Immunonutrition with Omega-3 Fatty Acid Supplementation in Severe TBI: Retrospective Analysis of Patient Characteristics and Outcomes.

Background: Early evidence-based medical interventions to improve patient outcomes after traumatic brain injury (TBI) are lacking. In patients admitted to the ICU after TBI, optimization of nutrition is an emerging field of interest. Specialized enteral nutrition (EN) formulas that include immunonutrition containing omega-3 polyunsaturated fatty acids (n-3 PUFAs) have been developed and are used for their proposed anti-inflammatory and pro-immune properties; however, their use has not been rigorously studied in human TBI populations. Methods: A single-center, retrospective, descriptive observational study was conducted at LAC + USC Medical Center. Patients with severe TBI (sTBI, Glasgow Coma Scale score ≤ 8) who remained in the ICU for ≥ 2 weeks and received EN were identified between 2017 and 2022 using the institutional trauma registry. Those who received immunonutrition formulas containing n-3 PUFAs were compared to those who received standard, polymeric EN in regard to baseline characteristics, clinical markers of inflammation and immune function, and short-term clinical outcomes. Results: A total of 151 patients with sTBI were analyzed. Those who received immunonutrition with n-3 PUFA supplementation were more likely to be male, younger, Hispanic/Latinx, and have polytrauma needing non-central nervous system surgery. No differences in clinical markers of inflammation or infection rate were found. In multivariate regression analysis, immunonutrition was associated with reduced hospital length of stay (LOS). ICU LOS was also reduced in the subgroup of patients with polytrauma and TBI. Conclusion: This study identifies important differences in patient characteristics and outcomes associated with the EN formula prescribed. Study results can directly inform a prospective pragmatic study of immunonutrition with n-3 PUFA supplementation aimed to confirm the biomechanistic and clinical benefits of the intervention.

Combined open revascularization and endovascular treatment of complex intracranial aneurysms: case series.

Background and purpose: The treatment of complex intracranial aneurysms can be challenging with stand-alone open or endovascular techniques, particularly after rupture. A combined open and endovascular strategy can potentially limit the risk of extensive dissections with open-only techniques, and allow for aggressive definitive endovascular treatments with minimized downstream ischemic risk. Materials and methods: Retrospective, single-institution review of consecutive patients undergoing combined open revascularization and endovascular embolization/occlusion for complex intracranial aneurysms from 1/2016 to 6/2022. Results: Ten patients (4 male [40%]; mean age 51.9 ± 8.7 years) underwent combined open revascularization and endovascular treatment of intracranial aneurysms. The majority of aneurysms, 9/10 (90%), were ruptured and 8/10 (80%) were fusiform in morphology. Aneurysms of the posterior circulation represented 8/10 (80%) of the cases (vertebral artery [VA] involving the posterior inferior cerebellar artery [PICA] origin, proximal PICA or anterior inferior cerebellar artery/PICA complex, or proximal posterior cerebral artery). Revascularization strategies included intracranial-to-intracranial (IC-IC; 7/10 [70%]) and extracranial-to-intracranial (EC-IC; 3/10 [30%]) constructs, with 100% postoperative patency. Initial endovascular procedures (consisting of aneurysm/vessel sacrifice in 9/10 patients) were performed early after surgery (0.7 ± 1.5 days). In one patient, secondary endovascular vessel sacrifice was performed after an initial sub-occlusive embolization. Treatment related strokes were diagnosed in 3/10 patients (30%), largely from involved or nearby perforators. All bypasses with follow-up were patent (median 14.0, range 4-72 months). Good outcomes (defined as a Glasgow Outcomes Scale ≥4 and modified Rankin Scale ≤2) occurred in 6/10 patients (60%). Conclusion: A variety of complex aneurysms not amenable to stand-alone open or endovascular techniques can be successfully treated with combined open and endovascular approaches. Recognition and preservation of perforators is critical to treatment success.

Anatomic Considerations Guiding Single Versus Multiportal Endoscopic Approaches for Resection of Juvenile Nasopharyngeal Angiofibroma: Cases Series With Graded Multicorridor Resections.

BACKGROUND: Juvenile nasopharyngeal angiofibromas (JNAs) are characterized by expansive and destructive growth, often invading the midline/paranasal sinuses, pterygopalatine fossa, and infratemporal fossa and can extend into the orbit, cavernous sinus, or intracranially. OBJECTIVE: To evaluete the major benefits of the extended endoscopic endonasal approach (EEA) for JNA resection as compared with more traditional and invasive transpalatal and transfacial approaches. When JNAs extend into lateral anatomic compartments, the optimal operative trajectory often requires additional approach strategies or surgical staging. METHODS: We retrospectively reviewed 8 cases of large JNAs arising in symptomatic adolescent boys (University of Pittsburgh Medical Center Stages II, III, and V) and discuss anatomic and tumor considerations guiding the decision of a pure EEA vs combined EEA and sublabial transmaxillary approach (Caldwell-Luc). RESULTS: A pure extended EEA was used in 6 JNA cases (UPMC Stages II-III); a multiportal EEA + Caldwell-Luc maxillotomy was used in 2 cases. One of the 2 patients (UPMC Stage V) previously treated with multiportal EEA + Caldwell-Luc maxillotomy underwent staged left temporal/transzygomatic craniotomy, obtaining gross total resection. Seven patients ultimately underwent complete removal without recurrence. One patient with a small residual JNA (UPMC II) underwent stereotactic radiosurgery without progression to date. CONCLUSION: JNAs with lateral extension into the infratemporal fossa often benefited from additional lateral exposure using a Caldwell-Luc maxillotomy. Cases with significant skull base and/or dural involvement may undergo staged surgical treatment; temporalis + transzygomatic craniotomy is often useful for second-stage approaches for residual tumor in these lateral infratemporal or intracranial regions. SRS should be considered for residual tumor if additional surgery is not warranted.

Neuroprotective effect of minocycline against acute brain injury in clinical practice: A systematic review.

Acute brain injury is a leading cause of morbidity and mortality worldwide. The term is inclusive of traumatic brain injury, cerebral ischemia, subarachnoid hemorrhage, and intracerebral hemorrhage. Current pharmacologic treatments have had minimal effect on improving neurological outcomes leading to a significant interest in the development neuroprotective agents. Minocycline is a second-generation tetracycline with high blood brain barrier penetrance due to its lipophilic properties. It functions across multiple molecular pathways involved in secondary-injury cascades following acute brain injury. Animal model studies suggest that minocycline might lead to improved neurologic outcomes, but few such trials exist in humans. Clinical investigations have been limited to small randomized trials in ischemic stroke patients which have not demonstrated a clear advantage in neurologic outcomes, but also have not been sufficiently powered to draw definitive conclusions. The potential neuroprotective effect of minocycline in the setting of traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage have all been limited to pilot studies with phase II/III investigations pending. The authors aim to synthesize what is currently known about minocycline as a neuroprotective agent against acute brain injury in humans.

Semiautomatic cerebrovascular territory mapping based on dynamic ASL MR angiography without vessel-encoded labeling.

PURPOSE: Characterizing vessel territories can provide crucial information for evaluation of cerebrovascular disorders. In this study, we present a novel postprocessing pipeline for vascular territorial imaging of cerebral arteries based on a noncontrast enhanced time-resolved 4D magnetic resonance angiography (MRA). METHODS: Eight healthy participants, 1 Moyamoya patient, and 1 arteriovenous malformations patient were recruited. Territorial segmentation and relative blood flow rate calculations of cerebral arteries including left and right middle cerebral arteries and left and right posterior cerebral arteries were carried out based on the 4D MRA-derived arterial arrival time maps of intracranial vessels. RESULTS: Among healthy young subjects, the average relative blood flow rate values corresponding to left and right middle cerebral arteries and left and right posterior cerebral arteries were 35.9 ± 5.9%, 32.9 ± 7.5%, 15.4 ± 3.8%, and 15.9 ± 2.5%, respectively. Excellent agreement was observed between relative blood flow rate values obtained from the proposed 4D MRA-based method and reference 2D phase contrast MRI. Abnormal cerebral circulations were visualized and quantified on both patients using the developed technique. CONCLUSION: The vascular territorial imaging technique developed in this study allowed for the generation of territorial maps with user-defined level of details within a clinically feasible scan time, and as such may provide useful information to assess cerebral circulation balance in different pathologies.

Unusual Pattern of Arterial Macrothrombosis Causing Stroke in a Young Adult Recovered from COVID-19.

Coronavirus disease-19 (COVID-19) pandemic continues to grow all over the world. Neurological manifestations related to COVID-19, including acute ischemic Stroke (AIS), have been reported in recent studies. In most of these, the patients are older, have multiple co-morbidities as risk factors for AIS and have developed a severe respiratory illness. Herein, we report a 36-year-old man with no significant past medical history who recently recovered from a mild COVID-19 infection and presented with unusual pattern of arterial macrothrombosis causing AIS. When the AIS happened, he had no COVID-19 related symptoms, had two negative screening tests for the infection and his chest CT was unremarkable.

Comparison of Rates and Outcomes of Readmission to Index vs Non-index Hospitals After Intravenous Thrombolysis in Acute Stroke Patients.

National and regional systems of stroke care are designed to provide patients with widespread access to hospitals with thrombolytic capabilities. However, such triaging systems may contribute to fragmentation of care. This study aims to compare rates of readmission and outcomes between index and non-index hospitals for stroke patients following intravenous thrombolytic therapy (IVT). This study utilized a nationally representative sample of stroke patients with IVT from the Nationwide Readmissions Database from 2010 to 2014. Descriptive and regression analyses were performed for patient and hospital level factors that influenced 90-day readmissions and regression models were used to identify differences in mortality, complications, and repeat readmissions between patients readmitted to index (facility where IVT was administered) and non-index hospitals. In the study, 49415 stroke patients were treated with IVT, of whom 21.7% were readmitted within 90 days. Among readmissions, 79.4% of patients were readmitted to index hospitals and 20.6% to non-index hospitals. On multivariate logistic regression analysis, index hospital readmission was independently associated with lower frequency of second readmissions (non-index OR 1.09, 95%CI 1.07-1.11, p<0.0001) but not with increased mortality or major complications (p=ns). Approximately one-fifth of stroke patients treated with thrombolysis were readmitted within 90 days, one-fifth of whom were readmitted to non-index hospitals. Although readmission to index hospital was associated with lower frequency of subsequent readmissions, readmission to non-index hospital was not associated with increased mortality or major complications. This difference may be due to standardized algorithms, mature systems of care, and demanding metrics required of stroke centers.

Discrepancy in Neurologic Outcomes Following Aneurysmal Subarachnoid Hemorrhage as a Function of Socioeconomic Class.

OBJECTIVE: To investigate potential health care discrepancies in patients with ruptured cerebral aneurysms undergoing microsurgical intervention. METHODS: We retrospectively reviewed patients with ruptured intracranial aneurysms treated at our tertiary referral university hospital (UH) and safety net county hospital (CH) from 2010 to 2015. We identified 73 UH patients and 58 CH patients. RESULTS: UH patients had shorter time duration between rupture and intervention (P < 0.001) and higher rates of intubation on admission (P = 0.01). Verapamil was more frequently used for clinical vasospasm in UH patients, at 0.13 (95% confidence interval [CI], 0.09-0.18) treatments per patient per day versus 0.077 (95% CI, 0.047-0.12) treatments per patient per day in CH patients, though there was no difference in delayed cerebral ischemia (P = 0.15). The majority of the CH cohort was uninsured (26.3%; UH 0%) or had Medicaid (59.7%; UH 35.2%) (P < 0.001). The UH had more dispositions to home or rehabilitation centers than the CH (82% vs. 67.3%; P = 0.04). After adjusting for disease severity, hospital stay, and insurance status, CH patients were 3.73 (95% CI, 1.25-12.14) times more likely to be discharged with a poor modified Rankin Scale score and 3.08 (95% CI, 1.04-9.61) times more likely to be discharged with a poor Glasgow Outcome Scale score compared with UH patients (P = 0.02 and P = 0.04, respectively). CONCLUSIONS: Limited resource availability in a safety net hospital system could be a major driving force behind the health care discrepancy identified in our ruptured cerebral aneurysm population. Reallocation of resources to supplement advanced inpatient acute care technologies and, more importantly, post-acute care environments can narrow the outcomes gap.

Frequency, predictors, and outcomes of readmission to index versus non-index hospitals after mechanical thrombectomy in patients with ischemic stroke.

BACKGROUND: Stroke systems of care employ a hub-and-spoke model, with fewer centers performing mechanical thrombectomy (MT) compared with stroke-receiving centers, where a higher number offer high-level, centralized treatment to a large number of patients. OBJECTIVE: To characterize rates and outcomes of readmission to index and non-index hospitals for patients with ischemic stroke who underwent MT. METHODS: This study leveraged a population-based, nationally representative sample of patients with stroke undergoing MT from the Nationwide Readmissions Database between 2010 and 2014. Descriptive, logistic regression analyses, and univariate and multivariate logistic regression models were carried out to determine patient- and hospital-level factors, mortality, complications, and subsequent readmissions associated with index and non-index hospitals' 90-day readmissions. RESULTS: In the study, 2111 patients with a stroke were treated with MT, of whom 534 were readmitted within 90 days. The most common reasons for readmission were: septicemia (5.9%), atrial fibrillation (4.8%), and cerebral artery occlusion with infarct (4.8%). Among readmitted patients, 387 (74%) were readmitted to index and 136 (26%) to non-index hospitals. On multivariable logistic regression analysis, non-index hospital readmission was not independently associated with major complications (p=0.09), mortality (p=0.34), neurological complications (p=0.47), or second readmission (p=0.92). CONCLUSION: One-quarter of patients with a stroke treated with MT were readmitted within 90 days, and one quarter of these patients were readmitted to non-index hospitals. Readmission to a non-index hospital was not associated with mortality or increased complication rates. In a hub-and-spoke model it is important that follow-up care for a specialized procedure can be performed effectively at a vast number of non-index hospitals covering a large geographic area.

Nonindex Readmission After Ruptured Brain Aneurysm Treatment Is Associated with Higher Morbidity and Repeat Readmission.

BACKGROUND: Aneurysmal subarachnoid hemorrhage (aSAH) requires complex multidisciplinary care. After initial treatment (index hospital), readmission to a different hospital (nonindex) can compromise quality of care, resulting in increased morbidity. We aimed to evaluate factors associated with nonindex readmission and evaluate association of nonindex hospital readmission on outcomes in patients with ruptured aneurysm. METHODS: Readmissions within 90 days after aSAH treatment were identified in the 2010-2014 Nationwide Readmissions Database. Multivariable logistic regression identified patient and hospital characteristics associated with nonindex readmission. Separate multivariable models determined increased morbidity or risk of second readmission for nonindex readmissions. RESULTS: A total of 9254 patients who underwent treatment of ruptured aneurysms from 2010 to 2014 were identified. Of these, 1985 (21.5%) were readmitted within 90 days. Three hundred and fifty-five of these readmissions (17.9%) occurred to nonindex hospitals. Patients that were discharged to a skilled nursing or other facility (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.27-2.28]) had higher odds of nonindex readmission, whereas patients with private insurance were associated with lower odds of nonindex readmission (OR, 0.65; 95% CI, 0.46-0.92). Patients readmitted to a nonindex (vs. index) hospital were associated with increased likelihood of major complications (OR, 1.71; 95% CI, 1.18-2.48) and second readmissions (OR, 1.51; 95% CI, 1.17-1.96). CONCLUSIONS: After treatment of a ruptured cerebral aneurysm, 17.9% of readmissions occurred at a nonindex hospital. These patients were at increased risk for major complications or subsequent readmissions, which may be because of care fragmentation. Interventions aimed at improving continuity of care may reduce higher morbidity associated with nonindex readmission.

Quantification of intracranial arterial blood flow using noncontrast enhanced 4D dynamic MR angiography.

PURPOSE: Noncontrast enhanced dynamic magnetic resonance angiography delineates the pattern of dynamic blood flow of the cerebral vasculature. A model-free solution was proposed to quantify arterial blood flow (aBF) by using the monotonic property of the residual function. THEORY AND METHODS: Analytical simulations and in-vivo studies were performed to evaluate the performance of the proposed method by comparing the aBF values generated from the proposed and conventional singular value decomposition methods. The aBF values were compared with blood flow velocity measured by 2D phase contrast MRI, and compared between balanced steady-state free precession-based radial and spoiled GRE-based Cartesian acquisitions. Hemodynamic parametric maps were generated in 1 patient with arteriovenous malformation. RESULTS: The proposed method generates reliable aBF measurement at different signal-to-noise ratio levels, whereas overestimation/underestimation of aBF was observed when a high/low threshold was applied in the singular value decomposition method. Average aBF in large vascular branches was 214.4 and 214.5 mL/mL/min with radial and Cartesian acquisitions, respectively. Significant correlations were found between aBF and blood flow velocity measured by phase contrast MRI (P = 0.0008), and between Cartesian and radial acquisitions (P < 0.0001). Altered hemodynamics were observed at the lesion site of the arteriovenous malformation patient. CONCLUSION: A robust analytical solution was proposed for quantifying aBF. This model-free method is robust to noise, and its clinical value in the diagnosis of cerebrovascular disorders awaits further evaluation.

Increased Hospital Surgical Volume Reduces Rate of 30- and 90-Day Readmission After Acoustic Neuroma Surgery.

BACKGROUND: Hospital readmissions are commonly linked to elevated health care costs, with significant financial incentive introduced by the Affordable Care Act to reduce readmissions. OBJECTIVE: To study the association between patient, hospital, and payer factors with national rate of readmission in acoustic neuroma surgery. METHODS: All adult inpatients undergoing surgery for acoustic neuroma in the newly introduced Nationwide Readmissions Database from 2013 to 2014 were included. We identified readmissions for any cause with a primary diagnosis of neurological, surgical, or systemic complication within 30- and 90-d after undergoing acoustic neuroma surgery. Multivariable models were employed to identify patient, hospital, and administrative factors associated with readmission. Hospital volume was measured as the number of cases per year. RESULTS: We included patients representing a weighted estimate of 4890 admissions for acoustic neuroma surgery in 2013 and 2014, with 355 30-d (7.7%) and 341 90-d (9.1%) readmissions. After controlling for patient, hospital, and payer factors, procedural volume was significantly associated with 30-d readmission rate (OR [odds ratio] 0.992, p = 0.03), and 90-d readmission rate (OR 0.994, p = 0.047). The most common diagnoses during readmission in both 30- and 90-d cohorts included general central nervous system complications/deficits, hydrocephalus, infection, and leakage of cerebrospinal fluid (rhinorrhea/otorrhea). CONCLUSION: After controlling for patient, hospital, and payer factors, increased procedural volume is associated with decreased 30- and 90-d readmission rate for acoustic neuroma surgery. Future studies seeking to improve outcomes and reduce cost in acoustic neuroma surgery may seek to further evaluate the role of hospital procedural volume and experience.

Predictors of Venous Thromboembolism After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis.

BACKGROUND: Venous thromboembolism (VTE) is responsible for many hospital readmissions each year, particularly among postsurgical cohorts. Because early and indiscriminate VTE prophylaxis carries catastrophic consequences in postcraniotomy cohorts, identifying factors associated with a high risk for thromboembolic complications is important for guiding postoperative management. OBJECTIVE: To determine VTE incidence in patients undergoing nonemergent craniotomy and to evaluate for factors that predict 30-day and 90-day readmission with VTE. METHODS: The 2010-2014 cohorts of the Nationwide Readmissions Database were used to generate a large heterogeneous craniotomy sample. RESULTS: There were 89,450 nonemergent craniotomies that met inclusion criteria. Within 30 days, 1513 patients (1.69%) were readmitted with VTE diagnoses; among them, 678 (44.8%) had a diagnosis of deep vein thrombosis alone, 450 (29.7%) had pulmonary embolism alone, and 385 (25.4%) had both. The corresponding 30-day deep vein thrombosis and pulmonary embolism incidences were 1.19% and 0.93%, respectively. In multivariate analysis, several factors were significantly associated with VTE readmission, namely, craniotomy for tumor, corticosteroids, advanced age, greater length of stay, and discharge to institutional care. CONCLUSIONS: Craniotomies for tumor, corticosteroids, advanced age, prolonged length of stay, and discharge to institutional care are significant predictors of VTE readmission. The implication of steroids, coupled with their ubiquity in neurosurgery, makes them a potentially modifiable risk factor and a prime target for VTE reduction in craniotomy cohorts. Furthermore, the fact that dose is proportional to VTE risk in the literature suggests that careful consideration should be given toward decreasing regimens in situations in which use of a lower dose might prove equally sufficient.

A3-A3 Anastomosis in the Management of Complex Anterior Cerebral Artery Aneurysms: Experience With in Situ Bypass and Lessons Learned From Pseudoaneurysm Cases.

BACKGROUND: A3-A3 side-to-side bypass is an intracranial-to-intracranial (IC-IC) revascularization option when aneurysm treatment involves occlusion of one anterior cerebral artery (ACA). OBJECTIVE: To describe applications of A3-A3 side-to-side bypass in the management of ACA true and pseudoaneurysms along with a review of pertinent literature. METHODS: Six consecutive patients undergoing an A3-A3 bypass as part of their aneurysm management, representing a single-surgeon experience in a 2-yr period, were included in this retrospective review of a prospectively collected database. RESULTS: Three male and three female patients with a median (range) age of 41.5 (11-69) years representing four ruptured and two unruptured aneurysms were included. Two of the aneurysms were communicating while four were postcommunicating from which three were pseudoaneurysms. Complete aneurysm obliteration was achieved in 5/6 cases. Bypass patency was evaluated in all cases intra- and postoperatively. Good outcomes (modified Rankin Scale score ≤ 2) at follow-up were observed in 4/6 patients. An improvement in mRS scores at the most recent follow-up as compared to preoperative status was achieved in three while scores remained the same in two patients. Ischemic complications related to aneurysm treatment were observed in two patients, both of which achieved good functional recovery upon follow-up. One patient deceased postoperatively due to progression of vasospasm-related infarcts. CONCLUSION: A3-A3 bypass in the management of true as well as pseudoaneurysms of the ACA can achieve good postoperative outcomes in selected patients. Prompt diagnosis and aggressive surgical treatment needs to be pursued if a vessel injury with pseudoaneurysm formation is suspected.

Fusiform vertebral artery aneurysms involving the posterior inferior cerebellar artery origin associated with the sole angiographic anterior spinal artery origin: technical case report and treatment paradigm proposal.

Fusiform aneurysms of the vertebral artery (VA) involving the posterior inferior cerebellar artery (PICA) origin are uncommon and challenging. The anterior spinal artery (ASA) commonly originates from a unilateral ramus just distal to the PICA. Occlusion of an unpaired ASA can result in bilateral medial medullary syndrome. The authors propose a treatment paradigm for ASA preservation based on the artery's proximity to fusiform VA aneurysms, and they present 3 representative cases. In the first case, they performed a V3-PICA bypass using an interposition graft and then performed endovascular coil embolization of the parent VA. A complete occlusion of the aneurysm and VA was complicated by ASA thrombosis. The subsequent cases were treated with PICA-PICA bypass and subsequent endovascular embolization of the VA. Filling of the sole angiographic ASA remote from the aneurysm was preserved in both cases. The anatomy of the ASA is the most critical determinant of treatment recommendations for fusiform VA aneurysms involving PICA. When the ASA originates from the aneurysm, proximal occlusion with or without a PICA bypass is suggested. In cases in which the ASA is removed from the aneurysm, the authors recommend revascularization followed by endovascular sacrifice. When the aneurysm is immediately adjacent to the ASA, revascularization and open trapping should be considered.

Treatment at Safety-Net Hospitals Is Associated with Delays in Coil Embolization in Patients with Subarachnoid Hemorrhage.

BACKGROUND: Successful endovascular management of aneurysmal subarachnoid hemorrhage (aSAH) requires timely access to substantial resources. Prior studies suggest an association between time to treatment and patient outcome. Patients treated at safety-net hospitals are thought to be particularly vulnerable to disparities in access to interventions that require substantial technologic resources. We hypothesized that patients with aSAH treated at safety-net hospitals are at greater risk for delayed access to endovascular treatment. METHODS: Adults undergoing endovascular coiling procedures between 2002 and 2011 in the Nationwide Inpatient Sample were included. Hospitals in the quartile with the highest proportion of Medicaid or uninsured patients were defined as safety-net hospitals. A multivariate model including patient-level and hospital-level factors was constructed to permit analysis of delays in endovascular treatment (defined as time to treatment >3 days). RESULTS: Analysis included 7109 discharges of patients with aSAH undergoing endovascular coil embolization procedures from 2002 to 2011. Median time to coil embolization in all patients was 1 day; 10.1% of patients waited >3 days until treatment. In multivariate analysis, patients treated at safety-net hospitals were more likely to have a prolonged time to coil embolization (odds ratio = 1.32, P < 0.01) compared with patients treated at low-burden hospitals. CONCLUSIONS: After controlling for patient and hospital factors, individuals with aSAH treated at safety-net hospitals from 2002 to 2011 were more likely to have a delay to endovascular coil embolization than individuals treated at non-safety-net hospitals. This disparity could affect patient outcomes.

Descending Branch of the Lateral Circumflex Femoral Artery Graft for Posterior Inferior Cerebellar Artery Revascularization.

BACKGROUND: Posterior inferior cerebellar artery (PICA) revascularization can be achieved with relative ease when a contralateral PICA is present. However, without a contralateral PICA, identification of a suitable vessel alternative can be challenging due to a size mismatch. OBJECTIVE: To propose the descending branch of the lateral circumflex femoral artery (DLCFA) to be an acceptable, if not preferred, arterial graft for PICA revascularization. METHODS: Data from patients who underwent PICA revascularization with DLCFA grafts were obtained from an institutional review board-approved prospectively maintained database with informed consent from the patients. RESULTS: Three patients, all presenting with ruptured aneurysms, were treated with PICA revascularization using the DLCFA. All cases achieved bypass patency and no ischemic events occurred during the bypass procedures. Graft spasm occurred in 2 patients. Two patients that presented with neurological deficits achieved excellent neurological outcomes and 1 suffered an anterior spinal artery stroke during a repeat endovascular treatment 1 wk after revascularization. CONCLUSION: The DLCFA is favorable for PICA revascularization when a contralateral PICA is not a viable option.

Safety-Net Hospitals Have Higher Complication and Mortality Rates in the Neurosurgical Management of Traumatic Brain Injuries.

BACKGROUND: Clinical outcomes in the surgical management of severe traumatic brain injury (TBI) have been shown to vary across different hospital institutions. The effect of the safety-net burden on postoperative mortality, complication rates, and failure to rescue rates is unclear. We evaluated the relationship of the safety-net burden with outcomes in the treatment of patients with severe TBI undergoing neurosurgery. METHODS: The hospitals were grouped according to their safety-net burden, defined as the proportion of Medicaid and uninsured patient charges for all hospitalizations during that time. Multivariate analyses were performed to examine significant associations with the degree of safety-net burden while controlling for potential confounders. RESULTS: Data from 20,989 encounters in 788 hospitals were included. Compared with low-burden hospitals (LBHs), high-burden hospitals (HBHs; odds ratio [OR], 1.48; 95% confidence interval [CI], 1.04-2.12; P = 0.03) had greater mortality rates. Major complications were more likely to occur at HBHs (OR, 1.44; 95% CI, 1.12-1.84; P < 0.01) compared with LBHs. The failure to rescue rates were similar among all safety-net burden hospital groups. Patients at HBHs also had an increased likelihood of an extended length of stay (OR, 1.92; 95% CI, 1.12-3.29; P = 0.02) and receiving a tracheostomy or gastrostomy (OR, 1.99; 95% CI, 1.36-2.89; P < 0.01) compared with patients at LBHs. CONCLUSIONS: The present study found that a greater hospital safety-net burden was independently associated with greater rates of mortality and major complications in the treatment of patients with severe TBI undergoing neurosurgery. Further research in evaluating the cause of disparities in mortality outcomes at high safety-burden hospitals is needed.

Botulinum toxin to improve vessel graft patency in cerebral revascularization surgery: report of 3 cases.

Surgical revascularization continues to play an important role in the management of complex intracranial aneurysms and ischemic cerebrovascular disease. Graft spasm is a common complication of bypass procedures and can result in ischemia or graft thrombosis. The authors here report on the first clinical use of botulinum toxin to prevent graft spasm following extracranial-intracranial (EC-IC) bypass. This technique was used in 3 EC-IC bypass surgeries, 2 for symptomatic carotid artery occlusions and 1 for a ruptured basilar tip aneurysm. In all 3 cases, the harvested graft was treated ex vivo with botulinum toxin before the anastomosis was performed. Post-bypass vascular imaging demonstrated patency and the absence of spasm in all grafts. Histopathological analyses of treated vessels did not show any immediate endothelial or vessel wall damage. Postoperative angiograms were without graft spasm in all cases. Botulinum toxin may be a reasonable option for preventing graft spasm and maintaining patency in cerebral revascularization procedures.