Amer Malik | University of Miami (original) (raw)

Papers by Amer Malik

Interventional Neuroradiology

Background While recent studies suggest a benefit of mechanical thrombectomy (MT) for the treatme... more Background While recent studies suggest a benefit of mechanical thrombectomy (MT) for the treatment of patients with isolated large vessel occlusions presenting after 24 hours from the last known well (LKW), the effect of MT for acute cervical tandem lesions (TLs) beyond 24 hours remains unknown. We aimed to evaluate the safety and effectiveness of MT beyond 24 hours of LKW in patients with TLs. Methods We conducted a subanalysis study of patients with anterior circulation TL enrolled in a large, multicenter registry between January 2015 and December 2020. Patients were divided into 2 groups: MT beyond 24 hours versus MT 0–24-hour window. Outcomes of interest were functional independence (90-day modified Rankin scale 0-2), complete reperfusion (modified thrombolysis in cerebral infarction 3), delta NIH Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), parenchymal hematoma 2 (PH2), in-hospital mortality, and 90-day mortality. Inverse probability of treatment weighting...

Stroke: vascular and interventional neurology, Nov 1, 2021

Introduction : Stroke is a major cause of morbidity and mortality around the globe. Mechanical th... more Introduction : Stroke is a major cause of morbidity and mortality around the globe. Mechanical thrombectomy (MT) is the standard of care for patients with large vessel occlusion strokes. However, mechanical thrombectomy is associated with a number of complications. Symptomatic intracranial hemorrhage is one of the most feared complications of mechanical thrombectomy. In the pooled analysis of five trials, 4.4% of patients developed symptomatic intracranial hemorrhage. Treating physicians should have a good understanding of the potential complications of MT in order to optimize the safety and benefits of this procedure. Yet, the causes of hemorrhagic transformation are largely unknown and the predictors identified in previous studies vary. The goal of our study is to identify the rate and reliable predictors of radiological hemorrhagic transformation (RHT) and symptomatic hemorrhagic transformation (sICH) post mechanical thrombectomy in large vessel ischemic strokes. Methods : This was a retrospective analysis of consecutive large vessel occlusion acute ischemic stroke patients undergoing mechanical thrombectomy in a comprehensive stroke center (spanning 02/2015 ‐ 09/2018). Outcome measures included radiological hemorrhagic transformation (RHT) and symptomatic hemorrhagic transformation (sICH). sICH was defined as RHT with worsening of 4points in 24–36h NIHSS (ECASS II criteria) and by at least 1point (NINDS criteria).RHT was further classified according to Heidelberg‐bleeding classification as HI1, HI2, PH1, PH2, and SAH. Independent covariates predictive of RHT or symptomatic hemorrhage (sICH) were identified with multivariable logistic regression. Clinical opinion and the existing literature were used to reduce the number of variables collected at baseline to those considered potentially predictive of stroke progression. Results : Out of 341 patients who underwent thrombectomy, 32% had a radiological hemorrhagic transformation. The median age was 71. Smoking, IV tPA, longer procedure time, and lower TICI scores were associated with RHT. On a separate multivariate analysis, coronary artery disease was a separate predictor of hemorrhagic transformation. Patients with RHT had higher inpatient mortality and less mRs < 3 at discharge. Conclusions : RHT is associated with poor functional outcomes and inpatient mortality. Factors such as smoking, IV tPA, longer procedure time, and lower TICI scores were associated with RHT.

Neurology, Apr 18, 2017

Objective: To examine outcomes for thrombectomy devices used for treatment of acute ischemic stro... more Objective: To examine outcomes for thrombectomy devices used for treatment of acute ischemic stroke (AIS) with middle cerebral artery (MCA) M2 segment emergent large vessel occlusion (ELVO) as the optimal device for such reperfusion is not clearly defined. Methods: A retrospective cohort study of consecutive AIS patients with MCA M2 ELVO undergoing thrombectomy from 3 academic medical centers was conducted from October 1999 through June 2016. The patients were divided based on the device utilized. Multivariate analysis of associations between devices (stent retriever or aspiration only [manual or pump aspiration system]) was performed. Primary outcomes were good recanalization (i.e., modified thrombolysis in cerebral infarction score ≥2b) and a favorable modified Rankin scale (mRS) score (i.e. ≤2). The secondary outcome was symptomatic intracerebral hemorrhage (sICH). Results: A total of 197 AIS patients underwent MCA M2 ELVO thrombectomy with either a stent retriever (n = 120) or aspiration only (n = 77). The aspiration-only group utilized either manual (n = 38) or pump aspiration (n = 39). Utilization of a stent retriever over manual aspiration is independently associated with higher odds of a favorable mRS score (OR = 3.2; 95% CI 1.02-9.7) and lower odds of sICH (OR = 0.09; 95% CI 0.03-0.31). Utilization of a stent retriever over a pump aspiration

Stroke: Vascular and Interventional Neurology

Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acu... more Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acute ischemic stroke patients with tandem lesions (TL). However, stent placement requires the use of antiplatelet medications to prevent in‐stent thrombosis and re‐occlusion of the artery. This must be balanced with the risk of intracerebral hemorrhage. In this multicenter study, we aimed to investigate the safety and feasibility of using antiplatelet regimens in patients with anterior circulation stroke with TLs. Methods Patient level data were pooled from 17 centers and included patients with intracranial occlusion of ICA or M1/M2 segment of MCA with a concomitant extracranial ICA occlusion or stenosis ≥ 50%. Inclusion criteria were; age ≥ 18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions demonstrated on CTA and/or DSA. Patients were divided into groups according to the number of antiplatelets administered at the time of endovascular therapy (...

Stroke: vascular and interventional neurology, Mar 1, 2023

Stroke: Vascular and Interventional Neurology

Introduction There are two approaches for treating stroke patients with tandem occlusions: the an... more Introduction There are two approaches for treating stroke patients with tandem occlusions: the anterograde approach (AA, extracranial lesions first) and the retrograde approach (RA, intracranial lesion first). Both techniques are associated with favorable functional outcomes. We aimed to compare both techniques for efficacy and safety outcomes in a multicenter study. Methods Patient data were pooled from 17 centers and divided into AA and RA groups. We performed multivariable logistic regressions to evaluate the association between each group with efficacy and safety outcomes. Results 552 patients were included in the study, 270 (48.4%) were treated with the AA, and 288 (51.6%) with the RA. There were no differences between groups for functional outcome (mRS 0–2) at 90 days (aOR = 0.93, 95%CI: 0.58‐1.48, p = 0.75), and successful reperfusion [mTICI >2b] (aOR = 0.83, 95%CI: 0.44‐1.56, p = 0.57). Similarly, we did not observe any differences for safety outcomes related to sICH (OR ...

ABSTRACTBackground and PurposeWe aimed to describe the safety and efficacy of mechanical thrombec... more ABSTRACTBackground and PurposeWe aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions (TLs) and whether using intraprocedural antiplatelet therapy (APT) influences MT’s safety with IVT treatment.MethodsThis is a sub-analysis of a pooled, international multicenter cohort of patients with acute anterior circulation TLs treated with MT. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2). Additional outcomes included hemorrhagic transformation (HT), successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3), complete reperfusion (mTICI 3), favorable functional outcome (90-day modified Rankin score [mRS] 0-2), excellent functional outcome (90-day mRS 0-1), in-hospital mortality, and 90-days mortality.ResultsOf 691 patients, 599 were included (255 underwent IVT+MT and 344 MT alone). There was no difference in t...

JAMA Network Open

ImportanceApproximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions... more ImportanceApproximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear.ObjectiveTo evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs.Design, Setting, and ParticipantsThis cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) d...

Stroke, 2019

Background: Oral anticoagulant (OAC) for atrial fibrillation use remains underutilized despite ev... more Background: Oral anticoagulant (OAC) for atrial fibrillation use remains underutilized despite evidence in favor of its utility. In a three-center study examining the efficacy of a technological intervention to improve OAC use, two sites were randomly selected to incorporate an embedded alert in the electronic health record (EHR) while the third site provided usual care. At the intervention sites, the EHR calculated each patient’s CHA 2 DS 2 -VASc score and alerted the clinician when OAC therapy was recommended. We aimed to investigate whether this system increased OAC use in elderly patients. Methods: Patient medication was tracked at the time of hospitalization, discharge, and within 30 days of discharge. Patients were categorized by age and study arm to assess medication use at last known follow-up via the Chi Square and Fisher’s Exact tests. Results: The control site contained 152 patients, 65 being 75+ years of age, while the two intervention sites contained 164 patients, also ...

Stroke, 2020

Introduction: Reversible Cerebral Vasoconstriction Syndrome (RCVS) is described as reversible con... more Introduction: Reversible Cerebral Vasoconstriction Syndrome (RCVS) is described as reversible constriction of cerebral arteries, presenting with severe headaches and associated with hemorrhagic or ischemic strokes. There is a dearth of the literature on demographics and risk factors associated with intracranial hemorrhage (ICH) in patients with RCVS in the US. Methods: All patients with a primary or secondary diagnosis of RCVS in 2016 Nationwide Readmission Database (NRD) using ICD-10 code I67.841 after excluding cerebral angiitis (N=57). Unique patients were included using a unique patient identifier. Weighted discharges were used to generate national estimates. ICH was defined as both intraparenchymal and subarachnoid hemorrhage. A multivariable logistic model was used to identify ICH predictors. Results: Among total 1,152 RCVS patients, 25.7% (296) patients developed ICH. Patients with ICH mean age was (years) (Mean±SE) 47.8 ±1.2 vs. 47.0±1.1 (P=0.62), female 85.4% vs. 78.0% (P=0...

Stroke, 2017

Background: Data on medical complications following intracerebral hemorrhage (ICH) are sparse. We... more Background: Data on medical complications following intracerebral hemorrhage (ICH) are sparse. We assessed trends in the prevalence of urinary tract infection (UTI), pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism (PE), acute renal failure (ARF) and acute myocardial infarction (AMI) following ICH in the United States and evaluated their association with in-hospital mortality (IM), cost, length-of-stay (LOS) and home disposition (HD). Methods: Adults admitted to US hospitals from 2004-2013 (n=582,736) were identified from the Nationwide Inpatient Sample. Weighted complication risks were computed by sex and by mechanical ventilation (MV) status. Multivariate models were used to evaluate trends in complication and to assess their association with IM, cost, LOS, and HD. Results: Overall risks of UTI, pneumonia, sepsis, DVT, PE, ARF and AMI following ICH were 14.8%, 7.7%, 4.1%, 2.7%, 0.7%, 8.2% and 2.0% respectively. Risks differed by sex (UTI: females (F) 19.8% vs ma...

Stroke: Vascular and Interventional Neurology

Background The Society of Vascular & Interventional Neurology Guidelines and Practice Standards c... more Background The Society of Vascular & Interventional Neurology Guidelines and Practice Standards committee established the “Brief Practice Update” format to provide up‐to‐date recommendations on focused clinical topics with emerging clinical trial results. For our inaugural Brief Practice Update, we review current evidence and provide recommendations for administering intravenous thrombolysis before mechanical thrombectomy; combination therapy (mechanical thrombectomy plus intravenous thrombolysis) versus stand‐alone mechanical thrombectomy approach in acute ischemic stroke secondary to emergent large vessel occlusion. Methods The Society of Vascular & Interventional Neurology Guidelines and Practice Standards committee members formed a writing group to review results of the most recent clinical trials of pre‐mechanical thrombectomy intravenous thrombolysis. The group summarized recent clinical data to provide recommendations for clinical practice. Brief Practice Update recommendatio...

Stroke, 2020

Background: The primary aim of this study is to describe current trends in racial-, age- and sex-... more Background: The primary aim of this study is to describe current trends in racial-, age- and sex-specific incidence, clinical characteristics and burden of cerebral venous thrombosis (CVT) in the United States (US). Methods: Validated International Classification of Disease codes were used to identify all adult new cases of CVT (n=5,567) in the State Inpatients Database of New York and Florida (2006-2016) and all cases of CVT in the entire US from the National Inpatient Sample 2005-2016 (weighted n=57,315). Incident CVT counts were combined with annual US Census data to compute age and sex-specific incidence of CVT. Joinpoint regression was used to evaluate trends in incidence over time. Results: From 2005-2016, 0.47%-0.80% of all strokes in the US were CVTs but this proportion increased by 70.4% over time. Of all CVTs over this period, 66.7% were in females but this proportion declined over time (p<0.001). Pregnancy/puerperium (27.4%) and cancer (11.8%) were the most common risk...

Journal of Stroke and Cerebrovascular Diseases, 2021

BACKGROUND Large vessel occlusion (LVO) strokes can in part be prevented with better atrial fibri... more BACKGROUND Large vessel occlusion (LVO) strokes can in part be prevented with better atrial fibrillation (AF) stroke prevention strategies; thus we evaluated the rate of AF in patients presenting with acute LVO strokes undergoing mechanical thrombectomy (MT) and assessed patterns of oral anticoagulant (OAC) use prior to the index stroke. METHODS AND RESULTS We identified 347 MT cases from February 2015 to September 2018. A retrospective chart review was conducted to identify patient sociodemographics, presence of AF, use of anticoagulation, stroke severity, CHA2DS2-VASc scores, and functional outcomes. AF was present in 161 (46%) cases. Patients with AF were older (mean 76 ± 11 years vs. 66 ± 15 years) and more likely to be female (56% vs. 46%) with higher rates of hypertension, dyslipidemia, heart failure and smoking. Of the 100 patients with known AF, 59 were not on anticoagulation prior to the index stroke. Of 39 patients with known AF on OAC, 57% were not therapeutic on warfarin and 20% were not taking prescribed direct OACs. A total of 72 (21%) thrombectomy cases were performed on patients with known AF who were not effectively anticoagulated. After multivariate adjustments, there was no significant difference in modified Rankin Scale score at discharge, in-hospital mortality, or symptomatic intracranial hemorrhage between the AF and non-AF groups. CONCLUSION In our study, 21% of patients with LVO stroke had known AF and were not effectively anticoagulated. Improved stroke preventive measures could potentially reduce the occurrence of stroke and avoid unnecessary procedures for patients with AF.

Stroke, 2020

Background: A significant proportion of mechanical thrombectomies for large vessel occlusion (LVO... more Background: A significant proportion of mechanical thrombectomies for large vessel occlusion (LVO) stroke are avoidable with improved oral anticoagulant (OAC) use in patients with atrial fibrillation (AF). We sought to identify the proportion of avoidable thrombectomies in elderly patients (age ≥70) with stroke due to AF. Methods: This study included 348 consecutive MT cases at a high-volume stroke center from Feb 2015 to Sept 2018. A retrospective chart review was conducted to identify patient sociodemographics, presence of AF, use of anticoagulation, stroke severity, CHA 2 DS 2 -VASc scores, and functional outcome Results: A total of 191 (55%) patients were ≥70 years (median age 81±7, 61% female), of which 116 (61%) had AF (median age 82±6, 67% female). Elderly patients with AF were more likely to have hypertension and heart failure and be on antiplatelets and OACs. Pre-existing AF was present in 75 (39%) patients, of which 38 (49%) were not on OACs prior to stroke. Of the 39 (51%...

Interventional Neuroradiology

Background While recent studies suggest a benefit of mechanical thrombectomy (MT) for the treatme... more Background While recent studies suggest a benefit of mechanical thrombectomy (MT) for the treatment of patients with isolated large vessel occlusions presenting after 24 hours from the last known well (LKW), the effect of MT for acute cervical tandem lesions (TLs) beyond 24 hours remains unknown. We aimed to evaluate the safety and effectiveness of MT beyond 24 hours of LKW in patients with TLs. Methods We conducted a subanalysis study of patients with anterior circulation TL enrolled in a large, multicenter registry between January 2015 and December 2020. Patients were divided into 2 groups: MT beyond 24 hours versus MT 0–24-hour window. Outcomes of interest were functional independence (90-day modified Rankin scale 0-2), complete reperfusion (modified thrombolysis in cerebral infarction 3), delta NIH Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), parenchymal hematoma 2 (PH2), in-hospital mortality, and 90-day mortality. Inverse probability of treatment weighting...

Stroke: vascular and interventional neurology, Nov 1, 2021

Introduction : Stroke is a major cause of morbidity and mortality around the globe. Mechanical th... more Introduction : Stroke is a major cause of morbidity and mortality around the globe. Mechanical thrombectomy (MT) is the standard of care for patients with large vessel occlusion strokes. However, mechanical thrombectomy is associated with a number of complications. Symptomatic intracranial hemorrhage is one of the most feared complications of mechanical thrombectomy. In the pooled analysis of five trials, 4.4% of patients developed symptomatic intracranial hemorrhage. Treating physicians should have a good understanding of the potential complications of MT in order to optimize the safety and benefits of this procedure. Yet, the causes of hemorrhagic transformation are largely unknown and the predictors identified in previous studies vary. The goal of our study is to identify the rate and reliable predictors of radiological hemorrhagic transformation (RHT) and symptomatic hemorrhagic transformation (sICH) post mechanical thrombectomy in large vessel ischemic strokes. Methods : This was a retrospective analysis of consecutive large vessel occlusion acute ischemic stroke patients undergoing mechanical thrombectomy in a comprehensive stroke center (spanning 02/2015 ‐ 09/2018). Outcome measures included radiological hemorrhagic transformation (RHT) and symptomatic hemorrhagic transformation (sICH). sICH was defined as RHT with worsening of 4points in 24–36h NIHSS (ECASS II criteria) and by at least 1point (NINDS criteria).RHT was further classified according to Heidelberg‐bleeding classification as HI1, HI2, PH1, PH2, and SAH. Independent covariates predictive of RHT or symptomatic hemorrhage (sICH) were identified with multivariable logistic regression. Clinical opinion and the existing literature were used to reduce the number of variables collected at baseline to those considered potentially predictive of stroke progression. Results : Out of 341 patients who underwent thrombectomy, 32% had a radiological hemorrhagic transformation. The median age was 71. Smoking, IV tPA, longer procedure time, and lower TICI scores were associated with RHT. On a separate multivariate analysis, coronary artery disease was a separate predictor of hemorrhagic transformation. Patients with RHT had higher inpatient mortality and less mRs &lt; 3 at discharge. Conclusions : RHT is associated with poor functional outcomes and inpatient mortality. Factors such as smoking, IV tPA, longer procedure time, and lower TICI scores were associated with RHT.

Neurology, Apr 18, 2017

Objective: To examine outcomes for thrombectomy devices used for treatment of acute ischemic stro... more Objective: To examine outcomes for thrombectomy devices used for treatment of acute ischemic stroke (AIS) with middle cerebral artery (MCA) M2 segment emergent large vessel occlusion (ELVO) as the optimal device for such reperfusion is not clearly defined. Methods: A retrospective cohort study of consecutive AIS patients with MCA M2 ELVO undergoing thrombectomy from 3 academic medical centers was conducted from October 1999 through June 2016. The patients were divided based on the device utilized. Multivariate analysis of associations between devices (stent retriever or aspiration only [manual or pump aspiration system]) was performed. Primary outcomes were good recanalization (i.e., modified thrombolysis in cerebral infarction score ≥2b) and a favorable modified Rankin scale (mRS) score (i.e. ≤2). The secondary outcome was symptomatic intracerebral hemorrhage (sICH). Results: A total of 197 AIS patients underwent MCA M2 ELVO thrombectomy with either a stent retriever (n = 120) or aspiration only (n = 77). The aspiration-only group utilized either manual (n = 38) or pump aspiration (n = 39). Utilization of a stent retriever over manual aspiration is independently associated with higher odds of a favorable mRS score (OR = 3.2; 95% CI 1.02-9.7) and lower odds of sICH (OR = 0.09; 95% CI 0.03-0.31). Utilization of a stent retriever over a pump aspiration

Stroke: Vascular and Interventional Neurology

Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acu... more Introduction Recent studies have shown beneficial effects of Carotid artery stenting (CAS) in acute ischemic stroke patients with tandem lesions (TL). However, stent placement requires the use of antiplatelet medications to prevent in‐stent thrombosis and re‐occlusion of the artery. This must be balanced with the risk of intracerebral hemorrhage. In this multicenter study, we aimed to investigate the safety and feasibility of using antiplatelet regimens in patients with anterior circulation stroke with TLs. Methods Patient level data were pooled from 17 centers and included patients with intracranial occlusion of ICA or M1/M2 segment of MCA with a concomitant extracranial ICA occlusion or stenosis ≥ 50%. Inclusion criteria were; age ≥ 18 years, EVT for intracranial occlusion, and underwent treatment for extracranial ICA lesions demonstrated on CTA and/or DSA. Patients were divided into groups according to the number of antiplatelets administered at the time of endovascular therapy (...

Stroke: vascular and interventional neurology, Mar 1, 2023

Stroke: Vascular and Interventional Neurology

Introduction There are two approaches for treating stroke patients with tandem occlusions: the an... more Introduction There are two approaches for treating stroke patients with tandem occlusions: the anterograde approach (AA, extracranial lesions first) and the retrograde approach (RA, intracranial lesion first). Both techniques are associated with favorable functional outcomes. We aimed to compare both techniques for efficacy and safety outcomes in a multicenter study. Methods Patient data were pooled from 17 centers and divided into AA and RA groups. We performed multivariable logistic regressions to evaluate the association between each group with efficacy and safety outcomes. Results 552 patients were included in the study, 270 (48.4%) were treated with the AA, and 288 (51.6%) with the RA. There were no differences between groups for functional outcome (mRS 0–2) at 90 days (aOR = 0.93, 95%CI: 0.58‐1.48, p = 0.75), and successful reperfusion [mTICI >2b] (aOR = 0.83, 95%CI: 0.44‐1.56, p = 0.57). Similarly, we did not observe any differences for safety outcomes related to sICH (OR ...

ABSTRACTBackground and PurposeWe aimed to describe the safety and efficacy of mechanical thrombec... more ABSTRACTBackground and PurposeWe aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions (TLs) and whether using intraprocedural antiplatelet therapy (APT) influences MT’s safety with IVT treatment.MethodsThis is a sub-analysis of a pooled, international multicenter cohort of patients with acute anterior circulation TLs treated with MT. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2). Additional outcomes included hemorrhagic transformation (HT), successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 2b-3), complete reperfusion (mTICI 3), favorable functional outcome (90-day modified Rankin score [mRS] 0-2), excellent functional outcome (90-day mRS 0-1), in-hospital mortality, and 90-days mortality.ResultsOf 691 patients, 599 were included (255 underwent IVT+MT and 344 MT alone). There was no difference in t...

JAMA Network Open

ImportanceApproximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions... more ImportanceApproximately 10% to 20% of large vessel occlusion (LVO) strokes involve tandem lesions (TLs), defined as concomitant intracranial LVO and stenosis or occlusion of the cervical internal carotid artery. Mechanical thrombectomy (MT) may benefit patients with TLs; however, optimal management and procedural strategy of the cervical lesion remain unclear.ObjectiveTo evaluate the association of carotid artery stenting (CAS) vs no stenting and medical management with functional and safety outcomes among patients with TL-LVOs.Design, Setting, and ParticipantsThis cross-sectional study included consecutive patients with acute anterior circulation TLs admitted across 17 stroke centers in the US and Spain between January 1, 2015, and December 31, 2020. Data analysis was performed from August 2021 to February 2022. Inclusion criteria were age of 18 years or older, endovascular therapy for intracranial occlusion, and presence of extracranial internal carotid artery stenosis (>50%) d...

Stroke, 2019

Background: Oral anticoagulant (OAC) for atrial fibrillation use remains underutilized despite ev... more Background: Oral anticoagulant (OAC) for atrial fibrillation use remains underutilized despite evidence in favor of its utility. In a three-center study examining the efficacy of a technological intervention to improve OAC use, two sites were randomly selected to incorporate an embedded alert in the electronic health record (EHR) while the third site provided usual care. At the intervention sites, the EHR calculated each patient’s CHA 2 DS 2 -VASc score and alerted the clinician when OAC therapy was recommended. We aimed to investigate whether this system increased OAC use in elderly patients. Methods: Patient medication was tracked at the time of hospitalization, discharge, and within 30 days of discharge. Patients were categorized by age and study arm to assess medication use at last known follow-up via the Chi Square and Fisher’s Exact tests. Results: The control site contained 152 patients, 65 being 75+ years of age, while the two intervention sites contained 164 patients, also ...

Stroke, 2020

Introduction: Reversible Cerebral Vasoconstriction Syndrome (RCVS) is described as reversible con... more Introduction: Reversible Cerebral Vasoconstriction Syndrome (RCVS) is described as reversible constriction of cerebral arteries, presenting with severe headaches and associated with hemorrhagic or ischemic strokes. There is a dearth of the literature on demographics and risk factors associated with intracranial hemorrhage (ICH) in patients with RCVS in the US. Methods: All patients with a primary or secondary diagnosis of RCVS in 2016 Nationwide Readmission Database (NRD) using ICD-10 code I67.841 after excluding cerebral angiitis (N=57). Unique patients were included using a unique patient identifier. Weighted discharges were used to generate national estimates. ICH was defined as both intraparenchymal and subarachnoid hemorrhage. A multivariable logistic model was used to identify ICH predictors. Results: Among total 1,152 RCVS patients, 25.7% (296) patients developed ICH. Patients with ICH mean age was (years) (Mean±SE) 47.8 ±1.2 vs. 47.0±1.1 (P=0.62), female 85.4% vs. 78.0% (P=0...

Stroke, 2017

Background: Data on medical complications following intracerebral hemorrhage (ICH) are sparse. We... more Background: Data on medical complications following intracerebral hemorrhage (ICH) are sparse. We assessed trends in the prevalence of urinary tract infection (UTI), pneumonia, sepsis, deep venous thrombosis (DVT), pulmonary embolism (PE), acute renal failure (ARF) and acute myocardial infarction (AMI) following ICH in the United States and evaluated their association with in-hospital mortality (IM), cost, length-of-stay (LOS) and home disposition (HD). Methods: Adults admitted to US hospitals from 2004-2013 (n=582,736) were identified from the Nationwide Inpatient Sample. Weighted complication risks were computed by sex and by mechanical ventilation (MV) status. Multivariate models were used to evaluate trends in complication and to assess their association with IM, cost, LOS, and HD. Results: Overall risks of UTI, pneumonia, sepsis, DVT, PE, ARF and AMI following ICH were 14.8%, 7.7%, 4.1%, 2.7%, 0.7%, 8.2% and 2.0% respectively. Risks differed by sex (UTI: females (F) 19.8% vs ma...

Stroke: Vascular and Interventional Neurology

Background The Society of Vascular & Interventional Neurology Guidelines and Practice Standards c... more Background The Society of Vascular & Interventional Neurology Guidelines and Practice Standards committee established the “Brief Practice Update” format to provide up‐to‐date recommendations on focused clinical topics with emerging clinical trial results. For our inaugural Brief Practice Update, we review current evidence and provide recommendations for administering intravenous thrombolysis before mechanical thrombectomy; combination therapy (mechanical thrombectomy plus intravenous thrombolysis) versus stand‐alone mechanical thrombectomy approach in acute ischemic stroke secondary to emergent large vessel occlusion. Methods The Society of Vascular & Interventional Neurology Guidelines and Practice Standards committee members formed a writing group to review results of the most recent clinical trials of pre‐mechanical thrombectomy intravenous thrombolysis. The group summarized recent clinical data to provide recommendations for clinical practice. Brief Practice Update recommendatio...

Stroke, 2020

Background: The primary aim of this study is to describe current trends in racial-, age- and sex-... more Background: The primary aim of this study is to describe current trends in racial-, age- and sex-specific incidence, clinical characteristics and burden of cerebral venous thrombosis (CVT) in the United States (US). Methods: Validated International Classification of Disease codes were used to identify all adult new cases of CVT (n=5,567) in the State Inpatients Database of New York and Florida (2006-2016) and all cases of CVT in the entire US from the National Inpatient Sample 2005-2016 (weighted n=57,315). Incident CVT counts were combined with annual US Census data to compute age and sex-specific incidence of CVT. Joinpoint regression was used to evaluate trends in incidence over time. Results: From 2005-2016, 0.47%-0.80% of all strokes in the US were CVTs but this proportion increased by 70.4% over time. Of all CVTs over this period, 66.7% were in females but this proportion declined over time (p<0.001). Pregnancy/puerperium (27.4%) and cancer (11.8%) were the most common risk...

Journal of Stroke and Cerebrovascular Diseases, 2021

BACKGROUND Large vessel occlusion (LVO) strokes can in part be prevented with better atrial fibri... more BACKGROUND Large vessel occlusion (LVO) strokes can in part be prevented with better atrial fibrillation (AF) stroke prevention strategies; thus we evaluated the rate of AF in patients presenting with acute LVO strokes undergoing mechanical thrombectomy (MT) and assessed patterns of oral anticoagulant (OAC) use prior to the index stroke. METHODS AND RESULTS We identified 347 MT cases from February 2015 to September 2018. A retrospective chart review was conducted to identify patient sociodemographics, presence of AF, use of anticoagulation, stroke severity, CHA2DS2-VASc scores, and functional outcomes. AF was present in 161 (46%) cases. Patients with AF were older (mean 76 ± 11 years vs. 66 ± 15 years) and more likely to be female (56% vs. 46%) with higher rates of hypertension, dyslipidemia, heart failure and smoking. Of the 100 patients with known AF, 59 were not on anticoagulation prior to the index stroke. Of 39 patients with known AF on OAC, 57% were not therapeutic on warfarin and 20% were not taking prescribed direct OACs. A total of 72 (21%) thrombectomy cases were performed on patients with known AF who were not effectively anticoagulated. After multivariate adjustments, there was no significant difference in modified Rankin Scale score at discharge, in-hospital mortality, or symptomatic intracranial hemorrhage between the AF and non-AF groups. CONCLUSION In our study, 21% of patients with LVO stroke had known AF and were not effectively anticoagulated. Improved stroke preventive measures could potentially reduce the occurrence of stroke and avoid unnecessary procedures for patients with AF.

Stroke, 2020

Background: A significant proportion of mechanical thrombectomies for large vessel occlusion (LVO... more Background: A significant proportion of mechanical thrombectomies for large vessel occlusion (LVO) stroke are avoidable with improved oral anticoagulant (OAC) use in patients with atrial fibrillation (AF). We sought to identify the proportion of avoidable thrombectomies in elderly patients (age ≥70) with stroke due to AF. Methods: This study included 348 consecutive MT cases at a high-volume stroke center from Feb 2015 to Sept 2018. A retrospective chart review was conducted to identify patient sociodemographics, presence of AF, use of anticoagulation, stroke severity, CHA 2 DS 2 -VASc scores, and functional outcome Results: A total of 191 (55%) patients were ≥70 years (median age 81±7, 61% female), of which 116 (61%) had AF (median age 82±6, 67% female). Elderly patients with AF were more likely to have hypertension and heart failure and be on antiplatelets and OACs. Pre-existing AF was present in 75 (39%) patients, of which 38 (49%) were not on OACs prior to stroke. Of the 39 (51%...