Akash Pravin Kansagra

All Publications

• Pediatric Intracerebral Hemorrhage Management-Consensus Statement of the International Pediatric Stroke Organization-Part 1: Acute Phase and Workup. Journal of the American Heart Association Boulouis, G., Fox, C. K., Waak, M., Sporns, P. B., Mailo, J. A., Beslow, L. A., Wintermark, M., Chung, M. G., Harrar, D. B., Vossough, A., Hausman-Kedem, M., Naggara, O., Jiang, B., Requejo, F., Chaudhary, N., Benichi, S., Radvany, M. G., Martinez, M., Vadivelu, S., Kansagra, A. P., Aagaard-Kienitz, B., Martí-Fàbregas, J., Chikkannaiah, M., Pasi, M., Grossberg, J. A., Chevignard, M., Mrakotsky, C., Fullerton, H. J., Dlamini, N., Lehman, L. L. 2025: e039594

  Abstract

  Pediatric intracerebral hemorrhage (pICH) is a rare but serious neurologic emergency associated with significant morbidity. Although pICH accounts for nearly half of all pediatric strokes, it remains understudied, and dedicated evidence-based management guidelines are lacking. To address this gap, the International Pediatric Stroke Organization convened a multidisciplinary international working group in 2020 to develop a comprehensive, consensus-based framework for the acute evaluation and management of pICH in children aged 28 days to 18 years. The working group included child neurologists, neurointensivists, neurosurgeons, neuroradiologists, and neurointerventionalists. Subgroups conducted systematic literature reviews and formulated key clinical questions. A modified Delphi process was used to derive consensus statements across 6 domains: prehospital and emergency care, diagnostic imaging and workup, neurocritical care and medical management, neurosurgical and neurointerventional approaches, and identification of knowledge gaps. Through rounds of structured review and voting, 21 consensus statements were developed and approved. The process was endorsed by multiple professional societies. This represents the first international, multidisciplinary, multisociety consensus statement focused on the acute management of pICH in children. It provides structured, expert-driven guidance to inform clinical decision-making, reduce practice variability, and highlight areas for future research. These consensus statements aim to support clinicians worldwide in improving outcomes for children with pICH.

  View details for DOI 10.1161/JAHA.124.039594

  View details for PubMedID 41467366

• Microsurgical Treatment of Intracranial Dural Arteriovenous Fistulas: A Collaborative Investigation From the Multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research NEUROSURGERY Raygor, K. P., Abdelsalam, A., Tonetti, D. A., Raper, D. M. S., Guniganti, R., Durnford, A. J., Giordan, E., Brinjikji, W., Chen, C., Abecassis, I., Levitt, M. R., Polifka, A. J., Derdeyn, C. P., Samaniego, E. A., Kwasnicki, A., Alaraj, A., Potgieser, A. R. E., Chen, S., Tada, Y., Kansagra, A. P., Satomi, J., Eatz, T., Peterson, E. C., Starke, R. M., van Dijk, J. C., Amin-Hanjani, S., Hayakawa, M., Gross, B. A., Fox, W., Kim, L., Sheehan, J., Lanzino, G., Du, R., Lai, P., Bulters, D. O., Zipfel, G. J., Abla, A. A., Consortium Dural Arteriovenous Fistula Outcomes Res 2025; 96 (5): 1023-1034

  Abstract

  First-line therapy for most intracranial dural arteriovenous fistulas (dAVFs) is endovascular embolization, but some require microsurgical ligation due to limited endovascular accessibility, anticipated lower cure rates, or unacceptable risk profiles. We investigated the most common surgically treated dAVF locations and the approaches and outcomes of each.The Consortium for Dural Arteriovenous Fistula Outcomes Research database was retrospectively reviewed. Patients who underwent dAVF microsurgical ligation were included. Patient demographics, angiographic information, surgical details, and postoperative outcomes were collected. The 5 most common surgically treated dAVF locations were analyzed about used surgical approaches and postoperative outcomes. Univariate analyses were performed with statistical significance set at a threshold of P < .05.In total, 248 patients in the Consortium for Dural Arteriovenous Fistula Outcomes Research database met inclusion criteria. The 5 most common surgically treated dAVF locations were tentorial, anterior cranial fossa (ACF), transverse-sigmoid sinus (TSS), convexity/superior sagittal sinus (SSS), and torcular. Most tentorial dAVFs were approached using a suboccipital, lateral supracerebellar infratentorial approach (39.3%); extended retrosigmoid approach (ERS) (25%); or posterior subtemporal approach (19.6%). All ACF dAVFs used a subfrontal approach; 5.3% also included an anterior interhemispheric approach. Most TSS dAVFs were ligated via ERS (31.3%) or subtemporal (31.3%) approaches. All convexity/SSS dAVFs used an interhemispheric approach. All torcular dAVFs used the suboccipital, lateral supracerebellar infratentorial approach, with 10.5% undergoing simultaneous ERS craniotomy. Angiographic occlusion rates after microsurgery were 85.5%, 100%, 75.8%, 79.2%, and 73.7% for tentorial, ACF, TSS, convexity/SSS, and torcular dAVFs, respectively (P = .02); the permanent neurological complication rates were 1.8%, 2.6%, 9.1%, 0%, and 0% (P = .31). There were no statistically significant differences in development of complications (P = .08) or Modified Rankin Scale at the last follow-up (P = .11) by fistula location.Although endovascular embolization is the first-line treatment for most intracranial dAVFs, surgical ligation is an important alternative. ACF and tentorial fistulas particularly demonstrate high rates of postoperative obliteration.

  View details for DOI 10.1227/neu.0000000000003204

  View details for Web of Science ID 001466926500033

  View details for PubMedID 39471093

• No child left behind JOURNAL OF NEUROINTERVENTIONAL SURGERY Kansagra, A. P. 2024; 16 (6): 535-536

  View details for DOI 10.1136/jnis-2024-021907

  View details for Web of Science ID 001265084200020

  View details for PubMedID 38772614

• Transient cortical weakness following cerebral angiography: A new syndrome. Radiology case reports Kansagra, A. P., Pham, R., Chatterjee, A. R., Moran, C. J. 2024; 19 (6): 2306-2309

  Abstract

  Transient cortical blindness is a known complication of iodinated contrast administration and is believed to reflect osmotic injury or autoregulatory dysfunction of the posterior circulation. Here, we report 2 cases of postangiography transient cortical weakness, a rare clinical analog to transient cortical blindness that affects the anterior circulation. The symptoms, timeline, and imaging findings of transient cortical weakness are distinct from more common post-procedural complications such as acute ischemic stroke or transient ischemic attack.

  View details for DOI 10.1016/j.radcr.2024.02.080

  View details for PubMedID 38559657

  View details for PubMedCentralID PMC10978451

• Dural Arteriovenous Fistulas With Cognitive Impairment: Angiographic Characteristics and Treatment Outcomes NEUROSURGERY Sanchez, S., Wendt, L., Hayakawa, M., Chen, C., Sheehan, J. P., Kim, L. J., Abecassis, I., Levitt, M. R., Meyer, R., Guniganti, R., Kansagra, A. P., Lanzino, G., Giordan, E., Brinjikji, W., Bulters, D. O., Durnford, A., Fox, W., Smith, J., Polifka, A. J., Gross, B., Amin-Hanjani, S., Alaraj, A., Kwasnicki, A., Starke, R. M., Chen, S. H., van Dijk, J. C., Potgieser, A. R. E., Satomi, J., Tada, Y., Phelps, R., Abla, A., Winkler, E., Du, R., Rosalind Lai, P., Ortega-Gutierrez, S., Zipfel, G. J., Derdeyn, C., Samaniego, E. A. 2024; 94 (5): 1035-1043

  Abstract

  Anecdotal cases of rapidly progressing dementia in patients with dural arteriovenous fistulas (dAVFs) have been reported in small series. However, large series have not characterized these dAVFs. We conducted an analysis of the largest cohort of dAVFs presenting with cognitive impairment (dAVFs-CI), aiming to provide a detailed characterization of this subset of dAVFs.Patients with dAVFs-CI were analyzed from the CONDOR Consortium, a multicenter repository comprising 1077 dAVFs. A propensity score matching analysis was conducted to compare dAVFs-CI with Borden type II and type III dAVFs without cognitive impairment (controls). Logistic regression was used to identify angiographic characteristics specific to dAVFs-CI. Furthermore, post-treatment outcomes were analyzed.A total of 60 patients with dAVFs-CI and 60 control dAVFs were included. Outflow obstruction leading to venous hypertension was observed in all dAVFs-CI. Sinus stenosis was significantly associated with dAVFs-CI (OR 2.85, 95% CI: 1.16-7.55, P = .027). dAVFs-CI were more likely to have a higher number of arterial feeders (OR 1.56, 95% CI 1.22-2.05, P < .001) and draining veins (OR 2.05, 95% CI 1.05-4.46, P = .004). Venous ectasia increased the risk of dAVFs-CI (OR 2.38, 95% CI 1.13-5.11, P = .024). A trend toward achieving asymptomatic status at follow-up was observed in patients with successful closure of dAVFs (OR 2.86, 95% CI 0.85-9.56, P = .09).Venous hypertension is a key angiographic feature of dAVFs-CI. Moreover, these fistulas present at a mean age of 58 years-old, and exhibit a complex angioarchitecture characterized by an increased number of arteriovenous connections and stenosed sinuses. The presence of venous ectasia further exacerbates the impaired drainage and contributes to the development of dAVFs-CI. Notably, in certain cases, closure of the dAVF has the potential to reverse symptoms.

  View details for DOI 10.1227/neu.0000000000002802

  View details for Web of Science ID 001233805700012

  View details for PubMedID 38095434

• In-hospital imaging utilization after elective endovascular brain aneurysm treatment: a surrogate metric for the value of hospitalization. Journal of neurosurgery Lauzier, D. C., Cler, S. J., Chatterjee, A. R., Osbun, J. W., Vellimana, A. K., Derdeyn, C. P., Cross, D. T., Moran, C. J., Kansagra, A. P. 2024; 140 (2): 430-435

  Abstract

  Despite the adoption of same-day outpatient surgical procedures in some specialties, it remains common practice to admit patients for monitoring after elective endovascular treatment of brain aneurysms to monitor for complications. The necessity of such monitoring has not been fully characterized. Here, the authors reviewed the utilization of imaging during posttreatment hospitalization, a surrogate measure for workup of suspected complications requiring hospital resources, to infer the value of inpatient monitoring after endovascular aneurysm treatment.Clinical and angiographic data from eligible patients were retrospectively assessed for demographic characteristics, imaging indications, timing of imaging, and imaging findings. Patients were included if they underwent elective endovascular brain aneurysm treatment, and patients were excluded if significant intraprocedural complications occurred. The recorded imaging modalities included CT, MRI, catheter-based imaging, and ultrasound; plain radiographs were excluded. Multivariable logistic regression analysis was performed to identify predictors of the need for posttreatment imaging.In total, 1229 elective endovascular procedures for brain aneurysm treatment were included. Patients underwent imaging before discharge in 13.4% (165/1229) of cases, with significant findings in 5.0% (61/1229) of cases. The median (interquartile range) time to first posttreatment imaging was 13.2 (4.2-22.8) hours. The need for imaging during posttreatment hospitalization was positively associated with larger aneurysm size (p < 0.05) and negatively associated with underlying cardiovascular disease (p < 0.05).More than 1 in 8 patients who underwent elective endovascular brain aneurysm treatment required imaging during posttreatment hospitalization, most within the first 24 hours, and 1 in 20 had significant findings. These results suggest the importance of short-term hospitalization after elective endovascular aneurysm treatment.

  View details for DOI 10.3171/2023.5.JNS23656

  View details for PubMedID 37548550

• Retreatment of previously flow diverted intracranial aneurysms with the pipeline embolization device. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences Lauzier, D. C., Cler, S. J., Chatterjee, A. R., Osbun, J. W., Moran, C. J., Kansagra, A. P. 2023; 29 (6): 710-714

  Abstract

  Flow diversion of intracranial aneurysms with the Pipeline Embolization Device (PED) is frequently performed, but the outcomes of retreatment for aneurysms that failed to occlude after prior treatment with PED have not been well studied. Here, we report the safety and efficacy of PED retreatment after initial failure to occlude.Clinical and angiographic data from eligible patients were retrospectively assessed for demographics, aneurysm occlusion status, and clinical outcomes. Patients were included in this study if they underwent PED retreatment to treat an aneurysm that had previously been treated with PED.Retreatment of previously flow-diverted aneurysms with PED was performed in 42 cases. At final angiographic follow-up, angiographic improvement was observed after 45% (19/42) of retreatments and complete aneurysm occlusion was observed following 26% (11/42). Significant clinical complications occurred in 10% (4/42) of PED retreatments.Retreatment of intracranial aneurysms with PED following initial failure to achieve aneurysm occlusion has a low rate of subsequent complete aneurysm occlusion.

  View details for DOI 10.1177/15910199221111284

  View details for PubMedID 35758311

  View details for PubMedCentralID PMC10680950

• Travel time and distance for bypass and non-bypass routing of stroke patients in the USA. Journal of neurointerventional surgery Yu, C. Y., Panagos, P. D., Kansagra, A. P. 2023; 15 (7): 634-638

  Abstract

  Endovascular thrombectomy is not available at all hospitals that offer intravenous thrombolysis, prompting debate regarding the preferred transport destination for acute ischemic stroke. This study aimed to quantify real-world travel time and distance of bypass and non-bypass transport models for large-vessel occlusion (LVO) and non-LVO stroke.This cross-sectional study included population data of census tracts in the contiguous USA from the 2014-2018 United States Census Bureau's American Community Survey, stroke (thrombolysis-capable) and thrombectomy-capable centers certified by a state or national body, and road network data from a mapping service. Census tracts were categorized by urbanization level. Data were retrieved from March to November 2020. Travel times and distances were calculated for each census tract to each of the following: nearest stroke center (nearest), nearest thrombectomy-capable center (bypass), and nearest stroke center then to the nearest thrombectomy-capable center (transfer). Population-weighted median and IQR were calculated nationally and by urbanization.72 538 census tracts, 2388 stroke hospitals, and 371 thrombectomy-capable centers were included. Nationally, population-weighted median travel time for nearest and bypass routing was 11.7 min (IQR 7.7-19.3) and 26.4 min (14.8-55.1), respectively. For transfer routing, the population-weighted median travel times with 60 min, 90 min, and 120 min door-in-door-out times were 94.1 min (78.5-127.7), 124.1 min (108.5-157.7), and 154.1 min (138.4-187.6), respectively.Bypass routing offers modest travel time benefits for LVO patients and incurs modest penalties for non-LVO patients. Differences are greatest in rural areas. A majority of Americans live in areas for which current guidelines recommend bypass.

  View details for DOI 10.1136/neurintsurg-2022-018787

  View details for PubMedID 35545427

  View details for PubMedCentralID PMC9649836

• Need for Y-stenting in stent-assisted coiling of wide-neck bifurcation aneurysms. Clinical neurology and neurosurgery Lauzier, D. C., Root, B. K., Chatterjee, A. R., Osbun, J. W., Moran, C. J., Kansagra, A. P. 2023; 229: 107748

  Abstract

  Stent-assisted coiling of wide neck bifurcation aneurysms in the anterior communicating segment and basilar tip region can be performed with varying stent configurations, including single stenting or Y-stenting. Y-stenting requires two stents and thus incurs greater cost and procedural complexity than single-stent constructs. The influence of first stent type on the need for Y-stenting remains unknown.Clinical and angiographic data were retrospectively obtained for patients that underwent stent-assisted coiling for basilar tip or anterior communicating aneurysms at a high-volume center. Patients were included in this study if stent-assisted coiling was performed using Neuroform Atlas or LVIS Jr stents. A multivariate binary logistic regression was performed to measure the influence of first stent type on the need for Y-stenting.Stent-assisted coiling was used to treat 82 aneurysms in 81 patients during the study period, and Y-stenting was performed in 18.3% (15/82) of cases. In multivariate logistic regression analysis, use of LVIS Jr. as the first stent did not significantly influence the need for subsequent Y-stenting after controlling for aneurysm morphology (OR 0.65, 95% CI 0.18-2.43).Controlling for aneurysm morphology and location, the use of Y-stenting for stent-assisted coiling was not independently influenced by the choice of LVIS Jr or Neuroform Atlas as the first stent. A larger cohort may reveal differences between these two stents, particularly for aneurysms with large neck sizes.

  View details for DOI 10.1016/j.clineuro.2023.107748

  View details for PubMedID 37146368

• The VEBAS score: a practical scoring system for intracranial dural arteriovenous fistula obliteration JOURNAL OF NEUROINTERVENTIONAL SURGERY Becerril-Gaitan, A., Ding, D., Ironside, N., Buell, T. J., Kansagra, A. P., Lanzino, G., Brinjikji, W., Kim, L., Levitt, M. R., Abecassis, I., Bulters, D., Durnford, A., Fox, W., Blackburn, S., Chen, P., Polifka, A. J., Laurent, D., Gross, B., Hayakawa, M., Derdeyn, C., Amin-Hanjani, S., Alaraj, A., van Dijk, J. C., Potgieser, A. R. E., Starke, R. M., Peterson, E. C., Satomi, J., Tada, Y., Abla, A. A., Winkler, E. A., Du, R., Lai, P., Zipfel, G. J., Chen, C., Sheehan, J. P. 2024; 16 (3): 272-279

  Abstract

  Tools predicting intracranial dural arteriovenous fistulas (dAVFs) treatment outcomes remain scarce. This study aimed to use a multicenter database comprising more than 1000 dAVFs to develop a practical scoring system that predicts treatment outcomes.Patients with angiographically confirmed dAVFs who underwent treatment within the Consortium for Dural Arteriovenous Fistula Outcomes Research-participating institutions were retrospectively reviewed. A subset comprising 80% of patients was randomly selected as training dataset, and the remaining 20% was used for validation. Univariable predictors of complete dAVF obliteration were entered into a stepwise multivariable regression model. The components of the proposed score (VEBAS) were weighted based on their ORs. Model performance was assessed using receiver operating curves (ROC) and areas under the ROC.A total of 880 dAVF patients were included. Venous stenosis (presence vs absence), elderly age (<75 vs ≥75 years), Borden classification (I vs II-III), arterial feeders (single vs multiple), and past cranial surgery (presence vs absence) were independent predictors of obliteration and used to derive the VEBAS score. A significant increase in the likelihood of complete obliteration (OR=1.37 (1.27-1.48)) with each additional point in the overall patient score (range 0-12) was demonstrated. Within the validation dataset, the predicted probability of complete dAVF obliteration increased from 0% with a 0-3 score to 72-89% for patients scoring ≥8.The VEBAS score is a practical grading system that can guide patient counseling when considering dAVF intervention by predicting the likelihood of treatment success, with higher scores portending a greater likelihood of complete obliteration.

  View details for DOI 10.1136/jnis-2023-020282

  View details for Web of Science ID 001014703100001

  View details for PubMedID 37130751

• Evolution of Elective Intracranial Aneurysm Treatment. World neurosurgery Lauzier, D. C., Cler, S. J., Vellimana, A. K., Osbun, J. W., Chatterjee, A. R., Derdeyn, C. P., Cross, D. T., Moran, C. J., Kansagra, A. P. 2022; 168: 309-310

  View details for DOI 10.1016/j.wneu.2022.08.133

  View details for PubMedID 36055621

• Letter: Safety and Efficacy of the Off-Label Use of Pipeline Embolization Device Based on the 2018 Food and Drug Administration-Approved Indications for Intracranial Aneurysms: A Single-Center Retrospective Cohort Study. Neurosurgery Cler, S. J., Lauzier, D. C., Kansagra, A. P. 2022; 91 (5): e135

  View details for DOI 10.1227/neu.0000000000002125

  View details for PubMedID 36001784

• Management of In-Stent Stenosis with Dual Antiplatelet Therapy Following Pipeline Embolization of Intracranial Aneurysms. World neurosurgery Lauzier, D. C., Cler, S. J., Osbun, J. W., Chatterjee, A. R., Moran, C. J., Kansagra, A. P. 2022; 167: e303-e309

  Abstract

  Flow diversion of intracranial aneurysms with the pipeline embolization device (PED) may produce angiographically apparent stenosis within the PED, which can lead to secondary ischemic complications. In-stent stenosis can be treated medically with dual antiplatelet therapy (DAPT), but the safety and efficacy of this approach are unknown. In this work, we review the safety and efficacy of DAPT to prevent progression of in-stent stenosis or development of cerebral ischemia.Clinical and angiographic data from eligible patients were assessed from a prospectively maintained neurointerventional database. Details surrounding in-stent stenosis and DAPT were extracted. Patients were included in this study if in-stent stenosis was detected at any angiographic follow-up and managed with DAPT. The primary efficacy endpoint was lack of angiographic progression of in-stent stenosis or new ipsilateral infarct following initiation of medical therapy.In total, 23 PED constructs developed in-stent stenosis and were managed with DAPT. Follow-up angiography was available for 19 constructs. Eighty-nine percent (17/19) of PED constructs achieved the primary endpoint of lack of stenosis progression and lack of new ipsilateral ischemic events. Of the 2 PED constructs that failed to achieve the primary endpoint of this study, one demonstrated worsening of in-stent stenosis from 55% to 76% over 16 months, while the other developed ipsilateral ischemic stroke 4 months after detection of in-stent stenosis. In addition, one patient experienced intracranial hemorrhage 9 months after the initiation of DAPT.Progression of in-stent stenosis and new ipsilateral ischemic events are limited in the presence of DAPT. However, hemorrhagic events related to DAPT may occasionally occur.

  View details for DOI 10.1016/j.wneu.2022.08.002

  View details for PubMedID 35948233

• Time Line of Occlusion for Intracranial Aneurysms Treated with the Pipeline Embolization Device. World neurosurgery Cler, S. J., Lauzier, D. C., Chatterjee, A. R., Osbun, J. W., Moran, C. J., Kansagra, A. P. 2022; 166: e750-e757

  Abstract

  Rates of aneurysm occlusion following treatment with flow-diverting stents have been quantified at predefined time points in clinical trials, but data characterizing the continuous temporal progression of aneurysm occlusion are lacking. This study used real-world variability in timing of angiographic follow-up to characterize the time line of aneurysm occlusion following treatment with the Pipeline embolization device (PED).All aneurysms treated with a PED at our institution between 2011 and 2020 were screened. Nonsaccular or ruptured aneurysms were excluded. Aneurysm occlusion status and time since treatment were recorded for each follow-up angiogram. Aneurysm occlusion was characterized using Kaplan-Meier and Cox proportional hazards analysis after censoring at last follow-up or subsequent treatment.There were 290 aneurysms in 222 patients analyzed. The median time of observed aneurysm occlusion was 7.5 months, and overall rate of aneurysm occlusion was 77.9%. Larger aneurysms demonstrated a longer median time to occlusion and lower rate of aneurysm occlusion (P = 0.029). There were no observed differences in the time line of occlusion for aneurysms treated with a single PED or multiple PEDs (P = 0.889) or without or with adjunctive coiling (P = 0.771).Aneurysms treated with a PED had a median time to observed occlusion of 7.5 months. Occlusion of larger aneurysms occurred more slowly than occlusion of smaller aneurysms following flow diversion. The number of PEDs deployed or the use of adjunctive coiling did not affect the time line or likelihood of aneurysm occlusion. These findings may guide optimal timing of follow-up after treatment with a PED.

  View details for DOI 10.1016/j.wneu.2022.07.084

  View details for PubMedID 35931339

• Comparative study of on-label versus off-label treatment of intracranial aneurysms with the Pipeline embolization device. Journal of neurosurgery Cler, S. J., Lauzier, D. C., Chatterjee, A. R., Osbun, J. W., Moran, C. J., Kansagra, A. P. 2022; 137 (3): 685-690

  Abstract

  The Pipeline embolization device (PED) is widely used for the treatment of intracranial aneurysms, including in off-label applications. In this work, the authors compared the real-world efficacy and safety of PED use in on-label and off-label aneurysm treatments.Clinical and angiographic data of patients who underwent PED placement at a high-volume academic medical center were retrospectively obtained. Treatments were classified as on-label if they fell within the applications approved by the United States Food and Drug Administration as of 2021. Recorded outcomes included aneurysm occlusion, procedural complications, ischemic events, in-stent stenosis, intracranial hemorrhage, postprocedural functional status, and death.In total, 416 aneurysms in 330 patients were treated with PED, comprising 256 aneurysms that received on-label treatments and 160 that received off-label treatments. The overall rate of complete aneurysm occlusion was 76.4% for on-label aneurysms and 75.6% for off-label aneurysms (p = 0.898). The risk of ischemic stroke in patients who underwent off-label treatments was 15.2%, which was higher than the 4.2% rate in patients who underwent on-label treatment (p = 0.003). All other clinical complications, procedural complications, and long-term functional status were comparable between the on-label and off-label groups.In real-world practice, off-label use of PED is common and can achieve similar efficacy as on-label use. However, in aggregate, off-label use was found to carry an increased rate of ischemic complications. With judicious attention to safety and individual patient characteristics, these results highlight the scale and general feasibility of off-label PED use by experts.

  View details for DOI 10.3171/2021.11.JNS212481

  View details for PubMedID 35090133

• Natural history, angiographic presentation and outcomes of anterior cranial fossa dural arteriovenous fistulas JOURNAL OF NEUROINTERVENTIONAL SURGERY Sanchez, S., Raghuram, A., Wendt, L., Hayakawa, M., Chen, C., Sheehan, J. P., Kim, L. J., Abecassis, I., Levitt, M. R., Meyer, R., Guniganti, R., Kansagra, A. P., Lanzino, G., Giordan, E., Brinjikji, W., Bulters, D. O., Durnford, A., Fox, W., Smith, J., Polifka, A. J., Gross, B., Amin-Hanjani, S., Alaraj, A., Kwasnicki, A., Starke, R. M., Chen, S. H., van Dijk, J. C., Potgieser, A. R. E., Satomi, J., Tada, Y., Phelps, R., Abla, A., Winkler, E., Du, R., Lai, P., Zipfel, G. J., Derdeyn, C., Samaniego, E. A. 2023; 15 (9): 903-908

  Abstract

  Anterior cranial fossa dural arteriovenous fistulas (ACF-dAVFs) are aggressive vascular lesions. The pattern of venous drainage is the most important determinant of symptoms. Due to the absence of a venous sinus in the anterior cranial fossa, most ACF-dAVFs have some degree of drainage through small cortical veins. We describe the natural history, angiographic presentation and outcomes of the largest cohort of ACF-dAVFs.The CONDOR consortium includes data from 12 international centers. Patients included in the study were diagnosed with an arteriovenous fistula between 1990-2017. ACF-dAVFs were selected from a cohort of 1077 arteriovenous fistulas. The presentation, angioarchitecture and treatment outcomes of ACF-dAVF were extracted and analyzed.60 ACF-dAVFs were included in the analysis. Most ACF-dAVFs were symptomatic (38/60, 63%). The most common symptomatic presentation was intracranial hemorrhage (22/38, 57%). Most ACF-dAVFs drained through cortical veins (85%, 51/60), which in most instances drained into the superior sagittal sinus (63%, 32/51). The presence of cortical venous drainage predicted symptomatic presentation (OR 9.4, CI 1.98 to 69.1, p=0.01). Microsurgery was the most effective modality of treatment. 56% (19/34) of symptomatic patients who were treated had complete resolution of symptoms. Improvement of symptoms was not observed in untreated symptomatic ACF-dAVFs.Most ACF-dAVFs have a symptomatic presentation. Drainage through cortical veins is a key angiographic feature of ACF-dAVFs that accounts for their malignant course. Microsurgery is the most effective treatment. Due to the high risk of bleeding, closure of ACF-dAVFs is indicated regardless of presentation.

  View details for DOI 10.1136/jnis-2022-019160

  View details for Web of Science ID 000838780700001

  View details for PubMedID 35944975

• Risk of Early Versus Later Rebleeding From Dural Arteriovenous Fistulas With Cortical Venous Drainage STROKE Durnford, A. J., Akarca, D., Culliford, D., Millar, J., Guniganti, R., Giordan, E., Brinjikji, W., Chen, C., Abecassis, I., Levitt, M., Polifka, A. J., Derdeyn, C. P., Samaniego, E. A., Kwasnicki, A., Alaraj, A., Potgieser, A. R. E., Chen, S., Tada, Y., Phelps, R., Abla, A., Satomi, J., Starke, R. M., van Dijk, J. C., Amin-Hanjani, S., Hayakawa, M., Gross, B., Fox, W., Kim, L., Sheehan, J., Lanzino, G., Kansagra, A. P., Du, R., Lai, R., Zipfel, G. J., Bulters, D. O., CONDOR Investigators 2022; 53 (7): 2340-2345

  Abstract

  Cranial dural arteriovenous fistulas with cortical venous drainage are rare lesions that can present with hemorrhage. A high rate of rebleeding in the early period following hemorrhage has been reported, but published long-term rates are much lower. No study has examined how risk of rebleeding changes over time. Our objective was to quantify the relative incidence of rebleeding in the early and later periods following hemorrhage.Patients with dural arteriovenous fistula and cortical venous drainage presenting with hemorrhage were identified from the multinational CONDOR (Consortium for Dural Fistula Outcomes Research) database. Natural history follow-up was defined as time from hemorrhage to first treatment, rebleed, or last follow-up. Rebleeding in the first 2 weeks and first year were compared using incidence rate ratio and difference.Of 1077 patients, 250 met the inclusion criteria and had 95 cumulative person-years natural history follow-up. The overall annualized rebleed rate was 7.3% (95% CI, 3.2-14.5). The incidence rate of rebleeding in the first 2 weeks was 0.0011 per person-day; an early rebleed risk of 1.6% in the first 14 days (95% CI, 0.3-5.1). For the remainder of the first year, the incidence rate was 0.00015 per person-day; a rebleed rate of 5.3% (CI, 1.7-12.4) over 1 year. The incidence rate ratio was 7.3 (95% CI, 1.4-37.7; P, 0.026).The risk of rebleeding of a dural arteriovenous fistula with cortical venous drainage presenting with hemorrhage is increased in the first 2 weeks justifying early treatment. However, the magnitude of this increase may be considerably lower than previously thought. Treatment within 5 days was associated with a low rate of rebleeding and appears an appropriate timeframe.

  View details for DOI 10.1161/STROKEAHA.121.036450

  View details for Web of Science ID 000850000800040

  View details for PubMedID 35420453

  View details for PubMedCentralID PMC9232241

• Neurointerventional management of cerebrovascular trauma. Journal of neurointerventional surgery Lauzier, D. C., Chatterjee, A. R., Kansagra, A. P. 2022; 14 (7): 718-722

  Abstract

  Traumatic cerebrovascular injuries following blunt or penetrating trauma are common and carry a high risk of permanent disability or death. Proper screening, diagnosis, and treatment of these lesions is essential to improve patient outcomes. Advances in imaging continue to improve the accuracy of non-invasive diagnosis of these injuries while new clinical data provide better evidence for optimal management, whether medical or invasive. Here, we review screening, diagnosis, and treatment of traumatic cerebrovascular injuries.

  View details for DOI 10.1136/neurintsurg-2021-017923

  View details for PubMedID 34949708

• The clear need for a prospective pediatric arteriovenous malformation trial. Journal of neurointerventional surgery Lauzier, D. C., Vellimana, A., Kansagra, A. P. 2022; 14 (6): e5

  View details for DOI 10.1136/neurintsurg-2022-018672

  View details for PubMedID 35177519

• The value of long-term angiographic follow-up following Pipeline embolization of intracranial aneurysms. Journal of neurointerventional surgery Lauzier, D. C., Cler, S. J., Chatterjee, A. R., Osbun, J. W., Moran, C. J., Kansagra, A. P. 2022; 14 (6): 585-588

  Abstract

  Flow diversion of intracranial aneurysms with the Pipeline Embolization Device (PED) is commonly performed, but the value of long-term angiographic follow-up has not been rigorously evaluated. Here we examine the prevalence of actionable findings of aneurysm recurrence and development of in-stent stenosis in a cohort of patients that underwent long-term angiographic follow-up at multiple time points.Angiographic data from eligible patients were retrospectively assessed for aneurysm occlusion, in-stent stenosis, and aneurysm regrowth or recurrence. Patients were included in this study if they underwent angiographic imaging at 6 months post-treatment and at least one later time point.100% (132/132) of aneurysms occluded at 6 months remained occluded at final follow-up. 85.7% (6/7), 56.3% (27/48), and 25% (6/24) of aneurysms with entry remnant, subtotal filling, and total filling, respectively, at 6 months were completely occluded at final follow-up. 98.7% (147/149) of PED constructs that demonstrated no stenosis at 6 months demonstrated no stenosis at final angiography, while 44.4% (8/18) of PED constructs demonstrating in-stent stenosis at 6 months had resolution of stenosis on final angiography.Among patients who undergo treatment of intracranial aneurysms with PED, the value of long-term angiography in patients demonstrating complete aneurysm occlusion and no in-stent stenosis on 6 month post-treatment angiography is low.

  View details for DOI 10.1136/neurintsurg-2021-017745

  View details for PubMedID 34210838

• Thrombectomy in Acute Ischemic Stroke. The New England journal of medicine Lauzier, D. C., Kansagra, A. P. 2022; 386 (14): 1351

  View details for DOI 10.1056/NEJMicm2116727

  View details for PubMedID 35363453

• Intervention for unruptured high-grade intracranial dural arteriovenous fistulas: a multicenter study JOURNAL OF NEUROSURGERY Chen, C., Buell, T. J., Ding, D., Guniganti, R., Kansagra, A. P., Lanzino, G., Giordan, E., Kim, L. J., Levitt, M. R., Abecassis, I., Bulters, D., Durnford, A., Fox, W., Polifka, A. J., Gross, B. A., Hayakawa, M., Derdeyn, C. P., Samaniego, E. A., Amin-Hanjani, S., Alaraj, A., Kwasnicki, A., van Dijk, J. C., Potgieser, A. R. E., Starke, R. M., Sur, S., Satomi, J., Tada, Y., Abla, A. A., Winkler, E. A., Du, R., Lai, P., Zipfel, G. J., Sheehan, J. P., Consortium Dural Arteriovenous Fis 2022; 136 (4): 962-970

  Abstract

  The risk-to-benefit profile of treating an unruptured high-grade dural arteriovenous fistula (dAVF) is not clearly defined. The aim of this multicenter retrospective cohort study was to compare the outcomes of different interventions with observation for unruptured high-grade dAVFs.The authors retrospectively reviewed dAVF patients from 12 institutions participating in the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR). Patients with unruptured high-grade (Borden type II or III) dAVFs were included and categorized into four groups (observation, embolization, surgery, and stereotactic radiosurgery [SRS]) based on the initial management. The primary outcome was defined as the modified Rankin Scale (mRS) score at final follow-up. Secondary outcomes were good outcome (mRS scores 0-2) at final follow-up, symptomatic improvement, all-cause mortality, and dAVF obliteration. The outcomes of each intervention group were compared against those of the observation group as a reference, with adjustment for differences in baseline characteristics.The study included 415 dAVF patients, accounting for 29, 324, 43, and 19 in the observation, embolization, surgery, and SRS groups, respectively. The mean radiological and clinical follow-up durations were 21 and 25 months, respectively. Functional outcomes were similar for embolization, surgery, and SRS compared with observation. With observation as a reference, obliteration rates were higher after embolization (adjusted OR [aOR] 7.147, p = 0.010) and surgery (aOR 33.803, p < 0.001) and all-cause mortality was lower after embolization (imputed, aOR 0.171, p = 0.040). Hemorrhage rates per 1000 patient-years were 101 for observation versus 9, 22, and 0 for embolization (p = 0.022), surgery (p = 0.245), and SRS (p = 0.077), respectively. Nonhemorrhagic neurological deficit rates were similar between each intervention group versus observation.Embolization and surgery for unruptured high-grade dAVFs afforded a greater likelihood of obliteration than did observation. Embolization also reduced the risk of death and dAVF-associated hemorrhage compared with conservative management over a modest follow-up period. These findings support embolization as the first-line treatment of choice for appropriately selected unruptured Borden type II and III dAVFs.

  View details for DOI 10.3171/2021.1.JNS202799

  View details for Web of Science ID 000782852100003

  View details for PubMedID 34608140

• Assessing the rate, natural history, and treatment trends of intracranial aneurysms in patients with intracranial dural arteriovenous fistulas: a Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) investigation JOURNAL OF NEUROSURGERY Abecassis, I., Meyer, R., Levitt, M. R., Sheehan, J. P., Chen, C., Gross, B. A., Lockerman, A., Fox, W., Brinjikji, W., Lanzino, G., Starke, R. M., Chen, S. H., Potgieser, A. R. E., van Dijk, J. C., Durnford, A., Bulters, D., Satomi, J., Tada, Y., Kwasnicki, A., Amin-Hanjani, S., Alaraj, A., Samaniego, E. A., Hayakawa, M., Derdeyn, C. P., Winkler, E., Abla, A., Lai, P., Du, R., Guniganti, R., Kansagra, A. P., Zipfel, G. J., Kim, L. J., Consortium Dural Arteriovenous Fis 2022; 136 (4): 971-980

  Abstract

  There is a reported elevated risk of cerebral aneurysms in patients with intracranial dural arteriovenous fistulas (dAVFs). However, the natural history, rate of spontaneous regression, and ideal treatment regimen are not well characterized. In this study, the authors aimed to describe the characteristics of patients with dAVFs and intracranial aneurysms and propose a classification system.The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database from 12 centers was retrospectively reviewed. Analysis was performed to compare dAVF patients with (dAVF+ cohort) and without (dAVF-only cohort) concomitant aneurysm. Aneurysms were categorized based on location as a dAVF flow-related aneurysm (FRA) or a dAVF non-flow-related aneurysm (NFRA), with further classification as extra- or intradural. Patients with traumatic pseudoaneurysms or aneurysms with associated arteriovenous malformations were excluded from the analysis. Patient demographics, dAVF anatomical information, aneurysm information, and follow-up data were collected.Of the 1077 patients, 1043 were eligible for inclusion, comprising 978 (93.8%) and 65 (6.2%) in the dAVF-only and dAVF+ cohorts, respectively. There were 96 aneurysms in the dAVF+ cohort; 10 patients (1%) harbored 12 FRAs, and 55 patients (5.3%) harbored 84 NFRAs. Dural AVF+ patients had higher rates of smoking (59.3% vs 35.2%, p < 0.001) and illicit drug use (5.8% vs 1.5%, p = 0.02). Sixteen dAVF+ patients (24.6%) presented with aneurysm rupture, which represented 16.7% of the total aneurysms. One patient (1.5%) had aneurysm rupture during follow-up. Patients with dAVF+ were more likely to have a dAVF located in nonconventional locations, less likely to have arterial supply to the dAVF from external carotid artery branches, and more likely to have supply from pial branches. Rates of cortical venous drainage and Borden type distributions were comparable between cohorts. A minority (12.5%) of aneurysms were FRAs. The majority of the aneurysms underwent treatment via either endovascular (36.5%) or microsurgical (15.6%) technique. A small proportion of aneurysms managed conservatively either with or without dAVF treatment spontaneously regressed (6.2%).Patients with dAVF have a similar risk of harboring a concomitant intracranial aneurysm unrelated to the dAVF (5.3%) compared with the general population (approximately 2%-5%) and a rare risk (0.9%) of harboring an FRA. Only 50% of FRAs are intradural. Dural AVF+ patients have differences in dAVF angioarchitecture. A subset of dAVF+ patients harbor FRAs that may regress after dAVF treatment.

  View details for DOI 10.3171/2021.1.JNS202861

  View details for Web of Science ID 000782852000002

  View details for PubMedID 34507300

• Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR): rationale, design, and initial characterization of patient cohort JOURNAL OF NEUROSURGERY Guniganti, R., Giordan, E., Chen, C., Abecassis, I., Levitt, M. R., Durnford, A., Smith, J., Samaniego, E. A., Derdeyn, C. P., Kwasnicki, A., Alaraj, A., Potgieser, A. R. E., Sur, S., Chen, S. H., Tada, Y., Winkler, E., Phelps, R. R. L., Lai, P., Du, R., Abla, A., Satomi, J., Starke, R. M., van Dijk, J. C., Amin-Hanjani, S., Hayakawa, M., Gross, B. A., Fox, W., Bulters, D., Kim, L. J., Sheehan, J., Lanzino, G., Piccirillo, J. F., Kansagra, A. P., Zipfel, G. J., Consortium Dural Arteriovenous Fis 2022; 136 (4): 951-961

  Abstract

  Cranial dural arteriovenous fistulas (dAVFs) are rare lesions, hampering efforts to understand them and improve their care. To address this challenge, investigators with an established record of dAVF investigation formed an international, multicenter consortium aimed at better elucidating dAVF pathophysiology, imaging characteristics, natural history, and patient outcomes. This report describes the design of the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) and includes characterization of the 1077-patient cohort.Potential collaborators with established interest in the field were identified via systematic review of the literature. To ensure uniformity of data collection, a quality control process was instituted. Data were retrospectively obtained.CONDOR comprises 14 centers in the United States, the United Kingdom, the Netherlands, and Japan that have pooled their data from 1077 dAVF patients seen between 1990 and 2017. The cohort includes 359 patients (33%) with Borden type I dAVFs, 175 (16%) with Borden type II fistulas, and 529 (49%) with Borden type III fistulas. Overall, 852 patients (79%) presented with fistula-related symptoms: 427 (40%) presented with nonaggressive symptoms such as tinnitus or orbital phenomena, 258 (24%) presented with intracranial hemorrhage, and 167 (16%) presented with nonhemorrhagic neurological deficits. A smaller proportion (224 patients, 21%), whose dAVFs were discovered incidentally, were asymptomatic. Many patients (85%, 911/1077) underwent treatment via endovascular embolization (55%, 587/1077), surgery (10%, 103/1077), radiosurgery (3%, 36/1077), or multimodal therapy (17%, 184/1077). The overall angiographic cure rate was 83% (758/911 treated), and treatment-related permanent neurological morbidity was 2% (27/1467 total procedures). The median time from diagnosis to follow-up was 380 days (IQR 120-1038.5 days).With more than 1000 patients, the CONDOR registry represents the largest registry of cranial dAVF patient data in the world. These unique, well-annotated data will enable multiple future analyses to be performed to better understand dAVFs and their management.

  View details for DOI 10.3171/2021.1.JNS202790

  View details for Web of Science ID 000782852000001

  View details for PubMedID 34507282

• Dural arteriovenous fistulas without cortical venous drainage: presentation, treatment, and outcomes. Journal of neurosurgery Samaniego, E. A., Roa, J. A., Hayakawa, M., Chen, C., Sheehan, J. P., Kim, L. J., Abecassis, I. J., Levitt, M. R., Guniganti, R., Kansagra, A. P., Lanzino, G., Giordan, E., Brinjikji, W., Bulters, D., Durnford, A., Fox, W. C., Polifka, A. J., Gross, B. A., Amin-Hanjani, S., Alaraj, A., Kwasnicki, A., Starke, R. M., Sur, S., van Dijk, J. M., Potgieser, A. R., Satomi, J., Tada, Y., Abla, A., Winkler, E., Du, R., Lai, P. M., Zipfel, G. J., Derdeyn, C. P., Consortium for Dural Arteriovenous Fistula Outcomes Research, CONDOR Collaborators, Zipfel, G. J., Kansagra, A. P., Guniganti, R., Piccirillo, J. F., Raman, H., Lipsey, K., Lanzino, G., Giordan, E., Brinjikji, W., Vine, R., Cloft, H. J., Kallmes, D. F., Pollock, B. E., Link, M. J., Sheehan, J., Chen, C., Patibandla, M. R., Ding, D., Buell, T., Paisan, G., Kim, L. J., Levitt, M. R., Abecassis, I. J., Meyer, R. M., Kelly, C., Bulters, D., Durnford, A., Duffill, J., Ditchfield, A., Millar, J., Macdonald, J., Fox, W. C., Polifka, A. J., Laurent, D., Hoh, B., Smith, J., Lockerman, A., Gross, B. A., Lunsford, L. D., Jankowitz, B. T., Hayakawa, M., Derdeyn, C. P., Samaniego, E. A., Gutierrez, S. O., Hasan, D., Roa, J. A., Rossen, J., Guerrero, W., McGruder, A., Amin-Hanjani, S., Alaraj, A., Kwasnicki, A., Charbel, F. T., Aletich, V. A., Rose-Finnell, L., van Dijk, J. M., Potgieser, A. R., Starke, R. M., Peterson, E. C., Yavagal, D. R., Sur, S., Chen, S. H., Satomi, J., Tada, Y., Kanematsu, Y., Yamamoto, N., Kinouchi, T., Korai, M., Yamaguchi, I., Yamamoto, Y., Abla, A., Winkler, E., Phelps, R. R., Lawton, M., Rutkowski, M., Du, R., Lai, P. M., Aziz-Sultan, M. A., Patel, N., Frerichs, K. U. 2022; 136 (4): 942-950

  Abstract

  OBJECTIVE: Current evidence suggests that intracranial dural arteriovenous fistulas (dAVFs) without cortical venous drainage (CVD) have a benign clinical course. However, no large study has evaluated the safety and efficacy of current treatments and their impact over the natural history of dAVFs without CVD.METHODS: The authors conducted an analysis of the retrospectively collected multicenter Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database. Patient demographics and presenting symptoms, angiographic features of the dAVFs, and treatment outcomes of patients with Borden type I dAVFs were reviewed. Clinical and radiological follow-up information was assessed to determine rates of new intracranial hemorrhage (ICH) or nonhemorrhagic neurological deficit (NHND), worsening of venous hyperdynamic symptoms (VHSs), angiographic recurrence, and progression or spontaneous regression of dAVFs over time.RESULTS: A total of 342 patients/Borden type I dAVFs were identified. The mean patient age was 58.1 ± 15.6 years, and 62% were women. The mean follow-up time was 37.7 ± 54.3 months. Of 230 (67.3%) treated dAVFs, 178 (77%) underwent mainly endovascular embolization, 11 (4.7%) radiosurgery alone, and 4 (1.7%) open surgery as the primary modality. After the first embolization, most dAVFs (47.2%) achieved only partial reduction in early venous filling. Multiple complementary interventions increased complete obliteration rates from 37.9% after first embolization to 46.7% after two or more embolizations, and 55.2% after combined radiosurgery and open surgery. Immediate postprocedural complications occurred in 35 dAVFs (15.2%) and 6 (2.6%) with permanent sequelae. Of 127 completely obliterated dAVFs by any therapeutic modality, 2 (1.6%) showed angiographic recurrence/recanalization at a mean of 34.2 months after treatment. Progression to Borden-Shucart type II or III was documented in 2.2% of patients and subsequent development of a new dAVF in 1.6%. Partial spontaneous regression was found in 22 (21.4%) of 103 nontreated dAVFs. Multivariate Cox regression analysis demonstrated that older age, NHND, or severe venous-hyperdynamic symptoms at presentation and infratentorial location were associated with worse prognosis. Kaplan-Meier curves showed no significant difference for stable/improved symptoms survival probability in treated versus nontreated dAVFs. However, estimated survival times showed better trends for treated dAVFs compared with nontreated dAVFs (288.1 months vs 151.1 months, log-rank p = 0.28). This difference was statistically significant for treated dAVFs with 100% occlusion (394 months, log-rank p < 0.001).CONCLUSIONS: Current therapeutic modalities for management of dAVFs without CVD may provide better symptom control when complete angiographic occlusion is achieved.

  View details for DOI 10.3171/2021.1.JNS202825

  View details for PubMedID 34507278

• Recurrence after cure in cranial dural arteriovenous fistulas: a collaborative effort by the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) JOURNAL OF NEUROSURGERY Abecassis, I., Meyer, R., Levitt, M. R., Sheehan, J. P., Chen, C., Gross, B. A., Smith, J., Fox, W., Giordan, E., Lanzino, G., Starke, R. M., Sur, S., Potgieser, A. R. E., van Dijk, J. C., Durnford, A., Bulters, D., Satomi, J., Tada, Y., Kwasnicki, A., Amin-Hanjani, S., Alaraj, A., Samaniego, E. A., Hayakawa, M., Derdeyn, C. P., Winkler, E., Abla, A., Lai, P., Du, R., Guniganti, R., Kansagra, A. P., Zipfel, G. J., Kim, L. J., Consortium Dural Arteriovenous Fis 2022; 136 (4): 981-989

  Abstract

  Cranial dural arteriovenous fistulas (dAVFs) are often treated with endovascular therapy, but occasionally a multimodality approach including surgery and/or radiosurgery is utilized. Recurrence after an initial angiographic cure has been reported, with estimated rates ranging from 2% to 14.3%, but few risk factors have been identified. The objective of this study was to identify risk factors associated with recurrence of dAVF after putative cure.The Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) data were retrospectively reviewed. All patients with angiographic cure after treatment and subsequent angiographic follow-up were included. The primary outcome was recurrence, with risk factor analysis. Secondary outcomes included clinical outcomes, morbidity, and mortality associated with recurrence. Risk factor analysis was performed comparing the group of patients who experienced recurrence with those with durable cure (regardless of multiple recurrences). Time-to-event analysis was performed using all collective recurrence events (multiple per patients in some cases).Of the 1077 patients included in the primary CONDOR data set, 457 met inclusion criteria. A total of 32 patients (7%) experienced 34 events of recurrence at a mean of 368.7 days (median 192 days). The recurrence rate was 4.5% overall. Kaplan-Meier analysis predicted long-term recurrence rates approaching 11% at 3 years. Grade III dAVFs treated with endovascular therapy were statistically significantly more likely to experience recurrence than those treated surgically (13.3% vs 0%, p = 0.0001). Tentorial location, cortical venous drainage, and deep cerebral venous drainage were all risk factors for recurrence. Endovascular intervention and radiosurgery were associated with recurrence. Six recurrences were symptomatic, including 2 with hemorrhage, 3 with nonhemorrhagic neurological deficit, and 1 with progressive flow-related symptoms (decreased vision).Recurrence of dAVFs after putative cure can occur after endovascular treatment. Risk factors include tentorial location, cortical venous drainage, and deep cerebral drainage. Multimodality therapy can be used to achieve cure after recurrence. A delayed long-term angiographic evaluation (at least 1 year from cure) may be warranted, especially in cases with risk factors for recurrence.

  View details for DOI 10.3171/2021.1.JNS202033

  View details for Web of Science ID 000782852100004

  View details for PubMedID 34507283

• Safety of pediatric cerebral angiography. Journal of neurosurgery. Pediatrics Lauzier, D. C., Osbun, J. W., Chatterjee, A. R., Moran, C. J., Kansagra, A. P. 2022; 29 (2): 192-199

  Abstract

  Catheter-based cerebral angiography is commonly used for neurovascular diagnosis in children. In this work, the authors aimed to quantify the complication rate of cerebral angiography in children, characterize these complications, and identify risk factors for complications.Relevant clinical data were retrospectively obtained for 587 consecutive cerebral angiography procedures performed in 390 children from March 2002 to March 2020. Complications were categorized as neurological or nonneurological, and severity was graded using a standard schema. Incidences of complications were reported as point estimates. Associations between risk factors and complications were characterized in univariate analysis using the two-tailed Fisher exact test and in multivariate analysis using multiple logistic regression with bidirectional elimination based on the Akaike information criterion. In both univariate and multivariate analyses, statistical significance was corrected for multiple comparisons using the Benjamini-Hochberg method.Complications occurred in 6.5% of procedures, including neurological complications in 1.9% and nonneurological complications in 4.8%. Permanent deficits occurred in only 0.2% of cases. Overall, 0.5% of procedures resulted in major complications, while 6.0% resulted in minor complications. Female sex and a history of hypertension or ischemic stroke were associated with an increased risk of complications, while femoral artery access was associated with a decreased risk of complications.Pediatric cerebral angiography was shown to have a low rate of major or permanent complications. Children who were female and those with a history of hypertension or ischemic stroke were shown to be at higher risk of complications, while the use of femoral access carried a lower risk of complications.

  View details for DOI 10.3171/2021.8.PEDS21301

  View details for PubMedID 34740194

• Pipeline embolization of proximal middle cerebral artery aneurysms: A multicenter cohort study. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences Lauzier, D. C., Root, B. K., Kayan, Y., Almandoz, J. E., Osbun, J. W., Chatterjee, A. R., Whaley, K. L., Tipps, M. E., Moran, C. J., Kansagra, A. P. 2022; 28 (1): 50-57

  Abstract

  Flow diversion of aneurysms located in the M1 segment and middle cerebral artery bifurcation with Pipeline embolization device is sometimes performed, but further study is needed to support its regular use in aneurysm treatment. Here, we report measures of safety and efficacy for Pipeline embolization in the proximal middle cerebral artery in a multi-center cohort.Clinical and angiographic data of eligible patients were retrospectively obtained from participating centers and assessed for key clinical and angiographic outcomes. Additional details were extracted for patients with complications.In our multi-center cohort, complete aneurysm occlusion was achieved in 71% (17/24) of treated aneurysms. There were no deaths or disabling strokes, but non-disabling ischemic strokes occurred in 8% (2/24) of patients. For aneurysms in the M1 segment, complete aneurysm occlusion was observed in 75% (12/16) of aneurysms, aneurysm volume reduction was observed in 100% (16/16) of aneurysms, and non-disabling ischemic strokes occurred in 13% (2/16) of patients. For aneurysms at the middle cerebral artery bifurcation, complete aneurysm occlusion was observed in 63% (5/8) of aneurysms, aneurysm volume reduction occurred in 88% (7/8) of aneurysms, and ischemic or hemorrhagic complications occurred in 0% (0/8) of patients.Pipeline embolization of cerebral aneurysms in the M1 segment and middle cerebral artery bifurcation demonstrated a 71% rate of complete aneurysm occlusion. There were no deaths or disabling strokes, but there was an 8% rate of non-disabling ischemic strokes.

  View details for DOI 10.1177/15910199211015578

  View details for PubMedID 33951971

  View details for PubMedCentralID PMC8905083

• Pipeline embolization of MCA aneurysms in the M2-M4 segment: Dual center study and meta-analysis. Clinical neurology and neurosurgery Lauzier, D. C., Root, B. K., Kayan, Y., Almandoz, J. E., Osbun, J. W., Chatterjee, A. R., Whaley, K. L., Tipps, M. E., Moran, C. J., Kansagra, A. P. 2022; 212: 107063

  Abstract

  Flow diversion of distal MCA aneurysms in the M2-M4 segments with Pipeline embolization device is promising, but further study is needed. Here, we seek to quantify the safety and efficacy of Pipeline embolization in the M2-M4 region in a dual-center cohort and comprehensive meta-analysis.Clinical and angiographic data of eligible patients was obtained from participating centers. A systematic review was performed with searches of Pubmed, Scopus, Embase, and the Cochrane Library for articles from inception to May 2021. 86 studies were identified in systematic review. Of these, 7 studies with 46 aneurysms met the inclusion criteria and were aggregated with 8 aneurysms from our dual-center cohort for analysis.In our dual-center cohort, complete occlusion was observed in 88% (7/8) of aneurysms, and no patients experienced hemorrhagic or thromboembolic complications. Clinical outcomes were reported for 100% (54/54) of aneurysms included in meta-analysis and angiographic follow-up was available for 91% (49/54). The overall rate of complete aneurysm occlusion was 80% (95% CI, 69-91%), and the overall rate of clinical complication was 9% (95% CI, 2-16%).Pipeline embolization of cerebral aneurysms of the M2-M4 segments of the MCA was reasonably effective and safe in a small group of selected patients, but further study is needed to validate these preliminary results.

  View details for DOI 10.1016/j.clineuro.2021.107063

  View details for PubMedID 34864490

• Return of the lesion: a meta-analysis of 1134 angiographically cured pediatric arteriovenous malformations. Journal of neurosurgery. Pediatrics Lauzier, D. C., Vellimana, A. K., Chatterjee, A. R., Osbun, J. W., Moran, C. J., Zipfel, G. J., Kansagra, A. P. 2021; 28 (6): 677-684

  Abstract

  Brain arteriovenous malformations (AVMs) carry a risk of rupture and subsequent morbidity or mortality unless fully treated. AVMs in pediatric patients are known to occasionally recur after obliteration. The objective of this study was to characterize the risk of AVM recurrence following angiographically confirmed obliteration in children.Consecutive pediatric AVMs treated at a single center were identified from a prospective database. Patients with angiographically confirmed AVM obliteration following treatment were included in this study. Associations between AVM recurrence and patient or procedural factors were characterized using the two-tailed Fisher exact test or Mann-Whitney U-test. A literature search was conducted using PubMed, Scopus, Embase, and the Clarivate Web of Science with defined search criteria, and eligible studies were included alongside this study cohort in a meta-analysis. Rates of AVM recurrence following obliteration were pooled across studies with a random-effects model and reported with 95% confidence intervals (CIs).Recurrence after angiographic confirmation of AVM obliteration was observed in 10.4% (7/67) of pediatric AVMs treated at the authors' center. Patients with recurrent AVMs were significantly younger than those without recurrence (p = 0.002). In the meta-analysis, which included 1134 patients across 24 studies, the rate of recurrence was 4.8% (95% CI 3.0%-6.7%). The rate of AVM recurrence following radiosurgery was 0.7% (95% CI 0%-1.6%), which was significantly lower than the 8.5% rate (95% CI 5.0%-12.0%) following microsurgery.Recurrence of obliterated brain AVMs is common in children. Recurrence is more common in young children and following microsurgery.

  View details for DOI 10.3171/2021.6.PEDS21227

  View details for PubMedID 34507285

• Pipeline embolization of distal posterior inferior cerebellar artery aneurysms. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences Lauzier, D. C., Root, B. K., Kayan, Y., Almandoz, J. E., Osbun, J. W., Chatterjee, A. R., Whaley, K. L., Tipps, M. E., Moran, C. J., Kansagra, A. P. 2021; 27 (6): 821-827

  Abstract

  Flow diversion is commonly used to treat intracranial aneurysms in various regions of the cerebral vasculature, but is only approved for use in the internal carotid arteries. Treatment of distal PICA aneurysms with PED is sometimes performed but has not been well studied. Here, we report our experience with flow diversion of distal PICA aneurysms with PED.Clinical and angiographic data of eligible patients was retrospectively obtained and assessed for key demographic characteristics and clinical and angiographic outcomes. Principal outcomes included rates of aneurysm occlusion, ischemic or hemorrhagic complication, technical complication, and in-stent stenosis.Three female and 2 male patients underwent placement of PED in the PICA for treatment of 5 distal PICA aneurysms. Clinical and angiographic follow-up was obtained for all patients. Complete aneurysm occlusion was observed in 100% (5/5) of treated aneurysms at 6 month and longest angiographic follow-up. While there were no ischemic or device-related complications, delayed hemorrhagic complications occurred in 20% (1/5) of patients.Pipeline embolization of distal PICA aneurysms can be performed in select patients. Further study is necessary in larger cohorts to better define clinical scenarios in which flow diversion in the distal PICA should be considered.

  View details for DOI 10.1177/15910199211013195

  View details for PubMedID 33892602

  View details for PubMedCentralID PMC8673893

• Effect of Intravenous Thrombolysis on Clot Survival during Mechanical Thrombectomy in Acute Large Vessel Occlusion Strokes. Neurosurgery Shehabeldin, M., Eby, B., Wallace, A. N., Salter, A., Chatterjee, A. R., Osbun, J. W., Moran, C. J., Cross, D. T., Kansagra, A. P. 2021; 89 (6): 1027-1032

  Abstract

  The benefit of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO) stroke is uncertain. Conventional metrics of final modified thrombolysis in cerebral ischemia (mTICI) score and 90-d modified Rankin Scale may be insensitive to IVT effects on procedural complexity and duration.To study the effect of IVT prior to MT on clot survival.We performed a single-center retrospective analysis of 257 acute stroke patients with LVO undergoing MT and analyzed the effect of IVT prior to MT using a novel, pass-by-pass clot survival methodology.The use of IVT was associated with a significantly lower number of passes to attain mTICI 2B or greater (P = .002) or mTICI 3 (P = .039) reperfusion. The number of patients who achieved mTICI 2B or greater after the first pass was significantly higher in the IVT group (P = .003). This increased rate of reperfusion persisted into subsequent passes.IVT prior to MT reduces the number of thrombectomy passes required to achieve mTICI 2B or mTICI 3 reperfusion. This information should be considered as the merits of IVT prior to MT are debated.

  View details for DOI 10.1093/neuros/nyab344

  View details for PubMedID 34528088

• Examining the Value of Neurointerventional Follow-up. World neurosurgery Lauzier, D. C., Cler, S. J., Kansagra, A. P. 2021; 155: 191-192

  View details for DOI 10.1016/j.wneu.2021.08.059

  View details for PubMedID 34724733

• Demographic Disparities in Proximity to Certified Stroke Care in the United States. Stroke Yu, C. Y., Blaine, T., Panagos, P. D., Kansagra, A. P. 2021; 52 (8): 2571-2579

  Abstract

  Demographic disparities in proximity to stroke care influence time to treatment and clinical outcome but remain understudied at the national level. This study quantifies the relationship between distance to the nearest certified stroke hospital and census-derived demographics.This cross-sectional study included population data by census tract from the United States Census Bureau’s 2014–2018 American Community Survey, stroke hospitals certified by a state or national body and providing intravenous thrombolysis, and geographic data from a public mapping service. Data were retrieved from March to November 2020. Quantile regression analysis was used to compare relationships between road distance to the nearest stroke center for each census tract and tract-level demographics of age, race, ethnicity, medical insurance status, median annual income, and population density.Two thousand three hundred eighty-eight stroke centers and 71 929 census tracts including 316 995 649 individuals were included. Forty-nine thousand nine hundred eighteen (69%) tracts were urban. Demographic disparities in proximity to certified stroke care were greater in nonurban areas than urban areas. Higher representation of individuals with age ≥65 years was associated with increased median distance to a certified stroke center in nonurban areas (0.51 km per 1% increase [99.9% CI, 0.42–0.59]) but not in urban areas (0.00 km [−0.01 to 0.01]). In urban and nonurban tracts, median distance was greater with higher representation of American Indian (urban: 0.10 km per 1% increase [0.06–0.14]; nonurban: 1.06 km [0.98–1.13]) or uninsured populations (0.02 km [0.00–0.03]; 0.27 km [0.15–0.38]). Each $10 000 increase in median income was associated with a decrease in median distance of 5.04 km [4.31–5.78] in nonurban tracts, and an increase of 0.17 km [0.10–0.23] in urban tracts.Disparities were greater in nonurban areas than in urban areas. Nonurban census tracts with greater representation of elderly, American Indian, or uninsured people, or low median income were substantially more distant from certified stroke care.

  View details for DOI 10.1161/STROKEAHA.121.034493

  View details for PubMedID 34107732

  View details for PubMedCentralID PMC8316304

• Changes in Patient Volumes and Outcomes After Adding Thrombectomy Capability STROKE Zhou, M. H., Kansagra, A. P. 2021; 52 (6): 2143-2149

  Abstract

  With the rising demand for endovascular thrombectomy (EVT) and introduction of thrombectomy-capable stroke centers (TSC), there is interest among existing stroke hospitals to add EVT capability to attract and retain stroke patient referrals. In this work, we quantify changes in patient volumes and outcomes when adding EVT capability to an existing stroke center.In MATLAB 2017a Simulink, we simulate a 3-center system comprising an EVT-capable comprehensive stroke center, an EVT-incapable primary stroke center, and an EVT-incapable primary stroke center that gains EVT capability (TSC). We model these changes in 2 geographic settings (urban and rural) using 2 routing paradigms (Nearest Center and Bypass). In Nearest Center, patients are sent to the nearest center regardless of EVT capability. In Bypass, patients with severe strokes are sent to the nearest EVT-capable center, and all others are sent to the nearest center. Probability of good clinical outcome is determined by type and timing of treatment using outcomes reported in clinical trials.Adding EVT capability in the Bypass model produced an absolute increase of 40.1% in total volume of patients with stroke and 31.2% to 31.9% in total volume of acute stroke treatments at the TSC. In the Nearest Center model, the total volume of patients with stroke did not change, but total volume of acute stroke treatment at the TSC had an absolute increase of 9.3% to 9.5%. Good clinical outcomes saw an absolute increase of 0.2% to 0.6% in the whole population and 0.3% to 1.8% in the TSC population.Adding EVT capability shifts patient and treatment volume to the TSC. However, these changes produce modest improvement in overall population health. Health systems should weigh relative hospital and patient benefits when considering adding EVT capability.

  View details for DOI 10.1161/STROKEAHA.120.032389

  View details for Web of Science ID 000653963600049

  View details for PubMedID 33866819

• Stroke Imaging Utilization According to Age and Severity during the COVID-19 Pandemic. Radiology Kansagra, A. P., Goyal, M. S., Hamilton, S., Albers, G. W. 2021: 204716

  View details for DOI 10.1148/radiol.2021204716

  View details for PubMedID 33847520

• Higher-Quality Data Collection Is Critical to Establish the Safety and Efficacy of Pediatric Mechanical Thrombectomy. Stroke Barry, M., Barry, D., Kansagra, A. P., Hallam, D., Abraham, M., Amlie-Lefond, C. 2021; 52 (4): 1213-1221

  Abstract

  Because children often have lifelong morbidity after stroke, there is considerable enthusiasm to pursue mechanical thrombectomy in childhood stroke based on literature reports. However, current published data may reflect inconsistent reporting and publication bias, which limit the ability to assess safety and efficacy of mechanical thrombectomy in childhood stroke.This retrospective cohort study compared reporting quality and clinical outcomes for mechanical thrombectomy between a trial-derived cohort of 42 children treated with mechanical thrombectomy for acute stroke at study sites and 133 patients reported in the literature. National Institutes of Health Stroke Scale at baseline, 24 hours after mechanical thrombectomy, and at discharge were compared between study site patients and literature patients. Odds ratios (ORs) were used to compare reporting frequencies. Proportional odds logistic regression was used to compare outcomes.Premechanical thrombectomy National Institutes of Health Stroke Scale was available in 93% of study patients compared with 74% of patients in the literature (OR, 4.42 [95% CI, 1.47-19.89]). Postmechanical thrombectomy National Institutes of Health Stroke Scale was available in 69% of study patients compared with 29% of literature cases at 24 hours (OR, 5.48 [95% CI, 2.62-12.06]), and 64% of study patients compared with 32% of cases at discharge (OR, 3.85 [95% CI, 1.87-8.19]). For study sites, median scores were 12 at baseline, 9 at 24 hours, and 5 at discharge. Median scores in case reports were 15 at baseline, 4 at 24 hours, and 3 at discharge. ORs for differences in outcomes between groups were 5.97 (95% CI, 2.28-15.59) at 24 hours and 3.68 (95% CI, 1.45-9.34) at discharge.Study site patients had higher rates of National Institutes of Health Stroke Scale reporting and worse short-term outcomes compared with literature reports. Rigorous data collection is needed before treatment guidelines for pediatric mechanical thrombectomy can be developed.

  View details for DOI 10.1161/STROKEAHA.120.032009

  View details for PubMedID 33719517

• Pediatric Thrombectomy: Design and Workflow Lessons From Two Experienced Centers. Stroke Lauzier, D. C., Galardi, M. M., Guilliams, K. P., Goyal, M. S., Amlie-Lefond, C., Hallam, D. K., Kansagra, A. P. 2021; 52 (4): 1511-1519

  Abstract

  Endovascular thrombectomy has played a major role in advancing adult stroke care and may serve a similar role in pediatric stroke care. However, there is a need to develop better evidence and infrastructure for pediatric stroke care. In this work, we review 2 experienced pediatric endovascular thrombectomy programs and examine key design features in both care environments, including a formalized protocol and workflow, integration with an adult endovascular thrombectomy workflow, simplification and automation of workflow steps, pediatric adaptations of stroke imaging, advocacy of pediatric stroke care, and collaboration between providers, among others. These essential features transcend any single hospital environment and may provide an important foundation for other pediatric centers that aim to enhance the care of children with stroke.

  View details for DOI 10.1161/STROKEAHA.120.032268

  View details for PubMedID 33691502

  View details for PubMedCentralID PMC7987698

• Onyx embolization for dural arteriovenous fistulas: a multi-institutional study JOURNAL OF NEUROINTERVENTIONAL SURGERY Li, Y., Chen, S. H., Guniganti, R., Kansagra, A. P., Piccirillo, J. F., Chen, C., Buell, T., Sheehan, J. P., Ding, D., Lanzino, G., Brinjikji, W., Kim, L. J., Levitt, M. R., Abecassis, I., Bulters, D. O., Durnford, A., Fox, W., Polifka, A. J., Gross, B. A., Sur, S., McCarthy, D. J., Yavagal, D. R., Peterson, E. C., Hayakawa, M., Derdeyn, C., Samaniego, E. A., Amin-Hanjani, S., Alaraj, A., Kwasnicki, A., Charbel, F. T., van Dijk, J. C., Potgieser, A. R. E., Satomi, J., Tada, Y., Abla, A., Phelps, R., Du, R., Lai, P., Zipfel, G. J., Starke, R. M., Consortium Dural Arteriovenous 2022; 14 (1): 57-+

  Abstract

  Although the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance.To carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs.From the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models.A total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0-129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes.In this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.

  View details for DOI 10.1136/neurintsurg-2020-017109

  View details for Web of Science ID 000727460000001

  View details for PubMedID 33632883

• Observation Versus Intervention for Low-Grade Intracranial Dural Arteriovenous Fistulas Chen, C., Buell, T. J., Ding, D., Guniganti, R., Kansagra, A. P., Lanzino, G., Brinjikji, W., Kim, L., Levitt, M. R., Abecassis, I., Bulters, D., Durnford, A., Fox, W., Polifka, A. J., Gross, B. A., Hayakawa, M., Derdeyn, C. P., Samaniego, E. A., Amin-Hanjani, S., Alaraj, A., Kwasnicki, A., van Dijk, J. C., Potgieser, A. R. E., Starke, R. M., Chen, S., Satomi, J., Tada, Y., Abla, A., Phelps, R. R. L., Du, R., Lai, R., Zipfel, G. J., Sheehan, J. P., Consortium Dural Arteriovenous Fis LIPPINCOTT WILLIAMS & WILKINS. 2021: 1111-1120

  Abstract

  Low-grade intracranial dural arteriovenous fistulas (dAVF) have a benign natural history in the majority of cases. The benefit from treatment of these lesions is controversial.To compare the outcomes of observation versus intervention for low-grade dAVFs.We retrospectively reviewed dAVF patients from institutions participating in the CONsortium for Dural arteriovenous fistula Outcomes Research (CONDOR). Patients with low-grade (Borden type I) dAVFs were included and categorized into intervention or observation cohorts. The intervention and observation cohorts were matched in a 1:1 ratio using propensity scores. Primary outcome was modified Rankin Scale (mRS) at final follow-up. Secondary outcomes were excellent (mRS 0-1) and good (mRS 0-2) outcomes, symptomatic improvement, mortality, and obliteration at final follow-up.The intervention and observation cohorts comprised 230 and 125 patients, respectively. We found no differences in primary or secondary outcomes between the 2 unmatched cohorts at last follow-up (mean duration 36 mo), except obliteration rate was higher in the intervention cohort (78.5% vs 24.1%, P < .001). The matched intervention and observation cohorts each comprised 78 patients. We also found no differences in primary or secondary outcomes between the matched cohorts except obliteration was also more likely in the matched intervention cohort (P < .001). Procedural complication rates in the unmatched and matched intervention cohorts were 15.4% and 19.2%, respectively.Intervention for low-grade intracranial dAVFs achieves superior obliteration rates compared to conservative management, but it fails to improve neurological or functional outcomes. Our findings do not support the routine treatment of low-grade dAVFs.

  View details for DOI 10.1093/neuros/nyab024

  View details for Web of Science ID 000661532300038

  View details for PubMedID 33582776

• Discovering New Imaging Biomarkers of Stroke Etiology. Radiology Kansagra, A. P., Goyal, M. S. 2021; 298 (2): 382-383

  View details for DOI 10.1148/radiol.2020204215

  View details for PubMedID 33325810

• Neurovascular trauma: Diagnosis and therapy. Handbook of clinical neurology Kansagra, A. P., Balasetti, V., Huang, M. C. 2021; 176: 325-344

  Abstract

  Traumatic cerebrovascular injuries are common in both military and civilian populations. Whether such injuries occur in the aftermath of blunt or penetrating trauma has major implications for characteristics, classification, diagnosis, and optimal management of these lesions. Advances in screening methods, including particularly the dramatic rise of high-quality CT angiography, have facilitated early detection of these lesions. Fortunately, these diagnostic advances have occurred alongside improvements in pharmacological treatment and endovascular intervention, which now play an important role alongside surgical intervention in reducing the likelihood of adverse clinical outcomes. While the management of victims of trauma remains challenging, improved understanding of and ability to appropriately manage traumatic cerebrovascular lesions promises to yield better clinical outcomes for these vulnerable patients.

  View details for DOI 10.1016/B978-0-444-64034-5.00012-2

  View details for PubMedID 33272402

• Strategies to reduce the impact of demand for concurrent endovascular thrombectomy. Journal of neurointerventional surgery Dalsania, A. K., Kansagra, A. P. 2020; 12 (11): 1072-1075

  Abstract

  The rise in demand for endovascular thrombectomy (EVT) has increased the possibility that multiple patients with acute ischemic stroke may present concurrently and exceed local capacity to provide timely treatment. In this work, we quantitatively compared the efficacy of various strategies to mitigate demand in excess of capacity (DEC).Strategies evaluated included a backup neurointerventional team for 3 hours, 8 hours, or 24 hours per day; a separate pre-intervention imaging team; and a 30% decrease in procedure duration. For each strategy, empirical distributions were used to probabilistically generate arrival time and case duration for 16 000 independent trials repeated across a range of annual case volumes. DEC was calculated from time series representing the number of concurrent cases at each minute of the year for each trial at each case volume.All strategies decreased DEC compared with baseline. At a representative volume of 250 cases per year, availability of a backup team for 3 hours, 8 hours, and 24 hours per day reduced DEC by 27.0%, 60.3%, and 97.2%, respectively, compared with baseline. Similarly, availability of a pre-intervention imaging team and a 30% decrease in procedure duration reduced DEC by 26.6% and 17.7%, respectively, compared with baseline.A backup neurointerventional team, even if available only part time, was an effective strategy for decreasing DEC for EVT. Understanding the actual quantitative benefit of each strategy can facilitate rational cost-benefit analyses underlying the development of efficient and sustainable models of care.

  View details for DOI 10.1136/neurintsurg-2020-015826

  View details for PubMedID 32188761

• Cerebrovascular Complications of Pediatric Blunt Trauma. Pediatric neurology Galardi, M. M., Strahle, J. M., Skidmore, A., Kansagra, A. P., Guilliams, K. P. 2020; 108: 5-12

  Abstract

  Ischemic and hemorrhagic stroke can occur in the setting of pediatric trauma, particularly those with head or neck injuries. The risk of stroke appears highest within the first two weeks after trauma. Stroke diagnosis may be challenging due to lack of awareness or concurrent injuries limiting detailed neurological assessment. Other injuries may also complicate stroke management, with competing priorities for blood pressure, ventilator management, or antithrombotic timing. Here we review epidemiology, clinical presentation, and diagnostic approach to blunt arterial injuries including dissection, cerebral sinovenous thrombosis, mineralizing angiopathy, stroke from abusive head trauma, and traumatic hemorrhagic stroke. Owing to the complexities and heterogeneity of concomitant injuries in stroke related to trauma, a single pathway for stroke management is impractical. Therefore providers must understand the goals and possible costs or consequences of stroke management decisions to individualize patient care. We discuss the physiological principles of cerebral perfusion and oxygen delivery, considerations for ventilator strategy when stroke and lung injury are present, and current available evidence of the risks and benefits of anticoagulation to provide a framework for multidisciplinary discussions of cerebrovascular injury management in pediatric patients with trauma.

  View details for DOI 10.1016/j.pediatrneurol.2019.12.009

  View details for PubMedID 32111560

  View details for PubMedCentralID PMC7306436

• Blood Pressure Goals and Clinical Outcomes after Successful Endovascular Therapy: A Multicenter Study. Annals of neurology Anadani, M., Arthur, A. S., Tsivgoulis, G., Simpson, K. N., Alawieh, A., Orabi, Y., Goyal, N., Alexandrov, A. V., Maier, I. L., Psychogios, M. N., Liman, J., Brinton, D., Swisher, C. B., Shah, S., Inamullah, O., Keyrouz, S., Kansagra, A. P., Allen, M., Giles, J. A., Wolfe, S. Q., Fargen, K. M., Gory, B., De Marini, P., Kan, P., Nascimento, F. A., Almallouhi, E., Petersen, N., Kodali, S., Rahman, S., Richard, S., Spiotta, A. M. 2020; 87 (6): 830-839

  Abstract

  Elevated systolic blood pressure (SBP) after successful revascularization (SR) via endovascular therapy (EVT) is a known predictor of poor outcome. However, the optimal SBP goal following EVT is still unknown. Our objective was to compare functional and safety outcomes between different SBP goals after EVT with SR.This international multicenter study included 8 comprehensive stroke centers and patients with anterior circulation large vessel occlusion who were treated with EVT and achieved SR. SR was defined as modified thrombolysis in cerebral ischemia 2b to 3. Patients were divided into 3 groups based on SBP goal in the first 24 hours after EVT. Inverse probability of treatment weighting (IPTW) propensity analysis was used to assess the effect of different SBP goals on clinical outcomes.A total of 1,019 patients were included. On IPTW analysis, the SBP goal of <140mmHg was associated with a higher likelihood of good functional outcome and lower odds of hemicraniectomy compared to SBP goal of <180mmHg. Similarly, SBP goal of <160mmHg was associated with lower odds of mortality compared to SBP goal of <180mmHg. In subgroup analysis including only patients with pre-EVT SBP of ≥140mmHg, an SBP of <140mmHg was associated with a higher likelihood of good functional outcome, lower odds of symptomatic intracranial hemorrhage, and lower odds of requirement for hemicraniectomy compared to SBP goal of <180mmHg.SBP goals of <140 and < 160mmHg following SR with EVT appear to be associated with better clinical outcomes than SBP of <180mmHg. ANN NEUROL 2020;87:830-839.

  View details for DOI 10.1002/ana.25716

  View details for PubMedID 32187711

• Large-Scale Assessment of Scan-Time Variability and Multiple-Procedure Efficiency for Cross-Sectional Neuroradiological Exams in Clinical Practice. Journal of digital imaging Zhang, R., Narra, V. R., Kansagra, A. P. 2020; 33 (1): 143-150

  Abstract

  Scheduling of CT and MR exams requires reasonable estimates for expected scan duration. However, scan-time variability and efficiency gains from combining multiple exams are not quantitatively well characterized. In this work, we developed an informatics approach to quantify typical duration, duration variability, and multiple-procedure efficiency on a large scale, and used the approach to analyze 48,766 CT- and MR-based neuroradiological exams performed over one year. We found MR exam durations demonstrated higher absolute variability, but lower relative variability and lower multiple-procedure efficiency, compared to CT exams (p < 0.001). Our approach enables quantification of real-world operational performance and variability to inform optimal patient scheduling, efficient resource utilization, and sustainable service planning.

  View details for DOI 10.1007/s10278-019-00252-w

  View details for PubMedID 31292770

  View details for PubMedCentralID PMC7064664

• Collateral Effect of Covid-19 on Stroke Evaluation in the United States. The New England journal of medicine Kansagra, A. P., Goyal, M. S., Hamilton, S. n., Albers, G. W. 2020

  View details for DOI 10.1056/NEJMc2014816

  View details for PubMedID 32383831

• Simultaneous patient presentation for endovascular thrombectomy in acute ischemic stroke. Journal of neurointerventional surgery Dalsania, A. K., Kansagra, A. P. 2019; 11 (12): 1201-1204

  Abstract

  Increased demand for endovascular thrombectomy has increased the likelihood of simultaneous patient presentation leading to competing demand for time-critical treatment that could adversely impact patient outcomes. We aimed to quantify the occurrence of simultaneous patient presentation at different patient volumes.Empirical distributions for time of patient presentation and case duration were used to probabilistically generate arrival time and case duration for a set annual patient volume, ranging from 1 to 500 cases per year, for 16 000 independent trials at each volume. Time series were generated for each trial to represent the number of cases being performed at each minute of the year. Time series were used to calculate daily thrombectomy demand, annual concurrent demand, and hourly excess demand.The patient volumes at which at least one annual occurrence of concurrent demand by two patients was 50% and 97.5% likely were 45 and 101, respectively. The volumes at which at least one annual occurrence of concurrent demand by three patients was 50% and 97.5% likely were 216 and 387, respectively. There was dramatic variation in the occurrence of excess demand by two or more patients throughout the day.The occurrence of simultaneous presentation by multiple patients for endovascular thrombectomy varies with annual patient volume and time of day. Understanding these trends and the associated patient impact can inform intelligent strategies at regional and national levels for optimizing patient care within real-world financial and operational constraints.

  View details for DOI 10.1136/neurintsurg-2019-014857

  View details for PubMedID 31030186

• Blood Pressure and Outcome After Mechanical Thrombectomy With Successful Revascularization. Stroke Anadani, M., Orabi, M. Y., Alawieh, A., Goyal, N., Alexandrov, A. V., Petersen, N., Kodali, S., Maier, I. L., Psychogios, M. N., Swisher, C. B., Inamullah, O., Kansagra, A. P., Giles, J. A., Wolfe, S. Q., Singh, J., Gory, B., De Marini, P., Kan, P., Nascimento, F. A., Freire, L. I., Pandhi, A., Mitchell, H., Kim, J. T., Fargen, K. M., Al Kasab, S., Liman, J., Rahman, S., Allen, M., Richard, S., Spiotta, A. M. 2019; 50 (9): 2448-2454

  Abstract

  Background and Purpose- Successful reperfusion can be achieved in more than two-thirds of patients treated with mechanical thrombectomy. Therefore, it is important to understand the effect of blood pressure (BP) on clinical outcomes after successful reperfusion. In this study, we investigated the relationship between BP on admission and during the first 24 hours after successful reperfusion with clinical outcomes. Methods- This was a multicenter study from 10 comprehensive stroke centers. To ensure homogeneity of the studied cohort, we included only patients with anterior circulation who achieved successful recanalization at the end of procedure. Clinical outcomes included 90-day modified Rankin Scale, symptomatic intracerebral hemorrhage (sICH), mortality, and hemicraniectomy. Results- A total of 1245 patients were included in the study. Mean age was 69±14 years, and 51% of patients were female. Forty-nine percent of patients had good functional outcome at 90-days, and 4.7% suffered sICH. Admission systolic BP (SBP), mean SBP, maximum SBP, SBP SD, and SBP range were associated with higher risk of sICH. In addition, patients in the higher mean SBP groups had higher rates of sICH. Similar results were found for hemicraniectomy. With respect to functional outcome, mean SBP, maximum SBP, and SBP range were inversely associated with the good outcome (modified Rankin Scale score, 0-2). However, the difference in SBP parameters between the poor and good outcome groups was modest. Conclusions- Higher BP within the first 24 hours after successful mechanical thrombectomy was associated with a higher likelihood of sICH, mortality, and requiring hemicraniectomy.

  View details for DOI 10.1161/STROKEAHA.118.024687

  View details for PubMedID 31318633

• Effect of routing paradigm on patient centered outcomes in acute ischemic stroke. Journal of neurointerventional surgery Zhou, M. H., Kansagra, A. P. 2019; 11 (8): 762-767

  Abstract

  To compare performance of routing paradigms for patients with acute ischemic stroke using clinical outcomes.We simulated different routing paradigms in a system comprising one primary stroke center (PSC) and one comprehensive stroke center (CSC), separated by distances representative of urban, suburban, and rural environments. In the nearest center paradigm, patients are initially sent to the nearest center, while in CSC first, patients are sent to the CSC. In the Rhode Island and distributive paradigms, patients with a FAST-ED (Facial palsy, Arm weakness, Speech changes, Time, Eye deviation, and Denial/neglect) score ≥4 are sent to the CSC, while others are sent to the nearest center or PSC, respectively. Performance and efficiency were compared using rates of good clinical outcome, determined by type and timing of treatment using clinical trial data, and number needed to bypass (NNB).Good clinical outcome was achieved in 43.76% of patients in nearest center, 44.48% in CSC first, and 44.44% in Rhode Island and distributive in an urban setting; 43.38% in nearest center, 44.19% in CSC first, and 44.17% in Rhode Island in a suburban setting; and 41.10% in nearest center, 43.20% in CSC first, and 42.73% in Rhode Island in a rural setting. In all settings, NNB was generally higher for CSC first compared with Rhode Island or distributive.Routing paradigms that allow bypass of nearer hospitals for thrombectomy capable centers improve population level patient outcomes. Differences are more pronounced with increasing distance between hospitals; therefore, paradigm choice may be most impactful in rural settings. Selective bypass, as implemented in the Rhode Island and distributive paradigms, improves system efficiency with minimal impact on outcomes.

  View details for DOI 10.1136/neurintsurg-2018-014537

  View details for PubMedID 30610073

• Response Letter Regarding "Utility of CT angiography in screening for traumatic cerebrovascular injury". Clinical neurology and neurosurgery Orlowski, H. L., Kansagra, A. P., Miller-Thomas, M. M., Vo, K. D., Goyal, M. S. 2019; 181: 53

  View details for DOI 10.1016/j.clineuro.2019.04.001

  View details for PubMedID 30986728

• Treatment of pediatric intracranial aneurysms: case series and meta-analysis. Journal of neurointerventional surgery Yasin, J. T., Wallace, A. N., Madaelil, T. P., Osbun, J. W., Moran, C. J., Cross, D. T., Limbrick, D. D., Zipfel, G. J., Dacey, R. G., Kansagra, A. P. 2019; 11 (3): 257-264

  Abstract

  There are limited outcome data to guide the choice of treatment in pediatric patients with cerebral aneurysms.To describe our institutional experience treating pediatric patients with cerebral aneurysms and to conduct a meta-analysis of available studies to provide the best current evidence on treatment related outcomes.We identified pediatric patients with cerebral aneurysms evaluated or treated at our institution using a comprehensive case log. We also identified studies to include in a meta-analysis through a systematic search of Pubmed, SCOPUS, EMBASE, and the Cochrane Database of Systematic Reviews. As part of both the local analysis and meta-analysis, we recorded patient characteristics, aneurysm characteristics, management, and outcomes. Statistical analysis was performed using Fisher's exact test and the two tailed Student's t test, as appropriate.42 pediatric patients with 57 aneurysms were evaluated at our institution, and treatment specific outcome data were available in 560 patients as part of our meta-analysis. Endovascular and surgical treatments yielded comparable rates of favorable outcome in all children (88.3% vs 82.7%, respectively, P=0.097), in children with ruptured aneurysms (75% vs 83%, respectively, P=0.357), and in children with unruptured aneurysms (96% vs 97%, respectively, P=1.000).Endovascular and surgical treatment yield comparable long term clinical outcomes in pediatric patients with cerebral aneurysms.

  View details for DOI 10.1136/neurintsurg-2018-014001

  View details for PubMedID 30100557

• Effect of routing paradigm on patient-centered outcomes in acute ischemic stroke. Journal of neurointerventional surgery Zhou, M. H., Kansagra, A. P. 2019; 11 (3): 251-256

  Abstract

  To compare performance of routing paradigms for patients with acute ischemic stroke using clinical outcomes.We simulated different routing paradigms in a system comprising one primary stroke center (PSC) and onecomprehensive stroke center (CSC), separated by distances representative of urban, suburban, and rural environments. In the Nearest Center paradigm, patients are initially sent to the nearest center, while in CSC First, patients are sent to the CSC. In Rhode Island and Distributive paradigms, patients with Field Assessment Stroke Triage for Emergency Destination (FAST-ED) score ≥4 are sent to the CSC, while others are sent to the nearest center or PSC, respectively. Performance and efficiency were compared using rates of good clinical outcome determined by type and timing of treatment using clinical trial data and number needed to bypass (NNB).Good clinical outcome was achieved in 43.67% of patients in Nearest Center and 44.62% in CSC First, Rhode Island, and Distributive in an urban setting; 42.79% in Nearest Center and 43.97% in CSC First and Rhode Island in a suburban setting; and 39.76% in Nearest Center, 41.73% in CSC First, and 41.59% in Rhode Island in a rural setting. In all settings, the NNB was considerably higher for CSC First than for Rhode Island or Distributive.Routing paradigms that allow bypass of nearer hospitals for thrombectomy-capable centers improve population-level patient outcomes. Differences are more pronounced with increasing distance between hospitals; therefore, the choice of model may have greater effect in rural settings. Selective bypass, as implemented in Rhode Island and Distributive paradigms, improves system efficiency with minimal effect on outcomes.

  View details for DOI 10.1136/neurintsurg-2018-013994

  View details for PubMedID 29970618

• Deep Learning in Radiology. Academic radiology McBee, M. P., Awan, O. A., Colucci, A. T., Ghobadi, C. W., Kadom, N., Kansagra, A. P., Tridandapani, S., Auffermann, W. F. 2018; 25 (11): 1472-1480

  Abstract

  As radiology is inherently a data-driven specialty, it is especially conducive to utilizing data processing techniques. One such technique, deep learning (DL), has become a remarkably powerful tool for image processing in recent years. In this work, the Association of University Radiologists Radiology Research Alliance Task Force on Deep Learning provides an overview of DL for the radiologist. This article aims to present an overview of DL in a manner that is understandable to radiologists; to examine past, present, and future applications; as well as to evaluate how radiologists may benefit from this remarkable new tool. We describe several areas within radiology in which DL techniques are having the most significant impact: lesion or disease detection, classification, quantification, and segmentation. The legal and ethical hurdles to implementation are also discussed. By taking advantage of this powerful tool, radiologists can become increasingly more accurate in their interpretations with fewer errors and spend more time to focus on patient care.

  View details for DOI 10.1016/j.acra.2018.02.018

  View details for PubMedID 29606338

• Utility of CT angiography in screening for traumatic cerebrovascular injury. Clinical neurology and neurosurgery Orlowski, H. L., Kansagra, A. P., Sipe, A. L., Miller-Thomas, M. M., Vo, K. D., Goyal, M. S. 2018; 172: 27-30

  Abstract

  Computed tomographic angiography (CTA) is increasingly utilized to evaluate for traumatic cerebrovascular injury (TCVI). The purpose of this study was to determine the yield, management effect, and risk of stroke or poor outcome of a positive CTA in a large cohort of trauma patients.A retrospective analysis was performed on 1290 consecutive trauma patients that underwent head and/or neck CTA at our level I trauma center from 2006 to 2015. Clinical variables assessed include mechanism of injury, neurological status, CTA findings, subsequent imaging results, patient management, and clinical outcomes.Among 1290 patients who underwent CTA, 200 (15.5%) were positive for TCVI, higher in blunt than penetrating trauma patients. In a generalized linear model, factors that increased likelihood of positive CTA included multiple cervical fractures, fractures with foraminal involvement, gunshot injury, Glasgow Coma Scale ≤ 13, and focal neurological deficit. Excluding cases with these factors lowered the positive rate to 4.3%. Of the 200 CTA-positives, 99 were treated for TCVI and 9 (4.5%) developed a subsequent stroke as compared to 5 (0.5%) in CTA-negative patients (odds ratio 10.2, Fisher exact test, p < 0.001). Risk of death or nursing facility discharge location was also higher in CTA-positive patients, correcting for age and presenting GCS (p < 0.01).CTA had a modest yield in identifying TCVI in this cohort. When positive, CTA influenced management and predicted an increased risk of subsequent stroke and poor outcome.

  View details for DOI 10.1016/j.clineuro.2018.06.001

  View details for PubMedID 29960103

• Streamlined triage and transfer protocols improve door-to-puncture time for endovascular thrombectomy in acute ischemic stroke. Clinical neurology and neurosurgery Kansagra, A. P., Wallace, A. N., Curfman, D. R., McEachern, J. D., Moran, C. J., Cross, D. T., Lee, J. M., Ford, A. L., Manu, S. G., Panagos, P. D., Derdeyn, C. P. 2018; 166: 71-75

  Abstract

  Shorter time from symptom onset to treatment is associated with improved outcomes in patients who undergo mechanical thrombectomy for treatment of acute ischemic stroke due to emergent large vessel occlusion. In this work, we detail pre-thrombectomy process improvements in a multi-hospital network and report the effect on door-to-puncture time in patients undergoing mechanical thrombectomy.A streamlined workflow was adopted to minimize door-to-puncture time. Key features of this workflow included rapid and concurrent clinical and radiological evaluation with point-of-care image interpretation, pre-transfer IV thrombolysis and CTA for transferred patients, immediate transport to the angiography suite potentially before neurointerventional radiology team arrival, and minimalist room setup. Door-to-puncture time was measured prospectively and analyzed retrospectively for 78 consecutive patients treated between January 2015 and December 2015. Statistical analysis was performed using the F-test on individual coefficients of a linear regression model.From quarter 1 to quarter 4, the number of thrombectomies performed increased by 173% (11 patients to 30 patients, p = 0.002), and there was a significant increase in the proportion of transferred patients that underwent pre-transfer CTA (p = 0.04). During this interval, overall median door-to-puncture time decreased by 74% (147 min to 39 min, p < 0.001); this decrease was greatest in transferred patients with pre-transfer CTA (81% decrease, 129 min to 25 min, p < 0.001) and smallest in patients presenting directly to the emergency department (52% decrease, 167 min to 87 min, p < 0.001).Simple workflow improvements to streamline in-hospital triage and perform critical workup at transferring hospitals can produce reductions in door-to-puncture time.

  View details for DOI 10.1016/j.clineuro.2018.01.026

  View details for PubMedID 29408777

• Isolated Internal Carotid Artery Thrombus and Cerebral Infarction in a Patient with Necrotizing Pancreatitis: Case Report. Journal of stroke and cerebrovascular diseases : the official journal of National Stroke Association Ludwig, D. R., Austin, M. J., Wallace, A. N., Kamran, M., Kansagra, A. P., Osbun, J. W., Cross, D. T., Moran, C. J. 2018; 27 (1): e1-e4

  Abstract

  Isolated internal carotid artery (ICA) thrombus in the absence of underlying atherosclerotic disease is a rare entity. We report a case of a patient presenting with right arm weakness, slurred speech, and altered mental status in the setting of acute on chronic pancreatitis. The patient was found to have scattered left cerebral hemisphere cortical infarctions, and catheter angiography confirmed the presence of intraluminal left ICA thrombus, with no evidence of atherosclerotic disease in the cervical or intracranial vasculature. Further workup also demonstrated the presence of anemia of chronic disease. The patient was initiated on anticoagulation, and follow-up imaging demonstrated a complete resolution of the left ICA thrombus. In the reported case, coagulopathy in the setting of acute on chronic pancreatitis was presumably the primary etiology. Anemia of chronic disease, related to a proinflammatory state, may also play a contributory role.

  View details for DOI 10.1016/j.jstrokecerebrovasdis.2017.08.012

  View details for PubMedID 28893576

• Unusual high-grade features in pediatric diffuse leptomeningeal glioneuronal tumor: comparison with a typical low-grade example. Human pathology Schwetye, K. E., Kansagra, A. P., McEachern, J., Schmidt, R. E., Gauvain, K., Dahiya, S. 2017; 70: 105-112

  Abstract

  Diffuse leptomeningeal glioneuronal tumor, a recent addition to the World Health Organization classification system, typically presents in the pediatric population with signs and symptoms related to elevated intracranial pressure and imaging characteristics that may mimic infectious etiologies. The tumor is usually low grade and tends to harbor BRAF rearrangement/duplication in up to 75% of cases, BRAF V600E mutation in a smaller subset of cases, and loss of chromosomal arm 1p in approximately 50%-60% of cases, with ~20% of those showing loss of both 1p and 19q (codeletion). We report here 2 contrasting cases of diffuse leptomeningeal glioneuronal tumors, one with typical low-grade features and an indolent, although not benign, course, in which the disease is currently successfully managed by chemotherapy, and a second case with unusually high-grade features on initial presentation, including frank anaplasia and elevated mitotic index, in which the disease showed an initial response to chemoradiation but ultimately was fatal.

  View details for DOI 10.1016/j.humpath.2017.06.004

  View details for PubMedID 28652147

• Acute management and outcomes of iatrogenic dissections during cerebral angiography. Journal of neurointerventional surgery Groves, A. P., Kansagra, A. P., Cross, D. T., Moran, C. J., Derdeyn, C. P. 2017; 9 (5): 499-501

  Abstract

  Iatrogenic dissection is a known complication of cerebral angiography, but the clinical outcomes and optimal treatment of these patients is not well established. We sought to review our experience with cerebral angiography to determine the incidence of iatrogenic dissections along with clinical outcomes associated with a generally conservative treatment strategy.We retrospectively reviewed clinical records for all patients that underwent cerebral angiography between March 2002 and May 2015. Demographic information, angiography reports, follow-up CT and MRI reports, and follow-up clinical notes were reviewed.17 418 cerebral angiograms were performed during the review period, including 13 485 diagnostic angiograms and 3933 endovascular interventional procedures. 68 iatrogenic dissections were identified, for a per procedure incidence of 0.39%. The vertebral artery was the most commonly dissected vessel (49/68, 72%). 67 of 68 cases (98.5%) were managed conservatively with either no treatment or medical therapy alone. There were two adverse events potentially attributable to the dissections, only one of which was symptomatic.Iatrogenic dissections occur infrequently during cerebral angiography. When dissections do occur, most cases can be safely managed without further intervention in the acute setting.

  View details for DOI 10.1136/neurintsurg-2016-012285

  View details for PubMedID 27084963

• Time to Endovascular Thrombectomy for Acute Stroke. JAMA Kansagra, A. P. 2017; 317 (11): 1175

  View details for DOI 10.1001/jama.2017.0370

  View details for PubMedID 28324082

• Image Sharing in Radiology-A Primer. Academic radiology Chatterjee, A. R., Stalcup, S., Sharma, A., Sato, T. S., Gupta, P., Lee, Y. Z., Malone, C., McBee, M., Hotaling, E. L., Kansagra, A. P. 2017; 24 (3): 286-294

  Abstract

  By virtue of its information technology-oriented infrastructure, the specialty of radiology is uniquely positioned to be at the forefront of efforts to promote data sharing across the healthcare enterprise, including particularly image sharing. The potential benefits of image sharing for clinical, research, and educational applications in radiology are immense. In this work, our group-the Association of University Radiologists (AUR) Radiology Research Alliance Task Force on Image Sharing-reviews the benefits of implementing image sharing capability, introduces current image sharing platforms and details their unique requirements, and presents emerging platforms that may see greater adoption in the future. By understanding this complex ecosystem of image sharing solutions, radiologists can become important advocates for the successful implementation of these powerful image sharing resources.

  View details for DOI 10.1016/j.acra.2016.12.002

  View details for PubMedID 28193378

• Response by Wallace et al. to letter regarding "Quadrigeminal Perimesencephalic Subarachnoid Hemorrhage". Clinical neurology and neurosurgery Wallace, A. N., Kansagra, A. P., Vyhmeister, R., Viets, R., Whisenant, J. T., Chatterjee, A. R., Cross, D. T., Moran, C. J., Derdeyn, C. P. 2017; 153: 109-111

  View details for DOI 10.1016/j.clineuro.2016.11.009

  View details for PubMedID 27887760

• Intra-arterial versus intravenous abciximab therapy for thromboembolic complications of neuroendovascular procedures: case review and meta-analysis. Journal of neurointerventional surgery Kansagra, A. P., McEachern, J. D., Madaelil, T. P., Wallace, A. N., Cross, D. T., Moran, C. J., Derdeyn, C. P. 2017; 9 (2): 131-136

  Abstract

  Abciximab is used to treat thromboembolic complications of neuroendovascular procedures, but outcomes of treatment are not well defined.To examine the angiographic and clinical outcomes based on route of abciximab administration and degree of vessel recanalization.A prospectively maintained database of neuroendovascular procedures performed between January 2004 and May 2015 was retrospectively reviewed to identify cases with thromboembolic complications treated with abciximab. In these cases, route of administration, degree of vessel recanalization, and presence or absence of infarction were determined. A meta-analysis of similar cases in the literature was also performed.Abciximab was administered in 0.24% (47 of 19 566) of procedures to treat thromboemboli in 59 vessels. Angiographic improvement was seen in 94% after IA therapy and 79% after IV therapy (p=0.133). In our meta-analysis of 391 treated patients, angiographic improvement was greater after IA (91.7%) than IV (77.4%) treatment (p<0.001). Postprocedural infarction occurred more frequently with distal lesions (42%) than local lesions (12%) (p=0.014), and occlusive lesions (36%) than non-occlusive lesions (4.8%) (p=0.010). Infarction was significantly less common with complete angiographic resolution (0%) than with partial or no improvement (54%) (p<0.001). Symptomatic intracranial hemorrhage occurred in 2.1%.Abciximab produces a high rate of angiographic improvement and a low incidence of postprocedural infarct in neuroendovascular procedures complicated by thromboemboli. IA abciximab produces greater angiographic improvement than IV treatment. Postprocedural infarction is less common in patients with complete angiographic response than in those with partial or no response.

  View details for DOI 10.1136/neurintsurg-2016-012587

  View details for PubMedID 27540089

• Malignant Transformation of an Aneurysmal Bone Cyst to Fibroblastic Osteosarcoma. American journal of orthopedics (Belle Mead, N.J.) Kansagra, A. P., Wan, J. J., Devulapalli, K. K., Horvai, A. E., O'Donnell, R. J., Link, T. M. 2016; 45 (6): E367-E372

  Abstract

  Aneurysmal bone cysts are uncommon primary bone tumors typically regarded as histologically and clinically benign. Malignant transformation of these lesions occurs almost exclusively in the context of prior radiation exposure. However, 4 cases of an osteosarcoma developing without prior radiation exposure have been reported. In this article, we report a fifth case of degeneration of an aneurysmal bone cyst to a fibroblastic osteosarcoma. In addition to reviewing the earlier cases, we describe the radiologic, pathologic, and immunohistochemical basis of this diagnosis.

  View details for PubMedID 27737291

• Microstructural maturation of white matter tracts in encephalopathic neonates CLINICAL IMAGING Kansagra, A. P., Mabray, M. C., Ferriero, D. M., Barkovich, A., Xu, D., Hess, C. P. 2016; 40 (5): 1009-1013

  Abstract

  This study aims to apply neurite orientation dispersion and density imaging (NODDI) to measure white matter microstructural features during early development.NODDI parameters were measured in twelve newborns and thirteen 6-month infants, all with perinatal clinical encephalopathy.Between 0 and 6 months, there were significant differences in fractional anisotropy (FA) for all tracts; in neurite density for internal capsules, optic radiations, and splenium; and in orientation dispersion for anterior limb of internal capsule and optic radiations. There were no appreciable differences in NODDI parameters related to outcome.NODDI may allow more detailed characterization of microstructural maturation than FA.

  View details for DOI 10.1016/j.clinimag.2016.05.009

  View details for Web of Science ID 000383305400033

  View details for PubMedID 27314214

  View details for PubMedCentralID PMC5010966

• Mechanical thrombectomy in pediatric acute ischemic stroke: Clinical outcomes and literature review. Interventional neuroradiology : journal of peritherapeutic neuroradiology, surgical procedures and related neurosciences Madaelil, T. P., Kansagra, A. P., Cross, D. T., Moran, C. J., Derdeyn, C. P. 2016; 22 (4): 426-31

  Abstract

  There are limited data on outcomes of mechanical thrombectomy for pediatric stroke using modern devices. In this study, we report two cases of pediatric acute ischemic stroke treated with mechanical thrombectomy, both with good angiographic result (TICI 3) and clinical outcome (no neurological deficits at 90 days). In addition, we conducted a literature review of all previously reported cases describing the use of modern thrombectomy devices. Including our two cases, the aggregate rate of partial or complete vessel recanalization was 100% (22/22), and the aggregate rate of favorable clinical outcome was 91% (20/22). This preliminary evidence suggests that mechanical thrombectomy with modern devices may be a safe and effective treatment option in pediatric patients with acute ischemic stroke.

  View details for DOI 10.1177/1591019916637342

  View details for PubMedID 26945589

  View details for PubMedCentralID PMC4984382

• Evaluation of an anatomic definition of non-aneurysmal perimesencephalic subarachnhoid hemorrhage. Journal of neurointerventional surgery Wallace, A. N., Vyhmeister, R., Dines, J. N., Chatterjee, A. R., Kansagra, A. P., Viets, R., Whisenant, J. T., Moran, C. J., Cross, D. T., Derdeyn, C. P. 2016; 8 (4): 378-85

  Abstract

  Perimesencephalic subarachnoid hemorrhage (PSAH) is not consistently defined in the existing literature. The purpose of this study was to test the inter-observer variability and specificity for non-aneurysmal subarachnoid hemorrhage (SAH) of an anatomic definition of PSAH.Medical records of all patients who underwent catheter angiography for evaluation of non-traumatic SAH between July 2002 and April 2012 were reviewed. Patients with anterior circulation aneurysms were excluded. Three blinded reviewers assessed whether each admission CT scan met the following anatomic criteria for PSAH: (1) center of bleeding located immediately anterior and in contact with the brainstem in the prepontine, interpeduncular, or posterior suprasellar cistern; (2) blood limited to the prepontine, interpeduncular, suprasellar, crural, ambient, and/or quadrigeminal cisterns and/or cisterna magna; (3) no extension of blood into the Sylvian or interhemispheric fissures; (4) intraventricular blood limited to incomplete filling of the fourth ventricle and occipital horns of the lateral ventricles (ie, consistent with reflux); (5) no intraparenchymal blood.56 patients with non-aneurysmal SAH and 50 patients with posterior circulation or posterior communicating artery aneurysms were identified. Seventeen (16%) of the 106 admission CT scans met the anatomic criteria for PSAH. No aneurysm was identified in this subgroup. Inter-observer agreement was excellent with κ scores of 0.89-0.96 and disagreement in 2.8% (3/106) of cases.Our anatomic definition of PSAH correlated with a low risk of brain aneurysm and was applied with excellent inter-observer agreement.

  View details for DOI 10.1136/neurintsurg-2015-011680

  View details for PubMedID 25801775

• Disruption of Radiologist Workflow CURRENT PROBLEMS IN DIAGNOSTIC RADIOLOGY Kansagra, A. P., Liu, K., Yu, J. J. 2016; 45 (2): 101-106

  Abstract

  The effect of disruptions has been studied extensively in surgery and emergency medicine, and a number of solutions-such as preoperative checklists-have been implemented to enforce the integrity of critical safety-related workflows. Disruptions of the highly complex and cognitively demanding workflow of modern clinical radiology have only recently attracted attention as a potential safety hazard. In this article, we describe the variety of disruptions that arise in the reading room environment, review approaches that other specialties have taken to mitigate workflow disruption, and suggest possible solutions for workflow improvement in radiology.

  View details for DOI 10.1067/j.cpradiol.2015.05.006

  View details for Web of Science ID 000439662800004

  View details for PubMedID 26122926

• Evolution of endovascular stroke therapies and devices. Expert review of medical devices Wallace, A. N., Kansagra, A. P., McEachern, J., Moran, C. J., Cross, D. T., Derdeyn, C. P. 2016; 13 (3): 263-70

  Abstract

  Acute ischemic stroke is caused by occlusion of a cerebral artery, resulting in loss of brain tissue and neurologic deficits. However, a portion of the ischemic brain can be salvaged if blood flow is restored within an appropriate time frame. The past year has seen the publication of five positive randomized controlled trials demonstrating substantial benefit of mechanical thrombectomy in select patients with large vessel cerebrovascular occlusion. This progress is related to several factors, but most importantly, dramatic improvements in speed and rates of recanalization with the latest generation devices. In this article, we review the evolution of endovascular acute ischemic stroke therapies and key design features of the most widely used devices.

  View details for DOI 10.1586/17434440.2016.1143772

  View details for PubMedID 26781520

• Big Data and the Future of Radiology Informatics ACADEMIC RADIOLOGY Kansagra, A. P., Yu, J. J., Chatterjee, A. R., Lenchik, L., Chow, D. S., Prater, A. B., Yeh, J., Doshi, A. M., Hawkins, C., Heilbrun, M. E., Smith, S. E., Oselkin, M., Gupta, P., Ali, S. 2016; 23 (1): 30-42

  Abstract

  Rapid growth in the amount of data that is electronically recorded as part of routine clinical operations has generated great interest in the use of Big Data methodologies to address clinical and research questions. These methods can efficiently analyze and deliver insights from high-volume, high-variety, and high-growth rate datasets generated across the continuum of care, thereby forgoing the time, cost, and effort of more focused and controlled hypothesis-driven research. By virtue of an existing robust information technology infrastructure and years of archived digital data, radiology departments are particularly well positioned to take advantage of emerging Big Data techniques. In this review, we describe four areas in which Big Data is poised to have an immediate impact on radiology practice, research, and operations. In addition, we provide an overview of the Big Data adoption cycle and describe how academic radiology departments can promote Big Data development.

  View details for DOI 10.1016/j.acra.2015.10.004

  View details for Web of Science ID 000367279800007

  View details for PubMedID 26683510

• Quadrigeminal perimesencephalic subarachnoid hemorrhage. Clinical neurology and neurosurgery Wallace, A. N., Vyhmeister, R., Viets, R., Whisenant, J. T., Chatterjee, A. R., Kansagra, A. P., Cross, D. T., Moran, C. J., Derdeyn, C. P. 2015; 137: 67-71

  Abstract

  A variant of perimesencephalic subarachnoid hemorrhage (PSAH) has been described characterized by blood centered in the quadrigeminal cistern and limited to the superior vermian and perimesencephalic cisterns. Herein, three cases of quadrigeminal PSAH are presented.Medical records of all patients who underwent digital subtraction angiography for evaluation of non-traumatic SAH between July 2002 and April 2012 were reviewed. Patients with anterior circulation aneurysms were excluded. Two blinded reviewers identified admission noncontrast CT scans with pretruncal and quadrigeminal patterns of PSAH.The total cohort included 106 patients: 53% (56/106) with one or more negative digital subtraction angiograms and 47% (50/106) with posterior circulation or posterior communicating artery aneurysms. Three patients with quadrigeminal PSAH were identified, two with nonaneurysmal SAH and one with a posterior circulation aneurysm. Seventeen patients (16%; 17/106) with pretruncal PSAH were identified, none of whom were found to have an aneurysm. The quadrigeminal pattern comprised 11% (2/19) of cases of pretruncal or quadrigeminal nonaneurysmal PSAH.A small subset of patients with nonaneurysmal PSAH present with blood centered in the quadrigeminal cistern, and the etiology of this pattern may be similar to that of the classic pretruncal variant. However, patients with quadrigeminal PSAH must still undergo thorough vascular imaging, including at least two digital subtraction angiograms, to exclude a ruptured aneurysm.

  View details for DOI 10.1016/j.clineuro.2015.06.018

  View details for PubMedID 26151343

• Space: The Final Frontier for IR JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kansagra, A. P., Shute, T. S. 2015; 26 (6): 825-828

  Abstract

  A manned mission to Mars requires advanced on-board medical capabilities to address medical incidents that may arise during long-duration interplanetary spaceflight. As this role does not exactly match that of any single specialty, the ideal choice of physician is not immediately obvious. In this work, we review the considerable challenges of providing medical care in the austere conditions of interplanetary space travel and explain why an interventional radiologist may be well-equipped to deliver diagnostic and therapeutic care within these severely constrained conditions.

  View details for DOI 10.1016/j.jvir.2015.02.011

  View details for Web of Science ID 000355963800008

  View details for PubMedID 25840834

• Entrepreneurship in the Academic Radiology Environment ACADEMIC RADIOLOGY Itri, J. N., Ballard, D. H., Kantartzis, S., Sullivan, J. C., Weisman, J. A., Durand, D. J., Ali, S., Kansagra, A. P. 2015; 22 (1): 14-24

  Abstract

  Innovation and entrepreneurship in health care can help solve the current health care crisis by creating products and services that improve quality and convenience while reducing costs.To effectively drive innovation and entrepreneurship within the current health care delivery environment, academic institutions will need to provide education, promote networking across disciplines, align incentives, and adapt institutional cultures. This article provides a general review of entrepreneurship and commercialization from the perspective of academic radiology departments, drawing on information sources in several disciplines including radiology, medicine, law, and business.Our review will discuss the role of universities in supporting academic entrepreneurship, identify drivers of entrepreneurship, detail opportunities for academic radiologists, and outline key strategies that foster greater involvement of radiologists in entrepreneurial efforts and encourage leadership to embrace and support entrepreneurship.

  View details for DOI 10.1016/j.acra.2014.08.010

  View details for Web of Science ID 000346692700003

  View details for PubMedID 25442799

• Building for Tomorrow Today: <i>Opportunities and Directions in Radiology Resident Research</i> ACADEMIC RADIOLOGY Yu, J. J., Kansagra, A. P., Thaker, A., Colucci, A., Sherry, S. J., Subramaniam, R. M. 2015; 22 (1): 50-57

  Abstract

  With rapid scientific and technological advancements in radiological research, there is renewed emphasis on promoting early research training to develop researchers who are capable of tackling the hypothesis-driven research that is typically funded in contemporary academic research enterprises. This review article aims to introduce radiology residents to the abundant radiology research opportunities available to them and to encourage early research engagement among trainees.To encourage early resident participation in radiology research, we review the various research opportunities available to trainees spanning basic, clinical, and translational science opportunities to ongoing research in information technology, informatics, and quality improvement research.There is an incredible breadth and depth of ongoing research at academic radiology departments across the country, and the material presented herein aspires to highlight both subject matter and opportunities available to radiology residents eager to engage in radiologic research. The opportunities for interested radiology residents are as numerous as they are broad, spanning the basic sciences to clinical research to informatics, with abundant opportunities to shape our future practice of radiology.

  View details for DOI 10.1016/j.acra.2014.08.012

  View details for Web of Science ID 000346692700006

  View details for PubMedID 25442797

  View details for PubMedCentralID PMC4427032

• The Radiologist's Workflow Environment: Evaluation is Disruptors and Potential Implications JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY Yu, J. J., Kansagra, A. P., Mongan, J. 2014; 11 (6): 589-593

  Abstract

  Workflow interruptions in the health care delivery environment are a major contributor to medical errors and have been extensively studied within numerous hospital settings, including the nursing environment and the operating room, along with their effects on physician workflow. Less understood, though, is the role of interruptions in other highly specialized clinical domains and subspecialty services, such as diagnostic radiology. The workflow of the on-call radiologist, in particular, is especially susceptible to disruption by telephone calls and other modes of physician-to-physician communication. Herein, the authors describe their initial efforts to quantify the degree of interruption experienced by on-call radiologists and examine its potential implications in patient safety and overall clinical care.

  View details for DOI 10.1016/j.jacr.2013.12.026

  View details for Web of Science ID 000337331000012

  View details for PubMedID 24775910

• Cerebral Arterial Fenestrations INTERVENTIONAL NEURORADIOLOGY Cooke, D. L., Stout, C. E., Kim, W. T., Kansagra, A. P., Yu, J., Gu, A., Jewell, N. P., Hetts, S. W., Higashida, R. T., Dowd, C. E., Halbach, V. V. 2014; 20 (3): 261-274

  Abstract

  Arterial fenestrations are an anatomic variant with indeterminate significance. Given the controversy surrounding fenestrations we sought their prevalence within our practice along with their association with other cerebrovascular anomalies. We retrospectively reviewed 10,927 patients undergoing digital subtraction angiography between 1992 and 2011. Dictated reports were searched for the terms "fenestration" or "fenestrated" with images reviewed for relevance, yielding 228 unique cases. A Medline database search from February 1964 to January 2013 generated 304 citations, 127 cases of which were selected for analysis. Cerebral arterial fenestrations were identified in 228 patients (2.1%). At least one aneurysm was noted in 60.5% of patients, with an aneurysm arising from the fenestration in 19.6% of patients. Aneurysmal subarachnoid hemorrhage or non-aneurysmal subarachnoid hemorrhage were present in 60.1% and 15.8%, respectively. For the subset of patients with an aneurysm arising directly from a fenestration relative to those patients with an aneurysm not immediately associated with a fenestration, the prevalence of aneurysmal subarachnoid hemorrhage was 66.7% vs. 58.6% (p = 0.58). Fenestrations were more often within the posterior circulation (73.2%) than the anterior circulation (24.6%), though there was no difference in the prevalence of aneurysms within these groups (61.1% vs. 60.7%, p = 1.0). Cerebral arterial fenestrations are an anatomic variant more often manifesting at the anterior communicating arterial complex and basilar artery and with no definite pathological relationship with aneurysms.

  View details for DOI 10.15274/INR-2014-10027

  View details for Web of Science ID 000342606200003

  View details for PubMedID 24976087

  View details for PubMedCentralID PMC4178766

• Current trends in endovascular management of traumatic cerebrovascular injury JOURNAL OF NEUROINTERVENTIONAL SURGERY Kansagra, A. P., Cooke, D. L., English, J. D., Sincic, R. M., Amans, M. R., Dowd, C. F., Halbach, V. V., Higashida, R. T., Hetts, S. W. 2014; 6 (1): 47-50

  Abstract

  The role of catheter angiography in the diagnosis and management of traumatic cerebrovascular injury has evolved rapidly with advances in CT and MR angiography and continued development of endovascular techniques.To identify the modern spectrum of traumatic arterial injury encountered during catheter neuroangiography and to examine current patterns of endovascular treatment.Records of trauma patients undergoing catheter neuroangiography over a 4 year period at two high volume centers were retrospectively reviewed. The sample comprised 100 separate arterial lesions that were classified according to mechanism, location, acuity, and endovascular treatment. Follow-up imaging and clinical notes were reviewed to identify procedural complications.Of 100 arterial lesions, 81% were related to blunt trauma. Distribution of lesions by location was 42% intracranial, 39% cervical, and 19% extracranial. The most common injuries were pseudoaneurysm (38%), fistula (29%), and dissection (19%). In total, 41% of lesions underwent endovascular treatment, with trends favoring treatment of non-acute, penetrating, non-cervical, and high grade lesions. Therapy involved coil embolization for 89% of treated lesions. There were a total of two immediate neurovascular complications and one delayed neurovascular complication; one of these resulted in a permanent neurological deficit.Our experience in a large cohort of patients suggests that a relatively high proportion of traumatic arterial lesions identified by catheter angiography are treated by endovascular means, with a low rate of immediate and delayed neurovascular complications.

  View details for DOI 10.1136/neurintsurg-2012-010605

  View details for Web of Science ID 000338289800019

  View details for PubMedID 23322749

• Early Resident-to-Resident Physics Education in Diagnostic Radiology JOURNAL OF THE AMERICAN COLLEGE OF RADIOLOGY Kansagra, A. P. 2014; 11 (1): 59-62

  Abstract

  The revised ABR board certification process has updated the method by which diagnostic radiology residents are evaluated for competency in clinical radiologic physics. In this work, the author reports the successful design and implementation of a resident-taught physics course consisting of 5 weekly, hour-long lectures intended for incoming first-year radiology residents in their first month of training. To the author's knowledge, this is the first description of a course designed to provide a very early framework for ongoing physics education throughout residency without increasing the didactic burden on faculty members. Twenty-six first-year residents spanning 2 academic years took the course and reported subjective improvement in their knowledge (90%) and interest (75%) in imaging physics and a high level of satisfaction with the use of senior residents as physics educators. Based on the success of this course and the minimal resources required for implementation, this work may serve as a blueprint for other radiology residency programs seeking to develop revised physics curricula.

  View details for DOI 10.1016/j.jacr.2013.08.002

  View details for Web of Science ID 000330681800013

  View details for PubMedID 24139318

• Cardiac arrest with impending circulatory collapse EMERGENCY MEDICINE JOURNAL Kansagra, A. P., Yu, J. J. 2013; 30 (9): 753

  View details for DOI 10.1136/emermed-2012-202139

  View details for Web of Science ID 000323166700017

  View details for PubMedID 23221452

• A Novel Image-guided Balloon Vaginoplasty Method to Treat Obstructive Vaginal Anomalies JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Kansagra, A. P., Miller, C. B., Roberts, A. C. 2011; 22 (5): 691-694

  Abstract

  Obstructive anomalies of the vagina that impair uterovaginal outflow and lead to hematocolpos have conventionally been corrected with surgery, but emerging nonsurgical therapies may offer an attractive alternative. The present report describes a method of serial balloon dilation over a transvaginally inserted guide wire to create a durable outflow tract from the uterus to the lower vagina. This technique was successfully used to treat one case each of vaginal atresia and transverse vaginal septum without the immediate need for surgery.

  View details for DOI 10.1016/j.jvir.2011.01.432

  View details for Web of Science ID 000290358700016

  View details for PubMedID 21514521