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Garcia G, Mantziaris G, Pikis S, Dumot C, Lunsford LD, Niranjan A, Wei Z, Srinivasan P, Tang LW, Liscak R, May J, Lee CC, Yang HC, Peker S, Samanci Y, Nabeel AM, Reda WA, Tawadros SR, Abdel Karim K, El-Shehaby AMN, Emad Eldin R, Elazzazi AH, Martínez Moreno N, Martínez Álvarez R, Padmanaban V, Jareczek FJ, McInerney J, Cockroft KM, Alzate JD, Kondziolka D, Tripathi M, Sheehan JP. Repeat stereotactic radiosurgery for persistent cerebral arteriovenous malformations in pediatric patients. J Neurosurg Pediatr 2024; 33:307-314. [PMID: 38277659 DOI: 10.3171/2023.12.peds23465] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/05/2023] [Indexed: 01/28/2024]
Abstract
OBJECTIVE The purpose of this study was to describe the long-term outcomes and associated risks related to repeat stereotactic radiosurgery (SRS) for persistent arteriovenous malformations (AVMs) in pediatric patients. METHODS Under the auspices of the International Radiosurgery Research Foundation, this retrospective multicenter study analyzed pediatric patients who underwent repeat, single-session SRS between 1987 and 2022. The primary outcome variable was a favorable outcome, defined as nidus obliteration without hemorrhage or neurological deterioration. Secondary outcomes included rates and probabilities of hemorrhage, radiation-induced changes (RICs), and cyst or tumor formation. RESULTS The cohort included 83 pediatric patients. The median patient age was 11 years at initial SRS and 15 years at repeat SRS. Fifty-seven children (68.7%) were managed exclusively using SRS, and 42 (50.6%) experienced hemorrhage prior to SRS. Median AVM diameter and volume were substantially different between the first (25 mm and 4.5 cm3, respectively) and second (16.5 mm and 1.6 cm3, respectively) SRS, while prescription dose and isodose line remained similar. At the 5-year follow-up evaluation from the second SRS, nidus obliteration was achieved in 42 patients (50.6%), with favorable outcome in 37 (44.6%). The median time to nidus obliteration and hemorrhage was 35.5 and 38.5 months, respectively. The yearly cumulative probability of favorable outcome increased from 2.5% (95% CI 0.5%-7.8%) at 1 year to 44% (95% CI 32%-55%) at 5 years. The probability of achieving obliteration followed a similar pattern and reached 51% (95% CI 38%-62%) at 5 years. The 5-year risk of hemorrhage during the latency period after the second SRS reached 8% (95% CI 3.2%-16%). Radiographically, 25 children (30.1%) had RICs, but only 5 (6%) were symptomatic. Delayed cyst formation occurred in 7.2% of patients, with a median onset of 47 months. No radiation-induced neoplasia was observed. CONCLUSIONS The study results showed nidus obliteration in most pediatric patients who underwent repeat SRS for persistent AVMs. The risks of symptomatic RICs and latency period hemorrhage were quite low. These findings suggest that repeat radiosurgery should be considered when treating pediatric patients with residual AVM after prior SRS. Further study is needed to define the role of repeat SRS more fully in this population.
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Affiliation(s)
- Gracie Garcia
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Georgios Mantziaris
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Stylianos Pikis
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Chloe Dumot
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - L Dade Lunsford
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania
| | - Ajay Niranjan
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania
| | - Zhishuo Wei
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania
| | - Priyanka Srinivasan
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania
| | - Lilly W Tang
- 2Department of Neurological Surgery, University of Pittsburgh Medical Center, Pennsylvania
| | - Roman Liscak
- 3Department of Stereotactic and Radiation Neurosurgery, Nemocnice Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir May
- 3Department of Stereotactic and Radiation Neurosurgery, Nemocnice Na Homolce Hospital, Prague, Czech Republic
| | - Cheng-Chia Lee
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 5School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huai-Che Yang
- 4Department of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan
- 5School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Selcuk Peker
- 6Department of Neurosurgery, Koç University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- 6Department of Neurosurgery, Koç University School of Medicine, Istanbul, Turkey
| | - Ahmed M Nabeel
- 7Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 8Neurosurgery Department, Benha University, Qalubiya, Egypt
| | - Wael A Reda
- 7Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 8Neurosurgery Department, Benha University, Qalubiya, Egypt
| | - Sameh R Tawadros
- 7Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 9Neurosurgery and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Khaled Abdel Karim
- 7Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 9Neurosurgery and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- 7Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 9Neurosurgery and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Reem Emad Eldin
- 7Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 10Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | | | | | | | - Varun Padmanaban
- 12Department of Neurosurgery, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Francis J Jareczek
- 12Department of Neurosurgery, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - James McInerney
- 12Department of Neurosurgery, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Kevin M Cockroft
- 12Department of Neurosurgery, Pennsylvania State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | - Manjul Tripathi
- 14Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Padmanaban V, Benjamin WJ, Cohrs A, Jareczek FJ, Hazard SW, Zacko JC, Church EW, Simon SD, Cockroft KM, Leslie DL, Wilkinson DA. Nationwide trends in intensive care unit utilization in the elective endovascular treatment of unruptured intracranial aneurysms. Interv Neuroradiol 2024:15910199241233028. [PMID: 38454799 DOI: 10.1177/15910199241233028] [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] [Indexed: 03/09/2024] Open
Abstract
OBJECTIVE Multiple studies suggest routine post-operative intensive care unit (ICU) stays after endovascular treatment (EVT) of unruptured intracranial aneurysms (UIAs) is unnecessary, though rates of ICU utilization nationwide are unknown. We aim to evaluate rates and characteristics of ICU utilization in patients undergoing elective endovascular repair of UIAs. METHODS This is a retrospective cohort study utilizing a nationwide private-payer database in the United States to evaluate the ICU utilization in patients undergoing elective endovascular repair of UIAs between 2005 and 2019. Demographics and pre-operative comorbidities as well as post-procedural complications and discharge status were compared. An analysis of charges and costs was also performed. RESULTS Among 6218 patients who underwent elective EVT of a UIA, 4890 (78.6%) were admitted to the ICU post-operatively. There were no differences in age, sex, or Charlson comorbidity scores in patients admitted to the ICU post-operatively compared to those admitted elsewhere. ICU utilization was more common in urban locations compared to rural. 12.7% of patients had ICU-specific needs sufficient to be billed by a critical care provider. Total provider costs were significantly higher in patients utilizing the ICU post-operatively, even among uncomplicated patients with routine discharges. CONCLUSION Most patients undergoing elective endovascular UIA repair in the United States are admitted to the ICU postoperatively. Only 12.7% have ICU needs, and these patients are predictable from pre-operative characteristics or peri-operative complications. Reducing ICU use in this subgroup of patients may be an important target to improve healthcare value in this patient population.
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Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | | | - Austin Cohrs
- Center for Applied Studies in Health Economics, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Francis J Jareczek
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Sprague W Hazard
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Anesthesia and Perioperative Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Joseph Christopher Zacko
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ephraim W Church
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Scott D Simon
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Anesthesia and Perioperative Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
- Department of Radiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Douglas L Leslie
- Center for Applied Studies in Health Economics, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - David Andrew Wilkinson
- Department of Neurosurgery, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Mantziaris G, Pikis S, Dumot C, Dayawansa S, Liscak R, May J, Lee CC, Yang HC, Martínez Moreno N, Martinez Álvarez R, Lunsford LD, Niranjan A, Wei Z, Srinivasan P, Tang LW, Nabeel AM, Reda WA, Tawadros SR, Abdel Karim K, El-Shehaby AMN, Emad Eldin RM, Elazzazi AH, Peker S, Samanci Y, Padmanaban V, Jareczek FJ, McInerney J, Cockroft KM, Mathieu D, Aldakhil S, Alzate JD, Kondziolka D, Tripathi M, Palmer JD, Upadhyay R, Lin M, Zada G, Yu C, Cifarelli CP, Cifarelli DT, Shaaban A, Xu Z, Sheehan JP. Effect of cerebral arteriovenous malformation location on outcomes of repeat, single-fraction stereotactic radiosurgery: a matched-cohort analysis. J Neurosurg 2023:1-9. [PMID: 38134430 DOI: 10.3171/2023.10.jns231957] [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: 08/25/2023] [Accepted: 10/17/2023] [Indexed: 12/24/2023]
Abstract
OBJECTIVE Patients with deep-seated arteriovenous malformations (AVMs) have a higher rate of unfavorable outcome and lower rate of nidus obliteration after primary stereotactic radiosurgery (SRS). The aim of this study was to evaluate and quantify the effect of AVM location on repeat SRS outcomes. METHODS This retrospective, multicenter study involved 505 AVM patients managed with repeat, single-session SRS. The endpoints were nidus obliteration, hemorrhage in the latency period, radiation-induced changes (RICs), and favorable outcome. Patients were split on the basis of AVM location into the deep (brainstem, basal ganglia, thalamus, deep cerebellum, and corpus callosum) and superficial cohorts. The cohorts were matched 1:1 on the basis of the covariate balancing score for volume, eloquence of location, and prescription dose. RESULTS After matching, 149 patients remained in each cohort. The 5-year cumulative probability rates for favorable outcome (probability difference -18%, 95% CI -30.9 to -5.8%, p = 0.004) and AVM obliteration (probability difference -18%, 95% CI -30.1% to -6.4%, p = 0.007) were significantly lower in the deep AVM cohort. No significant differences were observed in the 5-year cumulative probability rates for hemorrhage (probability difference 3%, 95% CI -2.4% to 8.5%, p = 0.28) or RICs (probability difference 1%, 95% CI -10.6% to 11.7%, p = 0.92). The median time to delayed cyst formation was longer with deep-seated AVMs (deep 62 months vs superficial 12 months, p = 0.047). CONCLUSIONS AVMs located in deep regions had significantly lower favorable outcomes and obliteration rates compared with superficial lesions after repeat SRS. Although the rates of hemorrhage in the latency period and RICs in the two cohorts were comparable, delayed cyst formation occurred later in patients with deep-seated AVMs.
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Affiliation(s)
- Georgios Mantziaris
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Stylianos Pikis
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Chloe Dumot
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
- 2Department of Neurological Surgery, Hospices Civils de Lyon, France
| | - Sam Dayawansa
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Roman Liscak
- 3Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir May
- 3Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Cheng-Chia Lee
- 4Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
- 5School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Huai-Che Yang
- 4Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taipei, Taiwan
- 5School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | | | - L Dade Lunsford
- 7Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Ajay Niranjan
- 7Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Zhishuo Wei
- 7Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | | | - Lilly W Tang
- 7Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Ahmed M Nabeel
- 8Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 9Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Wael A Reda
- 8Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 9Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Sameh R Tawadros
- 8Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 10Neurosurgery Department and
| | - Khaled Abdel Karim
- 8Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 21Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- 8Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 10Neurosurgery Department and
| | - Reem M Emad Eldin
- 8Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- 11Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | | | - Selcuk Peker
- 12Department of Neurosurgery, Koç University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- 12Department of Neurosurgery, Koç University School of Medicine, Istanbul, Turkey
| | - Varun Padmanaban
- 13Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Francis J Jareczek
- 13Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - James McInerney
- 13Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Kevin M Cockroft
- 13Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - David Mathieu
- 14Department of Neurosurgery, University of Sherbrooke, CHUS Research Center, Sherbrooke, Canada
| | - Salman Aldakhil
- 14Department of Neurosurgery, University of Sherbrooke, CHUS Research Center, Sherbrooke, Canada
| | | | | | - Manjul Tripathi
- 16Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Joshua D Palmer
- 17Department of Radiation Oncology, The James Comprehensive Cancer Center, Ohio State University, Columbus, Ohio
| | - Rituraj Upadhyay
- 17Department of Radiation Oncology, The James Comprehensive Cancer Center, Ohio State University, Columbus, Ohio
| | - Michelle Lin
- 18Department of Neurosurgery, University of Southern California, Los Angeles, California; and
| | - Gabriel Zada
- 18Department of Neurosurgery, University of Southern California, Los Angeles, California; and
| | - Cheng Yu
- 18Department of Neurosurgery, University of Southern California, Los Angeles, California; and
| | | | - Daniel T Cifarelli
- 20Radiation Oncology, West Virginia University, Morgantown, West Virginia
| | - Ahmed Shaaban
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Zhiyuan Xu
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
| | - Jason P Sheehan
- 1Department of Neurological Surgery, University of Virginia, Charlottesville, Virginia
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Pikis S, Mantziaris G, Dumot C, Shaaban A, Protopapa M, Xu Z, Niranjan A, Wei Z, Srinivasan P, Tang LW, Liscak R, May J, Martinez Moreno N, Martinez Álvarez R, Peker S, Samanci Y, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Elazzazi AH, Padmanaban V, Jareczek FJ, McInerney J, Cockroft KM, Lunsford D, Sheehan JP. Third Stereotactic Radiosurgery for Residual Arteriovenous Malformations: A Retrospective Multicenter Study. Neurosurgery 2023:00006123-990000000-01004. [PMID: 38108313 DOI: 10.1227/neu.0000000000002805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 11/06/2023] [Indexed: 12/19/2023] Open
Abstract
BACKGROUND AND OBJECTIVES There are no studies evaluating the efficacy and safety of more than 2 stereotactic radiosurgery (SRS) procedures for cerebral arteriovenous malformations (AVM). The aim of this study was to provide evidence on the role of third single-session SRS for AVM residual. METHODS This multicenter, retrospective study included patients managed with a third single-session SRS procedure for an AVM residual. The primary study outcome was defined as AVM nidus obliteration without AVM bleeding or symptomatic radiation-induced changes (RIC). Secondary outcomes evaluated were AVM obliteration, AVM hemorrhage, asymptomatic, and symptomatic RIC. RESULTS Thirty-eight patients (20/38 [52.6%] females, median age at third SRS 34.5 [IQR 20] years) were included. The median clinical follow-up was 46 (IQR 14.8) months, and 17/38 (44.7%) patients achieved favorable outcome. The 3-year and 5-year cumulative probability rates of favorable outcome were 23% (95% CI = 10%-38%) and 53% (95% CI = 29%-73%), respectively. The cumulative probability of AVM obliteration at 3 and 5 years after the third SRS was 23% (95% CI = 10%-37%) and 54% (95% CI = 29%-74%), respectively. AVM bleeding occurred in 2 patients, and 1 of them underwent subsequent resection. The cumulative probability rate of post-SRS AVM hemorrhage remained constant at 5.3% (95% CI = 1%-16%) during the first 5 years of follow-up. Transient symptomatic RIC managed conservatively occurred in 5/38 patients (13.2%) at a median time of 12.5 (IQR 22.5) months from third SRS. Radiation-induced cyst formation was noted in 1 patient (4.2%) 19 months post-SRS. No mortality, radiation-associated malignancy, or permanent symptomatic RIC was noted during follow-up. CONCLUSION A third single-session SRS to treat a residual intracranial AVM offers obliteration in most patients. The risk of RIC was low, and these effects were transient. While not often required, a third SRS can be performed in patients with persistent residual AVMs.
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Affiliation(s)
- Stylianos Pikis
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
- Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Glyfada, Greece
| | - Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Chloe Dumot
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
- Department of Neurological Surgery, Hospices Civils de Lyon, Lyon, France
| | - Ahmed Shaaban
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Maria Protopapa
- Department of Radiotherapy and Stereotactic Radiosurgery, Mediterraneo Hospital, Glyfada, Greece
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Priyanka Srinivasan
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Lilly W Tang
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Roman Liscak
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | - Jaromir May
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic
| | | | | | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department, Benha University, Qalubya, Egypt
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Reem M Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt
- Radiation Oncology Department, National Cancer Institute, Cairo University, Cairo, Egypt
| | - Ahmed Hesham Elazzazi
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt
| | - Varun Padmanaban
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Francis J Jareczek
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - James McInerney
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA
| | - Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia, USA
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5
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Mantziaris G, Pikis S, Dumot C, Dayawansa S, Liščák R, May J, Lee CC, Yang HC, Martinez Moreno N, Martinez Álvarez R, Lunsford LD, Niranjan A, Wei Z, Srinivasan P, Tang LW, Nabeel AM, Reda WA, Tawadros SR, Abdelkarim K, El-Shehaby AMN, Emad RM, Hesham Elazzazi A, Peker S, Samanci Y, Padmanaban V, Jareczek FJ, McInerney J, Cockroft KM, Mathieu D, Aldakhil S, Alzate JD, Kondziolka D, Tripathi M, Palmer JD, Upadhyay R, Lin M, Zada G, Yu C, Cifarelli CP, Cifarelli DT, Xu Z, Sheehan JP. Outcome Evaluation of Repeat Stereotactic Radiosurgery for Cerebral Arteriovenous Malformations. Stroke 2023. [PMID: 37350270 DOI: 10.1161/strokeaha.123.042515] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
BACKGROUND Repeat stereotactic radiosurgery (SRS) for persistent cerebral arteriovenous malformation (AVM) has generally favorable patient outcomes. However, reporting studies are limited by small patient numbers and single-institution biases. The purpose of this study was to provide the combined experience of multiple centers, in an effort to fully define the role of repeat SRS for patients with arteriovenous malformation. METHODS This multicenter, retrospective cohort study included patients treated with repeat, single-fraction SRS between 1987 and 2022. Follow-up began at repeat SRS. The primary outcome was a favorable patient outcome, defined as a composite of nidus obliteration in the absence of hemorrhage or radiation-induced neurological deterioration. Secondary outcomes were obliteration, hemorrhage risk, and symptomatic radiation-induced changes. Competing risk analysis was performed to compute yearly rates and identify predictors for each outcome. RESULTS The cohort comprised 505 patients (254 [50.3%] males; median [interquartile range] age, 34 [15] years) from 14 centers. The median clinical and magnetic resonance imaging follow-up was 52 (interquartile range, 61) and 47 (interquartile range, 52) months, respectively. At last follow-up, favorable outcome was achieved by 268 (53.1%) patients (5-year probability, 50% [95% CI, 45%-55%]) and obliteration by 300 (59.4%) patients (5-year probability, 56% [95% CI, 51%-61%]). Twenty-eight patients (5.6%) experienced post-SRS hemorrhage with an annual incidence rate of 1.38 per 100 patient-years. Symptomatic radiation-induced changes were evident in 28 (5.6%) patients, with most occurring in the first 3 years. Larger nidus volumes (between 2 and 4 cm3, subdistribution hazard, 0.61 [95% CI, 0.44-0.86]; P=0.005; >4 cm3, subdistribution hazard, 0.47 [95% CI, 0.32-0.7]; P<0.001) and brainstem/basal ganglia involvement (subdistribution hazard, 0.6 [95% CI, 0.45-0.81]; P<0.001) were associated with reduced probability of favorable outcome. CONCLUSIONS Repeat SRS confers reasonable obliteration rates with a low complication risk. With most complications occurring in the first 3 years, extending the latency period to 5 years generally increases the rate of favorable patient outcomes and reduces the necessity of a third intervention.
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Affiliation(s)
- Georgios Mantziaris
- Department of Neurological Surgery, University of Virginia, Charlottesville (G.M., S. Pikis, C.D., S.D., Z.X., J.P.S.)
| | - Stylianos Pikis
- Department of Neurological Surgery, University of Virginia, Charlottesville (G.M., S. Pikis, C.D., S.D., Z.X., J.P.S.)
| | - Chloe Dumot
- Department of Neurological Surgery, University of Virginia, Charlottesville (G.M., S. Pikis, C.D., S.D., Z.X., J.P.S.)
| | - Samantha Dayawansa
- Department of Neurological Surgery, University of Virginia, Charlottesville (G.M., S. Pikis, C.D., S.D., Z.X., J.P.S.)
| | - Roman Liščák
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic (R.L., J.M.)
| | - Jaromir May
- Department of Stereotactic and Radiation Neurosurgery, Na Homolce Hospital, Prague, Czech Republic (R.L., J.M.)
| | - Cheng-Chia Lee
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan (C.-c.L., H.-c.Y.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan (C.-c.L., H.-c.Y.)
| | - Huai-Che Yang
- Department of Neurosurgery, Neurological Institute, Taipei Veteran General Hospital, Taiwan (C.-c.L., H.-c.Y.)
- School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan (C.-c.L., H.-c.Y.)
| | | | | | - L Dade Lunsford
- Department of Neurological Surgery, University of Pittsburgh, PA (R.D.L., A.N., Z.W., P.S., L.W.T.)
| | - Ajay Niranjan
- Department of Neurological Surgery, University of Pittsburgh, PA (R.D.L., A.N., Z.W., P.S., L.W.T.)
| | - Zhishuo Wei
- Department of Neurological Surgery, University of Pittsburgh, PA (R.D.L., A.N., Z.W., P.S., L.W.T.)
| | - Priyanka Srinivasan
- Department of Neurological Surgery, University of Pittsburgh, PA (R.D.L., A.N., Z.W., P.S., L.W.T.)
| | - Lilly W Tang
- Department of Neurological Surgery, University of Pittsburgh, PA (R.D.L., A.N., Z.W., P.S., L.W.T.)
| | - Ahmed M Nabeel
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt (A.M.N., W.A.R., S.R.T., K.A., A.M.N.E.-S., R.M.E.)
- Neurosurgery Department, Benha University, Qalubya, Egypt (A.M.N., W.A.R.)
| | - Wael A Reda
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt (A.M.N., W.A.R., S.R.T., K.A., A.M.N.E.-S., R.M.E.)
- Neurosurgery Department, Benha University, Qalubya, Egypt (A.M.N., W.A.R.)
| | - Sameh R Tawadros
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt (A.M.N., W.A.R., S.R.T., K.A., A.M.N.E.-S., R.M.E.)
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt (S.R.T., K.A., A.M.N.E.-S., A.H.E.)
| | - Khaled Abdelkarim
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt (A.M.N., W.A.R., S.R.T., K.A., A.M.N.E.-S., R.M.E.)
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt (S.R.T., K.A., A.M.N.E.-S., A.H.E.)
| | - Amr M N El-Shehaby
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt (A.M.N., W.A.R., S.R.T., K.A., A.M.N.E.-S., R.M.E.)
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt (S.R.T., K.A., A.M.N.E.-S., A.H.E.)
| | - Reem M Emad
- Gamma Knife Center Cairo, Nasser Institute Hospital, Cairo, Egypt (A.M.N., W.A.R., S.R.T., K.A., A.M.N.E.-S., R.M.E.)
- Radiation Oncology Department, National Cancer Institute, Cairo University, Egypt (R.M.E.)
| | - Ahmed Hesham Elazzazi
- Neurosurgery Department and Clinical Oncology Department, Ain Shams University, Cairo, Egypt (S.R.T., K.A., A.M.N.E.-S., A.H.E.)
| | - Selcuk Peker
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey (S. Peker, Y.S.)
| | - Yavuz Samanci
- Department of Neurosurgery, Koc University School of Medicine, Istanbul, Turkey (S. Peker, Y.S.)
| | - Varun Padmanaban
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA (V.P., F.J.J., J.M., K.M.C.)
| | - Francis J Jareczek
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA (V.P., F.J.J., J.M., K.M.C.)
| | - James McInerney
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA (V.P., F.J.J., J.M., K.M.C.)
| | - Kevin M Cockroft
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA (V.P., F.J.J., J.M., K.M.C.)
| | - David Mathieu
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada (D.M., S.A.)
| | - Salman Aldakhil
- Department of Neurosurgery, Université de Sherbrooke, Centre de recherche du CHUS, Sherbrooke, Canada (D.M., S.A.)
| | | | | | - Manjul Tripathi
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India (M.T.)
| | - Joshua D Palmer
- Department of Radiation Oncology, The James Comprehensive Cancer Center Ohio State University, Columbus (J.D.P., R.U.)
| | - Rituraj Upadhyay
- Department of Radiation Oncology, The James Comprehensive Cancer Center Ohio State University, Columbus (J.D.P., R.U.)
| | - Michelle Lin
- Department of Neurosurgery, University of Southern California (M.L., G.Z., C.Y.)
| | - Gabriel Zada
- Department of Neurosurgery, University of Southern California (M.L., G.Z., C.Y.)
| | - Cheng Yu
- Department of Neurosurgery, University of Southern California (M.L., G.Z., C.Y.)
| | - Christopher P Cifarelli
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown (C.P.C., D.T.C.)
| | - Daniel T Cifarelli
- Departments of Neurosurgery and Radiation Oncology, West Virginia University, Morgantown (C.P.C., D.T.C.)
| | - Zhiyuan Xu
- Department of Neurological Surgery, University of Virginia, Charlottesville (G.M., S. Pikis, C.D., S.D., Z.X., J.P.S.)
| | - Jason P Sheehan
- Department of Neurological Surgery, University of Virginia, Charlottesville (G.M., S. Pikis, C.D., S.D., Z.X., J.P.S.)
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Jareczek FJ, Farrell MB, Lehman EB, Sila C, Terry JB, Sacks D, Kalapos P, Simon SD, Cockroft KM. Variation in Carotid Artery Stenosis Measurements Among Facilities Seeking Carotid Stenting Facility Accreditation. Stroke 2023; 54:1578-1586. [PMID: 37165866 DOI: 10.1161/strokeaha.122.041397] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
BACKGROUND Based on the inclusion criteria of clinical trials, the degree of cervical carotid artery stenosis is often used as an indication for stent placement in the setting of extracranial carotid atherosclerotic disease. However, the rigor and consistency with which stenosis is measured outside of clinical trials are unclear. In an agreement study using a cross-sectional sample, we compared the percent stenosis as measured by real-world physician operators to that measured by independent expert reviewers. METHODS As part of the carotid stenting facility accreditation review, images were obtained from 68 cases of patients who underwent carotid stent placement. Data collected included demographics, stroke severity measures, and the documented degree of stenosis, termed operator-reported stenosis (ORS), by 34 operators from 14 clinical sites. The ORS was compared with reviewer-measured stenosis (RMS) as assessed by 5 clinicians experienced in treating carotid artery disease. RESULTS The median ORS was 90.0% (interquartile range, 80.0%-90.0%) versus a median RMS of 61.1% (interquartile range, 49.8%-73.6%), with a median difference of 21.8% (interquartile range, 13.7%-34.4%), P<0.001. The median difference in ORS and RMS for asymptomatic versus symptomatic patients was not statistically different (24.6% versus 19.6%; P=0.406). The median difference between ORS and RMS for facilities granted initial accreditation was smaller compared with facilities whose accreditation was delayed (17.9% versus 25.5%, P=0.035). The intraclass correlation between ORS and RMS was 0.16, indicating poor agreement. If RMS measurements were used, 72% of symptomatic patients and 10% of asymptomatic patients in the population examined would meet the Centers for Medicare and Medicaid Services criteria for stent placement. CONCLUSIONS Real-world operators tend to overestimate carotid artery stenosis compared with external expert reviewers. Measurements from facilities granted initial accreditation were closer to expert measurements than those from facilities whose accreditation was delayed. Since decisions regarding carotid revascularization are often based on percent stenosis, such measuring discrepancies likely lead to increased procedural utilization.
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Affiliation(s)
- Francis J Jareczek
- Neurosurgery, Penn State Health, Milton S. Hershey Medical Center, PA. (F.J.J., S.D.S., K.M.C.)
| | | | - Erik B Lehman
- Public Health Sciences, Penn State College of Medicine, Hershey, PA. (E.B.L.)
| | - Cathy Sila
- Vascular Neurology, University Hospitals Cleveland, OH. (C.S.)
| | - John B Terry
- Interventional Neurology, Premier Health, Dayton, OH. (J.B.T.)
| | - David Sacks
- Interventional Radiology, Tower Health, Reading, PA. (D.S.)
| | - Paul Kalapos
- Neuroradiology, Penn State Health, Milton S. Hershey Medical Center, PA. (P.K.)
| | - Scott D Simon
- Neurosurgery, Penn State Health, Milton S. Hershey Medical Center, PA. (F.J.J., S.D.S., K.M.C.)
| | - Kevin M Cockroft
- Neurosurgery, Penn State Health, Milton S. Hershey Medical Center, PA. (F.J.J., S.D.S., K.M.C.)
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Jareczek FJ, Padmanaban V, Hallan DR, Wilkinson DA. Correspondence on “National reduction in cerebral arteriovenous malformation treatment correlated with increased rupture incidence” by Luther et al. J Neurointerv Surg 2022:jnis-2022-019866. [DOI: 10.1136/jnis-2022-019866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/16/2022] [Indexed: 12/24/2022]
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Jareczek FJ, Padmanaban V, Church EW, Simon SD, Cockroft KM, Wilkinson DA. Balloon-Assisted Roadmap Technique to Enable Flow Diversion of a High-Flow Direct Carotid-Cavernous Fistula. J Stroke Cerebrovasc Dis 2021; 31:106180. [PMID: 34823090 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106180] [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: 06/28/2021] [Revised: 10/06/2021] [Accepted: 10/15/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The use of flow diverters as a first-line treatment for direct carotid cavernous fistula (CCF) is a relatively new approach in the neurointerventional field which allows obliteration of the fistula with less mass effect from coils in the cavernous sinus. Safe and successful deployment of a flow diverter requires adequate imaging of the parent vessel, which may be challenging in the setting of high-flow CCF without antegrade flow. OBJECTIVE To facilitate adequate parent vessel imaging in the setting of high-flow CCF to enable the safe development of a flow diverter device. METHODS Here we present the case of a patient with delayed presentation of post-traumatic direct CCF after a motor vehicle accident, with no antegrade flow past the fistulous connection. We used temporary balloon occlusion of the fistulous connection to enable road-map imaging of the parent vessel and flow-diverter placement. "Drag and drop" device opening in the middle cerebral artery facilitated better deployment of the flow-diverter against retrograde cavernous flow through the fistula. RESULTS Temporary balloon occlusion of the fistulous connection was used to acquire a roadmap to facilitate safe deployment of a flow diverter and subsequent treatment of the CCF with transvenous coil embolization, with complete resolution of symptoms. CONCLUSION Balloon-assisted roadmap use is a novel means of visualizing the parent vessel in direct CCF to facilitate safe flow diverter deployment.
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Affiliation(s)
- Francis J Jareczek
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - Varun Padmanaban
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - Ephraim W Church
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - Scott D Simon
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - Kevin M Cockroft
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA
| | - D Andrew Wilkinson
- Penn State Health Milton S. Hershey Medical Center, Department of Neurosurgery, 500 University Dr. Hershey, PA, 17033, USA.
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Padmanaban V, Gigliotti M, Majid S, Jareczek FJ, Fritch C, Hazard SW, Zacko JC, Simon SD, Kalapos P, Church EW, Wilkinson DA, Cockroft KM. Risk Factors Associated with ICU-Specific Care in Patients Undergoing Endovascular Treatment of Unruptured Intracranial Aneurysms. Neurocrit Care 2021; 36:39-45. [PMID: 34309785 DOI: 10.1007/s12028-021-01306-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2021] [Accepted: 06/16/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Multiple studies suggest routine postoperative intensive care unit (ICUs) stays in presumed high-risk neurosurgical procedures may be unnecessary. Our objective was to evaluate the risk factors associated with ICU-specific needs in patients undergoing elective endovascular treatment of unruptured intracranial aneurysms. METHODS A retrospective review of consecutive patients undergoing elective endovascular treatment of unruptured aneurysms was performed between January 2010 and January 2020 in a single academic medical center. Patient demographic information, aneurysm and treatment characteristics, intraoperative and postoperative complications, as well as ICU-specific needs, were abstracted. The primary outcome was ICU-specific needs. RESULTS A total of 382 patient encounters in 344 unique patients were abstracted. 13.6% (52 of 382) of patient encounters had an ICU-specific need. Multivariate analysis revealed that age [adjusted odds ratio (OR) 1.04, 95% confidence interval (CI) 1.01-1.07, p = 0.03], procedure duration greater 200 min (adjusted OR 2.75, 95% CI 1.34-5.88, p = 0.007), and any intraoperative complication (adjusted OR 20.41, CI 7.97-56.57, p < 0.001) were independent predictors of postoperative ICU-specific needs. The majority of ICU-specific needs (94%, 49 of 52) occurred within 6 h of surgery. CONCLUSIONS Our results show that age, procedure duration greater than or equal to 200 min, and intraoperative complication were independent predictors of postoperative ICU-specific needs in patients presenting for elective endovascular treatment of unruptured intracranial aneurysms. The majority of ICU-specific needs and associated complications occurred in the immediate postoperative period. This data can be used to help decide the appropriate postoperative level of care in this patient population.
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Affiliation(s)
- Varun Padmanaban
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Michael Gigliotti
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Sonia Majid
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Francis J Jareczek
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Chanju Fritch
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Sprague W Hazard
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA.,Department of Anesthesia and Perioperative Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - J Christopher Zacko
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Scott D Simon
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Paul Kalapos
- Department of Radiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ephraim W Church
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - D Andrew Wilkinson
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA
| | - Kevin M Cockroft
- Department of Neurosurgery - EC110, 30 Hope Drive, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, 17033, USA. .,Department of Radiology, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA. .,Department of Public Health Services, Pennsylvania State University College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.
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10
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Holland MT, Trapp NT, McCormick LM, Jareczek FJ, Zanaty M, Close LN, Beeghly J, Greenlee JDW. Deep Brain Stimulation for Obsessive-Compulsive Disorder: A Long Term Naturalistic Follow Up Study in a Single Institution. Front Psychiatry 2020; 11:55. [PMID: 32184741 PMCID: PMC7058594 DOI: 10.3389/fpsyt.2020.00055] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 01/22/2020] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Deep brain stimulation (DBS) is a proven, effective tool in the treatment of movement disorders. Expansion of indications for DBS into the realm of neuropsychiatric disorders, especially obsessive-compulsive disorder (OCD), has gained fervent interest, although data on appropriate clinical utilization remains limited. METHODS A retrospective, naturalistic study followed nine severely affected OCD patients (average YBOCs score before implantation 34.2 ± 2.5) treated with DBS of ventral capsule/ventral striatum, with average follow up of 54.8 months. RESULTS With chronic stimulation (years), a majority of the patients achieved significant benefits in obsessive-compulsive and depressive symptoms. Six patients experienced periods of OCD remission following implantation. Four of the six responders required more than 12 months to achieve response. Relief of major depressive symptoms occurred in four out of six patients with documented co-morbid depression. Settings required to achieve efficacy were higher than those typically utilized for movement disorders, necessitating increased impulse generator (IPG) battery demand. We found patients benefited from conversion to a rechargeable IPG to prevent serial operations for IPG replacement. For patients with rechargeable IPGs, the repetitive habit of recharging did not appear to aggravate or trigger new obsessive-compulsive behaviors or anxiety symptoms. CONCLUSIONS Our study supports and builds upon other research suggesting that DBS for OCD in a real-world setting can be implemented successfully and provide long-term benefit for severely affected OCD patients. Optimal patient selection and DBS programming criteria are discussed. The use of rechargeable IPGs appears to be both cost effective and well-tolerated in this population.
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Affiliation(s)
- Marshall T Holland
- Department of Neurosurgery, University of Iowa, Iowa City, IA, United States
| | - Nicholas T Trapp
- Department of Psychiatry, University of Iowa, Iowa City, IA, United States
| | - Laurie M McCormick
- Department of Psychiatry, University of Iowa, Iowa City, IA, United States.,Rein Center: Emotional Health and Well-Being, Iowa City, IA, United States
| | | | - Mario Zanaty
- Department of Neurosurgery, University of Iowa, Iowa City, IA, United States
| | - Liesl N Close
- Department of Neurosurgery, University of Iowa, Iowa City, IA, United States
| | - James Beeghly
- Department of Psychiatry, University of Iowa, Iowa City, IA, United States
| | - Jeremy D W Greenlee
- Department of Neurosurgery, University of Iowa, Iowa City, IA, United States
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11
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Abstract
Neurosurgery for the treatment of psychological disorders has a checkered history in the United States. Prior to the advent of antipsychotic medications, individuals with severe mental illness were institutionalized and subjected to extreme therapies in an attempt to palliate their symptoms. Psychiatrist Walter Freeman first introduced psychosurgery, in the form of frontal lobotomy, as an intervention that could offer some hope to those patients in whom all other treatments had failed. Since that time, however, the use of psychosurgery in the United States has waxed and waned significantly, though literature describing its use is relatively sparse. In an effort to contribute to a better understanding of the evolution of psychosurgery, the authors describe the history of psychosurgery in the state of Iowa and particularly at the University of Iowa Department of Neurosurgery. An interesting aspect of psychosurgery at the University of Iowa is that these procedures have been nearly continuously active since Freeman introduced the lobotomy in the 1930s. Frontal lobotomies and transorbital leukotomies were performed by physicians in the state mental health institutions as well as by neurosurgeons at the University of Iowa Hospitals and Clinics (formerly known as the State University of Iowa Hospital). Though the early technique of frontal lobotomy quickly fell out of favor, the use of neurosurgery to treat select cases of intractable mental illness persisted as a collaborative treatment effort between psychiatrists and neurosurgeons at Iowa. Frontal lobotomies gave way to more targeted lesions such as anterior cingulotomies and to neuromodulation through deep brain stimulation. As knowledge of brain circuits and the pathophysiology underlying mental illness continues to grow, surgical intervention for psychiatric pathologies is likely to persist as a viable treatment option for select patients at the University of Iowa and in the larger medical community.
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Abode-Iyamah KO, Chiang HY, Woodroffe RW, Park B, Jareczek FJ, Nagahama Y, Winslow N, Herwaldt L, Greenlee JD. Deep brain stimulation hardware-related infections: 10-year experience at a single institution. J Neurosurg 2018; 130:629-638. [PMID: 29521584 PMCID: PMC6858932 DOI: 10.3171/2017.9.jns1780] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 09/25/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE Deep brain stimulation is an effective surgical treatment for managing some neurological and psychiatric disorders. Infection related to the deep brain stimulator (DBS) hardware causes significant morbidity: hardware explantation may be required; initial disease symptoms such as tremor, rigidity, and bradykinesia may recur; and the medication requirements for adequate disease management may increase. These morbidities are of particular concern given that published DBS-related infection rates have been as high as 23%. To date, however, the key risk factors for and the potential preventive measures against these infections remain largely uncharacterized. In this study, the authors endeavored to identify possible risk factors for DBS-related infection and analyze the efficacy of prophylactic intrawound vancomycin powder (VP). METHODS The authors performed a retrospective cohort study of patients who had undergone primary DBS implantation at a single institution in the period from December 2005 through September 2015 to identify possible risk factors for surgical site infection (SSI) and to assess the impact of perioperative (before, during, and after surgery) prophylactic antibiotics on the SSI rate. They also evaluated the effect of a change in the National Healthcare Safety Network's definition of SSI on the number of infections detected. Statistical analyses were performed using the 2-sample t-test, the Wilcoxon rank-sum test, the chi-square test, Fisher's exact test, or logistic regression, as appropriate for the variables examined. RESULTS Four hundred sixty-four electrodes were placed in 242 adults during 245 primary procedures over approximately 10.5 years; most patients underwent bilateral electrode implantation. Among the 245 procedures, 9 SSIs (3.7%) occurred within 90 days and 16 (6.5%) occurred within 1 year of DBS placement. Gram-positive bacteria were the most common etiological agents. Most patient- and procedure-related characteristics did not differ between those who had acquired an SSI and those who had not. The rate of SSIs among patients who had received intrawound VP was only 3.3% compared with 9.7% among those who had not received topical VP (OR 0.32, 95% CI 0.10-1.02, p = 0.04). After controlling for patient sex, the association between VP and decreased SSI risk did not reach the predetermined level of significance (adjusted OR 0.32, 95% CI 0.10-1.03, p = 0.06). The SSI rates were similar after staged and unstaged implantations. CONCLUSIONS While most patient-related and procedure-related factors assessed in this study were not associated with the risk for an SSI, the data did suggest that intrawound VP may help to reduce the SSI risk after DBS implantation. Furthermore, given the implications of SSI after DBS surgery and the frequency of infections occurring more than 90 days after implantation, continued follow-up for at least 1 year after such a procedure is prudent to establish the true burden of these infections and to properly treat them when they do occur.
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Affiliation(s)
- Kingsley O. Abode-Iyamah
- Departments of Neurosurgery, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Hsiu-Yin Chiang
- Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Royce W. Woodroffe
- Departments of Neurosurgery, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Brian Park
- The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | | | - Yasunori Nagahama
- Departments of Neurosurgery, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Nolan Winslow
- The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
| | - Loreen Herwaldt
- Internal Medicine, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
- Program of Hospital Epidemiology, University of Iowa Hospitals and Clinics, Iowa City, IA 52242, USA
- Department of Epidemiology, The University of Iowa College of Public Health, Iowa City, IA 55242, USA
| | - Jeremy D.W. Greenlee
- Departments of Neurosurgery, The University of Iowa Carver College of Medicine, Iowa City, IA 52242, USA
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Jareczek FJ, Abode-Iyamah KO, Cox EM, Dahdaleh NS, Hitchon PW, Howard MA. Letter: Reconsidering Bone Morphogenetic Protein in the Cervical Spine: Selective Use for Managing Type II Odontoid Fractures in the Elderly. Oper Neurosurg (Hagerstown) 2017; 13:E39-E42. [PMID: 29040717 DOI: 10.1093/ons/opx212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Francis J Jareczek
- Department of Neurosurgery Carver College of Medicine The University of Iowa Iowa City, Iowa
| | - Kingsley O Abode-Iyamah
- Department of Neurosurgery Carver College of Medicine The University of Iowa Iowa City, Iowa
| | - Efrem M Cox
- Department of Neurological Surgery Case Western Reserve University Cleveland, Ohio
| | - Nader S Dahdaleh
- Department of Neurological Surgery Feinberg School of Medicine Northwestern University Chicago, Illinois
| | - Patrick W Hitchon
- Department of Neurosurgery Carver College of Medicine The University of Iowa Iowa City, Iowa
| | - Matthew A Howard
- Department of Neurosurgery Carver College of Medicine The University of Iowa Iowa City, Iowa
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Jareczek FJ, White SR, Hammond DL. Plasticity in Brainstem Mechanisms of Pain Modulation by Nicotinic Acetylcholine Receptors in the Rat. eNeuro 2017; 4:ENEURO.0364-16.2017. [PMID: 28197544 PMCID: PMC5286660 DOI: 10.1523/eneuro.0364-16.2017] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 01/10/2017] [Accepted: 01/12/2017] [Indexed: 01/03/2023] Open
Abstract
Individuals with chronic pain may be driven to smoke more because the analgesic efficacy of nicotine diminishes. To determine whether persistent pain diminishes the actions of a nicotinic acetylcholine receptor (nAChR) agonist in pain modulatory pathways, we examined the effects of epibatidine in the rostral ventromedial medulla (RVM) of rats with and without inflammatory injury induced by intraplantar injection of complete Freund's adjuvant (CFA). In uninjured rats, epibatidine produced a dose-dependent antinociception that was completely blocked by dihydro-β-erythroidine (DHβE; α4β2 antagonist) and partially blocked by methyllycaconitine (MLA; α7 antagonist). Epibatidine reversed heat hyperalgesia when microinjected in the RVM 4 h, 4 d, or 2 weeks after CFA treatment. Although DHβE completely blocked epibatidine's antihyperalgesic effect at 4 h, at 2 weeks it elicited only partial antagonism. Methyllycaconitine was ineffective at both time points. Epibatidine's antinociceptive efficacy in the uninjured hind paw progressively declined, and it was without effect 2 weeks after CFA. Moreover, as early as 4 h after CFA, the antinociceptive effect of epibatidine was no longer antagonized by DHβE. Neither antagonist alone altered paw withdrawal latency in uninjured or CFA-treated rats, suggesting that neither α4β2 nor α7 nAChRs are tonically active in the RVM. The Bmax and Kd of α4β2 nAChRs in the RVM were unchanged after CFA treatment. These observations provide the first evidence of pharmacological plasticity of the actions of α4β2 nAChR agonists in a critical brainstem pain modulatory pathway and may in part explain why people with chronic pain smoke more than the general population.
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Affiliation(s)
- Francis J. Jareczek
- Medical Scientist Training Program, University of Iowa, Iowa City, IA 52242
- Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, IA 52242
| | | | - Donna L. Hammond
- Interdisciplinary Graduate Program in Neuroscience, University of Iowa, Iowa City, IA 52242
- Department of Anesthesia, University of Iowa, Iowa City, IA 52242
- Department of Pharmacology, University of Iowa, Iowa City, IA 52242
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Abstract
Indoor smoke exposure is responsible for two million deaths per year and has been studied globally, but the impacts of exposure have not yet been evaluated in Haiti, the Western hemisphere's poorest nation. This study measures the disproportionate impact of indoor smoke exposure on the women and children of Haiti. We studied 2296 clinic patients in four Haitian villages to determine the extent of carbon monoxide (CO) exposure, using carboxyhemoglobin saturation in the blood as a proxy for overall smoke exposure. We predicted CO levels to be higher in women, who traditionally perform the majority of cooking duties, and in children who accompany their mothers. CO levels averaged 4.9% in women and 3.4% in men. Women of child-bearing age carried a minimum relative risk (RR) for CO exposure of 1.22, relative to all males and younger females. Older females carried no significant difference in risk. Children averaged the lowest CO exposure among all cohorts. These findings demonstrate the burden of indoor smoke exposure that falls disproportionately on women in these regions of Haiti. Global efforts to mitigate indoor exposure have demonstrated the health, economic, environmental and social improvements that are possible by tackling this problem.
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Affiliation(s)
- Alexander M Hubbell
- Roy J. and Lucille K. Carver College of Medicine, University of Iowa Hospitals and Clinics, Iowa City, IA, USA.
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