Showing papers by "J Mocco published in 2023"
TL;DR: The Stentrode With Thought-Controlled Digital Switch (SWITCH) study as mentioned in this paper evaluated 5 patients with severe bilateral upper-limb paralysis, with a follow-up of 12 months.
Abstract: Importance
Brain-computer interface (BCI) implants have previously required craniotomy to deliver penetrating or surface electrodes to the brain. Whether a minimally invasive endovascular technique to deliver recording electrodes through the jugular vein to superior sagittal sinus is safe and feasible is unknown.
Objective
To assess the safety of an endovascular BCI and feasibility of using the system to control a computer by thought.
Design, Setting, and Participants
The Stentrode With Thought-Controlled Digital Switch (SWITCH) study, a single-center, prospective, first in-human study, evaluated 5 patients with severe bilateral upper-limb paralysis, with a follow-up of 12 months. From a referred sample, 4 patients with amyotrophic lateral sclerosis and 1 with primary lateral sclerosis met inclusion criteria and were enrolled in the study. Surgical procedures and follow-up visits were performed at the Royal Melbourne Hospital, Parkville, Australia. Training sessions were performed at patients' homes and at a university clinic. The study start date was May 27, 2019, and final follow-up was completed January 9, 2022.
Interventions
Recording devices were delivered via catheter and connected to subcutaneous electronic units. Devices communicated wirelessly to an external device for personal computer control.
Main Outcomes and Measures
The primary safety end point was device-related serious adverse events resulting in death or permanent increased disability. Secondary end points were blood vessel occlusion and device migration. Exploratory end points were signal fidelity and stability over 12 months, number of distinct commands created by neuronal activity, and use of system for digital device control.
Results
Of 4 patients included in analyses, all were male, and the mean (SD) age was 61 (17) years. Patients with preserved motor cortex activity and suitable venous anatomy were implanted. Each completed 12-month follow-up with no serious adverse events and no vessel occlusion or device migration. Mean (SD) signal bandwidth was 233 (16) Hz and was stable throughout study in all 4 patients (SD range across all sessions, 7-32 Hz). At least 5 attempted movement types were decoded offline, and each patient successfully controlled a computer with the BCI.
Conclusions and Relevance
Endovascular access to the sensorimotor cortex is an alternative to placing BCI electrodes in or on the dura by open-brain surgery. These final safety and feasibility data from the first in-human SWITCH study indicate that it is possible to record neural signals from a blood vessel. The favorable safety profile could promote wider and more rapid translation of BCI to people with paralysis.
Trial Registration
ClinicalTrials.gov Identifier: NCT03834857.
7 citations
TL;DR: In this article , a 20-year analysis of patients with acute ischemic stroke (AIS) was performed using a 1:1 nearest neighbor propensity score matched cohort, and the results showed that those with concomitant infections had higher rates of comorbidities and had higher NIHSS.
Abstract:
Introduction:
Infection of the central nervous system (CNS) - including meningitis, encephalitis and brain abscess - is a feared complication in hospitalized patients. Studies of CNS infection in patients with acute ischemic stroke (AIS) are scarce. We aimed to characterize AIS patients with CNS infections and assess their clinical outcomes over a 20-year period.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 434.01, 434.11, 434.91, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for the presence of CNS infections on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
Total of 10,415,286 patients with AIS were included; 74,731 (0.7%) had CNS infection. Infected patients had higher Elixhauser Comorbidity Score (12.02 ± 9.24 vs. 9.75 ± 8.82; p<0.001) and NIH Stroke Score (8.78 ± 8.86 vs. 6.65 ± 7.29; p<0.001). After propensity matching, these patients had lower rates of smoking, COPD and CKD, and higher rates of systemic inflammatory disease and burr hole drainage (p<0.001). Infected patients had longer hospital stay (3.88 days; 95% CI: 3.45-4.3), higher hospital charges ($49633.46; 95% CI: $44199.59-55067.33) and were less likely to be discharged home or short-term hospital (0.78; 95% CI: 0.74-0.82)(all p<0.001).
Conclusion:
In this 20 year nationally representative propensity matched analysis of patients with AIS, those with concomitant CNS infections had higher rates of comorbidities and had higher NIHSS. In addition to having longer and more expensive hospital stays, these patients were less likely to have good functional outcomes.
TL;DR: The authors compared outcomes in acute ischemic stroke (AIS) patients treated with endovascular thrombectomy (EVT) before and after 2015 and found that after 2015, EVT patients after 2015 were more likely to be discharged home (AOR 1.35, 95%CI:1.24-1.47), have increased hospital charges ($40828.79; 95% CI: $36391.76-45265), and had shorter hospital stay (-0.74 days, 0.99 - -0.48) with no difference in In-hospital mortality.
Abstract:
Background:
Endovascular thrombectomy (EVT) demonstrated superiority to medical management in the 2015 trials. We sought to compare outcomes in acute ischemic stroke (AIS) treated with EVT before and after 2015.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for EVT on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
A total of 10,415,286 patients with AIS were identified; 149,367 (1.4%) underwent EVT. Among the EVT cohort, 35,562 patients were treated before 2015 (23.8%) vs. 113,805 (76.2%) after. EVT patients after 2015 were more likely to be younger, on private insurance, treated at large urban nonteaching hospitals, had lower Elixhauser Comorbidity Scores (14.71 ± 9.15 vs. 16.21 ± 9.17; p<0.001) but increased markers of stroke severity such as higher rates of ventilator use, paresis, seizures, craniotomy and tracheostomy placement (all p<0.001). After propensity matching, EVT patients after 2015 were more likely to be discharged home (AOR 1.35, 95%CI:1.24-1.47), have increased hospital charges ($40828.79; 95%CI: $36391.76-45265.81), had shorter hospital stay (-0.74 days, 95%CI: -0.99 - -0.48)(all p<0.001), with no difference in In-hospital mortality.
Conclusions:
This 20-year nationally representative propensity matched analysis of AIS patients shows that outcomes after EVT continue to improve following the landmark 2015 publications, with a higher chance of favorable outcome, lower hospital charge and shorter hospital stay compared to before 2015.
TL;DR: In this paper , an economic evaluation study was performed from a US healthcare perspective, combining decision analysis and Markov modeling methods over a lifetime horizon to evaluate the cost-effectiveness of RR-EVT in suspected acute ischemic stroke patients at a primary stroke center (PSC) compared to the standard-of-care approach.
Abstract: OBJECTIVE
Clinical outcomes following endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) treatment are highly time sensitive. Remote robotic (RR)-EVT systems may be capable of mitigating time delays in patient transfer from a primary stroke center (PSC) to a comprehensive/thrombectomy-capable stroke center. However, health economic evidence is needed to assess the costs and benefits of an RR-EVT system. Therefore, the authors of this study aimed to determine whether performing RR-EVT in suspected AIS patients at a PSC as opposed to standard of care might translate to cost-effectiveness over a lifetime.
METHODS
An economic evaluation study was performed from a US healthcare perspective, combining decision analysis and Markov modeling methods over a lifetime horizon to evaluate the cost-effectiveness of RR-EVT in suspected AIS patients at a PSC compared to the standard-of-care approach. Total expected costs and quality-adjusted life-years (QALYs) were estimated.
RESULTS
In the cost-effectiveness analysis, RR-EVT yielded greater effectiveness per patient (4.05 vs 3.88 QALYs) and lower costs (US$321,269 vs US$321,397) than the standard-of-care approach. Owing to these lower costs and greater health benefits, RR-EVT was the dominant cost-effective strategy. After initiation of an RR-EVT system, the average costs per year were similar (or slightly reduced), according to this simulation. Sensitivity analyses revealed that RR-EVT remains cost-effective in a wide variety of time delays and cost assumptions. In a one-way sensitivity analysis, RR-EVT remained the most cost-effective strategy when time delays were greater than 2.5 minutes, its complication rate did not exceed 37%, and costs were lower than $54,081. When the cost of the RR-EVT strategy ranged from $19,340 to $54,081 and its complication rate varied from 15% to 37%, the RR-EVT strategy remained the most cost-effective throughout the two ranges. RR-EVT was also the most cost-effective strategy even when its cost doubled (to approximately $40,000) and time delays exceeded 20 minutes. In a probabilistic sensitivity analysis, RR-EVT was the long-term cost-effective strategy in 89.8% of iterations at a willingness-to-pay threshold of $100,000/QALY.
CONCLUSIONS
This analysis suggests that RR-EVT as an innovative solution to expedite EVT is cost-effective. An RR-EVT system could potentially extend access to care in underserved communities and rural areas, as well as improve care for socioeconomically disadvantaged populations affected by health inequities.
TL;DR: In this paper , the authors designed a set of four situational judgment tests mimicking common situations a neurosurgery resident would encounter during residency, and incorporated these SJT questions as part of the online interview process.
Abstract: INTRODUCTION: Neurosurgery residency selection is heavily reliant on pre-residency factors and unstructured interviews. These metrics, however, have not been shown to reliably predict residency performance, and have potential to introduce bias and discrimination. Outside of medicine, the science of selection is much better developed, and methods such as structured interviews, situational judgment tests (SJT), and personality assessments are routinely used with robust evidence for efficacy and reliability at predicting job performance. METHODS: We designed a set of 4 SJT questions mimicking common situations a neurosurgery resident would encounter during residency. Each question had individualized grading rubrics scored on a scale of 1 to 4. For the 2021 residency application cycle, our program incorporated these SJT questions as part of the online interview process. Four volunteer faculty interview pairs delivered one question each for every candidate, and recorded the scores. Other traditional evaluation metrics from the candidate’s application and interview were also collected post interview. RESULTS: All 44 interview candidates applying to our program during the 2021 cycle were assessed. Due to time constraints, the number of questions each candidate responded to varied from 2 to 3. The average score was 3.6 (SD 0.44, range 2-4). The SJT score was not associated with USMLE Step 1 score (p = 0.31), number of publications (p = 0.42), or letter of recommendation score (p = 0.21). The SJT scores had a moderate positive correlation with personality on interview (r = 0.42, p < 0.01), and overall interview score (r = 0.30, p = 0.04). CONCLUSIONS: It is feasible to incorporate SJT questions into the neurosurgery resident online interview process. They may provide objective metrics independent of academic and research abilities. Further investigations with long term follow up is needed to see if SJT can be validated and correlated with residency performance.
TL;DR: In this article , the authors identify the prevalence, characteristics, and in-hospital outcomes of patients presenting with vocal fold paralysis after acute ischemic stroke (AIS) and intracranial hemorrhage (ICH).
TL;DR: For example, this paper found that approximately 7% of patients with acute ischemic stroke experience seizure while hospitalized, with an overall stable incidence over 20 years, and that seizure is more likely to occur in women and younger patients and is associated with worse functional outcomes.
Abstract:
Background:
Seizure is a known complication following acute ischemic stroke (AIS) that can lead to severe morbidity. We sought to better characterize the risk factors for stroke following AIS and evaluate in-hospital outcomes in these patients.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for dysphagia on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
A total of 10,415,286 patients with AIS were identified; 694,495 (6.6%) had seizures. Patients with seizures had higher Elixhauser Comorbidity Score (14.81 ± 8.13 vs. 9.40 ± 8.76; p<0.001) and NIH Stroke Scale (NIHSS) Score (9.46 ± 8.68 vs. 6.50 ± 7.18; p<0.001). Patients with seizures were more likely to be female, younger, African American race, smokers, covered on Medicaid, be in the 0-25% percentile median income bracket, and be placed on a ventilator (all p<0.001). After propensity matching, seizure patients were slightly less likely to experience in-hospital mortality (AOR 0.94; 95%CI: 0.92-0.97), less likely to be discharged home (AOR 0.92, 95%CI:0.9-0.93), and had increased hospital charges ($6696.08; 95%CI: $5728.65-7663.51)(all p<0.001).
Conclusions:
Approximately 7% of patients with AIS experience seizure while hospitalized, with an overall stable incidence over 20 years. Seizure is more likely to occur in women and younger patients and is associated with worse functional outcomes. The percentage of patients with seizures in AIS remained similar per year despite an increase in the absolute numbers.
TL;DR: The World Federation of Interventional and Therapeutic Neuroradiology (WFITN) decided to construct a checklist for neurointerventional cases based on a review of the literature and insights from an expert panel as discussed by the authors .
Abstract: Over the last 10 years, there has been a rise in neurointerventional case complexity, device variety and physician distractions. Even among experienced physicians, this trend challenges our memory and concentration, making it more difficult to remember safety principles and their implications. Checklists are regarded by some as a redundant exercise that wastes time, or as an attack on physician autonomy. However, given the increasing case and disease complexity along with the number of distractions, it is even more important now to have a compelling reminder of safety principles that preserve habits that are susceptible to being overlooked because they seem mundane. Most hospitals have mandated a pre-procedure neurointerventional time-out checklist, but often it ends up being done in a cursory fashion for the primary purpose of 'checking off boxes'. There may be value in iterating the checklist to further emphasize safety and communication. The Federation Assembly of the World Federation of Interventional and Therapeutic Neuroradiology (WFITN) decided to construct a checklist for neurointerventional cases based on a review of the literature and insights from an expert panel.
TL;DR: In this paper , a 20-year cohort of 2,000,868 patients with intracerebral hemorrhage (ICH) were identified; 9.2% had Hydrocephalus (HCP).
Abstract:
Introduction:
Hydrocephalus (HCP) is a common consequence of intracerebral hemorrhage (ICH) and is a predictor of poor outcomes in ICH patients. We aimed to characterize ICH patients with HCP and assess their clinical outcomes over a 20-year period.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for the presence of hydrocephalus on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
2,000,868 patients with ICH were identified; 9.2% had HCP. Patients with HCP had higher NIHSS (17.16±11.13 vs 10.77±9.14) and Elixhauser Comorbidity Score (10.64±8.79 vs. 10.4±9.12) at presentation, longer hospital stays (13.92±18.13 vs 8.13± 11.3 days) and higher hospital charges ($160,604.36± 225,493.62 vs $74,930.99± 137,200.59) (all p<0.001). After propensity matching, HCP patients had higher rates of surgical intervention (including EVD and ventricular shunt placement), and higher tracheostomy and PEG/G-tube requirement (all p<0.001). On multivariate analysis, HCP patients had higher in-hospital mortality (2.21; 95% CI: 1.85-2.65) and lesser likelihood of discharge home or short-term hospital (0.46; 95% CI: 0.35-0.61) (p<0.001).
Conclusion:
In this 20-year nationally representative propensity matched analysis of patients with ICH, those with concomitant HCP had higher rates of surgical procedures (EVD, ventricular shunt, tracheostomy and PEG). Incidence of HCP increased more than two-fold from2000-2019, suggesting worsening disease severity over the study period.
TL;DR: In this paper, the safety and efficacy of using a balloon guide catheter for carotid stent placement through transradial access was studied in 20 patients with elective cataract angioplasty and stentation.
Abstract: BACKGROUND: Despite an overall surge in transradial access (TRA) for neurointerventional procedures, the feasibility and safety of TRA carotid artery angioplasty and stenting using balloon guide catheters (BGCs) through a short 8-Fr sheath have not been studied. In this study, we present our experience of using Walrus BGC through TRA for carotid artery stent placement. OBJECTIVE: To define the safety and efficacy of using a balloon guide catheter for carotid stenting by a transradial approach. METHODS: Our prospectively maintained retrospective database was reviewed, and consecutive patients were identified who underwent elective carotid artery stenting through TRA using Walrus BGC between January 2021 and June 2022. Demographics, procedural details including access site complications, the rate of radial to groin conversion, and procedure-related transient ischemic attack or stroke were reviewed. RESULTS: Twenty patients were identified who underwent carotid artery angioplasty and stenting through TRA Walrus BGC use; the mean age was 66 years (range 42-89), and 67% were male. A short 8-Fr sheath was used in all patients without any complications. Two of 20 patients required TRA conversion to transfemoral access, both secondary to severe spasm of the radial artery after initial access inhibiting further advancement of the Walrus BGC. CONCLUSION: Use of Walrus BGC by TRA through an 8-Fr sheath for carotid artery stenting is safe and feasible with a low rate of conversion to transfemoral access and no access site complications.
01 Feb 2023
TL;DR: In this article , the correlation between angiographic and MRI characteristics of embolized meningiomas was found to be a weak predictor of endovascular embolization.
Abstract: Introduction: Endovascular embolization can be an adjunct to surgical treatment of meningiomas. Data are limited on the correlation between angiographic and MRI characteristics of embolized meningiomas. Angiographic images obtained during tumor embolization are inherently 2D, making quantitative volumetric assessments of embolization challenging.
TL;DR: In this article , a query of the 2000-2019 National Inpatient Sample was performed for patients admitted with Intracerebral Hemorrhage (ICH), and 2,000,868 patients with ICH were identified; 234,382 had seizures (11.7%).
Abstract:
Introduction:
Intracerebral hemorrhage (ICH) accounts for 15% of strokes, and an early sequelae of hemorrhagic stroke is seizure. Studies have shown up to 43% of ICH patients experience electrographic seizure within 72 hours of ictus. The clinical course of patients with seizures in ICH remains unclear.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for the presence of seizures on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
2,000,868 patients with ICH were identified; 234,382 had seizures (11.7%). Patients with seizure had higher Elixhauser Comorbidity Score (15.12 ± 8.54 vs. 9.80 ± 8.98, p<0.001) and NIH Stroke Score (13.02 ± 9.85 vs. 11.17 ± 9.46, p<0.001). There were higher rates of coma, fluid/electrolyte dysfunction, CNS infections, craniotomy, and external ventricular drain placement (p<0.01). After propensity matching, patients with seizure were less likely to experience in-hospital mortality (AOR 0.85; 95% CI: 0.82-0.87), more likely to be discharged home or short-term hospital (AOR 1.31; 95% CI: 1.27-1.35), have shorter hospital stay (-0.63 days; 95% CI: -0.82 - -0.45), and lower hospital charges ($-3991.74; 95% CI: $-6196.22- -1787.27) (all p<0.001).
Conclusions:
The rate of seizure among ICH patients remains unchanged over the past 2 decades. Seizure is associated with more severe presentation; however, it does not independently worsen the clinical outcome.
TL;DR: In this article , a retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019, and the authors assessed real-world regional variation in emergent acute ischemic stroke (AIS) treatment, including growth in revascularization therapies and stroke center certification.
Abstract: Background Although national organizations recognize the importance of regionalized acute ischemic stroke (AIS) care, data informing expansion are sparse. We assessed real-world regional variation in emergent AIS treatment, including growth in revascularization therapies and stroke center certification. We hypothesized that we would observe overall growth in revascularization therapy utilization, but observed differences would vary greatly regionally. Methods A retrospective cross-sectional analysis was carried out of de-identified national inpatient Medicare Fee-for-Service datasets from 2016 to 2019. We identified AIS admissions and treatment with thrombolysis and endovascular thrombectomy (ET) with International Classification of Diseases, 10th Revision, Clinical Modification codes. We grouped hospitals in Dartmouth Atlas of Healthcare Hospital Referral Regions (HRR) and calculated hospital, demographic, and acute stroke treatment characteristics for each HRR. We calculated the percent of hospitals with stroke certification and AIS cases treated with thrombolysis or ET per HRR. Results There were 957 958 AIS admissions. Relative mean (SD) growth in percent of AIS admissions receiving revascularization therapy per HRR from 2016 to 2019 was 13.4 (31.7)% (IQR −6.1–31.7%) for thrombolysis and 28.0 (72.0)% (IQR 0–56.0%) for ET. The proportion of HRRs with decreased or no difference in ET utilization was 38.9% and the proportion of HRRs with decreased or no difference in thrombolysis utilization was 32.7%. Mean (SD) stroke center certification proportion across HRRs was 45.3 (31.5)% and this varied widely (IQR 18.3–73.4%). Conclusions Overall growth in AIS treatment has been modest and, within HRRs, growth in AIS treatment and the proportion of centers with stroke certification varies dramatically.
TL;DR: This paper evaluated the impact of race on ICH severity and outcome in a nationally representative database and found that black patients have worse hospital outcomes after ICH while the rate of in-hospital mortality seen in Whites was higher in comparison to other races.
Abstract:
Background:
Racial disparity in ICH management and outcome is a major concern. We sought to evaluate the impact of race on ICH severity and outcome in a nationally representative database.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Demographics, comorbidities, and outcomes were identified. Discharge location was used as a surrogate for functional outcome. Univariate analysis with t-tests or chi-square performed as appropriate, and significant variables were entered into a multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for race on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
A total of 390,015 patients with ICH were identified over the four years; 97,220 (24.9%) had a reported NIH Stroke Score (NIHSS). Mean Age was 69.22 ± 14.3 years. Patients were 61% White, 16.6 % Black, 9.9% Hispanic, and 4.8% Asian. Average NIHSS differed significantly among the groups, with Asian patients having more severe disease than White, Black, or Hispanic patients (p<0.001). After multivariate analysis, Hispanic patients had greater odds of discharge home compared to White patients (AOR 1.3, 95% CI 1.12-1.51, p<0.05). Black patients had greater odds of discharge to nursing care facilities (AOR 1.12, 95%CI: 1.02-1.23, p<0.001). In hospital mortality was less in Black (AOR 0.7, 95%CI: 0.6-0.81), Asian (AOR 0.66, 95% CI: 0.51-0.83) and Hispanic (AOR 0.67, 95%CI: 0.55-0.8) patients (all <0.05).
Conclusions:
This nationally representative analysis demonstrates that Black patients have worse hospital outcomes after ICH while the rate of in-hospital mortality seen in Whites was higher in comparison to other races. White patients were the majority of cases and had an overall stable trend of good discharge outcome. Incidence of in-hospital mortality was highest in the Black patients over four years.
TL;DR: In this article , the authors identify the risk factors and outcomes of patients presenting with dysphagia after acute ischemic stroke (AIS) over twenty years, using a propensity matched 20-year national analysis.
Abstract:
Introduction:
Dysphagia is a common complication among acute ischemic stroke (AIS) patients and is associated with increased mortality and morbidity. A complete understanding of the characteristics of patients who present with dysphagia after AIS is warranted.
Objective:
To identify the risk factors and outcomes of patients presenting with dysphagia after AIS over twenty years.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for dysphagia on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
10,415,286 patients with AIS were included; 956,662 (9.2%) had in-hospital dysphagia. A higher percentage of patients with dysphagia were older, had higher Elixhauser Comorbidity Score, higher NIH Stroke Scale (NIHSS) score and a were insured by Medicare (p<0.001). After propensity matching, patients with dysphagia after AIS were less likely to experience in-hospital mortality (OR 0.61; 95%CI: 0.60-0.63) or be discharged home (AOR 0.51; 95%CI: 0.51-0.52), had decreased length of stay (0.43 days; 95%CI: 0.36-0.50), and had increased hospital charges ($14411.96; 95%CI: 13565.68-15257.44) (all p<0.001).
Conclusion:
This propensity matched 20-year national analysis confirmed that dysphagia is a significant issue following AIS. These patients were more frequently male with worse neurological presentations. Despite better odds for survival and shorter hospital stay, they experience significant functional deficits at discharge and have increased hospital costs.
01 Feb 2023
TL;DR: In this paper , preoperative angiographic embolization can be used as an adjunct in the surgical resection of meningioma, but there is no standardized system to assess the efficacy or extent of embolisation.
Abstract: Introduction: Preoperative angiographic embolization can be used as an adjunct in the surgical resection of meningioma, but there is no standardized system to assess the efficacy or extent of embolization
TL;DR: In this article, the authors quantify cerebral blood volume changes and identify predictors of CBV increase in the pericavity parenchyma after minimally invasive intracerebral hemorrhage evacuation (MIS for ICH).
Abstract:
Introduction:
Computed tomography perfusion (CTP) characterizes hemodynamic changes within brain tissue, particularly after stroke. This study aims to quantify cerebral blood volume (CBV) changes and identify predictors of CBV increase in the pericavity parenchyma after minimally invasive intracerebral hemorrhage evacuation (MIS for ICH).
Methods:
Thirty-two patients underwent MIS for ICH with pre/postoperative native CT imaging and intraoperative perfusion imaging (DynaCT PBV Neuro, Artis Q, Siemens). Scans were segmented using ITK-SNAP software to calculate hematoma volumes pre/post-evacuation and to delineate the pericavity tissue. Helical CT segmentations were registered to cone beam CT data using elastix software. Mean CBVs were computed inside subvolumes by dilating the segmentations with spheres with varying diameters.
Results:
In 27 patients with complete imaging, CTP analysis demonstrated significant increases in CBV from the 6 mm to 20 mm pericavity regions. CBV increased on average 32.7% from 2.27 mL/100mg (IQR 1.87-3.02) to 2.80 mL/100mg (2.41-3.61) in the 10 mm pericavity region (P=0.003). Factors associated with increased CBV in the univariate analysis (P≤0.10) included age (P=0.082) and percentage of hematoma evacuation (P=0.078). Upon multivariate linear regression, age (OR 4.49, [95% CI, 1.01-1.98], P=0.048) and percentage of hematoma evacuation (OR 4.09, [95% CI, 1.70-9.84], P=0.046) remained significantly predictive of increased CBV.
Conclusions:
CTP analysis demonstrated a significant increase in pericavity cerebral blood volume after MIS for ICH. Patient age and hematoma evacuation percentage may be predictive of CBV increase after MIS for ICH.
Figure 1:
Topographic map showing blood flow improvement at different distances from the lesion.
TL;DR: In this article , a 20-year nationally representative analysis of racial disparities in primary intracerebral hemorrhage (ICH) patients has been conducted, showing that despite the increasing prevalence in Black and Hispanic patients over 20 years, they have greater odds of survival during their hospital stay when compared to White patients.
Abstract:
Background:
Primary intracerebral hemorrhage (ICH) is a devastating disease with limited therapeutic options and poor overall outcomes. We aimed to characterize racial disparities in patients with ICH over a 20 year period and examine the prognostic impact of race on functional outcomes.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Demographics, comorbidities, and outcomes were identified. Discharge location was used as a surrogate for functional outcome. Univariate analysis with t-tests or chi-square performed as appropriate, and significant variables were entered into a multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for race on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
A total of 2,000,868 patients with ICH were identified. Mean Age was 68.28 ±15.41 years. Patients were 57.2% White, 14.1 % Black, 8.3% Hispanic, and 3.9% Asian. Average Elixhauser Comorbidity Score was significantly different among the groups, with White patients having higher score on average than Asian, Black, or Hispanic Patients. There was no difference in NIH Stroke Scale among the groups. After multivariate analysis, there were no differences in odds of discharge to home or to nursing/long-term care facilities between races (p>0.001). In hospital mortality was less in Black (AOR 0.73, 95%CI: 0.64-0.84) and Hispanic (AOR 0.65, 95% CI: 0.55-0.78) patients compared to White (p<0.001).
Conclusions:
This 20 year nationally representative analysis of racial disparities in ICH patients shows that despite the increasing prevalence in Black and Hispanic patients over 20 years, they have greater odds of survival during their hospital stay when compared to White patients. Further examination of healthcare systems and patient-specific factors are warranted to elucidate this phenomenon.
TL;DR: In this paper , a minimally invasive (MIS) approach is proposed to reduce time-to-treatment and prevent further injury during intraventricular hemorrhage evacuation, and the functional outcomes of thalamic ICH evacuation should be considered when considering patient eligibility for MIS Hemorrhage Evacuation.
Abstract: INTRODUCTION: Intracerebral hemorrhage (ICH) carries a high risk of disability and death, with thalamic hemorrhages associated with the worst outcomes. A minimally invasive (MIS) approach is a promising option to reduce time-to-treatment and prevent further injury during ICH evacuation. The functional outcomes of thalamic ICH evacuation should be accounted for when considering patient eligibility for MIS Hemorrhage Evacuation. METHODS: Patients with spontaneous thalamic ICH who presented to a large healthcare system between December 2015 and December 2021 were triaged to a central hospital for MIS endoscopic or surgiscopic evacuation. Criteria for inclusion was age ≥18 years, hematoma volume ≥15 ml, National Institutes of Health Stroke Scale (NIHSS) score ≥6, premorbid mRS score ≤3, and time from ictus ≤72 hours. RESULTS: MIS evacuation was performed on 29 patients. 19 patients had hemorrhage confined to the thalamus, whereas 10 patients had hemorrhages extending into surrounding parenchymal structures. 25 patients (86%) had intraventricular hemorrhage. The average preoperative volume was 42.5 mL ± 33.7 mL and postoperative volume was 8.6 ± 11.3 mL indicating an evacuation rate of 78.0 ± 25.0%. One month after hemorrhage, two patients (6.9%) had expired. At 6-month, 6 patients (22.2%) had improved to a favorable outcome (mRS ≤ 3) with 2 patients lacking mRs outcome data. CONCLUSIONS: This study suggests that MIS evacuation can be safely performed in patients with thalamic hemorrhage. Moreover, it presents long-term functional outcomes to assist clinicians in determining treatment plans, and dictating randomization schemes or subgroup analyses for future comparison of MIS evacuation to standard hemorrhage evacuation.
TL;DR: In this article , a 20-year nationally representative analysis of racial disparities in patients with acute ischemic stroke (AIS) showed that while Black patients have worse odds of discharge home, they are less likely than White patients to die in the hospital.
Abstract:
Background:
Acute ischemic stroke (AIS) is associated with a high rate of morbidity and mortality. We aimed to characterize racial disparities in patients with AIS over a 20 year period and examine the prognostic impact of race on functional outcomes.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Discharge location was used as a surrogate for functional outcome. Univariate analysis with t-tests or chi-square performed as appropriate, and significant variables were entered into a multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for race on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
A total of 10,415,286 patients with AIS were identified. Mean Age was 70.91±13.8 years. Patients were 61% White, 14.3 % Black, 6.6% Hispanic, and 2.4% Asian. Average NIH Stroke Scale differed significantly among the groups, with Asian patients having more severe disease than White, Black, or Hispanic patients (p<0.001). After multivariate analysis, Black patients had worse odds for discharge home than white patients (AOR 0.8, 95%CI: 0.77-0.83, p<0.001) with a higher likelihood of discharge to nursing/long-term care facilities (AOR 1.3, 95%CI: 1.26-1.34, p<0.001). In hospital mortality was less in Black (AOR 0.64, 95%CI: 0.58-0.7) and Hispanic (AOR 0.78, 95% CI: 0.69-0.87) patients (p<0.001).
Conclusions:
This 20 year nationally representative analysis of racial disparities in patients with AIS shows that while Black patients have worse odds of discharge home, they are less likely than White patients to die in the hospital. White patients make up the majority of cases, but their percentage of total AIS cases decreased while Black patients increased over the twenty year study period.
TL;DR: The etiology of diffusion-weighted imaging (DWI) lesions in patients after minimally invasive surgery (MIS) for acute intracerebral hemorrhage (ICH) remains unclear as discussed by the authors .
Abstract:
Introduction:
The etiology of diffusion-weighted imaging (DWI) lesions in patients after minimally invasive surgery (MIS) for acute intracerebral hemorrhage (ICH) remains unclear.
Methods:
Postoperative brain MRIs of patients with spontaneous ICH from 2016-2021 who underwent imaging within one month of MIS were reviewed. DWI lesions were quantified. Lesions within 10 mm of the hematoma were excluded. Siderosis and microbleeds were identified. Leukoaraiosis was quantified using the Fazekas score. Univariate analyses were conducted to determine predictors of DWI lesion burden, and variables with P≤0.1 were included in multivariate analyses.
Results:
DWI lesions were present in 84 (49%) postoperative MRIs. The average number of DWI lesions was 2.11 (range 0-74, SD 6.50). Factors associated with DWI burden in univariate analyses included increased presenting systolic blood pressure (SBP) (P=0.003), Fazekas score (P=0.004), delta SBP on day of admission (P=0.034), preoperative angiogram (P=0.062), microbleeds on MRI (P=0.065), increased presenting National Institutes of Health Stroke Score (P=0.066), presence of intraventricular hemorrhage (P=0.069), and decreased presenting Glasgow Coma Scale (P=0.076). Upon multivariate analysis, increased Fazekas score (OR 2.04, 95% CI 1.21-3.43, P=0.008), presenting SBP (OR 1.04, 95% CI 1.00-1.06, P=0.014), and preoperative angiogram (OR 10.35, 95% CI 1.44-74.36], P=0.020) were predictive of DWI burden.
Conclusions:
In this unique postoperative ICH cohort, white matter changes, presenting SBP, and preoperative angiogram predicted DWI lesion burden. Larger studies are needed to understand the implications of DWI burden after MIS for ICH recovery.
TL;DR: In this paper , a measure of whole brain BBB permeability was computed from the perfusion MR scans and the authors examined the association between the BBB perfusion and clinical outcome and found that patients who achieved a good neurologic outcome were more likely to have a lower admission systolic blood pressure and NIH stroke scale (NIHSS score.
Abstract:
Introduction:
Patients with primary intracerebral hemorrhage (ICH) are known to demonstrate disruption of the blood-brain barrier (BBB) particularly in peri-hematomal regions. However, disruption of the BBB may also occur throughout the brain, even in areas remote from the acute bleed. We aimed to study the clinical significance of this finding.
Methods:
We performed a retrospective review of our prospectively collected ICH database from January 2020 to January 2022 to identify consecutive patients who had MR perfusion study performed within 5 days from admission. BBB permeability data was analyzed blinded to the clinical data. Baseline demographics, admission systolic blood pressure and NIH stroke scale (NIHSS) score were collected during the hospitalization. A measure of whole brain BBB permeability was computed from the perfusion MR scans. Primary outcome was good neurologic outcome defined as a modified Rankin Scale (mRS) score of 0-3 at 90 days. We examined the association between the BBB permeability and clinical outcome.
Results:
A total of 24 ICH patients were identified. Median age was 60 years old (Interquartile range (IQR) 57-70), with 11 females (45.8%) and 13 males (54.2%). Median hematoma volume was 40.3mL (IQR 14.9-53.2mL), with a median admission NIHSS of 17.5 (IQR 15-22). Thirteen out of 24 patients achieved a good neurologic outcome at 3 months (54.2%). Patients who achieved a good neurologic outcome were more likely to have a lower admission NIHSS (16 vs 20 p=0.04), smaller baseline hematoma volume (24.6mL vs 48.4 mL), (p=0.02), and a lower NIHSS at discharge (4 vs 19), (p=0.003). Median whole brain BBB permeability was insignificantly lower in patients who achieved a better neurologic outcome (1.8 vs 2.1, p=0.17). However, a threshold of whole brain BBB permeability less than 1.9% significantly correlated with improved neurologic outcome at 3 months (Odds Ratio=0.11, 95% Confidence Interval (0.02-0.71), p=0.02). Additionally, the same threshold was significantly associated with a lower NIHSS at discharge (5 vs 17.5, p=0.03).
Conclusion:
Diffuse disruption of the BBB in the days after presenting with ICH is associated with worse clinical outcome if the disruption is severe.
TL;DR: Ali, Muhammad BA*, Vasan, Vikram BA*, Rossitto, Christina P BA; Mocco, J MD, MS; Kellner, Christopher P MD Author Information as mentioned in this paper
Abstract: Ali, Muhammad BA*; Vasan, Vikram BA*; Rossitto, Christina P BA; Mocco, J MD, MS; Kellner, Christopher P MD Author Information
TL;DR: In this paper , the authors summarize some of the new clinical trials in two specific populations with relatively common and devastating strokes, and provide updated recommendations for treatment in a timely manner, given the importance of recent clinical trials.
Abstract: BACKGROUND Endovascular therapy (EVT) dramatically improves clinical outcomes for patients with emergent large vessel occlusion (ELVO). Later this year, the Society of NeuroInterventional Surgery (SNIS) Standards and Guidelines Committee will update and supplement the existing SNIS guidelines on ‘Embolectomy for stroke with emergent large vessel occlusion (ELVO)’, ‘Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO)’, and ‘Current endovascular strategies for posterior circulation large vessel occlusion stroke’. However, given the importance of recent clinical trials in two specific populations with relatively common and devastating strokes, we summarize some of the new trial data and provide updated recommendations for treatment in a timely manner.
TL;DR: The safety and efficacy of endovascular thrombectomy (EVT) in distal vessel occlusion (DVO) are not well described in literature as mentioned in this paper .
Abstract: BACKGROUND
The safety and efficacy of endovascular thrombectomy (EVT) in distal vessel occlusion (DVO) are not well described. We aimed to evaluate the technical feasibility and safety of EVT in patients with DVO.
METHODS
We performed a retrospective analysis of consecutive DVOs (defined as M3/M4, A1/A2, and P1/P2 occlusion) who underwent EVT within 24 h since last known well. The primary efficacy outcome was successful reperfusion (mTICI ≥ 2B). Secondary outcomes included successful recanalization with ≤3 passes. The safety outcome measures included the rate of subarachnoid hemorrhage (SAH), all intracerebral hemorrhage (ICH), and symptomatic ICH (sICH).
RESULTS
A total of 72 patients with DVO was identified: 39 (54%) with M3/M4, 13 (18%) with A1/A2, and 20 (28%) with P1/P2 occlusions. Admission NIHSS score median (IQR) was 12 (11), and 90% of the patients had baseline mRS ≤ 2. Thirty-six percent of the patients received intravenous thrombolytic therapy. Successful recanalization was achieved in 90% of the patients. The median number of passes was 2, with successful recanalization achieved with ≤3 passes in 83% of the patients. ICH was seen in 16% of the patients, including three SAHs. However, only one patient (1.4%) had sICH. Among 48 patients in whom 90-day outcome data were available, 33 (53.2%) had favorable clinical outcome (mRS ≤ 3). In a multivariable logistic regression, only baseline NIHSS was identified as an independent predictor of poor outcome.
CONCLUSION
This single-center real-world experience demonstrates that EVT in patients with DVO stroke is safe and feasible and may lead to improved clinical outcome.
TL;DR: The role of platelet function testing in patients with intracranial aneurysms undergoing flow diversion remains controversial with limited evidence of its influence on thrombotic outcomes as mentioned in this paper .
Abstract:
Introduction The role of platelet function testing in patients with intracranial aneurysms undergoing flow diversion remains controversial with limited evidence of its influence on thrombotic outcomes. We report an observational cohort analysis evaluating the association of P2Y12 assay testing with thrombotic events in patients undergoing flow diversion.
We performed a retrospective review of our prospectively maintained procedural database to identify patients who underwent flow diversion between January 2020 and July 2022. One physician within our practice never performs P2Y12 assay testing. All other physicians utilize P2Y12 assay testing as part of routine practice. These two different patient cohorts were compared. Acute thrombotic events were our primary outcome. Secondary outcomes included delayed intracerebral hemorrhage, intimal hyperplasia without clinical sequalae, and transient neurologic deficits.
We identified 150 patients who underwent flow diversion at our institution between January 2020 and July 2022. Median age was 59 years old (Interquartile range (IQR) 49–67), with 113 females (82.5%) and 24 males (17.5%). Out of 150 patients, 93 (62.0%) patients were treated by physicians who performed routine pre and postoperative testing of aspirin and Plavix assays, with subsequent adjustment of antithrombotic dosing accordingly, while 57 patients (38.0%) were treated by the single physician who prescribes aspirin and clopidogrel pre‐operatively without testing. In all, seven out of 150 patients (4.7%) had an acute thrombotic event requiring intraarterial anti‐thrombotic infusion or urgent thrombectomy, or both. Of these, six where from the 93 patient testing cohort (6.5%), and one in 57 patients non‐testing cohort (1.8%) (p = 0.2). Patients who had a thrombotic event were more likely to have underlying atrial fibrillation (28.6% vs 4.9%, p = 0.01) but otherwise had similar demographics, vascular risk factors, maximal aneurysmal diameter, and parent vessel diameter (Table 1). In a multivariable analysis adjusting for age, maximal aneurysm diameter, ruptured aneurysms, and atrial fibrillation, P2Y12 sensitivity assay testing was not significantly associated with acute thrombotic events in aneurysm patients undergoing flow diversion (Odds Ratio (OR) = 0.15, 95% Confidence Interval (CI) = 0.01‐2.67), p = 0.2). Secondary outcomes were also comparable between both groups; transient neurologic deficits were noted in 4/93 in the testing group (4.3%), and 6/57 in the non‐testing group (10%) (p = 0.14), intracranial hemorrhage occurred in only 2 patients, both in the testing group (p = 0.3), and mild intimal hyperplasia was observed in 18.3% in the testing group versus 12.3% in the non‐testing group (p = 0.33).
Platelet function testing showed no significant correlation with thrombotic events or outcomes in our cohort. The role of platelet function testing remains controversial, albeit widely used in patients undergoing flow diversion of intracranial aneurysms.
TL;DR: In this paper , the authors examined factors associated with LOS in a large cohort of patients who underwent minimally invasive endoscopic evacuation, which in turn was associated with poor long-term outcomes.
Abstract: Background Minimally invasive evacuation may help ameliorate outcomes after intracerebral hemorrhage (ICH). However, hospital length of stay (LOS) post-evacuation is often long and costly. Objective To examine factors associated with LOS in a large cohort of patients who underwent minimally invasive endoscopic evacuation. Methods Patients presenting to a large health system with spontaneous supratentorial ICH qualified for minimally invasive endoscopic evacuation if they met the following inclusion criteria: age ≥18, premorbid modified Rankin Scale (mRS) score ≤3, hematoma volume ≥15 mL, and presenting National Institutes of Health Stroke Scale (NIHSS) score ≥6. Demographic, clinical, radiographic, and operative characteristics were included in a multivariate logistic regression for hospital and ICU LOS dichotomized into short and prolonged stay at 14 and 7 days, respectively. Results Among 226 patients who underwent minimally invasive endoscopic evacuation, the median intensive care unit and hospital LOS were 8 (4–15) days and 16 (9–27) days, respectively. A greater extent of functional impairment on presentation (OR per NIHSS point 1.10 (95% CI 1.04 to 1.17), P=0.007), concurrent intraventricular hemorrhage (OR=2.46 (1.25 to 4.86), P=0.02), and deep origin (OR=per point 2.42 (1.21 to 4.83), P=0.01) were associated with prolonged hospital LOS. A longer delay from ictus to evacuation (OR per hour 1.02 (1.01 to 1.04), P=0.007) and longer procedure time (OR per hour 1.91 (1.26 to 2.89), P=0.002) were associated with prolonged ICU LOS. Prolonged hospital and ICU LOS were in turn longitudinally associated with a lower rate of discharge to acute rehabilitation (40% vs 70%, P<0.0001) and worse 6-month mRS outcomes (5 (4–6) vs 3 (2–4), P<0.0001). Conclusions We present factors associated with prolonged LOS, which in turn was associated with poor long-term outcomes. Factors associated with LOS may help to inform patient and clinician expectations of recovery, guide protocols for clinical trials, and select suitable populations for minimally invasive endoscopic evacuation.
TL;DR: In this paper , the effects of heavy alcohol abuse on patient outcomes over 20 years were examined. But the relationship between heavy alcohol consumption and stroke on in-hospital outcomes remains unclear.
Abstract:
Introduction:
Heavy alcohol (EtOH) consumption has been long recognized for its damaging effects to the brain and is considered a risk factor for stroke. However, the relationship between EtOH abuse and stroke on in-hospital outcomes remains unclear.
Objective:
To characterize stroke patients with an EtOH abuse and examine the effects of alcohol abuse on patient outcomes over 20 years.
Methods:
A query of the 2000-2019 National Inpatient Sample was performed for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 used in multivariate regression to generate adjusted odds ratios (AOR)/β-coefficients for EtOH abuse on outcomes. Significance set at an alpha level of <0.001. All analysis performed in R version 4.1.3.
Results:
A total of 10,415,286 patients with AIS were identified; 368,953 (3.5%) abused EtOH. EtOH abuse patients had higher Elixhauser Comorbidity Score (11.02 ± 10.38 vs. 9.72 ± 8.76; p<0.001) and NIH Stroke Score (7.19 ± 7.08 vs. 6.65 ± 7.30; p<0.001). Patients with EtOH abuse were more likely to be male, younger, smokers, covered on Medicaid, have atrial fibrillation, and be in the 0-25% percentile median income bracket (all p<0.001). After propensity matching, EtOH abuse patients had longer hospital stay (0.39 days; 95% CI: 0.28-0.5), lower hospital charges (-$3780.6; 95% CI: -$5053.16 - -$2508.04) and were less likely to be discharged home or short-term hospital (AOR 0.83; 95% CI: 0.81-0.85)(all p<0.001).
Conclusion:
In this 20 year nationally representative propensity matched analysis of patients with AIS, patients that abused EtOH had higher incidences of more severe disease with worse functional outcomes, as well as lower hospital charges despite longer hospital stays.