Neurosurgery
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The "Volume Pledge" aims to centralize carotid artery stenting (CAS) to hospitals and surgeons performing ≥10 and ≥5 procedures annually, respectively. ⋯ Most patients receive CAS by hospitals and providers meeting the Volume Pledge threshold for CAS. Surgeons but not hospitals who met the policy's volume standards were associated with superior outcomes across all measured outcomes.
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Poor natural history of hemorrhagic Moyamoya disease (MMD) is related to high rehemorrhage rates between 32% and 61%. Postrevascularization, rehemorrhage rates reportedly decrease to 12% to 17%. ⋯ Rehemorrhage rate following surgical revascularization of the hemorrhagic MMD patients at 7.7% is lower compared with much higher natural history rates. Surgical revascularization improved patients' performance status. These outcomes support performing revascularization procedure with a preference for direct STA-MCA bypasses.
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Traditional moyamoya disease (MMD) classification relies on morphological digital subtraction angiography (DSA) assessment, which do not reflect hemodynamic status, clinical symptoms, or surgical treatment outcome. ⋯ The Berlin MMD grading system is able to stratify preoperative hemispheric symptomatology. Furthermore, it correlated with postoperative new ischemic changes on MRI, and showed a strong trend in predicting clinical postoperative stroke.
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Stereotactic radiosurgery (SRS) is a common treatment modality for vestibular schwannoma (VS), with a role in primary and recurrent/progressive algorithms. At our institution, routine magnetic resonance imaging (MRI) is obtained at 6 and 12 mo following SRS for VS. ⋯ For clinically stable VS, 6-mo post-SRS MRI does not contribute significantly to management. We recommend omitting routine MRI before 12 mo, in patients without new or progressive neurological symptoms. If extrapolated nationally to the more than 100 active SRS centers, thousands of patients would be spared an inconvenient, nonindicated study, and national savings in health care dollars would be on the order of millions annually.
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Whether delayed cerebral infarction (DCIn) after aneurysmal subarachnoid hemorrhage (aSAH) is driven by large artery vasospasm is still controversial. ⋯ The necessary association between severe vasospasm and DCIn in our study brings additional arguments in favor of large artery vasospasm (especially of distal segments) as a major determinant of DCIn and a potential therapeutic target.