Timing and Morbidity of Intracranial Meningioma Resection Complications

BACKGROUND

Intracranial meningioma resection is associated with multiple acute postoperative complications, including cerebrovascular accidents, surgical site infections, and pneumonia. There is a paucity of research on the postoperative timeframe of these complications. Therefore, our objective is to characterize intracranial meningioma resection complications' time courses.

METHODS

The National Surgical Quality Improvement Project registry was queried for intracranial meningioma resection cases using CPT codes 61512 and 61519 from years 2016 to 2021. Baseline patient characteristics and 30-day complication frequency were calculated. The mean, median, and interquartile range of postoperative days to occurrence for 17 complications were calculated. Percent incidence predischarge was recorded. Time-to-occurrence curves were created. Rates of 30-day mortality and increased length-of-stay were compared between patients with and without each complication using a χ2 test. A covariance matrix showing associations between 11 complications using the Pearson method was made. Significance was set at P < 0.05.

RESULTS

Ten thousand eight hundred ninety cases were analyzed. The most frequent complications' median and interquartile range of postoperative days to occurrence and percentage occurring predischarge were bleeding requiring transfusion (0.0, 0.0-0.0, 99.9%), cerebrovascular accident/stroke with neurological deficit (2.0, 1.0-6.0, 83.8%), unplanned intubation (4.0, 1.0-8.0, 75.1%), on a ventilator for >48 hours (3.0; 2.0-5.5; 88.1%), deep vein thrombosis/thrombophlebitis (12.5, 5.2-19.7, 41.3%), urinary tract infection (13.0, 7.0-20.0, 44.2%), pneumonia (8.0, 4.0-16.0, 60.5%), and pulmonary embolism (14.0, 6.0-20.0, 29.1%). Most complications were associated with increased mortality and length-of-stay.

CONCLUSIONS

Postoperative meningioma resection complications have varying morbidity and timeframes. Surgeons should be aware of complication timing to better manage postoperative care.

All-cause and tumor-specific mortality trends in elderly primary central nervous system lymphoma (PCNSL) patients: a surveillance, epidemiology, and end results (SEER) analysis

BACKGROUND

Recent primary central nervous system lymphoma (PCNSL) literature indicates that younger patients benefit from improved survival; however, this benefit is not shared by those 70+ years of age. The purpose of this study was to examine mortality trends in PCNSL patients 70+ years of age to better understand why improved prognosis has not yet reached this rapidly growing population subset.

METHODS

Two thousand seventy-five cases (1973-2012, age at diagnosis 70+ years) within the Surveillance, Epidemiology, and End Results (SEER) database were included in Kaplan-Meier and multivariate Cox Regression analyses. Variables include age at diagnosis, decade of diagnosis (1=1973-1982, 2=1983-1992, 3=1993-2002, 4=2003-2012), sex, race and surgery.

RESULTS

Before stratification, both univariate and multivariate analyses agreed that patients aged 70-74 years at diagnosis lived the longest, while those 85+ years lived the shortest (median±SD; 6.0±0.5 months vs. 2.0±0.2 months, respectively, P<0.0005); women lived longer than men (5.0±0.3 months vs. 4.0±0.3 months, respectively, P=0.01); patients who received surgery (6.0±0.5 months) lived longer than those who did not (contraindicated=1.0±0.5 months, P<0.0005; not performed=4.0±0.3 months, P<0.0005). Univariate analysis showed decade 4 lived longer than only decade 3 (4.0±0.3 vs. 4.0±0.5, respectively, P=0.008), while multivariate analysis showed decade 4 lived longer than both 2 (5.0±0.8 months, P=0.03) and 3 (P<0.0005). Following stratification, decade and sex no longer influenced survival. Race did not influence survival.

CONCLUSIONS

Minimal clinically meaningful improvements in elderly PCNSL patient all-cause and tumor-specific mortality have been made since 1973, while the best predictors of longevity include younger age and surgery.

Costs, length of stay and inpatient complications of early surgical decompression after spinal cord injury in a geriatric cohort

Debate regarding timing of surgical decompression after spinal cord injury continues. Recent evidence indicates that early decompression improves neurological outcomes. However, little investigation has been performed regarding how it affects one's hospitalization in a geriatric cohort. 8,999 cases of traumatic SCI who underwent surgical decompression (2002-2011, age 65 + years) within the Nationwide Inpatient Sample were included in univariate and multivariate analyses. Univariate analysis shows that early decompression is more cost effective ($88,564.00 vs $107,849.00, p < 0.0005) and is associated with shorter length of stay (LOS) (8.00 ± 16.15 vs 12.00 ± 15.93 days, p < 0.0005) when compared to late decompression. In multivariate analysis, early decompression continued to be associated with a shorter LOS, though cost was no longer statistically different. Early decompression had less odds of surgical site infection, vasopressor use, decubitus ulcers, but higher odds of cardiac complications, acute renal failure, transfusions and hardware complications. Spinal level of SCI did not affect timing of surgery. Vertebral column fracture did not influence cost or length of stay. In summary, the complex mix of results regarding inpatient complications highlight the innumerable variables and complex decision making that involves surgical treatment of SCI, especially within a susceptible geriatric cohort. However, shorter LOS and lower costs associated with early decompression continue to support its uniform implementation after traumatic SCI.

Preoperative Embolization of Meningiomas Facilitates Reduced Surgical Complications and Improved Clinical Outcomes : A Meta-analysis of Matched Cohort Studies

PURPOSE

The utility of preoperative embolization (PE) of intracranial meningiomas is unclear and controversial. The aim of this study was to investigate the effect of PE on meningioma surgical resection by completing a meta-analysis of matched cohort studies.

METHODS

A systematic review and meta-analysis of matched cohort studies was completed to evaluate the effect of PE on meningioma resection and outcomes. Outcome measures included: intraoperative blood loss, major surgical complications, total surgical complications including minor ones, total major complications including major surgical and embolization complications, total overall complications, and postoperative functional independence defined as modified Rankin Score (mRS) of 0-2. Pooled odds ratios (OR) were determined via a fixed effects model.

RESULTS

A total of 6 matched cohort studies were identified with 219 embolized and 215 non-embolized meningiomas. There was no significant difference in intraoperative blood loss between the two groups (P = 0.87); however, the embolization group had a significantly lower odds ratio of major surgically related complications (OR: 0.37, 95% confidence interval, CI: 0.21-0.67, P = 0.0009, I2 = 0%), but no difference in minor surgical complications (P = 0.86). While there was a significantly lower odds ratio of total overall surgical and PE-related complications in PE cases (OR: 0.64, CI: 0.41-1.0, P = 0.05, I2 = 66%), there was no difference in total combined major complications between the groups (OR: 0.57, CI: 0.27-1.18, P = 0.13, I2 = 33%). Lastly, PE was associated with a higher odds ratio of functional independence on postoperative follow-up (OR: 2.3, CI: 1.06-5.02, P = 0.04, I2 = 0%).

CONCLUSION

For certain meningiomas, PE facilitates lower overall complications, lower major surgical complications, and improved functional independence. Further research is required to identify the particular subset of meningiomas that benefit from PE.

Ischemic stroke caused by spontaneous anterior circulation intracranial arterial dissections: patient series

BACKGROUND

Intracranial arterial dissections (IADs) are classically associated with the vertebrobasilar system, yet are a devastating cause of ischemic stroke within the anterior circulation. Current literature regarding the surgical management of anterior circulation IAD is lacking. As a result, data on 9 patients presenting with ischemic stroke due to spontaneous anterior circulation IAD between 2019 and 2021 were collected in a retrospective manner. Symptoms, diagnostic modalities, treatment, and outcomes are presented for each case. Patients who underwent endovascular procedures had 10-minute follow-up angiography performed to identify signs of reocclusion, which prompted initiation of glycoprotein IIb/IIIa therapy and stent placement.

OBSERVATIONS

Seven patients underwent emergent endovascular intervention (stenting: n = 5; thrombectomy alone: n = 2). The remaining 2 were managed medically. Two patients developed progressive flow limiting stenosis requiring further intervention, 2 developed asymptomatic progressive stenosis/occlusion with robust collateral formation and the remainder have patent vasculature upon follow up imaging at 6 to 12 months. Seven patients had a modified Rankin Scale score of 1 or less at the 3-month follow-up.

LESSONS

IAD is a devastating yet rare cause of anterior circulation ischemic stroke. The treatment algorithm proposed resulted in positive clinical and angiographic outcomes warranting future consideration and study in the emergent management of spontaneous anterior circulation IAD.

Comparison of semi-quantitative and visual assessment of early MRI signal evolution in acute ischaemic stroke

Background

The evaluation of DWI/FLAIR mismatch in ischaemic stroke patients with unknown, time from onset can determine the treatment strategy. This approach is based on, visual assessment and may be subject to insufficient inter-rater agreement.

Objective

To compare the inter-rater agreement of visual evaluation of FLAIR MRI and proposed region of interest (ROI) semiquantitative method in large vessel occlusion (LVO) strokes.

Methods

Five readers have analysed MRIs of 104 patients obtained within six hours of the onset of stroke symptoms resulting from LVO visually and semi-quantitatively. For the semiquantitative analysis, a ROI method was used to obtain relative signal intensity compared to the unaffected side. Cut-off values of 1.15 and 1.10 were tested. The analysis yielded FLAIR-positive (abnormal) and negative (normal) findings. Percentage agreement and Fleiss kappa coefficients were calculated.

Results

The visual agreement of 5/5 readers and ≥ 4/5 readers occurred in 31% and 59% of cases respectively. Semi-quantitative evaluation using a cut-off value of 1.15 increased the agreements to 67% and 88% respectively. The agreement of visual evaluation was fair. The semi-quantitative method utilising the cut-off of 1.15 had moderate agreement although it increased the number of FLAIR-negative results compared to the visual evaluation. A low cut-off value of 1.10 didn't improve the agreement significantly.

Conclusion

The inter-rater agreement of visual evaluation of FLAIR in patients with short-duration large vessel occlusion stroke was fair. The high cut-off value of semiquantitative evaluation increased the agreement although it changed the proportion of FLAIR positive and negative results.

Use of Intracranial Pressure Monitoring in Patients with Severe Traumatic Brain Injury

OBJECTIVE

The Brain Trauma Foundation (BTF) recommends intracranial pressure (ICP) monitoring for all salvageable patients with an abnormal computed tomography (CT) scan and a Glasgow Coma Scale <9. Studies have shown that compliance with this recommendation is low. We sought to obtain contemporary national rates of ICP monitor placement in patients with severe traumatic brain injury (TBI).

METHODS

Patients from the National Trauma Data Bank from 2013 to 2017 who met BTF criteria for ICP monitoring were included. Placement of an intraparenchymal ICP monitor or an external ventricular drain was queried. Binary logistic regression was used to determine factors that influenced the placement of an ICP monitor.

RESULTS

A total of 21,374 patients with severe TBI and an abnormal CT scan were included in the study. An ICP monitor was placed in 6543 patients (30.6%). ICP monitor placement increased modestly from 28.6% in 2013 to 32.8% in 2017. The pooled odds of ICP monitor placement between 2014 and 2017 were not different from 2013 (odds ratio, 1.04; 95% confidence interval, 0.99-1.09), but the adjusted odds of ICP monitor placement in 2017 were significantly greater (odds ratio, 1.18; 95% confidence interval, 1.06-1.30). Treatment at a teaching hospital, subdural hematoma, multiple intracranial abnormalities on CT, and greater Injury Severity Score were associated with ICP monitor placement, whereas older age was negatively associated with ICP monitor placement.

CONCLUSIONS

The rate of ICP monitoring in patients with severe TBI who meet BTF criteria is low and increased only slightly from 2013 to 2017.

Blastic plasmacytoid dendritic cell neoplasm: First retrospective study in the Czech Republic

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare hematologic malignancy with aggressive behavior and poor prognosis. We present the first retrospective analysis mapping its incidence and therapeutic outcomes in patients diagnosed and treated from 2000 to 2017 in the Czech Republic. The cohort comprised 14 patients (10 males, 4 females) with a median age at diagnosis of 39 years (range, 5-68 years). Initially, skin involvement was noted in 10 (71%) patients and bone marrow infiltration was present in 9 (64%). The first complete remission was achieved in 6/14 (43%) patients after acute lymphoblastic leukemia/lymphoma induction therapy and in 3/14 (21%) patients after acute myeloid leukemia regimen. Nine patients underwent allogeneic hematopoietic cell transplantation, with two patients achieving the first complete remission only after allogeneic transplantation. Patients undergoing allogeneic hematopoietic cell transplantation had longer overall survival than those treated without transplantation (the median survival over the period 16.4 vs. 8.1 months). Relapse of the disease was a significant predictor of mortality (p=0.05). Over the study period, patients' survival ranged from 3.3 to 44.2 months, with a median overall survival of 13 months. Our results revealed an effectivity of allogeneic hematopoietic cell transplantation on complete remission achievement in refractory/relapsed disease. The study aimed to present the actual data from the Czech Republic and thus contribute to a global understanding of BPDCN.

Annual incidences and predictors of 30-day readmissions following spontaneous intracerebral hemorrhage from 2010 to 2014 in the United States: A retrospective Nationwide analysis

Objective

30-day readmission rate is a quality metric often employed to represent hospital and provider performance. Currently, little is known regarding 30-day readmissions (30dRA) following spontaneous intracerebral hemorrhage (sICH). The purpose of this study was to use a national database to identify risk factors and trends in 30dRAs following sICH.

Patients and methods

64,909 cases with a primary diagnosis of sICH were identified within the Nationwide Readmission Database (NRD) from 2010 through 2014. Charlson Comorbidity Index (CCI) was used to adjust for the severity of each patient's comorbidities. A binary logistic regression model was constructed to identify predictors of 30-day readmission. Cochran-Mantel-Haenszel test was used to generate a pooled odd ratio (OR) describing the likelihood of experiencing a 30dRA according to year.

Results

The 30dRA rate following sICH decreased from 13.9% in 2010 to 12.5% in 2014 (pooled OR = 0.90, 95% CI 0.87–0.94). Cerebrovascular and cardiovascular etiologies accounted for the greatest number of admissions (36.1%). Sodium abnormality, healthcare-associated infection, gastrostomy, venous thromboembolism, and ischemic stroke during the index admission were associated with 30-day readmission. Furthermore, patients who underwent ventriculostomy (OR = 1.20, 95% CI 1.03–1.38) and craniotomy (OR = 1.20, 95% CI 1.09–1.31) were more likely to be readmitted within 30 days. Hospital volume, hospital teaching status, mechanical ventilation, and tracheostomy did not affect 30dRAs. Median readmission costs increased from $9,875 in 2012 to $11,028 in 2014 (p = 0.040).

Conclusion

The overall U.S. 30dRA rate after sICH from 2010 to 2014 was 12.9% and decreased slightly during this time period, but associated costs increased. Prospective studies are required to confirm the risk factors described in this study and to identify methods for preventing readmissions.

Costs and predictors of 30-day readmissions after craniotomy for traumatic brain injury: a nationwide analysis

OBJECTIVE

There is increasing interest in the use of 30-day readmission (30dRA) as a quality metric to represent hospital and provider performance. Data regarding the incidence and risk factors for 30dRA after traumatic brain injury (TBI) are sparse. The authors sought to characterize these variables using a national database.

METHODS

The Nationwide Readmissions Database was used to identify patients with a primary diagnosis of TBI who underwent craniotomy or craniectomy between 2010 and 2014. Our primary outcome of interest was 30dRA. Binary logistic regression was used to identify variables related to patient demographics, comorbidities, and index hospital admission that were associated with 30dRA.

RESULTS

A total of 25,354 patients met the inclusion criteria. The 30dRA rate during the entire study period was 15.5%. In 2010 the 30dRA rate was 16.8% and in 2014 it decreased to 15.1% (pooled OR 0.90, 95% CI 0.87-0.94). The mean cost associated with a 30dRA increased slightly but significantly, from $9999 in 2010 to $10,114 in 2014 (p = 0.021). Factors associated with increased odds of 30dRA in the binary logistic regression included increased age, greater comorbidity burden, more severe injury, tracheostomy, gastrostomy, sodium abnormality, and venous thromboembolism. In order of decreasing frequency, the most common causes for 30dRA were neurological, injury/iatrogenic, cardiovascular/cerebrovascular, infectious, and respiratory.

CONCLUSIONS

The incidence of 30dRA after craniotomy for TBI decreased slightly from 2010 to 2014. This study identified several variables associated with 30dRA that require confirmation in a prospective study, which could direct attempts to prevent readmissions.

β-Alanine supplementation increased physical performance and improved executive function following endurance exercise in middle aged individuals

Background

Sarcopenia, a reduction in muscle mass and function seen in aging populations, may be countered by improving systemic carnosine stores via beta-Alanine (β-alanine) supplementation. Increasing systemic carnosine levels may result in enhanced anti-oxidant, neuro-protective and pH buffering capabilities. This enhancement should result in improved exercise capacity and executive function.

Methods

Twelve healthy adults (average age = 60.5 ± 8.6 yrs, weight = 81.5 ± 12.6 kg) were randomized and given either 2.4 g/d of β-alanine (BA) or Placebo (PL) for 28 days. Exercise capacity was tested via bouts on a cycle ergometer at 70% VO₂ peak. Executive function was measured by Stroop Tests 5 min before exercise (T1), immediately before exercise (T2), immediately following fatigue (T3), and 5 min after fatigue (T4). Lactate measures were taken pre/post exercise. Heart rate, Rating of Perceived Exertion (RPE) and VO₂ were recorded throughout exercise testing.

Results

PRE average time-to-exhaustion (TTE) for the PL and BA group were not significantly different (Mean ± SD; 9.4 ± 1.4mins vs 11.1 ± 2.4mins, respectively, P = 0.7). POST BA supplemented subjects cycled significantly longer than PRE (14.6 ± 3.8mins vs 11.1 ± 2.4mins, respectively, P = 0.04) while those given PL did not (8.7 ± 2.4mins vs 9.4 ± 1.4mins, respectively, P = 0.7). PL subjects were slower in completing the Stroop test POST at T4 compared to T3 (T3 = − 13.3 ± 8.6% vs T4 = 2.1 ± 8.3%, P = 0.04), while the BA group (T3 = − 9.2 ± 6.4% vs T4 = − 2.5 ± 3.5%, P = 0.5) was not. POST lactate production expressed a trend when comparing treatments, as the BA group produced 2.4 ± 2.6 mmol/L more lactate than the PL group (P = 0.06). Within group lactate production for BA (P = 0.4) and PL (P = 0.5), RPE (P = 0.9) and heart rate (P = 0.7) did not differ with supplementation.

Conclusion

BA supplementation increased exercise capacity and eliminated endurance exercise induced declines in executive function seen after recovery. Increased POST TTE coupled with similar PRE vs POST lactate production indicates an improvement in the ability of BA to extend exercise durations. Furthermore, by countering endurance exercise’s accompanying deficits in executive function, the aging population can maintain benefits from exercise with improved safety.

Food choice: a conceptual model of the process

Interviews examining the food choice process were conducted with 29 adults, primarily individuals making grocery store food choice decisions, who were sampled for their diversity. These people were asked about how they chose foods when shopping and in other settings, and what influenced their choices. Verbatim transcripts of the interviews were analysed using qualitative methods that included constant comparison, concept mapping, and case summaries, and a conceptual food choice process model was developed. Data from the interviews are presented to illustrate the structure of this conceptual model. People's life course experiences affected major influences on food choice that included ideals, personal factors, resources, social contexts and the food context. These influences informed the development of personal systems for making food choices that incorporated value negotiations and behavioral strategies. Value negotiations weighed sensory perceptions, monetary considerations, health and nutrition beliefs and concerns, convenience, social relationships and quality of food choice decisions. Strategies employed to simplify the food choice process developed over time. The conceptual food choice process model represents the rich and complex bases of food practices, and provides a theoretical framework for research and practice in nutrition.