Journal of neurosurgery
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Journal of neurosurgery · May 2019
Clipping aneurysms improves outcomes for patients undergoing coiling.
Most intracranial aneurysms are now treated by endovascular rather than by microsurgical procedures. There is evidence to demonstrate superior outcomes for patients with aneurysmal subarachnoid hemorrhage (aSAH) treated by endovascular techniques. However, some cases continue to require microsurgery. The authors have examined the relationship between the number of aneurysms treated by microsurgery and outcome for patients undergoing treatment for aSAH at neurosurgical centers in England. ⋯ There is a statistically significant association between local microsurgical activity and center outcomes for patients with aSAH, even for patients treated endovascularly. The authors postulate that the number of microsurgical cases performed may be a surrogate indicator of closer neurosurgical involvement in the overall management of neurovascular patients and of optimal case selection.
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Journal of neurosurgery · May 2019
Thirty-day readmission rate as a surrogate marker for quality of care in neurosurgical patients: a single-center Canadian experience.
Readmission to the hospital within 30 days of discharge is used as a surrogate marker for quality and value of care in the United States (US) healthcare system. Concern exists regarding the value of 30-day readmission as a quality of care metric in neurosurgical patients. Few studies have assessed 30-day readmission rates in neurosurgical patients outside the US. The authors performed a retrospective review of all adult neurosurgical patients admitted to a single Canadian neurosurgical academic center and who were discharged to home to assess for the all-cause 30-day readmission rate, unplanned 30-day readmission rate, and avoidable 30-day readmission rate. ⋯ Almost one-fifth of neurosurgical patients were readmitted within 30 days of discharge. However, only about half of these patients were admitted for an unplanned reason, and only 10% of all readmissions were potentially avoidable. This study demonstrates unique challenges encountered in a publicly funded healthcare setting and supports the growing literature suggesting 30-day readmission rates may serve as an inappropriate quality of care metric in neurosurgical patients. Potentially avoidable readmissions can be predicted, and further research assessing predictors of avoidable readmissions is warranted.
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Journal of neurosurgery · May 2019
Feasibility, safety, and changes in systolic blood pressure associated with endovascular revascularization of symptomatic and chronically occluded cervical internal carotid artery using a newly suggested radiographic classification of chronically occluded cervical internal carotid artery: pilot study.
The overall risk of ischemic stroke from a chronically occluded internal carotid artery (COICA) is around 5%-7% per year despite receiving the best available medical therapy. Here, authors propose a radiographic classification of COICA that can be used as a guide to determine the technical success and safety of endovascular recanalization for symptomatic COICA and to assess the changes in systemic blood pressure following successful revascularization. ⋯ The pilot study suggested that our proposed classification of COICA may be useful as an adjunctive guide to determine the technical feasibility and safety of revascularization for symptomatic COICA using endovascular techniques. Additionally, successful revascularization may lead to a significant decrease in SBP postprocedure. A Phase 2b trial in larger cohorts to assess the efficacy of endovascular revascularization using our COICA classification is warranted.
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Journal of neurosurgery · May 2019
Prediction of cavernous sinus invasion in patients with Cushing's disease by magnetic resonance imaging.
Cavernous sinus invasion (CSI) in Cushing's disease (CD) negatively affects the probability of complete resection, biochemical cure, and need for adjuvant therapy. However, the prediction of CSI based on MRI findings has been inconsistent and variable. Among macroadenomas, the Knosp classification is the most widely utilized radiographic predictor of CSI, but its accuracy in predicting CSI and the probability of gross-total resection is limited in the setting of microadenomas or Knosp grade 0-2 macroadenomas. The authors noticed that the presence of a triangular shape of adenomas adjacent to the cavernous sinus on coronal MR images is frequently associated with CSI. The authors aimed to determine the correlation of this radiographic finding ("sail sign" [SS]) with CSI. ⋯ The presence of a positive SS among Cushing's adenomas adjacent to the CS provides strong PPV, specificity, and positive likelihood ratio for the prediction of CSI. This can be a useful tool for preoperative planning and for predicting the likelihood of long-term biochemical remission and the need for adjuvant radiosurgery.
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Journal of neurosurgery · May 2019
Comparison of flow diversion with clipping and coiling for the treatment of paraclinoid aneurysms in 115 patients.
Paraclinoid aneurysms represent approximately 5% of intracranial aneurysms (Drake et al. [1968]). Visual impairment, which occurs in 16%-40% of patients, is among the most common presentations of these aneurysms (Day [1990], Lai and Morgan [2013], Sahlein et al. [2015], and Silva et al. [2017]). Flow-diverting stents, such as the Pipeline Embolization Device (PED), are increasingly used to treat these aneurysms, in part because of their theoretical reduction of mass effect (Fiorella et al. [2009]). Limited data on paraclinoid aneurysms treated with a PED exist, and few studies have compared outcomes of patients after PED placement with those of patients after clipping or coiling. ⋯ In a large series in which patient outcomes after treatment of paraclinoid aneurysms were compared, the authors found a high rate of aneurysm occlusion and a comparable rate of procedural complications among patients treated with PED placement compared with the rates among those who underwent clipping or coiling. For patients who presented with visual symptoms, those treated with PED placement had the highest rate of visual improvement. The results of this study suggest that the PED is an effective and safe modality for treating paraclinoid aneurysms, especially for patients who present with visual symptoms.