Faculty Bibliography

INTRODUCTION: It is known that physicians sometimes recommend treatment that, in a similar clinical scenario, they might not choose for themselves. We sought to understand this dynamic across cerebrovascular practice and examine how neurosurgeons value the procedures they offer. METHODS: We conducted an online survey sent to a large cohort of neurosurgeons in May 2013. Respondents were randomised to answer either as the surgeon or as the patient. The questions involved patients presenting with 1) an epidural hematoma (control), 2) un-ruptured anterior communicating artery aneurysm, 3) incidentally found right temporal AVM, 4) spontaneous intracranial and intraventricular haemorrhage in deep structure. Data on practice parameters and experience levels was also collected. RESULTS: We obtained 534 survey responses, 279 responding as the "neurosurgeon", and 255 as the "patient," with a response rate of 19.7%. Demographics amongst the two groups of survey takers was similar. There was no difference in the management of an epidural hematoma, as expected. For the unruptured aneurysm, the rates of opting for treatment was similar amongst respondees. However within the treatment group there was a trend for survey takers to more often chose coiling for themselves and clipping for patients (p = 0.056). Surgeons, however, with a greater than 30% open-cerebrovascular practice had less of a tendency to do so. For arteriovenous malformation management, there was no statistical difference between choosing treatment or conservative management. However, amongst the respondees who chose treatment, more respondees chose resection/embolization for their patient but radiosurgery for self (p = 0.001). In a case of a large spontaneous intracranial and intraventricular haemorrhage neurosurgeons were more likely to place a ventricular drain in a patient than himself or herself. Neurosurgeons in practice more than 10 years since residency were more likely to recommend against interventions for aneurysms, AVMs or intracranial haemorrhage. CONCLUSIONS: In the majority of cases altering the role of the surgeon did not change the decision to pursue treatment or conservative treatment. In certain clinical scenarios, however, neurosurgeons choose treatment options for themselves that are different than what they would choose for their patients. For the management of an arteriovenous malformations, intracranial aneurysms, and hypertensive haemorrhage, responses favored less invasive interventions when the surgeon was the patient. These findings are likely a result of cognitive biases, previous training, experience, areas of expertise, and personal values. DISCLOSURES: O. Tanweer: None. T. Wilson: None. S. Kalhorn: None. J. Golfinos: None. P. Huang: None. D. Kondziolka: None.

SUMMARY:Does the world need another ICA classification scheme? We believe so. The purpose of proposed angiography-driven classification is to optimize description of the carotid artery from the endovascular perspective. A review of existing, predominantly surgically-driven classifications is performed, and a new scheme, based on the study of NYU aneurysm angiographic and cross-sectional databases is proposed. Seven segments - cervical, petrous, cavernous, paraophthlamic, posterior communicating, choroidal, and terminus - are named. This nomenclature recognizes intrinsic uncertainty in precise angiographic and cross-sectional localization of aneurysms adjacent to the dural rings, regarding all lesions distal to the cavernous segment as potentially intradural. Rather than subdividing various transitional, ophthalmic, and hypophyseal aneurysm subtypes, as necessitated by their varied surgical approaches and risks, the proposed classification emphasizes their common endovascular treatment features, while recognizing that many complex, trans-segmental, and fusiform aneurysms not readily classifiable into presently available, saccular aneurysm-driven schemes, are being increasingly addressed by endovascular means. We believe this classification may find utility in standardizing nomenclature for outcome tracking, treatment trials and physician communication.

BACKGROUND: Extracranial-intracranial (EC-IC) bypass and intracranial stenting (ICS) are both revascularization procedures that have emerged as treatment options for intracranial atherosclerotic disease (ICAD). This study describes and compares recent trends in utilization and outcomes of intracranial revascularization procedures in the United States using a population-based cohort. It also investigates the association of ICS and EC-IC bypass with periprocedural morbidity and mortality, unfavorable discharge status, length of stay (LOS), and total hospital charges. METHODS: The National Inpatient Sample (NIS) was queried for patients with ICAD who underwent EC-IC bypass or ICS during the years 2004-2010. Patient characteristics, demographics, perioperative complications, outcomes, and discharge data were collected. RESULTS: There were 627 patients who underwent ICS and 249 patients who underwent EC-IC bypass. Patients who underwent ICS were significantly older (P < 0.001) with more comorbidities (P = 0.027) than those who underwent EC-IC bypass. Patients who underwent EC-IC bypass experienced higher rates of postprocedure stroke (P = 0.014), but those who underwent ICS experienced higher rates of death (P = 0.006). Among asymptomatic patients, the rates of postprocedure stroke (P = 0.341) and death (P = 0.887) were similar between patients who underwent ICS and those who underwent EC-IC bypass. Among symptomatic patients, however, there was a higher rate of postprocedure stroke in patients who underwent EC-IC bypass (P < 0.001) and a higher rate of death among patients who underwent ICS (P = 0.015). CONCLUSION: The ideal management of patients with ICAD cannot yet be defined. Although much data from randomized and prospective trials on revascularization have been collected, many questions remain unanswered. There still remain cohorts of patients, specifically patients who have failed aggressive medical management, where not enough evidence is available to dictate decision-making. In order to further elucidate the safety and efficacy of these intracranial revascularization procedures, further clinical trials are needed.

BACKGROUND: Flexion-extension radiographs are often used to assess for removal of the cervical collar in the setting of trauma. The objective of this study was to evaluate their adequacy. We hypothesized that a significant proportion is inadequate. METHODS: This was a retrospective review of C-spine clearance at a level 1 trauma center. A trauma-trained radiologist interpreted all flexion-extension radiographs for adequacy. Studies performed within 7 days of injury were considered acute. RESULTS: Three hundred fifty-five flexion-extension radiographs were examined. Ninety-five percent% of these studies were inadequate (51% because of the inability to visualize the top of T1, whereas 44% had less than 30 degrees of angulation from neutral). Two hundred ten studies were performed acutely; of these, 97% were inadequate. When performed 7 days or longer from injury, 91% were inadequate. CONCLUSIONS: Injury to the C-spine may harbor significant consequences; therefore, its proper evaluation is critical. The majority of flexion-extension films are inadequate. As such, they should not be included in the algorithm for removal of the cervical collar. If used, adequacy must be verified and supplemental radiographic studies obtained as indicated.

Object Patients undergoing placement of an external ventricular drain (EVD) are at increased risk for development of venous thromboembolisms (VTEs). Early chemical prophylaxis has been shown to decrease rates of embolism formation, but the risks for bleeding and the optimal time to initiate prophylaxis have not been clearly defined for this patient population. The authors evaluated the safety and risks for bleeding when chemical prophylaxis for VTEs was started within 24 hours of EVD placement. Methods To compare rates of hemorrhage among patients who received prophylaxis within 24 hours and those who received it later than 24 hours after admission, the authors conducted an institutional review board-approved retrospective review. Patients were those who had had an EVD placed and postprocedural imaging conducted at Bellevue Hospital, New York, from January 2009 through April 2012. Data collected included demographics, diagnosis, coagulation panel results, time to VTE prophylaxis and imaging, and occurrence of VTEs. The EVD-associated hemorrhages were classified as Grade 0, no hemorrhage; Grade 1, petechial hyperdensity near the drain; Grade 2, hematoma of 1-15 ml; Grade 3, epidural or subdural hematoma greater than 15 ml; or Grade 4, intraventricular hemorrhage or hematoma requiring surgical intervention. Results Among 99 patients, 111 EVDs had been placed. Low-dose unfractionated heparin had been given within 24 hours of admission (early prophylaxis) to 56 patients and later than 24 hours after admission (delayed prophylaxis) to 55 patients. There were no statistical differences across all grades (0-4) among those who received early prophylaxis (n = 45, 5, 5, 1, and 0, respectively) and those who received delayed prophylaxis (n = 46, 4, 1, 1, and 3, respectively) (p = 0.731). In the early prophylaxis group, 3 VTEs were discovered among 32 of 56 patients screened for clinically suspected VTEs. In the delayed prophylaxis group, 5 VTEs were discovered among 33 of 55 patients screened for clinically suspected VTEs (p = 0.71). Conclusions Hemorrhagic complications did not increase when chemical prophylaxis was started within 24 hours of admission. Also, the incidence of VTEs did not differ between patients in the early and delayed prophylaxis groups. Larger randomized controlled trials are probably needed to assess decreases in VTEs with earlier prophylaxis.

The anti-cytotoxic T-lymphocyte-associated antigen 4 (CTLA-4) monoclonal antibody ipilimumab has been shown to improve survival in patients with metastatic non-CNS melanoma. The purpose of this study was to investigate the efficacy of CTLA-4 inhibitors in the treatment of metastatic melanoma with limited brain metastases treated with stereotactic radiosurgery (SRS). Between January 2008 and June 2011, 58 patients with limited brain metastases from melanoma were treated with SRS with a median dose of 20 Gy delivered to the 50% isodose line (range, 15-20 Gy). In 25 patients, ipilimumab was administered intravenously at a dose of 3 mg/kg over 90 min every 3 weeks for a median of four doses (range, 1-8). Local control (LC), freedom from new brain metastases, and overall survival (OS) were assessed from the date of the SRS procedure. The median LC, freedom from new brain metastases, and OS for the entire group were 8.7, 4.3, and 5.9 months, respectively. The cause of death was CNS progression in all but eight patients. Six-month LC, freedom from new brain metastases, and OS were 65, 35, and 56%, respectively, for those who received ipilimumab and 63, 47, and 46% for those who did not (P=NS). Intracranial hemorrhage was noted in seven patients who received ipilimumab compared with 10 patients who received SRS alone (P=NS). In this retrospective study, administration of ipilimumab neither increased toxicity nor improved intracerebral disease control in patients with limited brain metastases who received SRS.

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) syndrome is classified under trigeminal autonomic cephalalgias. This rare headache syndrome is infrequently associated with secondary pathologies. In this paper the authors report on a patient with paroxysmal left retroorbital pain with associated autonomic symptoms of ipsilateral conjunctival injection and lacrimation, suggestive of SUNCT syndrome. After failed medical treatment an MRI sequence was obtained in this patient, demonstrating an epidermoid tumor in the left cerebellopontine angle. The patient's symptoms completely resolved after a gross-total resection of the tumor. This case demonstrates the effectiveness of resection as definitive treatment for SUNCT syndrome associated with tumoral compression of the trigeminal nerve. Early MRI studies should be considered in all patients with SUNCT, especially those with atypical signs and symptoms.