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An analysis of potentially avoidable neurosurgical transfers to a tertiary-care level I trauma center

Clifford M. Marks, Ryan C. Burke, Martina Stippler, and Carlo L. Rosen

OBJECTIVE

Previous studies of neurosurgical transfers indicate that substantial numbers of patients may not need to be transferred, suggesting an opportunity to provide more patient-centered care by treating patients in their communities, while probably saving thousands of dollars in transport and duplicative workup. This study of neurosurgical transfers, the largest to date, aimed to better characterize how often transfers were potentially avoidable and which patient factors might affect whether transfer is needed.

METHODS

This was a retrospective cohort study of neurosurgical transfers to an urban, tertiary-care, level I trauma center between October 1, 2017, and October 1, 2022. Prior to data analysis, the authors devised criteria to differentiate necessary neurosurgical transfers from potentially avoidable ones. A transfer was considered necessary if 1) the patient went to the operating room within 12 hours of arrival at the emergency department (ED); 2) a neurological MRI study was conducted in the ED; 3) the patient was admitted to the ICU from the ED; or 4) the patient was admitted to either neurology or a surgical service (including neurosurgery). Transfers not meeting any of the above criteria were deemed potentially avoidable. Patient and clinical characteristics, including diagnostic groupings from Clinical Classification Software categories, were collected retrospectively via electronic health record data abstraction and stratified by whether the transfer was necessary or potentially avoidable. Statistical differences were assessed with a chi-square test.

RESULTS

A total of 5113 neurosurgical transfers were included in the study, of which 1701 (33.3%) were classified as potentially avoidable. Four percent of all transferred patients went to the operating room within 12 hours of reaching the receiving ED, 23.4% were admitted to the ICU from the ED, 26.6% had a neurological MRI study performed in the ED, and 54.4% were admitted to a surgical service or to neurology. Potentially avoidable transfers had a higher proportion of traumatic brain injury, headache, and syncope (p < 0.0001), as well as of spondylopathies/spondyloarthropathies (p = 0.0402), whereas patients needing transfer had a higher proportion of acute hemorrhagic cerebrovascular disease and cerebral infarction (p < 0.0001).

CONCLUSIONS

This study demonstrates that a large number of neurosurgical transfers can probably be treated in their home hospitals and highlights that the vast majority of patients transferred for neurosurgical conditions do not receive emergency neurosurgery. Further research is needed to better guide transferring and receiving facilities in reducing the burden of excessive transfers.

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Association of earlier surgery with improved postoperative language development in children with tuberous sclerosis complex

Sina Sadeghzadeh, Thomas M. Johnstone, Jurriaan M. Peters, Brenda E. Porter, and S. Katie Z. Ihnen

OBJECTIVE

The authors evaluated the impact of the timing of epilepsy surgery on postoperative neurocognitive outcomes in a cohort of children followed in the multiinstitutional Tuberous Sclerosis Complex (TSC) Autism Center of Excellence Research Network (TACERN) study.

METHODS

Twenty-seven of 159 patients in the TACERN cohort had drug-refractory epilepsy and underwent surgery. Ages at surgery ranged from 15.86 to 154.14 weeks (median 91.93 weeks). Changes in patients’ first preoperative (10–58 weeks) to last postoperative (155–188 weeks) scores on three neuropsychological tests—the Mullen Scales of Early Learning (MSEL), the Vineland Adaptive Behavior Scales, 2nd edition (VABS-2), and the Preschool Language Scales, 5th edition (PLS-5)—were calculated. Pearson correlation and multivariate linear regression models were used to correlate test outcomes separately with age at surgery and duration of epilepsy prior to surgery. Analyses were separately conducted for patients whose seizure burdens decreased postoperatively (n = 21) and those whose seizure burdens did not (n = 6). Regression analysis was specifically focused on the 21 patients who achieved successful seizure control.

RESULTS

Age at surgery was significantly negatively correlated with the change in the combined verbal subtests of the MSEL (R = −0.45, p = 0.039) and predicted this score in a multivariate linear regression model (β = −0.09, p = 0.035). Similar trends were seen in the total language score of the PLS-5 (R = −0.4, p = 0.089; β = −0.12, p = 0.014) and in analyses examining the duration of epilepsy prior to surgery as the independent variable of interest. Associations between age at surgery and duration of epilepsy prior to surgery with changes in the verbal subscores of VABS-2 were more variable (R = −0.15, p = 0.52; β = −0.05, p = 0.482).

CONCLUSIONS

Earlier surgery and shorter epilepsy duration prior to surgery were associated with greater improvement in postoperative language in patients with TSC. Prospective or comparative effectiveness clinical trials are needed to further elucidate surgical timing impacts on neurocognitive outcomes.

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A brief history of neurosurgery in Bosnia and Herzegovina: historical vignette

Ibrahim Omerhodžić, Bekir Rovčanin, Haso Sefo, Rasim Skomorac, Harun Brkić, and Kenan Arnautović

The modern period of neurosurgery in Bosnia and Herzegovina began with the first neurosurgical procedure performed by Dr. Karl Bayer in 1891 on 3 patients with depressed skull fractures and epilepsy. In 1956 the Department of Surgery in Sarajevo designated several beds specifically for a neurosurgical unit. A significant milestone in the history of neurosurgery in Bosnia and Herzegovina was the establishment of the Division of Neurosurgery at the Clinical Center University of Sarajevo in 1970. The first neurosurgeon to complete his training in Bosnia and Herzegovina was Dr. Faruk Konjhodžić. The first female neurosurgeon was Dr. Nermina Iblizović. Presently, there are 7 neurosurgical departments in the country, located in Sarajevo, Tuzla, Zenica, Mostar, Banja Luka, Bihać, and Foča. The Association of Neurosurgeons in Bosnia and Herzegovina, founded in 2003, is a member of the European Association of Neurosurgical Societies and the World Federation of Neurosurgical Societies. The aim of this historical paper is to provide a concise chronology of important events and mention key individuals who have contributed to the development of modern neurosurgery in Bosnia and Herzegovina.

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Deep brain stimulation in Latin America in comparison with the US and Europe in a real-world population: indications, demographics, techniques, technology, and adverse events

Adriana Lucia Lopez Rios, Fabián Piedimonte, Gabriel J. Arango, Manoel J. Teixeira, Alfonso Arellano-Reynoso, Griselda Del Carmen César, Hans Carmona, Daniel Ciampi de Andrade, Carlos Aníbal Restrepo-Bravo, Jose Miguel Gloria Escobar, Hui Xiong, Ricardo Martínez, and Todd Weaver

OBJECTIVE

The aim of this study was to provide geographic comparisons of deep brain stimulation (DBS) procedures in Latin America with the US and Europe regarding primary indications, demographic information, clinical and device-related adverse events, technology used, and patient outcomes using the Medtronic Product Surveillance Registry data as of July 31, 2021.

METHODS

Two thousand nine hundred twelve patients were enrolled in the registry (2782 received DBS and 1580 are currently active). Fourteen countries contributed 44,100 years of device experience to the registry. DBS centers in Latin America are located in Colombia (n = 3), Argentina (n = 1), Brazil (n = 1), and Mexico (n = 1). Fisher’s exact test was used to compare the difference in proportions of categorical variables between regions. The Wilcoxon signed-rank test was used for the EQ-5D index score change from baseline to follow-up.

RESULTS

The most common indication for DBS was Parkinson’s disease across all regions. In Latin America, dystonia was the second most common indication, compared to essential tremor in other regions. There was a striking finding with respect to age—patients were an average of 10 years younger at DBS implantation in Latin America. This difference was most likely due to the greater number of patients with dystonia receiving the device implants. The intraoperative techniques were quite similar, showing the same level of quality and covering the main principles of the surgeries with some variations in the brand of frames, planning software, and microrecording systems. Rechargeable batteries were significantly more common in Latin America (72.37%) than in the US (6.44%) and Europe (9.9%). Staging of the DBS procedure differed, with only 11.84% in Latin America staging the procedure compared with 97.58% and 34.86% in the US and Europe, respectively. The EQ-5D score showed significant improvements in all regions during the first 6–12 months (p < 0.0001). However, the 24-month follow-up only showed an improvement in the scale for Latin America (p < 0.0001).

CONCLUSIONS

DBS was performed in Latin America with similar indications, techniques, and technology as in the US and Europe. Important differences were found, with Latin America implementing more regular use of rechargeable devices, including younger patients at the time of surgery, and showing more sustained quality of life improvements at 24 months of follow-up. The authors hypothesize that these disparities stem from differences in resources among regions. However, more studies are needed to standardize DBS practice across the world to improve patients’ quality of life and provide high-quality care.

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Derivation of the Quebec Brain Injury Categories for complicated mild traumatic brain injuries

Jean-Nicolas Tourigny, Valérie Boucher, Xavier Dubucs, Christian Malo, Éric Mercier, Jean-Marc Chauny, Gregory Clark, Pierre-Gilles Blanchard, Pierre-Hugues Carmichael, Jean-Luc Gariépy, Myreille D’Astous, and Marcel Émond

OBJECTIVE

Approximately 10% of patients with mild traumatic brain injury (TBI) present with intracranial bleeding, and only 3.5% eventually require neurosurgical intervention, which often necessitates interhospital transfer. Better guidelines and recommendations are needed to manage complicated mild TBI in the emergency department (ED). The main objective of this study was to derive a clinical decision rule, the Quebec Brain Injury Categories (QueBIC), to predict the risk of adverse outcomes for complicated mild TBI in the ED. The secondary objective was to compare the QueBIC’s performance with those of other existing guidelines.

METHODS

The authors conducted a retrospective multicenter cohort study in 3 level I trauma centers. Consecutive patients with complicated mild TBI (Glasgow Coma Scale [GCS] score 13–15) who were aged ≥ 16 years were included. The primary outcome was a combination of neurosurgical intervention, mild TBI–related death, and clinical deterioration. Statistical analyses included set covering machine analyses.

RESULTS

In total, 477 patients were included in the study. The mean age was 62.9 years, and 68.1% were male. The algorithm classified patients into three risk categories (low, moderate, and high risk). The high-risk group (128 patients) (subdural hemorrhage [SDH] width > 7 mm or any midline shift) presented a sensitivity of 84% (95% CI 71%–93%) and a specificity of 80% (95% CI 76%–84%) to detect neurosurgical intervention and mild TBI–related death, leaving 8 undetected cases. Patients in the moderate-risk group (169 patients) had at least 1 variable: SDH width > 4 mm, initial GCS score ≤ 14, > 1 intraparenchymal hemorrhage, or intraparenchymal hemorrhage width > 4 mm. The combined QueBIC high- and moderate-risk category had a sensitivity of 100% (95% CI 63%–100%) and a specificity of 53% (95% CI 47%–58%) to detect mild TBI–related death or neurosurgical intervention. The sensitivity and specificity values for clinical deterioration when no death or neurosurgical intervention occurred were 81% (95% CI 64%–93%) and 44% (95% CI 39%–49%), respectively. The remaining 180 patients (37.7%) did not meet any high-risk or moderate-risk criteria and were considered low risk. None had neurosurgical intervention or mild TBI–related death. Only 6 (3.3%) low-risk patients showed clinical deterioration.

CONCLUSIONS

QueBIC is a safe and effective tool to guide the management of patients presenting to the ED with complicated mild TBI. It accurately identifies patients at low risk for specialized neurotrauma or neurosurgical care. Further validation is required before its use in EDs.

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The impact of the Woven EndoBridge device on the treatment of anterior circulation wide-neck bifurcation aneurysms: a single-center experience

Kareem El Naamani, Arbaz A. Momin, Nikolaos Mouchtouris, Adam Hunt, Charles L. Lawall, Marc Ghanem, Morena Paula Koorie, Jad El-Hajj, Shreya Vinjamuri, Abdulaziz Alhussein, Ruyof AlHussein, Stavropoula I. Tjoumakaris, M. Reid Gooch, Robert H. Rosenwasser, and Pascal M. Jabbour

OBJECTIVE

The paucity of literature comparing Woven EndoBridge (WEB) embolization to microsurgical clipping for anterior circulation wide-neck bifurcation aneurysms (WNBAs) underscores the need for further investigation into the optimal management of this patient subpopulation. The objective of this study was to compare the rate of endovascular and microsurgical treatment of WNBAs before and after the introduction of the WEB device. In addition, the authors performed a comparison of demographics, aneurysm characteristics, and treatment outcomes in patients before and after the introduction of the WEB device.

METHODS

This study was a retrospective review of the usage rate of different treatment modalities for WNBAs before and after the WEB device was approved by the US FDA on September 27, 2018.

RESULTS

The study cohort comprised 235 patients with anterior circulation WNBAs treated at the authors’ institution, including 127 aneurysms treated pre-WEB and 108 treated post-WEB. Generally, the rate of endovascular treatment of anterior circulation WNBAs was significantly higher post-WEB (86.1% vs 46.5%, p < 0.001), while the rate of clipping was significantly lower (13.9% vs 53.5%, p < 0.001). During follow-up, the rate of adequate aneurysm occlusion (Raymond-Roy occlusion classification [RROC] grades 1 and 2) was nonsignificantly higher in the post-WEB cohort (83.9% vs 78.5%, p = 0.34), while the rate of RROC grade 3 was nonsignificantly higher in the pre-WEB cohort (21.5% vs 16.1%, p = 0.34). Additionally, and although nonsignificant, the rates of recurrence (pre-WEB 25.3% vs post-WEB 14.9%, p = 0.12) and retreatment (pre-WEB 22.8% vs post-WEB 14.9%, p = 0.22) were higher in the pre-WEB cohort. Recurrence was assessed before retreatment.

CONCLUSIONS

After the introduction of the WEB device, the rate of endovascular treatment of WNBAs increased while the rate of microsurgical clipping decreased. It is essential for neurointerventionalists to become familiar with the indications, advantages, and shortcomings of all these different techniques to be able to match the right patient with the right technique to produce the best outcome.

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In-hospital outcomes following surgery versus conservative therapy in elderly patients with C2 fractures: a propensity score–matched analysis

Sam H. Jiang, Ryan K. Wang, Morteza Sadeh, Zayed Almadidy, Ankit I. Mehta, and Nauman S. Chaudhry

OBJECTIVE

Second cervical vertebrae (C2) fractures are a common traumatic spinal injury in the elderly population. Surgical fusion and nonoperative bracing are two primary treatments for cervical instability, but the former is often withheld in the elderly due to concerns for poor postoperative outcomes arising from patient frailty. This study sought to evaluate the in-hospital differences in mortality, outcomes, and discharge disposition in elderly patients with C2 fractures undergoing surgical intervention compared with conservative therapy.

METHODS

The National Trauma Data Bank was queried from 2017 to 2019 for all patients aged ≥ 65 years with C2 fractures undergoing either surgical stabilization or conservative therapy. Propensity score matching was performed using k-nearest neighbors with replacement based on patient demographics, comorbidities, insurance type, injury severity, and fracture type. Group differences were compared using Student t-tests and Pearson’s chi-square tests with Benjamini-Hochberg multiple comparisons correction. Subgroup analyses were performed in the 65–74, 75–79, and 80+ year age subgroups.

RESULTS

Six thousand forty-nine patients were identified, of whom 2156 underwent surgery and 3893 received conservative treatment. Following matching, the surgery group had significantly lower mortality rates (5.52% vs 9.6%, p < 0.001), a longer mean hospital length of stay (LOS; 12.64 vs 7.49 days p < 0.001), and slightly higher rates of several complications (< 3% difference), as well as lower rates of discharge home (14.56% vs 23.52%, p < 0.001) and to hospice (1.07% vs 2.09%, p = 0.02) and a higher rate of discharge to intermediate care (68.83% vs 48.28%, p < 0.001). Similar trends in mortality and LOS were noted in all 3 subgroups.

CONCLUSIONS

In elderly patients with C2 fractures, surgical stabilization confers a small survival advantage with a slightly higher in-hospital complication rate compared to conservative therapy. The increased rate of discharge to rehabilitation may represent better long-term prognosis following surgery. The increased risk of short-term complications is present but relatively small, thus surgery should not be withheld in patients with good long-term prognosis.

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In vitro evaluation of flow diverter performance using a human fibrinogen–based flow model

Cem Bilgin, Esref Alperen Bayraktar, Alexander A. Oliver, Jiahui Li, Juan R. Cebral, David F. Kallmes, and Ramanathan Kadirvel

OBJECTIVE

Fibrin deposition represents a key step in aneurysm occlusion, promoting endothelization of implants and connective tissue organization as part of the aneurysm-healing mechanism. In this study, the authors introduce a novel in vitro testing platform for flow diverters based on human fibrinogen.

METHODS

A flow diverter was deployed in 4 different glass models. The glass models had the same internal parent artery (4 mm) and aneurysm (8 mm) diameters with varying parent artery angulations (paraophthalmic, sidewall, bifurcation, and slightly curved models). The neck size and area were 4 mm and 25 mm2, respectively. Human fibrinogen (330 mg/dl) was circulated within the glass models at varying flow rates (0, 3, 4, and 5 ml/sec) with or without heparin, calcium chloride, and thrombin for as long as 6 hours or until complete fibrin coverage of the flow diverter’s neck was achieved. Aneurysm neck coverage was defined as macroscopic fibrin deposition occluding the flow diverters’ pores. Flow characteristics after flow diverter deployment were assessed with computational fluid dynamics analysis. The effects of flow rates, heparin, calcium chloride, and thrombin on fibrin deposition rates were tested using 1-way ANOVA and the Tukey test.

RESULTS

A total of 84 replicates were performed. Human fibrin did not accumulate on the flow diverter stents under static conditions. The fibrin deposition rate on the aneurysm neck was significantly greater with the 5 ml/sec flow rate as compared to 3 ml/sec for all models. The paraophthalmic model had the highest inflow velocity of 48.7 cm/sec. The bifurcation model had the highest maximum shear stress (SS) and maximum normalized shear stress values at the device cells at 843.3 dyne/cm2 and 35.1 SS/SSinflow, respectively. The fibrin deposition rates of the paraophthalmic and bifurcation models were significantly higher than those of sidewall and slightly curved models for all additive or flow rate comparisons (p = 0.001 for all comparisons). The incorporation of thrombin significantly increased the fibrin deposition rates across all models (p = 0.001 for all models).

CONCLUSIONS

Rates of fibrin deposition varied widely across different configurations and additive conditions in this novel in vitro model system. Fibrin accumulation started at the aneurysm inflow zone where flow velocity and shear stress were the highest. The primary factors influencing fibrin deposition included flow velocities, shear stress, and the addition of thrombin at a physiological concentration. Further research is needed to test the clinical utility of fibrinogen-based models for patient-specific aneurysms.

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Leading medical schools for female neurosurgery graduates

Kaho Adachi, Mishaal Hukamdad, Jonathan A. Ledesma, and Ankit I. Mehta

OBJECTIVE

The authors sought to determine the medical schools with the highest number and proportion of female graduates currently practicing neurosurgery and to identify medical school characteristics that increase female representation in neurosurgery, with the goal of addressing the gender disparity.

METHODS

The authors used the Physician Compare National Downloadable File from the Centers for Medicare & Medicaid Services. Physicians indicating neurosurgery as their primary specialty were extracted. Duplicates, physicians with medical school education listed as "other," and those expected to be in residency, fellowship, or research years (graduation years 2014–2023) were removed. Medical schools with the highest number and proportion of female neurosurgery graduates were stratified. A review of the current literature was conducted to identify characteristics of the institutions with high female representation.

RESULTS

A total of 3486 neurosurgeons (319 female [9.2%], 3167 male [90.8%]) were identified. Yale University (n = 12), Columbia University (n = 8), Johns Hopkins University (n = 8), Stanford University (n = 8), and the University of Maryland (n = 8) had the most female neurosurgery graduates. Schools with the highest proportion of female neurosurgery graduates included the University of California, San Diego (25%); the State University of New York Upstate Medical University (25%); Pennsylvania State University (22.2%); the University of Maryland (21.1%); and the University of Florida (18.4%).

CONCLUSIONS

Achieving gender diversity in neurosurgery necessitates a multifaceted approach. Institutions with a higher number and proportion of female neurosurgery graduates emphasized female-female mentorship, fostered diversity initiatives, and implemented inclusive policies. To increase female representation in neurosurgery, it is crucial to establish robust mentorship programs that provide aspiring female neurosurgeons with the guidance, support, and motivation required to navigate a traditionally male-dominated field.

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Microbial etiology of vertebral osteomyelitis/discitis amid the opioid epidemic

S. Alexander Ammerman, Alexander Keister, Joshua Vignolles-Jeong, Noah Mallory, David C. Gibbs, Ryan G. Eaton, Jianing Ma, David S. Xu, Stephanus Viljoen, and Andrew J. Grossbach

OBJECTIVE

The primary goal of this study was to establish the current microbial trends in vertebral osteomyelitis/discitis (VOD) amid the opioid epidemic and to determine if intravenous drug use (IVDU) predisposes one to a unique microbial profile of infection.

METHODS

The authors performed a retrospective cohort study consisting of 1175 adult patients diagnosed with VOD between 2011 and 2022 at a single quaternary center. Data were acquired through retrospective chart review, with pertinent demographic and clinical information collected.

RESULTS

Staphylococcus aureus was the most cultured organism in both the IVDU and non-IVDU groups at 56.1% and 40.7%, respectively. In the IVDU cohort, Serratia marcescens was the next most prevalently cultured organism at 13.9%.

CONCLUSIONS

The present study demonstrates that in the IVDU population S. marcescens is an organism of high concern. The potential for Serratia spp. infection should be accounted for when selecting empirical antimicrobial therapy in VOD patients.