Risk of adjacent level fracture after percutaneous vertebroplasty and kyphoplasty vs natural history for the management of osteoporotic vertebral compression fractures: a network meta-analysis of randomized controlled trials.

OBJECTIVES: Percutaneous vertebroplasty and kyphoplasty are common interventions for osteoporotic vertebral compression fractures. However, there is concern about an increased risk of adjacent-level fractures after treatment. This study aimed to compare the risk of adjacent-level fractures after vertebroplasty and kyphoplasty with the natural history after osteoporotic vertebral compression fractures. MATERIALS AND METHODS: A network meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to the natural history after osteoporotic vertebral compression fractures. Frequentist network meta-analysis was conducted using the "netmeta" package, and heterogeneity was assessed using Q statistics. The pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using random effects. RESULTS: Twenty-three RCTs with a total of 2838 patients were included in the analysis. The network meta-analysis showed comparable risks of adjacent-level fractures between vertebroplasty, kyphoplasty, and natural history after osteoporotic vertebral compression fractures with a mean follow-up of 21.2 (range: 3-49.4 months). The pooled RR for adjacent-level fractures after kyphoplasty compared to natural history was 1.35 (95% CI, 0.78-2.34, p = 0.23) and for vertebroplasty compared to natural history was 1.16 (95% CI, 0.62-2.14) p = 0.51. The risk of bias assessment showed a low to moderate risk of bias among included RCTs. CONCLUSION: There was no difference in the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to natural history after osteoporotic vertebral compression fractures. The inclusion of a large patient number and network meta-analysis of RCTs serve evidence-based clinical practice. CLINICAL RELEVANCE STATEMENT: The risk of adjacent-level fracture following percutaneous vertebroplasty or kyphoplasty is similar to that observed in the natural history after osteoporotic vertebral compression fractures. KEY POINTS: RCTs have examined the risk of adjacent-level fracture after intervention for osteoporotic vertebral compression fractures. There was no difference between vertebroplasty and kyphoplasty patients compared to the natural disease history for adjacent compression fractures. This is strong evidence that interventional treatments for these fractures do not increase the risk of adjacent fractures.

Clear cell meningiomas-case presentation, review of radiographic identifiers, and treatment approaches.

Spinal clear cell meningiomas (CCMs) are a rare histological subtype of meningiomas that pose preoperative diagnostic challenges due to their radiographic similarities with other lesions. They are also more aggressive, exhibiting higher rates of recurrence, particularly in pediatric patients. Overcoming diagnostic challenges of these tumors can improve patient outcomes. In this report, we describe a case of a pediatric patient presenting with a lumbar CCM in whom we were able to obtain gross total resection. Our report reviews previously identified predictors of CCM recurrence, including the Ki-67 proliferation index, number of spinal segments involved, and hormonal influences related to age and sex. We describe the characteristic radiographic features that differentiate spinal CCMs from other tumors to improve pre-operative diagnosis. Furthermore, we provide our rationale for adjuvant therapy for pediatric patients to refine treatment protocols for these rare tumors.

Ethnic-Associated Phenotype Variations in Moyamoya Cerebrovascular Outcomes.

INTRODUCTION: Moyamoya has been extensively described in East Asian populations, and despite its accepted clinical presentation and course, it is fundamental to describe major cerebrovascular complications in other ethnically diverse samples. Hence, we sought to determine if distinct ethnic groups are at higher risk of developing stroke using the National Inpatient Sample (NIS) database. METHODS: We included all moyamoya patients admitted from January 2013 until December 2018 in the NIS database. Multivariate regression analysis was used to determine the risk of developing stroke and poor outcomes in different races compared to white patients. RESULTS: Out of the 6093 admissions with diagnosis of moyamoya disease that were captured, 2,520 were white (41.6%), 2,078 were African American (AA) (34.1%), 721 were Hispanic (11.8%), and 496 were Asian (8.14%). For arterial ischemic stroke (AIS), we found that AA race had a significantly reduced risk of AIS compared to white patients (odds ratio = 0.8, 95% confidence interval: 0.7-0.9, p = 0.031). While being Hispanic or Asian significantly increased 1.5 and 2-fold the risk of hemorrhagic stroke. CONCLUSION: This study highlights the unique features and phenotypes of moyamoya cases among different ethnicities. While possibly AA are protected from developing AIS due to underlying causes of moyamoya such as sickle cell disease, Asians seems to be more susceptible to hemorrhagic stroke.

Classical Risk Factors for Ischemic Stroke are not Associated with Inpatient Post-Stroke Mortality in Sickle Cell Disease.

OBJECTIVES: Sickle cell disease is a common haemoglobinopathy that significantly increases the risk of ischemic stroke. Because the risk factors for ischemic stroke onset and mortality in non-sickle cell disease patients have been largely elucidated, this paper aims to analyze risk factors for ischemic stroke mortality in sickle cell disease patients, which remain largely unknown. MATERIALS/METHODS: The National Inpatient Sample database (2016-2017) was used to develop a multivariable regression model for risk quantification of known ischemic stroke risk factors for in-hospital mortality in ischemic stroke patients with and without sickle cell disease. RESULTS: Classical risk factors for ischemic stroke onset, including ischemic heart disease, carotid artery disease, lipidemias, hypertension, obesity, tobacco use, atrial fibrillation, personal or family history of stroke, congenital heart defects, congestive heart failure, cardiac valve disorder, peripheral vascular disease, and diabetes mellitus are associated with in-hospital mortality in non-sickle cell patients (p < 0.05). However, no significant association was found between these stroke risk factors and in-hospital mortality in sickle cell disease patients presenting with ischemic stroke (p > 0.05). CONCLUSIONS: While the classical risk factors for stroke onset are associated with in-hospital mortality in non-sickle cell stroke patients, they are not associated with in-hospital mortality in sickle cell stroke patients.

A Predictive Model for Functional Outcome in Patients with Acute Ischemic Stroke Undergoing Endovascular Thrombectomy.

INTRODUCTION: Endovascular thrombectomy (EVT) is a well-established treatment of acute ischemic stroke. Variability in outcomes among thrombectomy patients results in a need for patient centered approaches to recovery. Identifying key factors that are associated with outcomes can help prognosticate and direct resources for continued improvement post-treatment. Thus, we developed a comprehensive predictive model of short-term outcomes post-thrombectomy. METHODS: This is a retrospective chart review of adult patients who underwent EVT at our institution over the last four years. Primary outcome was dichotomized 90-day mRS (mRS 0-2 v mRS 3-6). Bivariate analyses were conducted, followed by logistic regression modelling via a backward-elimination approach to identify the best fit predictive model. RESULTS: 326 thrombectomies were performed; 230 cases were included in the model. In the final predictive model, adjusting for age, gender, race, diabetes, and presenting NIHSS, pre-admission mRS = 0-2 (OR 18.1; 95% 3.44-95.48; p < 0.001) was the strongest predictor of a good outcome at 90-days. Other independent predictors of good outcomes included being a non-smoker (OR 5.4; 95% CI 1.53-19.00; p = 0.01) and having a post-thrombectomy NIHSS<10 (OR 9.7; 95% CI 3.90-24.27; p < 0.001). A decompressive hemicraniectomy (DHC) was predictive of a poor outcome at 90-days (OR 0.07; 95% CI 0.01-0.72; p = 0.03). This model had a Sensitivity of 79%, a Specificity of 89% and an AUC=0.89. CONCLUSION: Our model identified low pre-admission mRS score, low post-thrombectomy NIHSS, non-smoker status and not requiring a DHC as predictors of good functional outcomes at 90-days. Future works include developing a prognostic scoring system.

Moyamoya Disease and Syndrome: A National Inpatient Study of Ischemic Stroke Predictors.

OBJECTIVES: Ischemic stroke and hemorrhagic stroke are the most common sequelae of the Moyamoya variants [Moyamoya disease (MMD) and syndrome (MMS)]. We sought to determine the rates of stroke subtypes and the predictive factors of arterial ischemic stroke (AIS) utilizing a large data sample of MMD and MMS patients in the US. MATERIALS AND METHODS: We queried the 2016 and 2017 National Inpatient Sample database for Moyamoya diagnosis plus any of the following associated conditions; sickle cell disease, neurofibromatosis type 1, cranial radiation therapy or Down Syndrome. Multivariate regression determined the risk factors for AIS onset in MMD and MMS. RESULTS: 2323 patients with a diagnosis of Moyamoya were included; 668 (28.8%) patients were classified as MMS and 1655 (71.2%) as MMD. AIS was the most common presentation in both cohorts; however, MMD patients had higher rates of AIS (20.4 vs 6%, p < 0.001), hemorrhagic stroke (7.4vs 2.5%, p < 0.001), and TIA (3.3vs 0.9%, p = 0.001) compared to MMS patients. Multivariate analysis showed that increasing age [OR = 1.017 95%CI: 1.008-1.03, p < 0.001], lipidemia [OR = 1.32 95%CI: 1.02-1.74, p = 0.049], and current smoking status [OR = 1.43 95%CI: 1.04-1.97, p = 0.026] were independent risk factors for AIS in MMD patients, whereas hypertension [OR = 2.61 95%CI: 1.29-5.25, p = 0.007] and African-American race [OR = 0.274, 95%CI: .117-.64, p = 0.003] were independent predictors in the MMS cohort. CONCLUSION: AIS is the most common presentation in both, MMD and MMS. However, MMD patients had higher rates of stroke events compared to MMS. Risk factors for AIS in MMD included increasing age, lipidemia and smoking status, whereas in MMS hypertension was the only independent risk factor.

The complex treatment paradigms for concomitant tethered cord and scoliosis: illustrative case.

BACKGROUND: Scoliosis associated with tethered cord syndrome is one of the most challenging spinal deformities to manage. Multiple surgical approaches have been developed, including traditional staged and concomitant procedures, spine-shortening osteotomies, and individual vertebral column resections. OBSERVATIONS: A 10-year-old female presented with congenital kyphoscoliosis with worsening curve progression, tethered spinal cord, and a history of enuresis. The scoliosis had progressed to a 26° coronal curve and 55° thoracolumbar kyphosis. Preoperative magnetic resonance imaging of the spine revealed a tethered cord between the levels of L3-4 and a large kyphotic deformity at L1. The patient underwent laminectomy, during which intraoperative motor signals were lost. A planned hemivertebrectomy at L1 was performed prior to an L4 laminectomy, untethering of the filum terminale, and posterior spinal fusion from T11 to L2. After surgery, the patient experienced transient lower-extremity weakness, with her neurological function improving from baseline over the next 2 months. Ultimately, the goal of this surgery was to halt the progressive decline in motor function, which was successfully achieved. LESSONS: Much remains to be learned about the treatment of this complicated disease, especially in the setting of concomitant scoliosis. This case serves to exemplify the complex treatment paradigms that exist when attempting to manage this clinical syndrome and that more remains to be learned.

Deadliness of Traumatic Subdural Hematomas in the First Quarter of the Year: A Measurement by the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP).

Background Traumatic acute subdural hematoma (ASDH) is a surgical emergency and has been associated with high morbidity and mortality. However, it is not known whether mortality from ASDH occurs more frequently in a particular season. Methodology We queried the American College of Surgeons-National Surgical Quality Improvement Program (ACS-NSQIP) from 2016 to 2019. They were identified in the NSQIP using the International Classification of Diseases (ICD-10) code S06.5 to capture all admissions with a primary diagnosis of traumatic subdural hematoma. Mortality rates were reviewed per season, defined as three consecutive months in the year. Demographics such as age, race, ethnicity, height, and weight were reviewed. Comorbidities such as diabetes, risk factors, including smoking history, and hospitalization characteristics, such as admission year, operation year, and inpatient/outpatient treatment type, were also reviewed. Results A total of 1,656 patients were included in this study. The mean age of all participants was 70.6 years, with 37% (604/1,656) being female. The mortality rate was highest in January, February, and March at 24.5% (104/425, P = 0.045) of admitted patients compared to mortality rates of 18.8% (70/373) in April to June, 18.4% (81/441) in July to September, and 17.5% (73/417) in October to December. Conclusions Mortality is significantly greater during the winter months of January, February, and March among patients with ASDH. Despite better survival rates of ASDH over the past two decades, postoperative mortality rates still remain high.

The role of venous anatomy in guiding treatment approach for dural arteriovenous fistulas of the craniocervical junction; case series & systematic review.

BACKGROUND: Dural arteriovenous fistulas (DAVF) of the craniocervical junction (CCF) are an uncommon entity with the following venous drainage pattern: inferior, superior and mixed. Patients may present with subarachnoid hemorrhage, myelopathy or brainstem dysfunction. CCJ DAVF can be treated with microsurgery or with transarterial and transvenous embolization, depending on the venous drainage pattern. We present our institutional experience of treating CCJ DAVFs along with a systematic review of the literature. METHODS: Six patients with CCJ DAVF were treated at our institution over five years. Data was collected using electronic medical record review. Systematic review was performed on CCJ DAVF using the PubMed database from 1990 to 2021. We characterized venous drainage patterns, treatment choices, and outcomes to create a classification system. RESULTS: 50 case reports, consisting of 115 patients, were included in our review. 61 (53.0 %) patients had inferior drainage while 32 (27.8 %) patients had superior drainage and 22 (19.2 %) patients had mixed venous drainage. Patients with inferior drainage had the fistulous connection at the foramen magnum while patients with superior drainage had a fistulous connection at C1-C2 (p value = 0.026). Patients with inferior drainage were more likely to present with myelopathy while patients with superior drainage presented with hemorrhage (p value = 0.000). CONCLUSIONS: Classifying the venous drainage pattern is essential in making treatment decision. Transvenous embolization works best with large superior venous drainage. If endovascular treatment is not an option, then surgical clipping can achieve successful cure. Transarterial embolization is a reasonable option in cases with a large arterial feeder.

Heart rate and heart rate variability during diagnostic and interventional neuroendovascular procedures.

INTRODUCTION: Heart rate variability (HRV) reflects the activity of the autonomic nervous system (ANS) and can be used as a potential predictor of stress-related cardiovascular diseases. This study aimed to assess whether physical and mental strain during the performance of cerebral endovascular procedure influence time-domain HRV parameters in operating surgeon. MATERIALS AND METHODS: Heart rate (HR) and HRV metrics were measured using a HR sensor chest strap before, during, and after neuroendovascular interventions performed by a single neurosurgeon. Three consecutive data series were reported by recording time domain: before procedure, during and after performing endovascular procedures. HR and HRV parameters were recorded during diagnostic and interventional neuroendovascular procedures. HR and HRV measures were analyzed by procedure type and recording time domain. RESULTS: HRV measures of a single endovascular neurosurgeon were recorded during 50 procedures. The median intraprocedural HRV score was the lowest and the median HR was the highest (HRV: 52, HR: 89 bpm) compared to preprocedural (HRV: 59, HR: 70 bpm) and postprocedural cardiovascular measures (HRV: 53, HR: 79, bpm, p < 0.001). On univariate linear regression, a negative association of interventional procedures with lower intraprocedural (ß = -0.905, p = 0.001) and postprocedural (ß = -1.12, p < 0.001) HRV scores compared to the diagnostic procedures was noted. CONCLUSIONS: HRV is a reliable tool to measure cardiovascular and mental stress. Interventional neuro-endovascular procedures seem to negatively impact the cardiovascular measures of neurointerventionalists. Further longitudinal studies utilizing HRV are warranted to address their long-term effects on the mental health of physicians.

Through-and-through stab wound of the cervical spinal canal with retained weapon but no neurological repercussions: an exceptionally rare injury and the case for direct withdrawal. Illustrative case.

BACKGROUND: Nonmissile penetrating spinal injuries are rare and potentially debilitating. Such injuries can sometimes be complicated by the retention of a foreign body, which is usually part of the assailant's weapon, making their management even more problematic. OBSERVATIONS: We present a unique case of stab wound to the neck with a retained ice pick, traversing the spinal canal from one intervertebral foramen to the other, yet with no ensuing neurological damage to the patient. After carefully analyzing the weapon's trajectory on computed tomography and ruling out vertebral artery injury via catheter angiography, the ice pick was successfully withdrawn under general anesthesia and intraoperative neurophysiological monitoring, averting the need for a more invasive surgical procedure. LESSONS: Stab wounds of the spinal canal with a retained foreign body can occasionally be managed by direct withdrawal. Whether this simple technique is a safe alternative to open surgical exploration should be determined on a case-by-case basis after careful review of spinal and vascular imaging. The absence of significant neurological or vascular injury is an absolute prerequisite for attempting direct withdrawal. Moreover, preparations should be made for possible conversion to open surgical exploration in the rare event of active hemorrhage, expanding hematoma, or acute neurological deterioration.

Transcarotid access for the treatment of recurrent, previously ruptured wide necked bifurcation aneurysm with the WEB device: A technical video.

The Woven Endobridge (WEB) device is an FDA-approved intrasaccular flow disruptor to treat most intracranial wide-necked bifurcation aneurysms.1 Based on the rising experience with safe and effective results, it has been increasingly utilized for the treatment of residual and recurrent aneurysms.2, 3 Additionally, the device has been reported as an off-label treatment option for Posterior communicating (Pcom) artery aneurysms with optimal morphology.4 A transfemoral or transradial artery access is conventionally utilized for WEB embolization.1- 3 In this technical video, we share our experience with the use of direct carotid puncture to perform WEB embolization for a large recurrent Pcom aneurysm in an elderly female with a history of subarachnoid hemorrhage that was initially treated with surgical clipping. A direct puncture of the left common carotid artery (CCA) under ultrasound guidance was performed after failed attempts to select the left ICA via both transfemoral and transradial access due to type 3 aortic arch and extreme tortuosity of the proximal left CCA. The aneurysm was successfully treated with a 5 mm × 2 mm WEB SL device. There are limited studies of transcarotid access for neurointerventional procedures including mechanical thrombectomy, intracranial stent placement etc.5, 6 To the best of our knowledge, this technical video represents the first documented report of WEB embolization via transcarotid access. We aim to highlight the feasibility of transcarotid arterial access for WEB embolization as an effective bailout strategy. In addition, the nuances of direct carotid puncture along with possible complications, and potential management strategies have been discussed.

Predictors of Radiographic and Symptomatic Hemorrhagic Conversion Following Endovascular Thrombectomy for Acute Ischemic Stroke Due to Large Vessel Occlusion.

Background Endovascular therapy is known to achieve a high rate of recanalization in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) and is currently the standard of care. Hemorrhagic conversion is a severe complication that may occur following AIS in patients undergoing endovascular thrombectomy (EVT). There is a scarcity of data on the risk factors related to HV in post-EVT patients, especially those who develop symptomatic hemorrhagic conversion. The main objective of our study is to identify independent predictors of radiographic and symptomatic hemorrhagic conversion in our diverse patient population with multiple baseline comorbidities that presented with AIS and were treated with EVT as per the most updated guidelines and practices. Methodology This is a retrospective chart review in which we enrolled adult patients treated with EVT for AIS at a comprehensive stroke center in the Bronx, NY, over a four-year period. Bivariate analyses followed by multiple logistic regression modeling were performed to determine the independent predictors of all and symptomatic hemorrhagic conversion. Results A total of 326 patients who underwent EVT for AIS were enrolled. Of these, 74 (22.7%) had an HC, while 252 (77.3%) did not. In total, 25 out of the 74 (33.7%) patients were symptomatic. In the logistic regression model, a history of prior ischemic stroke (odds ratio (OR) = 2.197; 95% confidence interval (CI) = 1.062-4.545; p-value = 0.034), Alberta Stroke Program Early CT Score (ASPECTS) of <6 (OR = 2.207; 95% CI = 1.477-7.194; p-value = 0.019), and Thrombolysis in Cerebral Infarction (TICI) 2B-3 recanalization (OR = 2.551; 95% CI = 1.998-6.520; p-value=0.045) were found to be independent predictors of all types of hemorrhagic conversion. The only independent predictor of symptomatic hemorrhagic conversion on multiple logistic regression modeling was an elevated international normalized ratio (INR) (OR = 11.051; 95% CI = 1.866-65.440; p-value = 0.008). Conclusions History of prior ischemic stroke, low ASPECTS score, and TICI 2B-3 recanalization are independent predictors of hemorrhagic conversion while an elevated INR is the only independent predictor of symptomatic hemorrhagic conversion in post-thrombectomy patients.

Thromboelastography (TEG) results are predictive of ischemic and hemorrhagic complications in patients with unruptured intracranial aneurysms treated with flow diversion.

INTRODUCTION: Flow diversion is an effective treatment modality for intracranial aneurysms but is associated with ischemic and hemorrhagic complications. Patients treated with flow diversion require dual antiplatelet therapy and subsequent platelet function tests. At our institution, Thromboelastography with Platelet Mapping (TEG-PM) is the test of choice. The primary objective of this study was to identify TEG parameters that are predictive of postoperative complications in patients treated with elective flow diversion. METHODS: This was a retrospective study of 118 patients with unruptured intracranial aneurysms treated with flow diversion. Data was collected via chart review. Bivariate analyses were performed to identify significant variables in patients who suffered an ischemic stroke or a groin hematoma. ROC curves were constructed for the TEG parameters with statistical significance. Bivariate analyses were repeated using dichotomized TEG results. RESULTS: Patients who experienced a symptomatic ischemic stroke had a history of stroke (p value = 0.007), larger aneurysm neck width (p value = 0.017), and a higher alpha angle (p value = 0.013). Cut off point for ischemic complication is 63° on ROC curve with a sensitivity of 100% and specificity of 65%. Patients who experienced a groin hematoma were no different from their healthy peers but had a lower alpha angle (p value = 0.033). Cut off point for hemorrhagic complication is 53.3° with a sensitivity of 82% and specificity of 67%. CONCLUSION: The Alpha Angle parameter of TEG-PM has a sizeable predictive ability for both ischemic complications of the central nervous system and hemorrhagic complications of the access site after elective flow diversion.

The incidence of venous thromboembolism following surgical resection of intracranial and intraspinal meningioma. A systematic review and retrospective study.

INTRODUCTION: Historically, the development of venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary thromboembolism (PE) was cited as a higher post-operative risk for patients harboring meningiomas. However, recent literature has suggested that there may be no elevated risk for VTE among these patients. The authors perform both a retrospective review of their own cases as well as a systematic review of the literature in order to determine the frequency of the VTE and rate of post-operative hemorrhage in this patient population. METHODOLOGY: Patients undergoing surgery for intracranial and spinal meningioma from 2012 to 2019 were retrospectively reviewed for patient demographics, clinical characteristics, and post-operative complications. Logistic regression was used to determine risk factors for the development of VTE. Additionally, a PubMed search was performed to identify patients addressing this topic. RESULTS: Our retrospective review included 189 patients who underwent 197 operations. The rate of VTE for patients receiving LMWH was 3.55 % vs. 4.06 % for those not receiving LMWH. There were no observed hemorrhages after initiation of LMWH. Multivariate analysis found tumor volume, history of DVT, and length of hospital stay as independent risk factors for VTE. In the systematic review, 11 papers describing 28,954 patients were included. The risk of developing a VTE with or without LMWH was 2.71 % versus 4.07 %, respectively. The hemorrhage risk was 2.23 % on LMWH versus 4.20 % not on LMWH. DISCUSSION: In several heterogeneous series of all types of neurosurgical procedures, the reported rate of VTE was 11.1 %. In our review of the literature, the VTE rate of 2.71 % was similar to our cohort's rate of 3.55 %, for patients administered LMWH postoperatively. Higher rates of VTE with meningiomas may not be the case as once thought. Regular use of LMWH appears to be a safe, but it also did not necessarily lower the rates of VTE in our cohort. The use of routine lower-extremity duplex ultrasound, mechanical prophylaxis, and early mobilization, may have contributed to these lower rates of VTEs in patients with meningiomas.

Sterile Leukocytosis Predicts Hemorrhagic Transformation in Arterial Ischemic Stroke: A National Inpatient Sample Study.

OBJECTIVE: Hemorrhage transformation (HT) is a known complication of arterial ischemic stroke (AIS). In addition, it is known that the increase of proinflammatory immune cells in the brain tissue after AIS predict worse outcomes. However, it is not clear whether inflammation due to preceding or post-stroke infections affect outcomes and moreover, if systemic inflammatory markers could be useful as a clinical prediction tool for HT post-stroke. Therefore, our objective was to assess the association between systemic pro-inflammatory profile in AIS patients with HT and in-hospital mortality that did not course with acute infections during hospitalization. METHODS: This study was conducted using the 2016 and 2017 National Inpatient Sample (NIS) with International Classification of Diseases (ICD-10) codes. Multivariate logistic regression was used to examine the association between HT and in-hospital mortality with pro-inflammatory anomalies of white blood cells (WBCs) in AIS patients. Exclusion criteria comprised patients with under 18 years old, and with a diagnosis of gastrointestinal, urogenital, respiratory infection, bacteremia, viral infection, sepsis, or fever. RESULTS: A total of 212,356 patients with AIS were included in the analysis. 422 (0.2%) patients had a HT and 10,230 (4.8%) patients died during hospitalization. The most common WBC pro-inflammatory marker was leukocytosis with 6.9% (n=29/422) of HT and 5.5% (n=560/10,230) of patients that died during hospitalization. After adjusting for socio-demographic, comorbidities and treatment factors, leukocytosis was found to be an independent risk factor for both outcomes, HT [OR = 1.5, 95% CI: 1-2.3, p=0.024] and, in-hospital mortality [OR = 1.5, 95% CI: 1.3-1.6, p < 0.001]. CONCLUSION: Sterile leukocytosis is a potential clinical prediction tool to determine which patients are at higher risk of developing HT and die during hospitalization.

How reliable is CT angiography in the etiologic workup of intracranial hemorrhage? A single surgeon's experience.

OBJECTIVES: CT angiography (CTA) is gradually replacing digital subtraction angiography (DSA) in the etiologic workup of intracranial hemorrhage, though debate persists regarding its diagnostic accuracy. To better define the role of CTA in a pragmatic, real-world setting, we reviewed the experience of a single dual vascular-endovascular neurosurgeon. PATIENTS AND METHODS: Nontraumatic intracranial hemorrhage cases managed by the senior author over a 15-month period were retrieved from a prospectively maintained database. Cases where a hypertensive etiology was presumed were excluded. Demographics, intracranial hemorrhage pattern, CTA and DSA findings were recorded. RESULTS: The study cohort consists of 59 cases where both CTA and DSA were obtained, including 32 women and 27 men with mean age 50 years (18-83). Intracranial hemorrhage pattern was: aneurysmal subarachnoid hemorrhage (SAH) in 37, perimesencephalic SAH (PMSAH) in 8, intraparenchymal in 11, intraventricular in 2, subdural in 1. The overall yield of vascular imaging was 62.7 % (37/59): 29 saccular aneurysms, 4 dissecting aneurysms, 4 microarteriovenous malformations (microAVMs). The specificity and positive predictive value of CTA were 100 %. Its sensitivity and negative predictive value were only 89.2 % and 84.6 %, respectively. CTA missed 4 lesions: 2 dissecting aneurysms, 1 microAVM, 1 small saccular aneurysm. Of 8 patients with PMSAH, 3 (37.5 %) had a vascular lesion: 1 vertebrobasilar dissection, 1 cerebellar microAVM, 1 basilar tip aneurysm. Of those, 2 were missed by CTA. CONCLUSIONS: DSA may identify a lesion in up to 15 % of intracranial hemorrhage cases with negative CTA. Excessive reliance on CTA can be potentially hazardous, especially in the setting of PMSAH.

Evaluating the natural growth rate of metastatic cancer to the brain.

BACKGROUND: Brain metastases are becoming increasingly more prevalent as cancer patients survive longer with both improved local and systemic therapy. Little is known, however, of the natural growth rates of brain metastases. This investigation aims to ascertain this growth rate of these lesions before the initiation of any CNS- directed therapy. METHODS: A total of 700 patients were screened, identifying 18 cancer patients (13 breast and 5 lung) with 29 brain metastases that were serially imaged from 2011 to 2017 before treatment for their intracranial metastases. Growth rates were measured by contouring lesions serially across at least two MRI studies in iPlan software by independent raters. These values were then compared between primary (breast and lung) cancer cohorts. RESULTS: The mean age at diagnosis was 53 and 95% were female. The interval between primary cancer diagnosis and brain metastases was 4.6 years and 1.2 years in the breast and lung cancer groups, respectively. Of the breast and lung cancer patients, 23% and 40% were deceased, with respective 5.08 cm3 and 2.44 cm3 initial tumor volumes. The average growth rate of lung and breast tumors was 0.018 and 0.040 cm3/day, respectively, with deceased patients having larger and faster growing tumors. Breast and lung metastases grew 2.39% and 1.14% of their total volumes daily and doubling times were 86 and 139 days, respectively. CONCLUSION: This investigation provides a unique perspective into the biological growth of metastatic brain lesions. It is our hope that this study guides timing of treatment and informs both clinicians and patients of tumor growth kinetics before initiating treatment for intracranial metastases.