Publications by authors named "Ronen R Leker"

111 Publications

Characteristics of cerebral sinus venous thrombosis in men.

Acta Neurol Scand 2021 May 11. Epub 2021 May 11.

Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Objectives: Cerebral sinus venous thrombosis (CSVT) is a rare stroke subtype that is more common in women, yet data regarding sex-specific characteristics are sparse. We aimed to study male-specific characteristics among patients with CSVT.

Materials & Methods: Data of consecutive patients with CSVT, admitted to a single medical centre between 2005 and 2020, were retrospectively studied. Demographics, clinical presentations, radiological and outcome parameters were compared between male and female patients. Male patients were further divided into older and younger than 35 years old for additional comparisons.

Results: Out of 15,224 patients diagnosed with stroke, 150 patients (1%) presented with CSVT and 47 (31.3%) of them were males. Males had significantly higher rates of previous thrombotic events (22% vs. 7%, p = .009), malignancies (32% vs. 16%, p = .022) and Behcet's disease (22% vs. 2%, p < .001). Additionally, we found that malignancies were significantly more prevalent in older males (48% vs. 17%, p = .022), while Behcet's disease was more often found in younger patients (35% vs. 9%, p = .032). Additional age-related differences in disease characteristics among male patients included a higher frequencies of papilledema (42% vs. 13%, p = .028), and cortical vein thromboses (21% vs. 0% p = .021) observed in the younger men.

Conclusions: There are important differences in risk factors for thrombosis between men and women with CSVT. Behcet's disease is common in younger men, while malignancies are major causes of CSVT in older men.
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http://dx.doi.org/10.1111/ane.13454DOI Listing
May 2021

Flow-diverter stents in the early management of acutely ruptured brain aneurysms: effective rebleeding protection with low thromboembolic complications.

J Neurosurg 2021 Apr 16:1-8. Epub 2021 Apr 16.

4Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; and.

Objective: Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome.

Methods: The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed.

Results: Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0-2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage.

Conclusions: Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors' experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.
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http://dx.doi.org/10.3171/2020.10.JNS201642DOI Listing
April 2021

Are there disparities in acute stroke treatment between the Jewish and Arab populations in Israel? Results from the National Acute Stroke Israeli registry.

J Neurol Sci 2021 04 20;423:117357. Epub 2021 Feb 20.

Department of Neurology, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel. Electronic address:

Background: According to the latest reported data from the National Acute Stroke Israeli Survey (NASIS), around 18,000 strokes occur annually in Israel. Data regarding disparities in stroke care between the Jewish and the Arab populations in Israel are lacking.

Aims: We wished to compare demographics, comorbidities, stroke characteristics and outcomes between Jewish and Arab stroke patients in Israel that were acutely treated with intravenous thrombolysis (IVT) and/or endovascular thrombectomy (EVT), in order to test if there are disparities or any ethnic-specific parameters.

Methods: The National Acute Stroke Israeli registry of patients undergoing revascularization (NASIS-REVASC) prospectively enrolled patients in six comprehensive stroke centers between 1/2014 and 3/2016. In this observational research, we compared demographics, comorbidities, time metrics, stroke characteristics and outcomes between Jewish and Arab patients enrolled.

Results: NASIS-REVASC included 1432 patients out of which 143 (10%) were of Arab ethnicity and 1289 (90%) of Jewish ethnicity. Arab patients were significantly younger (66 ± 14 vs. 73 ± 29, p = 0·004), exhibited higher rates of smoking and diabetes (31% vs. 18% and 57% vs. 34%, p < 0·001 for both), and were less often treated with systemic thrombolysis (48% vs. 59%, p = 0·012). However, the rates of any interventional treatment with either intravenous thrombolysis or endovascular thrombectomy as well as the rates of favorable outcomes and mortality were comparable between groups.

Conclusions: Despite several baseline differences between Arab and Jewish Israeli stroke patients, treatment allocations, survival and functional outcomes were similar indicating lack of disparity in stroke care among patients treated acutely with IVT and/or EVT in Israel.

Data Access Statement: Full data is available following a formal request to the NASIS-REVASC registry at the Israeli Health Ministry.
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http://dx.doi.org/10.1016/j.jns.2021.117357DOI Listing
April 2021

Overestimation of carotid stenosis on CTA - Real world experience.

J Clin Neurosci 2021 Mar 8;85:36-40. Epub 2021 Jan 8.

Neurology Department, Hadassah University Medical Center, Jerusalem, Israel.

Background: Symptomatic carotid stenosis is responsible for 10% of all strokes. Currently, CT angiography (CTA) is the main diagnostic tool for carotid stenosis. It is frequently the only diagnostic test preceding recommendations for carotid angioplasty and stenting (CAS) or carotid endarterectomy (CEA). However, the specificity of CTA, especially in patients with 50-70% stenosis, was previously reported to be relatively low. Most studies testing the diagnostic accuracy of CTA were published more than a decade ago. Therefore, we aimed to test the diagnostic accuracy of CTA, performed with current available technology, compared with digital subtraction angiography (DSA) in patients with carotid stenosis. This study aims to characterize patients who were candidates for CAS/CEA based on CTA, but may not require it based on DSA.

Methods: Consecutive candidates for carotid interventions (CAS or CEA) following CTA were identified from prospectively maintained stroke center registries at two large academic centers. As part of our institutional practice all patients had a routine pre-procedural diagnostic DSA. In each patient, degree of carotid stenosis was compared between CTA and DSA. Patients with concordant degree of stenosis on DSA and CTA (true positive group) were compared to patients with a discordant degree of stenosis with less than 50% on DSA (false positive group).

Results: Out of 90 patients with significant stenosis on CTA, only 70 (78%) were found to have a significant stenosis on DSA. Severe plaque calcification was significantly more common in the false-positive group. In those patients whose CTA reported stenosis of ≥90%, we found a strong agreement between CTA and DSA (positive predictive value [PPV] - 0.9) for a significant stenosis (≥50%). Conversely, the correlation between CTA and DSA in patients with CTA reported 50-70% stenosis was poor (PPV - 0.29) (p < 0.001).

Conclusions: Our results suggest that despite ongoing radiological progress, the specificity of CTA in accurately assessing carotid stenosis remains relatively low in patients with both moderate stenosis and heavily calcified plaques. Consequently, patients could possibly be referred for unnecessary CEA surgery and may become exposed to associated potential complications.
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http://dx.doi.org/10.1016/j.jocn.2020.12.018DOI Listing
March 2021

Intravenous Thrombolysis With Tenecteplase in Patients With Large Vessel Occlusions: Systematic Review and Meta-Analysis.

Stroke 2021 01 4;52(1):308-312. Epub 2020 Dec 4.

Second Department of Neurology, National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Greece (A. Safouris, G.T.).

Background And Purpose: Accumulating evidence from randomized controlled clinical trials suggests that tenecteplase may represent an effective treatment alternative to alteplase for acute ischemic stroke. In the present systematic review and meta-analysis, we sought to compare the efficacy and safety outcomes of intravenous tenecteplase to intravenous alteplase administration for acute ischemic stroke patients with large vessel occlusions (LVOs).

Methods: We searched MEDLINE (Medical Literature Analysis and Retrieval System Online) and Scopus for published randomized controlled clinical trials providing outcomes of acute ischemic stroke with confirmed LVO receiving intravenous thrombolysis with either tenecteplase at different doses or alteplase at a standard dose of 0.9 mg/kg. The primary outcome was the odds of modified Rankin Scale score of 0 to 2 at 3 months.

Results: We included 4 randomized controlled clinical trials including a total of 433 patients. Patients with confirmed LVO receiving tenecteplase had higher odds of modified Rankin Scale scores of 0 to 2 (odds ratio, 2.06 [95% CI, 1.15-3.69]), successful recanalization (odds ratio, 3.05 [95% CI, 1.73-5.40]), and functional improvement defined as 1-point decrease across all modified Rankin Scale grades (common odds ratio, 1.84 [95% CI, 1.18-2.87]) at 3 months compared with patients with confirmed LVO receiving alteplase. There was little or no heterogeneity between the results provided from included studies regarding the aforementioned outcomes (I≤20%). No difference in the outcomes of early neurological improvement, symptomatic intracranial hemorrhage, any intracranial hemorrhage, and the rates of modified Rankin Scale score 0 to 1 or all-cause mortality at 3 months was detected between patients with LVO receiving intravenous thrombolysis with either tenecteplase or alteplase.

Conclusions: Acute ischemic stroke patients with LVO receiving intravenous thrombolysis with tenecteplase have significantly better recanalization and clinical outcomes compared with patients receiving intravenous alteplase.
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http://dx.doi.org/10.1161/STROKEAHA.120.030220DOI Listing
January 2021

Cerebral micro-infarcts; the hidden missing link to vascular cognitive decline.

J Neurol Sci 2021 01 7;420:117171. Epub 2020 Oct 7.

Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.. Electronic address:

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http://dx.doi.org/10.1016/j.jns.2020.117171DOI Listing
January 2021

Impact of carotid tortuosity on outcome after endovascular thrombectomy.

Neurol Sci 2020 Oct 12. Epub 2020 Oct 12.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Background And Objectives: Endovascular thrombectomy (EVT) is efficacious in patients with large vessel occlusion stroke (LVO). We explored whether internal carotid (ICA) tortuosity increases the technical difficulty of EVT thereby lowering the chances of successful recanalization and favorable outcomes.

Patients And Methods: Consecutive patients with LVO and patent ICAs who underwent EVT were included. Carotid tortuosity was determined on pre-EVT CTA and classified by raters blinded to outcomes into: type 1-straight ICA trunk and type 2-severe tortuosity potentially impeding adequate catheter placement. Thrombolysis in cerebral infarction (TICI) 2b-3 was considered successful recanalization, and 90-day-modified Rankin Scale ≤ 2 was considered favorable functional outcome.

Results: Among 302 patients (mean age 70 ± 15, median NIHSS 17), 53% had type 1, and 47% type 2 tortuosity. Overall, 85% had successful recanalization. Patients with type 2 tortuosity were significantly older (p < 0.0001) and less frequently achieved successful recanalization (80% vs. 90%; p = 0.019) but had similar outcomes compared with those without tortuosity. On regression analysis, marked tortuosity was associated with lower chances of successful recanalization (OR 0.43 95% CI 0.20-0.92) but had no effect on clinical outcomes.

Conclusions: Carotid tortuosity does not appear to impact the likelihood of favorable functional outcome but may influence recanalization.
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http://dx.doi.org/10.1007/s10072-020-04813-8DOI Listing
October 2020

Post-stroke ASPECTS predicts outcome after thrombectomy.

Neuroradiology 2021 May 6;63(5):769-775. Epub 2020 Oct 6.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Purpose: Infarct growth and final infarct volume are established outcome modifiers following endovascular thrombectomy (EVT) for patients with large vessel occlusion stroke (LVO). Simple techniques for final infarct volume measurement are lacking, and therefore, we tested whether post-EVT ASPECTS can be used for prognostic evaluation after EVT.

Methods: Infarct size at baseline was measured in a prospective cohort of patients with LVO that underwent EVT with the ASPECTS score on admission non-contrast CT. Final infarct size was assessed with a post-EVT ASPECTS (ASPECTS-POST) obtained from a follow-up CT 24-72 h post-EVT. The best performing ASPECTS-POST was chosen based on comparisons of different thresholds. Outcome measures included survival rates and modified Rankin Score at 90 days.

Results: A total of 272 patients were included and 166 of them had an ASPECTS-POST ≥ 7. ASPECTS-POST ≥ 7 was associated with increased likelihood of favorable outcome at 90 days (67% vs. 21%, p < 0.001) with sensitivity, specificity, and positive and negative predictive values of 86%, 58%, 61%, and 85%, respectively. On multivariate analysis, ASPECTS-POST ≥ 7 was found to be a significant modifier of favorable outcome (Odds Ratio [OR] 6.2, 95% confidence intervals [CI] 3.1-12.4) and survival (OR 5.8 95% CI 2.4-14.3).

Conclusion: ASPECTS can be rapidly and easily obtained from the post-EVT NCCT and ASPECTS-POST ≥ 7 correlates with good outcome.
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http://dx.doi.org/10.1007/s00234-020-02576-9DOI Listing
May 2021

Anticoagulation Choice and Timing in Stroke Due to Atrial Fibrillation: A Survey of US Stroke Specialists (ACT-SAFe).

J Stroke Cerebrovasc Dis 2020 Oct 31;29(10):105169. Epub 2020 Jul 31.

University of Pennsylvania, Philadelphia, PA, USA.

Objective: Risk of early recurrent ischemic stroke in patients with atrial fibrillation may be high. ASA/AHA guidelines provide imprecise recommendations on the timing and anticoagulant choice for this indication. We assessed current opinions of stroke neurologists.

Methods: Case scenarios describing patients with acute ischemic stroke (AIS) due to paroxysmal atrial fibrillation (AF) were presented to US board-certified stroke neurologists in an internet-based questionnaire. Questions assessed timing and choice of anticoagulation for secondary stroke prevention, factors prompting earlier anticoagulation, reasons for specific anticoagulant choice, and alternatives to anticoagulation in ineligible patients. Open-ended comments were also solicited.

Results: Responses were available from 238/1239 stroke neurologists surveyed. In patients with small AIS without hemorrhagic transformation (HT), 51% elected to start anticoagulation within 96 hours. With increased stroke severity and asymptomatic HT, only 29% and 26% respectively chose to anticoagulate within 7 days. Few requested stability imaging before starting anticoagulation. With symptomatic HT the majority (79%) waited >14 days. 93% would anticoagulate earlier if left atrium/left atrial appendage or acute left ventricular thrombi, or mechanical heart valve were present. Direct oral anticoagulants (DOACs) were the preferred anticoagulation strategy (64%), and the remaining 38% preferred Warfarin. Aspirin was preferred by 57% in anticoagulation ineligible.

Conclusion: Apart from AIS with symptomatic HT, there is a remarkable lack of consensus among stroke neurologists regarding the timing of anticoagulation for secondary stroke prevention in patients with AIS due to PAF. DOACs are the preferred anticoagulation strategy. More studies are required to clarify anticoagulant management in this patient population.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105169DOI Listing
October 2020

More than five stentriever passes: real benefit or futile recanalization?

Neuroradiology 2020 Oct 16;62(10):1335-1340. Epub 2020 Jun 16.

Departments of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.

Background And Aims: Clot extraction is associated with favorable outcome in patients with large vessel occlusions (LVO) undergoing endovascular thrombectomy (EVT). However, whether revascularization becomes futile or harmful with an increasing number of passes remains unknown.

Methods: We performed a retrospective analysis of 271 consecutive patients with LVO who underwent stentriever-based EVT as the primary recanalization strategy. Primary outcomes including favorable recanalization, survival, and favorable functional outcomes were compared according to a dichotomized number of stentriever passes utilized with a cutoff of 4.

Results: In the entire cohort, 234 (86%) patients reached favorable recanalization and 46 (17%) patients had ≥ 5 passes (range 5-40). Patients that had ≤ 4 passes had significantly higher rates of favorable recanalization and favorable outcomes and a trend towards lower mortality rates compared with those that had ≥ 5 stentriever passes (92% vs. 61%; p < 0.001, 52% vs. 30%; p = 0.009 and 12% vs. 22%, p = 0.098). Among patients that received ≥ 5 stentriever passes, 30% reached favorable outcomes. Patients who achieved recanalization after ≥ 5 passes had higher rates of favorable outcome in comparison with those who did not (p = 0.009). Among patients that had ≥ 5 stentriever passes favorable recanalization (OR 97.3, 95%CI 2.8-3399.3) and admission NIHSS (OR 0.77, 95%CI 0.60-0.99) remained independent predictors of favorable outcome, whereas the number of passes did not.

Conclusions: A substantial proportion of patients reach favorable outcomes even when ≥ 5 stentriever passes are performed. Treatment choices should be individualized based on personal preferences and expertise as well as on patient and clot-specific characteristics.
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http://dx.doi.org/10.1007/s00234-020-02469-xDOI Listing
October 2020

Effect of time from onset to endovascular therapy on outcomes: the National Acute Stroke Israeli (NASIS)-REVASC registry.

J Neurointerv Surg 2020 Jan 25;12(1):13-18. Epub 2019 Jun 25.

Department of Neurology, Sheba Medical Center at Tel Hashomer, Tel Hashomer, Israel.

Background: Endovascular therapy (EVT) is currently the most effective treatment for emergent large vessel occlusion (ELVO) stroke. Earlier treatment is associated with a better clinical outcome. Our aim was to examine the association between onset-to-EVT (OTE) time and clinical outcomes using real-world nationwide data from the National Acute Stroke ISraeli (NASIS)-REVASC registry.

Methods: Stroke patients undergoing EVT within the Endovascular Capable Centres (ECCs) in Israel between January 2014 and March 2016 were prospectively included. Several clinical and radiological outcomes were evaluated. The association between OTE time and outcomes was analyzed with logistic regression models using time as a continuous variable and then by OTE groups of <2, 2-4, 4-6, and >6 hours.

Results: 299 patients with acute stroke were included in the analysis. OTE time was significantly associated with favorable outcomes. ORs for each hour of delay in EVT were 0.84 (95% CI 0.71 to 0.99) for significant early recovery, 0.80 (95% CI 0.68 to 0.94) for discharge to home, 0.80 (95% CI 0.66 to 0.95) for freedom from disability at discharge, and 0.78 (95% CI 0.67 to 0.91) for excellent reperfusion (Thrombolysis in Cerebral Ischemia 3). The <2 OTE group was significantly associated with better outcomes than the ≥2 OTE group including significant early recovery (OR 3.3, 95% CI 1.2 to 9.1), discharge to home (OR 3.32, 95% CI 1.3 to 8.5), and excellent reperfusion (OR 4.6, 95% CI 1.3 to 29.5). The same trend was observed for freedom from disability at discharge and 3 months (OR 2.08, 95% CI 0.7 to 5.7 and OR 2.57, 95% CI 0.8 to 8.3, respectively). Only 1% of transferred patients achieved an OTE time of <2 hours.

Conclusions: Nationwide real-life registry data indicate that benefit from EVT is strongly associated with OTE time and is most prominent within the 'two golden hours' from stroke onset. This time goal may not be applicable in inter-hospital transfer patients.
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http://dx.doi.org/10.1136/neurintsurg-2019-014928DOI Listing
January 2020

Controlling distinct signaling states in cultured cancer cells provides a new platform for drug discovery.

FASEB J 2019 08 30;33(8):9235-9249. Epub 2019 May 30.

Department of Internal Medicine III, Technische Universität Dresden, Dresden, Germany.

Cancer cells can switch between signaling pathways to regulate growth under different conditions. In the tumor microenvironment, this likely helps them evade therapies that target specific pathways. We must identify all possible states and utilize them in drug screening programs. One such state is characterized by expression of the transcription factor Hairy and Enhancer of Split 3 () and sensitivity to knockdown, and it can be modeled . Here, we cultured 3 primary human brain cancer cell lines under 3 different culture conditions that maintain low, medium, and high expression and characterized gene regulation and mechanical phenotype in these states. We assessed gene expression regulation following knockdown in the -high conditions. We then employed a commonly used human brain tumor cell line to screen Food and Drug Administration (FDA)-approved compounds that specifically target the -high state. We report that cells from multiple patients behave similarly when placed under distinct culture conditions. We identified 37 FDA-approved compounds that specifically kill cancer cells in the high--expression conditions. Our work reveals a novel signaling state in cancer, biomarkers, a strategy to identify treatments against it, and a set of putative drugs for potential repurposing.-Poser, S. W., Otto, O., Arps-Forker, C., Ge, Y., Herbig, M., Andree, C., Gruetzmann, K., Adasme, M. F., Stodolak, S., Nikolakopoulou, P., Park, D. M., Mcintyre, A., Lesche, M., Dahl, A., Lennig, P., Bornstein, S. R., Schroeck, E., Klink, B., Leker, R. R., Bickle, M., Chrousos, G. P., Schroeder, M., Cannistraci, C. V., Guck, J., Androutsellis-Theotokis, A. Controlling distinct signaling states in cultured cancer cells provides a new platform for drug discovery.
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http://dx.doi.org/10.1096/fj.201802603RRDOI Listing
August 2019

Number of stentriever passes and outcome after thrombectomy in stroke.

J Neuroradiol 2019 Sep 11;46(5):327-330. Epub 2019 Apr 11.

Departments of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Electronic address:

Background And Purposes: Stroke secondary to emergent large vessel occlusions (ELVO) involving the anterior circulation can be treated with intravenous tissue plasminogen activator (IV-tPA) or thrombectomy. Data regarding the influence of the number of stentriever passes needed for vessel recanalization on outcome is lacking.

Patients And Methods: We prospectively accrued data on consecutive patients with ELVO that were treated with thrombectomy. Procedural details including the number of stentriever passes needed to achieve vessel recanalization and clot length were collected. Functional outcome was determined with the modified Rankin Scale (mRS) at 90 days post stroke with mRS ≤ 2 considered favorable outcome. Data on demographics, risk factors, stroke severity, survival, and occurrence of symptomatic intracranial hemorrhage (sICH) was also collected.

Results: On univariate analysis more than one pass needed to achieve recanalization impacted survival and functional outcome after 90 days as did age, stroke severity and collateral and reperfusion status. On multivariate logistic regression the number of passes needed to achieve revascularization (OR: 10.0, 95% CI: 2.28-43.94, P = 0.002), age (OR: 0.90, 95% CI: 0.84-0.96, P = 0.001) and collateral status (OR: 7.90, 95% CI: 1.87-33.35, P = 0.005) remained significant modifiers for favorable outcome. On logistic regression the only variable associated with the need to perform more than a single stentriever pass was time from symptom onset to target vessel recanalization (OR: 1.007, 95% CI: 1.002-1.012).

Conclusions: The number of passes needed to achieve target vessel recanalization modifies outcome after thrombectomy and successful recanalization after a single pass is associated with favorable outcome.
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http://dx.doi.org/10.1016/j.neurad.2019.03.014DOI Listing
September 2019

Impact of previous stroke on outcome after thrombectomy in patients with large vessel occlusion.

Int J Stroke 2019 12 4;14(9):887-892. Epub 2019 Apr 4.

Rambam Medical Center, Haifa, Israel.

Background: Many patients with large vessel occlusion (LVO) who are otherwise candidates for endovascular treatment (EVT) have had previous strokes. We aimed to examine the effect of previous stroke on outcome after EVT.

Methods: Consecutive patients with LVO were prospectively entered into a National Acute Stroke registry of patients undergoing EVT. Patients treated with EVT were divided into those with and without previous strokes. The rates of favorable reperfusion status, mortality, and excellent outcome at 90 days post-stroke as well as symptomatic intracranial hemorrhage (sICH) were evaluated.

Results: A total of 390 underwent EVT and 35 had previous strokes. Patients with previous strokes were significantly older; more frequently had a history of prior myocardial infarction and more often had pre-existing functional disability. Favorable target vessel recanalization was less frequently achieved in patients with previous strokes (60% vs. 82%;  = 0.005) and ordinal regression analysis for functional outcome revealed higher frequency of deterioration at three months in patients with previous strokes. Nevertheless, 9% of these patients maintained their previous disability state and sICH rates did not differ between the groups. Mortality rates at one year post stroke were significantly higher in patients with previous strokes (37% vs. 16%;  = 0.005).

Conclusions: Previous strokes are associated with higher likelihoods of mortality and unfavorable outcome in patients with LVO undergoing EVT. However, because some of these patients maintain their previous disability state, the presence of previous stroke should not be used as an exclusion criterion from EVT.
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http://dx.doi.org/10.1177/1747493019841244DOI Listing
December 2019

Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions.

Interv Neurol 2018 Oct 4;7(6):403-412. Epub 2018 Jul 4.

Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Background And Aims: Patients with emergent large-vessel occlusion (ELVO) that present earlier than 4 h from onset are usually treated with bridging systemic thrombolysis followed by endovascular thrombectomy (EVT). Whether direct EVT (dEVT) could improve the chances of favorable outcome remains unknown.

Methods: Consecutively, prospectively enrolled patients with ELVO presenting within 4 h of onset were entered into a National Acute Stroke Registry of patients undergoing revascularization. Patients treated with bridging were compared to those treated with dEVT. Excellent outcome was defined as having a modified Rankin Scale score ≤1 at 90 days following stroke.

Results: Out of 392 patients that underwent thrombectomy, 270 (68%) presented within 4 h and were included. Of those, 159 (59%) underwent bridging and 111 (41%) underwent dEVT. Atrial fibrillation and congestive heart failure were more common in the dEVT group (43 vs. 30%, = 0.04 and 20 vs. 8%, = 0.009, respectively), but other risk factors, demographics, stroke severity and subtypes as well as baseline vessel patency state and time metrics did not differ. Excellent target vessel recanalization defined as TICI 3 (thrombolysis in cerebral infarction score) was more common in the dEVT group (75 vs. 61%, = 0.03), but in-hospital mortality, discharge destinations, short- and long-term excellent outcome rates did not differ. On multivariate regression analysis, treatment modality did not significantly modify the chances of excellent outcome at discharge (OR 0.7; 95% CI 0.3-1.5) or at 3 months (OR 0.78 95% CI 0.4-1.4).

Conclusions: The chances of attaining excellent functional outcomes are similar in ELVO patients undergoing dEVT or bridging.
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http://dx.doi.org/10.1159/000489575DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6216721PMC
October 2018

Treatment with antiepileptic drugs in patients with stroke. A change in clinical practice may be required.

J Neurol Sci 2018 12 22;395:4-7. Epub 2018 Sep 22.

Department of Neurology, The Agnes Ginges Center of Neurogenetics, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Electronic address:

Background: Stroke prevention is an important socio-economic aim. Epilepsy and antiepileptic drugs (AEDs), roughly divided into enzyme-inducers and non-enzyme-inducers, have been associated with increased risk of stroke.

Methods: A retrospective review of patients admitted with a diagnosis of anytime stroke and taking at least one AED was performed. A subgroup of subjects admitted for acute strokes was separately studied. Potential interactions between AEDs and other consumed medications were identified using MicroMedex and Lexi-Interact.

Results: The study included 827 patients, 59% of them using 5-10 medications. Two thirds of the patients received at least one enzyme-inducer AED, with phenytoin being the most commonly used AED (38% of the patients). Among the subgroup of 82 patients admitted for stroke, 61% were prescribed AEDs after the stroke. More patients had large vessel and embolic strokes among these than among the patients that had strokes while on AEDs. Statins, antiplatelet drugs, antidiabetics and calcium channel blockers (CCBs) were the most frequently used non-AED drugs, by 56, 55, 30 and 28%, respectively. The most common combinations between AEDs and non-AED medications bearing risk for potential major interactions were those of AEDs with statins, warfarin, calcium channel blockers and anti-depressants.

Conclusions: A change in the AEDs prescription practice in stroke patients should be implemented, to avoid interactions with major groups of other medications prescribed to these patients.
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http://dx.doi.org/10.1016/j.jns.2018.09.026DOI Listing
December 2018

Stent and flow diverter assisted treatment of acutely ruptured brain aneurysms.

J Neurointerv Surg 2018 Sep 19;10(9):851-858. Epub 2018 May 19.

Department of Neurosurgery, Rabin Medical Center, Petah Tikva, Israel.

Objective: We present our experience with stent techniques in the management of acutely ruptured aneurysms, focusing on aneurysm occlusion rates, intraprocedural complications, and late outcomes.

Methods: We retrospectively reviewed the clinical records of patients treated by stent techniques during the early acute phase of aneurysmal rupture, from June 2011 to June 2016. Patients who underwent stenting for the management of unruptured aneurysms, or in a delayed fashion for a ruptured lesion, were excluded.

Results: 47 patients met inclusion criteria, including 46 with subarachnoid hemorrhage (SAH). There were 27 men and 20 women, mean age 38 years (range 23-73). They harbored 71 aneurysms, including 56 treated in the acute phase. Aneurysmal dome and neck width averaged 4.7 mm (range 1.7-12.1) and 3.2 mm (range 1.5-7.1), respectively. Single stent techniques were used in 39 patients and dual stent techniques in 17. External ventricular drains (EVDs) were placed before embolization in 35 patients (92%) and after in 3. Intraprocedure thromboembolic complications due to a hyporesponse to antiplatlets in 4 patients (8.5%) were successfully managed with intra-arterial antiplatelet agents. In 45 surviving patients (96%), there was complete aneurysm occlusion at the 9-12 month follow-up in 26/29 aneurysms treated by stent-assisted coiling (90%), in 2/3 aneurysms treated by flow diverter-assisted coiling (66%), and in 19/22 aneurysms treated by flow diverter alone (86%); 42/45 patients (93%) presented with a modified Rankin Scale score of 0-2.

Conclusion: Stenting techniques in ruptured aneurysms can be performed with good technical success; however, procedural thromboembolic complications related to the antiplatelet strategy merit investigation. EVD placement before stenting must be considered.
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http://dx.doi.org/10.1136/neurintsurg-2017-013742DOI Listing
September 2018

Increased Risk for Unfavorable Outcome in Patients with Pre-Existing Disability Undergoing Endovascular Therapy.

J Stroke Cerebrovasc Dis 2018 Jan 4;27(1):92-96. Epub 2017 Sep 4.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Introduction: Most studies evaluating endovascular therapy (EVT) for stroke only included patients without pre-existing disabilities. However, in real life many patients have pre-existing disabilities, and whether they can benefit from EVT remains unknown.

Methods: Patients with emergent large vessel occlusions undergoing EVT were prospectively enrolled. Patients with no or mild pre-existing disabilities (modified Rankin Scale [mRS], 0-2) were compared with patients presenting with pre-existing moderate disability (mRS ≥ 3). Baseline demographics and risk factors, stroke severity (studied with the National Institutes of Health Stroke Scale [NIHSS]), imaging data including pretreatment Alberta Stroke Program Early Computerized Tomography Score (ASPECTS) and ASPECTS collateral scores, as well as procedure-related variables were accrued. Unfavorable outcome was defined as mRS ≥ 4 at day 90.

Results: Of 131 enrolled patients, 108 had a baseline mRS of 2 or lower, and 23 had a prestroke mRS score of 3 or higher. Patients with pre-existing mRS scores of 3 or higher were significantly older (80.3 ± 10 versus 66.9 ± 13.7; P = .001) and more often had previous strokes (39% versus 16%; P = .02). Patients with mRS scores of 3 or higher were more likely to have poor outcomes or death (odds ratio [OR], 4.4; 95% confidence interval [CI], 1.3-15.0). Of the 23 patients with pre-existing moderate disability, 8 (35%) maintained their previous degree of disability. On multivariate analysis, age (OR, .92; 95% CI, .88-.97; P = .001), admission NIHSS (OR, .92; 95% CI, .85-.99; P = .042) and pretreatment ASPECTS (OR, 6.4; 95% CI, 1.4-29.5; P = .017) remained significant modifiers of favorable outcome.

Discussion And Conclusions: Patients with pre-existing moderate disabilities have higher chances of sustaining unfavorable outcomes despite EVT. Nevertheless, some patients maintain the same level of moderate disabilities, and therefore, patients with pre-existing moderate disabilities should not be excluded from EVT.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.08.007DOI Listing
January 2018

What Makes New Ischemic Lesions Symptomatic after Aortic Valve Replacement?

J Stroke Cerebrovasc Dis 2017 Dec 24;26(12):2943-2948. Epub 2017 Aug 24.

Department of Anesthesiology, State University of New York, Stony Brook, Pennsylvania.

Background: Acute cerebral infarctions on diffusion-weighted magnetic resonance imaging (MRI) are common after cardiothoracic surgery. However, most are asymptomatic and we aimed to identify features associated with clinical stroke symptoms.

Methods: Patients over 65 years of age undergoing surgical aortic valve replacement (AVR) for calcific stenosis were prospectively recruited (N = 196). All patients underwent neurological evaluation preoperatively and on postoperative days 1, 3, and 7, and MRI on planned postoperative day 5. Among those with new postoperative DWI lesions, we performed univariate and multivariable analyses to identify clinical, demographic, surgical, and imaging factors associated with clinical stroke symptoms.

Results: Of the 129 patients who completed a postsurgical MRI, 79 (61%) had DWI lesions and 17 (21.5%) of these had new stroke symptoms concordant with the infarct distribution. In an exploratory multivariable analysis, focal neurological symptoms were associated with increased age, a longer bypass duration, and a larger pre-existing lesion burden on fluid-attenuated inversion recovery. Limiting the analysis to the 61 patients with analyzable volume and location data, logistic regression failed to identify any location-related determinant of symptomatic lesions.

Conclusions: New DWI lesions are common after AVR, but most are asymptomatic. Patients are more likely to have symptoms with longer bypass durations, increasing age, and larger pre-existing lesion burdens.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2017.07.036DOI Listing
December 2017

Wire escalation in emergent revascularization procedures of internal carotid artery occlusions: the use of high tip stiffness microguidewires.

J Neurointerv Surg 2017 Jun 6;9(6):547-552. Epub 2017 Jan 6.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Objective: We examined the usefulness and safety of high tip stiffness cardiac microguidewires in the endovascular revascularization of selected cases of internal carotid artery (ICA) occlusion.

Methods: Files of patients with acute ischemic symptoms due to ICA occlusions managed from August 2010 to August 2016 by urgent endovascular revascularization were retrospectively reviewed with a waiver of informed consent. Cases where there was escalation to stiff tipped cardiovascular microguidewires after at least two failed attempts to cross the carotid occlusion with standard neuro-microguidewires were included. Radiological and interventional data were recorded.

Results: 63 patients with acute carotid occlusions underwent emergent endovascular revascularization in the study period; 5/63 patients met the inclusion criteria. In 4/5 patients, there was no angiographic evidence of the remnant origin of the ICA; in 1/5 there was a wide round shaped proximal calcified cap that precluded soft guidewire entry. In all cases, antegrade wiring was achieved only after switching to stiffer guidewires designed for the management of chronic cardiac occlusions. The use of these stiffer tip wires was considered of critical importance in achieving the successful performance of the ICA revascularization procedure. In all patients, revascularization was achieved, and 90 day modified Rankin Scale score ranged from 0 to 2.

Conclusions: When regular neuro-guidewires do not allow antegrade wiring in cases of ICA occlusion, wire escalation to high tip stiffness guidewires may improve success. These wires, designed to deal with chronic total coronary occlusions, can serve as a platform for new neuro-guidewires to be used in the challenging field of resistant supra-aortic occlusions.
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http://dx.doi.org/10.1136/neurintsurg-2016-012850DOI Listing
June 2017

Stent Retriever-Based Thrombectomy in Octogenarians.

Interv Neurol 2016 Sep 4;5(3-4):111-117. Epub 2016 Jun 4.

Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Background And Aims: Stent retriever-based thrombectomy (SRT) may be beneficial in patients with large hemispheric stroke. Previous studies concluded that favorable outcomes are far less frequent after endovascular therapy in older patients but have not explored outcomes in the era of newer-generation stent retrievers.

Materials And Methods: Consecutive patients with large hemispheric stroke treated with SRT were included. We compared neurological and functional outcomes between patients younger and older than 80.

Results: We included 16 patients older than 80 (22.5%, mean age 84.1 ± 4.4, 56% females) and compared them to 55 patients that were younger than 80 (77.5%, mean age 63.1 ± 12.5, 51% females). Risk factor profile, admission neurological severity, stroke etiology and procedure-related variables including excellent target vessel recanalization did not differ between the groups. Favorable outcome at 90 days (modified Rankin score ≤2) was more common in younger patients (77 vs. 23%; p = 0.031). In contrast, mortality rates were higher in octogenarians (40 vs. 7%; p = 0.01). Logistic regression analysis adjusting for neurological severity and collateral state identified age over 80 (odds ratio, OR 0.15, 95% CI 0.03-0.75; p = 0.02) and reperfusion state (OR 7.4, 95% CI 1.1-49.9; p = 0.04) as significant modifiers of favorable outcome. Similarly, age over 80 was identified as a positive predictor of mortality (OR 8.1, 95% CI 1.8-36.7; p = 0.007).

Conclusions: Octogenarians have higher chances of mortality and lower probability of achieving functional independence even after SRT. Nevertheless, because some elderly patients do achieve favorable outcomes, the cost-effectiveness of SRT in this population needs to be further studied.
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http://dx.doi.org/10.1159/000446795DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5075837PMC
September 2016

Emergent revascularization of acute tandem vertebrobasilar occlusions: Endovascular approaches and technical considerations-Confirming the role of vertebral artery ostium stenosis as a cause of vertebrobasilar stroke.

J Clin Neurosci 2016 Dec 10;34:70-76. Epub 2016 Aug 10.

Departments of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.

Patients suffering from acute atherothrombotic occlusion of the proximal vertebral artery (VA) and concomitant basilar artery (BA) occlusion present a grim prognosis. We describe our experience in the endovascular recanalization of tandem vertebrobasilar occlusions using endovascular techniques. The BA was accessed through the normal VA (clean-road) or the occluded, thrombotic VA (dirty-road), and stentriever-based thrombectomy was performed using antegrade or reverse revascularization variants. Seven patients underwent successful stentriever-assisted mechanical thrombectomy of the BA and five sustained concomitant VA revascularization. Stroke onset to endovascular intervention initiation (time-to-treatment) ranged from 4.5-13hours (mean 8.6). In two of seven patients, the BA occlusion was approached with a 'clean-road' approach via the contralateral VA; in five of seven patients, a 'dirty-road' approach via the occluded VA was used. Mean time-to-recanalization was 66minutes (range 55-82). There were no perforations, iatrogenic vessel dissections, or other technical complications. Four patients presented mild-to-moderate disability (modified Rankin Scale [mRS] 0-3) at 3months, one remained with moderate-to-severe disability (mRS 4), and two patients died on days 9 and 23 after their strokes. Follow-up ranged from 6-45months (mean 24months). In selected patients with acute VA-BA occlusion, stentriever-based thrombectomy performed through either the patent or the occluded VA, may be feasible, effective, and safe. Clinical outcomes in these patients seem to equipoise the neurological outcome of patients with successful revascularization for isolated BA occlusion. This unique pair of occlusions confirms the role of VA ostium stenosis as a cause of vertebrobasilar stroke.
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http://dx.doi.org/10.1016/j.jocn.2016.05.005DOI Listing
December 2016

Iatrogenic intracranial hypotension and cerebral venous thrombosis.

J Neurol Sci 2016 Jul 7;366:191-194. Epub 2016 May 7.

Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Objective: To assess the manifestations of cerebral venous thrombosis (CVT) associated with intracranial hypotension (IH) following lumbar puncture (LP) or spinal anesthesia (SA).

Methods: Adult patients with acute CVT unrelated to infection, neurosurgery, or otolaryngological surgery were identified. CVT manifesting within 21days after LP/SA was considered associated with iatrogenic IH. Presentation of patients with and without associate IH was compared.

Results: 42 patients were included. 11/42 who had undergone LP/SA presented symptoms and imaging characteristics of IH; 31 had no evidence of IH. Those with IH were more often females (11/11 vs. 21/31, p=0.03), presented sooner after symptom onset (6.0±2.2 vs. 15.6±14days, p=0.002), and rates of venous infarction (45% vs. 23%) and seizures (27% vs. 10%) appeared somewhat elevated (p<0.15). Patients with CVT associated with IH had significantly more cortical vein thrombi (55% vs. 16%, p=0.02). Thrombi were significantly shorter in patients with IH (102±113mm vs. 246±133mm, p=0.002).

Conclusion: Patients with CVT secondary to IH were typically younger females, and presented with a more acute and severe course with frequent venous infarcts. Although thrombi in the IH group were less extensive, they were more often symptomatic.
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http://dx.doi.org/10.1016/j.jns.2016.05.009DOI Listing
July 2016

Emergency revascularization of acute internal carotid artery occlusion: Follow the spike, it guides you.

J Clin Neurosci 2016 Jul 28;29:95-9. Epub 2016 Feb 28.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.

The present study sought to examine the incidence of the angiographic "spike sign" and to assess its predictive significance for achieving carotid revascularization in 54 patients with acute internal carotid artery (ICA) occlusions that required urgent endovascular revascularization. Clinical and imaging files of consecutive patients with ICA occlusion who were treated in a tertiary care academic medical center from 2011-2015 were retrospectively examined under Institutional Review Board approval with a waiver of the requirement for informed consent. All proximal ICA occlusions were treated by stent-assisted carotid angioplasty, and all distal embolic occlusions were managed with stent-assisted mechanical thrombectomy. The study included 24 patients with acute ICA occlusion (group 1) and 30 patients with tandem ICA-intracranial occlusions (group 2). The spike sign was seen in 16/24 patients in group 1 (67%), and successful ICA revascularization was achieved in 14/16 (88%). The sign was seen in 26/30 patients in group 2 (87%), and ICA revascularization was successful in all 26 (100%). The remaining 12 patients had no spike sign, and ICA revascularization was successful in only 7/12 (58%). The spike sign is a transient finding that represents the proximal patent remnant of the stenotic corridor in fresh clot. Acute ICA occlusion frequently leaves the spike sign as a marker of the recent thrombotic event. The spike vertex points to the "path of least resistance" for the guidewire to cross the occlusion and engage the true arterial lumen, a critical step during ICA endovascular revascularization.
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http://dx.doi.org/10.1016/j.jocn.2015.12.013DOI Listing
July 2016

Emergency endovascular revascularization of tandem occlusions: Internal carotid artery dissection and intracranial large artery embolism.

J Clin Neurosci 2016 Jun 28;28:157-61. Epub 2016 Feb 28.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.

Internal carotid artery dissection (ICAD) with concomitant occlusive intracranial large artery emboli is an infrequent cause of acute stroke, with poor response to intravenous thrombolysis. Reports on the management of this entity are limited. We present our recent experience in the endovascular management of occlusive ICAD and major intracranial occlusion. Consecutive anterior circulation acute stroke patients meeting Medical Center criteria for endovascular management of ICAD from June 2011 to June 2015 were included. Clinical, imaging, and procedure data were collected retrospectively under Institutional Review Board approval. The endovascular procedure for carotid artery revascularization and intracranial stent thrombectomy is described. Six patients met inclusion criteria (National Institutes of Health Stroke Scale score 12-24, time from symptom onset 2-8hours). Revascularization of the extracranial carotid dissection and stent thrombectomy were achieved in 5/6 patients, resulting in complete recanalization (Thrombolysis in Myocardial Infarction flow grade 3 in a mean 2.7hours), and modified Rankin Scale score 0-2 at 90 day follow-up. In one patient, attempts to microcatheterize the true arterial lumen failed and thrombectomy was therefore not feasible. No arterial dissection, arterial rupture or accidental stent detachment occurred, and there was no intracerebral hemorrhage or hemorrhagic transformation. Our preliminary data on this selected subgroup of patients suggest the presented approach is safe, feasible in a significant proportion of patients, and efficacious in achieving arterial recanalization and improving patient outcome. Crossing the dissected segment remains the most important limiting factor in achieving successful ICA recanalization. Further evaluation in larger series is warranted.
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http://dx.doi.org/10.1016/j.jocn.2015.12.003DOI Listing
June 2016

Drops in Barometric Pressure Are Associated with Deep Intracerebral Hemorrhage.

J Stroke Cerebrovasc Dis 2016 Apr 20;25(4):872-6. Epub 2016 Jan 20.

Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Electronic address:

Background And Purpose: The objective of this study is to assess the effects of changes in barometric pressure and outdoor temperature on the incidence of different subtypes of intracerebral hemorrhage (ICH).

Methods: Consecutive patients with primary supratentorial ICH were included. All patients resided in the same geographic area. We compared patients with subcortical ICH to those with cortical ICH. Meteorological data were continuously accrued. High-risk ICH days were defined as those on which 1 or more patients with ICH were admitted and compared to non-high-risk days. We analyzed the relationship between spontaneous ICH location and averaged daily atmospheric pressures and temperatures.

Results: We included 206 patients (147 with deep ICH and 59 with lobar ICH). Patients with deep ICH were younger (P < .001), more often had histories of diabetes, smoking and previous lacunar strokes, and were more often male (P < .01 for all). Drops in mean air pressure 2 days prior to the ictus were associated with deep but not lobar ICH (P = .006). Deep ICH clustered during February months in parallel with larger changes in barometric pressures (P < .001).

Conclusions: Drops in daily atmospheric pressures were associated with deep but not cortical ICH, suggesting a link to hypertensive etiology. Changes in barometric pressures were also associated with higher monthly frequencies of ICH.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2015.11.027DOI Listing
April 2016

Increased High-Sensitivity Troponin-T Levels Are Associated with Mortality After Ischemic Stroke.

J Mol Neurosci 2015 Oct 11;57(2):160-5. Epub 2015 Jun 11.

Department of Neurology, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem, 91120, Israel.

Biomarkers for diagnosis, treatment, and outcome prediction after stroke are lacking. Therefore, we aimed to evaluate the association between increased serum troponin, stroke severity, and mortality. Unselected patients with acute ischemic stroke assessed for troponin levels were included over the span of 1 year. Risk-factor profile, stroke etiology, stroke severity, and mortality during acute admission were recorded. The study included 212 patients, and 35 had increased troponin levels. Elevated troponin levels were associated with older age (82.1 ± 10.7 vs. 72.2 ± 12.6, p < 0.001), poor kidney function (calculated GFR 58.7 ± 29.8 vs. 82.7 ± 28.4, p < 0.001), and known ischemic heart disease (51.4% vs. 33.9%, p = 0.049). Patients with increased troponin had increased stroke severity on admission (National Institutes of Health Stroke Scale (NIHSS) 16.0 ± 9.4 vs. 10.4 ± 8.0, p < 0.001). This association remained significant after multivariate analysis but was nonlinear. Mortality rates were significantly higher in patients with increased troponin (37.1 vs. 5.6%, p < 0.001). On multivariate analysis, elevated troponin (odds ratio [OR] 22.57, 95% CI 4.4-116.6), absence of ischemic heart disease (OR 10.3, 95% CI 1.8-57.6), and admission NIHSS score (OR 1.59 for every 5 points, 95% CI 1.1-2.4) were associated with mortality. This study indicates that elevated troponin is an independent marker for severe deficits on presentation and for mortality in stroke patients.
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http://dx.doi.org/10.1007/s12031-015-0593-7DOI Listing
October 2015

MRI in acute stroke: Good times are coming.

Neurology 2015 Jun 13;84(24):2394-5. Epub 2015 May 13.

From the Department of Neurology (A.L.F.), Washington University School of Medicine, St. Louis, MO; and Department of Neurology (R.R.L.), Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

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http://dx.doi.org/10.1212/WNL.0000000000001690DOI Listing
June 2015