Neurosurgical Consultation Research Articles

NIMG-04. MASSIVE THORACIC MENINGOCELE IN A PATIENT WITH NF1

Abstract Thoracic meningoceles are uncommon but when seen are often associated with neurofibromatosis 1 (NF1). Here we present a unique case where a massive thoracic meningocele presented with chest pain in a patient with NF1. A 56-year-old female with a diagnosis of NF1 presented with pain in the entire chest wall. She described the pain as circumferential around the entire chest “like a barrel”. Cardiology evaluation (with echocardiography) revealed no pulmonary hypertension or other cardiac disorder. MR angiogram of the chest also revealed no intrathoracic vascular structural abnormality. Inflammatory myopathy was considered to explain the pain but electromyography was unremarkable as were creatine kinase and erythrocyte sedimentation rate. MRI of thoracic spine demonstrated a large thoracic meningocele involving the spinal canal from T5-T10 and extending into the left hemithorax with measurements of 11.5 x 6.1 x 12.5 cm. Imaging was also notable for leftward displacement of the spinal cord toward the meningocele starting at the T6 level and extending to the T9 level with kyphosis of the thoracic spine centered on the block vertebral bodies forming the T7-T8 levels. Significant posterior scalloping was evident from T6-T10 with attendant dural ectasia. Neurosurgical consultation recommended no intervention to correct the meningocele as plication carried a risk of producing a subarachnoid-pleural fistula from the meningocele into the pleural space of the thoracic cavity. This case adds to our understanding of how unique and diverse the presentations of NF1 can be, and of the surgical challenges posed by NF1-associated meningoceles.

DISP-10. RACIAL AND SOCIOECONOMIC DIFFERENCES IN CLINICAL AND ACCESS TO CARE OUTCOMES IN NEUROSURGICAL-ONCOLOGY PATIENTS

Abstract BACKGROUND Large database studies have identified racial and socioeconomic differences in neurosurgical-oncologic outcomes. For clearer insights and understanding, more detailed and prospective evaluation is needed. METHODS We retrospectively analyzed a database of 1475 patients undergoing surgery for CNS tumors over 5 years. Multivariate analysis, specific to various pathologies, was conducted to identify demographic and socioeconomic factors (including age, sex, racial identity, primary language, insurance status, and income estimate) associated with access to care and clinical outcomes. Additionally, prospective patient-centered interviews were conducted on neuro- oncology patients to qualitatively explore reasons for disparities in healthcare. RESULTS Significant associations were found between racial identities (White n=911; Hispanic n=285; Asian n=206; Black n=74) and sex (ANOVA p 0.0043), age (p<0.0001), income estimate (p<0.0001), primary language (p<0.0001), and insurance status (p<0.0001). Among different pathologies, presentation to the ED, rather than outpatient setting, was consistently associated with a non- English primary language (p=0.0312) and Medi-Cal insurance (p=0.0029). Time from imaging diagnosis to neurosurgical consultation was associated with non- English primary language (p=0.0262) and Medi-Cal (p=0.0030). Delay between recommendation for surgery and date of surgery was significant in Black patients (p=0.0112). A non- English primary language was negatively associated with having a gross total resection (p=0.0087). Notably, adjuvant treatments were less likely for those with non-English primary language (p=0.0203), Black race (p=0.0049), and Medi-Cal coverage (p=0.0014). Cox regression analysis identified only age (p<0.0001) as a predictor of poorer overall survival in oncologic cases. Prospective interviews identified cultural, economic (work- related), and healthcare navigation issues as reasons for differences in access to care. CONCLUSIONS Across the spectrum of neurosurgical oncology diagnoses, racial and socioeconomic factors independently associate with access to care but not clinical outcome variables. Further investigation is needed, particularly in patients with non- English primary languages and cultural attitudes towards chemotherapy and radiation therapy.

Validating the Brain Injury Guidelines in a Pediatric Population with Mild Traumatic Brain Injury and Intracranial Injury at a Level I Trauma Center.

Children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) often receive unnecessary imaging and hospital admission, leading to avoidable burdens on patients and health systems. While most of these patients do not develop critical neurological injuries, identifying those at risk would allow for a more optimal determination of the appropriate level of initial emergency care. The Brain Injury Guidelines (BIG) were developed as a triage tool to identify adult patients with mTBI and ICI who can benefit from repeat imaging, hospital admission, or neurosurgical consultation. Here, we sought to validate BIG in children at a Level I trauma center and determine if the BIG algorithm can accurately identify which patients with mTBI/ICI have critical neurosurgical injuries. We hypothesize that the BIG can identify critical neurological injuries more accurately than the Glasgow Coma Scale (GCS) alone and that more severe injury according to BIG is associated with worse patient outcome. We retrospectively reviewed TBI admissions at a single center (2017-2023) using an institutional registry. Patients included (0-17 years) had an initial head computerized tomography scan with ICI and a GCS of 14-15. Patients were retrospectively classified into the BIG categories (BIG 1, 2, or 3). Medical records were reviewed to identify clinically important TBI (ciTBI): death, neurological deterioration, neurosurgical intervention, intubation >24 h, or hospital admission >48 h due to TBI. Repeat imaging studies obtained were evaluated for progression of injury. The incidence of clinically important TBI (ciTBI) and imaging progression were recorded and compared across BIG categories. Outcomes were evaluated using the Glasgow Outcome Score Extended (GOS-E) 6 months after injury. Univariable and chi-square tests were used to analyze comparisons. Overall, 804 subjects were included in the analysis of which 551 (68.5%) were transfers. Overall, 175 (21.8%) patients had a BIG 1, 402 (50.0%) a BIG 2, and 227 (28.2%) a BIG 3 injury. CiTBI occurred among 64 (8.0%) patients overall, and in 1 (0.6%), 4 (1.0%), and 59 (26.0%) of the BIG 1, 2, and 3 injuries (p < 0.0001). Progression on repeat imaging associated with neurological decline, neurosurgical intervention or resulting in additional evaluation was noted in 0 (0%), 2 (0.5%), and 41 (18.0%) of the BIG 1, 2, and 3 injuries (p < 0.001). Amongst 471 patients (58.6%) with available 6-month patient outcomes, 98% had a GOS-E ≥5 and no outcome difference between BIG categories was observed. Risk stratification of mild TBI using BIG allowed for reasonable identification of children who subsequently develop ciTBI, suggesting that BIG classification can aid in triage and management of patients who might benefit from neurosurgical consultation, repeat imaging, and potentially transfer to a dedicated trauma center. More severe injury according to BIG was not associated with a worse patient outcome.

A thematic analysis of shared decision-making in consultations with patients with a presumed brain tumor and neurosurgeons

Abstract Background Patients with a brain tumor, family members and healthcare professionals face complex healthcare decisions that can significantly impact everyday life. Engaging in shared decision-making (SDM) can help ensure treatment decisions align with patients’ preferences and goals. Little is known about the decision-making process in neurosurgical consultations. This study aims to qualitatively explore and describe the SDM process during neurosurgical consultations for patients with a presumed brain tumor. Methods The first consultation between patients with a presumed glioma or meningioma and their neurosurgeons was audio-recorded and transcribed. Decision-making models were used as sensitization concepts, with coding carried out inductively. We employed a reflexive thematic analysis to develop themes and sub-themes until saturation was beginning to emerge. Results Analyzing eleven consultations, we developed three main themes and twelve sub-themes. The results depict decision-making guided by neurosurgeons (theme 1), with varying degrees of engagement from patients and family members (theme 2) and personalization of the decision-making process based on the medical situation and everyday life priorities (theme 3). The consultations lacked specific attention to everyday life priorities of the patients. Conclusions The decision-making processes seemed to focus primarily on medically informing patients with a presumed brain tumor, in line with IDM. However, less emphasis was placed on learning more about the patient’s everyday life and preferences to integrate into the decision-making process, which is key to SDM. Incorporating patient goals may lead to greater personalization and decisions that align with both the patient’s medical situation and their goals.

Low-Value Clinical Practices in Pediatric Trauma Care

Reducing low-value care has the potential to improve patient experiences and outcomes and decrease the unnecessary use of health care resources. Research suggests that low-value practices (ie, the potential for harm exceeds the potential for benefit) in adult trauma care are frequent and subject to interhospital variation; evidence on low-value practices in pediatric trauma care is lacking. To estimate the incidence of low-value practices in pediatric trauma care and evaluate interhospital practice variation. A retrospective multicenter cohort study in a Canadian provincial trauma system was conducted. Children younger than 16 years admitted to any of the 59 provincial trauma centers from April 1, 2016, to March 31, 2022, were included. Low-value practices were identified from systematic reviews of clinical practice guidelines on pediatric trauma. The frequencies of low-value practices were evaluated by estimating incidence proportions and cases per 1000 admissions (low if ≤10% and ≤10 cases, moderate if >10% or >10 cases, and high if >10% and >10 cases) were identified. Interhospital variation with intraclass correlation coefficients (ICCs) were assessed (low if <5%, moderate if 5%-20%, and high if >20%). A total of 10 711 children were included (mean [SD] age, 7.4 [4.9] years; 6645 [62%] boys). Nineteen low-value practices on imaging, fluid resuscitation, hospital/intensive care unit admission, specialist consultation, deep vein thrombosis prophylaxis, and surgical management of solid organ injuries were identified. Of these, 14 (74%) could be evaluated using trauma registry data. Five practices had moderate to high frequencies and interhospital variation: head computed tomography in low-risk children (7.1%; 33 per 1000 admissions; ICC, 8.6%), pretransfer computed tomography in children with a clear indication for transfer (67.6%; 4 per 1000 admissions; ICC, 5.7%), neurosurgical consultation in children without clinically important intracranial lesions (11.6%; 13 per 1000 admissions; ICC, 15.8%), hospital admission in isolated mild traumatic brain injury (38.8%; 98 per 1000 admissions; ICC, 12.4%), and hospital admission in isolated minor blunt abdominal trauma (10%; 5 per 1000 admissions; ICC, 31%). In this cohort study, low-value practices appeared to be frequent and subject to interhospital variation. These practices may represent priority targets for deimplementation interventions, particularly as they can be measured using routinely collected data.

8188 Pituitary hyperplasia resulting from primary hypothyroidism: A case report

Abstract Disclosure: M. Aziz: None. M.I. Manolas: None. V. Tabatabaie: None. L. Rincon: None. Pituitary hyperplasia resulting from primary hypothyroidism: A case report.Background: Primary hypothyroidism is a common endocrine condition seen in 4.6% of USpopulation (1). We describe an uncommon presentation of prolonged severe primaryhypothyroidism leading to significant hyperplasia of the pituitary gland resembling a pituitarymacroadenoma. Clinical Case: A 34-year male with schizophrenia and Hashimoto’s hypothyroidism diagnosedat the age of 17 presented with hallucinations, chest pain, fatigue, and dyspnea. The patient hada 15-year history of uncontrolled hypothyroidism with persistently elevated TSH with values ashigh as 2,299 (n 0.30-4.20 uU/mL) due to poor adherence to levothyroxine. Initial laboratorystudies revealed hyponatremia (Na 130, n135-145 mEq/L), elevated TSH (&amp;gt;100, n0.30-4.20 uU/mL), undetectable FT4 (&amp;lt;0.4, n0.6-1.5 ng/dL) and elevated CK (5671, n&amp;lt;200 U/L).Levothyroxine was restarted at dose of 150 mcg daily. Head CT performed for evaluation ofaltered mental status and hallucinations revealed hyperdensity within the pituitary gland,concerning for underlying hemorrhage and apoplexy. Neurosurgical consultation was requested,and a pituitary MRI was obtained in preparation for potential surgical intervention. MRI showeda prominent anterior pituitary gland measuring up to 14 mm with homogeneous enhancementwithout evidence of hemorrhage. In the absence of any hemorrhage or definitive mass, thepituitary enlargement was considered secondary to the long-standing history of uncontrolledprimary hypothyroidism leading to pituitary hyperplasia, and surgical intervention was deemedunnecessary. Repeat labs 1 week later showed TSH &amp;gt;100uU/mL, FT4 0.6 ng/dL, CK 2799 andrepeat MRI showed slight decrease in size of the pituitary gland, confirming hyperplasiasecondary to severe, prolonged hypothyroidism. Conclusion: Prolonged primary hypothyroidism can lead to pituitary hyperplasia which can bemistaken as pituitary macroadenoma, leading to unnecessary surgical intervention. Carefulreview of history and TSH trends can help elucidate this diagnosis.

7102 Pituitary Apoplexy with Eventual Complete Tumour Involution

Abstract Disclosure: A. Ng: None. R. Lai: None. Pituitary apoplexy is an endocrinological emergency resulting from infarction or haemorrhage of the pituitary gland. We present a case of pituitary apoplexy from a non-functioning pituitary macroadenoma, complicated by pituitary insufficiency and subsequent tumour involution. An 80-year-old gentleman presented to the Emergency Department with sudden severe headaches and persistent vomiting and admitted for further evaluation. Computed tomography (CT) imaging of the brain showed a prominent pituitary gland and magnetic resonance imaging (MRI) confirmed a large sellar hyperintense lesion containing blood and proteinaceous material. It measured 1.6 cm by 1.2 cm by 1 cm and indented the optic chiasm. CT angiography did not reveal any aneurysms or intracranial haemorrhage. There were no neurological or visual field deficits at presentation. There was no indication for surgery upon neurosurgical consultation. Initial evaluation of the pituitary axis was consistent with central hypocortisolism (cortisol 75 nmol/L, adrenocorticotropic hormone 1.4 pmol/L [reference range (RR) 1.6-13.9]) and hypoprolactinaemia (prolactin 56 mIU/L, RR 73-351). Luteinising hormone levels were &amp;lt; 1 IU/L (RR 1-9); follicle stimulating hormone levels were 3 IU/L (RR 1-19) and testosterone levels were &amp;lt; 1 nmol/L (RR 5 to 30) as the patient was on androgen deprivation therapy for prostate cancer. Hydrocortisone was started and he was monitored for development of frank diabetes insipidus. He did not require regular desmopressin. He later developed anti-diuretic hormone mediated hyponatraemia (serum sodium nadir of 125 mmol/L, serum osmolality 275 mmol/kg, urine osmolality 390 mmol/kg) that was managed with fluid restriction and solute loading. He also developed central hypothyroidism on day 19 of admission (free thyroxine 11 pmol/L, thyroid stimulating hormone 0.49 mIU/L, RR 0.45-4.5) and oral levothyroxine was started. He was discharged with oral hydrocortisone and levothyroxine replacement. A repeat MRI of the pituitary 2 months later showed complete resolution of the mass and resolution of the mass effects. He was kept on oral hydrocortisone and levothyroxine replacement with regular follow-up.Most pituitary macroadenomas are non-functional, and can present with complications of apoplexy, mass effects or hormonal disturbances. However, the natural history of non-functional macroadenomas is not well known as most are operated on. Spontaneous regression of the tumour can rarely occur, notably in the setting of apoplexy and lymphocytic hypophysitis. Recovery of the pituitary axis may also accompany tumour regression. As spontaneous remission of pituitary macroadenomas may occur, close observation of tumours without visual field defects or significant mass effects may be an alternative to surgery. Presentation: 6/1/2024 12:15:00 PM

Creating and validating a neurosurgical intervention rule-out tool for patients with mild traumatic brain injury and isolated subdural hematoma: a 5-year, six-center retrospective cohort study.

Because there is no reliable method on admission to predict whether a patient will require neurosurgical intervention in the future, the general approach remains to treat each patient with mild traumatic brain injury (mTBI) and subdural hematoma (SDH) as if they will require such an intervention. Consequently, there is a growing population of patients with mTBI and SDH that is overtriaged despite having a low probability of needing neurosurgical intervention. This study aimed to train and validate a predictive rule-out tool for neurosurgical intervention in patients with mTBI and SDH. This was a retrospective cohort study of all trauma patients admitted to six level I trauma centers in three states. Patients were included if they met the following criteria: admitted between 2016 and 2020, ≥ 18 years of age, ICD-10 diagnosis of isolated SDH, initial head imaging available, initial Glasgow Coma Scale score of 13-15, and arrived within 48 hours of injury. Exclusion criteria included skull fracture, intracranial hemorrhage other than an SDH, and no neurosurgical consultation. Prediction variables included 34 demographic, clinical, and radiographic variables. The study outcome was neurosurgical intervention within 48 hours of hospital admission. Seventy-five percent of the data were used for training, and 25% for testing. Multivariable logistic regression with fivefold cross-validation was used on the training set to identify covariates with the highest specificity while holding sensitivity at 100%. Results were validated on the testing set. In total, 1000 patients were in the training set and 333 in the testing set. The overall neurosurgical intervention rate was 8.8%. For the fivefold cross-validation process, three variables were selected that maximized specificity while holding sensitivity at 100%: maximum hematoma thickness, initial Glasgow Coma Scale score, and preinjury antithrombotic use (sensitivity 100%, specificity 56%, area under the receiver operating characteristic curve 0.94). With a cutoff probability of neurosurgical intervention set at 1.88%, the final model was validated to predict neurosurgical intervention with a sensitivity of 100% (95% CI 88.4%-100%) and specificity of 55.1% (95% CI 49.3%-60.8%). In this study, the largest of its kind to date, the authors successfully developed and validated a new tool for ruling out the necessity of neurosurgical intervention in patients with mTBI and isolated SDH. By successfully identifying more than half of patients who are unlikely to require neurosurgery within the first 2 days of admission, this tool can be used to improve treatment efficiency and provide patients and clinicians with valuable prognostic information.

Management of cloacal exstrophy: Experience from tertiary hospital, Tanzania. Case series

Introduction and importanceCloacal exstrophy (CE) is defined as a complex anomaly that affects the urogenital and intestinal tracts. It is the most serious form of anomaly that is described within the so-called exstrophy-epispadias complex. These malformations usually present a challenge in the management of particular conditions, as most of these forms require multiple surgeries, resulting in the use of multidisciplinary approaches, including reconstructive urologists, pediatric surgeons, orthopedic surgeons, endocrinologists, pediatricians, psychologists and nutritionists. Additionally, these patients present with ambiguous genitalia, which is another aspect that needs to be taken into consideration during the management of this condition. Case presentationThe first patient, a baby who was 8 days of life and referred from a peripheral hospital, presented with classic features of cloaca exstrophy. He underwent first-stage cloacal exstrophy repair. The intraoperative findings included a bi-halved bladder and phallus, and the ureters were not appreciated, but there was continuous urine leakage from the bi-halved bladder and no uterus or ovaries. Poorly formed cecum, cecal-cutaneous fistula with an everted part of the terminal ileum protruding outside (mucosa-out), no transverse, no descending colon, collapsing small bowel, left undescended testis in the inguinal region, and right abdominal undescended testis. He first underwent surgery, which involved ileostomy, omphalocele closure and proper bladder exstrophy construction.The second patient, a 6-day-old female, had a similar presentation and physical findings as the first patient did, except that she had elephantoid trunk deformity with a cecal fistula, bifid clitoris, two cervical orifices, and two uteri completely separated with ovaries. Mobilization of the hindgut, closure of the cecal fistula, and proper bladder exstrophy after repair of the posterior wall were performed.The third patient was a 10-day-old female, similar to the second patient, but this patient presented with a left leg deformity with wide diastasis. In this case, the urinary bladder was not bivalved, and the cecal fistula had perforated just below the posterior wall of the urinary bladder. A mild omphalocele, bifid clitoris and vagina, one cervical orifice, and two uteri completely separated, with ovaries observed. Mobilization of the hindgut, closure of the cecal fistula, and proper bladder exstrophy after repair of the posterior wall were performed. The postoperative period was uneventful. Clinical discussionSurgical management of cloacal exstrophy is typically undertaken in the newborn period (48–72 h) as a combined effort between pediatric surgery and urology. In the setting of associated spinal dysraphism, neurosurgical consultation and closure should be undertaken as soon as the infant becomes medically stable. Early operation minimizes bacterial colonization of exposed viscera and may decrease the need for pelvic osteotomy. The goals of treatment include securing the abdominal wall and bladder closure, preserving renal function, preventing short bowel syndrome, creating functional and cosmetically acceptable genitalia, and attaining acceptable urinary and fecal continence. ConclusionCloacal exstrophy remains a rare and complex congenital anomaly characterized by an array of anatomical defects affecting multiple organ systems. With respect to the approach of this congenital malformation, it is therefore important that these individuals and their families remain under the care of a multidisciplinary team of providers who can offer medical care, counseling and life-long follow-up.

Less is more: Streamlining management of isolated traumatic subarachnoid hemorrhage in the modified brain injury guidelines

BackgroundPatients with isolated traumatic subarachnoid hemorrhage (iTSAH) are managed according to the modified Brain Injury Guidelines (mBIG) class. The current study aimed to describe patients with iTSAH and analyze their clinical outcomes. MethodsA retrospective analysis was performed on trauma patients with iTSAH. Exclusion criteria were Glasgow Coma Scale (GCS) ​< ​13 and pre-injury antiplatelet/anticoagulant use. Results276 patients were identified over the 8-year study period. The median number of head CT scans was 2. Neurosurgery consultation was obtained in 80.4 ​% of patients. A total of 19 (8.6 ​%) patients had radiographic progression. Six (2.2 ​%) patients had neurologic deterioration. No patients required operative intervention or readmission. No deaths were related to iTSAH. ConclusionsThere were no patients with iTSAH that required neurosurgical consultation despite a subset of patients having radiographic or neurologic progression. These patients may not require repeat head CT scan or neurosurgical consult, necessitating a change of SAH definitions in the mBIG.

A Clinical Review on Spinal Epidural Abscess: Epidemiology, Pathophysiology, Diagnosis, and Management for Emergency Medicine and Hospitalist Physicians.

Description Spinal epidural abscess (SEA), a critical surgical emergency, demands prompt recognition and intervention to prevent severe complications and fatalities. The incidence of SEA is notably increasing, particularly among individuals with diabetes, intravenous drug use, or a history of invasive spinal procedures. Although SEA can manifest through various clinical symptoms, the presence of its classic triad-back pain, fever, and neurological deficits-is noteworthy despite its occurrence in only 10% to 13% of cases. Identifying this triad is vital due to its high specificity for SEA, which is essential to guiding swift diagnostic and therapeutic actions in a condition where early intervention is critical. Magnetic resonance imaging is pivotal in diagnosing SEA, offering unmatched sensitivity and specificity compared to other imaging techniques. Immediate empirical antibiotic therapy and timely neurosurgical consultation, when required, form the foundation of SEA treatment. The prognosis significantly depends on the patient's initial neurological status, underlying health conditions, and the timeliness of their presentation, diagnosis, and treatment initiation. Given the complexity of SEA and the high risk of diagnostic delays, managing this condition involves substantial medicolegal considerations. Enhanced comprehension of SEA is imperative for improving patient outcomes and reducing health care resource burdens. Prompt and accurate diagnosis and appropriate interventions are essential for effectively managing this urgent condition.

Risk factors for neurosurgical intervention within 48 hours of admission for patients with mild traumatic brain injury and isolated subdural hematoma.

The objective was to identify demographic, clinical, and radiographic risk factors for neurosurgical intervention within 48 hours of admission in patients with mild traumatic brain injury and isolated subdural hematoma. The authors conducted a multicenter retrospective cohort study of all trauma patients admitted to 6 level I/II trauma centers who met the following criteria: admitted between January 1, 2016, and December 31, 2020, age ≥ 18 years, ICD-10 diagnosis code for isolated subdural hematoma, available initial head imaging, initial Glasgow Coma Scale score of 13-15, and arrival at the hospital within 48 hours of injury. Patients were excluded for skull fracture, non-subdural hematoma, and absence of neurosurgical consultation. The study outcome was neurosurgical intervention within 48 hours of hospital admission. Multivariable logistic regression with backward selection examined 30 demographic, clinical, and radiographic risk factors for neurosurgery. In total, 1333 patients were included, of whom 117 (8.8%) received a neurosurgical intervention. When only demographic and clinical variables were considered, sex, mechanism of injury, and hours from injury to initial head imaging were significant covariates (area under the receiver operating characteristic curve [AUROC] [95% CI] 0.70 [0.65-0.75]). When only radiographic risk factors were considered, only maximum hemorrhage thickness (in mm) and midline shift (in mm) were independent risk factors for the outcome (AUROC 0.95 [0.92-0.97]). When all demographic, clinical, and radiographic variables were considered together, advanced directive, Injury Severity Score, midline shift, and maximum hemorrhage thickness were identified as significant risk factors for neurosurgical intervention within 48 hours of hospital admission (AUROC 0.95 [0.94-0.97]). In the setting of mild traumatic brain injury with isolated subdural hematoma, radiographic risk factors were shown to be stronger than demographic and clinical variables in understanding future risk of neurosurgical intervention. These final radiographic risk factors should be considered in the creation of future prediction models and used to increase the efficiency of existing management guidelines.

Analysis of patients consulted to the neurosurgery clinic from the emergency department and evaluation of mortality

ABSTRACT Objective: To analyze neurosurgical consultations in emergency department admissions, to reveal the characteristics of patients in need of neurosurgery and to analyze mortality in patients. Materials and Methods: The study was conducted retrospectively in the emergency department of a secondary care hospital. All patients consulted to the neurosurgery clinic from the adult emergency department between 01.01.2023-31.12.2023 were evaluated in the study. Demographic data, admission and/or admission complaint, diagnosis, comorbid disease status, anticoagulant use, surgical procedure status, Glasgow Coma Score at the time of arrival to the emergency department, duration of hospitalization and in-hospital mortality status were analyzed. Results: 595 patients were evaluated in the study. 59.5% of the patients were male and the mean age was 45.17±25.77 years. The most common type of admission was general body trauma due to fall (48.9%). The most common diagnosis was isolated lumbar vertebral fracture (15%). Intensive care unit hospitalization, surgical procedures and mortality rates were significantly higher in patients with a lower Glasgow Coma Score at admission (p

Complexity in the diagnosis of endocrine ophthalmopathy with a carotid-cavernous fistula. A clinical case

Introduction. Clinical cases featuring a combination of endocrine ophthalmopathy with a carotid-cavernous fistula are scarce, with only four cases documented in the literature, thus posing a diagnostic challenge due to overlapping clinical symptoms. A carotid-cavernous fistula with high blood flow typically presents a clear clinical picture. However, low-flow variants are challenging to timely diagnose. A history of head trauma can be an essential diagnostic clue, as carotid-cavernous anastomosis develops in 75% of cases post-trauma and in 25% spontaneously. Bilateral carotid-cavernous fistulas are particularly rare.Purpose: to present the clinical features and outcomes of bilateral endocrine ophthalmopathy associated with a non-traumatic carotid-cavernous fistula, based on the prospective observation of a patient treated in various city healthcare hospitals during 2021–2022.Case description. The patient first visited the ophthalmologist in October 2021, presenting with bilateral exophthalmos, edema, and eye redness. A positive test for antibodies to thyroid-stimulating hormone and enlargement of the eye muscles, confirmed by orbital ultrasound, led to a diagnosis of “Endocrine Ophthalmopathy”. The patient’s condition was managed jointly by an endocrinologist and an ophthalmologist. Over two months, a worsening of ocular symptoms was observed, prompting a neurosurgical consultation. Cerebral angiography conducted in a hospital setting confirmed a carotid-cavernous fistula. An endovascular procedure was performed five months after the initial ocular symptoms appeared to separate the carotid-cavernous anastomosis on the right using a non-adhesive composition. Ocular symptoms resolved within 2–3 weeks post-surgery.Conclusions. Clinical manifestations of carotid-cavernous fistulas can resemble those of endocrine ophthalmopathy. The absence of a traumatic head injury history, complaints of unilateral head noise synchronous with the pulse, and the bilateral nature of the symptoms complicated the diagnosis of this neurosurgical pathology in a patient with endocrine ophthalmopathy. It is crucial to include both conditions in the differential diagnosis and to employ a multidisciplinary approach for effective management.

A Pediatric Brain Injury Guideline Allows Safe Management of Traumatic Brain Injuries by Trauma Surgeons

BackgroundWe implemented a pediatric Brain Injury Guideline (pBIG) to stratify traumatic brain injuries (TBI) and allow management of less severe cases without repeat CT imaging or neurosurgical consultation. Injuries were classified as mild (pBIG1), moderate (pBIG2), severe (pBIG3) or isolated skull fracture (ISF) based on neurologic status, size and number of bleeds. We hypothesize that pediatric TBIs can be safely managed with this guideline. MethodsIsolated TBIs (<18 years) were queried from the Pediatric Trauma Registry after pBIG implementation from July 2021–March 2023. Datasets included age, injury specifics, repeat head CTs, neurosurgical consultations and interventions. Analysis was performed with Stata, with significance set at p < 0.05. ResultsA total of 139 children with a median age of 2.8 years were included. Skull fractures (113, 81%) and subdural hematomas (54, 39%) were the most common injuries. Repeat head CTs were obtained in 44 (32%) and neurosurgical consultation in 89 (64%). Overall guideline compliance was 83.5%, with best performance in the pBIG3 category (96%). One pBIG1 patient had increasing symptoms requiring upgrade, neurosurgical consultation and repeat head CT, but no intervention. Five children (3.6%; 4 isolated skull fracture, 1 pBIG3) had post-discharge ED visits and 1 (0.7%, ISF) had a post-discharge CT. Three (2.2%) children, all in the pBIG3 group, died from their TBIs. ConclusionsAdherence to the algorithm was 83.5%, with the lowest compliance in the moderate TBI (pBIG2) category. This group had a high rate of neurosurgical consultation suggesting uneasiness with independent management of moderate injuries when compared to minor TBIs or isolated skull fracture. Outcomes with the use of the pBIG algorithm were otherwise acceptable. Level of EvidenceLevel IV, Therapeutic/Care Management.

Benefits of Neurosurgical Teleconsults in the Management of Intracerebral Hemorrhage: Transfers and Transportation Cost Reduction

Our study explores the efficacy and economic benefits of neurosurgical teleconsultations in managing intracerebral hemorrhage (ICH), focusing on reducing unnecessary patient transfers and associated costs. We conducted a cost-savings analysis at our institution of a previously published pilot study involving a cohort of patients with ICH who were potential candidates for airlift to our tertiary care center but instead received neurosurgical consultation via teleconsultation to avoid the transfer. Data on patient demographics, distances, and costs were collected and analyzed to assess the economic impact of teleconsultations. The cohort comprised 14 patients; we noted significant cost savings from avoiding interhospital transfers, ranging from $84,346.52 to $120,495.03 per patient. Teleconsultations facilitated immediate, collaborative decision-making between healthcare providers at community hospitals and a tertiary care center, reducing the need for expensive air transportation and unnecessary hospital transfers. Neurosurgical teleconsultations offer a cost-effective alternative to traditional patient transfer methods for ICH management, providing substantial economic benefits while maintaining high physician and patient-family satisfaction levels. This study underscores the potential of our teleneurosurgery program to significantly reduce costs by reducing unnecessary financial burdens on patients' families and healthcare systems.

Surgical Management of Spinal Cysticercosis: 2-Dimensional Operative Video.

Neurocysticercosis is a notorious—albeit relatively rare—parasitic infection of the nervous system caused by ingestion of embryonated eggs or gravid proglottids of the pork tapeworm Taenia solium. 1 Most cases appear intracranially and can present with seizures and/or headache; far fewer affect the spinal canal alone. 1-6 We describe a case of a 66-year-old Hispanic man with isolated spinal cysticercosis presenting to the emergency department initially with axial back pain. After lumbar x-rays and a computed tomography scan failed to find any pathology, he was discharged home without neurosurgical consultation. A week later he would re-present to the same emergency department with worsening back pain and new neurologic deficits, prompting an MRI revealing pathology within the lumbar spinal canal. After consultation, the neurosurgical team discussed management strategies and eventually opted for surgical exploration of the patient's lumbar spine. This exploration eventually culminated in an intradural exploration, revealing an impressive string of interconnected larval cysts of the T. solium tapeworm within the cauda equina. The patient's neurologic condition improved immediately after surgery, and final pathologic examination supported a diagnosis of spinal cysticercosis, prompting the appropriate workup and medical treatment. He would ultimately make a full recovery and continues to follow-up with infectious disease at our institution. The patient consented to the surgical intervention described herein after a discussion of its risks, benefits, and alternatives. Institutional review board and ethics committee approval was not sought because the intervention did not constitute experimental surgery, but rather represented standard of care given the patient's condition on presentation.

P.137 Neurosurgical consultations in Nova Scotia: a descriptive analysis

Background: Receiving and managing neurosurgical consultations are central to providing quality patient care but are resource intensive processes. As part of an ongoing quality improvement initiative, we conducted a single-institution descriptive analysis of adult neurosurgical consultations. Methods: A retrospective review of prospectively collected consultation records and call schedules from a 12-month period from February 2019 to 2020 was performed. Consults were graded according to disposition (admission for surgery, non-operative admission, additional investigations recommended, opinion without further investigations, unnecessary consult). Results: There were 1916 consultations reviewed, with 52% of calls (n=991) originating outside of our hospital, and 72% (n=1387) coming from an emergency department. Cranial cases made up 64% (n=1230) of consults, while the remaining 36% (n=688) were spine cases. The mean patient age was 60.1±0.4 years. In multinomial logistic regression analysis, age, geographical distance of consulting site, and consult specific variables (neurosurgical subspecialty, inside vs. outside call, emergency department vs. inpatient ward or private office) were associated with consult disposition (p &lt; 0.001). Conclusions: This study provides a descriptive analysis of neurosurgical consultations in Nova Scotia. Results from this study may be used to address inefficacies in the neurosurgical consultation process, including targeted education for consulting physicians.

P.148 Consult and kyphoplasty delay impacts on geriatric vertebral compression fracture outcomes

Background: Vertebral compression fractures (VCF) lead to both considerable morbidity and increased mortality. Kyphoplasty, a minimally invasive surgery, treats VCFs providing significant pain relief, preserving vertebral height, and reducing spinal deformity. Methods: A retrospective cohort study at Hamilton Health Sciences (HHS) was conducted on elderly patients (60 years or older) who underwent kyphoplasty at between 2012 and 2022. The patients had prior hospital admissions under non-spine-related specialties at HHS within two years before their surgery. Primary outcomes were the progression of vertebral height loss and focal kyphotic deformity. Results: The study included 119 patients (52.1% female, mean age 70.71 years). A significant increase in vertebral height loss was observed from diagnosis to pre-kyphoplasty (0.32% change, p &lt; 0.0001) and from diagnosis to post-kyphoplasty (0.24% change, p = 0.015). However, there were no significant correlations between delay times and changes in vertebral height or focal kyphotic deformity. Conclusions: Delays in neurosurgical consultation and kyphoplasty did not significantly affect radiographic outcomes in elderly patients with VCF despite the progression of vertebral height loss. This suggests that while timely patient care is essential, delayed treatment may not adversely affect key radiographic metrics in elderly VCF patients.

Global Neurosurgical Challenges: A Focus on Central Asia

Neurosurgical care in Central Asia is marked by significant variation across the region's five countries—Kazakhstan, Kyrgyzstan, Tajikistan, Turkmenistan, and Uzbekistan. This variation is influenced by factors such as limited modern technology, a shortage of neurosurgeons, and inadequate healthcare infrastructure. Despite these obstacles, there have been notable advancements in the field, particularly in Kazakhstan, where the number of neurosurgeons has increased, and specialized fields such as vascular neurosurgery and brain tumor management have seen significant progress. Other countries in the region, such as Uzbekistan, Tajikistan, and Kyrgyzstan, have also made strides in improving neurosurgical care. However, these advancements in neurosurgical care are insignificant to those seen globally which make standard neurosurgical care inaccessible to many patients in Central Asian countries due to shortages of neurosurgeons and limited facilities. The dearth of research data in some CA countries further emphasize the need for urgent intervention. Therefore, we recommend a multipronged approach involving targeted investments, policy reforms, international collaborations, and knowledge sharing is recommended to bolster neurosurgical care capabilities and expand access to essential care across Central Asia. This approach include establishing specialized neurosurgical training programs and fellowships, investing in infrastructure and technology for neurosurgical facilities, and fostering collaborations with international centers for training and research. Additionally, early introduction of neurosurgery education in medical schools, enhancing access to online education resources for neurosurgeons, and promoting the use of telemedicine for neurosurgical consultations and follow-up care are recommended