Mohamed Elfil | University of Nebraska Medical Center (original) (raw)

Papers by Mohamed Elfil

Interventional Neuroradiology, Oct 26, 2022

Background Mechanical thrombectomy (MT) is the standard treatment for acute large vessel occlusio... more Background Mechanical thrombectomy (MT) is the standard treatment for acute large vessel occlusion (LVO). Recurrent LVO can still occur in patients who already underwent MT for the first LVO. This study aimed to evaluate the efficacy of repeating MT for recurrent LVO. Methods This meta-analysis of the available literature was conducted to summarize the current evidence regarding repeated MT outcomes in patients with recurrent LVO. All studies with ≥ 1 outcomes of interest were included. The Newcastle-Ottawa Scale (NOS) was used for risk of bias assessment. Results Twenty studies, 10 observational (n = 21,251 patients) and 10 case reports (n = 10 patients), were included. 266 patients (62.78% females) with recurrent LVO were identified, with an overall prevalence of 1.6% and a mean age of 65.67 ± 16.23 years. Cardio-embolism was the most common mechanism in both times, with a median of 15 days between the first and second LVOs. Compared with pre-intervention, the first and second MTs significantly reduced the National Institute of Health Stroke Scale (NIHSS) score, (mean difference (MD) = −8.91) and (MD = −5.97) respectively, with a significant difference (p = 0.001). The rate of favorable outcome (modified Rankin scale (mRS) score 0–3) was 82.6% and 59.2% after the first and second MTs respectively, with a significant difference (p < 0.001). Conclusion In properly selected recurrent LVO patients, repeated MT is efficacious and safe. A prior MT procedure should not discourage aggressive treatment as many patients may achieve favorable outcomes.

Stroke: vascular and interventional neurology, Mar 1, 2023

Introduction Previous studies have compared the transradial access (TRA) with the transfemoral ac... more Introduction Previous studies have compared the transradial access (TRA) with the transfemoral access (TFA) in patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We conducted this meta‐analysis to provide comprehensive evidence regarding the comparison of procedural and clinical outcomes of the TRA versus the TFA in AIS patients undergoing MT. Methods We performed a comprehensive literature search of four electronic databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL) from inception until 1 May 2022. All duplicates were removed, and all references of the included studies were screened manually for any eligible studies. The full‐text articles of eligible abstracts were retrieved and screened for continued eligibility. Relevant data were extracted and then analyzed. For outcomes that constitute continuous data, the mean difference (MD) between the two groups and its standard deviation (SD) were pooled. For outcomes that constitute dichotomous data, the frequency of events and the total number of patients in each group were pooled as odds ratio (OR) between the two groups. Results Nine studies were included in this meta‐analysis, all of which were observational studies. The population of the studies was homogenous comprising a total of 2,161 patients who underwent MT, including 446 in the TRA group and 1,715 in the TFA group. There were no significant differences across the two groups in terms of successful recanalization (Thrombolysis in cerebral Infarction [TICI] score of 2b‐3: OR 0.83, 95% CI [0.55 to 1.25], P = 0.36) (Figure 1, A), complete recanalization (TICI 3: OR 1.16, 95% CI [0.50 to 2.68], P = 0.73), favorable functional outcome (90‐day modified Rankin scale [mRS] score of 0–2 (OR 0.86, 95% CI [0.53 to 1.41], P = 0.56), first‐pass reperfusion (OR 0.88, 95% CI [0.64 to 1.19], P = 0.41), number of passes (MD 0.12, 95% CI [‐0.18 to 0.42], P = 0.43) (Figure 1, B), access‐to‐reperfusion time (MD ‐3.92 minutes, 95% CI [‐9.49 to 1.65], P = 0.17), the amount of contrast used (MD 5.03 mL, 95% CI [‐20.27 to 30.33], P = 0.70), or symptomatic intracranial hemorrhage (OR 0.86, 95% CI [0.47 to 1.57], P = 0.62). However, access‐site complications were significantly less frequent in the TRA group as compared to the TFA group (OR 0.18, 95% CI [0.06 to 0.51], P = 0.001) (Finger 1, C). Conclusions In patients undergoing MT for AIS, the collective evidence suggests that the TRA seems to result in lower rates of access‐site complications than the TFA without any significant compromise in other clinical or procedural metrics. Large prospective studies are warranted.

Interventional Neuroradiology, Nov 16, 2022

Background The Contour is a new generation intrasaccular flow disruption tool that aims to cover ... more Background The Contour is a new generation intrasaccular flow disruption tool that aims to cover the aneurysm neck and is sized according to the neck diameter. While several case series have been published, no literature review has been performed on this promising device. Objective To assess the safety and effectiveness profile of the Contour Neurovascular System for wide-necked aneurysms. Methods We followed the recommendations of the PRISMA checklist Four databases were searched with a supplemental manual search. All data were analyzed using R software version 4.2.1. Results We finally included six studies with 131 treated aneurysms. The overall procedural time was 97.27 (95% CI = 70.07–124.47) minutes, ranging from 78.9 to 136.0 min. The pooled adequate occlusion rate was 84.21% (95% CI = 75.45–90.25), and the overall functional independence rate was 94.74% (87.97–97.79). The overall adverse event rate was 4.70 (95% CI = 3.24–6.76), varying among different events from 0.78 to 8.53%. Thromboembolic events were the most commonly encountered in 8.53% of the patients (95% CI = 4.78–14.74), followed by headache and minor stroke with incidence rates of 5.88 (95% CI = 2.83–11.83) and 4.35 (95% CI = 1.41–12.63), respectively. The overall procedural time in studies using the Contour system only was 86.17 (95% CI = 68.70–10.64) minutes, while it was 136 (95% CI = 90.96–181.04) in the Contour-assisted coiling procedures. However, both techniques were comparable regarding adequate occlusion rates and functional independence. Conclusion With the anticipation of future studies, the Contour Neurovascular System is a safe and effective treatment option for wide-necked intracranial aneurysms.

Journal of stroke, May 31, 2023

Background and Purpose New studies have shown that endovascular thrombectomy (EVT) is safe and ef... more Background and Purpose New studies have shown that endovascular thrombectomy (EVT) is safe and effective for acute ischemic stroke (AIS) patients with large ischemic areas. The aim of our study is to conduct a living systematic review and meta-analysis of randomized trials comparing EVT versus medical management only. Methods We searched MEDLINE, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT versus medical management alone in AIS patients with large ischemic regions. We conducted our meta-analysis using fixed-effect models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH) between EVT and standard medical management only. We assessed the risk of bias using the Cochrane risk-ofbias tool and the certainty of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Results Of 14,513 citations, we included 3 RCTs with a total of 1,010 participants. We found lowcertainty evidence of possibly a large increase in the proportion of patients with functional independence (risk difference [RD] 30.3%, 95% CI 15.0% to 52.3%), low-certainty evidence of possibly a small non-significant decrease in mortality (RD-0.7%, 95% CI-3.8% to 3.5%), and low-certainty evidence of possibly a small non-significant increase in sICH (RD 3.1%, 95% CI-0.3% to 9.8%) for AIS patients with large infarcts who underwent EVT compared to medical management only. Conclusion Low-certainty evidence shows that there is possibly a large increase in functional independence, a small non-significant decrease in mortality, and a small non-significant increase in sICH amongst AIS patients with large infarcts undergoing EVT compared to medical management only.

DOAJ (DOAJ: Directory of Open Access Journals), Apr 1, 2016

Multiple diagnostic tools are used by emergency physicians,every day. In addition, new tools are ... more Multiple diagnostic tools are used by emergency physicians,every day. In addition, new tools are evaluated to obtainmore accurate methods and reduce time or cost of conventionalones. In the previous parts of this educationalseries, we described diagnostic performance characteristicsof diagnostic tests including sensitivity, specificity, positiveand negative predictive values, and likelihood ratios. Thereceiver operating characteristics (ROC) curve is a graphicalpresentation of screening characteristics. ROC curve is usedto determine the best cutoff point and compare two or moretests or observers by measuring the area under the curve(AUC). In this part of our educational series, we explain ROCcurve and two methods to determine the best cutoff value.

DOAJ (DOAJ: Directory of Open Access Journals), Jul 1, 2015

Oxford Medical Case Reports, 2023

As COVID-19 vaccines became widely available, there have been reports of neurovascular complicati... more As COVID-19 vaccines became widely available, there have been reports of neurovascular complications. In this article, we aim to report a case of cerebral venous sinus thrombosis (CVST) induced by COVID-19 vaccination, with a literature review on similar cases as well as the potential pathophysiological mechanisms. Our case is a healthy male who developed headache, vomiting, photophobia and diplopia after receiving the Ad26.COV2.S vaccine. Fundus examination showed papilledema, and magnetic resonance imaging of the brain and cerebral veins showed CVST involving the superior sagittal sinus and right transverse sinus extending into the right jugular vein. Hypercoagulability workup was unremarkable, and the patient received immunotherapy and anticoagulation. Following this treatment, symptoms resolved, and he had no residual neurologic deficits. Developing neurologic manifestations, especially severe headaches with papilledema, after COVID-19 vaccination should warrant neuroimaging. Early recognition and management of CVST are essential for good clinical outcomes.

Stroke: vascular and interventional neurology, Jul 1, 2023

Background In patients undergoing mechanical thrombectomy for acute ischemic stroke, a few studie... more Background In patients undergoing mechanical thrombectomy for acute ischemic stroke, a few studies have compared transradial access (TRA) to transfemoral access (TFA) with inconsistent results. We conducted this systematic review and meta‐analysis to provide comprehensive evidence regarding the comparison of procedural and clinical outcomes of TRA versus TFA in patients with acute ischemic stroke undergoing mechanical thrombectomy. Methods We performed a comprehensive literature search of 4 electronic databases from inception until May 1, 2022. After title and full text screening, relevant data were extracted and then analyzed. For outcomes that constituted continuous data, the mean difference between the 2 groups and its SD were pooled. For outcomes that constituted dichotomous data, the frequency of events and the total number of patients in each group were pooled as odds ratio (OR) between the 2 groups. Results Nine observational studies were included in this meta‐analysis. The population of the studies was homogenous comprising a total of 2161 patients undergoing mechanical thrombectomy, including 446 patients via TRA and 1715 patients via TFA. There were no significant differences across the 2 groups in terms of successful recanalization (OR, 0.83 [95% CI, 0.55–1.25]; P =0.36), complete recanalization (OR 1.16 [95% CI, 0.50–2.68]; P =0.73), favorable functional outcomes (OR, 0.86 [95% CI, 0.53–1.41]; P =0.56), first‐pass reperfusion (OR, 0.88 [95% CI, 0.64–1.19]; P =0.41), number of passes (mean difference, 0.12 [95% CI, −0.18 to 0.42]; P =0.43), access‐to‐reperfusion time (mean difference, −3.92 minutes [95% CI, −9.49 to 1.65]; P =0.17), or symptomatic intracranial hemorrhage (OR, 0.86 [95% CI, 0.47–1.57]; P =0.62). However, access site complications were significantly less frequent in the TRA group as compared with the TFA group (OR, 0.18 [95% CI, 0.06–0.51; P =0.001). Conclusion In patients undergoing mechanical thrombectomy for acute ischemic stroke, the collective evidence suggests that TRA seems to result in lower rates of access site complications than TFA without significant compromise in other clinical or procedural metrics. Randomized or prospective studies are warranted to confirm these results.

DOAJ (DOAJ: Directory of Open Access Journals), Dec 1, 2018

Sleep, Apr 1, 2020

Introduction: Dopamine agonists (DAs) have been first-line therapy for restless legs syndrome (RL... more Introduction: Dopamine agonists (DAs) have been first-line therapy for restless legs syndrome (RLS) for 30 years. Long-term DA use is associated with augmentation, a dose-related iatrogenic worsening of RLS, which results in a vicious cycle of escalating DA dosing to manage worsening symptoms. The objective of this study was to investigate rates of high-dose DA prescribing in patients with RLS nationally. Methods: Patients with a diagnosis of RLS (ICD-10 G255.81), and no diagnosis of Parkinson's disease, treated with rotigotine, pramipexole, and ropinirole, alone or in combination for >180 days, were identified from National Prescription Audit database from October 2017-September 2018. Daily total dosage was grouped into low (FDA-approved) and high (above FDA-approved) dose ranges, respectively (rotigotine: >0-≤3mg/>3mg; pramipexole: >0-≤0.75mg/>0.75mg; ropinirole: >0-≤4mg/>4mg). When DAs were used in combination with each other, dose-equivalent algorithms were used (rotigotine/ropinirole/pramipexole, 1:1:4). Results: Prescriptions for 244,423 patients meeting inclusion criteria were sampled, constituting 71,181,466 therapy days. For all patients on DA therapy for RLS, 23.5% (57,552/244,423) were prescribed higher than FDA-recommended doses. For patients on DA monotherapy, high-dose prescriptions were provided to 42.7% (819/1919) on rotigotine, 40.7% (38,342/94,275) on pramipexole, and 11.5% (16,900/146,355) on ropinirole. Nearly one-quarter (23.2%) of all pramipexole monotherapy prescriptions were for very high dosages (>1.25 mg). For patients on DA combination therapy, high-dose prescriptions were provided to 79.6% (1,491/1,874). Conclusion: Roughly 25% of RLS patients treated with DAs were prescribed doses above FDA and expert guideline-recommended maximum doses. Patients on DA combination therapy had substantially higher rates of cumulative high-dose prescriptions. High-dosage DA use is likely due to dose escalation in response to augmentation, risking further augmentation and adverse events such as impulse control disorders. Prescriber education on risks of high-dose DA prescribing for RLS is important.

Interventional Neuroradiology

Background Procedural success following mechanical thrombectomy for acute ischemic stroke is asse... more Background Procedural success following mechanical thrombectomy for acute ischemic stroke is assessed using the thrombolysis in cerebral infarction scale. We conducted a systematic review and meta-analysis to determine whether outcomes differed between first pass thrombolysis in cerebral infarction 2b and multiple pass thrombolysis in cerebral infarction 2c-3. Methods We conducted a systematic review of the literature using PubMed, Embase, Scopus, and Web of Science. We included original studies in which outcomes were stratified based on first pass thrombolysis in cerebral infarction 2b and multiple pass thrombolysis in cerebral infarction 2c-3. The primary outcome of interest was the rate of modified Rankin Scale 0-2. Secondary outcomes of interest were rates of modified Rankin Scale 0-1, symptomatic intracranial hemorrhage, and mortality. We calculated odds ratios and corresponding 95% confidence intervals. Results Four studies with 1554 patients were included in the quantitative ...

Interventional Neuroradiology

Background The Contour is a new generation intrasaccular flow disruption tool that aims to cover ... more Background The Contour is a new generation intrasaccular flow disruption tool that aims to cover the aneurysm neck and is sized according to the neck diameter. While several case series have been published, no literature review has been performed on this promising device. Objective To assess the safety and effectiveness profile of the Contour Neurovascular System for wide-necked aneurysms. Methods We followed the recommendations of the PRISMA checklist Four databases were searched with a supplemental manual search. All data were analyzed using R software version 4.2.1. Results We finally included six studies with 131 treated aneurysms. The overall procedural time was 97.27 (95% CI = 70.07–124.47) minutes, ranging from 78.9 to 136.0 min. The pooled adequate occlusion rate was 84.21% (95% CI = 75.45–90.25), and the overall functional independence rate was 94.74% (87.97–97.79). The overall adverse event rate was 4.70 (95% CI = 3.24–6.76), varying among different events from 0.78 to 8.5...

Journal of Stroke and Cerebrovascular Diseases

Stroke: Vascular and Interventional Neurology

Introduction For more than three decades, robotic assisted surgery has been proposed, studied and... more Introduction For more than three decades, robotic assisted surgery has been proposed, studied and put into action clinically. Likewise, it was cleared by the Food and Drug Administration for percutaneous coronary intervention in 2012 (K120834) and peripheral vascular intervention including carotid intervention in 2018 (K173288), but has not yet received clearance for intracranial neurovascular intervention in the USA. Recently, several pilot clinical studies assessed robotically performed neurointerventions. Methods We performed comprehensive electronic search till July 2022 on PubMed/Medline to retrieve all relevant studies and data were extracted for baseline characteristics, design, procedure type, safety and feasibility outcomes for qualitative synthesis. Results Our results yielded nine single center studies in UK, USA and China performed since 2015. The performed procedures included diagnostic cerebral angiography (36 patients), caroti aartery stenting (37 patients), unspecifi...

Stroke: Vascular and Interventional Neurology

Introduction Cerebral Autosomal Dominant Arteriopathy with subcortical Infarcts and leuko‐encepha... more Introduction Cerebral Autosomal Dominant Arteriopathy with subcortical Infarcts and leuko‐encephalopathy (CADASIL) is a genetic condition characterized by migraine, ischemic strokes, mood disturbances, and cognitive impairment. Since COVID‐19 pandemic started in late 2019, six patients (including our case) were reported to present with neurological symptoms associated with CADASIL mutation and four of them were diagnosed while hospitalized for COVID‐19 illness. Methods A case report anda systematic literature review done via PubMed search that was performed up to Oct 15, 2022. Studies reporting on CADASIL and COVID‐19 infection were included. Results In addition to our case report, 5 case‐reports were identified, and full articles were reviewed and summarized. Including our case, the mean age of patients was 45.44 years, and all of them were females. The diagnosis of CADASIL was established after COVID‐19 infection in four of the cases including ours, while the diagnosis of CADASIL ...

Stroke: Vascular and Interventional Neurology

Introduction Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is known to be ... more Introduction Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is known to be associated with high rates of mortality and lifelong disability. In the past few years, two clinical trials (the BEST and the BASICS trials) investigated the benefits and safety of mechanical thrombectomy (MT) for BAO and did not provide evidence to support the efficacy of MT in BAO patients. Given the recent positive results from the ATTENTION and the BAOCHE clinical trials, we conducted this meta‐analysis to provide updated collective evidence regarding the benefits of MT in patients with BAO. Methods We searched for eligible papers till June 1st, 2021, in five databases: PubMed, Web of Science, Scopus, and Embase databases using keywords and/or medical subject (MeSH) terms. We included all randomized controlled trials (RCTs) with no restrictions on publication date, data, or language of the included studies to avoid missing any relevant papers. All data were analyzed using R software....

Stroke: Vascular and Interventional Neurology

Introduction In certain circumstances, mobile stroke units (MSU) with on‐site treatment teams and... more Introduction In certain circumstances, mobile stroke units (MSU) with on‐site treatment teams and a computed tomography scanner may offer faster therapy with tissue plasminogen activator (tPA) for stroke patients who need immediate treatment. We conducted a systematic review and meta‐analysis to compare clinical outcomes in MSU patients to those in conventional care. Methods We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 days and 90 days. The secondary outcomes included modified Rankin scale (mRS) at 90 days, alarm to intravenous thrombolysis (IVT) or intra‐arterial recanalization, and time from symptom onset or last known well (LKW) to thrombolysis. Results We included nineteen controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90‐day mortality rate significantly declined in MSU group as compared to conventional care group (OR = 0.81, 95%CI [0.69,0.95]), while there was ...

Interventional Neuroradiology

Background Funding may impact the quality and findings of systematic reviews (SRs). We aimed to c... more Background Funding may impact the quality and findings of systematic reviews (SRs). We aimed to compare the methodological quality of funded and non-funded SRs that investigated the outcomes in ischemic stroke patients undergoing mechanical thrombectomy. Methods We conducted a comprehensive search strategy in different databases, including Ovid Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid Medline (including epub ahead of print, in-process & other non-indexed citations), PubMed, Scopus and Web of Science Core Collection to retrieve all relevant SRs. Random sequence generation matched each funded SR with a non-funded one. A Measurement Tool to Assess Systematic Reviews (AMSTAR)-2 tool was used to assess the bias and quality of the included SRs. We also used uni- and multivariate analysis to perform our analysis, and results were expressed in odds ratio (OR) and 95% confidence interval (CI). Results We retrieved 150 articles, which were randomized and matched into ...

Stroke

Introduction: Mechanical thrombectomy (MT) is the gold standard for large vessel occlusion (LVO) ... more Introduction: Mechanical thrombectomy (MT) is the gold standard for large vessel occlusion (LVO) strokes. The current guidelines state that LVO patients who are eligible for intravenous thrombolysis (IVT) and MT should receive both treatments. However, a few trials investigated the benefits and safety of combining MT with IVT. We conducted this meta-analysis to provide collective evidence on the efficacy and safety of IVT+MT, and to estimate the risk of complications of this approach as compared to MT alone. Methods: We performed a comprehensive literature search of 4 databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL). For outcomes with continuous data, the mean difference (MD) between both groups from the baseline to the endpoint, with its standard deviation (SD), were pooled in the DerSimonian-Laird (DL) random-effect model. For studies reporting data in multiple time points, we considered the last endpoint for the primary analysis. For outcomes with dichotomous data, th...

Interventional Neuroradiology, Oct 26, 2022

Background Mechanical thrombectomy (MT) is the standard treatment for acute large vessel occlusio... more Background Mechanical thrombectomy (MT) is the standard treatment for acute large vessel occlusion (LVO). Recurrent LVO can still occur in patients who already underwent MT for the first LVO. This study aimed to evaluate the efficacy of repeating MT for recurrent LVO. Methods This meta-analysis of the available literature was conducted to summarize the current evidence regarding repeated MT outcomes in patients with recurrent LVO. All studies with ≥ 1 outcomes of interest were included. The Newcastle-Ottawa Scale (NOS) was used for risk of bias assessment. Results Twenty studies, 10 observational (n = 21,251 patients) and 10 case reports (n = 10 patients), were included. 266 patients (62.78% females) with recurrent LVO were identified, with an overall prevalence of 1.6% and a mean age of 65.67 ± 16.23 years. Cardio-embolism was the most common mechanism in both times, with a median of 15 days between the first and second LVOs. Compared with pre-intervention, the first and second MTs significantly reduced the National Institute of Health Stroke Scale (NIHSS) score, (mean difference (MD) = −8.91) and (MD = −5.97) respectively, with a significant difference (p = 0.001). The rate of favorable outcome (modified Rankin scale (mRS) score 0–3) was 82.6% and 59.2% after the first and second MTs respectively, with a significant difference (p < 0.001). Conclusion In properly selected recurrent LVO patients, repeated MT is efficacious and safe. A prior MT procedure should not discourage aggressive treatment as many patients may achieve favorable outcomes.

Stroke: vascular and interventional neurology, Mar 1, 2023

Introduction Previous studies have compared the transradial access (TRA) with the transfemoral ac... more Introduction Previous studies have compared the transradial access (TRA) with the transfemoral access (TFA) in patients undergoing mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We conducted this meta‐analysis to provide comprehensive evidence regarding the comparison of procedural and clinical outcomes of the TRA versus the TFA in AIS patients undergoing MT. Methods We performed a comprehensive literature search of four electronic databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL) from inception until 1 May 2022. All duplicates were removed, and all references of the included studies were screened manually for any eligible studies. The full‐text articles of eligible abstracts were retrieved and screened for continued eligibility. Relevant data were extracted and then analyzed. For outcomes that constitute continuous data, the mean difference (MD) between the two groups and its standard deviation (SD) were pooled. For outcomes that constitute dichotomous data, the frequency of events and the total number of patients in each group were pooled as odds ratio (OR) between the two groups. Results Nine studies were included in this meta‐analysis, all of which were observational studies. The population of the studies was homogenous comprising a total of 2,161 patients who underwent MT, including 446 in the TRA group and 1,715 in the TFA group. There were no significant differences across the two groups in terms of successful recanalization (Thrombolysis in cerebral Infarction [TICI] score of 2b‐3: OR 0.83, 95% CI [0.55 to 1.25], P = 0.36) (Figure 1, A), complete recanalization (TICI 3: OR 1.16, 95% CI [0.50 to 2.68], P = 0.73), favorable functional outcome (90‐day modified Rankin scale [mRS] score of 0–2 (OR 0.86, 95% CI [0.53 to 1.41], P = 0.56), first‐pass reperfusion (OR 0.88, 95% CI [0.64 to 1.19], P = 0.41), number of passes (MD 0.12, 95% CI [‐0.18 to 0.42], P = 0.43) (Figure 1, B), access‐to‐reperfusion time (MD ‐3.92 minutes, 95% CI [‐9.49 to 1.65], P = 0.17), the amount of contrast used (MD 5.03 mL, 95% CI [‐20.27 to 30.33], P = 0.70), or symptomatic intracranial hemorrhage (OR 0.86, 95% CI [0.47 to 1.57], P = 0.62). However, access‐site complications were significantly less frequent in the TRA group as compared to the TFA group (OR 0.18, 95% CI [0.06 to 0.51], P = 0.001) (Finger 1, C). Conclusions In patients undergoing MT for AIS, the collective evidence suggests that the TRA seems to result in lower rates of access‐site complications than the TFA without any significant compromise in other clinical or procedural metrics. Large prospective studies are warranted.

Interventional Neuroradiology, Nov 16, 2022

Background The Contour is a new generation intrasaccular flow disruption tool that aims to cover ... more Background The Contour is a new generation intrasaccular flow disruption tool that aims to cover the aneurysm neck and is sized according to the neck diameter. While several case series have been published, no literature review has been performed on this promising device. Objective To assess the safety and effectiveness profile of the Contour Neurovascular System for wide-necked aneurysms. Methods We followed the recommendations of the PRISMA checklist Four databases were searched with a supplemental manual search. All data were analyzed using R software version 4.2.1. Results We finally included six studies with 131 treated aneurysms. The overall procedural time was 97.27 (95% CI = 70.07–124.47) minutes, ranging from 78.9 to 136.0 min. The pooled adequate occlusion rate was 84.21% (95% CI = 75.45–90.25), and the overall functional independence rate was 94.74% (87.97–97.79). The overall adverse event rate was 4.70 (95% CI = 3.24–6.76), varying among different events from 0.78 to 8.53%. Thromboembolic events were the most commonly encountered in 8.53% of the patients (95% CI = 4.78–14.74), followed by headache and minor stroke with incidence rates of 5.88 (95% CI = 2.83–11.83) and 4.35 (95% CI = 1.41–12.63), respectively. The overall procedural time in studies using the Contour system only was 86.17 (95% CI = 68.70–10.64) minutes, while it was 136 (95% CI = 90.96–181.04) in the Contour-assisted coiling procedures. However, both techniques were comparable regarding adequate occlusion rates and functional independence. Conclusion With the anticipation of future studies, the Contour Neurovascular System is a safe and effective treatment option for wide-necked intracranial aneurysms.

Journal of stroke, May 31, 2023

Background and Purpose New studies have shown that endovascular thrombectomy (EVT) is safe and ef... more Background and Purpose New studies have shown that endovascular thrombectomy (EVT) is safe and effective for acute ischemic stroke (AIS) patients with large ischemic areas. The aim of our study is to conduct a living systematic review and meta-analysis of randomized trials comparing EVT versus medical management only. Methods We searched MEDLINE, Embase, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT versus medical management alone in AIS patients with large ischemic regions. We conducted our meta-analysis using fixed-effect models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH) between EVT and standard medical management only. We assessed the risk of bias using the Cochrane risk-ofbias tool and the certainty of evidence for each outcome using the Grading of Recommendations, Assessment, Development, and Evaluations approach. Results Of 14,513 citations, we included 3 RCTs with a total of 1,010 participants. We found lowcertainty evidence of possibly a large increase in the proportion of patients with functional independence (risk difference [RD] 30.3%, 95% CI 15.0% to 52.3%), low-certainty evidence of possibly a small non-significant decrease in mortality (RD-0.7%, 95% CI-3.8% to 3.5%), and low-certainty evidence of possibly a small non-significant increase in sICH (RD 3.1%, 95% CI-0.3% to 9.8%) for AIS patients with large infarcts who underwent EVT compared to medical management only. Conclusion Low-certainty evidence shows that there is possibly a large increase in functional independence, a small non-significant decrease in mortality, and a small non-significant increase in sICH amongst AIS patients with large infarcts undergoing EVT compared to medical management only.

DOAJ (DOAJ: Directory of Open Access Journals), Apr 1, 2016

Multiple diagnostic tools are used by emergency physicians,every day. In addition, new tools are ... more Multiple diagnostic tools are used by emergency physicians,every day. In addition, new tools are evaluated to obtainmore accurate methods and reduce time or cost of conventionalones. In the previous parts of this educationalseries, we described diagnostic performance characteristicsof diagnostic tests including sensitivity, specificity, positiveand negative predictive values, and likelihood ratios. Thereceiver operating characteristics (ROC) curve is a graphicalpresentation of screening characteristics. ROC curve is usedto determine the best cutoff point and compare two or moretests or observers by measuring the area under the curve(AUC). In this part of our educational series, we explain ROCcurve and two methods to determine the best cutoff value.

DOAJ (DOAJ: Directory of Open Access Journals), Jul 1, 2015

Oxford Medical Case Reports, 2023

As COVID-19 vaccines became widely available, there have been reports of neurovascular complicati... more As COVID-19 vaccines became widely available, there have been reports of neurovascular complications. In this article, we aim to report a case of cerebral venous sinus thrombosis (CVST) induced by COVID-19 vaccination, with a literature review on similar cases as well as the potential pathophysiological mechanisms. Our case is a healthy male who developed headache, vomiting, photophobia and diplopia after receiving the Ad26.COV2.S vaccine. Fundus examination showed papilledema, and magnetic resonance imaging of the brain and cerebral veins showed CVST involving the superior sagittal sinus and right transverse sinus extending into the right jugular vein. Hypercoagulability workup was unremarkable, and the patient received immunotherapy and anticoagulation. Following this treatment, symptoms resolved, and he had no residual neurologic deficits. Developing neurologic manifestations, especially severe headaches with papilledema, after COVID-19 vaccination should warrant neuroimaging. Early recognition and management of CVST are essential for good clinical outcomes.

Stroke: vascular and interventional neurology, Jul 1, 2023

Background In patients undergoing mechanical thrombectomy for acute ischemic stroke, a few studie... more Background In patients undergoing mechanical thrombectomy for acute ischemic stroke, a few studies have compared transradial access (TRA) to transfemoral access (TFA) with inconsistent results. We conducted this systematic review and meta‐analysis to provide comprehensive evidence regarding the comparison of procedural and clinical outcomes of TRA versus TFA in patients with acute ischemic stroke undergoing mechanical thrombectomy. Methods We performed a comprehensive literature search of 4 electronic databases from inception until May 1, 2022. After title and full text screening, relevant data were extracted and then analyzed. For outcomes that constituted continuous data, the mean difference between the 2 groups and its SD were pooled. For outcomes that constituted dichotomous data, the frequency of events and the total number of patients in each group were pooled as odds ratio (OR) between the 2 groups. Results Nine observational studies were included in this meta‐analysis. The population of the studies was homogenous comprising a total of 2161 patients undergoing mechanical thrombectomy, including 446 patients via TRA and 1715 patients via TFA. There were no significant differences across the 2 groups in terms of successful recanalization (OR, 0.83 [95% CI, 0.55–1.25]; P =0.36), complete recanalization (OR 1.16 [95% CI, 0.50–2.68]; P =0.73), favorable functional outcomes (OR, 0.86 [95% CI, 0.53–1.41]; P =0.56), first‐pass reperfusion (OR, 0.88 [95% CI, 0.64–1.19]; P =0.41), number of passes (mean difference, 0.12 [95% CI, −0.18 to 0.42]; P =0.43), access‐to‐reperfusion time (mean difference, −3.92 minutes [95% CI, −9.49 to 1.65]; P =0.17), or symptomatic intracranial hemorrhage (OR, 0.86 [95% CI, 0.47–1.57]; P =0.62). However, access site complications were significantly less frequent in the TRA group as compared with the TFA group (OR, 0.18 [95% CI, 0.06–0.51; P =0.001). Conclusion In patients undergoing mechanical thrombectomy for acute ischemic stroke, the collective evidence suggests that TRA seems to result in lower rates of access site complications than TFA without significant compromise in other clinical or procedural metrics. Randomized or prospective studies are warranted to confirm these results.

DOAJ (DOAJ: Directory of Open Access Journals), Dec 1, 2018

Sleep, Apr 1, 2020

Introduction: Dopamine agonists (DAs) have been first-line therapy for restless legs syndrome (RL... more Introduction: Dopamine agonists (DAs) have been first-line therapy for restless legs syndrome (RLS) for 30 years. Long-term DA use is associated with augmentation, a dose-related iatrogenic worsening of RLS, which results in a vicious cycle of escalating DA dosing to manage worsening symptoms. The objective of this study was to investigate rates of high-dose DA prescribing in patients with RLS nationally. Methods: Patients with a diagnosis of RLS (ICD-10 G255.81), and no diagnosis of Parkinson's disease, treated with rotigotine, pramipexole, and ropinirole, alone or in combination for >180 days, were identified from National Prescription Audit database from October 2017-September 2018. Daily total dosage was grouped into low (FDA-approved) and high (above FDA-approved) dose ranges, respectively (rotigotine: >0-≤3mg/>3mg; pramipexole: >0-≤0.75mg/>0.75mg; ropinirole: >0-≤4mg/>4mg). When DAs were used in combination with each other, dose-equivalent algorithms were used (rotigotine/ropinirole/pramipexole, 1:1:4). Results: Prescriptions for 244,423 patients meeting inclusion criteria were sampled, constituting 71,181,466 therapy days. For all patients on DA therapy for RLS, 23.5% (57,552/244,423) were prescribed higher than FDA-recommended doses. For patients on DA monotherapy, high-dose prescriptions were provided to 42.7% (819/1919) on rotigotine, 40.7% (38,342/94,275) on pramipexole, and 11.5% (16,900/146,355) on ropinirole. Nearly one-quarter (23.2%) of all pramipexole monotherapy prescriptions were for very high dosages (>1.25 mg). For patients on DA combination therapy, high-dose prescriptions were provided to 79.6% (1,491/1,874). Conclusion: Roughly 25% of RLS patients treated with DAs were prescribed doses above FDA and expert guideline-recommended maximum doses. Patients on DA combination therapy had substantially higher rates of cumulative high-dose prescriptions. High-dosage DA use is likely due to dose escalation in response to augmentation, risking further augmentation and adverse events such as impulse control disorders. Prescriber education on risks of high-dose DA prescribing for RLS is important.

Interventional Neuroradiology

Background Procedural success following mechanical thrombectomy for acute ischemic stroke is asse... more Background Procedural success following mechanical thrombectomy for acute ischemic stroke is assessed using the thrombolysis in cerebral infarction scale. We conducted a systematic review and meta-analysis to determine whether outcomes differed between first pass thrombolysis in cerebral infarction 2b and multiple pass thrombolysis in cerebral infarction 2c-3. Methods We conducted a systematic review of the literature using PubMed, Embase, Scopus, and Web of Science. We included original studies in which outcomes were stratified based on first pass thrombolysis in cerebral infarction 2b and multiple pass thrombolysis in cerebral infarction 2c-3. The primary outcome of interest was the rate of modified Rankin Scale 0-2. Secondary outcomes of interest were rates of modified Rankin Scale 0-1, symptomatic intracranial hemorrhage, and mortality. We calculated odds ratios and corresponding 95% confidence intervals. Results Four studies with 1554 patients were included in the quantitative ...

Interventional Neuroradiology

Background The Contour is a new generation intrasaccular flow disruption tool that aims to cover ... more Background The Contour is a new generation intrasaccular flow disruption tool that aims to cover the aneurysm neck and is sized according to the neck diameter. While several case series have been published, no literature review has been performed on this promising device. Objective To assess the safety and effectiveness profile of the Contour Neurovascular System for wide-necked aneurysms. Methods We followed the recommendations of the PRISMA checklist Four databases were searched with a supplemental manual search. All data were analyzed using R software version 4.2.1. Results We finally included six studies with 131 treated aneurysms. The overall procedural time was 97.27 (95% CI = 70.07–124.47) minutes, ranging from 78.9 to 136.0 min. The pooled adequate occlusion rate was 84.21% (95% CI = 75.45–90.25), and the overall functional independence rate was 94.74% (87.97–97.79). The overall adverse event rate was 4.70 (95% CI = 3.24–6.76), varying among different events from 0.78 to 8.5...

Journal of Stroke and Cerebrovascular Diseases

Stroke: Vascular and Interventional Neurology

Introduction For more than three decades, robotic assisted surgery has been proposed, studied and... more Introduction For more than three decades, robotic assisted surgery has been proposed, studied and put into action clinically. Likewise, it was cleared by the Food and Drug Administration for percutaneous coronary intervention in 2012 (K120834) and peripheral vascular intervention including carotid intervention in 2018 (K173288), but has not yet received clearance for intracranial neurovascular intervention in the USA. Recently, several pilot clinical studies assessed robotically performed neurointerventions. Methods We performed comprehensive electronic search till July 2022 on PubMed/Medline to retrieve all relevant studies and data were extracted for baseline characteristics, design, procedure type, safety and feasibility outcomes for qualitative synthesis. Results Our results yielded nine single center studies in UK, USA and China performed since 2015. The performed procedures included diagnostic cerebral angiography (36 patients), caroti aartery stenting (37 patients), unspecifi...

Stroke: Vascular and Interventional Neurology

Introduction Cerebral Autosomal Dominant Arteriopathy with subcortical Infarcts and leuko‐encepha... more Introduction Cerebral Autosomal Dominant Arteriopathy with subcortical Infarcts and leuko‐encephalopathy (CADASIL) is a genetic condition characterized by migraine, ischemic strokes, mood disturbances, and cognitive impairment. Since COVID‐19 pandemic started in late 2019, six patients (including our case) were reported to present with neurological symptoms associated with CADASIL mutation and four of them were diagnosed while hospitalized for COVID‐19 illness. Methods A case report anda systematic literature review done via PubMed search that was performed up to Oct 15, 2022. Studies reporting on CADASIL and COVID‐19 infection were included. Results In addition to our case report, 5 case‐reports were identified, and full articles were reviewed and summarized. Including our case, the mean age of patients was 45.44 years, and all of them were females. The diagnosis of CADASIL was established after COVID‐19 infection in four of the cases including ours, while the diagnosis of CADASIL ...

Stroke: Vascular and Interventional Neurology

Introduction Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is known to be ... more Introduction Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is known to be associated with high rates of mortality and lifelong disability. In the past few years, two clinical trials (the BEST and the BASICS trials) investigated the benefits and safety of mechanical thrombectomy (MT) for BAO and did not provide evidence to support the efficacy of MT in BAO patients. Given the recent positive results from the ATTENTION and the BAOCHE clinical trials, we conducted this meta‐analysis to provide updated collective evidence regarding the benefits of MT in patients with BAO. Methods We searched for eligible papers till June 1st, 2021, in five databases: PubMed, Web of Science, Scopus, and Embase databases using keywords and/or medical subject (MeSH) terms. We included all randomized controlled trials (RCTs) with no restrictions on publication date, data, or language of the included studies to avoid missing any relevant papers. All data were analyzed using R software....

Stroke: Vascular and Interventional Neurology

Introduction In certain circumstances, mobile stroke units (MSU) with on‐site treatment teams and... more Introduction In certain circumstances, mobile stroke units (MSU) with on‐site treatment teams and a computed tomography scanner may offer faster therapy with tissue plasminogen activator (tPA) for stroke patients who need immediate treatment. We conducted a systematic review and meta‐analysis to compare clinical outcomes in MSU patients to those in conventional care. Methods We searched key electronic databases from inception till September 2021. The primary outcomes were mortality at 7 days and 90 days. The secondary outcomes included modified Rankin scale (mRS) at 90 days, alarm to intravenous thrombolysis (IVT) or intra‐arterial recanalization, and time from symptom onset or last known well (LKW) to thrombolysis. Results We included nineteen controlled trials and cohort studies to conduct our final analysis. Our comparison revealed that 90‐day mortality rate significantly declined in MSU group as compared to conventional care group (OR = 0.81, 95%CI [0.69,0.95]), while there was ...

Interventional Neuroradiology

Background Funding may impact the quality and findings of systematic reviews (SRs). We aimed to c... more Background Funding may impact the quality and findings of systematic reviews (SRs). We aimed to compare the methodological quality of funded and non-funded SRs that investigated the outcomes in ischemic stroke patients undergoing mechanical thrombectomy. Methods We conducted a comprehensive search strategy in different databases, including Ovid Cochrane Central Register of Controlled Trials, Ovid Embase, Ovid Medline (including epub ahead of print, in-process & other non-indexed citations), PubMed, Scopus and Web of Science Core Collection to retrieve all relevant SRs. Random sequence generation matched each funded SR with a non-funded one. A Measurement Tool to Assess Systematic Reviews (AMSTAR)-2 tool was used to assess the bias and quality of the included SRs. We also used uni- and multivariate analysis to perform our analysis, and results were expressed in odds ratio (OR) and 95% confidence interval (CI). Results We retrieved 150 articles, which were randomized and matched into ...

Stroke

Introduction: Mechanical thrombectomy (MT) is the gold standard for large vessel occlusion (LVO) ... more Introduction: Mechanical thrombectomy (MT) is the gold standard for large vessel occlusion (LVO) strokes. The current guidelines state that LVO patients who are eligible for intravenous thrombolysis (IVT) and MT should receive both treatments. However, a few trials investigated the benefits and safety of combining MT with IVT. We conducted this meta-analysis to provide collective evidence on the efficacy and safety of IVT+MT, and to estimate the risk of complications of this approach as compared to MT alone. Methods: We performed a comprehensive literature search of 4 databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL). For outcomes with continuous data, the mean difference (MD) between both groups from the baseline to the endpoint, with its standard deviation (SD), were pooled in the DerSimonian-Laird (DL) random-effect model. For studies reporting data in multiple time points, we considered the last endpoint for the primary analysis. For outcomes with dichotomous data, th...