Predictors of devastating functional outcome despite successful basilar thrombectomy.

BACKGROUND: Basilar thrombosis frequently leads to poor functional outcomes, even with good endovascular reperfusion. We studied factors associated with severe disability or death in basilar thrombectomy patients achieving revascularization. METHODS: We retrospectively analyzed records from a health system's code stroke registry, including successful basilar thrombectomy patients from January 2017 to May 2023 who were evaluated with pretreatment computed tomography perfusion. The primary outcome was devastating functional outcome (90-day modified Rankin Scale [mRS] score 5-6). A multivariable logistic regression model was constructed to determine independent predictors of the primary outcome. The area under the receiver operator characteristics curve (AUC) was calculated for the model distinguishing good from devastating outcome. RESULTS: Among 64 included subjects, with mean (standard deviation) age 65.6 (14.1) years and median (interquartile range) National Institutes of Health Stroke Scale (NIHSS) 18 (5.75-24.5), the primary outcome occurred in 28 of 64 (43.8%) subjects. Presenting NIHSS (odds ratio [OR] 1.08, 95% confidence interval [CI] 1.01-1.14, p = 0.02), initial glucose (OR 0.99, 95% CI 0.97-1.00, p < 0.05), and proximal occlusion site (OR 7.38, 95% CI 1.84-29.60, p < 0.01) were independently associated with 90-day mRS 5-6. The AUC for the multivariable model distinguishing outcomes was 0.81 (95% CI 0.70-0.92). CONCLUSION: We have identified presenting stroke severity, lower glucose, and proximal basilar occlusion as predictors of devastating neurological outcome in successful basilar thrombectomy patients. These factors may be used in medical decision making or for patient selection in future clinical trials.

The Charlotte Large artery occlusion Endovascular therapy Outcome Score predicts independent outcome after thrombectomy.

BACKGROUND AND PURPOSE: Predicting functional outcomes after endovascular thrombectomy (EVT) is of interest to patients and families as they navigate hospital and post-acute care decision-making. We evaluated the prognostic ability of several scales to predict good neurological function after EVT. METHODS: We retrospectively analyzed records from a health system's code stroke registry, including consecutive successful thrombectomy patients from August 2020 to February 2023 presenting with an anterior circulation large vessel occlusion who were evaluated with pre-EVT CT perfusion. Primary and secondary outcomes were 90-day modified Rankin Scale (mRS) scores 0-2 and 0-1, respectively. Logistic regression was performed to evaluate the ability of each scale to predict the outcomes. Scales were compared by calculating the area under the curve (AUC). RESULTS: A total of 465 patients (mean age 68.1 [±14.9] years, median National Institutes of Health Stroke Scale [NIHSS] 16 [11-21]) met inclusion criteria. In the logistic regression, the Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS), Totaled Health Risks in Vascular Events, Houston Intra-Arterial Therapy-2, Pittsburgh Response to Endovascular therapy, and Stroke Prognostication using Age and NIHSS were significant in predicting the primary and secondary outcomes. CLEOS was superior to all other scales in predicting 90-day mRS 0-2 (AUC .75, 95% confidence interval [CI] .70-.80) and mRS 0-1 (AUC .74, 95% CI .69-.78). Twenty of 22 patients (90.9%) with CLEOS <315 had 90-day mRS 0-2. CONCLUSIONS: CLEOS predicts independent and excellent neurological function after anterior circulation EVT.

Predicting severe disability or death in endovascular thrombectomy with large computed tomography perfusion core infarction and limited penumbra.

BACKGROUND: Patients presenting with large core infarctions benefit from treatment with endovascular thrombectomy (EVT), with a notable 50% reduction in rates of severe disability (modified Rankin Scale [mRS] 5) at 90 days. We studied the ability of previously reported prognostic scales to predict devastating outcomes in patients with a large ischemic core and limited salvageable brain tissue. METHODS: Retrospective analysis from a health system's code stroke registry, including consecutive thrombectomy patients from November 2017 to December 2022 with an anterior circulation large vessel occlusion, computed tomography perfusion core infarct ≥ 50 ml, and mismatch volume < 15 ml or mismatch ratio < 1.8. Previously reported scales were compared using logistic regression and area under the curve (AUC) analyses to predict 90-day mRS 5-6. RESULTS: Sixty patients (mean age 62.38 ± 14.25 years, median core volume 103 ml [74.75-153]) met inclusion criteria, of whom 27 (45%) had 90-day mRS 5-6. The Charlotte Large artery occlusion endovascular therapy Outcome Score (CLEOS) (odds ratio [OR] 1.35, 95% CI [1.14-1.60], p = 0.0005), Houston Intra-Arterial Therapy-2 (OR 1.35, 95% CI [1.00-1.83], p = 0.0470), and Totaled Health Risks in Vascular Events (OR 1.53, 95% CI [1.07-2.18], p = 0.0199) predicted the primary outcome in the logistic regression analysis. CLEOS performed best in the AUC analysis (AUC 0.83, 95% CI [0.72-0.94]). CONCLUSION: CLEOS predicts devastating outcomes after EVT in patients with large core infarctions and small volumes of ischemic penumbra.

The charlotte large artery occlusion endovascular therapy outcome score compares favorably to the critical area perfusion score for prognostication before basilar thrombectomy.

INTRODUCTION: The Critical Area Perfusion Score (CAPS) predicts functional outcomes in vertebrobasilar thrombectomy patients based on computed tomography perfusion (CTP) hypoperfusion. We compared CAPS to the clinical-radiographic Charlotte Large artery occlusion Endovascular therapy Outcome Score (CLEOS). METHODS: Acute basilar thrombosis patients from January 2017-December 2021 were included in this retrospective analysis from a health system's stroke registry. Inter-rater reliability was assessed for 6 CAPS raters. A logistic regression with CAPS and CLEOS as predictors was performed to predict 90-day modified Rankin Scale (mRS) score 4-6. Area under the curve (AUC) analyses were performed to evaluate prognostic ability. RESULTS: 55 patients, mean age 65.8 (± 13.1) years and median NIHSS score 15.55-24, were included. Light's kappa among 6 raters for favorable versus unfavorable CAPS was 0.633 (95% CI 0.497-0.785). Increased CLEOS was associated with elevated odds of a poor outcome (odds ratio (OR) 1.0010, 95% CI 1.0007-1.0014, p<0.01), though CAPS was not (OR 1.0028, 95% CI 0.9420-1.0676, p=0.93). An overall favorable trend was observed for CLEOS (AUC 0.69, 95% CI 0.54-0.84) versus CAPS (AUC 0.49, 95% CI 0.34-0.64; p=0.051). Among 85.5% of patients with endovascular reperfusion, CLEOS had a statistically higher sensitivity than CAPS at identifying poor 90-day outcomes (71% versus 21%, p=0.003). CONCLUSIONS: CLEOS demonstrated better predictive ability than CAPS for poor outcomes overall and in patients achieving reperfusion after basilar thrombectomy.

The Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score Predicts Poor Outcomes 1 Year After Endovascular Thrombectomy.

OBJECTIVE: We evaluated the ability of several outcome prognostic scales to predict poor 1-year outcomes and mortality after endovascular thrombectomy. METHODS: In this retrospective analysis from the stroke registry of a large integrated health system, consecutive patients presenting from August 2020 to September 2021 with an anterior circulation large-vessel occlusion stroke treated with endovascular thrombectomy were included. Multivariable logistic regression was performed to determine the ability of each scale to predict the primary outcome (1-year modified Rankin Scale [mRS] score of 4-6) and the secondary outcome (1-year mortality). Area under the curve analyses were performed for each scale. RESULTS: In 237 included patients (mean age 68 [±15] years; median National Institutes of Health Stroke Scale score 16 [11-21]), poor 1-year outcomes were present in 116 patients (49%) and 1-year mortality was 34%. The CLEOS (Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score), which incorporates age, baseline National Institutes of Health Stroke Scale score, initial glucose level, and computed tomography perfusion cerebral blood volume index, had a significant association with poor 1-year outcomes (per 25-point increase; odds ratio, 1.0134; P = 0.02). CLEOS and PRE (Pittsburgh Response to Endovascular Therapy) were both significantly associated with 1-year mortality. Area under the curve values were comparable for CLEOS, PRE, Houston Intra-Arterial Therapy 2, and Totaled Health Risks in Vascular Events to predict 1-year mRS score 4-6 and mortality. Only 1 of 18 patients with CLEOS ≥690 had a 1-year mRS score of 0-3. CONCLUSIONS: CLEOS can predict poor 1-year outcomes and mortality for patients with anterior circulation large-vessel occlusion using prethrombectomy variables.

Endovascular treatment of pediatric basilar artery aneurysms: case series and literature review.

PURPOSE: Pediatric basilar artery aneurysms are rare and challenging to treat. Microsurgical options and standard endovascular coiling are often undesirable choices for treatment of this pathology. Additional endovascular strategies are needed. METHODS: Presentation, diagnosis, and management of pediatric basilar aneurysms were reviewed, with an emphasis on endovascular treatment strategies. Our case series of 2 patients was presented in detail, one treated with flow diversion and vessel sacrifice and one treated with stent-assisted coiling. An extensive review of the literation was performed to find other examples of pediatric basilar artery aneurysms treated with endovascular techniques. RESULTS: Twenty-nine studies met inclusion criteria. Fifty-nine aneurysms in 58 patients were treated using endovascular techniques. Mortality rate was 10.3% (6/58) and a poor outcome (GOS 1-3) occurred in 15.5% (9/58). There were 4 reported recurrences requiring retreatment; however, only 46.5% of patients had reported follow-up of at least 1 year. 71.1% (42/59) were dissecting aneurysms. CONCLUSION: Basilar artery aneurysms in the pediatric population are rare, commonly giant and fusiform, and often not amenable to microsurgical or coiling techniques. The surrounding vasculature, location, size, and morphology of the aneurysm along with the durability of treatment must be considered in treatment decisions. With proper patient selection, stent-assisted coiling and flow diversion may increase the durability and safety of endovascular treatment in this population.

Visualization of the Anterior Temporal Artery as a Predictor of Outcome in Middle Cerebral Artery Occlusion Patients Achieving Successful Recanalization After Transfer.

Introduction Anterior temporal artery (ATA) visualization on computed tomography angiography (CTA) has been previously associated with good outcomes in middle cerebral artery (MCA) occlusions, but not in the setting of patients who initially present to non-thrombectomy centers. Methods We retrospectively identified acute MCA (M1) occlusion patients who underwent mechanical thrombectomy after transfer from non-thrombectomy-capable centers. Neuroradiologists confirmed the MCA (M1) as the most proximal site of occlusion on CTA and assessed for visualization of the ATA. Thrombolysis in Cerebral Infarction (TICI) 2b or greater revascularization scores were confirmed by neurointerventionalists blinded to patient outcomes. Ninety-day modified Rankin scale (mRS) scores were obtained via a structured telephone questionnaire. Results We identified 102 M1 occlusion patients over a three-and-a-half-year period presenting to a non-thrombectomy-capable center who underwent transfer and mechanical thrombectomy. There were no significant differences in age, gender, race, comorbidities, or median National Institute of Health Stroke Scale (NIHSS) scores between the ATA visualized (n = 47) versus non-visualized (n = 55) cohort, and no significant differences in baseline Alberta Stroke Program Early Computed Tomography (ASPECT) scores, post-intervention TICI scores, or interval from last known well to revascularization. There was a strong trend in functional independent outcome (mRS ≤ 2) for patients with ATA visualization (63.8% vs. 45.5%, p = 0.064). Conclusion For patients presenting to non-thrombectomy centers without CT perfusion capability, ATA visualization should be further investigated as an outcome predictor, given its association with functional independence after successful recanalization. This article was previously presented as a meeting abstract at the 2021 International Stroke Conference on March 17-19, 2021.

Endovascular Thrombectomy Reduces Risk of Poor Functional Outcomes in Patients Presenting within 0-6 Hours with Large Ischemic Core Volumes on Computed Tomography Perfusion.

INTRODUCTION: Patients presenting with large ischemic core volumes (LICVs) on computed tomography perfusion (CTP) are at high risk for poor functional outcomes. We sought to identify predictors of outcome in patients with an internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion and LICV. METHODS: A large healthcare system's prospectively collected code stroke registry was utilized for this retrospective analysis of patients presenting within 6 hours with at least 50 ml of CTP reduced relative cerebral blood flow (CBF) < 30%. A multivariable logistic regression model was constructed to identify independent predictors (p < 0.05) of poor discharge outcome (modified Rankin scale score 4-6). RESULTS: Over a 38-month period, we identified 104 patients meeting inclusion criteria, with a mean age of 65.4 ± 16.2 years, median presenting National Institutes of Health Stroke Scale score 20 (IQR 16-24), median ischemic core volume (CBF < 30%) 82 ml (IQR 61-118), and median mismatch volume 80 ml (IQR 56-134). Seventy-five patients (72.1%) had a discharge modified Rankin scale score of 4-6. Sixty-six of 104 (63.5%) patients were treated with endovascular thrombectomy (EVT). In the multivariable regression model, EVT (OR 0.303; 95% CI 0.080-0.985; p = 0.049) and lower blood glucose (per 1-point increase, OR 1.014; 95% CI 1.003-1.030; p = 0.030) were independently protective against poor discharge outcome. CONCLUSIONS: EVT is independently associated with a reduced risk of poor functional outcome in patients presenting within 6 hours with ICA or MCA occlusions and LICV.

Reversible cerebral vasoconstriction syndrome successfully treated by intrathecal nicardipine.

Reversible cerebral vasoconstriction syndrome (RCVS) presents with a thunderclap headache, often prompting brain imaging. Most patients fully recover with supportive care and time, but oral calcium channel blockers are often used in patients with severe vasoconstriction. In this case report, we present a patient with severe vasoconstriction leading to weakness refractory to oral calcium channel blockers. Intrathecal nicardipine was administered via an external ventricular drain and the patient subsequently showed improvement of her weakness and significant improvement of vasospasm on Computed Tomography Angiography. We suggest further studies to determine the efficacy of intrathecal nicardipine in patients with RCVS not responsive to oral calcium channel blockers.

Outcomes After Decompressive Craniectomy for Ischemic Stroke: A Volumetric Analysis.

BACKGROUND: Decompressive hemicraniectomy (DHC) is a treatment of space-occupying hemispheric infarct. Current surgical guidelines use criteria of age <60 years and surgery within 48 hours of stroke onset. OBJECTIVE: The purpose of this study was to evaluate the neurologic outcome after DHC and evaluate the relationship of stroke volume and outcomes. METHODS: A retrospective review was performed of patients undergoing DHC for cerebral infarct from 2016 to 2019. Unfavorable outcome was defined as modified Rankin Scale (mRS) score >3. Patients with precraniectomy magnetic resonance imaging were selected as a subset for volumetric stroke volume analysis using RAPID software (iSchemaView, Redwood City, California), with stroke volume defined as apparent diffusion coefficient <620 on diffusion-weighted imaging. RESULTS: Fifty-two patients met the inclusion criteria. At 90 days, favorable outcome was achieved in 11 patients (21.2%), and 41 patients (78.8%) had unfavorable outcomes (15 [29%] died). Surgery after 48 hours, age >60 years, and multivessel distribution did not significantly affect 90-day mRS score (P = 0.091, 0.111, and 0.664, respectively). In volumetric subset analysis, 10 patients of 41 (31.3%) achieved favorable outcomes, and no patients with volume of infarct >280 mL had a favorable outcome. There was a trend of lower volumes associated with favorable outcomes, but this did not meet significance (favorable 207 ± 68.7 vs. unfavorable 262 ± 117.1; P = 0.163). CONCLUSIONS: Outcomes after DHC for malignant hemispheric infarct were not affected by current accepted guidelines. Volume of infarct may have an effect on outcome after DHC. Further research to aid in predicting which patients benefit from decompressive craniectomy is warranted.

Is There an Association Between Physician Review Websites and Press Ganey Survey Results in a Neurosurgical Outpatient Clinic?

OBJECTIVE: Recent studies suggest a poor association between physician review websites and the validated metrics used by the Centers for Medicare and Medicaid Services. The purpose of this study was to evaluate the association between online and outpatient Press Ganey (PG) measures of patient satisfaction in a neurosurgical department. METHODS: We obtained PG survey results from one large academic institution's outpatient neurosurgery clinic. Popular physician review websites were searched for each of the faculty captured in the PG data. Average physician rating and percent Top Box scores were calculated for each physician. PG data were separated into new and established clinic visits for subset analysis. Spearman's rank correlation coefficients were calculated to determine associations. RESULTS: Twelve neurosurgeons were included. Established patients demonstrated greater PG scores as compared with new patients, with an average physician rating increase of 0.55 and an average Top Box increase of 12.5%. Online physician ratings were found to demonstrate strong agreement with PG scores for the entire PG population, new patient subset, and established patient subset (ρ = 0.77-0.79, P < 0.05). Online Top Box scores demonstrated moderate agreement with overall PG Top Box scores (ρ = 0.59, P = 0.042), moderate agreement with the new patient population Top Box scores (ρ = 0.56, P = 0.059), and weak agreement with established patient population Top Box scores (ρ = 0.38, P = 0.217). CONCLUSIONS: Our findings demonstrated a strong agreement between PG ratings and online physician ratings and a poorer correlation when comparing PG Top Box scores with online physician Top Box scores, particularly in the established patient population.

Medical Management Versus Surgical Bypass for Symptomatic Intracranial Atherosclerotic Disease: A Systematic Review.

INTRODUCTION: Intracranial atherosclerotic disease (ICAD) is a major cause of stroke worldwide. The optimal management of patients with symptomatic ICAD is controversial. Therefore, the aim of this systematic review is to compare medical management versus surgical bypass for the treatment of symptomatic ICAD. METHODS: A literature review was performed to identify studies reporting outcomes of patients with ICAD who were managed medically or surgically with either direct or indirect bypass. Baseline, treatment, and outcomes data were analyzed. Complications included ischemic stroke, intracranial hemorrhage, and cerebrovascular death. Secondary analyses of the surgically treated cohort were performed to compare the outcomes of direct versus indirect bypass. RESULTS: The pooled analysis was derived from 18 studies, comprising a total of 2160 patients with ICAD, including 1790 managed medically and 370 treated with surgical bypass. The rates of ischemic stroke, intracranial hemorrhage, and cerebrovascular death were 16%, 1%, and 4.5% in the medical cohort, respectively, versus 8%, 0.6%, and 1.9% in the surgical cohort, respectively. Among patients with ICAD who underwent bypass surgery, the rates of ischemic stroke and cerebrovascular death were 7% and 1.9% in the direct bypass group, respectively, versus 19% and 2.1% in the indirect bypass group, respectively. CONCLUSIONS: Direct or indirect bypass surgery is a reasonable treatment option for appropriately selected patients with ICAD. Careful preoperative evaluation of hemodynamic parameters and the relevant donor and recipient vessels is crucial to maximizing the success of bypass for ICAD. Further studies remain necessary to clarify the roles of medical versus surgical management for ICAD.

Safety of Running Two Rooms: A Systematic Review and Meta-Analysis of Overlapping Neurosurgical Procedures.

OBJECTIVE: Overlapping surgery, a long-standing practice within academic neurosurgery centers nationwide, has recently come under scrutiny from the government and media as potentially harmful to patients. Therefore, the objective of this systematic review and meta-analysis is to determine the safety of overlapping neurosurgical procedures. METHODS: The authors performed a systematic review and meta-analysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A review of PubMed and Medline databases was undertaken with the search phrase "overlapping surgery AND neurosurgery AND outcomes." Data regarding patient demographics, type of neurosurgical procedure, outcomes, and complications were extracted from each study. The principle summary measure was odds ratio (OR) of the association of overlapping versus non-overlapping surgery with outcomes. RESULTS: The literature search yielded a total of 36 studies, of which 5 studies met inclusion criteria and were included in this study. These studies included a total of 25,764 patients undergoing neurosurgical procedures. Overlapping surgery was associated with an increased likelihood of being discharged home (OR, 1.32; 95% confidence interval [CI], 1.20-1.44; P < 0.001) and a reduced 30-day unexpected return to the operating room (OR, 0.79; 95% CI, 0.72-0.87; P < 0.001). Overlapping surgery did not significantly affect OR of length of surgery, 30-day mortality, or 30-day readmission. CONCLUSIONS: Overlapping neurosurgical procedures were not associated with worse patient outcomes. In addition, prospective studies are needed to assess the safety overlapping procedures.

The Patient Size Setting: A Novel Dose Reduction Strategy in Cerebral Endovascular Neurosurgery Using Biplane Fluoroscopy.

BACKGROUND: In some fluoroscopy machines, the dose-rate output of the fluoroscope is tied to a selectable patient size. Although patient size may play a significant role in visceral or cardiac procedures, head morphology is less variable, and high dose outputs may not be necessary even in very obese patients. We hypothesized that very small patient size setting can be used to reduce dose for cerebral angiography without compromising image quality. METHODS: Patients who underwent endovascular neurosurgical procedures during the 2015-2016 academic year were identified, and estimated procedural air kerma (AK) was tabulated retrospectively. Technologists were instructed to begin using the very small patient size setting for all procedures performed using our Philips Allura Xper FD20 biplane fluoroscopy system beginning in March 2016. No changes were made in a second procedure room using a Toshiba Infinix system. Student t tests and logistic regression models were used to compare radiation exposure before and after March 1, 2016, for both machines. RESULTS: For diagnostic cerebral angiograms performed on the Philips system (n = 302), AK was reduced by approximately 17% (1277 vs. 1061 mGy; P = 0.0006.) Changes in table height, total fluoroscopy time, patient weight, and body mass index did not contribute to this difference. No significant change was seen in total AK using the Toshiba system (n = 237). Blinded review by a neuroradiologist did not demonstrate any change in image quality. CONCLUSIONS: Using the very small patient size reduces fluoroscopy dose by 17% for cerebral angiography without impacting image quality.

Is intensive care monitoring necessary after coil embolization of unruptured intracranial aneurysms?

INTRODUCTION: Patients with an unruptured intracranial aneurysm treated with coil embolization are routinely admitted to the intensive care unit (ICU) after the procedure; however, this practice is questionable. The purpose of this study was to determine if routine admission to the ICU is necessary for patients undergoing coil embolization of an unruptured intracranial aneurysm. METHODS: We conducted a retrospective cohort study of all patients undergoing elective endovascular treatment of an unruptured intracranial aneurysm between 2005 and 2012 at our institution. Multivariate regression analysis was performed to identify predictors of outcome. Cost savings analysis compared ICU admission to step-down or telemetry unit admission. RESULTS: 311 unruptured intracranial aneurysms were treated by coil embolization (190), balloon remodeling (13), or stent-assisted coiling (108). Eleven (3.5%) neurologic complications were noted; 5 (1.6%) of these were permanent. Multivariate regression analysis identified female sex (p=0.028), hypercoagulability (p=0.021), aneurysm size >2 cm (p=0.003), and intraoperative rupture (p<0.001) as predictors of a post-procedural neurologic complication. Cost savings were 57% for admission to a step-down unit and 32% for admission to a telemetry unit compared with ICU admission. CONCLUSIONS: Neurologic complications are rare in the treatment of unruptured intracranial aneurysms, suggesting that routine ICU admission after treatment may not be necessary. Female sex, history of hypercoagulability, aneurysm size >2 cm, and an intraprocedural rupture were predictive of a postoperative complication. ICU monitoring in these subgroups may therefore be warranted.

Rapid, spontaneous obliteration of intracranial arteriovenous malformation.

A 35-year-old male presented with headaches and was found to have a Spetzler-Martin grade 2 right occipital arteriovenous malformation (AVM) with single, superficial draining vein. The patient opted to undergo embolization for possible cure with resection scheduled in the event complete obliteration was not achieved. Three weeks later, angiography during his embolization procedure revealed that the AVM had spontaneously obliterated; no treatment was required. In conjunction with prior case reports/series, this patient highlights the need for current imaging prior to proceeding with intervention to confirm that spontaneous obliteration has not occurred between diagnosis and treatment.

A Randomized Trial of Central Venous Catheter Type and Thrombosis in Critically Ill Neurologic Patients.

BACKGROUND: Observational studies suggest peripherally inserted central venous catheters (PICCs) are associated with a high risk of catheter-related large vein thrombosis (CRLVT) in critically ill neurologic patients. We evaluated the difference in thrombosis risk between PICCs and centrally inserted central venous catheters (CICVCs). METHODS: We conducted a pragmatic, randomized controlled trial of critically ill adult neurologic patients admitted to neurological and trauma critical care units at two level I trauma centers. Patients were randomized to receive either a PICC or CICVC and undergo active surveillance for CRLVT or death within 15 days of catheter placement. RESULTS: In total, 39 subjects received a PICC and 41 received a CICVC between February 2012 and July 2015. The trial was stopped after enrollment of 80 subjects due to feasibility affected by slow enrollment and funding. In the primary intention-to-treat analysis, 17 (43.6 %) subjects that received a PICC compared to 9 (22.0 %) that received a CICVC experienced the composite of CRLVT or death, with a risk difference of 21.6 % (95 % CI 1.57-41.71 %). Adjusted common odds ratio of CRLVT/death was significantly higher among subjects randomized to receive a PICC (adjusted OR 3.08; 95 % CI 1.1-8.65). The higher adjusted odds ratio was driven by risk of CRLVT, which was higher in those randomized to PICC compared to CICVC (adjusted OR 4.66; 95 % CI 1.3-16.76) due to increased large vein thrombosis without a reduction in proximal deep venous thrombosis. CONCLUSIONS: Our trial demonstrates that critically ill neurologic patients who require a central venous catheter have significantly lower odds of ultrasound-diagnosed CRLVT with placement of a CICVC as compared to a PICC.

Management of recurrent aneurysms following endovascular therapy.

The aim of the current study is to describe the complication rates and clinical outcomes in patients who either underwent repeat intervention or conservative management with radiographic surveillance when presenting with aneurysmal recurrence after endovascular treatment. Since publication of the international subarachnoid aneurysm trial (ISAT), an increasing number of patients are treated with endovascular therapy. However, recurrence after endovascular therapy continues to pose a challenge, and there is minimal evidence to guide its management. We performed a retrospective review of all patients who underwent endovascular treatment of an intracranial aneurysm from January 2005 to February 2013. The patients who had an aneurysmal recurrence following the initial endovascular treatment were identified and divided into two groups: those followed with conservative management (n=24), and those who underwent reintervention (n=65). The groups were compared for complications and clinical outcomes. When a reintervention was undertaken, microsurgical clip ligation was associated with a higher rate of occlusion than additional endovascular therapy (p<0.001). When comparing conservative treatment and reintervention, there was no statistically significant difference in complications or clinical outcomes. Reintervention was more common in patients who were younger, had presented with subarachnoid hemorrhage, or had a greater degree of recurrence. We conclude that clinical outcomes and repeat subarachnoid hemorrhage are similar in patients who underwent retreatment versus those who had conservative management for their recurrent cerebral aneurysms.

Intraoperative angiography does not lead to increased rates of surgical site infections.

BACKGROUND: Intraoperative angiography (IOA) is essential in evaluating residual aneurysm following clip ligation, but it does lead to an additional procedure which increases the duration of the procedure as well as increasing room traffic. We examined whether IOA during microsurgery is a risk factor for developing cranial surgical site infection. MATERIALS AND METHODS: A retrospective cohort study was performed of all patients undergoing craniotomy for aneurysm treatment between 2005 and 2012 at the University of Michigan. IOA was used at the surgeons' discretion. The primary outcome of interest was occurrence of a surgical site infection and the secondary outcome of interest was clip repositioning following IOA. Variables including IOA were tested for their independent association with the occurrence of a surgical site infection. RESULTS: During the study period 676 intracranial aneurysms were treated by craniotomy; IOA was used in 104 of these cases. There were a total of 20 surgical site infections, 2 in the IOA group (1.9%) and 18 in the non-IOA group (3.1%), indicating that IOA was not a statistically significant variable for infection (p=0.50). No additional single variable measured could be shown to have a statistically significant increase in infection, and there were no direct complications related to the use of IOA (stroke, dissection, perforation). CONCLUSIONS: IOA does not increase the risk of developing a surgical site infection. It can be conducted without exposing patients to an undue risk of infection.

Intraventricular hemorrhage is associated with early hydrocephalus, symptomatic vasospasm, and poor outcome in aneurysmal subarachnoid hemorrhage.

OBJECTIVE: We hypothesized that the subset of patients with early hydrocephalus following aneurysmal subarachnoid hemorrhage may represent a subset of patients with a more vehement inflammatory reaction to blood products in the subarachnoid space. We thus examined risk factors for early hydrocephalus and examined the relationship between early hydrocephalus and symptomatic vasospasm as well as clinical outcome. METHODS: We retrospectively analyzed all patients presenting to our institution with subarachnoid hemorrhage over a 7-year period. We examined for risk factors, including early hydrocephalus, for poor clinical outcome and symptomatic vasospasm. RESULTS: We found intraventricular hemorrhage to be strongly associated with the development of early hydrocephalus. In univariate analysis, early hydrocephalus was strongly associated with both poor functional outcome and symptomatic vasospasm. In multivariate analysis, intraventricular hemorrhage and tobacco use were associated with symptomatic vasospasm; intraventricular hemorrhage, intraparenchymal hemorrhage, and symptomatic vasospasm were associated with poor functional outcome. CONCLUSIONS: We found that intraventricular hemorrhage was strongly associated with early hydrocephalus. Further exploration of the mechanistic explanation is needed, but we suggest this may be from a combination of obstruction of cerebrospinal fluid pathways by blood products and inflammation in the choroid plexus resulting in increased cerebrospinal fluid production. Further, we suggest that both early hydrocephalus and cerebral vasospasm may be parts of the overall inflammatory cascade that occurs with intraventricular hemorrhage and ultimately results in a poorer clinical outcome.