Jawad F. Kirmani

Hackensack Meridian Health

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Document Type

Co-Authors

Siddhart Mehta

John F. Kennedy Medical Center

121

Adnan I. Qureshi

University of Missouri

100

Mohammad Moussavi

John F. Kennedy Medical Center

Spozhmy Panezai

John F. Kennedy Medical Center

Farah Fourcand

TESLA (Czechia)

Daniel Korya

John F. Kennedy Medical Center

Haralabos Zacharatos

Hackensack Meridian Health

Nazli Janjua

Pomona Valley Hospital Medical Center

Ashish Kulhari

John F. Kennedy Medical Center

Jaskiran Brar

Beaumont Hospital

Cooperative Institutions

TESLA (Czechia)

245

Boston Medical Center

171

Boston University

170

John F. Kennedy Medical Center

119

Neurological Surgery

100

Grady Memorial Hospital

100

Hospital de Clínicas de Porto Alegre

Universidade Federal do Rio Grande do Sul

University Medical Center

Hackensack Meridian Health

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Abstract TP35: Eptifibatide is Safe and May Improve Outcomes in Stroke Patients Undergoing Thrombectomy After Receiving IVtPA

Stroke (2016)

Siddhart Mehta Mohammad Moussavi Daniel Korya Jaskiran Brar Harina Chahal

Introduction: Recent trials have shown significant improvement in outcome for patients suffering from acute ischemic stroke (AIS) when mechanical thrombectomy is added to the standard of care of IV tPA. In addition to the acute anti-platelet properties eptifibatide may also reduce acute inflammatory response following neurovascular intervention. Our goal was to evaluate the potential benefit of adding IV eptifibatide to mechanical thrombectomy and IV tPA. Methods: Patients who presented to a community based university affiliated comprehensive stroke center from 2012-2015 with AIS over a 2 year period were included in the study. Only patients who received thrombectomy after IV tPA were included. A subgroup of those patients also received IV eptifibatide as a continuous drip during and after the procedure. Details of bolus dosing and duration of treatment were documented. The initial NIH Stroke Score (NIHSS) and 24-hour NIHSS were compared between the two groups with paired samples t-test using SPSS Version 22. Results: A total of 866 patients were evaluated, and 139 met the study criteria. All patients received mechanical thrombectomy after IV tPA, but 70 also received a bolus dose of 135 mcg/kg of eptifibatide followed by 0.5 mcg/kg/min continuous drip. The mean duration of the drip was 23.8 minutes (SD 14.13). There were no significant differences in complication or hemorrhage rates between groups. The mean initial minus 24-hour NIHSS (Initial-24) for the patients receiving only IV tPA/thrombectomy was 1.6. Patients who also received eptifibatide had a mean Initial-24 of 3.6. The paired mean difference was 2 (95% CI .19-3.8; p=.03), favoring the addition of eptifibatide. Conclusion: The addition of eptifibatide bolus followed by a continuous drip for a mean of 24-hours to IV tPA/thrombectomy was associated with a significantly better 24-hour post-procedure outcome. The mechanism of action may be related to the suppression of inflammation and potential prevention of rethrombosis after treatment. No additional complications were noted with eptifibatide and patients tolerated it well. A larger prospective trial is warranted to corroborate our findings.

Eptifibatide

Bolus (digestion)

Stroke

Neurovascular bundle

10.1161/str.47.suppl_1.tp35

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Neuroimaging of Stroke: A Review

Southern Medical Journal (2003)

Andrew Xavier Adnan I. Qureshi Jawad F. Kirmani Abutaher M. Yahia Rohit Bakshi

Advances in neuroimaging technology during the past 30 years have resulted in a virtual explosion in the amount of pathologic information that can be obtained in the clinical stroke setting. This neuroimaging revolution has led to a much better understanding of cerebrovascular and tissue pathology, creating a wide array of opportunities for acute treatment and secondary prevention. Advances include early and accurate detection of ischemic and infarcted tissue and the ability to reveal hypoperfused tissue at risk. Clinicians are increasingly able to noninvasively detect embolic and atherothrombotic intravascular lesions. Vascular lesions associated with stroke can be characterized through endovascular neuroimaging techniques and repaired by various means. In this article, we provide an overview and update on the various techniques used in the neuroimaging of stroke and intracranial hemorrhage, including computed tomography, magnetic resonance imaging, ultrasound, and catheter angiography. We outline the specific role of each modality in clinical practice.

Stroke

Intravascular Ultrasound

10.1097/01.smj.0000063468.11503.c1

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Citations (52)

Assessment of large vessel posterior circulation thrombus with MRI and noncontrast CT. (P6.286)

Neurology (2017)

Siddhart Mehta Spozhmy Panezai Ashish Kulhari Audrey Arango Briana DeCarvalho

Circulation (fluid dynamics)

10.1212/wnl.88.16_supplement.p6.286

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Cerebral vasospasm in intracerebral hemorrhage-case report.

PubMed (2009)

Ismail A. Khatri Navin Verma Ammar Alkawi Nazli Janjua Jawad F. Kirmani

Cerebral vasospasm is commonly seen in subarachnoid hemorrhage. However the vasospasm in spontaneous intracerebral hemorrhage without subarachnoid extension has not been described.We report a patient who developed intracerebral hemorrhage associated with cerebral vasospasm demonstrated by conventional angiography. The vasospasm involved the superior and inferior divisions of the middle cerebral artery on the side of intracerebral hemorrhage. The vasospasm resolved in six days as documented by a repeat angiography.Cerebral vasospasm can be rarely seen in patients with intracerebral hemorrhage. Further elaboration is required to understand the pathophysiology and subsequent impact on outcome in such patients.

Cerebral Vasospasm

Pathophysiology

Source

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Citations (6)

Update on Endovascular Treatment of Cerebrovascular Diseases

Journal of Endovascular Therapy (2004)

M. Shazam Hussain Adnan I. Qureshi Jawad F. Kirmani Afshin A. Divani L. Nelson Hopkins

The study of vascular biology has provided strong evidence for the role that free radical attack plays in the pathogenesis of cardiovascular diseases. The endothelial cell (EC) dysfunction that results from exposure to oxidative stresses, such as oxidized LDL, influences vascular cell gene expression, promoting smooth muscle cell (SMC) mitogenesis and apoptosis. These factors also play an important role in atherogenesis, which is attenuated by antioxidants. Thus, antioxidants are important to understanding the pathophysiology of cardiovascular diseases and to constructing an effective treatment strategy for these patients. Over the last decade, there has been a tremendous interest in the biology of heme oxygenase-1 (HO-1), which exhibits antioxidant effects in various forms of tissue injury. Moreover, the reaction is also the major source of carbon dioxide (CO) in the body, which is a physiologically important gaseous vasodilator that inhibits SMC proliferation. Thus, HO-1-derived products provide various mechanisms to maintain cardiovascular homeostasis. We review recent work on the cellular and molecular biological aspects of the HO/CO system in vascular pathophysiology.

Pathophysiology

Pathogenesis

Homeostasis

10.1177/15266028040110s607

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Citations (8)

Thrombolytics

Elsevier eBooks (2007)

Ahmed El-Gengaihy S.I. Abdelhadi Jawad F. Kirmani Adnan I. Qureshi

Reteplase

Thrombolytic drug

Tenecteplase

10.1016/b0-08-045044-x/00196-6

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Citations (2)

Abstract 1122‐000153: Larger Functional Shunts are Associated with Greater Cerebrovascular Disease Burden

Stroke Vascular and Interventional Neurology (2021)

Nancy Gadallah Danisette Torres Arifa Ghori Laura Suhan Spozhmy Panezai

Introduction : The relationship between embolic stroke and patent foramen ovale (PFO) is well‐established. Our objective was to evaluate the association between high intensity transient signals (HITS) in contrast‐enhanced transcranial doppler ultrasonography (ceTCD), baseline MRI brain small vessel ischemic changes, and rates of acute ischemic stroke in the setting of focal neurological deficits. Methods : Electronic medical records of subjects with acute onset neurological symptoms who had ceTCD and MRI brain were evaluated. Subjects without a reported Spencer grade and/or MRI brain without available DWI and FLAIR sequences were excluded. Acute stroke rates and baseline Fazekas score in low‐grade (Spencer grade 1–2) and high‐grade (Spender grade 3–5) shunts were analyzed using Z score for 2 population proportions and Mann‐Whitney U test, respectively. Social Science Statistics was used for data analysis. Results : From June 2016 to August 2021, of 7,498 consecutive ischemic stroke patients, 132 patients were identified as possible strokes related to PFO and were hospitalized with focal neurological deficit, underwent ceTCD and MRI brain. Acute stroke was confirmed on DWI in 60% of Spencer grade 1 (n = 73), 72.2% of grade 2 (n = 19), 72.7% of grade 3 (n = 29), and 80% of grades 4 and 5 shunts (n = 11). Acute stroke rates between low grade (grades 1–2) and high grade shunts (grades 3–5), did not reach statistical significance (z = ‐0.9181; p = 0.17879). There was no significant difference in periventricular white matter disease (z = 0.85697; p = 0.19489). Fazekas scores assessing deep white matter disease were statistically significant between low‐ and high‐grade shunts (z = 1.92818; p = 0.0268 Conclusions : A trend towards statistical significance was observed in high‐grade shunt association with higher rate of acute stroke. Deep white matter disease burden may be significantly higher in high‐grade shunts. Further prospective studies are needed to corroborate our findings.

Fluid-attenuated inversion recovery

Stroke

Acute stroke

Transcranial Doppler

10.1161/svin.01.suppl_1.000153

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Abstract 1122‐000170: Stent Retrievers Utilization in Endovascular Treatment of Cerebral Venous Sinus Thrombosis

Stroke Vascular and Interventional Neurology (2021)

Abdallah Amireh Hassan Ali Muhammad Nagy Siddhart Mehta Haralabos Zacharatos

Introduction : Patients with Cerebral Venous Sinus Thrombosis (CVT) are candidates for Endovascular Mechanical Thrombectomy (EMT) in cases of coma on presentation or clinical deterioration despite anticoagulation. We present two cases of CVT successfully treated with mechanical thrombectomy using Medtronic’s Solitaire Stent retriever. Methods : A retrospective review at a single center university hospital was performed for all cerebral venous sinus thrombosis case log from December 2018 to November 2020. Cases resistant to conventional medical therapy that underwent intrasinus stent retriever endovascular thrombectomy were noted. Results : Case 1: 26 year‐old male with a history of hypertension presented with 2 weeks of headaches, left sided numbness and blurriness of vision. Imaging revealed superior sagittal (SSS) and bilateral transverse sinus thrombosis. Patient was treated with heparin infusion and discharged home on oral apixaban. The following day he presented with new onset expressive aphasia. Imaging was unchanged. Due to worsening symptoms despite anticoagulation, Patient underwent mechanical thrombectomy using a stent retriever. Solitaire 6 × 40 mm stent was advanced and deployed through the microcatheter and retracted in the upper segment of posterior one third of SSS followed by alteplase infusion at 1 mg/hr (25 ml/hr) via Berenstein catheter for the next 36 hours. Intravenous heparin infusion was also started with aPTT goal 60–80. Cerebral angiogram was repeated two days later revealing successful recanalization of previously thrombosed SSS and bilateral transverse sinuses with significantly improved cerebral venous drainage. Patient was transitioned again to oral apixaban. Repeat CTA in 3 months showed significantly improved patency and recanalization. Case 2: A 42 year‐old male with history of ulcerative colitis presented with sudden onset right‐sided hemiparesis and hemisensory loss along with one month of headaches. Presenting NIHSS 14. Imaging revealed SSS thrombosis with thrombosis of the left transverse sinus complicated by left frontal intraparenchymal hemorrhage and subarachnoid hemorrhage. Patient underwent mechanical thrombectomy of SSS using Solitaire 6 × 40mm stent retriever with distal aspiration resulting in improved flow. Clinical course was complicated by seizures and acute respiratory distress syndrome requiring intubation followed by tracheostomy and G‐tube placement which were eventually removed during recovery. Patient was treated with high intensity heparin during his hospitalization and eventually transitioned to apixaban. Work up revealed protein S deficiency. Serial CT angiograms at 6 and 11 months revealed resolution of CVT. NIHSS improved to 1 with mRS of 2. Conclusions : These cases imply that intra‐cerebrovenous sinus mechanical thrombectomy with stent retrievers may be considered in patients with continuing worsening despite optimal medical management.

SSS*

Solitaire Cryptographic Algorithm

Dural venous sinuses

Sigmoid sinus

10.1161/svin.01.suppl_1.000170

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Risk of Distal Embolization in Large Vessel Occlusion Strokes Treated with Tenecteplase (P5-10.008)

Neurology (2022)

Siddhart Mehta Nasar Ali Teye Umanah Arifa Ghori Rafia Jawed

Our objective was to compare rates of distal embolization in subjects who received IV alteplase (tPA) or IV Tenecteplase (TNK) followed by EVT.

Tenecteplase

10.1212/wnl.98.18_supplement.3355

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Abstract W P53: Hydration After IV tPA Predicts Outcome for Acute Ischemic Stroke: A Substudy of THIRST-O

Stroke (2015)

Ildiko Torok Daniel Korya Jeffrey Lahrmann Saqib Chaudhry Bernard Galea

Background and Objective: Dehydration is potentially a precipitating factor in patients at risk for stroke. Patients who suffer from acute ischemic attacks are warned not to become dehydrated. Early animal models and studies on dehydration were linked to the development of hypercoagulation and thrombus formation. Previous studies have looked deeper into the enzymatic reactions occurring in the coagulation cascade and discovered the role of dehydration in catalyzing thrombus formation. Our objective was to study the effect hydration has on outcomes after IV tPA as a sub-study of our previous work on the Hydration Influence on the Risk of Stroke Outcome (THIRST-O) study. Methods: We reviewed the laboratory findings, clinical exam and overall hydration status of all patients who received IV tPA for the treatment of acute ischemic stroke from 2011-2013 at a university affiliated comprehensive stroke center. SPSS Software Version 22 was used to obtain descriptive statistics with frequencies, and the Spearman’s rho correlation coefficients were determined. Higher BUN/Creatinine ratio and serum osmolarity were used as markers for dehydration and were compared with the NIH Stroke Scale at admission, at 24-hours and discharge. Modified Rankin Scale at discharge (DCmRS) was recorded Results: Of the 1,565 ischemic stroke patients evaluated, 188 received IV tPA, and 162 met study criteria. Patients were mostly female [n=85, 52.7%), with the mean age of 73.4 (SD= 13.6). Patients with higher initial and later serum osmolarity had higher initial, 24-hour and DCNIHSS as well as higher DCmRS (r=.196, r=.207, r=.247, r=.411; p<.01). The initial BUN/Creatinine ratio correlated well with the ratio before discharge (r=.450; p=.0001). Patients with elevated BUN/Creatinine ratios were significantly more likely to have higher initial NIHSS, 24-hour NIHSS, DCNIHSS and DCmRS (r= 235, .216, .324, .431; p<.01). Conclusion: Dehydrated patients with acute ischemic stroke who received IV tPA had significantly worse clinical presentations and outcome. Our study suggests patients who receive IV tPA should be well hydrated for a better outcome. Our data needs to be validated in larger, prospective trials.

Stroke

10.1161/str.46.suppl_1.wp53

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