The global demographic shift to an older population has led to the emergence of the new field of geriatric neurosurgery. Beyond the complexities of disease states and multimorbidity, advanced age brings with it intricate ethical issues pertaining to both the practice and provision of medical and surgical care. In this paper, the authors describe the central ethical themes seen across the spectrum of common neurosurgical conditions in the elderly and highlight the use of foundational ethical principles to help guide treatment decision-making.
Laureen D. Hachem and Mark Bernstein
Laureen D. Hachem, Simeon M. Wong, and George M. Ibrahim
Vagus nerve stimulation (VNS) is increasingly considered for the treatment of intractable epilepsy and holds potential for the management of a variety of neuropsychiatric conditions. The emergence of the field of connectomics and the introduction of large-scale modeling of neural networks has helped elucidate the underlying neurobiology of VNS, which may be variably expressed in patient populations and related to responsiveness to stimulation. In this report, the authors outline current data on the underlying neural circuitry believed to be implicated in VNS responsiveness in what the authors term the “vagus afferent network.” The emerging role of biomarkers to predict treatment effect is further discussed and important avenues for future work are highlighted.
Gabriel Crevier-Sorbo, Tristan Brunette-Clément, Edgard Medawar, Francois Mathieu, Benjamin R. Morgan, Laureen D. Hachem, Michael C. Dewan, Aria Fallah, Alexander G. Weil, and George M. Ibrahim
Epilepsy disproportionately affects low- and/or middle-income countries (LMICs). Surgical treatments for epilepsy are potentially curative and cost-effective and may improve quality of life and reduce social stigmas. In the current study, the authors estimate the potential need for a surgical epilepsy program in Haiti by applying contemporary epilepsy surgery referral guidelines to a population of children assessed at the Clinique d’Épilepsie de Port-au-Prince (CLIDEP).
The authors reviewed 812 pediatric patient records from the CLIDEP, the only pediatric epilepsy referral center in Haiti. Clinical covariates and seizure outcomes were extracted from digitized charts. Electroencephalography (EEG) and neuroimaging reports were further analyzed to determine the prevalence of focal epilepsy or surgically amenable syndromes and to assess the lesional causes of epilepsy in Haiti. Lastly, the toolsforepilepsy instrument was applied to determine the proportion of patients who met the criteria for epilepsy surgery referral.
Two-thirds of the patients at CLIDEP (543/812) were determined to have epilepsy based on clinical and diagnostic evaluations. Most of them (82%, 444/543) had been evaluated with interictal EEG, 88% of whom (391/444) had abnormal findings. The most common finding was a unilateral focal abnormality (32%, 125/391). Neuroimaging, a prerequisite for applying the epilepsy surgery referral criteria, had been performed in only 58 patients in the entire CLIDEP cohort, 39 of whom were eventually diagnosed with epilepsy. Two-thirds (26/39) of those patients had abnormal findings on neuroimaging. Most patients (55%, 18/33) assessed with the toolsforepilepsy application met the criteria for epilepsy surgery referral.
The authors’ findings suggest that many children with epilepsy in Haiti could benefit from being evaluated at a center with the capacity to perform basic brain imaging and neurosurgical treatments.