Predictors of In-Hospital Mortality and Home Discharge in Patients with Aneurysmal Subarachnoid Hemorrhage: A 4-Year Retrospective Analysis.

BACKGROUND: Factors associated with discharge disposition and mortality following aneurysmal subarachnoid hemorrhage (aSAH) are not well-characterized. We used a national all-payer database to identify factors associated with home discharge and in-hospital mortality. METHODS: The National Inpatient Sample was queried for patients with aSAH within a 4-year range. Weighted multivariable logistic regression models were constructed and adjusted for age, sex, race, household income, insurance status, comorbidity burden, National Inpatient Sample SAH Severity Score, disease severity, treatment modality, in-hospital complications, and hospital characteristics (size, teaching status, and region). RESULTS: Our sample included 37,965 patients: 33,605 were discharged alive and 14,350 were discharged home. Black patients had lower odds of in-hospital mortality compared with White patients (adjusted odds ratio [aOR] = 0.67, 95% confidence interval [CI] 0.52-0.86, p = 0.002). Compared with patients with private insurance, those with Medicare were less likely to have a home discharge (aOR = 0.58, 95% CI 0.46-0.74, p < 0.001), whereas those with self-pay (aOR = 2.97, 95% CI 2.29-3.86, p < 0.001) and no charge (aOR = 3.21, 95% CI 1.57-6.55, p = 0.001) were more likely to have a home discharge. Household income percentile was not associated with discharge disposition or in-hospital mortality. Paradoxically, increased number of Elixhauser comorbidities was associated with significantly lower odds of in-hospital mortality. CONCLUSIONS: We demonstrate independent associations with hospital characteristics, patient characteristics, and treatment characteristics as related to discharge disposition and in-hospital mortality following aSAH, adjusted for disease severity.

Vision Deterioration and Hydrocephalus: Rare Presentations of Vestibular Schwannoma and Evolution of Management.

Introduction The incidence of vestibular schwannoma is reported as 12 to 54 new cases per million per year, increasing over time. These patients usually present with unilateral sensorineural hearing loss, tinnitus, or vertigo. Rarely, these patients present with symptoms of hydrocephalus or vision changes. Objective The study aimed to evaluate the surgical management of vestibular schwannoma at a single institution and to identify factors that may contribute to hydrocephalus, papilledema, and the need for pre-resection diversion of cerebrospinal fluid. Patients and Methods A retrospective review examining the data of 203 patients with vestibular schwannoma managed with surgical resection from May 2008 to May 2020. We stratified patients into five different groups to analyze: tumors with a diameter of ≥40 mm, clinical evidence of hydrocephalus, and of papilledema, and patients who underwent pre-resection cerebrospinal fluid (CSF) diversion. Results From May 2008 to May 2020, 203 patients were treated with surgical resection. Patients with tumors ≥40 mm were more likely to present with visual symptoms ( p < 0.001). Presentation with hydrocephalus was associated with larger tumor size ( p < 0.001) as well as concomitant visual symptoms and papilledema ( p < 0.001). Patients with visual symptoms presented at a younger age ( p = 0.002) and with larger tumors ( p < 0.001). Conclusion This case series highlights the rare presentation of vision changes and hydrocephalus in patients with vestibular schwannoma. We recommend urgent CSF diversion for patients with visual symptoms and hydrocephalus, followed by definitive resection. Further, vision may still deteriorate even after CSF diversion and tumor resection.

Bypassing the intensive care unit for patients with acute ischemic stroke secondary to large-vessel occlusion.

OBJECTIVE: Endovascular mechanical thrombectomy is safe and effective for the treatment of acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). Still, despite high rates of procedural success, it is routine practice to uniformly admit postthrombectomy patients to an intensive care unit (ICU) for postoperative observation. Predictors of ICU criteria and care requirements in the postmechanical thrombectomy ischemic stroke patient population are lacking. The goal of the present study is to identify risk factors associated with requiring ICU-level intervention following mechanical thrombectomy. METHODS: The authors retrospectively analyzed data from 245 patients undergoing thrombectomy for AIS from anterior circulation LVO at a comprehensive stroke and tertiary care center from January 2015 to March 2020. Clinical variables that predicted the need for critical care intervention were identified and compared. The performance of a binary classification test constructed from these predictive variables was also evaluated using a validation cohort. RESULTS: Seventy-six patients (31%) required critical care interventions. A recanalization grade lower than modified Thrombolysis in Cerebral Infarction (mTICI) scale grade 2B (odds ratio [OR] 3.625, p = 0.001), Alberta Stroke Program Early Computed Tomography Score (ASPECTS) < 8 (OR 3.643, p < 0.001), and presence of hyperdensity on postprocedure cone-beam CT (OR 2.485, p = 0.005) were significantly associated with the need for postthrombectomy critical care intervention. When applied to a validation cohort, a clearance classification scheme using these three variables demonstrated high positive predictive value (0.88). CONCLUSIONS: A recanalization grade lower than mTICI 2B, ASPECTS < 8, and postprocedure hyperdensity on cone-beam CT were shown to be independent predictors of requiring ICU-level care. Routine admission to ICU-level care can be costly and confer increased risk for hospital-acquired conditions. Safely and reliably identifying low-risk patients has the potential for cost savings, value-based care, and decreasing hospital-acquired conditions.

Management of giant prolactinoma causing craniocervical instability: illustrative case.

BACKGROUND: Giant prolactinomas (>4 cm) are a rare entity, constituting less than 1% of all pituitary tumors. Diagnosis can usually be achieved through endocrinological analysis, but biopsy may be considered when trying to differentiate between invasive nonfunctioning pituitary adenomas and primary clival tumors such as chordomas. OBSERVATIONS: The authors presented a rare case of a giant prolactinoma causing significant clival and occipital condyle erosion, which led to craniocervical instability. They provided a review of the multimodal management. Management involved medical therapy with dopamine agonists, and surgery was reserved for acute neural compression or dopamine agonist resistance, with the caveat that surgery was extremely unlikely to lead to normalization of serum prolactin in dopamine agonist-resistant tumors. LESSONS: Adjunctive surgical therapy may be necessary in cases of skull base erosion, particularly when erosion or pathological fractures involve the occipital condyles. Modern posterior occipital-cervical fusion techniques have high rates of arthrodesis and can lead to symptomatic improvement. This procedure should be considered early in the multimodal approach to giant prolactinomas because of the often dramatic response to medical therapy and potential for further craniocervical instability.

Cerebral vessel anatomy as a predictor of first-pass effect in mechanical thrombectomy for emergent large-vessel occlusion.

OBJECTIVE: Mechanical thrombectomy is effective in acute ischemic stroke secondary to emergent large-vessel occlusion, but optimal efficacy is contingent on fast and complete recanalization. First-pass recanalization does not occur in the majority of patients. The authors undertook this study to determine if anatomical parameters of the intracranial vessels impact the likelihood of first-pass complete recanalization. METHODS: The authors retrospectively evaluated data obtained in 230 patients who underwent mechanical thrombectomy for acute ischemic stroke secondary to large-vessel occlusion at their institution from 2016 to 2018. Eighty-six patients were identified as having pure M1 occlusions, and 76 were included in the final analysis. The authors recorded and measured clinical and anatomical parameters and evaluated their relationships to the first-pass effect. RESULTS: The first-pass effect was achieved in 46% of the patients. When a single device was employed, aspiration thrombectomy was more effective than stent retriever thrombectomy. A larger M1 diameter (p = 0.001), decreased vessel diameter tapering between the petrous segment of the internal carotid artery (ICA) and M1 (p < 0.001), and distal collateral grading (p = 0.044) were associated with first-pass recanalization. LASSO (least absolute shrinkage and selection operator) was used to generate a predictive model for recanalization using anatomical variables. CONCLUSIONS: The authors demonstrated that a larger M1 vessel diameter, low rate of vessel diameter tapering along the course of the intracranial ICA, and distal collateral status are associated with first-pass recanalization for patients with M1 occlusions.

Guidelines for the Early Management of Patients With Acute Ischemic Stroke: 2019 Update to the 2018 Guidelines for the Early Management of Acute Ischemic Stroke: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association.

Background and Purpose- The purpose of these guidelines is to provide an up-to-date comprehensive set of recommendations in a single document for clinicians caring for adult patients with acute arterial ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators. These guidelines supersede the 2013 Acute Ischemic Stroke (AIS) Guidelines and are an update of the 2018 AIS Guidelines. Methods- Members of the writing group were appointed by the American Heart Association (AHA) Stroke Council's Scientific Statements Oversight Committee, representing various areas of medical expertise. Members were not allowed to participate in discussions or to vote on topics relevant to their relations with industry. An update of the 2013 AIS Guidelines was originally published in January 2018. This guideline was approved by the AHA Science Advisory and Coordinating Committee and the AHA Executive Committee. In April 2018, a revision to these guidelines, deleting some recommendations, was published online by the AHA. The writing group was asked review the original document and revise if appropriate. In June 2018, the writing group submitted a document with minor changes and with inclusion of important newly published randomized controlled trials with >100 participants and clinical outcomes at least 90 days after AIS. The document was sent to 14 peer reviewers. The writing group evaluated the peer reviewers' comments and revised when appropriate. The current final document was approved by all members of the writing group except when relationships with industry precluded members from voting and by the governing bodies of the AHA. These guidelines use the American College of Cardiology/AHA 2015 Class of Recommendations and Level of Evidence and the new AHA guidelines format. Results- These guidelines detail prehospital care, urgent and emergency evaluation and treatment with intravenous and intra-arterial therapies, and in-hospital management, including secondary prevention measures that are appropriately instituted within the first 2 weeks. The guidelines support the overarching concept of stroke systems of care in both the prehospital and hospital settings. Conclusions- These guidelines provide general recommendations based on the currently available evidence to guide clinicians caring for adult patients with acute arterial ischemic stroke. In many instances, however, only limited data exist demonstrating the urgent need for continued research on treatment of acute ischemic stroke.

Common Data Elements for Unruptured Intracranial Aneurysms and Aneurysmal Subarachnoid Hemorrhage: Recommendations from the Working Group on Hospital Course and Acute Therapies-Proposal of a Multidisciplinary Research Group.

INTRODUCTION: The Common Data Elements (CDEs) initiative is a National Institute of Health/National Institute of Neurological Disorders and Stroke (NINDS) effort to standardize naming, definitions, data coding, and data collection for observational studies and clinical trials in major neurological disorders. A working group of experts was established to provide recommendations for Unruptured Aneurysms and Aneurysmal Subarachnoid Hemorrhage (SAH) CDEs. METHODS: This paper summarizes the recommendations of the Hospital Course and Acute Therapies after SAH working group. Consensus recommendations were developed by assessment of previously published CDEs for traumatic brain injury, stroke, and epilepsy. Unruptured aneurysm- and SAH-specific CDEs were also developed. CDEs were categorized into "core", "supplemental-highly recommended", "supplemental" and "exploratory". RESULTS: We identified and developed CDEs for Hospital Course and Acute Therapies after SAH, which included: surgical and procedure interventions; rescue therapy for delayed cerebral ischemia (DCI); neurological complications (i.e. DCI; hydrocephalus; rebleeding; seizures); intensive care unit therapies; prior and concomitant medications; electroencephalography; invasive brain monitoring; medical complications (cardiac dysfunction; pulmonary edema); palliative comfort care and end of life issues; discharge status. The CDEs can be found at the NINDS Web site that provides standardized naming, and definitions for each element, and also case report form templates, based on the CDEs. CONCLUSION: Most of the recommended Hospital Course and Acute Therapies CDEs have been newly developed. Adherence to these recommendations should facilitate data collection and data sharing in SAH research, which could improve the comparison of results across observational studies, clinical trials, and meta-analyses of individual patient data.

Relationship between middle cerebral parent artery asymmetry and middle cerebral artery aneurysm rupture risk factors.

OBJECTIVE: The exact pathophysiological mechanisms underlying cerebral aneurysm formation remain unclear. Asymmetrical local vascular geometry may play a role in aneurysm formation and progression. The object of this study was to investigate the association between the geometric asymmetry of the middle cerebral artery (MCA) and the presence of MCA aneurysms and associated high-risk features. METHODS: Using a retrospective case-control study design, the authors examined MCA anatomy in all patients who had been diagnosed with an MCA aneurysm in the period from 2008 to 2017 at the University Hospitals Cleveland Medical Center. Geometric features of the MCA ipsilateral to MCA aneurysms were compared with those of the unaffected contralateral side (secondary control group). Then, MCA geometry was compared between patients with MCA aneurysms and patients who had undergone CTA for suspected vascular pathology but were ultimately found to have normal intracranial vasculature (primary control group). Parent vessel and aneurysm morphological parameters were measured, calculated, and compared between case and control groups. Associations between geometric parameters and high-risk aneurysm features were identified. RESULTS: The authors included 247 patients (158 cases and 89 controls) in the study. The aneurysm study group consisted of significantly more women and smokers than the primary control group. Patients with MCA bifurcation aneurysms had lower parent artery inflow angles (p = 0.01), lower parent artery tortuosity (p < 0.01), longer parent artery total length (p = 0.03), and a significantly greater length difference between ipsilateral and contralateral prebifurcation MCAs (p < 0.01) than those in primary controls. Type 2 MCA aneurysms (n = 89) were more likely to be associated with dome irregularity or a daughter sac and were more likely to have a higher cumulative total of high-risk features than type 1 MCA aneurysms (n = 69). CONCLUSIONS: Data in this study demonstrated that a greater degree of parent artery asymmetry for MCA aneurysms is associated with high-risk features. The authors also found that the presence of a long and less tortuous parent artery upstream of an MCA aneurysm is a common phenotype that is associated with a higher risk profile. The aneurysm parameters are easily measurable and are novel radiographic biomarkers for aneurysm risk assessment.

Resection of 2 Intradural Extramedullary Cervical Spine Tumors in a Patient With Neurofibromatosis Type 2: 3-Dimensional Operative Video.

This 3-dimensional operative video illustrates resection of 2 cervical spine schwannomas in a 19-yr-old female with neurofibromatosis type 2. The patient presented with lower extremity hyperreflexity and hypertonicity. Magnetic resonance imaging (MRI) demonstrated 2 contrast-enhancing intradural extramedullary cervical spine lesions causing spinal cord compression at C4 and C5. The patient underwent a posterior cervical laminoplasty with a midline dural opening for tumor resection. Curvilinear spine cord compression is demonstrated in the operative video. After meticulous dissection, the tumors were resected without complication. The dural closure was performed in watertight fashion followed by laminoplasty using osteoplastic titanium miniplates and screws. Postoperative MRI demonstrated gross total resection with excellent decompression of the spinal cord. The postoperative course was uneventful. The natural history of this disease, treatment options, and potential complications are discussed.

Posterior Cervical Laminoplasty for Resection Intradural Extramedullary Spinal Meningioma: 2-Dimensional Operative Video.

This operative video demonstrates a posterior cervical laminoplasty for the resection of a cervical intradural extramedullary meningioma. In addition, the natural history, treatment options, and potential complications are discussed. The patient is a 68-yr-old male who presented with left-hand grip weakness and paresthesias. Magnetic resonance imaging (MRI) demonstrated an enhancing mass that displacing the spinal cord anteriorly and causing severe flattening of the cord at C4 and C5. The patient underwent a posterior cervical laminoplasty for tumor resection. Removal of the dorsal elements with a high-speed drill was performed at C3, C4, and C5. A midline durotomy was performed and a large extra-axial intradural tumor was encountered. The tumor was resected en bloc and specimens were sent for permanent pathological analysis. The dura was closed in a watertight fashion using 6-0 Prolene sutures. The laminoplasty was performed by using titanium miniplates and screws to reconstruct the dorsal bony elements, and the wound was closed in layers using sutures. There were no complications. Final pathology was consistent with a WHO grade I meningioma. Postoperative MRI demonstrated gross total resection. The patient's perioperative course was uncomplicated and his preoperative weakness completely resolved by time of discharge.

High Cervical Ependymoma Resection: 2-Dimensional Operative Video.

This operative video illustrates resection of a cervical ependymoma in a 40-yr-old female with numbness of upper and lower extremities and ataxia. Magnetic resonance imaging (MRI) demonstrated an enhancing intramedullary intradural spinal mass at C2-3. The patient underwent a posterior cervical laminoplasty for tumor resection. This video highlights the natural history of this disease, treatment options, surgical procedure, potential risks and complications, and postoperative management of ependymomas. A posterior midline skin incision was made from the inion to the level of C4 which exposed the posterolateral elements of C1-3. C2 and C3 lamina were removed as a single piece using the high-speed drill. A C1 laminectomy was then also performed to provide adequate superior exposure. The dura was opened widely in the midline. Careful midline myelotomy was then performed overlying the tumor. The tumor is noted to be densely adherent to the surrounding spinal cord. Gross total resection was completed using ultrasonic aspiration and microdissection. The dura was closed in a watertight fashion followed by a synthetic dural sealant. The bony elements of C2, C3 were then reconstructed using osteoplastic laminoplasty, titanium miniplates, and screws at C2-3. The wound was closed in multiple layers using sutures. Specimens were sent for frozen and permanent pathological analysis, eventually demonstrating WHO grade II ependymoma. There were no complications. Postoperative MRI demonstrated gross total resection. The patient had an uneventful postoperative course. The strength was at baseline at long term follow-up, with small sensory deficit.

Intratumoral Rathke's Cleft Cyst Remnants Within Craniopharyngioma, Pituitary Adenoma, Suprasellar Dermoid, and Epidermoid Cysts: A Ubiquitous Signature of Ectodermal Lineage or a Transitional Entity?

BACKGROUND: The authors present cystic epithelial masses in the suprasellar region which on histopathology revealed 4 mixed tumors having simple cuboidal epithelium of Rathke's Cleft Cyst (RCC) elements trapped within pituitary adenoma, epidermoid cyst, dermoid cyst, and papillary craniopharyngioma respectively. OBJECTIVE: To highlight the developmental theory of ectodermal continuum in the realm of suprasellar epithelial cystic lesions and examines the cardinal aspects that distinguish RCC from its confounder, ciliary craniopharyngioma. METHODS: The authors performed a medical chart review on 4 patients who had coexisting RCC with craniopharyngioma, pituitary adenoma, suprasellar dermoid, and epidermoid cysts. RESULTS: This series of unique suprasellar lesions elucidate the spectrum of cases from Rathke's cyst to other suprasellar epithelial cysts including a recently identified clinical entity called ciliary craniopharyngioma, which authors feel is a misnomer. The authors also report the first case of ruptured dermoid cyst admixed with elements of Rathke's cyst elements and xanthogranuloma in neurosurgical literature. CONCLUSION: We propose that the new entity of ciliary craniopharyngioma could be just another variant of RCC elements nested within a typical papillary or adamantinomatous lesion. Further study is warranted to understand the implications of natural history with tumors containing RCC elements.

Resection of a Thoracic Hemangioblastoma in a Patient With Von Hippel-Lindau: 3-Dimensional Operative Video.

This 3-dimensional operative video illustrates resection of a thoracic hemangioblastoma in a 30-year-old female with a history of Von Hippel-Lindau disease. The patient presented with right lower extremity numbness and flank pain. Magnetic resonance imaging (MRI) demonstrated an enhancing intradural intramedullary lesion at T 7 consistent with a hemangioblastoma. The patient underwent a thoracic laminectomy with a midline dural opening for tumor resection. This case demonstrates the principles of intradural intramedullary spinal cord tumor resection. In this particular case, internal debulking was untenable owing to the vascular nature of hemangioblastomas. The operative video demonstrates en bloc tumor removal. Postoperative MRI demonstrated gross total resection. The postoperative course was uneventful. The natural history of this disease, treatment options, and potential complications are discussed.

Is the Supraorbital Notch a Reliable Landmark to Avoid the Frontal Sinus?

BACKGROUND: When performing a craniotomy involving the orbital bar, the supraorbital notch is a potential landmark to localize the lateral extent of the frontal sinus. Avoidance of the frontal sinus is important to reduce the risk of postoperative surgical site infection, epidural abscess formation, and mucocele development. OBJECTIVE: To determine the reliability of the supraorbital notch as a marker of the lateral location of the frontal sinus. METHODS: Cadaveric dissections were used with image guidance software to define the relationship between the frontal sinus and supraorbital foramen. RESULTS: The supraorbital notch was located 2.54 cm from midline and the lateral extent of the frontal sinus extended 2.84 mm lateral to the supraorbital notch. When performing a craniotomy extending medially to the supraorbital notch at a perpendicular angle, the frontal sinus was breached in 65% of craniotomies. When the craniotomy ended 10 mm lateral to the supraorbital notch, the rate of frontal sinus breach decreased to 10%. CONCLUSION: When performing a craniotomy involving the supraorbital notch, a lateral to medial trajectory that ends 15 mm to the supraorbital notch will minimize the risk of frontal sinus violation.

Resection of a Lumbar Intradural Extramedullary Schwannoma: 3-Dimensional Operative Video.

This 3-dimensional operative video illustrates resection of a lumbar schwannoma in a 57-yr-old female who presented with right lower extremity numbness, paresthesias, as well as a long history of lower back pain with rest. On magnetic resonance imaging (MRI), there was evidence of an intradural extramedullary enhancing lesion at L5, nearly completely encompassing the spinal canal. This video demonstrates the natural history, treatment options, surgical procedure, risks, and complications of treatment of these types of tumors. The patient underwent a posterior lumbar laminectomy with a midline dural opening for tumor resection. The tumor was encountered intradurally and electromyography recording confirmed that the tumor arose from a lumbar sensory nerve root. The sensory root was then divided and the tumor was then removed. The mass was removed en bloc and histopathologic analysis was consistent with a schwannoma. Postoperative MRI demonstrated gross total resection of the patient's neoplasm with excellent decompression of the spinal cord. The patient had an uneventful postoperative course with full recovery and complete resolution of her back pain and leg paresthesias.

Retrosigmoid Transtentorial Approach: Technical Nuances and Quantification of Benefit From Tentorial Incision.

OBJECTIVE: The transtentorial extension of the retrosigmoid approach allows for improved visualization of the brainstem and petroclival region. This approach is an important tool in the skull base surgeon's armamentarium for pathologies involving the petroclival region. It has been shown that the addition of tentorial transection improves the exposed surface area of the brainstem. However, no data have been reported regarding the depth of the additional anterior and medial exposure. The goal of the present study was to describe the additional depth of exposure gained by performing tentorial transection. This information allows surgeons to preoperatively estimate the amount of operative exposure gained by this technique. METHODS: Five preserved cadaveric heads were dissected using frameless image guidance. A standard retrosigmoid craniotomy was performed, followed by tentorial transection. The boundaries of the surgical exposure and depth of the surgical field were compared before and after tentorial transection. RESULTS: After transection, we found a 20.1-mm increase in anterior exposure (P < 0.01) and a 13-mm increase in medial exposure (P < 0.01). No significant difference was found in the extent of the superior (P = 0.32) or lateral (P = 0.07) exposure. The surgical working distance increased significantly from 68.8 to 90.3 mm (P < 0.01). CONCLUSIONS: When performing retrosigmoid craniotomy, the addition of tentorial transection allows for a significant increase in anterior and medial exposure with no significant increase in superior or lateral exposure.