Ryan D. Tackla and Andrew J. Ringer
Ralph Rahme, Mario Zuccarello, Dawn Kleindorfer, Opeolu M. Adeoye and Andrew J. Ringer
Although decompressive hemicraniectomy has been shown to reduce death and improve functional outcome following malignant middle cerebral artery territory infarction, there is ongoing debate as to whether surgery should be routinely performed, considering the very high rates of disability and functional dependence in survivors. Through a systematic review of the literature, the authors sought to determine the outcome from a patient's perspective.
In September 2010, a MEDLINE search of the English-language literature was performed using various combinations of 12 key words. A total of 16 papers were reviewed and individual study data were extracted.
There was significant variability in study design, patient eligibility criteria, timing of surgery, and methods of outcome assessment. There were 382 patients (59% male, 41% female) with a mean age of 50 years, 25% with dominant-hemisphere infarction. The mortality rate was 24% and the mean follow-up in survivors was 19 months (range 3–114 months). Of 156 survivors with available modified Rankin Scale (mRS) scores, 41% had favorable functional outcome (mRS Score ≤ 3), whereas 47% had moderately severe disability (mRS Score 4). Among 157 survivors with quality of life assessment, the mean overall reduction was 45%: 67% for physical aspect and 37% for psychosocial aspect. Of 114 screened survivors, depression affected 56% and was moderate or severe in 25%. Most patients and/or caregivers (77% of the 209 interviewed) were satisfied and would give consent again for the procedure.
Despite high rates of physical disability and depression, the vast majority of patients are satisfied with life and do not regret having undergone surgery.
Andrew J. Ringer, Elizabeth Matern, Samir Parikh and Nicholas B. Levine
Blunt cerebrovascular injury (BCI) to the carotid and vertebral arteries is being recognized with increasing frequency in trauma victims. Yet, only broadly defined criteria exist for the use of screening angiography. In this study, the authors systematically identified the associated injuries that predict BCI and provide guidelines for the types of injuries best evaluated by angiography.
Criteria for screening angiography were developed with intentionally broad inclusion to maximize sensitivity. Screening criteria for each patient and angiographic results (5-point scale of BCI) were recorded prospectively. Injuries most often associated with a positive angiogram were identified. Dissection grades of 0–1 were classified as minor.
Of 365 patients evaluated for trauma by angiography between January 2000 and December 2005, 40 patients with penetrating trauma were excluded. Of the 325 patients included in the study, 100 (30.8%) had positive angiographic findings, including 79 (24.3%) with major injuries. Fractures of the cervical spine and midface (or mandibular ramus) were associated with major BCI (identified in 30.7% of patients with cervical fractures and 30.8% of patients with midface fractures). However, thoracic trauma and soft tissue injury of the neck were rarely associated with a significant BCI (0 and 3 cases, respectively). Horner syndrome and cervical bruit were associated with arterial dissection in 9 of 10 patients. Skull base fractures and unexplained neurological findings were associated with major BCI in 13 (18.3%) of 71 and 11 (16.9%) of 65 patients, respectively.
Cervical and facial fractures resulting from blunt trauma were highly associated with BCI. After significant thoracic trauma or soft tissue injury to the neck, angiography should be reserved for patients with unexplained neurological findings or expanding hematomas of the neck.
Philip V. Theodosopoulos, Andrew J. Ringer, Christopher M. McPherson, Ronald E. Warnick, Charles Kuntz IV, Mario Zuccarello and John M. Tew Jr.
Health care reform debate includes discussions regarding outcomes of surgical interventions. Yet quality of medical care, when judged as a health outcome, is difficult to define because of impediments affecting accuracy in data collection, analysis, and reporting. In this prospective study, the authors report the outcomes for neurosurgical treatment based on point-of-care interactions recorded in the electronic medical record (EMR).
The authors' neurosurgery practice collected outcome data for 19 physicians and ancillary personnel using the EMR. Data were analyzed for 5361 consecutive surgical cases, either elective or emergency procedures, performed during 2009 at multiple hospitals, offices, and an ambulatory spine surgery center. Main outcomes included complications, length of stay (LOS), and discharge disposition for all patients and for certain frequently performed procedures. Physicians, nurses, and other medical staff used validated scales to record the hospital LOS, complications, disposition at discharge, and return to work.
Of the 5361 surgical procedures performed, two-thirds were spinal procedures and one-third were cranial procedures. Organization-wide compliance with reporting rates of major complications improved throughout the year, from 80.7% in the first quarter to 90.3% in the fourth quarter. Auditing showed that rates of unreported complications decreased from 11% in the first quarter to 4% in the fourth quarter. Complication data were available for 4593 procedures (85.7%); of these, no complications were reported in 4367 (95.1%). Discharge dispositions reported were home in 86.2%, rehabilitation center in 8.9%, and nursing home in 2.5%. Major complications included culture-proven infection in 0.61%, CSF leak in 0.89%, reoperation within the same hospitalization in 0.38%, and new neurological deficits in 0.77%. For the commonly performed procedures, the median hospital LOS was 3 days for craniotomy for aneurysm or intraaxial tumor and less than 1 day for angiogram, anterior cervical discectomy with fusion, or lumbar discectomy.
With prospectively collected outcome data for more than 5000 surgeries, the authors achieved their primary end point of institution-wide compliance and data accuracy. Components of this process included staged implementation with physician pilot studies and oversight, nurse participation, point-of-service data capture, EMR form modification, data auditing, and confidential surgeon reports.
Shawn M. Vuong, Christopher P. Carroll, Ryan D. Tackla, William J. Jeong and Andrew J. Ringer
During the past 20 years, the traditional supportive treatment for stroke has been radically transformed by advances in catheter technologies and a cohort of prominent randomized controlled trials that unequivocally demonstrated significant improvement in stroke outcomes with timely endovascular intervention. However, substantial limitations to treatment remain, among the most important being timely access to care. Nonetheless, stroke care has continued its evolution by incorporating technological advances from various fields that can further reduce patients' morbidity and mortality. In this paper the authors discuss the importance of emerging technologies—mobile stroke treatment units, telemedicine, and robotically assisted angiography—as future tools for expanding access to the diagnosis and treatment of acute ischemic stroke.
Andrew J. Ringer, Clemens M. Schirmer, Brian T. Jankowitz and for the Endovascular Neurosurgery Research Group (ENRG)
R. Loch Macdonald
Joseph C. Serrone, Ryan D. Tackla, Yair M. Gozal, Dennis J. Hanseman, Steven L. Gogela, Shawn M. Vuong, Jennifer A. Kosty, Calen A. Steiner, Bryan M. Krueger, Aaron W. Grossman and Andrew J. Ringer
Many low-risk unruptured intracranial aneurysms (UIAs) are followed for growth with surveillance imaging. Growth of UIAs likely increases the risk of rupture. The incidence and risk factors of UIA growth or de novo aneurysm formation require further research. The authors retrospectively identify risk factors and annual risk for UIA growth or de novo aneurysm formation in an aneurysm surveillance protocol.
Over an 11.5-year period, the authors recommended surveillance imaging to 192 patients with 234 UIAs. The incidence of UIA growth and de novo aneurysm formation was assessed. With logistic regression, risk factors for UIA growth or de novo aneurysm formation and patient compliance with the surveillance protocol was assessed.
During 621 patient-years of follow-up, the incidence of aneurysm growth or de novo aneurysm formation was 5.0%/patient-year. At the 6-month examination, 5.2% of patients had aneurysm growth and 4.3% of aneurysms had grown. Four de novo aneurysms formed (0.64%/patient-year). Over 793 aneurysm-years of follow-up, the annual risk of aneurysm growth was 3.7%. Only initial aneurysm size predicted aneurysm growth (UIA < 5 mm = 1.6% vs UIA ≥ 5 mm = 8.7%, p = 0.002). Patients with growing UIAs were more likely to also have de novo aneurysms (p = 0.01). Patient compliance with this protocol was 65%, with younger age predictive of better compliance (p = 0.01).
Observation of low-risk UIAs with surveillance imaging can be implemented safely with good adherence. Aneurysm size is the only predictor of future growth. More frequent (semiannual) surveillance imaging for newly diagnosed UIAs and UIAs ≥ 5 mm is warranted.
Steven L. Gogela, Yair M. Gozal, Bin Zhang, Thomas A. Tomsick, Andrew J. Ringer, Joseph P. Broderick, Pooja Khatri and Todd A. Abruzzo
The impact of extracranial carotid stenosis on interventional revascularization of acute anterior circulation stroke is unknown. The authors examined the effects of high-grade carotid stenosis on the results of endovascular treatment of patients in the Interventional Management of Stroke (IMS)-III trial.
The 278 patients in the endovascular arm of the IMS-III trial were categorized according to the degree of carotid stenosis as determined by angiography. In comparing patients with severe stenosis or occlusion (≥ 70%) to those without severe stenosis (< 70%), the authors evaluated the time to endovascular reperfusion, modified Thrombolysis in Cerebrovascular Infarction (mTICI) scores, 24-hour mean infarct volumes, symptomatic intracerebral hemorrhage rates, and modified Rankin Scale (mRS) scores at 90 days.
Compared with the 249 patients with less than 70% stenosis, patients with severe stenosis (n = 29) were found to have a significantly longer mean time to reperfusion (105.7 vs 77.7 minutes, p = 0.004); differences in mTICI scores, infarct volumes, hemorrhage rates, and mRS scores at 90 days did not reach statistical significance. Multiple regression analysis revealed that severe carotid stenosis (p < 0.0001) and higher baseline National Institutes of Health Stroke Scale (NIHSS) scores (p = 0.004) were associated with an increase in time to reperfusion. Older age (p < 0.0001), higher NIHSS score (p < 0.0001), and the absence of reperfusion (p = 0.001) were associated with worse clinical outcomes.
Severe ipsilateral ICA stenosis was associated with a significantly longer time to reperfusion in the IMS-III trial. Although these findings may not translate directly to modern devices, this 28-minute delay in reperfusion has significant implications, raising concern over the treatment of tandem ICA stenosis and downstream large-vessel occlusion.