3) vs. 7(4–11); P < 0.001]; ≥5 CMBs were less prevalent in NOAC‐ICH (4% vs. 31%, P = 0.006). This inverse association between NOAC exposure and high CMB count persisted in multivariable logistic regression models adjusting for potential confounders (OR 0.10, 95%CI: 0.01–0.83; P = 0.034).
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Affiliation(s)
- Vasileios-Arsenios Lioutas
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Aristeidis H Katsanos
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Ramin Zand
- Department of Neurology, Geisinger Medical Center, Danville, Pennsylvania
| | - Vijay K Sharma
- Division of Neurology, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Konark Malhotra
- Department of Neurology, West Virginia University Charleston Division, Charleston, West Virginia
| | - Maurizio Paciaroni
- Stroke Unit and Division of Cardiovascular Medicine, University of Perugia, Perugia, Italy
| | - Aboubakar Sharaf
- Department of Neurology, Essentia Health-Duluth Clinic, Duluth, Minnesota
| | - Jason Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC
| | | | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Christoph Schroeder
- Department of Neurology, St. Josef-Hospital, Ruhr University of Bochum, Bochum, Germany
| | - Argyrios Tsantes
- Laboratory of Haematology and Blood Bank Unit (A.T.), "Attikon" Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Efstathios Boviatsis
- Second Department of Neurosurgery, "Attikon University Hospital", School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Chandan Mehta
- Department of Neurology, West Virginia University Charleston Division, Charleston, West Virginia
| | - Panayiotis D Mitsias
- Department of Neurology, Henry Ford Hospital, Detroit, Michigan.,Department of Neurology, School of Medicine, University of Crete, Crete, Greece
| | - Magdy H Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.,Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
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19
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Goyal N, Tsivgoulis G, Chang JJ, Malhotra K, Goyanes J, Pandhi A, Krishnan R, Ishfaq MF, Hoit D, Nickele C, Inoa-Acosta V, Katsanos AH, Elijovich L, Alexandrov A, Arthur AS. Intravenous thrombolysis pretreatment and other predictors of infarct in a new previously unaffected territory (INT) in ELVO strokes treated with mechanical thrombectomy. J Neurointerv Surg 2019; 12:142-147. [PMID: 31243068 DOI: 10.1136/neurintsurg-2019-014935] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 06/04/2019] [Accepted: 06/05/2019] [Indexed: 11/03/2022]
Abstract
INTRODUCTION One uncommon complication of mechanical thrombectomy (MT) is an infarct in a new previously unaffected territory (infarct in new territory (INT)). OBJECTIVE To evaluate the predictors of INT with special focus on intravenous thrombolysis(IVT)pretreatmentbefore MT. METHODS Consecutive patients with emergent large vessel occlusion (ELVO) treated with MT during a 5-year period were evaluated. INT was defined using standardized methodology proposed by ESCAPE investigators. The predictors of INT and its impact on outcomes were investigated. RESULTS A total of 419 consecutive patients with ELVO received MT (mean age 64±15 years, 50% men, median baseline National Institutes of Health Stroke Scale score 16 points (IQR 11-20), 69% pretreated with IVT). The incidence of INT was lower in patients treated with combination therapy (IVTandMT) than in patients treated with MT alone, respectively (10% vs 20%; p=0.011). The INT group had more patients with posterior circulation occlusions than the group without INT (28% vs 10%, respectively; p<0.001). The rates of 3-month functional independence were lower in patients with INT (30% vs 50%; p=0.007). IVT pretreatment was not independently related to INT (OR=0.75; 95% CI 0.32 to 1.76), and INT did not emerge as an independent predictor of 3-month functional independence (OR=0.69; 95% CI 0.29 to 1.62) on multivariable logistic regression models. Location of posterior circulation occlusion was independently associated with a higher odds of INT (OR=3.33; 95% CI 1.43 to 7.69; p=0.005). CONCLUSIONS IVT pretreatment is not independently associated with a lower likelihood of INT in patients with ELVO treated with MT. Patients with ELVO with posterior circulation occlusion are more likely to have INT after MT.
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Affiliation(s)
- Nitin Goyal
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Jason J Chang
- Critical Care, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Konark Malhotra
- West Virginia University Health Sciences Center Charleston Division, Charleston, West Virginia, USA
| | - Juan Goyanes
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Abhi Pandhi
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Rashi Krishnan
- Neurology, University of Tennessee Health Science Center, College of Medicine Memphis, Memphis, Tennessee, USA
| | - Muhammad F Ishfaq
- Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Daniel Hoit
- Neurosurgery, University of Tennessee, Memphis, Tennessee, USA
| | | | | | - Aristeidis H Katsanos
- Department of Neurology, University of Ioannina School of Medicine, Ioannina, Greece
| | | | | | - Adam S Arthur
- UT Department of Neurosurgery/Semmes-Murphey Clinic, Memphis, Tennessee, USA
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20
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Goyal N, Tsivgoulis G, Pandhi A, Malhotra K, Krishnan R, Ishfaq MF, Krishnaiah B, Nickele C, Inoa-Acosta V, Katsanos AH, Hoit D, Elijovich L, Alexandrov A, Arthur AS. Impact of pretreatment with intravenous thrombolysis on reperfusion status in acute strokes treated with mechanical thrombectomy. J Neurointerv Surg 2019; 11:1073-1079. [DOI: 10.1136/neurintsurg-2019-014746] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Revised: 03/06/2019] [Accepted: 03/14/2019] [Indexed: 01/04/2023]
Abstract
IntroductionWe sought to evaluate the impact of pretreatment with intravenous thrombolysis (IVT) on the rate and speed of successful reperfusion (SR) in patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT) in a high-volume tertiary care stroke center.MethodsConsecutive patients with ELVO treated with MT were evaluated. Outcomes were compared between patients who underwent combined IVT and MT (IVT+MT) and those treated with direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes required to achieve SR were also documented.ResultsA total of 287 and 132 patients were treated with IVT+MT and dMT, respectively. The IVT+MT group had higher SR (73.8% vs 62.9%; p=0.023) and 3-month functional independence (modified Rankin Scale score 0–2;51.6% vs 38.2%; p=0.008) rates. The median GPTBRT was shorter in the IVT+MT group (48 (IQR 33–70) vs 70 (IQR 44–98) min; p<0.001). Among patients who achieved SR (n=292), the median number of required device passes was lower in the IVT+MT subgroup (1 (IQR 1–1) vs 2 (IQR 1–2); p<0.001), while the rate of patients requiring ≤2 device passes was higher (98% vs 77%; p<0.001). IVT+MT was independently related to higher odds of SR (OR 1.64; 95% CI 1.03 to 2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient −20.39; 95% CI −27.56 to –13.22; p<0.001) on multivariable analyses adjusting for potential confounders. Among patients with SR, IVT+MT was independently associated with a higher likelihood of ≤2 device passes (OR 14.63; 95% CI 4.46 to 48.00; p<0.001).ConclusionsIVT pretreatment appears to increase the rates of SR and shortens the duration of the endovascular procedure by requiring fewer device passes in patients with ELVO treated with MT.
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21
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Anadani M, Orabi Y, Alawieh A, Goyal N, Pandhi A, Mitchell H, Alexandrov A, Maier IL, Psychogios MN, Liman J, Inamullah O, Swisher C, Rahman S, Keyrouz S, Giles JA, Allen M, Wolfe SQ, Kan P, Nascimento FA, Turkk AS, Spiotta AM. Abstract 3: Effect of BP Goal on Outcome post Mechanical Thrombectomy: Multicenter Study. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Current AHA/ASA guidelines recommend keeping blood pressure (BP) <180/105 after successful recanalization with MT. However, due to a concern of reperfusion injury, different BP goals are utilized across various endovascular centers. In this study, we compared functional and hemorrhagic outcomes between different BP goals.
Methods:
This was a multicenter international retrospective study that included 7 comprehensive stroke centers. Inclusion criteria were anterior circulation large vessel occlusion (LVO) that was treated with MT, and successful recanalization at the conclusion of the procedure. Patients were divided into three groups based on systolic BP (SBP) goals in the first 24 hours post MT. Group 1) included patients with SBP goal ≤140 mm Hg or ≤120 mm Hg; group 2 included patients with SBP goal ≤160 mm Hg; group 3) included patients with SBP goal ≤220 mm Hg or ≤180 mm Hg. Successful recanalization was defined as TICI 2b-3. Outcome measures included symptomatic intracerebral hemorrhage (sICH), 90-day modified Rankin Scale (mRS), and 90-day mortality.
Results:
A total of 985 patients were included in the study. More patients in group 3 were white and had Afib than groups 1-2. Likewise, more patients in group 3 received IV tPA. Complete recanalization (TICI 2c-3) was achieved in 88.2%, 53.6%, and 73.2% in groups 1,2,3 respectively (p <0.001). With respect to outcome, mRS 0-2 was achieved in 50%, 52, and 38% of patients (p=0.001) in groups 1,2,3 respectively. Similarly, sICH occurred in 2.8%, 7.1%, and 5.2% (p=0.04) in the respective groups. In multivariate analysis, moderate and intensive BP goals (groups 1-2) were associated with mRS 0-2 but not with sICH or mortality. In subgroup analysis that included only patients who achieved BP goal, group 1 but not 2 or 3 were associated with functional outcome.
Conclusion:
Blood pressure goals ≤140 and ≤160 were associated with favorable functional outcome.
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Affiliation(s)
| | - Yser Orabi
- Nerology, Med Univ of South Carolina, Charleston, SC
| | - Ali Alawieh
- Nerosurgery, Med Univ of South Carolina, Charleston, SC
| | - Nitin Goyal
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Abhi Pandhi
- Nerology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Hunter Mitchell
- Nerology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | - Ilko L Maier
- Neurology, Univ Med Cntr Göttingen, Göttingen, Germany
| | | | - Jan Liman
- Nerology, Univ Med Cntr Göttingen, Göttingen, Germany
| | | | | | | | - Salah Keyrouz
- Neurology, Washington Univ Sch of Medicine, St. Louis, MO
| | - James A Giles
- Neurology, Washington Univ Sch of Medicine, St. Louis, MO
| | - Michelle Allen
- Neurology, Washington Univ Sch of Medicine, St. Louis, MO
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest Sch of Medicine, Winston Salem, NC
| | - Peter Kan
- Neurosurgery, Baylor College of Medicine, Houston, Houston, TX
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22
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Goyal N, Tsivgoulis G, Pandhi A, Krishnan R, Malhotra K, Ishfaq M, Krishnaiah B, Nickele C, Inoa V, Hoit D, Elijovich L, Alexandrov A, Alexandrov A, Arthur A. Abstract TP24: Impact of Pretreatment With Intravenous Thrombolysis on Reperfusion Status in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT). Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp24] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
It currently remains unclear whether pre-treatment with intravenous thrombolysis (IVT) provides any additional benefits to emergent large vessel occlusion (ELVO) patients undergoing mechanical thrombectomy (MT). We sought to evaluate the impact of pretreatment with IVT on the rate and the speed of complete reperfusion (CR) in LVO patients treated with MT in a high-volume tertiary care stroke center.
Methods:
Consecutive ELVO patients treated with MT during a five-year period were evaluated. Baseline stroke severity was assessed by NIHSS-score. Standard safety [symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST definition] and efficacy outcomes [CR (modified Thrombolysis in Cerebral Infarction IIb/III), 3-month functional independence (FI; modified Rankin Scale scores of 0-2)] were compared between patients who underwent combined IVT and MT (IVT+MT) vs. direct MT (dMT). The elapsed time between groin puncture to beginning of reperfusion (GPTBRT) and the numbers of device passes (DP) required to achieve CR were also documented.
Results:
A total of 287 and 132 patients were treated with IVT+MT and dMT respectively. The IVT+MT group had higher CR (74% vs. 63%; p=0.023) and FI (52% vs.38%; p=0.008) rates and shorter median GPTBRT (48 vs. 70 min; p<0.001). The two groups did not differ in sICH rates (7% vs. 9%; p=0.368). Among patients who achieved CR, the median number of required DP was lower in the IVT+MT subgroup (1 vs. 2; p<0.001) and the rate of patients requiring ≤2 DP was higher (98% vs. 77%; p<0.001). IVT+MT was independently related to higher odds of CR (OR:1.64; 95%:1.03-2.61; p=0.036) and shorter GPTBRT (unstandardized linear regression coefficient: -20; 95%CI: -12, -27; p<0.001) on multivariable analyses adjusting for potential confounders including demographics, vascular risk factors, collateral status, stroke severity, location of occlusion and onset to groin puncture time. Among patients with CR, IVT+MT was independently associated with higher likelihood of ≤2 DP (OR:14.75; 95%:4.72-46.04; p<0.001).
Conclusions:
IVT pretreatment increases the rates of CR and shortens the duration of endovascular procedure by requiring fewer DP in ELVO patients treated with MT.
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23
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Singh S, Goyal N, Tsivgoulis G, Pandhi A, Malhotra K, Bryndziar T, Sukhdeo R, Aboud T, Shahripour R, Krishnaiah B, Nearing K, Alexandrov A, Alexandrov A. Abstract TP416: Safety and Efficacy Outcomes of Intravenous Thrombolysis (IVT) for In-Hospital Stroke. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Cross-sectional data suggest that IVT in patients with in-hospital (IHS) acute ischemic stroke (AIS) onset is associated with unfavourable outcomes compared to out-of-hospital (OHS) stroke onset patients. We sought to compare safety and efficacy outcomes between IHS and OHS patients treated with IVT.
Methods:
Consecutive AIS patients treated with IVT during a five-year period in a tertiary care stroke center were prospectively evaluated. Demographics, vascular risk factors, admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS by certified physicians. Three-month functional outcome was evaluated by mRS-score. We compared the following outcomes between IHS and OHS patients: 1.symptomatic intracranial hemorrhage (sICH) 2.favourable functional outcome (FFO) [3-month mRS scores of 0-1], 3.Functional independence (FI) [3-month mRS scores of 0-2], 4. Mortality at three months.
Results:
Of 1264 IVT-treated AIS patients, we identified 51 (4%) subjects with IHS. Baseline median NIHSS-score was higher in IHS (10 points; IQR: 6-16 vs. 6 points; IQR: 3-12; p=0.004), while median onset-to-treatment was shorter (75 min; IQR: 37-115 vs. 135 min; IQR: 100-185; p<0.001). In univariable analyses, IHS patients had higher three-month mortality rates (21% vs. 9%; p=0.009). There were no differences (p>0.1) between the two groups in FFO, FI and sICH rates. IHS was associated with higher likelihood three-month mortality (OR: 3.1; 95%CI: 1.2-7.8; p=0.016) on multivariable logistic regression models adjusting for demographics, risk factors, onset-to-treatment time, admission blood pressure and serum glucose levels, baseline NIHSS and ASPECTS.
Conclusions:
IHS patients treated with IVT have more severe strokes and higher mortality rates compared to OHS patients. IVT for IHS is not associated with higher hemorrhagic complications.
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24
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Sukhdeo RD, Goyal N, Tsivgoulis G, Nearing K, Krishnaiah B, Aboud T, Pandhi A, Bavasard Shahripour R, Bryndziar T, Quitasol P, Dusenbury W, Swatzell V, Fiornarelli A, Rhudy JP, Deep A, Ansari S, Ishfaq M, Alexandrov AW, Alexandrov AV. Abstract WP113: Racial Disparities in Patient Selection for Drip and Ship Thrombolytic Therapy for Acute Ischemic Stroke. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
There is preliminary data indicating potential racial disparities in use of intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to compare “drip and ship” (DNS) tPA use between African-Americans (AA) and Caucasians (CS) in a high-volume tertiary care stroke center.
Methods:
AIS patients treated with IVT during a seven-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. All patients who received IVT at an outside facility with subsequent transfer to our center were included in the DNS group. Safety of IVT was evaluated SITS-MOST symptomatic intracranial hemorrhage (sICH) definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores.
Results:
Out of total 1339 IVT-treated AIS patients [51% men, 63% AA, mean age 63±15years, median baseline NIHSS-score: 7 pts (IQR: 3-13)], 521 (39%) were treated using the DNS approach. DNS tPA use was less common in AA compared to CS (33% vs. 51%; p < 0.001). AA race was independently associated with lower likelihood of DNS tPA use (OR: 0.46; 95%CI: 0.35-0.62; p<0.001) on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, door-to-needle time, baseline stroke severity, serum glucose, BP parameters and ASPECTS. Among DNS patients, the rates of sICH, three-month favorable functional outcome (mRS-scores of 0-1) and mortality did not differ between AA and CS. Using geospatial software, the observed treatment disparity could not be explained by racial zipcode. distribution.
Conclusions:
Our study uncovers substantial racial disparities in the selection of AIS patients for DNS thrombolytic therapy that cannot be explained by racial geographic proximity to the primary stroke center.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Aman Deep
- Neurology, Univ of Tennessee, Memphis, TN
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25
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Pandhi A, Tsivgoulis G, Goyal N, Krishnan R, Ishfaq M, Swatzell V, Katsanos A, Krishnaiah B, Nickele C, Inoa V, Elijovich L, Alexandrov AW, Alexandrov AV, Arthur AS. Abstract TP19: Impact of Single-Pass Complete Reperfusion on Clinical Outcomes in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT). Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
There is mounting evidence indicating that first pass (FP) complete reperfusion (CR) may reduce peri-procedural complications for emergent large vessel occlusion (ELVO) patients treated with mechanical thrombectomy (MT). We investigated the impact of device passes (DP) on the clinical outcomes of ELVO patients who achieved CR following treatment with MT in a high-volume tertiary care stroke center.
Methods:
Consecutive ELVO patients with CR (modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT were evaluated during a five-year period. Baseline stroke severity was assessed by NIHSS-score. The numbers of DP during the procedure were documented. Standard safety outcomes included symptomatic Intracranial Hemorrhage (sICH) by SITS-MOST criteria and three-month mortality. Standard efficacy outcomes included neurological improvement at 24 hours (determined by the relative reduction in NIHSS-score compared to baseline) and functional improvement at three months [determined as the shift in modified Rankin Scale (mRS) scores].
Results:
Among 258 ELVO patients achieving CR during MT the rate of FPCR was 67% (n=173). Patients with FPCR had greater median relative NIHSS-reduction at 24 hours (46% vs. 33%; p=0.033), lower median mRS-scores at three months (2 vs. 3; p=0.034) and lower three-month mortality rates (12% vs. 26%; p=0.005) compared to the rest. The two groups did not differ in sICH rates (5% vs. 10%; p=0.200). FPCR was associated with lower odds of three-month mortality (OR:1.64; 95%:1.03-2.61; p=0.036) on multivariable logistic regression models adjusting for potential confounders (demographics, risk factors, occlusion site, collateral status, stroke severity, onset to groin puncture time, baseline blood pressure and serum glucose values).
Conclusions:
FPCR appears to impact favourably clinical outcomes in ELVO patients treated with MT. CR following FP results in greater neurological and functional improvement at 24 hours and 3 months respectively.
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26
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Anadani M, Orabi Y, Alawieh A, Goyal N, Pandhi A, Mitchell H, Alexandrov A, L. Maier I, Psychogios MN, Liman J, Inamullah O, Rahman S, Shah S, A Giles J, Allen M, Kansagra A, Q.Wolf S, Kan P, A. Nascimento F, Chaudry MI, M. Spiotta A. Abstract TMP3: Blood Pressure Variability Within 24 Hours After Mechanical Thrombectomy Correlates With Worse Outcome. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tmp3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
blood pressure variability (BPV) in the acute phase following ischemic stroke is associated with worse outcomes, especially in patients with large vessel occlusions. However, the relationship between BPV and outcome after successful recanalization is not well documented.
Objective:
The aim of this study was to evaluate the association between BPV and outcome after successful recanalization.
Methods:
This was a retrospective multicenter study of patients with anterior circulation large vessel occlusions who achieved successful recanalization with MT. Successful recanalization was defined as TICI≥2b. BP was recorded in hourly intervals for 24 hours post MT. BPV was defined as the difference between maximum and minimum blood pressure within 24 hours. BPV was calculated for mean arterial pressure (MAP), systolic BP (SBP), and diastolic BP (DBP). Outcome measures included 90 days mRS, symptomatic ICH (sICH), and mortality. sICH was defined based on ECASS criteria. Good outcome was defined as mRS 0-2.
Results:
A total of 985 patients were included. SBP and MAP variability were higher in poor outcome group (65.2±26 vs. 57± 24.6; p <0.001, and 49.7±21.2 vs. 46.9± 22.3; p=0.048 respectively). Likewise, SBP and MAP variability were higher in sICH group. The association between SBP variability and 90 day mRS, sICH, and mortality remained significant after adjusting for potential confounders.
Conclusion:
Higher blood pressure variability was associated with worse functional outcomes, higher likelihood of symptomatic hemorrhage, and increased mortality.
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Affiliation(s)
| | - Yser Orabi
- Med Univ of South Carolina, Charleston, SC
| | | | - Nitin Goyal
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Abhi Pandhi
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | | | - Ilko L. Maier
- Neurology, Univ Med Cntr Göttingen, Göttingen, Germany
| | | | - Jan Liman
- Neurology, Univ Med Cntr Göttingen, Göttingen, Germany
| | | | | | | | | | | | - Akash Kansagra
- Radiology, Washington Univ Sch of Medicine, Saint Louis, MO
| | | | - Peter Kan
- Neurosurgery, Baylor College of Medicine, Houston, TX
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27
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Saeed O, Malkoff M, Alexandrov A, Ishfaq F, Pandhi A, Singh S, Qureshi AI. Abstract TP536: Can Baseline Glomerular Filtration Rate Predict Outcomes in Hemorrhagic Stroke Patients? Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Chronic kidney disease with reduced glomerular filtration rates (GFR) has been described as a risk factor for hemorrhagic stroke. The goal of this analysis was to determine if baseline GFR can predict long-term outcomes and/or incidence of adverse events in those patients who presented with hemorrhagic stroke.
Methods:
Retrospective analysis was done using data from the Antihypertensive treatment of acute cerebral hemorrhage II (ATACH-2) trial to determine the effect of baseline GFR on occurrence of adverse events, mortality and death and disability at 90 days. GFR were calculated using the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation using specified race, sex and serum creatinine in mg/dl from the National Institute of Diabetes and Digestive and Kidney Disease for estimation in patients age 18 and over. We compared demographic and clinical characteristics of subjects dichotomized into none/mild CKD (GFR ≥60 mL/min/1.73m
2
) versus those who had moderate/severe CKD (GFR ≤59 mL/min/1.73m
2
). We performed a multivariate analysis using cox proportional hazard model after adjusting for confounders.
Results:
Of the total 1000 participants in ATACH-2 trial 562 had baseline creatinine levels out of which there were 122 (21.7%) who had baseline GFR of ≤59 mL/min/1.73m
2
defined as moderate/sever GFR with mean age 65.7 SD± 13.6 and 59.8% were males. Those with moderate to severe GFR had significantly higher rates of previous stroke (26.2% vs 13.6%), congestive heart failure (8.3% vs 1.8%), previous ischemic heart disease (13.1% vs 1.6%), hypertension (88.5% vs 75.2%), hyperlipidemia (37.7% vs 20.7%), and diabetes mellitus (32% vs 14.3%). In the multivariate analysis after adjusting for age, Asian race, white race, hypertension, diabetes, hyperlipidemia and smoking those with moderate to severe GFR had significantly higher risk of death (HR 18.1, 95% confidence interval [CI] 1.3- 278.6; p-vale .033) and unfavorable outcome defined by a 90 day mRS score of 4-6 (HR 1.4, 95% CI 1.1 -1.9; p-value .015).The wide confidence interval in death could be due to small sample size.
Conclusion:
Patients with moderate to severe GFR at baseline appear to have higher rates of mortality and death and disability with a mRS score of 4-6 at 90 days.
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28
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Ishfaq MF, Tsivgoulis G, Goyal N, Pandhi A, Krishnan R, Malhotra K, Krishnaiah B, Nickele C, Inoa V, Hoit D, Elijovich L, Alexandrov AW, Alexandrov AV, Arthur AS. Abstract WP15: Safety of Dual Antiplatelet Treatment in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT) and Extracranial Internal Carotid Artery Stenting. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Extracranial Internal carotid artery (ExICA) stenting may be required during mechanical thrombectomy (MT) for anterior circulation large vessel occlusions (ACLVO) with coexisting ExICA steno-occlusive disease. We sought to evaluate the safety of acute dual antiplatelet therapy (DAP) in this high-risk MT subgroup.
Methods:
Consecutive ACLVO patients treated with MT were evaluated during a five-year period. All patients receiving ExICA stenting during MT were also acutely treated with DAP coupled with heparin or eptifibatide drips. Baseline stroke severity and early hypodensity on baseline CT were assessed using NIHSS-score and ASPECTS. Complete reperfusion (CR) was defined as modified Thrombolysis in Cerebral Infarction grades IIb/III) at the end of MT. Final infarct volume (FIV) on brain MRI was assessed at 24-48 hours using standardized methodology. Safety outcomes included symptomatic Intracranial Hemorrhage (sICH) documented by SITS-MOST criteria, infarct in new unaffected territory (INT) determined according to ESCAPE trial methodology and three-month mortality. We also assessed 3-month functional outcomes using modified Rankin Scale (mRS) scores.
Results:
Among 309 ACLVO patients treated with MT, 24 received additional ExICA stenting. Eptifibatide and heparin drips were administered in 15 (65% of stenting subgroup: 9 patients: aspirin + clopidogrel, 6 patients: aspirin + ticagrelor) and 8 (35% of stenting subgroup: 6 patients: aspirin + clopidogrel, 2 patients: aspirin + ticagrelor) cases respectively. Patients with and without ExICA stenting had similar (p>0.1) median baseline NIHSS-scores (15 vs. 16 points) and ASPECTS (10 vs. 10 points). The two groups did not differ (p>0.1) in terms of median FIV (20 vs. 15 cm
3
) and median 3-month mRS-scores (2 vs. 2). Patients with ExICA stenting had similar (p>0.1) rates of sICH (5% vs. 8%), INT (0% vs. 9%), CR (74% vs. 70%) and 3-month mRS-scores of 0-2 (55% vs. 51%) compared to the rest.
Conclusions:
DAP coupled with eptifibatide or heparin drips does not appear to increase peri-procedural complications or to worsen clinical outcome of ELVO patients treated with MT and ExICA stenting.
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Affiliation(s)
- Muhammad F Ishfaq
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | - Nitin Goyal
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Abhi Pandhi
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Rashi Krishnan
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Konark Malhotra
- Dept of Neurology, West Virginia Univ-Charleston Div,, Charleston WV, WV
| | - Balaji Krishnaiah
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Christopher Nickele
- Dept of Neurosurgery, Univ of Tennessee Health Science Cntr and Semmes-Murphey Clinic, Memphis, TN
| | - Violiza Inoa
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Daniel Hoit
- Dept of Neurosurgery, Univ of Tennessee Health Science Cntr and Semmes-Murphey Clinic, Memphis, TN
| | - Lucas Elijovich
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Anne W Alexandrov
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | - Adam S Arthur
- Dept of Neurosurgery, Univ of Tennessee Health Science Cntr and Semmes-Murphey Clinic, Memphis, TN
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29
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Goyal N, Tsivgoulis G, Malhotra K, Katsanos A, Pandhi A, Alsherbini K, Chang J, Hoit D, Alexandrov A, Elijovich L, Fiorella D, Nickele C, Arthur AS. Abstract TP436: Minimally Invasive Endoscopic Hematoma Evacuation vs. Best Medical Management for Spontaneous Basal Ganglia Intracerebral Hemorrhage. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
We conducted a case-control study to assess the relative safety and efficacy of Apollo assisted minimally invasive endoscopic surgery (MIS) for clot evacuation in patients with basal-ganglia intracerebral hemorrhage (ICH).
Methods:
We evaluated consecutive patients with acute basal ganglia ICH at a single center over a 42-month period. Patients received either best medical management according to established guidelines (controls) or Apollo assisted MIS (cases) with best medical management. The following outcomes were compared before and after propensity-score matching (PSM): in-hospital mortality, discharge National Institutes of Health Stroke Scale (NIHSS) score, discharge disposition, modified Rankin Scale scores at discharge and at 3 months.
Results:
Among 224 ICH patients, 19 (8.5%) underwent MIS [mean age 50.9±10.9; 26.3% female, median ICH volume 40 (IQR; 25-51)]. The interventional cohort was younger with higher ICH volume and stroke severity as compared to the medically managed cohort. After PSM, 18 patients in the MIS cohort were matched to 54 medically managed individuals. The two cohorts did not differ in any of the baseline characteristics. The median ICH volume at 24 hours was lower in the intervention group [40cm
3
(IQR:25-50) vs. 15cm
3
(IQR:5-20), p<0.001). The two cohorts did not differ in any of the pre-specified outcomes measures with the exception of in-hospital mortality which was lower in intervention cohort (28% vs. 56%, p=0.041). The three-month mortality rates tended to be lower in the intervention cohort (38% vs. 60%, p=0.107). The intensive care unit length of stay was similar in the two groups [median LOS in days (IQR): intervention: 9 (7-12) vs. control: 9 (6-12), p=0.497]. The distribution of mRS-scores at discharge and at three months did not differ between the intervention and the control cohort (p by Cochran-Mantel-Haenszel test>0.4).
Conclusions:
Minimally invasive Apollo assisted endoscopic hematoma evacuation was associated with lower rates of in-hospital mortality in patients with spontaneous basal ganglia ICH. These findings support a randomized controlled trial of MIS versus medical-management for ICH.
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Affiliation(s)
| | | | | | | | | | | | - Jason Chang
- Medstar Washington Hosp Cntr, Washington, DC
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30
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Bavarsad Shahripour R, Goyal N, Tsivgoulis G, Pandhi A, Singh S, Malhotra K, Bryndziar T, Sukhdeo R, Aboud T, Krishnaiah B, Nearing K, Alexandrov AW, Alexandrov AV. Abstract TP158: Risk prediction for symptomatic Intracranial Hemorrhage (sICH) in Acute Ischemic Stroke (AIS) Patients Treated With Intravenous Thrombolysis (IVT): Does Infarct Location Matter? Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
There are mounting data supporting a substantially lower risk of sICH in AIS patients with posterior circulation stroke (PCS) following treatment with IVT. However, stroke location is not included in any of the numerous risk prediction scores for sICH complicating IVT in AIS. We sought to compare the safety and efficacy of IVT for AIS with respect to the location of acute cerebral ischemia in a high-volume tertiary care stroke center.
Methods:
Consecutive AIS patients treated with IVT during a five-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Stroke location was classified as posterior (PCS) vs. anterior circulation (ACS), and supratentorial (STN) vs. infraterorial (ITN) infarction. Safety of IVT was evaluated using the SITS-MOST sICH definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores.
Results:
Out of total 1008 IVT-treated AIS patients [52% men, mean age 64±15years, median baseline NIHSS-score: 8 pts (IQR: 4-4)], 181 (18%) had PC and 88 (9%) had STN location. The rates of sICH were lower in patients with PCS [2.8% vs. 6.9%; p=0.039 by Fisher’s exact test (FET)] and ITN infarction (0% vs. 6.7%; p=0.005 by FET). PCS and ITN strokes (OR computed using Firth’s penalized likelihood method for rare events: 0.11; 95%CI: 0.01-1.82) were not independently associated with lower likelihood of sICH on multivariable logistic regression models adjusting for multiple potential confounders including demographics, vascular risk factors, onset-to-treatment time, baseline stroke severity, serum glucose, BP parameters and ASPECTS, pretreatment with antiplatelets (single or dual), statins and oral anticoagulants.
Conclusions:
Our study indicates that infarct location appears not to be independently related to the risk of sICH in AIS patients treated with IVT.
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Affiliation(s)
| | - Nitin Goyal
- Neurology, Univ of Tennessee Health Science Cntr, memphis, TN
| | | | - Abhi Pandhi
- Neurology, Univ of Tennessee Health Science Cntr, memphis, TN
| | - Savdeep Singh
- Neurology, Univ of Tennessee Health Science Cntr, memphis, TN
| | - Konark Malhotra
- Neurology, West Virginia Univ-Charleston Div, West Virginia, VA
| | - Tomas Bryndziar
- Neurology, Univ of Tennessee Health Science Cntr, memphis, TN
| | - Rena Sukhdeo
- Neurology, Univ of Tennessee Health Science Cntr, memphis, TN
| | - Talal Aboud
- Neurology, Univ of Tennessee Health Science Cntr, memphis, TN
| | | | | | | | | |
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31
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Sarraj A, Chen M, Goyal N, Hassan A, Kamal H, Chen PR, Sitton C, Cai C, Cutter G, Pujara D, Imam B, Reddy S, Requena M, Elijovich L, Arthur A, Pandhi A, Grotta J, McCullough L, Savitz S, Abraham M, Ribo M. Abstract WMP9: Does Repeat Images Improve Patient Selection and Clinical Outcomes in Patients Transferred for Endovascular Thrombectomy? Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wmp9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
It is unknown if repeat imaging of transfer patients for endovascular thrombectomy (EVT) results in better patient selection and improved clinical outcomes or if bypassing repeat imaging and direct transfer to the angiosuite is safe, saves time and improve outcomes.
Methods:
A multicenter retrospective cohort was pooled from 6 centers (Europe and US) from 1/2014 to 4/2018 of patients with anterior circulation occlusion (ICA, M1, M2) transferred for EVT up to 24 hours from last known well. Patients were divided based on imaging acquisition at the EVT center into those who underwent any repeat imaging (CT+/- CTA, CTP) and those who bypassed imaging and went directly to the angiosuite. We compared good outcome (90 day mRS 0-2) and safety (sICH, mortality) between the two groups.
Results:
Of 646 patients, 559 received EVT and 87 were excluded for poor imaging profiles. In patients who received EVT, 173 (31%) had no repeat nd 386 (69%) had repeat images. The two groups had similar age and NIHSS. ASPECTS was lower in the repeat images group 8(7-10) when compared to ASPECTS from the outside facility in the non-repeat 9(8-10), p<0.001. Repeat imaging prolonged arrival to puncture times 65(41-98) in the repeat vs 23(14-62) min for non-repeat group, P<0.001 without correlating with better rates of good outcome (42% repeat vs 51% no repeat (Fig 1), aOR 0.75 (0.39-1.47), p=0.41) and similar safety: sICH (9% vs 6%, p=0.29) and mortality (20% vs 16%, p=0.35). The results did not vary when stratified by early (0-6 hrs) vs late (6-24 hrs) treatment. Matching patients who did not receive EVT due to low ASPECTS with those who underwent EVT with low ASPECTS showed no increase in sICH (0% vs 4%, p=1.0) and better rates of mRS 0-2 with EVT (33%) vs medical management only (7%), p=0.15.
Conclusion:
In patients transferred for EVT, repeat imaging resulted in treatment delays without improving good outcome. Direct angio suite access may result in more patients treated safely who achieve good outcome.
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Affiliation(s)
| | | | - Nitin Goyal
- Univ of Tennessee Health Sciences Cntr, Memphis, TN
| | - Ameer Hassan
- Univ of Texas - Rio Grande Valley, Harlingen, TX
| | - Haris Kamal
- UT Health Science Cntr at Houston, Houston, TX
| | - Peng R Chen
- UT Health Science Cntr at Houston, Houston, TX
| | | | - Chunyan Cai
- UT Health Science Cntr at Houston, Houston, TX
| | - Gary Cutter
- Univ of Alabama at Birmingham, Birmingham, AL
| | - Deep Pujara
- UT Health Science Cntr at Houston, Houston, TX
| | - Bita Imam
- UT Health Science Cntr at Houston, Houston, TX
| | - Sujan Reddy
- UT Health Science Cntr at Houston, Houston, TX
| | | | | | - Adam Arthur
- Univ of Tennessee Health Sciences Cntr, Memphis, TN
| | - Abhi Pandhi
- Univ of Tennessee Health Sciences Cntr, Memphis, TN
| | | | | | - Sean Savitz
- UT Health Science Cntr at Houston, Houston, TX
| | | | - Marc Ribo
- Vall d'Hebron Univ Hosp, Barcelona, Spain
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Bavarsad Shahripour R, Goyal N, Tsivgoulis G, Pandhi A, Singh S, Malhotra K, Bryndziar T, Sukhdeo R, Aboud T, Krishnaiah B, Nearing K, Alexandrov AW, Alexandrov AV. Abstract WP110: Does Paradoxical Embolism Impart Different Outcomes After IVT Treatment? Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
There are pilot data indicating that patients with acute ischemic stroke (AIS) due to paradoxical embolism (PxE) via patent foramen ovale (PFO) may respond better to intravenous thrombolysis compared to other stroke subtypes. We sought to compare the safety and efficacy of IVT in AIS patients with and without PxE as their stroke etiopathogenic mechanism in a high-volume tertiary care stroke center.
Methods:
Consecutive AIS patients treated with IVT during a five-year period were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Presence of PFO was diagnosed by echocardiography, while PxE was determined using the TOAST criteria. Safety of IVT was evaluated using SITS-MOST sICH definition. Three-month functional status was assessed using modified Rankin Scale (mRS) scores.
Results:
Out of total 1301 IVT-treated AIS patients, we identified 51 cases (4%) with PxE due to PFO. Patients with PxE were younger (mean age 52±15 vs. 63±15 years; p<0.001), but had similar baseline and 24-hour NIHSS-scores compared to the others. The rates of sICH (4% vs. 5%), 3-month functional independence (mRS-scores 0-2; 77% vs. 68%) and 3-month favourable functional outcome (mRS-scores 0-1; 64% vs. 53%) did not differ (p>0.1) between the two groups. Three-month mortality was lower in the PxE group (0% vs. 9% by Fisher exact test). PxE due to PFO (OR computed using Firth’s penalized likelihood method for rare events: 0.11; 95%CI: 0.01-1.74) was not independently associated with 3-month mortality on multivariable logistic regression models adjusting for potential confounders.
Conclusions:
Our study indicates that AIS patients with PxE due to PFO have similar response to IVT compared to AIS patients with other underlying mechanisms.
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Affiliation(s)
| | - Nitin Goyal
- Univ of Tennessee Health Science Cntr, memphis, TN
| | | | - Abhi Pandhi
- Neurology, Univ of Tennessee Health Science Cntr, memphis, TN
| | - Savdeep Singh
- Neurology, Univ of Tennessee Health Science Cntr, memphis, TN
| | - Konark Malhotra
- Neurology, West Virginia Univ-Charleston Div, West Virginia, VA
| | - Tomas Bryndziar
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Rena Sukhdeo
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Talal Aboud
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
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Anadani M, Orabi Y, Alawieh A, Goyal N, Pandhi A, Alexandrov A, L.Maier I, Psychogios MN, Inamullah O, Rahman S, Keyrouz S, A Giles J, Allen M, Q.Wolfe S, Kan P, A.Nascimento F, M. Spiotta A. Abstract 153: Blood Pressure and Outcome After Mechanical Thrombectomy: A Multicenter Study. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.153] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Hypertension is a known predictor of poor outcome and hemorrhagic complications after ischemic stroke. However, the effect of blood pressure (BP) on outcome of those undergoing mechanical thrombectomy and especially after successful recanalization is not well understood. In this study, we investigated the association between BP parameters and outcome measures after successful recanalization with MT.
Methods:
This was a retrospective, multicenter study, involving 7 comprehensive stroke centers, of patients with acute ischemic stroke due to large vessel occlusion who achieved successful recanalization with MT. Systolic BP (SBP), diastolic BP (DBP) and mean arterial pressure (MAP) were obtained at frequent intervals (at least hourly) for each patient in the first 24 hours following MT. Outcome measures included 90 day-modified Rankin Scale (mRS), 90-day morality, and symptomatic intracerebral hemorrhage (sICH). Successful recanalization was defined as TICI 2b-3, and sICH as any hemorrhage associated with > 4 points increase in NIHSS. A mixed logistic model was used to identify predictors of functional and hemorrhagic outcomes.
Results:
A total of 989 patients were included, of whom 453 (45.8%) achieved good outcome, defined as an mRS of 0-2. Mean, and maximum SBP were higher in the poor outcome group (131.6 +15 vs. 127 +14.3; p <0.001, and 166± 24.7 vs. 158±24.3; p<0.001, respectively). There was no significant difference in the rest of BP measurement between the two groups. With respect to hemorrhagic complications, 40 (4.2%) patients develop sICH after MT. SBP, DBP and MAP were higher in sICH group. Table 1 summarizes multivariable analysis results.
Conclusion:
Higher blood pressure was associated with hemorrhagic complications, and worse functional outcome following successful mechanical thrombectomy.
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Affiliation(s)
| | - Yser Orabi
- Neurology, Med Univ of South Carolina, charleston, SC
| | - Ali Alawieh
- Neurology, Med Univ of South Carolina, charleston, SC
| | - Nitin Goyal
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Abhi Pandhi
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | - Ilko L.Maier
- Neurology, Univ Med Cntr Göttingen, Göttingen, Germany
| | | | | | | | - Salah Keyrouz
- Neurology, Washington Univ Sch of Medicine, Saint Louis, MO
| | - James A Giles
- Neurology, Washington Univ Sch of Medicine, Saint Louis, MO
| | - Michelle Allen
- Neurology, Washington Univ Sch of Medicine,, Saint Louis, MO
| | | | - Peter Kan
- Neurosurgery, Baylor College of Medicine, Houston, TX
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Krishnaiah B, Goyal N, Tsivgoulis G, Ishfaq M, Pandhi A, Krishnan R, Bavarsad Shahripour R, Elijovich L, Hoit D, Alexandrov A, Arthur A, Alexandrov AV. Abstract WP28: Yield of ASPECTS and CTA-Based Selection Criteria for Mechanical Thrombectomy in Patients Treated Within 6-24 Hours From Symptom Onset. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp28] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Recent extended window (EW) trials support the benefit of mechanical thrombectomy (MT) in anterior circulation emergent large vessel occlusions (ELVO). However, only up to 1.7% of consecutive acute ischemic strokes (AIS) were eligible for EW-MT using clinical trial selection criteria. We examined eligibility and outcomes of EW-MT in consecutive ELVOs using pragmatic selection criteria.
Methods:
We prospectively evaluated consecutive patients presenting between 6-24 hours that underwent MT using selection criteria consisting of only non-contrast CT (ASPECTS
>
6), CTA occlusion
+
good collateral scores (JNIS 2016;8:559-562). Effectiveness outcomes included TICI 2b-3 and 3-month modified Rankin Scores (mRS); safety outcomes included in-hospital mortality and symptomatic intracerebral hemorrhage (sICH).
Results:
767 consecutive AIS patients presented within 6-24 hour window, and of these 48 (6%) anterior circulation ELVOs underwent MT (mean age 63±17 years; 56% men; median NIHSS 16 [IQR 10-19]; median groin puncture to recanalization 53 minutes [IQR 41-85]). Median ASPECTS was 9 (IQR 8-10), and 79% (n=38) of patients had good CTA collateral grade. Occlusions were primarily M1 MCA (46%), with 29% tandem occlusions. Successful recanalization (mTICI 2b or 3) was achieved in 73% (n=35), while 6% (n=3) of patients developed sICH. In-hospital mortality was 25% (n=12), however 40% (n=19) achieved 3-month mRS 0-2.
Conclusions:
The use of standard of care CT/CTA yields an acceptable rate of MT eligibility, allowing a group of patients facing likely death or severe disability to obtain reasonable safety and effectiveness outcomes.
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Affiliation(s)
| | | | - George Tsivgoulis
- Neurology, Attikon Univ General Hosp, Sch of Medicine, National & Kapodistrian Univ of Athens, Athens, Greece
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Goyal N, Tsivgoulis G, Pandhi A, Krishnan R, Malhotra K, Ishfaq MF, Krishnaiah B, Nickele C, Inoa V, Hoit D, Elijovich L, Atkins C, Alexandrov A, Alexandrov AV, Arthur AS. Abstract WP30: Does Pretreatment With Intravenous Thrombolysis Prevent Infarct in a New Previously Unaffected Territory (INT) in Emergent Large Vessel Occlusion (ELVO) Patients Treated With Mechanical Thrombectomy (MT)? Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
There are contradictory data concerning the preventive role of intravenous thrombolysis (IVT) in preventing infarct in a new previously unaffected territory (INT) in emergent large vessel occlusion (ELVO) patients treated with mechanical thrombectomy (MT). We sought to evaluate the potential association of IVT pretreatment with the likelihood of INT complicating MT in a high-volume tertiary care stroke center.
Methods:
Consecutive ELVO patients reated with MT during a five-year period were evaluated. Baseline stroke severity was assessed by NIHSS-score. INT was defined using standardized methodology proposed by ESCAPE investigators. Collateral status was graded using ASITN/SIR criteria. The association of INT with 3-month functional independence (FI) defined as modified Rankin Scale scores of 0-2 was also investigated.
Results:
A total of 419 consecutive ELVO patients received MT [mean age 64±15 years, 50% men, median NIHSS-score 16 points (IQR:11-20), 69% IVT pretreatment). The incidence of INT was lower in patients treated with combination therapy (IVT & MT) than in patients treated with direct MT respectively (10% vs. 20%; p=0.011). INT occurred more frequently in patients with posterior circulation occlusion (28% vs. 10%; p<0.001). Patients with good collaterals tended to have lower rates of INT (11% vs. 18%; p=0.072). The rates of 3-month FI were lower in patients with INT (30% vs. 50%; p=0.007). IVT pretreatment was not independently related to INT (OR: 0.79; 95%CI: 0.34-1.83) on multivariable logistic regression models adjusting for location of occlusion, collateral status and onset to groin puncture time. INT did not emerge as anindependent predictor of 3-month FI (OR: 0.69; 95%CI: 0.29-1.62) on multivariable analyses.
Conclusions:
IVT pretreatment is not independently associated with lower likelihood of INT in LVO patients treated with MT. INT does not appear to independently affect 3-month functional outcomes.
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Affiliation(s)
- Nitin Goyal
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | - Abhi Pandhi
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Rashi Krishnan
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Konark Malhotra
- Dept of Neurology, West Virginia Univ-Charleston Div,, Charleston, WV
| | - Muhammad F Ishfaq
- Dept of Neurology, Univ of Tennessee Health Science Cntr, memphis, TN
| | - Balaji Krishnaiah
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Christopher Nickele
- Dept of Neurosurgery, Univ of Tennessee Health Science Cntr and Semmes-Murphey Clinic, Memphis, TN
| | - Violiza Inoa
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Daniel Hoit
- Dept of Neurosurgery, Univ of Tennessee Health Science Cntr and Semmes-Murphey Clinic, Memphis, TN
| | - Lucas Elijovich
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Cole Atkins
- Univ of Tennessee Health Science Cntr, memphis, TN
| | - Anne Alexandrov
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | - Adam S Arthur
- Dept of Neurosurgery, Univ of Tennessee Health Science Cntr and Semmes-Murphey Clinic, Memphis, TN
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36
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Anadani M, Orabi Y, Alawieh A, Goyal N, Pandhi A, Mitchell H, Alexandrov A, Maier IL, Psychogios MN, Liman J, Inamullah O, Swisher C, Rahman S, Kansagra A, Giles JA, Allen M, Wolfe SQ, Kan P, Nascimento FA, Turner RD, Spiotta AM. Abstract WP17: Blood Pressure Reduction Within 24 Hours After Mechanical Thrombectomy Does Not Correlate With Outcome: A Collaborative Pooled Analysis. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Previous studies showed that lowering blood pressure in the acute phase after stroke may be harmful. However, the effect of blood pressure lowering on outcome after successful recanalization is not well known.
Objective:
The aim of this study was to evaluate the association between systolic blood pressure (SBP) reduction and outcome of thrombectomy after successful recanalization.
Methods:
This was a retrospective multicenter study of patients with anterior circulation large vessel occlusions who achieved successful recanalization (TICI 2b-3) with MT. Degree of SBP reduction was calculated using the following formula: 100*(admission SBP - minimum SBP within 24 hours)/admission SBP. Patients were divided into two groups: group 1) included patients with ≤25% SBP drop; group 2) included patients with > 25% SBP drop. Outcome measures included 90 days mRS, symptomatic ICH (sICH), and mortality
Results:
Of 991 screened patients, 917 had available admission SBP data. Average age was 68+14 years. The average admission SBP was 143 ±27 mm Hg. 383 (38.6%) patients had less than 25% SBP reduction, whereas 495 (49.9%) had > 25% SBP reduction in the first 24 hrs. There was no difference in the proportion of patients who achieved good outcome (mRS) between the two groups. Likewise there was no difference in the rate of sICH between two groups (4..2% vs. 4.5%;p=0.84). SBP reduction was not significantly associated with functional outcome on multivariate analysis (OR=1.003; 95% CI 0.99-1.013, p=0.54).
Conclusion:
blood pressure lowering after successful recanalization appears to be safe and was not associated with worse outcome. Further studies are needed to determine whether BP lowering is actually beneficial
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Affiliation(s)
| | - Yser Orabi
- Neurology, Med Univ of South Carolina, Charleston, SC
| | - Ali Alawieh
- Neurosurgery, Med Univ of South Carolina, Charleston, SC
| | | | - Abhi Pandhi
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Hunter Mitchell
- Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | - Ilko L Maier
- Neurology, Univ Med Cntr Göttingen, Göttingen, Germany
| | | | - Jan Liman
- Neurology, Univ Med Cntr Göttingen, Göttingen, Germany
| | | | | | | | - Akash Kansagra
- Radiology, Neurological Surgery; and Neurology, Washington Univ Sch of Medicine and Barnes-Jewish Hosp, St. Louis, MO
| | - James A Giles
- Neurology, Washington Univ Sch of Medicine, St. Louis, MO
| | - Michelle Allen
- Neurology, Washington Univ Sch of Medicine, St. Louis, MO
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest Sch of Medicine, Winston Salem, NC
| | - Peter Kan
- Neurosurgery, Baylor College of Medicine, Houston, TX
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Goyal N, Tsivgoulis G, Malhotra K, Katsanos AH, Pandhi A, Alsherbini KA, Chang JJ, Hoit D, Alexandrov AV, Elijovich L, Fiorella D, Nickele C, Arthur AS. Minimally invasive endoscopic hematoma evacuation vs best medical management for spontaneous basal-ganglia intracerebral hemorrhage. J Neurointerv Surg 2019; 11:579-583. [DOI: 10.1136/neurintsurg-2018-014447] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 10/31/2018] [Accepted: 11/05/2018] [Indexed: 11/04/2022]
Abstract
BackgroundWe conducted a case-control study to assess the relative safety and efficacy of minimally invasive endoscopic surgery (MIS) for clot evacuation in patients with basal-ganglia intracerebral hemorrhage (ICH).MethodsWe evaluated consecutive patients with acute basal-ganglia ICH at a single center over a 42-month period. Patients received either best medical management according to established guidelines (controls) or MIS (cases). The following outcomes were compared before and after propensity-score matching (PSM): in-hospital mortality; discharge National Institutes of Health Stroke Scale score; discharge disposition; and modified Rankin Scale scores at discharge and at 3 months.ResultsAmong 224 ICH patients, 19 (8.5%) underwent MIS (mean age, 50.9±10.9; 26.3% female, median ICH volume, 40 (IQR, 25–51)). The interventional cohort was younger with higher ICH volume and stroke severity compared with the medically managed cohort. After PSM, 18 MIS patients were matched to 54 medically managed individuals. The two cohorts did not differ in any of the baseline characteristics. The median ICH volume at 24 hours was lower in the intervention group (40 cm3 (IQR, 25–50) vs 15 cm3 (IQR, 5–20); P<0.001). The two cohorts did not differ in any of the pre-specified outcomes measures except for in-hospital mortality, which was lower in the interventional cohort (28% vs 56%; P=0.041).ConclusionsMinimally invasive endoscopic hematoma evacuation was associated with lower rates of in-hospital mortality in patients with spontaneous basal-ganglia ICH. These findings support a randomized controlled trial of MIS versus medical management for ICH.
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Pandhi A, Tsivgoulis G, Goyal N, Ishfaq MF, Male S, Boviatsis E, Chang JJ, Zand R, Voumvourakis K, Elijovich L, Alexandrov AW, Malkoff MD, Hoit D, Arthur AS, Alexandrov AV. Hemicraniectomy for Malignant Middle Cerebral Artery Syndrome: A Review of Functional Outcomes in Two High-Volume Stroke Centers. J Stroke Cerebrovasc Dis 2018; 27:2405-2410. [PMID: 29776804 DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 03/11/2018] [Accepted: 04/23/2018] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND AND PURPOSE Despite recent landmark randomized controlled trials showing significant benefits for hemicraniectomy (HCT) compared with medical therapy (MT) in patients with malignant middle cerebral artery infarction (MMCAI), HCT rates have not substantially increased in the United States. We sought to evaluate early outcomes in patients with MMCAI who were treated with HCT (cases) in comparison to patients treated with MT due to the perception of procedural futility by families (controls). METHODS We retrospectively evaluated consecutive patients with acute MMCAI treated in 2 tertiary care centers during a 7-year period. Pretreatment National Institutes of Health Stroke Scale (NIHSS) and modified Rankin Scale (mRS) at 3 months were documented. Functional independence (FI) and survival without severe disability (SWSD) were defined as mRS of 0-2 and 0-4, respectively. RESULTS A total of 66 patients (37 cases and 29 controls) fulfilled the study inclusion criteria (mean age 59 ± 15 years, 52% men, median admission NIHSS score: 19 points [interquartile range {IQR}: 16-22]). Cases were younger (51 ± 11 versus 68 ± 13 years; P < .001) and tended to have lower median admission NIHSS than controls (18 [IQR:16-20] versus 20 [IQR:18-23]; P = .072). The rates of FI and SWSD at 3 months were higher in cases than controls (16% versus 0% [P = .031] and 62% versus 0% [P < .001]), while 3-month mortality was lower (24% versus 77%; P < .001). Multivariable Cox regression analyses adjusting for potential confounders identified HCT as the most important predictor of lower risk of 3-month mortality (hazard ratio: .02, 95% confidence interval: .01-0.10; P < .001). CONCLUSIONS HCT is a critical and effective therapy for patients with MMCAI but cannot provide a guarantee of functional recovery.
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Affiliation(s)
- Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee.
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Second Department of Neurology, "Attikon University Hospital", School of Medicine, University of Athens, Athens, Greece
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Muhammad F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Shailesh Male
- Department of Neurology, University of Minnesota Medical Center, Minneapolis, Minnesota
| | - Efstathios Boviatsis
- Second Department of Neurosurgery, "Attikon University Hospital", School of Medicine, University of Athens, Athens, Greece
| | - Jason J Chang
- Neurointensivist, Medstar Washington Hospital Medical Center, Washington, DC
| | - Ramin Zand
- Neurology Director of Clinical Stroke Operations & Northeastern Regional Stroke Director, Geisinger Health System
| | | | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee; Professor and US Principle Investigator, Australian Catholic University, Sydney, Australia
| | - Marc D Malkoff
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee
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Qureshi AI, Ishfaq A, Ishfaq MF, Pandhi A, Ahmed SI, Singh S, Kerro A, Krishnan R, Deep A, Georgiadis AL. Therapeutic Benefit of Cilostazol in Patients with Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis of Randomized and Nonrandomized Studies. J Vasc Interv Neurol 2018; 10:33-40. [PMID: 30746008 PMCID: PMC6350875] [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] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To assess the effectiveness of cilostazol, a selective inhibitor of phosphodiesterase type III, in preventing cerebral ischemia related to cerebral vasospasm after aneurysmal subarachnoid hemorrhage (SAH). METHODS A total of six clinical studies met the inclusion criteria and were included in the meta-analysis. We calculated pooled risk ratios (RR) and 95% confidence intervals (CI) using random-effects models. The primary endpoint was cerebral ischemia related to vasospasm. Secondary endpoints were angiographic vasospasm, new cerebral infarct, mortality, and death or disability at the final follow-up. RESULTS A total of 136 (22%) of 618 subjects (38 and 98 assigned to cilostazol and control treatments, respectively) with SAH developed cerebral ischemia related to vasospasm. The risk of cerebral ischemia related to vasospasm was significantly lower in subjects assigned to cilostazol treatment (RR 0.43; 95% CI 0.31-0.60; p< 0.001). The risks of angiographic vasospasm (RR 0.67, 95% CI 0.54-0.84, p< 0.001 ) and new cerebral infarct (RR 0.37, 95% CI 0.24-0.57, p< 0.001) were significantly lower in subjects assigned to cilostazol treatment. There was a significantly lower rate of death or disability in subjects assigned to cilostazol treatment at follow-up (PR 0.55, 95% 0.39-0.78, p = 0.001). CONCLUSION The reduction in rates of cerebral ischemia related to vasospasm and death or disability at follow-up support further evaluation of oral cilostazol in patients with aneurysmal SAH in a large randomized clinical trial.
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Affiliation(s)
| | - Ammad Ishfaq
- Zeenat Qureshi Stroke Institute, St. Cloud, MN, USA
| | - Muhammad F. Ishfaq
- Zeenat Qureshi Stroke Institute, St. Cloud, MN, USA
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Abhi Pandhi
- University of Tennessee Health Science Center, Memphis, TN, USA
| | | | - Savdeep Singh
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Ali Kerro
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Rashi Krishnan
- University of Tennessee Health Science Center, Memphis, TN, USA
| | - Aman Deep
- University of Tennessee Health Science Center, Memphis, TN, USA
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40
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Tsivgoulis G, Goyal N, Kerro A, Katsanos AH, Krishnan R, Malhotra K, Pandhi A, Duden P, Deep A, Shahripour RB, Bryndziar T, Nearing K, Chulpayev B, Chang J, Zand R, Alexandrov AW, Alexandrov AV. Dual antiplatelet therapy pretreatment in IV thrombolysis for acute ischemic stroke. Neurology 2018; 91:e1067-e1076. [PMID: 30120131 DOI: 10.1212/wnl.0000000000006168] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Accepted: 06/11/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE We sought to determine the safety and efficacy of IV thrombolysis (IVT) in acute ischemic stroke (AIS) patients with a history of dual antiplatelet therapy pretreatment (DAPP) in a prospective multicenter study. METHODS We compared the following outcomes between DAPP+ and DAPP- IVT-treated patients before and after propensity score matching (PSM): symptomatic intracranial hemorrhage (sICH), asymptomatic intracranial hemorrhage, favorable functional outcome (modified Rankin Scale score 0-1), and 3-month mortality. RESULTS Among 790 IVT patients, 58 (7%) were on DAPP before stroke (mean age 68 ± 13 years; 57% men; median NIH Stroke Scale score 8). DAPP+ patients were older with more risk factors compared to DAPP- patients. The rates of sICH were similar between groups (3.4% vs 3.2%). In multivariable analyses adjusting for potential confounders, DAPP was associated with higher odds of asymptomatic intracranial hemorrhage (odds ratio = 3.53, 95% confidence interval: 1.47-8.47; p = 0.005) but also with a higher likelihood of 3-month favorable functional outcome (odds ratio = 2.41, 95% confidence interval: 1.06-5.46; p = 0.035). After propensity score matching, 41 DAPP+ patients were matched to 82 DAPP- patients. The 2 groups did not differ in any of the baseline characteristics or safety and efficacy outcomes. CONCLUSIONS DAPP is not associated with higher rates of sICH and 3-month mortality following IVT. DAPP should not be used as a reason to withhold IVT in otherwise eligible AIS candidates. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for IVT-treated patients with AIS, DAPP is not associated with a significantly higher risk of sICH. The study lacked the precision to exclude a potentially meaningful increase in sICH bleeding risk.
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Affiliation(s)
- Georgios Tsivgoulis
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Nitin Goyal
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Ali Kerro
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Aristeidis H Katsanos
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Rashi Krishnan
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Konark Malhotra
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Abhi Pandhi
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Peter Duden
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Aman Deep
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Reza Bavarsad Shahripour
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Tomas Bryndziar
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Katherine Nearing
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Boris Chulpayev
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Jason Chang
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Ramin Zand
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Anne W Alexandrov
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA
| | - Andrei V Alexandrov
- From the Department of Neurology (G.T., N.G., A.K., R.K., A.P., P.D., A.D., R.B.S., T.B., K.N., B.C., J.C., R.Z., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), Attikon University General Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece; Department of Neurology (K.M.), West Virginia University-Charleston Division; Department of Critical Care Medicine (J.C.), MedStar Washington Hospital Center, Washington, DC; and Department of Neurology (R.Z.), Geisinger Health System, Danville, PA.
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Malhotra K, Goyal N, Chang JJ, Broce M, Pandhi A, Kerro A, Shahripour RB, Alexandrov AV, Tsivgoulis G. Differential leukocyte counts on admission predict outcomes in patients with acute ischaemic stroke treated with intravenous thrombolysis. Eur J Neurol 2018; 25:1417-1424. [PMID: 29953701 DOI: 10.1111/ene.13741] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [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: 04/18/2018] [Accepted: 06/20/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE To determine the association of differential leukocyte counts on admission with efficacy and safety outcomes in patients with acute ischaemic stroke (AIS) treated with intravenous thrombolysis (IVT). METHODS Consecutive patients with AIS receiving IVT were evaluated at two stroke centers. Differential leukocyte counts and neutrophil:lymphocyte ratio (NLR) were determined during the initial 12 h of admission. Efficacy outcomes were favorable functional outcome (FFO) (modified Rankin Scale scores of 0-1) and functional independence (FI) (modified Rankin Scale scores of 0-2) at 3 months, whereas safety outcomes were symptomatic intracranial hemorrhage and 3-month mortality. RESULTS Among 657 IVT-treated patients with AIS, the mean age was 64 ± 14 years, 50% were female and median National Institutes of Health Stroke Scale score was 7 points (interquartile range, 4-13). Lower neutrophil and leukocyte counts and NLR counts were observed in patients with 3-month FFO and FI, whereas higher counts were observed in patients who died at 3 months. The best discriminative factors for 3-month FFO and FI were NLR < 2.2 (sensitivity 51.4%, specificity 63.1%) and leukocyte count <8100/μL (sensitivity 57.5%, specificity 55.1%), respectively. After adjustment for potential confounders, NLR < 2.2 was associated with higher odds of FFO [odds ratio (OR), 1.56; 95% confidence interval (CI), 1.08-2.24; P = 0.018], whereas leukocyte count <8100/μL demonstrated higher odds of 3-month FI (OR, 1.69; 95% CI, 1.11-2.57; P = 0.014) and lower odds of 3-month mortality (OR, 0.31; 95% CI, 0.16-0.60; P = 0.001). Combined neutrophil (<6800/μL) and leukocyte (<8100/μL) counts demonstrated a strong interaction for 3-month FI (OR, 1.73; 95% CI, 1.13-2.67; P interaction = 0.012). CONCLUSIONS Differential leukocyte counts on admission were independently associated with clinical outcomes in patients with AIS treated with IVT. These inflammatory biomarkers are potential targets for adjunctive neuroprotection in this stroke subgroup.
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Affiliation(s)
- K Malhotra
- Department of Neurology, Charleston Area Medical Center, West Virginia University, Charleston, WV
| | - N Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - J J Chang
- Medstar Washington Hospital Medical Center, Washington, DC
| | - M Broce
- Department of Health Services & Outcomes Research, Charleston Area Medical Center, Charleston, WV, USA
| | - A Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - A Kerro
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - R B Shahripour
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - A V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - G Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN.,Second Department of Neurology, School of Medicine, Attikon University Hospital, National & Kapodistrian University of Athens, Athens, Greece
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Goyal N, Tsivgoulis G, Malhotra K, Houck AL, Khorchid YM, Pandhi A, Inoa V, Alsherbini K, Alexandrov AV, Arthur AS, Elijovich L, Chang JJ. Serum Magnesium Levels and Outcomes in Patients With Acute Spontaneous Intracerebral Hemorrhage. J Am Heart Assoc 2018; 7:JAHA.118.008698. [PMID: 29654197 PMCID: PMC6015418 DOI: 10.1161/jaha.118.008698] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Magnesium (Mg) has potential hemostatic properties. We sought to investigate the potential association of serum Mg levels (at baseline and at 48 hours) with outcomes in patients with acute spontaneous intracerebral hemorrhage (ICH). METHODS AND RESULTS We reviewed data on all patients with spontaneous ICH with available Mg levels at baseline, over a 5-year period. Clinical and radiological outcome measures included initial hematoma volume, admission National Institutes of Health Stroke Scale and ICH scores, in-hospital mortality, favorable functional outcome (modified Rankin Scale scores, 0-1), and functional independence (modified Rankin Scale scores, 0-2) at discharge. Our study population consisted of 299 patients with ICH (mean age, 61±13 years; mean admission serum Mg, 1.8±0.3 mg/dL). Increasing admission Mg levels strongly correlated with lower admission National Institutes of Health Stroke Scale score (Spearman's r, -0.141; P=0.015), lower ICH score (Spearman's r, -0.153; P=0.009), and lower initial hematoma volume (Spearman's r, -0.153; P=0.012). Higher admission Mg levels were documented in patients with favorable functional outcome (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.025) and functional independence (1.9±0.3 versus 1.8±0.3 mg/dL; P=0.022) at discharge. No association between serum Mg levels at 48 hours and any of the outcome variables was detected. In multiple linear regression analyses, a 0.1-mg/dL increase in admission serum Mg was independently and negatively associated with the cubed root of hematoma volume at admission (regression coefficient, -0.020; 95% confidence interval, -0.040 to -0.000; P=0.049) and admission ICH score (regression coefficient, -0.053; 95% confidence interval, -0.102 to -0.005; P=0.032). CONCLUSIONS Higher admission Mg levels were independently related to lower admission hematoma volume and lower admission ICH score in patients with acute spontaneous ICH.
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Affiliation(s)
- Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN.,Second Department of Neurology, "Attikon University Hospital,", School of Medicine, National and Kapodistrian University of Athens, Greece
| | - Konark Malhotra
- Department of Neurology, West Virginia University Charleston Division, Charleston, WV
| | - Alexander L Houck
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Yasser M Khorchid
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Violiza Inoa
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN
| | - Khalid Alsherbini
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, TN
| | - Jason J Chang
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN.,Medstar Washington Hospital Medical Center, Washington, DC
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Goyal N, Tsivgoulis G, Frei D, Turk A, Baxter B, Froehler MT, Mocco J, Pandhi A, Zand R, Malhotra K, Hoit D, Elijovich L, Loy D, Turner RD, Mascitelli J, Espaillat K, Katsanos AH, Alexandrov AW, Alexandrov AV, Arthur AS. Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion. Neurology 2018; 90:e1274-e1282. [PMID: 29549221 DOI: 10.1212/wnl.0000000000005299] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 12/27/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE In this multicenter study, we sought to evaluate comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) vs direct MT in emergent large vessel occlusion (ELVO) patients. METHODS Consecutive ELVO patients treated with MT at 6 high-volume endovascular centers were evaluated. Standard safety and efficacy outcomes (successful reperfusion [modified Thrombolysis in Cerebral Infarction IIb/III], functional independence [FI] [modified Rankin Scale (mRS) score of 0-2 at 3 months], favorable functional outcome [mRS of 0-1 at 3 months], functional improvement [mRS shift by 1-point decrease in mRS score]) were compared between patients who underwent combined IVT and MT vs MT alone. Additional propensity score-matched analyses were performed. RESULTS A total of 292 and 277 patients were treated with combination therapy and direct MT, respectively. The combination therapy group had greater functional improvement (p = 0.037) at 3 months. After propensity score matching, 104 patients in the direct MT group were matched to 208 patients in the combination therapy group. IVT pretreatment was independently (p < 0.05) associated with higher odds of FI (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.02-2.99) and functional improvement (common OR 1.64; 95% CI 1.05-2.56). Combination therapy was independently (p < 0.05) related to lower likelihood of 3-month mortality (0.50; 95% CI 0.26-0.96). CONCLUSIONS This observational study provides preliminary evidence that IVT pretreatment may improve outcomes in ELVO patients treated with MT. The question of the potential effect of IVT on ELVO patients treated with MT should be addressed with a randomized controlled trial. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for stroke patients with emergent large vessel occlusion, combined IVT and MT is superior to direct MT in improving functional outcomes.
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Affiliation(s)
- Nitin Goyal
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Georgios Tsivgoulis
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Donald Frei
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Aquilla Turk
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Blaise Baxter
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Michael T Froehler
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - J Mocco
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Abhi Pandhi
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Ramin Zand
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Konark Malhotra
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Daniel Hoit
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Lucas Elijovich
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - David Loy
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Raymond D Turner
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Justin Mascitelli
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Kiersten Espaillat
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Aristeidis H Katsanos
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Anne W Alexandrov
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Andrei V Alexandrov
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Adam S Arthur
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis.
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Goyal N, Tsivgoulis G, Kerro A, Zand R, Krishnan R, Malhotra K, Pandhi A, Duden P, Deep A, Shahripour R, Bryndziar T, Nearing K, Chulpayev B, Elijovich L, Alexandrov A, Alexandrov A. Abstract TP68: Shorter Door-to-Needle Time is the Only Independent Predictor for Initiation of Intravenous Thrombolysis (IVT) Within the Golden Hour. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Administration of tPA in the first 60 min post-onset, the golden hour (GH), is associated with improved functional outcomes but remains unachievable in the vast majority of patients. We sought to identify independent predictors of IVT in the GH in a prospective, multi-center study.
Methods:
AIS patients treated with IVT during a five-year period in two tertiary care stroke centers were evaluated. Demographics, vascular risk factors, onset to treatment time, door-to-needle time (DTN) admission blood pressure and serum glucose levels were documented. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. The etiopathogenic mechanism of AIS was documented using TOAST criteria. Subjects with in-hospital stroke or treated in the mobile stroke unit were excluded.
Results:
Out of total 658 IVT-treated AIS patients (mean age 64±15 years; 50% men; median NIHSS-score 6, IQR: 4-12) we identified 26 (4%) subjects treated in the GH (mean age 62±15 years; 46% men; median NIHSS-score 8, IQR: 4-12). GH patients had shorter median DTN (23 min, IQR: 18-44 vs. 38 min, IQR: 26-49). DTN
2
30 min was more prevalent in the GH group (62% vs. 20%; p<0.001). DTN emerged as the only independent predictor of IVT in the GH in multivariable logistic regression models adjusting for demographics, risk factors, admission blood pressure and serum glucose levels, TOAST subtype, baseline NIHSS and ASPECTS. A 10-min delay in DTN approximately halved the odds of IVT in the GH (OR: 0.54; 95%CI: 0.41-0.71; p<0.001). Alternatively, DTN equal or less than 30min increased exponentially the likelihood of tPA initiation in the GH (OR: 6.29; 95%CI: 2.78-14.25; p<0.001).
Conclusions:
Shorter DTN is the only independent predictor of IVT initiation within the GH. Continued improvements in systems of acute stroke care should aim to further reduce DTN in order to increase the availability of tPA delivery in the GH.
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Affiliation(s)
| | | | - Ali Kerro
- UTHSC Dept of Neurology, Memphis, TN
| | | | | | - Konark Malhotra
- West Virginia Univ, Dept of Neurology, Charleston Div, Charleston, WV
| | | | | | - Aman Deep
- UTHSC Dept of Neurology, Memphis, TN
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Ishfaq A, Pandhi A, Ishfaq MF, Ahmed SI, Deep A, Singh S, Syed MA, Qureshi AI. Abstract 37: The Efficacy and Safety of Cilostazol in Subarachnoid Hemorrhage. A Meta-analysis of Randomized and Non Randomized Studies. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Extensive research has long been focused on improving morbidity and mortality related to cerebral vasospasm which is well known as a major complication in subarachnoid hemorrhage (SAH) patients. The aim of this meta-analysis is to assess the effectiveness of cilostazol, a selective inhibitor of phosphodiesterase Type III, on cerebral vasospasm after SAH.
Methods:
Randomized and non randomized studies that compared effectiveness of cilostazol in SAH were included. A total of 6 trials met the inclusion criteria and were included in the meta-analysis. We calculated pooled risk ratios (RR) and 95% CIs (confidence intervals) using random-effects models. Primary end point was symptomatic vasospasm. Secondary end points were angiographic vasospasm, new cerebral infarct, mortality, and functional outcome i.e Modified Rankin scale ≤ 2.
Results:
Of the 618 total subjects, total of 136 (22%) symptomatic vasospasm events occurred during the follow-up period. The RR of symptomatic vasospasm was lower in patients treated with Cilostazol (RR = 0.43; 95% CI, 0.31-0.60; P < 0.001). Angiographic vasospasm was also significantly lower among those who received cilostazol as compared to control group (RR 0.67, 95% CI 0.51-0.84, p = .001). Cilostazol was associated with lower likelihood of new cerebral infarct in comparison to best medical therapy (RR 0.33 CI 95% 0.20-0.54, p<0.001). There was no difference between the risk of mortality between subjects who received airway cilostazol compared with those who were in control group (RR 0.64 CI 95% 0.15-2.76, p=0.55). There was improvement of mRS noted in patients who received cilostazol therapy (RR 1.21 CI 95% 1.05-1.39, p=0.008).
Conclusion:
Cilostazol administration may improve the outcome of patients with SAH. Further studies are needed to confirm this efficacy of cilostazol
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Affiliation(s)
| | - Abhi Pandhi
- Dept of Neurology, Univ of Tennessee Health Sciences Cntr, Memphis, TN
| | - Muhammad F Ishfaq
- Dept of Neurology, Univ of Tennessee Health Sciences Cntr, Memphis, TN
| | | | - Aman Deep
- Dept of Neurology, Univ of Tennessee Health Sciences Cntr, Memphis, TN
| | - Savdeep Singh
- Dept of Neurology, Univ of Tennessee Health Sciences Cntr, Memphis, TN
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Goyal N, Tsivgoulis G, Kerro A, Katsanos AH, Krishnan R, Malhotra K, Pandhi A, Duden P, Deep A, Shahripour RB, Bryndziar T, Nearing K, Chulpayev B, Alexandrov AW, Alexandrov AV. Abstract TMP22: Safety of Pretreatment With Dual Antiplatelet Therapy in Intravenous Thrombolysis for Acute Ischemic Stroke. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tmp22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
There are preliminary data indicating that pretreatment with dual antiplatelet therapy (DAPT) may increase the risk of symptomatic intracranial hemorrhage (sICH) following intravenous thrombolysis (IVT) for acute ischemic stroke (AIS). We sought to identify the safety and efficacy of pretreatment with DAPT in IVT for AIS in a prospective, multi-center study.
Methods:
AIS patients treated with IVT during a five-year period in two tertiary care stroke centers were evaluated. Baseline stroke severity and early hypodensity on baseline CT were assessed by NIHSS-score and ASPECTS by certified physicians. Three-month functional status was assessed using modified Rankin Scale (mRS). We compared the following outcomes between DAPT (+) and DAPT (-) patients before and after propensity score matching (PSM): 1.sICH, 2. asymptomatic intracranial hemorrhage (aICH) 3. favourable functional outcome (FFO; mRS scores of 0-1), 4. 3-month mortality.
Results:
Out of total 790 IVT-treated AIS patients, we identified 58 (7%) pretreated with DAPT (mean age 68±13 years; 57% men; median NIHSS-score 8, IQR: 4-14). The two groups did not differ (p>0.05) in terms of sICH [DAPT(+): 3% vs. DAPT(-): 3%], FFO (64% vs. 50%) and 3-month mortality (9% vs. 9%) in unmatched analyses. DAPT pretreatment was associated with higher odds of aICH before (17% vs. 6%) and after adjustment (OR: 2.4; 95%CI: 1.1-5.5) for potential confounders. After PSM, patients with (n=41) and without (n=82) DAPT pretreatment did not differ in any of the baseline characteristics. The differences in rates of all outcome events were non-significant in the two groups including sICH (2% vs. 1%, p=0.63), aICH (17% vs. 7%, p=0.06) and 3-month mRS (p=0.60; Figure).
Conclusions:
Pretreatment with DAPT is not associated with higher rates of sICH or three-month mortality and does not reduce the odds of FFO following IVT for AIS. IVT should not be withheld in otherwise eligible candidates due to pretreatment with DAPT.
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Affiliation(s)
- Nitin Goyal
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Georgios Tsivgoulis
- Second Dept of Neurology, "Attikon" Univ Hosp, National and Kapodistrian Univ of Athens, Athens, Greece
| | - Ali Kerro
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Aristeidis H Katsanos
- Second Dept of Neurology, "Attikon" Univ Hosp, National and Kapodistrian Univ of Athens, Athens, Greece
| | - Rashi Krishnan
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Konark Malhotra
- Dept of Neurology, West Virginia Univ Charleston Div, Charleston, VA
| | - Abhi Pandhi
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Peter Duden
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Aman Deep
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | | | - Tomas Bryndziar
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Katherine Nearing
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Boris Chulpayev
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
| | - Anne W Alexandrov
- Dept of Neurology, Univ of Tennessee Health Science Cntr, Memphis, TN
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Goyal N, Tsivgoulis G, Pandhi A, Dillard K, Alsbrook D, Chang JJ, Krishnaiah B, Nickele C, Hoit D, Alsherbini K, Alexandrov AV, Arthur AS, Elijovich L. Blood pressure levels post mechanical thrombectomy and outcomes in non-recanalized large vessel occlusion patients. J Neurointerv Surg 2018; 10:925-931. [DOI: 10.1136/neurintsurg-2017-013581] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2017] [Revised: 12/21/2017] [Accepted: 12/28/2017] [Indexed: 11/04/2022]
Abstract
ObjectivePermissive hypertension may benefit patients with non-recanalized large vessel occlusion (nrLVO) post mechanical thrombectomy (MT) by maintaining brain perfusion. Data evaluating the impact of post-MT blood pressure (BP) levels on outcomes in nrLVO patients are scarce. We investigated the association of the post-MT BP course with safety and efficacy outcomes in nrLVO.MethodsHourly systolic BP (SBP) and diastolic BP (DBP) values were prospectively recorded for 24 hours following MT in consecutive nrLVO patients. Maximum, minimum, and mean BP levels were documented. Three-month functional independence (FI) was defined as modified Rankin Scale (mRS) scores of 0–2.ResultsA total of 88 nrLVO patients were evaluated post MT. Patients with FI had lower maximum SBP (160±19 mmHg vs 179±23 mmHg; P=0.001) and higher minimum SBP levels (119±12 mmHg vs 108±25 mmHg; P=0.008). Maximum SBP (183±20 mmHg vs 169±23 mmHg; P=0.008) and DBP levels (105±20 mmHg vs 89±18 mmHg; P=0.001) were higher in patients who died at 3 months while minimum SBP values were lower (102±28 mmHg vs 115±16 mmHg; P=0.007). On multivariable analyses, both maximum SBP (OR per 10 mmHg increase: 0.55, 95% CI 0.39 to 0.79; P=0.001) and minimum SBP (OR per 10 mmHg increase: 1.64, 95% CI 1.04 to 2.60; P=0.033) levels were independently associated with the odds of FI. Maximum DBP (OR per 10 mmHg increase: 1.61; 95% CI 1.10 to 2.36; P=0.014) and minimum SBP (OR per 10 mmHg increase: 0.65, 95% CI 0.47 to 0.90; P=0.009) values were independent predictors of 3-month mortality.ConclusionsOur study demonstrates that wide BP excursions from the mean during the first 24 hours post MT are associated with worse outcomes in patients with nrLVO.
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Pandhi A, Tsivgoulis G, Krishnan R, Ishfaq MF, Singh S, Hoit D, Arthur AS, Nickele C, Alexandrov A, Elijovich L, Goyal N. Antiplatelet pretreatment and outcomes following mechanical thrombectomy for emergent large vessel occlusion strokes. J Neurointerv Surg 2017; 10:828-833. [PMID: 29259123 DOI: 10.1136/neurintsurg-2017-013532] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [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: 10/02/2017] [Revised: 12/03/2017] [Accepted: 12/07/2017] [Indexed: 11/04/2022]
Abstract
BACKGROUND Few data are available regarding the safety and efficacy of antiplatelet (APT) pretreatment in acute ischemic stroke (AIS) patients with emergent large vessel occlusions (ELVO) treated with mechanical thrombectomy (MT). We sought to evaluate the association of APT pretreatment with safety and efficacy outcomes following MT for ELVO. METHODS Consecutive ELVO patients treated with MT during a 4-year period in a tertiary stroke center were evaluated. The following outcomes were documented using standard definitions: symptomatic intracranial hemorrhage (sICH), successful recanalization (SR; modified TICI score 2b/3), mortality, and functional independence (modified Rankin Scale scores of 0-2). RESULTS The study population included 217 patients with ELVO (mean age 62±14 years, 50% men, median NIH Stroke Scale score 16). APT pretreatment was documented in 71 cases (33%). Patients with APT pretreatment had higher SR rates (77% vs 61%; P=0.013). The two groups did not differ in terms of sICH (6% vs 7%), 3-month mortality (25% vs 26%), and 3-month functional independence (50% vs 48%). Pretreatment with APT was independently associated with increased likelihood of SR (OR 2.18, 95% CI1.01 to 4.73; P=0.048) on multivariable logistic regression models adjusting for potential confounders. A significant interaction (P=0.014) of intravenous thrombolysis (IVT) pretreatment on the association of pre-hospital antiplatelet use with SR was detected. APT pretreatment was associated with SR (OR 2.74, 95% CI 1.15 to 6.54; P=0.024) in patients treated with combination therapy (IVT and MT) but not in those treated with direct MT (OR 1.78, 95% CI 0.63 to 5.03; P=0.276). CONCLUSION APT pretreatment does not increase the risk of sICH and may independently improve the odds of SR in patients with ELVO treated with MT. The former association appears to be modified by IVT.
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Affiliation(s)
- Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Second Department of Neurology, School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Rashi Krishnan
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Muhammad F Ishfaq
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Savdeep Singh
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA
| | - Christopher Nickele
- Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA
| | - Andrei Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Semmes-Murphey Neurologic and Spine Clinic, Memphis, Tennessee, USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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Goyal N, Tsivgoulis G, Pandhi A, Chang JJ, Dillard K, Ishfaq MF, Nearing K, Choudhri AF, Hoit D, Alexandrov AW, Arthur AS, Elijovich L, Alexandrov AV. Blood pressure levels post mechanical thrombectomy and outcomes in large vessel occlusion strokes. Neurology 2017; 89:540-547. [DOI: 10.1212/wnl.0000000000004184] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 04/03/2017] [Indexed: 11/15/2022] Open
Abstract
Objective:There are limited data evaluating the effect of post mechanical thrombectomy (MT) blood pressure (BP) levels on early outcomes of patients with large vessel occlusions (LVO). We sought to investigate the association of BP course following MT with early outcomes in LVO.Methods:Consecutive patients with LVO treated with MT during a 3-year period were evaluated. Hourly systolic BP (SBP) and diastolic BP (DBP) values were recorded for 24 hours following MT and maximum SBP and DBP levels were identified. LVO patients with complete reperfusion following MT were stratified in 3 groups based on post-MT achieved BP goals: <140/90 mm Hg (intensive), <160/90 mm Hg (moderate), and <220/110 mm Hg or <180/105 mm Hg when pretreated with IV thrombolysis (permissive hypertension). Three-month functional independence was defined as modified Rankin Scale score of 0–2.Results:A total of 217 acute ischemic stroke patients with LVO were prospectively evaluated. A 10 mm Hg increment in maximum SBP documented during the first 24 hours post MT was independently (p = 0.001) associated with a lower likelihood of 3-month functional independence (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.56–0.87) and a higher odds of 3-month mortality (OR 1.49; 95% CI 1.18–1.88) after adjusting for potential confounders. In addition, achieving a BP goal of <160/90 mm Hg during the first 24 hours following MT was independently associated with a lower likelihood of 3-month mortality (OR 0.08; 95% CI 0.01–0.54; p = 0.010) in comparison to permissive hypertension.Conclusions:High maximum SBP levels following MT are independently associated with increased likelihood of 3-month mortality and functional dependence in LVO patients. Moderate BP control is also related to lower odds of 3-month mortality in comparison to permissive hypertension.
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Goyal N, Tsivgoulis G, Pandhi A, Dillard K, Katsanos AH, Magoufis G, Chang JJ, Zand R, Hoit D, Safouris A, Choudhri A, Alexandrov AW, Alexandrov AV, Arthur AS, Elijovich L. Admission hyperglycemia and outcomes in large vessel occlusion strokes treated with mechanical thrombectomy. J Neurointerv Surg 2017; 10:112-117. [PMID: 28289148 DOI: 10.1136/neurintsurg-2017-012993] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [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: 01/13/2017] [Revised: 02/14/2017] [Accepted: 02/18/2017] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Higher admission serum glucose levels have been associated with poor outcomes in patients with acute ischemic stroke (AIS) treated with IV thrombolysis. We sought to evaluate the association of admission serum glucose with early outcomes of patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT). METHODS Consecutive AIS patients due to ELVO treated with MT in three tertiary stroke centers were evaluated. The following outcomes were documented using standard definitions: symptomatic intracranial hemorrhage (sICH), complete reperfusion, mortality, functional independence (modified Rankin Scale (mRS) score of 0-2), and functional improvement (shift in mRS score) at 3 months. The association of admission serum glucose and admission hyperglycemia (>140 mg/dL) with outcomes was evaluated using univariable and multivariable binary and ordinal logistic regression models. RESULTS 231 AIS patients with ELVO (mean age 62±14 years, 51% men, median admission National Institute of Health Stroke Scale score 16 points (IQR 12-21), median admission serum glucose 125 mg/dL (IQR 104-162)) were treated with MT. Admission hyperglycemia was associated with a lower likelihood of functional improvement (common OR 0.53; 95% CI 0.31 to 0.97; p=0.027) and higher odds of 3 month mortality (OR 2.76; 95% CI 1.40 to 5.44; p=0.004) in multivariable analyses adjusting for potential confounders. A 10 mg/dL increase in admission blood glucose was associated with a higher likelihood of sICH (OR 1.07; 95% CI 1.01 to 1.13; p=0.033) and 3 month mortality (OR 1.07; 95% CI 1.02 to 1.12; p=0.004) in multivariable models. There was no association between admission serum glucose or hyperglycemia and complete reperfusion. CONCLUSIONS Higher admission serum glucose and admission hyperglycemia are independent predictors of adverse outcomes in ELVO patients treated with MT.
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Affiliation(s)
- Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Second Department of Neurology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece
| | - Abhi Pandhi
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Kira Dillard
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aristeidis H Katsanos
- Second Department of Neurology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.,International Clinical Research Center, St Anne's Hospital, Brno, Czech Republic
| | | | - Jason J Chang
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Ramin Zand
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Apostolos Safouris
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Acute Stroke Unit, Metropolitan Hospital, Piraeus, Greece
| | - Asim Choudhri
- Department of Radiology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Anne W Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Australian Catholic University, Sydney, Australia
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
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