OBJECTIVE The growth characteristics of vestibular schwannomas (VSs) under surveillance can be studied using a Bayesian method of growth risk stratification by time after surveillance onset, allowing dynamic evaluations of growth risks. There is no consensus on the optimum surveillance strategy in terms of frequency and duration, particularly for long-term growth risks. In this study, the long-term conditional probability of new VS growth was reported for patients after 5 years of demonstrated nongrowth. This allowed modeling of long-term VS growth risks, the creation of an evidence-based surveillance protocol, and the proposal of a cost-benefit analysis decision aid. METHODS The authors performed an international multicenter retrospective analysis of prospectively collected databases from five tertiary care referral skull base units. Patients diagnosed with sporadic unilateral VS between 1990 and 2010 who had a minimum of 10 years of surveillance MRI showing VS nongrowth in the first 5 years of follow-up were included in the analysis. Conditional probabilities of growth were calculated according to Bayes’ theorem, and nonlinear regression analyses allowed modeling of growth. A cost-benefit analysis was also performed. RESULTS A total of 354 patients were included in the study. Across the surveillance period from 6 to 10 years postdiagnosis, a total of 12 tumors were seen to grow (3.4%). There was no significant difference in long-term growth risk for intracanalicular versus extracanalicular VSs (p = 0.41). At 6 years, the residual conditional probability of growth from this point onward was seen to be 2.28% (95% CI 0.70%–5.44%); at 7 years, 1.35% (95% CI 0.25%–4.10%); at 8 years, 0.80% (95% CI 0.07%–3.25%); at 9 years, 0.47% (95% CI 0.01%–2.71%); and at 10 years, 0.28% (95% CI 0.00%–2.37%). Modeling determined that the remaining lifetime risk of growth would be less than 1% at 7 years 7 months, less than 0.5% at 8 years 11 months, and less than 0.25% at 10 years 4 months. CONCLUSIONS This multicenter study evaluates the conditional probability of VS growth in patients with long-term VS surveillance (6–10 years). On the basis of these growth risks, the authors posited a surveillance protocol with imaging at 6 months (t = 0.5), annually for 3 years (t = 1.5, 2.5, 3.5), twice at 2-year intervals (t = 5.5, 7.5), and a final scan after 3 years (t = 10.5). This can be used to better inform patients of their risk of growth at particular points along their surveillance timeline, balancing the risk of missing late growth with the costs of repeated imaging. A cost-benefit analysis decision aid was also proposed to allow units to make their own decisions regarding the cessation of surveillance.

N/A

Background and Issues: Transitions between stroke coordinators can have a deleterious effect upon stroke program development and operations. Typically, a one-month notice of resignation is given. This allows insufficient time to advertise, interview, hire and train or orient new staff. Complicating the issue, the number of experienced stroke coordinators has not kept pace with demand. Hence, extensive training may be required for the replacement if one with experience is not available. Purpose: The purpose of our project was to prepare for a seamless transition between a retiring stroke coordinator and her replacement while maintaining quality and adding neurovascular intervention to the program. Methods: Our facility provides a phased-retirement program that allows gradual transition between full time employment and retirement. In July 2009, a eighty percent stroke coordinator position was split between a coordinator mentee and the experienced coordinator mentor. Over an eighteen-month period, responsibilities were gradually shifted to the replacement with ongoing education, guidance and support from the previous coordinator. For the first six months, orientation and coaching took place on an almost daily basis. Over the following year, progressive periods were planned for independent program management with available backup and support Results: A cerebrovascular intervention program was successfully implemented during the period. Primary Stroke Center Certification was maintained. Compliance with stroke performance measures did not decrease. The Get with the Guidelines Gold Plus Award was received for 2009, 2010 and 2011. Acute stroke treatment rates increased due to program enhancements and improvements during the period. Conclusions: This planned, progressive approach to program leadership transition allowed sufficient training for the replacement coordinator. At the conclusion of the process, the mentee stepped into the full-time position. This seamless transition provided for successful program operations and development.

Background/Issue: Practitioners do not have clear guidelines on when to restart antihypertensive medications in an AIS patient with pre-existing diagnosis hypertension. The current guidelines by the American Heart Association states to restart antihypertensive medications within 24 hours of AIS is relatively safe especially in patients with pre-existing hypertension and who are neurologically stable(Class IIa; Level B). Currently there are no set guidelines for providers to follow for blood pressure control or what point during the admission the blood pressure should be treated. Purpose: The purpose of study was to review the current practice for providers caring for AIS patients and when antihypertensive medications were restarted. Methods: A retrospective cohort study of 240 charts was reviewed from a five hospital campuses during the months of May and June 2013. Inclusion criteria included for the study consisted of discharge diagnosis of ischemic stroke, pre-existing diagnosis of hypertension, and the patients was prescribed antihypertensive medications prior to admission. Charts were reviewed for: when home antihypertensive medication regimen was restarted, if the antihypertensive medication was held, and if so, was there a documented reason. Exclusion criteria consisted of: diagnosis of hypertension prior to admission, but the patient was not on any medication; or newly diagnosis of hypertension. Results: Of the 240 charts reviewed, 49 patients were identified with the pre-existing hypertension, currently taking antihypertensive medication, and discharged diagnosis with AIS. Of the 49 patients, 67% had antihypertensive medication restarted, while 33% of patient’s antihypertensive were held or restarted at time of discharge. On the day of hospital admission, 66% were restarted on home medications, while 34% of the patients had home medications held. Of those who held the home medications, approximately 8% of providers documented a reason. Conclusions: While more than half of the patients with AIS with hypertension had home medications restarted, providers inconstantly documented reasons why antihypertensive medications were held. There needs to be clarification in documentation in order to determine the variation in practice.