Browse

You are looking at 1 - 10 of 215 items for

  • Refine by Access: all x
  • By Author: Couldwell, William T. x
Clear All
Restricted access

Examining barriers to care: a retrospective cohort analysis investigating the relationship between hospital volume and outcomes in pediatric patients with cerebral arteriovenous malformations

Michael G. Brandel, Hernan Gonzalez, David D. Gonda, Michael L. Levy, Edward R. Smith, Sandi K. Lam, William T. Couldwell, Jeffrey Steinberg, and Vijay M. Ravindra

OBJECTIVE

Comprehensive data on treatment patterns of pediatric cerebral arteriovenous malformations (AVMs) are lacking. The authors’ aim was to examine national trends, assess the effect of hospital volume on outcomes, and identify variables associated with treatment at high-volume centers.

METHODS

Pediatric AVM admissions (for ruptured and unruptured lesions) occurring in the US in 2016 and 2019 were identified using the Kids’ Inpatient Database. Demographics, treatment methods, costs, and outcomes were recorded. The effect of hospital AVM volume on outcomes and factors associated with treatment at higher-volume hospitals were analyzed.

RESULTS

Among 2752 AVM admissions identified, 730 (26.5%) patients underwent craniotomy, endovascular treatment, or a combination. High-volume (vs low-volume) centers saw lower proportions of Black (8.7% vs 12.9%, p < 0.001) and lowest-income quartile (20.7% vs 27.9%, p < 0.001) patients, but were more likely to provide endovascular intervention (19.5%) than low-volume institutions (13.7%) (p = 0.001). Patients treated at high-volume hospitals had insignificantly lower numbers of complications (mean 2.66 vs 4.17, p = 0.105) but significantly lower odds of nonroutine discharge (OR 0.18 [95% CI 0.06–0.53], p = 0.009) and death (OR 0.13 [95% CI 0.02–0.75], p = 0.023). Admissions at high-volume hospitals cost more than at low-volume hospitals, regardless of whether intervention was performed ($64,811 vs $48,677, p = 0.001) or not ($64,137 vs $33,779, p < 0.001). Multivariable analysis demonstrated that Hispanic children, patients who received AVM treatment, and those in higher-income quartiles had higher odds of treatment at high-volume hospitals.

CONCLUSIONS

In this largest study of US pediatric cerebral AVM admissions to date, higher hospital volume correlated with several better outcomes, particularly when patients underwent intervention. Multivariable analysis demonstrated that higher income and Hispanic race were associated with treatment at high-volume centers, where endovascular care is more common. The findings highlight the fact that ensuring access to appropriate treatment of patients of all races and socioeconomic classes must be a focus.

Restricted access

Letter to the Editor. An additional pitfall in the practice of neurosurgery: healthcare policies

Naci Balak

Free access

Letter to the Editor. Neurosurgery practice

Bipin Chaurasia

Free access

Dolichoectatic vertebrobasilar aneurysms: a systematic review and meta-analysis of management strategies and outcomes

Othman Bin-Alamer, Jumanah Qedair, Paolo Palmisciano, Arka N. Mallela, Gautam M. Nayar, Victor M. Lu, Mohamed A. Labib, Michael J. Lang, Bradley A. Gross, David J. Langer, William T. Couldwell, Robert M. Friedlander, and Hussam Abou-Al-Shaar

OBJECTIVE

The aim of this study was to describe the efficacy, clinical outcomes, and complications of open cerebrovascular surgery, endovascular surgery, and conservative management of dolichoectatic vertebrobasilar aneurysms (DVBAs).

METHODS

Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane databases according to PRISMA guidelines. A meta-analysis was conducted for clinical presentation, treatment protocols, and clinical outcomes—good (improved or stable clinical status) or poor (deteriorated clinical status or death)—and mortality rates.

RESULTS

The 9 identified articles described 41 cases (27.5%) of open cerebrovascular surgery, 61 endovascular procedures (40.9%), and 47 cases (31.5%) of conservative management for DVBAs. The total cohort had a good outcome rate of 51.9% (95% CI 28.3%–74.6%), a poor outcome rate of 45.5% (95% CI 23.0%–70.1%), and a mortality rate of 22.3% (95% CI 11.8%–38.0%). The treatment groups had comparable good clinical outcome rates (open cerebrovascular surgery group: 24.7% [95% CI 2.9%–78.2%]; endovascular surgery group: 69.0% [95% CI 28.7%–92.5%]; conservative management group: 57.7% [95% CI 13.0%–92.5%]; p = 0.19) and poor outcome rates (open vascular surgery group: 75.3% [95% CI 21.8%–97.1%]; endovascular surgery group: 27.2% [95% CI 5.6%–0.70.2%]; conservative management group: 39.9% [95% CI 9.1%–81.6%]; p = 0.15). The treatment groups also had comparable mortality rates (open vascular surgery group: 39.5% [95% CI 11.4%–76.8%]; endovascular surgery group: 15.8% [95% CI 4.4%–43.0%]; conservative management group: 19.2% [95% CI 6.8%–43.5%]; p = 0.23).

CONCLUSIONS

The current study of DVBAs illustrated poor outcomes and high mortality rates regardless of the treatment modality. The subgroup analysis showed heterogeneity among the subgroups and advice for personalized management.

Free access

Safety and efficacy of the Pipeline Flex embolization device with Shield Technology for the acute treatment of ruptured internal carotid artery pseudoaneurysms: a multi-institution case series

Michael T. Bounajem, Evan Joyce, Jonathan P. Scoville, Joshua Seinfeld, Jessa Hoffman, Jonathan A. Grossberg, Vanesha Waiters, Andrew C. White, John Nerva, Jan-Karl Burkhardt, Daniel A. Tonetti, Kareem El Naamani, M. Reid Gooch, Pascal Jabbour, Stavropoula Tjoumakaris, Santiago Ortega Gutierrez, Michael R. Levitt, Michael Lang, William J. Ares, Sohum Desai, Justin R. Mascitelli, Craig J. Kilburg, Karol P. Budohoski, William T. Couldwell, Bradley A. Gross, and Ramesh Grandhi

OBJECTIVE

Ruptured blister, dissecting, and iatrogenic pseudoaneurysms are rare pathologies that pose significant challenges from a treatment standpoint. Endovascular treatment via flow diversion represents an increasingly popular option; however, drawbacks include the requirement for dual antiplatelet therapy and the potential for thromboembolic complications, particularly acute complications in the ruptured setting. The Pipeline Flex embolization device with Shield Technology (PED-Shield) offers reduced material thrombogenicity, which may aid in the treatment of ruptured internal carotid artery pseudoaneurysms.

METHODS

The authors conducted a multi-institution, retrospective case series to determine the safety and efficacy of PED-Shield for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. Clinical, radiographic, treatment, and outcomes data were collected.

RESULTS

Thirty-three patients were included in the final analysis. Seventeen underwent placement of a single device, and 16 underwent placement of two devices. No thromboembolic complications occurred. Four patients were maintained on aspirin alone, and all others were treated with long-term dual antiplatelet therapy. Among patients with 3-month follow-up, 93.8% had a modified Rankin Scale score of 0–2. Complete occlusion at follow-up was observed in 82.6% of patients.

CONCLUSIONS

PED-Shield represents a new option for the treatment of ruptured blister, dissecting, and iatrogenic pseudoaneurysms of the internal carotid artery. The reduced material thrombogenicity appeared to improve the safety of the PED-Shield device, as this series demonstrated no thromboembolic complications even among patients treated with only single antiplatelet therapy. The efficacy of PED-Shield reported in this series, particularly with placement of two devices, demonstrates its potential as a first-line treatment option for these pathologies.

Free access

In memoriam: Jules Hardy, 1932–2022

William T. Couldwell and Ian E. McCutcheon

Free access

Editorial. Margie Shreve and the Journal of Neurosurgery: "May it be said, ‘Well done.’"

William T. Couldwell and James T. Rutka

Free access

Editorial. Pitfalls in the practice of neurosurgery: identifying those at greatest risk

William T. Couldwell, Robert E. Harbaugh, and James T. Rutka

Open access

Natural history of pituitary carcinoma with metastasis to the cervical spine: illustrative case

Nicholas T. Gamboa, Christopher Wilkerson, Bornali Kundu, Brandon A. Sherrod, Andrew T. Dailey, and William T. Couldwell

BACKGROUND

Pituitary carcinoma is a rare tumor of the adenohypophysis with noncontiguous craniospinal dissemination and/or systemic metastases. Given the rarity of this malignancy, there is limited knowledge and consensus regarding its natural history, prognosis, and optimal treatment.

OBSERVATIONS

The authors present the case of a 46-year-old woman initially treated with invasive prolactin-secreting pituitary macroadenoma who developed metastatic disease of the cervical spine 6 years later. The patient presented with acutely worsening compressive cervical myelopathy and required posterior cervical decompression, tumor resection, and instrumented arthrodesis for posterolateral fusion.

LESSONS

This case underscores the importance of long-term monitoring of hormone levels and having a high clinical suspicion for metastatic disease to the spine in patients presenting with acute myelopathy or radiculopathy in the setting of previously treated invasive secreting pituitary adenoma.

Free access

Factors associated with hearing outcomes after a middle fossa approach in 131 consecutive patients with vestibular schwannomas

Karol P. Budohoski, Robert C. Rennert, Steven A. Gordon, Amol Raheja, Cameron Brandon, J. Curran Henson, Mohammed A. Azab, Neil S. Patel, Michael Karsy, Richard K. Gurgel, Clough Shelton, and William T. Couldwell

OBJECTIVE

The middle fossa approach is an effective option for the treatment of small (Koos grade I and II) vestibular schwannomas (VSs) when the goal is hearing preservation. The authors evaluated the rates of hearing preservation and examined the factors associated with improved hearing outcomes after the middle fossa approach for VSs.

METHODS

In this retrospective, single-center cohort study evaluating the clinical outcomes after resection of small VSs using the middle fossa approach, consecutive adult patients (> 18 years) who underwent surgery between January 2000 and December 2021 were included. Clinical and imaging characteristics were analyzed, including baseline hearing status, duration of surgery, anesthetic parameters, and imaging characteristics of the surgically treated tumors.

RESULTS

Among the 131 included patients, 102 had valid and discoverable pre- and postoperative audiology assessments. The mean follow-up was 26 months (range 1–180 months). There were 85 patients with serviceable hearing preoperatively, defined as American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) class A or B, of whom 78% retained class A or B hearing at the last follow-up. Binary logistic regression demonstrated that preoperative hearing AAO-HNS class (OR 0.19, 95% CI 0.05–0.77; p = 0.02), overlap between fundus and cochlea (OR 0.32, 95% CI 0.11–0.96; p = 0.04), and duration of anesthesia (OR 0.98, 95% CI 0.97–0.99; p = 0.03) were independent predictors of hearing outcomes. Additionally, 75% of patients with high diffusion-weighted imaging signal in the tumor (p = 0.009) and 67% of patients with the tumor originating at the modiolus of the cochlea (p = 0.004) had poor hearing outcomes.

CONCLUSIONS

The hearing preservation rates after microsurgical resection of small VSs using the middle fossa approach are high, with 78% of patients maintaining AAO-HNS class A or B hearing. Poor hearing status at baseline, longer duration of anesthesia, and large overlap between the fundus of the internal auditory canal and the cochlea were independently associated with unfavorable hearing outcomes. Imaging characteristics can be used to stratify patients’ risk of hearing loss.