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Deshaies E.M.,Crouse Neuroscience Institute | Deshaies E.M.,Syracuse University | Villwock M.R.,Crouse Neuroscience Institute | Singla A.,University of Florida | And 2 more authors.
Journal of Visualized Experiments

Less invasive surgical approaches for intracranial aneurysm clipping may reduce length of hospital stay, surgical morbidity, treatment cost, and improve patient outcomes. We present our experience with a minimally invasive pterional approach for anterior circulation aneurysms performed in a major tertiary cerebrovascular center and compare the results with an aged matched dataset from the Nationwide Inpatient Sample (NIS). From August 2008 to December 2012, 22 elective aneurysm clippings on patients ≤55 years of age were performed by the same dual fellowshiptrained cerebrovascular/endovascular neurosurgeon. One patient (4.5%) experienced transient post-operative complications. 18 of 22 patients returned for follow-up imaging and there were no recurrences through an average duration of 22 months. A search in the NIS database from 2008 to 2010, also for patients aged ≤55 years of age, yielded 1,341 hospitalizations for surgical clip ligation of unruptured cerebral aneurysms. Inpatient length of stay and hospital charges at our institution using the minimally invasive thumb-sized pterional technique were nearly half that of NIS (length of stay: 3.2 vs 5.7 days; hospital charges: $52,779 vs. $101,882). The minimally invasive thumb-sized pterional craniotomy allows good exposure of unruptured small and medium-sized supraclinoid anterior circulation aneurysms. Cerebrospinal fluid drainage from key subarachnoid cisterns and constant bimanual microsurgical techniques avoid the need for retractors which can cause contusions, localized venous infarctions, and post-operative cerebral edema at the retractor sites. Utilizing this set of techniques has afforded our patients with a shorter hospital stay at a lower cost compared to the national average. © 2015 Journal of Visualized Experiments. Source

Deshaies E.M.,Crouse Neuroscience Institute | Singla A.,University of Florida | Allott G.,New York University | Villwock M.R.,Crouse Neuroscience Institute | And 2 more authors.
Neurodiagnostic Journal

General anesthesia prohibits neurological examination during embolization of cerebrovascular malformations when provocative testing prior to pedicle occlusion is needed. Intraoperative neurophysiological monitoring (IONM) has the potential to fill this gap but remains relatively unexplored. We conduct a retrospective review of consecutive patients with cerebrovascular malformations treated with Onyx® (ethylene vinyl alcohol copolymer, dissolved in dimethyl sulfoxide) embolization under general anesthesia with IONM from 2009 to 2012. Somatosensory evoked potentials (SSEPs), transcranial motor evoked potentials (TcMEPs), visual evoked potential (VEPs), auditory brainstem response (ABR), and electroencephalography (EEG) were used selectively in all patients depending on the location of the malformation. Provocative testing combined with IONM was performed in 28 patients over 75 sessions. Three patients demonstrated changes in TcMEPs or ABR during provocative testing, which halted the planned embolization. Two patients demonstrated changes in baseline SSEPs after embolization, despite normal IONM during provocative testing, correlating with postprocedural contralateral weakness. Six patients developed visual deficits after arterial occlusion despite unchanged VEPs and occipital EEG during provocative testing and embolization. We therefore conclude that the sensitivity of TcMEPs and SSEPs is preferable to EEG, and we strongly caution against relying on occipital recorded VEPs to predict visual deficits. © ASET - The Neurodiagnostic Society. Source

Villwock M.R.,Crouse Neuroscience Institute | Singla A.,University of Florida | Padalino D.J.,New York University | Ramaswamy R.,New York University | Deshaies E.M.,Crouse Neuroscience Institute
Clinical Neurology and Neurosurgery

Objective There is debate concerning the optimum timing of revascularization for emergent admissions of carotid artery stenosis with infarction. Our intent was to stratify clinical and economic outcomes based on the timing of revascularization. Methods We performed a retrospective cohort study using the Nationwide Inpatient Sample from 2002 to 2011. Patients were included if they were admitted non-electively with a primary diagnosis of carotid artery stenosis with infarction and subsequently treated with revascularization. Cases were stratified into four groups based upon the timing of revascularization: (1) within 48-h of admission, (2) between 48-h and day four of hospitalization, (3) between days five and seven, and (4) during the second week of admission. Results 27,839 cases met our inclusion criteria. The lowest odds of iatrogenic complications (OR = 0.643, P <.001) and mortality (OR = 0.631, P <.001) coincided with revascularization between days five and seven of hospitalization. Treatment with carotid artery stenting (CAS) and administration of recombinant tissue plasminogen activator (rtPA) increased the odds of complications and death. With regards to economic measures, administration of rtPA and utilization of CAS drove cost and length-of-stay up, while lower co-morbidity burden and earlier time to revascularization drove both measures down. Conclusions The present study suggests that the optimum timing of revascularization may be near the end of the first week of hospitalization following acute stroke. However, this study must be cautioned with limitations including its inability to control for critical disease specific variables including symptom severity and degree of stenosis. Prospective examination seems warranted. © 2014 Elsevier B.V. Source

Villwock J.A.,SUNY Upstate Medical University | Villwock M.R.,Crouse Neuroscience Institute | Goyal P.,Syracuse Otolaryngology | Deshaies E.M.,Crouse Neuroscience Institute

Objectives/Hypothesis The goals of pituitary tumor resection include normalizing endocrine function, relieving mass effect, and minimizing risk of recurrence. This study investigated current trends in costs and complications for transfrontal and transsphenoidal pituitary surgery. Study Design Retrospective review of the 2008-2011 Nationwide Inpatient Sample for patients undergoing pituitary lesion resection. Methods Demographics and outcomes were compared between transfrontal and transsphenoidal surgical approaches using χ2 tests. Multivariate analysis was performed to investigate outcomes while controlling for confounders. Results There were 8,543 admissions for resection of pituitary lesions that met our inclusion criteria. Most (>90%) were treated transsphenoidally. The transfrontal approach was most frequent in the young (<35 years) and in the South. Rates of mortality and complications were higher in patients undergoing transfrontal surgery. Multivariate analysis found transsphenoidal resection was associated with a reduction in hospital costs and length of stay by over 50%; low-volume hospitals had increased cost and length of stay. There was an increased rate of transfrontal approaches at low-volume centers. Conclusions Multiple factors influence outcomes of pituitary tumor resection. Transsphenoidal pituitary surgery is associated with a shorter length of stay, lower cost, and lower complication rates when compared to transfrontal surgery. Case specifics, including tumor location and size, influence approach and lead to a selection bias that cannot be controlled for in the present study. The prevalence of transfrontal resections at low-volume centers may indicate an area of further investigation. Additionally, when controlling for surgical approach, low-volume centers were found to adversely affect economic outcomes and also warrants investigation. Level of Evidence 2c. © 2014 The American Laryngological, Rhinological and Otological Society, Inc. Source

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