The effect of age on cerebral vasospasm and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage.

BACKGROUND: The association between patient age and cerebral arterial vasospasm (CVS) and delayed cerebral ischemia (DCI) risk following aneurysmal subarachnoid hemorrhage (aSAH) remains unclear. This study aims to assess the role of age on aSAH-related complications. METHODS: Single-center retrospective study comprising aSAH patients treated between January 2009 and March 2023. Age was analyzed as continuous and categorical variables (<60yrs vs. ≥60yrs and by decade). Outcomes of interest included radiographic CVS, DCI, cerebral infarction, in-hospital mortality, length-of-stay, ventriculoperitoneal shunt placement, and modified Rankin Scale (mRS) scores at discharge and 3-month follow-up. RESULTS: 925 aSAH patients were included. Most (n=598; 64.6%) were <60yrs old (46±9.1yrs). CVS likelihood was lower in the older cohort (aOR=0.56 [0.38-0.82]). Patients ≥60yrs had higher mortality rates (aOR=2.24 [1.12-4.47]) and worse mRS scores at discharge (aOR=2.66 [1.91-3.72]) and 3-month follow-up (aOR=2.19 [1.44-3.32]). Advanced age did not have a significant effect on DCI or cerebral infarction risk. Higher in-hospital mortality was documented with increasing age (p<0.001). A significant interaction between CVS and age for the outcome of DCI was documented, with a stronger positive effect on poor outcomes (i.e., higher odds of DCI) among patients aged <60 years compared to those aged ≥60. CONCLUSION: There is an inverse relationship between patient age and CVS incidence following aSAH. Nonetheless, patients ≥60yrs had comparable DCI rates, higher in-hospital mortality, and worse functional outcomes than their younger counterparts. Routine screening and reliance on radiographic CVS as primary marker for aSAH-related complications should be reconsidered, particularly in older patients.

Racial and Ethnic Differences in Mortality and Functional Outcomes Following Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Ischemic and hemorrhagic stroke incidence tends to be higher among minority racial and ethnic groups. The effect of race and ethnicity following an aneurysmal subarachnoid hemorrhage (aSAH) remains poorly understood. Thus, we aimed to explore the association between race and ethnicity and aSAH outcomes. METHODS: Single-center retrospective review of patients with aSAH from January 2009 to March 2023. Primary outcome was in-hospital mortality. Secondary outcomes included delayed cerebral ischemia, cerebral infarction, radiographic and symptomatic vasospasm, pulmonary complications, epileptic seizures, external ventricular drain placement, and modified Rankin Scale score at discharge and 3-month follow-up. Associations between race and ethnicity and outcomes were assessed using binary and ordinal regression models, with multivariable models adjusted for significant covariates. RESULTS: A total of 1325 patients with subarachnoid hemorrhage presented to our center. Among them, 443 cases were excluded, and data from 882 patients with radiographically confirmed aSAH were analyzed. Distribution by race and ethnicity was 40.8% (n=360) White, 31.4% (n=277) Hispanic, 22.1% (n=195) Black, and 5.7% (n=50) Asian. Based on Hunt-Hess and modified Fisher grade, aSAH severity was similar among groups (P=0.269 and P=0.469, respectively). In-hospital mortality rates were highest for Asian (14.0%) and Hispanic (11.2%) patients; however, after adjusting for patient sex, age, health insurance, smoking history, alcohol and substance abuse, and aneurysm treatment, the overall likelihood was comparable to White patients. Hispanic patients had higher risks of developing cerebral infarction (adjusted odds ratio, 2.17 [1.20-3.91]) and symptomatic vasospasm (adjusted odds ratio, 1.64 [1.05-2.56]) than White patients and significantly worse discharge modified Rankin Scale scores (adjusted odds ratio, 1.44 [1.05-1.99]). Non-White patients also demonstrated a lower likelihood of 0 to 2 discharge modified Rankin Scale scores (adjusted odds ratio, 0.71 [0.50-0.98]). No significant interactions between race and ethnicity and age or sex were found for in-hospital mortality and functional outcomes. CONCLUSIONS: Our study identified significant differences in cerebral infarction and symptomatic vasospasm risk between Hispanic and White patients following aSAH. A higher likelihood of worse functional outcomes at discharge was found among non-White patients. These findings emphasize the need to better understand predisposing risk factors that may influence aSAH outcomes. Efforts toward risk stratification and patient-centered management should be pursued.

Minimally invasive anterior cervical foraminotomy for unilateral radiculopathy.

Anterior cervical foraminotomy (ACF) is an alternative surgical option for the treatment of refractory unilateral radiculopathy due to disc herniation or spondylosis. The efficacy and adverse event rate in experienced practitioners are comparable to those of anterior cervical discectomy and fusion, total disc arthroplasty, and posterior foraminotomy. However, this technique has not been widely adopted, likely because of the proximity of the working zone and the vertebral artery. The authors present a detailed operative video of a patient successfully treated with an ACF. They also present a review of the ACF literature. The video can be found here: https://stream.cadmore.media/r10.3171/2024.1.FOCVID23196.

Noninstrumented Free Fibula Flap for Cervical Osteomyelitis.

BACKGROUND AND IMPORTANCE: Severe cases of cervical vertebral osteomyelitis can pose a challenge regarding reconstruction, stability/alignment, and infection eradication. Here we describe the application of vascularized free fibula (FF) flaps to reconstruct the cervical spine without instrumentation in the setting of severe osteomyelitis. CLINICAL PRESENTATION: Two patients presented with symptomatic multilevel cervical osteomyelitis. Both patients were treated with corpectomy and FF flap without instrumentation using a novel wedging and distraction technique to secure the flap into position. Clinical outcomes were based on neurological recovery and infection management. Computed tomography (CT) and CT angiography with 3-dimensional reconstruction were used to measure fusion status and patency of the anastomoses. CT of the cervical spine completed 8 weeks postoperatively demonstrated robust fusion of the fibula flaps to adjacent cervical vertebrae. In both patients, CT angiography demonstrated patency of the arterial anastomoses. Both flaps maintained persistent deformity correction. Both patients made full neurological recovery. DISCUSSION: This reconstructive approach represents a salvage technique that offers advantages in cases of prior hardware failure or unfavorable host factors with rapid fusion and definitive treatment with a single surgery. CONCLUSION: The use of FF flap without instrumentation seems to be a safe and effective option for cervical spine reconstruction in the setting of severe osteomyelitis.

The chicken wing training model in cerebrovascular microsurgery for the side-to-side bypass.

In the expanding era of endovascular treatment and minimally invasive techniques, the neurosurgical trainees have a steady decrease in the exposure to microsurgical skills. However, there remain a need for neurosurgical trainees to be proficient at such skills, particularly for performing high-stakes interventions such as vascular bypasses. The scarcity of cerebrovascular bypasses coupled with the technical expertise it demands necessitates the presence of a training model for neurosurgical residents and fellows. Regarding the model utilizing the chicken wing for vascular anastomoses, the neurosurgical literature has described many models of bypasses involving the end-to-end and end-to-side anastomoses. The side-to-side anastomosis however is not clearly depicted in these papers. Here we focus on technique, chicken wing anatomy, and donor/recipient vessel diameters to provide a comprehensive guide for trainees. We describe a reproducible and reliable chicken wing model to perform an in-situ side-to-side bypass that incorporates integral elements of a successful bypass surgery.

Integrated Stroke System Model Expands Availability of Endovascular Therapy While Maintaining Quality Outcomes.

BACKGROUND AND PURPOSE: The optimal endovascular stroke therapy (EVT) care delivery structure is unknown. Here, we present our experience in creating an integrated stroke system (ISS) to expand EVT availability throughout our region while maintaining hospital and physician quality standards. METHODS: We identified all consecutive patients with large vessel occlusion acute ischemic stroke treated with EVT from January 2014 to February 2019 in our health care system. In October 2017, we implemented the ISS, in which 3 additional hospitals (4 total) became EVT-performing hospitals (EPHs) and physicians were rotated between all centers. The cohort was divided by time into pre-ISS and post-ISS, and the primary outcome was time from stroke onset to EPH arrival. Secondary outcomes included hospital and procedural quality metrics. We performed an external validation using data from the Southeast Texas Regional Advisory Council. RESULTS: Among 513 patients with large vessel occlusion acute ischemic stroke treated with EVT, 58% were treated pre-ISS and 43% post-ISS. Over the study period, EVT procedural volume increased overall but remained relatively low at the 3 new EPHs (<70 EVT/y). After ISS, the proportion of patients who underwent interhospital transfer decreased (46% versus 37%; P<0.05). In adjusted quantile regression, ISS implementation resulted in a reduction of time from stroke onset to EPH arrival by 40 minutes (P<0.01) and onset to groin puncture by 29 minutes (P<0.05). Rates of postprocedural hemorrhage, modified Thrombolysis in Cerebral Infarction (TICI) 2b/3, and 90-day modified Rankin Scale were comparable at the higher and lower volume EPHs. The improvement in onset-to-arrival time was not reflective of overall improvement in secular trends in regional prehospital care. CONCLUSIONS: In our system, increasing EVT availability decreased time from stroke onset to EPH arrival. The ISS provides a framework to maintain quality in lower volume hospitals.

Embolization of carotid-cavernous fistulas: A technical note on simultaneous balloon protection of the internal carotid artery.

A carotid-cavernous fistula (CCF) is an abnormal connection between the carotid circulation and the cavernous sinus. Treatment of CCFs often consists of obliteration of the fistula by a transarterial or transvenous endovascular approach using embolic agents. However, fistula embolization is often halted due to the potential embolic complications that may arise from the retrograde flow of the embolic agents into the arterial circulation, which often leads to the development of fistula recurrence. Moreover, retreatment of a CCF recurrence is challenging and more complex approaches may be required. In this technical note, we describe our experience with CCF embolization in 25 patients treated at a single center. We utilized a transvenous approach for CCF embolization with simultaneous balloon occlusion of the internal carotid artery during the infusion of the embolic material into the fistula. In our series, this simultaneous protection of the internal carotid artery showed to be a safe technique to prevent embolic complications and to achieve successful obliteration of the fistula. On follow-up, 2 cases presented a recurrence, one due to technical difficulties and the other related to an undetected vascular injury. In conclusion, this technique provides a safe approach in the treatment of CCFs by decreasing the risk of embolic complications and increasing the effectiveness of the embolic agents in accomplishing the obliteration of the CCF.

The Pipeline From Abstract Presentation to Publication in Pediatric Hospital Medicine.

BACKGROUND: The annual Pediatric Hospital Medicine (PHM) conference serves as a venue for the dissemination of research in this rapidly growing discipline. A measure of research validity is subsequent publication in peer-reviewed journals. OBJECTIVE: To identify the publication rate of abstracts submitted to the 2014 PHM conference and determine whether presentation format was associated with subsequent journal publication or time to publication. METHODS: We identified abstracts submitted to the 2014 PHM conference. Presentation formats included rejected abstracts and poster and oral presentations. Abstracts subsequently published in journals were identified by searching the author and abstract title in PubMed, MedEdPORTAL, and Google Scholar. We used logistic regression and Cox proportional hazards models to determine if presentation format was associated with publication, time to publication, and publishing journal impact factor. RESULTS: Of 226 submitted abstracts, 19.0% were rejected, 68.0% were selected for posters, and 12.8% were selected for oral presentations; 36.3% were subsequently published within 30 months after the conference. Abstracts accepted for oral presentation had more than 7-fold greater odds of publication (adjusted odds ratio 7.8; 95% confidence interval [CI], 2.6-23.5) and a 4-fold greater likelihood of publication at each month (adjusted hazard ratio 4.5; 95% CI, 2.1-9.7) compared with rejected abstracts. Median journal impact factor was significantly higher for oral presentations than other presentation formats (P < 0.01). CONCLUSIONS: Abstract reviewers may be able to identify methodologically sound studies for presentation; however, the low overall publication rate may indicate that presented results are preliminary or signify a need for increased mentorship and resources for research development in PHM.

Resection of a recurrent cervical internal carotid artery pseudoaneurysm after failed endovascular therapy.

BACKGROUND: Recurrence of a cervical internal carotid artery (ICA) pseudoaneurysm initially treated by endovascular means is rare. We report an instance where a patient returned with a recurrent, enlarging cervical ICA pseudoaneursym, 15 years after initial complete, endovascular occlusion of the ICA. CASE DESCRIPTION: Patient is a 64-year-old male with a history of a right cervical ICA pseudoaneurysm diagnosed 15 years ago after a car accident. At the time, he received endovascular occlusion of his right ICA. Recent serial imaging demonstrated progressive enlargement of his pseudoaneurysm, up to 6 cm × 5 cm × 5.5 cm, without evidence of internal flow or extravasation. Due to dysphagia and hoarseness, resection of the pseudoaneurysm was recommended. Dissection occurred down to the lesion, where its borders were skeletonized. Its stump at the proximal ICA was mobilized and clamped; the lesion was incised and the existing thrombus, as well as the coil mass, was removed. The distal ICA appeared completely scarred with no retrograde filling. There were branches from the external carotid artery that appeared to supply the pseudoaneurysm. The scarred remnant of the distal ICA was sutured and the stump at the proximal ICA was ligated. Once hemostasis was obtained, closure occurred via anatomical layers. Postoperatively, the patient woke up well; at discharge, he exhibited no respiratory distress or dysphagia. At 5 months follow-up, a computed tomography angiography of the neck revealed no evidence for a residual pseudoaneurysm. He continues on lifelong aspirin. CONCLUSION: Recurrence of a cervical ICA pseudoaneursym is rare. We caution that such a clinical scenario is possible, even 15 years after endovascular occlusion of the ICA. Branches from the external carotid artery may feed the pseudoaneursym and cause recurrence. This mechanism has not been reported. Perhaps longer clinical follow-up is necessary, especially if endovascular therapy is the initial treatment option.

Are we underestimating the burden of traumatic brain injury? Surveillance of severe traumatic brain injury using centers for disease control International classification of disease, ninth revision, clinical modification, traumatic brain injury codes.

BACKGROUND: The epidemiology of traumatic brain injury (TBI) is often studied through the use of International classification of disease, ninth revision, clinical modification (ICD-9-CM), diagnosis codes from the Centers for Disease Control and Prevention TBI Surveillance System. Recent studies suggest that these codes may underestimate the burden of TBI because of inaccuracies and low sensitivity. OBJECTIVE: To determine the sensitivity and specificity of ICD-9-CM codes in a severe TBI population. METHODS: We retrospectively reviewed medical records of all hospital admissions including computed tomography of the head at a single center to identify severe blunt TBI patients, their injuries, and the neurosurgical procedures performed. We calculated sensitivity and specificity by comparing ICD-9-CM diagnosis and procedure codes assigned by hospital coders with medical records, the gold standard. RESULTS: In 2008, there were 148 qualifying admissions. These codes were 89% sensitive for the presence of any severe TBI. However, one-fifth of these cases were identified only with a code defining a nonspecific head injury. Next, we studied types of TBI by categories defined by the Centers for Disease Control and Prevention (morbidity groups) and by ICD-9-CM codes for types of injury (any skull fracture, intracranial contusion, intracranial hemorrhage, concussion/loss of consciousness) and found widely varying sensitivity and specificity for both. In general, these codes had higher specificity than sensitivity. Both sensitivity and specificity were > 80% for only 2 categories: any skull fracture and intracranial hemorrhage. In contrast, we found high sensitivity and specificity for neurosurgical procedures (97% and 94%). CONCLUSION: ICD-9-CM codes were sensitive for the presence of any severe TBI, but further classification of specific types of TBI was limited by variable sensitivity/specificity. Use of these codes should be supplemented by other methodology.

The AIS-2005 Revision in Severe Traumatic Brain Injury: Mission Accomplished or Problems for Future Research?

The Abbreviated Injury Scale (AIS) is commonly used to score injury severity and describe types of injuries. In 2005, the AIS-Head section was revised to capture more detailed information about head injuries and to better reflect their clinical severity, but the impact of these changes is largely unknown. The purpose of this study was to compare AIS-1998 and AIS-2005 coding of traumatic brain injuries (TBI) using medical records at a single Level I trauma center. We included patients with severe TBI (Glasgow Coma Scale 3-8) after blunt injury, excluding those who were missing medical records. Detailed descriptions of injuries were collected, then manually coded into AIS-1998 and AIS-2005 by the same Certified AIS Specialist. Compared to AIS-1998, AIS-2005 coded the same injuries with lower severity scores [p<0.01] and with decreased mean and maximum AIS-Head scores [p<0.01]. Of the types of traumatic brain injuries, most of the changes occurred among cerebellar and cerebral injuries. Traumatic hypoxic brain injury secondary to systemic dysfunction was captured by AIS-2005 but not by AIS-1998. However, AIS-2005 captured fewer loss of consciousness cases due to changes in criteria for coding concussive injury. In conclusion, changes from AIS-1998 to AIS-2005 result in significant differences in severity scores and types of injuries captured. This may complicate future TBI research by precluding direct comparison to datasets using AIS-1998. TBIs should be coded into the same AIS-version for comparison or evaluation of trends, and specify which AIS-version is used.

Gamma knife radiosurgery for patients with nonfunctioning pituitary adenomas: results from a 15-year experience.

PURPOSE: To evaluate the efficacy and complications of stereotactic radiosurgery for patients with nonfunctioning pituitary adenomas (NFA). METHODS AND MATERIALS: This was a retrospective review of 62 patients with NFA undergoing radiosurgery between 1992 and 2004, of whom 59 (95%) underwent prior tumor resection. The median treatment volume was 4.0 cm(3) (range, 0.8-12.9). The median treatment dose to the tumor margin was 16 Gy (range, 11-20). The median maximum point dose to the optic apparatus was 9.5 Gy (range, 5.0-12.6). The median follow-up period after radiosurgery was 64 months (range, 23-161). RESULTS: Tumor size decreased for 37 patients (60%) and remained unchanged for 23 patients (37%). Two patients (3%) had tumor growth outside the prescribed treatment volume and required additional treatment (fractionated radiation therapy, n = 1; repeat radiosurgery, n = 1). Tumor growth control was 95% at 3 and 7 years after radiosurgery. Eleven (27%) of 41 patients with normal (n = 30) or partial (n = 11) anterior pituitary function before radiosurgery developed new deficits at a median of 24 months after radiosurgery. The risk of developing new anterior pituitary deficits at 5 years was 32%. The 5-year risk of developing new anterior pituitary deficits was 18% for patients with a tumor volume of < or = 4.0 cm(3) compared with 58% for patients with a tumor volume >4.0 cm(3) (risk ratio = 4.5; 95% confidence interval = 1.3-14.9, p = 0.02). No patient had a decline in visual function. CONCLUSIONS: Stereotactic radiosurgery is effective in the management of patients with residual or recurrent NFA, although longer follow-up is needed to evaluate long-term outcomes. The primary complication is hypopituitarism, and the risk of developing new anterior pituitary deficits correlates with the size of the irradiated tumor.