hglobal-Index: A Novel Author-Level Measure of the Diffusion of Scientific Ideas Among High-, Low-, and Middle-Income Countries

OBJECTIVE

To describe an intuitive and useful method for measuring the global impact of a medical scholar's research ideas by examining cross-border citations (CBCs) of peer-reviewed neurosurgical publications.

METHODS

Publication and citation data for a random sample of the top 50 most academically productive neurosurgeons were obtained from Scopus Application Programming Interface. We characterized an author-level global impact index analogous to the widely used h-index, the hglobal-index, defined as the number of published peer-reviewed manuscripts with at least the same number of CBCs. To uncover socioeconomic insights, we explored the hglobal-index for high-, middle-, and low-income countries.

RESULTS

The median (interquartile range) number of publications and CBCs were 144 (62-255) and 2704 (959-5325), respectively. The median (interquartile range) h-index and hglobal-index were 42 (23-61) and 32 (17-38), respectively. Compared with neurosurgeons in the random sample, the 3 global neurosurgeons had the highest hglobal-indices in low-income countries at 17, 13, and 9, despite below-average h-index scores of 33, 38, and 19, respectively.

CONCLUSION

This intuitive update to the h-index uses CBCs to measure the global impact of scientific research. The hglobal-index may provide insight into global diffusion of medical ideas, which can be used for social science research, author self-assessment, and academic promotion.

Sex differences in patients with and without high-risk factors associated with aneurysmal subarachnoid hemorrhage

BACKGROUND

Controversy remains regarding the appropriate screening for intracranial aneurysms or for the treatment of aneurysmal subarachnoid hemorrhage (aSAH) for patients without known high-risk factors for rupture. This study aimed to assess how sex affects both aSAH presentation and outcomes for aSAH treatment.

METHOD

A retrospective cohort study was conducted of all patients treated at a single institution for an aSAH during a 12-year period (August 1, 2007-July 31, 2019). An analysis of women with and without high-risk factors was performed, including a propensity adjustment for a poor neurologic outcome (modified Rankin Scale [mRS] score > 2) at follow-up.

RESULTS

Data from 1014 patients were analyzed (69% [n = 703] women). Women were significantly older than men (mean ± SD, 56.6 ± 14.1 years vs 53.4 ± 14.2 years, p < 0.001). A significantly lower percentage of women than men had a history of tobacco use (36.6% [n = 257] vs 46% [n = 143], p = 0.005). A significantly higher percentage of women than men had no high-risk factors for aSAH (10% [n = 70] vs 5% [n = 16], p = 0.01). The percentage of women with an mRS score > 2 at the last follow-up was significantly lower among those without high-risk factors (34%, 24/70) versus those with high-risk factors (53%, 334/633) (p = 0.004). Subsequent propensity-adjusted analysis (adjusted for age, Hunt and Hess grade, and Fisher grade) found no statistically significant difference in the odds of a poor outcome for women with or without high-risk factors for aSAH (OR = 0.7, 95% CI = 0.4-1.2, p = 0.18).

CONCLUSIONS

A higher percentage of women versus men with aSAH had no known high-risk factors for rupture, supporting more aggressive screening and management of women with unruptured aneurysms.

Modafinil Therapy and Mental Status Following Aneurysmal Subarachnoid Hemorrhage: Comprehensive Stroke Center Analysis

BACKGROUND

Disorders of consciousness impair early recovery after aneurysmal subarachnoid hemorrhage (aSAH). Modafinil, a wakefulness-promoting agent, is efficacious for treating fatigue in stroke survivors, but data pertaining to its use in the acute setting are scarce. This study sought to assess the effects of modafinil use on mental status after aSAH.

METHODS

Modafinil timing and dosage, neurological examination, intubation status, and physical and occupational therapy participation were documented. Repeated-measures paired tests were used for a before-after analysis of modafinil recipients. Propensity score matching (1:1 nearest neighbor) for modafinil and no-modafinil cohorts was used to compare outcomes.

RESULTS

Modafinil (100-200 mg/day) was administered to 21% (88/422) of aSAH patients for a median (IQR) duration of 10.5 (4-16) days and initiated 14 (7-17) days after aSAH. Improvement in mentation (alertness, orientation, or Glasgow Coma Scale score) was documented in 87.5% (77/88) of modafinil recipients within 72 hours and 86.4% (76/88) at discharge. Of 37 intubated patients, 10 (27%) were extubated within 72 hours after modafinil initiation. Physical and occupational therapy teams noted increased alertness or participation in 47 of 56 modafinil patients (83.9%). After propensity score matching for baseline covariates, the modafinil cohort had a greater mean (SD) change in Glasgow Coma Scale score than the no-modafinil cohort at discharge (2.2 [4.0] vs. -0.2 [6.32], P = 0.003).

CONCLUSIONS

A temporal relationship with improvement in mental status was noted for most patients administered modafinil after aSAH. These findings, a favorable adverse-effect profile, and implications for goals-of-care decisions favor a low threshold for modafinil initiation in aSAH patients in the acute-care setting.

A Review of Preoperative Embolization Effectiveness in Patients With Arteriovenous Malformations

BACKGROUND AND OBJECTIVES

Preoperative embolization of arteriovenous malformations (AVMs) remains controversial. This study sought to analyze the cost-effectiveness of preoperative embolization of AVMs.

METHODS

Patients who underwent AVM resection at a single institute (January 1, 2015-December 31, 2020) were analyzed. Patients with preoperative embolization (embolization cohort) were compared with those without preoperative embolization (nonembolization cohort). Cost-effectiveness score (CE) was the primary outcome of interest and was determined by dividing the total 1-year cost by effectiveness, which was derived from a validated preoperative to last follow-up change in the modified Rankin Scale utility score. A lower CE signifies a more cost-effective treatment strategy.

RESULTS

Of 188 patients, 88 (47%) underwent preoperative embolization. The mean (SD) total cost was higher in the embolization group than in the nonembolization group ($117 594 [$102 295] vs $84 348 [$82 326]; P < .001). The mean (SD) CE was higher in the embolization cohort ($336 476 [$1 303 842]) than in the nonembolization cohort ($100 237 [$246 255]; P < .001). Among patients with Spetzler-Martin (SM) grade I and II AVMs, the mean (SD) CE was higher in the embolization (n = 40) than in the nonembolization (n = 72) cohort ($164 950 [$348 286] vs $69 021 [$114 938]; P = .004). Among patients with SM grade III AVMs, the mean (SD) CE was lower in the embolization (n = 33) than in the nonembolization (n = 25) cohort ($151 577 [$219 130] vs $189 195 [$446 335]; P = .006). The mean (SD) CE was not significantly different between cohorts among patients with higher-grade AVMs (embolization cohort [n = 3] vs nonembolization cohort [n = 15]: $503 639 [$776 492] vs $2 048 419 [$4 794 758]; P = .49). The mean CE for embolized SM grade III aneurysms was nonsignificant in the ruptured group; however, for the unruptured group, CE was significantly higher in the embolization cohort (n = 26; $160 871 [$240 535]) relative to the nonembolization cohort (n = 15; $108 152 [$166 446]) ( P = .006).

CONCLUSION

Preoperative embolization was cost-effective for patients with SM grade III AVMs but not for patients with lower-grade AVMs.

Early Treatment of Ruptured Cerebral Arteriovenous Malformations: Analysis of Neurological Outcomes and Health Care Costs

BACKGROUND

The timing of surgical resection is controversial when managing ruptured arteriovenous malformations (AVMs) and varies considerably among centers.

OBJECTIVE

To retrospectively analyze clinical outcomes and hospital costs associated with delayed treatment in a ruptured cerebral AVM patient cohort.

METHODS

Patients undergoing surgical treatment for a ruptured cerebral AVM (January 1, 2015-December 31, 2020) were retrospectively analyzed. Patients who underwent emergent treatment of a ruptured AVM because of acute herniation were excluded, as were those treated >180 days after rupture. Patients were stratified by the timing of surgical intervention relative to AVM rupture into early (postbleed days 1-20) and delayed (postbleed days 21-180) treatment cohorts.

RESULTS

Eighty-seven patients were identified. The early treatment cohort comprised 75 (86%) patients. The mean (SD) length of time between AVM rupture and surgical resection was 5 (5) days in the early cohort and 73 (60) days in the delayed cohort ( P < .001). The cohorts did not differ with respect to patient demographics, AVM size, Spetzler-Martin grade, frequency of preoperative embolization, or severity of clinical presentation ( P ≥ .15). Follow-up neurological status was equivalent between the cohorts ( P = .65). The associated mean health care costs were higher in the delayed treatment cohort ($241 597 [$99 363]) than in the early treatment cohort ($133 989 [$110 947]) ( P = .02). After adjustment for length of stay, each day of delayed treatment increased cost by a mean of $2465 (95% CI = $967-$3964, P = .002).

CONCLUSION

Early treatment of ruptured AVMs was associated with significantly lower health care costs than delayed treatment, but surgical and neurological outcomes were equivalent.

Assessing the volume-outcome relationship of carotid artery stenting in nationwide administrative data: a challenge of patient population bias

BACKGROUND

Studies have shown an association between surgical treatment volume and improved quality metrics. This study evaluated nationwide results in carotid artery stenting (CAS) procedural readmission rates, costs, and length of stay based on hospital treatment volume.

METHODS

We used the Nationwide Readmissions Database for carotid stenosis from 2010 to 2015. Patients receiving CAS were matched based on demographics, illness severity, and relevant comorbidities. Patients were matched 1:1 between low- and high-volume centers using a non-parametric preprocessing matching program to adjust for parametric causal inferences. Nearest-neighbor propensity score matching was performed using logit distance.

RESULTS

Low- and high-volume centers admitted a mean (SD) of 4.68 (3.79) and 25.10 (16.86) patients undergoing CAS per hospital, respectively. Comorbidities were significantly different and initially could not be adequately matched. Because of significant differences in baseline patient population characteristics after attempted matching between low- and high-volume centers, we used propensity adjustment with multivariate analysis. Using this alternative approach, no significant differences were observed between low- and high-volume centers for the presence of any complication, postoperative stroke, postoperative myocardial infarction, and readmission at 30 days.

CONCLUSION

In 1:1 nearest-neighbor matching with a high number of patients, our analysis did not result in well-matched cohorts for the effect of case volume on outcomes. Comparing analytical techniques for various outcomes highlights that outcome disparities may not be related to quality differences based on hospital size, but rather variability in patient populations between low- and high-volume institutions.

Occipital Artery to Middle Cerebral Artery Direct Bypass: A Salvage Revascularization Technique for Ischemic Moyamoya Disease

OBJECTIVE

The main treatment for moyamoya disease (MMD) is revascularization surgery. Most bypasses use the superficial temporal artery (STA) as the donor vessel. However, even if the STA-middle cerebral artery (MCA) bypass is functioning, the affected hemisphere can continue to be symptomatically malperfused. We sought to assess the efficacy of salvage direct revascularization surgery using the occipital artery (OA) as a donor vessel in patients with ischemic MMD who experience continued cerebral malperfusion despite previous successful STA-MCA bypass.

METHODS

We retrospectively analyzed the cerebrovascular databases of 2 surgeons and described patients in whom the OA was used as the donor vessel for direct revascularization.

RESULTS

Seven patients were included (5 women). Previous STA-MCA bypasses were direct (n = 2), indirect (n = 3), or combined/multiple (n = 2). The mean (SD) interval between STA-MCA and OA-MCA procedures was 29.2 (13.1) months. Despite an intact STA-MCA bypass in all 7 cases, all 7 patients had recurrent symptoms and demonstrated residual impaired cerebral perfusion. All 7 patients underwent successful OA-MCA direct revascularization. Follow-up perfusion imaging was obtained for 6 of 7 patients. All 6 of these patients demonstrated improved cerebral blood flow to the revascularized hemispheres. All 7 patients demonstrated clinical improvement.

CONCLUSIONS

Patients with ischemic MMD who have continued symptoms and cerebral malperfusion despite previous successful STA-MCA bypass present a challenging clinical scenario. Our series highlights the potential utility of the OA-MCA direct bypass as a salvage therapy for these patients.

Direct puncture of the superior ophthalmic vein for carotid cavernous fistulas: a 21-year experience

BACKGROUND

Direct puncture of the superior ophthalmic vein (SOV) is an alternative approach to traversing the inferior petrosal sinus for embolization of carotid cavernous fistulas (CCFs).

OBJECTIVE

To analyze direct SOV puncture for the treatment of CCFs and review the literature.

METHODS

All patients at a single center, treated for a CCF with direct SOV cannulation between January 1, 2000, and December 31, 2020, were retrospectively analyzed. An additional review of the literature for all case series for direct puncture of the SOV for treatment of CCF was performed.

RESULTS

During the 21-year study period, direct cannulation of the SOV for treatment of a CCF was attempted for 19 patients, with the procedure aborted for one patient because of an inability to navigate the wire into the distal aspect of the cavernous sinus. In 18 patients with direct SOV CCF treatment, 1 experienced a minor complication with an asymptomatic postoperative hemorrhage. Angiographic cure and improvement of symptoms were achieved in 17 patients with a mean (SD) follow-up of 6 (5.2) months. In the review of the literature, an additional 45 patients were reported to have direct cannulation of the SOV for CCF treatment, with angiographic cure in 43 (96%) and decreased objective visual acuity in 1 (2%).

CONCLUSION

Direct SOV cannulation to treat CCFs is safe and effective. Although it is typically used after other endovascular approaches have failed, SOV access for CCF treatment may be warranted as a first-line treatment for select patients.

Relationship between cerebral vasospasm vascular territory and functional outcome after aneurysmal subarachnoid hemorrhage

BACKGROUND

Vasospasm following aneurysmal subarachnoid hemorrhage (SAH) contributes significant morbidity and mortality after brain aneurysm rupture. However, the association between vascular territory of vasospasm and clinical outcome has not been studied. We present a hypothesis-generating study to determine whether the location of vasospasm within the intracranial circulation is associated with functional outcome after SAH.

METHODS

A retrospective analysis of a prospective, intention-to-treat trial for aneurysmal SAH was performed to supplement trial outcomes with in-hospital angiographic imaging and treatment variables regarding vasospasm. The location of vasospasm and the position on the vessel (distal vs proximal) were evaluated. Modified Rankin scale (mRS) outcomes were assessed at discharge and 6 months, and predictive models were constructed.

RESULTS

A total of 406 patients were included, 341 with follow-up data at 6 months. At discharge, left-sided vasospasm was associated with poor outcome (odds ratio (OR), 2.37; 95% CI, 1.25 to 4.66; P=0.01). At 6 months, anterior cerebral artery (ACA) vasospasm (OR, 3.87; 95% CI, 1.29 to 11.88; P=0.02) and basilar artery (BA) vasospasm (OR, 6.22; 95% CI, 1.54 to 27.11; P=0.01) were associated with poor outcome after adjustment. A model predicting 6-month mRS score and incorporating vasospasm variables achieved an area under the curve of 0.85 and a net improvement in reclassification of 13.2% (P<0.01) compared with a previously validated predictive model for aneurysmal SAH.

CONCLUSIONS

In aneurysmal SAH, left-sided vasospasm is associated with worse discharge functional status. At 6 months, both ACA and BA vasospasm are associated with unfavorable functional status.

Retained radial catheters associated with variant radial anatomy in neurointerventional procedures

BACKGROUND

Transradial artery access (TRA) for neurointerventional procedures is gaining widespread acceptance. However, complications that were previously rare may arise as TRA procedures increase. Here we report a series of retained catheter cases with a literature review.

METHODS

All patients who underwent a neurointerventional procedure during a 23-month period at a single institution were retrospectively reviewed for a retained catheter in TRA cases. In cases of retained catheters, imaging was reviewed for anatomical variances in the radial artery, and clinical and demographic case details were analyzed.

RESULTS

A total of 1386 nondiagnostic neurointerventional procedures were performed during the study period, 631 (46%) initially via TRA. The 631 TRA cases were performed for aneurysm embolization (n=221, 35%), mechanical thrombectomy (n=116, 18%), carotid stent/angioplasty (n=40, 6%), arteriovenous malformation embolization (n=38, 6%), and other reasons (n=216, 34%). Thirty-nine (6%) TRA procedures crossed over to femoral access, most commonly because the artery of interest could not be catheterized (26/39, 67%). A retained catheter was identified in five cases (1%), and one (0.2%) patient had an entrapped catheter that was recovered. All six patients with a retained or entrapped catheter had aberrant radial anatomy.

CONCLUSION

Retained catheters for neurointerventional procedures performed via TRA are rare. However, this complication may be associated with variant radial anatomy. With the increased use of TRA for neurointerventional procedures, awareness of anatomical abnormalities that may lead to a retained catheter is necessary. We propose a simple protocol to avoid catheter entrapment, including in emergent situations such as TRA for stroke thrombectomy.

Endovascular Treatment of Cerebrovascular Lesions Using Nickel- or Nitinol-Containing Devices in Patients with Nickel Allergies

Nickel is used in many cerebral endovascular treatment devices. However, nickel hypersensitivity is the most common metal allergy, and the relative risk of treatment in these patients is unknown. This retrospective analysis identified patients with nickel or metal allergies who underwent cerebral endovascular treatment with nickel-containing devices. Seven patients with nickel and/or other metal allergies underwent treatment with 9 nickel-containing devices. None experienced periprocedural complications. No patient received treatment with corticosteroids or antihistamines. At a mean clinical follow-up for all patients of 22.8 months (range, 10.5-38.0 months), no patients had symptoms attributable to nickel allergic reactions. The mean radiographic follow-up for all patients at 18.4 months (range, 2.5-37.5 months) showed successful treatment of the targeted vascular pathologies, with no evidence of in-stent stenosis or other allergic or hypersensitivity sequelae. The treatment of cerebrovascular lesions with a nickel-containing device resulted in no adverse outcomes among these patients and was safe and effective.

Outcomes in Patients with Aneurysmal Subarachnoid Hemorrhage Receiving Sulfonylureas: A Propensity-Adjusted Analysis

OBJECTIVE

Aneurysmal subarachnoid hemorrhage (aSAH) is associated with increased blood-brain barrier permeability, disrupted tight junctions, and increased cerebral edema. Sulfonylureas are associated with reduced tight-junction disturbance and edema and improved functional outcome in aSAH animal models, but human data are scant. We analyzed neurological outcomes in aSAH patients prescribed sulfonylureas for diabetes mellitus.

METHODS

Patients treated for aSAH at a single institution (August 1, 2007-July 31, 2019) were retrospectively reviewed. Patients with diabetes were grouped by presence or absence of sulfonylurea therapy at hospital admission. The primary outcome was favorable neurologic status at last follow-up (modified Rankin Scale score ≤2). Variables with an unadjusted P-value of <0.20 were included in a propensity-adjusted multivariable logistic regression analysis to identify predictors of favorable outcomes.

RESULTS

Of 1013 aSAH patients analyzed, 129 (13%) had diabetes at admission, and 16 of these (12%) were receiving sulfonylureas. Fewer diabetic than nondiabetic patients had favorable outcomes (40% [52/129] vs. 51% [453/884], P = 0.03). Among diabetic patients, sulfonylurea use (OR 3.90, 95% CI 1.05-15.9, P = 0.046), Charlson Comorbidity Index <4 (OR 3.66, 95% CI 1.24-12.1, P = 0.02), and absence of delayed cerebral infarction (OR 4.09, 95% CI 1.20-15.5, P = 0.03) were associated with favorable outcomes in the multivariable analysis.

CONCLUSIONS

Diabetes was strongly associated with unfavorable neurologic outcomes. An unfavorable outcome in this cohort was mitigated by sulfonylureas, supporting some preclinical evidence of a possible neuroprotective role for these medications in aSAH. These results warrant further study on dose, timing, and duration of administration in humans.

Propensity-adjusted analysis of ultra-early aneurysmal subarachnoid hemorrhage treatment and patient outcomes

BACKGROUND

Optimal definitive treatment timing for patients with aneurysmal subarachnoid hemorrhage (aSAH) remains controversial. We compared outcomes for aSAH patients with ultra-early treatment versus later treatment at a single large center.

METHOD

Patients who received definitive open surgical or endovascular treatment for aSAH between January 1, 2014, and July 31, 2019, were included. Ultra-early treatment was defined as occurring within 24 h from aneurysm rupture. The primary outcome was poor neurologic outcome (modified Rankin Scale score > 2). Propensity adjustment was performed for age, sex, Charlson Comorbidity Index, Hunt and Hess grade, Fisher grade, aneurysm treatment type, aneurysm type, size, and anterior location.

RESULTS

Of the 1013 patients (mean [SD] age, 56 [14] years; 702 [69%] women, 311 [31%] men) included, 94 (9%) had ultra-early treatment. Compared with the non-ultra-early cohort, the ultra-early treatment cohort had a significantly lower percentage of saccular aneurysms (53 of 94 [56%] vs 746 of 919 [81%], P <0 .001), greater frequency of open surgical treatment (72 of 94 [77%] vs 523 of 919 [57%], P <0 .001), and greater percentage of men (38 of 94 [40%] vs 273 of 919 [30%], P = .04). After adjustment, ultra-early treatment was not associated with neurologic outcome in those with at least 180-day follow-up (OR = 0.86), the occurrence of delayed cerebral ischemia (OR = 0.87), or length of stay (exp(β), 0.13) (P ≥ 0.60).

CONCLUSIONS

In a large, single-center cohort of aSAH patients, ultra-early treatment was not associated with better neurologic outcome, fewer cases of delayed cerebral ischemia, or shorter length of stay.

Analysis of the Weekend Effect at a High-Volume Center for the Treatment of Intracranial Aneurysms

OBJECTIVE

The "weekend effect" is the negative effect on disease course and treatment resulting from being admitted to the hospital during a weekend. Whether the weekend effect is associated with worse outcomes for patients treated for aneurysmal subarachnoid hemorrhage (aSAH) is unknown. We assessed neurologic outcomes of patients with aSAH admitted during the weekend versus during the week.

METHODS

A retrospective database was reviewed to identify all patients with aSAH who received open or endovascular treatment from August 1, 2007, to July 31, 2019, at a quaternary center. The primary outcome was a poor neurologic outcome (modified Rankin Scale score >2). Propensity adjustment included age, sex, treatment type, Hunt and Hess grade, and Charlson Comorbidity Index.

RESULTS

A total of 1014 patients (women, 703 [69.3%]; men, 311 [30.7%]; mean age, 56 [standard deviation, 14]) met inclusion criteria; 726 (71.6%) had weekday admissions, and 288 (28.4%) had weekend admissions. There was no significant difference between patients with a weekday versus a weekend admission in mean (standard deviation) time to treatment (0.85 [1.29] vs. 0.93 [1.30] days, P = 0.10) or length of stay (19 [9] vs. 19 [9] days, P = 0.04). Total cost and rates of delayed cerebral ischemia and vasospasm were similar between the admission groups, both overall and within the open and endovascular treatment cohorts. After propensity adjustment, weekend admission was not a significant predictor of a modified Rankin Scale score greater than 2 (odds ratio [95% confidence interval]; 1.12 [0.85-1.49]; P = 0.4).

CONCLUSION

No difference in neurologic outcomes was associated with weekend admission among this cohort of patients with aSAH.

Nationwide Readmission Rates and Hospital Charges for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 2-Burr Hole Craniostomy

BACKGROUND

Nontraumatic subdural hematoma (SDH) is a common neurological disease that causes extensive morbidity and mortality. Craniotomy or burr hole craniostomy (BHC) is indicated for symptomatic lesions, but both are associated with high recurrence rates. Although extensive research exists on postoperative complications after BHCs, few studies have examined the underlying causes and predictors of unplanned 30-day hospital readmissions at the national level.

OBJECTIVE

To compare causes for hospital readmission within 30 days after surgical SDH evacuation with BHC and evaluate readmission rates and independent predictors of readmission.

METHODS

This retrospective cohort observational study was designed using the Nationwide Readmissions Database. We identified patients who had undergone BHC for SDH evacuation (2010-2015). National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables.

RESULTS

We analyzed 2753 patients who had BHC for SDH evacuation: 675 (24.5%) had at least one 30-day readmission. Annual readmission rates did not vary across the study period ( P = .60). The most common cause of readmission was recurrent SDH (n = 630, 93.3%), and the next most common was postoperative infection (n = 12, 1.8%). Comorbidities significantly associated with readmission included fluid and electrolyte disorders, chronic blood loss anemia, chronic obstructive pulmonary disease, depression, liver disease, and psychosis ( P ≤ .04), but statistically significant independent predictors for readmission included only chronic obstructive pulmonary disease and fluid and electrolyte disorders ( P ≤ .007).

CONCLUSION

These national trends in 30-day readmission rates after nontraumatic SDH evacuation by BHC not otherwise published provide quality benchmarks that can aid national quality improvement efforts.

Liver Cirrhosis and Inpatient Mortality in Aneurysmal Subarachnoid Hemorrhage: A Propensity-Adjusted Analysis

OBJECTIVE

Liver cirrhosis is associated with an increased risk of aneurysmal subarachnoid hemorrhage (aSAH). However, large studies analyzing the prognosis of cirrhotic patients after aSAH treatment are lacking. This study explores factors associated with inpatient mortality among aSAH patients with cirrhosis.

METHODS

All patients who underwent open or endovascular treatment for an aSAH at a large quaternary center between January 1, 2003, and July 31, 2019, were retrospectively reviewed. Patients were grouped into cirrhosis versus noncirrhosis groups. Univariate analysis determined variables associated with inpatient mortality. Variables with P < 0.20 were included in a propensity-adjusted multivariable logistic regression analysis to predict inpatient mortality.

RESULTS

A total of 1419 patients were treated for aSAH; 17 (1.2%) had confirmed cirrhosis. Inpatient mortality was significantly higher among cirrhotic patients than noncirrhotic patients (35.3% vs. 6.8%; P < 0.001). In the univariate analysis for inpatient mortality, the variables cirrhosis, age >65 years, Charlson Comorbidity Index >4, aneurysm size ≥10 mm, Hunt and Hess grade >3, Fisher grade 4, delayed cerebral ischemia (DCI), and posterior circulation aneurysm had P < 0.20 and were included in the multivariable analysis. The propensity-adjusted stepwise multivariable logistic regression analysis showed that cirrhosis (odds ratio [OR]: 12.7, 95% confidence interval [CI]: 3.3-48.7), Hunt and Hess grade >3 (OR: 3.9, 95% CI: 2.3-6.4), Fisher grade 4 (OR: 3.7, 95% CI: 1.3-10.7), and DCI (OR: 2.4, 95% CI: 1.5-3.9) were associated with inpatient mortality (P ≤ 0.01).

CONCLUSIONS

Cirrhosis was a predictor of inpatient mortality among aSAH patients and was a stronger predictor than DCI or a poor Hunt and Hess grade among patients in this study.

Health Care Expenditures Associated with Delayed Cerebral Ischemia Following Subarachnoid Hemorrhage: A Propensity-Adjusted Analysis

OBJECTIVE

The additional hospital costs associated with delayed cerebral ischemia (DCI) have not been well investigated in prior literature. In this study, the total hospital cost of DCI in aneurysmal subarachnoid hemmorhage (aSAH) patients treated at a single quaternary center was analyzed.

METHODS

All patients in the Post-Barrow Ruptured Aneurysm Trial treated for an aSAH between January 1, 2014, and July 31, 2019, were retrospectively analyzed. DCI was defined as cerebral infarction identified on computed tomography, magnetic resonance imaging, or autopsy after exclusion of procedure-related infarctions. The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis. Propensity score covariate-adjusted linear regression analysis included age, sex, open versus endovascular treatment, Hunt and Hess score, and Charlson Comorbidity Index score.

RESULTS

Of the 391 patients included, 144 (37%) had DCI. Patients with DCI had a significantly greater cost compared to patients without DCI (mean standard deviation $112,081 [$54,022] vs. $86,159 [$38,817]; P < 0.001) and a significantly greater length of stay (21 days [11] vs. 18 days [8], P = 0.003, respectively). In propensity-adjusted linear regression analysis, both DCI (odds ratio, $13,871; 95% confidence interval, $7558-$20,185; P < 0.001) and length of stay (odds ratio, $3815 per day; 95% confidence interval, $3480-$4149 per day; P < 0.001) were found to significantly increase the cost.

CONCLUSIONS

The significantly higher costs associated with DCI further support the evidence that adverse effects associated with DCI in aSAH pose a significant burden to the health care system.

Multiple hippocampal transection for mesial temporal lobe epilepsy: A systematic review

PURPOSE

Multiple hippocampal transection (MHT) is a surgical technique that offers adequate seizure control with minimal perioperative morbidity. However, there is little evidence available to guide neurosurgeons in selecting this technique for use in appropriate patients. This systematic review analyzes patient-level data associated with MHT for intractable epilepsy, focusing on postoperative seizure control and memory outcomes.

METHODS

The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Relevant articles were identified from 3 databases (PubMed, Medline, Embase) up to August 1, 2021. Inclusion criteria were that the majority of patients had received a diagnosis of intractable epilepsy, the article was written in English, MHT was the primary procedure, and patient-level metadata were included.

RESULTS

Fifty-nine unique patients who underwent MHT were identified across 11 studies. Ten (17%) of 59 patients underwent MHT alone. Forty-three (75%) of 57 patients who had a follow-up 12 months or longer were seizure free at last follow-up. With respect to postoperative verbal memory retention, 9 of 38 (24%) patient test scores did not change, 14 (37%) decreased, and 16 (42%) increased. With respect to postoperative nonverbal memory retention, 12 of 38 (34%) patient test scores did not change, 13 (34%) decreased, and 13 (33%) increased.

CONCLUSION

There are few reported patients analyzed after MHT. Although the neurocognitive benefits of MHT are unproven, this relatively novel technique has shown promise in the management of seizures in patients with intractable epilepsy. However, structured trials assessing MHT in isolation are warranted.

Emergency Department Visits for Chronic Subdural Hematomas within 30 Days after Surgical Evacuation with and without Middle Meningeal Artery Embolization

BACKGROUND AND PURPOSE

Middle meningeal artery embolization after surgical evacuation of a chronic subdural hematomas is associated with fewer treatment failures than surgical evacuation. We compared emergency department visits within 30 days for patients with chronic subdural hematomas with and without adjunctive middle meningeal artery embolization.

MATERIALS AND METHODS

All cases of chronic subdural hematoma treated from January 1, 2018, through December 31, 2020, were retrospectively reviewed. Treatment was classified as surgery only or surgery combined with middle meningeal artery embolization. The primary outcome was 30-day emergency department presentation and readmission.

RESULTS

Of 137 patients who met the study criteria, 28 (20%) underwent surgery combined with middle meningeal artery embolization. Of these 28 patients, 15 (54%) underwent planned middle meningeal artery embolization and 13 (46%) underwent embolization after surgical failure. The mean chronic subdural hematoma size at presentation in the group with surgery only (n = 109, 20.5 [SD, 6.9] mm) was comparable with that in the combined group (n = 28, 18.7 [SD, 4.5] mm; P = .16). A significantly higher percentage of the surgery-only group presented to the emergency department within 30 days compared with the combined group (32 of 109 [29%] versus 2 of 28 [7%] patients; P = .02). No significant difference was found with respect to readmission (16 [15%] versus 1 [4%] patient; P = .11). Nine patients (8%) in the surgery-only group were readmitted for significant reaccumulation or residual subdural hematoma compared with only 1 patient (4%) in the combined group (P = .40).

CONCLUSIONS

Surgical evacuation combined with middle meningeal artery embolization in patients with chronic subdural hematoma is associated with fewer 30-day emergency department visits compared with surgery alone.

Nationwide Readmission Rates and Hospital Charges for Patients With Surgical Evacuation of Nontraumatic Subdural Hematomas: Part 1-Craniotomy

BACKGROUND

Despite patients experiencing high recurrence and readmission rates after surgical management of nontraumatic subdural hematomas (SDHs), few studies have examined the causes and predictors of unplanned readmissions in this population on a national scale.

OBJECTIVE

To analyze independent factors predicting 30-day hospital readmissions after surgical treatment of nontraumatic SDH in patients who survived their index surgery and evaluate hospital readmission rates and charges.

METHODS

Using the Nationwide Readmissions Database, we identified patients who underwent craniotomy for nontraumatic SDH evacuation (2010-2015) using a retrospective cohort observational study design. National estimates and variances within the cohort were calculated after stratifying, hospital clustering, and weighting variables.

RESULTS

Among 49 013 patients, 10 643 (21.7%) had at least 1 readmission within 30 days of their index treatment and 38 370 (78.3%) were not readmitted. Annual readmission rates did not change during the study period ( P = .74). The most common primary causes of 30-day readmissions were recurrent SDH (n = 3949, 37.1%), venous thromboembolism (n = 1373, 12.9%), and delayed hyponatremia and syndrome of inappropriate antidiuretic hormone secretion (n = 1363, 12.8%). Comorbidities that independently predicted readmission included congestive heart failure, chronic obstructive pulmonary disease, coagulopathy, diabetes mellitus, liver disease, lymphoma, fluid and electrolyte disorders, metastatic cancer, peripheral vascular disease, psychosis, and renal failure ( P ≤ .03). Household income in the 51st to 75th percentile was associated with a decreased risk of readmission.

CONCLUSION

National trends in 30-day readmission rates after nontraumatic SDH treatment by craniotomy provide quality benchmarks that can be used to drive quality improvement efforts on a national level.

Clinical Trials of Microsurgery for Cerebral Aneurysms: Past and Future

BACKGROUND

New findings and research regarding the microsurgical treatment of intracerebral aneurysms (IAs) continue to advance even in the era of endovascular therapies. Research in the past 2 decades has continued to revolve around the question of whether open surgery or endovascular treatment is preferable. The answer remains both complex and in flux.

OBJECTIVE

This review focuses on microsurgery, reflects on the research decisions of previous landmark studies, and proposes future study designs that may further our understanding of IAs and how best to treat them.

RESULTS

The future of IA research may include a combination of pragmatic trials, artificial intelligence integrated tools, and mining of large data sets, in addition to the publication of high-quality single-center studies.

CONCLUSIONS

The future will likely emphasize testing innovative techniques, looking at granular patient data, and considering every patient encounter as a potential source of knowledge, creating a system in which data are updated daily because each patient interaction contributes to answering important research questions.

Surgeon-Led Initiatives to Increase Access to Surgical Treatment of Epilepsy at an Academic Level 4 Epilepsy Center: An Observational Cohort Study

BACKGROUND

Underutilization of surgical treatment for epilepsy is multifactorial, and the multidisciplinary nature of caring for these patients represents a significant hurdle in expanding surgical treatment of epilepsy.

OBJECTIVE

To develop internal and external surgical referral relationships for patients with medically refractory epilepsy with the goal of improving access to care.

METHODS

To expand access to surgical epilepsy treatment at University of California (UC)-Irvine, 4 broad approaches focused on developing referral relationships and process improvement of surgical evaluation were undertaken in 2015 and 2016. The authors performed a retrospective review of all surgical epilepsy case referrals of the senior author from 2014 through 2020.

RESULTS

Epilepsy surgical volume at UC-Irvine increased from an average of 5.2 cases annually to 32 cases in the first year (2015) of implementation. There was continued case volume growth from 2015 through 2020 to 52 procedures in the most recent year (P = .03). Hospital payments for epilepsy procedures increased from $1.09M in 2015 to $2.02M and $1.8M in 2019 and 2020 (P < .01), respectively, while maintaining a diverse payer mix. 79.4% of these patients did not have a previously established option for surgical epilepsy care.

CONCLUSION

We outline strategies that level 4 epilepsy centers may use to strengthen collaborations and improve patient access for surgical epilepsy treatment. Increased collaboration can both improve the number of patients with epilepsy with access to specialized surgical care and produce reimbursement benefits for the centers caring for these patients, regardless of insurance source.

Avoiding the Radial Paradox: Neuroendovascular Femoral Access Outcomes After Radial Access Adoption

BACKGROUND

Transradial access (TRA) for neuroendovascular procedures is increasing in prevalence. The safety benefits of TRA at a patient level may be offset at a population level by a paradoxical increase in transfemoral access (TFA) vascular access site complications (VASCs), the so-called "radial paradox."

OBJECTIVE

To study the effect of TRA adoption on TFA performance and outcomes in neuroendovascular procedures.

METHODS

Data were collected for all procedures performed over a 10-mo period after radial adoption at a single center.

RESULTS

Over the study period, 1084 procedures were performed, including 719 (66.3%) with an intent to treat by TRA and 365 (33.7%) with an intent to treat by TFA. Thirty-two cases (4.4%) crossed over from TRA to TFA, and 2 cases (0.5%) crossed over from TFA to TRA. TFA was performed in older patients (mean [standard deviation] TFA, 63 [15] vs TRA, 56 [16] years) using larger sheath sizes (≥7 French; TFA, 56.2% vs TRA, 2.3%) ( P < .001 for both comparisons). Overall, 29 VASCs occurred (2.7%), including 27 minor (TFA, 4.6% [18/395] vs TRA, 1.3% [9/689], P = .002) and 2 major (TFA, 0.3% [1/395] vs TRA, 0.1% [1/689], P > .99) complications. Independent predictors of VASC included TFA (OR 2.8, 95% confidence interval [CI] 1.1-7.4) and use of dual antiplatelet therapy (OR 4.2, 95% CI 1.6-11.1).

CONCLUSION

TFA remains an important access route, despite a predominantly radial paradigm, and is disproportionately used in patients at increased risk for VASCs. TFA proficiency may still be achieved in predominantly radial practices without an increase in femoral complications.

The times they are a-changin': increasing complexity of aneurysmal subarachnoid hemorrhages in patients treated from 2004 to 2018

BACKGROUND

Nationwide study results have suggested varying trends in the incidence of aneurysmal subarachnoid hemorrhage (aSAH) over time. Herein, trends over time for aSAH treated at a quaternary care center are compared to low-volume hospitals.

METHODS

Cases were retrospectively reviewed for patients with aSAH treated at our institution. Trend analyses were performed on the number of aSAH hospitalizations, treatment type, Charlson Comorbidity Index (CCI), Hunt and Hess (HH) grade, aneurysm location, aneurysm type, and in-hospital mortality. The National Inpatient Sample (NIS) was queried to compare the CCI scores of our patients with those of patients in low-volume hospitals (<20 aSAH/year) in our census division.

RESULTS

Some 1248 patients (321 during 2004-2006; 927 during 2008-2018) hospitalized with aSAH were treated with endovascular therapy (489, 39%) or microsurgery (759, 61%). A significant downtrend in the annual aSAH caseload occurred (123 patients in 2004, 75 in 2018, p<0.001). A linear uptrend was observed for the mean CCI score of patients (R²=0.539, p<0.001), with no change to in-hospital mortality (R²=0.220, p=0.24). Mean (SD) CCI for small-volume hospitals treating aSAH within our division was significantly lower than that of our patient population (1.8 [1.6] vs 2.1 [2.0]) for 2012-2015.

CONCLUSIONS

A decreasing number of patients were hospitalized with aSAH throughout the study. Compared with patients with aSAH admitted in 2004, those admitted more recently were sicker in terms of preexisting comorbidity and neurologic complexity. These trends could be attributable to the increasing availability of neurointerventional services at smaller-volume hospitals capable of treating healthier patients.

Comparative Anatomical Assessment of Full vs Limited Transcavernous Exposure of the Carotid-Oculomotor Window

BACKGROUND

Although the full transcavernous approach affords extensive mobilization of the oculomotor nerve (OMN) for exposure of the basilar apex and interpeduncular cistern region, this time-consuming procedure requires substantial dural dissection along the anterior middle cranial fossa.

OBJECTIVE

To quantify the extent to which limited middle fossa dural elevation affects the carotid-oculomotor window (C-OMW) surgical area during transcavernous exposure after OMN mobilization.

METHODS

Four cadaveric specimens were dissected bilaterally to study the C-OMW area afforded by the transcavernous exposure. Each specimen underwent full and limited transcavernous exposure and anterior clinoidectomy (1 procedure per side; 8 procedures). Limited exposure was defined as a dural elevation confined to the cavernous sinus. Full exposure included dural elevation over the gasserian ganglion, extending to the middle meningeal artery and lateral middle cranial fossa.

RESULTS

The C-OMW area achieved with the limited transcavernous exposure, compared with full transcavernous exposure, provided significantly less total area with OMN mobilization (22 ± 6 mm2 vs 52 ± 26 mm2, P = .03) and a smaller relative increase in area after OMN mobilization (11 ± 5 mm2 vs 36 ± 13 mm2, P = .03). The increase after OMN mobilization in the C-OMW area after OMN mobilization was 136% ± 119% with a limited exposure vs 334% ± 216% with a full exposure.

CONCLUSION

In this anatomical study, the full transcavernous exposure significantly improved OMN mobilization and C-OMW area compared with a limited transcavernous exposure. If a transcavernous exposure is pursued, the difference in the carotid-oculomotor operative corridor area achieved with a limited vs full exposure should be considered.

Double-barrel STA-MCA bypass and partial trapping of a ruptured mycotic MCA aneurysm with flash fluorescence technique

Mycotic brain aneurysms are rare and unusual cerebrovascular lesions arising from septic emboli that degrade the elastic lamina and vessel wall of intracranial arteries, which results in pathologic dilatation. Mycotic aneurysms are nonsaccular lesions that are not often suitable for clipping and instead require bypass, trapping, and flow reversal. This case demonstrates the use of indocyanine green “flash fluorescence” to identify the cortical distribution supplied by an aneurysm’s outflow, facilitating safe treatment with a double-barrel extracranial-intracranial bypass and partial trapping and conversion of a deep bypass to a superficial one.

The video can be found here: https://stream.cadmore.media/r10.3171/2021.10.FOCVID21163

Effects of Preoperative Embolization on Spetzler-Martin Grade I and II Arteriovenous Malformations: A Propensity-Adjusted Analysis

BACKGROUND

Cerebral arteriovenous malformations (AVMs) with low Spetzler-Martin grades (I and II) are associated with good neurological outcomes after microsurgical resection; however, the use of preoperative embolization for these lesions is controversial.

OBJECTIVE

To compare the neurological outcomes of preoperative embolization with no embolization in patients with low-grade AVMs.

METHODS

Patients with a Spetzler-Martin grade I or II AVM who underwent microsurgical resection during January 1, 1997, through December 31, 2019, were analyzed. Patients undergoing preoperative embolization were compared with patients not undergoing embolization. A propensity score was constructed from baseline characteristics and used to match intervention (embolization) and control (nonembolization) groups in a 1:1 ratio. The primary outcome was poor neurological status on last follow-up examination, defined as a modified Rankin Scale score >2 and a modified Rankin Scale score worse at follow-up than at the preoperative examination.

RESULTS

Of the 603 patients analyzed, 310 (51.4%) underwent preoperative embolization and 293 (48.6%) did not. Patients in the embolization cohort compared with those in the nonembolization cohort had a higher percentage of Spetzler-Martin grade II AVMs (71.6% vs 52.6%, P < .001) and a lower percentage of hemorrhage (41% vs 55%, P = .001). After propensity score matching, no differences were found between paired cohorts (each N = 203) for baseline characteristics with a significant reduction in absolute standardized mean differences. No significant differences were found in primary outcomes between treatment groups in the matched or unmatched cohorts.

CONCLUSION

Preoperative embolization of low-grade Spetzler-Martin AVMs is not associated with improved neurological outcomes after microsurgical resection.

Total 1-year hospital cost of middle meningeal artery embolization compared to surgery for chronic subdural hematomas: a propensity-adjusted analysis

BACKGROUND

Middle meningeal artery (MMA) embolization results in fewer treatment failures than surgical evacuation for chronic subdural hematomas (cSDHs). We compared the total 1-year hospital cost for MMA embolization versus surgical evacuation for patients with cSDH.

METHODS

Data for patients who presented with cSDHs from January 1, 2018, through May 31, 2020, were retrospectively reviewed. Patients were grouped by initial treatment (surgery vs MMA embolization), and total hospital cost was obtained. A propensity-adjusted analysis was performed. The primary outcome was difference in mean hospital cost between treatments.

RESULTS

Of 170 patients, 48 (28%) underwent embolization and 122 (72%) underwent surgery. cSDHs were larger in the surgical (20.5 (6.7) mm) than in the embolization group (16.9 (4.6) mm; P<0.001); and index hospital length of stay was longer in the surgical group (9.8 (7.0) days) than in the embolization group (5.7 (2.4) days; P<0.001). More patients required additional hematoma treatment in the surgical cohort (16%) than in the embolization cohort (4%; P=0.03), and more required readmission in the surgical cohort (28%) than in the embolization cohort (13%; P=0.04). After propensity adjustment, MMA embolization was associated with a lower total hospital cost compared to surgery (mean difference -$32 776; 95% CI -$52 766 to -$12 787; P<0.001). A propensity-adjusted linear regression analysis found that unexpected additional treatment was the only significant contributor to total hospital cost (mean difference $96 357; 95% CI $73 886 to $118 827; P<0.001).

CONCLUSIONS

MMA embolization is associated with decreased total hospital cost compared with surgery for cSDHs. This lower cost is directly related to the decreased need for additional treatment interventions.

Radiographic clearance of chronic subdural hematomas after middle meningeal artery embolization

BACKGROUND

Few reports discuss variables associated with improved outcomes after middle meningeal artery (MMA) embolization for chronic subdural hematomas (cSDHs). We analyzed radiographic evidence of cSDH clearance after MMA embolization to elucidate optimal techniques, hematoma clearance rates, and suitable length of follow-up.

METHODS

Patients who underwent MMA embolization for cSDH from January 1, 2018 through December 31, 2020 were analyzed. Patient characteristics, demographics, and technical procedural details were examined. Outcomes for cSDHs analyzed included complete or near-complete resolution at 30, 90, and 180 days following embolization. A multivariable logistic regression analysis identified variables predictive of rapid clearance and resolution of hematomas at 90 days.

RESULTS

The study cohort comprised 66 patients with 84 treated cSDHs. The mean (SD) cSDH size differed significantly at 30-day (8.8 (4.3) mm), 90-day (3.4 (3.0) mm), and 180-day (1.0 (1.7) mm) follow-up (p<0.001). More cSDHs had complete or near-complete resolution at 180 days (92%, 67/73) than at 90 (63%, 45/72) and 30 days (18%, 15/84) post-embolization (p<0.001). Only distal embolysate penetration was independently associated with rapid clearance (OR 3.9, 95% CI 1.4 to 11.1; p=0.01) and resolution of cSDHs at 90 days (OR 5.0, 95% CI 1.7 to 14.6; p=0.003).

CONCLUSION

Although 63% of cSDHs with MMA embolization had complete or near-complete resolution by 90 days post-procedure, 92% reached this stage by 180 days. Therefore, 90-day follow-up may be insufficient to determine the effectiveness of MMA embolization for cSDHs, particularly compared with surgical evacuation alone. Also, distal MMA penetration may be associated with more rapid hematoma clearance.

Saccular aneurysms in the post-Barrow Ruptured Aneurysm Trial era

OBJECTIVE

The Barrow Ruptured Aneurysm Trial (BRAT) was a single-center trial that compared endovascular coiling to microsurgical clipping in patients treated for aneurysmal subarachnoid hemorrhage (aSAH). However, because patients in the BRAT were treated more than 15 years ago, and because there have been advances since then-particularly in endovascular techniques-the relevance of the BRAT today remains controversial. Some hypothesize that these technical advances may reduce retreatment rates for endovascular intervention. In this study, the authors analyzed data for the post-BRAT (PBRAT) era to compare microsurgical clipping with endovascular embolization (coiling and flow diverters) in the two time periods and to examine how the results of the original BRAT have influenced the practice of neurosurgeons at the study institution.

METHODS

In this retrospective cohort study, the authors evaluated patients with saccular aSAHs who were treated at a single quaternary center from August 1, 2007, to July 31, 2019. The saccular aSAH diagnoses were confirmed by cerebrovascular experts. Patients were separated into two cohorts for comparison on the basis of having undergone microsurgery or endovascular intervention. The primary outcome analyzed for comparison was poor neurological outcome, defined as a modified Rankin Scale (mRS) score > 2. The secondary outcomes that were compared included retreatment rates for both therapies.

RESULTS

Of the 1014 patients with aSAH during the study period, 798 (79%) were confirmed to have saccular aneurysms. Neurological outcomes at ≥ 1-year follow-up did not differ between patients treated with microsurgery (n = 451) and those who received endovascular (n = 347) treatment (p = 0.51). The number of retreatments was significantly higher among patients treated endovascularly (32/347, 9%) than among patients treated microsurgically (6/451, 1%) (p < 0.001). The retreatment rate after endovascular treatment was lower in the PBRAT era (9%) than in the BRAT (18%).

CONCLUSIONS

Similar to results from the BRAT, results from the PBRAT era showed equivalent neurological outcomes and increased rates of retreatment among patients undergoing endovascular embolization compared with those undergoing microsurgery. However, the rate of retreatment after endovascular intervention was much lower in the PBRAT era than in the BRAT.

Intraventricular Tissue Plasminogen Activator and Shunt Dependency in Aneurysmal Subarachnoid Hemorrhage Patients With Cast Ventricles

BACKGROUND

Patients with intraventricular hemorrhage (IVH) are at higher risk of hydrocephalus requiring an external ventricular drain and long-term ventriculoperitoneal shunt placement.

OBJECTIVE

To investigate whether intraventricular tissue plasminogen activator (tPA) administration in patients with ventricular casting due to IVH reduces shunt dependence.

METHODS

Patients from the Post-Barrow Ruptured Aneurysm Trial (PBRAT) database treated for aneurysmal subarachnoid hemorrhage (aSAH) from August 1, 2010, to July 31, 2019, were retrospectively reviewed. Patients with and without IVH were compared. A second analysis compared IVH patients with and without ventricular casting. A third analysis compared patients with ventricular casting with and without intraventricular tPA treatment. The primary outcome was chronic hydrocephalus requiring permanent shunt placement.

RESULTS

Of 806 patients hospitalized with aSAH, 561 (69.6%) had IVH. IVH was associated with a higher incidence of shunt placement (25.7% vs 4.1%, P < .001). In multivariable logistic regression analysis, IVH was independently associated with increased likelihood of shunt placement (odds ratio [OR]: 7.8, 95% CI: 3.8-16.2, P < .001). Generalized ventricular casting was present in 80 (14.3%) patients with IVH. In a propensity-score adjusted analysis, generalized ventricular casting was an independent predictor of shunt placement (OR: 3.0, 95% CI: 1.8-4.9, P < .001) in patients with IVH. Twenty-one patients with ventricular casting received intraventricular tPA. These patients were significantly less likely to require a shunt (OR: 0.30, 95% CI: 0.010-0.93, P = .04).

CONCLUSION

Ventricular casting in aSAH patients was associated with an increased risk of chronic hydrocephalus and shunt dependency. However, this risk decreased with the administration of intraventricular tPA.

Telemedicine for endovascular neurosurgery consultation during the COVID-19 era: patient satisfaction survey

Background

The coronavirus disease 2019 pandemic necessitated the use of telemedicine for most medical specialties, including neurosurgery, although before the pandemic, neurosurgeons infrequently used telemedicine for outpatient visits. We conducted a patient-centric evaluation of telemedicine in our endovascular neurosurgery practice, covering a 4-month period early in the pandemic.

Methods

Survey e-mails after telemedicine visits were sent to all patients who underwent an outpatient telemedicine visit between March 11, 2020, and June 22, 2020, at an endovascular neurosurgery clinic affiliated with a tertiary care center.

Results

Of 140 patients, 65 (46%) completed the e-mail survey. Of the 65 respondents, 35 (54%) agreed or strongly agreed with the statement that even before their telemedicine experience, they thought telemedicine would be a convenient way to receive a neurological consultation. After their telemedicine visit, 47 (72%) agreed or strongly agreed with this statement, and 28 (43%) agreed or strongly agreed that they would prefer telemedicine for future visits. Of the 65 respondents, 61 (94%) rated their telemedicine visit as average or better: 34 (52%) rated it excellent, 12 (18%) rated it above average, and 15 (23%) rated it average. When patients compared their telemedicine visit with a prior in-person clinic visit, only 10 of 44 patients (23%) thought the telemedicine visit was more complicated than an in-person visit, and 21 of 44 (48%) said they would prefer telemedicine for future visits.

Conclusions

Our patients expressed satisfaction with their telemedicine visits, and telemedicine will likely play an important role in future outpatient endovascular neurosurgery consultations.

Treatment of octogenarians and nonagenarians with aneurysmal subarachnoid hemorrhage: a 17-year institutional analysis

BACKGROUND

Outcomes for octogenarians and nonagenarians after an aneurysmal subarachnoid hemorrhage (aSAH) are particularly ominous, with mortality rates well above 50%. The present analysis examines the neurologic outcomes of patients ≥ 80 years of age treated for aSAH.

METHOD

A retrospective review was performed of all aSAH patients treated at Barrow Neurological Institute from January 1, 2003, to July 31, 2019. Patients were placed in 2 groups by age, < 80 vs ≥ 80 years. The ≥ 80-year-old group of octogenarians and nonagenarians was subsequently analyzed to compare treatment modalities. Poor neurologic outcome was defined as a modified Rankin Scale (mRS) score of > 2.

RESULTS

During the study period, 1418 patients were treated for aSAH. The mean (standard deviation) age was 55.1 (13.6) years, the mean follow-up was 24.6 (40.0) months, and the rate of functional independence (mRS 0-2) at follow-up was 54% (751/1395). Logistic regression analysis found increasing age strongly associated with declining functional independence (R² = 0.929, p < 0.001). Forty-three patients ≥ 80 years old were significantly more likely to be managed endovascularly than with open microsurgery (67% [n = 29] vs 33% [n = 14], p < 0.001). Compared with younger patients, those ≥ 80 years old had an increased risk of mortality and poor neurologic outcomes at follow-up. In the ≥ 80-year-old group, only 4 patients had good outcomes; none of the 4 had preexisting comorbidities, and all 4 were treated endovascularly.

CONCLUSIONS

Age is a significant prognostic indicator of functional outcomes and mortality after aSAH. Most octogenarians and nonagenarians with aSAH will become severely disabled or die.

A comparative propensity-adjusted analysis of microsurgical versus endovascular treatment of unruptured ophthalmic artery aneurysms

OBJECTIVE

Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings.

METHODS

The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications.

RESULTS

A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1-64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01-0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02-0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications.

CONCLUSIONS

Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.