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Background and purpose Aplastic or twig-like middle cerebral artery (MCA) is a rare vascular anomaly characterized by replacement of the M1 segment by a plexiform network of small vessels. Though rare, familiarity with this entity and ability to differentiate it from radiological mimics such as moyamoya changes and steno-occlusive diseases are important. We review the clinical and radiological manifestations of patients diagnosed with twig-like MCA on cerebral angiograms over a five-year period. Materials and methods Retrospective review of all patients diagnosed with twig-like MCA on cerebral angiograms was performed from January 2015 to January 2020. This was the inclusion criterion for this retrospective study. For each patient, demographic data, clinical presentation, imaging findings and management strategies were reviewed. Results and conclusions Between January 2015 and January 2020, three patients with twig-like MCA were identified from 657 patients who underwent four-vessel diagnostic cerebral angiograms (0.45%). In all three cases, the involvement was unilateral (two left-sided and one right- sided). Two patients were male, and one was female. Patients ages were 25, 26 and 46 years. Two of the three patients presented with headache and the third patient with pulsatile tinnitus. There were otherwise no ischemic or hemorrhagic changes. No other vascular anomaly was identified. Twig-like MCA is a rare anatomical variant in which a plexiform network of small vessels replaces the M1 segment of the MCA. Accurate diagnosis and distinguishing this entity from radiological mimics such as moyamoya and steno-occlusive diseases are important for appropriate management and to prevent unnecessary investigations.

Delayed cerebral ischemia (DCI) following aneurysmal subarachnoid hemorrhage continues to be associated with high levels of morbidity and mortality. This complication had long been thought to occur secondary to severe cerebral vasospasm, but expert opinion now favors a multi-factorial etiology, opening the possibility of new therapies. To date, no definitive treatment option for DCI has been recommended as standard of care, highlighting a need for further research into potential therapies. Milrinone has been identified as a promising therapeutic agent for DCI, possessing a mechanism of action for the reversal of cerebral vasospasm as well as potentially anti-inflammatory effects to treat the underlying etiology of DCI. Intra-arterial and intravenous administration of milrinone has been evaluated for the treatment of DCI in single center case series and cohorts and appears safe and associated with improved clinical outcomes. Recent results have also brought attention to the potential outcome benefits of early, more aggressive dosing and titration of milrinone. Limitations exist within the available data, however, and questions remain about the generalizability of results across a broader spectrum of patients suffering from DCI. The development of a standardized protocol for milrinone use in DCI, specifically addressing areas requiring further clarification, is needed. Data generated from a standardized protocol may provide the impetus for a multi-center, randomized control trial. We review the current literature on milrinone for the treatment of DCI and propose a preliminary standardized protocol for further evaluation of both safety and efficacy of milrinone.

Background Although microvascular decompression (MVD) is a durable treatment for medically refractory trigeminal neuralgia, hemifacial spasm, or glossopharyngeal neuralgia attributable to neurovascular conflict, few national studies have analyzed predictors of postoperative complications. Objective To determine the incidence and risk factors for adverse events after MVD. Methods Patients who underwent MVD were extracted from the prospectively collected National Surgical Quality Improvement Program registry (2006–2017). Multivariable logistic regression identified predictors of 30-day adverse events and unplanned readmission; multivariable linear regression analyzed predictors of a longer hospital stay. Results Among the 1005 patients evaluated, the mortality was 0.3%, major neurologic complication rate 0.4%, and 2.8% had a nonroutine hospital discharge. Patient age was not a predictor of any adverse events. Statistically significant independent predictors both of any adverse event (9.2%) and of a longer hospitalization were American Society of Anesthesiologists (ASA) classification III–IV designation and longer operative duration (P ≤ 0.03) The 30-day readmission rate was 6.8%, and the most common reasons were surgical site infections (22.4%) and cerebrospinal fluid leakage (14.3%). Higher ASA classification, diabetes mellitus, and operative time were predictors of readmission (P Conclusions In this National Surgical Quality Improvement Program analysis, postoperative morbidity and mortality after MVD was low. Patient age was not a predictor of postoperative complications, whereas higher ASA classification, diabetes mellitus, and longer operative duration were predictive of any adverse event and readmission. ASA classification provided superior risk stratification compared with the total number of patient comorbidities or laboratory values. These data can assist with preoperative patient counseling and risk stratification.

OBJECTIVESThe goal of this study was to evaluate clinical predictors of abnormal preoperative laboratory values in pediatric neurosurgical patients.METHODSData obtained in children who underwent a neurosurgical operation were extracted from the prospective National Surgical Quality Improvement Program–Pediatrics (NSQIP-P, 2012–2013) registry. Multivariable logistic regression evaluated predictors of preoperative laboratory values that might require further evaluation (white blood cell count < 2000/μl, hematocrit < 24%, platelet count < 100,000/μl, international normalized ratio > 1.4, or partial thromboplastin time > 45 seconds) or a preoperative transfusion (within 48 hours prior to surgery). Variables screened included patient demographics; American Society of Anesthesiologists (ASA) physical designation classification; comorbidities; recent steroid use, chemotherapy, or radiation therapy; and admission type. Predictive score validation was performed using the NSQIP-P 2014 data.RESULTSOf the 6556 patients aged greater than 2 years, 68.9% (n = 5089) underwent laboratory testing, but only 1.9% (n = 125) had a critical laboratory value. Predictors of a laboratory abnormality were ASA class III–V; diabetes mellitus; hematological, hypothrombotic, or oncological comorbidities; nutritional support; recent chemotherapy; systemic inflammatory response syndrome; and a nonelective hospital admission. These 9 variables were used to create a predictive score, with a single point assigned for each predictor. The prevalence of critical values in the validation population (NSQIP-P 2014) of patients greater than 2 years of age was 0.3% with a score of 0, 1.0% in those with a score of 1, 1.6% in those with a score of 2, and 6.2% in those with a score ≥ 3. Higher score was predictive of a critical value (OR 2.33, 95% CI 1.91–2.83, p < 0.001, C-statistic 0.76) and with the requirement of a perioperative transfusion (intraoperatively or within 72 hours postoperatively; OR 1.42, 95% CI 1.22–1.67, p < 0.001) in the validation population. Moreover, when the same score was applied to children aged 2 years or younger, a greater score was predictive of a critical value (OR 2.47, 95% CI 2.15–2.84, p < 0.001, C-statistic 0.76).CONCLUSIONSCritical laboratory values in pediatric neurosurgical patients are largely predicted by clinical characteristics, and abnormal preoperative laboratory results are rare in patients older than 2 years of age without comorbidities who are undergoing elective surgery. The NSQIP-P critical preoperative laboratory value scale is proposed to indicate patients with the highest odds of an abnormal value. The scale can assist with triaging preoperative testing based on the surgical risk, as determined by the treating surgeon and anesthesiologist.

Background Perioperative cerebral infarction is a potential complication of glioma resection, of which insular tumors are at higher risk because of the proximity of middle cerebral artery branches, including the lateral lenticulostriates and long insular arteries. In this study, 3 patients received three-dimensional rotational angiography, which was fused with magnetic resonance imaging (MRI) for frameless stereotactic navigation during dominant-hemisphere insular glioma resection. Methods All patients obtained a preoperative catheter angiogram with a three-dimensional rotational acquisition of the ipsilateral internal carotid artery. The pixel-based axial three-dimensional angiography data, thin-cut structural MRI, tractography from diffusion tensor imaging, and expressive language activation from functional MRI were uploaded into the iPlan software (Brainlab, Heimstetten, Germany) and fused. The target tumor, regional blood vessels, adjacent functional areas, and their associated fiber tracts were segmented and overlaid on the appropriate MRI sequence. This image fusion was used preoperatively to visualize the relationship of the mass with the adjacent vasculature and intraoperatively for frameless stereotactic navigation to optimize preservation of arterial structures. Results Three patients aged 27–60 years with excellent baseline functional status presented with seizures and were found to have a large dominant-hemisphere T2 hyperintense nonenhancing insular mass. Surgical resection was performed using multimodality neuronavigation. None sustained a postoperative arterial infarction or a perioperative neurologic deficit. Conclusions Neuronavigation using a fusion of three-dimensional rotational angiography with MRI is a technique that can be used for preoperative planning and during resection of insular gliomas to optimize preservation of adjacent arteries.

Objective Variance between providers in neurosurgery can lead to inefficiencies and poor patient outcomes. Evidence-based guidelines (EBGs) have been developed; however, they have not been well implemented into the clinician workflow. Therefore, clinicians have been left to make decisions with incomplete information. Equally underused are the electronic health records (EHRs), which house enormous amounts of health data, but the power of that “big data” has failed to be capitalized on. Methods Early attempts at EBGs were rigid and nonadaptive; however, with the current advances in data informatics and machine learning algorithms, it is now possible to integrate “big data” and rapid data processing into clinical decision support tools. We have presented an overview of the background of EHRs and EBGs in neurosurgery and explored the possibility of integrating them to reduce unwanted variance. Results As we strive toward variance reduction in healthcare, the integration of “big data” and EBGs for decision-making will be key. We have proposed that EHRs are an ideal platform for integrating EBGs into the clinician workflow and have presented as an example of a successful early generation model, Neurocore. With this approach, it will be possible to build EBGs into the EHR software, to continuously update and optimize EBGs according to the flow of patient data into the EHR, and to present data-driven clinical decision support at the point of care. Conclusions Variance reduction in neurosurgery through the integration of evidence-based decision support in EHRs will lead to improved patient safety, a reduction in medical errors, maximization of the use of the available data, and enhanced decision-making power for clinicians.

BackgroundDuring the COVID-19 pandemic, decreased volumes of stroke admissions and mechanical thrombectomy were reported. The study’s objective was to examine whether subarachnoid haemorrhage (SAH) hospitalisations and ruptured aneurysm coiling interventions demonstrated similar declines.MethodsWe conducted a cross-sectional, retrospective, observational study across 6 continents, 37 countries and 140 comprehensive stroke centres. Patients with the diagnosis of SAH, aneurysmal SAH, ruptured aneurysm coiling interventions and COVID-19 were identified by prospective aneurysm databases or by International Classification of Diseases, 10th Revision, codes. The 3-month cumulative volume, monthly volumes for SAH hospitalisations and ruptured aneurysm coiling procedures were compared for the period before (1 year and immediately before) and during the pandemic, defined as 1 March–31 May 2020. The prior 1-year control period (1 March–31 May 2019) was obtained to account for seasonal variation.FindingsThere was a significant decline in SAH hospitalisations, with 2044 admissions in the 3 months immediately before and 1585 admissions during the pandemic, representing a relative decline of 22.5% (95% CI −24.3% to −20.7%, pInterpretationThere was a relative decrease in the volume of SAH hospitalisations, aneurysmal SAH hospitalisations and ruptured aneurysm embolisations during the COVID-19 pandemic. These findings in SAH are consistent with a decrease in other emergencies, such as stroke and myocardial infarction.

Introduction Early studies suggest that acute cerebrovascular events may be common in patients with coronavirus disease 2019 (COVID-19) and may be associated with a high mortality rate. Most cerebrovascular events described have been ischemic strokes, but both intracerebral hemorrhage and rarely cerebral venous sinus thrombosis (CVST) have also been reported. The diagnosis of CVST can be elusive, with wide-ranging and nonspecific presenting symptoms that can include headache or altered sensorium alone. Objective To describe the presentation, barriers to diagnosis, treatment, and outcome of CVST in patients with COVID-19. Methods We abstracted data on all patients diagnosed with CVST and COVID-19 from March 1 to August 9, 2020 at Boston Medical Center. Subsequently, we reviewed the literature and extracted all published cases of CVST in patients with COVID-19 from January 1, 2020 through August 9, 2020 and included all studies with case descriptions. Results We describe the clinical features and management of CVST in 3 women with COVID-19 who developed CVST days to months after initial COVID-19 symptoms. Two patients presented with encephalopathy and without focal neurologic deficits, while one presented with visual symptoms. All patients were treated with intravenous hydration and anticoagulation. None suffered hemorrhagic complications, and all were discharged home. We identified 12 other patients with CVST in the setting of COVID-19 via literature search. There was a female predominance (54.5%), most patients presented with altered sensorium (54.5%), and there was a high mortality rate (36.4%). Conclusions During this pandemic, clinicians should maintain a high index of suspicion for CVST in patients with a recent history of COVID-19 presenting with non-specific neurological symptoms such as headache to provide expedient management and prevent complications. The limited data suggests that CVST in COVID-19 is more prevalent in females and may be associated with high mortality.

BACKGROUND Transitional care programs (TCPs) coordinate care to improve safety and efficiency surrounding hospital discharge. While TCPs have the potential to reduce hospital length of stay and readmissions, their financial implications are less well understood. OBJECTIVE To perform a cost-benefit analysis of a previously published neurosurgical TCP implemented at an urban academic hospital from 2013 to 2015. METHODS Patients received intensive preoperative education and framing of expectations for hospitalization, in-hospital discharge planning and medication reconciliation with a nurse educator, and a follow-up phone call postdischarge. The cost-benefit analysis involved program costs (nurse educator salary) and total direct hospital costs within the 30-d perioperative window including readmission costs. RESULTS The average cost of the TCP was $435 per patient. The TCP was associated with an average total cost reduction of 17.2% (95% confidence interval [CI]: 7.3%-26.7%, P = .001). This decrease was driven by a 14.3% reduction in the average initial admission cost (95% CI: 6.2%-23.7%, P = .001), largely attributable to the 16.3% decrease in length of stay (95% CI: 9.93%-23.49%, P

OBJECTIVEReadmissions increasingly serve as a metric of hospital performance, inviting quality improvement initiatives in both medicine and surgery. However, few readmission reduction programs have targeted surgical patient populations. The objective of this study was to establish a transitional care program (TCP) with the goal of decreasing length of stay (LOS), improving discharge efficiency, and reducing readmissions of neurosurgical patients by optimizing patient education and postdischarge surveillance.METHODSPatients undergoing elective cranial or spinal neurosurgery performed by one of 5 participating surgeons at a quaternary care hospital were enrolled into a multifaceted intervention. A preadmission overview and establishment of an anticipated discharge date were both intended to set patient expectations for a shorter hospitalization. At discharge, in-hospital prescription filling was provided to facilitate medication compliance. Extended discharge appointments with a neurosurgery TCP-trained nurse emphasized postoperative activity, medications, incisional care, nutrition, signs that merit return to medical attention, and follow-up appointments. Finally, patients received a surveillance phone call 48 hours after discharge. Eligible patients omitted due to staff limitations were selected as controls. Patients were matched by sex, age, and operation type—key confounding variables—with control patients, who were eligible patients treated at the same time period but not enrolled in the TCP due to staff limitation. Multivariable logistic regression evaluated the association of TCP enrollment with discharge time and readmission, and linear regression with LOS. Covariates included matching criteria and Charlson Comorbidity Index scores.RESULTSBetween 2013 and 2015, 416 patients were enrolled in the program and matched to a control. The median patient age was 55 years (interquartile range 44.5–65 years); 58.4% were male. The majority of enrolled patients underwent spine surgery (59.4%, compared with 40.6% undergoing cranial surgery). Hospitalizations averaged 62.1 hours for TCP patients versus 79.6 hours for controls (a 16.40% reduction, 95% CI 9.30%–23.49%; p < 0.001). The intervention was associated with a higher proportion of morning discharges, which was intended to free beds for afternoon admissions and improve patient flow (OR 3.13, 95% CI 2.27–4.30; p < 0.001), and decreased 30-day readmissions (2.5% vs 5.8%; OR 2.43, 95% CI 1.14–5.27; p = 0.02).CONCLUSIONSThis neurosurgical TCP was associated with a significantly shorter LOS, earlier discharge, and reduced 30-day readmission after elective neurosurgery. These results underscore the importance of patient education and surveillance after hospital discharge.

Of adolescents in the United States, 20% have obesity and current treatment options prioritize intensive lifestyle interventions that are largely ineffective. Bariatric surgery is increasingly being offered to obese adolescent patients; however, large-scale effectiveness data is lacking. We used MEDLINE, Embase, and Cochrane databases, and a manual search of references to conduct a systematic review and meta-analysis on overall weight loss after gastric band, gastric sleeve, and gastric bypass in obese adolescent patients (age ≤19) and young adults (age ≤21) in separate analyses. We provided estimates of absolute change in body mass index (BMI, kg/m2) and percent excess weight loss across 4 postoperative time points (6, 12, 24, and 36 mo) for each surgical subgroup. Study quality was assessed using a 10 category scoring system. Data were extracted from 24 studies with 4 having multiple surgical subgroups (1 with 3, and 3 with 2 subgroups), totaling 29 surgical subgroup populations (gastric band: 16, gastric sleeve: 5, gastric bypass: 8), and 1928 patients (gastric band: 1010, gastric sleeve: 139, gastric bypass: 779). Mean preoperative BMI (kg/m2) was 45.5 (95% confidence interval [CI]: 44.7, 46.3) in gastric band, 48.8 (95%CI: 44.9, 52.8) in gastric sleeve, and 53.3 (95%CI: 50.2, 56.4) in gastric bypass patients. The short-term weight loss, measured as mean (95%CI) absolute change in BMI (kg/m2) at 6 months, was -5.4 (-3.0, -7.8) after gastric band, -11.5 (-8.8, -14.2) after gastric sleeve, and -18.8 (-10.9, -26.6) after gastric bypass. Weight loss at 36 months, measured as mean (95%CI) absolute change in BMI (kg/m2) was -10.3 (-7.0, -13.7) after gastric band, -13.0 (-11.0, -15.0) after gastric sleeve, and -15.0 (-13.5, -16.5) after gastric bypass. Bariatric surgery in obese adolescent patients is effective in achieving short-term and sustained weight loss at 36 months; however, long-term data remains necessary to better understand its long-term efficacy.

Background Open microsurgical clipping of unruptured intracranial aneurysms has long been the gold standard, yet advancements in endovascular coiling techniques have begun to challenge the status quo. Objective To compare endovascular coiling with microsurgical clipping among adults with unruptured middle cerebral artery aneurysms (MCAA) by conducting a meta-analysis. Methods A systematic search was conducted from January 2011 to October 2015 to update a previous meta-analysis. All studies that reported unruptured MCAA in adults treated by microsurgical clipping or endovascular coiling were included and cumulatively analyzed. Results Thirty-seven studies including 3352 patients were included. Using the random-effects model, pooled analysis of 11 studies of microsurgical clipping (626 aneurysms) revealed complete aneurysmal obliteration in 94.2% of cases (95% confidence interval [CI] 87.6%-97.4%). The analysis of 18 studies of endovascular coiling (759 aneurysms) revealed complete obliteration in 53.2% of cases (95% CI: 45.0%-61.1%). Among clipping studies, 22 assessed neurological outcomes (2404 aneurysms), with favorable outcomes in 97.9% (95% CI: 96.8%-98.6%). Among coiling studies, 22 examined neurological outcomes (826 aneurysms), with favorable outcomes in 95.1% (95% CI: 93.1%-96.5%). Results using the fixed-effect models were not materially different. Conclusion This updated meta-analysis demonstrates that surgical clipping for unruptured MCAA remains highly safe and efficacious. Endovascular treatment for unruptured MCAAs continues to improve in efficacy and safety; yet, it results in lower rates of occlusion.

Background and objectives RCVS (Reversible Cerebral Vasoconstrictive Syndrome) is a condition associated with vasoactive agents that alter endothelial function. There is growing evidence that endothelial inflammation contributes to cerebrovascular disease in patients with coronavirus disease 2019 (COVID-19). In our study, we describe the clinical features, risk factors, and outcomes of RCVS in a multicenter case series of patients with COVID-19. Materials and methods Multicenter retrospective case series. We collected clinical characteristics, imaging, and outcomes of patients with RCVS and COVID-19 identified at each participating site. Results Ten patients were identified, 7 women, ages 21 – 62 years. Risk factors included use of vasoconstrictive agents in 7 and history of migraine in 2. Presenting symptoms included thunderclap headache in 5 patients with recurrent headaches in 4. Eight were hypertensive on arrival to the hospital. Symptoms of COVID-19 included fever in 2, respiratory symptoms in 8, and gastrointestinal symptoms in 1. One patient did not have systemic COVID-19 symptoms. MRI showed subarachnoid hemorrhage in 3 cases, intraparenchymal hemorrhage in 2, acute ischemic stroke in 4, FLAIR hyperintensities in 2, and no abnormalities in 1 case. Neurovascular imaging showed focal segment irregularity and narrowing concerning for vasospasm of the left MCA in 4 cases and diffuse, multifocal narrowing of the intracranial vasculature in 6 cases. Outcomes varied, with 2 deaths, 2 remaining in the ICU, and 6 surviving to discharge with modified Rankin scale (mRS) scores of 0 (n=3), 2 (n=2), and 3 (n=1). Conclusions Our series suggests that patients with COVID-19 may be at risk for RCVS, particularly in the setting of additional risk factors such as exposure to vasoactive agents. There was variability in the symptoms and severity of COVID-19, clinical characteristics, abnormalities on imaging, and mRS scores. However, a larger study is needed to validate a causal relationship between RCVS and COVID-19.

BACKGROUND Reoperation has been increasingly utilized as a metric evaluating quality of care. OBJECTIVE To evaluate the rate of, reasons for, and predictors of unplanned reoperation after craniotomy for tumor in a nationally accrued population. METHODS Patients who underwent cranial tumor resection were extracted from the prospective National Surgical Quality Improvement Program registry (2012-2014). Multivariate logistic regression examined predictors of unplanned cranial reoperation. Predictors screened included patient age, sex, tumor location and histology, functional status, comorbidities, preoperative laboratory values, operative urgency, and time. RESULTS Of the 11 462 patients included, 3.1% (n = 350) underwent an unplanned cranial reoperation. The most common reasons for cranial reoperation were intracranial hematoma evacuation (22.5%), superficial or intracranial surgical site infections (11.9%), re-resection of tumor (8.4%), decompressive craniectomy (6.1%), and repair of cerebrospinal fluid leakage (5.6%). The strongest predictor of any cranial reoperation was preoperative thrombocytopenia (less than 100 000/μL, odds ratio [OR] = 2.51, 95% confidence interval [CI]: 1.23-5.10, P = .01). Thrombocytopenia, hypertension, emergent surgery, and longer operative time were predictors of reoperation for hematoma (P ≤ .004), while dependent functional status, morbid obesity, leukocytosis, and longer operative time were predictors of reoperation for infection (P < .05). Although any unplanned cranial reoperation was not associated with differential odds of mortality (OR = 1.68, 95% CI: 0.94-3.00, P = .08), hematoma evacuation was significantly associated with thirty-day death (P = .04). CONCLUSION In this national analysis, unplanned cranial reoperation was primarily associated with operative indices, rather than preoperative characteristics, suggesting that reoperation may have some utility as a quality indicator. However, hypertension and thrombocytopenia were potentially modifiable predictors of reoperation.

OBJECTIVEMedically refractory spasticity and dystonia are often alleviated with intrathecal baclofen (ITB) administration through an indwelling catheter inserted in the lumbar spine. In patients with cerebral palsy, however, there is a high incidence of concomitant neuromuscular scoliosis. ITB placement may be technically challenging in those who have severe spinal deformity or who have undergone prior instrumented thoracolumbar fusion. Although prior reports have described drilling through the lumbar fusion mass with a high-speed bur, as well as IT catheter implantation at the foramen magnum or cervical spine, these approaches have notable limitations. To the authors' knowledge, this is the first report of ITB placement using cone beam CT (CBCT) image guidance to facilitate percutaneous IT catheterization.METHODSData were prospectively collected on patients treated between November 2012 and June 2014. In the interventional radiology suite, general anesthesia was induced and the patient was positioned prone. Imaging was performed to identify the optimal trajectory. Percutaneous puncture was performed at an entry site with image-guided placement of a sheathed needle. CBCT provided real-time 2D projections and 3D reconstructions for detailed volumetric imaging. A biopsy drill was passed through the sheath, and subsequently a Tuohy needle was advanced intrathecally. The catheter was threaded cephalad under fluoroscopic visualization. After tip localization and CSF flow were confirmed, the stylet was replaced, the external catheter tubing was wrapped sterilely in a dressing, and the patient was transported to the operating room. After lateral decubitus positioning of the patient, the IT catheter was exposed and connected to the distal abdominal tubing with typical pump placement.RESULTSOf 15 patients with Gross Motor Function Classification System Levels IV and V cerebral palsy and instrumented thoracolumbar fusion, 8 had predominantly spasticity, and 7 had mixed spasticity and dystonia. The mean age of patients was 20.1 years (range 13–27 years). Nine patients underwent initial catheter and pump placement, and 6 underwent catheter replacement. The procedure was technically successful, with accurate spinal catheter placement in all patients. The median hospital stay was 4 days (IQR 3–5 days). One patient had an early postoperative urinary tract infection. With a mean follow-up of 25.8 months (median 26, range 18–38 months), no CSF leakage or catheter failure occurred. One late infection due to Pseudomonas aeruginosa (requiring pump explantation) occurred at 4 months, probably secondary to recurrent urinary tract infections.CONCLUSIONSImage-guided CBCT navigation resulted in accurate percutaneous placement of the IT catheter for ITB pumps in patients with prior instrumented thoracolumbar fusion. The multimodality approach is an alternate technique that may be used for IT catheter insertion in patients with complex lumbar spine anatomy, extending the potential to provide safe, durable ITB therapy in this population.

Background and Purpose— Previous clinical trials were not designed to discern the optimal timing of decompressive craniectomy for stroke, and the ideal surgical timing in patients with space-occupying infarction who do not exhibit deterioration within 48 hours is debated. Methods— Patients undergoing decompressive craniectomy for stroke were extracted from the Nationwide Inpatient Sample (2002–2011). Multivariable logistic regression evaluated the association of surgical timing with mortality, discharge to institutional care, and poor outcome (a composite end point including death, tracheostomy and gastrostomy, or discharge to institutional care). Covariates included patient demographics, comorbidities, year of admission, and hospital characteristics. However, standard stroke severity scales and infarct volume were not available. Results— Among 1301 admissions, 55.8% (n=726) underwent surgery within 48 hours. Teaching hospital admission was associated with earlier surgery ( P =0.02). The timing of intervention was not associated with in-hospital mortality. However, when evaluated continuously, later surgery was associated with increased odds of discharge to institutional care (odds ratio, 1.17; 95% confidence interval, 1.05–1.31, P =0.005) and of a poor outcome (odds ratio, 1.12; 95% confidence interval, 1.02–1.23; P =0.02). When evaluated dichotomously, the odds of discharge to institutional care and of a poor outcome did not differ at 48 hours after hospital admission, but increased when surgery was pursued after 72 hours. Subgroup analyses found no association of surgical timing with outcomes among patients who had not sustained herniation. Conclusion s—In this nationwide analysis, early decompressive craniectomy was associated with superior outcomes. However, performing decompression before herniation may be the most important temporal consideration.

OBJECTIVE Although there is a growing body of research highlighting the negative impact of obesity and malnutrition on surgical outcomes, few studies have evaluated these parameters in patients undergoing intracranial surgery. The goal of this study was to use a national registry to evaluate the association of body mass index (BMI) and hypoalbuminemia with 30-day outcomes after craniotomy for tumor. METHODS Adult patients who underwent craniotomy for tumor were extracted from the prospective National Surgical Quality Improvement Program registry. Patients were stratified by body habitus according to the WHO classification, as well as by preoperative hypoalbuminemia (< 3.5 g/dl). Multivariable logistic regression evaluated the association of body habitus and hypoalbuminemia with 30-day mortality, complications, and discharge disposition. Covariates included patient age, sex, race or ethnicity, tumor histology, American Society of Anesthesiology class, preoperative functional status, comorbidities (including hypertension and diabetes mellitus), and additional preoperative laboratory values. RESULTS Among the 11,510 patients included, 28.7% were classified as normal weight (BMI 18.5–24.9 kg/m2), 1.9% as underweight (BMI < 18.5 kg/m2), 33.4% as overweight (BMI 25.0–29.9 kg/m2), 19.1% as Class I obese (BMI 30.0–34.9 kg/m2), 8.3% as Class II obese (BMI 35.0–39.9 kg/m2), 5.5% as Class III obese (BMI ≥ 40.0 kg/m2), and 3.1% had missing BMI data. In multivariable regression models, body habitus was not associated with differential odds of mortality, postoperative stroke or coma, or a nonroutine hospital discharge. However, the adjusted odds of a major complication were significantly higher for Class I obese (OR 1.28, 99% CI 1.01–1.62; p = 0.008), Class II obese (OR 1.53, 99% CI 1.13–2.07; p < 0.001), and Class III obese (OR 1.67, 99% CI 1.19–2.36; p < 0.001) patients compared with those of normal weight; a dose-dependent effect was seen, with increased effect size with greater adiposity. The higher odds of major complications was primarily due to significantly increased odds of a venous thromboembolism in overweight and obese patients, as well as of a surgical site infection in those with Class II or III obesity. Additionally, 41.0% of patients had an albumin level ≥ 3.5 g/dl, 9.6% had hypoalbuminemia, and 49.4% had a missing albumin value. Hypoalbuminemia was associated with significantly higher odds of mortality (OR 1.91, 95% CI 1.41–2.60; p < 0.001) or a nonroutine hospital discharge (OR 1.46, 95% CI 1.21–1.76; p < 0.001). CONCLUSIONS In this National Surgical Quality Improvement Program analysis evaluating patients who underwent craniotomy for tumor, body habitus was not associated with differential mortality or neurological complications. However, obese patients had increased odds of a major perioperative complication, primarily due to higher rates of venous thromboembolic events and surgical site infections. Preoperative hypoalbuminemia was associated with increased odds of mortality and a nonroutine hospital discharge, suggesting that serum albumin may have utility in stratifying risk preoperatively in patients undergoing craniotomy.

BACKGROUND Although readmission has become a common quality indicator, few national studies have examined this metric in patients undergoing cranial surgery. OBJECTIVE To utilize the prospective National Surgical Quality Improvement Program 2011-2013 registry to evaluate the predictors of unplanned 30-d readmission and postdischarge mortality after cranial tumor resection. METHODS Multivariable logistic regression was applied to screen predictors, which included patient age, sex, tumor location and histology, American Society of Anesthesiologists class, functional status, comorbidities, and complications from the index hospitalization. RESULTS Of the 9565 patients included, 10.7% (n = 1026) had an unplanned readmission. Independent predictors of unplanned readmission were male sex, infratentorial location, American Society of Anesthesiologists class 3 designation, dependent functional status, a bleeding disorder, and morbid obesity (all P ≤ .03). Readmission was not associated with operative time, length of hospitalization, discharge disposition, or complications from the index admission. The most common reasons for readmission were surgical site infections (17.0%), infectious complications (11.0%), venous thromboembolism (10.0%), and seizures (9.4%). The 30-d mortality rate was 3.2% (n = 367), of which the majority (69.7%, n = 223) occurred postdischarge. Independent predictors of postdischarge mortality were greater age, metastatic histology, dependent functional status, hypertension, discharge to institutional care, and postdischarge neurological or cardiopulmonary complications (all P < .05). CONCLUSION Readmissions were common after cranial tumor resection and often attributable to new postdischarge complications rather than exacerbations of complications from the initial hospitalization. Moreover, the majority of 30-d deaths occurred after discharge from the index hospitalization. The preponderance of postdischarge mortality and complications requiring readmission highlights the importance of posthospitalization management.

Background The goal of this study was to create a comprehensive, integer‐weighted predictive scale of adverse events after carotid endarterectomy ( CEA ), which may augment risk stratification and patient counseling. Methods and Results The targeted carotid files from the prospective NSQIP (National Surgical Quality Improvement Program) registry (2011–2013) comprised the derivation population. Multivariable logistic regression evaluated predictors of a 30‐day adverse event (stroke, myocardial infarction, or death), the effect estimates of which were used to build a weighted predictive scale that was validated using the 2014 to 2015 NSQIP registry release. A total of 10 766 and 8002 patients were included in the derivation and the validation populations, in whom 4.0% and 3.7% developed an adverse event, respectively. The NSQIP registry CEA scale included 14 variables; the highest points were allocated for insulin‐dependent diabetes mellitus, high‐risk cardiac physiological characteristics, admission source other than home, an emergent operation, American Society of Anesthesiologists’ classification IV to V, modified Rankin Scale score ≥2, and presentation with a stroke. NSQIP registry CEA score was predictive of an adverse event (concordance=0.67), stroke or death (concordance=0.69), mortality (concordance=0.76), an extended hospitalization (concordance=0.73), and a nonroutine discharge (concordance=0.83) in the validation population, as well as among symptomatic and asymptomatic subgroups ( P NSQIP registry CEA scale score >8 and 17 had 30‐day stroke or death rates >3% and 6%, the recommended thresholds for asymptomatic and symptomatic patients, respectively. Conclusions The NSQIP registry CEA scale predicts adverse outcomes after CEA and can risk stratify patients with both symptomatic and asymptomatic carotid stenosis using different thresholds for each population.

Malignant cerebral edema is a potential consequence of large territory cerebral infarction, as the resultant elevation in intracranial pressure may progress to transtentorial herniation, brainstem compression, and death. In appropriate patients, decompressive hemicraniectomy (DHC) reduces mortality without increasing the risk of severe disability. However, as the foundational DHC randomized, controlled trials excluded patients greater than 60 years of age, the appropriateness of DHC in older adults remains controversial. Recent clinical trials among elderly participants, including DESTINY II, reported that DHC reduces mortality, but may leave patients with substantial morbidity. Nationwide analyses have demonstrated generalizability of such data. However, what constitutes an acceptable outcome - the perspective on quality of life after survival with substantial disability - varies between clinicians, patients, and caregivers. Consequently, quality of life measures are being increasingly incorporated into stroke research. This review summarizes the impact of DHC in space-occupying cerebral infarction, and the influence of patient age on postoperative survival, functional capacity, and quality of life-all key factors in the clinical decision process. Ultimately, these data underscore the inherent complexity in balancing scientific evidence, clinical expertise, and patient and family preference when pursuing hemicraniectomy among the elderly.

OBJECTIVEThe primary goal of the treatment of cerebral arteriovenous malformations (AVMs) is angiographic occlusion to eliminate future hemorrhage risk. Although multimodal treatment is increasingly used for AVMs, periprocedural hemorrhage after transarterial embolization is a potential endovascular complication that is only partially understood and merits quantification.METHODSSearching the period between 1990 and 2019, the authors of this meta-analysis queried the PubMed and Embase databases for studies reporting periprocedural hemorrhage (within 30 days) after liquid embolization (using cyanoacrylate or ethylene vinyl alcohol copolymer) of AVMs. Random effects meta-analysis was used to evaluate the pooled rate of flow-related hemorrhage (those attributed to alterations in AVM dynamics), technical hemorrhage (those related to procedural complications), and total hemorrhage. Meta-regression was used to analyze the study-level predictors of hemorrhage, including patient age, Spetzler-Martin grade, hemorrhagic presentation, embolysate used, intent of treatment (adjuvant vs curative), associated aneurysms, endovascular angiographic obliteration, year of study publication, and years the procedures were performed.RESULTSA total of 98 studies with 8009 patients were included in this analysis, and the mean number of embolization sessions per patient was 1.9. The pooled flow-related and total periprocedural hemorrhage rates were 2.0% (95% CI 1.5%–2.4%) and 2.6% (95% CI 2.1%–3.0%) per procedure and 3.4% (95% CI 2.6%–4.2%) and 4.8% (95% CI 4.0%–5.6%) per patient, respectively. The mortality and morbidity rates associated with hemorrhage were 14.6% and 45.1%, respectively. Subgroup analyses revealed a pooled total hemorrhage rate per procedure of 1.8% (95% CI 1.0%–2.5%) for adjuvant (surgery or radiosurgery) and 4.6% (95% CI 2.8%–6.4%) for curative intent. The treatment of aneurysms (p = 0.04) and larger patient populations (p < 0.001) were significant predictors of a lower hemorrhage rate, whereas curative intent (p = 0.04), angiographic obliteration achieved endovascularly (p = 0.003), and a greater number of embolization sessions (p = 0.03) were significant predictors of a higher hemorrhage rate. There were no significant differences in periprocedural hemorrhage rates according to the years evaluated or the embolysate utilized.CONCLUSIONSIn this study-level meta-analysis, periprocedural hemorrhage was seen after 2.6% of transarterial embolization procedures for cerebral AVMs. The adjuvant use of endovascular embolization, including in the treatment of associated aneurysms and in the presurgical or preradiosurgical setting, was a study-level predictor of significantly lower hemorrhage rates, whereas more aggressive embolization involving curative intent and endovascular angiographic obliteration was a predictor of a significantly higher total hemorrhage rate.

Decompressive hemicraniectomy (DHC) for space-occupying cerebral infarction in older adults remains controversial, and there are limited nationwide data evaluating the outcomes after craniectomy for stroke by patient age. Patients who underwent DHC for ischemic stroke were extracted from the Nationwide Inpatient Sample (2002–2011). Multivariable logistic regression examined in-hospital mortality and a poor outcome (death, tracheostomy and gastrostomy, or discharge to institutional care). Covariates included year of admission, comorbidities, severity indices, and treatment variables (including the timing of decompression). Craniectomy was performed in 1673 patients: 62.4 % were aged 18–60 years, 20.6 % aged 61–70 years, and 17.0 % aged greater than 70 years. DHC was associated with reduced adjusted odds of in-hospital death compared with medical treatment alone among patients with cerebral edema in all age categories, including those older than 70 years (p ≤ 0.008). However, among surgical patients, the adjusted odds of mortality were significantly greater for patients aged 61–70 (30.7 %, p = 0.02) and greater than 70 years (34.5 %, p = 0.02), but not different for patients aged 51–60 (22.8 %), compared to those aged 18–50 years (19.7 %). The adjusted odds of a poor outcome also increased significantly with age, particularly for patients greater than 60 years. In this nationwide analysis, DHC was associated with reduced mortality regardless of patient age, including among those aged greater than 70 years. However, patients aged greater than 60 years treated surgically experienced higher odds of mortality (32.4 %), discharge to institutional care (47.1 %), and a poor outcome (77.0 %) compared with younger patients.

Objective In early-generation hybrid biplane endovascular operating rooms, switching from surgical to angiographic position is cumbersome. In this report, we highlight the unique design of a new hybrid neuroendovascular operating suite that allows surgical access to the head while keeping the biplane system over the lower body of the patient. Current and future hybrid neuroendovascular operating suite applications are discussed. Methods We collaborated with engineers to implement the following modifications to the design of the angiographic system: translation of the bed toward the feet to allow biplane cerebral imaging in the head-side position and the biplane left-side position; translation of the base of the A-plane C-arm away from the feet to allow increased operator space at the head of the bed and to allow cerebral imaging in both the head-side and left-side positions; use of a specialized boom mount for the display panel to increase mobility; and use of a radiolucent tabletop with attachments for the headrest or radiolucent head clamp system. Results The modified hybrid neuroendovascular operating suite allows for seamless transition between surgical and angiographic positions within seconds, improving workflow efficiency and decreasing procedure time as compared with early-generation hybrid rooms. Conclusions Combined endovascular and surgical applications are facilitated by co-locating their respective technologies and refining the ergonomics of the system to ease transition between both sets of technologies. In so doing, hybrid neuroendovascular operating suites can be anticipated to improve patient outcomes, generate novel treatment paradigms, and improve time and cost efficiency.

BACKGROUND To the authors' knowledge, the current study is the first national analysis of the association between preoperative platelet count and outcomes after craniotomy. METHODS Patients who underwent craniotomy for tumor were extracted from the prospective National Surgical Quality Improvement Program registry (2007-2014) and stratified by preoperative thrombocytopenia, defined as mild (125,000-149,000/μL), moderate (100,000-124,000/μL), severe (75,000-99,000/μL), or very severe (

BACKGROUND Clostridium difficile infection (CDI) is an important cause of hospital-acquired morbidity and mortality. OBJECTIVE To evaluate the incidence of, predictors for, and effects on outcome by CDI after aneurysmal subarachnoid hemorrhage. METHODS Data were extracted from the Nationwide Inpatient Sample (2002-2011). Patients with subarachnoid hemorrhage who underwent microsurgical or endovascular aneurysm repair were included. Multivariate logistic regression was used to determine the independent predictors of developing CDI. Additional models were constructed to assess the impact of CDI on mortality, length of stay, and discharge disposition. RESULTS Of the 18 007 patients who were included, 1.9% (n = 346) developed CDI. Patients who developed CDI were significantly older and had more comorbidities (P ≤ .001). Independent predictors of developing CDI were Medicaid payer status; ventriculostomy; mechanical ventilation; a greater number of noninfectious complications; and the development of a urinary tract infection; pneumonia; meningitis/ventriculitis; and sepsis (all P ≤ .02). Only 1.5% of patients with CDI required gastrointestinal surgery. Although CDI was not associated with differential mortality, it was associated with increased adjusted odds of a hospital stay of at least 24 days (odds ratio, 3.16; 95% confidence interval, 2.32-4.29; P < .001) and of a nonroutine hospital discharge (odds ratio, 1.64; 95% confidence interval, 1.13-2.39; P = .01). CONCLUSION In this nationwide analysis, both infectious and noninfectious complications, as well as ventriculostomy, mechanical ventilation, and insurance status were independent predictors of CDI. Although CDI was not associated with mortality, it was associated with a longer hospital stay and nonroutine hospital discharge.

The goal of this study was to investigate the association of tracheostomy timing with outcomes after aneurysmal subarachnoid hemorrhage (SAH) in a national population.Poor-grade aneurysmal SAH patients were extracted from the Nationwide Inpatient Sample (2002-2011). Multivariable linear regression was used to analyze predictors of tracheostomy timing and multivariable logistic regression was used to evaluate the association of timing of intervention with mortality, complications, and discharge to institutional care. Covariates included patient demographics, comorbidities, severity of subarachnoid hemorrhage (measured using the NIS-SAH severity scale), hospital characteristics, and other complications and length of stay.The median time to tracheostomy among 1380 poor-grade SAH admissions was 11 (interquartile range: 7-15) days after intubation. The mean number of days from intubation to tracheostomy in SAH patients at the hospital (p 0.001) was the strongest predictor of tracheostomy timing for a patient, while comorbidities and SAH severity were not significant predictors. Mortality, neurologic complications, and discharge disposition did not differ significantly by tracheostomy time. However, later tracheostomy (when evaluated continuously) was associated with greater odds of pulmonary complications (p = 0.004), venous thromboembolism (p = 0.04), and pneumonia (p = 0.02), as well as a longer hospitalization (p 0.001). Subgroup analysis only found these associations between tracheostomy timing and medical complications in patients with moderately poor grade (NIS-SAH severity scale 7-9), while there were no significant differences by timing of intervention in very poor-grade patients (NIS-SAH severity scale 9).In this analysis of a large, national data set, variation in hospital practices was the strongest predictor of tracheostomy timing for an individual. In patients with moderately poor grade, later tracheostomy was independently associated with pulmonary complications, venous thromboembolism, pneumonia, and a longer hospitalization, but not with mortality, neurological complications, or discharge disposition. However, tracheostomy timing was not significantly associated with outcomes in very poor-grade patients.

OBJECTIVEThe complex decision analysis of unruptured intracranial aneurysms entails weighing the benefits of aneurysm repair against operative risk. The goal of the present analysis was to build and validate a predictive scale that identifies patients with the greatest odds of a postsurgical adverse event.METHODSData on patients who underwent surgical clipping of an unruptured aneurysm were extracted from the prospective National Surgical Quality Improvement Program registry (NSQIP; 2007–2014); NSQIP does not systematically collect data on patients undergoing intracranial endovascular intervention. Multivariable logistic regression evaluated predictors of any 30-day adverse event; variables screened included patient demographics, comorbidities, functional status, preoperative laboratory values, aneurysm location/complexity, and operative time. A predictive scale was constructed based on statistically significant independent predictors, which was validated using both NSQIP (2015–2016) and the Nationwide Inpatient Sample (NIS; 2002–2011).RESULTSThe NSQIP unruptured aneurysm scale was proposed: 1 point was assigned for a bleeding disorder; 2 points for age 51–60 years, cardiac disease, diabetes mellitus, morbid obesity, anemia (hematocrit < 36%), operative time 240–330 minutes; 3 points for leukocytosis (white blood cell count > 12,000/μL) and operative time > 330 minutes; and 4 points for age > 60 years. An increased score was predictive of postoperative stroke or coma (NSQIP: p = 0.002, C-statistic = 0.70; NIS: p < 0.001, C-statistic = 0.61), a medical complication (NSQIP: p = 0.01, C-statistic = 0.71; NIS: p < 0.001, C-statistic = 0.64), and a nonroutine discharge (NSQIP: p < 0.001, C-statistic = 0.75; NIS: p < 0.001, C-statistic = 0.66) in both validation populations. Greater score was also predictive of increased odds of any adverse event, a major complication, and an extended hospitalization in both validation populations (p ≤ 0.03).CONCLUSIONSThe NSQIP unruptured aneurysm scale may augment the risk stratification of patients undergoing microsurgical clipping of unruptured cerebral aneurysms.

Introduction Despite the increasing national adoption of automated computed tomography perfusion (CTP) to select thrombectomy patients 6 hours after last known well, reliability issues have been anecdotally reported. Unreliable diagnostic tests add time and confusion to a process that requires efficiency. Our study aims to critically assess an automated CTP program in a contemporary cohort of patients presenting with large vessel occlusion (LVO) in the extended time window by evaluating the rate of unreliable automated CTP maps and whether this influences clinical outcomes. Methods A retrospective review of consecutive thrombectomy candidates undergoing CTP imaging in the extended time window was performed. All automated CTP maps using RAPID software (iSchemaView, Menlo Park, CA) were assessed for reliability. Clinical outcomes were compared between patients with and without reliable RAPID reports. Results Ninety-nine consecutive thrombectomy candidates underwent automated CTP imaging from February 2017 to December 2018. Of these, 78 (79%) had LVO determined by CT angiographyand were included in the study population. Automated CTP maps were unreliable in 13% of cases as a result of motion artifact (n = 3) and contrast bolus flow issues (n = 7). Heart failure was more frequent in patients with unreliable studies. Clinical outcomes did not significantly differ between patients with and without unreliable studies. Conclusions Thirteen percent of CTP maps generated by automated software were unreliable, with an increased frequency among patients with heart failure. Given the rate of unreliable automated CTP maps, further studies are warranted to not only establish the true necessity of currently available CTP software, but also more reliable methods to select patients for thrombectomy presenting in the extended time window.

OBJECTIVEData evaluating the long-term outcomes, particularly with regard to treatment modality, of aneurysmal subarachnoid hemorrhage (SAH) in octogenarians are limited. The primary objectives were to evaluate the disposition (living at home vs institutional settings) and analyze the predictors of long-term survival and return to home for octogenarians after SAH.METHODSData pertaining to patients age 80 and older who underwent microsurgical clipping or endovascular coiling for SAH were extracted from 100% nationwide Medicare inpatient claims and linked with the Minimum Data Set (2008–2011). Patient disposition was tracked for 2 years after index SAH admission. Multivariable logistic regression stratified by aneurysm treatment modality, and adjusted for patient factors including SAH severity, evaluated predictors of return to home at 60 and 365 days after SAH. Survival 365 days after SAH was analyzed with a multivariable Cox proportional hazards model.RESULTSA total of 1298 cases were included in the analysis. One year following SAH, 56% of the patients had died or were in hospice care, 8% were in an institutional post–acute care setting, and 36% had returned home. Open microsurgical clipping (adjusted hazard ratio [aHR] 0.67, 95% confidence interval [CI] 0.54–0.81), male sex (aHR 0.70, 95% CI 0.57–0.87), tracheostomy (aHR 0.63, 95% CI 0.47–0.85), gastrostomy (aHR 0.60, 95% CI 0.48–0.76), and worse SAH severity (aHR 0.94, 95% CI 0.92–0.97) were associated with reduced likelihood of patients ever returning home. Older age (aHR 1.09, 95% CI 1.05–1.13), tracheostomy (aHR 2.06, 95% CI 1.46–2.91), gastrostomy (aHR 1.55, 95% CI 1.14–2.10), male sex (aHR 1.66, 95% CI 1.20–2.23), and worse SAH severity 1.51 (95% CI 1.04–2.18) were associated with reduced survival.CONCLUSIONSIn this national analysis, 56% of octogenarians with SAH died, and 36% returned home within 1 year of SAH. Coil embolization predicted returning to home, which may suggest a benefit to endovascular treatment in this patient population.

OBJECTIVEAlthough cigarette smoking is one of the strongest risk factors for cerebral aneurysm development and rupture, there are limited data evaluating the impact of smoking on outcomes after aneurysmal subarachnoid hemorrhage (SAH). Additionally, two recent studies suggested that nicotine replacement therapy was associated with improved neurological outcomes among smokers who had sustained an SAH compared with smokers who did not receive nicotine.METHODSPatients who underwent endovascular or microsurgical repair of a ruptured cerebral aneurysm were extracted from the Nationwide Inpatient Sample (NIS, 2009–2011) and stratified by cigarette smoking. Multivariable logistic regression analyzed in-hospital mortality, complications, tracheostomy or gastrostomy placement, and discharge to institutional care (a nursing or an extended care facility). Additionally, the composite NIS-SAH outcome measure (based on mortality, tracheostomy or gastrostomy, and discharge disposition) was evaluated, which has been shown to have excellent agreement with a modified Rankin Scale score greater than 3. Covariates included in regression constructs were patient age, sex, race/ethnicity, insurance status, socioeconomic status, comorbidities (including hypertension, drug and alcohol abuse), the NIS-SAH severity scale (previously validated against the Hunt and Hess grade), treatment modality used for aneurysm repair, and hospital characteristics. A sensitivity analysis was performed matching smokers to nonsmokers on age, sex, number of comorbidities, and NIS-SAH severity scale score.RESULTSAmong the 5784 admissions evaluated, 37.1% (n = 2148) had a diagnosis of tobacco use, of which 31.1% (n = 1800) were current and 6.0% (n = 348) prior tobacco users. Smokers were significantly younger (mean age 51.4 vs 56.2 years) and had more comorbidities compared with nonsmokers (p < 0.001). There were no significant differences in mortality, total complications, or neurological complications by smoking status. However, compared with nonsmokers, smokers had significantly decreased adjusted odds of tracheostomy or gastrostomy placement (11.9% vs 22.7%, odds ratio [OR] 0.63, 95% confidence interval [CI] 0.51–0.78, p < 0.001), discharge to institutional care (OR 0.71, 95% CI 0.57–0.89, p = 0.002), and a poor outcome (OR 0.65, 95% CI 0.55–0.77, p < 0.001). Similar statistical associations were noted in the matched-pairs sensitivity analysis and in a subgroup of poor-grade patients (the upper quartile of the NIS-SAH severity scale).CONCLUSIONSIn this nationwide study, smokers experienced SAH at a younger age and had a greater number of comorbidities compared with nonsmokers, highlighting the negative ramifications of cigarette smoking among patients with cerebral aneurysms. However, smoking was also associated with paradoxical superior outcomes on some measures, and future research to confirm and further understand the basis of this relationship is needed.

Background Older patients with aneurysmal subarachnoid hemorrhage ( aSAH ) are unique, and determinants of post–acute care outcomes are not well elucidated. The primary objective was to identify hospital characteristics associated with 30‐day readmission and mortality rates after hospital discharge among older patients with aSAH . Methods and Results This cohort study used Medicare patients ≥65 years discharged from US hospitals from January 1, 2008, to November 30, 2010, after aSAH . Medicare data were linked to American Hospital Association data to describe characteristics of hospitals treating these patients. Using multivariable logistic regression to adjust for patient characteristics, hospital factors associated with (1) hospital readmission and (2) mortality within 30 days after discharge were identified. A total of 5515 patients ≥65 years underwent surgical repair for aSAH in 431 hospitals. Readmission rate was 17%, and 8.5% of patients died within 30 days of discharge. In multivariable analyses, patients treated in hospitals with lower annualized aSAH volumes were more likely to be readmitted 30 days after discharge (lowest versus highest quintile, 1–2 versus 16–30 cases; adjusted odds ratio, 2.10; 95% confidence interval, 1.56–2.84). Patients treated in hospitals with lower annualized aSAH volumes (lowest versus highest quintile: adjusted odds ratio, 1.52; 95% confidence interval, 1.05–2.19) had a greater likelihood of dying 30 days after discharge. Conclusions Older patients with aSAH discharged from hospitals treating lower volumes of such cases are at greater risk of readmission and dying within 30 days. These findings may guide clinician referrals, practice guidelines, and regulatory policies influencing which hospitals should care for older patients with aSAH .

Background Although International Classification of Disease, Ninth Revision, Clinical Modification (ICD9-CM) coding is the basis of administrative claims data, no study has validated an ICD9-CM algorithm to identify patients undergoing decompressive craniectomy for space-occupying supratentorial infarction. Methods Patients who underwent decompressive craniectomy for stroke at our institution were retrospectively identified and their associated ICD9-CM codes were extracted from billing data. An ICD9-CM algorithm was generated and its accuracy compared against physician review. Results A total of 10,925 neurosurgical operations were performed from December 2008 to March 2015, of which 46 (0.4%) were decompressive craniectomy for space-occupying stroke. The ICD9-CM procedure code for craniectomy (01.25) was only encoded in 67.4% of patients, while craniotomy (01.24) was used in 19.6% and lobectomy (01.39, 01.53, 01.59) in 13.1%. The ICD-9-CM algorithm included patients with a diagnosis codes for cerebral infarction (433.11, 434.01, 434.11, and 434.91) and a procedure code for craniotomy, craniectomy, or lobectomy. Patients were excluded with an ICD9-CM diagnosis code for brain tumor, intracranial abscess, subarachnoid hemorrhage, vertebrobasilar infarction, intracranial aneurysm, Moyamoya disease, intracranial venous sinus thrombosis, vertebral artery dissection, congenital cerebrovascular anomaly, head trauma or an ICD9-CM procedure code for laminectomy. This algorithm had a sensitivity of 97.8%, specificity of 99.9%, positive predictive value of 88.2%, and negative predictive value of 99.9%. The majority of false-positive results were patients who underwent evacuation of a primary intracerebral hematoma. Conclusion An ICD-9-CM algorithm based on diagnosis and procedure codes can effectively identify patients undergoing decompressive craniectomy for supratentorial stroke.

BACKGROUND Pediatric low-grade gliomas are among the most common childhood neoplasms, yet their post-treatment surveillance remains nonstandardized, relying on arbitrarily chosen imaging intervals. OBJECTIVE To optimize postoperative magnetic resonance imaging (MRI) surveillance protocols for pediatric low-grade gliomas. METHODS Patients aged 0 to 21 yr with pediatric low-grade gliomas, treated between 1990 and 2016 were retrospectively analyzed. The timing of surveillance imaging and radiologic tumor outcomes were extracted, and the effect of patient age, tumor location, histology, and extent of resection as prognostic factors was studied. An algorithm was developed to analyze the detection efficacy and cost of all possible surveillance protocols. RESULTS A total of 517 patients were included with a median follow-up of 7.7 yr (range: 2-25.1 yr) who underwent 8061 MRI scans (mean 15.6 scans per patient). Tumor recurrence was detected radiologically in 292 patients (56.5%), of whom, 143 underwent reoperation. The hazards ratio (HR) of recurrence was higher in patients who underwent biopsy (HR = 3.60; 95% confidence interval (CI): 2.45-5.30; P

OBJECTIVEPatients with paraclinoid aneurysms commonly present with visual impairment. They have traditionally been treated with clipping or coiling, but flow diversion (FD) has recently been introduced as an alternative treatment modality. Although there is still initial aneurysm thrombosis, FD is hypothesized to reduce mass effect, which may decompress the optic nerve when treating patients with visually symptomatic paraclinoid aneurysms. The authors performed a meta-analysis to compare vision outcomes following clipping, coiling, or FD of paraclinoid aneurysms in patients who presented with visual impairment.METHODSA systematic literature review was performed using the PubMed and Web of Science databases. Studies published in English between 1980 and 2016 were included if they reported preoperative and postoperative visual function in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic segment) treated with clipping, coiling, or FD. Neuroophthalmological assessment was used when reported, but subjective patient reports or objective visual examination findings were also acceptable.RESULTSThirty-nine studies that included a total of 2458 patients (520 of whom presented with visual symptoms) met the inclusion criteria, including 307 visually symptomatic cases treated with clipping (mean follow-up 26 months), 149 treated with coiling (mean follow-up 17 months), and 64 treated with FD (mean follow-up 11 months). Postoperative vision in these patients was classified as improved, unchanged, or worsened compared with preoperative vision. A pooled analysis showed preoperative visual symptoms in 38% (95% CI 28%–50%) of patients with paraclinoid aneurysms. The authors found that vision improved in 58% (95% CI 48%–68%) of patients after clipping, 49% (95% CI 38%–59%) after coiling, and 71% (95% CI 55%–84%) after FD. Vision worsened in 11% (95% CI 7%–17%) of patients after clipping, 9% (95% CI 2%–18%) after coiling, and 5% (95% CI 0%–20%) after FD. New visual deficits were found in patients with intact baseline vision at a rate of 1% (95% CI 0%–3%) for clipping, 0% (95% CI 0%–2%) for coiling, and 0% (95% CI 0%–2%) for FD.CONCLUSIONSTo the authors’ knowledge, this is the first meta-analysis to assess vision outcomes after treatment for paraclinoid aneurysms. The authors found that 38% of patients with these aneurysms presented with visual impairment. These data also demonstrated a high rate of visual improvement after FD without a significant difference in the rate of worsened vision or iatrogenic visual impairment compared with clipping and coiling. These findings suggest that FD is an effective option for treatment of visually symptomatic paraclinoid aneurysms.

OBJECTIVEAlthough reoperation and readmission have been used as quality metrics, there are limited data evaluating the rate of, reasons for, and predictors of reoperation and readmission after microsurgical clipping of unruptured aneurysms.METHODSAdult patients who underwent craniotomy for clipping of an unruptured aneurysm electively were extracted from the prospective National Surgical Quality Improvement Program registry (2011–2014). Multivariable logistic regression and recursive partitioning analysis evaluated the independent predictors of nonroutine hospital discharge, unplanned 30-day reoperation, and readmission. Predictors screened included patient age, sex, comorbidities, American Society of Anesthesiologists (ASA) classification, functional status, aneurysm location, preoperative laboratory values, operative time, and postoperative complications.RESULTSAmong the 460 patients evaluated, 4.2% underwent any reoperation at a median of 7 days (interquartile range [IQR] 2–17 days) postoperatively, and 1.1% required a cranial reoperation. The most common reoperation was ventricular shunt placement (23.5%); other reoperations were tracheostomy, craniotomy for hematoma evacuation, and decompressive hemicraniectomy. Independent predictors of any unplanned reoperation were age greater than 51 years and longer operative time (p ≤ 0.04). Readmission occurred in 6.3% of patients at a median of 6 days (IQR 5–13 days) after discharge from the surgical hospitalization; 59.1% of patients were readmitted within 1 week and 86.4% within 2 weeks of discharge. The most common reason for readmission was seizure (26.7%); other causes of readmission included hydrocephalus, cerebrovascular accidents, and headache. Unplanned readmission was independently associated with age greater than 65 years, Class II or III obesity (body mass index > 35 kg/m2), preoperative hyponatremia, and preoperative anemia (p ≤ 0.04). Readmission was not associated with operative time, complications during the surgical hospitalization, length of stay, or discharge disposition. Recursive partitioning analysis identified the same 4 variables, as well as ASA classification, as associated with unplanned readmission. The most potent predictors of nonroutine hospital discharge (16.7%) were postoperative neurological and cardiopulmonary complications; other predictors were age greater than 51 years, preoperative hyponatremia, African American and Asian race, and a complex vertebrobasilar circulation aneurysm.CONCLUSIONSIn this national analysis, patient age greater than 65 years, Class II or III obesity, preoperative hyponatremia, and anemia were associated with adverse events, highlighting patients who may be at risk for complications after clipping of unruptured cerebral aneurysms. The preponderance of early readmissions highlights the importance of early surveillance and follow-up after discharge; the frequency of readmission for seizure emphasizes the need for additional data evaluating the utility and duration of postcraniotomy seizure prophylaxis. Moreover, readmission was primarily associated with preoperative characteristics rather than metrics of perioperative care, suggesting that readmission may be a suboptimal indicator of the quality of care received during the surgical hospitalization in this patient population.

Machine learning (ML) is a domain of artificial intelligence that allows computer algorithms to learn from experience without being explicitly programmed.To summarize neurosurgical applications of ML where it has been compared to clinical expertise, here referred to as "natural intelligence."A systematic search was performed in the PubMed and Embase databases as of August 2016 to review all studies comparing the performance of various ML approaches with that of clinical experts in neurosurgical literature.Twenty-three studies were identified that used ML algorithms for diagnosis, presurgical planning, or outcome prediction in neurosurgical patients. Compared to clinical experts, ML models demonstrated a median absolute improvement in accuracy and area under the receiver operating curve of 13% (interquartile range 4-21%) and 0.14 (interquartile range 0.07-0.21), respectively. In 29 (58%) of the 50 outcome measures for which a P-value was provided or calculated, ML models outperformed clinical experts (P.05). In 18 of 50 (36%), no difference was seen between ML and expert performance (P.05), while in 3 of 50 (6%) clinical experts outperformed ML models (P.05). All 4 studies that compared clinicians assisted by ML models vs clinicians alone demonstrated a better performance in the first group.We conclude that ML models have the potential to augment the decision-making capacity of clinicians in neurosurgical applications; however, significant hurdles remain associated with creating, validating, and deploying ML models in the clinical setting. Shifting from the preconceptions of a human-vs-machine to a human-and-machine paradigm could be essential to overcome these hurdles.

Introduction: Paraclinoid aneurysms commonly present with visual impairment. They were traditionally treated with clipping or coiling, but flow diversion has recently been introduced as an alternative treatment modality. Although there is still initial aneurysm thrombosis, flow diversion is hypothesized to reduce mass effect, which may decompress the optic nerve when treating visually symptomatic paraclinoid aneurysms. We performed a meta-analysis to compare vision outcomes following clipping, coiling, or flow diversion of paraclinoid aneurysms in patients presenting with visual impairment. Methods: A systematic literature review was performed using the PubMed and Web of Science databases. Studies written in English between 1980-2016 were included if they reported preoperative and postoperative visual function in at least 5 patients with visually symptomatic paraclinoid aneurysms (cavernous segment through ophthalmic segment) treated with clipping, coiling, or flow diversion. Neuro-ophthalmologic assessment was used when reported. Results: Thirty-nine studies totaling 2458 patients (20%, 510 of whom presented with visual symptoms) met our inclusion criteria, including 309 visually symptomatic cases treated with clipping (mean follow-up, 25.9 mo), 138 treated with coiling (17.1 mo), and 63 treated with flow diversion (11 mo). Postoperative vision in these patients was classified as improved, unchanged, or declined compared to preoperative vision. We found that vision improved in 57% (95% CI 47-67) of patients after clipping, 45% (34-57) after coiling, and 73% (56-88) after flow diversion. Vision worsened in 11% (7-17) of patients after clipping, 8% (2-17) after coiling, and 7% (0-27) after flow diversion. New visual deficits were found in patients with intact baseline vision at a rate of 0.69% (0-2) for clipping, 0.53% (0-3) for coiling, and 0.80% (0-3) for flow diversion. Conclusion: Our data demonstrates a high rate of visual improvement and a low rate of iatrogenic vision impairment for patients with paraclinoid aneurysms treated with flow diversion. Further analysis is needed to compare flow diversion to clipping and coiling and inform clinical management of visually symptomatic paraclinoid aneurysms.

Background and Purpose— The goal of this nationwide study is to evaluate the suitability of readmission as a quality indicator in the aneurysmal subarachnoid hemorrhage (SAH) population. Methods— Patients with aneurysmal SAH were extracted from the Nationwide Readmission Database (2013). Multivariable Cox proportional hazard regression was used to evaluate predictors of a 30-day readmission, and multivariable linear regression was used to analyze the association of hospital readmission rates with hospital mortality rates. Predictors screened included patient demographics, comorbidities, severity of SAH, complications from the SAH hospitalization, and hospital characteristics. Results— The 30-day readmission rate was 10.2% (n=346) among the 3387 patients evaluated, and the most common reasons for readmission were neurological, hydrocephalus, infectious, and venous thromboembolic complications. Greater number of comorbidities, increased severity of SAH, and discharge disposition other than to home were independent predictors of readmission ( P ≤0.03). Although hydrocephalus during the SAH hospitalization was associated with readmission for the same diagnosis, other readmissions were not associated with having sustained the same complication during the SAH hospitalization. Hospital mortality rate was inversely associated with hospital SAH volume ( P =0.03) but not significantly associated with hospital readmission rate; hospital SAH volume was also not associated with SAH readmissions. Conclusions— In this national analysis, readmission was primarily attributable to new medical complications in patients with greater comorbidities and severity of SAH rather than exacerbation of complications from the SAH hospitalization. Additionally, hospital readmission rates did not correlate with other established quality metrics. Therefore, readmission may be a suboptimal quality indicator in the SAH population.

Object Traditionally, hemisacrectomy and internal hemipelvectomy procedures have required both an anterior and a posterior approach. A posterior-only approach has the potential to complete an en bloc tumor resection and spinopelvic reconstruction while reducing surgical morbidity. Methods The authors describe 3 cases in which en bloc resection of the hemisacrum and ilium and subsequent lumbopelvic and pelvic ring reconstruction were performed from a posterior-only approach. Two more traditional anterior and posterior staged procedures are also included for comparison. Results In all 3 cases, an oncologically appropriate surgery and spinopelvic reconstruction were performed through a posterior-only approach. Conclusions The advantage of a midline posterior approach is the ability to perform a lumbosacral reconstruction, necessary in cases in which the S-1 body is iatrogenically disrupted during tumor resection.

Superior sagittal sinus (SSS) dural arteriovenous fistulas (DAVFs) are rare and present unique challenges to treatment. Complex, often bilateral, arterial supply and involvement of large volumes of eloquent cortical venous drainage may necessitate multimodality therapy such as endovascular, microsurgical, and stereotactic radiosurgery techniques. The authors present a complex SSS DAVF associated with an occluded/severely stenotic SSS. The patient underwent a successful endovascular transvenous approach with complete obliteration of the SSS. The authors discuss the management challenges faced on this case.The video can be found here: https://youtu.be/-rztg0_cBXY.

Tentorial dural arteriovenous fistulas (DAVFs) are uncommon, complex fistulas located between the leaves of the tentorium cerebelli with a specific anatomic and clinical presentation characterized by high hemorrhagic risk. They have an extensive arterial supply and complex venous drainages, making them difficult to treat. There is recent literature favoring treatment through an endovascular transarterial route. The authors present an uncommon tentorial/ambient cistern region DAVF with feeders arising from the external and internal carotid arteries. The patient underwent a combined transarterial and transvenous approach with successful obliteration of the DAVF. The authors discuss the management challenges faced in this case.The video can be found here: https://youtu.be/VXDD8zUvsSQ.

Acute basilar artery occlusion is one of the most devastating subtypes of ischemic stroke with an extremely high morbidity and mortality rate. The most common causes include embolism, large-artery atherosclerosis, penetrating small-artery disease, and arterial dissection. The heart and vertebral arteries are the main source of emboli in embolic basilar occlusions. The authors present an uncommon acute basilar occlusion secondary to a fusiform aneurysm with intraluminal thrombus. The patient underwent a mechanical thrombectomy with successful recanalization, but persistent intraluminal thrombus. The authors discuss the management dilemma and describe their choice for placement of flow diverter stents.The video can be found here: https://youtu.be/XzBdgxJPSWQ.

Introduction The Woven Endobridge (WEB) device is an innovative endovascular device for treatment of intracranial aneurysms, especially bifurcation and wide-neck aneurysms. Although not approved by the U.S. Food and Drug Administration, it has been available in Europe since 2011. The aim of this review is to evaluate the outcomes of WEB device use for intracranial aneurysm treatment. Methods A systematic review was conducted with MEDLINE search engines PubMed and Embase from 2011. The search strategy provided 6229 articles, and 19 articles were included. Results A total of 19 papers were identified describing the use of WEB devices in 687 patients with 718 aneurysms. The 2 largest prospective multicenter studies (WEBCAST and the French Observatory Trial) reported successful treatment, defined as complete closure or a neck remnant, in 85% and 79% of aneurysms, respectively. The use of a WEB device in combination with coiling or stenting was described with varying results in multiple small series. Outcomes of WEB device use in ruptured aneurysms in 2 studies showed 94% and 80% adequate treatment. Thromboembolic events were described in 71 patients (10.3% of all patients) and infarctions in 8 patients (1.2% of all patients). Conclusions Despite initial promising results, the WEB device should be used with caution given its potentially large learning curve and because it has primarily been investigated only in wide-neck and bifurcation aneurysms. In addition, currently available prospective studies have short follow-up, and the device has not been directly compared with other treatment modalities.

OBJECTIVEAlthough the prevalence of obesity is increasing rapidly both nationally and internationally, few studies have analyzed outcomes among obese patients undergoing cranial neurosurgery. The goal of this study, which used a nationwide data set, was to evaluate the association of both obesity and morbid obesity with treatment outcomes among patients with aneurysmal subarachnoid hemorrhage (SAH); in addition, the authors sought to analyze how postoperative complications for obese patients with SAH differ by the treatment modality used for aneurysm repair.METHODSClinical data for adult patients with SAH who underwent microsurgical or endovascular aneurysm repair were extracted from the Nationwide Inpatient Sample (NIS). The body habitus of patients was classified as nonobese (body mass index [BMI] < 30 kg/m2), obese (BMI ≥ 30 kg/m2 and ≤ 40 kg/m2), or morbidly obese (BMI > 40 kg/m2). Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality rate, complications, discharge disposition, and poor outcome as defined by the composite NIS-SAH outcome measure. Covariates included patient demographics, comorbidities (including hypertension and diabetes), health insurance status, the NIS-SAH severity scale, treatment modality used for aneurysm repair, and hospital characteristics.RESULTSIn total, data from 18,281 patients were included in this study; the prevalence of morbid obesity increased from 0.8% in 2002 to 3.5% in 2011. Obese and morbidly obese patients were significantly younger and had a greater number of comorbidities than nonobese patients (p < 0.001). Mortality rates for obese (11.5%) and morbidly obese patients (10.5%) did not significantly differ from those for nonobese patients (13.5%); likewise, no differences in neurological complications or poor outcome were observed among these 3 groups. Morbid obesity was associated with significantly increased odds of several medical complications, including venous thromboembolic (OR 1.52, 95% CI 1.01–2.30, p = 0.046) and renal (OR 1.64, 95% CI: 1.11–2.43, p = 0.01) complications and infections (OR 1.34, 95% CI 1.08–1.67, p = 0.009, attributable to greater odds of urinary tract and surgical site infections). Moreover, morbidly obese patients had higher odds of a nonroutine hospital discharge (OR 1.33, 95% CI 1.03–1.71, p = 0.03). Patients with milder obesity had decreased odds of some medical complications, including cardiac, pulmonary, and infectious complications, primarily among patients who had undergone coil embolization.CONCLUSIONSIn this study involving a nationwide administrative database, milder obesity was not significantly associated with increased mortality rates, neurological complications, or poor outcomes after SAH. Morbid obesity, however, was associated with increased odds of venous thromboembolic, renal, and infectious complications, as well as of a nonroutine hospital discharge. Notably, milder obesity was associated with decreased odds of some medical complications, primarily in patients treated with coiling.

Successful application of endovascular neurosurgery depends on high-quality imaging to define the pathology and the devices as they are being deployed. This is especially challenging in the treatment of complex cases, particularly in proximity to the skull base or in patients who have undergone prior endovascular treatment. The authors sought to optimize real-time image guidance using a simple algorithm that can be applied to any existing fluoroscopy system. Exposure management (exposure level, pulse management) and image post-processing parameters (edge enhancement) were modified from traditional fluoroscopy to improve visualization of device position and material density during deployment. Examples include the deployment of coils in small aneurysms, coils in giant aneurysms, the Pipeline embolization device (PED), the Woven EndoBridge (WEB) device, and carotid artery stents. The authors report on the development of the protocol and their experience using representative cases.The stent deployment protocol is an image capture and post-processing algorithm that can be applied to existing fluoroscopy systems to improve real-time visualization of device deployment without hardware modifications. Improved image guidance facilitates aneurysm coil packing and proper positioning and deployment of carotid artery stents, flow diverters, and the WEB device, especially in the context of complex anatomy and an obscured field of view.