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Dominguez JF, Sursal T, Kazim SF, Ng C, Vazquez S, DAS A, Naftchi A, Spirollari E, Elkun Y, Gatzoflias S, Ampie L, Feldstein E, Uddin A, Damodara N, Hanft SJ, Gandhi CD, Bowers CA. Frailty is a risk factor for intracranial abscess and is associated with longer length of stay: a retrospective single institution case-control study. J Neurosurg Sci 2024; 68:422-427. [PMID: 35416458 DOI: 10.23736/s0390-5616.22.05720-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Intracranial abscess (IA) causes significant morbidity and mortality. The impact of baseline frailty status on post-operative outcomes of IA patients remains largely unknown. The present study evaluated if frailty status can be used to prognosticate outcomes in IA patients. METHODS We retrospectively reviewed all IA patients undergoing craniotomy at our institution from 2011 to 2018 (N.=18). These IA patients were age and gender matched with patients undergoing craniotomy for intracranial tumor (IT), an internal control for comparison. Demographic and clinical data were collected to measure frailty, using the modified frailty index-11 (mFI-11) and pre-operative American Society of Anesthesiologists Physical Status Classification System (ASA). Post-operative complications were measured by the Clavien-Dindo Grade (CDG). RESULTS No significant difference in mFI-11 or ASA score was observed between the IA and IT groups (P=0.058 and P=0.131, respectively). IA patients had significantly higher CDG as compared with the control IT patients (P<0.001). There was a trend towards increasing LOS in the IA group as compared to the IT group (P=0.053). Increasing mFI and ASA were significant predictors of LOS by multiple linear regression in the IA group (P=0.006 and P=0.001, respectively), but not in the control IT group. Neither mFI-11 nor ASA were found to be predictors for CDG in either group. Within this case-control group of patients, we found an increase for odds of having IA with increasing mFI (OR=1.838, 95% CI: 1.016-3.362, P=0.044). CONCLUSIONS Frail IA patients tend to have more severe postoperative complications. The mFI-11 seems to predict increased resource utilization in the form of LOS. This study provides the initial retrospective data of another neurosurgical pathology where frailty leads to significantly worse outcomes. We also found that mFI may serve as a potential risk factor for severe disease.
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Affiliation(s)
- Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA -
| | - Tolga Sursal
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Syed F Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | | | | | - Ankita DAS
- New York Medical College, Valhalla, NY, USA
| | | | | | | | | | - Leonel Ampie
- Department of Neurosurgery, University of Virginia-National Institute of Health, Bethesda, MD, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Anaz Uddin
- New York Medical College, Valhalla, NY, USA
| | - Nitesh Damodara
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Simon J Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
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2
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Subah G, Patel R, Nolan B, Fortunato M, Lui A, Uddin A, Li A, Spirollari E, Nuoaman H, Adnan YA, Thomas A, Brill S, Pak I, Ng C, Hecht L, Bauerschmidt A, Mayer S, Gandhi CD, Al-Mufti F. Acute kidney injury in subarachnoid hemorrhage: Exploring its clinical significance and prognostic implications. J Stroke Cerebrovasc Dis 2024; 33:107843. [PMID: 38964524 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 06/24/2024] [Accepted: 06/27/2024] [Indexed: 07/06/2024] Open
Abstract
OBJECTIVES Subarachnoid hemorrhage (SAH) from spontaneous aneurysm rupture is a debilitating condition with high morbidity and mortality. Patients with SAH remain understudied, particularly concerning the evaluation of incidence and consequences of subsequent acute kidney injury (AKI). In this study, we aim to explore the risk factors and outcomes of AKI in SAH patients. MATERIALS AND METHODS International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) and International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes were used to query the National Inpatient Sample (NIS) for patients with a diagnosis of SAH between 2010-2019. Subgroup analysis was stratified by AKI diagnosis during the same hospitalization. AKI and non-AKI groups were assessed for baseline clinical characteristics, interventions, complications, and outcomes. Descriptive statistics, multivariate regressions, and propensity score-matching were performed using IBM SPSS 28. RESULTS Of 76,553 patients diagnosed with nontraumatic SAH between 2010-2019, 10,634 (13.89 %) had a comorbid diagnosis of AKI. SAH patients with AKI were older (p < 0.01) and more often obese (p < 0.01) compared to the non-AKI group. A multivariate regression found the diagnosis of AKI to be independently correlated with poor functional outcome (p < 0.001), above average length of stay (p < 0.001), and in-hospital mortality (p < 0.001) when controlling for age, SAH severity, and other comorbidities. CONCLUSIONS This study showed significant association between AKI and adverse outcomes in SAH patients, and a correlation between AKI and heightened complication rates, poor functional outcome, extended hospital stays, and elevated mortality rates. Early detection of AKI in SAH patients is vital to improve their chances of recovery.
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Affiliation(s)
| | | | | | | | - Aiden Lui
- New York Medical College, Valhalla, NY, USA
| | - Anaz Uddin
- New York Medical College, Valhalla, NY, USA
| | - Austin Li
- New York Medical College, Valhalla, NY, USA
| | | | - Halla Nuoaman
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Yasir Ammar Adnan
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Anish Thomas
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA
| | - Stuart Brill
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA
| | - Isaac Pak
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA
| | - Christina Ng
- Department of Neurosurgery, The University of Vermont Medical Center, Burlington, VT, USA
| | - Lee Hecht
- Department of Neurology, Downstate Medical Center, Brooklyn, NY, USA
| | - Andrew Bauerschmidt
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA
| | - Stephan Mayer
- Department of Neurocritical Care, Westchester Medical Center, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA; Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA.
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3
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Becerril-Gaitan A, Nguyen T, Liu C, Mokua C, Gusdon AM, Brown RJ, Cochran J, Blackburn S, Chen PR, Dannenbaum M, Choi HA, Chen CJ. The Effect of Age on Cerebral Vasospasm and Delayed Cerebral Ischemia in Patients with Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2024; 187:e1017-e1024. [PMID: 38750887 DOI: 10.1016/j.wneu.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Accepted: 05/07/2024] [Indexed: 06/04/2024]
Abstract
BACKGROUND The association between patient age and cerebral arterial vasospasm (CVS) and delayed cerebral ischemia (DCI) risk following aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. This study aims to assess the role of age on aSAH-related complications. METHODS Single-center retrospective study comprising aSAH patients treated between January 2009 and March 2023. Age was analyzed as continuous and categorical variables (<60 yrs vs. ≥60 yrs and by decade). Outcomes of interest included radiographic CVS, DCI, cerebral infarction, in-hospital mortality, length-of-stay (LOS), ventriculoperitoneal shunt placement, and modified Rankin Scale (mRS) scores at discharge and 3-month follow-up. RESULTS Nine hundred and twenty-five aSAH patients were included. Most (n = 598; 64.6%) were <60 yrs old (46 ± 9.1 yrs). CVS likelihood was lower in the older cohort (aOR = 0.56 [0.38-0.82]). Patients ≥60 yrs had higher mortality rates (aOR = 2.24 [1.12-4.47]) and worse mRS scores at discharge (aOR = 2.66 [1.91-3.72]) and 3-month follow-up (aOR = 2.19 [1.44-3.32]). Advanced age did not have a significant effect on DCI or cerebral infarction risk. Higher in-hospital mortality was documented with increasing age (P < 0.001). A significant interaction between CVS and age for the outcome of DCI was documented, with a stronger positive effect on poor outcomes (i.e., higher odds of DCI) among patients aged <60 years compared to those aged ≥60. CONCLUSIONS There is an inverse relationship between patient age and CVS incidence following aSAH. Nonetheless, patients ≥60 yrs had comparable DCI rates, higher in-hospital mortality, and worse functional outcomes than their younger counterparts. Routine screening and reliance on radiographic CVS as primary marker for aSAH-related complications should be reconsidered, particularly in older patients.
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Affiliation(s)
- Andrea Becerril-Gaitan
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Tien Nguyen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Collin Liu
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Collins Mokua
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Aaron M Gusdon
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Robert J Brown
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Joseph Cochran
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Spiros Blackburn
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Peng Roc Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Mark Dannenbaum
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Huimahn A Choi
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA
| | - Ching-Jen Chen
- Department of Neurosurgery, The University of Texas Health Science Center at Houston, Houston, Texas, USA.
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Hamouda AM, Cwajna M, Elfil M, Derhab M, Desouki MT, Kobeissi H, Ghozy S, Kallmes DF. Impact of frailty on post-operative outcomes following subarachnoid hemorrhage: A systematic review and meta-analysis. Clin Neurol Neurosurg 2024; 244:108413. [PMID: 38954868 DOI: 10.1016/j.clineuro.2024.108413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 06/17/2024] [Accepted: 06/28/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is associated with high rates of mortality and morbidity, particularly among elderly patients. The presence of frailty may impact survival rates in patients with SAH. In this study, we aim to investigate the impact of frailty on the clinical outcomes in SAH patients. METHODS We conducted a systematic review and meta-analysis following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Relevant papers through December 2023 were retrieved from PubMed, Scopus, Web of science, and Embase. RESULTS A total of 5 studies met inclusion/exclusion criteria with an aggregate 39,221 non-frail patients (mean age 52.4 ± 5.2 yr; 62.1 % Female), and 79,416 frail patients (mean age 61.1 ± 5.4 yr; 69.0 % Female). Frailty was significantly associated with higher mortality ratio (Odds ratio (OR)= 2.09; CI [1.04: 4.20], p= 0.04), and increased length of hospital stay (OR= 1.40; CI [1.07: 1.83], p= 0.015). Additionally, frailty was associated with higher odds of external ventricular drain insertion, the need of tracheostomy/endoscopic gastrostomy, increased risk of deep vein thrombosis, and postoperative neurological complications. CONCLUSION Frailty is associated with worse clinical outcomes and higher mortality rates in SAH patients. Our findings highlight that frailty, when considered alongside other established prognostic factors, serves as crucial predictor for peri-operative complications and overall hospital course in SAH patients.
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Affiliation(s)
| | - Mark Cwajna
- Saba University School of Medicine, Saba, The Bottom, Dutch Caribbean, the Netherlands
| | - Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Mohamed Derhab
- Department of Neurology, Mayo Clinic, Rochester, MN, 55905, USA
| | | | - Hassan Kobeissi
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA
| | - Sherief Ghozy
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, 55905, USA; Department of Radiology, Mayo Clinic, Rochester, MN, 55905, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN, 55905, USA
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Qiu W, Li W, Xu K, Zhu G, Luo H, Deng Y, Qin Z, Zeng K, Wei Y, Lin X. Prognostic significance of fibrinogen and neutrophil/lymphocyte ratio score and D-dimer/Albumin ratio for prognosis in patients with aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2023; 32:107338. [PMID: 37690163 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/26/2023] [Accepted: 08/31/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Recent research indicates that systemic inflammation significantly affects the overall prognosis of individuals with aneurysmal subarachnoid hemorrhage. To delve deeper into this issue, a retrospective study was undertaken. The study aimed to investigate the relationship between fibrinogen and neutrophil/lymphocyte ratio scores, D-dimer/Albumin ratios, and the Glasgow Outcome Scale at 6 months post-discharge for patients with aSAH. METHODS A retrospective analysis was conducted on 321 patients who experienced aneurysmal subarachnoid hemorrhage. These patients were monitored using the Glasgow Outcome Scale six months after being discharged from Huizhou Central People's Hospital. Patients with GOS scores between 1 and 3 were classified as having a poor prognosis, while those with scores ranging from 4 to 5 were considered to have a good prognosis. To create distinct sets, patients were randomly divided into both training and validation groups. The best cut-off value for the D-dimer/Albumin ratio was established through ROC curves, and the scores for fibrinogen and the neutrophil/lymphocyte ratio were calculated. Utilizing multivariate logistic regression analysis, independent risk factors linked to an unfavorable prognosis in aSAH patients were identified. A nomogram model was developed and validated based on these findings, providing an improved approach for evaluating the prognostic influence of risk factors. To gauge the model's predictive performance, several analytical tools such as ROC curves, calibration curves, and decision curve analysis were employed. This comprehensive approach ensured a thorough assessment of the prognostic prediction capabilities of the model. RESULTS Multivariate regression analysis revealed that Age (OR=3.87, 95%CI=1.54-9.73, p=0.004), Pneumonia (OR=3.54, 95%CI=1.41-8.86, p=0.007), WFNS (OR=3.24, 95%CI=1.23-8.54, p=0.017), DAR (OR=2.88, 95%CI=1.13-7.34, p=0.027), and F-NLR (OR=3.12, 95%CI=1.22-7.97, p=0.017) were identified as independent risk factors influencing the prognosis of patients with aSAH. Additionally, the area under the ROC curve was 0.866 (95%CI=0.805-0.927) for the training set and 0.924 (95%CI=0.849-0.999) for the validation set. The calibration curve analysis demonstrated a minor error of 0.02 for the training set and 0.051 for the validation set. Furthermore, both the training set and validation set displayed significant clinical benefits according to the DCA curves, underscoring the meaningful utility of the developed nomogram. CONCLUSIONS Fibrinogen and neutrophil/lymphocyte ratio scores, and the D-dimer/Albumin ratio emerged as significant independent risk factors for prognosticating the outcomes of patients with aSAH. Leveraging these factors, a robust nomogram model was meticulously developed, showcasing its impressive precision in prognostic predictions. These results underscore the promising clinical applicability of these biomarkers as effective prognostic indicators for individuals afflicted by aSAH.
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Affiliation(s)
- Wenjie Qiu
- Guangdong Medical University, Zhanjiang, China
| | - Wencai Li
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
| | - Ke Xu
- Guangdong Medical University, Zhanjiang, China
| | - Gang Zhu
- Guangdong Medical University, Zhanjiang, China; Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China.
| | - Honghai Luo
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
| | - Yifan Deng
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
| | - Zhongzong Qin
- Department of Neurosurgery, Huizhou Central People's Hospital, Huizhou, China
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Fortunato M, Lin F, Uddin A, Subah G, Patel R, Feldstein E, Lui A, Dominguez J, Merckling M, Xu P, McIntyre M, Gandhi C, Al-Mufti F. Frailty as a Predictor of Outcomes in Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. Brain Sci 2023; 13:1498. [PMID: 37891864 PMCID: PMC10605612 DOI: 10.3390/brainsci13101498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 10/17/2023] [Accepted: 10/20/2023] [Indexed: 10/29/2023] Open
Abstract
Frailty is an emerging concept in clinical practice used to predict outcomes and dictate treatment algorithms. Frail patients, especially older adults, are at higher risk for adverse outcomes. Aneurysmal subarachnoid hemorrhage (aSAH) is a neurosurgical emergency associated with high morbidity and mortality rates that have previously been shown to correlate with frailty. However, the relationship between treatment selection and post-treatment outcomes in frail aSAH patients is not established. We conducted a meta-analysis of the relevant literature in accordance with PRISMA guidelines. We searched PubMed, Embase, Web of Science, and Google Scholar using "Subarachnoid hemorrhage AND frailty" and "subarachnoid hemorrhage AND frail" as search terms. Data on cohort age, frailty measurements, clinical grading systems, and post-treatment outcomes were extracted. Of 74 studies identified, four studies were included, with a total of 64,668 patients. Percent frailty was 30.4% under a random-effects model in all aSAH patients (p < 0.001). Overall mortality rate of aSAH patients was 11.7% when using a random-effects model (p < 0.001). There was no significant difference in mortality rate between frail and non-frail aSAH patients, but this analysis only included two studies and should be interpreted cautiously. Age and clinical grading, rather than frailty, independently predicted outcomes and mortality in aSAH patients.
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Affiliation(s)
- Michael Fortunato
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Fangyi Lin
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Anaz Uddin
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Galadu Subah
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Rohan Patel
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Eric Feldstein
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Aiden Lui
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Jose Dominguez
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Matthew Merckling
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Patricia Xu
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
| | - Matthew McIntyre
- Department of Neurological Surgery, Oregon Health & Science University, Portland, OR 97239, USA
| | - Chirag Gandhi
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA; (M.F.); (F.L.); (A.U.); (R.P.); (A.L.); (P.X.); (C.G.)
- Brain and Spine Institute, Westchester Medical Center, New York Medical College, Valhalla, NY 10595, USA (E.F.); (J.D.)
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Kandregula S, Savardekar AR, Terrell D, Adeeb N, Whipple S, Beyl R, Birk HS, Newman WC, Kosty J, Cuellar H, Guthikonda B. Microsurgical clipping and endovascular management of unruptured anterior circulation aneurysms: how age, frailty, and comorbidity indexes influence outcomes. J Neurosurg 2023; 138:922-932. [PMID: 36461843 PMCID: PMC11104005 DOI: 10.3171/2022.8.jns22372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Accepted: 08/02/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Frailty is one of the important factors in predicting the outcomes of surgery. Many surgical specialties have adopted a frailty assessment in the preoperative period for prognostication; however, there are limited data on the effects of frailty on the outcomes of cerebral aneurysms. The object of this study was to find the effect of frailty on the surgical outcomes of anterior circulation unruptured intracranial aneurysms (UIAs) and compare the frailty index with other comorbidity indexes. METHODS A retrospective study was performed utilizing the National Inpatient Sample (NIS) database (2016-2018). The Hospital Frailty Risk Score (HFRS) was used to assess frailty. On the basis of the HFRS, the whole cohort was divided into low-risk (0-5), intermediate-risk (> 5 to 15), and high-risk (> 15) frailty groups. The analyzed outcomes were nonhome discharge, complication rate, extended length of stay, and in-hospital mortality. RESULTS In total, 37,685 patients were included in the analysis, 5820 of whom had undergone open surgical clipping and 31,865 of whom had undergone endovascular management. Mean age was higher in the high-risk frailty group than in the low-risk group for both clipping (63 vs 55.4 years) and coiling (64.6 vs 57.9 years). The complication rate for open surgical clipping in the high-risk frailty group was 56.1% compared to 0.8% in the low-risk group. Similarly, for endovascular management, the complication rate was 60.6% in the high-risk group compared to 0.3% in the low-risk group. Nonhome discharges were more common in the high-risk group than in the low-risk group for both open clipping (87.8% vs 19.7%) and endovascular management (73.1% vs 4.4%). Mean hospital charges for clipping were $341,379 in the high-risk group compared to $116,892 in the low-risk group. Mean hospital charges for coiling were $392,861 in the high-risk frailty group and $125,336 in the low-risk group. Extended length of stay occurred more frequently in the high-risk frailty group than in the low-risk group for both clipping (82.9% vs 10.7%) and coiling (94.2% vs 12.7%). Frailty had higher area under the receiver operating characteristic curve values than those for other comorbidity indexes and age in predicting outcomes. CONCLUSIONS Frailty affects surgical outcomes significantly and outperforms age and other comorbidity indexes in predicting outcome. It is imperative to include frailty assessment in preoperative planning.
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Affiliation(s)
| | | | | | - Nimer Adeeb
- Department of Neurosurgery, LSU Health, Shreveport, Louisiana
| | - Stephen Whipple
- Department of Neurosurgery, LSU Health, Shreveport, Louisiana
| | - Robbie Beyl
- Department of Statistics, Pennington Biomedical Research Center, Baton Rouge, Louisiana
| | - Harjus S. Birk
- Department of Neurosurgery, LSU Health, Shreveport, Louisiana
| | | | - Jennifer Kosty
- Department of Neurosurgery, LSU Health, Shreveport, Louisiana
| | - Hugo Cuellar
- Department of Radiology, LSU Health, Shreveport, Louisiana
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8
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Koo AB, Elsamadicy AA, Renedo D, Sarkozy M, Sherman J, Reeves BC, Havlik J, Antonios J, Sujijantarat N, Hebert R, Malhotra A, Matouk C. Higher Hospital Frailty Risk Score is associated with increased complications and healthcare resource utilization after endovascular treatment of ruptured intracranial aneurysms. J Neurointerv Surg 2023; 15:255-261. [PMID: 35292571 PMCID: PMC8931798 DOI: 10.1136/neurintsurg-2021-018484] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Accepted: 02/15/2022] [Indexed: 12/29/2022]
Abstract
AIM To use the Hospital Frailty Risk Score (HFRS) to investigate the impact of frailty on complication rates and healthcare resource utilization in patients who underwent endovascular treatment of ruptured intracranial aneurysms (IAs). METHODS A retrospective cohort study was performed using the 2016-2019 National Inpatient Sample database. All adult patients (≥18 years) undergoing endovascular treatment for IAs after subarachnoid hemorrhage were identified using ICD-10-CM codes. Patients were categorized into frailty cohorts: low (HFRS <5), intermediate (HFRS 5-15) and high (HFRS >15). Patient demographics, adverse events, length of stay (LOS), discharge disposition, and total cost of admission were assessed. Multivariate logistic regression analysis was used to identify independent predictors of prolonged LOS, increased cost, and non-routine discharge. RESULTS Of the 33 840 patients identified, 7940 (23.5%) were found to be low, 20 075 (59.3%) intermediate and 5825 (17.2%) high frailty by HFRS criteria. The rate of encountering any adverse event was significantly greater in the higher frailty cohorts (low: 59.9%; intermediate: 92.4%; high: 99.2%, p<0.001). There was a stepwise increase in mean LOS (low: 11.7±8.2 days; intermediate: 18.7±14.1 days; high: 26.6±20.1 days, p<0.001), mean total hospital cost (low: $62 888±37 757; intermediate: $99 670±63 446; high: $134 937±80 331, p<0.001), and non-routine discharge (low: 17.3%; intermediate: 44.4%; high: 69.4%, p<0.001) with increasing frailty. On multivariate regression analysis, a similar stepwise impact was found in prolonged LOS (intermediate: OR 2.38, p<0.001; high: OR 4.49, p<0.001)], total hospital cost (intermediate: OR 2.15, p<0.001; high: OR 3.62, p<0.001), and non-routine discharge (intermediate: OR 2.13, p<0.001; high: OR 4.17, p<0.001). CONCLUSIONS Our study found that greater frailty as defined by the HFRS was associated with increased complications, LOS, total costs, and non-routine discharge.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aladine A Elsamadicy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Daniela Renedo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Margot Sarkozy
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Josiah Sherman
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - John Havlik
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Joseph Antonios
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nanthiya Sujijantarat
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ryan Hebert
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Abstract
Stroke is a leading cause of long-term disability and fifth leading cause of death. Acute ischemic stroke, intracerebral hemorrhage, and subarachnoid hemorrhage, the 3 subtypes of strokes, have varying treatment modalities. Common themes in management advocate for early interventions to reduce morbidity and mortality but not all perception is supported through randomized controlled trials. Each stroke subtype has varying premorbid-related and ictus-related outcome predictive models that have differing sensitivities and specificities.
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Predictors of In-Hospital Mortality and Home Discharge in Patients with Aneurysmal Subarachnoid Hemorrhage: A 4-Year Retrospective Analysis. Neurocrit Care 2023; 38:85-95. [PMID: 36114314 DOI: 10.1007/s12028-022-01596-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 08/18/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Factors associated with discharge disposition and mortality following aneurysmal subarachnoid hemorrhage (aSAH) are not well-characterized. We used a national all-payer database to identify factors associated with home discharge and in-hospital mortality. METHODS The National Inpatient Sample was queried for patients with aSAH within a 4-year range. Weighted multivariable logistic regression models were constructed and adjusted for age, sex, race, household income, insurance status, comorbidity burden, National Inpatient Sample SAH Severity Score, disease severity, treatment modality, in-hospital complications, and hospital characteristics (size, teaching status, and region). RESULTS Our sample included 37,965 patients: 33,605 were discharged alive and 14,350 were discharged home. Black patients had lower odds of in-hospital mortality compared with White patients (adjusted odds ratio [aOR] = 0.67, 95% confidence interval [CI] 0.52-0.86, p = 0.002). Compared with patients with private insurance, those with Medicare were less likely to have a home discharge (aOR = 0.58, 95% CI 0.46-0.74, p < 0.001), whereas those with self-pay (aOR = 2.97, 95% CI 2.29-3.86, p < 0.001) and no charge (aOR = 3.21, 95% CI 1.57-6.55, p = 0.001) were more likely to have a home discharge. Household income percentile was not associated with discharge disposition or in-hospital mortality. Paradoxically, increased number of Elixhauser comorbidities was associated with significantly lower odds of in-hospital mortality. CONCLUSIONS We demonstrate independent associations with hospital characteristics, patient characteristics, and treatment characteristics as related to discharge disposition and in-hospital mortality following aSAH, adjusted for disease severity.
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11
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Ng C, Dominguez JF, Hosein-Woodley R, Feldstein E, Naftchi A, Lui A, Dicpinigaitis AJ, McIntyre MK, Kaur G, Santarelli J, Bauerschmidt A, Mayer SA, Bowers CA, Gandhi CD, Al-Mufti F. Utility of frailty as a predictor of acute kidney injury in patients with aneurysmal subarachnoid hemorrhage. Interv Neuroradiol 2023; 29:114-120. [PMID: 35109710 PMCID: PMC9893237 DOI: 10.1177/15910199221076626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/31/2021] [Accepted: 01/11/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is associated with poor outcome in aneurysmal subarachnoid hemorrhage patients (aSAH). Frailty has recently been demonstrated to correlate with elevated mortality and morbidity; its impact on predicting AKI and mortality in aSAH patients has not been investigated. OBJECTIVE Evaluating risk factors and predictors for AKI in aSAH patients. METHODS aSAH patients from a single-center's prospectively maintained database were retrospectively evaluated for development of AKI within 14 days of admission. Baseline demographic and clinical characteristics were collected. The effect of frailty and other risk factors were evaluated. RESULTS Of 213 aSAH patients, 53 (33.1%) were frail and 12 (5.6%) developed AKI. Admission serum creatinine (sCr) and peak sCr within 48 h were higher in frail patients. AKI patients showed a trend towards higher frailty. Mortality was significantly higher in AKI than non-AKI aSAH patients. Frailty was a poor predictor of AKI when controlling for Hunt and Hess (HH) grade or age. HH grade ≥ 4 strongly predicted AKI when controlling for frailty. CONCLUSION AKI in aSAH patients carries a poor prognosis. The HH grade appears to have superior utility as a predictor of AKI in aSAH patients than mFI.
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Affiliation(s)
- Christina Ng
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | | | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | | | - Aiden Lui
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Matthew K McIntyre
- Department of Neurological Surgery, Oregon Health & Science
University, Portland, OR, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Andrew Bauerschmidt
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico School of
Medicine, Albuquerque, NM, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
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12
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Kassicieh AJ, Varela S, Rumalla K, Kazim SF, Cole KL, Ghatalia DV, Schmidt MH, Bowers CA. Worse cranial neurosurgical outcomes predicted by increasing frailty in patients with interhospital transfer status: Analysis of 47,736 patients from the National Surgical Quality Improvement Program (NSQIP) 2015-2019. Clin Neurol Neurosurg 2022; 221:107383. [PMID: 35901555 DOI: 10.1016/j.clineuro.2022.107383] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Revised: 07/16/2022] [Accepted: 07/20/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION With limited healthcare resources and risks associated with unwarranted interhospital transfers (IHT), it is important to select patients most likely to have improved outcomes with IHT. The present study analyzed the effect of IHT and frailty on postoperative outcomes in a large database of patients who underwent cranial neurosurgical operations. METHODS The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent cranial neurosurgical procedures (2015-2019, N = 47,736). Baseline demographics, clinical characteristics, and outcome variables were compared between IHT and n-IHT patients. Univariate and multivariable analyses analyzed the effect of IHT status on postoperative outcomes and the utility of frailty (modified frailty index-5 [mFI-5] stratified into "pre-frail, "frail", and "severely frail") as a preoperative risk factor. Effect sizes from regression analyses were presented as odds ratio (OR) with associated 95% confidence intervals (95% CI). RESULTS Of 47,736 patients with cranial neurosurgical operations, 9612 (20.1%) were IHT. Patients with IHT were older, frailer, with a higher rate of functional dependence. In multivariable analysis adjusted for baseline covariates, IHT status was independent associated with 30-day mortality (OR: 2.0, 95% CI: 1.2-3.6), major complication (OR: 1.5, 95% CI: 1.1-2.1), extended hospital length of stay (eLOS) (OR: 3.8, 95% CI: 3.6-4.1), and non-routine discharge disposition (OR: 2.4, 95% CI: 1.8-3.2) (all p < 0.05). Within the IHT cohort, increasing frailty ("pre-frail", "frail", "severely frail") was independently associated with increasing odds of 30-day mortality (OR: 1.4, 1.9, 3.9), major complication (OR: 1.4, 1.9, 3.3), unplanned readmission (OR: 1.1, 1.4, 2.1), reoperation (OR: 1.3, 1.5, 1.9), eLOS (OR: 1.2, 1.3, 1.5), and non-routine discharge (OR: 1.4, 1.9, 4.4) (all p < 0.05). All levels of frailty were more strongly associated with postoperative outcomes than chronological age. CONCLUSIONS This novel analysis suggests that patients transferred for cranial neurosurgery operations are significantly more likely to have worse postoperative health outcomes. Furthermore, the analysis suggests that frailty (as measured by mFI-5) is a powerful independent predictor of outcomes in transferred cranial neurosurgery patients. The findings support the use of frailty scoring in the pre-transfer and preoperative setting for patient counseling and risk stratification.
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Affiliation(s)
| | - Samantha Varela
- School of Medicine, University of New Mexico, Albuquerque, NM 87106, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87106, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87106, USA
| | - Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, UT 84132, USA
| | - Desna V Ghatalia
- School of Medicine, University of New Mexico, Albuquerque, NM 87106, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87106, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM 87106, USA.
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13
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Guo Y, Wu H, Sun W, Hu X, Dai J. Effects of frailty on postoperative clinical outcomes of aneurysmal subarachnoid hemorrhage: results from the National Inpatient Sample database. BMC Geriatr 2022; 22:460. [PMID: 35624415 PMCID: PMC9145390 DOI: 10.1186/s12877-022-03141-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 05/13/2022] [Indexed: 11/24/2022] Open
Abstract
Background This study aimed to investigate the potential effect of preoperative frailty on postoperative clinical outcomes of patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods Data of patients aged 18 years and older who were diagnosed with subarachnoid hemorrhage or intracerebral hemorrhage, underwent aneurysm repair surgical intervention from 2005 to 2014. A retrospective database analysis was performed based on U.S. National Inpatient Sample (NIS) from 2005 to 2014. Frailty was determined using the Johns Hopkins Adjusted Clinical Groups (ACG) frailty-defining diagnoses indicator. Patients were stratified into frail and non-frail groups and the study endpoints were incidence of postoperative complications and related adverse clinical outcomes. Results Among 20,527 included aSAH patients, 2303 (11.2%) were frail and 18,224 (88.8%) were non-frail. Significant differences were found between frailty and non-frailty groups in the four clinical outcomes (all p < 0.05). Multivariate analysis showed that frailty was associated with significant higher risks of discharge to institutional care (aOR: 2.50, 95%CI: 2.10–2.97), tracheostomy or gastrostomy tube replacement (aOR: 4.41, 95%CI: 3.81–5.10) and postoperative complications (aOR: 3.29, 95%CI: 2.55–4.25) but a lower risk of death in hospital (aOR: 0.40, 95%CI: 0.33–0.49) as compared with non-frailty. Stratified analysis showed the impact of frailty on some of the outcomes were greater among patients younger than 65 years than their older counterparts. Conclusions Frailty is significantly correlated with the increased risk of discharge to institutional care, tracheostomy or gastrostomy tube placement, and postoperative complications but with the reduced risk of in-hospital mortality outcomes after aneurysm repair. Frailty seems to have greater impact among younger adults than older ones. Baseline frailty evaluation could be applied to risk stratification for aSAH patients who were undergoing surgery.
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Affiliation(s)
- Yubin Guo
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.1630 Dongfang Road, Shanghai, 200127, China.,Cerebrovascular Disease Center, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.2000 Jiangyue Road, Shanghai, 201112, China
| | - Hui Wu
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.1630 Dongfang Road, Shanghai, 200127, China.,Cerebrovascular Disease Center, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.2000 Jiangyue Road, Shanghai, 201112, China
| | - Wenhua Sun
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.1630 Dongfang Road, Shanghai, 200127, China.,Cerebrovascular Disease Center, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.2000 Jiangyue Road, Shanghai, 201112, China
| | - Xiang Hu
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.1630 Dongfang Road, Shanghai, 200127, China.,Cerebrovascular Disease Center, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.2000 Jiangyue Road, Shanghai, 201112, China
| | - Jiong Dai
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.1630 Dongfang Road, Shanghai, 200127, China. .,Cerebrovascular Disease Center, Renji Hospital, Shanghai Jiaotong University School of Medicine, No.2000 Jiangyue Road, Shanghai, 201112, China.
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14
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Association of baseline frailty status with clinical outcome following aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2022; 31:106394. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106394] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 01/09/2022] [Accepted: 02/02/2022] [Indexed: 01/02/2023] Open
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15
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Barros G, Sen RD, McGrath M, Nistal D, Sekhar LN, Kim LJ, Levitt MR. Frailty predicts postoperative functional outcomes after microsurgical resection of ruptured brain arteriovenous malformations in older patients. World Neurosurg 2022; 164:e844-e851. [DOI: 10.1016/j.wneu.2022.05.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/12/2022] [Accepted: 05/13/2022] [Indexed: 10/18/2022]
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16
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Lim JX, Lim YG, Kumar A, Cheong TM, Han JX, Chen MW, Wen D, Lim W, Ng IHB, Ng VYP, Kirollos RW, Keong NCH. Relevance of presenting risks of frailty, sarcopaenia and osteopaenia to outcomes from aneurysmal subarachnoid haemorrhage. BMC Geriatr 2022; 22:333. [PMID: 35428266 PMCID: PMC9013113 DOI: 10.1186/s12877-022-03005-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2021] [Accepted: 03/30/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction Aneurysmal subarachnoid haemorrhage (aSAH) is a condition with significant morbidity and mortality. Traditional markers of aSAH have established their utility in the prediction of aSAH outcomes while frailty markers have been validated in other surgical specialties. We aimed to compare the predictive value of frailty indices and markers of sarcopaenia and osteopaenia, against the traditional markers for aSAH outcomes. Methods An observational study in a tertiary neurosurgical unit on 51 consecutive patients with ruptured aSAH was performed. The best performing marker in predicting the modified Rankin scale (mRS) on discharge was selected and an appropriate threshold for the definition of frail and non-frail was derived. We compared various frailty indices (modified frailty index 11, and 5, and the National Surgical Quality Improvement Program score [NSQIP]) and markers of sarcopaenia and osteopaenia (temporalis [TMT] and zygoma thickness), against traditional markers (age, World Federation of Neurological Surgery and modified Fisher scale [MFS]) for aSAH outcomes. Univariable and multivariable analysis was then performed for various inpatient and long-term outcomes. Results TMT was the best performing marker in our cohort with an AUC of 0.82, Somers’ D statistic of 0.63 and Tau statistic 0.25. Of the frailty scores, the NSQIP performed the best (AUC 0.69), at levels comparable to traditional markers of aSAH, such as MFS (AUC 0.68). The threshold of 5.5 mm in TMT thickness was found to have a specificity of 0.93, sensitivity of 0.51, positive predictive value of 0.95 and negative predictive value of 0.42. After multivariate analysis, patients with TMT ≥ 5.5 mm (defined as non-frail), were less likely to experience delayed cerebral ischaemia (OR 0.11 [0.01 – 0.93], p = 0.042), any complications (OR 0.20 [0.06 – 0.069], p = 0.011), and had a larger proportion of favourable mRS on discharge (95.0% vs. 58.1%, p = 0.024) and at 3-months (95.0% vs. 64.5%, p = 0.048). However, the gap between unfavourable and favourable mRS was insignificant at the comparison of 1-year outcomes. Conclusion TMT, as a marker of sarcopaenia, correlated well with the presenting status, and outcomes of aSAH. Frailty, as defined by NSQIP, performed at levels equivalent to aSAH scores of clinical relevance, suggesting that, in patients presenting with acute brain injury, both non-neurological and neurological factors were complementary in the determination of eventual clinical outcomes. Further validation of these markers, in addition to exploration of other relevant frailty indices, may help to better prognosticate aSAH outcomes and allow for a precision medicine approach to decision making and optimization of best outcomes. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03005-7.
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Comparative associations of baseline frailty status and age with postoperative mortality and duration of hospital stay following metastatic brain tumor resection. Clin Exp Metastasis 2022; 39:303-310. [PMID: 35023030 DOI: 10.1007/s10585-021-10138-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Accepted: 11/28/2021] [Indexed: 12/12/2022]
Abstract
Metastatic brain tumors are the most common intracranial neoplasms diagnosed in the United States. Although baseline frailty status has been validated as a robust predictor of morbidity and mortality across various surgical disciplines, evidence within cranial neurosurgical oncology is limited. Adult metastatic brain tumor patients treated with resection were identified in the National Inpatient Sample during the period of 2015-2018. Frailty was quantified using the 11-point modified frailty index (mFI-11) and its association with clinical endpoints was evaluated through complex samples multivariable logistic regression and receiver operating characteristic (ROC) curve analyses. Among 13,650 metastatic brain tumor patients identified (mean age 62.8 years), 26.8% (n = 3665) were robust (mFI = 0), 31.4% (n = 4660) were pre-frail (mFI = 1), 23.2% (n = 3165) were frail (mFI = 2), and 15.8% (n = 2160) were severely frail (mFI ≥ 3). On univariable assessment, these cohorts stratified by increasing frailty were significantly associated with postoperative complications (13.6%, 15.9%, 23.9%, 26.4%; p < 0.001), mortality (1.2%, 1.4%, 2.7%, 3.2%; p = 0.028), and extended length of stay (eLOS) (15.7%, 22.5%, 28.9%, 37.7%; p < 0.001). Following multivariable logistic regression analysis, frailty (by mFI-11) was independently associated with postoperative mortality (aOR 1.34, 95% CI 1.08, 1.65) and eLOS (aOR 1.26, 95% CI 1.17, 1.37), while increasing age was not associated with these endpoints. ROC curve analysis demonstrated superior discrimination of frailty (by mFI-11) in comparison with age for both mortality (AUC 0.61 vs. 0.58) and eLOS (AUC 0.61 vs. 0.53). Further statistical assessment through propensity score adjustment and decision tree analysis confirmed and extended the findings of the primary analytical models. Frailty may be a more robust predictor of postoperative outcomes in comparison with age following metastatic brain tumor resection.
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Wang R, Zhang J, Shan B, He M, Xu J. XGBoost Machine Learning Algorithm for Prediction of Outcome in Aneurysmal Subarachnoid Hemorrhage. Neuropsychiatr Dis Treat 2022; 18:659-667. [PMID: 35378822 PMCID: PMC8976557 DOI: 10.2147/ndt.s349956] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/09/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Patients suffered aneurysmal subarachnoid hemorrhage (aSAH) usually develop poor survival and functional outcome. Evaluating aSAH patients at high risk of poor outcome is necessary for clinicians to make suitable therapeutical strategy. This study is conducted to develop prognostic model using XGBoost (extreme gradient boosting) algorithm in aSAH. METHODS A total of 351 aSAH patients admitted to West China hospital were identified. Patients were divided into training set and test set with ratio of 7:3 to testify the predictive value of XGBoost based prognostic model. Additionally, logistic regression model was also constructed and compared with XGBoost based model. Area under the receiver operating characteristic curve (AUC), sensitivity and specificity were calculated to evaluate the value of XGBoost and logistic regression. RESULTS There were 74 (21.1%) non-survivors and 148 (42.1%) patients with unfavorable functional outcome. Non-survivors had older age (p=0.025), lower Glasgow coma scale (GCS) (p<0.001), higher World Federation of Neurosurgical Societies WFNS score (p<0.001), mFisher score (p<0.001). The incidence of intraventricular hemorrhage (IVH) (p=0.025) and delayed cerebral ischemia (DCI) (p<0.001) was higher in non-survivors than survivors. The AUC of XGBoost model for predicting mortality and unfavorable functional outcome were 0.950 and 0.958, which were higher than 0.767 and 0.829 of logistic regression model. CONCLUSION XGBoost based model is more precise than logistic regression model in predicting outcome of aSAH patients. Using XGBoost prognostic model is helpful for clinicians to identify high-risk aSAH patients and therefore strengthen medical care.
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Affiliation(s)
- Ruoran Wang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Jing Zhang
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Baoyin Shan
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Min He
- Department of Critical care medicine, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Jianguo Xu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, People's Republic of China
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Rehman S, Phan HT, Reeves MJ, Thrift AG, Cadilhac DA, Sturm J, Breslin M, Callisaya ML, Vemmos K, Parmar P, Krishnamurthi RV, Barker-Collo S, Feigin V, Chausson N, Olindo S, Cabral NL, Carolei A, Marini C, Degan D, Sacco S, Correia M, Appelros P, Kõrv J, Vibo R, Minelli C, Sposato L, Pandian JD, Kaur P, Azarpazhooh MR, Morovatdar N, Gall S. Case-Fatality and Functional Outcome after Subarachnoid Hemorrhage (SAH) in INternational STRoke oUtComes sTudy (INSTRUCT). J Stroke Cerebrovasc Dis 2021; 31:106201. [PMID: 34794031 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106201] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 10/15/2021] [Accepted: 10/21/2021] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND There are few large population-based studies of outcomes after subarachnoid hemorrhage (SAH) than other stroke types. METHODS We pooled data from 13 population-based stroke incidence studies (10 studies from the INternational STRroke oUtComes sTudy (INSTRUCT) and 3 new studies; N=657). Primary outcomes were case-fatality and functional outcome (modified Rankin scale score 3-5 [poor] vs. 0-2 [good]). Harmonized patient-level factors included age, sex, health behaviours (e.g. current smoking at baseline), comorbidities (e.g.history of hypertension), baseline stroke severity (e.g. NIHSS >7) and year of stroke. We estimated predictors of case-fatality and functional outcome using Poisson regression and generalized estimating equations using log-binomial models respectively at multiple timepoints. RESULTS Case-fatality rate was 33% at 1 month, 43% at 1 year, and 47% at 5 years. Poor functional outcome was present in 27% of survivors at 1 month and 15% at 1 year. In multivariable analysis, predictors of death at 1-month were age (per decade increase MRR 1.14 [1.07-1.22]) and SAH severity (MRR 1.87 [1.50-2.33]); at 1 year were age (MRR 1.53 [1.34-1.56]), current smoking (MRR 1.82 [1.20-2.72]) and SAH severity (MRR 3.00 [2.06-4.33]) and; at 5 years were age (MRR 1.63 [1.45-1.84]), current smoking (MRR 2.29 [1.54-3.46]) and severity of SAH (MRR 2.10 [1.44-3.05]). Predictors of poor functional outcome at 1 month were age (per decade increase RR 1.32 [1.11-1.56]) and SAH severity (RR 1.85 [1.06-3.23]), and SAH severity (RR 7.09 [3.17-15.85]) at 1 year. CONCLUSION Although age is a non-modifiable risk factor for poor outcomes after SAH, however, severity of SAH and smoking are potential targets to improve the outcomes.
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Affiliation(s)
- Sabah Rehman
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia
| | - Hoang T Phan
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia
| | - Mathew J Reeves
- Department of Epidemiology and Biostatistics, Michigan State University, East Lansing, Michigan, USA
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Jonathan Sturm
- Faculty of Health and Medicine, University of Newcastle, New South Wales, Australia
| | - Monique Breslin
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia
| | - Michele L Callisaya
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia; Struttura Complessa di Neurologia, Ospedale Michele e Pietro Ferrero, Verduno (Cuneo), ASL CN2, Italy
| | | | - Priya Parmar
- National Institute for Stroke and Applied Neurosciences, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Rita V Krishnamurthi
- National Institute for Stroke and Applied Neurosciences, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | | | - Valery Feigin
- National Institute for Stroke and Applied Neurosciences, School of Clinical Sciences, Auckland University of Technology, Auckland, New Zealand
| | - Nicolas Chausson
- Stroke Unit, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Stephane Olindo
- Stroke Unit, University Hospital of Bordeaux, Bordeaux, France
| | - Norberto L Cabral
- Deceased. Formerly Clinica Neurológica de Joinville, Joinville Stroke Registry, University of Joinville Region-Univille, Joinville, Brazil
| | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, Italy
| | - Carmine Marini
- Department of Life, Health, and Environmental Sciences, University of L'Aquila, Italy
| | - Diana Degan
- Struttura Complessa di Neurologia, Ospedale Michele e Pietro Ferrero, Verduno (Cuneo), ASL CN2, Italy
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, Italy
| | - Manuel Correia
- Instituto de Ciências Biomédicas de Abel Salazar, Universidade do Porto, Portugal
| | - Peter Appelros
- Department of Neurology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Janika Kõrv
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Riina Vibo
- Department of Neurology and Neurosurgery, Institute of Clinical Medicine, University of Tartu, Tartu, Estonia
| | - Cesar Minelli
- Hospital Carlos Fernando Malzoni and Neurologic Center of Research and Rehabilitation, Matão, SP, Brazil
| | - Luciano Sposato
- Department of Neurology, Western University, London, Ontario, Canada
| | | | - Paramdeep Kaur
- Department of Obstetrics & Gynaecology, University of British Columbia, Vancouver, Canada
| | - M Reza Azarpazhooh
- Department of Clinical Neurological Sciences, University of Western, London, Ontario, Canada
| | - Negar Morovatdar
- Clinical Research Development Unit, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seana Gall
- Menzies Institute for Medical Research, Hobart, Tasmania, University of Tasmania, Australia; Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.
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Dicpinigaitis AJ, Kazim SF, Schmidt MH, Couldwell WT, Theriault BC, Gandhi CD, Hanft S, Al-Mufti F, Bowers CA. Association of baseline frailty status and age with postoperative morbidity and mortality following intracranial meningioma resection. J Neurooncol 2021; 155:45-52. [PMID: 34495456 DOI: 10.1007/s11060-021-03841-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/04/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Although numerous studies have established advanced patient age as a risk factor for poor outcomes following intracranial meningioma resection, large-scale evaluation of frailty for preoperative risk assessment has yet to be examined. METHODS Weighted discharge data from the National Inpatient Sample were queried for adult patients undergoing benign intracranial meningioma resection from 2015 to 2018. Complex samples multivariable logistic regression models and receiver operating characteristic curve analysis were performed to evaluate adjusted associations and discrimination of frailty, quantified using the 11-factor modified frailty index (mFI), for clinical endpoints. RESULTS Among 20,250 patients identified (mean age 60.6 years), 35.4% (n = 7170) were robust (mFI = 0), 34.5% (n = 6985) pre-frail (mFI = 1), 20.1% (n = 4075) frail (mFI = 2), and 10.0% (n = 2020) severely frail (mFI ≥ 3). On univariable analysis, these sub-cohorts stratified by increasing frailty were significantly associated with the development of Clavien-Dindo grade IV (life-threatening) complications (inclusive of those resulting in mortality) (1.3% vs. 3.1% vs. 6.5% vs. 9.4%, p < 0.001) and extended length of stay (eLOS) (15.4% vs. 22.5% vs. 29.3% vs. 37.4%, p < 0.001). Following multivariable analysis, increasing frailty (aOR 1.40, 95% CI 1.17, 1.68, p < 0.001) and age (aOR 1.20, 95% CI 1.05, 1.38, p = 0.009) were both independently associated with development of life-threatening complications or mortality, whereas increasing frailty (aOR 1.20, 95% CI 1.10, 1.32, p < 0.001), but not age, was associated with eLOS. Frailty (by mFI-11) achieved superior discrimination in comparison to age for both endpoints (AUC 0.69 and 0.61, respectively). CONCLUSION Frailty may be more accurate than advanced patient age alone for prognostication of adverse events and outcomes following intracranial meningioma resection.
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Affiliation(s)
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, 87106, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, 87106, USA
| | - William T Couldwell
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, 84132, USA
| | - Brianna Carusillo Theriault
- Department of Neurosurgery, Yale University School of Medicine/Yale New Haven Hospital, New Haven, CT, 06510, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, 10595, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, 10595, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, 10595, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, 87106, USA. .,Department of Neurosurgery, University of New Mexico Health Sciences Center, MSC10 5615, 1 University of New Mexico, Albuquerque, NM, 81731, USA.
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Khalafallah AM, Huq S, Jimenez AE, Brem H, Mukherjee D. The 5-factor modified frailty index: an effective predictor of mortality in brain tumor patients. J Neurosurg 2021; 135:78-86. [PMID: 32796147 DOI: 10.3171/2020.5.jns20766] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 05/11/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Health measures such as the Charlson Comorbidity Index (CCI) and the 11-factor modified frailty index (mFI-11) have been employed to predict general medical and surgical mortality, but their clinical utility is limited by the requirement for a large number of data points, some of which overlap or require data that may be unavailable in large datasets. A more streamlined 5-factor modified frailty index (mFI-5) was recently developed to overcome these barriers, but it has not been widely tested in neuro-oncology patient populations. The authors compared the utility of the mFI-5 to that of the CCI and the mFI-11 in predicting postoperative mortality in brain tumor patients. METHODS The authors retrospectively reviewed a cohort of adult patients from a single institution who underwent brain tumor surgery during the period from January 2017 to December 2018. Logistic regression models were used to quantify the associations between health measure scores and postoperative mortality after adjusting for patient age, race, ethnicity, sex, marital status, and diagnosis. Results were considered statistically significant at p values ≤ 0.05. Receiver operating characteristic (ROC) curves were used to examine the relationships between CCI, mFI-11, and mFI-5 and mortality, and DeLong's test was used to test for significant differences between c-statistics. Spearman's rho was used to quantify correlations between indices. RESULTS The study cohort included 1692 patients (mean age 55.5 years; mean CCI, mFI-11, and mFI-5 scores 2.49, 1.05, and 0.80, respectively). Each 1-point increase in mFI-11 (OR 4.19, p = 0.0043) and mFI-5 (OR 2.56, p = 0.018) scores independently predicted greater odds of 90-day postoperative mortality. Adjusted CCI, mFI-11, and mFI-5 ROC curves demonstrated c-statistics of 0.86 (CI 0.82-0.90), 0.87 (CI 0.83-0.91), and 0.87 (CI 0.83-0.91), respectively, and there was no significant difference between the c-statistics of the adjusted CCI and the adjusted mFI-5 models (p = 0.089) or between the adjusted mFI-11 and the adjusted mFI-5 models (p = 0.82). The 3 indices were well correlated (p < 0.01). CONCLUSIONS The adjusted mFI-5 model predicts 90-day postoperative mortality among brain tumor patients as well as our adjusted CCI and adjusted mFI-11 models. The simplified mFI-5 may be easily integrated into clinical workflows to predict brain tumor surgery outcomes in real time.
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Spiers GF, Kunonga TP, Hall A, Beyer F, Boulton E, Parker S, Bower P, Craig D, Todd C, Hanratty B. Measuring frailty in younger populations: a rapid review of evidence. BMJ Open 2021; 11:e047051. [PMID: 33753447 PMCID: PMC7986767 DOI: 10.1136/bmjopen-2020-047051] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 02/11/2021] [Accepted: 03/03/2021] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Frailty is typically assessed in older populations. Identifying frailty in adults aged under 60 years may also have value, if it supports the delivery of timely care. We sought to identify how frailty is measured in younger populations, including evidence of the impact on patient outcomes and care. DESIGN A rapid review of primary studies was conducted. DATA SOURCES Four databases, three sources of grey literature and reference lists of systematic reviews were searched in March 2020. ELIGIBILITY CRITERIA Eligible studies measured frailty in populations aged under 60 years using experimental or observational designs, published after 2000 in English. DATA EXTRACTION AND SYNTHESIS Records were screened against review criteria. Study data were extracted with 20% of records checked for accuracy by a second researcher. Data were synthesised using a narrative approach. RESULTS We identified 268 studies that measured frailty in samples that included people aged under 60 years. Of these, 85 studies reported evidence about measure validity. No measures were identified that were designed and validated to identify frailty exclusively in younger groups. However, in populations that included people aged over and under 60 years, cumulative deficit frailty indices, phenotype measures, the FRAIL Scale, the Liver Frailty Index and the Short Physical Performance Battery all demonstrated predictive validity for mortality and/or hospital admission. Evidence of criterion validity was rare. The extent to which measures possess validity across the younger adult age (18-59 years) spectrum was unclear. There was no evidence about the impact of measuring frailty in younger populations on patient outcomes and care. CONCLUSIONS Limited evidence suggests that frailty measures have predictive validity in younger populations. Further research is needed to clarify the validity of measures across the adult age spectrum, and explore the utility of measuring frailty in younger groups.
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Affiliation(s)
- Gemma F Spiers
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tafadzwa Patience Kunonga
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alex Hall
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Fiona Beyer
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Elisabeth Boulton
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Stuart Parker
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter Bower
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Dawn Craig
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Chris Todd
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Barbara Hanratty
- National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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Increasing Frailty, Not Increasing Age, Results in Increased Length of Stay Following Vestibular Schwannoma Surgery. Otol Neurotol 2020; 41:e1243-e1249. [DOI: 10.1097/mao.0000000000002831] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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McIntyre MK, Rawanduzy C, Afridi A, Honig JA, Halabi M, Hehir J, Schmidt M, Cole C, Miller I, Gandhi C, Al-Mufti F, Bowers CA. The Effect of Frailty versus Initial Glasgow Coma Score in Predicting Outcomes Following Chronic Subdural Hemorrhage: A Preliminary Analysis. Cureus 2020; 12:e10048. [PMID: 32983738 PMCID: PMC7515811 DOI: 10.7759/cureus.10048] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Accepted: 08/25/2020] [Indexed: 12/14/2022] Open
Abstract
Background Initial Glasgow Coma Score (iGCS) is a well-known predictor of adverse outcomes following chronic subdural hemorrhage (cSDH). Frailty, i.e. a reduced physiologic reserve, is associated with poorer outcomes across the surgical literature, however, there is no consensus on the best measure of frailty. To date, no study has compared frailty's ability to predict cSDH outcomes versus iGCS. The goal of this study was to, therefore, examine the prognostic value of the 5- (mFI-5) and 11-factor (mFI-11) modified frailty index, and Charlson Comorbidity Index (CCI) versus iGCS following cSDH. Methods Between January, 2016 and June, 2018, patients who presented to the emergency department with cSDH were retrospectively identified using the International Classification of Diseases (ICD) codes. mFI-5, mFI-11, and CCI scores were calculated using patient baseline characteristics. Primary endpoints were death and discharge home and subgroup analyses were performed among operative cSDH. Univariate and multivariate logistic regressions were used to determine predictors of primary endpoints. Results Of the 109 patients identified, the average age was 72.6±1.6 years and the majority (69/109, 63.3%) were male. The average CCI, mFI-5, and mFI-11 were 4.5 ±0.2, 1.5 ±0.1, and 2.2 ±0.1, respectively. Fifty (45.9%) patients required surgical intervention, 11 (10.1%) died, and 48 (43.4%) were discharged home. In the overall cohort, while the only multivariate predictor of mortality was iGCS (OR=0.58; 95%CI:0.44-0.77; p=0.0001), the CCI (OR=0.73; 95%CI:0.58-0.92; p=0.0082) was a superior predictor of discharge home compared to iGCS (OR=1.46; 95%CI:1.13-1.90; p=0.0041). Conversely, among those who received an operative intervention, the CCI, but not iGCS, independently predicted both mortality (OR=4.24; 95%CI:1.01-17.86; p=0.0491) and discharge home (OR=0.55; 95%CI:0.33-0.90; p=0.0170). Neither mFI nor age predicted primary outcomes in multivariate analysis. Conclusion While frailty is associated with worse surgical outcomes, the clinical utility of the mFI-5, mFI-11, and CCI in cSDH is unclear. We show that the iGCS is an overall superior predictor of mortality following cSDH but is outperformed by the CCI after operative intervention. Similarly, the CCI is the superior predictor of discharge home in cSDH patients overall and following an operative intervention. These results indicate that while the iGCS best predicts mortality overall, the CCI may be considered when prognosticating post-operative course and hospital disposition.
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Affiliation(s)
- Matthew K McIntyre
- Department of Neurological Surgery, Oregon Health & Science University, Portland, USA
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | | | - Adil Afridi
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Jesse A Honig
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Mohamed Halabi
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Jake Hehir
- Department of Neurosurgery, New York Medical College, Valhalla, USA
| | - Meic Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, USA
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, USA
| | - Ivan Miller
- Department of Emergency Medicine, Westchester Medical Center, Valhalla, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, USA
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Rawanduzy C, McIntyre MK, Afridi A, Honig J, Halabi M, Hehir J, Schmidt M, Cole C, Miller I, Gandhi C, Al-Mufti F, Bowers C. The Effect of Frailty and Patient Comorbidities on Outcomes After Acute Subdural Hemorrhage: A Preliminary Analysis. World Neurosurg 2020; 143:e285-e293. [PMID: 32711137 DOI: 10.1016/j.wneu.2020.07.106] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Frailty is associated with worse outcomes across a variety of neurosurgical diseases. However, its effect on acute subdural hemorrhage (aSDH) outcomes is unclear. The goal of this study is to compare 3 measures of frailty with the gold standard (i.e., initial Glasgow Coma Scale [iGCS] score) for predicting outcomes after aSDH. METHODS Patients who presented between January 2016 and June 2018 were retrospectively identified based on International Classification of Diseases codes for aSDH. Patients' modified Frailty Index (mFI), temporalis muscle thickness (TMT), and age-adjusted Charlson Comorbidity Index (CCI) were calculated. Primary end points were death and discharge home. RESULTS Of 167 patients included, the mean age was 63.4 ± 1.9 years, the average CCI was 3.4 ± 0.2, mFI was 1.4 ± 0.1, TMT was 7.1 ± 0.2 mm, and iGCS score was 11.9 ± 0.3. Sixty-nine patients (41.3%) were discharged home and 32 (19.2%) died during hospitalization. In multivariate analysis, decreasing iGCS score (odds ratio [OR], 0.84; 95% confidence interval [CI], 0.74-0.96; P = 0.0112) and midline shift (OR, 1.27; 95% CI, 1.08-1.50; P = 0.0048), but not age or frailty, predicted mortality. In addition to iGCS score (OR, 1.26; 95% CI, 1.10-1.44; P = 0.0011), lower CCI (OR, 0.32; 95% CI, 0.14-0.74; P = 0.0071) and larger TMT (OR, 2.63; 95% CI, 1.16-5.99; P = 0.0210) independently predicted increased rates of discharge home. mFI was not independently associated with either primary end point in multivariate analysis. CONCLUSIONS iGCS score predicts both mortality and discharge location after aSDH better than do age or frailty. However, CCI and TMT, but not mFI, are useful prognostic indicators of discharge to home after aSDH. The iGCS score should continue to be the primary prediction tool for patients with aSDH; however, frailty may be useful for resource allocation, especially when nearing discharge.
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Affiliation(s)
- Cameron Rawanduzy
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | | | - Adil Afridi
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jesse Honig
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Mohamed Halabi
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jacob Hehir
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Meic Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Ivan Miller
- Department of Emergency Medicine, Westchester Medical Center, Valhalla, New York, USA
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA; Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA.
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Low total cholesterol and high density lipoprotein are independent predictors of poor outcomes following aneurysmal subarachnoid hemorrhage: A preliminary report. Clin Neurol Neurosurg 2020; 197:106062. [PMID: 32688095 DOI: 10.1016/j.clineuro.2020.106062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) is devastating, with delayed cerebral ischemia (DCI) significantly contributing to the high morbidity and mortality rates. Cholesterol has been studied as a measure of nutritional status in other neurological pathologies, but reports examining cholesterol's effects on aSAH outcomes are sparse. This study aimed to elucidate the effect of low total cholesterol (TC) and high density lipoprotein (HDL) on mortality and DCI following aSAH. METHODS We performed a retrospective cohort study at a quaternary academic medical center between June 2014 and July 2018. All patients had aSAH confirmed by digital subtraction angiography and had TC measured on admission. Primary outcomes were mortality and DCI. Secondary outcome was radiographic vasospasm. Univariate and multivariate logistic regressions were performed. RESULTS There were 75 aSAH patients, with an average age of 58.7 ± 1.7 (range: 14-89) and Hunt & Hess score of 2.8 ± 0.1, included for analysis. Those with a low TC < 160 mg/dL had 3 times increased odds of DCI (OR = 3.4; 95 %CI: 1.3-9.0; p = 0.0175) and a nearly 5 times increased odds of death (OR = 4.9; 95 %CI: 1.1-18.3; p = 0.0339). Low HDL < 40 mg/dL was associated with 12 times increased odds of DCI (OR = 12.3; 95 %CI: 2.7-56.4; p = 0.0003) but no significant differences in death (p = 0.2205). In multivariate analysis, low TC was an independent risk factor for increased mortality (OR = 5.6; 95 %CI: 1.2-27.6; p = 0.0335) while low HDL was associated with increased risk for DCI (OR = 17.9; 95 %CI: 3.1-104.4; p = 0.0013). There was no effect of TC or HDL on radiographic vasospasm. CONCLUSIONS Low TC and HDL are independent predictors of increased mortality and DCI, respectively, following aSAH. Low TC and HDL may be markers of poor overall health, in addition to having some pathophysiological effect on cerebral vasculature. These results may have practical implications for the improvement of aSAH prognostication and management.
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McIntyre MK, Gandhi C, Schmidt M, Cole C, Bowers CA. In Reply to the Letter to the Editor Regarding “Increasing Frailty Predicts Worse Outcomes and Increased Complications After Angiogram-Negative Subarachnoid Hemorrhages”. World Neurosurg 2020; 134:676-677. [PMID: 32059285 DOI: 10.1016/j.wneu.2019.11.147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/23/2019] [Indexed: 12/21/2022]
Affiliation(s)
| | - Chirag Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Meic Schmidt
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Chad Cole
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Christian A Bowers
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA.
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