Gram-Negative Ventriculostomy-Associated Infections Predict Shunt Dependency in Stroke Diagnoses and Other Brain Injuries.

BACKGROUND: Several predictors have been studied for shunt dependency after stroke and other brain injuries. However, little is known about the association between ventriculostomy-associated infections (VAIs) and impaired cerebrospinal fluid (CSF) outflow. Moreover, gram-negative (GN) VAIs induce a potent neuroinflammatory process and are clinically challenging to treat. OBJECTIVE: To assess if GN-VAIs predict ventriculoperitoneal shunt (VPS) dependency. METHODS: Retrospective analysis of postprocedure infection rates was performed in 586 patients with external ventricle drainage (EVD) placed on site between 2012 and 2018. We collected sex, age, stroke and nonstroke related, location of EVD placement, type of hospital, EVD duration, and EVD exchange. RESULTS: Among 586 patients requiring an EVD, 55 developed a VAI. Most were caused by gram-positive (GP) pathogens (61.8%). A total of 120 patients required a conversion from EVD to VPS. Patients with VAIs had higher rates of VPS placement (49.09% vs 17.65%, P < .001), whereas patients with GN-VAIs had significantly higher rates of EVD conversion to VPS (77.78% vs 35.29%, P = .012) compared with GP-VAIs. The multivariate analysis showed that GN-VAIs were an independent predictor for shunt dependency (odds ratio = 12.896; 95% CI 3.407-48.82, P < .001). In receiver operating characteristics analysis, those less than 44.5 yr of age and more than 12 d of EVD duration were identified as the best cutoff values to discriminate the development of GN-VAI. CONCLUSION: Patients who experience a GN VAI are in greater risk of impaired CSF outflow, thus requiring VPS placement.

Trans-Carotid and Trans-Radial Access for Mechanical Thrombectomy for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis.

Objective We aim to demonstrate the safety and effectiveness of extra-femoral endovascular access for mechanical thrombectomy for acute ischemic stroke patients whose vascular anatomy precludes safe or maneuverable trans-femoral access. Methods Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to conduct a systematic review and meta-analysis with articles published until March 2018. The search protocol, including research questions and inclusion and exclusion criteria, were developed a priori. Our own institutional retrospective data were included in the cohort of case series. Results Eleven studies including 51 patients were included. Age ranged from 4th to 10th decade of life (average: 9.3rd decade) and 40.1% received IV tissue plasminogen activator. Initial National Institutes of Health Stroke Scale (NIHSS) score ranged from 1 to 36, (average: 17.6). Of the 51 patients, 39 (76%) patients suffered from anterior circulation large vessel occlusions versus 12 (24%) from posterior circulation occlusions. Site of access included 26 (51%) radial artery punctures, 23 (45%) direct percutaneous cervical carotid punctures, 1 brachial artery puncture, and 1 direct extradural vertebral artery puncture. Technical success was achieved in 43/51 (84%) of patients. The average modified Rankin Scale at discharge was 2.93 (n=26). There were no complications in 25 patients who underwent radial arterial access. Two (7.4%) of 27 cervical access patients developed hematoma. Conclusions Trans-carotid and trans-radial access for intervention in acute ischemic stroke is safe and effective. There may be instances in which these approaches should be considered first line before standard femoral approaches.

Trends in the Use of Bone Morphogenetic Protein-2 in Adult Spinal Deformity Surgery: A 10-Year Analysis of 54 054 Patients.

BACKGROUND: Bone morphogenetic protein-2 (BMP-2) is an available bone graft option in spinal fusion surgery. The purpose of this study is to investigate the trends of BMP-2 utilization in adult spinal deformity (ASD) surgery. METHODS: The Nationwide Inpatient Sample database from 2002 to 2011 was reviewed. Inclusion criteria were patients over 18 years of age who underwent spinal fusion for ASD. Trends of BMP-2 use were examined over time, as well as stratified based on patient and surgical characteristics. All analyses were done after application of discharge weights to produce national estimates. RESULTS: There were 54 054 patients who met inclusion criteria and were included in this study. The overall rate of BMP-2 use was 39.7% (95% confidence interval 35.0%- 44.3%). Overall, there was steady increase in its use over time, with the highest peak in 2009 (55.3% of all cases used BMP-2), and then a decrease up to 37.9% in 2011 (P < .001). The rate of BMP-2 use was significantly higher for patients older than 54 years of age (compared to patients <54, P < .001). It was also higher in females (P = .009), Caucasian patients (P = .006), and Medicare patients (P = .006). Its use was 28.6% in the Northeast, 38.1% in the South, 45.2% in the Midwest, and 48.2% in the West (P = .035). Circumferential procedures had the highest rate of BMP-2 use (44.3%, P = .045). Average total hospital charges were $152,403 ± 117,454 for patients who did not receive BMP-2 and $205,426 ± 137,561 for patients who did (P < .001). CONCLUSION: After analysis of a large nationwide database, it was found that the rate of BMP-2 use in ASD surgery is approximately 40%. There was a significant increase in use from 2002 to 2009, and a decrease thereafter. The highest rates of use were found in older patients, female patients, white patients, Medicare patients, circumferential approaches, and patients undergoing surgery in the Midwest and West regions.

Risk Factors for 30-Day Readmissions and Reoperations After 3-Column Osteotomy for Spinal Deformity.

STUDY DESIGN: Retrospective study of a prospectively collected database. OBJECTIVE: To investigate the rate and risk factors for 30-day readmissions and reoperations after 3-column osteotomy (3CO). METHODS: The American College of Surgeons National Surgical Quality Improvement Program database (2012-2014) was reviewed. Inclusion criteria were adult patients who underwent 3CO. The rate of 30-day readmission/reoperation was examined, and the association between patient/operative characteristics and outcome was investigated via multivariate analysis. RESULTS: There were 299 patients who underwent a 3CO for spinal deformity. The rate of 30-day readmission and reoperation was 11.0% and 8.4%, respectively; 7.7% of readmissions were related to the primary procedure and 3.3% were unrelated. The most common unique cause for readmission was wound infection in 27.2% of cases. Among reoperations, the most common unique indications were wound infection (20.0%) and implant-related complications (20.0%). On multivariate analysis, obesity (odds ratio [OR] = 2.96; 95% CI = 1.06-8.25; P = .038), chronic obstructive pulmonary disease (OR = 20.8; 95% CI = 3.49-123.5; P = .001), and fusion of 13 or more spinal levels were independent predictors of readmission (OR = 4.86; 95% CI = 1.21-19.5; P = .025). On the other hand, independent predictors of reoperation included chronic obstructive pulmonary disease (OR = 6.33; 95% CI = 1.16-34.5; P = .033) and chronic steroid use (OR = 6.69; 95% CI = 1.61-27.7; P = .009). CONCLUSION: Wound complications and short-term implant-related complications are important causes of readmission and/or reoperation after 3CO. Preoperative factors such as obesity, chronic lung disease, chronic steroid use, and long-segment fusion procedures may significantly increase the risk of 30-day morbidity following high-grade osteotomies.

Predicting critical care unit-level complications after long-segment fusion procedures for adult spinal deformity.

BACKGROUND: To identify predictive factors for critical care unit-level complications (CCU complication) after long-segment fusion procedures for adult spinal deformity (ASD). METHODS: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database [2010-2014] was reviewed. Only adult patients who underwent fusion of 7 or more spinal levels for ASD were included. CCU complications included intraoperative arrest/infarction, ventilation >48 hours, pulmonary embolism, renal failure requiring dialysis, cardiac arrest, myocardial infarction, unplanned intubation, septic shock, stroke, coma, or new neurological deficit. A stepwise multivariate regression was used to identify independent predictors of CCU complications. RESULTS: Among 826 patients, the rate of CCU complications was 6.4%. On multivariate regression analysis, dependent functional status (P=0.004), combined approach (P=0.023), age (P=0.044), diabetes (P=0.048), and surgery for over 8 hours (P=0.080) were significantly associated with complication development. A simple scoring system was developed to predict complications with 0 points for patients aged <50, 1 point for patients between 50-70, 2 points for patients 70 or over, 1 point for diabetes, 2 points dependent functional status, 1 point for combined approach, and 1 point for surgery over 8 hours. The rate of CCU complications was 0.7%, 3.2%, 9.0%, and 12.6% for patients with 0, 1, 2, and 3+ points, respectively (P<0.001). CONCLUSIONS: The findings in this study suggest that older patients, patients with diabetes, patients who depend on others for activities of daily living, and patients who undergo combined approaches or surgery for over 8 hours may be at a significantly increased risk of developing a CCU-level complication after ASD surgery.