Publications by authors named "Adnan I Qureshi"

615 Publications

Cost-effectiveness analysis of endovascular treatment with or without intravenous thrombolysis in acute ischemic stroke.

J Neurosurg 2022 Jun 10:1-10. Epub 2022 Jun 10.

1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri.

Objective: Intravenous (IV) recombinant tissue plasminogen activator (r-tPA) may not provide additional benefit in terms of functional outcomes in patients with acute ischemic stroke (AIS) who undergo endovascular treatment (EVT). In this context, the cost-effectiveness of EVT alone compared with its application following IV r-tPA has not been evaluated.

Methods: The authors determined the average rates of death or disability in each of the two treatment groups from four randomized clinical trials that enrolled patients with AIS within 4.5 hours of symptom onset and randomly assigned patients to EVT alone and IV r-tPA and EVT. By using three sources derived from previous studies, the authors determined the cost of IV r-tPA, cost of staff time for administration, cost of the EVT, cost of hospital stay, costs of supported discharge and community care, and cost of posthospitalization care and disability. They then assessed the cost-effectiveness of EVT alone using a decision tree for the 1st year after AIS and a Markov model with a 10-year horizon, including probabilistic assessment by Monte Carlo simulations.

Results: The 1-year cost was higher with IV r-tPA and EVT compared with EVT alone (incremental cost ranging between $3554 and $13,788 per patient). The mean incremental cost-effectiveness ratios (ICERs) were -$1589, -$78,327, and -$15,471 per quality-adjusted life-year gained for cost sources 1, 2, and 3, respectively, for EVT alone compared with IV r-tPA and EVT at 10 years. The ceiling ICER (willingness to pay) for a probability of 100% that EVT alone was more cost-effective ranged between $25,000 and $100,000 in the three models.

Conclusions: EVT alone appears to be more cost-effective compared with EVT and IV r-tPA for the treatment of AIS patients presenting within 4.5 hours of symptom onset.
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http://dx.doi.org/10.3171/2022.4.JNS22514DOI Listing
June 2022

New cardiovascular events in the convalescent period among survivors of SARS-CoV-2 infection.

Int J Stroke 2022 Aug 6:17474930221114561. Epub 2022 Aug 6.

Institute for Data Science and Informatics, University of Missouri, Columbia, MO, USA.

Background: Patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may have an increased risk of acute cardiovascular events in the convalescent period.

Aims: To determine whether patients with SARS-CoV-2 infection have an increased risk of cardiovascular events during the convalescent period.

Methods: We analyzed 10,691 hospitalized adult pneumonia patients with SARS-CoV-2 infection and contemporary matched controls of pneumonia patients without SARS-CoV-2 infection. The risk of new cardiovascular events following >30 days pneumonia admission (convalescent period) was ascertained using Cox proportional hazards regression analysis to adjust for potential confounders.

Results: Among 10,691 pneumonia patients with SARS-CoV-2 infection, 697 patients (5.8%; 95% CI, 5.4-6.2%) developed new cardiovascular events (median time interval of 218 days post pneumonia admission; interquartile range 1 = 117 days, 3 = 313 days). The risk of new cardiovascular events was not significantly higher among pneumonia patients with SARS-CoV-2 infection compared with those with pneumonia without SARS-CoV-2 infection (hazard ratio (HR), 0.90, 95% CI, 0.80-1.02) after adjustment for potential confounders. In addition, no significant difference in the rate of a new ischemic stroke (HR, 0.84; 95% CI, 0.70-1.02) or ischemic heart disease (HR, 1.00; 95% CI, 0.87-1.15) was observed between the pneumonia patients with and without SARS-CoV-2 infection.

Conclusion: Our study suggests that new cardiovascular events rate in the convalescent period among pneumonia patients with SARS-CoV-2 infection was not significantly higher than the rate seen with other pneumonias.
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http://dx.doi.org/10.1177/17474930221114561DOI Listing
August 2022

Endovascular Treatment Versus Best Medical Management in Acute Basilar Artery Occlusion Strokes: Results From the ATTENTION Multicenter Registry.

Circulation 2022 07 3;146(1):6-17. Epub 2022 Jun 3.

Department of Neurology, Anqing Hospital Affiliated to Anhui Medical University, China (X.S.).

Background: The authors compare the effectiveness and safety of endovascular treatment (EVT) versus best medical management (BMM) in strokes attributable to acute basilar artery occlusion (BAO).

Methods: The present analysis was based on the ongoing, prospective, multicenter ATTENTION (Endovascular Treatment for Acute Basilar Artery Occlusion) trial registry in China. Our analytic sample comprised 2134 patients recruited at 48 sites between 2017 and 2021 and included 462 patients who received BMM and 1672 patients who received EVT. We performed an inversed probability of treatment weighting analysis. Qualifying patients had to present within 24 hours of estimated BAO. The primary clinical outcome was favorable functional outcome (modified Rankin Scale score, 0-3) at 90 days. We also performed a sensitivity analysis with the propensity score matching-based and the instrumental variable-based analysis.

Results: In our primary analysis using the inversed probability of treatment weighting-based analysis, there was a significantly higher rate of favorable outcome at 90 days among EVT patients compared with BMM-treated patients (adjusted relative risk, 1.42 [95% CI, 1.19-1.65]; absolute risk difference, 11.8% [95% CI, 6.9-16.7]). The mortality was significantly lower (adjusted relative risk, 0.78 [95% CI, 0.69-0.88]; absolute risk difference, -10.3% [95% CI, -15.8 to -4.9]) in patients undergoing EVT. Results were generally consistent across the secondary end points. Similar associations were seen in the propensity score matching-based and instrumental variable-based analysis.

Conclusions: In this real-world study, EVT was associated with significantly better functional outcomes and survival at 90 days. Well-designed randomized studies comparing EVT with BMM in the acute BAO are needed.

Registration: URL: www.chictr.org.cn; Unique identifier: ChiCTR2000041117.
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http://dx.doi.org/10.1161/CIRCULATIONAHA.121.058544DOI Listing
July 2022

Early Hyperchloremia and Outcomes After Acute Ischemic Stroke.

J Stroke Cerebrovasc Dis 2022 Aug 25;31(8):106523. Epub 2022 May 25.

Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Objective: Based on the relationship between hyperchloremia and mortality in critically ill patients, we investigated the effect of early hyperchloremia on 90-day outcomes in acute ischemic stroke patients.

Materials And Methods: Acute ischemic stroke patients recruited within 5 h of symptom onset were analyzed. Hyperchloremia (defined as 110 mmol/L or greater) at either baseline, or 24, or 48 h after randomization was identified and classified as one occurrence or two or more occurrences. Logistic regression analyses were performed to determine the effects of hyperchloremia on: favorable outcomes (defined by a National Institutes of Health Stroke Scale and/or modified Rankin scale scores of 0-1) at 90-day, death or disability at 90-day, and death within 90-day after accounting for potential confounders.

Results: Among the total of 1275 patients, one and two or more occurrence of hyperchloremia within 48 h were seen in 191 patients and 108 patients, respectively. Compared with patients without hyperchloremia, patients with two or more occurrences of hyperchloremia at significantly higher odds of lack of favorable outcomes (odds ratio 3.0, 95% confidence interval 1.8-5.1) and death or disability (odds ratio 2.6, 95% confidence interval 1.6-4.1) at 90-day after adjustment for age, National Institutes of Health Stroke Scale score strata (6-9, 10-19, ≥ 20), study intervention, initial SBP, and intra-arterial treatment.

Conclusions: The independent association between sustained hyperchloremia and lack of favorable outcomes at 90-day suggest that avoidance of hyperchloremia may reduce the rate of lack of favorable outcomes and death or disability in patients with acute ischemic stroke.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2022.106523DOI Listing
August 2022

Early Hyperchloremia is Independently Associated with Death or Disability in Patients with Intracerebral Hemorrhage.

Neurocrit Care 2022 May 5. Epub 2022 May 5.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.

Background: On the basis of increased mortality associated with hyperchloremia among critically ill patients, we investigated the effect of occurrence of early hyperchloremia on death or disability at 90 days in patients with intracerebral hemorrhage (ICH).

Methods: We analyzed the data from Antihypertensive Treatment of Cerebral Hemorrhage 2 trial, which recruited patients with spontaneous ICH within 4.5 h of symptom onset. Patients with increased serum chloride levels (110 mmol/L or greater) at either baseline or 24, 48, or 72 h after randomization were identified. We further graded hyperchloremia into one occurrence or two or more occurrences within the first 72 h. Two logistic regression analyses were performed to determine the effects of hyperchloremia on (1) death within 90 days and (2) death or disability at 90 days after adjustment for potential confounders.

Results: Among the total of 1,000 patients analyzed, hyperchloremia within 72 h was seen in 114 patients with one occurrence and in 154 patients with two or more occurrences. Patients with one occurrence of hyperchloremia (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.1-5.5) and those with two or more occurrences (OR 2.6, 95% CI 1.3-5.0) had significantly higher odds of death within 90 days after adjustment for age, race and ethnicity, National Institutes of Health Stroke Scale score strata, hematoma volume, presence or absence of intraventricular hemorrhage, cigarette smoking, previous stroke, and maximum hourly dose of nicardipine. Patients with two or more occurrences of hyperchloremia (OR 3.4, 95% CI 2.1-5.6) had significantly higher odds of death or disability at 90 days compared with patients without hyperchloremia after adjustment for the abovementioned potential confounders.

Conclusions: The independent association between hyperchloremia and death or disability at 90 days suggests that avoidance of hyperchloremia may reduce the observed death or disability in patients with ICH.

Clinical Trial Registration: ClinicalTrials.gov: NCT01176565.
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http://dx.doi.org/10.1007/s12028-022-01514-2DOI Listing
May 2022

Endovascular Thrombectomy With or Without Intravenous Thrombolysis: A Meta-Analysis of Randomized Controlled Trials.

Interv Neuroradiol 2022 Apr 21:15910199221080232. Epub 2022 Apr 21.

Zeenat Qureshi Stroke Institute, St Cloud, MN.

Background: We performed this meta-analysis of randomized clinical trials to compare the outcomes in patients treated with endovascular thrombectomy who receive prior intravenous thrombolysis with those who do not receive such treatment. Recently, one randomized trial reported outcomes to address this issue, so timely update of meta-analysis is needed to determine the value of administering intravenous thrombolysis before endovascular thrombectomy.

Materials And Methods: Four randomized clinical trials are included in our meta-analysis. We calculated pooled odds ratios and 95% CIs using random-effects models. The primary efficacy endpoint was a favorable outcome defined by a modified Rankin Scale score of 0 (no symptoms), 1 (no significant disability), or 2 (slight disability) at 90 days post-randomization. Secondary endpoints analyzed were any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality.

Results: Of the 1633 patients randomized, the proportion of patients who achieved a favorable outcome was similar between endovascular thrombectomy alone and combined approach with intravenous thrombolysis and endovascular thrombectomy (1631 patients analyzed; odds ratio 1.02; CI 0.84-1.25; p = 0.83). Risk of any intracerebral hemorrhage was significantly lower among those randomized to endovascular thrombectomy alone (1633 patients analyzed; odds ratio 0.75; CI 0.57-0.99; p = 0.04). Rates of symptomatic intracerebral hemorrhage (p = 0.36) and mortality (p = 0.62) were not significantly different between the two groups.

Conclusions: Compared with endovascular thrombectomy preceded by intravenous thrombolysis, endovascular thrombectomy resulted in similar rates of favorable outcome with a lower rate of intracerebral hemorrhage. A large phase 3 trial is required to conclusively demonstrate equivalency of both approaches to guide future practice.
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http://dx.doi.org/10.1177/15910199221080232DOI Listing
April 2022

Hyperglycemic control in acute ischemic stroke patients undergoing endovascular treatment: post hoc analysis of the Stroke Hyperglycemia Insulin Network Effort trial.

J Neurointerv Surg 2022 Apr 12. Epub 2022 Apr 12.

Neurology, University of Missouri, Columbia, Missouri, USA.

Background: Hyperglycemia has been associated with poor outcomes in acute ischemic stroke patients undergoing endovascular treatment. We analyzed the effect of intensive glucose control on death and disability rates in patients with acute ischemic stroke undergoing endovascular treatment.

Methods: We analyzed the effect of intensive (serum glucose <110 mg/dL) glucose treatment (compared with standard treatment, serum glucose <180 mg/dL) in patients who received endovascular treatment in the Stroke Hyperglycemia Insulin Network Effort (SHINE) trial. We further analyzed the effect of area under the curve (AUC) of serum glucose, proportion of the time blood glucose was <140 mg/dL, and glucose variability defined as the glucose range during 72 hours. The primary outcomes were neurological deterioration within 72 hours and outcome at 90 days.

Results: A total of 146 patients (mean age 68.1±13.9 years, 50.7% men) underwent endovascular treatment for acute ischemic stroke; 72 and 74 patients were randomized to intensive and standard treatments, respectively. The rates of death (20.3% and 22.2%), favorable 90-day primary outcome (17.6% and 19.4%), and serious adverse events (41.9% and 56.98%) were similar between the two groups. The AUC of serum glucose was not associated with death within 90 days (OR 1, 95% CI 1 to 1) or favorable outcome at 90 days (OR 1, 95% CI 1 to 1). Glucose variability was not associated with death or favorable outcome at 90 days.

Conclusion: We did not identify any beneficial effect of intensive glucose reduction on rates of death or favorable outcomes at 90 days among acute ischemic stroke patients undergoing endovascular treatment.
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http://dx.doi.org/10.1136/neurintsurg-2021-018485DOI Listing
April 2022

Temporal Trajectory of Systolic Blood Pressure and Outcomes in Acute Intracerebral Hemorrhage: ATACH-2 Trial Cohort.

Stroke 2022 06 11;53(6):1854-1862. Epub 2022 Apr 11.

Department of Cerebrovascular Medicine (K. Tanaka, M.K., M.F.-D., K.M., K. Toyoda), National Cerebral and Cardiovascular Center, Suita, Japan.

Background: To highlight the heterogeneity of acute temporal blood pressure (BP) changes in the ATACH-2 trial (Antihypertensive Treatment of Acute Cerebral Hemorrhage-2) and associations with the outcomes of intracerebral hemorrhage.

Methods: One thousand patients with acute intracerebral hemorrhage, who had been randomized to intensive (110-139 mm Hg) or standard (140-179 mm Hg) systolic BP (SBP) lowering with intravenous nicardipine in ATACH-2 from 2011 to 2015, were analyzed about temporal changes in hourly maximum SBP up to 24 hours after randomization using group-based trajectory modeling. Outcomes included death or disability (modified Rankin Scale score 4-6) at 3 months, neurological deterioration within 24 hours (≥2-point decrease in Glasgow Coma Scale score or ≥4-point increase in National Institutes of Health Stroke Scale score), and acute kidney injury (≥0.3 mg/dL within 48 hours or ≥1.5-fold increase in serum creatinine) within 7 days after onset.

Results: Group-based trajectory modeling revealed 4 SBP trajectory groups: moderate SBP (from ≈190 mm Hg at hospital arrival to 150-160 mm Hg after randomization; n=298), moderate-to-low SBP (from ≈190 mm Hg to <140 mm Hg; n=395), high-to-low SBP (from >210 mm Hg to <140 mm Hg; n=134), and high SBP (from >210 mm Hg to 160-170 mm Hg; n=173). Patients with intensive treatment accounted for 11.1%, 88.6%, 85.1%, and 1.7% of each group, respectively. Compared with the moderate-to-low SBP group, the high-to-low SBP group showed increased risks of death or disability at 3 months (adjusted odds ratio, 2.29 [95% CI, 1.24-4.26]) and acute kidney injury (adjusted odds ratio, 3.50 [95% CI, 1.83-6.69]), while no increase in neurological deterioration was seen in this group (adjusted odds ratio, 0.48 [95% CI, 0.20-1.13]). The moderate SBP and high SBP groups showed no significant risk differences for such outcomes.

Conclusions: Data-driven observation using a group-based trajectory modeling approach may be useful to clarify the relationship between antihypertensive treatment, temporal SBP changes, and outcomes in acute intracerebral hemorrhage.

Registration: URL: https://www.

Clinicaltrials: gov; Unique identifier: NCT01176565.
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http://dx.doi.org/10.1161/STROKEAHA.121.037186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9126256PMC
June 2022

New-Onset Dementia Among Survivors of Pneumonia Associated With Severe Acute Respiratory Syndrome Coronavirus 2 Infection.

Open Forum Infect Dis 2022 Apr 7;9(4):ofac115. Epub 2022 Mar 7.

Institute for Data Science and Informatics, University of Missouri, Columbia, Missouri, USA.

Background: Case series without control groups suggest that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may result in cognitive deficits and dementia in the postinfectious period.

Methods: Adult pneumonia patients with SARS-CoV-2 infection (index hospitalization) and age-, gender-, and race/ethnicity-matched contemporary control pneumonia patients without SARS-CoV-2 infection were identified from 110 healthcare facilities in United States. The risk of new diagnosis of dementia following >30 days after the index hospitalization event without any previous history of dementia was identified using logistic regression analysis to adjust for potential confounders.

Results: Among 10 403 patients with pneumonia associated with SARS-CoV-2 infection, 312 patients (3% [95% confidence interval {CI}, 2.7%-3.4%]) developed new-onset dementia over a median period of 182 days (quartile 1 = 113 days, quartile 3 = 277 days). After adjustment for age, gender, race/ethnicity, hypertension, diabetes mellitus, hyperlipidemia, nicotine dependence/tobacco use, alcohol use/abuse, atrial fibrillation, previous stroke, and congestive heart failure, the risk of new-onset dementia was significantly higher with pneumonia associated with SARS-CoV-2 infection compared with pneumonia unrelated to SARS-CoV-2 infection (odds ratio [OR], 1.3 [95% CI, 1.1-1.5]). The association remained significant after further adjustment for occurrence of stroke, septic shock, and intubation/mechanical ventilation during index hospitalization (OR, 1.3 [95% CI, 1.1-1.5]).

Conclusions: Approximately 3% of patients with pneumonia associated with SARS-CoV-2 infection developed new-onset dementia, which was significantly higher than the rate seen with other pneumonias.
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http://dx.doi.org/10.1093/ofid/ofac115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8903511PMC
April 2022

Race/ethnicity and response to blood pressure lowering treatment after intracerebral hemorrhage.

Eur Stroke J 2021 Dec 21;6(4):343-348. Epub 2021 Sep 21.

Department of Neurology, University of Utah, Salt Lake, UT, USA.

Background: It is unknown if race/ethnicity modifies the response to blood pressure (BP) lowering treatment after intracerebral hemorrhage (ICH). We aimed to examine the race/ethnicity differences in the response to BP lowering treatment after ICH.

Methods: This is a post hoc analysis of the Antihypertensive Treatment of Acute Cerebral Hemorrhage II (ATACH-2) trial. The primary outcome is good outcome, defined as 90-day modified Rankin Scale 0-3. The primary predictor is race/ethnicity for which we included non-Hispanic categories of White, Black, Asian, and the category of Hispanic. We fit adjusted logistic regression models with the predictor of race/ethnicity and models with the interaction term of treatment*race/ethnicity.

Results: We included a total of 953 patients in our analysis (White = 213, Black = 112, Asian = 554, and Hispanic = 74). In the models with the interaction between race/ethnicity and treatment, we found that White patients assigned to the intensive treatment arm had lower predicted probability of good outcome than those assigned to the standard treatment arm (Model 1: 56.2% vs. 68.1%, = .027; Model 2: 53.4% vs. 68.3%, = .009). When divided into White and non-White groups, intensive treatment was associated with higher odds of serious adverse events in White group but not in the non-White group. In addition, there was an association between intensive treatment and higher risk of hematoma expansion in White patients and lower risk of hematoma expansion in non-White patients.

Conclusions: In the ATACH-2, there was an interaction between race/ethnicity and response to BP lowering treatment after ICH, with White patients having an association between intensive blood pressure reduction and worse outcome.
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http://dx.doi.org/10.1177/23969873211046116DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8948521PMC
December 2021

Clopidogrel Bolus is Inferior to Sustained Clopidogrel Pretreatment in Patients Undergoing Carotid Artery Stent Placement.

Neurosurgery 2022 06 14;90(6):717-724. Epub 2022 Mar 14.

Department of Neurology, University of Missouri, Columbia, Missouri, USA.

Background: Clopidogrel bolus is an option used before carotid artery stent (CAS) placement when sustained clopidogrel pretreatment is not used.

Objective: To compare the effect of clopidogrel bolus (450 mg administered ≥4 hours) with sustained clopidogrel pretreatment (48 hours or greater) before CAS among patients recruited in the Carotid Revascularization Endarterectomy versus Stenting Trial.

Methods: We compared the rates of primary end point (either any stroke, myocardial infarction, or death during the periprocedural period or any ipsilateral stroke within 4 years) between patients who received clopidogrel bolus and those who received sustained clopidogrel pretreatment using Cox proportional hazards analysis after adjusting for age, sex, symptomatic status, and initial severity of stenosis (≥70% vs <70%) over 4 years.

Results: The rate of periprocedural stroke (7.3% vs 3.4%, P = .03) and primary end point (11.3% vs 5.9%, P = .02) was significantly higher among patients who received clopidogrel bolus. The risk of primary end point was significantly higher in patients who received clopidogrel bolus (hazards ratio 1.9, 95% CI 1.1-3.4, P = .02) after adjusting for potential confounders. The overall mean (±standard deviation) primary end point-free survival based on Kaplan-Meier analysis was 7.0 ± 0.2 years for patients who received clopidogrel bolus and 8.9 ± 0.1 years for those who received sustained clopidogrel pretreatment (log-rank test P = .011).

Conclusion: Clopidogrel bolus was associated with higher rates of adverse outcomes compared with sustained clopidogrel pretreatment in patients who underwent CAS. Therefore, clopidogrel bolus may not be equivalent to sustained clopidogrel pretreatment.
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http://dx.doi.org/10.1227/neu.0000000000001899DOI Listing
June 2022

Annual Direct Cost of Dysphagia Associated with Acute Ischemic Stroke in the United States.

J Stroke Cerebrovasc Dis 2022 May 5;31(5):106407. Epub 2022 Mar 5.

Department of Neurology, University of Missouri, Columbia, MO, USA.

Background: Dysphagia after acute ischemic stroke is frequent and increases the risk of pneumonia, insertion of feeding tube, hospital length-of-stay and rates of discharge to institutional care. However, the financial impact of dysphagia after acute ischemic stroke is not well understood.

Methods: Estimates were derived from published medical and economic literature to provide a range of estimates for the annual direct hospital cost of dysphagia associated with acute ischemic stroke in the United States. We also estimated the cost savings associated with a hypothetical new therapeutic intervention under a variety of assumptions.

Results: The 1-year costs per patient of acute hospital and post hospitalization care were $67,100 to $112,400 in acute ischemic stroke patient with dysphagia and $54,0310 to $51,979.8 in acute ischemic stroke patient without dysphagia in the two models. The estimated incremental cost in United States for ischemic stroke patients with dysphagia was $ 4,610,038,961.13 (95% confidence interval [CI] $3,796,502,674-$5,423,575,248) according to assumptions of Model 1. The estimated incremental cost in United States for ischemic stroke patients with dysphagia was $ 20,114,218,586.23 (95% CI $16564650600.42-$23663786572.04) according to assumptions of Model 2. The cost savings per year with a new therapeutic intervention ranged from $509,444,886.6 to $3,601,651,036 depending upon the magnitude of benefit.

Conclusion: Our analysis provides additional justification using financial basis for a much larger investment in research and development for treatment of dysphagia associated with ischemic stroke.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2022.106407DOI Listing
May 2022

The Role of Parenteral Dantrolene in the Contemporary Management of Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage: A Systematic Review.

World Neurosurg 2022 May 18;161:e602-e607. Epub 2022 Feb 18.

Division of Neurosurgery, University of Missouri Health Care, Columbia, Missouri, USA.

Objective: Cerebral vasospasm remains a significant source of morbidity and mortality in patients with aneurysmal subarachnoid hemorrhage. Dantrolene has shown promise in several animal studies in the treatment of cerebral vasospasm. The present study seeks to critically review the evidence of its use in human subjects, aiming to 1) describe the forms and dosages used, 2) describe its safety profile, and 3) describe its effectiveness in treating cerebral vasospasm.

Methods: A systematic review of intra-arterial dantrolene use in cerebral vasospasm was performed. A total of 86 articles were identified across all databases, 6 of which were ultimately included in the present study. Primary outcomes included a description of the form and dosage of dantrolene prescribed, the incidence of adverse effects after dantrolene use, and its efficacy for the treatment of cerebral vasospasm.

Results: Study designs included 2 randomized controlled trials (33.3%), 2 case series (33.3%), and 2 case reports (33.3%). Both the intra-arterial and intravenous administration of dantrolene has been performed with varying dose regimens. Although there exists limited clinical information regarding side effects, a case of liver toxicity was reported. All existing studies reported benefit in vasospasm measured either by transcranial Doppler or digital subtraction angiography. The level of evidence was low, consisting largely of retrospective studies that had a high likelihood of bias.

Conclusions: Dantrolene is a promising new therapeutic agent in the treatment of cerebral vasospasm. Although existing reports of its use are encouraging, high-quality prospective randomized trials are necessary for recommendations pertaining to dose, route, indications, and efficacy.
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http://dx.doi.org/10.1016/j.wneu.2022.02.056DOI Listing
May 2022

Five Cases of Charcot-Marie-Tooth Disease With Positive COVID-19 Infection Reported Using Cerner Real-World Data™.

J Clin Neuromuscul Dis 2022 Mar;23(3):169-170

Department of Neurology, University of Missouri Health Care, Columbia, MO.

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http://dx.doi.org/10.1097/CND.0000000000000362DOI Listing
March 2022

Impact of COVID-19 infection among myasthenia gravis patients- a Cerner Real-World Data study.

BMC Neurol 2022 Jan 27;22(1):38. Epub 2022 Jan 27.

Department of Neurology, University of Missouri Health Care, Columbia, MO, 65201, USA.

Background: Myasthenia gravis (MG) is an auto-immune disease, and the mainstay of therapy is immunomodulation. Such patients are at high risk of acquiring any infections. Hence, we sought to determine the impact of the current global pandemic COVID-19 infection in MG patients.

Methods: For our study, we used Cerner Real-World Data that was provided through Cerner's HealtheDataLab research tool. We ran a database query from January 2019 to July 2020 in our study and identified myasthenia patients with and without COVID-19 infection. To extract these patients' data, we used ICD 9-CM, ICD-10, and SNOMED-CT codes. We reported the data using means, range, and prevalence rates, and the p-values were calculated using the two-sample t-test and Pearson's chi-squared test.

Results: In the COVID-19 data set, a total of twenty-seven myasthenia patients were identified with a positive COVID-19 infection, and four were diagnosed with an exacerbation. The male to female ratio was equal and one unknown gender (3.7%) with a mean (± SD) age of 64.33 ± 18.42 years. This study group was compared with a non-COVID-19 data set in which a total of sixty-four myasthenia patients were identified, and twenty-three had an exacerbation. Among the 13 hospitalized patients in the two groups, the mean length of hospitalization for the myasthenia patients in the COVID-19 data set was 8.28 days (n = 7), and the non-COVID-19 set was 4.33 days (n = 6), and it was statistically significant (p-value= 0.007).

Conclusions: The mean length of hospital stay is prolonged in myasthenia patients who tested positive for COVID-19.
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http://dx.doi.org/10.1186/s12883-022-02564-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8792518PMC
January 2022

J-shape relation of blood pressure reduction and outcome in acute intracerebral hemorrhage: A pooled analysis of INTERACT2 and ATACH-II individual participant data.

Int J Stroke 2022 Jan 5:17474930211064076. Epub 2022 Jan 5.

The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia.

Objective: The aim of this study was to better define the shape of association between the degree ("magnitude") of early (< 1 h) reduction in systolic blood pressure (SBP) and outcomes in patients with acute intracerebral hemorrhage (ICH) through pooled analysis of the second Intensive Blood Pressure Reduction in Acute Cerebral Hemorrhage Trial (INTERACT2) and second Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH-II) datasets.

Methods: Association of the continuous magnitude of SBP reduction described using cubic splines and an ordinal measure of the functional outcome on the modified Rankin scale (mRS) scores at 90 days were analyzed in generalized linear mixed models. Models were adjusted for achieved (mean) and variability (standard deviation, SD) of SBP between 1 and 24 h, various baseline covariates, and trial as a random effect.

Results: Among 3796 patients (mean age 63.1 (SD = 13.0) years; female 37.4%), with a mean magnitude (< 1 h) of SBP reduction of 28.5 (22.8) mmHg, those with larger magnitude were more often non-Asian and female, had higher baseline SBP, received multiple blood pressure (BP) lowering agents, and achieved lower SBP levels in 1-24 h. Compared to those patients with no SBP reduction within 1 h (reference), the adjusted odds of unfavorable functional outcome, according to a shift in mRS scores, were lower for SBP reductions up to 60 mmHg with an inflection point between 32 and 46 mmHg, but significantly higher for SBP reductions > 70 mmHg. Similar J-shape associations were evident across various time epochs across 24 h and consistent according to baseline hematoma volume and SBP and history of hypertension.

Interpretation: A moderate degree of rapid SBP lowering is associated with improved functional outcome after ICH, but large SBP reductions over 1 h (e.g. from > 200 to target < 140 mmHg) were associated with reduction, or reversal, of any such benefit.
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http://dx.doi.org/10.1177/17474930211064076DOI Listing
January 2022

Lessons Learned from Phase II and Phase III Trials Investigating Therapeutic Agents for Cerebral Ischemia Associated with Aneurysmal Subarachnoid Hemorrhage.

Neurocrit Care 2022 04 23;36(2):662-681. Epub 2021 Dec 23.

Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.

One of the challenges in bringing new therapeutic agents (since nimodipine) in for the treatment of cerebral ischemia associated with aneurysmal subarachnoid hemorrhage (aSAH) is the incongruence in therapeutic benefit observed between phase II and subsequent phase III clinical trials. Therefore, identifying areas for improvement in the methodology and interpretation of results is necessary to increase the value of phase II trials. We performed a systematic review of phase II trials that continued into phase III trials, evaluating a therapeutic agent for the treatment of cerebral ischemia associated with aSAH. We followed the Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines for systematic reviews, and review was based on a peer-reviewed protocol (International Prospective Register of Systematic Reviews no. 222965). A total of nine phase III trials involving 7,088 patients were performed based on eight phase II trials involving 1558 patients. The following therapeutic agents were evaluated in the selected phase II and phase III trials: intravenous tirilazad, intravenous nicardipine, intravenous clazosentan, intravenous magnesium, oral statins, and intraventricular nimodipine. Shortcomings in several design elements of the phase II aSAH trials were identified that may explain the incongruence between phase II and phase III trial results. We suggest the consideration of the following strategies to improve phase II design: increased focus on the selection of surrogate markers of efficacy, selection of the optimal dose and timing of intervention, adjustment for exaggerated estimate of treatment effect in sample size calculations, use of prespecified go/no-go criteria using futility design, use of multicenter design, enrichment of the study population, use of concurrent control or placebo group, and use of innovative trial designs such as seamless phase II to III design. Modifying the design of phase II trials on the basis of lessons learned from previous phase II and phase III trial combinations is necessary to plan more effective phase III trials.
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http://dx.doi.org/10.1007/s12028-021-01372-4DOI Listing
April 2022

Cerebral Microbleeds and Acute Hematoma Characteristics in the ATACH-2 and MISTIE III Trials.

Neurology 2022 03 22;98(10):e1013-e1020. Epub 2021 Dec 22.

From the Division of Neurocritical Care and Emergency Neurology (J.R.M.-B., A.M., C.Z., C.I., H.K., S.B.M.), Department of Neurology, Yale University School of Medicine, New Haven, CT; Brain Injury Outcomes Center (Y.L., R.A., N.M., D.H.), Johns Hopkins University; Division of Neurosciences Critical Care (S.-M.C., P.J.P., W.C.Z.), Johns Hopkins University School of Medicine, Baltimore, MD; Vagelos College of Physicians and Surgeons (D.J.R.), Department of Neurology, Columbia University; Department of Radiology (A.G.), Clinical and Translational Neuroscience Unit (G.F., K.S.), Feil Family Brain and Mind Research Institute, and Department of Neurology (G.F., K.S.), Weill Cornell Medicine, New York, NY; Department of Neurology (A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Zeenat Qureshi Stroke Institutes (A.Q.) and Department of Neurology (A.Q.), University of Missouri, Columbia; Henry and Allison McCance Center for Brain Health (J.R.), Hemorrhagic Stroke Research Program (J.R.), J. Philip Kistler Stroke Research Center, and Department of Emergency Medicine (J.G.), Massachusetts General Hospital, Boston; and Department of Neurological Surgery (I.A.), University of Chicago School of Medicine, IL. Yunke Li is currently at The George Institute China at Peking University Health Sciences Center, Beijing, China.

Background And Objectives: To study the relationship between the presence of cerebral microbleeds (CMBs) and acute hematoma characteristics among patients with primary intracerebral hemorrhage (ICH).

Methods: We pooled individual patient data from the Antihypertensive Treatment of Acute Cerebral Hemorrhage 2 (ATACH-2) trial and the Minimally Invasive Surgery Plus Alteplase for Intracerebral Hemorrhage Evacuation phase 3 (MISTIE III) trial. We included individuals with a brain MRI scan. Exposure was the presence of a CMB. The coprimary outcomes were admission ICH volume and hematoma expansion. Mixed-effects linear and logistic regression models were used, with demographics and comorbid conditions considered fixed effects and the study cohort treated as a random effect. Additional analyses assessed the relationship between CMB topography and number and hematoma characteristics.

Results: Of the 1,499 patients with ICH enrolled in the parent trials, 466 (31.1%) were included in this analysis, and 231 (49.6%) patients had CMBs. In adjusted models, presence of CMBs was associated with smaller ICH volume (β = -0.26, 95% confidence interval [CI] -0.44 to -0.08) and lower odds of hematoma expansion (odds ratio 0.65, 95% CI 0.40-0.95; = 0.04). The strength of association between CMBs and hematoma characteristics increased with increasing number of CMBs. The location of the CMBs and the severity of leukoaraiosis did not modify these results.

Discussion: In a pooled cohort of patients with ICH, our results are consistent with the hypothesis that more severe underlying small vessel disease, as represented by CMBs, leads to smaller baseline hematoma volumes and reduced hematoma expansion. Underlying cerebral small vessel disease may be of prognostic significance after ICH.

Trial Registration Information: ClinicalTrials.gov Identifier: NCT01176565 and NCT01827046.

Classification Of Evidence: This study provides Class II evidence that the presence of microbleeds on MRI is associated with a smaller ICH volume at presentation and a lower rate of hematoma expansion on follow-up imaging.
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http://dx.doi.org/10.1212/WNL.0000000000013247DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8967392PMC
March 2022

Effect of Moderate and Severe Persistent Hyperglycemia on Outcomes in Patients With Intracerebral Hemorrhage.

Stroke 2022 Apr 30;53(4):1226-1234. Epub 2021 Nov 30.

Department of Cerebrovascular Medicine (K.T.), National Cerebral and Cardiovascular Center, Suita, Japan.

Background: We evaluated the effect of persistent hyperglycemia on outcomes in 1000 patients with intracerebral hemorrhage enrolled within 4.5 hours of symptom onset.

Methods: We defined moderate and severe hyperglycemia based on serum glucose levels ≥140 mg/dL-<180 and ≥180 mg/dL, respectively, measured at baseline, 24, 48, and 72 hours. Persistent hyperglycemia was defined by 2 consecutive (24 hours apart) serum glucose levels. We evaluated the relationship between moderate and severe hyperglycemia and death or disability (defined by modified Rankin Scale score of 4-6) at 90 days in the overall cohort and in groups defined by preexisting diabetes.

Results: In the multivariate analysis, both moderate (odds ratio, 1.8 [95% CI, 1.1-2.8]) and severe (odds ratio, 1.8 [95% CI, 1.2-2.7]) hyperglycemia were associated with higher 90-day death or disability after adjusting for Glasgow Coma Scale score, hematoma volume, presence or absence of intraventricular hemorrhage, hyperlipidemia, cigarette smoking, and hypertension (no interaction between hyperglycemia and preexisting diabetes, =0.996). Among the patients without preexisting diabetes, both moderate (odds ratio, 1.8 [95% CI, 1.0-3.2]) and severe (odds ratio, 2.0 [95% CI, 1.1-3.7]) hyperglycemia were associated with 90-day death or disability after adjusting for above mentioned potential confounders. Among the patients with preexisting diabetes, moderate and severe hyperglycemia were not associated with 90-day death or disability.

Conclusions: Persistent hyperglycemia, either moderate or severe, increased the risk of death or disability in nondiabetic patients with intracerebral hemorrhage.

Registration: URL: https://www.

Clinicaltrials: gov; Unique identifier: NCT01176565.
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http://dx.doi.org/10.1161/STROKEAHA.121.034928DOI Listing
April 2022

COVID-19 Exposure During Neurology Practice: Results of American Academy of Neurology Survey.

Neurologist 2021 Nov 4;26(6):225-230. Epub 2021 Nov 4.

Zeenat Qureshi Stroke Institute and Department of Neurology.

Background: To determine the exposure risk for coronavirus 2019 (COVID-19) during neurology practice. Neurological manifestations of COVID-19 are increasingly being recognized mandating high level of participation by neurologists.

Methods: An American Academy of Neurology survey inquiring about various aspects of COVID-19 exposure was sent to a random sample of 800 active American Academy of Neurology members who work in the United States. Use of second tier protection (1 or more including sterile gloves, surgical gown, protective goggles/face shield but not N95 mask) or maximum protection (N95 mask in addition to second tier protection) during clinical encounter with suspected/confirmed COVID-19 patients was inquired.

Results: Of the 81 respondents, 38% indicated exposure to COVID-19 at work, 1% at home, and none outside of work/home. Of the 28 respondents who did experience at least 1 symptom of COVID-19, tiredness (32%) or diarrhea (8%) were reported. One respondent tested positive out of 12 (17%) of respondents who were tested for COVID-19 within the last 2 weeks. One respondent received health care at an emergency department/urgent care or was hospitalized related to COVID-19. When seeing patients, maximum protection personal protective equipment was used either always or most of the times by 16% of respondents in outpatient setting and 56% of respondents in inpatient settings, respectively.

Conclusions: The data could enhance our knowledge of the factors that contribute to COVID-19 exposure during neurology practice in United States, and inform education and advocacy efforts to neurology providers, trainees, and patients in this unprecedented pandemic.
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http://dx.doi.org/10.1097/NRL.0000000000000346DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8575116PMC
November 2021

Early lowering of blood pressure after acute intracerebral haemorrhage: a systematic review and meta-analysis of individual patient data.

J Neurol Neurosurg Psychiatry 2022 01 3;93(1):6-13. Epub 2021 Nov 3.

Stroke Trials Unit, University of Nottingham, Queen's Medical Centre, Nottingham, UK.

Objective: To summarise evidence of the effects of blood pressure (BP)-lowering interventions after acute spontaneous intracerebral haemorrhage (ICH).

Methods: A prespecified systematic review of the Cochrane Central Register of Controlled Trials, EMBASE and MEDLINE databases from inception to 23 June 2020 to identify randomised controlled trials that compared active BP-lowering agents versus placebo or intensive versus guideline BP-lowering targets for adults <7 days after ICH onset. The primary outcome was function (distribution of scores on the modified Rankin scale) 90 days after randomisation. Radiological outcomes were absolute (>6 mL) and proportional (>33%) haematoma growth at 24 hours. Meta-analysis used a one-stage approach, adjusted using generalised linear mixed models with prespecified covariables and trial as a random effect.

Results: Of 7094 studies identified, 50 trials involving 11 494 patients were eligible and 16 (32.0%) shared patient-level data from 6221 (54.1%) patients (mean age 64.2 [SD 12.9], 2266 [36.4%] females) with a median time from symptom onset to randomisation of 3.8 hours (IQR 2.6-5.3). Active/intensive BP-lowering interventions had no effect on the primary outcome compared with placebo/guideline treatment (adjusted OR for unfavourable shift in modified Rankin scale scores: 0.97, 95% CI 0.88 to 1.06; p=0.50), but there was significant heterogeneity by strategy (p=0.031) and agent (p<0.0001). Active/intensive BP-lowering interventions clearly reduced absolute (>6 ml, adjusted OR 0.75, 95%CI 0.60 to 0.92; p=0.0077) and relative (≥33%, adjusted OR 0.82, 95%CI 0.68 to 0.99; p=0.034) haematoma growth.

Interpretation: Overall, a broad range of interventions to lower BP within 7 days of ICH onset had no overall benefit on functional recovery, despite reducing bleeding. The treatment effect appeared to vary according to strategy and agent.

Prospero Registration Number: CRD42019141136.
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http://dx.doi.org/10.1136/jnnp-2021-327195DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8685661PMC
January 2022

Updated Perspective on Severe Acute Respiratory Syndrome Coronavirus-2 Infection and Ischemic Stroke.

Authors:
Adnan I Qureshi

Stroke 2021 12 4;52(12):3987-3988. Epub 2021 Nov 4.

Zeenat Qureshi Institute and Department of Neurology in the University of Missouri, Columbia.

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http://dx.doi.org/10.1161/STROKEAHA.121.037010DOI Listing
December 2021

Utilization and Outcomes of Acute Revascularization Treatments in Ischemic Stroke Patients with SARS-CoV-2 Infection.

J Stroke Cerebrovasc Dis 2022 Jan 8;31(1):106157. Epub 2021 Oct 8.

Institute for Data Science and Informatics, University of Missouri, Columbia, MO, USA; Department of Medicine, University of Missouri, Columbia, MO, USA; Department of Electrical Engineering and Computer Science, University of Missouri, Columbia, MO, USA.

Objectives: Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus maybe candidates for acute revascularization treatments (intravenous thrombolysis and/or mechanical thrombectomy).

Materials And Methods: We analyzed the data from 62 healthcare facilities to determine the odds of receiving acute revascularization treatments in severe acute respiratory syndrome coronavirus infected patients and determined the odds of composite of death and non-routine discharge with severe acute respiratory syndrome coronavirus infected and non-infected patients undergoing acute revascularization treatments after adjusting for potential confounders.

Results: Acute ischemic stroke patients with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments (odds ratio 0.6, 95% confidence interval 0.5-0.8, p = 0.0001). Among ischemic stroke patients who received acute revascularization treatments, severe acute respiratory syndrome coronavirus infection was associated with increased odds of death or non-routine discharge (odds ratio 3.0, 95% confidence interval 1.8-5.1). The higher odds death or non-routine discharge (odds ratio 2.1, 95% confidence interval 1.9-2.3) with severe acute respiratory syndrome coronavirus infection were observed in all ischemic stroke patients without any modifying effect of acute revascularization treatments (interaction term for death (p = 0.9) or death or non-routine discharge (p = 0.2).

Conclusions: Patients with acute ischemic stroke with severe acute respiratory syndrome coronavirus infection were significantly less likely to receive acute revascularization treatments. Severe acute respiratory syndrome coronavirus infection was associated with a significantly higher rate of death or non-routine discharge among acute ischemic stroke patients receiving revascularization treatments.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106157DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8498748PMC
January 2022

The coronal plane maximum diameter of deep intracerebral hemorrhage predicts functional outcome more accurately than hematoma volume.

Int J Stroke 2022 Aug 13;17(7):777-784. Epub 2021 Oct 13.

Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA.

Background: Among prognostic imaging variables, the hematoma volume on admission computed tomography (CT) has long been considered the strongest predictor of outcome and mortality in intracerebral hemorrhage.

Aims: To examine whether different features of hematoma shape are associated with functional outcome in deep intracerebral hemorrhage.

Methods: We analyzed 790 patients from the ATACH-2 trial, and 14 shape features were quantified. We calculated Spearman's Rho to assess the correlation between shape features and three-month modified Rankin scale (mRS) score, and the area under the receiver operating characteristic curve (AUC) to quantify the association between shape features and poor outcome defined as mRS>2 as well as mRS > 3.

Results: Among 14 shape features, the maximum intracerebral hemorrhage diameter in the coronal plane was the strongest predictor of functional outcome, with a maximum coronal diameter >∼3.5 cm indicating higher three-month mRS scores. The maximum coronal diameter versus hematoma volume yielded a Rho of 0.40 versus 0.35 ( = 0.006), an AUC of 0.71 versus 0.68 ( = 0.004), and an AUC of 0.71 versus 0.69 ( = 0.029). In multiple regression analysis adjusted for known outcome predictors, the maximum coronal diameter was independently associated with three-month mRS (p < 0.001).

Conclusions: A coronal-plane maximum diameter measurement offers greater prognostic value in deep intracerebral hemorrhage than hematoma volume. This simple shape metric may expedite assessment of admission head CTs, offer a potential biomarker for hematoma size eligibility criteria in clinical trials, and may substitute volume in prognostic intracerebral hemorrhage scoring systems.
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http://dx.doi.org/10.1177/17474930211050749DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9005571PMC
August 2022

Intensive blood pressure lowering with nicardipine and outcomes after intracerebral hemorrhage: An individual participant data systematic review.

Int J Stroke 2022 06 20;17(5):494-505. Epub 2021 Sep 20.

Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan.

Background And Aims: Nicardipine has strong, rapidly acting antihypertensive activity. The effects of acute systolic blood pressure levels achieved with intravenous nicardipine after onset of intracerebral hemorrhage on clinical outcomes were determined.

Methods: A systematic review and individual participant data analysis of articles before 1 October 2020 identified on PubMed were performed (PROSPERO: CRD42020213857). Prospective studies involving hyperacute intracerebral hemorrhage adults treated with intravenous nicardipine whose outcome was assessed using the modified Rankin Scale were eligible. Outcomes included death or disability at 90 days, defined as the modified Rankin Scale score of 4-6, and hematoma expansion, defined as an increase ≥6 mL from baseline to 24-h computed tomography.

Summary Of Review: Three studies met the eligibility criteria. For 1265 patients enrolled (age 62.6 ± 13.0 years, 484 women), death or disability occurred in 38.2% and hematoma expansion occurred in 17.4%. Mean hourly systolic blood pressure during the initial 24 h was positively associated with death or disability (adjusted odds ratio (aOR) 1.12, 95% confidence interval (CI) 1.00-1.26 per 10 mmHg) and hematoma expansion (1.16, 1.02-1.32). Mean hourly systolic blood pressure from 1 h to any timepoint during the initial 24 h was positively associated with death or disability. Later achievement of systolic blood pressure to ≤140 mmHg increased the risk of death or disability (aOR 1.02, 95% CI 1.00-1.05 per hour).

Conclusions: Rapid lowering of systolic blood pressure by continuous administration of intravenous nicardipine during the initial 24 h in hyperacute intracerebral hemorrhage was associated with lower risks of hematoma expansion and 90-day death or disability without increasing serious adverse events.
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http://dx.doi.org/10.1177/17474930211044635DOI Listing
June 2022

Acute intracranial stenting with mechanical thrombectomy is safe and efficacious in patients diagnosed with underlying intracranial atherosclerotic disease.

Interv Neuroradiol 2022 Aug 13;28(4):419-425. Epub 2021 Sep 13.

Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA.

Objective: To investigate whether significant differences exist in recanalization rates and primary outcomes between patients who undergo mechanical thrombectomy alone versus those who undergo mechanical thrombectomy with acute intracranial stenting.

Methods: Through the utilization of a prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2020, variables such as demographics, co-morbid conditions, symptomatic intracerebral hemorrhage, mortality rate at discharge, and good/poor outcomes in regard to modified thrombolysis in cerebral infarction score and modified Rankin Scale were examined. The outcomes between patients receiving acute intracranial stenting + mechanical thrombectomy and patients that underwent mechanical thrombectomy alone were compared.

Results: There were a total of 420 acute ischemic stroke patients who met criteria for the study (average age 70.6 ± 13.01 years; 46.9% were women). Analysis of 46 patients from the acute stenting + mechanical thrombectomy group (average age 70.34 ± 13.75 years; 37.0% were women), and 374 patients from the mechanical thrombectomy alone group (average age 70.64 ± 12.92 years; 48.1% were women). Four patients (8.7%) in the acute stenting + mechanical thrombectomy group experienced intracerebral hemorrhage versus 45 patients (12.0%) in the mechanical thrombectomy alone group ( = 0.506); no significant increases were noted in the median length of stay (7 vs 8 days;  = 0.208), rates of modified thrombolysis in cerebral infarction 2B-3 recanalization ( = 0.758), or good modified Rankin Scale scores ( = 0.806).

Conclusion: Acute intracranial stenting in addition to mechanical thrombectomy was not associated with an increase in overall length of stay, intracerebral hemorrhage rates, or any change in discharge modified Rankin Scale. Further research is required to determine whether mechanical thrombectomy and acute intracranial stenting in acute ischemic stroke patients is unsafe.
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http://dx.doi.org/10.1177/15910199211039403DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9326867PMC
August 2022

Intra-arterial injection of lidocaine into middle meningeal artery to treat intractable headaches and severe migraine.

J Neuroimaging 2021 Nov 13;31(6):1126-1134. Epub 2021 Aug 13.

Department of Neurology, University of Missouri, Columbia, Missouri, USA.

Background And Purpose: We report the results of intra-arterial injection of lidocaine in the middle meningeal artery in patients with intractable headache or status migrainosus.

Methods: We treated four patients with intra-arterial lidocaine (2 mg/ml) in doses up to 50 mg in each middle meningeal artery via a microcatheter bilaterally (except in one patient). In two patients with intractable headache, the daily maximum intensity of headache (graded by 11-point numeric rating scale) was recorded for 7 days postprocedure. In two patients with status migrainosus, migraine-related disability 3 months prior and after treatment using MIDAS (Migraine Disability Assessment) questionnaire was recorded.

Results: Intra-arterial lidocaine reduced the headache intensity from 8/10 and 10/10 to 0/10 in the two patients with intractable headaches for 2 days (day 0 and day 1) postprocedure. Despite recurrence of headache on day 2, the intensity was less than preprocedure intensity up to the last day recorded (by 3 and 2 points on day 7). In the two patients with status migrainosus, there was immediate reduction in headache intensity following intra-arterial lidocaine. The post treatment 3-month MIDAS score was lower in both patients compared with pretreatment 3-month score; 3 versus 30 and 55 versus 90. Severe disability preprocedure by MIDAS was reduced to little or no disability postprocedure in one patient.

Conclusions: Intra-arterial lidocaine resulted in amelioration of headache in patients with intractable headache and those with status migrainosus with improvement lasting longer than the short half-life of lidocaine possibly related to central desensitization.
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http://dx.doi.org/10.1111/jon.12918DOI Listing
November 2021

Effect of Heart Rate Variabilities on Outcome After Acute Intracerebral Hemorrhage: A Post Hoc Analysis of ATACH-2.

J Am Heart Assoc 2021 08 13;10(16):e020364. Epub 2021 Aug 13.

Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan.

Background To explore how the clinical impact of heart rate (HR) and heart rate variabilities (HRV) during the initial 24 hours after acute intracerebral hemorrhage (ICH) contribute to worse clinical outcomes. Methods and Results In the ATACH-2 (Antihypertensive Treatment in Intracerebral Hemorrhage 2) trial, the HR was recorded for every 15 minutes from baseline to 1 hour and hourly during the initial 24 hours post-randomization. We calculated the following: mean, standard deviation, coefficient of variation, successive variation, and average real variability (ARV). Outcomes were hematoma expansion at 24 hours and unfavorable functional outcome, defined as modified Rankin Scale score 4 to 6 at 90 days. Of the 1000 subjects in ATACH-2, 994 with available HR data were included in the analyses. Overall, 262 experienced hematoma expansion, and 362 had unfavorable outcomes. Increased mean HR was linearly associated with unfavorable outcome (per 10 bpm increase adjusted odds ratio [aOR], 1.31, 95% CI, 1.14-1.50) but not with hematoma expansion, while HR-ARV was associated with hematoma expansion (aOR, 1.06, 95% CI, 1.01-1.12) and unfavorable outcome (aOR, 1.07, 95% CI, 1.01-1.3). Every 10-bpm increase in mean HR increased the probability of unfavorable outcome by 4.3%, while every 1 increase in HR-ARV increased the probability of hematoma expansion by 1.1% and unfavorable outcome by 1.3%. Conclusions Increased mean HR and HR-ARV within the initial 24 hours were independently associated with unfavorable outcome in acute ICH. Moreover, HR-ARV was associated with hematoma expansion at 24 hours. This may have future therapeutic implications to accommodate HR and HRV in acute ICH. Registration URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01176565.
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http://dx.doi.org/10.1161/JAHA.120.020364DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8475052PMC
August 2021

Repeat Revascularization over 10 Years Following Carotid Endarterectomy or Carotid Stent Placement: An Analysis of Carotid Revascularization Endarterectomy Versus Stenting Trial.

World Neurosurg 2021 10 2;154:e671-e676. Epub 2021 Aug 2.

Department of Neurology, University of Missouri Columbia School of Medicine, Columbia, Missouri, USA.

Objective: To identify rates of and factors associated with repeat revascularization in a large cohort of patients prospectively followed over 10 years in Carotid Revascularization Endarterectomy versus Stenting Trial.

Methods: We compared the effect of carotid angioplasty and stenting (CAS) versus carotid endarterectomy (CEA) on risk of repeat revascularization after adjusting for age, sex, symptomatic status, and initial severity of stenosis (≥70% vs. <70%) using Cox proportional hazards analysis. We used Kaplan-Meier analysis to assess repeat revascularization-free survival for the overall cohort.

Results: Repeat revascularization was performed in 90 (3.9%, 95% confidence interval [CI] 3.1%-4.8%) of 2318 patients; 6 (6.7%, 95% CI 2.5%-14.0%) patients experienced the composite end point of any stroke, myocardial infarction, or death within 30 days after repeat revascularization. There was no difference in risk of repeat revascularization in patients who underwent CAS (compared with CEA) as the index procedure (hazard ratio 0.92, 95% CI 0.69-1.23, P = 0.5765). Patient's age (hazard ratio 1.01, 95% CI 1.01-1.02, P < 0.0001) was associated with performance of repeat revascularization. Mean ± SD repeat revascularization-free survival was 8.2 ± 0.1 years and 8.0 ± 0.1 years for CAS and CEA, respectively (log-rank test P = 0.0823).

Conclusions: A low rate of repeat revascularization was seen without any significant difference among patients who underwent CEA or CAS over 10 years. The 6.7% rate of composite end point within 30 days after procedure highlights the need for standardizing the indications for repeat revascularization.
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http://dx.doi.org/10.1016/j.wneu.2021.07.118DOI Listing
October 2021

Effect of Race and Ethnicity on In-Hospital Mortality in Patients with COVID-19.

Ethn Dis 2021 15;31(3):389-398. Epub 2021 Jul 15.

Institute for Data Science and Informatics, University of Missouri, Columbia, MO.

Objective: To identify differences in short-term outcomes of patients with coronavirus disease 2019 (COVID-19) according to various racial/ethnic groups.

Design: Analysis of Cerner de-identified COVID-19 dataset.

Setting: A total of 62 health care facilities.

Participants: The cohort included 49,277 adult COVID-19 patients who were hospitalized from December 1, 2019 to November 13, 2020.

Main Outcome Measures: The primary outcome of interest was in-hospital mortality. The secondary outcome was non-routine discharge (discharge to destinations other than home, such as short-term hospitals or other facilities including intermediate care and skilled nursing homes).

Methods: We compared patients' age, gender, individual components of Charlson and Elixhauser comorbidities, medical complications, use of do-not-resuscitate, use of palliative care, and socioeconomic status between various racial and/or ethnic groups. We further compared the rates of in-hospital mortality and non-routine discharges between various racial and/or ethnic groups.

Results: Compared with White patients, in-hospital mortality was significantly higher among African American (OR 1.5; 95%CI:1.3-1.6, P<.001), Hispanic (OR1.4; 95%CI:1.3-1.6, P<.001), and Asian or Pacific Islander (OR 1.5; 95%CI: 1.1-1.9, P=.002) patients after adjustment for age and gender, Elixhauser comorbidities, do-not-resuscitate status, palliative care use, and socioeconomic status.

Conclusions: Our study found that, among hospitalized patients with COVID-2019, African American, Hispanic, and Asian or Pacific Islander patients had increased mortality compared with White patients after adjusting for sociodemographic factors, comorbidities, and do-not-resuscitate/palliative care status. Our findings add additional perspective to other recent studies.
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http://dx.doi.org/10.18865/ed.31.3.389DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8288468PMC
August 2021
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