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Continuing medical education (CME) programs are planned to provide medical professionals with the opportunity to stay abreast of new developments in their field. After each program, CME attendees are given the chance to evaluate the success of the activity in meeting its defined learning objectives. Over one-third of intent-to-change statements from CME evaluations do not match the stated learning objectives. We examined unmatched objectives and intent-to-change statements to determine their usefulness for future meeting planning.This retrospective mixed-method content analysis used quantitative, deductive content analysis to compare intent-to-change statements and learning objectives from American Association of Neurological Surgeons-sponsored CME activities to explore unintended learning themes.We examined 85 CME activities with 424 meeting objectives and 1950 intent-to-change statements. Approximately 37% of intent-to-change statements were unrelated to any meeting objective, and 15% of learning objectives had no associated intent-to-change statements. Among unmatched objectives, those regarding more general subject matter often failed to be met with intent-to-change statements for multiple years, whereas those related to clinical practice were more likely to be unmatched for only 1 year. Some CME learning objectives are repeated for the same meeting for multiple years without change, although 22.6% of unmatched intent-to-change statements led to new learning objectives in subsequent years.An analysis of intent-to-change statements that are unmatched to meeting learning objectives is a potential avenue for understanding outcomes of CME activities. Our observations about general versus specific learning objective language may prove useful for CME planners' future educational event formulation.

STUDY DESIGN Retrospective review of prospectively collected data at a single institution. OBJECTIVE To compare perioperative and clinical outcomes in morbidly obese patients who underwent minimally invasive transforaminal lumbar interbody fusion (MiTLIF). SUMMARY OF BACKGROUND DATA Obesity remains a serious public health concern. Obese patients who undergo lumbar fusion have historically thought to be at higher risk for complications and fare worse regarding quality-of-life outcomes. However, recent literature may demonstrate comparable risk and outcomes in obese patients. An increasing number of patients are categorized as morbidly obese (body mass index [BMI] ≥ 40 kg/m2). Perioperative and patient-reported outcomes (PROs) are lacking in this patient population. METHODS The authors retrospectively reviewed a prospectively collected database of all morbidly obese and non-obese patients that underwent MiTLIF between 2015 and 2018 for degenerative conditions who had minimum 1-year follow-up for outcome assessment. An inverse propensity/probability of treatment weighting was utilized to create a synthetic weighted sample in which covariates were independent of obesity designation to adjust for imbalance between groups. Generalized estimating equations (GEE) was used to estimate the association of morbid obesity and complications and 1-year PROs. RESULTS A total of 292 patients were analyzed with 234 non-obese patients and 58 morbidly obese patients. Multivariate analysis failed to demonstrate any association between morbid obesity and achieving minimal clinically important difference (MCID) for Oswestry disability index (ODI), visual analog scale (VAS), or short form-12 (SF-12) physical component score. However, morbid obesity was associated with significant decrease in odds of achieving MCID for SF-12 mental component score (P = 0.001). Increased surgery duration was significantly associated with morbid obesity (P = 0.001). Morbid obesity exhibited no statistically significant association with postoperative complications, readmission, pseudarthrosis, or adjacent segment disease (ASD). CONCLUSION Morbidly obese patients who undergo MiTLIF can achieve meaningful clinical improvement comparable to nonobese patients. Morbid obesity was associated with longer surgical times but was not associated with postoperative complications, readmission, or ASD.Level of Evidence: 3.

STUDY DESIGN Retrospective review of a multi-institutional data registry. OBJECTIVE The authors sought to determine the association between age and complications & patient-reported outcomes (PRO) in patients undergoing multilevel transforaminal interbody lumbar fusion (MTLIF). SUMMARY OF BACKGROUND DATA Elderly patients undergoing MTLIF are considered high risk. However, data on complications and PRO are lacking. Additionally, safety of multilevel lumbar fusion in the elderly remains uncertain. METHODS Patients ≥50-year-old who underwent MTLIF for degenerative lumbar spine conditions were analyzed. Ninety-day complications and PROs (baseline, 90-d, 1-y, 2-y) were queried using the MSSIC database. PROs were measured by back & leg visual analog scale (VAS), Patient-reported Outcomes Measurement Information System (PROMIS), EuroQol-5D (EQ-5D), and North American Spine Society (NASS) Patient Satisfaction Index. Univariate analyses were used to compare among elderly and complication cohorts. Generalized estimating equation (GEE) was used to identify predictors of complications and PROs. RESULTS A total of 3120 patients analyzed with 961 (31%) ≥ 70-y-o and 2159 (69%) between 50-69. A higher proportion of elderly experienced postoperative complications (P = .003) including urinary retention (P =

Minimally invasive fusion of the sacroiliac (SI) joint has gained popularity for the treatment of refractory dysfunction. The purpose of this study was to compare the clinical outcomes of minimally invasive SI joint fusion between cylindrical threaded implants (CTIs) and triangular dowel implants (TDIs).We retrospectively reviewed consecutive patients who underwent SI joint fusions with either CTIs or TDIs. Data collected included patient demographics, perioperative data, and all patient-reported outcomes (PROs) including postoperative visual analog scale (VAS), Oswestry Disability Index, and Short Form-12 at 6 months and 1 year. The change from baseline PROs between the cohorts was analyzed as the primary outcome. Secondary outcomes included revision rates and time to revision between the two cohorts. A P value0.05 was considered significant.One hundred fifty-six consecutive patients underwent SI joint fusion, 74 patients with CTIs and 82 with TDIs. There was a significant difference in procedure length with CTI averaging 60.0 minutes (confidence interval: 55.7-64.3) and TDI averaging 41.2 minutes (confidence interval: 38.4-43.9, P0.0005). In both cohorts, there was a significant improvement in all PROs at 6 months when compared with preoperative values. However, when compared, there was no significant difference between the cohorts at 6-month follow-up or 1-year follow-up for either VAS-back, VAS-leg, Oswestry Disability Index, or Short Form-12. A 6.1% revision rate in the CTI cohort was observed compared with a 2.4% revision rate in the TDI cohort (P = 0.11).SI joint fusions with TDI or CTI offer a significant improvement in pain, disability, and quality of life. However, no difference was observed between devices to suggest superior clinical outcomes. Increased revision rates in the Rialto group warrants further investigation.

STUDY DESIGN Retrospective analysis of prospectively collected registry data using multivariable analyses of imputed data. OBJECTIVE We sought to demonstrate that age would not be associated with complications in patients undergoing anterior cervical discectomy and fusion (ACDF). SUMMARY OF BACKGROUND DATA Elderly patients (≥70 yrs) undergoing ACDF are considered a higher risk for complications. However, conclusive evidence is lacking. The Michigan Spine Surgery Improvement Collaborative (MSSIC) is a quality improvement collaborative with 30 hospitals across Michigan. METHODS The study included all patients who had 1 to 4 level ACDF (September 2015-August 2019) for 90-day complications. Major and minor complications were defined using a validated classification. Multiple imputations were used to generate complete covariate datasets. Generalized estimating equation model was used to identify associations with complications using the whole cohort and elderly subgroup analyses. Bonferroni correction was used. RESULTS Nine thousand one hundred thirty five patients (11.1% ≥ 70 yrs and 88.9%

Chronic encapsulated intracerebral hematoma is a rare pathology which may present after spontaneous intracerebral hemorrhage (ICH) or radiosurgery for arteriovenous malformations. A 66-year-old male presented with recent diagnosis of cerebrovascular accident (CVA) status post-treatment with tissue plasminogen activator and mechanical thrombectomy. His recent diagnoses included infective endocarditis, septic bacteremia, meningitis, and aspiration pneumonia. One month following his CVA, the patient presented with delayed altered mental status. In the setting of increasing lethargy, computed tomography and magnetic resonance imaging of the brain were performed, which suggested a brain abscess, septic emboli, and ventriculitis. The patient was taken to surgery emergently. Intraoperatively, the patient was found to have an encapsulated mass of liquid consistency. Tissue pathology demonstrated ischemic cortical tissue and hemorrhage. Multiple cultures were negative for growth. The patient was ultimately determined to have an encapsulated intracerebral hematoma. Encapsulated intracerebral hematoma should be a part of the differential diagnosis when presented with a brain abscess in the setting of a patient who is at risk of ICH.

Postoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses.We sought to demonstrate noninferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar interbody fusion. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period.This is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis.Adults with degenerative spinal conditions eligible to undergo a one to three-level MIS transforaminal lumbar interbody fusion (TLIF).Six-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent, length of stay, and drug-related complications. Self-reported and functional measures include validated visual analog scale, short-form 12, and Oswestry Disability Index.A double-blinded, randomized placebo-controlled, noninferiority trial of patients undergoing 1- to 3-level MIS TLIF was performed with bone morphogenetic protein (BMP). Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15 mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as milligram morphine equivalence, pain scores, length of stay (LOS), and quality-of-life outcomes. Univariate analyses were performed. The present study provides results from a planned interim analysis.Two hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion of solid fusion between the ketorolac and placebo groups did not reach inferiority (p=.072, 95% confidence interval, -.07 to .21). There was a significant reduction in total/48-hour mean opioid consumption (p.001) and LOS (p=.001) for the ketorolac group while demonstrating equivalent mean pain scores in 48 hours postoperative (p=.20). There was no significant difference in rates of perioperative complications.Short-term use of low-dose ketorolac in patients who have undergone MIS TLIF with BMP demonstrated noninferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control.

BACKGROUND CONTEXT Postoperative pain control following posterior lumbar fusion continues to be challenging and often requires high doses of opioids for pain relief. The use of ketorolac in spinal fusion is limited due to the risk of pseudarthrosis. However, recent literature suggests it may not affect fusion rates with short-term use and low doses. PURPOSE We sought to demonstrate non-inferiority regarding fusion rates in patients who received ketorolac after undergoing minimally invasive (MIS) posterior lumbar fusions. Additionally, we sought to demonstrate ketorolac's opioid-sparing effect on analgesia in the immediate postoperative period. STUDY DESIGN/SETTING This is a prospective, randomized, double-blinded, placebo-controlled trial. We are reporting our interim analysis. PATIENT SAMPLE Adults with degenerative spinal conditions eligible to undergo a 1- to 3-level minimally invasive lumbar spinal fusion. OUTCOME MEASURES Six-month and 1-year radiographic fusion as determined by Suk criteria, postoperative opioid consumption as measured by intravenous milligram morphine equivalent (MME), length of stay (LOS), and drug-related complications. Self-reported and functional measures include validated visual analog scale (VAS), short-form 12 (SF-12), and Oswestry Disability Index (ODI). METHODS A double-blinded, randomized placebo-controlled, non-inferiority trial of patients undergoing 1- to 3-level minimally invasive (MIS) transforaminal lumbar interbody fusion (TLIF) was performed. Patients were randomized to receive a 48-hour scheduled treatment of either intravenous ketorolac (15mg every 6 hours) or saline in addition to a standardized pain regimen. The primary outcome was fusion. Secondary outcomes included 48-hour and total postoperative opioid use demonstrated as MME, pain scores, LOS, and quality-of-life (QoL) outcomes. Univariate and multivariate analyses were performed. The present study provides results from a planned interim analysis. RESULTS Two hundred and forty-six patients were analyzed per protocol. Patient characteristics were comparable between the groups. There was no significant difference in 1-year fusion rates between the two treatments (p=.53). The difference in proportion for solid fusion between the ketorolac and placebo groups did not reach inferiority (.072, 95% CI, -.07-.21). There was a significant reduction in total/48-hour mean opioid consumption (p CONCLUSION Short-term use of low-dose ketorolac in patients who have undergone MIS lumbar fusion demonstrated favorable results suggesting non-inferior fusion rates. Ketorolac safely demonstrated a significant reduction in postoperative opioid use and LOS while maintaining equivalent postoperative pain control. FDA DEVICE/DRUG STATUS Not applicable.

Study design This was a single-institute retrospective study. Objective To describe perioperative and postoperative complications in elderly who underwent multilevel minimally invasive transforaminal lumbar interbody fusion (MIS TLIF) while identifying predictors of complications. Summary of background data The number of elderly patients undergoing spinal fusion is rising. Spinal surgery in the elderly is considered high risk with high rates of complications. Perioperative and postoperative complications in elderly undergoing multilevel MIS TLIF is, however, not known. Methods A retrospective analysis was performed on 467 consecutive patients who underwent multilevel MIS TLIF at a single institution from 2013 to 2017. Two cohorts, 70 years or older and 50 to 69 years old were analyzed. Multiple logistic regressions with minor and major complication rates as the dependent variables were performed to identify predictors of complication based on previously cited risk factors. A p-value of 0.008 or less was considered significant. Results One hundred fifty-two elderly and 315 nonelderly patients underwent multilevel MIS TLIFs. The average age was 76.4 and 60.4 years for the elderly and nonelderly cohorts. We observed 13 major (8.44%) and 72 minor (47.4%) complications in the elderly. No difference was noted in complication rates between the cohorts, except for urinary tract infection (P = .004) and urinary retention (P = .014). There were no myocardial infarctions; hardware complications; visceral, vascular, and neural injuries; or death. Length of stay, comorbidity, and length of surgery were predictive of major and minor complications. Conclusion Elderly may undergo multilevel MIS TLIF with comparable complication rates. Age was not a predictor of complications. Rather, attention should focus on evaluation of comorbidity and limiting operative times. Level of evidence 3.

Compression fractures are common among osteoporotic patients and can be a significant source of pain and disability. Patients who suffer a compression fracture at an instrumented level of a lumbar fusion are most often treated conservatively. Herein, we demonstrate a safe and effective treatment for a vertebral compression fracture (VCF) at a previous level with instrumented fusion and pedicle screw fixation. An 89-year-old female with a history of multiple osteoporotic compression fractures treated with previous kyphoplasties and a prior instrumented fusion at L4-L5 presented with debilitating lower back pain for one week. After failing conservative management, computed tomography (CT) and magnetic resonance imaging (MRI) study of the lumbar spine revealed an acute VCF of the previously instrumented L5 vertebral body. Under biplanar fluoroscopy, a balloon kyphoplasty was performed at the L5 vertebrae utilizing the Inflatable Vertebral Augmentation System (IVAS) from Stryker® (Kalamazoo, MI, USA). We were able to demonstrate that the treatment of an acute VCF with balloon kyphoplasty is feasible in patients who have a history of previous instrumentation with pedicle screws remaining at the fracture level.

We present a novel treatment with the use of intraventricular antibiotics delivered through a ventriculostomy in a patient who developed septic cavernous sinus thrombosis after sinus surgery. A 65-year-old woman presented with acute on chronic sinusitis. The patient underwent a diagnostic left maxillary antrostomy, ethmoidectomy, sphenoidotomy and sinusotomy. Postoperatively, the patient experienced altered mental status with episodic fever despite treatment with broad-spectrum antimicrobial therapy. MRI of the brain showed extensive meningeal enhancement with the involvement of the right trigeminal and abducens nerve along with thick enhancement along the right pons and midbrain. MR arteriogram revealed a large filling defect within the cavernous sinus. Intraventricular gentamicin was administered via external ventricular drain (ie, ventriculostomy) every 24 hours for 14 days with continued treatment of intravenous ceftriaxone and metronidazole. The patient improved with complete resolution of her cavernous sinus meningitis on repeat brain imaging at 6 months posthospitalisation.

IntroductionKetorolac has been shown to provide quality postoperative pain control and decrease opioid requirement with minimal side effects following spinal surgery. However, the literature addressing its use in spinal fusions is highly variable in both its effectiveness and complications, such as pseudarthrosis. Recent literature postulates that ketorolac may not affect fusion rates and large randomised controlled trials are needed to demonstrate ketorolac as a safe and effective adjuvant treatment to opioids for postoperative pain control.Methods and analysisThis is a multihospital, prospective, double-blinded, randomised placebo-controlled trial. Data concerning fusion rates, postoperative opioid use, pain scores, length of stay will be recorded with the aim of demonstrating that the use of ketorolac does not decrease thoracolumbar spinal fusion rates while identifying possible adverse events related to short-term minimal effective dose compared with placebo. Additionally, this investigation aims to demonstrate a decrease in postoperative opioid use demonstrated by a decrease in morphine equivalence while showing equivalent postoperative pain control and decrease the average length of stay.Ethics and disseminationEthical approval was obtained at all participating hospitals by the institutional review board. The results of this study will be submitted for publication in peer-reviewed journals.Trial registration numberNCT03278691.

Background Although initial studies of neuroendovascular intervention did not review benefit over intravenous thrombolytics (iv r-tPA), recent studies have suggested otherwise. Elderly patients (age ≥80 years) are typically excluded from clinical trials. Purpose To examine the utility of mechanical thrombectomy based on patient outcomes. Material and Methods All stroke-alert activations at our health system from January 2011 to June 2014 were examined. All patients aged ≥80 years who had undergone mechanical thrombectomy were identified. Clinical characteristics included physiologic imaging findings, use of intravenous thrombolytics, baseline and postoperative National Institute of Health Stroke Scale (NIHSS), thrombolysis in cerebral infarction scores (TICI), and discharge destination. Results Mean NIHSS on presentation was 18.2 (range, 6–31), and 13.3 (range, 3–30) post thrombectomy. Three (16.6%) patients received iv r-tPA, two (11.1%) had symptomatic intracranial hemorrhage. Eight (44.4%) died, eight (44.4%) were discharged to nursing homes, and two (11.7%) were discharged to inpatient rehab and subsequently home. Favorable outcome was achieved in five (27.7%) patients. Fourteen (77.7%) patients had physiologic imaging prior to intervention. Three (75%) of four patients who did not have physiologic imaging prior to thrombectomy died. Thirteen (66.6%) patients had TICI 3 recanalization. Conclusion Our study showed that although there remains a role of mechanical thrombectomy in the treatment of acute ischemic stroke in very elderly patients, it is associated with significant higher morbidity and mortality compared to younger patients, but should remain a very viable treatment option when quality of life is the most important consideration.

Background Computed tomography perfusion (CTP) is a commonly used modality of neurophysiologic imaging to aid the selection of acute ischemic stroke patients for neuroendovascular intervention by identifying the presence of penumbra versus infarcted brain tissue. However many patients present with evidence of cerebral ischemia with normal CTP, and in that case, should intravenous thrombolytics be given? Purpose To demonstrate if tissue-type plasminogen activator (tPA)-eligible stroke patients without perfusion defects demonstrated on CTP would benefit from administration of intravenous thrombolytics. Material and Methods We retrospectively identified patients presenting with acute ischemic symptoms who received intravenous tPA (IV-tPA) from January to June 2012 without a perfusion defect on CTP. Clinical and radiographic findings including the NIHSS at presentation, 24 h, and at discharge, symptomatic and asymptomatic hemorrhagic transformation, and the modified Rankin score at 30 days were collected. A reduction of NIHSS of greater than 4 points or resolution of symptoms was considered significant. Results Seventeen patients were identified with a mean NIHSS of 8.2 prior to administration of intravenous thrombolytics, 3.5 after 24 h, and 2.5 at discharge. Among them, 13 patients had significant improvement of NIHSS with a mean reduction of 6.15 points at 24 h. One patient initially improved but had delayed hemorrhagic transformation and died. Two patients had improvement in NIHSS but were not significant and two patients had increased in NIHSS at 24 h, although one eventually improved at discharge. There was no asymptomatic hemorrhagic transformation. Mean mRS at 3 months is 1.76. Conclusion The failure to identify a perfusion deficit by CTP should not be used as a contraindication for intravenous thrombolytics. Criteria for administration of intravenous thrombolytics should still be based on time from symptom onset as previously published by NINDS.

AIM To evaluate the feasibility of this novel surgical approach for treatment of cervical discitis and vertebral osteomyelitis. MATERIAL AND METHODS This is a report of two patients who underwent anterior cervical decompression for discitis and vertebral osteomyelitis (DVO) with cervical spine reconstruction with polymethylmethacrylate impregnated with antibiotics (AI-PMMA). RESULTS Both patients had successful procedures that were followed by 6 weeks of intravenous antibiotics. Stabilization and eradication of infection was achieved with clinical and radiographic stabilization seen in both. Follow-up is greater than 18 months and both patients remain off antibiotics. CONCLUSION The described technique using AI-PMMA offers immediate structural stability and local delivery of high concentration of antibiotics. Use in two patients has demonstrated a cost effective, long-term biomechanically stable construct and infection control.

Biventricular hydrocephalus caused by a Giant Basilar Apex Aneurysm (GBAA) is a rare finding that presents unique and challenging treatment decisions. We report a case of GBAA causing a life-threatening biventricular hydrocephalus in which both the aneurysm and hydrocephalus were given definitive treatment through a staged, minimally invasive approach. An obtunded 82-year-old male was found to have biventricular hydrocephalus caused by an unruptured GBAA obstructing the foramina of Monro. The patient was treated via staged, minimally invasive technique that first involved endoscopic fenestration of the septum pellucidum to create communication between the lateral ventricles. A programmable ventriculo-peritoneal shunt was then placed with a high-pressure setting. The patient was then loaded with dual anti-platelet therapy prior to undergoing endovascular coiling of the GBAA with adjacent stenting of the Posterior Cerebral Artery. He remained on dual anti-platelet therapy and the shunt setting was lowered at the bedside to treat the hydrocephalus. At 6-month follow up, the patient had returned to his cognitive baseline, speaking fluently and appropriately. Biventricular hydrocephalus caused by a GBAA can successfully be treated in a minimally invasive fashion utilizing a combination of endoscopy and endovascular therapy, even when a stent-assisted coiling is needed.

Introduction: The Trevo Retriever device (Stryker Neurovascular, Mountain View, CA) received FDA clearance as a 510K device in August 2012 for clot retrieval in acute ischemic stroke within eight hours of symptom onset. This study is an early look at the initial U.S. experience with the device following FDA clearance, examining the clinical results of the some of the first cases performed in the U.S. Methods: This was a retrospective analysis of prospectively collected clinical data from the early U.S. experience using the Trevo Retriever device. All physician operators were in-serviced on the use of the device and technique prior to first clinical use. Of the first patients treated, 6 were MCA occlusions, and 1 ICA occlusion. Four of the patients received intravenous tPA prior to their intervention, the remaining three patients did not did not qualify for IV tPA. The mean NIHSS pre-procedure was 19. Results: The Trevo device could be delivered across the intraluminal clot in all seven cases. There was a 100% success rate in revascularization of the target territory as judged by TICI score 2b or 3. One case resulted in an ACA embolus that was successfully revascularized. There was an average of 2.0 passes of the device to achieve this revascularization rate (range 1-4), with 71% of the cases needing 1 or 2 passes, and the remaining 3 or 4 passes. The mean time from femoral access to revascularization was 44 minutes (range 18-93 minutes, median 31 minutes). The average clot length was 11 mm. The clot was characterized as soft/friable in 2 cases, intermediate/rubbery in 3 cases, and hard/fibrous in 2 cases. The 24 hour post-procedure NIHSS was improved in 86% of the patients treated, and the mean NIHSS at 24 hours was 10 (range 0-27). Five of the seven patients had an improvement on the NIHSS of 9 points or greater. Conclusions: The technical success rate, as measured by a TICI score of 2b or 3, was excellent (100%) in this initial U.S. experience. With a high revascularization rate and a few number of passes, this shortened the endovascular revascularization time, and resulted in improved clinical exam in 6 of the 7 patients within 24 hours post-procedure.

We aim to analyze the impact of annual hospital volume on outcomes of endovascular mechanical thrombectomy (EMT) for acute ischemic stroke (AIS). In the recent past, increasing number of hospitals are acquiring capabilities for EMT procedure for the treatment of AIS, including some low-volume centers. There are few data on outcomes comparing these hospitals with high-volume centers.We queried the National Inpatient Sample from 2008 to 2011 using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9 CM) diagnosis codes 433 to 437.1 in any position for AIS. Adult patients with ICD-9-CM procedure code 39.74 for mechanical thrombectomy were included in the final cohort. Annual hospital procedure volume was computed using the unique hospital identification number (HOSPID) and was dichotomized corresponding to

During treatment of a right internal carotid artery terminus aneurysm, an acute iatrogenic flow limiting dissection was caused in the cervical internal carotid. The true lumen was catheterized using a Mirage 0.008 microwire over an Excelsior SL-10 microcatheter, which was exchanged for a Marksman microcatheter. A 6 mm × 30 mm Solitaire FR revascularization device was then deployed across the dissection as a salvage technique.

Hypothesis Focused helical computed tomographic (CT) scanning with rectal contrast only is a superior diagnostic modality compared with the traditional triple-contrast CT scan for the diagnosis of acute appendicitis. Design Prospective randomized analysis of both CT scan modalities. Interventions Only patients with uncertain diagnosis of acute appendicitis were entered in the study. The patients were then randomized to undergo the traditional triple-contrast CT scan or the new focused CT scan with rectal contrast only. Surgical management included operation or observation for 23 hours. Results Ninety-one patients participated in the study, including 52 in the triple-contrast group and 39 in the rectal-contrast group. The demographics of the triple-contrast vs the rectal-contrast groups were similar. The triple-contrast group had a sensitivity of 97%, specificity of 86%, positive predictive value of 90%, and negative predictive value of 93%. The rectal-contrast group had a sensitivity of 88%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 100%. There were 4 false-positive findings and 1 false-negative finding in the triple-contrast group compared with none in the rectal-contrast group. In the triple-contrast group, there were 13 perforated appendixes compared with 1 in the rectal-contrast group. The cost of a triple-contrast scan was $620 compared with $305 for a focused rectal-contrast scan. The negative appendectomy rate for the study was 8.0% (4 of 48 patients in the triple-contrast group vs 3 of 39 in the rectal-contrast group). Conclusions The demographics, sensitivity, specificity, and positive and negative predictive values were comparable in both groups. The focused rectal-contrast procedure was better tolerated by patients and demonstrated decreased morbidity, delay to diagnosis, perforation rate, and negative appendectomy rate with no missed diagnosis and decreased cost. Therefore, we believe that focused helical CT scanning with rectal contrast only is a superior diagnostic modality compared with the traditional triple-contrast CT scan for the diagnosis of acute appendicitis.