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Siyu Shi, Raghav Gupta, Justin M. Moore, Christoph J. Griessenauer, Nimer Adeeb, Rouzbeh Motiei-Langroudi, Ajith J. Thomas and Christopher S. Ogilvy

Brain arteriovenous malformations (AVMs) are traditionally considered congenital lesions, arising from aberrant vascular development during the intrauterine period. Rarely, however, AVMs develop in the postnatal period. Individual case reports of de novo AVM formation in both pediatric and adult patients have challenged the traditional dogma of a congenital origin. Instead, for these cases, a dynamic picture is emerging of AVM growth and development, initially triggered by ischemic and/or traumatic events, coupled with genetic predispositions. A number of pathophysiological descriptions involving aberrant angiogenic responses following trauma, hemorrhage, or inflammation have been proposed, although the exact etiology of these lesions remains to be elucidated. Here, the authors present 2 cases of de novo AVM formation in adult patients. The first case involves the development of an AVM following a venous sinus thrombosis and to the authors' knowledge is the first of its kind to be reported in the literature. They also present a case in which an elderly patient with a previously ruptured AVM developed a second AVM in the contralateral hemisphere 11 years later. In addition to presenting these cases, the authors propose a possible mechanism for de novo AVM development in adult patients following ischemic injury.

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Ajith J. Thomas, Christopher S. Ogilvy, Christoph J. Griessenauer and Khalid A. Hanafy

OBJECTIVE

Even though heme-induced cerebral inflammation contributes to many of the adverse sequelae seen in patients with subarachnoid hemorrhage (SAH), little is known about the mechanism; mouse models have shown a critical role for macrophages/microglia. Macrophage CD163 is a hemoglobin scavenger receptor involved in blood clearance after SAH. The authors hypothesized that the modified Fisher score is independently associated with cerebrospinal fluid (CSF) macrophage CD163 expression on postictal day 1, and that CSF macrophage CD163 expression is associated with 1-month neurological outcome.

METHODS

CSF macrophages from 21 SAH and 28 unruptured aneurysm patients (control) were analyzed for CD163 expression using flow cytometry and confocal microscopy on postictal day 1. Significant associations with modified Fisher scale grades or modified Rankin Scale scores were determined using linear regression and a matched case control analysis.

RESULTS

CSF macrophage CD163 expression was significantly increased in SAH patients compared with controls (p < 0.001). The modified Fisher scale (mF) grades (β = 0.407, p = 0.005) and CSF bilirubin concentrations (β = 0.311, p = 0.015) were positively and independently associated with CSF macrophage CD163 expression when the analysis was controlled for age and sex. CSF macrophages from an SAH patient with a high mF grade had increased co-localization of CD163 and glycophorin A (CD235a, an erythrocyte marker) compared with those from an SAH patient with a low mF grade. The controls had no co-localization. CSF macrophage CD163 expression (p = 0.003) was inversely associated with 1-month neurological outcome, when SAH patients were matched based on mF grade.

CONCLUSIONS

This early study suggests that CSF macrophage CD163 expression, as measured by flow cytometry, may have some neuroprotective function given its inverse association with outcome and provides unique insights into the neuroinflammatory process after SAH.

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Raghav Gupta, Christoph J. Griessenauer, Justin M. Moore, Nimer Adeeb, Apar S. Patel, Christopher S. Ogilvy and Ajith J. Thomas

OBJECTIVE

Given the highly complex and demanding clinical environment in which neurosurgeons operate, the probability of facing a medical malpractice claim is high. Recent emphasis on tort reform within the political sphere has brought this issue to the forefront of medical literature. Despite the widespread fear of litigation in the medical community, few studies have provided an analysis of malpractice litigation in the field. Here, the authors attempt to delineate the medicolegal factors that impel plaintiffs to file medical malpractice claims related to the management of brain aneurysms, and to better characterize the nature of these lawsuits.

METHODS

The online legal database WestLawNext was searched to find all medical malpractice cases related to brain aneurysms across a 30-year period. All state and federal jury verdicts and settlements relevant to the search criterion were considered.

RESULTS

Sixty-six cases were obtained. The average age of the patient was 46.7 years. Seventy-one percent were female. The cases were distributed across 16 states. The jury found in favor of the plaintiff in 40.9% of cases, with a mean payout of $8,765,405, and in favor of the defendant in 28.8% of the cases. A failure to diagnose and/or a failure to treat in a timely manner were the 2 most commonly alleged causes of malpractice. Settlements, which were reached in 25.8% of the cases, had a mean payout of $1,818,250. Neurosurgeons accounted for 6.7% of all defendants.

CONCLUSIONS

Unlike other medical specialties, a majority of the verdicts were not in the defendant's favor. The mean payouts were nearly 5-fold less in cases in which a settlement was reached, as opposed to a summary judgment. Neurosurgeons accounted for a small percentage of all codefendants.

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Ajith J. Thomas, Jack P. Rock, Christine C. Johnson, Linda Weiss, Gordon Jacobsen and Mark L. Rosenblum

Object. It has been suggested that synchronous brain metastases (that is, those occurring within 2 months of primary cancer diagnosis) are associated with a shorter survival time compared with metachronous lesions (those occurring more than 2 months after primary cancer diagnosis). In this study the authors used data obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results program to determine the incidence of synchronous brain metastases and length of survival of patients in a defined population of southeastern Michigan residents.

Methods. Data obtained in 2682 patients with synchronous brain metastases treated between 1973 and 1995 were reviewed. Study criteria included patients in whom at least one brain metastasis was diagnosed within 2 months of the diagnosis of primary cancer and those with an unknown primary source. The incidence per 100,000 population increased fivefold, from 0.69 in 1973 to 3.83 in 1995. The most frequent site for the primary cancer was the lung (75.4%). The second largest group (10.7%) consisted of patients in whom the primary site was unknown. The median length of survival was 3.2 months. There was no significant difference in the median survival of patients with primary lung/bronchus and those with an unknown primary site (3.3 months and 3.2 months, respectively).

Conclusions. Patients who present with synchronous lesions have a poor prognosis, and the predominant cause of death, in more than 90% of cases, is related to systemic disease; however, despite poor median survival times, certain patients will experience prolonged survival.

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Ajith J. Thomas, Jack P. Rock, Christine C. Johnson, Linda Weiss, Gordon Jacobsen and Mark L. Rosenblum

Object

It has been suggested that synchronous brain metastases (that is, those occurring within 2 months of primary cancer diagnosis) are associated with a shorter survival time compared with metachronous lesions (those occurring greater than 2 months after primary cancer diagnosis). In this study the authors used data obtained from the National Cancer Institute's Surveillance, Epidemiology, and End Results Program to determine the incidence of synchronous brain metastases and length of survival of patients in a defined population of southeastern Michigan residents.

Methods

Data obtained in 2682 patients with synchronous brain metastases treated from 1973 to 1995 were reviewed. Study criteria included patients in whom at least one brain metastasis was diagnosed within 2 months of the diagnosis of primary cancer and those with an unknown primary source. The incidence per 100,000 increased fivefold, from 0.69 in 1973 to 3.83 in 1995. The most frequent site for the primary cancer was the lung (75.4%). The second largest group (10.7%) consisted of patients in whom the primary site was unknown. The median survival length was 3.3 months. There was no significant difference in the median survival in patients with primary lung/bronchus and those with an unknown primary site (3.2 months and 3.4 months, respectively).

Conclusions

Patients who present with synchronous lesions have a poor prognosis, and the predominant cause of death, in greater than 90% of cases, is related to systemic disease; however, despite poor median survival lengths, certain patients will experience prolonged survival.

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Raghav Gupta, Nimer Adeeb, Christoph J. Griessenauer, Justin M. Moore, Apar S. Patel, Christopher Kim, Ajith J. Thomas and Christopher S. Ogilvy

OBJECTIVE

Health care education resources are increasingly available on the Internet. A majority of people reference these resources at one point or another. A threshold literacy level is needed to comprehend the information presented within these materials. A key component of health literacy is the readability of educational resources. The National Institutes of Health (NIH) and the American Medical Association have recommended that patient education materials be written between a 4th- and a 6th-grade education level. The authors assessed the readability of online patient education materials about brain aneurysms that have been published by several academic institutions across the US.

METHODS

Online patient education materials about brain aneurysms were downloaded from the websites of 20 academic institutions. The materials were assessed via 8 readability scales using Readability Studio software (Oleander Software Solutions), and then were statistically analyzed.

RESULTS

None of the patient education materials were written at or below the NIH's recommended 6th-grade reading level. The average educational level required to comprehend the texts across all institutions, as assessed by 7 of the readability scales, was 12.4 ± 2.5 (mean ± SD). The Flesch Reading Ease Scale classified the materials as “difficult” to understand, correlating with a college-level education or higher. An ANOVA test found that there were no significant differences in readability among the materials from the institutions (p = 0.215).

CONCLUSIONS

Brain aneurysms affect 3.2% of adults 50 years or older across the world and can cause significant patient anxiety and uncertainty. Current patient education materials are not written at or below the NIH's recommended 4th- to 6th-grade education level.

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Luis C. Ascanio, Raghav Gupta, Nimer Adeeb, Justin M. Moore, Christoph J. Griessenauer, Julie Mayeku, Yaw Tachie-Baffour, Ranjit Thomas, Abdulrahman Y. Alturki, Philip G. R. Schmalz, Christopher S. Ogilvy and Ajith J. Thomas

OBJECTIVE

Currently, there is no established standard regarding the ideal number of external ventricular drain (EVD) clamp trials performed before ventriculoperitoneal (VP) shunt insertion following nontraumatic subarachnoid hemorrhage (SAH). In this study, the authors aimed to evaluate this relationship.

METHODS

A retrospective review of all patients presenting with SAH between July 2007 and December 2016 was performed. Patients with SAH who had received an EVD within the first 24 hours of hospital admission and had undergone at least 1 clamp trial prior to EVD removal were eligible for inclusion in the study. Patient demographics, clinical presentations, SAH etiologies and grades, clamp trial data, hospital lengths of stay, and functional outcomes were recorded.

RESULTS

One hundred fourteen patients with nontraumatic SAH complicated by posthemorrhagic hydrocephalus were included in the study. The median patient age was 57 years (range 28–90 years), with a male/female ratio of 1:1.7. A ruptured aneurysm was the underlying etiology of SAH in 79.8% of patients. A majority of patients (69.4%) had a Hunt and Hess grade III–V on admission. The median number of clamp trials performed was 2 (range 1–6). A VP shunt was required in 40.4% of patients. In those who underwent 2 and 3 clamp trials, 60% and 38.9%, respectively, did not require subsequent VP shunt placement.

CONCLUSIONS

Surgical placement of a VP shunt is associated with complications. Clamp trials are routinely performed before making the decision to insert a shunt. In the present study, the authors found that a significant percentage of patients passed their second and third clamp trials without requiring subsequent shunt insertion. These data support performing multiple clamp trials prior to shunt placement.

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Rouzbeh Motiei-Langroudi, Martina Stippler, Siyu Shi, Nimer Adeeb, Raghav Gupta, Christoph J. Griessenauer, Efstathios Papavassiliou, Ekkehard M. Kasper, Jeffrey Arle, Ron L. Alterman, Christopher S. Ogilvy and Ajith J. Thomas

OBJECTIVE

Chronic subdural hematoma (CSDH) is commonly encountered in neurosurgical practice. However, surgical evacuation remains complicated by a high rate of reoperation. The optimal surgical approach to reduce the reoperation rate has not been determined. In the current study, the authors evaluated the prognostic value of clinical and radiographic factors to predict reoperation in the context of CSDH.

METHODS

A retrospective review of 325 CSDH patients admitted to an academic medical center in the United States, between 2006 and 2016, was performed. Clinical and radiographic factors predictive of the need for CSDH reoperation were identified on univariable and multivariable analyses.

RESULTS

Univariable analysis showed that warfarin use, clopidogrel use, mixed hypo- and isointensity on T1-weighted MRI, greater preoperative midline shift, larger hematoma/fluid residual on first postoperative day CT, lesser decrease in hematoma size after surgery, use of monitored anesthesia care (MAC), and lack of intraoperative irrigation correlated with a significantly higher rate of reoperation. Multivariable analysis, however, showed that only the presence of loculation, clopidogrel or warfarin use, and percent of hematoma change after surgery significantly predicted the need for reoperation. Our results showed that 0% (no reduction), 50%, and 100% hematoma maximum thickness change (complete resolution of hematoma after surgery) were associated with a 41%, 6%, and < 1% rate of reoperation, respectively. The use of drains, either large diameter or small caliber, did not have any effect on the likelihood of reoperation.

CONCLUSIONS

Among many factors, clopidogrel or warfarin use, hematoma loculation on preoperative CT, and the amount of hematoma evacuation on the first postoperative CT were the strongest predictors of reoperation.