Potential role of bolus-tracking data of carotid CT angiography for atrial fibrillation prediction.

OBJECTIVES: Atrial fibrillation (AF), a significant cause of ischemic stroke, often goes undetected because of its asymptomatic nature. This study investigated whether the total bolus-tracking time (TTT) and average slope (AS) of a bolus-tracking graph could be used to predict AF. METHODS: This single-center, retrospective study included patients who underwent carotid CTA and a 24-h Holter test. TTT and the average degree of enhancement during bolus-tracking, derived from carotid CTA, were defined as variables of interest. All patients underwent transthoracic echocardiography. Left ventricular diastolic dysfunction and elevated left atrial pressure (LAP) were identified according to the guidelines of the 2016 American Society of Echocardiography/European Association of Cardiovascular Imaging. RESULTS: The final cohort comprised 716 patients, 80 of whom presented with AF. The TTT of the AF group was significantly longer (23.8 ± 5.2 s) than that of the non-AF group (18.7 ± 2.8 s); p < 0.001. The AS of the bolus-tracking graph of the AF group was 0.80 ± 0.24, which was significantly lower than that of the non-AF group 1.38 ± 0.21 (p < 0.001). TTT was associated with a significantly higher risk of AF (odds ratio [OR]: 1.36; p < 0.001) and elevated LAP (OR: 1.46; p < 0.001). In contrast, the AS of the bolus-tracking graph was not significantly associated with either AF or an elevated LAP. CONCLUSION: TTT derived from bolus-tracking carotid CTA is an effective adjuvant tool for detecting AF related to left ventricular diastolic dysfunction and elevated LAP, confirmed using echocardiography. KEY POINTS: • Atrial fibrillation is not only a significant cause of ischemic stroke but is also often masked because of its atypical and asymptomatic features. • The total tracking time, derived from bolus tracking of carotid computed tomography angiography, may be an effective adjuvant tool for detecting undiagnosed atrial fibrillation and elevated left atrial pressure in patients.

Chronic Phase Survival Rate in Stroke Patients With Severe Functional Limitations According to the Frequency of Rehabilitation Treatment.

OBJECTIVE: To investigate the chronic phase survival rate according to the frequency of rehabilitation treatment in the acute and subacute phases in stroke patients with severe functional limitations. DESIGN: A retrospective longitudinal cohort study. SETTING: Population-based study using the Korean National Health Insurance Database from 2007 to 2018. PARTICIPANTS: We enrolled 593 patients who experienced stroke in 2009 with national disability registration (NDR) grade of 3 or less (N=593). INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The frequencies of rehabilitation treatment within 24 months after stroke were categorized into none, 1-50, 51-200, 201-400, and >400 treatments based on requests made to the Health Insurance Review and Assessment Service. As a dependent variable, we assessed all-cause mortality from 24 to 120 months after stroke. RESULTS: The study enrolled 283 patients in NDR grade 1 (the most severe), 158 in grade 2, and 152 in grade 3. Groups with more severe functional limitations showed a lower chronic phase survival rate (P<.001). The groups with higher frequencies of rehabilitation treatment in the acute and subacute phases showed a higher chronic phase survival rate (P<.001). In the Cox regression analysis, a higher degree of functional limitation, lower frequency of rehabilitation treatment, older age, male sex, and chronic kidney disease were independent risk factors for chronic phase mortality in stroke patients with severe functional limitations. CONCLUSIONS: A high frequency of rehabilitation treatment in the acute and subacute phases was associated with the long-term survival of stroke patients with severe functional limitations.

The effect of all-cause hospitalization on cognitive decline in older adults: a longitudinal study using databases of the National Health Insurance Service and the memory clinics of a self-run hospital.

BACKGROUND: Cognitive decline is common in older adults and imposes a burden on public health. Especially for older adults, hospitalization can be related to decreased physical fitness. This study aimed to investigate the quantitative association between hospitalization and cognitive decline. METHODS: This was a retrospective cohort study. We performed a longitudinal study by using the combined database from the Korean National Health Insurance Service (NHIS) and memory clinic data of its self-run hospital. We identified whether hospitalized, the number of hospitalizations, and the total hospitalization days through the claim information from the NHIS database. We also identified whether hospitalization was accompanied by delirium or surgery with general anesthesia for subgroup analysis. Primary outcome was the clinical dementia rating-sum of boxes (CDR-SB) score. Secondary outcomes were mini-mental state examination (MMSE) score, clinical dementia rating (CDR) grade, and Korean-instrumental activities of daily living (KIADL) score. Multivariable mixed models were established. RESULTS: Of the 1810 participants, 1200 experienced hospitalization at least once during the observation period. The increase in CDR-SB was significantly greater in the hospitalized group (ß = 1.5083, P < .001). The same results were seen in the total number of hospitalizations (ß = 0.0208, P < .001) or the total hospitalization days (ß = 0.0022, P < .001) increased. In the group that experienced hospitalization, cognitive decline was also significant in terms of CDR grade (ß = 0.1773, P < .001), MMSE score (ß = - 1.2327, P < .001), and KIADL score (ß = 0.2983, P < .001). Although delirium (ß = 0.2983, P < .001) and nonsurgical hospitalization (ß = 0.2983, P < .001) were associated with faster cognitive decline, hospitalization without delirium and with surgery were also related to faster cognitive decline than in the no hospitalization group. CONCLUSION: Cognitive decline was quantitatively related to all-cause hospitalization in older adults. Moreover, hospitalizations without delirium and surgery were also related to cognitive decline. It is vital to prevent various conditions that need hospitalization to avoid and manage cognitive dysfunction.

Characteristics of diabetic and non-diabetic carpal tunnel syndrome in terms of clinical, electrophysiological, and Sonographic features: a cross-sectional study.

BACKGROUND: Although diabetes is considered a major risk factor for carpal tunnel syndrome (CTS), the characteristics of diabetic CTS have not been fully understood. OBJECTIVE: This study is aimed at evaluation of the clinical, electrophysiological, and ultrasonographic findings of non-diabetic and diabetic CTS. METHODS: This retrospective, cross-sectional study included patients diagnosed with CTS. Patient age, sex, involved side, body mass index, clinical and electrophysiological findings, and median nerve cross-sectional area (CSA) were identified. Diabetes was identified through patient or guardian interviews, medical records, and medication history. Linear and binary logistic regression models were established to confirm the associations between the electrophysiological findings, median nerve CSA, and clinical outcomes. Covariates, such as age, sex, body mass index, diabetes, symptom duration, and thenar muscle weakness were adjusted. RESULTS: Out of the 920 hands, 126 and 794 belonged to the diabetic and non-diabetic CTS groups, respectively. The patients were significantly older in the diabetic CTS group (P < 0.001). The rate of thenar weakness in the diabetic CTS group was also significantly higher than that in the non-diabetic CTS group (P = 0.009). The diabetic CTS group had a more severe electrodiagnostic grade (P = 0.001). The prolonged onset latency of the compound motor nerve action potential (CMAP) and median nerve CSA were well associated with the degree of clinical symptoms. Increased median nerve CSA was significantly associated with prolonged CMAP onset latency (ß = 0.64; P = 0.012), prolonged transcarpal latency (ß = 0.95; P = 0.044), and decreased CMAP amplitude (ß = -0.17; P = 0.002) in the non-diabetic CTS group. CONCLUSION: Diabetic CTS had more profound electrophysiological abnormalities. Distal motor latency and median nerve CSA were not only associated with each other, but also with clinical symptoms. Further studies are needed to investigate the pathophysiological mechanisms underlying diabetic CTS.

Infrared thermographic changes after decompression surgery in patients with carpal tunnel syndrome.

BACKGROUND: Digital infrared thermal imaging (DITI), which detects infrared rays emitted from body surface to create a body heat map, has been utilized at various musculocutaneous conditions. Notably, DITI can demonstrate autonomic vasomotor activity in the nerve-innervated area, and thus may be of use in carpal tunnel syndrome (CTS). In this study, we compared DITI findings before and after carpal tunnel release (CTR) surgery in patients with unilateral CTS to investigate the corresponding neurophysiological changes. METHODS: In this retrospective cohort study, DITI parameters such as the temperature differences between the median and ulnar nerve territories and median nerve-innervated digital anisometry were measured. Subjective symptom duration, pain scale, and ultrasonographic findings were also compared before and after CTR. Patients were evaluated before and 6 weeks after CTR, respectively. RESULTS: A total of 27 patients aged 59.0 ± 11.2 years were finally included. After CTR, median nerve-innervated thermal anisometry was improved (2.55 ± 0.96 °C to 1.64 ± 1.34 °C; p = 0.003). The temperature differences between the median and ulnar nerve territories were not significantly changed. Subjective pain, the Simovic Weinberg Clinical Scale, and palmar bowing of the flexor retinaculum were also significantly improved (p <  0.001 for all comparisons). CONCLUSIONS: Our results demonstrated that DITI findings could reflect an improvement in autonomic function after CTR. Therefore, DITI can be an objective method to assess pre- and post-operative neurophysiologic changes in CTS.

In-hospital fall prediction using machine learning algorithms and the Morse fall scale in patients with acute stroke: a nested case-control study.

BACKGROUND: Falls are one of the most common accidents in medical institutions, which can threaten the safety of inpatients and negatively affect their prognosis. Herein, we developed a machine learning (ML) model for fall prediction in patients with acute stroke and compared its accuracy with that of the existing fall risk prediction tool, the Morse Fall Scale (MFS). METHODS: This is a retrospective nested case-control study. The initial sample size was 8462 admitted to a single cerebrovascular specialty hospital with acute stroke. A total of 156 fall events occurred, and each fall case was randomly matched with six control cases. Six ML algorithms were used, namely, regularized logistic regression, support vector machine, naïve Bayes (NB), k-nearest neighbors, random forest, and extreme-gradient boosting (XGB). RESULTS: We included 156 in the fall group and 934 in the non-fall group. The mean ages of the fall and non-fall groups were 68.3 (± 12.2) and 65.3 (± 12.9) years old, respectively. The MFS total score was significantly higher in the fall group (54.3 ± 18.3) than in the non-fall group (37.7 ± 14.7). The area under the receiver operating curve (AUROC) of the MFS in predicting falls was 0.76 (0.73-0.79). XGB had the highest AUROC of 0.85 (0.78-0.92), and XGB and NB had the highest F1 score of 0.44. CONCLUSIONS: The AUROC values of all of ML algorithms were similar to those of the MFS in predicting fall risk in patients with acute stroke, allowing for accurate and efficient fall screening.

Clinical Characteristics and Follow-up Assessment in Patients Diagnosed With Alzheimer's Dementia Through Regional Dementia Centers and Conventional Hospital System.

BACKGROUND: The rapidly increasing socioeconomic strain caused by dementia represents a significant public health concern. Regional dementia centers (RDCs) have been established nationwide, and they aim to provide timely screening and diagnosis of dementia. This study investigated the clinical characteristics and progression of patients diagnosed with Alzheimer's dementia (AD), who underwent treatment in RDCs or conventional community-based hospital systems. METHODS: This retrospective single-center cohort study included patients who were diagnosed with AD between January 2019 and March 2022. This study compared two groups of patients: the hospital group, consisting of patients who presented directly to the hospital, and the RDC group, those who were referred to the hospital from the RDCs in Pohang city. The clinical courses of the patients were monitored for a year after AD diagnosis. RESULTS: A total of 1,209 participants were assigned to the hospital (n = 579) or RDC group (n = 630). The RDC group had a mean age of 80.1 years ± 6.6 years, which was significantly higher than that of the hospital group (P < 0.001). The RDC group had a higher proportion of females (38.3% vs. 31.9%; P = 0.022), higher risk for alcohol consumption (12.4% vs. 3.3%; P < 0.001), and greater number of patients who discontinued treatment 1 year after diagnosis (48.3% vs. 39.0%; P = 0.001). In the linear regression model, the RDC group was independently associated with the clinical dementia rating sum of boxes increment (ß = 22.360, R²\n = 0.048, and P < 0.001). CONCLUSION: Patients in the RDC group were older, had more advanced stages of conditions, and exhibited a more rapid rate of cognitive decline than patients diagnosed through the conventional hospital system. Our results suggested that RDC contributed to the screening of AD in a local region, and further nationwide study with the RDC database of various areas of Korea is needed.

Detection of C8/T1 radiculopathy by measuring the root motor conduction time.

BACKGROUND: Root motor conduction time (RMCT) can noninvasively evaluate the status of the proximal root segment. However, its clinical application remains limited, and wider studies regarding its use are scarce. We aimed to investigate the association between C8/T1 level radiculopathy and RMCT. METHODS: This was a retrospective cross-sectional study. Subjects were extracted from a general hospital's spine clinic database. A total of 48 C8/T1 root lesions from 37 patients were included, and 48 C8/T1 root levels from control subjects were matched for age, sex, and height. RMCT was measured in the abductor pollicis brevis muscle and the assessment of any delays owing to C8/T1 radiculopathy. RESULTS: The RMCT of the C8/T1 radiculopathy group was 1.7 ± 0.6 ms, which was significantly longer than that in the control group (1.2 ± 0.8 ms; p = 0.001). The delayed RMCT was independently associated with radiculopathy (adjusted odds ratio, 1.15; 95% confidence interval, 1.06-1.27; p = 0.011) after adjusting for the peripheral motor conduction time, amplitude of median compound motor nerve action potential, and shortest F-wave latency. The area under the Receiver Operating Characteristic curve for diagnosing C8/T1 radiculopathy using RMCT was 0.72 (0.61-0.82). The RMCT was significantly correlated with symptom duration (coefficient = 0.58; p < 0.001) but was not associated with the degree of arm pain. CONCLUSION: Our findings illustrate the clinical applicability of the RMCT by demonstrating its utility in diagnosing radiculopathy at certain spinal levels.

The Association Between Antihypertensive Drug Use and Hospitalization for Pneumonia in the General Population: A Case-Crossover Study Using the National Health Insurance Database of Korea.

BACKGROUND: Previous studies have reported an association between pneumonia risk and the use of certain drugs. We investigated the relationship between antihypertensive drugs and pneumonia in the general population. METHODS: This case-crossover study utilized the nationwide data of South Korea. We included participants who were hospitalized for pneumonia. A single case period was defined as 30 days before pneumonia onset, and two control periods were established (90-120 and 150-180 days before pneumonia onset). Further, we performed sensitivity and subgroup analyses (according to the presence of diabetes, documented disability, and whether participants were aged ≥ 70 years). We used conditional logistic regression models adjusted for covariates, such as angiotensin-converting-enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), other antihypertensives, statins, antipsychotics, benzodiazepine, and the number of outpatient visits. RESULTS: In total, 15,463 subjects were included in this study. ACE inhibitors (adjusted odds ratio [aOR], 0.660; 95% confidence interval [CI], 0.558-0.781), ARBs (aOR, 0.702; 95% CI, 0.640-0.770), and other antihypertensive drugs (aOR, 0.737; 95% CI, 0.665-0.816) were significantly associated with reduced pneumonia risk. Subgroup analyses according to the presence of diabetes mellitus, documented disability, and whether participants were aged ≥ 70 years consistently showed the association of antihypertensives with a reduced risk of hospitalization for pneumonia. CONCLUSION: All antihypertensive drug types were related to a lower risk of hospitalization for pneumonia in the general population. Our results implied that frequent medical service usage and protective immunity were primarily related to a reduced risk of pneumonia in the general population of South Korea.

Effects of Socioeconomic Status and Residence Areas on Long-Term Survival in Patients With Early-Onset Dementia: The Korean National Health Insurance Service Database Study.

BACKGROUND: Early-onset dementia (EOD) is still insufficiently considered for healthcare policies. We investigated the effect of socio-environmental factors on the long-term survival of patients with EOD. METHODS: This retrospective cohort study utilized the Korean National Health Insurance Database from 2007 to 2018. We enrolled 3,825 patients aged 40 to 65 years old with all types of dementia newly diagnosed in 2009 as EOD cases. We defined socioeconomic status using the national health insurance premium (NHIP) levels. Residential areas were classified into capital, metropolitan, city, and county levels. All-cause mortality was the primary outcome. Kaplan-Meier curves and log-rank tests were employed. Further, Cox-proportional hazards models were established. RESULTS: The mean survival of the fourth NHIP level group was 96.31 ± 1.20 months, whereas that of the medical-aid group was 85.53 ± 1.30 months (P < 0.001). The patients living in the capital had a mean survival of 95.73 ± 1.34 months, whereas those living in the county had 89.66 ± 1.75 months (P = 0.035). In the Cox-proportional hazards model, the medical-aid (adjusted hazard ratio [aHR], 1.67; P < 0.001), first NHIP level (aHR, 1.26; P = 0.012), and second NHIP level (aHR, 1.26; P = 0.008) groups were significantly associated with a higher long-term mortality risk. The capital residents exhibited a significantly lower long-term mortality risk than did the county residents (aHR, 0.82; P = 0.041). CONCLUSION: Socioeconomic status and residential area are associated with long-term survival in patients with EOD. This study provides a rational basis for establishing a healthcare policy for patients with EOD.

Clinical Usefulness of the Korean Version of the Dysphagia Handicap Index: Reliability, Validity, and Role as a Screening Test.

This study aimed to measure the validity and reliability of the Korean version of the Dysphagia Handicap Index (K-DHI) and evaluate its diagnostic efficacy for predicting aspiration. We enrolled 104 patients with dysphagia symptoms (D group) and 88 controls (ND group). Among controls, there were 43 patients without dysphagia symptoms (ND patient group). All subjects completed the K-DHI survey. The D and ND group patients underwent the Gugging Swallowing Screen (GUSS) and videofluoroscopic swallowing study (VFSS). Two weeks later, the D group completed the second session of the K-DHI survey. The internal consistency of the K-DHI was good to excellent (Cronbach's α: 0.79-0.95). The test-retest reliability of the K-DHI survey was also high (interclass correlation coefficient = 0.88). There were moderate correlations between the K-DHI and GUSS (r = - 0.65, p < 0.001) as well as findings of VFSS-videofluoroscopic dysphagia scale (r = 0.55, p < 0.001) and American Speech-Language-Hearing Association National Outcome Measurement System swallowing scale (r = - 0.55, p < 0.001). For predicting aspiration, the K-DHI cutoff value was 11 (sensitivity, 0.82; specificity, 0.72; positive predictive value, 0.34; and negative predictive value, 0.96). K-DHI ≥ 11 [odds ratio (OR), 6.43; 95% Confidence Interval (CI) (1.87-22.16); p = 0.003] and GUSS ≤ 15 [OR 4.73; 95% CI (1.59-14.07); p = 0.005] were independent risk factors for aspiration on VFSS. The K-DHI is a reliable and valid self-reporting instrument for evaluating patient's quality of life associated with dysphagia among the Korean language population. It is also useful for the screening of aspiration.

Effect of Pre-Antibiotic Use Before First Stroke Incidence on Recurrence and Mortality: A Longitudinal Study Using the Korean National Health Insurance Service Database.

Purpose: Clinical studies on dysbiosis and stroke outcomes has been insufficient to establish clear evidence. This study aimed to investigate the effects of pre-antibiotic use before a stroke event on secondary outcomes using a longitudinal population-level database. Patients and Methods: This retrospective cohort study included adults aged 55 years or older diagnosed with acute ischemic stroke (AIS) and acute hemorrhagic stroke (AHS) between 2004 and 2007. Patients were followed-up until the end of 2019, and the target outcomes were secondary AIS, AHS, and all-cause mortality. Multivariable Cox regression analyses were applied, and we adjusted covariates such as age, sex, socioeconomic status, hypertension, diabetes, and dyslipidemia. Pre-antibiotic use was identified from 7 days to 1 year before the acute stroke event. Results: We included 159,181 patients with AIS (AIS group) and 49,077 patients with AHS (AHS group). Pre-antibiotic use significantly increased the risk of secondary AIS in the AIS group (adjusted hazard ratio [aHR], 1.03; 95% confidence interval [CI], 1.01-1.05; p = 0.009) and secondary AHS in the AHS group (aHR, 1.08; 95% CI, 1.03-1.12; p <0.001). Furthermore, pre-antibiotic use in the AIS group was associated with a lower risk of mortality (aHR, 0.95; 95% CI, 0.94-0.96; p <0.001). Conclusion: Our population-based longitudinal study revealed that pre-antibiotic use was associated with a higher risk of secondary stroke and a lower risk of mortality in the AIS and AHS groups. Further studies are needed to understand the relationship between dysbiosis and stroke outcomes.

Removal of schwannoma from the psoas muscle with intraoperative neurophysiological monitoring: A case report.

RATIONALE: The incidence of a schwannoma within the psoas muscle is rare, and only a few cases have been reported. The surgical approach to removing schwannomas present in the psoas muscle is challenging because of its anatomical proximity to the lumbar plexus. PATIENT CONCERNS: A 31-year-old man experienced right lower back pain and anterolateral thigh numbness for 2 months. DIAGNOSIS: Magnetic resonance imaging of the patient's lumbar spine revealed a mass lesion, which was radiologically diagnosed as a well-demarcated schwannoma. INTERVENTIONS: The patient underwent surgery for excision of the schwannoma in the right psoas muscle at the second to fourth lumbar vertebrae levels. During surgery, intraoperative neurophysiological monitoring modalities, free-running and triggered electromyography and evoked potentials, from the target muscles were recorded. OUTCOMES: There was no neurotonic discharge corresponding to neuronal injury. Compound motor nerve action potential was detected in the triggered electromyography of muscles around the medial margin of the tumor. However, direct integration of the motor nerve was not observed in the intra-tumor region. LESSONS: We report that schwannoma removal in the psoas muscle, which is adjacent to the lumbar plexus, can be safely performed using intraoperative neurophysiological monitoring.

A revised approach for electrodiagnosis-based severity classification in carpal tunnel syndrome.

BACKGROUND: An electrodiagnostic evaluation is conducted to diagnose carpal tunnel syndrome (CTS) and evaluate its severity. OBJECTIVE: This study proposes a revised approach for classifying the severity of electrophysiological findings for patients with CTS. METHODS: This retrospective cross-sectional study included patients with CTS confirmed through electrodiagnostic evaluations. Based on the Stevens' classification, the patients were divided into three groups (mild/moderate/severe). A new intermediate group was defined to identify patients with normal motor nerve conduction studies and abnormal electromyographic results. CTS pain was evaluated using a numeric rate scale. Physical examinations and sonographic evaluation were performed to detect anatomical abnormalities. RESULTS: Overall, 1,069 CTS hands of 850 CTS patients were included. The mean age was 57.9 ± 10.8 years, and 336 (39.5%) were men. There were 522 (48.8%) mild cases; 281 (26.3%) moderate cases; and 266 (24.9%) severe cases. In the severe group, 49 cases were reclassified into the intermediate group. The median cross-sectional area in the intermediate group significantly differed from that in the severe group. However, the pain score significantly differed from that of the moderate group. CONCLUSION: The intermediate CTS group showed clinical features that were intermediate to those of the moderate and severe CTS groups.

PECI-Net: Bolus segmentation from video fluoroscopic swallowing study images using preprocessing ensemble and cascaded inference.

Bolus segmentation is crucial for the automated detection of swallowing disorders in videofluoroscopic swallowing studies (VFSS). However, it is difficult for the model to accurately segment a bolus region in a VFSS image because VFSS images are translucent, have low contrast and unclear region boundaries, and lack color information. To overcome these challenges, we propose PECI-Net, a network architecture for VFSS image analysis that combines two novel techniques: the preprocessing ensemble network (PEN) and the cascaded inference network (CIN). PEN enhances the sharpness and contrast of the VFSS image by combining multiple preprocessing algorithms in a learnable way. CIN reduces ambiguity in bolus segmentation by using context from other regions through cascaded inference. Moreover, CIN prevents undesirable side effects from unreliably segmented regions by referring to the context in an asymmetric way. In experiments, PECI-Net exhibited higher performance than four recently developed baseline models, outperforming TernausNet, the best among the baseline models, by 4.54% and the widely used UNet by 10.83%. The results of the ablation studies confirm that CIN and PEN are effective in improving bolus segmentation performance.

Normal Values of Central, Peripheral, and Root Motor Conduction Times in a Healthy Korean Population.

PURPOSE: Central, peripheral, and root motor conduction times (CMCTs, PMCTs, and RMCTs, respectively) are valuable diagnostic tools for spinal cord and motor nerve root lesions. We investigated the normal values and the effects of age and height on each motor conduction time. METHODS: This study included 190 healthy Korean subjects who underwent magnetic stimulation of the cortex and spinous processes at the C7 and L1 levels. Recording muscles were abductor pollicis brevis and abductor digiti minimi in the unilateral upper limb and extensor digitorum brevis and abductor hallucis in the contralateral lower limb. F-wave and compound motor nerve action potentials were also recorded. Central motor conduction time was evaluated as the difference between cortical motor evoked potential onset latency and PMCT using calculation and spinal stimulation methods. Root motor conduction time was computed as the difference between spinal stimulated and calculated CMCTs. RESULTS: The average age and height of the participants were 41.21 ± 14.39 years and 164.64 ± 8.27 cm, respectively; 39.5% (75/190) patients were men. In the linear regression analyses, upper limb CMCTs showed a significant and weak positive relationship with height. Lower limb CMCTs demonstrated a significant and weak positive relationship with age and height. Peripheral motor conduction times were significantly and positively correlated with age and height. Root motor conduction times showed no significant relationship with age and height, except for abductor pollicis brevis-RMCT, which had a weak negative correlation with height. CONCLUSIONS: This study provides normal values of CMCTs, PMCTs, and RCMTs, which have potential clinical applications. When interpreting CMCTs, age and height should be considered.

Global Outcomes for Microsurgical Clipping of Unruptured Intracranial Aneurysms: A Benchmark Analysis of 2245 Cases.

BACKGROUND AND OBJECTIVES: Benchmarks represent the best possible outcome and help to improve outcomes for surgical procedures. However, global thresholds mirroring an optimal and reachable outcome for microsurgical clipping of unruptured intracranial aneurysms (UIA) are not available. This study aimed to define standardized outcome benchmarks in patients who underwent clipping of UIA. METHODS: A total of 2245 microsurgically treated UIA from 15 centers were analyzed. Patients were categorized into low- ("benchmark") and high-risk ("nonbenchmark") patients based on known factors affecting outcome. The benchmark was defined as the 75th percentile of all centers' median scores for a given outcome. Benchmark outcomes included intraoperative (eg, duration of surgery, blood transfusion), postoperative (eg, reoperation, neurological status), and aneurysm-related factors (eg, aneurysm occlusion). Benchmark cutoffs for aneurysms of the anterior communicating/anterior cerebral artery, middle cerebral artery, and posterior communicating artery were determined separately. RESULTS: Of the 2245 cases, 852 (37.9%) patients formed the benchmark cohort. Most operations were performed for middle cerebral artery aneurysms (53.6%), followed by anterior communicating and anterior cerebral artery aneurysms (25.2%). Based on the results of the benchmark cohort, the following benchmark cutoffs were established: favorable neurological outcome (modified Rankin scale ≤2) ≥95.9%, postoperative complication rate ≤20.7%, length of postoperative stay ≤7.7 days, asymptomatic stroke ≤3.6%, surgical site infection ≤2.7%, cerebral vasospasm ≤2.5%, new motor deficit ≤5.9%, aneurysm closure rate ≥97.1%, and at 1-year follow-up: aneurysm closure rate ≥98.0%. At 24 months, benchmark patients had a better score on the modified Rankin scale than nonbenchmark patients. CONCLUSION: This study presents internationally applicable benchmarks for clinically relevant outcomes after microsurgical clipping of UIA. These benchmark cutoffs can serve as reference values for other centers, patient registries, and for comparing the benefit of other interventions or novel surgical techniques.

Microsurgical Clipping of Unruptured Anterior Circulation Aneurysms-A Global Multicenter Investigation of Perioperative Outcomes.

BACKGROUND AND OBJECTIVES: Microsurgical aneurysm repair by clipping continues to be highly important despite increasing endovascular treatment options, especially because of inferior occlusion rates. This study aimed to present current global microsurgical treatment practices and to identify risk factors for complications and neurological deterioration after clipping of unruptured anterior circulation aneurysms. METHODS: Fifteen centers from 4 continents participated in this retrospective cohort study. Consecutive patients who underwent elective microsurgical clipping of untreated unruptured intracranial aneurysm between January 2016 and December 2020 were included. Posterior circulation aneurysms were excluded. Outcome parameters were postsurgical complications and neurological deterioration (defined as decline on the modified Rankin Scale) at discharge and during follow-up. Multivariate regression analyses were performed adjusting for all described patient characteristics. RESULTS: Among a total of 2192 patients with anterior circulation aneurysm, complete occlusion of the treated aneurysm was achieved in 2089 (95.3%) patients at discharge. The occlusion rate remained stable (94.7%) during follow-up. Regression analysis identified hypertension (P < .02), aneurysm diameter (P < .001), neck diameter (P < .05), calcification (P < .01), and morphology (P = .002) as preexisting risk factors for postsurgical complications and neurological deterioration at discharge. Furthermore, intraoperative aneurysm rupture (odds ratio 2.863 [CI 1.606-5.104]; P < .01) and simultaneous clipping of more than 1 aneurysm (odds ratio 1.738 [CI 1.186-2.545]; P < .01) were shown to be associated with an increased risk of postsurgical complications. Yet, none of the surgical-related parameters had an impact on neurological deterioration. Analyzing volume-outcome relationship revealed comparable complication rates (P = .61) among all 15 participating centers. CONCLUSION: Our international, multicenter analysis presents current microsurgical treatment practices in patients with anterior circulation aneurysms and identifies preexisting and surgery-related risk factors for postoperative complications and neurological deterioration. These findings may assist in decision-making for the optimal therapeutic regimen of unruptured anterior circulation aneurysms.

Sex-dependent characteristics and outcomes after clipping of unruptured intracranial aneurysms: a multicenter propensity score-matched study.

OBJECTIVE: Disparities in the epidemiology and growth rates of aneurysms between the sexes are known. However, little is known about sex-dependent outcomes after microsurgical clipping of unruptured intracranial aneurysms (UIAs). The aim of this study was to examine sex differences in characteristics and outcomes after microsurgical clipping of UIAs and to perform a propensity score-matched analysis using an international multicenter cohort. METHODS: This retrospective cohort study involved the participation of 15 centers spanning four continents. It included adult patients who underwent clipping of UIAs between January 2016 and December 2020. Patients were stratified according to their sex and analyzed for differences in morbidities and aneurysm characteristics. Based on this stratification, female patients were matched to male patients in a 1:1 ratio with a caliper width of 0.1 using propensity score matching. Endpoints included postoperative complications, neurological performance, and aneurysm occlusion at discharge and 24 months after clip placement. RESULTS: A total of 2245 patients with a mean age of 57.3 (range 20-87) years were included. Of these patients, 1675 (74.6%) were female. Female patients were significantly older (mean 57.6 vs 56.4 years, p = 0.03) but had fewer comorbidities. Aneurysms of the internal carotid artery (7.1% vs 4.2%), posterior communicating artery (6.9% vs 1.9%), and ophthalmic artery (6.0% vs 2.8%) were more commonly treated surgically in females, while clipping of aneurysms of the anterior communicating artery was more frequent in males (17.0% vs 25.3%; all p < 0.001). After propensity score matching, female patients were found to have had significantly fewer pulmonary complications (1.4% vs 4.2%, p = 0.01). However, general morbidity (24.5% vs 25.2%, p = 0.72) and mortality (0.5% vs 1.1%, p = 0.34), as well as neurological performance (p = 0.58), were comparable at discharge in both sexes. Lastly, rates of aneurysm occlusion at the time of discharge (95.5% vs 94.9%, p = 0.71) and 24 months after surgery (93.8% vs 96.1%, p = 0.22) did not significantly differ between male and female patients. CONCLUSIONS: Despite overall differences between male and female patients in demographics, comorbidities, and treated aneurysm location, sex did not relevantly affect surgical performance or perioperative complication rates.