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  1. Article ; Online: Hyperacute Management of Ischemic Strokes: JACC Focus Seminar.

    Patel, Pratit / Yavagal, Dileep / Khandelwal, Priyank

    Journal of the American College of Cardiology

    2020  Volume 75, Issue 15, Page(s) 1844–1856

    Abstract: Acute ischemic stroke is the leading cause of disability and among the leading causes of mortality worldwide. Intravenous tissue plasminogen activator has been a cornerstone for treatment of acute ischemic stroke for more than 20 years; however, its use ... ...

    Abstract Acute ischemic stroke is the leading cause of disability and among the leading causes of mortality worldwide. Intravenous tissue plasminogen activator has been a cornerstone for treatment of acute ischemic stroke for more than 20 years; however, its use is limited due to a narrow therapeutic window, several contraindications, and low efficacy to recanalize the artery in large vessel occlusion. Recently, the addition of endovascular mechanical thrombectomy of large artery occlusion has revolutionized the stroke treatment for most disabling strokes. The paper reviews updates to the thrombolytic treatment as well as catheter-based treatment, and results from recent trials in the selection of patients in an extended time window using perfusion imaging.
    MeSH term(s) Algorithms ; Anesthesia, General ; Arterial Occlusive Diseases/complications ; Arterial Occlusive Diseases/therapy ; Clinical Trials as Topic ; Conscious Sedation ; Contraindications, Drug ; Fibrinolytic Agents/therapeutic use ; Hemodynamics ; Humans ; Intracranial Arteriosclerosis/complications ; Intracranial Arteriosclerosis/therapy ; Ischemic Stroke/etiology ; Ischemic Stroke/therapy ; Neuroimaging ; Practice Guidelines as Topic ; Thrombectomy ; Time-to-Treatment ; Tissue Plasminogen Activator/therapeutic use ; Triage
    Chemical Substances Fibrinolytic Agents ; Tissue Plasminogen Activator (EC 3.4.21.68)
    Language English
    Publishing date 2020-04-16
    Publishing country United States
    Document type Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Review
    ZDB-ID 605507-2
    ISSN 1558-3597 ; 0735-1097
    ISSN (online) 1558-3597
    ISSN 0735-1097
    DOI 10.1016/j.jacc.2020.03.006
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  2. Article ; Online: Differential thrombectomy utilization across hospital classifications in the United States.

    Patel, Karan / Hamedani, Ali G / Taneja, Kamil / Koneru, Manisha / Wolfe, Jared / Sprankle, Kenyon / Patel, Pratit / Mullen, Michael T / Siegler, James E

    Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association

    2023  Volume 32, Issue 12, Page(s) 107401

    Abstract: Objectives: To determine hospital-level factors associated with thrombectomy uptake.: Materials and methods: The Nationwide Emergency Department Sample was retrospectively queried to determine the total number of thrombectomies performed based on ... ...

    Abstract Objectives: To determine hospital-level factors associated with thrombectomy uptake.
    Materials and methods: The Nationwide Emergency Department Sample was retrospectively queried to determine the total number of thrombectomies performed based on different hospital characteristics. Joint point analysis was used to determine which years were associated with significant increases in the number of high-volume thrombectomy centers (ostensibly defined as >50 thrombectomies/year), thrombectomy-capable centers (>15 thrombectomies/year), and total number of thrombectomies performed. Multivariable logistic regression was used to determine hospital factors associated with having an increased odds of performing thrombectomies, and of being classified as a high-volume thrombectomy or a thrombectomy-capable center.
    Results: Between 2007-2020 there was a stepwise increase in the number of thrombectomy-capable and high-volume thrombectomy centers in the United States. In 2020, there were a total of 15,705 thrombectomies performed, with 89 high-volume thrombectomy centers, and 359 thrombectomy-capable centers. The number of thrombectomy-capable centers significantly increased after 2011. After 2013 and 2016 there was a significant change in the growth rate of high-volume thrombectomy centers. There was also a significant increase in the total number of thrombectomies performed after 2016. Hospital characteristics that were associated with an increased likelihood of being classified as thrombectomy-capable or high-volume included trauma level 1 and 2 hospitals.
    Conclusions: Between 2007 and 2020, there was a marked growth in thrombectomy utilization for acute ischemic stroke. This growth outpaced new diagnoses of ischemic stroke, and was driven largely by certain hospital types, with the greatest rises following seminal publications of positive randomized thrombectomy trials.
    MeSH term(s) Humans ; United States ; Stroke/diagnostic imaging ; Stroke/surgery ; Brain Ischemia/diagnosis ; Retrospective Studies ; Ischemic Stroke ; Thrombectomy/adverse effects ; Hospitals ; Treatment Outcome
    Language English
    Publishing date 2023-10-27
    Publishing country United States
    Document type Journal Article
    ZDB-ID 1131675-5
    ISSN 1532-8511 ; 1052-3057
    ISSN (online) 1532-8511
    ISSN 1052-3057
    DOI 10.1016/j.jstrokecerebrovasdis.2023.107401
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  3. Article ; Online: "COVID-19 and cervical artery dissection- A causative association?"

    Patel, Pratit / Khandelwal, Priyank / Gupta, Gaurav / Singla, Amit

    Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association

    2020  Volume 29, Issue 10, Page(s) 105047

    Abstract: COVID-19 is a pandemic disease which predominantly affects the respiratory system, however it also causes multi-organ dysfunction in a subset of patients. There is a growing evidence that it increases the propensity of strokes in younger patients. ... ...

    Abstract COVID-19 is a pandemic disease which predominantly affects the respiratory system, however it also causes multi-organ dysfunction in a subset of patients. There is a growing evidence that it increases the propensity of strokes in younger patients. Besides producing a prothrombotic state, arterial dissection could be one of its many manifestations, increasing the risks of stroke. Herein, we report the first case of spontaneous bilateral vertebral artery dissection in a patient with COVID-19. 39-year female presented with spontaneous bilateral vertebral artery dissections without any instigating traumatic events and no history of connective tissue disorders. Whether this patient's vertebral artery dissections were triggered by exaggerated inflammatory response or arteriopathy secondary to COVID-19 remains speculative. Nonetheless, arterial dissection could be one of it's complications. It is important for the physicians to be aware of different clinical manifestations of COVID-19 as we manage these patients with no historical experience, to provide adequate care.
    MeSH term(s) Adult ; Anticoagulants/administration & dosage ; Betacoronavirus/pathogenicity ; COVID-19 ; Coronavirus Infections/complications ; Coronavirus Infections/diagnosis ; Coronavirus Infections/virology ; Female ; Host Microbial Interactions ; Humans ; Pandemics ; Pneumonia, Viral/complications ; Pneumonia, Viral/diagnosis ; Pneumonia, Viral/virology ; Risk Factors ; SARS-CoV-2 ; Stroke/diagnostic imaging ; Stroke/drug therapy ; Stroke/etiology ; Stroke/virology ; Vertebral Artery Dissection/diagnostic imaging ; Vertebral Artery Dissection/drug therapy ; Vertebral Artery Dissection/etiology ; Vertebral Artery Dissection/virology
    Chemical Substances Anticoagulants
    Keywords covid19
    Language English
    Publishing date 2020-06-13
    Publishing country United States
    Document type Case Reports
    ZDB-ID 1131675-5
    ISSN 1532-8511 ; 1052-3057
    ISSN (online) 1532-8511
    ISSN 1052-3057
    DOI 10.1016/j.jstrokecerebrovasdis.2020.105047
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  4. Article ; Online: A cortically-weighted versus total Alberta Stroke Program Early Computed Tomography Score in thrombectomy outcome models.

    Paul, Umika / Koneru, Manisha / Siegler, James E / Penckofer, Mary / Nguyen, Thanh N / Khalife, Jane / Oliveira, Renato / Abdalkader, Mohamad / Klein, Piers / Vigilante, Nicholas / Kamen, Scott / Gold, Justin / Thomas, Ajith / Patel, Pratit

    Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association

    2024  Volume 33, Issue 5, Page(s) 107607

    Abstract: Objectives: Individual subcortical infarct scoring for the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) can be difficult and is subjected to higher inter-reader variability. This study compares performance of the 10-point ASPECTS ... ...

    Abstract Objectives: Individual subcortical infarct scoring for the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) can be difficult and is subjected to higher inter-reader variability. This study compares performance of the 10-point ASPECTS with a new 7-point cortically-weighted score in predicting post-thrombectomy functional outcomes.
    Materials and methods: Prospective registry data from two comprehensive stroke centers (Site 1 2016-2021; Site 2: 2019-2021) included patients with either M1 segment of middle cerebral artery or internal carotid artery occlusions who underwent thrombectomy. Two multivariate proportional odds training models utilizing either 10-point or 7-point ASPECTS predicting 90-day shift in modified Rankin score were generated using Site 1 data and validated with Site 2 data. Models were compared using multiclass receiver operator characteristics, corrected Akaike's Information Criterion, and likelihood ratio test.
    Results: Of 328 patients (Site 1 = 181, Site 2 = 147), median age was 71y (IQR 61-82), 119 (36%) had internal carotid artery occlusions, and median 10-point ASPECTS was 9 (IQR 8-10). There was no difference in performance between models using either total or cortically-weighted ASPECTS (p=0.14). Validation cohort data were correctly (i.e., predicting modified Rankin score within one point) classified 50% (cortically-weighted score model) and 56% (total score model) of the time.
    Conclusions: The 7-point cortically-weighted ASPECTS was similarly predictive of post-thrombectomy functional outcome as 10-point ASPECTS. Given noninferior performance, the cortically-weighted score is a potentially reliable, but simplified, alternative to the traditional scoring paradigm, with potential implications in automated image analysis tool development.
    MeSH term(s) Humans ; Aged ; Alberta ; Stroke/diagnostic imaging ; Stroke/surgery ; Thrombectomy/adverse effects ; Tomography, X-Ray Computed ; Middle Cerebral Artery ; Treatment Outcome ; Retrospective Studies ; Brain Ischemia
    Language English
    Publishing date 2024-01-28
    Publishing country United States
    Document type Journal Article
    ZDB-ID 1131675-5
    ISSN 1532-8511 ; 1052-3057
    ISSN (online) 1532-8511
    ISSN 1052-3057
    DOI 10.1016/j.jstrokecerebrovasdis.2024.107607
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  5. Article ; Online: Outcomes following thrombectomy for acute large vessel occlusion beyond 24 hours or with unknown time of onset.

    Iezzi, Zachary / Patel, Pratit / Wolfe, Jared / Tiongson, Justin / Vigilante, Nicholas / Kamen, Scott / Penckofer, Mary / Khalife, Jane / Siegler, James E

    Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association

    2023  Volume 32, Issue 3, Page(s) 106952

    Abstract: Background: Endovascular thrombectomy (EVT) is recommended in medically eligible patients with large vessel occlusions (LVO) within 24 hours of symptom onset. While there is evidence that EVT ≥24h after last known well (LKW) is associated with favorable ...

    Abstract Background: Endovascular thrombectomy (EVT) is recommended in medically eligible patients with large vessel occlusions (LVO) within 24 hours of symptom onset. While there is evidence that EVT ≥24h after last known well (LKW) is associated with favorable outcomes in patients who meet DAWN/DEFUSE-3 criteria, it is unknown if more liberal criteria can be applied.
    Methods: A single center, prospective observational cohort of consecutive adult stroke patients was queried for symptomatic occlusions of the internal carotid (ICA) or proximal middle cerebral (M1) arteries (October 2019-January 2022), with a National Institutes of Health Stroke Scale (NIHSS) ≥6, pre-stroke modified Rankin Scale (mRS) 0-2, and Alberta Stroke Program Early Computed Tomography Scale score 3-10. These inclusion criteria were extrapolated from recently published data indicating a benefit with EVT with more liberal patient selection. Patients who underwent EVT ≥24h after LKW were compared against those treated medically. The primary outcome was a good functional outcome (90-day mRS 0-2), which was evaluated using multivariable logistic regression.
    Results: Of the 27 included patients, the median age was 65y (IQR 49-76) with a median NIHSS of 15 (IQR 8-26), and 17 (63.0%) underwent EVT (median LKW-to-puncture 35.5h (IQR 26.9-65.8h). The primary outcome was no different with EVT in unadjusted regression (OR 1.17, 95%CI 0.17-8.09), and there remained no association across all multivariable models tested. Age, pre-stroke disability, and M1 occlusions were non-significantly associated with the primary outcome (p>0.05). There was a non-significant trend indicating a favorable shift in 90-day mRS with EVT (proportional OR 2.04, 95%CI 0.44-9.48).
    Conclusions: Using more liberal inclusion criteria for EVT in the ultra-extended window, there was no statistically significant difference in the rate of good functional outcome with EVT. Larger studies are called upon to evaluate outcomes when more liberal criteria are used to assess thrombectomy eligibility.
    MeSH term(s) Humans ; Aged ; Treatment Outcome ; Endovascular Procedures/adverse effects ; Endovascular Procedures/methods ; Stroke/diagnostic imaging ; Stroke/therapy ; Thrombectomy/adverse effects ; Thrombectomy/methods ; Tomography, X-Ray Computed ; Brain Ischemia/diagnostic imaging ; Brain Ischemia/therapy ; Retrospective Studies
    Language English
    Publishing date 2023-01-19
    Publishing country United States
    Document type Observational Study ; Journal Article
    ZDB-ID 1131675-5
    ISSN 1532-8511 ; 1052-3057
    ISSN (online) 1532-8511
    ISSN 1052-3057
    DOI 10.1016/j.jstrokecerebrovasdis.2022.106952
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  6. Article ; Online: “COVID-19 and cervical artery dissection- A causative association?”

    Patel, Pratit / Khandelwal, Priyank / Gupta, Gaurav / Singla, Amit

    Journal of Stroke and Cerebrovascular Diseases

    2020  Volume 29, Issue 10, Page(s) 105047

    Keywords Surgery ; Rehabilitation ; Clinical Neurology ; Cardiology and Cardiovascular Medicine ; covid19
    Language English
    Publisher Elsevier BV
    Publishing country us
    Document type Article ; Online
    ZDB-ID 1131675-5
    ISSN 1052-3057
    ISSN 1052-3057
    DOI 10.1016/j.jstrokecerebrovasdis.2020.105047
    Database BASE - Bielefeld Academic Search Engine (life sciences selection)

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  7. Article ; Online: Microsurgical Clip Ligation of an Unruptured Azygos Bifurcation Aneurysm Indented by the Falx Cerebri: 3-Dimensional Operative Video.

    Taylor, Blake E S / Say, Irene / Patel, Pratit / Tomycz, Luke D

    Operative neurosurgery (Hagerstown, Md.)

    2020  Volume 19, Issue 3, Page(s) E294

    Abstract: Dissecting pericallosal aneurysms from the falx cerebri is technically challenging, as one must release the adherent dome but minimize shearing injury, which could result in intraoperative rupture. We discuss a 51-yr-old woman with a history of ... ...

    Abstract Dissecting pericallosal aneurysms from the falx cerebri is technically challenging, as one must release the adherent dome but minimize shearing injury, which could result in intraoperative rupture. We discuss a 51-yr-old woman with a history of hypertension and smoking who presented with severe headaches and was found to have a 6-mm unruptured, multilobulated pericallosal aneurysm abutting the falx, with anterior and superior projecting domes on either side. She also had an azygos anterior cerebral artery (ACA), a rare anatomic variant associated with pericallosal aneurysms, where both A1 segments form a single A2. After considering endovascular and open surgical techniques, we proceeded with clip ligation given her younger age, smoking history, daughter aneurysms seen on angiography, and azygos ACA. We positioned her supine with her head turned lateral, left side down to maximize gravitational retraction, mapped a bicoronal incision, and performed a small craniotomy, followed by an interhemispheric approach. Rather than cutting the falx around the dome, a described technique that risks blind vessel injury, we temporarily clipped inflow vessels to reduce the dome's turgor and sharply and bluntly dissected apart its attachments, which freed the aneurysm from beneath the falx and allowed visualization of associated vessels. Using suction to manipulate the dome, we then placed stacked, angled clips, and used a micro-Doppler to confirm brisk inflow and outflow. Postoperatively, she was neurologically intact, and her angiogram showed no residual aneurysm. Our 3-dimensional video demonstrates a safer, alternative approach to treating this rare aneurysm with its associated anatomical variant. Patient consented to her clinical presentation and microscope media being used for academic purposes.
    MeSH term(s) Aneurysm, Dissecting/diagnostic imaging ; Aneurysm, Dissecting/surgery ; Anterior Cerebral Artery ; Dura Mater ; Female ; Humans ; Intracranial Aneurysm/diagnostic imaging ; Intracranial Aneurysm/surgery ; Neurosurgical Procedures ; Surgical Instruments
    Language English
    Publishing date 2020-01-07
    Publishing country United States
    Document type Case Reports ; Journal Article ; Video-Audio Media
    ZDB-ID 2767575-0
    ISSN 2332-4260 ; 2332-4252
    ISSN (online) 2332-4260
    ISSN 2332-4252
    DOI 10.1093/ons/opz393
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  8. Article ; Online: The Neuro Radialist.

    Patel, Pratit / Haussen, Diogo C / Nogueira, Raul G / Khandelwal, Priyank

    Interventional cardiology clinics

    2019  Volume 9, Issue 1, Page(s) 75–86

    Abstract: Trans-radial approach (TRA) has been used in cardiac and peripheral interventional radiology practices for decades, because of safety and patient comfort. There is interest in TRA in the cerebrovascular field, with potential to replicate benefits over ... ...

    Abstract Trans-radial approach (TRA) has been used in cardiac and peripheral interventional radiology practices for decades, because of safety and patient comfort. There is interest in TRA in the cerebrovascular field, with potential to replicate benefits over trans-femoral approach. TRA is technically more challenging and has a learning curve, which hinders its use as the first-line approach; however, as more neuro-interventionalists embrace TRA, techniques are being optimized simultaneously for supra-aortic vessel catheterization. This article describes advantages, patient selection, conventional and distal radial access, and detailed techniques of trans-radial catheterization for diagnostic angiography, as well as cerebrovascular interventions and its current limitations.
    MeSH term(s) Catheterization/methods ; Cerebral Angiography/methods ; Humans ; Patient Selection ; Radial Artery
    Language English
    Publishing date 2019-10-21
    Publishing country Netherlands
    Document type Journal Article ; Review ; Video-Audio Media
    ISSN 2211-7466
    ISSN (online) 2211-7466
    DOI 10.1016/j.iccl.2019.08.008
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  9. Article: "COVID-19 and cervical artery dissection- A causative association?"

    Patel, Pratit / Khandelwal, Priyank / Gupta, Gaurav / Singla, Amit

    J Stroke Cerebrovasc Dis

    Abstract: COVID-19 is a pandemic disease which predominantly affects the respiratory system, however it also causes multi-organ dysfunction in a subset of patients. There is a growing evidence that it increases the propensity of strokes in younger patients. ... ...

    Abstract COVID-19 is a pandemic disease which predominantly affects the respiratory system, however it also causes multi-organ dysfunction in a subset of patients. There is a growing evidence that it increases the propensity of strokes in younger patients. Besides producing a prothrombotic state, arterial dissection could be one of its many manifestations, increasing the risks of stroke. Herein, we report the first case of spontaneous bilateral vertebral artery dissection in a patient with COVID-19. 39-year female presented with spontaneous bilateral vertebral artery dissections without any instigating traumatic events and no history of connective tissue disorders. Whether this patient's vertebral artery dissections were triggered by exaggerated inflammatory response or arteriopathy secondary to COVID-19 remains speculative. Nonetheless, arterial dissection could be one of it's complications. It is important for the physicians to be aware of different clinical manifestations of COVID-19 as we manage these patients with no historical experience, to provide adequate care.
    Keywords covid19
    Publisher WHO
    Document type Article
    Note WHO #Covidence: #597796
    Database COVID19

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  10. Article ; Online: Embolic infarct topology differs between atrial fibrillation subtypes and embolic stroke of undetermined source.

    Wolfe, Jared / Oak, Solomon / Tiongson, Justin / Vigilante, Nicholas / Frost, Emma / Penckofer, Mary / Thau, Lauren / Iezzi, Zachary / Patel, Pratit / Siegler, James E

    Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association

    2022  Volume 31, Issue 11, Page(s) 106782

    Abstract: Background: The lack of superiority of anticoagulation over antiplatelet therapy in embolic stroke of undetermined source (ESUS) may be in part due to the misclassification of radiographic ESUS patterns as cardioembolic. In this imaging analysis, we ... ...

    Abstract Background: The lack of superiority of anticoagulation over antiplatelet therapy in embolic stroke of undetermined source (ESUS) may be in part due to the misclassification of radiographic ESUS patterns as cardioembolic. In this imaging analysis, we sought to differentiate clinical and radiographic patterns of ESUS patients from patterns in patients with a highly probable cardioembolic source.
    Materials & methods: A prospective registry of consecutive adults with acute infarction on diffusion-weighted magnetic resonance imaging was queried. Patients with infarctions due to small vessel disease, large vessel disease, and other causes were excluded. Multivariable logistic regression was used to identify independent predictors of two potentially embolic patterns: (1) multifocal and (2) cortical lesions, comparing patients with ESUS against those with atrial fibrillation (AF).
    Results: Among 1243 screened patients, 343 (27.6%) experienced strokes due to ESUS or AF. Prior to the index stroke, patients with AF as compared to ESUS were older (median 75 vs. 65, p<0.01) and had more heart failure (25.9% vs. 8.4%, p<0.01). The odds of multifocal infarction were the same between patients with ESUS and both AF subtypes (p>0.05), however, cortical involvement was more associated with both AF versus ESUS (77.7% vs. 65.7%, P=0.02). A higher Fazekas grade of white matter disease was inversely associated with cortical infarction among included patients (aOR 0.77, 95% CI 0.62-0.96).
    Conclusion: Cortical infarctions were twice as common among patients with AF versus ESUS. Subcortical infarct topography was strongly associated with chronic microvascular ischemic changes and therefore may not represent embolic phenomena. Larger-scale investigations are warranted to discern whether large or multifocal subcortical infarcts ought to be excluded from the ESUS designation.
    MeSH term(s) Adult ; Humans ; Atrial Fibrillation/complications ; Atrial Fibrillation/diagnosis ; Intracranial Embolism/etiology ; Intracranial Embolism/complications ; Embolic Stroke/diagnostic imaging ; Embolic Stroke/etiology ; Platelet Aggregation Inhibitors ; Risk Factors ; Stroke/etiology ; Stroke/complications ; Embolism/etiology ; Embolism/complications ; Anticoagulants/therapeutic use ; Infarction/complications
    Chemical Substances Platelet Aggregation Inhibitors ; Anticoagulants
    Language English
    Publishing date 2022-09-18
    Publishing country United States
    Document type Journal Article
    ZDB-ID 1131675-5
    ISSN 1532-8511 ; 1052-3057
    ISSN (online) 1532-8511
    ISSN 1052-3057
    DOI 10.1016/j.jstrokecerebrovasdis.2022.106782
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