Luis C. Ascanio

Validation of a Predictive Scoring System for Ventriculoperitoneal Shunt Insertion After Aneurysmal Subarachnoid Hemorrhage

BACKGROUNDnHydrocephalus is a frequently encountered complication in the context of aneurysmal subarachnoid hemorrhage (aSAH). Here, we performed an external validation of the recently proposed postsubarachnoid shunt scoring (PS3) system, which aims to stratify patients presenting with aSAH based on their relative risk of requiring ventriculoperitoneal (VP) shunt insertion.nnnMETHODSnA retrospective review of all patients presenting with aSAH to our institution between July 2007 and December 2016, who underwent computed tomography imaging at the time of hospital admission, was performed.nnnRESULTSnA total of 242 patients (66.1% women) with aSAH were included in the analysis with a mean age of 55.6 years. Sixty-four (26.4%) patients had a Hunt and Hess grade of 4 or 5 on admission. An external ventricular drain (EVD) was placed in 130 (53.7%) patients during the hospital admission. EVD placement was found to correlate with an increased rate of VP shunt placement (P < 0.001), and a trend toward an association between a high Hunt and Hess grade and VP shunt placement was observed (Pxa0= 0.05). The area under the receiver operating characteristic curve for the PS3 system was found to be 0.845. The system reliably predicted shunt-dependent chronic hydrocephalus in our patient cohort (odds ratio, 3.36; 95% confidence interval, 2.31-4.89; P < 0.001).nnnCONCLUSIONSnData from this study validated the previously proposed PS3 system, which was found to more accurately predict shunt-dependent chronic hydrocephalus in patients with aSAH compared with other such systems in the neurosurgical literature, such as the chronic hydrocephalus ensuing from SAH score, Barrow Neurological Institute, and shunt dependency in aSAH systems.

Spontaneous Intracranial Hemorrhage in Pregnancy: A Systematic Review of the Literature.

Stroke in pregnant women has a mortality rate of 1.4 deaths per 100,000 deliveries. Vascular malformations are the most common cause of hemorrhagic stroke in this population; preeclampsia and other risk factors have been identified. However, nearly a quarter of strokes have an undeterminable cause. Spontaneous intracranial hemorrhage (ICH) is less frequent but results in significant morbidity. The main objective of this study is to review the literature on pregnant patients who had a spontaneous ICH. A systematic review of the literature was conducted on PubMed and the Cochrane library from January 1992 to September 2016 following the PRISMA guidelines. Studies reporting pregnant patients with spontaneous intraparenchymal hemorrhage (IPH), subarachnoid hemorrhage (SAH), and subdural hemorrhage (SDH) were selected and included if patients had non-structural ICH during pregnancy or up to 6xa0weeks postpartum confirmed by imaging. Twenty studies were included, and 43 patients identified. Twenty-two patients (51.3%) presented with IPH, 15 patients (34.8%) with SAH, and five patients (11.6%) with SDH. The most common neurosurgical management was clinical in 76.7% of patients, and cesarean section was the most common obstetrical management in 28% of patients. The most common maternal outcome was death (48.8%), and fetal outcomes were evenly distributed among term delivery, preterm delivery, and fetal or neonatal death. Spontaneous ICH carries a high maternal mortality with IPH being the most common type, most frequently presenting in the third trimester. Diagnosis and management do not differ for the parturient compared to the non-pregnant woman.

Statin Therapy and Diabetes Do Not Affect Aneurysm Occlusion or Clinical Outcomes Following Pipeline Embolization Device Treatment: a Preliminary Study

BACKGROUNDnThe effect of statins and diabetes on angiographic and clinical outcomes in aneurysms treated with pipelines has not been adequately reported. Our aim is to assess the effect of concurrent statin medications and diabetes mellitus (DM) on aneurysm occlusion status and outcomes in patients treated with the pipeline embolization device.nnnMETHODSnA retrospective review of our institutions database of aneurysms treated with the pipeline embolization device between 2013 and 2017 was conducted. We collected data about statin therapy status and intensity, and identified patients with a documented history of DM. Our primary outcome was aneurysm obliteration seen on digital subtracted angiography or magnetic resonance angiography at last follow-up.nnnRESULTSnWe identified 151 patients with 182 aneurysms for this cohort, with a median radiographic follow-up time of 7.2 months (6.1-14.5). Thirty-nine patients were taking statins, and 112 patients did not receive statins. Log-rank tests revealed no statistically significant difference in occlusion rates between patients with and without statin therapy (Pxa0= 0.30). A history of DM was documented in 11 patients, with 14 aneurysms in total; 140 patients with 168 aneurysms had no history of DM. Similarly, there were no differences in occlusion rates between the diabetic and nondiabetic groups in multivariate analysis (Pxa0=xa00.24). Only 2 patients showed significant in-stent stenosis on angiographic follow up, and both were diabetic.nnnCONCLUSIONSnOur analysis did not identify a statistically significant association between statin therapy or DM and higher occlusion rates or better outcomes after pipeline embolization. Diabetic patients may have a theoretic risk of significant in-stent stenosis.

Proposal of a Grading System for Predicting Discharge Mortality and Functional Outcome in Patients with Aneurysmal Subarachnoid Hemorrhage

BACKGROUNDnSeveral outcome prediction systems have been developed to evaluate aneurysmal subarachnoid hemorrhage (aSAH). However, they can be difficult to use and can contain subjective elements. We sought to identify the predictors of aSAH outcomes at discharge to provide an accurate and reliable scoring system.nnnMETHODSnA retrospective cohort study of patients with aSAH at an academic institution from 2007 to 2016 was conducted. The primary outcome measure was the modified Rankin scale (mRS) score at discharge, with mRS scores of 0-2 considered favorable and mRS scores of 3-6 considered unfavorable. Factors significant on multivariate regression were used to develop a scale, which was compared with other established grading systems using receiver operating characteristic curves.nnnRESULTSnWe identified 279 patients with aSAH, 37.3% of whom had unfavorable outcomes. The proposed scale assigns 2 points for postresuscitation Glasgow coma scale score of ≤8, 1 point for age ≥70 years, 1 for antiplatelet therapy on admission, and 1 for SAH thickness of ≥10 mm, with a total score of 0-5. The proposed, Subarachnoid Hemorrhage International Trialists, and Hunt and Hess scales had similar areas under the curve (85.2%, 84.8%, and 80.6%, respectively; P > 0.05) but were significantly better than the World Federation of Neurological Surgeons (78.5%; Pxa0= 0.001) and modified Fisher (60.8%; P < 0.001) scales.nnnCONCLUSIONnWe propose a grading scale to predict discharge mortality and functional outcomes in patients with aSAH. The proposed scale outperformed most other outcome prediction scales. The proposed scale contains objective elements, is easy to apply by memory, and can be a useful and effective measure to predict aSAH outcomes.

Patterns of Stroke Transfers and Identification of Predictors for Thrombectomy

BACKGROUNDnInterhospital transfers for endovascular thrombectomy (EVT) evaluation have increased since the publication of landmark neuroendovascular stroke trials in 2015. The lack of guidelines to select potential EVT candidates prior to transfer can lead to instances where, despite considerable costs and transport risks, transferred patients do not ultimately undergo EVT. Our aim was to characterize the patterns and identify predictors for EVT on transfer.nnnMETHODSnIn this observational cohort study, we retrospectively analyzed patients with acute ischemic stroke (AIS) transferred to our institution for EVT evaluation from January 2015 to March 2016. Clinical and radiographic predictors for EVT on transfer were determined with multivariable logistic regression analysis.nnnRESULTSnA total of 103 transfer patients with AIS were included in the study, and 52% were women. A higher collateral score (P < 0.01), a higher National Institutes of Health Stroke Scale (NIHSS) score (P < 0.01), computed tomography angiography (CTA) at referring hospital (P < 0.01), and large vessel occlusion on arrival CTA (P < 0.01) were significant in patients who underwent EVT on univariable analysis. More than half (61.1%) of transfers were futile and primarily related to absence of large vessel occlusion on arrival. A higher collateral score (Pxa0= 0.02), a higher NIHSS score (Pxa0= 0.006), and having undergone a CTA at the referring center (Pxa0= 0.002) remained the independent predictors of EVT. The C statistic for the model was 0.94.nnnCONCLUSIONSnA higher collateral score, the acquisition of CTA imaging at the referring centers, and a higher NIHSS score independently predicted EVT on transfer.

Factors Predicting the Need for Surgery of the Opposite Side After Unilateral Evacuation of Bilateral Chronic Subdural Hematomas

BACKGROUNDnPatients with bilateral chronic subdural hematoma (bCSDH) undergo unilateral evacuation for the large or symptomatic side because the contralateral hematoma is either small or asymptomatic. However, the contralateral hematoma may subsequently grow and require evacuation.nnnOBJECTIVEnTo characterize factors that predict contralateral hematoma growth and need for evacuation.nnnMETHODSnA retrospective study on 128 surgically treated bCSDHs.nnnRESULTSnFifty-one and 77 were bilaterally and unilaterally evacuated, respectively. Glasgow Coma Scale was lower and midline shift was higher in those evacuated unilaterally compared to those evacuated bilaterally. Hematoma size was a significant determinant of decision for unilateral vs bilateral evacuation. The contralateral side needed evacuation at a later stage in 7 cases (9.1%). There was no significant difference in terms of reoperation rate between those evacuated unilaterally and bilaterally. Greater contralateral hematoma thickness on the first postoperative day computed tomography (CT) and more postoperative midline shift reversal had higher rates of operation in the opposite side. There was no difference between the daily pace of hematoma decrease in the operated and nonoperated sides (0.7% decrease per day vs 0.9% for the operated and nonoperated sides, respectively).nnnCONCLUSIONnResults of this study show that most bCSDHs evacuated unilaterally do not experience growth in the nonoperated side and unilateral evacuation results in hematoma resolution for both sides in most cases. Hematoma thickness on the opposite side on the first postoperative day CT and amount of midline shift reversal after surgery are the most important factors predicting the need for surgery on the opposite side.

Accuracy and Safety of External Ventricular Drain Placement by Physician Assistants and Nurse Practitioners in Aneurysmal Acute Subarachnoid Hemorrhage

BackgroundIn the current dynamic health environment, increasing number of procedures are being completed by advanced practitioners (nurse practitioners and physician assistants). This is the first study to assess the clinical outcomes and safety of external ventricular drain (EVD) placements by specially trained advanced practitioners.ObjectiveCompare the safety and outcomes of EVD placement by advanced practitioners in patients with subarachnoid hemorrhage (SAH).MethodsA cohort comparison study was performed from an aneurysmal SAH database selecting patients treated with EVD from a single major academic institution in the USA between June 2007 and June 2017. Safety, accuracy, and complications of EVD placement were compared between advanced practitioners and neurosurgical physicians (attending neurosurgeon and subspecialty clinical fellow). Statistical analysis was performed using the Mann–Whitney test for continuous variables and χ2 test for categorical variables, with p values set atu2009<u20090.05 for significance.ResultsWe identified 203 patients for this cohort with 238 EVD placements; eighty-seven (36.6%) placements were performed by advanced practitioners and 151 (63.4%) by neurosurgeons. Most of the ventriculostomies were placed in the emergency room (nu2009=u2009114; 47.9%). Additional procedures performed concurrently with the EVD placements were significantly higher among the physicians’ group (21.8 vs. 4.6%; pu2009<u20090.001). Bedside placement and usage of Ghajar guide were significantly higher among advanced practitioner’s (58.3 vs. 98.9 and 9.9 vs. 64.4%, respectively, with a pu2009<u20090.001 for both). There were, however, no significant differences in terms ofxa0the number of attempts for insertion, intraprocedural complications, tract hemorrhages, accuracy, infection rates, catheter dislodgments, and need for repositioning/replacement of EVD.ConclusionAfter appropriate training, EVD placement can be safely performed by advanced practitioners with an adequate accuracy of placement.

Proposal of a follow-up imaging strategy following Pipeline flow diversion treatment of intracranial aneurysms

OBJECTIVEThere is currently no standardized follow-up imaging strategy for intracranial aneurysms treated with the Pipeline embolization device (PED). Here, the authors use follow-up imaging data for aneurysms treated with the PED to propose a standardizable follow-up imaging strategy.METHODSA retrospective review of all patients who underwent treatment for ruptured or unruptured intracranial aneurysms with the PED between March 2013 and March 2017 at 2 major academic institutions in the US was performed.RESULTSA total of 218 patients underwent treatment for 259 aneurysms with the PED and had undergone at least 1 follow-up imaging session to assess aneurysm occlusion status. There were 235 (90.7%) anterior and 24 posterior (9.3%) circulation aneurysms. On Kaplan-Meier analysis, the cumulative incidences of aneurysm occlusion at 6, 12, 18, and 24 months were 38.2%, 77.8%, 84.2%, and 85.1%, respectively. No differences in the cumulative incidence of aneurysm occlusion according to aneurysm location (p = 0.39) or aneurysm size (p = 0.81) were observed. A trend toward a decreased cumulative incidence of aneurysm occlusion in patients 70 years or older was observed (p = 0.088). No instances of aneurysm rupture after PED treatment or aneurysm recurrence after occlusion were noted. Sixteen (6.2%) aneurysms were re-treated with the PED; 11 of these had imaging follow-up data available, demonstrating occlusion in 3 (27.3%).CONCLUSIONSThe authors propose a follow-up imaging strategy that incorporates 12-month digital subtraction angiography and 24-month MRA for patients younger than 70 years and single-session digital subtraction angiography at 12 months in patients 70 years or older. For recurrent or persistent aneurysms, re-treatment with the PED or use of an alternative treatment modality may be considered.

Relationship between external ventricular drain clamp trials and ventriculoperitoneal shunt insertion following nontraumatic subarachnoid hemorrhage: a single-center study

OBJECTIVECurrently, there is no established standard regarding the ideal number of external ventricular drain (EVD) clamp trials performed before ventriculoperitoneal (VP) shunt insertion following nontraumatic subarachnoid hemorrhage (SAH). In this study, the authors aimed to evaluate this relationship.METHODSA retrospective review of all patients presenting with SAH between July 2007 and December 2016 was performed. Patients with SAH who had received an EVD within the first 24 hours of hospital admission and had undergone at least 1 clamp trial prior to EVD removal were eligible for inclusion in the study. Patient demographics, clinical presentations, SAH etiologies and grades, clamp trial data, hospital lengths of stay, and functional outcomes were recorded.RESULTSOne hundred fourteen patients with nontraumatic SAH complicated by posthemorrhagic hydrocephalus were included in the study. The median patient age was 57 years (range 28-90 years), with a male/female ratio of 1:1.7. A ruptured aneurysm was the underlying etiology of SAH in 79.8% of patients. A majority of patients (69.4%) had a Hunt and Hess grade III-V on admission. The median number of clamp trials performed was 2 (range 1-6). A VP shunt was required in 40.4% of patients. In those who underwent 2 and 3 clamp trials, 60% and 38.9%, respectively, did not require subsequent VP shunt placement.CONCLUSIONSSurgical placement of a VP shunt is associated with complications. Clamp trials are routinely performed before making the decision to insert a shunt. In the present study, the authors found that a significant percentage of patients passed their second and third clamp trials without requiring subsequent shunt insertion. These data support performing multiple clamp trials prior to shunt placement.

Moyamoya disease in pregnancy: a systematic review

BackgroundMoyamoya disease (MMD) management during pregnancy poses a challenge to health care providers, and recommendations are outdated, vague, and controversial. We conducted a systematic review to investigate and present the available evidence.MethodWe searched five online databases and bibliographies of relevant published original studies to identify case reports, case series, cohort studies, and reviews reporting on patients diagnosed with MMD before, during, or shortly after pregnancy. We report and analyze the respective data.ResultsFifty-four relevant articles were identified. In the group of patients with MMD diagnosed prior to pregnancy, 68.7% had previously undergone bypass surgery, 64.5% delivered via cesarean section, 95.2% of mothers had good outcomes, and no bad fetal outcomes were reported. In patients first diagnosed with MMD due to a cerebrovascular accident during pregnancy, the mean gestational age on symptom onset was 28.7xa0weeks and 69.5% presented with cerebral hemorrhage. In this group, 57.2% received neurosurgical operative management, and 80% underwent cesarean section with 13.6% maternal mortality and 23.5% fetal demise. In patients diagnosed with MMD immediately postpartum, 46.6% suffered a cerebrovascular event within 3xa0days of delivery, 78.3% of which were ischemic. Only 15.3% underwent surgical hematoma evacuation and one patient (9%) expired.ConclusionsMMD may coincide with pregnancy, but there is paucity of high-quality data. It appears that MMD is not a contraindication to pregnancy, if blood pressure and ventilation are properly managed. There is no clear evidence that bypass surgery before pregnancy or cesarean mode of delivery improve outcomes.