Neurosurgical Research Articles

Speech-Language Pathology Interventions in Pediatric Awake Brain Surgery: A Moroccan and Global Perspective

Speech-Language Pathology Interventions in Pediatric Awake Brain Surgery: A Moroccan and Global Perspective

Transformer-based neural speech decoding from surface and depth electrode signals.

This study investigates speech decoding from neural signals captured by intracranial electrodes. Most prior works can only work with electrodes on a 2D grid (i.e., Electrocorticographic or ECoG array) and data from a single patient. We aim to design a deep-learning model architecture that can accommodate both surface (ECoG) and depth (stereotactic EEG or sEEG) electrodes. The architecture should allow training on data from multiple participants with large variability in electrode placements. The model should not have subject-specific layers, and the trained model should perform well on participants unseen during training.

Approach: We propose a novel transformer-based model architecture named SwinTW that can work with arbitrarily positioned electrodes by leveraging their 3D locations on the cortex rather than their positions on a 2D grid. We train subject-specific models using data from a single participant and multi-subject models exploiting data from multiple participants.
Main Results: The subject-specific models using only low-density 8x8 ECoG data achieved high decoding Pearson Correlation Coefficient with ground truth spectrogram (PCC=0.817), over N=43 participants, significantly outperforming our prior convolutional ResNet model and the 3D Swin transformer model. Incorporating additional strip, depth, and grid electrodes available in each participant (N=39) led to further improvement (PCC=0.838). For participants with only sEEG electrodes (N=9), subject-specific models still enjoy comparable performance with an average PCC=0.798. A single multi-subject model trained on ECoG data from 15 participants yielded comparable results (PCC=0.837) as 15 models trained individually for these participants (PCC=0.831). Furthermore, the multi-subject models achieved high performance on unseen participants, with an average PCC=0.765 in leave-one-out cross-validation.

Significance: The proposed SwinTW decoder enables future speech decoding approaches to utilize any electrode placement that is clinically optimal or feasible for a particular participant, including using only depth electrodes, which are more routinely implanted in chronic neurosurgical procedures. The success of the single multi-subject model when tested on participants within the training cohort demonstrates that the model architecture is capable of exploiting data from multiple participants with diverse electrode placements. The architecture's flexibility in training with both single-subject and multi-subject data, as well as grid and non-grid electrodes, ensures its broad applicability. Importantly, the generalizability of the multi-subject models in our study population suggests that a model trained using paired acoustic and neural data from multiple patients can potentially be applied to new patients with speech disability where acoustic-neural training data is not feasible.

Three-Month Incidence of Venous Thromboembolism in Patients Who Underwent Neurological Surgeries

Three-Month Incidence of Venous Thromboembolism in Patients Who Underwent Neurological Surgeries

Implementation of ORBEYE®-Exoscope in the Operative Treatment of Spinal Dural Arteriovenous Fistula

Spinal dural arteriovenous fistulas (sDAVFs) are rather uncommon lesions of the spine. In sDAVFs, which represent the most frequent form of vascular malformations of the spine, operative treatment remains the most common treatment modality. In operative surgery, visualization and pathology detection have a key impact on the results of the neurosurgical treatment of an sDAVF. The exoscope is one of the most recent imaging devices developed alongside the microscope and endoscope. The exoscope is being increasingly applied in neurosurgical procedures as an alternative to operative microscopes due to various advantages, such as its non-space-occupying camera, excellent visualization of the anatomical details and the perfect teaching possibilities it thus provides. In this publication, we present our experience in the treatment of a patient with an sDAVF, where surgery was performed exclusively with an ORBEYE-exoscope for the entire duration of the procedure. This report outlines the workflow and some of the technical pitfalls involved in managing this vascular pathology using the exoscopic technique.

Impact of Country Income Level on Outcomes in Patients with Acute Brain Injury Requiring Invasive Mechanical Ventilation: A Secondary Analysis of the ENIO Study.

Invasive mechanical ventilation can present complex challenges for patients with acute brain injury (ABI) in middle-income countries (MICs). We characterized the impact of country income level on weaning strategies and outcomes in patients with ABI. A secondary analysis was performed on a registry of critically ill patients with ABI admitted to 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Patients were classified as high-income country (HIC) or MIC. The primary outcome was ICU mortality. Secondary outcomes were days to first extubation, tracheostomy, extubation failure, ICU length of stay, and hospital mortality. Multivariable analyses were adjusted for clinically preselected covariates such as age, sex, body mass index, neurological severity, comorbidities, and ICU management. Extubation and tracheostomy outcomes were also adjusted for arterial blood gas values and ventilatory settings. Of 1512 patients (median age = 54years, 66% male), 1170 (77%) were from HICs, and 342 (23%) were from MICs. Median age was significantly lower in MICs [35 (range 26-52) vs. 58 (range 45-68) years in HICs]. Neurosurgical procedures (47.7% vs. 38.2%) and decompressive craniectomy (30.7% vs. 15.9%) were more common in MICs, whereas intracranial pressure monitoring (12.0% vs. 51.5%) and external ventricular drain (7.6% vs. 35.6%) were less common. Compared with HICs, patients from MICs had 2.27 times the odds of ICU mortality [p = 0.009, 95% confidence interval (CI) 1.22-4.21]. Frequency of extubation failure was lower in MICs but not significant after adjustment. Patients from MICs had 3.38 times the odds of tracheostomy (p ≤ 0.001, 95% CI 2.28-5.01), 5.59days shorter mean ICU stay (p < 0.001, 95% CI - 7.82 to - 3.36), and 1.96 times the odds of hospital mortality (p = 0.011, 95% CI 1.17-3.30). In an international registry of patients with ABI requiring invasive mechanical ventilation, MICs had higher odds of ICU mortality, tracheostomy placement, and hospital mortality compared with HICs, which may be due to difference in neurocritical care resources and management.

Comparison of desflurane and sevoflurane as maintenance inhalational anaesthetic agents for adult patients undergoing neurosurgeries: A systematic review and meta-analysis of randomised trials

Background and Aims: Despite its superior blood–gas partition coefficient compared to sevoflurane, use of desflurane in neurosurgery is limited due to concerns about cerebral vasodilation and potential adverse haemodynamic effects. This study aims to systematically evaluate the comparative efficacy and safety of desflurane and sevoflurane in neurosurgical procedures. Methods: A search was performed in the Cochrane Library, Scopus, Europe PMC and Medline databases for articles published until 5 November 2024 using a combination of pertinent keywords. This review includes randomised controlled trials (RCTs) that analyse the comparison between desflurane and sevoflurane in neurosurgery. The risk of bias from each RCT was assessed using the Risk of Bias version 2 tool from Cochrane Collaboration. We utilised random-effects models to evaluate the mean difference (MD) and odds ratio (OR) for the outcomes presented. Results: Fourteen trials, encompassing 904 patients, were included in the analysis. Our analysis revealed significantly faster recovery profiles with desflurane, including reduced emergence time [MD -2.26; 95% confidence interval (CI): -2.99, -1.52, P &lt; 0.00001, I 2 = 71%], extubation time (MD -3.02; 95% CI: -3.89, -2.15, P &lt; 0.00001, I 2 = 79%) and overall recovery time (MD -3.26; 95% CI: -5.01, -1.51, P = 0.0003, I 2 = 83%), compared to sevoflurane. Desflurane was associated with better postoperative cognitive function, as evidenced by higher short orientation memory concentration test scores – a measure of attention and memory – at 15 min (MD: 2.26; 95% CI: 0.13, 4.39, P = 0.04, I 2 = 91%) and 60 min (MD: 0.29; 95% CI: 0.09, 0.50, P = 0.005, I 2 = 0%) after extubation. We did not find any significant difference in the intra- and/or postoperative events, such as emergence agitation, nausea and vomiting, shivering, hypertension, hypotension, tachycardia, bradycardia, pain and convulsions, between the two groups of intervention. Conclusion: This study suggests that desflurane anaesthesia offers faster recovery with a similar safety profile to sevoflurane for neurosurgery.

The Naked Neurosurgeon and the Anatomy of a Complication.

IntroductionThe neurosurgeon is always poised precariously between the operation and the abyss of a complication. As Wilder Penfield sagaciously wrote in 1961, "I will faithfully record and analyze my failures in the care of the sick, seeking the cause, so that those who follow may be warned of the danger."AimThis paper seeks to briefly overview the literature on complications in surgery, neurosurgery in particular.Materials and MethodProgress in our specialty has been accomplished by the overcoming of complications via technique or technology. Dr. Samer Nashef commented sarcastically that surgeons are not, as a general rule, well known for their rapacious appetite for reading. But knowing the literature on complications from our field and others is essential for progress. We must know the anatomy of complications to avoid and manage them.In 1992, Michael Apuzzo published his magnus opus, Brain surgery: Complication avoidance and management, which was admirably followed by Edward Benzel's edited work Spine surgery: Techniques, complication avoidance and management, setting standards in the science of complication avoidance and management in 1999 for years to come. In 2001, Crossing the quality chasm: A new health system for the twenty-first century was published in the United States by the Institute of Medicine. Lucian Leape (a pediatric and thoracic surgeon) published Error in Medicine in JAMA in December 1994, and in 1991, he published the Harvard Medical Practice Study, defining essential terms like adverse event and negligence. Atul Gawande, a general surgeon at Harvard University, wrote "The Bell Curve: What happens when patients find out how good their doctors really are," in the New Yorker on December 6, 2004; he went on to pen Complications-A surgeon's notes on an imperfect science in 2002 and Better: A surgeon's notes on performance in 2007; and he peaked with his classic The Checklist Manifesto-How to get things right in 2009. In 2015, The Naked Surgeon-The power and peril of transparency in medicine appeared. Written by a cardiothoracic surgeon, Samer Nashef, the book takes the study of complication avoidance to a different level and describes how cardiac surgery blazed the trail in quality monitoring and improvement, leaving no scope for other specialties but to follow. The era of the naked neurosurgeon may be beginning anytime.ConclusionEver since E. C. Pearce delivered the 34th Rovenstine lecture, 40years behind the mask-Safety revisited, in 1996, the literature on complication avoidance and management has been growing exponentially. Cross-specialty discourse and the exchange of ideas are essential for neurosurgery to maintain its position as the emperor of all specialties.

First-in-human experience of a portable electrical drill with smart autostop for bedside external ventricular drain placement

BackgroundTimely external ventricular drain (EVD) placement may be a lifesaving neurosurgical procedure. The manual twist drill used for intracranial access represents an opportunity for potential improvement in efficiency, safety, and ease of use. A new generation of portable electrical drills with smart autostop mechanisms, such as the Hubly cranial drill (Hubly Surgical; Lisle, IL), aim to address these opportunities for improvement. ResultsTwo patients received EVDs using the portable electrical autostop drill (PEAD): A 54-year-old woman who suffered a postoperative hemorrhage and a 59-year-old woman who presented with early hydrocephalus secondary to hypertensive subarachnoid hemorrhage (SAH). Between both patients, a total of 9 and 2 access attempts were necessary to breach the inner table and visual dura. Access times in both cases, from skin incision to dural puncture, were less than 5 min. There were no apparent complications with the use of the PEAD in either case, and there was excellent placement of the EVD at the foramen of Monroe in both cases. ConclusionWe demonstrate the first successful use of a portable electrical drill with smart autostop in humans. The PEAD has potential to reduce procedure time and human error. Further development of the smart autostop drill may allow for more consistent and safer EVD placement.

CRANIOPLASTY: AUTOLOGOUS BONE GRAFT VS TITANIUM MESH

Background: Cranioplasty (CP) is a neurosurgical procedure performed after decompressive craniectomy using autologous bone graft or various artificial materials. Objective: To determine differences in complications between patients who underwent CP using an autologous bone flap versus titanium mesh and to identify significant risk factors for post-CP complications. Study Design: Comparative cross-sectional study. Methods: A total of 38 patients, 29 males (76.4%) and 9 females (23.6%), were included in this study. All patients underwent cranioplasty with titanium mesh or autologous bone graft. Results: The results were compared between autografts and titanium implants. Autologous bone graft was used in 76.3% of the patients and titanium implant was used in 23.7%. Different complications occurred in 5.26% of the patients in both groups, 2.63% in the autologous group and 2.63% in the titanium mesh group respectively. Infection occurred in the surgical site in 5.26% of the patients in both groups (similar). Cranioplasty infection occurred in 2.63% of the patients who underwent autologous transplantation. One patient developed a hematoma in both groups. One patient underwent autologous bone graft removal, and one patient underwent mesh removal. Practical Implication: Titanium mesh cranioplasty is an essential procedure for junior neurosurgeons to learn and achieve good results, shorten hospital stay, and save hospital resources. Conclusion: Titanium mesh cranioplasty has similar complications to autologous bone cranioplasty.

Cranial Surgeries in a New Neurosurgery Centre in an Urban Specialist Hospital in Southeast Nigeria: A 40-Month Review

Background: The Imo State Specialist Hospital (IMSSH) commenced neurosurgical services in April 2021 with outpatient consultations, and a cranial surgery performed in the same month was her first neurosurgical procedure. This is an audit of cranial pathologies surgically managed in the hospital in her first 3 years since the commencement of neurosurgical procedures. Aims: The study aimed to look at the pattern of cranial pathologies surgically managed in the hospital from the commencement of neurosurgery services, including their age and gender distribution, the cranial pathologies and their distribution. Methods: The surgical records of all neurosurgery patients who had cranial surgical operations at IMSSH, Owerri, from April 2021 to July 2024 (40 months) were retrospectively reviewed. Results: One hundred and ninety-two (192) patients had cranial surgical operations during the study period (an average of 5 surgeries per month). The mean age of patients was 39 years with a male-to-female ratio of 1.5:1. The mean age for male patients was 43 years while that of female patients was 32 years. The peak age range at presentation was in the paediatric age group, 0 – 19 years (n=69, 36%), followed by the elderly age group, 60 – 79 years (n=55, 28.6%). The highest frequency of cranial surgeries was performed for hydrocephalus (n=85, 44.3%). This was followed by cranial haematomas (n=52, 27.1%), cranial tumours (n=33, 17.2%) and cranial infections (n=13, 6.8%). Among cases of hydrocephalus, hydrocephalus in children (n=46) accounted for the highest number of cranial surgeries, while among cranial haematomas and cranial tumours, chronic subdural haematoma (n=27, 59.1%) and meningiomas (n=13, 39.3%) accounted for the highest frequencies respectively. Conclusion: The study showed a male preponderance for cranial pathologies surgically managed in the hospital, with hydrocephalus in children and chronic subdural haematoma in the elderly having the highest presentation in our environment. A focus on preventive measures against hydrocephalus and chronic subdural haematoma may help in reducing the burden of these diseases in our environment.

Intraoperative stimulation mapping of sensory branches of the trigeminal nerve using unconditioned reflexes

Introduction: Intraoperative stimulation mapping enables to determine the location of nerves in the surgical field when visualization is difficult, as well as to identify visualized nerves, thereby reducing the risk of postoperative iatrogenic complications. Motor nerve mapping is widely used in neurosurgical procedures but only a few attempts at intraoperative sensory nerve mapping have been reported to date. The introduction of an effective method for mapping the sensory branches/portions of the trigeminal nerve can reduce the risk of complications such as facial hypo- and hyperesthesia after operations in the posterior cranial fossa. Objective: To demonstrate the possibility of using unconditioned reflex motor reactions for stimulation mapping of the sensory branches/portions of the trigeminal nerve.Methods: Intraoperative neuromonitoring records were analyzed in three patients with trigeminal neuralgia who underwent nerve stimulation mapping during microvascular decompression. The using of an extended to 40 ms time window for recording myographic responses enabled to record both short-latency direct motor responses to stimulation of motor nerves and long-latency reflex motor responses to stimulation of the sensory branches of the trigeminal nerve. Results: It was shown that unconditioned reflex reactions of the orbicularis oculi muscle (stimulation of the V1 portion of the trigeminal nerve, blink reflex) and tongue muscles (stimulation of V3, trigemino hypoglossal reflex) were successfully induced in patients under total intravenous anesthesia with both monopolar and bipolar stimulation. One patient also showed a reaction of the orbicularis oris muscle (stimulation of V2, snout reflex). The technique used enabled to differentiate not only the motor and sensory roots of the trigeminal nerve, but also its different sensory portions separately.Conclusion: The intraoperative stimulation mapping of sensory branches/portions of the trigeminal nerve via unconditioned reflex motor responses can be performed using the equipment and anesthesia regimen typical for motor nerve mapping. Received 10 October 2024. Revised 1 November 2024. Accepted 12 November 2024. Informed consentThe patients’ informed consent to use the records for medical purposes is obtained. FundingThe study was supported by the grant of Russian Science Foundation No. 23-25-00322. Conflict of interestThe authors declare no conflict of interest. Contribution of the authorsThe authors contributed equally to this article.

Bilateral Lesions in Parkinson's Disease: Gaps and Controversies.

Bilateral lesions of the basal ganglia using termocoagulation or radiation for improving tremor, bradykinesia, and rigidity in people with Parkinson's disease (PD) have been performed starting several decades ago, especially when levodopa and deep brain stimulation (DBS) surgery were not available. However, because of unclear additional benefit compared to unilateral lesion, and particularly to the evidence of increased adverse events occurrence, bilateral lesions were basically abandoned at the end of the 20th century. Therefore, bilateral DBS has become the standard procedure to treat PD. Magnetic resonance imaging-guided focused ultrasound (MRgFUS) is an emerging incisionless technique used to produce therapeutic brain ablation. The positive experiences of unilateral MRgFUS ablation for PD, along with the preliminary favorable outcomes of bilateral thalamic MRgFUS for essential tremor, raise the possibility to eventually reintroduce bilateral lesioning in the management of PD motor features. This possibility has so far only been tested in a few small studies. This article reviews the evidence of bilateral lesioning of the basal ganglia to treat PD, and elaborates on current gaps, controversies, and perspectives of the different available neurosurgical procedures and specifically of MRgFUS ablation. © 2024 The Author(s). Movement Disorders published by Wiley Periodicals LLC on behalf of International Parkinson and Movement Disorder Society.

Harvey Cushing: France Military Hospital Surgical Unit Head and World War I United States Army Medical Corps Commissioner.

This historical account reviews the course and lasting impact of Dr. Harvey Cushing (1869-1939) in neurosurgery. The writing of this project was sparked by the discovery of original scientific and bibliographical information about Cushing. It is a thorough review of archival documents about Harvey Cushing and the Cushing family. Harvey Cushing received his early schooling at the Cleveland Manual Training School, which provided him early access to science and developed his manual dexterity. Along with obtaining a degree at Yale University and training at both Harvard Medical School and The Johns Hopkins Hospital, Cushing collaborated with Louise Eisenhardt, Riva Rocci, Ivan Petrovich Pavlov, William Stewart Halstead, and Sir William Osler. Cushing wrote several monographs including "Blood Vessel Tumours of the Brain," "The Pituitary Body and its Disorders," and "Tumors of the Nervus Acousticus." Cushing served in the U.S. Army Medical Corps, worked as the surgical unit head for a French military hospital and treated Lieutenant Edward Revere Osler. Cushing's armamentarium included electromagnets for brain surgery. He was elected to the American Academy of Arts and Sciences and received various accolades. Cushing trained Walter Dandy, Louise Eisenhardt, and Wilder Penfield. This historical reconstruction provides glimpses into the personality of Dr. Harvey Cushing and his marked impact on neurosurgery and adds to the growing literature on his person.

Multiple burr hole and erythropoietin combination therapy: optimal early surgical intervention for patients with acute stroke episode of moyamoya disease or moyamoya syndrome

ObjectiveThe optimal timing of bypass surgery for patients with moyamoya disease (MMD) or moyamoya syndrome (MMS) following an acute stroke episode remains unclear, mainly owing to the risk of postoperative complications. In this study, we aim to validate the safety and efficacy of early intervention using multiple burr hole (MBH) and erythropoietin (EPO) therapy, thereby refining the management strategy for patients with acute stroke episode of MMD or MMS.MethodsWe retrospectively analyzed data from 70 patients with MMD or MMS who underwent MBH and EPO therapy. The cohort was divided based on the time interval between the latest neurological deterioration and surgery: early (&amp;lt;30 days) and later (≥30 days) groups. We evaluated and compared perioperative clinical parameters and the extent of neovascularization on a 6-month postoperative angiography. Long-term clinical outcomes, including transient ischemic attack (TIA), infarction, hemorrhage, and seizure, were also analyzed during the follow-up period.ResultsIn the cohort, 36 patients (51.4%) were in the early group, whereas 34 (48.6%) were in the later group. The 6-month follow-up angiography demonstrated that 34/47 hemispheres (72.3%) in the early group exhibited successful neovascularization (≥2/3 of MCA territories) compared with the 19/44 (43.2%) hemispheres in the later group (odds ratio [OR] = 3.44; 95% confidence interval [CI]: 1.46–8.45; p &amp;lt; 0.01). In addition, a notable reduction (≥50%) in basal moyamoya vessels was observed in 30/47 hemispheres (63.8%) from the early group vs. 12/44 (27.3%) hemispheres from the later group (OR = 4.71; 95% CI: 1.97–11.82; p &amp;lt; 0.001). During the average follow-up of 56.5 months, only six patients experienced infarction or hemorrhage.ConclusionOur dataset suggests that MBH and EPO combination therapy is an effective, minimally invasive, and acceptable treatment, even in the early period of patients with MMD or MMS following an acute stroke episode.

Showcasing diversity, equity, and inclusion in neurological surgery: a comparative analysis of neurological surgery residency program websites in the United States.

Residency websites can often be crucial for influencing neurosurgery applicants' first impressions of programs. This study explores the representation of diversity on neurological surgery residency program websites and evaluates the impact of Diversity, Equity, and Inclusion (DEI) statements. The websites of 117 neurological surgery residency programs were evaluated for the presence of 12 diversity and inclusion elements. Univariate analysis was conducted to determine significant differences in DEI scores between neurological surgery residency program websites. Program analysis revealed a mean diversity score of 7.9 out of a maximum score of 12, equating to the presence of 66% of possible DEI elements in our scoring system. Top-50 ranked programs (Doximity) exhibited a significantly higher mean diversity score (8.6 +/- 2.7) compared to those outside the top-50 (7.2 +/- 2.9) (p = 0.009). Accessibility of DEI content varied, with most program websites either having a direct link to a separate DEI webpage (41%) or lacking any DEI elements (42%). A secondary analysis found that the presence of a DEI statement on a program's webpage was not significantly associated with Doximity ranking, NIH funding, geographic region, or hospital funding. However, programs with a DEI statement were significantly more likely to have various additional DEI elements (p < 0.001). While many neurological surgery residencies include elements of DEI on their websites, this is not currently a consistent practice across all programs. We advocate that these initiatives should be prominently featured on program websites to aid applicants in making informed decisions about their training journey.

Bacterial meningitis in a quaternary NICU: A multiyear retrospective study.

Bacterial meningitis causes significant morbidity and mortality in infants. Lumbar punctures are often deferred until the results of blood cultures are known and sometimes not considered, making this population susceptible to a missed diagnosis. There are few studies describing the epidemiology of neonatal meningitis in quaternary neonatal intensive care unit settings. We describe the epidemiology of meningitis in a level IV neonatal intensive care unit; compare pathogens and rates of concordant bacteremia between infants with and without neurosurgical (NS) devices. Retrospective review of infants < 1 year of age in the Children's Hospital of Philadelphia neonatal intensive care unit with bacterial meningitis (June 2007-October 2021). Analysis included summary statistics, Wilcoxon rank sum, Chi square, and Fisher exact tests. We identified 101 episodes of bacterial meningitis (95 infants). 9 infants died. At diagnosis, 26 infants (27%) had NS devices. Group B streptococcus (GBS) and Escherichia coli (E coli) were most common pathogens, however, coagulase-negative staphylococci and Staphylococcus aureus (S aureus) predominated among infants with NS devices. While 86% had positive blood cultures in the absence of a NS device, only 14% of episodes with NS devices had concomitant bacteremia (P < .0001). Although Group B streptococcus and E coli remain most prevalent overall, coagulase-negative staphylococci and S aureus were common pathogens in NS patients. Infants with NS devices rarely had concomitant bacteremia. Meningitis was diagnosed in the absence of a positive blood culture in 36% of episodes, underscoring the importance of developing guidance for lumbar punctures in infants evaluated for sepsis.

The effect of time to neurosurgical or neuroradiological intervention therapy on outcomes and quality of care after traumatic brain injury, a registry-based observational study

BackgroundEvidence regarding the effect of time to neurosurgical and neuroradiological intervention on outcomes in traumatic brain injury (TBI) across Asia-Pacific region is limited. This study evaluates the quality of care and outcomes for TBI patients undergoing neurosurgical and neuroradiological procedures at different timings.MethodsAdult TBI patients who received any neurosurgical or neuroradiological interventions during the year 2015–2022 in the Pan-Asian Trauma Outcome Study database were analyzed. The time to intervention, as the main exposure, was classified into three groups (Early, Intermediate, and Delayed) using Restricted Cubic Spline (RCS) analysis. The outcomes were in-hospital mortality and unfavorable neurological outcomes. W score was utilized to compare the quality of care among exposure groups. Multivariable logistic regression analysis and interaction analysis were performed to identify the association between the exposure groups and outcomes, reported as adjusted odds ratios (AOR) with 95% confidence intervals (CI).ResultsA total of 1,780 patients were included. From the RCS analysis, patients were classified into three groups according to time to intervention: Early (< 1.9 h), Intermediate (1.9–4.1 h), and Delayed (> 4.1 h). According to the time to intervention, W score was − 8.6 in the early group, -1.1 in the intermediate group, and + 0.4 in the delayed group. Patients receiving intermediate and delayed intervention showed significantly lower mortality (AOR 0.64, 95% CI 0.47–0.86 and AOR 0.66, 95%CI 0.48–0.90, respectively).ConclusionEarly neurosurgical and neuroradiological interventions in TBI patients in the Asia-Pacific region were associated with lower quality of care and higher mortality. The quality of care should be focused and improved during the early hours of TBI.

Tubular single-port endoscope-assisted surgery for fetal myelomeningocele repair.

The authors aimed to describe a low-cost and easily reproducible alteration of the Bruner and Tulipan procedure to preserve uterine muscular fibers. They conducted a retrospective cohort study of 10 pregnant women whose fetuses developed lumbosacral myelomeningocele (MM). The MM was repaired through a fetal neurosurgical procedure using a tubular single-port endoscope-assisted technique. This study was conducted at the Santa Joana Hospital and São Paulo Hospital between January 2020 and June 2023. The procedure consisted of tubular retraction of circular fibers from the uterine body without excision of the uterine wall. Tubular devices with progressively larger diameters were used for retraction without cutting the uterine muscular fibers, and a 25-mm-diameter tubular retractor was used to allow endoscope-assisted closure of the MM using microsurgical techniques. The average birth age was 36 weeks 3 days. Defect repair was possible in all cases. The mean surgical time was 130 minutes. Two of the patients developed hydrocephalus. One patient underwent a ventriculoperitoneal shunt, and the other underwent endoscopic third ventriculostomy with choroid plexus coagulation. This procedure avoids excision of the uterine wall, promotes a workspace for microsurgical techniques assisted by endoscopy, and is possibly the first step for future single-port correction using robotic techniques.

How Women and Men with Parkinson's Disease Approach Decision-Making for Deep Brain Stimulation Surgery.

Women make up only 23% to 30% of recipients for deep brain stimulation (DBS) surgery for Parkinson's disease (PD), a discrepancy that is not accounted for by differences in disease incidence. One of the many factors that may contribute to this gap includes gender differences in decision-making. The aim was to explore how women and men approach the decision for DBS in terms of informational needs, weighing risks and benefits, and decision-making. Semistructured interviews were conducted with 33 participants with PD who had undergone DBS evaluation within the past 3 years. Data were analyzed using content analysis. Sixteen women and 17 men participated in interviews. We identified 4 key themes. First, information sources were similar between women and men, and they valued hearing personal experiences. Second, the motivations for DBS surgery were often very personal. Third, the decision-making process occurred over time, sometimes years. Fourth, although many expressed fear of brain surgery, trust in the surgeon helped many overcome this fear. Women overall had less support than men during decision-making and after surgery. Women also placed greater value on talking to other women who had undergone DBS, although they had a hard time finding these women. Men, on the contrary, were less often worried about support and valued numerical information when weighing risks and benefits. We found gender differences in information needs, support, motivating factors, and how patients weighed risks and benefits. These differences can be used to inform educational tools and counseling for DBS.

Mannitol versus mannitol with hypertonic saline for brain relaxation during craniotomies using ultra-sonographic optic nerve sheath diameter

ABSTRACT Background This study compared the effect of conventional doses of mannitol alone versus combined lower doses of mannitol-hypertonic saline on brain debulking during elective craniotomies. Patients and methods Sixty participants aged 18–60 years, ASA class I or II, who were scheduled for elective supratentorial brain tumor surgery, were randomly separated into 2 equal groups. Group (M) received 5 ml/kg of 20% mannitol at the onset of the surgical incision over 15 min. Group (MH) received 2.5 ml/kg of 20% mannitol plus 2.5 ml/kg 3% hypertonic saline (HTS) at the onset of the surgical incision over 15 min. Optic nerve sheath diameter (ONSD), brain relaxation score, serum lactate, electrolytes, and surgeon’s satisfaction were measured. Results Both groups yielded similar results concerning demographic and tumor characteristics. The Optic nerve sheath diameter (ONSD) was considerably lower in group MH compared to group M just before and immediately after dural incision (p = <0.001, and 0.001) respectively. The brain relaxation was considerably more adequate in group MH when compared to group M (p = 0.001). Group MH showed significant elevation in serum sodium, chloride, and osmolarity at 60 min and at the end of surgery with negligible changes at 12- and 24-hrs postoperatively. Moreover, group M showed a significant increase in serum potassium and lactate at 60 min and at the end of surgery, with insignificant change at 12- and 24-hrs postoperatively. Surgeons were more noteworthy satisfied in group MH. Conclusion Optic nerve sheath was comparable to brain relaxation score (BRS) for assessing the brain relaxation. In comparison to mannitol alone, lower prescribed doses of mannitol in combination with hypertonic saline (HTS) have provided better intraoperative brain debulking, clinically accepted electrolyte changes, and more surgeons’ satisfaction during supratentorial brain tumor surgery.