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Carrie E. Andrews, Nikolaos Mouchtouris, Evan M. Fitchett, Fadi Al Saiegh, Michael J. Lang, Victor M. Romo, Nabeel Herial, Pascal Jabbour, Stavropoula I. Tjoumakaris, Robert H. Rosenwasser and M. Reid Gooch

OBJECTIVE

Mechanical thrombectomy (MT) is now the standard of care for acute ischemic stroke (AIS) secondary to large-vessel occlusion, but there remains a question of whether elderly patients benefit from this procedure to the same degree as the younger populations enrolled in the seminal trials on MT. The authors compared outcomes after MT of patients 80–89 and ≥ 90 years old with AIS to those of younger patients.

METHODS

The authors retrospectively analyzed records of patients undergoing MT at their institution to examine stroke severity, comorbid conditions, medical management, recanalization results, and clinical outcomes. Univariate and multivariate logistic regression analysis were used to compare patients < 80 years, 80–89 years, and ≥ 90 years old.

RESULTS

All groups had similar rates of comorbid disease and tissue plasminogen activator (tPA) administration, and stroke severity did not differ significantly between groups. Elderly patients had equivalent recanalization outcomes, with similar rates of readmission, 30-day mortality, and hospital-associated complications. These patients were more likely to have poor clinical outcome on discharge, as defined by a modified Rankin Scale (mRS) score of 3–6, but this difference was not significant when controlled for stroke severity, tPA administration, and recanalization results.

CONCLUSIONS

Octogenarians, nonagenarians, and centenarians with AIS have similar rates of mortality, hospital readmission, and hospital-associated complications as younger patients after MT. Elderly patients also have the capacity to achieve good functional outcome after MT, but this potential is moderated by stroke severity and success of treatment.

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Nikolaos Mouchtouris, Fadi Al Saiegh, Breanna Valcarcel, Carrie E. Andrews, Evan Fitchett, David Nauheim, David Moskal, Nabeel Herial, Pascal Jabbour, Stavropoula I. Tjoumakaris, Ashwini D. Sharan, Robert H. Rosenwasser and M. Reid Gooch

OBJECTIVE

The 30-day readmission rate is of increasing interest to hospital administrators and physicians, as it is used to evaluate hospital performance and is associated with increased healthcare expenditures. The estimated yearly cost to Medicare of readmissions is $17.4 billion. The Centers for Medicare and Medicaid Services therefore track unplanned 30-day readmissions and institute penalties against hospitals whose readmission rates exceed disease-specific national standards. One of the most important conditions with potential for improvement in cost-effective care is ischemic stroke, which affects 795,000 people in the United States and is a leading cause of death and disability. Recent widespread adoption of mechanical thrombectomy has revolutionized stroke care, requiring reassessment of readmission causes and costs in this population.

METHODS

The authors retrospectively analyzed a prospectively maintained database of stroke patients and identified 561 patients who underwent mechanical thrombectomy between 2010 and 2019 at the authors’ institution. Univariate and multivariate analyses were conducted to identify clinical variables and comorbidities related to 30-day readmissions in this patient population.

RESULTS

Of the 561 patients, 85.6% (n = 480) survived their admission and were discharged from the hospital to home or rehabilitation, and 8.8% (n = 42/480) were readmitted within 30 days. The mean time to readmission was 10.9 ± 7.9 days postdischarge. The most common reasons for readmission were infection (33.3%) and acute cardiac or cerebrovascular events (19% and 20%, respectively). Multivariate analysis showed that hypertension (p = 0.030; OR 2.72) and length of initial hospital stay (p = 0.040; OR 1.032) were significantly correlated with readmission within 30 days, while hemorrhagic conversion (grades 3 and 4) approached significance (p = 0.053; OR 2.23). Other factors, such as unfavorable outcome at discharge, history of coronary artery disease, and discharge destination, did not predict readmission.

CONCLUSIONS

The study data demonstrate that hypertension, length of hospital stay, and hemorrhagic conversion were predictors of 30-day hospital readmission in stroke patients after mechanical thrombectomy. Infection was the most common cause of 30-day readmission, followed by cardiac and cerebrovascular diagnoses. These results therefore may serve to identify patients within the stroke population who require increased surveillance following discharge to reduce complications and unplanned readmissions.

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Nikolaos Mouchtouris, Fadi Al Saiegh, Evan Fitchett, Carrie E. Andrews, Michael J. Lang, Ritam Ghosh, Richard F. Schmidt, Nohra Chalouhi, Guilherme Barros, Hekmat Zarzour, Victor Romo, Nabeel Herial, Pascal Jabbour, Stavropoula I. Tjoumakaris, Robert H. Rosenwasser and M. Reid Gooch

OBJECTIVE

The advent of mechanical thrombectomy (MT) has become an effective option for the treatment of acute ischemic stroke in addition to tissue plasminogen activator (tPA). With recent advances in device technology, MT has significantly altered the hospital course and functional outcomes of stroke patients. The authors’ goal was to establish the most up-to-date reperfusion and functional outcomes with the evolution of MT technology.

METHODS

The authors conducted a retrospective study of 403 patients who underwent MT for ischemic stroke at their institution from 2010 to 2017. They collected data on patient comorbidities, National Institutes of Health Stroke Scale (NIHSS) score on arrival, tPA administration, revascularization outcomes, and functional outcomes on discharge.

RESULTS

In 403 patients, the mean NIHSS score on presentation was 15.8 ± 6.6, with 195 (48.0%) of patients receiving tPA prior to MT. Successful reperfusion (thrombolysis in cerebral infarction score 2B or 3) was achieved in 84.4%. Hemorrhagic conversion with significant mass effect was noted in 9.9% of patients. The median lengths of ICU and hospital stay were 3.0 and 7.0 days, respectively. Functional independence (modified Rankin Scale score 0–2) was noted in 125 (31.0%) patients, while inpatient mortality occurred in 43 (10.7%) patients.

CONCLUSIONS

As MT has established acute ischemic stroke as a neurosurgical disease, there is a pressing need to understand the hospital course, hospital- and procedure-related complications, and outcomes for this new patient population. The authors provide a detailed account of key metrics for MT with the latest device technology and identify the predictors of unfavorable outcomes and inpatient mortality.

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Nohra Chalouhi, Nikolaos Mouchtouris, Fadi Al Saiegh, Somnath Das, Ahmad Sweid, Adam E. Flanders, Robert M. Starke, Michael P. Baldassari, Stavropoula Tjoumakaris, Michael Reid Gooch, Syed Omar Shah, David Hasan, Nabeel Herial, Robin D’Ambrosio, Robert Rosenwasser and Pascal Jabbour

OBJECTIVE

MRI and MRA studies are routinely obtained to identify the etiology of intracerebral hemorrhage (ICH). The diagnostic yield of MRI/MRA in the setting of an acute ICH, however, remains unclear. The authors’ goal was to determine the utility of early MRI/MRA in detecting underlying structural lesions in ICH and to identify patients in whom additional imaging during hospitalization could safely be foregone.

METHODS

The authors reviewed data obtained in 400 patients with spontaneous ICH diagnosed on noncontrast head CT scans who underwent MRI/MRA between 2015 and 2017 at their institution. MRI/MRA studies were reviewed to identify underlying lesions, such as arteriovenous malformations, aneurysms, cavernous malformations, arteriovenous fistulas, tumors, sinus thrombosis, moyamoya disease, and abscesses.

RESULTS

The median patient age was 65 ± 15.8 years. Hypertension was the most common (72%) comorbidity. Structural abnormalities were detected on MRI/MRA in 12.5% of patients. Structural lesions were seen in 5.7% of patients with basal ganglia/thalamic ICH, 14.1% of those with lobar ICH, 20.4% of those with cerebellar ICH, and 27.8% of those with brainstem ICH. Notably, the diagnostic yield of MRI/MRA was 0% in patients > 65 years with a basal ganglia/thalamic hemorrhage and 0% in those > 85 years with any ICH location, whereas it was 37% in patients < 50 years and 23% in those < 65 years. Multivariate analysis showed that decreasing age, absence of hypertension, and non–basal ganglia/thalamic location were predictors of finding an underlying lesion.

CONCLUSIONS

The yield of MRI/MRA in ICH is highly variable, depending on patient age and hemorrhage location. The findings of this study do not support obtaining early MRI/MRA studies in patients ≥ 65 years with basal ganglia/thalamic ICH or in any ICH patients ≥ 85 years. In all other situations, early MRI/MRA remains valuable in ruling out underlying lesions.

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Ahmad Sweid, Joshua H. Weinberg, Rawad Abbas, Kareem El Naamani, Stavropoula Tjoumakaris, Christine Wamsley, Erica J. Mann, Christopher Neely, Jeffery Head, David Nauheim, Julie Hauge, M. Reid Gooch, Nabeel Herial, Hekmat Zarzour, Tyler D. Alexander, Symeon Missios, David Hasan, Nohra Chalouhi, James Harrop, Robert H. Rosenwasser and Pascal Jabbour

OBJECTIVE

External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI).

METHODS

The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018.

RESULTS

A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1–47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44–50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0–1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6–87.1; p = 0.003).

CONCLUSIONS

The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.