Cost burden of stroke mimics and transient ischemic attack after intravenous tissue plasminogen activator treatment.

BACKGROUND: Treatment decisions for patients with acute stroke symptoms are based on pertinent history, neurologic examination, laboratory studies, and head computed tomography. In this setting, patients with stroke mimic (SM) may mistakenly receive intravenous tissue plasminogen activator (IV-rtPA). The goal of this study was to investigate the excess direct/indirect hospital costs among patients who received IV-rtPA when final diagnosis was not ischemic stroke. METHODS: We reviewed the records of 535 IV-rtPA-treated patients who presented to our primary stroke centers. The diagnosis of SM or transient ischemic attack (TIA) was based on patient presentation, hospital course, electroencephalography, and negative neuroimaging studies. The excess cost analysis compared actual direct and indirect hospital costs of a patient to what their direct and indirect hospital costs would have been had they primarily been diagnosed with mimic or TIA. RESULTS: Seventy-four patients post-IV-rtPA treatment had final diagnosis of SM; 21 had TIAs. The excess direct and indirect hospital costs for mimics were $257,975 and $152,813, respectively. The median excess cost was $5401 per admission. The excess total cost for TIAs was $85,026 with a median of $3407 per admission. CONCLUSIONS: Administration of IV-rtPA to patients with SMs remains prevalent and costly. Certain clinical or radiographic characteristics can help diagnose mimics; however, more studies need to be done to determine the feasibility and effectiveness of further clinical investigations among suspected SM patients who are within the thrombolysis treatment window.

Correlation Between the Residual Tumor Volume, Extent of Tumor Resection, and O6-Methylguanine DNA Methyltransferase Status in Patients with Glioblastoma.

BACKGROUND: There is limited information on O6-methylguanine DNA methyltransferase (MGMT) status, extent of surgical resection, and its impact on overall outcomes in patients with glioblastoma (GBM). METHODS: After institutional review board approval, 233 newly diagnosed patients with GBM with known MGMT status (2009-2015) were included in our analysis. Clinical, imaging, and follow-up data were collected from the database. Overall survival (OS) and progression-free survival (PFS) were the primary and secondary end points, respectively. RESULTS: Of patients, 51.9% were younger than 65 years and 44.2% were noted to have promoter methylation of MGMT. Median residual tumor volume was 1.1 cm3 and extent of complete resection of enhancing tumor on imaging was 96%. Estimated median OS and PFS were 10.9 months and 5.4 months, respectively. MGMT status was an independent predictor of PFS (hazard ratio [HR], 0.52; P = 0.005) but only marginally associated with OS (P = 0.059). In MGMT methylated patients, extent of resection (≥86%) and good performance status (Karnofsky Performance Status ≥70) were independently associated with PFS and OS, respectively (PFS: HR, 0.21; P = 0.015; OS: HR, 0.05; P = 0.002). In MGMT promoter unmethylated patients, extent of resection (≥86%) was independently associated with OS (P = 0.039). Concurrent chemoradiotherapy was associated with OS/PFS irrespective of age and MGMT status. CONCLUSIONS: Greater extent of resection of enhancing tumor was associated with improved PFS in MGMT promoter methylated patients, OS regardless of MGMT status. Elderly patients with methylated MGMT promoter were found to have improved PFS whereas younger patients had improved OS with MGMT promoter methylated status.

Long-Term Outcome Following Stereotactic Radiosurgery for Glomus Jugulare Tumors: A Single Institution Experience of 20 Years.

BACKGROUND: Glomus jugulare tumors (GJTs) are rare benign tumors, which pose significant treatment challenges due to proximity to critical structures. OBJECTIVE: To evaluate the long-term clinical and radiological outcome in patients undergoing stereotactic radiosurgery (SRS) for GJTs through retrospective study. METHODS: Forty-two patients with 43 GJTs were treated using Gamma Knife radiosurgery (GKRS; Elekta AB, Stockholm, Sweden) at our institute from 1997 to 2016. Clinical, imaging, and radiosurgery data were collected from an institutional review board approved database. RESULTS: Most patients were females (n = 35, 83.3%) and median age was 61 yr (range 23-88 yr). Median tumor volume and diameter were 5 cc and 3 cm, respectively, with a median follow-up of 62.3 mo (3.4-218.6 mo). Overall, 20 patients (47.6%) improved clinically and 14 (33.3%) remained unchanged at last follow-up. New onset or worsening of hearing loss was noted in 6 patients (17.2%) after SRS. The median prescription dose to the tumor margin was 15 Gy (12-18 Gy). Median reduction in tumor volume and maximum tumor diameter at last follow-up was 33.3% and 11.54%, respectively. The 5-yr and 10-yr tumor control rates were 87% ± 6% and 69% ± 13%, respectively. There was no correlation between maximum or mean dose to the internal acoustic canal and post-GK hearing loss (P > .05). CONCLUSION: SRS is safe and effective in patients with GJTs and results in durable, long-term control. SRS has lower morbidity than that associated with surgical resection, particularly lower cranial nerve dysfunction, and can be a first-line management option in these patients.