Proposing a validated clinical app predicting hospitalization cost for extracranial-intracranial bypass surgery

Cost-Effectiveness Analysis of Encephaloduroarteriosynangiosis Surgery for Symptomatic Intracranial Atherosclerotic Disease

Encephaloduroarteriosynangiosis (EDAS) is a promising treatment for cerebral arterial steno-occlusive disorders, with proven efficacy in moyamoya disease and a growing interest in potential application for patients with symptomatic intracranial atherosclerotic disease, given the early results of intermediate development trials showing reduced rates of recurrence stroke and improved clinical outcomes compared with those patients treated with intense medical management (IMM) alone. Although clinical outcomes are the fundamental goal when considering patient care paradigms, a cost-effective analysis is key to obtaining a comprehensive understanding of the impact EDAS may provide to patients with atherosclerotic disease on a larger scale. Here, we evaluate the EDAS + IMM cost-effectiveness over time in the treatment of intracranial atherosclerotic disease compared with IMM alone.

Prognosis of ischemia recurrence in patients with moderate intracranial atherosclerotic disease using quantitative MRA measurements

PURPOSE

To investigate the relation between delayed ischemic stroke and the intracranial atherosclerotic disease (ICAD) hemodynamics as determined by Non-invasive Optimal Vessel Analysis (NOVA) MRI measurements.

MATERIALS AND METHODS

Thirty-three patients with ICAD were enrolled in this study. All patients underwent clinically indicated angioplasty followed by 2-dimensional phase contrast MR (2D PCMR) performed on a 3.0 Tesla MRI scanner using either a 16-channel neurovascular coil or 32-channel head coil. The volumetric flow rate measurements were calculated from 2D PCMR with Non-invasive Optimal Vessel Analysis (NOVA) software (VasSol, Chicago, IL, USA). Flow rate measurements were obtained in 20 major arteries distal, proximal and within the Circle of Willis. Patients were followed up for six month, and ischemia reoccurrence and location were recorded. Receiver operating characteristic (ROC) analysis was performed using flow rates measurements in the ipsilateral side of the ischemic event occurrence.

RESULTS

Complete set of measurements was achieved in n=34. Left and right hemisphere ischemia recurrence was observed in seven and three cases respectively. Best predictor of ischemic event reoccurrence was flow rate in the middle cerebral artery with area under the ROC of 0.821±0.109.

CONCLUSIONS

This is an effectiveness study to determine whether blood flow measurements in the intracranial vasculature may be predictive of future ischemic events. Our results demonstrated significant correlation between the blood flow measurements using 2D PCMR processed with the NOVA software and the reoccurrence of ischemia. These results support further investigation for using this method for risk stratification of ICAD patients.

Big data, machine learning, and artificial intelligence: a field guide for neurosurgeons

Big data has transformed into a trend phrase in healthcare and neurosurgery, becoming a pervasive and inescapable phrase in everyday life. The upsurge in big data applications is a direct consequence of the drastic boom in information technology as well as the growing number of internet-connected devices called the Internet of Things in healthcare. Compared with business, marketing, and other sectors, healthcare applications are lagging due to a lack of technical knowledge among healthcare workers, technological limitations in acquiring and analyzing the data, and improper governance of healthcare big data. Despite these limitations, the medical literature is flooded with big data-related articles, and most of these are filled with abstruse terminologies such as machine learning, artificial intelligence, artificial neural network, and algorithm. Many of the recent articles are restricted to neurosurgical registries, creating a false impression that big data is synonymous with registries. Others advocate that the utilization of big data will be the panacea to all healthcare problems and research in the future. Without a proper understanding of these principles, it becomes easy to get lost without the ability to differentiate hype from reality. To that end, the authors give a brief narrative of big data analysis in neurosurgery and review its applications, limitations, and the challenges it presents for neurosurgeons and healthcare professionals naive to this field. Awareness of these basic concepts will allow neurosurgeons to understand the literature regarding big data, enabling them to make better decisions and deliver personalized care.

Readmission following extracranial-intracranial bypass surgery in the United States: nationwide rates, causes, risk factors, and volume-driven outcomes

OBJECTIVE

Extracranial-intracranial (EC-IC) bypass surgery remains an important treatment option for patients with moyamoya disease (MMD), intracranial arteriosclerotic disease (ICAD) with symptomatic stenosis despite the best medical management, and complex aneurysms. The therapeutic benefit of cerebral bypass surgery depends on optimal patient selection and the minimization of periprocedural complications. The nationwide burden of readmissions and associated complications following EC-IC bypass surgery has not been previously described. Therefore, the authors sought to analyze a nationwide database to describe the national rates, causes, risk factors, complications, and morbidity associated with readmission following EC-IC bypass surgery for MMD, ICAD, and aneurysms.

METHODS

The Nationwide Readmissions Database (NRD) was queried for the years 2010-2014 to identify patients who had undergone EC-IC bypass for MMD, medically failed symptomatic ICAD, or unruptured aneurysms. Predictor variables included demographics, preexisting comorbidities, indication for surgery, and hospital bypass case volume. A high-volume center (HVC) was defined as one that performed 10 or more cases/year. Outcome variables included perioperative stroke, discharge disposition, length of stay, total hospital costs, and readmission (30 days, 90 days). Multivariable analysis was used to identify predictors of readmission and to study the effect of treatment at HVCs on quality outcomes.

RESULTS

In total, 2500 patients with a mean age of 41 years were treated with EC-IC bypass surgery for MMD (63.1%), ICAD (24.5%), or unruptured aneurysms (12.4%). The 30- and 90-day readmission rates were 7.5% and 14.0%, respectively. Causes of readmission included new stroke (2.5%), wound complications (2.5%), graft failure (1.5%), and other infection (1.3%). In the multivariable analysis, risk factors for readmission included Medicaid/self-pay (OR 1.6, 95% CI 1.1-2.4, vs private insurance), comorbidity score (OR 1.2, 95% CI 1.1-1.4, per additional comorbidity), and treatment at a non-HVC (OR 1.9, 95% CI 1.1-3.0). Treatment at an HVC (17% of patients) was associated with significantly lower rates of nonroutine discharge dispositions (13.4% vs 26.7%, p = 0.004), ischemic stroke within 90 days (0.8% vs 2.9%, p = 0.03), 30-day readmission (3.9% vs 8.2%, p = 0.03), and 90-day readmission (8.6% vs 15.2%, p = 0.01). These findings were confirmed in a multivariable analysis. The authors estimate that centralization to HVCs may result in 333 fewer nonroutine discharges (50% reduction), 12,000 fewer hospital days (44% reduction), 165 fewer readmissions (43%), and a cost savings of $15.3 million (11% reduction).

CONCLUSIONS

Readmission rates for patients after EC-IC bypass are comparable with those after other common cranial procedures and are primarily driven by preexisting comorbidities, socioeconomic status, and treatment at low-volume centers. Periprocedural complications, including stroke, graft failure, and wound complications, occurred at the expected rates, consistent with those in prior clinical series. The centralization of care may significantly reduce perioperative complications, readmissions, and hospital resource utilization.

Cerebrovascular bypass for ruptured aneurysms: A case series

In patients with aneurysmal subarachnoid hemorrhage (aSAH) unfavorable for endovascular or traditional open surgical techniques, surgical revascularization strategies comprise one of remaining limited options. There is nonetheless a paucity of data on the safety and efficacy of bypass in aSAH. In this study, we aimed to investigate complications and outcomes in a cohort of patients with aSAH treated with bypass. A prospective single-surgeon database of consecutive patients treated for aSAH between 2013 and 2018 was retrospectively analyzed. Complications and functional status at discharge were recorded and analyzed for the patients that underwent bypass surgery. Forty patients with aSAH were treated with bypass surgery (23 extracranial-intracranial; 17 intracranial-intracranial). All-cause perioperative mortality was 13% (6 patients). At discharge and at mean 14-month follow up, respectively, 16/40 (40%) and 16/25 (64%) of patients achieved a Glasgow Outcome Score of 4-5. All-cause, in-hospital complications occurred in 28 patients (70%), of which any ischemic complication occurred in 20 patients (50%), 7 (18%) being open surgical complications. This work represents the largest modern series of bypass for aSAH to date. In cases of aSAH unfavorable for endovascular intervention or traditional open surgical techniques, bypass remains a viable option in this complex group of patients.

Differing Surgical Outcomes in a Multiethnic Cohort Suggest Racial Phenotypes in Moyamoya Disease

BACKGROUND

Variable Moyamoya disease (MMD) genotypes and phenotypes between different races have been suggested previously. This study investigates differences in surgical complications and response to revascularization among Asian patients with MMD compared with other ethnicities in North America.

METHODS

From a database of 185 patients with moyamoya presenting to our institution between 1994 and 2015, 85 patients with MMD underwent surgery and constituted the study cohort. Baseline characteristics before surgery, procedure-related complications, length of hospital stay, and outcome variables including stroke and functional outcome were compared between Asian and non-Asian patients. Kaplan-Meier survival analyses were used to compare time to ipsilateral stroke and any cerebrovascular event after bypass.

RESULTS

Our surgical cohort consisted of 27% (23/85) Asian and 73% (62/85) non-Asian patients with MMD with a bimodal age distribution. Among the subset of patients who presented with stroke (n = 55), hemorrhage was significantly more common among Asian patients (P = 0.007). In 120 revascularization procedures, per-operative complication rates were greater among Asian patients while controlling for age, type of surgery, and stroke history (odds ratio 2.94; 95% confidence interval 1.16-7.48; P = 0.02). The mean follow-up time after surgery was 4.57 years. Ipsilateral cerebrovascular event rates were 4.77 per 100 person-years in non-Asian patients and 6.51 per 100 person-years in Asians (P = 0.66). Unfavorable modified Rankin Scale scores (>2) were found in 22% of Asian patients and 8% of non-Asian patients on last follow-up (P = 0.13).

CONCLUSIONS

Asian patients with MMD may be more susceptible to surgical complications and may differ from other races in their response to revascularization. Further long-term prospective studies are needed to investigate these findings.

Correction: Proposing a validated clinical app predicting hospitalization cost for extracranial-intracranial bypass surgery

[This corrects the article DOI: 10.1371/journal.pone.0186758.].