Neurosurgery

Curry, William T. Jr; Carter, Bob S.; Barker, Fred G. II

Neurosurgery. 66(3):427-438, March 2010.

doi: 10.1227/01.NEU.0000365265.10141.8E

BACKGROUND: Racial disparities in American health care outcomes are well-documented. OBJECTIVE: We investigated racial disparities in hospital mortality and adverse discharge disposition after brain tumor craniotomies performed in the US from, 1988 to 2004. We explored potential explanations for the disparities. METHODS: The data source was a nationwide inpatient sample. We utilized multivariate ordinal logistic regression corrected for clustering by hospital, and adjusted for age, sex, primary payer for care, income in postal code of residence, geographic region, admission type and source, medical comorbidity, treatment year, hospital case volume, and disease-specific factors. RESULTS: A total of 99,665 craniotomies were studied. Hospital mortality and adverse discharge disposition were more likely in black patients than others for all tumor types. Medicaid patients had higher mortality while private-pay patients had lower mortality. Hospital annual case volume was lower for black and Hispanic patients and for those with Medicaid as the primary payer in pooled analyses, while patients with private insurance received care at higher-volume hospitals. Black patients generally presented with higher disease severity. CONCLUSIONS: Black patients had a higher mortality and adverse discharge disposition after US tumor craniotomies in the period studied (1988–2004). Black patients had more severe disease at presentation and were treated at lower-volume hospitals for surgery. Other socially defined patient groups also showed disparities in access and outcomes of care.

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Meyer, Scott A.; Gandhi, Chirag D.; Johnson, David M.; Winn, H. Richard; Patel, Aman B.

Neurosurgery. 66(3):448-454, March 2010.

doi: 10.1227/01.NEU.0000365008.17803.AD

BACKGROUND: Carotid artery angioplasty and stenting (CAS) offers a viable alternative to carotid endarterectomy (CEA) for symptomatic and asymptomatic patients. OBJECTIVE: We evaluate the safety and efficacy of CAS in high surgical risk patients in a single neurovascular center retrospective review. METHODS: We analyze the clinical variables and treatment outcomes of 101 consecutive patients (109 stents) with carotid stenosis from July 2001 – March 2007 in high surgical risk patients with symptomatic and asymptomatic stenosis. RESULTS: Seventy-four percent of the patients were symptomatic (n = 81) and the mean stenosis in symptomatic patients was 83%. Reasons for stenting included: cardiac/pulmonary/medical risk (60%), contralateral ICA occlusion (8%), recurrent stenosis after CEA (11%), carotid dissection (6%), age greater than 80 (7%), previous radical neck surgery (7%), and previous neck radiation (1%). Stent deployment was achieved in 108/109 vessels (99%). Distal embolic protection devices were used in 72% of cases treated. The overall rate of in-hospital adverse events was 8.3% (9/109). Of these events, two patients (1.8%) suffered hemispheric TIA, two others (1.8%) suffered transiently symptomatic acute reperfusion syndrome. The 30-day stroke/death/MI risk was 4.6% (n = 5). CONCLUSIONS: CAS can be performed with a low 30-day complication rate. The results support the use of CAS in high surgical risk patients with significant symptomatic and asymptomatic carotid artery disease.

Abstract:

Haug, Tonje; Sorteberg, Angelika; Finset, Arnstein; Lindegaard, Karl-Fredrik; Lundar, Tryggve; Sorteberg, Wilhelm

Neurosurgery. 66(3):475-485, March 2010.

doi: 10.1227/01.NEU.0000365364.87303.AC

OBJECTIVE: The objective of this study was to determine cognitive functioning and health related quality of life one year after aneurysmal subarachnoid hemorrhage in preoperative comatose patients. METHODS: Patients were investigated for one year using a comprehensive neuropsychological test battery and two HRQOL questionnaires. RESULTS: Thirty-five of 70 patients survived the bleed, and 26 underwent neuropsychological testing. Two distinct patient groups emerged; one (n = 14) with good cognitive function, and the other (n = 12) with poor cognitive and motor function. Patients performing poorly were older (p = 0.04), had fewer years of education, (p = 0.005) larger preoperative ventricular scores, and were more often shunted (p = 0.02). There were also differences between the two groups in the Glasgow Outcome Scale (p = 0.001), modified Rankin Scale (p = 0.001), and employment status. HRQOL was more reduced in patients with poor cognitive function. CONCLUSION: A high fraction of survivors among preoperative comatose aneurysmal SAH patients (Hunt and Hess grade V patients) recover to a good physical and cognitive function.

Abstract:

Davidson, Andrew S. MS; Morgan, Michael K.

Neurosurgery. 66(3):498-505, March 2010.

doi: 10.1227/01.NEU.0000365518.47684.98

OBJECTIVES: We examine the risk of surgery for arteriovenous malformations (AVM) including cases excluded from surgery because of high surgical risk. METHODS: Data were collected on 640 consecutively enrolled AVMs in a database that specifically included all patients not considered for surgery. RESULTS: Patients with Spetzler-Martin grade 1–2 AVMs (n = 296) were treated with a surgical risk of 0.7% (95%CI 0 to 3%); patients with Spetzler-Martin grade 3–4 AVMs in noneloquent cortex (n = 65) were treated with a surgical risk of 17% (95%CI 10 to 28%). Patients with Spetzler-Martin grade 3–5 AVMs in eloquent cortex (n = 168) were treated with a surgical risk of 21% (95%CI 15 to 28%). CONCLUSIONS: The results of this series suggest that it is reasonable to offer surgery as preferred treatment option for Spetzler-Martin grade 1–2 AVMs. This study also reinforces the predictive value of the Spetzler-Martin grading system.

Abstract:

Cai, Rongsheng; Barnett, Gene H.; Novak, Eric; Chao, Samuel T.; Suh, John H.

Neurosurgery. 66(3):513-522, March 2010.

doi: 10.1227/01.NEU.0000365366.53337.88

BACKGROUND: Stereotactic radiosurgery (SRS) of meningiomas is associated with post-treatment peritumoral edema (PTE). OBJECTIVE: The purpose of this study was to evaluate the prevalence and risk factors of post-SRS PTE for intracranial meningiomas. METHODS: A total of 163 patients with 182 meningiomas treated with SRS were retrospectively reviewed. Tumors were divided into 4 pre-SRS groups by whether they had previous surgery and whether they had pre-existing PTE. Several risk factors were investigated by univariate and multivariate analysis. RESULTS: Of 182 tumors, 45 (24.7%) developed post-SRS PTE. Compared to tumors without preexisting PTE, the odds of developing post-SRS PTE in tumors with pre-existing PTE were 5.8 times higher in all tumors, and 6.9 times higher in tumors without previous surgery. CONCLUSION: Tumor-brain contact interface area, and pre-existing PTE were the most significant risk factors for post-SRS PTE.

Abstract:

Quest, Donald O.

Neurosurgery. 66(3):590-592, March 2010.

doi: 10.1227/01.NEU.0000364997.62303.E7

The year 2009 was the centennial of The Neurological Institute of New York, 1909–2009. The neurological institute was the first institution in the Americas dedicated solely to the care of patients with neurological illness. The proud traditions and accomplishments of this institution and its Department of Neurological Surgery, is depicted through the succession of the chairmen of the department over the past 100 years. This presentation is a succinct pictorial essay reviewing the history of the Neurological Institute of New York.

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