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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

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

Efficacy and safety of nerinetide for the treatment of acute ischaemic stroke (ESCAPE-NA1): a multicentre, double-blind, randomised controlled trial

Hill, Michael D; Goyal, Mayank; Menon, Bijoy K; Nogueira, Raul G; McTaggart, Ryan A; Demchuk, Andrew M; Poppe, Alexandre Y; Buck, Brian H; Field, Thalia S; Dowlatshahi, Dar; van Adel, Brian A; Swartz, Richard H; Shah, Ruchir A; Sauvageau, Eric; Zerna, Charlotte; Ospel, Johanna M; Joshi, Manish; Almekhlafi, Mohammed A; Ryckborst, Karla J; Lowerison, Mark W; Heard, Kathy; Garman, David; Haussen, Diogo; Cutting, Shawna M; Coutts, Shelagh B; Roy, Daniel; Rempel, Jeremy L; Rohr, Axel Cr; Iancu, Daniela; Sahlas, Demetrios J; Yu, Amy Y X; Devlin, Thomas G; Hanel, Ricardo A; Puetz, Volker; Silver, Frank L; Campbell, Bruce C V; Chapot, René; Teitelbaum, Jeanne; Mandzia, Jennifer L; Kleinig, Timothy J; Turkel-Parrella, David; Heck, Donald; Kelly, Michael E; Bharatha, Aditya; Bang, Oh Young; Jadhav, Ashutosh; Gupta, Rishi; Frei, Donald F; Tarpley, Jason W; McDougall, Cameron G; Holmin, Staffan; Rha, Joung-Ho; Puri, Ajit S; Camden, Marie-Christine; Thomalla, Götz; Choe, Hana; Phillips, Stephen J; Schindler, Joseph L; Thornton, John; Nagel, Simon; Heo, Ji Hoe; Sohn, Sung-Il; Psychogios, Marios-Nikos; Budzik, Ronald F; Starkman, Sidney; Martin, Coleman O; Burns, Paul A; Murphy, Seán; Lopez, George A; English, Joey; Tymianski, Michael
BACKGROUND:Nerinetide, an eicosapeptide that interferes with post-synaptic density protein 95, is a neuroprotectant that is effective in preclinical stroke models of ischaemia-reperfusion. In this trial, we assessed the efficacy and safety of nerinetide in human ischaemia-reperfusion that occurs with rapid endovascular thrombectomy in patients who had an acute ischaemic stroke. METHODS:For this multicentre, double-blind, randomised, placebo-controlled study done in 48 acute care hospitals in eight countries, we enrolled patients with acute ischaemic stroke due to large vessel occlusion within a 12 h treatment window. Eligible patients were aged 18 years or older with a disabling ischaemic stroke at the time of randomisation, had been functioning independently in the community before the stroke, had an Alberta Stroke Program Early CT Score (ASPECTS) greater than 4, and vascular imaging showing moderate-to-good collateral filling, as determined by multiphase CT angiography. Patients were randomly assigned (1:1) to receive intravenous nerinetide in a single dose of 2·6 mg/kg, up to a maximum dose of 270 mg, on the basis of estimated or actual weight (if known) or saline placebo by use of a real-time, dynamic, internet-based, stratified randomised minimisation procedure. Patients were stratified by intravenous alteplase treatment and declared endovascular device choice. All trial personnel and patients were masked to sequence and treatment allocation. All patients underwent endovascular thrombectomy and received alteplase in usual care when indicated. The primary outcome was a favourable functional outcome 90 days after randomisation, defined as a modified Rankin Scale (mRS) score of 0-2. Secondary outcomes were measures of neurological disability, functional independence in activities of daily living, excellent functional outcome (mRS 0-1), and mortality. The analysis was done in the intention-to-treat population and adjusted for age, sex, baseline National Institutes of Health Stroke Scale score, ASPECTS, occlusion location, site, alteplase use, and declared first device. The safety population included all patients who received any amount of study drug. This trial is registered with ClinicalTrials.gov, NCT02930018. FINDINGS/RESULTS:Between March 1, 2017, and Aug 12, 2019, 1105 patients were randomly assigned to receive nerinetide (n=549) or placebo (n=556). 337 (61·4%) of 549 patients with nerinetide and 329 (59·2%) of 556 with placebo achieved an mRS score of 0-2 at 90 days (adjusted risk ratio 1·04, 95% CI 0·96-1·14; p=0·35). Secondary outcomes were similar between groups. We observed evidence of treatment effect modification resulting in inhibition of treatment effect in patients receiving alteplase. Serious adverse events occurred equally between groups. INTERPRETATION/CONCLUSIONS:Nerinetide did not improve the proportion of patients achieving good clinical outcomes after endovascular thrombectomy compared with patients receiving placebo. FUNDING/BACKGROUND:Canadian Institutes for Health Research, Alberta Innovates, and NoNO.
PMID: 32087818
ISSN: 1474-547x
CID: 4322952

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
ISI:000536058001210
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
ISI:000536058002105
ISSN: 0028-3878
CID: 4561212

Incidence of Hemorrhage of Combination IV tPA and Eptifibatide Therapy in Stroke Endovascular Thrombectomy [Meeting Abstract]

Shrestha, Ashik; Ye, Phillip; Zhou, Ting; Tiwari, Ambooj; Turkel-Parrella, David; Farkas, Jeffrey; Arcot, Karthikeyan; Crotty, Danielle
ISI:000453090803120
ISSN: 0028-3878
CID: 3561432

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
ISI:000453090803127
ISSN: 0028-3878
CID: 3561882

Dose and Time Dependence of Eptifibitide Complications in Patients undergoing Neuroendovascular Therapy with and Without Hyperacute Stenting [Meeting Abstract]

Bo, Ryan; Shrestha, Ashik; Zhou, Ting; Turkel-Parrella, David; Arcot, Karthikeyan; Farkas, Jeffrey; Tiwari, Ambooj; Crotty, Danielle
ISI:000453090803126
ISSN: 0028-3878
CID: 3561892

Assessing the Affect of Clot Firmness on the Speed and Grade of Recanalization in Hyperacute Neuroendovascular Therapy [Meeting Abstract]

Kurgansky, Gregory; Ye, Phillip; Bo, Ryan; Farkas, Jeffrey; Arcot, Karthikeyan; Turkel-Parrella, David; Tiwari, Ambooj
ISI:000453090803118
ISSN: 0028-3878
CID: 3561902