Michael Moussouttas

Johnson University

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Mitchell Maltenfort

Children's Hospital of Philadelphia

Fred Rincón

Cooper University Hospital

Rodney Bell

Thomas Jefferson University

Nikolaos Papamitsakis

SUNY Downstate Health Sciences University

Jacqueline Urtecho

Thomas Jefferson University

Jack Jallo

Neurological Surgery

William McBride

Philadelphia University

Thanh Huynh

Dalat University

Ali Seifi

The University of Texas Health Science Center at San Antonio

Keith Dombrowski

University of South Florida

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Thomas Jefferson University

Thomas Jefferson University Hospital

Neurological Surgery

Universitat Autònoma de Barcelona

Neurology, Inc

Yale University

Vall d'Hebron Hospital Universitari

Heidelberg University

Inserm

University Hospital of Bern

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Cerebrospinal Fluid Catecholamine Levels as Predictors of Outcome in Subarachnoid Hemorrhage

Cerebrovascular Diseases (2012)

Michael Moussouttas Thanh Huynh John Khoury Edwin W. Lai Keith Dombrowski

Objective: Subarachnoid hemorrhage (SAH) is associated with marked sympathetic activation at the time of ictus. The purpose of this study is to determine whether early central catecholamine levels measured from cerebrospinal fluid (CSF) relate to outcome in patients with SAH. Methods: Observational study of consecutive SAH grade 3–5 patients who underwent ventriculostomy placement, but did not undergo open craniotomy for aneurysm obliteration. CSF samples were obtained during the first 48 h following symptom onset and assayed for catecholamine levels. Statistical analyses were performed to determine whether the levels predicted mortality by day 15 or mortality/disability by day 30. Results: For the 102 patients included, mean age was 58, and 73% were female – 21% experienced day-15 mortality, and 32% experienced mortality/disability by day 30. Early mortality was related to Hunt-Hess (H/H) grade (p < 0.001), neurogenic cardiomyopathy (NC) (p = 0.003), cerebral infarction (p = 0.001), elevated intracranial pressure (ICP) (p = 0.029), epinephrine (EPI) level (p = 0.002) and norepinephrine/3,4-dihydroxyphenylglycol (NE/DHPG) ratio (p = 0.003). Mortality/disability was related to H/H grade (p < 0.001), NC (p = 0.018), infarction (p < 0.001), elevated ICP (p = 0.002), EPI (p = 0.004) and NE/DHPG (p = 0.014). Logistic regression identified age [OR 1.09 (95% CI 1.01–1.17)], H/H grade [9.52 (1.19–77)], infarction [10.87 (1.22–100)], ICP elevation [32.26 (2–500)], EPI [1.06 (1.01–1.10)], and (inversely) DHPG [0.99 (0.99–1.00)] as independent predictors of early mortality. For mortality/disability, H/H grade [OR 21.74 (95% CI 5.62–83)], ICP elevation [18.52 (1.93–166)], and EPI [1.05 (1.02–1.09)] emerged as independent predictors. Proportional-hazards analysis revealed age [HR 1.041 (95% CI 1.003–1.08)], H/H grade [6.9 (1.54–31.25)], NC [4.31 (1.5–12.35)], and EPI [1.032 (1.009–1.054)] independently predicted early mortality. Conclusions: CSF catecholamine levels are elevated in SAH patients who experience early mortality or disability. EPI may potentially serve as useful index of outcome in this population of patients with SAH.

Ventriculostomy

10.1159/000334660

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Citations (35)

A critical appraisal of bypass surgery in moyamoya disease

Therapeutic Advances in Neurological Disorders (2020)

Michael Moussouttas Igor Rybinnik

Moyamoya disease (MMD) is a complex cerebrovascular disorder about which little is known. Conventionally, revascularization surgery is recommended for patients, despite an absence of conclusive data from adequate clinical trials. Underscoring the uncertainty that exists in treating MMD patients, investigators continue to present data comparing revascularization with conservative or medical management, most of which originates from East Asia where MMD is most prevalent. The purpose of this manuscript is to review contemporary large case series, randomized trials, and recent meta-analyses that compare surgical and medical treatments in adult patients with MMD, and to critically analyze the modern literature in the context of current practice standards. Data from the available literature is limited, but revascularization seems superior to conservative therapy in adult patients presenting with hemorrhage, and in preventing future hemorrhages. Conversely, evidence that surgery is superior to medical therapy is not convincing in adult patients presenting with cerebral ischemia, or for the prevention of future ischemic events. In contrast to East Asian populations, MMD in Europe and in the Americas is predominantly an ischemic disease that presents in adulthood. Adequate multinational trials are warranted.

Moyamoya Disease

Bypass surgery

Medical literature

Critical appraisal

Medical Therapy

10.1177/1756286420921092

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Citations (13)

Combination antiplatelet agents in ischemic cerebrovascular disease.

PubMed (2005)

Michael Moussouttas Nikolaos Papamitsakis

Combination antiplatelet agents with multiple mechanisms of action are being used with increasing frequency for vascular disorders, including cerebrovascular disease. Limited data exist regarding the efficacy of combination antiplatelet therapy in the primary or secondary prevention of cerebral ischemia, and combination therapies are often used without adequate evidence of efficacy. However, over the last few years, several cerebrovascular and cardiovascular trials have provided some preliminary information on the effectiveness of various combination therapies in preventing cerebral ischemic disease. This article reviews recently completed cerebrovascular and cardiovascular trials that tested a combination antiplatelet regimen against aspirin alone, and that assessed cerebral ischemia as an outcome measure. Controversies pertaining to these trials and to the use of the various combination antiplatelet regimens are discussed. Based on cardiovascular studies, clopidogrel in combination with aspirin has not been proven superior to aspirin alone for the primary prevention of cerebral ischemia. No data exists regarding the combination of clopidogrel and aspirin for the secondary prevention of cerebrovascular disease. The combination of aspirin plus extended-release dipyridamole (xrDP) appears to be superior to aspirin alone in the secondary prevention of cerebral ischemia, but may compromise cardiovascular protection in patients with coexisting coronary artery disease. Combination therapy with aspirin and clopidogrel seems to increase the risk of major hemorrhages, whereas aspirin plus xrDP does not. Ongoing trials are expected to clarify the role of various combination antiplatelet regimens.

Dipyridamole

Combination therapy

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Antiplatelet drug

Ticlopidine

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A comprehensive analysis of the relationship between ACA velocities and ACA infarction following aneurysmal subarachnoid hemorrhage

Journal of the Neurological Sciences (2017)

Michael Moussouttas Jocelyn Y. Cheng Joseph Antonakakis Ameesh Patel Maria Iuanow

Anterior cerebral artery

10.1016/j.jns.2017.03.024

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Impact of Acute Lung Injury and Acute Respiratory Distress Syndrome After Traumatic Brain Injury in the United States

Neurosurgery (2012)

Fred Rincón Sayantani Ghosh Saugat Dey Mitchell Maltenfort Matthew Vibbert

Traumatic brain injury (TBI) is a major cause of disability, morbidity, and mortality. The effect of the acute respiratory distress syndrome and acute lung injury (ARDS/ALI) on in-hospital mortality after TBI remains controversial.To determine the epidemiology of ARDS/ALI, the prevalence of risk factors, and impact on in-hospital mortality after TBI in the United States.Retrospective cohort study of admissions of adult patients>18 years with a diagnosis of TBI and ARDS/ALI from 1988 to 2008 identified through the Nationwide Inpatient Sample.During the 20-year study period, the prevalence of ARDS/ALI increased from 2% (95% confidence interval [CI], 2.1%-2.4%) in 1988 to 22% (95% CI, 21%-22%) in 2008 (P<.001). ARDS/ALI was more common in younger age; males; white race; later year of admission; in conjunction with comorbidities such as congestive heart failure, hypertension, chronic obstructive pulmonary disease, chronic renal and liver failure, sepsis, multiorgan dysfunction; and nonrural, medium/large hospitals, located in the Midwest, South, and West continental US location. Mortality after TBI decreased from 13% (95% CI, 12%-14%) in 1988 to 9% (95% CI, 9%-10%) in 2008 (P<.001). ARDS/ALI-related mortality after TBI decreased from 33% (95% CI, 33%-34%) in 1988 to 28% (95% CI, 28%-29%) in 2008 (P<.001). Predictors of in-hospital mortality after TBI were older age, male sex, white race, cancer, chronic kidney disease, hypertension, chronic liver disease, congestive heart failure, ARDS/ALI, and organ dysfunctions.Our analysis demonstrates that ARDS/ALI is common after TBI. Despite an overall reduction of in-hospital mortality, ARDS/ALI carries a higher risk of in-hospital death after TBI.

10.1227/neu.0b013e3182672ae5

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Citations (127)

Cannabis Use and Cerebrovascular Disease

The Neurologist (2004)

Michael Moussouttas

Cannabis is the most commonly abused illicit drug and is often considered innocuous. However, cases of acute onset neurologic dysfunction occurring in relation to cannabis use have been described and corresponding cerebral imaging studies have documented focal ischemic changes and vessel abnormalities.This article reviews all reported cases of presumed cannabis related cerebral ischemic events in the medical literature, as well as pertinent human and animal experimental studies on the cardiovascular and cerebrovascular effects of cannabis.Cannabis use seems to have been causally related to several instances of cerebral ischemia and infarction. Proposed etiologic mechanisms have included cerebral vasospasm, cardioembolization, and systemic hypotension with impaired cerebral autoregulation, but most of the available data points to a vasospastic process. The exact relation of cannabis to cerebrovascular disease remains to be determined.

Effects of cannabis

Cerebral Vasospasm

10.1097/01.nrl.0000107493.19282.b0

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Citations (68)

Analysis of the Endothelial Nitric Oxide Synthase Gene as a Modifier of the Cerebral Response to Ischemia

Journal of Stroke and Cerebrovascular Diseases (2006)

Ana Virginia Dutra Hsiu‐Fen Lin Suh‐Hang Hank Juo Melanie Boyadjis Michael Moussouttas

Stroke

Gene polymorphism

10.1016/j.jstrokecerebrovasdis.2006.03.002

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