The roles of early surgery and comorbid conditions on outcomes of severe necrotizing soft-tissue infections.

PURPOSE: Severe necrotizing soft-tissue infections (NSTIs) require immediate early surgical treatment to avoid adverse outcomes. This study aims to determine the impact of early surgery and comorbid conditions on the outcomes of NSTIs. METHODS: A retrospective cohort study was performed on all subjects presenting with NSTI at an academic medical center between 2005 and 2016. Patients were identified based on ICD codes. Those under the age of 18 or with intraoperative findings not consistent with NSTI diagnosis were excluded. RESULTS: There were 115 patients with a confirmed diagnosis of NSTI with a mean age of 55 ± 18 years; 41% were females and 55% were diabetics. Thirty percent of patients underwent early surgery (< 6 h). There were no significant differences between groups in baseline characteristics. The late group (≥ 6 h) had prolonged hospital stay (38 vs. 23 days, p < 0.008) in comparison to the early group (< 6 h). With every 1 h delay in time to surgery, there is a 0.268 day increase in length of stay, adjusted for these other variables: alcohol abuse, number of debridements, peripheral vascular disease, previous infection and clinical necrosis. Mortality was 16.5%. Multivariable analysis revealed that alcohol abuse, peripheral vascular disease, diabetes, obesity, hypothyroidism, and presence of COPD were associated with an increase in mortality. CONCLUSIONS: Early surgical intervention in patients with severe necrotizing soft-tissue infections reduces length of hospital stay. Presence of comorbid conditions such as alcohol abuse, peripheral vascular disease, diabetes, obesity and hypothyroidism were associated with increased mortality.

Type I Spinal Arteriovenous Fistula with Ventral Intradural Venous Drainage: A Proposal of a Modified Classification.

OBJECTIVES: Spinal arteriovenous fistula (AVF) is the most common spinal vascular lesion and constitutes an abnormal communication between a feeder artery and a draining vein. Arterialization of the venous plexus leads to venous hypertension; consequent edema and congestion of the spinal cord are associated with progressive neurological decline. PATIENTS AND METHODS: In this report, we describe two unique cases of type I cervical spinal AVF, in which a radiculomeningeal artery forms an intradural fistula that drains into the ventral venous plexus. RESULTS: Both patients underwent surgical obliteration of the fistula with complete occlusion confirmed on postoperative angiography. CONCLUSION: Both cases do not fit into the current classification scheme. A modified classification is proposed.

The Use of Single Stent-Assisted Coiling in Treatment of Bifurcation Aneurysms: A Multicenter Cohort Study With Proposal of a Scoring System to Predict Complete Occlusion.

BACKGROUND: The development of stent-assisted coiling has allowed for the endovascular treatment of wide-necked bifurcation aneurysms. A variety of options exist, and little is known about the optimal stent configuration in this setting. We report a large multicenter experience of stent-assisted coiling of bifurcations aneurysms using a single stent, with attention to factors predisposing to aneurysm recanalization. OBJECTIVE: To assess the safety and efficacy of single stent-assisted coiling, in addition to analyzing the factors associated with recanalization, and proposal of a predictive scoring scale. METHODS: A multicenter retrospective analysis of bifurcation aneurysms treated with a single stent-assisted coiling technique between 2007 and 2015 was performed. Clinical and radiographic data were collected and used to develop a scoring system to predict aneurysm occlusion. RESULTS: A total of 74 bifurcation aneurysms were treated with single stent-assisted coiling. At a median follow-up of 15.2 mo, complete occlusion or remnant neck was achieved in 90.6% of aneurysms. Aneurysm location, maximal diameter, neck size, and alpha angle were predictive of aneurysm occlusion at last follow-up. A scoring system to predict complete occlusion based on these factors was developed. An increasing score correlated with a higher rate of complete occlusion. CONCLUSION: The treatment of bifurcation aneurysm using single stent technique for stent-assisted coiling is safe and effective. Complete occlusion or remnant neck occlusion was achieved in 90.6% of cases. Class III aneurysms can be effectively treated using a single stent, while class I may require Y-stent technique.

Instability in Thoracolumbar Trauma: Is a New Definition Warranted?

STUDY DESIGN: Review of the articles. OBJECTIVE: The objective of this study was to review all articles related to spinal instability to determine a consensus statement for a contemporary, practical definition applicable to thoracolumbar injuries. SUMMARY OF BACKGROUND DATA: Traumatic fractures of the thoracolumbar spine are common. These injuries can result in neurological deficits, disability, deformity, pain, and represent a great economic burden to society. The determination of spinal instability is an important task for spine surgeons, as treatment strategies rely heavily on this assessment. However, a clinically applicable definition of spinal stability remains elusive. MATERIALS AND METHODS: A review of the Medline database between 1930 and 2014 was performed limited to papers in English. Spinal instability, thoracolumbar, and spinal stability were used as search terms. Case reports were excluded. We reviewed listed references from pertinent search results and located relevant manuscripts from these lists as well. RESULTS: The search produced a total of 694 published articles. Twenty-five articles were eligible after abstract screening and underwent full review. A definition for spinal instability was described in only 4 of them. Definitions were primarily based on biomechanical and classification studies. No definitive parameters were outlined to define stability. CONCLUSIONS: Thirty-six years after White and Panjabi's original definition of instability, and many classification schemes later, there remains no practical and meaningful definition for spinal instability in thoracolumbar trauma. Surgeon expertise and experience remains an important factor in stability determination. We propose that, at an initial assessment, a distinction should be made between immediate and delayed instability. This designation should better guide surgeons in decision making and patient counseling.

Soluble Fms-Like Tyrosine Kinase 1 (sFlt-1) and Risk of Cerebral Vasospasm After Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: The molecular mechanisms underlying cerebral vasospasm and delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH) are incompletely understood. We hypothesized that circulating antiangiogenic factors, such as soluble Fms-like tyrosine kinase 1 (sFlt-1) and soluble transforming growth factor ß coreceptor, soluble endoglin (sEng), are important markers of their pathophysiology. METHODS: We performed a prospective study in patients with aSAH and measured cerebrospinal fluid and serum levels of sFlt-1 and sEng on postbleed day 1 and 6 and correlated levels with incidence and severity of cerebral vasospasm and DCI. RESULTS: Twenty-seven patients with aSAH were enrolled in the study. Severe angiographic vasospasm was present in 14.8% of patients and DCI occurred in 33.3%. Serum sFlt1 levels were increased on postbleed day 6 in patients who developed vasospasm. However, on postbleed day 1, there were no differences in patients who developed vasospasm. Increased serum sFlt-1 levels on postbleed day 1 were found to predict the development of severe angiographic vasospasm with an area under the curve of 0.818 with an optimal cutoff value of 95 pg/mL. Alterations in sFlt1 were not associated with DCI. Serum and cerebrospinal fluid sEng levels did not correlate with vasospasm or DCI. CONCLUSIONS: Serum levels of sFlt-1 are increased in patients with aSAH who are at risk for severe vasospasm. Further studies with larger sample sizes are needed to evaluate whether sFlt-1 levels may predict onset of severe vasospasm and DCI.

Comparison of Stent-Assisted Coil Embolization and the Pipeline Embolization Device for Endovascular Treatment of Ophthalmic Segment Aneurysms: A Multicenter Cohort Study.

BACKGROUND: Stent-assisted coil embolization and flow diversion with the Pipeline embolization device (PED) are both effective endovascular treatment options for ophthalmic segment aneurysms (OSAs) of the internal carotid artery. Here we present a large comparative cohort study. METHODS: A multicenter, retrospective cohort comparison study of consecutively treated OSAs was conducted at 2 academic institutions in the United States comparing stent-coiling (between 2007 and 2015) and PED (between 2011 and 2016). RESULTS: A total of 62 of OSAs were treated with stent-coiling and 106 were treated with the PED. The stent-coiling-treated aneurysms were larger, although the maximum diameter was not significantly different between the 2 groups (P = 0.05). The median duration of follow-up was 22.5 months for the stent-coiling group and 8.7 months for the PED group (P = 0.0002). Complete occlusion at last follow-up was achieved in 75.9% of aneurysms in the stent-coiling group and in 81.1% of aneurysms in the PED group (P = 0.516). The retreatment rate was higher with stent-coiling, but the difference did not reach statistical significance (P = 0.062). A good functional outcome was achieved in 96.6% of patients in the stent-coiling group and in 94.7% of those in the PED group (P = 0.707). The rate of neurologic complications was 4.8% in the stent-coiling group and 9.4% in the PED group (P = 0.376). CONCLUSION: Stent-coiling and the PED were equally effective for treating OSAs. There were no significant differences in terms of procedural complications, angiographic, functional, and visual outcomes. PED may be more favorable for multiple adjacent OSAs.

A Multicenter Cohort Comparison Study of the Safety, Efficacy, and Cost of Ticagrelor Compared to Clopidogrel in Aneurysm Flow Diverter Procedures.

BACKGROUND: Thromboembolic and hemorrhagic complications are among the most feared adverse events in the endovascular treatment of aneurysms, and this is particularly the case for flow diverter devices. Dual antiplatelet therapy has become standard of care; however, the safety, efficacy, and cost profiles of newer antiplatelet agents are not well characterized in the neurovascular context. OBJECTIVE: To compare the safety, efficacy, and cost of one of these newer agents, ticagrelor, to the most frequently used agent, clopidogrel. METHODS: A multicenter, retrospective, cohort comparison study design of consecutively treated aneurysms with flow diverter embolization device and treated with either ticagrelor or clopidogrel was performed. Data were collected on patient demographics and risk factors, procedural details, antiplatelet treatment regime, complications, and angiographic and functional outcomes. RESULTS: Fifty patients undergoing flow diverter device deployment and treatment with ticagrelor were compared to 53 patients undergoing flow diversion and treatment with clopidogrel. The patients' age, sex, smoking status, aneurismal morphology and size, and procedural details did not differ between the 2 groups; neither did the rate of thromboembolic and hemorrhagic complications, angiographical, and functional outcomes. Ticagrelor was more expensive when compared to clopidogrel. CONCLUSION: Ticagrelor is a safe and effective agent for prevention of thromboembolic complications following flow diverter deployment when compared to clopidogrel. However, ticagrelor remains significantly more expensive than clopidogrel, and, thus, we would advise ticagrelor be reserved for patients who are hyporesponsive to clopidogrel.

Safety and Efficacy of Noncompliant Balloon Angioplasty for the Treatment of Subarachnoid Hemorrhage-Induced Vasospasm: A Multicenter Study.

OBJECTIVE: Cerebral vasospasm following subarachnoid hemorrhage is the most important cause of neurologic decline after successful treatment of the ruptured aneurysm. We report safety and efficacy of noncompliant balloon angioplasty for treatment of cerebral vasospasm. METHODS: Three major U.S. academic institutions provided data on cerebral vasospasm treated with noncompliant balloon angioplasty between October 2004 and February 2016. Baseline characteristics, procedure details, and radiographic and clinical outcome data were collected and analyzed. RESULTS: There were 52 patients (median age 50 years; range, 27-73 years) who underwent 165 noncompliant balloon angioplasty procedures. Balloon angioplasty was performed most frequently in the middle cerebral artery (MCA) (49.1%) followed by the internal carotid artery (27.2%). Improvement in vasospasm severity occurred in 160 arteries (97.0%) without procedure-related complications. No independent predictor of angioplasty success was identified on multivariate analysis. Delayed cerebral ischemia occurred in 24 patients (46.2%) encompassing 36 vascular territories. The rate of delayed cerebral ischemia in territories supplied by vessels that underwent angioplasty at least once was 29.4%, 24.2%, 19.3%, and 0% for the anterior cerebral artery (ACA) territory, internal carotid artery territory (ACA, ACA/MCA watershed, or MCA), MCA territory, and posterior circulation. CONCLUSIONS: Our data suggest that noncompliant balloon angioplasty for treatment of subarachnoid hemorrhage-induced cerebral vasospasm is safe and effective. No predictors of angioplasty success were identified. The rate of delayed cerebral ischemia in territories supplied by vessels that underwent angioplasty was highest in the ACA territory and lowest in the posterior circulation.

Evaluating the complexity of online patient education materials about brain aneurysms published by major academic institutions.

OBJECTIVE Health care education resources are increasingly available on the Internet. A majority of people reference these resources at one point or another. A threshold literacy level is needed to comprehend the information presented within these materials. A key component of health literacy is the readability of educational resources. The National Institutes of Health (NIH) and the American Medical Association have recommended that patient education materials be written between a 4th- and a 6th-grade education level. The authors assessed the readability of online patient education materials about brain aneurysms that have been published by several academic institutions across the US. METHODS Online patient education materials about brain aneurysms were downloaded from the websites of 20 academic institutions. The materials were assessed via 8 readability scales using Readability Studio software (Oleander Software Solutions), and then were statistically analyzed. RESULTS None of the patient education materials were written at or below the NIH's recommended 6th-grade reading level. The average educational level required to comprehend the texts across all institutions, as assessed by 7 of the readability scales, was 12.4 ± 2.5 (mean ± SD). The Flesch Reading Ease Scale classified the materials as "difficult" to understand, correlating with a college-level education or higher. An ANOVA test found that there were no significant differences in readability among the materials from the institutions (p = 0.215). CONCLUSIONS Brain aneurysms affect 3.2% of adults 50 years or older across the world and can cause significant patient anxiety and uncertainty. Current patient education materials are not written at or below the NIH's recommended 4th- to 6th-grade education level.

An analysis of malpractice litigation related to the management of brain aneurysms.

OBJECTIVE Given the highly complex and demanding clinical environment in which neurosurgeons operate, the probability of facing a medical malpractice claim is high. Recent emphasis on tort reform within the political sphere has brought this issue to the forefront of medical literature. Despite the widespread fear of litigation in the medical community, few studies have provided an analysis of malpractice litigation in the field. Here, the authors attempt to delineate the medicolegal factors that impel plaintiffs to file medical malpractice claims related to the management of brain aneurysms, and to better characterize the nature of these lawsuits. METHODS The online legal database WestLawNext was searched to find all medical malpractice cases related to brain aneurysms across a 30-year period. All state and federal jury verdicts and settlements relevant to the search criterion were considered. RESULTS Sixty-six cases were obtained. The average age of the patient was 46.7 years. Seventy-one percent were female. The cases were distributed across 16 states. The jury found in favor of the plaintiff in 40.9% of cases, with a mean payout of $8,765,405, and in favor of the defendant in 28.8% of the cases. A failure to diagnose and/or a failure to treat in a timely manner were the 2 most commonly alleged causes of malpractice. Settlements, which were reached in 25.8% of the cases, had a mean payout of $1,818,250. Neurosurgeons accounted for 6.7% of all defendants. CONCLUSIONS Unlike other medical specialties, a majority of the verdicts were not in the defendant's favor. The mean payouts were nearly 5-fold less in cases in which a settlement was reached, as opposed to a summary judgment. Neurosurgeons accounted for a small percentage of all codefendants.

Validity assessment of grading scales predicting complications from embolization of cerebral arteriovenous malformations.

OBJECTIVE: Endovascular embolization, though initially approved as an adjunctive therapy for surgical excision of cerebral arteriovenous malformations (AVMs), has found extensive use in the management of these lesions. A number of systems have been proposed to stratify AVMs by the procedural risk of embolization, including the Buffalo score and AVM Neuroendovascular grade. An external validity assessment of these systems has not been performed. PATIENTS AND METHODS: A retrospective review of all patients who underwent embolization of cerebral AVMs at a single institution, between 2010 and 2016, was performed. Data including patient demographics, AVM characteristics, procedural details, complications, and outcomes were collected. RESULTS: Fifty-five embolization procedures in 39 patients (median age 53.1 years) were identified. Ten (25.6%) patients underwent more than 1 embolization procedure. A triaxial catheter system for support was used in 48 (87.3%) of the embolization procedures and a detachable tip microcatheter was used in 28 (50.9%). Complete obliteration of the AVM was achieved in 10.9% of the cases. There was one (2.6%) mortality unrelated to the procedure. Three minor (5.5%) and 2 major (3.6%) clinical complications occurred. Neither Spetzler-Martin grade, Buffalo score, or AVM Neuroendovascular grade correlated with complications. CONCLUSION: Neither Buffalo score nor AVM Neuroendovascular grade predicted complications from embolization in the present study. Given the relative infrequency of complications, the number of factors that may influence AVM treatment, recent advancements in endovascular technologies, and the subjectivity inherent in these grading systems, the relative utility of risk stratification scales in the embolization of AVMs remains largely unknown.

Clinical presentation, progression, and treatment outcomes of moyamoya disease in the elderly.

BACKGROUND: Moyamoya disease is a vascular disorder characterized by progressive stenosis of the internal carotid artery. The presentation, progression, treatment options, and post-operative clinical outcomes for elderly (60 and older) Moyamoya patients have never been reported. METHODS: A retrospective analysis of all patients who were diagnosed with Moyamoya disease by the senior authors between 1991 and 2016 was performed. Patients who were 60 years or older at the time of surgery or last follow-up were further evaluated. RESULTS: Seventy patients were diagnosed with probable or definite Moyamoya disease during the study period (1991-2016). Eight patients (11.4 %; six females: two males; median age 63; range, 60-71 years) were found to be 60 years or older at the time of surgery or last follow-up and were included in the study. All patients had a modified Rankin scale (mRS) of either one or two (median 1) pre-operatively. Six patients (75 %) underwent surgical treatment on a total on seven hemispheres. Post-surgery, one patient had an improved mRS score, three had no changes, and two had worsening in their mRS scores. Both patients who did not undergo surgical interventions suffered from intra-parenchymal hemorrhages post-diagnosis. CONCLUSIONS: Moyamoya disease is most commonly seen in young and middle-aged patients. Presentation in the elderly (defined as 60 years and older in this study) is rare, and has never been reported in the literature. In this study, both direct and indirect revascularization procedures demonstrated potential benefit in some of these patients, with stabilization of progressive symptoms.

Assessment of Dual-Antiplatelet Regimen for Pipeline Embolization Device Placement: A Survey of Major Academic Neurovascular Centers in the United States.

INTRODUCTION: Flow diversion with the Pipeline Embolization Device (PED) currently is adopted for treatment of a variety of intracranial aneurysms. The elevated risk of thromboembolic complications associated with the device necessitates the need for administration of antiplatelet agents. We sought to assess current dual-antiplatelet therapy practices patterns and their associated costs after PED placement. MATERIALS AND METHODS: An online questionnaire that assessed dual-antiplatelet regimens after flow diversion for treatment of intracranial aneurysms was developed and disseminated to 80 neurosurgeons at major academic cerebrovascular centers. Pricing information from 2 of the largest prescription payers in Massachusetts was used to calculate the monthly cost of these agents. RESULTS: Twenty-six responses (32.5%) were received. All respondents (100%) affirmed using clopidogrel and aspirin dual-antiplatelet therapy as a first-line regimen. Twenty-three (88.5%) routinely use platelet function testing. Eleven respondents (42.3%) each identified that they administer aspirin/ticagrelor and aspirin/prasugrel to clopidogrel hypo- or nonresponders. For uninsured patients, prasugrel was found to have the highest cumulative monthly cost ($471), followed by ticagrelor ($396), clopidogrel ($149), and ticlopidine ($110). CONCLUSIONS: Significant heterogeneity in dual-antiplatelet regimens after PED placement and associated costs exists at major academic neurovascular centers. The most commonly used first-line dual-antiplatelet regimen consists of aspirin and clopidogrel. Two major alternate protocols involving ticagrelor and prasugrel are administered to clopidogrel hyporesponders. The optimal dual-antiplatelet regimen for patients with cerebrovascular conditions has not been established, given limited prospective data within the neurointerventional literature.

Removal of symptomatic titanium fixation plates after craniotomy.

INTRODUCTION: Titanium fixation plates are routinely used for rigid fixation of bone flaps after craniotomy. In craniofacial surgery or after craniotomy involving orbitozygomatic osteotomies, these plates are occasionally removed because of infection, pain, protrusion, soft tissue erosion, and plate malfunction. However, plate removal because of pain and protrusion after craniotomy without orbitozygomatic osteotomy has rarely been reported. METHODS: A retrospective analysis of all patients who underwent removal of cranial fixation plates after craniotomy, performed by the senior authors at one institution between 2014 and 2016, was conducted. RESULTS: A total of 319 patients underwent bone flap fixation after craniotomy using cranial fixation plates between 2014 and 2016. Five of those patients (1.6 %) had their cranial plates removed because of pain and protrusion. An additional four patients had a cranial fixation plate removed during that time frame with the original craniotomy performed before 2014. All nine patients had immediate resolution of symptoms after plate removal. CONCLUSION: We report our experience with cranial fixation plate removal because of pain and protrusion in patients who underwent craniotomy without orbitozygomatic osteotomy, particularly frontotemporal craniotomy. In an attempt to reduce this complication, we recently stopped placing a full-size burr hole in the keyhole area of a frontotemporal craniotomy, eliminating the need for a titanium burr hole cover plate.

Prognostic factors in traumatic atlanto-occipital dislocation.

Traumatic atlanto-occipital dislocation (AOD) is an ominous injury with high mortality and morbidity in trauma patients. Improved survival has been observed with advancements in pre-hospital and hospital care. Furthermore, high quality imaging studies are accessible at most trauma centers; these are crucial for prompt diagnosis of AOD. The objective of this study is to perform a comprehensive literature review of traumatic AOD, with specific emphasis on identifying prognostic factors for survival. A review of the literature was performed using the Medline database for all traumatic atlanto-occipital articles published between March 1959 and June 2015; 141 patients from 60 total studies met eligibility criteria for study inclusion. A binary logistic regression model was utilized to identify prognostic factors. The analysis assessed age, sex, spinal cord injury (SCI), traumatic brain injury (TBI), polytrauma injury (PI), and Traynelis AOD Classification. Only TBI was statistically significantly associated with death (OR 8.05 p<0.05); SCI did not reach statistical significance for predicting mortality in AOD patients (OR 1.25 p>0.05). Age, sex, PI, and Traynelis AOD Classification did not meet significance to predict mortality in AOD patients. We found that patients with TBI are eight times more likely to die than patients without TBI. A high degree of suspicion for AOD during pre-hospital care, as well as, prompt diagnosis and management in the trauma center play a key role in the treatment of this devastating injury. The relationship between survival and factors such as TBI and SCI should be further explored.

Reliability of dual- vs single-volume reconstruction of three-dimensional digital subtraction angiography for follow-up evaluation of endovascularly treated intracranial aneurysms.

INTRODUCTION: Single-volume reconstruction of three-dimensional (3D) digital subtraction angiography (DSA) can be effectively used for aneurysm assessment and planning of endovascular embolization. Unfortunately, post-embolization follow-up angiographic images can be obscured by artifact. The dual-volume reconstruction technique was developed in order to reduce artifact and enhance the visualization of the aneurysm, the parent vessel and side branches, and endovascular devices. The purpose of this study was to compare the reliability of dual- vs single-volume reconstruction of 3D DSA in evaluation of follow-up images after endovascular embolization of intracranial aneurysms. METHOD: Four cerebrovascular neurosurgeons independently and blindly reviewed 20 randomly selected dual-and single-volume reconstructions of 3D DSAs demonstrating cerebral aneurysms treated with primary coil embolization, stent-assisted coil embolization, or Pipeline embolization. Five images were repeated for each modality (single and dual volume) in order to assess intra-rater reliability. The intraclass correlation coefficient was calculated as a measure of the overall inter-rater agreement. Cohen's kappa value was used to assess repeat measurement consistency for each rater. RESULTS: Overall inter-rater agreement using dual- and single-volume reconstruction was 0.81 and 0.75, respectively. Dual-volume reconstruction resulted in superior agreement in assessing location, occlusion status, position of aneurysm recanalization or residual, status of nearby branches, presence of coil migration and presence of intravascular devices (stent or Pipeline). CONCLUSION: Three-dimensional reconstruction is an important complementary imaging technique in evaluating the angioarchitecture of aneurysms and recanalization after endovascular embolization. Dual-volume reconstruction imaging was associated with superior inter- and intra-rater reliability.

Landmark papers in cerebrovascular neurosurgery 2015.

The management of cerebrovascular disease has advanced considerably in 2015. Five randomized control trials have firmly established the role of endovascular thrombectomy for ischemic strokes due to large vessel occlusion. The randomized trial of intraarterial treatment for acute ischemic stroke (MR CLEAN) (Berkhemer et al. NEJM 2015;372:11-20) was the first of a series on the topic. There was a total of 5 randomized controlled trials published showing benefit in terms of functional outcomes at 90days for mechanical thrombectomy including the Endovascular Therapy for Ischemic stroke with perfusion-imaging selection (EXTEND IA) (Campbell et al. NEJM 2015;372:1009-18), the Randomized assessment of rapid endovascular treatment of ischemic stroke (ESCAPE) (Goyal et al. NEJM 2015;372:1019-30) trials, the stent-retriever thrombectomy after IV t-PA is t-PA alone in stroke (SWIFT-PRIME) (Saver et al. NEJM 2015;372:2285-95), and the thrombectomy within 8h after symptom onset in Ischemic stroke (REVASCAT) trial (Jovin et al. NEJM 2015; 372:2296-306). Six-year results from randomized controlled Barrow Ruptured Aneurysm Trial (BRAT) found no significant difference in functional outcomes in patients ruptured aneurysms treated surgically clippings versus endovascular treatment (Spetzler et al. JNS 2015;123:609-17. The 10-year results of the International Subarachnoid Aneurysm trial (ISAT) reported similar mortality rates and good functional outcomes between clipped and coiled patients (Molyneux et al. Lancet 2015;385:691-7). We also discuss the impact of genome wide sequencing studies in familial aneurysms, the largest publication on stent assisted coiling and flow diverter for aneurysms and noteworthy papers relevant to Moyamoya and cavernous malformations (Yang et al. Neurosurgery 2015;77:241-7).

Evaluating Imaging Follow-Up Strategies and Costs of Unruptured Intracranial Aneurysms Treated with Endovascular Techniques: A Survey of Academic Neurovascular Centers in the United States.

BACKGROUND: Unruptured intracranial aneurysms (UIAs) are being detected and treated with endovascular techniques at an increasing rate, with little evidence on the optimal imaging follow-up protocol. We performed a survey of academic neurovascular centers in the United States to assess imaging follow-up strategies and costs after endovascular treatment of UIAs. METHODS: An online survey on 5-year follow-up strategies of UIAs treated with endovascular techniques was distributed to neurovascular directors of 101 academic neurovascular centers using the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Cerebrovascular Section database. An online healthcare marketplace, NewChoiceHealth, was used to calculate costs. RESULTS: Of 33 (32.7%) institutions that responded to the survey, 26 (25.7%) provided data suitable for analysis. Nine (34.6%), 10 (38.5%), 4 (15.4%), and 3 (11.5%) centers were located in the northeastern, southern, midwestern, and western regions of the United States. Total costs of 5-year follow-up imaging after primary coil embolization and stent-assisted coiling procedures were $3391-$32,882. Costs for aneurysms treated with flow diversion were $2788-$46,670. Eighteen (69.2%) institutions performed cerebral angiography at 6-month follow-up after coil embolization and stent-assisted coiling, and 19 (73.1%) institutions performed cerebral angiography 6 months after flow diversion. Of institutions, 20% affirmed that they maintained an identical imaging follow-up regimen after treatment of ruptured aneurysms. CONCLUSIONS: There is significant heterogeneity in imaging follow-up strategies and their associated costs. Stratification of patients by risk of recanalization and corresponding adjustment of follow-up imaging may be 1 strategy to limit unnecessary imaging and control costs.

Impact of Coil Packing Density and Coiling Technique on Occlusion Rates for Aneurysms Treated with Stent-Assisted Coil Embolization.

BACKGROUND AND OBJECTIVE: Stent-assisted coil embolization is an established endovascular technique for wide-necked intracranial aneurysms. Although recanalization after coil embolization is reduced with the use of a stent, the impact of aneurysm packing density is less clear in stent-coiled aneurysms. The purpose of the present study was to assess packing density in stent-coiled aneurysms and evaluate its effect on recanalization and retreatment. METHODS: A retrospective analysis of consecutive aneurysms treated with stent-assisted coiling was performed at 2 academic institutions between 2007 and 2015. Aneurysm occlusion was assessed using digital subtraction angiography. Packing density was calculated using the AngioCalc app. RESULTS: Two hundred fifty-three aneurysms were identified (median age, 59 years). The median packing density was 35.3%. At last follow-up, 72.7% of aneurysms were completely obliterated and 19.4% had a neck remnant. Complete occlusion was associated with smaller aneurysms and coiling through stent interstices. A higher packing density was associated with increased rate of complete occlusion when analyzed as continuous variable. After adjustment for confounding variables, packing density was no longer predictive of complete occlusion (odds ratio = 1.018, P = 0.122). Similarly, there was no significant association between aneurysm occlusion, retreatment, and packing density when assessed by categories of high (>22%), moderate (12%-22%), and low (<12%) packing density. CONCLUSIONS: Aneurysm size remains the most important predictor of aneurysm recanalization and retreatment after stent-assisted coiling. Although higher packing densities were associated with increased rates of aneurysm occlusion in unadjusted statistical comparisons, this finding was no longer significant after adjusting for confounders.