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Giovanni G. Vercelli, Norbert G. Campeau, Thanila A. Macedo, Elliot T. Dawson and Giuseppe Lanzino

A carotid web is a shelf-like intraluminal filling defect typically arising from the posterolateral wall of the proximal internal carotid artery. It is recognized as a possible cause of ischemic stroke in young adults. However, its etiopathogenesis is controversial and remains to be fully elucidated. The authors report de novo formation of a carotid web from an intimal dissection documented on serial imaging studies. The findings in this case suggest that a focal intimal dissection could be the underlying cause of a carotid web. Lower shear stress at the posterolateral wall of the proximal internal carotid artery is hypothesized to be a predisposing factor and explains the predilection of a carotid web for this specific location.

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Wajd N. Al-Holou, Thomas J. Wilson, Zarina S. Ali, Ryan P. Brennan, Kelly J. Bridges, Tannaz Guivatchian, Ghaith Habboub, Ajit A. Krishnaney, Giuseppe Lanzino, Kendall A. Snyder, Tracy M. Flanders, Khoi D. Than and Aditya S. Pandey

OBJECTIVE

Gastrostomy tube placement can temporarily seed the peritoneal cavity with bacteria and thus theoretically increases the risk of shunt infection when the two procedures are performed contemporaneously. The authors hypothesized that gastrostomy tube placement would not increase the risk of ventriculoperitoneal shunt infection. The object of this study was to test this hypothesis by utilizing a large patient cohort combined from multiple institutions.

METHODS

A retrospective study of all adult patients admitted to five institutions with a diagnosis of aneurysmal subarachnoid hemorrhage between January 2005 and January 2015 was performed. The primary outcome of interest was ventriculoperitoneal shunt infection. Variables, including gastrostomy tube placement, were tested for their association with this outcome. Standard statistical methods were utilized.

RESULTS

The overall cohort consisted of 432 patients, 47% of whom had undergone placement of a gastrostomy tube. The overall shunt infection rate was 9%. The only variable that predicted shunt infection was gastrostomy tube placement (p = 0.03, OR 2.09, 95% CI 1.07–4.08), which remained significant in the multivariate analysis (p = 0.04, OR 2.03, 95% CI 1.04–3.97). The greatest proportion of shunts that became infected had been placed more than 2 weeks (25%) and 1–2 weeks (18%) prior to gastrostomy tube placement, but the temporal relationship between shunt and gastrostomy was not a significant predictor of shunt infection.

CONCLUSIONS

Gastrostomy tube placement significantly increases the risk of ventriculoperitoneal shunt infection.

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Pui Man Rosalind Lai and Nirav J. Patel

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Enrico Giordan, Giorgio Palandri, Giuseppe Lanzino, Mohammad Hassan Murad and Benjamin D. Elder

OBJECTIVE

Different CSF diversion procedures (ventriculoperitoneal, ventriculoatrial, and lumboperitoneal shunting) have been utilized for the treatment of idiopathic normal pressure hydrocephalus. More recently, endoscopic third ventriculostomy has been suggested as a reasonable alternative in some studies. The purpose of this study was to perform a systematic review and meta-analysis to assess overall rates of favorable outcomes and adverse events for each of these treatments. An additional objective was to determine the outcomes and complication rates in relation to the type of valve utilized (fixed vs programmable).

METHODS

Multiple databases (PubMed, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE, Ovid Embase, Ovid Cochrane Central Register of Controlled Trials, Ovid Cochrane Database of Systematic Reviews, and Scopus) were searched for studies involving patients with idiopathic ventriculomegaly, no secondary cause of hydrocephalus, opening pressure < 25 mm Hg on high-volume tap or drainage trial, and age > 60 years. Outcomes included the proportion of patients who showed improvement in gait, cognition, and bladder function. Adverse events considered in the analysis included postoperative ischemic/hemorrhagic complications, subdural fluid collections, seizures, need for revision surgery, and infection.

RESULTS

A total of 33 studies, encompassing 2461 patients, were identified. More than 75% of patients experienced improvement after shunting, without significant differences among the different techniques utilized. Overall, gait improvement was observed in 75% of patients, cognitive function improvement in more than 60%, and improvement of incontinence in 55%. Adjustable valves were associated with a reduction in revisions (12% vs 32%) and subdural collections (9% vs 22%) as compared to fixed valves.

CONCLUSIONS

Outcomes did not differ significantly among different CSF diversion techniques, and overall improvement was reported in more than 75% of patients. The use of programmable valves decreased the incidence of revision surgery and of subdural collections after surgery, potentially justifying the higher initial cost associated with these valves.

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Meisam Shahsavari and Soodeh Shahsavari

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Lorenzo Rinaldo, Desmond Brown, Giuseppe Lanzino and Ian F. Parney

OBJECTIVE

The clinical course of high-grade central nervous system gliomas is occasionally complicated by hydrocephalus. The risks of shunt placement and clinical outcome following CSF diversion in this population are not well defined.

METHODS

The authors retrospectively reviewed the outcomes of patients with pathologically confirmed WHO grade III or IV gliomas with shunt-treated hydrocephalus at their institution. Outcomes of patients in this cohort were compared with those of patients who underwent shunt treatment for normal pressure hydrocephalus (NPH). Hospital-reported outcomes in a national database for malignant primary brain tumor patients undergoing a ventricular shunt procedure were also reviewed.

RESULTS

Forty-one patients undergoing CSF shunting between 2001 and 2016 at the authors’ institution were identified. Noncommunicating and communicating hydrocephalus occurred at similar rates (51.2% vs 48.8%). Symptomatic improvement after shunting was observed in 75.0% of patients. A major complication occurred in 17.1% of cases, with 2 patients suffering an intracranial hemorrhage. Prior administration of bevacizumab was significantly associated with the incidence of hemorrhage (p = 0.026). Three patients (7.3%) died during admission, and 8 (19.5%) died within 30 days of shunt placement. The presence of ependymal or leptomeningeal enhancement was more common in patients who died within 30 days (75.0% vs 11.1%, p = 0.001). Six patients (18.1%) required readmission to the hospital within 30 days of discharge. Revision surgery was necessary in 7 patients (17.1%). The median time from shunt placement to death was 150.5 days. In comparison with patients with NPH, shunt-treated high-grade glioma patients had increased in-hospital (7.3% vs 0.5%, p = 0.008) and 30-day (19.5% vs 0.8%, p < 0.001) mortality but no difference in the incidence of revision surgery (17.1% vs 17.5%, p = 0.947). Similarly, in the national Vizient Clinical Database Resource Manager, shunt-treated patients with malignant primary brain tumors had an increased length of stay (6.9 vs 3.5 days, p < 0.001), direct cost of admission ($15,755.80 vs $9871.50, p < 0.001), and 30-day readmission rates (20.6% vs 2.4%, p < 0.001) compared with patients without brain tumors who received a shunt for NPH.

CONCLUSIONS

Shunting can be an effective treatment for the symptoms of hydrocephalus in patients with high-grade gliomas. However, the authors’ results suggest that this procedure carries a significant risk of complications in this patient population.

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Lorenzo Rinaldo, Joshua D. Hughes, Alejandro A. Rabinstein and Giuseppe Lanzino

OBJECTIVE

It has been suggested that increased body mass index (BMI) may confer a protective effect on patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). Whether the modality of aneurysm occlusion influences the effect of BMI on patient outcomes is not well understood. The authors aimed to compare the effect of BMI on outcomes for patients with aSAH treated with surgical clipping versus endovascular coiling.

METHODS

The authors retrospectively reviewed the outcomes for patients admitted to their institution for the management of aSAH treated with either clipping or coiling. BMI at the time of admission was recorded and used to assign patients to a group according to low or high BMI. Cutoff values for BMI were determined by classification and regression tree analysis. Predictors of poor functional outcome (defined as modified Rankin Scale score > 2 measured ≥ 90 days after the ictus) and posttreatment cerebral hypodensities detected during admission were then determined separately for patients treated with clipping or coiling using stepwise multivariate logistic regression analysis.

RESULTS

Of the 469 patients admitted to the authors’ institution with aSAH who met the study’s inclusion criteria, 144 were treated with clipping and 325 were treated with coiling. In the clipping group, the frequency of poor functional outcome was higher in patients with BMI ≥ 32.3 kg/m2 (47.6% vs 19.0%; p = 0.007). In contrast, in the coiling group, patients with BMI ≥ 32.3 kg/m2 had a lower frequency of poor functional outcome at ≥ 90 days (5.8% vs 30.9%; p < 0.001). On multivariate analysis, high BMI was independently associated with an increased (OR 3.92, 95% CI 1.20–13.41; p = 0.024) and decreased (OR 0.13, 95% CI 0.03–0.40; p < 0.001) likelihood of poor functional outcome for patients treated with clipping and coiling, respectively. For patients in the surgical group, BMI ≥ 28.4 kg/m2 was independently associated with incidence of cerebral hypodensities during admission (OR 2.44, 95% CI 1.16–5.25; p = 0.018) on multivariate analysis. For patients treated with coiling, BMI ≥ 33.2 kg/m2 was independently associated with reduced odds of hypodensities (OR 0.45, 95% CI 0.21–0.89; p = 0.021).

CONCLUSIONS

The results of this study suggest that BMI may differentially affect functional outcomes after aSAH, depending on treatment modality. These findings may aid in treatment selection for patients with aSAH.

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Thomas J. Sorenson, Waleed Brinjikji, Kelly D. Flemming and Giuseppe Lanzino

Incidental vascular lesions are being discovered at an increasing frequency due to widespread noninvasive brain imaging studies. One of these lesions has recently been termed a “pure arterial malformation” (PAM), which is defined as dilated, overlapping, and tortuous arteries forming a mass of arterial loops with a coil-like appearance in the absence of arteriovenous shunting. The pathogenesis of these lesions is not known, but a congenital etiology is suspected. The authors report the case of a 17-year-old female who was found to have a PAM of the posterior inferior cerebellar artery with adipose tissue interspersed within the arterial loops. The authors believe that this abnormal intracranial association between blood vessel and adipose tissue lends further support to the theory that PAMs are the result of a congenital malformation and are therefore safe to manage conservatively given their presumed benign natural history. Far from offering conclusive evidence, this unique case report adds to the growing body of PAM literature and strengthens an increasingly supported congenital theory of genesis.

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Lorenzo Rinaldo, Diane M. Johnson, Roanna L. Vine, Alejandro A. Rabinstein and Giuseppe Lanzino

OBJECTIVE

Clinical trials forming the basis of current guidelines for the management of intracranial aneurysms have relied on patient-reported modified Rankin Scale (mRS) scores to assess functional outcome. The effect of patient demographics on perception of disability and, by extension, patient-reported mRS score, is not well understood.

METHODS

A consecutive series of patients with a previously treated or untreated unruptured intracranial aneurysm (UIA) prospectively underwent a structured interview with a trained nurse. At the conclusion of this interview, the patients were assigned an mRS score in accordance with their degree of disability. During the same visit, patients were also required to grade themselves on a paper sheet containing the mRS and corresponding information. Data on patient and aneurysm characteristics were also collected during the same visit. Agreement between patient- and nurse-reported mRS scores was assessed using Cohen’s kappa coefficient. The effect of patient demographics on the frequency of higher patient- than nurse-reported mRS scores was assessed using the Pearson’s chi-square and Fisher’s exact tests.

RESULTS

A total of 209 patients with a UIA were included in the study, 38 of whom (18.2%) had undergone previous treatment. The majority of patients were female (161/209, 77.0%), and the mean age of the cohort was 60.2 years (SD 13.7 years). Agreement between patient- and nurse-reported mRS scores occurred in 72.7% of cases (95% CI 66.3%–78.3%), with a kappa coefficient of 0.58 (95% CI 0.49–0.67). Patients younger than 75 years were more likely to report a higher mRS score than the nurse (19.4% vs 3.4%, p = 0.034). Among female patients, those without a college degree were more likely to report a higher mRS score than the nurse (22.5% vs 9.5%, p = 0.035).

CONCLUSIONS

The results suggest that patient demographics may influence perception of disability. These findings should be considered when using patient-reported mRS scores to determine functional outcome.

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Waleed Brinjikji, Harry J. Cloft, Kelly D. Flemming, Simone Comelli and Giuseppe Lanzino

OBJECTIVE

Over the last half century, there have been isolated case reports of purely arterial malformations. In this study, the authors report a consecutive series of patients with pure arterial malformations, emphasizing the clinical and radiological features of these lesions.

METHODS

Pure arterial malformations were defined as dilated, overlapping, and tortuous arteries with a coil-like appearance and/or a mass of arterial loops without any associated venous component. Demographic characteristics of the patients, cardiovascular risk factors, presentation, radiological characteristics, and follow-up data were collected. Primary outcomes were new neurological symptoms including disability, stroke, and hemorrhage.

RESULTS

Twelve patients meeting the criteria were identified. Ten patients were female (83.3%) and 2 were male (16.6%). Their mean age at diagnosis was 26.2 ± 11.6 years. The most common imaging indication was headache (7 patients [58.3%]). In 3 cases the pure arterial malformation involved the anterior cerebral arteries (25.0%); in 4 cases the posterior communicating artery/posterior cerebral artery (33.3%); in 2 cases the middle cerebral artery (16.6%); and in 1 case each, the superior cerebellar artery, basilar artery/anterior inferior cerebellar artery, and posterior inferior cerebellar artery. The mean maximum diameter of the malformations was 7.2 ± 5.0 mm (range 3–16 mm). Four lesions had focal aneurysms associated with the pure arterial malformation, and 5 were partially calcified. In no cases was there associated intracranial hemorrhage or infarction. One patient underwent treatment for the pure arterial malformation. All 12 patients had follow-up (mean 29 months, median 19 months), and there were no cases of disability, stroke, or hemorrhage.

CONCLUSIONS

Pure arterial malformations are rare lesions that are often detected incidentally and probably have a benign natural history. These lesions can affect any of the intracranial arteries and are likely best managed conservatively.