Try a new search

Format these results:

Searched for:

person:arcotk01

in-biosketch:true

Total Results:

33


Recurrence and Coniglobus Volumetric Resolution of Subacute and Chronic Subdural Hematoma Post-Middle Meningeal Artery Embolization

Tiwari, Ambooj; Dmytriw, Adam A; Bo, Ryan; Farkas, Nathan; Ye, Phillip; Gordon, David S; Arcot, Karthikeyan M; Turkel-Parrella, David; Farkas, Jeffrey
OBJECTIVE:To study the efficacy of middle meningeal artery (MMA) embolization for the treatment of chronic subdural hematoma (SDH) and characterize its post-embolization volumetric resolution. METHODS:Ten patients diagnosed with 13 cSDH underwent MMA embolization. SDH volumes were measured from time of initial discovery on imaging to pre-operative, post-operative, short-term and long-term follow-up. Time between procedure to obliteration was also measured. Volumetric analysis was done using the coniglobus formula, and recurrence rate as well as resolution timeline was defined using best-fit models. RESULTS:Out of 10 patients, five were recurrent lesions, three were bilateral and seven unilateral cSDH. Average and median pre-operative volumes were 105.3 cc and 97.4 cc, respectively. Embolization on average was performed 21 days after discovery. Sixty percent of patients had concurrent antiplatelets or anticoagulation use. Forty percent underwent embolization treatment as the primary therapy. Recurrence was not seen in any patients treated with embolization. There were no peri- or post-operative complications. Five patients experienced complete or near-complete obliteration, while those with partial resolution showed a composite average of 75% volumetric reduction in 45 days. Post-embolization, the volumetric resolution followed an exponential decay curve over time and was independent of initial volume. CONCLUSION/CONCLUSIONS:MMA embolization contributed to a marked reduction in SDH volume post-operatively and can be used as a curative therapy for primary or recurrent chronic SDH.
PMID: 33562252
ISSN: 2075-4418
CID: 4779642

Acute stroke care in a New York City comprehensive stroke center during the COVID-19 pandemic

Agarwal, Shashank; Scher, Erica; Rossan-Raghunath, Nirmala; Marolia, Dilshad; Butnar, Mariya; Torres, Jose; Zhang, Cen; Kim, Sun; Sanger, Matthew; Humbert, Kelley; Tanweer, Omar; Shapiro, Maksim; Raz, Eytan; Nossek, Erez; Nelson, Peter K; Riina, Howard A; de Havenon, Adam; Wachs, Michael; Farkas, Jeffrey; Tiwari, Ambooj; Arcot, Karthikeyan; Parella, David Turkel; Liff, Jeremy; Wu, Tina; Wittman, Ian; Caldwell, Reed; Frontera, Jennifer; Lord, Aaron; Ishida, Koto; Yaghi, Shadi
BACKGROUND AND PURPOSE/OBJECTIVE:The coronavirus disease-2019 (COVID-19) pandemic caused unprecedented demand and burden on emergency health care services in New York City. We aim to describe our experience providing acute stroke care at a comprehensive stroke center (CSC) and the impact of the pandemic on the quality of care for patients presenting with acute ischemic stroke (AIS). METHODS:We retrospectively analyzed data from a quality improvement registry of consecutive AIS patients at New York University Langone Health's CSC between 06/01/2019-05/15/2020. During the early stages of the pandemic, the acute stroke process was modified to incorporate COVID-19 screening, testing, and other precautionary measures. We compared stroke quality metrics including treatment times and discharge outcomes of AIS patients during the pandemic (03/012020-05/152020) compared with a historical pre-pandemic group (6/1/2019-2/29/2020). RESULTS:A total of 754 patients (pandemic-120; pre-pandemic-634) were admitted with a principal diagnosis of AIS; 198 (26.3%) received alteplase and/or mechanical thrombectomy. Despite longer median door to head CT times (16 vs 12 minutes; p = 0.05) and a trend towards longer door to groin puncture times (79.5 vs. 71 min, p = 0.06), the time to alteplase administration (36 vs 35 min; p = 0.83), door to reperfusion times (103 vs 97 min, p = 0.18) and defect-free care (95.2% vs 94.7%; p = 0.84) were similar in the pandemic and pre-pandemic groups. Successful recanalization rates (TICI≥2b) were also similar (82.6% vs. 86.7%, p = 0.48). After adjusting for stroke severity, age and a prior history of transient ischemic attack/stroke, pandemic patients had increased discharge mortality (adjusted OR 2.90 95% CI 1.77 - 7.17, p = 0.021) CONCLUSION: Despite unprecedented demands on emergency healthcare services, early multidisciplinary efforts to adapt the acute stroke treatment process resulted in keeping the stroke quality time metrics close to pre-pandemic levels. Future studies will be needed with a larger cohort comparing discharge and long-term outcomes between pre-pandemic and pandemic AIS patients.
PMCID:7305900
PMID: 32807471
ISSN: 1532-8511
CID: 4565632

Mechanical Thrombectomy in Nonagenarians: A Propensity Score Matched Analysis

Agarwal, Shashank; Huang, Jeffrey; Scher, Erica; Farkas, Jeffrey; Arcot, Karthikeyan; Gordon, David; Turkel-Parrella, David; Tiwari, Ambooj; Liff, Jeremy; Yaghi, Shadi; Dehkharghani, Seena; Ishida, Koto; Riina, Howard; Frontera, Jennifer A
BACKGROUND:Little data exists on outcomes of mechanical thrombectomy (MT) in nonagenarians. We aimed to compare the procedural and discharge outcomes of MT for acute ischemic stroke (AIS) in nonagenarians versus younger patients. METHODS:Procedural outcomes and discharge disposition were compared in propensity score-matched groups of nonagenarians versus patients aged≤69 with AIS who underwent MT. Patients aged 70-89 were excluded in order to compare nonagenarians to a younger cohort that most closely approximates the age of patients in the seminal MT trials. Good discharge disposition was defined as a discharge to home or acute rehabilitation. RESULTS:Of 3010 AIS patients, 46/297(16%) nonagenarians underwent MT compared to 159/1337(12%) aged≤69 (P = 0.091). Of 78 propensity score-matched patients (N = 39 ≥90, N = 39 ≤69), the median admission NIHSS was 22 versus 20, median ASPECTS was 9 versus 9, pre-stroke mRS<4 was 82% versus 87%, 18% versus 8% received IV tPA, and mTICI≥2b was 90% versus 90%, respectively (all P>0.05). Revascularization time (569 versus 372 min), door to groin puncture time (82 versus 71 min) and groin puncture to revascularization times (39 versus 24 min) were similar in between nonagenarians and ≤69, respectively (both P>0.05). Symptomatic ICH (2.6% versus 10.3%; p = 0.165) and in-hospital death rates (10% vs 26%; p = 0.077) trended lower among nonagenarians versus aged≤69. Good discharge disposition occurred in 44% of nonagenarians versus 51% aged≤69 years (p = 0.496). CONCLUSIONS:In propensity score analysis, 90% of nonagenarians achieved successful recanalization and almost half (44%) were discharged to home/acute rehabilitation, which was similar to a younger (aged≤69 years) cohort.
PMID: 32414578
ISSN: 1532-8511
CID: 4438332

Carotid intimal sarcoma causing stroke and intracranial metastasis via tumor embolization

Agarwal, Shashank; Derman, Anna; Raz, Eytan; Hoda, Syed T; Arcot, Karthikeyan; Yaghi, Shadi; Sanger, Matthew; Kim, Sun; Galetta, Steven
OBJECTIVE:To present the clinical, radiologic, and pathologic findings of a patient with carotid intimal sarcoma. METHODS:Detailed medical interview, neurologic examination, and diagnostic evaluation including CT angiography head and neck, MRI brain and neck, digital subtraction angiography, and biopsy of the mass were performed. RESULTS:We report a patient who presented with symptoms of multifocal, bilateral strokes over weeks caused by an enlarging tumor thrombus associated with an intimal sarcoma of the carotid artery. The presence of a carotid space mass encasing the left internal carotid artery was initially not recognized on imaging and was mistakenly attributed to soft atheromatous plaque rather than tumor thrombus. Rapid disease progression resulted in multiple intracranial metastases from tumor embolization. CONCLUSION/CONCLUSIONS:Clinical and radiologic findings of intimal sarcoma may be similar to those of thrombotic disease. However, patients with sarcoma may show an associated perivascular soft tissue mass and an unusual distribution of vessel stenosis. Reevaluation of imaging should be considered in patients presenting with initial imaging findings suggestive of rapidly progressive thrombotic disease who have a poor response to antithrombotic therapy and do not follow an expected clinical course.
PMID: 31949089
ISSN: 1526-632x
CID: 4263952

Safety and Efficacy of Flow Reversal in Acute and Elective Carotid Angioplasty and Stenting Using the Mo.Ma Device with Short-Term Follow-Up

Tiwari, Ambooj; Bo, Ryan; Sivakumar, Keithan; Arcot, Karthikeyan M; Ye, Philip; Parrella, David T; Farkas, Jeffrey
Objective/UNASSIGNED:To determine the safety and efficacy of flow reversal following proximal flow arrest as an embolic protection strategy for carotid angioplasty and stenting (CAS) with short-term follow-up. Method/UNASSIGNED:We performed a retrospective review of our CAS database for patients who underwent stent-supported carotid revascularization in the setting of acute/subacute stroke or TIA. We reviewed clinical and radiographic data during a 36-month period. Primary outcome was clinical evidence of ipsilateral stroke in the first 30 days. Secondary outcomes include clinical outcomes and sonographic and/or angiographic follow-up over 6 months, 6-month functional scale, and all-cause mortality. Results/UNASSIGNED:Fifty-five patients underwent CAS using flow reversal: 26 females and 29 males with a mean age of 69.7 years. Median time to treatment from index event was 3 days. 11% underwent stenting as part of hyperacute stroke therapy. Average luminal stenosis was 86%. The 9-Fr Mo.Ma device was used in combination with Penumbra aspiration in all cases. There were no ipsilateral strokes. Incidence of any ischemic event was 3.64%, but only 1 (1.82%) patient had a postoperative stroke. Clinical follow-up was available for 94.5%, while lesion follow-up was available for 73% of patients. Three patients had evidence of restenosis, but none were symptomatic. Luminal restenosis was ≤30% in all three. Median pre- and post-NIHSS were 1 and 1, respectively. Conclusion/UNASSIGNED:Flow reversal using the Mo.Ma device is a safe and effective strategy in preventing distal embolization during carotid artery revascularization.
PMCID:7253868
PMID: 32508902
ISSN: 1664-9737
CID: 4474492

Association Between Functional Outcomes of Stroke Patients Receiving Mechanical Thrombectomy and CT Perfusion Imaging Acquisition [Meeting Abstract]

Agarwal, Shashank; Mistry, Eva; Scher, Erica; Kim, Sun; Sanger, Matthew; Humbert, Kelley; Ishida, Koto; Torres, Jose; Rostanski, Sara; Zhang, Cen; Arcot, Karthikeyan; Turkel-Parrella, David; Farkas, Jeffrey; Raz, Eytan; Gordon, David; Riina, Howard; Shapiro, Maksim; Tanweer, Omar; Nossek, Erez; Nelson, Peter; Lord, Aaron; Frontera, Jennifer; Yaghi, Shadi
ISI:000536058002105
ISSN: 0028-3878
CID: 4561212

Etiologic Subtypes of Ischemic Stroke in SARS-CoV-2 Patients in a Cohort of New York City Hospitals

Tiwari, Ambooj; Berekashvili, Ketevan; Vulkanov, Volodomyr; Agarwal, Shashank; Khaneja, Amit; Turkel-Parella, David; Liff, Jeremy; Farkas, Jeffrey; Nandakumar, Thambirajah; Zhou, Ting; Frontera, Jennnifer; Kahn, David E; Kim, Sun; Humbert, Kelly A; Sanger, Matthew D; Yaghi, Shadi; Lord, Aaron; Arcot, Karthikeyan; Dmytriw, Adam A
Objective: To describe the ischemic stroke subtypes related to coronavirus disease 2019 (COVID-19) in a cohort of New York City hospitals and explore their etiopathogenesis. Background: Most neurological manifestations are non-focal, but few have reported the characteristics of ischemic strokes or investigated its pathophysiology. Methods: Data were collected prospectively April 1-April 15, 2020 from two centers in New York City to review possible ischemic stroke types seen in COVID-19-positive patients. Patient presentation, demographics, related vascular risk factors, associated laboratory markers, as well as imaging and outcomes were collected. Results: The age of patients ranged between 27 and 82 years. Approximately 81% of patients had known vascular risk factors, the commonest being hypertension (75%) followed by diabetes (50%) coronary disease or atrial fibrillation. Eight patients presented with large vessel occlusion (LVO) with median age 55 years (27-82) and all were male. Eight patients presented with non-LVO syndromes, with median age 65.5 years (59-82) and most were female (62.5%). Both groups were 50% African Americans and 37.5% South Asian. Both groups had similar D-dimer levels although other acute phase reactants/disease severity markers (Ferritin, CRP, procalcitonin) were higher in the LVO group. The LVO group also had a significantly higher mortality compared to the non-LVO group. The most common etiology was cryptogenic (6 patients) followed by small vessel occlusion (3 patients) and undetermined-unclassified (3 patients). For the remaining 4 patients, 2 were identified as cardioembolic and 2 with large artery atherosclerosis. Conclusion: COVID-19-related ischemic events can present as small vessel occlusions, branch emboli or large vessel occlusions. The most common etiology is cryptogenic. Patients with LVO syndromes tend to be younger, male and may have elevated acute inflammatory markers.
PMCID:7527497
PMID: 33041972
ISSN: 1664-2295
CID: 4632392

Recurrence and volumetric resolution of subacute and chronic subdural hematoma post-middle meningeal artery embolization [Meeting Abstract]

Farkas, N; Tiwari, A; Gordon, D; Arcot, K; Turkel-Perrella, D; Bo, R; Ye, P; Farkas, J
Objective: To study the efficacy of Middle Meningeal Artery (MMA) embolization for treatment of chronic subdural hematoma (SDH) and characterize its post-embolization volumetric resolution.
Background(s): Chronic subdural hematoma (cSDH) can be associated with slow neurological deterioration and increased mortality. Open surgical treatment may not always be feasible or successful. Recurrence has been estimated in among 10-20% of cases. MMA embolization has become a new approach used for both initial treatment and for recalcitrant lesions.
Method(s): 10 patients diagnosed with 13 cSDH underwent MMA embolization. SDH volume were measured from time of initial discovery on imaging to pre-operative, post-operative, short-term and long-term follow-up. Time between procedure to obliteration was also measured. Volumetric analysis was done using the 'Coniglobus' formula and recurrence rate as well as resolution timeline was defined using best-fit models.
Result(s): Out of 10 patients; 5 were recurrent lesions, 3 were bilateral and 7 unilateral cSDH. Average and median preoperative volumes were 105.3 cc and 97.4 cc, respectively. Embolization on average was performed 21 days after discovery. 60 percent of patients had concurrent use of antiplatelets or anticoagulation. 40% patients had embolization treatment as a primary modality. Recurrence was not seen in any patients treated with embolization. There was no peri- or post-operative complication. 5 patients reported complete or near-complete obliteration while those with partial resolution showed a composite average of 75% volumetric reduction in 45 days. Postembolization the volumetric resolution followed an exponential decay curve over time and was independent of initial volume.
Conclusion(s): MMA embolization is assosciated with a marked reduction in SDH volume post-operatively and can be used as a curative therapy for primary or recurrent SDH
EMBASE:631518560
ISSN: 1531-8249
CID: 4399842

Mechanical thrombectomy in the oldest of the old: A propensity score-matched analysis. is 90 the new 60? [Meeting Abstract]

Agarwal, S; Huang, J; Ishida, K; Riina, H; Turkel-Parella, D; Liff, J; Farkas, J; Arcot, K; Frontera, J A
Introduction The 5 seminal mechanical thrombectomy (MT) trials had a median age of 68 years. Though some of these trials included nonagenarians, there is little data on their outcomes. We aimed to compare the procedural, discharge outcomes and complications, of MT for acute ischemic stroke (AIS) in nonagenarians versus younger patients(<=69) Methods Patients with AIS admitted to two comprehensive stroke centers were enrolled prospectively in a registry. Rates of MT were compared between nonagenarians vs <=69. Among those who underwent MT, procedural outcomes, complications, and discharge disposition were compared in propensity scorematched groups (matched for NIHSS, pre-stroke mRS, IV-tPA administration and T IG grade>=2b) of nonagenarians to patients<=69. Good discharge disposition was defined as a discharge to home/acute rehabilitation. Results Of the 3010 AIS patients, 46/297 (16%) nonagenarians underwent MT compared to 159/1337 (12%) patients <=69 (P=0.091) with TICI>=2b of 89% vs 94%; p=0.238 respectively. 78 patients (N=39 >=90, N=39 <69) were propensity score-matched with a median admission NIHSS of 22 and 19, and median ASPECTS of 9 and 9, respectively (both P>0.05). Those <69 more often had Ml occlusions than nonagenarians (84% vs 50%, P=0.035), whereas ICA (10% vs 13%, p=0.76), and M2 (21% vs 43%, p=0.19) occlusions were similar between the two groups. Time to groin puncture (100+/-65 vs 76+/-34; p=0.124), revascularization time (134+/-72 vs 110+/-54; p=0.145), complication rates (0 vs 5.1%; p=0.494) and inhospital deaths (11% vs 24%; p=0.155) were similar among the two groups. 44% of nonagenarians had good discharge disposition, compared to 51% of patients <69 years (p=0.650) Conclusions We present one of the largest series of MT among nonagenarians with 89% successful recanalization rates. In propensity score analysis almost half of nonagenarians (44%) were discharged to home/rehab, which is comparable to a younger cohort (51%). Aggressive management is warranted in the oldest of the old
EMBASE:631884823
ISSN: 1556-0961
CID: 4472832

Subclavian steal syndrome due to dialysis fistula corrected with subclavian artery stenting

Agarwal, Shashank; Schwartz, Lisa; Kwon, Patrick; Selas, George; Farkas, Jeffrey; Arcot, Karthikeyan; Tiwari, Ambooj
PMCID:6276325
PMID: 30564504
ISSN: 2163-0402
CID: 3556582