Rates of adverse events in patients with ischemic stroke treated at thrombectomy capable hospitals.

OBJECTIVE: To identify the beneficial effects of thrombectomy capable hospitals (TCHs), by comparing the incidence of in-hospital adverse events and discharge outcomes among patients with ischemic stroke treated at thrombectomy capable and non-thrombectomy capable hospitals in the United States. METHODS: We used the data from the Nationwide Inpatient Sample from January 2012 to December 2017. Thrombectomy capable hospitals were identified based on the number of thrombectomy procedures performed by a hospital each year among patients with ischemic stroke. If a hospital performed 10 or more thrombectomy procedures, it was labelled a TCH. The inclusion criteria were age ≥18 years, and ischemic stroke (International Classification of Diseases 433 .x1-434.x1 (ICD-9) or I63 (ICD-10)) as primary discharge diagnosis. A comparative analysis of propensity-matched patient groups was done to study the influence of TCH admissions on in-hospital outcomes. RESULTS: A total of 2 826 334 patients with primary ischemic stroke were identified. In a multivariate logistic regression model after adjusting for age, sex, race/ethnicity, hospital teaching status, comorbidities, and all patients refined diagnosis-related groups-based disease severity, patients admitted to a TCH were found to have low incidence of in-hospital adverse events: pneumonia (OR=0.86, 95% CI 0.78 to 0.93), urinary tract infection (OR=0.87, 95% CI 0.84 to 0.91), sepsis (OR=0.91, 95% CI 0.81 to 1.02), and pulmonary embolism (OR=0.89, 95% CI 0.77 to 1.03); in-hospital death (OR=0.82, 95% CI 0.78 to 0.88); and higher rate of home discharge (OR=1.09, 95% CI 1.06 to 1.12). CONCLUSIONS: A decrease in-hospital adverse events and improved discharge outcomes were observed among patients with ischemic stroke admitted to a TCH compared with a non-TCH.

The impact of COVID-19 on acute ischemic stroke admissions: Analysis from a community-based tertiary care center.

BACKGROUND/OBJECTIVE: To evaluate the impact of the COVID-19 pandemic on hospital admissions and outcomes in patients admitted with acute ischemic stroke. METHODS: Single-center retrospective analysis of patients admitted to the hospital with acute ischemic stroke, between December 1st, 2019 and June 30th, 2020. Outcomes were classified as none-to-minimal disability, moderate-to-severe disability, and death based on discharge disposition, and compared between two time periods: pre-COVID-19 era (December 1st, 2019 to March 11th, 2020) and COVID-19 era (March 12th to June 30th, 2020). We also performed a comparative trend analysis for the equivalent period between 2019 and 2020. RESULTS: Five hundred and seventy-five patients with a mean age (years±SD) of 68±16 were admitted from December 1st, 2019 to June 30th, 2020, with a clinical diagnosis of acute ischemic stroke. Of these, 255 (44.3%) patients were admitted during the COVID-19 era. We observed a 22.1% and 39.5% decline in admission for acute ischemic stroke in April and May 2020, respectively. A significantly higher percentage of patients with acute ischemic stroke received intravenous thrombolysis during the COVID-19 era (p = 0.020). In patients with confirmed COVID-19, we found a higher percentage of older men with preexisting comorbidities such as hyperlipidemia, coronary artery disease, and diabetes mellitus but a lower rate of atrial fibrillation. In addition, we found a treatment delay in both intravenous thrombolysis (median 94.5 min versus 38 min) and mechanical thrombectomy (median 244 min versus 86 min) in patients with confirmed COVID-19 infection. There were no differences in patients' disposition including home, short-term, and long-term facility (p = 0.60). CONCLUSIONS: We observed a reduction of hospital admissions in acute ischemic strokes and some delay in reperfusion therapy during the COVID-19 pandemic. Prospective studies and a larger dataset analysis are warranted.

Prospective Endovascular Treatment in Acute Ischemic Stroke Evaluating Non-Contrast Head CT versus CT Perfusion (PLEASE No CTP).

BACKGROUND: Studies have shown a lack of agreement of computed tomography perfusion (CTP) in the selection of acute ischemic stroke (AIS) patients for endovascular treatment. PURPOSE: To demonstrate whether non-contrast computed tomography (CT) within 8 h of symptom onset is comparable to CTP imaging. METHODS: Prospective study of consecutive anterior circulation AIS patients with a National Institute of Health Stroke Scale (NIHSS) score > 7 presenting within 8 h of symptom onset with endovascular treatment. All patients had non-contrast CT, CT angiography, and CTP. The neuro-interventionalist was blinded to the results of the CTP and based the treatment decision using the Alberta Stroke Program Early CT score (ASPECTS). Baseline demographics, co-morbidities, and baseline NIHSS scores were collected. Outcomes were modified Rankin scale (mRS) score at discharge and in-hospital mortality. Good outcomes were defined as a mRS score of 0-2. RESULTS: 283 AIS patients were screened for the trial, and 119 were enrolled. The remaining patients were excluded for: posterior circulation stroke, no CTP performed, could not obtain consent, and NIHSS score < 7. Mean -NIHSS score at admission was 16.8 ± 3, and mean ASPECTS was 8.4 ± 1.4. There was no statistically significant correlation with CTP penumbra and good outcomes: 50 versus 47.8% with no penumbra present (p = 0.85). In patients without evidence of CTP penumbra, there was 22.5% mortality compared to 22.1% mortality in patients with a CTP penumbra. If ASPECTS ≥7, 64.6% had good outcome versus 13.3% if ASPECTS < 7 (p < 0.001). Patients with an ASPECTS ≥7 had 10% mortality versus 51.4% in patients with an ASPECTS < 7 (p < 0.001). CONCLUSIONS: CTP penumbra did not identify patients who would benefit from endovascular treatment when patients were selected with non-contrast CT ASPECTS ≥7. There is no correlation of CTP penumbra with good outcomes or mortality. Larger prospective trials are warranted to justify the use of CTP within 6 h of symptom onset.

Asymptomatic Extracranial Vertebral Artery Disease in Patients with Internal Carotid Artery Stenosis.

BACKGROUND: Extracranial vertebral artery disease is seen in patients with internal carotid artery stenosis, although the clinical significance is not well understood. OBJECTIVE: To determine the prevalence and natural history of extracranial vertebral artery disease in patients with recently symptomatic internal carotid artery stenosis. METHODS: We analyzed data collected for patients with recently symptomatic internal carotid artery stenosis in the Stent-Protected Angioplasty vs Carotid Endarterectomy trial. We used Cox proportional hazards analysis to compare the relative risk of various endpoints (any stroke, ipsilateral stroke, and death) between the 3 categories of extracranial vertebral artery disease (normal/hypoplastic, moderate/severe stenosis, occlusion) adjusting for age, gender, severity of internal carotid artery stenosis at baseline (<70% and ≥70%), allocated procedure (carotid angioplasty and stent placement or carotid endarterectomy) and hypertension. RESULTS: Moderate to severe stenosis and occlusion of 1 of both extracranial vertebral arteries were diagnosed in 152 (12.9%) and 57 (4.8%) of 1181 subjects, respectively. Comparing subjects with normal or hypoplastic vertebral artery, there was nonsignificant 30%, 40%, and 50% higher risk of any stroke (hazard ratio [HR] 1.3, 95% confidence interval [CI] 0.7-2.3), ipsilateral stroke (HR 1.4, 95% CI 0.7-2.5), and death (HR 1.5, 95% CI 0.7-3.1) among subjects with moderate to severe vertebral artery stenosis after adjusting for potential confounders. CONCLUSIONS: There may be an increased risk of stroke and death in patients with symptomatic internal carotid artery stenosis with concurrent asymptomatic extracranial vertebral artery stenosis.

A New Risk Index for Predicting Outcomes among Patients Undergoing Carotid Endarterectomy in Large Administrative Data Sets.

BACKGROUND: We developed and validated a new index to provide risk adjustment and to predict in-hospital patient mortality and other outcomes in patients undergoing carotid endarterectomy (CEA). METHODS: The primary endpoint was occurrence of stroke, cardiac complications, or death during hospitalization for CEA derived from the Nationwide Inpatient Sample. Multivariate logistic regression was performed to identify the effect of clinical and demographic factors on occurrence of the primary endpoint. Data from 2005 to 2006 (study period 1) were used to derive risk index score whereas data from 2007 to 2009 (study period 2) were used for validation of the risk index. RESULTS: A total of 120,633 patients with mean age in years [ ±SD] of 71.1[ ±9.5] (42.4% women) underwent CEA during the derivation period. The rate of occurrence of composite endpoint during study period 1 was 3.1%. Predictors of the composite endpoint were (odds ratio [OR], P value) as follows: age 70 years or older (1.15, .013 assigned 1 point), atrial fibrillation (3.18, <.0001 assigned 3 points), Congestive Heart Failure (CHF) (1.81, <.0001 assigned 2 points), cigarette smoking (1.64, <.0001 assigned 2 points), symptomatic status (1.87, <.001 assigned 2 points), and chronic renal failure (1.64, <.0001 assigned 2 points). When applied to the validation cohort (n = 71,222), patients with scores 0-1 (OR 1.6, 95% confidence interval [CI] 1.5-1.8), scores 2-3 (OR 4.0, 95% CI 3.8-4.3), scores 4-5 (OR 7.5, 95% CI 6.8-8.2), and scores greater than 5 (OR 10.9, 95% CI 9.8-12.2) had composite rates of endpoint. The receiver operating characteristic curve of the risk index was 68.5% [±SE 0.5%]. CONCLUSION: New risk index will assist in risk adjustment for analyses of outcomes in large administrative data sets for comparative studies involving patients undergoing CEA.

Rates of Adverse Events and Outcomes among Stroke Patients Admitted to Primary Stroke Centers.

BACKGROUND AND PURPOSE: To identify the beneficial effects of primary stroke centers (PSCs) certification by Joint Commission (JC), we compared the rates of in-hospital adverse events and discharge outcomes among ischemic stroke patients admitted to PSCs and those admitted to non-PSC hospitals in the United States. METHODS: We obtained the data from the Nationwide Inpatient Sample from 2010 and 2011. The analysis was limited to states that publicly reported hospital identity. PSCs were identified by matching the Nationwide Inpatient Sample hospital files with the list provided by JC. The analysis was limited to patients (age ≥18 years) discharged with a principal diagnosis of ischemic stroke (International Classification of Disease, 9th Revision, codes 433.x1, 434.x1). RESULTS: We identified a total of 123,131 ischemic stroke patients from 28 states. A total of 72,982 (59.3%) patients were admitted to PSCs. After adjusting for age, gender, race or ethnicity, comorbidities, All Patients Refined Diagnosis Related Groups (APR-DRG)-based disease severity, and hospital teaching status, patients admitted to PSCs were at lower risk of in-hospital adverse events complications: pneumonia (odds ratio [OR], .8; 95% confidence interval [CI], .7-.8) and sepsis (OR, .7; 95% CI, .6-.8). Patients admitted to PSCs were more likely to receive thrombolysis (OR, 1.6; 95% CI, 1.5-1.7). The mean cost of hospitalization (95% CI) of the patients was significantly higher in patients admitted at PSCs compared with those admitted at non PSC hospitals $47621 (47099-48144) vs. $35229 (34803-35654), P < .0001). The patients admitted to PSCs had lower inpatient mortality (OR, .8; 95% CI, .8-.9) and were more likely to be discharged with none to minimal disability (OR, 1.1; 95% CI, 1.0-1.1). CONCLUSIONS: Compared with non-PSC admissions, patients admitted to PSCs are less likely to experience hospital adverse events and more likely to experience better discharge outcomes.

Post-IV thrombolytic headache and hemorrhagic transformation risk in acute ischemic stroke.

Background: Headache during or soon after administration of IV tissue plasminogen activator (tPA) in patients with acute ischemic stroke (AIS) is a concern for hemorrhagic transformation (HT). However, no data are available regarding the incidence of HT in these patients or the prognostic indication of these headaches. We examine the importance of tPA-associated headaches among AIS patients in terms of HT rates and clinical outcomes. Methods: AIS patients treated with IV tPA at a comprehensive stroke center between January 2007 and November 2012 were retrospectively reviewed for documented tPA-associated headache in the first 24 hours post-tPA. We compared the headache and nonheadache groups for differences in various clinical and radiologic outcomes. Results: Of the 193 patients, 63 (32.6%) had tPA-associated headache. Headache patients (HP) were younger than nonheadache patients (NHP) (mean ± SD, 59.5 ± 17.4 years vs 69.9 ± 15.5 years, p < 0.0001), and 53% of HP were men, compared to 49.2% of NHP (p = 0.537). Comorbid conditions did not differ between the 2 groups. There were no statistical differences between HP and NHP in admission NIH Stroke Scale (NIHSS) score (11.2 ± 5.7 vs 11.5 ± 5.5, p = 0.646), NIHSS score at 24 hours (6.5 ± 5.7 vs 7.4 ± 6.9, p = 0.466), NIHSS score at discharge (6.7 ± 10.1 vs 8.1 ± 11.6, p = 0.448), HT (12.7% vs 18.4%, p = 0.3), cervical artery dissection (4.7% vs 5.38%, p = 0.764), length of hospitalization (6.29 ± 5 days vs 6.35 ± 4.7 days, p = 0.935), and disposition. Conclusion: tPA-associated headache does not predict increased risk of HT and has no other prognostic importance in patients with AIS. Prospective studies with a larger cohort may be needed to further explore this relationship.

Human Immunodeficiency Viral Infection and Status Epilepticus in United States (2002-2009).

OBJECTIVE: To determine the association between human immunodeficiency virus (HIV) infection and status epilepticus and compare the outcomes of patients with status epilepticus with or without underlying HIV infection. METHODS: Patients with primary diagnosis of status epilepticus (cases) and status asthmaticus (controls) were identified from the 2002-2009 Nationwide Inpatient Sample (NIS) which is representative of all admissions in the United States. We performed logistic regression analysis adjusting for age, gender, co-morbid conditions, including hypertension, diabetes mellitus (DM), renal failure, alcohol use, and opportunistic infections. We compared the in hospital outcomes among patients admitted with status epilepticus in strata defined by underlying HIV infection. RESULTS: The rate of concurrent status epilepticus and HIV has increased over the last 7 years in hospitalized patients with status epilepticus in United States (0.14%-0.27% p<0.0001). The HIV infection was significantly associated with status epilepticus (odds ratio [OR]: 2.2; 95% confidence interval [CI]: 1.8-2.6; p<0.0001)) after adjusting for age, gender, opportunistic infections, and cardiovascular risk factors. The in-hospital mortality was significantly higher while discharge with none or minimal disability was significantly lower in status epilepticus patients with underlying HIV infection (17.5% vs. 9.9%, p<0.0001) and (50.4% vs. 63.3%, p<0.0001), respectively. CONCLUSIONS: Our study suggests that there is a direct association between HIV infection and status epilepticus. The proportion of patients admitted with concurrent status epilepticus and HIV infections is increasing and such patients have higher rates of poor discharge outcomes.

The impact of Sleep Time-Related Information and Communication Technology (STRICT) on sleep patterns and daytime functioning in American adolescents.

This cross-sectional study explored the extent and impact of mobile device-based Sleep Time-Related Information and Communication Technology (STRICT) use among American adolescents (N = 3139, 49.3% female, mean age = 13.3 years). Nearly 62% used STRICT after bedtime, 56.7% texted/tweeted/messaged in bed, and 20.8% awoke to texts. STRICT use was associated with insomnia, daytime sleepiness, eveningness, academic underperformance, later bedtimes and shorter sleep duration. Moderation analysis demonstrated that the association between STRICT use and insomnia increased with age, the association between STRICT use and daytime sleepiness decreased with age, and the association between STRICT use and shorter sleep duration decreased with age and was stronger in girls. Insomnia and daytime sleepiness partially mediated the relationship between STRICT use and academic underperformance. Our results illustrate the adverse interactions between adolescent STRICT use and sleep, with deleterious effects on daytime functioning. These worrisome findings suggest that placing reasonable limitations on adolescent STRICT use may be appropriate.

Antithrombotic Utilization Trends after Noncardioembolic Ischemic Stroke or TIA in the Setting of Large Antithrombotic Trials (2002-2009).

BACKGROUND AND PURPOSE: Several large trials published over the last decade have significantly altered recommended guidelines for therapy following a noncardioembolic ischemic stroke or transient ischemic attack (TIA). The impact of these studies on patient usage of alternative antithrombotic agents has hitherto not been evaluated. We examined the usage of these agents in the United States over the last decade, with regard to the publication of the Management of Atherothrombosis with Clopidogrel in High-Risk Patients (MATCH), European/Australasian Stroke Prevention in Reversible Ischaemia Trial (ESPRIT), and Prevention Regimen for Effectively Avoiding Second Strokes (PRoFESS) clinical trials, in order to test the hypothesis that resulting recommendations are reflected in usage trends. METHODS: Antithrombotic utilization was prospectively collected as part of the National Ambulatory Medical Care Survey (NAMCS) on a total of 53,608,351 patients in the United States between 2002 and 2009. Patients with a history of ischemic stroke or TIA were included. Patients were excluded if there was a prior history of subarachnoid or intracerebral hemorrhage, or if other indications for antithrombotic treatment were present, including deep venous thrombosis, pulmonary embolism, atrial fibrillation or flutter, mechanical cardiac valve replacement, congestive heart failure, coronary artery disease, peripheral arterial disease, and rheumatoid arthritis. Annual utilization of the following antithrombotic strategies was compared in 53,608,351 patients: 1) aspirin monotherapy, 2) clopidogrel monotherapy, 3) combined clopidogrel and aspirin, 4) combined extended-release dipyridamole (ERDP) and aspirin, and 5) warfarin. Annual utilization was compared before and after publication of MATCH, ESPRIT, and PRoFESS in 2004, 2006, and 2008, respectively. Trend analysis was performed with the Mantel-Haenszel test for trends. Sensitivity analysis of demographic and clinical characteristics stratified by antithrombotic-usage group was performed using the Wald Chi-square test. RESULTS: Utilization of combined clopidogrel and aspirin increased from 3.3% to 6.7% after the MATCH trial (p<0.0001). Following the results of the ESPRIT trial, utilization of combination ERDP and aspirin decreased from 4% to 3% (p<0.0001), utilization of clopidogrel declined from 6.8% to 6% (p<0.0001), and utilization of aspirin remained essentially unchanged. After the PRoFESS trial, utilization of clopidogrel increased from 5% to 9% (p<0.0001), utilization of ERDP-aspirin increased from 3 % to 4.6% (p<0.0001), and utilization of aspirin increased from 15.6% to 17.8% (p<0.0001). The proportion of patients on none of the five antithrombotic secondary prevention strategies steadily declined from a peak of 74% in 2003 to 57% by 2009. CONCLUSIONS: The impact of the MATCH, ESPRIT, and PRoFESS trials on antithrombotic utilization has been variable. These findings highlight the importance of addressing factors that affect the implementation of findings from major clinical trials.

The effect of atrial fibrillation on outcomes in patients undergoing carotid endarterectomy or stent placement in general practice.

BACKGROUND: Atrial fibrillation is a common comorbid condition among patients undergoing carotid endarterectomy (CEA) and carotid artery stent placement (CAS); however, the outcomes of patients with atrial fibrillation undergoing CAS have not been fully examined. We sought to investigate the impact of atrial fibrillation on outcomes of CEA and CAS in general practice. METHODS: We analyzed the data from the National Inpatient Sample (NIS), which is representative of all admissions in the United States from 2005 to 2009. The primary end point was postoperative stroke, cardiac complication, postoperative mortality, and composite of these end points. Univariate and multivariate regression analyses were performed to determine, first, the association of atrial fibrillation (compared to without atrial fibrillation) and, second, the association of CEA (compared with CAS) in patients with atrial fibrillation with the occurrence of postoperative stroke, cardiac complication, or death. Covariates included in the logistic regression were the patient's gender, age, race/ethnicity, comorbid conditions, and symptom status (symptomatic vs asymptomatic status) and the hospital's characteristics. RESULTS: Of the total 672,074 patients who underwent CAS or CEA, 8.8% (95% confidence interval [CI], 8.7-8.9) of the procedures were performed in patients with atrial fibrillation. Atrial fibrillation was associated with an increased risk of postoperative stroke in patients undergoing CEA (n = 879 [1.7%]; P < .0001; odds ratio [OR], 1.57; 95% CI, 1.32-1.86) but not in patients undergoing CAS. The relative risk of the composite end point of postoperative stroke, cardiac complications, and mortality was increased in patients with atrial fibrillation undergoing CAS (OR, 1.43; 95% CI, 1.18-1.74) and in those undergoing CEA (OR, 3.18; 95% CI, 2.89-3.49). After adjustment for potential confounders, the odds of the composite end point of postoperative stroke, cardiac complications, and mortality (OR, 1.31; 95% CI, 1.08-1.59) in atrial fibrillation patients were significantly higher among patients who underwent CEA (compared with those who underwent CAS). An opposite relationship was seen in patients without atrial fibrillation, in whom the composite end point was significantly lower in patients undergoing CEA. CONCLUSIONS: Our analysis suggests that almost 10% of CAS and CEA is performed in patients with atrial fibrillation in general practice, and higher rates of adverse events are observed among these patients, particularly those undergoing CEA.

Rates and predictors of 5-year survival in a national cohort of asymptomatic elderly patients undergoing carotid revascularization.

BACKGROUND: Current American Heart Association guidelines recommend carotid revascularization for asymptomatic patients on the basis of life expectancy. OBJECTIVE: To determine the rates and predictors of 5-year survival in elderly patients with asymptomatic carotid artery stenosis who underwent either carotid artery stent placement (CAS) or carotid endarterectomy (CEA). METHODS: The rates of 5-year survival were determined by use of Kaplan-Meier survival methods in a representative sample of fee-for-service Medicare beneficiaries ≥65 years of age who underwent CAS or CEA for asymptomatic carotid artery stenosis with postprocedural follow-up of 3.4 ± 1.7 years. Cox proportional hazards analysis was used to assess the relative risk of all-cause mortality for patients in the presence of selected comorbidities, including ischemic heart disease, chronic renal failure, and atrial fibrillation, after adjustment for potential confounders such as age, sex, race/ethnicity, and procedure type. RESULTS: A total of 22,177 patients with asymptomatic carotid artery stenosis were treated with either CAS (n = 2144) or CEA (n = 20,033). The overall estimated 5-year survival rate (±SE) was 95.3 ± 0.00149; it was 95.5% and 93.8% in patients treated with CEA and CAS, respectively. After adjustment for potential confounders, relative risk of all-cause 5-year mortality was significantly higher among patients with atrial fibrillation (relative risk, 1.8; 95% confidence interval, 1.5-2.1) and those with chronic renal failure (relative risk, 2.1; 95% confidence interval, 1.7-2.6). CONCLUSION: Risks and benefits must be carefully weighed before carotid revascularization in elderly patients with asymptomatic carotid artery stenosis who have concurrent atrial fibrillation or chronic renal failure.

Incidences of unruptured intracranial aneurysms and subarachnoid hemorrhage: results of a statewide study.

BACKGROUND: The incidence of unruptured intracranial aneurysms (UIAs) and the current public health impact may be higher than that reported in previous studies owing to an increase in the elderly population in the United States. OBJECTIVE: To report the current incidences of UIAs and subarachnoid hemorrhages (SAH) by using a population-based methodology. METHODS: Statewide estimates of patients admitted with UIAs and SAH were obtained from the data obtained by the Minnesota Hospital Association. We calculated the annual incidences per 100,000 persons by using the 2010 census data from the U.S. Census Bureau. For the denominator, total persons in each year were categorized into 10-year intervals. RESULTS: The incidences of UIAs and SAH were 15.6 and 7.7 per 100,000 persons, respectively. There were higher incidences of both UIAs and SAH among women (22.5 and 9.6 per 100,000 persons, respectively). The highest incidence of UIAs occurred in those aged between 75 and 84 years (61.6 per 100,000 persons). The highest incidence of SAH occurred in those aged 85 years and older (30.1 per 100,000 persons). CONCLUSION: An increase in both incidences of UIAs and SAH can be expected owing to the continued increase of the elderly population, particularly women.

A survey of preprocedural intubation practices for endovascular treatment of acute ischemic stroke.

BACKGROUND: In the absence of specific guidelines, there is considerable variance in preprocedural intubation practices for endovascular treatment of acute ischemic stroke. The purpose of this study is to understand and characterize the variance in preprocedural intubation practices and identify the reasons that influence the choice of preprocedural intubation practices among treating physicians. METHODS: We selected 10 random cases from a prospective database of patients undergoing endovascular treatment for acute ischemic stroke and prepared a case summary providing pertinent demographic, clinical, and imaging data. Twenty clinicians independently reviewed the case summaries and responded to whether they would intubate any of the 10 patients and identified the reasons for their choices. Clinicians were also asked to identify their training background (neurology-, neurosurgery-, or radiology-trained endovascular specialist, vascular neurologist or neurointensivist). Reasons for intubation and agreement between clinicians for each case were ascertained. RESULTS: The decision to intubate the patient was made in 63 of 200 total clinical scenarios. The major reasons identified by the physicians for preprocedural intubation were high National Institute of Health stroke scale scores on admission 26.9% (n = 17), labored breathing or desaturation 23.8% (n = 15), less than optimal respiratory status of patients combined with drowsiness or reduced level of consciousness 14.3% (n = 9), inability to follow command due to aphasia 12.7% (n = 8), seizures 1.6% ( n = 1), and no reason 20.6% (n = 13). Overall agreement between clinicians regarding decision of preprocedural intubation among the 10 case scenarios was 30.1% (standard error [SE] 2.3%). The agreement between neurosurgeons was 37.5% (SE = 31.6), interventional neurologist 19.8% (SE = 4.7), and vascular neurologist/neurointensivist 39.3% (SE = 5.9). CONCLUSION: The decision of preprocedural intubation varies widely among clinicians. Because of recent data that suggests that decision of preprocedural intubation may impact on patients' outcomes, better standardization of such practices is required.

Flow-independent dynamics in aneurysm (FIDA): pressure measurements following partial and complete flow impairment in experimental aneurysm model.

BACKGROUND: There have been growing concerns regarding delayed aneurysm rupture subsequent to the flow-diverting stent deployment. Therefore, more investigations are needed regarding hemodynamic changes secondary to flow-diverting stent deployment. OBJECTIVE: To study intra-aneurysmal and perianeurysmal pressures after partial and complete flow impairment into the aneurysm. METHODS: A silicone model of an 8-mm-sized aneurysm (neck diameter: 5 mm, vessel size: 4 mm) was used. The aneurysm wall was encapsulated and sealed within a 5 ml syringe filled with saline and a pressure sensor guide wire (ComboWire, Volcano Corp.) to detect pressure changes in the perivascular compartment (outer aneurysm wall). A second pressure sensor guide wire was advanced inside the aneurysm sac. Both pressure sensors were continuously measuring pressure inside and outside the aneurysm under pulsatile flow under the following conditions: 1) baseline (reference); 2) a 16 mm by 3.75 mm flow-diverting stent (ev3/Covidien Vascular, Mansfield, MA) deployed in front of the aneurysm; 3) two flow-diverting stents (16 mm by 3.5 mm) were deployed; and 4) a covered stent (4 mm by 16 mm VeriFlex coronary artery stent covered with rubber sheet) was deployed. RESULTS: Mean (±SD) baseline pressures inside and outside the aneurysm were 53.9 (±2.4) mmHg (range 120-40 mmHg) and 15.4 (±0.7) mmHg (range 40-8mmHg), respectively. There was no change in pressure inside and outside the aneurysm after deploying the first and second flow-diverting stents (partial flow impairment) and it remained at 53.9 (±2.7) mmHg and 14.9 (±1) mmHg for the pressure inside and outside the aneurysm, respectively. The pressure recording from outside the aneurysm dropped from 15.4 (±0.7) mmHg to 0.3 (±0.7) mmHg after deploying the covered stent (complete flow impairment). There was no change in pressure inside the aneurysm after deploying the covered stent. Mean (±SD) pressure within the aneurysm was 55.1 (±1.7) mmHg and it remained 54.7 (±1.7) mmHg after covered stent deployment. CONCLUSION: Our findings suggest a major discordance between the pressures within the aneurysm and partial or complete flow impairment (flow independent). The outer wall pressure is reduced after covered stent placement. These finding may assist clinicians in better understanding of aneurysm hemodynamics and rupture after flow-diverting stent deployment.

Comparison of long-term outcomes associated with endovascular treatment vs surgical treatment among Medicare beneficiaries with unruptured intracranial aneurysms.

BACKGROUND: Long-term outcomes associated with endovascular and surgical treatments for unruptured intracranial aneurysms are not well studied to date. OBJECTIVE: To determine the 5-year risk of new intracranial hemorrhage, second procedure, and all-cause mortality in elderly patients with unruptured intracranial aneurysms who underwent either surgical or endovascular treatment. METHODS: The study cohort included a representative sample of fee-for-service Medicare beneficiaries aged ≥65 years who underwent endovascular or surgical treatment for unruptured intracranial aneurysms with postprocedure follow-up of 4.7 (±3.0) years. Cox proportional hazards analysis was used to assess the relative risk (RR) of all-cause mortality, new intracranial hemorrhage, or second procedure for patients who underwent endovascular treatment compared with those who underwent surgical treatment after adjusting for potential confounders. The 5-year survival was estimated for both treatment groups by using Kaplan-Meier survival methods. RESULTS: A total of 688 patients with unruptured intracranial aneurysms were treated with either endovascular (n = 398) or surgical treatment (n = 290). The rate of immediate postprocedural neurological complications (10.3% vs 3.5%, P = .001) was higher among patients treated with surgery than among those who underwent endovascular treatment. The estimated 5-year survival was 92.8% and 94.8% in patients who underwent surgical and endovascular treatments, respectively. After adjusting for age, sex, and race/ethnicity, the RRs of all-cause mortality (RR, 0.6; 95% confidence interval, 0.3-1.1) and new intracranial hemorrhage (RR, 0.4; 95% confidence interval, 0.2-0.8) were lower with endovascular treatment. CONCLUSION: In elderly patients with unruptured intracranial aneurysms, endovascular treatment was associated with lower rates of acute adverse events and long-term all-cause mortality and new intracranial hemorrhages.

Cocaine use and the likelihood of cardiovascular and all-cause mortality: data from the Third National Health and Nutrition Examination Survey Mortality Follow-up Study.

BACKGROUND: Numerous case series have implicated cocaine use as a cause of both myocardial infarction (MI) and stroke on the basis of the temporal relationship between drug use and event onset. The relatively high prevalence of cocaine use in the US population, especially in younger individuals, mandates a more extensive investigation of this relationship. METHODS: We determined the relationship between cocaine use and cardiovascular and all-cause mortality in a nationally representative sample of 9013 US adults aged 18 to 45 years who participated in the Third National Health and Nutrition Examination Survey Mortality Follow-up Study using Cox proportional hazards analyses. We categorized the participants as nonusers if they responded to the lifetime cocaine use question as never used, as infrequent users if they responded as using <10 times, and as frequent or regular users if they reported using 10-99 times or >100 times, respectively. Potential confounding factors in the association between cocaine use and death (cardiovascular and all cause) included age, sex, race/ethnicity, cigarette smoking, hypertension, diabetes mellitus, hyperlipidemia, educational attainment, body mass index, and insurance status. To estimate the impact of cocaine use on MI or stroke, we calculated the population attributable risk (PAR) percent for cocaine use with cardiovascular and all-cause mortality. We also estimated the years of life lost and total annual financial cost due to premature deaths in persons who reported regular use of cocaine. RESULTS: A total of 60 cardiovascular deaths and 384 all causes deaths were reported during a mean follow-up period of 14.7 ± 2.6 years. After adjusting for differences in potential confounders, persons who reported regular lifetime cocaine use had a significantly higher likelihood of all-cause mortality (relative risk [RR], 1.9; 95% confidence interval [CI], 1.2-3.0 for ≥100 times in lifetime) but not cardiovascular mortality (RR, 0.6; 95% CI, 0.1-4.7 for ≥100 times in lifetime). The PAR of regular cocaine use for all cause mortality among was 1.79%. The years of life lost due to regular cocaine use was 10.3 years for an adult aged 31 years. The overall yearly cost incurred due to premature deaths related to regular cocaine use was $1.1 billion. CONCLUSION: Regular cocaine use was associated with an increased risk of all cause mortality but this effect was not mediated through cardiovascular events. Behavior modification by public awareness and education may reduce the mortality and financial burden associated with cocaine use.

Should ischemic stroke patients with aphasia or high National Institutes of Health stroke scale score undergo preprocedural intubation and endovascular treatment?

BACKGROUND: Presence of aphasia or severe neurologic deficits is considered an indication for preprocedural intubation (PPI) for endovascular treatment (ET) in acute ischemic stroke patients. We determined the feasibility, technical success rates, and outcomes of ET without PPI in 2 groups of patients: those with aphasia and those with an admission NIHSS score of 20 or more. METHODS: The rates of intraprocedural intubation (IPI), good functional outcome at discharge (modified Rankin Scale score of 0-2), mortality, and intracerebral hemorrhage (ICH) were compared between those who did or did not undergo PPI in the above-mentioned patient groups. RESULTS: A total of 60 (50%) of 120 patients with aphasia underwent ET without PPI; 6 of 60 patients required IPI. The odds of any ICH (odds ratio [OR] 6.3) and in-hospital mortality (OR 9.3) were significantly higher in those undergoing PPI. In the second analysis, 36 (39%) of 93 patients with an NIHSS score of 20 or more underwent ET without PPI; 6 of 57 patients required IPI. The risk of any ICH (OR 7.6) and in-hospital mortality (OR 5.0) was higher among patients who underwent PPI. The rates of good outcome at discharge were significantly lower among patients with aphasia (OR .1, 95% confidence interval [CI] .04-.2) or those with an NIHSS score of 20 or more (OR .07, 95% CI .005-.9) with PPI compared with those without PPI. CONCLUSIONS: Despite the risk of IPI, patients with aphasia or an admission NIHSS score of 20 or more who underwent ET with PPI had lower rates of good outcomes and higher rates of ICH and death.

Eligibility determination for intravenous thrombolysis based on radiology interpretation report of the head CT scan in patients with acute ischemic stroke.

OBJECTIVE: To evaluate the variability of determining eligibility for intravenous thrombolysis (IV t-PA) by a stroke team interpretation of computed tomographic (CT) scan of the head versus review of the radiology interpretation (presented in final report) in patients with acute ischemic stroke. METHODS: We compiled a database of all IV t-PA-treated ischemic stroke patients at our academic institution based on the stroke team's CT scan interpretation. The CT scan reports of 171 patients were reviewed by an independent board-certified vascular neurologist who was blinded to clinical information except that all patients were being considered for IV t-PA to determine their eligibility for thrombolysis. The reviewer's responses were then compared with the treating team's decision to identify discrepancies, and the impact of the discrepant decisions on clinical outcome including 24-hour National Institute of Health stroke Scale (NIHSS) score and discharge modified Rankin scale (mRS), symptomatic hemorrhage (sICH), and asymptomatic hemorrhage (aICH). We compared the outcomes of patients who received IV t-PA despite cautionary neuroradiologist interpretation and placebo-treated patients from NINDS t-PA study. RESULTS: The independent reviewer decided to treat with IV t-PA 123 patients (72%) after reviewing the radiology reports. The rate of NIHSS score improvement (52.0% vs. 62.5%, P = .22) was not different between patients in whom IV t-PA should or should not have been used based on radiology reports. Favorable clinical outcome defined by mRS of 0-2 at discharge (50.4% vs. 47.9%, P = .77) and in-hospital mortality (15.6% vs. 12.5%, P = .61) were similar between the 2 groups. Favorable outcome (discharge or day 7-10 mRS 0-2) was significantly higher in patients who received t-PA compared with placebo-treated patients (48% vs. 28%, P = .006). CONCLUSION: Our study demonstrates that administering IV t-PA to patients based on the stroke team's interpretation of the CT scan versus review of the radiology interpretation does not lead to significant differences in clinical outcome, aICH, or sICH.

A critical analysis of intra-arterial thrombolytic doses in acute ischemic stroke treatment.

BACKGROUND: Intra-arterial thrombolytics (IAT) such as Alteplase, Tenecteplase, and Reteplase are currently used in patients with acute ischemic stroke in varying doses. We evaluated the relationship of IA thrombolytic dose with angiographic recanalization, intracerebral hemorrhage (ICH) rates, and clinical outcomes at three comprehensive stroke centers. METHODS: We stratified patients who underwent endovascular treatment into tertiles based on intra-arterial thrombolytic dose administered: lower tertile (range 1.5-5 mg), middle tertile (range 6-10 mg), and upper tertile (range 10.3-68.5 mg) of rt-PA equivalent. The rates of angiographic recanalization, ICH, and favorable clinical outcomes (discharge modified Rankin score [mRS] = 0-2) were ascertained and compared within the three tertiles. Logistic regression analyses were performed to determine the association between IA thrombolytic dosages and angiographic recanalization, ICH, and favorable clinical outcomes after adjusting for potential confounders. RESULTS: A total of 197 patients were treated with IAT; mean age ±SD was 65.6 ± 16 years; 105 (53.3%) were women. Ninety-one (46.2%) patients received both IVT and IAT. IA rt-PA equivalent dose was not different between the patients with and without ICH [mean (mg) ± SD, 9.8 ± 6.1 versus 9.8 ± 9.5, p = 0.9]. We did not find any relation between increasing doses of IAT (from 2 to 69 mg rt-PA equivalent) and symptomatic or asymptomatic ICH: (p = 0.1630) and (p = 0.6702), respectively. Multivariate analysis demonstrated that IAT dose was not associated with ICH (OR 1.0, 95% CI 0.97-1.07, p = 0.3919) or favorable outcome (OR, 1.00, 95% CI 0.95-1.06, p = 0.7375). In a subset analysis of IVT patients, total doses ranged from 48.2 to 149 mg and were not associated with either symptomatic (p = 0.23) or asymptomatic (p = 0.24) ICHs. CONCLUSION: Our study demonstrates that IAT in doses up to 69 mg is safe without any evidence of dose-related ICHs even in those patients who had received IVT.