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Badhiwala JH, Hachem LD, Merali Z, Witiw CD, Nassiri F, Akbar MA, Almenawer SA, Schomacher M, Wilson JR, Fehlings MG. Predicting Outcomes After Surgical Decompression for Mild Degenerative Cervical Myelopathy: Moving Beyond the mJOA to Identify Surgical Candidates. Neurosurgery 2020; 86:565-573. [PMID: 31225604 DOI: 10.1093/neuros/nyz160] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 01/21/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Patients with mild degenerative cervical myelopathy (DCM) represent a heterogeneous population, and indications for surgical decompression remain controversial. OBJECTIVE To dissociate patient phenotypes within the broader population of mild DCM associated with degree of impairment in baseline quality of life (QOL) and surgical outcomes. METHODS This was a post hoc analysis of patients with mild DCM (modified Japanese Orthopedic Association [mJOA] 15-17) enrolled in the AOSpine CSM-NA/CSM-I studies. A k-means clustering algorithm was applied to baseline QOL (Short Form-36 [SF-36]) scores to separate patients into 2 clusters. Baseline variables and surgical outcomes (change in SF-36 scores at 1 yr) were compared between clusters. A k-nearest neighbors (kNN) algorithm was used to evaluate the ability to classify patients into the 2 clusters by significant baseline clinical variables. RESULTS One hundred eighty-five patients were eligible. Two groups were generated by k-means clustering. Cluster 1 had a greater proportion of females (44% vs 28%, P = .029) and symptoms of neck pain (32% vs 11%, P = .001), gait difficulty (57% vs 40%, P = .025), or weakness (75% vs 59%, P = .041). Although baseline mJOA correlated with neither baseline QOL nor outcomes, cluster 1 was associated with significantly greater improvement in disability (P = .003) and QOL (P < .001) scores following surgery. A kNN algorithm could predict cluster classification with 71% accuracy by neck pain, motor symptoms, and gender alone. CONCLUSION We have dissociated a distinct patient phenotype of mild DCM, characterized by neck pain, motor symptoms, and female gender associated with greater impairment in QOL and greater response to surgery.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Laureen D Hachem
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Zamir Merali
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Christopher D Witiw
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Muhammad A Akbar
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Saleh A Almenawer
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada
| | - Markus Schomacher
- Department of Neurosurgery, Charité University Hospital, Berlin, Germany
| | - Jefferson R Wilson
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Michael G Fehlings
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Canada.,Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Canada.,Division of Neurosurgery, Toronto Western Hospital, University Health Network, Toronto, Canada
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Affiliation(s)
- Alex Koziarz
- University of Toronto, Toronto, Ontario, Canada (A.K.)
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Oitment C, Watson T, Lam V, Aref M, Koziarz A, Kachur E, Badhiwala JH, Almenawer SA, Cenic A. The Role of Anterior Cervical Discectomy and Fusion on Relieving Axial Neck Pain in Patients With Single-Level Disease: A Systematic Review and Meta-Analysis. Global Spine J 2020; 10:312-323. [PMID: 32313797 PMCID: PMC7160803 DOI: 10.1177/2192568219837923] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
STUDY DESIGN Systematic review and meta-analysis. OBJECTIVES This study aims to evaluate the effects of anterior cervical decompression and fusion (ACDF) on axial neck pain in adult patients receiving surgery for myelopathy, radiculopathy, or a combination of both. METHODS Two independent reviewers completed a librarian-assisted search of 4 databases. Visual Analogue Scale (VAS) and Neck Disability Index (NDI) scores were extracted preoperatively and at 3, 6, 12, 24, 36, 48, and 48+ months postoperatively for ACDF groups and pooled using a random-effects model. RESULTS Of 17 850 eligible studies, 37 were included for analysis, totaling 2138 patients analyzed with VAS and 2477 with NDI score. Individual VAS mean differences were reduced at 6 weeks (-2.5 [95% confidence interval (CI): -3.5 to -1.6]), 3 months (-2.9 [-3.7 to -2.2]), 6 months (-3.2 [-3.9 to -2.6]), 12 months (-3.7 [-4.3 to -3.1]), 24 months (-4.0 [-4.4 to -3.5]), 48 months (-4.6 [-5.5 to -3.8]), and >48 months (-4.7 [-5.8 to -3.6]) follow-up (P < .0001 for all endpoints). Individual NDI mean differences were reduced at 6 weeks (-26.7 [-30.9 to -22.6]), 3 months (-29.8 [-32.7 to -26.8]), 6 months (-31.2 [-35.5 to -26.8)], 12 months (-29.3 [-33.2 to -25.4]), 24 months (-28.9 [-32.6 to -25.2]), 48 months (-33.1 [-37.4 to -28.7]), and >48 months (-37.6 [-45.9 to -29.3]) follow-up (P < .0001 for all endpoints). CONCLUSIONS ACDF is associated with a significant reduction in axial neck pain compared with preoperative values in patients being treated specifically for myelopathy or radiculopathy. This influences the preoperative discussions surgeons may have with patients regarding their expectations for surgery. The effects seen are stable over time and represent a clinically significant reduction in axial neck pain.
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Affiliation(s)
| | | | - Victor Lam
- University of Western Ontario, London, Ontario, Canada
| | | | - Alex Koziarz
- McMaster University, Hamilton, Ontario, Canada,University of Toronto, Toronto, Ontario, Canada
| | | | | | | | - Aleksa Cenic
- McMaster University, Hamilton, Ontario, Canada,Aleksa Cenic, Division of Neurosurgery, Hamilton
Health Sciences, 237 Barton St E, Hamilton, Ontario L8L 2X2, Canada.
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Koziarz A, Sne N, Kegel F, Nath S, Badhiwala JH, Nassiri F, Mansouri A, Yang K, Zhou Q, Rice T, Faidi S, Passos E, Healey A, Banfield L, Mensour M, Kirkpatrick AW, Nassar A, Fehlings MG, Hawryluk GWJ, Almenawer SA. Bedside Optic Nerve Ultrasonography for Diagnosing Increased Intracranial Pressure: A Systematic Review and Meta-analysis. Ann Intern Med 2019; 171:896-905. [PMID: 31739316 DOI: 10.7326/m19-0812] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Optic nerve ultrasonography (optic nerve sheath diameter sonography) has been proposed as a noninvasive, quick method for diagnosing increased intracranial pressure. PURPOSE To examine the accuracy of optic nerve ultrasonography for diagnosing increased intracranial pressure in children and adults. DATA SOURCES 13 databases from inception through May 2019, reference lists, and meeting proceedings. STUDY SELECTION Prospective optic nerve ultrasonography diagnostic accuracy studies, published in any language, involving any age group or reference standard. DATA EXTRACTION 3 reviewers independently abstracted data and performed quality assessment. DATA SYNTHESIS Of 71 eligible studies involving 4551 patients, 61 included adults, and 35 were rated as having low risk of bias. The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio of optic nerve ultrasonography in patients with traumatic brain injury were 97% (95% CI, 92% to 99%), 86% (CI, 74% to 93%), 6.93 (CI, 3.55 to 13.54), and 0.04 (CI, 0.02 to 0.10), respectively. Respective estimates in patients with nontraumatic brain injury were 92% (CI, 86% to 96%), 86% (CI, 77% to 92%), 6.39 (CI, 3.77 to 10.84), and 0.09 (CI, 0.05 to 0.17). Accuracy estimates were similar among studies stratified by patient age, operator specialty and training level, reference standard, sonographer blinding status, and cutoff value. The optimal cutoff for optic nerve sheath dilatation on ultrasonography was 5.0 mm. LIMITATION Small studies, imprecise summary estimates, possible publication bias, and no evaluation of effect on clinical outcomes. CONCLUSION Optic nerve ultrasonography can help diagnose increased intracranial pressure. A normal sheath diameter measurement has high sensitivity and a low negative likelihood ratio that may rule out increased intracranial pressure, whereas an elevated measurement, characterized by a high specificity and positive likelihood ratio, may indicate increased intracranial pressure and the need for additional confirmatory tests. PRIMARY FUNDING SOURCE None. (PROSPERO: CRD42017055485).
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Affiliation(s)
- Alex Koziarz
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Niv Sne
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Fraser Kegel
- McGill University, Montreal, Quebec, Canada (F.K.)
| | - Siddharth Nath
- School of Medicine, McMaster University, Hamilton, Ontario, Canada (S.N.)
| | - Jetan H Badhiwala
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Farshad Nassiri
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Alireza Mansouri
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | - Kaiyun Yang
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Qi Zhou
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Timothy Rice
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Samir Faidi
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Edward Passos
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Andrew Healey
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Laura Banfield
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
| | - Mark Mensour
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada (M.M.)
| | | | | | - Michael G Fehlings
- University of Toronto, Toronto, Ontario, Canada (A.K., J.H.B., F.N., A.M., M.G.F.)
| | | | - Saleh A Almenawer
- McMaster University, Hamilton, Ontario, Canada (N.S., K.Y., Q.Z., T.R., S.F., E.P., A.H., L.B., S.A.A.)
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5
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Fernando SM, Tran A, Cheng W, Rochwerg B, Taljaard M, Kyeremanteng K, English SW, Sekhon MS, Griesdale DEG, Dowlatshahi D, McCredie VA, Wijdicks EFM, Almenawer SA, Inaba K, Rajajee V, Perry JJ. Diagnosis of elevated intracranial pressure in critically ill adults: systematic review and meta-analysis. BMJ 2019; 366:l4225. [PMID: 31340932 PMCID: PMC6651068 DOI: 10.1136/bmj.l4225] [Citation(s) in RCA: 81] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/30/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVES To summarise and compare the accuracy of physical examination, computed tomography (CT), sonography of the optic nerve sheath diameter (ONSD), and transcranial Doppler pulsatility index (TCD-PI) for the diagnosis of elevated intracranial pressure (ICP) in critically ill patients. DESIGN Systematic review and meta-analysis. DATA SOURCES Six databases, including Medline, EMBASE, and PubMed, from inception to 1 September 2018. STUDY SELECTION CRITERIA English language studies investigating accuracy of physical examination, imaging, or non-invasive tests among critically ill patients. The reference standard was ICP of 20 mm Hg or more using invasive ICP monitoring, or intraoperative diagnosis of raised ICP. DATA EXTRACTION Two reviewers independently extracted data and assessed study quality using the quality assessment of diagnostic accuracy studies tool. Summary estimates were generated using a hierarchical summary receiver operating characteristic (ROC) model. RESULTS 40 studies (n=5123) were included. Of physical examination signs, pooled sensitivity and specificity for increased ICP were 28.2% (95% confidence interval 16.0% to 44.8%) and 85.9% (74.9% to 92.5%) for pupillary dilation, respectively; 54.3% (36.6% to 71.0%) and 63.6% (46.5% to 77.8%) for posturing; and 75.8% (62.4% to 85.5%) and 39.9% (26.9% to 54.5%) for Glasgow coma scale of 8 or less. Among CT findings, sensitivity and specificity were 85.9% (58.0% to 96.4%) and 61.0% (29.1% to 85.6%) for compression of basal cisterns, respectively; 80.9% (64.3% to 90.9%) and 42.7% (24.0% to 63.7%) for any midline shift; and 20.7% (13.0% to 31.3%) and 89.2% (77.5% to 95.2%) for midline shift of at least 10 mm. The pooled area under the ROC (AUROC) curve for ONSD sonography was 0.94 (0.91 to 0.96). Patient level data from studies using TCD-PI showed poor performance for detecting raised ICP (AUROC for individual studies ranging from 0.55 to 0.72). CONCLUSIONS Absence of any one physical examination feature is not sufficient to rule out elevated ICP. Substantial midline shift could suggest elevated ICP, but the absence of shift cannot rule it out. ONSD sonography might have use, but further studies are needed. Suspicion of elevated ICP could necessitate treatment and transfer, regardless of individual non-invasive tests. REGISTRATION PROSPERO CRD42018105642.
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Affiliation(s)
- Shannon M Fernando
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Alexandre Tran
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Department of Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Wei Cheng
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Bram Rochwerg
- Department of Medicine, Division of Critical Care, McMaster University, Hamilton, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Monica Taljaard
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Kwadwo Kyeremanteng
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Shane W English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Mypinder S Sekhon
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Donald E G Griesdale
- Department of Medicine, Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
- Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, Vancouver, BC, Canada
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Dar Dowlatshahi
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
- Divison of Neurology, Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, ON, Canada
- Toronto Western Hospital, University Health Network, Toronto, ON, Canada
| | - Eelco F M Wijdicks
- Division of Neurocritical Care and Hospital Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Saleh A Almenawer
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Kenji Inaba
- Division of Acute Care Surgery, Department of Surgery, University of Southern California, Los Angeles, CA, USA
| | - Venkatakrishna Rajajee
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey J Perry
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
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Badhiwala JH, Nassiri F, Witiw CD, Mansouri A, Almenawer SA, da Costa L, Fehlings MG, Wilson JR. Investigating the utility of intraoperative neurophysiological monitoring for anterior cervical discectomy and fusion: analysis of over 140,000 cases from the National (Nationwide) Inpatient Sample data set. J Neurosurg Spine 2019; 31:76-86. [PMID: 30925481 DOI: 10.3171/2019.1.spine181110] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Accepted: 01/08/2019] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Intraoperative neurophysiological monitoring (IONM) is a useful adjunct in spine surgery, with proven benefit in scoliosis-correction surgery. However, its utility for anterior cervical discectomy and fusion (ACDF) is unclear, as there are few head-to-head comparisons of ACDF outcomes with and without the use of IONM. The authors sought to evaluate the impact of IONM on the safety and cost of ACDF. METHODS This was a retrospective analysis of data from the National (Nationwide) Inpatient Sample of the Healthcare Cost and Utilization Project from 2009 to 2013. Patients with a primary procedure code for ACDF were identified, and diagnosis codes were searched to identify cases with postoperative neurological complications. The authors performed univariate and multivariate logistic regression for postoperative neurological complications with use of IONM as the independent variable; additional covariates included age, sex, surgical indication, multilevel fusion, Charlson Comorbidity Index (CCI) score, and admission type. They also conducted propensity score matching in a 1:1 ratio (nearest neighbor) with the use of IONM as the treatment indicator and the aforementioned variables as covariates. In the propensity score-matched cohort, they compared neurological complications, length of stay (LOS), and hospital charges (in US dollars). RESULTS A total of 141,007 ACDF operations were identified. IONM was used in 9540 cases (6.8%). No significant association was found between neurological complications and use of IONM on univariate analysis (OR 0.80, p = 0.39) or multivariate regression (OR 0.82, p = 0.45). By contrast, age ≥ 65 years, multilevel fusion, CCI score > 0, and a nonelective admission were associated with greater incidence of neurological complication. The propensity score-matched cohort consisted of 18,760 patients who underwent ACDF with (n = 9380) or without (n = 9380) IONM. Rates of neurological complication were comparable between IONM and non-IONM (0.17% vs 0.22%, p = 0.41) groups. IONM and non-IONM groups had a comparable proportion of patients with LOS ≥ 2 days (19% vs 18%, p = 0.15). The use of IONM was associated with an additional $6843 (p < 0.01) in hospital charges. CONCLUSIONS The use of IONM was not associated with a reduced rate of neurological complications following ACDF. Limitations of the data source precluded a specific assessment of the effectiveness of IONM in preventing neurological complications in patients with more complex pathology (i.e., ossification of the posterior longitudinal ligament or cervical deformity).
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Affiliation(s)
- Jetan H Badhiwala
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Farshad Nassiri
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Christopher D Witiw
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Alireza Mansouri
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Saleh A Almenawer
- 2Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Leodante da Costa
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Michael G Fehlings
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
| | - Jefferson R Wilson
- 1Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario; and
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Yang K, Nath S, Koziarz A, Badhiwala JH, Ghayur H, Sourour M, Catana D, Nassiri F, Alotaibi MB, Kameda-Smith M, Manoranjan B, Aref MH, Mansouri A, Singh S, Almenawer SA. Biopsy Versus Subtotal Versus Gross Total Resection in Patients with Low-Grade Glioma: A Systematic Review and Meta-Analysis. World Neurosurg 2018; 120:e762-e775. [DOI: 10.1016/j.wneu.2018.08.163] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 08/20/2018] [Accepted: 08/21/2018] [Indexed: 12/21/2022]
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Mansouri A, Taslimi S, Abbasian A, Badhiwala JH, Akbar MA, Alotaibi NM, Almenawer SA, Weil AG, Fallah A, Carmant L, Ibrahim GM. Surgical outcomes for medically intractable epilepsy in low- and middle-income countries: a systematic review and meta-analysis. J Neurosurg 2018; 131:1-11. [PMID: 30497170 DOI: 10.3171/2018.5.jns18599] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Accepted: 05/29/2018] [Indexed: 01/08/2023]
Abstract
OBJECTIVEThe aim of this study was to describe the current state of epilepsy surgery and establish estimates of seizure outcomes following surgery for medically intractable epilepsy (MIE) in low- and middle-income countries (LMICs).METHODSThe MEDLINE and Embase databases were searched without publication date restriction. This search was supplemented by a manual screen of key epilepsy and neurosurgical journals (January 2005 to December 2016). Studies that reported outcomes for at least 10 patients of any age undergoing surgery for MIE in LMICs over a defined follow-up period were included. A meta-analysis with a random-effects model was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement and MOOSE (Meta-analysis of Observational Studies in Epidemiology) guidelines. Pooled estimates of seizure freedom and favorable seizure outcomes following anterior temporal lobectomy with or without amygdalohippocampectomy (ATL ± AH) were reported.RESULTSTwenty studies were selected, of which 16 were from Asian centers. The average age at surgery in all studies was less than 30 years, and the average preoperative duration of epilepsy ranged from 3 to 16.1 years. Mesial temporal sclerosis accounted for 437 of 951 described pathologies, and 1294 of the 1773 procedures were ATL ± AH. Based on 7 studies (646 patients) the pooled seizure freedom estimate following ATL ± AH was 68% (95% CI 55%-82%). Based on 8 studies (1096 patients), the pooled estimate for favorable seizure outcomes was 79% (95% CI 74%-85%).CONCLUSIONSSurgery for MIE in LMICs shows a high percentage of seizure freedom and favorable outcomes. These findings call for a concerted global effort to improve timely access to surgery for MIE patients in these regions, including investments aimed at refining existing and establishing additional centers.
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Affiliation(s)
- Alireza Mansouri
- 1Department of Neuro-Oncology, Johns Hopkins University, Baltimore, Maryland
| | | | | | | | | | | | | | | | - Aria Fallah
- 6Department of Neurosurgery, Mattel Children's Hospital, David Geffen School of Medicine at University of California Los Angeles, California; and
| | - Lionel Carmant
- 7Division of Neurology, CHU Sainte-Justine Hospital, University of Montreal, Quebec, Canada
- 8Clinique d'Epilepsie de Port-au-Prince, Haiti
| | - George M Ibrahim
- 9Division of Neurosurgery, The Hospital for Sick Children, Department of Surgery, University of Toronto, Ontario
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10
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Abstract
Glioblastoma (GBM) is the most common and fatal primary adult brain tumor. To date, various promising chemotherapeutic regimens have been trialed for use in GBM; however, temozolomide (TMZ) therapy remains the only US Food and Drug Administration-approved first-line chemotherapeutic option for newly diagnosed GBM. Despite maximal therapy with surgery and combined concurrent chemoradiation and adjuvant TMZ therapy, the median overall survival remains approximately 14 months. Given the failure of conventional chemotherapeutic strategies in GBM, there has been renewed interest in the role of immunotherapy in GBM. Dendritic cells are immune antigen-presenting cells that play a role in both the innate and adaptive immune system, thereby making them prime vehicles for immunotherapy via dendritic cell vaccinations (DCVs) in various cancers. There is great enthusiasm surrounding the use of DCVs for GBM with multiple ongoing trials. In this review, we comprehensively summarize the safety, efficacy, and quality of life results from 33 trials reporting on DCV for high-grade gliomas.
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Affiliation(s)
- Matthew E Eagles
- Section of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada, .,MacFeeters-Hamilton Neuro-Oncology Program, University Health Network, Toronto, ON, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada,
| | - Suganth Suppiah
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON, Canada,
| | - Saleh A Almenawer
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, ON, Canada
| | - Gelareh Zadeh
- MacFeeters-Hamilton Neuro-Oncology Program, University Health Network, Toronto, ON, Canada.,Division of Neurosurgery, University Health Network, Toronto, ON, Canada
| | - Kenneth D Aldape
- MacFeeters-Hamilton Neuro-Oncology Program, University Health Network, Toronto, ON, Canada.,Division of Pathology, University Health Network, Toronto, ON, Canada
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Rochwerg B, Almenawer SA, Siemieniuk RAC, Vandvik PO, Agoritsas T, Lytvyn L, Alhazzani W, Archambault P, D'Aragon F, Farhoumand PD, Guyatt G, Laake JH, Beltrán-Arroyave C, McCredie V, Price A, Chabot C, Zervakis T, Badhiwala J, St-Onge M, Szczeklik W, Møller MH, Lamontagne F. Atraumatic (pencil-point) versus conventional needles for lumbar puncture: a clinical practice guideline. BMJ 2018; 361:k1920. [PMID: 29789372 PMCID: PMC6364256 DOI: 10.1136/bmj.k1920] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Bram Rochwerg
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | | | - Reed A C Siemieniuk
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Per Olav Vandvik
- Institute of Health and Society, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Medicine, Innlandet Hospital Trust-division, Gjøvik, Norway
| | - Thomas Agoritsas
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Lyubov Lytvyn
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine & Department of Anesthesiology and Critical Care Medicine, Université Laval, Québec City, Canada
- Centre intégré de santé et de services sociaux de Chaudière-Appalaches, Centre hospitalier affilié universitaire Hôtel-Dieu de Lévis, Lévis, Canada
- CHU de Québec - Université Laval Research Center, CHU de Québec - Université Laval, Université Laval, Québec City, Canada
| | - Frederick D'Aragon
- Faculty of Medicine and Health Sciences Université de Sherbrooke, Sherbrooke, Canada
- Research Centre, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
| | - Pauline Darbellay Farhoumand
- Division General Internal Medicine & Division of Clinical Epidemiology, University Hospitals of Geneva, Geneva, Switzerland
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Canada
| | - Jon Henrik Laake
- Department of Anaesthesiology, Division of Emergency and Critical Care, Rikshospitalet Medical Centre, Oslo University Hospital, Oslo, Norway
| | | | - Victoria McCredie
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, Department of Medicine, University Health Network, Toronto, Canada
| | - Amy Price
- The BMJ (Research and Evaluation), London, UK
- Department of Continuing Education, University of Oxford, Oxford, UK
| | | | | | - Jetan Badhiwala
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Maude St-Onge
- CHU de Québec - Université Laval Research Center, CHU de Québec - Université Laval, Université Laval, Québec City, Canada
- Centre intégré de santé et de services sociaux de la Capitale-Nationale, Québec City, Canada
- Department of Family and Emergency Medicine & Department of Anesthesiology and Critical Care & Faculty of Medicine, Université Laval, Laval, Canada
| | - Wojciech Szczeklik
- Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Francois Lamontagne
- Faculty of Medicine and Health Sciences Université de Sherbrooke, Sherbrooke, Canada
- Research Centre, Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, Canada
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12
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Chu DK, Kim LHY, Young PJ, Zamiri N, Almenawer SA, Jaeschke R, Szczeklik W, Schünemann HJ, Neary JD, Alhazzani W. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet 2018; 391:1693-1705. [PMID: 29726345 DOI: 10.1016/s0140-6736(18)30479-3] [Citation(s) in RCA: 442] [Impact Index Per Article: 73.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 12/15/2017] [Accepted: 12/19/2017] [Indexed: 12/15/2022]
Abstract
BACKGROUND Supplemental oxygen is often administered liberally to acutely ill adults, but the credibility of the evidence for this practice is unclear. We systematically reviewed the efficacy and safety of liberal versus conservative oxygen therapy in acutely ill adults. METHODS In the Improving Oxygen Therapy in Acute-illness (IOTA) systematic review and meta-analysis, we searched the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, HealthSTAR, LILACS, PapersFirst, and the WHO International Clinical Trials Registry from inception to Oct 25, 2017, for randomised controlled trials comparing liberal and conservative oxygen therapy in acutely ill adults (aged ≥18 years). Studies limited to patients with chronic respiratory diseases or psychiatric disease, patients on extracorporeal life support, or patients treated with hyperbaric oxygen therapy or elective surgery were excluded. We screened studies and extracted summary estimates independently and in duplicate. We also extracted individual patient-level data from survival curves. The main outcomes were mortality (in-hospital, at 30 days, and at longest follow-up) and morbidity (disability at longest follow-up, risk of hospital-acquired pneumonia, any hospital-acquired infection, and length of hospital stay) assessed by random-effects meta-analyses. We assessed quality of evidence using the grading of recommendations assessment, development, and evaluation approach. This study is registered with PROSPERO, number CRD42017065697. FINDINGS 25 randomised controlled trials enrolled 16 037 patients with sepsis, critical illness, stroke, trauma, myocardial infarction, or cardiac arrest, and patients who had emergency surgery. Compared with a conservative oxygen strategy, a liberal oxygen strategy (median baseline saturation of peripheral oxygen [SpO2] across trials, 96% [range 94-99%, IQR 96-98]) increased mortality in-hospital (relative risk [RR] 1·21, 95% CI 1·03-1·43, I2=0%, high quality), at 30 days (RR 1·14, 95% CI 1·01-1·29, I2=0%, high quality), and at longest follow-up (RR 1·10, 95% CI 1·00-1·20, I2=0%, high quality). Morbidity outcomes were similar between groups. Findings were robust to trial sequential, subgroup, and sensitivity analyses. INTERPRETATION In acutely ill adults, high-quality evidence shows that liberal oxygen therapy increases mortality without improving other patient-important outcomes. Supplemental oxygen might become unfavourable above an SpO2 range of 94-96%. These results support the conservative administration of oxygen therapy. FUNDING None.
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Affiliation(s)
- Derek K Chu
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Lisa H-Y Kim
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand; Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand
| | - Nima Zamiri
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Roman Jaeschke
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Wojciech Szczeklik
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Holger J Schünemann
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - John D Neary
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, ON, Canada; Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
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13
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Nath S, Koziarz A, Badhiwala JH, Alhazzani W, Jaeschke R, Sharma S, Banfield L, Shoamanesh A, Singh S, Nassiri F, Oczkowski W, Belley-Côté E, Truant R, Reddy K, Meade MO, Farrokhyar F, Bala MM, Alshamsi F, Krag M, Etxeandia-Ikobaltzeta I, Kunz R, Nishida O, Matouk C, Selim M, Rhodes A, Hawryluk G, Almenawer SA. Atraumatic versus conventional lumbar puncture needles: a systematic review and meta-analysis. Lancet 2018; 391:1197-1204. [PMID: 29223694 DOI: 10.1016/s0140-6736(17)32451-0] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2017] [Revised: 08/25/2017] [Accepted: 08/29/2017] [Indexed: 11/22/2022]
Abstract
BACKGROUND Atraumatic needles have been proposed to lower complication rates after lumbar puncture. However, several surveys indicate that clinical adoption of these needles remains poor. We did a systematic review and meta-analysis to compare patient outcomes after lumbar puncture with atraumatic needles and conventional needles. METHODS In this systematic review and meta-analysis, we independently searched 13 databases with no language restrictions from inception to Aug 15, 2017, for randomised controlled trials comparing the use of atraumatic needles and conventional needles for any lumbar puncture indication. Randomised trials comparing atraumatic and conventional needles in which no dural puncture was done (epidural injections) or without a conventional needle control group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of postdural-puncture headache incidence and additional safety and efficacy outcomes were assessed by random-effects and fixed-effects meta-analysis. This study is registered with the International Prospective Register of Systematic Reviews, number CRD42016047546. FINDINGS We identified 20 241 reports; after exclusions, 110 trials done between 1989 and 2017 from 29 countries, including a total of 31 412 participants, were eligible for analysis. The incidence of postdural-puncture headache was significantly reduced from 11·0% (95% CI 9·1-13·3) in the conventional needle group to 4·2% (3·3-5·2) in the atraumatic group (relative risk 0·40, 95% CI 0·34-0·47, p<0·0001; I2=45·4%). Atraumatic needles were also associated with significant reductions in the need for intravenous fluid or controlled analgesia (0·44, 95% CI 0·29-0·64; p<0·0001), need for epidural blood patch (0·50, 0·33-0·75; p=0·001), any headache (0·50, 0·43-0·57; p<0·0001), mild headache (0·52, 0·38-0·70; p<0·0001), severe headache (0·41, 0·28-0·59; p<0·0001), nerve root irritation (0·71, 0·54-0·92; p=0·011), and hearing disturbance (0·25, 0·11-0·60; p=0·002). Success of lumbar puncture on first attempt, failure rate, mean number of attempts, and the incidence of traumatic tap and backache did not differ significantly between the two needle groups. Prespecified subgroup analyses of postdural-puncture headache revealed no interactions between needle type and patient age, sex, use of prophylactic intravenous fluid, needle gauge, patient position, indication for lumbar puncture, bed rest after puncture, or clinician specialty. These results were rated high-quality evidence as examined using the grading of recommendations assessment, development, and evaluation. INTERPRETATION Among patients who had lumbar puncture, atraumatic needles were associated with a decrease in the incidence of postdural-puncture headache and in the need for patients to return to hospital for additional therapy, and had similar efficacy to conventional needles. These findings offer clinicians and stakeholders a comprehensive assessment and high-quality evidence for the safety and efficacy of atraumatic needles as a superior option for patients who require lumbar puncture. FUNDING None.
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Affiliation(s)
- Siddharth Nath
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Alex Koziarz
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Waleed Alhazzani
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Roman Jaeschke
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Laura Banfield
- Health Sciences Library, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Ashkan Shoamanesh
- Division of Neurology and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Sheila Singh
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, University of Toronto, Toronto, ON, Canada
| | - Wieslaw Oczkowski
- Division of Neurology and Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Emilie Belley-Côté
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Ray Truant
- Department of Biochemistry and Biomedical Sciences, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Kesava Reddy
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Maureen O Meade
- Division of Critical Care, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Forough Farrokhyar
- Department of Health Research Methods, Evidence, and Impact, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Malgorzata M Bala
- Department of Hygiene and Dietetics, Jagiellonian University, Krakow, Poland
| | - Fayez Alshamsi
- Department of Internal Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Mette Krag
- Department of Intensive Care, Copenhagen University Hospital, Copenhagen, Denmark
| | - Itziar Etxeandia-Ikobaltzeta
- Department of Health Research Methods, Evidence, and Impact, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
| | - Regina Kunz
- Evidence based Insurance Medicine, University Hospital of Basel, Basel, Switzerland
| | - Osamu Nishida
- Department of Anesthesiology and Critical Care Medicine, School of Medicine, Fujita Health University, Toyoake, Japan
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, CT, USA
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Andrew Rhodes
- Department of Anaesthesia and Intensive Care, St George's Hospital, University of London, London, UK
| | - Gregory Hawryluk
- Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Saleh A Almenawer
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada.
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14
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Affiliation(s)
- Siddharth Nath
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Alex Koziarz
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, L8S 4L8, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Saleh A Almenawer
- Division of Neurosurgery, Hamilton Health Sciences and McMaster University, Hamilton, ON, L8S 4L8, Canada
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15
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Zagzoog N, Ra G, Koziarz A, Provias J, Sommer D, Almenawer SA, Reddy K. Metastatic Liposarcoma of the Skull Base: A Case Report and Review of Literature. Neurosurgery 2017; 80:219-223. [PMID: 28362929 DOI: 10.1093/neuros/nyw157] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Accepted: 08/14/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Myxoid liposarcoma is not an uncommon form of sarcoma. However, it usually affects the lower extremity long bones. Scapular involvement is extremely rare, as is a metastasis to the parasellar region. We present a case of liposarcoma of the skull base originating in the scapular region and metastasizing to the sellar and parasellar regions and provide a review of the pertinent literature. CLINICAL PRESENTATION A 43-year-old female patient diagnosed with left scapular myxoid liposarcoma was treated with surgical resection. She had clear resection margins and was treated pre- and postoperatively with radiotherapy to the region. She remained asymptomatic for 2 years following surgery, after which she abruptly developed diplopia with right lateral gaze. There were no symptoms of raised intracranial pressure or impaired vision. Her examination was normal apart from complete right sixth nerve palsy. Imaging studies of the brain showed a large mass in the clivus eroding into the floor of the sella, encircling the right internal carotid artery in the cavernous sinus. The mass also displaced the sellar contents superiorly. An endonasal, endoscopic skull base approach was undertaken, and a subtotal resection was performed in an effort to avoid multiple cranial nerve pareses. CONCLUSION Our literature search revealed that this case report is the first to document liposarcoma metastasis to the skull base originating from the scapular region. Subtotal surgical resection resulted in minimal improvement of the patient's sixth nerve palsy. Postoperative radiation was undertaken. A multidisciplinary approach on an individual patient basis is recommended.
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Affiliation(s)
- Nirmeen Zagzoog
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Greta Ra
- Mount Sinai Hospital Centre for Inflammatory Bowel Disease, University of Toronto, Toronto, Ontario, Canada
| | - Alex Koziarz
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - John Provias
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Doron Sommer
- Division of Otolaryngology Head and Neck Surgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Saleh A Almenawer
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Kesava Reddy
- Division of Neurosurgery, Department of Surgery, McMaster University, Hamilton, Ontario, Canada
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16
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Nassiri F, Badhiwala JH, Witiw CD, Mansouri A, Davidson B, Almenawer SA, Lipsman N, Da Costa L, Pirouzmand F, Nathens AB. The clinical significance of isolated traumatic subarachnoid hemorrhage in mild traumatic brain injury. J Trauma Acute Care Surg 2017; 83:725-731. [DOI: 10.1097/ta.0000000000001617] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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17
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Koziarz A, Sne N, Kegel F, Alhazzani W, Nath S, Badhiwala JH, Rice T, Engels P, Samir F, Healey A, Kahnamoui K, Banfield L, Sharma S, Reddy K, Hawryluk GWJ, Kirkpatrick AW, Almenawer SA. Optic nerve sheath diameter sonography for the diagnosis of increased intracranial pressure: a systematic review and meta-analysis protocol. BMJ Open 2017; 7:e016194. [PMID: 28801417 PMCID: PMC5629711 DOI: 10.1136/bmjopen-2017-016194] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION Increased intracranial pressure (ICP) is a significant neurological issue that may lead to permanent neurological sequelae. When evaluating patients with traumatic brain injury, it is crucial to identify those with high ICP in order to expedite ICP lowering measures and maintain adequate cerebral perfusion. Several measures are used to recognise patients with increased ICP including CT scan, MRI, ICP monitor, and lumbar puncture (LP). However, these tests can be invasive, associated with radiation exposure, contraindicated, or not readily available. Ultrasonography measurement of the optic nerve sheath diameter (ONSD) is proposed as a non-invasive and quick measure to identify high ICP. The aim of this systematic review and meta-analysis will be to examine the accuracy of ONSD sonography for increased ICP diagnosis. METHODS AND ANALYSES We will include published and unpublished randomised controlled trials, observational studies, and abstracts, with no publication type or language restrictions. Search strategies will be designed to peruse the MEDLINE, Embase, Web of Science, WHO Clinical Trials, ClinicalTrials.gov, CINAHL, and the Cochrane Library databases. We will also implement strategies to search grey literature. Two reviewers will independently complete data abstraction and conduct quality assessment. Included studies will be assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool. We will construct the hierarchical summary receiver operating characteristic curve for included studies and pool sensitivity and specificity using the bivariate model. We also plan to conduct prespecified subgroup analyses to explore heterogeneity. The overall quality of evidence will be rated using Grading of Recommendations, Assessment, Development and Evaluations (GRADE). ETHICS AND DISSEMINATION Research ethics board approval is not required for this study as it draws from published data and raises no concerns related to patient privacy. This review will provide a comprehensive assessment of the evidence on ONSD sonography diagnostic accuracy and is directed to a wide audience. Results from the review will be disseminated extensively through conferences and submitted to a peer-reviewed journal for publication. PROSPERO REGISTRATION NUMBER CRD42017055485. CLINICAL TRIAL NUMBER Trial registration number is NCT00783809.
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Affiliation(s)
- Alex Koziarz
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Niv Sne
- Division of General Surgery and Trauma, McMaster University, Hamilton, Ontario, Canada
| | - Fraser Kegel
- Division of General Surgery and Trauma, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Siddharth Nath
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Timothy Rice
- Division of General Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Paul Engels
- Division of General Surgery, Trauma, and Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Faidi Samir
- Division of General Surgery and Trauma, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Healey
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kamyar Kahnamoui
- Division of General Surgery and Critical Care, McMaster University, Hamilton, Ontario, Canada
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Kesava Reddy
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Gregory W J Hawryluk
- Department of Neurosurgery and Neurology, University of Utah, Salt Lake City, Utah, USA
| | | | - Saleh A Almenawer
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
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18
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Koziarz A, Aref M, Vinh B, Mensinkai A, Almenawer SA, Reddy K. Sublaminar wire migration into the medulla oblongata: a case report. J Spine Surg 2017; 3:267-271. [PMID: 28744511 DOI: 10.21037/jss.2017.05.09] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Atlantoaxial procedures have been developed in an effort to ensure solid C1-C2 fusion. However, techniques that involve sublaminar wiring have the potential for neural structure injury. We present the management of a patient who previously underwent Gallie fusion 10 years ago and is presenting with a dislodged titanium wire that has migrated into the medulla oblongata. A 52-year-old female patient known with rheumatoid arthritis presented with truncal ataxia and food regurgitation 10 years after undergoing a C1-C2 Gallie fusion. A computerized tomography (CT) scan revealed that a wire from her Gallie fusion procedure migrated into the medulla oblongata. The patient underwent foramen magnum decompression with C1 bilateral laminectomy, instrumentation, and removal of a migrated wire. Six months later, a CT scan showed that all occipital screws were pulled out. In the revision surgery, new occipital screws were placed with a resultant significant improvement in patient's gait postoperatively. Wire migration as a differential diagnosis should be considered in patients presenting with neurological dysfunction who underwent surgical treatment with sublaminar wire fusion techniques.
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Affiliation(s)
- Alex Koziarz
- 1Division of Neurosurgery, Department of Surgery, 2Division of Neuroradiology, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Mohammed Aref
- 1Division of Neurosurgery, Department of Surgery, 2Division of Neuroradiology, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Brian Vinh
- 1Division of Neurosurgery, Department of Surgery, 2Division of Neuroradiology, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Arun Mensinkai
- 1Division of Neurosurgery, Department of Surgery, 2Division of Neuroradiology, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Saleh A Almenawer
- 1Division of Neurosurgery, Department of Surgery, 2Division of Neuroradiology, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
| | - Kesava Reddy
- 1Division of Neurosurgery, Department of Surgery, 2Division of Neuroradiology, Department of Radiology, McMaster University, Hamilton, Ontario, Canada
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19
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Aref M, Martyniuk A, Nath S, Koziarz A, Badhiwala J, Algird A, Farrokhyar F, Almenawer SA, Reddy K. Endoscopic Third Ventriculostomy: Outcome Analysis of an Anterior Entry Point. World Neurosurg 2017; 104:554-559. [PMID: 28532915 DOI: 10.1016/j.wneu.2017.05.052] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2016] [Revised: 05/09/2017] [Accepted: 05/11/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Endoscopic third ventriculostomy (ETV) is a safe and effective treatment for hydrocephalus. An entry point located 4 cm anterior to the coronal suture, 3 cm anterior to Kocher point, and approximately 9 cm from the pupil at the midpupillary line has been used successfully for the last 20 years in our center. We aimed to evaluate this alternative anterior entry point routinely used for ETV, with or without concurrent endoscopic biopsy. METHODS Patients undergoing this proposed entry point were examined to evaluate its safety and efficacy. Factors such as patients' age, sex, hydrocephalus etiology, tumor location and pathology, and complication rate were examined through regression analyses to evaluate their impact on tumor biopsy and ETV success rates, and the need for subsequent ventricular shunting. RESULTS A total of 131 patients were included in the study. ETV was successful in 125 (95.4%) patients. Of these, 26 (19.8%) patients required a biopsy, which was successful in 21 (80.8%) cases. A complication was observed in 10 (7.6%) patients, with a trend toward complications occurring after ETV failure. There was no association between ETV success rate and patients' age (P = 0.5) or sex (P = 0.99). CONCLUSIONS The anterior entry point is a safe and effective method for ETV, especially when considering concurrent ventricular tumor biopsy. This entry point may be considered as a more minimally invasive procedure when using rigid endoscopy and may also eliminate the need for a flexible scope.
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Affiliation(s)
- Mohammed Aref
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Amanda Martyniuk
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Siddharth Nath
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Alex Koziarz
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Jetan Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Almunder Algird
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Saleh A Almenawer
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada; Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada.
| | - Kesava Reddy
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
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20
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Nath S, Badhiwala JH, Alhazzani W, Nassiri F, Belley-Cote E, Koziarz A, Shoamanesh A, Banfield L, Oczkowski W, Sharma M, Sahlas D, Reddy K, Farrokhyar F, Singh S, Sharma S, Zytaruk N, Selim M, Almenawer SA. Atraumatic versus traumatic lumbar puncture needles: a systematic review and meta-analysis protocol. BMJ Open 2017; 7:e014478. [PMID: 28363928 PMCID: PMC5387934 DOI: 10.1136/bmjopen-2016-014478] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION Lumbar puncture is one of the oldest and most commonly performed procedures in medicine, used to diagnose and treat disease. Headache following lumbar puncture remains a frequent complication, causing significant patient discomfort and often requiring narcotic analgesia or invasive therapy. Needle tip design has been proposed to affect the incidence of headache postlumbar puncture, with pencil-point 'atraumatic' needles thought to reduce its incidence in comparison to bevelled 'traumatic' needles. Despite this, the use of atraumatic needles and knowledge of their existence remains significantly limited among clinicians. This study will systematically review the evidence on atraumatic lumbar puncture needles and compare them with traumatic needles across a variety of clinical outcomes. METHODS AND ANALYSES We will include published randomised controlled trials (RCTs), observational studies and abstracts, with no publication type or language restrictions. Search strategies will be designed to peruse the MEDLINE, EMBASE, Web of Science, ClinicalTrials.gov, CINAHL, WHO Clinical Trials Database and Cochrane Library databases. We will also implement strategies to search the grey literature. 3 reviewers will thoroughly and independently examine the search results, complete data abstraction and conduct quality assessment. Included RCTs will be assessed using the Cochrane risk of bias assessment tool and eligible observational studies will be examined using the Newcastle-Ottawa Scale. We will examine the outcomes of: headache and its type, intensity, duration and treatment; backache; success rate; hearing disturbance and nerve root irritation. The primary outcome will be the incidence of postdural puncture headache. We will calculate pooled estimates, relative risks for dichotomous outcomes and weighted mean differences for continuous outcomes, with corresponding 95% CIs. Statistical heterogeneity will be measured using Cochran's Q test and quantified using the I2 statistic. We will also conduct prespecified subgroup and sensitivity analyses to examine if covariates exist and to explore potential heterogeneity. ETHICS AND DISSEMINATION Research ethics board approval is not required for this study as it draws from published data and raises no concerns related to patient privacy. This review will provide a comprehensive assessment of the evidence on atraumatic needles for lumbar puncture and is directed to a wide audience. Results from the review will be disseminated extensively through conferences and submitted to a peer-reviewed journal for publication. TRIAL REGISTRATION NUMBER CRD42016047546.
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Affiliation(s)
- Siddharth Nath
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | | | - Alex Koziarz
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Ashkan Shoamanesh
- Division of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Laura Banfield
- Health Sciences Library, McMaster University, Hamilton, Ontario, Canada
| | - Wieslaw Oczkowski
- Division of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Mike Sharma
- Division of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Demetrios Sahlas
- Division of Neurology, McMaster University, Hamilton, Ontario, Canada
| | - Kesava Reddy
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Forough Farrokhyar
- Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Sheila Singh
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Sunjay Sharma
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Nicole Zytaruk
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Magdy Selim
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Saleh A Almenawer
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
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Koziarz A, Almenawer SA. In Reply to the Letter to the Editor “Lentiform Subdural Hematoma—A Rare Mimicker of Extradural Hematoma”. World Neurosurg 2017; 97:742. [DOI: 10.1016/j.wneu.2016.09.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 09/26/2016] [Indexed: 11/15/2022]
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Manoranjan B, Mahendram S, Almenawer SA, Venugopal C, McFarlane N, Hallett R, Vijayakumar T, Algird A, Murty NK, Sommer DD, Provias JP, Reddy K, Singh SK. The identification of human pituitary adenoma-initiating cells. Acta Neuropathol Commun 2016; 4:125. [PMID: 27894339 PMCID: PMC5127041 DOI: 10.1186/s40478-016-0394-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2016] [Accepted: 11/16/2016] [Indexed: 01/26/2023] Open
Abstract
Classified as benign central nervous system (CNS) tumors, pituitary adenomas account for 10% of diagnosed intracranial neoplasms. Although surgery is often curative, patients with invasive macroadenomas continue to experience significant morbidity and are prone to tumor recurrence. Given the identification of human brain tumor-initiating cells (TICs) that initiate and maintain tumor growth while promoting disease progression and relapse in multiple CNS tumors, we investigated whether TICs also drive the growth of human pituitary adenomas. Using a nanoString-based 80-gene custom codeset specific for developmental pathways, we identified a differential stem cell gene expression profile within human pituitary adenomas. Prospective functional characterization of stem cell properties in patient-derived adenomas representing all hormonal subtypes yielded a subtype-dependent self-renewal profile, which was enriched within the CD15+ cell fraction. The tumor-initiating capacity of CD15high adenoma cells was assayed in comparison to CD15low adenomas using in vivo limiting dilutions, which maintained the rare frequency of TICs. Repeated analyses using sorted cell populations for CD15+ TICs compared to CD15- adenoma cells provided further evidence of xenograft tumor formation to support CD15+ cells as putative pituitary adenoma-initiating cells (PAICs). The clinical utility of our findings was established through in silico analyses and comparative gene expression profiling of primary and recurrent pituitary adenomas. CD15 was enriched in recurrent adenomas, which was validated using routine clinical immunohistochemistry in a limited number of samples. Our work reports the first prospective identification of human PAICs using CD15. Patients with CD15high adenomas may therefore benefit from more aggressive surgical interventions and chemo/radiotherapy.
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Catana D, Koziarz A, Cenic A, Nath S, Singh S, Almenawer SA, Kachur E. Subdural Hematoma Mimickers: A Systematic Review. World Neurosurg 2016; 93:73-80. [PMID: 27268313 DOI: 10.1016/j.wneu.2016.05.084] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Revised: 05/24/2016] [Accepted: 05/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND A variety of subdural pathologies that may mimic hematomas are reported in the literature. We aimed to identify the atypical clinical and radiologic presentations of subdural masses that may mimic subdural hematomas. METHODS A systematic review of MEDLINE and Embase was conducted independently by 2 reviewers to identify articles describing subdural hematoma mimickers. We also present a patient from our institution with a subdural pathology mimicking a subdural hematoma. We analyzed patient clinical presentations, underlying pathologies, radiologic findings, and clinical outcomes. RESULTS We included 43 articles totaling 48 patients. The mean ± SD patient age was 55.7 ± 16.8 years. Of the 45 cases describing patient history, 13 patients (27%) had a history of trauma. The underlying pathologies of the 48 subdural collections were 10 metastasis (21%), 14 lymphoma (29%), 7 sarcoma (15%), 4 infectious (8%), 4 autoimmune (8%), and 9 miscellaneous (19%). Findings on computed tomography (CT) scan were 18 hyperdense (41%), 11 hypodense (25%), 9 isodense (20%), 3 isodense/hyperdense (7%), and 3 hypodense/isodense (7%). Thirty-four patients (71%) were treated surgically; among these patients, 65% had symptom resolution. Neither the pathology (P = 0.337) nor the management strategy (P = 0.671) was correlated with improved functional outcomes. CONCLUSIONS Identification of atypical history and radiologic features should prompt further diagnostic tests, including magnetic resonance imaging (MRI), to elucidate the proper diagnosis, given that certain pathologies may be managed nonsurgically. A subdural collection that is hyperdense on CT scan and hyperintense on T2-weighted MRI, along with a history of progressive headache with no trauma, may raise the suspicion of an atypical subdural pathology.
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Affiliation(s)
- Dragos Catana
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Alex Koziarz
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Aleksa Cenic
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Siddharth Nath
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Sheila Singh
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
| | - Saleh A Almenawer
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada.
| | - Edward Kachur
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
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Alshamsi F, Belley-Cote E, Cook D, Almenawer SA, Alqahtani Z, Perri D, Thabane L, Al-Omari A, Lewis K, Guyatt G, Alhazzani W. Efficacy and safety of proton pump inhibitors for stress ulcer prophylaxis in critically ill patients: a systematic review and meta-analysis of randomized trials. Crit Care 2016; 20:120. [PMID: 27142116 PMCID: PMC4855320 DOI: 10.1186/s13054-016-1305-6] [Citation(s) in RCA: 86] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2016] [Accepted: 04/19/2016] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The relative efficacy and safety of proton pump inhibitors (PPIs) compared to histamine-2-receptor antagonists (H2RAs) should guide their use in reducing bleeding risk in the critically ill. METHODS We searched the Cochrane library, MEDLINE, EMBASE, ACPJC, clinical trials registries, and conference proceedings through November 2015 without language or publication date restrictions. Only randomized controlled trials (RCTs) of PPIs vs H2RAs for stress ulcer prophylaxis in critically ill adults for clinically important bleeding, overt gastrointestinal (GI) bleeding, nosocomial pneumonia, mortality, ICU length of stay and Clostridium difficile infection were included. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess our confidence in the evidence for each outcome. RESULTS In 19 trials enrolling 2117 patients, PPIs were more effective than H2RAs in reducing the risk of clinically important GI bleeding (RR 0.39; 95 % CI 0.21, 0.71; P = 0.002; I (2) = 0 %, moderate confidence) and overt GI bleeding (RR 0.48; 95 % CI 0.34, 0.66; P < 0.0001; I (2) = 3 %, moderate confidence). PPI use did not significantly affect risk of pneumonia (RR 1.12; 95 % CI 0.86, 1.46; P = 0.39; I (2) = 2 %, low confidence), mortality (RR 1.05; 95 % CI 0.87, 1.27; P = 0.61; I (2) = 0 %, moderate confidence), or ICU length of stay (mean difference (MD), -0.38 days; 95 % CI -1.49, 0.74; P = 0.51; I (2) = 30 %, low confidence). No RCT reported Clostridium difficile infection. CONCLUSIONS PPIs were superior to H2RAs in preventing clinically important and overt GI bleeding, without significantly increasing the risk of pneumonia or mortality. Their impact on Clostridium difficile infection is yet to be determined.
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Affiliation(s)
- Fayez Alshamsi
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Internal Medicine, United Arab Emirates University, Alain, United Arab Emirates
| | - Emilie Belley-Cote
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Deborah Cook
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Saleh A Almenawer
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
- Department of Surgery, Division of Neurosurgery, McMaster University, Hamilton, Canada
| | - Zuhoor Alqahtani
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Dan Perri
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Lehana Thabane
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Awad Al-Omari
- Department of Critical Care, Security Forces Hospital, Riyadh, Saudi Arabia
- Department of Medicine, Alfaisal University, Riyadh, Saudi Arabia
| | - Kim Lewis
- Department of Medicine, McMaster University, Hamilton, Canada
| | - Gordon Guyatt
- Department of Medicine, McMaster University, Hamilton, Canada
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada
| | - Waleed Alhazzani
- Department of Medicine, McMaster University, Hamilton, Canada.
- Department of Clinical Epidemiology & Biostatistics, McMaster University, Hamilton, Canada.
- Department of Medicine, Division of Critical Care, St Joseph's Healthcare, 50 Charlton Avenue East, Hamilton, ON, L8N 4A6, Canada.
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Badhiwala JH, Nassiri F, Almenawer SA. Mechanical Thrombectomy and Functional Outcomes After Stroke--Reply. JAMA 2016; 315:1792-3. [PMID: 27115389 DOI: 10.1001/jama.2016.0389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Saleh A Almenawer
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada
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Badhiwala JH, Nassiri F, Alhazzani W, Selim MH, Farrokhyar F, Spears J, Kulkarni AV, Singh S, Alqahtani A, Rochwerg B, Alshahrani M, Murty NK, Alhazzani A, Yarascavitch B, Reddy K, Zaidat OO, Almenawer SA. Endovascular Thrombectomy for Acute Ischemic Stroke: A Meta-analysis. JAMA 2015; 314:1832-43. [PMID: 26529161 DOI: 10.1001/jama.2015.13767] [Citation(s) in RCA: 322] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
IMPORTANCE Endovascular intervention for acute ischemic stroke improves revascularization. But trials examining endovascular therapy yielded variable functional outcomes, and the effect of endovascular intervention among subgroups needs better definition. OBJECTIVE To examine the association between endovascular mechanical thrombectomy and clinical outcomes among patients with acute ischemic stroke. DATA SOURCES We systematically searched MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library without language restriction through August 2015. STUDY SELECTION Eligible studies were randomized clinical trials of endovascular therapy with mechanical thrombectomy vs standard medical care, which includes the use of intravenous tissue plasminogen activator (tPA). DATA EXTRACTION AND SYNTHESIS Independent reviewers evaluated the quality of studies and abstracted the data. We calculated odds ratios (ORs) and 95% CIs for all outcomes using random-effects meta-analyses and performed subgroup and sensitivity analyses to examine whether certain imaging, patient, treatment, or study characteristics were associated with improved functional outcome. The strength of the evidence was examined for all outcomes using the GRADE method. MAIN OUTCOMES AND MEASURES Ordinal improvement across modified Rankin scale (mRS) scores at 90 days, functional independence (mRS score, 0-2), angiographic revascularization at 24 hours, symptomatic intracranial hemorrhage within 90 days, and all-cause mortality at 90 days. RESULTS Data were included from 8 trials involving 2423 patients (mean [SD] age, 67.4 [14.4] years; 1131 [46.7%] women), including 1313 who underwent endovascular thrombectomy and 1110 who received standard medical care with tPA. In a meta-analysis of these trials, endovascular therapy was associated with a significant proportional treatment benefit across mRS scores (OR, 1.56; 95% CI, 1.14-2.13; P = .005). Functional independence at 90 days (mRS score, 0-2) occurred among 557 of 1293 patients (44.6%; 95% CI, 36.6%-52.8%) in the endovascular therapy group vs 351 of 1094 patients (31.8%; 95% CI, 24.6%-40.0%) in the standard medical care group (risk difference, 12%; 95% CI, 3.8%-20.3%; OR, 1.71; 95% CI, 1.18-2.49; P = .005). Compared with standard medical care, endovascular thrombectomy was associated with significantly higher rates of angiographic revascularization at 24 hours (75.8% vs 34.1%; OR, 6.49; 95% CI, 4.79-8.79; P < .001) but no significant difference in rates of symptomatic intracranial hemorrhage within 90 days (70 events [5.7%] vs 53 events [5.1%]; OR, 1.12; 95% CI, 0.77-1.63; P = .56) or all-cause mortality at 90 days (218 deaths [15.8%] vs 201 deaths [17.8%]; OR, 0.87; 95% CI, 0.68-1.12; P = .27). CONCLUSIONS AND RELEVANCE Among patients with acute ischemic stroke, endovascular therapy with mechanical thrombectomy vs standard medical care with tPA was associated with improved functional outcomes and higher rates of angiographic revascularization, but no significant difference in symptomatic intracranial hemorrhage or all-cause mortality at 90 days.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Farshad Nassiri
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Waleed Alhazzani
- Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Magdy H Selim
- Department of Neurology, Stroke Division, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
| | - Forough Farrokhyar
- Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Julian Spears
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Abhaya V Kulkarni
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Sheila Singh
- Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | | - Bram Rochwerg
- Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | | - Naresh K Murty
- Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Adel Alhazzani
- Department of Neurology, King Khalid University, Abha, Saudi Arabia
| | - Blake Yarascavitch
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas
| | - Kesava Reddy
- Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Osama O Zaidat
- Departments of Neurology, Radiology, and Neurosurgery, Medical College of Wisconsin, Milwaukee
| | - Saleh A Almenawer
- Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Ali M, Bennardo M, Almenawer SA, Zagzoog N, Smith AA, Dao D, Ajani O, Farrokhyar F, Singh SK, Singh SK. Exploring predictors of surgery and comparing operative treatment approaches for pediatric intracranial arachnoid cysts: a case series of 83 patients. J Neurosurg Pediatr 2015; 16:275-82. [PMID: 26067335 DOI: 10.3171/2015.2.peds14612] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Although intracranial arachnoid cysts are a common incidental finding on pediatric brain imaging, only a subset of patients require surgery for them. For the minority who undergo surgery, the comparative effectiveness of various surgical approaches is debated. The authors explored predictors of surgery and compared operative techniques for pediatric patients with an intracranial arachnoid cyst seen at a tertiary care center. METHODS The authors reviewed records of pediatric patients with an intracranial arachnoid cyst. For each patient, data on baseline characteristics, the method of intervention, and surgical outcomes for the initial surgery were extracted, and cyst size at diagnosis was calculated (anteroposterior × craniocaudal × mediolateral). Baseline variables were analyzed as predictors of surgery by using logistic regression modeling, excluding patients whose surgery was not related to cyst size (i.e., those with obstructive hydrocephalus secondary to the cyst compressing a narrow CSF flow pathway or cyst rupture/hemorrhage). Data collected regarding surgical outcomes were analyzed descriptively. RESULTS Among 83 pediatric patients with an intracranial arachnoid cyst seen over a 25-year period (1989-2013), 27 (33%) underwent surgery; all had at least 1 cyst-attributed symptom/finding. In the multivariate model, age at presentation and cyst size at diagnosis were independent predictors of surgery. Cyst size had greater predictive value; specifically, the area under the curve for the receiver-operating-characteristic curve was 0.89 (95% CI 0.82-0.97), with an ideal cutoff point of ≥ 68 cm(3). This cutoff point had 100% sensitivity (95% CI 79%-100%), 75% specificity (95% CI 61%-85%), a 53% positive predictive value (95% CI 36%-70%), and a 100% negative predictive value (95% CI 91%-100%); the positive likelihood ratio was 4.0 (95% CI 2.5-6.3), and the negative likelihood ratio was 0 (95% CI 0-0.3). Although the multivariate model excluded 7 patients who underwent surgery (based on prespecified criteria), excluding these 7 cases did not change the overall findings, as shown in a sensitivity analysis that included all the cases. Descriptive results regarding surgical outcomes did not indicate any salient differences among the surgical techniques (endoscopic fenestration, cystoperitoneal shunting, or craniotomy-based procedures) in terms of symptom resolution within 6 months, need for reoperation to date, cyst-size change from before the operation, morbidity, or mortality. CONCLUSIONS The results of these exploratory analyses suggest that pediatric patients with an intracranial arachnoid cyst are more likely to undergo surgery if the cyst is large, compresses a narrow CSF flow pathway to cause hydrocephalus, or has ruptured/hemorrhaged. There were no salient differences among the 3 surgical techniques for several clinically important outcomes. A prospective multicenter study is required to enable more robust analyses, which could ultimately provide a decision-making framework for surgical indications and clarify any differences in the comparative effectiveness of surgical approaches to treating pediatric intracranial arachnoid cysts.
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Affiliation(s)
- Mohsin Ali
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | | | | | | | | | - Forough Farrokhyar
- Departments of 3 Surgery and.,Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Badhiwala JH, Almenawer SA. Extent of surgical resection of high-grade glioma among the elderly. Neuro Oncol 2015; 17:903-4. [PMID: 26023101 DOI: 10.1093/neuonc/nov059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A.)
| | - Saleh A Almenawer
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Division of Neurosurgery, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A.)
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Badhiwala JH, Lai CK, Alhazzani W, Farrokhyar F, Nassiri F, Meade M, Mansouri A, Sne N, Aref M, Murty N, Witiw C, Singh S, Yarascavitch B, Reddy K, Almenawer SA. Cervical spine clearance in obtunded patients after blunt traumatic injury: a systematic review. Ann Intern Med 2015; 162:429-37. [PMID: 25775316 DOI: 10.7326/m14-2351] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Cervical spine clearance protocols are controversial for unconscious patients after blunt traumatic injury and negative findings on computed tomography (CT). PURPOSE To review evidence about the utility of different cervical spine clearance protocols in excluding significant cervical spine injury after negative CT results in obtunded adults with blunt traumatic injury. DATA SOURCES MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library were searched from January 2000 through November 2014. STUDY SELECTION English-language studies that examined patients with negative CT results having confirmatory routine testing with magnetic resonance imaging (MRI), dynamic radiography, or clinical examination and that reported outcome measures of missed cervical spine injury, need for operative stabilization, or prolonged use of cervical collars. DATA EXTRACTION Independent reviewers evaluated the quality of studies and abstracted the data according to a predefined protocol. DATA SYNTHESIS Of 28 observational studies (3627 patients) that met eligibility criteria, 7 were prospective studies (1686 patients) with low risk of bias and well-interpreted, high-quality CT scans. These 7 studies showed that 0% of significant injuries were missed after negative CT results. The overall studies using confirmatory routine testing with MRI showed incidence rates of 0% to 1.5% for cervical spine instability (16 studies; 1799 patients), 0% to 7.3% for need for operative fixation (17 studies; 1555 patients), and 0% to 29.5% for prolonged collar use (16 studies; 1453 patients). LIMITATIONS Most studies were retrospective. Approaches to management of soft tissue changes with collars varied markedly. CONCLUSION Cervical spine clearance in obtunded adults after blunt traumatic injury with negative results from a well-interpreted, high-quality CT scan is probably a safe and efficient practice. PRIMARY FUNDING SOURCE None.
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Affiliation(s)
- Jetan H. Badhiwala
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Chung K. Lai
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Waleed Alhazzani
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Forough Farrokhyar
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Farshad Nassiri
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Maureen Meade
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Alireza Mansouri
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Niv Sne
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Mohammed Aref
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Naresh Murty
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher Witiw
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Sheila Singh
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Blake Yarascavitch
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Kesava Reddy
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
| | - Saleh A. Almenawer
- From the University of Toronto, Toronto, Ontario, Canada; McMaster University, Hamilton, Ontario, Canada; and University of Texas Southwestern Medical Center, Dallas, Texas
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Almenawer SA, Badhiwala JH, Alhazzani W, Greenspoon J, Farrokhyar F, Yarascavitch B, Algird A, Kachur E, Cenic A, Sharieff W, Klurfan P, Gunnarsson T, Ajani O, Reddy K, Singh SK, Murty NK. Biopsy versus partial versus gross total resection in older patients with high-grade glioma: a systematic review and meta-analysis. Neuro Oncol 2015; 17:868-81. [PMID: 25556920 DOI: 10.1093/neuonc/nou349] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 11/29/2014] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Optimal extent of surgical resection (EOR) of high-grade gliomas (HGGs) remains uncertain in the elderly given the unclear benefits and potentially higher rates of mortality and morbidity associated with more extensive degrees of resection. METHODS We undertook a meta-analysis according to a predefined protocol and systematically searched literature databases for reports about HGG EOR. Elderly patients (≥60 y) undergoing biopsy, subtotal resection (STR), and gross total resection (GTR) were compared for the outcome measures of overall survival (OS), postoperative karnofsky performance status (KPS), progression-free survival (PFS), mortality, and morbidity. Treatment effects as pooled estimates, mean differences (MDs), or risk ratios (RRs) with corresponding 95% confidence intervals (CIs) were determined using random effects modeling. RESULTS A total of 12 607 participants from 34 studies met eligibility criteria, including our current cohort of 211 patients. When comparing overall resection (of any extent) with biopsy, in favor of the resection group were OS (MD 3.88 mo, 95% CI: 2.14-5.62, P < .001), postoperative KPS (MD 10.4, 95% CI: 6.58-14.22, P < .001), PFS (MD 2.44 mo, 95% CI: 1.45-3.43, P < .001), mortality (RR = 0.27, 95% CI: 0.12-0.61, P = .002), and morbidity (RR = 0.82, 95% CI: 0.46-1.46, P = .514) . GTR was significantly superior to STR in terms of OS (MD 3.77 mo, 95% CI: 2.26-5.29, P < .001), postoperative KPS (MD 4.91, 95% CI: 0.91-8.92, P = .016), and PFS (MD 2.21 mo, 95% CI: 1.13-3.3, P < .001) with no difference in mortality (RR = 0.53, 95% CI: 0.05-5.71, P = .600) or morbidity (RR = 0.52, 95% CI: 0.18-1.49, P = .223). CONCLUSIONS Our findings suggest an upward improvement in survival time, functional recovery, and tumor recurrence rate associated with increasing extents of safe resection. These benefits did not result in higher rates of mortality or morbidity if considered in conjunction with known established safety measures when managing elderly patients harboring HGGs.
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Affiliation(s)
- Saleh A Almenawer
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Jetan H Badhiwala
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Waleed Alhazzani
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Jeffrey Greenspoon
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Forough Farrokhyar
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Blake Yarascavitch
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Almunder Algird
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Edward Kachur
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Aleksa Cenic
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Waseem Sharieff
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Paula Klurfan
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Thorsteinn Gunnarsson
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Olufemi Ajani
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Kesava Reddy
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Sheila K Singh
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
| | - Naresh K Murty
- Division of Neurosurgery, McMaster University, Hamilton, Ontario, Canada (S.A.A., A.A., E.K., A.C., P.K., T.G., O.A., K.R., S.K.S., N.K.M.); Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada (S.A.A., W.A., F.F.); Department of Medicine, McMaster University, Hamilton, Ontario, Canada (W.A.); Department of Oncology, McMaster University, Hamilton, Ontario, Canada (J.G.); Stem Cell and Cancer Research Institute, McMaster University, Hamilton, Ontario, Canada (S.K.S.); Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada (J.H.B.); Department of Radiation Oncology, Dalhousie University, Halifax, Nova Scotia, Canada (W.S.); Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas (B.Y.)
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Badhiwala JH, Farrokhyar F, Alhazzani W, Yarascavitch B, Aref M, Algird A, Murty N, Kachur E, Cenic A, Reddy K, Almenawer SA. Surgical outcomes and natural history of intramedullary spinal cord cavernous malformations: a single-center series and meta-analysis of individual patient data. J Neurosurg Spine 2014; 21:662-76. [DOI: 10.3171/2014.6.spine13949] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Information pertaining to the natural history of intramedullary spinal cord cavernous malformations (ISCCMs) and patient outcomes after surgery is scarce. To evaluate factors associated with favorable outcomes for patients with surgically and conservatively managed ISCCMs, the authors performed a systematic review and metaanalysis of the literature. In addition, they included their single-center series of ISCCMs.
Methods
The authors searched MEDLINE, EMBASE, CINAHL, Google Scholar, and The Cochrane Library for studies published through June 2013 that reported cases of ISCCMs. Data from all eligible studies were used to examine the epidemiology, clinical features, and neurological outcomes of patients with surgically managed and conservatively treated ISCCMs. To evaluate several variables as predictors of favorable neurological outcomes, the authors conducted a meta-analysis of individual patient data and performed univariate and multivariate logistic regression analyses. Variables included patient age, patient sex, lesion spinal level, lesion size, cerebral cavernomas, family history of cavernous malformations, clinical course, presenting symptoms, treatment strategy (operative or conservative), symptom duration, surgical approach, spinal location, and extent of resection. In addition, they performed a meta-analysis to determine a pooled estimate of the annual hemorrhage rate of ISCCMs.
Results
Eligibility criteria were met by 40 studies, totaling 632 patients, including the authors' institutional series of 24 patients. Mean patient age was 39.1 years (range 2–80 years), and the male-to-female ratio was 1.1:1. Spinal levels of cavernomas were cervical (38%), cervicothoracic (2.4%), thoracic (55.2%), thoracolumbar (0.6%), lumbar (2.1%), and conus medullaris (1.7%). Average cavernoma size was 9.2 mm. Associated cerebral cavernomas occurred in 16.5% of patients, and a family history of cavernous malformation was found for 11.9% of evaluated patients. Clinical course was acute with stepwise progression for 45.4% of patients and slowly progressive for 54.6%. Symptoms were motor (60.5%), sensory (57.8%), pain (33.8%), bladder and/or bowel (23.6%), respiratory distress (0.5%), or absent (asymptomatic; 0.9%). The calculated pooled annual rate of hemorrhage was 2.1% (95% CI 1.3%–3.3%). Most (89.9%) patients underwent resection, and 10.1% underwent conservative management (observation). Outcomes were better for those who underwent resection than for those who underwent conservative management (OR 2.79, 95% CI 1.46–5.33, p = 0.002). A positive correlation with improved neurological outcomes was found for resection within 3 months of symptom onset (OR 2.11, 95% CI 1.31–3.41, p = 0.002), hemilaminectomy approach (OR 3.20, 95% CI 1.16–8.86, p = 0.03), and gross-total resection (OR 3.61, 95% CI 1.24–10.52, p = 0.02). Better outcomes were predicted by an acute clinical course (OR 1.72, 95% CI 1.10–2.68, p = 0.02) and motor symptoms (OR 1.76, 95% CI 1.08–2.86, p = 0.02); poor neurological recovery was predicted by sensory symptoms (OR 0.58, 95% CI 0.35–0.98, p = 0.04). Rates of neurological improvement after resection were no higher for patients with superficial ISCCMs than for those with deep-seated ISCCMs (OR 1.36, 95% CI 0.71–2.60, p = 0.36).
Conclusions
Intramedullary spinal cord cavernous malformations tend to be clinically progressive. The authors' findings support an operative management plan for patients with a symptomatic ISCCM. Surgical goals include gross-total resection through a more minimally invasive hemilaminectomy approach within 3 months of presentation.
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Affiliation(s)
| | - Forough Farrokhyar
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
| | | | - Mohammed Aref
- 1Division of Neurosurgery, Department of Surgery, and
| | | | - Naresh Murty
- 1Division of Neurosurgery, Department of Surgery, and
| | - Edward Kachur
- 1Division of Neurosurgery, Department of Surgery, and
| | - Aleksa Cenic
- 1Division of Neurosurgery, Department of Surgery, and
| | - Kesava Reddy
- 1Division of Neurosurgery, Department of Surgery, and
| | - Saleh A. Almenawer
- 1Division of Neurosurgery, Department of Surgery, and
- 2Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
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Almenawer SA, Bogza I, Yarascavitch B, Sne N, Farrokhyar F, Murty N, Reddy K. The Value of Scheduled Repeat Cranial Computed Tomography After Mild Head Injury. Neurosurgery 2013; 72:56-62; discussion 63-4. [DOI: 10.1227/neu.0b013e318276f899] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Yarascavitch BA, Chuback JE, Almenawer SA, Reddy K, Bhandari M. Levels of Evidence in the Neurosurgical Literature. Neurosurgery 2012; 71:1131-7; discussion 1137-8. [DOI: 10.1227/neu.0b013e318271bc99] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Almenawer SA, Bogza J, Yarascavitch B, Sne N, Farrokhyar F, Murty N, Reddy K. 152 The Value of Scheduled Repeat Cranial Computed Tomography Following Mild Head Injury. Neurosurgery 2012. [DOI: 10.1227/01.neu.0000417742.32171.86] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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