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Work 1-10 of 10

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Article

Door-to-Puncture: A Practical Metric for Capturing and Enhancing System Processes Associated With Endovascular Stroke Care, Preliminary Results From the Rapid Reperfusion Registry

by Chung-Huan J. Sun; Marc Ribo; Mayank Goyal; Albert J. Yoo; Tudor Jovin; Carolyn A. Cronin; Osama Zaidat; Raul Nogueira; Thanh Nguyen; M. Shazam Hussain; Bijoy K. Menon; Brijesh Mehta; Gaurav Jindal; Anat Horev; Alexander Norbash; Thabele Leslie-Mazwi; Dolora Wisco; Rishi Gupta

2014

Subjects
  • Biology, Neuroscience
  • Health Sciences, Radiology
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BACKGROUND: In 2011, the Brain Attack Coalition proposed door-to-treatment times of 2 hours as a benchmark for patients undergoing intra-arterial therapy (IAT). We designed the Rapid Reperfusion Registry to capture the percentage of stroke patients who meet the target and its impact on outcomes. METHODS AND RESULTS: This is a retrospective analysis of anterior circulation patients treated with IAT within 9 hours of symptom onset. Data was collected from December 31, 2011 to December 31, 2012 at 2 centers and from July 1, 2012 to December 31, 2012 at 7 centers. Short “Door-to-Puncture” (D2P) time was hypothesized to be associated with good patient outcomes. A total of 478 patients with a mean age of 68±14 years and median National Institutes of Health Stroke Scale (NIHSS) of 18 (IQR 14 to 21) were analyzed. The median times for IAT delivery were 234 minutes (IQR 163 to 304) for “last known normal-to-groin puncture” time (LKN-to-GP) and 112 minutes (IQR 68 to 176) for D2P time. The overall good outcome rate was 39.7% for the entire cohort. In a multivariable model adjusting for age, NIHSS, hypertension, diabetes, reperfusion status, and symptomatic hemorrhage, both short LKN-to-GP (OR 0.996; 95% CI [0.993 to 0.998]; P<0.001) and short D2P times (OR 0.993, 95% CI [0.990 to 0.996]; P<0.001) were associated with good outcomes. Only 52% of all patients in the registry achieved the targeted D2P time of 2 hours. CONCLUSIONS: The time interval of D2P presents a clinically relevant time frame by which system processes can be targeted to streamline the delivery of IAT care nationally. At present, there is much opportunity to enhance outcomes through reducing D2P.

Article

Time From Imaging to Endovascular Reperfusion Predicts Outcome in Acute Stroke

by Jenny P. Tsai; Michael Mlynash; Soren Christensen; Stephanie Kemp; Sun Kim; Nishant Mishra; Christian Federau; Raul Nogueira; Tudor Jovin; Thomas G. Devlin; Naveed Akhtar; Dileep R. Yavagal; Roland Bammer; Matus Straka; Gregory Zaharchuk; Michael P. Marks; Gregory W. Albers; Maarten G. Lansberg

2018

Subjects
  • Biology, Neuroscience
  • Health Sciences, General
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Background and Purpose-This study aims to describe the relationship between computed tomographic (CT) perfusion (CTP)-to-reperfusion time and clinical and radiological outcomes, in a cohort of patients who achieve successful reperfusion for acute ischemic stroke. Methods-We included data from the CRISP (Computed Tomographic Perfusion to Predict Response in Ischemic Stroke Project) in which all patients underwent a baseline CTP scan before endovascular therapy. Patients were included if they had a mismatch on their baseline CTP scan and achieved successful endovascular reperfusion. Patients with mismatch were categorized into target mismatch and malignant mismatch profles, according to the volume of their Tmax >10s lesion volume (target mismatch, <100 mL; malignant mismatch, >100 mL). We investigated the impact of CTP-toreperfusion times on probability of achieving functional independence (modifed Rankin Scale, 0-2) at day 90 and radiographic outcomes at day 5. Results-Of 156 included patients, 108 (59%) had the target mismatch profle, and 48 (26%) had the malignant mismatch profle. In patients with the target mismatch profle, CTP-to-reperfusion time showed no association with functional independence (P=0.84), whereas in patients with malignant mismatch profle, CTP-to-reperfusion time was strongly associated with lower probability of functional independence (odds ratio, 0.08; P=0.003). Compared with patients with target mismatch, those with the malignant mismatch profle had signifcantly more infarct growth (90 [49-166] versus 43 [18-81] mL; P=0.006) and larger fnal infarct volumes (110 [61-155] versus 48 [21-99] mL; P=0.001). Conclusions-Compared with target mismatch patients, those with the malignant profle experience faster infarct growth and a steeper decline in the odds of functional independence, with longer delays between baseline imaging and reperfusion. However, this does not exclude the possibility of treatment beneft in patients with a malignant profle.

Article

Imaging in StrokeNet Realizing the Potential of Big Data

by David S. Liebeskind; Gregory W. Albers; Karen Crawford; Colin P. Derdeyn; Mark S. George; Yuko Y. Palesch; Arthur W. Toga; Steven Warach; Wenle Zhao; Thomas G. Brott; Ralph L. Sacco; Pooja Khatri; Jeffrey L. Saver; Steven C. Cramer; Steven Wolf; Joseph P. Broderick; Max Wintermark

2015

Subjects
  • Biology, Bioinformatics
  • Biology, Neuroscience
  • Health Sciences, Radiology
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Article

International survey of acute Stroke imaging used to make revascularization treatment decisions

by Max Wintermark; Marie Luby; Natan M. Bornstein; Andrew Demchuk; Jens Fiehler; Kohsuke Kudo; Kennedy R. Lees; David S. Liebeskind; Patrik Michel; Raul Nogueira; Mark W. Parsons; Makoto Sasaki; Joanna M. Wardlaw; Ona Wu; Weiwei Zhang; Guangming Zhu; Steven J. Warach

2015

Subjects
  • Biology, Neuroscience
  • Health Sciences, Medicine and Surgery
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Background To assess the differences across continental regions in terms of stroke imaging obtained for making acute revascularization therapy decisions, and to identify obstacles to participating in randomized trials involving multimodal imaging. Methods Stroke Imaging Repository (STIR) and Virtual International Stroke Trials Archive (VISTA)-Imaging circulated an online survey through its website, through the websites of national professional societies from multiple countries as well as through email distribution lists from STIR and the above mentioned societies. Results We received responses from 223 centers (2 from Africa, 38 from Asia, 10 from Australia, 101 from Europe, 4 from Middle East, 55 from North America, 13 from South America). In combination, the sites surveyed administered acute revascularization therapy to a total of 25 326 acute stroke patients in 2012. Seventy-three percent of these patients received intravenous (IV) tissue plasminogen activator (tPA), and 27%, endovascular therapy. Vascular imaging was routinely obtained in 79% (152/193) of sites for endovascular therapy decisions, and also as part of standard IV tPA treatment decisions at 46% (92/198) of sites. Modality, availability and use of acute vascular and perfusion imaging before revascularization varied substantially between geographical areas. The main obstacles to participate in randomized trials involving multimodal imaging included: mainly insufficient research support and staff (50%, 79/158) and infrequent use of multimodal imaging (27%, 43/158). Conclusion There were significant variations among sites and geographical areas in terms of stroke imaging work-up used to make decisions both for intravenous and endovascular revascularization. Clinical trials using advanced imaging as a selection tool for acute revascularization therapy should address the need for additional resources and technical support, and take into consideration the lack of routine use of such techniques in trial planning.

Article

The THRIVE score strongly predicts outcomes in patients treated with the Solitaire device in the SWIFT and STAR trials

by Alexander C. Flint; Sean P. Cullen; Vivek A. Rao; Bonnie S. Faigeles; Vitor M. Pereira; Elad I. Levy; Tudor G. Jovin; David S. Liebeskind; Raul Gomes Nogueira; Reza Jahan; Jeffrey L. Saver

2014

Subjects
  • Biology, Neuroscience
  • Health Sciences, Medicine and Surgery
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Background: The Totaled Health Risks in Vascular Events (THRIVE) score strongly predicts clinical outcome, mortality, and risk of thrombolytic haemorrhage in ischemic stroke patients, and performs similarly well in patients receiving intravenous tissue plasminogen activator, endovascular stroke treatment, or no acute treatment. It is not known if the THRIVE score predicts outcomes with the Solitaire endovascular stroke treatment device. Aims: To validate the relationship between the THRIVE score and outcomes after treatment with the Solitaire endovascular stroke treatment device. Methods: The study conducted a retrospective analysis of the prospective SWIFT and STAR trials to examine the relationship between THRIVE and outcomes after treatment with the Solitaire device. We examined the relationship between THRIVE and clinical outcomes (good outcome or death at 90days) among patients in SWIFT and STAR. Receiver-operator characteristics curve analysis was used to compare THRIVE score performance with other stroke prediction scores. Multivariable modeling was used to confirm the independence of the THRIVE score from procedure-specific predictors (successful recanalization or device used) and other predictors of functional outcome. Results: The THRIVE score strongly predicts good outcome and death among patients treated with the Solitaire device in SWIFT and STAR (Mantel-Haenszel chi-square test for trend P<0·001 for good outcome, P=0·01 for death). In receiver-operator characteristics (ROC) curve comparisons, totaled health risks in vascular events score is superior to Stroke Prognostication using Age and NIH Stroke Scale score-100 (P<0·001) and performed similarly to Houston Intra-Arterial Therapy score (HIAT) (P=0·98) and HIAT-2 (P=0·54). In multivariable models, THRIVE's prediction of good outcome is not altered after controlling for recanalization or after controlling for device used. The THRIVE score remains a strong independent predictor after controlling for the above predictors together with time to procedure, rate of symptomatic haemorrhage, and use of general anesthesia. Of note, use of general anesthesia was not an independent predictor of outcome in SWIFT+STAR after controlling for totaled health risks in vascular events and other factors. Conclusions: The THRIVE score strongly predicts clinical outcome and mortality in patients treated with the Solitaire device in the SWIFT and STAR trials. The lack of interaction between THRIVE and procedure-specific elements such as vessel recanalization or device choice makes the THRIVE score a reasonable candidate for use as a patient selection criterion in stroke clinical trials.

Article

Detailed Analysis of Periprocedural Strokes in Patients Undergoing Intracranial Stenting in Stenting and Aggressive Medical Management for Preventing Recurrent Stroke in Intracranial Stenosis (SAMMPRIS)

by David Fiorella; Colin P. Derdeyn; Michael Lynn; Stanley L. Barnwell; Brian L. Hoh; Elad I. Levy; Mark R. Harrigan; Richard P. Klucznik; Cameron G. McDougall; G. Lee Pride; Osama O. Zaidat; Helmi L. Lutsep; Michael F. Waters; J. Maurice Hourihane; Andrei V. Alexandrov; David Chiu; Joni M. Clark; Mark D. Johnson; Michel T. Torbey; Zoran Rumboldt; Harry J. Cloft; Tanya N. Turan; Bethany F. Lane; L. Scott Janis; Marc I. Chimowitz

2012

Subjects
  • Biology, Neuroscience
  • Health Sciences, Radiology
  • Biology, Biostatistics
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BACKGROUND AND PURPOSE-: Enrollment in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial was halted due to the high risk of stroke or death within 30 days of enrollment in the percutaneous transluminal angioplasty and stenting arm relative to the medical arm. This analysis focuses on the patient and procedural factors that may have been associated with periprocedural cerebrovascular events in the trial. METHODS-: Bivariate and multivariate analyses were performed to evaluate whether patient and procedural variables were associated with cerebral ischemic or hemorrhagic events occurring within 30 days of enrollment (termed periprocedural) in the percutaneous transluminal angioplasty and stenting arm. RESULTS-: Of 224 patients randomized to percutaneous transluminal angioplasty and stenting, 213 underwent angioplasty alone (n=5) or with stenting (n=208). Of these, 13 had hemorrhagic strokes (7 parenchymal, 6 subarachnoid), 19 had ischemic stroke, and 2 had cerebral infarcts with temporary signs within the periprocedural period. Ischemic events were categorized as perforator occlusions (13), embolic (4), mixed perforator and embolic (2), and delayed stent occlusion (2). Multivariate analyses showed that higher percent stenosis, lower modified Rankin score, and clopidogrel load associated with an activated clotting time above the target range were associated (P≤0.05) with hemorrhagic stroke. Nonsmoking, basilar artery stenosis, diabetes, and older age were associated (P≤0.05) with ischemic events. CONCLUSIONS-: Periprocedural strokes in SAMMPRIS had multiple causes with the most common being perforator occlusion. Although risk factors for periprocedural strokes could be identified, excluding patients with these features from undergoing percutaneous transluminal angioplasty and stenting to lower the procedural risk would limit percutaneous transluminal angioplasty and stenting to a small subset of patients. Moreover, given the small number of events, the present data should be used for hypothesis generation rather than to guide patient selection in clinical practice.

Article

Association of US Centers for Medicare and Medicaid Services Hospital 30-Day Risk-Standardized Readmission Metric With Care Quality and Outcomes After Acute Myocardial Infarction Findings From the National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines

by Ambarish Pandey; Harsh Golwala; Hurst M. Hall; Tracy Y. Wang; Di Lu; Ying Xian; Karen Chiswell; Karen E. Joynt; Abhinav Goyal; Sandeep R. Das; Dharam Kumbhani; Howard Julien; Gregg C. Fonarow; James A. de Lemos

2017

Subjects
  • Biology, Neuroscience
  • Health Sciences, Public Health
  • Health Sciences, Epidemiology
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IMPORTANCE The US Centers for Medicare and Medicaid Services Hospital Readmissions Reduction Program penalizes hospitals with higher-than-expected risk-adjusted 30-day readmission rates (excess readmission ratio [ERR] > 1) after acutemyocardial infarction (MI). However, the association of ERR with MI care processes and outcomes are notwell established. OBJECTIVE To evaluate the association between ERR forMI with in-hospital process of care measures and 1-year clinical outcomes. DESIGN, SETTING, AND PARTICIPANTS Observational analysis of hospitalized patients with MI from National Cardiovascular Data Registry/Acute Coronary Treatment and Intervention Outcomes Network Registry-Get With the Guidelines centers subject to the first cycle of the Hospital Readmissions Reduction Program between July 1, 2008, and June 30, 2011. EXPOSURES The ERR forMI (MI-ERR) in 2011. MAIN OUTCOMES AND MEASURES Adherence to process of care measures during index hospitalization in the overall study population and risk of the composite outcome of mortality or all-cause readmission within 1 year of discharge and its individual components among participants with available Centers for Medicare and Medicaid Services-linked data. RESULTS The median ages of patients in the MI-ERR greater than 1 and tertiles 1, 2, and 3 of the MI-ERR greater than 1 groupswere 64, 63, 64, and 63 years, respectively. Among 380 hospitals that treated a total of 176 644 patients with MI during the study period, 43%had MI-ERR greater than 1. The proportions of patients of black race, those with heart failure signs at admission, and bleeding complications increased with higher MI-ERR. Therewas no significant association between adherence to MI performance measures and MI-ERR (adjusted odds ratio, 0.94; 95%CI, 0.81-1.08, per 0.1-unit increase in MI-ERR for overall defect-free care). Among the 51 453 patients with 1-year outcomes data available, higher MI-ERRwas associated with higher adjusted risk of the composite outcome and all-cause readmission within 1 year of discharge. This associationwas largely driven by readmissions early after discharge andwas not significant in landmark analyses beginning 30 days after discharge. The MI-ERRwas not associated with risk for mortality within 1 year of discharge in the overall and 30-day landmark analyses. CONCLUSIONS AND RELEVANCE During the first cycle of the Hospital Readmissions Reduction Program, participating hospitals' risk-adjusted 30-day readmission rates followingMI were not associated with in-hospital quality ofMI care or clinical outcomes occurring after the first 30 days after discharge.

Article

Morbidity and Mortality Associated With Meningioma After Cranial Radiotherapy: A Report From the Childhood Cancer Survivor Study

by Daniel C. Bowers; Chaya S. Moskowitz; Joanne F. Chou; Claire M. Mazewski; Joseph P. Neglia; Gregory T. Armstrong; Wendy M. Leisenring; Leslie L. Robison; Kevin C. Oeffinger

2017

Subjects
  • Health Sciences, Oncology
  • Biology, Neuroscience
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Purpose: Little is known about neurologic morbidity attributable to cranial radiotherapy (CRT) -associated meningiomas. Materials and Methods: From 4,221 survivors exposed to CRT in the Childhood Cancer Survivor Study, a diagnosis of meningioma and onset of neurologic sequelae were ascertained. Cox proportional hazards regression was used to estimate hazard ratios (HR) and 95% CIs to evaluate the factors associated with neurologic sequelae after subsequent meningioma. Results: One hundred ninety-nine meningiomas were identified among 169 participants. The median interval from primary cancer to meningioma diagnosis was 22 years (5 to 37 years). The cumulative incidence of a subsequent meningioma by age 40 years was 5.6% (95% CI, 4.7% to 6.7%). CRT doses of 20 to 29.9 Gy (HR, 1.6; 95% CI,1.0 to 2.6) and doses ≥ 30 Gy (HR, 2.6; 95% CI, 1.6 to 4.2) were associated with an increased risk of meningioma compared with CRT doses of 1.5 to 19.9 Gy (P < .001). Within 6 months before or subsequent to a meningioma diagnosis, 20% (30 of 149) reported at least one new neurologic sequela, including seizures (8.3%), auditory-vestibular-visual deficits (6%), focal neurologic dysfunction (7.1%), and severe headaches (5.3%). Survivors reporting a meningioma had increased risks of neurologic sequelae > 5 years after primary cancer diagnosis, including seizures (HR, 10.0; 95% CI, 7.0 to 15.3); auditory-vestibular-visual sensory deficits (HR, 2.3; 95% CI, 1.3 to 4.0); focal neurologic dysfunction (HR, 4.9; 95% CI, 3.2 to 7.5); and severe headaches (HR, 3.2; 95% CI, 1.9 to 5.4). With a median follow-up of 72 months after meningioma diagnosis (range, 3.8 to 395 months), 22 participants (13%) were deceased, including six deaths attributed to a meningioma. Conclusion: Childhood cancer survivors exposed to CRT and subsequently diagnosed with a meningioma experience significant neurologic morbidity.

Article

Field Assessment Stroke Triage for Emergency Destination A Simple and Accurate Prehospital Scale to Detect Large Vessel Occlusion Strokes

by Fabricio O. Lima; Gisele S. Silva; Karen L. Furie; Michael Frankel; Michael H. Lev; Érica CS Camargo; Diogo Haussen; Aneesh B. Singhal; Walter J. Koroshetz; Wade S. Smith; Raul Nogueira

2016

Subjects
  • Biology, Neuroscience
  • Health Sciences, Radiology
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Background and Purpose - Patients with large vessel occlusion strokes (LVOS) may be better served by direct transfer to endovascular capable centers avoiding hazardous delays between primary and comprehensive stroke centers. However, accurate stroke field triage remains challenging. We aimed to develop a simple field scale to identify LVOS. Methods - The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale was based on items of the National Institutes of Health Stroke Scale (NIHSS) with higher predictive value for LVOS and tested in the Screening Technology and Outcomes Project in Stroke (STOPStroke) cohort, in which patients underwent computed tomographic angiography within the first 24 hours of stroke onset. LVOS were defined by total occlusions involving the intracranial internal carotid artery, middle cerebral artery-M1, middle cerebral artery-2, or basilar arteries. Patients with partial, bihemispheric, and anterior+posterior circulation occlusions were excluded. Receiver operating characteristic curve, sensitivity, specificity, positive predictive value, and negative predictive value of FAST-ED were compared with the NIHSS, Rapid Arterial Occlusion Evaluation (RACE) scale, and Cincinnati Prehospital Stroke Severity (CPSS) scale. Results - LVO was detected in 240 of the 727 qualifying patients (33%). FAST-ED had comparable accuracy to predict LVO to the NIHSS and higher accuracy than RACE and CPSS (area under the receiver operating characteristic curve: FAST-ED=0.81 as reference; NIHSS=0.80, P=0.28; RACE=0.77, P=0.02; and CPSS=0.75, P=0.002). A FAST-ED ≥4 had sensitivity of 0.60, specificity of 0.89, positive predictive value of 0.72, and negative predictive value of 0.82 versus RACE ≥5 of 0.55, 0.87, 0.68, and 0.79, and CPSS ≥2 of 0.56, 0.85, 0.65, and 0.78, respectively. Conclusions - FAST-ED is a simple scale that if successfully validated in the field, it may be used by medical emergency professionals to identify LVOS in the prehospital setting enabling rapid triage of patients.

Article

Rationale and Design of the ATHENA-HF Trial Aldosterone Targeted Neurohormonal Combined With Natriuresis Therapy in Heart Failure

by Javed Butler; Adrian F. Hernandez; Kevin J. Anstrom; Andreas Kalogeropoulos; Margaret M. Redfield; Marvin A. Konstam; W. H. Wilson Tang; G. Michael Felker; Monica R. Shah; Eugene Braunwald

2016

Subjects
  • Biology, Neuroscience
  • Health Sciences, Medicine and Surgery
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Although therapy with mineralocorticoid receptor antagonists (MRAs) is recommended for patients with chronic heart failure (HF) with reduced ejection fraction and in post-infarction HF, it has not been studied well in acute HF (AHF) despite being commonly used in this setting. At high doses, MRA therapy in AHF may relieve congestion through its natriuretic properties and mitigate the effects of adverse neurohormonal activation associated with intravenous loop diuretics. The ATHENA-HF (Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure) trial is a randomized, double-blind, placebo-controlled study of the safety and efficacy of 100 mg/day spironolactone versus placebo (or continued low-dose spironolactone use in participants who are already receiving spironolactone at baseline) in 360 patients hospitalized for AHF. Patients are randomized within 24 h of receiving the first dose of intravenous diuretics. The primary objective is to determine if high-dose spironolactone, compared with standard care, will lead to greater reductions in N-terminal pro−B-type natriuretic peptide levels from randomization to 96 h. The secondary endpoints include changes in the clinical congestion score, dyspnea relief, urine output, weight change, loop diuretic dose, and in-hospital worsening HF. Index hospital length of stay and 30-day clinical outcomes will be assessed. Safety endpoints include risk of hyperkalemia and renal function. Differences among patients with reduced versus preserved ejection fraction will be determined.
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