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1.
J Neurointerv Surg ; 2021 Oct 13.
Artigo em Inglês | MEDLINE | ID: mdl-34645705

RESUMO

BACKGROUND: We investigated the effects of the side of large vessel occlusion (LVO) on post-thrombectomy infarct volume and clinical outcome with regard to admission National Institutes of Health Stroke Scale (NIHSS) score. METHODS: We retrospectively identified patients with anterior LVO who received endovascular thrombectomy and follow-up MRI. Applying voxel-wise general linear models and multivariate analysis, we assessed the effects of occlusion side, admission NIHSS, and post-thrombectomy reperfusion (modified Thrombolysis in Cerebral Infarction, mTICI) on final infarct distribution and volume as well as discharge modified Rankin Scale (mRS) score. RESULTS: We included 469 patients, 254 with left-sided and 215 with right-sided LVO. Admission NIHSS was higher in those with left-sided LVO (median (IQR) 16 (10-22)) than in those with right-sided LVO (14 (8-16), p>0.001). In voxel-wise analysis, worse post-thrombectomy reperfusion, lower admission NIHSS score, and poor discharge outcome were associated with right-hemispheric infarct lesions. In multivariate analysis, right-sided LVO was an independent predictor of larger final infarct volume (p=0.003). There was a significant three-way interaction between admission stroke severity (based on NIHSS), LVO side, and mTICI with regard to final infarct volume (p=0.041). Specifically, in patients with moderate stroke (NIHSS 6-15), incomplete reperfusion (mTICI 0-2b) was associated with larger final infarct volume (p<0.001) and worse discharge outcome (p=0.02) in right-sided compared with left-sided LVO. CONCLUSIONS: When adjusted for admission NIHSS, worse post-thrombectomy reperfusion is associated with larger infarct volume and worse discharge outcome in right-sided versus left-sided LVO. This may represent larger tissue-at-risk in patients with right-sided LVO when applying admission NIHSS as a clinical biomarker for penumbra.

2.
J Stroke Cerebrovasc Dis ; 31(1): 106155, 2021 Oct 20.
Artigo em Inglês | MEDLINE | ID: mdl-34688213

RESUMO

OBJECTIVES: Improvements in acute stroke care have led to an increase in ischemic stroke survivors, who are at risk for development of post-ischemic stroke epilepsy (PISE). The impact of therapies such as thrombectomy and thrombolysis on risk of hospital revisits for PISE is unclear. We utilized administrative data to investigate the association between stroke treatment and PISE-related visits. MATERIALS AND METHODS: Using claims data from California, New York, and Florida, we performed a retrospective analysis of adult survivors of acute ischemic strokes. Patients with history of epilepsy, trauma, infections, or tumors were excluded. Included patients were followed for a primary outcome of revisits for seizures or epilepsy. Cox proportional hazards regression was used to identify covariates associated with PISE. RESULTS: In 595,545 included patients (median age 74 [IQR 21], 52% female), the 6-year cumulative rate of PISE-related revisit was 2.20% (95% CI 2.16-2.24). In multivariable models adjusting for demographics, comorbidities, and indicators of stroke severity, IV-tPA (HR 1.42, 95% CI 1.31-1.54, p<0.001) but not MT (HR 1.62, 95% CI 0.90-1.50, p=0.2) was associated with PISE-related revisit. Patients who underwent decompressive craniectomy experienced a 2-fold increase in odds for returning with PISE (HR 2.35, 95% CI 1.69-3.26, p<0.001). In-hospital seizures (HR 4.06, 95% CI 3.76-4.39, p<0.001) also elevated risk for PISE. SIGNIFICANCE: We demonstrate that ischemic stroke survivors who received IV-tPA, underwent decompressive craniectomy, or experienced acute seizures were at increased risk PISE-related revisit. Close attention should be paid to these patients with increased potential for long-term development of and re-hospitalization for PISE.

3.
Stroke ; : STROKEAHA121034268, 2021 Sep 22.
Artigo em Inglês | MEDLINE | ID: mdl-34547927

RESUMO

BACKGROUND AND PURPOSE: The purpose of the COMPLETE (International Acute Ischemic Stroke Registry With the Penumbra System Aspiration Including the 3D Revascularization Device) registry was to evaluate the generalizability of the safety and efficacy of the Penumbra System (Penumbra, Inc, Alameda) in a real-world setting. METHODS: COMPLETE was a global, prospective, postmarket, multicenter registry. Patients with large vessel occlusion-acute ischemic stroke who underwent mechanical thrombectomy using the Penumbra System with or without the 3D Revascularization Device as frontline approach were enrolled at 42 centers (29 United States, 13 Europe) from July 2018 to October 2019. Primary efficacy end points were successful postprocedure angiographic revascularization (modified Thrombolysis in Cerebral Infarction ≥2b) and 90-day functional outcome (modified Rankin Scale score 0-2). The primary safety end point was 90-day all-cause mortality. An imaging core lab determined modified Thrombolysis in Cerebral Infarction scores, Alberta Stroke Program Early CT Scores, clot location, and occurrence of intracranial hemorrhage at 24 hours. Independent medical reviewers adjudicated safety end points. RESULTS: Six hundred fifty patients were enrolled (median age 70 years, 54.0% female, 49.2% given intravenous recombinant tissue plasminogen activator before thrombectomy). Rate of modified Thrombolysis in Cerebral Infarction 2b to 3 postprocedure was 87.8% (95% CI, 85.3%-90.4%). First pass and postprocedure rates of modified Thrombolysis in Cerebral Infarction 2c to 3 were 41.5% and 66.2%, respectively. At 90 days, 55.8% (95% CI, 51.9%-59.7%) had modified Rankin Scale score 0 to 2, and all-cause mortality was 15.5% (95% CI, 12.8%-18.3%). CONCLUSIONS: Using Penumbra System for frontline mechanical thrombectomy treatment of patients with large vessel occlusion-acute ischemic stroke in a real-world setting was associated with angiographic, clinical, and safety outcomes that were comparable to prior randomized clinical trials with stringent site and operator selection criteria. REGISTRATION: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03464565.

4.
Stroke ; : STROKEAHA120033326, 2021 Sep 14.
Artigo em Inglês | MEDLINE | ID: mdl-34517765

RESUMO

BACKGROUND AND PURPOSE: Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race. METHODS: Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days. RESULTS: Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72-84), compared with 63 years (54-74) for NHB, and 71 years (60-80) for NHW patients (P<0.001). Hispanic patients had a higher incidence of diabetes (41%; P<0.001) and hypertension (82%; P<0.001) compared with NHW and NHB patients. Median procedure time was shorter in Hispanics (36 minutes) compared to NHB (39 minutes) and NHW (44 minutes) patients (P<0.001). In multivariate analysis, Hispanic patients were less likely to have favorable outcome (odds ratio, 0.502 [95% CI, 0.263-0.959]), controlling for other significant predictors (age, admission National Institutes Health Stroke Scale, onset to groin time, number of attempts, procedure time). CONCLUSIONS: Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.

5.
J Neurointerv Surg ; 2021 Sep 02.
Artigo em Inglês | MEDLINE | ID: mdl-34475250

RESUMO

Carotid revascularization is an important method of stroke prevention and includes carotid endarterectomy and transfemoral carotid angioplasty and stenting. More recently, a hybrid open-endovascular approach, termed transcarotid artery revascularization (TCAR), is garnering increased attention. Although fundamentally a 'stenting procedure', unlike transfemoral carotid angioplasty and stenting, TCAR allows for a proximal neuroprotection strategy based on flow reversal. In this technical video, we will review operative techniques and nuances of the TCAR procedure, with a particular focus on the neurovascular proceduralist looking to adopt this technique into routine clinical practice(video 1).neurintsurg;neurintsurg-2021-018024v1/V1F1V1Video 1.

6.
Nat Commun ; 12(1): 5119, 2021 08 25.
Artigo em Inglês | MEDLINE | ID: mdl-34433813

RESUMO

Radiological examination of the brain is a critical determinant of stroke care pathways. Accessible neuroimaging is essential to detect the presence of intracerebral hemorrhage (ICH). Conventional magnetic resonance imaging (MRI) operates at high magnetic field strength (1.5-3 T), which requires an access-controlled environment, rendering MRI often inaccessible. We demonstrate the use of a low-field MRI (0.064 T) for ICH evaluation. Patients were imaged using conventional neuroimaging (non-contrast computerized tomography (CT) or 1.5/3 T MRI) and portable MRI (pMRI) at Yale New Haven Hospital from July 2018 to November 2020. Two board-certified neuroradiologists evaluated a total of 144 pMRI examinations (56 ICH, 48 acute ischemic stroke, 40 healthy controls) and one ICH imaging core lab researcher reviewed the cases of disagreement. Raters correctly detected ICH in 45 of 56 cases (80.4% sensitivity, 95%CI: [0.68-0.90]). Blood-negative cases were correctly identified in 85 of 88 cases (96.6% specificity, 95%CI: [0.90-0.99]). Manually segmented hematoma volumes and ABC/2 estimated volumes on pMRI correlate with conventional imaging volumes (ICC = 0.955, p = 1.69e-30 and ICC = 0.875, p = 1.66e-8, respectively). Hematoma volumes measured on pMRI correlate with NIH stroke scale (NIHSS) and clinical outcome (mRS) at discharge for manual and ABC/2 volumes. Low-field pMRI may be useful in bringing advanced MRI technology to resource-limited settings.


Assuntos
Hemorragia Cerebral/diagnóstico por imagem , Imageamento por Ressonância Magnética/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Encéfalo/diagnóstico por imagem , Feminino , Humanos , Imageamento por Ressonância Magnética/economia , Imageamento por Ressonância Magnética/instrumentação , Masculino , Pessoa de Meia-Idade , Neuroimagem/economia , Neuroimagem/instrumentação , Neuroimagem/métodos
7.
JAMA Neurol ; 78(8): 993-1003, 2021 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-34125151

RESUMO

Importance: Moyamoya disease (MMD), a progressive vasculopathy leading to narrowing and ultimate occlusion of the intracranial internal carotid arteries, is a cause of childhood stroke. The cause of MMD is poorly understood, but genetic factors play a role. Several familial forms of MMD have been identified, but the cause of most cases remains elusive, especially among non-East Asian individuals. Objective: To assess whether ultrarare de novo and rare, damaging transmitted variants with large effect sizes are associated with MMD risk. Design, Setting, and Participants: A genetic association study was conducted using whole-exome sequencing case-parent MMD trios in a small discovery cohort collected over 3.5 years (2016-2019); data were analyzed in 2020. Medical records from US hospitals spanning a range of 1 month to 1.5 years were reviewed for phenotyping. Exomes from a larger validation cohort were analyzed to identify additional rare, large-effect variants in the top candidate gene. Participants included patients with MMD and, when available, their parents. All participants who met criteria and were presented with the option to join the study agreed to do so; none were excluded. Twenty-four probands (22 trios and 2 singletons) composed the discovery cohort, and 84 probands (29 trios and 55 singletons) composed the validation cohort. Main Outcomes and Measures: Gene variants were identified and filtered using stringent criteria. Enrichment and case-control tests assessed gene-level variant burden. In silico modeling estimated the probability of variant association with protein structure. Integrative genomics assessed expression patterns of MMD risk genes derived from single-cell RNA sequencing data of human and mouse brain tissue. Results: Of the 24 patients in the discovery cohort, 14 (58.3%) were men and 18 (75.0%) were of European ancestry. Three of 24 discovery cohort probands contained 2 do novo (1-tailed Poisson P = 1.1 × 10-6) and 1 rare, transmitted damaging variant (12.5% of cases) in DIAPH1 (mammalian diaphanous-1), a key regulator of actin remodeling in vascular cells and platelets. Four additional ultrarare damaging heterozygous DIAPH1 variants (3 unphased) were identified in 3 other patients in an 84-proband validation cohort (73.8% female, 77.4% European). All 6 patients were non-East Asian. Compound heterozygous variants were identified in ena/vasodilator-stimulated phosphoproteinlike protein EVL, a mammalian diaphanous-1 interactor that regulates actin polymerization. DIAPH1 and EVL mutant probands had severe, bilateral MMD associated with transfusion-dependent thrombocytopenia. DIAPH1 and other MMD risk genes are enriched in mural cells of midgestational human brain. The DIAPH1 coexpression network converges in vascular cell actin cytoskeleton regulatory pathways. Conclusions and Relevance: These findings provide the largest collection to date of non-East Asian individuals with sporadic MMD harboring pathogenic variants in the same gene. The results suggest that DIAPH1 is a novel MMD risk gene and impaired vascular cell actin remodeling in MMD pathogenesis, with diagnostic and therapeutic ramifications.

8.
World Neurosurg ; 151: e871-e879, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-33974981

RESUMO

BACKGROUND: Mechanical thrombectomy (MT) is the standard of care for the treatment of proximal anterior circulation large vessel occlusions. However, little is known about its efficacy and safety in the treatment of distal intracranial occlusions. METHODS: This is a multicenter retrospective study of patients treated with MT at 15 comprehensive centers between January 2015 and December 2018. The study cohort was divided into 2 groups based on the location of occlusion (proximal vs. distal). Distal occlusion was defined as occlusion of M3 segment of the middle cerebral artery, any segment of the anterior cerebral artery, or any segment of the posterior cerebral artery. Only isolated distal occlusion was included. Good outcome was defined as 90-day modified Rankin scale score 0-2. RESULTS: A total of 4710 patients were included in this study, of whom 189 (4%) had MT for distal occlusions. Compared with the proximal occlusion group, distal occlusion group had a higher rate of good outcome (45% vs. 36%; P = 0.03) and a lower rate of successful reperfusion (78% vs. 84%; P = 0.04). However, the differences did not retain significance in adjusted models. Otherwise there was no difference in the rate of hemorrhagic complications, mortality, or procedure-related complications between the 2 groups. Successful reperfusion, age, and admission stroke severity emerged as predictors of good functional outcome in the distal occlusion group. CONCLUSIONS: Thrombectomies of distal vessels achieve high rate of successful reperfusion with similar safety profile to those in more proximal locations.


Assuntos
Doenças Arteriais Cerebrais/patologia , Doenças Arteriais Cerebrais/cirurgia , Trombectomia/métodos , Adulto , Idoso , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Trombectomia/efeitos adversos , Resultado do Tratamento
9.
J Neurosurg ; : 1-11, 2021 May 07.
Artigo em Inglês | MEDLINE | ID: mdl-33962378

RESUMO

OBJECTIVE: The utility of endovascular thrombectomy (EVT) in patients with acute ischemic stroke, large vessel occlusion (LVO), and low Alberta Stroke Program Early CT Scores (ASPECTS) remains uncertain. The objective of this study was to determine the health outcomes and cost-effectiveness of EVT versus medical management in patients with ASPECTS < 6. METHODS: A decision-analytical study was performed with Markov modeling to estimate the lifetime quality-adjusted life-years (QALYs) and associated costs of EVT-treated patients compared to medical management. The study was performed over a lifetime horizon with a societal perspective in the US setting. RESULTS: The incremental cost-effectiveness ratios were $412,411/QALY and $1,022,985/QALY for 55- and 65-year-old groups in the short-term model. EVT was the long-term cost-effective strategy in 96.16% of the iterations and resulted in differences in health benefit of 2.21 QALYs and 0.79 QALYs in the 55- and 65-year-old age groups, respectively, equivalent to 807 days and 288 days in perfect health. EVT remained the more cost-effective strategy when the probability of good outcome with EVT was above 16.8% or as long as the good outcome associated with the procedure was at least 1.6% higher in absolute value than that of medical management. EVT remained cost-effective even when its cost exceeded $100,000 (threshold was $108,036). Although the cost-effectiveness decreased with age, EVT was cost-effective for 75-year-old patients as well. CONCLUSIONS: This study suggests that EVT is the more cost-effective approach compared to medical management in patients with ASPECTS < 6 in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with nonreperfusion.

11.
World Neurosurg ; 152: e23-e31, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33862298

RESUMO

OBJECTIVE: For idiopathic normal pressure hydrocephalus (iNPH), risk stratifying patients and identifying those who are likely to fare well after ventriculoperitoneal shunt (VP) surgery may help improve quality of care and reduce unplanned readmissions. The aim of this study was to investigate the drivers of 30- and 90-day readmissions after VP shunt surgery for iNPH in elderly patients. METHODS: The Nationwide Readmission Database, years 2013 to 2015, was queried. Elderly patients (≥65 years old) undergoing VP shunt surgery were identified using the International Classification of Diseases, Ninth Revision, Clinical Modification coding system. Unique patient linkage numbers were used to follow patients and identify 30- and 31- to 90-day readmission rates. Patients were grouped by no readmission (Non-R), readmission within 30 days (30-R), and readmission within 31 to 90 days (90-R). RESULTS: We identified 7199 elderly patients undergoing VP shunt surgery for iNPH. A total of 1413 (19.6%) patients were readmitted (30-R: n = 812 [11.3%] vs. 90-R: n = 601 [8.3%] vs. Non-R: n = 5786). The most prevalent 30- and 90-day complications seen among the readmitted cohort were mechanical complication of nervous system device implant (30-R: 16.1%, 90-R: 12.4%), extracranial postoperative infection (30-R: 10.4%, 90-R: 7.0%), and subdural hemorrhage (30-R: 6.0%, 90-R: 16.4%). On multivariate regression analysis, age, diabetes, and renal failure were independently associated with 30-day readmission; female sex, and 26th to 50th household income percentile were independently associated with reduced likelihood of 90-day readmission. Having any complication during the index admission independently associated with both 30- and 90-day readmission. CONCLUSIONS: In this study, we identify the most common drivers for readmission for elderly patients with iNPH undergoing VP shunt surgery.


Assuntos
Hidrocefalia de Pressão Normal/epidemiologia , Hidrocefalia de Pressão Normal/cirurgia , Readmissão do Paciente/tendências , Complicações Pós-Operatórias/epidemiologia , Derivação Ventriculoperitoneal/tendências , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Feminino , Seguimentos , Humanos , Hidrocefalia de Pressão Normal/diagnóstico , Masculino , Complicações Pós-Operatórias/diagnóstico , Estudos Retrospectivos , Fatores de Risco , Fatores de Tempo , Estados Unidos/epidemiologia , Derivação Ventriculoperitoneal/efeitos adversos
12.
Sci Immunol ; 6(56)2021 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-33891558

RESUMO

Opportunities to interrogate the immune responses in the injured tissue of living patients suffering from acute sterile injuries such as stroke and heart attack are limited. We leveraged a clinical trial of minimally invasive neurosurgery for patients with intracerebral hemorrhage (ICH), a severely disabling subtype of stroke, to investigate the dynamics of inflammation at the site of brain injury over time. Longitudinal transcriptional profiling of CD14+ monocytes/macrophages and neutrophils from hematomas of patients with ICH revealed that the myeloid response to ICH within the hematoma is distinct from that in the blood and occurs in stages conserved across the patient cohort. Initially, hematoma myeloid cells expressed a robust anabolic proinflammatory profile characterized by activation of hypoxia-inducible factors (HIFs) and expression of genes encoding immune factors and glycolysis. Subsequently, inflammatory gene expression decreased over time, whereas anti-inflammatory circuits were maintained and phagocytic and antioxidative pathways up-regulated. During this transition to immune resolution, glycolysis gene expression and levels of the potent proresolution lipid mediator prostaglandin E2 remained elevated in the hematoma, and unexpectedly, these elevations correlated with positive patient outcomes. Ex vivo activation of human macrophages by ICH-associated stimuli highlighted an important role for HIFs in production of both inflammatory and anti-inflammatory factors, including PGE2, which, in turn, augmented VEGF production. Our findings define the time course of myeloid activation in the human brain after ICH, revealing a conserved progression of immune responses from proinflammatory to proresolution states in humans after brain injury and identifying transcriptional programs associated with neurological recovery.

13.
J Patient Saf ; 2021 Apr 14.
Artigo em Inglês | MEDLINE | ID: mdl-33852541

RESUMO

BACKGROUND: The presentation of critically ill patients to emergency departments often necessitates interhospital transfer (IHT) to a tertiary care center for specialized neurocritical care. Patients with nontraumatic intracranial hemorrhage represent a critically ill population subject to high rates of IHT and who is thus an important target for research and quality improvement of IHT. We describe the use of an innovative simulation methodology engaging transfer staff, clinicians, and stakeholders to refine and facilitate the adoption of a standardized IHT protocol for transferring patients with neurovascular emergencies. METHODS: This was a qualitative study using a phenomenological approach. Participants consisted of IHT call center staff members, neurointensivists, neurosurgeons, and emergency physicians. We conducted a standardized telephone-based simulation case to prime participants for feedback on their experiences with IHT for intracranial hemorrhage patients. Facilitators conducted focus groups immediately after the simulation to identify process improvement opportunities. A structured thematic analysis identified overarching concepts from the data. RESULTS: We achieved data saturation with 7 simulations and a total of 24 participants. Thematic analysis identified 3 IHT-specific themes: (1) challenges unique to multispecialty critical illness, (2) interdisciplinary relationships and dynamics, and (3) communication and information processing for IHT. Three quality improvement initiatives emerged from the debriefings: standardized communication checklist, early acceptance protocol, and structure for telephone-based care handoffs. CONCLUSIONS: We demonstrate the use of telephone-based simulation technology to identify potential pitfalls and accelerate the adoption of a new IHT protocol for patients with nontraumatic intracranial hemorrhage. New quality improvement strategies can organically result through interprofessional debriefings for patients with potentially complex handoffs between hospitals.

14.
World Neurosurg ; 149: e1-e10, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33662608

RESUMO

OBJECTIVE: It is difficult to predict which patients with idiopathic normal pressure hydrocephalus (iNPH) will improve after shunt surgery. This study investigated the association between preoperative imaging parameters in patients with iNPH and long-term outcome after shunt placement. METHODS: Patients with iNPH who showed a response to large-volume cerebrospinal fluid drainage and subsequently underwent ventriculoperitoneal shunt surgery were reviewed. Long-term patient-reported outcomes were obtained by telephone interview. Preoperative computed tomography and/or magnetic resonance imaging were retrospectively reviewed to determine associations between imaging parameters and clinical outcome. RESULTS: The final analysis included 37 patients. The median duration between shunt surgery and telephone interview was 30 months (range, 12-56 months). Gait improvement after shunting was present more often in patients without focally dilated sulci (95% vs. 71%, P = 0.04), but a statistically significant relationship was not established after logistic regression. Patients with cognitive improvement after shunting had a higher preoperative Evans index (mean 0.41 vs. 0.36, P < 0.01), and Evans index was a predictor of cognitive improvement (odds ratio = 1.40, scale of 0.01, P = 0.01). CONCLUSIONS: Higher Evans index is a predictor of long-term cognitive improvement after shunt placement; however, no cutoff value demonstrates sufficient accuracy for the selection of shunt candidates. None of the evaluated imaging features was predictive of long-term gait or urinary improvement. The utility of imaging to predict a response to shunting is limited, and no imaging feature alone can be used to exclude patients from shunt surgery.


Assuntos
Hidrocefalia de Pressão Normal/diagnóstico por imagem , Hidrocefalia de Pressão Normal/cirurgia , Resultado do Tratamento , Derivação Ventriculoperitoneal , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
15.
Int J Stroke ; : 17474930211008701, 2021 Apr 15.
Artigo em Inglês | MEDLINE | ID: mdl-33759645

RESUMO

BACKGROUND: Triage for suspected acute stroke has two main options: (1) transport to the closest primary stroke center (PSC) and then to the nearest comprehensive stroke center (CSC) (Drip-and-Ship) or (2) transport the patient to the nearest CSC, bypassing a closer PSC (mothership). The purpose was to evaluate the effectiveness of drip-and-ship versus mothership models for acute stroke patients. METHODS: A Markov decision-analytic model was constructed. All model parameters were derived from recent medical literature. Our target population was adult patient with sudden onset of acute stroke within 8 h of onset over a one-year horizon. The primary outcome was quantified in terms of quality-adjusted-life-years (QALYs). RESULTS: The base case scenario show that the drip-and-ship strategy has a slightly higher expected health benefit, 0.591 QALY, as compared to 0.586 QALY in the mothership strategy when the time to PSC is 30 min and to CSC is 65 min, although the difference in health benefit becomes minimal as the time to PSC increases towards 60 min. Multiple sensitivity analyses show that when both PSC and CSC are far from place of onset (>1.5 h away), drip-and-ship becomes the better strategy. Mothership strategy is favored by smaller difference between distances to PSC and CSC, shorter transfer time from PSC to CSC, and longer delay in reperfusion in CSC for transferred patients. Drip-and-ship is favored by the reverse. CONCLUSION: Drip-and-ship has a slightly higher utility than mothership. This study assesses the complex issue of prehospital triage of acute stroke patients and can provide a framework for real-world data input.

16.
Stroke ; 52(5): 1733-1740, 2021 May.
Artigo em Inglês | MEDLINE | ID: mdl-33682454

RESUMO

BACKGROUND AND OBJECTIVES: IL-6 (interleukin 6) is a proinflammatory cytokine and an established biomarker in acute brain injury. We sought to determine whether admission IL-6 levels are associated with severity and functional outcome after spontaneous intracerebral hemorrhage (ICH). METHODS: We performed an exploratory analysis of the recombinant activated FAST trial (Factor VII for Acute ICH). Patients with admission serum IL-6 levels were included. Regression analyses were used to assess the associations between IL-6 and 90-day modified Rankin Scale. In secondary analyses, we used linear regression to evaluate the association between IL-6 and baseline ICH and perihematomal edema volumes. RESULTS: Of 841 enrolled patients, we included 552 (66%) with available admission IL-6 levels (mean age 64 [SD 13], female sex 203 [37%]). IL-6 was associated with poor outcome (modified Rankin Scale, 4-6; per additional 1 ng/L, odds ratio, 1.30 [95% CI, 1.04-1.63]; P=0.02) after adjustment for known predictors of outcome after ICH and treatment group. IL-6 was associated with ICH volume after adjustment for age, sex, and ICH location, and this association was modified by location (multivariable interaction, P=0.002), with a stronger association seen in lobar (ß, 12.51 [95% CI, 6.47-18.55], P<0.001) versus nonlobar (ß 5.32 [95% CI, 3.36-7.28], P<0.001) location. IL-6 was associated with perihematomal edema volume after adjustment for age, sex, ICH volume, and ICH location (ß 1.22 [95% CI, 0.15-2.29], P=0.03). Treatment group was not associated with IL-6 levels or outcome. CONCLUSIONS: In the FAST trial population, higher admission IL-6 levels were associated with worse 90-day functional outcome and larger ICH and perihematomal edema volumes.

17.
JCI Insight ; 6(6)2021 03 22.
Artigo em Inglês | MEDLINE | ID: mdl-33749664

RESUMO

Intracerebral hemorrhage (ICH) is a devastating form of stroke with a high mortality rate and few treatment options. Discovery of therapeutic interventions has been slow given the challenges associated with studying acute injury in the human brain. Inflammation induced by exposure of brain tissue to blood appears to be a major part of brain tissue injury. Here, we longitudinally profiled blood and cerebral hematoma effluent from a patient enrolled in the Minimally Invasive Surgery with Thrombolysis in Intracerebral Hemorrhage Evacuation trial, offering a rare window into the local and systemic immune responses to acute brain injury. Using single-cell RNA-Seq (scRNA-Seq), this is the first report to our knowledge that characterized the local cellular response during ICH in the brain of a living patient at single-cell resolution. Our analysis revealed shifts in the activation states of myeloid and T cells in the brain over time, suggesting that leukocyte responses are dynamically reshaped by the hematoma microenvironment. Interestingly, the patient had an asymptomatic rebleed that our transcriptional data indicated occurred prior to detection by CT scan. This case highlights the rapid immune dynamics in the brain after ICH and suggests that sensitive methods such as scRNA-Seq would enable greater understanding of complex intracerebral events.

18.
J Neurointerv Surg ; 2021 Feb 16.
Artigo em Inglês | MEDLINE | ID: mdl-33593800

RESUMO

BACKGROUND: The benefit of complete reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 3) over near-complete reperfusion (≥90%, mTICI 2c) remains unclear. The goal of this study is to compare clinical outcomes between mechanical thrombectomy (MT)-treated stroke patients with mTICI 2c versus 3. METHODS: This is a retrospective study from the Stroke Thrombectomy and Aneurysm Registry (STAR) comprising 33 centers. Adults with anterior circulation arterial vessel occlusion who underwent MT yielding mTICI 2c or mTICI 3 reperfusion were included. Patients were categorized based on reperfusion grade achieved. Primary outcome was modified Rankin Scale (mRS) 0-2 at 90 days. Secondary outcomes were mRS scores at discharge and 90 days, National Institutes of Health Stroke Scale score at discharge, procedure-related complications, and symptomatic intracerebral hemorrhage. RESULTS: The unmatched mTICI 2c and mTICI 3 cohorts comprised 519 and 1923 patients, respectively. There was no difference in primary (42.4% vs 45.1%; p=0.264) or secondary outcomes between the unmatched cohorts. Reperfusion status (mTICI 2c vs 3) was also not predictive of the primary outcome in non-imputed and imputed multivariable models. The matched cohorts each comprised 191 patients. Primary (39.8% vs 47.6%; p=0.122) and secondary outcomes were also similar between the matched cohorts, except the 90-day mRS which was lower in the matched mTICI 3 cohort (p=0.049). There were increased odds of the primary outcome with mTICI 3 in patients with baseline mRS ≥2 (36% vs 7.7%; p=0.011; pinteraction=0.014) and a history of stroke (42.3% vs 15.4%; p=0.027; pinteraction=0.041). CONCLUSIONS: Complete and near-complete reperfusion after MT appear to confer comparable outcomes in patients with acute stroke.

19.
Crit Care Med ; 49(5): 828-837, 2021 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-33591003

RESUMO

OBJECTIVES: To test the hypothesis that admission hemoglobin levels are associated with outcome in primary, nontraumatic intracerebral hemorrhage. DESIGN: Individual patient data meta-analysis of three studies of intracerebral hemorrhage. SETTING: Two randomized clinical trials and one multiethnic observational study. PATIENTS: Patients with spontaneous, nontraumatic intracerebral hemorrhage. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Our exposure of interest was admission hemoglobin levels and the primary outcome was 3-month postintracerebral hemorrhage-dichotomized modified Rankin Scale (0-3 vs 4-6). Intermediate outcomes were admission hematoma volume and hematoma expansion defined as 6 mL or 33% increase in hemorrhage size on repeat CT. A total of 4,172 intracerebral hemorrhage patients were included in the study (mean age 63 [sd = 14]; female sex 1,668 [40%]). Each additional g/dL of admission hemoglobin was associated with 14% (odds ratio, 0.86; 95% CI, 0.82-0.91) and 7% (odds ratio, 0.93; 95% CI, 0.88-0.98) reductions in the risk of poor outcome in unadjusted and adjusted analyses, respectively. Dose-response analyses indicated a linear relationship between admission hemoglobin levels and poor outcome across the entire evaluated range (test-for-trend p < 0.001). No consistent associations were found between the admission hemoglobin levels and hematoma volume or hematoma expansion. CONCLUSIONS: Higher hemoglobin levels are associated with better outcome in intracerebral hemorrhage. Further research is needed to evaluate admission hemoglobin levels as both a therapeutic target and predictor of outcome.


Assuntos
Hemorragia Cerebral/metabolismo , Hemorragia Cerebral/fisiopatologia , Hemoglobinas/metabolismo , Idoso , Hemorragia Cerebral/diagnóstico por imagem , Feminino , Sistema de Condução Cardíaco/fisiopatologia , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Observacionais como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo
20.
Neurocrit Care ; 35(1): 232-240, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-33403581

RESUMO

BACKGROUND/OBJECTIVE: Inter-hospital patient transfers for neurocritical care are increasingly common due to increased regionalization for acute care, including stroke and intracerebral hemorrhage. This process of transfer is uniquely vulnerable to errors and risk given numerous handoffs involving multiple providers, from several disciplines, located at different institutions. We present failure mode and effect analysis (FMEA) as a systems engineering methodology that can be applied to neurocritical care transitions to reduce failures in communication and improve patient safety. Specifically, we describe our local implementation of FMEA to improve the safety of inter-hospital transfer for patients with intracerebral and subarachnoid hemorrhage as evidence of success. METHODS: We describe the conceptual basis for and specific use-case example for each formal step of the FMEA process. We assembled a multi-disciplinary team, developed a process map of all components required for successful transfer, and identified "failure modes" or errors that hinder completion of each subprocess. A risk or hazard analysis was conducted for each failure mode, and ones of highest impact on patient safety and outcomes were identified and prioritized for implementation. Interventions were then developed and implemented into an action plan to redesign the process. Importantly, a comprehensive evaluation method was established to monitor outcomes and reimplement interventions to provide for continual improvement. RESULTS: This intervention was associated with significant reductions in emergency department (ED) throughput (ED length of stay from 300 to 149 min, (p < .01), and improvements in inter-disciplinary communication (increase from pre-intervention (10%) to post- (64%) of inter-hospital transfers where the neurological intensive care unit and ED attendings discussed care for the patient prior to their arrival). CONCLUSIONS: Application of the FMEA approach yielded meaningful and sustained process change for patients with neurocritical care needs. Utilization of FMEA as a change instrument for quality improvement is a powerful tool for programs looking to improve timely communication, resource utilization, and ultimately patient safety.


Assuntos
Segurança do Paciente , Transferência de Pacientes , Comunicação , Serviço Hospitalar de Emergência , Humanos , Melhoria de Qualidade
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