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Shoji Yomo, Kyota Oda, and Kazuhiro Oguchi

Western countries. 1 , 4 , 5 These positive results raise a simple clinical question: can we anticipate whether or not this 2-session GKS treatment strategy would further improve the outcomes of patients with symptomatic midsize brain metastases, which are regarded as high-risk tumors? In the present study, we sought to analyze differences in local therapeutic efficacy and safety between single- and 2-session GKS for midsize symptomatic brain metastases. To reduce the bias and heterogeneity effects, we applied propensity score–matched analysis, and the clinical

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Shoji Yomo, Kyota Oda, and Kazuhiro Oguchi

Western countries. 1 , 4 , 5 These positive results raise a simple clinical question: can we anticipate whether or not this 2-session GKS treatment strategy would further improve the outcomes of patients with symptomatic midsize brain metastases, which are regarded as high-risk tumors? In the present study, we sought to analyze differences in local therapeutic efficacy and safety between single- and 2-session GKS for midsize symptomatic brain metastases. To reduce the bias and heterogeneity effects, we applied propensity score–matched analysis, and the clinical

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Junichi Ohya, Yasushi Oshima, Hirotaka Chikuda, Takeshi Oichi, Hiroki Matsui, Kiyohide Fushimi, Sakae Tanaka, and Hideo Yasunaga

who had been treated using MED and open discectomy based on a propensity score–matched analysis of data obtained from a nationwide administrative database in Japan. Methods Data Source We used data abstracted from the Japanese Diagnosis Procedure Combination (DPC) database, the details of which have been described previously. 4–7 , 17 , 24 Briefly, the database includes administrative claims data and discharge abstract data from approximately 1000 hospitals across Japan. All 82 academic hospitals are obliged to contribute to the database, but the

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Keita Shibahashi, Kazuhiro Sugiyama, Jun Tomio, Hidenori Hoda, and Akio Morita

OBJECTIVE

The optimal surgical treatment for acute subdural hemorrhage (ASDH) remains controversial. The purpose of this study was to compare outcomes in patients who underwent craniotomy with those in patients who underwent decompressive craniectomy for the treatment of ASDH.

METHODS

Using the Japan Trauma Data Bank, a nationwide trauma registry, the authors identified patients aged ≥ 18 years with ASDH who underwent surgical evacuation after blunt head trauma between 2004 and 2015. Logistic regression analysis was used to estimate a propensity score to predict decompressive craniectomy use. They then used propensity score–matched analysis to compare patients who underwent craniotomy with those who underwent decompressive craniectomy. To identify the potential benefits and disadvantages of decompressive craniectomy among different subgroups, they estimated the interactions between treatment and the subgroups using logistic regression analysis.

RESULTS

Of 236,698 patients who were registered in the database, 1788 were eligible for propensity score–matched analysis. The final analysis included 514 patients who underwent craniotomy and 514 patients who underwent decompressive craniectomy. The in-hospital mortality did not differ significantly between the groups (41.6% for the craniotomy group vs 39.1% for the decompressive craniectomy group; absolute difference −2.5%; 95% CI −8.5% to 3.5%). The length of hospital stay was significantly longer in patients who underwent decompressive craniectomy (median 23 days [IQR 4–52 days] vs 30 days [IQR 7–60 days], p = 0.005). Subgroup analyses demonstrated qualitative interactions between decompressive craniectomy and the patient subgroups, suggesting that patients who were more severely injured (Glasgow Coma Scale score < 9 and probability of survival < 0.64) and those involved in high-energy injuries may be good candidates for decompressive craniectomy.

CONCLUSIONS

The results of this study showed that overall, decompressive craniectomy did not appear to be superior to craniotomy in ASDH treatment in terms of in-hospital mortality. In contrast, there were significant differences in the effectiveness of decompressive craniectomy between the subgroups. Thus, future studies should prioritize the identification of a subset of patients who will possibly benefit from the performance of each of the procedures.

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Zongze Li, Junlin Lu, Li Ma, Chunxue Wu, Zongsheng Xu, Xiaolin Chen, Xun Ye, Rong Wang, and Yuanli Zhao

order to minimize the difference of baseline characteristics between the treatment and control groups, we used a propensity score–matched analysis. Therefore, the beneficial effect of NBP on postoperative neurological function observed in this study might be related to the therapeutic influence on the preoperative mild disabling ischemic stroke, although it remained significant after adjusting for preoperative neurological function. On the other hand, the differences between our matched cohorts and the overall population of MMD patients might affect the generalizable

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Xiaofeng Deng, Faliang Gao, Dong Zhang, Yan Zhang, Rong Wang, Shuo Wang, Yong Cao, Yuanli Zhao, Yuesong Pan, Xingju Liu, Qian Zhang, and Jizong Zhao

OBJECTIVE

The optimal surgical modality for moyamoya disease (MMD) remains unclear. The aim of this study was to compare the surgical effects of direct bypass (DB) and indirect bypass (IB) in the treatment of adult ischemic-type MMD.

METHODS

Adult patients with ischemic-type MMD who underwent either DB or IB from 2009 to 2015 were identified retrospectively from a prospective database. Patients lost to follow-up or with a follow-up period less than 12 months were excluded. Recurrent stroke events and modified Rankin Scale (mRS) scores at the last follow-up were compared between the 2 surgical groups after 1:1 propensity score matching.

RESULTS

A total of 220 patients were considered, including 143 patients who underwent DB and 77 patients who underwent IB. After propensity score matching, 70 pairs were obtained. The median follow-up period was 40.5 months (range 14–75 months) in the DB group and 31.5 months (range 14–71 months) in the IB group (p = 0.004). Kaplan-Meier analysis showed that patients who received DB had a longer stroke-free time (mean 72.1 months) compared with patients who received IB (mean 61.0 months) (p = 0.045). Good neurological status (mRS score ≤ 2) was achieved in 64 patients in the DB group (91.4%) and 66 patients in the IB group (94.3%), but there was no significant difference (p = 0.512).

CONCLUSIONS

Although neurological function outcome was not determined by the surgical modality, DB is more effective in preventing recurrent ischemic strokes than IB for adult ischemic-type MMD.

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Hiroki Ushirozako, Tomohiko Hasegawa, Yu Yamato, Go Yoshida, Tatsuya Yasuda, Tomohiro Banno, Hideyuki Arima, Shin Oe, Yuki Mihara, Tomohiro Yamada, Koichiro Ide, Yuh Watanabe, Keichi Nakai, Takaaki Imada, and Yukihiro Matsuyama

occurrence, 15 , 16 but the results of a few randomized controlled trials (RCTs) and some retrospective studies have not supported this conclusion. 17–19 The use of intrawound vancomycin powder in reducing SSI occurrence after spine surgery has remained controversial due to the lack of large-scale, high-quality studies. Using a propensity score–matched analysis for the adjustment of patient baseline and surgical data, including nutritional status, we aimed to clarify whether intrawound vancomycin powder decreases SSI rates after posterior spinal surgery in a single

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Cian J. O'Kelly, Abhaya V. Kulkarni, Peter C. Austin, M. Christopher Wallace, and David Urbach

. The HRs, ORs, and probability values were determined using the appropriate multivariate regression models adjusting for the measured covariates. Abbreviation: NA = not applicable. Discussion The results of this study suggest that endovascular repair of a ruptured intracranial aneurysm using detachable platinum coils is associated with worse hemorrhagefree survival and 30-day mortality than surgical clipping. Coiling was associated with a 25% increase in the hazard of death or readmission for SAH in both an adjusted multivariable model and in a propensity score–matched

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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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Rimal H. Dossani and Hai Sun

TO THE EDITOR: We read with interest the article by Deng et al. 2 ( Deng X, Gao F, Zhang D, et al: Direct versus indirect bypasses for adult ischemic-type moyamoya disease: a propensity score–matched analysis. J Neurosurg [epub ahead of print August 11, 2017. DOI: 10.3171/2017.2.JNS162405 ]) demonstrating that direct bypass (DB) is better than indirect bypass (IB) in preventing recurrent ischemic strokes in adults with ischemic-type moyamoya disease. A common shortcoming of some studies on moyamoya disease is the heterogeneity of the patient population (adult