The objective of this paper was to assess applications of the supratentorial-infraoccipital (STIO) approach for cerebrovascular neurosurgery.
The authors conducted a cohort study of all consecutive ...cases in which the STIO approach was used during the study period, December 1995 to January 2021, as well as a systematic review of the literature.
Twenty-five cerebrovascular cases were identified in which the STIO approach was used. Diagnoses included arteriovenous malformation (n = 15), cerebral cavernous malformation (n = 5), arteriovenous fistula (n = 4), and aneurysm (n = 1). The arteriovenous malformations consisted of Spetzler-Martin grade II (n = 3), grade III (n = 8), and grade IV (n = 4) lesions. Lesion locations included the occipital lobe (n = 15), followed by the tentorial dural (n = 4), temporal-occipital (n = 3), temporal (n = 1), thalamic (n = 1), and quadrigeminal cistern (n = 1) regions. Many patients (75%) experienced transient visual deficits attributable to retraction of the occipital lobe, all of which resolved. As of last follow-up (n = 12), modified Rankin Scale scores had improved for 6 patients and were unchanged for 6 patients compared with the preoperative baseline.
The STIO approach is a safe and effective skull base approach that provides a specialized access corridor for appropriately selected cerebrovascular lesions.
In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH).
To compare the cost of endovascular vs microsurgical treatment for aSAH ...at a single quaternary center.
All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis.
Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance.
Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.
Objective
We assessed types of cadaveric head and brain tissue specimen preparations that are used in a high throughput neurosurgical research laboratory to determine optimal preparation methods for ...neurosurgical anatomical research, education, and training.
Methods
Cadaveric specimens (
N
= 112) prepared using different preservation and vascular injection methods were imaged, dissected, and graded by 11 neurosurgeons using a 21-point scale. We assessed the quality of tissue and preservation in both the anterior and posterior circulations. Tissue quality was evaluated using a 9-point magnetic resonance imaging (MRI) scale.
Results
Formalin-fixed specimens yielded the highest scores for assessment (mean ± SD 17.0 ± 2.8) vs. formalin-flushed (17.0 ± 3.6) and MRI (6.9 ± 2.0). Cadaver assessment and MRI scores were positively correlated (
P
< 0.001, R
2
0.60). Analysis showed significant associations between cadaver assessment scores and specific variables: nonformalin fixation (β = −3.3), preservation within ≤72 h of death (β = 1.8), and MRI quality score (β = 0.7). Formalin-fixed specimens exhibited greater hardness than formalin-flushed and nonformalin-fixed specimens (
P
≤ 0.006). Neurosurgeons preferred formalin-flushed specimens injected with colored latex.
Conclusion
For better-quality specimens for neurosurgical education and training, formalin preservation within ≤72 h of death was preferable, as was injection with colored latex. Formalin-flushed specimens more closely resembled live brain parenchyma. Assessment scores were lower for preparation techniques performed > 72 h postmortem and for nonformalin preservation solutions. The positive correlation between cadaver assessment scores and our novel MRI score indicates that donation organizations and institutional buyers should incorporate MRI as a screening tool for the selection of high-quality specimens.
Fourth-generation bypass techniques are novel constructs that may be useful when standard bypass methods fail.1-3 They involve the use of an unconventional (i.e., intraluminal) suturing technique ...(type 4A) or vascular orientation (type 4B).4 We report the use of a type 4B fourth-generation reimplantation bypass for treatment of a recurrent middle cerebral artery (MCA) aneurysm. A woman in her mid-60s presented with recurrence of a previously treated unruptured MCA aneurysm. Her aneurysm was partially coiled, and recurrence developed at the base of the coil mass. Informed consent was obtained from the patient.
The MCA bifurcation was exposed with a pterional-transsylvian approach (Video 1). The aneurysm fundus was mobilized to visualize the origin at the bifurcation between the middle and frontal trunk of the MCA. Clip reconstruction was attempted via a “picket-fence” technique.5 Indocyanine green videoangiography revealed occlusion of the middle trunk. The middle trunk was transected and reimplanted to the frontal trunk in end-side fashion, with intraluminal suturing (type 4A bypass). Indocyanine green videoangiography showed no flow because of endothelial damage from the endovascular therapy. The middle trunk was transected off the frontal trunk and diverted to the temporal trunk, where a type 4B side-to-side reimplantation bypass was performed using a longer arteriotomy to maximize the anastomotic area. Patency and aneurysm occlusion were confirmed with Yellow 560 fluorescence.
The patient tolerated the procedure well, and no postoperative neurologic deficits were noted. The fourth-generation bypass concepts allow the surgeon to conceive atypical constructs, which are especially useful for troubleshooting challenging revascularization scenarios.3
Abstract
BACKGROUND: Public reporting is at the forefront of health care reform.
OBJECTIVE: To investigate whether patient satisfaction as expressed in a public reporting platform correlates with ...objective outcomes for cranial neurosurgery patients.
METHODS: We performed a cohort study involving patients undergoing cranial neurosurgery from 2009 to 2013 who were registered in the Statewide Planning and Research Cooperative System database. This cohort was merged with the corresponding data from the Centers for Medicare and Medicaid Services Hospital Compare website. The association of patient satisfaction metrics with outcomes was examined with the use of a propensity-adjusted regression model.
RESULTS: Overall, 19 591 patients underwent cranial neurosurgery during the study. Using a propensity-adjusted multivariable regression analysis, we demonstrated that hospitals with a greater percentage of patient-assigned “high” scores had decreased mortality (OR, 0.60; 95% CI, 0.53-0.67), rate of discharge to rehabilitation (OR, 0.93; 95% CI, 0.88-0.98), length of stay (adjusted difference, –1.29; 95% CI, –1.46 to –1.13), and hospitalization charges (adjusted difference, –23%; 95% CI, –36% to –9%) after cranial neurosurgery. Similar associations were identified for hospitals with a higher percentage of patients, who would recommend these institutions to others.
CONCLUSION: In a Centers for Medicare and Medicaid Services Hospital Compare–Statewide Planning and Research Cooperative System merged dataset, we observed an association of higher performance in patient satisfaction measures with decreased mortality, rate of discharge to rehabilitation, hospitalization charges, and length of stay.
Patients with intraventricular hemorrhage (IVH) are at higher risk of hydrocephalus requiring an external ventricular drain and long-term ventriculoperitoneal shunt placement.
To investigate whether ...intraventricular tissue plasminogen activator (tPA) administration in patients with ventricular casting due to IVH reduces shunt dependence.
Patients from the Post-Barrow Ruptured Aneurysm Trial (PBRAT) database treated for aneurysmal subarachnoid hemorrhage (aSAH) from August 1, 2010, to July 31, 2019, were retrospectively reviewed. Patients with and without IVH were compared. A second analysis compared IVH patients with and without ventricular casting. A third analysis compared patients with ventricular casting with and without intraventricular tPA treatment. The primary outcome was chronic hydrocephalus requiring permanent shunt placement.
Of 806 patients hospitalized with aSAH, 561 (69.6%) had IVH. IVH was associated with a higher incidence of shunt placement (25.7% vs 4.1%, P < .001). In multivariable logistic regression analysis, IVH was independently associated with increased likelihood of shunt placement (odds ratio OR: 7.8, 95% CI: 3.8-16.2, P < .001). Generalized ventricular casting was present in 80 (14.3%) patients with IVH. In a propensity-score adjusted analysis, generalized ventricular casting was an independent predictor of shunt placement (OR: 3.0, 95% CI: 1.8-4.9, P < .001) in patients with IVH. Twenty-one patients with ventricular casting received intraventricular tPA. These patients were significantly less likely to require a shunt (OR: 0.30, 95% CI: 0.010-0.93, P = .04).
Ventricular casting in aSAH patients was associated with an increased risk of chronic hydrocephalus and shunt dependency. However, this risk decreased with the administration of intraventricular tPA.
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