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1.
Neurosurg Focus ; 42(6): E5, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28565991

RESUMO

OBJECTIVE Although the use of dual antiplatelet therapy with flow diversion is recommended and commonplace, the testing of platelet inhibition is more controversial. METHODS The authors reviewed the medical literature to establish and describe the physiology of platelet adhesion, the pharmacology of antiplatelet medications, and the mechanisms of the available platelet function tests. Additionally, they present a review of the pertinent neurointerventional and interventional cardiology literature. RESULTS Competing reports in the neurointerventional literature argue for and against the use of routine platelet function testing, with adjustments to the dosage or medications based on the results. The interventional cardiology literature has also wrestled with this dilemma after percutaneous coronary interventions, with conflicting reports of the benefits of platelet function testing. CONCLUSIONS Despite its prevalence, the benefits of platelet function testing prior to flow diversion are unproven. This practice will likely remain controversial until the level of evidence improves through more rigorous testing and reporting.


Assuntos
Plaquetas/efeitos dos fármacos , Inibidores da Agregação Plaquetária/farmacologia , Testes de Função Plaquetária/métodos , Animais , Plaquetas/fisiologia , Humanos
2.
J Stroke Cerebrovasc Dis ; 24(7): 1597-608, 2015 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-25972283

RESUMO

BACKGROUND: North American and Asian forms of moyamoya have distinct clinical characteristics. Asian adults with moyamoya are known to respond better to direct versus indirect revascularization. It is unclear whether North American adults with moyamoya have a similar long-term angiographic response to direct versus indirect bypass. METHODS: A retrospective review of surgical revascularization for adult moyamoya phenomenon was performed. Preoperative and postoperative cerebral angiograms underwent consensus review, with degree of revascularization quantified as extent of new middle cerebral artery (MCA) territory filling. RESULTS: Late angiographic follow-up was available in 15 symptomatic patients who underwent 20 surgical revascularization procedures. In 10 hemispheres treated solely with indirect arterial bypass, 3 had 2/3 revascularization, 4 had 1/3 revascularization, and 3 had no revascularization of the MCA territory. In the 10 hemispheres treated with direct arterial bypass (8 as a stand-alone procedure and 2 in combination with an indirect procedure), 2 had complete revascularization, 7 had 2/3 revascularization, and 1 had 1/3 revascularization. Direct bypass provided a higher rate of "good" angiographic outcome (complete or 2/3 revascularization) when compared with indirect techniques (P = .0198). CONCLUSIONS: Direct bypass provides a statistically significant, more consistent, and complete cerebral revascularization than indirect techniques in this patient population. This is similar to that reported in the Asian literature, which suggests that the manner of presentation (ischemia in North American adults versus hemorrhage in Asian adults) is likely not a contributor to the extent of revascularization achieved after surgical intervention.


Assuntos
Angiografia Digital , Angiografia Cerebral/métodos , Revascularização Cerebral/métodos , Artéria Cerebral Média/diagnóstico por imagem , Artéria Cerebral Média/cirurgia , Doença de Moyamoya/diagnóstico por imagem , Doença de Moyamoya/cirurgia , Artérias Temporais/diagnóstico por imagem , Artérias Temporais/cirurgia , Adulto , Revascularização Cerebral/efeitos adversos , Circulação Cerebrovascular , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Artéria Cerebral Média/fisiopatologia , Missouri/epidemiologia , Doença de Moyamoya/epidemiologia , Doença de Moyamoya/fisiopatologia , Valor Preditivo dos Testes , Estudos Retrospectivos , Artérias Temporais/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
3.
World Neurosurg ; 180: 6-9, 2023 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-37657592

RESUMO

BACKGROUND: Pseudoaneurysms of the posterior circulation pose a unique management challenge. The fragile nature of the pseudoaneurysm wall presents a high risk of rupture and demands treatment. Small vasculature, particularly distal in the posterior circulation, can preclude management with traditional flow diverters, where the alternative of vessel sacrifice is unacceptable. Small stents can have flow-diversion properties and can be used in these high-risk, difficult-to-access aneurysms. METHODS: We describe a 40-year-old woman presenting with a ruptured dissecting right superior cerebellar artery pseudoaneurysm after minor trauma. Given the aneurysm's small size and morphology, it was not amenable to coiling and parent vessel sacrifice was potentially morbid. The pseudoaneurysm was initially stabilized with a Low-Profile Visualized Intraluminal Support Junior (LVIS Jr.) stent due to its reported flow-diverting properties. RESULTS: At six-month follow-up the pseudoaneurysm was stable and the vasospasm had resolved. At this point, definitive treatment with a "FRED Jr." (Flow Re-Direction Endoluminal Device Junior) flow diverter was pursued. Complete obliteration of the pseudoaneurysm was seen at 12 months' follow-up after staged treatment. CONCLUSIONS: Due to the unique challenges associated with ruptured pseudoaneurysms located on small-caliber vessels, the options for definitive treatment are limited. The small size of the LVIS Jr. stent and its flow-diverting properties make it a practical treatment option in a difficult situation. This case report provides further support for the flow-diverting properties of the LVIS Jr. and its potential application in the treatment of ruptured pseudoaneurysms in small-caliber intracranial vessels.


Assuntos
Falso Aneurisma , Embolização Terapêutica , Procedimentos Endovasculares , Aneurisma Intracraniano , Feminino , Humanos , Adulto , Falso Aneurisma/diagnóstico por imagem , Falso Aneurisma/cirurgia , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Stents , Artéria Basilar , Resultado do Tratamento , Estudos Retrospectivos , Angiografia Cerebral
4.
Cells ; 12(7)2023 03 24.
Artigo em Inglês | MEDLINE | ID: mdl-37048068

RESUMO

Leptomeningeal disease occurs when cancer cells migrate into the ventricles of the brain and spinal cord and then colonize the meninges of the central nervous system. The triple-negative subtype of breast cancer often progresses toward leptomeningeal disease and has a poor prognosis because of limited treatment options. This is due, in part, to a lack of animal models with which to study leptomeningeal disease. Here, we developed a translucent zebrafish casper (roy-/-; nacre-/-) xenograft model of leptomeningeal disease in which fluorescent labeled MDA-MB-231 human triple-negative breast cancer cells are microinjected into the ventricles of zebrafish embryos and then tracked and measured using fluorescent microscopy and multimodal plate reader technology. We then used these techniques to measure tumor area, cell proliferation, and cell death in samples treated with the breast cancer drug doxorubicin and a vehicle control. We monitored MDA-MB-231 cell localization and tumor area, and showed that samples treated with doxorubicin exhibited decreased tumor area and proliferation and increased apoptosis compared to control samples.


Assuntos
Antineoplásicos , Neoplasias de Mama Triplo Negativas , Animais , Humanos , Neoplasias de Mama Triplo Negativas/patologia , Peixe-Zebra , Apoptose , Antineoplásicos/farmacologia , Doxorrubicina/farmacologia , Doxorrubicina/uso terapêutico
5.
World Neurosurg ; 173: 79-87, 2023 May.
Artigo em Inglês | MEDLINE | ID: mdl-36796627

RESUMO

BACKGROUND: Suprasellar extension, cavernous sinus invasion, and involvement of intracranial vascular structures and cranial nerves are among the challenges faced by surgeons operating on giant pituitary macroadenomas. Intraoperative tissue shifts may render neuronavigation techniques inaccurate. Intraoperative magnetic resonance imaging can solve this problem, but it may be costly and time consuming. However, intraoperative ultrasonography (IOUS) allows for quick, real-time feedback and may be particularly useful when facing giant invasive adenomas. Here, we present the first study examining technique for IOUS-guided resection specifically focusing on giant pituitary adenomas. OBJECTIVE: To describe the use of a side-firing ultrasound probe in the resection of giant pituitary macroadenomas. METHODS: We describe an operative technique using a side-firing ultrasound probe (Fujifilm/Hitachi) to identify the diaphragma sellae, confirm optic chiasm decompression, identify vascular structures related to tumor invasion, and maximize extent of resection in giant pituitary macroadenomas. RESULTS: Side-firing IOUS allows for identification of the diaphragma sellae to help prevent intraoperative cerebrospinal fluid leak and maximize extent of resection. Side-firing IOUS also aids in confirmation of decompression of the optic chiasm via identification of a patent chiasmatic cistern. Furthermore, direct identification of the cavernous and supraclinoid internal carotid arteries and arterial branches is achieved when resecting tumors with significant parasellar and suprasellar extension. CONCLUSIONS: We describe an operative technique in which side-firing IOUS may assist in maximizing extent of resection and protecting vital structures during surgery for giant pituitary adenomas. Use of this technology may be particularly valuable in settings in which intraoperative magnetic resonance imaging is not available.


Assuntos
Adenoma , Neoplasias Hipofisárias , Humanos , Neoplasias Hipofisárias/diagnóstico por imagem , Neoplasias Hipofisárias/cirurgia , Neoplasias Hipofisárias/patologia , Procedimentos Neurocirúrgicos/métodos , Microcirurgia/métodos , Neuronavegação , Adenoma/diagnóstico por imagem , Adenoma/cirurgia , Adenoma/patologia , Imageamento por Ressonância Magnética/métodos , Resultado do Tratamento
6.
Front Oncol ; 13: 1039159, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-36937453

RESUMO

Clival chordomas are locally invasive midline skull base tumors arising from remnants of the primitive notochord. Intracranial vasculature and cranial nerve involvement of tumors in the paraclival region necessitates image guidance that provides accurate real-time feedback during resection. Several intraoperative image guidance modalities have been introduced as adjuncts to endoscopic endonasal surgery, including stereotactic neuronavigation, intraoperative ultrasound, intraoperative MRI, and intraoperative CT. Gross total resection of chordomas is associated with a lower recurrence rate; therefore, intraoperative imaging may improve long-term outcomes by enhancing the extent of resection. However, among these options, effectiveness and accessibility vary between institutions. We previously published the first use of an end-firing probe in the resection of a clival chordoma. End-firing probes provide a single field of view, primarily limited to depth estimation. In this case report, we discuss the benefits of employing a novel minimally invasive side-firing ultrasound probe as a cost-effective and time-efficient option to navigate the anatomy of the paraclival region and guide endoscopic endonasal resection of a large complex clival chordoma.

7.
Front Oncol ; 12: 1043697, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-36531061

RESUMO

Introduction: Multiple intraoperative navigation and imaging modalities are currently available as an adjunct to endoscopic transsphenoidal resection of pituitary adenomas, including intraoperative CT and MRI, fluorescence guidance, and neuronavigation. However, these imaging techniques have several limitations, including intraoperative tissue shift, lack of availability in some centers, and the increased cost and time associated with their use. The side-firing intraoperative ultrasound (IOUS) probe is a relatively new technology in endoscopic endonasal surgery that may help overcome these obstacles. Methods: A retrospective analysis was performed on patients admitted for resection of pituitary adenomas by a single surgeon at the University of Mississippi Medical Center. The control (non-ultrasound) group consisted of twelve (n=12) patients who received surgery without IOUS guidance, and the IOUS group was composed of fifteen (n=15) patients who underwent IOUS-guided surgery. Outcome measures used to assess the side-firing IOUS were the extent of tumor resection, postoperative complications, length of hospital stay (LOS) in days, operative time, and self-reported surgeon confidence in estimating the extent of resection intraoperatively. Results: Preoperative data analysis showed no significant differences in patient demographics or presenting symptoms between the two groups. Postoperative data revealed no significant difference in the rate of gross total resection between the groups (p = 0.716). Compared to the non-US group, surgeon confidence was significantly higher (p < 0.001), and operative time was significantly lower for the US group in univariate analysis (p = 0.011). Multivariate analysis accounting for tumor size, surgeon confidence, and operative time confirmed these findings. Interestingly, we noted a trend for a lower incidence of postoperative diabetes insipidus in the US group, although this did not quite reach our threshold for statistical significance. Conclusion: Incorporating IOUS as an aid for endonasal resection of pituitary adenomas provides real-time image guidance that increases surgeon confidence in intraoperative assessment of the extent of resection and decreases operative time without posing additional risk to the patient. Additionally, we identified a trend for reduced diabetes insipidus with IOUS.

8.
J Trauma ; 71(2): 358-63, 2011 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-21825939

RESUMO

INTRODUCTION: To determine whether there is a benefit to platelet transfusion in mild traumatic brain injury (MTBI) patients with intracranial hemorrhage (ICH), taking antiplatelet therapy before hospitalization. MATERIALS AND METHODS: The study design retrospectively reviewed patients admitted to a Level I trauma center during a 2-year period with an isolated MTBI (Glasgow Coma Scale score ≥13, ICH seen on a head computed tomographic scan (head computed tomography [HCT]), and taking an antiplatelet agent before hospitalization. HCT's were categorized based on the Marshall Classification, Rotterdam Score, and ICH volume. Hospital records were reviewed noting neurologic, cardiac, respiratory events, and discharge Glasgow Outcome Scale. RESULTS: There were 1,101 patients with TBI hospitalized during the 2-year study period. Three hundred twenty-one of these patients had an MTBI with ICH at the time of admission, and from this group, 113 were taking an antiplatelet agent. Only 4 (1.2%) of the 321 patients suffered a neurologic decline. All were gradual in nature, and none required emergent intervention. An analysis of the 113 patients taking antiplatelet agents, comparing patients who were not given a platelet transfusion with those who received a platelet transfusion, found no significant difference in the rate of HCT progression, neurologic decline, or Glasgow Outcome Scale at hospital discharge between the two groups. There was a trend, which was not significant, toward more medical declines in patients who received a platelet transfusion. A further review, analyzing all 321 patients with ICH showed receiving a transfusion of any type (i.e., platelets, fresh frozen plasma, or blood) was a strong predictor of medical decline (p < 0.0001). The odds ratio of having a medical decline after transfusion was 5.8 (95% confidence interval, 1.2-28.2). CONCLUSIONS: Platelet transfusion did not improve short-term outcomes after MTBI. Further randomized controlled trials need to be done to truly assess if there is no benefit in platelet transfusion in patients taking antiplatelet agents suffering an MTBI. Because the overall outcome in MTBI patients is favorable, platelet transfusion in these patients may not be indicated.


Assuntos
Lesões Encefálicas/terapia , Hemorragias Intracranianas/terapia , Inibidores da Agregação Plaquetária/uso terapêutico , Transfusão de Plaquetas , Adulto , Progressão da Doença , Feminino , Escala de Coma de Glasgow , Escala de Resultado de Glasgow , Humanos , Tempo de Internação , Masculino , Estudos Retrospectivos , Resultado do Tratamento
9.
Neurocrit Care ; 15(2): 312-7, 2011 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-21748499

RESUMO

Delayed cerebral ischemia (DCI) after subarachnoid hemorrhage can be evaluated using clinical assessment, non-invasive and invasive techniques. An electronic literature search was conducted on English-language articles investigating DCI in human subjects with subarachnoid hemorrhage. A total of 31 relevant papers were identified evaluating the role of clinical assessment, transcranial Doppler, computed tomographic angiography, and computed tomographic perfusion. Clinical assessment by bedside evaluations is limited, especially in patients initially in poorer clinical condition or who are receiving sedative medication for whom deterioration may be more difficult to identify. Transcranial Doppler is a useful screening tool for middle cerebral artery vasospasm, with less utility in evaluating other intracranial vessels. Computed tomographic angiography correlates well with digital subtraction angiography. Computed tomographic perfusion may help predict DCI when used early or identify DCI when used later.


Assuntos
Isquemia Encefálica/diagnóstico por imagem , Isquemia Encefálica/etiologia , Hemorragia Subaracnóidea/complicações , Vasoespasmo Intracraniano/diagnóstico por imagem , Vasoespasmo Intracraniano/etiologia , Angiografia Cerebral , Cuidados Críticos/métodos , Humanos , Fatores de Tempo , Ultrassonografia
10.
Clin Neurol Neurosurg ; 205: 106633, 2021 Apr 02.
Artigo em Inglês | MEDLINE | ID: mdl-33887506

RESUMO

OBJECTIVE: The current literary evidence suggests but does not heavily endorse the use of prophylactic antiepileptic drugs (AEDs) after aneurysmal subarachnoid hemorrhage. Literature continues to emerge suggesting not only a lack of efficacy but associated poor outcomes. This study is a retrospective review comparing seizure incidence in aneurysmal subarachnoid patients between those given prophylactic AEDs and those not. METHODS: With IRB approval, a retrospective chart review was performed on all aneurysmal subarachnoid patients from 2012 to 2019 at the University of Mississippi Medical center. Univariate and Multivariate analysis was performed using SAS. Primary outcome was seizure incidence between groups. Factors associated with seizure and poor outcome were also investigated. RESULTS: 348 patients were identified: 120 in the AED group, and 228 patients in the non-AED group. There was no significant difference in mean age, gender, ethnicity, HH scores, treatment modality, or mean aneurysm size. The AED group had a higher history of prior aneurysmal rupture (6.7% vs. 1.3%, p = 0.01) and associated intracranial hemorrhage (22.5% vs. 10.5%, p = 0.0004). There was no significant difference in seizure incidence between the two groups (8.3% vs. 4.8%, p = 0.24). On multivariate analysis, aneurysm clipping compared to coiling (OR 3.8, p = 0.012) and delayed cerebral ischemia (OR 2.77, p = 0.023) were associated with seizures. DCI (OR 8.34), HH grade, Age (OR 1.07), Seizure (8.34), and AED use (1.7) were significantly associated with poor outcome. CONCLUSION: This retrospective review adds to the evidence that prophylactic AED use in aneurysmal subarachnoid hemorrhage patients has not been proven to improve seizure rates and may result in worse patient outcomes.

11.
Neurosurgery ; 89(4): 591-596, 2021 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-34271587

RESUMO

BACKGROUND: The Nationwide Inpatient Sample Subarachnoid Hemorrhage (SAH) Severity Score (NIS-SSS) was developed as a measure of SAH severity for use in administrative databases. The NIS-SSS consists of International Classification of Diseases Ninth Revision (ICD-9) diagnostic and procedure codes derived from the SAH inpatient course and has been validated against the Hunt-Hess score (HH). OBJECTIVE: To externally validate both the NIS-SSS and a modified version of the NIS-SSS (m-NIS-SSS) consisting of codes present only on admission, against the HH in a Canadian province-wide registry and administrative database of SAH patients. METHODS: A total of 1467 SAH patients admitted to Ontario stroke centers between 2003 and 2013 with recorded HH were included. The NIS-SSS and m-NIS-SSS were validated against the HH by testing correlation between the NIS-SSS/m-NIS-SSS and HH, comparing discriminative ability of the NIS-SSS/m-NIS-SSS vs HH for poor outcome by calculating area under the curve (AUC), and comparing calibration of the NIS-SSS, m-NIS-SSS, and HH by plotting predicted vs observed outcome. RESULTS: Correlation with HH was 0.417 (P ≤ .001) for NIS-SSS, and 0.403 (P ≤ .001) for m-NIS-SSS. AUC for prediction of poor outcome was 0.786 (0.764-0.808) for HH, 0.771 (0.748-0.793) for NIS-SSS, and 0.744 (0.721-0.767) for m-NIS-SSS. Calibration plots demonstrated that HH had the most accurate prediction of outcome, whereas the NIS-SSS and m-NIS-SSS did not accurately predict low risk of poor outcome. CONCLUSION: The NIS-SSS and m-NIS-SSS have good external validity, and therefore, may be suitable to approximate traditional clinical scores of disease severity in SAH research using administrative data.


Assuntos
Hemorragia Subaracnóidea , Canadá , Hospitalização , Humanos , Pacientes Internados , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/epidemiologia , Resultado do Tratamento
12.
Neurosurg Focus ; 29(3): E7, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20809765

RESUMO

Cavernous malformations (CMs) are angiographically occult, low-pressure neurovascular lesions with distinct imaging and clinical characteristics. They present with seizure, neurological compromise due to lesion hemorrhage or expansion, or as incidental findings on neuroimaging studies. Treatment options include conservative therapy, medical management of seizures, surgical intervention for lesion resection, and in select cases stereotactic radiosurgery. Optimal management requires a thorough understanding of the natural history of CMs including consideration of issues such as mode of presentation, lesion location, and genetics that may impact the associated neurological risk. Over the past 2 decades, multiple studies have been published, shedding valuable light on the clinical characteristics and natural history of these malformations. The purpose of this review is to provide the reader with a concise consolidation of this published material such that they may better understand the risks associated with CMs and their implications on patient treatment.


Assuntos
Hemangioma Cavernoso do Sistema Nervoso Central/diagnóstico , Encéfalo/patologia , Hemorragia Cerebral/diagnóstico , Hemorragia Cerebral/genética , Hemorragia Cerebral/patologia , Feminino , Hemangioma Cavernoso do Sistema Nervoso Central/genética , Hemangioma Cavernoso do Sistema Nervoso Central/patologia , Humanos , Angiografia por Ressonância Magnética , Imageamento por Ressonância Magnética/métodos , Imageamento por Ressonância Magnética/estatística & dados numéricos , Masculino , Estudos Retrospectivos
13.
Clin Neurol Neurosurg ; 196: 106043, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32653799

RESUMO

OBJECTIVES: The relationship between outcomes, patient safety indicators and volume has been well established in patient's undergoing craniotomy for brain tumor. However, the determination of "high" and "low" volume centers have been subjectively derived. We present a paper with a novel method of objectively determining "high" volume centers for craniotomy for brain tumor. METHODS: Patients from 2002 to 2011 were identified in the Nationwide Inpatient Sample database using ICD-9 codes related to craniotomy for brain tumor. Primary endpoints of interest were hospital PSI event rate, in-hospital mortality rate, observed-to-expected PSI event ratio, and O/E in-hospital mortality ratio. Using a zero-inflated gamma model analysis and a cutpoint analysis we determined the volume threshold between and "high" and "low" volume hospitals. We then completed an analysis using this determined threshold to look at PSI events and mortality as they relate to "high" volume and "low" volume hospitals. RESULTS: 12.4 % of hospitals were categorized as good performers using O/E ratios. Regarding in-hospital mortality, 16.8 % were good performers. Using the above statistical analysis the threshold to define high vs. low volume centers was determined to be 27 craniotomies. High volume centers had significantly lower O/E ratios for both PSI and mortality events. The PSI O/E ratio was reduced 55 % and mortality O/E ratio reduced 73 % at high volume centers as defined by our analysis. CONCLUSIONS: Patients treated at institutions performing >27 craniotomies per year for brain tumors have a lower likelihood of PSI events and decreased in-hospital morbidity and mortality.


Assuntos
Neoplasias Encefálicas/cirurgia , Craniotomia/efeitos adversos , Hospitais com Alto Volume de Atendimentos/estatística & dados numéricos , Segurança do Paciente/estatística & dados numéricos , Adulto , Idoso , Neoplasias Encefálicas/mortalidade , Craniotomia/mortalidade , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Estados Unidos
14.
J Neurosurg ; 132(5): 1589-1597, 2019 Apr 26.
Artigo em Inglês | MEDLINE | ID: mdl-31026839

RESUMO

OBJECTIVE: Deep vein thrombosis (DVT) is a major focus of patient safety indicators and a common cause of morbidity and mortality. Many practices have employed lower-extremity screening ultrasonography in addition to chemoprophylaxis and the use of sequential compression devices in an effort to reduce poor outcomes. However, the role of screening in directly decreasing pulmonary emboli (PEs) and mortality is unclear. At the University of Mississippi Medical Center, a policy change provided the opportunity to compare independent groups: patients treated under a prior paradigm of weekly screening ultrasonography versus a post-policy change group in which weekly surveillance was no longer performed. METHODS: A total of 2532 consecutive cases were reviewed, with a 4-month washout period around the time of the policy change. Criteria for inclusion were admission to the neurosurgical service or consultation for ≥ 72 hours and hospitalization for ≥ 72 hours. Patients with a known diagnosis of DVT on admission or previous inferior vena cava (IVC) filter placement were excluded. The primary outcome examined was the rate of PE diagnosis, with secondary outcomes of all-cause mortality at discharge, DVT diagnosis rate, and IVC filter placement rate. A p value < 0.05 was considered significant. RESULTS: A total of 485 patients met the criteria for the pre-policy change group and 504 for the post-policy change group. Data are presented as screening (pre-policy change) versus no screening (post-policy change). There was no difference in the PE rate (2% in both groups, p = 0.72) or all-cause mortality at discharge (7% vs 6%, p = 0.49). There were significant differences in the lower-extremity DVT rate (10% vs 3%, p < 0.01) or IVC filter rate (6% vs 2%, p < 0.01). CONCLUSIONS: Based on these data, screening Doppler ultrasound examinations, in conjunction with standard-of-practice techniques to prevent thromboembolism, do not appear to confer a benefit to patients. While the screening group had significantly higher rates of DVT diagnosis and IVC filter placement, the screening, additional diagnoses, and subsequent interventions did not appear to improve patient outcomes. Ultimately, this makes DVT screening difficult to justify.

16.
J Neurosurg ; 129(2): 471-479, 2018 08.
Artigo em Inglês | MEDLINE | ID: mdl-29053070

RESUMO

OBJECTIVE The Agency of Healthcare Research and Quality (AHRQ) has defined Patient Safety Indicators (PSIs) for assessments in quality of inpatient care. The hypothesis of this study is that, in the treatment of unruptured cerebral aneurysms (UCAs), PSI events are less likely to occur in hospitals meeting the volume thresholds defined by The Joint Commission for Comprehensive Stroke Center (CSC) certification. METHODS Using the 2002-2011 National (Nationwide) Inpatient Sample, patients treated electively for a nonruptured cerebral aneurysm were selected. Patients were evaluated for PSI events (e.g., pressure ulcers, retained surgical item, perioperative hemorrhage, pulmonary embolism, sepsis) defined by AHRQ-specified ICD-9 codes. Hospitals were categorized by treatment volume into CSC or non-CSC volume status based on The Joint Commission's annual volume thresholds of at least 20 patients with subarachnoid hemorrhage and performance of 15 or more endovascular coiling or surgical clipping procedures for aneurysms. RESULTS A total of 65,824 patients underwent treatment for an unruptured cerebral aneurysm. There were 4818 patients (7.3%) in whom at least 1 PSI event occurred. The overall inpatient mortality rate was 0.7%. In patients with a PSI event, this rate increased to 7% compared with 0.2% in patients without a PSI event (p < 0.0001). The overall rate of poor outcome was 3.8%. In patients with a PSI event, this rate increased to 23.3% compared with 2.3% in patients without a PSI event (p < 0.0001). There were significant differences in PSI event, poor outcome, and mortality rates between non-CSC and CSC volume-status hospitals (PSI event, 8.4% vs 7.2%; poor outcome, 5.1% vs 3.6%; and mortality, 1% vs 0.6%). In multivariate analysis, all patients treated at a non-CSC volume-status hospital were more likely to suffer a PSI event with an OR of 1.2 (1.1-1.3). In patients who underwent surgery, this relationship was more substantial, with an OR of 1.4 (1.2-1.6). The relationship was not significant in the endovascularly treated patients. CONCLUSIONS In the treatment of unruptured cerebral aneurysms, PSI events occur relatively frequently and are associated with significant increases in morbidity and mortality. In patients treated at institutions achieving the volume thresholds for CSC certification, the likelihood of having a PSI event, and therefore the likelihood of poor outcome and mortality, was significantly decreased. These improvements are being driven by the improved outcomes in surgical patients, whereas outcomes and mortality in patients treated endovascularly were not sensitive to the CSC volume status of the hospital and showed no significant relationship with treatment volumes.


Assuntos
Aneurisma Intracraniano/cirurgia , Segurança do Paciente/estatística & dados numéricos , Indicadores de Qualidade em Assistência à Saúde , Feminino , Hospitais com Alto Volume de Atendimentos , Humanos , Masculino , Pessoa de Meia-Idade
17.
Neurosurgery ; 83(5): 922-930, 2018 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-29136204

RESUMO

BACKGROUND: Thrombolysis is the standard of care for acute ischemic stroke patients presenting in the appropriate time window. Studies suggest that the risk of recurrent ischemia is lower if carotid revascularization is performed early after the index event. The safety of early carotid revascularization in this patient population is unclear. OBJECTIVE: To evaluate the safety of carotid revascularization in patients who received thrombolysis for acute ischemic stroke. METHODS: The Nationwide Inpatient Sample database was queried for patients admitted through the emergency room with a primary diagnosis of carotid stenosis and/or occlusion. Each patient was reviewed for administration of thrombolysis, carotid endarterectomy, (CEA) or carotid angioplasty and stenting (CAS). Primary endpoints were intracerebral hemorrhage (ICH), postprocedural stroke (PPS), poor outcome, and in-hospital mortality. Potential risk factors were examined using univariate and multivariate analyses. RESULTS: A total of 310 257 patients were analyzed. Patients who received tissue plasminogen activator (tPA) and underwent either CEA or CAS had a significantly higher risk of developing an ICH or PPS than patients who underwent either CEA or CAS without tPA administration. The increased risk of ICH or PPS in tPA-treated patients who underwent carotid revascularization diminished with time, and became similar to patients who underwent carotid revascularization without tPA administration by 7 d after thrombolysis. Patients who received tPA and underwent CEA or CAS also had higher odds of poor outcome and in-hospital mortality. CONCLUSION: Thrombolysis is a strong risk factor for ICH, PPS, poor outcome, and in-hospital mortality in patients with carotid stenosis/occlusion who undergo carotid revascularization. The increased risk of ICH or PPS due to tPA declines with time after thrombolysis. Delaying carotid revascularization in these patients may therefore be appropriate. This delay, however, will expose these patients to the risk of recurrent stroke. Future studies are needed to determine the relative risks of these 2 adverse events.


Assuntos
Revascularização Cerebral/efeitos adversos , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Terapia Trombolítica/efeitos adversos , Idoso , Estenose das Carótidas/complicações , Estenose das Carótidas/cirurgia , Hemorragia Cerebral/epidemiologia , Hemorragia Cerebral/etiologia , Revascularização Cerebral/métodos , Bases de Dados Factuais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Razão de Chances , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Terapia Trombolítica/métodos , Ativador de Plasminogênio Tecidual/efeitos adversos , Resultado do Tratamento
18.
J Neurosurg ; 126(6): 1847-1854, 2017 06.
Artigo em Inglês | MEDLINE | ID: mdl-27494820

RESUMO

OBJECTIVE Despite persisting questions regarding its appropriateness, 30-day readmission is an increasingly common quality metric used to influence hospital compensation in the United States. However, there is currently insufficient evidence to identify which patients are at highest risk for readmission after aneurysmal subarachnoid hemorrhage (SAH). The objective of this study was to identify predictors of 30-day readmission after SAH, to focus preventative efforts, and to provide guidance to funding agencies seeking to risk-adjust comparisons among hospitals. METHODS The authors performed a case-control study of 30-day readmission among aneurysmal SAH patients treated at a single center between 2003 and 2013. To control for geographic distance from the hospital and year of treatment, the authors randomly matched each case (30-day readmission) with approximately 2 SAH controls (no readmission) based on home ZIP code and treatment year. They evaluated variables related to patient demographics, socioeconomic characteristics, comorbidities, presentation severity (e.g., Hunt and Hess grade), and clinical course (e.g., need for gastrostomy or tracheostomy, length of stay). Conditional logistic regression was used to identify significant predictors, accounting for the matched design of the study. RESULTS Among 82 SAH patients with unplanned 30-day readmission, the authors matched 78 patients with 153 nonreadmitted controls. Age, demographics, and socioeconomic factors were not associated with readmission. In univariate analysis, multiple variables were significantly associated with readmission, including Hunt and Hess grade (OR 3.0 for Grade IV/V vs I/II), need for gastrostomy placement (OR 2.0), length of hospital stay (OR 1.03 per day), discharge disposition (OR 3.2 for skilled nursing vs other disposition), and Charlson Comorbidity Index (OR 2.3 for score ≥ 2 vs 0). However, the only significant predictor in the multivariate analysis was discharge to a skilled nursing facility (OR 3.2), and the final model was sensitive to criteria used to enter and retain variables. Furthermore, despite the significant association between discharge disposition and readmission, less than 25% of readmitted patients were discharged to a skilled nursing facility. CONCLUSIONS Although discharge disposition remained significant in multivariate analysis, most routinely collected variables appeared to be weak independent predictors of 30-day readmission after SAH. Consequently, hospitals interested in decreasing readmission rates may consider multifaceted, cost-efficient interventions that can be broadly applied to most if not all SAH patients.


Assuntos
Readmissão do Paciente , Hemorragia Subaracnóidea/terapia , Adulto , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Fatores de Risco
19.
J Neurosurg ; 124(3): 743-9, 2016 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-26361278

RESUMO

OBJECTIVE: Hospital readmission is a common but controversial quality measure increasingly used to influence hospital compensation in the US. The objective of this study was to evaluate the causes for 30-day hospital readmission following aneurysmal subarachnoid hemorrhage (SAH) to determine the appropriateness of this performance metric and to identify potential avenues for improved patient care. METHODS: The authors retrospectively reviewed the medical records of all patients who received surgical or endovascular treatment for aneurysmal SAH at Barnes-Jewish Hospital between 2003 and 2013. Two senior faculty identified by consensus the primary medical/surgical diagnosis associated with readmission as well as the underlying causes of rehospitalization. RESULTS: Among 778 patients treated for aneurysmal SAH, 89 experienced a total of 97 readmission events, yielding a readmission rate of 11.4%. The median time from discharge to readmission was 9 days (interquartile range 3-17.5 days). Actual hydrocephalus or potential concern for hydrocephalus (e.g., headache) was the most frequent diagnosis (26/97, 26.8%), followed by infections (e.g., wound infection [5/97, 5.2%], urinary tract infection [3/97, 3.1%], and pneumonia [3/97, 3.1%]) and thromboembolic events (8/97, 8.2%). In most cases (75/97, 77.3%), we did not identify any treatment lapses contributing to readmission. The most common underlying causes for readmission were unavoidable development of SAH-related pathology (e.g., hydrocephalus; 36/97, 37.1%) and complications related to neurological impairment and immobility (e.g., thromboembolic event despite high-dose chemoprophylaxis; 21/97, 21.6%). The authors determined that 22/97 (22.7%) of the readmissions were likely preventable with alternative management. In these cases, insufficient outpatient medical care (for example, for hyponatremia; 16/97, 16.5%) was the most common shortcoming. CONCLUSIONS: Most readmissions after aneurysmal SAH relate to late consequences of hemorrhage, such as hydrocephalus, or medical complications secondary to severe neurological injury. Although a minority of readmissions may potentially be avoided with closer medical follow-up in the transitional care environment, readmission after SAH is an insensitive and likely inappropriate hospital performance metric.


Assuntos
Readmissão do Paciente , Hemorragia Subaracnóidea/terapia , Adulto , Idoso , Feminino , Acessibilidade aos Serviços de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Indicadores de Qualidade em Assistência à Saúde , Estudos Retrospectivos , Fatores de Risco , Hemorragia Subaracnóidea/complicações , Hemorragia Subaracnóidea/diagnóstico , Fatores de Tempo
20.
J Neurointerv Surg ; 8(1): 75-80, 2016 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-25423951

RESUMO

INTRODUCTION: While the use of intraoperative angiography (IA) has been shown to be a useful adjunct in aneurysm surgery, its routine use remains controversial. OBJECTIVE: We wished to determine if IA is required in all patients undergoing aneurysm surgery (ie, routine IA) or if intraoperative assessment can reliably predict the need for IA (ie, select IA). METHODS: We prospectively evaluated all patients undergoing craniotomy for aneurysm clipping. In these patients, the treating surgeons were asked to record whether they felt IA was required at two time points: (1) prior to surgery and (2) immediately after clip application but before IA. All patients underwent IA as per the institutional protocol. IA results and the need for post-IA clip adjustments were recorded. RESULTS: Of the 200 patients enrolled, 197 were included for analysis. IA was deemed necessary on preoperative assessment in 144 cases (73%) and on post-clip assessment in 116 cases (59%). Post-clip IA demonstrated 47 (24%) positive findings and post-IA clip adjustments were made in 19 of 198 cases (10%). On preoperative assessment, there were four cases where IA was deemed unnecessary, yet post-IA clip adjustment was required, resulting in a sensitivity of 79% and false negative rate of 8%. Regarding post-clip assessment, there were five cases where IA was thought to be unnecessary and clip adjustment was required, resulting in a sensitivity of 73% and false negative rate of 6%. CONCLUSIONS: The accuracy of a strategy of select IA was not improved by assessing the need for IA immediately after aneurysm clipping versus prior to surgery onset. This suggests that intraoperative assessment regarding the adequacy of aneurysm clip application should be viewed with caution.


Assuntos
Angiografia Digital/normas , Angiografia Cerebral/normas , Aneurisma Intracraniano/diagnóstico por imagem , Aneurisma Intracraniano/cirurgia , Monitorização Intraoperatória/normas , Cuidados Pré-Operatórios/normas , Adulto , Idoso , Angiografia Digital/métodos , Angiografia Cerebral/métodos , Craniotomia , Humanos , Pessoa de Meia-Idade , Monitorização Intraoperatória/métodos , Cuidados Pré-Operatórios/métodos , Estudos Prospectivos , Sensibilidade e Especificidade , Resultado do Tratamento
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