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Hartung V, Augustin AM, Grunz JP, Huflage H, Hennes JL, Kleefeldt F, Ergün S, Peter D, Lichthardt S, Bley TA, Gruschwitz P. Training for endovascular therapy of acute arterial disease and procedure-related complication: An extracorporeally-perfused human cadaver model study. PLoS One 2024; 19:e0297800. [PMID: 38330071 PMCID: PMC10852297 DOI: 10.1371/journal.pone.0297800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 01/12/2024] [Indexed: 02/10/2024] Open
Abstract
PURPOSE The aim of this study was to evaluate the usability of a recently developed extracorporeally-perfused cadaver model for training the angiographic management of acute arterial diseases and periprocedural complications that may occur during endovascular therapy of the lower extremity arterial runoff. MATERIALS AND METHODS Continuous extracorporeal perfusion was established in three fresh-frozen body donors via inguinal and infragenicular access. Using digital subtraction angiography for guidance, both arterial embolization (e.g., embolization using coils, vascular plugs, particles, and liquid embolic agents) and endovascular recanalization procedures (e.g., manual aspiration or balloon-assisted embolectomy) as well as various embolism protection devices were tested. Furthermore, the management of complications during percutaneous transluminal angioplasty, such as vessel dissection and rupture, were exercised by implantation of endovascular dissection repair system or covered stents. Interventions were performed by two board-certified interventional radiologists and one resident with only limited angiographic experience. RESULTS Stable extracorporeal perfusion was successfully established on both thighs of all three body donors. Digital subtraction angiography could be performed reliably and resulted in realistic artery depiction. The model allowed for repeatable training of endovascular recanalization and arterial embolization procedures with typical tactile feedback in a controlled environment. Furthermore, the handling of more complex angiographic devices could be exercised. Whereas procedural success was be ascertained for most endovascular interventions, thrombectomies procedures were not feasible in some cases due to the lack of inherent coagulation. CONCLUSION The presented perfusion model is suitable for practicing time-critical endovascular interventions in the lower extremity runoff under realistic but controlled conditions.
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Affiliation(s)
- Viktor Hartung
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Anne Marie Augustin
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Jan-Peter Grunz
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Henner Huflage
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Jan-Lucca Hennes
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Florian Kleefeldt
- Institute of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany
| | - Süleyman Ergün
- Institute of Anatomy and Cell Biology, University of Würzburg, Würzburg, Germany
| | - Dominik Peter
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Sven Lichthardt
- Department of General, Visceral, Transplant, Vascular, and Pediatric Surgery, University Hospital of Würzburg, Würzburg, Germany
| | - Thorsten Alexander Bley
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
| | - Philipp Gruschwitz
- Department of Diagnostic and Interventional Radiology, University Hospital of Würzburg, Würzburg, Germany
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Hersh AM, Jimenez AE, Pellot KI, Gong JH, Jiang K, Khalifeh JM, Ahmed AK, Raad M, Veeravagu A, Ratliff JK, Jain A, Lubelski D, Bydon A, Witham TF, Theodore N, Azad TD. Contemporary Trends in Minimally Invasive Sacroiliac Joint Fusion Utilization in the Medicare Population by Specialty. Neurosurgery 2023; 93:1244-1250. [PMID: 37306413 DOI: 10.1227/neu.0000000000002564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/20/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Sacroiliac (SI) joint dysfunction constitutes a leading cause of pain and disability. Although surgical arthrodesis is traditionally performed under open approaches, the past decade has seen a rise in minimally invasive surgical (MIS) techniques and new federally approved devices for MIS approaches. In addition to neurosurgeons and orthopedic surgeons, proceduralists from nonsurgical specialties are performing MIS procedures for SI pathology. Here, we analyze trends in SI joint fusions performed by different provider groups, along with trends in the charges billed and reimbursement provided by Medicare. METHODS We review yearly Physician/Supplier Procedure Summary data from 2015 to 2020 from the Centers for Medicare and Medicaid Services for all SI joint fusions. Patients were stratified as undergoing MIS or open procedures. Utilization was adjusted per million Medicare beneficiaries and weighted averages for charges and reimbursements were calculated, controlling for inflation. Reimbursement-to-charge (RCR) ratios were calculated, reflecting the proportion of provider billed amounts reimbursed by Medicare. RESULTS A total of 12 978 SI joint fusion procedures were performed, with the majority (76.5%) being MIS procedures. Most MIS procedures were performed by nonsurgical specialists (52.1%) while most open fusions were performed by spine surgeons (71%). Rapid growth in MIS procedures was noted for all specialty categories, along with an increased number of procedures offered in the outpatient setting and ambulatory surgical centers. The overall RCR increased over time and was ultimately similar between spine surgeons (RCR = 0.26) and nonsurgeon specialists (RCR = 0.27) performing MIS procedures. CONCLUSION Substantial growth in MIS procedures for SI pathology has occurred in recent years in the Medicare population. This growth can largely be attributed to adoption by nonsurgical specialists, whose reimbursement and RCR increased for MIS procedures. Future studies are warranted to better understand the impact of these trends on patient outcomes and costs.
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Affiliation(s)
- Andrew M Hersh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Adrian E Jimenez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | | | - Jung Ho Gong
- The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Kelly Jiang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Jawad M Khalifeh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - A Karim Ahmed
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Micheal Raad
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Anand Veeravagu
- Department of Neurosurgery, Stanford University School of Medicine, Stanford , California , USA
| | - John K Ratliff
- Department of Neurosurgery, Stanford University School of Medicine, Stanford , California , USA
| | - Amit Jain
- Department of Orthopedic Surgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Ali Bydon
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Nicholas Theodore
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
| | - Tej D Azad
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore , Maryland , USA
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Goyal N, Patil AK, Kuldeep R, Rajpal G. Need to Incorporate Endovascular Neurosurgery in Neurosurgery Curriculum in India: Stay Abreast or be Left Behind. Neurol India 2023; 71:1222-1225. [PMID: 38174462 DOI: 10.4103/0028-3886.391393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2024]
Abstract
Endovascular neurosurgery is one of the most rapidly evolving subspecialties in the field of neurosurgery. Since its inception, it has taken up almost 50%-60% of the cerebrovascular workload. Various specialties are competing to claim this field; still, no one can argue against a neurosurgeon's suitability in performing endovascular techniques. Currently, the field is shared between neurosurgeons and neuroradiologists, each getting different pie shares in various parts of the world. However, in India, barring a few residency programs, most neurosurgery programs offer little or no exposure to endovascular techniques. There is an urgent need for endovascular neurosurgery to be incorporated in the neurosurgery training curriculum in the country. Performing DSAs is the first step toward starting an endovascular neurosurgery unit. We have presented here the data of the DSAs done by a single neurosurgeon over almost 3 years. We have discussed our experience in the hope that fellow neurosurgeons across the country find it useful.
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Affiliation(s)
- Nishant Goyal
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Aditya Kiran Patil
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Robi Kuldeep
- Department of Neurosurgery, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India
| | - Girish Rajpal
- Interventional Neurology, Max Super Speciality Hospital, Vaishali, Ghaziabad, Uttar Pradesh, India
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Nie X, Yang Y, Liu Q, Wu J, Chen J, Ma X, Liu W, Wang S, Chen L, He H. A deep-learning system to help make the surgical planning of coil embolization for unruptured intracranial aneurysms. Chin Neurosurg J 2023; 9:24. [PMID: 37691095 PMCID: PMC10494453 DOI: 10.1186/s41016-023-00339-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/30/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Coil embolization is a common method for treating unruptured intracranial aneurysms (UIAs). To effectively perform coil embolization for UIAs, clinicians must undergo extensive training with the assistance of senior physicians over an extended period. This study aimed to establish a deep-learning system for measuring the morphological features of UIAs and help the surgical planning of coil embolization for UIAs. METHODS Preoperative computational tomography angiography (CTA) data and surgical data from UIA patients receiving coil embolization in our medical institution were retrospectively reviewed. A convolutional neural network (CNN) model was trained on the preoperative CTA data, and the morphological features of UIAs were measured automatically using this CNN model. The intraclass correlation coefficient (ICC) was utilized to examine the similarity between the morphologies measured by the CNN model and those determined by experienced clinicians. A deep neural network model to determine the diameter of first coil was further established based on the CNN model within the derivation set (75% of all patients) using neural factorization machines (NFM) model and was validated using a validation set (25% of all patients). The general match ratio (the difference was within ± 1 mm) between the predicted diameter of first coil by model and that used in practical scenario was calculated. RESULTS One-hundred fifty-three UIA patients were enrolled in this study. The CNN model could diagnose UIAs with an accuracy of 0.97. The performance of this CNN model in measuring the morphological features of UIAs (i.e., size, height, neck diameter, dome diameter, and volume) was comparable to the accuracy of senior clinicians (all ICC > 0.85). The diameter of first coil predicted by the model established based on CNN model and the diameter of first coil used actually exhibited a high general match ratio (0.90) within the derivation set. Moreover, the model performed well in recommending the diameter of first coil within the validation set (general match ratio as 0.91). CONCLUSION This study presents a deep-learning system which can help to improve surgical planning of coil embolization for UIAs.
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Affiliation(s)
- Xin Nie
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100050 China
| | - Yi Yang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100050 China
| | - Qingyuan Liu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100050 China
| | - Jun Wu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100050 China
| | - Jingang Chen
- Unimed Technology (Beijing) Co., Ltd., Tsinghua Tongfang Science and Technology Mansion, Beijing, 100083 China
| | - Xuesheng Ma
- Unimed Technology (Beijing) Co., Ltd., Tsinghua Tongfang Science and Technology Mansion, Beijing, 100083 China
| | - Weiqi Liu
- Unimed Technology (Beijing) Co., Ltd., Tsinghua Tongfang Science and Technology Mansion, Beijing, 100083 China
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China
- China National Clinical Research Center for Neurological Diseases, Beijing, 100050 China
| | - Lei Chen
- Department of Neurosurgery, The First Dongguan Affiliated Hospital, Guangdong Medical University, No. 42 Jiaoping Road, Tangxia Town, Dongguan, Guangdong China
| | - Hongwei He
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050 China
- Beijing Neurosurgical Institution, Capital Medical University, Beijing, 100050 China
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Gaub M, Kromenacker B, Avila MJ, Gonzales-Portillo GS, Aguilar-Salinas P, Dumont TM. Evolution of open surgery for unruptured intracranial aneurysms over a fifteen year period-increased difficulty and morbidity. J Clin Neurosci 2023; 107:178-183. [PMID: 36443125 DOI: 10.1016/j.jocn.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 09/27/2022] [Accepted: 10/10/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The approach to intervention for unruptured intracranial aneurysms (UIAs) remains controversial. Utilization of endovascular techniques for aneurysm repair increased dramatically during the last decade. We sought to analyze recent national trends for electively treated (open and endovascular) UIAs focusing on pre-existing patient disease burden and intervention modality selection. METHODS The Nationwide Inpatient Sample (NIS) national database was used to identify patients with primary diagnosis codes of unruptured intracranial aneurysm between 1999 and 2014. Patients were dichotomized by intervention into endovascular or open surgical treatment. Analysis of pre-existing disease severity were calculated using the Elixhauser comorbidity index. Complications of combined peri-procedural stroke or death during admission and hospital length of stay were used as primary endpoints for comparison. RESULTS The percent of total UIAs treated electively with open approach decreased from more than 95 % of cases in 1999 to less than 25 % in 2014. Patients undergoing clipping were 3 years younger than those in the endovascular group (p < 0.001). The rate of primary endpoint complications (stroke and death) and length of stay for open cases saw a decrease throughout the study but remained statistically higher when compared to the endovascular group over the study period (p < 0.001). Additionally, non-neurologic complications increased over the time period for open cases. The average preoperative co-morbid disease severity for all groups treated increased over this interval. Conversely, the relative volume of endovascular cases increased but the rate of complications and average group disease remained statistically lower than the surgical clipping group (p < 0.05). CONCLUSION The percent of UIAs treated electively with open approach has decreased since 1999 with a concomitant increase in complication rate in particular compared to endovascular cases. However, the health characteristics of patients treated with surgical clipping show an increase in severity of pre-existing co-morbidities. Further research into factors contributing to this finding, including potential socioeconomic differences and changes in surgeon experience are needed.
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Affiliation(s)
- Michael Gaub
- The University of Arizona, College of Medicine, Tucson, AZ, United States; UT Health San Antonio, United States
| | - Bryan Kromenacker
- The University of Arizona, College of Medicine, Tucson, AZ, United States
| | - Mauricio J Avila
- The University of Arizona, College of Medicine, Tucson, AZ, United States; Department of Neurosurgery, University of Arizona, Tucson, AZ, United States
| | | | - Pedro Aguilar-Salinas
- The University of Arizona, College of Medicine, Tucson, AZ, United States; Department of Neurosurgery, University of Arizona, Tucson, AZ, United States
| | - Travis M Dumont
- The University of Arizona, College of Medicine, Tucson, AZ, United States; Department of Neurosurgery, University of Arizona, Tucson, AZ, United States.
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Silva MA, Chen S, Starke RM. Unruptured cerebral aneurysm risk stratification: Background, current research, and future directions in aneurysm assessment. Surg Neurol Int 2022; 13:182. [PMID: 35509527 PMCID: PMC9062958 DOI: 10.25259/sni_1112_2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 04/07/2022] [Indexed: 12/04/2022] Open
Abstract
Background: The optimal management of unruptured cerebral aneurysms is widely debated in the medical field. Rapid technology advances, evolving understanding of underlying pathophysiology, and shifting practice patterns have made the cerebrovascular field particularly dynamic in recent years. Despite progress, there remains a dearth of large randomized studies to help guide the management of these controversial patients. Methods: We review the existing literature on the natural history of unruptured cerebral aneurysms and highlight ongoing research aimed at improving our ability to stratify risk in these patients. Results: Landmark natural history studies demonstrated the significance of size, location, and other risk factors for aneurysm rupture, but prior studies have significant limitations. We have begun to understand the underlying pathophysiology behind aneurysm formation and rupture and are now applying new tools such as flow dynamics simulations and machine learning to individualize rupture risk stratification. Conclusion: Prior studies have identified several key risk factors for aneurysmal rupture, but have limitations. New technology and research methods have enabled us to better understanding individual rupture risk for patients with unruptured cerebral aneurysms.
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Yadav N, Kumar A, Hedaoo K, Jain A, Singh K, Vikram A. Establishing a New Neurointerventional Facility in a Remote Area of a Low–Middle Income Country (LMIC): Initial Experience. Asian J Neurosurg 2022; 17:50-57. [PMID: 35873835 PMCID: PMC9298586 DOI: 10.1055/s-0042-1749150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background
Timely performed Neurointervention procedures in patients with neurovascular disorders save them from mortality and lifelong morbidity, in addition to relieving the immense economic and social burden associated with these diseases.
Materials and Methods
We retrospectively reviewed data of neurointerventions performed in our hospital from November 2019 till March 2021. Patient age, sex, diagnosis, preoperative, and postoperative imaging findings were collected and analyzed. Types of procedures, success/failure, procedure-related and procedure-unrelated complications were noted and described.
Results
Total 161 procedures were done (diagnostic n = 89, therapeutic n = 72). Among the 72 cases of therapeutic procedures, angiographic success was noted in 60 cases, partial success was noted in 5 cases (RR grade 3 occlusion) and failure was noted in 7 cases [mechanical thrombectomy (n = 2), coiling (n = 1), flow diverter (n = 1), Caroticocavernous fistula (n = 1), cerebral Arteriovenous malformation (n = 2)]. Among therapeutic cases (n = 72), patient outcome was categorized as improved (with mRS 0-2 at discharge) in 64 cases (60 neurointerventions, 4 converted to surgery), morbidity in form of weakness was noted in 2 cases, mortality was noted in 8 cases. There were no hemorrhagic complications due to rupture or dissection. Ischemic complications were noted in form of thromboembolic complications in three cases and vessel occlusion (delayed MCA occlusion) in one case.
Conclusion
With recent efforts by medical associations and governments to provide access to these lifesaving, disability averting neuro-interventions, it’s important to recognize and define challenges in implementation of neuro-intervention services. In this article, we share our early experience in establishing a neurointervention facility in a backward region of a low–middle income country.
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Affiliation(s)
- Nishtha Yadav
- Department of Neuroradiology, School of Excellence in Neurosurgery Super Speciality Hospital, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | - Ambuj Kumar
- Department of Neurosurgery, Super Speciality Hospital, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | - Ketan Hedaoo
- Department of Neurosurgery, Super Speciality Hospital, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | - Anivesh Jain
- Department of Anaesthesia, Super Speciality Hospital, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | - Kamalraj Singh
- Department of Anaesthesia, Super Speciality Hospital, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
| | - Aditya Vikram
- Department of Neurosurgery, Super Speciality Hospital, Netaji Subhash Chandra Bose Medical College, Jabalpur, Madhya Pradesh, India
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Chaganty SS, Ozair A, Rahman F. State of Accredited Endovascular Neurosurgery Training in India in 2021: Challenges to Capacity Building in Subspecialty Neurosurgical Care. Front Surg 2021; 8:705246. [PMID: 34540885 PMCID: PMC8448280 DOI: 10.3389/fsurg.2021.705246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 08/05/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Ahmad Ozair
- Faculty of Medicine, King George's Medical University, Lucknow, India
| | - Faique Rahman
- Jawaharlal Nehru Medical College and Hospital, Aligarh Muslim University, Aligarh, India
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Winkler EA, Rutledge WC, Abla AA. Commentary: Outcome After Clipping and Coiling for Aneurysmal Subarachnoid Hemorrhage in Clinical Practice in Europe, USA, and Australia. Neurosurgery 2019; 84:E264-E265. [PMID: 29878164 DOI: 10.1093/neuros/nyy256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 05/14/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Ethan A Winkler
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - W Caleb Rutledge
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
| | - Adib A Abla
- Department of Neurological Surgery, University of California San Francisco, San Francisco, California
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Lindgren A, Turner EB, Sillekens T, Meretoja A, Lee JM, Hemmen TM, Koivisto T, Alberts M, Lemmens R, Jääskeläinen JE, Vergouwen MDI, Rinkel GJE. Outcome After Clipping and Coiling for Aneurysmal Subarachnoid Hemorrhage in Clinical Practice in Europe, USA, and Australia. Neurosurgery 2019; 84:1019-1027. [PMID: 29846713 PMCID: PMC8764701 DOI: 10.1093/neuros/nyy223] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 05/02/2018] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Within randomized clinical trials (RCTs), coiling of the ruptured aneurysm to prevent rebleeding results in better outcomes than clipping in patients with aneurysmal subarachnoid hemorrhage (aSAH). OBJECTIVE To study the association of coiling and clipping with outcome after aSAH in daily clinical practice. METHODS In this controlled, nonrandomized study, we compared outcomes after endovascular coiling and neurosurgical clipping of ruptured intracranial aneurysms in an administrative dataset of 7658 aSAH patients (22 tertiary care hospitals from Europe, USA, Australia; 2007-2013). Because the results contradicted those of the randomized trials, findings were further explored in a large clinical dataset from 2 European centers (2006-2016) of 1501 patients. RESULTS In the administrative dataset, the crude 14-d case-fatality rate was 6.4% (95% confidence interval [CI] 5.6%-7.2%) after clipping and 8.2% (95% CI 7.4%-9.1%) after coiling. After adjustment for age, sex, and comorbidity/severity, the odds ratio (OR) for 14-d case-fatality after coiling compared to clipping was 1.32 (95% CI 1.10-1.58). In the clinical dataset crude 14-d case fatality rate was 5.7% (95% CI 4.2%-7.8%) for clipping and 9.0% (95% CI 7.3%-11.2%) for coiling. In multivariable logistic regression analysis, the OR for 14-d case-fatality after coiling compared to clipping was 1.7 (95% CI 1.1-2.7), for 90-d case-fatality 1.28 (95% CI 0.91-1.82) and for 90-d poor functional outcome 0.78 (95% CI 0.6-1.01). CONCLUSION In clinical practice, coiling after aSAH is associated with higher 14-d case-fatality than clipping and nonsuperior outcomes at 90 d. Both options need to be considered in aSAH patients. Further studies should address the reasons for the discrepancy between current data and those from the RCTs.
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Affiliation(s)
- Antti Lindgren
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | | | - Tomas Sillekens
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Atte Meretoja
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
- Department of Medicine at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Jin-Moo Lee
- Department of Neurology, and the Hope Center for Neurological disorders, Washington University School of Medicine, St. Louis, Missouri
| | - Thomas M Hemmen
- Department of Neurosciences, University of California, San Diego, California
| | - Timo Koivisto
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Mark Alberts
- Department of Neurology, Hartford Hospital, Hartford, Connecticut
| | - Robin Lemmens
- KU Leuven – University of Leuven, Department of Neurosciences, Experimental Neurology, Leuven Institute for Neuroscience and Disease (LIND), Leuven, Belgium
- VIB, Center for Brain & Disease Research, Laboratory of Neurobiology, Leuven, Belgium
- University Hospitals Leuven, Department of Neurology, Leuven, Belgium
| | - Juha E Jääskeläinen
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
| | - Mervyn D I Vergouwen
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery, University Medical Centre Utrecht, Utrecht, The Netherlands
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Algra AM, Lindgren A, Vergouwen MDI, Greving JP, van der Schaaf IC, van Doormaal TPC, Rinkel GJE. Procedural Clinical Complications, Case-Fatality Risks, and Risk Factors in Endovascular and Neurosurgical Treatment of Unruptured Intracranial Aneurysms: A Systematic Review and Meta-analysis. JAMA Neurol 2019; 76:282-293. [PMID: 30592482 PMCID: PMC6439725 DOI: 10.1001/jamaneurol.2018.4165] [Citation(s) in RCA: 117] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Accepted: 11/02/2018] [Indexed: 01/16/2023]
Abstract
Importance The risk of procedural clinical complications and the case-fatality rate (CFR) from preventive treatment of unruptured intracranial aneurysms varies between studies and may depend on treatment modality and risk factors. Objective To assess current procedural clinical 30-day complications and the CFR from endovascular treatment (EVT) and neurosurgical treatment (NST) of unruptured intracranial aneurysms and risk factors of clinical complications. Data Sources We searched PubMed, Excerpta Medica Database, and the Cochrane Database for studies published between January 1, 2011, and January 1, 2017. Study Selection Studies reporting on clinical complications, the CFR, and risk factors, including 50 patients or more undergoing EVT or NST for saccular unruptured intracranial aneurysms after January 1, 2000, were eligible. Data Extraction and Synthesis Per treatment modality, we analyzed clinical complication risk and the CFR with mixed-effects logistic regression models for dichotomous data. For studies reporting data on complication risk factors, we obtained risk ratios (RRs) or odds ratios (ORs) with 95% CIs and pooled risk estimates with weighted random-effects models. Main Outcomes and Measures Clinical complications within 30 days and the CFR. Results We included 114 studies (106 433 patients with 108 263 aneurysms). For EVT (74 studies), the pooled clinical complication risk was 4.96% (95% CI, 4.00%-6.12%), and the CFR was 0.30% (95% CI, 0.20%-0.40%). Factors associated with complications from EVT were female sex (pooled OR, 1.06 [95% CI, 1.01-1.11]), diabetes (OR, 1.81 [95% CI, 1.05-3.13]), hyperlipidemia (OR, 1.76 [95% CI, 1.3-2.37]), cardiac comorbidity (OR, 2.27 [95% CI, 1.53-3.37]), wide aneurysm neck (>4 mm or dome-to-neck ratio >1.5; OR, 1.71 [95% CI, 1.38-2.11]), posterior circulation aneurysm (OR, 1.42 [95% CI, 1.15-1.74]), stent-assisted coiling (OR, 1.82 [95% CI, 1.16-2.85]), and stenting (OR, 3.43 [95% CI, 1.45-8.09]). For NST (54 studies), the pooled complication risk was 8.34% (95% CI, 6.25%-11.10%) and the CFR was 0.10% (95% CI, 0.00%-0.20%). Factors associated with complications from NST were age (OR per year increase, 1.02 [95% CI, 1.01-1.02]), female sex (OR, 0.43 [95% CI, 0.32-0.85]), coagulopathy (OR, 2.14 [95% CI, 1.13-4.06]), use of anticoagulation (OR, 6.36 [95% CI, 2.55-15.85]), smoking (OR, 1.95 [95% CI, 1.36-2.79]), hypertension (OR, 1.45 [95% CI, 1.03-2.03]), diabetes (OR, 2.38 [95% CI, 1.54-3.67]), congestive heart failure (OR, 2.71 [95% CI, 1.57-4.69]), posterior aneurysm location (OR, 7.25 [95% CI, 3.70-14.20]), and aneurysm calcification (OR, 2.89 [95% CI, 1.35-6.18]). Conclusions and Relevance This study identifies risk factors for procedural complications. Large data sets with individual patient data are needed to develop and validate prediction scores for absolute complication risks and CFRs from EVT and NST modalities.
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Affiliation(s)
- Annemijn M. Algra
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Antti Lindgren
- Department of Neurosurgery, NeuroCenter, Kuopio University Hospital, Kuopio, Finland
- Department of Neurosurgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio, Finland
| | - Mervyn D. I. Vergouwen
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Jacoba P. Greving
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Irene C. van der Schaaf
- Department of Radiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Tristan P. C. van Doormaal
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Gabriel J. E. Rinkel
- Brain Center Rudolf Magnus, Department of Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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Lindgren A, Vergouwen MDI, van der Schaaf I, Algra A, Wermer M, Clarke MJ, Rinkel GJE. Endovascular coiling versus neurosurgical clipping for people with aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2018; 8:CD003085. [PMID: 30110521 PMCID: PMC6513627 DOI: 10.1002/14651858.cd003085.pub3] [Citation(s) in RCA: 51] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Around 30% of people who are admitted to hospital with aneurysmal subarachnoid haemorrhage (SAH) will rebleed in the initial month after the haemorrhage if the aneurysm is not treated. The two most commonly used methods to occlude the aneurysm for prevention of rebleeding are microsurgical clipping of the neck of the aneurysm and occlusion of the lumen of the aneurysm by means of endovascular coiling. This is an update of a systematic review that was previously published in 2005. OBJECTIVES To compare the effects of endovascular coiling versus neurosurgical clipping in people with aneurysmal SAH on poor outcome, rebleeding, neurological deficit, and treatment complications. SEARCH METHODS We searched the Cochrane Stroke Group Trials Register (March 2018). In addition, we searched CENTRAL (2018, Issue 2), MEDLINE (1966 to March 2018), Embase (1980 to March 2018), US National Institutes of Health Ongoing Trials Register (March 2018), and World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (last searched March 2018). We also contacted trialists. SELECTION CRITERIA We included randomised trials comparing endovascular coiling with neurosurgical clipping in people with SAH from a ruptured aneurysm. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data, and assessed trial quality and risk of bias using the GRADE approach. We contacted trialists to obtain missing information. We defined poor outcome as death or dependence in daily activities (modified Rankin scale 3 to 6 or Glasgow Outcome Scale (GOS) 1 to 3). In the special worst-case scenario analysis, we assumed all participants in the group with better outcome with missing follow-up information had a poor outcome and those in the other group with missing data a good outcome. MAIN RESULTS We included four randomised trials involving 2458 participants (range per trial: 20 to 2143 participants). Evidence is mostly based on the largest trial. Most participants were in good clinical condition and had an aneurysm on the anterior circulation. None of the included trials was at low risk of bias in all domains. One trial was at unclear risk in one domain, two trials at unclear risk in three domains, and one trial at high risk in one domain.After one year of follow-up, 24% of participants randomised to endovascular treatment and 32% of participants randomised to the surgical treatment group had poor functional outcome. The risk ratio (RR) of poor outcome (death or dependency) for endovascular coiling versus neurosurgical clipping was 0.77 (95% confidence interval (CI) 0.67 to 0.87; 4 trials, 2429 participants, moderate-quality evidence), and the absolute risk reduction was 7% (95% CI 4% to 11%). In the worst-case scenario analysis for poor outcome, the RR for endovascular coiling versus neurosurgical clipping was 0.80 (95% CI 0.71 to 0.91), and the absolute risk reduction was 6% (95% CI 2% to 10%). The RR of death at 12 months was 0.80 (95% CI 0.63 to 1.02; 4 trials, 2429 participants, moderate-quality evidence). In a subgroup analysis of participants with an anterior circulation aneurysm, the RR of poor outcome was 0.78 (95% CI 0.68 to 0.90; 2 trials, 2157 participants, moderate-quality evidence), and the absolute risk decrease was 7% (95% CI 3% to 10%). In subgroup analysis of those with a posterior circulation aneurysm, the RR was 0.41 (95% CI 0.19 to 0.92; 2 trials, 69 participants, low-quality evidence), and the absolute decrease in risk was 27% (95% CI 6% to 48%). At five years, 28% of participants randomised to endovascular treatment and 32% of participants randomised to surgical treatment had poor functional outcome. The RR of poor outcome for endovascular coiling versus neurosurgical clipping was 0.87 (95% CI 0.75 to 1.01, 1 trial, 1724 participants, low-quality evidence). At 10 years, 35% participants allocated to endovascular and 43% participants allocated to surgical treatment had poor functional outcome. At 10 years RR of poor outcome for endovascular coiling versus neurosurgical clipping was 0.81 (95% CI 0.70 to 0.92; 1 trial, 1316 participants, low-quality evidence). The RR of delayed cerebral ischaemia at two to three months for endovascular coiling versus neurosurgical clipping was 0.84 (95% CI 0.74 to 0.96; 4 trials, 2450 participants, moderate-quality evidence). The RR of rebleeding for endovascular coiling versus neurosurgical clipping was 1.83 (95% CI 1.04 to 3.23; 4 trials, 2458 participants, high-quality evidence) at one year, and 2.69 (95% CI 1.50 to 4.81; 1 trial, 1323 participants, low-quality evidence) at 10 years. The RR of complications from intervention for endovascular coiling versus neurosurgical clipping was 1.05 (95% CI 0.44 to 2.53; 2 trials, 129 participants, low-quality evidence). AUTHORS' CONCLUSIONS The evidence in this systematic review comes mainly from one large trial, and long-term follow-up is available only for a subgroup of participants within that trial. For people in good clinical condition with ruptured aneurysms of either the anterior or posterior circulation the data from randomised trials show that, if the aneurysm is considered suitable for both neurosurgical clipping and endovascular coiling, coiling is associated with a better outcome. There is no reliable trial evidence that can be used directly to guide treatment in people with a poor clinical condition.
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Affiliation(s)
- Antti Lindgren
- Kuopio University HospitalDepartment of NeurosurgeryPuijonlaaksontie 2KuopioKuopioFinland70029
| | - Mervyn DI Vergouwen
- University Medical Center UtrechtDepartment of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
| | - Irene van der Schaaf
- University Medical Center UtrechtDepartment of RadiologyHeidelberglaan 100UtrechtNetherlands3508 GA
| | - Ale Algra
- University Medical Center UtrechtJulius Center for Health Sciences and Primary Care/Department of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
| | - Marieke Wermer
- Leiden University Medical CenterDepartment of NeurologyAlbinusdreef 2LeidenNetherlands2333 ZA
| | - Mike J Clarke
- Queen's University BelfastCentre for Public HealthInstitute of Clinical Sciences, Block B, Royal Victoria HospitalGrosvenor RoadBelfastNorthern IrelandUKBT12 6BJ
| | - Gabriel JE Rinkel
- University Medical Center UtrechtDepartment of Neurology and NeurosurgeryPO Box 85500UtrechtNetherlands3508 GA
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Stegink-Jansen CW, Collins PM, Lindsey RW, Wilson JL. A geographical workforce analysis of hand therapy services in relation to US population characteristics. J Hand Ther 2018; 30:383-396.e1. [PMID: 28689925 DOI: 10.1016/j.jht.2017.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 06/11/2017] [Indexed: 02/09/2023]
Abstract
INTRODUCTION A paucity of work force planning literature exists for hand therapy services. PURPOSE This descriptive study aimed to map the geographical distribution of US Certified Hand Therapists (CHTs) and describe characteristics of US populations living in respective CHT workplace Zip Code Tabulation Areas (ZCTAs). METHODS A de-identified Zip Code list of all active CHTs through April 2016 from the Hand Therapy Certification Commission, included 5572 CHTs with US ZCTAs. The CHT ZCTAs were matched with population parameters "rurality", "poverty" and "race and ethnicity" from the 2010 US Census and 2014 American Community Survey. RESULTS The 5,572 CHTs practice ZCTAs mostly overlapped with high density US population areas, covering just 9% of the total number of 33,120 US ZCTAs. The population in CHT ZCTAs was 1) urban in nature, 2) with lower poverty rates than ZCTAs without CHTs, and 3) mostly reflecting US race and ethnicity population distribution. Only 3.7% of CHTs worked in large concentrations of 11 to 26 CHTs per ZCTA near or in urban centers. Most CHTs, 67%, worked in one to three CHTs per ZCTA concentrations, contributing to a larger geographic spread of CHT locations than expected. DISCUSSION AND CONCLUSION This study provides a foundational snap shot of the distribution, the potential availability, of the 2016 CHT workforce in the context of US population characteristics. It may serve as baseline for supply and demand studies and interventions to grow the CHT profession and optimize the distribution of CHTs to better meet population needs.
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Affiliation(s)
- Caroline W Stegink-Jansen
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, School of Medicine, Galveston, TX, USA.
| | - Prisca M Collins
- Physical Therapy Program, Northern Illinois University, School of Allied Health and Communicative Disorders, College of Health and Human Sciences, DeKalb, IL, USA
| | - Ronald W Lindsey
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, School of Medicine, Galveston, TX, USA
| | - James L Wilson
- Department of Geography, Northern Illinois University, College of Liberal Arts and Sciences, DeKalb, IL, USA
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Karhade AV, Larsen AMG, Cote DJ, Dubois HM, Smith TR. National Databases for Neurosurgical Outcomes Research: Options, Strengths, and Limitations. Neurosurgery 2017; 83:333-344. [DOI: 10.1093/neuros/nyx408] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 06/21/2017] [Indexed: 01/12/2023] Open
Affiliation(s)
- Aditya V Karhade
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Alexandra M G Larsen
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - David J Cote
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Heloise M Dubois
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Timothy R Smith
- Cushing Neurosurgery Outcomes Center, Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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Thomas JE, Rose JC. Microneurosurgical Clip Ligation of Acutely Ruptured Cerebral Aneurysm Immediately Preceded by Intentional Subtotal Endovascular Coil Embolization Under a Single Anesthesia: Observations Using a Deliberate Combined Sequential Treatment Strategy in 13 Cases. World Neurosurg 2017; 106:1054.e1-1054.e12. [PMID: 28733225 DOI: 10.1016/j.wneu.2017.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2017] [Revised: 07/06/2017] [Accepted: 07/07/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Endovascular coil embolization and craniotomy with clip ligation are the 2 most commonly used treatments for ruptured cerebral aneurysm. Although coiling maintains the advantages of brevity and complete avoidance of brain retraction and manipulation, clipping offers the benefits of decompression of the injured brain and lower rates of aneurysm recurrence. A combined, immediately sequential treatment strategy for acutely ruptured cerebral aneurysm that simultaneously maximizes the advantages of both techniques, while minimizing their respective disadvantages, may be a useful paradigm. OBJECTIVE To demonstrate the complementarity of clipping and coiling in acutely ruptured cerebral aneurysm. METHODS Patients with ruptured anterior circulation cerebral aneurysm standing to benefit from brain decompression were treated by a combination of coiling and microneurosurgery in rapid succession, under the same general anesthetic. Surgery consisted of clipping of the aneurysm via either craniotomy or craniectomy with expansion duraplasty in all cases, and ventriculostomy in selected cases. RESULTS Coil embolization of the ruptured aneurysm was carried out rapidly and improved the efficiency of subsequent clipping by allowing early unequivocal identification of the aneurysm dome and decreased brain retraction, reducing risk of intraoperative rupture and obviating temporary occlusion. All aneurysms were shown eliminated by postoperative cerebral angiography. CONCLUSIONS A deliberate combined treatment strategy that uses clipping immediately preceded by subtotal coiling under a single anesthetic may be ideal for selected ruptured cerebral aneurysms, takes advantage of the unique strengths of both techniques, makes both techniques easier, and maximizes opportunity for brain protection against delayed complications in the prolonged aftermath of aneurysmal subarachnoid hemorrhage.
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Affiliation(s)
- Jeffrey E Thomas
- Section of Neurosurgery, Department of Surgery, Washington Hospital and Washington Township Medical Foundation, Fremont, California, USA.
| | - Jack C Rose
- Section of Neurosurgery, Department of Surgery, Washington Hospital and Washington Township Medical Foundation, Fremont, California, USA
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Oravec CS, Motiwala M, Reed K, Kondziolka D, Barker FG, Michael LM, Klimo P. Big Data Research in Neurosurgery: A Critical Look at this Popular New Study Design. Neurosurgery 2017; 82:728-746. [DOI: 10.1093/neuros/nyx328] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/17/2017] [Indexed: 01/10/2023] Open
Affiliation(s)
- Chesney S Oravec
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mustafa Motiwala
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Kevin Reed
- College of Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Douglas Kondziolka
- Department of Neurosurgery, New York University Langone Medical Center, New York, New York
| | - Fred G Barker
- Department of Neurosurgery, Massachusetts General Hospital, Boston, Massachusetts
| | - L Madison Michael
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
| | - Paul Klimo
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
- Semmes Murphey Clinic, Memphis, Tennessee
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
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Simon SD, Harbaugh RE, Day AL. Letter to the Editor: Does physician specialty really matter? J Neurosurg 2016; 125:523-4. [DOI: 10.3171/2016.3.jns16721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Sarabia R, Arrese I. [Is it time to integrate the neurointerventionism into the practice of vascular neurosurgery?]. Neurocirugia (Astur) 2016; 27:150-1. [PMID: 27068031 DOI: 10.1016/j.neucir.2016.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Accepted: 03/06/2016] [Indexed: 11/18/2022]
Affiliation(s)
- Rosario Sarabia
- Unidad Neurovascular Río Hortega, Hospital Universitario Río Hortega, Valladolid, España.
| | - Ignacio Arrese
- Unidad Neurovascular Río Hortega, Hospital Universitario Río Hortega, Valladolid, España
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Maud A, Rodriguez GJ, Piriyawat P, Cruz-Flores S. Letter to the Editor: Physician specialty and endovascular treatment of intracerebral aneurysms. J Neurosurg 2016; 124:1876-8. [PMID: 27058196 DOI: 10.3171/2015.9.jns152035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Alberto Maud
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX
| | | | - Paisith Piriyawat
- Texas Tech University Health Sciences Center of El Paso, El Paso, TX
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Khandelwal P, Patel N, See AP, Ali Aziz-Sultan M. Letter to the Editor: Failing our colleagues, are we supporting our cerebrovascular partners? J Neurosurg 2016; 124:1134-5. [PMID: 26848915 DOI: 10.3171/2015.8.jns151914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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