Browsing by Author "Messé, Steven R"
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Item Open Access Infarct‐related structural disconnection and delirium in surgical aortic valve replacement patients(Annals of Clinical and Translational Neurology) Browndyke, Jeffrey N; Tomalin, Lewis E; Erus, Guray; Overbey, Jessica R; Kuceyeski, Amy; Moskowitz, Alan J; Bagiella, Emilia; Iribarne, Alexander; Acker, Michael; Mack, Michael; Mathew, Joseph; O'Gara, Patrick; Gelijns, Annetine C; Suarez-Farinas, Mayte; Messé, Steven R; Cardiothoracic Surgical Trials Network (CTSN) InvestigatorsAbstractObjectiveAlthough acute brain infarcts are common after surgical aortic valve replacement (SAVR), they are often unassociated with clinical stroke symptoms. The relationship between clinically “silent” infarcts and in‐hospital delirium remains uncertain; obscured, in part, by how infarcts have been traditionally summarized as global metrics, independent of location or structural consequence. We sought to determine if infarct location and related structural connectivity changes were associated with postoperative delirium after SAVR.MethodsA secondary analysis of a randomized multicenter SAVR trial of embolic protection devices (NCT02389894) was conducted, excluding participants with clinical stroke or incomplete neuroimaging (N = 298; 39% female, 7% non‐White, 74 ± 7 years). Delirium during in‐hospital recovery was serially screened using the Confusion Assessment Method. Parcellation and tractography atlas‐based neuroimaging methods were used to determine infarct locations and cortical connectivity effects. Mixed‐effect, zero‐inflated gaussian modeling analyses, accounting for brain region‐specific infarct characteristics, were conducted to examine for differences within and between groups by delirium status and perioperative neuroprotection device strategy.Results23.5% participants experienced postoperative delirium. Delirium was associated with significantly increased lesion volumes in the right cerebellum and temporal lobe white matter, while diffusion weighted imaging infarct‐related structural disconnection (DWI‐ISD) was observed in frontal and temporal lobe regions (p‐FDR < 0.05). Fewer brain regions demonstrated DWI‐ISD loss in the suction‐based neuroprotection device group, relative to filtration‐based device or standard aortic cannula.InterpretationStructural disconnection from acute infarcts was greater in patients who experienced postoperative delirium, suggesting that the impact from covert perioperative infarcts may not be as clinically “silent” as commonly assumed.Item Open Access Outcomes After Endovascular Thrombectomy With or Without Alteplase in Routine Clinical Practice.(JAMA neurology, 2022-08) Smith, Eric E; Zerna, Charlotte; Solomon, Nicole; Matsouaka, Roland; Mac Grory, Brian; Saver, Jeffrey L; Hill, Michael D; Fonarow, Gregg C; Schwamm, Lee H; Messé, Steven R; Xian, YingImportance
The effectiveness and safety of intravenous alteplase given before or concurrently with endovascular thrombectomy (EVT) is uncertain. Randomized clinical trials suggest there is little difference in outcomes but with only modest precision and insufficient power to analyze uncommon outcomes including symptomatic intracranial hemorrhage (sICH).Objective
To determine whether 8 prespecified outcomes are different in patients with acute ischemic stroke treated in routine clinical practice with EVT with alteplase compared with patients treated with EVT alone without alteplase. It was hypothesized that alteplase would be associated with higher risk of sICH.Design, setting, and participants
This was an observational cohort study conducted from February 1, 2019, to June 30, 2020, that included adult patients with acute ischemic stroke treated with EVT within 6 hours of time last known well, after excluding patients without information on discharge destination and patients with in-hospital stroke. Participants were recruited from Get With The Guidelines-Stroke, a large nationwide registry of patients with acute ischemic stroke from 555 hospitals in the US.Exposures
Intravenous alteplase or no alteplase.Main outcomes and measures
Prespecified outcomes were discharge destination, independent ambulation at discharge, modified Rankin score at discharge, discharge mortality, cerebral reperfusion according to modified Thrombolysis in Cerebral Infarction grade, and sICH.Results
There were 15 832 patients treated with EVT (median [IQR] age, 72.0 [61.0-82.0] years; 7932 women [50.1%]); 10 548 (66.7%) received alteplase and 5284 (33.4%) did not. Patients treated with alteplase were younger, arrived via Emergency Medical Services sooner, were less likely to have certain comorbidities, including atrial fibrillation, hypertension, and diabetes, but had similar National Institutes of Health Stroke Severity (NIHSS) scores. Compared with patients who did not receive alteplase treatment, patients treated with alteplase were less likely to die (11.1% [1173 of 10 548 patients] vs 13.9% [734 of 5284 patients]; adjusted odds ratio [aOR] 0.83; 95% CI, 0.77-0.89; P < .001), more likely to have no major disability based on modified Rankin scale of 2 or less at discharge (28.5% [2415 of 8490 patients] vs 20.7% [894 of 4322 patients]; aOR, 1.36; 95% CI, 1.28-1.45; P < .001), and to have better reperfusion based on modified Thrombolysis in Cerebral Infarction grade 2b or greater (90.9% [8474 of 9318 patients] vs 88.0% [4140 of 4705 patients]; aOR, 1.39; 95% CI, 1.28-1.50; P < .001). However, alteplase treatment was associated with higher risk of sICH (6.5% [685 of 10 530 patients] vs 5.3% [279 of 5249 patients]; OR, 1.28; 95% CI, 1.16-1.42; P < .001).Conclusions and relevance
In this observational cohort study of patients treated with EVT, intravenous alteplase treatment was associated with better in-hospital survival and functional outcomes but higher sICH risk after adjusting for other covariates.Item Open Access Quality of Care and Outcomes for Patients With Stroke in the United States Admitted During the International Stroke Conference.(Journal of the American Heart Association, 2018-11) Messé, Steven R; Mullen, Michael T; Cox, Margueritte; Fonarow, Gregg C; Smith, Eric E; Saver, Jeffrey L; Reeves, Mathew J; Bhatt, Deepak L; Matsouaka, Roland; Schwamm, Lee HBackground Patients presenting to hospitals during non-weekday hours experience worse outcomes, often attributed to reduced staffing. The American Heart Association International Stroke Conference ( ISC ) is well attended by stroke clinicians. We sought to determine whether patients with acute ischemic stroke ( AIS ) admitted during the ISC receive less guideline-adherent care and experience worse outcomes. Methods and Results We performed a retrospective cohort study of US hospitals participating in Get With The Guidelines-Stroke and assessed use of intravenous tissue plasminogen activator, other quality measures, and outcomes for patients with AIS admitted during the ISC compared with those admitted the weeks before and after the conference. A total of 69 738 patients with AIS were included: mean age, 72 years; 52% women; 29% nonwhite. There was no difference between the average weekly number of AIS cases admitted during ISC weeks versus non- ISC weeks (1984 versus 1997; P=0.95). Patient and hospital characteristics were similar between ISC and non- ISC time periods. There were no significant differences in 14 quality metrics and 5 clinical outcomes between patients with AIS treated during the ISC versus non- ISC weeks. Patients with AIS who presented within 2 hours of onset had no difference in the likelihood of receiving intravenous tissue plasminogen activator within 3 hours (adjusted odds ratio, 0.89; 95% confidence interval, 0.77-1.03; P=0.13) or the likelihood of receiving intravenous tissue plasminogen activator within 60 minutes of arrival (adjusted odds ratio, 0.92; 95% confidence interval, 0.83-1.02; P=0.13). Conclusions Patients with acute stroke admitted to Get With The Guidelines-Stroke hospitals during ISC received the same quality care and had similar outcomes as patients admitted at other times.