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Stereotaxic Surgery for Parkinsonism

A Method of Evaluation and Clinical Results

Grant Levin, Bertram Feinstein, E. James Kreul, W. Watson Alberts, and Elwood W. Wright Jr.

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James M. Wright, Alankrita Raghavan, Christina H. Wright, Berje Shammassian, Yifei Duan, Martha Sajatovic, and Warren R. Selman

OBJECTIVE

Informed consent, when performed appropriately, serves many roles beyond simply obtaining the prerequisite medicolegal paperwork to perform a surgery. Prior studies have suggested that patient understanding is poor when verbal communication is the sole means of education. Virtual reality platforms have proven effective in enhancing medical education. No studies exist that have demonstrated the utility of virtual reality–facilitated informed consent (VR-IC) in improving the physician-patient alliance. The aim of this study was to determine the utility of VR-IC among patients providing consent for surgery and the impact of this educational and information technology–based strategy on enhancing the physician-patient alliance, patient satisfaction, and resident-physician perception of the consent process.

METHODS

Prospective, single-site, pre- and postconsent surveys were administered to assess patient and resident perception of informed consent performed with the aid of VR-IC at a large tertiary academic medical center in the US. Participants were adult patients (n = 50) undergoing elective surgery for tumor resection and neurosurgical residents (n = 19) who obtained patient informed consent for these surgical procedures. Outcome measures included scores on the Patient-Doctor Relationship Questionnaire (PDRQ-9), the modified Satisfaction with Simulation Experience Scale, and the Maslach Burnout Inventory. Patient pre- and postconsent data were recorded in real time using a secure online research data platform (REDCap).

RESULTS

A total of 48 patients and 2 family members provided consent using VR-IC and completed the surveys pre- and postconsent; 47.9% of patients were women. The mean patient age was 57.5 years. There was a statistically significant improvement from pre- to post–VR-IC consent in patient satisfaction scores. Measures of patient-physician alliance, trust, and understanding of their illness all increased. Among the 19 trainees, perceived comfort and preparedness with the informed consent process significantly improved.

CONCLUSIONS

VR-IC led to improved patient satisfaction, patient-physician alliance, and patient understanding of their illness as measured by the PDRQ-9. Using VR-IC contributed to residents’ increased comfort in the consent-gathering process and handling patient questions. In an era in which satisfaction scores are directly linked with hospital and service-line outcomes and reimbursement, positive results from VR-IC may augment physician and hospital satisfaction scores in addition to increasing measures of trust between physicians and patients.

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James M. Wright, Christina L. Huang, Rahul Sharma, Sunil Manjila, Feng Xu, Barbara Dabb, and Nicholas C. Bambakidis

Since the first surgery for an intracranial aneurysm in 1931, neurological surgeons have long strived to determine the optimal methods of surgical correction. Significant challenges of aneurysm clipping include intraoperative rupture and complex dome morphology. Hypothermia, cardiopulmonary bypass, pharmacologically induced hypotension, and cardiac standstill are a few of the methodologies historically and currently employed in the management of these issues. In the 1980s, significant advances in pharmacology and anesthesiology led to the use of agents such as adenosine for chemically induced hypotension and eventually complete circulatory arrest. Since the institution of the use of these agents, the traditional methods of circulatory arrest under conditions of hypothermia and cardiopulmonary bypass have fallen out of favor. However, there still exists a subset of technically difficult aneurysms for which cardiac standstill, both chemical and hypothermic, remains a viable therapeutic option. In this paper, the authors describe the history of cardiac standstill by both hypothermic and chemically induced means as well as provide examples in which these techniques are still necessary.

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James M. Wright, Michael D. Staudt, Andrea Alonso, Jonathan P. Miller, and Andrew E. Sloan

The authors describe the case of a 22-month-old boy who presented with gelastic seizures and developmental delay. Magnetic resonance imaging and video-electroencephalography monitoring revealed a primarily intraventricular hypothalamic hamartoma and gelastic seizures occurring 20–30 times daily. The patient was treated with various regimens of antiepileptic medications for 16 months, but the seizures remained medically intractable. At 3 years of age, he underwent stereotactic laser ablation with an aim of disconnection of the lesion. The procedure was performed with the NeuroBlate SideFire probe. To the authors’ knowledge, this is the first reported use of this technology for this procedure and serves as proof of concept. There were no perioperative complications, and 2 years postprocedure, the patient remains seizure free with marked behavioral and cognitive improvements.

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John Q. H. Bui, Rajith L. Mendis, James M. van Gelder, Mark M. P. Sheridan, Kylie M. Wright, and Matthias Jaeger

Object

Routine postoperative admission to the intensive care unit (ICU) is often considered a necessity in the treatment of patients following elective craniotomy but may strain already limited resources and is of unproven benefit. In this study the authors investigated whether routine postoperative admission to a regular stepdown ward is a safe alternative.

Methods

Three hundred ninety-four consecutive patients who had undergone elective craniotomy over 54 months at a single institution were retrospectively analyzed. Indications for craniotomy included tumor (257 patients) and transsphenoidal (63 patients), vascular (31 patients), ventriculostomy (22 patients), developmental (13 patients), and base of skull conditions (8 patients). Recorded data included age, operation, reason for ICU admission, medical emergency team (MET) calls, in-hospital mortality, and postoperative duration of stay.

Results

Three hundred forty-three patients were admitted to the regular ward after elective craniotomy, whereas there were 43 planned and 8 unplanned ICU admissions. The most common reasons for planned ICU admissions were anticipated lengthy operations (42%) and anesthetic risks (40%); causes for unplanned ICU admissions were mainly unexpected slow neurological recovery and extensive intraoperative blood loss. Of the 343 regular ward admissions, 10 (3%) required a MET call; only 3 of these MET calls occurred within the first 48 postoperative hours and did not lead to an ICU admission. The overall mortality rate in the investigated cohort was 1%, with no fatalities in patients admitted to the normal ward postoperatively.

Conclusions

Routine ward admission for patients undergoing elective craniotomies with selective ICU admission appears safe; however, approximately 2% of patients may require a direct postoperative unplanned ICU admission. Patients with anticipated long operation times, extensive blood loss, and high anesthetic risks should be selected for postoperative ICU admission, but further study is needed to determine the preoperative factors that can aid in identifying and caring for these groups of patients.

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Sanjit Shah, George L. Yang, Diana T. Le, Christina Gerges, James M. Wright, Ann M. Parr, Joseph S. Cheng, and Laura B. Ngwenya

The Emergency Medical Treatment and Active Labor Act (EMTALA) protects patient access to emergency medical treatment regardless of insurance or socioeconomic status. A significant result of the COVID-19 pandemic has been the rapid acceleration in the adoption of telemedicine services across many facets of healthcare. However, very little literature exists regarding the use of telemedicine in the context of EMTALA. This work aimed to evaluate the potential to expand the usage of telemedicine services for neurotrauma to reduce transfer rates, minimize movement of patients across borders, and alleviate the burden on tertiary care hospitals involved in the care of patients with COVID-19 during a global pandemic. In this paper, the authors outline EMTALA provisions, provide examples of EMTALA violations involving neurosurgical care, and propose guidelines for the creation of telemedicine protocols between referring and consulting institutions.