87 results on '"Krishna Amuluru"'
Search Results
2. Neuroendovascular Surgery Applications in Craniocervical Trauma
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Michael Kim, Galadu Subah, Jared Cooper, Michael Fortunato, Bridget Nolan, Christian Bowers, Kartik Prabhakaran, Rolla Nuoman, Krishna Amuluru, Sauson Soldozy, Alvin S. Das, Robert W. Regenhardt, Saef Izzy, Chirag Gandhi, and Fawaz Al-Mufti
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neuroendovascular surgery ,cerebrovascular injuries ,neurointerventional ,head and neck trauma ,craniocervical trauma ,angiography ,Biology (General) ,QH301-705.5 - Abstract
Cerebrovascular injuries resulting from blunt or penetrating trauma to the head and neck often lead to local hemorrhage and stroke. These injuries present with a wide range of manifestations, including carotid or vertebral artery dissection, pseudoaneurysm, occlusion, transection, arteriovenous fistula, carotid-cavernous fistula, epistaxis, venous sinus thrombosis, and subdural hematoma. A selective review of the literature from 1989 to 2023 was conducted to explore various neuroendovascular surgical techniques for craniocervical trauma. A PubMed search was performed using these terms: endovascular, trauma, dissection, blunt cerebrovascular injury, pseudoaneurysm, occlusion, transection, vasospasm, carotid-cavernous fistula, arteriovenous fistula, epistaxis, cerebral venous sinus thrombosis, subdural hematoma, and middle meningeal artery embolization. An increasing array of neuroendovascular procedures are currently available to treat these traumatic injuries. Coils, liquid embolics (onyx or n-butyl cyanoacrylate), and polyvinyl alcohol particles can be used to embolize lesions, while stents, mechanical thrombectomy employing stent-retrievers or aspiration catheters, and balloon occlusion tests and super selective angiography offer additional treatment options based on the specific case. Neuroendovascular techniques prove valuable when surgical options are limited, although comparative data with surgical techniques in trauma cases is limited. Further research is needed to assess the efficacy and outcomes associated with these interventions.
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- 2023
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3. Adjustment of Malpositioned Woven EndoBridge Device Using Gooseneck Snare: Complication Management Technique
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Krishna Amuluru, Fawaz Al-Mufti, Daniel H. Sahlein, John Scott, and Andrew Denardo
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cerebral aneurysm ,subarachnoid hemorrhage ,device malposition ,device retrieval ,woven endobridge ,gooseneck snare ,Medicine (General) ,R5-920 ,Neurosciences. Biological psychiatry. Neuropsychiatry ,RC321-571 - Abstract
The Woven EndoBridge (WEB) is an intrasaccular flow-disrupting device for the treatment of wide-necked saccular cerebral aneurysms. As with any neuroendovascular device, complications in the form of malpositioning and migration must be managed quickly and safely. Few studies have reported complication management techniques in instances of dislocated or migrated WEB devices. We retrospectively describe a case of a malpositioned WEB device that was successfully adjusted with the use of a gooseneck snare. Multiple other intra-procedural bailout strategies for management of WEB malposition and migration were considered, and are herein discussed. Operators should be aware of the causes of WEB malposition and a variety of bailout strategies.
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- 2021
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4. Clinical and Angiographic Imaging Features of Isolated Cortical Venous Thrombosis
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Krishna Amuluru, Fawaz Al‐Mufti, Daniel H. Sahlein, Andrew Denardo, John Scott, Annaliise Hayrynen, Troy Payner, Charles Kulwin, and Charles E. Romero
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cerebral venous thrombosis ,cortical venous thrombosis ,dural sinus thrombosis ,stroke ,digital subtraction angiography ,venography ,Neurology. Diseases of the nervous system ,RC346-429 ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Cerebral venous thrombosis usually presents as dural sinus thrombosis. More rarely, it occurs in an isolated form (isolated cortical vein thrombosis; ICoVT). ICoVT is poorly recognized and underdiagnosed, and noninvasive imaging remains nebulous. The digital subtraction angiographic (DSA) patterns of ICoVT are neither well known nor documented. We present clinical and imaging details of the largest series of ICoVT, with all cases demonstrating both noninvasive imaging findings, along with angiographic confirmation. We propose a preliminary compilation of the DSA patterns of ICoVT. Methods We identified all patients with cerebral venous thrombosis at our institution between January 2013 and June 2019. Only patients in whom ICoVT was diagnosed and/or suspected with computed tomographic venography and/or magnetic resonance imaging/MR venogram with subsequent DSA confirmation were included. DSA imaging was reviewed for direct and indirect signs. Clinical data, outcomes, and follow‐up imaging were analyzed. Results We identified 109 patients with cerebral venous thrombosis; in 21 patients ICoVT was suspected on noninvasive imaging and eventually had DSA confirmation. Headache and focal neurological deficit were the most common presentations (each 67%). Ten patients (47%) presented with parenchymal changes due to ICoVT and 15 patients (71%) presented with subarachnoid hemorrhage. We identified 5 DSA patterns of ICoVT (3 direct; 2 indirect). Filling defects in cortical veins and the regional absence of cortical veins and decreased subcortical opacification were the most common patterns (52% and 90%, respectively). Sixteen patients (76%) were anticoagulated. Eighteen patients were discharged without disability or minor disability (84%). No deaths occurred. Conclusions Catheter angiography/venography may be important in diagnosing ICoVT, especially when magnetic resonance imaging/MR venogram is unclear. The angiographic patterns of ICoVT are presented.
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- 2022
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5. Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery
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Mohamad Abdalkader, Anurag Sahoo, Adam A. Dmytriw, Waleed Brinjikji, Guilherme Dabus, Eytan Raz, Leonardo Renieri, Antonio Laiso, Alberto Maud, Mario Martínez‐Galdámez, Jorge Galván‐Fernández, Miguel Schüller‐Arteaga, Fawaz Al‐Mufti, Krishna Amuluru, Johanna T. Fifi, Shahram Majidi, Priyank Khandelwal, Justin M. Moore, Santiago Ortega‐Gutierrez, Ameer E. Hassan, James E. Siegler, Simon Nagel, Osama O. Zaidat, and Thanh N. Nguyen
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acute stroke ,fetal posterior cerebral artery ,mechanical thrombectomy ,Neurology. Diseases of the nervous system ,RC346-429 ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Background Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. Methods We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. Results There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. Conclusions Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.
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- 2021
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6. Abstract 1122‐000207: Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery
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Mohamad Abdalkader, Anurag Sahoo, Adam A Dmytriw, Waleed Brinjikji, Guilherme Dabus, Eytan Raz, Leonardo Renieri, Antonio Laiso, Alberto Maud, Mario Martinez‐Galdamez, Jorge Galvan‐Fernandez, Miguel Schuller Arteaga, Fawaz Al‐Mufti, Krishna Amuluru, Johanna T Fifi, Shahram Majidi, Priyank Khandelwal, Justin Moore, Nicole Kiley, Santiago Ortega‐Gutierrez, Ameer E Hassan, James E Siegler, Simon Nagel, Osama O Zaidat, and Thanh N Nguyen
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Acute Stroke ,Acute Ischemic Stroke Intervention ,Mechanical Thrombectomy ,Endovascular Therapy ,Neurology. Diseases of the nervous system ,RC346-429 ,Diseases of the circulatory (Cardiovascular) system ,RC666-701 - Abstract
Introduction: Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion (LVO) stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety and outcome of mechanical thrombectomy (MT) in acute FPCA occlusions. Methods: We performed a multi‐center retrospective review of consecutive patients who underwent MT of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure CT angiogram or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different LVO. Demographics, clinical presentation, imaging findings, endovascular treatment and outcome were reviewed. Results: There were twenty‐five patients with acute FPCA occlusion who underwent MT, distributed across 14 centers. Median NIHSS on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial CTA in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. TICI 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intra‐procedural complications. At 90 days, 48% (12/25) were functionally independent as defined by mRS≤2. Conclusions: Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the fetal posterior cerebral artery in patients presenting with anterior circulation stroke syndrome and patent anterior circulation.
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- 2021
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7. Complication Rates Following Cerebral and Coronary Angiography: Nationwide Analysis 2008–2014
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Justin M. Lapow, Rajkumar S. Pammal, Martina Brozynski, Samantha Sudol, Smit D. Patel, Eric Feldstein, Bridget E. Nolan, Kevin M. Clare, Steven Shapiro, Haris Kamal, Krishna Amuluru, William Frishman, Srihari Naidu, Howard Cooper, Chirag D. Gandhi, and Fawaz Al-Mufti
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General Medicine ,Cardiology and Cardiovascular Medicine - Published
- 2023
8. Significant Mortality Associated With COVID-19 and Comorbid Cerebrovascular Disease: A Quantitative Systematic Review
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Tolga Sursal, Chirag D. Gandhi, Kevin Clare, Eric Feldstein, Ilya Frid, Martin Kefina, Daniela Galluzzo, Haris Kamal, Rolla Nuoman, Krishna Amuluru, Carrie R. Muh, Jared M. Pisapia, Edwin Gulko, Philip Overby, Dipak Chandy, Mill Etienne, Christeena Kurian, Gurmeen Kaur, Katarina Dakay, May AlHamid, Hosam Al-Jehani, Stephan A. Mayer, and Fawaz Al-Mufti
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General Medicine ,Cardiology and Cardiovascular Medicine - Abstract
We report the first quantitative systematic review of cerebrovascular disease in coronavirus disease 2019 (COVID-19) to provide occurrence rates and associated mortality. Through a comprehensive search of PubMed we identified 8 cohort studies, 5 case series, and 2 case reports of acute cerebrovascular disease in patients with confirmed COVID-19 diagnosis. Our first meta-analysis utilizing the identified publications focused on comorbid cerebrovascular disease in recovered and deceased patients with COVID-19. We performed 3 additional meta-analyses of proportions to produce point estimates of the mortality and incidence of acute cerebrovascular disease in COVID-19 patients. Patient's with COVID-19 who died were 12.6 times more likely to have a history of cerebrovascular disease. We estimated an occurrence rate of 2.6% (95% confidence interval, 1.2-5.4%) for acute cerebrovascular disease among consecutively admitted patients with COVID-19. While for those with severe COVID-19' we estimated an occurrence rate of 6.5% (95% confidence interval, 4.4-9.6%). Our analysis estimated a rate of 35.5% for in-hospital mortality among COVID-19 patients with concomitant acute cerebrovascular disease. This was consistent with a mortality rate of 34.0% which we obtained through an individual patient analysis of 47 patients derived from all available case reports and case series. COVID-19 patients with either acute or chronic cerebrovascular disease have a high mortality rate with higher occurrence of cerebrovascular disease in patients with severe COVID-19.
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- 2022
9. Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee
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Stavropoula Tjoumakaris, Neil Haranhalli, Krishna Amuluru, Steven W. Hetts, Neeraj Chaudhary, Isaac Josh Abecassis, Robert M. Starke, Ketan R. Bulsara, Fawaz Al-Mufti, Reade De Leacy, and Clemens M. Schirmer
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medicine.medical_specialty ,Special populations ,Arterial Occlusive Diseases ,Brain Ischemia ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,Pregnancy ,medicine ,Humans ,Endocarditis ,Child ,Stroke ,Ischemic Stroke ,Retrospective Studies ,Thrombectomy ,Aged, 80 and over ,medicine.diagnostic_test ,business.industry ,General Medicine ,Guideline ,medicine.disease ,Thrombocytopenia ,Surgery ,Mechanical thrombectomy ,Clinical trial ,Treatment Outcome ,Female ,Collagen ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,Cerebral angiography ,Large vessel occlusion - Abstract
BackgroundThe purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis.MethodsWe performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged 80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence.ResultsMT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.
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- 2021
10. Cerebral Ischemic Reperfusion Injury: Preventative and Therapeutic Strategies
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Francisco Gomez, Mohammad El-Ghanem, Eric Feldstein, Matt Jagdeo, Prateeka Koul, Rolla Nuoman, Gaurav Gupta, Chirag D. Gandhi, Krishna Amuluru, and Fawaz Al-Mufti
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General Medicine ,Cardiology and Cardiovascular Medicine - Abstract
Acute ischemic stroke is a leading cause of morbidity and mortality in the United States. Treatment goals remain focused on restoring blood flow to compromised areas. However, a major concern arises after reperfusion occurs. Cerebral ischemic reperfusion injury is defined as damage to otherwise salvageable brain tissue occurring with the reestablishment of the vascular supply to that region. The pool of eligible patients for revascularization continues to grow, especially with the recently expanded endovascular therapeutic window. Neurointensivists should understand and manage complications of successful recanalization. In this review, we examine the pathophysiology, diagnosis, and potential management strategies in cerebral ischemic reperfusion injury.
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- 2022
11. Endovascular intervention for the treatment of epistaxis: cone beam CT review of anatomy, collateral, and treatment implications/efficacy
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Madeline Hoover, Robert Berwanger, John A Scott, Andrew DeNardo, Krishna Amuluru, Troy Payner, Charles Kulwin, Eytan Raz, Daniel Gibson, and Daniel H Sahlein
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Surgery ,Neurology (clinical) ,General Medicine - Abstract
Epistaxis is common, impacting more than half the population, and can require procedural intervention in approximately 10% of cases. With an aging population and increasing use of antiplatelets and anticoagulants, severe epistaxis is likely to increase in frequency significantly over the next two decades. Sphenopalatine artery embolization is rapidly becoming the most common type of procedural intervention. The efficacy of endovascular embolization is dependent on a refined understanding of the anatomy and collateral physiology of this circulation as well as the impact of temporizing measures such as nasal packing and inflation of a nasal balloon. Likewise, safety is dependent on a detailed appreciation of collateralization with the internal carotid artery and ophthalmic artery. Cone beam CT imaging has the resolution to enable a clear visualization of the anatomy and collateral circulation associated with the arterial supply to the nasal cavity, in addition to assisting with hemorrhage localization. We present a review of epistaxis treatment, a detailed description of anatomic and physiologic considerations informed by cone beam CT imaging, and a proposed protocol for sphenopalatine embolization for which there is currently no standard.
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- 2023
12. Middle Meningeal Artery Embolization Using Combined Particle Embolization and n-BCA with the Dextrose 5% in Water Push Technique for Chronic Subdural Hematomas: A Prospective Safety and Feasibility Study
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Jared M Pisapia, Carrie R. Muh, Chad Cole, Chirag D. Gandhi, Krishna Amuluru, Christian A. Bowers, Fawaz Al-Mufti, Stephan A. Mayer, Gurmeen Kaur, Jared B. Cooper, Rachana Tyagi, Justin Santarelli, Katarina Dakay, S. Rosner, and Mohammad El-Ghanem
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medicine.medical_specialty ,business.industry ,Middle meningeal artery ,medicine.medical_treatment ,medicine.disease ,030218 nuclear medicine & medical imaging ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,Hematoma ,Chronic subdural hematoma ,Refractory ,Concomitant ,medicine.artery ,Medicine ,Radiology, Nuclear Medicine and imaging ,Neurology (clinical) ,Embolization ,Bolus (digestion) ,Prospective cohort study ,business ,030217 neurology & neurosurgery - Abstract
BACKGROUND AND PURPOSE: Embolization of the middle meningeal artery for treatment of refractory or recurrent chronic subdural hematomas has gained momentum during the past few years. Little has been reported on the use of the n-BCA liquid embolic system for middle meningeal artery embolization. We present the technical feasibility of using diluted n-BCA for middle meningeal artery embolization. MATERIALS AND METHODS: We sought to examine the safety and technical feasibility of the diluted n-BCA liquid embolic system for middle meningeal artery embolization. Patients with chronic refractory or recurrent subdural hematomas were prospectively enrolled from September 2019 to June 2020. The primary outcome was the safety and technical feasibility of the use of diluted n-BCA for embolization of the middle meningeal artery. The secondary end point was the efficacy in reducing hematoma volume. RESULTS: A total of 16 patients were prospectively enrolled. Concomitant burr-hole craniotomies were performed in 12 of the 16 patients. Two patients required an operation following middle meningeal artery embolization for persistent symptoms. The primary end point was met in 100% of cases in which there were no intra- or postprocedural complications. Distal penetration of the middle meningeal artery branches was achieved in all the enrolled cases. A 7-day post–middle meningeal artery embolization follow-up head CT demonstrated improvement (>50% reduction in subdural hematoma volume) in 9/15 (60%) patients, with 6/15 (40%) showing an unchanged or stable subdural hematoma. At day 21, available CT scans demonstrated substantial further improvement (>75% reduction in subdural hematoma volume). CONCLUSIONS: Embolization of the middle meningeal artery using diluted n-BCA and ethiodized oil (1:6) is safe and feasible from a technical standpoint. The use of a dextrose 5% bolus improves distal penetration of the glue.
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- 2021
13. Body Mass Index and Overall Outcome Following Subarachnoid Hemorrhage: An Obesity Paradox?
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Christian A. Bowers, Sydney Moseley, Priyank Khandelwal, Hussein Alshammari, Rolla Nuoman, Nitesh Damodara, Krishna Amuluru, Mohammad El-Ghanem, Fawaz Al-Mufti, and Chirag D. Gandhi
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Adult ,Male ,medicine.medical_specialty ,Subarachnoid hemorrhage ,Overweight ,Body Mass Index ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Modified Rankin Scale ,Internal medicine ,Odds Ratio ,medicine ,Humans ,Vasospasm, Intracranial ,Obesity ,Aged ,business.industry ,Body Weight ,Odds ratio ,Middle Aged ,Subarachnoid Hemorrhage ,medicine.disease ,Treatment Outcome ,030220 oncology & carcinogenesis ,Cohort ,Female ,Surgery ,Neurology (clinical) ,medicine.symptom ,business ,Body mass index ,030217 neurology & neurosurgery ,Obesity paradox - Abstract
Background Conventional understanding of obesity demonstrates negative consequences for overall health, whereas more modern studies have found that it can provide certain advantages. The current literature on the effect of body mass index (BMI) in subarachnoid hemorrhage (SAH) is similarly inconsistent. Methods cohort of 406 patients with SAH were retrospectively reviewed and stratified into 3 BMI categories: normal weight, 18.5–24.9 kg/m2; overweight, 25–29.9 kg/m2; and obese, >30 kg/m2. Neurologic status, the presence of clinical cerebral vasospasm, and outcome as assessed by the modified Rankin scale (mRS) were obtained. Results Statistical differences were evident for all outcome categories. A categorical analysis of the different groups revealed that compared with the normal weight group, the overweight group had an odds ratio (OR) for mortality of 0.415 (P = 0.023), an OR for poor mRS score at 90 days of 0.432 (P = 0.014), and an OR for poor mRS score at 180 days of 0.311 (P = 0.001), and the obese group had statistically significant ORs for poor mRS score at 90 days of 2.067 (P = 0.041) and at 180 days of 1.947 (P = 0.049). These significant ORs persisted in a multivariable model controlling for age and Hunt and Hess grade. Conclusions The overweight group exhibited strikingly lower odds of death and poor outcome compared with the normal weight group, whereas the obese group demonstrated the opposite. These associations persisted in a multivariable model; thus, BMI can be considered an important predictor of outcome after SAH.
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- 2020
14. Spontaneous Regression of Cerebral Arteriovenous Malformation Following Onyx Embolization
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Krishna Amuluru, Chirag D. Gandhi, Fawaz Al-Mufti, Gerald J Riccardello, and Eric Feldstein
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medicine.medical_specialty ,business.industry ,cerebral avm ,medicine.medical_treatment ,General Engineering ,Neurosurgery ,interventional radiology guided embolization ,arteriovenous malformation ,Onyx embolization ,Arteriovenous malformation ,embolization ,medicine.disease ,spontaneous regression ,Disease course ,Cerebral arteriovenous malformations ,Natural history ,Neurology ,Medicine ,Embolization ,Radiology ,Endovascular treatment ,Lost to follow-up ,business - Abstract
Little is known about the natural history of arteriovenous malformations (AVM) and less is known about their potential for spontaneous regression. The advent of endovascular treatment for embolization or pre-surgical embolization of cerebral arteriovenous malformations (cAVM) has seen several reports of spontaneous regression of partial embolization of cAVMs surface in the literature. A 66-year-old patient had an initial diagnostic cerebral angiogram revealing a left frontoparietal region Spetzler-Martin (SM) grading 4 cAVM. The patient underwent three stages of embolization over eight months leading to a 90% reduction in nidal volume, before being lost to follow up for six years. A six-vessel diagnostic cerebral angiogram was performed at that time to assess for any interval changes and surprisingly, the previously visualized left frontoparietal AVM had regressed. There was evidence of prior onyx embolization with no residual filling or recurrence. Spontaneous regression after partial embolization may be under-reported or the natural history is simply unable to temporally unfold because the typical treatment course results in surgery following partial embolization. Given the potential to forgo the risks of an open procedure, we believe this topic deserves further attention.
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- 2021
15. Mechanical Thrombectomy of the Fetal Posterior Cerebral Artery
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James E. Siegler, Thanh N. Nguyen, Priyank Khandelwal, Mohamad Abdalkader, Ameer E Hassan, Justin M. Moore, Osama O. Zaidat, Santiago Ortega-Gutierrez, Anurag Sahoo, Jorge Galván-Fernández, Miguel Schüller-Arteaga, Guilherme Dabus, Adam A Dmytriw, Simon Nagel, Fawaz Al-Mufti, Mario Martínez-Galdámez, Eytan Raz, Krishna Amuluru, Waleed Brinjikji, Shahram Majidi, Alberto Maud, Johanna T Fifi, Antonio Laiso, and Leonardo Renieri
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medicine.medical_specialty ,Fetus ,business.industry ,Large vessel ,Posterior cerebral artery ,medicine.disease ,Mechanical thrombectomy ,Internal medicine ,medicine.artery ,Occlusion ,Cardiology ,Medicine ,Endovascular treatment ,business ,Stroke ,Acute stroke - Abstract
Background Fetal posterior cerebral artery (FPCA) occlusion is a rare but potentially disabling cause of stroke. While endovascular treatment is established for acute large vessel occlusion stroke, FPCA occlusions were excluded from acute ischemic stroke trials. We aim to report the feasibility, safety, and outcome of mechanical thrombectomy in acute FPCA occlusions. Methods We performed a multicenter retrospective review of consecutive patients who underwent mechanical thrombectomy of acute FPCA occlusion. Primary FPCA occlusion was defined as an occlusion that was identified on the pre‐procedure computed tomography angiography or baseline angiogram whereas a secondary FPCA occlusion was defined as an occlusion that occurred secondary to embolization to a new territory after recanalization of a different large vessel occlusion. Demographics, clinical presentation, imaging findings, endovascular treatment, and outcome were reviewed. Results There were 25 patients with acute FPCA occlusion who underwent mechanical thrombectomy, distributed across 14 centers. Median National Institutes of Health Stroke Scale on presentation was 16. There were 76% (19/25) of patients who presented with primary FPCA occlusion and 24% (6/25) of patients who had a secondary FPCA occlusion. The configuration of the FPCA was full in 64% patients and partial or “fetal‐type” in 36% of patients. FPCA occlusion was missed on initial computed tomography angiography in 21% of patients with primary FPCA occlusion (4/19). The site of occlusion was posterior communicating artery in 52%, P2 segment in 40% and P3 in 8% of patients. Thrombolysis in cerebral infarction 2b/3 reperfusion was achieved in 96% of FPCA patients. There were no intraprocedural complications. At 90 days, 48% (12/25) were functionally independent as defined by modified Rankin scale≤2. Conclusions Endovascular treatment of acute FPCA occlusion is safe and technically feasible. A high index of suspicion is important to detect occlusion of the FPCA in patients presenting with anterior circulation stroke syndrome and patent anterior circulation. Novelty and significance This is the first multicenter study showing that thrombectomy of FPCA occlusion is feasible and safe.
- Published
- 2021
16. Intravenous thrombolysis plus mechanical thrombectomy versus mechanical thrombectomy alone for acute ischemic stroke: A systematic review and updated meta-analysis of clinical trials
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Mohamed Elfil, Hazem S Ghaith, Hanaa Elsayed, Mohammad Aladawi, Ahmed Elmashad, Neisha Patel, Chaitanya Medicherla, Mohammad El-Ghanem, Krishna Amuluru, and Fawaz Al-Mufti
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General Medicine - Abstract
Background Mechanical thrombectomy (MT) is the gold standard treatment for large vessel occlusion (LVO). A vital factor that might influence MT outcomes is the use of intravenous thrombolysis (IVT). A few clinical trials in this domain thus far have not yielded consistent outcomes. We conducted this meta-analysis to synthesize collective evidence in this regard. Methods The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement guidelines were followed, and we performed a comprehensive literature search of four databases (PubMed, Scopus, Web of Science, Cochrane CENTRAL). For outcomes constituting continuous data, the mean difference (MD) and its standard deviation (SD) were pooled. For outcomes constituting dichotomous data, the frequency of events and the total number of patients were pooled as the risk ratio (RR). Results Seven clinical trials with a total of 2317 patients are included in this meta-analysis. Six trials are randomized, and one trial was nonrandomized. No significant differences were found between MT plus IVT and MT alone in successful recanalization (RR 1.04, 95% Confidence Interval (CI) [0.92 to 1.17], P = 0.53), 90-day functional independence (RR 1.03, 95% CI [0.90 to 1.19], P = 0.65), symptomatic intracranial hemorrhage (sICH) (RR 1.22, 95% CI [0.84 to 1.75], P = 0.30), or mortality (RR 0.94, 95% CI [0.76 to 1.18], P = 0.61). Conclusion The current evidence does not favor either MT plus IVT or MT alone for LVO except for the procedural time. More trials are needed in this regard, and certain factors should be considered when comparing the two approaches.
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- 2022
17. Neurocritical care management of poor-grade subarachnoid hemorrhage: Unjustified nihilism to reasonable optimism
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Gurmeen Kaur, Nicole Matluck, Rolla Nuoman, Matthew L Holstein, Chirag D. Gandhi, Faizan S Ali, Krishna Amuluru, Fawaz Al-Mufti, Hussein Alshammari, Stephan A. Mayer, Christian A. Bowers, Daniel Bassily, Haris Kamal, Jood Ani, Mohammad El-Ghanem, and Boyi Li
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Nihilism ,medicine.medical_specialty ,Subarachnoid hemorrhage ,Intracranial Pressure ,business.industry ,media_common.quotation_subject ,Neurointensive care ,Brain Edema ,Intracranial Aneurysm ,General Medicine ,Subarachnoid Hemorrhage ,medicine.disease ,Optimism ,Treatment Outcome ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Poor grade ,Neurology (clinical) ,Intensive care medicine ,business ,Review Articles ,Intracranial pressure ,media_common - Abstract
Background and purpose Historically, overall outcomes for patients with high-grade subarachnoid hemorrhage (SAH) have been poor. Generally, between physicians, either reluctance to treat, or selectivity in treating such patients has been the paradigm. Recent studies have shown that early and aggressive care leads to significant improvement in survival rates and favorable outcomes of grade V SAH patients. With advancements in both neurocritical care and end-of-life care, non-treatment or selective treatment of grade V SAH patients is rarely justified. Current paradigm shifts towards early and aggressive care in such cases may lead to improved outcomes for many more patients. Materials and methods We performed a detailed review of the current literature regarding neurointensive management strategies in high-grade SAH, discussing multiple aspects. We discussed the neurointensive care management protocols for grade V SAH patients. Results Acutely, intracranial pressure control is of utmost importance with external ventricular drain placement, sedation, optimization of cerebral perfusion pressure, osmotherapy and hyperventilation, as well as cardiopulmonary support through management of hypotension and hypertension. Conclusions Advancements of care in SAH patients make it unethical to deny treatment to poor Hunt and Hess grade patients. Early and aggressive treatment results in a significant improvement in survival rate and favorable outcome in such patients.
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- 2021
18. Relation between brain natriuretic peptide and delayed cerebral ischemia in patients with aneurysmalsubarachnoid hemorrhage
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Chirag D. Gandhi, Jose F. Dominguez, Kristen T. Huang, Gaurav Gupta, Jonathan V Ogulnick, Mohammad El-Ghanem, Krishna Amuluru, Priyank Khandelwal, Nitesh Damodara, Eric Feldstein, Fawaz Al-Mufti, Gurmeen Kaur, Stephan A. Mayer, and Rolla Nuoman
- Subjects
Adult ,Male ,medicine.medical_specialty ,Subarachnoid hemorrhage ,Ischemia ,Cardiomyopathy ,Brain Ischemia ,Predictive Value of Tests ,Internal medicine ,Natriuretic Peptide, Brain ,medicine ,Humans ,In patient ,cardiovascular diseases ,Prospective cohort study ,Aged ,Retrospective Studies ,business.industry ,Curve analysis ,General Medicine ,Middle Aged ,Subarachnoid Hemorrhage ,medicine.disease ,Brain natriuretic peptide ,Hospitalization ,ROC Curve ,Heart failure ,cardiovascular system ,Cardiology ,Surgery ,Female ,Neurology (clinical) ,business ,human activities ,hormones, hormone substitutes, and hormone antagonists ,circulatory and respiratory physiology - Abstract
Background Brain natriuretic peptide (BNP), often used to evaluate degree of heart failure, has been implicated in fluid dysregulation and inflammation in critically-ill patients. Twenty to 30% of patients with aneurysmal subarachnoid hemorrhage (aSAH) will develop some degree of neurogenic stress cardiomyopathy (NSC) and in turn elevation of BNP levels. We sought to explore the association between BNP levels and development of delayed cerebral ischemia (DCI) in patients with aSAH. Methods We retrospectively evaluated the records of 149 patients admitted to the Neurological Intensive Care Unit between 2006 and 2015 and enrolled in an existing prospectively maintained aSAH database. Demographic data, treatment and outcomes, and BNP levels at admission and throughout the hospital admission were noted. Results Of the 149 patients included in the analysis, 79 developed DCI during their hospital course. We found a statistically significant association between DCI and the highest recorded BNP (OR 1.001, 95% CI-1.001–1.002, p = 0.002). The ROC curve analysis for DCI based on BNP showed that the highest BNP level during hospital admission (AUC 0.78) was the strongest predictor of DCI compared to the change in BNP over time (AUC 0.776) or the admission BNP (AUC 0.632). Conclusion Our study shows that DCI is associated not only with higher baseline BNP values (admission BNP), but also with the highest BNP level attained during the hospital course and the rapidity of change or increase in BNP over time. Prospective studies are needed to evaluate whether routine measurement of BNP may help identify SAH patients at high risk of DCI.
- Published
- 2021
19. E-114 Coiling of recurrent aneurysms from the contralateral circulation following flow diversion: Technical aspects
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Krishna Amuluru, John A. Scott, J Steele, Andrew J. DeNardo, and Daniel H. Sahlein
- Subjects
medicine.medical_specialty ,Flow diversion ,medicine.diagnostic_test ,business.industry ,medicine.medical_treatment ,Balloon catheter ,Stent ,medicine.disease ,Surgery ,Aneurysm ,medicine.anatomical_structure ,medicine.artery ,Occlusion ,Angiography ,medicine ,cardiovascular diseases ,business ,Circle of Willis ,Artery - Abstract
Introduction One concern for aneurysm remnants following flow diversion are the limited retreatment options since the aneurysm sac cannot be directly cannulated through the stent pores. This argument is often used by groups using laser cut stents, where the aneurysm can be re-accessed through the stent, despite their dramatically diminished efficacy and similar risk profile. There are options for retreatment of remnant aneurysms after flow diversion besides placement of more flow diverters, which risks occluding parent vessel branches and increased patient morbidity. The authors discuss the technical aspects of accessing previously flow diverted aneurysms at the base of the brain from the contralateral circulation by using the Circle of Willis. Methods Dual arterial access recommended, although single artery access possible depending on the anatomy. Dual injection angiography, both hand and power injection, is used to confirm angiographic relationships. Ipsilateral balloon catheter inflation inside the previously placed stent is used to confirm contralateral communication (figure 1). Results Coil embolization from the contralateral circulation with ipsilateral angiography results in occlusion of the recurrence (figure 2). Conclusions The Circle of Willis may increase the risk of aneurysm recurrence on flow diverted segments. That being said, it provides a valuable path through which future access to treated aneurysms can be gained. Aneurysm coiling from the contralateral circulation is possible after flow diversion. Disclosures J. Steele: None. J. Scott: None. A. Denardo: 2; C; Cerenovus. K. Amuluru: None. D. Sahlein: 2; C; Medtronic.
- Published
- 2021
20. Artificial intelligence aneurysm measurement tool finds growth in all aneurysms that ruptured during conservative management
- Author
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Daniel H, Sahlein, Daniel, Gibson, John A, Scott, Andrew, DeNardo, Krishna, Amuluru, Troy, Payner, David, Rosenbaum-Halevi, and Charles, Kulwin
- Subjects
Surgery ,Neurology (clinical) ,General Medicine - Abstract
BackgroundCerebral aneurysm rupture is associated with high rates of morbidity and mortality. Detecting aneurysms at high risk of rupture is critical in management decision making. Rupture risk has traditionally been associated with size—measured as a maximum dimension. However, aneurysms are morphologically dynamic, a characteristic ignored by large prospective aneurysm risk studies. Manual measurement is challenging and fraught with error. We used an artificial intelligence (AI) measurement tool to study aneurysms that ruptured during conservative management to detect changes in size not appreciated by manual linear measurement.MethodsA single practice database with >5000 aneurysms was queried. Patients followed conservatively for an unruptured aneurysm were identified using appropriate diagnosis codes. This cohort was screened for subsequent rupture using procedure codes. Only patients with two vascular imaging studies before rupture were included.ResultsFive patients met the criteria. All patients had aneurysm enlargement, two of which were not detected from manual linear measurements, including adjudication and analysis, during a multidisciplinary neurovascular conference in a high volume practice. Maximum dimension increased at a minimum of 1.8% (range 1.8–63.3%) from the first scan to the last, and aneurysm volume increased at a minimum of 5.9% (5.9–385.5%), highlighting the importance of volumetric measurement.ConclusionsAI-enabled volumetric measurements are more sensitive to changes in size and detected enlargement in all aneurysms that ruptured during conservative management. This finding has major implications for clinical practice and methods used for interval aneurysm measurement in patients being conservatively followed.
- Published
- 2022
21. Safety and Effectiveness of Mechanical Thrombectomy for Acute Ischemic Stroke Using Single Plane Angiography
- Author
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Krishna Amuluru, Jimmy Nguyen, Fawaz Al-Mufti, Andrew Denardo, John Scott, Dileep Yavagal, and Daniel H. Sahlein
- Subjects
Stroke ,Treatment Outcome ,Rehabilitation ,Angiography ,Humans ,Surgery ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,Brain Ischemia ,Ischemic Stroke ,Retrospective Studies ,Thrombectomy - Abstract
Nearly all data on mechanical thrombectomy for acute ischemic stroke is based on procedures performed on biplane angiography systems. However, thrombectomy may be performed on single-plane systems in situations of triage or limited resources. We present the first US study comparing the safety and effectiveness of mechanical thrombectomy performed on single-plane vs. biplane systems.A retrospective review of a prospectively maintained database identified all patients treated with thrombectomy between July 2020 and July 2021 by a high-volume practice. Patients were dichotomized into those treated on single plane and biplane systems. Demographic, procedural, clinical and follow-up characteristics were compared.Of the 246 patients treated with mechanical thrombectomy, 70 (33%) and 141 (66%) patients were treated on SP and BP systems, respectively. No significant differences were detected in follow-up 'good functional outcome' (mRS ≤ 2; SP 51% vs BP 43%, p = 0.14), successful recanalization (SP 87% vs BP 88%, p = 0.72), intra-procedural vascular injury (SP 3% vs BP 2%, p = 0.96), or time from groin puncture to reperfusion (SP 24 min vs BP 26 min, p = 0.58). Additionally, no significant differences were detected in peri-procedural complications, fluoroscopy times or total radiation. Patients treated on single plane systems required significantly more contrast.Mechanical thrombectomy for acute ischemic stroke performed on single plane angiography systems is as safe and efficacious as when performed on biplane systems. Our results may have implications for increasing stroke care access, both domestically in underserved/rural areas and internationally when considering requirements for stroke care in lower-income countries.
- Published
- 2022
22. Cerebral vasospasm following arteriovenous malformation rupture: a population-based cross-sectional study
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Alis J. Dicpinigaitis, Eric Feldstein, Steven D. Shapiro, Haris Kamal, Andrew Bauerschmidt, Jon Rosenberg, Krishna Amuluru, Jared Pisapia, Neha S. Dangayach, John W. Liang, Christian A. Bowers, Stephan A. Mayer, Chirag D. Gandhi, and Fawaz Al-Mufti
- Subjects
Adult ,Intracranial Arteriovenous Malformations ,Rupture ,Leukocytosis ,Cerebral Infarction ,General Medicine ,Middle Aged ,Subarachnoid Hemorrhage ,Brain Ischemia ,Cross-Sectional Studies ,Humans ,Vasospasm, Intracranial ,Surgery ,Neurology (clinical) ,Hyponatremia - Abstract
OBJECTIVE Studies examining the risk factors and clinical outcomes of arterial vasospasm secondary to cerebral arteriovenous malformation (cAVM) rupture are scarce in the literature. The authors used a population-based national registry to investigate this largely unexamined clinical entity. METHODS Admissions for adult patients with cAVM ruptures were identified in the National Inpatient Sample during the period from 2015 to 2019. Complex samples multivariable logistic regression and chi-square automatic interaction detection (CHAID) decision tree analyses were performed to identify significant associations between clinical covariates and the development of vasospasm, and a cAVM–vasospasm predictive model (cAVM-VPM) was generated based on the effect sizes of these parameters. RESULTS Among 7215 cAVM patients identified, 935 developed vasospasm, corresponding to an incidence rate of 13.0%; 110 of these patients (11.8%) subsequently progressed to delayed cerebral ischemia (DCI). Multivariable adjusted modeling identified the following baseline clinical covariates: decreasing age by decade (adjusted odds ratio [aOR] 0.87, 95% CI 0.83–0.92; p < 0.001), female sex (aOR 1.68, 95% CI 1.45–1.95; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.34, 95% CI 1.01–1.79; p = 0.045), intraventricular hemorrhage (aOR 1.87, 95% CI 1.17–2.98; p = 0.009), hypertension (aOR 1.77, 95% CI 1.50–2.08; p < 0.001), obesity (aOR 0.68, 95% CI 0.55–0.84; p < 0.001), congestive heart failure (aOR 1.34, 95% CI 1.01–1.78; p = 0.043), tobacco smoking (aOR 1.48, 95% CI 1.23–1.78; p < 0.019), and hospitalization events (leukocytosis [aOR 1.64, 95% CI 1.32–2.04; p < 0.001], hyponatremia [aOR 1.66, 95% CI 1.39–1.98; p < 0.001], and acute hypotension [aOR 1.67, 95% CI 1.31–2.11; p < 0.001]) independently associated with the development of vasospasm. Intraparenchymal and subarachnoid hemorrhage were not associated with the development of vasospasm following multivariable adjustment. Among significant associations, a CHAID decision tree algorithm identified age 50–59 years (parent node), hyponatremia, and leukocytosis as important determinants of vasospasm development. The cAVM-VPM achieved an area under the curve of 0.65 (sensitivity 0.70, specificity 0.53). Progression to DCI, but not vasospasm alone, was independently associated with in-hospital mortality (aOR 2.35, 95% CI 1.29–4.31; p = 0.016) and lower likelihood of routine discharge (aOR 0.62, 95% CI 0.41–0.96; p = 0.031). CONCLUSIONS This large-scale assessment of vasospasm in cAVM identifies common clinical risk factors and establishes progression to DCI as a predictor of poor neurological outcomes.
- Published
- 2022
23. Impact of pre-ictal antiplatelet therapy use in aneurysmal subarachnoid hemorrhage
- Author
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Syed Ali, Sanjana Marikunte, Fawaz Al-Mufti, Stephan A. Mayer, Jose F. Dominguez, Eric Feldstein, Priyank Khandelwal, Vikas Patel, Kristen T. Huang, Hussein Alshammari, Nitesh Damodara, Jonathan V Ogulnick, Chirag D. Gandhi, Krishna Amuluru, Jared B. Cooper, and Michelle Bravo
- Subjects
Male ,medicine.medical_specialty ,Subarachnoid hemorrhage ,Ischemia ,Aneurysm, Ruptured ,Logistic regression ,Brain Ischemia ,Cerebral vasospasm ,Internal medicine ,medicine ,Humans ,Prospective cohort study ,Aged ,Retrospective Studies ,Aspirin ,business.industry ,Glasgow Coma Scale ,Retrospective cohort study ,Intracranial Aneurysm ,General Medicine ,Middle Aged ,Subarachnoid Hemorrhage ,medicine.disease ,Treatment Outcome ,Surgery ,Female ,Neurology (clinical) ,business ,Platelet Aggregation Inhibitors ,medicine.drug - Abstract
Objective There is limited evidence on the use of antiplatelet therapy (APT) to reduce the risk and morbidity of cerebral aneurysmal rupture. This analysis retrospectively assessed APT use in patients presenting to our institution with aneurysmal subarachnoid hemorrhage (aSAH). Methods We evaluated the records of 186 patients over 7 years of retrospective data from our tertiary care center and an existing database of patients with aSAH. A total of 18 cases with patients on APT and 168 patients not on APT (controls) were identified. Primary outcomes measured were clinical grade (Hunt and Hess score), radiographic grade (Fisher score), and presence of delayed cerebral ischemia (DCI). Secondary outcomes were modified Rankin score at discharge and at 3 months. DCI from cerebral vasospasm was defined as the occurrence of focal neurological impairment or a decrease in at least 2 points on the Glasgow Coma Scale. Logistic regression models were generated. Results We found that APT use did not appear to lead to statistically significant differences in initial presentation, including Hunt-Hess score and Fisher grade (2.91 vs 3.06, p = 0.66, and 3.23 vs 3.22, p = 0.96 respectively). In addition, APT use was not associated with increased rates of delayed cerebral ischemia (DCI) (OR 0.27 p = 0.12). Our analysis showed that increased Hunt Hess score and the presence of DCI are both associated with increased mRS at 90 days (OR 2.32 p Conclusion The patients in this retrospective observational study did not demonstrate worse outcomes from their aSAH despite APT therapy. Larger prospective studies should be performed to see if this relationship holds and if decreased rates of DCI can be observed.
- Published
- 2021
24. Admission neutrophil–lymphocyte ratio predicts delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage
- Author
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Michael Schmidt, Vincent Dodson, Nitesh Damodara, Sachin Agarwal, Fawaz Al-Mufti, Philip M. Meyers, Krishna Amuluru, E. Sander Connolly, Jan Claassen, David Roh, and Soojin Park
- Subjects
Adult ,Male ,medicine.medical_specialty ,Subarachnoid hemorrhage ,Neutrophils ,Ischemia ,030204 cardiovascular system & hematology ,Brain Ischemia ,Cohort Studies ,Sepsis ,03 medical and health sciences ,Patient Admission ,0302 clinical medicine ,Cerebral vasospasm ,Internal medicine ,Occlusion ,medicine ,Humans ,Glasgow Coma Scale ,Lymphocytes ,Prospective Studies ,Aged ,business.industry ,Vasospasm ,General Medicine ,Middle Aged ,Subarachnoid Hemorrhage ,medicine.disease ,Cardiology ,Biomarker (medicine) ,Female ,Surgery ,Neurology (clinical) ,business ,Biomarkers ,030217 neurology & neurosurgery - Abstract
BackgroundDelayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) has a multifactorial pathophysiology, with immune dysregulation being an important component. The neutrophil–lymphocyte ratio (NLR) is an established prognostic marker in patients with cancer, cardiac disease, and sepsis.ObjectiveTo determine whether there is a relationship between NLR and DCI in patients with aSAH.MethodsWe evaluated 1067 patients with aSAH between 2006 and 2015 enrolled in a single-center, prospective, observational cohort study. Admission white blood cell differentials (NLR) were analyzed using a cut-off point of ≥5.9. DCI from cerebral vasospasm was defined as the occurrence of focal neurological impairment, or a decrease in at least two points on the Glasgow Coma Scale, which was not apparent immediately after aneurysm occlusion, and could not be attributed to other causes. Cerebral infarct was defined as a new infarct on CT that was not visible on the admission or immediate postoperative scan, when the cause was thought to be vasospasm by the research team. Logistic regression models were generated.ResultsWe found that 768 (72%) patients had an admission NLR ≥5.9. In a multivariable model, elevated NLR was associated with poor admission Hunt-Hess grade (OR=1.6, 95% CI 1.2 to 2.6, p=0.005), Caucasian ethnicity (OR=2.6, 95% CI 1.9 to 3.7, pConclusionsThis study provides further evidence of the association between inflammation and DCI. Admission NLR is a readily available and convenient biomarker that may be a clinically useful tool for prognostication when evaluating aSAH.
- Published
- 2019
25. Neutrophil–Lymphocyte ratio is associated with poor clinical outcome after mechanical thrombectomy in stroke in patients with COVID-19
- Author
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Fawaz Al-Mufti, Priyank Khandelwal, Tolga Sursal, Jared B. Cooper, Eric Feldstein, Krishna Amuluru, Jayaji M. Moré, Ambooj Tiwari, Amit Singla, Adam A Dmytriw, Mariangela Piano, Luca Quilici, Guglielmo Pero, Leonardo Renieri, Nicola Limbucci, Mario Martínez-Galdámez, Miguel Schüller-Arteaga, Jorge Galván, Juan Francisco Arenillas-Lara, Zafar Hashim, Sanjeev Nayak, Keith Desousa, Hai Sun, Pankaj K. Agarwalla, J Sudipta Roychowdhury, Emad Nourollahzadeh, Tannavi Prakash, Andrew R Xavier, J Diego Lozano, Gaurav Gupta, Dileep R Yavagal, Mohammad Elghanem, Chirag D. Gandhi, and Stephan A. Mayer
- Subjects
General Medicine - Abstract
BackgroundThe neutrophil–lymphocyte ratio (NLR) is emerging as an important biomarker of acute physiologic stress in a myriad of medical conditions, and is a confirmed poor prognostic indicator in COVID-19.ObjectiveWe sought to describe the role of NLR in predicting poor outcome in COVID-19 patients undergoing mechanical thrombectomy for acute ischemic stroke.MethodsWe analyzed NLR in COVID-19 patients with large vessel occlusion (LVO) strokes enrolled into an international 12-center retrospective study of laboratory-confirmed COVID-19, consecutively admitted between March 1, 2020 and May 1, 2020. Increased NLR was defined as ≥7.2. Logistic regression models were generated.ResultsIncidence of LVO stroke was 38/6698 (.57%). Mean age of patients was 62 years (range 27–87), and mortality rate was 30%. Age, sex, and ethnicity were not predictive of mortality. Elevated NLR and poor vessel recanalization (Thrombolysis in Cerebral Infarction (TICI) score of 1 or 2a) synergistically predicted poor outcome (likelihood ratio 11.65, p = .003). Patients with NLR > 7.2 were 6.8 times more likely to die (OR 6.8, CI95% 1.2–38.6, p = .03) and almost 8 times more likely to require prolonged invasive mechanical ventilation (OR 7.8, CI95% 1.2–52.4, p = .03). In a multivariate analysis, NLR > 7.2 predicted poor outcome even when controlling for the effect of low TICI score on poor outcome (NLR p = .043, TICI p = .070).ConclusionsWe show elevated NLR in LVO patients with COVID-19 portends significantly worse outcomes and increased mortality regardless of recanalization status. Severe neuro-inflammatory stress response related to COVID-19 may negate the potential benefits of successful thrombectomy.
- Published
- 2022
26. Mandatory Neuroendovascular Evolution: Meeting the New Demands
- Author
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Eric R. Cohen, Rolla Nuoman, Mohammad El-Ghanem, Prateeka Koul, Philip M. Meyers, Krishna Amuluru, Chirag D. Gandhi, Francisco Gomez, Justin Santarelli, and Fawaz Al-Mufti
- Subjects
medicine.medical_specialty ,business.industry ,Review ,Stroke care ,medicine.disease ,Triage ,030218 nuclear medicine & medical imaging ,Mechanical thrombectomy ,Clinical trial ,03 medical and health sciences ,0302 clinical medicine ,Intervention (counseling) ,Emergency medicine ,Medicine ,Surgery ,cardiovascular diseases ,Neurology (clinical) ,Endovascular treatment ,Level of care ,Cardiology and Cardiovascular Medicine ,business ,Stroke ,030217 neurology & neurosurgery - Abstract
Background: Traditionally, patients undergoing acute ischemic strokes were candidates for mechanical thrombectomy if they were within the 6-h window from onset of symptoms. This timeframe would exclude many patient populations, such as wake-up strokes. However, the most recent clinical trials, DAWN and DEFUSE3, have expanded the window of endovascular treatment for acute ischemic stroke patients to within 24 h from symptom onset. This expanded window increases the number of potential candidates for endovascular intervention for emergent large vessel occlusions and raises the question of how to efficiently screen and triage this increase of patients. Summary: Abbreviated pre-hospital stroke scales can be used to guide EMS personnel in quickly deciding if a patient is undergoing a stroke. Telestroke networks connect remote hospitals to stroke specialists to improve the transportation time of the patient to a comprehensive stroke center for the appropriate level of care. Mobile stroke units, mobile interventional units, and helistroke reverse the traditional hub-and-spoke model by bringing imaging, tPA, and expertise to the patient. Smartphone applications and social media aid in educating patients and the public regarding acute and long-term stroke care. Key Messages: The DAWN and DEFUSE3 trials have expanded the treatment window for certain acute ischemic stroke patients with mechanical thrombectomy and subsequently have increased the number of potential candidates for endovascular intervention. This expansion brings patient screening and triaging to greater importance, as reducing the time from symptom onset to decision-to-treat and groin puncture can better stroke patient outcomes. Several strategies have been employed to address this issue by reducing the time of symptom onset to decision-to-treat time.
- Published
- 2018
27. Endovascular Techniques for Emergent Large Vessel Occlusion
- Author
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Krishna Amuluru and Fawaz Al-Mufti
- Subjects
medicine.medical_specialty ,business.industry ,Medicine ,Radiology ,business ,Large vessel occlusion - Published
- 2021
28. Correction to: Cerebrovascular Disorders
- Author
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Krishna Amuluru and Fawaz Al-Mufti
- Published
- 2021
29. Cerebral Aneurysms: Formation, Growth, and Rupture
- Author
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Krishna Amuluru and Fawaz Al-Mufti
- Subjects
business.industry ,Medicine ,business - Published
- 2021
30. Cryptogenic Stroke and Stroke of 'Unknown Cause'
- Author
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Fawaz Al-Mufti, Yuval Elkun, Krishna Amuluru, and Francisco Gomez
- Subjects
Cryptogenic stroke ,medicine.medical_specialty ,business.industry ,Internal medicine ,Cardiology ,Medicine ,business ,medicine.disease ,Stroke - Published
- 2021
31. Cerebral Venous Thrombosis in COVID-19: A New York Metropolitan Cohort Study
- Author
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Haris Kamal, Ambooj Tiwari, Chirag D. Gandhi, Jose F. Dominguez, Mohammad El-Ghanem, Katarina Dakay, Tolga Sursal, Gaurav Gupta, Jonathan V Ogulnick, K. Bekelis, Ramandeep Sahni, Philip Overby, Neha S. Dangayach, Edwin Gulko, Fawaz Al-Mufti, Stephan A. Mayer, Jared B. Cooper, Priyank Khandelwal, Blake E.S. Taylor, John W. Liang, Krishna Amuluru, K. Berekashvili, R. Karimi, and Rolla Nuoman
- Subjects
Adult ,Male ,Pediatrics ,medicine.medical_specialty ,Constitutional symptoms ,Population ,Comorbidity ,030218 nuclear medicine & medical imaging ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Thromboembolism ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,education ,Retrospective Studies ,Thrombectomy ,Venous Thrombosis ,education.field_of_study ,business.industry ,Incidence (epidemiology) ,Mortality rate ,Adult Brain ,COVID-19 ,Retrospective cohort study ,Middle Aged ,medicine.disease ,Causality ,Venous thrombosis ,Female ,New York City ,Neurology (clinical) ,Intracranial Thrombosis ,business ,030217 neurology & neurosurgery ,Cohort study - Abstract
BACKGROUND AND PURPOSE: Severe Acute Respiratory Syndrome coronavirus 2 (SARS-CoV-2) infection is associated with hypercoagulability. We sought to evaluate the demographic and clinical characteristics of cerebral venous thrombosis among patients hospitalized for coronavirus disease 2019 (COVID-19) at 6 tertiary care centers in the New York City metropolitan area. MATERIALS AND METHODS: We conducted a retrospective multicenter cohort study of 13,500 consecutive patients with COVID-19 who were hospitalized between March 1 and May 30, 2020. RESULTS: Of 13,500 patients with COVID-19, twelve had imaging-proved cerebral venous thrombosis with an incidence of 8.8 per 10,000 during 3 months, which is considerably higher than the reported incidence of cerebral venous thrombosis in the general population of 5 per million annually. There was a male preponderance (8 men, 4 women) and an average age of 49 years (95% CI, 36–62 years; range, 17–95 years). Only 1 patient (8%) had a history of thromboembolic disease. Neurologic symptoms secondary to cerebral venous thrombosis occurred within 24 hours of the onset of the respiratory and constitutional symptoms in 58% of cases, and 75% had venous infarction, hemorrhage, or both on brain imaging. Management consisted of anticoagulation, endovascular thrombectomy, and surgical hematoma evacuation. The mortality rate was 25%. CONCLUSIONS: Early evidence suggests a higher-than-expected frequency of cerebral venous thrombosis among patients hospitalized for COVID-19. Cerebral venous thrombosis should be included in the differential diagnosis of neurologic syndromes associated with SARS-CoV-2 infection.
- Published
- 2020
32. Patient Characteristics and Outcomes Associated with Decline in Stroke Volumes during the Early COVID-19 Pandemic
- Author
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Scott Geraghty, E. Francis LaFranchise, Jefferson T Miley, Krishna Amuluru, Adam N. Wallace, K. Derek Kreitel, Kaiz Asif, Marian P. LaMonte, Daniel H. Sahlein, Timothy Malisch, Daniel Gibson, and Steven Warach
- Subjects
Male ,Delayed Diagnosis ,Time Factors ,Psychological intervention ,Logistic regression ,Severity of Illness Index ,0302 clinical medicine ,Risk Factors ,Pandemic ,Thrombolytic Therapy ,Stroke ,Thrombectomy ,COVID-19, coronavirus disease 2019 ,Aged, 80 and over ,Univariate analysis ,Tissue plasminogen activator ,Rehabilitation ,Middle Aged ,Outcome and Process Assessment, Health Care ,Treatment Outcome ,MT, mechanical thrombectomy ,Female ,Cardiology and Cardiovascular Medicine ,mRS, Modified Rankin Scale ,medicine.medical_specialty ,Coronavirus disease 2019 (COVID-19) ,Risk Assessment ,Article ,Time-to-Treatment ,03 medical and health sciences ,medicine ,NIHSS, National Institute of Health Stroke Scale ,Humans ,cardiovascular diseases ,Aged ,Quality Indicators, Health Care ,Retrospective Studies ,LKW, last known well ,business.industry ,Public health ,ED, Emergency Department ,COVID-19 ,Patient Acceptance of Health Care ,medicine.disease ,Coronavirus ,CI, confidence interval ,OR, odds ratio ,Functional Status ,Propensity score matching ,Emergency medicine ,IV tPA, intravenous tissue plasminogen activator ,Surgery ,Neurology (clinical) ,business ,Mechanical thrombectomy ,030217 neurology & neurosurgery - Abstract
Highlights 5• Analysis of 7,389 patients from 11 states presenting before and after onset of COVID-19 pandemic 5• Stroke, IV tPA, and thrombectomy volumes decreased 35.0%, 33.4%, and 8.9% during early pandemic 5• Stroke patients during pandemic had higher baseline function and higher NIHSS on presentation 5• Stroke process measures and outcomes during early pandemic did not differ from pre-pandemic period, Background and Purpose Delayed evaluation of stroke may contribute to COVID-19 pandemic-related morbidity and mortality. This study evaluated patient characteristics, process measures and outcomes associated with the decline in stroke presentation during the early pandemic. Methods Volumes of stroke presentations, intravenous thrombolytic administrations, and mechanical thrombectomies from 52 hospitals from January 1-June 30, 2020 were analyzed with piecewise linear regression and linear spline models. Univariate analysis compared pandemic (case) and control groups defined in relation to the nadir of daily strokes during the study period. Significantly different patient characteristics were further evaluated with logistic regression, and significantly different process measures and outcomes were re-analyzed after propensity score matching. Results Analysis of 7,389 patients found daily stroke volumes decreased 0.91/day from March 12-26 (P < 0.0001), reaching a nadir 35.0% less than expected, and increased 0.15 strokes/day from March 27 – June 23, 2020 (P < 0.0001). Thrombolytic administrations decreased 3.3/week from February 19-March 31 (P=0.0023), reaching a nadir 33.4% less than then expected, and increased 1.4 administrations/week from April 1-June 23 (P
- Published
- 2020
33. The Dilator-Dotter Technique: A Modified Method of Rapid Internal Carotid Artery Revascularization in Acute Ischemic Stroke
- Author
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Krishna Amuluru, Daniel H. Sahlein, Andrew J. DeNardo, Fawaz Al-Mufti, T Payner, C Kulwin, and John A. Scott
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,Cerebral Revascularization ,Revascularization ,030218 nuclear medicine & medical imaging ,Brain Ischemia ,03 medical and health sciences ,0302 clinical medicine ,Angioplasty ,medicine.artery ,Occlusion ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Vertebral Artery ,Ischemic Stroke ,Interventional ,business.industry ,medicine.disease ,Stroke ,Stenosis ,Catheter ,Dilator ,Neurology (clinical) ,Radiology ,Internal carotid artery ,business ,030217 neurology & neurosurgery ,Carotid Artery, Internal - Abstract
BACKGROUND AND PURPOSE: Acute ischemic stroke due to tandem occlusive lesions involves high-grade ICA stenosis or occlusion with a distal intracranial occlusion. Several approaches and devices exist in the treatment of tandem occlusions; however, a consensus on the optimal technique does not exist. The Dotter technique is a method of catheter-based angioplasty to recanalize cervical ICA occlusions. We present a modified dilator-Dotter technique, which involves a polyethylene, tapered inner dilator to initially cross the occlusion, followed by guide catheterization and subsequent intracranial thrombectomy. The purpose of this study was to examine the safety and efficacy of this dilator-Dotter technique. MATERIALS AND METHODS: We performed a retrospective review of patients with acute stroke due to tandem ICA intracranial occlusions, treated with our dilator-Dotter technique and thrombectomy between June 2018 and December 2019. We examined clinical, radiographic, and procedural data, as well as complications and outcomes. RESULTS: Thirty-two patients were included. In 100% of cases, the dilator-Dotter technique resulted in ICA recanalization allowing successful thrombectomy. TICI 2b-3 revascularization was obtained in 31 patients (96%), within an average time of 25 minutes. The average preprocedural ICA stenosis was 98%, including 23 patients (72%) with complete occlusion. Following the dilator-Dotter technique, average ICA stenosis improved to 59%. There were no instances of death, iatrogenic dissection, emboli to new territory, or symptomatic intracranial hemorrhage. CONCLUSIONS: The dilator-Dotter technique may be a safe and effective modification of the traditional Dotter technique in allowing rapid ICA recanalization in cases of acute ischemic stroke due to tandem occlusions.
- Published
- 2020
34. Cardiac arrest in spontaneous subarachnoid hemorrhage and associated outcomes
- Author
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Eric Feldstein, Jose F. Dominguez, Gurkamal Kaur, Smit D. Patel, Alis J. Dicpinigaitis, Rosa Semaan, Leanne E. Fuentes, Jonathan Ogulnick, Christina Ng, Cameron Rawanduzy, Haris Kamal, Jared Pisapia, Simon Hanft, Krishna Amuluru, Srihari S. Naidu, Howard A. Cooper, Kartik Prabhakaran, Stephan A. Mayer, Chirag D. Gandhi, and Fawaz Al-Mufti
- Subjects
Hospitalization ,Treatment Outcome ,Humans ,Surgery ,Neurology (clinical) ,General Medicine ,Subarachnoid Hemorrhage ,United States ,Heart Arrest ,Retrospective Studies - Abstract
OBJECTIVE The authors sought to analyze a large, publicly available, nationwide hospital database to further elucidate the impact of cardiopulmonary arrest (CA) in association with subarachnoid hemorrhage (SAH) on short-term outcomes of mortality and discharge disposition. METHODS This retrospective cohort study was conducted by analyzing de-identified data from the National (Nationwide) Inpatient Sample (NIS). The publicly available NIS database represents a 20% stratified sample of all discharges and is powered to estimate 95% of all inpatient care delivered across hospitals in the US. A total of 170,869 patients were identified as having been hospitalized due to nontraumatic SAH from 2008 to 2014. RESULTS A total of 5415 patients (3.2%) were hospitalized with an admission diagnosis of CA in association with SAH. Independent risk factors for CA included a higher Charlson Comorbidity Index score, hospitalization in a small or nonteaching hospital, and a Medicaid or self-pay payor status. Compared with patients with SAH and not CA, patients with CA-SAH had a higher mean NIS Subarachnoid Severity Score (SSS) ± SD (1.67 ± 0.03 vs 1.13 ± 0.01, p < 0.0001) and a vastly higher mortality rate (82.1% vs 18.4%, p < 0.0001). In a multivariable model, age, NIS-SSS, and CA all remained significant independent predictors of mortality. Approximately 18% of patients with CA-SAH survived and were discharged to a rehabilitation facility or home with health services, outcomes that were most predicted by chronic disease processes and large teaching hospital status. CONCLUSIONS In the largest study of its kind, CA at onset was found to complicate roughly 3% of spontaneous SAH cases and was associated with extremely high mortality. Despite this, survival can still be expected in approximately 18% of patients.
- Published
- 2022
35. Severity of cerebral vasospasm associated with development of collaterals following aneurysmal subarachnoid hemorrhage
- Author
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Krishna Amuluru, Nathan W Manning, Joshua Z. Willey, Sachin Agarwal, Jan Claassen, Philip M. Meyers, E. Sander Connolly, Jens Witsch, Hooman Kamel, Fawaz Al-Mufti, Soojin Park, and Michael Crimmins
- Subjects
Adult ,Male ,medicine.medical_specialty ,Subarachnoid hemorrhage ,Ischemia ,Collateral Circulation ,030204 cardiovascular system & hematology ,Severity of Illness Index ,Brain Ischemia ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Aneurysm ,Cerebral vasospasm ,Internal medicine ,medicine ,Humans ,Vasospasm, Intracranial ,Prospective Studies ,cardiovascular diseases ,Retrospective Studies ,business.industry ,Reproducibility of Results ,Vasospasm ,General Medicine ,Middle Aged ,Subarachnoid Hemorrhage ,medicine.disease ,Infarct size ,Collateral circulation ,Cerebrovascular Circulation ,Cardiology ,Female ,Surgery ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,Cohort study - Abstract
IntroductionCerebral collateral circulation has been studied extensively in ischemic stroke where it has been shown to be a predictor of reperfusion, final infarct size, and outcome. Little is known about the significance of the collaterals in the setting of aneurysmal subarachnoid hemorrhage (aSAH). We sought to evaluate the effect of cerebral vasospasm on the development of cerebral collaterals following aneurysmal subarachnoid hemorrhage and the effects of the latter on delayed cerebral ischemia (DCI).MethodsWe retrospectively evaluated 64 aSAH patients with evidence of DCI between day 5 and 7, enrolled in a prospectively maintained observational cohort study. Angiograms were evaluated by four blinded neurointerventionalists. We compared good collateral grades to poor collateral grades, additionally we compared enrolled individuals with any collaterals versus patients who had no collaterals.ResultsInter-rater reliability for collateral grades was substantial (weighted kappa 0.632). Mild vasospasm was more frequent in patients with poor collateral grades compared with patients with good collateral grades (32% vs 4% P=0.012). There was no difference between the collateral groups with regards to DCI, functional, or cognitive outcome. Patients adjudicated to have any collaterals were more likely to have severe vasospasm (62% vs 33% P=0.023) and less likely to have mild vasospasm (37% vs 9% P=0.007). In a multivariable model, vasospasm severity remained associated with collateral status, while aneurysm location was not.ConclusionsThe severity of vasospasm following aSAH was associated with the development of collaterals. There was no difference between collateral grades with regards to DCI or outcome.
- Published
- 2018
36. Mechanical Thrombectomy of Acute Middle Cerebral Artery Occlusion Using Trans-Anterior Communicating Artery Approach
- Author
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Krishna Amuluru, Fawaz Al-Mufti, Mohammad El-Ghanem, Logan Pyle, and Charles E. Romero
- Subjects
Communicating Artery ,medicine.medical_specialty ,03 medical and health sciences ,0302 clinical medicine ,medicine.artery ,Occlusion ,medicine ,Humans ,cardiovascular diseases ,030212 general & internal medicine ,Common carotid artery ,Posterior communicating artery ,Stroke ,Aged ,Thrombectomy ,business.industry ,Endovascular Procedures ,Infarction, Middle Cerebral Artery ,Middle Aged ,medicine.disease ,Surgery ,Anterior communicating artery ,medicine.anatomical_structure ,cardiovascular system ,Female ,Neurology (clinical) ,Internal carotid artery ,business ,030217 neurology & neurosurgery ,Artery - Abstract
Background A cross-circulation technique involves gaining access to a cerebral vessel through a patent anterior or posterior communicating artery. This technique may be used in patients with emergent large-vessel occlusions and an unfavorable direct route to the occlusion. While few previous reports have demonstrated a successful cross-circulation technique for treatment of emergent large-vessel occlusions, we present the first 2 cases of transanterior communicating artery stent retriever thrombectomy. Case Description Case #1: A 64-year-old female presented with acute right middle cerebral artery (MCA) occlusion. She demonstrated a “triple-tandem” brachiocephalic–internal carotid artery–middle cerebral artery occlusion, thus precluding direct access to the right MCA. Successful stent retriever mechanical thrombectomy was performed across the anterior communicating artery, using a left internal carotid artery approach. Case #2: A 70-year old female presented with acute occlusion of the left MCA and tandem occlusion of the cervical left internal carotid artery. Multiple attempts to catheterize the left common carotid artery were unsuccessful. She underwent successful stent retriever mechanical thrombectomy across a patent anterior communicating artery, using a right internal carotid artery approach. Conclusions Timely recanalization of an occluded artery plays a critical role in the prognosis of patients with acute ischemic stroke. Successful stent retriever mechanical thrombectomy of an occluded MCA is possible using a transanterior communicating artery approach in patients without a direct access route to the occluded intracranial vessel. We review the pathophysiology of tandem lesions, access routes to intracranial occlusions, and the literature on cross-circulation techniques to treat emergent large-vessel occlusions.
- Published
- 2018
37. Rescue Therapy for Procedural Complications Associated With Deployment of Flow-Diverting Devices in Cerebral Aneurysms
- Author
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Vikas Patel, Vincent Dodson, Chirag D. Gandhi, Ethan Wajswol, Krishna Amuluru, Neha S. Dangayach, Sarmad Al-Marsoummi, Neil Majmundar, Mohammad El-Ghanem, Fawaz Al-Mufti, Eric R. Cohen, and Rolla Nuoman
- Subjects
medicine.medical_specialty ,business.industry ,medicine.disease ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,Aneurysm ,Rescue therapy ,Software deployment ,Side branch ,Occlusion ,medicine ,Surgery ,Neurology (clinical) ,Intensive care medicine ,business ,Intraparenchymal hemorrhage ,030217 neurology & neurosurgery ,Military deployment ,Flow diverter - Abstract
Flow diverting devices (FDDs) have revolutionized the treatment of morphologically complex intracranial aneurysms such as wide-necked, giant, or fusiform aneurysms. Although FDDs are extremely effective, they carry a small yet significant risk of intraprocedural complications. As the implementation of these devices increases, the ability to predict and rapidly treat complications, especially those that are iatrogenic or intraprocedural in nature, is becoming increasingly more necessary.Our objective in this paper is to provide a descriptive summary of the various types of intraprocedural complications that may occur during FDDs deployment and how they may best be treated. A systematic and qualitative review of the literature was conducted using electronic databases MEDLINE and Google Scholar. Searches consisted of Boolean operators "AND" and "OR" for the following terms in different combinations: "aneurysm," "endovascular," "flow diverter," "intracranial," and "pipeline."A total of 94 papers were included in our analysis; approximately 87 of these papers dealt with periprocedural endovascular (mainly related to FDDs) complications and their treatment; 7 studies concerned background material. The main categories of periprocedural complications encountered during deployment of FDDs are failure of occlusion, parent vessel injury and/or rupture, spontaneous intraparenchymal hemorrhage, migration or malposition of the FDDs, thromboembolic or ischemic events, and side branch occlusionPeriprocedural complications occur mainly due to thromboembolic events or mechanical issues related to device deployment and placement. With increasing use and expanding versatility of FDDs, the understanding of these complications is vital in order to effectively manage such situations in a timely manner.
- Published
- 2018
38. Clinical and Radiographic Predictors of Intracerebral Hemorrhage Outcome
- Author
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Krishna Amuluru, Tarundeep Singh, Ahmad M. Thabet, Fawaz Al-Mufti, Mohammad El-Ghanem, and Chirag D. Gandhi
- Subjects
Intracerebral hemorrhage ,medicine.medical_specialty ,Poor prognosis ,business.industry ,Radiography ,Mortality rate ,Incidence (epidemiology) ,Review ,030204 cardiovascular system & hematology ,medicine.disease ,Outcome (game theory) ,03 medical and health sciences ,High morbidity ,0302 clinical medicine ,Emergency medicine ,medicine ,Surgery ,Neurology (clinical) ,Cardiology and Cardiovascular Medicine ,business ,Stroke ,030217 neurology & neurosurgery - Abstract
Background: Intracerebral hemorrhage (ICH) represents 10-15% of all stroke cases in the US annually. Fewer than 40% of these patients ever reach long-term functional independence, and mortality rate is roughly 40% at 1 month. Due to the high morbidity and mortality rates after ICH, early detection of high-risk patients would be beneficial in directing the management course and goals of care. This review aims to discuss relevant clinical and radiographic characteristics that can serve as predictors of poor prognosis and examine their efficacy in predicting patient outcomes after ICH. Summary: A literature review was conducted on various clinical and radiographic factors. They were examined for their predictive value in relation to ICH outcome. Studies that focused on each of these factors were included, and their results analyzed for trends with regard to incidence, patient outcome, and mortality rate. Key Message: In this review, we examined clinical and radiographic characteristics that have been found to be significantly associated to a varying degree with poor outcome. Clinical and radiographic predictors of poor patient outcome are invaluable when it comes to identifying high-risk patients and triaging accordingly as well as guiding decision-making.
- Published
- 2018
39. Acute Ischemic Stroke due to Common Carotid Ostial Disease with Tandem Intracranial Occlusions Treated with Thrombectomy and Staged Retrograde Stenting
- Author
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Fawaz Al-Mufti, Krishna Amuluru, and Charles E. Romero
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,030218 nuclear medicine & medical imaging ,Lesion ,03 medical and health sciences ,0302 clinical medicine ,medicine.artery ,Occlusion ,Medicine ,cardiovascular diseases ,Common carotid artery ,Stroke ,business.industry ,medicine.disease ,Ostium ,Stenosis ,cardiovascular system ,Neurological Emergencies and Critical Care ,Surgery ,Neurology (clinical) ,Radiology ,Carotid stenting ,medicine.symptom ,Internal carotid artery ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery - Abstract
Background: Acute ischemic stroke due to tandem occlusive lesions of the anterior circulation involves an intracranial large vessel occlusion as well as a concurrent occlusion or high-grade stenosis of the proximal carotid system. The vast majority of proximal lesions in tandem occlusive cases involve the extracranial internal carotid artery, although the lesion can theoretically exist anywhere along the carotid artery pathway, including the common carotid ostium. Summary: To the best of our knowledge, only 1 report describes common carotid artery ostial lesions in the setting of acute ischemic stroke due to tandem occlusions, in which the authors describe an anterograde treatment paradigm. We present the first 2 cases of acute ischemic stroke secondary to common carotid ostial disease with tandem intracranial occlusion, treated with intracranial thrombectomy followed by subsequent staged balloon-mounted stenting of the common carotid ostium. We review the pathophysiology of tandem occlusions, the controversy surrounding treatment techniques, and various approaches used in the treatment of ostial occlusive lesions. Key Message: In certain situations where acute carotid stenting is not safe or technically possible, immediate intracranial thrombectomy with a subsequent staged balloon-mounted stenting of the ostial lesion may be a reasonable and safe option.
- Published
- 2018
40. Emerging Markers of Early Brain Injury and Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage
- Author
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Brendan Smith, Neha S. Dangayach, Mohammad El-Ghanem, Inder Paul Singh, Fawaz Al-Mufti, Nitesh Damodara, Chirag D. Gandhi, and Krishna Amuluru
- Subjects
Subarachnoid hemorrhage ,Intracranial Pressure ,Ischemia ,Brain Edema ,Context (language use) ,Unconsciousness ,030204 cardiovascular system & hematology ,Brain Ischemia ,Cerebral edema ,03 medical and health sciences ,0302 clinical medicine ,Risk Factors ,Humans ,Vasospasm, Intracranial ,Medicine ,Ictal ,business.industry ,Electroencephalography ,Subarachnoid Hemorrhage ,Bleed ,Prognosis ,medicine.disease ,Systemic Inflammatory Response Syndrome ,Pathophysiology ,Systemic inflammatory response syndrome ,Early Diagnosis ,Brain Injuries ,Anesthesia ,Surgery ,Neurology (clinical) ,Epidemiologic Methods ,business ,Biomarkers ,030217 neurology & neurosurgery - Abstract
Background Delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage is characterized by a highly complex pathophysiology and results in neurologic deterioration after the inciting bleed. Despite its significant consequences, prompt diagnosis can be elusive and treatment is often administered too late. Early brain injury, which occurs within the first 72 hours after ictus, may be an important factor for delayed cerebral ischemia and poor overall outcome. Here, we explore the purported clinical and pathologic manifestations of early brain injury to identify biomarkers that could have prognostic value. Methods We review the literature and discuss potential emerging markers of delayed cerebral ischemia in the context of early brain injury. Results The following clinical features and biomarkers were examined: global cerebral edema, ictal loss of consciousness, ultra early angiographic vasospasm, continuous electroencephalogram monitoring, systemic inflammatory response syndrome, cellular mediators of the inflammatory response, and hematologic derangements. Conclusions Some of these markers possess independent value for determining the risk of complications after aneurysmal subarachnoid hemorrhage. However, their use is limited because of a variety of factors, but they do provide an avenue of further study to aid in diagnosis and management.
- Published
- 2017
41. Spontaneous Bilateral Carotid-Cavernous Fistulas Secondary to Cavernous Sinus Thrombosis
- Author
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Abhinav R Changa, Charles J. Prestigiacomo, Inder Paul Singh, Mohammad El-Ghanem, Krishna Amuluru, Fawaz Al-Mufti, and Chirag D. Gandhi
- Subjects
Male ,medicine.medical_specialty ,Cavernous sinus thrombosis ,Endovascular therapy ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,Carotid-Cavernous Sinus Fistula ,0302 clinical medicine ,medicine ,Bendamustine Hydrochloride ,Humans ,Pathologic fistula ,Aged ,Neuroradiology ,business.industry ,Endovascular Procedures ,Cavernous Sinus Thrombosis ,Anticoagulants ,Middle Aged ,medicine.disease ,Embolization, Therapeutic ,Surgery ,Shunt (medical) ,Neurology (clinical) ,business ,030217 neurology & neurosurgery - Abstract
Bilateral carotid cavernous fistulas are rare entities that can cause debilitating symptoms and can lead to more severe consequences if left untreated. Therefore, the recognition and adequate treatment of these pathologies is very important. We present 2 cases of bilateral carotid cavernous fistulas that arose as a result of cavernous sinus thrombosis. We review the literature and discuss the pathophysiology, symptomatology, management, and treatment of bilateral carotid cavernous fistulas. Within our own cases, treatment of the patients was varied. The patient in case 1 was successfully treated with endovascular therapy after a failed trial of anticoagulation. The patient in case 2 demonstrated resolution of bilateral carotid cavernous fistulas after anticoagulation therapy. Case 2 highlights the fact that certain cases of bilateral carotid cavernous fistulas due to cavernous sinus thrombosis may benefit from extensive anticoagulation therapy. If anticoagulation therapy is unsuccessful, endovascular therapy may prove beneficial in resolving the fistulous shunt.
- Published
- 2017
42. Anchoring Pipeline Flow Diverter Construct in the Treatment of Traumatic Distal Cervical Carotid Artery Injury
- Author
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Chirag D. Gandhi, Fawaz Al-Mufti, Charles J. Prestigiacomo, William Roth, and Krishna Amuluru
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Revascularization ,03 medical and health sciences ,Pseudoaneurysm ,0302 clinical medicine ,medicine.artery ,Adventitia ,medicine ,cardiovascular diseases ,Embolization ,Original Paper ,Arterial dissection ,business.industry ,medicine.disease ,Surgery ,Dissection ,medicine.anatomical_structure ,cardiovascular system ,Neurology (clinical) ,Radiology ,Internal carotid artery ,Cardiology and Cardiovascular Medicine ,business ,Complication ,030217 neurology & neurosurgery - Abstract
Background: Traumatic extracranial internal carotid artery (ICA) dissections are uncommon and can be difficult to treat. Thinning of adventitia and dilatation may occur following arterial dissection, thus resulting in a fusiform pseudoaneurysm, which can subsequently cause bleeding, expanding, or pulsatile hematoma. Currently, medical management with anticoagulation remains the first line of treatment and yields good outcomes in 75% of cases with a mortality rate of 3-4%. Endovascular intervention is indicated with failure of medical therapy, progressive enlargement of a traumatic pseudoaneurysm, acute flow-related infarcts due to vessel occlusion, or when anticoagulation is contraindicated due to risk of pseudoaneurysm rupture and hemorrhage. Recognized interventional treatments include parent artery occlusion with or without revascularization, endovascular coil embolization, and covered stenting. Summary: A wide variety of endovascular stents are available that are capable of opening a stenosed vessel while obliterating the associated false lumen and providing a scaffold for embolization of the pseudoaneurysm. The use of the Pipeline Embolization Device (PED) in the management of traumatic intracranial pseudoaneurysms has been described. However, there are few reports on the usage of the PED for treating traumatic extracranial ICA dissection and/or pseudoaneurysms. However, a potential complication of the use of PED in the extracranial ICA is a hypothetical tendency to migrate in a mobile vessel. Thus, the risk of migration of the PED has encouraged practitioners to adopt strategies to limit this risk. Key Messages: We describe different techniques employed to anchor the flow-diverting construct within tortuous, mobile vessels.
- Published
- 2017
43. Off-Label Uses for Flow Diversion in Intracranial Aneurysm Management
- Author
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Mohammad El-Ghanem, Chirag D. Gandhi, Krishna Amuluru, Gomez Francisco, Fawaz Al-Mufti, Charles J. Prestigiacomo, and Vincent Dodson
- Subjects
medicine.medical_specialty ,Subarachnoid hemorrhage ,business.industry ,medicine.medical_treatment ,Perforation (oil well) ,Stent ,Fusiform Aneurysm ,Blood flow ,medicine.disease ,Thrombosis ,030218 nuclear medicine & medical imaging ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,Aneurysm ,Occlusion ,cardiovascular system ,medicine ,Radiology, Nuclear Medicine and imaging ,cardiovascular diseases ,Neurology (clinical) ,business ,030217 neurology & neurosurgery - Abstract
Treatment of complex aneurysms using microsurgical and other conventional neuroendovascular techniques remains challenging. As a result, stent- and balloon-assisted coiling are instead performed to treat morphologically complex aneurysms, which include giant, wide-necked, and fusiform aneurysms. While these techniques have had success in treating these complex aneurysms, recanalization rates associated with these techniques are still problematic. In the constant effort to improve the outcome of complex aneurysm treatment, flow-diverting stents (FDSs) have emerged in recent years as the preferred treatment. Instead of directly obstructing the flow of blood into the aneurysmal sac, as is the case for stent- and balloon-assisted coiling, FDSs are placed in the parent blood vessel to divert blood flow away from the aneurysm itself. Subsequent to the diverting away of blood from the aneurysm, a thrombotic cascade ensues that ultimately results in the closure of the aneurysm while the parent vessel's perforators are preserved. Current known risks for this procedure include vessel rupture or perforation, in-stent thrombosis, perforator occlusion, procedural or delayed hemorrhages, and perianeurysmal edema. In this review, we will evaluate the mechanisms of actions, clinical applications, complications, and ongoing studies for FDSs.
- Published
- 2016
44. Flow diversion treatment of anterior communicating artery region aneurysms
- Author
-
Charles E. Romero, Fawaz Al-Mufti, and Krishna Amuluru
- Subjects
medicine.medical_specialty ,medicine.medical_treatment ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,Aneurysm ,medicine.artery ,Occlusion ,medicine ,Humans ,Radiology, Nuclear Medicine and imaging ,Embolization ,Retrospective Studies ,Radiological and Ultrasound Technology ,Flow diversion ,Groin ,business.industry ,Endovascular Procedures ,Intracranial Aneurysm ,Arteries ,medicine.disease ,Embolization, Therapeutic ,Surgery ,Cerebral Angiography ,Anterior communicating artery ,medicine.anatomical_structure ,Treatment Outcome ,Hemorrhagic complication ,Neurology (clinical) ,business ,030217 neurology & neurosurgery ,Circle of Willis - Abstract
Background and purpose Reports on flow diversion treatment of aneurysms beyond the Circle of Willis are limited, with few series dedicated to anterior communicating artery region aneurysms. The purpose of this study is to evaluate the safety and effectiveness of the pipeline embolization device in the treatment of anterior communicating artery region aneurysms. Materials and methods The neuro-interventional database of a single institution was retrospectively reviewed for anterior communicating artery aneurysms treated with the pipeline embolization device between November 2016 and December 2018. Data on clinical presentation, aneurysm location, type, vessel size, procedural complications, clinical and imaging follow-up were analyzed. Results Ten patients with 11 anterior communicating artery aneurysms were included. Procedural success was achieved in 9/10 patients (90%). Flow diversion with the pipeline embolization device yielded occlusion in 100% of patients at 6.5 months. Symptomatic ischemic complications occurred in 2/10 patients (20%); only one of who had permanent symptoms. Hemorrhagic groin complications were encountered in 2/10 patients (20%). There were no deaths and no cerebral hemorrhagic complications. Conclusions Flow diversion therapy may provide a feasible solution for anterior communicating artery region aneurysms that are not amenable to traditional surgical or endovascular modalities.
- Published
- 2019
45. Pipeline embolization device deployment via an envoy distal access XB guiding catheter—biaxial platform: A technical note
- Author
-
Chirag D. Gandhi, Charles J. Prestigiacomo, Fawaz Al-Mufti, Inder Paul Singh, and Krishna Amuluru
- Subjects
medicine.medical_specialty ,Catheters ,medicine.medical_treatment ,Posterior cerebral artery ,Magnetic resonance angiography ,Catheterization ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,Aneurysm ,medicine.artery ,medicine ,Humans ,Vasospasm, Intracranial ,Embolization ,Intraoperative Complications ,Posterior Cerebral Artery ,medicine.diagnostic_test ,business.industry ,Methodology ,Angiography, Digital Subtraction ,Intracranial Aneurysm ,Middle Aged ,medicine.disease ,Embolization, Therapeutic ,Pipeline (software) ,Cerebral Angiography ,Surgery ,Catheter ,Software deployment ,cardiovascular system ,Female ,Stents ,business ,Magnetic Resonance Angiography ,030217 neurology & neurosurgery ,Cerebral angiography - Abstract
With the increased reliance on the Pipeline embolization device (PED) for the treatment of complex intracranial aneurysms, our experience in managing intraoperative complications and challenges continues to accumulate amid a scarcity of reports on rescue strategies and innovative techniques. We describe the case of a 50-year-old woman who presented for elective repeat embolization of a right posterior communicating artery aneurysm with some residual aneurysmal filling. During the procedure the patient developed severe vasospasm due to vessel irritation and this led us to proceed to deploy the PED through a biaxial construct composed of the 6 French Envoy MPD DA XB, and the Marksman catheters. The biaxial construct in select patients may provide the required stability while eliminating the need for an intermediate catheter, minimizing embolic risk, and allowing for less irritation to the vessel. Larger studies are required for further validation.
- Published
- 2016
46. Arteriovenous Malformations in the Pediatric Population: Review of the Existing Literature
- Author
-
Yazan J. Alderazi, Mohammad El-Ghanem, Krishna Amuluru, Fawaz Al-Mufti, Chirag D. Gandhi, Charles J. Prestigiacomo, Tareq Kass-Hout, and Omar Kass-Hout
- Subjects
medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Gold standard ,Review ,Multimodality Therapy ,Microsurgery ,Radiosurgery ,030218 nuclear medicine & medical imaging ,Surgery ,Natural history ,03 medical and health sciences ,0302 clinical medicine ,medicine ,Adjuvant therapy ,Neurology (clinical) ,Radiology ,Embolization ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery ,Pediatric population - Abstract
Arteriovenous malformations (AVMs) in the pediatric population are relatively rare but reportedly carry a higher rate of rupture than in adults. This could be due to the fact that most pediatric AVMs are only detected after rupture. We aimed to review the current literature regarding the natural history and the clinical outcome after multimodality AVM treatment in the pediatric population, as optimal management for pediatric AVMs remains controversial. A multidisciplinary approach using multimodality therapy if needed has been proved to be beneficial in approaching these lesions in all age groups. Microsurgical resection remains the gold standard for the treatment of all accessible pediatric AVMs. Embolization and radiosurgery should be considered as an adjunctive therapy. Embolization provides a useful adjunct therapy to microsurgery by preventing significant blood loss and to radiosurgery by decreasing the volume of the AVM. Radiosurgery has been described to provide an alternative treatment approach in certain circumstances either as a primary or adjuvant therapy.
- Published
- 2016
47. Flow Diverters for Treatment of Intracranial Aneurysms: Technical and Clinical Updates
- Author
-
Krishna Amuluru, Charles J. Prestigiacomo, Inder Paul Singh, Chirag D. Gandhi, and Fawaz Al-Mufti
- Subjects
medicine.medical_specialty ,business.industry ,Treatment outcome ,Intracranial Aneurysm ,Equipment Design ,Combined Modality Therapy ,Embolization, Therapeutic ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,Treatment Outcome ,0302 clinical medicine ,Recurrence ,Humans ,Medicine ,Stents ,Surgery ,Neurology (clinical) ,Radiology ,business ,030217 neurology & neurosurgery ,Flow diverter - Published
- 2016
48. In Defense of Our Patients: Indirect Negative Neurological Consequences of SARS-CoV-2 in the New York Epicenter
- Author
-
Jose F. Dominguez, Fawaz Al-Mufti, Stephan A. Mayer, Rachana Tyagi, Alan A. Stein, Anubhav G. Amin, Michael G. Kim, Jared B. Cooper, Krishna Amuluru, and Chirag D. Gandhi
- Subjects
medicine.medical_specialty ,2019-20 coronavirus outbreak ,Coronavirus disease 2019 (COVID-19) ,Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ,Clinical Neurology ,medicine.disease_cause ,Article ,law.invention ,law ,Pandemic ,Medicine ,Coronavirus ,COVID-19, coronavirus disease 2019 ,CoViD-19 ,biology ,business.industry ,SARS-CoV-2 ,Disease progression ,Rehabilitation ,NIHSS, National Institutes of Health Stroke Scale ,biology.organism_classification ,Intensive care unit ,ICU, intensive care unit ,CT, computed tomography ,Emergency medicine ,Surgery ,ED, emergency department ,Neurology (clinical) ,business ,Cardiology and Cardiovascular Medicine ,Betacoronavirus - Published
- 2020
49. Endovascular intervention of acute ischemic stroke due to occlusion of fetal posterior cerebral artery
- Author
-
Sten Solander, Fawaz Al-Mufti, Charles E. Romero, James Ho, and Krishna Amuluru
- Subjects
Male ,medicine.medical_specialty ,Computed Tomography Angiography ,Posterior cerebral artery ,030218 nuclear medicine & medical imaging ,03 medical and health sciences ,0302 clinical medicine ,medicine.artery ,Internal medicine ,Occlusion ,medicine ,Humans ,In patient ,cardiovascular diseases ,Cerebral infarcts ,Acute ischemic stroke ,Stroke ,Aged ,Retrospective Studies ,Thrombectomy ,Posterior Cerebral Artery ,Fetus ,Endarterectomy, Carotid ,business.industry ,Endovascular Procedures ,Angiography, Digital Subtraction ,Middle Aged ,medicine.disease ,Magnetic Resonance Imaging ,Cerebral Angiography ,Treatment Outcome ,Cardiology ,cardiovascular system ,Internal carotid artery ,business ,Tomography, X-Ray Computed ,030217 neurology & neurosurgery - Abstract
A fetal posterior cerebral artery (FPCA) is an anatomic variant in which the posterior cerebral artery is an embryological derivative of the internal carotid artery. Although most cases of ischemic strokes in patients with FPCAs involve embolic infarcts, emergent large vessel occlusion of a FPCA is extremely rare. We present two cases of successful endovascular intervention for emergent occlusion of a FPCA, one of which is only the second reported case of a mechanical thrombectomy of a FPCA. We review the embryology of FPCA, the controversy regarding its association with cerebral infarcts, and various approaches used in the treatment of such occlusive lesions.
- Published
- 2018
50. E-171 Low glasgow coma score in traumatic intracranial hemorrhage predicts development of cerebral vasospasm
- Author
-
Krishna Amuluru, Megan Lander, Fawaz Al-Mufti, Chirag D. Gandhi, Vikas Patel, Neil Majmundar, Mohammad El-Ghanem, S Park, M Matthew, and Rolla Nuoman
- Subjects
Subarachnoid hemorrhage ,medicine.diagnostic_test ,business.industry ,Traumatic brain injury ,Trauma center ,Ischemia ,Glasgow Coma Scale ,Vasospasm ,Digital subtraction angiography ,medicine.disease ,nervous system diseases ,Cerebral vasospasm ,Anesthesia ,Medicine ,cardiovascular diseases ,business - Abstract
Background The exact mechanism, incidence and risk factors for cerebral vasospasm following traumatic intracranial hemorrhage (ICH) continues to be poorly characterized. The incidence of post-traumatic vasospasm (PTV) varies depending on the detection modality. Objective We aimed to shed light on the predictors, associations and true incidence of cerebral vasospasm following traumatic ICH using digital subtraction angiography (DSA) as the gold standard. Methods We examined a prospectively maintained database of traumatic brain injury (TBI) patients to identify patients with ICH secondary to TBI enrolled between 2002 and 2015 at our trauma center. Patients with TBI-associated ICH and evidence of vasospasm confirmed with digital subtraction angiography (DSA) were included. The diagnostic cerebral angiograms were evaluated by 2 blinded neurointerventionalists for cerebral vasospasm. Statistical analyses were conducted to determine predictors of PTV. Results 20 patients with ICH secondary to TBI and evidence of vasospasm underwent DSAs. Seven patients (7/20; 35%) with traumatic ICH developed cerebral vasospasm and of those, one developed delayed cerebral ischemia (DCI) (1/7; 14%). Of these 7 patients, 6 presented with subarachnoid hemorrhage (SAH) (6/7; 85%). Vasospasm was substantially more common in patients with a Glasgow Coma Scale (GCS) Conclusions PTV as demonstrated by DCA may be more common than previously reported. Patients who exhibit PTV were more likely to have a GCS Disclosures F. Al-Mufti: None. K. Amuluru: None. N. Majmundar: None. M. Lander: None. M. Matthew: None. M. El-Ghanem: None. R. Nuoman: None. S. Park: None. V. Patel: None. C. Gandhi: None.
- Published
- 2018
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