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Gauging the feasibility of cost-sharing and medical student interest groups to reduce interview costs

Bryan A. Lieber, Taylor A. Wilson, Randy S. Bell, William W. Ashley Jr., Daniel L. Barrow, and Stacey Quintero Wolfe

Indirect costs of the interview tour can be prohibitive. The authors sought to assess the desire of interviewees to mitigate these costs through ideas such as sharing hotel rooms and transportation, willingness to stay with local students, and the preferred modality to coordinate this collaboration. A survey link was posted on the Uncle Harvey website and the Facebook profile page of fourth-year medical students from 6 different medical schools shortly after the 2014 match day. There were a total of 156 respondents to the survey. The majority of the respondents were postinterview medical students (65.4%), but preinterview medical students (28.2%) and current residents (6.4%) also responded to the survey. Most respondents were pursuing a field other than neurosurgery (75.0%) and expressed a desire to share a hotel room and/or transportation (77.4%) as well as stay in the dorm room of a medical student at the program in which they are interviewing (70.0%). Students going into neurosurgery were significantly more likely to be interested in sharing hotel/transportation (89.2% neurosurgery vs 72.8% nonneurosurgery; p = 0.040) and in staying in the dorm room of a local student when on interviews (85.0% neurosurgery vs 57.1% nonneurosurgery; p = 0.040) than those going into other specialties. Among postinterview students, communication was preferred to be by private, email identification–only chat room. Given neurosurgery resident candidates' interest in collaborating to reduce interview costs, consideration should be given to creating a system that could allow students to coordinate cost sharing between interviewees. Moreover, interviewees should be connected to local students from neurosurgery interest groups as a resource.

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Outcomes of 33 patients from the wars in Iraq and Afghanistan undergoing bilateral or bicompartmental craniectomy

Clinical article

Robert D. Ecker, Lisa P. Mulligan, Michael Dirks, Randy S. Bell, Meryl A. Severson, Robin S. Howard, and Rocco A. Armonda

Object

There are no published long-term data for patients with penetrating head injury treated with bilateral supratentorial craniectomy, or supra- and infratentorial craniectomy. The authors report their experience with 33 patients treated with bilateral or bicompartmental craniectomy from the ongoing conflicts in Iraq and Afghanistan.

Methods

An exploratory analysis of Glasgow Outcome Scale (GOS) scores at 6 months in 33 patients was performed. Follow-up lasting a median of more than 2 years was performed in 30 (91%) of these patients. The association of GOS score with categorical variables was explored using the Wilcoxon rank-sum test or Kruskal-Wallis analysis of variance. The Spearman correlation coefficient was used for ordinal/continuous data. To provide a clinically meaningful format to present GOS scores with categorical variables, patients with GOS scores of 1–3 were categorized as having a poor outcome and those with scores of 4 and 5 as having a good outcome. This analysis does not include the patients who died in theater or in Germany who underwent bilateral decompressive craniectomy because those figures have not been released due to security concerns.

Results

All patients were men with a median age of 24 years (range 19–46 years) and a median initial Glasgow Coma Scale (GCS) score of 5 (range 3–14). At 6 months, 9 characteristics were statistically significant: focus of the initial injury, systemic infection, initial GCS score, initial GCS score excluding patients with a GCS score of 3, GCS score on arrival to the US, GCS score on dismissal from the medical center, Injury Severity Score, and patients with cerebrovascular injury. Six factors were significant at long-term follow-up: focus of initial injury, systemic infection, initial GCS score excluding patients with a GCS score of 3, GCS score on arrival to the US, and GCS score on dismissal from the medical center. At long-term follow-up, 7 (23%) of 30 patients had died, 5 (17%) of 30 had a GOS score of 2 or 3, and 18 (60%) of 30 had a GOS score of 4 or 5.

Conclusions

In this selected group of patients who underwent bilateral or bicompartmental craniectomy, 60% are independent at long-term follow-up. Patients with bifrontal injury fared best. Systemic infection and cerebrovascular injury corresponded with a worse outcome.

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Two-year mortality and functional outcomes in combat-related penetrating brain injury: battlefield through rehabilitation

M. Benjamin Larkin, Erin K. M. Graves, Jason H. Boulter, Nicholas S. Szuflita, R. Michael Meyer, Michael E. Porambo, John J. Delaney, and Randy S. Bell

OBJECTIVE

There are limited data concerning the long-term functional outcomes of patients with penetrating brain injury. Reports from civilian cohorts are small because of the high reported mortality rates (as high as 90%). Data from military populations suggest a better prognosis for penetrating brain injury, but previous reports are hampered by analyses that exclude the point of injury. The purpose of this study was to provide a description of the long-term functional outcomes of those who sustain a combat-related penetrating brain injury (from the initial point of injury to 24 months afterward).

METHODS

This study is a retrospective review of cases of penetrating brain injury in patients who presented to the Role 3 Multinational Medical Unit at Kandahar Airfield, Afghanistan, from January 2010 to March 2013. The primary outcome of interest was Glasgow Outcome Scale (GOS) score at 6, 12, and 24 months from date of injury.

RESULTS

A total of 908 cases required neurosurgical consultation during the study period, and 80 of these cases involved US service members with penetrating brain injury. The mean admission Glasgow Coma Scale (GCS) score was 8.5 (SD 5.56), and the mean admission Injury Severity Score (ISS) was 26.6 (SD 10.2). The GOS score for the cohort trended toward improvement at each time point (3.6 at 6 months, 3.96 at 24 months, p > 0.05). In subgroup analysis, admission GCS score ≤ 5, gunshot wound as the injury mechanism, admission ISS ≥ 26, and brain herniation on admission CT head were all associated with worse GOS scores at all time points. Excluding those who died, functional improvement occurred regardless of admission GCS score (p < 0.05). The overall mortality rate for the cohort was 21%.

CONCLUSIONS

Good functional outcomes were achieved in this population of severe penetrating brain injury in those who survived their initial resuscitation. The mortality rate was lower than observed in civilian cohorts.

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Early decompressive craniectomy for severe penetrating and closed head injury during wartime

Randy S. Bell, Corey M. Mossop, Michael S. Dirks, Frederick L. Stephens, Lisa Mulligan, Robert Ecker, Christopher J. Neal, Anand Kumar, Teodoro Tigno, and Rocco A. Armonda

Object

Decompressive craniectomy has defined this era of damage-control wartime neurosurgery. Injuries that in previous conflicts were treated in an expectant manner are now aggressively decompressed at the far-forward Combat Support Hospital and transferred to Walter Reed Army Medical Center (WRAMC) and National Naval Medical Center (NNMC) in Bethesda for definitive care. The purpose of this paper is to examine the baseline characteristics of those injured warriors who received decompressive craniectomies. The importance of this procedure will be emphasized and guidance provided to current and future neurosurgeons deployed in theater.

Methods

The authors retrospectively searched a database for all soldiers injured in Operations Iraqi Freedom and Enduring Freedom between April 2003 and October 2008 at WRAMC and NNMC. Criteria for inclusion in this study included either a closed or penetrating head injury suffered during combat operations in either Iraq or Afghanistan with subsequent neurosurgical evaluation at NNMC or WRAMC. Exclusion criteria included all cases in which primary demographic data could not be verified. Primary outcome data included the type and mechanism of injury, Glasgow Coma Scale (GCS) score and injury severity score (ISS) at admission, and Glasgow Outcome Scale (GOS) score at discharge, 6 months, and 1–2 years.

Results

Four hundred eight patients presented with head injury during the study period. In this population, a total of 188 decompressive craniectomies were performed (154 for penetrating head injury, 22 for closed head injury, and 12 for unknown injury mechanism). Patients who underwent decompressive craniectomies in the combat theater had significantly lower initial GCS scores (7.7 ± 4.2 vs 10.8 ± 4.0, p < 0.05) and higher ISSs (32.5 ± 9.4 vs 26.8 ± 11.8, p < 0.05) than those who did not. When comparing the GOS scores at hospital discharge, 6 months, and 1–2 years after discharge, those receiving decompressive craniectomies had significantly lower scores (3.0 ± 0.9 vs 3.7 ± 0.9, 3.5 ± 1.2 vs 4.0 ± 1.0, and 3.7 ± 1.2 vs 4.4 ± 0.9, respectively) than those who did not undergo decompressive craniectomies. That said, intragroup analysis indicated consistent improvement for those with craniectomy with time, allowing them, on average, to participate in and improve from rehabilitation (p < 0.05). Overall, 83% of those for whom follow-up data are available achieved a 1-year GOS score of greater than 3.

Conclusions

This study of the provision of early decompressive craniectomy in a military population that sustained severe penetrating and closed head injuries represents one of the largest to date in both the civilian and military literature. The findings suggest that patients who undergo decompressive craniectomy had worse injuries than those receiving craniotomy and, while not achieving the same outcomes as those with a lesser injury, did improve with time. The authors recommend hemicraniectomy for damage control to protect patients from the effects of brain swelling during the long overseas transport to their definitive care, and it should be conducted with foresight concerning future complications and reconstructive surgical procedures.

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Letter to the Editor

Traumatic brain injury or decompression

Satoru Takeuchi, Kojiro Wada, Kimihiro Nagatani, Naoki Otani, and Hiroshi Nawashiro

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A comparison of computed tomography angiography and digital subtraction angiography for the diagnosis of penetrating cerebrovascular injury: a prospective multicenter study

R. Michael Meyer, Ramesh Grandhi, Do H. Lim, Walid K. Salah, Malia McAvoy, Zachary A. Abecassis, Robert H. Bonow, Melanie Walker, Basavaraj V. Ghodke, Sarah T. Menacho, Sharon Durfy, Randall M. Chesnut, Louis J. Kim, Randy S. Bell, and Michael R. Levitt

OBJECTIVE

In this research, the authors sought to characterize the incidence and extent of cerebrovascular lesions after penetrating brain injury in a civilian population and to compare the diagnostic value of head computed tomography angiography (CTA) and digital subtraction angiography (DSA) in their diagnosis.

METHODS

This was a prospective multicenter cohort study of patients with penetrating brain injury due to any mechanism presenting at two academic medical centers over a 3-year period (May 2020 to May 2023). All patients underwent both CTA and DSA. The sensitivity and specificity of CTA was calculated, with DSA considered the gold standard. The number of DSA studies needed to identify a lesion requiring treatment that had not been identified on CTA was also calculated.

RESULTS

A total of 73 patients were included in the study, 33 of whom had at least 1 penetrating cerebrovascular injury, for an incidence of 45.2%. The injuries included 13 pseudoaneurysms, 11 major arterial occlusions, 9 dural venous sinus occlusions, 8 dural arteriovenous fistulas, and 6 carotid cavernous fistulas. The sensitivity of CTA was 36.4%, and the specificity was 85.0%. Overall, 5.6 DSA studies were needed to identify a lesion requiring treatment that had not been identified with CTA.

CONCLUSIONS

Cerebrovascular injury is common after penetrating brain injury, and CTA alone is insufficient to diagnosis these injuries. Patients with penetrating brain injuries should routinely undergo DSA.

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2017 AANS Annual Scientific Meeting Los Angeles, CA • April 22–26, 2017

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Oral Presentations 2016 AANS Annual Scientific Meeting Chicago, IL • April 30–May 4, 2016

Published online April 1, 2016; DOI: 10.3171/2016.4.JNS.AANS2016abstracts