bluuebunny/crossref_metadata_2025_split huggingface dataset:
389 Neutrophils: Novel Contributors to Estrogen-Dependent Intracranial Aneurysm Rupture Via Neutrophil Extracellular Trap Formation
Authors: Patel Devan , Dodd William S. , Lucke-Wold Brandon , Hosaka Koji , Hoh Brian Lim 
Published: March 2023

INTRODUCTION:
Intracranial aneurysms (IAs) are more prevalent in women than men and aneurysmal subarachnoid hemorrhage disproportionately affects postmenopausal women. These sex differences suggest estrogen protects against IA progression that can lead to rupture, but the underlying mechanisms are not fully understood. Although studies have demonstrated estrogen regulates inflammatory processes that contribute to IA pathogenesis, the role of neutrophils remains to be characterized.

METHODS:
We compared neutrophil infiltration in C57BL/6 mice that develop IAs to those with a normal circle of Willis. Next, we investigated the role of neutrophils in female estrogen-deficient mice, female estrogen-intact mice, and male mice using a neutrophil depletion antibody. Finally, we studied the role of neutrophil extracellular trap formation (NETosis) as an underlying mechanism of aneurysm progression.

RESULTS:
Mice that developed aneurysms had increased neutrophil infiltration compared to those with a normal circle of Willis. In female estrogen-deficient mice, both neutrophil depletion and NETosis inhibition decreased aneurysm rupture, but not formation, and had no effect on symptom-free survival. In female estrogen-intact mice, neither neutrophil depletion nor NETosis inhibition affected IA formation, rupture, or symptom-free survival. In male mice, neutrophil depletion decreased IA formation but did not affect rupture or symptom-free survival. NETosis inhibition in male mice did not affect IA formation, rupture, or symptom-free survival.

CONCLUSIONS:
Neutrophils contribute to aneurysm rupture in the setting of estrogen deficiency. NETosis appears to be an underlying mechanism for neutrophil-mediated IA rupture in estrogen deficiency. In males, neutrophils contribute to IA formation, but not rupture. Targeting NETosis may lead to the development of novel therapeutics to protect against IA progression, particularly IA rupture in post-menopausal women.
391 Stereotactic Radiosurgery for Intermediate and High-Grade Arteriovenous Malformations: Outcomes Stratified by the Supplemented Spetzler-Martin Grading System
Authors: Naylor Ryan M. , Graffeo Christopher Salvatore , Nesvick Cody L. , Link Michael J. , Brown Paul D. , Stafford Scott , Laack Nadia , Pollock Bruce E. 
Published: March 2023

INTRODUCTION:
The Supplemented Spetzler-Martin (Supp-SM) grading system is predictive of surgical risk for patients with brain arteriovenous malformations (AVM).

METHODS:
219 patients had SRS from 1990 to 2016 for SM III (n = 154) or SM IV-V (n = 65) AVM. The Supp-SM grades were 4 (n = 14, 6%), 5 (n = 36, 16%), 6 (n = 67, 31%), 7 (n = 76, 35%), and 8-9 (n = 26, 12%). 60 patients (27%) had deep AVM (basal ganglia, thalamus, or brainstem). 39 patients (18%) had volume-staged SRS; 41 (19%) underwent repeat SRS. The median follow-up was 69 months for grade III AVM and 113 months for grade IV-V AVM.

RESULTS:
163 patients (74%) had obliteration at a median of 38 months after initial SRS. The obliteration rates at 4 and 8 years were 59% and 76%, respectively. 31 patients (14%) had post-SRS deficits from hemorrhage (n = 7, 3%) or radiation injury (n = 24, 11%). 6 patients (3%) died after SRS (hemorrhage, n = 5; radiation injury, n = 1). The rates of neurologic decline or death at 4 and 8 years were 11% and 18%, respectively. Factors predictive of non-obliteration were deep location (HR 0.57, 95% CI 0.39-0.82, p = 0.003) and increasing AVM volume (HR 0.96, 95% CI 0.93-0.99, p = 0.002). Increasing AVM volume was the only factor associated with neurologic decline (HR 1.05, 95% CI 1.02-1.08, p = 0.002). The Supp-SM grading system did not correlate with obliteration (HR 0.94, 95% CI 0.82-1.09, p = 0.43) or neurologic decline (HR 1.15, 95% CI 0.84-1.56, p = 0.38).

CONCLUSIONS:
The Supp-SM grading system was not predictive of outcomes after SRS of intermediate or high-grade AVM. In a cohort which included a high percentage (47%) of “inoperable” AVM (Supp-SM ≥7), most patients had obliteration after SRS, although the chance of neurologic decline was significant.
396 North American Multicenter Experience of the Flow-Redirection Endoluminal Device (FRED) in the Treatment of Intracranial Aneurysms
Authors: Khorasanizadeh MirHojjat , Shutran Max , Schirmer Clemens M. , Salem Mohamed M. , Ringer Andrew J. , Grandhi Ramesh , Mitha Alim P. , Levitt Michael Robert , Jankowitz Brian T. , Taussky Phil , Thomas Ajith J. , Moore Justin M. , Ogilvy Christopher S. 
Published: March 2023

INTRODUCTION:
Flow-diverters have revolutionized the endovascular treatment of intracranial aneurysms. The evidence on the Flow Re-direction Endoluminal Device (FRED) is limited compared to some counterparts that have been available for clinical use longer.

METHODS:
Between June 2020 and November 2021, consecutive cerebral aneurysms treated using FRED were included across 7 North American centers. Data collected included patient demographics, aneurysm characteristics, peri-procedural and long-term complications, modified Rankin Scale (mRS) scores, and radiologic follow-up.

RESULTS:
133 aneurysms in 116 patients treated in 123 FRED deployment procedures were included. One hundred twenty-six aneurysms (94.7%) were unruptured, 117 (88.0%) were saccular, and 123 (92.5%) aneurysms were located in the anterior circulation. Mean aneurysm maximal width and neck sizes were 7.2 mm and 4.1 mm, respectively. Successful FRED deployment was achieved in 122 (99.2%) procedures. Radiologic follow-up was available for 101 aneurysms at a median duration of 7.0 months. At the last follow-up, complete occlusion was observed in 55.4%, residual neck in 8.9%, and filling aneurysm in 35.6%. On multivariate regression analysis, age (OR = 0.93; p = 0.001) and aneurysm neck size (OR = 0.83; p = 0.048) negatively correlated with odds of complete occlusion. The retreatment rate was 6/124 (4.8%). The overall complication rate was 31/116 (26.7%). Parent vessel occlusion, covered branch occlusion, and in-stent stenosis were detected in 9/99 (9.1%), 6/63 (9.5%), and 15/99 (15.2%) of the cases, respectively. FRED-related, symptomatic, thromboembolic, and hemorrhagic complication rates were 22.4%, 12.9%, 6.9%, and 0.9% respectively. The morbidity rate was 10/116 (8.6%).

CONCLUSIONS:
As the first large-scale North American multi-center FRED experience, this study confirms FRED’s ease of successful deployment but suggests a lower efficacy and higher rate of complications compared to previous European and South American FRED studies and other flow diverting devices.
397 Direct Carotid Puncture for Mechanical Thrombectomy After Failed Peripheral Access: A Systematic Review and Meta-Analysis
Authors: Domingo Ricardo , Tripathi Shashwat , Abello-Vaamode Jorge , Singh Rohin , Perez-Vega Carlos , Ramos-Fresnedo Andres , Tawk Rabih G. 
Published: March 2023

INTRODUCTION:
Direct carotid puncture (DCP) is an alternative route for mechanical thrombectomy (MT), especially in patients with difficult anatomy preventing access through the femoral or radial routes. However, DCP has increased morbidity and mortality due to access site complications related to cervical hematomas.

METHODS:
A systematic search of electronic databases from inception to March 2022 identified 197 related articles for screening. After applying inclusion and exclusion criteria, 10 studies were included, and data was extracted and analyzed using meta-analysis of proportions.

RESULTS:
213 patients were included in this analysis, of which 44% also received intravenous thrombolysis. The overall success rate was 84% (95% CI, 73.66–90.85%; I2 = 25.6%; p = 0.64). The average time to recanalization was 30.33 minutes (95%CI, 23.04–37.62 min; I2 = 89.5%; p < 0.01) and 74% had good reperfusion (TICI >2a) (95% CI, 67–79%; I2 = 0%; p = 0.81). The overall complication rate was 20.38% (95%CI, 15.48–26.35%; I2 = 0%; p = 0.55). The rate of cervical hematomas was 18% (95% CI, 12–16%; I2 = 70%; p = 0.27), of which 24.92% required surgical evacuation (95% CI, 27.5–95.9%; I2 = 70%; p = 0.67). Other reported complications included carotid dissection, pseudoaneurysm, jugular vein puncture, and stroke related to access. The 90-day mortality rate from all causes was 35% based on 7 studies (95% CI, 22.5– 49.9%; I2 = 44.8%; p = 0.08). The mRS at last follow-up was 4.09 (95% CI, 3.68–4.49; I2 = 6.8%; p = 0.37).

CONCLUSIONS:
DCP is a reasonable alternative in patients that fail femoral and radial access for MT and the success rate of access with DCP is 84% with a TICI 2B or TICI 3 achieved in 74% of patients. The complications are mostly related to bleeding at the access site. The high rate of morbidity and mortality warrant further studies to improve the safety of DCP.
400 Availability of Online Second Opinion Services for Spine Surgery: The Market Landscape
Authors: Brown Nolan James , Lien Brian , Gattas Sandra , Sahyouni Ronald , Campos Jessica , Zhang Angie , Reardon Taylor , Singh Rohin , Gendreau Julian , Oh Michael 
Published: March 2023

INTRODUCTION:
Second medical opinions may provide patients with a better understanding of their medical condition and empower them to make informed decisions about their health, particularly with respect to surgical treatments. However, the market landscape surrounding “online second opinion” services for spine surgery in the United States is not well-studied.

METHODS:
We utilized Google Trends (i.e., search data since 2010) to ascertain the level of interest in receiving second opinions for spinal surgery. In addition, we contacted the top 30 hospitals for neurology and neurosurgery in the U.S. News rankings by phone to obtain information regarding when/how and at what cost they provide second opinions for spine surgery.

RESULTS:
The cost of the second surgical opinions averaged $493 (±$343) USD (range $90–$1,300); the time to receive a second opinion averaged 20 (±19) days (range 1 day–5 months). Remote or “online second opinion” programs charged an average of $643 (±$259) USD (range $100–$850), and the time to receive an “online second opinion” averaged 14 (±7) days (range 1–4 weeks). We found statistically significant increases in the relative interest for the search term “second medical opinion” over the past decade (P < 0.0001, t = 21.5201). ∼97% of hospitals (29/30) provided in-person consultations for patients seeking a second opinion from a spine surgeon. However, 63% (19/30) did not have remote options (phone/video call consultations or “online second opinions”), but provided in-person consultations as the sole choice.

CONCLUSIONS:
Although second opinions have been shown to be beneficial to patients, ambiguous or high costs and long wait times may serve as barriers for certain groups (i.e., uninsured or underinsured) and potentially diminish the quality of care.
401 Global Neurosurgery Advances from Trenches to Bedside: Lessons from Neurosurgical Care in War, Humanitarian Assistance, and Disaster Response
Authors: Asfaw Zerubabbel , Greisman Jacob , Comunielo Brianna , Zuckerman Scott L. , Etienne Mill , Barthelemy Ernest Joseph 
Published: March 2023

INTRODUCTION:
War has influenced the development of neurosurgery. Armed conflict and mass casualty events, including Humanitarian Assistance Disaster Relief (HADR) missions, require military surgeons to innovate to meet extreme demands. Neurosurgeons serving in the military have provided a pragmatic template for global neurosurgeons to emulate in humanitarian disaster responses

METHODS:
We performed a narrative review of the literature examining the influence of wars and mass casualty disasters on contemporary global neurosurgery practices.

RESULTS:
Wartime innovations that influenced global neurosurgery include the development of triage systems and modernization with airlifts, implementation of ambulance corps, early operation on cranial injuries in hospital camps near the battlefield, use of combat body armor, and the rise of damage control neurosurgery. Workforce shortages during wars and disasters have promoted task-shifting and task-sharing in low-resource settings that catalyzed the establishment of the physician associate profession in the United States (US). Neurosurgical care has been utilized by the US as a form of "soft power" during natural and humanitarian disasters. Low-and middle-income countries (LMICs) face similar challenges in developing trauma systems and obtaining advanced technology, including neurosurgical equipment like battery-powered computed tomography scanners. These challenges— ubiquitous in low-resource settings— have underpinned innovations in triage and wound care, rapid evacuation to tertiary care centers, and minimizing infection risk.

CONCLUSIONS:
War and mass casualty disasters have catalyzed significant advancements in neurosurgical care both in the pre-hospital and inpatient settings. Most of these innovations originated in the military with subsequent spread to the civilian sector as military neurosurgeons and civilian neurosurgeons, who are military reservists, returned from the battlefront or other low-resource locations. LMICs have, by necessity, responded to challenges arising from resource shortages by developing innovative, context-specific care paradigms and technologies.
406 Assessing Correlations Between NASS Patient Satisfaction Index and Patient-Reported Outcomes (PROs) at 3-month, 12-month, and 24-month Timepoints in Patients Undergoing Cervical Spine Surgery Using the QOD Registry
Authors: Zaki Mark M. , Joshi Rushikesh Sanjeev , Linzey Joseph Raynor , Strong Michael J. , Yee Timothy Joseph , Saadeh Yamaan S. , Upadhyaya Cheerag D. , Coric Domagoj , Potts Eric A. , Bisson Erica Fay Randy , Turner Jay D. , Knightly Jack , Fu Kai-Ming G. , Foley Kevin T. , Tumialan Luis Manuel , Shaffrey Mark Edwin , Bydon Mohamad , Mummaneni Praveen V. , Chou Dean , Chan Andrew K. , Meyer Scott A. , Asher Anthony L. , Shaffrey Christopher I. , Gottfried Oren N. , Than Khoi Duc , Wang Michael Y. , Buchholz Avery , Haid Regis W. , Park Paul 
Published: March 2023

INTRODUCTION:
In value-based healthcare, measuring appropriate outcomes is essential to accurately determine value. Tracked outcomes should reflect the desires of patients undergoing surgical interventions.

METHODS:
The Quality Outcomes Database (QOD), a prospectively collected multi-institutional database, was used to analyze North American Spine Society (NASS) satisfaction, Neck Disability Index (NDI), Visual analog scale for neck pain (NP-VAS) and arm pain (AP- VAS), EuroQoL-Visual Analog Scale (EQ-VAS), and modified Japanese Orthopedic Association (mJOA) at 3, 12, and 24-month follow up.

RESULTS:
1141 patients were surgically treated (anterior approach n = 785, 69%; posterior approach n=356, 31%) for cervical spondylotic myelopathy. Average demographics were 60.5 years old, 52.6% male, 92.4% non-Hispanic, BMI 30.2, and length of stay 2.1 days. At 3 month follow up, satisfaction was positively correlated with NP-VAS (R = 0.298, p<.001), AP-VAS (R = 0.315, p < .001), NDI (R = 0.362, p <.001), and negatively correlated with EQ-VAS (R = -0.294, p<.001) and mJOA (R = -0.287, p < .001). At 12 month follow up, satisfaction was positively correlated with NP-VAS (R = 0.442, p<.001), AP-VAS (R = 0.384, p< .001), NDI (R = 0.459, p < .001), and negatively correlated with EQ-VAS (R = -0.357, p<.001) and mJOA (R = -0.363, p <.001). At 24 month follow up, satisfaction was positively correlated with NP-VAS (R = 0.490, p<.001), AP-VAS (R = 0.358, p < .001), NDI (R = 0.491, p < .001), and negatively correlated with EQ-VAS (R= -0.310, p<.001) and mJOA (R= -0.378, p <.001).

CONCLUSIONS:
NDI was most correlated with satisfaction at 3, 12 and 24-month follow up. mJOA was least correlated with satisfaction at 3 month follow up, whereas EQ-VAS was the least correlated with satisfaction at 12 and 24-month follow up. These findings may better guide outcome selection in patient follow up and help clinicians appropriately counsel patients on expected outcomes.
407 Anterior Cervical Discectomy and Fusion in Ambulatory Surgery Center Versus Hospital Setting: One-Year Cost Utility and Cost Benefit Analysis
Authors: Hani Ummey , Monk Steve Hubert , Pfortmiller Deborah , Adamson Tim E. , Bohl Michael , Kim Paul Keetae , Holland Christopher Michael , McGirt Matthew J. 
Published: March 2023

INTRODUCTION:
Outpatient anterior cervical discectomy and fusion (ACDF) has recently gained popularity due to improved care and reduced costs. Cost-utility studies for ambulatory vs. inpatient ACDF are largely limited to small series, precluding an accurate assessment of cost-effectiveness.

METHODS:
A 6,504, ASA 1-3, patient sample (520 ASC, 5,984 inpatient) was used to propensity-match 748 patients (374/cohort) undergoing 1-2-level ACDF. Data was queried from the National Quality Outcomes Database (QOD). Medical resource utilization, missed work, and quality adjusted life years (QALYs) were assessed. Direct cost (one-year resource use x unit costs based on Medicare national allowable payment amounts) and indirect cost (missed workdays x average US daily wage) were recorded and incremental cost-effectiveness ratio was calculated.

RESULTS:
Estimated blood loss, length of surgery, and hospitalization were less for ASC vs. inpatient ACDF (p < 0.001). ASC vs. inpatient ACDF demonstrated similar improvement in patient reported outcomes. ASC vs. inpatient ACDF was associated with lower total one-year cost of $5,879.46 for Medicare patients and $12,873.97 for private payers (p < 0.001), with similar QALYs gained. Hospital vs ASC had a highly cost ineffective ICER of $3,674,662.50/QALY-gained and $8,046,231.25/QALY for Medicare and private payer patients, respectively.

CONCLUSIONS:
1-2-level ACDF in the hospital vs ASC is associated with increased mean costs, without a QALY, safety, or outcome benefit. Hence, health economics strongly favor the ASC setting to the hospital for ACDF.
411 The Cost of a Single Sport-Related Concussion in Adolescent Athletes
Authors: Liles David Campbell , Tang Alan Ruigang , Williams Kristen , Yengo-Kahn Aaron Michael , Zuckerman Scott L. , Terry Douglas 
Published: March 2023

INTRODUCTION:
Despite the ubiquity of sport-related concussions (SRC), the healthcare costs incurred by a single SRC are unknown.

METHODS:
We conducted a retrospective cohort study examining concussed athletes ages 12-23 who presented to a multi-disciplinary concussion center between 11/2017-10/2020. Athletes presenting for treatment more than 10 days post-injury and those sustaining >1 concussion during the study period were excluded. The primary outcome was the direct cost of the concussion care episode, derived by matching visit and imaging dates with institution inflation-adjusted cost data. A multivariable linear regression examined predictors of total concussion care costs. Independent variables included relevant demographics, medical/family medical history, injury characteristics, and initial Post-Concussion Symptom Scale (PCSS) score.

RESULTS:
In total, 710 athletes were included. Median age was 16.1 years (IQR = 15.1-17.2; 66.5% male). Median initial PCSS was 26 (IQR = 6-39). Sports with the highest prevalence of SRC were football (n = 261, 36.8%), soccer (n = 102, 14.4%) and basketball (n = 97, 13.7%). The mean cost of an SRC care episode was $822 (SD = $1,233). The mean costs associated with a softball-related concussion were highest (M = $2,372, SD = $4,707), followed by basketball (M = $1,012 SD = $1,863), lacrosse (M = $924, SD = $1,101), and football (M = $814, SD = $993). A multivariable linear regression showed that higher initial PCSS (b = 4.87, 95% CI = 1.32-8.42, p = .007), number of prior concussions (b = 118.79, 95% CI = 42.71-194.88, p = .002), and having an emergency department/urgent care visit (b = 670.20, 95% CI = 497.66-842.74) were significant predictors of greater cost.

CONCLUSIONS:
With a mean value of $822 per SRC, healthcare costs associated with this common injury total over $3 billion annually in the U.S. Greater costs were associated with higher initial symptom burden, prior concussion history, and emergency department/urgent care utilization. A nuanced understanding of cost-driving factors associated with SRC is a prerequisite to understanding cost-effectiveness of prevention and treatment.
412 A Protocol for Reducing Intensive Care Utilization After Craniotomy: A Three-Year Assessment
Authors: Colon Gabriela Ruiz , Ohkuma Rika , Pendharkar Arjun Vivek , Heifets Boris , Li Gordon , Lu Amy , Gephart Melanie Hayden , Ratliff John K. 
Published: March 2023

INTRODUCTION:
Craniotomy patients have traditionally received intensive care unit (ICU) care postoperatively. Our institution developed the “Non-Intensive CarE” (NICE) protocol to identify craniotomy patients that did not require postoperative ICU care.

METHODS:
Our institution’s electronic medical record (EMR) was queried to identify craniotomies prior to protocol deployment (May 2014-May 2018), and after deployment (May 2018-December 2021). Patients are considered for the protocol if they are having an elective craniotomy for select procedures (e.g. microvascular decompressions, extra-axial tumor resection), are under age of 65, have no history of coagulopathy, and have no other medical contraindications. Reason for readmission or reoperation among NICE protocol patients was collected via chart review. The primary endpoints were average POLS and ICU utilization; secondary endpoints included readmission, reoperation, and postoperative complications rates. Endpoints were compared among pre- and post-protocol cohorts.

RESULTS:
4,837 craniotomies were performed from May 2014-December 2021 (2,302 pre-protocol, 2,535 post-protocol). 21% percent of post-protocol craniotomies were enrolled in the NICE protocol. After protocol deployment, overall POLS decreased from 4.0 to 3.5 days (p = 0.0031), which was driven by deceased POLS among protocol patients (average 2.4 days).ICU utilization decreased from 57% of patients to 42% (p < 0.0001), generating ∼$760,000 in savings. Return to the ICU and complications decreased after protocol deployment. 5.8% of protocol patients had a readmission within thirty days; none could have been prevented through ICU stay.

CONCLUSIONS:
The NICE protocol is an effective, sustainable method to increase ICU bed availability and decrease costs without changing outcomes. To our knowledge, this study features the largest series of patients enrolling in an ICU utilization reduction protocol. Careful patient selection is a requirement for the success of this approach.