Faculty Bibliography

BACKGROUND:Outcomes for octogenarians and nonagenarians after an aneurysmal subarachnoid hemorrhage (aSAH) are particularly ominous, with mortality rates well above 50%. The present analysis examines the neurologic outcomes of patients ≥ 80 years of age treated for aSAH. METHOD:A retrospective review was performed of all aSAH patients treated at Barrow Neurological Institute from January 1, 2003, to July 31, 2019. Patients were placed in 2 groups by age, < 80 vs ≥ 80 years. The ≥ 80-year-old group of octogenarians and nonagenarians was subsequently analyzed to compare treatment modalities. Poor neurologic outcome was defined as a modified Rankin Scale (mRS) score of > 2. RESULTS: = 0.929, p < 0.001). Forty-three patients ≥ 80 years old were significantly more likely to be managed endovascularly than with open microsurgery (67% [n = 29] vs 33% [n = 14], p < 0.001). Compared with younger patients, those ≥ 80 years old had an increased risk of mortality and poor neurologic outcomes at follow-up. In the ≥ 80-year-old group, only 4 patients had good outcomes; none of the 4 had preexisting comorbidities, and all 4 were treated endovascularly. CONCLUSIONS:Age is a significant prognostic indicator of functional outcomes and mortality after aSAH. Most octogenarians and nonagenarians with aSAH will become severely disabled or die.

OBJECTIVE:Ophthalmic artery (OA) aneurysms are surgically challenging lesions that are now mostly treated using endovascular procedures. However, in specialized tertiary care centers with experienced neurosurgeons, controversy remains regarding the optimal treatment of these lesions. This study used propensity adjustment to compare microsurgical and endovascular treatment of unruptured OA aneurysms in experienced tertiary and quaternary settings. METHODS:The authors retrospectively reviewed the medical records of all patients who underwent microsurgical treatment of an unruptured OA aneurysm at the University of California, San Francisco, from 1997 to 2017 and either microsurgical or endovascular treatment at Barrow Neurological Institute from 2011 to 2019. Patients were categorized into two cohorts for comparison: those who underwent open microsurgical clipping, and those who underwent endovascular flow diversion or coil embolization. Outcomes included neurological or visual outcomes, residual or recurrent aneurysms, retreatment, and severe complications. RESULTS:A total of 345 procedures were analyzed: 247 open microsurgical clipping procedures (72%) and 98 endovascular procedures (28%). Of the 98 endovascular procedures, 16 (16%) were treated with primary coil embolization and 82 (84%) with flow diversion. After propensity adjustment, microsurgical treatment was associated with higher odds of a visual deficit (OR 8.5, 95% CI 1.1-64.9, p = 0.04) but lower odds of residual aneurysm (OR 0.06, 95% CI 0.01-0.28, p < 0.001) or retreatment (OR 0.12, 95% CI 0.02-0.58, p = 0.008) than endovascular therapy. No difference was found between the two cohorts with regard to worse modified Rankin Scale score, modified Rankin Scale score greater than 2, or severe complications. CONCLUSIONS:Compared with endovascular therapy, microsurgical clipping of unruptured OA aneurysms is associated with a higher rate of visual deficits but a lower rate of residual and recurrent aneurysms. In centers experienced with both open microsurgical and endovascular treatment of these lesions, the treatment choice should be based on patient preference and aneurysm morphology.

BACKGROUND:Owing to prolonged hospitalization and the complexity of care required for patients with aneurysmal subarachnoid hemorrhage (aSAH), these patients have a high risk of complications. The risk for wound infection after microsurgical treatment for aSAH was analyzed. METHODS:All patients who underwent microsurgical treatment for aSAH between August 1, 2007, and July 31, 2019, and were recorded in the Post-Barrow Ruptured Aneurysm Trial database were retrospectively reviewed. The patients were analyzed for risk factors for wound infection after treatment. RESULTS:Of 594 patients who underwent microsurgical treatment for aSAH, 23 (3.9%) had wound infections. There was no significant difference in age between patients with wound infection and patients without infection (mean, 52.6 ± 12.2 years vs. 54.2 ± 4.0 years; P = 0.45). The presence of multiple comorbidities (including diabetes, tobacco use, and obesity), external ventricular drain, ventriculoperitoneal shunt, pneumonia, or urinary tract infection was not associated with an increased risk for wound infection. Furthermore, there was no significant difference in mean operative time between patients with wound infection and those without infection (280 ± 112 minutes vs. 260 ± 92 minutes; P = 0.38). Patients who required decompressive craniectomy (DC) were at increased risk of wound infection (odds ratio, 5.0; 95% confidence interval, 1.8-14.1; P = 0.002). Among the 23 total infections, 9 were diagnosed following cranioplasty after DC. CONCLUSIONS:Microsurgical treatment for aSAH is associated with a relatively low risk of wound infection. However, patients undergoing DC may be at an increased risk for infection. Additional attention and comprehensive wound care are warranted for these patients.

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BACKGROUND/PURPOSE/OBJECTIVE:The prevalence of intracranial aneurysms, as well as the incidence of subarachnoid hemorrhage (SAH), increase with age, and the elderly have poor outcomes after SAH. Age is a key factor in the unruptured intracranial aneurysm treatment score (UIATS),but the sensitivity of the UIATS model in detecting risk of SAH among the elderly is unknown. METHODS:We retrospectively analyzed 153 consecutive cases of ruptured aneurysms between 2012 and 2018. We used Fisher's exact test, analysis of variance, and multivariate logistic regression to compare outcomes between those >65 years of age and those younger. We then applied the UIATS model and evaluated the sensitivity of the model as a predictor of SAH in the elderly compared with younger patients. RESULTS:Elderly patients made up 32% (n = 49 of 153) of our cohort. They had significantly higher in-hospital mortality (19 of 49, 39%) than younger patients (14 of 104, 13%) (P < 0.01). In a multivariate logistic regression, controlling for Hunt-Hess grade and comorbidities, age >65 years remained a significant predictor of unfavorable outcome at discharge (P = 0.03). The UIATS model had low sensitivity in the elderly compared with younger patients: 63% (59 of 136) of younger patients would have been recommended aneurysm repair had their aneurysm been detected unruptured, compared with only 12% (5 of 42) of elderly patients >65 years (P < 0.01). CONCLUSIONS:Elderly patients >65 years in age have far worse outcomes after SAH. The sensitivity of the UIATS model for detecting those at risk of SAH was significantly lower in elderly patients. The UIATS model may lead to undertreatment of elderly patients at risk of SAH.

BACKGROUND:Transradial artery (TRA) access for neuroendovascular procedures is associated with fewer complications than transfemoral artery (TFA) access. This study compares hospital costs associated with TRA access to those associated with TFA access for neurointerventions. METHODS:Elective neuroendovascular procedures at a single center were retrospectively analyzed from October 1, 2018 to May 31, 2019. Hospital costs for each procedure were obtained from the hospital financial department. The primary outcome was the difference in the mean hospital costs after propensity adjustment between patients who underwent TRA compared with TFA access. RESULTS:Of the 338 elective procedures included, 63 (19%) were performed through TRA versus 275 (81%) through TFA access. Diagnostic procedures were more common in the TRA cohort (51 of 63, 81%) compared with the TFA cohort (197 of 275, 72%), but the difference was not significant (p=0.48). The TRA cohort had a shorter length of hospital stay (mean (SD) 0.3 (0.5) days) compared with the TFA cohort (mean 0.7 (1.3) days; p=0.02) and lower hospital costs (mean $12 968 ($6518) compared with the TFA cohort (mean $17 150 ($10 946); p=0.004). After propensity adjustment for age, sex, symptoms, angiographic findings, procedure type, sheath size, and catheter size, TRA access was associated with a mean hospital cost of $2514 less than that for TFA access (95% CI -$4931 to -$97; p=0.04). CONCLUSION/CONCLUSIONS:Neuroendovascular procedures performed through TRA access are associated with lower hospital costs than TFA procedures. The lower cost is likely due to a decreased length of hospital stay for TRA.

OBJECTIVE:Sporadic brain arteriovenous malformation (BAVM) is a tangled vascular lesion characterized by direct artery-to-vein connections that can cause life-threatening intracerebral hemorrhage (ICH). Recently, somatic mutations in KRAS have been reported in sporadic BAVM, and mutations in other mitogen-activated protein kinase (MAPK) signaling pathway genes have been identified in other vascular malformations. The objectives of this study were to systematically evaluate somatic mutations in MAPK pathway genes in patients with sporadic BAVM lesions and to evaluate the association of somatic mutations with phenotypes of sporadic BAVM severity. METHODS:The authors performed whole-exome sequencing on paired lesion and blood DNA samples from 14 patients with sporadic BAVM, and 295 genes in the MAPK signaling pathway were evaluated to identify genes with somatic mutations in multiple patients with BAVM. Digital droplet polymerase chain reaction was used to validate KRAS G12V and G12D mutations and to assay an additional 56 BAVM samples. RESULTS:The authors identified a total of 24 candidate BAVM-associated somatic variants in 11 MAPK pathway genes. The previously identified KRAS G12V and G12D mutations were the only recurrent mutations. Overall, somatic KRAS G12V was present in 14.5% of BAVM lesions and G12D was present in 31.9%. The authors did not detect a significant association between the presence or allelic burden of KRAS mutation and three BAVM phenotypes: lesion size (maximum diameter), age at diagnosis, and age at ICH. CONCLUSIONS:The authors confirmed the high prevalence of somatic KRAS mutations in sporadic BAVM lesions and identified several candidate somatic variants in other MAPK pathway genes. These somatic variants may contribute to understanding of the etiology of sporadic BAVM and the clinical characteristics of patients with this condition.

OBJECTIVE:The incidence and severity of stroke are disproportionately greater among Black patients. In this study, the authors sought to examine clinical outcomes among Black versus White patients after mechanical thrombectomy for stroke at a single US institution. METHODS:All patients who underwent mechanical thrombectomy at a single center from January 1, 2014, through March 31, 2020, were retrospectively analyzed. Patients were grouped based on race, and demographic characteristics, preexisting conditions, clinical presentation, treatment, and stroke outcomes were compared. The association of race with mortality was analyzed in multivariable logistic regression analysis adjusted for potential confounders. RESULTS:In total, 401 patients (233 males) with a reported race of Black (n = 28) or White (n = 373) underwent mechanical thrombectomy during the study period. Tobacco use was more prevalent among Black patients (43% vs 24%, p = 0.04), but there were no significant differences between the groups with respect to insurance, coronary artery disease, diabetes, illicit drug use, hypertension, or hyperlipidemia. The mean time from stroke onset to hospital presentation was significantly greater among Black patients (604.6 vs 333.4 minutes) (p = 0.007). There were no differences in fluoroscopy time, procedural success (Thrombolysis in Cerebral Infarction grade 2b or 3), hospital length of stay, or prevalence of hemicraniectomy. In multivariable analysis, Black race was strongly associated with higher mortality (32.1% vs 14.5%, p = 0.01). The disparity in mortality rates resolved after adjusting for the average time from stroke onset to presentation (p = 0.14). CONCLUSIONS:Black race was associated with an increased risk of death after mechanical thrombectomy for stroke. The increased risk may be associated with access-related factors, including delayed presentation to stroke centers.

BACKGROUND:Transradial artery (TRA) catheterization for neuroendovascular procedures is associated with a lower risk of complications than transfemoral artery (TFA) procedures. However, the majority of literature on TRA access pertains to diagnostic procedures rather than interventional treatments. OBJECTIVE:To compare TRA and TFA approaches for cerebrovascular interventions. METHODS:All patients with an endovascular intervention performed at a single center from October 1, 2018 to December 31, 2019 were retrospectively analyzed. Patients were grouped into 2 cohorts on the basis of whether TRA or TFA access was used. Outcomes included complications, fluoroscopy times, and total contrast administered. RESULTS:A total 579 interventional treatments were performed during the 15-mo study period. TFA procedures (n = 417) were associated with a significantly higher complication rate than TRA (n = 162) procedures (43 cases [10%] vs 5 cases [3%]; P = .008). After excluding patients who underwent thrombectomy and performing a propensity adjustment (including age, sex, pathology, procedure, sheath size, and catheter size), TRA catheterization was associated with decreased odds of a complication (odds ratio, 0.25; 95% CI 0.085-0.72; P = .01), but no significant difference in the amount of contrast administered (6.7-mL increase; 95% CI, -7.2 to 20.6; P = .34) or duration of fluoroscopy (2.1-min increase; 95% CI, -2.5 to 6.7; P = .37) compared with TFA catheterization. CONCLUSION/CONCLUSIONS:Neurointerventional procedures and treatments for a variety of pathologies can be performed successfully using the TRA approach, which is associated with a lower risk of complications and no difference in fluoroscopy duration compared with the TFA approach.