Publications by authors named "Kurt A Yaeger"

28 Publications

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Student Survey Results of a Virtual Medical Student Course Developed as a Platform for Neurosurgical Education During the COVID-19 Pandemic.

World Neurosurg 2021 May 28. Epub 2021 May 28.

Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2021.05.076DOI Listing
May 2021

Making a match: trends in the application, interview, and ranking process for the neurological surgery residency programs.

J Neurosurg 2021 May 28:1-7. Epub 2021 May 28.

Objective: Neurosurgery is a highly competitive residency field with a match rate lower than that of other specialties. The aim of this study was to analyze trends associated with the residency match process from the applicants' and program directors' perspectives.

Methods: Between 2010 and 2020, the National Residency Matching Program (NRMP) Applicant and Program Director Surveys, the NRMP Charting Outcomes reports, and the Accreditation Council for Graduate Medical Education (ACGME) Data Resource Books were analyzed to identify the number of applicants interviewed and ranked in US programs, the applicants' ranking preferences, the program directors' preferential factors in offering interviews, and rank list order. Applicants were divided between US senior medical students and independent applicants. Each cohort was dichotomized for matched and unmatched applicants.

Results: Over the study period, 2935 applicants applied to neurosurgery residency, including 2135 US senior medical students and 800 independent applicants, with an overall match rate of 65%. Overall, matched applicants had a significantly higher number of publications (p < 0.05). Among US senior medical student applicants, the application-to-interview ratio more than doubled over the study period, yet the number of interview invitations received, interviews accepted, and programs ranked remained unchanged. In the US senior medical student cohort, the number of submitted applications, interview invitations, accepted interviews, and programs ranked did not significantly differ between matched and unmatched applicants. In both cohorts, applicants shifted ranking factors from a more academic focus in early years to more well-being in later years. Letters of recommendation and board scores were key factors for program directors while screening applicants for interviews and ranking.

Conclusions: Neurosurgery residency continues to be a highly competitive field in medicine, with match rates of 65%. Recently, applicants have placed greater importance on ranking programs that value residents' well-being, as opposed to strictly academic factors. A data-driven understanding of factors important to applicants and program directors during the match process has the potential to improve resident candidate recruitment and overall resident-program fit, thereby improving well-being during residency, reducing the attrition rate, and overall enhancing the diversity of the neurosurgery resident workforce.
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http://dx.doi.org/10.3171/2020.11.JNS203637DOI Listing
May 2021

Bilateral middle cerebral artery occlusions treated with simultaneous bilateral thrombectomy: an approach to multivessel occlusions.

BMJ Case Rep 2021 May 19;14(5). Epub 2021 May 19.

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

The scarcely described phenomenon of acute ischaemic stroke due to bilateral large vessel occlusions and limited reports of its treatment raises the question about the best method for revascularisation. We present a simultaneous bilateral thrombectomy method on a patient with acute bilateral middle cerebral artery occlusions. This technique resulted in successful vessel recanalisation within 35 min without haemorrhagic complications-deeming the method both safe and effective. Patient outcome was unfavourable, complicated by the patient's history of heart failure and other cardiac-related problems. Patient is residing at a skilled nursing facility with maximal assistance.
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http://dx.doi.org/10.1136/bcr-2020-237965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8137163PMC
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

Time from image acquisition to endovascular team notification: a new target for enhancing acute stroke workflow.

J Neurointerv Surg 2021 Apr 8. Epub 2021 Apr 8.

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

Objective: To quantify the time between initial image acquisition (CT angiography (CTA)) and notification of the neuroendovascular surgery (NES) team, a potentially high yield time window to target for optimization of endovascular thrombectomy (ET) treatment times.

Methods: We reviewed our multihospital database for all patients with a stroke with emergent large vessel occlusion treated with ET between January 1, 2017 and August 5, 2020. We dichotomized patients into rapid (≤20 min) and delayed (>20 min) notification times and analyzed treatment characteristics and outcomes.

Results: Of 367 patients with ELVO undergoing ET for whom notification data were available, the median time from CTA to NES team notification was 24 min (IQR 12-47). The median total treatment time was 180 min (IQR 129-252). The median times from CTA to NES team notification for rapid (n=163) and delayed (n=204) cohorts were 11 (IQR 6-15) and 43 (IQR 30-80) min, respectively (p<0.001). The median overall times to reperfusion were 134 min (IQR 103-179) and 213 min (IQR 172-291), respectively (p<0.001). The delayed patients had a significantly lower National Institutes of Health Stroke Scale (NIHSS) score on presentation (15 (IQR 9-20) vs 16 (IQR 11-22), p=0.03), were younger (70 (IQR 60-79) vs 77 (IQR 64-85), p<0.001), and more often presented with posterior circulation occlusion (16.7% vs 7.4%, p<0.01). The group with rapid notification time had a statistically larger median improvement in NIHSS score from admission to discharge (6 (IQR 0.5-14) vs 5 (IQR 0.5-10), p=0.04).

Conclusions: Time delays from initial CTA acquisition to NES team notification can prevent expedient treatment with ET. Process improvements and automated stroke detection on imaging with automated notification of the NES team may ultimately improve time to reperfusion.
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http://dx.doi.org/10.1136/neurintsurg-2021-017297DOI Listing
April 2021

Trials in thrombectomy for acute ischemic stroke: Describing the state of clinical research in the field.

Clin Neurol Neurosurg 2021 01 10;200:106360. Epub 2020 Nov 10.

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

Background: Endovascular thrombectomy has revolutionized treatment of ischemic stroke. Given the clinical and socioeconomic support for thrombectomy, new devices, procedures, and pharmaceuticals have emerged in recent years, and have been subject to a growing number of clinical trials worldwide.

Objective: To define the current state of thrombectomy clinical trials, highlight recent trends, and help guide future research in this area.

Methods: Current and previous clinical trials involving thrombectomy for ischemic stroke were queried from the Clinicaltrials.gov database. Trials were categorized by their current status, study design, funding type, exclusion criteria, study phase, enrollment, start and completion dates, country of origin, item of investigation, outcome metrics, and whether a peer-reviewed publication was linked to the trial.

Results: Querying the ClinicalTrials.gov registry yielded 196 trials, of which 161 (82.1 %) were started within the past 5 years. The average time to completion was 30.6 months. A total of 62 studies (31.6 %) examined the safety or efficacy of a thrombectomy device, 29 (14.8 %) investigated a pharmacological intervention alone or in combination with a device, 59 (30.1 %) examined aspects of the endovascular procedure on patient outcomes, and 14 (7.2 %) examined diagnostic utility during thrombectomy. Most trials were funded by academic centers (53.1 %) or industry (34.7 %). Although the United States contributed the most studies overall (59; 30.1 %), studies from European and Asian countries have been increasing since 2015.

Conclusion: These trends indicate an increasing number of trials starting the past few years, with most occurring in Europe and examining devices or aspects of the thrombectomy procedure.
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http://dx.doi.org/10.1016/j.clineuro.2020.106360DOI Listing
January 2021

Academic Output of the Neurosurgery Profession During the COVID-19 Pandemic.

Authors:
Kurt A Yaeger

World Neurosurg 2020 11;143:572-574

Department of Neurological Surgery, Mount Sinai Health System, New York, New York, USA.

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http://dx.doi.org/10.1016/j.wneu.2020.08.200DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7607232PMC
November 2020

Transpedicular Approach for Ventral Epidural Abscess Evacuation in the Cervical Spine.

World Neurosurg 2021 01 17;145:127-133. Epub 2020 Sep 17.

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

Objective: Spinal epidural abscess may require prompt surgical intervention. Ventral cervical abscesses pose a particular challenge regarding the approach for surgical evacuation. The aim of this article was to describe the technical nuances of a posterior transpedicular cervical approach for evacuation of a ventral epidural abscess.

Methods: After a standard laminectomy, a foraminotomy was performed to identify the exiting nerve root. Then the medial aspect of the pedicle below the nerve was drilled. This allowed the insertion of a dissector to reach the ventral epidural space and drain the contents in conjunction with suction and irrigation. The posterolateral aspect of the superior endplate of the respective vertebra could be further drilled at this point, allowing access to the disc space with minimal retraction of the exiting nerve root.

Results: Two patients underwent emergent evacuation of a ventral epidural abscess in the cervical spine using this technique. Radiographic and clinical improvement was evident after evacuation of the abscesses in both cases.

Conclusions: Access to the ventral epidural space is feasible using a transpedicular approach in the cervical spine for evacuation of an epidural abscess.
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http://dx.doi.org/10.1016/j.wneu.2020.09.062DOI Listing
January 2021

Minimally invasive surgiscopic evacuation of intracerebral hemorrhage.

J Neurointerv Surg 2021 Apr 8;13(4):400. Epub 2020 Sep 8.

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

Intracerebral hemorrhage (ICH) is a devastating form of stroke associated with a 40% mortality rate at 30 days and a 75% functional dependence rate at 6 months. The role of surgery to treat ICH remains controversial. Preclinical studies suggest minimally invasive clot evacuation following ICH may benefit patients by mitigating primary and secondary brain injury.1 2 In this video, we report the operative technique used in minimally invasive surgicsopic evacuation following ICH (video 1). We demonstrate our presurgical approach using preoperative volumetric imaging loaded onto a stereotactic guidance system. Evacuation of intraparenchymal and intraventricular components of a hemorrhage are shown under direct surgiscopic vision using the Aurora System (Integra LifeSciences, Princeton, NJ, USA). Hemostasis is achieved when actively bleeding vessels are directly cauterized and irrigation of the clot cavity yields no fresh blood. Pre- and postevacuation radiographic differences illustrate the mitigation of clot burden in an elderly patient. neurintsurg;13/4/400/V1F1V1Video 1.
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http://dx.doi.org/10.1136/neurintsurg-2020-016553DOI Listing
April 2021

Emergent Large Vessel Occlusion Stroke During New York City's COVID-19 Outbreak: Clinical Characteristics and Paraclinical Findings.

Stroke 2020 09 31;51(9):2656-2663. Epub 2020 Jul 31.

Department of Neurosurgery (S.M., J.T.F., T.R.L., J.L.-R., K.A.Y., B.Y., N.D., T.J.O., T.S., R.D.L., J.M.), Icahn School of Medicine at Mount Sinai, New York, NY.

Background And Purpose: The 2019 novel coronavirus outbreak and its associated disease (coronavirus disease 2019 [COVID-19]) have created a worldwide pandemic. Early data suggest higher rate of ischemic stroke in severe COVID-19 infection. We evaluated whether a relationship exists between emergent large vessel occlusion (ELVO) and the ongoing COVID-19 outbreak.

Methods: This is a retrospective, observational case series. Data were collected from all patients who presented with ELVO to the Mount Sinai Health System Hospitals across New York City during the peak 3 weeks of hospitalization and death from COVID-19. Patients' demographic, comorbid conditions, cardiovascular risk factors, COVID-19 disease status, and clinical presentation were extracted from the electronic medical record. Comparison was made between COVID-19 positive and negative cohorts. The incidence of ELVO stroke was compared with the pre-COVID period.

Results: Forty-five consecutive ELVO patients presented during the observation period. Fifty-three percent of patients tested positive for COVID-19. Total patients' mean (±SD) age was 66 (±17). Patients with COVID-19 were significantly younger than patients without COVID-19, 59±13 versus 74±17 (odds ratio [95% CI], 0.94 [0.81-0.98]; =0.004). Seventy-five percent of patients with COVID-19 were male compared with 43% of patients without COVID-19 (odds ratio [95% CI], 3.99 [1.12-14.17]; =0.032). Patients with COVID-19 were less likely to be White (8% versus 38% [odds ratio (95% CI), 0.15 (0.04-0.81); =0.027]). In comparison to a similar time duration before the COVID-19 outbreak, a 2-fold increase in the total number of ELVO was observed (estimate: 0.78 [95% CI, 0.47-1.08], ≤0.0001).

Conclusions: More than half of the ELVO stroke patients during the peak time of the New York City's COVID-19 outbreak were COVID-19 positive, and those patients with COVID-19 were younger, more likely to be male, and less likely to be White. Our findings also suggest an increase in the incidence of ELVO stroke during the peak of the COVID-19 outbreak.
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http://dx.doi.org/10.1161/STROKEAHA.120.030397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7434004PMC
September 2020

"Staying Home"-Early Changes in Patterns of Neurotrauma in New York City During the COVID-19 Pandemic.

World Neurosurg 2020 11 27;143:e344-e350. Epub 2020 Jul 27.

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

Objective: New York City is the epicenter of the novel coronavirus disease 2019 (COVID-19) pandemic in the United States. Traumatic brain injury accounts for a significant proportion of admissions to our trauma center. We sought to characterize the effect of the pandemic on neurotraumas, given the cancellation of nonessential activities during the crisis.

Methods: Retrospective and prospective reviews were performed from November 2019 to April 2020. General demographics, clinical status, mechanism of trauma, diagnosis, and treatment instituted were recorded. We dichotomized the data between pre-COVID-19 (before 1 March) and COVID-19 periods and compared the differences between the 2 groups. We present the timeline of events since the beginning of the crisis in relation to the number of neurotraumas.

Results: A total of 150 patients composed our cohort with a mean age of 66.2 years (standard deviation ±18.9), and 66% were male. More males sustained neurotrauma in the COVID-19 period compared with the pre-COVID-19 (60.4% vs. 77.6%, P = 0.03). The most common mechanism of trauma was mechanical fall, but it was observed less frequently compared with the pre-COVID-19 period (61.4% vs. 40.8; P = 0.03). Subdural hematoma, traumatic subarachnoid hemorrhage, and intracerebral contusion accounted for the most common pathologies in both periods. Nonoperative management was selected for most patients (79.2 vs. 87.8%, P = 0.201) in both periods.

Conclusions: A decrease in the frequency of neurotraumas was observed during the COVID-19 crisis concomitant with the increase in COVID-19 patients in the city. This trend began after the cancellation of nonessential activities and implementation of social distancing recommendations.
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http://dx.doi.org/10.1016/j.wneu.2020.07.155DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7383169PMC
November 2020

By the Numbers Analysis of Effect of COVID-19 on a Neurosurgical Residency at the Epicenter.

World Neurosurg 2020 10 17;142:e434-e439. Epub 2020 Jul 17.

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

Background: The severe acute respiratory syndrome coronavirus 2 pandemic has created challenges to neurosurgical patient care. Despite editorials evaluating neurosurgery responses to 2019 novel coronavirus disease (COVID-19), data reporting effects of COVID-19 on neurosurgical case volume, census, and resident illness are lacking. The aim of this study was to present a real-world analysis of neurosurgical volumes, resident deployment, and unique challenges encountered during the severe acute respiratory syndrome coronavirus 2 outbreak peak in New York City.

Methods: Daily census and case volume data were prospectively collected throughout the severe acute respiratory syndrome coronavirus 2 outbreak in spring 2020. Neurosurgical census was compared against COVID-19 system-wide data. Neurosurgical cases during the crisis were analyzed and compared with 7-week periods from 2019 and early 2020. Resident deployment and illness were reviewed.

Results: From March 16, 2020, to May 5, 2020, residents participated in 72 operations and 69 endovascular procedures compared with 448 operations and 253 endovascular procedures from January 2020 to February 2020 and 530 operations and 340 endovascular procedures from March 2019 to May 2019. There was a 59% reduction in neurosurgical census during the outbreak (median 24 patients, 2.75 average total cases daily). COVID-19 neurosurgical admissions peaked in concert with the system-wide pandemic. Three residents demonstrated COVID-19 symptoms (no hospitalizations occurred) for a total 24 workdays lost (median 7 workdays).

Conclusions: These data provide real-world guidance on neurosurgical infrastructure needs during a COVID-19 outbreak. While redeployment to support the COVID-19 response was required, a significant need remained to continue to provide critical neurosurgical service.
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http://dx.doi.org/10.1016/j.wneu.2020.07.063DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7367024PMC
October 2020

Embolic Agents and Microcatheters for Endovascular Treatment of Cerebral Arteriovenous Malformations.

World Neurosurg 2020 09 24;141:383-388. Epub 2020 Jun 24.

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

Endovascular embolization of cerebral arteriovenous malformations (AVMs) originally entailed delivery of N-butyl cyanoacrylate glue to the nidus via a flow-directed microcatheter. Within the past decade, several new liquid embolic agents and novel microcatheter technologies have become available that have improved the ease of use and efficacy of endovascular therapies for AVMs. Nonadhesive copolymers, such as Onyx and Precipitating Hydrophobic Injectable Liquid, have largely replaced N-butyl cyanoacrylate given a lower risk of catheter entrapment. The emergence of balloon microcatheters has allowed for improved protection of the normal cerebral vasculature and has improved the penetration of liquid embolics into large AVMs, ultimately reducing procedure times and radiation exposure. Finally, several detachable tip microcatheters have been developed to facilitate removal of the catheter from hardened liquid embolic cast, preventing the morbidity associated with distal catheter entrapment. This article reviews the embolic agents and microcatheters currently available for the treatment of cerebral AVMs in the United States as well as the data demonstrating the safety and efficacy of these devices.
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http://dx.doi.org/10.1016/j.wneu.2020.06.118DOI Listing
September 2020

Neurological manifestations of pediatric multi-system inflammatory syndrome potentially associated with COVID-19.

Childs Nerv Syst 2020 08 25;36(8):1579-1580. Epub 2020 Jun 25.

Department of Neurosurgery, Mount Sinai Health System, 1468 Madison Avenue, Annenberg 8th Floor, New York, NY, 10029, USA.

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http://dx.doi.org/10.1007/s00381-020-04755-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7314616PMC
August 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

Trends in United States neurosurgery residency education and training over the last decade (2009-2019).

Neurosurg Focus 2020 03;48(3):E6

1Department of Neurological Surgery, Icahn School of Medicine at Mount Sinai Hospital, New York, New York; and.

Objective: Postgraduate training in medicine has been under scrutiny in the last 10 years, with a focus on improving residents' education. The aim of this study was to quantify trends in neurosurgery residency (NSR) training and education over the last 10 years.

Methods: The authors assessed Accreditation Council for Graduate Medical Education (ACGME), National Resident Matching Program, and American Board of Neurological Surgeons records and searched PubMed to collate 2009-2019 data. Analyzed trends included residents' demographic data, programs' characteristics, graduation and attrition rates, match data, resident case logs, and qualitative educational curriculum changes.

Results: Significant increases in residents' demographic data (p < 0.05) included the number of female residents (from 12.7% to 17.6%) and the absolute number of residents (from 1112 to 1462). Age (mean 28.8 years), ethnicity, and number of residents per program (mean 13 residents per program) were unchanged. There were 16 new ACGME NSR programs, with currently 115 programs nationwide. The number of applicants per year (324 applicants per year) and the matching rate (mean 64%) remained stable. The mean attrition rate of 2.6% (range 2%-4%) was higher than the mean 2.1% ACGME attrition rate, a rate that decreased from 3% in 2009 to 1.6% in 2019. Education curriculum changes aimed at the standardization of training across the US included residents' boot camp (2009), the Milestones project (2012), and mandatory 7-year training initiated in 2013. An increase in endovascular, functional, trauma, and spine resident caseload was noted. The number of yearly publications about US NSR education has significantly increased (p < 0.05).

Conclusions: NSR education has received greater attention over the last decade in the US. Standardization of training has been implemented. A steady number of students remain interested in neurosurgery, with an increased number of women entering the field. Attention to wellness, in addition to high-quality education, should be further assessed as a factor to improve the overall NSR training and retention rate.
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http://dx.doi.org/10.3171/2019.12.FOCUS19827DOI Listing
March 2020

Mortality reduction after thrombectomy for acute intracranial large vessel occlusion: meta-analysis of randomized trials.

J Neurointerv Surg 2020 Jun 29;12(6):568-573. Epub 2019 Oct 29.

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

Background: Thrombectomy for patients with emergent large vessel occlusion (ELVO) is currently recognized as the standard of care for appropriately selected patients. As proven in several randomized clinical trials and meta-analyses, treatment with thrombectomy lowers rates of poor functional outcomes after ELVO, compared with standard medical management. However, combined mortality rates of the most recent, high-quality clinical trials have not been collectively assessed.

Objective: The goal of this study was to assess the combined mortality rates of patients with ELVO following thrombectomy using data from the most recent, high-quality clinical trials.

Methods: Meta-analysis was performed in clinical trials comparing thrombectomy and medical management for patients with anterior circulation ELVO. Cumulative rates of mortality (mRS 6) as well as mortality or severe disability (mRS 5-6) were calculated.

Results: Ten clinical trials fit the inclusion criteria, including PISTE, REVASCAT, DAWN, THRACE, SWIFT PRIME, ESCAPE, DEFUSE 3, THERAPY, EXTEND-IA, and MR CLEAN, with 2233 patients assessed for mortality alone and 2229 for mortality or severe disability. There was a significantly reduced risk of death with thrombectomy compared with standard medical care (14.9% vs 18.3%, P=0.03; RR 0.81, 95% CI 0.67 to 0.98), as well as a reduced risk of mortality or severe disability (mRS 5-6) in ELVO patients treated with thrombectomy (21.1% vs 30.5%, P<0.0001; RR 0.69, 95% CI 0.60 to 0.80).

Conclusions: Overall, these results suggest a lower risk of death, as well as death or severe disability, in patients with ELVO treated with thrombectomy compared with medical management alone.
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http://dx.doi.org/10.1136/neurintsurg-2019-015383DOI Listing
June 2020

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

Patterns of Health Care Costs Due to External Ventricular Drain Infections.

World Neurosurg 2019 Aug 28;128:e31-e37. Epub 2019 Mar 28.

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

Background: External ventricular drain (EVD) infections are a significant cause of morbidity among neurosurgical patients and have been correlated with increased length of hospital stay and longer requirements for intensive care. To date, no studies have examined the financial impact of EVD infections.

Methods: Patients who underwent EVD placement between December 2010 and January 2016 were included in the study. Clinical records were retrospectively reviewed and health care cost data were obtained from the hospital's finance department. Clinical information included patient demographics, details from the hospital course, and outcomes. Total costs, direct/indirect, and fixed/variable costs were analyzed for every patient.

Results: Over the 5-year study period, 246 EVDs were placed in 243 patients with an overall infection rate of 9.9% (N = 24). The median EVD duration for infected versus noninfected patients was 19 and 9 days, respectively (P < 0.0001). Median length of intensive care unit stay also was increased for patients with EVD infection (30 days vs. 13 days, P < 0.0001). Total health care costs were significantly greater for infected patients (US$ 168,692 vs. US$ 83,919, P < 0.0001). This trend was comparable for all other cost subtypes, including fixed-direct costs, fixed-indirect costs, variable direct costs, and variable-indirect costs.

Conclusions: EVD infection has a substantial effect on clinical morbidity and healthcare costs. These results demonstrate the imperative need to improve EVD infection prevention, particularly in the setting of a value-based health care system.
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http://dx.doi.org/10.1016/j.wneu.2019.03.197DOI Listing
August 2019

Commentary: Neurosurgery and the Ongoing American Opioid Crisis.

Neurosurgery 2018 04;82(4):E79-E90

Mount Sinai Hospital, New York, New York.

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http://dx.doi.org/10.1093/neuros/nyx584DOI Listing
April 2018

Prospective analysis of atypical epithelial cells as a high-risk cytologic feature for malignancy in pancreatic cysts.

Cancer Cytopathol 2013 Jan 6;121(1):29-36. Epub 2012 Nov 6.

Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts 01907, USA.

Background: Pancreatic cysts are aspirated to assess whether a cyst is mucinous on one hand and malignant on the other. The authors' retrospective data have indicated that high-grade atypical epithelial cells (AECs) identified on cytology are a high-risk feature and a better threshold than "positive" for detecting malignancy. The objective of the current study was to assess the accuracy of AECs in predicting malignancy in pancreatic cysts.

Methods: Cysts aspirated by endoscopic ultrasound (EUS)-guided fine-needle aspiration (EUS-FNAs) obtained between January 2006 and June 2011 were evaluated. Cytologic, histologic, imaging, and cyst fluid analysis data were recorded. AECs were defined as cells that had an increased nuclear-to-cytoplasmic ratio and nuclear hyperchromasia with or without membrane abnormalities and with or without cytoplasmic vacuoles, but of insufficient quality and quantity for a "positive" interpretation. Malignancy included mucinous cysts with high-grade dysplasia and invasive carcinoma. Performance characteristics of cytology with AECs or worse (high-grade atypia [HGA]) for predicting malignancy were assessed.

Results: There were 70 FNAs that had histologic confirmation from 404 EUS-FNAs in 352 patients. Excluding 4 nondiagnostic FNAs, the study cohort consisted of 66 FNAs for analysis. There were 24 malignant cysts with 20 true-positive, 4 false-negative, 36 true-negative, and 6 false-positive results. For the detection of malignancy, HGA had 83% sensitivity, 86% specificity, a positive predictive value of 77%, a negative predictive value of 90%, and 85% overall accuracy. The lower threshold for malignancy with AECs resulted in a 12% increase in the detection of malignancy.

Conclusions: A finding of AECs on cytology is a high-risk feature for malignancy and is an accurate triage threshold for resection. Cancer (Cancer Cytopathol) 2013;121:29-36 © 2012 American Cancer Society.
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http://dx.doi.org/10.1002/cncy.21242DOI Listing
January 2013

Cytological analysis of small branch-duct intraductal papillary mucinous neoplasms provides a more accurate risk assessment of malignancy than symptoms.

Cytojournal 2011 21;8:21. Epub 2011 Nov 21.

Department of Pathology, Division of Gastroenterology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States.

Objectives: The Sendai guidelines for management of patients with clinically suspected intraductal papillary mucinous neoplasms (IPMN) recommend resection of cysts > 30 mm, a dilated main pancreatic duct (MPD) > 6 mm, a mural nodule (MN), symptoms or positive cytology. Although sensitive, asymptomatic cysts, nonspecific symptoms, and a high threshold for positive cytology limit the specificity of the guidelines. We have assessed the value of cytology relative to symptom for predicting malignancy in IPMNs without high-risk imaging features.

Materials And Methods: We retrospectively reviewed the clinical, radiological, and cytological data of 31 small branch-duct IPMNs without a MN. The cytological presence of high-grade atypical epithelial cells (HGA) was considered true positive, with a corresponding histology of high-grade dysplasia or invasive carcinoma. The performance of cytology versus symptoms was evaluated by calculating the sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), and accuracy.

Results: The sensitivity (0.80), specificity (0.85), and accuracy (0.84) of HGA were higher than the corresponding performance characteristics of symptoms (0.60, 0.45, and 0.48, respectively). The NPV of no HGA on cytology was > 95%.

Conclusions: Cytology is a better predictor of malignancy than symptoms, for the conservative management of small branch-duct IPMNs. Cytology contributes to a highly accurate triple negative test for malignancy in small IPMN: No dilated MPD, MN or HGA.
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http://dx.doi.org/10.4103/1742-6413.90084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3229770PMC
August 2012

Amyloid goiter.

Diagn Cytopathol 2010 Oct;38(10):742-3

Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, USA.

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http://dx.doi.org/10.1002/dc.21250DOI Listing
October 2010

Emperipolesis in Rosai-Dorfman disease presenting as a peritonsillar mass.

Diagn Cytopathol 2010 May;38(5):349-50

Department of Pathology, Massachusetts General Hospital, Boston, Massachusetts 02114, USA.

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http://dx.doi.org/10.1002/dc.21175DOI Listing
May 2010