Feasibility, safety, and utility of brain MRI for patients with non-MRI-conditioned CIED.

Feasibility, safety, and utility of brain MRI for patients with non-MRI-conditioned cardiac implantable electrical devices (CIEDs) remains controversial. While a growing number of studies have shown safe employment in select patients under strict protocols, there is an increasing clinical need for further off-label investigations. To assess the feasibility and utility of brain MRI in neurological and neurosurgical patients with non-MRI-conditioned CIEDs using off-label protocol. We retrospectively evaluated 126 patients with non-MRI-conditioned CIEDs referred to our hospital between 2014 to 2018 for MRI under an IRB-approved protocol. A total of 126 off-label brain MRI scans were performed. The mean age was 67.5 ± 13.0. Seventy percent of scans were performed on female patients. Indications for MRI are neurosurgical (45.2%), neurological (51.6%), and others (3.2%). MRI utilization for tumor cases was highest for tumor cases (68.3%), but employment was valuable for vascular (12.7%), deep brain stimulators (3.2%), and other cases (15.9%). In the tumor category, (37.2%) of the scans were performed for initial diagnosis and pre-surgical planning, (47.7%) for post-intervention evaluation/surveillance, (15.1%) for stereotactic radiosurgery treatment (CyberKnife). No clinical complications were encountered. No functional device complications of the CIED were identified during and after the MRI in 96.9% of the studies. A 49.6% of the off-label brain MRI scans performed led to a clinically significant decision and/or intervention for the patients. A 42.9% of obtained MRI studies did not change the plan of care. A 7.9% of post-scan decision-making data was not available. We demonstrate that off-label brain MRI scans performed on select patients under a strict protocol is feasible, safe, and relevant. Almost 50% of scans provided critical information resulting in clinical intervention of the patients.

Subfascial drains are safe and effective in preventing postoperative cerebrospinal fluid leaks after intradural spine tumor surgery.

Background: Delayed cerebrospinal fluid (CSF) leaks are a known complication following intradural spinal tumor surgery. The placement of subfascial drains in these patients undergoing requisite intradural surgery is controversial. Here, we demonstrated that placing a subfascial drain on partial suction for 48 h, with early ambulation, proved to be safe and effective in preventing early/delayed recurrent CSF fistulas. Methods: Medical records of 17 patients undergoing surgery for intradural spinal tumors over a 30-month were reviewed. All patients underwent intradural tumor resection followed by primary dural closure, placement of Gelfoam in a non-compressive fashion, application of fibrin sealant, and utilization of a subfascial drain placed on partial suction for 48 h postoperatively. Patients are mobilized the morning following surgery. We tracked the incidence of postoperative recurrent CSF leaks, over drainage, infection, wound dehiscence, pseudo meningocele formation, and the reoperation rate. Results: For the 17 patients, our programmed average utilization of subfascial drains was 48 h. Moreover, the average drain output was 165 mL. Over the 1-year follow-up period, no patient developed a recurrent early/ delayed CSF leak, there were no wound complications, nor need for revision surgery. Conclusion: Utilizing subfascial drains on partial suction following the resection of intradural spinal tumors with primary dural closure proved to be safe and effective.

Trends in Spinal Orthosis Utilization Among Patients Insured through Medicare Part B.

STUDY DESIGN: Retrospective population-based database analysis from the Physician/Supplier Procedure Summary Medicare/Medicaid Dataset. OBJECTIVE: To provide a comprehensive analysis of trends in spinal orthosis utilization over a 12-year period. SUMMARY OF BACKGROUND DATA: Widespread prescription of spinal orthosis persists, despite evidence suggesting equivocal efficacy in many spinal conditions. The utilization of spinal orthosis on a national level, including prescribing specialty data, has not been previously analyzed. METHODS: Healthcare common procedure coding system (HCPCS) codes for cervical (CO), thoracic-lumbar-sacral (TLSO), lumbar (LO), lumbar-sacral (LSO), and cervical-thoracic-lumbar-sacral (CTLSO) orthosis were used to determine spinal orthosis utilization from 2010 to 2021. Provider specialty codes were utilized to compare trends between select specialties. Additionally, a neurosurgical CO analysis, based on subclassifications of cervical bracing, was performed. Linear trendlines were implemented to elucidate and present trends by slope (ß). RESULTS: Among 332,241 claims, decreases in CO (ß=-0.3387), TLSO (ß=-0.0942), LO (ß=-0.3485), and LSO (ß=-0.1545) per 100,000 Medicare Part B enrollees and CTLSO (ß=-0.052) per 1,000,000 Medicare Part B enrollees were observed. Decreases among neurosurgery (ß=-7.9208), family medicine (ß=-1.0097), emergency medicine (ß=-2.1958), internal medicine (ß=-1.1151), interventional pain management (ß=-5.0945), and chiropractic medicine (ß=-49.012), and increases among orthopedic surgery (ß=5.5891), pain management (ß=30.416), physical medicine and rehabilitation (ß=4.6524), general practice (ß=79.111), and osteopathic manipulative medicine (ß=45.303) in total spinal orthosis use per 100,000 specialty claims were observed. Analysis on subclassifications of cervical orthosis among neurosurgeons revealed decreases in flexible (ß=-1.7641), semi-rigid (ß=-0.6157), and collar bracing (ß=-2.7603), and an increase in multi-post collar bracing (ß=2.2032) per 100 neurosurgical cervical orthosis claims. CONCLUSIONS: While utilization of spinal orthosis decreased between 2010-2021, increased utilization was observed among a subset of specialties. Identifying these specialties allows for focused research and educational efforts to minimize unnecessary durable medical equipment use for effective healthcare spending.

Basilar apex aneurysm systematic review: Microsurgical versus endovascular treatment.

BACKGROUND: Both microsurgical and endovascular techniques continued to be treatment options for basilar apex aneurysms (BAA). We conducted a systematic review to compare both treatment options in terms of both clinical and radiological outcomes. METHODS: The PRISMA method was used to identify related articles. Data collected from each article and the two treatment approaches were compared in terms of favorable clinical outcome and complete/near complete occlusion rate. Subgroup analysis was done based on the size and the rupture status of BAA. RESULTS: Fifty-nine (59) and 32 articles reported a measurable clinical and radiological outcome respectively. The weighted average favorable clinical outcome was significantly higher in the endovascular group (86.4% vs 79.6%, P<0.0001), while the weighted average complete/near complete occlusion rate was significantly higher in the surgical group (92.6% vs 83.8%, P<0.0001). In the subgroup analysis, the favorable clinical outcome remained significantly higher in the endovascular group for the ruptured, unruptured and giant/large BAA (P<0.001), but not in the small BAA subgroup (P=0.26). The occlusion rate remained significantly higher in the surgical group for all subgroups (P<0.001). CONCLUSION: Treatment of BAA remains in a trade-off between favorable clinical outcome and complete or near-complete occlusion depending on the treatment modality selected. Careful selection of cases and judicial discussion between open surgical and endovascular team is warranted for treatment optimization.

Immunoglobulin G4-related disease of the cavernous sinus with orbit invasion - A case report.

BACKGROUND: Immunoglobulin G4-related disease (IgG4-RD) is a rare systemic disease of unknown etiology. It is characterized by tissue infiltration caused by IgG4 plasma cells and sclerosing inflammation of various body organs. At present, there are very few reported cases of IgG4-RD invasion of cavernous sinus and the orbit. CASE DESCRIPTION: A 56-year-old female with a history of rheumatoid arthritis was presented with a gradual onset of right oculomotor, abducens, and trigeminal nerve deficits. Four weeks after the onset of symptoms, the patient developed gradual visual deficit. Following this, a trial of steroids was administered to the patient. However, the treatment did not work as expected and patient's condition worsened. She progressed on to suffer complete visual loss in the right eye. Extensive work-up conducted on her turned out to be nondiagnostic. After this, the patient was referred to us for our evaluation. Neuroimaging revealed a right-sided cavernous sinus and orbital apex lesion. Given the lack of diagnosis and response to steroid treatment, we recommended surgical intervention and performed a modified pterional and pretemporal approach with extradural anterior clinoidectomy and transcavernous approach. We performed a lesion biopsy and cavernous sinus decompression, which helped in the partial recovery of visual function. The pathology report was consistent with IgG4-RD. CONCLUSION: IgG4-RD is a rare disease that occurs even less in combination with cavernous sinus and orbit invasion. The rarity of the disease and the diverse presentation of symptoms have sometimes caused delayed diagnosis and intervention. Patients who failed to respond to conservative management and patients in the fibrotic stage of the disease without other organ involvement may benefit from surgical intervention if amenable. Early suspicion, diagnosis, and intervention can facilitate better prognosis.

Evaluation of the utility of early routine computed tomography angiography in subarachnoid hemorrhage patient outcomes.

OBJECTIVES: The role of an early CTA approach in neurologically stable patients with nontraumatic SAH has not been assessed. This study explored the use of CTA in clinically stable SAH patients to pre-emptively identify cerebral vasospasm, to evaluate whether this approach is associated with improved clinical outcomes. METHODS: We conducted a retrospective chart review of SAH patients presenting between July 2007 and December 2016 in a single academic center. Patients were divided into two groups: (1) Early CTA (stable patients who underwent a CTA between days 5-8 post-SAH), and (2) Standard Protocol. The co-primary outcomes were a composite of the mRS at discharge and last clinical follow-up (good = 0-2; poor = 3-6). A multivariable binary logistic regression was conducted to compare both groups against outcomes, controlling for potential confounders. RESULTS: A total of 415 patients were included, 103 (24.8%) with early CTA, and 312 (75.2%) undergoing the standard protocol; the mean age was 57 years and 248 (59.8%) patients were female. Patients in the early CTA group had a higher modified Fisher grade (3-4) (87.4% vs 63.1%; p < 0.02). The multivariable analysis showed that early CTA was independently associated with lower poor outcomes at discharge (OR = 0.21, 95% CI 0.07-0.61, p = 0.004). Plus, vasospasm detection was associated with an increased risk of poor outcomes (OR = 4.77, 95% CI 1.41 - 16.10, p = 0.01). Early CTA was not associated with outcomes at clinical follow-up. CONCLUSION: The early CTA surveillance approach was associated with better functional outcomes at discharge when compared to the current imaging standard practice.

Current Surgical Options for Moyamoya Disease.

Moyamoya disease (MMD) is a cerebrovascular disease of unknown etiology characterized by stenotic and occlusive arterial changes of the anterior circulation, with subsequent proliferative development of arterial collateralization. In spite of there being limited understanding of the clear etiology of MMD, surgical revascularization for MMD is considered the standard treatment to prevent further stroke. While the use of surgical revascularization to prevent future hemorrhagic stroke in MMD is still controversial, it is considered effective in the case of ischemic stroke. This article presents a review of the current surgical management of MMD based on an analysis of the most recent data from peer-reviewed articles and opinion based on personal experience with surgical revascularization in the treatment of MMD.

Relationship between external ventricular drain clamp trials and ventriculoperitoneal shunt insertion following nontraumatic subarachnoid hemorrhage: a single-center study.

OBJECTIVE: Currently, there is no established standard regarding the ideal number of external ventricular drain (EVD) clamp trials performed before ventriculoperitoneal (VP) shunt insertion following nontraumatic subarachnoid hemorrhage (SAH). In this study, the authors aimed to evaluate this relationship. METHODS: A retrospective review of all patients presenting with SAH between July 2007 and December 2016 was performed. Patients with SAH who had received an EVD within the first 24 hours of hospital admission and had undergone at least 1 clamp trial prior to EVD removal were eligible for inclusion in the study. Patient demographics, clinical presentations, SAH etiologies and grades, clamp trial data, hospital lengths of stay, and functional outcomes were recorded. RESULTS: One hundred fourteen patients with nontraumatic SAH complicated by posthemorrhagic hydrocephalus were included in the study. The median patient age was 57 years (range 28-90 years), with a male/female ratio of 1:1.7. A ruptured aneurysm was the underlying etiology of SAH in 79.8% of patients. A majority of patients (69.4%) had a Hunt and Hess grade III-V on admission. The median number of clamp trials performed was 2 (range 1-6). A VP shunt was required in 40.4% of patients. In those who underwent 2 and 3 clamp trials, 60% and 38.9%, respectively, did not require subsequent VP shunt placement. CONCLUSIONS: Surgical placement of a VP shunt is associated with complications. Clamp trials are routinely performed before making the decision to insert a shunt. In the present study, the authors found that a significant percentage of patients passed their second and third clamp trials without requiring subsequent shunt insertion. These data support performing multiple clamp trials prior to shunt placement.