The weekend effect in aneurysmal subarachnoid haemorrhage: a single centre experience and review.

Clinical outcomes for patients admitted to hospital during weekend hours have been reported to be poorer than for those admitted during the week. Aneurysmal subarachnoid haemorrhage (aSAH) is a devastating form of haemorrhagic stroke, with a mortality rate greater than 30%. A number of studies have reported higher mortality for patients with aSAH who are admitted during weekend hours. This study evaluates the effect of weekend admission on patients in our unit with aSAH in terms of time to treatment, treatment type, rebleeding rates, functional outcome, and mortality. We analysed a retrospective database of all patients admitted to our tertiary referral centre with aneurysmal subarachnoid haemorrhage between February 2016 and February 2020. Chi-square tests and t-tests were used to compare weekday and weekend demographic and clinical variables. Univariate and multivariate logistic regression analyses were performed to assess for any association between admission during weekend hours and increased neurological morbidity (assessed via Glasgow Outcome Scale at 3 months) and mortality. Of the 571 patients included in this study, 191 were admitted during on-call weekend hours. There were no significant differences found in time to treatment, type of treatment, rebleeding rates, neurological morbidity, or mortality rates between patients admitted during the week and those admitted during weekend hours. Weekend admission was not associated with worsened functional outcome or increased mortality in this cohort. These results suggest that provision of 7-day cover by vascular neurosurgeons and interventional neuroradiologists in high-volume centres could mitigate the weekend effect sometimes reported in the aSAH cohort.

WITHDRAWN: Middle Meningeal Artery Embolization for Chronic Subdural Hematoma-A New Treatment Paradigm?

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.wneu.2023.01.069. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

The impact of the COVID-19 pandemic on the provision of endovascular thrombectomy for stroke: an Irish perspective.

BACKGROUND: The COVID-19 pandemic produced unprecedented challenges to healthcare systems. These challenges were amplified in the setting of endovascular thrombectomy (EVT) for large vessel occlusion strokes given the time-sensitive nature of the procedure. AIMS: To assess the impact of the COVID-19 pandemic on service provision at the primary endovascular stroke centre in Ireland. METHODS: A retrospective review of the National Thrombectomy Service database was performed. All patients undergoing EVT from 1 January to 31 December inclusive of 2019 to 2021 were included. Patient demographics, functional outcomes and endovascular treatment time metrics were recorded. RESULTS: Data from 2019, 2020 and 2021 were extracted. Three hundred seven thrombectomies were performed in 2019 and 2020; this number increased to 327 in 2021. Median time from arrival to groin puncture for thrombectomy was 64 min in 2019, increasing to 65 min in 2020. In 2021, this decreased to 52 min. Median time taken from groin puncture to first perfusion remained stable from 2019 to 2021 years at 20 min. Total duration of emergency thrombectomies reduced from 32 min in 2019 to 27 min in 2020. This increased to 29 min in 2021. CONCLUSIONS: Despite the myriad of challenges presented by the pandemic, service provision at the primary Irish ESC, and the referring hospitals, has proven to be robust. Procedural time metrics were maintained whilst the expected reduction in number of EVTs performed did not materialise, there actually being a significant increase in number of EVTs performed in the pandemic's second year.

Radiological follow-up of endovascularly treated intracranial aneurysms: a survey of current practice in the UK and Ireland.

PURPOSE: Due to the risk of intracranial aneurysm (IA) recurrence and the potential requirement for re-treatment following endovascular treatment (EVT), radiological follow-up of these aneurysms is necessary. There is little evidence to guide the duration and frequency of this follow-up. The aim of this study was to establish the current practice in neurosurgical units in the UK and Ireland. METHODS: A survey was designed with input from interventional neuroradiologists and neurosurgeons. Neurovascular consultants in each of the 30 neurosurgical units providing a neurovascular service in the UK and Ireland were contacted and asked to respond to questions regarding the follow-up practice for IA treated with EVT in their department. RESULTS: Responses were obtained from 28/30 (94%) of departments. There was evidence of wide variations in the duration and frequency of follow-up, with a minimum follow-up duration for ruptured IA that varied from 18 months in 5/28 (18%) units to 5 years in 11/28 (39%) of units. Young patient age, previous subarachnoid haemorrhage and incomplete IA occlusion were cited as factors that would prompt more intensive surveillance, although larger and broad-necked IA were not followed-up more closely in the majority of departments. CONCLUSIONS: There is a wide variation in the radiological follow-up of IA treated with EVT in the UK and Ireland. Further standardisation of this aspect of patient care is likely to be beneficial, but further evidence on the behaviour of IA following EVT is required in order to inform this process.

Management of Chronic Subdural Hematoma: A Systematic Review and Component Network Meta-analysis of 455 Studies With 103 645 Cases.

BACKGROUND: Chronic subdural hematoma (CSDH) is a common neurosurgical condition with a high risk of recurrence after treatment. OBJECTIVE: To assess and compare the risk of recurrence, morbidity, and mortality across various treatments for CSDH. METHODS: A systematic review and meta-analysis was performed. PubMed/MEDLINE, EMBASE, SCOPUS, and Web of Science were searched from January 01, 2000, to July 07, 2021. The primary outcome was recurrence, and secondary outcomes were morbidity and mortality. Component network meta-analyses (CNMAs) were performed for surgical and medical treatments, assessing recurrence and morbidity. Incremental risk ratios (iRRs) with 95% CIs were estimated for each component. RESULTS: In total, 12 526 citations were identified, and 455 studies with 103 645 cases were included. Recurrence occurred in 11 491/93 525 (10.8%, 95% CI 10.2-11.5, 418 studies) cases after surgery. The use of a postoperative drain (iRR 0.53, 95% CI 0.44-0.63) and middle meningeal artery embolization (iRR 0.19, 95% CI 0.05-0.83) reduced recurrence in the surgical CNMA. In the pharmacological CNMA, corticosteroids (iRR 0.47, 95% CI 0.36-0.61) and surgical intervention (iRR 0.11, 95% CI 0.07-0.15) were associated with lower risk. Corticosteroids were associated with increased morbidity (iRR 1.34, 95% CI 1.05-1.70). The risk of morbidity was equivalent across surgical treatments. CONCLUSION: Recurrence after evacuation occurs in approximately 10% of cSDHs, and the various surgical interventions are approximately equivalent. Corticosteroids are associated with reduced recurrence but also increased morbidity. Drains reduce the risk of recurrence, but the position of drain (subdural vs subgaleal) did not influence recurrence. Middle meningeal artery embolization is a promising treatment warranting further evaluation in randomized trials.

Experiences of a "COVID protected" robotic surgical centre for colorectal and urological cancer in the COVID-19 pandemic.

The recent COVID-19 pandemic led to the cancellation of elective surgery across the United Kingdom. Re-establishing elective surgery in a manner that ensures patient and staff safety has been a priority. We report our experience and patient outcomes from setting up a "COVID protected" robotic unit for colorectal and renal surgery that housed both the da Vinci Si (Intuitive, Sunnyvale, CA, USA) and the Versius (CMR Surgical, Cambridge, UK) robotic systems. "COVID protected" robotic surgery was undertaken in a day-surgical unit attached to the main hospital. A standard operating procedure was developed in collaboration with the trust COVID-19 leadership team and adapted to national recommendations. 60 patients underwent elective robotic surgery in the initial 10-weeks of the study. This included 10 colorectal procedures and 50 urology procedures. Median length of stay was 4 days for rectal cancer procedures, 2 days less than prior to the COVID period, and 1 day for renal procedures. There were no instances of in-patient coronavirus transmission. Six rectal cancer patients waited more than 62 days for their surgery because of the initial COVID peak but none had an increase T-stage between pre-operative staging and post-operative histology. Robotic surgery can be undertaken in "COVID protected" units within acute hospitals in a safe way that mitigates the increased risk of undergoing major surgery in the current pandemic. Some benefits were seen such as reduced length of stay for colorectal patients that may be associated with having a dedicated unit for elective robotic surgical services.

Timing of treatment of aneurysmal subarachnoid haemorrhage: are the goals set in international guidelines achievable?

BACKGROUND AND AIMS: International guidelines emphasise the importance of securing ruptured cerebral aneurysms within 48-72 h of ictus. We assessed the timing of treatment of patients with aneurysmal subarachnoid haemorrhage (aSAH) referred to a national neurosurgical centre. MATERIALS AND METHODS: Analysis of a prospective database of patients with aSAH admitted between 1st of February 2016 and 29th of February 2020 was performed. The timing to treatment was expressed in days and analysed in three ways: ictus to treatment, ictus to referral and referral to treatment. ORs with 95% CI were calculated for aneurysm treatment within 24, 48 and 72 h for good grade (WFSN 1-3) and poor grade (WFNS 4-5) cohorts separately. RESULTS: Of a total of 538 patients with aSAH, the aneurysm was secured in 312 (58%) within 24 h and in 398 (74%) within 48 h of ictus. Securing the aneurysm within 48 h of ictus was achieved in 89% (395/444) of patients who were referred within 24 h of ictus, but in only 3.2% (3/94) who were referred > 24 h after ictus. Poor grade patients (WFNS 4-5) were more likely than good grade patients (WFNS 1-3) to be referred to neurosurgery within 48 h of ictus (OR 22.87, 95% CI 3.14-166.49, p = 0.0020) and for their aneurysm to be secured within 48 h (OR 1.78, 95% CI 1.06-2.98, p = 0.0297) of ictus. Ictus to referral delay was highest in WFNS grade 1 patients. CONCLUSIONS: In centres with 7 day per week provision of interventional neuroradiology and vascular neurosurgery, the majority of patients with aSAH can be treated within the timeframes recommended by international guidelines and this applies to all grades of aSAH. However, delays still occur in a significant proportion of patients and this particularly applies to delays in presentation and diagnosis in good grade patients.

Mechanical thrombectomy is efficacious in patients with pre-stroke moderate disability.

INTRODUCTION: Patients with ischaemic stroke due to large vessel occlusion (LVO) can be treated successfully with mechanical thrombectomy (MT) and/or intravenous thrombolysis. In the landmark trials, MT was only performed for those with no functional disability prior to stroke (mRS 0-2). There are limited data available regarding clinical outcomes for patients with pre-stroke moderate disability (mRS ≥ 3). The aims of this study were to analyse the clinical outcomes and financial implications in regard to accommodation costs of performing MT in patients with pre-stroke mRS = 3. METHODS: An observational cohort study was performed of 802 patients with anterior circulation LVO ischaemic stroke who underwent MT between October 2016 and January 2020 at three tertiary hospitals. Patient demographics, premorbid mRS, stroke and interventional data, 90-day mRS and accommodation situation were recorded. RESULTS: Eighty-two patients with anterior circulation LVO ischaemic stroke were pre-stroke mRS 3. 38% had a good clinical outcome, as defined by mRS 3 at 90 days. Mortality rate was 38%. The majority of patients presented from home (83%) and greater than one third of those returned home during the 90 days post treatment. 81% of patients had no increase in accommodation cost at 90 days. CONCLUSION: Patients with pre-stroke moderate disability may benefit from MT if they are appropriately selected. This may result in fewer patients requiring nursing home placement and less financial burden on the public health system, indicating significant savings are possible.

The IDENTIFY study: the investigation and detection of urological neoplasia in patients referred with suspected urinary tract cancer - a multicentre observational study.

OBJECTIVE: To evaluate the contemporary prevalence of urinary tract cancer (bladder cancer, upper tract urothelial cancer [UTUC] and renal cancer) in patients referred to secondary care with haematuria, adjusted for established patient risk markers and geographical variation. PATIENTS AND METHODS: This was an international multicentre prospective observational study. We included patients aged ≥16 years, referred to secondary care with suspected urinary tract cancer. Patients with a known or previous urological malignancy were excluded. We estimated the prevalence of bladder cancer, UTUC, renal cancer and prostate cancer; stratified by age, type of haematuria, sex, and smoking. We used a multivariable mixed-effects logistic regression to adjust cancer prevalence for age, type of haematuria, sex, smoking, hospitals, and countries. RESULTS: Of the 11 059 patients assessed for eligibility, 10 896 were included from 110 hospitals across 26 countries. The overall adjusted cancer prevalence (n = 2257) was 28.2% (95% confidence interval [CI] 22.3-34.1), bladder cancer (n = 1951) 24.7% (95% CI 19.1-30.2), UTUC (n = 128) 1.14% (95% CI 0.77-1.52), renal cancer (n = 107) 1.05% (95% CI 0.80-1.29), and prostate cancer (n = 124) 1.75% (95% CI 1.32-2.18). The odds ratios for patient risk markers in the model for all cancers were: age 1.04 (95% CI 1.03-1.05; P < 0.001), visible haematuria 3.47 (95% CI 2.90-4.15; P < 0.001), male sex 1.30 (95% CI 1.14-1.50; P < 0.001), and smoking 2.70 (95% CI 2.30-3.18; P < 0.001). CONCLUSIONS: A better understanding of cancer prevalence across an international population is required to inform clinical guidelines. We are the first to report urinary tract cancer prevalence across an international population in patients referred to secondary care, adjusted for patient risk markers and geographical variation. Bladder cancer was the most prevalent disease. Visible haematuria was the strongest predictor for urinary tract cancer.

Current process and outcomes of the surgical management of LUTS due to benign prostatic enlargement: how consistent are we? - results from the multi-institutional audit of surgical management of BPE (AuSuM BPE) in the United Kingdom.

OBJECTIVE: In view of changing landscape of surgical treatment for LUTS secondary to BPE, this audit was undertaken to assess key aspects of the processes and outcomes of the current interventional treatments for BPE, across different units in the UK. MATERIALS AND METHOD: A multi-institutional snapshot audit was conducted for patients undergoing interventions for LUTS/BPE over 8-week period. Using Delphi process two-part proforma was designed to capture data. RESULTS: 529 patients were included across 20 NHS trusts in England and Wales. Median age was 73 years. Indications for surgery were acute retention (47%) and LUTS (45%). 80% of patients had prior medical therapy. TURP formed the commonest procedure. 27% patients had <23 hour hospital stay. Immediate (21%) and delayed (18%) complications were Clavien-Dindo <2 category. High proportion of patients reported residual symptoms. Type and indication of surgery were significant predictor of complications, length of stay and failure of TWOC outcomes, on multivariate analyses. There were variations in departmental processes, 50% centres used PROMs. CONCLUSION: Monopolar TURP still remains the commonest intervention for BPE. Most departments are adopting newer technologies. The audit identified opportunities for development of consistent, effective and patient centric practices as well as need for large-scale focused studies.

Nephrometry scores: a validation of three systems for peri-operative outcomes in retroperitoneal robot-assisted partial nephrectomy.

OBJECTIVE: To externally validate the RENAL, PADUA and SPARE nephrometry scoring systems for use in retroperitoneal robot-assisted partial nephrectomy (RAPN). MATERIALS AND METHODS: Nephrometry scores were calculated for 322 consecutive patients receiving retroperitoneal RAPN at a tertiary referral centre from 2017. Patients with multiple tumours were excluded. Scores were correlated with peri-operative outcomes, including the trifecta (warm ischaemia time <25 min, no peri-operative complications and a negative surgical margin), both as continuous and categorical variables. Comparisons were performed using Spearman correlation and ability to predict the trifecta was assessed using binomial logistical regression. RESULTS: All three scoring systems correlated significantly with the main variables (operating time, warm ischaemia time and estimated blood loss), both as continuous and categorical variables. Only PADUA and SPARE were able to predict achievement of the trifecta (PADUA area under the curve [AUC] 0.623, 95% confidence interval [CI] 0.559-0.668; SPARE AUC 0.612, 95% CI 0.548-0.677). CONCLUSION: This study validates the RENAL, PADUA and SPARE scoring systems to predict key intra-operative outcomes in retroperitoneal RAPN. Only PADUA and SPARE were able to predict achievement of the trifecta. As a simplified version of the PADUA scoring system with comparable outcomes, we recommend using the SPARE system.

Transradial versus transfemoral access for anterior circulation mechanical thrombectomy: analysis of 375 consecutive cases.

OBJECTIVE: To compare transradial artery access (TRA) to the gold standard of transfemoral artery access (TFA) in mechanical thrombectomy (MT) for stroke caused by anterior circulation large vessel occlusion. METHODS: The clinical outcomes, procedural speed, angiographic efficacy and safety of both techniques were analysed in 375 consecutive cases over an 18-month period in a high volume statewide neurointerventional service. RESULTS: There was no significant difference in patient characteristics, stroke parameters, imaging techniques or intracranial techniques. The median time elapsed between CT scanning and reperfusion was 96.5 min (IQR 68-123) in the TFA group and 95 min (IQR 68-123) in the TRA group (p=0.456). Of 336 patients who were independent at presentation 58% (124/214) of the TFA group and 67% (82/122) of the TRA group had a modified Rankin score of 0-2 at 90-day follow-up (p=0.093). Cross-over from radial to femoral was 4.6% (4/130) compared with 1.6% cross-over from femoral to radial (4/245), but did not meet the predetermined level of statistical significance (OR 2.92, 95% CI 0.81 to 10.52), p=0.088) and did not impact median procedural speed. Adequate angiographic reperfusion, first pass reperfusion, embolisation to new territory and symptomatic intracranial haemorrhage were similar in both groups. There was a significant difference in major access site complications requiring an additional procedure. None of the TRA cases had a major access site complication but 6.5% (16/245) of the TFA cases did (p=0.003). CONCLUSION: This study suggests that using TRA for anterior circulation MT is fast, efficacious, safe and not inferior to the gold standard of TFA.

Transradial intracranial aneurysm treatment via an aberrant right subclavian artery.

We report two cases of successfully treated intracranial saccular aneurysms via transradial access with aberrant right subclavian artery anatomy. Two patients aged 74 and 82 years with anterior communicating artery aneurysms deemed suitable for endovascular treatment and anomalous aortic arch anatomy (aberrant right subclavian artery) underwent successful treatment with transradial access. Transradial access was obtained in both patients, in the first patient, without prior knowledge of the aortic arch anatomy. Aberrant right subclavian artery anatomy was negotiated, and the aneurysms were successfully treated in both cases with intrasaccular flow disrupting devices (WEB-SL).

First line transradial access for posterior circulation stroke intervention; initial 12-month experience at a high volume thrombectomy center.

BACKGROUND: The Neurointerventional Surgery Standards and Guidelines Committee has advocated the use of transradial access in the setting of posterior circulation stroke intervention, however there is a paucity of published data on this approach. The purpose of this study is to present 12-months of prospectively collected data from a high volume thrombectomy center following the adoption of a first line transradial approach for posterior circulation stroke intervention. METHODS: A range of data on patient characteristics, procedural metrics, complications and outcomes was prospectively collected between August 2018 - August 2019 following the adoption of first line transradial access for posterior circulation stroke intervention at a high volume thrombectomy center. RESULTS: Transradial access was successful in 22/23 cases (96%), median arteriotomy to reperfusion time was 24 min (IQR 18-40), good angiographic outcome (mTICI 2b-3) was achieved in all cases and good clinical outcome (mRs 0-2) was achieved in 61% of cases. No intracranial or radial artery access site complications occurred. CONCLUSION: The fast procedure times, excellent outcomes and low complication rates achieved in this prospective 12-month study indicate that transradial access is a viable first line strategy in posterior circulation stroke intervention.

Air retrieval for clot retrieval; time-metrics and outcomes of stroke patients from rural and remote regions air-transported for mechanical thrombectomy at a state stroke unit.

BACKGROUND: Providing thrombectomy services to rural or remote regions with small, dispersed populations presents a particular challenge. Sustaining local thrombectomy services is not viable given the low throughput of cases, therefore large vessel occlusion (LVO) stroke patients require emergent transfer, often by air, to the closest high volume urban thrombectomy unit. The aim of this paper is to present logistical, time-metric data and outcome data on LVO stroke patients that have been aeromedically retrieved for thrombectomy from the vast, 2,500,000-km2 rural catchment of the Western Australian state thrombectomy unit. METHODS: The prospectively collected state thrombectomy registry was reviewed and all patients that underwent thrombectomy for LVO strokes following aeromedical retrieval from remote or rural catchments were identified. Multiple logistic and time-metric data points were recorded and outcomes were compared to a cohort of urban patients treated over the same period. RESULTS: Over a 2-year period 30 patients underwent thrombectomy following aeromedical retrieval, either by helicopter or fixed wing aircraft, from rural and remote regions of Western Australia. The mean aeromedical retrieval distance was 393 km while the maximum retrieval distance was over 2600 km. The mean ictus to recanalization time was 657 min, an mTICI 2b-3 recanalization was achieved in 93% of cases and 62% of anterior circulation, and 50% of posterior circulation LVO stroke patients achieved functional independence at 90-days. Outcome data for rural patients compared favourably to urban patients treated over the same time period. CONCLUSION: With the availability of an efficient aeromedical retrieval service, LVO stroke patients in rural and remote regions can achieve excellent outcomes following transfer to a high volume thrombectomy unit, even if distances involved are very large.