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Douglas A. Hardesty, Matthew R. Sanborn, Whitney E. Parker and Phillip B. Storm

Object

The incidence of, and risk factors for, perioperative seizures and the need for perioperative antiepileptic drugs (AEDs) in previously seizure-free children with brain tumors remains unclear. The authors have undertaken a review of previously seizure-free pediatric patients with brain tumors undergoing resection to identify the incidence of seizures in the perioperative period, and to characterize risk factors for perioperative seizures in this population.

Methods

A retrospective review was conducted of all patients between 0 and 19 years of age without prior seizures who underwent intracranial tumor resection at the authors' institution between January 2005 and December 2009.

Results

Of the 223 patients undergoing 229 operations, 7.4% experienced at least 1 clinical seizure during the surgical admission. Over half of all tumors were supratentorial. Only 4.4% of patients received prophylactic AEDs. Independent factors associated with perioperative seizures included supratentorial tumor, age < 2 years, and hyponatremia due to syndrome of inappropriate antidiuretic hormone or cerebral salt wasting. Tumor type, lobe affected, operative blood loss, and length of surgery were not independently associated with seizure incidence.

Conclusions

Perioperative seizures in previously seizure-free children undergoing resection of brain tumors are associated with supratentorial tumor location, age < 2 years, and postoperative hyponatremia. Perioperative seizures are not associated with tumor pathology, tumor size, or frontotemporal location. Due to the low incidence of seizures in this series in patients more than 2 years old with normal serum sodium, the authors recommend that pediatric patients with brain tumors not routinely receive perioperative prophylactic AEDs. However, the role for prophylaxis in patients younger than 2 years of age deserves further study.

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Matthew R. Sanborn, Michael L. DiLuna, Robert G. Whitmore and Phillip B. Storm

Fractures through the ring of the C-1 vertebrae are very rare in the pediatric patient population. In this report, the authors describe the case of a widely displaced fracture of the C-1 anterior arch in a 6-year-old boy. The fracture was initially treated using a fluoroscopy-guided, transoral, closed reduction with subsequent halo vest immobilization. Although conservative management of C-1 fractures is generally adequate and efficacious in the pediatric population, mechanistic and anatomical considerations in this case were concerning for potential instability in extension, and prompted an unusual method of closed reduction followed by treatment in a halo vest.

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Robert G. Whitmore, Jayesh P. Thawani, M. Sean Grady, Joshua M. Levine, Matthew R. Sanborn and Sherman C. Stein

Object

The object of this study was to determine whether aggressive treatment of severe traumatic brain injury (TBI), including invasive intracranial monitoring and decompressive craniectomy, is cost-effective.

Methods

A decision-analytical model was created to compare costs, outcomes, and cost-effectiveness of 3 strategies for treating a patient with severe TBI. The aggressive-care approach is compared with “routine care,” in which Brain Trauma Foundation guidelines are not followed. A “comfort care” category, in which a single day in the ICU is followed by routine floor care, is included for comparison only. Probabilities of each treatment resulting in various Glasgow Outcome Scale (GOS) scores were obtained from the literature. The GOS scores were converted to quality-adjusted life years (QALYs), based on expected longevity and calculated quality of life associated with each GOS category. Estimated direct (acute and long-term medical care) and indirect (loss of productivity) costs were calculated from the perspective of society. Sensitivity analyses employed a 2D Monte Carlo simulation of 1000 trials, each with 1000 patients. The model was also used to estimate these values for patients 40, 60, and 80 years of age.

Results

For the average 20-year-old, aggressive care yields 11.7 (± 1.6 [SD]) QALYs, compared with routine care (10.0 ± 1.5 QALYs). This difference is highly significant (p < 0.0001). Although the differences in effectiveness between the 2 strategies diminish with advancing age, aggressive care remains significantly better at all ages. When all costs are considered, aggressive care is also significantly less costly than routine care ($1,264,000 ± $118,000 vs $1,361,000 ± $107,000) for the average 20-year-old. Aggressive care remains significantly less costly until age 80, at which age it costs more than routine care. However, even in the 80-year-old, aggressive care is likely the more cost-effective approach. Comfort care is associated with poorer outcomes at all ages and with higher costs for all groups except 80-year-olds.

Conclusions

When all the costs of severe TBI are considered, aggressive treatment is a cost-effective option, even for older patients. Comfort care for severe TBI is associated with poor outcomes and high costs, and should be reserved for situations in which aggressive approaches have failed or testing suggests such treatment is futile.

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Shih-Shan Lang, Joel A. Bauman, Michael W. Aversano, Matthew R. Sanborn, Arastoo Vossough, Gregory G. Heuer and Phillip B. Storm

Object

Electrolyte and endocrinological complications of endoscopic third ventriculostomy (ETV) are infrequent but serious events, likely due to transient hypothalamic-pituitary dysfunction. While the incidence of diabetes insipidus is relatively well known, hyponatremia is not often reported. The authors report on a series of 5 patients with post-ETV hyponatremia.

Methods

The records of patients undergoing ETV between 2008 and 2010 were reviewed. All ETVs were performed with a rigid neuroendoscope via a frontal bur hole, standard third ventricle floor blunt perforation, Fogarty catheter dilation, and intermittent normal saline irrigation. Postoperative MR images were evaluated for endoscope tract injury as well as the trajectory from the bur hole center to the fenestration site.

Results

Thirty-two patients (20 male and 12 female) underwent ETV. Their median age was 6 years (range 3 weeks–28 years). Hydrocephalus was most commonly due to nontumoral aqueductal stenosis (43%), nontectal tumor (25%), or tectal glioma (13%). Five patients (16%) had multicystic/loculated hydrocephalus. Five patients (16%) developed hyponatremia between 1 and 8 days following ETV, including 2 patients with seizures (1 of whom was still hospitalized at the time of the seizure and 1 of whom was readmitted as a result of the seizure) and 3 patients who were readmitted because of decline in their condition following routine discharge. No hypothalamic injuries were noted on imaging. Univariate risk factors consisted of age of 2 years or less (p = 0.02), presence of cystic lesions (p = 0.02), and ETV trajectory angle 10° or more from perpendicular (p = 0.001).

Conclusions

Endoscopic third ventriculostomy is a well-tolerated procedure but can result in serious complications. Hyponatremia is rare and may be more likely in younger patients or those with cystic loculations. Patients with altered craniometry may be at particular risk with a rigid endoscopic approach requiring greater manipulation of subforniceal or hypothalamic structures.

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Min S. Park, Michael Nanaszko, Matthew R. Sanborn, Karam Moon, Felipe C. Albuquerque and Cameron G. McDougall

OBJECT

The optimal strategy for use of the Pipeline Embolization Device (PED, ev3 Neurovascular) has not been clearly defined. The authors examined re-treatment rates after treatment with PED alone versus PED and adjunctive coil embolization (PED/coil).

METHODS

The authors retrospectively examined cerebral aneurysms treated with the PED from May 2011 to March 2014. Overall, 133 patients (25 men, 108 women; mean age 60.4 years, range 23–85 years) were treated for 140 aneurysms (mean size 11.8 ± 8.3 mm) requiring 224 PEDs (mean 1.7 PEDs per patient). Sixty-eight patients (13 men, 55 women) were treated with PED alone for 73 aneurysms (mean size 10.6 ± 9.2 mm) and 65 patients (12 men, 53 women) were treated with PED/coil for 67 aneurysms (mean size 12.8 ± 7.4 mm).

RESULTS

Eight aneurysms in 8 patients were re-treated in the PED-alone cohort versus only 1 aneurysm in 1 patient in the PED/coil cohort for re-treatment rates of 11.8% (8/68) and 1.5% (1/65), respectively (p = 0.03). Two patients in the PED-alone cohort were re-treated due to PED contraction, while the other 6 were re-treated for persistent filling of the aneurysms. The PED/coil patient experienced continued filling of a vertebrobasilar artery aneurysm. No aneurysms in either group ruptured after treatment.

CONCLUSIONS

Adjunctive coil embolization during flow diversion with the PED resulted in a significantly lower re-treatment rate compared with PED alone, suggesting an added benefit with adjunctive coil embolization. This result may provide the basis for future evaluation with randomized, controlled trials.

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Matthew R. Sanborn, Jayesh P. Thawani, Robert G. Whitmore, Michael Shmulevich, Benjamin Hardy, Conrad Benedetto, Neil R. Malhotra, Paul Marcotte, William C. Welch, Stephen Dante and Sherman C. Stein

Object

There is considerable variation in the use of adjunctive technologies to confirm pedicle screw placement. Although there is literature to support the use of both neurophysiological monitoring and isocentric fluoroscopy to confirm pedicle screw positioning, there are no studies examining the cost-effectiveness of these technologies. This study compares the cost-effectiveness and efficacy of isocentric O-arm fluoroscopy, neurophysiological monitoring, and postoperative CT scanning after multilevel instrumented fusion for degenerative lumbar disease.

Methods

Retrospective data were collected from 4 spine surgeons who used 3 different strategies for monitoring of pedicle screw placement in multilevel lumbar degenerative disease. A decision analysis model was developed to analyze costs and outcomes of the 3 different monitoring strategies. A total of 448 surgeries performed between 2005 and 2010 were included, with 4 cases requiring repeat operation for malpositioned screws. A sample of 64 of these patients was chosen for structured interviews in which the EuroQol-5D questionnaire was used. Expected costs and quality-adjusted life years were calculated based on the incidence of repeat operation and its negative effect on quality of life and costs.

Results

The decision analysis model demonstrated that the O-arm monitoring strategy is significantly (p < 0.001) less costly than the strategy of postoperative CT scanning following intraoperative uniplanar fluoroscopy, which in turn is significantly (p < 0.001) less costly than neurophysiological monitoring. The differences in effectiveness of the different monitoring strategies are not significant (p = 0.92).

Conclusions

Use of the O-arm for confirming pedicle screw placement is the least costly and therefore most cost-effective strategy of the 3 techniques analyzed.

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Matthew R. Sanborn, Stephen R. Thom, Leif-Erik Bohman, Sherman C. Stein, Joshua M. Levine, Tatyana Milovanova, Eileen Maloney-Wilensky, Suzanne Frangos and Monisha A. Kumar

Object

Microparticles (MPs), small membrane fragments shed from various cell types, have been implicated in thrombosis, inflammation, and endothelial dysfunction. Their involvement in subarachnoid hemorrhage (SAH) and the development of cerebral infarction and clinical deterioration caused by delayed cerebral ischemia (DCI) remain ill defined. The authors sought to quantify the magnitude of elevations in MPs, delineate the temporal dynamics of elevation, and analyze the correlation between MPs and DCI in patients with SAH.

Methods

On the day of hemorrhage and on Days 1, 3, 5, 7, and 10 after hemorrhage, peripheral blood samples were drawn from 22 patients with SAH. Plasma samples were labeled with Annexin V and CD142, CD41a, CD235a, CD146, CD66b, or von Willebrand factor (vWF) and were quantified by flow cytometry. Clinical data, including the 3-month extended Glasgow Outcome Scale (GOS-E) scores, infarction as measured on MRI at 14 days after SAH, and vasospasm as measured by transcranial Doppler ultrasonography and angiography, were collected and compared with the MP burden.

Results

When averaged over time, all MP subtypes were elevated relative to controls. The CD235a+(erythrocyte)−, CD66b+(neutrophil)−, and vWF-associated MPs peaked on the day of hemorrhage and quickly declined. The CD142+(tissue factor [TF])–associated MPs and CD146+(endothelial cell)–associated MPs were significantly elevated throughout the study period. There was a strong negative correlation between TF-expressing and endothelial-derived MPs at Day 1 after SAH and the risk of infarction at Day 14 after SAH.

Conclusions

Microparticles of various subtypes are elevated following SAH; however, the temporal profile of this elevation varies by subtype. Those subtypes closely associated with thrombosis and endothelial dysfunction, for example, CD145+(TF)-associated MPs and CD146+(endothelial cell)–associated MPs, had the most durable response and demonstrated a significant negative correlation with radiographic infarction at 14 days after SAH. Levels of these MPs predict infarction as early as Day 1 post-SAH.