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1.
World Neurosurg ; 2022 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-35367640

RESUMO

BACKGROUND: The introduction of carotid stenting (CAS) has led to numerous comparative trials with carotid endarterectomy (CEA). OBJECTIVE: The objective of the study was to review real-world volumes, outcomes, and complications following CEA versus CAS over an extended period to identify durable changes in practice. METHODS: Data were extracted from the National Inpatient Sample. Trends were assessed by annual percent change (APC), and adjusted risk ratios were calculated across the last 5 years of the study period. RESULTS: During 1997-2015, 199,330 symptomatic and 1,995,637 asymptomatic patients underwent carotid revascularization. In symptomatic patients, CEA declined (1997-2004; APC = -7.68%, P < 0.001) and CAS rose (1997-2008; APC = 15.48%, P < 0.001) during the first decade, subsequently becoming more muted. In asymptomatic patients, CEA decreased, whereas CAS initially increased (1997-2006; APC = 20.27%, P < 0.001) and then decreased (2007-2015; APC = -4.52%, P < 0.001). Routine discharge after symptomatic revascularization declined in CEA after 2003 and in CAS after 2006 (APC = -1.72% and -3.11%, respectively, P < 0.001 for both), corresponding to increasing patient comorbidity; similar trends were seen in asymptomatic patients. Death decreased after CEA (symptomatic and asymptomatic; APC = -4.85% and -3.53%, respectively, P < 0.001 for both) and CAS (asymptomatic only, APC = -2.53%, P = 0.04). CAS remained associated with a higher adjusted risk ratio for death, venous thromboembolism, and seizures in all patients and stroke and nonroutine discharge in symptomatic patients, during the last 5 years of the study period. CONCLUSIONS: Mortality has improved, but routine discharge has decreased following both CEA and CAS, congruent with increasing patient comorbidity. Trends in volumes, outcomes, and complication rates continue to favor CEA in real-world practice.

2.
Proc Natl Acad Sci U S A ; 119(12): e2116264119, 2022 03 22.
Artigo em Inglês | MEDLINE | ID: mdl-35286202

RESUMO

SignificanceWe provide the first assessment of aboveground live tree biomass in a mixed conifer forest over the late Holocene. The biomass record, coupled with local Native oral history and fire scar records, shows that Native burning practices, along with a natural lightning-based fire regime, promoted long-term stability of the forest structure and composition for at least 1 millennium in a California forest. This record demonstrates that climate alone cannot account for observed forest conditions. Instead, forests were also shaped by a regime of frequent fire, including intentional ignitions by Native people. This work suggests a large-scale intervention could be required to achieve the historical conditions that supported forest resiliency and reflected Indigenous influence.


Assuntos
Conservação dos Recursos Naturais , Incêndios , California , Florestas , Humanos , Árvores
3.
J Neurol Surg Rep ; 83(1): e23-e28, 2022 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-35273900

RESUMO

Prostate carcinomas are the most common malignancy to metastasize to the dura. These metastases can commonly mimic subdural hematomas and may similarly present with brain compression. The optimal management and outcomes after surgical management are not well characterized. We present a case of prostate carcinoma metastatic to the dura that was initially thought to be a large isodense subdural hematoma and was treated with surgical decompression. We also review the literature regarding prostate dural metastases mimicking subdural hematomas and discuss the relevant imaging findings, treatments, and outcomes. Dural metastasis should be considered when a patient with known metastatic prostate cancer presents with imaging evidence of a subdural mass.

4.
Neurosurgery ; 90(4): 383-389, 2022 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-35132970

RESUMO

BACKGROUND: Intracranial hemorrhage (ICH) is considered an emergency that requires rapid medical or surgical management. Previous studies have used artificial intelligence to attempt to expedite the diagnosis of this pathology on neuroimaging. However, these studies have used local, institution-specific data for training of networks that limit deployment of across broader hospital networks or regions because of data biases. OBJECTIVE: To demonstrate the creation of a neural network based on an openly available imaging data tested on data from our institution demonstrating a high-efficacy, institution-agnostic network. METHODS: A data set was created from publicly available noncontrast computed tomography images of known ICH. These data were used to train a neural network using distinct windowing and augmentation. This network was then validated in 2 phases using cohort-based (phase 1) and longitudinal (phase 2) approaches. RESULTS: Our convolutional neural network was trained on 752 807 openly available slices, which included 112 762 slices containing intracranial hemorrhage. In phase 1, the final network performance for intracranial hemorrhage showed a receiver operating characteristic curve (AUC) of 0.99. At the inflection point, our model showed a sensitivity of 98% at a threshold specificity of 99%. In phase 2, we obtained an AUC of 0.98 after analysis of 726 scans with a negative predictive value of 99.70% (n = 726). CONCLUSION: We demonstrate an effective neural network trained on completely open data for screening ICH at an unrelated institution. This study demonstrates a proof of concept for screening networks for multiple sites while maintaining high efficacy.


Assuntos
Inteligência Artificial , Redes Neurais de Computação , Humanos , Hemorragias Intracranianas/diagnóstico por imagem , Neuroimagem , Estudos Retrospectivos , Tomografia Computadorizada por Raios X
5.
J Neurointerv Surg ; 2022 Feb 15.
Artigo em Inglês | MEDLINE | ID: mdl-35169035

RESUMO

BACKGROUND: Hospital readmissions are costly and reflect negatively on care delivered. OBJECTIVE: To have a better understanding of unplanned readmissions after carotid revascularization, which might help to prevent them. METHODS: The Nationwide Readmissions Database was used to determine rates and reasons for unplanned readmission following carotid endarterectomy (CEA) and carotid artery stenting (CAS). Trends were assessed by annual percent change, modified Poisson regression was used to estimate risk ratios (RR) for readmission, and propensity scores were used to match cohorts. RESULTS: Analysis yielded 522 040 asymptomatic and 55 485 symptomatic admissions for carotid revascularization between 2010 and 2015. Higher 30-day readmission rates were noted after CAS versus CEA in both symptomatic (9.1% vs 7.7%, p<0.001) and asymptomatic (6.8% vs 5.7%, p<0.001) patients. Readmission rates trended lower over time, significantly so for 90-day readmissions in symptomatic patients undergoing CEA. The most common cause for 30-day readmission was stroke in both symptomatic (5.5%) and asymptomatic (3.9%) patients. Factors associated with a higher risk of readmission included age over 80; male gender; Medicaid health insurance; and increases in severity of illness, mortality risk, and comorbidity indices. Analysis of matched cohorts showed that CAS had higher readmission than CEA (RR=1.14 (95% CI 1.06 to 1.22); p<0.001) only in asymptomatic patients. Adverse events during initial admission which predicted 30-day readmission included acute renal failure and acute respiratory failure in asymptomatic patients; hematoma and cardiac events were additional predictive adverse events in symptomatic patients. CONCLUSIONS: Readmission is not uncommon after carotid revascularization, occurs more often after CAS, and is predicted by baseline factors and by preventable adverse events at initial admission.

6.
World Neurosurg ; 160: e601-e607, 2022 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-35092816

RESUMO

OBJECTIVE: To comprehensively analyze malpractice claims relating to arteriovenous malformations. METHODS: Westlaw and LexisNexis databases were cross-referenced to obtain a comprehensive list of medical malpractice lawsuits related to arteriovenous malformations. The initial search yielded 147 results, of which 78 were considered eligible for analysis. RESULTS: Plaintiff age was reported in 16 cases (mean age 30.9 ± 19.9 years). In 53 cases, the location of the lesions was reported: 38 (90.9%) were intracranial, and 15 (28.3%) were spinal. The main complaints were medical error (34 cases, 43.6%), failure to diagnose (33 cases, 42.3%), failure to treat (20, 25.6%), misdiagnosis (7 cases, 9.0%), lack of informed consent (7 cases, 9.0%), and other causes (11 cases, 14.1%). The medical specialties most commonly involved were neurosurgery (22 cases, 34.4%), radiology (16 cases, 25.0%), and neurology (10 cases, 15.6%). Neurosurgeons were more frequently sued than neurologists (P = 0.01) but not radiologists (P = 0.25). The court rulings included in favor of the defendant in 23 cases (29.5%), in favor of the plaintiff in 6 cases (7.7%), a settlement in 27 cases (34.6%), mediation in 1 case (1.3%), and unknown/other in 21 cases (26.9%). Rulings in favor of the defendant (P = 0.0005) or settlements (P < 0.0001) were more frequent than rulings in favor of the plaintiff, but there was no difference in rulings in favor of the defendant compared with settlements (P = 0.69). CONCLUSIONS: While the courts rule in favor of defendants more than plaintiffs, the time and psychological demands of litigation place a high burden on physicians.


Assuntos
Malformações Arteriovenosas , Imperícia , Médicos , Adolescente , Adulto , Sistema Nervoso Central , Criança , Bases de Dados Factuais , Humanos , Pessoa de Meia-Idade , Coluna Vertebral/cirurgia , Adulto Jovem
7.
S Afr J Physiother ; 77(2): 1569, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34859161

RESUMO

BACKGROUND: High-quality evidence exists to support physiotherapy and brace treatment for scoliosis and other spinal deformities. However, according to previous systematic reviews, it seems that no evidence exists for surgery. Nevertheless, the number of research articles focussing on spinal surgery highly exceeds the number of articles focussing on conservative treatment. OBJECTIVE: The purpose of this study is to conduct an updated search for systematic reviews providing high-quality evidence for spinal surgery in patients with spinal deformities. METHOD: A narrative review including PubMed and the Cochrane database was conducted on April 12, 2020, with the following search terms: (1) spinal deformities, surgery, systematic review and outcome; (2) kyphosis, surgery, systematic review and outcome; (3) Scheuermann's disease, surgery, systematic review and outcome, and (4) scoliosis, surgery, systematic review and outcome. RESULTS: No reviews containing prospective controlled or randomised controlled studies were found providing evidence for surgery. CONCLUSIONS: A general indication for spine surgery just based on the Cobb angle is not given. In view of the long-term unknown variables and the possible long-term complications of such treatment, a surgical indication for patients with spinal deformities must be reviewed on an individual basis and considered carefully. A current systematic review appears necessary in order to be able to draw final conclusions on the indication for surgery in patients with spinal deformities. CLINICAL IMPLICATIONS: In view of the increasing number of surgeons with an affiliation to industry, the indication for surgery needs to be given by independent conservative specialists for spinal deformities in order to provide an objective recommendation.

8.
Sci Rep ; 11(1): 17684, 2021 09 03.
Artigo em Inglês | MEDLINE | ID: mdl-34480073

RESUMO

Positional brain shift (PBS), the sagging of the brain under the effect of gravity, is comparable in magnitude to the margin of error for the success of stereotactic interventions ([Formula: see text] 1 mm). This non-uniform shift due to slight differences in head orientation can lead to a significant discrepancy between the planned and the actual location of surgical targets. Accurate in-vivo measurements of this complex deformation are critical for the design and validation of an appropriate compensation to integrate into neuronavigational systems. PBS arising from prone-to-supine change of head orientation was measured with magnetic resonance imaging on 11 young adults. The full-field displacement was extracted on a voxel-basis via digital volume correlation and analysed in a standard reference space. Results showed the need for target-specific correction of surgical targets, as a significant displacement ranging from 0.52 to 0.77 mm was measured at surgically relevant structures. Strain analysis further revealed local variability in compressibility: anterior regions showed expansion (both volume and shape change), whereas posterior regions showed small compression, mostly dominated by shape change. Finally, analysis of correlation demonstrated the potential for further patient- and intervention-specific adjustments, as intra-cranial breadth and head tilt correlated with PBS reaching statistical significance.


Assuntos
Encéfalo/diagnóstico por imagem , Imageamento por Ressonância Magnética , Posicionamento do Paciente , Técnicas Estereotáxicas , Cirurgia Assistida por Computador/métodos , Adulto , Feminino , Humanos , Imageamento Tridimensional , Masculino , Neuronavegação , Orientação , Adulto Jovem
9.
Neurosurgery ; 89(5): 792-799, 2021 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-34383947

RESUMO

BACKGROUND: Postpartum vertebral artery dissections (ppVADs) are rare but potentially morbid conditions that occur in otherwise healthy patients. OBJECTIVE: To evaluate clinical characteristics of ppVADs. METHODS: Demographic, clinical, treatment, and outcome data were collected on ppVADs and are presented in a case series of 12 patients and compared to the general cohort. RESULTS: In total, 12 patients had ppVADs in our cohort of 310 patients with vertebral artery dissections (VADs). They occurred 11.27 days (95% CI, -0.85 to 23.39) postdelivery. Of these, there were 5 (42%) with a hypertensive disorder of pregnancy, and 4 (33%) who had migraines. A total of 3 (25%) had ischemic strokes and 1 (8%) had a subarachnoid hemorrhage. In total, 2 patients (17%) had unfavorable modified Rankin Scale (mRS, 2-6) at discharge from hospital. Patients with ppVADs more often had bilateral VADs (42% vs 17%, P = .03), had pseudoaneurysms (50% vs 18%, P = .0068), were younger (33.83 years vs 44.32 years, P = .018), and had lower Charlson Comorbidity Index (CCI = 0 vs 0.99, P = .0038). Anticoagulant treatment was used in a similar percentage of patients. Multivariate analysis revealed 3 factors were predictive of change in mRS: CCI (OR = 1.09, 95% CI, 1.02-1.15), stroke (OR = 0.78, 95% CI, 0.65-0.95), and mRS at hospital discharge (OR = 0.80, 95% CI, 0.74-0.87). CONCLUSION: There are only 15 isolated ppVADs reported in the literature; this study adds 12 patients with 17 ppVADs. Postpartum VADs occur in younger, healthier patients than in the general cohort, raising questions about mechanism of injury. The majority of ppVADs have good neurological outcomes.


Assuntos
Acidente Vascular Cerebral , Hemorragia Subaracnóidea , Dissecação da Artéria Vertebral , Estudos de Coortes , Feminino , Humanos , Período Pós-Parto , Gravidez , Hemorragia Subaracnóidea/epidemiologia , Resultado do Tratamento , Dissecação da Artéria Vertebral/epidemiologia
10.
Oper Neurosurg (Hagerstown) ; 21(5): 343-350, 2021 10 13.
Artigo em Inglês | MEDLINE | ID: mdl-34392360

RESUMO

BACKGROUND: Vertebral artery dissections (VADs) are rare yet potentially devastating events. While the etiology of these events is either traumatic or spontaneous, there is a paucity of quantitative literature comparing the two. OBJECTIVE: To identify differences in predisposing factors, event characteristics, and clinical outcomes between traumatic VADs (tVADs) and spontaneous VADs (sVADs). METHODS: We retrospectively identified patients with VADs presenting to our institution at VAD onset with at least a 3-mo follow-up. Demographics, event characteristics, treatment details, and neurological outcomes as modified Rankin scale (mRS) scores were collected. RESULTS: Of the 310 patients sustaining 366 VADs total, 187 (60.3%) patients experienced a total of 221 (60.4%) sVADs and 123 (39.7%) patients experienced a total of 145 (39.6%) tVADs. sVADs were more likely to occur in the intracranial course of the artery (P = .042) and have a lower mRS at discharge, 3-month, and last clinical follow-up (P = 003, .002, and .001, respectively). tVADs were more likely associated with concomitant fractures (P < .001). CONCLUSION: Despite similar patient populations, tVADs are associated with higher mRS scores at all time points. Although further study is needed, this may suggest other concomitant trauma rather than the VAD itself is contributing to worse neurological status in patients with tVADs.


Assuntos
Dissecação da Artéria Vertebral , Estudos de Coortes , Humanos , Estudos Retrospectivos , Dissecação da Artéria Vertebral/diagnóstico por imagem , Dissecação da Artéria Vertebral/epidemiologia
11.
World Neurosurg ; 153: e147-e152, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34166830

RESUMO

BACKGROUND: Venous thromboembolism (VTE), including deep vein thrombosis (DVT) and pulmonary embolism (PE), and intracranial hemorrhage (ICH) may complicate the post-operative course of patients undergoing craniotomy. While prophylaxis with unfractionated heparin (UFH) has been shown to reduce VTE rates, twice-daily (BID) and three-times-daily (TID) UFH dosing regimens have not been compared in neurosurgical procedures. The objective of this study was to explore the association between UFH dosing regimen and rates of VTE and ICH in craniotomy patients. METHODS: A retrospective chart review was conducted for 159 patients at Northwestern University receiving 5000 units/0.5 mL UFH injections either BID (n = 132) or TID (n = 27). General linear regression models were run to predict rates of DVT, PE, and reoperation due to bleeding from UFH dosing regimen while controlling for age at surgery, sex, VTE history, craniotomy for tumor resection, surgery duration, length of stay, reoperation, infections, and IDH/MGMT mutations. RESULTS: Receiving UFH TID was significantly associated with a lower rate of PE when compared with receiving UFH BID (ß = -0.121, P = 0.044; TID rate = 0%, BID rate = 10.6%). UFH TID also showed a trend toward lower rates of DVT (ß = -0.0893, P = 0.295; TID rate = 18.5%, BID rate = 21.2%) when compared with UFH BID. UFH TID showed no significant difference in rate of reoperation for bleeding when compared to UFH BID (ß = -0.00623, P = 0.725; TID rate = 0%, BID rate = 0.8%). CONCLUSIONS: UFH TID dosing is associated with lower rates of PE when compared with BID dosing in patients undergoing craniotomy.


Assuntos
Anticoagulantes/administração & dosagem , Craniotomia , Heparina/administração & dosagem , Hemorragias Intracranianas/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Hemorragia Pós-Operatória/epidemiologia , Embolia Pulmonar/prevenção & controle , Trombose Venosa/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Encefálicas/cirurgia , Esquema de Medicação , Feminino , Glioblastoma/cirurgia , Hematoma/cirurgia , Humanos , Hemorragias Intracranianas/induzido quimicamente , Modelos Lineares , Masculino , Neoplasias Meníngeas/cirurgia , Meningioma/cirurgia , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Hemorragia Pós-Operatória/induzido quimicamente , Embolia Pulmonar/epidemiologia , Reoperação , Estudos Retrospectivos , Trombose Venosa/epidemiologia , Adulto Jovem
12.
Clin Neurol Neurosurg ; 206: 106665, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-34020327

RESUMO

BACKGROUND: Vertebral artery dissections (VAD) are a rare but important cause of ischemic stroke, especially in younger patients. Many etiologies have been identified, including MVAs, cervical fractures, falls, physical exercise, and cervical chiropractic manipulation. The goal of this study was to investigate the subgroup of patients who suffered a chiropractor-associated injury and determine how their prognosis compared to other-cause VAD. METHODS: We conducted a retrospective chart review of 310 patients with vertebral artery dissections who presented at our institution between January 2004 and December 2018. Variables included demographic data, event characteristics, treatment, radiographic outcomes, and clinical outcomes measured using the modified Rankin Scale. FINDINGS: Overall, 34 out of our 310 patients suffered a chiropractor-associated injury. These patients tended to be younger (p = 0.01), female (p = 0.003), and have fewer comorbidities (p = 0.005) compared to patients with other-cause VADs. The characteristics of the injuries were similar, but chiropractor-associated injuries appeared to be milder at discharge and at follow-up. A higher proportion of the chiropractor-associated group had injuries in the 0-2 mRS range at discharge and at 3 months (p = 0.05, p = 0.04) and no patients suffered severe long-term neurologic consequences or death (0% vs. 9.8%, p = 0.05). However, when a multivariate binomial regression was performed, these effects dissipated and the only independent predictor of a worse injury at discharge was the presence of a cervical spine fracture (p < 0.001). INTERPRETATION: Chiropractor-associated injuries are similar to VADs of other causes, and apparent differences in the severity of the injury are likely due to demographic differences between the two populations.


Assuntos
Manipulação Quiroprática/efeitos adversos , Dissecação da Artéria Vertebral/etiologia , Adulto , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico
13.
J Neurosurg Pediatr ; 27(6): 668-676, 2021 Apr 23.
Artigo em Inglês | MEDLINE | ID: mdl-33892469

RESUMO

OBJECTIVE: Cerebral aneurysms in the pediatric population are rare and optimal treatment strategies are not as well characterized as in adults. The Pipeline embolization device (PED) is an endoluminal flow diverter that is commonly used to treat aneurysms in adults, but experience with this device in children is limited. The authors sought to further characterize PED use and outcomes in this specific population by performing both a systematic review of patient-level data from studies reporting the use of the PED to treat pediatric aneurysms and a retrospective review of their experience. METHODS: A systematic review of the PubMed, Embase, and Scopus databases was performed to identify studies reporting the use of the PED in pediatric patients (age ≤ 18 years). Disaggregated data regarding demographics, aneurysm characteristics, treatment, and outcomes were collected. Retrospective data from the authors' two institutions were also included. RESULTS: Thirty studies comprising patient-level data on 43 pediatric patients with 47 aneurysms were identified. An additional 9 patients with 9 aneurysms were included from the authors' institutions for a total of 52 patients with 56 aneurysms. The mean patient age was 11.1 years. Presentations included aneurysm rupture (17.3%) and symptomatic mass effect (23.1%). Aneurysms were located in the anterior circulation in 55.4% of cases, and 73.2% were described as nonsaccular. Imaging follow-up was available for 89.3% with a mean follow-up of 13.3 months. Aneurysm occlusion was reported in 75%, with 1 case each (1.8%) demonstrating significant in-stent stenosis and parent vessel occlusion. Clinical follow-up was reported in 90.4% with a mean follow-up of 14.7 months. Good functional outcomes (modified Rankin Scale score of 0-1 or Glasgow Outcome Scale score of 5) were reported in 65.4% of the total population. Two major complications were reported, including 1 death. CONCLUSIONS: Despite substantial differences in aneurysm location and type between published pediatric and adult patient populations treated with the PED, the use of the PED in the pediatric population appears to be safe. While the short-term effectiveness is also similar to that of adults, additional studies are needed to further characterize the long-term outcomes and better define the use of this device in pediatric patients.


Assuntos
Embolização Terapêutica/instrumentação , Embolização Terapêutica/métodos , Procedimentos Endovasculares/instrumentação , Procedimentos Endovasculares/métodos , Aneurisma Intracraniano/terapia , Adolescente , Prótese Vascular , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Estudos Retrospectivos
14.
Neurocrit Care ; 35(2): 506-517, 2021 10.
Artigo em Inglês | MEDLINE | ID: mdl-33821403

RESUMO

BACKGROUND: Intracranial hemorrhage (ICH) is a devastating complication for patients with ventricular assist devices (VADs). The safety of emergent anticoagulation reversal with four-factor prothrombin complex concentrate (PCC) and optimal timing of anticoagulation resumption are not clear. In addition, lactate dehydrogenase (LDH) is used as a biomarker for thromboembolic risk, but its utility in guiding anticoagulation management after reversal with PCC has not be described. METHODS: We retrospectively reviewed a consecutive series of patients with VADs presenting with ICH between 2014 and 2020 who received four-factor PCC for rapid anticoagulation reversal. We collected the timing of PCC administration, timing of resumption of anticoagulation, survival, occurrence of thromboembolic events, and LDH levels throughout hospitalization. RESULTS: We identified 16 ICH events in 14 patients with VADs treated with rapid anticoagulation reversal using four-factor PCC (11 intraparenchymal, 4 subdural, 1 subarachnoid hemorrhage). PCC was administered at a mean of 3.3 ± 0.3 h after imaging diagnosis of ICH. Overall mortality was 63%. Survivors had higher presenting Glasgow Coma Scale (median 15, interquartile range [IQR] 15-15 versus 14, IQR 8-14.7, P = 0.041). In all six instances where the patient survived, anticoagulation was resumed on average 9.16 ± 1.62 days after reversal. There were no thromboembolic events prior to resumption of anticoagulation. Three events occurred after anticoagulation resumption and within 3 months of reversal: VAD thrombosis in a patient with thrombosis at the time of reversal, ischemic stroke, and readmission for elevated LDH in the setting of subtherapeutic international normalized ratio. CONCLUSIONS: Our limited series found no thromboembolic complications immediately following anticoagulation reversal with PCC prior to resumption of anticoagulation. LDH trends may be useful to monitor thromboembolic risk after reversal.


Assuntos
Coração Auxiliar , Anticoagulantes/efeitos adversos , Fatores de Coagulação Sanguínea , Humanos , Coeficiente Internacional Normatizado , Hemorragias Intracranianas/tratamento farmacológico , Estudos Retrospectivos
15.
J Clin Neurosci ; 86: 1-5, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33775310

RESUMO

The standard of care for idiopathic normal pressure hydrocephalus (iNPH) is placement of a ventriculoperitoneal (VP) shunt. However, VP shunts require intracranial intervention and are associated with notable postoperative complications, with some groups reporting complication rates for VP shunts ranging from 17 to 33%, along with failure rates up to 17.7%. Lumboperitoneal (LP) shunts are an alternative for cerebrospinal fluid diversion that do not require intracranial surgery, thus providing utility in patients where intracranial surgery is not possible or preferred. Here we retrospectively reviewed our 25 patients with LP horizontal-vertical (LP-HV) shunts placement for initial treatment for iNPH from 2014 to 2019. All patients had preoperative gait dysfunction, 16 (64%) had urinary incontinence, and 21 (84%) exhibited cognitive insufficiency. Two weeks post-shunt placement, 23/25 (92%) patients demonstrated improvement in gait, 11/16 (68%) had improvement in incontinence, and 14/21 (66%) had improvement cognitive insufficiency. At six months or greater follow up 13/20 (65%) had improvement in gait, 7/15 (47%) showed improvement in incontinence, and 11/15 (73%) demonstrated improvement in cognitive function. Six patients (24%) required at least one revision of the LP shunt. Shunt malfunctions resulted from CSF leak in one patient, shunt catheter migration in two patients, peritoneal catheter pain in one patient, and clinical symptoms for overdrainage in two patients. Thus, we demonstrate that LP-HV shunt placement is safe and efficacious alternative to VP shunting for iNPH, resulting in notable symptomatic improvement and low risk of overdrainage, and may be considered for patients where cranial approaches should be avoided.


Assuntos
Derivações do Líquido Cefalorraquidiano/métodos , Hidrocefalia de Pressão Normal/cirurgia , Resultado do Tratamento , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Complicações Pós-Operatórias/cirurgia , Estudos Retrospectivos
16.
Radiology ; 299(1): 179-189, 2021 04.
Artigo em Inglês | MEDLINE | ID: mdl-33591890

RESUMO

Background Following publication of trials demonstrating the efficacy of thrombectomy, societal guidelines were revised in 2015 to recommend this procedure for large-vessel stroke. Purpose To evaluate real-world thrombectomy rates, adverse events, outcomes, and readmissions across the United States in the 2 years after large-scale adoption of thrombectomy for acute stroke. Materials and Methods In this retrospective study, the authors queried the National Inpatient Sample and Nationwide Readmissions Database for patients undergoing thrombectomy between 2016 and 2017. Thrombectomy rates were compared by using the χ2 test. Adjusted risk ratios (aRRs) were obtained for factors affecting routine discharge, mortality, and readmission by using multivariable Poisson regression with clustering at the hospital level. Results There were 290 460 admissions (mean age, 70.5 years ± 14.2 [standard deviation]; 148 620 women) for internal carotid or middle cerebral artery stroke; 30 835 (10.6%) of these patients underwent thrombectomy. Thrombectomy rates were lower in patients aged 90 years or older (1815 of 24 090 patients, 7.5%), Black patients (4280 of 43 365 patients, 9.9%), patients with the lowest income (8520 of 85 905 patients, 9.9%), and those treated in West South Central division hospitals (2695 of 34 355 patients, 7.8%) (P < .001 for all). The inpatient mortality rate was 12.1% (3740 of 30 835 patients), and 19.1% of patients (5900 of 30 835) were discharged to home. In adjusted analyses, routine discharge was less likely in patients aged 90 years or older (aRR: 0.12; 95% CI: 0.09, 0.16; P < .001) and octogenarians (aRR: 0.37; 95% CI: 0.33, 0.41; P < .001). Patients aged 90 years or older (aRR: 1.78; 95% CI: 1.48, 2.14; P < .001), octogenarians (aRR: 1.76; 95% CI: 1.51, 2.06; P < .001), Asians and/or Pacific Islanders (aRR: 1.21; 95% CI: 1.06, 1.39; P = .005), and those treated in teaching (aRR: 1.20; 95% CI: 1.07, 1.34; P = .001) or West South Central division (aRR: 1.35; 95% CI: 1.14, 1.60; P < .001) hospitals had a higher risk of death. Following discharge, 18.9% of patients (3449 of 18 274) were readmitted within 90 days. Conclusion Rates and outcomes of thrombectomy are affected by demographic, socioeconomic, and hospital-related factors. Fewer than one-fifth of patients are discharged to home, nearly one-fifth are readmitted within 90 days, and mortality and outcomes may be less favorable than in published trials. © RSNA, 2021 Online supplemental material is available for this article.


Assuntos
Procedimentos Endovasculares/métodos , AVC Isquêmico/cirurgia , Readmissão do Paciente/estatística & dados numéricos , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , AVC Isquêmico/mortalidade , Masculino , Avaliação de Processos e Resultados em Cuidados de Saúde , Seleção de Pacientes , Estudos Retrospectivos , Estados Unidos/epidemiologia
17.
World Neurosurg ; 149: e1128-e1133, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-33388459

RESUMO

BACKGROUND: Vertebral artery dissections (VADs) are a rare cause of ischemic stroke that can occasionally lead to intracranial hemorrhage (ICH). This study aims to identify differences in predisposing factors, event characteristics, and outcomes between patients with only a VAD and patients with VAD and concomitant ICH. METHODS: We conducted a retrospective chart review of 301 patients who presented with VADs at our institution from 2004-2018. A total of 13 patients were identified with VAD and concomitant ICH. Data were collected on demographics, event characteristics, treatments, and neurologic outcomes, measured using the modified Rankin Scale (mRS). RESULTS: VAD+ICH and VAD-only groups were similar in terms of age, sex, and recorded comorbidities. Additionally, etiology of the dissections did not seem to vary between groups (P = 0.6), even when selecting for traumatic causes such as motor vehicle accidents (P = 0.22) and violence (P = 0.25). Concomitant strokes and aneurysms/pseudoaneurysms occurred in similar proportions as well, but cervical fractures were more common in the VAD+ICH group (P = 0.003). Using the mRS as a measure of neurological outcome, we found that the VAD+ICH group had worse neurologic function at discharge, 3-month follow-up, and last follow-up (P < 0.001). CONCLUSIONS: Patients who experienced an ICH in addition to a VAD did not have any identifiable risk factors. Cervical spine fractures were more common in patients with VAD and ICH. VAD patients with a concomitant ICH have worse neurologic outcomes than patients with only a VAD.


Assuntos
Hemorragias Intracranianas/complicações , Hemorragias Intracranianas/cirurgia , Dissecação da Artéria Vertebral/complicações , Dissecação da Artéria Vertebral/cirurgia , Acidentes de Trânsito , Adulto , Idoso , Hemorragia Encefálica Traumática/complicações , Hemorragia Encefálica Traumática/cirurgia , Estudos de Coortes , Comorbidade , Feminino , Seguimentos , Humanos , Aneurisma Intracraniano/complicações , Masculino , Pessoa de Meia-Idade , Doenças do Sistema Nervoso/etiologia , Complicações Pós-Operatórias/epidemiologia , Fraturas da Coluna Vertebral/complicações , Resultado do Tratamento , Violência
18.
J Stroke Cerebrovasc Dis ; 30(4): 105632, 2021 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-33517033

RESUMO

OBJECTIVE: The "weekend effect" has been shown to affect outcomes in acute ischemic stroke. We sought to compare metrics and outcomes of emergent stroke thrombectomy at three affiliated comprehensive stroke centers on weekdays versus nights/weekends for a three-year period beginning in 2015, when thrombectomy became common practice for large vessel occlusion acute ischemic stroke. METHODS: We performed a retrospective analysis of all stroke thrombectomy patients treated from 2015 to 2018 to compare standard thrombectomy metrics and outcomes in patients presenting during weekdays or nights/weekends. RESULTS: Two hundred-sixteen mechanical thrombectomy cases were evaluated, with 50.9% of patients presenting on weekdays and 49.1% presenting on nights/weekends. There were no statistical differences in baseline characteristics in demographics, stroke risk factors, or stroke severity, but patients presenting on nights/weekends had longer times from last known normal to presentation (130 versus 72.5 minutes, p=0.03). Door-to-groin times were delayed in patients presenting on nights/weekends compared to weekdays (median 104.5 versus 86 minutes, respectively; p=0.007) but groin-to-reperfusion times were similar (51.5 versus 48 minutes, respectively; p=0.4). Successful reperfusion was similar in both groups (90.6% nights/weekends versus 90% weekdays; p=1.0) as were the incidence of symptomatic intracerebral hemorrhage (10.4% nights/weekend versus 7.3% weekdays; p=0.48) and 90-day good functional outcomes based on the modified Rankin Scale did not differ between the two groups in a shift analysis (p=0.545). CONCLUSIONS: Despite delays in door-to-groin puncture times in acute ischemic stroke patients presenting on nights/weekends compared to weekdays, we did not identify significant differences in successful reperfusion or functional outcomes in this cohort. Further studies are warranted to continue to evaluate differences in stroke care on nights/weekends versus weekdays.


Assuntos
Plantão Médico , AVC Isquêmico/terapia , Trombectomia , Tempo para o Tratamento , Centros Médicos Acadêmicos , Adulto , Idoso , Idoso de 80 Anos ou mais , Chicago , Emergências , Feminino , Hospitais Comunitários , Humanos , AVC Isquêmico/diagnóstico , AVC Isquêmico/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Trombectomia/efeitos adversos , Trombectomia/mortalidade , Terapia Trombolítica , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
19.
Oper Neurosurg (Hagerstown) ; 20(5): 456-461, 2021 04 15.
Artigo em Inglês | MEDLINE | ID: mdl-33448296

RESUMO

BACKGROUND: Vertebral artery dissections (VADs) are a common cause of stroke in young patients and can result in various secondary effects, including pseudoaneurysm formation. OBJECTIVE: To identify differences in predisposing factors and outcomes for VADs with and without concomitant pseudoaneurysms. METHODS: We retrospective chart reviewed patients who presented to our institution at the time of VAD with at least a 3-mo clinical follow-up. Demographics, VAD characteristics, treatment, and outcomes represented as modified Rankin scale (mRS) scores were collected. RESULTS: Of 310 patients with a VAD included in this study, 301 patients had an identified pseudoaneurysm status, with 54 pseudoaneurysm-associated VADs and 247 VADs not associated with pseudoaneurysm. VAD patients with associated pseudoaneurysms were more likely to be female (P < .004), have bilateral VADs (P < .001), and have fewer vertebral artery segments affected (P = .018), and less likely to have stroke (P < .008) or occlusion of the vertebral artery (P < .001). There was no difference in the proportion of patients treated with antiplatelet agents (P = .12) or anticoagulants (P = .27) between the groups. VAD patients with associated pseudoaneurysms were more likely to have a higher mRS at 3-mo follow-up (P = .044) but not discharge (P = .18) or last follow-up (P = .05). VAD patients with pseudoaneurysms were equally likely to have resolution of occlusion (P = .40) and stenosis (P = .19). CONCLUSION: Demographics and clinical and radiological characteristics of VADs associated with pseudoaneurysms are different from those without associated pseudoaneurysms. Vertebral artery dissections with concomitant pseudoaneurysms are neither associated with worse functional nor radiographic outcomes.


Assuntos
Falso Aneurisma , Acidente Vascular Cerebral , Dissecação da Artéria Vertebral , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/epidemiologia , Falso Aneurisma/etiologia , Feminino , Humanos , Masculino , Estudos Retrospectivos , Artéria Vertebral/diagnóstico por imagem , Dissecação da Artéria Vertebral/complicações , Dissecação da Artéria Vertebral/diagnóstico por imagem , Dissecação da Artéria Vertebral/epidemiologia
20.
J Neurointerv Surg ; 13(7): 609-613, 2021 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32763917

RESUMO

BACKGROUND: Admission neutrophil-lymphocyte ratio (NLR) is significantly correlated to clinical outcomes in acute ischemic stroke (AIS). We investigated follow-up NLR and temporal changes in NLR after endovascular thrombectomy (EVT) with respect to successful revascularization, clinical outcomes, symptomatic intracranial hemorrhage (sICH) and mortality. METHODS: Retrospective analysis of EVT for anterior circulation emergent LVO was performed with both admission (NLR1) and 3-7 day follow-up NLR (NLR2) laboratory data. Patient demographics, National Institutes of Health Stroke Scale (NIHSS) presentations, reperfusion efficacy (modified Thrombolysis in Cerebral Infarction (mTICI) score), sICH, and clinical outcomes (modified Rankin Scale (mRS)) at 90 days were studied. Univariate analyses correlated NLR1, NLR2, and temporal change in NLR (NLR2-NLR1) with successful reperfusion (mTICI ≥2b), favorable outcomes (mRS ≤2), sICH, and mortality. Multivariable logistic regression model evaluated the independent effects of NLR2 on favorable outcomes. RESULTS: 142 AIS patients with median NIHSS 17 underwent EVT within 24 hours, and met NLR laboratory inclusion criteria. Lower follow-up NLR2 and less temporal change in NLR over 3-7 days, but not admission NLR1, inversely correlated with successful reperfusion (p<0.05) and favorable clinical outcomes (p<0.001). Higher follow-up NLR2 and greater temporal change in NLR was significantly associated with sICH and mortality (p≤0.05). In multivariable logistic regression, lower follow-up NLR2 remained a predictor of favorable outcomes (OR 0.785, p=0.001), independent of age or successful reperfusion. CONCLUSIONS: Follow-up NLR is a readily available and modifiable biomarker that correlates with the degree of reperfusion after mechanical stroke thrombectomy. Lower follow-up NLR2 at 3-7 days is associated with successful reperfusion and an independent predictor of favorable clinical outcomes, with reduced risk for sICH and mortality.


Assuntos
Isquemia Encefálica/sangue , Linfócitos/metabolismo , Neutrófilos/metabolismo , Acidente Vascular Cerebral/sangue , Trombectomia/métodos , Idoso , Idoso de 80 Anos ou mais , Biomarcadores/sangue , Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/cirurgia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Reperfusão/métodos , Reperfusão/tendências , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Trombectomia/tendências , Resultado do Tratamento
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