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Maldaner N, Zeitlberger AM, Sosnova M, Goldberg J, Fung C, Bervini D, May A, Bijlenga P, Schaller K, Roethlisberger M, Rychen J, Zumofen DW, D'Alonzo D, Marbacher S, Fandino J, Daniel RT, Burkhardt JK, Chiappini A, Robert T, Schatlo B, Schmid J, Maduri R, Staartjes VE, Seule MA, Weyerbrock A, Serra C, Stienen MN, Bozinov O, Regli L. Development of a Complication- and Treatment-Aware Prediction Model for Favorable Functional Outcome in Aneurysmal Subarachnoid Hemorrhage Based on Machine Learning. Neurosurgery 2021; 88:E150-E157. [PMID: 33017031 DOI: 10.1093/neuros/nyaa401] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Accepted: 07/12/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Current prognostic tools in aneurysmal subarachnoid hemorrhage (aSAH) are constrained by being primarily based on patient and disease characteristics on admission. OBJECTIVE To develop and validate a complication- and treatment-aware outcome prediction tool in aSAH. METHODS This cohort study included data from an ongoing prospective nationwide multicenter registry on all aSAH patients in Switzerland (Swiss SOS [Swiss Study on aSAH]; 2009-2015). We trained supervised machine learning algorithms to predict a binary outcome at discharge (modified Rankin scale [mRS] ≤ 3: favorable; mRS 4-6: unfavorable). Clinical and radiological variables on admission ("Early" Model) as well as additional variables regarding secondary complications and disease management ("Late" Model) were used. Performance of both models was assessed by classification performance metrics on an out-of-sample test dataset. RESULTS Favorable functional outcome at discharge was observed in 1156 (62.0%) of 1866 patients. Both models scored a high accuracy of 75% to 76% on the test set. The "Late" outcome model outperformed the "Early" model with an area under the receiver operator characteristics curve (AUC) of 0.85 vs 0.79, corresponding to a specificity of 0.81 vs 0.70 and a sensitivity of 0.71 vs 0.79, respectively. CONCLUSION Both machine learning models show good discrimination and calibration confirmed on application to an internal test dataset of patients with a wide range of disease severity treated in different institutions within a nationwide registry. Our study indicates that the inclusion of variables reflecting the clinical course of the patient may lead to outcome predictions with superior predictive power compared to a model based on admission data only.
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Affiliation(s)
- Nicolai Maldaner
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Anna M Zeitlberger
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Marketa Sosnova
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Johannes Goldberg
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Christian Fung
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland.,Department of Neurosurgery, Medical Center - University of Freiburg, Germany
| | - David Bervini
- Department of Neurosurgery, University Hospital Bern, Bern, Switzerland
| | - Adrien May
- Department of Neurosurgery, University Clinic Geneva, Geneva, Switzerland
| | - Philippe Bijlenga
- Department of Neurosurgery, University Clinic Geneva, Geneva, Switzerland
| | - Karl Schaller
- Department of Neurosurgery, University Clinic Geneva, Geneva, Switzerland
| | | | - Jonathan Rychen
- Department of Neurosurgery, Basel University Hospital, Basel, Switzerland
| | - Daniel W Zumofen
- Department of Neurosurgery, Neurology, and Radiology, Maimonides Medical Center, SUNY Downstate University, Brooklyn, NY, USA
| | - Donato D'Alonzo
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Serge Marbacher
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Javier Fandino
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Alessio Chiappini
- Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland
| | - Thomas Robert
- Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland
| | - Bawarjan Schatlo
- Department of Neurosurgery, University Hospital Göttingen, Germany
| | | | - Rodolfo Maduri
- Neurosurgery, Clinique de Genolier, Swiss Medical Network, Genolier, Switzerland
| | - Victor E Staartjes
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Martin A Seule
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Astrid Weyerbrock
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Carlo Serra
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Martin Nikolaus Stienen
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
| | - Oliver Bozinov
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland.,Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Luca Regli
- Department of Neurosurgery, University Hospital Zurich & Clinical Neuroscience Center, University of Zurich, Zurich, Switzerland
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Broekema AEH, Groen RJM, Simões de Souza NF, Smidt N, Reneman MF, Soer R, Kuijlen JMA. Surgical Interventions for Cervical Radiculopathy without Myelopathy: A Systematic Review and Meta-Analysis. J Bone Joint Surg Am 2020; 102:2182-2196. [PMID: 32842045 DOI: 10.2106/jbjs.20.00324] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The effectiveness of surgical interventions for cervical degenerative disorders has been investigated in multiple systematic reviews. Differences in study population (e.g., patients with myelopathy and/or radiculopathy) were often neglected. Therefore, the objective of this study was to investigate the effectiveness of surgical interventions for patients with symptoms of cervical radiculopathy without myelopathy by conducting a systematic review and meta-analysis based on randomized controlled trials (RCTs). METHODS A comprehensive systematic search was conducted in MEDLINE, Embase, and CENTRAL (Cochrane Central Register of Controlled Trials) to identify RCTs that investigated the effectiveness of surgical interventions using an anterior or posterior approach compared with other interventions for patients with pure cervical radiculopathy. Outcomes were success rates (Odom criteria, similar rating scales, or percentage of patients who improved), complication and reoperation rates, work status, disability (Neck Disability Index), and pain (arm and neck). The Cochrane risk-of-bias tool was used to assess the likelihood of the risk of bias. A random-effects model was used. Heterogeneity among study results (I2 ≥ 50% or p < 0.05) was explored by conducting subgroup analyses. Funnel plots were used to assess the likelihood of publication bias. RESULTS A total of 21 RCTs were included, comprising 1,567 patients. For all outcomes, among all surgical techniques, only 1 pooled estimate showed a significant effect on success rate, which was in favor of anterior cervical discectomy with fusion compared with anterior cervical discectomy without an intervertebral spacer (p = 0.02; risk ratio [RR] = 0.87; 95% confidence interval [CI] = 0.77 to 0.98). Complication rates were higher when autologous bone graft from the iliac crest was used as an intervertebral spacer (p < 0.01; RR = 3.40; 95% CI = 1.56 to 7.43), related to donor-site morbidity. CONCLUSIONS This meta-analysis demonstrated consistent results regarding clinical outcome for pure cervical radiculopathy among all studied interventions. Complication and reoperation rates were also similar, with the exception of higher complication rates in patients in whom autologous bone grafts were used. On the basis of clinical outcome and safety, there is no superior surgical intervention for pure cervical radiculopathy. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Anne E H Broekema
- Departments of Neurosurgery (A.E.H.B., R.J.M.G., N.F.S.d.S., and J.M.A.K.), Epidemiology (N.S.), and Rehabilitation (M.F.R.), and Pain Center (R.S.), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Rob J M Groen
- Departments of Neurosurgery (A.E.H.B., R.J.M.G., N.F.S.d.S., and J.M.A.K.), Epidemiology (N.S.), and Rehabilitation (M.F.R.), and Pain Center (R.S.), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Nádia F Simões de Souza
- Departments of Neurosurgery (A.E.H.B., R.J.M.G., N.F.S.d.S., and J.M.A.K.), Epidemiology (N.S.), and Rehabilitation (M.F.R.), and Pain Center (R.S.), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Nynke Smidt
- Departments of Neurosurgery (A.E.H.B., R.J.M.G., N.F.S.d.S., and J.M.A.K.), Epidemiology (N.S.), and Rehabilitation (M.F.R.), and Pain Center (R.S.), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Michiel F Reneman
- Departments of Neurosurgery (A.E.H.B., R.J.M.G., N.F.S.d.S., and J.M.A.K.), Epidemiology (N.S.), and Rehabilitation (M.F.R.), and Pain Center (R.S.), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Remko Soer
- Departments of Neurosurgery (A.E.H.B., R.J.M.G., N.F.S.d.S., and J.M.A.K.), Epidemiology (N.S.), and Rehabilitation (M.F.R.), and Pain Center (R.S.), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands.,Saxion University of Applied Sciences, Enschede, the Netherlands
| | - Jos M A Kuijlen
- Departments of Neurosurgery (A.E.H.B., R.J.M.G., N.F.S.d.S., and J.M.A.K.), Epidemiology (N.S.), and Rehabilitation (M.F.R.), and Pain Center (R.S.), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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Maldaner N, Steinsiepe VK, Goldberg J, Fung C, Bervini D, May A, Bijlenga P, Schaller K, Roethlisberger M, Zumofen DW, D'Alonzo D, Marbacher S, Fandino J, Maduri R, Daniel RT, Burkhardt JK, Chiappini A, Robert T, Schatlo B, Seule MA, Weyerbrock A, Regli L, Stienen MN. Patterns of care for ruptured aneurysms of the middle cerebral artery: analysis of a Swiss national database (Swiss SOS). J Neurosurg 2020; 133:1811-1820. [PMID: 31731273 DOI: 10.3171/2019.9.jns192055] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/11/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to determine patterns of care and outcomes in ruptured intracranial aneurysms (IAs) of the middle cerebral artery (MCA) in a contemporary national cohort. METHODS The authors conducted a retrospective analysis of prospective data from a nationwide multicenter registry of all aneurysmal subarachnoid hemorrhage (aSAH) cases admitted to a tertiary care neurosurgical department in Switzerland in the years 2009-2015 (Swiss Study on Aneurysmal Subarachnoid Hemorrhage [Swiss SOS]). Patterns of care and outcomes at discharge and the 1-year follow-up in MCA aneurysm (MCAA) patients were analyzed and compared with those in a control group of patients with IAs in locations other than the MCA (non-MCAA patients). Independent predictors of a favorable outcome (modified Rankin Scale score ≤ 3) were identified, and their effect size was determined. RESULTS Among 1866 consecutive aSAH patients, 413 (22.1%) harbored an MCAA. These MCAA patients presented with higher World Federation of Neurosurgical Societies grades (p = 0.007), showed a higher rate of concomitant intracerebral hemorrhage (ICH; 41.9% vs 16.7%, p < 0.001), and experienced delayed cerebral ischemia (DCI) more frequently (38.9% vs 29.4%, p = 0.001) than non-MCAA patients. After adjustment for confounders, patients with MCAA were as likely as non-MCAA patients to experience DCI (aOR 1.04, 95% CI 0.74-1.45, p = 0.830). Surgical treatment was the dominant treatment modality in MCAA patients and at a significantly higher rate than in non-MCAA patients (81.7% vs 36.7%, p < 0.001). An MCAA location was a strong independent predictor of surgical treatment (aOR 8.49, 95% CI 5.89-12.25, p < 0.001), despite statistical adjustment for variables traditionally associated with surgical treatment, such as (space-occupying) ICH (aOR 1.73, 95% CI 1.23-2.45, p = 0.002). Even though MCAA patients were less likely to die during the acute hospitalization (aOR 0.52, 0.30-0.91, p = 0.022), their rate of a favorable outcome was lower at discharge than that in non-MCAA patients (55.7% vs 63.7%, p = 0.003). At the 1-year follow-up, 68.5% and 69.6% of MCAA and non-MCAA patients, respectively, had a favorable outcome (p = 0.676). CONCLUSIONS Microsurgical occlusion remains the predominant treatment choice for about 80% of ruptured MCAAs in a European industrialized country. Although patients with MCAAs presented with worse admission grades and greater rates of concomitant ICH, in-hospital mortality was lower and long-term disability was comparable to those in patients with non-MCAA.
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Affiliation(s)
| | | | | | - Christian Fung
- 2Department of Neurosurgery, University Hospital Bern
- 13Department of Neurosurgery, University Hospital Freiburg, University of Freiburg, Germany
| | - David Bervini
- 2Department of Neurosurgery, University Hospital Bern
| | - Adrien May
- 3Department of Neurosurgery, University Clinic Geneva
| | | | - Karl Schaller
- 3Department of Neurosurgery, University Clinic Geneva
| | | | | | - Donato D'Alonzo
- 5Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, Basel
- 6Department of Neurosurgery, Kantonsspital Aarau
| | - Serge Marbacher
- 5Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, Basel
- 6Department of Neurosurgery, Kantonsspital Aarau
| | - Javier Fandino
- 5Section for Diagnostic and Interventional Neuroradiology, Department of Radiology, Basel University Hospital, Basel
- 6Department of Neurosurgery, Kantonsspital Aarau
| | - Rodolfo Maduri
- 7Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Roy Thomas Daniel
- 7Department of Clinical Neurosciences, Service of Neurosurgery, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | | | - Alessio Chiappini
- 8Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Thomas Robert
- 9Department of Neurosurgery, Ospedale Regionale di Lugano, Switzerland
| | - Bawarjan Schatlo
- 10Department of Neurosurgery, University Hospital Göttingen, Germany
| | | | | | - Luca Regli
- 11Department of Neurosurgery, University Hospital Zurich
- 12Clinical Neuroscience Center, University of Zurich, Switzerland; and
| | - Martin Nikolaus Stienen
- 11Department of Neurosurgery, University Hospital Zurich
- 12Clinical Neuroscience Center, University of Zurich, Switzerland; and
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