1
|
Asikainen A, Korja M, Kaprio J, Rautalin I. Case Fatality of Aneurysmal Subarachnoid Hemorrhage Varies by Geographic Region Within Finland: A Nationwide Register-Based Study. Neurology 2023; 101:e1950-e1959. [PMID: 37775314 PMCID: PMC10662974 DOI: 10.1212/wnl.0000000000207850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/03/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Previous studies have reported a substantial between-country variation in the case fatality rates (CFRs) of aneurysmal subarachnoid hemorrhage (SAH). However, contrary to comparisons among countries, nationwide comparisons within countries that focus on populations with equal access to health care and include out-of-hospital deaths in analyses are lacking. Thus, we aimed to investigate whether the SAH CFRs vary between geographic regions within Finland. METHODS We identified all hospitalized and nonhospitalized (sudden-death) cases with aneurysmal SAH in Finland during 1998-2017 through 2 externally validated nationwide registers. According to the municipality of residence, we divided the cases with SAH into 5 geographic regions: Southern, Central, Western, Northern, and Eastern Finland, each served by a University Central Hospital with a neurosurgical service. In addition to overall 30-day CFRs, we computed sudden death rates and 30-day CFRs after hospitalization for each region. Using logistic and Poisson regression models, we calculated regional age-adjusted, sex-adjusted, and year-adjusted odds ratios and annual percent changes with 95% CIs for CFRs. RESULTS During 1998-2017, we identified a total of 9,443 cases with SAH, of which 3,484 (36.9%) occurred in Southern Finland. In comparison with the overall 30-day CFR of Southern Finland (35.1%), the age-adjusted, sex-adjusted, and study year-adjusted odds of SAH death were 32% (16%-50%) higher in Central Finland (42.7%), 39% (23%-58%) higher in Eastern Finland (43.4%), and 52% (33%-74%) higher in Western Finland (47.1%). The regional differences were present among both sexes, in all age groups, in sudden death rates, and in 30-day CFRs after hospitalization. Between 1998 and 2017, the overall 30-day CFRs decreased in Central (2.4% [1.0%-3.8%] per year) and Southern (1.2% [0.2%-2.2%] per year) Finland, whereas CFRs remained stable in the other regions. In the last 4 years of the study period (2014-2017), Southern Finland had the lowest 30-day CFR (16.5%) among hospitalized patients. DISCUSSION SAH CFRs seem to vary significantly even within a country with relatively equal access to health care. Future studies with detailed individual-level data are needed to explore whether health inequities explain the reported findings.
Collapse
Affiliation(s)
- Aleksanteri Asikainen
- From the Department of Neurosurgery (A.A., M.K., I.R.), University of Helsinki and Helsinki University Hospital, Finland; Department of Public Health (A.A.) and Institute for Molecular Medicine FIMM (J.K.), University of Helsinki, Finland; and National Institute for Stroke and Applied Neurosciences (I.R.), Auckland University of Technology, New Zealand.
| | - Miikka Korja
- From the Department of Neurosurgery (A.A., M.K., I.R.), University of Helsinki and Helsinki University Hospital, Finland; Department of Public Health (A.A.) and Institute for Molecular Medicine FIMM (J.K.), University of Helsinki, Finland; and National Institute for Stroke and Applied Neurosciences (I.R.), Auckland University of Technology, New Zealand
| | - Jaakko Kaprio
- From the Department of Neurosurgery (A.A., M.K., I.R.), University of Helsinki and Helsinki University Hospital, Finland; Department of Public Health (A.A.) and Institute for Molecular Medicine FIMM (J.K.), University of Helsinki, Finland; and National Institute for Stroke and Applied Neurosciences (I.R.), Auckland University of Technology, New Zealand
| | - Ilari Rautalin
- From the Department of Neurosurgery (A.A., M.K., I.R.), University of Helsinki and Helsinki University Hospital, Finland; Department of Public Health (A.A.) and Institute for Molecular Medicine FIMM (J.K.), University of Helsinki, Finland; and National Institute for Stroke and Applied Neurosciences (I.R.), Auckland University of Technology, New Zealand
| |
Collapse
|
2
|
Yi HJ, Shin DS, Kim BT. Elevated blood viscosity is associated with delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage. J Stroke Cerebrovasc Dis 2022; 31:106732. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/28/2022] [Accepted: 08/14/2022] [Indexed: 11/21/2022] Open
|
3
|
Rhim JK, Park JJ, Kim H, Jeon JP. Early and Prolonged Mild Hypothermia in Patients with Poor-Grade Subarachnoid Hemorrhage: A Pilot Study. Ther Hypothermia Temp Manag 2022; 12:229-234. [PMID: 36130134 DOI: 10.1089/ther.2022.0013] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
We assessed the feasibility of therapeutic early and prolonged mild hypothermia (MH) in patients with poor-grade subarachnoid hemorrhage (SAH). A retrospective pilot study was conducted for poor-grade SAH patients at two university hospitals from March 2015 to December 2018 who had received MH immediately after coil embolization and maintained a target temperature of 34-35°C for 5 days. A matched controlled design at a 1:2 ratio was used to compare MH therapy outcomes. The primary goal was to assess the two groups' severe functional outcomes at discharge defined as a modified Rankin Scale score of 4-6. The secondary aim was to assess mortality and severe vasospasm depending upon MH. A binary logistic regression analysis was performed to identify relevant risk factors for the outcomes. A total of 54 patients (18 with MH treatment and 36 without MH treatment) were included. Severe functional outcome was significantly decreased in poor-grade SAH patients with MH (n = 7, 38.9%) than those without MH (n = 25, 69.4%; p = 0.031). In patients treated with MH, mortality and severe vasospasm tended to be less common, although the difference was not statistically significant. A binary logistic regression analysis revealed that early and prolonged MH (odds ratio [OR] = 0.156, 95% confidence intervals [CI]: 0.037-0.644) and severe vasospasm (OR = 5.593, 95% CI: 1.372-22.812) were risk factors for severe functional outcomes. This study shows potential therapeutic effect of early and prolonged MH treatment in poor-grade SAH patients. A randomized controlled study with a large number of patients is warranted in the future.
Collapse
Affiliation(s)
- Jong-Kook Rhim
- Department of Neurosurgery, Jeju National University College of Medicine, Jeju, Republic of Korea
| | - Jeong Jin Park
- Department of Neurology, Konkuk University Medical Center, Seoul, Republic of Korea
| | - Heungcheol Kim
- Department of Radiology, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Jin Pyeong Jeon
- Department of Neurosurgery, Hallym University College of Medicine, Chuncheon, Republic of Korea
| |
Collapse
|
4
|
Shah VA, Kazmi SO, Damani R, Harris AH, Hohmann SF, Calvillo E, Suarez JI. Regional Variability in the Care and Outcomes of Subarachnoid Hemorrhage Patients in the United States. Front Neurol 2022; 13:908609. [PMID: 35785364 PMCID: PMC9243235 DOI: 10.3389/fneur.2022.908609] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/25/2022] [Indexed: 11/14/2022] Open
Abstract
Background and Objectives Regional variability in subarachnoid hemorrhage (SAH) care is reported in physician surveys. We aimed to describe variability in SAH care using patient-level data and identify factors impacting hospital outcomes and regional variability in outcomes. Methods A retrospective multi-center cross-sectional cohort study of consecutive non-traumatic SAH patients in the Vizient Clinical Data Base, between January 1st, 2009 and December 30th, 2018 was performed. Participating hospitals were divided into US regions: Northeast, Midwest, South, West. Regional demographics, co-morbidities, severity-of-illness, complications, interventions and discharge outcomes were compared. Multivariable logistic regression was performed to identify factors independently associated with primary outcomes: hospital mortality and poor discharge outcome. Poor discharge outcome was defined by the Nationwide Inpatient Sample-SAH Outcome Measure, an externally-validated outcome measure combining death, discharge disposition, tracheostomy and/or gastrostomy. Regional variability in the associations between care and outcomes were assessed by introducing an interaction term for US region into the models. Results Of 109,034 patients included, 24.3% were from Northeast, 24.9% Midwest, 34.9% South, 15.9% West. Mean (SD) age was 58.6 (15.6) years and 64,245 (58.9%) were female. In-hospital mortality occurred in 21,991 (20.2%) and 44,159 (40.5%) had poor discharge outcome. There was significant variability in severity-of-illness, co-morbidities, complications and interventions across US regions. Notable findings were higher prevalence of surgical clipping (18.8 vs. 11.6%), delayed cerebral ischemia (4.3 vs. 3.1%), seizures (16.5 vs. 14.8%), infections (18 vs. 14.7%), length of stay (mean [SD] days; 15.7 [19.2] vs. 14.1 [16.7]) and health-care direct costs (mean [SD] USD; 80,379 [98,999]. vs. 58,264 [74,430]) in the West when compared to other regions (all p < 0.0001). Variability in care was also associated with modest variability in hospital mortality and discharge outcome. Aneurysm repair, nimodipine use, later admission-year, endovascular rescue therapies reduced the odds for poor outcome. Age, severity-of-illness, co-morbidities, hospital complications, and vasopressor use increased those odds (c-statistic; mortality: 0.77; discharge outcome: 0.81). Regional interaction effect was significant for admission severity-of-illness, aneurysm-repair and nimodipine-use. Discussion Multiple hospital-care factors impact SAH outcomes and significant variability in hospital-care and modest variability in discharge-outcomes exists across the US. Variability in SAH-severity, nimodipine-use and aneurysm-repair may drive variability in outcomes.
Collapse
Affiliation(s)
- Vishank A. Shah
- Division of Neurosciences Critical Care, Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
- *Correspondence: Vishank A. Shah
| | | | - Rahul Damani
- Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Alyssa Hartsell Harris
- Center for Advanced Analytics and Informatics, Vizient, Inc., Chicago, IL, United States
| | - Samuel F. Hohmann
- Center for Advanced Analytics and Informatics, Vizient, Inc., Chicago, IL, United States
| | - Eusebia Calvillo
- Division of Neurosciences Critical Care, Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Jose I. Suarez
- Division of Neurosciences Critical Care, Department of Neurology, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| |
Collapse
|
5
|
Schmidt TP, Albanna W, Weiss M, Veldeman M, Conzen C, Nikoubashman O, Blume C, Kluger DS, Clusmann H, Loosen SH, Schubert GA. The Role of Soluble Urokinase Plasminogen Activator Receptor (suPAR) in the Context of Aneurysmal Subarachnoid Hemorrhage (aSAH)—A Prospective Observational Study. Front Neurol 2022; 13:841024. [PMID: 35359651 PMCID: PMC8960720 DOI: 10.3389/fneur.2022.841024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/31/2022] [Indexed: 01/04/2023] Open
Abstract
Objective Outcome after aneurysmal subarachnoid hemorrhage (aSAH) is highly variable and largely determined by early brain injury and delayed cerebral ischemia (DCI). Soluble urokinase plasminogen activator receptor (suPAR) represents a promising inflammatory marker which has previously been associated with outcome in traumatic brain injury and stroke patients. However, its relevance in the context of inflammatory changes after aSAH is unclear. Here, we aimed to characterize the role of circulating suPAR in both serum and cerebrospinal fluid (CSF) as a novel biomarker for aSAH patients. Methods A total of 36 aSAH patients, 10 control patients with unruptured abdominal aneurysm and 32 healthy volunteers were included for analysis. suPAR was analyzed on the day of admission in all patients. In aSAH patients, suPAR was also determined on the day of DCI and the respective time frame in asymptomatic patients. One- and two-sample t-tests were used for simple difference comparisons within and between groups. Regression analysis was used to assess the influence of suPAR levels on outcome in terms of modified Rankin score. Results Significantly elevated suPAR serum levels (suPAR-SL) on admission were found for aSAH patients compared to healthy controls, but not compared to vascular control patients. Disease severity as documented according to Hunt and Hess grade and modified Fisher grade was associated with higher suPAR CSF levels (suPAR-CSFL). In aSAH patients, suPAR-SL increased daily by 4%, while suPAR-CSFL showed a significantly faster daily increase by an average of 22.5% per day. Each increase of the suPAR-SL by 1 ng/ml more than tripled the odds of developing DCI (OR = 3.06). While admission suPAR-CSFL was not predictive of DCI, we observed a significant correlation with modified Rankin's degree of disability at discharge. Conclusion Elevated suPAR serum level on admission as a biomarker for early inflammation after aSAH is associated with an increased risk of DCI. Elevated suPAR-CSFL levels correlate with a higher degree of disability at discharge. These distinct relations and the observation of a continuous increase over time affirm the role of inflammation in aSAH and require further study.
Collapse
Affiliation(s)
- Tobias P. Schmidt
- Department of Neurosurgery, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Hospital, Aachen, Germany
- *Correspondence: Tobias P. Schmidt
| | - Walid Albanna
- Department of Neurosurgery, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Hospital, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Hospital, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Hospital, Aachen, Germany
| | - Catharina Conzen
- Department of Neurosurgery, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Hospital, Aachen, Germany
| | - Omid Nikoubashman
- Clinic for Diagnostic and Interventional Neuroradiology, RWTH Aachen University Hospital, Aachen, Germany
| | - Christian Blume
- Department of Neurosurgery, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Hospital, Aachen, Germany
| | - Daniel S. Kluger
- Institute for Biomagnetism and Biosignal Analysis, University of Münster, Münster, Germany
| | - Hans Clusmann
- Department of Neurosurgery, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Hospital, Aachen, Germany
| | - Sven H. Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Gerrit A. Schubert
- Department of Neurosurgery, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University Hospital, Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
- Gerrit A. Schubert
| |
Collapse
|
6
|
Labeyrie MA, Simonato D, Gargalas S, Morisson L, Cortese J, Ganau M, Fuschi M, Patel J, Froelich S, Gaugain S, Chousterman B, Houdart E. Intensive therapies of delayed cerebral ischemia after subarachnoid hemorrhage: a propensity-matched comparison of different center-driven strategies. Acta Neurochir (Wien) 2021; 163:2723-2731. [PMID: 34302553 DOI: 10.1007/s00701-021-04935-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 07/01/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Intensive therapies of delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage (aSAH) have still controversial and unproven benefit. We aimed to compare the overall efficacy of two different center-driven strategies for the treatment of DCI respectively with and without vasospasm angioplasty. METHODS Two hundred consecutive patients with aSAH were enrolled in each of two northern European centers. In an interventional center, vasospasm angioplasty was indicated as first line rather than rescue treatment of DCI using distal percutaneous balloon angioplasty technique combined with intravenous milrinone. In non-interventional center, induced hypertension was the only intensive therapy of DCI. Radiological DCI (new cerebral infarcts not visible on immediate post-treatment imaging), death at 1 month, and favorable outcome at 6 months (modified Rankin scale score ≤ 2) were retrospectively analyzed by independent observers and compared between two centers before and after propensity score (PS) matching for baseline characteristics. RESULTS Baseline characteristics only differed between centers for age and rate of smokers and patients with chronic high blood pressure. In the interventional center, vasospasm angioplasty was performed in 38% of patients with median time from bleeding of 8 days (Q1 = 6.5;Q3 = 10). There was no significant difference of incidence of radiological DCI (9% vs.14%, P = 0.11), death (8% vs. 9%, P = 0.4), and favorable outcome 74% vs. 72% (P = 0.4) between interventional and non-interventional centers before and after PS matching. CONCLUSIONS Our results suggest either that there is no benefit, or might be minimal, of one between two different center-driven strategies for intensive treatment of DCI. Despite potential lack of power or unknown confounders in our study, these results question the use of such intensive therapies in daily practice without further optimization and validation.
Collapse
Affiliation(s)
- Marc-Antoine Labeyrie
- Interventional Neuroradiology Unit, Hôpital Lariboisière, Université de Paris, 2 rue Ambroise Paré, 75010, Paris, France.
| | - Davide Simonato
- Interventional Neuroradiology Unit, John Radcliffe Hospital, Oxford, UK
| | - Sergios Gargalas
- Interventional Neuroradiology Unit, John Radcliffe Hospital, Oxford, UK
| | - Louis Morisson
- Intensive Care Unit, Hôpital Lariboisière, Université de Paris, Paris, France
| | - Jonathan Cortese
- Interventional Neuroradiology Unit, Hôpital Lariboisière, Université de Paris, 2 rue Ambroise Paré, 75010, Paris, France
| | - Mario Ganau
- Neurosurgery Unit, John Radcliffe Hospital, Oxford, UK
| | - Maurizio Fuschi
- Interventional Neuroradiology Unit, John Radcliffe Hospital, Oxford, UK
| | - Jash Patel
- Neurosurgery Unit, John Radcliffe Hospital, Oxford, UK
| | - Sébastien Froelich
- Neurosurgery Unit, Hôpital Lariboisière, Université de Paris, Paris, France
| | - Samuel Gaugain
- Intensive Care Unit, Hôpital Lariboisière, Université de Paris, Paris, France
| | - Benjamin Chousterman
- Intensive Care Unit, Hôpital Lariboisière, Université de Paris, Paris, France
- UMR 1123, Université de Paris, INSERM, Paris, France
| | - Emmanuel Houdart
- Interventional Neuroradiology Unit, Hôpital Lariboisière, Université de Paris, 2 rue Ambroise Paré, 75010, Paris, France
| |
Collapse
|
7
|
Claassen J, Akbari Y, Alexander S, Bader MK, Bell K, Bleck TP, Boly M, Brown J, Chou SHY, Diringer MN, Edlow BL, Foreman B, Giacino JT, Gosseries O, Green T, Greer DM, Hanley DF, Hartings JA, Helbok R, Hemphill JC, Hinson HE, Hirsch K, Human T, James ML, Ko N, Kondziella D, Livesay S, Madden LK, Mainali S, Mayer SA, McCredie V, McNett MM, Meyfroidt G, Monti MM, Muehlschlegel S, Murthy S, Nyquist P, Olson DM, Provencio JJ, Rosenthal E, Sampaio Silva G, Sarasso S, Schiff ND, Sharshar T, Shutter L, Stevens RD, Vespa P, Videtta W, Wagner A, Ziai W, Whyte J, Zink E, Suarez JI. Proceedings of the First Curing Coma Campaign NIH Symposium: Challenging the Future of Research for Coma and Disorders of Consciousness. Neurocrit Care 2021; 35:4-23. [PMID: 34236619 PMCID: PMC8264966 DOI: 10.1007/s12028-021-01260-x] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/15/2021] [Indexed: 01/04/2023]
Abstract
Coma and disorders of consciousness (DoC) are highly prevalent and constitute a burden for patients, families, and society worldwide. As part of the Curing Coma Campaign, the Neurocritical Care Society partnered with the National Institutes of Health to organize a symposium bringing together experts from all over the world to develop research targets for DoC. The conference was structured along six domains: (1) defining endotype/phenotypes, (2) biomarkers, (3) proof-of-concept clinical trials, (4) neuroprognostication, (5) long-term recovery, and (6) large datasets. This proceedings paper presents actionable research targets based on the presentations and discussions that occurred at the conference. We summarize the background, main research gaps, overall goals, the panel discussion of the approach, limitations and challenges, and deliverables that were identified.
Collapse
Affiliation(s)
- Jan Claassen
- Department of Neurology, Columbia University and New York-Presbyterian Hospital, 177 Fort Washington Avenue, MHB 8 Center, Room 300, New York City, NY, 10032, USA.
| | - Yama Akbari
- Departments of Neurology, Neurological Surgery, and Anatomy & Neurobiology and Beckman Laser Institute and Medical Clinic, University of California, Irvine, Irvine, CA, USA
| | - Sheila Alexander
- Acute and Tertiary Care, School of Nursing and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - Kathleen Bell
- Department of Physical Medicine and Rehabilitation, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Thomas P Bleck
- Davee Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Melanie Boly
- Department of Neurology, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Jeremy Brown
- Office of Emergency Care Research, Division of Clinical Research, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
| | - Sherry H-Y Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Michael N Diringer
- Department of Neurology, Washington University in St. Louis, St. Louis, MO, USA
| | - Brian L Edlow
- Department of Neurology, Center for Neurotechnology and Neurorecovery, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, MA, USA
| | - Brandon Foreman
- Departments of Neurology and Rehabilitation Medicine, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Joseph T Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Olivia Gosseries
- GIGA Consciousness After Coma Science Group, University of Liege, Liege, Belgium
| | - Theresa Green
- School of Nursing, Queensland University of Technology, Kelvin Grove, QLD, Australia
| | - David M Greer
- Department of Neurology, School of Medicine, Boston University, Boston, MA, USA
| | - Daniel F Hanley
- Division of Brain Injury Outcomes, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jed A Hartings
- Department of Neurosurgery, College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Raimund Helbok
- Neurocritical Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - J Claude Hemphill
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - H E Hinson
- Department of Neurology, School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Karen Hirsch
- Department of Neurology, Stanford University, Palo Alto, CA, USA
| | - Theresa Human
- Department of Pharmacy, Barnes Jewish Hospital, St. Louis, MO, USA
| | - Michael L James
- Departments of Anesthesiology and Neurology, Duke University, Durham, NC, USA
| | - Nerissa Ko
- Department of Neurology, Weill Institute for Neurosciences, School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Daniel Kondziella
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Department of Neurology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sarah Livesay
- College of Nursing, Rush University, Chicago, IL, USA
| | - Lori K Madden
- Center for Nursing Science, University of California, Davis, Sacramento, CA, USA
| | - Shraddha Mainali
- Department of Neurology, The Ohio State University, Columbus, OH, USA
| | - Stephan A Mayer
- Department of Neurology, New York Medical College, Valhalla, NY, USA
| | - Victoria McCredie
- Interdepartmental Division of Critical Care, Department of Respirology, University of Toronto, Toronto, ON, Canada
| | - Molly M McNett
- College of Nursing, The Ohio State University, Columbus, OH, USA
| | - Geert Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven and University of Leuven, Leuven, Belgium
| | - Martin M Monti
- Departments of Neurosurgery and Psychology, Brain Injury Research Center, University of California, Los Angeles, Los Angeles, CA, USA
| | - Susanne Muehlschlegel
- Departments of Neurology, Anesthesiology/Critical Care, and Surgery, Medical School, University of Massachusetts, Worcester, MA, USA
| | - Santosh Murthy
- Department of Neurology, Weill Cornell Medical College, New York City, NY, USA
| | - Paul Nyquist
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - DaiWai M Olson
- Departments of Neurology and Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - J Javier Provencio
- Departments of Neurology and Neuroscience, School of Medicine, University of Virginia, Charlottesville, VA, USA
| | - Eric Rosenthal
- Department of Neurology, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gisele Sampaio Silva
- Department of Neurology, Albert Einstein Israelite Hospital and Universidade Federal de São Paulo, São Paulo, Brazil
| | - Simone Sarasso
- Department of Biomedical and Clinical Sciences "L. Sacco", Università degli Studi di Milano, Milan, Italy
| | - Nicholas D Schiff
- Department of Neurology and Brain Mind Research Institute, Weill Cornell Medicine, Cornell University, New York City, NY, USA
| | - Tarek Sharshar
- Department of Intensive Care, Paris Descartes University, Paris, France
| | - Lori Shutter
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Robert D Stevens
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Paul Vespa
- Departments of Neurosurgery and Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Walter Videtta
- National Hospital Alejandro Posadas, Buenos Aires, Argentina
| | - Amy Wagner
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Wendy Ziai
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - John Whyte
- Moss Rehabilitation Research Institute, Elkins Park, PA, USA
| | - Elizabeth Zink
- Division of Neurosciences Critical Care, Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| |
Collapse
|
8
|
Veldeman M, Lepore D, Höllig A, Clusmann H, Stoppe C, Schubert GA, Albanna W. Procalcitonin in the context of delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Neurosurg 2021; 135:29-37. [PMID: 32886914 DOI: 10.3171/2020.5.jns201337] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 05/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Aneurysmal subarachnoid hemorrhage (aSAH) initiates a deleterious cascade activating multiple inflammatory processes, which can contribute to delayed cerebral ischemia (DCI). Procalcitonin (PCT) is an established marker for sepsis treatment monitoring, and its time course in the context of DCI after aSAH remains unclear. The aim of this trial was to assess the predictive and confirmative value of PCT levels in the context of DCI. METHODS All patients admitted to the authors' institution with aSAH between 2014 and 2018 were prospectively screened for eligibility. Daily PCT levels were recorded alongside relevant aSAH characteristics. The predictive and confirmative values of PCT levels were assessed using a receiver operating characteristic and area under the curve (AUC) analysis. The course of PCT levels around the DCI event was evaluated in an infection-free subgroup of patients. RESULTS A total of 132 patients with aSAH were included. Early PCT levels (first 3 days post-aSAH) had a low predictive value for the development of DCI (AUC 0.661, standard error [SE] 0.050; p = 0.003) and unfavorable long-term outcome (i.e., Glasgow Outcome Scale-Extended scores 1-4; AUC 0.674, SE 0.054; p = 0.003). In a subgroup analysis of infection-free patients (n = 72), PCT levels were higher in patients developing DCI (p = 0.001) and DCI-related cerebral infarction (p = 0.002). PCT concentrations increased gradually after DCI and decreased with successful intervention. In refractory cases progressing to cerebral infarction, PCT levels showed a secondary increase. CONCLUSIONS Early higher PCT levels were associated with the later development of DCI and unfavorable outcome. Analysis of PCT beyond the first couple of days after hemorrhage is hampered by nosocomial infections. In infection-free patients, however, PCT levels rise during DCI and an additional increase develops in patients developing cerebral infarction. Clinical trial registration no.: NCT02142166 (clinicaltrials.gov).
Collapse
Affiliation(s)
| | - Daniel Lepore
- 2Intensive Care and Intermediate Care, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany; and
- 3Department of Anesthesia and Intensive Care Medicine, Centre Hospitalier Universitaire de Liège, Belgium
| | | | | | - Christian Stoppe
- 2Intensive Care and Intermediate Care, Rheinisch-Westfälische Technische Hochschule (RWTH) Aachen University, Aachen, Germany; and
| | | | | |
Collapse
|
9
|
Veldeman M, Weiss M, Simon TP, Hoellig A, Clusmann H, Albanna W. Body mass index and leptin levels in serum and cerebrospinal fluid in relation to delayed cerebral ischemia and outcome after aneurysmal subarachnoid hemorrhage. Neurosurg Rev 2021; 44:3547-3556. [PMID: 33866464 PMCID: PMC8593057 DOI: 10.1007/s10143-021-01541-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/24/2021] [Accepted: 04/07/2021] [Indexed: 11/28/2022]
Abstract
Aneurysmal subarachnoid hemorrhage (SAH) is associated with a high mortality rate and may leave surviving patients severely disabled. After the initial hemorrhage, clinical outcome is further compromised by the occurrence of delayed cerebral ischemia (DCI). Overweight and obesity have previously been associated with protective effects in the post-bleeding phase. The aim of this study was to assess the effects of a patient’s body mass index (BMI) and leptin levels on the occurrence of DCI, DCI-related cerebral infarction, and clinical outcome. In total, 263 SAH patients were included of which leptin levels were assessed in 24 cases. BMI was recorded along disease severity documented by the Hunt and Hess and modified Fisher scales. The occurrence of clinical or functional DCI (neuromonitoring, CT Perfusion) was assessed. Long-term clinical outcome was documented after 12 months (extended Glasgow outcome scale). A total of 136 (51.7%) patients developed DCI of which 72 (27.4%) developed DCI-related cerebral infarctions. No association between BMI and DCI occurrence (P = .410) or better clinical outcome (P = .643) was identified. Early leptin concentration in serum (P = .258) and CSF (P = .159) showed no predictive value in identifying patients at risk of unfavorable outcomes. However, a significant increase of leptin levels in CSF occurred from 326.0 pg/ml IQR 171.9 prior to DCI development to 579.2 pg/ml IQR 211.9 during ongoing DCI (P = .049). In our data, no association between obesity and clinical outcome was detected. After DCI development, leptin levels in CSF increased either by an upsurge of active transport or disruption of the blood-CSF barrier. This trial has been registered at ClinicalTrials.gov (NCT02142166) as part of a larger-scale prospective data collection. BioSAB: https://clinicaltrials.gov/ct2/show/NCT02142166
Collapse
Affiliation(s)
- Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Tim Philipp Simon
- Department of Intensive Care and Intermediate Care, RWTH Aachen University, Aachen, Germany
| | - Anke Hoellig
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University Hospital, Pauwelsstrasse 30, 52074, Aachen, Germany.
| |
Collapse
|
10
|
de Winkel J, van der Jagt M, Lingsma HF, Roozenbeek B, Calvillo E, Chou SHY, Dziedzic PH, Etminan N, Huang J, Ko NU, Loch MacDonald R, Martin RL, Potu NR, Venkatasubba Rao CP, Vergouwen MDI, Suarez JI. International Practice Variability in Treatment of Aneurysmal Subarachnoid Hemorrhage. J Clin Med 2021; 10:jcm10040762. [PMID: 33672807 PMCID: PMC7917699 DOI: 10.3390/jcm10040762] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Revised: 02/03/2021] [Accepted: 02/07/2021] [Indexed: 12/18/2022] Open
Abstract
Prior research suggests substantial between-center differences in functional outcome following aneurysmal subarachnoid hemorrhage (aSAH). One hypothesis is that these differences are due to practice variability. To characterize practice variability, we sent a survey to 230 centers, of which 145 (63%) responded. Survey respondents indicated that an estimated 65% of ruptured aneurysms were treated endovascularly. Sixty-five percent of aneurysms were treated within 24 h of symptom onset, 18% within 24–48 h, and eight percent within 48–72 h. Centers in the United States (US) and Europe (EU) treat aneurysms more often endovascularly (72% and 70% vs. 51%, respectively, US vs. other p < 0.001, and EU vs. other p < 0.01) and more often within 24 h (77% and 64% vs. 46%, respectively, US vs. other p < 0.001, EU vs. other p < 0.01) compared to other centers. Most centers aim for euvolemia (96%) by administrating intravenous fluids to 0 (53%) or +500 mL/day (41%) net fluid balance. Induced hypertension is more often used in US centers (100%) than in EU (87%, p < 0.05) and other centers (81%, p < 0.05), and endovascular therapies for cerebral vasospasm are used more often in US centers than in other centers (91% and 60%, respectively, p < 0.05). We observed significant practice variability in aSAH treatment worldwide. Future comparative effectiveness research studies are needed to investigate how practice variation leads to differences in functional outcome.
Collapse
Affiliation(s)
- Jordi de Winkel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (J.d.W.); (B.R.)
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Hester F. Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands;
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, 3000 CA Rotterdam, The Netherlands; (J.d.W.); (B.R.)
| | - Eusebia Calvillo
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Sherry H-Y. Chou
- Departments of Critical Care Medicine, Neurology, and Neurosurgery, School of Medicine, University of Pittsburgh, Pittsburgh, PA 15260, USA;
| | - Peter H. Dziedzic
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Nima Etminan
- Department of Neurosurgery, University of Heidelberg School of Medicine, 69117 Mannheim, Germany;
| | - Judy Huang
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA;
| | - Nerissa U. Ko
- Department of Neurology, UCSF Weill Institute for Neurosciences, UCSF School of Medicine, San Francisco, CA 94143, USA;
| | - Robert Loch MacDonald
- UCSF Fresno Department of Neurosurgery, UCSF School of Medicine, University Neuroscience Institute, Fresno, CA 93701, USA;
| | - Renee L. Martin
- Department of Biostatistics and Epidemiology, Medical University of South Carolina, Charleston, SC 29425, USA;
| | - Niteesh R. Potu
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA; (E.C.); (P.H.D.); (N.R.P.)
| | - Chethan P. Venkatasubba Rao
- Departments of Neurology, Neurosurgery, and Center for Space medicine, Baylor College of Medicine, Houston, TX 77030, USA;
| | - Mervyn D. I. Vergouwen
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, 3508 GA Utrecht, The Netherlands;
| | - Jose I. Suarez
- Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
- Correspondence:
| |
Collapse
|
11
|
Outcome prediction in aneurysmal subarachnoid hemorrhage: a comparison of machine learning methods and established clinico-radiological scores. Neurosurg Rev 2021; 44:2837-2846. [PMID: 33474607 PMCID: PMC8490233 DOI: 10.1007/s10143-020-01453-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 11/11/2020] [Accepted: 12/01/2020] [Indexed: 01/16/2023]
Abstract
Reliable prediction of outcomes of aneurysmal subarachnoid hemorrhage (aSAH) based on factors available at patient admission may support responsible allocation of resources as well as treatment decisions. Radiographic and clinical scoring systems may help clinicians estimate disease severity, but their predictive value is limited, especially in devising treatment strategies. In this study, we aimed to examine whether a machine learning (ML) approach using variables available on admission may improve outcome prediction in aSAH compared to established scoring systems. Combined clinical and radiographic features as well as standard scores (Hunt & Hess, WFNS, BNI, Fisher, and VASOGRADE) available on patient admission were analyzed using a consecutive single-center database of patients that presented with aSAH (n = 388). Different ML models (seven algorithms including three types of traditional generalized linear models, as well as a tree bosting algorithm, a support vector machine classifier (SVMC), a Naive Bayes (NB) classifier, and a multilayer perceptron (MLP) artificial neural net) were trained for single features, scores, and combined features with a random split into training and test sets (4:1 ratio), ten-fold cross-validation, and 50 shuffles. For combined features, feature importance was calculated. There was no difference in performance between traditional and other ML applications using traditional clinico-radiographic features. Also, no relevant difference was identified between a combined set of clinico-radiological features available on admission (highest AUC 0.78, tree boosting) and the best performing clinical score GCS (highest AUC 0.76, tree boosting). GCS and age were the most important variables for the feature combination. In this cohort of patients with aSAH, the performance of functional outcome prediction by machine learning techniques was comparable to traditional methods and established clinical scores. Future work is necessary to examine input variables other than traditional clinico-radiographic features and to evaluate whether a higher performance for outcome prediction in aSAH can be achieved.
Collapse
|
12
|
Gao G, Wu X, Feng J, Hui J, Mao Q, Lecky F, Lingsma H, Maas AIR, Jiang J. Clinical characteristics and outcomes in patients with traumatic brain injury in China: a prospective, multicentre, longitudinal, observational study. Lancet Neurol 2020; 19:670-677. [PMID: 32702336 DOI: 10.1016/s1474-4422(20)30182-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 05/02/2020] [Accepted: 05/04/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Large-scale studies are required to better characterise traumatic brain injury (TBI) and to identify the most effective treatment approaches for TBI. However, evidence is scarce and mostly originates from high-income countries. We aimed to describe the existing care for patients with TBI and the outcomes in China. METHODS The Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) China registry is a prospective, multicentre, longitudinal, observational study done in 56 neurosurgical centres across China. We collected data of patients who were admitted to hospital with a clinical diagnosis of TBI and an indication for CT. Patients who were discharged directly from the emergency room were excluded. The primary endpoint was survival on discharge. Prognostic analyses were applied to identify predictors of mortality. Variations in mortality were compared between centres and provinces within China. Mortality was compared with expected mortality, estimated using the CRASH basic model. This study was registered with ClinicalTrials.gov, NCT02210221. FINDINGS From Dec 22, 2014, to Aug 1, 2017, 13 627 patients with TBI from 56 centres were enrolled in the registry. Data from 13 138 patients from 52 hospitals in 22 provinces of China were analysed. Most patients were male (9782 [74%]), with a median age of 48 years (IQR 33-61). The median Glasgow Coma Scale (GCS) score was 13 (IQR 9-15), and the leading cause of injury was road-traffic incident (6548 [50%]). Overall, 637 (5%) patients died, including 552 (20%) patients with severe TBI. Age, GCS score, injury severity score, pupillary light reflex, CT findings (compressed basal cistern and midline shift ≥5 mm), presence of hypoxia, systemic hypotension, altitude higher than >500 m, and GDP per capita were significantly associated with survival in all patients with TBI. Variation in mortality existed between centres and regions. The expected 14-day mortality was 1116 (13%), but 544 (7%) deaths within 14 days were observed (observed to expected ratio 0·49 [95% CI 0·45-0·53]). INTERPRETATION The results show differences in mortality between centres and regions across China, which indicates potential for identifying best practices through comparative effectiveness research. The risk factors identified in prognostic analyses might contribute to developing benchmarks for assessing quality of care. FUNDING None.
Collapse
Affiliation(s)
- Guoyi Gao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Xiang Wu
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Junfeng Feng
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Jiyuan Hui
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Qing Mao
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester Lingsma
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital, Edegem, Belgium; University of Antwerp, Edegem, Belgium
| | - Jiyao Jiang
- Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China; Shanghai Institute of Head Trauma, Shanghai, China; Department of Neurosurgery, The Affiliated Hospital of Southwest Medical University, Luzhou, China; Department of Neurosurgery, The First Affiliated Hospital of Shenzhen University, Shenzhen Second People's Hospital, Shenzhen, China.
| |
Collapse
|
13
|
Scullen T, Amenta PS, Nerva JD, Dumont AS. Commentary: Predicting Long-Term Outcomes After Poor-Grade Aneurysmal Subarachnoid Hemorrhage Using Decision Tree Modeling. Neurosurgery 2020; 87:E293-E295. [DOI: 10.1093/neuros/nyaa074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 02/03/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- Tyler Scullen
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Peter S Amenta
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - John D Nerva
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| | - Aaron S Dumont
- Department of Neurological Surgery, Tulane Medical Center, New Orleans, Louisiana
| |
Collapse
|