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Pahwa B, Kazim SF, Vellek J, Alvarez-Crespo DJ, Shah S, Tarawneh O, Dicpinigaitis AJ, Grandhi R, Couldwell WT, Schmidt MH, Bowers CA. Frailty as a predictor of poor outcomes in patients with chronic subdural hematoma (cSDH): A systematic review of literature. World Neurosurg X 2024; 23:100372. [PMID: 38638610 PMCID: PMC11024655 DOI: 10.1016/j.wnsx.2024.100372] [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: 03/04/2023] [Revised: 03/22/2024] [Accepted: 03/22/2024] [Indexed: 04/20/2024] Open
Abstract
Objective In recent years, frailty has been reported to be an important predictive factor associated with worse outcomes in neurosurgical patients. The purpose of the present systematic review was to analyze the impact of frailty on outcomes of chronic subdural hematoma (cSDH) patients. Methods We performed a systematic review of literature using the PubMed, Cochrane library, Wiley online library, and Web of Science databases following PRISMA guidelines of studies evaluating the effect of frailty on outcomes of cSDH published until January 31, 2023. Results A comprehensive literature search of databases yielded a total of 471 studies. Six studies with 4085 patients were included in our final qualitative systematic review. We found that frailty was associated with inferior outcomes (including mortality, complications, recurrence, and discharge disposition) in cSDH patients. Despite varying frailty scales/indices used across studies, negative outcomes occurred more frequently in patients that were frail than those who were not. Conclusions While the small number of available studies, and heterogenous methodology and reporting parameters precluded us from conducting a pooled analysis, the results of the present systematic review identify frailty as a robust predictor of worse outcomes in cSDH patients. Future studies with a larger sample size and consistent frailty scales/indices are warranted to strengthen the available evidence. The results of this work suggest a strong case for using frailty as a pre-operative risk stratification measure in cSDH patients.
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Affiliation(s)
- Bhavya Pahwa
- Medical Student, University College of Medical Sciences and GTB Hospital, New Delhi, India
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - John Vellek
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Smit Shah
- Department of Neurology, PRISMA Health/University of South Carolina School of Medicine, Columbia, SC, USA
| | - Omar Tarawneh
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
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Vellek J, Tarawneh OH, Kazim SF, Owodunni OP, Arbuiso S, Shah S, Dicpinigaitis AJ, Schmidt MH, McKee RG, Miskimins R, Al-Mufti F, Bowers CA. Andexanet alfa therapy showed No increased rate of thromboembolic events in spontaneous intracranial hemorrhage patients: A multicenter electronic health record study. World Neurosurg X 2024; 23:100367. [PMID: 38590738 PMCID: PMC10999854 DOI: 10.1016/j.wnsx.2024.100367] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 03/06/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024] Open
Abstract
•Intracranial hemorrhage accounts for two out of every three major intracranial hemorrhages.•Systemic anticoagulation is routinely prescribed for prevention of cerebrovascular accidents.•The FDA approved Andexanet alfa to treat life-threatening bleeding.•Andexanet alfa relationship to outcomes requires further investigation.
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Affiliation(s)
- John Vellek
- School of Medicine, New York Medical College, Valhalla, NY, 10595, United States
| | - Omar H. Tarawneh
- School of Medicine, New York Medical College, Valhalla, NY, 10595, United States
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, 87131, United States
| | - Oluwafemi P. Owodunni
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, 87131, United States
| | - Sophia Arbuiso
- School of Medicine, New York Medical College, Valhalla, NY, 10595, United States
| | - Smit Shah
- PRISMA Health Richland/University of South Carolina School of Medicine, 1 Medical Park, Suite 230, Columbia, SC, 29203, United States
| | | | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, 87131, United States
| | - Rohini G. McKee
- Department of Surgery, University of New Mexico, Albuquerque, NM, 87106, United States
| | - Richard Miskimins
- Department of Surgery, University of New Mexico, Albuquerque, NM, 87106, United States
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, 10595, United States
| | - Christian A. Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, UT, United States
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Dicpinigaitis AJ, Syed SA, Al-Mufti J, Medicherla C, Kaur G, Gandhi CD, Al-Mufti F. Endovascular thrombectomy for treatment of isolated posterior cerebral artery occlusion: a real-world analysis of hospitalizations in the United States. Acta Neurochir (Wien) 2024; 166:191. [PMID: 38656712 DOI: 10.1007/s00701-024-06050-w] [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: 02/15/2024] [Accepted: 03/17/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Despite renewed interest and recently demonstrated efficacy for endovascular thrombectomy (EVT) for treatment of acute ischemic stroke (AIS) of the posterior circulation, to date, no randomized clinical trials have been conducted to evaluate EVT for isolated occlusions of the posterior cerebral artery (IPCA). METHODS Hospitalizations for adult patients with primary admission diagnoses of IPCA occlusion were identified in the National Inpatient Sample registry during the period of 2016-2020. The study exposure was treatment with EVT, and primary clinical endpoints included favorable functional outcome (defined as discharge disposition to home without services, previously shown to have high concordance with modified Rankin scale scores 0-2), in-hospital mortality, and any intracranial hemorrhage (ICH). Inverse probability of treatment weighting (IPTW) was performed to balance baseline clinical characteristics between those receiving EVT or medical management (MM). RESULTS This analysis identified 34,880 IPCA occlusion hospitalizations, 730 (2.1%) of which documented treatment with EVT. Following IPTW adjustment, EVT was associated with favorable outcome in IPCA patients presenting with mild deficits (M-D) (NIHSS < 6) [adjusted odds ratio (aOR) 2.36, 95% confidence interval (CI) 2.27, 2.45; p < 0.001] and in those presenting with moderate-to-severe deficits (M-S-D) (NIHSS 6-42) (aOR 2.00, 95% CI 1.86, 2.15; p < 0.001). Mortality rates did not differ among those with M-S-D [EVT 4.8% vs. MM 4.7%, p = 0.742], while ICH rates were lower. CONCLUSION Retrospective analysis of a large administrative registry in the Unites States demonstrates an association of EVT with favorable outcomes following IPCA occlusion, without concomitant risk of hemorrhagic transformation or mortality.
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Affiliation(s)
- Alis J Dicpinigaitis
- Department of Neurology, New York Presbyterian - Weill Cornell Medical Center, New York, NY, USA
| | - Shoaib A Syed
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jude Al-Mufti
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Chaitanya Medicherla
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY, 10595, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY, 10595, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY, 10595, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Macy Pavilion 1331, Valhalla, NY, 10595, USA.
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Courville E, Rumalla K, Kazim SF, Dicpinigaitis AJ, Schmidt M, Robinson TM, Bowers CA. Risk Analysis Index as a preoperative frailty tool for elective ventriculoperitoneal shunt surgery for idiopathic normal pressure hydrocephalus. J Neurosurg 2024; 140:1110-1116. [PMID: 38564806 DOI: 10.3171/2023.7.jns23767] [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: 04/08/2023] [Accepted: 07/27/2023] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Idiopathic normal pressure hydrocephalus (iNPH) predominantly occurs in older patients, and ventriculoperitoneal shunt (VPS) placement is the definitive surgical treatment. VPS surgery carries significant postoperative complication rates, which may tip the risk/benefit balance of this treatment option for frail, or higher-risk, patients. In this study, the authors investigated the use of frailty scoring for preoperative risk stratification for adverse event prediction in iNPH patients who underwent elective VPS placement. METHODS The Nationwide Readmissions Database (NRD) was queried from 2018 to 2019 for iNPH patients aged ≥ 60 years who underwent VPS surgery. Risk Analysis Index (RAI) and modified 5-item Frailty Index (mFI-5) scores were calculated and RAI cross-tabulation was used to analyze trends in frailty scores by the following binary outcome measures: overall complications, nonhome discharge (NHD), extended length of stay (eLOS) (> 75th percentile), and mortality. Area under the receiver operating characteristic curve analysis was performed to assess the discriminatory accuracy of RAI and mFI-5 for primary outcomes. RESULTS A total of 9319 iNPH patients underwent VPS surgery, and there were 685 readmissions (7.4%), 593 perioperative complications (6.4%), and 94 deaths (1.0%). Increasing RAI score was significantly associated with increasing rates of postoperative complications: RAI scores 11-15, 5.4% (n = 80); 16-20, 5.6% (n = 291); 21-25, 7.6% (n = 166); and ≥ 26, 11.6% (n = 56). The discriminatory accuracy of RAI was statistically superior (DeLong test, p < 0.05) to mFI-5 for the primary endpoints of mortality, NHD, and eLOS. All RAI C-statistics were > 0.60 for mortality within 30 days (C-statistic = 0.69, 95% CI 0.68-0.70). CONCLUSIONS In a nationwide database analysis, increasing frailty, as measured by RAI, was associated with NHD, 30-day mortality, unplanned readmission, eLOS, and postoperative complications. Although the RAI outperformed the mFI-5, it is essential to account for the potentially reversible clinical issues related to the underlying disease process, as these factors may inflate frailty scores, assign undue risk, and diminish their utility. This knowledge may enhance provider understanding of the impact of frailty on postoperative outcomes for patients with iNPH, while highlighting the potential constraints associated with frailty assessment tools.
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Affiliation(s)
- Evan Courville
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque; and
- 2Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico
| | - Kavelin Rumalla
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque; and
- 2Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico
| | - Syed Faraz Kazim
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque; and
- 2Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico
| | - Alis J Dicpinigaitis
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque; and
- 2Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico
| | - Meic Schmidt
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque; and
- 2Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico
| | - Timothy M Robinson
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque; and
| | - Christian A Bowers
- 1Department of Neurosurgery, University of New Mexico Hospital, Albuquerque; and
- 2Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico
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Roy JM, Kazim SF, Macciola D, Rangel DN, Rumalla K, Karimov Z, Link R, Iqbal J, Riaz MA, Skandalakis GP, Venero CV, Sidebottom RB, Dicpinigaitis AJ, Kassicieh CS, Tarawneh O, Conlon MS, Thommen R, Alvarez-Crespo DJ, Chhabra K, Sridhar S, Gill A, Vellek J, Nguyen PA, Thompson G, Robinson M, Bowers CA. Frailty as a predictor of postoperative outcomes in neurosurgery: a systematic review. J Neurosurg Sci 2024; 68:208-215. [PMID: 37878249 DOI: 10.23736/s0390-5616.23.06130-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
INTRODUCTION Baseline frailty status has been utilized to predict a wide range of outcomes and guide preoperative decision making in neurosurgery. This systematic review aims to analyze existing literature on the utilization of frailty as a predictor of neurosurgical outcomes. EVIDENCE ACQUISITION We conducted a systematic review following PRISMA guidelines. Studies that utilized baseline frailty status to predict outcomes after a neurosurgical intervention were included in this systematic review. Studies that utilized sarcopenia as the sole measure of frailty were excluded. PubMed, EMBASE, and Cochrane library was searched from inception to March 1st, 2023, to identify relevant articles. EVIDENCE SYNTHESIS Overall, 244 studies met the inclusion criteria. The 11-factor modified frailty index (mFI-11) was the most utilized frailty measure (N.=91, 37.2%) followed by the five-factor modified Frailty Index (mFI-5) (N.=80, 32.7%). Spine surgery was the most common subspecialty (N.=131, 53.7%), followed by intracranial tumor resection (N.=57, 23.3%), and post-operative complications were the most reported outcome (N.=130, 53.2%) in neurosurgical frailty studies. The USA and the Bowers author group published the greatest number of articles within the study period (N.=176, 72.1% and N.=37, 15.2%, respectively). CONCLUSIONS Frailty literature has grown exponentially over the years and has been incorporated into neurosurgical decision making. Although a wide range of frailty indices exist, their utility may vary according to their ability to be incorporated in the outpatient clinical setting.
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Affiliation(s)
- Joanna M Roy
- Topiwala National Medical College, Mumbai, India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
| | - Syed F Kazim
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Dylan Macciola
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Dante N Rangel
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Kavelin Rumalla
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Zafar Karimov
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Remy Link
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Javed Iqbal
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Muhammad A Riaz
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Georgios P Skandalakis
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | | | | | | | | | - Omar Tarawneh
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Matt S Conlon
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Rachel Thommen
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Karizma Chhabra
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Sahaana Sridhar
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA
| | - Amanpreet Gill
- Burrell College of Osteopathic Medicine, Las Cruces, NM, USA
| | - John Vellek
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Phuong A Nguyen
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Grace Thompson
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Myranda Robinson
- School of Medicine, University of New Mexico, Albuquerque, NM, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, NM, USA -
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
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Dicpinigaitis AJ, Fortunato MP, Goyal A, Syed SA, Patel R, Subah G, Rosenberg JB, Bowers CA, Mayer SA, Jankowitz B, Gandhi CD, Al-Mufti F. Mapping geographic disparities in treatment and clinical outcomes of high-grade aneurysmal subarachnoid hemorrhage in the United States. J Neurointerv Surg 2024:jnis-2023-021330. [PMID: 38378239 DOI: 10.1136/jnis-2023-021330] [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: 11/30/2023] [Accepted: 02/03/2024] [Indexed: 02/22/2024]
Abstract
BACKGROUND AND OBJECTIVE Although high-grade (Hunt and Hess 4 and 5) aneurysmal subarachnoid hemorrhage (aSAH) typically portends a poor prognosis, early and aggressive treatment has previously been demonstrated to confer a significant survival advantage. This study aims to evaluate geographic, demographic, and socioeconomic determinants of high-grade aSAH treatment in the United States. METHODS The National Inpatient Sample (NIS) was queried to identify adult high-grade aSAH hospitalizations during the period of 2015 to 2019 using the International Classification of Diseases, 10th Revision, Clinical Modification (ICD) codes. The primary clinical endpoint of this analysis was aneurysm treatment by surgical or endovascular intervention (SEI), while the exposure of interest was geographic region by census division. Favorable functional outcome (assessed by the dichotomous NIS-SAH Outcome Measure, or NIS-SOM) and in-hospital mortality were evaluated as secondary endpoints in treated and conservatively managed groups. RESULTS Among 99 460 aSAH patients identified, 36 795 (37.0%) were high-grade, and 9210 (25.0%) of these were treated by SEI. Following multivariable logistic regression analysis, determinants of treatment by SEI included female sex (adjusted OR (aOR) 1.42, 95% CI 1.35 to 1.51), transfer admission (aOR 1.18, 95% CI 1.12 to 1.25), private insurance (ref: government-sponsored insurance) (aOR 1.21, 95% CI 1.14 to 1.28), and government hospital ownership (ref: private ownership) (aOR 1.17, 95% CI 1.09 to 1.25), while increasing age (by decade) (aOR 0.93, 95% CI 0.91 to 0.95), increasing mortality risk (aOR 0.60, 95% CI 0.57 to 0.63), urban non-teaching hospital status (aOR 0.66, 95% CI 0.59 to 0.73), rural hospital location (aOR 0.13, 95% CI 0.7 to 0.25), small hospital bedsize (aOR 0.68, 95% CI 0.60 to 0.76), and geographic region (South Atlantic (aOR 0.72, 95% CI 0.63 to 0.83), East South Central (aOR 0.75, 95% CI 0.64 to 0.88), and Mountain (aOR 0.72, 95% CI 0.61 to 0.85)) were associated with a lower likelihood of treatment. High-grade aSAH patients treated by SEI experienced significantly greater rates of favorable functional outcomes (20.1% vs 17.3%; OR 1.20, 95% CI 1.13 to 1.28, P<0.001) and lower rates of mortality (25.8% vs 49.1%; OR 0.36, 95% CI 0.34 to 0.38, P<0.001) in comparison to those conservatively managed. CONCLUSION A complex interplay of demographic, socioeconomic, and geographic factors influence treatment patterns of high-grade aSAH in the United States.
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Affiliation(s)
| | | | - Anjali Goyal
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Shoaib A Syed
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Rohan Patel
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Galadu Subah
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Jon B Rosenberg
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Sandy, Utah, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Brian Jankowitz
- Hackensack Meridian Neuroscience Institute, JFK University Medical Center, Hackensack, New Jersey, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- School of Medicine, New York Medical College, Valhalla, New York, USA
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
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7
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Covell MM, Roy JM, Rumalla K, Dicpinigaitis AJ, Kazim SF, Hall DE, Schmidt MH, Bowers CA. The Limited Utility of the Hospital Frailty Risk Score as a Frailty Assessment Tool in Neurosurgery: A Systematic Review. Neurosurgery 2024; 94:251-262. [PMID: 37695046 DOI: 10.1227/neu.0000000000002668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 07/13/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The Hospital Frailty Risk Score (HFRS) is an International Classification of Disease 10th Revision-based scale that was originally designed for, and validated in, the assessment of patients 75 years or older presenting in an acute care setting. This study highlights central tenets inherent to the concept of frailty; questions the logic behind, and utility of, HFRS' recent implementation in the neurosurgical literature; and discusses why there is no useful role for HFRS as a frailty-based neurosurgical risk assessment (FBNRA) tool. METHODS The authors performed a systematic review of the literature per Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, including all cranial and spinal studies that used HFRS as their primary frailty tool. Seventeen (N = 17) studies used HFRS to assess frailty's impact on neurosurgical outcomes. Thirteen total journals, 10 of which were neurosurgical journals, including the highest impact factor journals, published the 17 papers. RESULTS Increasing HFRS score was associated with adverse outcomes, including prolonged length of stay (11 of 17 studies), nonroutine discharge (10 of 17 studies), and increased hospital costs (9 of 17 studies). Four different HFRS studies, of the 17, predicted one of the following 4 adverse outcomes: worse quality of life, worse functional outcomes, reoperation, or in-hospital mortality. CONCLUSION Despite its rapid acceptance and widespread proliferation through the leading neurosurgical journals, HFRS lacks any conceptual relationship to the frailty syndrome or FBNRA for individual patients. HFRS measures acute conditions using International Classification of Disease 10th Revision codes and awards "frailty" points for symptoms and examination findings unrelated to the impaired baseline physiological reserve inherent to the very definition of frailty. HFRS lacks clinical utility as it cannot be deployed point-of-care at the bedside to risk stratify patients. HFRS has never been validated in any patient population younger than 75 years or in any nonacute care setting. We recommend HFRS be discontinued as an individual FBNRA tool.
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Affiliation(s)
- Michael M Covell
- School of Medicine, Georgetown University, Washington , District of Columbia , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Joanna Mary Roy
- Topiwala National Medical College, Mumbai , India
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Alis J Dicpinigaitis
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla , New York , USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh , Pennsylvania , USA
- Center for Health Equity Research and Promotion, Virginia Pittsburgh Healthcare System, Pittsburgh , Pennsylvania , USA
- Wolff Center at UPMC, Pittsburgh , Pennsylvania , USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque , New Mexico , USA
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque , New Mexico , USA
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Dicpinigaitis AJ, Seitz A, Berkin J, Al-Mufti F, Kamel H, Navi BB, Pawar A, White H, Liberman AL. Association of Assisted Reproductive Technology and Stroke During Hospitalization for Delivery in the United States. Stroke 2024. [PMID: 38299332 DOI: 10.1161/strokeaha.124.046419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 01/31/2024] [Indexed: 02/02/2024]
Abstract
Background: Infertility treatment with assisted reproductive technologies (ART) has been associated with adverse vascular events in some, but not all previous studies. Endothelial damage, prothrombotic factor release, and a higher prevalence of cardiovascular risk factors in those receiving ART have been invoked to explain this association. We sought to explore the relationship between ART and stroke risk using population-level data. Methods: We conducted a retrospective cohort study using data from the National Inpatient Sample (NIS) registry from 2015-2020, including all delivery hospitalizations for patients aged 15-55 years. The study exposure was use of ART. The primary endpoint was any stroke defined as ischemic stroke (IS), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), or cerebral venous thrombosis (CVT) during index delivery hospitalization. Individual stroke subtypes (IS, SAH, ICH, and CVT) were evaluated as secondary endpoints. Standard International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) algorithms were used to define study exposure, comorbidities, and prespecified endpoints. In addition to reporting population-level estimates, propensity score (PS) adjustment by inverse probability weighting (IPW) was used to mimic the effects of randomization by balancing baseline clinical characteristics associated with stroke between ART and non-ART users. Results: Among 19,123,125 delivery hospitalizations identified, patients with prior ART (n = 202,815, 1.1%) experienced significantly higher rates of any stroke (27.1/100,000 vs. 9.1/100,000), IS (9.9/100,000 vs. 3.3/100,000), SAH (7.4/100,000 vs. 1.6/100,000), ICH (7.4/100,000 vs. 2.0/100,000), and CVT (7.4/100,000 vs. 2.7/100,000) in comparison to non-ART users (all p < 0.001 for all unadjusted comparisons). Following IPW analysis, ART was associated with increased odds of any stroke (aOR 2.14 [95% CI 2.02-2.26]; p < 0.001). Conclusion: Using population-level data among patients hospitalized for delivery in the United States, we found an association between ART and stroke after adjustment for measured confounders.
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Affiliation(s)
| | - Alison Seitz
- Neurology, New York Presbyterian Hospital - Weill Cornell Medical College, UNITED STATES
| | | | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, UNITED STATES
| | - Hooman Kamel
- Neurology, Weill Cornell Medical College, UNITED STATES
| | - Babak Benjamin Navi
- Neurology and Brain and Mind Research Institute, Weill Cornell Medicine, UNITED STATES
| | | | - Halina White
- Neurology, Weill Cornell Medicine, UNITED STATES
| | - Ava L Liberman
- Clinical and Translational Neuroscience Unit, Department of Neurology, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, UNITED STATES
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9
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Alvarez-Crespo DJ, Conlon M, Kazim SF, Skandalakis GP, Bowers CA, Chhabra K, Tarawneh O, Arbuiso S, Cole KL, Dominguez J, Dicpinigaitis AJ, Vellek J, Thommen R, Bisson EF, Couldwell WT, Cole CD, Schmidt MH. Clinical Characteristics and Surgical Outcomes of 2542 Patients with Spinal Schwannomas: A Systematic Review and Meta-Analysis. World Neurosurg 2024; 182:165-183.e1. [PMID: 38006933 DOI: 10.1016/j.wneu.2023.11.090] [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: 11/14/2023] [Accepted: 11/18/2023] [Indexed: 11/27/2023]
Abstract
OBJECTIVE This study was conducted to systematically analyze the data on the clinical features, surgical treatment, and outcomes of spinal schwannomas. METHODS We conducted a systematic review and meta-analysis under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of bibliographic databases from January 1, 2001, to May 31, 2021, yielded 4489 studies. Twenty-six articles were included in our final qualitative systematic review and quantitative meta-analysis. RESULTS Analysis of 2542 adult patients' data from 26 included studies showed that 53.5% were male, and the mean age ranged from 35.8 to 57.1 years. The most common tumor location was the cervical spine (34.2%), followed by the thoracic spine (26.2%) and the lumbar spine (18.5%). Symptom severity was the most common indicator for surgical treatment, with the most common symptoms being segmental back pain, sensory/motor deficits, and urinary dysfunction. Among all patients analyzed, 93.8% were treated with gross total resection, which was associated with better prognosis and less chance of recurrence than subtotal resection. The posterior approach was the most common (87.4% of patients). The average operative time was 4.53 hours (95% confidence interval [CI], 3.18-6.48); the average intraoperative blood loss was 451.88 mL (95% CI, 169.60-1203.95). The pooled follow-up duration was 40.6 months (95% CI, 31.04-53.07). The schwannoma recurrence rate was 5.3%. Complications were particularly low and included cerebrospinal fluid leakage, wound infection, and the sensory-motor deficits. Most of the patients experienced complete recovery or significant improvement of preoperative neurological deficits and pain symptoms. CONCLUSIONS Our analysis suggests that segmental back pain, sensory/motor deficits, and urinary dysfunction are the most common symptoms of spinal schwannomas. Surgical resection is the treatment of choice with overall good reported outcomes and particularly low complication rates. gross total resection offers the best prognosis with the slightest chance of tumor recurrence and minimal risk of complications.
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Affiliation(s)
| | - Matthew Conlon
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | | | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Karizma Chhabra
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Omar Tarawneh
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Sophia Arbuiso
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Jose Dominguez
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, New York, USA
| | | | - John Vellek
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Rachel Thommen
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Erica F Bisson
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Chad D Cole
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA.
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10
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Zeller SL, Spirollari E, Dicpinigaitis AJ, Wainwright JV, Hanft SJ, Gandhi CD, Jhanwar-Uniyal M. Brain Metastases Are Regulated by Immuno-inflammatory Signaling Pathways Governed by STAT3, MAPK and Tumor Suppressor p53 Status: Possible Therapeutic Targets. Anticancer Res 2024; 44:13-22. [PMID: 38160007 DOI: 10.21873/anticanres.16783] [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: 11/30/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND/AIM Brain metastasis (BM) is a complex multi-step process involving various immune checkpoint proteins. Mitogen-activated protein kinase (MAPK), extracellular signal-regulated kinases 1/2 (ERK1/2), and signal transducer and activator of transcription 3 (STAT3) are implicated in tumorigenesis and are critical upstream regulators of Programmed Death Ligand 1 (PD-L1), an immunotherapy target. Tumor suppressor p53, dysregulated in cancers, regulates STAT3 and ERK1/2 signaling. This study examined the roles of STAT3, MAPK and p53 status in BM initiation and maintenance. MATERIALS AND METHODS Twenty-six BM, with various primary malignancies, were used (IRB-approved) to determine mutant p53 (p53mt), pSTAT3Tyr705, pERK1/2Thr202/Tyr204, and PD-L1 expression using immunohistochemistry. cDNA microarray was used for gene expression analysis. Brain-metastatic breast cancer cells (MDA-MB-231) were treated with STAT3 (NSC74859) or MAPK/ERK1/2 (U0126) inhibitors in regular or astrocytic media. ERK1/2 pathway was assessed using western blotting, and cell proliferation and migration were determined using MTT and scratch-wound assays, respectively. RESULTS pSTAT3Tyr705 and pERK1/2Thr202/Tyr204 were expressed at tumor margins, whereas p53mt and PD-L1 were uniformly expressed, with significant overlap between expression of these proteins. Gene expression analysis identified alterations in 18 p53- and 32 STAT3- or MAPK-associated genes contributing to dysregulated immune responses and cell cycle regulation. U0126 and NSC74859 reduced pERK1/2Thr202/Tyr204 expression. Cell proliferation decreased following each treatment (p≤0.01). Migration stagnated following U0126 treatment in astrocytic media (p≤0.01). CONCLUSION Activation of STAT3 and ERK1/2 promotes BM and provides compelling evidence for use of STAT3, ERK1/2 and p53 status as potential immunotherapeutic targets in BM.
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Affiliation(s)
- Sabrina L Zeller
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, U.S.A
| | - Eris Spirollari
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, U.S.A
| | - Alis J Dicpinigaitis
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, U.S.A
| | - John V Wainwright
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, U.S.A
| | - Simon J Hanft
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, U.S.A
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, U.S.A
| | - Meena Jhanwar-Uniyal
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, U.S.A.
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11
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Dicpinigaitis AJ, Chowdhury A, Gagliardi TA, Soliman Z, Mahmoud NA, Nolan B, Clare K, Willey JZ, Rostanski SK, Medicherla C, Patel N, Kaur G, Chong JY, Bowers CA, Gandhi CD, Al-Mufti F. Effect of chronic antiplatelet therapy on clinical outcomes of endovascular thrombectomy for treatment of acute ischemic stroke. Neurosurg Focus 2023; 55:E20. [PMID: 37778040 DOI: 10.3171/2023.7.focus23365] [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: 05/30/2023] [Accepted: 07/26/2023] [Indexed: 10/03/2023]
Abstract
OBJECTIVE The objective of this study was to investigate the prognostic significance of chronic antiplatelet therapy (APT) usage in acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT). Long-term APT may enhance recanalization but may also predispose patients to an increased risk of hemorrhagic transformation. METHODS Weighted hospitalizations for anterior-circulation AIS treated with EVT were identified in a large United States claims-based registry. Baseline clinical characteristics and outcomes were compared between patients with and without chronic APT usage prior to admission. Multivariable logistic regression analysis was performed to assess adjusted associations between APT and study endpoints. RESULTS This analysis identified 36,560 patients, of whom 8170 (22.3%) were on a chronic APT regimen prior to admission. These patients were older and demonstrated a higher burden of comorbid disease, but had similar stroke severity on presentation in comparison with those not on APT. On unadjusted analysis, patients with prior APT demonstrated higher rates of favorable outcomes (24.3% vs 21.5%, p < 0.001), lower rates of mortality (7.0% vs 10.1%, p < 0.001), and lower rates of any intracranial hemorrhage (ICH; 20.3% vs 24.2%, p < 0.001), but no difference in rates of symptomatic ICH (sICH). Following multivariable adjustment for baseline clinical characteristics including age, acute stroke severity, and comorbidity burden, prior APT was associated with favorable outcome (adjusted odds ratio [aOR] 1.21, 95% CI 1.17-1.24, p < 0.001) and a lower likelihood of mortality (aOR 0.73, 95% CI 0.70-0.77, p < 0.001), without an increased likelihood of ICH (any ICH aOR 0.84, 95% CI 0.81-0.87, p < 0.001; sICH aOR 0.92, 95% CI 0.82-1.03, p = 0.131). CONCLUSIONS Retrospective evaluation of patients with AIS treated with EVT using registry-based data demonstrated an association of prior APT usage with favorable outcomes, without an increased risk of hemorrhagic transformation.
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Affiliation(s)
| | - Adeeb Chowdhury
- 1New York Medical College, School of Medicine, Valhalla, New York
| | | | - Zeina Soliman
- 1New York Medical College, School of Medicine, Valhalla, New York
| | - Noor A Mahmoud
- 2Department of Neurology, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Bridget Nolan
- 1New York Medical College, School of Medicine, Valhalla, New York
- 3Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Kevin Clare
- 1New York Medical College, School of Medicine, Valhalla, New York
- 3Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Joshua Z Willey
- 5Department of Neurology, Neurological Institute of New York, Columbia University Irving Medical Center, New York, New York
| | - Sara K Rostanski
- 6Department of Neurology, New York University Grossman School of Medicine, New York, New York; and
| | | | - Neisha Patel
- 4Department of Neurology, Westchester Medical Center, Valhalla, New York
| | - Gurmeen Kaur
- 1New York Medical College, School of Medicine, Valhalla, New York
- 3Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
- 4Department of Neurology, Westchester Medical Center, Valhalla, New York
| | - Ji Y Chong
- 4Department of Neurology, Westchester Medical Center, Valhalla, New York
| | - Christian A Bowers
- 7Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico
| | - Chirag D Gandhi
- 1New York Medical College, School of Medicine, Valhalla, New York
- 3Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Fawaz Al-Mufti
- 1New York Medical College, School of Medicine, Valhalla, New York
- 3Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
- 4Department of Neurology, Westchester Medical Center, Valhalla, New York
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12
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Dicpinigaitis AJ, Kazim SF, Al-Mufti F, Hall DE, Reitz KE, Rumalla K, McIntyre MK, Arthur AS, Srinivasan VM, Burkhardt JK, Schmidt MH, Gandhi CD, Bowers CA. Frailty in aneurysmal subarachnoid hemorrhage: the risk analysis index. J Neurol 2023; 270:4820-4826. [PMID: 37329347 DOI: 10.1007/s00415-023-11805-z] [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: 04/29/2023] [Revised: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/19/2023]
Abstract
BACKGROUND Few studies have evaluated frailty in the setting of aneurysmal subarachnoid hemorrhage (aSAH) using large-scale data. The risk analysis index (RAI) may be implemented at the bedside or assessed retrospectively, differentiating it from other indices used in administrative registry-based research. METHODS Adult aSAH hospitalizations were identified in the National Inpatient Sample (NIS) from 2015 to 2019. Complex samples statistical methods were performed to evaluate the comparative effect size and discriminative ability of the RAI, the modified frailty index (mFI), and the Hospital Frailty Risk Score (HFRS). Poor functional outcome was determined by the NIS-SAH Outcome Measure (NIS-SOM), shown to have high concordance with modified Rankin Scale scores > 2. RESULTS 42,300 aSAH hospitalizations were identified in the NIS during the study period. By both ordinal [adjusted odds ratio (aOR) 3.20, 95% confidence interval (CI) 3.05, 3.36, p < 0.001] and categorical stratification [frail aOR 3.59, 95% CI 3.39, 3.80, p < 0.001; severely frail aOR 6.67, 95% CI 5.78, 7.69, p < 0.001], the RAI achieved the largest effect sizes for NIS-SOM in comparison with the mFI and HFRS. Discrimination of the RAI for NIS-SOM in high-grade aSAH was significantly greater than that of the HFRS (c-statistic 0.651 vs. 0.615). The mFI demonstrated the lowest discrimination in both high-grade and normal-grade patients. A combined Hunt and Hess-RAI model (c-statistic 0.837, 95% CI 0.828, 0.845) for NIS-SOM achieved significantly greater discrimination than both the combined models for mFI and HFRS (p < 0.001). CONCLUSION The RAI was robustly associated with poor functional outcomes in aSAH independent of established risk factors.
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Affiliation(s)
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA
| | - Fawaz Al-Mufti
- School of Medicine, New York Medical College, Valhalla, NY, 10595, USA
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, 10595, USA
| | - Daniel E Hall
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Katherine E Reitz
- Department of Surgery, University of Pittsburgh, Pittsburgh, PA, 15213, USA
| | - Kavelin Rumalla
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA
| | - Matthew K McIntyre
- Department of Neurological Surgery, Oregon Health and Science University, Portland, OR, 97239, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Sciences Center/Semmes-Murphy Clinic, Memphis, TN, 38120, USA
| | - Visish M Srinivasan
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA
| | - Chirag D Gandhi
- School of Medicine, New York Medical College, Valhalla, NY, 10595, USA
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, 10595, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM, 81731, USA.
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13
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Lui A, Feldstein E, Clare K, Dicpinigaitis AJ, Reddy M, Khan F, Semaan R, Galluzzo D, Shapiro S, Kamal H, Yaghi S, Pisapia J, Muh C, Nuoman R, Overby P, Etienne M, Chong J, Mayer S, Gandhi CD, Al-Mufti F. Acute ischemic strokes in patients with developmental disabilities: A cross-sectional analysis. Interv Neuroradiol 2023; 29:555-560. [PMID: 35786031 PMCID: PMC10549715 DOI: 10.1177/15910199221110327] [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: 03/31/2022] [Accepted: 06/01/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Patients with developmental disabilities (DD) are frequently excluded from acute ischemic stroke (AIS) randomized control trials. We sought to evaluate the impact of having DD on this patient cohort. METHODS The National Inpatient Sample was analyzed to explore the impact of AIS and treatment on discharge dispositions in patients with DD. Clinical characteristics, treatments, and outcomes were compared to fully-abled patients with AIS. RESULTS 1,605,723 patients with AIS were identified from 2010-2019, of whom 4094 (0.30%) had a DD. AIS patients with DD were younger (60.31 vs 70.93 years, p < 0.01), less likely to be Caucasian (66.37%vs 68.09%, p = 0.01), and had higher AIS severity (0.63 vs 0.58, p < 0.01). Tissue plasminogen activator (tPA) was administered in 99,739 (6.2%) fully-abled patients and 196 (4.79%) of patients with DD (p < 0.01). Endovascular thrombectomy (EVT) was performed in 21,066 (1.31%) of fully-abled patients and 35 (0.85%) of patients with DD (p < 0.01). The presence of developmental disabilities were predictive of lower rates of tPA (OR:0.71,CI:0.56-0.87,p < 0.01) and EVT (OR:0.24,CI:0.16-0.36,p < 0.01). In a propensity score-matched cohort of all AIS patients who underwent EVT, there was no difference in functional outcome (p = 0.41), in-hospital mortality (0.10), and LOS (p = 0.79). CONCLUSION AIS patients with DD were less likely to receive tPA and EVT compared to fully-abled patients. Individuals with DD had higher mortality and worse discharge disposition. There was no significant difference in post-EVT outcomes between fully-abled patients and patients with developmental disabilities. In the absence of prospective clinical trials, population based cross-sectional analyses such as the present study provide valuable clinical insight.
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Affiliation(s)
- Aiden Lui
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Kevin Clare
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Medha Reddy
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Farzana Khan
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Rosa Semaan
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Daniela Galluzzo
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Steve Shapiro
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence, RI, USA
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Carrie Muh
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Philip Overby
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Mill Etienne
- School of Medicine, New York Medical College, Valhalla, NY, USA
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Ji Chong
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Stephan Mayer
- Department of Neurology, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA
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14
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Elfil M, Ghozy S, Elmashad A, Ghaith HS, Aladawi M, Dicpinigaitis AJ, Mansour OY, Khandelwal P, Asif K, Nour M, Toth G, Al-Mufti F. Effect of intra-arterial thrombolysis following successful endovascular thrombectomy on functional outcomes in patients with large vessel occlusion acute ischemic stroke: A post-CHOICE meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107194. [PMID: 37216750 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107194] [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: 03/24/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/24/2023] Open
Abstract
INTRODUCTION Endovascular thrombectomy (EVT) is the standard treatment of acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Although > 70% of patients in the trials assessing EVT for AIS-LVO had successful recanalization, only a third ultimately achieved favorable outcomes. A "no-reflow" phenomenon due to distal microcirculation disruption might contribute to such suboptimal outcomes. Combining intra-arterial (IA) tissue plasminogen activator (tPA) and EVT to reduce the distal microthrombi burden was investigated in a few studies. We present a pooled-data meta-analysis of the existing evidence of this combinatorial treatment. METHODS We followed the Preferred Reporting Items for Systematic Review and Meta-analyses (PRISMA) recommendations. We aimed to include all original studies investigating EVT plus IA tPA in AIS-LVO patients. Using R software, we calculated pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI). A fixed-effects model was adopted to evaluate pooled data. RESULTS Five studies satisfied the inclusion criteria. Successful recanalization was comparable between the IA tPA and control groups at 82.9% and 82.32% respectively. The 90-day functional independence was similar between both groups (OR= 1.25; 95% CI= 0.92-1.70; P= 0.154). Symptomatic intracranial hemorrhage (sICH) was also comparable between both groups (OR= 0.66; 95% CI= 0.34-1.26; P= 0.304). CONCLUSION Our current meta-analysis does not show significant differences between EVT alone and EVT plus IA tPA in terms of functional independence or sICH. However, with the limited number of studies and included patients, more randomized controlled trials (RCTs) are needed to further investigate the benefits and safety of combined EVT and IA tPA.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ahmed Elmashad
- Department of Neurology, University of Connecticut, Farmington, CT, USA
| | | | - Mohammad Aladawi
- Department of Neurological Sciences, University of Nebraska Medical Center, Omaha, NE, USA
| | | | - Ossama Yassin Mansour
- Department of Neurology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Priyank Khandelwal
- Department of Neurosurgery, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Kaiz Asif
- Ascension Health and University of Illinois-Chicago, Chicago, IL, USA
| | - May Nour
- Department of Neurology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, New York Medical College at Westchester Medical Center, Valhalla, NY, USA.
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15
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Estes E, Rumalla K, Dicpinigaitis AJ, Kazim SF, Segura A, Kassicieh AJ, Schmidt MH, Bowers CA. Preoperative Frailty Predicts Worse Outcomes after Microvascular Decompression for Trigeminal Neuralgia, Hemifacial Spasm, and Glossopharyngeal Neuralgia: A Multicenter Analysis of 1,473 Patients from a Prospective Surgical Registry. Stereotact Funct Neurosurg 2023:1-7. [PMID: 37232028 DOI: 10.1159/000529763] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 01/23/2023] [Indexed: 05/27/2023]
Abstract
INTRODUCTION Microvascular decompression (MVD) is an efficacious neurosurgical intervention for patients with medically intractable neurovascular compression syndromes. However, MVD may occasionally cause life-threatening or altering complications, particularly in patients unfit for surgical operations. Recent literature suggests a lack of association between chronological age and surgical outcomes for MVD. The Risk Analysis Index (RAI) is a validated frailty tool for surgical populations (both clinical and large database). The present study sought to evaluate the prognostic ability of frailty, as measured by RAI, to predict outcomes for patients undergoing MVD from a large multicenter surgical registry. METHODS The American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) database (2011-2020) was queried using diagnosis/procedure codes for patients undergoing MVD procedures for trigeminal neuralgia (n = 1,211), hemifacial spasm (n = 236), or glossopharyngeal neuralgia (n = 26). The relationship between preoperative frailty (measured by RAI and 5-factor modified frailty index [mFI-5]) for primary endpoint of adverse discharge outcome (AD) was analyzed. AD was defined as discharge to a facility which was not home, hospice, or death within 30 days. Discriminatory accuracy for prediction of AD was assessed by computation of C-statistics (with 95% confidence interval) from receiver operating characteristic (ROC) curve analysis. RESULTS Patients undergoing MVD (N = 1,473) were stratified by RAI frailty bins: 71% with RAI 0-20, 28% with RAI 21-30, and 1.2% with RAI 31+. Compared to RAI score 19 and below, RAI 20 and above had significantly higher rates of postoperative major complications (2.8% vs. 1.1%, p = 0.01), Clavien-Dindo grade IV complications (2.8% vs. 0.7%, p = 0.001), and AD (6.1% vs. 1.0%, p < 0.001). The rate of primary endpoint was 2.4% (N = 36) and was positively associated with increasing frailty tier: 1.5% in 0-20, 5.8% in 21-30, and 11.8% in 31+. RAI score demonstrated excellent discriminatory accuracy for primary endpoint in ROC analysis (C-statistic: 0.77, 95% CI: 0.74-0.79) and demonstrated superior discrimination compared to mFI-5 (C-statistic: 0.64, 95% CI: 0.61-0.66) (DeLong pairwise test, p = 0.003). CONCLUSIONS This was the first study to link preoperative frailty to worse surgical outcomes after MVD surgery. RAI frailty score predicts AD after MVD with excellent discrimination and holds promise for preoperative counseling and risk stratification of surgical candidates. A risk assessment tool was developed and deployed with a user-friendly calculator: <ext-link ext-link-type="uri" xlink:href="https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression" xmlns:xlink="http://www.w3.org/1999/xlink">https://nsgyfrailtyoutcomeslab.shinyapps.io/microvascularDecompression</ext-link>.
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Affiliation(s)
- Emily Estes
- Texas Tech University Health Sciences Center School of Medicine, El Paso, Texas, USA,
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA,
| | - Kavelin Rumalla
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Alis J Dicpinigaitis
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Syed Faraz Kazim
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Aaron Segura
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Alexander J Kassicieh
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Meic H Schmidt
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
| | - Christian A Bowers
- Bowers Neurosurgical Frailty and Outcomes Data Science Lab, Albuquerque, New Mexico, USA
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, USA
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16
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Dicpinigaitis AJ, Dick-Godfrey R, Gellerson O, Shapiro SD, Kamal H, Ghozy S, Kaur G, Desai SM, Ortega-Gutierrez S, Yaghi S, Altschul DJ, Jadhav AP, Hassan AE, Nguyen TN, Brook AL, Mayer SA, Jovin TG, Nogueira RG, Gandhi CD, Al-Mufti F. Real-World Outcomes of Endovascular Thrombectomy for Basilar Artery Occlusion: Results of the BArONIS Study. Ann Neurol 2023. [PMID: 36897101 DOI: 10.1002/ana.26640] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 03/04/2023] [Accepted: 03/08/2023] [Indexed: 03/11/2023]
Abstract
OBJECTIVE To evaluate clinical outcomes of endovascular thrombectomy (EVT) for acute basilar artery occlusion (BAO) using population-level data from the United States. METHODS Weighted discharge data from the National Inpatient Sample were queried to identify adult patients with acute BAO during the period of 2015 to 2019 treated with EVT or medical management only. Complex samples statistical methods and propensity-score adjustment using inverse probability of treatment weighting (IPTW) were performed to assess clinical endpoints. RESULTS Among 3,950 BAO patients identified, 1,425 (36.1%) were treated with EVT [mean age 66.7 years, median National Institute of Health Stroke Scale (NIHSS) score 22]. On unadjusted analysis, 155 (10.9%) EVT patients achieved favorable functional outcomes (discharge disposition to home without services), while 515 (36.1%) experienced in-hospital mortality, and 20 (1.4%) developed symptomatic intracranial hemorrhage (sICH). Following propensity-score adjustment by IPTW accounting for age, stroke severity, and comorbidity burden, EVT was independently associated with favorable functional outcome [adjusted odds ratio (aOR) 1.25, 95% confidence interval (CI) 1.07, 1.46; p = 0.004], but not with in-hospital mortality or sICH. In an IPTW-adjusted sub-group analysis of patients with NIHSS scores >20, EVT was associated with both favorable functional outcome (discharge disposition to home or to acute rehabilitation) (aOR 1.55, 95% CI 1.24, 1.94; p < 0.001) and decreased mortality (aOR 0.78, 95% CI 0.69, 0.89; p < 0.001), but not with sICH. INTERPRETATION This retrospective population-based analysis using a large national registry provides real-world evidence of a potential benefit of EVT in acute BAO patients. ANN NEUROL 2023.
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Affiliation(s)
| | | | | | - Steven D Shapiro
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Sherief Ghozy
- Departments of Neurology and Neurosurgery, Mayo Clinic, Rochester, MN
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Shashvat M Desai
- Department of Neurology and Neurosurgery, Barrow Neurological Institute, Phoenix, AZ
| | | | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital at the Warren Alpert Medical School of Brown University, Providence, RI
| | - David J Altschul
- Department of Neurological Surgery and Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Ashutosh P Jadhav
- Department of Neurology and Neurosurgery, Barrow Neurological Institute, Phoenix, AZ
| | - Ameer E Hassan
- Department of Neurology and Neurosurgery, University of Texas Rio Grande Valley, Edinburg, TX and Valley Baptist Medical Center, Harlingen, TX
| | - Thanh N Nguyen
- Department of Neurology and Neurosurgery, Boston Medical Center at the Boston University School of Medicine, Boston, MA
| | - Allan L Brook
- Department of Neurological Surgery and Radiology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, NJ
| | - Raul G Nogueira
- UPMC Stroke Institute, Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY
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17
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Elfil M, Ghozy S, El‐Qushayri AE, Dicpinigaitis AJ, Al‐Mufti F. Abstract Number: LBA6 Mechanical Thrombectomy for Basilar Artery Occlusion: Systematic Review and Meta‐analysis of Randomized Controlled Trials. SVIN 2023; 3. [DOI: 10.1161/svin.03.suppl_1.lba6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Introduction
Acute ischemic stroke (AIS) caused by basilar artery occlusion (BAO) is known to be associated with high rates of mortality and lifelong disability. In the past few years, two clinical trials (the BEST and the BASICS trials) investigated the benefits and safety of mechanical thrombectomy (MT) for BAO and did not provide evidence to support the efficacy of MT in BAO patients. Given the recent positive results from the ATTENTION and the BAOCHE clinical trials, we conducted this meta‐analysis to provide updated collective evidence regarding the benefits of MT in patients with BAO.
Methods
We searched for eligible papers till June 1st, 2021, in five databases: PubMed, Web of Science, Scopus, and Embase databases using keywords and/or medical subject (MeSH) terms. We included all randomized controlled trials (RCTs) with no restrictions on publication date, data, or language of the included studies to avoid missing any relevant papers. All data were analyzed using R software. We computed the pooled risk ratios (RRs) and their corresponding 95% confidence intervals (CI), using a random‐effect model or fixed‐effect model depending on heterogeneity among the included studies. Heterogeneity was assessed with Q statistics and the I2 test considering it significant with I2 value > 50% or P‐value < 0.05.
Results
Four trials were included in this meta‐analysis, namely the BEST, the BASICS, the BAOCHE, and the ATTENTION trials. The four trials recruited a total of 988 patients. The MT group achieved a significantly higher rate of modified Rankin scale (mRS) score of 0–3 was as compared to the best medical treatment (BMT) one (RR = 1.54; 95% CI = 1.16‐2.04; P‐value = 0.002). Similarly, the mRS 0–2 rate was significantly higher in the MT group as compared to the BMT group (RR = 1.79; 95% CI = 1.09‐2.95; P‐value = 0.022). Nevertheless, heterogeneity was noticed amongst the included studies. Moreover, there was a significant reduction in the 90‐day mortality in the MT group as compared to the BMT group (RR = 0.76; 95% CI = 0.65‐0.89; P‐value = 0.002). On the other hand, there was a significantly higher rate of symptomatic intracerebral hemorrhage (sICH) in the MT group compared to the BMT group (RR = 7.48; 95% CI = 2.27‐24.61; P‐value< 0.001). There with no heterogeneity observed in both outcomes of mortality and sICH. Noted that there were no significant differences in overall parenchymal hemorrhage (PH) and type I PH rates, yet type II PH was more prevalent in the MT group compared to the BMT one (RR = 5.53; 95% CI = 1.47‐20.84; P‐value = 0.011).
Conclusions
The current evidence favors MT for basilar artery occlusions over the conservative approach in terms of achieving higher rates of good functional outcomes and decreasing mortality rates. Further large‐scale trials of different populations are needed to corroborate these results and also to ensure generalizability.
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Affiliation(s)
- Mohamed Elfil
- Department of Neurological Sciences University of Nebraska Medical Center Omaha Nebraska United States of America
| | - Sherief Ghozy
- Department of Neuroradiology Mayo Clinic Rochester Minnesota United States of America
| | | | | | - Fawaz Al‐Mufti
- Department of Neurosurgery Westchester Medical Center Valhalla New York United States of America
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18
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Ng C, Dominguez JF, Hosein-Woodley R, Feldstein E, Naftchi A, Lui A, Dicpinigaitis AJ, McIntyre MK, Kaur G, Santarelli J, Bauerschmidt A, Mayer SA, Bowers CA, Gandhi CD, Al-Mufti F. Utility of frailty as a predictor of acute kidney injury in patients with aneurysmal subarachnoid hemorrhage. Interv Neuroradiol 2023; 29:114-120. [PMID: 35109710 PMCID: PMC9893237 DOI: 10.1177/15910199221076626] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 12/31/2021] [Accepted: 01/11/2022] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) is associated with poor outcome in aneurysmal subarachnoid hemorrhage patients (aSAH). Frailty has recently been demonstrated to correlate with elevated mortality and morbidity; its impact on predicting AKI and mortality in aSAH patients has not been investigated. OBJECTIVE Evaluating risk factors and predictors for AKI in aSAH patients. METHODS aSAH patients from a single-center's prospectively maintained database were retrospectively evaluated for development of AKI within 14 days of admission. Baseline demographic and clinical characteristics were collected. The effect of frailty and other risk factors were evaluated. RESULTS Of 213 aSAH patients, 53 (33.1%) were frail and 12 (5.6%) developed AKI. Admission serum creatinine (sCr) and peak sCr within 48 h were higher in frail patients. AKI patients showed a trend towards higher frailty. Mortality was significantly higher in AKI than non-AKI aSAH patients. Frailty was a poor predictor of AKI when controlling for Hunt and Hess (HH) grade or age. HH grade ≥ 4 strongly predicted AKI when controlling for frailty. CONCLUSION AKI in aSAH patients carries a poor prognosis. The HH grade appears to have superior utility as a predictor of AKI in aSAH patients than mFI.
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Affiliation(s)
- Christina Ng
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | | | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | | | - Aiden Lui
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Matthew K McIntyre
- Department of Neurological Surgery, Oregon Health & Science
University, Portland, OR, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Andrew Bauerschmidt
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico School of
Medicine, Albuquerque, NM, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center and New York
Medical College, Valhalla, NY, USA
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Conlon M, Thommen R, Kazim SF, Dicpinigaitis AJ, Schmidt MH, McKee RG, Bowers CA. Risk Analysis Index and Its Recalibrated Version Predict Postoperative Outcomes Better Than 5-Factor Modified Frailty Index in Traumatic Spinal Injury. Neurospine 2022; 19:1039-1048. [PMID: 36597640 PMCID: PMC9816576 DOI: 10.14245/ns.2244326.163] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 05/01/2022] [Accepted: 10/14/2022] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVE To assess the discriminative ability of the Risk Analysis Index-administrative (RAI-A) and its recalibrated version (RAI-Rev), compared to the 5-factor modified frailty index (mFI-5), in predicting postoperative outcomes in patients undergoing surgical intervention for traumatic spine injuries (TSIs). METHODS The Current Procedural Terminology (CPT) and International Classification of Disease-9 (ICD-9) and ICD-10 codes were used to identify patients ≥ 18 years who underwent surgical intervention for TSI from National Surgical Quality Improvement Program (ACS-NSQIP) database 2015-2019 (n = 6,571). Multivariate analysis and receiver operating characteristic (ROC) curve analysis were conducted to evaluate the comparative discriminative ability of RAI-Rev, RAI-A, and mFI-5 for 30-day postoperative outcomes. RESULTS Multivariate regression analysis showed that with all 3 frailty scores, increasing frailty tiers resulted in worse postoperative outcomes, and patients identified as frail and severely frail using RAI-Rev and RAI-A had the highest odds of poor outcomes. In the ROC curve/C-statistics analysis for prediction of 30-day mortality and morbidity, both RAI-Rev and RAI-A outperformed mFI-5, and for many outcomes, RAI-Rev showed better discriminative performance compared to RAI-A, including mortality (p = 0.0043, DeLong test), extended length of stay (p = 0.0042), readmission (p < 0.0001), reoperation (p = 0.0175), and nonhome discharge (p < 0.0001). CONCLUSION Both RAI-Rev and RAI-A performed better than mFI-5, and RAI-Rev was superior to RAI-A in predicting postoperative mortality and morbidity in TSI patients. RAI-based frailty indices can be used in preoperative risk assessment of spinal trauma patients.
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Affiliation(s)
- Matthew Conlon
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Rachel Thommen
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | | | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Rohini G. McKee
- Department of Surgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA,Corresponding Author Christian A. Bowers Department of Neurosurgery, University of New Mexico Health Sciences Center, 1 University New Mexico, MSC10 5615, Albuquerque, NM 81731, USA
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20
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Cole KL, Babajanian E, Anderson R, Gordon S, Patel N, Dicpinigaitis AJ, Kazim SF, Bowers CA, Gurgel RK. Association of Baseline Frailty Status and Age With Postoperative Complications After Cochlear Implantation: A National Inpatient Sample Study. Otol Neurotol 2022; 43:1170-1175. [PMID: 36190901 DOI: 10.1097/mao.0000000000003717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To conduct a national registry-based evaluation of the independent associations of chronological age and frailty, as measured by 5- and 11-factor modified frailty index (mFI-5, mFI-11) score, on postoperative outcomes of participants undergoing cochlear implantation (CI). STUDY DESIGN Cross-sectional analysis. SETTING Multicenter national database. PARTICIPANTS Adults 18 years or older who underwent CI during 2001 to 2018. MAIN OUTCOME MEASURES Any postoperative complications (determined as the presence of major, minor, or implant-specific), extended hospital length of stay (eLOS) (≥75th percentile of study population), and nonhome discharge destination. RESULTS There were 5,130 participants included with a median age of 60 years (interquartile range, 44-73 y) and slight female predominance (53.5%). Under mFI-5 scoring, there were 2,979 (58.1%) robust (mFI-5 = 0), 1710 (33.3%) prefrail (mFI-5 = 1), 362 (7.1%) frail (mFI-5 = 2), and 78 (1.5%) severely frail (mFI-5 ≥ 3) participants. Three hundred twenty-eight (6.49%) participants experienced a postoperative complication, with 320 (6.2%) discharged to a nonhome destination. Multivariate analysis showed no statistically significant correlation between increasing participant age or frailty status and postoperative complications; however, increasing baseline frailty tier showed an independent association with risk of eLOS (severely frail: odds ratio, 4..83; 95% confidence interval, 3.00-7.75; p < 0.001) and nonhome discharge (severely frail: odds ratio, 6.51; 95% confidence interval, 3.81-11.11; p < 0.001). The mFI-11 showed very similar trends. CONCLUSION Among those evaluated, this study demonstrates that CI is a low-risk procedure in participants of all ages. Increasing frailty does not predispose to postoperative complications. However, frail patients are at additional risk for an eLOS and nonhome discharge. Short follow-up time, hospital-coding errors, and selection bias of more robust patients may limit the true results of this study.
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Affiliation(s)
- Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Eric Babajanian
- Division of Otolaryngology, University of Utah, Salt Lake City, Utah, USA
| | - Ryan Anderson
- Division of Otolaryngology, University of Utah, Salt Lake City, Utah, USA
| | - Steve Gordon
- Division of Otolaryngology, University of Utah, Salt Lake City, Utah, USA
| | - Neil Patel
- Division of Otolaryngology, University of Utah, Salt Lake City, Utah, USA
| | | | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Richard K Gurgel
- Division of Otolaryngology, University of Utah, Salt Lake City, Utah, USA
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21
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Dicpinigaitis AJ, Shapiro SD, Nuoman R, Kamal H, Overby P, Kaur G, Chong JY, Fifi JT, Dangayach N, Miller EC, Yaghi S, Al-Mufti F. Intravenous thrombolysis for treatment of pediatric acute ischemic stroke: Analysis of 20 years of population-level data in the United States. Int J Stroke 2022; 18:555-561. [PMID: 36149254 DOI: 10.1177/17474930221130911] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND AIMS Although intravenous thrombolysis (IVT) represents standard-of-care treatment for acute ischemic stroke (AIS) in eligible adult patients, definitive evidence-based guidelines and randomized clinical trial data evaluating its safety and efficacy in the pediatric population remain absent from the literature. We aimed to evaluate the utilization and outcomes of IVT for the treatment of pediatric AIS using a large national registry. METHODS Weighted hospitalizations for pediatric (<18 years of age) AIS patients were identified in the National Inpatient Sample during the period of 2001 to 2019. Complex sample statistical methods were performed to assess unadjusted and adjusted outcomes in patients treated with IVT or other medical management. RESULTS Among 13,901 pediatric AIS patients, 270 (1.9%) were treated with IVT monotherapy (median age 12.8 years). IVT-treated patients developed any intracranial hemorrhage (ICH) at a rate of 5.6% (n = 15), and 71.9% (n = 194) experienced favorable functional outcomes at discharge (to home or to acute rehabilitation). Following propensity-score adjustment for age, acute stroke severity, infarct location, and etiological/comorbid conditions, IVT was not associated with an increased risk of any ICH (5.6% vs 5.4%, p = 0.931; adjusted odds ratio (aOR) = 1.01, 95% confidence interval (CI) = 0.48-2.14, p = 0.971), nor with favorable functional outcome (71.9% vs 74.5%, p = 0.489; aOR = 0.88, 95% CI = 0.60-1.29, p = 0.511) in comparison with other medical therapy. CONCLUSIONS Twenty years of population-level data in the United States demonstrate that pediatric AIS patients treated with IVT experienced high rates of favorable outcomes without an increased risk of hemorrhagic transformation.
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Affiliation(s)
| | - Steven D Shapiro
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Philip Overby
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Ji Y Chong
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Johanna T Fifi
- Departments of Neurology and Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | - Neha Dangayach
- Departments of Neurology and Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | - Eliza C Miller
- Department of Neurology, Columbia University Irving Medical Center, New York, NY, USA
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital at the Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
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22
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Colasacco CJ, Abouezzi J, Arbuiso S, Asserson DB, Kazim SF, Cole KL, Dicpinigaitis AJ, Dominguez J, McKee RG, Schmidt MH, Couldwell WT, Bowers CA. Association of baseline frailty and age with postoperative outcomes in metastatic brain tumor patients. J Neurosurg Sci 2022:S0390-5616.22.05865-9. [PMID: 36345969 DOI: 10.23736/s0390-5616.22.05865-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The impact of baseline frailty status versus that of chronological age on surgical outcomes of metastatic brain tumor patients remains largely unknown. The present study aimed to evaluate this relationship for preoperative risk stratification using a large national database. METHODS The National Surgical Quality Improvement Program database was queried to extract data of metastatic brain tumor patients who underwent surgery between 2015 and 2019 (n=5,943). Univariate and multivariate analyses were performed to assess the effect of age and modified frailty index-5 (mFI-5) on mortality, major complications, unplanned readmission and reoperation, extended length of stay (eLOS), and non-home discharge. RESULTS Both univariate and multivariate analyses demonstrated that frailty status was significantly predictive of 30-day mortality, major complications, eLOS, and non-home discharge. Although increasing age was also a significant predictor of eLOS and discharge to non-home destination, effect sizes were smaller compared with frailty. CONCLUSIONS The present study, based on analysis of data from a large national registry, shows that frailty, when compared with age, is a superior predictor of postoperative outcomes in metastatic brain tumor patients. A future prospective study, namely a randomized controlled trial, would be beneficial in helping to corroborate the findings of this retrospective study.
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Affiliation(s)
| | - Joanna Abouezzi
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Sophia Arbuiso
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Derek B Asserson
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Syed F Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | | | - Jose Dominguez
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, USA
| | - Rohini G McKee
- Department of Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neuroscience Center, University of Utah, Salt Lake City, UT, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, NM, USA -
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Dicpinigaitis AJ, Al-Mufti F, Bempong PO, Kazim SF, Cooper JB, Dominguez JF, Stein A, Kalakoti P, Hanft S, Pisapia J, Kinon M, Gandhi CD, Schmidt MH, Bowers CA. Prognostic Significance of Baseline Frailty Status in Traumatic Spinal Cord Injury. Neurosurgery 2022; 91:575-582. [PMID: 35944118 DOI: 10.1227/neu.0000000000002088] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 05/14/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Literature evaluating frailty in traumatic spinal cord injury (tSCI) is limited. OBJECTIVE To evaluate the prognostic significance of baseline frailty status in tSCI. METHODS Patients with tSCI were identified in the National Inpatient Sample from 2015 to 2018 and stratified according to frailty status, which was quantified using the 11-point modified frailty index (mFI). RESULTS Among 8825 operatively managed patients with tSCI identified (mean age 57.9 years, 27.6% female), 3125 (35.4%) were robust (mFI = 0), 2530 (28.7%) were prefrail (mFI = 1), 1670 (18.9%) were frail (mFI = 2), and 1500 (17.0%) were severely frail (mFI ≥ 3). One thousand four-hundred forty-five patients (16.4%) were routinely discharged (to home), and 320 (3.6%) died during hospitalization, while 2050 (23.3%) developed a severe complication, and 2175 (24.6%) experienced an extended length of stay. After multivariable analysis adjusting for age, illness severity, trauma burden, and other baseline covariates, frailty (by mFI-11) was independently associated with lower likelihood of routine discharge [adjusted odds ratio (aOR) 0.82, 95% CI 0.77-0.87; P < .001] and development of a severe complication (aOR 1.17, 95% CI 1.12-1.23; P < .001), but not with in-hospital mortality or extended length of stay. Subgroup analysis by age demonstrated robust associations of frailty with routine discharge in advanced age groups (aOR 0.71 in patients 60-80 years and aOR 0.69 in those older than 80 years), which was not present in younger age groups. CONCLUSION Frailty is an independent predictor of clinical outcomes after tSCI, especially among patients of advanced age. Our large-scale analysis contributes novel insights into limited existing literature on this topic.
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Affiliation(s)
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Phillip O Bempong
- School of Medicine, Meharry Medical College, Nashville, Tennessee, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Alan Stein
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Piyush Kalakoti
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Merritt Kinon
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA
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24
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Dicpinigaitis AJ, Feldstein E, Shapiro SD, Kamal H, Bauerschmidt A, Rosenberg J, Amuluru K, Pisapia J, Dangayach NS, Liang JW, Bowers CA, Mayer SA, Gandhi CD, Al-Mufti F. Cerebral vasospasm following arteriovenous malformation rupture: a population-based cross-sectional study. Neurosurg Focus 2022; 53:E15. [DOI: 10.3171/2022.4.focus2277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 04/20/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Studies examining the risk factors and clinical outcomes of arterial vasospasm secondary to cerebral arteriovenous malformation (cAVM) rupture are scarce in the literature. The authors used a population-based national registry to investigate this largely unexamined clinical entity.
METHODS
Admissions for adult patients with cAVM ruptures were identified in the National Inpatient Sample during the period from 2015 to 2019. Complex samples multivariable logistic regression and chi-square automatic interaction detection (CHAID) decision tree analyses were performed to identify significant associations between clinical covariates and the development of vasospasm, and a cAVM–vasospasm predictive model (cAVM-VPM) was generated based on the effect sizes of these parameters.
RESULTS
Among 7215 cAVM patients identified, 935 developed vasospasm, corresponding to an incidence rate of 13.0%; 110 of these patients (11.8%) subsequently progressed to delayed cerebral ischemia (DCI). Multivariable adjusted modeling identified the following baseline clinical covariates: decreasing age by decade (adjusted odds ratio [aOR] 0.87, 95% CI 0.83–0.92; p < 0.001), female sex (aOR 1.68, 95% CI 1.45–1.95; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.34, 95% CI 1.01–1.79; p = 0.045), intraventricular hemorrhage (aOR 1.87, 95% CI 1.17–2.98; p = 0.009), hypertension (aOR 1.77, 95% CI 1.50–2.08; p < 0.001), obesity (aOR 0.68, 95% CI 0.55–0.84; p < 0.001), congestive heart failure (aOR 1.34, 95% CI 1.01–1.78; p = 0.043), tobacco smoking (aOR 1.48, 95% CI 1.23–1.78; p < 0.019), and hospitalization events (leukocytosis [aOR 1.64, 95% CI 1.32–2.04; p < 0.001], hyponatremia [aOR 1.66, 95% CI 1.39–1.98; p < 0.001], and acute hypotension [aOR 1.67, 95% CI 1.31–2.11; p < 0.001]) independently associated with the development of vasospasm. Intraparenchymal and subarachnoid hemorrhage were not associated with the development of vasospasm following multivariable adjustment. Among significant associations, a CHAID decision tree algorithm identified age 50–59 years (parent node), hyponatremia, and leukocytosis as important determinants of vasospasm development. The cAVM-VPM achieved an area under the curve of 0.65 (sensitivity 0.70, specificity 0.53). Progression to DCI, but not vasospasm alone, was independently associated with in-hospital mortality (aOR 2.35, 95% CI 1.29–4.31; p = 0.016) and lower likelihood of routine discharge (aOR 0.62, 95% CI 0.41–0.96; p = 0.031).
CONCLUSIONS
This large-scale assessment of vasospasm in cAVM identifies common clinical risk factors and establishes progression to DCI as a predictor of poor neurological outcomes.
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Affiliation(s)
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Steven D. Shapiro
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | | | - Jon Rosenberg
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Krishna Amuluru
- Goodman Campbell Brain and Spine, Ascension St. Vincent Medical Center, Carmel, Indiana
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Neha S. Dangayach
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York; and
| | - John W. Liang
- Department of Neurosurgery, Mount Sinai Hospital, New York, New York; and
| | - Christian A. Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico
| | - Stephan A. Mayer
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Chirag D. Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
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25
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Dicpinigaitis AJ, Galea VP, Sursal T, Al-Shammari H, Feldstein E, Ali S, Wong S, Bowers C, Becker C, Pisapia J, Muh C, Hanft S, Tyagi R, Mayer SA, Gandhi CD, Al-Mufti F. Low serum albumin as a risk factor for delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage: eICU collaborative research database analysis. J Neurosurg Sci 2022:S0390-5616.22.05604-1. [PMID: 35766203 DOI: 10.23736/s0390-5616.22.05604-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2024]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) represents a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH) and is a significant predictor of morbidity and mortality. Recent studies have implicated inflammatory processes in the pathogenesis of DCI. METHODS aSAH patient data were retrospectively obtained from the eICU Collaborative Research Database (eICU CRD). Multivariable logistic regression models and receiver operating characteristic (ROC) curve analyses were employed to assess the association between low serum albumin (< 3.4 g/dL) and clinical endpoints: DCI and in-hospital mortality. RESULTS Among 276 aSAH patients included in the analysis, 35.5% (n=98) presented with low serum albumin levels and demonstrated a higher incidence of DCI (18.4% vs. 8.4%, OR=2.45, 95% CI 1.17, 5.10; p=0.017) and in-hospital mortality (27.6% vs. 16.3%, OR=1.95, 95% CI 1.08, 3.54; p=0.027) compared to patients with normal admission albumin values. In a multivariable model controlling for age and World Federation of Neurosurgical Societies grade, low serum albumin remained significantly associated with DCI (OR=2.52, 95% CI 1.18, 5.36; p=0.017), but not with in-hospital mortality. A combined model for prediction of DCI, encompassing known risk factors in addition to low serum albumin, achieved an area under the curve of 0.65 (sensitivity=0.55, specificity=0.75). CONCLUSIONS Serum albumin, a routine and inexpensive laboratory measurement, can may potentially aid in the identification of patients with aSAH at risk for the development of DCI.
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Affiliation(s)
| | - Vincent P Galea
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Tolga Sursal
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | | | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Syed Ali
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA
| | - Serena Wong
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Christian Becker
- Department of Medicine, Westchester Medical Center, Valhalla, NY, USA
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Carrie Muh
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Rachana Tyagi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Stephan A Mayer
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurology, Westchester Medical Center, Valhalla, NY, USA -
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26
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Sursal T, Ronecker JS, Dicpinigaitis AJ, Mohan AL, Tobias ME, Gandhi CD, Jhanwar-Uniyal M. Molecular Stratification of Medulloblastoma: Clinical Outcomes and Therapeutic Interventions. Anticancer Res 2022; 42:2225-2239. [PMID: 35489737 DOI: 10.21873/anticanres.15703] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [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: 12/30/2021] [Revised: 03/07/2022] [Accepted: 03/18/2022] [Indexed: 11/10/2022]
Abstract
Medulloblastoma (MB) is the most common malignant pediatric posterior fossa tumor. Recent genetic, epigenetic, and transcriptomic analyses have classified MB into three subgroups, Wingless Type (WNT), Sonic Hedgehog (SHH), and non-WNT/non-SHH (originally termed Group 3 and Group 4), with discrete patient profiles and prognoses. WNT is the least common subgroup with the best prognosis, characterized by nuclear β-catenin expression, mutations in Catenin beta-1 (CTNNB1), and chromosome 6 monosomy. SHH tumors contain mutations and alterations in GLI1, GLI2, SUFU, and PTCH1 genes, which constitutively activate the SHH pathway. Originally, the presence of TP53 gene alterations and/or MYC amplifications was considered the most reliable prognostic factor. However, recent molecular analyses have subdivided SHH MB into several subtypes with distinct characteristics such as age, TP53 mutation, MYC amplification, presence of metastases, TERT promoter alterations, PTEN loss, and other chromosomal alterations as well as SHH pathway-related gene mutations. The third non-WNT/non-SHH MB (Group3/4) subgroup is genetically highly heterogeneous and displays several molecular patterns, including MYC and OTX2 amplification, GFI1B activation, KBTBD4 mutation, GFI1 rearrangement, PRDM6 enhancer hijacking, KDM6A mutation, LCA histology, chromosome 10 loss, isochromosome 17q, SNCAIP duplication, and CDK6 amplification. However, based on molecular profiling and methylation patterns, additional non-WNT/non-SHH MB subtypes have been described. Recent WHO (2021) guidelines stratified MB into four molecular subgroups with four and eight further subgroups for SHH and non-WNT/non-SHH MB, respectively. In this review, we discuss advancements in genetics, epigenetics, and transcriptomics for better characterization, prognostication, and treatment of MB using precision medicine.
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Affiliation(s)
- Tolga Sursal
- Department of Neurosurgery, New York Medical College/Westchester Medical Center, Valhalla, NY, U.S.A
| | - Jennifer S Ronecker
- Department of Neurosurgery, New York Medical College/Westchester Medical Center, Valhalla, NY, U.S.A
| | - Alis J Dicpinigaitis
- Department of Neurosurgery, New York Medical College/Westchester Medical Center, Valhalla, NY, U.S.A
| | - Avinash L Mohan
- Department of Neurosurgery, New York Medical College/Westchester Medical Center, Valhalla, NY, U.S.A
| | - Michael E Tobias
- Department of Neurosurgery, New York Medical College/Westchester Medical Center, Valhalla, NY, U.S.A
| | - Chirag D Gandhi
- Department of Neurosurgery, New York Medical College/Westchester Medical Center, Valhalla, NY, U.S.A
| | - Meena Jhanwar-Uniyal
- Department of Neurosurgery, New York Medical College/Westchester Medical Center, Valhalla, NY, U.S.A.
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27
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Dicpinigaitis AJ, Feldstein E, Gandhi CD, Hanft S. Letter: Early Experience Using Omniscient Neurotechnology Fiber Tracking Software for Resection of Intra-Axial Brain Tumors. Oper Neurosurg (Hagerstown) 2022; 22:e306-e308. [DOI: 10.1227/ons.0000000000000239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 02/16/2022] [Indexed: 11/19/2022] Open
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28
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Dicpinigaitis AJ, Gandhi CD, Pisapia J, Muh CR, Cooper JB, Tobias M, Mohan A, Nuoman R, Overby P, Santarelli J, Hanft S, Bowers C, Yaghi S, Mayer SA, Al-Mufti F. Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke. Stroke 2022; 53:1530-1539. [PMID: 35272483 DOI: 10.1161/strokeaha.121.036361] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Evidence regarding the utilization and outcomes of endovascular thrombectomy (EVT) for pediatric ischemic stroke is limited, and justification for its use is largely based on extrapolation from clinical benefits observed in adults. METHODS Weighted discharge data from the National Inpatient Sample were queried to identify pediatric patients with ischemic stroke (<18 years old) during the period of 2010 to 2019. Complex samples statistical methods were used to characterize the profiles and clinical outcomes of EVT-treated patients. Propensity adjustment was performed to address confounding by indication for EVT based on disparities in baseline characteristics between EVT-treated patients and those medically managed. RESULTS Among 7365 pediatric patients with ischemic stroke identified, 190 (2.6%) were treated with EVT. Utilization significantly increased in the post-EVT clinical trial era (2016-2019; 1.7% versus 4.0%; P<0.001), while the use of decompressive hemicraniectomy decreased (2.8% versus 0.7%; P<0.001). On unadjusted analysis, 105 (55.3%) EVT-treated patients achieved favorable functional outcomes at discharge (home or to acute rehabilitation), while no periprocedural iatrogenic complications or instances of contrast-induced kidney injury were reported. Following propensity adjustment, EVT-treated patients demonstrated higher absolute but nonsignificant rates of favorable functional outcomes in comparison with medically managed patients (55.3% versus 52.8%; P=0.830; adjusted hazard ratio, 1.01 [95% CI, 0.51-2.03]; P=0.972 for unfavorable outcome). Among patients with baseline National Institutes of Health Stroke Scale score >11 (75th percentile of scores in cohort), EVT-treated patients trended toward higher rates of favorable functional outcomes compared with those treated medically only (71.4% versus 55.6%; P=0.146). In a subcohort assessment of EVT-treated patients, those administered preceding thrombolytic therapy (n=79, 41.6%) trended toward higher rates of favorable functional outcomes (63.3% versus 49.5%; P=0.060). CONCLUSIONS This cross-sectional evaluation of the clinical course and short-term outcomes of pediatric patients with ischemic stroke treated with EVT demonstrates that EVT is likely a safe modality which confers high rates of favorable functional outcomes.
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Affiliation(s)
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Carrie R Muh
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Michael Tobias
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Avinash Mohan
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Rolla Nuoman
- Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
| | - Philip Overby
- Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
| | - Justin Santarelli
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.)
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque (C.B.)
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Alpert Medical School of Brown University, Providence (S.Y.)
| | - Stephan A Mayer
- Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY. (C.D.G., J.P., C.R.M., J.B.C., M.T., A.M., J.S., S.H., F.A.-M.).,Department of Neurology, Westchester Medical Center, Valhalla, NY. (R.N., P.O., S.A.M., F.A.-M.)
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29
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Feldstein E, Dominguez JF, Kaur G, Patel SD, Dicpinigaitis AJ, Semaan R, Fuentes LE, Ogulnick J, Ng C, Rawanduzy C, Kamal H, Pisapia J, Hanft S, Amuluru K, Naidu SS, Cooper HA, Prabhakaran K, Mayer SA, Gandhi CD, Al-Mufti F. Cardiac arrest in spontaneous subarachnoid hemorrhage and associated outcomes. Neurosurg Focus 2022; 52:E6. [DOI: 10.3171/2021.12.focus21650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
The authors sought to analyze a large, publicly available, nationwide hospital database to further elucidate the impact of cardiopulmonary arrest (CA) in association with subarachnoid hemorrhage (SAH) on short-term outcomes of mortality and discharge disposition.
METHODS
This retrospective cohort study was conducted by analyzing de-identified data from the National (Nationwide) Inpatient Sample (NIS). The publicly available NIS database represents a 20% stratified sample of all discharges and is powered to estimate 95% of all inpatient care delivered across hospitals in the US. A total of 170,869 patients were identified as having been hospitalized due to nontraumatic SAH from 2008 to 2014.
RESULTS
A total of 5415 patients (3.2%) were hospitalized with an admission diagnosis of CA in association with SAH. Independent risk factors for CA included a higher Charlson Comorbidity Index score, hospitalization in a small or nonteaching hospital, and a Medicaid or self-pay payor status. Compared with patients with SAH and not CA, patients with CA-SAH had a higher mean NIS Subarachnoid Severity Score (SSS) ± SD (1.67 ± 0.03 vs 1.13 ± 0.01, p < 0.0001) and a vastly higher mortality rate (82.1% vs 18.4%, p < 0.0001). In a multivariable model, age, NIS-SSS, and CA all remained significant independent predictors of mortality. Approximately 18% of patients with CA-SAH survived and were discharged to a rehabilitation facility or home with health services, outcomes that were most predicted by chronic disease processes and large teaching hospital status.
CONCLUSIONS
In the largest study of its kind, CA at onset was found to complicate roughly 3% of spontaneous SAH cases and was associated with extremely high mortality. Despite this, survival can still be expected in approximately 18% of patients.
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Affiliation(s)
- Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Jose F. Dominguez
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Gurkamal Kaur
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Smit D. Patel
- Department of Neurosurgery, University of California, Los Angeles, David Geffen School of Medicine, Los Angeles, California; and
| | - Alis J. Dicpinigaitis
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Rosa Semaan
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Leanne E. Fuentes
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Jonathan Ogulnick
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Christina Ng
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Cameron Rawanduzy
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, Goodman Campbell Brain and Spine, Indianapolis, Indiana
| | - Srihari S. Naidu
- Department of Medicine, Westchester Medical Center, New York Medical College of Medicine
| | - Howard A. Cooper
- Department of Cardiology, Westchester Medical Center, New York Medical College of Medicine
| | - Kartik Prabhakaran
- Department of Surgery, Westchester Medical Center, New York Medical College of Medicine, Valhalla, New York
| | - Stephan A. Mayer
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Chirag D. Gandhi
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, New York Medical College School of Medicine
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30
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Dicpinigaitis AJ, Feldstein E, Damodara N, Cooper JB, Shapiro SD, Kamal H, Kinon MD, Pisapia J, Rosenberg J, Gandhi CD, Al-Mufti F. Development of cerebral vasospasm following traumatic intracranial hemorrhage: incidence, risk factors, and clinical outcomes. Neurosurg Focus 2022; 52:E14. [DOI: 10.3171/2021.12.focus21668] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/22/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE
Limited evidence exists characterizing the incidence, risk factors, and clinical associations of cerebral vasospasm following traumatic intracranial hemorrhage (tICH) on a large scale. Therefore, the authors sought to use data from a national inpatient registry to investigate these aspects of posttraumatic vasospasm (PTV) to further elucidate potential causes of neurological morbidity and mortality subsequent to the initial insult.
METHODS
Weighted discharge data from the National (Nationwide) Inpatient Sample from 2015 to 2018 were queried to identify patients with tICH who underwent diagnostic angiography in the same admission and, subsequently, those who developed angiographically confirmed cerebral vasospasm. Multivariable logistic regression analysis was performed to identify significant associations between clinical covariates and the development of vasospasm, and a tICH vasospasm predictive model (tICH-VPM) was generated based on the effect sizes of these parameters.
RESULTS
Among 5880 identified patients with tICH, 375 developed PTV corresponding to an incidence of 6.4%. Multivariable adjusted modeling determined that the following clinical covariates were independently associated with the development of PTV, among others: age (adjusted odds ratio [aOR] 0.98, 95% CI 0.97–0.99; p < 0.001), admission Glasgow Coma Scale score < 9 (aOR 1.80, 95% CI 1.12–2.90; p = 0.015), intraventricular hemorrhage (aOR 6.27, 95% CI 3.49–11.26; p < 0.001), tobacco smoking (aOR 1.36, 95% CI 1.02–1.80; p = 0.035), cocaine use (aOR 3.62, 95% CI 1.97–6.63; p < 0.001), fever (aOR 2.09, 95% CI 1.34–3.27; p = 0.001), and hypokalemia (aOR 1.62, 95% CI 1.26–2.08; p < 0.001). The tICH-VPM achieved moderately high discrimination, with an area under the curve of 0.75 (sensitivity = 0.61 and specificity = 0.81). Development of vasospasm was independently associated with a lower likelihood of routine discharge (aOR 0.60, 95% CI 0.45–0.78; p < 0.001) and an extended hospital length of stay (aOR 3.53, 95% CI 2.78–4.48; p < 0.001), but not with mortality.
CONCLUSIONS
This population-based analysis of vasospasm in tICH has identified common clinical risk factors for its development, and has established an independent association between the development of vasospasm and poorer neurological outcomes.
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Affiliation(s)
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center, and
| | | | | | | | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, and
| | | | - Jared Pisapia
- Department of Neurosurgery, Westchester Medical Center, and
| | - Jon Rosenberg
- Department of Neurology, Westchester Medical Center, Valhalla, New York
| | | | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, and
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31
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Dicpinigaitis AJ, Palumbo KE, Gandhi CD, Cooper JB, Hanft S, Kamal H, Shapiro SD, Feldstein E, Kafina M, Kurian C, Chong JY, Mayer SA, Al-Mufti F. Association of Elevated Body Mass Index with Functional Outcome and Mortality following Acute Ischemic Stroke: The Obesity Paradox Revisited. Cerebrovasc Dis 2022; 51:565-569. [PMID: 35158366 DOI: 10.1159/000521513] [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: 11/10/2021] [Accepted: 12/03/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Previous literature has identified a survival advantage in acute ischemic stroke (AIS) patients with elevated body mass indices (BMIs), a phenomenon termed the "obesity paradox." OBJECTIVE The aim of this study was to evaluate the independent association between obesity and clinical outcomes following AIS. METHODS Weighted discharge data from the National Inpatient Sample were queried to identify AIS patients from 2015 to 2018. Multivariable logistic regression and Cox proportional hazards modeling were performed to evaluate associations between obesity (BMI ≥ 30) and clinical endpoints following adjustment for acute stroke severity and comorbidity burden. RESULTS Among 1,687,805 AIS patients, 216,775 (12.8%) were obese. Compared to nonobese individuals, these patients were younger (64 vs. 72 mean years), had lower baseline NIHSS scores (6.9 vs. 7.9 mean score), and a higher comorbidity burden. Multivariable analysis demonstrated independent associations between obesity and lower likelihood of mortality (adjusted odds ratio [aOR] 0.76, 95% confidence interval [CI]: 0.71, 0.82, p < 0.001; hazard ratio 0.84, 95% CI: 0.73, 0.97, p = 0.015), intracranial hemorrhage (aOR 0.87, 95% CI: 0.82, 0.93, p < 0.001), and routine discharge to home (aOR 0.97, 95% CI: 0.95, 0.99; p = 0.015). Mortality rates between obese and nonobese patients were significantly lower across stroke severity thresholds, but this difference was attenuated among high severity (NIHSS > 20) strokes (21.6% vs. 23.2%, p = 0.358). Further stratification of the cohort into BMI categories demonstrated a "U-shaped" association with mortality (underweight aOR 1.58, 95% CI: 1.39, 1.79; p < 0.001, overweight aOR 0.64, 95% CI: 0.42, 0.99; p = 0.046, obese aOR 0.77, 95% CI: 0.71, 0.83; p < 0.001, severely obese aOR 1.18, 95% CI: 0.74, 1.87; p = 0.485). Sub-cohort assessment of thrombectomy-treated patients demonstrated an independent association of obesity (BMI 30-40) with lower mortality (aOR 0.79, 95% CI: 0.65, 0.96; p = 0.015), but not with routine discharge. CONCLUSION This cross-sectional analysis demonstrates a lower likelihood of discharge to home as well as in-hospital mortality in obese patients following AIS, suggestive of a protective effect of obesity against mortality but not against all poststroke neurological deficits in the short term which would necessitate placement in acute rehabilitation and long-term care facilities.
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Affiliation(s)
| | - Kieran E Palumbo
- Chicago Medical School at Rosalind Franklin University, North Chicago, Illinois, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Steven D Shapiro
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Martin Kafina
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Christeena Kurian
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Ji Y Chong
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA.,Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
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32
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Kazim SF, Dicpinigaitis AJ, Bowers CA, Shah S, Couldwell WT, Thommen R, Alvarez-Crespo DJ, Conlon M, Tarawneh OH, Vellek J, Cole KL, Dominguez JF, Mckee RN, Ricks CB, Shin PC, Cole CD, Schmidt MH. Frailty Status Is a More Robust Predictor Than Age of Spinal Tumor Surgery Outcomes: A NSQIP Analysis of 4,662 Patients. Neurospine 2022; 19:53-62. [PMID: 35130424 PMCID: PMC8987561 DOI: 10.14245/ns.2142770.385] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 11/22/2021] [Indexed: 11/19/2022] Open
Abstract
Objective The present study aimed to evaluate the effect of baseline frailty status (as measured by modified frailty index-5 [mFI-5]) versus age on postoperative outcomes of patients undergoing surgery for spinal tumors using data from a large national registry.
Methods The National Surgical Quality Improvement Program database was used to collect spinal tumor resection patients’ data from 2015 to 2019 (n = 4,662). Univariate and multivariate analyses for age and mFI-5 were performed for the following outcomes: 30-day mortality, major complications, unplanned reoperation, unplanned readmission, hospital length of stay (LOS), and discharge to a nonhome destination. Receiver operating characteristic (ROC) curve analysis was used to evaluate the discriminative performance of age versus mFI-5.
Results Both univariate and multivariate analyses demonstrated that mFI-5 was a more robust predictor of worse postoperative outcomes as compared to age. Furthermore, based on categorical analysis of frailty tiers, increasing frailty was significantly associated with increased risk of adverse outcomes. ‘Severely frail’ patients were found to have the highest risk, with odds ratio 16.4 (95% confidence interval [CI],11.21–35.44) for 30-day mortality, 3.02 (95% CI, 1.97–4.56) for major complications, and 2.94 (95% CI, 2.32–4.21) for LOS. In ROC curve analysis, mFI-5 score (area under the curve [AUC] = 0.743) achieved superior discrimination compared to age (AUC = 0.594) for mortality.
Conclusion Increasing frailty, as measured by mFI-5, is a more robust predictor as compared to age, for poor postoperative outcomes in spinal tumor surgery patients. The mFI-5 may be clinically used for preoperative risk stratification of spinal tumor patients.
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Affiliation(s)
- Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | | | | | - Smit Shah
- Department of Neurology, Prisma Health–Midlands/University of South Carolina School of Medicine, Columbia, SC, USA
| | - William T. Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Rachel Thommen
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - Matthew Conlon
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | | | - John Vellek
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Kyrill L. Cole
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Jose F. Dominguez
- Department of Neurosurgery, Westchester Medical Center & New York Medical College, Valhalla, NY, USA
| | - Rohini N. Mckee
- Department of Surgery, University of New Mexico, Albuquerque, NM, USA
| | - Christian B. Ricks
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Peter C. Shin
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Chad D. Cole
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Meic H. Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
- Corresponding Author Meic H. Schmidt https://orcid.org/0000-0003-2259-9459 Department of Neurosurgery, University of New Mexico Hospital, 1 University New Mexico, MSC10 5615, Albuquerque, NM, USA
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Cole KL, Kazim SF, Thommen R, Alvarez-Crespo DJ, Vellek J, Conlon M, Tarawneh OH, Dicpinigaitis AJ, Dominguez J, McKee RG, Schmidt MH, Couldwell WT, Cole CD, Bowers CA. Association of baseline frailty status and age with outcomes in patients undergoing intracranial meningioma surgery: Results of a nationwide analysis of 5818 patients from the National Surgical Quality Improvement Program (NSQIP) 2015–2019. Eur J Surg Oncol 2022; 48:1671-1677. [DOI: 10.1016/j.ejso.2022.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 02/02/2022] [Accepted: 02/10/2022] [Indexed: 12/13/2022] Open
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34
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Thommen R, Kazim SF, Cole KL, Olson GT, Shama L, Lovato CM, Gonzales KM, Dicpinigaitis AJ, Couldwell WT, Mckee RN, Cole CD, Schmidt MH, Bowers CA. Worse Pituitary Adenoma Surgical Outcomes Predicted by Increasing Frailty, Not Age. World Neurosurg 2022; 161:e347-e354. [DOI: 10.1016/j.wneu.2022.02.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 01/31/2022] [Accepted: 02/01/2022] [Indexed: 11/30/2022]
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35
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Dave P, Pakhchanian H, Tarawneh OH, Kazim SF, Garay S, Raiker R, Liu IZ, Vellek J, Dicpinigaitis AJ, Cole KL, Spader HS, Botros JA, Schmidt MH, Bowers CA. Trends in United States pediatric neurosurgical practice during the COVID-19 pandemic. J Clin Neurosci 2022; 97:21-24. [PMID: 35033777 PMCID: PMC8733216 DOI: 10.1016/j.jocn.2022.01.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 10/17/2021] [Accepted: 01/02/2022] [Indexed: 02/04/2023]
Abstract
There is minimal information on COVID-19 pandemic’s national impact on pediatric neurosurgical operative volumes. In this study, using a national database, TriNetX, we compared the overall and seasonal trends of pediatric neurosurgical procedure volumes in the United States during the pandemic to pre-pandemic periods. In the United States, the incidence of COVID-19 began to rise in September 2020 and reached its maximum peak between December 2020 and January 2021. During this time, there was an inverse relationship between pediatric neurosurgical operative volumes and the incidence of COVID-19 cases. From March 2020 to May 2021, there was a significant decrease in the number of pediatric shunt (−11.7% mean change, p = 0.006), epilepsy (−16.6%, p < 0.001), and neurosurgical trauma (−13.8%, p < 0.001) surgeries compared to pre-pandemic years. The seasonal analysis also yielded a broad decrease in most subcategories in spring 2020 with significant decreases in pediatric spine, epilepsy, and trauma cases. To the best of our knowledge, this is the first study to report a national decline in pediatric shunt, epilepsy, and neurosurgical trauma operative volumes during the pandemic. This could be due to fear-related changes in health-seeking behavior as well as underdiagnosis during the COVID-19 pandemic.
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Affiliation(s)
- Pooja Dave
- George Washington University, School of Medicine, Washington, DC, USA
| | - Haig Pakhchanian
- George Washington University, School of Medicine, Washington, DC, USA
| | - Omar H Tarawneh
- New York Medical College, School of Medicine, Valhalla, NY, USA
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Steven Garay
- George Washington University, School of Medicine, Washington, DC, USA
| | - Rahul Raiker
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Ivan Z Liu
- Medical College of Georgia, Augusta, GA, USA
| | - John Vellek
- New York Medical College, School of Medicine, Valhalla, NY, USA
| | | | - Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Heather Stevens Spader
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - James A Botros
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital (UNMH), Albuquerque, NM, USA.
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36
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Dicpinigaitis AJ, Gandhi CD, Shah SP, Galea VP, Cooper JB, Feldstein E, Shapiro SD, Kamal H, Kurian C, Kaur G, Tyagi R, Biswas A, Rosenberg J, Bauerschmidt A, Bowers CA, Mayer SA, Al-Mufti F. Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients. J Neurol Sci 2022; 434:120168. [DOI: 10.1016/j.jns.2022.120168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/28/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
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37
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Lapow JM, Dicpinigaitis AJ, Pammal RS, Coghill GA, Rechester O, Feldstein E, Nuoman R, Maselli K, Kodi S, Bauerschmidt A, Rosenberg JB, Yaghi S, Kaur G, Kurian C, Chong JY, Mayer SA, Gandhi CD, Al-Mufti F. Obstructive sleep apnea confers lower mortality risk in acute ischemic stroke patients treated with endovascular thrombectomy: National Inpatient Sample analysis 2010-2018. J Neurointerv Surg 2021; 14:1195-1199. [PMID: 34930802 DOI: 10.1136/neurintsurg-2021-018161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 08/23/2021] [Accepted: 12/06/2021] [Indexed: 11/04/2022]
Abstract
BackgroundObstructive sleep apnea (OSA) portends increased morbidity and mortality following acute ischemic stroke (AIS). Evaluation of OSA in the setting of AIS treated with endovascular mechanical thrombectomy (MT) has not yet been evaluated in the literature. METHODS The National Inpatient Sample from 2010 to 2018 was utilized to identify adult AIS patients treated with MT. Those with and without OSA were compared for clinical characteristics, complications, and discharge disposition. Multivariable logistic regression analysis and propensity score adjustment (PA) were employed to evaluate independent associations between OSA and clinical outcome. RESULTS Among 101 093 AIS patients treated with MT, 6412 (6%) had OSA. Those without OSA were older (68.5 vs 65.6 years old, p<0.001), female (50.5% vs 33.5%, p<0.001), and non-caucasian (29.7% vs 23.7%, p<0.001). The OSA group had significantly higher rates of obesity (41.4% vs 10.5%, p<0.001), atrial fibrillation (47.1% vs 42.2%, p=0.001), hypertension (87.4% vs 78.5%, p<0.001), and diabetes mellitus (41.2% vs 26.9%, p<0.001). OSA patients treated with MT demonstrated lower rates of intracranial hemorrhage (19.1% vs 21.8%, p=0.017), treatment of hydrocephalus (0.3% vs 1.1%, p=0.009), and in-hospital mortality (9.7% vs 13.5%, p<0.001). OSA was independently associated with lower rate of in-hospital mortality (aOR 0.76, 95% CI 0.69 to 0.83; p<0.001), intracranial hemorrhage (aOR 0.88, 95% CI 0.83 to 0.95; p<0.001), and hydrocephalus (aOR 0.51, 95% CI 0.37 to 0.71; p<0.001). Results were confirmed by PA. CONCLUSIONS Our findings suggest that MT is a viable and safe treatment option for AIS patients with OSA.
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Affiliation(s)
- Justin M Lapow
- New York Medical College School of Medicine, Valhalla, New York, USA
| | | | - Rajkumar S Pammal
- New York Medical College School of Medicine, Valhalla, New York, USA
| | - Griffin A Coghill
- New York Medical College School of Medicine, Valhalla, New York, USA
| | | | - Eric Feldstein
- Neurosurgery, New York Medical College Department of Neurosurgery, Valhalla, New York, USA
| | - Rolla Nuoman
- Neurology, Westchester Medical Center, Valhalla, New York, USA
| | | | - Shyla Kodi
- New York Medical College School of Medicine, Valhalla, New York, USA.,Westchester Medical Center, Valhalla, New York, USA
| | - Andrew Bauerschmidt
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Jon B Rosenberg
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, Rhode Island, USA
| | - Gurmeen Kaur
- Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | | | - Ji Y Chong
- Neurology, Westchester Medical Center, Valhalla, New York, USA.,Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Stephan A Mayer
- Neurology, Westchester Medical Center, Valhalla, New York, USA
| | - Chirag D Gandhi
- Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Fawaz Al-Mufti
- Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
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38
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Dicpinigaitis AJ, Al-Mufti F, Cooper JB, Faraz Kazim S, Couldwell WT, Schmidt MH, Gandhi CD, Cole CD, Bowers CA. Nationwide trends in middle meningeal artery embolization for treatment of chronic subdural hematoma: A population-based analysis of utilization and short-term outcomes. J Clin Neurosci 2021; 94:70-75. [PMID: 34863465 DOI: 10.1016/j.jocn.2021.10.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 09/02/2021] [Revised: 09/29/2021] [Accepted: 10/03/2021] [Indexed: 11/29/2022]
Abstract
Middle meningeal artery (MMA) embolization represents a promising novel treatment modality for chronic subdural hematoma (cSDH), yet utilization and efficacy data are limited. This study evaluates the utilization and short-term outcomes of MMA embolization for cSDH treatment in a large national inpatient registry. cSDH patients treated with MMA embolization and/or surgical evacuation (craniotomy/burr hole drainage) were identified using the National Inpatient Sample (NIS) during 2012-2018 period. Temporal trends, complications, and discharge disposition were evaluated, and propensity score matching was implemented for adjusted comparisons and to mitigate confounding by indication. Among 60,045 cSDH patients identified, 390 (0.6%) underwent MMA embolization. Embolized patients presented more with high acute illness severity subclasses in comparison with surgically evacuated patients (53% vs. 34%, p = 0.004) yet did not experience any procedure-related hemorrhagic or ischemic complications. Although discharge disposition did not differ from those surgically managed, embolized patients had longer mean hospital stays (13 vs. 8 days, p = 0.023) and accrued greater hospital charges (p < 0.001). Following propensity adjustment, length of stay and charges remained greater in the embolization cohort, yet rates of routine discharge increased appreciably (40% vs. 30%, p = 0.141) relative to surgically treated cSDH patients. The utilization of embolization increased exponentially after 2015, reaching an apex in 2018 (3.7% of treated cSDH). This population-based national assessment demonstrates exponential increases in utilization of MMA embolization for cSDH treatment in recent years. Embolized patients had uncomplicated clinical courses and similar discharge dispositions as surgical evacuation patients. Large-scale prospective trials are warranted to further assess the efficacy of this modality.
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Affiliation(s)
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Jared B Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Syed Faraz Kazim
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - William T Couldwell
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA
| | - Meic H Schmidt
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Chad D Cole
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA
| | - Christian A Bowers
- Depertment of Neurosurgery, University of New Mexico, Albuquerque, NM, USA.
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39
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Varela S, Kazim SF, Schmidt MH, Chaurasia B, Dicpinigaitis AJ, Ogulnick JV, Cole KL, Conlon M, Tarawneh O, Thommen R, Cole CD, Jean WC, Couldwell WT, Litvack ZN, Al-Mufti F, Bowers CA. Neurosurgery virtual education in the COVID-19 pandemic era: results of a global survey. J Neurosurg Sci 2021; 66:274-277. [PMID: 34647717 DOI: 10.23736/s0390-5616.21.05579-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Samantha Varela
- School of Medicine, University of New Mexico (UNM), Albuquerque, NM, USA
| | - Syed F Kazim
- Department of Neurosurgery, University of New Mexico (UNM) School of Medicine, Albuquerque, NM, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico (UNM) School of Medicine, Albuquerque, NM, USA
| | - Bipin Chaurasia
- Department of Neurosurgery, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | | | | | - Kyril L Cole
- School of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Matthew Conlon
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Omar Tarawneh
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Rachel Thommen
- School of Medicine, New York Medical College, Valhalla, NY, USA
| | - Chad D Cole
- Department of Neurosurgery, University of New Mexico (UNM) School of Medicine, Albuquerque, NM, USA
| | - Walter C Jean
- Department of Neurosurgery, George Washington University, Washington, WA, USA
| | - William T Couldwell
- Department of Neurosurgery, University of Utah, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, USA
| | - Zachary N Litvack
- Department of Neurosurgery, Swedish Neuroscience Institute, Swedish Medical Center, Seattle, WA, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico (UNM) School of Medicine, Albuquerque, NM, USA -
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40
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Dicpinigaitis AJ, Sursal T, Morse CA, Briskin C, Dakay K, Kurian C, Kaur G, Sahni R, Bowers C, Gandhi CD, Mayer SA, Al-Mufti F. Endovascular Thrombectomy for Treatment of Acute Ischemic Stroke During Pregnancy and the Early Postpartum Period. Stroke 2021; 52:3796-3804. [PMID: 34538088 DOI: 10.1161/strokeaha.121.034303] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke (AIS) is a rare occurrence during pregnancy and the postpartum period. Existing literature evaluating endovascular mechanical thrombectomy (MT) for this patient population is limited. METHODS The National Inpatient Sample was queried from 2012 to 2018 to identify and characterize pregnant and postpartum patients (up to 6 weeks following childbirth) with AIS treated with MT. Complications and outcomes were compared with nonpregnant female patients treated with MT and to other pregnant and postpartum patients managed medically. Complex samples regression models and propensity score matching were implemented to assess adjusted associations and to address confounding by indication, respectively. RESULTS Among 4590 pregnant and postpartum patients with AIS, 180 (3.9%) were treated with MT, and rates of utilization increased following the MT clinical trial era (2015-2018; 1.9% versus 5.3%, P=0.011). Compared with nonpregnant patients with AIS treated with MT, they experienced lower rates of intracranial hemorrhage (11% versus 24%, P=0.069) and poor functional outcome (50% versus 72%, P=0.003) at discharge. Pregnant/postpartum status was independently associated with a lower likelihood of development of intracranial hemorrhage (adjusted odds ratio, 0.26 [95% CI, 0.09-0.70]; P=0.008) following multivariable analysis adjusting for age, illness severity, and stroke severity. Following propensity score matching, pregnant and postpartum patients treated with MT and those medically managed differed in frequency of venous thromboembolism (17% versus 0%, P=0.001) and complications related to pregnancy (44% versus 64%, P=0.034), but not in functional outcome at discharge or hospital length of stay. Pregnant and postpartum women treated with MT did not experience mortality or miscarriage during hospitalization. CONCLUSIONS This large-scale analysis utilizing national claims data suggests that MT is a safe and efficacious therapy for AIS during pregnancy and the postpartum period. In the absence of prospective clinical trials, population-based cross-sectional analyses such as the present study provide valuable clinical insight.
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Affiliation(s)
| | - Tolga Sursal
- Department of Neurosurgery (T.S., C.D.G.), Westchester Medical Center, Valhalla, NY
| | - Catherine A Morse
- School of Medicine, New York Medical College, Valhalla, (A.L.D., C.A.M., C.B.)
| | - Camille Briskin
- School of Medicine, New York Medical College, Valhalla, (A.L.D., C.A.M., C.B.)
| | - Katarina Dakay
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Christeena Kurian
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Gurmeen Kaur
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Ramandeep Sahni
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque (C.B.)
| | - Chirag D Gandhi
- Department of Neurosurgery (T.S., C.D.G.), Westchester Medical Center, Valhalla, NY
| | - Stephan A Mayer
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
| | - Fawaz Al-Mufti
- Department of Neurology (K.D., C.K., G.K., R.S., S.A.M., F.A.-M.), Westchester Medical Center, Valhalla, NY
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Dicpinigaitis AJ, Kazim SF, Schmidt MH, Couldwell WT, Theriault BC, Gandhi CD, Hanft S, Al-Mufti F, Bowers CA. Association of baseline frailty status and age with postoperative morbidity and mortality following intracranial meningioma resection. J Neurooncol 2021; 155:45-52. [PMID: 34495456 DOI: 10.1007/s11060-021-03841-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 06/29/2021] [Accepted: 09/04/2021] [Indexed: 12/21/2022]
Abstract
PURPOSE Although numerous studies have established advanced patient age as a risk factor for poor outcomes following intracranial meningioma resection, large-scale evaluation of frailty for preoperative risk assessment has yet to be examined. METHODS Weighted discharge data from the National Inpatient Sample were queried for adult patients undergoing benign intracranial meningioma resection from 2015 to 2018. Complex samples multivariable logistic regression models and receiver operating characteristic curve analysis were performed to evaluate adjusted associations and discrimination of frailty, quantified using the 11-factor modified frailty index (mFI), for clinical endpoints. RESULTS Among 20,250 patients identified (mean age 60.6 years), 35.4% (n = 7170) were robust (mFI = 0), 34.5% (n = 6985) pre-frail (mFI = 1), 20.1% (n = 4075) frail (mFI = 2), and 10.0% (n = 2020) severely frail (mFI ≥ 3). On univariable analysis, these sub-cohorts stratified by increasing frailty were significantly associated with the development of Clavien-Dindo grade IV (life-threatening) complications (inclusive of those resulting in mortality) (1.3% vs. 3.1% vs. 6.5% vs. 9.4%, p < 0.001) and extended length of stay (eLOS) (15.4% vs. 22.5% vs. 29.3% vs. 37.4%, p < 0.001). Following multivariable analysis, increasing frailty (aOR 1.40, 95% CI 1.17, 1.68, p < 0.001) and age (aOR 1.20, 95% CI 1.05, 1.38, p = 0.009) were both independently associated with development of life-threatening complications or mortality, whereas increasing frailty (aOR 1.20, 95% CI 1.10, 1.32, p < 0.001), but not age, was associated with eLOS. Frailty (by mFI-11) achieved superior discrimination in comparison to age for both endpoints (AUC 0.69 and 0.61, respectively). CONCLUSION Frailty may be more accurate than advanced patient age alone for prognostication of adverse events and outcomes following intracranial meningioma resection.
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Affiliation(s)
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, 87106, USA
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, 87106, USA
| | - William T Couldwell
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, 84132, USA
| | - Brianna Carusillo Theriault
- Department of Neurosurgery, Yale University School of Medicine/Yale New Haven Hospital, New Haven, CT, 06510, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, 10595, USA
| | - Simon Hanft
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, 10595, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center/New York Medical College, Valhalla, NY, 10595, USA
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, NM, 87106, USA. .,Department of Neurosurgery, University of New Mexico Health Sciences Center, MSC10 5615, 1 University of New Mexico, Albuquerque, NM, 81731, USA.
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Dicpinigaitis AJ, Kalakoti P, Schmidt M, Gurgel R, Cole C, Carlson A, Pickett B, Sun H, Mukherjee D, Al-Mufti F, Bowers CA. Associations of Baseline Frailty Status and Age With Outcomes in Patients Undergoing Vestibular Schwannoma Resection. JAMA Otolaryngol Head Neck Surg 2021; 147:608-614. [PMID: 33914061 DOI: 10.1001/jamaoto.2021.0670] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Although numerous studies have evaluated the influence of advanced age on surgical outcomes following vestibular schwannoma (VS) resection, few if any large-scale investigations have assessed the comparative prognostic effects of age and frailty. As the population continues to age, it is imperative to further evaluate treatment and management strategies for older patients. Objective To conduct a population-based evaluation of the independent associations of chronological age and frailty (physiological age) with outcomes following VS resection. Design, Setting, and Participants In this large-scale, multicenter, cross-sectional analysis, weighted discharge data from the National Inpatient Sample were searched to identify adult patients (≥18 years old) who underwent VS resection from 2002 through 2017 using International Classification of Diseases, Ninth Revision, Clinical Modification and Tenth Revision, Clinical Modification codes. Data collection and analysis took place September to December 2020. Main Outcomes and Measures Complex samples regression models and receiver operating characteristic curve analysis were used to evaluate the independent associations of frailty and age (along with demographic confounders) with complications and discharge disposition. Frailty was evaluated using the previously validated 11-point modified frailty index (mFI). Results Among the 27 313 patients identified for VS resection, the mean (SEM) age was 50.4 (0.2) years, 15 031 (55.0%) were women, and 4720 (21.0%) were of non-White race/ethnicity, as determined by the National Inpatient Sample data source. Of the included patients, 15 090 (55.2%) were considered robust (mFI score = 0), 8204 (30.0%) were prefrail (mFI score = 1), 3022 (11.1%) were frail (mFI score = 2), and 996 (3.6%) were severely frail (mFI score ≥3). On univariable analysis, increasing frailty was associated with development of postoperative hemorrhagic or ischemic stroke (odds ratio [OR], 2.44 [95% CI, 2.07-2.87]; area under the curve, 0.73), while increasing age was not. Following multivariable analysis, increasing frailty and non-White race/ethnicity were independently associated with both mortality (adjusted OR [aOR], 2.32 [95% CI, 1.70-3.17], and aOR, 3.05 [95% CI, 1.02-9.12], respectively) and extended hospital stays (aOR, 1.54 [95% CI, 1.41-1.67], and aOR, 1.71 [95% CI, 1.42-2.05], respectively), while increasing age was not. Increasing frailty (aOR, 0.61 [95% CI, 0.56-0.67]), age (aOR, 0.98 [95% CI, 0.97-0.99]), and non-White race/ethnicity (aOR, 0.62 [95% CI 0.51-0.75]) were all independently associated with routine discharge. Conclusions and Relevance In this cross-sectional study, findings suggest that frailty may be more accurate for predicting outcomes and guiding treatment decisions than advanced patient age alone following VS resection.
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Affiliation(s)
| | - Piyush Kalakoti
- Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland
| | - Meic Schmidt
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque
| | - Richard Gurgel
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City
| | - Chad Cole
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque
| | - Andrew Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque
| | - Brad Pickett
- Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of New Mexico School of Medicine, Albuquerque
| | - Hai Sun
- Department of Neurosurgery, Robert Wood Johnson Medical School, Rutgers University, New Brunswick, New Jersey.,Department of Neurosurgery, New Jersey Medical School, Rutgers University, Newark
| | - Debraj Mukherjee
- Department of Neurosurgery, Johns Hopkins Medicine, Baltimore, Maryland
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque
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Ogulnick JV, Kazim SF, Carlson AP, Shah S, Dicpinigaitis AJ, SantaCruz K, Schmidt MH, Bowers CA. Fenestration of intracranial neurenteric cyst: A case report. Surg Neurol Int 2021; 12:287. [PMID: 34221618 PMCID: PMC8247734 DOI: 10.25259/sni_169_2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 02/16/2021] [Accepted: 05/07/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Neurenteric cysts are rare congenital lesions of endodermal origin which result from the failure of the neurenteric canal to close during embryogenesis. The majority of neurenteric cysts occur in the spinal cord, though in rare instances can occur intracranially, typically in the posterior fossa anterior to the pontomedullary junction (80%) or in the supratentorial region adjacent to the frontal lobes (20%). Case Description: We present the case of a 75-year-old woman with an extra-axial cystic lesion centered in the premedullary cistern causing brainstem compression. The lesion was later histopathologically confirmed to be a neurenteric cyst. She presented initially with a 4-month history of worsening headache, dizziness, and unsteady gait. We performed a left retrosigmoid craniotomy for cyst fenestration/biopsy with the aid of operating microscope and stealth neuronavigation. Following the procedure, the patient recovered without complications or residual deficits. Conclusion: This case illustrates the successful fenestration of an intracranial neurenteric cyst with good clinical outcome. We present the pre- and post-operative imaging findings, a technical video of the procedure, histopathological confirmation, and a brief review of the relevant clinical literature on the topic.
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Affiliation(s)
- Jonathan V Ogulnick
- School of Medicine, New York Medical College, Valhalla, New York, United States
| | - Syed Faraz Kazim
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, United States
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, United States
| | - Smit Shah
- Department of Neurology, University of South Carolina School of Medicine, Columbia, South Carolina, United States
| | | | - Karen SantaCruz
- Department of Pathology, University of New Mexico Hospital, Albuquerque, New Mexico, United States
| | - Meic H Schmidt
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, United States
| | - Christian A Bowers
- Department of Neurosurgery, University of New Mexico Hospital, Albuquerque, New Mexico, United States
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Dicpinigaitis AJ, Li B, Ogulnick J, McIntyre MK, Bowers C. Evaluating the Impact of Neurosurgical Educational Interventions on Patient Knowledge and Satisfaction: A Systematic Review of the Literature. World Neurosurg 2020; 147:70-78. [PMID: 33276172 DOI: 10.1016/j.wneu.2020.11.144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 10/15/2020] [Revised: 11/24/2020] [Accepted: 11/25/2020] [Indexed: 12/09/2022]
Abstract
OBJECTIVE In this systematic review, preoperative educational interventions for patients undergoing neurosurgical treatment are identified and their impact on patient knowledge acquisition and satisfaction is assessed. METHODS The review was conducted in accordance with the PRISMA guidelines and used PubMed, Google Scholar, and MEDLINE databases. Studies evaluating before and after cohort or control group comparison were identified between 2007 and 2019 and were independently scored and evaluated by 3 authors. RESULTS Eighty-one articles were assessed for eligibility and 15 met the inclusion criteria. Patient educational interventions were text-based (2 studies), multimedia/video-based (3), mobile/tablet-based (5), or used virtual reality (2) or three-dimensional printing (3). Interventions were disease-specific for cerebrovascular lesions (5), degenerative spine disease (2), concussion/traumatic brain injury (2), movement disorders (1), brain tumor (1), adolescent epilepsy (1), and other cranial/spinal elective procedures (3). Eleven studies (n = 18-175) documented patient knowledge acquisition using self-reported knowledge questionnaires (5) or more objective assessments based on true/false or multiple-choice questions (6). Most studies (10/11) reported statistically significant increases in patient knowledge after implementation of the intervention. Ten studies (n = 14-600) documented patient satisfaction using validated satisfaction surveys (2), Likert scale surveys (6), or other questionnaires (2). Although all studies reported increases in patient satisfaction after the intervention, only 4 were statistically significant. CONCLUSIONS Patient educational interventions using various modalities are broadly applicable within neurosurgery and ubiquitously enhance patient knowledge and satisfaction. Interventions should be implemented when possible.
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Affiliation(s)
| | - Boyi Li
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Jonathan Ogulnick
- School of Medicine, New York Medical College, Valhalla, New York, USA
| | - Matthew K McIntyre
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA
| | - Christian Bowers
- Department of Neurosurgery, University of New Mexico, Albuquerque, New Mexico, USA.
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Dicpinigaitis PV, Lee Chang A, Dicpinigaitis AJ, Negassa A. Effect of Electronic Cigarette Use on the Urge-to-Cough Sensation. Nicotine Tob Res 2016; 18:1763-5. [PMID: 26803150 DOI: 10.1093/ntr/ntw021] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2015] [Accepted: 01/12/2016] [Indexed: 12/22/2022]
Abstract
INTRODUCTION Electronic cigarettes (e-cigs) have attained common usage worldwide, yet knowledge of their physiological effects remains minimal. The aim of this study was to evaluate the effect of a single exposure to e-cig vapor on the urge-to-cough (UTC) threshold and C5. METHODS Seventeen healthy nonsmokers underwent C5 measurement employing capsaicin cough challenge at baseline, 15 minutes, and 24 hours after e-cig exposure (30 puffs 30 seconds apart). The endpoint of cough challenge is C5, the concentration of capsaicin inducing five or more coughs. The UTC threshold (Cu) is defined as the lowest concentration of capsaicin inducing UTC without an associated motor cough. RESULTS The Cu and C5 were significantly inhibited (Cu and C5 increased) 15 minutes after e-cig use. Mean log Cu rose from -0.035±0.08 (SEM) to 0.21±0.12 (P = .005). Mean log C5 increased from 0.60±0.11 to 0.92±0.16 (P = .001). By 24 hours after e-cig exposure, Cu and C5 had returned to baseline levels. CONCLUSIONS A single session of e-cig use, approximating nicotine exposure of one tobacco cigarette, induces significant inhibition of the Cu, as well as C5. Previous studies implicate nicotine as the agent responsible for suppression of C5, and we hypothesize a similar role for nicotine in the suppression of the Cu. Given our observation of the effect of a single e-cig exposure, studies of the respiratory physiologic implications of repeated or chronic e-cig use are warranted. IMPLICATIONS This is the first study to demonstrate that a single exposure to an e-cig significantly inhibits the Cu as measured by capsaicin cough challenge testing. These findings add to the growing body of evidence that e-cig vapor is not a physiologically benign substance, and support further investigation of the effects of repeated or chronic use of e-cigs on cough sensitivity and other respiratory parameters.
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Affiliation(s)
- Peter V Dicpinigaitis
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Alfredo Lee Chang
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Alis J Dicpinigaitis
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
| | - Abdissa Negassa
- Department of Medicine, Albert Einstein College of Medicine and Montefiore Medical Center, Bronx, NY
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