B. Gregory Thompson

Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Purpose— The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH). Methods— A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Councils Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years. Results— Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications. Conclusions— aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

Surgeon volume as an indicator of outcomes after carotid endarterectomy: An effect independent of specialty practice and hospital volume

BACKGROUND High-volume hospitals have been shown to have superior outcomes after carotid endarterectomy (CEA), but the contribution of surgeon volume and specialty practice to CEA outcomes in a national sample is unknown. STUDY DESIGN Using the National Inpatient Sample for 1996 and 1997, 35,821 patients who underwent CEA (ICD-9-CM code 3812) and had data for unique surgeon identification were studied. Surgeons were categorized in terms of annual CEA volume as low-volume surgeons (< 10 procedures), medium-volume surgeons (10 to 29), and high-volume surgeons (> or = 30). Data from cardiac, general, neurologic, and vascular surgical practices were analyzed. In-hospital mortality, postoperative stroke, and prolonged length of stay (> 4 days) were the primary outcomes variables. Unadjusted and case-mix adjusted analyses were performed. RESULTS The overall in-hospital mortality was 0.61%. CEA was performed annually by high-volume surgeons in 52% of patients, by medium-volume surgeons in 30% of patients, and by low-volume surgeons in 18% of patients. Observed mortality by surgeon volume was 0.44% for high-volume surgeons, 0.63% for medium-volume surgeons, and 1.1% for low-volume surgeons (p < 0.001). The postoperative stroke rate was 1.14% for high-volume surgeons, 1.63% for medium-volume surgeons, and 2.03% for low-volume surgeons (p < 0.001). Surgeon specialty had no statistically significant effect on mortality or postoperative stroke. In the logistic regression model, increased risk of mortality was associated with emergent admission (odds ratio [OR] = 2.1; 95% confidence interval [CI] 1.6 to 2.8, p < 0.001), patient age > 65 years (OR = 2.0; 95% CI 1.3 to 3.1, p = 0.001), low-volume surgeon (OR = 1.9; 95% CI 1.4 to 2.5, p < 0.001), and COPD (OR = 1.8; 95% CI 1.3 to 2.5, p = 0.001). Low hospital CEA volume (< 100) was not a significant risk factor in the multivariate analysis. CONCLUSIONS More than 50% of the CEAs in the United States are performed by high-volume surgeons with superior outcomes. Health policy efforts should focus on reducing the number of low-volume surgeons, regardless of surgeon specialty or total hospital CEA volume.

Guidelines for the Management of Patients With Unruptured Intracranial Aneurysms A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

Purpose— The aim of this updated statement is to provide comprehensive and evidence-based recommendations for management of patients with unruptured intracranial aneurysms. Methods— Writing group members used systematic literature reviews from January 1977 up to June 2014. They also reviewed contemporary published evidence-based guidelines, personal files, and published expert opinion to summarize existing evidence, indicate gaps in current knowledge, and when appropriate, formulated recommendations using standard American Heart Association criteria. The guideline underwent extensive peer review, including review by the Stroke Council Leadership and Stroke Scientific Statement Oversight Committees, before consideration and approval by the American Heart Association Science Advisory and Coordinating Committee. Results— Evidence-based guidelines are presented for the care of patients presenting with unruptured intracranial aneurysms. The guidelines address presentation, natural history, epidemiology, risk factors, screening, diagnosis, imaging and outcomes from surgical and endovascular treatment.

Recombinant activated factor VII for the rapid correction of coagulopathy in nonhemophilic neurosurgical patients.

OBJECTIVECoagulopathy is a significant contraindication for neurosurgery. Unfortunately, many coagulopathic patients require urgent neurosurgical intervention. Standard use of blood products, including fresh-frozen plasma or prothrombin complexes, to correct the coagulopathy often leads to significant delays in treatment. Recombinant activated factor VII (rFVIIa) is a medication originally designed to treat bleeding in hemophiliacs but also seems to correct a wide variety of coagulopathies rapidly and safely in nonhemophilic patients. METHODSThe medical records of nine patients with coagulopathy requiring urgent neurosurgical intervention were reviewed retrospectively. Each patient was given a dose ranging from 40 to 90 &mgr;g/kg of rFVIIa before undergoing surgery. Pre-rFVIIa coagulation and post-rFVIIa coagulation parameters were obtained. Once correction of the coagulopathy was verified, each patient underwent the appropriate neurosurgical procedure. RESULTSThe average age of the patients was 40.9 years; six were women. The causes of the coagulopathy included anticoagulant medication, liver dysfunction, and dilutional coagulopathy after traumatic hemorrhage. Neurosurgical indications included intraparenchymal/intraventricular hemorrhage, hydrocephalus, diffuse cerebral edema, and epidural hematoma. Post-rFVIIa coagulation parameters obtained as early as 20 minutes after infusion of the medication showed normalization of values. There were no procedural or operative complications and no postoperative hemorrhagic complications. No associated thromboembolic or other complications with the use of rFVIIa were observed. CONCLUSIONThe use of rFVIIa for the urgent surgical treatment of coagulopathic patients is quite promising. Further studies, including randomized, prospective trials using rFVIIa to address issues such as optimal dosing, efficacy, surgical indications, cost-effectiveness, morbidity, and mortality are needed.

Antiplatelet therapy: An alternative to heparin for blunt carotid injury

BACKGROUND Blunt carotid injuries (BCIs) are uncommon. Most single-center studies are small and highlight the use of anticoagulation for treatment. In a retrospective review, we identified 22 patients who presented with BCI and assessed neurologic and survival outcomes on the basis of injury grade and treatment with anticoagulation or antiplatelet therapy. METHODS Patient demographics were identified using the trauma registry at a single Level I trauma center. Chart reviews assessed neurologic function, modalities used for diagnosis, and treatment. Neurologic outcomes were graded good (minimal to no deficit), fair (moderate deficit needing some assistance), poor (requiring institutionalization), and dead. RESULTS Twenty-two adult trauma patients were diagnosed with BCI, for an incidence of 0.45% in the 8-year study period. All BCI patients underwent head computed tomography and four-vessel cerebral arteriography. Eight patients were not anticoagulated, five because of intracranial injuries, two who had surgical CCA repairs, and one with an aortic injury. Full anticoagulation with heparin was attempted in seven patients, with four major bleeding complications requiring cessation of heparin and blood transfusions. Seven patients received antiplatelet therapy. No difference in neurologic outcome was observed between those receiving anticoagulation and those receiving antiplatelet therapy. Bleeding complications from full anticoagulation were higher than with antiplatelet agents (p = 0.05). CONCLUSION Contrary to previous reports, we did not observe improved outcomes with full anticoagulation compared with antiplatelet therapy. Anticoagulation was associated with increased extracranial bleeding complications. The risks and possible benefits, as well as timing, of anticoagulation or antiplatelet therapy for BCI should be carefully weighed by the major care providers of the patient with multiple injuries.

Basilar Artery Perforation as a Complication of Endoscopic Third Ventriculostomy

The morbidity and mortality associated with third ventriculostomy has decreased significantly over the past 75 years since its introduction by Walter Dandy. Now more commonly performed using an endoscopic method, the significant morbidity of third ventriculostomy has dropped to approximately 5%; essentially that associated with ventriculoscopy in general. However, the possible complication of massive subarachnoid hemorrhage resulting from perforation of the basilar artery or its branches in the course of fenestration of the floor of the third ventricle has only recently been reported. In our case, subsequent to a vascular injury, a pseudoaneurysm developed at the site of vascular perforation, which was then appropriately controlled. The patient has since made a full recovery. Our goal is to remind the endoscopist of this unusual complication and to discuss our management strategies.

The impact of provider volume on mortality after intracranial tumor resection.

OBJECTIVEPolicies of regionalization and selective referral for a number of “high-risk” surgical procedures are being explored and implemented as a result of significant variation in postoperative mortality between high- and low-volume providers. The effect of provider volume on outcomes after intracranial tumor resection is unknown and warrants investigation. METHODSBy use of the Nationwide Inpatient Sample for 1996 and 1997, patients (older than 19 yr) who had a diagnosis of a malignant central nervous system neoplasm and underwent craniotomy or craniectomy were included. Hospital volume and surgeon volume were categorized by quartiles (very low, low, high, or very high volume). Unadjusted and case mix-adjusted analyses were performed with regard to postoperative in-hospital mortality. RESULTSThe crude in-hospital mortality was 2.8% for a total of 7547 patients. The mean patient age was 55.8 years (66.5% <65; 33.5% ≥65). Mortality for very low- to very high-volume hospitals was as follows: 3.8, 3.2, 2.4, and 1.8% (P < 0.001). Mortality for very low- to very high-volume surgeons was as follows: 4.1, 3.9, 3.1, and 1.4% (P = 0.003). Predictors of mortality in a logistic regression model were emergent admission (odds ratio [OR], 2.97; 95% confidence interval [CI], 2.02–4.38;P < 0.001), and age 65 years or greater (OR, 1.63; 95% CI, 1.16–2.30;P = 0.005). The risk of mortality was reduced for very high-volume hospitals (OR, 0.58; 95% CI, 0.35–0.97;P = 0.038) and very high-volume surgeons (OR, 0.42; 95% CI, 0.22–0.84;P = 0.012). CONCLUSIONHigher-volume providers have superior outcomes after surgical resection of malignant intracranial tumors. This reduction was maintained despite adjustment for case mix. As the regionalization of high-risk surgery moves forward, it is important for neurosurgeons to maintain leadership roles in the development of specialty-specific data collection and health policy initiatives that improve and reduce variation in outcomes.

Risk of infection with prolonged ventricular catheterization.

OBJECTIVE:The relationship between extended ventricular catheterization and infection remains controversial. Although studies have substantiated an increasing infection rate with prolonged catheterization, there has been less agreement on whether this trend continues beyond 10 days. Our study reviews the daily infection rate of 595 patients, 213 of whom underwent more than 10 days of catheterization. METHODS:All patients who underwent ventricular monitoring in the neurological intensive care unit from 1995 to 2003 at the University of Michigan Health System were reviewed retrospectively. Infection was defined as a positive cerebrospinal fluid culture. Life-table analysis was used to calculate daily hazard (infection) rates. Patient age, sex, diagnosis, catheter exchanges, location of patient during catheter insertion, and cerebrospinal fluid leak were evaluated as risk factors for infection. RESULTS:The average patient age was 51.3 years, and 51.3% were male. Duration of catheterization averaged 8.6 days. The overall infection rate was 8.6%. Daily infection rates increased from the onset of catheter insertion but reached a plateau after Day 4, with subsequent rates ranging predominantly between 1 and 2%, even with extended catheterization beyond 10 days. Only ventricular catheters that had been placed at other institutions significantly affected the infection rate. CONCLUSION:A relationship between duration of catheterization and infection seems to be present. However, this relationship is not linear. There is an extremely low daily infection rate that rises over the initial 4 days but then remains relatively constant even with prolonged catheter use. Clinical decisions to continue ventricular catheterization should reflect this low daily risk of infection, which does not seem to increase with extended catheter use.

Hearing preservation and facial nerve outcomes in vestibular schwannoma surgery: results using the middle cranial fossa approach.

Objective: To evaluate surgical results using the middle cranial fossa approach for hearing preservation vestibular schwannoma surgery. Study Design: Retrospective case review. Setting: Tertiary referral academic center. Patients: Seventy-three consecutive patients with vestibular schwannoma operated on using the middle cranial fossa approach between February 1999 and February 2005. Interventions: The tumors were removed via the middle cranial fossa approach with modifications to improve exposure. Standard auditory brainstem and facial nerve monitoring were used. Main Outcome Measures: Pre- and postoperative hearing measures and facial function, tumor size, and postoperative complications. Hearing status was categorized into Classes A, B, C, and D as described by the American Academy of Otolaryngology-Head and Heck Surgery “Guidelines for the Evaluation of Hearing Preservation in Acoustic Neuroma, 1995.” Results: Thirty-four patients presented with Class A hearing preoperatively. Among patients presenting with Class A hearing, a total of 27 (80%) maintained Class A or B hearing postoperatively. Of these, 21 (62%) remained in Class A, 6 (18%) deteriorated slightly to Class B, and 7 (20%) deteriorated to Class D postoperatively. Twenty-eight patients presented with Class B hearing preoperatively. Of these, 18 (64%) remained in Class B, 3 (11%) deteriorated to Class C, and 7 (25%) deteriorated to Class D. Three patients had Class C hearing preoperatively. Of these, 2 (66%) remained in Class C and 1 (33%) deteriorated to Class D. Eight patients presented in Class D and one of these improved to Class C postoperatively. Overall, 62 patients presented with useful (Class A or B) hearing and 45 (73%) remained in Class A or B. Nineteen patients had tumors larger than 10 mm in greatest dimension and had Class A or B hearing preoperatively. Of these, 11 (58%) retained Class A or B hearing postoperatively. At 4 months or greater follow-up, facial nerve outcome were excellent in 96%: House-Brackmann Grade I in 61 (85%), Grade II in 8 (11%), and Grade III in 3 (4%). There were no Grade IV, V, or VI results on final follow-up. Six (8%) patients developed cerebrospinal fluid leaks. Conclusion: By achieving excellent exposure and using meticulous microsurgical technique, it is possible to resect small vestibular schwannomas via the middle fossa approach, with preservation of hearing at excellent or preoperative levels in the majority of patients, with excellent or satisfactory facial nerve outcomes in 96% of patients.

Use of endovascular coil embolization and surgical clip occlusion for cerebral artery aneurysms

OBJECT In recent years, endovascular treatment of cerebral artery aneurysms (CAAs) has received greater attention. The authors evaluated patient demographics, endovascular and surgical approaches, and basic outcomes in the treatment of CAAs in a nationally representative administrative database. METHODS Using the Nationwide Inpatient Sample from 1998 to 2003, diagnosed CAA coded as either an unruptured or ruptured lesion and treated with surgical clip occlusion, wrapping combined with endovascular repair, or endovascular repair alone was included in the present study. RESULTS Treatment of CAAs significantly increased for unruptured (from 4036 to 8334 cases, p = 0.002) but not ruptured (from 9330 to 11,269 cases, p = 0.231) lesions. Endovascular treatment of CAAs in particular also increased in patients with unruptured (from 11 to 43%, p < 0.001) and ruptured (from 5 to 31%, p < 0.001) lesions. In 2003, the mortality rate associated with unruptured CAAs treated using clip occlusion (1.36%) or endovascular repair (1.41%) was similar, whereas rate differences were noted between these treatments for ruptured CAAs (12.7% for clip occlusion compared with 16.6% for endovascular repair; p = 0.05). Endovascular treatment of unruptured CAAs was associated with a shorter length of stay (LOS) and higher rate of discharge to home compared with those for clip occlusion. The LOS was also shorter in patients with endovascularly treated ruptured CAAs. Aneurysm type (odds ratio [OR] 10.1, ruptured lesion), patient age (OR 1.28, each 10 years), comorbid conditions (OR 1.08, each condition), and hospital case volume (OR 0.97, each additional case) were significant predictors of death in the regression model. CONCLUSIONS Endovascular techniques for the treatment of CAAs are being used increasingly in the US, although the majority of patients with this pathological entity still undergo surgical clip occlusion. In cases of unruptured CAAs, endovascular treatment is associated with a shorter LOS and higher discharge-to-home rate. Aneurysm status, patient age, comorbid conditions, and hospital case volume are significant predictors of death. Finally, demographic differences exist between the populations presenting with unruptured or ruptured CAAs.