Thrombectomy vs Medical Management for Posterior Cerebral Artery Stroke: Systematic Review, Meta-Analysis, and Real-World Data.

BACKGROUND AND OBJECTIVES: There is a paucity of high-level evidence for endovascular thrombectomy (EVT) in posterior cerebral artery (PCA) strokes. METHODS: The MEDLINE, Embase, and Web of Science databases were queried for well-conducted cohort studies comparing EVT vs medical management (MM) for PCA strokes. Outcomes of interest included 90-day functional outcomes, symptomatic intracranial hemorrhage (sICH), and death. The level of evidence was determined per the Oxford Centre for Evidence-Based Medicine criteria. We also conducted a propensity score matched (PSM) analysis of the 2016-2020 National Inpatient Sample (NIS) to provide support for our findings with real-world data. RESULTS: A total of 2,095 patients (685 EVT and 1,410 MM) were identified across 5 well-conducted cohort studies. EVT was significantly associated with higher odds of no disability at 90 days (odds ratio [OR] 1.25, 95% CI 1.04-1.50, p = 0.015) but not functional independence (OR 0.87, 95% CI 0.72-1.07, p = 0.18). EVT was also associated with higher odds of sICH (OR 2.48, 95% CI 1.55-3.97, p < 0.001) and numerically higher odds of death (OR 1.32, 95% CI 0.73-2.38; p = 0.35). PSM analysis of 95,585 PCA stroke patients in the NIS showed that EVT (n = 1,540) was associated with lower rates of good discharge outcomes (24.4% vs 30.7%, p = 0.037), higher rates of in-hospital mortality (8.8% vs 4.9%, p = 0.021), higher rates of ICH (18.2% and 11.7%, p = 0.008), and higher rates of subarachnoid hemorrhage (3.9% vs 0.6%, p < 0.001). Among patients with moderate to severe strokes (NIH Stroke Scale 5 or greater), EVT was associated with significantly higher rates of good outcomes (21.7% vs 13.8%, p = 0.023) with similar rates of mortality (7.6% vs 6.6%, p = 0.67) and ICH (17.8% vs, 13.1%, p = 0.18). DISCUSSION: Our meta-analysis revealed that while EVT may be effective in alleviating disabling deficits due to PCA strokes, it is not associated with different odds of functional independence and may be associated with higher odds of sICH. These findings were corroborated by our large propensity score matched analysis of real-world data in the United States. Thus, the decision to pursue PCA thrombectomies should be carefully individualized for each patient. Future randomized trials are needed to further explore the efficacy and safety of EVT for the treatment of PCA strokes. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that in patients with acute PCA ischemic stroke, treatment with EVT compared with MM alone was associated with higher odds of no disabling deficit at 90 days and higher odds of sICH.

Sex discrepancies in the population incidence of stroke and hemorrhage related to atrial fibrillation or flutter.

INTRODUCTION: Atrial fibrillation or flutter (AF) is a well-known risk factor for ischemic stroke. While female sex has been associated with higher stroke risk among AF patients, overall sex-specific real-world burdens of AF-related strokes and hemorrhages are unknown. METHODS: The 2016-2020 National Inpatient Sample was queried for hospitalizations, morbidity, and mortality due to AF-related ischemic strokes and bleeds. Patient demographic information, vascular risk factors, comorbidities, and stroke characteristics were extracted using ICD-10 codes. Overall incidences were calculated using total population estimates provided by the United States Census Bureau, and relative risk was calculated by comparing annual incidences between men and women. RESULTS: 2,420,870 ischemic stroke hospitalizations were identified; 542,635 (22.4%) were associated with AF. Overall, women had similar risk of hospitalization due to AF-related ischemic strokes compared to men; however, women had a higher risk of morbidity and mortality (RR 1.13 and 1.17, respectively; both p<0.001). In contrast, women had lower incidences of hospitalization, morbidity, and mortality due to AF-related bleeds (RR 0.82, 0.94, and 0.74, respectively; all p<0.001). Among patients with AF-related ischemic strokes, women had lower rates of anticoagulation use, higher rates of large vessel occlusion, and higher stroke severity (all p<0.001). These trends persisted among patients 80 years or older (all p<0.001). CONCLUSION: Women in the United States have higher incidences of morbidity and mortality from AF-related ischemic strokes than men. Future studies should investigate strategies to reduce morbidity and mortality due to AF-related strokes in women.

Financial Conflicts of Interest Among Physician Authors of ACR Appropriateness Criteria.

BACKGROUND: The accuracy and completeness of self-disclosures by authors of imaging guidelines are not well known. OBJECTIVE: The aim of this study was to assess the accuracy of financial disclosures by US authors of ACR appropriateness criteria. METHODS: We reviewed financial disclosures provided by US-based authors of all ACR-AC published in 2019, 2021 and 2023. For each US- based author, payment reports were extracted from the Open Payments Database (OPD) in the previous 36 months related to general category and research payments categories. We analyzed each author individually to determine if the reported disclosures matched results from OPD. RESULTS: A total of 633 authorships, including 333 unique authors were included from 38 ACR AC articles in 2019, with 606 authorships (387 unique authors) from 35 ACR-AC articles published in 2021, and 540 authorships (367 unique authors) from 32 ACR AC articles published in 2023. Among authors who received industry payments, failure to disclose any financial relationship was seen in 125/147 unique authors in 2019, 142/148 authors in 2021 and 95/125 unique authors in 2023. The proportion of nondisclosed total value of payments was 86.1% in 2019, 88.6% in 2021 and 56.7% in 2023. General category payments were nondisclosed in 94.1% in 2019, 89.7% in 2021 and 94.4% in 2023 by payment value. CONCLUSION: Industry payments to authors of radiology guidelines are common and frequently undisclosed.

Accuracy of Financial Disclosures in Radiology Journals.

BACKGROUND: The accuracy and completeness of self-disclosures for value of industry payments by authors publishing in radiology journals are not well known. OBJECTIVE: The aim of this study was to assess the accuracy of financial disclosures by US authors in five prominent radiology journals. METHODS: We reviewed financial disclosures provided by US-based authors in five prominent radiology journals from original research and review articles published in 2021. For each author, payment reports were extracted from the Open Payments Database (OPD) in the previous 36 months related to general category, research, and ownership payments categories. We analyzed each author individually to determine if the reported disclosures matched results from OPD. RESULTS: A total of 4076 authorships, including 3406 unique authors, were selected from 643 articles across the five journals. 1388 (1032 unique authors) received industry payments within the previous 36 months, with a median total amount received per authorship of $6,650 (interquartile range = $355 to $87,725). 61 (4.4%) authors disclosed all industry relationships, 205 (14.8%) disclosed some of the OPD-reported relationships, and 1122 (80.8%) failed to disclose any relationship. Undisclosed payments totaled $186,578,350 representing 67.2% of all payments. Radiology had the highest proportion of authorships who disclosed some or all OPD-reported relationships (32.3%), compared to JVIR (18.2%), AJNR (17.3%), JACR (13.1%), and AJR (10.3%). CONCLUSIONS: Financial relationships with industry are common among US physician authors in prominent radiology journals and non-disclosure rates are high.

Single-Cell Analysis Reveals a Subset of High IL-12p40-Secreting Dendritic Cells within Mouse Bone Marrow-Derived Macrophages Differentiated with M-CSF.

Macrophages and dendritic cells (DCs), although ontogenetically distinct, have overlapping functions and exhibit substantial cell-to-cell heterogeneity that can complicate their identification and obscure innate immune function. In this study, we report that M-CSF-differentiated murine bone marrow-derived macrophages (BMDMs) exhibit extreme heterogeneity in the production of IL-12, a key proinflammatory cytokine linking innate and adaptive immunity. A microwell secretion assay revealed that a small fraction of BMDMs stimulated with LPS secrete most IL-12p40, and we confirmed that this is due to extremely high expression of Il12b, the gene encoding IL-12p40, in a subset of cells. Using an Il12b-YFP reporter mouse, we isolated cells with high LPS-induced Il12b expression and found that this subset was enriched for genes associated with the DC lineage. Single-cell RNA sequencing data confirmed a DC-like subset that differentiates within BMDM cultures that is transcriptionally distinct but could not be isolated by surface marker expression. Although not readily apparent in the resting state, upon LPS stimulation, this subset exhibited a typical DC-associated activation program that is distinct from LPS-induced stochastic BMDM cell-to-cell heterogeneity. Overall, our findings underscore the difficulty in distinguishing macrophages and DCs even in widely used in vitro murine BMDM cultures and could affect the interpretation of some studies that use BMDMs to explore acute inflammatory responses.

Systematic Review of Prophylactic Plastic Surgery Closure to Prevent Postoperative Wound Complications Following Spine Surgery.

Spinal surgeries are increasingly performed in the United States, but complication rates can be unacceptably high at up to 26%. Consequently, plastic surgeons (PS) are sometimes recruited by spine surgeons (SS) for intraoperative assistance with soft tissue closures. An electronic multidatabase literature search was systematically conducted to determine whether spinal wound closure performed by PS minimizes postoperative wound healing complications when compared to closure by SS (neurosurgical or orthopedic), with the hypothesis that closures by PS minimizes incidence of complications. All published studies involving patients who underwent posterior spinal surgery with closure by PS or SS at index spine surgery were identified. Filtering by exclusion criteria identified 10 studies, 4 of which were comparative in nature and included both closures by PS and SS. Of these 4, none reported significant differences in postoperative outcomes between the groups. Across all studies, PS were involved in cases with higher baseline risk for wound complications and greater comorbidity burden. Closures by PS were significantly more likely to have had prior chemotherapy in 2 of the 4 (50%) studies (P = 0.014, P < 0.001) and radiation in 3 of the 4 (75%) studies (P < 0.001, P < 0.01, P < 0.001). In conclusion, closures by PS are frequently performed in higher risk cases, and use of PS in these closures may normalize the risk of wound complications to that of the normal risk cohort, though the overall level of evidence of the published literature is low.

Predictors for large vessel recanalization before stroke thrombectomy: the HALT score.

BACKGROUND: Large vessel recanalization (LVR) before endovascular therapy (EVT) for acute large vessel ischemic strokes is a poorly understood phenomenon. Better understanding of predictors for LVR is important for optimizing stroke triage and patient selection for bridging thrombolysis. METHODS: In this retrospective cohort study, consecutive patients presenting to a comprehensive stroke center for EVT treatment were identified from 2018 to 2022. Demographic information, clinical characteristics, intravenous thrombolysis (IVT) use, and LVR before EVT were recorded. Factors independently associated with different rates of LVR were identified, and a prediction model for LVR was constructed. RESULTS: 640 patients were identified. 57 (8.9%) patients had LVR before EVT. A minority (36.4%) of LVR patients had significant improvements in National Institutes of Health Stroke Scale. Independent predictors for LVR were identified and used to construct the 8-point HALT score: hyperlipidemia (1 point), atrial fibrillation (1 point), location of vascular occlusion (internal carotid: 0 points, M1: 1 point, M2: 2 points, vertebral/basilar: 3 points), and thrombolysis at least 1.5 hours before angiography (3 points). The HALT score had an area under the receiver-operating curve (AUC) of 0.85 (95% CI 0.81 to 0.90, P<0.001) for predicting LVR. LVR before EVT occurred in only 1 of 302 patients (0.3%) with low (0-2) HALT scores. CONCLUSIONS: IVT at least 1.5 hours before angiography, site of vascular occlusion, atrial fibrillation, and hyperlipidemia are independent predictors for LVR. The 8-point HALT score proposed in this study may be a valuable tool for predicting LVR before EVT.

Radiographic signs of advanced cerebral venous thrombosis negatively modulate the effectiveness of endovascular treatments.

INTRODUCTION: Endovascular treatment (EVT) is a therapeutic option for cerebral venous thrombosis (CVT); however, its benefit over conservative medical management has not been proven. Whether current patient selection practices are appropriate for EVT is unclear. METHODS: This was a nationwide study of the 2016-2020 National Inpatient Sample database. Adult CVT patients and EVT treatments were identified. Patient demographics, medical comorbidities, CVT risk factors, and CVT manifestations were identified. Presence of radiographic signs of advanced and severe CVT (venous infarction, cerebral edema, and intracranial hemorrhage) were recorded. Primary and secondary outcomes were good discharge outcomes and in-hospital mortality, respectively. RESULTS: 17,130 CVT patients were identified, and 56.7% had good discharge outcomes while 4.6% died during hospitalization. 945 (5.5%) received EVT, and EVT patients were more likely to have cerebral infarction (35.4% vs. 21.8%, p<0.001), edema (35.4% vs. 20.1%, p<0.001), and hemorrhage (37.6% vs. 19.7%, p<0.001). After multivariable adjustments, EVT for patients without infarction, edema, or hemorrhage was moderately associated with higher odds of good outcomes (OR 1.86 [95%CI 0.98 - 3.53], p=0.059) and resulted in zero deaths. However, with increasing burden of radiographic signs of advanced CVT measured by the cumulative presence of infraction, edema, and hemorrhage, EVT was associated with decreasing odds of good outcomes and increasing odds of in-hospital mortality compared to medical management (interaction p=0.046 and 0.029, respectively). CONCLUSIONS: EVT may lead to higher rates of favorable hospitalization outcomes in patients who have not yet developed overt parenchymal manifestations of backpressure changes; presence of infarction, edema, and hemorrhage may diminish the short-term effectiveness of EVT.

Intravenous thrombolysis prior to endovascular thrombectomy in elderly stroke patients: An analysis of the National Inpatient Sample database.

BACKGROUND: The effectiveness of intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT), also termed bridging thrombolysis, remains uncertain, and there is limited data on its use for elderly patients who may be more prone to hemorrhagic complications. METHODS: This was a large-scale cross-sectional study of the 2016-2020 National Inpatient Sample (NIS) database. Adult EVT patients presenting directly to thrombectomy centers without prior treatment were identified. Patient demographics, stroke risk factors, stroke etiology, medical comorbidities, and IVT treatment were recorded. Outcomes of interest include in-hospital mortality, rates of discharge to home, and hemorrhagic complications. Multivariable logistic regression models were used to account for possible confounders. RESULTS: 35,735 EVT patients presenting directly to thrombectomy centers without prior thrombolytic treatment were identified. 32.5% (11,630 patients) were treated with bridging thrombolysis. Overall, bridging thrombolysis was significantly associated with lower rates of in-hospital mortality (8.8% vs. 11.2%, p < 0.001) and higher rates of discharge to home (38.0% vs. 28.7%, p < 0.001). IVT's association with lower odds of in-hospital mortality was significantly attenuated with increasing age (interaction p = 0.038), and there was no significant association between IVT treatment with in-hospital mortality for patients 80 years or older (OR 0.99 [95%CI 0.72-1.35], p = 0.94). Similarly, older age significantly amplifies the hemorrhagic risk associated with bridging thrombolysis (interaction p = 0.006). When considering only patients without hemorrhagic complications, age does not significantly modulate IVT's association with patient outcomes. CONCLUSIONS: Bridging thrombolysis may be associated with better outcomes; however, its benefit may be diminished among elderly patients due to higher rates of hemorrhagic complications.

Analysis of Medical Malpractice Claims Involving Interventional Radiologists: A Comprehensive Analysis From Two National Legal Databases.

PURPOSE: The nature of lawsuits involving interventional radiologists (IRs) is not well understood. The purposes of this article are to provide an overview of the causes of action underlying medical malpractice lawsuits related to IRs and to characterize the associated factors and outcomes. METHODS: Two large legal databases were used to search for US legal cases in which there were jury awards and settlements involving IRs in the United States. Cases were screened to include only those cases in which the cause of action involved negligence on the part of IRs. RESULTS: A total of 389 published case summaries were identified, of which 93 were eligible to be included in the analysis. In 46% of the cases (43 of 93), medical malpractice was alleged against an individual IR, whereas in 43% (40 of 93), it was alleged against both an individual IR and a health care institution. Thirty-five percent of IR malpractice cases (33 of 93) involved the performance of a vascular procedure, most commonly embolization procedures (30% [n = 10]), stenting or angioplasty (21% [n = 7]), and diagnostic arteriography and angiography (18% [n = 6]). Twenty-six percent of cases (24 of 93) involved IR performance of a biopsy. Eighteen percent of cases (17 of 93) involved a failure to gain informed consent in addition to an allegation of medical negligence during treatment. Eleven percent of cases (10 of 93) were resolved by settlement, with an average settlement amount of $877,500 (range, $200,000-$2,700,000). Among the 72 cases that went to trial, 74% (53 of 72) resulted in judgments for the defendants, and 26% (19 of 72) resulted in judgements for the plaintiffs, with an average award of $2,012,243 (range, $101,667-$6,400,000). CONCLUSIONS: Vascular procedures and biopsies were the most frequent reasons for malpractice lawsuits involving IRs. Failure to gain informed consent in addition to an allegation of medical negligence during treatment was not infrequent. Although the majority of published medical malpractice claims involving IRs resulted in judgments in favor of the defendants, the average amount awarded to plaintiffs was higher compared with previous data reported for all physicians.

Contrast Agent Administration as a Source of Liability: A Legal Database Analysis.

Background Radiology ranks high in terms of specialties implicated in medical malpractice claims. While most radiologists understand the risks of liability for missed findings or lapses of communication, liability for the use of contrast agents in imaging procedures may be underappreciated. Purpose To review the clinical context and outcomes of lawsuits alleging medical malpractice for contrast-related imaging procedures. Materials and Methods Two large U.S. legal databases were queried using the terms "Contrast" and "Radiology OR Radiologist" from database inception to October 31, 2022, to identify cases with published decisions or settlements related to medical malpractice in patients who underwent contrast-related imaging procedures. The search results were screened to include only those cases involving the practice area of health care law where there was at least one claim of medical negligence against a health care institution or provider. Data on the medical complications alleged by patients after contrast agent administration and on the trial were extracted and reported using descriptive statistics. Results A total of 151 published case summaries were included in the analysis. Anaphylactic reaction following contrast agent administration was the most common medical complication observed (30% [45 of 151 cases]), of which failure to diagnose developing anaphylaxis or failure to treat the anaphylactic reaction made up the majority of allegations (93% [42 of 45]). Inappropriate management of contrast media extravasation (27% [41 of 151]) and alleged contrast agent-induced acute kidney injury (13% [19 of 151]) were the next most frequent causes of lawsuits. Of the 11 cases of alleged kidney injury that went to trial, all resulted in a judgment in favor of the defense. Conclusion This study highlights the key reasons for medical malpractice lawsuits associated with use of contrast media and outcomes from these lawsuits. © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Trop in this issue.

Diversity in Radiology Residents Relative to Other Specialties- Trends Over the Past Decade.

RATIONALE AND OBJECTIVES: The objective of this study was to assess diversity among radiology residents relative to other specialties and compare it with historical trends. MATERIALS AND METHODS: The Graduate Medical Education results from 2010-2011 to 2020-2021 were accessed for demographic information for major medical specialties (number of residents > 500 as of the 2020-2021 report). Subspecialties and fellowship programs were not included in this analysis. The racial and ethnicity breakdowns were extracted, including Black, White/Caucasian, Asian, Hispanic, and others. The changes in racial and ethnicity composition of residents in radiology was compared to other specialties using the Chi Squared test using a significance level of p < 0.05. RESULTS: In 2020-2021, radiology ranked ninth in total resident enrollment among the 21 largest ACGME training programs, unchanged when compared to 2010-2011. Amongst all specialties, Radiology ranked 10th for Black and 9th for Hispanic representation in 2020-2021.The percentage of Black residents increased from 3.07% in 2010-2011 to 3.83% in 2020-2021. The percentage of Hispanic Radiology residents increased from 4.83% to 7.35%, constituting the third largest increase amongst all specialties. CONCLUSION: The representation of Blacks and Hispanics in Radiology has improved relative to other medical specialties in the last decade.