Publications by authors named "Judy Huang"

229 Publications

Isolated aneurysms of the spinal circulation: a systematic review of the literature.

Neurosurg Rev 2021 Sep 20. Epub 2021 Sep 20.

Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Meyer 5-109, Baltimore, MD, 21287, USA.

Aneurysms arising in the spinal circulation are rare and underreported. The objective of this study was to systematically review the English literature on different aspects of isolated spinal aneurysms using the PubMed, Ovid MEDLINE, and Google Scholar databases. Eighty-two papers reporting 107 individual patient cases were included. Most isolated spinal aneurysms have a fusiform morphology, and are most commonly found in the anterior spinal artery at the thoracic or cervical levels. Subarachnoid hemorrhage is the most common form of presentation, and sudden onset back pain is the most common initial symptom. The diagnosis of spinal aneurysms requires a high degree of clinical suspicion. Because of their small size, they can be missed on CT/MR angiography and spinal angiogram may be employed. Treatment of spinal aneurysms should be individualized on a case-by-case basis. Conservative management can be a valid option in spinal aneurysms where the risk of treatment is high. Surgical or endovascular intervention may be indicated in cases of significant or progressive neurologic decline due aneurysmal mass effect, or progressive growth of the aneurysm despite conservative treatment.
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http://dx.doi.org/10.1007/s10143-021-01645-8DOI Listing
September 2021

Comparison of management approaches in deep-seated intracranial arteriovenous malformations: Does treatment improve outcome?

J Clin Neurosci 2021 Oct 24;92:191-196. Epub 2021 Aug 24.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States. Electronic address:

Deep-seated intracranial arteriovenous malformations (AVMs) represent a subset of AVMs characterized by variably reported outcomes regarding the risk of hemorrhage, microsurgical complications, and response to stereotactic radiosurgery (SRS). We aimed to compare outcomes of microsurgery, SRS, endovascular therapy, and conservative follow-up in deep-seated AVMs. A prospectively maintained database of AVM patients (1990-2017) was queried to identify patients with ruptured and unruptured deep-seated AVMs (extension into thalamus, basal ganglia, or brainstem). Comparisons of hemorrhage-free survival and poor functional outcome (modified Rankin scale [mRS] > 2) were performed between conservative management, microsurgery (±pre-procedural embolization), SRS (±pre-procedural embolization), and embolization utilizing multivariable Cox and logistic regression analyses controlling for univariable factors with p < 0.05. Of 789 AVM patients, 102 had deep-seated AVMs (conservative: 34; microsurgery: 6; SRS: 54; embolization: 8). Mean follow-up time was 6.1 years and did not differ significantly between management groups (p = 0.393). Complete obliteration was achieved in 49% of SRS patients. Upon multivariable analysis controlling for baseline rupture with conservative management as a reference group, embolization was associated with an increased hazard of hemorrhage (HR = 6.2, 95%CI [1.1-40.0], p = 0.037), while microsurgery (p = 0.118) and SRS (p = 0.167) provided no significant protection from hemorrhage. Controlling for baseline mRS, microsurgery was associated with an increased risk of poor outcome (OR = 9.2[1.2-68.3], p = 0.030), while SRS (p = 0.557) and embolization (p = 0.541) did not differ significantly from conservative management. Deep AVMs harbor a high risk of hemorrhage, but the benefit from intervention Remains uncertain. SRS may be a relatively more effective approach if interventional therapy is indicated.
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http://dx.doi.org/10.1016/j.jocn.2021.08.010DOI Listing
October 2021

Epidemiology and outcomes of pediatric intracranial aneurysms: comparison with an adult population in a 30-year, prospective database.

J Neurosurg Pediatr 2021 Sep 10:1-10. Epub 2021 Sep 10.

1Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and.

Objective: Pediatric intracranial aneurysms are rare. Most large series in the last 15 years reported on an average of only 39 patients. The authors sought to report their institutional experience with pediatric intracranial aneurysms from 1991 to 2021 and to compare pediatric patient and aneurysm characteristics with those of a contemporaneous adult cohort.

Methods: Pediatric (≤ 18 years of age) and adult patients with one or more intracranial aneurysms were identified in a prospective database. Standard epidemiological features and outcomes of each pediatric patient were retrospectively recorded. These results were compared with those of adult aneurysm patients managed at a single institution over the same time period.

Results: From a total of 4500 patients with 5150 intracranial aneurysms admitted over 30 years, there were 47 children with 53 aneurysms and 4453 adults with 5097 aneurysms; 53.2% of children and 36.4% of adults presented with a subarachnoid hemorrhage (SAH). Pediatric aneurysms were significantly more common in males, more likely giant (≥ 25 mm), and most frequently located in the middle cerebral artery. Overall, 85.1% of the pediatric patients had a modified Rankin Scale score ≤ 2 at the last follow-up (with a mean follow-up of 65.9 months), and the pediatric mortality rate was 10.6%; all 5 patients who died had an SAH. The recurrence rate of treated aneurysms was 6.7% (1/15) in the endovascular group but 0% (0/31) in the microsurgical group. No de novo aneurysms occurred in children (mean follow-up 5.5 years).

Conclusions: Pediatric intracranial aneurysms are significantly different from adult aneurysms in terms of sex, presentation, location, size, and outcomes. Future prospective studies will better characterize long-term aneurysm recurrence, rebleeds, and de novo aneurysm occurrences. The authors currently favor microsurgical over endovascular treatment for pediatric aneurysms.
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http://dx.doi.org/10.3171/2021.6.PEDS21268DOI Listing
September 2021

Adapting the 5-factor modified frailty index for prediction of postprocedural outcome in patients with unruptured aneurysms.

J Neurosurg 2021 Aug 13:1-8. Epub 2021 Aug 13.

Objective: The 5-factor modified frailty index (mFI-5) is a practical tool that can be used to estimate frailty by measuring five accessible factors: functional status, history of diabetes, chronic obstructive pulmonary disease, congestive heart failure, and hypertension. The authors aimed to validate the utility of mFI-5 for predicting endovascular and microsurgical treatment outcomes in patients with unruptured aneurysms.

Methods: A prospectively maintained database of consecutive patients with unruptured aneurysm who were treated with clip placement or endovascular therapy was used. Because patient age is an important predictor of treatment outcomes in patients with unruptured aneurysm, mFI-5 was supplemented with age to create the age-supplemented mFI-5 (AmFI-5). Associations of scores on these indices with major complications (symptomatic ischemic or hemorrhagic stroke, pulmonary embolism, pneumonia, or surgical site infection requiring reoperation) were evaluated. Validation was carried out with the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database (2006-2017).

Results: The institutional database included 275 patients (88 underwent clip placement, and 187 underwent endovascular treatment). Multivariable analysis of the surgical cohort showed that major complication was significantly associated with mFI-5 (OR 2.0, p = 0.046) and AmFI-5 (OR 1.9, p = 0.028) scores. Significant predictive accuracy for major complications was provided by mFI-5 (c-statistic = 0.709, p = 0.011) and AmFI-5 (c-statistic = 0.720, p = 0.008). The American Society of Anesthesiologists Physical Status Classification System (ASA) provided poor discrimination (area under the curve = 0.541, p = 0.618) that was significantly less than that of mFI-5 (p = 0.023) and AmFI-5 (p = 0.014). Optimal relative fit was achieved with AmFI-5, which had the lowest Akaike information criterion value. Similar results were obtained after equivalent analysis of the endovascular cohort, with additional significant associations between index scores and length of stay (β = 0.6 and p = 0.009 for mFI-5; β = 0.5 and p = 0.003 for AmFI-5). In 1047 patients who underwent clip placement and were included in the NSQIP database, mFI-5 (p = 0.001) and AmFI-5 (p < 0.001) scores were significantly associated with severe postoperative adverse events and provided greater discrimination (c-statistic = 0.600 and p < 0.001 for mFI-5; c-statistic = 0.610 and p < 0.001 for AmFI-5) than ASA score (c-statistic = 0.580 and p = 0.003).

Conclusions: mFI-5 and AmFI-5 represent potential predictors of procedure-related complications in unruptured aneurysm patients. After further validation, integration of these tools into clinical workflows may optimize patients for intervention.
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http://dx.doi.org/10.3171/2021.2.JNS204420DOI Listing
August 2021

Perceptions of the Virtual Neurosurgery Application Cycle During the Coronavirus Disease 2019 (COVID-19) Pandemic: A Program Director Survey.

World Neurosurg 2021 Aug 4. Epub 2021 Aug 4.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Objective: The novel coronavirus disease 2019 (COVID-19) pandemic has led to a shift to virtual residency interviews for the 2020-2021 neurosurgery match, with unknown implications for stakeholders. This study seeks to analyze the perceptions of residency program directors (PDs) and associate program directors (APDs) regarding the current virtual format used for residency selection and interviews.

Methods: An anonymous, 30-question survey was constructed and sent to 115 neurosurgery PDs and 26 APDs to assess respondent demographics, factors used to review applicants, perceptions of applicants and applicant engagement, perceptions of standardized letters and interview questions, the effect of the virtual interview format on various stakeholders, and the future outlook for the virtual residency interview format.

Results: A total of 38 PDs and APDs completed this survey, constituting a response rate of 27.0%. Survey respondents received significantly more Electronic Residency Application Service applications in the 2020-2021 cycle compared with the 2019-2020 cycle (P = 0.0029). Subinternship performance by home-rotators, (26.3%), letters of recommendation (23.7%), and Step 1 score (18.4%) were ranked as the most important factors for evaluating candidates during the current virtual application cycle.

Conclusions: Our study highlights that applicants applied to a greater number of residency programs compared with years prior, that the criteria used by PDs/APDs to evaluate applicants remained largely consistent compared to previous years, and that the virtual residency interview format may disproportionately disadvantage Doctor of Osteopathic medicine and international medical graduate applicants. Further exploring attitudes toward signaling mechanisms and standardized letters may serve to inform changes to future neurosurgery match cycles.
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http://dx.doi.org/10.1016/j.wneu.2021.07.078DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8461646PMC
August 2021

The Impact of Hydrocephalus Shunt Devices on Quality of Life.

J Craniofac Surg 2021 Jul-Aug 01;32(5):1746-1750

Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery.

Background: Despite advances in hydrocephalus shunt technology and improvement in hydrocephalus management, many patients have chronic disability and require multiple surgeries throughout their lifetime. There is limited data from patients' perspective regarding the impact of shunt devices on quality-of-life.

Methods: A cross-sectional survey was developed to evaluate the impact of shunt devices on patient quality-of-life. The survey was distributed via social media platforms of the Hydrocephalus Association, and patients self-selected to anonymously complete the online questionnaire. A literature review was performed to contextualize the findings from the survey.

Results: A total of 562 survey responses were obtained from a network encompassing 35,000 members. The mean age was 30 years old (0.5-87), and 65% identified as female. Eighty one percent underwent at least 1 shunt revision surgery, with a reported average of 10 shunt revision surgeries per patient (1-200 surgeries). Occlusion, shunt migration and infection were the leading causes for revision at 60%, 47%, and 35%, respectively. In addition, 72% of patients reported pain and discomfort from the device, and 68% expressed avoidance of certain activities due to "fear of bumping shunt." Despite numerous articles discussing shunt technology, a review of the literature indicated a paucity of studies specifically evaluating the burden of shunt devices from a patient/caregiver perspective.

Conclusions: The findings from this study suggest long-term physical and psychosocial burden associated with shunt devices. Importantly, this study highlights the need for concerted efforts to develop validated tools to study patient reported outcomes as it relates to neurocranial implanted devices.
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http://dx.doi.org/10.1097/SCS.0000000000007579DOI Listing
July 2021

Impact of international research fellows in neurosurgery: results from a single academic center.

J Neurosurg 2021 Jul 23:1-11. Epub 2021 Jul 23.

Objective: International research fellows have been historically involved in academic neurosurgery in the United States (US). To date, the contribution of international research fellows has been underreported. Herein, the authors aimed to quantify the academic output of international research fellows in the Department of Neurosurgery at The Johns Hopkins University School of Medicine.

Methods: Research fellows with Doctor of Medicine (MD), Doctor of Philosophy (PhD), or MD/PhD degrees from a non-US institution who worked in the Hopkins Department of Neurosurgery for at least 6 months over the past decade (2010-2020) were included in this study. Publications produced during fellowship, number of citations, and journal impact factors (IFs) were analyzed using ANOVA. A survey was sent to collect information on personal background, demographics, and academic activities.

Results: Sixty-four international research fellows were included, with 42 (65.6%) having MD degrees, 17 (26.6%) having PhD degrees, and 5 (7.8%) having MD/PhD degrees. During an average 27.9 months of fellowship, 460 publications were produced in 136 unique journals, with 8628 citations and a cumulative journal IF of 1665.73. There was no significant difference in total number of publications, first-author publications, and total citations per person among the different degree holders. Persons holding MD/PhDs had a higher number of citations per publication per person (p = 0.027), whereas those with MDs had higher total IFs per person (p = 0.048). Among the 43 (67.2%) survey responders, 34 (79.1%) had nonimmigrant visas at the start of the fellowship, 16 (37.2%) were self-paid or funded by their country of origin, and 35 (81.4%) had mentored at least one US medical student, nonmedical graduate student, or undergraduate student.

Conclusions: International research fellows at the authors' institution have contributed significantly to academic neurosurgery. Although they have faced major challenges like maintaining nonimmigrant visas, negotiating cultural/language differences, and managing self-sustainability, their scientific productivity has been substantial. Additionally, the majority of fellows have provided reciprocal mentorship to US students.
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http://dx.doi.org/10.3171/2021.1.JNS203824DOI Listing
July 2021

Predictors of Academic Neurosurgical Career Trajectory among International Medical Graduates Training Within the United States.

Neurosurgery 2021 Aug;89(3):478-485

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: Within the literature, there has been limited research tracking the career trajectories of international medical graduates (IMGs) following residency training.

Objective: To compare the characteristics of IMG and US medical school graduate (USMG) neurosurgeons holding academic positions in the United States and also analyze factors that influence IMG career trajectories following US-based residency training.

Methods: We collected data on 243 IMGs and 2506 USMGs who graduated from Accreditation Council for Graduate Medical Education (ACGME)-accredited neurosurgery residency programs. We assessed for significant differences between cohorts, and a logistic regression model was used for the outcome of academic career trajectory.

Results: Among the 2749 neurosurgeons in our study, IMGs were more likely to pursue academic neurosurgery careers relative to USMGs (59.7% vs 51.1%; P = .011) and were also more likely to complete a research fellowship before beginning residency (odds ratio [OR] = 9.19; P < .0001). Among current US academic neurosurgeons, USMGs had significantly higher pre-residency h-indices relative to IMGs (1.23 vs 1.01; P < .0001) with no significant differences between cohorts when comparing h-indices during (USMG = 5.02, IMG = 4.80; P = .67) or after (USMG = 14.05, IMG = 13.90; P = .72) residency. Completion of a post-residency clinical fellowship was the only factor independently associated with an academic career trajectory among IMGs (OR = 1.73, P = .046).

Conclusion: Our study suggests that while IMGs begin their US residency training with different research backgrounds and achievements relative to USMG counterparts, they attain similar levels of academic productivity following residency. Furthermore, IMGs are more likely to pursue academic careers relative to USMGs. Our work may be useful for better understanding IMG career trajectories following US-based neurosurgery residency training.
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http://dx.doi.org/10.1093/neuros/nyab194DOI Listing
August 2021

Commentary: External Validation of the R2eD AVM Score to Predict the Likelihood of Rupture Presentation of Brain Arteriovenous Malformations.

Neurosurgery 2021 07;89(2):E109-E111

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

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http://dx.doi.org/10.1093/neuros/nyab151DOI Listing
July 2021

Monocyte-based inflammatory indices predict outcomes following aneurysmal subarachnoid hemorrhage.

Neurosurg Rev 2021 Apr 10. Epub 2021 Apr 10.

Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps Building, Suite 102, Baltimore, MD, 21287, USA.

The contribution of specific immune cell populations to the post-hemorrhagic inflammatory response in aneurysmal subarachnoid hemorrhage (aSAH) and correlations with clinical outcomes, such as vasospasm and functional status, remains unclear. We aimed to compare the predictive value of leukocyte ratios that include monocytes as compared to the neutrophil-to-lymphocyte ratio (NLR) in aSAH. A prospectively accrued database of consecutive patients presenting to our institution with aSAH between January 2013 and December 2018 was used. Patients with signs and symptoms of infection (day 1-3) were excluded. Admission values of the NLR, monocyte-neutrophil-to-lymphocyte ratio (M-NLR), and lymphocyte-to-monocyte ratio (LMR) were calculated. Associations with functional status, the primary outcome, and vasospasm were evaluated using univariable and multivariable logistic regression analyses. In the cohort of 234 patients with aSAH, the M-NLR and LMR, but not the NLR, were significantly associated with poor functional status (modified Rankin scale > 2) at 12-18 months following discharge (p = 0.001, p = 0.023, p = 0.161, respectively). The area under the curve for predicting poor functional status was significantly lower for the NLR (0.543) compared with the M-NLR (0.603, p = 0.024) and LMR (0.608, p = 0.040). The M-NLR (OR = 1.01 [1.01-1.02]) and LMR (OR = 0.88 [0.78-0.99]) were independently associated with poor functional status while controlling for age, hypertension, Fisher grade, and baseline clinical status. The LMR was significantly associated with vasospasm (OR = 0.84 [0.70-0.99]) while adjusting for age, hypertension, Fisher grade, aneurysm size, and current smoking. Inflammatory indices that incorporate monocytes (e.g., M-NLR and LMR), but not those that include only neutrophils, predict outcomes after aSAH.
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http://dx.doi.org/10.1007/s10143-021-01525-1DOI Listing
April 2021

Hemorrhage Following Complete Arteriovenous Malformation Resection With No Detectable Recurrence: Insights From a 27-Year Registry.

Neurosurgery 2021 07;89(2):212-219

Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.

Background: Although recurrence and de novo formation of arteriovenous malformations (AVMs) have been reported following complete resection, the occurrence of hemorrhage in the same location of an AVM with no detectable lesion (lesion-negative hemorrhage) has not been described after microsurgery.

Objective: To characterize the incidence and properties of lesion-negative hemorrhage following complete microsurgical resection.

Methods: A prospectively maintained registry of AVM patients seen at our institution between 1990 and 2017 was used. Microsurgically treated patients were selected, and the incidence of a lesion-negative hemorrhage was calculated and described with a Kaplan-Meier curve. Baseline characteristics as well as functional outcome at last follow-up were compared between patients with and without a lesion-negative hemorrhage.

Results: From a total of 789 AVM patients, 619 (79%) were treated, and 210 out of 619 patients (34%) underwent microsurgery with or without preoperative embolization or radiosurgery. The microsurgically treated cohort was followed up for a mean of 6.1 ± 3.0 yr after surgery with 5 (2.4%) patients experiencing postresection lesion-negative hemorrhage (3.9 per 1000 person-years) at an average of 8.6 ± 9.0 yr following surgery. Follow-up angiograms after hemorrhage (up to 2 mo posthemorrhage) confirmed the absence of a recurrent or de novo AVM in all cases. All patients with a lesion-negative hemorrhage initially presented with rupture before resection (Fisher P = .066; log-rank P = .057). The occurrence of a lesion-negative hemorrhage was significantly associated with worse modified Rankin scale scores at last follow-up (P = .031).

Conclusion: A lesion-negative hemorrhage can occur following complete microsurgical resection in up to 2.4% of patients. Exploration of possible underlying causes is warranted.
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http://dx.doi.org/10.1093/neuros/nyab104DOI Listing
July 2021

Application of unruptured aneurysm scoring systems to a cohort of ruptured aneurysms: are we underestimating rupture risk?

Neurosurg Rev 2021 Apr 2. Epub 2021 Apr 2.

Department of Neurosurgery, Johns Hopkins Hospital, Johns Hopkins University School of Medicine, 1800 Orleans Street, Sheikh Zayed Tower 6115C, Baltimore, MD, 21287, USA.

The predictive values of current risk stratification scales such as the Unruptured Intracranial Aneurysm Treatment Score (UIATS) and the PHASES score are debatable. We evaluated these scores using a cohort of ruptured intracranial aneurysms to simulate their management recommendations had the exact same patients presented prior to rupture. A prospectively maintained database of ruptured saccular aneurysm patients presenting to our institution was used. The PHASES score was calculated for 992 consecutive patients presenting between January 2002 and December 2018, and the UIATS was calculated for 266 consecutive patients presenting between January 2013 and December 2018. A shorter period was selected for the UIATS cohort given the larger number of variables required for calculation. Clinical outcomes were compared between UIATS-recommended "observation" aneurysms and all other aneurysms. Out of 992 ruptured aneurysms, 54% had a low PHASES score (≤5). Out of the 266 ruptured aneurysms, UIATS recommendations were as follows: 68 (26%) "observation," 97 (36%) "treatment," and 101 (38%) "non-definitive." The UIATS conservative group of patients developed more SAH-related complications (78% vs. 65%, p=0.043), had a higher rate of non-home discharge (74% vs. 46%, p<0.001), and had a greater incidence of poor functional status (modified Rankin scale >2) after 12-18 months (68% vs. 51%, p=0.014). Current predictive scoring systems for unruptured aneurysms may underestimate future rupture risk and lead to more conservative management strategies in some patients. Patients that would have been recommended for conservative therapy were more likely to have a worse outcome after rupture.
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http://dx.doi.org/10.1007/s10143-021-01523-3DOI Listing
April 2021

Cerebrovascular Reactivity Mapping Using Resting-State BOLD Functional MRI in Healthy Adults and Patients with Moyamoya Disease.

Radiology 2021 05 9;299(2):419-425. Epub 2021 Mar 9.

From the Departments of Radiology (P.L., G.L., Z.L., H.L.) and Neurosurgery (J.H.), Johns Hopkins University School of Medicine, 600 N Wolfe St, Park 324, Baltimore, MD 21287; Department of Radiology (M.C.P., B.G.W.), Advanced Imaging Research Center (M.C.P., B.P.T.), and Department of Neurologic Surgery (B.G.W.), UT Southwestern Medical Center, Dallas, Tex; and Center for Vital Longevity, University of Texas at Dallas, Dallas, Tex (M.R., D.C.P.).

Background Cerebrovascular reserve, the potential capacity of brain tissue to receive more blood flow when needed, is a desirable marker in evaluating ischemic risk. However, current measurement methods require acetazolamide injection or hypercapnia challenge, prompting a clinical need for resting-state (RS) blood oxygen level-dependent (BOLD) functional MRI data to measure cerebrovascular reactivity (CVR). Purpose To optimize and evaluate an RS CVR MRI technique and demonstrate its relationship to neurosurgical treatment. Materials and Methods In this HIPAA-compliant study, RS BOLD functional MRI data collected in 170 healthy controls between December 2008 and September 2010 were retrospectively evaluated to identify the optimal frequency range of temporal filtering on the basis of spatial correlation with the reference standard CVR map obtained with CO inhalation. Next, the optimized RS method was applied in a new, prospective cohort of 50 participants with Moyamoya disease who underwent imaging between June 2014 and August 2019. Finally, CVR values were compared between brain hemispheres with and brain hemispheres without revascularization surgery by using Mann-Whitney test. Results A total of 170 healthy controls (mean age ± standard deviation, 51 years ± 20; 105 women) and 100 brain hemispheres of 50 participants with Moyamoya disease (mean age, 41 years ± 12; 43 women) were evaluated. RS CVR maps based on a temporal filtering frequency of [0, 0.1164 Hz] yielded the highest spatial correlation ( = 0.74) with the CO inhalation CVR results. In patients with Moyamoya disease, 77 middle cerebral arteries (MCAs) had stenosis. RS CVR in the MCA territory was lower in the group that did not undergo surgery ( = 30) than in the group that underwent surgery ( = 47) (mean, 0.407 relative units [ru] ± 0.208 vs 0.532 ru ± 0.182, respectively; = .006), which is corroborated with the CO inhalation CVR data (mean, 0.242 ru ± 0.273 vs 0.437 ru ± 0.200; = .003). Conclusion Cerebrovascular reactivity mapping performed by using resting-state blood oxygen level-dependent functional MRI provided a task-free method to measure cerebrovascular reserve and depicted treatment effect of revascularization surgery in patients with Moyamoya disease comparable to that with the reference standard of CO inhalation MRI. © RSNA, 2021 See also the editorial by Wolf and Ware in this issue.
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http://dx.doi.org/10.1148/radiol.2021203568DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8108558PMC
May 2021

International Practice Variability in Treatment of Aneurysmal Subarachnoid Hemorrhage.

J Clin Med 2021 Feb 14;10(4). Epub 2021 Feb 14.

Division of Neurosciences Critical Care, Departments of Anesthesiology and Critical Care Medicine, Neurology, and Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.

Prior research suggests substantial between-center differences in functional outcome following aneurysmal subarachnoid hemorrhage (aSAH). One hypothesis is that these differences are due to practice variability. To characterize practice variability, we sent a survey to 230 centers, of which 145 (63%) responded. Survey respondents indicated that an estimated 65% of ruptured aneurysms were treated endovascularly. Sixty-five percent of aneurysms were treated within 24 h of symptom onset, 18% within 24-48 h, and eight percent within 48-72 h. Centers in the United States (US) and Europe (EU) treat aneurysms more often endovascularly (72% and 70% vs. 51%, respectively, US vs. other < 0.001, and EU vs. other < 0.01) and more often within 24 h (77% and 64% vs. 46%, respectively, US vs. other < 0.001, EU vs. other < 0.01) compared to other centers. Most centers aim for euvolemia (96%) by administrating intravenous fluids to 0 (53%) or +500 mL/day (41%) net fluid balance. Induced hypertension is more often used in US centers (100%) than in EU (87%, < 0.05) and other centers (81%, < 0.05), and endovascular therapies for cerebral vasospasm are used more often in US centers than in other centers (91% and 60%, respectively, < 0.05). We observed significant practice variability in aSAH treatment worldwide. Future comparative effectiveness research studies are needed to investigate how practice variation leads to differences in functional outcome.
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http://dx.doi.org/10.3390/jcm10040762DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7917699PMC
February 2021

Total Fasting and Dehydration in the Operating Room: How Can Surgeons Survive and Thrive?

J Surg Educ 2021 Jul-Aug;78(4):1295-1304. Epub 2021 Jan 6.

Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland.

Objectives: Hydration and nutrition are critical to achieving optimal performance. This study aimed to assess the impact of limited oral intake in the operating room environment on surgical resident health, well-being, and performance.

Design: Electronic survey was sent to 94 surgical trainees at our institution in 2020. Chi-square analyses were performed to assess for differences in survey responses by sex.

Setting: A single tertiary-care institution.

Participants: Surveys were sent to surgical residents and fellows in general surgery, neurosurgery, and orthopedic surgery. Seventy-nine (80%) of the 94 residents and fellows responded.

Results: Of the 79 responses, most trainees (79%) experienced dehydration within 6 hours of operating. Forty-four (56%) reported no fluid intake for greater than 6 hours on average, and 39 (49%) reported that they frequently had difficulty rehydrating in between cases. Most of the respondents (70%) frequently experienced symptoms of dehydration, including orthostasis, headache, and constipation. Fifty-six (71%) believed that dehydration frequently affected their performance. Compared to men, women were more likely to feel dehydrated within 4 hours of operating (58% vs. 25%, p = 0.005). Women were also more likely to have difficulty rehydrating in between cases (75% vs. 38%, p = 0.0026), experience symptoms of dehydration (92% vs. 60%, p = 0.0049), and report that dehydration affects surgical performance (88% vs. 64%, p = 0.0318).

Conclusions: Prolonged fasting and dehydration are common issues that may negatively impact performance and wellbeing of surgical trainees. Also, dehydration may affect men and women differently.
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http://dx.doi.org/10.1016/j.jsurg.2020.12.018DOI Listing
June 2021

PD-1+ Monocytes Mediate Cerebral Vasospasm Following Subarachnoid Hemorrhage.

Neurosurgery 2021 03;88(4):855-863

Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Cerebral vasospasm is a major source of morbidity and mortality following aneurysm rupture and has limited treatment options.

Objective: To evaluate the role of programmed death-1 (PD-1) in cerebral vasospasm.

Methods: Endovascular internal carotid artery perforation (ICAp) was used to induce cerebral vasospasm in mice. To evaluate the therapeutic potential of targeting PD-1, programmed death ligand-1 (PD-L1) was administered 1 h after ICAp and vasospasm was measured histologically at the level of the ICA bifurcation bilaterally. PD-1 expressing immune cell populations were evaluated by flow cytometry. To correlate these findings to patients and evaluate the potential of PD-1 as a biomarker, monocytes were isolated from the peripheral blood and analyzed by flow cytometry in a cohort of patients with ruptured cerebral aneurysms. The daily frequency of PD-1+ monocytes in the peripheral blood was correlated to transcranial Doppler velocities as well as clinical and radiographic vasospasm.

Results: We found that PD-L1 administration prevented cerebral vasospasm by inhibiting ingress of activated Ly6c+ and CCR2+ monocytes into the brain. Human correlative studies confirmed the presence of PD-1+ monocytes in the peripheral blood of patients with ruptured aneurysms and the frequency of these cells corresponded with cerebral blood flow velocities and clinical vasospasm.

Conclusion: Our results identify PD-1+ monocytes as mediators of cerebral vasospasm and support PD-1 agonism as a novel therapeutic strategy.
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March 2021

Aging Patient Population With Ruptured Aneurysms: Trend Over 28 Years.

Neurosurgery 2021 02;88(3):658-665

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

Background: Given increasing life expectancy in the United States and worldwide, the proportion of elderly patients affected by aneurysmal subarachnoid hemorrhage (aSAH) would be expected to increase.

Objective: To determine whether an aging trend exists in the population of aSAH patients presenting to our institution over a 28-yr period.

Methods: A prospectively maintained database of consecutive patients presenting to our institution with subarachnoid hemorrhage between January 1991 and December 2018 was utilized. The 28-yr period was categorized into 4 successive 7-yr quarter intervals. The age of patients was compared among these intervals, and yearly trends were derived using linear regression.

Results: The cohort consisted of 1671 ruptured aneurysm patients with a mean age of 52.8 yr (standard deviation = 15.0 yr). Over the progressive 7-yr time intervals during the 28-yr period, there was an approximately 4-fold increase in the proportion of patients aged 80 yr or above (P < .001) and an increase in mean patient age from 51.2 to 54.6 yr (P = .002). Independent of this trend but along the same lines, there was a 29% decrease in the proportion of younger patients (<50 yr) from 49% to 35%. On linear regression, there was 1-yr increase in mean patient age per 5 calendar years (P < .001).

Conclusion: Analyses of aSAH patients demonstrate an increase in patient age over time with a considerable rise in the proportion of octogenarian patients and a decrease in patients younger than 50 yr. This aging phenomenon presents a challenge to the continued improvement in outcomes of aSAH patients.
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February 2021

Translucent Customized Cranial Implants Made of Clear Polymethylmethacrylate: An Early Outcome Analysis of 55 Consecutive Cranioplasty Cases.

Ann Plast Surg 2020 12;85(6):e27-e36

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.

Background: Large skull reconstruction, with the use of customized cranial implants, restores cerebral protection, physiologic homeostasis, and one's preoperative appearance. Cranial implants may be composed of either bone or a myriad of alloplastic biomaterials. Recently, patient-specific cranial implants have been fabricated using clear polymethylmethacrylate (PMMA), a visually transparent and sonolucent variant of standard opaque PMMA. Given the new enhanced diagnostic and therapeutic applications of clear PMMA, we present here a study evaluating all outcomes and complications in a consecutive patient series.

Methods: A single-surgeon, retrospective, 3-year study was conducted on all consecutive patients undergoing large cranioplasty with clear PMMA implants (2016-2019). Patients who received clear PMMA implants with embedded neurotechnologies were excluded due to confounding variables. All outcomes were analyzed in detail and compared with previous studies utilizing similar alloplastic implant materials.

Results: Fifty-five patients underwent cranioplasty with customized clear PMMA implants. Twenty-one (38%) were performed using a single-stage cranioplasty method (ie, craniectomy and cranioplasty performed during the same operation utilizing a prefabricated, oversized design and labor-intense, manual modification), whereas the remaining 34 (62%) underwent a standard, 2-stage reconstruction (craniectomy with a delayed surgery for cranioplasty and minimal-to-no implant modification necessary). The mean cranial defect size was 101.8 cm. The mean follow-up time was 9 months (range, 1.5-39). Major complications requiring additional surgery occurred in 7 patients (13%) consisting of 2 (4%) cerebrospinal fluid leaks, 2 (4%) epidural hematomas, and 3 (4%) infections. In addition, 3 patients developed self-limiting or nonoperative complications including 2 (4%) with new onset seizures and 1 (2%) with delayed scalp healing.

Conclusions: This is the first reported consecutive case series of cranioplasty reconstruction using customized clear PMMA implants, demonstrating excellent results with regard to ease of use, safety, and complication rates well below published rates when compared with other alloplastic materials. Clear PMMA also provides additional benefits, such as visual transparency and sonolucency, which is material specific and unavailable with autologous bone. Although these early results are promising, further studies with multicenter investigations are well justified to evaluate long-term outcomes.
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http://dx.doi.org/10.1097/SAP.0000000000002441DOI Listing
December 2020

The Neuroplastic Surgery Fellowship Experience: Where Tradition Meets Innovation.

J Craniofac Surg 2021 Jan-Feb 01;32(1):12-14

Section of Neuroplastic and Reconstructive Surgery, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine.

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May 2021

Multi-band MR fingerprinting (MRF) ASL imaging using artificial-neural-network trained with high-fidelity experimental data.

Magn Reson Med 2021 04 26;85(4):1974-1985. Epub 2020 Oct 26.

Department of Biomedical Engineering, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.

Purpose: We aim to leverage the power of deep-learning with high-fidelity training data to improve the reliability and processing speed of hemodynamic mapping with MR fingerprinting (MRF) arterial spin labeling (ASL).

Methods: A total of 15 healthy subjects were studied on a 3T MRI. Each subject underwent 10 runs of a multi-band multi-slice MRF-ASL sequence for a total scan time of approximately 40 min. MRF-ASL images were averaged across runs to yield a set of high-fidelity data. Training of a fully connected artificial neural network (ANN) was then performed using these data. The results from ANN were compared to those of dictionary matching (DM), ANN trained with single-run experimental data and with simulation data. Initial clinical performance of the technique was also demonstrated in a Moyamoya patient.

Results: The use of ANN reduced the processing time of MRF-ASL data to 3.6 s, compared to DM of 3 h 12 min. Parametric values obtained with ANN and DM were strongly correlated (R between 0.84 and 0.96). Results obtained from high-fidelity ANN were substantially more reliable compared to those from DM or single-run ANN. Voxel-wise coefficient of variation (CoV) of high-fidelity ANN, DM, and single-run ANN was 0.15 ± 0.08, 0.41 ± 0.20, 0.30 ± 0.16, respectively, for cerebral blood flow and 0.11 ± 0.06, 0.20 ± 0.19, 0.15 ± 0.10, respectively, for bolus arrival time. In vivo data trained ANN also outperformed ANN trained with simulation data. The superior performance afforded by ANN allowed more conspicuous depiction of hemodynamic abnormalities in Moyamoya patient.

Conclusion: Deep-learning-based parametric reconstruction improves the reliability of MRF-ASL hemodynamic maps and reduces processing time.
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http://dx.doi.org/10.1002/mrm.28560DOI Listing
April 2021

Continuous improvement in patient safety and quality in neurological surgery: the American Board of Neurological Surgery in the past, present, and future.

J Neurosurg 2020 Oct 16:1-7. Epub 2020 Oct 16.

22Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, California.

The American Board of Neurological Surgery (ABNS) was incorporated in 1940 in recognition of the need for detailed training in and special qualifications for the practice of neurological surgery and for self-regulation of quality and safety in the field. The ABNS believes it is the duty of neurosurgeons to place a patient's welfare and rights above all other considerations and to provide care with compassion, respect for human dignity, honesty, and integrity. At its inception, the ABNS was the 13th member board of the American Board of Medical Specialties (ABMS), which itself was founded in 1933. Today, the ABNS is one of the 24 member boards of the ABMS.To better serve public health and safety in a rapidly changing healthcare environment, the ABNS continues to evolve in order to elevate standards for the practice of neurological surgery. In connection with its activities, including initial certification, recognition of focused practice, and continuous certification, the ABNS actively seeks and incorporates input from the public and the physicians it serves. The ABNS board certification processes are designed to evaluate both real-life subspecialty neurosurgical practice and overall neurosurgical knowledge, since most neurosurgeons provide call coverage for hospitals and thus must be competent to care for the full spectrum of neurosurgery.The purpose of this report is to describe the history, current state, and anticipated future direction of ABNS certification in the US.
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http://dx.doi.org/10.3171/2020.6.JNS202066DOI Listing
October 2020

An Online Calculator for Predicting Academic Career Trajectory in Neurosurgery in the United States.

World Neurosurg 2021 01 5;145:e155-e162. Epub 2020 Oct 5.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Objective: Determining factors that predict a career in academic neurosurgery can help to improve neurosurgical training and faculty mentoring efforts. Although many academic career predictors have been established in the literature, no method has yet been developed to allow for individualized predictions of an academic career trajectory. The objective of the present study was to develop a Web-based calculator for predicting the probability of a career in academic neurosurgery.

Methods: The present study used data from neurosurgeons listed in the American Association of Neurological Surgeons database. A logistic regression model was used to predict probability of an academic career, and bootstrapping with 2000 samples was used to calculate an optimism-corrected C-statistic. P < 0.05 was considered statistically significant.

Results: A total of 1818 neurosurgeons were included in our analysis. Most surgeons were male (89.7%) and employed in nonacademic positions (60.2%). Factors independently associated with an academic career were female sex, attending a residency program affiliated with a top 10 U.S. News medical school, attaining a Doctor of Philosophy (PhD) degree, attaining a Master of Science (MS) degree, higher h-index during residency, more months of protected research time during residency, and completing a clinical fellowship. Our final model had an optimism-corrected C-statistic of 0.74. This model was incorporated into a Web-based calculator (https://neurooncsurgery.shinyapps.io/academic_calculator/).

Conclusions: The present study consolidates previous research investigating neurosurgery career predictors into a simple, open-access tool. Our work may serve to better clarify the many factors influencing trainees' likelihood of pursuing a career in academic neurosurgery.
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http://dx.doi.org/10.1016/j.wneu.2020.09.161DOI Listing
January 2021

Emergency Department Visits Following Suboccipital Decompression for Adult Chiari Malformation Type I.

World Neurosurg 2020 12 18;144:e789-e796. Epub 2020 Sep 18.

Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, USA. Electronic address:

Background: Postoperative emergency department (ED) visits following suboccipital decompression in Chiari malformation type I (CM-1) patients are not well described. We sought to evaluate the magnitude, etiology, and significance of postoperative ED service utilization in adult CM-1 patients at a tertiary referral center.

Methods: A prospectively maintained database of CM-1 patients seen at our institution between January 1, 2006 and December 31, 2019 was used. ED visits occurring within 30 days after surgery were tracked for postoperative patients, while comparing clinical, imaging, and operative characteristics between patients with and without an ED visit. Clinical improvement at last follow-up was also compared between both groups of patients in a univariable and multivariable analysis using the Chicago Chiari Outcome Scale (CCOS).

Results: In 175 surgically treated patients, 44 (25%) visited an ED in the 1-month period after surgery. The most common reason for seeking care was isolated headache (41%), and concentration disturbance at presentation was the only factor significantly associated with a postoperative ED visit (P = 0.023). The occurrence of a postoperative ED visit was independently associated with a lower chance of clinical improvement at last follow-up (adjusted odds ratio of CCOS ≥13 = 0.35, P = 0.021; adjusted odds ratio of CCOS ≥14 = 0.38, P = 0.016).

Conclusions: Adult CM-1 patients undergoing surgery at a tertiary referral center have an elevated rate of postoperative ED visits, which are mostly due to pain-related complaints. Such visits are hard to predict but are associated with worse long-term clinical outcome. Interventions that decrease the magnitude of postoperative ED service utilization are warranted.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500401PMC
December 2020

Investigation of a Valve-Agnostic Cranial Implant for Adult Hydrocephalus Patients Requiring Ventriculoperitoneal Shunting.

J Craniofac Surg 2020 Oct;31(7):1998-2002

Section of Neuroplastic and Reconstructive Surgery, Departments of Plastic Surgery and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD.

Introduction: Currently, the most effective treatment strategy for adults with hydrocephalus involves cerebrospinal fluid diversion by means of a shunt system, most commonly ventriculoperitoneal shunts (VPS). Ventriculoperitoneal shunting is associated with high complication and/or revision rates, in part due to the high-profile programmable valve designs. Thus, the valve-agnostic cranial implant (VACI) was designed and investigated as a safe and effective method of reducing the valve's high profile and is currently undergoing clinical trials. As such, the objective of this study was to collate preliminary, multi-institutional data of early outcomes using a VACI approach for patients requiring VPS by way of an Institutional Review Board approved registry.

Methods: A total of 25 adult patients across 4 institutions and 6 surgeons underwent VACI placement for VPS based on preoperative evaluation and perceived benefit. Patient demographics, operative details, and preliminary outcomes are presented here.

Results: Valve-agnostic cranial implant placement via a limited size craniectomy at time of shunt revision was performed with no adverse events. Over an average follow-up period of 1 year (394 ± 178 days), 92% of patients experienced no major shunt-related or scalp-related complications. There were 2 cases with a major complication requiring reoperation: 1 shunt tubing extrusion and 1 case of meningitis. The most frequent postsurgical intervention seen in this study was related to adjustment of drainage: a non-invasively performed valve reprogramming after initial shunt placement when proper flow rate is being established. Of the 8 cases of drainage adjustment, all but 1 (88%) were receiving a VPS for the first time, with the exception undergoing a fourth shunt revision. All instances of improper flow were treated non-surgically and remediated effectively via shunt reprogramming in clinic. Removal of the VACI was not indicated in any treatment course. In this way, all complications as they relate to the shunt valve were minor and required nonsurgical intervention, and no complications reported were directly or indirectly caused by using the VACI.

Conclusion: Preliminary findings from this multicenter trial suggest promising outcomes with a low complication rate for patients with hydrocephalus undergoing VACI placement during VPS. Ongoing research will continue to provide a more robust clinical picture of VACI in hydrocephalus management as more data becomes available.
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http://dx.doi.org/10.1097/SCS.0000000000006730DOI Listing
October 2020

Intracerebral and subarachnoid hemorrhage in pregnancy.

Handb Clin Neurol 2020 ;172:33-50

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, United States. Electronic address:

Maternal stroke occurs in around 34 out of every 100,000 deliveries and is responsible for around 5%-12% of all maternal deaths. It is most commonly hemorrhagic, and women are at highest risk for developing pregnancy-related hemorrhage during the early postpartum period through 6 weeks following the delivery. The most common causes of hemorrhagic stroke in pregnant patients are arteriovenous malformations and cerebral aneurysms. Management is similar to that for acute hemorrhagic stroke in the nonpregnant population with standard use of computed tomography and judicious utilization of intracranial vessel imaging and contrast. The optimal delivery method is evaluated on a case-by-case basis, and cesarean delivery is not always required. As most current studies are limited by retrospective design, relatively small sample sizes, and heterogeneous study term definitions, strong and comprehensive evidence-based guidelines on the management of acute hemorrhagic stroke in pregnant patients are still lacking. In the future, multicenter registries and prospective studies with uniform definitions will help improve management strategies in this complex patient population.
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http://dx.doi.org/10.1016/B978-0-444-64240-0.00002-7DOI Listing
June 2021

Commentary: Clinical Course of Unilateral Moyamoya Disease.

Neurosurgery 2020 Jul 25. Epub 2020 Jul 25.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland.

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http://dx.doi.org/10.1093/neuros/nyaa293DOI Listing
July 2020

Management of unruptured intracranial aneurysms: correlation of UIATS, ELAPSS, and PHASES with referral center practice.

Neurosurg Rev 2021 Jun 22;44(3):1625-1633. Epub 2020 Jul 22.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.

Concordance between the Unruptured Intracranial Aneurysm Treatment Score (UIATS), Earlier Subarachnoid Hemorrhage, Location, Age, Population, Size, Shape (ELAPSS) score, and Population, Hypertension, Age, Size, Earlier Subarachnoid Hemorrhage, Site (PHASES) score with real-world management decisions in unruptured intracranial aneurysms (UIAs) remains unclear, especially in current practice. This study aimed to investigate this concordance, while developing an optimal model predictive of recent decision practices at a quaternary referral center. A prospective database of patients presenting with UIAs to our institution from January 1 to December 31, 2018, was used. Concordance between the scores and real-world management decisions on every UIA was assessed. Complications and length of stay (LOS) were compared between aneurysms in the UIATS-recommended treatment and observation groups. A subgroup analysis of concordance was also conducted among junior and senior surgeons. An optimal logistic regression model predictive of real-world decisions was also derived. The cohort consisted of 198 patients with 271 UIAs, of which 42% were treated. The UIATS demonstrated good concordance with an AUC of 0.765. Of the aneurysms in the UIATS-recommended "observation" group, 22% were discordantly treated. The ELAPSS score demonstrated good discrimination (AUC = 0.793), unlike the PHASES score (AUC = 0.579). Endovascular treatment rates, complications, and LOS were similar between aneurysms in the UIATS-recommended treatment and observation groups. Similar concordance was obtained among junior and senior surgeons. The optimal predictive model consisted of several significantly associated variables and had an AUC of 0.942. Cerebrovascular specialists may be treating aneurysms slightly more than these scores would recommend, independently of years in practice. Wide variation still exists in management practices of UIAs.
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http://dx.doi.org/10.1007/s10143-020-01356-6DOI Listing
June 2021

Twisting: Incidence and Risk Factors of an Intraprocedural Challenge Associated With Pipeline Flow Diversion of Cerebral Aneurysms.

Neurosurgery 2020 12;88(1):25-35

Department of Neurosurgery, Carondelet Neurological Institute, Tucson, Arizona.

Background: Pipeline Embolization Device (PED; Medtronic) "twisting" manifests with the appearance of a "figure 8" in perpendicular planes on digital subtraction angiography. This phenomenon has received little attention in the literature, requires technical precision to remediate, and has potential to cause ischemic stroke if not properly remediated.

Objective: To report incidence, risk factors, and sequelae of PED twisting and to discuss techniques to remediate a PED twist.

Methods: Case images were reviewed for instances of twisting from a prospectively-maintained, Institutional Review Board-approved cohort of patients undergoing flow diversion for cerebral aneurysm.

Results: From August 2011 to December 2017, 999 PED flow diverting stents were attempted in 782 cases for 653 patients. A total of 25 PED twists were observed while treating 20 patients (2.50%, 25/999). Multivariate analysis revealed predictors of twisting to be: Large and giant aneurysms (odds ratio (OR) = 9.66, P = .005; OR = 27.47, P < .001), increased PED length (OR = 1.14, P < .001), and advanced patient age (OR = 1.07, P = .002). Twisted PEDs were able to be remediated 75% of the time, and procedural success was achieved in 90% of cases. PED twisting was not found to be a significant cause of major or minor complications. However, at long-term follow-up, there was a trend towards poor occlusion outcomes for the cases that encountered twisting.

Conclusion: Twisting is a rare event during PED deployment that was more likely to occur while treating large aneurysms with long devices in older patients. While twisting did not lead to major complications in this study, remediation can be challenging and may be associated with inferior occlusion outcomes.
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http://dx.doi.org/10.1093/neuros/nyaa309DOI Listing
December 2020

Family History in Chiari Malformation Type I: Presentation and Outcome.

World Neurosurg 2020 10 9;142:e350-e356. Epub 2020 Jul 9.

Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA. Electronic address:

Background: Some patients with Chiari malformation type I (CM-1) present with a positive family history of CM-1, the significance of which remains unknown. We aimed to study whether family history affects the clinical presentation characteristics and surgical outcome of adult patients with CM-1.

Methods: A database of adult patients with CM-1 presenting between January 1, 2006 and December 31, 2018 was used. Presenting characteristics were compared between patients with and without a family history (first, second, or third degree) of CM-1. Among surgically treated patients, perioperative and long-term outcomes, with favorable outcome defined as a Chiari Outcome Scale score ≥14, were compared between patients with and without CM-1 family history. All patients completed at least 6 months of postoperative follow-up.

Results: The database consisted of 233 adult patients with CM-1, 14 of whom (6%) had a positive family history. Presenting characteristics were comparable between patients with and without a positive family history. A total of 150 patients underwent suboccipital decompression, 12 of whom (8%) had a positive family history. After a mean follow-up of 1.9 years, patients with a family history of CM-1 were significantly less likely to achieve a favorable outcome (odds ratio, 0.22; 95% confidence interval, 0.06-0.78; P = 0.019) while controlling for several covariates. Post hoc analysis showed that the difference was most significant when looking at pain symptoms.

Conclusions: Presentation characteristics are comparable between patients with and without a family history of CM-1. Patients with a positive family history may be less likely to respond favorably to suboccipital decompression.
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http://dx.doi.org/10.1016/j.wneu.2020.06.238DOI Listing
October 2020
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