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Pediatric orbital and skull base pathologies encompass a spectrum of inflammatory, sporadic, syndromic, and neoplastic processes that require a broad and complex clinical approach for both medical and surgical treatment. Given their complexity and often multicompartment involvement, a multidisciplinary approach for diagnosis, patient and family counseling, and ultimately treatment provides the best patient satisfaction and clinical outcomes. Advances in minimally invasive surgical approaches, including endoscopic endonasal and transorbital approaches allows for more targeted surgical approaches through smaller corridors beyond more classic transcranial or transracial approaches.
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Base do Crânio , Humanos , Criança , Base do Crânio/cirurgia , Doenças Orbitárias/cirurgia , Neoplasias da Base do Crânio/cirurgia , Endoscopia/métodos , Procedimentos Cirúrgicos Minimamente InvasivosRESUMO
BACKGROUND: Obstructive sleep apnea (OSA) is a pervasive problem that can result in diminished neurocognitive performance, increased risk of all-cause mortality, and significant cardiovascular disease. While previous studies have examined risk factors that influence outcomes following cervical fusion procedures, to our knowledge, no study has examined the cost or outcome profiles for posterior cervical decompression and fusion (PCDF) procedures in patients with OSA. METHODS: All cases at a single institution between 2008 and 2016 involving a PCDF were included. The primary outcome was prolonged extubation, defined as an extubation that took place outside of the operating room. Secondary outcomes included admission to the intensive care unit (ICU), complications, extended hospitalization, nonhome discharge, readmission within 30 and 90 days, emergency room visit within 30 and 90 days, and higher total costs. RESULTS: We reviewed 1191 PCDF cases, of which 93 patients (7.81%) had a history of OSA. At the univariate level, patients with OSA had higher rates of ICU admissions (33.3% vs 16.8%, P < 0.0001), total complications (29.0% vs 19.0%, P = 0.0202), and respiratory complications (12.9% vs 6.6%, P = 0.0217). Multivariate regression analyses revealed no difference in the odds of a prolonged extubation (P = 0.4773) and showed that history of OSA was not predictive of higher costs. However, a significant difference was observed in the odds of having an ICU admission (P = 0.0046). CONCLUSION: While patients with sleep apnea may be more likely to be admitted to the ICU postoperatively, OSA status a lone is not a risk factor for poor primary and secondary clinical outcomes following posterior cervical fusion procedures. CLINICAL RELEVANCE: Various deformities of the cervical spine can exert extraluminal forces that partially collapse or obstruct the airway, thereby predisposing patients to OSA; however, no study has examined the cost or outcome profiles for PCDF procedures in patients with OSA. Therefore, this investigation highlights the ways in which OSA influences the risks, outcomes, and costs following PCDF using medical data from an institutional registry.
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BACKGROUND: Little evidence supports acquisition of routine head imaging after uncomplicated elective neurosurgical procedures for patients with unchanged neurological examinations; however, imaging is still performed by some neurointerventionalists. We assessed the clinical utility of routine computed tomography of the head (CTH) following elective neuroendovascular interventions, including aneurysm coiling, aneurysm stent-assisted coiling, aneurysm flow diversion, arteriovenous malformation/fistula embolization, middle meningeal artery embolization for subdural hematoma, extracranial carotid artery stenting, and venous sinus stenting. METHODS: Retrospective chart review identified patients undergoing neuroendovascular intervention from 2011 to 2021 at our institution. Demographic, clinical, and radiographic variables, including presenting signs and symptoms, antiplatelets and/or anticoagulant medications, intraprocedural complications, postprocedural CTH findings, and postprocedural neurological examinations, were recorded. Association of clinical variables with an abnormal postprocedural CTH was assessed with univariate analysis. Patients with ruptured vascular pathology, preoperative embolizations, and missing postprocedural CTH images and/or reports were excluded. RESULTS: Of 509 procedures identified, 354 were eligible for analysis; 4.8% of patients (17/354) had abnormal findings on postprocedural CTH. Nine patients had intraprocedural complications or new postprocedural neurological deficits that would have prompted imaging regardless of institutional practice. None of the remaining 8 (2.3%) patients required additional procedures. New postprocedural neurological deficit was the only significant predictor of abnormal postprocedural CTH (odds ratio = 6.79; 95% confidence interval, 2.01-20.32; P = 0.0009). CONCLUSIONS: In a large cohort of patients undergoing elective neuroendovascular intervention, no patients were identified for whom routine postprocedural CTH alone meaningfully altered their clinical care. Routine CTH is not necessary after uncomplicated elective neuroendovascular interventions performed with careful postprocedural neurological assessment.
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Aneurisma , Fístula Arteriovenosa , Estenose das Carótidas , Procedimentos Endovasculares , Humanos , Estudos Retrospectivos , Stents , Tomografia Computadorizada por Raios X , Procedimentos Endovasculares/métodosRESUMO
OBJECTIVE: Seizures are the second most common presenting symptom of brain arteriovenous malformations (bAVMs) after hemorrhage. Risk factors for preoperative seizures and subsequent seizure control outcomes have been well studied. There is a paucity of literature on postoperative, de novo seizures in initially seizure-naïve patients who undergo resection. Whereas this entity has been documented after craniotomy for a wide variety of neurosurgically treated pathologies including tumors, trauma, and aneurysms, de novo seizures after bAVM resection are poorly studied. Given the debilitating nature of epilepsy, the purpose of this study was to elucidate the incidence and risk factors associated with de novo epilepsy after bAVM resection. METHODS: A retrospective review of patients who underwent resection of a bAVM over a 15-year period was performed. Patients who did not present with seizure were included, and the primary outcome was de novo epilepsy (i.e., a seizure disorder that only manifested after surgery). Demographic, clinical, and radiographic characteristics were compared between patients with and without postoperative epilepsy. Subgroup analysis was conducted on the ruptured bAVMs. RESULTS: From a cohort of 198 patients who underwent resection of a bAVM during the study period, 111 supratentorial ruptured and unruptured bAVMs that did not present with seizure were included. Twenty-one patients (19%) developed de novo epilepsy. One-year cumulative rates of developing de novo epilepsy were 9% for the overall cohort and 8.5% for the cohort with ruptured bAVMs. There were no significant differences between the epilepsy and no-epilepsy groups overall; however, the de novo epilepsy group was younger in the cohort with ruptured bAVMs (28.7 ± 11.7 vs 35.1 ± 19.9 years; p = 0.04). The mean time between resection and first seizure was 26.0 ± 40.4 months, with the longest time being 14 years. Subgroup analysis of the ruptured and endovascular embolization cohorts did not reveal any significant differences. Of the patients who developed poorly controlled epilepsy (defined as Engel class III-IV), all had a history of hemorrhage and half had bAVMs located in the temporal lobe. CONCLUSIONS: De novo epilepsy after bAVM resection occurs at an annual cumulative risk of 9%, with potentially long-term onset. Younger age may be a risk factor in patients who present with rupture. The development of poorly controlled epilepsy may be associated with temporal lobe location and a delay between hemorrhage and resection.
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Embolização Terapêutica , Epilepsia , Malformações Arteriovenosas Intracranianas , Encéfalo , Epilepsia/epidemiologia , Epilepsia/etiologia , Epilepsia/cirurgia , Humanos , Malformações Arteriovenosas Intracranianas/complicações , Malformações Arteriovenosas Intracranianas/diagnóstico por imagem , Malformações Arteriovenosas Intracranianas/epidemiologia , Estudos Retrospectivos , Convulsões/terapia , Resultado do TratamentoRESUMO
OBJECTIVE: To determine the effectiveness of the modified Frailty Index-5 (mFI-5) in predicting postoperative functional outcome after microsurgical resection of ruptured brain arteriovenous malformations (bAVMs). METHODS: A retrospective review was performed of patients undergoing microsurgical resection of acutely ruptured bAVMs. Demographics, bAVM characteristics, mFI-5, Ruptured Arteriovenous Malformation Grading Scale (RAGS) score, and Spetzler-Martin (S-M) grade were recorded. Predictive ability of mFI-5 for postoperative functional outcome measured by modified Rankin Scale (mRS) was assessed with univariate and multivariate logistic and linear regression. RAGS score and S-M grade alone were compared with adding mFI-5 to either RAGS score or S-M grade using area under the curve (AUC) analysis. RESULTS: In total, 109 patients were included. For every 1-point increase in mFI-5, there was a lower likelihood of good functional outcome (mRS score ≤2; odds ratio [OR], 0.33; confidence interval [CI], 0.15-0.60; P = 0.011). Healthy patients (mFI-5 = 0) were more likely to have good postoperative outcomes versus frail patients (mFI-5 ≥1) (OR, 3.32; CI, 1.24-8.97; P = 0.017). In multivariate analysis controlling for RAGS score, for every 1-point mFI-5 increase, there was a decreased likelihood of postoperative good functional outcome (OR, 0.32; CI, 0.14-0.63; P = 0.0026) and mFI-5 did not significantly predict secondary outcomes. S-M grade with mFI-5 showed better discrimination for postoperative good functional outcome (AUC 0.616), compared with S-M grade alone (AUC 0.544). RAGS score with mFI-5 showed the best discrimination for postoperative good functional outcome (AUC 0.798), compared with RAGS score alone (AUC 0.721). CONCLUSIONS: Measuring frailty with mFI-5 additive to established bAVM grading systems may improve assessment of individual patient likelihood of postoperative good functional outcome after hemorrhagic bAVM resection.
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Fragilidade , Malformações Arteriovenosas Intracranianas , Idoso , Encéfalo , Fragilidade/complicações , Humanos , Malformações Arteriovenosas Intracranianas/complicações , Malformações Arteriovenosas Intracranianas/cirurgia , Complicações Pós-Operatórias/epidemiologia , Estudos Retrospectivos , Resultado do TratamentoRESUMO
PURPOSE: Delayed auditory feedback (DAF) interferes with speech output. DAF causes distorted and disfluent productions and errors in the serial order of produced sounds. Although DAF has been studied extensively, the specific patterns of elicited speech errors are somewhat obscured by relatively small speech samples, differences across studies, and uncontrolled variables. The goal of this study was to characterize the types of serial order errors that increase under DAF in a systematic syllable sequence production task, which used a closed set of sounds and controlled for speech rate. METHOD: Sixteen adult speakers repeatedly produced CVCVCV (C = consonant, V = vowel) sequences, paced to a "visual metronome," while hearing self-generated feedback with delays of 0-250 ms. Listeners transcribed recordings, and speech errors were classified based on the literature surrounding naturally occurring slips of the tongue. A series of mixed-effects models were used to assess the effects of delay for different error types, for error arrival time, and for speaking rate. RESULTS: DAF had a significant effect on the overall error rate for delays of 100 ms or greater. Statistical models revealed significant effects (relative to zero delay) for vowel and syllable repetitions, vowel exchanges, vowel omissions, onset disfluencies, and distortions. Serial order errors were especially dominated by vowel and syllable repetitions. Errors occurred earlier on average within a trial for longer feedback delays. Although longer delays caused slower speech, this effect was mediated by the run number (time in the experiment) and small compared with those in previous studies. CONCLUSIONS: DAF drives a specific pattern of serial order errors. The dominant pattern of vowel and syllable repetition errors suggests possible mechanisms whereby DAF drives changes to the activity in speech planning representations, yielding errors. These mechanisms are outlined with reference to the GODIVA (Gradient Order Directions Into Velocities of Articulators) model of speech planning and production. SUPPLEMENTAL MATERIAL: https://doi.org/10.23641/asha.19601785.
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Percepção da Fala , Fala , Adulto , Retroalimentação , Retroalimentação Sensorial , Humanos , Fonética , LínguaRESUMO
STUDY DESIGN: Retrospective cohort study. OBJECTIVE: The present study analyzes complication rates and episode-based costs for patients with and without diabetes mellitus (DM) following posterior lumbar fusion (PLF). METHODS: PLF cases at a single institution from 2008 to 2016 were queried (n = 3226), and demographic and perioperative data were analyzed. Patients with and without the diagnosis of DM were compared using chi-square, Student's t test, and multivariable regression modeling. RESULTS: Patients with diabetes were older (63.10 vs 56.48 years, P < .001) and possessed a greater number of preoperative comorbidities (47.84% of patients had Elixhauser Comorbidity Index >0 vs 42.24%, P < .001) than did patients without diabetes. When controlling for preexisting differences, diabetes remained a significant risk factor for prolonged length of stay (OR = 1.59, 95% CI 1.26-2.01, P < .001), intensive care unit stay (OR = 1.52, 95% CI 1.07-2.17, P = .021), nonhome discharge (OR = 1.86, 95% CI 1.46-2.37, P < .001), 30-day readmission (OR = 2.15, 95% CI 1.28-3.60, P = .004), 90-day readmission (OR = 1.65, 95% CI 1.05-2.59, P = .031), 30-day emergency room visit (OR = 2.15, 95% CI 1.27-3.63, P = .004), and 90-day emergency room visit (OR = 2.27, 95% CI 1.41-3.65, P < .001). Cost modeling controlling for overall comorbidity burden demonstrated that diabetes was associated with a $1709 increase in PLF costs (CI $344-$3074, P = .014). CONCLUSIONS: The present findings indicate a correlation between diabetes and a multitude of postoperative adverse outcomes and increased costs, thus illustrating the substantial medical and financial burdens of diabetes for PLF patients. Future studies should explore preventive measures that may mitigate these downstream effects.
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OBJECTIVE: Cranioplasty is a technically simple procedure, although one with potentially high rates of complications. The ideal timing of cranioplasty should minimize the risk of complications, but research investigating cranioplasty timing and risk of complications has generated diverse findings. Previous studies have included mixed populations of patients undergoing cranioplasty following decompression for traumatic, vascular, and other cerebral insults, making results challenging to interpret. The objective of the current study was to examine rates of complications associated with cranioplasty, specifically for patients with traumatic brain injury (TBI) receiving this procedure at the authors' high-volume level 1 trauma center over a 25-year time period. METHODS: A single-institution retrospective review was conducted of patients undergoing cranioplasty after decompression for trauma. Patients were identified and clinical and demographic variables obtained from 2 neurotrauma databases. Patients were categorized into 3 groups based on timing of cranioplasty: early (≤ 90 days after craniectomy), intermediate (91-180 days after craniectomy), and late (> 180 days after craniectomy). In addition, a subgroup analysis of complications in patients with TBI associated with ultra-early cranioplasty (< 42 days, or 6 weeks, after craniectomy) was performed. RESULTS: Of 435 patients identified, 141 patients underwent early cranioplasty, 187 patients received intermediate cranioplasty, and 107 patients underwent late cranioplasty. A total of 54 patients underwent ultra-early cranioplasty. Among the total cohort, the mean rate of postoperative hydrocephalus was 2.8%, the rate of seizure was 4.6%, the rate of postoperative hematoma was 3.4%, and the rate of infection was 6.0%. The total complication rate for the entire population was 16.8%. There was no significant difference in complications between any of the 3 groups. No significant differences in postoperative complications were found comparing the ultra-early cranioplasty group with all other patients combined. CONCLUSIONS: In this cohort of patients with TBI, early cranioplasty, including ultra-early procedures, was not associated with higher rates of complications. Early cranioplasty may confer benefits such as shorter or fewer hospitalizations, decreased financial burden, and overall improved recovery, and should be considered based on patient-specific factors.
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BACKGROUND AND PURPOSE: We present a retrospective analysis of patients who underwent minimally invasive endoscopic intracerebral hemorrhage (ICH) evacuation to identify variables that were associated with long-term outcome. METHODS: Minimally invasive endoscopic ICH evacuation was performed on patients with supratentorial ICH who fit prespecified clinical inclusion and exclusion criteria. Demographic, clinical, and radiographic factors previously demonstrated to impact functional outcome in ICH were included in a univariate analysis to identify factors associated with favorable outcome (modified Rankin Scale score, 0-3) at 6 months. Factors associated with a favorable outcome in the univariate analysis (P≤0.20) were included in a multivariate logistic regression analysis with the same dependent variable. RESULTS: Ninety patients underwent MIS endoscopic ICH evacuation within 72 hours of ictus. In a multivariate analysis, factors associated with good long-term functional outcome included time to evacuation (per hour; OR, 0.95 [95% CI, 0.92-0.98], P=0.004), age (per decade, odds ratio [OR], 0.49 [95% CI, 0.28-0.77], P=0.005), presence of intraventricular hemorrhage (OR, 0.15 [95% CI, 0.04-0.47], P=0.002), and lobar location (OR, 18.5 [95% CI, 4.5-103], P=0.0005). Early evacuation was not associated with an increased risk of rebleeding. CONCLUSIONS: Young age, lack of intraventricular hemorrhage, lobar location, and time to evacuation were independently associated with good long-term functional outcome in patients undergoing minimally invasive endoscopic ICH evacuation. The OR for time to evacuation suggests that for each additional hour, there was a 5% reduction in the odds of achieving a favorable outcome.
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Hemorragia Cerebral/cirurgia , Hematoma/cirurgia , Acidente Vascular Cerebral/cirurgia , Resultado do Tratamento , Adulto , Idoso , Hemorragia Cerebral/complicações , Craniotomia/métodos , Hematoma/complicações , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Razão de ChancesRESUMO
BACKGROUND: Intracerebral hemorrhage (ICH) is a severe form of stroke with limited treatment options. Statins have shown promise as a therapy for ICH in animal and human studies. We systematically reviewed and assessed the quality of preclinical studies exploring statin-use after ICH to guide clinical trial decision-making and design. METHODS: We identified preclinical trials assessing the efficacy of statins in ICH via a systematic review of the literature according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. In total, 16 studies were identified that described statin use in an animal model of ICH and assessed histological outcomes, behavioral scores, or both. Design characteristics were analyzed using Stroke Therapy Academic Industry Roundtable (STAIR) criteria modified for ICH. Meta-analysis was performed using a random effects model. RESULTS: Behavioral outcomes were assessed in 12 of the studies with 100% (n = 12) reporting that statins significantly improved ICH recovery. Histologic hematoma volume and brain water content outcomes were analyzed in 10 of the studies, with 50% (n = 5) reporting significant improvement. The ratio of means between experimental and control cases for modified Neurological Severity Score was 0.63 (95% confidence interval 0.49-0.82). The ratio of means between experimental and control cases for hemorrhagic volume was 0.85 (95% confidence interval 0.70-1.03). There was heterogeneity between studies (P < 0.0001) but no evidence of publication bias (P = 0.89, P = 0.59, respectively). CONCLUSIONS: Behavioral outcomes in ICH were found to consistently improve with administration of statins in preclinical studies suggesting that statin therapy may be suitable for randomized clinical trials in humans. In addition, the STAIR criteria can be modified to effectively evaluate preclinical studies in ICH.
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Hemorragia Cerebral/tratamento farmacológico , Modelos Animais de Doenças , Inibidores de Hidroximetilglutaril-CoA Redutases/uso terapêutico , Acidente Vascular Cerebral/tratamento farmacológico , Animais , Encéfalo/efeitos dos fármacos , Encéfalo/patologia , Hemorragia Cerebral/patologia , Avaliação Pré-Clínica de Medicamentos/métodos , Humanos , Inibidores de Hidroximetilglutaril-CoA Redutases/farmacologia , Acidente Vascular Cerebral/patologiaRESUMO
OBJECTIVE: Recombinant human bone morphogenetic protein-2 (rhBMP-2) is used in spinal arthrodesis procedures to enhance bony fusion. Research has suggested that it is the most cost-effective fusion enhancer, but there are significant upfront costs for the healthcare system. The primary objective of this study was to determine whether intraoperative dosing and corresponding costs changed with surgeon cost awareness. The secondary objective was to describe surgical complications before and after surgeon awareness of rhBMP-2 cost. METHODS: A retrospective medical record review was conducted to identify patients who underwent spinal arthrodesis procedures performed by a single surgeon, supplemented with rhBMP-2, from June 2016 to June 2018. Collected data included rhBMP-2 dosage, rhBMP-2 list price, and surgical complications. Expected Medicare reimbursement was calculated. Data were analyzed before and after surgeon awareness of rhBMP-2 cost. RESULTS: Forty-eight procedures were performed using rhBMP-2, 16 before and 32 after surgeon cost awareness. Prior to cost awareness, the most frequent rhBMP-2 dosage level was x-small (38.9%, n = 7), followed by large (27.8%, n = 5) and small (22.2%, n = 4). After cost awareness, the most frequent rhBMP-2 dosage was xx-small (56.8%, n = 21), followed by x-small (21.6%, n = 8) and large (13.5%, n = 5). The rhBMP-2 average cost per surgery was $4116.56 prior to surgeon cost awareness versus $2268.38 after. Two complications were observed in the pre-cost awareness surgical group; 2 complications were observed in the post-cost awareness surgical group. CONCLUSIONS: Surgeon awareness of rhBMP-2 cost resulted in use of smaller rhBMP-2 doses, decreased rhBMP-2 cost per surgery, and decreased overall hospital admission charges, without a detectable increase in surgical complications.
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Fusão Vertebral , Cirurgiões , Idoso , Proteína Morfogenética Óssea 2 , Humanos , Vértebras Lombares , Medicare , Proteínas Recombinantes , Estudos Retrospectivos , Fator de Crescimento Transformador beta , Estados UnidosRESUMO
BACKGROUND: Intracerebral hemorrhage (ICH) is the most devastating form of stroke, with thalamic hemorrhages carrying the worst outcomes. Minimally invasive (MIS) endoscopic ICH evacuation is a promising new therapy for the condition. However, it remains unclear whether therapy success is location dependent. Here we present long-term functional outcomes after MIS evacuation of spontaneous thalamic hemorrhages. METHODS: Patients presenting to a single urban health system with spontaneous ICH were triaged to a central hospital for management of ICH. Operative criteria for MIS evacuation included hemorrhage volume ≥15 mL, age ≥18, National Institutes of Health Stroke Scale ≥6, and baseline modified Rankin Score (mRS) ≤3. Demographic, radiographic, and clinical data were collected prospectively, and descriptive statistics were performed retrospectively. Functional outcomes were assessed using 6-month mRS scores. RESULTS: Endoscopic ICH evacuation was performed on 21 patients. Eleven patients had hemorrhage confined to the thalamus, whereas 10 patients had hemorrhages in the thalamus and surrounding structures. Eighteen patients (85.7%) had intraventricular extension. The average preoperative volume was 39.8 mL (standard deviation [SD]: 31.5 mL) and postoperative volume was 3.8 mL (SD: 6.1 mL), resulting in an average evacuation rate of 91.4% (SD: 11.1%). One month after hemorrhage, 2 patients (9.5%) had expired and all other patients remained functionally dependent (90.5%). At 6-month follow-up, 4 patients (19.0%) had improved to a favorable outcome (mRS ≤ 3). CONCLUSION: Among patients with ICH undergoing medical management, those with thalamic hemorrhages have especially poor outcomes. This study suggests that MIS evacuation can be safely performed in a thalamic population. It also presents long-term functional outcomes that can aid in planning randomization schemes or subgroup analyses in future MIS evacuation clinical trials.
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Hemorragia Cerebral/cirurgia , Endoscopia , Hematoma/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos , Tálamo/cirurgia , Idoso , Hemorragia Cerebral/etiologia , Endoscopia/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Estudos Retrospectivos , Resultado do TratamentoRESUMO
OBJECTIVE: The impact of interhospital transfer (IHT) on outcomes of patients with intracerebral hemorrhage (ICH) has not been well studied. We seek to describe the protocolized IHT and systems of care approach of a New York City hospital system, where ICH patients undergoing minimally invasive surgery (MIS) are transferred to a dedicated ICH center. METHODS: We retrospectively reviewed 100 consecutively admitted patients with spontaneous ICH. We gathered information on demographics, variables related to IHT, clinical and radiographic characteristics, and details about the clinical course and outpatient follow-up. We grouped patients into 2 cohorts: those admitted through IHT and those directly admitted through the emergency department. Primary outcome was good functional outcome at 6 months, defined as modified Rankin Scale score 0-3. RESULTS: Of 100 patients, 89 underwent IHT and 11 were directly admitted. On multivariable analysis, there were no significant differences in 6-month functional outcome between the 2 cohorts. All transfers were managed by a system-wide transfer center and 24/7 hotline for neuroemergencies. An ICH-specific IHT protocol was followed, in which a neurointensivist provided recommendations for stabilizing patients for transfer. Average transfer time was 199.7 minutes and average distance travelled was 13.6 kilometers. CONCLUSIONS: In our hospital system, a centralized approach to ICH management and a dedicated ICH center increased access to specialist services, including MIS. Most patients undergoing MIS were transferred from outside hospitals, which highlights the need for additional studies and descriptions of experiences to further elucidate the impact of and best protocols for the IHT of ICH patients.
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Hemorragia Cerebral/cirurgia , Hospitais Urbanos/organização & administração , Procedimentos Neurocirúrgicos , Transferência de Pacientes , Idoso , Avaliação da Deficiência , Emergências , Serviço Hospitalar de Emergência , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos , Cidade de Nova Iorque , Admissão do Paciente , Equipe de Assistência ao Paciente , Estudos Retrospectivos , Técnicas Estereotáxicas , TriagemRESUMO
STUDY DESIGN: Retrospective analysis of prospectively acquired data. OBJECTIVE: The aim of this study was to identify interaction effects that modulate nonhome discharge (NHD) risk by applying coalitional game theory principles to interpret machine learning models and understand variable interaction effects underlying NHD risk. SUMMARY OF BACKGROUND DATA: NHD may predispose patients to adverse outcomes during their care. Previous studies identified potential factors implicated in NHD; however, it is unclear how interaction effects between these factors contribute to overall NHD risk. METHODS: Of the 11,150 reviewed cases involving procedures for degenerative spine conditions, 1764 cases (15.8%) involved NHD. Gradient boosting classifiers were used to construct predictive models for NHD for each patient. Shapley values, which assign a unique distribution of the total NHD risk to each model variable using an optimal cost-sharing rule, quantified feature importance and examined interaction effects between variables. RESULTS: Models constructed from features identified by Shapley values were highly predictive of patient-level NHD risk (mean C-statisticâ=â0.91). Supervised clustering identified distinct patient subgroups with variable NHD risk and their shared characteristics. Focused interaction analysis of surgical invasiveness, age, and comorbidity burden suggested age as a worse risk factor than comorbidity burden due to stronger positive interaction effects. Additionally, negative interaction effects were found between age and low blood loss, indicating that intraoperative hemostasis may be critical for reducing NHD risk in the elderly. CONCLUSION: This strategy provides novel insights into feature interactions that contribute to NHD risk after spine surgery. Patients with positively interacting risk factors may require special attention during their hospitalization to control NHD risk.Level of Evidence: 3.
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Teoria dos Jogos , Aprendizado de Máquina , Alta do Paciente/estatística & dados numéricos , Doenças da Coluna Vertebral , Coluna Vertebral/cirurgia , Comorbidade , Humanos , Modelos Estatísticos , Complicações Pós-Operatórias , Fatores de Risco , Doenças da Coluna Vertebral/epidemiologia , Doenças da Coluna Vertebral/cirurgiaRESUMO
In this case report, we describe bilateral endoscopic intracerebral hemorrhage (ICH) evacuations in patients presenting on temporally distinct occasions with separate, contralateral lesions. Two patients presented with spontaneous right-sided ICH and underwent endoscopic evacuations. Both patients achieved some degree of functional improvement postoperatively. Each patient then experienced a second ICH in the left hemisphere months later, and again underwent endoscopic evacuation of the contralateral lesion. Postoperatively, both patients faced significantly longer hospitalizations and severe drops in functional independence compared to the first surgery. Functional outcomes after contralateral endoscopic ICH evacuation may vary significantly, and bilateral disease portends a worse prognosis.
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STUDY DESIGN: Retrospective cohort study. OBJECTIVES: To conduct the first comprehensive national-level study examining specific risks, outcomes, and costs surrounding surgical treatment of lumar spinal stenosis (LSS) in patients with and without neurogenic claudication (NC). METHODS: Data for patients with or without NC who underwent decompression with a lumbar interbody fusion approached anteriorly (ALIF), posteriorly (PLIF), or laterally (LLIF) for LSS was collected from the 2013-2014 National Inpatient Sample using International Classification of Disease codes. RESULTS: A total of 121 025 LSS cases without NC and 20 095 cases with NC were included in this study. The most significant complications associated with NC status by organ system included renal (P = .0030) and hematological complications (P = .0003). Multivariate regression controlling for key demographic and comorbidity variables showed that patients with NC did not have significantly higher odds of complication, non-home discharge, or extended hospitalization compared to patients without NC regardless of fusion type. Interestingly, NC patients had comparatively lower total charges for their hospitalization following PLIFs (P = .0001) and LLIFs (P < .0001), but not ALIFs (P = .6121). CONCLUSION: NC does not appear to significantly increase odds of adverse outcomes following fusion in LSS. Given the large prevalence of LSS and coincidental NC, these findings may carry important implications in managing this challenging patient population and justifies future prospective investigation of this topic.
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BACKGROUND AND OBJECTIVE: Unilateral subaxial non-subluxed facet fractures (USNSFF) are a pathology seen in traumatic events such as motor vehicle accidents. Management involves either rigid collar bracing or surgical intervention. There currently is no consensus on the treatment of these injuries; this review aims to examine the extant data for recommendations as to which treatment is more effective. METHODS: MEDLINE, Scopus, and the Cochrane trial register were all searched on January 16, 2020, comparing outcomes for surgical and conservative therapy for USNSFF. The meta-analysis examined rates of treatment failure (need for subsequent operative management) in conservative versus surgical management. The meta-analysis was performed using a random effects model, with visualization in forest and L'Abbé plots. RESULTS: We identified six retrospective studies describing 270 patients, with three studies describing 137 patients used in the meta-analysis. Overall, a surgical success rate of 97.7 % and a non-operative success rate of 79.7 % was observed. A random effects model risk ratio of 1.66 (95 % CI: 0.61-4.52) was obtained, suggesting efficacy of surgical management over conservative management. CONCLUSION: The need for surgical intervention subsequent to initial management in the treatment of USNSFF was found to be lower in surgical treatment in contrast to conservative management. However, the studies that were included in the meta-analysis had patient cohorts with much higher rates of neurological deficit and ligamentous injury on presentation, indicating that these may be prognostic indicators of conservative management failure. Furthermore, those that did fail conservative management did not develop severely debilitating conditions. Accordingly, conservative treatment is generally sufficient as a first step in a majority of cases of USNSFF lacking neurological deficit or ligamentous involvement.
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Tratamento Conservador/métodos , Fixação de Fratura/métodos , Fraturas da Coluna Vertebral/cirurgia , Articulação Zigapofisária/cirurgia , Tratamento Conservador/tendências , Fixação de Fratura/tendências , Humanos , Estudos Retrospectivos , Fraturas da Coluna Vertebral/diagnóstico por imagem , Fraturas da Coluna Vertebral/terapia , Articulação Zigapofisária/diagnóstico por imagemRESUMO
INTRODUCTION: Maximal extent of resection (EOR) of glioblastoma (GBM) is associated with greater progression free survival (PFS) and improved patient outcomes. Recently, a novel surgical system has been developed that includes a 2D, robotically-controlled exoscope and brain tractography display. The purpose of this study was to assess outcomes in a series of patients with GBM undergoing resections using this surgical exoscope. METHODS: A retrospective review was conducted for robotic exoscope assisted GBM resections between 2017 and 2019. EOR was computed from volumetric analyses of pre- and post-operative MRIs. Demographics, pathology/MGMT status, imaging, treatment, and outcomes data were collected. The relationship between these perioperative variables and discharge disposition as well as progression-free survival (PFS) was explored. RESULTS: A total of 26 patients with GBM (median age = 57 years) met inclusion criteria, comprising a total of 28 cases. Of these, 22 (79%) tumors were in eloquent regions, most commonly in the frontal lobe (14 cases, 50%). The median pre- and post-operative volumes were 24.0 cc and 1.3 cc, respectively. The median extent of resection for the cohort was 94.8%, with 86% achieving 6-month PFS. The most common neurological complication was a motor deficit followed by sensory loss, while 8 patients (29%) were symptom-free. CONCLUSIONS: The robotic exoscope is safe and effective for patients undergoing GBM surgery, with a majority achieving large-volume resections. These patients experienced complication profiles similar to those undergoing treatment with the traditional microscope. Further studies are needed to assess direct comparisons between exoscope and microscope-assisted GBM resection.
Assuntos
Neoplasias Encefálicas/cirurgia , Glioblastoma/cirurgia , Procedimentos Neurocirúrgicos/mortalidade , Complicações Pós-Operatórias/epidemiologia , Procedimentos Cirúrgicos Robóticos/mortalidade , Adulto , Idoso , Neoplasias Encefálicas/patologia , Feminino , Seguimentos , Glioblastoma/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Estados Unidos/epidemiologiaRESUMO
BACKGROUND: Subarachnoid hemorrhage (SAH) is the most morbid sequela of intracranial aneurysms. Although mortality from SAH has been declining, opioid use in the United States has surged, and neurosurgeons are increasingly tasked with operating on patients with opioid use disorders (OUDs). There is a deficit in the literature regarding how OUDs affect SAH outcomes, particularly transient cerebral ischemic (TCI) events. The objective of this study was to investigate the influence of clinically diagnosed OUDs on the outcomes after acute SAH, with a specific focus on the rate of symptomatic TCI. METHODS: Patients with and without a diagnosed OUD who underwent either microsurgical clipping or endovascular coiling for SAH were queried from the 2012-2014 National Inpatient Sample using International Classification of Disease codes. The primary outcome was the rate of TCI after SAH treatment. RESULTS: A total of 25,330 patients were included, 310 of whom (1.22%) also carried a diagnosis of OUD. Univariate and multivariate regression showed that patients with OUD faced significantly increased odds of TCI (P = 0.044) compared with patients without OUD. OUD status was not associated with increased odds of other adverse outcomes, including overall complication, in-hospital mortality, poor outcome by a validated National Inpatient Sample SAH Outcome Measure, nonhome discharge, or extended hospitalization. CONCLUSIONS: Patients with OUD face significantly higher odds of symptomatic TCI events producing clinical deficits during hospitalization for acute SAH. These findings suggest usefulness in screening patients for OUD to identify individuals who may benefit from a higher level of clinical scrutiny for post-SAH TCI.