Publications by authors named "Christopher P Kellner"

96 Publications

Student Survey Results of a Virtual Medical Student Course Developed as a Platform for Neurosurgical Education During the Coronavirus Disease 2019 Pandemic.

World Neurosurg 2021 May 28. Epub 2021 May 28.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address:

Background: Before the coronavirus disease 2019 (COVID-19) pandemic, medical students training in neurosurgery relied on external subinternships at institutions nationwide for immersive educational experiences and to increase their odds of matching. However, external rotations for the 2020-2021 cycle were suspended given concerns of spreading COVID-19. Our objective was to provide foundational neurosurgical knowledge expected of interns, bootcamp-style instruction in basic procedures, and preinterview networking opportunities for students in an accessible, virtual format.

Methods: The virtual neurosurgery course consisted of 16 biweekly 1-hour seminars over a 2-month period. Participants completed comprehensive precourse and postcourse surveys assessing their backgrounds, confidence in diverse neurosurgical concepts, and opinions of the qualities of the seminars. Responses from students completing both precourse and postcourse surveys were included.

Results: An average of 82 students participated live in each weekly lecture (range, 41-150). Thirty-two participants completed both surveys. On a 1-10 scale self-assessing baseline confidence in neurosurgical concepts, participants were most confident in neuroendocrinology (6.79 ± 0.31) and least confident in spine oncology (4.24 ± 0.44), with an average of 5.05 ± 0.32 across all topics. Quality ratings for all seminars were favorable. The mean postcourse confidence was 7.79 ± 0.19, representing an improvement of 3.13 ± 0.38 (P < 0.0001).

Conclusions: Feedback on seminar quality and improvements in confidence in neurosurgical topics suggest that an interactive virtual course may be an effective means of improving students' foundational neurosurgical knowledge and providing networking opportunities before application cycles. Comparison with in-person rotations when these are reestablished may help define roles for these tools.
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http://dx.doi.org/10.1016/j.wneu.2021.05.076DOI Listing
May 2021

Middle Meningeal Artery Embolization of a Pediatric Patient With Progressive Chronic Subdural Hematoma.

Oper Neurosurg (Hagerstown) 2021 May 6. Epub 2021 May 6.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background And Importance: Evidence suggests middle meningeal artery (MMA) embolization benefits adult patients with chronic subdural hematoma (CSDH) at high risk for recurrence or hemorrhagic complications. Yet, there has not been any report discussing MMA embolization in the pediatric population. Thus, we present a case of an infant with CSDH successfully managed with MMA embolization without surgical management.

Clinical Presentation: A 5-mo-old girl with idiopathic dilated cardiomyopathy underwent surgical implantation of a left ventricular assist device for a bridge to heart transplantation. This was complicated by left ventricular thrombus causing stroke. She was placed on dual antiplatelet antithrombotic therapy on top of bivalirudin infusion. She sustained a left middle cerebral artery infarction, but did not have neurological deficits. Subsequent computed tomography scans of the head showed a progressively enlarging asymptomatic CSDH, and the heart transplant was repeatedly postponed. The decision was made to proceed with MMA embolization at the age of 7 mo. Bilateral modified MMA embolization, using warmed, low-concentration n-butyl-cyanoacrylate (n-BCA) from distal microcatheter positioning, allowed the embolic material to close the distal MMA and subdural membranous vasculature. The patient underwent successful heart transplant and the CSDH improved significantly. She remained neurologically asymptomatic and had normal neurological development after the MMA embolization.

Conclusion: MMA embolization may represent a safe and effective minimally invasive option for pediatric CSDH, especially for patients at high risk for surgery or hematoma recurrence.
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http://dx.doi.org/10.1093/ons/opab144DOI Listing
May 2021

Real-World Experience with Artificial Intelligence-Based Triage in Transferred Large Vessel Occlusion Stroke Patients.

Cerebrovasc Dis 2021 Apr 13:1-6. Epub 2021 Apr 13.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, New York, USA.

Background And Purpose: Randomized controlled trials have demonstrated the importance of time to endovascular therapy (EVT) in clinical outcomes in large vessel occlusion (LVO) acute ischemic stroke. Delays to treatment are particularly prevalent when patients require a transfer from hospitals without EVT capability onsite. A computer-aided triage system, Viz LVO, has the potential to streamline workflows. This platform includes an image viewer, a communication system, and an artificial intelligence (AI) algorithm that automatically identifies suspected LVO strokes on CTA imaging and rapidly triggers alerts. We hypothesize that the Viz application will decrease time-to-treatment, leading to improved clinical outcomes.

Methods: A retrospective analysis of a prospectively maintained database was assessed for patients who presented to a stroke center currently utilizing Viz LVO and underwent EVT following transfer for LVO stroke between July 2018 and March 2020. Time intervals and clinical outcomes were compared for 55 patients divided into pre- and post-Viz cohorts.

Results: The median initial door-to-neuroendovascular team (NT) notification time interval was significantly faster (25.0 min [IQR = 12.0] vs. 40.0 min [IQR = 61.0]; p = 0.01) with less variation (p < 0.05) following Viz LVO implementation. The median initial door-to-skin puncture time interval was 25 min shorter in the post-Viz cohort, although this was not statistically significant (p = 0.15).

Conclusions: Preliminary results have shown that Viz LVO implementation is associated with earlier, more consistent NT notification times. This application can serve as an early warning system and a failsafe to ensure that no LVO is left behind.
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http://dx.doi.org/10.1159/000515320DOI Listing
April 2021

Minimally Invasive Intracerebral Hemorrhage Evacuation Techniques: A Review.

Diagnostics (Basel) 2021 Mar 23;11(3). Epub 2021 Mar 23.

Department of Neurosurgery, Icahn School of Medicine at Mt Sinai, New York, NY 10029, USA.

Intracerebral hemorrhage (ICH) continues to have high morbidity and mortality. Improving ICH outcomes likely requires rapid removal of blood from the parenchyma and restraining edema formation while also limiting further neuronal damage due to the surgical intervention. Minimally invasive surgery (MIS) approaches promise to provide these benefits and have become alluring options for management of ICH. This review describes six MIS techniques for ICH evacuation including craniopuncture, stereotactic aspiration with thrombolysis, endoport-mediated evacuation, endoscope-assisted evacuation, adjunctive aspiration devices, and the surgiscope. The efficacy of each modality is discussed based on current literature. The largest clinical trials have yet to demonstrate definitive effects of MIS intervention on mortality and functional outcomes for ICH. Thus, there is a significant need for further innovation for ICH treatment. Multiple ongoing trials promise to better clarify the potential of the newer, non-thrombolytic MIS techniques.
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http://dx.doi.org/10.3390/diagnostics11030576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8005063PMC
March 2021

Definition and time course of pericavity edema after minimally invasive endoscopic intracerebral hemorrhage evacuation.

J Neurointerv Surg 2021 Mar 15. Epub 2021 Mar 15.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Perihematomal edema (PHE) volume correlates with intracerebral hemorrhage (ICH) volume and is associated with functional outcome. Minimally invasive surgery (MIS) for ICH decreases clot burden and PHE. MIS may therefore alter the time course of PHE, mitigating a critical source of secondary injury.

Objective: To describe a new method for the quantitative measurement of cerebral edema surrounding the evacuated hematoma cavity, termed pericavity edema (PCE), and obtain details of its time course following MIS for ICH.

Methods: The study included 48 consecutive patients presenting with ICH who underwent MIS evacuation. Preoperative and postoperative CT scans were assessed by two independent raters. Hematoma, edema, cavity, and pneumocephalus volumes were calculated using semi-automatic, threshold-guided volume segmentation software (AnalyzePro). Follow-up CT scans at variable delayed time points were available for 36 patients and were used to describe the time course of PCE.

Results: Mean preoperative, postoperative, and delayed PCE were 21.0 mL (SD 15.5), 18.6 mL (SD 11.4), and 18.4 mL (SD 15.5), respectively. The percentage of ICH evacuated correlated significantly with a decrease in postoperative PCE (r=-0.46, p<0.01). Linear regression analysis revealed a significant relation between preoperative hematoma volume and both postoperative PCE (p<0.001) and postoperative relative PCE (p<0.001). The mean peak PCE was 26.4 mL (SD 15.6) and occurred at 6.5 days (SD 4.8) post-ictus. The 2-week postoperative time course of relative PCE did not fluctuate, suggesting stability in edema during the perioperative period surrounding evacuation and up to 2 weeks after the initial bleed.

Conclusions: We present a detailed and accurate method for measuring PCE volume with semi-automatic, threshold-guided segmentation software in the postoperative patient with ICH. Decrease in PCE after MIS evacuation correlated with evacuation percentage, and relative PCE remained stable after minimally invasive endoscopic ICH evacuation.
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http://dx.doi.org/10.1136/neurintsurg-2020-017077DOI Listing
March 2021

Epidemiological Surveillance of the Impact of the COVID-19 Pandemic on Stroke Care Using Artificial Intelligence.

Stroke 2021 05 4;52(5):1682-1690. Epub 2021 Mar 4.

Department of Neurosurgery, Mount Sinai Health System, New York (C.P.K., J.M.).

Background And Purpose: The degree to which the coronavirus disease 2019 (COVID-19) pandemic has affected systems of care, in particular, those for time-sensitive conditions such as stroke, remains poorly quantified. We sought to evaluate the impact of COVID-19 in the overall screening for acute stroke utilizing a commercial clinical artificial intelligence platform.

Methods: Data were derived from the Viz Platform, an artificial intelligence application designed to optimize the workflow of patients with acute stroke. Neuroimaging data on suspected patients with stroke across 97 hospitals in 20 US states were collected in real time and retrospectively analyzed with the number of patients undergoing imaging screening serving as a surrogate for the amount of stroke care. The main outcome measures were the number of computed tomography (CT) angiography, CT perfusion, large vessel occlusions (defined according to the automated software detection), and severe strokes on CT perfusion (defined as those with hypoperfusion volumes >70 mL) normalized as number of patients per day per hospital. Data from the prepandemic (November 4, 2019 to February 29, 2020) and pandemic (March 1 to May 10, 2020) periods were compared at national and state levels. Correlations were made between the inter-period changes in imaging screening, stroke hospitalizations, and thrombectomy procedures using state-specific sampling.

Results: A total of 23 223 patients were included. The incidence of large vessel occlusion on CT angiography and severe strokes on CT perfusion were 11.2% (n=2602) and 14.7% (n=1229/8328), respectively. There were significant declines in the overall number of CT angiographies (-22.8%; 1.39-1.07 patients/day per hospital, <0.001) and CT perfusion (-26.1%; 0.50-0.37 patients/day per hospital, <0.001) as well as in the incidence of large vessel occlusion (-17.1%; 0.15-0.13 patients/day per hospital, <0.001) and severe strokes on CT perfusion (-16.7%; 0.12-0.10 patients/day per hospital, <0.005). The sampled cohort showed similar declines in the rates of large vessel occlusions versus thrombectomy (18.8% versus 19.5%, =0.9) and comprehensive stroke center hospitalizations (18.8% versus 11.0%, =0.4).

Conclusions: A significant decline in stroke imaging screening has occurred during the COVID-19 pandemic. This analysis underscores the broader application of artificial intelligence neuroimaging platforms for the real-time monitoring of stroke systems of care.
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http://dx.doi.org/10.1161/STROKEAHA.120.031960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8078127PMC
May 2021

Functional Outcome After Minimally Invasive Endoscopic Evacuation of Thalamic Intracerebral Hemorrhage.

World Neurosurg 2021 May 3;149:e592-e599. Epub 2021 Feb 3.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Background: Intracerebral hemorrhage (ICH) is the most devastating form of stroke, with thalamic hemorrhages carrying the worst outcomes. Minimally invasive (MIS) endoscopic ICH evacuation is a promising new therapy for the condition. However, it remains unclear whether therapy success is location dependent. Here we present long-term functional outcomes after MIS evacuation of spontaneous thalamic hemorrhages.

Methods: Patients presenting to a single urban health system with spontaneous ICH were triaged to a central hospital for management of ICH. Operative criteria for MIS evacuation included hemorrhage volume ≥15 mL, age ≥18, National Institutes of Health Stroke Scale ≥6, and baseline modified Rankin Score (mRS) ≤3. Demographic, radiographic, and clinical data were collected prospectively, and descriptive statistics were performed retrospectively. Functional outcomes were assessed using 6-month mRS scores.

Results: Endoscopic ICH evacuation was performed on 21 patients. Eleven patients had hemorrhage confined to the thalamus, whereas 10 patients had hemorrhages in the thalamus and surrounding structures. Eighteen patients (85.7%) had intraventricular extension. The average preoperative volume was 39.8 mL (standard deviation [SD]: 31.5 mL) and postoperative volume was 3.8 mL (SD: 6.1 mL), resulting in an average evacuation rate of 91.4% (SD: 11.1%). One month after hemorrhage, 2 patients (9.5%) had expired and all other patients remained functionally dependent (90.5%). At 6-month follow-up, 4 patients (19.0%) had improved to a favorable outcome (mRS ≤ 3).

Conclusion: Among patients with ICH undergoing medical management, those with thalamic hemorrhages have especially poor outcomes. This study suggests that MIS evacuation can be safely performed in a thalamic population. It also presents long-term functional outcomes that can aid in planning randomization schemes or subgroup analyses in future MIS evacuation clinical trials.
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http://dx.doi.org/10.1016/j.wneu.2021.01.128DOI Listing
May 2021

Early Minimally Invasive Endoscopic Intracerebral Hemorrhage Evacuation.

World Neurosurg 2021 Apr 28;148:115. Epub 2021 Jan 28.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Intracerebral hemorrhage (ICH) is the most deadly form of stroke with a 40% mortality rate and bleak functional outcomes. There is currently no effective treatment of the condition, but preliminary trials focusing on endoscopic minimally invasive evacuation have suggested a potential benefit. The "SCUBA" technique (Stereotactic Intracerebral Hemorrhage Underwater Blood Aspiration) builds on prior strategies by permitting effective clot removal with visualization and cauterization of active arterial bleeding. The patient was a male in his '50s who presented with left-sided numbness after loss of consciousness and was found to have a right basal ganglia 5 mL ICH with a spot sign on computed tomography angiography CTA (Video 1). The hematoma then expanded to 28 mL and his examination worsened significantly for a National Institutes of Health Stroke Scale score of 15, a Glasgow Coma Scale score of 14, and an ICH score of 1. Approximately 8 hours after the patient was last known to be well, he was taken to the angiography suite for a diagnostic cerebral angiogram and right frontal minimally invasive endoscopic ICH evacuation with the Artemis system. The hematoma was evacuated using the stereotactic ICH underwater blood aspiration technique. After significant debulking of the clot, suction strength was decreased to 25% and irrigation was maintained on high. Sites of active bleeding were cauterized with the endoscopic bipolar cautery. The patient improved neurologically and was discharged from the hospital neurologically intact on postbleed day 4 with a National Institutes of Health Stroke Scale score of 0.
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http://dx.doi.org/10.1016/j.wneu.2021.01.017DOI Listing
April 2021

Interhospital Transfer of Intracerebral Hemorrhage Patients Undergoing Minimally Invasive Surgery: The Experience of a New York City Hospital System.

World Neurosurg 2021 Apr 8;148:e390-e395. Epub 2021 Jan 8.

Icahn School of Medicine at Mount Sinai, Department of Neurosurgery, New York, New York, USA. Electronic address:

Objective: The impact of interhospital transfer (IHT) on outcomes of patients with intracerebral hemorrhage (ICH) has not been well studied. We seek to describe the protocolized IHT and systems of care approach of a New York City hospital system, where ICH patients undergoing minimally invasive surgery (MIS) are transferred to a dedicated ICH center.

Methods: We retrospectively reviewed 100 consecutively admitted patients with spontaneous ICH. We gathered information on demographics, variables related to IHT, clinical and radiographic characteristics, and details about the clinical course and outpatient follow-up. We grouped patients into 2 cohorts: those admitted through IHT and those directly admitted through the emergency department. Primary outcome was good functional outcome at 6 months, defined as modified Rankin Scale score 0-3.

Results: Of 100 patients, 89 underwent IHT and 11 were directly admitted. On multivariable analysis, there were no significant differences in 6-month functional outcome between the 2 cohorts. All transfers were managed by a system-wide transfer center and 24/7 hotline for neuroemergencies. An ICH-specific IHT protocol was followed, in which a neurointensivist provided recommendations for stabilizing patients for transfer. Average transfer time was 199.7 minutes and average distance travelled was 13.6 kilometers.

Conclusions: In our hospital system, a centralized approach to ICH management and a dedicated ICH center increased access to specialist services, including MIS. Most patients undergoing MIS were transferred from outside hospitals, which highlights the need for additional studies and descriptions of experiences to further elucidate the impact of and best protocols for the IHT of ICH patients.
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http://dx.doi.org/10.1016/j.wneu.2020.12.163DOI Listing
April 2021

National Trends in Utilization and Outcome of Endovascular Thrombectomy for Acute Ischemic Stroke in Elderly.

J Stroke Cerebrovasc Dis 2021 Feb 1;30(2):105505. Epub 2020 Dec 1.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA. Electronic address:

Objective: Octogenarians were excluded and/or underrepresented in the major endovascular thrombectomy (EVT) randomized controlled trials, but continue to make up a growing proportion of stroke patients. To evaluate real-world trends in utilization and outcome of EVT in patients ≥80 years in a large nationally representative database.

Methods: Using the Nationwide Inpatient Sample (2014-2016), we identified patients admitted to United States hospitals with acute ischemic stroke (AIS) who also underwent EVT. The primary endpoint was good outcome (discharge to home/acute rehabilitation center). Poor outcome (discharge to skilled nursing facility or hospice and in-hospital mortality), intracerebral hemorrhage and in-hospital mortality were secondary outcome measures.

Results: In 376,956 patients with AIS, 6,230(1.54%) underwent EVT. 1,547(24.83%) were ≥80. The rate of EVT in AIS patients ≥80 more than doubled from 0.83%(n = 317) in 2014 to 1.83%(n = 695) in 2016. The rate of good outcome in patients ≥80 was 9%, significantly lower than younger patients (26%, p<0.001). In-hospital mortality was 19% in patients ≥80 compared to 13% in the younger cohort (p < 0.001). There was no difference in the rate of hemorrhagic transformation between octogenarians and younger patients (18.52% vs 17.01%, p=0.19). In patients ≥80 years of age, decreasing baseline comorbidity burden independently predicted good outcome (OR 0.258, 95% CI [0.674- 0.935]).

Conclusions: A two-fold increase in the utilization of EVT in patients ≥80 years of age was seen from 2014 to 2016. While the comparative rate of good outcome is significantly lower in this age group, elderly patients with fewer comorbidities demonstrated better outcomes after EVT.
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http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2020.105505DOI Listing
February 2021

Mobile Interventional Stroke Team Model Improves Early Outcomes in Large Vessel Occlusion Stroke: The NYC MIST Trial.

Stroke 2020 12 2;51(12):3495-3503. Epub 2020 Nov 2.

Department of Neurosurgery (J.R.M., T.J.O., D.W., C.P.K., N.S.D., D.H., L.R., H.S., R.A.D.L., I.P.S., X.Z., S.P., J.B., J.M., J.T.F.).

Background And Purpose: Triage of patients with emergent large vessel occlusion stroke to primary stroke centers followed by transfer to comprehensive stroke centers leads to increased time to endovascular therapy. A Mobile Interventional Stroke Team (MIST) provides an alternative model by transferring a MIST to a Thrombectomy Capable Stroke Center (TSC) to perform endovascular therapy. Our aim is to determine whether the MIST model is more time-efficient and leads to improved clinical outcomes compared with standard drip-and-ship (DS) and mothership models.

Methods: This is a prospective observational cohort study with 3-month follow-up between June 2016 and December 2018 at a multicenter health system, consisting of one comprehensive stroke center, 4 TSCs, and several primary stroke centers. A total of 228 of 373 patients received endovascular therapy via 1 of 4 models: mothership with patient presentation to a comprehensive stroke center, DS with patient transfer from primary stroke center or TSC to comprehensive stroke center, MIST with patient presentation to TSC and MIST transfer, or a combination of DS with patient transfer from primary stroke center to TSC and MIST. The prespecified primary end point was initial door-to-recanalization time and secondary end points measured additional time intervals and clinical outcomes at discharge and 3 months.

Results: MIST had a faster mean initial door-to-recanalization time than DS by 83 minutes (<0.01). MIST and mothership had similar median door-to-recanalization times of 192 minutes and 179 minutes, respectively (=0.83). A greater proportion had a complete recovery (National Institutes of Health Stroke Scale of 0 or 1) at discharge in MIST compared with DS (37.9% versus 16.7%; <0.01). MIST had 52.8% of patients with modified Rankin Scale of ≤2 at 3 months compared with 38.9% in DS (=0.10).

Conclusions: MIST led to significantly faster initial door-to-recanalization times compared with DS, which was comparable to mothership. This decrease in time has translated into improved short-term outcomes and a trend towards improved long-term outcomes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03048292.
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http://dx.doi.org/10.1161/STROKEAHA.120.030248DOI Listing
December 2020

COVID-19 and Decompressive Hemicraniectomy for Acute Ischemic Stroke.

Stroke 2020 09 8;51(9):e215-e218. Epub 2020 Jul 8.

Departments of Neurosurgery (J.W.L., A.S.R., K.R., C.L., C.P.K., T.S., J.G., S.M., J.B.B., J.M., N.S.D.), Icahn School of Medicine at Mount Sinai, New York, NY.

Background And Purpose: Young patients with malignant cerebral edema have been shown to benefit from early decompressive hemicraniectomy. The impact of concomitant infection with coronavirus disease 2019 (COVID-19) and how this should weigh in on the decision for surgery is unclear.

Methods: We retrospectively reviewed all COVID-19-positive patients admitted to the neuroscience intensive care unit for malignant edema monitoring. Patients with >50% of middle cerebral artery involvement on computed tomography imaging were considered at risk for malignant edema.

Results: Seven patients were admitted for monitoring of whom 4 died. Cause of death was related to COVID-19 complications, and these were either seen both very early and several days into the intensive care unit course after the typical window of malignant cerebral swelling. Three cases underwent surgery, and 1 patient died postoperatively from cardiac failure. A good outcome was attained in the other 2 cases.

Conclusions: COVID-19-positive patients with large hemispheric stroke can have a good outcome with decompressive hemicraniectomy. A positive test for COVID-19 should not be used in isolation to exclude patients from a potentially lifesaving procedure.
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http://dx.doi.org/10.1161/STROKEAHA.120.030804DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7359903PMC
September 2020

Increased Risk of Transient Cerebral Ischemia After Subarachnoid Hemorrhage in Patients with Premorbid Opioid Use Disorders: A Nationwide Analysis of Outcomes.

World Neurosurg 2020 09 17;141:e195-e203. Epub 2020 May 17.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA. Electronic address:

Background: Subarachnoid hemorrhage (SAH) is the most morbid sequela of intracranial aneurysms. Although mortality from SAH has been declining, opioid use in the United States has surged, and neurosurgeons are increasingly tasked with operating on patients with opioid use disorders (OUDs). There is a deficit in the literature regarding how OUDs affect SAH outcomes, particularly transient cerebral ischemic (TCI) events. The objective of this study was to investigate the influence of clinically diagnosed OUDs on the outcomes after acute SAH, with a specific focus on the rate of symptomatic TCI.

Methods: Patients with and without a diagnosed OUD who underwent either microsurgical clipping or endovascular coiling for SAH were queried from the 2012-2014 National Inpatient Sample using International Classification of Disease codes. The primary outcome was the rate of TCI after SAH treatment.

Results: A total of 25,330 patients were included, 310 of whom (1.22%) also carried a diagnosis of OUD. Univariate and multivariate regression showed that patients with OUD faced significantly increased odds of TCI (P = 0.044) compared with patients without OUD. OUD status was not associated with increased odds of other adverse outcomes, including overall complication, in-hospital mortality, poor outcome by a validated National Inpatient Sample SAH Outcome Measure, nonhome discharge, or extended hospitalization.

Conclusions: Patients with OUD face significantly higher odds of symptomatic TCI events producing clinical deficits during hospitalization for acute SAH. These findings suggest usefulness in screening patients for OUD to identify individuals who may benefit from a higher level of clinical scrutiny for post-SAH TCI.
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http://dx.doi.org/10.1016/j.wneu.2020.05.075DOI Listing
September 2020

Increases in Subdural Hematoma with an Aging Population-the Future of American Cerebrovascular Disease.

World Neurosurg 2020 09 13;141:e166-e174. Epub 2020 May 13.

Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA. Electronic address:

Background: Subdural hematomas (SDHs) are a common and dangerous condition, with potential for a rapid rise in incidence given the aging U.S. population, but the magnitude of this increase is unknown. Our objective was to characterize the number of SDHs and practicing neurosurgeons from 2003-2016 and project these numbers to 2040.

Methods: Using the National Inpatient Sample years 2003-2016 (nearly 500 million hospitalizations), all hospitalizations with a diagnosis of SDH were identified and grouped by age. Numerical estimates of SDHs were projected to 2040 in 10-year increments for each age group using Poisson modeling with population estimates from the U.S. Census Bureau. The number of neurosurgeons who billed the Centers for Medicare and Medicaid Services from 2012 to 2017 was noted and linearly projected to 2040.

Results: From 2020-2040, SDH volume is expected to increase by 78.3%, from 135,859 to 208,212. Most of this increase will be seen in the elderly, as patients 75-84 years old will experience an increase from 37,941 to 69,914 and patients older than 85 years old will experience an increase from 31,200 to 67,181. The number of neurosurgeons is projected to increase from 4675 in 2020 to 6252 in 2040.

Conclusions: SDH is expected to increase significantly from 2020-2040, with the majority of this increase being concentrated in elderly patients. While the number of neurosurgeons will also increase, the ability of current neurosurgical resources to properly handle this expected increase in SDH will need to be addressed on a national scale.
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http://dx.doi.org/10.1016/j.wneu.2020.05.060DOI Listing
September 2020

Advanced Techniques for Endoscopic Intracerebral Hemorrhage Evacuation: A Technical Report With Case Examples.

Oper Neurosurg (Hagerstown) 2020 12;20(1):119-129

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York.

Background: Multiple surgical techniques to perform minimally invasive intracerebral hemorrhage (ICH) evacuation are currently under investigation. The use of an adjunctive aspiration device permits controlled suction through an endoscope, minimizing collateral damage from the access tract. As with increased experience with any new procedure, performance of endoscopic minimally invasive ICH evacuation requires development of a unique set of operative tenets and techniques.

Objective: To describe operative nuances of endoscopic minimally invasive ICH evacuation developed at a single center over an experience of 80 procedures.

Methods: Endoscopic minimally invasive ICH evacuation was performed on 79 consecutive eligible patients who presented a single Health System between March 2016 and May 2018. We summarize 4 core operative tenets and 4 main techniques used in 80 procedures.

Results: A total of 80 endoscopic minimally invasive ICH evacuations were performed utilizing the described surgical techniques. The average preoperative and postoperative volumes were 49.5 mL (standard deviation [SD] 31.1 mL, interquartile range [IQR] 30.2) and 5.4 mL (SD 9.6, mL IQR 5.1), respectively, with an average evacuation rate of 88.7%. All cause 30-d mortality was 8.9%.

Conclusion: As experience builds with endoscopic minimally invasive ICH evacuation, academic discussion of specific surgical techniques will be critical to maximizing its safety and efficacy.
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http://dx.doi.org/10.1093/ons/opaa089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8044389PMC
December 2020

Minimally invasive endoscopic evacuation of intracerebral haemorrhage: reaching the goal.

Lancet 2020 01;395(10218):e5

Icahn School of Medicine at Mount Sinai, New York, NY, USA.

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http://dx.doi.org/10.1016/S0140-6736(19)33007-7DOI Listing
January 2020

Long-term functional outcome following minimally invasive endoscopic intracerebral hemorrhage evacuation.

J Neurointerv Surg 2020 May 8;12(5):489-494. Epub 2020 Jan 8.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, New York, USA.

Background And Purpose: Preclinical studies suggest that clot removal may mitigate primary and secondary brain injury following intracerebral hemorrhage (ICH). Although the MISTIE trial did not demonstrate an overall outcome benefit, it did demonstrate outcome benefit from effective reduction of clot burden. Minimally invasive endoscopic ICH evacuation may provide an alternative option for clot evacuation.

Methods: Patients presenting to a single healthcare system from December 2015 to October 2018 with supratentorial spontaneous ICH were evaluated for minimally invasive endoscopic evacuation. Inclusion and exclusion criteria were prospectively established by a multidisciplinary group in the healthcare system. The prespecified primary analysis was the proportion of patients with modified Rankin Score (mRS) 0-3 at 6 months.

Results: One hundred patients met the inclusion and exclusion criteria and underwent minimally invasive endoscopic ICH evacuation. The mean (SD) hematoma size was 49.7 (30.6) mL, the mean (SD) evacuation percentage was 88.2 (20.3)%, and 86% of patients had postoperative residual hematoma ≤15 mL. At 6 months the proportion of patients with an mRS of 0-3 was 46%.

Conclusions: This study suggests that minimally invasive endoscopic ICH evacuation may produce favorable long-term functional outcomes. Further evaluation of this technique in a randomized clinical trial is necessary.
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http://dx.doi.org/10.1136/neurintsurg-2019-015528DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7231458PMC
May 2020

A Compendium of Modern Minimally Invasive Intracerebral Hemorrhage Evacuation Techniques.

Oper Neurosurg (Hagerstown) 2020 06;18(6):710-720

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York.

Background: Minimally invasive intracerebral hemorrhage (ICH) evacuation has gained popularity with success in early-phase clinical trials. This procedure, however, is performed in very different ways around the world.

Objective: To provide a technical description of these strategies that facilitates comparison and aids decisions in which surgery to perform, and to inform further improvements in minimally invasive ICH evacuation.

Methods: Major authors of clinical trials evaluating each of the main techniques were contacted and asked to supply a case example and technical description of their respective surgeries.

Results: Five major techniques are presented including stereotactic thrombolysis, craniopuncture, endoscopic, endoscope-assisted, and endoport-mediated. Techniques differ in numerous ways including the size of the cranial access, the size of the access corridor through the brain to the hematoma, and the evacuation strategy. Regarding cranial access, a burr hole is created in stereotactic thrombolysis and craniopuncture, a small craniectomy in endoscopic, and a small craniotomy in the other 2. Access corridors through the parenchyma range from 3 mm in craniopuncture to 13.5 mm in the endoport-mediated evacuation. Regarding evacuation strategies, stereotactic thrombolysis and craniopuncture rely on passive drainage from a catheter placed during surgery that remains in place for multiple days, while the other 3 techniques rely on active evacuation with suction and bipolar cautery.

Conclusion: Future comparative clinical trials may identify the advantageous components of each strategy and contribute to improved outcomes in this patient population.
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http://dx.doi.org/10.1093/ons/opz308DOI Listing
June 2020

Systematic Review of Malpractice Litigation in the Diagnosis and Treatment of Acute Stroke.

Stroke 2019 10 19;50(10):2858-2864. Epub 2019 Aug 19.

From the Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York City, NY (J.J.H., L.G., X.Z., J.B., J.M., C.P.K.).

Background and Purpose- The emergency management of stroke is complex and highly time-sensitive. Recent landmark trials demonstrating the strong benefit of thrombectomy have led to rapid change in stroke management. This article reviews a large number of medical malpractice lawsuits related to the emergency management of stroke to characterize factors involved in these lawsuits. Methods- Three large legal databases were used to search for jury verdicts and settlements in cases related to the acute care of stroke patients in the United States. Search terms included "stroke" and "medical malpractice." Cases were screened to include only cases in which the allegation involved negligence in the acute care of a patient suffering a stroke. Results- We found 246 medical malpractice cases related to the acute management of ischemic stroke and 26 related to intracranial hemorrhage. Seventy-one cases specifically alleged a failure to treat with tPA (tissue-type plasminogen activator) and 7 cases alleged a failure to treat, or to timely treat, with thrombectomy. Overall there were 151 cases (56%) which ended with no payout, 74 cases (27%) were settled out of court, and 47 cases (17%) went to court and resulted in a verdict for the plaintiff. The average payout in settlements was $1 802 693, and the average payout in plaintiff verdicts was $9 705 099. Conclusions- Malpractice litigation is a risk in acute stroke care and can lead to significant financial consequences. The majority of malpractice lawsuits related to the emergency management of stroke allege a failure to diagnose and failure to treat. Allegations of a failure to treat acute ischemic stroke with tPA were frequently found and are common in lawsuits. Allegations of a failure to treat a large vessel occlusion with thrombectomy were less frequently found. Given recent changes in practice guidelines and the demonstrated strong treatment effect of thrombectomy, it is likely that such litigation will increase in the coming years.
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http://dx.doi.org/10.1161/STROKEAHA.119.025352DOI Listing
October 2019

Wide-neck aneurysms: systematic review of the neurosurgical literature with a focus on definition and clinical implications.

J Neurosurg 2019 Jun 14:1-7. Epub 2019 Jun 14.

1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.

Objective: Wide-necked aneurysms (WNAs) are a variably defined subset of cerebral aneurysms that require more advanced endovascular and microsurgical techniques than those required for narrow-necked aneurysms. The neurosurgical literature includes many definitions of WNAs, and a systematic review has not been performed to identify the most commonly used or optimal definition. The purpose of this systematic review was to highlight the most commonly used definition of WNAs.

Methods: The authors searched PubMed for the years 1998-2017, using the terms "wide neck aneurysm" and "broad neck aneurysm" to identify relevant articles. All results were screened for having a minimum of 30 patients and for clearly stating a definition of WNA. Reference lists for all articles meeting the inclusion criteria were also screened for eligibility.

Results: The search of the neurosurgical literature identified 809 records, of which 686 were excluded (626 with < 30 patients; 60 for lack of a WNA definition), leaving 123 articles for analysis. Twenty-seven unique definitions were identified and condensed into 14 definitions. The most common definition was neck size ≥ 4 mm or dome-to-neck ratio < 2, which was used in 49 articles (39.8%). The second most commonly used definition was neck size ≥ 4 mm, which was used in 26 articles (21.1%). The rest of the definitions included similar parameters with variable thresholds. There was inconsistent reporting of the precise dome measurements used to determine the dome-to-neck ratio. Digital subtraction angiography was the only imaging modality used to study the aneurysm morphology in 87 of 122 articles (71.3%).

Conclusions: The literature has great variability regarding the definition of a WNA. The most prevalent definition is a neck diameter of ≥ 4 mm or a dome-to-neck ratio of < 2. Whether this is the most appropriate and clinically useful definition is an area for future study.
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http://dx.doi.org/10.3171/2019.3.JNS183160DOI Listing
June 2019

Emerging Technologies in Optimizing Pre-Intervention Workflow for Acute Stroke.

Neurosurgery 2019 07;85(suppl_1):S9-S17

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai Medical System, New York, New York.

Over the last several years, thrombectomy for large vessel occlusions (LVOs) has emerged as a standard of care for acute stroke patients. Furthermore, the time to reperfusion has been identified as a predictor of overall patient outcomes, and much effort has been made to identify potential areas to target in enhancing preintervention workflow. As medical technology and stroke devices improve, nearly all time points can be affected, from field stroke triage to automated imaging interpretation to mass mobile stroke code communications. In this article, we review the preintervention stroke workflow with specific regard to emerging technologies in improving time to reperfusion and overall patient outcomes.
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http://dx.doi.org/10.1093/neuros/nyz058DOI Listing
July 2019

An analysis of malpractice litigation in the surgical management of carotid artery disease.

J Neurosurg 2019 May 24;132(6):1900-1906. Epub 2019 May 24.

1Department of Neurosurgery, Mount Sinai Hospital, New York, New York; and.

Objective: Carotid artery disease is a common illness that can pose a significant risk if left untreated. Treatment via carotid endarterectomy (CEA) or carotid artery stenting (CAS) can also lead to complications. Given the risk of adverse events related to treating, or failing to treat, carotid artery disease, this is a possible area for litigation. The aim of this review is to provide an overview of the medicolegal factors involved in treating patients suffering carotid artery disease and to compare litigation related to CEA and CAS.

Methods: Three large legal databases were used to search for jury verdicts and settlements in cases related to untreated carotid artery disease, CEA, and CAS. Search terms included "endarterectomy," "medical malpractice," "carotid," "stenosis," "stenting," "stent," and combinations of those words. Three types of cases were considered relevant: 1) cases in which the primary allegation was negligence performing a CEA or perioperative care (CEA-related cases); 2) cases in which the primary allegation was negligence performing a CAS or perioperative care (CAS-related cases); and 3) cases in which the plaintiff alleged that a CEA or CAS should have been performed (failure-to-treat [FTT] cases).

Results: One hundred fifty-four CEA-related cases, 3 CAS-related cases, and 67 FTT cases were identified. Cases resulted in 133 verdicts for the defense (59%), 64 settlements (29%), and 27 plaintiff verdicts (12%). The average payout in cases that were settled outside of court was $1,097,430 and the average payout in cases that went to trial and resulted in a plaintiff verdict was $2,438,253. Common allegations included a failure to diagnose and treat carotid artery disease in a timely manner, treating with inappropriate indications, procedural error, negligent postprocedural management, and lack of informed consent. Allegations of a failure to timely treat known carotid artery disease were likely to lead to a payout (60% of cases involved a payout). Allegations of procedural error, specifically where the resultant injury was nerve injury, were relatively less likely to lead to a payout (28% of cases involved a payout).

Conclusions: Both diagnosing and treating carotid artery disease has serious medicolegal implications and risks. In cases resulting in a plaintiff verdict, the payouts were significantly higher than cases resolved outside the courtroom. Knowledge of common allegations in diagnosing and treating carotid artery disease as well as performing CEA and CAS may benefit neurosurgeons. The lack of CAS-related litigation suggests these procedures may entail a lower risk of litigation compared to CEA, even accounting for the difference in the frequency of both procedures.
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http://dx.doi.org/10.3171/2019.3.JNS182934DOI Listing
May 2019

Aneurysmal Subarachnoid Hemorrhage with Spinal Subdural Hematoma: A Case Report and Systematic Review of the Literature.

World Neurosurg 2019 Aug 17;128:240-247. Epub 2019 May 17.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objective: Spinal subdural hematoma (S-SDH) rarely occurs after aneurysmal subarachnoid hemorrhage (SAH). Little information is known regarding the management and prognosis of patients with both S-SDH and SAH. Here, we present an illustrative case and provide a systematic review of S-SDH in the setting of SAH.

Methods: A systematic literature review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines revealed 11 previous cases of concurrent intracranial SAH and spinal SDH, which are presented with our new reported case.

Results: Intracranial sources of spontaneous SAH included 8 aneurysms, 1 pseudoaneurysm, and 3 angiogram-negative cases. Hunt Hess grades ranged from 1 to 4, mean time between SAH and S-SDH was 5.8 days, and S-SDH presented most frequently in the lumbar spine. Eight patients showed significant to complete clinical recovery, 2 had continued plegia of the lower extremities, and 2 expired. Modified Rankin scores (mRS) ranged from 0 to 6, with mRS >2 for 4 of 12 patients. Patients with a poor clinical outcome (mRS >2) had an initially negative cerebral angiogram, earlier presentation with less time between SAH and S-SDH (0.8 vs. 7.6 days), use of antithrombotic medication, no diversion of cerebrospinal fluid, and cervical or thoracic S-SDH.

Conclusion: S-SDH is uncommon in the setting of aneurysmal SAH; better outcomes are associated with lumbar location, delayed presentation, cerebrospinal fluid diversion, and lack of antithrombotic use. Conservative treatment may be sufficient in patients with delayed S-SDH and lack of significant neurologic deficits. More reported cases will allow greater understanding of this clinical entity.
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http://dx.doi.org/10.1016/j.wneu.2019.05.069DOI Listing
August 2019

MISTIE III: a big step in the right direction.

J Neurointerv Surg 2019 Apr;11(4):326-327

Department of Neurosurgery, The Mount Sinai Health System, New York, NY, USA.

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http://dx.doi.org/10.1136/neurintsurg-2019-014870DOI Listing
April 2019

Obesity Paradox in Intracerebral Hemorrhage.

Stroke 2019 04;50(4):999-1002

From the Department of Neurosurgery (S.R.P., A.C.L., N.S.D., X.Z., J.M., C.P.K.), Mount Sinai Hospital, New York.

Background and Purpose- Although obesity is an established risk factor for cardiovascular disease and stroke, studies have shown evidence of an obesity paradox-a protective effect of obesity in patients who already have these disease states. Data on the obesity paradox in intracerebral hemorrhage is limited. Methods- Clinical data for adult intracerebral hemorrhage patients were extracted from the National Inpatient Sample between 2007 and 2014. Multivariable logistic regression analyzed the association of body habitus with in-hospital mortality, discharge disposition, length of stay, tracheostomy or gastrostomy placement, and ventriculoperitoneal shunt placement. Results- There were 99 212 patients who were eligible. Patients with both obesity (OR=0.69; 95% CI=0.62-0.76; P<0.001) and morbid obesity (OR=0.85; 95% CI=0.74-0.97; P=0.02) were associated with decreased odds of in-hospital mortality. Morbid obesity was significantly associated with increased odds of a tracheostomy or gastrostomy placement (OR=1.42; 1.20-1.69; P<0.001) and decreased odds of a routine discharge disposition (OR=0.84; 0.74-0.97; P=0.014). Conclusions- Obesity and morbid obesity appear to protect against mortality in intracerebral hemorrhage.
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http://dx.doi.org/10.1161/STROKEAHA.119.024638DOI Listing
April 2019

Biopsy During Minimally Invasive Intracerebral Hemorrhage Clot Evacuation.

World Neurosurg 2018 Dec 24. Epub 2018 Dec 24.

Department of Neurosurgery, Mount Sinai Hospital, New York, New York, USA. Electronic address:

Background: The safety and efficacy of brain parenchyma biopsy during minimally invasive (MIS) intracerebral hemorrhage (ICH) clot evacuation has not been previously reported. The objective of this study was to establish the safety and diagnostic efficacy of brain biopsy during MIS ICH clot evacuation and to validate the modified Boston criteria as a predictor of cerebral amyloid angiopathy (CAA) in this cohort.

Methods: From October 2016 to March 2018, superficial and perihematomal biopsies were collected for 40 patients undergoing MIS ICH clot evacuation and analyzed by the pathology department to assess for various ICH etiologies. Additionally, the admission magnetic resonance imaging or computed tomography scan of each patient was analyzed and evaluated for the likelihood of a CAA etiology based on the modified Boston criteria. Student t test was used to analyze intergroup differences in continuous variables, and a 2-tailed Fisher exact test was used to determine intergroup differences of categorical variables, with significance set at P < 0.05.

Results: Two of the 40 patients (5%) experienced postoperative rebleed. Four of the 40 patients (10%) had evidence of CAA on biopsy. Patients with CAA on biopsy were older (P = 0.005) and had a higher prevalence of parietal lobe (P = 0.02) and occipital lobe (P = 0.001) hemorrhage. The modified Boston criteria had a sensitivity of 100% (95% confidence interval [CI], 39.6%-100%) and a specificity of 72.2% (95% CI, 54.6%-84.2%) for predicting CAA on biopsy.

Conclusions: Brain biopsy in MIS ICH clot evacuation is safe and allows for the diagnosis of various ICH etiologies.
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http://dx.doi.org/10.1016/j.wneu.2018.12.058DOI Listing
December 2018

Nutrition, Energy Expenditure, Dysphagia, and Self-Efficacy in Stroke Rehabilitation: A Review of the Literature.

Brain Sci 2018 Dec 7;8(12). Epub 2018 Dec 7.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA.

While significant research has been performed regarding the use of thrombolytic agents and thrombectomy in the setting of acute stroke, other factors, such as nutritional status of stroke patients, is a less explored topic. The topic of nutrition is critical to the discussion of stroke, as up to half of stroke survivors may be considered malnourished at discharge. Dysphagia, old age, restricted upper limb movement, visuospatial impairment, and depression are all important risk factors for malnutrition in this cohort. The purpose of this review is to analyze current literature discussing neuroprotective diets, nutritional, vitamin, and mineral supplementation, dysphagia, and post-stroke coaching in stroke patients.
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http://dx.doi.org/10.3390/brainsci8120218DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6316714PMC
December 2018

Effects of music therapy on anxiety and physiologic parameters in angiography: a systematic review and meta-analysis.

J Neurointerv Surg 2019 Apr 10;11(4):416-423. Epub 2018 Nov 10.

Department of Neurosurgery, Mount Sinai Hospital, New York, USA.

Background: Given the anxiety patients experience during angiography, evidence supporting the efficacy of music therapy during these angiographic procedures is potentially of clinical value.

Objective: To analyze the existing literature forthe use of music therapy during cerebral, coronary, and peripheral angiography to determine whether it improves patient anxiety levels, heart rate, and blood pressure during the procedure.

Methods: PubMed, Embase, and Scopus were searched to identify studies of interest. Inclusion criteria included studies reporting using music therapy in either cerebral, coronary, or peripheral angiography. Studies focused on a pediatric population; animal studies and case reports were excluded. Participant demographics, interventions, and outcomes were collected by two study authors. Bias and study quality of randomized controlled trials (RCTs) were assessed using the Cochrane Risk of Bias Tool. Separate meta-analyses of the RCTs were performed to compare State Trait Anxiety Inventory (STAI), heart rate (HR), and systolic and diastolic blood pressure (SBP and DBP) in the music intervention group versus control group. Heterogeneity was determined by calculating I values, and a random-effects model was used when heterogeneity exceeded 50%.

Results: The preprocedure to postprocedure improvement in STAI was significantly greater in the experimental group than the control group (p=0.004), while the decrease in HR, SBP, and DBP was not significant.

Conclusions: Recorded music and/or music therapy in angiography significantly decreases patients' anxiety levels, while it has little to no effect on HR and BP. This meta-analysis is limited by the relatively few RCTs published on this subject.

Prospero Registration Number: CRD42018099103.
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http://dx.doi.org/10.1136/neurintsurg-2018-014313DOI Listing
April 2019

Minimally Invasive Surgery for Intracerebral Hemorrhage.

Stroke 2018 11;49(11):2612-2620

From the Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, NY.

Background and Purpose- Minimally invasive surgery (MIS) for intracerebral hemorrhage (ICH) has been evaluated in numerous clinical trials. Although meta-analyses for this strategy have been performed in the past, recent trials add important information to results of the comparison and permit strategy-specific analyses, including evaluation of endoscopic evacuation and stereotactic thrombolysis. Methods- Major scientific databases including but not limited to Pubmed, the CENTRAL (Cochrane Central Register of Controlled Trials), Embase, Web of Science, Scopus, the ICTRP (International Clinical Trials Registry Platform), the Internet Stroke Center, and the CNKI (Chinese National Knowledge Infrastructure) were searched in October of 2017 for randomized controlled trials of MIS treatment of supratentorial spontaneous ICH. The primary outcome was defined as death or dependence at the end of follow-up, and the secondary outcome was defined as death. Results- The initial search yielded 958 reports, which were reduced to 15 high-quality randomized controlled trials involving 2152 patients. We analyzed odds ratios for MIS overall, endoscopic surgery, and stereotactic thrombolysis compared with conventional treatment, including medical treatment and conventional craniotomy. The odds ratio and CIs of the primary and secondary outcomes were 0.46 (0.36-0.57) and 0.59 (0.45-0.76) for MIS versus conventional treatment; 0.40 (0.25-0.66) and 0.37 (0.20-0.67) for endoscopic surgery versus conventional treatment; 0.47 (0.34-0.65) and 0.76 (0.56-1.04) for stereotactic thrombolysis versus conventional treatment; and 0.44 (0.29-0.67) and 0.56 (0.37-0.84) for MIS versus craniotomy. We also conducted subgroup analyses focusing on time to evacuation for MIS versus conventional treatment and found 0.36 (0.22-0.59) and 0.59 (0.34-1.00) for evacuations performed within 24 hours and 0.49 (0.38-0.63) and 0.57 (0.43-0.76) for evacuations performed within 72 hours. Conclusions- This meta-analysis demonstrates that select patients with supratentorial ICH benefit from MIS over other treatments. This beneficial effect remains true when analyzing specific techniques and evacuation timing subgroups.
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http://dx.doi.org/10.1161/STROKEAHA.118.020688DOI Listing
November 2018