Rinaldo, Lorenzo

Abstract BACKGROUND Flow diversion (FD) is effective for treatment of intracranial internal carotid artery (ICA) aneurysms. OBJECTIVE To determine whether carotid siphon (CS) geometry influences the efficacy of FD when employed for ICA aneurysms. METHODS Outcomes of a consecutive series of patients with ICA aneurysms treated with FD were retrospectively reviewed. CS anatomy was quantified through measurement of the posterior, anterior, and anterosuperior bend angles in accordance with previously described methodology. The relationship of CS geometry to likelihood of incomplete aneurysm occlusion at 1 yr after treatment was assessed with multivariate logistic regression analysis. RESULTS There were 167 ICA aneurysms in 164 patients treated with FD during the study period. The mean age of our cohort was 55.7 yr (standard deviation [SD]: 12.3) and a majority of patients were female (145/164, 86.8%). Anterior (47.4 degrees vs 8.5, P < .001) and anterosuperior bend angles (100.9 vs 76.5, P = .002) were significantly greater in aneurysms that required repeat FD after initial treatment. On multivariate logistic regression analysis, increasing patient age (unit odds ratio [OR]: 1.05, 95% confidence interval [CI] 1.01-1.08; P = .003) and anterior bend angle ≥–3.5 (OR: 2.47, 95% CI 1.04-5.86; P = .046) were associated with increased odds of incomplete aneurysm occlusion at 1 yr after treatment. CONCLUSION These findings suggest that variations in CS anatomy may influence the efficacy of FD treatment and should be analyzed prior to offering FD for treatment of ICA aneurysms. Further investigation into the hemodynamic effects of CS geometry is warranted.

OBJECTIVEClinical trials forming the basis of current guidelines for the management of intracranial aneurysms have relied on patient-reported modified Rankin Scale (mRS) scores to assess functional outcome. The effect of patient demographics on perception of disability and, by extension, patient-reported mRS score, is not well understood.METHODSA consecutive series of patients with a previously treated or untreated unruptured intracranial aneurysm (UIA) prospectively underwent a structured interview with a trained nurse. At the conclusion of this interview, the patients were assigned an mRS score in accordance with their degree of disability. During the same visit, patients were also required to grade themselves on a paper sheet containing the mRS and corresponding information. Data on patient and aneurysm characteristics were also collected during the same visit. Agreement between patient- and nurse-reported mRS scores was assessed using Cohen’s kappa coefficient. The effect of patient demographics on the frequency of higher patient- than nurse-reported mRS scores was assessed using the Pearson’s chi-square and Fisher’s exact tests.RESULTSA total of 209 patients with a UIA were included in the study, 38 of whom (18.2%) had undergone previous treatment. The majority of patients were female (161/209, 77.0%), and the mean age of the cohort was 60.2 years (SD 13.7 years). Agreement between patient- and nurse-reported mRS scores occurred in 72.7% of cases (95% CI 66.3%–78.3%), with a kappa coefficient of 0.58 (95% CI 0.49–0.67). Patients younger than 75 years were more likely to report a higher mRS score than the nurse (19.4% vs 3.4%, p = 0.034). Among female patients, those without a college degree were more likely to report a higher mRS score than the nurse (22.5% vs 9.5%, p = 0.035).CONCLUSIONSThe results suggest that patient demographics may influence perception of disability. These findings should be considered when using patient-reported mRS scores to determine functional outcome.

Abstract BACKGROUND Increased body mass index (BMI) may be protective against cerebral ischemia in certain clinical contexts. OBJECTIVE To investigate whether increased BMI was associated with delayed cerebral ischemia (DCI) and subsequent infarction after aneurysmal subarachnoid hemorrhage (aSAH). METHODS We retrospectively reviewed the clinical course of patients presenting to our institution for management of aSAH. Patient were segregated according to BMI< or ≥29.4, a value determined by Classification and Regression Tree analysis. Predictors of DCI and delayed infarction were identified using stepwise multivariate logistic regression analysis. RESULTS There were 161 patients included for analysis. Average BMI within our patient cohort was 28.9, with 67 patients presenting with a BMI of ≥29.4 on admission. DCI occurred in 50 patients (31.1%) and was complicated by delayed infarction in 15 patients (9.3%). On stepwise multivariate analysis, BMI ≥ 29.4 was independently associated with reduced likelihood of DCI (odds ratio [OR] 0.42, 95% confidence interval [CI] 0.18-0.92) and delayed infarction (OR 0.13, 95% CI 0.02-0.61; P = .008). Increasing maximum flow velocity on transcranial Doppler ultrasound was independently associated with increased odds of both DCI (Unit OR 1.19, 95% CI 1.09-1.30; P < .001) and delayed infarction (Unit OR 1.31, 95% CI 1.13-1.56; P < .001), while intracerebral hemorrhage was independently associated with increased odds of delayed infarction (OR 6.99, 95% CI 1.82-30.25; P = .005). CONCLUSION We report an association between elevated BMI and reduced incidence of DCI and delayed infarction, suggesting a protective effect of increasing BMI on the risk of ischemic complications after aSAH.

OBJECTIVEIt has been suggested that increased body mass index (BMI) may confer a protective effect on patients who suffer from aneurysmal subarachnoid hemorrhage (aSAH). Whether the modality of aneurysm occlusion influences the effect of BMI on patient outcomes is not well understood. The authors aimed to compare the effect of BMI on outcomes for patients with aSAH treated with surgical clipping versus endovascular coiling.METHODSThe authors retrospectively reviewed the outcomes for patients admitted to their institution for the management of aSAH treated with either clipping or coiling. BMI at the time of admission was recorded and used to assign patients to a group according to low or high BMI. Cutoff values for BMI were determined by classification and regression tree analysis. Predictors of poor functional outcome (defined as modified Rankin Scale score > 2 measured ≥ 90 days after the ictus) and posttreatment cerebral hypodensities detected during admission were then determined separately for patients treated with clipping or coiling using stepwise multivariate logistic regression analysis.RESULTSOf the 469 patients admitted to the authors’ institution with aSAH who met the study’s inclusion criteria, 144 were treated with clipping and 325 were treated with coiling. In the clipping group, the frequency of poor functional outcome was higher in patients with BMI ≥ 32.3 kg/m2 (47.6% vs 19.0%; p = 0.007). In contrast, in the coiling group, patients with BMI ≥ 32.3 kg/m2 had a lower frequency of poor functional outcome at ≥ 90 days (5.8% vs 30.9%; p < 0.001). On multivariate analysis, high BMI was independently associated with an increased (OR 3.92, 95% CI 1.20–13.41; p = 0.024) and decreased (OR 0.13, 95% CI 0.03–0.40; p < 0.001) likelihood of poor functional outcome for patients treated with clipping and coiling, respectively. For patients in the surgical group, BMI ≥ 28.4 kg/m2 was independently associated with incidence of cerebral hypodensities during admission (OR 2.44, 95% CI 1.16–5.25; p = 0.018) on multivariate analysis. For patients treated with coiling, BMI ≥ 33.2 kg/m2 was independently associated with reduced odds of hypodensities (OR 0.45, 95% CI 0.21–0.89; p = 0.021).CONCLUSIONSThe results of this study suggest that BMI may differentially affect functional outcomes after aSAH, depending on treatment modality. These findings may aid in treatment selection for patients with aSAH.

IN BRIEF Diabetes has been associated with the incidence of back pain. However, the relationship between markers of diabetes progression and back pain has not been studied. The objective of this study was to correlate clinical and laboratory measures of diabetes disease severity to the presence of back pain to provide insight into the relationship between these conditions. Findings showed that markers of diabetes disease progression were associated with the presence of back pain, suggesting that uncontrolled diabetes may contribute to the development of chronic back pain.