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Central Retinal Artery Visualization with Cone-Beam CT Angiography

Raz, Eytan; Shapiro, Maksim; Shepherd, Timothy M; Nossek, Erez; Yaghi, Shadi; Gold, Doria M; Ishida, Koto; Rucker, Janet C; Belinsky, Irina; Kim, Eleanore; Grory, Brian Mac; Mir, Osman; Hagiwara, Mari; Agarwal, Shashank; Young, Matthew G; Galetta, Steven L; Nelson, Peter Kim
Background There are multiple tools available to visualize the retinal and choroidal vasculature of the posterior globe. However, there are currently no reliable in vivo imaging techniques that can visualize the entire retrobulbar course of the retinal and ciliary vessels. Purpose To identify and characterize the central retinal artery (CRA) using cone-beam CT (CBCT) images obtained as part of diagnostic cerebral angiography. Materials and Methods In this retrospective study, patients with catheter DSA performed between October 2019 and October 2020 were included if CBCT angiography included the orbit in the field of view. The CBCT angiography data sets were postprocessed with a small field-of-view volume centered in the posterior globe to a maximum resolution of 0.2 mm. The following were evaluated: CRA origin, CRA course, CRA point of penetration into the optic nerve sheath, bifurcation of the CRA at the papilla, visualization of anatomic variants, and visualization of the central retinal vein. Descriptive statistical analysis was performed. Results Twenty-one patients with 24 visualized orbits were included in the analysis (mean age, 55 years ± 15; 14 women). Indications for angiography were as follows: diagnostic angiography (n = 8), aneurysm treatment (n = 6), or other (n = 7). The CRA was identified in all orbits; the origin, course, point of penetration of the CRA into the optic nerve sheath, and termination in the papilla were visualized in all orbits. The average length of the intraneural segment was 10.6 mm (range, 7-18 mm). The central retinal vein was identified in six of 24 orbits. Conclusion Cone-beam CT, performed during diagnostic angiography, consistently demonstrated the in vivo central retinal artery, demonstrating excellent potential for multiple diagnostic and therapeutic applications. © RSNA, 2021 Online supplemental material is available for this article.
PMID: 34783593
ISSN: 1527-1315
CID: 5049072

Biomarkers of Coagulation and Inflammation in COVID-19-Associated Ischemic Stroke

Esenwa, Charles; Cheng, Natalie T; Luna, Jorge; Willey, Joshua; Boehme, Amelia K; Kirchoff-Torres, Kathryn; Labovitz, Daniel; Liberman, Ava L; Mabie, Peter; Moncrieffe, Khadean; Soetanto, Ainie; Lendaris, Andrea; Seiden, Johanna; Goldman, Inessa; Altschul, David; Holland, Ryan; Benton, Joshua; Dardick, Joseph; Fernandez-Torres, Jenelys; Flomenbaum, David; Lu, Jenny; Malaviya, Avinash; Patel, Nikunj; Toma, Aureliana; Lord, Aaron; Ishida, Koto; Torres, Jose; Snyder, Thomas; Frontera, Jennifer; Yaghi, Shadi
[Figure: see text].
PMCID:8547586
PMID: 34428931
ISSN: 1524-4628
CID: 5037592

Thrombosis at Hospital Presentation in Patients with and without COVID-19

Brosnahan, Shari B; Smilowitz, Nathaniel R; Amoroso, Nancy E; Barfield, Michael; Berger, Jeffery S; Goldenberg, Ronald; Ishida, Koto; Talmor, Nina; Torres, Jose; Yaghi, Shadi; Yuriditsky, Eugene; Maldonado, Thomas
OBJECTIVE:To better characterize COVID-19 patients most at risk for severe, outpatient thrombosis by defining patients hospitalized with COVID-19 with an arterial or venous thrombosis diagnosed at admission METHODS AND RESULTS: We conducted a single center retrospective analysis of COVID-19 patients. There was a shift in the proportions of thrombosis subtypes from 2019 to 2020, with declines in STEMI (from 22.0% to 10.1% of thrombotic events) and stroke (from 48.6% to 37.2%), and an increase in the proportion of patients with VTE (29.4% to 52.7%). COVID-associated thrombosis were younger (58 years vs. 64 years, p=0.043), trended to be less frequently female (31.3% vs. 43.9%, p =0.16), but there was no difference body mass index or major comorbidities between those with and without COVID-19. COVID-19-associted thrombosis was correlated with a higher mortality (15.2% vs. 4.3%, p=0.016). The biometric profile of patients admitted with COVID-associated thrombosis compared to regular thrombosis had significant changes in the complete blood count, liver function tests, d-dimer, c-related protein, ferritin, and coagulation panels. CONCLUSIONS:Outpatients with COVID-19 who developed thrombosis requiring hospitalization have an increased mortality over non-COVID-19 outpatients who develop thrombosis requiring hospitalization. Given the significantly higher inflammatory markers, it is possible this is related to different mechanisms of thrombotic disease in these patients. The inflammation may be a target to reduce the risk of or aid in the treatment of thrombosis. We call for more studies elucidating the role immunothrombosis maybe playing in COVID.
PMCID:7655032
PMID: 33186750
ISSN: 2213-3348
CID: 4672082

New Focus on Endovascular Therapy for Ischemic Stroke

Kelly, Sean; Raz, Eytan; Shapiro, Maksim; Ishida, Koto
BACKGROUND:Over the past 2 decades, a growing number of large-scale clinical trials have helped expand the toolkit for emergency management of acute ischemic stroke. This article is intended to be an up-to-date resource to aid nonstroke specialist neurology providers and ophthalmologists in identifying situations and patient populations in which urgent stroke evaluation should be completed with options for emergent reperfusion therapy considered. EVIDENCE ACQUISITION/METHODS:The literature forming the foundation of the guidelines for early management of patients with acute ischemic stroke was reviewed, annotated, and summarized. RESULTS:Data from both initial and follow-up trials investigating the benefits and indications for use of intravenous thrombolysis and endovascular intervention for stroke are reviewed systematically, with an emphasis on new updates to qualifying patient populations and time periods for treatment. CONCLUSIONS:Recent studies underscore the conclusion that timely reperfusion in acute ischemic stroke is the most effective available treatment and that there are a growing number of new scenarios and patients for which interventions maybe applied.
PMID: 33999888
ISSN: 1536-5166
CID: 4876682

Anticoagulation use and Hemorrhagic Stroke in SARS-CoV-2 Patients Treated at a New York Healthcare System

Kvernland, Alexandra; Kumar, Arooshi; Yaghi, Shadi; Raz, Eytan; Frontera, Jennifer; Lewis, Ariane; Czeisler, Barry; Kahn, D Ethan; Zhou, Ting; Ishida, Koto; Torres, Jose; Riina, Howard A; Shapiro, Maksim; Nossek, Erez; Nelson, Peter K; Tanweer, Omar; Gordon, David; Jain, Rajan; Dehkharghani, Seena; Henninger, Nils; de Havenon, Adam; Grory, Brian Mac; Lord, Aaron; Melmed, Kara
BACKGROUND AND PURPOSE/OBJECTIVE:While the thrombotic complications of COVID-19 have been well described, there are limited data on clinically significant bleeding complications including hemorrhagic stroke. The clinical characteristics, underlying stroke mechanism, and outcomes in this particular subset of patients are especially salient as therapeutic anticoagulation becomes increasingly common in the treatment and prevention of thrombotic complications of COVID-19. METHODS:We conducted a retrospective cohort study of patients with hemorrhagic stroke (both non-traumatic intracerebral hemorrhage and spontaneous non-aneurysmal subarachnoid hemorrhage) who were hospitalized between March 1, 2020, and May 15, 2020, within a major healthcare system in New York, during the coronavirus pandemic. Patients with hemorrhagic stroke on admission and who developed hemorrhage during hospitalization were both included. We compared the clinical characteristics of patients with hemorrhagic stroke and COVID-19 to those without COVID-19 admitted to our hospital system between March 1, 2020, and May 15, 2020 (contemporary controls), and March 1, 2019, and May 15, 2019 (historical controls). Demographic variables and clinical characteristics between the individual groups were compared using Fischer's exact test for categorical variables and nonparametric test for continuous variables. We adjusted for multiple comparisons using the Bonferroni method. RESULTS:During the study period in 2020, out of 4071 patients who were hospitalized with COVID-19, we identified 19 (0.5%) with hemorrhagic stroke. Of all COVID-19 with hemorrhagic stroke, only three had isolated non-aneurysmal SAH with no associated intraparenchymal hemorrhage. Among hemorrhagic stroke in patients with COVID-19, coagulopathy was the most common etiology (73.7%); empiric anticoagulation was started in 89.5% of these patients versus 4.2% in contemporary controls (p ≤ .001) and 10.0% in historical controls (p ≤ .001). Compared to contemporary and historical controls, patients with COVID-19 had higher initial NIHSS scores, INR, PTT, and fibrinogen levels. Patients with COVID-19 also had higher rates of in-hospital mortality (84.6% vs. 4.6%, p ≤ 0.001). Sensitivity analyses excluding patients with strictly subarachnoid hemorrhage yielded similar results. CONCLUSION/CONCLUSIONS:We observed an overall low rate of imaging-confirmed hemorrhagic stroke among patients hospitalized with COVID-19. Most hemorrhages in patients with COVID-19 infection occurred in the setting of therapeutic anticoagulation and were associated with increased mortality. Further studies are needed to evaluate the safety and efficacy of therapeutic anticoagulation in patients with COVID-19.
PMCID:7444897
PMID: 32839867
ISSN: 1556-0961
CID: 4574182

Systemic Inflammatory Response Syndrome is Associated with Hematoma Expansion in Intracerebral Hemorrhage

Melmed, Kara R; Carroll, Elizabeth; Lord, Aaron S; Boehme, Amelia K; Ishida, Koto; Zhang, Cen; Torres, Jose L; Yaghi, Shadi; Czeisler, Barry M; Frontera, Jennifer A; Lewis, Ariane
OBJECTIVES/OBJECTIVE:Systemic inflammatory response syndrome (SIRS) and hematoma expansion are independently associated with worse outcomes after intracerebral hemorrhage (ICH), but the relationship between SIRS and hematoma expansion remains unclear. MATERIALS AND METHODS/METHODS:We performed a retrospective review of patients admitted to our hospital from 2013 to 2020 with primary spontaneous ICH with at least two head CTs within the first 24 hours. The relationship between SIRS and hematoma expansion, defined as ≥6 mL or ≥33% growth between the first and second scan, was assessed using univariable and multivariable regression analysis. We assessed the relationship of hematoma expansion and SIRS on discharge mRS using mediation analysis. RESULTS:Of 149 patients with ICH, 83 (56%; mean age 67±16; 41% female) met inclusion criteria. Of those, 44 (53%) had SIRS. Admission systolic blood pressure (SBP), temperature, antiplatelet use, platelet count, initial hematoma volume and rates of infection did not differ between groups (all p>0.05). Hematoma expansion occurred in 15/83 (18%) patients, 12 (80%) of whom also had SIRS. SIRS was significantly associated with hematoma expansion (OR 4.5, 95% CI 1.16 - 17.39, p= 0.02) on univariable analysis. The association remained statistically significant after adjusting for admission SBP and initial hematoma volume (OR 5.72, 95% CI 1.40 - 23.41, p= 0.02). There was a significant indirect effect of SIRS on discharge mRS through hematoma expansion. A significantly greater percentage of patients with SIRS had mRS 4-6 at discharge (59 vs 33%, p=0.02). CONCLUSION/CONCLUSIONS:SIRS is associated with hematoma expansion of ICH within the first 24 hours, and hematoma expansion mediates the effect of SIRS on poor outcome.
PMID: 34077823
ISSN: 1532-8511
CID: 4891632

Superficial Temporal Artery to Middle Cerebral Artery Cranial Bypass for Nonmoyamoya Steno-Occlusive Disease in Patients Who Failed Optimal Medical Treatment: A Case Series

Haynes, Joseph; Kronenburg, Annick; Raz, Eytan; Rostanski, Sara; Yaghi, Shadi; Ishida, Koto; Shapiro, Maksim; Nelson, Peter Kim; Tanweer, Omar; Langer, David J; Riina, Howard A; Eichel, Roni; Nossek, Erez
BACKGROUND:In the post-Carotid Occlusion Surgery Study (COSS) era, multiple reviews suggested subset groups of patients as potential candidates for superficial temporal artery to middle cerebral artery (STA-MCA) bypass. Among them are patients with recurrent strokes despite optimal medical therapy. There is a paucity of data on the outcome of bypass in these specific patients. OBJECTIVE:To examine the safety and efficacy of direct STA-MCA bypass in patients with nonmoyamoya, symptomatic steno-occlusive disease with impaired distal perfusion, who failed optimal medical management or endovascular treatment. METHODS:A retrospective review was performed to identify patients with cerebrovascular steno-occlusive disease who underwent bypass after symptomatic recurrent or rapidly progressive strokes, despite optimal conservative or endovascular treatment. RESULTS:A total of 8 patients (mean age 60 ± 6 yr) underwent direct or combined direct/indirect STA-MCA bypass between 2016 and 2019. All anastomoses were patent. One bypass carried slow flow. There were no procedure-related permanent deficits. One patient developed seizures which were controlled by medications. A total of 7 out of 8 patients were stable or improved clinically at last follow-up (mean 27.3 ± 13.8 mo) without recurrent strokes. One patient did not recover from their presenting stroke, experienced severe bilateral strokes 4 mo postoperatively, and subsequently expired. Modified Rankin Scale (mRS) improved in 6 patients (75%), remained stable in 1 patient (12.5%), and deteriorated in 1 (12.5%). Good long-term functional outcome was achieved in 5 patients (63%, mRS ≤ 2). CONCLUSION/CONCLUSIONS:Patients with symptomatic, hypoperfused steno-occlusive disease who fail optimal medical or endovascular treatment may benefit from cerebral revascularization. Direct or combined STA-MCA bypass was safe and provided favorable outcomes in this small series.
PMID: 33475724
ISSN: 2332-4260
CID: 4760762

Resident and Fellow Training in a Pandemic

Grossman, Scott N; Galetta, Steven L; Lee, Andrew G; Biousse, Valerie; Ishida, Koto
PMID: 33587533
ISSN: 1536-5166
CID: 4786502

Acute Stroke

Sangha, Navdeep; Ishida, Koto
PMID: 33618375
ISSN: 1098-9021
CID: 4794312

A Prospective Study of Neurologic Disorders in Hospitalized COVID-19 Patients in New York City

Frontera, Jennifer A; Sabadia, Sakinah; Lalchan, Rebecca; Fang, Taolin; Flusty, Brent; Millar-Vernetti, Patricio; Snyder, Thomas; Berger, Stephen; Yang, Dixon; Granger, Andre; Morgan, Nicole; Patel, Palak; Gutman, Josef; Melmed, Kara; Agarwal, Shashank; Bokhari, Matthew; Andino, Andres; Valdes, Eduard; Omari, Mirza; Kvernland, Alexandra; Lillemoe, Kaitlyn; Chou, Sherry H-Y; McNett, Molly; Helbok, Raimund; Mainali, Shraddha; Fink, Ericka L; Robertson, Courtney; Schober, Michelle; Suarez, Jose I; Ziai, Wendy; Menon, David; Friedman, Daniel; Friedman, David; Holmes, Manisha; Huang, Joshua; Thawani, Sujata; Howard, Jonathan; Abou-Fayssal, Nada; Krieger, Penina; Lewis, Ariane; Lord, Aaron S; Zhou, Ting; Kahn, D Ethan; Czeisler, Barry M; Torres, Jose; Yaghi, Shadi; Ishida, Koto; Scher, Erica; de Havenon, Adam; Placantonakis, Dimitris; Liu, Mengling; Wisniewski, Thomas; Troxel, Andrea B; Balcer, Laura; Galetta, Steven
OBJECTIVE:To determine the prevalence and associated mortality of well-defined neurologic diagnoses among COVID-19 patients, we prospectively followed hospitalized SARS-Cov-2 positive patients and recorded new neurologic disorders and hospital outcomes. METHODS:We conducted a prospective, multi-center, observational study of consecutive hospitalized adults in the NYC metropolitan area with laboratory-confirmed SARS-CoV-2 infection. The prevalence of new neurologic disorders (as diagnosed by a neurologist) was recorded and in-hospital mortality and discharge disposition were compared between COVID-19 patients with and without neurologic disorders. RESULTS:Of 4,491 COVID-19 patients hospitalized during the study timeframe, 606 (13.5%) developed a new neurologic disorder in a median of 2 days from COVID-19 symptom onset. The most common diagnoses were: toxic/metabolic encephalopathy (6.8%), seizure (1.6%), stroke (1.9%), and hypoxic/ischemic injury (1.4%). No patient had meningitis/encephalitis, or myelopathy/myelitis referable to SARS-CoV-2 infection and 18/18 CSF specimens were RT-PCR negative for SARS-CoV-2. Patients with neurologic disorders were more often older, male, white, hypertensive, diabetic, intubated, and had higher sequential organ failure assessment (SOFA) scores (all P<0.05). After adjusting for age, sex, SOFA-scores, intubation, past history, medical complications, medications and comfort-care-status, COVID-19 patients with neurologic disorders had increased risk of in-hospital mortality (Hazard Ratio[HR] 1.38, 95% CI 1.17-1.62, P<0.001) and decreased likelihood of discharge home (HR 0.72, 95% CI 0.63-0.85, P<0.001). CONCLUSIONS:Neurologic disorders were detected in 13.5% of COVID-19 patients and were associated with increased risk of in-hospital mortality and decreased likelihood of discharge home. Many observed neurologic disorders may be sequelae of severe systemic illness.
PMID: 33020166
ISSN: 1526-632x
CID: 4626712