The weekend effect on mechanical thrombectomy: A nationwide analysis before and after the pivotal 2015 trials.

OBJECTIVES: As hospitals rapidly implement mechanical thrombectomy (MT) into stroke protocols following the pivotal trials in 2015, access to and outcomes from MT may be poorer for weekend-admitted patients. We sought to investigate whether a "weekend effect" influences MT outcomes nationally. MATERIALS AND METHODS: We identified stroke patients from 2010-2014 (pre-trials) to 2015-2017 (posttrials) using the Nationwide Readmissions Database. On multivariate analyses, we determined factors independently associated with receiving MT. Among MT patients, we then determined whether weekend admission was independently associated with inpatient mortality and unfavorable discharge. RESULTS: We identified 2,121,462 patients from 2010 to 2014, of whom 1.11% of weekday-admitted and 1.08% of weekend-admitted patients underwent MT. Of the 1,286,501 patients identified from 2015 to 2017, MT was performed in 2.82% and 2.91%, respectively. In the earlier cohort, weekend admission was independently associated with reduced odds of MT (odds ratio [OR] = 0.92, 95% confidence interval [CI]: 0.89-0.95, P < 0.0001), although this was not statistically significant in the later cohort. During both periods, age >80 years was independently associated with a reduced likelihood of receiving MT, and status as a teaching or large bed-size hospital was associated with a greater likelihood. Weekend admission was independently associated with unfavorable discharge only in the 2015-2017 cohort (OR = 1.11, 95% CI: 1.02-1.22, P = 0.02). CONCLUSIONS: While nationwide access to MT has improved for weekend-admitted patients, the elderly and those at smaller, nonteaching hospitals remain underserved. Although we found no effect of weekend admission on inpatient mortality, since the major shift in practice, an emerging "weekend effect" may influence discharge outcomes. Data suggest that some hospitals are being challenged to provide this new standard of care efficiently and equitably.

National Rates, Reasons, and Risk Factors for 30- and 90-Day Readmission and Reoperation Among Patients Undergoing Anterior Cervical Discectomy and Fusion: An Analysis Using the Nationwide Readmissions Database.

STUDY DESIGN: Retrospective cohort study of the Nationwide Readmissions Database (NRD). OBJECTIVE: To determine causes of and independent risk factors for 30- and 90-day readmission in a cohort of anterior cervical discectomy and fusion (ACDF) patients. SUMMARY OF BACKGROUND DATA: Identifying populations at high-risk of 30-day readmission is a priority in healthcare reform so as to reduce cost and patient morbidity. However, among patients undergoing ACDF, nationally-representative data have been limited, and have seldom described 90-day readmissions, early reoperation, or socioeconomic influences. METHODS: We queried the NRD, which longitudinally tracks 49.3% of hospitalizations, for all adult patients undergoing ACDF. We calculated the rates of, and determined reasons for, readmission and reoperation at 30 and 90 days, and determined risk factors for readmission at each timepoint. RESULTS: We identified 50,126 patients between January and September 2014. Of these, 2294 (4.6%) and 4152 (8.3%) were readmitted within 30 and 90 days of discharge, respectively, and were most commonly readmitted for infections, medical complications, and dysphagia. The characteristics most strongly associated with readmission were Medicare or Medicaid insurance, length of stay greater than or equal to 4 days, three or more comorbidities, and non-routine discharge, whereas surgical factors (e.g., greater number of vertebrae fused) were more modest. By 30 and 90 days, 8.2% and 11.7% of readmitted patients underwent an additional spinal procedure, respectively. CONCLUSION: Our analysis uses the NRD to thoroughly characterize readmission in the general ACDF population. Readmissions are often delayed (after 30 days), strongly associated with insurance status, and many result in reoperation. Our results are crucial for risk-stratifying future ACDF patients and developing interventions to reduce readmission.Level of Evidence: 3.

Microsurgical Clip Ligation of an Unruptured Azygos Bifurcation Aneurysm Indented by the Falx Cerebri: 3-Dimensional Operative Video.

Dissecting pericallosal aneurysms from the falx cerebri is technically challenging, as one must release the adherent dome but minimize shearing injury, which could result in intraoperative rupture. We discuss a 51-yr-old woman with a history of hypertension and smoking who presented with severe headaches and was found to have a 6-mm unruptured, multilobulated pericallosal aneurysm abutting the falx, with anterior and superior projecting domes on either side. She also had an azygos anterior cerebral artery (ACA), a rare anatomic variant associated with pericallosal aneurysms, where both A1 segments form a single A2. After considering endovascular and open surgical techniques, we proceeded with clip ligation given her younger age, smoking history, daughter aneurysms seen on angiography, and azygos ACA. We positioned her supine with her head turned lateral, left side down to maximize gravitational retraction, mapped a bicoronal incision, and performed a small craniotomy, followed by an interhemispheric approach. Rather than cutting the falx around the dome, a described technique that risks blind vessel injury, we temporarily clipped inflow vessels to reduce the dome's turgor and sharply and bluntly dissected apart its attachments, which freed the aneurysm from beneath the falx and allowed visualization of associated vessels. Using suction to manipulate the dome, we then placed stacked, angled clips, and used a micro-Doppler to confirm brisk inflow and outflow. Postoperatively, she was neurologically intact, and her angiogram showed no residual aneurysm. Our 3-dimensional video demonstrates a safer, alternative approach to treating this rare aneurysm with its associated anatomical variant. Patient consented to her clinical presentation and microscope media being used for academic purposes.

Ethical and medicolegal aspects in the management of neurosurgical emergencies among Jehovah's Witnesses: Clinical implications and review.

When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness.

Outcomes and Spectrum of Major Neurovascular Events Among COVID-19 Patients: A 3-Center Experience.

BACKGROUND: Preliminary data suggest that Coronavirus Disease-2019 (COVID-19) is associated with hypercoagulability and neurovascular events, but data on outcomes is limited. OBJECTIVE: To report the clinical course and outcomes of a case series of COVID-19 patients with a variety of cerebrovascular events. METHODS: We performed a multicentric, retrospective chart review at our three academic tertiary care hospitals, and identified all COVID-19 patients with cerebrovascular events requiring neuro-intensive care and/or neurosurgical consultation. RESULTS: We identified 26 patients between March 1 and May 24, 2020, of whom 12 (46%) died. The most common event was a large-vessel occlusion (LVO) in 15 patients (58%), among whom 8 died (8/15, 53%). A total of 9 LVO patients underwent mechanical thrombectomy, of whom 5 died (5/9, 56%). A total of 7 patients (27%) presented with intracranial hemorrhage. Of the remaining patients, 2 had small-vessel occlusions, 1 had cerebral venous sinus thrombosis, and another had a vertebral artery dissection. Acute Respiratory Distress Syndrome occurred in 8 patients, of whom 7 died. Mortalities had a higher D-dimer on admission (mean 20 963 ng/mL) than survivors (mean 3172 ng/mL). Admission Glasgow Coma Scale (GCS) score was poor among mortalities (median 7), whereas survivors had a favorable GCS at presentation (median 14) and at discharge (median 14). CONCLUSION: COVID-19 may be associated with hemorrhage as well as ischemia, and prognosis appears poorer than expected-particularly among LVO cases, where outcome remained poor despite mechanical thrombectomy. However, a favorable neurological condition on admission and lower D-dimer may indicate a better outcome.

Return to the Emergency Room with or without Readmission After Endoscopic Transsphenoidal Surgery in Socioeconomically Disadvantaged Patients at an Urban Medical Center.

BACKGROUND: Although reducing 30-day hospital readmissions is now a priority in neurosurgical quality improvement, postoperative emergency room (ER) visits have remained poorly understood, in particular, in populations with limited access to outpatient care. After endoscopic transsphenoidal surgery, the unique pathologic entities treated can engender a variety of surgical and metabolic complications-often dangerous, delayed, and nonspecific in presentation. We sought to characterize the causes and timing of ER visits-with or without readmission-in a socioeconomically disadvantaged population. METHODS: We reviewed all the patients undergoing ETS by our skull base team from 2009 to 2017 to determine their socioeconomic profile and causes of ER visits. For external validation, we compared our results with national data from the American College of Surgeons National Surgical Quality Improvement Program. RESULTS: Of the 229 patients, 35 (15.3%) had visited the ER within 30 days of discharge. Of these 229 patients, 21 (9.2%) were readmitted, and 109 (47.6%) were insured by Medicaid. The most common reasons for the ER visits were headache (8 of 35 [22.9%]), hyponatremia (7 of 35 [20.0%]), and epistaxis (5 of 35 [14.3%]). The most common cause for readmission was symptomatic hyponatremia (6 of 21 [28.6%]). The other reasons for readmission included meningitis (2 of 21 [9.5%]), adrenal crisis (2 of 21 [9.5%]), and cerebrospinal fluid leakage (1 of 21 [4.8%]). The average time to readmission was 10.9 days. According to the National Surgical Quality Improvement Program database, the 30-day readmission rate was 5.5%, of which 22.2% were for hyponatremia. CONCLUSION: Delayed hyponatremia accounts for a large proportion of ER visits and unplanned readmissions. Close follow-up with diligent, multidisciplinary care might reduce the number of ER visits and readmission in this population.

Impact of Hyponatremia on Morbidity, Mortality, and Complications After Aneurysmal Subarachnoid Hemorrhage: A Systematic Review.

BACKGROUND: Hyponatremia is a common metabolic disturbance after aneurysmal subarachnoid hemorrhage (SAH), and it may worsen outcomes. This review aims to characterize the effect of hyponatremia on morbidity and mortality after SAH. OBJECTIVES: We sought to determine the prevalence of hyponatremia after SAH, including in subgroups, as well as its effect on mortality and certain outcome measures, including degree of disability and duration of hospitalization. METHODS: A search of terms "hyponatremia" and "subarachnoid hemorrhage" was performed on PubMed, the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, and EMBASE. Studies were included if they reported prevalence of hyponatremia and if they discussed outcomes such as mortality, duration of stay, functional outcomes (e.g., Glasgow Outcomes Scale), or incidence of complications in patients with aneurysmal SAH. Two independent researchers assessed the titles and abstracts and reviewed articles for inclusion. RESULTS: Thirteen studies met inclusion criteria. The prevalence of at least mild hyponatremia was 859 of 2387 (36%) of patients. Hyponatremia was associated with vasospasm and duration of hospitalization, but it did not influence mortality. CONCLUSION: Hyponatremia is common after SAH, and there is evidence that it is associated with certain poorer outcomes. Larger, prospective studies are needed to assess these findings and provide further evidence.

Assessment of the "July Effect": outcomes after early resident transition in adult neurosurgery.

OBJECT Each July, 4th-year medical students become 1st-year resident physicians and have much greater responsibility in making management decisions. In addition, incumbent residents and fellows advance to their next postgraduate year and face greater challenges. It has been suggested that among patients who have resident physicians as members of their neurosurgical team, this transition may be associated with increased rates of morbidity and mortality, a phenomenon known as the "July Effect." In this study, the authors compared morbidity and mortality rates between the initial and later months of the academic year to determine whether there is truly a July Effect that has an impact on this patient population. METHODS The authors compared 30-day postoperative outcomes of neurosurgery performed by surgical teams that included resident physicians in training during the first academic quarter (Q1, July through September) with outcomes of neurosurgery performed with resident participation during the final academic quarter (Q4, April through June), using 2006-2012 data from the prospectively collected American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database. Regression analyses were performed on outcome data that included mortality, surgical complications, and medical complications, which were graded as mild or severe. To determine whether a July Effect was present in subgroups, secondary analyses were performed to analyze the association of outcomes with each major neurosurgical subspecialty, the postgraduate year of the operating resident, and the academic quarter during which the surgery was performed. To control for possible seasonal trends in certain diseases, the authors compared patient outcomes at academic medical centers to those at community-based hospitals, where procedures were not performed by residents. In addition, the efficiency of academic centers was compared to that of community centers in terms of operative duration and total length of hospital stay. RESULTS Overall, there were no statistically significant differences in mortality, morbidity, or efficiency between the earlier and later quarters of the academic year, a finding that also held true among neurosurgical subspecialties and among postgraduate levels of training. There was, however, a slight increase in intraoperative transfusions associated with the transitional period in July (6.41% of procedures in Q4 compared to 7.99% in Q1 of the prior calendar year; p = 0.0005), which primarily occurred in cases involving junior (2nd- to 4th-year) residents. In addition, there was an increased rate of reoperation (1.73% in Q4 to 2.19% in Q1; p < 0.0001) observed mainly among senior (5th- to 7th-year) residents in the early academic months and not paralleled in our community cohort. CONCLUSIONS There is minimal evidence for a significant July Effect in adult neurosurgery. Our results suggest that, overall, the current resident training system provides enough guidance and support during this challenging transition period.

Association of Steroid Use with Deep Venous Thrombosis and Pulmonary Embolism in Neurosurgical Patients: A National Database Analysis.

OBJECTIVE: Venous thromboembolism (VTE) is a major preventable cause of morbidity and mortality in hospitalized patients and is a widely accepted measure for quality of care. Prolonged corticosteroid therapy, which is common in neurosurgical patients, has been associated with VTE. Using a national database, we sought to determine whether corticosteroid use for >10 days was an independent risk factor for deep venous thrombosis (DVT) and pulmonary embolism (PE). METHODS: The well-validated American College of Surgeons National Surgical Quality Improvement Program database was queried to evaluate the rates of VTE during the period 2006-2013 in patients undergoing neurosurgical procedures. A multivariate regression model was constructed to assess the effect of prolonged corticosteroid use on the occurrence of PE and DVT by postoperative day 30. RESULTS: Of 94,620 patients identified, 565 (0.60%) developed PE and 1057 (1.12%) developed DVT within 30 days after surgery. In the multivariate model, patients receiving corticosteroids were significantly more likely to have PE (odds ratio = 1.47, 95% confidence interval = 1.13-1.90, P = 0.004) and DVT (odds ratio = 1.55, 95% confidence interval = 1.28-1.87, P < 0.001). Other factors independently associated with development of PE and DVT included the presence of malignancy, longer hospitalization, certain infections (including pneumonia and urinary tract infections), and stroke with a neurologic deficit. CONCLUSIONS: In the neurosurgical population, prolonged courses of corticosteroids are associated with an increased risk of developing postoperative DVT and PE, even when controlling for potential confounders.

Causes and Timing of Unplanned Early Readmission After Neurosurgery.

BACKGROUND: Reducing the rate of 30-day hospital readmission has become a priority in healthcare quality improvement policy, with a focus on better characterizing the reasons for unplanned readmission. In neurosurgery, however, peer-reviewed analyses describing the patterns of readmission have been limited in their number and generalizability. OBJECTIVE: To determine the incidence, timing, and causes of 30-day readmission after neurosurgical procedures. METHODS: We conducted a retrospective longitudinal study from 2009 to 2012 using the Statewide Planning And Research Cooperative System, which collects patient-level details for all admissions and discharges within New York. We identified patients readmitted within 30 days of initial discharge. The rate of, reasons for, and time to readmission were determined overall and within 4 subgroups: craniotomies, cranial surgery without craniotomy, spine, and neuroendovascular procedures. RESULTS: There were 163 743 index admissions, of whom 14 791 (9.03%) were readmitted. The most common reasons for unplanned readmission were infection (29.52%) and medical complications (19.22%). Median time to readmission was 11 days, with hemorrhagic strokes and seizures occurring earlier, and medical complications and infections occurring later. Readmission rates were highest among patients undergoing cerebrospinal fluid shunt revision and malignant tumor resection (15.57%-22.60%). Spinal decompressions, however, accounted for the largest volume of readmissions (33.13%). CONCLUSION: Many readmissions may be preventable and occur at predictable time intervals. The causes and timing of readmission vary significantly across neurosurgical subgroups. Future studies should focus on detecting specific complications in select cohorts at predefined time points, which may allow for interventions to lower costs and reduce patient morbidity. ABBREVIATIONS: CSF, cerebrospinal fluidIQR, interquartile rangeSPARCS, Statewide Planning And Research Cooperative System.

Motion Sensors to Assess and Monitor Medical and Surgical Management of Parkinson Disease.

Patients with Parkinson disease (PD) often suffer from a resting tremor, bradykinesia, rigidity, postural instability, and gait difficulty. Determining a patient's candidacy for deep-brain stimulation (DBS) surgery and tracking their clinical response postoperatively requires that the frequency, duration, and severity of these symptoms be characterized in detail. Conventional means of assessing these symptoms, however, rely heavily on patient self-reporting, which often fails to provide the necessary level of detail. Wearable accelerometers are a novel tool that can detect and objectively characterize these movement abnormalities in both the clinical setting and the patient's home environment. In this article, we review the role of accelerometers in surgical candidate selection, recording and predicting falls, recording and predicting freezing of gait, evaluating surgical outcomes, and evaluating postoperative recovery and in altering DBS settings. Although accelerometry has yet to make it into the mainstream clinic, there is great promise for this technology in monitoring Parkinson patients.