Background and Purpose— Racial and ethnic disparities in the access to mechanical thrombectomy (MT) for treatment of acute ischemic stroke (AIS) secondary to large vessel occlusion have been previously described. The effect of recent randomized trials validating MT as an effective therapy for AIS secondary to large vessel occlusion on such disparities has not been investigated. Methods— Information on admissions for AIS to endovascular centers occurring between January 2016 and September 2018 was obtained from a national database. The number of patients receiving IV-tPA (intravenous tissue-type plasminogen activator) and MT at each institution was determined, and patient demographics were characterized according to age, sex, race/ethnicity, and insurance status. Comparisons of patients who did and did not undergo MT and between patients of different racial and ethnic backgrounds were performed. Demographic variables independently associated with the utilization of MT were identified using multivariate linear regression analysis. Results— There were 206 853 admissions to 173 endovascular centers during the time period of interest. The overall utilization of MT was 8.4%. The utilization of MT for black/Hispanic patients was lower than that among white/non-Hispanic patients (7.0% versus 9.8%; P <0.001). Black/Hispanic patients were also less likely to receive IV-tPA (16.2% versus 20.5%; P <0.001) and to be admitted to the endovascular center after transfer from a different hospital (20.0% versus 30.1%; P <0.001). On multivariate linear regression analysis, increasing institutional proportions of patients with female sex (β=−0.601; P <0.001), insurance with Medicaid or uninsured status (β=−0.153; P =0.029), and black/Hispanic race/ethnicity (β=−0.062; P =0.046) were independently associated with lower institutional utilization of MT. Conclusions— Despite the mainstream acceptance of MT for the treatment of AIS secondary to large vessel occlusion, racial and ethnic disparities in the utilization of MT persist.
ObjectiveRelatively little is known about the effect of malignancy on patient outcomes after acute ischemic stroke (AIS) or utilization rates of stroke interventions in this population. We aimed to assess the effect of underlying malignancy on outcomes and treatment of AIS at a population level.MethodsOutcomes after AIS between patients with and without malignancy were compared using a national database of hospital reported outcomes.ResultsThere were 351 institutions reporting the outcomes of 3 18 127 admissions for AIS. Of these admissions, 16 141 patients carried a pre-existing diagnosis of malignancy at the time of admission. Administration of intravenous tissue plasminogen activator (IV tPA) was less common in patients with malignancy compared with patients without malignancy (7.3% vs 10.7%; P<0.001) but there was no difference in the rate of mechanical thrombectomy (3.1% vs 3.1%; P=0.967). Mortality rates were higher among patients with malignancy (7.1% vs 3.7%; P<0.001), a relationship which persisted when analysis was restricted to patients receiving IV tPA (10.8% vs 6.1%; P<0.001) or thrombectomy (20.3% vs 13.5%; P<0.001). Rates of both IV tPA administration (2.5% vs 10.5%; P<0.001) and mechanical thrombectomy (2.1% vs 5.4%; P<0.001) were lower in patients with brain malignancy relative to patients with malignancy of non-CNS origin.ConclusionA diagnosis of malignancy on admission for acute stroke was associated with a higher rate of mortality. Malignancy was also associated with a lower rate of IV tPA administration but no difference in mechanical thrombectomy utilization.
Background and purposePrevious studies have documented disparate access to cerebrovascular neurosurgery for patients of different racial and socioeconomic backgrounds. We further investigated the effect of race and insurance status on access to treatment of unruptured intracranial aneurysms (UIAs) and compared it with data on patients with aneurysmal subarachnoid hemorrhage (aSAH).MethodsThrough the use of a national database, admissions for clipping or coiling of an UIA and for aSAH were identified. Demographic characteristics of patients were characterized according to age, sex, race/ethnicity, and insurance status, and comparisons between patients admitted for treatment of an UIA versus aSAH were performed.ResultsThere were 10 545 admissions for clipping or coiling of an UIA and 33 166 admissions for aSAH between October 2014 and July 2018. White/non-Hispanic patients made up a greater proportion of patients presenting for treatment of an UIA than those presenting with aSAH (64.3% vs 48.2%; P<0.001), whereas black/Hispanic patients presented more frequently with aSAH than for treatment of an UIA (29.3% vs 26.1%; P=0.006). On multivariate linear regression analysis, the proportion of patients admitted for management of an UIA relative to those admitted for aSAH increased with the proportion of patients who were women (P<0.001) and decreased with the proportion of patients with a black/Hispanic background (P=0.010) and those insured with Medicaid or without insurance (P=0.003).ConclusionFor patients with UIAs, racial, ethnic, and socioeconomic backgrounds appear to continue to influence access to treatment.
BACKGROUND There is a paucity of literature regarding treatment options for extracranial pseudoaneurysms of the internal carotid artery (ICA). To date, Pipeline Embolization Device (PED; Medtronic Inc) use for the treatment of extracranial pseudoaneurysms of the ICA has only been reported from single-center case series. OBJECTIVE To evaluate the safety and efficacy of PED for the treatment of extracranial ICA pseudoaneurysms. METHODS This is a multicenter retrospective study involving 6 high-volume tertiary academic institutions in the United States. We analyzed patients with extracranial ICA pseudoaneurysms treated with PED between January 1, 2011, and January 1, 2019. Clinical assessment was performed pre- and postintervention using the modified Rankin Scale (mRS) and National Institution of Health Stroke Scale (NIHSS) at a minimum of 4-mo follow-up. RESULTS A total of 28 pseudoaneurysms with a mean diameter of 17.7 mm (range: 4.1-52.5 mm) were treated with PED in 24 patients at 6 participating centers. The mean age was 52.1 yr (17-73) ± 14.3 with 14 females and 10 males. At a mean of 21-mo (range 4-66 mo) follow-up, complete occlusion was achieved in 89% (n = 25/28), with near-complete occlusion (>90% occlusion) in the remainder. There were no periprocedural complications. Postprocedure NIHSS was 0 in 88% (n = 21/24) and 1 in 12% (n = 3/24) of patients, and mRS was 0 in 83% (n = 20/24) and 1 in 17% (n = 4/24) of patients. CONCLUSION The treatment of extracranial ICA pseudoaneurysms with PED is safe and effective in selected patients. Randomized controlled trials and prospective cohort studies are needed to establish the role of flow diversion for ICA pseudoaneurysms.
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