Frailty in intracranial meningioma resection: the risk analysis index demonstrates strong discrimination for predicting non-home discharge and in-hospital mortality.

PURPOSE: Frailty is an independent risk factor for adverse postoperative outcomes following intracranial meningioma resection (IMR). The role of the Risk Analysis Index (RAI) in predicting postoperative outcomes following IMR is nascent but may inform preoperative patient selection and surgical planning. METHODS: IMR patients from the Nationwide Inpatient Sample were identified using diagnostic and procedural codes (2019-2020). The relationship between preoperative RAI-measured frailty and primary outcomes (non-home discharge (NHD), in-hospital mortality) and secondary outcomes (extended length of stay (eLOS), complication rates) was assessed via multivariate analyses. The discriminatory accuracy of the RAI for primary outcomes was measured in area under the receiver operating characteristic (AUROC) curve analysis. RESULTS: A total of 23,230 IMR patients (mean age = 59) were identified, with frailty statuses stratified by RAI score: 0-20 "robust" (R)(N = 10,665, 45.9%), 21-30 "normal" (N)(N = 8,895, 38.3%), 31-40 "frail" (F)(N = 2,605, 11.2%), and 41+ "very frail" (VF)(N = 1,065, 4.6%). Rates of NHD (R 11.5%, N 29.7%, F 60.8%, VF 61.5%), in-hospital mortality (R 0.5%, N 1.8%, F 3.8%, VF 7.0%), eLOS (R 13.2%, N 21.5%, F 40.9%, VF 46.0%), and complications (R 7.5%, N 11.6%, F 15.7%, VF 16.0%) significantly increased with increasing frailty thresholds (p < 0.001). The RAI demonstrated strong discrimination for NHD (C-statistic: 0.755) and in-hospital mortality (C-statistic: 0.754) in AUROC curve analysis. CONCLUSION: Increasing RAI-measured frailty is significantly associated with increased complication rates, eLOS, NHD, and in-hospital mortality following IMR. The RAI demonstrates strong discrimination for predicting NHD and in-hospital mortality following IMR, and may aid in preoperative risk stratification.

Assessing readability of online patient educational material on concussion and return to play.

OBJECTIVE: Concussions are self-limited forms of mild traumatic brain injury (TBI). Gradual return to play (RTP) is crucial to minimizing the risk of second impact syndrome. Online patient educational materials (OPEM) are often used to guide decision-making. Previous literature has reported that grade-level readability of OPEM is higher than recommended by the American Medical Association and the National Institutes of Health. The authors evaluated the readability of OPEM on concussion and RTP. METHODS: An online search engine was used to identify websites providing OPEM on concussion and RTP. Text specific to concussion and RTP was extracted from each website and readability was assessed using the following six standardized indices: Flesch Reading Ease (FRE), Flesch-Kincaid Grade Level, Gunning Fog Index, Coleman-Liau Index, Simple Measure of Gobbledygook Index, and Automated Readability Index. One-way ANOVA and Tukey's post hoc test were used to compare readability across sources of information. RESULTS: There were 59 concussion and RTP articles, and readability levels exceeded the recommended 6th grade level, irrespective of the source of information. Academic institutions published OPEM at simpler readability levels (higher FRE scores). Private organizations published OPEM at more complex (higher) grade-level readability levels in comparison with academic and nonprofit institutions (p < 0.05). CONCLUSIONS: The readability of OPEM on RTP after concussions exceeds the literacy of the average American. There is a critical need to modify the concussion and RTP OPEM to improve comprehension by a broad audience.

Frailty indices in patients undergoing surgical resection of brain metastases: a systematic review.

Brain metastases are a relatively common occurrence in patients with primary malignancies, with an incidence ranging from 9 to 17%. Their prevalence has increased due to treatment advancements that have led to improved survival in cancer patients. Frailty has demonstrated the ability to outperform greater patient age in surgical decision-making by predicting postoperative adverse events that include mortality, extended length of hospital stay, non-routine discharge disposition, and postoperative complications. Although predictive models based on frailty have been increasingly utilized in literature, their generalizability remains questionable due to inadequacies in model development and validation. Our systematic review describes development and validation cohorts of frailty indices used in patients undergoing surgical resection of brain metastases and serves as a guide to their incorporation in the outpatient clinical setting. A systematic review of literature was performed using PubMed and Google Scholar. Articles that reported outcomes using frailty indices in patients undergoing surgical resection of brain metastases were included. The Newcastle Ottawa Scale (NOS) was used to assess for risk of bias across individual studies. Studies with NOS > 5 were considered high quality. We identified 238 articles through our search strategy. After a title and abstract screen, followed by a full text review, 9 articles met criteria for inclusion. The 5- and 11-factor modified frailty indices were most frequently utilized (n = 4). Five studies utilized single-hospital databases, and four utilized nationwide databases. Six studies were considered high-quality based on the NOS. Although frailty indices have demonstrated the ability to predict outcomes in patients undergoing surgical resection of brain metastases, further validation of these indices is necessary prior to their incorporation in clinical practice.

Failure to rescue as a patient safety indicator for neurosurgical patients: are we there yet? A systematic review.

Failure to rescue (FTR) is a standardized patient safety indicator (PSI-04) developed by the Agency for Healthcare Research and Quality (AHRQ) to assess the ability of a healthcare team to prevent mortality following a major complication. However, FTR rates vary and are impacted by non-modifiable individual patient characteristics such as baseline frailty. This raises concerns regarding the validity of FTR as an objective quality metric, as not all patients have the same baseline frailty level, or physiological reserve, to recover from major complications. Literature from other surgical specialties has identified flaws in FTR and called for risk-adjusted metrics. Currently, knowledge of factors influencing FTR and its subsequent implementation in neurosurgical patients are limited. The present review assesses trends in FTR utilization to assess how FTR performs as an objective neurosurgery quality metric. This review then proposes how FTR may be best modified to optimize use in neurosurgical patients. A PubMed search was performed to identify articles published until August 9, 2023. Studies that reported FTR as an outcome in patients undergoing neurosurgical procedures were included. A qualitative assessment was performed using the Newcastle Ottawa Scale (NOS). The initial search revealed 1232 citations. After a title and abstract screen, followed by a full text screen, 12 studies met criteria for inclusion. These articles measured FTR across a total of 764,349 patients undergoing neurosurgical procedures. Five studies analyzed FTR with regard to hospital characteristics, and three studies utilized patient characteristics to predict FTR. All studies were considered high quality based on the NOS. Modifications in criteria to measure FTR are necessary since FTR depends on patient characteristics like frailty. This would allow for the incorporation of risk-adjusted FTR metrics that would aid in clinical decision making in neurosurgical patients.

Preoperative frailty and 30-day mortality after resection of brain metastases: a multicenter surgical registry analysis of 11,038 patients.

OBJECTIVE: Surgery plays a key role in the management of brain metastases. Stratifying surgical risk and individualizing treatment will help optimize outcomes because there is clinical equipoise between radiation and resection as treatment options for many patients. Here, the authors used a multicenter database to assess the prognostic utility of baseline frailty, calculated with the Risk Analysis Index (RAI), for prediction of mortality within 30 days after surgery for brain metastasis. METHODS: The authors pooled patients who had been surgically treated for brain metastasis from the American College of Surgeons National Surgical Quality Improvement Program database (2012-2020). The authors studied the relationship between preoperative calculated RAI score and 30-day mortality after surgery for brain metastasis by using linear-by-linear proportional trend tests and binary logistic regression. The authors calculated C-statistics (with 95% CIs) in receiver operating characteristic (ROC) curve analysis to assess discriminative accuracy. RESULTS: The authors identified 11,038 patients who underwent brain metastasis resection with a median (interquartile range) age of 62 (54-69) years. The authors categorized patients into four groups on the basis of RAI: robust (RAI 0-20), 8.1% of patients; normal (RAI 21-30), 9.2%; frail (RAI 31-40), 75%; and severely frail (RAI ≥ 41), 8.1%. The authors found a positive correlation between 30-day mortality and frailty. RAI demonstrated superior predictive discrimination for 30-day mortality as compared with the 5-factor modified frailty index (mFI-5) on ROC analysis (C-statistic 0.65, 95% CI 0.65-0.66). CONCLUSIONS: The RAI frailty score accurately estimates 30-day mortality after brain metastasis resection and can be calculated online with an open-access software tool: https://nsgyfrailtyoutcomeslab.shinyapps.io/BrainMetsResection/. Accordingly, RAI can be utilized to measure surgical risk, guide treatment options, and optimize outcomes for patients with brain metastases. RAI has superior discrimination for predicting 30-day mortality compared with mFI-5.

Gender concordance and publication productivity within Neurosurgical Focus: a 10-year review (2013-2022).

OBJECTIVE: The "leaky academic pipeline" describes how female representation in leadership positions has remained stagnant despite an increase in the number of female trainees. Female mentorship to female mentees, and female role models at higher academic positions have been shown to positively influence academic productivity. To the authors' knowledge, the impact of female editorial board representation on authorship trends in neurosurgical journals remains undescribed. This study aimed to analyze trends in the representation of female topic editors and its impact on female authorship within Neurosurgical Focus over a 10-year period. METHODS: Publicly available data were collected from the journal's website, inclusive from January 2013 to December 2022. The articles were grouped into technical and nontechnical themes based on their relevance to specific technical details regarding surgical techniques. Female gender-concordant publications were defined as publications having a female first author (or co-first author) and a female senior author. Linear regression analysis determined trends in publishing. Odds ratios and 95% CIs were calculated using logistic regression analysis. Pearson correlation and cross-correlation analyses were used to examine each pairwise comparison of time series. The statistical significance of associations was evaluated using t-tests and chi-square and Fisher's exact tests. RESULTS: The number of female topic editors and gender-concordant authors increased over time (p < 0.05). Women accounted for ≥ 50% of the topic editors on nontechnical themes relevant to education and gender diversity. Having a female senior author was associated with higher publication productivity for original research and review articles among female authors (OR 13.73, 95% CI 1.75-394.31; p < 0.05). Female authors had higher odds of publishing editorials with a female topic editor (OR 3.81, 95% CI 1.37-11.02; p < 0.01). Publications with female first and senior authors were significantly more likely to have female topic editors (OR 4.05, 95% CI 1.38-12.92; p < 0.01). A positive association was observed between female senior authors and female topic editors at lag -8, with a correlation coefficient of 0.19 (p = 0.03). CONCLUSIONS: Female attending-to-female trainee mentorship and female representation among editorial boards play a crucial role in enhancing academic productivity among women. Efforts to sustain academic productivity during the early-career period would presumably help increase female representation in neurosurgery.

Tetra ostial coronary arterial anatomy-A rare pattern in transposition.

BACKGROUND: Meticulous transfer of coronary arteries is of crucial importance in transposition and determines the success of the switch procedure. This report describes a coronary arterial anatomy consisting of four separate ostia from the two facing sinuses in a 6-month-old infant presenting with transposition and ventricular septal defect. CONCLUSION: Being a rare coronary arterial pattern not described in previous coding systems, the surgeon would do well to be aware of this possibility while performing the switch procedure.

Reporting of Participant Race and Ethnicity in Cerebrovascular Randomized Controlled Trials.

BACKGROUND: Randomized controlled trials (RCTs) provide information on appropriate management protocols in patients with cerebrovascular diseases. Despite growing evidence of race and ethnicity being independent predictors of outcomes, recent literature has drawn attention to inadequate reporting of these demographic profiles across RCTs. To our knowledge, the adherence to reporting race and/or ethnicity in cerebrovascular RCTs remains undescribed. Our study describes trends in the reporting of race and/or ethnicity across cerebrovascular RCTs. METHODS: Web of Science was searched to identify the top 100-cited cerebrovascular RCTs. Additional articles were retrieved from guidelines issued by the American Heart Association for the management of ischemic stroke, intracerebral hemorrhage, and aneurysmal subarachnoid hemorrhage. Univariate and multivariate analyses were performed to assess for factors influencing reporting of race/ethnicity. RESULTS: Sixty-five percent of cerebrovascular RCTs lacked reporting of participant race and/or ethnicity. Multivariate regression revealed that studies from North America had a 14.74- fold higher odds (95% CI: 4.574-47.519) of reporting race/ethnicity. Impact factor of the journal was associated with 1.007-fold odds of reporting race/ethnicity (95% CI: 1.000-1.013). Reporting of race and/or ethnicity did not increase with time, or vary according to the number of participating centers, median number of study participants, source of funding, or category of RCT. Among RCTs that reported race, Blacks and Asians were underrepresented compared to Whites. CONCLUSIONS: Sixty-five percent of prominent cerebrovascular RCTs lack adequate reporting of participant race/ethnicity. Reasons for inadequate reporting of these variables remain unclear and warrant additional investigation.

A Medical Student's Guide to Online Resources in Neurosurgery.

Early exposure to neurosurgery during medical school is critical to improving recruitment into the specialty. About 30% of medical schools in the U.S. lack a home program in neurosurgery, thereby, limiting their exposure to the field of neurosurgery. The transition to virtual education was largely facilitated through webinars during the coronavirus disease of 2019 pandemic. Advantages of these resources include their widespread global outreach, with a large number of attendees being international medical students. Although many such resources exist, they are primarily available through social media platforms. To our knowledge, there exists no clear outline of these resources. We identified 16 resources through a database search and through popular social media platforms. Nine out of 16 resources were video based, and 2 utilized the concept of spaced repetition through flashcards. Our review describes these educational resources and aims to serve as a guide for medical students interested in neurosurgery.

Baseline Frailty Measured by the Risk Analysis Index and 30-Day Mortality After Surgery for Spinal Malignancy: Analysis of a Prospective Registry (2011-2020).

OBJECTIVE: To evaluate the prognostic utility of baseline frailty, measured by the Risk Analysis Index (RAI), for prediction of postoperative mortality among patients with spinal malignancy (SM) undergoing resection. METHODS: SM surgery cases were queried from the American College of Surgeons - National Surgical Quality Improvement Program database (2011-2020). The relationship between preoperative RAI frailty score and increasing rate of primary endpoint (mortality or discharge to hospice within 30 days, "mortality/hospice") were assessed. Discriminatory accuracy was assessed by computation of C-statistics (with 95% confidence interval [CI]) in receiver operating characteristic (ROC) curve analysis. RESULTS: A total of 2,235 cases were stratified by RAI score: 0-20, 22.7%; 21-30, 11.9%; 31-40, 54.7%; and ≥ 41, 10.7%. The rate of mortality/hospice was 6.5%, which increased linearly with increasing RAI score (p < 0.001). RAI was also associated with increasing rates of major complication, extended length of stay, and nonhome discharge (all p < 0.05). The RAI demonstrated acceptable discriminatory accuracy for prediction of primary endpoint (C-statistic, 0.717; 95% CI, 0.697-0.735). In pairwise ROC comparison, RAI demonstrated superiority versus modified frailty index-5 and chronological age (p < 0.001). CONCLUSION: Preoperative frailty, as measured by RAI, is a robust predictor of mortality/ hospice after SM surgery. The frailty score may be applied in clinical settings using a user-friendly calculator, deployed here: https://nsgyfrailtyoutcomeslab.shinyapps.io/spinalMalignancyRAI/.

Risk Analysis Index Predicts Nonhome Discharge Following Resection of Cavernous Malformations.

OBJECTIVE: Intracranial cavernous malformations (CMs) are benign vascular lesions associated with hemorrhage, seizures, and corresponding neurological deficits. Recent evidence shows that frailty predicts neurosurgical adverse outcomes with superior discrimination compared to greater patient age. Therefore, we utilized the Risk Analysis Index (RAI) to predict adverse outcomes following cavernous malformation resection (CMR). METHODS: This retrospective study utilized the Nationwide Inpatient Sample to identify patients who underwent craniotomy for CMR (2019-2020). Multivariate analysis used RAI to assess the ability of frailty to predict nonhome discharge (NHD), extended length of stay (eLOS), and postoperative adverse outcomes. Receiver operating characteristic curve analysis evaluated the discriminatory accuracy of RAI for prediction of NHD. RESULTS: One thousand two hundred CMR patients were identified. Mean patient age was 38±1.2 years, 53.3% (N=640) were female, and 58.3% (N=700) had private insurance. Patients were stratified into 4 frailty tiers based on RAI scores: "robust" (0-20, R), N=905 (80.8%); "normal" (21-30, N), N=110 (9.8%); "frail" (31-40, F), N=25 (2.2%); and "very frail" (41+, VF), N = 80 (7.1%). Increasing frailty was associated with eLOS and higher rates of NHD (P<0.05). The RAI demonstrated strong discriminatory accuracy (C-statistic=0.722) for prediction of NHD following CMR in area under the receiver operating characteristics. CONCLUSIONS: Preoperative frailty independently predicts adverse outcomes, including eLOS and NHD in patients undergoing resection of cranial CMs. Integrating RAI into preoperative frailty risk assessment may optimize risk stratification and improve patient selection and reallocate perioperative management resources for better patient outcomes.

Assessing the predictive value of the Risk Analysis Index for short-term outcomes in acute spinal cord injury surgery.

BACKGROUND: Acute traumatic spinal cord injury (tSCI) requires rapid surgical intervention to maximize neurological function. Older patients comprise an increasingly larger proportion of SCI patients annually, necessitating accurate preoperative risk stratification tools. This study utilized a frailty-based preoperative risk stratification score to predict adverse events following non-elective neurosurgical intervention for acute tSCI patients. METHODS: The National Inpatient Sample (NIS) was queried for acute tSCI patients aged ≥18 who underwent spine surgery in 2019-2020. The Risk Analysis Index (RAI) was implemented with crosstabulation, to analyze frailty scores with the following binary outcome measures: overall complications, non-home discharge (NHD), extended length of stay (eLOS) (>75th percentile), and mortality. Area Under the Receiver Operating Characteristic (AUROC) analysis assessed the discriminative threshold of RAI compared to the modified 5-item Frailty Index (mFI-5) for NHD and 30-day mortality. RESULTS: A total of 9995 SCI patients underwent non-elective spine surgery. There were 1525 perioperative complications (15.3%) and 510 (5.1%) mortalities. An increasing RAI score was significantly associated with increasing postoperative mortality rates: RAI 0-20 (1.5%, N.=45), RAI 21-30 (3.4%, N.=110), RAI 31-40 (6.8%, N.=115), and RAI>41 (11.8%, N.=240) (P<0.001). RAI demonstrated superior discrimination compared to the mFI-5 for mortality and NHD with a C-statistic >0.72. CONCLUSIONS: Increasing frailty, as measured by RAI, was a reliable predictor of non-home discharge and 30-day mortality for SCI patients who underwent non-elective spinal surgery and RAI demonstrated superior discrimination compared to the mFI-5 for NHD and mortality.

Frailty predicts non-home discharge in anterior lumbar interbody fusion patients.

BACKGROUND: Anterior lumbar interbody fusion (ALIF) is a well-established surgical approach in the treatment of degenerative pathology, trauma, infection, and neoplasia of the spine. This study sought to assess the usefulness of frailty as a predictor of non-home discharge (NHD) for patients who undergo the procedure. METHODS: Patient cases were extracted from the American College of Surgeons's National Surgical Quality Improvement Program database from 2012 to 2020. Univariable and receiver operating characteristic curve analyses were used to compare the 5-item Modified Frailty Index (mFI-5) to the Revised Risk Analysis Index (RAI-rev) in relation to NHD. RESULTS: Simple linear regression demonstrated that increasing frailty was associated with an increased likelihood of NHD among 25,317 patients (mFI-5 odds ratio: 2.13, 3.23, 8.4; RAI-rev odds ratio: 3.22, 9.6, 23.6 [P<0.001 for all]). In each instance, a Cochran-Armitage trend test was significant (P<0.001), indicating a linear association of increasing odds. The RAI-rev resulted in a C-statistic of 0.722, compared to 0.628 for the mFI-5, and was shown to have superior discriminative ability with a DeLong Test (P<0.001). CONCLUSIONS: Frailty, as measured by mFI-5 and RAI-rev, was associated with an increased likelihood of NHD in patients who underwent ALIF. This finding supports recent literature on the promising utility of these indices, especially the RAI-rev, in preoperative decision-making across multiple facets of neurosurgery.

Hospital frailty risk score predicts high-value care outcomes following brain metastasis resection.

OBJECTIVE: Brain metastases (BM) are the most common adult intracranial tumors, representing a significant source of morbidity in patients with systemic malignancy. Frailty indices, including 11- and 5-factor modified frailty indices (mFI-11 and mFI-5), American Society of Anesthesiologists (ASA) physical status classification, and Charlson Comorbidity Index (CCI), have recently demonstrated an important role in predicting high-value care outcomes in neurosurgery. This study aims to investigate the efficacy of the newly developed Hospital Frailty Risk Score (HFRS) on postoperative outcomes in BM patients. METHODS: Adult patients with BM treated surgically at a single institution were identified (2017-2019). HFRS was calculated using ICD-10 codes, and patients were subsequently separated into low (<5), intermediate (5-15), and high (>15) HFRS cohorts. Multivariate logistic regressions were utilized to identify associations between HFRS and complications, length of stay (LOS), hospital charges, and discharge disposition. Model discrimination was assessed using receiver operating characteristic (ROC) curves. RESULTS: A total of 356 patients (mean age: 61.81±11.63 years; 50.6 % female) were included. The mean±SD for HFRS, mFI-11, mFI-5, ASA, and CCI were 6.46±5.73, 1.31±1.24, 0.95±0.86, 2.94±0.48, and 8.69±2.07, respectively. On multivariate analysis, higher HFRS was significantly associated with greater complication rate (OR=1.10, p<0.001), extended LOS (OR=1.13, p<0.001), high hospital charges (OR=1.14, p<0.001), and nonroutine discharge disposition (OR=1.12, p<0.001), and comparing the ROC curves of mFI-11, mFI-5, ASA,and CCI, the predictive accuracy of HFRS was the most superior for all four outcomes assessed. CONCLUSION: The predictive ability of HFRS on BM resection outcomes may be superior than other frailty indices, offering a new avenue for routine preoperative frailty assessment and for managing postoperative expectations.

Predictors of Extended Length of Stay After Treatment of Unruptured Intracranial Aneurysms.

BACKGROUND: Despite their asymptomatic occurrence, unruptured intracranial aneurysms (UIAs) account for a significant proportion of hospital charges and healthcare resource utilization in the United States. Hospital length of stay (LOS) is a reimbursement metric utilized to incentivize value-based care. Our study identifies predictors of extended LOS (eLOS) after elective treatment of UIAs. METHODS: This was a retrospective study of 525 patients who underwent elective treatment of an UIA at a single institution. Data were collected with regard to demographics, clinical presentation, treatment characteristics, and postoperative outcomes. The primary outcome, eLOS, was defined as hospital stay in the upper quartile of the median (≥75th percentile). Univariate and multivariate analyses were performed to identify factors predictive of eLOS in this cohort. RESULTS: The average age of the cohort was 61.40, standard deviation=11.41. 77.3% of the cohort was female. The median duration of LOS was 2 days (interquartile range: 1-5). 11.6% experienced eLOS (≥5 days). Multivariate logistic regression identified age (OR: 1.04, 95% confidence interval [CI]: 1.01-1.07), coexistent vascular pathology (OR: 21.33, 95% CI: 8.06-56.39), open surgery (OR: 3.93, 95% CI: 1.85-8.34), and postoperative stroke (OR: 11.72, 95% CI: 3.18-43.18) as independent predictors of eLOS. CONCLUSIONS: Our study identified predictors of eLOS that could help promote risk stratification prior to treatment of UIAs. Future research that identifies predictors of long-term outcomes based on treatment modality could help identify ways to improve healthcare resource utilization in this cohort.

The frailty-driven predictive model for failure to rescue among patients who experienced a major complication following cervical decompression and fusion: an ACS-NSQIP analysis of 3,632 cases (2011-2020).

BACKGROUND CONTEXT: Preoperative risk stratification for patients considering cervical decompression and fusion (CDF) relies on established independent risk factors to predict the probability of complications and outcomes in order to help guide pre and perioperative decision-making. PURPOSE: This study aims to determine frailty's impact on failure to rescue (FTR), or when a mortality occurs within 30 days following a major complication. STUDY DESIGN/SETTING: Cross-sectional retrospective analysis of retrospective and nationally-representative data. PATIENT SAMPLE: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried for all CDF cases from 2011-2020. OUTCOME MEASURES: CDF patients who experienced a major complication were identified and FTR was calculated as death or hospice disposition within 30 days of a major complication. METHODS: Frailty was measured by the Risk Analysis Index-Revised (RAI-Rev). Baseline patient demographics and characteristics were compared for all FTR patients. Significant factors were assessed by univariate and multivariable regression for the development of a frailty-driven predictive model for FTR. The discriminative ability of the predictive model was assessed using a receiving operating characteristic (ROC) curve analysis. RESULTS: There were 3632 CDF patients who suffered a major complication and 7.6% (277 patients) subsequently expired or dispositioned to hospice, the definition of FTR. Independent predictors of FTR were nonelective surgery, frailty, preoperative intubation, thrombosis or embolic complication, unplanned intubation, on ventilator for >48 hours, cardiac arrest, and septic shock. Frailty, and a combination of preoperative and postoperative risk factors in a predictive model for FTR, achieved outstanding discriminatory accuracy (C-statistic = 0.901, CI: 0.883-0.919). CONCLUSION: Preoperative and postoperative risk factors, combined with frailty, yield a highly accurate predictive model for FTR in CDF patients. Our model may guide surgical management and/or prognostication regarding the likelihood of FTR after a major complication postoperatively with CDF patients. Future studies may determine the predictive ability of this model in other neurosurgical patient populations.

Extended Length of Stay After Mechanical Thrombectomy for Stroke: A Single-Center Analysis of 703 Patients.

BACKGROUND AND OBJECTIVES: Mechanical thrombectomy (MT) is crucial for improving functional outcomes for acute ischemic stroke. Length of stay (LOS) is a reimbursement metric implemented to incentivize value-based care. Our study aims to identify predictors of LOS in patients undergoing MT at a high-volume center in the United States. METHODS: This was a retrospective study of patients who underwent MT at a single institution from 2017 to 2023. Patients who experienced mortality during their course of hospital stay were excluded from this study. Extended LOS (eLOS) was defined as the upper quartile (≥75th) of the median duration of hospital stay. Univariate and multivariate analyses were performed, with P values < .05 denoting statistical significance. RESULTS: Seven hundred three patients met criteria for inclusion. The median age of the cohort was 72 years (IQR: 61-82), and 57.2% was female. The median LOS was 6, IQR: 4-10. A total of 28.9% of the cohort (n = 203) patients experienced eLOS. The multivariate regression model identified age (odds ratio [OR]: 0.98, 95% CI: 0.97-0.99), diabetes mellitus (OR: 1.68, 95% CI: 1.15-2.44), and hemorrhagic transformation of stroke (OR: 2.89, 95% CI: 0.39-0.90) as predictors of eLOS, whereas antiplatelet use before admission (OR: 0.55, 95% CI: 0.34-0.89) and higher baseline modified Rankin Scale before stroke were associated with lower odds (OR: 0.59 [0.39-0.90]; P < .05) of eLOS. CONCLUSION: By identifying predictors of eLOS, we provide a foundation for targeted interventions aimed at optimizing post-thrombectomy care pathways and improving patient outcomes. The implications of our study extend beyond clinical practice, offering insights into healthcare resource utilization, reimbursement strategies, and value-based care initiatives.

Use of the Scepter Dual-Lumen Balloon Catheter for Transarterial Onyx Embolization of Cranial Dural Arteriovenous Fistulas.

BACKGROUND: Dual-lumen balloon microcatheters allow for controlled anterograde flow of Onyx while providing proximal flow arrest, thereby obviating the need for a second microcatheter or Onyx plug formation. We sought to assess the safety and efficiency of the Scepter dual-lumen balloon microcatheter in trans arterial Onyx embolization of intracranial dural arteriovenous fistulas (DAVFs). METHODS: We conducted a retrospective study of 36 patients with cranial DAVFs in which a Scepter balloon microcatheter was used between 2016 and 2023. RESULTS: Our study comprised 36 patients, mostly male (n = 23, 63.8%) with a mean age of 60.8 years. Most DAVFs were in the occipital lobe (n = 24, 66.7%), and 50% had external carotid artery supply from the occipital artery. Eighteen (50%) of DAVFs were Cognard type III and IV, respectively. About one third (33.3%, n = 12) of the DAVFs drained into the transverse sigmoid junction, and 27.7% (n = 10) had direct cortical venous drainage into supratentorial or posterior fossa veins. Complete occlusion was obtained in 22 (61.1%) patients while partial occlusion was observed in 14 (38.9%) patients. One patient (2.8%) developed a retroperitoneal hematoma. At final follow-up, complete occlusion was observed in 21 (77.8%) and partial occlusion was observed in 8 (22.2%). Recurrence was observed in 4/30 (13.3%) patients, and retreatment was required in 6 (18.75%) cases. CONCLUSIONS: At midterm follow-up, our study showed low morbidity and modest complete occlusion rates using the Scepter for transarterial Onyx embolization of high-grade DAVFs.

Initial Experience with the Eclipse Double-Lumen Balloon Catheter for Embolization of Cranial Vascular Malformations.

BACKGROUND: Double lumen balloon catheters (DLBCs) have emerged as a potential alternative to single lumen balloon catheters for endovascular embolization of arteriovenous malformations (AVMs) and dural arteriovenous fistulas (dAVFs). This study describes our preliminary experience with the Eclipse 2L DLBC in treating AVMs and dAVFs. METHODS: Patients who underwent embolization of cranial dAVFs or AVMs at our institution from August 2021 to March 2024 were included. Spinal vascular malformations were excluded. Descriptive statistics were used to analyze procedural outcomes, technical nuances, and postoperative outcomes on follow-up. RESULTS: Twenty-five patients who underwent 38 embolization procedures (15 AVMs and 23 dAVFs) met criteria for inclusion in this study. The mean age of the cohort was 52.44 (standard deviation = 17.26), and 48% of the overall cohort (n = 13) was female. The average procedure times for AVMs and dAVFs were 80.4 minutes and 96.73 minutes, respectively. There was 1 instance of catheter entrapment. Two patients in the AVM cohort experienced mortality, and 1 experienced postoperative rupture. CONCLUSIONS: Our preliminary experience using the Eclipse 2L balloon catheter for Onyx embolization reported procedural outcomes comparable to other DLBCs despite relatively higher procedure times and radiation doses. Further long-term studies on its efficacy as primary modality in treating AVMs and dAVFs are encouraged.

Correlation of Computed Tomography Angiography to Digital Subtraction Angiography in Carotid Stenosis with Real-World Assessment of Overestimation of Carotid Stenosis on Computed Tomography Angiography.

OBJECTIVE: Computed tomography angiography (CTA) is a well-established diagnostic modality for carotid stenosis. However, false-positive CTA results may expose patients to unnecessary procedural complications in cases where surgical intervention is not warranted. We aim to assess the correlation of CTA to digital subtraction angiography (DSA) in carotid stenosis and characterize patients who were referred for intervention based on CTA and did not require it based on DSA. METHODS: We retrospectively reviewed 186 patients who underwent carotid angioplasty and stenting following preprocedural CTA at our institution from April 2017 to December 2022. RESULTS: Twenty-one of 186 patients (11.2%) were found to have <50% carotid stenosis on DSA (discordant group). Severe plaque calcification on CTA was associated with a discordant degree of stenosis on DSA (LR+=7.4). Among 186 patients, agreement between the percentage of stenosis from CTA and DSA was weak-moderate (r2=0.27, P<0.01). Among concordant pairs, we found moderate-strong agreement between CTA and DSA (adj r2=0.37) (P < 0.0001). Of 186 patients, 127 patients had CTA stenosis of ≥70%, and 59 had CTA of 50%-69%. Correlation between CTA and DSA in severe CTA stenosis was weak (r2=0.11, P<0.01). CONCLUSIONS: In patients with stenosis found on CTA, over 88% also had stenosis on DSA, with this positive predictive value in line with previous studies. The percent-stenosis value from CTA and DSA was weakly correlated but does not affect the overall clinical judgement of stenosis. Severe calcification found on CTA may potentially indicate nonstenosis on DSA.