Journal of Neurosurgery
Volume 139: Issue 6 (Dec 2023)
Illustration from Phillips et al. (pp 1604–1612). © Michael McDowell, published with permission.

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The central focus of the 2023 annual gathering of the American Association of Neurological Surgeons in Los Angeles revolved around the concept of neurosurgeons as advocates. Beyond their roles in clinical practice and patient care, neurosurgeons frequently unite in their commitment to advocacy. This shared dedication empowers them to thrive in areas such as innovation, teaching, advanced research, and comprehensive training to shape the future of the neurosurgical field. The substantial outcome of this approach is the establishment of an environment dedicated to delivering the utmost quality of care to neurosurgery patients.

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In Brief

Researchers examined the external causes, contributing diseases, and preinjury medication in adult patients with fatal traumatic brain injury (TBI) in a nationwide Finnish cohort. Cardiovascular diseases and psychiatric conditions were the most common diseases contributing to death. Finland is at the upper end of the incidence of fatal TBI in Europe.

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In Brief

Using a Japanese nationwide inpatient database, the authors performed a propensity score matched analysis to investigate the real-world impact of intracranial pressure (ICP) monitoring in managing severe traumatic brain injury (TBI). ICP monitoring was associated with significantly more frequent medical interventions and lower in-hospital mortality (within-hospital difference -7.2%). In the real-world setting, active ICP monitoring may improve outcomes after TBI.

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In Brief

This study aimed to identify metrics that could predict recovery following severe traumatic brain injury. The researchers found that a posterior dominant rhythm on electroencephalography is strongly associated with positive outcomes and developed a machine learning–based model that accurately forecasts the return of consciousness. This model performed better than previously reported models and can be valuable in clinical decision-making as well as counseling families following these types of injuries.

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In Brief

Researchers investigated the association of intracranial pressure variability (ICPV) with intracranial hypertension and mortality in the intensive care unit. A higher ICPV was significantly and independently associated with intracranial hypertension and mortality, and these researchers developed a machine learning model using ICPV to predict intracranial hypertensive episodes with good results. Adding ICPV to existing algorithms for predicting intracranial hypertension may help clinicians react expediently to ICP changes in critically ill patients.

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In Brief

Whether Schwann cell migration-induced artificial nerve (SCiAN), induced via end-to-side neurorrhaphy, can bridge a 20-mm nerve defect, a length exceeding the regenerative limit, was investigated using rats. The SCiAN group showed significantly better axonal regeneration and better improvement of sensory nerves compared with a conventional artificial nerve (AN). The technique may extend the limitation of AN and make it even more useful for a longer nerve defect such as trauma and tumor resection.

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In Brief

Novel and impactful contributions to scientific literature are increasingly produced by teams spanning multiple disciplines. In this review, the authors present data from the business and management literature about the development and maintenance of effective teams and then demonstrate the application of these principles in the setting of an interdisciplinary brachial plexus and peripheral nerve research group. These experiences can serve as a template for other interdisciplinary groups within the field of neurosurgery.

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In Brief

This study highlights the radiological features in patients with a foot drop following total hip arthroplasty. The key finding was that patients with an identified focal structural etiology had discrete nerve abnormalities on MRI; while patients with a traction injury had diffuse continuous abnormalities, of varying degrees of severity. We propose a mechanism where anatomic tether points, similar to two hands pulling on an elastic band, act as points of origin and propagation of traction nerve injuries.

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In Brief

The objective of this paper was to compare brain plasticity after nerve transfers, using a scale that was previously reported in two different populations of brachial plexus injuries: infants who attain obstetric lesions during delivery versus children and adults who have sustained a traumatic brachial plexus injury. The key finding was that infants have perfect brain plasticity, whereas adults do not. This is the first article in the literature reporting this comparison, adding completely new data on this subject.

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In Brief

Researchers examined whether preoperative white matter network organization predicts memory decline after temporal lobe surgery. Although whole-brain network organization predicted verbal memory decline in left temporal lobe epilepsy, asymmetry of the medial temporal lobe subnetwork organization was the most robust predictor and outperformed hippocampal volume asymmetry. This highlights the promise of using network-based metrics in presurgical planning and for understanding the mechanisms of structural network adequacy and reserve when considering surgical risk.

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In Brief

Researchers examined their institutional series of "hybrid" stereo-electroencephalography (SEEG) combined with microelectrodes in 218 consecutive patients over 26 years to evaluate its clinical and scientific utility and safety. Hybrid SEEG was safe and effective in guiding epilepsy surgery and provided unique information at the single-neuron level to advance our understanding of epilepsy and neurocognitive processes unique to humans. This approach may become a useful tool to interrogate personalized brain networks in other brain disorders.

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In Brief

Researchers performed a retrospective analysis on the effects of various operative variables including implantation techniques (external vs internal stylet) on the implantation accuracy of stereoelectroencephalography (SEEG) depth electrodes. Better target radial accuracy was achieved with the external stylet technique, and a target radial error increased with a larger entry angle with the internal stylet technique but not with the external stylet technique. These data add to a foundational literature in the technical aspects of modern SEEG approaches.

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Mesial temporal lobe epilepsy (mTLE) is an important cause of drug-resistant epilepsy (DRE) in adults and children. Traditionally, the surgical option of choice for mTLE includes a frontotemporal craniotomy and open resection of the anterior temporal cortex and mesial temporal structures. Although this technique is effective and durable, the neuropsychological morbidity resulting from temporal neocortical resections has resulted in the investigation of alternative approaches to resect the mesial temporal structures to achieve seizure freedom while minimizing postoperative cognitive deficits. Outcomes supporting the use of selective temporal resections have resulted in alternative approaches to directly access the mesial temporal structures via endoscopic approaches whose direct trajectory to the epileptogenic zone minimizes retraction, resection, and manipulation of surrounding cortex.

The authors reviewed the utility of the endoscopic transmaxillary, endoscopic endonasal, endoscopic transorbital, and endoscopic supracerebellar transtentorial approaches for the treatment of drug-resistant mesial temporal lobe epilepsy. First, a review of the literature demonstrated the anatomical feasibility of each approach, including the limits of exposure provided by each trajectory. Next, clinical data assessing the safety and effectiveness of these techniques in the treatment of DRE were analyzed. An outline of the surgical techniques is provided to highlight the technical nuances of each approach.

The direct access to mesial temporal structures and avoidance of lateral temporal manipulation makes endoscopic approaches promising alternatives to traditional methods for the treatment of DRE arising from the temporal pole and mesial temporal lobe. A dearth of literature outlining clinical outcomes, a need for qualified cosurgeons, and a lack of experience with endoscopic approaches remain major barriers to widespread application of the aforementioned techniques. Future studies are warranted to define the utility of these approaches moving forward.

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In Brief

The objective of this study was to determine whether progressive interior carotid artery (ICA) stenosis associated with skull base meningiomas (SBMs) encasing the ICA increased the risk of clinical stroke. The authors found that the risk of stroke was not increased. This finding allows neurosurgeons managing patients with stenosis in SBM-encased ICAs to reassure them that there is no increased clinical risk of stroke. Moreover, this finding reassures the neurosurgeons that stroke prevention treatments (including antiplatelet therapy and arterial bypass) are not necessary in these patients.

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and
Sunit Das , on behalf of the Canadian Adolescent and Young Adult Neuro-Oncology Network (CANON)

Adolescent and young adult (AYA) patients with glioma have historically had poorer outcomes than similar patients of younger or older age, a disparity thought to be attributable to the social and economic challenges faced by this group in the transition from childhood to adult life, delays in diagnosis, low participation of AYA patients in clinical trials, and the lack of standardized treatment approaches specific to this patient group. Recent work from many groups has informed a revision of the World Health Organization classification schema for gliomas to identify biologically divergent pediatric- and adult-type tumors, both types of which may occur in AYA patients, and revealed exciting opportunities for the use of targeted therapies for many of these patients. In this review, the authors focus on the glioma types of specific concern to practitioners caring for AYA patients and the factors that should be considered in the development of multidisciplinary teams to facilitate their care.

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In Brief

Researchers retrospectively investigated whether stereotactic radiosurgery (SRS) for brain metastases from lung cancer combined with immune checkpoint inhibitors (ICIs) enhances treatment efficacy using propensity score matching analysis. SRS with concurrent ICIs was associated with longer survival and durable intracranial disease control, with no detectable increase in treatment-related adverse events. Future work is needed to identify optimal radiation dose and timing, as well as patient subgroups likely to benefit from synergistic effects.

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In Brief

Researchers performed an extensive literature review to investigate findings regarding the relationship between progesterone, estrogen, and androgen receptors and patient and meningioma characteristics, given evidence of the sensitivity of meningiomas to gonadal steroid hormones. Hormone receptor status was found to have strong associations with patient age and sex and tumor WHO grade, histology, and anatomical location. The findings from this comprehensive study may increase understanding of receptor heterogeneity and lay the groundwork for revisiting and improving patient stratification for meningioma treatment based on proper targeting of hormonal therapy.

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In Brief

Researchers sought to determine whether the behavior of NF2 mutant sporadic meningiomas varies based on intracranial location. They found that infratentorial tumors, as compared to their supratentorial counterparts, have more benign clinical and genomic features. Despite undergoing less extensive resection, infratentorial NF2 mutant sporadic meningiomas had similar rates of recurrence. These findings underscore the importance of achieving maximal resection, only when safe, and suggest that there may be additional biological mechanisms related to tumor location.

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In Brief

Oxytocin (OXT) secretion appears to be transiently elevated in patients developing syndrome of inappropriate secretion of antidiuretic hormone (SIADH)–related hyponatremia after transsphenoidal pituitary surgery (TPS). However, a potential role for this hormone in postoperative sodium homeostasis was never studied. Comparing OXT with sodium urinary output in patients subjected to TPS, the authors found a correlation between OXT secretion and natriuresis, suggesting a possible role for this hormone in postoperative dysnatremias.

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In Brief

The authors found that portable low-field MRI is effective in evaluating optic nerve decompression after endoscopic endonasal surgery for sellar and suprasellar pathologies. These findings suggest that this new technology could be beneficial in tumor neurosurgery, particularly in settings where resource limitations may make access to conventional MRI during or after surgery difficult.

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In Brief

This study aimed to assess the usefulness of MET-PET for patients with suspected recurrent Cushing's disease (CD). MET-PET was extremely useful for confirming MRI-equivocal lesions in 15 patients and deciding on further treatment options. Furthermore, MET-PET can be used to determine medical treatment efficacy. Accordingly, the authors propose a novel protocol based on MET-PET results for treating relapsing CD patients in whom even cutting-edge MRI cannot confirm the recurrent tumors.

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In Brief

The authors introduce an anatomical taxonomy for thalamic cavernomas that defines their unique pathoanatomy. The classification into 6 thalamic subtypes-anterior (7/75, 9%), medial (22/75, 29%), lateral (10/75, 13%), choroidal (9/75, 12%), pulvinar (19/75, 25%), and geniculate (8/75, 11%)-helped to increase diagnostic acumen at the patient's bedside, identify optimal surgical approaches, enhance the clarity of clinical academic communications, and improve surgical outcomes. Most patients (53/66, 80%) had favorable functional outcomes.

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In Brief

The goal of this study was to evaluate the usefulness of the ivy sign in assessing cerebral perfusion status following bypass surgery in patients with adult moyamoya disease (MMD). In adult MMD, the ivy sign significantly decreased after combined bypass surgery, which was well correlated with postoperative hemodynamic improvement in the anterior circulation territories. The ivy sign can be suggested as a simple and effective radiological marker to evaluate hemodynamic status during follow-up after bypass surgery in patients with adult MMD.

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In Brief

Researchers used peripheral and intracranial blood to screen biomarkers for moyamoya disease (MMD) diagnosis and prognosis. Combining the results of intracranial and peripheral blood sampling, sTie-2 shows consistent expression patterns within the group of patients with MMD, which could also be used to predict postoperative collateral formation. This study, for the first time, demonstrated the differences of certain growth factors between intracranial and peripheral blood, and emphasized the importance of using intracranial samples for the investigation of the etiology of MMD.

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In Brief

This study aimed to evaluate the effect of collateral status on outcomes in patients who had undergone endovascular treatment (EVT) for acute basilar artery occlusion (BAO) due to large-artery atherosclerosis (LAA) by using the composite collateral score. A good collateral status (composite collateral score 3-5) was a strong prognostic factor after EVT in patients with BAO underlying LAA. This study has provided evidence for evaluation of the collateral circulation in the posterior circulation.

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In Brief

In Part 1, the authors conducted a single-institution survey and interviews to assess factors contributing to specialty decision-making and perceptions of neurosurgery by gender. Female students and residents considered different factors, such as maternity/paternity leave, more strongly when choosing a medical specialty. Most respondents across genders perceived the field to be malignant, suggesting the need for institutional intervention to create more welcoming environments where medical students across all demographic groups can see themselves in the future.

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In Brief

In Part 2, the authors investigated differences in specialty decision-making and perceptions of neurosurgery between individuals underrepresented in medicine (URM) and others. URM students more strongly considered research opportunities in specialty decision-making, and URM residents were more hesitant toward neurosurgery due to their perceived lack of opportunity for health equity work. These data provide a basis to develop and structure initiatives focused on recruitment and retention of URM trainees in neurosurgery.

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In Brief

A survey of US neurosurgical trainees, residency directors, and chairs evaluated the impact of the coronavirus disease 2019 pandemic on academic neurosurgery. Over half of trainees reported that the pandemic negatively impacted surgical skills training and roughly a quarter reported a lower likelihood of choosing an academic career. Financial distress, reduced comradery, and redeployment during the pandemic were associated with a lower likelihood of choosing academics. A plurality of residents favored continuing remote conferences after the pandemic.

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In Brief

This paper demonstrates the validity of a new tool, medical student milestones (MSM), for assessing the competence of medical students as they apply to neurosurgical residency programs. The MSM successfully differentiated students by Society of Neurological Surgeons recommendation percentile scores and demonstrated greater spread and faculty interrater reliability. Residents scored students lower than the students themselves or faculty members. The MSM may be useful for residency admissions as well as the transition to residency as part of lifelong learning.

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In Brief

This study highlights research efforts using different modules of the Quality Outcomes Database (QOD). The authors summarized evidence yielded through 94 original investigations in spinal surgery and neurosurgical oncology, describing the infrastructure and workflow of the QOD and focused research collaboratives, such as the QOD Study Group. The authors also provided insights into future areas of academic focus and the transition of the spinal modules to the American Spine Registry.

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OBJECTIVE

Temporary drainage of CSF with lumbar puncture or lumbar drainage has a high predictive value for identifying patients with suspected idiopathic normal pressure hydrocephalus (iNPH) who may benefit from ventriculoperitoneal shunt insertion. However, it is unclear what differentiates responders from nonresponders. The authors hypothesized that nonresponders to temporary CSF drainage would have patterns of reduced regional gray matter volume (GMV) as compared with those of responders. The objective of the current investigation was to compare regional GMV between temporary CSF drainage responders and nonresponders. Machine learning using extracted GMV was then used to predict outcomes.

METHODS

This retrospective cohort study included 132 patients with iNPH who underwent temporary CSF drainage and structural MRI. Demographic and clinical variables were examined between groups. Voxel-based morphometry was used to calculate GMV across the brain. Group differences in regional GMV were assessed and correlated with change in results on the Montreal Cognitive Assessment (MoCA) and gait velocity. A support vector machine (SVM) model that used extracted GMV values and was validated with leave-one-out cross-validation was used to predict clinical outcome.

RESULTS

There were 87 responders and 45 nonresponders. There were no group differences in terms of age, sex, baseline MoCA score, Evans index, presence of disproportionately enlarged subarachnoid space hydrocephalus, baseline total CSF volume, or baseline white matter T2-weighted hyperintensity volume (p > 0.05). Nonresponders demonstrated decreased GMV in the right supplementary motor area (SMA) and right posterior parietal cortex as compared with responders (p < 0.001, p < 0.05 with false discovery rate cluster correction). GMV in the posterior parietal cortex was associated with change in MoCA (r2 = 0.075, p < 0.05) and gait velocity (r2 = 0.076, p < 0.05). Response status was classified by the SVM with 75.8% accuracy.

CONCLUSIONS

Decreased GMV in the SMA and posterior parietal cortex may help identify patients with iNPH who are unlikely to benefit from temporary CSF drainage. These patients may have limited capacity for recovery due to atrophy in these regions that are known to be important for motor and cognitive integration. This study represents an important step toward improving patient selection and predicting clinical outcomes in the treatment of iNPH.

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In Brief

The authors examined prognostic factors in patients with basal ganglia hemorrhage, a common type of intracerebral hemorrhage, after treatment with endoscopic evacuation. Important findings were that a larger volume of postoperative perihematomal edema (PHE) was independently associated with functional dependence. Postoperatively, patients with large or extra-large PHE volumes (≥ 50 to < 75 or ≥ 75 to 100 ml) had a > 4.61 times greater likelihood of long-term dependence than patients with small PHE volumes (≥ 10 to < 25 ml). To the authors' knowledge, this is the first study showing that a larger postoperative PHE volume is an independent risk factor for functional dependence.

Open access

Surgeons spend years honing their skills in arduous training programs: harsh feedback from senior surgeons is the norm, and our mistakes are dissected publicly in a monthly fashion (known as morbidity and mortality conferences). After we graduate from training, we step out of this regimented setting. Trained surgeons are expected to self-regulate, collecting our own data about performance and complications. Although experts from our community review surgical morbidities and mortalities, most surgeries go unreviewed and few surgical performance data are collected. These self-regulatory processes govern the provision of care for 15 million surgical patients in the US each

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Negotiating a job as a neurosurgeon, especially your first, is daunting. You will have to weigh and consider salary, operating room (OR) time, call requirements, clinical support staff, malpractice insurance, and many other factors. A surgeon-scientist, though, has a second full-time job—running a laboratory. This leads to a parallel world of additional considerations, such as laboratory space, research budget, grants management support, protected time, and more.

This article will describe the unique considerations that arise when negotiating a job as an academic neurosurgeon-scientist. For brevity, this article will leave out general aspects of negotiation, such as negotiation techniques

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With the hope that an experimental treatment will provide a cure, patients often ask for advice and clearance from their current treatment providers to participate in research studies. A recent study has shown that 89% of the neurologists surveyed were consulted on experimental treatments for neurological diseases. 1 The exact number of neuro-oncology patients interested in traveling for experimental therapy is unclear, although there is an increase in options for patients to plan their own care abroad through social media platforms, websites, and travel broker companies. 25

Driven by a poor prognosis, such as median

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In Brief

Authors of this study aimed to characterize clinical outcomes following stereotactic radiosurgery (SRS) for cavernous malformations of the basal ganglia or thalamus. Patients treated with marginal prescription doses (MPDs) ≤ 12 Gy had favorable outcomes with more than 90% of patients not experiencing hemorrhage or SRS-related toxicities using this approach. This multicenter study supports MPDs of approximately 12 Gy in 1 fraction for the management of basal ganglia or thalamic cavernous malformations.

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In Brief

Researchers sought to determine whether there was a time point after apparent gross-total resection of pituitary adenoma with negative imaging findings when patients and clinicians could be confident that recurrence would not occur. By analyzing recurrence conditioned on negative imaging at 3, 5, 7, and 10 years after surgery, researchers found no point after surgery wherein the annual risk of radiographic recurrence rate decreased. These findings suggest that patients require long-term imaging surveillance for recurrence.

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In Brief

For appropriately selected olfactory groove meningiomas, a keyhole, endoscope-assisted supraorbital approach can achieve equivalent extent of resection and olfactory outcomes with a statistically shorter length of stay compared with traditional transcranial approaches.

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In Brief

Researchers analyzed sound measurements obtained in the external ear canal of patients with pulsatile tinnitus who were referred for digital subtraction angiography to exclude cranial dural arteriovenous fistula (DAVF). In contrast to patients without DAVF, the presence of a pulsatile sound is common for patients with DAVF. Sound measurements show potential as a screening tool to help the clinician and patient in making an informed decision regarding the necessity of digital subtraction angiography.

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In Brief

The aim of this study was to identify the ratio and trend of female neurosurgery residents to the total number of residents during the past 7 years across all US neurosurgery residency programs. The trend line showed a significant increase, from 15.9% in 2016 to 29.8% in 2022 (p = 0.035). Although the study showed an increased trend, the percentage of female neurosurgery residents remains low and more should be done to increase female mentorship and representation.

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When the Women in Neurosurgery (WINS) group published their seminal Journal of Neurosurgery paper in 2008, it set the goal of increasing women representation in neurosurgery to 20% of residents by 2012 and 20% of faculty by 2020. 1 This group emphasized the need to increase recruitment of women medical students, establish a mentorship model for younger women trainees, and advocate for the promotion of women into leadership positions in organized neurosurgery. Since that time, there has been an increase in women in neurosurgery, with more women medical students matriculating into neurosurgical residencies, 2

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In Brief

Researchers assessed the safety and long-term efficacy of less-than-total surgical removal for Koos grade IV vestibular schwannoma followed by wait-and-scan and stereotactic radiation therapy in case of relapse. Excellent facial outcomes (92%) and long-term tumor control (96%) were achieved; 29% of patients needed second-line radiation therapy, and none needed salvage surgery after a mean follow-up time of 4.4 years. These findings support the growing evidence that gross-total resection should be abandoned to optimize functional results.

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OBJECTIVE

Intracranial saccular aneurysms are vascular malformations responsible for 80% of nontraumatic brain hemorrhage. Recently, flow diverters have been used as a less invasive therapeutic alternative for surgery. However, they fail to achieve complete occlusion after 6 months in 25% of cases. In this study, the authors built a tool, using machine learning (ML), to predict the aneurysm occlusion outcome 6 months after treatment with flow diverters.

METHODS

A total of 667 aneurysms in 616 patients treated with the Pipeline embolization device at a tertiary referral center between January 2011 and December 2017 were included. To build the predictive tool, two experiments were conducted. In the first experiment, six ML algorithms (support vector machine [SVM], decision tree, random forest [RF], k-nearest neighbor, XGBoost, and CatBoost) were trained using 26 features related to patient risk factors and aneurysm morphological characteristics, and the results were compared with logistic regression (LR) modeling. In the second experiment, the models were trained using the top 10 features extracted by Shapley additive explanation (SHAP) analysis performed on the RF model.

RESULTS

The results showed that the authors’ tool can better predict the occlusion outcome than LR (accuracy of 89% for the SVM model vs 62% for the LR model), even when trained using a subset of the features (83% accuracy). SHAP analysis revealed that age, hypertension, smoking status, branch vessel involvement, aneurysm neck, and larger diameter dimensions were among the most important features contributing to accurate predictions.

CONCLUSIONS

In this study, an ML-based tool was developed that successfully predicts outcome in intracranial aneurysms treated with flow diversion, thus helping neurosurgeons to practice a more refined approach and patient-tailored medicine.

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In Brief

Dysphagia is a significant complication in fourth ventricle surgery. This study demonstrated that vagus nerve motor evoked potentials are reliable predictors of postoperative swallowing function, suggesting that they can be feasibly included in the intraoperative neuromonitoring armamentarium.

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In Brief

Modern neurosurgical developments enable minimally invasive surgery with shorter operation times, faster recovery, and earlier hospital discharge. This retrospective, single-center analysis of 630 patients shows that same-day discharge after craniotomy can be safe in carefully selected patients after both general anesthesia and awake craniotomy for supratentorial tumor resection.

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OBJECTIVE

Carotid artery stenosis (CAS) is associated with an annual stroke risk of 2%–5%, and revascularization with carotid endarterectomy (CEA) can reduce this risk. While studies have demonstrated that hospital CEA volume is associated with mortality and myocardial infarction, CEA volume cutoffs in studies are relatively arbitrary, and no specific analyses on broad complications and discharge disposition have been performed. In this study, the authors systematically set out to identify a cutoff at which CEA procedural volume was significantly associated with major complications and nonroutine discharge.

METHODS

Asymptomatic and symptomatic CAS patients undergoing CEA were retrospectively identified in the Nationwide Readmissions Database (2010–2018). The association of CEA volume with outcomes was explored as a continuous variable using locally estimated scatterplot smoothing. The identified volume cutoff was used to generate dichotomous volume cohorts, and multivariate analyses of patient and hospital characteristics were conducted to evaluate the association of CEA volume with major complications and discharge disposition.

RESULTS

Between 2010 and 2018, 308,933 asymptomatic and 32,877 symptomatic patients underwent CEA. Analysis of CEA volume with outcomes as a continuous variable demonstrated that an increase in volume was associated with a lower risk until a volume of approximately 7 cases per year (20th percentile). A total of 6702 (2.2%) asymptomatic and 1040 (3.2%) symptomatic patients were treated at the bottom 20% of hospital procedure volume. Increased rates of complications were seen at low-volume centers among asymptomatic (3.66% vs 2.77%) and symptomatic (7.4% vs 6.87%) patients. Asymptomatic patients treated at low-volume centers had an increased likelihood of major complications (OR 1.26, 95% CI 1.07–1.49; p = 0.007) and nonroutine discharge (OR 1.36, 95% CI 1.24–1.50; p < 0.0001). Symptomatic patients treated at low-volume centers were also more likely to experience major complications (OR 1.47, 95% CI 1.07–2.02; p = 0.02) and nonroutine discharge (OR 1.26, 95% CI 1.07–1.47; p = 0.005). Mortality rates were similar between low- and high-volume hospitals among asymptomatic (0.36% and 0.32%, respectively) and symptomatic (1.06% and 1.49%, respectively) patients, while volume was not significantly associated with mortality among asymptomatic (OR 1.06, 95% CI 0.67–1.65; p = 0.81) and symptomatic (OR 0.81, 95% CI 0.43–1.54; p = 0.52) patients in multivariate analysis.

CONCLUSIONS

CEA patients, asymptomatic or symptomatic, are at a higher risk of major complications and nonroutine discharge at low-volume centers. Analysis of CEA as a continuous variable demonstrated a cutoff at 7 cases per year, and further study may identify factors associated with improved outcome at the lowest-volume centers.

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TO THE EDITOR: We read with great interest the meta-analysis published by Sattari et al. 1 regarding the sacrifice or preservation of the superior petrosal vein (SPV) during microvascular decompression (MVD) (Sattari SA, Shahbandi A, Xu R, et al. Sacrifice or preserve the superior petrosal vein in microvascular decompression surgery: a systematic review and meta-analysis. J Neurosurg. 2023;138[2]:390-398). The authors concluded that SPV sacrifice is as safe as SPV preservation, and recommended intentional SPV sacrifice to enhance surgical field visualization. We congratulate the authors for their excellent work. Nevertheless, there are several viewpoints on their

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In Brief

Patient-reported outcome measures (PROMs) have become increasingly utilized in clinical research, as they can capture information that is important to patients but has not been captured by traditional measures in past clinical research. The authors reviewed the literature to identify PROMs specific to cerebrovascular disease. The review revealed critical gaps in disease-specific outcome measures and identified opportunities to create new ways of assessing what happens after the onset of these cerebrovascular disorders and following treatment.

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In Brief

Researchers retrospectively evaluated the treatment outcomes of stereotactic radiosurgery for noncavernous sinus dural arteriovenous fistulas and predictors of their obliteration. At a median follow-up of 17 months, the overall complete obliteration rate was 63.1%. The effects of stereotactic radiosurgery on noncavernous sinus dural arteriovenous fistulas vary according to location. High-flow shunt and venous ectasia were associated with incomplete obliteration.

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Dexamethasone, a long-acting potent glucocorticoid, is one of the most widely used medications in neurosurgery. In this paper, the authors recount the history of dexamethasone’s rise in neurosurgery and discuss its use in brain tumors in the context of emerging neuro-oncological immunotherapies. In 1958, Glen E. Arth synthesized a 16-alpha-methylated analog of cortisone (dexamethasone) for treatment of rheumatoid arthritis. Joseph Galicich, a neurosurgery resident at the time, applied the rheumatological drug to neurosurgery. He gave doses to patients who had undergone craniotomy for tumor removal and saw their paresis improve, midline shift resolve, and mortality rates decrease. He advocated for clinical trials and the drug became a mainstay in neurosurgery. As neuro-oncological treatments evolve to include immunotherapy, the immunosuppressive effects of dexamethasone are becoming an unwanted effect. The question then becomes: how does one treat the patient’s symptoms if the only drug that has been used throughout history may become a detriment to their oncological treatment? Since its discovery, dexamethasone has maintained an impressive staying power in the field, acting as a standard drug for cerebral edema for more than 60 years. However, with the advent of immunotherapy, research is warranted to evaluate ways of treating symptomatic edema in the context of modern neuro-oncological therapies.