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Nitin Agarwal, Ahmed Kashkoush, Michael M. McDowell, William R. Lariviere, Naveed Ismail and Robert M. Friedlander

OBJECTIVE

Ventricular shunt (VS) durability has been well studied in the pediatric population and in patients with normal pressure hydrocephalus; however, further evaluation in a more heterogeneous adult population is needed. This study aims to evaluate the effect of diagnosis and valve type—fixed versus programmable—on shunt durability and cost for placement of shunts in adult patients.

METHODS

The authors retrospectively reviewed the medical records of all patients who underwent implantation of a VS for hydrocephalus at their institution over a 3-year period between August 2013 and October 2016 with a minimum postoperative follow-up of 6 months. The primary outcome was shunt revision, which was defined as reoperation for any indication after the initial procedure. Supply costs, shunt durability, and hydrocephalus etiologies were compared between fixed and programmable valves.

RESULTS

A total of 417 patients underwent shunt placement during the index time frame, consisting of 62 fixed shunts (15%) and 355 programmable shunts (85%). The mean follow-up was 30 ± 12 (SD) months. The shunt revision rate was 22% for programmable pressure valves and 21% for fixed pressure valves (HR 1.1 [95% CI 0.6–1.8]). Shunt complications, such as valve failure, infection, and overdrainage, occurred with similar frequency across valve types. Kaplan-Meier survival curve analysis showed no difference in durability between fixed (mean 39 months) and programmable (mean 40 months) shunts (p = 0.980, log-rank test). The median shunt supply cost per index case and accounting for subsequent revisions was $3438 (interquartile range $2938–$3876) and $1504 (interquartile range $753–$1584) for programmable and fixed shunts, respectively (p < 0.001, Wilcoxon rank-sum test). Of all hydrocephalus etiologies, pseudotumor cerebri (HR 1.9 [95% CI 1.2–3.1]) and previous shunt malfunction (HR 1.8 [95% CI 1.2–2.7]) were found to significantly increase the risk of shunt revision. Within each diagnosis, there were no significant differences in revision rates between shunts with a fixed valve and shunts with a programmable valve.

CONCLUSIONS

Long-term shunt revision rates are similar for fixed and programmable shunt pressure valves in adult patients. Hydrocephalus etiology may play a significant role in predicting shunt revision, although programmable valves incur higher supply costs regardless of initial diagnosis. Utilization of fixed pressure valves versus programmable pressure valves may reduce supply costs while maintaining similar revision rates. Given the importance of developing cost-effective management protocols, this study highlights the critical need for large-scale prospective observational studies and randomized clinical trials of ventricular shunt valve revisions and additional patient-centered outcomes.

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Nitin Agarwal, Ahmed Kashkoush, Michael M. McDowell, William R. Lariviere, Naveed Ismail and Robert M. Friedlander

OBJECTIVE

Ventricular shunt (VS) durability has been well studied in the pediatric population and in patients with normal pressure hydrocephalus; however, further evaluation in a more heterogeneous adult population is needed. This study aims to evaluate the effect of diagnosis and valve type—fixed versus programmable—on shunt durability and cost for placement of shunts in adult patients.

METHODS

The authors retrospectively reviewed the medical records of all patients who underwent implantation of a VS for hydrocephalus at their institution over a 3-year period between August 2013 and October 2016 with a minimum postoperative follow-up of 6 months. The primary outcome was shunt revision, which was defined as reoperation for any indication after the initial procedure. Supply costs, shunt durability, and hydrocephalus etiologies were compared between fixed and programmable valves.

RESULTS

A total of 417 patients underwent shunt placement during the index time frame, consisting of 62 fixed shunts (15%) and 355 programmable shunts (85%). The mean follow-up was 30 ± 12 (SD) months. The shunt revision rate was 22% for programmable pressure valves and 21% for fixed pressure valves (HR 1.1 [95% CI 0.6–1.8]). Shunt complications, such as valve failure, infection, and overdrainage, occurred with similar frequency across valve types. Kaplan-Meier survival curve analysis showed no difference in durability between fixed (mean 39 months) and programmable (mean 40 months) shunts (p = 0.980, log-rank test). The median shunt supply cost per index case and accounting for subsequent revisions was $3438 (interquartile range $2938–$3876) and $1504 (interquartile range $753–$1584) for programmable and fixed shunts, respectively (p < 0.001, Wilcoxon rank-sum test). Of all hydrocephalus etiologies, pseudotumor cerebri (HR 1.9 [95% CI 1.2–3.1]) and previous shunt malfunction (HR 1.8 [95% CI 1.2–2.7]) were found to significantly increase the risk of shunt revision. Within each diagnosis, there were no significant differences in revision rates between shunts with a fixed valve and shunts with a programmable valve.

CONCLUSIONS

Long-term shunt revision rates are similar for fixed and programmable shunt pressure valves in adult patients. Hydrocephalus etiology may play a significant role in predicting shunt revision, although programmable valves incur higher supply costs regardless of initial diagnosis. Utilization of fixed pressure valves versus programmable pressure valves may reduce supply costs while maintaining similar revision rates. Given the importance of developing cost-effective management protocols, this study highlights the critical need for large-scale prospective observational studies and randomized clinical trials of ventricular shunt valve revisions and additional patient-centered outcomes.

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Ajay Niranjan, Ahmed Kashkoush, Hideyuki Kano, Edward A. Monaco III, John C. Flickinger and L. Dade Lunsford

OBJECTIVE

Seizures are the second-most common presenting symptom in patients with lobar arteriovenous malformations (AVMs). However, few studies have assessed the long-term effect of stereotactic radiosurgery (SRS) on seizure control. The authors of this study assess the outcome of SRS for these patients to identify prognostic factors associated with seizure control.

METHODS

Patients with AVM who presented with a history of seizure and underwent SRS at the authors’ institution between 1987 and 2012 were retrospectively assessed. The total cohort included 155 patients with a mean follow-up of 86 months (range 6–295 months). Primary outcomes assessed were seizure frequency, antiepileptic drug regimen, and seizure freedom for 6 months prior to last follow-up.

RESULTS

Seizure-free status was achieved in 108 patients (70%), with an additional 23 patients (15%) reporting improved seizure frequency as compared to their pre-SRS status. The median time to seizure-free status was estimated to be 12 months (95% CI 0–27 months) as evaluated via Kaplan-Meier survival analysis. The mean seizure frequency prior to SRS was 14.2 (95% CI 5.4–23.1) episodes per year. Although not all patients tried, the proportion of patients successfully weaned off all antiepileptic drugs was 18% (28/155 patients). On multivariate logistic regression, focal impaired awareness seizure type (also known as complex partial seizures) and superficial venous drainage were significantly associated with a decreased odds ratio for seizure-free status at last follow-up (OR 0.37 [95% CI 0.15–0.92] for focal impaired awareness seizures; OR 0.36 [95% CI 0.16–0.81] for superficial venous drainage). The effects of superficial venous drainage on seizure outcome were nonsignificant when excluding patients with < 2 years of follow-up. AVM obliteration did not correlate with long-term seizure freedom (p = 0.202, chi-square test).

CONCLUSIONS

This study suggests that SRS improves long-term seizure control and increases the likelihood of being medication free, independently of AVM obliteration. Patients with focal impaired awareness seizures were less likely to obtain long-term seizure relief.

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Ahmed Kashkoush, Nitin Agarwal, Ashley Ayres, Victoria Novak, Yue-Fang Chang and Robert M. Friedlander

OBJECTIVE

The preoperative scrub has been shown to lower the incidence of surgical site infections (SSIs). Various scrubbing and gloving techniques exist; however, it is unknown how specific scrubbing technique influences SSI rates in neurosurgery. The authors aimed to assess whether the range of scrubbing practice in neurosurgery is associated with the incidence of SSIs.

METHODS

The authors conducted a retrospective review of a prospectively maintained database to identify all 90-day SSIs for neurosurgical procedures between 2012 and 2017 at one of their teaching hospitals. SSIs were classified by procedure type (craniotomy, shunt, fusion, or laminectomy). Surveys were administered to attending and resident physicians to understand the variation in scrubbing methods (wet vs dry, iodine vs chlorhexidine, single vs double glove). The chi-square followed by multivariate logistic regression analyses were utilized to identify independent predictors of SSI.

RESULTS

Forty-two operating physicians were included in the study (18 attending physicians, 24 resident physicians), who performed 14,200 total cases. Overall, SSI rates were 2.1% (296 SSIs of 14,200 total cases) and 2.0% (192 of 9,669 cases) for attending physicians and residents, respectively. Shunts were independently associated with an increased risk of SSI (OR 1.7 [95% CI 1.3–2.1]), whereas laminectomies were associated with a decreased SSI risk (OR 0.4 [95% CI 0.2–0.8]). Wet versus dry scrub (OR 0.9 [95% CI 0.6–1.4]), iodine versus chlorhexidine (OR 0.6 [95% CI 0.4–1.1]), and single- versus double-gloving (OR 1.1 [95% CI 0.8–1.4]) preferences were not associated with SSIs.

CONCLUSIONS

There is no evidence to suggest that perioperative infection is associated with personal scrubbing or gloving preference in neurosurgical procedures.

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Nitin Agarwal, Sumana S. Kommana, David R. Hansberry, Ahmed I. Kashkoush, Robert M. Friedlander and L. Dade Lunsford

OBJECTIVE

Closing the knowledge gap that exists between patients and health care providers is essential and is facilitated by easy access to patient education materials. Although such information has the potential to be an effective resource, it must be written in a user-friendly and understandable manner, especially when such material pertains to specialized and highly technical fields such as neurological surgery. The authors evaluated the accessibility, usability, and reliability of current educational resources provided by the American Association of Neurological Surgeons (AANS), Healthwise, and the National Institute for Neurological Disorders and Stroke (NINDS).

METHODS

Online neurosurgical patient education information provided by AANS, Healthwise, and NINDS was evaluated using the LIDA scale, a website quality assessment tool, by medical professionals and nonmedical professionals. A high achieving score is regarded as 90% or greater using the LIDA scale.

RESULTS

Accessibility scores were 76.7% (AANS), 83.3% (Healthwise), and 75.0% (NINDS). Average usability scores for the AANS, Healthwise, and NINDS were 73.3%, 82.6%, and 82.9%, respectively, when evaluated by medical professionals and 78.5%, 80.7%, and 75.9%, respectively, for nonmedical professionals, respectively. Average reliability scores were 58.5%, 53.3%, 72.6%, respectively, for medical professionals and 70.4%, 66.7%, and 78.5%, respectively, for nonmedical professionals when evaluating the AANS, Healthwise, and NINDS websites.

CONCLUSIONS

Although organizations like AANS, Healthwise, and NINDS should be commended for their ongoing commitment to provide health care–oriented materials, modification of this material is suggested to improve the patient education value.