Planchard, Ryan

Background: Cerebral microbleeds (CMB) incidentally found during an MRI evaluation of ischemic stroke present a therapeutic dilemma. Case control studies suggest a relationship of cerebral microbleeds and intracerebral hemorrhage. Limited prospective studies of patients with ischemic stroke show variability in whether CMB hemorrhage rates are greater than recurrent ischemic stroke rates. Our aim was to determine the prevalence and characteristics of CMB in patients with atrial fibrillation presenting with stroke and secondly what the rate of prospective intracerebral hemorrhage (ICH) was in those same patients. Methods: Consecutive patients admitted with atrial fibrillation and stroke were identified in our institution’s Get with the Guideline database between 2008-2009. Data from the incident hospitalization included: demographic information, use of antithrombotic and/or anticoagulation, and cerebrovascular risk factors. Radiologic imaging was reviewed to determine if a GRE or SWI sequence was included and record the number and location of CMB. Follow up information was obtained by chart review and written survey or phone call. Death certificates were obtained where applicable. Results: 240 patients were identified, 128 of whom had a CT only and 112 who had an MRI. Of those with an MRI, 76 had GRE or SWI sequences. Twenty-one of 76 patients with a GRE or SWI sequence had a CMB (prevalence: 27.6%). One patient in the CMB (+) group had a prospective hemorrhage during an average follow up of 3 years (rate: 0.33 ICH per patient year of follow up). No patients in the CMB negative group had an ICH. Conclusions: Our study demonstrates the prevalence of cerebral microbleeds is much higher than the actual prospective hemorrhage rate. The prospective hemorrhage rate is low and consistent with findings from large, randomized anticoagulation studies in patients with atrial fibrillation.

Study Design Retrospective study. Objective This study reviews 1,768 consecutive cervical decompressions with or without instrumented fusion to identify patient-specific and procedural risk factors significantly correlated with the development of delayed cervical palsy (DCP). Methods Baseline demographic and procedural information was collected from the electronic medical record. Particular attention was devoted to reviewing each chart for recognized risk factors of postsurgical inflammatory neuropathy: autoimmune disease, blood transfusions, diabetes, and smoking. Results Of 1,669 patients, 56 (3.4%) developed a DCP. Although 71% of the palsies involved C5, 55% of palsies were multimyotomal and 18% were bilateral. Significant risk factors on univariate analysis included age ( p = 0.0061, odds ratio [OR] = 1.07, 95% confidence interval [CI] 1.008 to 1.050), posterior instrumented fusion ( p < 0.0001, OR = 3.30, 95% CI 1.920 to 5.653), prone versus semisitting/sitting position ( p = 0.0036, OR = 3.58, 95% CI 1.451 to 11.881), number of operative levels ( p < 0.0001, OR = 1.42, 95% CI 1.247 to 1.605), intraoperative transfusions ( p = 0.0231, OR = 2.57, 95% CI 1.152 to 5.132), and nonspecific autoimmune disease ( p = 0.0107, OR = 3.83, 95% CI 1.418 to 8.730). On multivariate analysis, number of operative levels ( p = 0.0053, OR = 1.27, 95% CI 1.075 to 1.496) and nonspecific autoimmune disease ( p = 0.0416, OR 2.95, 95% CI 1.047 to 7.092) remained significant. Conclusions Although this study partially supports a mechanical etiology in the pathogenesis of a DCP, we also describe a notable correlation with autoimmune risk factors. Bilateral and multimyotomal involvement provides additional support that some DCPs may result from an inflammatory response and thus an underlying multifactorial etiology for this complication.

Study Design Retrospective case series. Objective To determine the effect of obesity on the resource utilization and cost in 3270 consecutive patients undergoing elective noninstrumented decompressive surgeries for degenerative spine disease at Mayo Clinic Rochester between 2005 and 2012. Methods Groups were assessed for baseline differences (age, gender, and American Society of Anesthesiologists [ASA] classification, procedure type, and number of operative levels). Outcome variables included the transfusion requirements during surgery, the total anesthesia and surgical times, intensive care unit (ICU) admissions, standardized costs, as well as the ICU and hospital length of stay (LOS). Regression analysis was used to evaluate for strength of association between obesity and outcome variables. Results Baseline differences between the groups (nonobese: n = 1,853; obese: n = 1,417) were found with respect to age, ASA class, gender, procedure type, and number of operative levels. After correcting for differences, we found significant associations between obesity and surgical ( p < 0.0001) and anesthesia times ( p < 0.0001) and hospital LOS ( p < 0.0001). Additionally, ICU admission rates ( p = 0.02) and requirement for postoperative ventilation ( p = 0.048) were significantly higher in obese patients. Finally, mean difference in total cost ($1,632, p < 0.0001) was significantly higher for the obese cohort. Conclusion Obesity is associated with increased resource utilization and cost in patients undergoing a noninstrumented decompressive surgery for degenerative spine disease.