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Background and purpose Previous studies suggest that mechanisms and outcomes in patients with COVID-19-associated stroke differ from those in patients with non-COVID-19-associated strokes, but there is limited comparative evidence focusing on these populations. The aim of this study, therefore, was to determine if a significant association exists between COVID-19 status with revascularization and functional outcomes following thrombectomy for large vessel occlusion (LVO), after adjustment for potential confounding factors. Methods A cross-sectional, international multicenter retrospective study was conducted in consecutively admitted COVID-19 patients with concomitant acute LVO, compared to a control group without COVID-19. Data collected included age, gender, comorbidities, clinical characteristics, details of the involved vessels, procedural technique, and various outcomes. A multivariable-adjusted analysis was conducted. Results In this cohort of 697 patients with acute LVO, 302 had COVID-19 while 395 patients did not. There was a significant difference (p < 0.001) in the mean age (in years) and gender of patients, with younger patients and more males in the COVID-19 group. In terms of favorable revascularization (modified Thrombolysis in Cerebral Infarction [mTICI] grade 3), COVID-19 was associated with lower odds of complete revascularization (odds ratio 0.33, 95% confidence interval [CI] 0.23-0.48; p < 0.001), which persisted on multivariable modeling with adjustment for other predictors (adjusted odds ratio 0.30, 95% CI 0.12-0.77; p = 0.012). Moreover, endovascular complications, in-hospital mortality, and length of hospital stay were significantly higher among COVID-19 patients (p < 0.001). Conclusion COVID-19 was an independent predictor of incomplete revascularization and poor functional outcome in patients with stroke due to LVO. Furthermore, COVID-19 patients with LVO were more often younger and had higher morbidity/mortality rates.

BackgroundThe mechanisms and outcomes in coronavirus disease (COVID-19)-associated stroke are unique from those of non-COVID-19 stroke.ObjectiveTo describe the efficacy and outcomes of acute revascularization of large vessel occlusion (LVO) in the setting of COVID-19 in an international cohort.MethodsWe conducted an international multicenter retrospective study of consecutively admitted patients with COVID-19 with concomitant acute LVO across 50 comprehensive stroke centers. Our control group constituted historical controls of patients presenting with LVO and receiving a mechanical thrombectomy between January 2018 and December 2020.ResultsThe total cohort was 575 patients with acute LVO; 194 patients had COVID-19 while 381 patients did not. Patients in the COVID-19 group were younger (62.5 vs 71.2; P < .001) and lacked vascular risk factors (49, 25.3% vs 54, 14.2%; P = .001). Modified thrombolysis in cerebral infarction 3 revascularization was less common in the COVID-19 group (74, 39.2% vs 252, 67.2%; P < .001). Poor functional outcome at discharge (defined as modified Ranklin Scale 3-6) was more common in the COVID-19 group (150, 79.8% vs 132, 66.7%; P = .004). COVID-19 was independently associated with a lower likelihood of achieving modified thrombolysis in cerebral infarction 3 (odds ratio [OR]: 0.4, 95% CI: 0.2-0.7; P < .001) and unfavorable outcomes (OR: 2.5, 95% CI: 1.4-4.5; P = .002).ConclusionCOVID-19 was an independent predictor of incomplete revascularization and poor outcomes in patients with stroke due to LVO. Patients with COVID-19 with LVO were younger, had fewer cerebrovascular risk factors, and suffered from higher morbidity/mortality rates.

BackgroundThe coronavirus disease 2019 is associated with neurological manifestations including stroke.ObjectivesWe present a case series of coronavirus disease 2019 patients from two institutions with acute cerebrovascular pathologies. In addition, we present a pooled analysis of published data on large vessel occlusion in the setting of coronavirus disease 2019 and a concise summary of the pathophysiology of acute cerebrovascular disease in the setting of coronavirus disease 2019.MethodsA retrospective study across two institutions was conducted between 20 March 2020 and 20 May 2020, for patients developing acute cerebrovascular disease and diagnosed with coronavirus disease 2019. We performed a literature review using the PubMed search engine.ResultsThe total sample size was 22 patients. The mean age was 59.5 years, and 12 patients were female. The cerebrovascular pathologies were 17 cases of acute ischemic stroke, 3 cases of aneurysm rupture, and 2 cases of sinus thrombosis. Of the stroke and sinus thrombosis patients, the mean National Institute of Health Stroke Scale was 13.8 ± 8.0, and 16 (84.2%) patients underwent a mechanical thrombectomy procedure. A favorable thrombolysis in cerebral infarction score was achieved in all patients. Of the 16 patients that underwent a mechanical thrombectomy, the mortality incidence was five (31.3%). Of all patients (22), three (13.6%) patients developed hemorrhagic conversion requiring decompressive surgery. Eleven (50%) patients had a poor functional status (modified Rankin Score 3–6) at discharge, and the total mortality incidence was eight (36.4%).ConclusionsDespite timely intervention and favorable reperfusion, the mortality rate in coronavirus disease 2019 patients with large vessel occlusion was high in our series and in the pooled analysis. Notable features were younger age group, involvement of both the arterial and venous vasculature, multivessel involvement, and complicated procedures due to the clot consistency and burden.

Background The coronavirus disease 2019 (COVID-19) pandemic is an ongoing public health emergency. While most cases end in asymptomatic or minor illness, there is growing evidence that some COVID-19 infections result in nonconventional dire consequences. We sought to describe the characteristics of patients with intracranial hemorrhage who were infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Also, with the existing literature, we raise the idea of a possible association between SARS-CoV-2 infection and intracranial hemorrhage and propose possible pathophysiological mechanisms connecting the two. Methods We retrospectively collected and analyzed intracranial hemorrhage cases who were also positive for SARS-CoV-2 from 4 tertiary-care cerebrovascular centers. Results We identified a total of 19 patients consisting of 11 males (58%) and 8 females (42%). Mean age was 52.2, with 95% younger than 75 years of age. With respect to COVID-19 illness, 50% had mild-to-moderate disease, 21% had severe disease, and 20% had critical disease requiring intubation. Of the 19 cases, 12 patients had intraparenchymal hemorrhage (63%), 6 had subarachnoid hemorrhage (32%), and 1 patient had a subdural hematoma (5%). A total of 43% had an intracerebral hemorrhage score of 0–2 and 57% a score of 3–6. Modified Rankin Scale cores at discharge were 0–2 in 23% and 3–6 in 77%. The mortality rate was 59%. Conclusions Our series sheds light on a distinct pattern of intracerebral hemorrhage in COVID-19–positive cases compared with typical non–COVID-19 cases, namely the severity of hemorrhage, high mortality rate, and the young age of patients. Further research is warranted to delineate a potential association between SARS-CoV-2 infection and intracranial hemorrhage.

Background and purpose Flow diversion has established as standard treatment for intracranial aneurysms, the Surpass Streamline is the only FDA-approved braided cobalt/chromium alloy implant with 72-96 wires. We aimed to determine the safety and efficacy of the Surpass in a post-marketing large United States cohort. Materials and methods This is a retrospective multicenter study of consecutive patients treated with the Surpass for intracranial aneurysms between 2018 and 2021. Baseline demographics, comorbidities, and aneurysm characteristics were collected. Efficacy endpoint included aneurysm occlusion on radiographic follow-up. Safety endpoints were major ipsilateral ischemic stroke or treatment-related death. Results A total of 277 patients with 314 aneurysms were included. Median age was 60 years, 202 (73%) patients were females. Hypertension was the most common comorbidity in 156 (56%) patients. The most common location of the aneurysms was the anterior circulation in 89% (279/314). Mean aneurysm dome width was 5.77 ± 4.75 mm, neck width was 4.22 ± 3.83 mm, and dome/neck ratio was 1.63 ± 1.26. Small-sized aneurysms were 185 (59%). Single device was used in 94% of the patients, mean number of devices per patient was 1.06. At final follow-up, complete obliteration rate was 81% (194/239). Major stroke and death were encountered in 7 (3%) and 6 (2%) cases, respectively. Conclusion This is the largest cohort study using a 72–96 wire flow diverter. The Surpass Streamline demonstrated a favorable safety and efficacy profile, making it a valuable option for treating not only large but also wide-necked small and medium-sized intracranial aneurysms.

Supplemental Digital Content is available in the text., Background and Purpose: The impact of coronavirus disease 2019 (COVID-19) on the occurrence of ischemic stroke has been the subject of increased speculation but has not been confirmed in large observational studies. We investigated the association between COVID-19 and stroke. Methods: We performed a cross-sectional study involving patients discharged from a healthcare system in New York State, from January to April 2020. A mixed-effects logistic regression analysis and a propensity score–weighted analysis were used to control for confounders and investigate the association of COVID-19 with ischemic stroke. Similar techniques were used to detect the impact of concurrent COVID-19 infection on unfavorable outcomes for patients with stroke. Results: Among 24 808 discharges, 2513 (10.1%) were diagnosed with COVID-19, and 566 (0.2%) presented with acute ischemic stroke. Patients diagnosed with COVID-19 were at one-quarter the odds of stroke compared with other patients (odds ratio, 0.25 [95% CI, 0.16–0.40]). This association was consistent in all age groups. Our results were robust in sensitivity analyses, including propensity score–weighted regression models. In patients presenting with stroke, concurrent infection with severe acute respiratory syndrome-coronavirus 2 (SARS-CoV-2) was associated with higher case-fatality (odds ratio, 10.50 [95% CI, 3.54–31.18]) and a trend towards increased occurrence of discharge to rehabilitation (odds ratio, 2.45 [95% CI, 0.81–1.25]). Conclusions: Using a comprehensive cross-section of patients from a large NY-based healthcare system, we did not identify a positive association between ischemic stroke and COVID-19. However, patients with stroke with COVID-19 had worse outcomes compared with those without, with over a 9-fold increase in mortality. Although no definitive conclusions can be reached from our observational study, our data do not support the concerns for an epidemic of stroke in young adults with COVID-19.

A property and criticism of instrumental variable (IV) estimators are that they estimate the exposure effect in the compliers; individuals whose exposure is influenced by the instrument. It is conceivable that the exposure effect is different in individuals whose exposure is not influenced by the instrument. For that reason, it is useful to know who the compliers are. We present methods for reporting averages and other statistics, and comparing them between the compliers and non-compliers, which are applicable to scenarios in which the instrument and exposure are fixed in time and dichotomous. The methods are illustrated in a comparison of outcomes between teaching and nonteaching hospitals in patients undergoing brain or spinal surgery.

OBJECTIVEThromboembolic complications continue to be encountered with Pipeline embolization devices (PEDs) despite routine clopidogrel/aspirin antiplatelet therapy. This study examined the safety and efficacy of prasugrel in the management of clopidogrel-resistant patients treated for cerebral aneurysms.METHODSFour hundred thirty-seven consecutive patients were identified between January 2011 and May 2016. Patients allergic, or having less than 30% platelet inhibition, to a daily 75-mg dose of clopidogrel received 10 mg of prasugrel daily (n = 20) or 90 mg of ticagrelor twice daily (n = 2). The mean (± SD) follow-up duration was 15.8 ± 12.4 months. The primary outcome was the modified Rankin Scale (mRS) score registered before discharge and at each follow-up visit. To control confounding, multivariable mixed-effects logistic regression and propensity score conditioning were used.RESULTSTwenty-six (5.9%) of 437 patients presented with a subarachnoid hemorrhage (SAH). The mean patient age was 56.3 years, and 62 were women (14.2%). One of the 7 patients lost to follow-up received prasugrel. One patient was allergic to clopidogrel and prasugrel simultaneously. All patients receiving prasugrel or ticagrelor (n = 22) had an mRS score ≤ 2 on their latest follow-up visit (mean score 0.67 ± 1.15). In a multivariate analysis, clopidogrel did not affect the mRS score on last follow-up (p = 0.14). Multivariable logistic regression showed that clopidogrel was not associated with an increased long-term recurrence rate (OR 0.17, 95% CI 0.01–2.70, p = 0.21), an increased thromboembolic complication rate (OR 0.46, 95% CI 0.12–1.67, p = 0.24), or an increased hemorrhagic event rate (OR 0.39, 95% CI 0.91–1.64, p = 0.20). None of the patients receiving prasugrel or ticagrelor died or suffered a long-term recurrence or a hemorrhagic event; only 1 patient suffered from mild aphasia subsequent to a thromboembolic event. Three patients taking clopidogrel died during the study: 2 from acute SAH and 1 from intraparenchymal hemorrhage. Clopidogrel was not associated with an increased mortality rate (OR 2.18, 95% CI 0.11–43.27, p = 0.61). The same associations were present in propensity score–adjusted models.CONCLUSIONSIn a cohort of patients treated with PEDs, prasugrel (10 mg/day) was a safe alternative to clopidogrel-resistant or clopidogrel-allergic patients, or nonresponders.

Background An increasing number of elderly patients with dementia are undergoing surgical operations. Little is known about the differential impact of dementia on surgical outcomes. We investigated whether demented patients undergoing surgical operations have worse outcomes than their non-demented counterparts. Methods We performed a cohort study of all patients undergoing a series of surgical operations who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2013. We examined the association of dementia with inpatient case-fatality, discharge to a facility, and length of stay (LOS). Coarsened exact matching was used to balance comorbidities among the comparison groups, and mixed effect methods were used to control for clustering at the hospital level. Results During the study period, 342,075 patients underwent surgical operations that met the inclusion criteria. Multivariable logistic regression models, after coarsened exact matching, demonstrated that demented patients were not associated with higher case-fatality (OR, 0.43; 95% CI, 0.13–1.36), but were associated with higher rates of discharge to a facility (OR, 1.71; 95% CI, 1.26–2.31) and longer LOS (Adjusted difference, 31%; 95% CI, 26%–36%). These persisted in pre-specified subgroups stratified on particular operations. Conclusions Using a comprehensive all-payer cohort of surgical patients in New York State we identified an association of dementia with increased rate of discharge to rehabilitation and longer LOS. No difference was identified in the case fatality of the two groups. Policy makers, payers, and physicians should take these findings into account when designing new policies, and when counseling patients.

Direct oral anticoagulant (DOAC) use is growing as monotherapy and combined with platelet inhibitors. The safety of such combination therapy, especially in comparison to regimens including warfarin, in real world populations remains uncertain. We investigated hemorrhage associated with DOAC and antiplatelet combination therapy in a cohort of elderly coronary artery stent recipients. We employed Medicare data 2010 to 2013 for a 40% random sample of beneficiaries enrolled in inpatient, outpatient and prescription benefits. We used Cox proportional hazards models to examine the association of the combination anticoagulant (DOAC or warfarin) plus antiplatelets with major hemorrhage events (upper gastrointestinal or intracranial) in the 12 months following stent placement. We identified 70,900 stent recipients. 14.4% had atrial fibrillation (AF) diagnosis preoperatively. Among the 24.5 million observation days, exposure distribution was: 73.8% antiplatelets only, 4.7% antiplatelets plus warfarin, 0.6% antiplatelets plus DOAC, 2.2% warfarin only, 0.3% DOAC only and 18.4% no observed antiplatelets or anticoagulant. Overall, 8,029 patients (11.3%) experienced major hemorrhage. Among AF patients, compared to antiplatelets only, DOAC plus antiplatelets was associated with increased hemorrhage risk (HR, 1.94; 95%CI, 1.48–2.54); warfarin plus antiplatelets conferred comparable bleed risk (HR, 1.69; 95%CI, 1.47–1.94). In the non-AF group, compared to antiplatelets alone, combination DOAC plus antiplatelets (HR, 3.09; 95%CI, 2.15–4.46), and warfarin plus antiplatelets (HR, 2.21; 95%CI, 1.97–2.48) conferred greater bleed risk. Among elderly coronary artery stent recipients with AF, the two drug combinations, DOAC plus antiplatelets and warfarin plus antiplatelets, were associated with similarly increased risk of major hemorrhage compared to antiplatelets alone.

OBJECTIVEFragmentation of care has been recognized as a major contributor to 30-day readmissions after surgical procedures. The authors investigated the association of evaluation in the hospital where the original procedure was performed with the rate of 30-day readmissions for patients presenting to the emergency department (ED) after craniotomy for primary brain tumor resection.METHODSA cohort study was conducted, involving patients who were evaluated in the ED within 30 days after discharge following a craniotomy for primary brain tumor resection between 2009 and 2013, and who were registered in the Statewide Planning and Research Cooperative System (SPARCS) database of New York State. A propensity score–adjusted model was used to control for confounding, whereas a mixed-effects model accounted for clustering at the hospital level.RESULTSOf the 610 patients presenting to the ED, 422 (69.2%) were evaluated in a hospital different from the one where the original procedure was performed (28.9% were readmitted), and 188 (30.8%) were evaluated at the original hospital (20.3% were readmitted). In a multivariable analysis, the authors demonstrated that being evaluated in the ED of the original hospital was associated with a decreased rate of 30-day readmission (OR 0.64, 95% CI 0.41–0.98). Similar associations were found in a mixed-effects logistic regression model (OR 0.63, 95% CI 0.40–0.96) and a propensity score–adjusted model (OR 0.64, 95% CI 0.41–0.98). This corresponds to one less readmission per 12 patients evaluated in the hospital where the original procedure was performed.CONCLUSIONSUsing a comprehensive all-payer cohort of patients in New York State who were evaluated in the ED after craniotomy for primary brain tumor resection, the authors identified an association of assessment in the hospital where the original procedure was performed with a lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.

Flow diversion with the Pipeline Embolization Device (PED) is reported as a safe and efficient treatment for patients with intracranial aneurysms; however, literature discussing the antiplatelet (APT) regimen used before and after the PED is limited. Our aim was to systematically review and summarize available data regarding the APT regimen and the platelet function test (PFT) that was used. We also sought to provide an overview of the aneurysm morphologies and adverse event rates associated with the PED use. This systematic review was conducted according to the PRISMA statement and eligible studies were identified through search of the PubMed and Cochrane databases. We reviewed 28 studies, involving 1556 patients that underwent aneurysm treatment with the PED. The preprocedural aspirin (ASA) 300- 325mg (2-14days) combined with clopidogrel 75mg (3 to >10days) were used as a treatment strategy in 61.7% of patients and ASA 81mg with clopidogrel 75mg for 5-10days for 27%. Patients who received low versus high dose pre-PED ASA, were at less risk for a hemorrhagic event (0.7% versus 3.3%, p=0.053); however no statistical significance was reached. There was also lack of relationship between patients that received low versus high preprocedural ASA in terms of thromboembolic events. Regarding postprocedural APT, ASA (>6months) and clopidogrel (3- 12 months) was the regimen of choice for 93% of patients. Most studies conducted at least one PFT, most common being the VerifyNow. The most frequently reported target P2Y12 Reaction unit (PRU) and Aspirin Reaction Unit (ARU) values were

OBJECTIVEThe accuracy of public reporting in health care, especially from private vendors, remains an issue of debate. The authors investigated the association of the publicly reported physician complication rates in an online platform with real-world adverse outcomes of the same physicians for patients undergoing posterior lumbar fusion.METHODSThe authors performed a cohort study involving physicians performing posterior lumbar fusions between 2009 and 2013 who were registered in the Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data over the same time period from ProPublica, a private company. Mixed-effects multivariable regression models were used to investigate the association of publicly available complication rates with the rate of discharge to a rehabilitation facility, length of stay, mortality, and hospitalization charges for the same surgeons.RESULTSDuring the selected study period, there were 8,457 patients in New York State who underwent posterior lumbar fusion performed by the 56 surgeons represented in the ProPublica Surgeon Scorecard over the same time period. Using a mixed-effects multivariable regression model, the authors demonstrated that publicly reported physician-level complication rates were not associated with the rate of discharge to a rehabilitation facility (OR 0.97, 95% CI 0.72–1.31), length of stay (adjusted difference −0.1, 95% CI −0.5 to 0.2), mortality (OR 0.87, 95% CI 0.49–1.55), and hospitalization charges (adjusted difference $18,735, 95% CI −$59,177 to $96,647). Similarly, no association was observed when utilizing propensity score–adjusted models, and when restricting the cohort to a predefined subgroup of Medicare patients.CONCLUSIONSAfter merging a comprehensive all-payer posterior lumbar fusion cohort in New York State with data from the ProPublica Surgeon Scorecard over the same time period, the authors observed no association of publicly available physician complication rates with objective outcomes.

To investigate the effect of exposure to a virtual reality (VR) environment preoperatively on patient-reported outcomes for surgical operations.There is a scarcity of well-developed quality improvement initiatives targeting patient satisfaction.We performed a randomized controlled trial of patients undergoing cranial and spinal operations in a tertiary referral center. Patients underwent a 1:1 randomization to an immersive preoperative VR experience or standard preoperative experience stratified on type of operation. The primary outcome measures were the Evaluation du Vecu de l'Anesthesie Generale (EVAN-G) score and the Amsterdam Preoperative Anxiety and Information (APAIS) score, as markers of the patient's experience during the surgical encounter.During the study period, a total of 127 patients (mean age 55.3 years, 41.9% females) underwent randomization. The average EVAN-G score was 84.3 (standard deviation, SD, 6.4) after VR, and 64.3 (SD, 11.7) after standard preoperative experience (difference, 20.0; 95% confidence interval, CI, 16.6-23.3). Exposure to an immersive VR experience also led to higher APAIS score (difference, 29.9; 95% CI, 24.5-35.2). In addition, VR led to lower preoperative VAS stress score (difference, -41.7; 95% CI, -33.1 to -50.2), and higher preoperative VAS preparedness (difference, 32.4; 95% CI, 24.9-39.8), and VAS satisfaction (difference, 33.2; 95% CI, 25.4-41.0) scores. No association was identified with VAS stress score (difference, -1.6; 95% CI, -13.4 to 10.2).In a randomized controlled trial, we demonstrated that patients exposed to preoperative VR had increased satisfaction during the surgical encounter. Harnessing the power of this technology, hospitals can create an immersive environment that minimizes stress, and enhances the perioperative experience.

Background The association of Magnet hospital status with improved surgical outcomes remains an issue of debate. Objective To investigate whether hospitalization in a Magnet hospital is associated with improved outcomes for patients undergoing neurosurgical operations. Methods A cohort study was executed using all patients undergoing neurosurgical operations in New York registered in the Statewide Planning and Research Cooperative System database from 2009 to 2013. We examined the association of Magnet status hospitalization after neurosurgical operations with inpatient case fatality and length of stay (LOS). We employed an instrumental variable analysis to simulate a randomized trial. Results Overall, 190 787 patients underwent neurosurgical operations. Of these, 68 046 (35.7%) were hospitalized in Magnet hospitals, and 122 741 (64.3%) in non-Magnet institutions. Instrumental variable analysis demonstrated that hospitalization in Magnet hospitals was associated with decreased case fatality (adjusted difference, -0.8%; -95% confidence interval, -0.7% to -0.6%), and LOS (adjusted difference, -1.9; 95% confidence interval, -2.2 to -1.5) in comparison to non-Magnet hospitals. These associations were also observed in propensity score adjusted mixed effects models. These associations persisted in prespecified subgroups of patients undergoing spine surgery, craniotomy for tumor resection, or neurovascular interventions. Conclusion We identified an association of Magnet hospitals with lower case fatality, and shorter LOS in a comprehensive New York State patient cohort undergoing neurosurgical procedures.

Despite numerous advances over the last 50 years, stroke continues to be a leading cause of death and disability worldwide. The treatment and prevention of stroke has undergone extensive study, and significant advances in medical management have occurred within the past decade principally with the development of new classes of orally active anticoagulant drugs. Here we review these recent breakthroughs and the varying roles of anticoagulants and antiplatelet agents in the prevention and management of different ischemic stroke subtypes, as well as describe the benefits and ongoing challenges to incorporating the novel oral anticoagulants (NOACs) into clinical management guidelines. Current guidelines recommend (a) administration of the antiplatelet agent aspirin in the acute management of ischemic stroke, (b) antiplatelet therapy - aspirin, clopidogrel, dypiridamole - in the secondary prevention of noncardioembolic (large artery atherosclerosis) ischemic stroke, and (c) anticoagulants - warfarin and the NOACs - in the secondary prevention of cardioembolic (atrial fibrillation related) ischemic stroke. In phase III clinical trials of the NOACs, dabigatran 150mg BID and apixaban 5mg BID were superior to warfarin in the prevention of stroke/systemic embolism while rivaroxaban 20mg QD demonstrated noninferiority. Both dabigatran and rivaroxaban had similar rates of major bleeding as warfarin but apixaban showed significantly reduced incidence of this complication. As application of novel anticoagulant agents increases, with concomitant study in a variety of clinical settings; their promise in reducing the incidence of stroke, as well as that of therapeutic complications related to warfarin, should be further elaborated.

OBJECTIVE The comparative effectiveness of the 2 treatment options—surgical clipping and endovascular coiling—for unruptured cerebral aneurysms remains an issue of debate and has not been studied in clinical trials. The authors investigated the association between treatment method for unruptured cerebral aneurysms and outcomes in elderly patients. METHODS The authors performed a cohort study of 100% of Medicare fee-for-service claims data for elderly patients who had treatment for unruptured cerebral aneurysms between 2007 and 2012. To control for measured confounding, the authors used propensity score conditioning and inverse probability weighting with mixed effects to account for clustering at the level of the hospital referral region (HRR). An instrumental variable (regional rates of coiling) analysis was used to control for unmeasured confounding and to create pseudo-randomization on the treatment method. RESULTS During the study period, 8705 patients underwent treatment for unruptured cerebral aneurysms and met the study inclusion criteria. Of these patients, 2585 (29.7%) had surgical clipping and 6120 (70.3%) had endovascular coiling. Instrumental variable analysis demonstrated no difference between coiling and clipping in 1-year postoperative mortality (OR 1.25, 95% CI 0.68–2.31) or 90-day readmission rate (OR 1.04, 95% CI 0.66–1.62). However, clipping was associated with a greater likelihood of discharge to rehabilitation (OR 6.39, 95% CI 3.85–10.59) and 3.6 days longer length of stay (LOS; 95% CI 2.90–4.71). The same associations were present in propensity score–adjusted and inverse probability–weighted models. CONCLUSIONS In a cohort of Medicare patients, there was no difference in mortality and the readmission rate between clipping and coiling of unruptured cerebral aneurysms. Clipping was associated with a higher rate of discharge to a rehabilitation facility and a longer LOS.

BACKGROUND The association of operative duration with the risk of venous thromboembolism (VTE) has not been quantified in neurosurgery. OBJECTIVE To investigate the association of surgical duration for several neurosurgical procedures and the incidence of VTE. METHODS We performed a retrospective cohort study involving patients who underwent neurosurgical procedures from 2005 to 2012 and were registered in the American College of Surgeons National Quality Improvement Project registry. In order to control for confounding, we used multivariable regression models, and propensity score conditioning. RESULTS During the study period, there were 94 747 patients, who underwent neurosurgical procedures, and met the inclusion criteria. Of these, 1358 (1.0%) developed VTE within 30 days postoperatively. Multivariable logistic regression demonstrated an association of longer operative duration with higher 30-day incidence of VTE (odds ratio [OR], 1.22; 95% confidence interval [CI], 1.19-1.25). Compared with procedures of moderate duration (third quintile, 40-60th percentile), patients undergoing the longest procedures (>80th percentile) had higher odds (OR, 3.15; 95% CI, 2.49-3.99) of developing VTE. The shortest procedures (

OBJECTIVE The molecular mechanisms behind cerebral aneurysm formation and rupture remain poorly understood. In the past decade, microRNAs (miRNAs) have been shown to be key regulators in a host of biological processes. They are noncoding RNA molecules, approximately 21 nucleotides long, that posttranscriptionally inhibit mRNAs by attenuating protein translation and promoting mRNA degradation. The miRNA and mRNA interactions and expression levels in cerebral aneurysm tissue from human subjects were profiled. METHODS A prospective case-control study was performed on human subjects to characterize the differential expression of mRNA and miRNA in unruptured cerebral aneurysms in comparison with control tissue (healthy superficial temporal arteries [STA]). Ion Torrent was used for deep RNA sequencing. Affymetrix miRNA microarrays were used to analyze miRNA expression, whereas NanoString nCounter technology was used for validation of the identified targets. RESULTS Overall, 7 unruptured cerebral aneurysm and 10 STA specimens were collected. Several differentially expressed genes were identified in aneurysm tissue, with MMP-13 (fold change 7.21) and various collagen genes (COL1A1, COL5A1, COL5A2) being among the most upregulated. In addition, multiple miRNAs were significantly differentially expressed, with miR-21 (fold change 16.97) being the most upregulated, and miR-143–5p (fold change −11.14) being the most downregulated. From these, miR-21, miR-143, and miR-145 had several significantly anticorrelated target genes in the cohort that are associated with smooth muscle cell function, extracellular matrix remodeling, inflammation signaling, and lipid accumulation. All these processes are crucial to the pathophysiology of cerebral aneurysms. CONCLUSIONS This analysis identified differentially expressed genes and miRNAs in unruptured human cerebral aneurysms, suggesting the possibility of a role for miRNAs in aneurysm formation. Further investigation for their importance as therapeutic targets is needed.

Background Context The value of continuity of care in preventing 30-day readmissions after surgical procedures remains an issue of debate. Purpose This study aimed to investigate the association of being evaluated in the emergency room (ER) of the hospital where the original procedure was performed with 30-day readmissions for spine surgery patients. Study Design/Setting This is a cohort study. Patient Sample A total of 16,483 spine surgery patients were evaluated in the emergency department within 30-days postoperatively. Outcome Measures A 30-day post-discharge readmission was the outcome measure. Methods We performed a cohort study involving patients who were evaluated in the ER within 30-days after discharge following spine surgery from 2009 to 2013, and were registered in the Statewide Planning and Research Cooperative System database. A propensity score adjusted model was used to control for confounding. Results From our patients, 11,638 (70.6%) were seen in a hospital different from the one where the original procedure was performed (12.0% readmitted), and 4,845 (29.4%) were evaluated at the original hospital (10.9% readmitted). In a multivariable analysis, we demonstrated that being evaluated in the original hospital was associated with decreased rate of 30-day readmission (odds ratio [OR], 0.87; 95% confidence interval [CI], 0.77–0.97). We found similar associations in a propensity score adjusted model (OR, 0.87; 95% CI, 0.78–0.97). This corresponded to seven patients who needed to be evaluated in the hospital where the original procedure was performed to prevent one readmission. Conclusions Using a comprehensive all-payer cohort of patients in New York State, who were evaluated in the ER after spine surgery, we identified an association of assessment in the hospital where the original procedure was performed with lower rate of 30-day readmissions. This underscores the potential importance of continuity of care in readmission prevention for these patients.

Major (above-knee or below-knee) amputation is a complication of diabetes and is seen more common among black and Hispanic patients. While amputation rates have declined for patients with diabetes in the last decade, it remains unknown if these improvements have equitably extended across racial groups and if measures of diabetic care, such as hemoglobin A1c testing, are associated with these improvements. We set out to characterize secular changes in amputation rates among black, Hispanic, and white patients, and to determine associations between hemoglobin A1c testing and amputation risk.We identified 11,942,840 Medicare patients (55% female) with diabetes over the age of 65 years between 2002 and 2012 and followed them for a mean of 6.6 years. Of these, 86% were white, 11.5% were black, and 2.5% were Hispanic. We recorded the occurrence of major amputation and hemoglobin A1c testing during this time period and studied secular changes in amputation rate by race (black, Hispanic, and white). Finally, we examined associations between amputation risk and hemoglobin A1c testing. We measured both the presence of any testing and testing consistency using 3 categories: poor consistency (hemoglobin A1c testing in 0-50% of years), medium consistency (testing in 50-90% of years), and high consistency (testing in90% of the years in the cohort).Between 2002 and 2012, the average major lower-extremity amputation rate in diabetic Medicare patients was 1.78 per 1,000 per year for black patients, 1.15 per 1,000 per year for Hispanic patients, and 0.56 per 1,000 per year for white patients (P 0.001). Over the study period, the incidence of major amputation in Medicare patients with diabetes declined by 54%, from 1.15 per 1,000 in 2002 to 0.53 per 1,000 in 2012 (rate ratio = 0.53, 95% CI = 0.51-0.54). The reduction in amputation rate was similar across racial groups: 52% for black patients, 61% for Hispanic patients, and 55% for white patients. In multivariable analysis adjusting for patient characteristics, including race, any use of hemoglobin A1c testing was associated with a 15% decline in amputation risk (hazard ratio, 0.85; 95% CI, 0.83-0.87; P 0.001). High consistency hemoglobin A1c testing was associated with a 39% decline in amputation (hazard ratio, 0.61; 95% CI, 0.59-0.62; P 0.0001).Although more frequent among racial minorities, major lower-extremity amputation rates have declined similarly across black, Hispanic, and white patients over the last decade. Hemoglobin A1c testing, particularly the consistency of testing over time, may be an effective component metric of longitudinal quality measures toward limiting amputation in all races.

OBJECTIVE The accuracy of public reporting in health care is an issue of debate. The authors investigated the association of patient satisfaction measures from a public reporting platform with objective outcomes for patients undergoing spine surgery. METHODS The authors performed a cohort study involving patients undergoing elective spine surgery from 2009 to 2013 who were registered in the New York Statewide Planning and Research Cooperative System database. This cohort was merged with publicly available data from the Centers for Medicare and Medicaid Services (CMS) Hospital Compare website. A mixed-effects regression analysis, controlling for clustering at the hospital level, was used to investigate the association of patient satisfaction metrics with outcomes. RESULTS During the study period, 160,235 patients underwent spine surgery. Using a mixed-effects multivariable regression analysis, the authors demonstrated that undergoing elective spine surgery in hospitals with a higher percentage of patient-assigned high satisfaction scores was not associated with a decreased rate of discharge to rehabilitation (OR 0.77, 95% CI 0.57–1.06), mortality (OR 0.96, 95% CI 0.90–1.01), or hospitalization charges (β 0.04, 95% CI −0.16 to 0.23). However, it was associated with decreased length of stay (LOS; β −0.19, 95% CI −0.33 to −0.05). Similar associations were identified for hospitals with a higher percentage of patients who claimed they would recommend these institutions to others. CONCLUSIONS Merging a comprehensive all-payer cohort of spine surgery patients in New York state with data from the CMS Hospital Compare website, the authors were not able to demonstrate an association of improved performance in patient satisfaction measures with decreased mortality, rate of discharge to rehabilitation, and hospitalization charges. Increased patient satisfaction was associated with decreased LOS.

Objective The risk of leg amputation among patients with diabetes has declined over the past decade, while use of preventative measures—such as hemoglobin A1c monitoring—has increased. However, the relationship between hemoglobin A1c testing and amputation risk remains unclear. Methods We examined annual rates of hemoglobin A1c testing and major leg amputation among Medicare patients with diabetes from 2003 to 2012 across 306 hospital referral regions. We created linear regression models to study associations between hemoglobin A1c testing and lower extremity amputation. Results From 2003 to 2012, the proportion of patients who received hemoglobin A1c testing increased 10% (74% to 84%), while their rate of lower extremity amputation decreased 50% (430 to 232/100,000 beneficiaries). Regional hemoglobin A1c testing weakly correlated with crude amputation rate in both years (2003 R = −0.20, 2012 R = −0.21), and further weakened with adjustment for age, sex, and disability status (2003 R = −0.11, 2012 R = −0.17). In a multivariable model of 2012 amputation rates, hemoglobin A1c testing was not a significant predictor. Conclusion Lower extremity amputation among patients with diabetes nearly halved over the past decade but only weakly correlated with hemoglobin A1c testing throughout the study period. Better metrics are needed to understand the relationship between preventative care and amputation.

The impact of scope of practice of providers (predominantly adult versus predominantly pediatric) on the outcomes of cerebrovascular procedures in children remains an issue of debate. We investigated the association of scope of practice with the outcomes of cerebrovascular interventions.We performed a cohort study of all pediatric patients (younger than 18 years old) who underwent cerebrovascular procedures from 2009 to 2013 and were registered in the Statewide Planning and Research Cooperative System (SPARCS) database. In order to control for confounding, we used propensity score conditioning and mixed effects analysis to account for clustering at the hospital level.During the study period, there were 1243 pediatric patients who underwent cerebrovascular procedures and met the inclusion criteria. Of these, 631 (50.7 %) underwent treatment by providers with predominantly adult practices and 612 (49.3 %) by physicians who operated predominantly on children. The mixed-effects multivariable regression analysis demonstrated lack of association of predominantly adult practice with inpatient mortality (OR, 1.20; 95 % CI, 0.61-2.38), discharge to a facility (OR, 1.50; 95 % CI, 0.73-3.09), and length of stay (LOS) (adjusted difference, 0.003; 95 % CI, -0.09 to 0.10). These associations persisted in propensity-adjusted models.In a cohort of pediatric patients undergoing cerebrovascular procedures from a comprehensive all-payer database, we did not demonstrate a difference in mortality, discharge to a facility, and LOS between providers with predominantly adult and predominantly pediatric practices.

Background: The association of speed of diffusion of Hemoglobin A1C (hbA1c) testing with temporal changes in outcomes of primary importance to patients with diabetes, such as amputation, remains an issue of debate. We investigated these correlations. Methods: We performed a retrospective cohort study of diabetics, based on Medicare fee-for-service claims data from 2002 to 2012. We examined the association of the rate of diffusion of HbA1c testing with changes in amputation rates. Our unit of analysis was the hospital referral region (HRR), a definition of tertiary care markets defined in the Dartmouth Atlas of Health Care. Results: From the 11 096 270 diabetics followed in our study for a mean follow-up of 4.1 years, 106 340 (0.96%) underwent lower extremity amputations. The speed of diffusion of HbA1c testing had a moderate association with the speed of diffusion of lower extremity amputations, after adjusting for multiple factors including baseline regional amputation and testing rates (adjusted difference, −0.7%; 95% confidence interval, −1.0% to −0.3%). The risk-adjusted HRR-level speed of diffusion of testing demonstrated significant correlation with the risk-adjusted HRR-level diffusion of amputations ( r = .250, P < .001). Conclusions: We observed a moderate association of the speed of diffusion of HbA1c testing with the speed of diffusion of lower extremity amputations among Medicare patients with diabetes. Improvements in performance on quality metrics such as HbA1c testing may not immediately translate into tangible patient outcomes.

Introduction The influence of non-medical factors on the volume of procedures undergone by TBI patients remains an issue of debate. We investigated the association of lack of insurance and African-American race with the procedural volume of TBI patients. Methods We performed a retrospective cohort study involving TBI patients, who were registered in the National Trauma Data Bank (NTDB) between 2009 and 2011. Multivariable logistic regression with mixed effects to control for clustering at the hospital level was used to investigate the association of insurance status and race with high volume of procedures for TBI patients. Results Of the 392,292 TBI patients, who were registered in NTDB and met the inclusion criteria, 9850 (3.8%) underwent high procedural volume, defined as 2 or more procedures during hospitalization (2 standard deviations over the mean). Multivariable logistic regression analysis demonstrated an association of uninsured patients with decreased possibility of high procedural volume (OR, 0.68; 95% CI, 0.63–0.73). This persisted after using a mixed effects model to control for clustering at the hospital level (OR, 0.66; 95% CI, 0.61–0.71). In stratified samples, uninsured patients demonstrated similar associations even for GCS below 8 (OR, 0.69; 95% CI, 0.64–0.75), or ISS above 15 (OR, 0.74; 95% CI, 0.69–0.79). Multivariable logistic regression analysis did not demonstrate an association of African Americans with procedural volume (OR, 0.93; 95% CI, 0.86–1.02). Conclusions During the hospitalization of TBI patients, lack of insurance was associated with lower procedural volume. When controlling for insurance status, we did not observe any race associated disparities in procedural volume.

Background The emergent disposition of acute stroke patients remains an issue of debate. We investigated whether a hub-and-spoke model was associated with worse stroke outcomes when compared to care exclusively in comprehensive centers. Methods We performed a cohort study of all acute ischemic stroke patients who were hospitalized in endovascular-capable facilities, and were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database from 2009 to 2015. We examined the association of transfer status (transfer to endovascular capable hospitals versus initial treatment in these facilities) with inpatient case-fatality, discharge to a facility, and length of stay (LOS). An instrumental variable analysis was used to control for unmeasured confounding and simulate a randomized trial. Results During the study period, 128,122 acute stroke patients met inclusion criteria. Instrumental variable analysis demonstrated that patients transferred to endovascular-capable hospitals did not have higher case-fatality (Adjusted difference, 4.4%; 95% CI, −0.1% to 9.0%), rate discharge to a facility (Adjusted difference, −2.3%; 95% CI, −5.2% to 0.6%), or longer LOS (Adjusted difference, 4.2; 95% CI, −2.2 to 10.1) in comparison to patients presenting for initial treatment in these facilities. The same associations were present when restricting the cohort to patients receiving intravenous tissue plasminogen (IV-tPA) and to patients receiving mechanical thrombectomy. Conclusions Using a comprehensive all-payer cohort of acute ischemic stroke patients in New York State we demonstrated that patients treated in a hub-and-spoke model were not associated with worse outcomes than patients receiving care exclusively in comprehensive institutions. This needs to be taken into consideration when considering acute emergency services in this setting.

Telemedicine rapidly connects patients, with acute ischemic stroke symptoms, with neurovascular specialists for assessment to reduce chemical thrombolysis delivery times. Management of AIS includes maintaining target systolic blood pressures (SBP). In this retrospective study, we assess the efficacy of the telestroke (TS) system at a primary stroke center and the prognostic value of SBP throughout the transportation process.Patients presenting with acute-onset neurological symptoms to the TS hospitals network, over a 5-year period, were assessed. Those with a confirmed diagnosis of AIS were included. We examined demographics, presenting-NIHSS, last SBP before transfer from the network hospital and continuous BP during transport, stroke risk factors, hospital-course, door-to-needle (DTN) time, treatments, and modified Rankin Scale(mRS). Multivariate analysis was conducted to evaluate the prognostic value of SBP on stroke outcome.Of 2,928 patients identified, 1,353 were diagnosed with AIS. Mean age was 66.6 years (SD = 15.4), 47.6% female. Most cases affected the MCA(44.5%). Mean presenting-NIHSS was 8.67(SD = 8.38) and mean SBP was 148 mmHg(SD = 25.39). 73.2% treated using a standard protocol, 23.7% given IVrt-PA, and 6.8% received mechanical thrombectomy(MT). Mean DTN was 96 min(SD = 46; 27.3%60 min). Age, presenting-NIHSS and pre-existing hypertension were associated with higher mortality and/or higher mRS. SBP was not associated with higher mortality and morbidity.This study displays better clinical outcomes at latest follow-up when compared to current international TS studies. SBP during transportation to the hub hospital did not prove to be a useful prognostic metric. However, future studies should address the limitations of this study to confirm these findings.

Background Pipeline embolization device (PED; Medtronic, Dublin, Ireland) utilization is not limited to the treatment of giant wide-necked aneurysms. It has been expanded to handle small blisters, fusiforms, and dissecting intracranial aneurysms. Objective To report the use of the PED in various off-label distal cerebral circulation (DCC) arteries with a follow-up to assess clinical outcomes. Methods Between 2011 and 2016, of 437 consecutive patients, 23 patients with aneurysms located in DCCs were treated with PED. Data on patient presentation, aneurysm characteristics, procedural outcomes, postoperative course, and aneurysm occlusion were gathered. To control confounding, we used multivariable logistic regression and propensity score conditioning. Results A total of 437 patients (mean age 52.12 years; 62 women [14.2%]) underwent treatment with PED in our institution. Twenty-three of 437 (5.2%) received a pipeline in a distal artery: 11/23 middle cerebral artery, 6/23 posterior cerebral artery, 3/23 anterior cerebral artery (A1/A2, pericallosal artery), and 3/23 posterior inferior cerebellar artery. Twenty percent of the aneurysms were treated in the past, 10% had previously ruptured, and 5.9% ruptured at presentation to our hospital. The mean aneurysm size was 9.0 ± 6 mm. The mean follow-up was 12 mo (SD = 12.5). In multivariable logistic regression, no associations were found between PED deployment in DCCs and aneurysm occlusion or thromboembolic complications. PED use in DCC was associated with a good clinical outcome. Twenty-two people of 23 (95%) had a good clinical outcome in the latest follow-up. Conclusion Treatment of DCC aneurysms with PED is technically challenging mainly because of the small caliber and tortuosity of the parent arteries. The results of this study further support the safety of flow diverters in the treatment of various distal aneurysms.

The quality of physicians practicing in hospitals recognized for nursing excellence by the American Nurses Credentialing Center has not been studied before. We investigated whether Magnet hospital recognition is associated with higher quality of physicians performing neurosurgical procedures.We performed a cohort study of patients undergoing neurosurgical procedures from 2009-2013, who were registered in the New York Statewide Planning and Research Cooperative System (SPARCS) database. Propensity score adjusted multivariable regression models were used to adjust for known confounders, with mixed effects methods to control for clustering at the facility level. An instrumental variable analysis was used to control for unmeasured confounding and simulate the effect of a randomized trial.During the study period, 185,277 patients underwent neurosurgical procedures, and met the inclusion criteria. Of these, 66,607 (35.6%) were hospitalized in Magnet hospitals, and 118,670 (64.4%) in non-Magnet institutions. Instrumental variable analysis demonstrated that undergoing neurosurgical operations in Magnet hospitals was associated with a 13.6% higher chance of being treated by a physician with superior performance in terms of mortality (95% CI, 13.2% to 14.1%), and a 4.3% higher chance of being treated by a physician with superior performance in terms of length-of-stay (LOS) (95% CI, 3.8% to 4.7%) in comparison to non-Magnet institutions. The same associations were present in propensity score adjusted mixed effects models.Using a comprehensive all-payer cohort of neurosurgical patients in New York State we identified an association of Magnet hospital recognition with superior physician performance.

Background: The use of flow diverters has stretched to address several sets of aneurysms such as giant, small blister, fusiform, distal IAs of the anterior and posterior circulation. Only very few studies considered addressing the rate and the characteristics of intra-pipeline stenosis(IPS). Objective: we aimed to appraise the prevalence, the predictors and outcomes of IPS and the consequent clinical implications. Method: We reviewed the charts of 537patients treated with pipeline for their IAs between 2011 and 2017. We consecutively gathered clinical and angiographic data related to IPS. Stenosis was interpreted by the operating neurointerventionist: mild75%. To control confounding, we used multivariable logistic regression and propensity score conditioning. Results: Of 537patients, 31(15.6% were females) had an angiography perceived IPS. 8(25.8%) of our patients were >65yo. 23(74%) patients had their IPS detected at 6moths follow-up. The mean follow-up time to detect IPS was 7.2months(SD=6.33). 23(74.2%) and 8(25.8%) patients had their aneurysms located in the anterior & posterior circulation respectively. The average pipeline size was 3.8x19.4mm. Six patients had an IPS located, at the proximal (n=3) and distal end (n=3) of the pipeline, 25 patients had IPS somewhere along the body of the pipeline. 20/31 patients had mild IPS, 5/31 had moderate IPS and 6/31 had severe IPS. Regression of IPS was perceived in 9/31 patient. IPS progression was noted in one patient from 70% to 90%. 4(12%) patients had >90% IPS, all were symptomatic: 3 had a right hemispheric stroke and 1 patient precipitated an intra-cerebral hemorrhage. In multivariable analysis, patients of older age (>65yo) were less likely to develop IPS (OR0.96;CI95%,0.9-1;p=0.03). Those with a history of hypertension were more prone to develop IPS (OR3.3;CI95%,1.1-9.8;p=0.03). Per-procedural use of balloon angioplasty, aneurysm size and ruptured aneurysm were not independent predictors of IPS. Conclusion: Young patients

Objectives Neurologists have continually led the assessment and management of Acute Ischemic Stroke(AIS) by use of IV-rtPA, anti-platelet therapy, antihypertensives, and other pharmacologic agents. Since the advent of mechanical thrombectomy(MT) and its proven efficacy, neurovascular surgeons(NS) are playing an increasingly important role in the management and overall care of AIS. We assessed outcomes of AIS patients managed by NS, who have been traditionally managed by neurologists. Patients and Methods Outcomes of AIS patients who presented to the telestroke system, over a 5-year period, were assessed. NIHSS and mRS stroke scales were used as outcome metrics. Multivariate analysis was conducted to compare outcomes of patients treated by neurovascular surgeons and those treated by neurologists. Results 1353 AIS patients were identified. 21.6% received care from neurosurgeons and 78.4% received care from neurologists. Of the neurologist-managed group: 7.8% received MT and were followed by NS, 34% received IVrt-PA, average discharge NIHSS = 9.0 (SD = 8.42), latest follow-up mRS 2 = 57.5% and mortality rate = 9.4%. Of the neurovascular surgeon-managed group: 7.4% patients received MT, 20% received IVrt-PA, average discharge NIHSS = 0.14(SD = 0.72), latest follow-up mRS ≤2 = 98.6% and mortality rate = 8.3%. There were no significant differences between groups in MT use (OR 1.22; CI95%, 0.971–2.09; p = 0.464), IVrt-PA administration (OR 0.98; CI95%, 0.70–1.38; p = 0.924), mortality rate (OR 1.21; 0.71–2.03; p = 0.483) and patients’ latest mRS, p = 0.873. Conclusions AIS requires multidisciplinary management. Care provided by neurosurgeons has similar efficacy and patient outcomes as the care provided by neurologists. These findings support the role and ability of neurosurgeons to manage and care for these patients.

The objective of this study was to develop and validate a predictive model of hospitalization costs after spine surgery. Several initiatives have been put in place to minimize healthcare expenditures but there are limited data on the magnitude of the contribution of procedure-specific drivers of cost. We performed a retrospective cohort study involving 672,591 patients who underwent spine surgery and were registered in the National Inpatient Sample from 2005-2010. The cohort underwent 1:1 randomization to create derivation and validation subsamples. Regression techniques were used for the creation of a parsimonious predictive model of total hospitalization cost after spine surgery. Included were 356,783 patients (53.1%) who underwent fusions, and 315,808 (46.9%) non-fusion surgeries. The median hospitalization cost was $14,202 (interquartile range $4772-23,632). Common drivers of cost identified in the multivariate analysis included the length of stay, number of admission diagnoses and procedures, hospital size and region, patient income, fusion surgery, acute renal failure, sex, and coagulopathy. The model was validated in an independent cohort and demonstrated a final coefficient of determination that was very similar to the initial model. The predicted and observed values in the validation cohort demonstrated good correlations. This national study quantified the magnitude of significant drivers of hospitalization cost after spine surgery. We developed a predictive model that can be utilized as an adjunct in the cost containment debate and the creation of data driven policies.

OBJECTIVE: To investigate the association of lack of insurance and African American race with the probability of transfer to level I/II trauma centers after evaluation in the emergency department of level III/IV trauma centers for traumatic brain injury (TBI). BACKGROUND: The influence of nonmedical factors on the disposition of TBI patients initially seen in less specialized institutions is debated. METHODS: We conducted a retrospective cohort study involving TBI patients who were registered in the National Trauma Data Bank between 2009 and 2011. Regression methods were used to investigate the association of insurance status and race with the disposition of TBI patients evaluated in less specialized trauma centers. RESULTS: During the study period, there were 26,031 TBI patients who were registered in the National Trauma Data Bank and met inclusion criteria. Of these, 10,572 (35.9%) were transferred to a higher level of care institution. Multivariable logistic regression after coarsened exact matching demonstrated an association of uninsured patients with an increased possibility of transfer (odds ratio [OR] = 1.22; 95% confidence interval [CI], 1.05-1.42). On the contrary, there was no association of African Americans with transfers (OR = 1.27; 95% CI, 0.99-1.62). Those with Glasgow Coma Scale score above 8 (OR = 1.22; 95% CI, 1.08-1.39) or Injury Severity Score below 16 (OR = 1.33; 95% CI, 1.13-1.56) had a higher possibility of transfer. CONCLUSIONS: In TBI patients, lack of insurance was associated with an increased possibility of transfer to higher level of care institutions after evaluation in a level III or IV trauma center emergency department. Regardless of insurance status, this transfer pattern was also observed for African Americans, but only for those with milder injuries. Language: en

Background Statins have been shown to decrease aneurysm progression and rupture in two experimental settings: animals with cerebral aneurysm and humans with abdominal aortic aneurysms. Aims To investigate statin use and outcomes in humans with unruptured cerebral aneurysms through Medicare administrative data. Methods We used a 40% random sample Medicare denominator file and corresponding inpatient, outpatient (2003-2011), and prescription (2006-2011) claims to conduct a retrospective cohort study of patients diagnosed with unruptured cerebral aneurysms, between 2003 and 2011. We used propensity score-adjusted models to investigate the association between statin use and risk of subarachnoid hemorrhage. Secondary analyses repeated the main models stratified on tobacco use status and separately assessed other composite outcomes. Results We identified 28 931 patients with unruptured cerebral aneurysms (average age 72.0 years, 72.6% female); mean follow-up was 30.0 months; 41.3% used statins. Overall, 593 patients developed subarachnoid hemorrhage, and 703 underwent treatment before subarachnoid hemorrhage. Current or recent statin use was not associated with a difference in subarachnoid hemorrhage risk (odds ratio, 1.03; 95% conflict of interest 0.86-1.23); models stratified on tobacco use status were nearly identical. No association was observed between statin use and the composite outcome of subarachnoid hemorrhage or aneurysm treatment (odds ratio, 0.94; 95% conflict of interest, 0.84-1.06). The risk of subarachnoid hemorrhage or out-of-hospital death was lower among statin users (odds ratio, 0.69; 95% conflict of interest, 0.64-0.74). Conclusions Statin use by patients with unruptured cerebral aneurysms was not associated with subarachnoid hemorrhage risk. Given the prior animal experimental studies demonstrating a protective effect, further prospective studies are needed to investigate the potential relationship.

To investigate the variability in head computed tomographic (CT) scanning in patients with hemorrhagic stroke in U.S. hospitals, its association with mortality, and the number of different physicians consulted.The study was approved by the Committee for the Protection of Human Subjects at Dartmouth College. A retrospective analysis of the Medicare fee-for-service claims data was performed for elderly patients admitted for hemorrhagic stroke in 2008-2009, with 1-year follow-up through 2010. Risk-adjusted primary outcome measures were mean number of head CT scans performed and high-intensity use of head CT (six or more head CT scans performed in the year after admission). We examined the association of high-intensity use of head CT with the number of different physicians consulted and mortality.A total of 53 272 patients (mean age, 79.6 years; 31 377 women [58.9%]) with hemorrhagic stroke were identified in the study period. The mean number of head CT scans conducted in the year after admission for stroke was 3.4; 8737 patients (16.4%) underwent six or more scans. Among the hospitals with the highest case volume (more than 50 patients with hemorrhagic stroke), risk-adjusted rates ranged from 8.0% to 48.1%. The correlation coefficient between number of physicians consulted and rates of high-intensity use of head CT was 0.522 (P.01) for all hospitals and 0.50 (P.01) for the highest-volume hospitals. No improvement in 1-year mortality was found for patients undergoing six or more head CT scans (odds ratio, 0.84; 95% confidence interval: 0.69, 1.02).High rates of head CT use for patients with hemorrhagic stroke are frequently observed, without an association with decreased mortality. A higher number of physicians consulted was associated with high-intensity use of head CT.

To investigate the association of helicopter transport with survival of patients with traumatic brain injury (TBI), in comparison with ground emergency medical services (EMS).Helicopter utilization and its effect on the outcomes of TBI remain controversial.We performed a retrospective cohort study involving patients with TBI who were registered in the National Trauma Data Bank between 2009 and 2011. Regression techniques with propensity score matching were used to investigate the association of helicopter transport with survival of patients with TBI, in comparison with ground EMS.During the study period, there were 209,529 patients with TBI who were registered in the National Trauma Data Bank and met the inclusion criteria. Of these patients, 35,334 were transported via helicopters and 174,195 via ground EMS. For patients transported to level I trauma centers, 2797 deaths (12%) were recorded after helicopter transport and 8161 (7.8%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival [OR (odds ratio), 1.95; 95% confidence interval (CI), 1.81-2.10; absolute risk reduction (ARR), 6.37%]. This persisted after propensity score matching (OR, 1.88; 95% CI, 1.74-2.03; ARR, 5.93%). For patients transported to level II trauma centers, 1282 deaths (10.6%) were recorded after helicopter transport and 5097 (7.3%) after ground EMS. Multivariable logistic regression analysis demonstrated an association of helicopter transport with increased survival (OR, 1.81; 95% CI, 1.64-2.00; ARR 5.17%). This again persisted after propensity score matching (OR, 1.73; 95% CI, 1.55-1.94; ARR, 4.69).Helicopter transport of patients with TBI to level I and II trauma centers was associated with improved survival, in comparison with ground EMS.

BackgroundCost containment is the cornerstone of the Affordable Care Act. Although studies have compared the cost of cerebral aneurysm clipping (CAC) and coiling, they have not focused on identification of drivers of cost after CAC, or prediction of its magnitude. The objective of the present study was to develop and validate a predictive model of hospitalization cost after CAC.MethodsWe performed a retrospective study involving CAC patients who were registered in the Nationwide Inpatient Sample (NIS) database from 2005 to 2010. The two cohorts of ruptured and unruptured aneurysms underwent 1:1 randomization to create derivation and validation subsamples. Regression techniques were used for the creation of a parsimonious predictive model.ResultsOf the 7798 patients undergoing CAC, 4505 (58%) presented with unruptured and 3293 (42%) with ruptured aneurysms. Median hospitalization cost was US$24 398 (IQR $17 079 to $38 249) and $73 694 (IQR $46 270 to $115 128) for the two cohorts, respectively. Common drivers of cost identified in the multivariate analyses included the following: length of stay, number of admission diagnoses and procedures, hospital size and region, and patient income. The models were validated in independent cohorts and demonstrated final R2 values very similar to the initial models. The predicted and observed values in the validation cohort demonstrated good correlation.ConclusionsThis national study identified significant drivers of hospitalization cost after CAC. The presented model can be utilized as an adjunct in the cost containment debate and the creation of data driven policies.