Publications by authors named "Pui Man Rosalind Lai"

31 Publications

Direct vs Indirect Revascularization in a North American Cohort of Moyamoya Disease.

Neurosurgery 2021 May 6. Epub 2021 May 6.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Background: In adults with ischemic moyamoya disease (MMD), the efficacy of direct vs indirect revascularization procedures remains a matter of debate.

Objective: To investigate the outcomes of ischemic MMD in a North American cohort treated by direct and indirect revascularizations.

Methods: We retrospectively reviewed medical records of adult patients with MMD with ischemic presentation from 1984 to 2018 at the Brigham and Women's Hospital and Massachusetts General Hospital who underwent either direct or indirect bypasses. Early postoperative events and outcome at more than 6 mo postoperatively were evaluated using multivariable logistic regression analyses. Multivariable Cox proportional hazards regression analyses were used to evaluate delayed ischemic and hemorrhagic events. Analyses were performed per hemisphere.

Results: A total of 95 patients with MMD and 127 hemispheres were included in this study. A total of 3.5% and 8.6% of patients had early surgical complications in the direct and indirect bypass cohorts, respectively (P = .24). Hemispheres with direct bypasses had fewer long-term ischemic and hemorrhagic events at latest follow-up (adjusted hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.058-0.63, P = .007; median follow-up 4.5 [interquartile range, IQR 1-8] yr). There was no difference between the direct and indirect bypass groups when the endpoint was limited to infarction and hemorrhage only (P = .12). There was no difference in outcome (modified Rankin Scale [mRS] ≥ 3) between the 2 cohorts (P = .92).

Conclusion: There was no difference in early postoperative events, long-term infarction or hemorrhage, or clinical outcome between direct and indirect revascularization. However, there was a significant decrease in all ischemic and hemorrhagic events combined in direct revascularizations compared to indirect revascularizations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyab156DOI Listing
May 2021

Tobacco use and age are associated with different morphologic features of anterior communicating artery aneurysms.

Sci Rep 2021 Feb 26;11(1):4791. Epub 2021 Feb 26.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.

We present a cohort of patients with anterior communicating artery (ACoA) aneurysms to investigate morphological characteristics and clinical factors associated with rupture of the aneurysms. 505 patients with ACoA aneurysms were identified at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016, with available CT angiography (CTA). Three-dimensional (3D) reconstructions were performed to evaluate aneurysmal morphologic features, including location, projection, irregularity, the presence of daughter dome, height, height/width ratio, and relationships between surrounding vessels. Patient risk factors assessed included patient age, sex, tobacco use, alcohol use, and family history of aneurysms and aneurysmal subarachnoid hemorrhage. Logistic regression was used to build a predictive ACoA score for rupture. Morphologic features associated with ruptured ACoA aneurysms were the presence of a daughter dome (OR 21.4, 95% CI 10.6-43.1), smaller neck diameter (OR 0.55, 95% CI 0.42-0.71), larger aspect ratio (OR 3.57, 95% CI 2.05-6.24), larger flow angle (OR 1.03, 95% CI 1.02-1.05), and smaller ipsilateral A2-ACoA angle (OR 0.98, 95% CI 0.97-1.00). Tobacco use was predominantly associated with morphological factors intrinsic to the aneurysm that were associated with rupture while younger age was also associated with morphologic features extrinsic to the aneurysm that were associated with rupture. The ACoA score had good predictive capacity for rupture with AUC = 0.92 using the 0.632 bootstrap cross-validation for correction of overfitting bias. Ruptured ACoA aneurysms were associated with morphological features that are simple to assess using a simple scoring system. Tobacco use and younger age were predominantly associated with intrinsic and extrinsic morphological features characteristic of rupture, respectively.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41598-021-84315-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7910488PMC
February 2021

Onyx embolization for dural arteriovenous fistulas: a multi-institutional study.

J Neurointerv Surg 2021 Feb 25. Epub 2021 Feb 25.

Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois, USA.

Background: Although the liquid embolic agent, Onyx, is often the preferred embolic treatment for cerebral dural arteriovenous fistulas (DAVFs), there have only been a limited number of single-center studies to evaluate its performance.

Objective: To carry out a multicenter study to determine the predictors of complications, obliteration, and functional outcomes associated with primary Onyx embolization of DAVFs.

Methods: From the Consortium for Dural Arteriovenous Fistula Outcomes Research (CONDOR) database, we identified patients who were treated for DAVF with Onyx-only embolization as the primary treatment between 2000 and 2013. Obliteration rate after initial embolization was determined based on the final angiographic run. Factors predictive of complete obliteration, complications, and functional independence were evaluated with multivariate logistic regression models.

Results: A total 146 patients with DAVFs were primarily embolized with Onyx. Mean follow-up was 29 months (range 0-129 months). Complete obliteration was achieved in 80 (55%) patients after initial embolization. Major cerebral complications occurred in six patients (4.1%). At last follow-up, 84% patients were functionally independent. Presence of flow symptoms, age over 65, presence of an occipital artery feeder, and preprocedural home anticoagulation use were predictive of non-obliteration. The transverse-sigmoid sinus junction location was associated with fewer complications, whereas the tentorial location was predictive of poor functional outcomes.

Conclusions: In this multicenter study, we report satisfactory performance of Onyx as a primary DAVF embolic agent. The tentorium remains a more challenging location for DAVF embolization, whereas DAVFs located at the transverse-sigmoid sinus junction are associated with fewer complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2020-017109DOI Listing
February 2021

Morphological variables associated with ruptured basilar tip aneurysms.

Sci Rep 2021 Jan 28;11(1):2526. Epub 2021 Jan 28.

Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.

Morphological factors of intracranial aneurysms and the surrounding vasculature could affect aneurysm rupture risk in a location specific manner. Our goal was to identify image-based morphological parameters that correlated with ruptured basilar tip aneurysms. Three-dimensional morphological parameters obtained from CT-angiography (CTA) or digital subtraction angiography (DSA) from 200 patients with basilar tip aneurysms diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016 were evaluated. We examined aneurysm wall irregularity, the presence of daughter domes, hypoplastic, aplastic or fetal PCoAs, vertebral dominance, maximum height, perpendicular height, width, neck diameter, aspect and size ratio, height/width ratio, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine statistical significance. In multivariable analysis, presence of a daughter dome, aspect ratio, and larger flow angle were significantly associated with rupture status. We also introduced two new variables, diameter size ratio and parent-daughter angle ratio, which were both significantly inversely associated with ruptured basilar tip aneurysms. Notably, multivariable analyses also showed that larger diameter size ratio was associated with higher Hunt-Hess score while smaller flow angle was associated with higher Fisher grade. These easily measurable parameters, including a new parameter that is unlikely to be affected by the formation of the aneurysm, could aid in screening strategies in high-risk patients with basilar tip aneurysms. One should note, however, that the changes in parameters related to aneurysm morphology may be secondary to aneurysm rupture rather than causal.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41598-021-81364-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7844275PMC
January 2021

Geometric variations associated with posterior communicating artery aneurysms.

J Neurointerv Surg 2021 Jan 21. Epub 2021 Jan 21.

Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA

Background: Hemodynamic stress, conditioned by the morphology of the surrounding vasculature, plays an important role in aneurysm formation. Our goal was to identify image-based location-specific parameters that are associated with posterior communicating artery (PCoA) aneurysms.

Methods: Three-dimensional morphological parameters obtained from CT angiography or digital subtraction angiography from 187 patients with unilateral PCoA aneurysms, diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016, were evaluated. In order to control for genetic and clinical risk factors, we chose the contralateral unaffected PCoA as a control group. We examined diameters and angles of the surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine statistical significance. Sensitivity analyses with small aneurysms (≤5 mm) only and an unmatched analysis of 432 PCoA aneurysms and 197 control patients without PCoA aneurysms were also performed.

Results: In a multivariable conditional logistic regression model we showed that smaller diameter size ratio (OR 1.45×10, 95% CI 1.12×10 to 1.88×10) and larger daughter-daughter angle (OR 1.04, 95% CI 1.02 to 1.07) were significantly associated with PCoA aneurysm presence after correcting for other variables. In subgroup analyses of small aneurysms (≤5 mm) and in an unmatched analysis the significance and direction of these results were preserved.

Conclusions: Larger daughter-daughter angles and smaller diameter size ratio are significantly associated with the presence of PCoA aneurysms. These simple parameters can be utilized to guide the risk assessment for the formation of PCoA aneurysms in high risk patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/neurintsurg-2020-017062DOI Listing
January 2021

Vascular Geometry Associated with Anterior Communicating Artery Aneurysm Formation.

World Neurosurg 2021 Feb 9;146:e1318-e1325. Epub 2020 Dec 9.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Channing Division of Network Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: To identify clinical and morphologic risk factors correlated with anterior communicating artery (ACoA) aneurysm formation.

Methods: Three-dimensional morphologic parameters obtained from computed tomography angiography or digital subtraction angiography from 504 patients with ACoA aneurysms and 201 patients with aneurysms in other locations that were diagnosed at Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016 were evaluated. The presence of hypoplastic and aplastic A1 segments and diameters and angles of surrounding parent and daughter vessels were examined. Univariable and multivariable statistical analyses were performed to determine statistical significance. Sensitivity analyses for small (≤3 mm) aneurysms only were also performed.

Results: Aplastic and hypoplastic A1 segments were more common in the ACoA group (38.9% vs. 6.5% hypoplastic and 22.2% vs. 0.5% aplastic). In multivariable analysis, the presence of a hypoplastic A1 segment was associated with ACoA aneurysms. An A2-ACoA (daughter-daughter) angle was also significantly associated with ACoA aneurysms in multivariable analysis; however, as Pearson's correlation test between aneurysm width and daughter-daughter angle was significant, the daughter-daughter angle was most likely not independently associated with aneurysm presence, but rather might have been a result of the presence of an aneurysm. Subgroup analyses of small aneurysms (≤3 mm) and of unruptured aneurysms showed similar results.

Conclusions: Our results demonstrate that of all the morphologic parameters, the presence of a hypoplastic A1 segment was the only parameter independently associated with the presence of ACoA aneurysms that was not correlated with aneurysm size and could aid as a simple screening parameter.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.11.160DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7897254PMC
February 2021

Surrounding vascular geometry associated with basilar tip aneurysm formation.

Sci Rep 2020 10 21;10(1):17928. Epub 2020 Oct 21.

Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, USA.

Hemodynamic stress is thought to play an important role in the formation of intracranial aneurysms, which is conditioned by the geometry of the surrounding vasculature. Our goal was to identify image-based morphological parameters that were associated with basilar artery tip aneurysms (BTA) in a location-specific manner. Three-dimensional morphological parameters obtained from CT-angiography (CTA) or digital subtraction angiography (DSA) from 207 patients with BTAs and a control group of 106 patients with aneurysms elsewhere to control for non-morphological factors, who were diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016, were evaluated. We examined the presence of hypoplastic, aplastic or fetal PCoAs, vertebral dominance, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine statistical significance. Sensitivity analyses with small (≤ 3 mm) aneurysms only and with angles excluded, were also performed. In multivariable analysis, daughter-daughter angle was directly, and parent artery diameter and diameter size ratio were inversely associated with BTAs. These results remained significant in the subgroup analysis of small aneurysms (width ≤ 3 mm) and when angles were excluded. These easily measurable and robust parameters that are unlikely to be affected by aneurysm formation could aid in risk stratification for the formation of BTAs in high-risk patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41598-020-74266-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7578056PMC
October 2020

Familial Predisposition and Differences in Radiographic Patterns in Spontaneous Nonaneurysmal Subarachnoid Hemorrhage.

Neurosurgery 2021 01;88(2):413-419

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.

Background: Subarachnoid hemorrhage (SAH) from an intracranial aneurysmal rupture is the most common nontraumatic etiology for SAH, but up to 15% of patients with SAH have no identifiable source.

Objective: To assess familial predisposition to spontaneous nonaneurysmal SAH (naSAH) and to evaluate whether family history affects the severity of presentation and prognosis of this condition.

Methods: We conducted a retrospective analysis of all spontaneous SAH with negative digital subtraction angiography from 2004 to 2018. Patients were divided into 2 groups: patients with first- or second-degree relatives with intracranial aneurysms and patients with no family history. Univariate and multivariate regression analyses were used to study patient presentation, radiographic patterns of hemorrhage, and clinical outcome.

Results: A total of 100 patients met the inclusion criteria. There were no individuals with family history of naSAH. A total of 15 patients (15%) had at least one family member with an intracranial aneurysm, of which 12 (12%) presented as SAH. Patients without family history had a higher percentage of perimesencephalic presentation, whereas those with family history had a higher percentage of nonperimesencephalic SAH presentation (47% vs 13%, odds ratio [OR] 0.17 [95% CI 0.04, 0.81]).

Conclusion: We found a high rate of family history of intracranial aneurysms in patients who presented with naSAH. Although there was no difference in clinical outcome in patients with and without family history, there appears to be a higher percentage of nonperimesencephalic radiographic patterns of SAH in those with family history, suggesting possible different etiologies of these hemorrhages.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyaa396DOI Listing
January 2021

Return to Driving Is a Better Predictor of Patient Outcome Than Return to Work After Aneurysmal Subarachnoid Hemorrhage.

World Neurosurg 2020 12 20;144:e285-e295. Epub 2020 Aug 20.

Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: Return to work and driving are major rehabilitation goals for patients after an aneurysmal subarachnoid hemorrhage (aSAH). Our goal is to identify factors that may predict return to work or driving after aSAH.

Methods: Medical records of patients with aSAH were retrospectively reviewed from 2010 to 2018. Information on return to work and driving were prospectively collected. Univariate analyses were performed to assess the association between return to work or driving with patient characteristics, social factors, and admission clinical and radiographic severity. Multivariate regression models were used to evaluate return to work and driving and generate predictive models.

Results: A total of 193 patients were included, of whom 32% (62/193) resumed work and 57% (110/193) returned to driving. Median follow-up time was 3.4 years (interquartile range, 0.7-7.5 years). Return to work was associated with younger age (odds ratio [OR], 0.89; 95% CI, 0.85-0.94), lower Hunt and Hess grade (OR, 0.34; 95% CI, 0.23-0.54), and lack of seizures (OR, 0.09; 95% CI, 0.02-0.47). Return to driving was associated with younger age (OR, 0.94; 95% CI, 0.91-0.98), lower Hunt and Hess grade (OR, 0.36; 95% CI, 0.23-0.56), married status (OR, 3.4; 95% CI, 1.2-9.4), current or former smoking (OR, 3.9; 95% CI, 1.5-10.1), lack of recreational drug use (OR, 0.08; 95% CI, 0.01-0.77), and lack of seizures (OR, 0.28; 95% CI, 0.08-0.96). Admission risk factors were predictive of return to driving and return to work in the final multivariate models generated (area under the receiver operating characteristic curve 88% vs. 89%, respectively).

Conclusions: Because work may be highly dependent on complex individual and social factors, driving is a simple and more accurate assessment for an individual's status after aSAH.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.08.113DOI Listing
December 2020

Age and morphology of posterior communicating artery aneurysms.

Sci Rep 2020 07 14;10(1):11545. Epub 2020 Jul 14.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.

Risk of intracranial aneurysm rupture could be affected by geometric features of intracranial aneurysms and the surrounding vasculature in a location specific manner. Our goal is to investigate the morphological characteristics associated with ruptured posterior communicating artery (PCoA) aneurysms, as well as patient factors associated with the morphological parameters. Three-dimensional morphological parameters in 409 patients with 432 PCoA aneurysms diagnosed at the Brigham and Women's Hospital and Massachusetts General Hospital between 1990 and 2016 who had available CT angiography (CTA) or digital subtraction angiography (DSA) were evaluated. Morphological parameters examined included aneurysm wall irregularity, presence of a daughter dome, presence of hypoplastic or aplastic A1 arteries and hypoplastic or fetal PCoA, perpendicular height, width, neck diameter, aspect and size ratio, height/width ratio, and diameters and angles of surrounding parent and daughter vessels. Univariable and multivariable statistical analyses were performed to determine the association of morphological parameters with rupture of PCoA aneurysms. Additional analyses were performed to determine the association of patient factors with the morphological parameters. Irregular, multilobed PCoA aneurysms with larger height/width ratios and larger flow angles were associated with ruptured PCoA aneurysms, whereas perpendicular height was inversely associated with rupture in a multivariable model. Older age was associated with lower aspect ratio, with a trend towards lower height/width ratio and smaller flow angle, features that are associated with a lower rupture risk. Morphological parameters are easy to assess and could help in risk stratification in patients with unruptured PCoA aneurysms. PCoA aneurysms diagnosed at older age have morphological features associated with lower risk.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41598-020-68276-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360743PMC
July 2020

The Ruptured Arteriovenous Malformation Grading Scale (RAGS): An Extension of the Hunt and Hess Scale to Predict Clinical Outcome for Patients With Ruptured Brain Arteriovenous Malformations.

Neurosurgery 2020 08;87(2):193-199

Department of Neurosurgery, Brigham and Women's Hospital, School of Medicine, Harvard University, Boston, Massachusetts.

Background: Arteriovenous malformation (AVM) rupture is highly morbid. Outcomes after AVM rupture differ from other types of brain hemorrhage. There are no specific widely used grading systems designed to predict clinical outcome after AVM rupture.

Objective: To develop an all-comers scoring system to grade patients with AVM rupture and predict clinical outcome more accurately than grading systems currently in use.

Methods: We retrospectively reviewed patients who presented to our institution with a ruptured AVM. Using change in modified Rankin Score (mRS) as our response variable, we generated an ordinal logistic regression model to test for significant predictor variables. The full model was sequentially condensed until the simplest model with the highest area under the receiver operating curve (AUROC) was achieved.

Results: A total of 115 patients who presented with ruptured AVMs were included in the study, with a mean follow-up time of 4 yr. The Ruptured AVM Grading Scale (RAGS) consists of the Hunt and Hess (HH) score (1-5), patient age (<35 = 0, 35-70 = 1, and >70 = 2), deep venous drainage (1), and eloquence (1). The RAGS score outperformed other neurosurgical grading scales in predicting change in mRS, with an AUROC greater than 0.80 across all follow-up periods.

Conclusion: The RAGS score is a simple extension of the HH scale that predicts clinical outcome after AVM rupture more accurately than other grading systems.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyz404DOI Listing
August 2020

Age-Dependent Radiographic Vasospasm and Delayed Cerebral Ischemia in Women After Aneurysmal Subarachnoid Hemorrhage.

World Neurosurg 2019 Oct 13;130:e230-e235. Epub 2019 Jun 13.

Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: Recent literature suggests there are sex differences in delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Our study serves to compare sex differences in radiographic vasospasm, DCI, and clinical outcome after aSAH, and to determine whether there are age-dependent differences.

Methods: A total of 328 patients with ruptured cerebral aneurysms were evaluated for radiographic vasospasm, clinical deterioration, cerebral infarction, and modified Rankin Scale-determined clinical outcome at 6 months to 1 year after rupture. Multivariate regression analyses were performed to evaluate the associations between these outcome measures and sex, adjusting for age, hypertension, aneurysm location, admission Hunt and Hess grade, and modified Fisher grade.

Results: After multivariate adjustment, women had higher rates of radiographic vasospasm (β = 0.35; 95% confidence interval [CI], 0.068-0.63; P = 0.015), clinical deterioration (odds ratio [OR], 2.8; 95% CI, 1.3-6.0; P = 0.008) and cerebral infarction (OR, 2.4; 95% CI, 1.0-5.5; P = 0.039), but no difference was observed in follow-up modified Rankin Scale (mRS) outcome score at 6 months to 1 year (P = 0.96). Older women (age >55 years) have a higher rate of clinical deterioration than men in the same age group (OR, 3.5; 95% CI, 1.0-12; P = 0.043). In contrast, younger women (age ≤55 years) had increased radiographic vasospasm (β = 0.55; 95% CI, 0.17-0.93; P = 0.005) and worse mRS outcome score (β = 0.042; 95% CI, -0.021 to 1.1; P = 0.042) compared with men.

Conclusions: Female sex is associated with a higher risk of radiographic vasospasm, clinical deterioration, and cerebral infarction. Furthermore, this association appears to be age-dependent. This study further supports the unique role of sex, and highlights the need to better understand the possible role of female hormones in the development of complications of subarachnoid hemorrhage.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.06.040DOI Listing
October 2019

Decreased Total Iron Binding Capacity May Correlate with Ruptured Intracranial Aneurysms.

Sci Rep 2019 04 15;9(1):6054. Epub 2019 Apr 15.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.

Iron and its derivatives play a significant role in various physiological and biochemical pathways, and are influenced by a wide variety of inflammatory, infectious, and immunological disorders. We hypothesized that iron and its related factors play a role in intracranial aneurysm pathophysiology and investigated if serum iron values are associated with ruptured intracranial aneurysms. 4,701 patients with 6,411 intracranial aneurysms, including 1201 prospective patients, who were diagnosed at the Massachusetts General Hospital and Brigham and Women's Hospital between 1990 and 2016 were evaluated. A total of 366 patients with available serum iron, ferritin and total iron binding capacity (TIBC) values were ultimately included in the analysis. 89% of included patients had anemia. Patients were categorized into ruptured and non-ruptured groups. Univariable and multivariable logistic regression analyses were performed to determine the association between ruptured aneurysms and iron, ferritin, and TIBC. TIBC values (10 g/L) within 1 year of diagnosis (OR 0.41, 95% CI 0.28-0.59) and between 1 and 3 years from diagnosis (OR 0.52, 95% CI 0.29-0.93) were significantly and inversely associated with intracranial aneurysm rupture. In contrast, serum iron and ferritin were not significant. In this case-control study, low TIBC was significantly associated with ruptured aneurysms, both in the short- and long term. However, this association may not apply to the general population as there may be a selection bias as iron studies were done in a subset of patients only.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41598-019-42622-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6465340PMC
April 2019

Differentially Expressed Genes Associated with the Estrogen Receptor Pathway in Cerebral Aneurysms.

World Neurosurg 2019 Jun 2;126:e557-e563. Epub 2019 Mar 2.

Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Background: The pathophysiology of cerebral aneurysm formation remains to be elucidated. Estrogen is thought to be protective against the development of aneurysms. The aim of this study is to identify differentially expressed genes in the estrogen receptor pathway that may be linked to the development of cerebral aneurysms.

Methods: Data from 6 Gene Expression Omnibus (GEO) databases with gene expression profiles of cerebral aneurysm tissue were analyzed (GSE6551, GSE15629, GSE26969, GSE46337, GSE54083, and GSE75436). Ninety-four genes associated with the estrogen receptor pathway were identified from the Kyoto Encyclopedia of Genes and Genomes pathway database. A meta-analysis using a random-effects model was used to evaluate the association of the estrogen receptor pathway genes with aneurysm formation.

Results: Four genes related to the estrogen receptor pathway were significantly associated with intracranial aneurysms, 2 of which were downregulated (PIK3R1: fold change [FC] = 0.41, false discovery rate [FDR] = 6.1 × 10, ADCY9: FC = 0.55, FDR = 2.3 × 10) and 2 of which were upregulated (HBEGF: FC = 1.46, FDR = 4.9 × 10; ADCY7: FC = 2.11, FDR = 6.0 × 10). Furthermore, subgroup analysis of 2 GEO databases with information provided about sex demonstrated PIK3R1 to be significant independently in both men (FC = 0.46, FDR = 6.3 × 10) and women (FC = 0.46, FDR = 2.3 × 10), whereas JUN, ADCY5, and MMP9 were significant in women only.

Conclusions: The analysis of 6 GEO databases revealed 4 differentially expressed genes (PIK3R1, HBEGF, ADCY7, and ADCY9) in cerebral aneurysm tissue that are associated with the estrogen receptor pathway. Further analysis of estrogen-associated differentially expressed genes may provide information about the protective effects of estrogen on cerebral aneurysm development.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.02.094DOI Listing
June 2019

Noninfectious Fever in Aneurysmal Subarachnoid Hemorrhage: Association with Cerebral Vasospasm and Clinical Outcome.

World Neurosurg 2019 Feb 7;122:e1014-e1019. Epub 2018 Nov 7.

Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: The purpose of this study was to evaluate the association between noninfectious fever onset and radiographic vasospasm, delayed ischemic neurologic deficit (DIND), delayed cerebral infarction (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage.

Methods: We evaluated 44 patients for the association between noninfectious fever (greater than 101.5°F) and the development of radiographic vasospasm by digital subtraction angiography (DSA) and transcranial Doppler (TCD), DIND, DCI, and modified Rankin scale outcome score at 6 months to 2 years. Multivariate logistic regression analyses were performed to account for patient age, sex, admission Hunt and Hess grade, and Fisher grade. TCD was additionally used for temporal analysis.

Results: Noninfectious fever was significantly associated with radiographic vasospasm using both DSA (odds ratio [OR], 2.2; 95% confidence interval [CI], 1.2-4.5; P = 0.02) and TCD (OR, 2.4; 95% CI, 1.2-5.6; P = 0.02), but it was not associated with DIND, DCI, or outcome. The maximum cross correlation between TCD velocity and temperature occurred for temperatures taken 1 day prior to TCD velocity measurement. A quadratic mixed-effects model demonstrated that TCD velocity was significantly associated with temperature from 1 day prior to TCD velocity measurement (β = 13.5; 95% CI, 0.83-8.79, P = 0.01), posthemorrhage day (β = 20.1; 95% CI, 2.14-7.52; P < 0.001), and (posthemorrhage day) (β = -0.72; 95% CI, -0.26 to -0.11; P < 0.001).

Conclusions: Noninfectious fever was associated with the development of radiographic vasospasm but not with DIND, DCI, or clinical outcome. Furthermore, there is a temporal association between the onset of noninfectious fever and radiographic vasospasm by 1 day. Fever independent of patient's infectious profile may be an early marker for the development of radiographic vasospasm.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2018.10.203DOI Listing
February 2019

Neurenteric cyst at the dorsal craniocervical junction in a child: Case report.

J Clin Neurosci 2018 Feb 11;48:86-89. Epub 2017 Nov 11.

Department of Neurosurgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA. Electronic address:

Neurenteric cysts, also known as enterogenous cysts, are uncommon, benign, congenital lesions that usually occur in the posterior mediastinum but can be seen at any level of the neuraxis. Here, we report a pediatric patient with a neurenteric cyst in the dorsal craniocervical junction as the only third reported pediatric case in the literature in this rare location, and describe the clinical course and pathologic findings with a review of the literature on this rare entity.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2017.10.014DOI Listing
February 2018

Cigarette smoking and outcomes after aneurysmal subarachnoid hemorrhage: a nationwide analysis.

J Neurosurg 2018 08 27;129(2):446-457. Epub 2017 Oct 27.

OBJECTIVE Although cigarette smoking is one of the strongest risk factors for cerebral aneurysm development and rupture, there are limited data evaluating the impact of smoking on outcomes after aneurysmal subarachnoid hemorrhage (SAH). Additionally, two recent studies suggested that nicotine replacement therapy was associated with improved neurological outcomes among smokers who had sustained an SAH compared with smokers who did not receive nicotine. METHODS Patients who underwent endovascular or microsurgical repair of a ruptured cerebral aneurysm were extracted from the Nationwide Inpatient Sample (NIS, 2009-2011) and stratified by cigarette smoking. Multivariable logistic regression analyzed in-hospital mortality, complications, tracheostomy or gastrostomy placement, and discharge to institutional care (a nursing or an extended care facility). Additionally, the composite NIS-SAH outcome measure (based on mortality, tracheostomy or gastrostomy, and discharge disposition) was evaluated, which has been shown to have excellent agreement with a modified Rankin Scale score greater than 3. Covariates included in regression constructs were patient age, sex, race/ethnicity, insurance status, socioeconomic status, comorbidities (including hypertension, drug and alcohol abuse), the NIS-SAH severity scale (previously validated against the Hunt and Hess grade), treatment modality used for aneurysm repair, and hospital characteristics. A sensitivity analysis was performed matching smokers to nonsmokers on age, sex, number of comorbidities, and NIS-SAH severity scale score. RESULTS Among the 5784 admissions evaluated, 37.1% (n = 2148) had a diagnosis of tobacco use, of which 31.1% (n = 1800) were current and 6.0% (n = 348) prior tobacco users. Smokers were significantly younger (mean age 51.4 vs 56.2 years) and had more comorbidities compared with nonsmokers (p < 0.001). There were no significant differences in mortality, total complications, or neurological complications by smoking status. However, compared with nonsmokers, smokers had significantly decreased adjusted odds of tracheostomy or gastrostomy placement (11.9% vs 22.7%, odds ratio [OR] 0.63, 95% confidence interval [CI] 0.51-0.78, p < 0.001), discharge to institutional care (OR 0.71, 95% CI 0.57-0.89, p = 0.002), and a poor outcome (OR 0.65, 95% CI 0.55-0.77, p < 0.001). Similar statistical associations were noted in the matched-pairs sensitivity analysis and in a subgroup of poor-grade patients (the upper quartile of the NIS-SAH severity scale). CONCLUSIONS In this nationwide study, smokers experienced SAH at a younger age and had a greater number of comorbidities compared with nonsmokers, highlighting the negative ramifications of cigarette smoking among patients with cerebral aneurysms. However, smoking was also associated with paradoxical superior outcomes on some measures, and future research to confirm and further understand the basis of this relationship is needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2016.10.JNS16748DOI Listing
August 2018

Risk factors for hyponatremia in aneurysmal subarachnoid hemorrhage.

J Clin Neurosci 2016 Oct 25;32:115-8. Epub 2016 Jul 25.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA. Electronic address:

Hyponatremia occurs commonly in patients with aneurysmal subarachnoid hemorrhage (aSAH). Our objective was to determine the time course of, and factors associated with, hyponatremia after aSAH. We performed a retrospective review of 259 patients with ruptured aneurysms at a single institution. Multivariate regression analysis was performed to determine the factors associated with hyponatremia. Increasing age was significantly associated with lower initial sodium (p=0.04) and incidence of delayed hyponatremia (p=0.01) while smoking was associated with longer duration of hyponatremia (p=0.02). Older patients should therefore be monitored closely for hyponatremia and patients who smoke should be treated more aggressively for hyponatremia given the greater frequency and longer duration of hyponatremia in these two groups, respectively.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2016.04.006DOI Listing
October 2016

Association between S100B Levels and Long-Term Outcome after Aneurysmal Subarachnoid Hemorrhage: Systematic Review and Pooled Analysis.

PLoS One 2016 23;11(3):e0151853. Epub 2016 Mar 23.

Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America.

S100 calcium binding protein B (S100B), a well-studied marker for neurologic injury, has been suggested as a candidate for predicting outcome after subarachnoid hemorrhage. We performed a pooled analysis summarizing the associations between S100B protein in serum and cerebrospinal fluid (CSF) with radiographic vasospasm, delayed ischemic neurologic deficit (DIND), delayed cerebral infarction, and Glasgow Outcome Scale (GOS) outcome. A literature search using PubMed, the Cochrane Library, and the EMBASE databases was performed to identify relevant studies published up to May 2015. The weighted Stouffer's Z method was used to perform a pooled analysis of outcome measures with greater than three studies. A total of 13 studies were included in this review. Higher serum S100B level was found to be associated with cerebral infarction as diagnosed by CT (padj = 3.1 x 10(-4)) and worse GOS outcome (padj = 5.5 x 10(-11)). There was no association found between serum and CSF S100B with radiographic vasospasm or DIND. S100B is a potential prognostic marker for aSAH outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0151853PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4805236PMC
August 2016

Role of Genetic Polymorphisms in Predicting Delayed Cerebral Ischemia and Radiographic Vasospasm After Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis.

World Neurosurg 2015 Oct 11;84(4):933-41.e2. Epub 2015 Jun 11.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: The pathophysiology on cerebral vasospasm and delayed cerebral ischemia (DCI) remains poorly understood. Much research has been dedicated to finding genetic loci associated with vasospasm and ischemia. We present a systematic review and meta-analysis to identify genetic polymorphisms associated with delayed ischemic neurologic deficit (DIND), radiographic infarction attributed to ischemia, and radiographic vasospasm.

Methods: PubMed, the Cochrane Library, and Excerpta Medica dataBASE (EMBASE) databases were used to identify relevant studies published up to March 2015 containing the subject terms cerebral or intracranial vasospasm and DCI in combination with genetics, gene, polymorphism or marker. Meta-analyses were performed using a random-effects model to calculate summary odds ratio (ORs) and 95% confidence intervals for each respective gene.

Results: Of 269 articles initially identified, 20 studies with 1670 patients were included in our comprehensive review, including 27 polymorphisms in 11 genes. The following 6 polymorphisms in 3 genes were selected for subsequent meta-analyses: apolipoprotein E (ApoE2, E4); endothelial nitric oxide (eNOS T786C, VNTR intron 4 a/b, G894T); and haptoglobin (Hp) 1/2 phenotypes. The eNOS VNTR a allele was associated with DIND (a vs. b allele: OR 1.92 [1.31-2.81], padj = 0.008). The Hp 2-2 allele was associated with radiographic vasospasm (2-2 vs. 2-1 and 1-1: OR 3.86 [1.86-8.03], padj = 0.003) but did not reach significance for DIND.

Conclusions: This is the first systemic review and meta-analysis to study and evaluate the associations between genetic polymorphism with DCI and radiographic vasospasm independently. In our study, eNOS VNTR and Hp polymorphisms appear to have the strongest associations with DIND and radiographic vasospasm, respectively.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2015.05.070DOI Listing
October 2015

Neurogenic Stress Cardiomyopathy After Aneurysmal Subarachnoid Hemorrhage.

World Neurosurg 2015 Jun 3;83(6):880-5. Epub 2015 Feb 3.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.

Background: Neurogenic stress cardiomyopathy (NSC) is a known complication of aneurysmal subarachnoid hemorrhage (SAH). Detailed analyses of risk factors for its occurrence across large cohorts are relatively sparse.

Methods: A consecutive group of 300 patients with aneurysmal SAH was reviewed for the presence of markers of myocardial injury, including electrocardiogram changes (long QT, T-wave inversion), elevated plasma troponin levels (≥0.1), and echocardiogram findings (decreased ejection fraction and wall motion abnormalities). NSC was defined as the presence of at least 1 marker of myocardial injury. Univariate and multivariate analyses were conducted to assess the correlation of NSC and individual markers of myocardial injury with age, gender, medical comorbidities, medications, current smoking status, Hunt-Hess grade, and Fisher grade. Medical comorbidities were assessed based on reported medical history or reported use of comorbidity-specific medications at the time of presentation.

Results: Across the cohort, 27% of patients had a plasma troponin elevation of at least 0.1; 13%, a prolonged QT interval; 16%, new T-wave inversions; 18%, a depressed ejection fraction (<55%); and 15%, echocardiographic wall motion abnormalities. After a multivariate analysis, significant risk factors for NSC included higher Hunt-Hess grade on presentation (odds ratio [OR] = 2.33, P = 4.52 × 10(-6)), current smoking status (OR = 2.00, P = 0.030), and older age (OR = 1.03, P = 0.048). Hypertension was protective against NSC (OR = 0.48, P = 0.031). Patient gender, hyperlipidemia, diabetes, coronary artery disease, statin use, beta blocker use, angiotensin-converting enzyme inhibitor use, aspirin use, and thicker SAH (Fisher grade 3) were not significant risk factors for NSC.

Conclusions: Higher Hunt-Hess grade, current smoking status, lack of hypertension, and older age were the strongest predictors of NSC.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2015.01.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4466211PMC
June 2015

Transient pupillary dilation following local papaverine application in intracranial aneurysm surgery.

J Clin Neurosci 2015 Apr 3;22(4):676-9. Epub 2015 Jan 3.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA. Electronic address:

Isolated cases of transient pupillary changes after local intracisternal papaverine administration during aneurysm surgery have been reported. This study aimed to determine the prevalence and factors associated with this phenomenon. We assessed a total of 103 consecutive patients who underwent craniotomy for cerebral aneurysm clipping for the presence of postoperative pupillary dilation (mydriasis) after intracisternal papaverine administration. Univariate and multivariate logistic regression were conducted to evaluate the association of mydriasis with patient age, sex, duration of surgery, and aneurysm location. We observed either ipsilateral or bilateral pupillary dilation in the immediate postoperative period in nine out of 103 patients (8.7%). This phenomenon was not associated with patient age or sex. There was a trend towards positive correlation with aneurysms located at the anterior communicating artery (odds ratio 3.76, p=0.10), and a negative correlation with the duration of surgery (odds ratio 0.57, p=0.08). All pupillary dilation resolved within several hours, and the onset and resolution were consistent with the half-life of papaverine. To our knowledge, this represents the largest study of posteropative pupillary changes due to papaverine. The current findings are consistent with the small number of prior case reports of transient pupillary changes after papaverine administration and appear to reflect the local anesthetic action of papaverine on the oculomotor nerve.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2014.10.016DOI Listing
April 2015

The association between meteorological parameters and aneurysmal subarachnoid hemorrhage: a nationwide analysis.

PLoS One 2014 13;9(11):e112961. Epub 2014 Nov 13.

Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts, United States of America; Harvard Medical School, Boston, Massachusetts, United States of America.

Prior research has suggested that regional weather patterns impact the risk of rupture of cerebral aneurysms, but the findings in the literature have been inconsistent. Furthermore, no nationwide analysis to date has examined the association between meteorological factors and the post-procedural outcomes of patients after the treatment for ruptured cerebral aneurysms. The purpose of this study was to use a nationwide sample to analyze the association between specific meteorological parameters--temperature, precipitation, sunlight, and humidity--and hospital admission rate for and outcome after aneurysmal subarachnoid hemorrhage. Patients were identified using the Nationwide Inpatient Sample (2001-2010): Those with an ICD-9 diagnosis code for subarachnoid hemorrhage and a procedural code for aneurysm repair were included. Climate data were obtained from the State of the Climate Report 2010 released by the National Climatic Data Center. Multivariate regression models were constructed to analyze the association between average state monthly temperature, precipitation, and percent possible sunlight, as well as relative morning humidity and both monthly hospital admission rate, adjusted for annual state population in millions, and in-hospital mortality. 16,970 admissions were included from 723 hospitals across 41 states. Decreased daily sunlight and lower relative humidity were associated with an increased rate of admission for ruptured cerebral aneurysms (p<0.001), but had no association with differential inpatient mortality. No significant changes in these observed associations were seen when multivariate analyses were constructed. This is the first nationwide study to suggest that decreased sunlight and lower relative humidity are associated with admission for ruptured cerebral aneurysms. While it has been postulated that external atmospheric factors may cause hormonal and homeostatic changes that impact the risk of rupture of cerebral aneurysms, additional research is needed to confirm and further understand these relationships.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0112961PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4231088PMC
December 2015

Impact of aneurysm location on hemorrhage risk.

Clin Neurol Neurosurg 2014 Aug 29;123:78-82. Epub 2014 May 29.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis St, Boston 02115, USA. Electronic address:

Introduction: Recent studies have reinforced anterior communicating (AComm) artery location as a significant risk factor for aneurysm rupture in addition to posterior circulation/posterior communicating (PComm) artery location. However, studies stratifying aneurysm location in greater detail are sparse.

Methods: We reviewed the records of 747 consecutive patients with 1013 aneurysms seen at our institution over a 7 year period, noting aneurysm location and rupture status at the time of presentation.

Results: High proportions of ruptured aneurysms were seen among frontopolar/pericallosal (59%, OR 3.07, p=0.011), vertebral/posteroinferior cerebellar (PICA; 53%, OR 2.49, p=0.0037), AComm (50%, OR 2.46, p<0.0001), and PComm aneurysms (44%, OR 1.77, p=0.0016). Low proportions of ruptured aneurysms were seen among superior hypophyseal artery (SHA; 6%, OR 0.12, p=0.0001), internal carotid artery (ICA) bifurcation (12%, OR 0.27, p=0.0012), and ophthalmic artery aneurysms (15%, OR 0.33, p=0.0002). The proportion of ruptured PComm aneurysms demonstrated a trend toward being greater than anterior choroidal artery aneurysms (OR 2.14, p=0.09); however the proportion was significantly greater among anterior choroidal artery aneurysms as compared to nonPComm intradural ICA aneurysms (OR 2.78, p=0.03). Notably, the lower rupture rate of SHA aneurysms as compared to ophthalmic artery aneurysms neared statistical significance (OR 0.38, p=0.10).

Conclusion: Aneurysm location has a significant impact on risk of rupture and should be stratified in greater detail in future studies of aneurysm natural history.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clineuro.2014.05.014DOI Listing
August 2014

The impact of insurance status on the outcomes after aneurysmal subarachnoid hemorrhage.

PLoS One 2013 29;8(10):e78047. Epub 2013 Oct 29.

Department of Neurosurgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, United States of America.

Investigation into the association of insurance status with the outcomes of patients undergoing neurosurgical intervention has been limited: this is the first nationwide study to analyze the impact of primary payer on the outcomes of patients with aneurysmal subarachnoid hemorrhage who underwent endovascular coiling or microsurgical clipping. The Nationwide Inpatient Sample (2001-2010) was utilized to identify patients; those with both an ICD-9 diagnosis codes for subarachnoid hemorrhage and a procedure code for aneurysm repair (either via an endovascular or surgical approach) were included. Hierarchical multivariate regression analyses were utilized to evaluate the impact of primary payer on in-hospital mortality, hospital discharge disposition, and length of hospital stay with hospital as the random effects variable. Models were adjusted for patient age, sex, race, comorbidities, socioeconomic status, hospital region, location (urban versus rural), and teaching status, procedural volume, year of admission, and the proportion of patients who underwent ventriculostomy. Subsequent models were also adjusted for time to aneurysm repair and time to ventriculostomy; subgroup analyses evaluated for those who underwent endovascular and surgical procedures separately. 15,557 hospitalizations were included. In the initial model, the adjusted odds of in-hospital mortality were higher for Medicare (OR 1.23, p<0.001), Medicaid (OR 1.23, p<0.001), and uninsured patients (OR 1.49, p<0.001) compared to those with private insurance. After also adjusting for timing of intervention, Medicaid and uninsured patients had a reduced odds of non-routine discharge (OR 0.75, p<0.001 and OR 0.42, p<0.001) despite longer hospital stays (by 8.35 days, p<0.001 and 2.45 days, p = 0.005). Variations in outcomes by primary payer-including in-hospital post-procedural mortality-were more pronounced for patients of all insurance types who underwent microsurgical clipping. The observed differences by primary payer are likely multifactorial, attributable to varied socioeconomic factors and the complexities of the American healthcare delivery system.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0078047PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3812119PMC
September 2014

Treatment modality and vasospasm after aneurysmal subarachnoid hemorrhage.

World Neurosurg 2014 Dec 14;82(6):e725-30. Epub 2013 Aug 14.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: Vasospasm is the leading source of neurological morbidity after aneurysmal subarachnoid hemorrhage. Our objective was to evaluate the impact of treatment modality on vasospasm, delayed cerebral infarction, and clinical deterioration caused by delayed cerebral ischemia (CD-DCI).

Methods: We reviewed an institutional cohort, comparing rates of vasospasm, delayed cerebral infarction, and CD-DCI between patients managed with only microsurgical clipping and those treated with only endovascular coiling within 72 hours of rupture. Age, sex, smoking status, Hunt-Hess grade, and Fisher grade were adjusted for in a multivariate regression model.

Results: Two hundred three patients were treated with clipping and 52 with coiling. There was no significant difference in patient age, sex, smoking status, aneurysm location, and presenting clinical (Hunt-Hess) and radiographic (Fisher) grade between these two groups. Sixty-percent of patients had moderate or severe vasospasm after clipping compared with 38% after coiling (Multivariate odds ratio [OR] 2.32, 95% confidence interval [95% CI] 1.21-4.47, P = 0.01). Clipping was associated with a greater number of territories with vasospasm (mean of 3.1 vs. 2.3, P = 0.03 after multivariate analysis). Delayed radiographic cerebral infarction was more common in the clipping group (17% vs. 6%, multivariate OR 3.66, 95% CI 1.06-12.71, P = 0.04). For CD-DCI, a trend was seen as 16% of patients treated with clipping had CD-DCI compared with 6% of patients treated with coiling (multivariate OR 3.11, 95% CI 0.89-10.86, P = 0.07).

Conclusion: We demonstrate significantly lower rates of vasospasm and delayed infarction after endovascular coiling of ruptured aneurysms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2013.08.017DOI Listing
December 2014

Effect of teaching hospital status on outcome of aneurysm treatment.

World Neurosurg 2014 Sep-Oct;82(3-4):380-385.e6. Epub 2013 Jul 24.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA. Electronic address:

Objective: There is increasing literature supporting the importance in triaging patients to teaching hospitals for complex surgical procedures. This study analyzes the effect of teaching hospital status on outcome of endovascular coiling and microsurgical clipping of ruptured and unruptured intracranial aneurysms using the Nationwide Inpatient Sample database.

Methods: We analyzed patients with cerebral aneurysms using the Nationwide Inpatient Sample 2001 to 2010. Patients with ruptured aneurysms were identified by International Classification of Diseases, 9th revision codes for diagnoses of subarachnoid hemorrhage or intracerebral hemorrhage and at least one procedural code for aneurysm repair. Patients with unruptured cerebral aneurysms were identified by diagnosis code 437.3 and at least one procedural code. Multivariate linear models were used to analyze the association of in-hospital death, nonroutine discharge, and length of stay with teaching hospital status, adjusting for patient age, sex, race, comorbidities, household income, time to aneurysm repair procedure, aneurysm procedure volume, hospital region, and location.

Results: There were 34,843 hospitalizations for treatments of unruptured (14,763 in teaching and 1794 in nonteaching hospitals) and ruptured (15,628 in teaching and 2658 in nonteaching hospitals) aneurysms. In patients with ruptured aneurysms, the odds ratio of in-hospital death and nonroutine discharges were 0.69 (95% confidence interval 0.54-0.88) and 0.77 (95% confidence interval 0.60-0.99) in teaching hospitals, respectively, independent of hospital aneurysm procedure volume.

Conclusions: Our results suggest that the teaching status of a hospital is an independent factor for favorable outcome in the treatment of ruptured aneurysms. The difference in in-hospital death is accentuated in patients who underwent microsurgical clipping.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2013.07.015DOI Listing
March 2015

Angiotensin-converting enzyme-inhibitors, statins and the risk of hemorrhage from cerebral dural arteriovenous fistulae.

J Clin Neurosci 2013 Sep 22;20(9):1228-31. Epub 2013 May 22.

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA.

Leptomeningeal venous drainage and symptomatic presentation are known risk factors for cerebral dural arteriovenous fistula (dAVF) hemorrhage. An evaluation of potentially modifiable risk factors such as hypertension and medication usage has not been undertaken to our knowledge. The authors thus reviewed a cohort of 45 consecutive patients with cerebral dAVF with leptomeningeal venous drainage and compared the rate of hemorrhagic presentation for patients with and without a history of hypertension, hyperlipidemia or the usage of certain medications. Logistic regression was performed to determine the statistical significance of associations of each factor with hemorrhagic presentation. On univariate analysis, angiotensin-converting enzyme (ACE)-inhibitors (odds ratio [OR] 0.100, 95% confidence interval [CI] 0-0.764, p=0.024) and statins (OR 0.142, 95% CI 0.025-0.825, p=0.030) were associated with a statistically significant lower rate of hemorrhagic presentation. A trend toward a lower rate of hemorrhagic presentation was seen for patients taking aspirin (OR 0.153, 95% CI 0.016-1.43, p=0.10). These trends continued on multivariate analysis; however they did not meet statistical significance (p>0.05). Beta-blockers, calcium channel blockers, warfarin and selective serotonin reuptake inhibitors did not have a statistically significant association with the rate of hemorrhagic presentation (p>0.05). Although limited by small sample size, these results may suggest a beneficial effect of statins and ACE-inhibitors on the rate of dAVF hemorrhagic presentation, potentially as a result of anti-inflammatory, anti-angiogenic or even venous antithrombotic mechanisms. Despite this study's limitations, we hope it encourages further evaluation of potentially modifiable risk factors for vascular malformation hemorrhage.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2013.01.005DOI Listing
September 2013

Hydrocephalus after arteriovenous malformation rupture.

Neurosurg Focus 2013 May;34(5):E11

Department of Neurological Surgery, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts 02115, USA.

Object: The rates and risk factors for external ventricular drain (EVD) placement and long-term shunt dependence in patients with ruptured arteriovenous malformations (AVMs) have not been systematically studied. In this study the authors evaluated the rates of EVD placement and shunt dependence, and risk factors for them, in a cohort of patients with ruptured AVMs.

Methods: The records of 87 consecutive patients with ruptured AVMs were reviewed for patient demographics, hemorrhage pattern, AVM angioarchitectural features, and surgical treatment. Univariate and multivariate logistic regression analyses were performed to evaluate risk factors for EVD placement, permanent shunt dependence, and long-term outcome (as measured by the modified Rankin Scale).

Results: Thirty-eight patients (44%) required EVD placement, and 16 (18%) required a permanent shunt. Statistically significant risk factors for EVD placement in the univariate analysis included initial Glasgow Coma Scale (GCS) score (p = 0.002), the presence of intraventricular hemorrhage (IVH; p < 0.001), AVM-associated aneurysms (p = 0.002), and early surgery (p = 0.01). Multivariate analysis revealed only AVM-associated aneurysms as statistically significant (p = 0.006). Risk factors for shunt placement included initial GCS score (p = 0.003), IVH (p = 0.01), deep supratentorial location (p = 0.034), and associated aneurysms (p = 0.03). Multivariate analysis revealed initial GCS score as a statistically significant risk factor (p = 0.041) as well as a strong trend for associated aneurysms (p = 0.06). Patient age, sex, associated subarachnoid hemorrhage, AVM grade, AVM size, and deep venous drainage were not associated with EVD placement or long-term shunt dependence.

Conclusions: Hydrocephalus from AVM rupture was associated with initial GCS score, IVH, and AVM-associated aneurysms. Arteriovenous malformations with associated aneurysms thus not only have a greater risk of hemorrhage but also a greater risk of hemorrhage-associated morbidity as a result of hydrocephalus.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2013.2.FOCUS12368DOI Listing
May 2013