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Endovascular Revascularization of Multi Segment Chronically Occluded ICA [Case Report]

Mulchan, Nicholas; Yeun, Phillip; Frontera, Jennifer; Farkas, Jeffrey; Berekashvili, Ketevan; Sanger, Matthew; Torres, Jose; Tiwari, Ambooj
This case report describes a novel endovascular method for treating chronically occluded internal carotid artery (COICA). The patient is a 55-year-old male with vascular risk factors who presented to an outside institution with right-sided weakness and dysarthria, was diagnosed as having a stroke, and discharged with medical management. The patient's symptoms failed to improve throughout the week prompting him to visit another outside institution, where computed tomography (CT) angiography showed bilateral occlusion of the ICAs at their origins extending intracranially. The patient was then transferred to our hospital, where head CT revealed bilateral acute infarcts predominantly in the left centrum ovale/corona radiata and left temporoparietal region. CT perfusion showed a large area of hypoperfusion in the entire left hemisphere as well as part of the right hemisphere (mismatch volume of 438-526 mL). The patient had significant neurological deficits despite sustained high perfusion pressure, so the following morning, the patient was taken for angiography showing complete occlusion of the left ICA with support mostly from the left external carotid artery (ECA)/ophthalmic collateralization. The microcatheter was able to be advanced to the level of the ophthalmic segment of the left ICA, so the decision was made to proceed with stenting from the left ophthalmic ICA to the cervical ICA. Seven consecutive coronary-carotid stents were placed to essentially reconstruct the left ICA. Post-stenting, the patient was treated with an Integrilin drip and transitioned to Aspirin and Brilinta the following morning. The patient's symptoms markedly improved after the procedure. CT perfusion, as well as diffusion magnetic resonance imaging (MRI), revealed recovery of the patient's penumbra and stability of the existing infarcts despite the delayed nature of revascularization respectively. This is a rarely reported study in literature describing the successful deployment of multiple stents in recreating the ICA from its extracranial to intracranial portion.
PMID: 35576859
ISSN: 1532-8511
CID: 5275882

Pre-admission antithrombotic use is associated with 3-month mRS score after thrombectomy for acute ischemic stroke

Krieger, Penina; Melmed, Kara R; Torres, Jose; Zhao, Amanda; Croll, Leah; Irvine, Hannah; Lord, Aaron; Ishida, Koto; Frontera, Jennifer; Lewis, Ariane
In patients who undergo thrombectomy for acute ischemic stroke, the relationship between pre-admission antithrombotic (anticoagulation or antiplatelet) use and both radiographic and functional outcome is not well understood. We sought to explore the relationship between pre-admission antithrombotic use in patients who underwent thrombectomy for acute ischemic stroke at two medical centers in New York City between December 2018 and November 2020. Analyses were performed using analysis of variance and Pearson's chi-squared tests. Of 234 patients in the analysis cohort, 65 (28%) were on anticoagulation, 64 (27%) were on antiplatelet, and 105 (45%) with no antithrombotic use pre-admission. 3-month Modified Rankin Scale (mRS) score of 3-6 was associated with pre-admission antithrombotic use (71% anticoagulation vs. 77% antiplatelet vs. 56% no antithrombotic, p = 0.04). There was no relationship between pre-admission antithrombotic use and Thrombolysis in Cerebral Iinfarction (TICI) score, post-procedure Alberta Stroke Program Early CT Score (ASPECTS) score, rate of hemorrhagic conversion, length of hospital admission, discharge NIH Stroke Scale (NIHSS), discharge mRS score, or mortality. When initial NIHSS score, post-procedure ASPECTS score, and age at admission were included in multivariate analysis, pre-admission antithrombotic use was still significantly associated with a 3-month mRS score of 3-6 (OR 2.36, 95% CI 1.03-5.54, p = 0.04). In this cohort of patients with acute ischemic stroke who underwent thrombectomy, pre-admission antithrombotic use was associated with 3-month mRS score, but no other measures of radiographic or functional outcome. Further research is needed on the relationship between use of specific anticoagulation or antiplatelet agents and outcome after acute ischemic stroke, but moreover, improve stroke prevention.
PMCID:9302951
PMID: 35864280
ISSN: 1573-742x
CID: 5279342

Social Determinants of Health Attenuate the Relationship Between Race and Ethnicity and White Matter Hyperintensity Severity but not Microbleed Presence in Patients with Intracerebral Hemorrhage

Bauman, Kristie M; Yaghi, Shadi; Lewis, Ariane; Agarwal, Shashank; Changa, Abhinav; Dogra, Siddhant; Litao, Miguel; Sanger, Matthew; Lord, Aaron; Ishida, Koto; Zhang, Cen; Czeisler, Barry; Torres, Jose; Dehkharghani, Seena; Frontera, Jennifer A; Melmed, Kara R
BACKGROUND:The association between race and ethnicity and microvascular disease in patients with intracerebral hemorrhage (ICH) is unclear. We hypothesized that social determinants of health (SDOHs) mediate the relationship between race and ethnicity and severity of white matter hyperintensities (WMHs) and microbleeds in patients with ICH. METHODS:We performed a retrospective observational cohort study of patients with ICH at two tertiary care hospitals between 2013 and 2020 who underwent magnetic resonance imaging of the brain. Magnetic resonance imaging scans were evaluated for the presence of microbleeds and WMH severity (defined by the Fazekas scale; moderate to severe WMH defined as Fazekas scores 3-6). We assessed for associations between sex, race and ethnicity, employment status, median household income, education level, insurance status, and imaging biomarkers of microvascular disease. A mediation analysis was used to investigate the influence of SDOHs on the associations between race and imaging features. We assessed the relationship of all variables with discharge outcomes. RESULTS:We identified 233 patients (mean age 62 [SD 16]; 48% female) with ICH. Of these, 19% were Black non-Hispanic, 32% had a high school education or less, 21% required an interpreter, 11% were unemployed, and 6% were uninsured. Moderate to severe WMH, identified in 114 (50%) patients, was associated with age, Black non-Hispanic race and ethnicity, highest level of education, insurance status, and history of hypertension, hyperlipidemia, or diabetes (p < 0.05). In the mediation analysis, the proportion of the association between Black non-Hispanic race and ethnicity and the Fazekas score that was mediated by highest level of education was 65%. Microbleeds, present in 130 (57%) patients, was associated with age, highest level of education, and history of diabetes or hypertension (p < 0.05). Age, highest level of education, insurance status, and employment status were associated with discharge modified Rankin Scale scores of 3-6, but race and ethnicity was not. CONCLUSIONS:The association between Black non-Hispanic race and ethnicity and moderate to severe WMH lost significance after we adjusted for highest level of education, suggesting that SDOHs may mediate the association between race and ethnicity and microvascular disease.
PMID: 34918215
ISSN: 1556-0961
CID: 5084672

Neuroprotective association of preoperative renin-angiotensin system blocking agents use in patients undergoing carotid interventions

Li, Chong; Rockman, Caron; Chang, Heepeel; Patel, Virendra I; Siracuse, Jeffrey J; Cayne, Neal; Veith, Frank J; Torres, Jose L; Maldonado, Thomas S; Nigalaye, Anjali A; Jacobowitz, Glenn; Garg, Karan
OBJECTIVE:The optimal medical management strategy in the periprocedural period for patients undergoing carotid artery interventions is not well described. Renin-angiotensin-system blocking (RASB) agents are considered to be among the first line anti-hypertensive agents; however, their role in the perioperative period is unclear. The objective of this study was to examine the relationship between the use of RASB agents on periprocedural outcomes in patients undergoing carotid interventions-carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS), and transcervical carotid artery revascularization (TCAR). METHOD/METHODS:The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA, and TCAR between 2003 and 2020. Patients were stratified into two groups based upon their use of RASB agents in the periprocedural period. The primary endpoint was periprocedural neurologic events (including both strokes and transient ischemic attacks (TIAs)). The secondary endpoints were peri-procedural mortality and significant cardiac events, including myocardial infarction, dysrhythmia, and congestive heart failure. RESULTS:= 0.461). CONCLUSION/CONCLUSIONS:The use of peri-procedural RASB agents was associated with a significantly decreased rate of neurologic events in patients undergoing both CEA and TCAR. This effect was not observed in patients undergoing CAS. As carotid interventions warrant absolute minimization of perioperative complications in order to provide maximum efficacy with regard to stroke protection, the potential neuro-protective effect associated with RASB agents use following CEA and TCAR warrants further examination.
PMID: 35603781
ISSN: 1708-539x
CID: 5247832

Psychological Outcome after Hemorrhagic Stroke is Related to Functional Status

Ecker, Sarah; Lord, Aaron; Gurin, Lindsey; Olivera, Anlys; Ishida, Koto; Melmed, Kara; Torres, Jose; Zhang, Cen; Frontera, Jennifer; Lewis, Ariane
BACKGROUND:To identify opportunities to improve morbidity after hemorrhagic stroke, it is imperative to understand factors that are related to psychological outcome. DESIGN/METHODS/METHODS:We prospectively identified patients with non-traumatic hemorrhagic stroke (intracerebral or subarachnoid hemorrhage) between January 2015 and February 2021 who were alive 3-months after discharge and telephonically assessed 1) psychological outcome using the Quality of Life in Neurological Disorders anxiety, depression, emotional and behavioral dyscontrol, fatigue and sleep disturbance inventories and 2) functional outcome using the modified Rankin Scale (mRS) and Barthel Index. We also identified discharge destination for all patients. We then evaluated the relationship between abnormal psychological outcomes (T-score >50) and discharge destination other than home, poor 3-month mRS score defined as 3-5 and poor 3-month Barthel Index defined as <100. RESULTS:73 patients were included; 41 (56%) had an abnormal psychological outcome on at least one inventory. There were 41 (56%) patients discharged to a destination other than home, 44 (63%) with poor mRS score and 28 (39%) with poor Barthel Index. Anxiety, depression, emotional and behavioral dyscontrol and sleep disturbance were all associated with a destination other than home, poor mRS score, and poor Barthel Index (all p<0.05). Fatigue was related to poor mRS score and poor Barthel Index (p=0.005 and p=0.006, respectively). CONCLUSION/CONCLUSIONS:Multiple psychological outcomes 3-months after hemorrhagic stroke are related to functional status. Interventions to improve psychological outcome and reduce morbidity in patients with poor functional status should be explored by the interdisciplinary team.
PMID: 35594604
ISSN: 1532-8511
CID: 5247722

Tachycardia is associated with mortality and functional outcome after thrombectomy for acute ischemic stroke

Krieger, Penina; Zhao, Amanda; Croll, Leah; Irvine, Hannah; Torres, Jose; Melmed, Kara R; Lord, Aaron; Ishida, Koto; Frontera, Jennifer; Lewis, Ariane
BACKGROUND:The relationship between cardiac function and mortality after thrombectomy for acute ischemic stroke is not well elucidated. METHODS:We analyzed the relationship between cardiac function and mortality prior to discharge in a cohort of patients who underwent thrombectomy for acute ischemic stroke at two large medical centers in New York City between December 2018 and November 2020. All analyses were performed using Welch's two sample t-test and logistic regression accounting for age, initial NIHSS and post-procedure ASPECTS score, where OR is for each unit increase in the respective variables. RESULTS:Of 248 patients, 41 (16.5%) died prior to discharge. Mortality was significantly associated with higher initial heart rate (HR; 89 ± 19 bpm vs 80 ± 18 bpm, p = 0.004) and higher maximum HR over entire admission (137 ± 26 bpm vs 114 ± 25 bpm, p < 0.001). Mortality was also associated with presence of NSTEMI/STEMI (63% vs 29%, p < 0.001). When age, initial NIHSS score, and post-procedure ASPECTS score were included in multivariate analysis, there was still a significant relationship between mortality and initial HR (OR 1.03, 95% CI 1.01- 1.05, p = 0.02), highest HR over the entire admission (OR 1.03, 95% CI 1.02-1.05, p < 0.001), and presence of NSTEMI/STEMI (OR 3.76, 95% CI 1.66-8.87, p = 0.002). CONCLUSIONS:Tachycardia is associated with mortality in patients who undergo thrombectomy. Further investigation is needed to determine whether this risk is modifiable.
PMID: 35367848
ISSN: 1532-8511
CID: 5192412

Severity of stenosis in symptomatic patients undergoing carotid interventions may influence perioperative neurologic events

Garg, Karan; Chang, Heepeel; Siracuse, Jeffrey J; Jacobowitz, Glenn R; Torres, Jose; Veith, Frank J; Patel, Virendra I; Maldonado, Thomas S; Sadek, Mikel; Cayne, Neal S; Rockman, Caron B
OBJECTIVE:Carotid artery plaque burden, indirectly measured by the degree of stenosis, quantifies future embolic risk. In natural history studies, patients with moderate degrees of stenosis have a lower stroke risk than those with severe stenosis. However, patients with symptomatic carotid stenosis who have experienced TIA or stroke are found to have both moderate and severe degrees of stenosis. We sought to examine the association carotid artery stenosis severity with outcomes in symptomatic patients undergoing carotid interventions including carotid endarterectomy (CEA), transfemoral carotid artery stenting (CAS) and transcervical carotid artery revascularization (TCAR). METHODS:The Society for Vascular Surgery Quality Initiative database was queried for all patients undergoing CAS, CEA and TCAR between 2003 and 2020. Patients were stratified into two groups based on the severity of stenosis - non-severe (0 - 69%) and severe (≥ 70%). Primary endpoints were periprocedural neurologic events (strokes and transient ischemic attacks (TIAs)). Secondary endpoints were periprocedural death, myocardial infarction (MI) and composite outcomes of stroke/death and stroke/death/MI per reporting standards for carotid interventions. RESULTS:Of 29,614 symptomatic patients included in the analysis, 5,296 (17.9%) patients underwent TCAR, 7,844 (26.5%) underwent CAS, and 16,474 (55.6%) underwent CEA for symptomatic carotid artery stenosis. In the CEA cohort, the neurologic event rate was similarly significantly lower in patients with severe stenosis when compared to those with non-severe stenosis (2.6% vs. 3.2%, P=.024). In the TCAR cohort, the periprocedural neurologic even rate was lower in patients with severe stenosis when compared to those with non-severe stenosis (3% vs. 4.3%, P=.033). There was no similar difference noted in the CAS cohort, with periprocedural neurologic event rates of 3.8% in the severe group versus 3.5% in the non-severe group (P=.518). On multivariable analysis, severe stenosis was associated with significantly decreased odds of post procedural neurologic events in patients undergoing CEA (odds ratio [OR] 0.75, 95% confidence interval [CI], 0.6 - 0.92; P=.007) and TCAR (OR .83; CI, .69 - 0.99; P=.039), but not CAS. CONCLUSION/CONCLUSIONS:Severe carotid stenosis as opposed to more moderate degrees of stenosis was associated with decreased rates of periprocedural stroke and TIAs in symptomatic patients undergoing TCAR and CEA, but not CAS. The finding of increased rates of periprocedural neurologic events in symptomatic patients with lesser degrees of stenosis undergoing TCAR and CEA warrants further evaluation with a particular focus on plaque morphology and brain physiology, and their inherent risks with carotid revascularization procedures.
PMID: 35272001
ISSN: 1097-6809
CID: 5183632

Hemorrhagic Conversion Of Ischemic Stroke Is Associated With Hematoma Expansion [Meeting Abstract]

Palaychuk, Natalie; Changa, Abhinav; Dogra, Siddhant; Wei, Jason; Lewis, Ariane; Lord, Aaron; Ishida, Koto; Zhang, Cen; Czeisler, Barry M.; Torres, Jose L.; Frontera, Jennifer; Dehkharghani, Seena; Melmed, Kara R.
ISI:000788100600385
ISSN: 0039-2499
CID: 5243802

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

Intracranial vertebrobasilar arterial calcification as a predictor for ischemic stroke due to atherosclerotic disease [Meeting Abstract]

Valdes, E; Raz, E; De, Havenon A; Torres, J; Yaghi, S
Background and aims: Intracranial arterial calcification (IAC) has been identified as an independent risk factor for ischemic stroke. The predictive value of calcification severity for the underlying pathophysiological mechanism of an ischemic stroke remains undetermined. We aimed to assess the degree of intracranial artery calcification in patients with ischemic stroke and evaluate its correlation with intracranial artery atherosclerotic disease as the underlying mechanism.
Method(s): Two hundred and eleven patients with strokes attributed to large vessel atherosclerotic disease from the NYU Ischemic Stroke Database, determined by two independent vascular neurologists, were enrolled. Patients with tandem lesions or competing pathophysiologic mechanisms were excluded. Head CT scans for each patient were reviewed. The degree of calcification of each vertebral and basilar artery was determined by two physicians using the Woodcock Score (interrater reliability score of kappa = 0.88).
Result(s): The highest prevalence of calcification was seen in the left vertebral artery (47%), and less commonly in the basilar artery (15%). There was a trend towards higher prevalence of moderate-severe IAC in patients with stroke due to intracranial atherosclerosis than patients with stroke due to extracranial atherosclerosis (40% vs. 28%, P = 0.073). The most common risk factors were hypertension (42 vs. 26%, p = 0.890), dyslipidemia (25 vs. 19%, p = 0.496), and type 2 diabetes (21 vs. 13%, p = 0.415), in patients with stroke due to intracranial atherosclerosis vs extracranial atherosclerosis, respectively.
Conclusion(s): There may be a positive correlation between the severity of vertebrobasilar atherosclerotic disease as determined by the Woodcock score and the likelihood that the underlying pathophysiological mechanism of an ischemic stroke is intracranial atherosclerotic disease.
Copyright
EMBASE:2014981691
ISSN: 1878-5883
CID: 5024542