BACKGROUND Long-term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms... Show moreBACKGROUND Long-term results from the International Subarachnoid Hemorrhage Trial (ISAT) and Barrow Ruptured Aneurysm Trial (BRAT) indicate considerably higher retreatment rates for aneurysms treated with coiling compared to clipping, but do not report the outcome of retreatment.OBJECTIVE To evaluate retreatment related outcomes.METHODS A meta-analysis in accordance with PRISMA guidelines was conducted using Medline search engines PubMed and EMBASE to identify articles describing outcomes after retreatment for intracranial aneurysms. Pooled prevalence rates for complete occlusion rate and mortality were calculated. Outcomes of different treatment and retreatment combinations were not compared because of indication bias.RESULTS Twenty-five articles that met the inclusion criteria were included in the meta-analysis. Surgery after coiling had a pooled complete occlusion rate of 91.2% (95% confidence interval [CI]: 87.0-94.1) and a pooled mortality rate of 5.6% (95% CI: 3.7-8.3). Coiling after coiling had a pooled complete occlusion rate of 51.3% (95% CI: 22.1-78.0) and a pooled mortality rate of 0.8% (95% CI: 0.15-3.7). Surgery after surgery did not provide a pooled estimate for complete occlusion as only one study was identified but had a pooled mortality rate of 5.9% (95% CI: 3.1-11.2). Coiling after surgery had a pooled complete occlusion rate of 56.1% (95% CI: 11.4-92.7) and a pooled mortality rate of 9.3% (95% CI: 4.1-19.9). All pooled incidence rates were produced using random-effect models.CONCLUSION Surgical retreatment was associated with a high complete occlusion rate but considerable mortality. Conversely, endovascular retreatment was associated with low mortality but also a low complete occlusion rate. Show less
OBJECTIVE Nonroutine discharge after elective spine surgery increases healthcare costs, negatively impacts patient satisfaction, and exposes patients to additional hospital-acquired complications.... Show moreOBJECTIVE Nonroutine discharge after elective spine surgery increases healthcare costs, negatively impacts patient satisfaction, and exposes patients to additional hospital-acquired complications. Therefore, prediction of nonroutine discharge in this population may improve clinical management. The authors previously developed a machine learning algorithm from national data that predicts risk of nonhome discharge for patients undergoing surgery for lumbar disc disorders. In this paper the authors externally validate their algorithm in an independent institutional population of neurosurgical spine patients.METHODS Medical records from elective inpatient surgery for lumbar disc herniation or degeneration in the Transitional Care Program at Brigham and Women's Hospital (2013-2015) were retrospectively reviewed. Variables included age, sex, BMI, American Society of Anesthesiologists (ASA) class, preoperative functional status, number of fusion levels, comorbidities, preoperative laboratory values, and discharge disposition. Nonroutine discharge was defined as postoperative discharge to any setting other than home. The discrimination (c-statistic), calibration, and positive and negative predictive values (PPVs and NPVs) of the algorithm were assessed in the institutional sample.RESULTS Overall, 144 patients underwent elective inpatient surgery for lumbar disc disorders with a nonroutine discharge rate of 6.9% (n = 10). The median patient age was 50 years and 45.1% of patients were female. Most patients were ASA class II (66.0%), had 1 or 2 levels fused (80.6%), and had no diabetes (91.7%). The median hematocrit level was 41.2%. The neural network algorithm generalized well to the institutional data, with a c-statistic (area under the receiver operating characteristic curve) of 0.89, calibration slope of 1.09, and calibration intercept of -0.08. At a threshold of 0.25, the PPV was 0.50 and the NPV was 0.97.CONCLUSIONS This institutional external validation of a previously developed machine learning algorithm suggests a reliable method for identifying patients with lumbar disc disorder at risk for nonroutine discharge. Performance in the institutional cohort was comparable to performance in the derivation cohort and represents an improved predictive value over clinician intuition. This finding substantiates initial use of this algorithm in clinical practice. This tool may be used by multidisciplinary teams of case managers and spine surgeons to strategically invest additional time and resources into postoperative plans for this population. Show less
Gliomas are primary, diffusely infiltrating brain tumors. Microglia are innate immune cells in the CNS and make up a substantial portion of the tumor mass. Glioma cells shape their microenvironment... Show moreGliomas are primary, diffusely infiltrating brain tumors. Microglia are innate immune cells in the CNS and make up a substantial portion of the tumor mass. Glioma cells shape their microenvironment, communicating with and reprogramming surrounding cells, resulting in enhanced angiogenesis, immune suppression, and remodeling of the extracellular matrix. Glioma cells communicate with microglia, in part by releasing extracellular vesicles (EVs). Mouse glioma cells stably expressing a palmitoylated GFP to label EVs were implanted intracranially into syngeneic miR-21-null mice. Here, we demonstrate functional delivery of miR-21, regulating specific downstream mRNA targets in microglia after uptake of tumor-derived EVs. These findings attest to EV-dependent microRNA delivery as studied in an in vivo-based model and provide insight into the reprograming of microglial cells by tumor cells to create a favorable microenvironment for cancer progression. Show less
Glioblastoma cells release extracellular vesicles (EVs), sometimes referred to as microvesicles and exosomes, to transfer immune modulating molecules to immune cells, resulting in an immune... Show moreGlioblastoma cells release extracellular vesicles (EVs), sometimes referred to as microvesicles and exosomes, to transfer immune modulating molecules to immune cells, resulting in an immune privileged microenvironment. Here we discuss the potential EV-mediated mechanisms underlying glioma immune modulation, as well as the technical difficulties in studying these interactions. Show less
Neurosurgical interventions frequently occur in an emergency setting. In this setting, patients often have impaired consciousness and are unable to directly express their values and wishes... Show moreNeurosurgical interventions frequently occur in an emergency setting. In this setting, patients often have impaired consciousness and are unable to directly express their values and wishes regarding their treatment. The limited time available for clinical decision making has great ethical implications, as the informed consent procedure may become compromised. The ethical situation may be further challenged by different views between the patient, family members, and the neurosurgeon; the presence of advance directives; the use of an innovative procedure; or if the procedure is part of a research project. This moral opinion piece presents the implications of time constraints and a lack of patient capacity for autonomous decision making in emergency neurosurgical situations. Potential solutions to these challenges are presented that may help to improve ethical patient management in emergency settings. Emergency neurosurgery challenges the respect of autonomy of the patient. The outcome in most scenarios will rely on the neurosurgeon acting in a professional way to manage each unique situation in an ethically sound manner. Show less
