Publications by authors named "Sami Al Kasab"

67 Publications

Effect of Hispanic Status in Mechanical Thrombectomy Outcomes After Ischemic Stroke: Insights From STAR.

Stroke 2021 Sep 14:STROKEAHA120033326. Epub 2021 Sep 14.

Department of Neurosurgery, Bon Secours Health System, Greenville, SC (S.W.).

Background And Purpose: Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race.

Methods: Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days.

Results: Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72-84), compared with 63 years (54-74) for NHB, and 71 years (60-80) for NHW patients (<0.001). Hispanic patients had a higher incidence of diabetes (41%; <0.001) and hypertension (82%; <0.001) compared with NHW and NHB patients. Median procedure time was shorter in Hispanics (36 minutes) compared to NHB (39 minutes) and NHW (44 minutes) patients (<0.001). In multivariate analysis, Hispanic patients were less likely to have favorable outcome (odds ratio, 0.502 [95% CI, 0.263-0.959]), controlling for other significant predictors (age, admission National Institutes Health Stroke Scale, onset to groin time, number of attempts, procedure time).

Conclusions: Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.
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http://dx.doi.org/10.1161/STROKEAHA.120.033326DOI Listing
September 2021

Mechanical Thrombectomy of Carotid Terminus Occlusion Using Direct Aspiration Technique-Video Illustration: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Jul 31. Epub 2021 Jul 31.

Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.

Acute carotid terminus occlusion (CTO) is responsible for up to 5% of acute ischemic strokes secondary to emergent large vessel occlusion (ELVO) and up to 20% of acute internal carotid artery (ICA) occlusions.1 The term "CTO" has also been used to describe occlusions in the supra-clinoid segment or at the bifurcation of the ICA. Compared to other ELVOs, patients with CTO present with higher stroke severity and larger infarct volume, likely to be a result of disruption of direct Circle of Willis collaterals across the anterior communicating artery (AComA) and posterior communicating artery (PComA).2,3  Similary, CTO is usually associated with worse prognosis compared to other ELVOs in general. With regard to response to treatment, previous studies have reported significantly lower recanalization rates with intravenous alteplase with CTO compared to M1 segment occlusion. With regard to the safety and efficacy of mechanical thrombectomy, prior reports provide conflicting results with some reporting lower successful recanalization rates with CTO compared to M1 occlusion, and others reporting similar results. In our experience, we have found that successful recanalization of CTO can be achieved with a similar approach to M1 occlusions utilizing a direct aspiration first pass technique (ADAPT).3,4 Herein, we present a case of CTO for which we performed mechanical thrombectomy using ADAPT. This procedure was an emergent standard of care procedure for which a consent was not required and so not obtained.
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http://dx.doi.org/10.1093/ons/opab272DOI Listing
July 2021

Endovascular Management of Distal Anterior Cerebral Artery Aneurysms: A Multicenter Retrospective Review.

World Neurosurg 2021 Jul 18. Epub 2021 Jul 18.

Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston, South Carolina, USA.

Introduction: Distal anterior cerebral artery aneurysms (DACAA) are a rare and difficult entity to manage. Endovascular treatment has evolved for safe and durable treatment of these lesions. The objective of this study is to report the safety, efficacy, and outcomes of endovascular treatment of DACAA.

Methods: A retrospective review of DACAA endovascularly treated at 5 different institutions was performed. Data included demographics, rupture status, radiographic features, endovascular technique, complication rates, and long-term angiographic and clinical outcomes. A primary endpoint was a good clinical outcome (modified Rankin scale 0-2). Secondary endpoints included complications and radiographic occlusion at follow-up.

Results: A total of 84 patients were reviewed. The mean age was 56, and 64 (71.4%) were female. Fifty-two (61.9%) aneurysms were ruptured. A good functional outcome was achieved in 59 patients (85.5%). Sixty (71.4%) aneurysms were treated with primary coiling, and the remaining 24 were treated with flow diversion. Adequate occlusion was achieved in 41 (95.3%) aneurysms treated with coiling, and 17 (89.5%) with flow diversion. There were total 11 (13%) complications. In the flow diversion category, there were 2, both related to femoral access. In the coiling category, there were 9: 5 thromboembolic, 3 ruptures, and 1 related to femoral access.

Conclusion: Endovascular treatment, and in particular, flow diversion for DACAA, is safe, feasible, and associated with good long-term angiographic and clinical outcomes.
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http://dx.doi.org/10.1016/j.wneu.2021.07.055DOI Listing
July 2021

Neuroendovascular Management of Acute Ischemic Basilar Strokes: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Sep;21(4):E346-E347

Division of Neuroendovascular Surgery, Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.

Basilar artery occlusions (BAOs) are devastating ischemic strokes that account for 1% of all strokes with high morbidity and mortality; however, neuroendovascular techniques such as ADAPT have recently revolutionized the clinical outcomes of these patients.1-3 Common underlying pathology in patients with BAO include intracranial atherosclerotic disease (ICAD) as well as thromboembolic origin.4 Basilar artery ICAD in a setting of acute stroke portends a poor prognosis and post-thrombectomy residual critical flow limiting stenosis treatment options, including balloon angioplasty with or without stent placement.5-7 We present a video illustration of neuroendovascular technique and challenges encountered when managing this pathology. Image at 5:42 reprinted with permission from Alawieh et al, Lessons learned over more than 500 stroke thrombectomies using ADAPT with increasing aspiration catheter size, Neurosurgery, 86(1), 2020, pp. 61-70, with permission from the Congress of Neurological Surgeons.1.
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http://dx.doi.org/10.1093/ons/opab180DOI Listing
September 2021

Outcomes of Rescue Endovascular Treatment of Emergent Large Vessel Occlusion in Patients With Underlying Intracranial Atherosclerosis: Insights From STAR.

J Am Heart Assoc 2021 Jun 5;10(12):e020195. Epub 2021 Jun 5.

Department of Neurosurgery Medical University of South Carolina Charleston SC.

Background Some emergent large vessel occlusions (ELVOs) are refractory to reperfusion because of underlying intracranial atherosclerosis (ICAS), often requiring rescue therapy (RT) with balloon angioplasty, stenting, or both. In this study, we investigate the safety, efficacy, and long-term outcomes of RT in the setting of mechanical thrombectomy for ICAS-related ELVO. Methods and Results We queried the databases of 10 thrombectomy-capable centers in North America and Europe included in STAR (Stroke Thrombectomy and Aneurysm Registry). Patients with ELVO who underwent ICAS-related RT were included. A matched sample was produced for variables of age, admission National Institute of Health Stroke Scale, Alberta Stroke Program Early CT Score, onset to groin puncture time, occlusion site, and final recanalization. Out of 3025 patients with MT, 182 (6%) patients required RT because of underlying ICAS. Balloon angioplasty was performed on 122 patients, and 117 patients had intracranial stenting. In the matched analysis, 141 patients who received RT matched to a similar number of controls. The number of thrombectomy passes was higher (3 versus 1, <0.001), and procedural time was longer in the RT group (52 minutes versus 36 minutes, =0.004). There was a higher rate of symptomatic hemorrhagic transformation in the RT group (7.8% versus 4.3%, =0.211), however, the difference was not significant. There was no difference in 90-day modified Rankin scale of 0 to 2 (44% versus 47.5%, =0.543) between patients in the RT and control groups. Conclusions In patients with ELVO with underlying ICAS requiring RT, despite longer procedure time and a more thrombectomy passes, the 90 days favorable outcomes were comparable with patients with embolic ELVO.
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http://dx.doi.org/10.1161/JAHA.120.020195DOI Listing
June 2021

High-resolution vessel wall imaging after mechanical thrombectomy.

Neuroradiol J 2021 May 20:19714009211017782. Epub 2021 May 20.

Department of Radiology, University of Iowa Hospitals and Clinics,USA.

Objectives: High-resolution magnetic resonance imaging has the potential of characterising arterial wall changes after endovascular mechanical thrombectomy. The purpose of this study is to evaluate high-resolution magnetic resonance imaging features of large intracranial arteries following mechanical thrombectomy.

Methods: Patients who presented with acute ischaemic stroke due to large vessel occlusion and underwent mechanical thrombectomy were prospectively recruited. Subjects underwent high-resolution magnetic resonance imaging within 24 hours of the procedure. Magnetic resonance imaging sequences included whole brain T1 pre and post-contrast black-blood imaging, three-dimensional T2, contrast-enhanced magnetic resonance angiography and susceptibility-weighted imaging. Arterial wall enhancement was objectively assessed after normalisation with the pituitary stalk. The contrast ratio of target vessels was compared with non-affected reference vessels.

Results: Twenty patients with 22 target vessels and 20 reference vessels were included in the study. Sixteen patients were treated with stentriever with or without aspiration, and four with contact aspiration only. Significantly higher arterial wall enhancement was identified on the target vessel when compared to the reference vessel (U = 22.5,  < 0.01). The stentriever group had an 82% increase in the contrast ratio of the target vessel (x̄ = 0.75 ± 0.21) when compared to the reference vessel (x̄ = 0.41 ± 0.13), whereas the contact aspiration group had a 64% increase of the contrast ratio difference between target (x̄ = 0.62 ± 0.07) and reference vessels (x̄ = 0.38 ± 0.12). Approximately 65% of patients in the stentriever group had a positive parenchymal susceptibility-weighted imaging versus 25% in the contact aspiration group. There was no statistically significant correlation between susceptibility-weighted imaging volume and the percentage increase in the contrast ratio ( = 0.098,  = 0.748).

Conclusions: This prospective pilot study used the objective quantification of arterial wall enhancement in determining arterial changes after mechanical thrombectomy. Preliminary data suggest that the use of stentrievers is associated with a higher enhancement as compared to reperfusion catheters.
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http://dx.doi.org/10.1177/19714009211017782DOI Listing
May 2021

Mechanical Thrombectomy for Distal Occlusions: Efficacy, Functional and Safety Outcomes: Insight from the STAR Collaboration.

World Neurosurg 2021 07 8;151:e871-e879. Epub 2021 May 8.

Texas Stroke Institute, Dallas-Fort Worth, Texas, USA.

Background: Mechanical thrombectomy (MT) is the standard of care for the treatment of proximal anterior circulation large vessel occlusions. However, little is known about its efficacy and safety in the treatment of distal intracranial occlusions.

Methods: This is a multicenter retrospective study of patients treated with MT at 15 comprehensive centers between January 2015 and December 2018. The study cohort was divided into 2 groups based on the location of occlusion (proximal vs. distal). Distal occlusion was defined as occlusion of M3 segment of the middle cerebral artery, any segment of the anterior cerebral artery, or any segment of the posterior cerebral artery. Only isolated distal occlusion was included. Good outcome was defined as 90-day modified Rankin scale score 0-2.

Results: A total of 4710 patients were included in this study, of whom 189 (4%) had MT for distal occlusions. Compared with the proximal occlusion group, distal occlusion group had a higher rate of good outcome (45% vs. 36%; P = 0.03) and a lower rate of successful reperfusion (78% vs. 84%; P = 0.04). However, the differences did not retain significance in adjusted models. Otherwise there was no difference in the rate of hemorrhagic complications, mortality, or procedure-related complications between the 2 groups. Successful reperfusion, age, and admission stroke severity emerged as predictors of good functional outcome in the distal occlusion group.

Conclusions: Thrombectomies of distal vessels achieve high rate of successful reperfusion with similar safety profile to those in more proximal locations.
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http://dx.doi.org/10.1016/j.wneu.2021.04.136DOI Listing
July 2021

Telestroke Across the Continuum of Care: Lessons from the COVID-19 Pandemic.

J Stroke Cerebrovasc Dis 2021 Jul 8;30(7):105802. Epub 2021 Apr 8.

Department of Neurology, University of Virginia, Charlottesville, VA, USA; Department of Public Health Sciences, University of Virginia, Charlottesville, VA, USA.

While use of telemedicine to guide emergent treatment of ischemic stroke is well established, the COVID-19 pandemic motivated the rapid expansion of care via telemedicine to provide consistent care while reducing patient and provider exposure and preserving personal protective equipment. Temporary changes in re-imbursement, inclusion of home office and patient home environments, and increased access to telehealth technologies by patients, health care staff and health care facilities were key to provide an environment for creative and consistent high-quality stroke care. The continuum of care via telestroke has broadened to include prehospital, inter-facility and intra-facility hospital-based services, stroke telerehabilitation, and ambulatory telestroke. However, disparities in technology access remain a challenge. Preservation of reimbursement and the reduction of regulatory burden that was initiated during the public health emergency will be necessary to maintain expanded patient access to the full complement of telestroke services. Here we outline many of these initiatives and discuss potential opportunities for optimal use of technology in stroke care through and beyond the pandemic.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105802DOI Listing
July 2021

Endovascular Treatment of Basilar Bifurcation Aneurysms With PulseRider-Assisted Coiling: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Jul;21(2):E109-E110

Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.

Wide-necked bifurcation aneurysms pose technical and anatomical challenges to endovascular treatment, which make the simpler assisted (balloon or single stent) coiling techniques less effective.1 Consequently, unique endovascular solutions to treat such aneurysms have been devised.2,3 One such device is PulseRider (Cerenovus, New Brunswick, New Jersey), which is designed to provide neck support for a coil mass while protecting the bifurcation.3 The device comprises a body or stem that is deployed in the parent artery and a saddle component that sits at the aneurysm neck to keep the coil mass away from the bifurcation. There are several technical nuances involved in successful use of the device during positioning, deployment, and detachment.3 We present a surgical video detailing the steps of PulseRider-assisted coiling of unruptured basilar bifurcation (or basilar apex) aneurysms. The first case highlights index treatment at diagnosis and the second showcases treatment of a recurrent basilar apex aneurysm. Both patients provided informed consent to the procedure. We also briefly discuss the rationale for treating basilar apex aneurysms.4,5.
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http://dx.doi.org/10.1093/ons/opab102DOI Listing
July 2021

Telestroke Consultation in the Emergency Medical Services Unit: A Novel Approach to Improve Thrombolysis Times.

J Stroke Cerebrovasc Dis 2021 May 6;30(5):105710. Epub 2021 Mar 6.

Neurology, Medical University of South Carolina, Charleston, SC, United States.

Background: Faster treatment times are associated with improved outcomes in patients with acute ischemic stroke. In this prospective pilot study, we assess the feasibility of initiating telestroke consultation in emergency medical services unit (TEMS).

Methods: Patients with stroke symptoms were evaluated via TEMS using a video-call with a stroke provider. After TEMS evaluation, patients were transferred to the nearest stroke center (NSC) or thrombectomy capable center (TCS) depending on stroke severity and symptom onset time. We compared time metrics between patients evaluated via TEMS to those via standard telestroke (STS) consultation.

Results: 49 patients were evaluated via TEMS between May 2017 and March 2020. Median age was 66, 24 (49%) were females, 15 (30.6%) received intravenous alteplase (tPA) after arrival to a local hospital, and 3 (6.1%) underwent mechanical thrombectomy (MT) after bypassing the NSC. Compared to 52 tPA patients treated through STS consultation, TEMS patients had shorter door to needle (DTN) time (21 vs. 38 min, p < 0.001). In addition, patients who received MT after bypassing the NSC had shorter onset to groin time compared to those transferred from NSC (216 vs. 293 min, P = 0.04).

Conclusion: Prehospital stroke triaging using TEMS is feasible, and could result in shorter DTN and onset to groin times.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.105710DOI Listing
May 2021

Letter by Almallouhi and Al Kasab Regarding Article, "Antiphospholipid Antibody and Recurrent Ischemic Stroke: A Systematic Review and Meta-Analysis".

Stroke 2021 Jan 25;52(2):e68. Epub 2021 Jan 25.

Department of Neurology (E.A., S.A.K.), Medical University of South Carolina, Charleston.

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http://dx.doi.org/10.1161/STROKEAHA.120.033073DOI Listing
January 2021

Increased telestroke call burden after the extended thrombectomy window trials.

J Telemed Telecare 2021 Jan 20:1357633X20982738. Epub 2021 Jan 20.

Department of Neurology, Medical University of South Carolina, USA.

Introduction: Clinical trials have proven the efficacy of mechanical thrombectomy in stroke patients with large-vessel occlusion presenting within 24 hours of symptom onset. Extending the thrombectomy window to 24 hours resulted in a higher number of thrombectomies being performed. However, little is known about the impact of the extended thrombectomy window on the telestroke call burden.

Methods: We used the prospectively maintained database of a telestroke network covering a large geographic area in the Southeast USA. We included patients presenting between January 2015 and December 2019. We compared the characteristics and outcomes between patients who presented before and after the publication of the extended window thrombectomy trials.

Results: A total of 9041 patients presented with stroke-like symptoms during the study period. Of these, 4995 presented after February 2018. There was no difference in the patient demographics in both groups. However, patients in the post extended window group had a lower National Institute of Health Stroke Scale on presentation (3 vs. 4;  < 0.001) and longer symptom-onset-to-door time (124 vs. 85 minutes;  < 0.001). The number of consults per month nearly doubled (200 vs. 103;  < 0.001) in the extended thrombectomy window era. Similarly, the number of mechanical thrombectomies performed per month increased from four to seven since extending the thrombectomy window ( < 0.001).

Discussion: The number of telestroke consults nearly doubled after the publication of the extended thrombectomy window trials, with an increase in the number of thrombectomies performed. These findings have important operational implications for hospitals implementing telestroke call coverage.
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http://dx.doi.org/10.1177/1357633X20982738DOI Listing
January 2021

Alarming downtrend in mechanical thrombectomy rates in African American patients during the COVID-19 pandemic-Insights from STAR.

J Neurointerv Surg 2021 Apr 6;13(4):304-307. Epub 2021 Jan 6.

Neurosurgery, Medical University of South Carolina, Charleston, SC, USA.

Background: The coronavirus disease (COVID-19) pandemic has affected stroke care globally. In this study, we aim to evaluate the impact of the current pandemic on racial disparities among stroke patients receiving mechanical thrombectomy (MT).

Methods: We used the prospectively collected data in the Stroke Thrombectomy and Aneurysm Registry from 12 thrombectomy-capable stroke centers in the US and Europe. We included acute stroke patients who underwent MT between January 2017 and May 2020. We compared baseline features, vascular risk factors, location of occlusion, procedural metrics, complications, and discharge outcomes between patients presenting before (before February 2020) and those who presented during the pandemic (February to May 2020).

Results: We identified 2083 stroke patients: of those 235 (11.3%) underwent MT during the COVID-19 pandemic. Compared with pre-pandemic, stroke patients who received MT during the pandemic had longer procedure duration (44 vs 38 min, P=0.006), longer length of hospitalization (6 vs 4 days, P<0.001), and higher in-hospital mortality (18.7% vs 11%, P<0.001). Importantly, there was a lower number of African American patients undergoing MT during the COVID-19 pandemic (609 (32.9%) vs 56 (23.8%); P=0.004).

Conclusion: The COVID-19 pandemic has affected the care process for stroke patients receiving MT globally. There is a significant decline in the number of African American patients receiving MT, which mandates further investigation.
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http://dx.doi.org/10.1136/neurintsurg-2020-016946DOI Listing
April 2021

Outcomes of interfacility helicopter transportation in acute stroke care.

Neurol Clin Pract 2020 Oct;10(5):422-427

Department of Neurology (EA, NT, ED, CAH), Medical University of South Carolina, Charleston; Departments of Neurology, Epidemiology and Neurosurgery (SAK, ECL), University of Iowa Carver College of Medicine; Department of Neurology (MN, JC, D-VG, JAS), Augusta University, GA; and Department of Healthcare Leadership and Management (JBH), College of Health Professions, Medical University of South Carolina, Charleston.

Objective: To evaluate the long-term functional outcome of interhospital transfer of patients with stroke with suspected large vessel occlusion (LVO) using Helicopter Emergency Medical Services (HEMS).

Methods: Records of consecutive patients evaluated through 2 telestroke networks and transferred to thrombectomy-capable stroke centers between March 2017 and March 2018 were reviewed. Inverse probability of treatment weighting (IPTW) using the propensity score was performed to address confounding factors. Multivariate logistic regression analysis with IPTW was used to determine whether HEMS were associated with good long-term functional outcome (modified Rankin scale score ≤ 2).

Results: A total of 199 patients were included; median age was 67 years (interquartile range [IQR] 55-79 years), 90 (45.2%) were female, 120 (60.3%) were white, and 100 (50.3%) were transferred by HEMS. No significant differences between the 2 groups were found in mean age, sex, race, IV tissue plasminogen activator (tPA) receipt, and thrombectomy receipt. The median baseline NIH Stroke Scale score was 14 (IQR 9-18) in the helicopter group vs 11 (IQR 6-18) for patients transferred by ground ( = 0.039). The median transportation time was 60 minutes (IQR 49-70 minutes) by HEMS and 84 minutes (IQR 25-102 minutes) by ground ( < 0.001). After weighting baseline characteristics, the use of HEMS was associated with higher odds of good long-term outcome (OR 4.738, 95% CI 2.15-10.444, < 0.001) controlling for transportation time, door-in-door-out time, and thrombectomy and tPA receipt. The magnitude of the HEMS effect was larger in thrombectomy patients who had successful recanalization (OR 1.758, 95% CI 1.178-2.512, = 0.027).

Conclusions: HEMS use was associated with better long-term functional outcome in patients with suspected LVO, independently of transportation time.
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http://dx.doi.org/10.1212/CPJ.0000000000000737DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7717633PMC
October 2020

In-House Anesthesia and Interventional Radiology Technologist Support Optimize Mechanical Thrombectomy Workflow after Hours.

J Stroke Cerebrovasc Dis 2020 Nov 21;29(11):105246. Epub 2020 Aug 21.

Department of Neurology, University of Iowa Carver College of Medicine, Comprehensive Stroke Center, Iowa City, IA; Department of Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, IA; Department of Radiology, University of Iowa Carver College of Medicine, Iowa City, IA. Electronic address:

Background And Purpose: Prior literature suggests after-hours delay leads to poor functional outcomes in stroke patients undergoing thrombectomy. We aimed to evaluate the impact of time of presentation on mechanical thrombectomy (MT) metrics and its association with long-term functional outcome in an Interventional Radiology (IR) suite equipped operating room (OR) setting.

Methods: Retrospective review of prospectively maintained database on all stroke patients undergoing mechanical thrombectomy between January 2015 and December 2018 at our CSC. Work hours were defined by official OR work hours (Monday-Friday 7 AM and 5 PM) and after-hours as between 5 PM and 7 AM during weekdays and weekends as well as official hospital holidays. Primary outcome was 90-day modified Rankin Scale (mRS). Secondary outcomes included door to groin puncture time and procedural complications.

Results: A total of 315 patients were included in the analyses. 209 (66.4%) received mechanical thrombectomy after hours and 106 (33.6%) during work hours. There was no difference in the shift distribution of functional outcome on the mRS at 90 days (OR: 1.14, CI: 0.72-1.78, p=0.58) and the percentage of patients achieving functional independence (mRS 0-2) at 90 days (43.1% vs. 41.3%; p=0.83) between the after hour and work hour groups respectively. Similarly, there was no difference in median door to groin times and procedural complications among both groups, with significant year on year improvement in overall time metrics.

Conclusions: Our study showed that undergoing MT during off-hours had similar functional outcomes when compared to MT during working hours in an OR setting. The after-hours deleterious effect might disappear when MT is performed in a system with 24-hours in-house Anesthesia and IR tech services.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105246DOI Listing
November 2020

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma: A Multi-Center Experience of 154 Consecutive Embolizations.

Neurosurgery 2021 01;88(2):268-277

Department of Neurological Surgery, University of Washington, Seattle, Washington.

Background: Middle meningeal artery (MMA) embolization has emerged as a promising treatment for chronic subdural hematoma (cSDH).

Objective: To determine the safety and efficacy of MMA embolization.

Methods: Consecutive patients who underwent MMA embolization for cSDH (primary treatment or recurrence after conventional surgery) at 15 centers were included. Clinical details and follow-up were collected prospectively. Primary clinical and radiographic outcomes were the proportion of patients requiring additional surgical treatment within 90 d after index treatment and proportion with > 50% cSDH thickness reduction on follow-up computed tomography imaging within 90 d. National Institute of Health Stroke Scale and modified Rankin Scale were also clinical outcomes.

Results: A total of 138 patients were included (mean age: 69.8, 29% female). A total of 15 patients underwent bilateral interventions for 154 total embolizations (66.7% primary treatment). At presentation, 30.4% and 23.9% of patients were on antiplatelet and anticoagulation therapy, respectively. Median admission cSDH thickness was 14 mm. A total of 46.1% of embolizations were performed under general anesthesia, and 97.4% of procedures were successfully completed. A total of 70.2% of embolizations used particles, and 25.3% used liquid embolics with no significant outcome difference between embolization materials (P > .05). On last follow-up (mean 94.9 d), median cSDH thickness was 4 mm (71% median thickness reduction). A total of 70.8% of patients had >50% improvement on imaging (31.9% improved clinically), and 9 patients (6.5%) required further cSDH treatment. There were 16 complications with 9 (6.5%) because of continued hematoma expansion. Mortality rate was 4.4%, mostly unrelated to the index procedure but because of underlying comorbidities.

Conclusion: MMA embolization may provide a safe and efficacious minimally invasive alternative to conventional surgical techniques.
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http://dx.doi.org/10.1093/neuros/nyaa379DOI Listing
January 2021

International experience of mechanical thrombectomy during the COVID-19 pandemic: insights from STAR and ENRG.

J Neurointerv Surg 2020 Nov 25;12(11):1039-1044. Epub 2020 Aug 25.

Neurosurgery, University of South Florida, Tampa, Florida, USA.

Background: In response to the COVID-19 pandemic, many centers altered stroke triage protocols for the protection of their providers. However, the effect of workflow changes on stroke patients receiving mechanical thrombectomy (MT) has not been systematically studied.

Methods: A prospective international study was launched at the initiation of the COVID-19 pandemic. All included centers participated in the Stroke Thrombectomy and Aneurysm Registry (STAR) and Endovascular Neurosurgery Research Group (ENRG). Data was collected during the peak months of the COVID-19 surge at each site. Collected data included patient and disease characteristics. A generalized linear model with logit link function was used to estimate the effect of general anesthesia (GA) on in-hospital mortality and discharge outcome controlling for confounders.

Results: 458 patients and 28 centers were included from North America, South America, and Europe. Five centers were in high-COVID burden counties (HCC) in which 9/104 (8.7%) of patients were positive for COVID-19 compared with 4/354 (1.1%) in low-COVID burden counties (LCC) (P<0.001). 241 patients underwent pre-procedure GA. Compared with patients treated awake, GA patients had longer door to reperfusion time (138 vs 100 min, P=<0.001). On multivariate analysis, GA was associated with higher probability of in-hospital mortality (RR 1.871, P=0.029) and lower probability of functional independence at discharge (RR 0.53, P=0.015).

Conclusion: We observed a low rate of COVID-19 infection among stroke patients undergoing MT in LCC. Overall, more than half of the patients underwent intubation prior to MT, leading to prolonged door to reperfusion time, higher in-hospital mortality, and lower likelihood of functional independence at discharge.
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http://dx.doi.org/10.1136/neurintsurg-2020-016671DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453763PMC
November 2020

Blacks Are Less Likely to Present With Strokes During the COVID-19 Pandemic: Observations From the Buckle of the Stroke Belt.

Stroke 2020 10 5;51(10):3107-3111. Epub 2020 Aug 5.

Department of Neurology, Medical University of South Carolina, Charleston. (C.C., E.A., S.A.K., C.A.H.).

Background And Purpose: The impact of the coronavirus disease 2019 (COVID-19) pandemic on stroke systems has not been systematically evaluated. Our study aims to investigate trends in telestroke consults during the pandemic.

Methods: We did retrospective chart review of consecutive patients seen through a telestroke network in South Carolina from March 2019 to April 2020. We dichotomized patients to preCOVID-19 pandemic (March 2019 to February 2020) and during COVID-19 pandemic (March to April 2020).

Results: A total of 5852 patients were evaluated during the study period, 613 (10.5%) were seen during the pandemic. The median number of weekly consults dropped from 112 to 77 during the pandemic, =0.002. There was no difference in baseline features; however, Black patients were less likely to present with strokes during the pandemic (13.9% versus 29%, ≤0.002).

Conclusions: The COVID-19 pandemic has led to a significant drop in telestroke volume. The impact seems to disproportionately affect Black patients.
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http://dx.doi.org/10.1161/STROKEAHA.120.031121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434003PMC
October 2020

Safety and Efficacy of the Pipeline Embolization Device Use in the Outside Circle of Willis Located Intracranial Aneurysms: A Single-Center Experience.

Interv Neurol 2020 Jan 16;8(2-6):83-91. Epub 2019 Jan 16.

Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA.

Background: The use of Pipeline Embolization Device (PED) is approved by the US Food and Drug Administration (FDA) to treat aneurysms located between the petrous and superior hypophyseal segments of the internal carotid artery. The purpose of this study is to evaluate the feasibility and efficacy of treating aneurysms outside the FDA approved anatomical locations. Furthermore, we analyze the safety of our antiplatelet protocol.

Methods: Data on all patients treated with PED at our center from March 2015 to December 2017 were reviewed. Only patients with aneurysms treated with PED as off label use were included. Procedural complications and long-term functional outcome measured by modified Rankin Scale (mRS) were recorded. Tirofiban maintenance infusion was administered intravenously after PED deployment. None of the patients had platelet function testing.

Results: A total of 36 patients harboring 36 aneurysms were included in the study. Mean age was 58.2 years ±14.6. Nineteen were women (52.8%) and most aneurysms were unruptured (80.6%). There were no intraoperative complications. Five patients experienced postoperative complications - 4 ischemic strokes and one groin hematoma. None led to any significant disability at follow-up. Thirty-one patients (86.1%) achieved an mRS of 0-2 at follow-up. A Raymond-Roy classification of 1 was achieved in 78.9% of patients.

Conclusion: The use of PED to treat aneurysms located outside the circle of Willis is feasible and effective. Our novel antiplatelet protocol did not require platelet function assay testing and did not lead to a higher rate of thrombo-embolic events compared to what has been previously reported.
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http://dx.doi.org/10.1159/000495074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7253860PMC
January 2020

Letter to the Editor 'Acute stroke management during the COVID-19 Pandemic: from Trough of Disillusionment to Slope of Enlightenment'.

World Neurosurg 2020 06 3;138:603-604. Epub 2020 Jun 3.

Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.

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http://dx.doi.org/10.1016/j.wneu.2020.04.153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7266773PMC
June 2020

Impact of Stroke Center Certification on Thrombolysis Time Metrics in Telestroke Setting.

Telemed J E Health 2021 02 12;27(2):167-171. Epub 2020 May 12.

Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.

Previous studies have shown that primary stroke centers (PSCs) have shorter door to needle (DTN) time than non-PSCs hospitals. We aimed to validate these findings in a high-volume telestroke network. The prospectively maintained data on all consecutive stroke patients who received intravenous alteplase (tissue plasminogen activator [tPA]) between July 2016 and November 2019 through a large telestroke program in Southeast United States was reviewed. Wilcoxon Rank-sum (Mann-Whitney) test was used to compare median times between different groups. Multivariate logistic regression model was used to assess the association between presenting to PSC and having DTN ≤45 and ≤60 min. During the study period, 1,517 patients received tPA, 874 (57.6%) at PSC sites. There were more white patients in the PSC group (64.3%) compared to non-PSC group (58%) (p < 0.001). Other characteristics were similar in patients in both groups. Time metrics were as follows, Door to telestroke page: 16 min versus 13 min (p < 0.001), telestroke page to tPA recommendation: 23 min versus 22 min (p = 0.975), tPA recommendation to tPA bolus administration: 13 min versus 10 min (p < 0.001), and DTN 58 min versus 49 min (p < 0.001) at non-PSC and PSC sites, respectively. On multivariate analysis, there were significantly higher odds for achieving a DTN ≤45 min (OR 2.8, 95% CI 1.8-4.4, p < 0.001) and DTN ≤60 min (OR 3, 95% CI 2.1-4.3, p < 0.001) in the PSC group. In our study, PSCs had better performance in the procedural metrics for tPA administration than non-PSCs in a large contemporary telestroke cohort.
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http://dx.doi.org/10.1089/tmj.2020.0020DOI Listing
February 2021

Optimizing the Use Of Teleneurology During the COVID-19 Pandemic.

Telemed J E Health 2020 10 24;26(10):1197-1198. Epub 2020 Apr 24.

Department of Neurology and Medical University of South Carolina, Charleston, South Carolina, USA.

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http://dx.doi.org/10.1089/tmj.2020.0109DOI Listing
October 2020

Quantitative Susceptibility Mapping and Vessel Wall Imaging as Screening Tools to Detect Microbleed in Sentinel Headache.

J Clin Med 2020 Apr 1;9(4). Epub 2020 Apr 1.

Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA.

Background: MR-quantitative susceptibility mapping (QSM) can identify microbleeds (MBs) in intracranial aneurysm (IA) wall associated with sentinel headache (SH) preceding subarachnoid hemorrhage. However, its use is limited, due to associated skull base bonny and air artifact. MR-vessel wall imaging (VWI) is not limited by such artifact and therefore could be an alternative to QSM. The purpose of this study was to investigate the correlation between QSM and VWI in detecting MBs and to help develop a diagnostic strategy for SH.

Methods: We performed a prospective study of subjects with one or more unruptured IAs in our hospital. All subjects underwent evaluation using 3T-MRI for MR angiography (MRA), QSM, and pre- and post-contrast VWI of the IAs. Presence/absence of MBs detected by QSM was correlated with aneurysm wall enhancement (AWE) on VWI.

Results: A total of 40 subjects harboring 51 unruptured IAs were enrolled in the study. MBs evident on the QSM sequence was detected in 12 (23.5%) IAs of 11 subjects. All these subjects had a history of severe headache suggestive of SH. AWE was detected in 22 (43.1%) IAs. Using positive QSM as a surrogate for MBs, the sensitivity, specificity, positive predictive value, and negative predictive value of AWE on VWI for detecting MBs were 91.7%, 71.8%, 50%, and 96.6%, respectively.

Conclusions: Positive QSM findings strongly suggested the presence of MBs with SH, whereas, the lack of AWE on VWI can rule it out with a probability of 96.6%. If proven in a larger cohort, combining QSM and VWI could be an adjunctive tool to help diagnose SH, especially in cases with negative or non-diagnostic CT and lumbar puncture.
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http://dx.doi.org/10.3390/jcm9040979DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7230854PMC
April 2020

Incorporation of transradial approach in neuroendovascular procedures: defining benchmarks for rates of complications and conversion to femoral access.

J Neurointerv Surg 2020 Nov 26;12(11):1122-1126. Epub 2020 Mar 26.

Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA

Background: The transradial approach (TRA) has gained increasing popularity for neuroendovascular procedures. However, the experience with TRA in neuroangiography is still in early stages in most centers, and the safety and feasibility of this approach have not been well established. The purpose of this study is to report the safety and feasibility of TRA for neuroendovascular procedures.

Methods: We reviewed charts from six institutions in the USA to include consecutive patients who underwent diagnostic or interventional neuroendovascular procedures through TRA from July 2018 to July 2019. Collected data included baseline characteristics, procedural variables, complications, and whether there was a crossover to transfemoral access.

Results: A total of 2203 patients were included in the study (age 56.1±15.2, 60.8% women). Of these, 1697 (77%) patients underwent diagnostic procedures and 506 (23%) underwent interventional procedures. Successfully completed procedures included aneurysm coiling (n=97), flow diversion (n=89), stent-assisted coiling (n=57), balloon-assisted coiling (n=19), and stroke thrombectomy (n=76). Crossover to femoral access was required in 114 (5.2%). There were no major complications related to the radial access site. Minor complications related to access site were seen in 14 (0.6%) patients.

Conclusion: In this early stage of transforming to the 'radial-first' approach for neuroendovascular procedures, TRA was safe with low complication rates for both diagnostic and interventional procedures. A wide range of procedures were completed successfully using TRA.
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http://dx.doi.org/10.1136/neurintsurg-2020-015893DOI Listing
November 2020

Relationship Between Vascular Risk Factors and Location of Intracranial Atherosclerosis in the SAMMPRIS Trial.

J Stroke Cerebrovasc Dis 2020 May 21;29(5):104713. Epub 2020 Feb 21.

Department of Neurology, Medical University of South Carolina, Charleston, South Carolina.

Background: Previous studies have reported that different locations of intracranial atherosclerosis (ICAS) are associated with different demographic features and vascular risk factors. We aimed to examine this observation in the Stenting and Aggressive Medical Management for Preventing Recurrent stroke in Intracranial Stenosis (SAMMPRIS) trial population.

Methods: SAMMPRIS was a randomized controlled trial that enrolled 451 patients with recent transient ischemic attack or stroke-related due to severe (70%-99%) stenosis of a major intracranial artery. We compared the baseline demographic features and vascular risk factors between the symptomatic artery locations. Wilcoxon test was used to compare continuous variables, and chi-square test was used for categorical variables.

Results: Of 449 patients included in the analysis; 289 (64.4%) had ICAS in the anterior circulation and 160 (35.6%) in the posterior circulation. Features that were significantly different between patients with anterior versus posterior ICAS were: median age (58.3 years versus 64.0 years, P < .001), males/females (52.9%/47.1% versus 74.4%/25.6% P < .001), white/black (66.8%/26.6% versus 79.4%/16.9%, P = .02), and history of hyperlipidemia (85.5% versus 92.5%, P = .03).

Conclusions: The observed differences in the distribution of demographic characteristics and vascular risk factors depending on the location of symptomatic ICAS suggest the possibility of different underlying pathological processes involved in the formation of atherosclerotic plaques in different locations.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.104713DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7534892PMC
May 2020

Intracranial Atherosclerosis: A Disease of Functional, not Anatomic Stenosis? How Trans-Stenotic Pressure Gradients Can Help Guide Treatment.

Oper Neurosurg (Hagerstown) 2020 06;18(6):599-605

Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa.

Background: Most trials have assessed intracranial atherosclerotic disease (ICAD) severity based on angiographic stenosis. However, anatomic stenosis might not accurately identify the actual state of functional post-stenotic flow limitation.

Objective: To investigate whether angiographic stenosis correlates with physiologic distal flow limitation, measured as trans-stenotic pressure gradients, in ICAD patients.

Methods: In patients referred for endovascular treatment of anterior circulation symptomatic ICAD who failed maximal medical therapy (MMT) per SAMMPRIS (Stenting versus Aggressive Medical Therapy for Intracranial Arterial Stenosis) criteria, angiographic luminal diameters and percentages of stenosis were correlated with trans-stenotic pressure gradients, calculated as distal/proximal pressure ratios (DPPR) and proximal minus distal pressure gradients (PDPG), by way of Spearman correlation coefficients.

Results: Nine patients (3 men, 6 women) were evaluated. Atherosclerotic lesions' locations included internal carotid artery in 5 subjects (2 cavernous, 3 supraclinoid) and proximal middle cerebral artery (M1) in 4 patients. Mean percentage of stenosis was 80 ± 8% (range 75%-94%). Minimal lumen diameter at the most stenotic ICAD site ranged from 0.2 to 0.9 mm (0.59 ± 0.41 mm). DPPR ranged from 0.38 to 0.63 (0.56 ± 0.14). PDPG ranged from 35 to 57 mm Hg (50 ± 8 mm Hg). Spearman coefficients showed no correlation between DPPR or PDPG and angiographic minimal luminal diameters or percentages of stenosis. There were no procedural complications related to trans-stenotic pressure measurements.

Conclusion: Angiographic stenosis does not reflect the physiologic severity of distal flow limitation in patients with ICAD. Hemodynamic assessment using trans-stenotic pressure ratios and gradients may serve as a more reliable predictive biomarker for MMT failure and response to revascularization.
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http://dx.doi.org/10.1093/ons/opz335DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7443592PMC
June 2020

Endovascular management of acute large vessel occlusion stroke in pregnancy is safe and feasible.

J Neurointerv Surg 2020 Jun 4;12(6):552-556. Epub 2019 Dec 4.

Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA

Introduction: Stroke is a leading cause of adult death and disability. Although acute ischemic stroke (AIS) in pregnancy is rare, it has devastating consequences on the life of the mother and fetus. Pregnancy was an exclusion criterion in endovascular thrombectomy (EVT) trials and so there are no evidence-based treatment recommendations in this subgroup. The objective of this study was to evaluate the safety and feasibility of mechanical thrombectomy in large vessel occlusion (LVO) stroke in pregnancy.

Methods: Patients with AIS due to LVO treated with EVT during pregnancy between 2000 and 2019 were identified at seven tertiary care centers. After IRB approval, retrospective analysis of prospectively maintained stroke/endovascular databases was performed.

Results: A total of seven subjects were identified. The average age was 33.2 years (range 25-38 years) and the average initial National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15 (range 9-28). Three patients received IV tissue plasminogen activator. Techniques of EVT included stent retriever thrombectomy, stent retriever-assisted continuous aspiration, direct contact aspiration, and multimodal techniques including a rescue balloon mounted coronary stent placement. While one patient was noted to have petechial hemorrhage, no individuals developed parenchymal hematoma. Mean discharge NIHSS score was 1.7 (range 0-5).

Conclusion: EVT is a safe and effective treatment for acute stroke secondary to LVO in this series of pregnant patients. While EVT for acute stroke is standard of care in select patient populations, our study suggests that treatment should be considered in the gravid population.
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http://dx.doi.org/10.1136/neurintsurg-2019-015578DOI Listing
June 2020

Racial/Ethnic Disparities in Acute Ischemic Stroke Treatment Within a Telestroke Network.

Telemed J E Health 2020 10 22;26(10):1221-1225. Epub 2019 Nov 22.

Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA.

The growth of telestroke services expanded the reach of acute stroke treatment. However, ethnic disparities in receiving such treatment have not been fully assessed. We reviewed prospectively maintained data on patients evaluated through the Medical University of South Carolina telestroke program between January 2016 and November 2018. Outcomes included odds of receiving intravenous recombinant tissue plasminogen activator (tPA), receiving mechanical thrombectomy (MT), and achieving door-to-needle (DTN) time ≤60 and ≤45 min among patients receiving tPA. We used logistic regression to analyze the contribution of race/ethnicity. We included 2,977 patients, of whom 1,093 (36.7%) identified as nonwhite; of these, 1,048 patients (95.9%) identified as black or African American. Significantly more nonwhite patients were seen at a primary stroke center (PSC) (68.4% vs. 52.3% in whites, p < 0.001). However, white patients had significantly higher odds of receiving tPA (odds ratio [OR] 1.47, confidence interval [95% CI] 1.17-1.84). There was no significant difference in receiving MT between races. Among patients receiving tPA, whites had higher odds of DTN ≤45 min (OR 1.76, 1.20-2.57) and ≤60 min (OR 1.87, 95% CI 1.31-2.66). White patients had better odds achieving DTN ≤45 min and DTN ≤60 min if receiving tPA within a telestroke setting, as well as higher odds of receiving tPA, even after adjustment for comorbidities. This was noted despite white patients having less access to PSCs. However, larger scale studies are needed to further study the impact of ethnic disparities.
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http://dx.doi.org/10.1089/tmj.2019.0127DOI Listing
October 2020

Aspirin associated with decreased rate of intracranial aneurysm growth.

J Neurosurg 2019 Oct 29:1-8. Epub 2019 Oct 29.

Departments of1Neurosurgery.

Objective: Aspirin has emerged as a potential agent in the prevention of rupture of intracranial aneurysms (IAs). In this study, the authors' goal was to test if aspirin is protective against aneurysm growth in patients harboring multiple IAs ≤ 5 mm.

Methods: The authors performed a retrospective review of a prospectively maintained database covering the period July 2009 through January 2019. Patients' data were included if the following criteria were met: 1) the patient harbored multiple IAs; 2) designated primary aneurysms were treated by surgical/endovascular means; 3) the remaining aneurysms were observed for growth; and 4) a follow-up period of at least 5 years after the initial treatment was available. Demographics, earlier medical history, the rupture status of designated primary aneurysms, aneurysms' angiographic features, and treatment modalities were gathered.

Results: The authors identified 146 patients harboring a total of 375 IAs. At the initial encounter, 146 aneurysms were treated and the remaining 229 aneurysms (2-5 mm) were observed. During the follow-up period, 24 (10.48%) of 229 aneurysms grew. All aneurysms observed to grow later underwent treatment. None of the observed aneurysms ruptured. Multivariate analysis showed that aspirin was significantly associated with a decreased rate of growth (odds ratio [OR] 0.19, 95% confidence interval [CI] 0.05-0.63). Variables associated with an increased rate of growth included hypertension (OR 14.38, 95% CI 3.83-53.94), drug abuse (OR 11.26, 95% CI 1.21-104.65), history of polycystic kidney disease (OR 9.48, 95% CI 1.51-59.35), and subarachnoid hemorrhage at presentation (OR 5.91, 95% CI 1.83-19.09).

Conclusions: In patients with multiple IAs, aspirin significantly decreased the rate of aneurysm growth over time. Additional prospective interventional studies are needed to validate these findings.
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http://dx.doi.org/10.3171/2019.6.JNS191273DOI Listing
October 2019
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