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Ian A. Buchanan, Brian Lee, Arun P. Amar and Steven L. Giannotta

Abciximab is a glycoprotein IIb/IIIa receptor antagonist that functions to prevent platelet aggregation, thus reducing thrombus initiation and propagation. It has been widely used during percutaneous endovascular interventions, such as aneurysm coil embolization, angioplasty, atherectomy, and stent placement, as both a preventative and a salvage therapy. The use of abciximab in cardiac and neurosurgical procedures has been associated with a reduced incidence of ischemic complications and a decreased need for repeated intervention. In these settings, abciximab has been delivered transarterially via a microcatheter or infused intravenously for systemic administration. The authors describe novel in situ delivery of abciximab as an agent to dissolve “white clots,” which are composed primarily of platelets, during an intracranial superficial temporal artery to middle cerebral artery bypass in a 28-year-old woman with severe intracranial occlusive disease. Abciximab was able to resolve multiple platelet-based clots after unsuccessful attempts with conventional clot dispersal techniques, such as heparinized saline, tissue plasminogen activator, mechanical passage of a wire through the vessel lumen, and multiple takedowns and re-anastomosis. After abciximab was administered, patency was demonstrated intraoperatively using indocyanine green dye and confirmed postoperatively at 1 and 10 months via CT angiography. The in situ use of abciximab as an agent to disperse a thrombus during intracranial bypass surgery is novel and has not previously been described in the literature, and serves as an additional tool during intracranial vessel bypass surgery.

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Mohamed Macki, Azam Basheer, Ian Lee, Ryan Kather, Ilan Rubinfeld and Muwaffak M. Abdulhak

OBJECTIVE

In the past, spine surgeons have avoided the transoral approach to the atlantoaxial segment because of concerns for unacceptable patient morbidity. The objective of this study was to measure 30-day postoperative complications, especially surgical site infection (SSI), after transoral versus posterior approach to atlantoaxial fusion.

METHODS

The source population was provided by the American College of Surgeons National Surgical Quality Improvement Program database, which was queried for all patients who underwent atlantoaxial fusion for degenerative/spondylotic disease and/or trauma between 2005 and 2014. To eliminate bias from unequal sample sizes, patients who underwent the transoral approach were matched with patients who underwent the posterior approach (generally 1:5 ratio) based on age ± 5 years and modified frailty index score (a measure of preoperative comorbidity burden). Because of rare SSI incidence, adjusted odds ratios (ORadj) of SSI were calculated using penalized maximum likelihood estimation.

RESULTS

A total of 318 patients were included in the study. There were no statistically significant differences between the transoral cohort (n = 56) and the posterior cohort (n = 262) in terms of 30-day postoperative individual complications, including SSI (1.79% vs 1.91%; p = 0.951) and composite complications (10.71% vs 6.87%; p = 0.323). Controlling for sex and smoking, the odds of SSI in the transoral approach were almost equal to the odds in the posterior approach (ORadj 1.17; p = 0.866). While the unplanned reoperation rate of 5.36% after transoral surgery was higher than the 1.53% rate after posterior surgery, the difference approached, but did not reach, statistical significance (p = 0.076).

CONCLUSIONS

Transoral versus posterior surgery for atlantoaxial fusion did not differ in 30-day unexpected outcomes. Therefore, spinal pathology, rather than concern for postoperative complications, should adjudicate the technical approach to the atlantoaxial segment.

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Kevin A. Reinard, Hesham M. Zakaria, Ahmad Qatanani, Ian Y. Lee, Jack P. Rock and Herman P. Houin

OBJECTIVE

Reconstruction of large solitary cranial defects after multiple craniotomies is challenging because scalp contraction generally requires more than simple subcutaneous undermining to ensure effective and cosmetically appealing closure. In plastic and reconstructive surgery, soft tissue expansion is considered the gold standard for reconstructing scalp defects; however, these techniques are not well known nor are they routinely practiced among neurosurgeons. The authors here describe a simple external tissue expansion technique that is associated with low morbidity and results in high cosmetic satisfaction among patients.

METHODS

The authors reviewed the medical records of patients with large cranial defects (> 5 cm) following multiple complicated craniotomies who had undergone reconstructive cranioplasty with preoperative tissue expansion using the DermaClose RC device. In addition to gathering data on patient age, sex, primary pathology, number of craniotomies and/or craniectomies, history of radiation therapy, and duration of external scalp tissue expansion, the authors screened patient charts for cerebrospinal fluid (CSF) leak, meningitis, intracranial abscess formation, dermatitis, and patient satisfaction rates.

RESULTS

The 6 identified patients (5 female, 1 male) had an age range from 36 to 70 years. All patients had complicating factors such as recalcitrant scalp infections after multiple craniotomies or cranial radiation, which led to secondary scalp tissue scarring and retraction. All patients were deemed to be potential candidates for rotational flaps with or without skin grafts. All patients underwent the same preoperative tissue expansion followed by standard cranial bone reconstruction. None of the patients developed CSF leak, meningitis, intracranial abscess, dermatitis, or permanent cosmetic defects. None of the patients required a reoperation. Mean follow-up was 117 days.

CONCLUSIONS

Preoperative scalp tissue expansion with the DermaClose RC device allows for simple and reliable completion of complicated cranial reconstruction with low morbidity rates and high cosmetic satisfaction among patients.

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Hesham Mostafa Zakaria, Azam Basheer, David Boyce-Fappiano, Erinma Elibe, Lonni Schultz, Ian Lee, Farzan Siddiqui, Brent Griffith and Victor Chang

OBJECTIVE

Predicting the survival rate for patients with cancer is currently performed using the TNM Classification of Malignant Tumors (TNM). Identifying accurate prognostic markers of survival would allow better treatment stratification between more aggressive treatment strategies or palliation. This is especially relevant for patients with spinal metastases, who all have identical TNM staging and whose surgical decision-making is potentially complex. Analytical morphometrics quantifies patient frailty by measuring lean muscle mass and can predict risk for postoperative morbidity after lumbar spine surgery. This study evaluates whether morphometrics can be predictive of survival in patients with spinal metastases.

METHODS

Utilizing a retrospective registry of patients with spinal metastases who had undergone stereotactic body radiation therapy, the authors identified patients with primary lung cancer. Morphometric measurements were taken of the psoas muscle using CT of the lumbar spine. Additional morphometrics were taken of the L-4 vertebral body. Patients were stratified into tertiles based on psoas muscle area. The primary outcome measure was overall survival, which was measured from the date of the patient's CT scan to date of death.

RESULTS

A total of 168 patients were identified, with 54% male and 54% having multiple-level metastases. The median survival for all patients was 185.5 days (95% confidence interval [CI] 146–228 days). Survival was not associated with age, sex, or the number of levels of metastasis. Patients in the smallest tertile for the left psoas area had significantly shorter survival compared with a combination of the other two tertiles: 139 days versus 222 days, respectively, hazard ratio (HR) 1.47, 95% CI 1.06–2.04, p = 0.007. Total psoas tertiles were not predictive of mortality, but patients whose total psoas size was below the median size had significantly shorter survival compared with those greater than the median size: 146 days versus 253.5 days, respectively, HR 1.43, 95% CI 1.05–1.94, p = 0.025. To try to differentiate small body habitus from frailty, the ratio of psoas muscle area to vertebral body area was calculated. Total psoas size became predictive of mortality when normalized to vertebral body ratio, with patients in the lowest tertile having significantly shorter survival (p = 0.017). Left psoas to vertebral body ratio was also predictive of mortality in patients within the lowest tertile (p = 0.021). Right psoas size was not predictive of mortality in any calculations.

CONCLUSIONS

In patients with lung cancer metastases to the spine, morphometric analysis of psoas muscle and vertebral body size can be used to identify patients who are at risk for shorter survival. This information should be used to select patients who are appropriate candidates for surgery and for the tailoring of oncological treatment regimens.

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Wenya Linda Bi, Ryan Brewster, Dennis Poe, David Vernick, Daniel J. Lee, C. Eduardo Corrales and Ian F. Dunn

Superior semicircular canal dehiscence (SSCD) syndrome is an increasingly recognized cause of vestibular and/or auditory symptoms in both adults and children. These symptoms are believed to result from the presence of a pathological mobile “third window” into the labyrinth due to deficiency in the osseous shell, leading to inadvertent hydroacoustic transmissions through the cochlea and labyrinth. The most common bony defect of the superior canal is found over the arcuate eminence, with rare cases involving the posteromedial limb of the superior canal associated with the superior petrosal sinus. Operative intervention is indicated for intractable or debilitating symptoms that persist despite conservative management and vestibular sedation. Surgical repair can be accomplished by reconstruction or plugging of the bony defect or reinforcement of the round window through a variety of operative approaches. The authors review the etiology, pathophysiology, presentation, diagnosis, surgical options, and outcomes in the treatment of this entity, with a focus on potential pitfalls that may be encountered during clinical management.

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Jessin K. John, Adam M. Robin, Aqueel H. Pabaney, Richard A. Rammo, Lonni R. Schultz, Neema S. Sadry and Ian Y. Lee

OBJECTIVE

Recent studies have demonstrated that periventricular tumor location is associated with poorer survival and that tumor location near the ventricle limits the extent of resection. This finding may relate to the perception that ventricular entry leads to further complications and thus surgeons may choose to perform less aggressive resection in these areas. However, there is little support for this view in the literature. This study seeks to determine whether ventricular entry is associated with more complications during craniotomy for brain tumor resection.

METHODS

A retrospective analysis of patients who underwent craniotomy for tumor resection at Henry Ford Hospital between January 2010 and November 2012 was conducted. A total of 183 cases were reviewed with attention to operative entry into the ventricular system, postoperative use of an external ventricular drain (EVD), subdural hematoma, hydrocephalus, and symptomatic intraventricular hemorrhage (IVH).

RESULTS

Patients in whom the ventricles were entered had significantly higher rates of any complication (46% vs 21%). Complications included development of subdural hygroma, subdural hematoma, intraventricular hemorrhage, subgaleal collection, wound infection, urinary tract infection/deep venous thrombosis, hydrocephalus, and ventriculoperitoneal (VP) shunt placement. Specifically, these patients had significantly higher rates of EVD placement (23% vs 1%, p < 0.001), hydrocephalus (6% vs 0%, p = 0.03), IVH (14% vs 0%, p < 0.001), infection (15% vs 5%, p = 0.04), and subgaleal collection (20% vs 4%, p < 0.001). It was also observed that VP shunt placement was only seen in cases of ventricular entry (11% vs 0%, p = 0.001) with 3 of 4 of these patients having a large ventricular entry (defined here as entry greater than a pinhole [< 3 mm] entry). Furthermore, in a subset of glioblastoma patients with and without ventricular entry, Kaplan-Meier estimates for survival demonstrated a median survival time of 329 days for ventricular entry compared with 522 days for patients with no ventricular entry (HR 1.13, 95% CI 0.65–1.96; p = 0.67).

CONCLUSIONS

There are more complications associated with ventricular entry during brain tumor resection than in nonviolated ventricular systems. Better strategies for management of periventricular tumor resection should be actively sought to improve resection and survival for these patients.

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John R. W. Kestle, Amy Lee, Richard C. E. Anderson, Barbu Gociman, Kamlesh B. Patel, Matthew D. Smyth, Craig Birgfeld, Ian F. Pollack, Jesse A. Goldstein, Mandeep Tamber, Thomas Imahiyerobo, Faizi A. Siddiqi and for the Synostosis Research Group

OBJECTIVE

The authors created a collaborative network, the Synostosis Research Group (SynRG), to facilitate multicenter clinical research on craniosynostosis. To identify common and differing practice patterns within the network, they assessed the SynRG surgeons’ management preferences for sagittal synostosis. These results will be incorporated into planning cooperative studies.

METHODS

The SynRG consists of 12 surgeons at 5 clinical sites. An email survey was distributed to SynRG surgeons in late 2016, and responses were collected through early 2017. Responses were collated and analyzed descriptively.

RESULTS

All of the surgeons—7 plastic/craniofacial surgeons and 5 neurosurgeons—completed the survey. They varied in both experience (1–24 years) and sagittal synostosis case volume in the preceding year (5–45 cases). Three sites routinely perform preoperative CT scans. The preferred surgical technique for children younger than 3 months is strip craniectomy (10/12 surgeons), whereas children older than 6 months are all treated with open cranial vault surgery. Pre-incision cefazolin, preoperative complete blood count panels, and an arterial line were used by most surgeons, but tranexamic acid was used routinely at 3 sites and never at the other 2 sites. Among surgeons performing endoscopic strip craniectomy surgery (SCS), most create a 5-cm-wide craniectomy, whereas 2 surgeons create a 2-cm strip. Four surgeons routinely send endoscopic SCS patients to the intensive care unit after surgery. Two of the 5 sites routinely obtain a CT scan within the 1st year after surgery.

CONCLUSIONS

The SynRG surgeons vary substantially in the use of imaging, the choice of surgical procedure and technique, and follow-up. A collaborative network will provide the opportunity to study different practice patterns, reduce variation, and contribute multicenter data on the management of children with craniosynostosis.

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Ian F. Caplan, Gregory Glauser, Stephen Goodrich, H. Isaac Chen, Timothy H. Lucas, John Y. K. Lee, Scott D. McClintock and Neil R. Malhotra

OBJECTIVE

Obstructive sleep apnea (OSA) is known to be associated with negative outcomes and is underdiagnosed. The STOP-Bang questionnaire is a screening tool for OSA that has been validated in both medical and surgical populations. Given that readmission after surgical intervention is an undesirable event, the authors sought to investigate, among patients not previously diagnosed with OSA, the capacity of the STOP-Bang questionnaire to predict 30-day readmissions following craniotomy for a supratentorial neoplasm.

METHODS

For patients undergoing craniotomy for treatment of a supratentorial neoplasm within a multiple-hospital academic medical center, data were captured in a prospective manner via the Neurosurgery Quality Improvement Initiative (NQII) EpiLog tool. Data were collected over a 1-year period for all supratentorial craniotomy cases. An additional criterion for study inclusion was that the patient was alive at 30 postoperative days. Statistical analysis consisted of simple logistic regression, which assessed the ability of the STOP-Bang questionnaire and additional variables to effectively predict outcomes such as 30-day readmission, 30-day emergency department (ED) visit, and 30-day reoperation. The C-statistic was used to represent the receiver operating characteristic (ROC) curve, which analyzes the discrimination of a variable or model.

RESULTS

Included in the sample were all admissions for supratentorial neoplasms treated with craniotomy (352 patients), 49.72% (n = 175) of which were female. The average STOP-Bang score was 1.91 ± 1.22 (range 0–7). A 1-unit higher STOP-Bang score accurately predicted 30-day readmissions (OR 1.31, p = 0.017) and 30-day ED visits (OR 1.36, p = 0.016) with fair accuracy as confirmed by the ROC curve (C-statistic 0.60–0.61). The STOP-Bang questionnaire did not correlate with 30-day reoperation (p = 0.805) or home discharge (p = 0.315).

CONCLUSIONS

The results of this study suggest that undiagnosed OSA, as assessed via the STOP-Bang questionnaire, is a significant predictor of patient health status and readmission risk in the brain tumor craniotomy population. Further investigations should be undertaken to apply this prediction tool in order to enhance postoperative patient care to reduce the need for unplanned readmissions.