Long-Term Impact of Implementation of a Stroke Protocol on Door-to-Needle Time in the Administration of Intravenous Tissue Plasminogen Activator.

BACKGROUND: This study aims to evaluate the effectiveness of implementing a stroke protocol (SP) in improving door-to-needle time (DTNT) and door-to-computed tomography (DTCT) time from 2010 to 2014. Published data from the Get With The Guidelines-Stroke (GWTGS) participating hospitals showed that median DTNT = 75 minutes with 26.6% of the patients achieving the recommended DTNT of 60 minutes or less. Implementation of an SP, which specifies the role of nurses, physicians, and technicians during acute stroke evaluation, can improve DTNT. METHODS: This longitudinal quality assurance study was designed to compare the DTNT and the DTCT time pre- and post implementation of an SP in our hospital. Patients' data before (2009-2010) and after (2010-2014) the implementation of an SP were collected each year during the same 6-month period and compared using statistical software SPSS 20.0 for Windows (SPSS Inc., Chicago, IL). RESULTS: Although our DTNT did not significantly improve over the years, the median DTNT (59 minutes) was much less than the reported 75 minutes of GWTGS hospitals. Our DTCT time diminished from 20.6 minutes in 2009 to 15.9 minutes in 2014. The percentage of patients with a DTNT of 1 hour or less did not differ among all years (P = .296) and was 55.8%. CONCLUSIONS: Our study suggests that our performance in evaluating acute ischemic stroke patients within the American Heart Association/American Stroke Association suggested time window is reachable for prolonged periods of time. Continuous monitoring and education of all players involved are crucial to ensure best possible outcomes in the timely administration of intravenous tissue plasminogen activator.

Isolated sciatic neuropathy as an initial manifestation of a high grade B-cell lymphoma: A case report and literature review.

Sciatic nerve neuropathy due to infiltrating of a high grade B-cell lymphoma is a very rare situation and has not often been reported. We report a case with a previous history of indolent lymphoma who presented with isolated sciatic nerve neuropathy and was found to have diffuse large B cell lymphoma involving the sciatic nerve. Although the current case is not a primary sciatic nerve lymphoma given the systematic involvement shown on MRI and PET/CT scan, the case represents a neurolymphomatosis of the sciatic nerve given the direct invasion of the lymphoma cells into the sciatic nerve. Due to the rarity of this condition, we subsequently reviewed related literatures.

Options in treating trigeminal neuralgia: Experience with 195 patients.

OBJECTIVE: For patients with medically unresponsive trigeminal neuralgia (TN), surgical options include microvascular decompression (MVD), radiofrequency rhizotomy (RF), and stereotactic radiosurgery (SRS). In an attempt to identify the risks and benefits and cost inherent with each of the three modalities, we performed a retrospective review of our experience with 195 cases of TN treated over the past 15 years. METHODS: Since 2001, 195 patients with previously untreated TN were managed: with MVD in 79, RF in 36, and SRS in 80. All patients reported herein underwent preoperative MRI. Women outnumbered men 122/73 (p=0.045). Follow-up after surgery was 32±46months. RESULTS: The patients qualifying for MVD were generally healthier and younger, with a mean age±SD of 57±14, compared to those undergoing RF (75±15) or SRS (73±13, p<0.0001). In case of relapse, medical treatment was always tried and failed prior to consideration of surgical intervention. A second surgical procedure was necessary in 2, 23, and 18 patients initially treated with MVD, RF, and SRS respectively (p<0.0001). In the patients treated with MVD, RF, and SRS, the average number of procedures per patient necessary to achieve pain control was 1.1, 2.0, and 1.3 respectively (p=0.001). There were 7 complications in the patients treated with MVD but no deaths. Numbness was present in 13, 18, and 29 patients treated with MVD, RF, and SRS respectively (p=0.008). CONCLUSION: MVD for TN is the treatment least likely to fail or require additional treatment. Patients who underwent MVD were younger than those undergoing RF or SRS. The highest rate of recurrence of TN was encountered in patients undergoing RF (64%). Facial numbness was least likely to occur with MVD (16%) compared to RF and SRS (50% and 36% respectively).

Risk factors and outcomes in thoracic stenosis with myelopathy: A single center experience.

OBJECTIVE: Identify risk factors predisposing to thoracic spinal stenosis and myelopathy (TS) and address treatment options and outcomes. METHODS: A retrospective review of our center's experience with TS over 10 years. Clinical and magnetic resonance imaging (MRI) data, surgical intervention and outcomes using Frankel and Japanese Orthopedic Association (JOA) scales were collected. RESULTS: A total of 44 patients with TS were identified. There were 30 men and 14 women with a mean age±SD of 66±15years. Neurological performance was evaluated using the Frankel scale (A-E or 1-5), and JOA scale for myelopathy (0-11). Frankel scores (1-5) and JOA scores (0-11) on admission were 3.5±0.9 and 6.8±2.6 respectively. At follow-up, Frankel scores had improved to 4.1±0.8 (p=0.041) and JOA scores had improved to 8.3±2.4 (p=0.021). The presence on admission of increased signal from the cord on T2-weighted MRI was associated with lower Frankel and JOA scores (3.3±0.9, and 6.2±2.5 respectively) than in those with absent increased signal (4.0±0.4 and 8.6±2.1, p=0.02 and p=0.008 respectively). There were 4 complications, requiring exploration and debridement for dehiscence in 3 and an epidural hematoma in the fourth that necessitated evacuation, with a good outcome. A fifth patient underwent reoperation at the same level 18 months later for persistent stenosis. CONCLUSION: Thoracic stenosis with myelopathy should be entertained in patients with myelopathy. Over half of our patients with TS were over the age of 70, and men outnumbered women by a ratio of 2:1. Nearly half the patients with TS had concomitant cervical and/or lumbar degenerative disease warranting surgery also. Increased signal intensity on T2-weighted MRI images correlated with lower Frankel and JOA scores compared to those without. Decompression for thoracic stenosis is associated with neurological improvement.

Drug eluting stents versus bare metal stents for the treatment of extracranial vertebral artery disease: a meta-analysis.

BACKGROUND: While a growing number of reports offer evidence for the potential of drug eluting stents (DES) in treating atherosclerotic stenosis of the extracranial vertebral artery, their efficacy when compared with bare metal stents (BMS) is uncertain due to the lack of a large prospective randomized trial. METHODS: A search strategy using the terms 'stents', 'drug-eluting stents', 'atherosclerosis', 'vertebral artery', and 'vertebrobasilar insufficiency' was employed through Medline. Five studies met the criteria for a comparative meta-analysis. The technical/clinical success, periprocedural complications, target vessel revascularization (TVR), rates of restenosis, recurrent symptoms, and overall survival were compared. RESULTS: There was no significant difference in the technical success (OR=1.528, p=0.622), clinical success (OR=1.917, p=0.274), and periprocedural complications (OR=0.741, p=0.614) between the two groups. An OR of 0.388 for no restenosis in the BMS to DES arms (p=0.001) indicated a significantly higher restenosis rate in the BMS group relative to the DES group (33.57% vs 15.49%). When compared with the DES group, the BMS group had a significantly higher rate of recurrent symptoms (2.76% vs 11.26%; OR=3.319, p=0.011) and TVR (4.83% vs 19.21%; OR=4.099, p=0.001). CONCLUSIONS: A significantly lower rate of restenosis, recurrent symptoms, and TVR was noted in the DES group compared with the BMS group.

Nonoperative Management in Neurologically Intact Thoracolumbar Burst Fractures: Clinical and Radiographic Outcomes.

STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The identification of factors that lead to the failure of nonoperative management in neurologically intact thoracolumbar burst fractures. SUMMARY OF BACKGROUND DATA: The treatment of thoracolumbar burst fractures (TLBF) can be controversial, particularly in the neurologically intact. Surgery for intact burst fractures has been advocated for early mobilization and a shorter hospital stay. These goals, however, have not always been achieved, rejuvenating an interest in nonoperative treatment. METHODS: Sixty-eight neurologically intact patients with burst fractures of the thoracolumbar junction (T11-L2), and a thoracolumbar injury classification and severity score (TLICS) of 2, were treated at our institution. Based on CT scans, patients were scored based on the load-sharing classification (LSC) scale. Initial treatment consisted of bracing in clamshell thoracolumbar orthosis and gradual mobilization. RESULTS: Owing to pain limiting mobilization, 18 patients failed nonoperative management and required instrumentation. Those who failed nonsurgical management were significantly more kyphotic (8° ± 10) and stenotic (52% ± 14%) than those successfully treated nonoperatively (3° ± 7 and 63 ± 12%, respectively). The LSC score of those undergoing surgery (6.9 ± 1.1) was also greater than those successfully treated nonoperatively (5.8 ± 1.3, P = 0.006). Length of hospitalization was longer, and hospital charges higher in those requiring surgery compared to the nonoperative group. At follow-up there was no difference between groups in the visual analog score for pain (VAS) or the Oswestry disability index. CONCLUSION: Owing to pain limiting mobilization, a quarter of neurologically intact patients with thoracolumbar burst fractures and a TLICS score of 2 failed nonsurgical management. The greater the kyphosis, stenosis, and fragmentation of the fracture, the more likely patients required surgery. In addition to the TLICS classification, other radiographic and clinical parameters should be included in selecting appropriate treatment strategy. The cost savings with nonoperative treatment of intact burst fractures, when appropriate, are significant.

Microvascular decompression and MRI findings in trigeminal neuralgia and hemifacial spasm. A single center experience.

OBJECTIVE: For patients with medically unresponsive trigeminal neuralgia (TIC) and hemifacial spasm (HS), surgical microvascular decompression (MVD) is the procedure of choice. The authors of this report sought to review their outcomes with MVD in patients with TIC and HS, and the success of preoperative magnetic resonance imaging (MRI) in identifying the offending vascular compression. METHODS: Since 2004, there were a total of 51 patients with TIC and 12 with HS with available MRI scans. All patients underwent preoperative MRI to rule out non-surgical etiologies for facial pain and facial spasm, and confirm vascular compression. Follow-up after surgery was 13 ± 22 months for the patients with TIC and 33 ± 27 months for the patients with HS. RESULTS: There were 45 responders to MVD in the TIC cohort (88%), with a Visual Analog Score (VAS) of 1 ± 3. All patients with HS responded to MVD between 25 and 100%, with a mean of 75 ± 22%. Wound complications occurred in 10% of patients with MVD for TIC, and 1 patient reported hearing loss after MVD for HS, documented by audiogram. The congruence rate between the preoperative MRI and operative findings of vascular compression was 84% in TIC and 75% in HS. CONCLUSION: MVD is an effective and safe modality of treatment for TIC and HS. In addition to ruling out structural lesions, MRI can offer additional information by highlighting vascular loops associated with compressions. On conventional scans as obtained here, the resolution of MRI was congruent with operative findings in 84% in TIC and 75% in HS. This review emphasizes that the decision to undertake MVD in TIC or HS should be based on clinical diagnosis and not visualization of a compressing vessel by MRI. Conversely, the presence of a compressing vessel by MRI demands perseverance by the surgeon until the nerve is decompressed.

The cost-effectiveness of surgery for trigeminal neuralgia in surgically naïve patients: a retrospective study.

OBJECTIVE: For 75% of patients with trigeminal neuralgia (TN), the pain can be controlled with medication. For those who fail medication therapy, surgical options include microvascular decompression (MVD), percutaneous radiofrequency rhizotomy (RFR), and stereotactic radiosurgery (SRS). Few studies have explored the relative cost-effectiveness of these interventions, particularly in surgically naïve patients. METHODS: A retrospective chart review performed between January 2003 and January 2013 identified a total of 89 patients who underwent surgical treatment for TN (MVD=27, RFR=23, SRS=39). Outcome measures included facial pain (excellent=no pain, no medications; good=no pain, medications required; fair=>50% decrease in pain; and poor=<50% decrease in pain/secondary surgery), numbness, cost, and the need for a subsequent procedure. RESULTS: The average age of patients for each procedure was MVD=53.9±16, RFR=76.2±16, and SRS=74.5±12 (p<0.001 MVD vs. other modalities). Total charges for the procedures (US dollars) were MVD=50,100±9600, RFR=4700±2200, and SRS=39,300±6000 (p<0.001). Actual collections varied by insurance. Percentages of postoperative facial numbness were MVD=11%, RFR=52%, and SRS=28% (p<0.01). At two years, the rates of recurrence requiring a second procedure were MVD=22%, RFR=74%, and SRS=31% (p<0.01). Average times to secondary procedure in months were MVD=26±29, RFR=59±76, and SRS=35±25. Mean quality adjusted pain-free years were MVD=1.58, RFR=2.28, and SRS=0.99. Cost-effectiveness calculations in US dollars showed MVD=31,800, RFR=2100, and SRS=39,600 (p<0.001). CONCLUSION: There are significant cost differences among the three most common surgical procedures for TN. MVD was the most expensive procedure, was more likely to be performed on younger patients, had the lowest rate of facial numbness, and had the lowest rate of recurrence requiring a secondary procedure. SRS was slightly less costly, more likely to be performed on an older population, and had a rate of recurrence similar to MVD. RFR was the least expensive procedure, provided immediate relief, but was associated with the highest rates of facial numbness and recurrence. Based on cost-effectiveness, considering both cost and outcome, RFR was the most cost-effective, followed by MVD, and finally SRS.

Metastatic involvement of the pituitary gland: a systematic review with pooled individual patient data analysis.

PURPOSE: To report a rare case of pituitary metastasis (PM) from hepatocellular carcinoma (HCC) and help better understand the incidence of PM and its most common presenting symptoms through a pooled individual patient data analysis. METHODS: Literature regarding PM was systematically reviewed with a pooled individual patient data analysis conducted. Pooled individual data analysis result is also compared with the result in a most recent systematic review. RESULTS: Our results demonstrate that the incidence of PM among all intracranial metastases is 0.87% (95% CI 0.56, 1.18); it is 1.9% (95% CI 1.46, 2.34) among all autopsied cancer cases; it is 11.56% (95% CI 7.08, 16.04) among all breast cancer patients who had hypophysectomies and 12.83% (95% CI 10.5, 15.16) among all autopsied breast cancer patients. The fixed effect model showed that the incidence of PM in breast cancer patients group is significantly higher (p < 0.001) with an odds ratio of 6.71 (95% CI 4.24, 10.61). Breast and lung cancer are the most common primary cancer of PM with a percentage of 37.2 and 24.2 respectively. The next most common primary sites are prostate and kidney respectively, although the percentages for each are only about 5. Diabetes insipidus (DI) remains the most common symptom among all reported PM cases with a pooled incidence of 42.34% (95% CI 36.15, 48.53). Although not significant (χ(2) = 2.846, df = 1, p = 0.061), it is less common in the most recent reported cases which has a pooled incidence of 32.76% (95% CI 20.31, 45.21). DI is extremely rare in the reported PM cases from HCC (none of the eight cases presented with DI). The symptoms of anterior hypopituitarism (23.68 vs 39.66%, p = 0.015), visual deterioration (27.89 vs 41.38%, p = 0.039), cranial nerve palsies (21.58 vs 41.38%, p = 0.003) and headaches (15.79 vs 32.76%, p = 0.005) were reported significantly higher than previously described in the literature. CONCLUSIONS: Pituitary metastasis is rare in patients with cancer, and the pituitary gland is an uncommonly involved location in patients with intracranial metastases. With advanced diagnostic imaging techniques and increased awareness about the manifestation of sellar lesions, the incidence of cranial nerve palsies and anterior pituitarism are higher than reported. This information may allow earlier diagnosis of PM.

Risk factors for supplementary posterior instrumentation after anterolateral decompression and instrumentation in thoracolumbar burst fractures.

BACKGROUND: In spite of the established benefits of anterolateral decompression and instrumentation (ALDI) for thoracolumbar burst fractures (TLBF), the indications for supplementary posterior instrumentation remain unclear. METHODS: A retrospective review of clinical and radiographic data of a prospective cohort of 73 patients who underwent ALDI for TLBF from T12 to L4. RESULTS: The mean age of the cohort was 42 ± 15 years, with 49 males and 24 females. Forty-six patients had neurological deficit, and 27 were intact. Owing to symptomatic settling, supplemental posterior instrumentation was performed in 7 out of 73 patients. The age of patients requiring supplemental posterior instrumentation (59 ± 14 years) exceeded that of patients who did not (41 ± 16, p=0.004). Otherwise, the patients who required posterior instrumentation were comparable to those treated with ALDI in terms of body mass index (BMI), American Spinal Injury Association (ASIA) scores on admission and follow-up, residual spinal canal, and local kyphosis on admission and follow-up. The posterior ligamentous complex (PLC) integrity was assessed in 38 patients in whom the MRI scans were retrievable, 31 successfully treated with ALDI, and all 7 undergoing supplementary posterior instrumentation. Subgroup analysis demonstrated that there was no difference in the incidence of PLC disruption between the 2 groups (p=0.257). CONCLUSIONS: Secondary supplemental posterior instrumentation was deemed necessary in 10% of cases following ALDI. Age was the only significant risk factor predicating supplemental posterior instrumentation.

Comparison of neurological healthcare oriented educational resources for patients on the internet.

The internet has become a major contributor to health literacy promotion. The average American reads at 7th-8th grade level and it is recommended to write patient education materials at or below 6th grade reading level. We tried to assess the level of literacy required to read and understand online patient education materials (OPEM) for neurological diseases from various internet resources. We then compared those to an assumed reference OPEM source, namely the patient education brochures from the American Academy of Neurology (AAN), the world's largest professional association of neurologists. Disease specific patient education brochures were downloaded from the AAN website. OPEM for these diseases were also accessed from other common online sources determined using a predefined criterion. All OPEM were converted to Microsoft Word (Microsoft Corp., Redmond, WA, USA) and their reading level was analyzed using Readability Studio Professional Edition version 2012.1 (Oleander Software, Vandalia, OH, USA). Descriptive analysis and analysis of variance were used to compare reading levels of OPEM from different resources. Medline Plus, Mayo clinic and Wikipedia qualified for OPEM analysis. All OPEM from these resources, including the AAN, were written above the recommended 6th grade reading level. They were also found to be "fairly difficult", "difficult" or "confusing" on the Flesch Reading Ease scale. AAN OPEM on average needed lower reading level, with Wikipedia OPEM being significantly (p<0.01) more difficult to read compared to the other three resources. OPEM on neurological diseases are being written at a level of reading complexity higher than the average American and the recommended reading levels. This may be undermining the utility of these resources.

Post-traumatic syringomyelia: outcome predictors.

OBJECTIVE: To identify risk factors that predispose to post-traumatic syringomyelia (PTS) and describe the outcome of surgical management. METHODS: Retrospective cohort study of 27 patients with post-traumatic syringomyelia. Spinal cord injury of these patients spanned the period from 1963 to 2008. All data were collected retrospectively using available medical records and radiological images. RESULTS: There were 24 males and 3 females. The level of initial spine injury was thoracic in 21, cervical in 4, and lumbar in 2. The average age (±SD) at diagnosis of PTS was 40±13 years. The mean follow-up ±SD from injury was 18±11 years. On admission after injury, there were 14 patients with American Spinal Injuries Association (ASIA) disability scores of A, 3 with ASIA C, and 10 with ASIA score of D. At the time of diagnosis of PTS, local kyphosis at the site of injury measured 28±12°, and the residual canal was 67±19% compared to the average rostral and caudal anteroposterior diameter. Fourteen patients underwent a single operation for PTS, and 13 needed two or more procedures. In the 11 patients in whom the initial surgery included a duraplasty, 3 required reoperation for unsuccessful reduction in the size of the syrinx and failure to improve symptoms. In the 16 patients in whom the initial procedure was that of a shunt alone, 10 required revision (p=0.0718 rate of revision between shunting and duraplasty). As a result of treatment for PTS, improvement in symptoms of PTS occurred in 14, symptoms were unchanged in 10, and progressed in 3. In the 11 patients with sequential MRI scans, a significant correlation was shown between the reduction in the size of the syrinx and clinical improvement (p<0.001). CONCLUSION: PTS is often the result of severe spinal cord injuries, with over half of patients having an ASIA disability score of A. Our review corroborates other published reports showing that PTS is associated with significant deformity and stenosis. Irrespective of treatment, over half of the patients required reoperation for their PTS. Duraplasty and arachnolysis are the preferred treatment for PTS over shunting alone. Treatment was associated with cessation of symptoms or improvement in nearly 90% of the patients.

Predictors of outcome in the non-operative management of thoracolumbar and lumbar burst fractures.

AIM: Burst fractures without neurological deficit are often treated successfully without surgery. A subgroup may fail non-operative treatment owing to pain, and opt for surgery. The following review was conducted to identify predictors of success or failure in the non-operative treatment of thoracolumbar burst fractures. METHODS: A cohort of 60 patients with T11-L4 thoracolumbar burst fractures were treated non-operatively, with bed rest and bracing until the pain abated sufficiently to allow mobilization. Patients were followed prospectively for a mean ± SD of 12 ± 14 months, and their data were reviewed retrospectively. RESULTS: Fifty-one patients successfully completed non-operative treatment. Owing to intractable pain in nine, surgery was undertaken. Ages in the non-operative and operative groups were 46 ± 18 and 68 ± 15 years respectively (p = 0.002). The residual canal and angulation at the site of the fracture were 63 ± 12% and 1.6 ± 8.4° in the non-operative group and 47 ± 15% and 6.6 ± 13.6° in the surgical group (p = 0.001 and 0.149 between groups, respectively). Regression analysis of age, gender, angulation, and residual canal showed that only age (OR, 1.099; 95% CI, 1.022-1.183; p = 0.011) and residual canal (OR, 0.795; 95% CI, 0.642-0.985; p = 0.035) were significant predictors of failure, ultimately undergoing surgery. CONCLUSION: Non-surgical treatment was more likely to prove sufficient in patients aged 46 ± 18 years, and residual canal of 63 ± 12%, than in older patients with ages of 68 ± 15, and canal of 47 ± 15%. The latter group was more likely to fail, undergoing surgery because of pain or instability.

Pre- and perinatal risk factors for autism spectrum disorder in a New Jersey cohort.

This study evaluated the prevalence of pre- and perinatal risk factors in a cohort of children with autism spectrum disorders compared with the New Jersey population. Our cohort included 268 individuals with an autism spectrum disorder. Birth histories were obtained by a self-administered questionnaire. The autism spectrum disorders cohort rates of 7 perinatal risk factors were significantly higher than New Jersey state rates: mother's age 35 years or older, low birth weight, multiple gestation, prematurity, vaginal bleeding, prolonged labor, and hypoxia. Analysis of clustering of risk factors in the cohort showed no significant differences across maternal and paternal age groups. Older mothers in the cohort had a higher risk of infant hypoxia. Multiple risk factors during pregnancy appear to be associated with a higher risk of autism spectrum disorders in offspring, supporting the hypothesis that environmental influences in conjunction with genetics contribute to the causes of autism spectrum disorders.

Endovascular treatment for acute ischemic stroke in octogenarians compared with younger patients: a meta-analysis.

BACKGROUND: Little is known about the safety and efficacy of endovascular therapy for acute ischemic stroke in octogenarians. AIM: We performed a systematic review and meta-analysis of published studies comparing outcomes of octogenarians and younger patients after endovascular treatment for acute ischemic stroke. METHODS: A computerized search of the medical literature from 1990 to 2012 was performed to identify comparative studies of endovascular treatment of ischemic stroke patients 80 years or older and younger patients. Data on clinical outcomes, mortality, symptomatic intracerebral hemorrhage, and recanalization were abstracted. RESULTS: Data from eight studies with 2729 patients were included in the final analysis. Good functional outcome defined as modified Rankin score 2 or less within 90 days was more common in younger patients compared with octogenarians [odds ratio 2.694; 95% confidence interval 1.941-3.740, P < 0.001). Symptomatic hemorrhage and death were significantly more come in patients 80 years or older (odds ratio 1.604; 95% confidence interval 1.013-2.540, P = 0.04 and odds ratio 3.695; 95% confidence interval 2.517-5.424, P < 0.001, respectively). Successful recanalization defined as Thrombolysis in Myocardial Infarction (TIMI) 2-3 was seen less frequently in older patients; however, this did not reach statistical significance (odds ratio 0.814; 95% confidence interval 0.522-1.269, P = 0.364). CONCLUSION: Formal meta-analysis showed that octogenarians are less likely to achieve functional independence and have higher rates of mortality and intracerebral hemorrhage following endovascular treatment for ischemic stroke compared with younger patients. Decisions regarding endovascular treatment of elderly patients should be individualized until randomized controlled trials are available.

Alternative grafts in anterior cervical fusion.

OBJECTIVE: The present retrospective study was conducted to compare the clinical and radiographic outcomes in patients undergoing anterior cervical discectomy with fusion (ACDF) using carbon fiber reinforced polymer (CFRP) cages, or allograft. METHODS: We retrospectively reviewed cases of ACDF using allograft in 20 patients, and CFRP in 19 who had sequential radiographs before and after surgery, and at 1 year. RESULTS: There were no apparent significant differences between the 2 groups in age (p=0.057), gender (p=0.635), or complications (p=0.648). At 12 months, there were no cases of construct failure, and fusion appeared to have been achieved in patients of both groups. Lordosis was increased significantly in both groups after surgery (p<0.001 in allograft and p=0.025 in CFRP), and was maintained up until 1 year (p<0.018 in allograft and p=0.05 in CFRP) without a difference between groups (p=0.721). Anterior interbody height was significantly increased (p<0.001 in both groups at each time points) after surgery, without a significant difference between groups (p>0.21). This increase in height was greatest in magnitude immediately after surgery, and declined with the passage of time. There was no detectable health-related quality of life difference between allograft and CFRP group after surgery (p>0.05). CONCLUSION: The present study demonstrates that CFRP cages appear to have comparable fusion rates, restoration of lordosis and disc space height, and complication rates to patients who undergo ACDF with allograft.

Computed tomographic angiography versus digital subtraction angiography for the postoperative detection of residual aneurysms: a single-institution series and meta-analysis.

BACKGROUND: Computed tomographic angiography (CTA) has recently emerged as a non-invasive alternative to digital subtraction angiography (DSA) for the detection of residual cerebral aneurysms (RA). OBJECTIVE: To compare the diagnostic accuracy of CTA with the current 'gold standard', DSA, in the postoperative detection of RA. METHODS: Patient data from this single institution were prospectively gathered, and imaging results retrospectively blinded and analyzed. Between 2001 and 2005 eligible patients received microsurgical repair of cerebral aneurysms and were evaluated postoperatively by DSA and CTA. These single-institutional data were compiled with qualified studies published from 1997 to 2009, and a meta-analysis was performed. RESULTS: This institutional series reports sensitivity, specificity, positive (PPV) and negative predictive values (NPV) of 100%. Eleven studies met the inclusion criteria for the meta-analysis. A total of 427 patients with 513 aneurysms were included, with 61 RA detected by DSA and 40 detected by CTA. Unweighted analysis resulted in pooled sensitivity of 73.8%, specificity of 96.3%, PPV of 91.0% and NPV of 86.1%. Stratified analysis of studies using 16-slice CTA versus 2D DSA reported pooled sensitivity of 92.6%, specificity of 99.3%, PPV of 95.8%, and NPV of 97.8%. CONCLUSIONS: This meta-analysis supports CTA as an acceptable modality for postoperative detection of RA, although DSA remains the gold standard. By implementing multidetector CTA technology in experienced centers, the sensitivity and specificity of CTA may approach that of traditional DSA for detecting RA. As a cost-effective, non-invasive modality, CTA is a promising alternative to DSA for initial and long-term evaluation of RA.

True aneurysms of the posterior communicating artery: a systematic review and meta-analysis of individual patient data.

OBJECTIVE: To review and analyze systematically the reported cases of "true" posterior communicating artery (PCoA) aneurysm. METHODS: A retrospective review of the published literature was performed, and a meta-analysis of individual patient data was conducted. RESULTS: Pooled data showed that "true" PCoA aneurysms represent about 1.3% (95% confidence interval [CI] 0.8%, 1.7%) of all intracranial aneurysms and 6.8% (95% CI 4.3%, 9.2%) of all PCoA aneurysms. Mean patient age was 53.5 years (53.5 years ± 15.4), and age range was 23-79 years. Of the 49 patients reported in the literature, 44 (89.8%) were reported as ruptured, and 4 (10.2%) were reported as unruptured. There were no significant differences in ruptured status between age (P = 0.321), left vs right aneurysm (P = 0.537), and shape of aneurysm (P = 0.408). No significant differences in complication rates were found between rupture status (P = 0.27), and operative modalities (P = 0.878). The mean ages of patients who had no complications and patients who had complications were 53 years (53 years ± 2.59) vs 53.2 years (53.2 years ± 5.02) (P = 0.972). CONCLUSIONS: "True" PCoA aneurysms represent about 1.3% of all intracranial aneurysms and 6.8% of all PCoA aneurysms. They are more prone to rupture compared with their counterpart junctional aneurysms. When surgical management is indicated, a good understanding of the location and configuration of the aneurysm neck before surgical treatment is critical in the successful treatment of these lesions.

Three dimensional CT angiography versus digital subtraction angiography in the detection of intracranial aneurysms in subarachnoid hemorrhage.

INTRODUCTION: Ruptured intracranial aneurysms are responsible for over 90% of cases of spontaneous subarachnoid hemorrhage (SAH). Conventional digital subtraction angiography (DSA) remains the gold standard for diagnosing the source of SAH. A prospective study is presented wherein SAH patients underwent three dimensional CT angiography (CTA) prior to DSA in order to assess the specificity and sensitivity of this non-invasive modality to detect aneurysms. METHODS: 179 consecutive patients with spontaneous SAH presented over 36 months, as identified by screening CT and CTA. Patients with negative CTA findings underwent DSA within 24 h of presentation. All patients who were determined to have angiographically negative SAH underwent follow-up DSA 2 weeks later. RESULTS: Of the 179 patients screened by CTA, 13 (7%) were negative for aneurysms or other vascular lesions (arteriovenous malformation or dural fistula) on CTA and underwent DSA. No new lesions were identified on six vessel angiography, resulting in a 0% false negative rate (sensitivity 100%, predictive value 100%). MRI to rule out thrombosed aneurysms and repeat angiography at the 2 week follow-up were negative. CONCLUSIONS: Sensitivity and specificity were higher than previously reported, suggesting that CTA may be used as an initial screening tool in lieu of DSA. Further studies are necessary to determine if CTA can supplant DSA in ruling out all forms of vascular disease in idiopathic SAH.

True posterior communicating artery aneurysms: are they more prone to rupture? A biomorphometric analysis.

OBJECT: Posterior communicating artery (PCoA) aneurysms can occur at the junction with the internal carotid artery, posterior cerebral artery (PCA), or the proximal PCoA itself. Hemodynamic stressors contribute to aneurysm formation and may be associated with parent vessel size and aneurysm location. This study evaluates the correlation of various biomorphometric characteristics in 2 of the aforementioned types of PCoA aneurysms. METHODS: Patients with PCoA aneurysms were analyzed using CT angiography. Source images and reconstructions were used to determine which aneurysms originated purely from the PCoA and those that originated from the internal carotid artery/PCoA junction. Morphometric analysis was performed on the aneurysm, the precommunicating segment of the PCA (P(1)), the ambient segment of the PCA (P(2)), and both PCoA arteries and were correlated to clinical presentation. Parametric and nonparametric analyses were performed to test for significance. RESULTS: A total of 77 PCoA aneurysms were analyzed, and 10 were found to be true PCoA aneurysms (13.0%). The ipsilateral PCoA/P(1) ratio (1.77 +/- 0.44 vs 0.82 +/- 0.46, p = 0.0001) and ipsilateral P(2)/P(1) ratio (1.73 +/- 0.40 vs 1.22 +/- 0.41, p = 0.0003) were significantly larger in true PCoA aneurysms. Interestingly, aneurysm size was statistically larger in the junctional aneurysms (0.14 +/- 0.1 vs 0.072 +/- 0.04 cm(3), p = 0.03). The prevalence of ruptured aneurysms was similar in both groups (approximately 80%, p value not significant). CONCLUSIONS: These data suggest that true PCoA aneurysms have a larger PCoA relative to the ipsilateral P(1) segment. To the authors' knowledge, this represents the first such biomorphometric comparison of these different types of PCoA aneurysms. Although statistically smaller in size, true PCoA aneurysms also have a similar prevalence of presenting as a ruptured aneurysm, suggesting that they might be more prone to rupture than a junctional aneurysms of similar size. Further analysis will be required to determine the biophysical factors affecting rupture rates.