Clinical Utility of the Transthoracic Echocardiogram for Isolated Lacunar Infarcts: A Single-Center Experience.

BACKGROUND: Stroke is a prominent and financially burdensome disease. Lacunar strokes are traditionally attributed to small vessel disease rather than cardioemboli, which typically occlude larger arteries. Thus, the benefit of screening for potential sources of cardioemboli in lacunar stroke patients is unclear. We evaluated the clinical utility of the transthoracic echocardiogram performed in patients with lacunar strokes. METHODS: A single-center retrospective analysis of ischemic stroke patients from January 2013 through December 2017 was performed. Brain magnetic resonance imaging was used to select patients with a single lacunar infarct. Patients presenting with acute symptoms of cardiac disease or an abnormal electrocardiogram were excluded. Transthoracic echocardiogram results were reviewed, and their utility in decision-making was evaluated. RESULTS: Of the 442 patients at our institution diagnosed with ischemic stroke during the inclusion period, 89 met inclusion criteria. Transthoracic echocardiogram detected a patent foramen ovale in 5.6% of patients, mitral annular calcification in 9.0% of patients, and abnormal wall motion in 4.5% of patients. For all patients, there were no findings that prompted anticoagulation, antibiotic, or surgical intervention. The cost of an inpatient transthoracic echocardiogram is $4100, resulting in $364,900 in unnecessary health care spending. CONCLUSIONS: Transthoracic echocardiogram appears to have minimal therapeutic value in most patients with lacunar strokes. In stroke patients with no acute symptoms of cardiac disease and a normal electrocardiogram, it may be reasonable to forgo the transthoracic echocardiogram if the brain magnetic resonance imaging shows an isolated lacunar infarct.

Long-term catheter angiography after aneurysm coil therapy: results of 209 patients and predictors of delayed recurrence and retreatment.

OBJECT: Aneurysm recurrence after coil therapy remains a major shortcoming in the endovascular management of cerebral aneurysms. The need for long-term imaging follow-up was recently investigated. This study assessed the diagnostic yield of long-term digital subtraction angiography (DSA) follow-up and determined predictors of delayed aneurysm recurrence and retreatment. METHODS: Inclusion criteria were as follows: 1) available short-term and long-term (> 36 months) follow-up DSA images, and 2) no or only minor aneurysm recurrence (not requiring further intervention, i.e., < 20%) documented on short-term follow-up DSA images. RESULTS: Of 209 patients included in the study, 88 (42%) presented with subarachnoid hemorrhage. On shortterm follow-up DSA images, 158 (75%) aneurysms showed no recurrence, and 51 (25%) showed minor recurrence (< 20%, not retreated). On long-term follow-up DSA images, 124 (59%) aneurysms showed no recurrence, and 85 (41%) aneurysms showed recurrence, of which 55 (26%) required retreatment. In multivariate analysis, the predictors of recurrence on long-term follow-up DSA images were as follows: 1) larger aneurysm size (p = 0.001), 2) male sex (p = 0.006), 3) conventional coil therapy (p = 0.05), 4) aneurysm location (p = 0.01), and 5) a minor recurrence on short-term follow-up DSA images (p = 0.007). Ruptured aneurysm status was not a predictive factor. The sensitivity of short-term follow-up DSA studies was only 40.0% for detecting delayed aneurysm recurrence and 45.5% for detecting delayed recurrence requiring further treatment. CONCLUSIONS: The results of this study highlight the importance of long-term angiographic follow-up after coil therapy for ruptured and unruptured intracranial aneurysms. Predictors of delayed recurrence and retreatment include large aneurysms, recurrence on short-term follow-up DSA images (even minor), male sex, and conventional coil therapy.

Nasal MRSA colonization: impact on surgical site infection following spine surgery.

BACKGROUND: Prior studies published in the cardiothoracic, orthopedic and gastrointestinal surgery have identified the importance of nasal (methicillin-resistant Staphylococcus aureus) MRSA screening and subsequent decolonization to reduce MRSA surgical site infection (SSI). This is the first study to date correlating nasal MRSA colonization with postoperative spinal MRSA SSI. OBJECTIVE: To assess the significance of nasal MRSA colonization in the setting of MRSA SSI. METHODS: A retrospective electronic chart review of patients from year 2011 to June 2013 was conducted for patients with both nasal MRSA colonization within 30 days prior to spinal surgery. Patients who tested positive for MRSA were put on contact isolation protocol. None of these patients received topical antibiotics for decolonization of nasal MRSA. RESULTS: A total of 519 patients were identified; 384 negative (74%), 110 MSSA-positive (21.2%), and 25 (4.8%) MRSA-positive. Culture positive surgical site infection (SSI) was identified in 27 (5.2%) cases and was higher in MRSA-positive group than in MRSA-negative and MSSA-positive groups (12% vs. 5.73% vs. 1.82%; p=0.01). The MRSA SSI rate was 0.96% (n=5). MRSA SSI developed in 8% of the MRSA-positive group as compared to only in 0.61% of MRSA-negative group, with a calculated odds ratio of 14.23 (p=0.02). In the presence of SSI, nasal MRSA colonization was associated with MRSA-positive wound culture (66.67 vs. 12.5%; p<0.0001). CONCLUSION: Preoperative nasal MRSA colonization is associated with postoperative spinal MRSA SSI. Preoperative screening and subsequent decolonization using topical antibiotics may help in decreasing the incidence of MRSA SSI after spine surgery. Nasal MRSA+ patients undergoing spinal surgery should be informed regarding their increased risk of developing surgical site infection.

Efficacy of intraoperative vancomycin powder use in intrathecal baclofen pump implantation procedures: single institutional series in a high risk population.

We aimed to assess the efficacy of intraoperative vancomycin powder in intrathecal baclofen pump placement patients, a high risk population. A retrospective review was conducted using prospectively collected data at an academic tertiary care unit. The neurosurgical adult patient population was queried for all intrathecal baclofen pump implantation procedures. Patients were then reviewed for the use of intraoperative crystalline vancomycin powder. Those with a history of prior surgical site infection, chronic systemic infections or osteomyelitis were excluded. Anhydrous, crystalline vancomycin was utilized in the wound bed after completion of implantation, distributed evenly in the case of multiple incisions. Patients received 500 mg or 1,000 mg of crystallized vancomycin, evenly distributed through the wound layers based on a 70 kg weight cutoff. Intraoperative institutional standards of infection prophylaxis were unchanged throughout the study period. Infection rate of baclofen pump placement prior to the use of vancomycin powder from 2001-2009 at the same institution was monitored. Wound infection rate was tracked for a 12 month postoperative period. Six patients out of 26 baclofen pump implantations (23%) in this cohort were identified to have seven infections despite vancomycin powder placement in the lumbar and catheter wounds. Prior infection rates have been investigated for intrathecal drug delivery systems from 2001 to 2009 at the same institution with an overall infection rate of 3% (8/274). The use of vancomycin powder in patients with implants in this series did not reduce infection rates compared to published historical controls, and was elevated compared to institutional controls. Further prospective study of this high risk patient population is warranted.

Microsurgical clipping of large and giant cerebral aneurysms: a single-center contemporary experience.

Several treatment strategies are available to manage large and giant cerebral aneurysms, including surgical, endovascular and combined approaches. We present our experience with microsurgical clipping of large and giant aneurysms. A total of 138 patients with 139 aneurysms of which 128 were large (≥10mm) and 11 were giant (≥25mm) were treated at our institution between 2004 and 2011. Data were collected from a prospectively maintained neurovascular database. Of 138 patients, 53 (38.4%) patients presented with subarachnoid hemorrhage (SAH). Peri-operative complications occurred in 16.7% of patients causing permanent morbidity in 4.4% and death in 0.7%. Complete occlusion, as evident on intra-operative angiography, was achieved in all clipped aneurysms (100%). Long-term follow-up angiography showed no recurrence (mean follow-up time, 43.9 months; range: 1-72 months). Favorable outcomes at discharge (Glasgow Outcome Scale score 4 or 5) were noted in 64.1% of SAH patients and 93% of non-SAH patients. Favorable outcomes at follow-up (mean follow up time, 42.5 months) were seen in 96% of patients. In our experience, microsurgical clipping of large and giant aneurysms carries low rates of morbidity and mortality with high rates of favorable outcomes. The excellent durability of surgical treatment stands in stark contrast with the high recurrence rates observed with coiling for this subset of aneurysms. These data suggest that microsurgical clipping continues to be a viable option that can be offered for patients with large and giant aneurysms.

Endovascular management of cerebral vasospasm following aneurysm rupture: outcomes and predictors in 116 patients.

OBJECTIVE: To retrospectively assess the safety and efficacy of endovascular treatment of cerebral vasospasm with different modalities and assess predictors of outcome. METHODS: Endovascular treatment was indicated in the event of neurological deterioration refractory to medical therapy. Data were collected for 116 patients treated at our institution. RESULTS: Vasospasm was treated with balloon angioplasty in 52.6%, intra-arterial nicardipine infusion in 19.8%, or both in 27.6%. Angiographic vasospasm was reversed in all but 4 (96.6%) patients. The complication rate was 0.9%. Twenty patients (17.2%) had incipient pre-procedure hypodensities; 3 (15%) hypodensities were reversed and neurological improvement occurred in 60% of these patients. Retreatment was required in 22 (19%) patients. Higher Hunt and Hess grades and treatment with nicardipine alone predicted retreatment. Neurological improvement was noted in 82%. Male gender, pre-procedure hypodensities, and posterior communicating artery aneurysm location negatively predicted neurological recovery. Favorable outcomes were noted in 73%. Higher Hunt and Hess grades, pre-procedure hypodensities, posterior circulation aneurysms, and no neurological recovery predicted poor outcome. CONCLUSION: Endovascular therapy for vasospasm has an excellent safety-efficacy profile. Balloon angioplasty and nicardipine are equally effective but effects of nicardipine are less durable. Patients with incipient pre-procedure hypodensities benefit from endovascular intervention and should probably not be excluded from treatment.

Intraoperative vancomycin use in spinal surgery: single institution experience and microbial trends.

STUDY DESIGN: Retrospective case series. OBJECTIVE: To demonstrate the microbial trends of spinal surgical site infections in patients who had previously received crystallized vancomycin in the operative bed. SUMMARY OF BACKGROUND DATA: Prior large, case control series demonstrate the significant decrease in surgical site infection with the administration of vancomycin in the wound bed. METHODS: A single institution, electronic database search was conducted for all patients who underwent spinal surgery who had received prophylactic crystalline vancomycin powder in the wound bed. Patients with a prior history of wound infection, intrathecal pumps, or spinal stimulators were excluded. RESULTS: A total of 981 consecutive patients (494 males, 487 females; mean age, 59.4 yr; range, 16-95 yr) were identified from January 2011 to June 2013. The average dose of vancomycin powder was 1.13 g (range, 1-6 g). Sixty-six patients (6.71%) were diagnosed with a surgical site infection, of which 51 patients had positive wound cultures (5.2%). Of the 51 positive cultures, the most common organism was Staphylococcus aureus. The average dose of vancomycin was 1.3 g in the 38 cases where a gram-positive organism was cultured. A number of gram-negative infections were encountered such as Serratia marcescens, Enterobacter aerogenes, Bacteroides fragilis, Enterobacter cloacae, Citrobacter koseri, and Pseudomonas aeruginosa. The average dose of vancomycin was 1.2 g in 23 cases where a gram-negative infection was cultured. Fifteen of the 51 positive cultures (29.4%) were polymicrobial. Eight (53%) of these 15 polymicrobial cultures contained 3 or more distinct organisms. CONCLUSION: Prophylactic intraoperative vancomycin use in the wound bed in spinal surgery may increase the incidence of gram-negative or polymicrobial spinal infections. The use of intraoperative vancomycin may correlate with postoperative seromas, due to the high incidence of nonpositive cultures. Large, randomized, prospective trials are needed to demonstrate causation and dose-response relationship.

Subarachnoid hemorrhage with negative initial catheter angiography: a review of 254 cases evaluating patient clinical outcome and efficacy of short- and long-term repeat angiography.

BACKGROUND: Subarachnoid hemorrhage (SAH) is found to have no vascular origin by initial catheter angiography in approximately 15% of cases. The most appropriate course for the type and frequency of additional diagnostic workup remains controversial. OBJECTIVE: To retrospectively assess the diagnostic yield of short-term and long-term repeat catheter angiography in the era of advanced imaging. METHODS: Between 2003 and 2011, 254 consecutive patients diagnosed with SAH had negative initial angiography. SAH was perimesencephalic (PM) in 46.5% and nonperimesencephalic (NPM) in 53.5%. Angiography was repeated at 1-week (short-term) and 6-week (long-term) intervals from the initial negative angiogram. RESULTS: Ten of 254 patients had a vascular source of hemorrhage on short-term follow-up angiography with a diagnostic yield of 3.9%. One hundred seventy-four patients with negative findings on the first 2 angiograms received a third angiogram, and 7 of these patients were found to have a vascular abnormality. The estimated yield of this third angiogram was 4.0%. The overall diagnostic yield of repeat angiography was 0% in the PM group and 12.5% in the NPM group. The diagnostic yield of short-term and long-term follow-up angiography in patients with NPM SAH was 7.3% and 7.8%, respectively. NPM patients were more likely to experience vasospasm and hydrocephalus requiring external ventricular drainage or cerebrospinal fluid diversion than PM patients. CONCLUSION: Our results support a protocol of short-term and long-term angiographic follow-up in patients with NPM SAH and negative initial angiography. Aggressive protocols of follow-up angiography may not be necessary in patients with PM SAH.