Assessing survival in non-small cell lung cancer brain metastases after stereotactic radiosurgery: before and after the start of the targetable mutation era.

PURPOSE: Targeted treatment options for non-small cell lung cancer (NSCLC) brain metastases (BMs) may be combined with stereotactic radiosurgery (SRS) to optimize survival. We assessed patient outcomes after SRS for NSCLC BMs, identifying survival trajectories associated with targetable mutations. METHODS: In this retrospective time-dependent analysis, we analyzed median overall survival of patients who received ≥ 1 SRS courses for BM from NSCLC from 2001 to 2021. We compared survival of patients with and without targetable mutations based on clinical variables and treatment. RESULTS: Among the 213 patients included, 87 (40.8%) had targetable mutations-primarily EGFR (22.5%)-and 126 (59.2%) did not. Patients with targetable mutations were more often female (63.2%, p <.001) and nonsmokers (58.6%, p <.001); had higher initial lung-molGPA (2.0 vs. 1.5, p <.001) and lower cumulative tumor volume (3.7 vs. 10.6 cm3, p <.001); and received more concurrent (55.2% vs. 36.5%, p =.007) and total (median 3 vs. 2, p <.001) systemic therapies. These patients had lower mortality rates (74.7% vs. 91.3%, p <.001) and risk (HR 0.298 [95%CI 0.190-0.469], p <.001) and longer median overall survival (20.2 vs. 7.4 months, p <.001), including survival ≥ 3 years (p =.001). Survival was best predicted by SRS with tumor resection in patients with non-targetable mutations (HR 0.491 [95%CI 0.318-757], p =.001) and by systemic therapy with SRS for those with targetable mutations (HR 0.124 [95%CI 0.013-1.153], p =.067). CONCLUSION: The presence of targetable mutations enhances survival in patients receiving SRS for NSCLC BM, particularly when used with systemic therapies. Survival for patients without targetable mutations was longest with SRS and surgical resection. These results inform best practices for managing patients with NSCLC BM based on driver mutation status.

Factors Associated with Venous Thromboembolism Development in Patients with Traumatic Brain Injury.

BACKGROUND: Venous thromboembolic (VTE) events are a major concern in trauma and intensive care, with the prothrombotic state caused by traumatic brain injury (TBI) increasing the risk in affected patients. We sought to identify critical demographic and clinical variables and determine their influence on subsequent VTE development in patients with TBI. METHODS: This was a cross-sectional study with data retrospectively collected from 818 patients with TBI admitted to a level I trauma center in 2015-2020 and placed on VTE prophylaxis. RESULTS: The overall VTE incidence was 9.1% (7.6% deep vein thrombosis, 3.2% pulmonary embolism, 1.7% both). The median time to diagnosis was 7 days (interquartile range 4-11) for deep vein thrombosis and 5 days (interquartile range 3-12) for pulmonary embolism. Compared with those who did not develop VTE, patients who developed VTE were younger (44 vs. 54 years, p = 0.02), had more severe injury (Glasgow Coma Scale 7.5 vs. 14, p = 0.002, Injury Severity Score 27 vs. 21, p < 0.001), were more likely to have experienced polytrauma (55.4% vs. 34.0%, p < 0.001), more often required neurosurgical intervention (45.9% vs. 30.5%, p = 0.007), more frequently missed ≥ 1 dose of VTE prophylaxis (39.2% vs. 28.4%, p = 0.04), and were more likely to have had a history of VTE (14.9% vs. 6.5%, p = 0.008). Univariate analysis demonstrated that 4-6 total missed doses predicted the highest VTE risk (odds ratio 4.08, 95% confidence interval 1.53-10.86, p = 0.005). CONCLUSIONS: Our study highlights patient-specific factors that are associated with VTE development in a cohort of patients with TBI. Although many of these are unmodifiable patient characteristics, a threshold of four missed doses of chemoprophylaxis may be particularly important in this critical patient population because it can be controlled by the care team. Development of intrainstitutional protocols and tools within the electronic medical record to avoid missed doses, particularly among patients who require operative interventions, may result in decreasing the likelihood of future VTE formation.

Hospital-Acquired Infection at Time of Stroke and Cognitive Decline: The Cardiovascular Health Study.

Introduction Hospital-acquired infections (HAIs) after stroke are associated with additional morbidity and mortality, but whether HAIs increase long-term cognitive decline in stroke patients is unknown. We hypothesized that older adults with incident stroke with HAI experience faster cognitive decline than those having stroke without HAI and those without stroke. Methods We performed a longitudinal analysis in the population-based prospective Cardiovascular Health Study. Medicare-eligible participants aged >65 years with and without incident stroke had cognition assessed annually. HAIs were assessed by hospital discharge codes. Global cognitive function was assessed annually by Modified Mini-Mental State Examination (3MSE) and executive function by Digit Symbol Substitution Test (DSST). We used linear mixed models to estimate the mean decline and 95% confidence intervals (95% CI) for 3MSE and DSST scores by incident stroke and HAI status, adjusted for demographics and vascular risk factors. Results Among 5,443 participants >65 years without previous history of stroke, 393 participants had stroke with HAI (SI), 766 had a stroke only (SO), and 4,284 had no stroke (NS) throughout a maximum 9-year follow-up. For 3MSE, compared with NS participants, SO participants had a similar adjusted mean decline (additional 0.08 points/year, 95%CI -0.15, 0.31), while SI participants had a more rapid decline (additional 0.28 points/year, 95%CI 0.16, 0.40). Adjusted mean decline was 0.20 points/year faster (95%CI -0.05, 0.45) among SI than SO participants. For DSST, compared with NS participants, SO participants had a faster adjusted mean decline (additional 0.17 points/year (95%CI 0.003, 0.33), as did SI participants (additional 0.27 points/year (95%CI 0.19, 0.35). Conclusion Stroke, when accompanied by HAI, leads to a faster long-term decline in cognitive ability than in those without stroke. The clinical and public health implications of the effect of infection on post-stroke cognitive decline warrant further attention.

High-grade glioma imaging volumes and survival: a single-institution analysis of 101 patients after resection using intraoperative MRI.

PURPOSE: Intraoperative magnetic resonance imaging (iMRI) has been efficacious in maximizing resection of high-grade gliomas (HGGs). In this single-institution study of patients with HGGs who underwent resection using iMRI, the authors present a volumetric-based survival analysis to evaluate progression-free survival (PFS) and overall survival (OS), as well as the impact of additional resection on survival. METHODS: This retrospective analysis included patients with HGGs who underwent resection using iMRI from 2011 to 2021. Volumetric analyses of T1-weighted contrast-enhancing (T1W-CE), T2-weighted (T2W), and T2W fluid-attenuated inversion recovery (FLAIR) MRI sequences were assessed at preoperative, intraoperative, immediate postoperative, and three-month postoperative timepoints. Statistical analyses were carried out using log-rank and multivariable Cox proportional hazard regression analyses. RESULTS: A total of 101 patients (median age 57.0 years) were treated. In keeping with prior studies, statistically significant associations between greater EOR and longer PFS and OS were seen (p = 0.012 and p = 0.006, respectively). The results demonstrated significant associations of lower preoperative T2W, 3-month postoperative T2W, and 3-month postoperative FLAIR volumes with longer PFS and OS (p = 0.045 and p = 0.026, p = 0.031 and p = 0.006, p = 0.018 and p = 0.004, respectively), as well as associations between lower immediate postoperative T2W and immediate postoperative FLAIR volumes with longer OS (p = 0.002 and p = 0.02). There was no observed association in either PFS or OS for patients undergoing additional resection after initial iMRI scan (p = 0.387 and p = 0.592). CONCLUSION: This study of 101 patients with new or recurrent HGGs shows three-month postoperative T2W and FLAIR imaging volumes were significant prognosticators with respect to PFS and OS.

Development of a residents-as-teachers curriculum for neurosurgical training programs.

Neurosurgery residents spend a significant amount of their time teaching patients, families, students, residents, and other health professionals. To help ensure competence in their residents' teaching abilities, many specialties have established formal residents-as-teachers (RAT) curricula; however, such formalized curricula are often lacking in neurosurgery programs. The authors' goal was to develop and implement a formal RAT curriculum, designed with neurosurgery residents' other responsibilities in mind, to improve residents' formal and informal teaching abilities. Here, the authors report on the design of a formalized teaching curriculum tailored for the needs of neurosurgical residents, with a focus on deliberate practice and minimal time needed for preparation. The curriculum, designed using Kern's 6 steps of curriculum design as a framework, comprises 5 lecture series spread over 3 years, repeated twice through a resident's training, with each lecture series outlined with its respective topics and objectives. Opportunities for observed teaching as well as informal and formal evaluation will be provided to residents. The program will be evaluated on a yearly basis using direct and anonymized resident feedback on the RAT curriculum. Measures of program success will also include pre- and postprogram medical student and peer evaluation of residents. These data will be used for continual improvement of the curriculum as it is implemented. Successes and shortcomings of this program will be disseminated by publication, presentations, and placement on the authors' department website and social media. This paper may serve as a foundation for other neurosurgical programs to develop RAT curricula for greater enhancement of resident teaching abilities.

Surgical Management of Ipsilateral Internal Carotid Artery Stenosis and Unruptured Intracranial Aneurysm: Case Review and Treatment Considerations.

Introduction The coexistence of carotid artery stenosis and a concomitant downstream ipsilateral unruptured intracranial aneurysm requires unique treatment considerations to balance the risk of thromboembolic complications from carotid artery stenosis and the risk of subarachnoid hemorrhage from intracranial aneurysm rupture. These considerations include the selection of optimal treatment modalities, the order and timing of interventions, and potential management of antiplatelet agents with endovascular approaches. We present strategies to optimize treatment in such a case. Case Report We discuss the case of a 69-year-old woman with 90% stenosis of the right internal carotid artery and an ipsilateral, wide-necked, 4.8-mm, irregular-appearing right A1-2 junction aneurysm with an associated daughter sac. Open, endovascular, and mixed treatment strategies were considered. The patient selected and underwent a staged, open treatment approach with a carotid endarterectomy followed by a right craniotomy for microsurgical clipping of the aneurysm 5 days later. Both procedures were performed on daily full-dose aspirin without complications. On follow-up, the right carotid artery was widely patent, the aneurysm was secured, and the patient remained at her neurologic baseline. Discussion The presented strategy for ipsilateral carotid artery stenosis and an unruptured intracranial aneurysm initially optimized cerebral perfusion to mitigate ischemic risks while permitting timely aneurysm intervention without a need for dual antiplatelet therapy or to traverse an earlier procedure site.

Emerging Treatments for Subarachnoid Hemorrhage.

The current landscape of therapeutic strategies for subarachnoid hemorrhage (SAH), a significant adverse neurological event commonly resulting from the rupture of intracranial aneurysms, is rapidly evolving. Through an in-depth exploration of the natural history of SAH, historical treatment approaches, and emerging management modalities, the present work aims to provide a broad overview of the shifting paradigms in SAH care. By synthesizing the historical management protocols with contemporary therapeutic advancements, patient-specific treatment plans can be individualized and optimized to deliver outstanding care for the best possible SAH-related outcomes.

Management Patterns and Outcomes After Traumatic Brain Injury With Associated Blunt Cerebrovascular Injury.

BACKGROUND AND OBJECTIVES: Although blunt cerebrovascular injuries (BCVIs) are relatively common in patients with traumatic brain injuries (TBIs), uncertainty remains regarding optimal management strategies to prevent neurological complications, morbidity, and mortality. Our objectives were to characterize common care patterns; assess the prevalence of adverse outcomes, including stroke, functional deficits, and death, by BCVI grade; and evaluate therapeutic approaches to treatment in patients with BCVI and TBI. METHODS: Patients with TBI and BCVI treated at our Level I trauma center from January 2016 to December 2020 were identified. Presenting characteristics, treatment, and outcomes were captured for univariate and multivariate analyses. RESULTS: Of 323 patients with BCVI, 145 had Biffl grade I, 91 had grade II, 49 had grade III, and 38 had grade IV injuries. Lower-grade BCVIs were more frequently managed with low-dose (81 mg) aspirin ( P < .01), although all grades were predominantly treated with high-dose (150-600 mg) aspirin ( P = .10). Patients with low-grade BCVIs had significantly fewer complications ( P < .01) and strokes ( P < .01). Most strokes occurred in the acute time frame (<24 hours), including 10/11 (90.9%) grade IV-related strokes. Higher BCVI grade portended elevated risk of stroke (grade II odds ratio [OR] 5.3, grade III OR 12.2, and grade IV OR 19.6 compared with grade I; all P < .05). The use of low- or high-dose aspirin was protective against mortality (both OR 0.1, P < .05). CONCLUSION: In patients with TBI, BCVIs impart greater risk for stroke and other associated morbidities as their severity increases. It may prove difficult to mitigate high-grade BCVI-related stroke, considering most events occur in the acute window. The paucity of late time frame strokes suggest that current management strategies do help mitigate risks.

The clinical potential of radiomics to predict hematoma expansion in spontaneous intracerebral hemorrhage: a narrative review.

Spontaneous intracerebral hemorrhage (sICH) is associated with significant morbidity and mortality, with subsequent hematoma expansion (HE) linked to worse neurologic outcomes. Accurate, real-time predictions of the risk of HE could enable tailoring management-including blood pressure control or surgery-based on individual patient risk. Although multiple radiographic markers of HE have been proposed based on standard imaging, their clinical utility remains limited by a reliance on subjective interpretation of often ambiguous findings and a poor overall predictive power. Radiomics refers to the quantitative analysis of medical images that can be combined with machine-learning algorithms to identify predictive features for a chosen clinical outcome with a granularity beyond human limitations. Emerging data have supported the potential utility of radiomics in the prediction of HE after sICH. In this review, we discuss the current clinical management of sICH, the impact of HE and standard imaging predictors, and finally, the current data and potential future role of radiomics in HE prediction and management of patients with sICH.

Clinical Characteristics and Surgical Outcomes of 2542 Patients with Spinal Schwannomas: A Systematic Review and Meta-Analysis.

OBJECTIVE: This study was conducted to systematically analyze the data on the clinical features, surgical treatment, and outcomes of spinal schwannomas. METHODS: We conducted a systematic review and meta-analysis under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A search of bibliographic databases from January 1, 2001, to May 31, 2021, yielded 4489 studies. Twenty-six articles were included in our final qualitative systematic review and quantitative meta-analysis. RESULTS: Analysis of 2542 adult patients' data from 26 included studies showed that 53.5% were male, and the mean age ranged from 35.8 to 57.1 years. The most common tumor location was the cervical spine (34.2%), followed by the thoracic spine (26.2%) and the lumbar spine (18.5%). Symptom severity was the most common indicator for surgical treatment, with the most common symptoms being segmental back pain, sensory/motor deficits, and urinary dysfunction. Among all patients analyzed, 93.8% were treated with gross total resection, which was associated with better prognosis and less chance of recurrence than subtotal resection. The posterior approach was the most common (87.4% of patients). The average operative time was 4.53 hours (95% confidence interval [CI], 3.18-6.48); the average intraoperative blood loss was 451.88 mL (95% CI, 169.60-1203.95). The pooled follow-up duration was 40.6 months (95% CI, 31.04-53.07). The schwannoma recurrence rate was 5.3%. Complications were particularly low and included cerebrospinal fluid leakage, wound infection, and the sensory-motor deficits. Most of the patients experienced complete recovery or significant improvement of preoperative neurological deficits and pain symptoms. CONCLUSIONS: Our analysis suggests that segmental back pain, sensory/motor deficits, and urinary dysfunction are the most common symptoms of spinal schwannomas. Surgical resection is the treatment of choice with overall good reported outcomes and particularly low complication rates. gross total resection offers the best prognosis with the slightest chance of tumor recurrence and minimal risk of complications.

Biophysiologic Monitoring for the Neurosurgical Patient.

Biophysiologic monitoring exists as a method of collecting objective information about the neurosurgical patient throughout their treatment and recovery process. Such data is crucial for an improved understanding of the disease processes while providing the surgeon additional clarity as they decipher the next best steps in decision-making and medical recommendations. In the current review article, the authors discuss the commonly used wearable and placeable monitoring devices and the biophysiological data that can be collected to monitor, as well as, assess the neurosurgical patient. Special focus is placed on invasive and non-invasive neurologic monitoring devices, but important and commonly used monitors for the rest of the body are also discussed as they relate to the neurosurgical patient. Last, the authors review new, as well as, upcoming devices and measurements to better analyze the neurosurgical patient's bodily function and physiologic status as needed. The synthesis of methods contained herein may provide meaningful guidance for neurosurgeons in effectively monitoring and treating their patients while also helping to guide their future efforts in patient biophysiologic monitoring developments within neurosurgery.

The Role of Advanced Imaging in Neurosurgical Diagnosis.

Neurosurgery as a specialty has developed at a rapid pace as a result of the continual advancements in neuroimaging modalities. With more sophisticated imaging options available to the modern neurosurgeon, diagnoses become more accurate and at a faster rate, allowing for greater surgical planning and precision. Herein, the authors review the current heavily used imaging modalities within neurosurgery, weighing their strengths and weaknesses, and provide a look into new advances and imaging options within the field. Of the many imaging modalities currently available to the practicing neurosurgeon, magnetic resonance imaging (MRI), computed tomography (CT), positron emission tomography (PET), and ultrasonography (US) are used most heavily within the field for appropriate diagnosis of neuropathologies in question. For each, their strengths are weighed regarding appropriate capabilities in accurate diagnosis of cranial or spinal lesions. Reasoning for choosing one over the other for various pathologies is also reviewed. Current limitations of each is also assessed, providing insight for possible improvement for each. New advancements in imaging options are subsequently reviewed for best uses within neurosurgery, including the new utilization of FIESTA sequencing, glymphatic mapping, black-blood MRI, and functional MRI. The specialty of neurosurgery will continue to heavily rely on improvements within imaging options available for improved diagnosis and greater surgical outcomes for the patients treated. The synthesis of techniques provided herein may provide meaningful guidance for neurosurgeons in effectively diagnosing neurological pathologies while also helping guide future efforts in neuroimaging developments.

Frailty predicts worse outcomes for spine surgery patients with interhospital transfer status: Analysis of 295,875 patients from the National Surgical Quality Improvement Program (NSQIP) 2015-2019.

STUDY DESIGN: Retrospective analysis of a prospectively maintained database. OBJECTIVES: To evaluate the effects of interhospital transfer (IHT) status, age, and frailty on postoperative outcomes in patients who underwent spine surgery. METHODS: The National Surgical Quality Improvement Program (NSQIP) database was queried for patients who underwent spine surgeries from 2015 to 2019 (N = 295,875). Univariate and multivariable analyses were utilized to analyze the effect of IHT on postoperative outcomes and the contribution of baseline frailty status (mFI-5 score stratified into "pre-frail", "frail", and "severely frail") on outcomes in IHT patients. Effect sizes were summarized by odds ratio (OR) with associated 95% confidence intervals (95% CI). RESULTS: Of 295,875 patients in the study, 3.3% (N = 9666) were IHT status. On multivariable analysis, controlling for covariates, IHT status was significantly associated with greater likelihood of 30-day mortality (odds ratio [OR] = 9.3), major complications (OR=5.0), Clavien-Dindo (CD) grade IV complications (OR=7.0), unplanned readmission (OR=2.1), unplanned reoperation (OR=2.6), eLOS (OR=16.1), and discharge to non-home destination (OR=12.7) (all P < 0.001). Increasing frailty was significantly associated with poor outcomes in spine surgery patients with IHT status compared to chronological age. CONCLUSIONS: This study provides evidence that IHT status is associated with poor outcomes in spine surgery patients. Furthermore, increasing frailty more than increasing age was a robust predictor of poor outcomes among IHT spine surgical patients. Baseline frailty status, as measured by the mFI-5, may be utilized for preoperative risk stratification of patients with IHT status with anticipated spine surgery.

Hospital-acquired infection following spinal tumor surgery: A frailty-driven pre-operative risk model.

BACKGROUND: Hospital-acquired infection (HAI) after spinal tumor resection surgery contributes to adverse patient outcomes and excess healthcare resource utilization. This study sought to develop a predictive model for HAI occurrence following surgery for spinal tumors. METHODS: The National Surgical Quality Improvement Program (NSQIP) 2015-2019 database was queried for spinal tumor resections. Baseline demographics and preoperative clinical characteristics, including frailty, were analyzed. Frailty was measured by modified frailty score 5 (mFI-5) and risk analysis index (RAI). Univariate and multivariable analyses were performed to identify independent risk factors for HAI occurrence. A logit-based predictive model for HAI occurrence was designed and discriminative power was assessed via receiver operating characteristic (ROC) analysis. RESULTS: Of 5883 patients undergoing spinal tumor surgery, HAI occurred in 574 (9.8 %). The HAI (vs. non-HAI) cohort was older and frailer with higher rates of preoperative functional dependence, chronic steroid use, chronic lung disease, coagulopathy, diabetes, hypertension, tobacco smoking, unintentional weight loss, and hypoalbuminemia (all P < 0.05). In multivariable analysis, independent predictors of HAI occurrence included severe frailty (mFI-5, OR: 2.3, 95 % CI: 1.1-5.2, P = 0.035), nonelective surgery (OR: 1.7, 95 % CI: 1.1-2.4, P = 0.007), and hypoalbuminemia (OR: 1.5, 95 % CI: 1.1-2.2, P = 0.027). A logistic regression model with frailty score alongside age, race, BMI, elective vs. non-elective surgery, and pre-operative labs have predicted HAI occurrence with a C-statistic of 0.68 (95 % CI: 0.64-0.72). CONCLUSIONS: HAI occurrence after spinal tumor surgery can be predicted by standardized frailty metrics, mFI-5 and RAI-rev, alongside routinely measured preoperative characteristics (demographics, comorbidities, pre-operative labs).

Immunohistochemical Profiling and Staging in Esthesioneuroblastoma: A Single-Center Cohort Study and Systematic Review.

OBJECTIVE: Esthesioneuroblastoma (ENB) is a rare sinonasal malignant neoplasm with 40% 5-year survival. Because of the rarity of the tumor, the optimal treatment and subsequent prediction of prognosis are unclear. We studied a modern series of patients with ENB to evaluate the association of immunohistochemical (IHC) markers and clinical stages/grades with outcomes. METHODS: A single-center retrospective review of patients with ENB treated during a 25-year period was performed. A systematic literature review evaluating the prognostic benefits of current staging systems in evaluating survival outcomes in ENB was undertaken. RESULTS: Among 29 included patients, 25 (85%) were treated surgically at our institution, with 76% of those endoscopically resected; 7 (24.1%) received chemotherapy, and 18 (62.1%) received radiation therapy. The 5-year overall survival (OS) was 91.3%, and 10-year OS was 78.3%. Progression-free survival at 5 and 10 years was 85.6% and 68.2%, respectively. A total of 36 distinct IHC markers were used to diagnose ENB but were inconsistent in predicting survival. A systematic literature review revealed predictive accuracy for OS using the Kadish, TNM, and Hyams staging/grading systems was 68%, 42%, and 50%, respectively. CONCLUSIONS: This study reports the 5- and 10-year OS and progression-free survival in a modern series of patients with ENB. No traditional IHC marker consistently predicted outcome. Some novel reviewed markers show promise but have yet to enter clinical mainstream use. Our systematic review of accepted staging/grading systems also demonstrated a need for further investigation due to limited prognostic accuracy.

Understanding the Unique Challenges Faced by Homeless Patients With Acute Traumatic Neurosurgical Injuries.

BACKGROUND: Homelessness is associated with high risk of acute neurotraumatic injury in the ∼600 000 Americans affected on any given night. OBJECTIVE: To compare care patterns and outcomes between homeless and nonhomeless individuals with acute neurotraumatic injuries. METHODS: Adults hospitalized for acute neurotraumatic injuries between January 1, 2015, and December 31, 2020, were identified in this retrospective cross-sectional study at our Level 1 trauma center. We evaluated demographics, in-hospital characteristics, discharge dispositions, readmissions, and adjusted readmission risk. RESULTS: Of 1308 patients, 8.5% (n = 111) were homeless on admission to neurointensive care. Compared with nonhomeless individuals, homeless patients were younger ( P = .004), predominantly male ( P = .003), and less frail ( P = .003) but had similar presenting Glasgow Coma Scale scores ( P = .85), neurointensive care unit stay time ( P = .15), neurosurgical interventions ( P = .27), and in-hospital mortality ( P = .17). Nevertheless, homeless patients had longer hospital stays (11.8 vs 10.0 days, P = .02), more unplanned readmissions (15.3% vs 4.8%, P < .001), and more complications while hospitalized (54.1% vs 35.8%, P = .01), particularly myocardial infarctions (9.0% vs 1.3%, P < .001). Homeless patients were mainly discharged to their previous living situation (46.8%). Readmissions were primarily for acute-on-chronic intracranial hematomas (4.5%). Homelessness was an independent predictor of 30-day unplanned readmissions (odds ratio 2.41 [95% CI 1.33-4.38, P = .004]). CONCLUSION: Homeless individuals experience longer hospital stays, more inpatient complications such as myocardial infarction, and more unplanned readmissions after discharge compared with their housed counterparts. These findings combined with limited discharge options in the homeless population indicate that better guidance is needed to improve the postoperative disposition and long-term care of this vulnerable patient population.

Application of Radiomics to the Differential Diagnosis of Temporal Bone Skull Base Lesions: A Pilot Study.

BACKGROUND: Temporal bone skull base pathologies represent a complex differential because they can be radiographically obscure and difficult to diagnose without biopsy. Radiomics involves the use of mathematical quantification of imaging data beyond simple intensity, size, and location to inform diagnosis and prognosis. We examined the feasibility of using radiomic parameters to help predict temporal bone tumor type. METHODS: A total of 117 radiomic parameters were analyzed from 5 magnetic resonance imaging sequences (T1 without contrast, T1 with contrast, T2, fluid-attenuated inversion recovery, apparent diffusion coefficient [ADC]) for each tumor. Statistical analysis was used to delineate known primary, metastatic/secondary, and lymphoma lesions using radiomics. RESULTS: The mean tumor volumes for the 14 primary, 12 secondary, and 8 lymphoma lesions were 2.98 ± 2.11, 3.28 ± 2.31, and 12.16 ± 7.1 cm3, respectively (P = 0.2). No significant differences in mean intensity values for any sequence helped distinguish tumors (P > 0.05), but 6 radiomic parameters were significantly correlated with diagnostic accuracy. Discriminant analysis using a stepwise algorithm generated a model where radiomic parameters for T1 cluster prominence, ADC dependence nonuniformity, T1 with contrast zone percentage, and ADC informational measure of correlation 2 achieved the best predictive model (P = 0.0001). These significant characteristics were often indirect measures of tumor heterogeneity on different magnetic resonance imaging sequences. CONCLUSIONS: These data suggest that quantitative measures of tumor heterogeneity can be discriminatory of pathology and might be integrated into clinical workflow. Although this pilot study requires further validation, these data support the exploration of radiomics in temporal bone radiographic diagnostics.

O-Arm Accuracy and Radiation Exposure in Adult Deformity Surgery.

OBJECTIVE: In long thoracolumbar deformity surgery, accurate screw positioning is critical for spinal stability. We assessed pedicle and pelvic screw accuracy and radiation exposure in patients undergoing long thoracolumbar deformity fusion surgery (≥4 levels) involving 3-dimensional fluoroscopy (O-Arm/Stealth) navigation. METHODS: In this retrospective single-center cohort study, all patients aged >18 years who underwent fusion in 2016-2018 were reviewed. O-Arm images were assessed for screw accuracy. Effective radiation doses were calculated. The primary outcome was pedicle screw accuracy (Heary grade). Secondary outcomes were pelvic fixation screw accuracy, radiation exposure, and screw-related perioperative and postoperative complications or revision surgery within 3 years. RESULTS: Of 1477 pedicle screws placed in 91 patients (mean 16.41 ± 5.6 screws/patient), 1208 pedicle screws (81.8%) could be evaluated by 3-dimensional imaging after placement. Heary Grade I placement was achieved in 1150 screws (95.2%), Grade II in 47 (3.9%), Grade III in 10 (0.82%), Grade IV in 1 (0.08%), and Grade V in 0; Grade III-V were replaced intraoperatively. One of 60 (1.6%) sacroiliac screws placed showed medial cortical breach and was replaced. The average O-Arm-related effective dose was 29.54 ± 14.29 mSv and effective dose/spin was 8.25 ± 2.65 mSv. No postoperative neurological worsening, vascular injuries, or revision surgeries for screw misplacement were recorded. CONCLUSIONS: With effective radiation doses similar to those in interventional neuroendovascular procedures, the use of O-Arm in multilevel complex deformity surgery resulted in high screw accuracy, no need for surgical revision because of screw malposition, less additional imaging, and no radiation exposure for the surgical team.

The 5-item modified frailty index predicts spinal osteotomy outcomes better than age in adult spinal deformity patients: an ACS - NSQIP analysis.

PURPOSE: To evaluate the utility of 5-Item Modified Frailty Index (mFI-5) as compared to chronological age in predicting outcomes of spinal osteotomy in Adult Spinal Deformity (ASD) patients. METHODS: Using Current Procedural and Terminology (CPT) codes, the American College of Surgeons National Surgery Quality Improvement Program (ACS-NSQIP) database was queried for adult patients undergoing spinal osteotomy from 2015 to 2019. Multivariate regression analysis was performed to evaluate the effect of baseline frailty status, measured by mFI-5 score, and chronological age on postoperative outcomes. Receiver-operating characteristic (ROC) curve analysis was performed to analyze the discriminative performance of age versus mFI-5. RESULTS: A total of 1,789 spinal osteotomy patients (median age 62 years) were included in the analysis. Among the patients assessed, 38.5% (n = 689) were pre-frail, 14.6% frail (n = 262), and 2.2% (n = 39) severely frail using the mFI-5. Based on the multivariate analysis, increasing frailty tier was associated with worsening outcomes, and higher odds ratios (OR) for poor outcomes were found for increasing frailty tiers as compared to age. Severe frailty was associated with the worst outcomes, e.g., unplanned readmission (OR 9.618, [95% CI 4.054-22.818], p < 0.001) and major complications (OR 5.172, [95% CI 2.271-11.783], p < 0.001). In the ROC curve analysis, mFI-5 score (AUC 0.838) demonstrated superior discriminative performance than age (AUC 0.601) for mortality. CONCLUSIONS: The mFI5 frailty score was found to be a better predictor than age of worse postoperative outcomes in ASD patients. Incorporating frailty in preoperative risk stratification is recommended in ASD surgery.