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  • 1
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    The impact of postoperative aspirin in patients undergoing Woven EndoBridge: a multicenter, institutional, propensity score-matched analysis
    BMJ ; 2024
    In:  Journal of NeuroInterventional Surgery
    Details
    In: Journal of NeuroInterventional Surgery, BMJ
    Abstract: The Woven EndoBridge (WEB) device is frequently used for the treatment of intracranial aneurysms. Postoperative management, including the use of aspirin, varies among clinicians and institutions, but its impact on the outcomes of the WEB has not been thoroughly investigated. Methods This was a retrospective, multicenter study involving 30 academic institutions in North America, South America, and Europe. Data from 1492 patients treated with the WEB device were included. Patients were categorized into two groups based on their postoperative use of aspirin (aspirin group: n=1124, non-aspirin group: n=368). Data points included patient demographics, aneurysm characteristics, procedural details, complications, and angiographic and functional outcomes. Propensity score matching (PSM) was applied to balance variables between the two groups. Results Prior to PSM, the aspirin group exhibited significantly higher rates of modified Rankin scale (mRS) mRS 0–1 and mRS 0–2 (89.8% vs 73.4% and 94.1% vs 79.8%, p 〈 0.001), lower rates of mortality (1.6% vs 8.6%, p 〈 0.001), and higher major compaction rates (13.4% vs 7%, p 〈 0.001). Post-PSM, the aspirin group showed significantly higher rates of retreatment (p=0.026) and major compaction (p=0.037) while maintaining its higher rates of good functional outcomes and lower mortality rates. In the multivariable regression, aspirin was associated with higher rates of mRS 0–1 (OR 2.166; 95% CI 1.16 to 4, p=0.016) and mRS 0–2 (OR 2.817; 95% CI 1.36 to 5.88, p=0.005) and lower rates of mortality (OR 0.228; 95% CI 0.06 to 0.83, p=0.025). However, it was associated with higher rates of retreatment (OR 2.471; 95% CI 1.11 to 5.51, p=0.027). Conclusions Aspirin use post-WEB treatment may lead to better functional outcomes and lower mortality but with higher retreatment rates. These insights are crucial for postoperative management after WEB procedures, but further studies are necessary for validation.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/jnis-2023-021082
    Language: English
    Publisher: BMJ
    Publication Date: 2024
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  • 2
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    Abstract 15733: Investigation of Cerebral Vessel Geometric Morphometrics for Prediction of Mechanical Thrombectomy First Pass Outcome
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Circulation Vol. 146, No. Suppl_1 ( 2022-11-08)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 146, No. Suppl_1 ( 2022-11-08)
    Abstract: Introduction: Vessel tortuosity is a major factor in successful first pass outcomes for mechanical thrombectomy (MT), but prior methods to quantify tortuosity are not accurate enough to predict outcome. We investigated a new method for vessel characterization and outcome prediction based on geometric morphometrics (GMM). Hypothesis: Our hypothesis was that morphometric analysis of engineered centerline landmarks would identify vessel characteristics that can better predict first pass MT outcome. Methods: Vessels and clots were manually segmented and reconstructed from pre-treatment CTA and nCCT images ( n =5 cases) (Fig. 1A). The vasculature corresponding to the ICA and MCA from the affected hemisphere was isolated, and centerlines were engineered as curved landmarks. MorphoJ, a GMM software, was used to complete generalized Procrustes and principal component (PC) Analysis that included registration of patient geometries, calculation of average morphology and landmark variation, and identification of anatomical landmarks differentiating MT outcomes (Fig. 1B). Morphometrics were compared against local and overall tortuosity by measuring the separability of and cohesion within outcome classes. Results: GMM produced two PCs, which described local variation in M1 (PC1) and the ICA (PC2) (Fig. 1B). When compared against vessel tortuosity features, GMM PCs increased the distance between outcome classes (first pass effect vs. no first pass effect), improving separability by 23.6%. Further, GMM PCs increased the compactness/cohesion of outcome classes, reducing cumulative distance between failures by 50% and successes by 9.4% (Fig. 1C). Conclusions: GMM analysis of pre-treatment vessel characteristic highlights regional variation in M1 as a strong indicator of MT failure and suggests that GMM has the potential to better predict MT outcome than ICA tortuosity alone. Investigation of more complex vessel morphometry through feature engineering is needed.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.146.suppl_1.15733
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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  • 3
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    Stroke thrombectomy volume, rather than stroke center accreditation status of hospitals, is associated with mortality and discharge disposition
    BMJ ; 2023
    In:  Journal of NeuroInterventional Surgery Vol. 15, No. 3 ( 2023-03), p. 209-213
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 15, No. 3 ( 2023-03), p. 209-213
    Abstract: Few studies have explored the association between stroke thrombectomy (ST) volume and hospital accreditation with clinical outcomes. Objective To assess the association of ST case volume and accreditation status with in-hospital mortality and home discharge disposition using the national Medicare Provider Analysis and Review (MEDPAR) database. Methods Rates of hospital mortality, home discharge disposition, and hospital stay were compared between accredited and non-accredited hospitals using 2017–2018 MEDPAR data. The association of annual ST case volume with mortality and home disposition was determined using Pearson’s correlation. Median rate of mortality and number of ST cases at hospitals within the central quartiles were estimated. Results A total of 29 355 cases were performed over 2 years at 847 US centers. Of these, 354 were accredited. There were no significant differences between accredited and non-accredited centers for hospital mortality (14.8% vs 14.5%, p=0.34) and home discharge (12.1% vs 12.0%, p=0.78). A significant positive correlation was observed between thrombectomy volume and home discharge (r=0.88; 95% CI 0.58 to 0.97, p=0.001). A significant negative relationship was found between thrombectomy volume and mortality (r=−0.86; 95% CI −0.97 to −0.49, p=0.002). Within the central quartiles, the median number of ST cases at hospitals with mortality was 24/year, and the median number of ST cases at hospitals with home discharge rate was 23/year. Conclusion A higher volume of ST cases was associated with lower mortality and higher home discharge rate. No significant differences in mortality and discharge disposition were found between accredited and non-accredited hospitals.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2021-018079
    Language: English
    Publisher: BMJ
    Publication Date: 2023
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  • 4
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    Comparison of PED and FRED flow diverters for posterior circulation aneurysms: a propensity score matched cohort study
    BMJ ; 2021
    In:  Journal of NeuroInterventional Surgery Vol. 13, No. 2 ( 2021-02), p. 153-158
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 13, No. 2 ( 2021-02), p. 153-158
    Abstract: Flow diversion is a common endovascular treatment for cerebral aneurysms, but studies comparing different types of flow diverters are scarce. Objective To perform a propensity score matched cohort study comparing the Pipeline Embolization Device (PED) and Flow Redirection Intraluminal Device (FRED) for posterior circulation aneurysms. Methods Consecutive aneurysms of the posterior circulation treated at 25 neurovascular centers with either PED or FRED were collected. Propensity score matching was used to control for age, duration of follow-up imaging, adjunctive coiling, and aneurysm location, size, and morphology; previously ruptured aneurysms were excluded. The two devices were compared for the following outcomes: procedural complications, aneurysm occlusion, and functional outcome. Results A total of 375 aneurysms of the posterior circulation were treated in 369 patients. The PED was used in 285 (77.2%) and FRED in 84 (22.8%) procedures. Aneurysms treated with the PED were more commonly fusiform and larger than those treated with FRED. To account for these important differences, propensity score matching was performed resulting in 33 PED and FRED unruptured aneurysm pairs. No differences were found in occlusion status and neurologic thromboembolic or hemorrhagic complications between the two devices. The proportion of patients with favorable functional outcome was higher with FRED (100% vs 87.9%, p=0.04). Conclusion Comparative analysis of PED and FRED for the treatment of unruptured posterior circulation aneurysms did not identify significant differences in aneurysm occlusion or neurologic complications. Variations in functional outcomes warrant additional investigations.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2020-016055
    Language: English
    Publisher: BMJ
    Publication Date: 2021
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  • 5
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    Clot imaging characteristics predict first pass effect of aspiration—first approach to thrombectomy
    SAGE Publications ; 2022
    In:  Interventional Neuroradiology Vol. 28, No. 2 ( 2022-04), p. 152-159
    Details
    In: Interventional Neuroradiology, SAGE Publications, Vol. 28, No. 2 ( 2022-04), p. 152-159
    Abstract: The value of clot imaging in patients with emergent large vessel occlusion (ELVO) treated with thrombectomy is unknown. Methods We performed retrospective analysis of clot imaging (clot density, perviousness, length, diameter, distance to the internal carotid artery (ICA) terminus and angle of interaction (AOI) between clot and the aspiration catheter) of consecutive cases of middle cerebral artery (MCA) occlusion and its association with first pass effect (FPE, TICI 2c-3 after a first attempt). Results Patients ( n = 90 total) with FPE had shorter clot length (9.9 ± 4.5 mm vs. 11.7 ± 4.6 mm, P = 0.07), shorter distance from ICA terminus (11.0 ± 7.1 mm vs. 14.7 ± 9.8 mm, P = 0.048), higher perviousness (39.39 ± 29.5 vs 25.43 ± 17.6, P = 0.006) and larger AOI (153.6 ± 17.6 vs 140.3 ± 23.5, P = 0.004) compared to no-FPE patients. In multivariate analysis, distance from ICA terminus to clot ≤13.5 mm (odds ratio (OR) 11.05, 95% confidence interval (CI) 2.65–46.15, P = 0.001), clot length ≤9.9 mm (OR 7.34; 95% CI 1.8–29.96, P = 0.005), perviousness ≥ 19.9 (OR 2.54, 95% CI 0.84–7.6, P = 0.09) and AOI ≥ 137°^ (OR 6.8, 95% CI 1.55–29.8, P = 0.011) were independent predictors of FPE. The optimal cut off derived using Youden’s index was 6.5. The area under the curve of a score predictive of FPE success was 0.816 (0.728–0.904, P  〈  0.001). In a validation cohort ( n = 30), sensitivity, specificity, positive and negative predictive value of a score of 6–10 were 72.7%, 73.6%, 61.5% and 82.3%. Conclusions Clot imaging predicts the likelihood of achieving FPE in patients with MCA ELVO treated with the aspiration-first approach.
    Type of Medium: Online Resource
    ISSN: 1591-0199 , 2385-2011
    URL: Article
    DOI: 10.1177/15910199211019174
    Language: English
    Publisher: SAGE Publications
    Publication Date: 2022
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  • 6
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    Mapping access to endovascular stroke care in the USA and implications for transport models
    BMJ ; 2022
    In:  Journal of NeuroInterventional Surgery Vol. 14, No. 1 ( 2022-01), p. neurintsurg-2020-016942-
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 14, No. 1 ( 2022-01), p. neurintsurg-2020-016942-
    Abstract: The purpose of this cross-sectional study was to determine the percentage of the US population with 60 min ground or air access to accredited or state-designated endovascular-capable stroke centers (ECCs) and non-endovascular capable stroke centers (NECCs) and the percentage of NECCs with an ECC within a 30 min drive. Methods Stroke centers were identified and classified broadly as ECCs or NECCs. Geographic mapping of stroke centers was performed. The population was divided into census blocks, and their centroids were calculated. Fastest air and ground travel times from centroid to nearest ECC and NECC were estimated. Results Overall, 49.6% of US residents had 60 min ground access to ECCs. Approximately 37.7% (113 million) lack 60 min ground or air access to ECCs. Approximately 84.4% have 60 min access to NECCs. Ground-only access was available to 77.9%. Approximately 738 NECCs (45.4%) had an ECC within a 30 min drive. Conclusion Nearly one-third of the US population lacks 60 min access to endovascular stroke care, but this is highly variable. Transport models and planning of additional centers should be tailored to each state depending on location and proximity of existing facilities.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2020-016942
    Language: English
    Publisher: BMJ
    Publication Date: 2022
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  • 7
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    Aneurysm characteristics, coil packing, and post-coiling hemodynamics affect long-term treatment outcome
    BMJ ; 2020
    In:  Journal of NeuroInterventional Surgery Vol. 12, No. 7 ( 2020-07), p. 706-713
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 12, No. 7 ( 2020-07), p. 706-713
    Abstract: Recurrence of intracranial aneurysms after endovascular coiling is a serious clinical concern. Objective We hypothesized that recurrence is associated with aneurysm morphology and flow, as well as the coil intervention and the induced flow modifications. Methods We collected 52 primary-coiling aneurysm cases that were either occluded (n=34) or recurrent (n=18) at 〉 1 year follow-up. We created aneurysm models from pre-coiling digital subtraction angiographic images, calculated aneurysm morphology, simulated pre-coiling hemodynamics, modeled coil deployment, and obtained post-coiling hemodynamics for each case. We performed univariable analysis on 26 morphologic, treatment-specific, and hemodynamic parameters to distinguish between recurrent and occluded groups, and multivariable analysis to identify independently significant parameters associated with recurrence. Univariable analysis was also performed on ruptured and unruptured aneurysm subcohorts separately to investigate if they shared specific significant parameters. Results Recurrence was associated with pre-coiling aneurysm morphologic and flow parameters including larger size (maximum dimension and volume), larger neck (diameter, area, and neck-to-parent-artery ratio), and higher flow momentum and kinetic energy. Recurrence was also associated with lower coil packing (packing density and uncoiled volume), higher post-treatment flow (velocity, momentum, and kinetic energy), lower post-treatment washout time, and higher post-treatment impingement force at the neck. Multivariable analysis identified two aneurysmal characteristics (neck diameter and pre-coiling flow kinetic energy), one coil packing parameter (uncoiled volume), and one post-treatment hemodynamic parameter (flow momentum) that were independently associated with recurrence. In ruptured aneurysms, recurrence was associated with larger neck (diameter and area), whereas in unruptured aneurysms, recurrence was associated with larger size (maximum dimension and volume). In both subcohorts, recurrence was associated with higher post-coiling flow momentum and kinetic energy. Conclusion Recurrence at 〉 1 year after coil treatment is associated with intrinsic aneurysm characteristics, coiling itself, and flow changes induced by coiling. Larger aneurysm size and neck, less coil packing, and higher intra-aneurysmal flow before and after coiling predict recurrence.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2019-015422
    Language: English
    Publisher: BMJ
    Publication Date: 2020
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  • 8
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    Multimodal CT imaging of ischemic stroke thrombi identifies scale-invariant radiomic features that reflect clot biology
    BMJ ; 2023
    In:  Journal of NeuroInterventional Surgery
    Details
    In: Journal of NeuroInterventional Surgery, BMJ
    Abstract: Biological interpretability of ischemic stroke clot imaging remains challenging. Objective To carry out paired CT/micro-CT imaging of ischemic stroke clots retrieved by thrombectomy with the aim of identifying interpretable image features that are correlated among pretreatment image modalities and post-treatment histopathology. Methods We performed multimodal CT imaging and histology for 10 stroke clots retrieved by mechanical thrombectomy. Clots were manually segmented from co-registered, pretreatment CT angiography (CTA) and non-contrast CT (NCCT). For the same cases, retrieved clots were iodine-stained, and imaged with a ScanCo micro-CT 100 (4.9 µm resolution). Afterwards, clots were subjected to histological processing (hematoxylin and eosin staining) and whole slide scanned (40X). Clot radiomic features (RFs) (n=93 per modality, 279 total) were extracted using PyRadiomics and histological composition was computed using Orbit Image Analysis. Correlation analysis was used to test associations between micro-CT and CTA (or NCCT) RFs as well as between RFs and histological composition. Statistical significance was considered at R≥0.65 and q 〈 0.05. Results From paired RF correlation analysis, we identified 23 scale-invariant RFs with significant correlation between micro-CT and CTA (18), and micro-CT and NCCT (5). Correlation of unpaired RFs identified 377 positively and 36 negatively correlated RFs between micro-CT and CTA, and 168 positively and 41 negatively correlated RFs between micro-CT and NCCT. Scale-invariant RFs computed from CTA and NCCT demonstrated significant correlation with red blood cell and fibrin-platelet components, while micro-CT RFs were found to be correlated with white blood cell percent composition. Conclusion Multimodal CT, radiomic, and histological analysis of stroke clots can help to bridge the gap between pretreatment imaging and clot pathobiology.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/jnis-2022-019967
    Language: English
    Publisher: BMJ
    Publication Date: 2023
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  • 9
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    Gene expression profiles of ischemic stroke clots retrieved by mechanical thrombectomy are associated with disease etiology
    BMJ ; 2023
    In:  Journal of NeuroInterventional Surgery Vol. 15, No. e1 ( 2023-09), p. e33-e40
    Details
    In: Journal of NeuroInterventional Surgery, BMJ, Vol. 15, No. e1 ( 2023-09), p. e33-e40
    Abstract: Determining stroke etiology is crucial for secondary prevention, but intensive workups fail to classify ~30% of strokes that are cryptogenic. Objective To examine the hypothesis that the transcriptomic profiles of clots retrieved during mechanical thrombectomy are unique to strokes of different subtypes. Methods We isolated RNA from the clots of 73 patients undergoing mechanical thrombectomy. Samples of sufficient quality were subjected to 100-cycle, paired-end RNAseq, and transcriptomes with less than 10 million unique reads were excluded from analysis. Significant differentially expressed genes (DEGs) between subtypes (defined by the Trial of Org 10 172 in Acute Stroke Treatment) were identified by expression analysis in edgeR. Gene ontology enrichment analysis was used to study the biologic differences between stroke etiologies. Results In all, 38 clot transcriptomes were analyzed; 6 from large artery atherosclerosis (LAA), 21 from cardioembolism (CE), 5 from strokes of other determined origin, and 6 from cryptogenic strokes. Among all comparisons, there were 816 unique DEGs, 174 of which were shared by at least two comparisons, and 20 of which were shared by all three. Gene ontology analysis showed that CE clots reflected high levels of inflammation, LAA clots had greater oxidoreduction and T-cell processes, and clots of other determined origin were enriched for aberrant platelet and hemoglobin-related processes. Principal component analysis indicated separation between these subtypes and showed cryptogenic samples clustered among several different groups. Conclusions Expression profiles of stroke clots were identified between stroke etiologies and reflected different biologic responses. Cryptogenic thrombi may be related to multiple etiologies.
    Type of Medium: Online Resource
    ISSN: 1759-8478 , 1759-8486
    URL: Article
    DOI: 10.1136/neurintsurg-2022-018898
    Language: English
    Publisher: BMJ
    Publication Date: 2023
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  • 10
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    Abstract 15608: Validation of Enhancer/Silencer Activity of the Intracranial Aneurysm-Associated SNP at SOX17 in Primary Human Endothelia
    Ovid Technologies (Wolters Kluwer Health) ; 2022
    In:  Circulation Vol. 146, No. Suppl_1 ( 2022-11-08)
    Details
    In: Circulation, Ovid Technologies (Wolters Kluwer Health), Vol. 146, No. Suppl_1 ( 2022-11-08)
    Abstract: Introduction: GWAS have identified multiple SNPs that occur more commonly in those with intracranial aneurysms. Many SNPs are located in noncoding genomic regions, suggesting that genetic risk may operate on functional regulatory elements that influence gene expression. However, regulatory elements are most often only indirectly identified through methods such as DNAse hypersensitivity without direct assessment of activity. Hypothesis: We hypothesize CRISPR mediated ablation of putative regulatory elements located within intergenic loci associated with IA will result in mRNA transcript modulation of genes located within the respective topology associated domain. Methods: We investigated a SNP within a haplotype block near SOX17. The haplotype was predicted to have active enhance activity, and to mediate SOX17 expression, based on assessment of its topologically associated domain. Lentiviral constructs (each with unique antibiotic resistance and fluorescent protein reporters) for the expression of Cas9 nuclease and two gRNAs flanking a putative element located at chr8:54412191-54413910 were transfected into the Lenti-X viral propagating cell line (Figure, left). Viral supernatants were transduced into primary HUVEC cells by spinfection with 5 ug/mL polybrene. After antibiotic selection and fluorescence validation, mRNA was isolated, and transcripts quantified through PCR. Results: Lentiviral transduction of HUVECs resulted in CRISPR-mediated removal of the enhancer element located within the haplotype block chr8:54397171-54415556 and resulted in a substantial increase of the SOX17 gene mRNA located within its topology associated domain (Figure, right). Conclusions: CRISPR mediated ablation was used to efficiently remove and validate a genomic element with putative regulatory activity in HUVECs. The methods will be employed to study additional regulatory elements with IA associations as well as other primary vascular cells.
    Type of Medium: Online Resource
    ISSN: 0009-7322 , 1524-4539
    URL: Article
    DOI: 10.1161/circ.146.suppl_1.15608
    Language: English
    Publisher: Ovid Technologies (Wolters Kluwer Health)
    Publication Date: 2022
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