Browse

You are looking at 1 - 10 of 36,010 items for

Restricted access

Shaarada Srivatsa, Yifei Duan, John P. Sheppard, Shivani Pahwa, Jonathan Pace, Xiaofei Zhou and Nicholas C. Bambakidis

OBJECTIVE

Mechanical thrombectomy is effective in acute ischemic stroke secondary to emergent large-vessel occlusion, but optimal efficacy is contingent on fast and complete recanalization. First-pass recanalization does not occur in the majority of patients. The authors undertook this study to determine if anatomical parameters of the intracranial vessels impact the likelihood of first-pass complete recanalization.

METHODS

The authors retrospectively evaluated data obtained in 230 patients who underwent mechanical thrombectomy for acute ischemic stroke secondary to large-vessel occlusion at their institution from 2016 to 2018. Eighty-six patients were identified as having pure M1 occlusions, and 76 were included in the final analysis. The authors recorded and measured clinical and anatomical parameters and evaluated their relationships to the first-pass effect.

RESULTS

The first-pass effect was achieved in 46% of the patients. When a single device was employed, aspiration thrombectomy was more effective than stent retriever thrombectomy. A larger M1 diameter (p = 0.001), decreased vessel diameter tapering between the petrous segment of the internal carotid artery (ICA) and M1 (p < 0.001), and distal collateral grading (p = 0.044) were associated with first-pass recanalization. LASSO (least absolute shrinkage and selection operator) was used to generate a predictive model for recanalization using anatomical variables.

CONCLUSIONS

The authors demonstrated that a larger M1 vessel diameter, low rate of vessel diameter tapering along the course of the intracranial ICA, and distal collateral status are associated with first-pass recanalization for patients with M1 occlusions.

Restricted access

Chelsea J. Hendow, Alexander Beschloss, Alejandro Cazzulino, Joseph M. Lombardi, Philip K. Louie, Andrew H. Milby, Andrew J. Pugely, Ali K. Ozturk, Steven C. Ludwig and Comron Saifi

OBJECTIVE

The objective of this study was to investigate revision burden and associated demographic and economic data for atlantoaxial (AA) fusion procedures in the US.

METHODS

Patient data from the National Inpatient Sample (NIS) database for primary AA fusion were obtained from 1993 to 2015, and for revision AA fusion from 2006 to 2014 using ICD-9 procedure codes. Data from 2006 to 2014 were used in comparisons between primary and revision surgeries. National procedure rates, hospital costs/charges, length of stay (LOS), routine discharge, and mortality rates were investigated.

RESULTS

Between 1993 and 2014, 52,011 patients underwent primary AA fusion. Over this period, there was a 111% increase in annual number of primary surgeries performed. An estimated 1372 patients underwent revision AA fusion between 2006 and 2014, and over this time period there was a 6% decrease in the number of revisions performed annually. The 65–84 year-old age group increased as a proportion of primary AA fusions in the US from 35.9% of all AA fusions in 1997 to 44.2% in 2015, an increase of 23%. The mean hospital cost for primary AA surgery increased 32% between 2006 and 2015, while the mean cost for revision AA surgery increased by 35% between 2006 and 2014. Between 2006 and 2014, the mean hospital charge for primary AA surgery increased by 67%; the mean charge for revision surgery over that same period increased by 57%. Between 2006 and 2014, the mean age for primary AA fusions was 60 years, while the mean age for revision AA fusions was 52 years. The mean LOS for both procedures decreased over the study period, with primary AA fusion decreasing by 31% and revision AA fusion decreasing by 24%. Revision burden decreased by 21% between 2006 and 2014 (mean 4.9%, range 3.2%–6.4%). The inpatient mortality rate for primary AA surgery decreased from 5.3% in 1993 to 2.2% in 2014.

CONCLUSIONS

The number of primary AA fusions between 2006 and 2014 increased 22%, while the number of revision procedures has decreased 6% over the same period. The revision burden decreased by 21%. The inpatient mortality rate decreased 62% (1993–2014) to 2.2%. The increased primary fusion rate, decreased revision burden, and decreased inpatient mortality determined in this study may suggest an improvement in the safety and success of primary AA fusion.

Free access

Stephanie Schipmann, Michael Müther, Louise Stögbauer, Sebastian Zimmer, Benjamin Brokinkel, Markus Holling, Oliver Grauer, Eric Suero Molina, Nils Warneke and Walter Stummer

OBJECTIVE

High-grade glioma (HGG) prognosis remains dismal, with inevitable, mostly local recurrence. Regimens for improving local tumor control are therefore needed. Photodynamic therapy (PDT) using porfimer sodium has been investigated but was abandoned due to side effects and lack of survival benefits. Intracellular porphyrins induced by 5-aminolevulinic acid (5-ALA) are approved for fluorescence-guided resections (FGRs), but are also photosensitizers. Activated by light, they generate reactive oxygen species with resultant cytotoxicity. The authors present a combined approach of 5-ALA FGR and PDT.

METHODS

After 5-ALA FGR in recurrent HGG, laser diffusors were strategically positioned inside the resection cavity. PDT was applied for 60 minutes (635 nm, 200 mW/cm diffusor, for 1 hour) under continuous irrigation for maintaining optical clarity and ventilation with 100% oxygen. MRI was performed at 24 hours, 14 days, and every 3 months after surgery, including diffusion tensor imaging and apparent diffusion coefficient maps.

RESULTS

Twenty patients were treated. One surgical site infection after treatment was noted at 6 months as the only adverse event. MRI revealed cytotoxic edema along resection margins in 16 (80%) of 20 cases, mostly annular around the cavity, corresponding to prior laser diffusor locations (mean volume 3.3 cm3). Edema appeared selective for infiltrated tissue or nonresected enhancing tumor. At the 14-day follow-up, enhancement developed in former regions of edema, in some cases vanishing after 4–5 months. Median progression-free survival (PFS) was 6 months (95% CI 4.8–7.2 months).

CONCLUSIONS

Combined 5-ALA FGR and PDT provides an innovative and safe method of local tumor control resulting in promising PFS. Further prospective studies are warranted to evaluate long-term therapeutic effects.

Restricted access

Hyung-Chul Lee, Hyun-Kyu Yoon, Jung Hee Kim, Yong Hwy Kim and Hee-Pyoung Park

OBJECTIVE

In this double-blind randomized trial, the necessity of preoperative steroid administration in patients without adrenal insufficiency (AI) undergoing endoscopic transsphenoidal surgery (ETSS) for pituitary adenoma was evaluated.

METHODS

Forty patients with and without AI, defined as a peak cortisol level > 18 µg/dl on the insulin tolerance test or rapid adrenocorticotropic hormone (ACTH) test, undergoing ETSS for nonfunctioning pituitary adenomas were randomly allocated to treatment with either 100 mg of preoperative hydrocortisone (group HC, n = 20) or normal saline (group C, n = 20). The patients with pituitary apoplexy, the use of a drug within the last 3 months that could affect the hypothalamic-pituitary-adrenal axis, or a previous history of brain or adrenal surgery were excluded. Intraoperative cortisol and ACTH levels were measured after anesthesia induction, dura incision, and tumor removal, and at the end of surgery. Intraoperative hypotension, early postoperative AI, and postoperative 3-month pituitary function were investigated.

RESULTS

Intraoperative serum cortisol levels were significantly higher in the HC group than in the C group after anesthesia induction (median 69.0 µg/dl [IQR 62.2–89.6 µg/dl] vs 12.7 µg/dl [IQR 8.4–18.2 µg/dl], median difference 57.5 µg/dl [95% CI 33.0–172.9 µg/dl]), after dura incision (median 53.2 µg/dl [IQR 44.9–63.8 µg/dl] vs 6.4 [IQR 4.8–9.2 µg/dl], median difference 46.6 µg/dl [95% CI 13.3–89.2 µg/dl]), after tumor removal (median 49.5 µg/dl [IQR 43.6–62.4 µg/dl] vs 9.2 µg/dl [IQR 5.75–16.7 µg/dl], median difference 39.4 µg/dl [95% CI 0.3–78.1 µg/dl]), and at the end of surgery (median 46.9 µg/dl [IQR 40.1–63.4 µg/dl] vs 16.9 µg/dl [IQR 12.1–23.2 µg/dl], median difference 32.2 µg/dl [95% CI −42.0 to 228.1 µg/dl]). Serum ACTH levels were significantly lower in group HC than in group C after anesthesia induction (median 3.9 pmol/L [IQR 1.7–5.2 pmol/L] vs 6.9 pmol/L [IQR 3.9–11.9 pmol/L], p = 0.007). No patient showed intraoperative hypotension due to AI. Early postoperative AI was observed in 3 and 5 patients in groups HC and C, respectively. The postoperative 3-month pituitary hormone outcomes including ACTH deficiency were not different between groups.

CONCLUSIONS

Preoperative steroid administration may be unnecessary in patients without AI undergoing ETSS for nonfunctioning pituitary adenomas. However, a further large-scale study is needed to determine whether preoperative steroid administration has a significant impact on clinically meaningful events such as perioperative AI and postoperative 3-month ACTH deficiency in these patients.

Korean Clinical Trial Registry no.: KCT0002426 (https://cris.nih.go.kr/cris/).

Restricted access

Andrew K. Chan, Rory R. Mayer, Praveen V. Mummaneni and Dean Chou

Free access

Alejandro Tomasello, David Hernandez, Laura Ludovica Gramegna, Sonia Aixut, Roger Barranco Pons, Olav Jansen, Michal Zawadzki, Antonio Lopez-Rueda, Carmen Parra-Fariñas, Carlos Piñana, Lavinia Dinia, Fuat Arikan and Alex Rovira

OBJECTIVE

The goal of this study was to evaluate the effectiveness and safety of a new noncompletely occlusive net-assisted remodeling technique in which the Cascade net device is used for temporary bridging of intracranial aneurysms.

METHODS

Between July 2018 and May 2019, patients underwent coil embolization with the Cascade net device within 4 centers in Europe. Analysis of angiographic (modified Raymond-Roy classification [MRRC]) and clinical outcomes data was conducted immediately following treatment and at the 6-month follow-up.

RESULTS

Fifteen patients were included in the study (mean age 58 ± 13 years, 11/15 [73.3%] female). Ten patients had unruptured aneurysms, and 5 presented with ruptured aneurysms with acute subarachnoid hemorrhage. The mean aneurysm dome length was 6.27 ± 2.33 mm and the mean neck width was 3.64 ± 1.19 mm. Immediately postprocedure, MRRC type I (complete obliteration) was achieved in 11 patients (73.3%), whereas a type II (residual neck) was achieved in 4 patients (26.7%). Follow-up examination was performed in 7/15 patients and showed stabilization of aneurysm closure with no thromboembolic complications and only 1 patient with an increased MRRC score (from I to II) due to coil compression.

CONCLUSIONS

Initial experience shows that the use of a new noncompletely occlusive net-assisted remodeling technique with the Cascade net device may be safe and effective for endovascular coil embolization of intracranial aneurysms.

Free access

Baha’eddin A. Muhsen, Krishna C. Joshi, Bryan S. Lee, Bicky Thapa, Hamid Borghei-Razavi, Xuefei Jia, Gene H. Barnett, Samuel T. Chao, Alireza M. Mohammadi, John H. Suh, Michael A. Vogelbaum and Lilyana Angelov

OBJECTIVE

Gamma Knife radiosurgery (GKRS) as monotherapy is an option for the treatment of large (≥ 2 cm) posterior fossa brain metastases (LPFMs). However, there is concern regarding possible posttreatment increase in peritumoral edema (PTE) and associated compression of the fourth ventricle. This study evaluated the effects and safety of GKRS on tumor and PTE control in LPFM.

METHODS

The authors performed a single-center retrospective review of 49 patients with 51 LPFMs treated with GKRS. Patients with at least 1 clinical and radiological follow-up visit were included. Tumor, PTE, and fourth ventricle volumetric measurements were used to assess efficacy and safety. Overall survival was a secondary outcome.

RESULTS

Fifty-one lesions in 49 consecutive patients were identified; 57.1% of patients were male. At the time of GKRS, the median age was 61.5 years, and the median Karnofsky Performance Status score was 90. The median number of LPFMs and overall brain metastases were 1 and 2, respectively. The median overall tumor, PTE, and fourth ventricle volumes at diagnosis were 4.96 cm3 (range 1.4–21.1 cm3), 14.98 cm3 (range 0.6–71.8 cm3), and 1.23 cm3 (range 0.3–3.2 cm3), respectively, and the median lesion diameter was 2.6 cm (range 2.0–5.07 cm). The median follow-up time was 7.3 months (range 1.6–57.2 months). At the first follow-up, 2 months posttreatment, the median tumor volume decreased by 58.66% (range −96.95% to +48.69%, p < 0.001), median PTE decreased by 78.10% (range −99.92% to +198.35%, p < 0.001), and the fourth ventricle increased by 24.97% (range −37.96% to +545.6%, p < 0.001). The local control rate at first follow-up was 98.1%. The median OS was 8.36 months. No patient required surgical intervention, external ventricular drainage, or shunting between treatment and first follow-up. However, 1 patient required a ventriculoperitoneal shunt at 23 months from treatment. Posttreatment, 65.30% received our general steroid taper, 6.12% received no steroids, and 28.58% required prolonged steroid treatment.

CONCLUSIONS

In this retrospective analysis, patients with LPFMs treated with GKRS had a statistically significant posttreatment reduction in tumor size and PTE and marked opening of the fourth ventricle (all p < 0.001). This study demonstrates that GKRS is well tolerated and can be considered in the management of select cases of LPFMs, especially in patients who are poor surgical candidates.

Restricted access

Mark N. Pernik, Luke J. Dosselman, Salah G. Aoun, Adrienne D. Walker, Kristen Hall, Valery Peinado Reyes, David L. McDonagh and Carlos A. Bagley

OBJECTIVE

The aim of this study was to determine if the use of tranexamic acid (TXA) in long-segment spinal fusion surgery can help reduce perioperative blood loss, transfusion requirements, and morbidity.

METHODS

In this retrospective single-center study, the authors included 119 consecutive patients who underwent thoracolumbar fusion spanning at least 4 spinal levels from October 2016 to February 2019. Blood loss, transfusion requirements, perioperative morbidity, and adverse thrombotic events were compared between a cohort receiving intravenous TXA and a control group that did not.

RESULTS

There was no significant difference in any measure of intraoperative blood loss (1514.3 vs 1209.1 mL, p = 0.29) or transfusion requirement volume between the TXA and control groups despite a higher number of pelvic fusion procedures in the TXA group (85.9% vs 62.5%, p = 0.003). Postoperative transfusion volume was significantly lower in TXA patients (954 vs 572 mL, p = 0.01). There was no difference in the incidence of thrombotic complications between the groups.

CONCLUSIONS

TXA appears to provide a protective effect against blood loss in long-segment spine fusion surgery specifically when pelvic dissection and fixation is performed. TXA also seems to decrease postoperative transfusion requirements without increasing the risk of adverse thrombotic events.

Restricted access

Steven Tominey, Chandrasekaran Kaliaperumal and Pasquale Gallo

OBJECTIVE

Contention exists regarding appropriate classification and management of spinal lipomas (SLs). Given the heterogeneity of SLs, omissions and overlap between surgically incomparable groups exist in conventional classification systems. The new classification of spinal lipoma (NCSL) recently proposed by Morota et al. delineates morphology by embryological pathogenesis and the resultant operative difficulty. Here, the authors aimed to validate the NCSL by applying it to patients who had been operated on at their institution.

METHODS

All children who had undergone resection for SL between 2014 and 2018 were included in this analysis. MRI studies were independently reviewed and classified by three adjudicators. Baseline characteristics, inter-adjudicator agreement, coexisting anomalies and/or malformations, and postoperative outcomes and complications were analyzed.

RESULTS

Thirty-six patients underwent surgical untethering for SL: NCSL type 1 in 5 patients (14%), type 2 in 14 patients (39%), type 3 in 4 patients (11%), and type 4 in 13 patients (36%). All classification was agreed on first assignment by the adjudicators. Radical or near-radical resection, which was attempted in all patients, was always possible in those with type 1 and 4 SL, but never in those with type 2 and 3 SL. Neurological stabilization and/or improvement were observed in all patients at the last follow-up.

CONCLUSIONS

The NCSL was found to be a logical and reproducible system to apply in this SL population. All cases were successfully classified with a high degree of inter-assessor agreement. Widespread establishment of a commonly adopted and clinically useful classification system will enable clinicians to improve patient selection as well as discussion with patient representatives during the decision-making process.

Restricted access

Mikhail Lew P. Ver, Jeffrey L. Gum, Charles H. Crawford III, Mladen Djurasovic, R. Kirk Owens II, Morgan Brown, Portia Steele and Leah Y. Carreon

OBJECTIVE

Posterior fixation with interbody cage placement can be accomplished via numerous techniques. In an attempt to expedite recovery by limiting muscle dissection, midline lumbar interbody fusion (MIDLIF) has been described. More recently, the authors have developed a robot-assisted MIDLIF (RA-MIDLIF) technique. The purpose of this study was to compare the index episode-of-care (iEOC) parameters between patients undergoing traditional open transforaminal lumbar interbody fusion (tTLIF), MIDLIF, and RA-MIDLIF.

METHODS

A retrospective review of a prospective, multisurgeon surgical database was performed. Consecutive patients undergoing 1- or 2-level tTLIF, MIDLIF, or RA-MIDLIF for degenerative lumbar conditions were identified. Patients in each cohort were propensity matched based on age, sex, smoking status, BMI, diagnosis, American Society of Anesthesiologists (ASA) class, and number of levels fused. Index EOC parameters such as length of stay (LOS), estimated blood loss (EBL), operating room (OR) time, and actual, direct hospital costs for the index surgical visit were analyzed.

RESULTS

Of 281 and 249 patients undergoing tTLIF and MIDLIF, respectively, 52 cases in each cohort were successfully propensity matched to the authors’ first 55 RA-MIDLIF cases. Consistent with propensity matching, there was no significant difference in age, sex, BMI, diagnosis, ASA class, or levels fused. Spondylolisthesis was the most common indication for surgery in all cohorts. The mean total iEOC was similar across all cohorts. Patients undergoing RA-MIDLIF had a shorter average LOS (1.53 days) than those undergoing either MIDLIF (2.71 days) or tTLIF (3.58 days). Both MIDLIF and RA-MIDLIF were associated with lower EBL and less OR time compared with tTLIF.

CONCLUSIONS

Despite concerns for additional cost and time while introducing navigation or robotic technology, a propensity-matched comparison of the authors’ first 52 RA-MIDLIF surgeries with tTLIF and MIDLIF showed promising results for reducing OR time, EBL, and LOS without increasing cost.