Whether prior intravenous thrombolysis provides any additional benefits to the patients undergoing mechanical thrombectomy for large vessel, acute ischemic stroke remains unclear.
We conducted a ...meta-analysis of 13 studies obtained through PubMed and EMBASE database searches to determine whether functional outcome (modified Rankin Scale) at 90 days, successful recanalization rate, and symptomatic intracerebral hemorrhage rate differed between patients who underwent mechanical thrombectomy with (MT+IVT) and without (MT-IVT) pre-treatment with intravenous thrombolysis.
MT+IVT patients compared with MT-IVT patients had better functional outcomes (modified Rankin Scale score, 0-2; summary odds ratio OR, 1.27 95% confidence interval (CI), 1.05-1.55;
=0.02; n=1769/1174), lower mortality (OR, 0.71 95% CI, 0.55-0.91;
=0.006; n=1774/1202), and higher rate of successful recanalization (OR, 1.46 95% CI, 1.09-1.96;
=0.01; n=1652/1216) without having increased odds of symptomatic intracerebral hemorrhage (OR, 1.11 95% CI, 0.69-1.77;
=0.67; n=1471/1143). A greater number of MT+IVT patients required ≤2 passes with a neurothrombectomy device to achieve successful recanalization (OR, 2.06 95% CI, 1.37-3.10;
=0.0005; n=316/231).
Our results demonstrated that MT+IVT patients had better functional outcomes, lower mortality, higher rate of successful recanalization, requiring lower number of device passes, and equal odds of symptomatic intracerebral hemorrhage compared with MT-IVT patients. The results support the current guidelines of offering intravenous thrombolysis to eligible patients even if they are being considered for mechanical thrombectomy. Because the data are compiled from studies where the 2 groups differed based on eligibility for intravenous thrombolysis, randomized trials are necessary to accurately evaluate the added value of intravenous thrombolysis in patients treated with mechanical thrombectomy.
Background
Moyamoya is a progressive intracranial vasculopathy, primarily affecting distal segments of the internal carotid and middle cerebral arteries. Treatment may comprise angiogenesis‐inducing ...surgical revascularization; however, lack of randomized trials often results in subjective treatment decisions.
Hypothesis
Compensatory presurgical posterior vertebrobasilar artery (VBA) flow‐territory reactivity, including greater cerebrovascular reactivity (CVR) and reduced vascular delay time, portends greater neoangiogenic response verified on digital subtraction angiography (DSA) at 1‐year follow‐up.
Study Type
Prospective intervention cohort.
Subjects
Thirty‐one patients with moyamoya (26 females; age = 45 ± 13 years; 41 revascularized hemispheres).
Methods
Anatomical MRI, hypercapnic CVR MRI, and DSA acquired presurgically in adult moyamoya participants scheduled for clinically indicated surgical revascularization. One‐year postsurgery, DSA was repeated to evaluate collateralization.
Field Strength
3 T.
Sequence
Hypercapnic T2*‐weighted gradient‐echo blood‐oxygenation‐level‐dependent, T2‐weighted turbo‐spin‐echo fluid‐attenuated‐inversion‐recovery, T1‐weighted magnetization‐prepared‐rapid‐gradient‐echo, and T2‐weighted diffusion‐weighted‐imaging.
Assessment
Presurgical maximum CVR and response times were evaluated in VBA flow‐territories. Revascularization success was determined using an ordinal scoring system of neoangiogenic collateralization from postsurgical DSA by two cerebrovascular neurosurgeons (R.V.C. with 8 years of experience; M.R.F. with 9 years of experience) and one neuroradiologist (L.T.D. with 8 years of experience). Stroke risk factors (age, sex, race, vasculopathy, and diabetes) were recorded.
Statistical Tests
Fisher's exact and Wilcoxon rank‐sum tests were applied to compare presurgical variables between cohorts with angiographically confirmed good (>1/3 middle cerebral artery MCA territory revascularized) vs. poor (<1/3 MCA territory revascularized) outcomes. Significance: two‐sided P < 0.05. Normalized odds ratios (ORs) were calculated.
Results
Criteria for good collateralization were met in 25 of the 41 revascularized hemispheres. Presurgical normalized VBA flow‐territory CVR was significantly higher in those with good (1.12 ± 0.13 unitless) vs. poor (1.04 ± 0.05 unitless) outcomes. Younger (OR = −0.60 ± 0.67) and White (OR = −1.81 ± 1.40) participants had highest revascularization success (good outcomes: age = 42 ± 14 years, race = 84% White; poor outcomes: age = 49 ± 11 years, race = 44% White).
Data Conclusion
Presurgical MRI‐measures of VBA flow‐territory CVR are highest in moyamoya participants with better angiographic responses to surgical revascularization.
Level of Evidence
1
Technical Efficacy Stage
4
Harvey Cushing's 14-month Wanderjahr had a profound effect on his subsequent personal career, which in turn ushered in the modern age of American neurosurgery. From July 1900 to August 1901, he ...traveled to European neurosurgical centers in England, France, Switzerland, Italy, and Germany. His excursion happened at a crucial moment in his trajectory; it was built on his existing foundation of Halstedian surgical training and occurred at a time when interest in the special field of neurological surgery was emerging. The research and clinical experiences on his journey—good and bad—undoubtedly informed his fledgling neurosurgical practice. We present a concise account of Harvey Cushing's time in Europe that consolidates accounts from Cushing's travel journals, biographers, and other neurosurgeons. This article highlights tensions in prior works and reveals new insights into the transformative nature of his Wanderjahr. Furthermore, we contextualize his travels and achievements within the broader transformation of American medical education at the turn of the 20th century to elucidate how Europe influenced American medicine. We briefly consider parallel benefits of Harvey Cushing's Wanderjahr and modern domestic or international training opportunities and present potential areas of implementation.
Letters of recommendation (LORs) are historically an important, though subjective, component of the neurosurgery residency application process. Standardized LORs (SLORs) were introduced during the ...2020 to 2021 application cycle. The intent of SLORs is to allow objective comparison of applicants and to reduce bias.
To examine the utility of SLORs during this application cycle. We hypothesized that "grade inflation" and poor inter-rater reliability, as described by other specialties using SLORs, would limit the utility of SLORs in their current form.
This cross-sectional study analyzed all SLORs submitted to a single neurosurgery residency program over the 2020 to 2021 cycle. Data from 7 competency domains and the overall rating were recorded and stratified by academic category of letter writer. Inter-rater reliability was evaluated using Krippendorff's alpha.
One or more SLORs was submitted as part of 298 of 393 applications (76%). Approximately 58.3% of letters written by neurosurgery chairpersons rated a given applicant as being within the top 5% across all competencies. Approximately 44.4% of program director letters similarly rated applicants as amongst the top 5%, while 73.2% and 81.4% of letters by other neurosurgeons and general surgery evaluators, respectively, rated applicants in the top 5%. Inter-rater reliability was poor (<0.33) in all rating categories, including overall (α = 0.18).
The utility of the first iteration of SLORs in neurosurgery applications is undermined by significant "grade inflation" and poor inter-rater reliability. Improvements are necessary for SLORs if they are to provide meaningful information in future application cycles.
Standardized letters of recommendation (SLORs) were introduced during the 2020-2021 neurosurgery residency application cycle, but suffered from poor interrater reliability and grade inflation. ...Changes were made to the SLOR template and utilization patterns in response to these shortcomings. The authors examined the second year of SLOR utilization. They hypothesized that grade inflation and interrater reliability would be improved from the first iteration. They also hypothesized that increased numbers of letters by single writers would correlate with broader rating distributions.
This cross-sectional study analyzed all SLORs submitted to a single neurosurgery residency program over the 2021-2022 cycle. Data from 7 competency domains and the overall rating were recorded and stratified by academic category of the letter writer. Interrater reliability was evaluated using Krippendorff's alpha. The frequency of letters written was evaluated using the Kruskal-Wallis H test.
Ninety percent of SLORs rated applicants among the top 25%, but there was a significant decrease in the usage of the top 1% and top 2%-5% ratings. Interrater reliability was poor across all competencies. Writers who completed 1 SLOR rated applicants higher and had a narrower range than those who completed multiple SLORs.
Changes in the format and subsequent utilization patterns of SLORs have slightly decreased grade inflation; however, interrater reliability remains poor. The most wide-ranging evaluators submitted the highest number of SLORs, suggesting that future evaluation and usage of SLORs should emphasize letter-writer characteristics and numbers of SLORs written. Overall, SLORs have been well and broadly accepted with subtle improvements in the second year of utilization.
Abstract
BACKGROUND
Neurosurgery residency programs are tasked with imparting large volumes of both clinical knowledge and technical skill to trainees in limited time. Many investigators have ...described local practices, which may offer evidence-based interventions in neurosurgical residency education, but this literature has not been systematically reviewed.
OBJECTIVE
To perform a scoping review of educational practices in neurosurgery, which are supported by quantitative, peer-reviewed research.
METHODS
A scoping review of the literature was performed. PubMed, Embase, and Web of Science databases were queried for articles describing educational interventions for neurosurgery residents, which included a quantitative assessment of the effect on resident performance.
RESULTS
From an initial set of 1785 unique articles, 29 studies were ultimately screened and included. Studies were into the following 6 topics: (1) didactics and curricula (n = 13), (2) nontechnical skills (n = 6), (3) wellness and burnout (n = 4), (4) assessment and feedback (n = 2), (5) mentorship and career development (n = 2), and (6) research (n = 2). Individual study results were described.
CONCLUSION
Several educational interventions in neurosurgical training are supported by quantitative evidence. Methodological shortcomings are prevalent among studies of education, particularly in the selection of meaningful outcome measures. A summary of evidence-based considerations is provided for current and future program directors.
Current guidelines suggest treating blood pressure above 180/105 mm Hg during the first 24 hours in patients with acute ischemic stroke undergoing any form of recanalization therapy. Currently, no ...studies exist to guide blood pressure management in patients with stroke treated specifically with mechanical thrombectomy. We aimed to determine the association between blood pressure parameters within the first 24 hours after mechanical thrombectomy and patient outcomes.
We retrospectively studied a consecutive sample of adult patients who underwent mechanical thrombectomy for acute ischemic stroke of the anterior cerebral circulation at 3 institutions from March 2015 to October 2016. We collected the values of maximum, minimum, and average values of systolic blood pressure, diastolic blood pressure, and mean arterial pressures in the first 24 hours after mechanical thrombectomy. Primary and secondary outcomes were patients' functional status at 90 days measured on the modified Rankin scale and the incidence and severity of intracranial hemorrhages within 48 hours. Associations were explored using an ordered multivariable logistic regression analyses. A total of 228 patients were included (mean age 65.8±14.3; 104 males, 45.6%). Maximum systolic blood pressure independently correlated with a worse 90-day modified Rankin scale and hemorrhagic complications within 48 hours (adjusted odds ratio=1.02 1.01-1.03,
=0.004; 1.02 1.01-1.04,
=0.002; respectively) in multivariable analyses, after adjusting for several possible confounders.
Higher peak values of systolic blood pressure independently correlated with worse 90-day modified Rankin scale and a higher rate of hemorrhagic complications. Further prospective studies are warranted to identify whether systolic blood pressure is a therapeutic target to improve outcomes.
Dual-energy CT allows differentiation between blood and iodinated contrast. This study aims to determine the predictive value of contrast density and volume on post-thrombectomy dual-energy CT for ...delayed hemorrhagic transformation and its impact on 90-day outcomes.
A retrospective analysis was performed on patients who underwent thrombectomy for anterior circulation large-vessel occlusion at a comprehensive stroke center from 2018-2021. Per institutional protocol, all patients underwent dual-energy CT immediately post-thrombectomy and MRI or CT 24 hours afterward. The presence of hemorrhage and contrast staining was evaluated by dual-energy CT. Delayed hemorrhagic transformation was determined by 24-hour imaging and classified into petechial hemorrhage or parenchymal hematoma using ECASS III criteria. Univariable and multivariable analyses were performed to determine predictors and outcomes of delayed hemorrhagic transformation.
Of 97 patients with contrast staining and without hemorrhage on dual-energy CT, 30 and 18 patients developed delayed petechial hemorrhage and delayed parenchymal hematoma, respectively. On multivariable analysis, delayed petechial hemorrhage was predicted by anticoagulant use (OR,3.53;p=0.021;95%CI,1.19-10.48) and maximum contrast density (OR,1.21;p=0.004;95%CI,1.06-1.37;per 10 HU increase), while delayed parenchymal hematoma was predicted by contrast volume (OR,1.37;p=0.023;95%CI,1.04-1.82;per 10 mL increase) and low-density lipoprotein (OR,0.97;p=0.043;95%CI,0.94-1.00;per 1 mg/dL increase). After adjusting for potential confounders, delayed parenchymal hematoma was associated with worse functional outcomes (OR,0.07;p=0.013;95%CI,0.01-0.58) and mortality (OR,7.83;p=0.008;95%CI,1.66-37.07), while delayed petechial hemorrhage was associated with neither.
Contrast volume predicted delayed parenchymal hematoma, which was associated with worse functional outcomes and mortality. Contrast volume can serve as a useful predictor of delayed parenchymal hematoma following thrombectomy and may have implications for patient management.
BACKGROUND AND OBJECTIVES: Competition for neurosurgical residency training positions remains fierce. The support provided by applicants' home neurosurgery residency training programs (NRTP) is ...suspected to play a key role in the National Resident Matching Program (NRMP) process. We sought to evaluate the impact of the presence of an Accreditation Council for Graduate Medical Education–accredited NRTP at medical students' home institutions has on NRMP match outcomes. METHODS: Our cross-sectional observational study examined all US allopathic senior student Electronic Residency Application Service applications to a single NRTP from 2016 to 2022. RESULTS: We analyzed a total of 1650 Electronic Residency Application Service applications to a single NRTP, of which 1432 (86.8%) were from schools with an Accreditation Council for Graduate Medical Education–accredited NRTP (NRTP+) and 218 (13.2%) were from schools without a residency (NRTP−). NRTP+ applicants matched a higher rate on both pooled analysis (80.8% vs 71.6%, P = .002) and paired analysis ( P = .02) over the seven-cycle study period. This difference was present before (82.4% vs 73.9%, P = .01) and after (77.2% vs 65.6%, P = .046) the COVID-19 pandemic. Cohorts were overall similar; however, NRTP+ applicants had more publication experiences (19.6 ± 19.0 vs 13.1 ± 10.2, P < .001) and were more likely to complete a research gap year (RGY) (25.8% vs 17.0%, P = .004). Completing a RGY was associated with an increased likelihood of matching for NRTP+ applicants but not for NRTP− applicants: NRTP+: 84.9% vs 78.1% ( P = .0056); NRTP−: 70.3% vs 70.9% ( P = .94). CONCLUSION: The presence of a NRTP at a medical student's home institution is associated with improved NRMP match outcomes. This held true both before and after the COVID-19 pandemic. Applicants from schools with a NRTP had more publication experiences and were more likely to complete a RGY. Completion of a RGY is associated with an increased likelihood of matching only for students with an affiliated NRTP.
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