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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

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

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

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
ISSN: 1556-0961
CID: 4472832

Outcome of Distal Clot Migration in the Setting of IV r-tPA and Stroke Endovascular Thrombectomy [Meeting Abstract]

Ye, Phillip; Bo, Ryan; Liff, Jeremy; Farkas, Jeffrey; Arcot, Karthikeyan; Turkel-Parrella, David; Tiwari, Ambooj
ISSN: 0028-3878
CID: 3561882

Impact of ultra-rapid-sequential IV/IA contrast on incidence of CIN in a comprehensive stroke center [Meeting Abstract]

Ye, P; Kurgansky, G; Liff, J; Farkas, J; Arcot, K; Turkel-Parrella, D; Tiwari, A; Frontera, J A
Introduction: The efficacy of MDCT-based-angiography in management of acute stroke and/or emergent-large-vessel-occlusion is well established. However, concern for contrast-induced nephropathy(CIN) especially in patients with major risk factors like Diabetes & Chronic kidney disease often delays rapid evaluation of ELVO patients. Many published studies report the overall incidence of CIN after administration of IV or IA iodinated contrast and highlight the direct correlation of dose on higher incidence of CIN. None, however, have examined impact of sequential IV-IA bolus for neuroangiographic evaluation on renal function in patients with DM and/or CKD. Methods: A retrospective study of our 2015-2017 stroke database of 168 patients was conducted to identify all patients with preexisting DM and/or CKD who developed CIN during their hospital course. We also reviewed the prevalence of dehydration (BUN/Cr <20), CHF and anemia (Hb <8 g/dL) for these patients on admission. Results: For all 168 patients; average IA, IV and cumulative IV-IA contrast (Omnipaque 350) doses within 24 hours were 89.9, 91.7 and 181.6 cc respectively. 68 patients had DM and/or CKD of which 3 developed CIN. Under the definition of >=25% increase in baseline Cr within 72-120 hours of receiving contrast, all 3 had CIN. However, under the definition of >=0.5 mg/dL increase in Cr within 72 hours, none had CIN. All 3 only had preexisting DM as risk factor and had age appropriate baseline Cr on admission. The baseline Cr for each of the 3 patients were 0.82, 1.17 & 0.47 mg/dL respectively while the elevated Cr were 1.03, 1.17 & 0.76 mg/dL respectively. All 3 returned to within baseline by discharge with no mortality or need for hemodialysis. Conclusions: There is low risk of developing CIN in high risk patients like CKD or DM following rapid sequential dual IV/IA contrast bolus in acute stroke patients and therefore should not delay rapid neuro-angiographic evaluation
ISSN: 1664-5545
CID: 2862302

Comparing safety and efficacy of biplane versus monoplane angiography in hyperacute neuroendovascular therapy [Meeting Abstract]

Kurgansky, G D; Ye, P; Bo, R T; Liff, J M; Arcot, K; Turkel-Parrella, D; Farkas, J; Tiwari, A
Introduction: Most stroke/neuro-interventional centers require advanced biplane imaging for evaluation of complex cerebrovascular lesions. Purchasing such equipment is cost-prohibitive for many hospital systems. Additionally, operator-preference often prevents the use of other imaging platforms as a back up for acute neuro-interventional cases. However, most hospitals are often equipped with multiple single plane imaging platforms for IR & Cardiac purposes. Advanced single plane imaging in most catheterization labs provide reasonable penetration and field of view (FOV) for doing acute cases like mechanical thrombectomy. Methods: A retrospective review of our multi-center database of acute stroke patients treated with endovascular therapy was performed. 207 patients were categorized by type of imaging platform on which thrombectomy was performed and relevant angiographic and clinical data was gathered. Primary outcome was measured using angiographic outcome. This included comparisons between two groups of TICI scores: TICI 0-2A vs. TICI 2B-3 and TICI 2B vs. TICI 2C/3. Secondary outcome was safety which was reported as incidence of intracranial hemorrhage between the two groups Results: 146 biplane patients achieved scores of 2B or higher, meanwhile 12 biplane patients received scores of 2A or lower. 44 of 49 single plane patients achieved TICI scores of 2B-3 while 5 had scores of 0-2A, showing no significant difference (p > 0.05). In a second comparison, 97 biplane patients that had outcomes of 2C or 3, and 49 patients with outcomes of 2B; while 29 monoplane patients achieved a score of 2c or 3 and 15 with 2B (p > 0.05). For our secondary measure, ICH in the biplane group was 38/146 and in monoplane group was 9/49, the difference not being statistically significant (p > 0.05) Conclusions: There was no significant difference in safety or efficacy outcomes when comparing thrombectomies performed using biplane vs. monoplane imaging. Thrombectomies performed with either imaging system is equally safe and effective
ISSN: 1664-5545
CID: 2862312

Transient hemiparesis (Todd's paralysis) after electroconvulsive therapy (ECT) in a patient with major depressive disorder [Case Report]

Liff, Jeremy M; Bryson, Ethan O; Maloutas, Eleni; Garruto, Kimberly; Pasculli, Rosa M; Briggs, Mimi C; Kellner, Charles H
We report the case of a 50-year-old man who exhibited transient left hemiparesis (Todd's paralysis) after electroconvulsive therapy, which completely resolved within 10 minutes. Subsequent neurological evaluation was unremarkable for discrete etiologies for this event, other than Todd's paralysis. We review the literature of this phenomenon in association with electroconvulsive therapy.
PMID: 23291704
ISSN: 1533-4112
CID: 2198622

Tapia Syndrome, Resulting from Internal Carotid Artery Dissection in the Setting of Yoga and Review the Localization and Mechanism of Injury to the Vagal and Hypoglossal Nerves [Meeting Abstract]

Arcot, Karthikeyan; Liff, Jeremy; Horowitz, Deborah
ISSN: 0028-3878
CID: 2119162