Mushtaq Qureshi

Validation of intracerebral hemorrhage-specific intensity of care quality metrics.

BACKGROUND Given the considerable variation in care of patients with intracerebral hemorrhage (ICH) among centers that results in differences in outcome among these patients, a new intensity of care quality metrics has been proposed. This study aimed to validate the new ICH-specific intensity of care quality metrics. METHODS A total of 50 consecutive patients with ICH who were admitted within 24 hours of symptom onset were identified. Twenty-six quality indicators related to 18 facets of care were incorporated into a metric providing the variable, definition of the variable, and quality parameter. A score of 1 point was assigned if the quality parameter met the threshold for appropriate performance or if the parameter was not applicable, creating a total score of up to 26 points. The predictive validity of the classification scheme was tested by using the bootstrap method. RESULTS Fourteen of the 50 patients with ICH died during hospitalization (28%). The intensity of care quality metric score ranged from 17 points to 26 points. The mean score was higher in those who survived compared with those who died (23 ± 3 vs 21 ± 2; P = .02). Survival increased with tertile based on higher scores (100%, 67%, and 55%; P = .017). The receiver operating characteristic curve demonstrated a high discriminating ability of intensity of care quality metrics for in-hospital mortality (0.730, 95% confidence interval, 0.591-0.869) and a C-statistic of 0.91 (95% confidence interval, 0.90-0.92). CONCLUSIONS Correlation of the new ICH-specific intensity of care quality metric with in-hospital mortality supports its broader use for improving and standardizing medical care among patients with ICH.

Effect of Carotid Revascularization Endarterectomy Versus Stenting Trial Results on the Performance of Carotid Artery Stent Placement and Carotid Endarterectomy in the United States.

BACKGROUND CREST (Carotid Revascularization Endarterectomy Versus Stenting Trial) results, published in 2010, showed no difference in the rates of composite outcome (stroke, myocardial infarction, or death) between carotid artery stent placement (CAS) and carotid endarterectomy (CEA). OBJECTIVE To identify any changes in use and outcomes of CAS and CEA subsequent to the CREST results. METHODS We estimated the frequency of CAS and CEA procedures in the years 2009 (pre-CREST period) and 2011 (post-CREST period), using data from the National Inpatient Sample (NIS). Demographic and clinical characteristics and in-hospital outcomes of pre- and post-CREST CAS-treated and post-CREST CEA-treated patients were compared with pre-CREST CEA-treated patients. RESULTS A total of 225,191 patients underwent CEA or CAS in the pre- and post-CREST periods. The frequency of CAS among carotid revascularization procedures did not change after publication of the CREST results (12.3% vs. 12.7%, P = .9). In the pre-CREST period, the CAS group (compared with the CEA group) had higher rates of congestive heart failure (P < .001), coronary artery disease (P < .001), and renal failure (P < .001). The post-CREST CAS group had a higher frequency of atrial fibrillation (P = .003), congestive heart failure (P < .0001), coronary artery disease (P < .0001), and renal failure (P = .0001). Discharge with moderate to severe disability (P < .0001) and postprocedure neurological complications (P = .005) were more frequently reported in the post-CREST CAS group. After adjusting for age, sex, and risk factors, the odds ratio (OR) for moderate to severe disability was 1.0 (95% confidence interval [CI]: 0.8-1.2) in the pre-CREST CAS group and 1.4 (95% CI: 1.1-1.7) in the post-CREST CAS group compared with the reference group. The adjusted OR for neurological complications in the pre-CREST CAS group was 1.6 (95% CI: 1.2-2.1, P = .002), and 1.5 (95% CI: 1.1-2.0, P = .01) in the post-CREST CAS group. CONCLUSION The frequency of CAS and CEA for carotid artery stenosis has not changed after publication of the CREST. The demographics, pretreatment comorbidity profile, and in-hospital complication rates remained unchanged during the 2 time periods.

Detachable-tip microcatheters for liquid embolization of brain arteriovenous malformations and fistulas: A United States single-center experience

BACKGROUND: The US Food and Drug Administration recently approved a detachable-tip microcatheter, the Apollo microcatheter (eV3, Inc, Irvine, California), to prevent catheter entrapment during embolization of brain arteriovenous malformations (AVMs) using liquid embolic systems. OBJECTIVE: To report technical aspects and clinical results of cerebral embolizations with the Apollo microcatheter in 7 embolizations in 3 adult patients. METHODS: A 62-year-old man presented with an AVM in the parieto-occipital region measuring 3.6 × 1.6 cm with major cortical feeders from the right middle cerebral artery (MCA) and minor contribution from the distal right anterior cerebral artery. Two pedicles originating from the MCA were embolized. A 48-year-old woman presented with a left frontal AVM measuring 3.3 × 1.8 cm with arterial feeders from the left MCA, left middle meningeal artery, and contralateral anterior cerebral artery. Three pedicles originating from the left MCA were embolized. A 76-year-old man presented with an arteriovenous fistula with multiple fistulous connections and feeders from both vertebral and occipital arteries and the left posterior cerebral artery draining into the left transverse, torcula, and left sigmoid sinus. Two major occipital artery feeders were embolized. RESULTS: Seven Apollo microcatheters were used with the Onyx 18 liquid embolic system. The length of the detachable tip was 15 mm in 2 and 30 mm in 5 embolizations. The mean microcatheter in-position time within the pedicle was 20 minutes. Detachment of tip occurred in 3 instances. No limitations in accessing target arterial feeders and safe tip disengagement were noted despite prolonged injection times. CONCLUSION: Our initial experience supports the feasibility, safety, and effectiveness of detachable-tip microcatheters in treating brain AVMs and arteriovenous fistulas. ABBREVIATIONS: AVM, arteriovenous malformation AVF, arteriovenous fistula DMSO, dimethyl sulfoxide MCA, middle cerebral artery n-BCA, n-butyl cyanoacrylate PCA, posterior cerebral artery

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

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

Detection of Intraparenchymal Hemorrhage After Endovascular Therapy in Patients with Acute Ischemic Stroke Using Immediate Postprocedural Flat-Panel Computed Tomography Scan.

To assess the diagnostic value of parenchymal hyperdense lesions visualized on the flat‐panel CT scan in detecting/excluding intraparenchymal hemorrhage (IPH) after the endovascular treatment of acute stroke patients.

Middle Cerebral Artery Residual Contrast Stagnation on Noncontrast CT Scan Following Endovascular Treatment in Acute Ischemic Stroke Patients

We evaluated the relationship between middle cerebral artery (MCA) residual contrast stagnation on immediate postprocedural noncontrast CT scan and intraparenchymal hemorrhage (IPH) after endovascular treatment in acute ischemic stroke patients.

Worse in-hospital outcomes in patients with transient ischemic attack in association with acute kidney injury: analysis of nationwide in-patient sample.

Objectives: The effect of acute kidney injury (AKI) on outcomes of transient ischemic attack (TIA) is largely unknown. We wanted to determine the impact of AKI on the outcomes of patients admitted with TIA. Methods: Data from all adult patients admitted to the U.S. hospitals between 2005 and 2011 with a primary discharge diagnosis of TIA and secondary diagnosis of AKI were included, using the nationwide in-patient dataset. The association of AKI with TIA-related mortality and discharge outcomes was analyzed after adjusting for potential confounders using logistic regression analysis. Results: Of the 1,173,340 patients admitted with TIA, 45,974 (3.8%) had AKI. Dialysis was required in 29 (0.06%) patients. TIA patients with AKI had higher rates of moderate-to-severe disability (21.2 vs. 13.7%, p ≤ 0.0001), and in-hospital mortality (0.6 vs. 0.1%, p ≤ 0.0001) compared with those without AKI. After adjusting for age, sex, and potential confounders; TIA patients with AKI had higher odds of moderate-to-severe disability [OR 1.3, 95% CI 1.2-1.4, p < 0.0001] and death (OR 4.2, 95% CI 3.0-6.1, p < 0.0001). Conclusions: AKI in patients with TIA is associated with significantly higher rates of moderate-to-severe disability at discharge and in-hospital mortality compared with those without AKI.

Blood Pressure-Attained Analysis of ATACH 2 Trial

Background and Purpose— We compared the rates of death or disability, defined by modified Rankin Scale score of 4 to 6, at 3 months in patients with intracerebral hemorrhage according to post-treatment systolic blood pressure (SBP)–attained status. Methods— We divided 1000 subjects with SBP ≥180 mm Hg who were randomized within 4.5 hours of symptom onset as follows: SBP <140 mm Hg achieved or not achieved within 2 hours; subjects in whom SBP <140 mm Hg was achieved within 2 hours were further divided: SBP <140 mm Hg for 21 to 22 hours (reduced and maintained) or SBP was ≥140 mm Hg for at least 2 hours during the period between 2 and 24 hours (reduced but not maintained). Results— Compared with subjects without reduction of SBP <140 mm Hg within 2 hours, subjects with reduction and maintenance of SBP <140 mm Hg within 2 hours had a similar rate of death or disability (relative risk of 0.98; 95% confidence interval, 0.74–1.29). The rates of neurological deterioration within 24 hours were significantly higher in reduced and maintained group (10.4%; relative risk, 1.98; 95% confidence interval, 1.08–3.62) and in reduced but not maintained group (11.5%; relative risk, 2.08; 95% confidence interval, 1.15–3.75) compared with reference group. The rates of cardiac-related adverse events within 7 days were higher among subjects with reduction and maintenance of SBP <140 mmHg compared to subjects without reduction (11.2% versus 6.4%). Conclusions— No decline in death or disability but higher rates of neurological deterioration and cardiac-related adverse events were observed among intracerebral hemorrhage subjects with reduction with and without maintenance of intensive SBP goals. Clinical Trial Registration— URL: https://www.clinicaltrials.gov. Unique identifier: NCT01176565.

Acute hypertensive response in patients with intracerebral hemorrhage pathophysiology and treatment

Acute hypertensive response is a common systemic response to occurrence of intracerebral hemorrhage which has gained unique prominence due to high prevalence and association with hematoma expansion and increased mortality. Presumably, the higher systemic blood pressure predisposes to continued intraparenchymal hemorrhage by transmission of higher pressure to the damaged small arteries and may interact with hemostatic and inflammatory pathways. Therefore, intensive reduction of systolic blood pressure has been evaluated in several clinical trials as a strategy to reduce hematoma expansion and subsequent death and disability. These trials have demonstrated either a small magnitude benefit (second intensive blood pressure reduction in acute cerebral hemorrhage trial and efficacy of nitric oxide in stroke trial) or no benefit (antihypertensive treatment of acute cerebral hemorrhage 2 trial) with intensive systolic blood pressure reduction compared with modest or standard blood pressure reduction. The differences may be explained by the variation in intensity of systolic blood pressure reduction between trials. A treatment threshold of systolic blood pressure of ≥180 mm with the target goal of systolic blood pressure reduction to values between 130 and 150 mm Hg within 6 h of symptom onset may be best supported by current evidence.

Preprocedure change in arterial occlusion in acute ischemic stroke patients undergoing endovascular treatment by computed tomographic angiography.

BACKGROUND The American Heart Association/American Stroke Association guidelines strongly recommend a noninvasive intracranial vascular study such as computed tomographic (CT) angiogram in acute stroke patient if endovascular treatment is contemplated. OBJECTIVE The objective was to determine the frequency of change in occlusion site between CT angiogram and cerebral angiogram in acute ischemic stroke patients undergoing endovascular treatment. METHODS All acute ischemic stroke patients who underwent a CT angiogram and subsequently underwent endovascular treatment were included. The CT and cerebral angiographic images were reviewed independently to determine presence and location of arterial occlusion. Severity of occlusion was classified by a previously described grading scheme. Clinical outcome at discharge was determined using modified Rankin scale. RESULTS Computed tomographic angiogram was performed in 150 patients (mean age ± SD, 64.7 ± 16 years) before endovascular treatment. The mean interval (±SD) between CT angiogram and cerebral angiogram was 193 ± 164 minutes, and 65 (43.3%) of 150 patients received intravenous recombinant tissue plasminogen activator before cerebral angiography. Recanalization between CT angiogram and cerebral angiography was seen in 28 (18.7%) patients, whereas worsening of occlusion was seen in 31 (20.7%) patients. We noticed a trend towards higher rates of improvement (60.7% vs 42.0%, P = .07) and favorable outcome at discharge (42.9% vs 28.7%, P = .1) among patients who experienced preprocedure recanalization. After adjusting for age and initial National Institutes of Health Stroke Scale score strata, preprocedure recanalization was not associated with significantly higher rate of favorable outcome (modified Rankin scale, 0-2) at discharge (odds ratio, 2.1; 95% confidence interval, 0.8-5.5). After adjusting for age and National Institutes of Health Stroke Scale score strata, preprocedure worsening was not associated with significantly lower rates of favorable outcomes at discharge (odds ratio,0.4; 95% confidence interval, 0.1-1.4). CONCLUSIONS A relatively high proportion of patients have preprocedure recanalization or worsening between CT angiogram and cerebral angiogram in acute ischemic stroke patients selected for endovascular treatment.