Hassan Saad

An Analysis of Publication Productivity During Residency for 1506 Neurosurgical Residents and 117 Residency Departments in North America

BACKGROUNDnBibliometrics is defined as the study of statistical and mathematical methods used to quantitatively analyze scientific literature. The application of bibliometrics in neurosurgery continues to evolve.nnnOBJECTIVEnTo calculate a number of publication productivity measures for almost all neurosurgical residents and departments within North America. These measures were correlated with survey results on the educational environment within residency programs.nnnMETHODSnDuring May to June 2017, data were collected from departmental websites and Scopus to compose a bibliometric database of neurosurgical residents and residency programs. Data related to authorship value and study content were collected on all articles published by residents. A survey of residency program research and educational environment was administered to program directors and coordinators; results were compared with resident academic productivity.nnnRESULTSnThe median number of publications in residency was 3; median h-index and Resident index were 1 and 0.17 during residency, respectively. There was a statistically significant difference in academic productivity among male neurosurgical residents compared with females. The majority of articles published were tier 1 clinical articles. Residency program research support was significantly associated with increased resident productivity (P < .001). Scholarly activity requirements were not associated with increased resident academic productivity.nnnCONCLUSIONnThis study represents the most comprehensive bibliometric assessment of neurosurgical resident academic productivity during training to date. New benchmarks for individual and department academic productivity are provided. A supportive research environment for neurosurgical residents is associated with increased academic productivity, but a scholarly activity requirement was, surprisingly, not shown to have a positive effect.

Biocompatible Amniotic Sac Implant Maintains a Scar-Free Brain Surface During Recurrent Glioma Surgery

BACKGROUNDnDissection of brain surface adhesions during recurrent glioma surgery carries a risk of injury to cortical vessels and important surface vessels. We present our experience with the use of BioD film, a biocompatible amniotic membrane implant, to help prevent postoperative adhesions. We describe a novel method for preventing postoperative adhesions after high-grade glioma surgery using BioD film.nnnMETHODSnAmniotic sac implants were laid on the brain surface after resection of gliomas located near major surface arteries (sylvian fissure) and major veins (parasagittal convexity). Seven cases involved reoperation for tumor recurrence.nnnRESULTSnIn all 7 of the cases requiring reoperation, a new arachnoid-like surface layer was formed without any dural adhesions. The newly formed layer allowed for easy and simple dissection and mobilization of surface vessels while avoiding any trauma to the cortex.nnnCONCLUSIONSnAmniotic sac implants have a promising role in preventing most surgical brain adhesions associated with recurrent glioma surgery, reducing the risks of cortical vessel and tissue injury.

Rapid M1 Hemoclips Arteriotomy Repair After Emergency Coil Embolectomy

BACKGROUNDnThe vascular closure staple clips have been studied in animal models and shown to have comparable results with sutured repair when it comes to the healing process, degree of vessel narrowing, and risk of thrombosis. However, they are clearly superior when the speed of application is taken into account, and they were clinically used in many vascular repair processes. Nevertheless, their usefulness in intracranial vascular surgery has not been described.nnnOBJECTIVEnTo describe the usefulness of hemoclips in fast and efficient repair of medium-sized and large intracranial vessels.nnnMETHODSnTwo female patients diagnosed with giant symptomatic cavernous sinus aneurysms were undergoing elective endovascular procedures that were complicated by the dislodgement of coils into the M1 segment of the middle cerebral artery. Both patients were treated performing M1 arteriotomies and coil embolectomy. To avoid prolonged temporary occlusion in the M1 perforators territory, the arteriotomies were repaired using microhemoclips in less than 10 min with re-establishment of flow.nnnRESULTSnIn both patients, flow was re-established in the M1 segments. In 1 patient, the coils extended to the temporal M2 causing intimal injury and leading to diminished flow. M1 segments in both patients were patent on later angiographic studies.nnnCONCLUSIONnWe describe the advantage of emergent cerebrovascular arteriotomy and embolectomy in a rapid repair process that helped avoid massive ischemic injury. We believe this technique should be added to the armamentarium of neurosurgical cerebrovascular options.

Pseudoaneurysm Surgery Simulation Using the “Live Cadaver” Model for Neurosurgical Education

Reduced number of working hours for residents and the trend toward minimal or even noninvasive treatment of cerebral aneurysms have resulted in residents’ decreased exposure to live surgery in the operating room. This decrease becomes increasingly relevant when surgeons encounter complications, especially vascular injuries and intraoperative rupture of aneurysms, after completion of their training, neurosurgery residents will face complicated cases and intraoperative aneurysmal rupture in their practice while they are on their own, and to develop competency in managing cerebral aneurysms, laboratory training will be the compensation mechanism to cover the decreased hands-on experience in the OR. In this chapter we will describe a more realistic aneurysm model, which allows repetitive training under lifelike conditions for residents and other trainees to practice surgical clipping of cerebral aneurysms.

A Review of Industry Funding in Randomized Controlled Trials Published in the Neurosurgical Literature—The Elephant in the Room

OBJECTIVEnTo analyze the role of industry sponsorship of randomized controlled trials (RCTs) published exclusively in 3 major North American neurosurgical journals.nnnMETHODSnOur primary objective was to determine whether an association exists between study conclusion(s) in favor of industry sponsored drugs, devices/implants, or surgical techniques and industry sponsorship. The secondary objective was to describe the quality/quantity of these neurosurgical RCTs.nnnRESULTSnA total of 110 RCTs were analyzed, the majority were published in the Journal of Neurosurgery (85%) and were international in origin (55%). The most common subspecialty was spine (n = 29) and drug study was the most common type (n = 49). Overall quality was good with median Jadad and Detsky scores of 4 (range, 1-5) and 18 (range, 8-21), respectively. There was a statistically significant difference in RCTs with industry funding (31/40, 78%) versus those without (9/70, 13%) that published a favorable conclusion of the new drug, device/implant, or surgical technique (odds ratio [OR], 23.35; P < .0001). Multiple binomial logistic regression analysis identified number of authors as mildly protective (OR, 0.79; 95% confidence interval, 0.69-0.91; P = .001) and industry funding strongly predictive (OR, 12.34; 95% confidence interval, 2.97-51.29; P = .001) of a positive trial.nnnCONCLUSIONnIndustry funding was associated with a much greater chance of positive findings in RCTs published in neurosurgical journals. Further efforts are needed to define the relationship between the authors and financial sponsors of neurosurgical research and explore the reasons for this finding.

A comparison of two stroke cohorts cared for by two different specialties in a practice-based tele-stroke population

OBJECTIVESnNeurologists have continually led the assessment and management of Acute Ischemic Stroke(AIS) by use of IV-rtPA, anti-platelet therapy, antihypertensives, and other pharmacologic agents. Since the advent of mechanical thrombectomy(MT) and its proven efficacy, neurovascular surgeons(NS) are playing an increasingly important role in the management and overall care of AIS. We assessed outcomes of AIS patients managed by NS, who have been traditionally managed by neurologists.nnnPATIENTS AND METHODSnOutcomes of AIS patients who presented to the telestroke system, over a 5-year period, were assessed. NIHSS and mRS stroke scales were used as outcome metrics. Multivariate analysis was conducted to compare outcomes of patients treated by neurovascular surgeons and those treated by neurologists.nnnRESULTSn1353 AIS patients were identified. 21.6% received care from neurosurgeons and 78.4% received care from neurologists. Of the neurologist-managed group: 7.8% received MT and were followed by NS, 34% received IVrt-PA, average discharge NIHSSu202f=u202f9.0 (SDu202f=u202f8.42), latest follow-up mRSu202f<u202f2u202f=u202f57.5% and mortality rateu202f=u202f9.4%. Of the neurovascular surgeon-managed group: 7.4% patients received MT, 20% received IVrt-PA, average discharge NIHSSu202f=u202f0.14(SDu202f=u202f0.72), latest follow-up mRSu202f≤2u202f=u202f98.6% and mortality rateu202f=u202f8.3%. There were no significant differences between groups in MT use (OR 1.22; CI95%, 0.971-2.09; pu202f=u202f0.464), IVrt-PA administration (OR 0.98; CI95%, 0.70-1.38; pu202f=u202f0.924), mortality rate (OR 1.21; 0.71-2.03; pu202f=u202f0.483) and patients latest mRS, pu202f=u202f0.873.nnnCONCLUSIONSnAIS requires multidisciplinary management. Care provided by neurosurgeons has similar efficacy and patient outcomes as the care provided by neurologists. These findings support the role and ability of neurosurgeons to manage and care for these patients.

Safety and Efficacy of a 600-mg Loading Dose of Clopidogrel 24 Hours Before Pipeline Embolization Device Treatment

BACKGROUNDnClopidogrel/aspirin antiplatelet therapy routinely is administered 7-10 days before pipeline aneurysm treatment. Our study assessed the safety and efficacy of a 600-mg loading dose of clopidogrel 24 hours before Pipeline Embolization Device (PED) treatment.nnnMETHODSnWe performed a retrospective cohort study involving patients treated with pipeline from October 2010 to May 2016. A total of 39.7% (nxa0= 158) of patients were dispensed a loading dose of 650 mg of aspirin plus at least 600 mg of clopidogrel 24 hours preceding PED deployment; 60.3% (nxa0= 240) received 81-325 mg of aspirin daily for 10 days with 75 mg of clopidogrel daily preprocedurally. The mean follow-up was 15.8 months (standard deviation [SD] 12.4 months). modified Rankin Scale (mRS) was registered before the discharge and at each follow-up visit. To control confounding, we used multivariable logistic regression and propensity score conditioning.nnnRESULTSnOf 398 patients, the proportion of female patients was ≈16.5% (41/240) in both groups and shared the same mean of age ≈56.46 years. Similarly, ≈12.2% (meanxa0= 0.09; SDxa0= 0.30) had a subarachnoid hemorrhage. A total of 92% (meanxa0= 0.29; SDxa0= 0.70) from the pretreatment group and 85.7% (meanxa0= 0.44; SDxa0= 0.91) of the bolus group had a mRS ≤2. In a multivariate analysis, bolus did not affect the mRS score, Pxa0= 0.24. Seven patients had a long-term recurrence, 2 (0.83%; meanxa0= 0.01; SDxa0= 0.10) from the pretreatment group. In a multivariable logistic regression, bolus was not associated with a long-term recurrence rate (odds ratio [OR] 1.91; 95% confidence interval [CI] 0.27-13.50; Pxa0= 0.52) neither with thromboembolic accidents (OR 0.99; 95% CI 0.96-1.03; Pxa0= 0.83) nor with hemorrhagic events (OR 1.00; 95% CI 0.97-1.03; Pxa0= 0.99). Three patients died: 1 who received a bolus had an acute subarachnoid hemorrhage. The mean mortality rate was parallel in both groups ≈0.25 (SDxa0= 0.16). Bolus was not associated with mortality (ORxa01.11; 95% CI 0.26-4.65; Pxa0= 0.89). The same associations were present in propensity score-adjusted models.nnnCONCLUSIONSnIn a cohort receiving PED, a 600-mg loading dose of clopidogrel should be safe and efficacious in those off the standard protocol or showing <30% platelet inhibition before treatment.

The use of alternatives to clopidogrel in flow-diversion treatment with the Pipeline embolization device

OBJECTIVEThromboembolic complications continue to be encountered with Pipeline embolization devices (PEDs) despite routine clopidogrel/aspirin antiplatelet therapy. This study examined the safety and efficacy of prasugrel in the management of clopidogrel-resistant patients treated for cerebral aneurysms.METHODSFour hundred thirty-seven consecutive patients were identified between January 2011 and May 2016. Patients allergic, or having less than 30% platelet inhibition, to a daily 75-mg dose of clopidogrel received 10 mg of prasugrel daily (n = 20) or 90 mg of ticagrelor twice daily (n = 2). The mean (± SD) follow-up duration was 15.8 ± 12.4 months. The primary outcome was the modified Rankin Scale (mRS) score registered before discharge and at each follow-up visit. To control confounding, multivariable mixed-effects logistic regression and propensity score conditioning were used.RESULTSTwenty-six (5.9%) of 437 patients presented with a subarachnoid hemorrhage (SAH). The mean patient age was 56.3 years, and 62 were women (14.2%). One of the 7 patients lost to follow-up received prasugrel. One patient was allergic to clopidogrel and prasugrel simultaneously. All patients receiving prasugrel or ticagrelor (n = 22) had an mRS score ≤ 2 on their latest follow-up visit (mean score 0.67 ± 1.15). In a multivariate analysis, clopidogrel did not affect the mRS score on last follow-up (p = 0.14). Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (OR 0.17, 95% CI 0.01-2.70, p = 0.21), an increased thromboembolic complication rate (OR 0.46, 95% CI 0.12-1.67, p = 0.24), or an increased hemorrhagic event rate (OR 0.39, 95% CI 0.91-1.64, p = 0.20). None of the patients receiving prasugrel or ticagrelor died or suffered a long-term recurrence or a hemorrhagic event; only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. Three patients taking clopidogrel died during the study: 2 from acute SAH and 1 from intraparenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR 2.18, 95% CI 0.11-43.27, p = 0.61). The same associations were present in propensity score-adjusted models.CONCLUSIONSIn a cohort of patients treated with PEDs, prasugrel (10 mg/day) was a safe alternative to clopidogrel-resistant or clopidogrel-allergic patients, or nonresponders.