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Mehta AM, Fifi JT, Shoirah H, Shigematsu T, Oxley TJ, Kellner CP, Leacy RD, Mocco J, Majidi S. Racial and Socioeconomic Disparities in the Use and Outcomes of Endovascular Thrombectomy for Acute Ischemic Stroke. AJNR Am J Neuroradiol 2021; 42:1576-1583. [PMID: 34353781 DOI: 10.3174/ajnr.a7217] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 04/26/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Racial and socioeconomic disparities in the incidence, treatment, and outcomes of acute ischemic stroke exist and have been described. We aimed to characterize disparities in the use of endovascular thrombectomy in a nationally representative analysis. MATERIALS AND METHODS Discharge data from the Nationwide Inpatient Sample between 2006 and 2016 were queried using validated International Classification of Disease codes. Patients admitted to US hospitals with acute ischemic stroke were included and stratified on the basis of race, income, and primary payer. Trends in endovascular thrombectomy use, good outcome (discharge to home/acute rehabilitation), and poor outcome (discharge to skilled nursing facility, hospice, in-hospital mortality) were studied using univariate and multivariable analyses. RESULTS In this analysis of 1,322,162 patients, endovascular thrombectomy use increased from 53/111,829 (0.05%) to 3054/146,650 (2.08%) between 2006 and 2016, respectively. Less increase was observed in black patients from 4/12,733 (0.03%) to 401/23,836 (1.68%) and those in the lowest income quartile from 10/819 (0.03%) to 819/44,984 (1.49%). Greater increase was observed in the highest income quartile from 18/22,138 (0.08%) to 669/27,991 (2.39%). Black race predicted less endovascular thrombectomy use (OR = 0.79; 95% CI, 0.72-0.86). The highest income group predicted endovascular thrombectomy use (OR = 1.24; 95% CI, 1.13-1.36) as did private insurance (OR = 1.30; 95% CI, 1.23-1.38). High income predicted good outcome (OR = 1.10; 95% CI. 1.06-1.14), as did private insurance (OR = 1.36; 95% CI, 1.31-1.39). Black race predicted poor outcome (OR = 1.33; 95% CI, 1.30-1.36). All results were statistically significant (P < .01). CONCLUSIONS Despite a widespread increase in endovascular thrombectomy use, black and low-income patients may be less likely to receive endovascular thrombectomy. Future effort should attempt to better understand the causes of these disparities and develop strategies to ensure equitable access to potentially life-saving treatment.
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Affiliation(s)
- A M Mehta
- From the Department of Neurosurgery (A.M.M., J.T.F., H.S., T.S., T.J.O., C.P.K., R.D.L., J.M., S.M.), Icahn School of Medicine at Mount Sinai, New York, New York.,Department of Neurology (A.M.M.), Columbia University, New York, New York
| | - J T Fifi
- From the Department of Neurosurgery (A.M.M., J.T.F., H.S., T.S., T.J.O., C.P.K., R.D.L., J.M., S.M.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - H Shoirah
- From the Department of Neurosurgery (A.M.M., J.T.F., H.S., T.S., T.J.O., C.P.K., R.D.L., J.M., S.M.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - T Shigematsu
- From the Department of Neurosurgery (A.M.M., J.T.F., H.S., T.S., T.J.O., C.P.K., R.D.L., J.M., S.M.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - T J Oxley
- From the Department of Neurosurgery (A.M.M., J.T.F., H.S., T.S., T.J.O., C.P.K., R.D.L., J.M., S.M.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - C P Kellner
- From the Department of Neurosurgery (A.M.M., J.T.F., H.S., T.S., T.J.O., C.P.K., R.D.L., J.M., S.M.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - R De Leacy
- From the Department of Neurosurgery (A.M.M., J.T.F., H.S., T.S., T.J.O., C.P.K., R.D.L., J.M., S.M.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - J Mocco
- From the Department of Neurosurgery (A.M.M., J.T.F., H.S., T.S., T.J.O., C.P.K., R.D.L., J.M., S.M.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - S Majidi
- From the Department of Neurosurgery (A.M.M., J.T.F., H.S., T.S., T.J.O., C.P.K., R.D.L., J.M., S.M.), Icahn School of Medicine at Mount Sinai, New York, New York
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Goldman DT, Bageac D, Mills A, Yim B, Yaeger K, Majidi S, Kellner CP, De Leacy RA. Transradial Approach for Neuroendovascular Procedures: A Single-Center Review of Safety and Feasibility. AJNR Am J Neuroradiol 2021; 42:313-318. [PMID: 33446499 DOI: 10.3174/ajnr.a6971] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 09/05/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In recent years, the transradial approach has become more widely adopted for neuroendovascular procedures. The purpose of this study was to evaluate the safety and feasibility of a transradial approach and distal transradial access for neuroendovascular procedures in a single center. MATERIALS AND METHODS Retrospective analysis was performed for all patients who underwent transradial approach or distal transradial access neuroendovascular procedures from January 2016 to August 2019 at a single center. Exclusion criteria included a Barbeau D waveform, a radial artery of <2 mm on sonographic evaluation, and known radial artery occlusion. Procedures were evaluated for technical success (defined as successful radial artery access and completion of the intended procedure without crossover to an auxiliary access site), complications, and adverse events during follow-up at 30 days. RESULTS The transradial approach or distal transradial access was attempted in 279 consecutive patients (58.1% women; median age, 57.7 years) who underwent 328 standard or distal transradial approach procedures. Two-hundred seventy-nine transradial approach and 49 distal transradial approach procedures were performed (cerebral angiography [n = 213], intracranial intervention [n = 64], head and neck intervention [n = 30], and stroke intervention [n = 21]). Technical success was 92.1%. Immediate adverse events (2.1%) included radial access site hematoma (n = 5), radial artery occlusion (n = 1), and acute severe radial artery spasm (n = 1). Thirty-day adverse events (0.3%) included a radial artery pseudoaneurysm (n = 1). Twenty-six cases (7.9%) required crossover to transfemoral access. CONCLUSIONS The transradial approach for neuroendovascular procedures is safe and feasible across a wide range of neuroendovascular interventions.
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Affiliation(s)
- D T Goldman
- From the Departments of Radiology (D.T.G., R.A.D.L.)
| | - D Bageac
- Neurosurgery (D.B., B.Y., K.Y., S.M., C.P.K., R.A.D.L.), Icahn School of Medicine at Mount Sinai (A.M.), New York, New York
| | - A Mills
- Neurosurgery (D.B., B.Y., K.Y., S.M., C.P.K., R.A.D.L.), Icahn School of Medicine at Mount Sinai (A.M.), New York, New York
| | - B Yim
- Neurosurgery (D.B., B.Y., K.Y., S.M., C.P.K., R.A.D.L.), Icahn School of Medicine at Mount Sinai (A.M.), New York, New York
| | - K Yaeger
- Neurosurgery (D.B., B.Y., K.Y., S.M., C.P.K., R.A.D.L.), Icahn School of Medicine at Mount Sinai (A.M.), New York, New York
| | - S Majidi
- Neurosurgery (D.B., B.Y., K.Y., S.M., C.P.K., R.A.D.L.), Icahn School of Medicine at Mount Sinai (A.M.), New York, New York
| | - C P Kellner
- Neurosurgery (D.B., B.Y., K.Y., S.M., C.P.K., R.A.D.L.), Icahn School of Medicine at Mount Sinai (A.M.), New York, New York
| | - R A De Leacy
- From the Departments of Radiology (D.T.G., R.A.D.L.)
- Neurosurgery (D.B., B.Y., K.Y., S.M., C.P.K., R.A.D.L.), Icahn School of Medicine at Mount Sinai (A.M.), New York, New York
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Hao Q, Tsankova NM, Shoirah H, Kellner CP, Nael K. Vessel Wall MRI Enhancement in Noninflammatory Cerebral Amyloid Angiopathy. AJNR Am J Neuroradiol 2020; 41:446-448. [PMID: 32139424 DOI: 10.3174/ajnr.a6445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Accepted: 01/09/2020] [Indexed: 01/06/2023]
Abstract
Cerebral amyloid angiopathy is characterized by deposition of amyloid-β fibrils in the walls of small-to-medium-sized blood vessels. In this retrospective review of 5 patients with histologically confirmed noninflammatory cerebral amyloid angiopathy, high-resolution vessel wall MRI showed arterial wall enhancement in 2 patients (40%). Despite common consensus of equating vessel wall enhancement with inflammation, this report demonstrates that β-amyloid accumulation alone without inflammation can be associated with arterial wall enhancement in a subset of patients.
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Affiliation(s)
- Q Hao
- From the Departments of Neurology (Q.H.)
| | | | | | - C P Kellner
- and Radiology (K.N.), Icahn School of Medicine at Mount Sinai, New York, New York
| | - K Nael
- Department of Radiological Sciences (K.N.), David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California.
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Wei D, Mascitelli JR, Nistal DA, Kellner CP, Fifi JT, Mocco JD, De Leacy RA. The Use and Utility of Aspiration Thrombectomy in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2017; 38:1978-1983. [PMID: 28751516 DOI: 10.3174/ajnr.a5309] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 05/24/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND Thrombectomy trials are often specifically interpreted as evidence for the effectiveness of stent retrievers. The effectiveness of other thrombectomy techniques such as aspiration thrombectomy should be validated through further investigation and review. PURPOSE To evaluate published treatment times and clinical outcomes in patients treated with aspiration thrombectomy or ADAPT (A Direct Aspiration, First Pass Technique) for acute ischemic stroke. DATA SOURCES A systematic literature review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. MEDLINE, Scopus, and the Cochrane trial register were searched on November 8, 2016. STUDY SELECTION Twenty studies (n = 1523 patients) were included in this review and meta-analysis. One of these studies was prospective, and the rest were retrospective. DATA ANALYSIS Meta-analysis was performed by using a random effects model. Data and publication bias were visualized with forest plots and funnel plots. DATA SYNTHESIS Five studies investigated aspiration thrombectomy only, and 16 studies investigated ADAPT. Of the 16 studies on ADAPT, the rate of successful recanalization (TICI 2b/3) was 89.3% (95% CI, 85.4%-92.3%). The proportion of patients with good clinical outcome (90-day mRS ≤2) was 52.7% (95% CI, 48.0%-57.4%). LIMITATIONS Studies on ADAPT were retrospective, and there was heterogeneity between studies for successful recanalization (P < .001) and good clinical outcome (P < .001). There was evidence of publication bias for recanalization rates (P = .01), but not for clinical outcomes (P = .42). CONCLUSIONS ADAPT and aspiration thrombectomy are effective approaches to thrombectomy, with high recanalization rates and excellent clinical outcomes reported in the literature. Aspiration thrombectomy is a promising neurointervention, but large prospective randomized studies are needed to validate its utility.
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Affiliation(s)
- D Wei
- From the Departments of Neurosurgery (D.W., J.R.M., D.A.N., C.P.K., J.T.F., J.D.M., R.A.D.L.)
| | - J R Mascitelli
- From the Departments of Neurosurgery (D.W., J.R.M., D.A.N., C.P.K., J.T.F., J.D.M., R.A.D.L.)
| | - D A Nistal
- From the Departments of Neurosurgery (D.W., J.R.M., D.A.N., C.P.K., J.T.F., J.D.M., R.A.D.L.)
| | - C P Kellner
- From the Departments of Neurosurgery (D.W., J.R.M., D.A.N., C.P.K., J.T.F., J.D.M., R.A.D.L.)
| | - J T Fifi
- From the Departments of Neurosurgery (D.W., J.R.M., D.A.N., C.P.K., J.T.F., J.D.M., R.A.D.L.).,Neurology (J.T.F.)
| | - J D Mocco
- From the Departments of Neurosurgery (D.W., J.R.M., D.A.N., C.P.K., J.T.F., J.D.M., R.A.D.L.)
| | - R A De Leacy
- From the Departments of Neurosurgery (D.W., J.R.M., D.A.N., C.P.K., J.T.F., J.D.M., R.A.D.L.) .,Radiology (R.A.D.L.), Mount Sinai Health System, New York, New York
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