Kyle M. Fargen

The prevalence of patient safety indicators and hospital-acquired conditions in patients with ruptured cerebral aneurysms: establishing standard performance measures using the Nationwide Inpatient Sample database

OBJECTnThe Agency for Healthcare Research and Quality (AHRQ) patient safety indicators (PSIs) and the Centers for Medicare and Medicaid Services hospital-acquired conditions (HACs) are publicly reported metrics used to gauge the quality of health care provided by health care institutions. To better understand the prevalence of these events in hospitalized patients treated for ruptured cerebral aneurysms, the authors determined the incidence rates of PSIs and HACs among patients with a diagnosis of subarachnoid hemorrhage and procedure codes for either coiling or clipping in the Nationwide Inpatient Sample database.nnnMETHODSnThe authors queried the Nationwide Inpatient Sample database, part of the AHRQs Healthcare Cost and Utilization Project, for all hospitalizations between 2002 and 2010 involving coiling or clipping of ruptured cerebral aneurysms. The incidence rate of each PSI and HAC was determined by searching the hospital records for ICD-9 codes. The authors used the SAS statistical software package to calculate incidence rates and perform multivariate analyses to determine the effects of patient variables on the probability of developing each indicator.nnnRESULTSnThere were 62,972 patient admissions with a diagnosis code of subarachnoid hemorrhage between the years 2002 and 2010; 10,274 (16.3%) underwent clipping and 8248 (13.1%) underwent endovascular coiling. A total of 6547 PSI and HAC events occurred within the 10,274 patients treated with clipping; at least 1 PSI or HAC occurred in 47.9% of these patients. There were 5623 total PSI and HAC events among the 8248 patients treated with coils; at least 1 PSI or HAC occurred in 51.0% of coil-treated patients. Age, sex, comorbidities, hospital size, and hospital type had statistically significant associations with indicator occurrence. Compared with patients without events, those treated by either clipping or coiling and had at least 1 PSI during their hospitalization had significantly longer lengths of stay (p < 0.001), higher hospital costs (p < 0.001), and higher in-hospital mortality rates (p < 0.001).nnnCONCLUSIONSnThese results estimate baseline national rates of PSIs and HACs in patients treated for ruptured cerebral aneurysms. These data may be used to gauge individual institutional quality of care and patient safety metrics in comparison with national data.

Long term experience using the ADAPT technique for the treatment of acute ischemic stroke

Introduction The direct aspiration first pass technique (ADAPT) has been introduced as a simple and fast method for achieving good angiographic and clinical outcomes using large bore aspiration catheters for the treatment of acute ischemic stroke (AIS). We present a single centers long term experience with ADAPT. Methods Retrospective analysis of a database was gathered on patients undergoing stroke thrombectomy with ADAPT at a stroke center. Specific parameters captured included age, gender, National Institutes of Health Stroke Scale (NIHSS) score at presentation, time to presentation from last normal, and modified Rankin Scale (mRS) score at the 90u2005day follow-up. Radiological and angiographic imaging was reviewed to document the location of the vascular occlusion, Thrombolysis in Cerebral Infarction (TICI) flow postprocedure, and procedural complications. Results 191 consecutive patients who suffered an AIS treated with ADAPT were reviewed; 91 were women, and mean age was 67u2005years. Patients presented with a mean NIHSS score of 15.4, and 71 patients received intravenous tissue plasminogen activator. The average time from onset to puncture was 7.8u2005h. The average time for recanalization was 37.3u2005min. TICI 2B or better recanalization was achieved in 180 (94.2%) patients. 98 (54.1%) patients had an mRS of 0–2 at 90u2005days. Direct aspiration alone was performed in 145 cases, and 43 cases required the additional use of a stent retriever. There was no significant difference in presenting NIHSS score, average time to presentation, average mRS at 90u2005days, or 90u2005day mortality between the two groups. Time to recanalization was 29.6u2005min for direct aspiration compared with 61.4u2005min in cases that required adjunct devices (p=0.00000201). 79 (57.7%) patients who underwent direct aspiration only achieved a good outcome at 90u2005days (mRS 0–2) compared with 19 (43.2%) who underwent adjunct therapies (p=0.12). Conclusions ADAPT is an effective method to achieve good clinical and angiographic outcomes, and serves as a useful firstline method for revascularization.

Challenges of acute endovascular stroke trials.

Intravenous thrombolytic therapy with tissue-type plasminogen activator (tPA) has been approved for acute ischemic stroke since 1996. However, its tight time window means that many centers only treat a minority of patients. Effectiveness is limited by the low recanalization rates of large intracranial occlusions (4% distal internal carotid and basilar artery and 32%–37% M1 middle cerebral artery),1,2 which has high disability and mortality.3 Clinical outcome at 3 months is strongly associated with the timeliness and extent of reperfusion.4,5 These findings call for therapies beyond intravenous tPA to improve clinical outcomes in such patients.nnThere is an unmet need to develop efficient therapies for acute stroke caused by proximal intracranial occlusion. Three recent endovascular randomized controlled trials (RCTs) were negative.6–8 These trials have been criticized for the use of older first-generation devices, slow recruitment, delayed times to reperfusion, and nonuniform requirement for demonstration of large-vessel occlusion for enrollment. Second-generation devices (Solitaire, Trevo), now referred to as stentrievers, in 2 RCTs have shown improved outcomes over the first-generation Merci device.9,10nnDespite the absence of phase III randomized controlled trials showing their superiority, there has been a 6-fold increase in the endovascular procedures in the United States between 2004 and 2009 (0.1%–0.6%) when compared with a tripling in usage of intravenous tPA (1.2%–3.4%).11 This increase likely represents changes in the systems of developing treatment pathways for acute stroke victims.nnIt is clear that further clinical trials are needed to provide definitive evidence that endovascular therapy is an effective adjunct to intravenous tPA. Several new trials have been started. Although there is hope that this generation of trials will show the superiority of endovascular treatment, it is important to recognize the challenges that these trials face. In addition, given the …

Neurothrombectomy trial results: stroke systems, not just devices, make the difference

The overwhelming benefit demonstrated in the four recent randomized trials comparing intra-arterial therapies to medical management alone will have a transformative effect on the emergent management of strokes throughout the world. New generation neurothrombectomy devices were critical to trial success, but not the sole driver of patient outcomes in these trials. Patients in the positive trials were treated at hospitals with complex, efficient, resource-rich, team-based stroke systems in place. To ensure attainment of trial results in actual practice, patients should receive treatment at facilities certified as having the resources, personnel, organization, and continuous quality improvement processes characteristic of trial centers. It is our hope that, through greater education initiatives, robust resource investment, and developing quality-based certification processes, the results demonstrated by these trials may be extrapolated to greater numbers of centers – in turn allowing greater access for patients to high-quality, advanced stroke care.

A prospective randomized single-blind trial of patient comfort following vessel closure: extravascular synthetic sealant closure provides less pain than a self-tightening suture vascular compression device

Background and purpose The Mynx M5 (AccessClosure, Inc., Mountain View, California, USA), a novel vascular closure device (VCD) utilizing extravascular synthetic sealant, may effectively seal the arteriotomy while reducing the pain associated with arteriotomy closure seen with other VCDs. To date, no studies exist comparing the pain associated with deployment between differing VCDs as a primary end point. Methods A blinded, randomized controlled trial was performed comparing the Mynx and a popular VCD that utilizes a self-tightening suture, the Angio-Seal Evolution (St Jude Medical, St Paul, Minnesota, USA). Subjects were all adult patients undergoing diagnostic cerebral angiography via femoral access. Local anesthesia and intraprocedural intravenous pain medication were standardized. Pain was assessed using a horizontal visual analog scale both before and after VCD deployment. Results 64 patients were enrolled with 32 in each treatment arm. Both pain at closure and pain increase from baseline to closure were significantly higher in the Angio-Seal group (p=0.009 and 0.002, respectively). 88% of patients receiving an Angio-Seal reported closure as the most painful part of the procedure compared with only 34% of patients receiving the Mynx (p<0.001). No adverse events were detected in either treatment arm. Conclusions In a blinded, randomized trial comparing the Mynx with the Angio-Seal Evolution, pain with device deployment at arteriotomy closure was significantly lower with the Mynx. The reason for the large pain gradient between groups is likely due to the presence, and absence, of compression elements within the Angio-Seal and Mynx, respectively.

Vessel perforation during stent retriever thrombectomy for acute ischemic stroke: technical details and clinical outcomes

Background Vessel perforation during stent retriever thrombectomy is a rare complication; typically only single instances have been reported. Objective To report on a series of patients whose stent retriever thrombectomy was complicated by intraprocedural vessel perforation and discuss its potential mechanisms, rescue treatment strategies, and clinical significance. Methods Cases with intraprocedural vessel perforation, where a stent retriever was used either as a primary treatment approach or as a part of a direct aspiration first pass technique (ADAPT), were included in the final analysis. Clinical data, procedural details, radiographic and clinical outcomes were collected from nine participating centers. Results Intraprocedural vessel perforation during stent retriever thrombectomy occurred in 16 (1.0%) of 1599 cases. 63% of intraprocedural perforations occurred at distal locations. Endovascular rescue techniques (most commonly, intracranial balloon occlusion for tamponade) were attempted in 50% of cases. Procedure was aborted without any rescue attempts in 44% of cases. Mortality during hospitalization and at 3u2005months was 56% and 63%, respectively. 25% of patients achieved good functional outcome at 3u2005months after the procedure. Conclusions Intraprocedural perforations during stent retriever thrombectomy were rare, but when they occurred were associated with high mortality. Perforations most commonly occurred at distal occlusion sites and were often characterized by difficulty traversing the occlusion with a microcatheter or microwire, or while withdrawing the stent retriever. Nevertheless, 25% of patients had a favorable functional outcome, suggesting that in some patients with this complication good neurological recovery is achievable.

A survey of neurointerventionalists on thrombectomy practices for emergent large vessel occlusions

Background The effect of the five positive randomized controlled trials on thrombectomy practices and procedural volume has yet to be defined. Further, few studies have attempted to define modern thrombectomy practices in terms of selection criteria and devices used. Methods A 21 question survey of Society of Neurointerventional Surgery (SNIS) physicians was administered using the SurveyMonkey website, addressing current practices as well as changes from before January 1, 2015 to the months after this date. Results A total of 78 responses were obtained (approximately 10% of SNIS membership). Prior to January 2015, two-thirds of respondents reported performing 1–5 thrombectomies per month (67%), with 31% performing more than 5 per month. Following January 2015, 62% of respondents reported performing more than 5 thrombectomies per month; 45% of respondents reported a higher number of thrombectomies after trial publication. 73% and 80% of respondents indicated that inpatient consultations and hospital to hospital transfers for thrombectomy have increased, respectively. A plurality of respondents reported using A Direct Aspiration First Pass Technique (40%) as the first strategy for revascularization. Most commonly, neurointerventionalists reported using conscious sedation (56%) for anesthesia. 74% of respondents indicated being successful with their primary technique in at least 70% of cases. Conclusions This survey of predominantly academic SNIS physicians indicates that inpatient consultations, hospital to hospital transfers, and thrombectomy procedural volumes have increased modestly since the publication of the five major stroke trials this year. In addition, many respondents indicated an increase in aggressiveness in pursuing thrombectomy based on selection criteria.

Factors That Affect Physiologic Tremor and Dexterity During Surgery: A Primer for Neurosurgeons.

INTRODUCTIONnAll individuals have a physiologic tremor that may become more pronounced in periods of stress, stimulant use, or caffeine. There are few publications measuring the effects of these factors on surgeons or trainees and no comprehensive reviews. We sought to review the representative literature.nnnMATERIALS AND METHODSnAn exhaustive literature search to identify journal articles evaluating factors that affect surgical tremor or dexterity was performed.nnnRESULTSnOur search identified 34 studies. All included manuscripts are from small, single-center studies and the vast majority evaluated procedural skills on the basis of laparoscopic simulators. Only one study in which the authors evaluated microsurgical procedural performance was identified.nnnCONCLUSIONSnThe literature evaluating tremor and its relationship to surgical performance is limited. Surgeons wishing to optimize surgical dexterity may benefit from avoiding caffeine use or fasting before operating and avoiding sleep deprivation or alcohol use the night before procedures. Those surgeons prone to anxiety or stress-related tremor may obtain a benefit from certain beta-blockers. Finally, the use of appropriate surgical ergonomics with hand or wrist steadying may improve surgical tremor and reduce fatigue.

Needed Dialog Regionalization of Stroke Systems of Care Along the Trauma Model

The burden of stroke is indisputable. Stroke is the fourth leading cause of death and the leading cause of major disability in the United States, and affects ≈800 000 people every year.1 Of these events, ≈87% are acute ischemic strokes, or ≈700 000 per year. Furthermore, stroke accounts for ≈200 000 deaths and results in an estimated

Occipitocervicothoracic stabilization in pediatric patients

73 billion cost to the United States healthcare system annually,2 the single highest Medicare reimbursement entity for long-term adult care. Interventions that positively impact the outcome of ischemic stroke would be of tremendous value to both patients and society at large.nnAlthough improvements have been made with increased public awareness, enhanced prehospital triage systems, and hospital stroke certification programs, recent studies suggest that acute ischemic stroke reperfusion interventions (both intravenous and intra-arterial) remain significantly underused.3 In most community settings, only 5% of patients with acute stroke actually receive intravenous recombinant tissue-type plasminogen activator (r-tPA) therapy.3,4 Furthermore, advanced stroke care goes beyond acute reperfusion with intravenous or intra-arterial techniques: for patients who develop significant infarcts, subsequent care, such as dedicated neurointensive management, intracranial pressure monitoring and control, decompressive surgery, or hemorrhage evacuation are all potentially critical aspects of managing ischemic or hemorrhagic strokes that can significantly affect patient outcome. These resources are often found only at comprehensive stroke centers (CSCs).nnIntra-arterial therapies, such as intra-arterial (IA) thrombolysis or mechanical thrombectomy, have emerged as a means of restoring perfusion after large vessel occlusion and have exhibited excellent recanalization and outcome measures in recent prospective trials.5–13 Although 3 randomized trials published in 2013 demonstrated no added benefit to IA intervention compared with intravenous tPA alone,14–16 the randomized controlled trials the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands …