Tag: Predictors

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Outcomes After Standardized Burr-Hole Surgery for Chronic Subdural Hematomas: A Population-Based Consecutive Cohort Study of 2655 Patients

Neurosurgery 97:298–309, 2025

This large population-based study of 2655 chronic subdural hematoma patients treated with mostly single burr-hole craniotomy found an 11% recurrence and complication rate, 12% 1-year mortality, and identified male sex, diabetes, antithrombotic use, midline shift, and bilateral surgery as independent recurrence predictors.

• Large cohort study (n=2655) analyzed outcomes after standardized burr-hole craniotomy (BHC) for chronic subdural hematoma (CSDH) at a single center (2006–2022).

• Reoperation for hematoma recurrence occurred in 11% of patients, with most recurrences happening within 23 days.

• Independent predictors of recurrence included male sex, diabetes, preoperative antithrombotic therapy, midline shift, and bilateral hematomas.

• Postoperative complications occurred in 11% (3.9% moderate-to-severe); urinary tract infections, subdural empyema, and seizures were most common.

• 1-year postoperative mortality was 12%.

• Higher Charlson Comorbidity Index and lower Glasgow Coma Scale score were independent predictors of moderate-to-severe complications.

• Minicraniotomy was used in 9.3% of cases, with similar recurrence but slightly higher complication rates compared to BHC.

• Predictive models for recurrence and complications had low performance, suggesting other unmeasured factors are important.

 

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Pediatric Vagus Nerve Stimulation: Case Series Outcomes and Future Directions

Neurosurgery 92:1043–1051, 2023

Vagus nerve stimulation (VNS) is a neuromodulatory procedure most extensively studied as an adjunct to medically refractory epilepsy. Despite widespread adoption and decades of clinical experience, clinical predictors of response to VNS remain unclear. OBJECTIVE: To evaluate a retrospective cohort of pediatric patients undergoing VNS at our institution to better understand who may benefit from VNS and identify factors which may predict response to VNS.

METHODS: We conducted a retrospective cohort study examining pediatric patients undergoing VNS over nearly a 20-year span at a single institution. Presurgical evaluation, including demographics, clinical history, and diagnostic electroencephalogram, and imaging findings were examined. Primary outcomes included VNS response.

RESULTS: Two hundred ninety-seven subjects were studied. The mean age at surgery was 10.1 (SD = 4.9, range = 0.8-25.3) years; length of follow-up was a mean of 4.6 years (SD = 3.5, median = 3.9 years, range 1 day-16.1 years). There was no association between demographic factors, epilepsy etiology, or genetic basis and VNS outcomes. There was an association between reduction in main seizure type with positive MRI finding. Of all MRI findings analyzed, brain atrophy was significantly associated with worse VNS outcomes, whereas dysplastic hippocampus and chronic periventricular leukomalacia findings were found to be associated with improved outcomes. Increased seizure semiology variability and seizure type were also associated with improved seizure outcomes.

CONCLUSION: Predicting response to VNS remains difficult, leading to incompletely realized benefits and suboptimal resource utilization. Specific MRI findings and increased seizure semiology variability and type can help guide clinical decision making and patient counseling.

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Shunt Failure—The First 30 Days

Neurosurgery 87:123–129, 2020

Incontrovertible predictors of shunt malfunction remain elusive.

OBJECTIVE: To determine predictors of shunt failure within 30 d of index surgery.

METHODS: This was a single-center retrospective cohort study from January 2010 through November 2016. Using a ventricular shunt surgery research database, clinical and procedural variables were procured. An “index surgery” was defined as implantation of a new shunt or revision or augmentation of an existing shunt system. The primary outcome was shunt failure of any kind within the first 30 days of index surgery. Bivariate models were created, followed by a final multivariable logistic regression model using a backward-forward selection procedure.

RESULTS: Our dataset contained 655 unique patients with a total of 1206 operations. The median age for the cohort at the time of first shunt surgery was 4.6 yr (range, 0-28; first and third quartile, .37 and 11.8, respectively). The 30-day failure rates were 12.4% when analyzing the first-index operation only (81/655), and 15.7% when analyzing all-index operations (189/1206). Small or slit ventricles at the time of index surgery and prior ventricular shunt operations were found to be significant covariates in both the “first-index” (P < .01 and P=.05, respectively) and “all-index”(P=.02 and P<.01, respectively) multivariable models. Intraventricular hemorrhage at the time of index surgery was an additional predictor in the all-index model (P = .01).

CONCLUSION: This study demonstrates that only 3 variables are predictive of 30-day shunt failure when following established variable selection procedures, 2 of which are potentially under direct control of the surgeon.

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Pain Outcomes Following Microvascular Decompression for Drug-Resistant Trigeminal Neuralgia: A Systematic Review and Meta-Analysis

Neurosurgery, Volume 86, Issue 2, February 2020, Pages 182–190

Microvascular decompression (MVD) is a potentially curative surgery for drug-resistant trigeminal neuralgia (TN). Predictors of pain freedom after MVD are not fully understood. OBJECTIVE: To describe rates and predictors for pain freedom following MVD.

METHODS: Using preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines, PubMed, Cochrane Library, and Scopus were queried for primary studies examining pain outcomes after MVD for TN published between 1988 and March 2018. Potential biases were assessed for included studies. Pain freedom (ie, Barrow Neurological Institute score of 1) at last follow-up was the primary outcome measure. Variables associated with pain freedom on preliminary analysis underwent formal meta-analysis. Odds ratios (OR) and 95% confidence intervals (CI) were calculated for possible predictors.

RESULTS: Outcome data were analyzed for 3897 patients from 46 studies (7 prospective, 39 retrospective). Overall, 76.0% of patients achieved pain freedom afterMVD with amean follow-up of 1.7 ± 1.3 (standard deviation) yr. Predictors of pain freedom on meta-analysis using random effectsmodels included (1) disease duration≤5 yr (OR=2.06, 95% CI=1.08- 3.95); (2) arterial compression over venous or other (OR = 3.35, 95% CI = 1.91-5.88); (3) superior cerebellar artery involvement (OR = 2.02, 95% CI = 1.02-4.03), and (4) type 1 Burchiel classification (OR = 2.49, 95% CI = 1.32-4.67).

CONCLUSION: Approximately three-quarters of patients with drug-resistant TN achieve pain freedom after MVD. Shorter disease duration, arterial compression, and type 1 Burchiel classification may predict more favorable outcome. These results may improve patient selection and provider expectations.

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Lumbar drain trial outcomes of normal pressure hydrocephalus: a single-center experience of 254 patients

J Neurosurg 132:306–312, 2020

A short-term lumbar drain (LD) trial is commonly used to assess the response of normal pressure hydrocephalus (NPH) patients to CSF diversion. However, it remains unknown whether the predictors of passing an LD trial match the predictors of improvement after ventriculoperitoneal shunting. The aim of this study was to examine outcomes, complication rates, and associations between predictors and outcomes after an LD trial in patients with NPH.

METHODS The authors retrospectively reviewed the records of 254 patients with probable NPH who underwent an LD trial between March 2008 and September 2017. Multivariate regression models were constructed to examine predictors of passing the LD trial. Complications associated with the LD trial procedure were recorded.

RESULTS The mean patient age was 77 years and 56.7% were male. The mean durations of gait disturbance, cognitive decline, and urinary incontinence were 29 months, 32 months, and 28 months, respectively. Of the 254 patients, 30% and 16% reported objective and subjective improvement after the LD trial, respectively. Complications included a sheared LD catheter, meningitis, lumbar epidural abscess, CSF leak at insertion site, transient lower extremity numbness, slurred speech, refractory headaches, and hyponatremia. Multivariate analyses using MAX-R revealed that a prior history of stroke predicted worse outcomes, while disproportionate subarachnoid spaces (uneven enlargement of supratentorial spaces) predicted better outcomes after the LD trial (r2 = 0.12, p < 0.05).

CONCLUSIONS The LD trial is generally safe and well tolerated. The best predictors of passing the LD trial include a negative history of stroke and having disproportionate subarachnoid spaces.

 

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Frontal Lobe Epilepsy Surgery in Childhood and Adolescence: Predictors of Long-Term Seizure Freedom, Overall Cognitive and Adaptive Functioning

Neurosurgery 83:93–103, 2018

Although frontal lobe resections account for one-third of intralobar resections in pediatric epilepsy surgery, there is a dearth of information regarding long-term seizure freedom, overall cognitive and adaptive functioning.

OBJECTIVE: To identify outcome predictors and define the appropriate timing for surgery.

METHODS: We retrospectively analyzed the data of 75 consecutive patients aged 10.0 ± 4.9 yr at surgery that had an 8.1 yr mean follow-up.

RESULTS: Etiology comprised focal cortical dysplasia (FCD) in 71% and benign tumors in 16% cases. All patients but one had a magnetic resonance imaging-visible lesion. At last follow-up, 63% patients remained seizure-free and 37% had discontinued antiepileptic drugs. Presurgical predictors of seizure freedom were a shorter epilepsy duration, strictly regional epileptic discharges in electroencephalography (EEG), and an epileptogenic zone and/or lesion distant fromeloquent cortex. Postsurgical predictorswere the completeness of resection and the lack of early postoperative seizures or epileptic discharges in EEG. Higher presurgical overall cognitive and adaptive functioning was related to later epilepsy onset and to a sublobar epileptogenic zone and/or lesion. Following surgery, scores remained stable in themajority of patients. Postsurgical gains were determined by higher presurgical performance and tumors vs FCD.

CONCLUSION: Our findings highlight the favorable long-term outcomes following frontal lobe epilepsy surgery in childhood and adolescence and underline the importance of early surgical intervention in selected candidates. Early postsurgical relapses and epileptic discharges in EEG constitute key markers of treatment failure and should prompt timely reevaluation. Postsurgical overall cognitive and adaptive functioning is stable in most patients, whereas those with benign tumors have higher chances of improvement.

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Predictors of an unfavorable outcome 1.5 and 12 years after a first, uncomplicated lumbar disc surgery

How to predict return to work after lumbar discectomy- answers from the NeuroPoint-SD registry

Eur Spine J (2016) 25:3520–3527

To identify predictors of both intermediate and long-term unfavorable outcomes after first time, uncomplicated lumbar disc surgery.

Methods Patients (n = 120) who had undergone lumbar disc surgery were followed up 1.5 and 12 years thereafter. Baseline assessments were carried out 5–8 days after surgery. Clinical outcome was assessed in both follow-ups using the Low Back Pain Rating Scale. Statistical analysis included binary logistic and linear regression.

Results Unfavorable outcomes were found in 50.5 % (1.5 years) and 52.6 % (12 years) of patients available for follow-up examination. Low pre-operative physical activity and severe pain in the first week after surgery were predictive of an unfavorable post-operative outcome at both follow-ups.

Conclusions Identified predictors suggest that particular emphasis should put on comprehensive post-operative care at large and encouragement to adapt a physically active lifestyle in particular in rehabilitation concepts after first time uncomplicated lumbar disc surgery.

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Microsurgical unilateral laminotomy for decompression of lumbar spinal stenosis

Microsurgical unilateral laminotomy for decompression of lumbar spinal stenosis

Acta Neurochir (2016) 158:1103–1113

The microsurgical unilateral laminotomy (MUL) technique for bilateral decompression of lumbar spinal stenosis (LSS) is a less destabilizing alternative to laminectomy and leads to good short-term outcomes. However, little is known about the long-term results including predictive factors.

Methods: Medical records of patients who underwent MUL for LSS decompression between 2005 and 2010 were reviewed, and a questionnaire was distributed to complement the long-term outcome data. The study population consisted of 176 patients including 17 patients with stable grade I spondylolisthesis. Complications and reoperations were meticulously analyzed. Clinical outcome was measured using a modified Prolo scale and was further dichotomized in good vs. poor outcome. Predictive factors were obtained from uni- and multivariate analyses.

Results: The median age of the cohort was 70.0 years and the follow-up 71.7 months. Complications occurred in 5.1%of the patients. The overall reoperation rate was 17.0 %, including surgery, which was exclusively performed at other levels in 4.0 %. The reoperation rate for fusion was 4.5 %. Good neurogenic claudication outcome faded from 98.3 % at hospital discharge to 47.2 % at 6 years. Multivariate analysis identified previous lumbar operation as a potential independent predictor of a reoperation; potential independent predictors of poor longterm claudication outcome were older age, female gender, higher body mass index (BMI) and tobacco smoking.

Conclusions: In our experience, the long-term reoperation rate after MUL for LSS is not negligible and higher in previously operated patients. It seems like the good initial clinical results after MUL may fade over time, and several patient-related predictive factors including potentially modifiable obesity and tobacco smoking seem to play an important role.

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Delayed Facial Palsy After Vestibular Schwannoma Resection

vestibular-schwannoma

Neurosurgery 78:251–255, 2016

Preservation of facial nerve function following vestibular schwannoma surgery is a high priority. Even those patients with normal to near-normal function in the early postoperative period remain at risk for delayed facial palsy (DFP).

OBJECTIVE: To evaluate the incidence and prognosis of DFP and to identify risk factors for its occurrence.

METHODS: A retrospective cohort study of 489 patients who underwent vestibular schwannoma resection at our institution between 2000 and 2014. Delayed facial palsy was defined as deterioration in facial function of at least 2 House-Brackmann (HB) grades between postoperative days 5 to 30. Only patients with a HB grade of I to III by postoperative day 5 were eligible for study inclusion.

RESULTS: One hundred twenty-one patients with HB grade IV to VI facial weakness at postoperative day 5 were excluded from analysis. Of the remaining 368, 60 (16%) patients developed DFP (mean 12 days postoperatively, range: 5-25 days). All patients recovered function to HB grade I to II by a mean of 33 days (range: 7-86 days). Patients that developed DFP had higher rates of gross total resections (83% vs 71%, P = .05) and retrosigmoid approaches (72% vs 52%, P, .01). There was no difference in recovery time between patients who received treatment with steroids, steroids with antivirals, or no treatment at all (P = .530).

CONCLUSION: Patients with a gross total tumor resection or undergoing a retrosigmoid approach may be at higher risk of DFP. The prognosis is favorable, with patients likely recovering to normal or near-normal facial function within 1 month of onset.

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A clinical prediction model to assess surgical outcome in patients with cervical spondylotic myelopathy

A clinical prediction model to assess surgical outcome in patients with cervical spondylotic myelopathy

The Spine Journal 15 (2015) 388–397

Clinical prediction rules are valuable tools in a surgical setting but should not be used to guide clinical practice until validated in other populations.

PURPOSE: The objective of this study was to validate a clinical prediction rule developed to determine surgical outcome in patients with cervical spondylotic myelopathy (CSM). The study will also identify key clinical predictors of outcome at a global level.

STUDY DESIGN/SETTING: This is a prospective multicenter cohort study.

PATIENT SAMPLE: Two-hundred seventy-eight and 479 surgical CSM patients enrolled in the AOSpine CSM—North American (CSM-NA) and CSM—International (CSM-I) studies, respectively.

OUTCOME MEASURES: The outcome measure was a Modified Japanese Orthopedic Association (mJOA) Scale.

METHODS: A clinical prediction model was built using data from 272 patients enrolled in the CSM-NA study. Bootstrapping was used for internal validation. The original model was externally validated using data on 471 patients participating in the CSM-I study. The predictive performance of the model was evaluated, including its discrimination, measured by area under the receiver operating curve (AUC), and calibration, assessed by calibration slope, observed: expected ratios, and Hosmer-Lemeshow goodness-of-fit test.

RESULTS: The modified original model consisted of six covariates: age (odds ratio [OR], 0.96), duration of symptoms (0.76), baseline severity score (1.21), psychiatric comorbidities (0.44), impairment of gait (2.48), and smoking status (0.50). The AUC for the original model was 0.77 (95% confidence interval [CI]: 0.71, 0.82) and across the bootstrap replicates was 0.77 (95% CI: 0.76, 0.77), reflecting good discrimination and internal validity. The model tested on the CSM-I dataset yielded an AUC of 0.74 (95% CI: 0.69, 0.79), a calibration slope of 0.75, and an insignificant Hosmer-Lemeshow test. The ORs generated for baseline mJOA (OR, 1.26), impairment of gait (2.67), age (0.97), and smoking (0.55) were very similar to the original values of 1.28, 2.39, and 0.97, respectively. Duration of symptoms (OR, 0.94) had a significantly different odds ratio than in the original model, but the direction of its relationship with outcome was the same. Psychiatric comorbidities was not a significant predictor at an international level, likely because of underreporting: only six patients outside of North American centers were diagnosed with depression or bipolar.

CONCLUSIONS: The parameter estimates generated from the original analysis were internally valid. The original model was also externally valid. The most significant global predictors of surgical outcome were baseline myelopathy severity, age, smoking status and impaired gait.

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Which Variables Help Explain the Poor Health-Related Quality of Life After Subarachnoid Hemorrhage? A Meta-analysis

Neurosurgery 66:772-783, 2010. DOI: 10.1227/01.NEU.0000367548.63164.B2
Patients with subarachnoid hemorrhage (SAH) are younger than typical stroke patients. Poor psychosocial outcome after SAH therefore leads to a disproportionately high impact on patients, relatives, and society. Addressing this problem requires an understanding of what causes poor psychosocial outcome. Numerous studies have examined potential predictors but produced conflicting results. We aim to resolve this uncertainty about the potential value of individual predictors by conducting a meta-analysis. This approach allows us to quantitatively combine the findings from all relevant studies to identify promising predictors of psychosocial outcome and determine the strength with which those predictors are associated with measures of psychosocial health.
METHODS: Psychosocial health was measured by health-related quality of life (HRQOL). We included in our analysis those predictors that were most frequently examined in this context, namely patient age, sex, neurologic state at the time of hospital admission, bleed severity, physical disability, cognitive impairment, and time between ictus and psychosocial assessment.
RESULTS: Only 1 of the traditional variables, physical disability, had any notable affect on HRQOL. Therefore, the cause of most HRQOL impairment after SAH remains unknown. The situation is even worse for mental HRQOL, an area that is often significantly affected in SAH patients. Here, 90% of the variance remains unexplained by traditional predictors.
CONCLUSION: Studies need to turn to new factors to account for poor patient outcome.

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