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Mittal AM, Nowicki KW, Mantena R, Cao C, Rochlin EK, Dembinski R, Lang MJ, Gross BA, Friedlander RM. Advances in biomarkers for vasospasm - Towards a future blood-based diagnostic test. World Neurosurg X 2024; 22:100343. [PMID: 38487683 PMCID: PMC10937316 DOI: 10.1016/j.wnsx.2024.100343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2023] [Accepted: 02/21/2024] [Indexed: 03/17/2024] Open
Abstract
Objective Cerebral vasospasm and the resultant delayed cerebral infarction is a significant source of mortality following aneurysmal SAH. Vasospasm is currently detected using invasive or expensive imaging at regular intervals in patients following SAH, thus posing a risk of complications following the procedure and financial burden on these patients. Currently, there is no blood-based test to detect vasospasm. Methods PubMed, Web of Science, and Embase databases were systematically searched to retrieve studies related to cerebral vasospasm, aneurysm rupture, and biomarkers. The study search dated from 1997 to 2022. Data from eligible studies was extracted and then summarized. Results Out of the 632 citations screened, only 217 abstracts were selected for further review. Out of those, only 59 full text articles met eligibility and another 13 were excluded. Conclusions We summarize the current literature on the mechanism of cerebral vasospasm and delayed cerebral ischemia, specifically studies relating to inflammation, and provide a rationale and commentary on a hypothetical future bloodbased test to detect vasospasm. Efforts should be focused on clinical-translational approaches to create such a test to improve treatment timing and prediction of vasospasm to reduce the incidence of delayed cerebral infarction.
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Affiliation(s)
- Aditya M. Mittal
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | | | - Rohit Mantena
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Catherine Cao
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Emma K. Rochlin
- Loyola University Stritch School of Medicine, Maywood, IL, USA
| | - Robert Dembinski
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Michael J. Lang
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Bradley A. Gross
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
| | - Robert M. Friedlander
- University of Pittsburgh Medical Center, Department of Neurosurgery, Pittsburgh, PA, USA
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Belkhir JR, Pease M, McCarthy DJ, Legarretta A, Mittal AM, Crago EA, Gross BA, Lang MJ. Subarachnoid Hemorrhage Outcomes in an Endovascular Right of First Refusal Neurosurgical Environment. World Neurosurg 2024; 181:e524-e532. [PMID: 37879435 PMCID: PMC10842161 DOI: 10.1016/j.wneu.2023.10.091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/27/2023]
Abstract
BACKGROUND Randomized controlled trials demonstrate that endovascular techniques yield improved outcomes compared with microsurgical approaches. However, not all patients are suitable candidates for endovascular management. This study aimed to determine if healthy patients managed microsurgically could achieve functional outcomes comparable to patients managed endovascularly. METHODS Patients treated for ruptured aneurysmal subarachnoid hemorrhage at 2 level 1 stroke centers from January 2012 through December 2020 were retrospectively reviewed. All cases were evaluated in an endovascular right of first refusal neurosurgical environment. We collected relevant clinical and follow-up data and created a generalized linear model to identify differences between patients treated endovascularly versus microsurgically. A propensity score model accounting for these differences was used to predict patient outcomes. Functional outcomes were independently assessed using the modified Rankin Scale (mRS) with good functional outcome defined as modified Rankin Scale score <3. RESULTS The study included 588 patients (211 microsurgical, 377 endovascular); median age was 58 years (interquartile range: 40-86 years); in-hospital mortality was 13%. Age, aneurysm size, and aneurysm location significantly predicted treatment modality (all P < 0.05). After greedy-type matching (210 microsurgical, 210 endovascular), patients managed microsurgically were less likely to be discharged home (odds ratio = 0.6, 95% confidence interval 0.4-0.9, P = 0.01). Functional differences disappeared over time; patients in the 2 treatment arms had similar functional outcomes at 3 months (odds ratio = 1.1, 95% confidence interval 0.7-1.8, P = 0.66) and 1 year after subarachnoid hemorrhage (odds ratio = 1.3, 95% confidence interval 0.8-2.1, P = 0.38). CONCLUSIONS In an endovascular right of first refusal neurosurgical environment, practitioners can treat patients who are not good endovascular candidates microsurgically and achieve functional outcomes comparable to patients managed endovascularly.
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Affiliation(s)
- J Raouf Belkhir
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
| | - Matthew Pease
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - David J McCarthy
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Andrew Legarretta
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Aditya M Mittal
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Elizabeth A Crago
- University of Pittsburgh School of Nursing, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Eagle SR, Mittal AM, Kellogg RT, Vargas J, Nwachuku E, Deng H, Buell TJ, Okonkwo DO, Pease M. Interaction of admission platelet count with current medications and the risk for chronic subdural recurrence. Neurosurg Focus 2023; 55:E4. [PMID: 37778037 DOI: 10.3171/2023.7.focus23240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 07/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE Chronic subdural hematoma (cSDH) has a reported 10%-24% rate of recurrence after surgery, and prognostic models for recurrence have produced equivocal results. The objective of this study was to leverage a data mining algorithm, chi-square automatic interaction detection (CHAID), which can incorporate continuous, nominal, and binary data into a decision tree, to identify the most robust predictors of repeat surgery for cSDH patients. METHODS This was a retrospective cohort study of all patients with SDH from two level 1 trauma centers at a single institution. All patients underwent cSDH evacuation performed by 15 neurosurgeons between 2011 and 2020. The primary outcome was the rate of repeat surgery for recurrent cSDH following the initial evacuation. The authors used CHAID to identify relevant predictors of repeat surgery, including age, sex, comorbidities, postsurgical complications, platelet count prior to the first procedure, midline shift prior to the first procedure, hematoma volume, and preoperative use of anticoagulants, antiplatelets, or statins. RESULTS Sixty (13.8%) of 435 study-eligible patients (average age 74.0 years) had a cSDH recurrence. These patients had 2.0 times greater odds of having used anticoagulants. The final CHAID model had an overall accuracy of 87.4% and an area under the curve of 0.76. According to the model, the predictor with the strongest association with cSDH recurrence was admission platelet count. Approximately 26% of patients (n = 23/87) with an admission platelet count < 157 × 109/L had a cSDH recurrence, whereas none of the 44 patients with admission platelets > 313 × 109/L had a recurrence. Approximately 17% of patients in the 157-313 × 109/L platelet group who had used preoperative statins required a second procedure, which was associated with a 2.3 times increased risk for repeat surgery compared to those who had not used statins preoperatively. Among those who had not used preoperative statins, a platelet count ≤ 179 × 109/L on admission for the first procedure was the strongest differentiator for a second surgery (n = 5/22 [23%]), which increased the risk of recurrence by 4.5 times. Among the patients using preoperative statins, the use of anticoagulants was the strongest differentiator for requiring repeat surgery (n = 11/33 [33%]). CONCLUSIONS The described model identified platelet count on admission as the most important predictor of repeat cSDH surgery, followed by preoperative statin use and anticoagulant use. Critical cutoffs for platelet count were identified, which future studies should evaluate to determine if they are modifiable or reflective of underlying disease states.
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Affiliation(s)
- Shawn R Eagle
- 1Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Aditya M Mittal
- 1Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Ryan T Kellogg
- 2Department of Neurosurgery, University of Virginia, Charlottesville, Virginia; and
| | - Jan Vargas
- 3Department of Neuroendovascular Surgery, Prisma Health-Upstate, Greenville, South Carolina
| | - Enyinna Nwachuku
- 1Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Hansen Deng
- 1Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Thomas J Buell
- 1Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - David O Okonkwo
- 1Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Matthew Pease
- 1Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
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Nowicki KW, Mittal AM, Abou-Al-Shaar H, Rochlin EK, Lang MJ, Gross BA, Friedlander RM. A Future Blood Test to Detect Cerebral Aneurysms. Cell Mol Neurobiol 2023:10.1007/s10571-023-01346-4. [PMID: 37046105 DOI: 10.1007/s10571-023-01346-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Accepted: 04/04/2023] [Indexed: 04/14/2023]
Abstract
Intracranial aneurysms are reported to affect 2-5% of the population. Despite advances in the surgical management of this disease, diagnostic technologies have marginally improved and still rely on expensive or invasive imaging procedures. Currently, there is no blood-based test to detect cerebral aneurysm formation or quantify the risk of rupture. The aim of this review is to summarize current literature on the mechanism of aneurysm formation, specifically studies relating to inflammation, and provide a rationale and commentary on a hypothetical future blood-based test. Efforts should be focused on clinical-translational approaches to create an assay to screen for cerebral aneurysm presence and risk-stratify patients to allow for superior treatment timing and management. Cerebral Aneurysm Blood Test Considerations: There are multiple caveats to development of a putative blood test to detect cerebral aneurysm presence.
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Affiliation(s)
- Kamil W Nowicki
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Aditya M Mittal
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Hussam Abou-Al-Shaar
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Emma K Rochlin
- Loyola University Stritch School of Medicine, Loyola University Medical Center, Maywood, IL, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Robert M Friedlander
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Andrews EG, Hect JL, Mittal AM, Nowicki KW, Agarwal V, Gerszten PC. Tetra-compartmental spinal infection with conus medullaris syndrome: illustrative case. J Neurosurg Case Lessons 2023; 5:CASE22447. [PMID: 36748756 PMCID: PMC10550562 DOI: 10.3171/case22447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/12/2022] [Indexed: 06/18/2023]
Abstract
BACKGROUND Recent literature suggests that spinal infections are increasing in prevalence. Any compartment can be infected in the spine; however, multicompartmental infections are rare. OBSERVATIONS To the authors' knowledge, this report is the only reported case of a tetra-compartmental spinal infection consisting of epidural, subdural, subarachnoid, and intramedullary components with a contiguous lumbar spondylodiscitis resulting in conus medullaris syndrome requiring surgical intervention. LESSONS This case highlights the importance of surgical intervention in severe cases such as the one illustrated in this report. Second, magnetic resonance imaging with and without contrast is required to check for spreading of the infection as these findings may change the surgical approach. Last, the use of intraoperative ultrasound is paramount to evaluate the subdural and intramedullary compartments in severe cases.
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Affiliation(s)
| | | | | | | | - Vikas Agarwal
- Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Mittal AM, Andrews EG, Nowicki KW, Wecht DA, Agarwal V, Monaco EA. Arachnoid webs causing rostral syrinx due to ball-valve effect: an illustrative report of two cases. Br J Neurosurg 2023:1-6. [PMID: 36636902 DOI: 10.1080/02688697.2022.2154749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/17/2022] [Accepted: 11/29/2022] [Indexed: 01/14/2023]
Abstract
An arachnoid web is a pathological formation of the arachnoid membrane. It is a rare phenomenon but is known to lead to syrinx formation in the spinal cord along with pain and neurological deficits. On imaging, the 'scalpel sign' is pathognomonic for an arachnoid web. The etiology of syrinx formation from an arachnoid web is currently unknown. This report documents the only two cases of arachnoid webs with an extensive syrinx in which a likely pathophysiologic mechanism is identified. Both cases presented with motor deficits. The patients had no history of trauma or infection. After extensive workup in both patients and observation of the scalpel sign an arachnoid web was suspected. In both cases, the patients were treated surgically after an arachnoid web was suspected. Intra-operative ultrasound visualized in both cases demonstrates a fenestration in the web that allowed passage of cerebrospinal fluid in a rostral-caudal direction due to a ball-valve effect.
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Affiliation(s)
- Aditya M Mittal
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Edward G Andrews
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kamil W Nowicki
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel A Wecht
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Vikas Agarwal
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Edward A Monaco
- Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Danville, PA, USA
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Mittal AM, Nowicki KW, Fernández-de Thomas RJ, Mayor J, McEnaney RM, Gerszten PC. Intraoperative ultrasound evidence of accidental simultaneous cannulation of the common carotid artery and internal jugular vein: illustrative case. J Neurosurg Case Lessons 2022; 4:CASE22286. [PMID: 36083774 PMCID: PMC9451053 DOI: 10.3171/case22286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 07/27/2022] [Indexed: 01/16/2023]
Abstract
BACKGROUND Establishing central venous access is important to provide fluid resuscitation or medications intravenously to patients. OBSERVATIONS Although accidental cannulation of the internal carotid artery has been reported in the literature, to our knowledge this report is the first documented intraoperative ultrasound video demonstrating accidental and simultaneous common carotid artery and internal jugular cannulation during central line placement in the internal jugular vein. LESSONS Ultrasound use minimizes accidental carotid cannulation during central line placement in the internal jugular vein. Carotid artery puncture can be managed by external application of pressure or surgical reexploration.
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Affiliation(s)
- Aditya M. Mittal
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - Kamil W. Nowicki
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | | | - Jessica Mayor
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ryan M. McEnaney
- Division of Vascular Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Peter C. Gerszten
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
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Jahagirdar OB, Mittal AM, Song-Naba WL, Jha R, Kiven SB, Thompson ST, Connett JE, Gupta K. Diet and gender influence survival of transgenic Berkley sickle cell mice. Haematologica 2019; 104:e331-e334. [PMID: 30765475 DOI: 10.3324/haematol.2018.208322] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Affiliation(s)
- Om B Jahagirdar
- Vascular Biology Center, Division of Hematology, Oncology & Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Aditya M Mittal
- Vascular Biology Center, Division of Hematology, Oncology & Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Waogwende L Song-Naba
- Vascular Biology Center, Division of Hematology, Oncology & Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Ritu Jha
- Vascular Biology Center, Division of Hematology, Oncology & Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Stacy B Kiven
- Vascular Biology Center, Division of Hematology, Oncology & Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - Susan T Thompson
- Vascular Biology Center, Division of Hematology, Oncology & Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
| | - John E Connett
- School of Public Health, Division of Biostatistics, University of Minnesota, Minneapolis, MN, USA
| | - Kalpna Gupta
- Vascular Biology Center, Division of Hematology, Oncology & Transplantation, Department of Medicine, University of Minnesota, Minneapolis, MN
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