Lower total protein and absence of neuronavigation are novel poor prognostic factors of endoscopic hematoma removal for intracerebral hemorrhage

Relationship between changes in neurological deficit severity and adverse cardiac events in elderly patients with hypertensive intracerebral hemorrhage: a retrospective cohort study

OBJECTIVE

To explore the relationship between changes in neurological deficit severity and the occurrence of adverse cardiac events in elderly patients with hypertensive intracerebral hemorrhage.

METHODS

Receiver operating characteristic (ROC) curve analysis was used to evaluate the predictive value of NIHSS scores for adverse cardiac events.

RESULTS

There were significant differences between the two groups. Multivariate logistic regression analysis showed that advanced age, high NIHSS score, large intracerebral hemorrhage volume, and high CK level were independent risk factors for adverse cardiac events in elderly patients with hypertensive intracerebral hemorrhage (p < 0.05). The NIHSS scores of both groups gradually increased after admission, peaking at 48 h after admission. In Group A, this elevation persisted until 72 h after admission, while in Group B, there was a significant decrease at 72 h after admission (p < 0.05). From admission to 7 days after admission, the NIHSS scores in Group A were higher than those in Group B (p < 0.05). The area under the curve (AUC) of the NIHSS scores at 48 h after admission was 0.776, with sensitivity and specificity of 80.9% and 84.5%, respectively, which were higher than those of other indicators (p < 0.05).

CONCLUSION

The occurrence of adverse cardiac events in elderly patients with hypertensive intracerebral hemorrhage is influenced by multiple factors, and as the NIHSS score increases, the risk of such events gradually increases. Clinicians should pay attention to monitoring NIHSS scores after admission, as they have value in predicting adverse cardiac events in elderly patients with hypertensive intracerebral hemorrhage.

Endoscopic surgery versus craniotomy for spontaneous intracerebral hemorrhage in the late elderly patients

OBJECTIVES

To compare the prognosis of late elderly patients with spontaneous intracerebral hemorrhage (ICH) treated by endoscopic evacuation and craniotomy MATERIALS AND METHODS: Using the Diagnosis Procedure Combination database, we identified patients aged ≥ 75 years who underwent surgery for spontaneous ICH within 48 hours after admission between April 2014 and March 2018. Eligible patients were classified into two groups according to the type of surgery (endoscopic surgery and craniotomy). Propensity-score matching weight analysis was conducted to compare the good neurological outcome modified Rankin Scale (mRS) score (0-4) at discharge as the primary endpoint between the two groups. Secondary endpoints were postoperative meningitis, tracheostomy, reoperation within 3 days and total hospitalization costs.

RESULTS

Among the 5,396 eligible patients, endoscopic surgery and craniotomy were performed in 895 and 4,501 patients, respectively. In the propensity-score matching weight analysis, all covariates were well balanced. The proportions of patients with a good prognosis (mRS score at discharge: 0-4) did not significantly differ between the surgical procedures (42.1% vs. 42.8%, p = 0.828). The proportions of meningitis, tracheostomy and reoperation were not significantly different between the two groups. Hospitalization costs were significantly higher in the craniotomy group than in the endoscopic surgery group (25,536 vs. 29,603 US dollars, p = 0.012).

CONCLUSIONS

Inhospital outcomes did not differ between endoscopic and open surgeries for spontaneous ICH in the late-stage elderly patients aged ≥75 years. Hospitalization costs were significantly higher in the craniotomy group, suggesting that endoscopic surgery may be more acceptable.

Association of temporalis muscle thickness with functional outcomes in patients undergoing endovascular thrombectomy

INTRODUCTION

Temporalis muscle thickness (TMT) is a surrogate marker for sarcopenia. This study investigated the association of TMT with clinical outcomes in patients receiving endovascular thrombectomy (EVT) for stroke involving acute large vessel occlusion (LVO).

MATERIAL AND METHODS

We enrolled consecutive patients who had undergone EVT between September 2014 and December 2021 at three thrombectomy-capable institutes. TMT was measured through preprocedural computerized tomography angiography. The clinical variables affecting TMT were investigated. The associations between TMT and clinical functional outcomes, defined using the modified Rankin scale, were also studied.

RESULTS

A total of 657 patients were included (mean age: 72.0 ± 12.7 years; male: 52.1%). The mean TMT was 6.35 ± 1.84 mm. Younger age, male sex, higher body mass index, and premorbid functional independence were associated with larger TMT in both univariate and multivariate linear regression (P <.05). Ordinal logistic regression revealed that TMT was associated with better clinical outcomes at 90 days (P_trend = 0.047); multivariate logistic regression indicated that larger TMT was an independent predictor (adjusted odds ratio: 1.14, 95% confidence interval: 1.03-1.27, P = 0.02) of favorable functional independence (modified Rankin scale score: 0-2). The effect was stronger in older patients (≥80 years) than younger patients, as revealed by interaction modeling analysis (P_interaction = 0.06).

CONCLUSION

TMT is associated with age, sex, body mass index, and premorbid functional status. Larger TMT is associated with better outcomes after EVT. The effects of TMT are more pronounced in older adults, indicating that sarcopenia may have influence on stroke outcomes.

Low Serum Total Protein at Admission Predicts in-Hospital Mortality Among General Inpatients: Historical Cohort Study

Purpose

Low total protein (TP) is associated with mortality among patients with specific diseases, but its association was uncertain among general patients. We evaluated the effects of low TP on in-hospital mortality among general inpatients.

Patients and Methods

We used data from the Japan Adverse Drug Events study series. We enrolled adult inpatients (≥ 16 years) admitted to a tertiary care hospital between September 1 and November 30, 2013. We excluded patients with multiple myeloma, pregnant women, and bone marrow graft donors. Patient data were extracted from electronic medical records. All patients were stratified into those with and without malignancy and divided into the low and normal TP groups. Low TP was defined as < 6.5 g/dL. We compared the in-hospital mortality of the low and normal TP groups stratified by the presence of malignancy.

Results

Among the 2235 enrolled patients (mean age, 67.8 years), the TP value was lower in 516 patients with malignancy than in 1719 patients without malignancy (6.6 g/dL vs 6.8 g/dL, P = 0.0002). Among patients without or with malignancy, 27% (462/1719) and 35% (183/516) were in the low TP group, respectively. Mortality was higher in the low TP group among patients without malignancy (23.2% vs 10.2%, P < 0.0001). Likewise, among patients with malignancy, mortality was higher in the low TP group (34.7% vs 11.3%, P = 0.0029). The adjusted hazard ratio of the low TP group was 1.75 (95% confidence interval, 1.04–2.96) in patients without malignancy and 2.45 (95% confidence interval, 1.12–5.37) in patients with malignancy, but the interaction was not significant (P = 0.23).

Conclusion

Low TP values were associated with higher in-hospital mortality among general inpatients, and this association was observed among patients with and those without malignancy. Routinely measured TP should be utilized to risk stratification on admission.

Pre-operative nutritional status and its association with short-term post-operative outcomes in Iranian children with CHD

BACKGROUND

Nutritional assessment appears to be an essential component of the evaluation of children with CHD undergoing surgery because nutritional status may impact corrective surgery-associated morbidity.

METHODS

A prospective single-centre cohort study with children between 6 and 24 months of age. Patients who had genetic syndromes or those who were premature or low birthweight at birth were excluded. Pre-operative nutritional parameters included anthropometric measurements and serum concentrations of total protein, vitamin D, iron, and ferritin. Outcome measures included ICU length of stay, mechanical ventilation, vasoactive-inotropic score, and duration of inotropes. Linear regression analysis was performed to determine whether pre-operative variables were associated with outcomes.

RESULTS

Analysis was performed on 120 patients (median age of 8 months), of whom 67 were male. Prior to surgery, 50.8% of patients had reduced (z ≤ -2.0) weight-for-age z score, 23.3% had reduced length-for-age z score, and 59.2% had reduced mid-upper arm circumference z score. Pre-operative serum total protein levels were 59.36 ± 9.16 g/L. Multiple regression analysis showed that low serum protein was associated with longer ICU length of stay and length of mechanical ventilation, while mid-upper arm circumference z score ≤ -2 was associated with longer ICU length of stay and mechanical ventilation and inotropes duration.

CONCLUSIONS

Pre-operative assessment of nutritional status by performing anthropometric and biochemical measurements including mid-upper arm circumference z score and serum protein concentrations in children undergoing CHD surgery appears to be predictors of some post-operative short-term outcomes and could be used as a guide to highlight patients needing appropriate perioperative nutritional interventions.

Temporal Muscle and Stroke-A Narrative Review on Current Meaning and Clinical Applications of Temporal Muscle Thickness, Area, and Volume

BACKGROUND

Evaluating muscle mass and function among stroke patients is important. However, evaluating muscle volume and function is not easy due to the disturbances of consciousness and paresis. Temporal muscle thickness (TMT) has been introduced as a novel surrogate marker for muscle mass, function, and nutritional status. We herein performed a narrative literature review on temporal muscle and stroke to understand the current meaning of TMT in clinical stroke practice.

METHODS

The search was performed in PubMed, last updated in October 2021. Reports on temporal muscle morphomics and stroke-related diseases or clinical entities were collected.

RESULTS

Four studies reported on TMT and subarachnoid hemorrhage, two studies on intracerebral hemorrhage, two studies on ischemic stroke, two studies on standard TMT values, and two studies on nutritional status. TMT was reported as a prognostic factor for several diseases, a surrogate marker for skeletal muscle mass, and an indicator of nutritional status. Computed tomography, magnetic resonance imaging, and ultrasonography were used to measure TMT.

CONCLUSIONS

TMT is gradually being used as a prognostic factor for stroke or a surrogate marker for skeletal muscle mass and nutritional status. The establishment of standard methods to measure TMT and large prospective studies to further investigate the relationship between TMT and diseases are needed.

Deep Learning-Based Functional Independence Measure Score Prediction After Stroke in Kaifukuki (Convalescent) Rehabilitation Ward Annexed to Acute Care Hospital

Introduction

Prediction models of functional independent measure (FIM) score after kaifukuki (convalescent) rehabilitation ward (KRW) are needed to decide the treatment strategies and save medical resources. Statistical models were reported, but their accuracies were not satisfactory. We made such prediction models using the deep learning (DL) framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan).

Methods

Of the 559 consecutive stroke patients, 122 patients were transferred to our KRW. We divided our 122 patients’ data randomly into halves of training and validation datasets. Prediction One made three prediction models from the training dataset using (1) variables at the acute care ward admission, (2) those at the KRW admission, and (3) those combined (1) and (2). The models’ determination coefficients (R²), correlation coefficients (rs), and residuals were calculated using the validation dataset.

Results

Of the 122 patients, the median age was 71, length of stay (LOS) in acute care ward 23 (17-30) days, LOS in KRW 53 days, total FIM scores at the admission of KRW 85, those at discharge 108. The mean FIM gain and FIM efficiency were 19 and 0.417. All patients were discharged home. Model (1), (2), and (3)’s R² were 0.794, 0.970, and 0.972. Their mean residuals between the predicted and actual total FIM scores were -1.56±24.6, -4.49±17.1, and -2.69±15.7.

Conclusion

Our FIM gain and efficiency were better than national averages of FIM gain 17.1 and FIM efficiency 0.187. We made DL-based total FIM score prediction models, and their accuracies were superior to those of previous statistically calculated ones. The DL-based FIM score prediction models would save medical costs and perform efficient stroke and rehabilitation medicine.

Easily Created Prediction Model Using Automated Artificial Intelligence Framework (Prediction One, Sony Network Communications Inc., Tokyo, Japan) for Subarachnoid Hemorrhage Outcomes Treated by Coiling and Delayed Cerebral Ischemia

Introduction Reliable prediction models of subarachnoid hemorrhage (SAH) outcomes and delayed cerebral ischemia (DCI) are needed to decide the treatment strategy. Automated artificial intelligence (AutoAI) is attractive, but there are few reports on AutoAI-based models for SAH functional outcomes and DCI. We herein made models using an AutoAI framework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to other previous statistical prediction scores. Methods We used an open dataset of 298 SAH patients, who were with non-severe neurological grade and treated by coiling. Modified Rankin Scale 0-3 at six months was defined as a favorable functional outcome and DCI occurrence as another outcome. We randomly divided them into a 248-patient training dataset and a 50-patient test dataset. Prediction One made the model using training dataset with 5-fold cross-validation. We evaluated the model using the test dataset and compared the area under the curves (AUCs) of the created models. Those of the modified SAFIRE score and the Fisher computed tomography (CT) scale to predict the outcomes. Results The AUCs of the AutoAI-based models for functional outcome in the training and test dataset were 0.994 and 0.801, and those for the DCI occurrence were 0.969 and 0.650. AUCs for functional outcome calculated using modified SAFIRE score were 0.844 and 0.892. Those for the DCI occurrence calculated using the Fisher CT scale were 0.577 and 0.544. Conclusions We easily and quickly made AutoAI-based prediction models. The models' AUCs were not inferior to the previous prediction models despite the easiness.

Chronic subdural hematoma in patients over 65 years old: Results of using a postoperative cognitive evaluation to determine whether to permit return to driving

Background:

Chronic subdural hematoma (CSDH) is usually associated with good recovery with burr hole irrigation and postoperative drainage under local anesthesia. In Japan, traffic accidents by the elderly drivers over 65 years old are severely increasing, and there is no consensus on whether or not to return to driving after CSDH treatment. We perform a postoperative cognitive assessment. We retrospectively investigated the return-to-driving rate and associated factors.

Methods:

Of the 45 patients over 65 y.o. and who had usually driven, 30 patients wished to drive again. We performed tests composed of Mini-Mental State Examination (MMSE), line cancellation and line bisection task, Kohs block design test, trail making test (TMT)-A and B, Kana-hiroi test, Rey-Osterrieth complex figure test, and behavioral assessment of the dysexecutive syndrome, in order. When all tests’ scores were better than the cutoff values, we let patients drive again. When some of the scores were worse than the cutoff values, we reevaluated the patients at the outpatient every month. If the patients’ scores could not improve at the outpatient, we recommended them to stop driving.

Results:

Nineteen of 30 patients could return to driving. Worse MMSE, Kohs block design test, TMT-A, TMT-B scores, higher age, dementia, or consciousness disturbance as chief complaints were associated with driving disability.

Conclusion:

CSDH is known as treatable dementia. However, we should perform an objective cognitive assessment before discharge because only 63% of the patients over 65 y.o. who wished to drive could return to driving.

Postsurgical functional outcome prediction model using deep learning framework (Prediction One, Sony Network Communications Inc.) for hypertensive intracerebral hemorrhage

BACKGROUND

Reliable prediction models of intracerebral hemorrhage (ICH) outcomes are needed for decision-making of the treatment. Statistically making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on DL-based functional outcome prediction models for ICH outcomes after surgery. We herein made a functional outcome prediction model using DLframework, Prediction One (Sony Network Communications Inc., Tokyo, Japan), and compared it to original ICH score, ICH Grading Scale, and FUNC score.

METHODS

We used 140 consecutive hypertensive ICH patients' data in our hospital between 2012 and 2019. All patients were surgically treated. Modified Rankin Scale 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 100 patients training dataset and 40 patients validation dataset. Prediction One made the prediction model using the training dataset with 5-fold cross-validation. We calculated area under the curves (AUCs) regarding the outcome using the DL-based model, ICH score, ICH Grading Scale, and FUNC score. The AUCs were compared.

RESULTS

The model made by Prediction One using 64 variables had AUC of 0.997 in the training dataset and that of 0.884 in the validation dataset. These AUCs were superior to those derived from ICH score, ICH Grading Scale, and FUNC score.

CONCLUSION

We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the DL-based model was superior to those of previous statistically calculated models.

Standard values for temporal muscle thickness in the Japanese population who undergo brain check-up by magnetic resonance imaging

BACKGROUND

Skeletal muscle mass is an important factor for various diseases' outcomes. The psoas muscle cross-sectional area on the abdominal computed tomography (CT), gait speed, and handgrip strength is used to measure it. However, it is difficult to measure the neurological patients' muscle mass or function because (1) we do not perform abdominal CT. (2) Such patients have impaired consciousness, gait disturbance, paresis, and need of rest. Temporal muscle thickness (TMT) on magnetic resonance imaging (MRI) is now attractive for skeletal muscle volume indicator, but the reference values are not established. We herein investigated the standard value of the Japanese TMT using the brain check-up database by MRI.

METHODS

We retrospectively investigated 360 Japanese individuals from two institutions between 2017 and 2019. We measured TMT on the T1-weighted images in the previously reported way. The associations between TMT and other variables were analyzed.

RESULTS

TMT of 214 women and 146 men, ranging from 35 to 84 years old, was investigated. TMT ranged from 3.69 to 16.90 mm. Mean TMT values were significantly higher in men compared to women except for the over 70-year-old cohort. TMT was correlated to weight and body mass index in both sexes.

CONCLUSION

This is the first retrospective study on the standard TMT values from the Japanese brain check-up database. Our results were just reference values, but these would be useful for further investigation in other neurosurgical and neurological diseases regarding muscle volume or sarcopenia.

Where to make burr hole for endoscopic hematoma removal against intracerebral hemorrhage at the basal ganglia to increase the hematoma removal rate - Comparison between trans-forehead and along-the-long-axis approaches

Background:

Endoscopic hematoma removal is performed to treat intracerebral hemorrhage (ICH) at the basal ganglia. In our hospital, young neurosurgical trainees perform it for the only 1^st to the 3^rd time. We perform a “trans-forehead approach” and hypothesized that our technique would contribute to higher hematoma removal rate and easiness despite their inexperience. We compared our dataset with an open dataset with along-the-long-axis approaches using pre- and intraoperative neuronavigation by well-trained neurosurgeons and tested the utility of our trans-forehead approach.

Methods:

We retrospectively investigated our 17 consecutive patients with hypertensive ICH who underwent endoscopic hematoma removal using the trans-forehead approach. We obtained the open dataset and compared our data with the 12 patients from the open dataset using the inverse probability weighting method. Operative time, hematoma removal rate, postoperative hematoma volume, Glasgow Coma Scale (GCS) on day 7, and modified Rankin Scale (mRS) at 6 months were assessed as outcomes.

Results:

The median age was 68 (interquartile range; 58–78) years. Median postoperative hematoma volume, removal rate, operative time, GCS on day 7, and mRS at 6 months were 9 (2–24) mL, 90 (79–98)%, 53 (41–80) min, 13 (12–13), and 4 (2–5), respectively. The weighted generalized estimating equations revealed that operative time was shorter in the along-the-long-axis group, but other items were not significantly different between the two approaches.

Conclusion:

The hematoma removal rate of endoscopic hematoma removal with the trans-forehead approach by young trainees was not different from that of the along-the-long-axis approach by well-trained neurosurgeons using neuronavigation.

Easily created prediction model using deep learning software (Prediction One, Sony Network Communications Inc.) for subarachnoid hemorrhage outcomes from small dataset at admission

BACKGROUND

Reliable prediction models of subarachnoid hemorrhage (SAH) outcomes are needed for decision-making of the treatment. SAFIRE score using only four variables is a good prediction scoring system. However, making such prediction models needs a large number of samples and time-consuming statistical analysis. Deep learning (DL), one of the artificial intelligence, is attractive, but there were no reports on prediction models for SAH outcomes using DL. We herein made a prediction model using DL software, Prediction One (Sony Network Communications Inc., Tokyo, Japan) and compared it to SAFIRE score.

METHODS

We used 153 consecutive aneurysmal SAH patients data in our hospital between 2012 and 2019. Modified Rankin Scale (mRS) 0-3 at 6 months was defined as a favorable outcome. We randomly divided them into 102 patients training dataset and 51 patients external validation dataset. Prediction one made the prediction model using the training dataset with internal cross-validation. We used both the created model and SAFIRE score to predict the outcomes using the external validation set. The areas under the curve (AUCs) were compared.

RESULTS

The model made by Prediction One using 28 variables had AUC of 0.848, and its AUC for the validation dataset was 0.953 (95%CI 0.900-1.000). AUCs calculated using SAFIRE score were 0.875 for the training dataset and 0.960 for the validation dataset, respectively.

CONCLUSION

We easily and quickly made prediction models using Prediction One, even with a small single-center dataset. The accuracy of the model was not so inferior to those of previous statistically calculated prediction models.

The dataset on the characteristics of the intracerebral hemorrhage patients treated by endoscopic hematoma removal or craniotomy

These data present the characteristics of 148 intracerebral hemorrhage (ICH) patients surgically treated. We retrospectively collected data from the medical records of Suwa Red Cross Hospital, including neurological and physiological symptoms, laboratory data, radiological data on admission, complication rate, Glasgow Coma Scale scores on admission or postoperative day 7, and modified Rankin Scale scores at 6 months. Our two articles on the endoscopic hematoma removal and craniotomy for ICH were based on these data [1,2]. This dataset includes detailed laboratory data and radiological features, and it would be useful for reference value for other neurosurgeons or further analysis.