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Sheriff FG, Ahmad A, Inam ME, Khatri R, Maud A, Rodriguez GJ. A systematic review on the assessment of cerebral autoregulation in patients with Large Vessel Occlusion. Front Neurol 2023; 14:1287873. [PMID: 38046584 PMCID: PMC10693431 DOI: 10.3389/fneur.2023.1287873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/02/2023] [Indexed: 12/05/2023] Open
Abstract
As the majority of large vessel occlusion (LVO) patients are not treated with revascularization therapies or efficiently revascularized, complementary management strategies are needed. In this article we explore the importance of cerebral autoregulation (CA) assessment in the prediction and/or modification of infarct growth and hemorrhagic transformation. In patients with LVO, these are important factors that affect prognosis. A systematic search of the PubMed, EMBASE databases and a targeted Google search was conducted, resulting in the inclusion of 34 relevant articles. There is an agreement that CA is impaired in patients with LVO; several factors have been identified such as time course, revascularization status, laterality, disease subtype and location, some of which may be potentially modifiable and affect outcomes. The personalized CA assessment of these patients suggests potential for better understanding of the inter-individual variability. Further research is needed for the development of more accurate, noninvasive techniques for continuous monitoring and personalized thresholds for CA.
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Affiliation(s)
- Faheem G. Sheriff
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | | | - Mehmet E. Inam
- University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Rakesh Khatri
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Alberto Maud
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
| | - Gustavo J. Rodriguez
- Department of Neurology, Section of Interventional Neurology, Texas Tech University Health Sciences Center El Paso, El Paso, TX, United States
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Matuja SS, Ahmed RA, Munseri P, Khanbhai K, Tessua K, Lyimo F, Rodriguez GJ, Gupta V, Maud A, Chaudhury MR, Manji M, Sheriff F. Ischemic Stroke at a Tertiary Academic Hospital in Tanzania: A Prospective Cohort Study With a Focus on Presumed Large Vessel Occlusion. Front Neurol 2022; 13:882928. [PMID: 35911912 PMCID: PMC9330741 DOI: 10.3389/fneur.2022.882928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background Large vessel ischemic strokes account for more than one-third of all strokes associated with substantial morbidity and mortality without early intervention. The incidence of large vessel occlusion (LVO) is not known in sub-Saharan Africa (SSA). Definitive vessel imaging is not routinely available in resource-limited settings. Aims We aimed to investigate the burden and outcomes of presumed LVO among patients with ischemic stroke admitted to a large tertiary academic hospital in Tanzania. Methods This cohort study recruited all consenting first-ever ischemic stroke participants admitted at a tertiary hospital in Tanzania. Demographic data were recorded, and participants were followed up to 1 year using the modified Rankin Scale (mRS). A diagnosis of presumed LVO was made by a diagnostic neuroradiologist and interventional neurologist based on contiguous ischemic changes in a pattern consistent with proximal LVO on a non-contrast computed tomography head. We examined factors associated with presumed LVO using logistic regression analysis. Inter-observer Kappa was calculated. Results We enrolled 158 first-ever ischemic strokes over 8 months with a mean age of 59.7 years. Presumed LVO accounted for 39.2% [95% confidence interval (CI) 31.6–47.3%] and an overall meantime from the onset of stroke symptoms to hospital arrival was 1.74 days. Participants with presumed LVO were more likely to involve the middle cerebral artery (MCA) territory (70.9%), p < 0.0001. Independent factors on multivariate analysis associated with presumed LVO were hypertension [adjusted odds ratio (aOR) 5.74 (95% CI: 1.74–18.9)] and increased waist-hip ratio [aOR 7.20 (95% CI: 1.83–28.2)]. One-year mortality in presumed LVO was 80% when compared with 73.1% in participants without presumed LVO. The Cohen's Kappa inter-observer reliability between the diagnostic neuroradiologist and interventional neurologist was 0.847. Conclusion There is a high burden of presumed LVO associated with high rates of 1-year morbidity and mortality at a tertiary academic hospital in Tanzania. Efforts are needed to confirm these findings with definitive vessel imaging, promoting cost-effective preventive strategies to reduce the burden of non-communicable diseases (NCDs), and a call for adopting endovascular therapies to reduce morbidity and mortality.
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Affiliation(s)
- Sarah Shali Matuja
- Department of Internal Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- *Correspondence: Sarah Shali Matuja
| | - Rashid Ali Ahmed
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Patricia Munseri
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Khuzeima Khanbhai
- Department of Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Kezia Tessua
- Department of Internal Medicine, Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Frederick Lyimo
- Department of Radiology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Gustavo J. Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Vikas Gupta
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Mohammad Rauf Chaudhury
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Mohamed Manji
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Faheem Sheriff
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
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Khandelwal P, Majmundar N, Rodriguez GJ, Patel P, Dodson V, Singla A, Khatri R, Gupta V, Sheriff F, Vellipuram A, Cruz-Flores S, Maud A. Dual-center study comparing transradial and transfemoral approaches for flow diversion treatment of intracranial aneurysms. Brain Circ 2021; 7:65-70. [PMID: 34189348 PMCID: PMC8191526 DOI: 10.4103/bc.bc_38_20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Revised: 12/30/2020] [Accepted: 01/26/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND The transfemoral approach (TFA) has been the traditional approach for neurointerventional cases. While the TFA allows for triaxial support in flow diverting stent cases, it is associated with access site complications. Recently, the transradial approach (TRA) has emerged as a safer alternative to the TFA. To the best of our knowledge, there have only been single-center studies comparing outcomes in flow diverter cases for these approaches. We demonstrate the safety and feasibility of the TRA for placement of flow diverting stents in the treatment of unruptured intracranial aneurysms at two high-volume centers. MATERIALS AND METHODS We performed a retrospective review of prospectively collected institutional databases at two high-volume neuroendovascular centers. Cases from 2016 to 2018 of unruptured intracranial aneurysms treated by flow diverting stenting accessed through either the TRA or the TFA were compared. Patient demographics, procedural and radiographic metrics including location and size of the aneurysm, size, and length of the flow diverter implant, and fluoroscopic time were recorded. Puncture site complications and length of hospital stay were also included in the data analysis. RESULTS There were three out of 29 TRA cases which were converted to the TFA. None of the TRA patients experienced site complications, whereas three TFA patients experienced site complications. While TRA and TFA patients did not differ significantly in their exposure to radiation, TRA patients experienced shorter hospital stays. CONCLUSIONS While long-term studies are still lacking regarding this approach, we demonstrate that the TRA is a safe and feasible approach for flow diverter stent placement.
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Affiliation(s)
- Priyank Khandelwal
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Neil Majmundar
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Pratit Patel
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Vincent Dodson
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Amit Singla
- Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Vikas Gupta
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Faheem Sheriff
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Anantha Vellipuram
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
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Sheriff FG, Rodriguez GJ, Gupta V, Maud A. Letter regarding 'Radial first or patient first : a case series and meta-analysis of transradial (TRA) versus transfemoral (TFA) access for acute ischemic stroke intervention'. J Neurointerv Surg 2021; 13:e16. [PMID: 33906939 DOI: 10.1136/neurintsurg-2021-017655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 04/15/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Faheem G Sheriff
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA.,Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA.,Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Vikas Gupta
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA.,Paul L Foster School of Medicine, El Paso, Texas, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas, USA .,Paul L Foster School of Medicine, El Paso, Texas, USA
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Chaudhry MR, Gill H, Chaudhry S, Singh B, Bandaru H, Vellipuram AR, Piriyawat P, Maud A, Rodriguez GJ, Cruz-Flores S. Abstract P399: Do Not Resuscitate Orders in Subarachnoid Hemorrhage Patients. Impact on Mortality. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p399] [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/background:
Do not resuscitate (DNR) orders have been associated with higher mortality in hospitalized patients which the question if they these patients are victims of the self-fulfilling prophecy; that the odds of their survival is made worse by withholding aggressive treatment. In addition, previous reports show that racial and ethnic minorities tend to opt for more aggressive and lifesaving procedures as compared to Whites.
Methods:
We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all subarachnoid hemorrhage (ICH) patients. DNR code status was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, length of stay) were compared between the two groups. DNR code status was compared between different racial groups.
Results:
Of the 325923 patients with SAH, 20127 (6.17%%) had DNR order. SAH patients with DNR order had higher proportion of females (61.7% versus 59.4%, P=0.0048) and were older (70.9 years versus 58.4 years, P <.0001) compared to SAH patients without DNR. The in-hospital mortality was also higher (66.4% versus 22.4%, p≤.0001) among patients with DNR both univariate and multivariate analysis (OR = 5.05 (4.58 -5.56), p<.0001) after adjusting for potential confounders. Whites have a higher rate (7.59% versus 5.84%, P <.0001) of DNR order as compared to other racial/ethnic groups
Conclusions:
While there may be other explanations at play, the higher mortality and shorter LOS suggest that early DNR orders do lead to the self-fulfilling prophecy. The lower proportion of DNR orders among minorities suggest a sociocultural aspect in accepting the concept of DNR. These two facts raise concerns about what the real vs perceived meaning of DNR orders.
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Affiliation(s)
| | - Hussan Gill
- College of Medicine, Univ of Oklahoma, Tulsa, OK
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Chaudhry MR, Gill H, Chaudhry S, Singh B, Bandaru H, Vellipuram AR, Piriyawat P, Maud A, Rodriguez GJ, Cruz-Flores S. Abstract P456: Myocardial Infarction in Patients With Intracerebral Hemorrhage. Prevalence and Impact on Outcome. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p456] [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/background:
Comorbidities can potentially affect outcome of patients with intracerebral hemorrhage (ICH). It is unclear what the prevalence of acute myocardial infarction (AMI) and its impact on outcome are in patients with intracerebral hemorrhage.
Methods:
We analyzed the data from Nationwide Inpatient Sample (2005-2014) for all intracerebral hemorrhage (ICH) patients. AMI was identified using the International Classification of Disease, 9th Revision, Clinical Modification codes. Baseline characteristics, discharge outcomes (mortality, discharge disposition, length of stay and in-hospital charges) were compared between the two groups.
Results:
Of the 884379 patients with ICH, 27692 (3.13%) had in-hospital myocardial infraction. ICH patients with AMI order had lower proportion of females (47.8% versus 49.7%, P= 0.0028) and were older (69.7 years versus 67.2 years, P <.0001) compared to ICH patients without MI. The in-hospital mortality was higher (40.9% versus 25.5%, p≤.0001) among ICH patients with AMI in both univariate and multivariate analysis (OR = 1.22 (1.14 -1.31), P<.0001) after adjusting for potential confounders. ICH patients with MI had higher (72.4% versus 58.8%, P <.0001) proportion of moderate to severe disability at discharge compared to ones without. Similarly, mean length of in-hospital stay (12.4 days versus 8.94 days, P <.0001) and mean hospital charges ($129328 versus $ 81984.0, P <.0001) were also higher in ICH patients with MI
Conclusions:
While only 3.13% of patients with ICH have an AMI, there is a 22% increase in worse outcome among those patients with AMI and ICH.
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Affiliation(s)
| | - Hussan Gill
- College of Medicine, Univ of Oklahoma, Broken Arrow, OK
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7
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Chaudhry MRA, Gill H, Chaudhry S, Singh B, Bandaru H, Vellipuram AR, Maud A, Rodriguez GJ, Cruz-Flores S, Qureshi AI. Abstract P437: Trends in Outcomes, and Length and Costs of Hospitalization in Patients With Intracerebral Hemorrhage in United States. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p437] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
It remains unclear whether there is any improvement in outcomes of patients with intracerebral hemorrhage over the last decade.
Objective:
To determine trends pertaining in-hospital outcomes in patients with intracerebral hemorrhage using nationally representative data.
Methods:
We determined the national estimates of intracerebral hemorrhage admissions from 2005 to 2014 and associated in-hospital outcomes, length of stay, mortality, and cost incurred using the Nationwide Inpatient Survey (NIS) data. The NIS is the largest all-payer inpatient care database in the US and contains data from 986 hospitals approximating a 20% stratified sample of US hospitals. Outcome was classified as none to minimal disability, moderate to severe disability, and death based on discharge destination.
Results:
In the 10-year period, there were 70,637 admissions for intracerebral hemorrhage (annual estimate 80804 in 2005 to 109930 in 2014). There was a significant reduction in in-hospital mortality in patients with intracerebral hemorrhage from 30% to 23% (trend test, p < 0.0001). There was a trend towards increase in proportion of patients with moderate to severe disability (trend test, p < 0.097). The mean length of hospitalization increased from 8.58 days to 9.23 days (trend test, p < 0.0001) and cost of hospitalization increased from $50532.1 to $110932.1 (trend test, p < 0.0001).
Conclusions:
The mortality in patients with intracerebral hemorrhage has decreased but there is increased rates of moderate to severe disability, length of hospitalization, and hospitalization cost over the last decade.
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Affiliation(s)
| | - Hussan Gill
- College of Medicine Univ of Oklahoma, Tulsa, OK
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Wu TC, Ankrom C, Joseph M, Trevino A, Zhu L, Warach S, Novakovic RR, Goldberg MP, Birnbaum LA, Mir O, Rodriguez GJ, Alderazi YJ, Hassan AE, Savitz SI. IAT-TiMeS: Intra-Arterial Thrombectomy Transfer Metric Study in Texas. J Stroke Cerebrovasc Dis 2021; 30:105602. [PMID: 33461026 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105602] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/28/2020] [Accepted: 01/04/2021] [Indexed: 10/22/2022] Open
Abstract
OBJECTIVE We aim to report intra-arterial thrombectomy transfer metrics for ischemic stroke patients that were transferred to hub hospitals for possible intra-arterial thrombectomy in multiple geographic regions throughout the state of Texas and to identify potential barriers and delays in the intra-arterial thrombectomy transfer process. METHOD We prospectively collected data from 8 participating Texas comprehensive stroke/thrombectomy capable centers from 7 major regions in the State of Texas. We collected baseline clinical and imaging data related to the pre-transfer evaluation, transfer metrics, and post-transfer clinical and imaging data. RESULTS A total of 103 acute ischemic stroke patients suspected/confirmed to have large vessel occlusions between December 2016 to May 2019 that were transferred to hubs as possible intra-arterial thrombectomy candidates were enrolled. A total of 56 (54%) patients were sent from the spoke to the hub via ground ambulance with 47 (46%) patients traveling via air ambulance. The median spoke arrival to hub arrival time was 174 min, median spoke arrival to departure from spoke was 131 min, and median travel time was 39 min. The spoke arrival time to transfer initiation was 68 min. CT-perfusion obtained at the spoke and earlier initiation of transfer were statistically associated with shorter transfer times. CONCLUSION Transfer of intra-arterial thrombectomy patients in Texas may take over 4 h from spoke arrival to hub arrival. This time may be shortened by earlier transfer initiation and acceptance.
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Affiliation(s)
- Tzu-Ching Wu
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Christy Ankrom
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Michele Joseph
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Alyssa Trevino
- Department of Neurology, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Liang Zhu
- Department of Internal Medicine, McGovern Medical School, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
| | - Steven Warach
- Dell Medical School, The University of Texas at Austin, Austin, Texas, USA.
| | - Roberta R Novakovic
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas, USA.
| | - Mark P Goldberg
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas, USA.
| | - Lee A Birnbaum
- Department of Neurology, The University of Texas Health Science Center at San Antonio, Texas, USA.
| | - Osman Mir
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Science Center, El Paso, Texas, USA.
| | - Yazan J Alderazi
- Department of Neurology, Texas Tech University Health Sciences Center, Lubbock, Texas, USA.
| | - Ameer E Hassan
- Department of Neuroscience, University of Texas Rio Grande Valley, Valley Baptist Medical Center, Harlingen, Texas, USA
| | - Sean I Savitz
- Institute for Stroke and Cerebrovascular Disease and Department of Neurology, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
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Qureshi AI, Agunbiade S, Huang W, Akhtar IN, Abraham MG, Akhtar N, Al-Mufti F, Aytac E, Balgetir F, Grigoryan M, Gomez CR, Hassan AE, Jani V, Janjua NA, Jiao L, Khatri R, Kirmani JF, Kobayashi A, Kozak O, Lee J, Lobanova I, Mansour OY, Maud A, Mazighi M, Piotin M, Rodriguez GJ, Siddiq F, Suri MFK, Tekle WG. Changes in Neuroendovascular Procedural Volume During the COVID-19 Pandemic: An International Multicenter Study. J Neuroimaging 2020; 31:171-179. [PMID: 33227167 PMCID: PMC7753603 DOI: 10.1111/jon.12803] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 10/07/2020] [Accepted: 10/09/2020] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND AND PURPOSE The effect of coronavirus disease 2019 (COVID‐19) pandemic on performance of neuroendovascular procedures has not been quantified. METHODS We performed an audit of performance of neuroendovascular procedures at 18 institutions (seven countries) for two periods; January‐April 2019 and 2020, to identify changes in various core procedures. We divided the region where the hospital was located based on the median value of total number of COVID‐19 cases per 100,00 population‐into high and low prevalent regions. RESULTS Between 2019 and 2020, there was a reduction in number of cerebral angiograms (30.9% reduction), mechanical thrombectomy (8% reduction), carotid artery stent placement for symptomatic (22.7% reduction) and asymptomatic (43.4% reduction) stenoses, intracranial angioplasty and/or stent placement (45% reduction), and endovascular treatment of unruptured intracranial aneurysms (44.6% reduction) and ruptured (22.9% reduction) and unruptured brain arteriovenous malformations (66.4% reduction). There was an increase in the treatment of ruptured intracranial aneurysms (10% increase) and other neuroendovascular procedures (34.9% increase). There was no relationship between procedural volume change and intuitional location in high or low COVID‐19 prevalent regions. The procedural volume reduction was mainly observed in March‐April 2020. CONCLUSIONS We provided an international multicenter view of changes in neuroendovascular practices to better understand the gaps in provision of care and identify individual procedures, which are susceptible to change.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Samiat Agunbiade
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO.,Division of Neurological Surgery, University of Missouri, Columbia, MO
| | - Wei Huang
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Iqra N Akhtar
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Michael G Abraham
- Departments of Neurology and Radiology, University of Kansas Medical Center, Kansas City, KS
| | - Naveed Akhtar
- Department of Neurointervention, Marion Bloch Neuroscience Institute/Saint Luke's Hospital, Kansas City, MO
| | - Fawaz Al-Mufti
- Departments of Neurology, Neurosurgery and Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Emrah Aytac
- Zeenat Qureshi Stroke Institute, Department of Neurology, University of FIRAT, Elazig, Turkey
| | - Ferhat Balgetir
- Zeenat Qureshi Stroke Institute, Department of Neurology, University of FIRAT, Elazig, Turkey
| | - Mikayel Grigoryan
- Adventist Health Glendale Comprehensive Stroke Center, Los Angeles, CA
| | - Camilo R Gomez
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley - Valley Baptist Medical Center, Harlingen, TX
| | - Vishal Jani
- Department of Neurology, Creighton University Medical Center/CHI Health, Omaha, NE
| | | | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Jawad F Kirmani
- Stroke and Neurovascular Center, Hackensack Meridian Health-JFK University Medical Center, Hackensack, NJ
| | - Adam Kobayashi
- Department of Neurology and Interventional Stroke Treatment Centre, Kazimierz Pulaski University of Technology and Humanities, Radom, Poland
| | - Osman Kozak
- Department of Neurology, Jefferson Health Abington, Philadelphia, PA
| | - Jun Lee
- Department of Neurology, Yeungnam University School of Medicine, Daegu, Korea
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, MO
| | - Ossama Yassin Mansour
- Department of Neurology, Stroke and Neurointervention Section, Alexandria University Hospital, Faculty of medicine, Alexandria, Egypt
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Michel Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX
| | - Farhan Siddiq
- Division of Neurological Surgery, University of Missouri, Columbia, MO
| | | | - Wondwossen G Tekle
- Department of Neurology, University of Texas Rio Grande Valley - Valley Baptist Medical Center, Harlingen, TX
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Qureshi AI, Grigoryan M, Saleem MA, Aytac E, Wallery SS, Rodriguez GJ, Suri MFK. Prolonged Microcatheter-Based Local Thrombolytic Infusion as a Salvage Treatment After Failed Endovascular Treatment for Cerebral Venous Thrombosis: A Multicenter Experience. Neurocrit Care 2019; 29:54-61. [PMID: 29484582 DOI: 10.1007/s12028-018-0502-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND AND PURPOSE To determine the effectiveness of prolonged microcatheter-based local thrombolytic infusion in treatment of patients with cerebral venous thrombosis who achieved no or suboptimal recanalization with transvenous endovascular treatment. METHODS Data collection: Prospectively registries supplemented by retrospective review. SETTINGS Three hospitals with tertiary referral base. PATIENTS Patients who underwent transvenous endovascular treatment for cerebral venous thrombosis. INTERVENTION Prolonged microcatheter-based local thrombolytic infusion of alteplase at the rate of 0.5-1 mg/h in patients in whom initial angiographic outcome was deemed suboptimal, either due to incomplete or no recanalization. RESULTS Serial angiograms were performed to assess treatment response as follows: grade I, partial recanalization of one or more occluded dural sinuses with improved flow or visualization of branches; grade II, complete recanalization of one sinus but persistent occlusion of the other sinuses (A-no residual flow, B-nonocclusive flow); grade III, complete recanalization. Clinical outcome was determined at 1-3 months using modified Rankin scale. A total of 14 patients underwent 15 transvenous endovascular treatments. Initial treatment was considered suboptimal in 12/15 procedures due to no recanalization in five (grade 0), partial recanalization (grade I) in four, complete recanalization of one sinus but persistent occlusion of the other sinuses (grade 2A in two and 2B in one). A prolonged microcatheter-based local recombinant tissue plasminogen activator infusion was used following ten of the 15 procedures for a median duration of 18 h (range 13-22 h). Follow-up angiography demonstrated complete recanalization in four procedures and improvement in grades of partial recanalization in six procedures (final grades 2A in three and 2B in three procedures). None of the patients developed new symptomatic intracranial hemorrhage associated with local thrombolytic infusion. At follow-up, patients in five of ten procedures had achieved a modified Rankin scale of 0 and one patient had achieved a score of 1 (no neurological deficits but had residual headaches). CONCLUSION Prolonged microcatheter-based local thrombolytic infusion appeared to be effective treatment in patients who have suboptimal response to acute transvenous endovascular treatment without any additional adverse events.
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Affiliation(s)
- Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, 519 2nd Street North, St. Cloud, MN, 56303, USA
- University of Illinois and Mercyhealth, Rockford, IL, USA
| | - Mikayel Grigoryan
- Zeenat Qureshi Stroke Institute, 519 2nd Street North, St. Cloud, MN, 56303, USA
| | - Muhammad A Saleem
- Zeenat Qureshi Stroke Institute, 519 2nd Street North, St. Cloud, MN, 56303, USA.
- Mercyhealth, Janesville, WI, USA.
| | - Emrah Aytac
- Zeenat Qureshi Stroke Institute, 519 2nd Street North, St. Cloud, MN, 56303, USA
| | | | - Gustavo J Rodriguez
- Zeenat Qureshi Stroke Institute, 519 2nd Street North, St. Cloud, MN, 56303, USA
| | - Muhammad F K Suri
- Zeenat Qureshi Stroke Institute, 519 2nd Street North, St. Cloud, MN, 56303, USA
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Khatri R, Afzal MR, Qureshi MA, Maud A, Huanyu D, Rodriguez GJ. Response to “Letter to the Editor” by Bhattacharyya et al. J Stroke Cerebrovasc Dis 2019; 28:2361. [DOI: 10.1016/j.jstrokecerebrovasdis.2019.04.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Vellipuram AR, Cruz-Flores S, Chaudhry MRA, Rawla P, Maud A, Rodriguez GJ, Kassar D, Piriyawat P, Qureshi MA, Khatri R. Comparative Outcomes of Respiratory Failure Associated with Common Neuromuscular Emergencies: Myasthenia Gravis versus Guillain-Barré Syndrome. Medicina (Kaunas) 2019; 55:E375. [PMID: 31311172 PMCID: PMC6681261 DOI: 10.3390/medicina55070375] [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] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 07/09/2019] [Accepted: 07/11/2019] [Indexed: 01/05/2023]
Abstract
Background and objectives: Myasthenia gravis (MG) and Guillain-Barré Syndrome (GBS) are autoimmune neuromuscular disorders that may present as neuromuscular emergencies requiring mechanical ventilation and critical care. Comparative outcomes of these disease processes, once severe enough to require mechanical ventilation, are not known. In this study, we compared the patients requiring mechanical ventilation in terms of in-hospital complications, length of stay, disability, and mortality between these two disease entities at a national level. Materials and Methods: Mechanically ventilated patients with primary diagnosis of MG (n = 6684) and GBS (n = 5834) were identified through retrospective analysis of Nationwide Inpatient Sample (NIS) database for the years 2006 to 2014. Results: Even though mechanically ventilated MG patients were older (61.0 ± 19.1 versus 54.9 ± 20.1 years) and presented with more medical comorbidities, they had lower disease severity on admission, as well as lower in-hospital complications sepsis, pneumonia, and urinary tract infections as compared with GBS patients. In the multivariate analysis, after adjusting for confounders including treatment, GBS patients had significantly higher disability (odds ratio (OR) 15.6, 95% confidence interval (CI) 10.9-22.2) and a longer length of stay (OR 3.48, 95% CI 2.22-5.48). There was no significant difference in mortality between the groups (8.45% MG vs. 10.0% GBS, p = 0.16). Conclusion: Mechanically ventilated GBS patients have higher disease severity at admission along with more in-hospital complications, length of stay, and disability compared with MG patients. Potential explanations for these findings include delay in the diagnosis, poor response to immunotherapy particularly in patients with axonal GBS variant, or longer recovery time after nerve damage.
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Affiliation(s)
- Anantha R Vellipuram
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA.
| | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Mohammad Rauf A Chaudhry
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Prashanth Rawla
- Department of Internal Medicine, Hospitalist Sovah Health, Martinsville, VA 24112, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Darine Kassar
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Paisith Piriyawat
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Mohtashim A Qureshi
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
| | - Rakesh Khatri
- Department of Neurology, Texas Tech University Health Sciences Center El Paso, Paul L. Foster School of Medicine, El Paso, TX 79905, USA
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Cruz-Flores S, Rodriguez GJ, Chaudhry MRA, Qureshi IA, Qureshi MA, Piriyawat P, Vellipuram AR, Khatri R, Kassar D, Maud A. Racial/ethnic disparities in hospital utilization in intracerebral hemorrhage. Int J Stroke 2019; 14:686-695. [DOI: 10.1177/1747493019835335] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and purpose There is evidence that racial and ethnic differences among intracerebral hemorrhage (ICH) patients exist. We sought to establish the occurrence of disparities in hospital utilization in the United States. Methods We identified ICH patients from United States Nationwide Inpatient Sample database for years 2006–2014 using codes (DX1 = 431, 432.0) from the International Classification of Diseases, 9th edition. We compared five race/ethnic categories: White, Black, Hispanic, Asian or Pacific Islander, and Others ( Native American and other) with regard to demographics, comorbidities, disease severity, in-hospital complications, in-hospital procedures, length of stay (LOS), total hospital charges, in-hospital mortality, palliative care, (PC) and do not resuscitate (DNR). We categorized procedures as lifesaving (i.e. ventriculostomy, craniotomy, craniectomy, and ventriculoperitoneal (VP) shunt), life sustaining (i.e. mechanical ventilation, tracheostomy, transfusions, and gastrostomy). White race/ethnicity was set as the reference group. Results Out of 710,293 hospitalized patients with ICH 470,539 (66.2%), 114,821 (16.2%), 66,451 (9.3%), 30,297 (4.3%) and 28,185 (3.9%) were White, Black, Hispanic, Asian or Pacific Islander, and Others, respectively. Minorities (Black, Hispanic, Asian or Pacific Islander, and Others) had a higher rate of in-hospital complications, in-hospital procedures, mean LOS, and hospital charges compared to Whites. In contrast, Whites had a higher rate of in-hospital mortality, PC, and DNR. In multivariable analysis, all minorities had higher rate of MV, tracheostomy, transfusions, and gastrostomy compared to Whites, while Hispanics had higher rate of craniectomy and VP shunt; and Asian or Pacific Islander and Others had higher rate of craniectomy. Whites had a higher rate of in-hospital mortality, palliative care, and DNR compared to minorities. In mediation analysis, in-hospital mortality for whites remained high after adjusting with PC and DNR. Conclusion Minorities had greater utilization of lifesaving and life sustaining procedures, and longer LOS. Whites had greater utilization of palliative care, hospice, and higher in-hospital mortality. These results may reflect differences in culture or access to care and deserve further study.
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Affiliation(s)
- Salvador Cruz-Flores
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Mohammad Rauf A Chaudhry
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Ihtesham A Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Mohtashim A Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Paisith Piriyawat
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Anantha R Vellipuram
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Darine Kassar
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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Rawla P, Vellipuram A, Khatri R, Maud A, Rodriguez GJ, Cruz-Flores S. Abstract WP212: Trends in Acute Ischemic Stroke Hospitalizations by Age Groups, Length of Stay, Mortality and Hospital Costs in the United States From 2000-2014. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp212] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Acute Ischemic Stroke (AIS) is a significant cause of long term disability. The primary objective of our study was to analyze the trends in AIS hospitalizations by age groups, Length of Stay (LOS), Mortality and hospital costs in the United States over a 15-year period from the years 2000 to 2014.
Methods:
Nationwide inpatient sample (NIS) database was used to identify AIS admissions in all patients from 2000 to 2014 using ICD-9-CM codes 433.01, 433.11, 433.21, 433.31, 433.81, 433.91, 434.01, 434.11, 434.91, and 436 as the principal discharge diagnosis. NIS is the largest all-payer inpatient care database in the United States, containing data on more than 7 million hospital stays. It has a large sample size which is ideal for developing national and regional estimates.
Results:
A total of 554,226,249 discharges with a diagnosis of AIS were analyzed from 2000 to 2014 from the NIS database. Hospitalization rates for AIS increased significantly from years 2000 to 2014 for ages 18-44 (relative percentage change (RPC): +33.75%) and ages 45-64(RPC: +41.21%). Hospitalization rates for AIS have significantly decreased in the age group 65-84 (RPC: -16.69%). In-hospital mortality decreased from 6.97% in 2000 to 4.4% in 2014. Mean LOS has decreased from 6.19 days to 4.2 days during the same period. Mean hospital costs have gone up from $6,975 to $12,322.
Conclusion:
Overall in-hospital mortality and LOS associated with AIS has decreased over the years. AIS US hospitalizations have significantly increased in the age groups from 18-64 while there was a significant decrease in the rate of hospitalizations in the age groups 65-84. Further research needs to be done to identify the risk factors contributing to a substantial rise in AIS hospitalizations in young to middle age adults.
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Affiliation(s)
| | | | - Rakesh Khatri
- Neurology, Texas Tech Univ Health Sciences Cntr El Paso, El Paso, TX
| | - Alberto Maud
- Neurology, Texas Tech Univ Health Sciences Cntr El Paso, El Paso, TX
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Maud A, Khatri R, Lin LM, Diaz OM, Vellipuram AR, Cruz-Flores S, Rodriguez GJ. Internal Carotid Artery Dilatation Induced by General Anesthesia: Technical Observation. J Vasc Interv Neurol 2018; 10:52-55. [PMID: 30746011 PMCID: PMC6350873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Affiliation(s)
- A Maud
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
| | - R Khatri
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
| | - L M Lin
- Department of Neurosurgery, University of California Irvine Medical Center, Orange, CA, USA
| | - O M Diaz
- Interventional Neuroradiology, Methodist Hospital, Houston, TX, USA
| | - A R Vellipuram
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
- Department of Neurosurgery, University of California Irvine Medical Center, Orange, CA, USA
- Interventional Neuroradiology, Methodist Hospital, Houston, TX, USA
| | - S Cruz-Flores
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
| | - G J Rodriguez
- Department of Neurology, Texas Tech University Health Science Center, El Paso, TX, USA
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Qureshi IA, Rodriguez GJ, Cruz-Flores S, Maud A. Persistent focal enhancement of the cisternal segment of oculomotor nerve in ophthalmoplegic migraine. Neurol Clin Pract 2018; 7:381-383. [PMID: 29620088 DOI: 10.1212/cpj.0000000000000303] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/04/2016] [Indexed: 11/15/2022]
Affiliation(s)
- Ihtesham A Qureshi
- Neurology Department, Texas Tech University of Health Sciences Center, El Paso
| | - Gustavo J Rodriguez
- Neurology Department, Texas Tech University of Health Sciences Center, El Paso
| | | | - Alberto Maud
- Neurology Department, Texas Tech University of Health Sciences Center, El Paso
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Khatri R, Vellipuram AR, Maud A, Afzal MR, Qureshi MA, Qureshi IA, Piriyawat P, Cruz-Flores S, Rodriguez GJ. Abstract TP166: Frequency of Brain Death in Acute Cerebrovascular Disease Related Mortality. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tp166] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Despite the frequent occurrence of brain death in intensive care unit, the prevalence rate of brain death in ischemic stroke (IS), intracranial hemorrhage (ICH) and subarachnoid hemorrhage (SAH) is not known at national level. In addition the prevalence of cardiac arrest in these patients is not established.
Methods:
From 2012, ICD-9-CM includes a specific code for brain death (348.82). Brain death patients were identified from the nationwide in-patient sample database for the years 2012 to 2014. Associated in-hospital cardiac arrest patients were also identified under each category. Demographics, medical comorbidities, in-hospital complications, procedures, length of stay and hospital charges were compared.
Results:
Rate of brain death was highest in SAH related mortality (22%, 3255 brain deaths/ 14620 in-hospital mortality), followed by ICH, (12.5%, 5760 brain deaths/ 45945 in-hospital mortality) and ischemic stroke (3%, 1840 brain death/62285 in-hospital mortality). Majority of the patients had brain death secondary to neurological insult (ICH n=5260, 91.3%; SAH n= 2625 (80.6%) and IS n=1640, 89.1%) without any secondary diagnosis of in-hospital cardiac arrest. Length of stay was shorter in patients with SAH and ICH (mean 2.92±4.13 days and 2.53±3.56 days respectively) compared to IS patients (mean 4.93 ± 10.2 days, p < 0.001) suggesting brain death is an early event in hemorrhagic stroke.
Conclusion:
Brain death in the majority of cerebrovascular patients occurs as a result of primary neurological insult without associated cardiac arrest. It occurs much earlier in hemorrhagic stroke compared to ischemic stroke.
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Affiliation(s)
- Rakesh Khatri
- Texas Tech Univ Health Sciences Cntr El Paso, El Paso, TX
| | | | - Alberto Maud
- Texas Tech Univ Health Sciences Cntr El Paso, El Paso, TX
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Afzal MR, Maud A, Cruz-Flores S, Qureshi MA, Qureshi IA, Vellipuram AR, Piriyawat P, Rodriguez GJ, Khatri R. Abstract WP319: Continued Nationwide Decline in Stroke Related In-hospital Mortality in United States. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp319] [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 and Purpose:
Previously a downward trend in stroke related in-hospital mortality was noted from 1996 to 2006 reflecting advancements in acute stroke care. Given ongoing improvement in acute stroke care models and therapies, our study assessed nationwide patterns in in-hospital mortality related to acute stroke for next decade.
Methods:
Patients with acute stroke were identified from the nationwide in-patient sample database for the years 2007 to 2014 using International Classification of Diseases, Ninth Revision procedure codes. Time trends in the proportion of stroke hospitalizations that resulted in death were assessed.
Results:
Between 2007 and 2014, overall stroke hospitalizations increased from 1017 414 in 2007 to 2008 to 1114 960 in 2013 to 2014, whereas percentage stroke hospitalizations that resulted in death decreased from 8.98% in 2007-2008 to 7.34% in 2013-2014 (P<0.0001). Unadjusted Odds of mortality decreased regardless of stroke type: ischemic stroke (IS) (OR 0.798, 95% CI 0.762 to 0.835), subarachnoid hemorrhage (SAH) (OR 0.885, 95% CI 0.810 to 0.968), and intracerebral hemorrhage (ICH) (OR 0.865, 95% CI 0.824 to 0.908). In multivariate analysis these odds remained significant (IS: OR 0.813, 95% CI 0.770 to 0.859), SAH: OR 0.680, 95% CI 0.611 to 0.757, ICH: OR 0.707, 95% CI 0.664to 0.754) after adjusting with age, gender, race, medical comorbidities, in-hospital complications, insurance status and APRDRG Severity scale).
Conclusions:
There is continued decline in Nationwide In-Hospital Mortality among hospitalized acute stroke patients. This reflects ongoing improvement in stroke care models and advancement in therapies.
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Gavito-Higuera J, Khatri R, Qureshi IA, Maud A, Rodriguez GJ. Aggressive blood pressure treatment of hypertensive intracerebral hemorrhage may lead to global cerebral hypoperfusion: Case report and imaging perspective. World J Radiol 2017; 9:448-453. [PMID: 29354210 PMCID: PMC5746648 DOI: 10.4329/wjr.v9.i12.448] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [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] [Received: 02/08/2017] [Revised: 08/22/2017] [Accepted: 11/30/2017] [Indexed: 02/06/2023] Open
Abstract
Hypoperfusion injury related to blood pressure decrease in acute hypertensive intracerebral hemorrhage continues to be a controversial topic. Aggressive treatment is provided with the intent to stop the ongoing bleeding. However, there may be additional factors, including autoregulation and increased intracranial pressure, that may limit this approach. We present here a case of acute hypertensive intracerebral hemorrhage, in which aggressive blood pressure management to levels within the normal range led to global cerebral ischemia within multiple border zones. Global cerebral ischemia may be of concern in the management of hypertensive hemorrhage in the presence of premorbid poorly controlled blood pressure and increased intracranial pressure.
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Affiliation(s)
- Jose Gavito-Higuera
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Ihtesham A Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University of Health Sciences Center, El Paso, TX 79905, United States
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Afzal MR, Qureshi MA, Miran MS, Rodriguez GJ, Maud A, Khatri R. Delayed Coil Migration: Uncommon Cause of Ischemic Stroke and Retrieval Technique. J Vasc Interv Neurol 2017; 9:36-37. [PMID: 29445437 PMCID: PMC5805907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Mohammad Rauf Afzal
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Mohtashim Arbaab Qureshi
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | | | - Gustavo J. Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
| | - Rakesh Khatri
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center El Paso, El Paso, TX, USA
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Qureshi IA, Rodriguez GJ, Chacon-Quesada T, Jose GH, Cruz-Flores S, Maud A. Cervical Arterial Fibromuscular Dysplasia in a Biethnic Population: A Retrospective Study in the U.S.-Mexican Border. Int J Angiol 2017; 26:253-258. [PMID: 29142493 DOI: 10.1055/s-0036-1593773] [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] [Indexed: 10/20/2022] Open
Abstract
Background There have been studies trying to characterize Fibromuscular Dysplasia (FMD); however, most of them are based in mainly non-Hispanic sample. The objective of this study is to better understand the epidemiology and clinical characteristics of craniocervical FMD in the Hispanic population. Methods We retrospectively reviewed the cerebral angiograms performed in our center in a period of 3.5 years under any indication looking for angiographic patterns of FMD. Exclusion criteria consisted of cases in which the first angiogram was done when the patients were younger than 18 years. Patients were subdivided based on those with FMD and those without it for baseline characteristics and were looked for any associations. We further compared the same baseline characteristics among Hispanic FMD and non-Hispanic FMD population. A chart review was conducted looking for clinical features and vascular events. Results We analyzed 448 angiograms among patients younger than 18 years. We identified 47 patients with evidence of FMD involving the cervical arteries and 401 patients without FMD. Of the 47 patients with FMD in our neuroendovascular registry, we found that 76.6% were women and 57.4% were Hispanics. There was no statistical significant difference when comparing the variables across ethnicities, except history of cigarette smoking and dyslipidemia. The most common associated supra-aortic arterial lesions seen in the FMD group were intracranial aneurysm and arterial dissections. We then used same variables to compare Hispanic FMD with non-Hispanic FMD. We have found that there has been a positive association of cigarette smoking and dyslipidemia with FMD ( p ≤ 0.05). Conclusion Our study suggests that FMD affecting the carotid and vertebral arteries has similar demographic pattern across ethnicities in the United States. In Hispanics, the disease appears to have a predilection for women and history of cigarette smoking. Intracranial aneurysm and arterial dissection were the most commonly associated arterial lesions.
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Affiliation(s)
- Ihtesham A Qureshi
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas
| | | | - Gavito-Higuera Jose
- Department of Radiology, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, Texas
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Lapid D, Qureshi MA, Quresh IA, Afzal MR, Maud A, Rodriguez GJ, Khatri R. Possible Reversible Cerebral Vasoconstriction Syndrome Associated with Eucalyptus: Case Report. J Vasc Interv Neurol 2017; 9:17-20. [PMID: 29163745 PMCID: PMC5683022] [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: 06/07/2023]
Abstract
BACKGROUND Reversible cerebral vasoconstrictive syndrome (RCVS) has characteristic clinical features, brain imaging and Angiographic features. The majority of RCVS cases are associated with the use of antidepressants, polysubstance abuse, and nasal decongestants. We here present a case that highlights the use of eucalyptus herbs as a possible precipitant factor for RCVS formation. CASE PRESENTATION A 42-year-old woman presented to the emergency department with a tingling sensation on the right-hand side of her body and a two-week progressive throbbing severe holocranial headache radiating to the neck, with associated nausea, photophobia, and phonophobia. She denied any seizures and recent trauma or fevers. She was not taking scheduled medications, but she had used inhaling vapors obtained from boiling eucalyptus leaves to alleviate sinus congestion. Initial imaging revealed subarachnoid hemorrhage at bilateral posterior parietal convexity leading to her admission into the intensive care unit. Further work up disclosed the presence of findings consistent with RCVS. CONCLUSION In conclusion, we hereby postulate that some herbal remedies used in alternative medicine, including eucalyptus, could play a role in causing serotonergic symptoms including dizziness, diarrhea, and cerebral vasoconstriction. Understanding that eucalyptus has the potential to contribute to RCVS due to its serotoninergic activity may be of importance in the diagnosis and management of these patients.
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Affiliation(s)
| | | | - Ihtesham Aatif Quresh
- Corresponding Author: Ihtesham Aatif Qureshi MD, Department of Neurology, Texas Tech University of Health Sciences Center, 4800 Alberta Avenue, El Paso, TX, USA. Tel.: (312) 888-6929; fax: (915) 215-5900.
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24
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Hassan AE, Zacharatos H, Grigoryan M, Tekle WG, Khan A, Siddiq F, Rodriguez GJ, Tummala R, Jagadeesan B, Suri MFK, Qureshi AI. Open-Label Phase I Clinical Study to Assess the Safety and Efficacy of Cilostazol in Patients Undergoing Internal Carotid Artery Stent Placement. Interv Neurol 2017; 6:42-48. [PMID: 28611833 DOI: 10.1159/000452308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND One-month dual antiplatelet treatment, with aspirin and clopidogrel, following internal carotid artery stent placement is the current standard of care to prevent in-stent thrombosis. Cilostazol, an antiplatelet drug, has been demonstrated to have a safety profile comparable to aspirin and clopidogrel. OBJECTIVE To evaluate the safety and clinical efficacy of cilostazol and aspirin therapy following internal carotid artery stent placement up to 1 month postprocedure. METHODS A phase I open-label, nonrandomized two-center prospective study was conducted. All subjects received aspirin (325 mg/day) and cilostazol (200 mg/day) 3 days before extracranial stent placement. Two antiplatelet agents were continued for 1 month postprocedure followed by aspirin daily monotherapy. The primary efficacy end point was the 30-day composite occurrence of death, cerebral infarction, transient ischemic attack, and in-stent thrombosis. The primary safety end point was bleeding. RESULTS Twelve subjects (mean age ± SD, 66 ± 12 years; 9 males) were enrolled and underwent internal carotid artery angioplasty and stent placement. None of the subjects who successfully followed the study protocol experienced any complications at the 1- and 3-month follow-ups. One patient had a protocol deviation due to concurrent use of enoxaparin (1 mg/kg twice daily) in addition to aspirin and cilostazol, resulting in a fatal symptomatic intracerebral hemorrhage following successful stent placement on postprocedure day 1. One patient discontinued cilostazol after the first dose secondary to dizziness. CONCLUSION The use of cilostazol and aspirin for internal carotid artery stent placement appears to be safe, but protocol compliance needs to be emphasized.
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Affiliation(s)
- Ameer E Hassan
- Valley Baptist Brain and Spine Network, University of Texas Health Science Center - San Antonio, Harlingen, TX, MN, USA
| | | | | | - Wondwossen G Tekle
- Valley Baptist Brain and Spine Network, University of Texas Health Science Center - San Antonio, Harlingen, TX, MN, USA
| | | | | | | | | | | | | | - Adnan I Qureshi
- Zeenat Qureshi Stroke Research Center, University of Minnesota, Minneapolis, MN, USA
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25
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Chompoopong P, Rostambeigi N, Kassar D, Maud A, Qureshi IA, Cruz-Flores S, Rodriguez GJ. Are We Overlooking Stroke Chameleons? A Retrospective Study on the Delayed Recognition of Stroke Patients. Cerebrovasc Dis 2017; 44:83-87. [PMID: 28511184 DOI: 10.1159/000471929] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Accepted: 03/22/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND AND PURPOSE New effective recanalization therapies are currently available for acute ischemic stroke; yet a vast majority of stroke patients are left untreated. The lack of early recognition may be because often times, stroke patients present with atypical manifestations that resemble other conditions (which are referred to as "stroke chameleons"). We set to study the proportion of patients with delayed stroke recognition in a single center. METHODS We performed a retrospective analysis of a prospectively collected data over a 9-year period. All adult patients discharged with the diagnosis of ischemic stroke or transient ischemic attack (TIA) were identified and traced for their diagnosis on admission. Those cases with a diagnosis other than ischemic stroke or TIA on admission were identified as possible stroke chameleons and categorized into different groups according to the occurrence of neurological or non-neurological manifestations at presentation. RESULTS Of 2,303 cases with discharge diagnosis of ischemic stroke or TIA, 919 (39.9%) were found to be possible stroke chameleons. More than half of these patients (58.4%) presented with neurological manifestations including disorders of the somatic sensation (33%), alteration of consciousness (30%), and disorders of speech/language (11%). The remaining possible stroke chameleons had manifestations pertaining to other organ systems such as cardiopulmonary, gastrointestinal, systemic infection, trauma, and thromboembolic events elsewhere. CONCLUSIONS In our cohort, a surprisingly large percentage of possible stroke chameleons was observed. It is important to confirm our findings, study the impact on clinical outcome, and develop strategies for early stroke patient recognition.
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26
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Galaz-Montoya M, Wright SJ, Rodriguez GJ, Lichtarge O, Wensel TG. β 2-Adrenergic receptor activation mobilizes intracellular calcium via a non-canonical cAMP-independent signaling pathway. J Biol Chem 2017; 292:9967-9974. [PMID: 28442571 DOI: 10.1074/jbc.m117.787119] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Revised: 04/24/2017] [Indexed: 11/06/2022] Open
Abstract
Beta adrenergic receptors (βARs) are G-protein-coupled receptors essential for physiological responses to the hormones/neurotransmitters epinephrine and norepinephrine which are found in the nervous system and throughout the body. They are the targets of numerous widely used drugs, especially in the case of the most extensively studied βAR, β2AR, whose ligands are used for asthma and cardiovascular disease. βARs signal through Gαs G-proteins and via activation of adenylyl cyclase and cAMP-dependent protein kinase, but some alternative downstream pathways have also been proposed that could be important for understanding normal physiological functioning of βAR signaling and its disruption in disease. Using fluorescence-based Ca2+ flux assays combined with pharmacology and gene knock-out methods, we discovered a previously unrecognized endogenous pathway in HEK-293 cells whereby β2AR activation leads to robust Ca2+ mobilization from intracellular stores via activation of phospholipase C and opening of inositol trisphosphate (InsP3) receptors. This pathway did not involve cAMP, Gαs, or Gαi or the participation of the other members of the canonical β2AR signaling cascade and, therefore, constitutes a novel signaling mechanism for this receptor. This newly uncovered mechanism for Ca2+ mobilization by β2AR has broad implications for adrenergic signaling, cross-talk with other signaling pathways, and the effects of βAR-directed drugs.
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Affiliation(s)
- Monica Galaz-Montoya
- From the Verna and Marrs McLean Department of Biochemistry and Molecular Biology and
| | - Sara J Wright
- From the Verna and Marrs McLean Department of Biochemistry and Molecular Biology and
| | - Gustavo J Rodriguez
- From the Verna and Marrs McLean Department of Biochemistry and Molecular Biology and
| | - Olivier Lichtarge
- From the Verna and Marrs McLean Department of Biochemistry and Molecular Biology and.,the Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas 77030
| | - Theodore G Wensel
- From the Verna and Marrs McLean Department of Biochemistry and Molecular Biology and
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27
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Khatri R, Afzal MR, Rodriguez GJ, Maud A, Miran MS, Qureshi MA, Cruz-Flores S, Qureshi AI. Albumin-Induced Neuroprotection in Focal Cerebral Ischemia in the ALIAS Trial: Does Severity, Mechanism, and Time of Infusion Matter? Neurocrit Care 2017; 28:60-64. [DOI: 10.1007/s12028-017-0400-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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28
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Qureshi MA, Afzal MR, Qureshi IA, Ghatali M, Piriyawat P, Maud A, Cruz-Flores S, Rodriguez GJ. Abstract WP24: The Middle Cerebral Artery Occlusion, Anatomy Study and Pitfalls in the Design and Classification of Its Segment Occlusions in the Clinical Trials. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp24] [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:
The middle cerebral artery (MCA) occlusion is the most commonly treated vessel with mechanical thrombectomy. The MCA is defined in segments. The M1 segment is classically defined as the horizontal segment extending from the internal carotid artery bifurcation to the Sylvian fissure. It is assumed that the MCA bifurcation occurs in the M1-2 junction, and terms M2 occlusion and division occlusion are used indistinctly, however it is not known how often the MCA bifurcation occurs within the M1 segment.
Methodology:
Consecutive patients undergoing cerebral angiograms were selected between 2011 and 2015. The anatomy of the MCA was classified as classical, when the bifurcation occurs at the M1-2 junction and non-classical when the bifurcation occurs within the M1 segment, having the M1 segment a pre-bifurcation (main trunk) and a post-bifurcation (division) occlusion. Demographics and vascular risk factors were also collected.
Results:
A total of 500 patients underwent a cerebral angiogram and were studied. The classical pattern was found in 47.5% patients on the left and 53.5% patients on the right. There were no differences between the classical and non-classical anatomical pattern when demographics or vascular risk factors were compared.
Conclusion:
In our series of patients the non-classical pattern was found in almost 50.0% of the patients undergoing a cerebral angiogram. In the endovascular treatment of acute ischemic stroke, it is necessary to develop a new classification as an M1 occlusion could relate to a post-bifurcation (division) or a pre-bifurcation (main trunk) occlusion and comparison of these groups may lead to confounding results.
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Qureshi AI, Grigoryan M, Guliani GK, Saleem MA, Aytac E, Rodriguez GJ, Suri MF. Abstract WP10: Prolonged Microcatheter-based Local Thrombolytic Infusion as a Salvage Treatment for Failed Endovascular Treatment for Cerebral Venous Thrombosis: A Multicenter Registry. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp10] [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:
Transvenous endovascular treatment including combination pharmacological and mechanical modalities is reserved for patients with cerebral venous thrombosis (CVT) not responsive to standard anticoagulation. However, transvenous endovascular treatment may not always be successful in achieving recanalization.
Objective:
To determine the effectiveness of prolonged microcatheter based local thrombolytic infusion in treatment of patients with CVT who achieved no or suboptimal recanalization with endovascular treatment.
Methods:
Patients who underwent transvenous endovascular treatment for cerebral venous thrombosis at three hospitals were identified through local registries. The final response to treatment was assessed and prolonged microcatheter based local thrombolytic infusion was instituted in selected patients as second line treatment. Serial angiograms were performed to assess treatment response and determine the duration of infusion.
Results:
Of the 85 patients admitted with CVT, 13 patients underwent 14 transvenous endovascular treatments. Initial treatment was considered suboptimal in 10/14 procedures due to no recanalization in 6, partial recanalization in 3, and re-occlusion in 1 patient. A prolonged microcatheter-based local recombinant tissue plasminogen activator (rt-PA) infusion was used in 9 of the 10 procedures for a median duration of 16 hours (range 15-22 hours). Follow up angiography demonstrated complete recanalization in 4 procedures and improvement of the partial recanalization in 5 additional procedures. One patient died before the follow up imaging could be acquired. None of the patients developed intracranial hemorrhage associated with local thrombolytic infusion. The microcatheter position had shifted during the infusion in one procedure.
Conclusion:
Prolonged microcatheter based local thrombolytic infusion appears to effective treatment in patients who have suboptimal response to acute transvenous endovascular treatment without any additional adverse events.
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Affiliation(s)
| | | | | | | | - Emrah Aytac
- Zeenat Qureshi Stroke Institute, St. Cloud, MN
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Afzal MR, Qureshi MA, Qureshi IA, Piriyawat P, Maud A, Cruz-Flores S, Rodriguez GJ. Abstract WP22: Endovascular Treatment for Distal Middle cerebral Artery Occlusions in Patients with Acute Ischemic Stroke From Interventional Management of Stroke Trial (IMS III). Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp22] [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:
Currently, endovascular treatment is advocated for middle cerebral artery (MCA) occlusions, however not much is known about the natural history of an M1 compared to an M2 occlusion.
Objective:
To compare the clinical outcome in endovascularly treated patients with proximal vessel occlusion (M1) versus a more distal occlusion (M2) among patients with ischemic stokes in a negative trial.
Methods:
Data from Interventional Management of Stroke trial (IMS-III) for patients with acute ischemic stroke with distal MCA (mainly M2 and beyond) occlusions diagnosed by either computed tomographic angiography (CTA) or catheter angiography were analyzed. NIHSS at admission, baseline characteristics, infarct volume at baseline and outcome at 90 days (mRS score) were compared between the two groups. Favorable outcome was defined by discharge modified Rankin scale (mRS) score of 0-2, at 3 months. Multivariate logistical regression was performed to compare the outcomes after adjusting for potential confounders.
Results:
Of the
434
from the endovascular therapy group,
215 (49.5%)
and
98 (22.5%)
patients had M1 and M2 occlusion respectively. Patients with M1 occlusion had higher mean NIHSS at admission
(18.76± 4.94 versus 17.37± 5.72, P-value = 0.029)
and higher infarct volume
(105.92 ± 113.23
versus 49.67 ± 63.42, P-value = 0.000)
. Rate of favorable outcome defined by mRS at discharge was lower among patients with M1
(31.53%vs.46.67%p-value = 0.0128)
. After adjusting for age, sex, total NIHSS score at admission, hepato-biliary disorders, anticoagulants, antiplatelet, NSAIDS, patients with M1 occlusion had higher rates of poor outcomes; odds ratio
(OR) 1.819
(confidence interval
[CI] 1.032- 3.205, P=0.03860).
Conclusions:
In patients enrolled in IMS-III trial, an M1 occlusion demonstrated a larger tissue infarct size and a lower rate of favorable outcome than an M2 occlusion, given the negative results of the trial, these findings reflect the natural history of these two occlusion sites.
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Afzal MR, Qureshi MA, Qureshi IA, Piriyawat P, Maud A, Cruz-Flores S, Rodriguez GJ. Abstract WP363: Outcomes for Intracerebral Hemorrhage Patients with Renal Failure as Comorbidity in the United States. Stroke 2017. [DOI: 10.1161/str.48.suppl_1.wp363] [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:
Clinical characteristics and outcomes for patients with intracerebral hemorrhage and underlying chronic kidney disease (CKD) are not well determined. We hypothesized rate adverse events and in-hospital mortality is higher in patients with intracerebral hemorrhage and underlying renal disease.
Objective:
To determine the Outcomes for intracerebral hemorrhage stroke patients with renal failure as comorbidity in the United States
Methods:
We analyzed the data from Nationwide Inpatient Sample
(2009-2011)
for all intracerebral hemorrhage stroke patients with or without renal failure as comorbidity. Patients were identified using the International Classification of Disease, Ninth Revision. Baseline characteristics, in-hospital complications including myocardial infarction), sepsis, pneumonia, deep venous thrombosis, urinary tract infections, and discharge outcomes (mortality, minimal disability, and moderate-to-severe disability) were compared between the two groups. All in-hospital outcomes were analyzed after adjusting for potential confounders using multivariate analysis.
Results:
Of the
33521
patients with intracerebral hemorrhage stroke,
3899 (11.6%)
had renal failure as comorbidity. Patients with underlying renal disease were higher rates for in hospital complications like myocardial infarction
(3.64% versus 2.03%, P≤.0001)
, sepsis
(5.82% versus 3.14%, P≤.0001)
, pneumonia
(6.92% versus 5.18%, P≤.0001)
, deep venous thrombosis
(1.67 % versus 1.17%, P≤ .0.0078)
, urinary tract infections
(16.41% versus 15.08%, P≤ 0.0293)
and hypernatremia
(8.62% versus 4.98%, P≤ <.0001).
In multivariate analysis adjusted for baseline cormorbitdities and in hospital complications, intracerebral hemorrhage patients with underlying renal disease had higher in hospital mortality
(OR 1.146 (95% confidence interval (CI)
1.058- 1.240p-value=0.0008)
, while there is no statistically significant difference for minimal/moderate disability between two groups (
OR = 0.980 (95% CI
0.896- 1.072 p-value=0.6571).
Conclusions:
Intracerebral hemorrhage patients with underlying renal disease have higher rate of in hospital complications and mortality. Future prospective studies are indicated to study this finding.
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Villalobos E, Barnes SR, Qureshi IA, Cruz-Flores S, Maud A, Rodriguez GJ. Spanish Version of the National Institutes of Health Stroke Scale: Awareness and Use in United States. A Survey Study. J Vasc Interv Neurol 2017; 9:1-6. [PMID: 28243343 PMCID: PMC5317283] [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: 06/06/2023]
Abstract
OBJECTIVE To investigate the awareness and the use of Spanish version of National Institutes of Health Stroke Scale (NIHSS) throughout the United States (US) by regions using a web-based survey. METHODS A survey targeting physicians from two specialties that regularly manage acute stroke patients was conducted from February to August of 2015. Academic centers from the Accreditation Council for Graduate Medical Education online directory belonging to emergency medicine (EM) and neurology residency programs were identified. The questionnaire was composed of ten questions separated into three different groups. The responses received from the programs were separated by specialty and grouped into different regions in the US for comparison. RESULTS Out of 230 residency-invited programs, we received a total of 73 responses, 35 from EM and 26 responses from neurology residency programs. In addition, 12 respondents were categorized as unknown recipients. The South region had the highest response rate with 30.3%. There was no significant difference in the responses by region if Puerto Rico was not analyzed. Interviewees reported a substantial percentage of Spanish-speaking patients reported across the regions and more than 75% of the programs report lack of knowledge of the Spanish version of the NIHSS and/or the use of it. CONCLUSION There may be a need to increase awareness and to promote the use of the Spanish version of the NIHSS. Spanish-speaking population in the US may be inaccurately assessed for acute stroke and could impact the outcomes. Larger population studies should be conducted to confirm our findings. AUTHOR CONTRIBUTIONS Dr. Villalobos and Dr. Barnes are involved in formulating the study concept and design; Dr. Rodriguez and Dr. Maud are involved in manuscript writing; Dr. Qureshi is involved in statistical analysis of the data; Dr. Cruz-Flores is involved in critical revision of the manuscript. DISCLOSURES Dr. Villalobos reports no disclosure; Dr. Barnes reports no disclosure; Dr. Qureshi reports no disclosure; Dr. Cruz-Flores reports no disclosure; Dr. Maud reports no disclosure; Dr. Rodriguez reports no disclosure.
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Affiliation(s)
- Enrique Villalobos
- Department of Emergency Medicine, Texas Tech University Health Science Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Scott R. Barnes
- Department of Emergency Medicine, Texas Tech University Health Science Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Ihtesham A. Qureshi
- Department of Neurology, Texas Tech University Health Science Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University Health Science Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Science Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
| | - Gustavo J. Rodriguez
- Department of Neurology, Texas Tech University Health Science Center, 4800 Alberta Avenue, El Paso, TX 79905, USA
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Remirez JM, Sabet Y, Baca M, Maud A, Cruz-Flores S, Rodriguez GJ, Mukherjee D, Abbas A. Mycotic Intracranial Aneurysm Secondary to Left Ventricular Assist Device Infection. J Vasc Interv Neurol 2017; 9:23-25. [PMID: 28243347 PMCID: PMC5317288] [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: 06/06/2023]
Abstract
BACKGROUND Mycotic aneurysms are a complication of infective endocarditis. Infection of left ventricular assist devices (LVADs) may lead to bacteremia and fever causing complications similar to those seen in patients with prosthetic valve endocarditis. Intracranial mycotic aneurysms are rare, and their presence is signaled by the development of subarachnoid hemorrhage in the setting of bacteremia and aneurysms located distal to the circle of Willis. CASE PRESENTATION We present the case of a patient with a LVAD presenting with headache who is found to have an intracranial mycotic aneurysm through computed tomography angiography of the head. The patient was successfully treated with endovascular intervention. CONCLUSION In patients with LVADs, mycotic aneurysms have been reported, however not intracranially. To the best of our knowledge, this is the first intracranial mycotic aneurysm secondary to LVAD infection that was successfully treated with endovascular repair. Intracranial mycotic aneurysms associated with LVADs are a rare phenomenon. The diagnosis of mycotic aneurysms requires a high index of suspicion in patients who present with bacteremia with or without headache and other neurological symptoms. DISCLOSURE None.
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Affiliation(s)
- Juan M. Remirez
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Yasmin Sabet
- Department of Internal Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Marshall Baca
- Department of Emergency Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Gustavo J. Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Debabrata Mukherjee
- Department of Internal Medicine, Division of Cardiology, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Aamer Abbas
- Department of Internal Medicine, Division of Cardiology, Texas Tech University Health Sciences Center, El Paso, TX, USA
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Bagherpour AN, Rodriguez GJ, Moorthy C, Trier TT, Maud A. Combined surgical and endovascular treatment of complex high-flow conus medullaris arteriovenous fistula associated with Parkes Weber syndrome: case report. J Neurosurg Spine 2016; 25:234-8. [DOI: 10.3171/2016.1.spine151156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Parkes Weber syndrome (PWS) is a congenital overgrowth disorder characterized by unilateral limb and axial hypertrophy, capillary malformations of the skin, and high-flow arteriovenous fistulas (AVFs). Spinal AVFs in the setting of PWS are challenging vascular lesions that often contain multiple arteriovenous (AV) shunts. The present case report highlights an adolescent girl with PWS who presented with a ruptured complex high-flow conus medullaris AVF. She was successfully treated with endovascular embolization and microsurgery. At the 2-year follow-up, the patient remained free of neurological symptoms and had no recurrence of the vascular malformation.
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Affiliation(s)
| | | | | | - Todd T. Trier
- 4Neurosurgery, Texas Tech University Health Sciences Center, El Paso, Texas
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Maud A, Qureshi IA, Cruz‐Flores S, Rodriguez GJ. Topsy‐turvy by the Belly Dancer. Clin Case Rep 2016; 4:844-5. [PMID: 27525100 PMCID: PMC4974444 DOI: 10.1002/ccr3.622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Revised: 05/09/2016] [Accepted: 06/07/2016] [Indexed: 11/25/2022] Open
Abstract
In our patient presenting with abdominal myoclonus, it is important to understand its pathophysiology. Various etiologies need to be taken into consideration before coming to a conclusion. The finding on Magnetic resonance imaging (MRI)‐Spine disclosing cervical lesion may just be an incidental finding.
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Affiliation(s)
- Alberto Maud
- Neurology department Texas Tech University Health Sciences Center 4800 Alberta Avenue El Paso Texas 79905 USA
| | - Ihtesham A. Qureshi
- Neurology department Texas Tech University Health Sciences Center 4800 Alberta Avenue El Paso Texas 79905 USA
| | - Salvador Cruz‐Flores
- Neurology department Texas Tech University Health Sciences Center 4800 Alberta Avenue El Paso Texas 79905 USA
| | - Gustavo J. Rodriguez
- Neurology department Texas Tech University Health Sciences Center 4800 Alberta Avenue El Paso Texas 79905 USA
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Rodriguez GJ, Maud A, Piriyawat P, Cruz-Flores S. Comment: The elusive search for markers of hematoma expansion. Neurology 2016; 87:363. [DOI: 10.1212/wnl.0000000000002902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Accepted: 04/17/2016] [Indexed: 11/15/2022] Open
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37
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Maud A, Rodriguez GJ, Piriyawat P, Cruz-Flores S. Letter to the Editor: Physician specialty and endovascular treatment of intracerebral aneurysms. J Neurosurg 2016; 124:1876-8. [PMID: 27058196 DOI: 10.3171/2015.9.jns152035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alberto Maud
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX
| | | | - Paisith Piriyawat
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX
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Qureshi IA, Maud A, Cruz-Flores S, Rodriguez GJ. Main Trunk and Division Middle Cerebral Artery Occlusions: Differences in Recanalization Times, Number of Stent Retriever Passes and Clinical Outcomes: A Single-Center Experience. Interv Neurol 2016; 4:83-9. [PMID: 27051403 DOI: 10.1159/000442578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND AND PURPOSE In this article, we present our experience with the recanalization of the middle cerebral artery (MCA), we hypothesize that there are higher rates of recanalization with fewer stent retriever passes and better clinical outcomes in patients with division MCA occlusions. A more complex anatomy at the bifurcation may prevent a faster recanalization in main trunk MCA occlusions. METHODS We retrospectively identified consecutive patients admitted with MCA occlusions who underwent mechanical thrombectomy using stent retrievers. We categorized patients into division MCA and main trunk MCA occlusions based on angiography. Variables were compared between the groups. We further analyzed patients with trunk MCA occlusions to identify reasons for delays in recanalization. RESULTS There were 32 MCA occlusions that underwent mechanical thrombectomy and eligible for the analysis during the study period. Of those, 11 were main trunk MCA occlusions. Univariate analysis disclosed a trend toward a lower GP-to-recanalization time (p = 0.05) and a lower number of passes required for recanalization in division MCA occlusions. However, there was a significantly better outcome in patients with division MCA occlusion after multivariate analysis. Analyzing main trunk MCA occlusion data, we found that the need for more than one pass to achieve recanalization led to a trend toward a longer GP-to-recanalization time and a worse outcome. When the stent was placed in the dominant division, the chances of recanalization were significantly higher. CONCLUSIONS Division MCA occlusions have higher recanalization rates with fewer stent retriever passes and better clinical outcomes than main trunk MCA occlusions, likely due to a more favorable anatomy. Measures like placing the stent retriever in the dominant division may decrease recanalization times and improve clinical outcomes in main trunk MCA occlusions.
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Affiliation(s)
- Ihtesham A Qureshi
- Neurology Department, Texas Tech University Health Sciences Center, El Paso, Tex., USA
| | - Alberto Maud
- Neurology Department, Texas Tech University Health Sciences Center, El Paso, Tex., USA
| | - Salvador Cruz-Flores
- Neurology Department, Texas Tech University Health Sciences Center, El Paso, Tex., USA
| | - Gustavo J Rodriguez
- Neurology Department, Texas Tech University Health Sciences Center, El Paso, Tex., USA
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Chompoopong P, Rostambeigi N, Darine K, Maud A, Piriyawat P, Cruz-Flores S, Rodriguez GJ. Abstract TP133: Should Early Identification of Stroke Patients be Focused on Stroke Mimics or Chameleons? A Retrospective Study on the Hospital Stroke Chameleon Prevalence. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.tp133] [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 and Purpose:
Although we count with effective recanalization therapies for acute stroke treatment, the vast majority of ischemic stroke patients who present within 4.5 hours of symptom onset are still left untreated. We hypothesized that lack of early stroke recognition, mainly due to stroke symptoms disguising as “stroke chameleons”, is a possible explanation.
Methods:
Retrospective cross-sectional analysis was performed on 9-year hospital chart records. Patients with discharge diagnoses of ischemic stroke were traced back to their admitting diagnoses. Cases with non-cerebrovascular events admitting diagnoses were identified as possible stroke chameleons and sorted into groups according to the occurrence of presenting neurological or non-neurological manifestations.
Results:
Of 1,754 ischemic stroke cases, 678 (38.7%) were found to be possible stroke chameleons. More than half of the chameleons (58.6%) presented with neurological manifestations. The four most common ones were disorders of somatic sensation (31.7%), alteration of consciousness (31.5%), disorders of speech/language (10.8%), and disorder of motility (10.1%). The rest of possible stroke chameleons camouflaged themselves with presenting manifestations pertaining to conditions of other organ systems such as cardiopulmonary, gastrointestinal, systemic infection, trauma, and vascular events elsewhere.
Conclusions:
We found a large percentage of possible stroke chameleons. In this new era of effective recanalization therapies for ischemic stroke, more attention should be placed on stroke chameleons. More studies should confirm our results and the proper efforts should be taken to increase the number of patients treated for acute ischemic stroke that arrive within the therapeutic window.
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Affiliation(s)
| | | | - Kassar Darine
- Neurology, Texas Tech Univ Health Sciences Cntr, El Paso, TX
| | - Alberto Maud
- Neurology, Texas Tech Univ Health Sciences Cntr, El Paso, TX
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Qureshi IA, Maud A, Chacon T, Cruz-Flores S, J Rodriguez G. Abstract WP393: Cervical Arterial Fibromuscular Dysplasia in a Bi-ethnic Population: a Retrospective Study in U.S.-Mexican Border. Stroke 2016. [DOI: 10.1161/str.47.suppl_1.wp393] [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:
There have been studies trying to characterize Fibromuscular Dysplasia (FMD), however most of them are based in mainly non-Hispanic samples. The objective of this study is to describe the epidemiology, clinical characteristics, angiographic findings, and associated vascular conditions of cervical arterial fibromuscular dysplasia in Hispanics in the US-Mexican border.
Methods:
We retrospectively reviewed the cerebral angiograms performed in our center in a period of 3.5 years under different indications (cervical and intracranial steno-occlusive arterial disease, intracranial vascular malformation, cranial and facial tumor embolization, and subarachnoid hemorrhage) looking for angiographic patterns of FMD involving the cervical (internal carotid and vertebral) arteries. Exclusion criteria included subjects younger than 18 years old. Patients were subdivided by their self-reported ethnicity in Hispanics and non Hispanics. Of those patients found to have FMD, we looked for the association with the demographics, co-morbidities and related supra-aortic vascular abnormalities.
Results:
We analyzed 467 angiograms among patients >18 years of 323 (69.1%) were Hispanics and 144 (30.8%) were non-Hispanics. We found that 27 (8.3%) Hispanics patients with FMD involving the cervical arteries (internal carotid, vertebral artery isolated and in different combinations), while 20 (13.8%) cases of FMD among the non-Hispanics. There was no significant difference between the two groups regarding the frequency of FMD. In the Hispanic FMD group the mean age was 57.5 ± 15.76 years and 77.7% were females (p-value=0.007). The most common intracranial and cervical arterial conditions associated with FMD in the Hispanic group were aneurysms and arterial dissections that account for 60% and 25.9% respectively. There was a significant association between Hispanic with Female FMD and intracranial aneurysm (p=0.03).
Conclusion:
Our study suggests that FMD might follow the same demographic and clinical characteristics in Hispanics and non Hispanic populations in North-America. FMD in Hispanics has a clear predilection for women and intracranial aneurysm and supra-aortic arterial dissection are most commonly associated conditions.
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Affiliation(s)
| | - Alberto Maud
- Texas Tech Univ Heath Sciences Cntr, El Paso, Texas, El Paso, TX
| | - Tatiana Chacon
- Texas Tech Univ Heath Sciences Cntr, El Paso, Texas, El Paso, TX
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Murrough JW, Soleimani L, DeWilde KE, Collins KA, Lapidus KA, Iacoviello BM, Lener M, Kautz M, Kim J, Stern JB, Price RB, Perez AM, Brallier JW, Rodriguez GJ, Goodman WK, Iosifescu DV, Charney DS. Ketamine for rapid reduction of suicidal ideation: a randomized controlled trial. Psychol Med 2015; 45:3571-3580. [PMID: 26266877 DOI: 10.1017/s0033291715001506] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Suicide is a devastating public health problem and very few biological treatments have been found to be effective for quickly reducing the intensity of suicidal ideation (SI). We have previously shown that a single dose of ketamine, a glutamate N-methyl-d-aspartate (NMDA) receptor antagonist, is associated with a rapid reduction in depressive symptom severity and SI in patients with treatment-resistant depression. METHOD We conducted a randomized, controlled trial of ketamine in patients with mood and anxiety spectrum disorders who presented with clinically significant SI (n = 24). Patients received a single infusion of ketamine or midazolam (as an active placebo) in addition to standard of care. SI measured using the Beck Scale for Suicidal Ideation (BSI) 24 h post-treatment represented the primary outcome. Secondary outcomes included the Montgomery-Asberg Depression Rating Scale--Suicidal Ideation (MADRS-SI) score at 24 h and additional measures beyond the 24-h time-point. RESULTS The intervention was well tolerated and no dropouts occurred during the primary 7-day assessment period. BSI score was not different between the treatment groups at 24 h (p = 0.32); however, a significant difference emerged at 48 h (p = 0.047). MADRS-SI score was lower in the ketamine group compared to midazolam group at 24 h (p = 0.05). The treatment effect was no longer significant at the end of the 7-day assessment period. CONCLUSIONS The current findings provide initial support for the safety and tolerability of ketamine as an intervention for SI in patients who are at elevated risk for suicidal behavior. Larger, well-powered studies are warranted.
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Affiliation(s)
- J W Murrough
- Mood and Anxiety Disorders Program,Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - L Soleimani
- Mood and Anxiety Disorders Program,Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - K E DeWilde
- Mood and Anxiety Disorders Program,Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - K A Collins
- Mood and Anxiety Disorders Program,Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - K A Lapidus
- Departments of Psychiatry and Neurobiology,Stony Brook University,Stony Brook,NY,USA
| | - B M Iacoviello
- Mood and Anxiety Disorders Program,Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - M Lener
- Mood and Anxiety Disorders Program,Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - M Kautz
- Mood and Anxiety Disorders Program,Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - J Kim
- Deparment of Psychology,UCLA,Los Angeles,CA,USA
| | - J B Stern
- Department of Psychology,Drexel University,Philadelphia,PA,USA
| | - R B Price
- Department of Psychiatry,University of Pittsburgh School of Medicine,Pittsburgh,PA,USA
| | - A M Perez
- Department of Anesthesiology,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - J W Brallier
- Department of Anesthesiology,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - G J Rodriguez
- Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - W K Goodman
- Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - D V Iosifescu
- Mood and Anxiety Disorders Program,Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
| | - D S Charney
- Mood and Anxiety Disorders Program,Department of Psychiatry,Icahn School of Medicine at Mount Sinai,New York,NY,USA
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Jenson AV, Rodriguez GJ, Alvarado LA, Cruz-Flores S, Maud A. Higher Rate of Intracerebral Hemorrhage in Hispanic Patients with Cerebral Cavernous Malformation. J Vasc Interv Neurol 2015; 8:1-4. [PMID: 26600922 PMCID: PMC4634773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
UNLABELLED Cerebral cavernous malformations (CCM) are vascular malformations prone to intracerebral hemorrhage and epilepsy. Studies about the natural history and clinical presentation in the Hispanic population are lacking [7]. Retrospectively, we identified demographics and clinical features of Hispanic patients with CCM in our neurology clinic. Comparison with studies in the non-Hispanic White population with CCM was conducted. RESULTS A total of 15 Hispanic patients diagnosed with CCM were identified in our neurology clinic. The majority of our patients presented with symptomatic hemorrhage (27%, n = 4) or seizure(s) (47%, n = 7). Of 15 patients, there were a total of four patients (27%) that had recurrent hemorrhages with an annual rate of recurrent hemorrhage of 8.04%. Our cohort had a higher rate of intracerebral hemorrhage after any initial mode of presentation (47%, n = 7) compared with non-Hispanic White population studies: 11% (n = 32) and 4% (n = 5). (p < 0.05). CONCLUSIONS Hispanic patients with CCM have a higher rate of hemorrhage during follow-up after any presentation of CCM (p<0.05) when compared to CCM in the non-Hispanic White population.
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Affiliation(s)
- Amanda V Jenson
- Department of Neurology, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Luis A Alvarado
- Department of Neurology, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Salvador Cruz-Flores
- Department of Neurology, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center Paul L. Foster School of Medicine, El Paso, TX, USA
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Chaudhry SA, Afzal MR, Rodriguez GJ, Majidi S, Bundlie S, Hassan AE, Suri MFK, Qureshi AI. Human Immunodeficiency Viral Infection and Status Epilepticus in United States (2002-2009). J Vasc Interv Neurol 2015; 8:56-61. [PMID: 26301033 PMCID: PMC4535595] [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: 06/04/2023]
Abstract
OBJECTIVE To determine the association between human immunodeficiency virus (HIV) infection and status epilepticus and compare the outcomes of patients with status epilepticus with or without underlying HIV infection. METHODS Patients with primary diagnosis of status epilepticus (cases) and status asthmaticus (controls) were identified from the 2002-2009 Nationwide Inpatient Sample (NIS) which is representative of all admissions in the United States. We performed logistic regression analysis adjusting for age, gender, co-morbid conditions, including hypertension, diabetes mellitus (DM), renal failure, alcohol use, and opportunistic infections. We compared the in hospital outcomes among patients admitted with status epilepticus in strata defined by underlying HIV infection. RESULTS The rate of concurrent status epilepticus and HIV has increased over the last 7 years in hospitalized patients with status epilepticus in United States (0.14%-0.27% p<0.0001). The HIV infection was significantly associated with status epilepticus (odds ratio [OR]: 2.2; 95% confidence interval [CI]: 1.8-2.6; p<0.0001)) after adjusting for age, gender, opportunistic infections, and cardiovascular risk factors. The in-hospital mortality was significantly higher while discharge with none or minimal disability was significantly lower in status epilepticus patients with underlying HIV infection (17.5% vs. 9.9%, p<0.0001) and (50.4% vs. 63.3%, p<0.0001), respectively. CONCLUSIONS Our study suggests that there is a direct association between HIV infection and status epilepticus. The proportion of patients admitted with concurrent status epilepticus and HIV infections is increasing and such patients have higher rates of poor discharge outcomes.
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Affiliation(s)
- Saqib A. Chaudhry
- Department of Neurology and Ophthalmology, Michigan State University
| | - Mohammad Rauf Afzal
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, MN, USA
| | | | - Shahram Majidi
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, MN, USA
| | - Scott Bundlie
- Hennepin County Medical Center, Minneapolis, MN, USA
| | - Ameer E. Hassan
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, MN, USA
| | - M. Fareed K. Suri
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, MN, USA
| | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Research Center, Department of Neurology, University of Minnesota, MN, USA
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Miley JT, Rodriguez GJ, Tummala RP. Endovascular retrieval of a prematurely deployed covered stent. World J Radiol 2015; 7:139-142. [PMID: 26120384 PMCID: PMC4473308 DOI: 10.4329/wjr.v7.i6.139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 04/20/2015] [Accepted: 05/06/2015] [Indexed: 02/06/2023] Open
Abstract
Several techniques have been reported to address different endovascular device failures. We report the case of a premature deployment of a covered balloon mounted stent during endovascular repair of a post-traumatic carotid-cavernous fistula (CCF). A 50-year-old male suffered a fall resulting in loss of consciousness and multiple facial fractures. Five weeks later, he developed decreased left visual acuity, proptosis, chemosis, limited eye movements and cranial/orbit bruit. Cerebral angiography demonstrated a direct left CCF and endovascular repair with a 5.0 mm × 19 mm covered stent was planned. Once in the lacerum segment, increased resistance was encountered and the stent was withdrawn resulting in premature deployment. A 3 mm × 9 mm balloon was advanced over an exchange length microwire and through the stent lumen. Once distal to the stent, the balloon was inflated and slowly pulled back in contact with the stent. All devices were successfully withdrawn as a unit. The use of a balloon to retrieve a prematurely deployed balloon mounted stent is a potential rescue option if leaving the stent in situ carries risks.
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Qureshi AI, Malik AA, Saeed O, Adil MM, Rodriguez GJ, Suri MFK. Incident Cancer in a Cohort of 3,247 Cancer Diagnosis Free Ischemic Stroke Patients. Cerebrovasc Dis 2015; 39:262-8. [DOI: 10.1159/000375154] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Accepted: 01/12/2015] [Indexed: 11/19/2022] Open
Abstract
Background: Subclinical cancer can manifest as a thromboembolic event and may be detected at a later interval in ischemic stroke survivors. We determined the rate of incident cancer and effect on cardiovascular endpoints in a large cohort of ischemic stroke survivors. Methods: An analysis of 3,680 adults with nondisabling cerebral infarction who were followed for two years within the randomized, double-blinded VISP trial was performed. The primary intervention was best medical/surgical management plus a daily supplementation of vitamin B6, vitamin B12, and folic acid. We calculated age-adjusted rates of incidence of cancer among ischemic stroke survivors and standardized incidence ratios (SIR) with 95% confidence intervals (CI) based on comparison with age-adjusted rates in the general population. The significant variables from univariate analysis were entered in a Cox Proportional Hazards analysis to identify the association between various baseline factors and incident cancer after adjusting age, gender, and race/ethnicity. A logistic regression analysis evaluated the association between incident cancer and various endpoints including stroke, coronary heart disease, myocardial infarction, and death after adjusting age, gender, and race/ethnicity. Results: A total of 3,247 patients (mean age ± SD of 66 ± 11; 2,013 were men) were cancer free at the time of enrollment. The incidence of new cancer was 0.15, 0.80, 1.2, and 2.0 per 100 patients at 1 month, 6 months, 1 year, and 2 years, respectively. The age-adjusted annual rate of cancer in patients with ischemic stroke was higher than in persons in the general population at 1 year (581.8/100,000 persons vs. 486.5/100,000 persons, SIR 1.2, 95% CI 1.16-1.24) and 2 years (1,301.7/100,000 vs. 911.5/100,000, SIR 1.4, 95% CI 1.2-1.6) after recruitment. There was a higher risk for death (odds ratio (OR) 3.1, 95% CI 1.8-5.4), and composite endpoint of stroke, coronary heart disease, and/or death (OR 1.4, 95% CI 1.0-2.2) among participants who developed incident cancer compared with those who were cancer free after adjusting for potential confounders. Conclusions: The annual rate of age-adjusted cancer incidence was higher among ischemic stroke patients compared with those in the general population. The odds of mortality were three folds higher among stroke survivors who developed incident cancer.
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Chacón-Quesada T, Rodriguez GJ, Maud A, Ramos-Duran L, Torabi A, Fitzgerald T, Akle N, Cruz Flores S, Trier T. Trans-arterial Onyx Embolization of a Functional Thoracic Paraganglioma. Neurointervention 2015; 10:34-8. [PMID: 25763296 PMCID: PMC4355644 DOI: 10.5469/neuroint.2015.10.1.34] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2015] [Accepted: 02/12/2015] [Indexed: 11/24/2022] Open
Abstract
Paragangliomas are rare tumors of the endocrine system. They are highly vascular and in some cases hormonally active, making their management challenging. Although there is strong evidence of the safety and effectiveness of preoperative embolization in the management of spinal tumors, only five cases have been reported in the setting of thoracic paragangliomas. We present the case of a 19-year-old man with a large, primary, functional, malignant paraganglioma of the thoracic spine causing a vertebral fracture and spinal cord compression. To our knowledge this is the first report of preoperative trans-arterial balloon augmented Onyx embolization of a thoracic paraganglioma.
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Affiliation(s)
- Tatiana Chacón-Quesada
- Center of Excellence in Neurosciences, Texas Tech University Health Sciences Center, Paul L. Foster School of Medicine, EL Paso, TX, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L, Foster School of Medicine, EL Paso, TX, USA
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L, Foster School of Medicine, EL Paso, TX, USA
| | - Luis Ramos-Duran
- Department of Radiology, Texas Tech University Health Sciences Center, Paul L, Foster School of Medicine, EL Paso, TX, USA
| | - Alireza Torabi
- Department of Pathology, Texas Tech University Health Sciences Center, Paul L, Foster School of Medicine, EL Paso, TX, USA
| | - Tamara Fitzgerald
- Department of Pediatric Surgery, Texas Tech University Health Sciences Center, Paul L, Foster School of Medicine, EL Paso, TX, USA
| | - Nassim Akle
- Department of Radiology, Texas Tech University Health Sciences Center, Paul L, Foster School of Medicine, EL Paso, TX, USA
| | - Salvador Cruz Flores
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L, Foster School of Medicine, EL Paso, TX, USA
| | - Todd Trier
- Department of Neurosurgery, University Medical Center, EL Paso, TX, USA
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Tekle WG, Chaudry SA, Hassan AE, Qaiser H, Grigoryan M, Rodriguez GJ, Qureshi AI. High risk of new episode of symptomatic vasospasm in unaffected arteries in subarachnoid hemorrhage patients receiving targeted endovascular treatment for symptomatic focal vasospasm. Neurocrit Care 2015; 20:399-405. [PMID: 23463421 DOI: 10.1007/s12028-013-9825-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND There is controversy whether asymptomatic vasospasm in other arteries should be concurrently treated (global treatment) in patients receiving targeted endovascular treatment [percutaneous-transluminal-angioplasty (PTA) and/or intra-arterial (IA) vasodilators] for focal symptomatic vasospasm. OBJECTIVE To determine the rates of occurrence of new symptomatic vasospasm in previously asymptomatic arterial distributions among patients with aneurysmal subarachnoid hemorrhage (SAH) who underwent targeted endovascular treatment for focal symptomatic vasospasm. METHODS We identified all patients with SAH who had received targeted endovascular treatment during a 4-year period. We ascertained any new occurrence of symptomatic vasosopasm requiring endovascular treatment in previously unaffected (and untreated) arterial distributions within the same hospitalization. Blinded reviewers quantitatively graded angiographic vasospasm (<25, 26-49, ≥50 %) in all major arteries for each patient at the time of targeted treatment. RESULTS Of the 41 patients who received targeted endovascular treatment (PTA in 41 % and vasodilators in 59 %), 11 (27 %) developed new symptomatic vasospasm in previously asymptomatic vascular distributions requiring endovascular treatment. Moderate severity of angiographic vasospasm in asymptomatic arteries at the time of targeted treatment tended to predict the occurrence of new symptomatic vasospasm. The rate of death and disability at discharge [modified Rankin scale (mRS) of 3-6] was 82 % (9/11) among those who developed a new episode of symptomatic vasospasm compared with 70 % (21/30) in those who did not (P = 0.58). CONCLUSIONS High risk of new occurrence of ischemic symptoms in previously asymptomatic (and untreated) arterial distributions among patients receiving targeted treatment should be recognized. Further studies should evaluate the benefit of performing global endovascular treatment during the initial targeted endovascular treatment session.
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Affiliation(s)
- Wondwossen G Tekle
- Zeenat Qureshi Stroke Research Center and Department of Neurology, University of Minnesota, 420 Delaware St. SE. MMC 295, Minneapolis, MN, 55455, USA,
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Barboza MA, Maud A, Rodriguez GJ. Reversible cerebral vasoconstriction syndrome and nonaneurysmal subarachnoid hemorrhage. J Vasc Interv Neurol 2014; 7:17-20. [PMID: 25132905 PMCID: PMC4132938] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Reversible cerebral vasoconstriction syndrome was first described by Call, Fleming, and colleagues. Clinically this entity presents acutely, with severe waxing and waning headaches ("thunderclap"), and occasional fluctuating neurological signs. CASE PRESENTATION We present four subsequent cases of patients with severe thunderclap headache and brain tomography with evidence of subarachnoid hemorrhage. The brain angiogram showed no aneurysm but intracranial vasculopathy consistent with multiple areas of stenosis and dilatation (angiographic beading) in different territories. CONCLUSION Neurologists should be aware of Call Fleming syndrome presenting with severe headache and associated convexity subarachnoid hemorrhage. After other diagnoses are excluded, patients can be reassured about favorable prognosis with symptomatic management. ABBREVIATIONS RCVSReversible cerebral vasoconstriction syndromeCTComputed tomographySAHSubarachnoid hemorrhageMRMagnetic resonanceCTAComputed tomography angiographyMRAMagnetic resonance angiography.
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Affiliation(s)
- Miguel A Barboza
- Texas Tech University Health Sciences Center, Universidad de Costa Rica, El Paso, TX 79905-2709, USA
| | - Alberto Maud
- Department of Neurology and Radiology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center
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Qureshi AI, Gilani S, Adil MM, Majidi S, Hassan AE, Miley JT, Rodriguez GJ. Pattern of informed consent acquisition in patients undergoing emergent endovascular treatment for acute ischemic stroke. J Vasc Interv Neurol 2014; 7:21-25. [PMID: 25132906 PMCID: PMC4132944] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Telephone consent and two physician consents based on medical necessity are alternate strategies for time sensitive medical decisions but are not uniformly accepted for clinical practice or recruitment into clinical trials. We determined the rate of and associated outcomes with alternate consenting strategies in consecutive acute ischemic stroke patients receiving emergent endovascular treatment. METHODS We divided patients into those treated based on in-person consent and those based on alternate strategies. We identified clinical and procedural differences and differences in hospital outcomes: symptomatic ICH and favorable outcome (defined by modified Rankin Scale of 0-2 at discharge) based on consenting methodology. RESULTS Of a total of 159 patients treated, 119 were treated based on in-person consent (by the patient in 27 and legally authorized representative in 92 procedures). Another 40 patients were treated using alternate strategies (20 telephone consents and 20 two physician consents based on medical necessity). There was no difference in the mean ages and proportion of men among the two groups based on consenting methodology. There was a significantly greater time interval incurred between CT scan and initiation of endovascular procedure in those in whom in-person consent was obtained (117 ± 65 min versus 101 ± 45 min, p = 0.01). There was no significant difference in rates of ICH (9% versus 8%, p = 0.9), or favorable outcome at discharge (28% versus 30%, p = 0.8). CONCLUSIONS Consent through alternate strategies does not adversely affect procedural characteristics or outcome of patients and may be more time efficient than in-person consenting process.
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Affiliation(s)
| | | | - Malik M Adil
- Zeenat Qureshi Stroke Institute, St. Cloud, MN, USA
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Maud A, Rodriguez GJ, Barboza MA. Endovascular treatment of intracranial aneurysms by interventional neurologists: first year single-center experience. J Vasc Interv Neurol 2014; 7:13-16. [PMID: 25132904 PMCID: PMC4132939] [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: 06/03/2023]
Abstract
BACKGROUND Endovascular embolization of ruptured intracranial aneurysms provides an adequate treatment and long-term results with less morbidity and mortality (M&M) compared with surgical treatment. Since the last decade more and more ruptured and unruptured intracranial aneurysms (IA) undergo endovascular embolization in the United States. We present our experience of the initial one year periprocedural M&M at Paul L. Foster School of Medicine (PLFSM), Texas Tech Health Science Center (TTUHSC) in El Paso, Texas. METHODS Demographics, technical aspects of the endovascular procedure and clinical assessment, including several commonly used scales to assess the severity in case of subarachnoid hemorrhage were collected. Perioperative complications were classified as minor and major. All data is prospectively collected in a local database. Only endovascular treated aneurysms were included in the study. RESULTS During the first year of opening of the interventional neurology program at our school of medicine (March 2011 and March 2012), a total 45 ruptured and unruptured intracranial aneurysms were treated with endovascular embolization. Two thirds of the patients (n = 27) presented with a ruptured IA. Within those with a ruptured aneurysm, the most median Hunt and Hess grade was 3. By large the vast majority of treated IA were in the anterior circulation and more than half measured 7-12 mm. Only three unruptured IA were <7 mm (average 5.5 mm). Complications occurred in seven patients (15%), four of them were minor without any clinical sequelae. The remaining three included; intracranial dissection and aneurysmal rupture resulting in both hemorrhagic or ischemic stroke and death in only one patient. CONCLUSION The first year experience of interventional neurology services at Paul L. Foster School of Medicine in El Paso, Texas demonstrates successful treatments with comparable national rates of morbidity and mortality. ABBREVIATIONS ACAAnterior cerebral arteryAcommAnterior communicating arteryESNEndovascular surgical neuroradiologyH&HHunt and Hess scaleIAIntracranial aneurysmICAInternal carotid arteryMCAMiddle cerebral arteryM&MMorbidity and mortalitySAHSubarachnoid hemorrhagePcommPosterior communicating arteryPLFSMPaul L. Foster School of MedicineTTUHSCTexas Tech University Health Science CenterVAVertebral artery.
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Affiliation(s)
- Alberto Maud
- Department of Neurology and Radiology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Gustavo J Rodriguez
- Department of Neurology, Paul L. Foster School of Medicine, Texas Tech University Health Sciences Center, El Paso, TX, USA
| | - Miguel A Barboza
- Texas Tech University Health Sciences Center, Universidad de Costa Rica, El Paso, TX, USA
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