Author
Santiago Ortega-Gutierrez
Other affiliations: Columbia University, Mount Sinai Hospital, University of Iowa ...read more
Bio: Santiago Ortega-Gutierrez is an academic researcher from University of Iowa Hospitals and Clinics. The author has contributed to research in topics: Medicine & Stroke (engine). The author has an hindex of 23, co-authored 138 publications receiving 3591 citations. Previous affiliations of Santiago Ortega-Gutierrez include Columbia University & Mount Sinai Hospital.
Topics: Medicine, Stroke (engine), Modified Rankin Scale, Occlusion, Stroke
Papers published on a yearly basis
Papers
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University of Southern California1, Stanford University2, University of Iowa3, Brown University4, Ohio State University5, University of Cincinnati6, Medical University of South Carolina7, New York University8, Harvard University9, University of Texas Health Science Center at Houston10, University of Pennsylvania11, Northwestern University12, University of Calgary13
TL;DR: Endovascular thrombectomy for ischemic stroke 6 to 16 hours after a patient was last known to be well plus standard medical therapy resulted in better functional outcomes than standard medical Therapy alone among patients with proximal middle‐cerebral‐artery or internal‐carotid‐arterY occlusion and a region of tissue that was ischeMIC but not yet infarcted.
Abstract: Background Thrombectomy is currently recommended for eligible patients with stroke who are treated within 6 hours after the onset of symptoms. Methods We conducted a multicenter, randomized, open-label trial, with blinded outcome assessment, of thrombectomy in patients 6 to 16 hours after they were last known to be well and who had remaining ischemic brain tissue that was not yet infarcted. Patients with proximal middle-cerebral-artery or internal-carotid-artery occlusion, an initial infarct size of less than 70 ml, and a ratio of the volume of ischemic tissue on perfusion imaging to infarct volume of 1.8 or more were randomly assigned to endovascular therapy (thrombectomy) plus standard medical therapy (endovascular-therapy group) or standard medical therapy alone (medical-therapy group). The primary outcome was the ordinal score on the modified Rankin scale (range, 0 to 6, with higher scores indicating greater disability) at day 90. Results The trial was conducted at 38 U.S. centers and termina...
2,292 citations
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TL;DR: Strategies directed toward minimizing early brain injury and aneurysm rebleeding, along with prevention and treatment of medical complication, hold the best promise for further reducing mortality after SAH.
Abstract: Subarachnoid hemorrhage (SAH) is a devastating form of stroke. Causes and mechanisms of in-hospital death after SAH in the modern era of neurocritical care remain incompletely understood. We studied 1200 consecutive SAH patients prospectively enrolled in the Columbia University SAH Outcomes Project between July 1996 and January 2009. Analysis was performed to identify predictors of in-hospital mortality. In-hospital mortality was 18 % (216/1200): 3 % for Hunt-Hess grade 1 or 2, 9 % for grade 3, 24 % for grade 4, and 71 % for grade 5. The most common adjudicated primary causes of death or neurological devastation leading to withdrawal of support were direct effects of the primary hemorrhage (55 %), aneurysm rebleeding (17 %), and medical complications (15 %). Among those who died, brain death was declared in 42 %, 50 % were do-not-resuscitate at the time of cardiac death (86 % of whom had life support actively withdrawn), and 8 % died despite full support. Admission predictors of mortality were age, loss of consciousness at ictus, admission Glasgow Coma Scale score, large aneurysm size, Acute Physiology and Chronic Health Evaluation II (APACHE II) physiologic subscore, and Modified Fisher Scale score. Hospital complications that further increased the risk of dying in multivariable analysis included rebleeding, global cerebral edema, hypernatremia, clinical signs of brain stem herniation, hypotension of less than 90 mm Hg treated with pressors, pulmonary edema, myocardial ischemia, and hepatic failure. Delayed cerebral ischemia, defined as deterioration or infarction from vasospasm, did not predict mortality. Strategies directed toward minimizing early brain injury and aneurysm rebleeding, along with prevention and treatment of medical complication, hold the best promise for further reducing mortality after SAH.
239 citations
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Raul G Nogueira1, Mohamad Abdalkader2, Muhammed M. Qureshi2, Michael Frankel1 +269 more•Institutions (98)
TL;DR: In this paper, the authors measured the global impact of the COVID-19 pandemic on the volumes of the volumes for medical care in the United Kingdom and the United States.
Abstract: BackgroundThe COVID-19 pandemic led to profound changes in the organization of health care systems worldwide.AimsWe sought to measure the global impact of the COVID-19 pandemic on the volumes for m...
109 citations
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Cooper University Hospital1, Rowan University2, Bellvitge University Hospital3, University of Valladolid4, Spanish National Research Council5, Robert Wood Johnson University Hospital6, Rutgers University7, Autonomous University of Barcelona8, Emory University9, Grady Memorial Hospital10, University of Barcelona11, Alexandria University12, Carol Davila University of Medicine and Pharmacy13, Boston University14, University of Texas Health Science Center at Houston15, Ronald Reagan UCLA Medical Center16, University of Iowa Hospitals and Clinics17, University of Texas at Austin18
TL;DR: COVID-19 is associated with a small but significant risk of clinically relevant cerebrovascular events, particularly ischemic stroke, and aggressive monitoring and early intervention should be pursued to mitigate poor outcomes.
Abstract: BackgroundSevere acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) has been associated with a significant risk of thrombotic events in critically ill patients.AimTo summarize the findings of a ...
108 citations
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Boston University1, Rowan University2, Grady Memorial Hospital3, University of Pittsburgh4, University of Texas at Austin5, University of Texas Southwestern Medical Center6, University of Iowa7, Washington University in St. Louis8, University of South Alabama9, Baptist Memorial Hospital-Memphis10, Alexandria University11, University of Miami12, State University of New York Upstate Medical University13, Texas Tech University14, St Vincent Hospital15, University of California, Los Angeles16
TL;DR: A modified algorithm to acute ischemic large vessel occlusion stroke workflow in the era of the COVID-19 pandemic is presented, based on shared best practices, consensus among academic and nonacademic practicing vascular and interventional neurologists, literature review, and would be adapted to the available resources of a local institution.
Abstract: In December 2019, coronavirus disease 2019 (COVID-19), an infectious disease caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) caused an international outbreak. The World Health Organization designated this as a global pandemic on March 11, 2020, with over 200 countries affected worldwide. As of April 24, 2020, there were 2 790 986 patients with confirmed COVID-19 and 195 775 deaths worldwide, with the United States, Spain, Italy, France, Germany, United Kingdom, Turkey, and Iran surpassing China in the number of confirmed cases. In a consecutive series of 221 patients with confirmed COVID-19 admitted to a hospital in Wuhan, China, acute ischemic stroke occurred in 11(5%) of patients with a broad range of stroke subtypes. These patients with stroke were older, more likely to have cardiovascular risk factors, presenting with severe COVID-19 with multiple organ involvement. Of note, presence of COVID-19 in these patients does not imply that COVID-19 was the mechanism leading to the patient’s stroke. Shortages of Personal Protective Equipment (PPE) such as N95 masks, facial shields, hand sanitizer, and cleansing wipes have presented a major challenge in the allocation of resources, as healthcare workers are frontline in the treatment of these patients. Redeployment of clinical staff, nursing, stroke and neurocritical care specialists to care for patients with COVID-19 may create staffing shortages for dedicated stroke care. In an effort to mitigate the spread of COVID-19 to neuroscience healthcare workers, their patients, and their families, and to optimize allocation of healthcare resources, we present a modified algorithm to acute ischemic large vessel occlusion stroke workflow in the era of the COVID-19 pandemic. This guidance statement is based on shared best practices, consensus among academic and nonacademic practicing vascular and interventional neurologists, literature review, and would be adapted to the available resources of a local institution. The patients with acute stroke are a vulnerable group to address because these patients often come emergently from the community with little information. Radical changes are felt to be necessary to optimize the safety of the providing team and our patients, limit unnecessary tests, conserve PPE resources and mechanical ventilator usage. This document divides into the following: prehospital phase to the Emergency Department (ED), prethrombectomy procedure, thrombectomy intraprocedure, and postreperfusion therapy phases (Table).
97 citations
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28,685 citations
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TL;DR: These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks.
Abstract: Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.
3,819 citations
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TL;DR: Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on antICOagulation.
Abstract: The current manuscript is the second update of the original Practical Guide, published in 2013 [Heidbuchel et al. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace 2013;15:625-651; Heidbuchel et al. Updated European Heart Rhythm Association Practical Guide on the use of non-vitamin K antagonist anticoagulants in patients with non-valvular atrial fibrillation. Europace 2015;17:1467-1507]. Non-vitamin K antagonist oral anticoagulants (NOACs) are an alternative for vitamin K antagonists (VKAs) to prevent stroke in patients with atrial fibrillation (AF) and have emerged as the preferred choice, particularly in patients newly started on anticoagulation. Both physicians and patients are becoming more accustomed to the use of these drugs in clinical practice. However, many unresolved questions on how to optimally use these agents in specific clinical situations remain. The European Heart Rhythm Association (EHRA) set out to coordinate a unified way of informing physicians on the use of the different NOACs. A writing group identified 20 topics of concrete clinical scenarios for which practical answers were formulated, based on available evidence. The 20 topics are as follows i.e., (1) Eligibility for NOACs; (2) Practical start-up and follow-up scheme for patients on NOACs; (3) Ensuring adherence to prescribed oral anticoagulant intake; (4) Switching between anticoagulant regimens; (5) Pharmacokinetics and drug-drug interactions of NOACs; (6) NOACs in patients with chronic kidney or advanced liver disease; (7) How to measure the anticoagulant effect of NOACs; (8) NOAC plasma level measurement: rare indications, precautions, and potential pitfalls; (9) How to deal with dosing errors; (10) What to do if there is a (suspected) overdose without bleeding, or a clotting test is indicating a potential risk of bleeding; (11) Management of bleeding under NOAC therapy; (12) Patients undergoing a planned invasive procedure, surgery or ablation; (13) Patients requiring an urgent surgical intervention; (14) Patients with AF and coronary artery disease; (15) Avoiding confusion with NOAC dosing across indications; (16) Cardioversion in a NOAC-treated patient; (17) AF patients presenting with acute stroke while on NOACs; (18) NOACs in special situations; (19) Anticoagulation in AF patients with a malignancy; and (20) Optimizing dose adjustments of VKA. Additional information and downloads of the text and anticoagulation cards in different languages can be found on an EHRA website (www.NOACforAF.eu).
1,499 citations
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TL;DR: In patients with acute stroke with an unknown time of onset, intravenous alteplase guided by a mismatch between diffusion‐weighted imaging and FLAIR in the region of ischemia resulted in a significantly better functional outcome and numerically more intracranial hemorrhages than placebo at 90 days.
Abstract: Background Under current guidelines, intravenous thrombolysis is used to treat acute stroke only if it can be ascertained that the time since the onset of symptoms was less than 4.5 hours. We sought to determine whether patients with stroke with an unknown time of onset and features suggesting recent cerebral infarction on magnetic resonance imaging (MRI) would benefit from thrombolysis with the use of intravenous alteplase. Methods In a multicenter trial, we randomly assigned patients who had an unknown time of onset of stroke to receive either intravenous alteplase or placebo. All the patients had an ischemic lesion that was visible on MRI diffusion-weighted imaging but no parenchymal hyperintensity on fluid-attenuated inversion recovery (FLAIR), which indicated that the stroke had occurred approximately within the previous 4.5 hours. We excluded patients for whom thrombectomy was planned. The primary end point was favorable outcome, as defined by a score of 0 or 1 on the modified Rankin scale ...
836 citations
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Sichuan University1, Clinical Trial Service Unit2, Capital Medical University3, The George Institute for Global Health4, University of Edinburgh5, Peking University6, Peking Union Medical College Hospital7, Chinese PLA General Hospital8, China Rehabilitation Research Center9, Nanjing University10, Huazhong University of Science and Technology11, Chongqing Medical University12, The Chinese University of Hong Kong13
TL;DR: Future efforts should focus on providing more balanced availability of specialised stroke services across the country, enhancing evidence-based practice, and encouraging greater translational research to improve outcome of patients with stroke.
Abstract: With over 2 million new cases annually, stroke is associated with the highest disability-adjusted life-years lost of any disease in China. The burden is expected to increase further as a result of population ageing, an ongoing high prevalence of risk factors (eg, hypertension), and inadequate management. Despite improved access to overall health services, the availability of specialist stroke care is variable across the country, and especially uneven in rural areas. In-hospital outcomes have improved because of a greater availability of reperfusion therapies and supportive care, but adherence to secondary prevention strategies and long-term care are inadequate. Thrombolysis and stroke units are accepted as standards of care across the world, including in China, but bleeding-risk concerns and organisational challenges hamper widespread adoption of this care in China. Despite little supporting evidence, Chinese herbal products and neuroprotective drugs are widely used, and the increased availability of neuroimaging techniques also results in overdiagnosis and overtreatment of so-called silent stroke. Future efforts should focus on providing more balanced availability of specialised stroke services across the country, enhancing evidence-based practice, and encouraging greater translational research to improve outcome of patients with stroke.
740 citations