Triage and systems of care in stroke.

There has been increasing adoption of endovascular stroke treatment in the United States following multiple clinical trials demonstrating superior efficacy. Next steps in enhancing this treatment include an analysis and development of stroke systems of care geared toward efficient delivery of endovascular and comprehensive stroke care. The chapter presents epidemiological data and an overview of the current state of stroke delivery and potential improvements for the future in the light of clinical data.

Development and Evaluation of a Preoperative Trigeminal Neuralgia Scoring System to Predict Long-Term Outcome Following Microvascular Decompression.

Background: Microvascular decompression (MVD) can be an effective intervention for trigeminal neuralgia (TN); however, an optimal system for patient selection and surgical outcome prediction has not been defined.

Objective: To develop and validate a preoperative TN grading system for the prediction of long-term pain relief after MVD.

Methods: This retrospective cohort study included consecutive patients suffering unilateral TN who underwent MVD with >18-mo follow-up.

Low preoperative serum prealbumin levels and the postoperative surgical site infection risk in elective spine surgery: a consecutive series.

OBJECTIVENutritional deficiency negatively affects outcomes in many health conditions. In spine surgery, evidence linking preoperative nutritional deficiency to postoperative surgical site infection (SSI) has been limited to small retrospective studies. Authors of the current study analyzed a large consecutive cohort of patients who had undergone elective spine surgery to determine the relationship between a serum biomarker of nutritional status (preoperative prealbumin levels) and SSI.

Stent Reconstruction of Carotid Tonsillar Loop Dissection Using Telescoping Peripheral Stents.

Background: Endovascular treatment options for internal carotid artery (ICA) dissection with tandem intracranial occlusion are evolving. We report 2 cases of stent reconstruction of carotid loop dissections.

Methods: Two patients with symptomatic ICA dissections of true 360° tonsillar loops and tandem intracranial occlusions were treated with manual aspiration thrombectomy (MAT) and telescoping Zilver self-expanding peripheral stents.

Graft subsidence as a predictor of revision surgery following stand-alone lateral lumbar interbody fusion.

OBJECTIVE Lateral lumbar interbody fusion (LLIF) is a less invasive surgical option commonly used for a variety of spinal conditions, including in high-risk patient populations. LLIF is often performed as a stand-alone procedure, and may be complicated by graft subsidence, the clinical ramifications of which remain unclear. The aim of this study was to characterize further the sequelae of graft subsidence following stand-alone LLIF.

Septoplasty: Scepter Balloon Angioplasty for Vasospasm after Aneurysmal Subarachnoid Hemorrhage.

Introduction: Balloon angioplasty can be a requisite approach for the treatment of symptomatic and/or severe vasospasm. Dual-lumen microcatheter balloons have multiple potential advantages for this indication including accommodating a 0.014-inch wire and the potential to deliver superselective vasodilators directly via the microcatheter prior to angioplasty.

A Critical Analysis of the Utility of Intraoperative Angiography.

Objective: Intraoperative digital subtraction angiography (ioDSA) is touted as the gold standard imaging evaluation for aneurysm clip constructs. Candid evaluations of its limitations are sparse.

Methods: A prospectively collected hospital billing database was queried to identify craniotomies for aneurysm clipping from January 2010 to December 2013.

Limitations of multidetector computed tomography angiography for the diagnosis of blunt cerebrovascular injury.

OBJECTIVE Blunt cerebrovascular injuries (BCVIs) following trauma carry risk for morbidity and mortality. Since patients with BCVI are often asymptomatic at presentation and neurological sequelae often occur within 72 hours, timely diagnosis is essential. Multidetector CT angiography (CTA) has been shown to be a noninvasive, cost-effective, reliable means of screening; however, the false-positive rate of CTA in diagnosing patients with BCVI represents a key drawback.

Diagnostic Accuracy of Somatosensory Evoked Potential Monitoring in Evaluating Neurological Complications During Endovascular Aneurysm Treatment.

Background: Somatosensory evoked potential (SSEP) monitoring is used extensively for early detection and prevention of neurological complications in patients undergoing many different neurosurgical procedures. However, the predictive ability of SSEP monitoring during endovascular treatment of cerebral aneurysms is not well detailed.

Objective: To evaluate the performance of intraoperative SSEP in the prediction postprocedural neurological deficits (PPNDs) after coil embolization of intracranial aneurysms.

Utility of the Aspirin and P2Y12 Response Assays to Determine the Effect of Antiplatelet Agents on Platelet Reactivity in Traumatic Brain Injury.

Background: Premorbid antithrombotic medication may worsen intracranial injury and outcome after traumatic brain injury (TBI). Routine laboratory tests are insufficient to evaluate platelet activity.

Objective: To profile the spectrum of platelet inhibition, as measured by aspirin and P2Y12 response unit assays, in a TBI population on antiplatelet therapy.

Use of Aspirin and P2Y12 Response Assays in Detecting Reversal of Platelet Inhibition With Platelet Transfusion in Patients With Traumatic Brain Injury on Antiplatelet Therapy.

Background: At present, guidelines are lacking on platelet transfusion in patients with a traumatic intracranial bleed and history of antiplatelet therapy. The aspirin and P2Y 12 response unit (ARU and PRU, respectively) assays detect the effect of aspirin and P2Y 12 inhibitors in the cardiac population.

Objective: To describe the reversal of platelet inhibition after platelet transfusion using the ARU and PRU assays in patients with traumatic brain injury.

Endovascular Treatment of Tandem Common Carotid Artery Origin and Distal Intracranial Occlusion in Acute Ischemic Stroke.

Background: Tandem occlusion resulting in acute ischemic stroke is associated with high morbidity and mortality and a poor response to thrombolytic therapy. The use of endovascular strategies for tandem stroke cases results in an improved outcome for this subgroup of patients. We present 2 cases with a pattern of tandem occlusion consisting of proximal obstruction at the origin of the common carotid artery (CCA) with concomitant intracranial occlusion treated by endovascular techniques.

Successful Manual Aspiration Thrombectomy in a Pediatric Patient.

Background: Timely recognition of stroke at major pediatric medical centers is improving, and although treatment guidelines for pediatric stroke exist, no extensive study establishing the efficacy of surgical or thrombolytic treatment has been completed. Extrapolation of adult guidelines to pediatric patients remains the mainstay of treatment in the absence of adequate information regarding safety and efficacy in children. Recent trials have demonstrated revascularization and clinical improvement after endovascular retrieval therapy in adults with acute large vessel occlusive stroke.

A Blinded, Case-Control Trial Assessing the Value of Steady State Free Precession Magnetic Resonance Imaging in the Diagnosis of Trigeminal Neuralgia.

Objective: High-resolution magnetic resonance imaging (MRI) may be a useful and readily available adjunct in identifying trigeminal neuralgia secondary to vascular contact (TNVC). This study evaluated the reliability and predictive ability of 1.5-tesla steady state free precession (SSFP) MRI sequences for the diagnosis of symptomatic vascular contact and response to operative intervention in patients with TNVC.

Evaluation of Occipitocervical Arthrodesis Rates with Screw-based Fixation and Osteoinductive Fusion Adjuncts.

Occipitocervical (OC) instability may be associated with neurologic impairment and even death. There is a paucity of research on the rate of arthrodesis utilizing modern screw-based constructs coupled with adjuvant osteoinductive agents. We reviewed our experience with OC constructs and compared the fusion rate, functional outcome, and rate of adverse events between recombinant human bone morphogenetic protein (BMP)-2, autologous iliac crest bone graft (ICBG), a combination of BMP and ICBG, and local bone autograft alone.

Measurement of the glial fibrillary acidic protein and its breakdown products GFAP-BDP biomarker for the detection of traumatic brain injury compared to computed tomography and magnetic resonance imaging.

Glial fibrillary acidic protein and its breakdown products (GFAP-BDP) are brain-specific proteins released into serum as part of the pathophysiological response after traumatic brain injury (TBI). We performed a multi-center trial to validate and characterize the use of GFAP-BDP levels in the diagnosis of intracranial injury in a broad population of patients with a positive clinical screen for head injury. This multi-center, prospective, cohort study included patients 16-93 years of age presenting to three level 1 trauma centers with suspected TBI (loss of consciousness, post-trauma amnesia, and so on).

The multidisciplinary concussion management program.

Over the past decade, research has increased scientific and public knowledge about the importance of identification and proper management of concussion. These concerns have prompted many state, regional, and private organizations to mandate the creation of, and strict adherence to, concussion management protocols, particularly with regard to sport-related concussion and subsequent return to play. Because of the individualized nature of the concussive injury and its recovery, a multidisciplinary approach provides comprehensive patient care that best addresses treatment and management of changing symptoms and their impact on multiple aspects of a patient's life and overall function.

Lifetime attributable risk of cancer from CT among patients surviving severe traumatic brain injury.

Objective: The purpose of this study was to determine the lifetime attributable risk of cancer from CT among patients surviving severe traumatic brain injury.

Materials And Methods: A retrospective cross-sectional study was conducted with prospectively collected data on patients 16 years old and older admitted with a Glasgow coma scale score of 8 or less to a single level 1 trauma center from 2007 to 2010. The effective dose of each CT examination the patients underwent was predicted with literature-accepted effective dose values of standard helical CT protocols.

GFAP-BDP as an acute diagnostic marker in traumatic brain injury: results from the prospective transforming research and clinical knowledge in traumatic brain injury study.

Reliable diagnosis of traumatic brain injury (TBI) is a major public health need. Glial fibrillary acidic protein (GFAP) is expressed in the central nervous system, and breakdown products (GFAP-BDP) are released following parenchymal brain injury. Here, we evaluate the diagnostic accuracy of elevated levels of plasma GFAP-BDP in TBI.

Prospective independent validation of IMPACT modeling as a prognostic tool in severe traumatic brain injury.

Clinical trials in traumatic brain injury (TBI) have been fraught with failure due in part to heterogeneity in pathology and insensitive outcome measurements. The International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) prognostic model has been purposed as a means of risk adjustment and outcome prediction for use in trial design and analysis. The purpose of this study was to evaluate the performance of the IMPACT model in predicting 6-month functional outcome and mortality using prospectively collected data at a large, Level 1 neurotrauma center.

Comparative effectiveness of using computed tomography alone to exclude cervical spine injuries in obtunded or intubated patients: meta-analysis of 14,327 patients with blunt trauma.

Object: The current standard of practice for clearance of the cervical spine in obtunded patients suffering blunt trauma is to use CT and an adjuvant imaging modality (such as MR imaging). The objective of this study was to determine the comparative effectiveness of multislice helical CT alone to diagnose acute unstable cervical spine injury following blunt trauma.

Methods: The authors performed a meta-analysis of studies comparing modern CT with adjunctive imaging modalities and required that studies present acute traumatic findings as well as treatment for unstable injuries.

Premorbid oral antithrombotic therapy and risk for reaccumulation, reoperation, and mortality in acute subdural hematomas.

Object: Acute subdural hematomas (SDHs) impart serious morbidity and mortality on the elderly population, with only 5% of those older than 65 years of age attaining functional independence. Despite its widespread use, oral antithrombotic therapy (OAT) in the context of acute SDH has not been extensively studied. The authors sought to evaluate the impact of premorbid OAT on recurrence of SDH, radiographic outcome, and mortality in patients undergoing surgical evacuation of an acute SDH.

The use of a hybrid dynamic stabilization and fusion system in the lumbar spine: preliminary experience.

Object: The authors report the use and preliminary results of a novel hybrid dynamic stabilization and fusion construct for the surgical treatment of degenerative lumbar spine pathology.

Methods: The authors performed a retrospective chart review of all patients who underwent posterior lumbar instrumentation with the Dynesys-to-Optima (DTO) hybrid dynamic stabilization and fusion system. Preoperative symptoms, visual analog scale (VAS) pain scores, perioperative complications, and the need for subsequent revision surgery were recorded.