Faculty Bibliography

OBJECTIVE:Liver cirrhosis is associated with an increased risk of aneurysmal subarachnoid hemorrhage (aSAH). However, large studies analyzing the prognosis of cirrhotic patients after aSAH treatment are lacking. This study explores factors associated with inpatient mortality among aSAH patients with cirrhosis. METHODS:All patients who underwent open or endovascular treatment for an aSAH at a large quaternary center between January 1, 2003, and July 31, 2019, were retrospectively reviewed. Patients were grouped into cirrhosis versus noncirrhosis groups. Univariate analysis determined variables associated with inpatient mortality. Variables with P < 0.20 were included in a propensity-adjusted multivariable logistic regression analysis to predict inpatient mortality. RESULTS:A total of 1419 patients were treated for aSAH; 17 (1.2%) had confirmed cirrhosis. Inpatient mortality was significantly higher among cirrhotic patients than noncirrhotic patients (35.3% vs. 6.8%; P < 0.001). In the univariate analysis for inpatient mortality, the variables cirrhosis, age >65 years, Charlson Comorbidity Index >4, aneurysm size ≥10 mm, Hunt and Hess grade >3, Fisher grade 4, delayed cerebral ischemia (DCI), and posterior circulation aneurysm had P < 0.20 and were included in the multivariable analysis. The propensity-adjusted stepwise multivariable logistic regression analysis showed that cirrhosis (odds ratio [OR]: 12.7, 95% confidence interval [CI]: 3.3-48.7), Hunt and Hess grade >3 (OR: 3.9, 95% CI: 2.3-6.4), Fisher grade 4 (OR: 3.7, 95% CI: 1.3-10.7), and DCI (OR: 2.4, 95% CI: 1.5-3.9) were associated with inpatient mortality (P ≤ 0.01). CONCLUSIONS:Cirrhosis was a predictor of inpatient mortality among aSAH patients and was a stronger predictor than DCI or a poor Hunt and Hess grade among patients in this study.

Calcification of intracranial aneurysms is a well-known phenomenon. Whether microsurgical or endovascular techniques are used, calcifications may increase the difficulty of treatment. However, the implications of calcification on aneurysm biology and stability have received little attention. We review both investigational and clinical methods that are used to detect aneurysmal calcification. We also discuss the pathophysiology of aneurysm calcification, specifically the role that inflammation and smooth muscle cells play. We finally turn our attention to the clinical implications of aneurysm calcification including rupture risk and treatment considerations. Calcification may represent an important feature in the life cycle of an aneurysm and as imaging methods continue to improve, we may yet discover a biomarker for this process.

Despite advances in endovascular techniques, microsurgery continues to play an important role in the treatment of cerebral aneurysms. This article reviews the history of surgical treatment of intracranial aneurysms and the evolving role of microsurgery in the endovascular era. Although endovascular tools and techniques have changed significantly since the placement of the first Guglielmi coils in 1990, with the development of endoluminal flow-diverting stents and now endosaccular flow-diverting devices, microsurgical treatment of aneurysms has also continued to evolve. Since the first treatment with Hunterian ligation by Horsley in the 1800s, surgical treatment of intracranial aneurysms has advanced significantly beginning with the introduction of the microscope and microsurgical techniques in the 1950s. More recent advances in microsurgical treatment of aneurysms include microsurgical adjuncts, such as indocyanine green angiography, adenosine, and the exoscope, as well as tailored craniotomies, retractorless surgery, and novel bypass constructs for complex aneurysms. Microsurgery continues to play an important role in the endovascular era.

With the rapid advancements in endovascular therapy over previous decades, the treatment of spinal arteriovenous malformations (AVMs) continues to evolve. The decision to use endovascular versus surgical therapy largely depends on the type of lesion and its anatomic location. Recent studies demonstrate that endovascular treatment is effective for extradural arteriovenous fistulas (AVFs), intradural ventral (perimedullary) AVMs, and intramedullary spinal AVMs. Treatment of intradural dorsal (dural) AVFs remains largely surgical because of lower recurrence rates, although recent studies demonstrate equivocal outcomes. Extradural-intradural (juvenile) AVMs and conus AVMs remain difficult-to-treat lesions.

BACKGROUND:Nationwide study results have suggested varying trends in the incidence of aneurysmal subarachnoid hemorrhage (aSAH) over time. Herein, trends over time for aSAH treated at a quaternary care center are compared with low-volume hospitals. METHODS:Cases were retrospectively reviewed for patients with aSAH treated at our institution. Trend analyses were performed on the number of aSAH hospitalizations, treatment type, Charlson Comorbidity Index (CCI), Hunt and Hess grade, aneurysm location, aneurysm type, and in-hospital mortality. The National Inpatient Sample (NIS) was queried to compare the CCI scores of our patients with those of patients in low-volume hospitals (<20 aSAH/year) in our census division. RESULTS: = 0.220, P = 0.24). Mean (standard deviation) CCI for small-volume hospitals treating aSAH within our division was significantly lower than that of our patient population (1.8 [1.6] vs 2.1 [2.0]) for 2012-2015. CONCLUSIONS:A decreasing number of patients were hospitalized with aSAH throughout the study. Compared with patients with aSAH admitted in 2004, those admitted more recently were sicker in terms of preexisting comorbidity and neurologic complexity. These trends could be attributable to the increasing availability of neurointerventional services at smaller-volume hospitals capable of treating healthier patients.

BACKGROUND:Transradial arterial access (TRA) for cerebral diagnostic angiography is associated with fewer access site complications than transfemoral access (TFA). However, concerns about increased procedure time and radiation exposure with TRA may slow its adoption. Our objective was to measure TRA rates of success and fluoroscopy time per vessel after 'radial-first' adoption and to compare these rates to those obtained with TFA. METHODS:We examined 500 consecutive cerebral angiograms on an intent-to-treat basis during the first full year of radial-first adoption, recording patient and procedural characteristics and outcomes. RESULTS:Over a 9-month period at a single center, 457 of 500 angiograms (91.4%) were performed with intent-to-treat via TRA, and 431 cases (86.2%) were ultimately performed via TRA. One patient (0.2%) experienced a temporary neurologic deficit in the TRA group, and none (0%) did in the TFA group (p=0.80). The mean±SD fluoroscopy time per vessel decreased significantly from the first half of the study to the second half for TRA (5.0±3.8 vs 3.4±3.5 min/vessel; p<0.001), while TFA time remained unchanged (3.7±1.8 vs 3.5±1.4 min/vessel; p=0.69). The median fluoroscopy time per vessel for TRA became faster than that for TFA after 150 angiograms. CONCLUSION/CONCLUSIONS:Of 500 consecutive angiograms performed during the first full year of radial-first implementation, 86.2% were performed successfully using TRA. TRA efficiency exceeded that of TFA after 150 angiograms. Concerns about the length of procedure or radiation exposure should not be barriers to TRA adoption.

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.