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Blood Pressure Trajectories and Outcomes After Endovascular Thrombectomy for Acute Ischemic Stroke

Katsanos, Aristeidis H; Joundi, Raed A; Palaiodimou, Lina; Ahmed, Niaz; Kim, Joon-Tae; Goyal, Nitin; Maier, Ilko L; de Havenon, Adam; Anadani, Mohammad; Matusevicius, Marius; Mistry, Eva A; Khatri, Pooja; Arthur, Adam S; Sarraj, Amrou; Yaghi, Shadi; Shoamanesh, Ashkan; Catanese, Luciana; Psychogios, Marios-Nikos; Tsioufis, Konstantinos; Malhotra, Konark; Spiotta, Alejandro M; Sandset, Else Charlotte; Alexandrov, Andrei V; Petersen, Nils H; Tsivgoulis, Georgios
BACKGROUND/UNASSIGNED:Data on systolic blood pressure (SBP) trajectories in the first 24 hours after endovascular thrombectomy (EVT) in acute ischemic stroke are limited. We sought to identify these trajectories and their relationship to outcomes. METHODS/UNASSIGNED:We combined individual-level data from 5 studies of patients with acute ischemic stroke who underwent EVT and had individual blood pressure values after the end of the procedure. We used group-based trajectory analysis to identify the number and shape of SBP trajectories post-EVT. We used mixed effects regression models to identify associations between trajectory groups and outcomes adjusting for potential confounders and reported the respective adjusted odds ratios (aORs) and common odds ratios. RESULTS/UNASSIGNED:There were 2640 total patients with acute ischemic stroke included in the analysis. The most parsimonious model identified 4 distinct SBP trajectories, that is, general directional patterns after repeated SBP measurements: high, moderate-high, moderate, and low. Patients in the higher blood pressure trajectory groups were older, had a higher prevalence of vascular risk factors, presented with more severe stroke syndromes, and were less likely to achieve successful recanalization after the EVT. In the adjusted analyses, only patients in the high-SBP trajectory were found to have significantly higher odds of early neurological deterioration (aOR, 1.84 [95% CI, 1.20-2.82]), intracranial hemorrhage (aOR, 1.84 [95% CI, 1.31-2.59]), mortality (aOR, 1.75 [95% CI, 1.21-2.53), death or disability (aOR, 1.63 [95% CI, 1.15-2.31]), and worse functional outcomes (adjusted common odds ratio,1.92 [95% CI, 1.47-2.50]). CONCLUSIONS/UNASSIGNED:Patients follow distinct SBP trajectories in the first 24 hours after an EVT. Persistently elevated SBP after the procedure is associated with unfavorable short-term and long-term outcomes.
PMID: 38164751
ISSN: 1524-4563
CID: 5635172

Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection: The STOP-CAD Study

Yaghi, Shadi; Shu, Liqi; Mandel, Daniel M; Leon Guerrero, Christopher R; Henninger, Nils; Muppa, Jayachandra; Affan, Muhammad; Ul Haq Lodhi, Omair; Heldner, Mirjam R; Antonenko, Kateryna; Seiffge, David J; Arnold, Marcel; Salehi Omran, Setareh; Crandall, Ross Curtiss; Lester, Evan; Lopez Mena, Diego; Arauz, Antonio; Nehme, Ahmad; Boulanger, Marion; Touzé, Emmanuel; Sousa, João André; Sargento-Freitas, Joao; Barata, Vasco; Castro-Chaves, Paulo; Brito, Maria Teresa Álvares Pereira; Khan, Muhib; Mallick, Dania; Rothstein, Aaron; Khazaal, Ossama; Kaufmann, Josefin; Engelter, Stefan T; Traenka, Christopher; Aguiar de Sousa, Diana; Soares, Mafalda; Rosa, Sara Db; Zhou, Lily W; Gandhi, Preet; Field, Thalia S; Mancini, Steven; Metanis, Issa; Leker, Ronen R; Pan, Kelly; Dantu, Vishnu; Baumgartner, Karl Viktor; Burton, Tina M; Freiin von Rennenberg, Regina; Nolte, Christian H; Choi, Richard K; MacDonald, Jason A; Bavarsad Shahripour, Reza; Guo, Xiaofan; Ghannam, Malik; AlMajali, Mohammad; Samaniego, Edgar A; Sanchez, Sebastian; Rioux, Bastien; Zine-Eddine, Faycal; Poppe, Alexandre Y; Fonseca, Ana Catarina; Baptista, Maria; Cruz, Diana; Romoli, Michele; De Marco, Giovanna; Longoni, Marco; Keser, Zafer; Griffin, Kim J; Kuohn, Lindsey; Frontera, Jennifer A; Amar, Jordan; Giles, James A; Zedde, Marialuisa; Pascarella, Rosario; Grisendi, Ilaria; Nzwalo, Hipólito; Liebeskind, David S; Molaie, Amir M; Cavalier, Annie; Kam, Wayneho; Mac Grory, Brian; Al Kasab, Sami; Anadani, Mohammad; Kicielinski, Kimberly P; Eltatawy, Ali Rada; Chervak, Lina M; Chulluncuy-Rivas, Roberto; Aziz, Yasmin Ninette; Bakradze, Ekaterina; Tran, Thanh Lam; Rodrigo-Gisbert, Marc; Requena, Manuel; Saleh Velez, Faddi Ghassan; Ortiz Garcia, Jorge G; Muddasani, Varsha; de Havenon, Adam; Vishnu, Venugopalan Y; Yaddanapudi, Sridhara S; Adams, Latasha; Browngoehl, Abigail; Ranasinghe, Tamra; Dunston, Randy; Lynch, Zachary; Penckofer, Mary; Siegler, James E; Mayer, Silvia V; Willey, Joshua Z; Zubair, Adeel S; Cheng, Yee Kuang; Sharma, Richa; Marto, João Pedro; Mendes Ferreira, Vitor; Klein, Piers; Nguyen, Thanh N; Asad, Syed Daniyal; Sarwat, Zoha; Balabhadra, Anvesh; Patel, Shivam; Secchi, Thais Leite; Martins, Sheila Co; Mantovani, Gabriel Paulo; Kim, Young Dae; Krishnaiah, Balaji; Elangovan, Cheran; Lingam, Sivani; Qureshi, Abid Y; Fridman, Sebastian; Alvarado-Bolaños, Alonso; Khasiyev, Farid; Linares, Guillermo; Mannino, Marina; Terruso, Valeria; Vassilopoulou, Sofia; Tentolouris-Piperas, Vasileios; Martínez-Marino, Manuel; Carrasco Wall, Víctor A; Indraswari, Fransisca; El Jamal, Sleiman; Liu, Shilin; Alvi, Muhammad; Ali, Farman; Sarvath, Mohammed Madani; Morsi, Rami Z; Kass-Hout, Tareq; Shi, Feina; Zhang, Jinhua; Sokhi, Dilraj; Said, Jamil; Simpkins, Alexis N; Gomez, Roberto; Sen, Shayak; Ghani, Mohammad Ravi; Elnazeir, Marwa; Xiao, Han; Kala, Narendra Sharma; Khan, Farhan; Stretz, Christoph; Mohammadzadeh, Nahid; Goldstein, Eric D; Furie, Karen L
PMID: 38335240
ISSN: 1524-4628
CID: 5632012

Use of Carotid Web Angioarchitecture for Stroke Risk Assessment

von Oiste, Grace G; Sangwon, Karl L; Chung, Charlotte; Narayan, Vinayak; Raz, Eytan; Shapiro, Maksim; Rutledge, Caleb; Nelson, Peter Kim; Ishida, Koto; Torres, Jose L; Rostanski, Sara K; Zhang, Cen; Yaghi, Shadi; Riina, Howard; Oermann, Eric K; Nossek, Erez
OBJECTIVE:To examine the usefulness of carotid web (CW), carotid bifurcation and their combined angioarchitectural measurements in assessing stroke risk. METHODS:Anatomic data on the internal carotid artery (ICA), common carotid artery (CCA), and the CW were gathered as part of a retrospective study from symptomatic (stroke) and asymptomatic (nonstroke) patients with CW. We built a model of stroke risk using principal-component analysis, Firth regression trained with 5-fold cross-validation, and heuristic binary cutoffs based on the Minimal Description Length principle. RESULTS:The study included 22 patients, with a mean age of 55.9 ± 12.8 years; 72.9% were female. Eleven patients experienced an ischemic stroke. The first 2 principal components distinguished between patients with stroke and patients without stroke. The model showed that ICA-pouch tip angle (P = 0.036), CCA-pouch tip angle (P = 0.036), ICA web-pouch angle (P = 0.036), and CCA web-pouch angle (P = 0.036) are the most important features associated with stroke risk. Conversely, CCA and ICA anatomy (diameter and angle) were not found to be risk factors. CONCLUSIONS:This pilot study shows that using data from computed tomography angiography, carotid bifurcation, and CW angioarchitecture may be used to assess stroke risk, allowing physicians to tailor care for each patient according to risk stratification.
PMID: 38006939
ISSN: 1878-8769
CID: 5617512

Continued Infarction Growth and Penumbral Consumption After Reperfusion in Vaccine-Naïve Patients With COVID-19: A Case-Control Study

Dehkharghani, Seena; Vogel, Andre; Jandhyala, Nora; Chung, Charlotte; Shu, Liqi; Frontera, Jennifer; Yaghi, Shadi
PMID: 37195793
ISSN: 1546-3141
CID: 5544252

Large Vessel Occlusion Stroke due to Intracranial Atherosclerotic Disease: Identification, Medical and Interventional Treatment, and Outcomes

de Havenon, Adam; Zaidat, Osama O; Amin-Hanjani, Sepideh; Nguyen, Thanh N; Bangad, Aaron; Abbasi, Mehdi; Anadani, Mohammad; Almallouhi, Eyad; Chatterjee, Rano; Mazighi, Mikael; Mistry, Eva A; Yaghi, Shadi; Derdeyn, Colin P; Hong, Keun-Sik; Kvernland, Alexandra; Leslie-Mazwi, Thabele M; Al Kasab, Sami
Large vessel occlusion stroke due to underlying intracranial atherosclerotic disease (ICAD-LVO) is prevalent in 10 to 30% of LVOs depending on patient factors such as vascular risk factors, race and ethnicity, and age. Patients with ICAD-LVO derive similar functional outcome benefit from endovascular thrombectomy as other mechanisms of LVO, but up to half of ICAD-LVO patients reocclude after revascularization. Therefore, early identification and treatment planning for ICAD-LVO are important given the unique considerations before, during, and after endovascular thrombectomy. In this review of ICAD-LVO, we propose a multistep approach to ICAD-LVO identification, pretreatment and endovascular thrombectomy considerations, adjunctive medications, and medical management. There have been no large-scale randomized controlled trials dedicated to studying ICAD-LVO, therefore this review focuses on observational studies.
PMCID:10202848
PMID: 36938708
ISSN: 1524-4628
CID: 5502452

Bilateral Medial Medullary Infarction: The Airpod Sign

Agarwal, Shashank; Raz, Eytan; Yaghi, Shadi
PMID: 36756878
ISSN: 1524-4628
CID: 5420912

Association between blood pressure variability and outcomes after endovascular thrombectomy for acute ischemic stroke: An individual patient data meta-analysis

Palaiodimou, Lina; Joundi, Raed A.; Katsanos, Aristeidis H.; Ahmed, Niaz; Kim, Joon Tae; Goyal, Nitin; Maier, Ilko L.; de Havenon, Adam; Anadani, Mohammad; Matusevicius, Marius; Mistry, Eva A.; Khatri, Pooja; Arthur, Adam S.; Sarraj, Amrou; Yaghi, Shadi; Shoamanesh, Ashkan; Catanese, Luciana; Psychogios, Marios Nikos; Malhotra, Konark; Spiotta, Alejandro M.; Vassilopoulou, Sofia; Tsioufis, Konstantinos; Sandset, Else Charlotte; Alexandrov, Andrei V.; Petersen, Nils; Tsivgoulis, Georgios
Introduction: Data on the association between blood pressure variability (BPV) after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) and outcomes are limited. We sought to identify whether BPV within the first 24 hours post EVT was associated with key stroke outcomes. Methods: We combined individual patient-data from five studies among AIS-patients who underwent EVT, that provided individual BP measurements after the end of the procedure. BPV was estimated as either systolic-BP (SBP) standard deviation (SD) or coefficient of variation (CV) over 24 h post-EVT. We used a logistic mixed-effects model to estimate the association [expressed as adjusted odds ratios (aOR)] between tertiles of BPV and outcomes of 90-day mortality, 90-day death or disability [modified Rankin Scale-score (mRS) > 2], 90-day functional impairment (⩾1-point increase across all mRS-scores), and symptomatic intracranial hemorrhage (sICH), adjusting for age, sex, stroke severity, co-morbidities, pretreatment with intravenous thrombolysis, successful recanalization, and mean SBP and diastolic-BP levels within the first 24 hours post EVT. Results: There were 2640 AIS-patients included in the analysis. The highest tertile of SBP-SD was associated with higher 90-day mortality (aOR:1.44;95% CI:1.08"“1.92), 90-day death or disability (aOR:1.49;95% CI:1.18"“1.89), and 90-day functional impairment (adjusted common OR:1.42;95% CI:1.18"“1.72), but not with sICH (aOR:1.22;95% CI:0.76"“1.98). Similarly, the highest tertile of SBP-CV was associated with higher 90-day mortality (aOR:1.33;95% CI:1.01"“1.74), 90-day death or disability (aOR:1.50;95% CI:1.19"“1.89), and 90-day functional impairment (adjusted common OR:1.38;95% CI:1.15"“1.65), but not with sICH (aOR:1.33;95% CI:0.83"“2.14). Conclusions: BPV after EVT appears to be associated with higher mortality and disability, independently of mean BP levels within the first 24 h post EVT. BPV in the first 24 h may be a novel target to improve outcomes after EVT for AIS.
SCOPUS:85175984208
ISSN: 2396-9873
CID: 5616252

Life stressors significantly impact long-term outcomes and post-acute symptoms 12-months after COVID-19 hospitalization

Frontera, Jennifer A; Sabadia, Sakinah; Yang, Dixon; de Havenon, Adam; Yaghi, Shadi; Lewis, Ariane; Lord, Aaron S; Melmed, Kara; Thawani, Sujata; Balcer, Laura J; Wisniewski, Thomas; Galetta, Steven L
BACKGROUND:Limited data exists evaluating predictors of long-term outcomes after hospitalization for COVID-19. METHODS:We conducted a prospective, longitudinal cohort study of patients hospitalized for COVID-19. The following outcomes were collected at 6 and 12-months post-diagnosis: disability using the modified Rankin Scale (mRS), activities of daily living assessed with the Barthel Index, cognition assessed with the telephone Montreal Cognitive Assessment (t-MoCA), Neuro-QoL batteries for anxiety, depression, fatigue and sleep, and post-acute symptoms of COVID-19. Predictors of these outcomes, including demographics, pre-COVID-19 comorbidities, index COVID-19 hospitalization metrics, and life stressors, were evaluated using multivariable logistic regression. RESULTS:Of 790 COVID-19 patients who survived hospitalization, 451(57%) completed 6-month (N = 383) and/or 12-month (N = 242) follow-up, and 77/451 (17%) died between discharge and 12-month follow-up. Significant life stressors were reported in 121/239 (51%) at 12-months. In multivariable analyses, life stressors including financial insecurity, food insecurity, death of a close contact and new disability were the strongest independent predictors of worse mRS, Barthel Index, depression, fatigue, and sleep scores, and prolonged symptoms, with adjusted odds ratios ranging from 2.5 to 20.8. Other predictors of poor outcome included older age (associated with worse mRS, Barthel, t-MoCA, depression scores), baseline disability (associated with worse mRS, fatigue, Barthel scores), female sex (associated with worse Barthel, anxiety scores) and index COVID-19 severity (associated with worse Barthel index, prolonged symptoms). CONCLUSIONS:Life stressors contribute substantially to worse functional, cognitive and neuropsychiatric outcomes 12-months after COVID-19 hospitalization. Other predictors of poor outcome include older age, female sex, baseline disability and severity of index COVID-19.
PMCID:9637014
PMID: 36379135
ISSN: 1878-5883
CID: 5383312

Borderzone infarction and recurrent stroke in intracranial atherosclerosis

Kvernland, Alexandra; Torres, Jose; Raz, Eytan; Nossek, Erez; de Havenon, Adam; Gebregziabher, Mulugeta; Khatri, Pooja; Prabhakaran, Shyam; Liebeskind, David S; Yaghi, Shadi
BACKGROUND:Intracranial stenosis (ICAS) is a common cause of stroke worldwide and patients with symptomatic ICAS exhibit a high rate of recurrence, particularly in the early period after the initial event. In this study, we aimed to study the association between borderzone infarct and recurrent ischemic stroke in patients hospitalized with symptomatic ICAS. METHODS:This is a retrospective single center study that included patients hospitalized with acute ischemic stroke in the setting of intracranial stenosis (50% or more and an acute ischemic stroke in the territory supplied by the stenosed artery) over a 32-month period. We excluded patients who did not receive a brain MRI or did not have an infarct on brain imaging. The primary predictor is infarct pattern (any borderzone vs. no borderzone infarct) and the primary outcome was recurrent cerebrovascular events (RCVE) within 90 days. We used unadjusted, and age and sex adjusted logistic regression models to determine associations between infarct pattern and RCVE at 90-days. RESULTS:Among 99 patients who met the inclusion criteria (4 tandem), the mean age was 70.1 ± 11.2 years and 41.4% were women; 43 had borderzone infarcts and 19 had RCVE. In adjusted binary logistic regression analysis, borderzone infarct was associated with increased risk of RCVE (adjusted OR 4.00 95% CI 1.33-11.99, p=0.013). The association between borderzone infarction and RCVE was not different among anterior circulation ICAD (adjusted HR 2.85 95% CI 0.64-12.76, p=0.172) vs. posterior circulation ICAD (adjusted HR 6.69 95% CI 1.06-42.11, p=0.043), p-value for interaction = 0.592. CONCLUSION/CONCLUSIONS:In real world post-SAMMPRIS medically treated patients with ICAD, the borderzone infarct pattern was associated with 90-day RCVE. Borderzone infarcts are likely a surrogate marker of impaired distal blood flow, highlighting the importance of targeting stroke mechanisms and developing alternative treatment strategies for high-risk cohorts.
PMID: 36402094
ISSN: 1532-8511
CID: 5371792

Trajectories of Neurologic Recovery 12 Months After Hospitalization for COVID-19: A Prospective Longitudinal Study

Frontera, Jennifer A; Yang, Dixon; Medicherla, Chaitanya; Baskharoun, Samuel; Bauman, Kristie; Bell, Lena; Bhagat, Dhristie; Bondi, Steven; Chervinsky, Alexander; Dygert, Levi; Fuchs, Benjamin; Gratch, Daniel; Hasanaj, Lisena; Horng, Jennifer; Huang, Joshua; Jauregui, Ruben; Ji, Yuan; Kahn, D Ethan; Koch, Ethan; Lin, Jessica; Liu, Susan; Olivera, Anlys; Rosenthal, Jonathan; Snyder, Thomas; Stainman, Rebecca; Talmasov, Daniel; Thomas, Betsy; Valdes, Eduard; Zhou, Ting; Zhu, Yingrong; Lewis, Ariane; Lord, Aaron S; Melmed, Kara; Meropol, Sharon B; Thawani, Sujata; Troxel, Andrea B; Yaghi, Shadi; Balcer, Laura J; Wisniewski, Thomas; Galetta, Steven
BACKGROUND/OBJECTIVES/OBJECTIVE:Little is known about trajectories of recovery 12-months after hospitalization for severe COVID. METHODS:We conducted a prospective, longitudinal cohort study of patients with and without neurological complications during index hospitalization for COVID-19 from March 10, 2020-May 20, 2020. Phone follow-up batteries were performed at 6- and 12-months post-COVID symptom onset. The primary 12-month outcome was the modified Rankin Scale (mRS) comparing patients with or without neurological complications using multivariable ordinal analysis. Secondary outcomes included: activities of daily living (Barthel Index), telephone Montreal Cognitive Assessment (t-MoCA) and Neuro-QoL batteries for anxiety, depression, fatigue and sleep. Changes in outcome scores from 6 to 12-months were compared using non-parametric paired-samples sign test. RESULTS:Twelve-month follow-up was completed in N=242 patients (median age 65, 64% male, 34% intubated during hospitalization) and N=174 completed both 6- and 12-month follow-up. At 12-months 197/227 (87%) had ≥1 abnormal metric: mRS>0 (75%), Barthel<100 (64%), t-MoCA≤18 (50%), high anxiety (7%), depression (4%), fatigue (9%) and poor sleep (10%). 12-month mRS scores did not differ significantly among those with (N=113) or without (N=129) neurological complications during hospitalization after adjusting for age, sex, race, pre-COVID mRS and intubation status (adjusted OR 1.4, 95% CI0.8-2.5), though those with neurological complications had higher fatigue scores (T-score 47 vs 44, P=0.037). Significant improvements in outcome trajectories from 6- to 12-months were observed in t-MoCA scores (56% improved, median difference 1 point, P=0.002), and Neuro-QoL anxiety scores (45% improved, P=0.003). Non-significant improvements occurred in fatigue, sleep and depression scores in 48%, 48% and 38% of patients, respectively. Barthel and mRS scores remained unchanged between 6 and 12-months in >50% of patients. DISCUSSION/CONCLUSIONS:At 12-months post-hospitalization for severe COVID, 87% of patients had ongoing abnormalities in functional, cognitive or Neuro-QoL metrics and abnormal cognition persisted in 50% of patients without a prior history of dementia/cognitive abnormality. Only fatigue severity differed significantly between patients with or without neurological complications during index hospitalization. However, significant improvements in cognitive (t-MoCA) and anxiety (Neuro-QoL) scores occurred in 56% and 45% of patients, respectively, between 6- to 12-months. These results may not be generalizable to those with mild/moderate COVID.
PMID: 35314503
ISSN: 1526-632x
CID: 5192402