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Nicholas Theodore, Paul M. Arnold and Ankit I. Mehta

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Ryan G. Chiu, Angelica M. Fuentes and Ankit I. Mehta

OBJECTIVE

Several studies have indicated that racial disparities may exist in the management and outcomes of acute trauma care. One segment of trauma care that has not been as extensively investigated, however, is that of cranial trauma care. The goal of this study was to determine whether significant differences exist among racial and ethnic groups in various measures of inpatient management and outcomes after gunshot wounds to the head (GWH).

METHODS

In this study, the authors used the Nationwide (National) Inpatient Sample (NIS) to investigate all-cause mortality, receipt of surgery, days from admission to initial intervention, discharge disposition, length of hospital stay, and total hospital charges of those with GWH from 2012 to 2016. A 1:1 propensity score–matched analysis was conducted to evaluate the effect of race on these endpoints, while controlling for baseline demographics and comorbidities.

RESULTS

A total of 333 patients met the inclusion and exclusion criteria: 148 (44.44%) white/Caucasian, 123 (36.94%) black/African American, 54 (16.22%) Hispanic/Latinx, and 8 (2.40%) Asian. African American patients were sent to immediate care and rehabilitation significantly less often than Caucasian patients (RR 0.17 [95% CI 0.04–0.71]). There were no significant differences in mortality, length of stay, rates of surgical intervention, or total hospital charges among any of the racial groups.

CONCLUSIONS

The authors’ findings suggest that racial disparities in inpatient cranial trauma care and outcomes may not be as prevalent as previously thought. In fact, the disparities seen were only in disposition. More research is needed to further elucidate and address disparities within this population, particularly those that may exist prior to, and after, hospitalization.

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Ankit Patel, Sameer Ruparel, Tarun Dusad, Gaurav Mehta and Vishal Kundnani

OBJECTIVE

Spinal osteotomy in pediatric patients is challenging due to various factors. For correction of severe rigid kyphoscoliosis in children, numerous techniques with anterior or posterior or combined approaches, as well as multilevel osteotomies, have been described. These techniques are associated with prolonged operative times and large amounts of blood loss. The purpose of this study was to evaluate the clinical and radiologically confirmed efficacy of a modification of the apical spinal osteotomy (ASO) technique—posterior-only single-level asymmetric closing osteotomy—in pediatric patients with severe rigid kyphoscoliosis.

METHODS

The authors performed a retrospective study of a case series involving pediatric patients with severe spinal deformity operated on by a single surgeon at a single institution over a period of approximately 5 years. The inclusion criteria were age < 14 years, rigid thoracic/thoracolumbar/lumbar kyphosis (> 70°) with or without neurological deficit and with or without scoliosis, and a minimum of 2 years of follow-up. Patients with cervical or lumbosacral kyphoscoliosis were excluded from the study. Demographic and clinical parameters, including age, sex, etiology of kyphoscoliosis, neurological examination status (Frankel grade), and visual analog scale (VAS) and Oswestry Disability Index (ODI) scores, were noted. Operative parameters (level of osteotomy, number of levels fused, duration of surgery, blood loss, and complications) were also recorded. Radiological assessment was done for preoperative and postoperative kyphosis and scoliosis as well as the final Cobb angle. Similarly, sagittal vertical axis (SVA) correction was calculated. Fusion was assessed in all patients at the final follow-up evaluation.

RESULTS

A total of 26 pediatric patients (18 male and 8 female) with a mean age of 9 years met the inclusion criteria and had data available for analysis, and all of these patients had severe scoliosis as well as kyphosis. Comparison of preoperative and postoperative values showed a significant improvement (p < 0.05) in radiological, clinical, and functional parameters (Cobb angle for scoliosis and kyphosis, SVA, VAS, and ODI). With respect to kyphosis, the mean preoperative Cobb angle was 96.54°, the mean postoperative angle was 30.77°, and the mean angle at final follow-up was 34.81° (average loss of correction of 4.23°), for a final average correction of 64.15%. With respect to scoliosis, the mean preoperative angle was 52.54°, the mean postoperative angle was 15.77°, and the mean angle at final follow-up was 19.42° (average loss of correction of 3.66°), for a final average correction of 60.95%. The preoperative SVA averaged 7.6 cm; the mean SVA improved to 3.94 cm at the end of 2 years. Bony fusion was achieved in all patients. The mean number of levels fused was 5.69. The mean operative time was 243.46 minutes, with an average intraoperative blood loss of 336.92 ml. Nonneurological complications occurred in 15.39% of patients (2 dural tears, 1 superficial infection, 1 implant failure). At the 2-year follow-up, 25 of the 26 patients had maintained or improved their neurological status. One patient developed paraplegia immediately after the operation and recovered only partially.

CONCLUSIONS

Analysis of data from this series of 26 cases indicates that this posterior-approach single-level technique is effective for the correction of severe rigid kyphoscoliosis in pediatric patients, providing good clinical and radiological results in most cases.

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Abhinav K. Reddy, James S. Ryoo, Steven Denyer, Laura S. McGuire and Ankit I. Mehta

OBJECTIVE

The aim of this study was to illustrate the demographic characteristics of meningioma patients and observe the effect of adjuvant radiation therapy on survival by using the Surveillance, Epidemiology, and End Results (SEER) database. More specifically, the authors aimed to answer the question of whether adjuvant radiotherapy following resection of atypical meningioma confers a cause-specific survival benefit. Additionally, they attempted to add to previous characterizations of the epidemiology of primary meningiomas and assess the effectiveness of the standard of care for benign and anaplastic meningiomas. They also sought to characterize the efficacy of various treatment options in atypical and anaplastic meningiomas separately since nearly all other analyses have grouped these two together despite varying treatment regimens for these behavior categories.

METHODS

SEER data from 1973 to 2015 were queried using appropriate ICD-O-3 codes for benign, atypical, and anaplastic meningiomas. Patient demographics, tumor characteristics, and treatment choices were analyzed. The effects of treatment were examined using a multivariate Cox proportional hazards model and Kaplan-Meier survival analysis.

RESULTS

A total of 57,998 patients were included in the analysis of demographic, meningioma, and treatment characteristics. Among this population, cases of unspecified WHO tumor grade were excluded in the multivariate analysis, leaving a total of 12,931 patients to examine outcomes among treatment paradigms. In benign meningiomas, gross-total resection (HR 0.289, p = 0.013) imparted a significant cause-specific survival benefit over no treatment. In anaplastic meningioma cases, adjuvant radiotherapy imparted a significant survival benefit following both subtotal (HR 0.089, p = 0.018) and gross-total (HR 0.162, p = 0.002) resection as compared to gross-total resection alone. In atypical tumors, gross-total resection plus radiotherapy did not significantly change the hazard risk (HR 1.353, p = 0.628) compared to gross-total resection alone. Similarly, it was found that adjuvant radiation did not significantly benefit survival after a subtotal resection (HR 1.440, p = 0.644).

CONCLUSIONS

The results of this study demonstrate that the role of adjuvant radiotherapy, especially after the resection of atypical meningioma, remains somewhat unclear. Thus, given these results, prospective randomized clinical studies are warranted to provide clear information on the effects of adjuvant radiation in meningioma treatment.

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Ryan G. Chiu, Blake E. Murphy, David M. Rosenberg, Amy Q. Zhu and Ankit I. Mehta

OBJECTIVE

Much of the current discourse surrounding healthcare reform in the United States revolves around the role of the profit motive in medical care. However, there currently exists a paucity of literature evaluating the effect of for-profit hospital ownership status on neurological and neurosurgical care. The purpose of this study was to compare inpatient mortality, operation rates, length of stay, and hospital charges between private nonprofit and for-profit hospitals in the treatment of intracranial hemorrhage.

METHODS

This retrospective cohort study utilized data from the National Inpatient Sample (NIS) database. Primary outcomes, including all-cause inpatient mortality, operative status, patient disposition, hospital length of stay, total hospital charges, and per-day hospital charges, were assessed for patients discharged with a primary diagnosis of intracranial (epidural, subdural, subarachnoid, or intraparenchymal) hemorrhage, while controlling for baseline demographics, comorbidities, and interhospital differences via propensity score matching. Subgroup analyses by hemorrhage type were then performed, using the same methodology.

RESULTS

Of 155,977 unique hospital discharges included in this study, 133,518 originated from private nonprofit hospitals while the remaining 22,459 were from for-profit hospitals. After propensity score matching, mortality rates were higher in for-profit centers, at 14.50%, compared with 13.31% at nonprofit hospitals (RR 1.09, 95% CI 1.00–1.18; p = 0.040). Surgical operation rates were also similar (25.38% vs 24.42%; RR 0.96, 95% CI 0.91–1.02; p = 0.181). Of note, nonprofit hospitals appeared to be more intensive, with intracranial pressure monitor placement occurring in 2.13% of patients compared with 1.47% in for-profit centers (RR 0.69, 95% CI 0.54–0.88; p < 0.001). Discharge disposition was also similar, except for higher rates of absconding at for-profit hospitals (RR 1.59, 95% CI 1.12–2.27; p = 0.018). Length of stay was greater among for-profit hospitals (mean ± SD: 7.46 ± 11.91 vs 6.50 ± 8.74 days, p < 0.001), as were total hospital charges ($141,141.40 ± $218,364.40 vs $84,863.54 ± $136,874.71 [USD], p < 0.001). These findings remained similar even after segregating patients by subgroup analysis by hemorrhage type.

CONCLUSIONS

For-profit hospitals are associated with higher inpatient mortality, lengths of stay, and hospital charges compared with their nonprofit counterparts.

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Matthew K. Tobin, Joseph R. Geraghty, Herbert H. Engelhard, Andreas A. Linninger and Ankit I. Mehta

Intramedullary spinal cord tumors have low incidence rates but are associated with difficult treatment options. The majority of patients with these tumors can be initially treated with an attempted resection. Unfortunately, those patients who cannot undergo gross-total resection or have subtotal resection are left with few treatment options, such as radiotherapy and chemotherapy. These adjuvant treatments, however, are associated with the potential for significant adverse side effects and still leave patients with a poor prognosis. To successfully manage these patients and improve both their quality of life and prognosis, novel treatment options must be developed to supplement subtotal resection. New research is underway investigating alternative therapeutic approaches for these patients, including directed, localized drug delivery and nanomedicine techniques. These and other future investigations will hopefully lead to promising new therapies for these devastating diseases.

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Bhargav Desai, Ying Hsu, Benjamin Schneller, Jonathan G. Hobbs, Ankit I. Mehta and Andreas Linninger

Aquaporin-4 (AQP4) channels play an important role in brain water homeostasis. Water transport across plasma membranes has a critical role in brain water exchange of the normal and the diseased brain. AQP4 channels are implicated in the pathophysiology of hydrocephalus, a disease of water imbalance that leads to CSF accumulation in the ventricular system. Many molecular aspects of fluid exchange during hydrocephalus have yet to be firmly elucidated, but review of the literature suggests that modulation of AQP4 channel activity is a potentially attractive future pharmaceutical therapy. Drug therapy targeting AQP channels may enable control over water exchange to remove excess CSF through a molecular intervention instead of by mechanical shunting. This article is a review of a vast body of literature on the current understanding of AQP4 channels in relation to hydrocephalus, details regarding molecular aspects of AQP4 channels, possible drug development strategies, and limitations. Advances in medical imaging and computational modeling of CSF dynamics in the setting of hydrocephalus are summarized. Algorithmic developments in computational modeling continue to deepen the understanding of the hydrocephalus disease process and display promising potential benefit as a tool for physicians to evaluate patients with hydrocephalus.

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Isaac O. Karikari, Ankit I. Mehta, Can Solakoglu, Carlos A. Bagley, Michael C. Ain and Oren N. Gottfried

Object

Spinopelvic parameters in children with achondroplasia have not been described. Because they observed a unique sagittal spinopelvic phenotype in some achondroplastic children with very horizontal sacrums, the authors sought to quantify the spinopelvic parameters in a pediatric patient population.

Methods

A retrospective review was performed to identify all children (age range 1 month–10 years) with a diagnosis of achondroplasia between 2004 and 2009. Clinical and radiographic data were analyzed for age, sex, lumbar lordosis (LL), thoracic kyphosis (TK), thoracolumbar kyphosis (TLK), sacral slope (SS), pelvic tilt (PT), and pelvic incidence (PI). Differences among these variables were analyzed using a 2-tailed, unpaired Student t-test.

Results

Forty children, 23 males and 17 females, with achondroplasia were identified during the study period. The mean age was 2.6 years. Two groups of patients were identified based on PT (that is, negative or positive tilt and horizontal or not horizontal sacrum). A negative PT was identified in all children with an extremely horizontal sacrum. Seventeen children had a negative PT (mean −16.6°), and the mean parameters in this group were 65.4° for LL, 31.7° for TLK, 18.5° for TK, 43.3° for SS, and 26.4° for PI. Twenty-three children had a positive PT (mean 17.9°), and the mean parameters in this group were 53.4° for LL, 41.5° for TLK, 9.6° for TK, 30.8° for SS, and 43.8° for PI. A statistically significant difference was observed for LL (p = 0.01), TLK (p = 0.05), SS (p = 0.006), PT (p = 0.006), and PI (0.0002).

Conclusions

Spinopelvic parameters in achondroplasia are potentially dichotomous. The future implications of this observation are not known and will need to be explored in future long-term studies that follow pediatric patients with achondroplasia through adulthood.

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Mari Kusumi, Takanori Fukushima, Ankit I. Mehta, Hamidreza Aliabadi, Yoichi Nonaka, Allan H. Friedman and Kiyotaka Fujii

Object

The combined petrosal approach is a suitable technique for the resection of medium-to-large petroclival meningiomas (PCMs). Multiple technical modifications have been reported to increase the surgical corridor, including the method of dural and tentorial opening. The authors describe their method of dural opening and tentorial resection, and detail the microanatomy related to their technique to clarify pitfalls and effects.

Methods

The relationship of temporal bridging veins and cranial nerves (CNs) around the tentorial resection area was examined during the combined petrosal approach in 20 cadaveric specimens. The authors also reviewed their 23 consecutive clinical cases treated using this technique between 2002 and 2010, focusing on the effects and risks of the procedure.

Results

In the authors' method, the tentorial resection extends from 5 to 10 mm anterior to the junction of the sigmoid sinus and the superior petrosal sinus (“sinodural point”) to the trigeminal fibrous ring and the dural sleeve of CN IV. Temporal bridging veins enter the transverse sinus no more than 5 mm anterior to the sinodural point. The CN IV should be freed from its tentorial dural sleeve while avoiding disruption of the posterior cavernous sinus. The clinical data demonstrate a total resection rate of 78.3%, intraoperative estimated blood loss < 400 ml at a rate of 80.9%, and a venous congestion rate of 0%.

Conclusions

Understanding the anatomical relationship between the tentorium and temporal bridging veins and CNs IV–VI allows neurosurgeons the ability to develop a combined petrosal approach to PCMs that will effectively supply a wide operative corridor after resecting the tentorium, while significantly devascularizing tumors.

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Austin K. Mattox, Ankit I. Mehta, Peter M. Grossi, Thomas J. Cummings and D. Cory Adamson

Dermatofibrosarcoma protuberans (DFSP) is an uncommon, locally aggressive, malignant cutaneous tumor that sparingly presents on the scalp. Dermatofibrosarcomas often result from the formation of a fusion oncogene on translocated or supernumerary ring chromosomes 17 and 22, causing the overexpression of PDGFRβ driven by the COL1A1 promoter. Because of uncertainty surrounding appropriate treatment of aggressive scalp DFSP, the authors performed an extensive review of the available data from a MEDLINE (Ovid) search to describe the clinical presentation and treatment options for this rare tumor. Their search identified 39 different cases, including the illustrative case presented in this study.

Adjuvant therapy for this malignant lesion is not universally established in the literature. In the present case, the authors successfully treated a locally invasive scalp DFSP with presurgical therapy that specifically inhibited the PDGFβ receptor. Imatinib significantly shrank the DFSP tumor mass, reduced hypervascularity, reduced metabolic activity on PET scanning, and permitted a safe gross-total resection. Although wide excision and Mohs micrographic surgery remain the standard surgical treatments for DFSP, the authors illustrate that presurgical chemotherapeutic treatment by imatinib provides a critical adjunct to traditional therapy.