1
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Padmanaban V, Yee PP, Koduri S, Zaidat B, Daou BJ, Chaudhary N, Gemmete JJ, Thompson BG, Kazmierczak CD, Cockroft KM, Pandey AS, Wilkinson DA. Neuroendovascular Procedures in Patients with Ehlers-Danlos Type IV: Multicenter Case Series and Systematic Review. World Neurosurg 2023; 170:e529-e541. [PMID: 36402305 DOI: 10.1016/j.wneu.2022.11.067] [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: 08/18/2022] [Revised: 11/13/2022] [Accepted: 11/14/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ehlers-Danlos type IV or vascular Ehlers-Danlos syndrome (vEDS) is a rare inherited disorder characterized by profound vascular fragility resulting from defective production of type III procollagen. Cerebrovascular diseases including spontaneous dissections, cerebral aneurysms, and cavernous carotid fistulae are common. Endovascular therapies in this patient population are known to be higher risk, although many studies (before 2000) involved older techniques and equipment. The purpose of this study is to investigate the safety and efficacy of modern neuroendovascular techniques in the treatment of cerebrovascular diseases in patients with vEDS. METHODS We combined a multi-institutional retrospective case series at 3 quaternary-care centers with a systematic literature review of individual case reports and case series spanning 2000-2021 to evaluate the safety and efficacy of neuroendovascular procedure in patients with vEDS with cerebrovascular diseases. RESULTS Fifty-nine patients who underwent 66 neuroendovascular procedures were evaluated. Most of the patients had direct cavernous carotid fistulas (DCCF). Neuroendovascular procedures had a 94% success rate, with a complication rate of 30% and a mortality of 7.5%. CONCLUSIONS Neuroendovascular procedures can be performed with a high rate of success in the treatment of cerebrovascular diseases in patients with vEDS, although special care is required because complication rates and mortality are high. Access site and procedure-related vascular injuries remain a significant hurdle in treating vEDS with cerebrovascular diseases, even with modern techniques.
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Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Patricia P Yee
- Medical Scientist Training Program, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Bashar Zaidat
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Badih J Daou
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Chris D Kazmierczak
- Department of Radiology, Oakland University-William Beaumont School of Medicine, Auburn Hills, Michigan, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA; Department of Radiology, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan Medical Center, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA.
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2
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Savastano L, Mousavi H, Liu Y, Khalsa SSS, Zheng Y, Davis E, Reddy A, Brinjikji W, Bhambri A, Cockrum J, Pandey AS, Thompson BG, Gordon D, Seibel EJ, Yonas H. Unifying theory of carotid plaque disruption based on structural phenotypes and forces expressed at the lumen/wall interface. Stroke Vasc Neurol 2022; 7:465-475. [PMID: 35649687 PMCID: PMC9811551 DOI: 10.1136/svn-2021-001451] [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: 12/03/2021] [Accepted: 04/08/2022] [Indexed: 01/28/2023] Open
Abstract
OBJECTIVES To integrate morphological, haemodynamic and mechanical analysis of carotid atheroma driving plaque disruption. MATERIALS AND METHODS First, we analysed the phenotypes of carotid endarterectomy specimens in a photographic dataset A, and matched them with the likelihood of preoperative stroke. Second, laser angioscopy was used to further define the phenotypes in intact specimens (dataset B) and benchmark with histology. Third, representative vascular geometries for each structural phenotype were analysed with Computational Fluid Dynamics (CFD), and the mechanical strength of the complicated atheroma to resist penetrating forces was quantified (n=14). RESULTS In dataset A (n=345), ulceration (fibrous cap disruption) was observed in 82% of all plaques, intraplaque haemorrhage in 68% (93% subjacent to an ulcer) and false luminal formation in 48%. At least one of these 'rupture' phenotypes was found in 97% of symptomatic patients (n=69) compared with 61% in asymptomatic patients. In dataset B (n=30), laser angioscopy redemonstrated the structural phenotypes with near-perfect agreement with histology. In CFD, haemodynamic stress showed a large pulse magnitude, highest upstream to the point of maximal stenosis and on ulceration the inflow stream excavates the necrotic core cranially and then recirculates into the true lumen. Based on mechanical testing (n=14), the necrotic core is mechanically weak and penetrated by the blood on fibrous cap disruption. CONCLUSIONS Fibrous cap ulceration, plaque haemorrhage and excavation are sequential phenotypes of plaque disruption resulting from the chiselling effect of haemodynamic forces over unmatched mechanical tissue strength. This chain of events may result in thromboembolic events independently of the degree of stenosis.
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Affiliation(s)
| | - Hossein Mousavi
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
| | - Yang Liu
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Siri Sahib S Khalsa
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Yihao Zheng
- Department of Mechanical Engineering, Worcester Polytechnic Institute, Worcester, Massachusetts, USA
| | - Evan Davis
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Adithya Reddy
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Ankur Bhambri
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joshua Cockrum
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aditya S Pandey
- Neurosurgery, Michigan Medicine, Ann Arbor, Michigan, USA,Radiology, Michigan Medicine, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - David Gordon
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Eric J Seibel
- Department of Mechanical Engineering, University of Washington, Seattle, Washington, USA
| | - Howard Yonas
- Department of Neurology, University of New Mexico School of Medicine, Albuquerque, New Mexico, USA
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3
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Jiang C, Bhattacharya A, Linzey JR, Joshi RS, Cha SJ, Srinivasan S, Alber D, Kondepudi A, Urias E, Pandian B, Al-Holou WN, Sullivan SE, Thompson BG, Heth JA, Freudiger CW, Khalsa SSS, Pacione DR, Golfinos JG, Camelo-Piragua S, Orringer DA, Lee H, Hollon TC. Rapid Automated Analysis of Skull Base Tumor Specimens Using Intraoperative Optical Imaging and Artificial Intelligence. Neurosurgery 2022; 90:758-767. [PMID: 35343469 PMCID: PMC9514725 DOI: 10.1227/neu.0000000000001929] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 12/16/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Accurate specimen analysis of skull base tumors is essential for providing personalized surgical treatment strategies. Intraoperative specimen interpretation can be challenging because of the wide range of skull base pathologies and lack of intraoperative pathology resources. OBJECTIVE To develop an independent and parallel intraoperative workflow that can provide rapid and accurate skull base tumor specimen analysis using label-free optical imaging and artificial intelligence. METHODS We used a fiber laser-based, label-free, nonconsumptive, high-resolution microscopy method (<60 seconds per 1 × 1 mm2), called stimulated Raman histology (SRH), to image a consecutive, multicenter cohort of patients with skull base tumor. SRH images were then used to train a convolutional neural network model using 3 representation learning strategies: cross-entropy, self-supervised contrastive learning, and supervised contrastive learning. Our trained convolutional neural network models were tested on a held-out, multicenter SRH data set. RESULTS SRH was able to image the diagnostic features of both benign and malignant skull base tumors. Of the 3 representation learning strategies, supervised contrastive learning most effectively learned the distinctive and diagnostic SRH image features for each of the skull base tumor types. In our multicenter testing set, cross-entropy achieved an overall diagnostic accuracy of 91.5%, self-supervised contrastive learning 83.9%, and supervised contrastive learning 96.6%. Our trained model was able to segment tumor-normal margins and detect regions of microscopic tumor infiltration in meningioma SRH images. CONCLUSION SRH with trained artificial intelligence models can provide rapid and accurate intraoperative analysis of skull base tumor specimens to inform surgical decision-making.
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Affiliation(s)
- Cheng Jiang
- Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Joseph R. Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Rushikesh S. Joshi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Sung Jik Cha
- School of Medicine, Western Michigan University, Kalamazoo, Michigan, USA
| | | | - Daniel Alber
- Division of Applied Mathematics, Brown University, Providence, Rhode Island, USA
| | - Akhil Kondepudi
- College of Literature, Science and the Arts, University of Michigan, Ann Arbor, Michigan, USA
| | - Esteban Urias
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Balaji Pandian
- School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Wajd N. Al-Holou
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Stephen E. Sullivan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - B. Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Jason A. Heth
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | | | | | - Donato R. Pacione
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | - John G. Golfinos
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
| | | | - Daniel A. Orringer
- Department of Neurosurgery, NYU Langone Health, New York, New York, USA
- Department of Pathology, NYU Langone Health, New York, New York, USA
| | - Honglak Lee
- Department of Computer Science and Engineering, University of Michigan, Ann Arbor, Michigan, USA
| | - Todd C. Hollon
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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4
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Daou BJ, Muhlestein WE, Palmateer G, Thompson BG, Pandey AS. Clipping of unruptured intracranial aneurysms in patients older than sixty: An age-based analysis. Clin Neurol Neurosurg 2021; 207:106737. [PMID: 34134009 DOI: 10.1016/j.clineuro.2021.106737] [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: 01/18/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE The diagnosis of unruptured intracranial aneurysms (UIAs) is being made more frequently in elderly patients. The goal of this study is to evaluate complications and clinical outcome in patients ≥ 60 years-old who underwent clipping of UIAs. METHODS We performed a retrospective cohort study. Clinical outcome (modified Rankin scale score) was determined at the latest clinical follow-up. Complications and outcomes were compared between age groups (60-69, 70-80) and subgroups (60-64, 65-69, 70-74, and >75). RESULTS The study population consisted of 255 patients (range 60-80 years-old) who underwent 262 clipping procedures for UIAs. Mean follow-up duration was 15.6 months (± 27.5). Major complications occurred in 20 patients (7.6%) and mortality in 3 patients (1.1%). Medical complications occurred in 26 patients (10%). Mean length of hospital-stay was 4.7 days (± 5.8). 89.6% were discharged to home. 87.8% had a favorable clinical outcome. The 70-80 age group had significantly more complications (P = 0.03) than the 60-69 group and a significantly longer hospital stay (6.02 vs. 4.3 days, P = 0.04). The older group was less likely to discharge to home and more likely to require rehabilitation (P = 0.002). Favorable clinical outcome did not significantly differ between the two groups (85.7% vs. 88.4%, P = 0.56). There was a trend for increasing complications from the younger to older subgroups (P = 0.008) and a reduction in the likelihood to discharge to home (P < 0.0001). The rate of ultimate favorable clinical outcome did not differ significantly between subgroups (P = 0.79). CONCLUSION Although complications, length of hospital-stay, and discharge to non-home destinations increase with older age, the majority of patients ≥ 60 may have favorable clinical outcomes.
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Affiliation(s)
- Badih J Daou
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Whitney E Muhlestein
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Gregory Palmateer
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States.
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5
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Linzey JR, Foshee R, Moriguchi F, Adapa AR, Koduri S, Kahn EN, Williamson CA, Sheehan K, Rajajee V, Thompson BG, Muraszko KM, Pandey AS. Length of Stay Beyond Medical Readiness in a Neurosurgical Patient Population and Associated Healthcare Costs. Neurosurgery 2021; 88:E259-E264. [PMID: 33370820 DOI: 10.1093/neuros/nyaa535] [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: 05/23/2020] [Accepted: 09/28/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Length of stay beyond medical readiness (LOS-BMR) leads to increased expenses and higher morbidity related to hospital-acquired conditions. OBJECTIVE To determine the proportion of admitted neurosurgical patients who have LOS-BMR and associated risk factors and costs. METHODS We performed a prospective, cohort analysis of all neurosurgical patients admitted to our institution over 5 mo. LOS-BMR was assessed daily by the attending neurosurgeon and neuro-intensivist with a standardized criterion. Univariate and multivariate logistic regressions were performed. RESULTS Of the 884 patients admitted, 229 (25.9%) had a LOS-BMR. The average LOS-BMR was 2.7 ± 3.1 d at an average daily cost of $9 148.28 ± $12 983.10, which resulted in a total cost of $2 076 659.32 over the 5-mo period. Patients with LOS-BMR were significantly more likely to be older and to have hemiplegia, dementia, liver disease, renal disease, and diabetes mellitus. Patients with a LOS-BMR were significantly more likely to be discharged to a subacute rehabilitation/skilled nursing facility (40.2% vs 4.1%) or an acute/inpatient rehabilitation facility (22.7% vs 1.7%, P < .0001). Patients with Medicare insurance were more likely to have a LOS-BMR, whereas patients with private insurance were less likely (P = .048). CONCLUSION The most common reason for LOS-BMR was inefficient discharge of patients to rehabilitation and nursing facilities secondary to unavailability of beds at discharge locations, insurance clearance delays, and family-related issues.
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Affiliation(s)
- Joseph R Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Rachel Foshee
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | | | - Arjun R Adapa
- School of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Elyne N Kahn
- Saint Joseph Mercy Health System, Ypsilanti, Michigan
| | | | - Kyle Sheehan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | | | | | - Karin M Muraszko
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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6
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Daou BJ, Maher CO, Thompson BG, Pandey AS. Author reply to letter to the editor regarding "Seizure Prophylaxis in Unruptured Aneurysm Repair: A Randomized Controlled Trial". J Stroke Cerebrovasc Dis 2021; 30:105722. [PMID: 33712370 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105722] [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: 10/21/2022] Open
Affiliation(s)
- Badih J Daou
- Neurological Surgery and Radiology, Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109-5338, USA
| | - Cormac O Maher
- Neurological Surgery and Radiology, Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109-5338, USA
| | - B Gregory Thompson
- Neurological Surgery and Radiology, Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109-5338, USA
| | - Aditya S Pandey
- Neurological Surgery and Radiology, Department of Neurosurgery, University of Michigan, Ann Arbor, MI 48109-5338, USA.
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7
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Daou BJ, Palmateer G, Linzey JR, Thompson BG, Chaudhary N, Gemmete JJ, Pandey AS. Stent-assisted coiling of cerebral aneurysms: Head to head comparison between the Neuroform Atlas and EZ stents. Interv Neuroradiol 2021; 27:353-361. [PMID: 33509014 DOI: 10.1177/1591019921989476] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 11/17/2022] Open
Abstract
BACKGROUND The Neuroform Atlas stent is thought to have features allowing for an improved stent delivery system. We aimed to provide a comparison of the Atlas and Neuroform EZ stents in patients treated with stent-assisted coiling. METHODS Seventy-seven aneurysms treated with the Atlas stent and 77 aneurysms with similar characteristics treated with the EZ stent were retrospectively compared. Outcomes included angiographic occlusion per the Raymond-Roy (RR) scale, recanalization, retreatment and procedural complications. RESULTS With the Atlas stent, technical success was 100% and immediate RR1 occlusion was 81.8%. Follow-up RR1 was achieved in 83.7%. The recanalization rate was 7% and the retreatment rate was 4.6%. The complication rate was 6.5% (new neurological deficit in 1.3%). With the EZ stent, technical success was 96%, immediate RR1 occlusion was 67.6% and follow-up RR1 was 67.6%. The recanalization rate was 12.7% and the retreatment rate was 14.1%. The complication rate was 10.4% (new neurological deficit in 2.6%). The rate of immediate RR1 occlusion was significantly higher with the Atlas stent (p = 0.03), and the rate of follow-up RR1 was nonsignificantly higher with the Atlas stent (p = 0.08). The retreatment rate was significantly lower with the Atlas stent (p = 0.009). There were no significant differences in the rates of recanalization (p = 0.5) and complications (p = 0.6). CONCLUSIONS Stent-assisted coiling with the Atlas stent is safe and effective and shows better immediate results as compared to the EZ stent, with improved overall follow-up outcomes.
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Affiliation(s)
- Badih J Daou
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Gregory Palmateer
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Joseph R Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Radiology, University of Michigan, Ann Arbor, MI, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
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8
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Daou BJ, Palmateer G, Wilkinson DA, Thompson BG, Maher CO, Chaudhary N, Gemmete JJ, Hayman JA, Lam K, Wahl DR, Kim M, Pandey AS. Radiation-Induced Imaging Changes and Cerebral Edema following Stereotactic Radiosurgery for Brain AVMs. AJNR Am J Neuroradiol 2020; 42:82-87. [PMID: 33214183 DOI: 10.3174/ajnr.a6880] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 08/17/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE T2 signal and FLAIR changes in patients undergoing stereotactic radiosurgery for brain AVMs may occur posttreatment and could result in adverse radiation effects. We aimed to evaluate outcomes in patients with these imaging changes, the frequency and degree of this response, and factors associated with it. MATERIALS AND METHODS Through this retrospective cohort study, consecutive patients treated with stereotactic radiosurgery for brain AVMs who had at least 1 year of follow-up MR imaging were identified. Logistic regression analysis was used to evaluate predictors of outcomes. RESULTS One-hundred-sixty AVMs were treated in 148 patients (mean, 35.6 years of age), including 42 (26.2%) pediatric AVMs. The mean MR imaging follow-up was 56.5 months. The median Spetzler-Martin grade was III. The mean maximal AVM diameter was 2.8 cm, and the mean AVM target volume was 7.4 mL. The median radiation dose was 16.5 Gy. New T2 signal and FLAIR hyperintensity were noted in 40% of AVMs. T2 FLAIR volumes at 3, 6, 12, 18, and 24 months were, respectively, 4.04, 55.47, 56.42, 48.06, and 29.38 mL Radiation-induced neurologic symptoms were encountered in 34.4%. In patients with radiation-induced imaging changes, 69.2% had new neurologic symptoms versus 9.5% of patients with no imaging changes (P = .0001). Imaging changes were significantly associated with new neurologic findings (P < .001). Larger AVM maximal diameter (P = .04) and the presence of multiple feeding arteries (P = .01) were associated with radiation-induced imaging changes. CONCLUSIONS Radiation-induced imaging changes are common following linear particle accelerator-based stereotactic radiosurgery for brain AVMs, appear to peak at 12 months, and are significantly associated with new neurologic findings.
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Affiliation(s)
- B J Daou
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - G Palmateer
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - D A Wilkinson
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - B G Thompson
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - C O Maher
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
| | - N Chaudhary
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.).,Radiology (N.C., J.J.G.)
| | - J J Gemmete
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.).,Radiology (N.C., J.J.G.)
| | - J A Hayman
- From the Departments of Radiation Oncology (J.A.H., K.L., D.R.W., M.K.).,Radiation Oncology (J.A.H., K.L., D.R.W., M.K.), University of Michigan, Ann Arbor, Michigan
| | - K Lam
- From the Departments of Radiation Oncology (J.A.H., K.L., D.R.W., M.K.).,Radiation Oncology (J.A.H., K.L., D.R.W., M.K.), University of Michigan, Ann Arbor, Michigan
| | - D R Wahl
- From the Departments of Radiation Oncology (J.A.H., K.L., D.R.W., M.K.).,Radiation Oncology (J.A.H., K.L., D.R.W., M.K.), University of Michigan, Ann Arbor, Michigan
| | - M Kim
- From the Departments of Radiation Oncology (J.A.H., K.L., D.R.W., M.K.).,Radiation Oncology (J.A.H., K.L., D.R.W., M.K.), University of Michigan, Ann Arbor, Michigan
| | - A S Pandey
- Neurosurgery (B.J.D., G.P., D.A.W., B.G.T., C.O.M., N.C., J.J.G., A.S.P.)
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9
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Adapa AR, Linzey JR, Daou BJ, Mehta UV, Patel T, Ponnaluri-Wears S, Washer LL, Thompson BG, Park P, Pandey AS. Evaluating the role of methicillin-resistant Staphylococcus aureus (MRSA)-specific antibiotic prophylaxis for neurosurgical patients. Clin Neurol Neurosurg 2020; 200:106353. [PMID: 33168331 DOI: 10.1016/j.clineuro.2020.106353] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE Surgical site infection (SSI) in neurosurgical patients increases morbidity. Despite the rise of methicillin-resistant Staphylococcus aureus (MRSA) colonization, there is little consensus regarding antibiotic prophylaxis for SSI in MRSA-colonized neurosurgical patients. Our objective was to examine the incidence of SSI in MRSA-colonized neurosurgical patients and interrogate whether MRSA-specific antibiotic prophylaxis reduces SSIs. METHODS We performed a retrospective analysis of adult patients undergoing neurosurgical procedures between 2013 and 2018. The primary outcome was SSI in patients with MRSA colonization receiving MRSA-specific antibiotics. Secondary outcomes included predictors of SSI, including whether broad use of MRSA-specific antibiotics affects SSI rate. RESULTS Of 9739 procedures, 376 had SSI (3.9 %). Seven hundred forty-four procedures (7.6 %) were performed on patients screened preoperatively for MRSA, including 54 procedures on MRSA-colonized patients. MRSA-colonized patients were more likely than MRSA-non-colonized patients to receive MRSA-specific antibiotics (35.2 % vs. 17.8 %, p = 0.002) for prophylaxis. Nevertheless, MRSA-colonized patients had higher SSI rates compared to MRSA-non-colonized patients (22.2 % vs. 6.4 %, p = 0.00002). MRSA-colonization led to 3.49 greater odds (95 % CI 1.52-7.65, p = 0.002) of SSI relative to MRSA-non-colonization. MRSA-colonized patients receiving MRSA-specific antibiotics, compared to those receiving non-MRSA-specific antibiotics, had lower SSI rates, but this difference was not statistically significant (15.8 % vs. 25.7 %, p = 0.40). In the non-screened population, those receiving MRSA-specific antibiotics, compared to those receiving non-MRSA-specific antibiotics, had significantly higher SSI rates (6.9 % vs. 3.0 %, p = 0.00001). The use of MRSA-specific antibiotic prophylaxis in the non-screened population increased the odds of SSI (OR 1.90, 95 % CI 1.45-2.46, p = 0.0001). CONCLUSION MRSA-colonized neurosurgical patients had a higher SSI rate compared to MRSA-non-colonized patients. While MRSA-specific antibiotics may benefit those with MRSA colonization, the difference in SSI rate between MRSA-colonized patients receiving MRSA-specific antibiotics vs. non-specific antibiotics requires further investigation. The broader use of MRSA-specific antibiotics may paradoxically confer an increased risk of SSI in a non-screened neurosurgical population.
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Affiliation(s)
- Arjun Rohit Adapa
- University of Michigan Medical School, Ann Arbor, MI, USA; Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Badih Junior Daou
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Unnati Vikram Mehta
- Department of Environmental Health, Harvard University T.H. Chan School of Public Health, Boston, MA, USA
| | - Twisha Patel
- Department of Pharmacy Services, University of Michigan, Ann Arbor, MI, USA
| | | | - Laraine Lynn Washer
- Division of Infectious Disease, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Paul Park
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA; Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, MI, USA
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10
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Daou BJ, Maher CO, Holste K, Palmateer G, Lint C, Elenbaas J, Thompson BG, Pandey AS. Seizure Prophylaxis in Unruptured Aneurysm Repair: A Randomized Controlled Trial. J Stroke Cerebrovasc Dis 2020; 29:105171. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105171] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 06/26/2020] [Accepted: 07/16/2020] [Indexed: 11/29/2022] Open
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11
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Abstract
Remarkable developments in the field of endovascular neurosurgery have been witnessed in the last decade. The success of endovascular therapy for ischemic stroke treatment is now irrefutable, making it an accepted standard of care. Endovascular treatment of cerebral aneurysms is no longer limited to primary coiling but now includes options such as stent or balloon assistance and flow diversion and applications utilizing neck reconstruction, intrasaccular, and bifurcation-specific devices. Balloons, liquid embolic agents, and flow-directed catheters have revolutionized the treatment of arteriovenous malformations and fistulae. The ongoing development of endovascular tools has led to novel and expanding approaches (for example, transvenous arteriovenous malformation embolization and transradial access). With improved technology, transposterior communicating artery access and other endovascular strategies are being applied successfully across the anterior and posterior circulations and to lesions once deemed only surgically approachable. Yet, we would be remiss to attribute the successes of endovascular strategies only to the development of their tools. Improvements in both noninvasive and angiographic imaging (such as three-dimensional road map guidance) have provided a greater understanding of pathologic entities and allowed the pursuit of endovascular cures.In this issue of Neurosurgical Focus, we present a wide range of endovascular strategies for a variety of neurovascular pathologies. We hope this video supplement will not only demonstrate the applicability of tried-and-true endovascular strategies to difficult clinical situations but also highlight new and developing endovascular technologies. We thank the authors for their outstanding contributions.
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Affiliation(s)
- Elad I Levy
- 1Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo.,Departments of2Neurosurgery and.,3Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo.,4Canon Stroke and Vascular Research Center, University at Buffalo, New York
| | - Stephan A Munich
- 1Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo.,Departments of2Neurosurgery and
| | - Robert H Rosenwasser
- 5Department of Neurological Surgery, Thomas Jefferson University and Jefferson Hospital for Neuroscience, Philadelphia, Pennsylvania
| | - Peter Kan
- 6Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and
| | - B Gregory Thompson
- 7Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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12
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Daou BJ, Koduri S, Palmateer G, Thompson BG, Chaudhary N, Gemmete JJ, Pandey AS. Letter: Neurological Implications of COVID-19 and Lessons Learned From Prior Epidemics and Pandemics. Neurosurgery 2020; 87:E234-E238. [PMID: 32361745 PMCID: PMC7197577 DOI: 10.1093/neuros/nyaa186] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Badih J Daou
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan
| | - Sravanthi Koduri
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan
| | - Gregory Palmateer
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan
| | | | - Neeraj Chaudhary
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan
- Department of Radiology University of Michigan Ann Arbor, Michigan
| | - Joseph J Gemmete
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan
- Department of Radiology University of Michigan Ann Arbor, Michigan
| | - Aditya S Pandey
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan
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13
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Daou BJ, Palmateer G, Thompson BG, Maher CO, Hayman JA, Lam KL, Wahl DR, Kim M, Pandey AS. Stereotactic Radiosurgery for Brain Arteriovenous Malformations: Evaluation of Obliteration and Review of Associated Predictors. J Stroke Cerebrovasc Dis 2020; 29:104863. [PMID: 32689634 DOI: 10.1016/j.jstrokecerebrovasdis.2020.104863] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [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: 02/09/2020] [Revised: 03/11/2020] [Accepted: 04/02/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND High arteriovenous malformation (AVM) obliteration rates have been reported with stereotactic radiosurgery (SRS), and multiple factors have been found to be associated with AVM obliteration. These predictors have been inconsistent throughout studies. We aimed to analyze our experience with linear accelerator (LINAC)-based SRS for brain AVMs, evaluate outcomes, assess factors associated with AVM obliteration and review the various reported predictors of AVM obliteration. METHODS Electronic medical records were retrospectively reviewed to identify consecutive patients with brain AVMs treated with SRS over a 27-year period with at least 2 years of follow-up. Logistic regression analysis was performed to identify factors associated with AVM obliteration. RESULTS One hundred twenty-eight patients with 142 brain AVMs treated with SRS were included. Mean age was 34.4 years. Fifty-two percent of AVMs were associated with a hemorrhage before SRS, and 14.8% were previously embolized. Mean clinical and angiographic follow-up times were 67.8 months and 58.6 months, respectively. The median Spetzler-Martin grade was 3. Mean maximal AVM diameter was 2.8 cm and mean AVM target volume was 7.4 cm3 with a median radiation dose of 16 Gy. Complete AVM obliteration was achieved in 80.3%. Radiation-related signs and symptoms were encountered in 32.4%, only 4.9% of which consisted of a permanent deficit. Post-SRS AVM-related hemorrhage occurred in 6.3% of cases. In multivariate analysis, factors associated with AVM obliteration included younger patient age (P = .019), male gender (P = .008), smaller AVM diameter (P = .04), smaller AVM target volume (P = .009), smaller isodose surface volume (P = .005), a higher delivered radiation dose (P = .013), and having only one major draining vein (P = .04). CONCLUSIONS AVM obliteration with LINAC-based radiosurgery was safe and effective and achieved complete AVM obliteration in about 80% of cases. The most prominent predictors of AVM success included AVM size, AVM volume, radiation dose, number of draining veins and patient age.
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Affiliation(s)
- Badih J Daou
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - Gregory Palmateer
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - B Gregory Thompson
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - Cormac O Maher
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
| | - James A Hayman
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Kwok L Lam
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Daniel R Wahl
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Michelle Kim
- Radiation Oncology, University of Michigan, Ann Arbor, Michigan.
| | - Aditya S Pandey
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan.
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14
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Pandey AS, Daou BJ, Tsai JP, Zaidi SF, Salahuddin H, Gemmete JJ, Oliver MJ, Singer J, Elder TA, Mbabuike N, Adel JG, Gujrati Y, Saleemi MA, Siddiqui FM, Elias AE, Rehman MF, Marin H, Chebl AB, Kole M, Wilseck JM, Kazmierczak CD, Mick JM, Majjhoo AQ, Naravetla BR, Rayes M, Luqman AW, Richards BF, Kelkar P, Burgess R, Thompson BG, Chaudhary N, Mazaris PA, Qahwash O, Razak MA, Jumaa MA. Letter: COVID-19 Pandemic-The Bystander Effect on Stroke Care in Michigan. Neurosurgery 2020; 87:E397-E399. [PMID: 32496518 PMCID: PMC7313842 DOI: 10.1093/neuros/nyaa252] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
- Aditya S Pandey
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan
| | - Badih J Daou
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan
| | - Jenny P Tsai
- Spectrum Health West Michigan Grand Rapids, Michigan
| | - Syed F Zaidi
- ProMedica Neurosciences Institute Toledo, Ohio.,Department of Neurology University of Toledo Toledo, Ohio
| | | | - Joseph J Gemmete
- Department of Radiology University of Michigan Ann Arbor, Michigan
| | | | - Justin Singer
- Spectrum Health West Michigan Grand Rapids, Michigan
| | - Theresa A Elder
- Field Neuroscience Institute Saginaw, Michigan.,Ascension St. Mary's Hospital Saginaw, Michigan
| | | | - Joseph G Adel
- Field Neuroscience Institute Saginaw, Michigan.,Ascension St. Mary's Hospital Saginaw, Michigan
| | - Yogesh Gujrati
- Michigan State University East Lansing, Michigan.,Sparrow Health System East Lansing, Michigan
| | - Muhammad Adeel Saleemi
- Michigan State University East Lansing, Michigan.,Sparrow Health System East Lansing, Michigan
| | | | | | | | | | | | | | - Jeffrey M Wilseck
- Oakland University William Beaumont School of Medicine Auburn Hills, Michigan
| | - Chris D Kazmierczak
- Oakland University William Beaumont School of Medicine Auburn Hills, Michigan
| | - James M Mick
- Oakland University William Beaumont School of Medicine Auburn Hills, Michigan
| | | | | | | | - Ali W Luqman
- Detroit Medical Center Wayne State University Detroit, Michigan
| | | | | | | | | | - Neeraj Chaudhary
- Department of Neurosurgery University of Michigan Ann Arbor, Michigan.,Department of Radiology University of Michigan Ann Arbor, Michigan
| | | | | | - M Anmar Razak
- Michigan State University East Lansing, Michigan.,Sparrow Health System East Lansing, Michigan
| | - Mouhammad A Jumaa
- ProMedica Neurosciences Institute Toledo, Ohio.,Department of Neurology University of Toledo Toledo, Ohio
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15
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Linzey JR, Foshee RL, Fiestan GO, Srinivasan S, Mossner JM, Rajajee V, Sullivan SE, Thompson BG, Muraszko KM, Pandey AS. Late Surgical Start Time and the Effect on Rates of Complications in a Neurosurgical Population: A Prospective Longitudinal Analysis. World Neurosurg 2020; 140:e328-e342. [PMID: 32434015 DOI: 10.1016/j.wneu.2020.05.081] [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: 03/09/2020] [Accepted: 05/09/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The after-hours effect on postoperative complications has been poorly studied in the neurosurgical literature. A recent retrospective analysis showed that patients with a surgical start time (SST) between 09:01 pm and 07:00 am had a greater risk of complications. This study used a prospective registry to examine the relationship between SST and postoperative complications in a large neurosurgical population. METHODS We performed a prospective longitudinal cohort analysis of all consecutive adult patients admitted to our neurosurgery service between October 1, 2018 and May 1, 2019. Complications were prospectively recorded and classified as surgical or medical. Univariate and multivariate logistic regressions were used to analyze these data. RESULTS Eighty-five surgical complications (6.6%) and 110 medical complications (8.6%) resulted from 1285 operations on 1145 patients. Later SST was predictive of complications in the emergent population (odds ratio [OR], 2.28; 95% confidence interval [CI], 1.01-5.15; P = 0.048) but not in the elective population. Extubation in the neurosurgical intensive care unit (NICU) versus the operating room strongly predicted medical complications (OR, 6.91; 95% CI, 3.33-14.34; P < 0.0001). Patients with a later SST were significantly more likely to be extubated in the NICU (P < 0.0001). CONCLUSIONS Patients undergoing emergent operations with a later SST were significantly more likely to have a postoperative complication. Patients who were extubated in the NICU versus the operating room were significantly more likely to have a medical complication. Patients were more likely to be extubated in the NICU if they had a later SST; therefore, SST may indirectly be associated with an increase in medical complications.
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Affiliation(s)
- Joseph R Linzey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Rachel L Foshee
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Gic-Owens Fiestan
- School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - James M Mossner
- School of Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | | | - Stephen E Sullivan
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Karin M Muraszko
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
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16
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Pandey AS, Ringer AJ, Rai A, Kan PT, Jabbour PM, Siddiqui A, Levy E, Snyder KV, Riina HA, Tanweer O, Levitt MR, Kim LJ, Veznedaroglu E, Binning M, Arthur AS, Mocco J, Schirmer CM, Thompson BG, Langer D. Letter: Considerations for Performing Emergent Neurointerventional Procedures in a COVID-19 Environment. Neurosurgery 2020; 87:E203-E206. [PMID: 32358606 PMCID: PMC7197580 DOI: 10.1093/neuros/nyaa173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Aditya S Pandey
- Department of Neurosurgery and Radiology University of Michigan Ann Arbor, Michigan
| | | | - Ansaar Rai
- Department of Neuroradiology West Virginia University Morgantown, West Virginia
| | - Peter T Kan
- Department of Neurosurgery Baylor College of Medicine Houston, Texas
| | - Pascal M Jabbour
- Department of Neurosurgery Thomas Jefferson University Hospital Philadelphia, Pennsylvania
| | - Adnan Siddiqui
- Department of Neurosurgery Jacobs School of Medicine University at Buffalo Buffalo, New York
| | - Elad Levy
- Department of Neurosurgery Jacobs School of Medicine University at Buffalo Buffalo, New York
| | - Kenneth V Snyder
- Department of Neurosurgery Jacobs School of Medicine University at Buffalo Buffalo, New York
| | - Howard A Riina
- Department of Neurosurgery New York University Langone Health New York, New York
| | - Omar Tanweer
- Department of Neurosurgery New York University Langone Health New York, New York
| | - Michael R Levitt
- Department of Neurological Surgery University of Washington Seattle, Washington
| | - Louis J Kim
- Department of Neurological Surgery University of Washington Seattle, Washington
| | - Erol Veznedaroglu
- Department of Neurosurgery Drexel University College of Medicine Philadelphia, Pennsylvania
| | - Mandy Binning
- Department of Neurosurgery Drexel University College of Medicine Philadelphia, Pennsylvania
| | - Adam S Arthur
- Department of Neurosurgery Semmes Murphy Clinic University of Tennessee Memphis, Tennessee
| | - J Mocco
- Department of Neurosurgery Mount Sinai New York, New York
| | - Clemens M Schirmer
- Department of Neurosurgery Geisinger Health System Danville, Pennsylvania
| | - B Gregory Thompson
- Department of Neurosurgery and Radiology University of Michigan Ann Arbor, Michigan
| | - David Langer
- Department of Neurosurgery Lenox Hill Hospital New York, New York
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17
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Wilkinson DA, Heung M, Deol A, Chaudhary N, Gemmete JJ, Thompson BG, Pandey AS. Cerebral Aneurysms in Autosomal Dominant Polycystic Kidney Disease: A Comparison of Management Approaches. Neurosurgery 2020; 84:E352-E361. [PMID: 30060240 DOI: 10.1093/neuros/nyy336] [Citation(s) in RCA: 6] [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] [Received: 01/04/2018] [Accepted: 06/23/2018] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Autosomal dominant polycystic kidney disease (ADPKD) is a risk factor for formation of intracranial aneurysms (IAs), though the ideal screening and treatment strategies in this population are unclear. OBJECTIVE To report outcomes of observation, open surgical, or endovascular management of ruptured and unruptured aneurysms in patients with ADPKD. METHODS We performed a retrospective analysis of all patients with ADPKD and IAs at a single center from 2000 to 2016. RESULTS Forty-five patients with ADPKD harboring 71 aneurysms were identified, including 11 patients with subarachnoid hemorrhage (SAH). Of 22 aneurysms managed with observation, none ruptured in 136 yr of clinical follow-up. Thirty-five aneurysms were treated with open surgery and 14 with an endovascular approach. Among treated aneurysms, poor neurologic outcome (modified Rankin scale >2) was seen only in patients presenting with SAH (17% SAH vs 0% elective, P = .06). Acute kidney injury (AKI) was also significantly associated with SAH presentation (22% SAH vs 0% elective, P = .05). Neither procedural complications nor AKI were associated with treatment modality. Among 175 yr of radiographic follow-up in patients with known IAs, 8 de novo aneurysms were found, including 3 that were treated. Of 11 patients with SAH, 7 ruptured in the setting of previously known ADPKD, including 2 with prior angiographic screening and 5 without screening. CONCLUSION Poor outcomes occurred only with ruptured presentation but were equivalent between treatment modalities. Screening is performed only selectively, and 64% (7 of 11) of patients presenting with SAH had previously known ADPKD.
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Affiliation(s)
| | - Michael Heung
- Division of Nephrology, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | - Amrit Deol
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | | | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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18
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Hollon TC, Pandian B, Adapa AR, Urias E, Save AV, Khalsa SSS, Eichberg DG, D'Amico RS, Farooq ZU, Lewis S, Petridis PD, Marie T, Shah AH, Garton HJL, Maher CO, Heth JA, McKean EL, Sullivan SE, Hervey-Jumper SL, Patil PG, Thompson BG, Sagher O, McKhann GM, Komotar RJ, Ivan ME, Snuderl M, Otten ML, Johnson TD, Sisti MB, Bruce JN, Muraszko KM, Trautman J, Freudiger CW, Canoll P, Lee H, Camelo-Piragua S, Orringer DA. Near real-time intraoperative brain tumor diagnosis using stimulated Raman histology and deep neural networks. Nat Med 2020; 26:52-58. [PMID: 31907460 PMCID: PMC6960329 DOI: 10.1038/s41591-019-0715-9] [Citation(s) in RCA: 307] [Impact Index Per Article: 76.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 11/24/2019] [Indexed: 12/18/2022]
Abstract
Intraoperative diagnosis is essential for providing safe and effective care during cancer surgery1. The existing workflow for intraoperative diagnosis based on hematoxylin and eosin staining of processed tissue is time, resource and labor intensive2,3. Moreover, interpretation of intraoperative histologic images is dependent on a contracting, unevenly distributed, pathology workforce4. In the present study, we report a parallel workflow that combines stimulated Raman histology (SRH)5-7, a label-free optical imaging method and deep convolutional neural networks (CNNs) to predict diagnosis at the bedside in near real-time in an automated fashion. Specifically, our CNNs, trained on over 2.5 million SRH images, predict brain tumor diagnosis in the operating room in under 150 s, an order of magnitude faster than conventional techniques (for example, 20-30 min)2. In a multicenter, prospective clinical trial (n = 278), we demonstrated that CNN-based diagnosis of SRH images was noninferior to pathologist-based interpretation of conventional histologic images (overall accuracy, 94.6% versus 93.9%). Our CNNs learned a hierarchy of recognizable histologic feature representations to classify the major histopathologic classes of brain tumors. In addition, we implemented a semantic segmentation method to identify tumor-infiltrated diagnostic regions within SRH images. These results demonstrate how intraoperative cancer diagnosis can be streamlined, creating a complementary pathway for tissue diagnosis that is independent of a traditional pathology laboratory.
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Affiliation(s)
- Todd C Hollon
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Balaji Pandian
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Arjun R Adapa
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Esteban Urias
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Akshay V Save
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | | | - Daniel G Eichberg
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Randy S D'Amico
- Department of Neurological Surgery, Columbia University, New York, NY, USA
| | | | - Spencer Lewis
- School of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Petros D Petridis
- College of Physicians and Surgeons, Columbia University, New York, NY, USA
| | - Tamara Marie
- Department of Pediatrics Oncology, Columbia University, New York, NY, USA
| | - Ashish H Shah
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Hugh J L Garton
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Jason A Heth
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Erin L McKean
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
- Department of Otolaryngology, University of Michigan, Ann Arbor, MI, USA
| | | | - Shawn L Hervey-Jumper
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Parag G Patil
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Oren Sagher
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University, New York, NY, USA
| | - Ricardo J Komotar
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Michael E Ivan
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Matija Snuderl
- Department of Pathology, New York University, New York, NY, USA
| | - Marc L Otten
- Department of Neurological Surgery, Columbia University, New York, NY, USA
| | - Timothy D Johnson
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - Michael B Sisti
- Department of Neurological Surgery, Columbia University, New York, NY, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University, New York, NY, USA
| | - Karin M Muraszko
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | | | - Peter Canoll
- Department of Pathology & Cell Biology, Columbia University, New York, NY, USA
| | - Honglak Lee
- Department of Electrical Engineering and Computer Science, University of Michigan, Ann Arbor, MI, USA
| | | | - Daniel A Orringer
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
- Department of Neurosurgery, New York University, New York, NY, USA.
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19
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Daou BJ, Koduri S, Thompson BG, Chaudhary N, Pandey AS. Clinical and experimental aspects of aneurysmal subarachnoid hemorrhage. CNS Neurosci Ther 2019; 25:1096-1112. [PMID: 31583833 PMCID: PMC6776745 DOI: 10.1111/cns.13222] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 08/30/2019] [Accepted: 09/01/2019] [Indexed: 11/30/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) continues to be associated with significant morbidity and mortality despite advances in care and aneurysm treatment strategies. Cerebral vasospasm continues to be a major source of clinical worsening in patients. We intended to review the clinical and experimental aspects of aSAH and identify strategies that are being evaluated for the treatment of vasospasm. A literature review on aSAH and cerebral vasospasm was performed. Available treatments for aSAH continue to expand as research continues to identify new therapeutic targets. Oral nimodipine is the primary medication used in practice given its neuroprotective properties. Transluminal balloon angioplasty is widely utilized in patients with symptomatic vasospasm and ischemia. Prophylactic "triple-H" therapy, clazosentan, and intraarterial papaverine have fallen out of practice. Trials have not shown strong evidence supporting magnesium or statins. Other calcium channel blockers, milrinone, tirilazad, fasudil, cilostazol, albumin, eicosapentaenoic acid, erythropoietin, corticosteroids, minocycline, deferoxamine, intrathecal thrombolytics, need to be further investigated. Many of the current experimental drugs may have significant roles in the treatment algorithm, and further clinical trials are needed. There is growing evidence supporting that early brain injury in aSAH may lead to significant morbidity and mortality, and this needs to be explored further.
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Affiliation(s)
- Badih J. Daou
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Sravanthi Koduri
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | | | - Neeraj Chaudhary
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
| | - Aditya S. Pandey
- Department of Neurological SurgeryUniversity of MichiganAnn ArborMichigan
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20
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Savastano LE, Gordon D, Bhambri A, Pandey A, Cockrum J, Thompson BG, Reddy A, Seibel E. Abstract WMP39: Laser Angioscopy in Carotid Artery Disease: Imaging Findings and Histopathological Correlation. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wmp39] [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] [Indexed: 11/16/2022]
Abstract
Our understanding and management of carotid artery disease has largely relied on angiography, US and MR. However, existing modalities cannot accurately identify the spectrum of thrombogenic lesions on the vascular surface or reliably detect structural markers of instability. Thus, the natural history of the different histopathological hallmarks of advanced or complicated plaques is unknown, and many patients with culprit substenotic plaques are misdiagnosed with cryptogenic stroke. An intraluminal approach to directly inspect the endovascular surfaces at unprecedented resolutions would enable detailed structural analysis of carotid plaques and the identification of the root cause of carotid-related strokes. A scanning fiber angioscope (SFA), a high-definition 1.2-mm forward-viewing camera that generates videos by spirally scanning low-power laser beams, was developed for clinical use and employed to analyze the endovascular surfaces of
ex vivo
human carotid arteries (n=95) and endarterectomized plaques (n=20). Specimens were then imaged with US and micro-CT, and all vascular diagnostic tests obtained in the patients undergoing carotid revascularization were accessed. Imaging findings in the vascular surfaces were then validated by histomorphological analysis of >300 lesions, and an angioscopic classifier for atherosclerosis was generated. Full-color videos at 30Hz and at a resolution >200,000 pixels were generated from the entire endovascular circumference in all specimens with depth-of-focus larger than 5cm in saline solution. The ability to analyze the surface anatomy with unparalleled detail allowed the identification of early, intermediate, advanced and complex atherosclerotic lesions, including ulceration of fibrotic cap, excavation of the necrotic core leading to pseudolumens, intimal flaps, exposed necrotic core to the lumen, erosions, recent and remote intimal hemorrhages, luminal thrombus, eruptive calcified nodules and calcified intimal sheaths and plates. SFA offers a direct view of the endoluminal surfaces with unparalleled resolution and has the potential to revolutionize research, diagnosis, prognosis and image-guided therapy in carotid atherosclerosis.
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Affiliation(s)
| | | | | | | | | | | | | | - Eric Seibel
- Mechanical Engineering, Univ of Washington, Seattle, WA
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21
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Wilkinson DA, Burke JF, Nadel JL, Maher CO, Chaudhary N, Gemmete JJ, Heung M, Thompson BG, Pandey AS. A Large Database Analysis of Rates of Aneurysm Screening, Elective Treatment, and Subarachnoid Hemorrhage in Patients With Polycystic Kidney Disease. Neurosurgery 2018; 85:E266-E274. [DOI: 10.1093/neuros/nyy551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 10/23/2018] [Indexed: 01/20/2023] Open
Abstract
Abstract
BACKGROUND
Professional societies provide conflicting guidelines on aneurysm screening in patients with polycystic kidney disease (PKD), and the rate of subarachnoid hemorrhage (SAH) is poorly understood.
OBJECTIVE
To evaluate screening, elective treatment, and the rate of SAH in patients with known PKD.
METHODS
We examined longitudinally linked claims data from a large private insurer, identifying screening, elective treatment, aneurysmal subarachnoid hemorrhage (aSAH) and secured aneurysmal SAH (saSAH) in 2004 to 2014 amongst patients with known PKD.
RESULTS
We identified 20 704 patients diagnosed with PKD. Among patients with an initial PKD diagnosis, 51/446 (15.9%) underwent angiographic screening within 2 yr. Forty aneurysms were treated electively in 48 868 yr at risk in PKD patients (82/100K patient yr, 95% confidence interval [CI] 60-112) vs 24 elective treatments in 349 861 yr at risk in age- and sex-matched controls (7/100K patient yr, 95% CI 5-10, P < .0001). Eleven admissions for aSAH were identified in PKD patients (23/100K patient yr, 95% CI 13-41) and 22 admissions for aSAH in controls (6/100K patient yr, 95% CI 4-10), giving an incidence rate ratio (IRR) of 3.6 (95% CI 1.7-7.4, P < .0001) and a comorbidity-adjusted IRR of 3.1 (95% CI 1.4-6.9). The incidence of saSAH was proportionally even higher in PKD patients than controls, 16 vs 2/100K patient years, IRR 9.5 (95% CI 3.3-27.5, P < .0001).
CONCLUSION
Screening in PKD is performed only selectively, though resulting rates of elective treatment were over 10× those of controls. Despite screening and treatment, the rate of SAH remains significantly elevated over that of controls.
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Affiliation(s)
| | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey L Nadel
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Michael Heung
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Pandey AS, Wilkinson DA, Gemmete JJ, Chaudhary N, Thompson BG, Burke JF. Impact of Weekend Presentation on Short-Term Outcomes and Choice of Clipping vs Coiling in Subarachnoid Hemorrhage. Neurosurgery 2018; 81:87-91. [PMID: 28475807 DOI: 10.1093/neuros/nyx015] [Citation(s) in RCA: 10] [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: 04/11/2016] [Accepted: 04/24/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Presentation on a weekend is commonly associated with higher mortality and a decreased likelihood of receiving invasive procedures. OBJECTIVE To determine whether weekend presentation influences mortality, discharge destination, or type of treatment received (clip vs coil) in subarachnoid hemorrhage (SAH). METHODS We performed a serial cross-sectional retrospective study using the Nationwide Inpatient Sample. All adult discharges with a primary diagnosis of SAH (ICD-9-CM 435) from 2005 to 2010 were included, and records with trauma or arteriovenous malformation were excluded. Unadjusted and adjusted associations between weekend presentation and 3 outcomes (in-hospital mortality, discharge destination, and treatment with clip vs coil) were estimated using chi-square tests and multilevel logistic regression. RESULTS A total of 46 093 admissions for nontraumatic SAH were included in the sample; 24.6% presented on a weekend, 68.9% on a weekday, and 6.5% had unknown day of presentation. Weekend admission was not a significant predictor of inpatient mortality (25.4% weekend vs 24.9% weekday; P = .44), or a combined poor outcome measure of mortality or discharge to long-term acute care or hospice (30.3% weekend vs 29.4% weekday; P = .23). Among those treated for aneurysm obliteration, the proportion of clipped vs coiled did not change with weekend vs weekday presentation (21.5% clipped with weekend presentation vs 21.6% weekday, P = .95; 21.5% coiled with weekend presentation vs 22.4% weekday, P = .19). CONCLUSION Presentation with nontraumatic SAH on a weekend did not influence mortality, discharge destination, or type of treatment received (clip vs coil) compared with weekday presentation.
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Affiliation(s)
| | | | | | | | | | - James F Burke
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
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23
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Caveney AF, Langenecker SA, Pandey AS, Farah LB, Ortiz JA, Huq N, Bhaumik R, Thompson BG, Giordani BJ, Auer D, Morgenstern LB. Neuropsychological Changes in Patients Undergoing Treatment of Unruptured Intracranial Aneurysms. Neurosurgery 2018; 84:581-587. [DOI: 10.1093/neuros/nyy077] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2017] [Accepted: 02/15/2018] [Indexed: 11/12/2022] Open
Affiliation(s)
- Angela F Caveney
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | | | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Laura B Farah
- Department of Psychiatry, University of Illinois, Chicago, Illinois
| | - J Alexis Ortiz
- Center for Health Policy, University of New Mexico, Albuquerque, New Mexico
| | - Nadia Huq
- Department of Psychology, University of North Carolina, Greensboro, North Carolina
| | - Runa Bhaumik
- Department of Psychiatry, University of Illinois, Chicago, Illinois
| | | | - Bruno J Giordani
- Department of Psychiatry, University of Michigan, Ann Arbor, Michigan
| | - Donna Auer
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Lewis B Morgenstern
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
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Linzey JR, Wilson TJ, Sullivan SE, Thompson BG, Pandey AS. Frontal Sinus Breach During Routine Frontal Craniotomy Significantly Increases Risk of Surgical Site Infection: 10-Year Retrospective Analysis. Neurosurgery 2018; 81:504-511. [PMID: 28327980 DOI: 10.1093/neuros/nyx046] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [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: 03/28/2016] [Accepted: 01/24/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Frontotemporal craniotomies are commonly performed for a variety of neurosurgical pathologies. Infections related to craniotomies cause significant morbidity. We hypothesized that the risk of cranial surgical site infections (SSIs) may be increased in patients whose frontal sinuses are breached during craniotomy. OBJECTIVE To compare the rate of cranial SSIs in patients undergoing frontotemporal craniotomies with and without frontal sinus breach (FSB). METHODS We performed a retrospective analysis of all patients undergoing frontotemporal craniotomies for the management of cerebral aneurysms from 2005 to 2014. This study included 862 patients undergoing 910 craniotomies. Primary outcome of interest was occurrence of a cranial SSI. Standard statistical methods were utilized to explore associations between a variety of variables including FSB, cranial SSI, and infections requiring reoperation. RESULTS Of the 910 craniotomies, 141 (15.5%) involved FSB. Of those involving FSB, 22 (15.6%) developed a cranial SSI, compared to only 56 of the 769 without FSB (7.3%; P = .001). Cranial SSI requiring reoperation was much more likely in patients with FSB compared to those without a breach (7.8% vs 1.6%; P < .001). In those presenting with cranial SSIs, epidural abscess formation was more common with FSB compared to no FSB (27.3% vs 5.4%; P = .006). In multivariate analysis, breach of the frontal sinus was significantly associated with cranial SSI (OR 2.16; 95% CI 1.24-3.78; P = .01) and reoperation (OR 4.20; 95% CI 1.66-10.65; P = .003). CONCLUSION Patients undergoing frontotemporal craniotomies are at significantly greater risk of serious cranial SSIs if the frontal sinus has been breached.
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Affiliation(s)
| | - Thomas J Wilson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | | | | | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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25
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Hollon TC, Savastano LE, Argersinger DP, Quint DJ, Thompson BG. Microvascular Brainstem Ischemia After Vestibular Schwannoma Surgery: A Clinical and Microanatomic Study. World Neurosurg 2018; 112:e415-e424. [PMID: 29355807 DOI: 10.1016/j.wneu.2018.01.056] [Citation(s) in RCA: 3] [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: 10/06/2017] [Revised: 01/09/2018] [Accepted: 01/11/2018] [Indexed: 10/18/2022]
Abstract
OBJECTIVE To identify a potential microvascular etiology in patients who underwent vestibular schwannoma surgery (VSS) complicated by postoperative microvascular brainstem ischemia. METHODS Charts were retrospectively reviewed of all patients who had an MRI within 14 days of VSS in years 2005-2016. Patient characteristics, preoperative and postoperative imaging features, clinical course and potential predictors of brainstem ischemia were recorded. Cadaveric dissections of 4 cerebellopontine angle (CPA) cisterns with focus on the anterior inferior cerebellar artery (AICA) microvascular were also performed to identify candidate vessels and potential etiology. RESULTS Fifty-four of 258 patients had an MRI within 14 days of VSS. Retrosigmoid approach was used in 61.1% of patients, translabyrinthine approach in 25.9%, and middle fossa approach in 13.0%. Four patients (7.4%) had acute microvascular ischemia involving the middle cerebellar peduncle (MCP) adjacent to the cranial nerve (CN) VII-VIII complex demonstrated on postoperative MRI. A statistically significant association was found between the translabyrinthine approach and acute brainstem ischemia (odds ratio, 10.6; 95% confidence interval, 1.004-112.7). Dissection of CPAs revealed 10-20 perforating arteries per specimen originating from the lateral pontine and the flocculopeduncular segments of the AICA. Most microvessels travelled in retrograde fashion along the anteroinferior surface of the CN VII-VIII complex to perforate the cisternal surface of the MCP. No patient had residual or delayed neurologic deficits related to brainstem ischemia at final follow-up. CONCLUSIONS While effort should be made to preserve perforating vessels, microvascular brainstem ischemia is often asymptomatic and did not lead to permanent neurologic deficits in our series.
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Affiliation(s)
- Todd C Hollon
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.
| | - Luis E Savastano
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Davis P Argersinger
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Douglas J Quint
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA; Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
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26
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Linzey JR, Burke JF, Sabbagh MA, Sullivan S, Thompson BG, Muraszko KM, Pandey AS. The Effect of Surgical Start Time on Complications Associated With Neurological Surgeries. Neurosurgery 2017; 83:501-507. [DOI: 10.1093/neuros/nyx485] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 09/20/2017] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - James F Burke
- Department of Neurology, University of Michigan Health System, Ann Arbor, Michigan
| | - M Amr Sabbagh
- University of Michigan Medical School, Ann Arbor, Michigan
| | - Stephen Sullivan
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Karin M Muraszko
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan
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27
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Wilkinson DA, Pandey AS, Thompson BG, Keep RF, Hua Y, Xi G. Injury mechanisms in acute intracerebral hemorrhage. Neuropharmacology 2017; 134:240-248. [PMID: 28947377 DOI: 10.1016/j.neuropharm.2017.09.033] [Citation(s) in RCA: 151] [Impact Index Per Article: 21.6] [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: 06/30/2017] [Accepted: 09/21/2017] [Indexed: 10/18/2022]
Abstract
Intracerebral hemorrhage (ICH) is the most common hemorrhagic stroke subtype, and rates are increasing with an aging population. Despite an increase in research and trials of therapies for ICH, mortality remains high and no interventional therapy has been demonstrated to improve outcomes. We review known mechanisms of injury, recent clinical trial results, and newly discovered signaling pathways involved in hematoma clearance. Enthusiasm remains high for methods of minimally invasive clot removal as well as pharmacologic strategies to improve recovery after ICH, both of which are currently being evaluated in clinical trials. This article is part of the Special Issue entitled 'Cerebral Ischemia'.
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Affiliation(s)
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Richard F Keep
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
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28
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Linzey JR, Chen KS, Savastano L, Thompson BG, Pandey AS. Optic neuropathy after anterior communicating artery aneurysm clipping: 3 cases and techniques to address a correctable pitfall. J Neurosurg 2017; 128:1808-1812. [PMID: 28841123 DOI: 10.3171/2017.2.jns162654] [Citation(s) in RCA: 2] [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] [Indexed: 12/28/2022]
Abstract
Brain shifts following microsurgical clip ligation of anterior communicating artery (ACoA) aneurysms can lead to mechanical compression of the optic nerve by the clip. Recognition of this condition and early repositioning of clips can lead to reversal of vision loss. The authors identified 3 patients with an afferent pupillary defect following microsurgical clipping of ACoA aneurysms. Different treatment options were used for each patient. All patients underwent reexploration, and the aneurysm clips were repositioned to prevent clip-related compression of the optic nerve. Near-complete restoration of vision was achieved at the last clinic follow-up visit in all 3 patients. Clip ligation of ACoA aneurysms has the potential to cause clip-related compression of the optic nerve. Postoperative visual examination is of utmost importance, and if any changes are discovered, reexploration should be considered as repositioning of the clips may lead to resolution of visual deterioration.
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Affiliation(s)
| | - Kevin S Chen
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Luis Savastano
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - B Gregory Thompson
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Aditya S Pandey
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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29
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Awori J, Wilkinson DA, Gemmete JJ, Thompson BG, Chaudhary N, Pandey AS. Penetrating Head Injury by a Nail Gun: Case Report, Review of the Literature, and Management Considerations. J Stroke Cerebrovasc Dis 2017; 26:e143-e149. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 04/03/2017] [Indexed: 11/26/2022] Open
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Linzey JR, Williamson C, Rajajee V, Sheehan K, Thompson BG, Pandey AS. Twenty-four-hour emergency intervention versus early intervention in aneurysmal subarachnoid hemorrhage. J Neurosurg 2017; 128:1297-1303. [PMID: 28731402 DOI: 10.3171/2017.2.jns163017] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 11/06/2022]
Abstract
OBJECTIVE Recent observational data suggest that ultra-early treatment of ruptured aneurysms prevents rebleeding, thus improving clinical outcomes. However, advances in critical care management of patients with ruptured aneurysms may reduce the rate of rebleeding in comparison with earlier trials, such as the International Cooperative Study on the Timing of Aneurysm Surgery. The objective of the present study was to determine if an ultra-early aneurysm repair protocol will or will not significantly reduce the number of incidents of rebleeding following aneurysmal subarachnoid hemorrhage (SAH). METHODS A retrospective analysis of data from a prospectively collected cohort of patients with SAH was performed. Rebleeding was diagnosed as new or expanded hemorrhage on CT, which was determined by independent review conducted by multiple physicians. Preventability of rebleeding by ultra-early aneurysm clipping or coiling was also independently reviewed. Standard statistics were used to determine statistically significant differences between the demographic characteristics of those with rebleeding compared with those without. RESULTS Of 317 patients with aneurysmal SAH, 24 (7.6%, 95% CI 4.7-10.5) experienced rebleeding at any time point following initial aneurysm rupture. Only 1/24 (4.2%, 95% CI -3.8 to 12.2) incidents of rebleeding could have been prevented by a 24-hour ultra-early aneurysm repair protocol. The other 23 incidents could not have been prevented for the following reasons: rebleeding prior to admission to the authors' institution (14/23, 60.9%); initial diagnostic angiography negative for aneurysm (4/23, 17.4%); postoperative rebleeding (2/23, 8.7%); patient unable to undergo operation due to medical instability (2/23, 8.7%); intraoperative rebleeding (1/23, 4.3%). CONCLUSIONS At a single tertiary academic center, the overall rebleeding rate was 7.6% (95% CI 4.7-10.5) for those presenting with ruptured aneurysms. Implementation of a 24-hour ultra-early aneurysm repair protocol would only result in, at most, a 0.3% (95% CI -0.3 to 0.9) reduction in the incidence of rebleeding.
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Affiliation(s)
| | - Craig Williamson
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | | | - Kyle Sheehan
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - B Gregory Thompson
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Aditya S Pandey
- 2Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Futchko J, Starr J, Lau D, Leach MR, Roark C, Pandey AS, Thompson BG. Influence of smoking on aneurysm recurrence after endovascular treatment of cerebrovascular aneurysms. J Neurosurg 2017. [PMID: 28644100 DOI: 10.3171/2016.12.jns161625] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [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: 11/06/2022]
Abstract
OBJECTIVE Smoking is a known risk factor for aneurysm development and aneurysmal subarachnoid hemorrhage, as well as subsequent vasospasm in both untreated individuals and patients who have undergone surgical clipping of cerebrovascular aneurysms. However, there is a lack of data in the current scientific literature about the long-term effects that smoking has on the integrity of endovascular repairs of cerebral aneurysms. This study was designed to determine if any smoking history increased the risk of poorer outcomes and/or aneurysm recurrence in patients who have had endovascular repair of cerebral aneurysms. METHODS The authors retrospectively analyzed the medical records of patients admitted to the University of Michigan Health System from January 1999 to December 2011 with coiled aneurysms and angiography, CT angiography, or MR angiography follow-up. Patients were identified and organized based on many criteria including age, sex, smoking history, aneurysm recurrence, aneurysm location, and Hunt and Hess grade. Analysis was targeted to the patient population with a history of smoking. Bivariate chi-square tests were used to analyze the association between a positive smoking history and documented aneurysm recurrence and were adjusted for potential confounders by fitting multivariate logistic regression models of recurrence. RESULTS A total of 247 patients who had undergone endovascular treatment of 296 documented cerebral aneurysms were included in this study. The recurrence rate among all patients treated with endovascular repair was 24.3%, and the average time to the most recent follow-up imaging studies was 1.62 years. Smokers accounted for 232 aneurysms and were followed up for an average of 1.57 years, with a recurrence rate of 26.3%. Never smokers accounted for the remaining 64 aneurysms and were followed up for an average of 1.82 years, with a recurrence rate of 17.2%. Multivariate analysis revealed that, after controlling for potential confounders, a history of smoking-whether current or former-was associated with a significantly increased risk of aneurysm recurrence. The odds ratios for aneurysm recurrence for current and former smokers were 2.739 (95% CI 1.127-7.095, p = 0.0308) and 2.698 (95% CI 1.078-7.212, p = 0.0395), respectively, compared with never smokers. CONCLUSIONS A positive smoking history is associated with a significantly increased risk of aneurysm recurrence in patients who have undergone endovascular repair of a cerebral aneurysm, compared with the risk in patients who have never smoked.
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Affiliation(s)
- John Futchko
- 1Department of Vascular Surgery, Montefiore Medical Center, Bronx, New York
| | - Jordan Starr
- 2Department of Anesthesiology, University of Washington, Seattle, Washington
| | - Darryl Lau
- 3Department of Neurosurgery, University of California, San Francisco, California
| | | | - Christopher Roark
- 5Department of Neurosurgery, University of Colorado-Denver, Colorado; and
| | - Aditya S Pandey
- 6Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan
| | - B Gregory Thompson
- 6Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan
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32
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Roark C, Vadlamudi V, Chaudhary N, Gemmete JJ, Seinfeld J, Thompson BG, Pandey AS. ABC/2 Method Does not Accurately Predict Cerebral Arteriovenous Malformation Volume. Neurosurgery 2017; 82:220-225. [DOI: 10.1093/neuros/nyx139] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 05/25/2017] [Indexed: 11/14/2022] Open
Abstract
Abstract
BACKGROUND
Stereotactic radiosurgery (SRS) is a treatment option for cerebral arteriovenous malformations (AVMs) to prevent intracranial hemorrhage. The decision to proceed with SRS is usually based on calculated nidal volume. Physicians commonly use the ABC/2 formula, based on digital subtraction angiography (DSA), when counseling patients for SRS.
OBJECTIVE
To determine whether AVM volume calculated using the ABC/2 method on DSA is accurate when compared to the exact volume calculated from thin-cut axial sections used for SRS planning.
METHODS
Retrospective search of neurovascular database to identify AVMs treated with SRS from 1995 to 2015. Maximum nidal diameters in orthogonal planes on DSA images were recorded to determine volume using ABC/2 formula. Nidal target volume was extracted from operative reports of SRS. Volumes were then compared using descriptive statistics and paired t-tests.
RESULTS
Ninety intracranial AVMs were identified. Median volume was 4.96 cm3 [interquartile range (IQR) 1.79-8.85] with SRS planning methods and 6.07 cm3 (IQR 1.3-13.6) with ABC/2 methodology. Moderate correlation was seen between SRS and ABC/2 (r = 0.662; P < .001). Paired sample t-tests revealed significant differences between SRS volume and ABC/2 (t = –3.2; P = .002). When AVMs were dichotomized based on ABC/2 volume, significant differences remained (t = 3.1, P = .003 for ABC/2 volume < 7 cm3; t = –4.4, P < .001 for ABC/2 volume > 7 cm3).
CONCLUSION
The ABC/2 method overestimates cerebral AVM volume when compared to volumetric analysis from SRS planning software. For AVMs > 7 cm3, the overestimation is even greater. SRS planning techniques were also significantly different than values derived from equations for cones and cylinders.
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Affiliation(s)
- Christopher Roark
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Venu Vadlamudi
- Department of Radiology, Inova Alexandria Hospital, Alexandria, Virginia
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Joseph J Gemmete
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Joshua Seinfeld
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
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Williamson CA, Co I, Pandey AS, Gregory Thompson B, Rajajee V. Accuracy of Daily Lung Ultrasound for the Detection of Pulmonary Edema Following Subarachnoid Hemorrhage. Neurocrit Care 2017. [PMID: 26209281 DOI: 10.1007/s12028-015-0161-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 12/22/2022]
Abstract
BACKGROUND Early detection of pulmonary edema is vital to appropriate fluid management following subarachnoid hemorrhage (SAH). Lung ultrasound (LUS) has been shown to accurately identify pulmonary edema in patients with acute respiratory failure (ARF). Our objective was to determine the accuracy of daily screening LUS for the detection of pulmonary edema following SAH. METHODS Screening LUS was performed in conjunction with daily transcranial doppler for SAH patients within the delayed cerebral ischemia (DCI) risk period in our neuroICU. We reviewed records of SAH patients admitted 7/2012-5/2014 who underwent bilateral LUS on at least 5 consecutive days. Ultrasound videos were reviewed by an investigator blinded to the final diagnosis. "B+ lines" were defined as ≥3 B-lines on LUS. Two other investigators blinded to ultrasound results determined whether pulmonary edema with ARF (PE-ARF) was present during the period of evaluation on the basis of independent chart review, with a fourth investigator performing adjudication in the event of disagreement. The diagnostic accuracy of B+ lines for the detection of PE-ARF and RPE was determined. RESULTS Of 59 patients meeting criteria for inclusion, 21 (36%) had PE-ARF and 26 (44%) had B+ lines. Kappa for inter-rater agreement was 0.821 (p < 0.0001) for clinical diagnosis of PE-ARF between the two investigators. B+ lines demonstrated sensitivity 90% (95% CI 70-99%) and specificity 82% (66-92%), for PE-ARF. Median days from B+ lines onset to PE-ARF was 1 (IQR 0-1). CONCLUSION Screening LUS was a sensitive test for the detection of symptomatic pulmonary edema following SAH and may assist with fluid titration during the risk period for DCI.
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Affiliation(s)
- Craig A Williamson
- Departments of Neurosurgery and Neurology, University of Michigan, 3552 Taubman Health Care Center; 1500 E. Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109, USA
| | - Ivan Co
- Division of Pulmonary & Critical Care Medicine, Department of Internal Medicine, 3916 Taubman Center, SPC 5360, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center; 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center; 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Venkatakrishna Rajajee
- Departments of Neurosurgery and Neurology, University of Michigan, 3552 Taubman Health Care Center; 1500 E. Medical Center Drive, SPC 5338, Ann Arbor, MI, 48109, USA.
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Savastano LE, Chaudhary N, Murga-Zamalloa C, Wang M, Wang T, Thompson BG. Diagnostic and Interventional Optical Angioscopy in Ex Vivo Carotid Arteries. Oper Neurosurg (Hagerstown) 2016; 13:36-46. [DOI: 10.1093/ons/opw002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Accepted: 12/21/2015] [Indexed: 12/13/2022] Open
Abstract
Abstract
BACKGROUND: Angioscopy – or endovascular endoscopy – is a catheter-based technique employing a flexible fiberoptic angioscope to directly visualize arterial lumen. Poor resolution and excessive stiffness of pre-existent angioscopes limited their use clinically. Recent advances resulted in novel fused optical fiber bundle angioscopes with improved flexibility and imaging resolution. Use of these devices in endovascular neurosurgery is still largely unexplored.
OBJECTIVE: To evaluate image quality and feasibility of optical angioscopes for diagnostic and interventional neuro-angioscopy in carotid arteries of human cadavers.
METHODS: A 5-F optical angioscope was used in human cadaveric carotid arteries to inspect integrity of arterial walls, identify atherosclerotic plaques and associated lesions prone to thrombogenicity, place intravascular occlusion coils, and deploy endovascular stents with real-time visualization.
RESULTS: Angioscopy provided key information about endoluminal anatomy such as presence and characteristics of atherosclerotic plaques and thrombogenic lesions not detected by conventional diagnostic methods. Direct real-time visualization of vascular lumen during endovascular interventions provided information on spatial distribution of coils, coil loop herniation, and apposition of stent cells against carotid artery wall complementary to angiography.
CONCLUSIONS: Fused optical fiber bundle angioscopes provide good-quality endoluminal images in human carotid arteries. Their use can feasibly assist in navigation of extracranial carotid arteries to inspect integrity of the arterial wall and identify atherosclerotic plaques and associated lesions vulnerable to thrombogenicity, allow placement of intravascular occlusion coils, and assess apposition of stents to vessel wall. Further in Vivo validation needs to be conducted along with additional research to improve image quality, flexibility, and size of angioscopes.
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Affiliation(s)
- Luis E. Savastano
- Departments of Neurosurgery, Univer-sity of Michigan, Ann Arbor, Michigan
| | - Neeraj Chaudhary
- Departments of Neurosurgery, Univer-sity of Michigan, Ann Arbor, Michigan
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan
| | | | - Michael Wang
- Departments of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Thomas Wang
- Departments of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Guo D, Wilkinson DA, Thompson BG, Pandey AS, Keep RF, Xi G, Hua Y. MRI Characterization in the Acute Phase of Experimental Subarachnoid Hemorrhage. Transl Stroke Res 2016; 8:234-243. [PMID: 27896625 DOI: 10.1007/s12975-016-0511-5] [Citation(s) in RCA: 36] [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: 08/17/2016] [Revised: 11/06/2016] [Accepted: 11/08/2016] [Indexed: 12/12/2022]
Abstract
A number of mechanisms have been proposed for the early brain injury after subarachnoid hemorrhage (SAH). In this study, we investigated the radiographic characteristics and influence of gender on early brain injury after experimental SAH. SAH was induced by endovascular perforation in male and female rats. Magnetic resonance imaging was performed in a 7.0-T Varian MR scanner at 24 h after SAH. The occurrence and size of T2 lesions, ventricular dilation, and white matter injury (WMI) were determined on T2-weighted images (T2WI). The effects of SAH on heme oxygenase-1 and fibrin/fibrinogen were examined by Western blotting and immunohistochemistry. SAH severity was assessed using a MRI grading system, and neurological function was evaluated according to a modified Garcia's scoring system. T2 hyperintensity areas and enlarged ventricles were observed in T2WI coronal sections 24 h after SAH. The overall incidence of T2 lesions, WMI, and hydrocephalus was 54, 20, and 63%, respectively. Female rats had a higher incidence of T2 hyperintensity lesions and hydrocephalus, as well as larger T2 lesion volumes and higher average ventricular volume. SAH rats graded at 3-4 (our previously validated MRI grading scale) had larger T2 lesion volumes, more hydrocephalus, and worse neurological function compared with those graded at 0-2. In conclusion, T2 lesion, WMI, and hydrocephalus were the most prevalent MRI characteristics 24 h after experimental SAH. The T2 lesion area matched with fibrinogen/fibrin positive staining in the acute phase of SAH. SAH induced more severe brain injury in females compared to males in the acute phase of SAH.
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Affiliation(s)
- Dewei Guo
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.,Department of Neurosurgery, the First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - D Andrew Wilkinson
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Richard F Keep
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA
| | - Ya Hua
- Department of Neurosurgery, University of Michigan, 109 Zina Pitcher Place, Ann Arbor, MI, 48109-2200, USA.
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Zhang C, Li P, Xi G, Gemmete JJ, Chaudhary N, Thompson BG, Pandey AS. Aspirin and Clopidogrel Inhibit Aneurysm Healing after HydroCoil Implantation in External Carotid Artery Aneurysm Model. J Stroke Cerebrovasc Dis 2016; 25:2610-2618. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 07/01/2016] [Indexed: 10/21/2022] Open
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Joseph JR, Delavari N, Wilkinson DA, Roark C, Thompson BG. A Case of Complete Resolution of Hemiballismus After Carotid Endarterectomy. World Neurosurg 2016; 95:624.e5-624.e7. [DOI: 10.1016/j.wneu.2016.01.026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/05/2016] [Accepted: 01/06/2016] [Indexed: 11/26/2022]
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Linzey JR, Griauzde J, Guan Z, Bentley N, Gemmete JJ, Chaudhary N, Thompson BG, Pandey AS. Stent-assisted coiling of cerebrovascular aneurysms: experience at a large tertiary care center with a focus on predictors of recurrence. J Neurointerv Surg 2016; 9:1081-1085. [DOI: 10.1136/neurintsurg-2016-012704] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 09/21/2016] [Accepted: 09/22/2016] [Indexed: 11/04/2022]
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Pandey AS, Meurer WJ, Chaudhary N, Gemmete JJ, Thompson BG, Morgenstern LB, Burke JF. Intra-arterial Stroke Treatment prior to the Stent-Retriever Era: High Mortality and Lack of Volume–Outcome Association. J Stroke Cerebrovasc Dis 2016; 25:2553-8. [DOI: 10.1016/j.jstrokecerebrovasdis.2016.06.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 06/25/2016] [Indexed: 11/25/2022] Open
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Williamson CA, Sheehan KM, Tipirneni R, Roark CD, Pandey AS, Thompson BG, Rajajee V. The Association Between Spontaneous Hyperventilation, Delayed Cerebral Ischemia, and Poor Neurological Outcome in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2016; 23:330-8. [PMID: 25846710 DOI: 10.1007/s12028-015-0138-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [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] [Indexed: 01/12/2023]
Abstract
BACKGROUND The frequency and associations of spontaneous hyperventilation in subarachnoid hemorrhage (SAH) are unknown. Because hyperventilation decreases cerebral blood flow, it may exacerbate delayed cerebral ischemia (DCI) and worsen neurological outcome. METHODS This is a retrospective analysis of data from a prospectively collected cohort of SAH patients at an academic medical center. Spontaneous hyperventilation was defined by PaCO2 <35 mmHg and pH >7.45 and subdivided into moderate and severe groups. Clinical and demographic characteristics of patients with and without spontaneous hyperventilation were compared using χ (2) or t tests. Bivariate and multivariable logistic regression analyses were conducted to examine the association of moderate and severe hyperventilation with DCI and discharge neurological outcome. RESULTS Of 207 patients, 113 (55 %) had spontaneous hyperventilation. Spontaneously hyperventilating patients had greater illness severity as measured by the Hunt-Hess, World Federation of Neurosurgical Societies (WFNS), and SAH sum scores. They were also more likely to develop the following complications: pneumonia, neurogenic myocardial injury, systemic inflammatory response syndrome (SIRS), radiographic vasospasm, DCI, and poor neurological outcome. In a multivariable logistic regression model including age, gender, WFNS, SAH sum score, pneumonia, neurogenic myocardial injury, etiology, and SIRS, only moderate [odds ratio (OR) 2.49, 95 % confidence interval (CI) 1.10-5.62] and severe (OR 3.12, 95 % CI 1.30-7.49) spontaneous hyperventilation were associated with DCI. Severe spontaneous hyperventilation (OR 4.52, 95 % CI 1.37-14.89) was also significantly associated with poor discharge outcome in multivariable logistic regression analysis. CONCLUSION Spontaneous hyperventilation is common in SAH and is associated with DCI and poor neurological outcome.
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Affiliation(s)
- Craig A Williamson
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA.
- Department of Neurology, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Kyle M Sheehan
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Renuka Tipirneni
- Robert Wood Johnson Foundation Clinical Scholars Program, University of Michigan, Ann Arbor, MI, 48109, USA
- Division of General Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Christopher D Roark
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
| | - Venkatakrishna Rajajee
- Department of Neurosurgery, University of Michigan, 3552 Taubman Health Care Center, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109, USA
- Department of Neurology, University of Michigan, Ann Arbor, MI, 48109, USA
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Savastano LE, Smith A, Vega K, Murga-Zamalloa C, Gordon D, Wang M, Thompson BG, Seibel E, Wang T. 109 Multimodal Endovascular Endoscopy in Carotid Atherosclerotic Disease. Neurosurgery 2016. [DOI: 10.1227/01.neu.0000489680.52851.2e] [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] [Indexed: 11/19/2022] Open
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Stetler WR, Griauzde J, Saadeh Y, Wilson TJ, Al-Holou WN, Chaudhary N, Thompson BG, Pandey AS, Gemmete JJ. Is intensive care monitoring necessary after coil embolization of unruptured intracranial aneurysms? J Neurointerv Surg 2016; 9:756-760. [PMID: 27382122 DOI: 10.1136/neurintsurg-2016-012511] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [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: 05/09/2016] [Revised: 06/17/2016] [Accepted: 06/20/2016] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Patients with an unruptured intracranial aneurysm treated with coil embolization are routinely admitted to the intensive care unit (ICU) after the procedure; however, this practice is questionable. The purpose of this study was to determine if routine admission to the ICU is necessary for patients undergoing coil embolization of an unruptured intracranial aneurysm. METHODS We conducted a retrospective cohort study of all patients undergoing elective endovascular treatment of an unruptured intracranial aneurysm between 2005 and 2012 at our institution. Multivariate regression analysis was performed to identify predictors of outcome. Cost savings analysis compared ICU admission to step-down or telemetry unit admission. RESULTS 311 unruptured intracranial aneurysms were treated by coil embolization (190), balloon remodeling (13), or stent-assisted coiling (108). Eleven (3.5%) neurologic complications were noted; 5 (1.6%) of these were permanent. Multivariate regression analysis identified female sex (p=0.028), hypercoagulability (p=0.021), aneurysm size >2 cm (p=0.003), and intraoperative rupture (p<0.001) as predictors of a post-procedural neurologic complication. Cost savings were 57% for admission to a step-down unit and 32% for admission to a telemetry unit compared with ICU admission. CONCLUSIONS Neurologic complications are rare in the treatment of unruptured intracranial aneurysms, suggesting that routine ICU admission after treatment may not be necessary. Female sex, history of hypercoagulability, aneurysm size >2 cm, and an intraprocedural rupture were predictive of a postoperative complication. ICU monitoring in these subgroups may therefore be warranted.
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Affiliation(s)
- William R Stetler
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Julius Griauzde
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Yamaan Saadeh
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Thomas J Wilson
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Wajd N Al-Holou
- Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Neeraj Chaudhary
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Aditya S Pandey
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Joseph J Gemmete
- Departments of Radiology, University of Michigan, Ann Arbor, Michigan, USA.,Departments of Neurosurgery, University of Michigan, Ann Arbor, Michigan, USA.,Departments of Otolaryngology, University of Michigan, Ann Arbor, Michigan, USA
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Awori J, Rajajee V, Gemmete JJ, Chaudhary N, Thompson BG, Pandey AS. Posterior reversible encephalopathy syndrome following hemodynamic treatment of aneurysmal subarachnoid hemorrhage-induced vasospasm. J Clin Neurosci 2016; 26:33-6. [DOI: 10.1016/j.jocn.2015.11.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Accepted: 11/10/2015] [Indexed: 11/25/2022]
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Pandey AS, Gemmete JJ, Wilson TJ, Chaudhary N, Thompson BG, Morgenstern LB, Burke JF. High Subarachnoid Hemorrhage Patient Volume Associated With Lower Mortality and Better Outcomes. Neurosurgery 2016; 77:462-70; discussion 470. [PMID: 26110818 DOI: 10.1227/neu.0000000000000850] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND High-volume centers have better outcomes than low-volume centers when managing complex conditions including subarachnoid hemorrhage (SAH). OBJECTIVE To quantify SAH volume-outcome association and determine the extent to which this association is influenced by aggressiveness of care. METHODS A serial cross-sectional retrospective study using the Nationwide Inpatient Sample for 2002 to 2010 was performed. Included were all adult (older than 18 years of age) discharged patients with a primary diagnosis of SAH admitted from the emergency department or transferred to a discharging hospital; cases of trauma or arteriovenous malformation were excluded. Survey-weighted descriptive statistics estimated temporal trends. Multilevel logistic regression estimated volume-outcome associations for inpatient mortality and discharge home. Models were adjusted for demographic characteristics, year, transfer status, insurance status, all individual Charlson comorbidities, intubation, and all patient-refined, diagnosis-related group mortality. Analyses were repeated, excluding cases in which aggressive care was not pursued. RESULTS A total of 32,336 discharges were included; 13,398 patients underwent clipping (59.1%) or coiling (40.9%). The inpatient mortality rate decreased from 32.2% in 2002 to 22.2% in 2010; discharge home increased from 28.5% to 40.8% during the same period. As SAH volume decreased from 100/year, the mortality rate increased from 18.7% to 19.8% at 80/year, 21.7% at 60/year, 24.5% at 40/year, and 28.4% at 20/year. As SAH patient volume decreased, the probability of discharge home decreased from 40.3% at 100/year to 38.7% at 60/year, and 35.3% at 20/year. Better outcomes persisted in patients receiving aggressive care and in those not receiving aggressive care. CONCLUSION Short-term SAH outcomes have improved. High-volume hospitals have more favorable outcomes than low-volume hospitals. This effect is substantial, even for hospitals conventionally classified as high volume.
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Affiliation(s)
- Aditya S Pandey
- Departments of *Neurosurgery, ‡Radiology, and §Neurology, University of Michigan, Ann Arbor, Michigan
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Li P, Chaudhary N, Gemmete JJ, Thompson BG, Hua Y, Xi G, Pandey AS. Intraventricular Injection of Noncellular Cerebrospinal Fluid from Subarachnoid Hemorrhage Patient into Rat Ventricles Leads to Ventricular Enlargement and Periventricular Injury. Acta Neurochir Suppl 2016; 121:331-4. [PMID: 26463970 DOI: 10.1007/978-3-319-18497-5_57] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Early brain injury and hydrocephalus (HCP) are important mediators of poor outcome in subarachnoid hemorrhage (SAH) patients. We aim to understand the development of HCP and subependymal cellular injury after intraventricular injection of noncellular human SAH cerebrospinal fluid (CSF) into rat ventricles. Two-hundred microliters of noncellular CSF from SAH patients or normal controls were injected into the right lateral ventricle of seven adult male Sprague-Dawley rats. Propidium iodide (PI) was simultaneously injected to detect necrotic cellular death. Rats were then sacrificed 24 h after surgery and the brain specimens were cut and stained for heme oxygenase 1 (HO-1), an oxidative stress marker. We found that the ventricular area at the bregma level in the CSF injection group was significantly larger than that in the control group (p < 0.05). The periventricular tissue in the CSF injection group had significantly more necrotic cell death as well as HO-1 expression as compared with the control group (p < 0.05). In conclusion, injection of SAH patients' CSF into the rat ventricle leads to HCP as well as subependymal injury compared with injection of control CSF.
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Affiliation(s)
- Peiliang Li
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.,Department of Neurosurgery, Huashan Hospital, Fudan University, Shanghai, China
| | - Neeraj Chaudhary
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Ya Hua
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA.
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Thompson BG, Brown RD, Amin-Hanjani S, Broderick JP, Cockroft KM, Connolly ES, Duckwiler GR, Harris CC, Howard VJ, Johnston SCC, Meyers PM, Molyneux A, Ogilvy CS, Ringer AJ, Torner J. Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2368-400. [PMID: 26089327 DOI: 10.1161/str.0000000000000070] [Citation(s) in RCA: 590] [Impact Index Per Article: 65.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. METHODS Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. RESULTS Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.
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Wilson TJ, Stetler WR, Davis MC, Giles DA, Khan A, Chaudhary N, Gemmete JJ, Xi G, Thompson BG, Pandey AS. Intraventricular hemorrhage is associated with early hydrocephalus, symptomatic vasospasm, and poor outcome in aneurysmal subarachnoid hemorrhage. J Neurol Surg A Cent Eur Neurosurg 2014; 76:126-32. [PMID: 25545809 DOI: 10.1055/s-0034-1394189] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
OBJECTIVE We hypothesized that the subset of patients with early hydrocephalus following aneurysmal subarachnoid hemorrhage may represent a subset of patients with a more vehement inflammatory reaction to blood products in the subarachnoid space. We thus examined risk factors for early hydrocephalus and examined the relationship between early hydrocephalus and symptomatic vasospasm as well as clinical outcome. METHODS We retrospectively analyzed all patients presenting to our institution with subarachnoid hemorrhage over a 7-year period. We examined for risk factors, including early hydrocephalus, for poor clinical outcome and symptomatic vasospasm. RESULTS We found intraventricular hemorrhage to be strongly associated with the development of early hydrocephalus. In univariate analysis, early hydrocephalus was strongly associated with both poor functional outcome and symptomatic vasospasm. In multivariate analysis, intraventricular hemorrhage and tobacco use were associated with symptomatic vasospasm; intraventricular hemorrhage, intraparenchymal hemorrhage, and symptomatic vasospasm were associated with poor functional outcome. CONCLUSIONS We found that intraventricular hemorrhage was strongly associated with early hydrocephalus. Further exploration of the mechanistic explanation is needed, but we suggest this may be from a combination of obstruction of cerebrospinal fluid pathways by blood products and inflammation in the choroid plexus resulting in increased cerebrospinal fluid production. Further, we suggest that both early hydrocephalus and cerebral vasospasm may be parts of the overall inflammatory cascade that occurs with intraventricular hemorrhage and ultimately results in a poorer clinical outcome.
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Affiliation(s)
- Thomas J Wilson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - William R Stetler
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Matthew C Davis
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - David A Giles
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Adam Khan
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, United States
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan, Ann Arbor, Michigan, United States
| | - Joseph J Gemmete
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Guohua Xi
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan, United States
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Kashlan ON, Wilson TJ, Chaudhary N, Gemmete JJ, Stetler WR, Dunnick NR, Thompson BG, Pandey AS. Reducing costs while maintaining quality in endovascular neurosurgical procedures. J Neurosurg 2014; 121:1071-6. [DOI: 10.3171/2014.7.jns14236] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
As medical costs continue to rise during a time of increasing medical resource utilization, both hospitals and physicians must attempt to limit superfluous health care expenses. Neurointerventional treatment has been shown to be costly, but it is often the best treatment available for certain neuropathologies. The authors studied the effects of 3 policy changes designed to limit the costs of performing neurointerventional procedures at the University of Michigan.
Methods
The authors retrospectively analyzed the costs of performing neurointerventional procedures during the 6-month periods before and after the implementation of 3 cost-saving policies: 1) the use of an alternative, more economical contrast agent, 2) standardization of coil prices through negotiation with industry representatives to receive economies of scale, and 3) institution of a feedback method to show practitioners the costs of unused products per patient procedure. The costs during the 6-month time intervals before and after implementation were also compared with costs during the most recent 6-month time period.
Results
The policy requiring use of a more economical contrast agent led to a decrease in the cost of contrast usage of $42.79 per procedure for the first 6 months after implementation, and $137.09 per procedure for the most current 6-month period, resulting in an estimated total savings of $62,924.31 for the most recent 6-month period. The standardized coil pricing system led to savings of $159.21 per coil after the policy change, and $188.07 per coil in the most recent 6-month period. This yielded total estimated savings of $76,732.56 during the most recent 6-month period. The feedback system for unused items decreased the cost of wasted products by approximately $44.36 per procedure in the 6 months directly after the policy change and by $48.20 per procedure in the most recent 6-month period, leading to total estimated savings of $22,123.80 during the most recent 6-month period. According to extrapolation over a 1-year period, the 3 policy changes decreased costs by an estimated $323,561.34.
Conclusions
Simple cost-saving policies can lead to substantial reductions in costs of neurointerventional procedures while maintaining high levels of quality and growth of services.
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Stetler WR, Wilson TJ, Al-Holou WN, Khan A, Thompson BG, Pandey AS. Intraoperative angiography does not lead to increased rates of surgical site infections. J Neurointerv Surg 2014; 7:744-7. [PMID: 25155479 DOI: 10.1136/neurintsurg-2014-011346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2014] [Accepted: 08/04/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Intraoperative angiography (IOA) is essential in evaluating residual aneurysm following clip ligation, but it does lead to an additional procedure which increases the duration of the procedure as well as increasing room traffic. We examined whether IOA during microsurgery is a risk factor for developing cranial surgical site infection. MATERIALS AND METHODS A retrospective cohort study was performed of all patients undergoing craniotomy for aneurysm treatment between 2005 and 2012 at the University of Michigan. IOA was used at the surgeons' discretion. The primary outcome of interest was occurrence of a surgical site infection and the secondary outcome of interest was clip repositioning following IOA. Variables including IOA were tested for their independent association with the occurrence of a surgical site infection. RESULTS During the study period 676 intracranial aneurysms were treated by craniotomy; IOA was used in 104 of these cases. There were a total of 20 surgical site infections, 2 in the IOA group (1.9%) and 18 in the non-IOA group (3.1%), indicating that IOA was not a statistically significant variable for infection (p=0.50). No additional single variable measured could be shown to have a statistically significant increase in infection, and there were no direct complications related to the use of IOA (stroke, dissection, perforation). CONCLUSIONS IOA does not increase the risk of developing a surgical site infection. It can be conducted without exposing patients to an undue risk of infection.
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Affiliation(s)
- William R Stetler
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Thomas J Wilson
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Wajd N Al-Holou
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Adam Khan
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - B Gregory Thompson
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Aditya S Pandey
- Department of Neurosurgery, University of Michigan Health System, Ann Arbor, Michigan, USA
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Mikhaylov Y, Wilson TJ, Rajajee V, Gregory Thompson B, Maher CO, Sullivan SE, Jacobs TL, Kocan MJ, Pandey AS. Efficacy of antibiotic-impregnated external ventricular drains in reducing ventriculostomy-associated infections. J Clin Neurosci 2014; 21:765-8. [DOI: 10.1016/j.jocn.2013.09.002] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 09/12/2013] [Indexed: 10/25/2022]
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