Preoperative prescription opioid use as an independent predictor of 90-day mortality and adverse events in craniotomy and craniectomy patients.

OBJECTIVE: A growing body of literature suggests that preoperative opioid exposure is an independent predictor of poor outcomes in surgical patients. No outcomes data exist on preoperative opioid use and craniotomies/craniectomies. The objective of this study was to determine the impact of preoperative opioid use on 90-day adverse events after craniotomy or craniectomy. METHODS: A single-center retrospective cohort study of 2445 patients undergoing a craniotomy/craniectomy between January 1, 2013, and October 1, 2018, was conducted. Baseline demographics, pre- and postoperative opioid use (morphine milligram equivalents [MMEs]), and surgical metrics were recorded. Patients were categorized based on whether they took prescription opioids preoperatively, defined as within 1 month of surgery, or were opioid naive. The outcomes were mortality and adverse events 90 days after craniotomy/craniectomy. RESULTS: Overall, 26.6% of patients composed the preoperative opioid group. The median daily MME intake among this group was 34.6 (IQR 14.1-90) MMEs. Lower employment rates (p < 0.001), uninsured status (p = 0.016), and intravenous drug use (p = 0.006) were associated with preoperative opioid use. Preoperative opioid use was associated with increased venous thromboembolism (p = 0.001), acute kidney injury (p = 0.002), acute respiratory failure (p < 0.001), myocardial infarction (p = 0.002), delirium (p < 0.001), and infection (p < 0.001). Preoperative opioid use was an independent predictor of overall 90-day adverse events (OR 1.643, 95% CI 1.289-2.095; p < 0.001) and 90-day mortality (OR 1.690, 95% CI 1.254-2.277; p < 0.001). CONCLUSIONS: Preoperative opioid use was independently associated with 90-day postoperative adverse events and mortality. Opioid use increases vulnerability in craniotomy/craniectomy patients and necessitates close monitoring to improve outcomes.

Adjuvant convection-enhanced delivery for the treatment of brain tumors.

BACKGROUND: Malignant gliomas are a therapeutic challenge and remain nearly uniformly fatal. While new targeted chemotherapeutic agentsagainst malignant glioma have been developed in vitro, these putative therapeutics have not been translated into successful clinical treatments. The lack of clinical effectiveness can be the result of ineffective biologic strategies, heterogeneous tumor targets and/or the result of poortherapeutic distribution to malignant glioma cells using conventional nervous system delivery modalities (intravascular, cerebrospinal fluid and/orpolymer implantation), and/or ineffective biologic strategies. METHODS: The authors performed a review of the literature for the terms "convection enhanced delivery", "glioblastoma", and "glioma". Selectclinical trials were summarized based on their various biological mechanisms and technological innovation, focusing on more recently publisheddata when possible. RESULTS: We describe the properties, features and landmark clinical trials associated with convection-enhanced delivery for malignant gliomas.We also discuss future trends that will be vital to CED innovation and improvement. CONCLUSION: Efficacy of CED for malignant glioma to date has been mixed, but improvements in technology and therapeutic agents arepromising.

Resection of intradural intramedullary subependymoma of the cervicothoracic spine: 2-dimensional operative video.

This video presents the case of a 44-year-old male with a 2-year history of pain in the left upper extremity that had worsened over the course of the last 6 months with associated weakened grip strength and had extended into his right arm. T2-weighted sagittal and axial MRI demonstrated an expansive nonenhancing solid intramedullary lesion extending from C5 to T1. The patient underwent a C5-T1 laminectomy and laminoplasty with near-complete resection of the intradural intramedullary subependymoma. At 3 months' follow-up, he reported doing well and had experienced significant improvement in motor strength with ongoing therapies.

Intraoperative Predictor of Remission in Cushing Disease.

BACKGROUND: Cushing disease represents a challenge for neurosurgeons, with high recurrence rates reported. Characteristics associated with remission are incompletely understood; thus, an intraoperative predictor for outcome would be valuable for assessing resection of adrenocorticotropic hormone (ACTH) secreting tissue. OBJECTIVE: To evaluate whether intraoperative ACTH measurement could predict outcome after surgery for Cushing disease. METHODS: Retrospective cohort study of 55 consecutive encounters with Cushing disease who had peripheral plasma ACTH levels measured intraoperatively before, during, and after tumor resection. The primary outcome measure was remission, defined by either 2 negative 24-hour urine free cortisol or 2 negative midnight salivary cortisol measurements. A logistic regression machine learning model was generated using recursive feature elimination. RESULTS: Fifty-five operative encounters, comprising 49 unique patients, had a mean follow-up of 2.73 years (±2.11 years) and a median follow-up of 2.07 years. Remission was achieved in 69.1% (n = 38) of all operations and in 78.0% (n = 32) of those without cavernous sinus invasion. The final ACTH level measured intraoperatively correctly predicted outcome (area under the curve = 0.766; P value = .002). The odds ratio of remission in patients with the lowest quartile vs highest quartile final intraoperative ACTH was 23.4 ( P value = .002). Logistic regression machine learning model resulted in incorporating postoperative day 1 morning cortisol, final intraoperative ACTH that predicted outcome with an average area under the curve of 0.80 ( P = .0027). CONCLUSION: Intraoperative ACTH may predict outcome after surgery in Cushing disease; furthermore, investigation is warranted.

Pituitary Stalk Stretch Predicts Postoperative Diabetes Insipidus After Pituitary Macroadenoma Transsphenoidal Resection.

BACKGROUND: Manipulation of the pituitary stalk, posterior pituitary gland, and hypothalamus during transsphenoidal pituitary adenoma resection can cause disruption of water electrolyte regulation leading to diabetes insipidus (DI). OBJECTIVE: To determine whether pituitary stalk stretch is an independent risk factor for postoperative DI after pituitary adenoma resection. METHODS: A retrospective review was performed of patients undergoing endoscopic endonasal resection of pituitary macroadenoma between July 2010 and December 2016 by a single neurosurgeon. We analyzed preoperative and postoperative imaging metrics to assess predictors for postoperative DI. RESULTS: Of the 234 patients undergoing resection, 41 (17.5%) developed postoperative DI. DI was permanent in 10 (4.3%) and transient in 31 (13.2%). The pituitary stalk stretch, measured as the change in stalk length from preoperative to postoperative imaging, was greater in the DI compared with the non-DI group (10.1 mm vs 5.9 mm, P < .0001). The pituitary stalk stretch was associated with DI with significant difference in mean pituitary stalk stretch between non-DI group vs DI group (5.9 mm vs 10.1 mm, P < .0001). Multivariate analysis revealed that pituitary stalk stretch >10 mm was a significant independent predictor of postoperative DI [odds ratios = 2.56 (1.10-5.96), P = .029]. When stratified into transient and permanent DI, multivariable analysis showed that pituitary stalk stretch >10 mm was a significant independent predictor of transient DI [odds ratios = 2.71 (1.0-7.1), P = .046] but not permanent DI. CONCLUSION: Postoperative pituitary stalk stretch after transsphenoidal pituitary adenoma surgery is an important factor for postoperative DI. We propose a reconstruction strategy to mitigate stalk stretch.

Intraoperative Prediction of Long-Term Remission in Acromegaly.

BACKGROUND: The features of long-term remission in acromegaly adenomectomy are incompletely understood. An intraoperative predictor for long-term outcome would be valuable for assessing resection of growth hormone (GH)-secreting tumors in real-time. OBJECTIVE: To evaluate whether intraoperative GH measurement could predict long-term outcomes for acromegaly. METHODS: In 47 patients, peripheral blood GH levels were measured thrice intraoperatively: once before tumor dissection, once during tumor dissection, and once after tumor dissection. Long-term remission was defined by age-appropriate, normalized insulin-like growth factor-1 at most recent follow-up and a random GH less than 1.0 ng/mL. Patients were only considered to be in long-term remission without the use of postoperative medical therapy for acromegaly or radiation therapy. RESULTS: The median length of follow-up was 4.51 (range: 0.78-9.80) years. Long-term remission was achieved in 61.7% (29/47) of operations. Like previous studies, cavernous sinus invasion (odds ratio [OR]: 0.060; 95% CI: 0.014-0.260; P value < .01), suprasellar extension (OR: 0.191; 95% CI: 0.053-0.681; P value<.01), and tumor size greater than 1 cm (OR: 0.177; 95% CI: 0.003-0.917; P value = .03) were associated with not being in long-term remission. The minimum GH measured intraoperatively predicted long-term outcome (area under the curve: 0.7107; 95% CI: 0.537-0.884; P value < .01). The odds ratio of remission in patients with the lowest quartile minimum intraoperative GH compared with patients with the highest quartile minimum intraoperative GH was 27.0 (95% CI: 2.343-311.171; P value < .01). CONCLUSION: Minimum intraoperative GH may predict long-term outcome for acromegaly, which in principle could provide the pituitary neurosurgeon with real-time feedback and inform intraoperative decision making.

Supraprophylactic Anti-Factor Xa Levels Are Associated with Major Bleeding in Neurosurgery Patients Receiving Prophylactic Enoxaparin.

BACKGROUND: Prior studies demonstrated reduced risk for venous thromboembolism (VTE) in neurosurgical patients secondary to prophylaxis with both heparin and low-molecular-weight heparin. The ability to monitor low-molecular-weight heparin by obtaining anti-factor Xa (anti-Xa) serum levels provides an opportunity to evaluate safety and efficacy. The aim of this study was to describe characteristics of patients who have anti-Xa levels outside of the goal range (0.2-0.4/0.5 IU/mL) and investigate incidence of major bleeding and VTE. METHODS: A single-center, retrospective, observational study was conducted on neurosurgical patients receiving enoxaparin for VTE prophylaxis between August 2019 and December 2020. Significance testing was conducted via Fisher exact test and independent samples t test. RESULTS: The study included 85 patients. Patients were less likely to have an anti-Xa level in the goal range if they were male, had a higher weight, or were morbidly obese. Three neuroendovascular patients (3.5%) experienced a major bleed. Serum anti-Xa levels were significantly higher in patients who experienced major bleeds compared with patients who did not (0.45 ± 0.16 IU/mL vs. 0.28 ± 0.09 IU/mL, P = 0.003). Patients with a supraprophylactic anti-Xa level (>0.5 IU/mL) were more likely to experience a major bleed (P = 0.005). One VTE event occurred: the patient experienced a pulmonary embolism with anti-Xa level at goal. CONCLUSIONS: Anti-Xa-guided enoxaparin dosing for VTE prophylaxis in neurosurgical patients may help prevent major bleeding. These data suggest that a higher anti-Xa level may predispose patients to major bleeding. Further evaluation is needed to identify the goal anti-Xa level for VTE prophylaxis in this population.

The Effect of an Enhanced Recovery Protocol on Colorectal Surgery Patients With Diabetes.

BACKGROUND: The effect of an enhanced recovery protocol including preoperative carbohydrate loading on patients with diabetes is unclear. This study investigated the effect of both on perioperative glucose management and postoperative outcomes in patients with diabetes undergoing colorectal surgery. MATERIALS AND METHODS: A retrospective study was conducted on patients undergoing elective colorectal surgery before and after implementation of an enhanced recovery protocol. Ninety-nine patients with type 2 diabetes (DM, 41 control versus 58 enhanced recovery) and 366 patients without diabetes (NDM, 158 control versus 158 enhanced recovery) were included. Multivariate analyses were run to compare mean peak perioperative serum glucose and postoperative outcomes in enhanced recovery and control cohorts with (DM) and without diabetes (NDM). RESULTS: Mean peak preoperative glucose was elevated in DM enhanced recovery compared with DM control patients (192.2 [72.2] versus 139.8 [41.4]; P < 0.001). Mean peak intraoperative (162.3 [43.1] versus 163.8 [39.6]; P = 0.869) and postoperative glucose (207.7 [75.8] versus 217.8 [78.5]; P = 0.523) were similar in DM enhanced recovery compared with DM control group. Enhanced recovery led to decreased LOS in DM (P = 0.001) and NDM enhanced recovery patients (P < 0.000) compared with their control groups. CONCLUSIONS: An enhanced recovery protocol may lead to increased peak preoperative glucose levels and 30-d readmissions in patients with type 2 diabetes undergoing colorectal surgery. However, the ultimate clinical significance of transiently elevated preoperative glucose in DM patients is uncertain. Our results suggest that an enhanced recovery protocol and preoperative carbohydrate loading does not lead to poorer postoperative glycemic control overall in patients with diabetes undergoing colorectal surgery.

The impact of pre-operative symptoms on carotid endarterectomy Outcomes: Analysis of the ACS-NSQIP carotid endarterectomy database.

Carotid artery stenosis accounts for up to 20% of ischemic strokes. Since the 1950 s, one of the primary surgical treatment for this condition is carotid endarterectomy (CEA). Because of improvement of medical therapy for carotid artery atherosclerosis and the increased use of carotid artery stents, CEA is indicated if the risk of stroke and death are low. The goal of this study is to characterize the impact of pre-operative stroke and stroke risk factors on post-operative CEA patient outcomes, using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Targeted Vascular Module on CEA. Using the Targeted Vascular Module of the ACS-NSQIP, 22,116 patients who underwent CEA were identified from 2011 to 2016. Univariate analysis and multivariable logistic regression analyses were conducted to identify significant risk factors that predispose patients to stroke. Patients with pre-operative stroke comprise 42.1% of the group, with post-operative stroke being the second most common complication (2.1%). Pre-operative stroke patients were also at a higher risk for transient ischemic attacks, post-operative restenosis, post-operative distal embolization, and other complications. Patients with pre-operative risk factors, including stroke or stroke-like symptoms, high risk physiologic factors, high risk anatomic factors, and contralateral internal carotid artery stenosis were at a higher risk of developing post-operative stroke and other complications. Patients with these pre-operative risk factors should be closely monitored for post-operative complications in an effort to improve patient outcomes.

Scoring of Middle Cerebral Artery Collaterals Predicts RAPID CT-Perfusion Analysis and Short-Term Outcomes in Acute Ischemic Stroke Patients Undergoing Thrombectomy.

OBJECTIVE: The rapid processing of perfusion and diffusion (RAPID) system for automating perfusion and diffusion data from head computed tomography has improved acute ischemic stroke treatment by quickly and accurately identifying those patients who may benefit from thrombectomy. Collateral scoring (CS) of cerebral arteries using computed tomography angiography (CTA) has proven useful in predicting postintervention infarct volumes and functional outcomes in ischemic stroke patients. Here we evaluate the relationship between CS and RAPID software in an effort to augment triage and provide improved predictability of functional outcomes in ischemic stroke patients. METHODS: A retrospective review of 77 mechanical thrombectomy patients from January 2017 to October 2018 with large vessel occlusions of the anterior circulation who underwent RAPID and CTA imaging was performed. Baseline characteristics, RAPID data, CS, modified Rankin Scale score, and procedural data were collected. magnetic resonance imaging was used to calculate the postintervention stroke volume. RESULTS: CS inversely correlates with the volume of RAPID cerebral blood flow <30% (ß= -18.131, 95% confidence interval [CI] -24.384 to -11.879, P < 0.001), RAPID Tmax >6s (ß= -22.205, 95% CI -39.125 to -5.285, P = 0.011), postintervention stroke volume (ß= -30.637, 95% CI -41.554 to -19.720, P < 0.001), and discharge National Institutes of Health Stroke Scale score (ß= -1.922, 95% CI -3.575 to -0.269, P = 0.023). CONCLUSIONS: CS on CTA may be a useful way to identify patients who would benefit from mechanical thrombectomy and predict functional outcomes postintervention. CS may allow the stroke team to optimize the care of patients who may not be able to obtain RAPID analysis.

Perioperative use of blood products is associated with risk of morbidity and mortality after surgery.

BACKGROUND: Administration of blood products may be associated with increased morbidity and perioperative mortality in surgical patients. METHODS: Patients aged 18 + who underwent gastrointestinal surgery at the Ohio State University Wexner Medical Center 9/10/2015-5/9/2018 were identified. Multivariable logistic regression models were used to evaluate impact of blood product use on survival and complications, as well as to identify factors associated with receipt of transfusions. RESULTS: Among 10,756 patients, 35,517 units of blood products were transfused. Preoperative nadir hemoglobin was associated with receipt of blood product transfusion (OR 0.55, 95% CI 0.53, 0.68). After adjusting for patient and procedural characteristics, patients undergoing transfusion of blood products had an increased risk of perioperative mortality (OR 7.80, 95% CI 6.02, 10.10). CONCLUSIONS: The use of blood products was associated with increased risk of complication and death. Patient blood management programs should be implemented to provide rational criteria and guidance for the transfusion of blood products.

Reputation and the Best Hospital Rankings: What Does It Really Mean?

U.S. News & World Report's annual Best Hospital Rankings are determined by an index of quality based on objective and subjective measures. This study investigates relationships between U.S. News score and its individual subjective and objective components that ultimately determine the relative ranking of the top 50 hospitals in the 2015 Best Hospital Rankings for the study's selected specialties-cancer, cardiology, gastroenterology, neurology, and orthopedics. A 2-step linear regression model was employed; first, to control for objective components' influence on U.S. News score ( R2 = 0.365; P < .001), then, to isolate the subjective component of reputation's effect on U.S. News score ( R2 = 0.565; P < .001). The second model confirmed that reputation has a more significant influence on total U.S. News score than its objective counterparts. This indicates that a hospital's U.S. News score and relative ranking in the Best Hospital Rankings may be disproportionately influenced by its reputation.