Direct versus indirect revascularization in the treatment of moyamoya disease

OBJECTIVE For patients with moyamoya disease (MMD), surgical intervention is usually required because of progressive occlusion of the internal carotid artery. The indirect bypass method has been widely accepted as the treatment of choice in pediatric patients. However, in adult patients with MMD, the most effective treatment method remains a matter of debate. Here, the authors compared the clinical outcomes from MMD patients treated with either extracranial-intracranial arterial bypass (EIAB; 43 hemispheres) or modified encephaloduroarteriosynangiosis (mEDAS; 75 hemispheres) to investigate whether mEDAS is an effective surgical method for treating adults with symptomatic MMD. METHODS A comparative analysis was performed in patients treated using either mEDAS or EIAB. Collateral grading, collateral vein counting, and symptom analysis were used to assess the outcome of surgery. RESULTS Seventy-seven percent (58/75) of mEDAS cases and 83.7% (36/43) of EIAB cases in the analysis experienced improvement in their symptoms after surgery. Furthermore, patients in 98.7% (74/75) of mEDAS cases and those in 95.3% (41/43) of EIAB cases exhibited improved collateral grades. Increases in regions of perfusion were seen after both procedures. CONCLUSIONS Modified EDAS and EIAB both result in positive outcomes for symptomatic adults with MMD. However, when considering the benefit of both surgeries, the authors propose mEDAS, a simpler and less strenuous surgery with a lower risk of complications, as a sufficient and safe treatment option for symptomatic adults with MMD.

Quantitative cerebral blood flow using xenon-enhanced CT after decompressive craniectomy in traumatic brain injury

OBJECTIVE Few studies have reported on changes in quantitative cerebral blood flow (CBF) after decompressive craniectomy and the impact of these measures on clinical outcome. The aim of the present study was to evaluate global and regional CBF patterns in relation to cerebral hemodynamic parameters in patients after decompressive craniectomy for traumatic brain injury (TBI). METHODS The authors studied clinical and imaging data of patients who underwent xenon-enhanced CT (XeCT) CBF studies after decompressive craniectomy for evacuation of a mass lesion and/or to relieve intractable intracranial hypertension. Cerebral hemodynamic parameters prior to decompressive craniectomy and at the time of the XeCT CBF study were recorded. Global and regional CBF after decompressive craniectomy was measured using XeCT. Regional cortical CBF was measured under the craniectomy defect as well as for each cerebral hemisphere. Associations between CBF, cerebral hemodynamics, and early clinical outcome were assessed. RESULTS Twenty-seven patients were included in this study. The majority of patients (88.9%) had an initial Glasgow Coma Scale score ≤ 8. The median time between injury and decompressive surgery was 9 hours. Primary decompressive surgery (within 24 hours) was performed in the majority of patients (n = 18, 66.7%). Six patients had died by the time of discharge. XeCT CBF studies were performed a median of 51 hours after decompressive surgery. The mean global CBF after decompressive craniectomy was 49.9 ± 21.3 ml/100 g/min. The mean cortical CBF under the craniectomy defect was 46.0 ± 21.7 ml/100 g/min. Patients who were dead at discharge had significantly lower postcraniectomy CBF under the craniectomy defect (30.1 ± 22.9 vs 50.6 ± 19.6 ml/100 g/min; p = 0.039). These patients also had lower global CBF (36.7 ± 23.4 vs 53.7 ± 19.7 ml/100 g/min; p = 0.09), as well as lower CBF for the ipsilateral (33.3 ± 27.2 vs 51.8 ± 19.7 ml/100 g/min; p = 0.07) and contralateral (36.7 ± 19.2 vs 55.2 ± 21.9 ml/100 g/min; p = 0.08) hemispheres, but these differences were not statistically significant. The patients who died also had significantly lower cerebral perfusion pressure (52 ± 17.4 vs 75.3 ± 10.9 mm Hg; p = 0.001). CONCLUSIONS In the presence of global hypoperfusion, regional cerebral hypoperfusion under the craniectomy defect is associated with early mortality in patients with TBI. Further study is needed to determine the value of incorporating CBF studies into clinical decision making for severe traumatic brain injury.

Jackson-Pratt drainage in pediatric craniofacial reconstructive surgery: is it helping or hurting?

OBJECTIVE Jackson-Pratt drains (JPDs) are commonly employed in pediatric craniofacial reconstructive surgery (CRFS) to reduce postoperative wound complications, but their risk profile remains unknown. Perioperative blood loss and volume shifts are major risks of CFRS. The goal of this study was to evaluate the risks of JPD usage in CFRS, particularly with regard to perioperative blood loss, hyponatremia, intensive care unit (ICU) length of stay, and postoperative wound complications. METHODS The authors performed a retrospective review of data obtained in pediatric patients who underwent CFRS at a single institution, as performed by multiple surgeons between January 2010 and December 2014. Data were gathered from patients who did and did not receive JPDs at the time of surgery. Outcome measures were compared between the JPD and no-JPD groups. RESULTS The overall population 179 pediatric patients: 128 who received JPDs and 51 who did not. In their analysis, the authors found no significant differences in baseline patient characteristics between the two groups. The average JPD output over the first 48 hours was 222 ± 142 ml. When examining the immediate preoperative to immediate postoperative time period, no significant differences were noted between the groups with regard to the need for blood transfusion or changes in hemoglobin, hematocrit, or serum sodium levels. These differences were also not significant when examining the 48-hour postoperative period. Finally, no significant differences in hospital length of stay, ICU length of stay, or emergency department visits at 60 days were noted between the two groups. CONCLUSIONS In this retrospective study, the use of JPDs in pediatric CFRS was not associated with an increased risk of serious perioperative complications, although the benefits of this practice remain unclear.

Evaluation of a novel noninvasive ICP monitoring device in patients undergoing invasive ICP monitoring: preliminary results

OBJECTIVE There is no established method of noninvasive intracranial pressure (NI-ICP) monitoring that can serve as an alternative to the gold standards of invasive monitoring with external ventricular drainage or intraparenchymal monitoring. In this study a new method of NI-ICP monitoring performed using algorithms to determine ICP based on acoustic properties of the brain was applied in patients undergoing invasive ICP (I-ICP) monitoring, and the results were analyzed. METHODS In patients with traumatic brain injury and subarachnoid hemorrhage who were undergoing treatment in a neurocritical intensive care unit, the authors recorded ICP using the gold standard method of invasive external ventricular drainage or intraparenchymal monitoring. In addition, the authors simultaneously measured the ICP noninvasively with a device (the HS-1000) that uses advanced signal analysis algorithms for acoustic signals propagating through the cranium. To assess the accuracy of the NI-ICP method, data obtained using both I-ICP and NI-ICP monitoring methods were analyzed with MATLAB to determine the statistical significance of the differences between the ICP measurements obtained using NI-ICP and I-ICP monitoring. RESULTS Data were collected in 14 patients, yielding 2543 data points of continuous parallel ICP values in recordings obtained from I-ICP and NI-ICP. Each of the 2 methods yielded the same number of data points. For measurements at the ≥ 17-mm Hg cutoff, which was arbitrarily chosen for this preliminary analysis, the sensitivity and specificity for the NI-ICP monitoring were found to be 0.7541 and 0.8887, respectively. Linear regression analysis indicated that there was a strong positive relationship between the measurements. Differential pressure between NI-ICP and I-ICP was within ± 3 mm Hg in 63% of data-paired readings and within ± 5 mm Hg in 85% of data-paired readings. The receiver operating characteristic-area under the curve analysis revealed that the area under the curve was 0.895, corresponding to the overall performance of NI-ICP monitoring in comparison with I-ICP monitoring. CONCLUSIONS This study provides the first clinical data on the accuracy of the HS-1000 NI-ICP monitor, which uses advanced signal analysis algorithms to evaluate properties of acoustic signals traveling through the brain in patients undergoing I-ICP monitoring. The findings of this study highlight the capability of this NI-ICP device to accurately measure ICP noninvasively. Further studies should focus on clinical validation for elevated ICP values.

Safety and cost efficiency of a restrictive transfusion protocol in patients with traumatic brain injury

OBJECTIVE Blood loss and moderate anemia are common in patients with traumatic brain injury (TBI). However, despite evidence of the ill effects and expense of the transfusion of packed red blood cells, restrictive transfusion practices have not been universally adopted for patients with TBI. At a Level I trauma center, the authors compared patients with TBI who were managed with a restrictive (target hemoglobin level > 7 g/dl) versus a liberal (target hemoglobin level > 10 g/dl) transfusion protocol. This study evaluated the safety and cost-efficiency of a hospital-wide change to a restrictive transfusion protocol. METHODS A retrospective analysis of patients with TBI who were admitted to the intensive care unit (ICU) between January 2011 and September 2015 was performed. Patients < 16 years of age and those who died within 24 hours of admission were excluded. Demographic data and injury characteristics were compared between groups. Multivariable regression analyses were used to assess hospital outcome measures and mortality rates. Estimates from an activity-based cost analysis model were used to detect changes in cost with transfusion protocol. RESULTS A total of 1565 patients with TBI admitted to the ICU were included in the study. Multivariable analysis showed that a restrictive transfusion strategy was associated with fewer days of fever (p = 0.01) and that patients who received a transfusion had a larger fever burden. ICU length of stay, ventilator days, incidence of lung injury, thromboembolic events, and mortality rates were not significantly different between transfusion protocol groups. A restrictive transfusion protocol saved approximately $115,000 annually in hospital direct and indirect costs. CONCLUSIONS To the authors' knowledge, this is the largest study to date to compare transfusion protocols in patients with TBI. The results demonstrate that a hospital-wide change to a restrictive transfusion protocol is safe and cost-effective in patients with TBI.

Depression as an independent predictor of postoperative delirium in spine deformity patients undergoing elective spine surgery

OBJECTIVE Depression is the most prevalent affective disorder in the US, and patients with spinal deformity are at increased risk. Postoperative delirium has been associated with inferior surgical outcomes, including morbidity and mortality. The relationship between depression and postoperative delirium in patients undergoing spine surgery is relatively unknown. The aim of this study was to determine if depression is an independent risk factor for the development of postoperative delirium in patients undergoing decompression and fusion for deformity. METHODS The medical records of 923 adult patients (age ≥ 18 years) undergoing elective spine surgery at a single major academic institution from 2005 through 2015 were reviewed. Of these patients, 255 (27.6%) patients had been diagnosed with depression by a board-certified psychiatrist and constituted the Depression group; the remaining 668 patients constituted the No-Depression group. Patient demographics, comorbidities, and intra- and postoperative complication rates were collected for each patient and compared between groups. The primary outcome investigated in this study was rate of postoperative delirium, according to DSM-V criteria, during initial hospital stay after surgery. The association between depression and postoperative delirium rate was assessed via multivariate logistic regression analysis. RESULTS Patient demographics and comorbidities other than depression were similar in the 2 groups. In the Depression group, 85.1% of the patients were taking an antidepressant prior to surgery. There were no significant between-group differences in intraoperative variables and rates of complications other than delirium. Postoperative complication rates were also similar between the cohorts, including rates of urinary tract infection, fever, deep and superficial surgical site infection, pulmonary embolism, deep vein thrombosis, urinary retention, and proportion of patients transferred to the intensive care unit. In total, 66 patients (7.15%) had an episode of postoperative delirium, with depressed patients experiencing approximately a 2-fold higher rate of delirium (10.59% vs 5.84%). In a multivariate logistic regression analysis, depression was an independent predictor of postoperative delirium after spine surgery in spinal deformity patients (p = 0.01). CONCLUSIONS The results of this study suggest that depression is an independent risk factor for postoperative delirium after elective spine surgery. Further studies are necessary to understand the effects of affective disorders on postoperative delirium, in hopes to better identify patients at risk.

Reoperations within 48 hours following 7942 pediatric neurosurgery procedures

OBJECTIVE Various indicators are used to evaluate the quality of care delivered by surgical services, one of which is early reoperation rate. The indications and rate of reoperations within a 48-hour time period have not been previously reported for pediatric neurosurgery. METHODS Between May 1, 2009, and December 30, 2014, 7942 surgeries were performed by the pediatric neurosurgery service in the operating rooms at a single institution. Demographic, socioeconomic, and clinical characteristics associated with each of the operations were prospectively collected. The procedures were grouped into 31 categories based on the nature of the procedure and underlying diseases. Reoperations within 48 hours at the conclusion of the index surgery were reviewed to determine whether the reoperation was planned or unplanned. Multivariate logistic regression was employed to analyze risk factors associated with unplanned reoperations. RESULTS Cerebrospinal fluid shunt-and hydrocephalus-related surgeries accounted for 3245 (40.8%) of the 7942 procedures. Spinal procedures, craniotomy for tumor resections, craniotomy for traumatic injury, and craniofacial reconstructions accounted for an additional 8.7%, 6.8%, 4.5%, and 4.5% of surgical volume. There were 221 reoperations within 48 hours of the index surgery, yielding an overall incidence of 2.78%; 159 of the reoperation were unplanned. Of these 159 unplanned reoperations, 121 followed index operations involving shunt manipulations. Using unplanned reoperations as the dependent variable (n = 159), index operations with a starting time after 3 pm and admission through the emergency department (ED) were associated with a two- to threefold increase in the likelihood of reoperations (after-hour surgery, odds ratio [OR] 2.01 [95% CI 1.43-2.83, p < 0.001]; ED admission, OR 1.97 (95% CI 1.32-2.96, p < 0.05]). CONCLUSIONS Approximately 25% of the reoperations within 48 hours of a pediatric neurosurgical procedure were planned. When reoperations were unplanned, contributing factors could be both surgeon related and system related. Further study is required to determine the extent to which these reoperations are preventable. The utility of unplanned reoperation as a quality indicator is dependent on proper definition, analysis, and calculation.

Medical necessity of routine admission of children with mild traumatic brain injury to the intensive care unit

OBJECTIVE Approximately 475,000 children are treated for traumatic brain injury (TBI) in the US each year; most are classified as mild TBI (Glasgow Coma Scale [GCS] Score 13-15). Patients with positive findings on head CT, defined as either intracranial hemorrhage or skull fracture, regardless of severity, are often transferred to tertiary care centers for intensive care unit (ICU) monitoring. This practice creates a significant burden on the health care system. The purpose of this investigation was to derive a clinical decision rule (CDR) to determine which children can safely avoid ICU care. METHODS The authors retrospectively reviewed patients with mild TBI who were ≤ 16 years old and who presented to a Level 1 trauma center between 2008 and 2013. Data were abstracted from institutional TBI and trauma registries. Independent covariates included age, GCS score, pupillary response, CT characteristics, and Injury Severity Score. A composite outcome measure, ICU-level care, was defined as cardiopulmonary instability, transfusion, intubation, placement of intracranial pressure monitor or other invasive monitoring, and/or need for surgical intervention. Stepwise logistic regression defined significant predictors for model inclusion with p < 0.10. The authors derived the CDR with binary recursive partitioning (using a misclassification cost of 20:1). RESULTS A total of 284 patients with mild TBI were included in the analysis; 40 (14.1%) had ICU-level care. The CDR consisted of 5 final predictor variables: midline shift > 5 mm, intraventricular hemorrhage, nonisolated head injury, postresuscitation GCS score of < 15, and cisterns absent. The CDR correctly identified 37 of 40 patients requiring ICU-level care (sensitivity 92.5%; 95% CI 78.5-98.0) and 154 of 244 patients who did not require an ICU-level intervention (specificity 63.1%; 95% CI 56.7-69.1). This results in a negative predictive value of 98.1% (95% CI 94.1-99.5). CONCLUSIONS The authors derived a clinical tool that defines a subset of pediatric patients with mild TBI at low risk for ICU-level care. Although prospective evaluation is needed, the potential for improved resource allocation is significant.

Intracranial pressure monitoring in severe blunt head trauma: does the type of monitoring device matter?

OBJECTIVE Intracranial pressure (ICP) monitoring has become the standard of care in the management of severe head trauma. Intraventricular devices (IVDs) and intraparenchymal devices (IPDs) are the 2 most commonly used techniques for ICP monitoring. Despite the widespread use of these devices, very few studies have investigated the effect of device type on outcomes. The purpose of the present study was to compare outcomes between 2 types of ICP monitoring devices in patients with isolated severe blunt head trauma. METHODS This retrospective observational study was based on the American College of Surgeons Trauma Quality Improvement Program database, which was searched for all patients with isolated severe blunt head injury who had an ICP monitor placed in the 2-year period from 2013 to 2014. Extracted variables included demographics, comorbidities, mechanisms of injury, head injury specifics (epidural, subdural, subarachnoid, intracranial hemorrhage, and diffuse axonal injury), Abbreviated Injury Scale (AIS) score for each body area, Injury Severity Score (ISS), vital signs in the emergency department, and craniectomy. Outcomes included 30-day mortality, complications, number of ventilation days, intensive care unit and hospital lengths of stay, and functional independence. RESULTS During the study period, 105,721 patients had isolated severe traumatic brain injury (head AIS score ≥ 3). Overall, an ICP monitoring device was placed in 2562 patients (2.4%): 1358 (53%) had an IVD and 1204 (47%) had an IPD. The severity of the head AIS score did not affect the type of ICP monitoring selected. There was no difference in the median ISS; ISS > 15; head AIS Score 3, 4, or 5; or the need for craniectomy between the 2 device groups. Unadjusted 30-day mortality was significantly higher in the group with IVDs (29% vs 25.5%, p = 0.046); however, stepwise logistic regression analysis showed that the type of ICP monitoring was not an independent risk factor for death, complications, or functional outcome at discharge. CONCLUSIONS This study demonstrated that compliance with the Brain Trauma Foundation guidelines for ICP monitoring is poor. In isolated severe blunt head injuries, the type of ICP monitoring device does not have any effect on survival, systemic complications, or functional outcome.

A protocol for postoperative admission of elective craniotomy patients to a non-ICU or step-down setting

OBJECTIVE Selecting the appropriate patients undergoing craniotomy who can safely forgo postoperative intensive care unit (ICU) monitoring remains a source of debate. Through a multidisciplinary work group, the authors redefined their institutional care process for postoperative monitoring of patients undergoing elective craniotomy to include transfer from the postanesthesia care unit (PACU) to the neurosurgical floor. The hypothesis was that an appropriately selected group of patients undergoing craniotomy could be safely managed outside the ICU in the postoperative period. METHODS The work group developed and implemented a protocol for transfer of patients to the neurosurgical floor after 4-hour recovery in the PACU following elective craniotomy for supratentorial tumor. Criteria included hemodynamically stable adults without significant new postoperative neurological impairment. Data were prospectively collected including patient demographics, clinical characteristics, surgical details, postoperative complications, and events surrounding transfer to a higher level of care. RESULTS Of the first 200 consecutive patients admitted to the floor, 5 underwent escalation of care in the first 48 hours. Three of these escalations were for agitation, 1 for seizure, and 1 for neurological change. Ninety-eight percent of patients meeting criteria for transfer to the floor were managed without incident. No patient experienced a major complication or any permanent morbidity or mortality following this care pathway. CONCLUSIONS Care of patients undergoing uneventful elective supratentorial craniotomy for tumor on a neurosurgical floor after 4 hours of PACU monitoring appears to be a safe practice in this patient population. This tailored practice safely optimized hospital resources, is financially responsible, and is a strong tool for improving health care value.

Outcome after Hunt and Hess Grade V subarachnoid hemorrhage: a comparison of pre-coiling era (1980-1995) versus post-ISAT era (2005-2014)

OBJECTIVE Outcome analysis of comatose patients (Hunt and Hess Grade V) after subarachnoid hemorrhage (SAH) is still lacking. The aims of this study were to analyze the outcome of Hunt and Hess Grade V SAH and to compare outcomes in the current period with those of the pre-International Subarachnoid Aneurysm Trial (ISAT) era as well as with published data from trials of decompressive craniectomy (DC) for middle cerebral artery (MCA) infarction. METHODS The authors analyzed cases of Hunt and Hess Grade V SAH from 1980-1995 (referred to in this study as the earlier period) and 2005-2014 (current period) and compared the results for the 2 periods. The outcomes of 257 cases were analyzed and stratified on the basis of modified Rankin Scale (mRS) scores obtained 6 months after SAH. Outcomes were dichotomized as favorable (mRS score of 0-2) or unfavorable (mRS score of 3-6). Data and number needed to treat (NNT) were also compared with the results of decompressive craniectomy (DC) trials for middle cerebral artery (MCA) infarctions. RESULTS Early aneurysm treatment within 72 hours occurred significantly more often in the current period (in 67% of cases vs 22% in earlier period). In the earlier period, patients had a significantly higher 30-day mortality rate (83% vs 39% in the current period) and 6-month mortality rate (94% vs 49%), and no patient (0%) had a favorable outcome, compared with 23% overall in the current period (p < 0.01, OR 32), or 29.5% of patients whose aneurysms were treated (p < 0.01, OR 219). Cerebral infarctions occurred in up to 65% of the treated patients in the current period. Comparison with data from DC MCA trials showed that the NNTs were significantly lower in the current period with 2 for survival and 3 for mRS score of 0-3 (vs 3 and 7, respectively, for the DC MCA trials). CONCLUSIONS Early and aggressive treatment resulted in a significant improvement in survival rate (NNT = 2) and favorable outcome (NNT = 3 for mRS score of 0-3) for comatose patients with Hunt and Hess Grade V SAH compared with the earlier period. Independent predictors for favorable outcome were younger age and bilateral intact corneal reflexes. Despite a high rate of cerebral infarction (65%) in the current period, 29.5% of the patients who received treatment for their aneurysms during the current era (2005-2014) had a favorable outcome. However, careful individual decision making is essential in these cases.

Adult sports-related traumatic brain injury in United States trauma centers

OBJECTIVE Sports-related traumatic brain injury (TBI) is an important public health concern estimated to affect 300,000 to 3.8 million people annually in the United States. Although injuries to professional athletes dominate the media, this group represents only a small proportion of the overall population. Here, the authors characterize the demographics of sports-related TBI in adults from a community-based trauma population and identify predictors of prolonged hospitalization and increased morbidity and mortality rates. METHODS Utilizing the National Sample Program of the National Trauma Data Bank (NTDB), the authors retrospectively analyzed sports-related TBI data from adults (age ≥ 18 years) across 5 sporting categories-fall or interpersonal contact (FIC), roller sports, skiing/snowboarding, equestrian sports, and aquatic sports. Multivariable regression analysis was used to identify predictors of prolonged hospital length of stay (LOS), medical complications, inpatient mortality rates, and hospital discharge disposition. Statistical significance was assessed at α < 0.05, and the Bonferroni correction for multiple comparisons was applied for each outcome analysis. RESULTS From 2003 to 2012, in total, 4788 adult sports-related TBIs were documented in the NTDB, which represented 18,310 incidents nationally. Equestrian sports were the greatest contributors to sports-related TBI (45.2%). Mild TBI represented nearly 86% of injuries overall. Mean (± SEM) LOSs in the hospital or intensive care unit (ICU) were 4.25 ± 0.09 days and 1.60 ± 0.06 days, respectively. The mortality rate was 3.0% across all patients, but was statistically higher in TBI from roller sports (4.1%) and aquatic sports (7.7%). Age, hypotension on admission to the emergency department (ED), and the severity of head and extracranial injuries were statistically significant predictors of prolonged hospital and ICU LOSs, medical complications, failure to discharge to home, and death. Traumatic brain injury during aquatic sports was similarly associated with prolonged ICU and hospital LOSs, medical complications, and failure to be discharged to home. CONCLUSIONS Age, hypotension on ED admission, severity of head and extracranial injuries, and sports mechanism of injury are important prognostic variables in adult sports-related TBI. Increasing TBI awareness and helmet use-particularly in equestrian and roller sports-are critical elements for decreasing sports-related TBI events in adults.

Treatment of chronic subdural hematomas with subdural evacuating port system placement in the intensive care unit: evolution of practice and comparison with bur hole evacuation in the operating room

OBJECTIVE The aims of this study were to evaluate a multiyear experience with subdural evacuating port system (SEPS) placement for chronic subdural hematoma (cSDH) in the intensive care unit at a tertiary neurosurgical center and to compare SEPS placement with bur hole evacuation in the operating room. METHODS All cases of cSDH evacuation were captured over a 7-year period at a tertiary neurosurgical center within an integrated health care delivery system. The authors compared the performance characteristics of SEPS and bur hole placement with respect to recurrence rates, change in recurrence rates over time, complications, length of stay, discharge disposition, and mortality rates. RESULTS A total of 371 SEPS cases and 659 bur hole cases were performed (n = 1030). The use of bedside SEPS placement for cSDH treatment increased over the 7-year period, from 14% to 80% of cases. Reoperation within 6 months was higher for the SEPS (15.6%) than for bur hole drainage (9.1%) across the full 7-year period (p = 0.002). This observed overall difference was due to a higher rate of reoperation during the same hospitalization (7.0% for SEPS vs 3.2% for bur hole; p = 0.008). Over time, as the SEPS procedure became more common and modifications of the SEPS technique were introduced, the rate of in-hospital reoperation after SEPS decreased to 3.3% (p = 0.02 for trend), and the difference between SEPS and bur hole recurrence was no longer significant (p = 0.70). Complications were uncommon and were similar between the groups. CONCLUSIONS Overall performance characteristics of bedside SEPS and bur hole drainage in the operating room were similar. Modifications to the SEPS technique over time were associated with a reduced reoperation rate.

Beneficial impact of high-field intraoperative magnetic resonance imaging on the efficacy of pediatric low-grade glioma surgery

OBJECTIVE

Intraoperative MRI (iMRI) is assumed to safely improve the extent of resection (EOR) in patients with gliomas. This study focuses on advantages of this imaging technology in elective low-grade glioma (LGG) surgery in pediatric patients.

METHODS

The surgical results of conventional and 1.5-T iMRI-guided elective LGG surgery in pediatric patients were retrospectively compared. Tumor volumes, general clinical data, EOR according to reference radiology assessment, and progression-free survival (PFS) were analyzed.

RESULTS

Sixty-five patients were included in the study, of whom 34 had undergone conventional surgery before the iMRI unit opened (pre-iMRI period) and 31 had undergone surgery with iMRI guidance (iMRI period). Perioperative data were comparable between the 2 cohorts, apart from larger preoperative tumor volumes in the pre-iMRI period, a difference without statistical significance, and (as expected) significantly longer surgeries in the iMRI group. According to 3-month postoperative MRI studies, an intended complete resection (CR) was achieved in 41% (12 of 29) of the patients in the pre-iMRI period and in 71% (17 of 24) of those in the iMRI period (p = 0.05). Of those cases in which the surgeon was postoperatively convinced that he had successfully achieved CR, this proved to be true in only 50% of cases in the pre-iMRI period but in 81% of cases in the iMRI period (p = 0.055). Residual tumor volumes on 3-month postoperative MRI were significantly smaller in the iMRI cohort (p < 0.03). By continuing the resection of residual tumor after the intraoperative scan (when the surgeon assumed that he had achieved CR), the rate of CR was increased from 30% at the time of the scan to 85% at the 3-month postoperative MRI. The mean follow-up for the entire study cohort was 36.9 months (3-79 months). Progression-free survival after surgery was noticeably better for the entire iMRI cohort and in iMRI patients with postoperatively assumed CR, but did not quite reach statistical significance. Moreover, PFS was highly significantly better in patients with CRs than in those with incomplete resections (p < 0.001).

CONCLUSIONS

Significantly better surgical results (CR) and PFS were achieved after using iMRI in patients in whom total resections were intended. Therefore, the use of high-field iMRI is strongly recommended for electively planned LGG resections in pediatric patients.

Direct heart shunt placement for CSF diversion: technical note

The authors report a complex case of an 18-year-old male with a history of hydrocephalus secondary to intraventricular hemorrhage of prematurity, with more than 30 previous shunt revisions, who presented to the authors' institution with shunt malfunction. After exhausting his peritoneal cavity and pleural space as possible distal sites of shunt placement, he underwent a direct heart shunt placement when it was discovered he had thrombosis of his subclavian vein precluding a standard wire-guided atrial cannulation. His course was complicated by postoperative distal catheter migration and repeat surgery for reimplantation of the shunt directly into the atrium. At the 16-month follow-up visit, the patient showed no symptoms of shunt malfunction or pericardial effusion. Imaging studies demonstrated a functioning shunt system. This is the second reported successful ventricle to direct heart shunt placement in an adult. The authors report on the technical aspects of the case and review the relevant literature.

Interhospital transfer of pediatric neurosurgical patients

OBJECTIVE The purpose of this study was to describe patterns of transfer, resource utilization, and clinical outcomes associated with the interhospital transfer of pediatric neurosurgical patients. METHODS All consecutive, prospectively collected requests for interhospital patient transfer to the pediatric neurosurgical service at Texas Children's Hospital were retrospectively analyzed from October 2013 to September 2014. Demographic patient information, resource utilization, and outcomes were recorded and compared across predefined strata (low [< 5%], moderate [5%-30%], and high [> 30%]) of predicted probability of mortality using the Pediatric Risk of Mortality score. RESULTS Requests for pediatric neurosurgical care comprised 400 (3.7%) of a total of 10,833 calls. Of 400 transfer admissions, 96.5%, 2.8%, and 0.8% were in the low, moderate, and high mortality risk groups, respectively. The median age was 54 months, and 45% were female. The median transit time was 125 minutes. The majority of transfers were after-hours (69.8%); nearly a third occurred during the weekend (32.3%). The median intensive care unit stay for 103 patients was 3 days (range 1-269 days). Median length of hospital stay was 2 days (range 1-269 days). Ninety patients (22.5%) were discharged from the emergency room after transfer. Seventy-seven patients (19.3%) required neurosurgical intervention after transfer, with the majority requiring a cranial procedure (66.2%); 87.3% of patients were discharged home. CONCLUSIONS This study highlights patient characteristics, resource utilization, and outcomes among pediatric neurosurgical patients. Opportunities for quality improvement were identified in diagnosing and managing isolated skull fractures and neck pain after trauma.

Variation in seizure prophylaxis in severe pediatric traumatic brain injury

OBJECTIVE Posttraumatic seizure is a major complication following traumatic brain injury (TBI). The aim of this study was to determine the variation in seizure prophylaxis in select pediatric trauma centers. The authors hypothesized that there would be wide variation in seizure prophylaxis selection and use, within and between pediatric trauma centers. METHODS In this retrospective multicenter cohort study including 5 regional pediatric trauma centers affiliated with academic medical centers, the authors examined data from 236 children (age < 18 years) with severe TBI (admission Glasgow Coma Scale score ≤ 8, ICD-9 diagnosis codes of 800.0-801.9, 803.0-804.9, 850.0-854.1, 959.01, 950.1-950.3, 995.55, maximum head Abbreviated Injury Scale score ≥ 3) who received tracheal intubation for ≥ 48 hours in the ICU between 2007 and 2011. RESULTS Of 236 patients, 187 (79%) received seizure prophylaxis. In 2 of the 5 centers, 100% of the patients received seizure prophylaxis medication. Use of seizure prophylaxis was associated with younger patient age (p < 0.001), inflicted TBI (p < 0.001), subdural hematoma (p = 0.02), cerebral infarction (p < 0.001), and use of electroencephalography (p = 0.023), but not higher Injury Severity Score. In 63% cases in which seizure prophylaxis was used, the patients were given the first medication within 24 hours of injury, and 50% of the patients received the first dose in the prehospital or emergency department setting. Initial seizure prophylaxis was most commonly with fosphenytoin (47%), followed by phenytoin (40%). CONCLUSIONS While fosphenytoin was the most commonly used medication for seizure prophylaxis, there was large variation within and between trauma centers with respect to timing and choice of seizure prophylaxis in severe pediatric TBI. The heterogeneity in seizure prophylaxis use may explain the previously observed lack of relationship between seizure prophylaxis and outcomes.

Rapid de novo aneurysm formation after clipping of a ruptured middle cerebral artery aneurysm in an infant with an MYH11 mutation

The authors report the case of a previously healthy 6-month-old girl who presented with right arm and leg stiffening consistent with seizure activity. An initial CT scan of the head demonstrated acute subarachnoid hemorrhage in the basal cisterns extending into the left sylvian fissure. Computed tomography angiography demonstrated a 7 × 6 × 5-mm saccular aneurysm of the inferior M₂ division of the left middle cerebral artery. The patient underwent left craniotomy and microsurgical clip ligation with wrapping of the aneurysm neck because the vessel appeared circumferentially dysplastic in the region of the aneurysm. Postoperative angiography demonstrated a small remnant, sluggish distal flow, but no significant cerebral vasospasm. Fifty-five days after the initial aneurysm rupture, the patient presented again with an acute intraparenchymal hemorrhage of the left anterior temporal lobe. Angiogram revealed a circumferentially dysplastic superior division of the M₂ branch, with a new 5 × 4-mm saccular aneurysm distinct from the first, with 2 smaller aneurysms distal to the new ruptured aneurysm. Endovascular parent vessel occlusion with Onyx was performed. Genetic testing revealed a mutation of the MYH11. To the authors' knowledge, this is the first report of rapid de novo aneurysm formation in an infant with an MYH11 mutation. The authors review the patient's clinical presentation and management and comprehensively review the literature on this topic.

Outcomes of endoscopic suturectomy with postoperative helmet therapy in bilateral coronal craniosynostosis

OBJECTIVE Historically, bilateral frontoorbital advancement (FOA) has been the keystone for treatment of turribrachycephaly caused by bilateral coronal synostosis. Early endoscopic suturectomy has become a popular technique for treatment of single-suture synostosis, with acceptable results and minimal perioperative morbidity. Boston Children's Hospital has adopted this method of treating early-presenting cases of bilateral coronal synostosis. METHODS A retrospective review of patients with bilateral coronal craniosynostosis who were treated with endoscopic suturectomy between 2005 and 2012 was completed. Patients were operated on between 1 and 4 months of age. Hospital records were reviewed for perioperative morbidity, length of stay, head circumference and cephalic indices, and the need for further surgery. RESULTS Eighteen patients were identified, 8 males and 10 females, with a mean age at surgery of 2.6 months (range 1-4 months). Nine patients had syndromic craniosynostosis. The mean duration of surgery was 73.3 minutes (range 50-93 minutes). The mean blood loss was 40 ml (range 20-100 ml), and 2 patients needed a blood transfusion. The mean duration of hospital stay was 1.2 days (range 1-2 days). There was 1 major complication in the form of a CSF leak. The mean follow-up was 37 months (range 6-102 months). Eleven percent of nonsyndromic patients required a subsequent FOA; 55.6% of syndromic patients underwent FOA. The head circumference percentiles and cephalic indices improved significantly. CONCLUSIONS Early endoscopic suturectomy successfully treats the majority of patients with bilateral coronal synostosis, and affords a short procedure time, a brief hospital stay, and an expedited recovery. Close follow-up is needed to detect patients who will require a secondary FOA due to progressive suture fusion or resynostosis of the released coronal sutures.

Lateral interbody fusion combined with open posterior surgery for adult spinal deformity

OBJECTIVE Lateral interbody fusion (LIF) with percutaneous screw fixation can treat adult spinal deformity (ASD) in the coronal plane, but sagittal correction is limited. The authors combined LIF with open posterior (OP) surgery using facet osteotomies and a rod-cantilever technique to enhance lumbar lordosis (LL). It is unclear how this hybrid strategy compares to OP surgery alone. The goal of this study was to evaluate the combination of LIF and OP surgery (LIF+OP) for ASD. METHODS All thoracolumbar ASD cases from 2009 to 2014 were reviewed. Patients with < 6 months follow-up, prior fusion, severe sagittal imbalance (sagittal vertical axis > 200 mm or pelvic incidence-LL > 40°), and those undergoing anterior lumbar interbody fusion were excluded. Deformity correction, complications, and outcomes were compared between LIF+OP and OP-only surgery patients. RESULTS LIF+OP (n = 32) and OP-only patients (n = 60) had similar baseline features and posterior fusion levels. On average, 3.8 LIFs were performed. Patients who underwent LIF+OP had less blood loss (1129 vs 1833 ml, p = 0.016) and lower durotomy rates (0% vs 23%, p = 0.002). Patients in the LIF+OP group required less ICU care (0.7 vs 2.8 days, p < 0.001) and inpatient rehabilitation (63% vs 87%, p = 0.015). The incidence of new leg pain, numbness, or weakness was similar between groups (28% vs 22%, p = 0.609). All leg symptoms resolved within 6 months, except in 1 OP-only patient. Follow-up duration was similar (28 vs 25 months, p = 0.462). LIF+OP patients had significantly less pseudarthrosis (6% vs 27%, p = 0.026) and greater improvement in visual analog scale back pain (mean decrease 4.0 vs 1.9, p = 0.046) and Oswestry Disability Index (mean decrease 21 vs 12, p = 0.035) scores. Lumbar coronal correction was greater with LIF+OP surgery (mean [± SD] 22° ± 13° vs 14° ± 13°, p = 0.010). LL restoration was 22° ± 13°, intermediately between OP-only with facet osteotomies (11° ± 7°, p < 0.001) and pedicle subtraction osteotomy (29° ± 10°, p = 0.045). CONCLUSIONS LIF+OP is an effective strategy for ASD of moderate severity. Compared with the authors' OP-only operations, LIF+OP was associated with faster recovery, fewer complications, and greater relief of pain and disability.

External validation of the Practical Risk Chart for the prediction of delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage

OBJECTIVE Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) occurs in approximately 30% of patients. The Practical Risk Chart was developed to predict DCI based on admission characteristics; the authors seek to externally validate and critically appraise this prediction tool. METHODS A prospective cohort of aSAH patients was used to externally validate the previously published Practical Risk Chart. The model consists of 4 variables: clinical condition on admission, amount of cisternal and intraventricular blood on CT, and age. External validity was assessed using logistic regression. Model discrimination was evaluated using the area under the receiver operating characteristic curve (AUC). RESULTS In a cohort of 125 patients with aSAH, the Practical Risk Chart adequately predicted DCI, with an AUC of 0.66 (95% CI 0.55-0.77). Clinical grade on admission and amount of intracranial blood on CT were the strongest predictors of DCI and clinical vasospasm. The best-fit model used a combination of the Hunt and Hess grade and the modified Fisher scale to yield an AUC of 0.76 (95% CI 0.675-0.85) and 0.70 (95% CI 0.602-0.8) for the prediction of DCI and clinical vasospasm, respectively. CONCLUSIONS The Practical Risk Chart adequately predicts the risk of DCI following aSAH. However, the best-fit model represents a simpler stratification scheme, using only the Hunt and Hess grade and the modified Fisher scale, and produces a comparable AUC.

Questioning the need for ICU level of care in pediatric patients following elective uncomplicated craniotomy for brain tumors

OBJECTIVE The object of this study is to address what factors may necessitate the need for intensive care monitoring after elective uncomplicated craniotomy in pediatric patients who are initially managed in a non-intensive care unit setting postoperatively. METHODS A retrospective chart review was undertaken for all patients who underwent elective craniotomy for brain tumor between April of 2007 and April of 2012 and who were directly admitted to the floor postoperatively. Factors such as age, tumor type, craniotomy location, neurological comorbidities, reason for transfer to intensive care unit (ICU) level of care (if applicable), time between admittance to floor and transfer to ICU level of care, and reason for transfer to ICU level of care were assessed. RESULTS Adjusted logistic regression found 2 significant positive predictors of postoperative transfer to the ICU after initial admission to the floor: primitive neuroectodermal tumor pathology (OR 44.10, 95% CI 1.24-1572.16, p = 0.04), and repeat craniotomy during the same hospitalization (OR 13.97, 95% CI 1.21-160.66, p = 0.03). Conversely, 1 negative factor was found: low-grade glioma pathology (OR 0.05, 95% CI 0.00-0.87, p = 0.04). CONCLUSIONS Select pediatric patients may not require ICU level of care after elective uncomplicated pediatric craniotomy. Additional studies are needed to adequately address which patients would benefit from initial ICU admittance following elective craniotomies for brain tumors.

Association of increased morbidity with the occurrence of hyperglycemia in the immediate postoperative period after elective pediatric neurosurgery

OBJECTIVE The acute elevation of blood glucose in perioperative pediatric patients subjected to cardiac surgery and in victims of head trauma is associated with higher rates of postoperative complications. Data on the occurrence of hyperglycemia and its association with unfavorable outcomes among patients who have undergone elective neurosurgery are scarce in the literature. This study aimed to determine whether the occurrence of hyperglycemia during the perioperative period of elective neurosurgery for the resection of tumors of the CNS in children is associated with increased morbidity. METHODS This retrospective cohort analysis included 105 children up to 12 years of age who underwent elective neurosurgery for resection of supratentorial and infratentorial CNS tumors between January 2005 and December 2010 at the São Rafael Hospital, a tertiary care medical center in Salvador, Brazil. Demographic data and intraoperative and postoperative information were collected from the medical records. Differences in blood glucose levels during the perioperative period were evaluated with nonparametric tests. RESULTS The patients who developed postoperative complications exhibited higher blood glucose levels on admission to the intensive care unit (ICU) (162.0 ± 35.8 mg/dl vs 146.3 ± 43.3 mg/dl; p = 0.016) and peak blood glucose levels on postoperative Day 1 (171.9 ± 30.2 mg/dl vs 156.1 ± 43.2 mg/dl; p = 0.008). Multivariate analysis showed that peak blood glucose levels on postoperative Day 1 were independently associated with a higher odds ratio for postoperative complication (OR 1.05). The occurrence of hyperglycemia (>150 mg/dl) upon admission to the ICU was associated with longer ICU (p = 0.003) and hospital (p = 0.001) stays. CONCLUSIONS The occurrence of hyperglycemia during the postoperative period after elective pediatric neurosurgery for the resection of CNS tumors was associated with longer hospital and ICU stays. Postoperative complications were associated with higher blood glucose levels upon admission to the ICU and higher peak blood glucose on the first postoperative day.

Assessing the cost of contemporary pituitary care

OBJECT

Knowledge of the costs incurred through the delivery of neurosurgical care has been lagging, making it challenging to design impactful cost-containment initiatives. In this report, the authors describe a detailed cost analysis for pituitary surgery episodes of care and demonstrate the importance of such analyses in helping to identify high-impact cost activities and drive value-based care.

METHODS

This was a retrospective study of consecutively treated patients undergoing an endoscopic endonasal procedure for the resection of a pituitary adenoma after implementation and maturation of quality-improvement initiatives and the implementation of cost-containment initiatives.

RESULTS

The cost data pertaining to 27 patients were reviewed. The 2 most expensive cost activities during the index hospitalization were the total operating room (OR) and total bed-assignment costs. Together, these activities represented more than 60% of the cost of hospitalization. Although value-improvement initiatives contributed to the reduction of variation in the total cost of hospitalization, specific cost activities remained relatively variable, namely the following: 1) OR charged supplies, 2) postoperative imaging, and 3) use of intraoperative neuromonitoring. These activities, however, each contributed to less than 10% of the cost of hospitalization. Bed assignment was the fourth most variable cost activity. Cost related to readmission/reoperation represented less than 5% of the total cost of the surgical episode of care.

CONCLUSIONS

After completing a detailed assessment of costs incurred throughout the management of patients undergoing pituitary surgery, high-yield opportunities for cost containment should be identified among the most expensive activities and/or those with the highest variation. Strategies for safely reducing the use of the targeted resources, and related costs incurred, should be developed by the multidisciplinary team providing care for this patient population.

Impact of Glasgow Coma Scale score and pupil parameters on mortality rate and outcome in pediatric and adult severe traumatic brain injury: a retrospective, multicenter cohort study

OBJECTIVE Prediction of death and functional outcome is essential for determining treatment strategies and allocation of resources for patients with severe traumatic brain injury (TBI). The aim of this study was to evaluate, by using pupillary status and Glasgow Coma Scale (GCS) score, if patients with severe TBI who are ≤ 15 years old have a lower mortality rate and better outcome than adults with severe TBI. METHODS A retrospective cohort analysis of patients suffering from severe TBI registered in the Trauma Registry of the German Society for Trauma Surgery between 2002 and 2013 was undertaken. Severe TBI was defined as an Abbreviated Injury Scale of the head (AIS_head) score of ≥ 3 and an AIS score for any other part of the body that does not exceed the AIS_head score. Only patients with complete data (GCS score, age, and pupil parameters) were included. To assess the impact of GCS score and pupil parameters, the authors also used the recently introduced Eppendorf-Cologne Scale and divided the study population into 2 groups: children (0-15 years old) and adults (16-55 years old). Each patient's outcome was measured at discharge from the trauma center by using the Glasgow Outcome Scale. RESULTS A total of 9959 patients fulfilled the study inclusion criteria; 888 (8.9%) patients were ≤ 15 years old (median 10 years). The overall mortality rate and the mortality rate for patients with a GCS of 3 and bilaterally fixed and dilated pupils (19.9% and 16.3%, respectively) were higher for the adults than for the pediatric patients (85% vs 80.9%, respectively), although cardiopulmonary resuscitation rates were significantly higher in the pediatric patients (5.6% vs 8.8%, respectively). In the multivariate logistic regression analysis, no motor response (OR 3.490, 95% CI 2.240-5.435) and fixed pupils (OR 4.197, 95% CI 3.271-5.386) and bilateral dilated pupils (OR 2.848, 95% CI 2.282-3.556) were associated with a higher mortality rate. Patients ≤ 15 years old had a statistically lower mortality rate (OR 0.536, 95% CI 0.421-0.814; p = 0.001). The rate of good functional outcomes (Glasgow Outcome Scale Score 4 or 5) was higher in pediatric patients than in the adults (72.2% vs 63.1%, respectively). CONCLUSIONS This study found that severe TBI in children aged ≤ 15 years is associated with a lower mortality rate and superior functional outcome than in adults. Also, children admitted with a missing motor response or fixed and bilaterally dilated pupils also have a lower mortality rate and higher functional outcome than adults with the same initial presentation. Therefore, patients suffering from severe TBI, especially pediatric patients, could benefit from early and aggressive treatment.