Publications by authors named "Steven L Giannotta"

86 Publications

Utilization of Discarded Surgical Tissue from Ultrasonic Aspirators to Establish Patient-Derived Metastatic Brain Tumor Cells: A Guide from the Operating Room to the Research Laboratory.

Curr Protoc 2021 Jun;1(6):e140

Department of Neurological Surgery, Keck School of Medicine of USC, Los Angeles, California.

Patient-derived cells from surgical resections are of paramount importance to brain tumor research. It is well known that there is cellular and microenvironmental heterogeneity within a single tumor mass. Thus, current established protocols for propagating tumor cells in vitro are limiting because resections obtained from conventional singular samples limit the diversity in cell populations and do not accurately model the heterogeneous tumor. Utilization of discarded tissue obtained from cavitron ultrasonic surgical aspirator (CUSA) of the whole tumor mass allows for establishing novel cell lines in vitro from the entirety of the tumor, thereby creating an accurate representation of the heterogeneous population of cells originally present in the tumor. Furthermore, while others have described protocols for establishing patient tumor lines once tissue has arrived in the research lab, a primer from the operating room (OR) to the research lab has not been described before. This is integral, as basic research scientists need to understand the surgical environment of the OR, including the methods utilized to obtain a patient's tumor resection, in order to more accurately model cancer biology in laboratory. © 2021 Wiley Periodicals LLC. Basic Protocol 1: Establishment of brain tumor cell lines from patient-derived CUSA samples: processing brain tumor sample from the OR to the lab Support Protocol 1: Sterilization of microsurgical tools in preparation for dissection Support Protocol 2: Collagen coating of tissue culture flasks Basic Protocol 2: Selection of tumor cells in vitro Support Protocol 3: FACS sorting tumor sample to isolate cancer cells from heterogeneous cell population.
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http://dx.doi.org/10.1002/cpz1.140DOI Listing
June 2021

Neuroprotective effect of minocycline against acute brain injury in clinical practice: A systematic review.

J Clin Neurosci 2021 Apr 27;86:50-57. Epub 2021 Jan 27.

Department of Neurosurgery, University of Southern California, Los Angeles, CA 90033, USA.

Acute brain injury is a leading cause of morbidity and mortality worldwide. The term is inclusive of traumatic brain injury, cerebral ischemia, subarachnoid hemorrhage, and intracerebral hemorrhage. Current pharmacologic treatments have had minimal effect on improving neurological outcomes leading to a significant interest in the development neuroprotective agents. Minocycline is a second-generation tetracycline with high blood brain barrier penetrance due to its lipophilic properties. It functions across multiple molecular pathways involved in secondary-injury cascades following acute brain injury. Animal model studies suggest that minocycline might lead to improved neurologic outcomes, but few such trials exist in humans. Clinical investigations have been limited to small randomized trials in ischemic stroke patients which have not demonstrated a clear advantage in neurologic outcomes, but also have not been sufficiently powered to draw definitive conclusions. The potential neuroprotective effect of minocycline in the setting of traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage have all been limited to pilot studies with phase II/III investigations pending. The authors aim to synthesize what is currently known about minocycline as a neuroprotective agent against acute brain injury in humans.
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http://dx.doi.org/10.1016/j.jocn.2021.01.005DOI Listing
April 2021

Tracking Scan to Incision Time in Patients with Emergent Operative Traumatic Brain Injuries as a Measure for Systems-Based Practice in Neurosurgical Trainees.

World Neurosurg 2021 May 5;149:e491-e497. Epub 2021 Feb 5.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Evaluation of trainee performance remains a challenge in resident education, particularly for systems-based practice (SysBP) metrics including care coordination and interdisciplinary teamwork. Time to intervention is an important modifiable outcome variable in severe traumatic brain injury (TBI) and may serve as a trackable metric for SysBP evaluation.

Methods: We retrospectively studied time from computed tomography head scan to surgical incision (CTH-INC, minutes) among neurosurgical trainees treating patients with emergently operative TBI as a proxy SysBP measure. Our institutional operative database was utilized to identify all emergent TBI cases between July 2015 and June 2020. Patients evaluated by program year (PGY)-2 residents proceeding directly to the operating room from the emergency department were included. Statistical analysis was performed using linear regression.

Results: One hundred sixty-six cases triaged by 14 PGY-2 neurosurgical trainees were analyzed. Median CTH-INC was 104 minutes (interquartile range, 82-136 minutes). CTH-INC improved 20.1% over the academic year (95% confidence interval, 4.3%-33.2%, P = 0.015). Between the first and second 6-month periods, the rate of CTH-INC within 90 minutes (29% vs. 46%, P = 0.04) improved. On a per-individual PGY-2 basis, median CTH-INC ranged from 83-127 minutes, 25th percentile CTH-INC ranged from 62-108 minutes, and fastest CTH-INC ranged from 45-92 minutes.

Conclusions: CTH-INC is an objective and trackable proxy measure for evaluating SysBP during neurosurgical training. Use of CTH-INC or other time metrics in resident evaluations should not supersede the safe and effective delivery of patient care.
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http://dx.doi.org/10.1016/j.wneu.2021.01.150DOI Listing
May 2021

Rate of Intracranial Hemorrhage After Minor Head Injury.

Cureus 2020 Sep 25;12(9):e10653. Epub 2020 Sep 25.

Department of Neurosurgery, University of Southern California Keck School of Medicine, Los Angeles, USA.

Introduction: Computed tomography scans of the head (CTH) are an important component of the initial patient evaluation after blunt head trauma in select patients. Here we review findings of CTH performed for mild traumatic brain injury (TBI) at a Level I trauma center over a two-year period. We subsequently discuss the role and limitations of published clinical decision rules aiming to decrease unnecessary CTH in mild TBI patients.

Methods: We reviewed all Emergency Department CTH obtained after blunt head trauma between 2010 and 2011. Patient demographics and radiology report texts were collected. Reports were cross-referenced with our institutional trauma database to obtain initial Glasgow Coma Scale (GCS). Mild TBI was defined by an initial GCS 13-15 with or without loss of consciousness or post-traumatic amnesia.

Results: There were 5,634 mild TBI patients evaluated with CTH. A total of 477 scans (8.5%) were positive for intracranial hemorrhage. Of these, 188 (39.4%) showed more than one type of intracranial hemorrhage. The most common findings were subdural hematomas (262, 4.7% of scans), traumatic subarachnoid hemorrhages (252, 4.5% of scans), and cerebral contusions/intraparenchymal hematomas (212, 3.8% of scans). Older age (p<0.001) and male gender (p<0.001) were associated with positive CTH.

Conclusions: The rate of positive CTH in mild TBI patients in our population falls within a historical range. The clinical and medicolegal implications of missed intracranial hemorrhage have remained important factors limiting the implementation of clinical decision rules in screening mild TBI patients for CTH.
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http://dx.doi.org/10.7759/cureus.10653DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7586355PMC
September 2020

Risk Factors for Cerebral Vasospasm in Aneurysmal Subarachnoid Hemorrhage: A Population-Based Study of 8346 Patients.

World Neurosurg 2021 01 10;145:e233-e241. Epub 2020 Oct 10.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA. Electronic address:

Background: A recent systematic review and meta-analysis found that there was a lack of consensus regarding risk factors for cerebral vasospasm in aneurysmal subarachnoid hemorrhage (aSAH).

Objective: To identify risk factors associated with increased likelihood of cerebral vasospasm after aSAH using the largest, all-payer, inpatient database in the United States.

Methods: The Nationwide Readmissions Database (2016) was queried using International Classification of Diseases, Tenth Revision codes to identify patients (age ≥18 years) treated (coiling or clipping) for aSAH. Exposure variables included demographics, comorbidities, location and clinical grade of aSAH, treatment type, and laboratory anomalies. Multivariable analysis was conducted to identify factors independently associated with cerebral vasospasm (ICD-10 code I67.84).

Results: The rate of vasospasm was 28.1% in 8346 patients with treated aSAH. In multivariable analysis, vasospasm risk was inversely proportional to age (P < 0.001). Substance abuse, particularly tobacco smoking and cocaine, was associated with vasospasm (P < 0.05). Advanced SAH severity (Hunt and Hess grade ≥2) approximately doubled risk of vasospasm (P < 0.001). Poor hemodynamic status, including anemia (odds ratio [OR], 1.8), hypovolemia (OR, 1.6), and hypotension (OR, 1.4), was correlated with vasospasm. Laboratory abnormalities, including leukocytosis (OR, 1.3), hyponatremia (OR, 1.4), and hypokalemia (OR, 1.3), were associated with vasospasm (all P < 0.05).

Conclusions: In the first nationwide analysis of cerebral vasospasm, risk factors included younger age, female sex, smoking history, hemodynamic compromise, and clinical severity of aSAH. Recently proposed biomarkers, including leukocytosis and hypokalemia, were supported by our findings. This study may assist risk stratification and earlier detection of vasospasm.
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http://dx.doi.org/10.1016/j.wneu.2020.10.008DOI Listing
January 2021

Epigenetic modulator inhibition overcomes temozolomide chemoresistance and antagonizes tumor recurrence of glioblastoma.

J Clin Invest 2020 11;130(11):5782-5799

Broad Center for Regenerative Medicine and Stem Cell Research, Keck Department of Stem Cell Biology and Regenerative Medicine, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Glioblastoma multiforme (GBM) heterogeneity causes a greater number of deaths than any other brain tumor, despite the availability of alkylating chemotherapy. GBM stem-like cells (GSCs) contribute to GBM complexity and chemoresistance, but it remains challenging to identify and target GSCs or factors that control their activity. Here, we identified a specific GSC subset and show that activity of these cells is positively regulated by stabilization of methyl CpG binding domain 3 (MBD3) protein. MBD3 binds to CK1A and to BTRCP E3 ubiquitin ligase, triggering MBD3 degradation, suggesting that modulating this circuit could antagonize GBM recurrence. Accordingly, xenograft mice treated with the CK1A activator pyrvinium pamoate (Pyr-Pam) showed enhanced MBD3 degradation in cells expressing high levels of O6-methylguanine-DNA methyltransferase (MGMT) and in GSCs, overcoming temozolomide chemoresistance. Pyr-Pam blocked recruitment of MBD3 and the repressive nucleosome remodeling and deacetylase (NuRD) complex to neurogenesis-associated gene loci and increased acetyl-histone H3 activity and GSC differentiation. We conclude that CK1A/BTRCP/MBD3/NuRD signaling modulates GSC activation and malignancy, and that targeting this signaling could suppress GSC proliferation and GBM recurrence.
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http://dx.doi.org/10.1172/JCI127916DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7598052PMC
November 2020

Readmission with venous thromboembolism after surgical treatment by primary cancer site.

Surg Oncol 2020 Dec 9;35:268-275. Epub 2020 Sep 9.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Background: Venous thromboembolism (VTE) is a common, high-mortality condition among surgical cancer patients. Comprehensive analyses of VTE among postoperative cancer patients are lacking. We sought to determine the association between readmission with VTE and primary cancer diagnosis in a nationwide database at 90- and 180-days after initial admission for cancer surgery.

Methods: Retrospective analyses of post-surgical cancer patients readmitted with VTE were conducted using data from the Nationwide Readmissions Database (NRD) (2010-2014). Multivariate logistic regression models adjusting for patient and hospital factors were used to determine 90- and 180-day readmission rates for VTE by cancer type. Patient factors associated with readmission were also examined.

Results: Among a sample of 535,992 cancer patients undergoing tumor resection, readmission with VTE occurred in 1.7% within 90-days and 2.3% within 180-days. Patients readmitted for VTE experienced a 7% mortality rate. Highest rates of VTE readmission at 180 days occurred in brain (6.7%), pancreatic (5.6%), and respiratory and intrathoracic cancers (4.4%). Using pancreatic cancer as reference, brain cancer had the highest odds of readmission at 180-days (OR 2.23, 95% CI [1.95-2.55]).

Conclusion: Readmission with VTE among surgical cancer patients occurred in 2.3% of patients within 180 days. Among cancer types, primary brain cancer was independently associated with readmission with VTE.
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http://dx.doi.org/10.1016/j.suronc.2020.09.013DOI Listing
December 2020

Comorbid depression associated with non-routine discharge following craniotomy for low-grade gliomas and benign tumors - a nationwide readmission database analysis.

Acta Neurochir (Wien) 2020 11 2;162(11):2671-2681. Epub 2020 Sep 2.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Purpose: Prior studies have demonstrated elevated rates of depression in patients with malignant brain tumor; however, the prevalence and effect on surgical outcomes in patients with low-grade gliomas (LGG) and benign brain tumors (BBT) remain unknown. Readmission and non-routine discharge, which includes discharge to skilled nursing, rehabilitative, and other inpatient facilities, are well-established quality of care indicators. We sought to analyze the association between comorbid depression and non-routine discharge, readmission, and other post-operative inpatient outcomes in patients with LGG and BBT.

Methods: The Nationwide Readmissions Database from 2010 to 2014 was retrospectively queried to select for surgically treated patients with LGG and BBT. Multivariable logistic regression models adjusting for patient and hospital characteristics were used to determine the effects of comorbid depression on post-operative outcomes. Interaction of gender and depression on non-routine disposition was analyzed.

Results: We identified 31,654 craniotomies for resection of BBT and LGG (2010-2014). The majority of patients (64.1%) were female. The rate of depression comorbid with BBT and LGG was 11.9%. Depression was associated with non-routine discharge after surgery (OR 1.19, p 0.0002*), but was not associated with increased morbidity, mortality, or readmission at 30 or 90 days. The rate of comorbid depression was higher among female than male patients (14.0 vs. 8.0%). Depression in males was associated with a 38% increased likelihood of non-routine disposition (p = 0.0002*), while depression in females was associated with a 13% increased likelihood of non-routine disposition (p = 0.03*).

Conclusion: Depression is prevalent in patients with LGG and BBT and is associated with increased risk of non-routine discharge following surgical intervention. The increased likelihood of non-routine disposition is greater for males than that for females. Awareness of the risk factors for depression may aid in early screening and intervention and improve overall patient outcomes.
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http://dx.doi.org/10.1007/s00701-020-04559-4DOI Listing
November 2020

Predictors of readmission after craniotomy for meningioma resection: a nationwide readmission database analysis.

Acta Neurochir (Wien) 2020 11 11;162(11):2637-2646. Epub 2020 Aug 11.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, 1200 North State St. Suite 3300, Los Angeles, CA, 90033, USA.

Background: Meningiomas are the most common benign primary brain tumors. The mainstay of treatment, surgical resection, is often curative. Given the excellent prognosis of these lesions, minimizing perioperative complications is of the utmost importance. With the establishment of the National Readmissions Database (NRD), researchers are now able to identify variables associated with postoperative complications beyond the index admission.

Objective: In this study, we sought to identify the leading causes for non-elective readmission and variables associated with increased likelihood of readmission at 30 and 90 days after discharge following a craniotomy for meningioma resection.

Methods: Adult inpatients who underwent craniotomy for meningioma resection between 2010 and 2014 were queried from the NRD. All-cause readmissions following craniotomy at 30 and 90 days were identified, and a multivariable logistic regression model was used to characterize independent risk factors.

Results: Among 26,034 patients who received craniotomy for meningioma resection, 2825 (10.9%) were readmitted at 30 days and 3436 (16.1%) were readmitted at 90 days. Postoperative wound infection was the most common readmission diagnosis, occurring in 9.32% and 10.2% of 30- and 90-day readmissions respectively. Patient factors associated with increased likelihood of readmission included male gender, greater illness severity, non-routine discharge, index length of hospitalization, and having Medicare or Medicaid insurance.

Conclusions: Readmission following craniotomy for meningioma resection occurs at a clinically significant rate. Several patient factors were identified in association with all-cause 30- and 90-day readmissions. Further studies are required to identify means for preventing complications following discharge in these vulnerable patient populations.
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http://dx.doi.org/10.1007/s00701-020-04528-xDOI Listing
November 2020

miR-18a Inhibits BMP4 and HIF-1α Normalizing Brain Arteriovenous Malformations.

Circ Res 2020 10 5;127(9):e210-e231. Epub 2020 Aug 5.

Departments of Pathology (T.C.C., F.M.H.), Keck School of Medicine, University of Southern California, Los Angeles.

Rationale: Brain arteriovenous malformations (AVMs) are abnormal tangles of vessels where arteries and veins directly connect without intervening capillary nets, increasing the risk of intracerebral hemorrhage and stroke. Current treatments are highly invasive and often not feasible. Thus, effective noninvasive treatments are needed. We previously showed that AVM-brain endothelial cells (BECs) secreted higher VEGF (vascular endothelial growth factor) and lower TSP-1 (thrombospondin-1) levels than control BEC; and that microRNA-18a (miR-18a) normalized AVM-BEC function and phenotype, although its mechanism remained unclear.

Objective: To elucidate the mechanism of action and potential clinical application of miR-18a as an effective noninvasive treatment to selectively restore the phenotype and functionality of AVM vasculature.

Methods And Results: The molecular pathways affected by miR-18a in patient-derived BECs and AVM-BECs were determined by Western blot, RT-qPCR (quantitative reverse transcription polymerase chain reaction), ELISA, co-IP, immunostaining, knockdown and overexpression studies, flow cytometry, and luciferase reporter assays. miR-18a was shown to increase TSP-1 and decrease VEGF by reducing PAI-1 (plasminogen activator inhibitor-1/SERPINE1) levels. Furthermore, miR-18a decreased the expression of BMP4 (bone morphogenetic protein 4) and HIF-1α (hypoxia-inducible factor 1α), blocking the BMP4/ALK (activin-like kinase) 2/ALK1/ALK5 and Notch signaling pathways. As determined by Boyden chamber assays, miR-18a also reduced the abnormal AVM-BEC invasiveness, which correlated with a decrease in MMP2 (matrix metalloproteinase 2), MMP9, and ADAM10 (ADAM metallopeptidase domain 10) levels. In vivo pharmacokinetic studies showed that miR-18a reaches the brain following intravenous and intranasal administration. Intranasal co-delivery of miR-18a and NEO100, a good manufacturing practices-quality form of perillyl alcohol, improved the pharmacokinetic profile of miR-18a in the brain without affecting its pharmacological properties. Ultra-high-resolution computed tomography angiography and immunostaining studies in an Mgp AVM mouse model showed that miR-18a decreased abnormal cerebral vasculature and restored the functionality of the bone marrow, lungs, spleen, and liver.

Conclusions: miR-18a may have significant clinical value in preventing, reducing, and potentially reversing AVM.
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http://dx.doi.org/10.1161/CIRCRESAHA.119.316317DOI Listing
October 2020

Discrepancy in Neurologic Outcomes Following Aneurysmal Subarachnoid Hemorrhage as a Function of Socioeconomic Class.

World Neurosurg 2020 06 23;138:e787-e794. Epub 2020 Mar 23.

Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Objective: To investigate potential health care discrepancies in patients with ruptured cerebral aneurysms undergoing microsurgical intervention.

Methods: We retrospectively reviewed patients with ruptured intracranial aneurysms treated at our tertiary referral university hospital (UH) and safety net county hospital (CH) from 2010 to 2015. We identified 73 UH patients and 58 CH patients.

Results: UH patients had shorter time duration between rupture and intervention (P < 0.001) and higher rates of intubation on admission (P = 0.01). Verapamil was more frequently used for clinical vasospasm in UH patients, at 0.13 (95% confidence interval [CI], 0.09-0.18) treatments per patient per day versus 0.077 (95% CI, 0.047-0.12) treatments per patient per day in CH patients, though there was no difference in delayed cerebral ischemia (P = 0.15). The majority of the CH cohort was uninsured (26.3%; UH 0%) or had Medicaid (59.7%; UH 35.2%) (P < 0.001). The UH had more dispositions to home or rehabilitation centers than the CH (82% vs. 67.3%; P = 0.04). After adjusting for disease severity, hospital stay, and insurance status, CH patients were 3.73 (95% CI, 1.25-12.14) times more likely to be discharged with a poor modified Rankin Scale score and 3.08 (95% CI, 1.04-9.61) times more likely to be discharged with a poor Glasgow Outcome Scale score compared with UH patients (P = 0.02 and P = 0.04, respectively).

Conclusions: Limited resource availability in a safety net hospital system could be a major driving force behind the health care discrepancy identified in our ruptured cerebral aneurysm population. Reallocation of resources to supplement advanced inpatient acute care technologies and, more importantly, post-acute care environments can narrow the outcomes gap.
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http://dx.doi.org/10.1016/j.wneu.2020.03.087DOI Listing
June 2020

Intentional Subtotal Resection of Vestibular Schwannoma: A Reexamination.

J Neurol Surg B Skull Base 2020 Apr 1;81(2):136-141. Epub 2019 Mar 1.

Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, United States.

 Treatment of vestibular schwannomas (VS) remains controversial. Historical surgical series prioritized gross total resections (GTR); however, near total resections (NTR) and intentional subtotal resections (STR) aiming at improving cranial nerve outcomes are becoming more popular.  The main purpose of this article is to assess the tumor control and facial nerve outcomes in VS patients treated with STR or NTR.  VS patients undergoing STR or NTR at our institution between 1984 and 2016 were retrospectively reviewed. Patient demographics, extent of tumor resection, facial nerve injury, tumor recurrence, and need for Gamma Knife radiosurgery were analyzed. Facial nerve outcomes were quantified using House-Brackmann (HB) scores. Tumor regrowth was defined by the San Francisco criteria.  Four-hundred fifty-seven VS resections were performed in a 32-year period. Sixty cases met inclusion criteria. The mean (range) follow-up duration was 30.9 (12-103) months. The STR cohort (  = 33) demonstrated regrowth in 12 patients (36.3%) at an average of 23.6 months. The NTR cohort (  = 27) did not experience tumor recurrence. Risk of tumor recurrence was positively correlated with preoperative tumor size (  = 0.002), size of residual tumor (  < 0.001), and STR (  < 0.001). Facial nerve outcomes of HB1-2 were observed in the majority of patients in both cohorts (74.1% NTR, 56% STR), though NTR was associated with a higher likelihood of facial nerve recovery (  = 0.003).  GTR remains the gold standard as long as facial nerve outcomes remain acceptable. NTR achieved superior tumor control and higher likelihood of facial nerve recovery compared with STR.
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http://dx.doi.org/10.1055/s-0039-1679898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082167PMC
April 2020

Surgical Closed Suction Drain Use After Craniotomy for Evacuation of Supratentorial Epidural Hematomas: A Case Series of Radiographic and Clinical Outcomes.

World Neurosurg 2020 Feb 24;134:e460-e468. Epub 2019 Oct 24.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Surgical closed suction drain (SCSDs) are used in a variety of surgical disciplines to prevent postoperative fluid collections. Use of SCSDs has not been well studied in the neurosurgical literature. Practice patterns have varied within our institution with respect to SCSDs after craniotomies for neurotrauma. In this study we describe SCSD use for patients undergoing evacuation of supratentorial epidural hematomas (EDHs) and examine the effect on patient outcomes and length of hospital stay.

Methods: We performed a retrospective review of craniotomies for supratentorial EDH performed at our Level I trauma center between May 2015 and May 2018. Imaging and clinical data were obtained from chart review.

Results: Fifty-two patients with EDH received operations from 8 attending surgeons. The number of drains used was 0 or 1 in 36 cases and 2 or more in 16 cases. Drain location was subgaleal in 25 cases, epidural in 8 cases, and both subgaleal and epidural in 13 cases. Attending preference (P < 0.001) but not hematoma size was associated with use of an epidural drain and use of 2 or more drains. After controlling for age, initial neurologic exam, and presence of other injuries, use of more drains was associated with longer intensive care unit lengths of stay. Drain use pattern was not associated with patient outcome measures, and no return to the operating room was necessary for residual or recurrent EDH.

Conclusions: Use of fewer SCSDs did not affect radiographic outcome after evacuation of epidural hematomas but was associated with decreased intensive care unit length of stay.
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http://dx.doi.org/10.1016/j.wneu.2019.10.098DOI Listing
February 2020

Increased complication and mortality among non-index hospital readmissions after brain tumor resection is associated with low-volume readmitting hospitals.

J Neurosurg 2019 Oct 4:1-13. Epub 2019 Oct 4.

2Departments of Neurological Surgery and.

Objective: Fragmentation of care following craniotomy for tumor resection is increasingly common with the regionalization of neurosurgery. Hospital readmission to a hospital (non-index) other than the one from which patients received their original care (index) has been associated with increases in both morbidity and mortality for cancer patients. The impact of non-index readmission after surgical management of brain tumors has not previously been evaluated. The authors set out to determine rates of non-index readmission following craniotomy for tumor resection and evaluated outcomes following index and non-index readmissions.

Methods: Retrospective analyses of data from cases involving resection of a primary brain tumor were conducted using data from the Nationwide Readmissions Database (NRD) for 2010-2014. Multivariate logistic regression was used to evaluate the independent association of patient and hospital factors with readmission to an index versus non-index hospital. Further analysis evaluated association of non-index versus index hospital readmission with mortality and major complications during readmission. Effects of readmission hospital procedure volume on mortality and morbidity were evaluated in post hoc analysis.

Results: In a total of 17,459 unplanned readmissions, 84.4% patients were readmitted to index hospitals and 15.6% to non-index hospitals. Patient factors associated with increased likelihood of non-index readmission included older age (75+: OR 1.44, 95% CI 1.19-1.75), elective index admission (OR 1.19, 95% CI 1.08-1.30), increased Elixhauser comorbidity score ≥2 (OR 1.18, 95% CI 1.01-1.37), and malignant tumor diagnosis (OR 1.32, 95% CI 1.19-1.45) (all p < 0.04). Readmission to a non-index facility was associated with a 28% increase in major complications (OR 1.28, 95% CI 1.14-1.43, p < 0.001) and 21% increase in mortality (OR 1.21, 95% CI 1.02-1.44, p = 0.032) in initial analysis. Following a second multivariable logistic regression analysis including the readmitting hospital characteristics, low procedure volume of a readmitting facility was significantly associated with non-index readmission (p < 0.001). Readmission to a lower-procedure-volume facility was associated with a 46%-75% increase in mortality (OR 1.46-1.75, p < 0.005) and a 21%-35% increase in major complications (OR 1.21-1.34, p < 0.005). Following adjustment for volume at a readmitting facility, admission to a non-index facility was no longer associated with mortality (OR 0.90, 95% CI 0.71-1.14, p = 0.378) or major complications (OR 1.09, CI 0.94-1.26, p = 0.248).

Conclusions: Of patient readmissions following brain tumor resection, 15.6% occur at a non-index facility. Low procedure volume is a confounder for non-index analysis and is associated with an increased likelihood of major complications and mortality, as compared to readmission to high-procedure-volume hospitals. Further studies should evaluate interventions targeting factors associated with unplanned readmission.
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http://dx.doi.org/10.3171/2019.6.JNS183469DOI Listing
October 2019

Nonindex Readmission After Ruptured Brain Aneurysm Treatment Is Associated with Higher Morbidity and Repeat Readmission.

World Neurosurg 2019 Oct 5;130:e753-e759. Epub 2019 Jul 5.

Department of Neurological, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) requires complex multidisciplinary care. After initial treatment (index hospital), readmission to a different hospital (nonindex) can compromise quality of care, resulting in increased morbidity. We aimed to evaluate factors associated with nonindex readmission and evaluate association of nonindex hospital readmission on outcomes in patients with ruptured aneurysm.

Methods: Readmissions within 90 days after aSAH treatment were identified in the 2010-2014 Nationwide Readmissions Database. Multivariable logistic regression identified patient and hospital characteristics associated with nonindex readmission. Separate multivariable models determined increased morbidity or risk of second readmission for nonindex readmissions.

Results: A total of 9254 patients who underwent treatment of ruptured aneurysms from 2010 to 2014 were identified. Of these, 1985 (21.5%) were readmitted within 90 days. Three hundred and fifty-five of these readmissions (17.9%) occurred to nonindex hospitals. Patients that were discharged to a skilled nursing or other facility (odds ratio [OR], 1.70; 95% confidence interval [CI], 1.27-2.28]) had higher odds of nonindex readmission, whereas patients with private insurance were associated with lower odds of nonindex readmission (OR, 0.65; 95% CI, 0.46-0.92). Patients readmitted to a nonindex (vs. index) hospital were associated with increased likelihood of major complications (OR, 1.71; 95% CI, 1.18-2.48) and second readmissions (OR, 1.51; 95% CI, 1.17-1.96).

Conclusions: After treatment of a ruptured cerebral aneurysm, 17.9% of readmissions occurred at a nonindex hospital. These patients were at increased risk for major complications or subsequent readmissions, which may be because of care fragmentation. Interventions aimed at improving continuity of care may reduce higher morbidity associated with nonindex readmission.
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http://dx.doi.org/10.1016/j.wneu.2019.06.214DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6778018PMC
October 2019

Commentary: Modern Training and Credentialing in Neuroendovascular Acute Ischemic Stroke Therapy.

Neurosurgery 2019 07;85(suppl_1):S58-S59

Department of Neurosurgery, Keck Medicine of University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1093/neuros/nyz085DOI Listing
July 2019

State of the Union in Open Neurovascular Training.

World Neurosurg 2019 02 26;122:e553-e560. Epub 2018 Oct 26.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA.

Background: The evolution of minimally invasive endovascular approaches and training paradigms has reduced open neurovascular case exposure for neurosurgical residents. There are no published estimates of open neurovascular case volumes during residency or Committee on Advanced Subspecialty Training (CAST) accredited fellowships.

Methods: Case volumes from residency programs submitting data for CAST accredited fellowship applications were collected and analyzed. The study period covered the academic years of 2013-2016. Case index volumes were calculated to provide an estimate of total volume of cases each trainee participated in a given year. The case index volume was defined as the total volume of cases per year divided by the total training complement.

Results: Over the study period, institutional data from 46 programs were available. Of those programs, 9 programs had CAST accredited open cerebrovascular fellowships. Across all 46 programs, the median number of vascular cases was 246 (interquartile range [IQR]: 148-340), whereas the median number of open vascular cases was 105 (IQR: 67-152). The median number of open aneurysm cases among programs with CAST cerebrovascular fellowships was 80 (IQR: 54-103) and among programs without CAST cerebrovascular fellowships was 34 (IQR: 24-63). The median open aneurysm case index volume for trainees at programs with and without CAST cerebrovascular fellowships was 23 (IQR: 14-29) and 19 (IQR: 11-24).

Conclusions: Strong neurovascular training can be obtained through dedication and planning. Completion of a CAST accredited cerebrovascular fellowship will often more than double aneurysm case exposure of trainees.
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http://dx.doi.org/10.1016/j.wneu.2018.10.099DOI Listing
February 2019

Early Readmission After Ventricular Shunting in Adults with Hydrocephalus: A Nationwide Readmission Database Analysis.

World Neurosurg 2019 Aug 28;128:e38-e50. Epub 2019 Mar 28.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Ventricular shunting is one of the primary modalities for addressing hydrocephalus in both children and adults. Despite advances in shunt technology and surgical practices, shunt failure is a persistent challenge for neurosurgeons, and shunt revisions account for a substantial proportion of all shunt-related procedures. There are a wealth of studies elucidating failure patterns and patient demographics in pediatric cohorts; however, data in adults are less uniform. We sought to determine the rates of all-cause and shunt failure readmission in adults who underwent the insertion of a ventricular shunt.

Methods: We queried the Nationwide Readmissions Database from 2010 to 2014 to evaluate new ventricular shunts placed in adults with hydrocephalus. We sought to determine the rates of all-cause and shunt revision-related readmissions and to characterize factors associated with readmissions. We analyzed predictors including patient demographics, hospital characteristics, shunt type, and hydrocephalus cause.

Results: Analysis included 24,492 initial admissions for shunt placement in patients with hydrocephalus. Of patients, 9.17% required a shunt revision within the first 6 months; half of all revisions occurred within the first 41 days. There were 4044 (16.50%) 30-day and 5758 (28.8%) 90-day all-cause readmissions. In multivariable analysis, patients with a ventriculopleural shunt, Medicare insurance, and younger age had increased likelihood for shunt revision. Notable predictors for all-cause readmission were insurance type, length of hospitalization, age, comorbidities, and hydrocephalus cause.

Conclusions: Most shunt revisions occurred during the first 2 months. Readmissions occurred frequently. We identified patient factors that were associated with all-cause and shunt failure readmissions.
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http://dx.doi.org/10.1016/j.wneu.2019.03.217DOI Listing
August 2019

Simulation of Dural Repair in Minimally Invasive Spine Surgery With the Use of a Perfusion-Based Cadaveric Model.

Oper Neurosurg (Hagerstown) 2019 12;17(6):616-621

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Background And Importance: In an era of curtailed work hours and concerns over achieving technical proficiency in the repertoire of procedures necessary for independent practice, many residencies have turned to model simulation as an educational adjunct. Cerebrospinal fluid (CSF) leak repair after inadvertent durotomy in spine surgery is a fundamental skillset for any spine surgeon. While primary closure with suture is not always necessary for small durotomies, larger defects, on the other hand, must be repaired. However, the dire consequences of inadequate repair dictate that it is generally performed by the most experienced surgeon. Few intraoperative opportunities, therefore, exist for CSF leak repair by trainees.

Objective: To simulate dural repair in spine surgery using minimal-access techniques.

Methods: A cohort of 8 neurosurgery residents was evaluated on their durotomy repair efforts in a perfusion-based cadaveric model.

Results: Study participants demonstrated consistent improvement across trials, with a significant reduction in closure times between their initial (12 min, 7 sec ± 4 min, 43 sec) and final attempts (7 min, 4 sec ± 2 min, 6 sec; P = .02). Moreover, all trainees-irrespective of postgraduate year-were able to accomplish robust dural closures resistant to simulated Valsalva maneuvers. Participants reported high degrees of model realism and exhibited significant increases in postprocedure confidence scores.

Conclusion: Our results support use of perfusion-based simulation models as a complement to neurosurgery training, as it affords unrestricted opportunities for honing psychomotor skillsets when resident learning is increasingly being challenged by work-hour limitations and stricter oversight in the context of value-based healthcare.
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http://dx.doi.org/10.1093/ons/opz041DOI Listing
December 2019

Revision Microvascular Decompression for Trigeminal Neuralgia and Hemifacial Spasm: Factors Associated with Surgical Failure.

J Neurol Surg B Skull Base 2019 Feb 29;80(1):31-39. Epub 2018 Jun 29.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, United Sates.

 To investigate risk factors for symptom recurrence in patients requiring a revision microvascular decompression (MVD) for trigeminal neuralgia (TN) or hemifacial spasm (HFS).  Retrospective review of a prospectively maintained database.  Seventeen consecutive patients undergoing revision MVD at our institution between January 1993 and September 2017.  The incidence and causes for revision MVDs were recorded. Response to revision MVD for TN was tracked using the Barrow Neurological Institute (BNI) grading scale. Response to revision MVD for HFS was graded as "no improvement," "some relief," or "complete resolution" of symptoms.  Revision MVD rate for the senior author across all MVDs performed in this period was 1.9% for TN and 9.3% for HFS. Initial MVD failure was primarily caused by active inflammation and/or scarring and adhesions in 5/17 patients, malposition/slippage of Teflon in 3/17 patients, and insufficient Teflon in 1/17 patients. Without other factors, a new site of neurovascular conflict was identified in 4/17 patients, while the same site of neurovascular conflict was found in 3/17 patients. No cause could be identified in 1/17 patients. Scarring was found primarily in the TN group and was associated with symptom persistence.  Revision MVD for recurrent TN and HFS is an effective procedure offering the prospect of a complete cure. Proper Teflon use is crucial for surgical success. Scarring after initial MVD is a negative prognostic factor requiring destructive treatment consideration. Although morbidity rates were slightly increased with revision versus original MVDs, the complications were non-disabling and resolved over time.
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http://dx.doi.org/10.1055/s-0038-1661348DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6365246PMC
February 2019

Venous Thromboembolism After Degenerative Spine Surgery: A Nationwide Readmissions Database Analysis.

World Neurosurg 2019 05 23;125:e165-e174. Epub 2019 Jan 23.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Venous thromboembolism (VTE) is an appreciable burden on health care. The protracted recumbency experienced by many spinal patients juxtaposed with concerns for postoperative hemorrhage from early anticoagulation results in conflicting stances regarding chemoprophylaxis. Identifying risk factors associated with VTE is therefore instrumental in guiding management.

Objective: To identify VTE risk factors in patients undergoing degenerative spine surgery.

Methods: The Nationwide Readmissions Database was searched for adults undergoing spine surgery for degenerative diseases between 2010 and 2014. The 30-day and 90-day VTE incidence was estimated from readmissions with new VTE diagnoses. A multivariate survey-adjusted logistic regression model was used to identify variables associated with VTE diagnoses on readmission.

Results: Of 838,507 degenerative spine cases queried, 3499 patients (0.42%) were readmitted with a VTE diagnosis within 30 days and 4321 patients (0.62%) were readmitted within 90 days. In multivariate analysis, steroids were independently associated with a higher likelihood of readmission with VTE at both 30 days (odds ratio, 1.58; P < 0.001) and 90 days (odds ratio, 1.97; P < 0.001). Significant associations were also identified with thoracolumbar surgery, length of stay, and discharge to institutional care.

Conclusions: The incidence of readmission with VTE diagnoses in spine surgery is low. However, their devastating consequences underscore the need to identify those patients deemed high risk. These patients include those having thoracolumbar surgery, of advanced age, with prolonged length of stay, using corticosteroids, and with a disposition to institutional care (e.g., skilled nursing facility or long-term acute care). Given the association between steroids and VTE, clinicians should be judicious about perioperative administration despite their obvious antiinflammatory benefits.
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http://dx.doi.org/10.1016/j.wneu.2019.01.029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650385PMC
May 2019

Predictors of Venous Thromboembolism After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis.

World Neurosurg 2019 Feb 20;122:e1102-e1110. Epub 2018 Nov 20.

Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Venous thromboembolism (VTE) is responsible for many hospital readmissions each year, particularly among postsurgical cohorts. Because early and indiscriminate VTE prophylaxis carries catastrophic consequences in postcraniotomy cohorts, identifying factors associated with a high risk for thromboembolic complications is important for guiding postoperative management.

Objective: To determine VTE incidence in patients undergoing nonemergent craniotomy and to evaluate for factors that predict 30-day and 90-day readmission with VTE.

Methods: The 2010-2014 cohorts of the Nationwide Readmissions Database were used to generate a large heterogeneous craniotomy sample.

Results: There were 89,450 nonemergent craniotomies that met inclusion criteria. Within 30 days, 1513 patients (1.69%) were readmitted with VTE diagnoses; among them, 678 (44.8%) had a diagnosis of deep vein thrombosis alone, 450 (29.7%) had pulmonary embolism alone, and 385 (25.4%) had both. The corresponding 30-day deep vein thrombosis and pulmonary embolism incidences were 1.19% and 0.93%, respectively. In multivariate analysis, several factors were significantly associated with VTE readmission, namely, craniotomy for tumor, corticosteroids, advanced age, greater length of stay, and discharge to institutional care.

Conclusions: Craniotomies for tumor, corticosteroids, advanced age, prolonged length of stay, and discharge to institutional care are significant predictors of VTE readmission. The implication of steroids, coupled with their ubiquity in neurosurgery, makes them a potentially modifiable risk factor and a prime target for VTE reduction in craniotomy cohorts. Furthermore, the fact that dose is proportional to VTE risk in the literature suggests that careful consideration should be given toward decreasing regimens in situations in which use of a lower dose might prove equally sufficient.
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http://dx.doi.org/10.1016/j.wneu.2018.10.237DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6363858PMC
February 2019

Long-Term Tumor Control Rates Following Gamma Knife Radiosurgery for Acoustic Neuroma.

World Neurosurg 2019 Feb 15;122:366-371. Epub 2018 Nov 15.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Acoustic neuromas (ANs) are benign intracranial tumors that arise from myelin-forming Schwann cells surrounding the vestibular branch of the vestibulocochlear nerve (cranial nerve VIII). Treatment options for AN include observation, radiosurgery, and microsurgical resection. Gamma Knife radiosurgery (GKRS) for AN has well-documented short-term safety and efficacy for carefully selected patients. Recent innovations in GKRS technology may improve long-term outcomes. The aim of this study was to report long-term tumor control and complication rates after GKRS for sporadic AN.

Methods: A retrospective review was performed of patients with sporadic ANs at Keck Hospital of USC who underwent GKRS from 1995 to 2015 with a minimum follow-up of 12 months.

Results: Median age at treatment was 63.7 years (range, 19.4-84.2 years). Median follow-up time was 69 months. Median tumor diameter was 17.5 mm (range, 5.0-29.0 mm), and median treatment volume was 2.41 cm (range, 0.09-12.8 cm). Median prescribed dose was 12.50 Gy. Tumor control was achieved in 51 (98.1%) patients over the follow-up period (12-192 months). One patient experienced tumor progression at 22 months after GKRS, requiring surgical intervention, which ultimately resulted in remission. Complications included hearing loss (17.3%), worsened balance/ataxia (7.7%), and hydrocephalus (1.92%).

Conclusions: Patients undergoing GKRS for sporadic ANs had high rates of tumor control over a median follow-up time of >5 years. Improvements in radiosurgery treatment planning were seen in the most recent cohort of patients. GKRS is a safe and effective modality for treating sporadic ANs in selected patients.
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http://dx.doi.org/10.1016/j.wneu.2018.11.009DOI Listing
February 2019

Predictors of Surgical Site Infection After Nonemergent Craniotomy: A Nationwide Readmission Database Analysis.

World Neurosurg 2018 Dec 25;120:e440-e452. Epub 2018 Aug 25.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Objective: Surgical site infections (SSIs) carry significant patient morbidity and mortality and are a major source of readmissions after craniotomy. Because of their deleterious effects on health care outcomes and costs, identifying modifiable risk factors holds tremendous value. However, because SSIs after craniotomy are rare and most existing data comprise single-institution studies with small sample sizes, many are likely underpowered to discern for such factors. The objective of this study was to use a large hetereogenous patient sample to determine SSI incidence after nonemergent craniotomy and identify factors associated with readmission and subsequent need for wound washout.

Methods: We used the 2010-2014 Nationwide Readmissions Database cohorts to discern for factors predictive of SSI and washout.

Results: We identified 93,920 nonemergent craniotomies. There were 2079 cases of SSI (2.2%) and 835 reoperations for washout (0.89%) within 30 days of index admission and there were 2761 cases of SSI (3.6%) and 1220 reoperations for washout (1.58%) within 90 days. Several factors were predictive of SSI in multivariate analysis, including tumor operations, external ventricular drain (EVD), age, length of stay, diabetes, discharge to an intermediate-care facility, insurance type, and hospital bed size. Many of these factors were similarly implicated in reoperation for washout.

Conclusions: SSI incidence in neurosurgery is low and most readmissions occur within 30 days. Several factors predicted SSI after craniotomy, including operations for tumor, younger age, hospitalization length, diabetes, discharge to institutional care, larger hospital bed size, Medicaid insurance, and presence of an EVD. Diabetes and EVD placement may represent modifiable factors that could be explored in subsequent prospective studies for their associations with cranial SSIs.
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http://dx.doi.org/10.1016/j.wneu.2018.08.102DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6563908PMC
December 2018

Extracranial-Intracranial Bypass for Treatment of Blister Aneurysms: Efficacy and Analysis of Complications Compared with Alternative Treatment Strategies.

World Neurosurg 2018 Sep 18;117:e417-e424. Epub 2018 Jun 18.

Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California, USA.

Objective: Blister aneurysms (BAs) represent a clinical challenge without a consensus treatment strategy. We report our institution's experience with BAs with an emphasis on the use of extracranial-to-intracranial (EC-IC) bypass.

Methods: Seventeen patients with BAs (88% [15/17] ruptured) were treated with microsurgical techniques (5 clip wrappings, 4 clip ligations, 4 EC-IC bypasses and clip trappings, 2 internal carotid artery ligations [1 combined with clip wrapping], and 2 clip trappings).

Results: Six of 17 patients experienced intraoperative ruptures. There were no intraoperative ruptures among the bypass cases and 75% (3/4) of patients achieved a good neurologic outcome. Further, a literature review was performed to identify all previously reported cases of BAs undergoing clip ligation, clip wrapping, EC-IC bypass/clip trapping, and endovascular therapies, encompassing 246 BA cases across 33 studies. Intraoperative ruptures occurred in 29% of clip ligations (23/79), 27.2% of clip wrappings (6/35), 16.1% of EC-IC bypasses (5/31), and 0% of endovascular treatments. Aneurysm recurrence occurred in 2.97% (3/101) with endovascular therapies to 0% with EC-IC bypass. Mortality was 8.8% for clip ligation/wrapping (10/114), 6.5% for EC-IC bypass (2/31), and 4.0% for endovascular treatments (4/101).

Conclusions: Endovascular interventions have a favorable procedural safety profile but high rates of retreatment for persistent filling or posttreatment aneurysmal growth. Clip ligation and clip wrapping techniques have lower retreatment rates but slightly higher intraoperative risk. EC-IC bypass can safely provide definitive aneurysm securement and should be considered as a first-line therapy for BAs at high-volume bypass centers.
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http://dx.doi.org/10.1016/j.wneu.2018.06.046DOI Listing
September 2018

Increased Hospital Surgical Volume Reduces Rate of 30- and 90-Day Readmission After Acoustic Neuroma Surgery.

Neurosurgery 2019 03;84(3):726-732

Department of Neurological Surgery, University of Southern California, Los Angeles, California.

Background: Hospital readmissions are commonly linked to elevated health care costs, with significant financial incentive introduced by the Affordable Care Act to reduce readmissions.

Objective: To study the association between patient, hospital, and payer factors with national rate of readmission in acoustic neuroma surgery.

Methods: All adult inpatients undergoing surgery for acoustic neuroma in the newly introduced Nationwide Readmissions Database from 2013 to 2014 were included. We identified readmissions for any cause with a primary diagnosis of neurological, surgical, or systemic complication within 30- and 90-d after undergoing acoustic neuroma surgery. Multivariable models were employed to identify patient, hospital, and administrative factors associated with readmission. Hospital volume was measured as the number of cases per year.

Results: We included patients representing a weighted estimate of 4890 admissions for acoustic neuroma surgery in 2013 and 2014, with 355 30-d (7.7%) and 341 90-d (9.1%) readmissions. After controlling for patient, hospital, and payer factors, procedural volume was significantly associated with 30-d readmission rate (OR [odds ratio] 0.992, p = 0.03), and 90-d readmission rate (OR 0.994, p = 0.047). The most common diagnoses during readmission in both 30- and 90-d cohorts included general central nervous system complications/deficits, hydrocephalus, infection, and leakage of cerebrospinal fluid (rhinorrhea/otorrhea).

Conclusion: After controlling for patient, hospital, and payer factors, increased procedural volume is associated with decreased 30- and 90-d readmission rate for acoustic neuroma surgery. Future studies seeking to improve outcomes and reduce cost in acoustic neuroma surgery may seek to further evaluate the role of hospital procedural volume and experience.
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http://dx.doi.org/10.1093/neuros/nyy187DOI Listing
March 2019

Ruptured Mycotic Aneurysm of the Distal Circulation in a Patient with Mucormycosis Without Direct Skull Base Extension: Case Report.

Oper Neurosurg (Hagerstown) 2019 03;16(3):E101-E107

Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Background And Importance: Infectious intracranial aneurysms are a rare subset of intracranial aneurysms caused by bacterial, fungal, or viral sources. Intracranial aneurysms of fungal etiology carry a high mortality risk and typically occur in immunocompromised patients via direct extension of skull base infections, or more rarely, after intracranial surgery.

Clinical Presentation: We present the case of a 27-yr-old female with systemic lupus erythematous and primary pulmonary mucormycosis, who suffered a subarachnoid hemorrhage from a ruptured fusiform distal middle cerebral artery aneurysm. Despite undergoing a successful extracranial-to-intracranial bypass and aneurysm excision, the patient ultimately died following progressive disseminated infection and a secondary intracranial hemorrhage of unknown etiology. Pathological examination of the excised artery confirmed Mucor infection.

Conclusion: To the best of our knowledge, this case represents one of the first mycotic cerebral aneurysms from mucormycosis in a patient without an underlying skull base infection or previous intracranial surgery. Despite optimal surgical management, clinical outcomes for mycotic cerebral aneurysms are largely dependent on the success of medical therapies at controlling systemic disease.
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http://dx.doi.org/10.1093/ons/opy127DOI Listing
March 2019

Factors associated with burnout among US neurosurgery residents: a nationwide survey.

J Neurosurg 2018 11;129(5):1349-1363

10Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee.

OBJECTIVEExcessive dissatisfaction and stress among physicians can precipitate burnout, which results in diminished productivity, quality of care, and patient satisfaction and treatment adherence. Given the multiplicity of its harms and detriments to workforce retention and in light of the growing physician shortage, burnout has garnered much attention in recent years. Using a national survey, the authors formally evaluated burnout among neurosurgery trainees.METHODSAn 86-item questionnaire was disseminated to residents in the American Association of Neurological Surgeons database between June and November 2015. Questions evaluated personal and workplace stressors, mentorship, career satisfaction, and burnout. Burnout was assessed using the previously validated Maslach Burnout Inventory. Factors associated with burnout were determined using univariate and multivariate logistic regression.RESULTSThe response rate with completed surveys was 21% (346/1643). The majority of residents were male (78%), 26-35 years old (92%), in a stable relationship (70%), and without children (73%). Respondents were equally distributed across all residency years. Eighty-one percent of residents were satisfied with their career choice, although 41% had at some point given serious thought to quitting. The overall burnout rate was 67%. In the multivariate analysis, notable factors associated with burnout included inadequate operating room exposure (OR 7.57, p = 0.011), hostile faculty (OR 4.07, p = 0.008), and social stressors outside of work (OR 4.52, p = 0.008). Meaningful mentorship was protective against burnout in the multivariate regression models (OR 0.338, p = 0.031).CONCLUSIONSRates of burnout and career satisfaction are paradoxically high among neurosurgery trainees. While several factors were predictive of burnout, including inadequate operative exposure and social stressors, meaningful mentorship proved to be protective against burnout. The documented negative effects of burnout on patient care and health care economics necessitate further studies for potential solutions to curb its rise.
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http://dx.doi.org/10.3171/2017.9.JNS17996DOI Listing
November 2018

In situ administration of abciximab for thrombus resolution during intracranial bypass surgery: case report.

J Neurosurg 2018 01;130(1):268-272

Abciximab is a glycoprotein IIb/IIIa receptor antagonist that functions to prevent platelet aggregation, thus reducing thrombus initiation and propagation. It has been widely used during percutaneous endovascular interventions, such as aneurysm coil embolization, angioplasty, atherectomy, and stent placement, as both a preventative and a salvage therapy. The use of abciximab in cardiac and neurosurgical procedures has been associated with a reduced incidence of ischemic complications and a decreased need for repeated intervention. In these settings, abciximab has been delivered transarterially via a microcatheter or infused intravenously for systemic administration. The authors describe novel in situ delivery of abciximab as an agent to dissolve "white clots," which are composed primarily of platelets, during an intracranial superficial temporal artery to middle cerebral artery bypass in a 28-year-old woman with severe intracranial occlusive disease. Abciximab was able to resolve multiple platelet-based clots after unsuccessful attempts with conventional clot dispersal techniques, such as heparinized saline, tissue plasminogen activator, mechanical passage of a wire through the vessel lumen, and multiple takedowns and re-anastomosis. After abciximab was administered, patency was demonstrated intraoperatively using indocyanine green dye and confirmed postoperatively at 1 and 10 months via CT angiography. The in situ use of abciximab as an agent to disperse a thrombus during intracranial bypass surgery is novel and has not previously been described in the literature, and serves as an additional tool during intracranial vessel bypass surgery.
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http://dx.doi.org/10.3171/2017.8.JNS17430DOI Listing
January 2018
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