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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

Stroke Treatment Delay Limits Outcome After Mechanical Thrombectomy: Stratification by Arrival Time and ASPECTS

Snyder, Thomas; Agarwal, Shashank; Huang, Jeffrey; Ishida, Koto; Flusty, Brent; Frontera, Jennifer; Lord, Aaron; Torres, Jose; Zhang, Cen; Rostanski, Sara; Favate, Albert; Lillemoe, Kaitlyn; Sanger, Matthew; Kim, Sun; Humbert, Kelley; Scher, Erica; Dehkharghani, Seena; Raz, Eytan; Shapiro, Maksim; K Nelson, Peter; Gordon, David; Tanweer, Omar; Nossek, Erez; Farkas, Jeffrey; Liff, Jeremy; Turkel-Parrella, David; Tiwari, Ambooj; Riina, Howard; Yaghi, Shadi
BACKGROUND AND PURPOSE/OBJECTIVE:Mechanical thrombectomy (MT) has helped many patients achieve functional independence. The effect of time-to-treatment based in specific epochs and as related to Alberta Stroke Program Early CT Score (ASPECTS) has not been established. The goal of the study was to evaluate the association between last known normal (LKN)-to-puncture time and good functional outcome. METHODS:We conducted a retrospective cohort study of prospectively collected acute ischemic stroke patients undergoing MT for large vessel occlusion. We used binary logistic regression models adjusted for age, Modified Treatment in Cerebral Ischemia score, initial National Institutes of Health Stroke Scale, and noncontrast CT ASPECTS to assess the association between LKN-to-puncture time and favorable outcome defined as Modified Rankin Score 0-2 on discharge. RESULTS:Among 421 patients, 328 were included in analysis. Increased LKN-to-puncture time was associated with decreased probability of good functional outcome (adjusted odds ratio [aOR] ratio per 15-minute delay = .98; 95% confidence interval [CI], .97-.99; P = .001). This was especially true when LKN-puncture time was 0-6 hours (aOR per 15-minute delay = .94; 95% CI, .89-.99; P = .05) or ASPECTS 8-10 (aOR = .98; 95% CI, .97-.99; P = .002) as opposed to when LKN-puncture time was 6-24 hours (aOR per 15-minute delay = .99; 95% CI, .97-1.00; P = .16) and ASPECTS <8 (aOR = .98; 95% CI, .93-1.03; P = .37). CONCLUSION/CONCLUSIONS:Decreased LKN-groin puncture time improves outcome particularly in those with good ASPECTS presenting within 6 hours. Strategies to decrease reperfusion times should be investigated, particularly in those in the early time window and with good ASPECTS.
PMID: 32592619
ISSN: 1552-6569
CID: 4503652

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.
PMID: 32807471
ISSN: 1532-8511
CID: 4565632

DynaCT enhancement of subdural membranes after MMA embolization: insights into pathophysiology

Mureb, Monica C; Kondziolka, Douglas; Shapiro, Maksim; Raz, Eytan; Haynes, Joseph; Farkas, Jeffrey; Riina, Howard A; Tanweer, Omar
OBJECTIVE:Middle meningeal artery (MMA) embolization may be an effective means of inhibiting neovascularization of the subdural capsular membrane and preventing hematoma maintenance. We sought to better understand how the MMA may affect subdural hematoma physiology and how this process may be modified by embolization. METHODS:A retrospective review was done. We studied 27 patients with 29 SDHs who underwent MMA embolization from July 2018 to May 2019. Eight of these patients had post-embolization DynaCT imaging and were included. RESULTS:Average patient age was 75 years old. Baseline non-contrast head CT showed the presence of a hematoma membrane in all 8 patients. Post-embolization DynaCTs in all patients demonstrated enhancement of all four components (dura, capsular membrane, septations, and subdural hematoma fluid). All patients had a minimum 60-day imaging and clinical follow-up. There was an average 87% decrease in SDH volume at last follow-up compared to baseline. There was a significant difference between the average baseline and average last follow-up SDH volume (paired t-test, p < 0.0001) in all patients. Average last follow-up scan was 89 days (range 61-122 days) from the date of procedure. No patient experienced post-embolization complications, subsequent SDH drainage, or mortality. CONCLUSIONS:Our data lends support to the theory of contiguous vascular networks between the MMA and SDH membranes. Targeting these leaky vascular networks may remove the source of hematoma accumulation. This adds to the pathophysiological understanding of the disease and suggests potential insight into the mechanism of action of MMA embolization.
PMID: 32298816
ISSN: 1878-8769
CID: 4383722

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

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.
PMID: 32508902
ISSN: 1664-9737
CID: 4474492

Predicting Symptomatic Intracranial Hemorrhage After Mechanical Thrombectomy: The TAG Score [Meeting Abstract]

Montalvo, Mayra; Mistry, Eva; Chang, Andrew; Yakhkind, Aleksandra; Dakay, Katarina; Azher, Idrees; Mistry, Akshitkumar; Chitale, Rohan; Cutting, Shawna; Burton, Tina; Mac Grory, Brian; Reznik, Michael; Mahta, Ali; Thompson, Bradford; Ishida, Koto; Frontera, Jennifer; Riina, Howard; Gordon, David; Turkel-Parrella, David; Scher, Erica; Farkas, Jeffrey; McTaggart, Ryan A.; Khatri, Pooja; Furie, Karen; Jayaraman, Mahesh; Yaghi, Shadi
ISSN: 0028-3878
CID: 4561172

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
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.
PMID: 33041972
ISSN: 1664-2295
CID: 4632392

Predicting symptomatic intracranial haemorrhage after mechanical thrombectomy: the TAG score

Montalvo, Mayra; Mistry, Eva; Chang, Andrew Davey; Yakhkind, Aleksandra; Dakay, Katarina; Azher, Idrees; Kaushal, Ashutosh; Mistry, Akshitkumar; Chitale, Rohan; Cutting, Shawna; Burton, Tina; Mac Grory, Brian; Reznik, Michael; Mahta, Ali; Thompson, Bradford B; Ishida, Koto; Frontera, Jennifer; Riina, Howard A; Gordon, David; Parella, David; Scher, Erica; Farkas, Jeffrey; McTaggart, Ryan; Khatri, Pooja; Furie, Karen L; Jayaraman, Mahesh; Yaghi, Shadi
BACKGROUND:There is limited data on predictors of symptomatic intracranial haemorrhage (sICH) in patients who underwent mechanical thrombectomy. In this study, we aim to determine those predictors with external validation. METHODS:and t tests to identify independent predictors of sICH with p<0.1. Significant variables were then combined in a multivariate logistic regression model to derive an sICH prediction score. This score was then validated using data from the Blood Pressure After Endovascular Treatment multicentre prospective registry. RESULTS:We identified 578 patients with acute ischaemic stroke who received thrombectomy, 19 had sICH (3.3%). Predictive factors of sICH were: thrombolysis in cerebral ischaemia (TICI) score, Alberta stroke program early CT score (ASPECTS), and glucose level, and from these predictors, we derived the weighted TICI-ASPECTS-glucose (TAG) score, which was associated with sICH in the derivation (OR per unit increase 1.98, 95% CI 1.48 to 2.66, p<0.001, area under curve ((AUC)=0.79) and validation (OR per unit increase 1.48, 95% CI 1.22 to 1.79, p<0.001, AUC=0.69) cohorts. CONCLUSION/CONCLUSIONS:High TAG scores are associated with sICH in patients receiving mechanical thrombectomy. Larger studies are needed to validate this scoring system and test strategies to reduce sICH risk and make thrombectomy safer in patients with elevated TAG scores.
PMID: 31427365
ISSN: 1468-330x
CID: 4046642