Comparing Outcomes for Emergent Cranial Neurosurgical Procedures Performed "During Hours" and "After Hours".

OBJECTIVE: Surgery performed at night and on weekends is thought to be associated with increased complications. However, the impact of time of day on outcomes has not been studied within cranial neurosurgery. We aim to determine if there are differences in outcomes for cranial neurosurgery performed after hours (AH) compared with during hours (DH). METHODS: We performed a single-center retrospective study of cranial neurosurgery patients who underwent emergent surgery from January 2015 through December 2019. Surgery was considered DH if the incision occurred between 8 am and 5 pm Monday through Friday. We assessed outcome measures for differences between operations performed DH or AH. RESULTS: Three-hundred and ninety-three patients (114 DH, 279 AH) underwent surgery. There was a lower rate of return to the operating room within 30 days for AH (8.6%) compared with DH (14.0%), P = 0.03, on multivariate analysis. There were no significant differences in length of operation, estimated blood loss, improvement in Glasgow Coma Scale, intensive care unit and total hospital length of stay, 30-day readmission, 30-day mortality, and in-hospital mortality for cases performed DH compared with AH. Further subgroup analyses were performed for patients who underwent immediate surgery for subdural hematomas, with no differences noted in outcomes on multivariate analysis. CONCLUSIONS: This study suggests that operating AH does not appear to negatively impact outcomes when compared with operating DH, in cases of cranial neurosurgical emergencies. Further study assessing the impact on elective neurosurgical cases is required.

Symptomatic carotid artery intraluminal thrombus: risk of medical management failure and distal embolization.

BACKGROUND: Carotid artery intraluminal thrombus (ILT), or free-floating thrombus, is an uncommon cerebrovascular entity with considerable equipoise regarding its clinical management. Likewise, in patients treated with medical management (MM), distal embolization and/or intracranial hemorrhage (ICH) may still occur. METHODS: All patients with symptomatic ILT from 2016 to 2023 were identified from our tertiary care institution. Patients with MM failure (recurrent cerebral ischemia and/or symptomatic ICH) were compared with patients with MM non-failure. Differences in ILT volume and length were calculated. Receiver operator characteristic (ROC) curve analysis was used to identify the cut-off volume and length for risk of MM failure. RESULTS: In total, 45 patients with ILT were identified with 41 treated with frontline MM. Of these 41 patients treated with MM, seven (17%) had MM failure with six (14.6%) having new embolic stroke and one (2.3%) with symptomatic ICH. Patients with MM failure had a significantly higher mean thrombus volume than MM non-failure patients (257 mm3 vs 59.6 mm3, P=0.0006). Likewise, patients with MM failure had significantly longer thrombus on average (21 mm vs 6.6 mm, P=0.0009). ROC curve analysis showed that an ILT volume of 90 mm3 resulted in a sensitivity of 71.4% and specificity of 85.3% for MM failure (AUC 0.775; CI 0.55 to 1.0, P=0.023). CONCLUSIONS: Carotid ILTs that fail MM are significantly larger and longer. These findings suggest that a thrombus volume of 90 mm3 may serve as a guide for intervention with good sensitivity and specificity for risk of MM failure.

Comparing 30-Day Outcomes After Emergent Spine Procedures Performed "During Hours" vs "After Hours".

BACKGROUND: Spinal injuries, whether mechanical or neurological, frequently require urgent intervention. Superior outcomes are associated with earlier intervention, which often requires operating overnight and on weekends. However, operating after hours has been associated with increased risks of complications in selected studies. The authors sought to determine whether there are differences in outcomes for "after hours" surgery compared with "during hours" surgery for spinal emergencies. METHODS: This is a single-center retrospective cohort study of spine surgery patients who underwent urgent surgery within 6 hours, from January 2015 through December 2019. Surgery was considered during hours if it started between 8 am and 5 pm Monday through Friday. After hours was defined as from 5 pm through 8 am on a weekday or Saturday or Sunday. We assessed 30-day outcome measures for differences between operations performed during hours or after hours. RESULTS: There were 241 spine procedures performed (49 during hours and 192 after hours). There was no significant difference between the length of operation (145.3 vs 129.8 minutes, P = 0.29), estimated blood loss (303.9 vs 274.4 mL, P = 0.61), improvement in American Spinal Injury Association scale (0.26 vs 0.24 grade, P = 0.85), 30-day return to the operating room (OR; 14.3% vs 6.8%, P = 0.09), 30-day readmission (2.0% vs 6.3% P = 0.24), intensive care unit length of stay (4.6 vs 6.3 days, P = 0.27), hospital length of stay (13.5 days vs 14.2 days, P = 0.72), or 30-day mortality (4.1% vs 7.3%, P = 0.42) for cases performed during hours compared with those after hours, respectively. On multivariate analysis, prior malignancy (P = 0.008) and blue immediate status (P = 0.004) were predictors of 30-day mortality. However, "after hours" surgery was not a predictor of 30-day return to the OR, readmission, or mortality in either univariate or multivariate analysis. CONCLUSIONS: Spine surgery must often be performed after hours. However, the time of day does not significantly impact the 30-day outcomes for emergent spine surgery.

Approaches to and outcomes of intra-arterial tPA in embolectomy for large vessel occlusion.

INTRODUCTION: Intra-arterial tissue plasminogen activator (IA tPA) is sometimes used in conjunction with aspiration catheters and stentrievers to achieve recanalization in endovascular thrombectomy (ET) for large vessel occlusion (LVO). Reports of safety and efficacy of this approach are limited by technical heterogeneity and sample size. METHODS: We retrospectively reviewed a data set of patients undergoing ET for LVO between August 2017 and September 2020 to identify those that received IA tPA. IA tPA usage, timing and dosage was at the discretion of the operative neurosurgeon. We identified three broad categories of IA tPA administration: (1) adjunctive with the first pass; (2) salvage with subsequent passes after first pass achieved incomplete revascularization; and (3) post-thrombectomy residual distal occlusions. Univariate and multivariate logistic regression were performed to test associations with recanalization, hemorrhage, and functional independence. RESULTS: Among 271 patients, 158 (58%) patients had IA tPA, of which 83 received adjuvant IA tPA, 60 received salvage IA tPA, and 15 received post-thrombectomy IA tPA for distal occlusions. There were no differences in demographics, stroke etiology and premorbid medications between these groups. Patients receiving salvage IA tPA had longer times from groin access to recanalization and more passes, as expected. On multivariate analysis neither adjunctive nor salvage IA tPA was significantly associated with recanalization, post-operative hemorrhage, or functional outcomes. On univariate analysis, patients receiving salvage IA tPA had lower rates of TICI 3 or 2b revascularization (80% vs. 89% adjunctive and 92% no IA tPA, p =  0.003) and higher rates of any postoperative hemorrhage (33% vs. 22% adjunctive and 19% no IA tPA, p =  0.003). CONCLUSIONS: In this retrospective, single-institution series, IA tPA used adjunctively or as salvage therapy in ET for LVO was not associated with recanalization, post-operative hemorrhage, or functional outcomes, suggesting IA tPA is an available modality that can be utilized in cases of recalcitrant clots.

Endovascular Therapy is Effective for Large Vessel Occlusion Despite Concurrent Cancer.

OBJECTIVES: Ischemic stroke and concurrent cancer is increasingly recognized. However, optimal management is uncertain. As mechanical thrombectomy has become the standard of care for large vessel occlusion, more patients with cancer are presenting for embolectomy. However, it is unknown whether this subgroup has the same benefit profile described in multiple randomized trials for thrombectomy for large vessel occlusion. Our objective was to retrospectively evaluate a North American embolectomy database for safety and outcomes in patients with active cancer. MATERIALS AND METHODS: A case series of 284 embolectomies over 30 months at a single North American stroke center were divided into thrombectomy patients with active cancer(n=25) and those without active cancer (n=259). We compared patient characteristics, procedural characteristics, and procedural outcomes between patients with and without active cancer. Univariate and multivariate analysis of angiographic outcomes, postoperative hemorrhage, and functional outcome was performed. RESULTS: Of the 284 thrombectomy cases, 9% were performed on patients with active cancer. Active cancer patients had a similar recanalization grade and post-operative hemorrhage rate, compared to patients without cancer. Active cancer patients had a significantly higher 90 day mortality (40% vs 20%, p=0.018). On multivariate analysis, good functional outcome (mRS 0-2) was not impacted by active cancer. However, when mRS was evaluated as an ordinal shift analysis, worse functional outcome was associated with active cancer (OR 2.98; 95% CI, 1.29 to 6.59), greater age, NIHSS> 10, and ASPECTS<9. CONCLUSIONS: This single center retrospective series of active cancer patients undergoing thrombectomy for large vessel occlusion demonstrates similar rates of recanalization, post-operative hemorrhage, and good outcomes. While the active cancer group has a high short-term mortality, the potential to maintain quality of life in the survivors makes thrombectomy reasonable in this patient population. Awareness of ischemic stroke as a complication of cancer and the safety of thrombectomy in this population are important as this population subtype is expected to grow with improved oncology and stroke care.

Credentialing, Certification, and Peer Review Essentials for the Neurosurgeon.

Credentialing and certification are essential processes during hiring to ensure that the physician is competent and possesses the qualifications and skill sets claimed. Peer review ensures the continuing evolution of these skills to meet a standard of care. We have provided an overview and discussion of these processes in the United States. Credentialing is the process by which a physician is determined to be competent and able to practice, used to ensure that medical staff meets specific standards, and to grant operative privileges at an institution. Certification is a standardized affirmation of a physician's competence on a nationwide basis. Although not legally required to practice in the United States, many institutions emphasize certification for full privileges on an ongoing basis at a hospital. In the United States, peer review of adverse events is a mandatory prerequisite for accreditation. The initial lack of standardization led to the development of the Health Care Quality Improvement Act, which protects those involved in the peer review process from litigation, and the National Provider Databank, which was established as a national database to track misconduct. A focus on quality improvement in the peer review process can lead to improved performance and patient outcomes. A thorough understanding of the processes of credentialing, certification, and peer review in the United States will benefit neurosurgeons by allowing them to know what institutions are looking for as well and their rights and responsibilities in any given situation. It could also be useful to compare these policies and practices in the United States to those in other countries.

Workplace Violence and Neurosurgery: Insights from a Nationwide Survey.

OBJECTIVE: Workplace violence (WPV) against neurosurgeons is an understudied phenomenon, as previous research has focused on high-risk specialties like emergency medicine and psychiatry. We sought to fill in this gap in the literature by determining the frequency and type of WPV that neurosurgeons experience. METHODS: We sent a 26-question online survey to members of the American Association of Neurological Surgery via SurveyMonkey. This survey contained questions about WPV experienced over the previous two years, as well as questions about security measures and workplace protocols for WPV. RESULTS: We received 107 responses of 4757 surveys disseminated, a response rate of 2.25%. Although small, this response rate is representative of historical survey response rates. In total, 53.3% of our sample reported WPV, and 4.7% reported at least one physical assault. In total, 50.5% of respondents were afraid of becoming a victim of WPV, and 40.4% felt less secure today than when they began practicing. A total of 17.8% of respondents reported that they had obtained a weapon or a concealed weapon permit due to a perceived threat. Tests for association revealed that early career and female neurosurgeons were significantly more likely to receive verbal threats than other neurosurgeons (P = 0.049 and 0.01, respectively). CONCLUSIONS: WPV is prevalent in neurosurgery at rates comparable with a range of other specialties. Many neurosurgeons feel unsafe in the workplace, with some taking significant actions such as weapon acquisition. An opportunity for education and resources regarding WPV exists, especially among early career and female neurosurgeons.

Treatment of glenohumeral arthritis pain utilizing spinal cord stimulation.

BACKGROUND: Dorsal column stimulation may be utilized to treat non-neuropathic pain attributed to glenohumeral arthritis. CASE DESCRIPTION: An 84-year-old female presented with right shoulder pain for 3 years. She was diagnosed with glenohumeral arthritis and a complete loss of the joint space. She was treated with a dorsal column stimulator, requiring the electrodes to be placed from the inferior aspect of C3 to the superior aspect of T1. Six weeks postoperatively, she reported >90% coverage of her shoulder pain, demonstrated increased right arm function, and a reduction in her use of narcotics. CONCLUSION: Dorsal column stimulation of C3-T1 proved to be an effective alternative treatment for drug-resistant glenohumeral arthritis in an 84-year-old female with a complete loss of the joint space.