Predictors of acute post-thrombectomy intracranial hemorrhage expansion in anterior circulation infarcts.

BACKGROUND: Post-mechanical thrombectomy (MT) intracranial hemorrhage (ICH) is a major source of morbidity in treated acute ischemic stroke patients with large vessel occlusion. ICH expansion may further contribute to morbidity. We sought to identify factors associated with ICH expansion on imaging evaluation post-MT. METHODS: We performed a retrospective cohort study of patients undergoing MT at a single comprehensive stroke center. Per protocol, patients underwent dual-energy head CT (DEHCT) post-MT followed by a 24-h interval non-contrast enhanced MRI. ICH expansion was defined as any increase in blood volume between the two studies if identified on the DEHCT. Univariate and multivariable analyses were performed to identify risk factors for ICH expansion. RESULTS: ICH was identified on DEHCT in 13% of patients (n = 35/262), with 20% (7/35) demonstrating expansion on interval MRI. The average increase in blood volume was 11.4 ml (SD 6.9). Univariate analysis identified anticoagulant usage (57% vs 14%, p = 0.03), petechial hemorrhage inside the infarct margins or intraparenchymal hematoma on DEHCT (ECASS-II HI2/PH1/PH2) (71% vs 14%, p < 0.01), basal ganglia hemorrhage (71% vs 21%, p = 0.02), and basal ganglia infarction (86% vs 32%, p = 0.03) as factors associated with ICH expansion. Multivariate regression demonstrated that anticoagulant usage (OR 20.3, 95% C.I. 2.43-446, p < 0.05) and ECASS II scores of HI2/PH1/PH2 (OR 11.7, 95% C.I. 1.24-264, p < 0.05) were significantly predictive of ICH expansion. CONCLUSION: Expansion of post-MT ICH on 24-h interval MRI relative to immediate post-thrombectomy DEHCT is significantly associated with baseline anticoagulant usage and petechial hemorrhage inside the infarct margins or presence of intraparenchymal hematoma (ECASS-II HI2/PH1/PH2).

Cerebrovascular reactivity dispersion as a new biomarker of recent stroke symptomatology in moyamoya.

Background: Moyamoya disease (MMD) is a non-atherosclerotic intracranial steno-occlusive condition placing patients at high risk for ischemic stroke. Direct and indirect surgical revascularization can improve blood flow in MMD; however, randomized trials demonstrating efficacy have not been performed and biomarkers of parenchymal hemodynamic impairment are needed to triage patients for interventions and evaluate post-surgical efficacy. We test the hypothesis that hypercapnia-induced maximum cerebrovascular reactivity (CVR MAX ) and the more novel indicator cerebrovascular reactivity (CVR) response time (CVR DELAY ), both assessed from time-regression analyses of non-invasive hypercapnic imaging, correlate with recent focal ischemic symptoms. Methods: Hypercapnic reactivity medical resonance imaging (blood oxygenation level-dependent; echo time=35ms; spatial resolution=3.5×3.5×3.5mm) and catheter angiography assessments of cortical reserve capacity and vascular patency, respectively, in MMD participants (n=73) were performed in sequence. Time regression analyses were applied to quantify CVR MAX and CVR DELAY . Symptomatology information for each hemisphere (n=109) was categorized into symptomatic (ischemic symptoms within six months) or asymptomatic (no history of ischemic symptoms) and logistic regression analysis assessed the association of CVR metrics with ischemic symptoms after controlling for age and sex. Results: Symptomatic hemispheres displayed lengthened CVR DELAY (p<0.001), which was more discriminatory between hemispheres than CVR MAX (p=0.037). CVR DELAY (p<0.001), but not CVR MAX (p=0.127), was found to be sensitively related to age in asymptomatic tissue (0.33-unit increase/year); age-dependent normative ranges are presented to enable quantitative assessment of patient-specific impairment. Furthermore, the area under the receiver operating characteristic curves shows that CVR DELAY predicts ischemic symptoms (p<0.001), whereas CVR MAX does not (p=0.056). Conclusion: Findings support that CVR metrics are uniquely altered in hemispheres with recent ischemic symptoms, motivating the investigation of CVR as a surrogate of ischemic symptomatology and treatment efficacy.

"Home Field Advantage": The Presence of a "Home" Neurosurgical Residency Training Program is Associated With Improved Match Outcomes.

BACKGROUND AND OBJECTIVES: Competition for neurosurgical residency training positions remains fierce. The support provided by applicants' home neurosurgery residency training programs (NRTP) is suspected to play a key role in the National Resident Matching Program (NRMP) process. We sought to evaluate the impact of the presence of an Accreditation Council for Graduate Medical Education-accredited NRTP at medical students' home institutions has on NRMP match outcomes. METHODS: Our cross-sectional observational study examined all US allopathic senior student Electronic Residency Application Service applications to a single NRTP from 2016 to 2022. RESULTS: We analyzed a total of 1650 Electronic Residency Application Service applications to a single NRTP, of which 1432 (86.8%) were from schools with an Accreditation Council for Graduate Medical Education-accredited NRTP (NRTP+) and 218 (13.2%) were from schools without a residency (NRTP-). NRTP+ applicants matched a higher rate on both pooled analysis (80.8% vs 71.6%, P = .002) and paired analysis (P = .02) over the seven-cycle study period. This difference was present before (82.4% vs 73.9%, P = .01) and after (77.2% vs 65.6%, P = .046) the COVID-19 pandemic. Cohorts were overall similar; however, NRTP+ applicants had more publication experiences (19.6 ± 19.0 vs 13.1 ± 10.2, P < .001) and were more likely to complete a research gap year (RGY) (25.8% vs 17.0%, P = .004). Completing a RGY was associated with an increased likelihood of matching for NRTP+ applicants but not for NRTP- applicants: NRTP+: 84.9% vs 78.1% (P = .0056); NRTP-: 70.3% vs 70.9% (P = .94). CONCLUSION: The presence of a NRTP at a medical student's home institution is associated with improved NRMP match outcomes. This held true both before and after the COVID-19 pandemic. Applicants from schools with a NRTP had more publication experiences and were more likely to complete a RGY. Completion of a RGY is associated with an increased likelihood of matching only for students with an affiliated NRTP.

Endovascular Detection of Catheter-Thrombus Contact by Vacuum Excitation.

OBJECTIVE: The objective of this work is to introduce and demonstrate the effectiveness of a novel sensing modality for contact detection between an off-the-shelf aspiration catheter and a thrombus. METHODS: A custom robotic actuator with a pressure sensor was used to generate an oscillatory vacuum excitation and sense the pressure inside the extracorporeal portion of the catheter. Vacuum pressure profiles and robotic motion data were used to train a support vector machine (SVM) classification model to detect contact between the aspiration catheter tip and a mock thrombus. Validation consisted of benchtop accuracy verification, as well as user study comparison to the current standard of angiographic presentation. RESULTS: Benchtop accuracy of the sensing modality was shown to be 99.67%. The user study demonstrated statistically significant improvement in identifying catheter-thrombus contact compared to the current standard. The odds ratio of successful detection of clot contact was 2.86 (p = 0.03) when using the proposed sensory method compared to without it. CONCLUSION: The results of this work indicate that the proposed sensing modality can offer intraoperative feedback to interventionalists that can improve their ability to detect contact between the distal tip of a catheter and a thrombus. SIGNIFICANCE: By offering a relatively low-cost technology that affords off-the-shelf aspiration catheters as clot-detecting sensors, interventionalists can improve the first-pass effect of the mechanical thrombectomy procedure while reducing procedural times and mental burden.

Choroid plexus vascular reactivity in moyamoya: Implications for choroid plexus regulation in ischemic stress.

BACKGROUND AND PURPOSE: Choroid plexus (ChP) hyperemia has been observed in patients with intracranial vasculopathy and to reduce following successful surgical revascularization. This observation may be attributable to impaired vascular reserve of the ChP or other factors, such as the ChP responding to circulating markers of stress. We extend this work to test the hypothesis that vascular reserve of the ChP is unrelated to intracranial vasculopathy. METHODS: We performed hypercapnic reactivity (blood oxygenation level-dependent; echo time = 35 ms; spatial resolution = 3.5 × 3.5 × 3.5 mm, repetition time = 2000 ms) and catheter angiography assessments of ChP reserve capacity and vascular patency in moyamoya patients (n = 53) with and without prior surgical revascularization. Time regression analyses quantified maximum cerebrovascular reactivity and reactivity delay time in ChP and cortical flow territories of major intracranial vessels with steno-occlusion graded as <70%, 70%-99%, and occlusion using Warfarin-Aspirin-Symptomatic-Intracranial-Disease stenosis grading criteria. Analysis of variance (significance: two-sided Bonferroni-corrected p < .05) was applied to evaluate cortical and ChP reactivity, after accounting for end-tidal carbon dioxide change, for differing vasculopathy categories. RESULTS: In patients without prior revascularization, arterial vasculopathy was associated with reduced cortical reactivity and lengthened reactivity delay (p ≤ .01), as expected. Regardless of surgical history, the ChP reactivity metrics were not significantly related to the degree of proximal stenosis, consistent with ChP reactivity being largely preserved in this population. CONCLUSIONS: Findings are consistent with ChP reactivity in moyamoya not being dependent on observed vasculopathy. Future work may investigate the extent to which ChP hyperemia in chronic ischemia reflects circulating markers of glial or ischemic stress.

Blood Pressure Management After Endovascular Therapy for Acute Ischemic Stroke: The BEST-II Randomized Clinical Trial.

Importance: The effects of moderate systolic blood pressure (SBP) lowering after successful recanalization with endovascular therapy for acute ischemic stroke are uncertain. Objective: To determine the futility of lower SBP targets after endovascular therapy (<140 mm Hg or 160 mm Hg) compared with a higher target (≤180 mm Hg). Design, Setting, and Participants: Randomized, open-label, blinded end point, phase 2, futility clinical trial that enrolled 120 patients with acute ischemic stroke who had undergone successful endovascular therapy at 3 US comprehensive stroke centers from January 2020 to March 2022 (final follow-up, June 2022). Intervention: After undergoing endovascular therapy, participants were randomized to 1 of 3 SBP targets: 40 to less than 140 mm Hg, 40 to less than 160 mm Hg, and 40 to 180 mm Hg or less (guideline recommended) group, initiated within 60 minutes of recanalization and maintained for 24 hours. Main Outcomes and Measures: Prespecified multiple primary outcomes for the primary futility analysis were follow-up infarct volume measured at 36 (±12) hours and utility-weighted modified Rankin Scale (mRS) score (range, 0 [worst] to 1 [best]) at 90 (±14) days. Linear regression models were used to test the harm-futility boundaries of a 10-mL increase (slope of 0.5) in the follow-up infarct volume or a 0.10 decrease (slope of -0.005) in the utility-weighted mRS score with each 20-mm Hg SBP target reduction after endovascular therapy (1-sided α = .05). Additional prespecified futility criterion was a less than 25% predicted probability of success for a future 2-group, superiority trial comparing SBP targets of the low- and mid-thresholds with the high-threshold (maximum sample size, 1500 with respect to the utility-weighted mRS score outcome). Results: Among 120 patients randomized (mean [SD] age, 69.6 [14.5] years; 69 females [58%]), 113 (94.2%) completed the trial. The mean follow-up infarct volume was 32.4 mL (95% CI, 18.0 to 46.7 mL) for the less than 140-mm Hg group, 50.7 mL (95% CI, 33.7 to 67.7 mL), for the less than 160-mm Hg group, and 46.4 mL (95% CI, 24.5 to 68.2 mL) for the 180-mm Hg or less group. The mean utility-weighted mRS score was 0.51 (95% CI, 0.38 to 0.63) for the less than 140-mm Hg group, 0.47 (95% CI, 0.35 to 0.60) for the less than 160-mm Hg group, and 0.58 (95% CI, 0.46 to 0.71) for the high-target group. The slope of the follow-up infarct volume for each mm Hg decrease in the SBP target, adjusted for the baseline Alberta Stroke Program Early CT score, was -0.29 (95% CI, -0.81 to ∞; futility P = .99). The slope of the utility-weighted mRS score for each mm Hg decrease in the SBP target after endovascular therapy, adjusted for baseline utility-weighted mRS score, was -0.0019 (95% CI, -∞ to 0.0017; futility P = .93). Comparing the high-target SBP group with the lower-target groups, the predicted probability of success for a future trial was 25% for the less than 140-mm Hg group and 14% for the 160-mm Hg group. Conclusions and Relevance: Among patients with acute ischemic stroke, lower SBP targets less than either 140 mm Hg or 160 mm Hg after successful endovascular therapy did not meet prespecified criteria for futility compared with an SBP target of 180 mm Hg or less. However, the findings suggested a low probability of benefit from lower SBP targets after endovascular therapy if tested in a future larger trial. Trial Registration: ClinicalTrials.gov Identifier: NCT04116112.

Low Levels of Low-Density Lipoprotein Cholesterol Increase the Risk of Post-Thrombectomy Delayed Parenchymal Hematoma.

PURPOSE: Low levels of low-density lipoprotein cholesterol (LDL-C) have been suggested to increase the risk of hemorrhagic transformation (HT) following acute ischemic stroke. However, the literature on the relationship between LDL-C levels and post-thrombectomy HT is sparse. The aim of our study is to investigate the association between LDL-C and delayed parenchymal hematoma (PH) that was not seen on immediate post-thrombectomy dual-energy computed tomography (DECT). MATERIALS AND METHODS: A retrospective analysis was conducted on all patients with anterior circulation large vessel occlusion who underwent thrombectomy at a comprehensive stroke center from 2018-2021. Per institutional protocol, all patients received DECT immediately post-thrombectomy and magnetic resonance imaging or CT at 24 hours. The presence of immediate hemorrhage was assessed by DECT, while delayed PH was assessed by 24-hour imaging. Multivariable analysis was performed to identify predictors of delayed PH. Patients with hemorrhage on immediate post-thrombectomy DECT were excluded to select only those with delayed PH. RESULTS: Of 159 patients without hemorrhage on immediate post-thrombectomy DECT, 18 (11%) developed delayed PH on 24-hour imaging. In multivariable analysis, LDL-C (odds ratio [OR], 0.76; P=0.038; 95% confidence interval [CI], 0.59-0.99; per 10 mg/dL increase) independently predicted delayed PH. High-density lipoprotein cholesterol, triglyceride, and statin use were not associated. After adjusting for potential confounders, LDL-C ≤50 mg/dL was associated with an increased risk of delayed PH (OR, 5.38; P=0.004; 95% CI, 1.70-17.04), while LDL-C >100 mg/dL was protective (OR, 0.26; P=0.041; 95% CI, 0.07-0.96). CONCLUSION: LDL-C ≤50 mg/dL independently predicted delayed PH following thrombectomy and LDL-C >100 mg/dL was protective, irrespective of statin. Thus, patients with low LDL-C levels may warrant vigilant monitoring and necessary interventions, such as blood pressure control or anticoagulation management, following thrombectomy even in the absence of hemorrhage on immediate post-thrombectomy DECT.

The clinical utility of dual-energy CT in post-thrombectomy care: Part 2, the predictive value of contrast density and volume for delayed hemorrhagic transformation.

OBJECTIVES: Dual-energy CT allows differentiation between blood and iodinated contrast. This study aims to determine the predictive value of contrast density and volume on post-thrombectomy dual-energy CT for delayed hemorrhagic transformation and its impact on 90-day outcomes. MATERIALS AND METHODS: A retrospective analysis was performed on patients who underwent thrombectomy for anterior circulation large-vessel occlusion at a comprehensive stroke center from 2018-2021. Per institutional protocol, all patients underwent dual-energy CT immediately post-thrombectomy and MRI or CT 24 hours afterward. The presence of hemorrhage and contrast staining was evaluated by dual-energy CT. Delayed hemorrhagic transformation was determined by 24-hour imaging and classified into petechial hemorrhage or parenchymal hematoma using ECASS III criteria. Univariable and multivariable analyses were performed to determine predictors and outcomes of delayed hemorrhagic transformation. RESULTS: Of 97 patients with contrast staining and without hemorrhage on dual-energy CT, 30 and 18 patients developed delayed petechial hemorrhage and delayed parenchymal hematoma, respectively. On multivariable analysis, delayed petechial hemorrhage was predicted by anticoagulant use (OR,3.53;p=0.021;95%CI,1.19-10.48) and maximum contrast density (OR,1.21;p=0.004;95%CI,1.06-1.37;per 10 HU increase), while delayed parenchymal hematoma was predicted by contrast volume (OR,1.37;p=0.023;95%CI,1.04-1.82;per 10 mL increase) and low-density lipoprotein (OR,0.97;p=0.043;95%CI,0.94-1.00;per 1 mg/dL increase). After adjusting for potential confounders, delayed parenchymal hematoma was associated with worse functional outcomes (OR,0.07;p=0.013;95%CI,0.01-0.58) and mortality (OR,7.83;p=0.008;95%CI,1.66-37.07), while delayed petechial hemorrhage was associated with neither. CONCLUSION: Contrast volume predicted delayed parenchymal hematoma, which was associated with worse functional outcomes and mortality. Contrast volume can serve as a useful predictor of delayed parenchymal hematoma following thrombectomy and may have implications for patient management.

The clinical utility of dual-energy CT in post-thrombectomy care: Part 1, predictors and outcomes of subarachnoid and intraparenchymal hemorrhage.

OBJECTIVES: Dual-energy CT allows differentiation between blood and iodinated contrast. We aimed to determine predictors of subarachnoid and intraparenchymal hemorrhage on dual-energy CT performed immediately post-thrombectomy and the impact of these hemorrhages on 90-day outcomes. MATERIALS AND METHODS: A retrospective analysis was performed on patients who underwent thrombectomy for anterior circulation large-vessel occlusion and subsequent dual-energy CT at a comprehensive stroke center from 2018-2021. The presence of contrast, subarachnoid hemorrhage, or intraparenchymal hemorrhage immediately post-thrombectomy was assessed by dual-energy CT. Univariable and multivariable analyses were performed to identify predictors of post-thrombectomy hemorrhages and 90-day outcomes. Patients with unknown 90-day mRS were excluded. RESULTS: Of 196 patients, subarachnoid hemorrhage was seen in 17, and intraparenchymal hemorrhage in 23 on dual-energy CT performed immediately post-thrombectomy. On multivariable analysis, subarachnoid hemorrhage was predicted by stent retriever use in the M2 segment of MCA (OR,4.64;p=0.017;95%CI,1.49-14.35) and the number of thrombectomy passes (OR,1.79;p=0.019;95%CI,1.09-2.94;per an additional pass), while intraparenchymal hemorrhage was predicted by preprocedural non-contrast CT-based ASPECTS (OR,8.66;p=0.049;95%CI,0.92-81.55;per 1 score decrease) and preprocedural systolic blood pressure (OR,5.10;p=0.037;95%CI,1.04-24.93;per 10 mmHg increase). After adjusting for potential confounders, intraparenchymal hemorrhage was associated with worse functional outcomes (OR,0.25;p=0.021;95%CI,0.07-0.82) and mortality (OR,4.30;p=0.023,95%CI,1.20-15.36), while subarachnoid hemorrhage was associated with neither. CONCLUSIONS: Intraparenchymal hemorrhage immediately post-thrombectomy was associated with worse functional outcomes and mortality and can be predicted by low ASPECTS and elevated preprocedural systolic blood pressure. Future studies focusing on management strategies for patients presenting with low ASPECTS or elevated blood pressure to prevent post-thrombectomy intraparenchymal hemorrhage are warranted.

The cost of a plastic surgery team assisting with cranioplasty.

OBJECTIVES: Cranioplasty is a commonly performed neurosurgical procedure that restores cranial anatomy. While plastic surgeons are commonly involved with cranioplasties, the cost of performing a cranioplasty with neurosurgery alone (N) vs. neurosurgery and plastic surgery (N + P) is unknown. METHODS: A single-center, multi-surgeon, retrospective cohort study was undertaken on all cranioplasties performed from 2012 to 22. The primary exposure variable of interest was operating team, comparing N vs. N + P. Cost data was inflation-adjusted to January 2022 using Healthcare Producer Price Index as calculated by the US Bureau of Labor Statistics. RESULTS: 186 patients (105 N vs. 81 N + P) underwent cranioplasties. The N + P group has a significantly longer length-of-stay (LOS) 4.5 ± 1.6days, vs. 6.0 ± 1.3days (p < 0.001), but no significant difference in reoperation, readmission, sepsis, or wound breakdown. N was significantly less expensive than N + P during both the initial cranioplasty cost ($36,739 ± $4592 vs. $41,129 ± $4374, p 0.014) and total cranioplasty costs including reoperations ($38,849 ± $5017 vs. $53,134 ± $6912, p < 0.001). Univariable analysis (threshold p = 0.20) was performed to justify inclusion into a multivariable regression model. Multivariable analysis for initial cranioplasty cost showed that sepsis (p = 0.024) and LOS (p = 0.003) were the dominant cost contributors compared to surgeon type (p = 0.200). However, surgeon type (N vs. N + P) was the only significant factor (p = 0.011) for total cost including revisions. CONCLUSIONS: Higher costs to N + P involvement without obvious change in outcomes were found in patients undergoing cranioplasty. Although other factors are more significant for the initial cranioplasty cost (sepsis, LOS), surgeon type proved the independent dominant factor for total cranioplasty costs, including revisions.

Angiographic factors leading to hemorrhage in AVMs: A systematic review and meta-analysis.

For patients with unruptured intracranial arteriovenous malformations (AVMs), the risk of a hemorrhagic event is approximately 2% to 4% annually. These events have an associated 20-50% morbidity and 10% mortality rate. An understanding of risk factors that predispose these lesions to rupture is important for optimal management. We aimed to pool a large cohort of both ruptured and unruptured AVMs from the literature with the goal of identifying angiographic risk factors that contribute to rupture. A systematic review of the literature was conducted in accordance with the PRISMA guidelines using Pubmed, Embase, Scopus, and Web of Science databases. Studies that presented patient-level data from ruptured AVMs from January 1990 to January 2022 were considered for inclusion. The initial screening of 8,304 papers resulted in a quantitative analysis of 25 papers, which identified six angiographic risk factors for AVM rupture. Characteristics that significantly increase the odds of rupture include the presence of aneurysm (OR = 1.45 [1.19, 1.77], p < 0.001, deep location (OR = 3.08 [2.56, 3.70], p < 0.001), infratentorial location (OR = 2.79 [2.08, 3.75], p < 0.001), exclusive deep venous drainage (OR = 2.50 [1.73, 3.61], p < 0.001), single venous drainage (OR = 2.97 [1.93, 4.56], p < 0.001), and nidus size less than 3 cm (OR = 2.54 [1.41, 4.57], p = 0.002). Although previous literature has provided insight into AVM rupture risk factors, obscurity still exists regarding which risk factors pose the greatest risk. We have identified six major angiographic risk factors (presence of an aneurysm, deep location, infratentorial location, exclusive deep venous drainage, single venous drainage, and nidus size less than 3 cm) that, when identified by a clinician, may help to tailor patient-specific approaches and guide clinical decisions.

Flat-panel dual-energy head computed tomography in the angiography suite after thrombectomy for acute stroke: A clinical feasibility study.

BACKGROUND: Management of large vessel occlusion (LVO) patients after thrombectomy is affected by the presence of intracranial hemorrhage (ICH) on post-procedure imaging. Differentiating contrast staining from hemorrhage on post-procedural imaging has been facilitated by dual-energy computed tomography (DECT), traditionally performed in dedicated computed tomography (CT) scanners with subsequent delays in treatment. We employed a novel method of DECT using the Siemens cone beam CT (DE-CBCT) in the angiography suite to evaluate for post-procedure ICH and contrast extravasation. METHODS: After endovascular treatment for LVO was performed and before the patient was removed from the operating table, DE-CBCT was performed using the Siemens Q-biplane system, with two separate 20-second CBCT scans at two energy levels: 70 keV (standard) and 125 keV with tin filtration (nonstandard). Post-procedurally, patients also underwent a standard DECT using Siemens SOMATOM Force CT scanner. Two independent reviewers blindly evaluated the DE-CBCT and DECT for hemorrhage and contrast extravasation. RESULTS: We successfully performed intra-procedural DE-CBCT in 10 subjects with no technical failure. The images were high-quality and subjectively useful to differentiate contrast from hemorrhage. The one hemorrhage seen on standard DECT was very small and clinically silent. The interrater reliability was 100% for both contrast and hemorrhage detection. CONCLUSION: We demonstrate that intra-procedural DE-CBCT after thrombectomy is feasible and provides clinically meaningful images. There was close agreement between findings on DE-CBCT and standard DECT. Our findings suggest that DE-CBCT could be used in the future to improve stroke thrombectomy patient workflow and to more efficiently guide the postoperative management of these patients.

Oral health and functional outcomes following mechanical thrombectomy for ischemic stroke.

BACKGROUND: An association between poor dentition and the risk of ischemic stroke has previously been reported in the literature. In this study we assessed oral hygiene (OH), including tooth loss and the presence of dental disease, to determine if an association exists with functional outcomes following mechanical thrombectomy (MT) for large-vessel ischemic stroke. METHODS: A retrospective review was conducted of consecutive adult patients at a single comprehensive stroke center who underwent MT from 2012 to 2018. Inclusion criteria included availability of CT imaging to radiographically assess OH. A multivariate analysis was performed, with the primary outcome being 90-day post-thrombectomy modified Rankin Scale (mRS) score >2. RESULTS: A total of 276 patients met the inclusion criteria. The average number of missing teeth was significantly higher in patients with a poor functional outcome (mean (SD) 10 (11) vs 4 (6), p<0.001). The presence of dental disease was associated with poor functional outcome, including cavities (21 (27%) vs 13 (8%), p<0.001), periapical infection (18 (23%) vs 11 (6.7%), p<0.001), and bone loss (27 (35%) vs 11 (6.7%), p<0.001). Unadjusted, missing teeth was a univariate predictor of poor outcome (OR 1.09 (95% CI 1.06 to 1.13), p<0.001). After adjustment for recanalization scores and use of tissue plasminogen activator (tPA), missing teeth remained a predictor of poor outcome (OR 1.07 (95% CI 1.03 to 1.11), p<0.001). CONCLUSION: Missing teeth and the presence of dental disease are inversely correlated with functional independence following MT, independent of thrombectomy success or tPA status.

Race as a factor in adverse outcomes following unruptured aneurysm surgery.

INTRODUCTION: Strong evidence demonstrates that race is associated with health outcomes. Previous neurosurgical research has focused predominantly on subjective data, such as patient satisfaction. Our objective was to assess whether racial disparities are present in primary objective outcomes for treatment of intracranial, unruptured aneurysms in the United States. METHODS: Data from the 2012-2015 National Inpatient Sample (NIS) database was analyzed. Patients who underwent either open or endovascular treatment of unruptured intracranial aneurysms were included (n = 11663). Patients were stratified by race, and those of unknown race or whose race sample size was too underpowered for analysis were excluded (n = 1202), along with those who experienced head trauma (n = 110) or concurrent AVM (n = 71). Poor outcome was defined as in-hospital mortality, discharge to a nursing facility or hospice, placement of a tracheostomy tube, or placement of a gastrostomy tube. The associations between race and adverse outcomes were determined through multivariate logistic regression, corrected for potentially confounding variables such as age, sex, procedural type, elective procedure, obesity, diabetes, tobacco, severity of illness, and hospital type. RESULTS: 7478 White, 1460 Black, 1086 Hispanic, and 279 Asian patients were included in the final analysis. Complication rates were not significantly different between races, however Black patients experienced the highest proportion of complications (24 %). After adjusting for confounders, the odds of poor outcomes were significantly higher for Black patients (OR = 1.32 95 % CI: 1.07-1.62; p = 0.008) when compared to White patients. Black and Hispanic patients demonstrated a longer length of stay (Black, B: 0.04; 95 % CI: 0.03, 0.06; p < 0.001; Hispanic, B: 0.04; 95 % CI: 0.02, 0.05; p < 0.001) when compared to White patients. CONCLUSION: Our nationwide analysis using the NIS suggests that Black patients treated for unruptured intracranial aneurysms experience worse outcomes and longer lengths of stay when compared to White patients. Recognizing the differences in objective outcomes and the presence of neurosurgical healthcare disparities is an important first step in providing equitable care to all patients. Future studies that carefully follow the social determinants of health and consider more confounding factors in the association between outcomes and determinants are needed.

Trends in utilization of standardized letters of recommendation in the 2021-2022 neurosurgery application process.

OBJECTIVE: Standardized letters of recommendation (SLORs) were introduced during the 2020-2021 neurosurgery residency application cycle, but suffered from poor interrater reliability and grade inflation. Changes were made to the SLOR template and utilization patterns in response to these shortcomings. The authors examined the second year of SLOR utilization. They hypothesized that grade inflation and interrater reliability would be improved from the first iteration. They also hypothesized that increased numbers of letters by single writers would correlate with broader rating distributions. METHODS: This cross-sectional study analyzed all SLORs submitted to a single neurosurgery residency program over the 2021-2022 cycle. Data from 7 competency domains and the overall rating were recorded and stratified by academic category of the letter writer. Interrater reliability was evaluated using Krippendorff's alpha. The frequency of letters written was evaluated using the Kruskal-Wallis H test. RESULTS: Ninety percent of SLORs rated applicants among the top 25%, but there was a significant decrease in the usage of the top 1% and top 2%-5% ratings. Interrater reliability was poor across all competencies. Writers who completed 1 SLOR rated applicants higher and had a narrower range than those who completed multiple SLORs. CONCLUSIONS: Changes in the format and subsequent utilization patterns of SLORs have slightly decreased grade inflation; however, interrater reliability remains poor. The most wide-ranging evaluators submitted the highest number of SLORs, suggesting that future evaluation and usage of SLORs should emphasize letter-writer characteristics and numbers of SLORs written. Overall, SLORs have been well and broadly accepted with subtle improvements in the second year of utilization.

Words matter: using natural language processing to predict neurosurgical residency match outcomes.

OBJECTIVE: Narrative letters of recommendation (NLORs) are considered by neurosurgical program directors to be among the most important parts of the residency application. However, the utility of these NLORs in predicting match outcomes compared to objective measures has not been determined. In this study, the authors compare the performance of machine learning models trained on applicant NLORs and demographic data to predict match outcomes and investigate whether narrative language is predictive of standardized letter of recommendation (SLOR) rankings. METHODS: This study analyzed 1498 NLORs from 391 applications submitted to a single neurosurgery residency program over the 2020-2021 cycle. Applicant demographics and match outcomes were extracted from Electronic Residency Application Service applications and training program websites. Logistic regression models using least absolute shrinkage and selection operator were trained to predict match outcomes using applicant NLOR text and demographics. Another model was trained on NLOR text to predict SLOR rankings. Model performance was estimated using area under the curve (AUC). RESULTS: Both the NLOR and demographics models were able to discriminate similarly between match outcomes (AUCs 0.75 and 0.80; p = 0.13). Words including "outstanding," "seamlessly," and "AOA" (Alpha Omega Alpha) were predictive of match success. This model was able to predict SLORs ranked in the top 5%. Words including "highest," "outstanding," and "best" were predictive of the top 5% SLORs. CONCLUSIONS: NLORs and demographic data similarly discriminate whether applicants will or will not match into a neurosurgical residency program. However, NLORs potentially provide further insight regarding applicant fit. Because words used in NLORs are predictive of both match outcomes and SLOR rankings, continuing to include narrative evaluations may be invaluable to the match process.

Does Plastic Surgery Involvement Decrease Complications After Cranioplasty? A Retrospective Cohort Study.

OBJECTIVES: To compare postoperative outcomes after cranioplasties performed by neurosurgery only (N) versus neurosurgery and plastic surgery combined (N+P). METHODS: A single-center, multisurgeon, retrospective cohort study was undertaken on all cranioplasties performed from November 2006 to December 2021. The primary exposure variable was operating team (N vs. N+P). The primary outcome was the need for reoperation. Secondary outcomes included surgical site infections, complications, length of stay (LOS), and length of drain placement. RESULTS: Of 188 patients undergoing cranioplasty during the study period, 106 (56%) patients were in the N group, and 82 (44%) were in the N+P group. Patient demographics were similar between the 2 groups. For the primary outcome, a total of 20 (18.9%) reoperations were seen in the N group, and 13 (15.9%) in the N+P group (P = 0.708). However, the median time to reoperation was slightly longer in the N+P group in the survival analysis. Wound dehiscence (1.9% vs. 3.7%, P = 0.454), surgical site infection (5.7% vs. 9.8%, P = 0.289), and complication rate (30.2% vs. 32.9%, P = 0.688) did not differ between the 2 groups. Furthermore, the N group had less Jackson-Pratt drain use (58.5% vs. 85.4%, P < 0.001), earlier drain removal (1.9 ± 1.6 vs. 3.4 ± 3.9 days, P < 0.001), and shorter LOS (3.8 ± 5.9 vs. 4.7 ± 3.9 days, P < 0.001). On multivariate regression analysis controlling for age, body mass index, smoking, craniectomy type, reason for craniectomy, and graft type, N+P was associated with increased drain use (odds ratio = 4.90, 95% confidence interval 2.28-11.30, P < 0.001) and longer drain duration (ß = 1.50, 95% confidence interval 0.43-2.60, P = 0.007). CONCLUSIONS: Despite similar complication and reoperation rates between groups, reoperations in the N group occurred sooner, whereas the N+P group more commonly used drains and kept drains in for longer.

Saline versus Balanced Crystalloids for Adults with Aneurysmal Subarachnoid Hemorrhage: A Subgroup Analysis of the SMART Trial.

Background: Whether the composition of intravenous crystalloid solutions affects outcomes in adults with aneurysmal subarachnoid hemorrhage (aSAH) remains unknown. Therefore, we determined whether the use of saline is associated with lower risk of disability and death in aSAH patients compared to balanced crystalloids. Methods: We conducted a post hoc subgroup analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART), a pragmatic, unblinded, cluster-randomized, multiple-crossover clinical trial that enrolled 15,802 adults between June 2015 and April 2017. We compared intravenous administration of saline to balanced crystalloids in consecutively enrolled aSAH patients aged 18 years or older whose ruptured aneurysm was procedurally secured at a single academic center in the United States. The primary outcome was the score on the modified Rankin scale (mRS, range, 0 [no symptoms] to 6 [death]) at 90 days obtained from a prospective institutional stroke registry. Secondary outcome included death by 90 days. Logistic or proportional odds regression models were used to test for between-group differences adjusted for age, hypertension, aSAH grade, and procedure type. Results: Of the 79 aSAH patients procedurally treated during the SMART study period, 78 were enrolled (median age, 58 years; IQR, 49 to 64.5; 64% female), with 41 (53%) assigned to saline and 37 (47%) to balanced crystalloids. Plasma-Lyte was the primary balanced crystalloid used. Among 72 patients with 90-day mRS assessment, the adjusted common odds ratio, aOR, for mRS was 0.68 (95% CI, 0.28-1.63; P=0.39), with values less than 1.0 favoring saline. By 90 days, 2/39 patients (5%) in the saline group and 9/35 (26%) in the balanced-crystalloids group had died (aOR, 0.06; 95% CI, 0.00-0.50; P=0.02). Conclusions: Among procedurally treated aSAH patients, the risk of disability or death at 90 days did not significantly differ between saline and balanced crystalloids. Death occurred less frequently with saline than balanced crystalloids.