Endoscopic third ventriculostomy inpatient failure rates compared with shunting in post-hemorrhagic hydrocephalus of prematurity

Treatment of post-thalamic hemorrhage hydrocephalus: ventriculoperitoneal shunt or endoscopic third ventriculostomy? A retrospective observational study

BACKGROUND

The aim of this study was to compare the efficacy of ventriculoperitoneal shunt (VPS) and endoscopic third ventriculostomy (ETV) for the treatment of hydrocephalus after thalamic hemorrhage (TH) where external ventricular drainage (EVD) could not be removed after hematoma absorption, and to provide a theoretical basis for the clinical treatment of hydrocephalus after TH.

METHODS

The clinical data of patients with hydrocephalus after TH whose EVD could not be removed after hematoma absorption were retrospectively analyzed. According to the patients' surgical methods, the patients were divided into the VPS group and ETV group. The operative time, length of hospital stay, complications, and reoperation rates of the two groups were compared.

RESULTS

There was no statistically significant difference in intraoperative bleeding, length of hospital stay between the two groups. The EVD tubes were successfully removed in all patients after surgery. There were 4 (9.5%) complications in the ETV group and 3 (6.7%) complications in the VPS group, with no statistically significant difference in postoperative complications between the two groups. During the 1-year follow-up, 7 patients (16.7%) in the ETV group and 3 patients (6.7%) in the VPS group required reoperation. In the subgroup analysis of TH combined with fourth ventricular hemorrhage, 6 patients (14.3%) in the ETV group and 1 patient (2.2%) in the VPS group required reoperation, and the difference between the two groups was statistically significant.

CONCLUSIONS

ETV had good efficacy in treating hydrocephalus caused by TH and TH that broke into the lateral ventricle and the third ventricle. However, if hydrocephalus was caused by TH with the fourth ventricular hematoma, VPS was a better surgical method because the recurrence rate of hydrocephalus in ETV was higher than that in VPS. Therefore, the choice of surgical method should be based on the patient's clinical features and hematoma location.

The Effect of the Coronavirus Disease 2019 Pandemic on Pituitary Surgery

OBJECTIVE

As the coronavirus disease 2019 (COVID-19) pandemic spread to the United States in 2020, there was an impetus toward postponing or ceasing nonurgent transsphenoidal pituitary surgeries to prevent the spread of the virus. Some centers encouraged transcranial approaches for patients with declining neurologic function. However, no large-scale data exist evaluating the effects that this situation had on national pituitary practice patterns.

METHODS

Pituitary surgeries in the National Inpatient Sample were identified from 2017 to 2020. Surgeries in 2020 were compared with the 3 years previously to determine any differences in demographics, surgical trends/approaches, and perioperative outcomes.

RESULTS

In 2020, there was a decline in overall pituitary surgeries (34.2 vs. 36.3%; odds ratio (OR), 0.88; P < 0.001) yet transsphenoidal approaches represented a higher proportion of interventions (69.0 vs. 64.9%; P < 0.001). Neurosurgical complications were higher (51.9 vs. 47.4%; OR, 1.13; P < 0.001) and patients were less likely to be discharged home (86.4 vs. 88.5%; OR, 0.84; P < 0.001). This finding was especially true in April 2020 during the first peak in COVID-19 cases, when transcranial approaches and odds of mortality/complications were highest.

CONCLUSIONS

In 2020, transsphenoidal surgery remained the preferred approach for pituitary tumor resection despite initial recommendations against the approach to prevent COVID-19 spread. Pituitary surgeries had a higher risk of periprocedural complications despite accounting for preoperative comorbidities, COVID-19 infection status, and surgical approach, suggesting that an overwhelmed hospital system can negatively influence surgical outcomes in noninfected patients.

Low surgical weight associated with ETV failure in pediatric hydrocephalus patients

The use of endoscopic third ventriculostomy (ETV) for treatment of pediatric hydrocephalus has higher failure rates in younger patients. Here we investigate the impact of select perioperative variables, specifically gestational age, chronological age, birth weight, and surgical weight, on ETV failure rates. A retrospective review was performed on patients treated with ETV - with or without choroid plexus cauterization (CPC) - from 2010 to 2021 at a large academic center. Analyses included Cox regression for independent predictors and Kaplan-Meier survival curves for time to-event outcomes. In total, 47 patients were treated with ETV; of these, 31 received adjunctive CPC. Overall, 66% of the cohort experienced ETV failure with a median failure of 36 days postoperatively. Patients aged < 6 months at time of surgery experienced 80% failure rate, and those > 6 months at time of surgery experienced a 41% failure rate. Univariate Cox regression analysis showed weight at the time of ETV surgery was significantly inversely associated with ETV failure with a hazard ratio of 0.92 (95% CI 0.82, 0.99). Multivariate analysis redemonstrated the inverse association of weight at time of surgery with ETV failure with hazard ratio of 0.76 (95% CI 0.60, 0.92), and sensitivity analysis showed < 4.9 kg as the optimal cutoff predicting ETV/CPC failure. Neither chronologic age nor gestational age were found to be significantly associated with ETV failure.In this study, younger patients experienced higher ETV failure rates, but multivariate regression found that weight was a more robust predictor of ETV failure than chronologic age or gestational age, with an optimal cutoff of 4.9 kg in our small cohort. Given the limited sample size, further study is needed to elucidate the independent role of weight as a peri-operative variable in determining ETV candidacy in young infants. Previous presentations: Poster Presentation, Congress of Neurological Surgeons.

Outcomes in patients with large vessel occlusion strokes undergoing mechanical thrombectomy with concurrent COVID-19: a nationwide retrospective analysis

BACKGROUND

Preliminary studies show that patients with large vessel occlusion (LVO) acute ischemic strokes have worse outcomes with concurrent COVID-19 infection. We investigated the outcomes for patients with LVO strokes undergoing mechanical thrombectomy (MT) with concurrent COVID-19 infection.

METHODS

The National Inpatient Database (NIS) was used for our analysis. Patients in the year 2020 with an ICD-10 diagnosis code for acute ischemic stroke and procedural code for MT were included with and without COVID-19. Odds ratios (OR) were calculated using a logistic regression model with age, sex, stroke location, Elixhauser comorbidity score, and other patient variables deemed clinically relevant as covariates.

RESULTS

Patients in the COVID-19 group were younger (64.3±14.4 vs 69.4±14.5 years, P<0.001), had a higher rate of inpatient mortality (22.4% vs 10.1%, P<0.001), and a longer length of stay (10 vs 6 days, P<0.001). Patients with COVID-19 had higher odds of death (OR 2.78, 95% CI 2.11 to 3.65) and lower odds of a routine discharge (OR 0.65, 95% CI 0.48 to 0.89). There was no difference in the odds of subsequent stroke and cerebral hemorrhage, but patients with COVID-19 had statistically significantly higher odds of respiratory failure, pulmonary embolism, deep vein thrombosis, myocardial infarction, acute kidney injury, and sepsis.

CONCLUSIONS

Patients with LVOs undergoing MT within the 2020 NIS database had worse outcomes when co-diagnosed with COVID-19, likely due to non-neurological manifestations of COVID-19.

Perioperative Outcomes in Transcarotid Artery Revascularization Versus Carotid Endarterectomy or Stenting Nationwide

BACKGROUND AND OBJECTIVES

Transcarotid artery revascularization (TCAR) is a newer treatment for carotid stenosis where the carotid artery is accessed directly in the neck for stenting. It is less invasive than carotid endarterectomy (CEA) and has less embolic potential than carotid artery stenting (CAS), but population-level utilization of TCAR and outcomes are currently unknown. Our study compares outcomes of TCAR with those of CEA and CAS.

METHODS

The National Inpatient Database was used for years 2015 to 2019. A multivariate logistic regression model was used to compare CEA, CAS, and TCAR outcomes with age, sex, race, hospital teaching status, symptomatic carotid disease status, side of procedure, intraoperative monitoring, and the weighted Elixhauser comorbidity score as covariates.

RESULTS

TCAR comprised 0.69% of these procedures in 2016, rising to 1.35% in 2019. The inpatient rates of death, stroke, and myocardial infarction for TCAR were 0.63% (95% confidence interval: 0.36%, 1.06%), 0.42% (0.21%, 0.80%), and 1.46% (1.04%, 2.05%), respectively. Compared with CEA, TCAR had statistically insignificant difference odds of death, odds ratio (95% CI) for stroke was 0.47 (0.25, 0.87), and for myocardial infarction, it was 0.66 (0.37, 0.94). Compared with CAS, for TCAR, the odds ratio for death was 0.41 (0.24, 0.71), and for stroke, it was 0.48 (0.26, 0.91).

CONCLUSION

TCAR is underutilized relative to other revascularization techniques yet has favorable outcomes compared with CEA and CAS. TCAR may be preferred to CAS in patients not surgical candidates for CEA and has a less invasive possibility for those eligible for CEA.

Revision rates of flow- versus pressure-regulated ventricular shunt valves for the treatment of hydrocephalus in neonates following germinal matrix haemorrhage-a retrospective review

PURPOSE

Neonates with ventricular shunts inserted for hydrocephalus following germinal matrix haemorrhage (GMH) have high rates of shunt revision. The shunt valve plays a key role in regulating the function of the shunt. In this study, we aim to determine if the choice of flow-regulated or pressure-regulated valve used in the initial implantation of a shunt affects the rate of shunt revision.

METHODS

A retrospective cohort comparison study was performed on 34 neonates with hydrocephalus following GMH who underwent placement of a ventricular shunt at the Queensland Children's Hospital from November 2014 to June 2020. The primary outcome examined was the need for revision or replacement of the ventricular shunt after successful initial placement within 2 years of implantation. The secondary outcome examined was the survival time of the shunt.

RESULTS

16 patients had placement of a flow-regulated valve, and 18 patients had placement of a pressure-regulated valve. 14 (87.5%) patients with flow-regulated valves required replacement during the follow-up period. 2 (18.18%) patients with a fixed pressure regulated underwent revision, while 2 (28.57%) programmable pressure-regulated shunts required revision. Patients that had a flow-regulated valve had a statistically significant higher rate of revision compared to those who had a pressure-regulated valve, (87.5% flow vs 22.22% pressure) with a P-value of < 0.001. Valve obstruction was also more common in patients with flow-regulated valves than pressure-regulated valves (4 vs 0) with a P-value of 0.010. Overall mean median survival time was 22.06 months, shunts with flow-regulated valves had a shorter median survival time of 3.19 months compared with over 24 months for pressure-regulated valves with a P-value of < 0.001.

CONCLUSION

Our study suggests that the initial implantation of flow-regulated valves may carry an increased total rate of shunt revision and valve obstruction within the first 2 years following implantation compared to pressure-regulated valves in patients with hydrocephalus following GMH.