bluuebunny/crossref_metadata_2025 huggingface dataset:
496 Impact of the Mean Cochlear Biologically Effective Dose on Hearing Preservation After Stereotactic Radiosurgery for Vestibular Schwannoma
Authors: Tuleasca Constantin , Toma-Dasu Iuliana , Duroux Sebastien , George Mercy , Maire Raphael , Daniel Roy , Patin David , Schiappacasse Luis , Dasu Alexandru , Faouzi Mohamed , Levivier Marc
Published: March 2024

INTRODUCTION:

Stereotactic radiosurgery (SRS) is a useful alternative for small to medium size vestibular schwannoma (VSs).

METHODS:

This is a retrospective longitudinal single center study. Were analyzed 213 patients with useful baseline hearing. Risk of hearing decline was assessed for GR classes and pure tone average (PTA) loss. Mean follow-up period was 39 months (median 36, 6-84).

RESULTS:

Hearing decline (GR class) 3 years after SRS was associated with higher cochlear BEDGy2.47 mean (OR 1.39, p = 0.009). BEDGy2.47 mean was more relevant compared to BEDGy2.47 max (OR 1.13, p = 0.04). Mean (p = 0.91) and maximal (p = 0.66) cochlear doses were not statistically significant. Risk of PTA loss (continuous outcome, follow-up minus baseline) was significantly corelated with BEDGy2.47 mean at 24 (beta coefficient 1.55, p = 0.002) and 36 (beta coefficient 2.01, p = 0.004) months after SRS. Mean (p = 0.27) and maximal (p= 0.87) cochlear doses were not significant. Risk of PTA loss (> 20 dB versus <=20) was associated with higher BEDGy2.47 mean at 6 (OR 1.36, p= 0.002), 12 (OR 1.36, p = 0.007) and 36 (OR 1.37, p = 0.02) months. Mean cochlear dose was statistically significant only at 24 months. Risk of hearing decline at 36 months for BEDGy2.47 mean of 7-8, 10 and 12 Gy2.47 was 28%, 57% and 85%, respectively.

CONCLUSIONS:

Cochlear BEDGy2.47 mean is relevant for hearing decline after SRS and more relevant as compared with BEDGy2.47 max. Three years after SRS, this was sustained for all hearing decline evaluation modalities. Our data suggests BEDGy2.47 mean cut-off of <= 8 Gy2.47 for better hearing preservation rates.
497 Superficial MRI-guided Laser Interstitial Thermal Therapy (LITT) for Intracranial Metastasis Is Associated With a Significantly Higher Rate of Leptomeningeal Disease
Authors: Vohra Sanah , Torres Lisette , Harary Maya , Mozaffari Khashayar , Chow Ariana , Ivan Michael E. , Ellingson Benjamin , Kim Won , Yang Isaac
Published: March 2024

INTRODUCTION:

Evolving brain metastases treatment standards has led to shifting intracranial recurrence patterns, especially with respect to pachymeningeal and leptomeningeal disease (PMD/LMD). As an emerging technique, it remains unclear if the depth of magnetic resonance imaging-guided laser interstitial thermal therapy (LITT) is associated with frequency of iatrogenic PMD/LMD.

METHODS:

A single-institute retrospective analysis of patients who underwent LITT surgery between 2014 and 2022 was conducted to investigate the development of PMD/LMD. P-values <0.05 were considered statistically significant.

RESULTS:

Eleven patients undergoing thirteen LITT procedures were analyzed. Mean age was 62.6 (±11.7), and 69.2% of patients were female. PMD/LMD developed in 4/13 cases (30.8%). There was no significant difference between superficial vs. deep LITT ablation in terms of age, sex, follow-up time, and primary cancer site. Superficial LITT ablation had a significantly higher frequency of PMD/LMD compared to deep LITT ablation (p = 0.02). Time to PMD/LMD development among patients who underwent superficial LITT ablation was significantly shorter compared to that among patients who had deep LITT ablation (p = 0.02).

CONCLUSIONS:

Superficial LITT ablation was associated with significantly higher frequency and shorter time to PMD/LMD development compared to deep LITT ablation. These results suggest that iatrogenic PMD/LMD spread during superficial LITT ablation may increase the proportion of PMD/LMD and accelerate disease timeline.
500 Endoscopic Endonasal Resection of the Medial Wall of the Cavernous Sinus: Initial Experience and Impact on Pituitary Surgery Outcomes
Authors: Sanchez-Garavito Jesus Emiliano , Perez-Vega Carlos , Alvarez-Caicedo Diana , Figueredo Luisa Fernanda , Navarro Garcia de Llano Juan Pablo , Michaelides Loizos , Ramos-Fresnedo Andres , Donaldson Angela , Olomu Osarenoma , Samson Susan , Quinones-Hinojosa Alfredo , Chaichana Kaisorn L. , Almeida Joao P.
Published: March 2024

INTRODUCTION:

Invasion of the medial wall of the cavernous sinus (CS) by pituitary tumors is a factor associated with persistence of disease and subtotal resection of these tumors. Resection of the medial wall of the CSis therefore an option for maximum resection of such tumors, however, there is concern with potential complications associated with this technique and at this time, limited data is available in the literature.

METHODS:

Single center retrospective study evaluating patients that underwent endoscopic endonasal resection of pituitary adenomas and resection of the medial wall of the CS, between January 2022 and February 2023. Extent of resection, remission rates, complications and histopathological diagnosis were assessed.

RESULTS:

Out of a population of 120 pituitary surgeries, sixteen cases were eligible for this study. 5 (31.2%) patients had non-functional adenomas, and 11 (68.7%) had functional adenomas, including 4 adrenocorticotropic hormone, 3 prolactin, 3 growth-hormone, 1 pluri-hormonal (GH and prolactin)—secreting tumors. Complete tumor resection, based on intraoperative impression and postoperative MRI, was achieved in all cases. At last follow-up, complete biochemical remission (using current criteria) was seen in 11 cases (100%) of functional adenomas. One case developed pulmonary embolism and another one sino-nasal infection postoperatively. No fatalities, carotid injuries or cranial nerve palsies were reported.

CONCLUSIONS:

Resection of the medial wall of the cavernous sins, performed when there is potential tumor extension into the medial wall, is associated with high rates of disease control. It is particularly useful in cases of functioning but also has a role in non-functional adenomas adherent to the medial wall of the CS. Long term follow up is necessary to evaluate the durability of these results.
502 Endoscopic Versus Microsurgery Resection of Third Ventricle Colloid Cysts: A Single-center Case-series of 140 Consecutive Patients
Authors: Mohammadi Esmaeil , Sharifi Guive , Jafari Ali , Bahranian Arefeh , Paraandavaji Elham , Daneshmand Yahya , Mohammadkhani Maryam
Published: March 2024

INTRODUCTION:

The resection of colloid cysts of third ventricle can be done with either open microsurgery or endoscopy with each having different cons and pros.

METHODS:

Data of patients who underwent surgical resection of third ventricle colloid cyst via either endoscopic or microsurgery approach by a single surgeon between 2005-2020 were retrospectively collected. After administration of criteria, 140 records were retrieved (60 through endoscopic and 80 by trans-cranial microsurgery). Clinical and surgical measures were compared between approaches after adjustment for confounders with generalized linear multivariate regression.

RESULTS:

Length of hospital stay, postoperative meningitis, and operation time, cyst size, and baseline comorbidities did not differ between groups. Gross total resection (GTR) was achieved for all cases in microsurgery group while in endoscopic group it was lower (90% vs 100%; p = 0.005). Intraoperative hemorrhage occurred in 14 (23.3%) of endoscopic patients while for microscopic group it was zero (p < 0.001). Post-operative shunt was required for two patients (one in endoscopic group and the other in microscopic group). Two patients had tumor recurrence, both being in endoscopic group. No mortality was detected in either group. Multivariate analyses were insignificant for the effects of clinical and demographic factors in occurrence of worse surgical outcomes (non-GTR and hemorrhage).

CONCLUSIONS:

Rate of intra-operative hemorrhage was higher in endoscopic method and GTR was lower, even after adjustment for other factors. This could be due to technologic shortcomings and limited space for resection maneuvers and complication management.
503 Engineering GBM-specific T Cells Using Photothermal Prussian Blue Nanoparticles
Authors: Sanchez Carlos Esmond , Sweeney Elizabeth , Sekhri Palak , Muniraj Nethaji , Chen Jie , Bollard Catherine , Cruz Conrad Russell , Fernandes Rohan
Published: March 2024

INTRODUCTION:

Adoptive T cell therapy (ATCT) has successfully treated hematological malignancies and is currently under investigation for solid tumor therapy. In contrast to existing chimeric antigen receptor (CAR) T cell and/or antigen-specific T cell approaches, which target defined antigens, our PBNP-based approach can target a broad repertoire of antigens in GBM in an antigen-agnostic manner.

METHODS:

We treated GBM cells with PBNP-based photothermal therapy (PBNP-PTT) prior to culturing with dendritic cells (DCs), and subsequent stimulation of T cells.

RESULTS:

When PBNP-PTT was administered to U87 cells at an immunogenic thermal dose, we effectively expanded U87-specific T cells. DCs cultured ex vivo with PBNP-PTT-treated U87 cells enabled 15- 30-fold expansion of CD4+ and CD8+ T cells. Upon co-culture with target U87 cells, these T cells secreted IFN-G in a specific and dose-dependent manner (up to 647-fold over controls). T cells manufactured using PBNP-PTT elicited specific cytolytic activity against target U87 cells (33-93% killing at an E:T ratio of 20:1), while sparing normal human astrocytes. Similarly, PBNP-PTT on SNB19 cells resulted in a 7-39-fold expansion of T cells, which elicited 25-66% killing of SNB19 cells at an E:T ratio of 20:1. U87-luc cells were then orthotopically inoculated into NSG mice to establish xenograft GBM, and U87-specific T cells developed via PBNP-PTT were intracranially injected. These T cells eliminated U87 tumors in vivo and significantly improved mouse survival compared to mice treated with PBS (p = 0.0047) or non-specific T cells (p = 0.0123) from the same donor.

CONCLUSIONS:

These findings provide proof-of-concept data supporting the use of PBNP-PTT to stimulate and expand tumor-specific T cells ex vivo for potential use as an ATCT approach for patients with GBM. We are currently using patient-derived tumor samples to generate IND-enabling data.
504 Anterior-posterior Diameter Is a Key Driver of Resectability and Complications for Pituitary Adenomas With Suprasellar Extension in Endoscopic Transsphenoidal Surgery
Authors: Park Jung , Golub Danielle , White Timothy G. , Ruelle Marianne , Yang Kaiyun , Shah Harshal , Eisenberg Mark B. , Dehdashti Amir R.
Published: March 2024

INTRODUCTION:

As endoscopic transsphenoidal approaches are more routinely selected for larger pituitary adenomas with parasellar extension, understanding potential anatomical factors that limit resection and contribute to complications becomes increasingly important.

METHODS:

A single-center retrospective review of all endoscopic transsphenoidal surgeries for pituitary adenomas with suprasellar extension from 2015-2020 was performed. Preoperative MRIs were systematically assessed to assign a Knosp classification, a Zurich Pituitary Score (ZPS), and to measure lesional suprasellar dimensions. Univariate comparisons and multivariate regression models were employed to assess the influence of these factors on extent of resection (EOR) and postoperative complications.

RESULTS:

Of the 96 patients with suprasellar pituitary adenomas who underwent endoscopic transsphenoidal surgery, 74 patients (77%) had a gross total resection (GTR). Neither Knosp grade nor ZPS were associated with GTR (Knosp 3A-4 versus Knosp 0-2, p = 0.069; ZPS III-IV versus ZPS I-II, p = 0.079). Multivariate regression identified suprasellar anterior-posterior tumor diameter (SSAP) as the only significant predictor of EOR (OR 0.951, 95% CI 0.905-1.000, p = 0.048*). Higher SSAP also showed the strongest association with an increased overall complication rate (p = 0.0003*) and intraoperative CSF leaks (p = 0.0012*). Further analysis of the regression model for GTR suggested an optimal cut point value for SSAP of 23.7 mm, above which predictability for failing to achieve GTR carried a sensitivity of 89% and specificity of 41%.

CONCLUSIONS:

This study is unique in its examination of endoscopic transsphenoidal surgical outcomes for pituitary adenomas with suprasellar extension. Our findings suggest that previously established grading systems based on lateral extension into the cavernous sinus lose their predictive value in lesions with suprasellar extension and, more specifically, with increasing suprasellar anterior-posterior diameter.
508 Preparing Physicians For Failures: A Needs Assessment
Authors: Williamson Theresa , Wang Keying , Hadis Syntia , Duerr Emily , Mitchell Taylor , DeGaetano Aimee , Lovett Ben , Levy Elad I. , Lin Xiaodong
Published: March 2024

INTRODUCTION:

Although anecdotal evidence points to high levels of stress among neurosurgeons and trainees, there is little systematic research documenting the nature of stress in detail.

METHODS:

We conducted a detailed survey of neurosurgeons and trainees, obtaining 22/26 responses (85% response rate) with 2 responses removed for missingness. Participants were purposefully sampled from two academic center neurosurgery programs.

RESULTS:

Participants reported more high-arousal negative emotions (particularly frustration and anxiety) than low-arousal negative emotions (e.g., helplessness, discouragement), suggesting relatively high levels of motivation. Within training levels, sources of stress varied considerably, suggesting the need for tailored approaches to stress management. Attendings reported quite a lot of stress from patient expectations and administrative constraints, whereas trainees focused more on teamwork and difficult patients. A focus on processes and specific mechanisms of problems at work was associated with more high-arousal emotions, whereas a focus on outcomes was associated with low-arousal emotions; this pattern is consistent with prior research on other populations. As expected, residents were most likely to use coping strategies that reflected a lack of control over one’s schedule (e.g., immersing oneself in work) whereas attendings were most likely to use healthy strategies, particularly physical exercise. Only one of the 20 participants reported seeking professional support due to stress; residents were most likely to attribute this to a lack of time or resources but most participants did not feel a need to seek professional help. Attendings were least likely to report ideas for what education or training they could have benefited from to better cope with stress.

CONCLUSIONS:

This work points to key ways dealing with failure and stress contributes to individual well-being as well as neurosurgical culture.
688 Stratified Assessment of Treatment Approach for Craniocervical Junction Arteriovenous Fistulas: A Multicenter Cohort and Pool Analysis
Authors: Li Zongze
Published: March 2024

INTRODUCTION:

Cranio-cervical junction arteriovenous fistulas (CCJ-AVFs) are complex vascular shunts that present a challenge for treatment.

METHODS:

We conducted a retrospective analysis of 132 patients who underwent microsurgery or endovascular embolization for CCJ-AVF. The baseline characteristics, angioarchitectural features, and clinical outcomes were compared between the two treatment groups. A subgroup analysis was also performed in CCJ-AVF with carotid artery feeders.

RESULTS:

The complete obliteration rate was 97.1% in the microsurgery group, 85.3% in the embolization via carotid artery (CA) approach group, and 62.5% in the embolization via vertebral artery (VA) approach group. After adjusting for baseline and confounding features, the occlusion rate was significantly lower in embolization via VA approach (adjusted OR, 0.04; 95% CI, 0.005-0.40, p = 0.006). None of the patients in the microsurgical group appeared new-onset infarction, while 1 (2.9%) in CA embolization and 3 (12.5%) in VA embolization suffered new-onset infarction after treatment. The neurological improvement rate of microsurgery was similar to that of embolization via CA approach. Embolization via VA was associated with less neurological improvement (adjusted OR, 0.11; 95% CI, 0.03-0.38, p = 0.001). In the subgroup analysis of CCJ-AVF with CA feeders, the occlusion rate and neurological improvement of embolization via CA approach were comparable to those of microsurgery.

CONCLUSIONS:

Our study suggests that microsurgery and embolization via CA approach can achieve similar clinical outcomes for CCJ-AVF. Embolization via VA approach may result in a lower occlusion rate and less neurological improvement. In CCJ-AVF with CA feeders, embolization via CA approach may be a safe and effective alternative to microsurgery.
689 Technical Success and Occlusion Rates of eCLIPs Bifurcation Remodeling System for Treatment of Wide-neck Bifurcation Aneurysms: Summary of the Early Experience
Authors: Ghozy Sherief , Abdelghaffar Mariam , Motawei Ahmed Sallam , Kallmes David , Kadirvel Ramanathan
Published: March 2024

INTRODUCTION:

Wide-necked bifurcation aneurysms (WNBA) are among the most difficult aneurysms to treat. Very low dome-to-neck and aspect ratios provide an even greater challenge in the management of WNBAs.

METHODS:

A systematic review and meta-analysis was conducted following the PRISMA recommendations. On April 4, 2022, we searched for eligible papers in Pubmed, Web of Science (ISI), Scopus, and Embase databases. The meta-analysis was done using R software version 4.3.0. and the "meta" package. Pooled prevalence (%) and their corresponding 95% confidence intervals (CI), random-effects model based and the generalized linear mixed models (GLMMs) method. On the presence of multiple follow-up points, we included the last available in the analysis. Complete occlusion was defined as Raymond–Roy occlusion classification (RROC) class I, and adequate occlusion was defined as RROC class I or II.

RESULTS:

Four studies were finally included following the double-reviewer screening of the retrieved literature. The patients' mean age ranged from 56 ± 5.4 to 60±9.2 years, and 82.5% were females. The mean follow-up duration ranged from 8 ± 6.6 months to 28.8 ± 17.6, with all studies giving dual antiplatelet regimens and one added heparinization to their anticoagulation protocol. Technical success was achieved in 88.61% (95% CI = 75.54-95.15) of the cases, while successful adjunctive coiling was obtained in 91.38% (95% CI = 70.71-97.90) of them. The complete occlusion rate was 50.65 (95% CI = 39.63-61.60), while the adequate occlusion rate was 84.42 (95% CI = 74.53-90.93). There was no significant heterogeneity in all pooled outcomes.

CONCLUSIONS:

The early experience of the device shows an efficacy profile comparable with the currently available devices in treating WNBAs.
692 Impact of Dual Antiplatelet Therapy After Stent-assisted Coiling of Unruptured Aneurysms on Risk of Complications
Authors: Ringer Andrew J. , Hanel Ricardo , Baig Ammad , Siddiqui Adnan Hussain , Lopes Demetrius K. , Levitt Michael Robert , Naylor Ryan M. , Lanzino Giuseppe , Crowley R. Webster , Serrone Joseph , Kan Peter T. , Binning Mandy Jo , Veznedaroglu Erol , Boulos Alan S. , Tawk Rabih G.
Published: March 2024

INTRODUCTION:

Despite some consensus on the need for perioperative dual antiplatelet therapy (DAPT) after stent-assisted coiling (SAC), the ideal duration of therapy is not clear.

METHODS:

Ten institutions retrospectively reviewed data from databases prospectively maintained as part of a collaborative research group. Patients with unruptured intracranial aneurysms treated with DAPT following SAC (excluding flow diverters) between January 1, 2016 and December 31, 2020 with at least 6 months follow-up. Records were reviewed for type and duration of DAPT before and after SAC, type of stent, outcome (mRS), follow-up duration, peri-procedural and delayed complications, and rate of significant in-stent stenosis. Complications were considered “during period of risk” if they occurred during DAPT when short term had completed (hemorrhagic) or after completing DAPT when long term continued (thrombotic).

RESULTS:

556 patients were reviewed. 450 met all inclusion criteria. Nine patients treated for fewer than 29 days after SAC and 10 treated 43-89 days were excluded from analysis. 80 were treated with short-term DAPT (30-42 days), 188 with medium term (90-179 days), and 163 with long term (180+ days). There were no significant differences in the rate of thrombotic complications during the period of risk in short (1/80; 1.25%), medium (2/188; 1.1%) or long (0/163; 0%) term groups, but rates of hemorrhagic complications were lower in the short-term group (0/80; 0%) versus medium (3/188; 1.6%) or long (1/163; 0.6%). Longer duration DAPT did not reduce the risk of in-stent stenosis (0%; 2.5%; 3.2%).

CONCLUSIONS:

Continuing DAPT beyond 42 days after SAC did not reduce the risk of thrombotic complications or in-stent stenosis and may increase the risk of hemorrhagic complications. It may be reasonable to discontinue DAPT after 42 days following SAC.
693 Treatment Differences of Ruptured Versus Unruptured Wide Neck Aneurysms: Insights From the EVERRUN Registry
Authors: Hardigan Trevor , Hendricks Benjamin K. , Yoon James Seungwon , Kellner Christopher P. , Lawton Michael T. , Mocco J. D. , Mascitelli Justin Robert
Published: March 2024

INTRODUCTION:

Wide neck aneurysms (WNAs) are more challenging to treat compared to narrow neck aneurysms, requiring more advanced techniques. The Wide Neck / EVERRUN Registry compared endovascular versus microsurgical techniques for unruptured and ruptured aneurysms.

METHODS:

Saccular and not previously treated WNA were examined. WNA definition was aneurysm neck=4mm or dome-to-neck-ratio (DTNR)<2. Differences in treatment strategy (EVT vs. MS) and angiographic results were the primary outcomes. Angiographic outcome was assessed immediately following treatment and at last follow-up using the Raymond-Roy scale (core lab review, adequate occlusion: RR 1-2). Statistical significance set at p<0.05. All analysis performed using R(v.4.2.1).

RESULTS:

310 WNA were included (87 ruptured (R) aneurysms vs. 223 unruptured (U)). There were no significant differences in the rate of EVT vs. MS between ruptured (R) vs. unruptured (U) aneurysms (Clipping, R: 36.8%, U: 37.7%). Amongst EVT, ruptured WNA were treated more with stand-alone coiling (R: 27.6%, U: 5.8%) and balloon-assisted coiling (R: 32.2%, U: 10.8%). Unruptured aneurysms were more commonly treated with flow diversion (R: 1.1%, U: 22.9%) and stent-assisted coiling (R: 2.3%, U: 21.5%) (p < 0.05 for all). Ruptured aneurysms had higher rates of adequate angiographic occlusion after initial treatment (R: 88.5%, U: 74.3%) (p < 0.05). There was no difference in final adequate occlusion at follow-up (R: 90.1%, U: 90.7%). Ruptured WNA had higher retreatment rates (R: 14.3%, U: 3.1%) (p < 0.05). Ruptured WNA had more procedural complications (R: 28.7%, U: 17%) (p < 0.05). Rates of good mRS (0-2) at one year were higher in unruptured WNA patients (R: 72.8%, U: 90.3%) (p < 0.05).

CONCLUSIONS:

WNA rupture status significantly influences the EVT choice, likely based on the need for DAPT. The lower initial adequate occlusion in the unruptured cohort is likely due to more flow diverter use. Ruptured WNAs were more difficult to treat as evidenced by higher rates of retreatment and procedural complications, however this did not impact the final angiographic outcomes.
694 Morphological Differences of Ruptured Versus Unruptured Wide Neck Aneurysms: Insights From the EVERRUN Registry
Authors: Hardigan Trevor , Hendricks Benjamin K. , Yoon James Seungwon , Kellner Christopher P. , Lawton Michael T. , Mocco J D. , Mascitelli Justin Robert
Published: March 2024

INTRODUCTION:

Wide neck aneurysms (WNAs) have been defined as having a neck width >4 mm (N > 4) and/or dome-to-neck ratio <2 (DTNR < 2). Despite literature detailing treatment options for WNAs, there has been less study on the natural history of WNAs.

METHODS:

Ruptured and unruptured, saccular, not previously treated WNAs (N > 4, DTNR < 2, or both) were included. Differences in WNA morphology and patient demographics were compared between ruptured (R) and unruptured (U) cohorts. Statistical significance set at p < 0.05. All analysis performed using R(v.4.2.1).

RESULTS:

There were 310 WNA (87 R vs. 223 U). There were more females in both groups (R: 80.5%, U: 75.8%). Ruptured WNA were smaller (neck size R: 3.72 ± 1.39 mm, U: 4.5 ± 1.78 mm; dome width R: 5.04 ± 2.39 mm, U: 6.29 ± 3.37 mm, p < 0.05) with a trend towards reduced height (R: 5.04 ± 2.16 mm, U: 5.74 ± 3.01 mm) (p = 0.05). Ruptured aneurysms had higher rates of DTNR<2 alone (R: 60.9%, U: 42.2%) and unruptured aneurysms had higher rates of combined DTNR <2 and N >4 (R: 34.5%, U: 50.7%, p < 0.05). N > 4 alone was more prevalent in the unruptured cohort (R: 4.6%, U: 7.2%). ICA-Pcomm location (R: 21.1%, U: 9.4%) and AComm (R: 24.1%, U: 15.2%) were more common in the ruptured cohort. ICA-Oph location was more common in the unruptured cohort (R: 2.3%, U: 17.0%) (p < 0.05). Higher percentages of Asian (A), African American (AA), and Hispanic (H) patients were in the ruptured cohort compared to Caucasian (C) patients (A, R: 6.9%, U:0.9%; AA, R: 12.6%, U: 7.2%; H,R: 35.5%, U: 29.6%; C,R: 42.5%,U: 60.1%) (p < 0.05).

CONCLUSIONS:

Ruptured WNAs tend to be smaller with unfavorable DTNR whereas unruptured WNAs tend to be larger with a favorable DTNR. Higher rates of Pcomm/Acomm location in ruptured WNA are consistent with previous studies of all aneurysms. The significant racial disparity in ruptured vs. unruptured WNAs highlights the need to examine the biological and societal risks underlying these results.
696 Optimal Management Strategy for Carotid Cavernous Aneurysm From Cost-effectiveness Perspective
Authors: Salih Mira , Young Michael , Ramapriyan Rishab , Shutran Max , Taussky Philipp , Ogilvy Christopher S.
Published: March 2024

INTRODUCTION:

Most cavernous carotid aneurysms (CCAs) are asymptomatic benign lesions; therefore, they are frequently detected during routine clinical diagnostic processes. Most providers recommend routine surveillance instead of immediate management for CCAs given a natural history with a low risk of life-threatening complications. However, the cost-effectiveness of such care and the optimal follow-up interval remains unknown.

METHODS:

A decision analysis study was performed utilizing a Markov model with Monte Carlo simulations to simulate patients undergoing treatment or routine surveillance at different time intervals (half, 1-,2-,3-, 5-and 7-year intervals) for different size of CCAs (=<12 mm, 13- 24 mm, >=25 mm ). Input data for the model was extracted from the current literature. Probabilistic and deterministic sensitivity analyses were performed to evaluate the robustness of the Model.

RESULTS:

On base case analysis, following-up every 2 years with noninvasive imaging is the most cost-effective strategy for CCAs =< 12 mm, while annual follow up is cost-effective for large/giant (13-24 mm, >=25 mm) CCAs. The conclusions remain robust in probabilistic sensitivity and deterministic sensitivity analyses. As the risk of thrombo-embolic event gets higher and annual growth risk and annual rupture risk of CCAs increases, immediate treatment for large/giant (13- 24 mm, >=25 mm ) CCAs and annual follow up even prompt treatment for CCAs =< 12 mm is optimal.

CONCLUSIONS:

The most cost-effective management strategy for CCAs=< 12 mm and large/giant CCAs are following up every 2 years and following up every year, respectively. More frequent follow-up strategies or prompt preventive treatment for CCAs =< 12 mm and immediate treatment for large/giant CCAs would be more appropriate in patients with higher risk factors for cerebral ischemia, aneurysm growth and aneurysm rupture.
699 Immune Activation on Stroke Thrombus Proteome Associated With Failed First Pass Recanalization by Thrombectomy
Authors: Akkipeddi Sajal Medha , Rahmani Redi , Ellens Nathaniel R. , Kohli Gurkirat S. , Houk Clifton , Schartz Derrek , Chittaranjan Siddharth , Jalal Muhammad Ibrahim , Worley Logan , Bhalla Tarun , Mattingly Thomas , Morrell Craig , Bender Matthew T.
Published: March 2024

INTRODUCTION:

Endovascular thrombectomy remains one of the most potent tools in the treatment kit for acute ischemic stroke. Prior cursory histopathological studies have demonstrated relationships between cellular composition of the thrombus and successful endovascular treatment.

METHODS:

Quantitative proteomes were generated using mass spectrometry from thromboembolic material from 59 stroke patients retrieved by mechanical thrombectomy. Clinical data, including whether or not Thrombolysis In Cerebral Infarction (TICI) score of 2b or greater was achieved on the first pass (FP±), was gathered by retrospective chart review. FP effect was related to the clinical variables, as well as the abundances of proteins identified by mass spectrometry. Finally, gene ontology and KEGG pathway analysis was used to examine the functional implications of proteins significantly associated with FP±.

RESULTS:

Both discharge and 90-day follow-up mRS were significantly greater in greater in patients who were FP- (Wilcoxon; Z = -1.84, -2.32; p = 0.03, 0.01). Additionally, mortality was significantly associated with FP effect (Fisher’s; p = 0.04). Numerous proteins were negatively and positively associated with FP± (Wilcoxon; 1.6 < |Z| < 2.8, p < 0.05). Notably, several neutrophil and histone proteins were associated with FP- thrombectomy (Wilcoxon; |Z| > 1.9, p < 0.05). GO tags represented in the proteins FP- thrombectomy included, among others, immune activation and granule secretion (padj < 0.001). KEGG pathways significantly represented in the FP- group also include immune activation, in particular neutrophil degranulation (padj < 1E-13).

CONCLUSIONS:

This study suggests that not only is angiographic FP effect significantly associated with short and long-term functional outcomes, but it is also associated with significant proteome-level differences in the composition of retrieved stroke thrombi. Specifically, immune activation may be related to failure to achieve FP recanalization.
704 Different Therapeutic Effects on the Ipsilateral Retinal-choroidal Blood Flow and the Visual Acuity Between Carotid Endarterectomy and Carotid Artery Stentinga
Authors: Oya Soichi , Yoshida Shinsuke , Saito Akira , Iihoshi Satoshi , Shojima Masaaki , Obata Hiroto , Yamazaki Atsushi , Ooigawa Hidetoshi , Kohyama Shinya , Kikkawa Yuichiro , Kurita Hiroki
Published: March 2024

INTRODUCTION:

We previously reported that ipsilateral retinal-choroidal blood flow increased, and ipsilateral visual acuity improved after carotid endarterectomy (CEA) for internal carotid artery stenosis.

METHODS:

Twenty-eight patients who underwent CAS at participating centers were enrolled for this prospective observational study. Retinal-choroidal blood flow was evaluated by Mean Blur Ratio (MBR) with Laser Speckled Flowgraphy before and after CAS. In addition, visual acuity was measured precisely with the CSV-1000 before and after surgery. The MBR was defined as an increase in retinal blood flow above 1.14 based on the results of measurements in normal subjects.

RESULTS:

MBR significantly increased after CAS (MBR 34.2 vs 34.3, p = 0.02), but there was no improvement in the CSV-1000 score observed after CEA as shown in our previous CEA study (4.8 vs 4.9, p = 0.57). Furthermore, the CSV-1000 score did not improve after CAS even when the evaluation was limited to the group with a significant increase in MBR.

CONCLUSIONS:

The improvement in visual function after CEA that we have shown in the past was not observed after CAS. One reason for this is that postoperative MRI showed scattered microembolic infarctions after CAS in 17.9% (5 patients), whereas 7.3% after CEA in our previous study, which may have caused micro-occlusion of the retinal arteries. Although a direct comparison cannot be conducted, postoperative microembolism occurred in only 7.3% (3/41 patients) in our previous study that demonstrated improved vision after CEA. We also cannot rule out the possibility that intraoperative microemboli caused the deterioration of higher brain functions such as visual cognition, leading to the decreased score of the CSV-1000. This study might provide details on the therapeutic effects of carotid revascularization other than stroke prevention and may contribute to optimizing treatment choices for individual patients.
705 Urgent or Emergent Endovascular Intervention for Neurological Deficits Post-carotid Endarterectomy: A Single-institutional Case Series and Systematic Review of the Literature
Authors: Porto Carl Michael , Sastry Rahul , Moldovan Krisztina , Torabi Radmehr
Published: March 2024

INTRODUCTION:

Historically the management of acute neurological deficit following carotid endarterectomy (CEA) has been operative re-exploration; however, given the proliferation of endovascular techniques, and utilization of CT angiography, endovascular intervention is an alternative to redo-CEA.

METHODS:

All patients undergoing CEA in the Department of Neurosurgery at Rhode Island Hospital (Providence, RI) were reviewed. A systematic literature review was conducted in PubMed according to PRISMA guidelines to identify papers relevant to endovascular procedures addressing acute neurological deficits following CEA, which yielded 2499 unique articles. Review by 2 investigators revealed 12 relevant articles.

RESULTS:

Four patients from our institutional cohort met inclusion criteria. Among these, stenting was technically successful in 3 patients, 2 of which achieved near-full recovery. One patient underwent successful carotid stenting and ipsilateral M2 thrombectomy for tandem occlusion. Stent placement was unsuccessful in the remaining patient due to mechanical constriction. Articles obtained through the literature review revealed 57 further relevant cases. Of those with sufficiently complete data, 30/39 (76.9%) were male with an age range of 43 - 78 years old. Twenty-eight of 32 (87.5%) patients underwent CEA for symptomatic carotid stenosis. Post-CEA angiographic evaluation was most commonly conducted for routine completion imaging (21/57, 36.8%), non-specific stroke symptoms (15/57, 26.3%), and extremity weakness (7/57, 12.3%). Thrombotic stenosis (23/43, 53.4%) and arterial dissection (15/43, 34.9%) were the most common angiography findings. Two (3.5%) stent procedures were unsuccessful, and in the immediate postoperative period 8 patients (14.0%) had significant neurological deficits and only 3 deaths (5.3%) were reported.

CONCLUSIONS:

Endovascular intervention may be considered in situations where patients have neurological deficit after CEA. Direct comparison of outcomes in patients who have endovascular intervention vs. redo CEA may help identify the optimal management strategy.
709 Establishment of an Early ICU De-escalation Pathway Using the Modified Frailty Index Among Angiogram-Negative Subarachnoid Hemorrhage Patients
Authors: McIntyre Matthew , Cheaney Barry , Jia-Xin Liu Jesse , Dogan Aclan , Sanusi Olabisi
Published: March 2024

INTRODUCTION:

Angiogram-negative subarachnoid hemorrhage (ANSAH) may have a benign clinical course. Our standard practice is to observe ANSAH patients for a prolonged period in the ICU. Previous work has established frailty as a strong predictor of ANSAH outcomes.

METHODS:

A retrospective cohort analysis was performed among patients admitted between 2011 and 2022 with non-traumatic subarachnoid hemorrhage and initial angiogram (DCA) negative for source. Primary endpoints were in-hospital complications, discharge home, and length-of-stay (LOS). Cost analysis was performed using hospital charges.

RESULTS:

101 patients were included with an average age of 59.7 ±1.2 years, Hunt and Hess score of 2.0 ± 0.1, and 51 (50.5%) with a perimesencephalic hemorrhage distribution. 2 patients had a subsequent DCA showing aneurysmal etiology, both of whom would have been considered high risk. 38 (37.6%) were frail, 38 (37.6%) required an EVD, and 68 (67.3%) were intact on arrival. Multivariate analysis showed that frailty but not age or perimesencephalic distribution predicted the 3 primary endpoints (p < 0.039) while lack of EVD predicted LOS (p = 0.004) and intact neurologic exam predicted discharge home (p = 0.043). Low-risk patients (40/101, 39.6%) had no deaths, significantly reduced odds of any complication (OR 0.14, 95%CI: 0.04-0.44, p < 0.001), increased odds of discharge home (OR 9.98; 95%CI: 2.19-45.46, p < 0.001), and shorter LOS (7.8 ± 0.4 v. 14.7 ± 1.1 days, p < 0.001). Assuming a 6-day ward stay after 1-day of ICU observation, early de-escalation of low-risk ANSAH patients would, on average, save $20,177.70 per patient.

CONCLUSIONS:

Non-frail ANSAH patients who are neurologically intact and without an EVD are likely to have a benign clinical course and may benefit from early ICU de-escalation.
767 Racial and Gender Disparities in Traumatic Brain Injury Clinical Trial Enrollment
Authors: Bah Momodou G. , Naik Anant , Barrie Umaru , Dharnipragada Rajiv Sai , Eden Sonia Veronica , Cramer Samuel , Arnold Paul M.
Published: March 2024

INTRODUCTION:

Despite the increasing number of women and racial/ethnic minorities sustaining Traumatic Brain Injuries (TBI), they are underrepresented in TBI clinical trials.

METHODS:

The authors conducted a review of TBI clinical trials with reported results registered in ClinicalTrials.gov between 2008 and 2022. The studies were assessed for the proportion of women and racial/ethnic minorities enrolled as well as their reporting of race and gender-specific characteristics such as Gender Ratio (GR) and Racial Diversity Index (RDI). Furthermore, study parameters including year and duration, phase, trial design, type of funding, and trial completion were included.

RESULTS:

135 clinical trials met inclusion criteria, of which 65 and 134 reported race and gender, respectively. 25 trials were found to have existing racial disparity (RDI < 1). Comparatively, industry-funded trials had a 26% more likelihood of racial disparities (p = 0.026), whereas federally-funded trials were 30% less likely (p = 0.031). 66 trials had gender disparities (GR < 0.4) present, with federally-funded trials having 37.1% greater rates of gender disparity (p < 0.001, aOR: 5.47, 95% CI: 2.26-14.25). The impact of funding source on race and gender remained significant despite adjusting for other covariates in the multivariate analyses. Racial disparity was negatively correlated with trial completion rate (p < 0.001). Disparities were not found to improve over the 14-year span.

CONCLUSIONS:

Racial and gender disparities in TBI clinical trial enrollment persist, and the lack of diversity may lead to biased evidence-based medicine. Efforts should be made to increase the representation of women and racial/ethnic minorities in TBI clinical trials to ensure equitable access to effective treatments for all populations.
784 Effects of Optimal Versus Suboptimal Median Household Income on the Operative Traumatic Brain Injury Population: A Propensity Score-matched Analysis
Authors: Ravina Kristine , Safransky Michelle , Sconzo Daniel , Binello Emanuela
Published: March 2024

INTRODUCTION:

Median household income is a useful metric for healthcare disparity assessment. New England holds a highly diverse, densely populated metropolitan area with one of the highest living wages in the US. To our knowledge, there is no published data on the effects of optimal vs. suboptimal median household income on the operative traumatic brain injury (TBI) patients.

METHODS:

Demographic, clinical and outcome data of operative TBI patients between 2015 and 2021 were collected and stratified based on optimal (80 000$ or more) and suboptimal (less than 80 000$) median residential household income. 1:1 tight caliper (0.01) propensity score matching was performed to balance the groups for comparative analysis.

RESULTS:

From the initial 91 patients in the optimal and 102 patients in the suboptimal income groups, 62 patients were included in each group after propensity matching. There were significantly more ethnic minority patients in the suboptimal as compared to the optimal income group (66.1% and 35.7%, respectively; p=0.002). Optimal income group patients presented as transfers from other hospitals significantly more frequently than the suboptimal group (52.5% and 30.7%, respectively; p = 0.02). There were no significant differences in post-operative Glasgow coma scale scores (p = 0.15), modified Rankin scale scores at discharge (p = 0.92) and upon follow-up (p = 0.1), mortality (p > 0.999) or disposition destination distribution (p = 0.3).

CONCLUSIONS:

While the suboptimal income group is significantly more ethnically diverse, optimal versus suboptimal median household income does not seem to affect TBI outcomes and disposition. Optimal income group patients are more frequently presenting as transfers from other facilities indicating fair high-level care at a specialized high safety-net burden trauma center adapted to an ethnically diverse population.
785 Variability in Withdrawal of Life Sustaining Treatment Decision for Patients With Severe Traumatic Brain Injury: An Analysis of 510 North American Trauma Centers
Authors: Malhotra Armaan K. , Shakil Husain , Smith Christopher , Wijeysundera Duminda , Kulkarni Abhaya Vivek , Ladha Karim , Wilson Jefferson , Nathens Avery , Witiw Christopher
Published: March 2024

INTRODUCTION:

Withdrawal of life sustaining treatment (WLST) in severe traumatic brain injury (TBI) is complex with a paucity of standardized guidelines to inform practice patterns. We hypothesized presence of variability in WLST decision-making across centers, which could have important implications for equitable trauma care provision.

METHODS:

This retrospective study utilized data from adult severe TBI patients treated at trauma centers participating in the Trauma Quality Improvement Program between 2017-2020. Multivariable hierarchical logistic regression was used to adjust for patient, injury and hospital attributes influencing WLST. Residual between-center variability was characterized using the median odds ratio. Disparate WLST practices were further assessed by ranking centers' tendencies for WLST and assessing mortality between quartiles.

RESULTS:

We identified a total of 85511 subjects with severe TBI treated across 510 trauma centers, of which 20,300 (24%) had WLST. Patient-level factors associated with increased likelihood of WLST were advanced age, white race, treatment in a non-profit trauma center or self-pay/ Medicare insurance status (compared to private insurance). Black race was associated with reduced tendency for WLST. Higher severity intracranial and extracranial injuries also increased likelihood for WLST.After adjustment for patient and hospital attributes, the median odds ratio was 1.44 (1.40-1.48 95%CI), suggesting substantial residual variation in WLST between centers. When centers were grouped into quartiles by their propensity for WLST, there was a 1.37 (1.30-1.42 95%CI) increased adjusted odds of mortality between fourth versus first quartile centers.

CONCLUSIONS:

We highlighted the presence of disparate WLST practice patterns between trauma centers after adjustment for case-mix and hospital attributes. These findings highlight a strong need for examination of center-level factors contributing to heterogenous WLST practices to ultimately improve equity of care provision for severe TBI patients.
815 Gender Parity in Neurosurgery Residencies: An Analysis
Authors: Kabangu Jean-Luc , Lei Catherine , Yekzaman Bailey R. , Minchew Heather , Birney Jalee , Heskett Cody , Lundy Paige , Miller Christopher
Published: March 2024

INTRODUCTION:

The number of women graduating from U.S. medical schools has reached parity with that of men. However, persistent inequalities and barriers have made the pace towards equity in application and representation in neurosurgery residency slow despite initiatives to increase female representation.

METHODS:

Data on the number of active female neurosurgery residents and female applicants to neurosurgery was collected from the American Council of Graduation Medical Education Data Resource Book from 2007 to 2021 and Electronic Residency Application Service from 2014 to 2022, respectively. Bivariate linear regression analysis was used to predict percent of active female residents based on academic year (AY). Pearson Chi-squared was conducted to determine the odds ratio of a female applicant to neurosurgery.

RESULTS:

The percent of active female residents in neurosurgery increased from 11.0% in 2007 to 21.8% in 2021. Bivariate linear regression analysis using AY as predictor of percent of active females was statistically significant. On average, the percent of active female residents increases by 0.65% per year. If trends persist, parity in neurosurgery will not be reached until 2069. Linear regression analysis of the overall rate of attrition in neurosurgery as a predictor of percent of active female residents revealed that for every 1% increase in rate of attrition the percent of active female residents decreases between 1.4% to 4.4%. The percent of female applicants to neurosurgery increased from 19.6% in 2014 to 29.8% in 2022, yet the odds of a female applying to neurosurgery remains low.

CONCLUSIONS:

Neurosurgery continues to struggle with recruitment of female medical students, despite achievement of parity for female medical school matriculants. Greater effort is needed to recruit and retain female applicants to neurosurgery, including increased transparency in match and attrition metrics.
816 Comparing Match Data for Neurological and Orthopaedic Surgery Applicants From 2016-2022: Is There a Point of Diminishing Return for Research Experiences and Publications?
Authors: Allen Austin James , O'Connell Daniel , de Araujo Olivia , Ullman Lawrence , Carolyn Quinsey MD
Published: March 2024

INTRODUCTION:

The application process for neurological surgery (NSGY) and orthopaedic surgery (Ortho) residency positions is highly competitive. Prior work has characterized variables associated with improved match rates; however, limited analyses have been published in recent years.

METHODS:

Data on the characteristics of NSGY and Ortho applicants was obtained from the National Residency Matching Program Interactive Charting Outcomes in the Match tool from 2016 to 2022. The POM was computed for each subgroup classification available for applicant characteristics.

RESULTS:

Applicant characteristics that correlated with an improved POM into both NSGY and Ortho included increasing USMLE Step 1 and Step 2 scores, being a US MD Senior, number (#) of contiguous ranks (a proxy for # of interviews), # of volunteer experiences, and being a member of AOA. An increasing # of publications correlated with an increased POM until 25+ were reported for NSGY applicants but only until more than 11-15 were reported for Ortho applicants. A PhD correlated positively with the POM for NSGY applicants but negatively for Ortho applicants. Non-PhD graduate degrees correlated negatively with the POM for both NSGY and Ortho applicants. An increasing # of work experiences correlated negatively with the POM for NSGY applicants at all levels, and correlated negatively with the POM for Ortho applicants after 3-5 were reported.

CONCLUSIONS:

There appeared to be a point of diminishing return where an increasing number of publications no longer increased the probability of matching for both NSGY and Ortho applicants. Non-PhD graduate degrees did not improve the POM. Ranking more programs was associated with a higher POM for both NSGY and Ortho applicants, suggesting an incentive to take as many interviews as possible if not otherwise restricted.