Neurosurgical Setting Research Articles

Abstract 233: Cortical Spread Depolarization: Monitoring Techniques and Clinical Applications

Introduction/Purpose Cortical spreading depolarization (CSD) describes a slow, sustained, synchronized depolarization within the cerebral gray matter that renders neurons unable to fire action potentials, resulting in widespread neuronal depression. CSD has been observed in stroke, subarachnoid hemorrhage, epilepsy, traumatic brain injury and migraines and is a potential indicator of imminent neuronal death. Therefore, the identification, monitoring and treatment of CSD are crucial in both neurointensive care and neurosurgical settings. Such measures are paramount for optimizing outcomes among patients with neurological injuries. However, this slow spreading depolarization at low amplitudes presents challenges to identify and monitor CSD in clinical settings. We aim to identify various current and potential techniques for monitoring CSD in neurocritical care and neurosurgical settings, alongside exploring available treatment modalities. We also analyze current limitations in the detection of CSD, including identification of potential biomarkers. Methods/Materials A comprehensive review of available literature utilizing search engines such as PubMed and Google Scholar was conducted using key search terms such as “cortical spreading depression”, “CSD”, “spreading depolarization” and “CSD monitoring”. Eligibility for this review was restricted to full‐text, english, peer‐reviewed literature articles. There were no restrictions on publication dates. Results 224 articles discussing CSD were reviewed and ultimately 93 articles were included in the analysis. Electrocorticography (ECoG) remains the primary modality to detect CSD, both in the neurological intensive care unit (nICU) and during neurosurgical procedures. However, there are other potential modalities for detection such as Electroencephalogram (EEG), pressure reactivity index (PRx), magnetoencephalography (MEG), MRI/fMRI and laser speckle imaging (LSI). These methods have been tested in animal models and/or in clinical practice but each has drawbacks that render these modalities not readily available or nonfunctional as independent detection methods in the nICU. Nevertheless, a multimodal monitoring approach utilizing a combination monitoring modalities such as ECoG in conjunction with tools that measure cerebral vascular response such as cerebral perfusion pressure, cerebral blood flow and PRx could provide timely measurements of CSD. There are potential biomarkers being studied for early detection of CSD which include adenosine, GFAP, lactate, IL‐6 or TNF‐alpha. Some treatment modalities have been studied that inhibit or halt CSD include: dizocilpine (NMDA‐R blocker), topiramate, valproate, propranolol, amitriptyline, methysergide, propofol and glutamate receptor inhibitors. Conclusion Although several methods have been studied, ECoG remains the gold standard for CSD detection. Nevertheless, a multimodal approach which utilizes ECoG in conjunction with different methods of monitoring, could prove a useful tool in nICU as well as neurosurgical procedures. Further research is needed to determine the utility and application of other monitoring methods in the clinical setting.

Clinical Management of Respiratory Diseases in Neurosurgical Settings

Respiratory diseases, such as chronic obstructive pulmonary disease(COPD)and asthma, are becoming increasingly prevalent in super-aging societies. In Japan, the estimated prevalence of COPD among individuals aged 40 years and above is 8.6%, while asthma affects about 10% of adults. These statistics highlight the similarities between COPD and asthma in clinical settings. Both diseases involve chronic airway inflammation and present with symptoms such as chronic cough, sputum production, wheezing, and dyspnea. Exacerbations of these symptoms and complications are critical concerns during the perioperative period. COPD, often caused by long-term smoking, leads to irreversible airway and lung damage, while asthma is characterized by episodic and reversible airway constriction due to chronic inflammation. COPD diagnosis involves spirometry and the exclusion of other diseases, with treatment goals focusing on symptom improvement and risk reduction through smoking cessation, pharmacotherapy(mainly bronchodilators), and non-pharmacological methods(such as pulmonary rehabilitation). Asthma management aims to control inflammation and prevent exacerbations using inhaled corticosteroids and bronchodilators as standard treatments. Perioperative management of both diseases involves improving respiratory function with pharmacotherapy, careful anesthesia selection, and early postoperative mobilization. Consultation with respiratory specialists is recommended for effective management, especially in complex cases.

African Women in Neurosurgery: An Exploration of Historical Perspectives, Current Realities, and Future Prospects

Gender disparities remain a significant issue, particularly impacting African women in the field of neurosurgery. Databases, articles, and perspectives were reviewed to identify challenges faced by African Women in Neurosurgery (AWIN), and explore solutions for recruitment, retention, and career advancement of AWIN. In 1982, Africa saw its first female neurosurgeon, with the first female president of the World Federation of Neurosurgical Societies appointed 4 null decades later. Presently, the continent hosts 245 female neurosurgeons, with North Africa comprising the majority at 76.3%, with Algeria notably contributing 72.2% of this total. Southern Africa contributes 7.8%, while West Africa, East Africa, and Central Africa contribute 6.5%, 6.1%, and 3.3%, respectively. Thirteen countries lack neurosurgeons entirely and 30 out of the 54 African nations face shortages of female neurosurgeons, with distributions as follows: North Africa (1-country), Southern Africa (6-countries), West Africa (8-countries), East Africa (9-countries), and Central Africa (6-countries). Our analysis mapped the distribution of 245 AWIN across the African regions and examined the professional trajectories and achievements of 17 pioneering AWIN. Additionally, we compiled registries for: 1) 76 neurosurgical training programs across 26 African countries, 2) organizations tackling gender disparities in neurosurgery, and 3) recommendations to promote AWIN across governmental, community, and academic spheres. To boost AWIN representation in neurosurgery, concerted and comprehensive efforts are vital. Collaboration among medical schools, training programs, and governments is key to fostering diversity and inclusivity in African neurosurgical settings.

Intraoperative Neurophysiological Monitoring in Neurosurgery.

Intraoperative neurophysiological monitoring (IONM) is a crucial advancement in neurosurgery, enhancing procedural safety and precision. This technique involves continuous real-time assessment of neurophysiological signals, aiding surgeons in timely interventions to protect neural structures. In addition to inherent limitations, IONM necessitates a detailed anesthetic plan for accurate signal recording. Given the growing importance of IONM in neurosurgery, we conducted a narrative review including the most relevant studies about the modalities and their application in different fields of neurosurgery. In particular, this review provides insights for all physicians and healthcare professionals unfamiliar with IONM, elucidating commonly used techniques in neurosurgery. In particular, it discusses the roles of IONM in various neurosurgical settings such as tumoral brain resection, neurovascular surgery, epilepsy surgery, spinal surgery, and peripheral nerve surgery. Furthermore, it offers an overview of the anesthesiologic strategies and limitations of techniques essential for the effective implementation of IONM.

Rates of delirium referrals to the Neuropsychiatry Service in a tertiary referral centre hospital

IntroductionBeaumont Hospital is the National Neurosurgical Centre in Ireland. Due to the high numbers of referrals from Neurology and Neurosurgery, The Department of Psychiatry established a specialist Neuropsychiatry inpatient Liaison service and a weekly Neuropsychiatry outpatient clinic. Many of the referrals that the service receive involve the management of delirium. Delirium is a common medical complication, particularly in neurosurgical settings. Delirium causes significant symptom burden which can lead to distress to all involved and impacts quality of life.ObjectivesThe aim was to improve the rates of referrals for delirium presentations and referral rates overall from Neurology and Neurosurgery. The neuropsychiatry service have implemented a delirium protocol for all medical and surgical teams in Beaumont Hospital. This protocol can be accessed through the Beaumont hospital phone app, or on site on each ward. For this reason, delirium can be managed by medical teams in the first instance. If this is not successful, neuropsychiatry can be contacted for further advice or review of patients with more complicated presentations.MethodsThe neuropsychiatry service receives referrals through the Patient Information Profile Explorer system which is accessed through the Beaumont Hospital online portal. In the event of an urgent referral, neurology or neurosurgery teams can contact the neuropsychiatry service directly by phone. Referrals are logged on the team referral log book, and details of the referral are recorded along with diagnosis and management. Data was collected retrospectively from the PIPE and log book to measure the rates and reasons for referrals over a one year period. Rates and details of referrals were initially recorded between July-December 2022. An educational intervention was provided where psychoeducation was provided to junior hospital doctors during protected teaching times and further education was provided over the phone when referrals were discussed between team members. Rates and details of referrals were then recorded between January-July 2023.ResultsThere was a reduction in referrals when comparing the two six month periods. There were 115 neuropsychiatry referrals from July to December 2022 and 78 referrals from January to July 2023. Rates of delirium referrals also reduced from 31% to 25% after psychoeducation was provided to junior doctors.ConclusionsThis audit highlights the importance of communication and education for medical and surgical trainees in the management of delirium. There is a high rate of turnover of junior doctors throughout the year in Beaumont Hospital. For this reason, it is imperative that continued education is provided to allow them to follow the delirium protocol independently before seeking tertiary service assistance. Ultimately, early and rapid intervention of delirium can have a positive impact on patient care and prognosisDisclosure of InterestNone Declared

Evaluating the efficacy of standardized pressure ulcer management protocols in the prevention of pressure injuries among patients undergoing neurosurgical procedures.

Pressure injuries are a significant concern for patients undergoing neurosurgical procedures due to prolonged immobility and the complexity of care. This study evaluates the efficacy of standardized pressure ulcer management protocols in preventing pressure injuries and enhancing patient care in a neurosurgical context. A comprehensive retrospective analysis was conducted at a single institution from December 2020 to December 2023, comparing 50 patients who received standardized pressure ulcer management (intervention group) with 50 patients who received conventional care (control group). The study assessed the incidence of pressure ulcers, patient comfort levels using the Kolcaba Comfort Scale and sleep quality using the Richards-Campbell Sleep Questionnaire (RCSQ). Statistical analysis was performed using SPSS software, version 27.0, applying t-tests and chi-square tests as appropriate. The intervention group exhibited a significantly lower incidence of pressure ulcers at all measured time points post-surgery compared to the control group. Patient comfort levels in the intervention group were consistently higher across psychological, environmental, physiological and socio-cultural domains. Sleep quality metrics, including sleep depth, latency to sleep onset and overall sleep quality, were significantly improved in the intervention group. The implementation of standardized pressure ulcer management protocols in neurosurgical care significantly reduces the incidence of pressure injuries, enhances patient comfort and improves sleep quality. These findings highlight the importance of adopting structured care protocols to improve postoperative outcomes and patient well-being in neurosurgical settings.

Walking forward or on hold: Could the ChatGPT be applied for seeking health information in neurosurgical settings?

Self-management is important for patients suffering from cerebrovascular events after neurosurgical procedures. An increasing number of artificial intelligence (AI)-assisted tools have been used in postoperative health management. ChatGPT is a new trend dialog-based chatbot that could be used as a supplemental tool for seeking health information. Responses fromChatGPT version 3.5 and 4.0 toward13 questions raised by experienced neurosurgeons were evaluated in this exploratory study for their consistency and appropriatenessblindly by the other three neurosurgeons. The readability of response text was investigated quantitively by word countand the Gunning Fogand Flesch-Kincaid indices. Results showed that the chatbot could provide relatively stable output between the two versions on consistency and appropriateness (χ² = 0.348). As for readability, there was a higher demand for readers to comprehend the output text in the 4.0 version (more counts of words; lower Flesch-Kincaid reading ease score; and higher Flesch-Kincaid grade level). In general, the capacity ofChatGPT to deliver effective health information is still under debate.

NnU-Net versus mesh growing algorithm as a tool for the robust and timely segmentation of neurosurgical 3D images in contrast-enhanced T1 MRI scans

PurposeThis study evaluates the nnU-Net for segmenting brain, skin, tumors, and ventricles in contrast-enhanced T1 (T1CE) images, benchmarking it against an established mesh growing algorithm (MGA).MethodsWe used 67 retrospectively collected annotated single-center T1CE brain scans for training models for brain, skin, tumor, and ventricle segmentation. An additional 32 scans from two centers were used test performance compared to that of the MGA. The performance was measured using the Dice-Sørensen coefficient (DSC), intersection over union (IoU), 95th percentile Hausdorff distance (HD95), and average symmetric surface distance (ASSD) metrics, with time to segment also compared.ResultsThe nnU-Net models significantly outperformed the MGA (p < 0.0125) with a median brain segmentation DSC of 0.971 [95CI: 0.945–0.979], skin: 0.997 [95CI: 0.984–0.999], tumor: 0.926 [95CI: 0.508–0.968], and ventricles: 0.910 [95CI: 0.812–0.968]. Compared to the MGA’s median DSC for brain: 0.936 [95CI: 0.890, 0.958], skin: 0.991 [95CI: 0.964, 0.996], tumor: 0.723 [95CI: 0.000–0.926], and ventricles: 0.856 [95CI: 0.216–0.916]. NnU-Net performance between centers did not significantly differ except for the skin segmentations Additionally, the nnU-Net models were faster (mean: 1139 s [95CI: 685.0–1616]) than the MGA (mean: 2851 s [95CI: 1482–6246]).ConclusionsThe nnU-Net is a fast, reliable tool for creating automatic deep learning-based segmentation pipelines, reducing the need for extensive manual tuning and iteration. The models are able to achieve this performance despite a modestly sized training set. The ability to create high-quality segmentations in a short timespan can prove invaluable in neurosurgical settings.

Image Guided Intraoperative Radiation Therapy After Surgical Resection of Brain Metastases: A First In-Human Feasibility Report

PurposeA correct placement of the applicator during intraoperative radiotherapy (IORT) for brain metastasis is of paramount importance, in order to deliver a precise and safe treatment. The applicator-to-surface contact assessment cannot be performed under direct observation, as the applicator itself limits the visual range. No image-guided (IG) verification is currently performed intracranially. We hypothesize that IG-IORT would assure a more precise delivery in the target area. We describe our workflow in a first in-human experience. Methods and MaterialsPhantom-based measurements were performed to reach the best cone-beam computed-tomography (CBCT) imaging quality possible. Once defined, a clinical feasibility study was initiated. An in-room CBCT device is used to acquire intraoperative images after placing the applicator. Repositioning the applicator is thereafter discussed with the surgeon, according to the imaging outcomes, if required. ResultsAn optimal image quality was achieved with 120-kV voltage, 20-mA current and a tube current–time product of 150 mAs. An additional 0.51–mSv patient exposure was calculated for the entire procedure. The wide dynamic range (−600 HU to +600 HU) of CBCT and a 27-HU mean CT values difference between brain tissue and spherical applicator allows distinguishing both structures. In this first in-human experience, the applicator was repositioned after evidencing air gaps, assuring full applicator-to-surface contact. ConclusionThis first in-human procedure confirmed the feasibility of kilovoltage IG-IORT in a neurosurgical setting. A prospective study has been initiated and will provide further dosimetric details.

Bell’s mania as a clinical presentation in a neurosurgical setting from a tertiary care neuropsychiatric hospital in India

Bell’s mania is the co-occurrence of delirium and mania. We present two cases of Bell’s mania in a neurosurgical setting. The first case is of a 52-year-old male who presented with holocranial headache, disorientation, and manic symptoms for five months. He was found to have suprasellar craniopharyngioma. He significantly improved with olanzapine, but re-emergence of mood symptoms was noted after surgery. The second case is of a 42-year-old male who presented with a 15-day history of seizures and disorientation. He was found to have a dural arteriovenous fistula. He developed Bell’s mania in the post-procedural period, which improved with olanzapine. Compression of the hypothalamo-pituitary stalk in the first case and vascular and inflammatory changes in the second case could have led to Bell’s mania. Atypical age of onset and presence of neurological symptoms in patients presenting with psychiatric symptoms should raise the suspicion of an underlying organicity. Atypical anti-psychotics can be a useful management strategy for Bell’s mania.

Artificial Intelligence and Neurosurgery: Tracking Antiplatelet Response Patterns for Endovascular Intervention.

Platelets play a critical role in blood clotting and the development of arterial blockages. Antiplatelet therapy is vital for preventing recurring events in conditions like coronary artery disease and strokes. However, there is a lack of comprehensive guidelines for using antiplatelet agents in elective neurosurgery. Continuing therapy during surgery poses a bleeding risk, while discontinuing it before surgery increases the risk of thrombosis. Discontinuation is recommended in neurosurgical settings but carries an elevated risk of ischemic events. Conversely, maintaining antithrombotic therapy may increase bleeding and the need for transfusions, leading to a poor prognosis. Artificial intelligence (AI) holds promise in making difficult decisions regarding antiplatelet therapy. This paper discusses current clinical guidelines and supported regimens for antiplatelet therapy in neurosurgery. It also explores methodologies like P2Y12 reaction units (PRU) monitoring and thromboelastography (TEG) mapping for monitoring the use of antiplatelet regimens as well as their limitations. The paper explores the potential of AI to overcome such limitations associated with PRU monitoring and TEG mapping. It highlights various studies in the field of cardiovascular and neuroendovascular surgery which use AI prediction models to forecast adverse outcomes such as ischemia and bleeding, offering assistance in decision-making for antiplatelet therapy. In addition, the use of AI to improve patient adherence to antiplatelet regimens is also considered. Overall, this research aims to provide insights into the use of antiplatelet therapy and the role of AI in optimizing treatment plans in neurosurgical settings.

P15.05.B THE IMPACT OF IOMRI ON GLIOBLASTOMA RESECTION AND CLINICAL OUTCOMES IN A STATE-OF-THE-ART NEURO-ONCOLOGICAL SETUP

Abstract BACKGROUND Intraoperative magnetic resonance imaging (ioMRI) is applied to improve the extent of resection in patients suffering from primary brain tumors, especially glioblastoma (GBM). While some older randomized trials reported data on safety and feasibility, ioMRI’s actual impact in a modern neurosurgical setting has not been sufficiently investigated. We therefore aimed to evaluate the effect of ioMRI on tumor resection and progression-free survival (PFS) in GBM patients in a modern high-volume center. MATERIAL AND METHODS Patients undergoing ioMRI for resection of supratentorial GBM were prospectively included between March 2018 and June 2020. In all cases, ioMRI was performed after complete macroscopic tumor resection. The extent of resection (EOR) was determined by volumetric analysis. Gross total resection (GTR) was defined as EOR ≥95%. Furthermore, progression-free survival (PFS) was analyzed through univariate and multivariate Cox proportional regression analysis. RESULTS Overall, 172 patients were enrolled in this study. The mean EOR increased from 93·9% on ioMRI to 98·3% (p&amp;lt;0·0001) on postoperative MRI, with residual tumor volume decreasing from 1·3 ± 4·2 cm3 to 0·6 ± 2·5 cm3(p=0·0037). The GTR rate increased from 78·5% to 93·0% (p=0·0002). Logistic regression revealed recurrent GBM (odds ratio [OR] =3·047, 95% confidence interval [CI] 1·165-7·974, p=0·023) and tumor volume less than 15 cm3 (OR=3·031, 95% CI 1·062-8·651, p=0·038) as independent risk factors leading to STR. Tumor resection performed additionally after ioMRI lead to equally long PFS compared to patients with complete tumor removal achieved before ioMRI (HR=0·898, 95%CI 0·543-1·483, p=0·67). CONCLUSION ioMRI serves as a valuable tool in a modern neurosurgical setting, severely decreasing residual tumor volume. ioMRI considerably helps to achieve comparable PFS even in cases, where an unexpected tumor residual is found on ioMRI after initial resection.

The Impact of ioMRI on Glioblastoma Resection and Clinical Outcomes in a State-of-the-Art Neuro-Oncological Setup.

Intraoperative magnetic resonance imaging (ioMRI) aims to improve gross total resection (GTR) in glioblastoma (GBM) patients. Despite some older randomized data on safety and feasibility, ioMRI's actual impact in a modern neurosurgical setting utilizing a larger armamentarium of techniques has not been sufficiently investigated to date. We therefore aimed to analyze its effects on residual tumor, patient outcome, and progression-free survival (PFS) in GBM patients in a modern high-volume center. Patients undergoing ioMRI for resection of supratentorial GBM were enrolled between March 2018 and June 2020. ioMRI was performed in all cases at the end of resection when surgeons expected complete macroscopic tumor removal. Extent of resection (EOR) was performed by volumetric analysis, with GTR defined as an EOR ≥ 95%, respectively. Progression-free survival (PFS) was analyzed through univariate and multivariate Cox proportional regression analyses. In total, we enrolled 172 patients. Mean EOR increased from 93.9% to 98.3% (p < 0.0001) due to ioMRI, equaling an increase in GTR rates from 78.5% to 93.0% (p = 0.0002). Residual tumor volume decreased from 1.3 ± 4.2 cm3 to 0.6 ± 2.5 cm3 (p = 0.0037). Logistic regression revealed recurrent GBM as a risk factor leading to subtotal resection (STR) (odds ratio (OR) = 3.047, 95% confidence interval (CI) 1.165-7.974, p = 0.023). Additional resection after ioMRI led to equally long PFS compared to patients with complete tumor removal before ioMRI (hazard ratio (HR) = 0.898, 95%-CI 0.543-1.483, p = 0.67). ioMRI considerably reduces residual tumor volume and helps to achieve comparable PFS, even in patients with unexpected residual tumor after initial resection before ioMRI.

Tranexamic Acid Use in Pediatric Craniotomies at a Large Tertiary Care Pediatric Hospital: A Five Year Retrospective Study.

Tranexamic acid (TXA), a synthetic antifibrinolytic drug, has proven efficacy and is recommended for major pediatric surgery to decrease perioperative blood loss. Accumulating evidence suggests that TXA reduces bleeding and transfusion in a variety of adult neurosurgical settings. However, there is a paucity of research regarding TXA indications for pediatric neurosurgery and thus, there are currently no recommendations for its use with this specific population. The objective of this study is to evaluate the existing practice of TXA administration for pediatric neurosurgery at a U.S. tertiary care pediatric hospital over a five-year period. The authors conclude that TXA administration is feasible and should be considered for pediatric neurosurgical cases where potential blood loss is a concern.

Telemedicine Utilization in an Outpatient Pediatric Neurosurgical Clinic: A Prospective Survey of Patient and Family Preferences

After becoming widespread during the COVID-19 pandemic, telemedicine continues to play an important role in outpatient neurosurgical care. Nevertheless, the factors that influence individual decisions to choose telemedicine versus in-person appointments remain understudied. Here, we performed a prospective survey of pediatric neurosurgical patients and caregivers presenting for telemedicine or in-person outpatient visits, to identify factors associated with appointment choice. All patients and caregivers with an outpatient pediatric neurosurgical encounter at Connecticut Children's between January 31st and May 20th, 2022, were invited to participate in this survey. Data related to demographics, socioeconomics, technological access, COVID-19 vaccination status, and appointment preferences were collected. During the study period, there were 858 unique pediatric neurosurgical outpatient encounters (86.1% in-person and 13.9% telemedicine). A total of 212 (24.7%) respondents completed the survey. Those with a telemedicine appointment were more likely to be white (P= 0.005), not Hispanic or Latino (P= 0.020), have private insurance (P= 0.003), be established patients (P < 0.001), have a household income >$80,000 (P= 0.005), and have caregivers who completed a 4-year college degree (P < 0.001). Those who were seen in-person cited the patient's condition, quality of care, and communication as important factors, whereas those who were seen via telemedicine cited time, travel, and convenience. While convenience influences some to choose telemedicine, concerns regarding the quality of care persist among those who prefer in-person encounters. Recognizing these factors will minimize barriers to care, better define the appropriate populations/contexts for each encounter type, and improve the integration of telemedicine within an outpatient neurosurgical setting.

Intraoperative air embolism diagnosis and treatment using hyperbaric oxygen therapy after craniotomy: illustrative case.

This report describes the use of hyperbaric oxygen therapy for the acute management of an intraoperative air embolism encountered during a neurosurgical procedure. Furthermore, the authors highlight the concomitant diagnosis of tension pneumocephalus requiring evacuation prior to hyperbaric therapy. A 68-year-old male developed acute ST-segment elevation and hypotension during elective disconnection of a posterior fossa dural arteriovenous fistula. The semi-sitting position had been used to minimize cerebellar retraction, raising the concern for acute air embolism. Intraoperative transesophageal echocardiography was utilized to establish the diagnosis of air embolism. The patient was stabilized on vasopressor therapy, and immediate postoperative computed tomography revealed air bubbles in the left atrium along with tension pneumocephalus. He underwent urgent evacuation for the tension pneumocephalus followed by hyperbaric oxygen therapy to manage the hemodynamically significant air embolism. The patient was eventually extubated and went on to fully recover; a delayed angiogram revealed complete cure of the dural arteriovenous fistula. Hyperbaric oxygen therapy should be considered for an intracardiac air embolism resulting in hemodynamic instability. In the postoperative neurosurgical setting, care should be taken to exclude pneumocephalus requiring operative intervention prior to hyperbaric therapy. A multidisciplinary management approach facilitated expeditious diagnosis and management for the patient.

The Evolving Need for Neuropsychology in Neurosurgical Settings: Challenges Facing Transformative Care

Clinical neuropsychology has been a valuable asset to neurologic surgery, contributing to lateralization and localization of pathologic brain tissue, identification of eloquent cortex, and evaluation of postoperative neuropsychological functioning. Moreover, neuropsychologists provide empirically driven interventions aimed at supporting preparation and/or recovery of neurosurgery patients. Nonetheless, several challenges may limit the reliability, validity, and generalizability of the assessment data obtained and reduce the usefulness of other neuropsychological services provided. Specifically, linguistic, cultural, educational, and other biases associated with demographic characteristics can lead to a narrowed view of an individual's life experiences, which must be confronted to fulfill the mission of ensuring that all patients have access to care that is appropriate to their needs. Instead of perceiving these challenges as insurmountable barriers, such issues can be viewed as opportunities to catalyze change and foster innovation for the future of neuropsychological care in neurosurgical settings. In addition to reviewing the possible mechanisms of these obstacles, the current article offers tangible solutions at both a macro level (e.g., discipline-wide transformations) and micro level (e.g., individualized patient-centric approaches). Outlined are practical techniques to potentially improve consensus and standardization of methods, advance and globalize research, expand representativeness of measures and practices to serve diverse individuals, and increase treatment adherence through engagement of patients and their families.

A systematic review and meta-analysis of the effects of tranexamic acid in surgical procedure for intracranial meningioma.

During intracranial meningioma surgery, surgeons experience considerable blood loss. Tranexamic acid (TXA) is used to minimize blood loss in several neurosurgical settings. However, evidence and trials are lacking. Our objective is to establish the most recent evidence on TXA safety and efficacy in intracranial meningioma surgery. Based upon Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA), the authors collected fully published English literature on the administration of tranexamic acid for patients undergoing intracranial meningioma surgery using the keywords ["tranexamic acid" and "meningioma"] and its synonyms from Cochrane Central Database, the WHO International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov, and PubMed. The primary outcome of the current study was total blood loss. The secondary outcomes include individuals requiring blood transfusion, anesthesia duration, surgical duration, and complicationrate. Each included studies' quality was assessed using the JADAD scale. For qualitative and quantitative data synthesis, we included five RCTs (n = 321) with the mean age was 47.5 ± 11.9years for the intervention group and 47.2 ± 11.9years for the control group. Our meta-analysis showed that the administration of TXA is associated with decreased total blood loss of standardized mean difference (SMD) of -1.40 (95% CI [-2.49, -0.31]), anesthetic time SMD -0.36 (95% CI [-0.63, -0.09]), and blood transfusion requirements RR 0.58 (95% CI [0.34, 0.99]). The current study showed that TXA was associated with reduced intraoperative blood loss and intra- and postoperative blood transfusion. However, the studies are small. More RCT studies with a greater sample size are favorable.

Understanding intracranial arachnoid cysts: a review of etiology, pathogenesis, and epidemiology.

Arachnoid cysts (AC) are one of the common pathologies encountered in pediatric neurosurgical settings. It comes to clinical attention more often incidentally but also more often than previously due to the wide availability of diagnostic imaging. However, the accurate incidence and prevalence remain unknown. There is an ongoing debate on symptomatology, indications of treatment, and best treatment modalities. In this review, we aimed to discuss the current general knowledge about the arachnoid cyst, focusing on the etiology, pathogenesis, and epidemiology. Specific findings related to locations, such as the Sylvian fissure, are also emphasized.

PRESSURE ULCERS INCIDENCE IN A PERIOPERATIVE NEUROSURGICAL SETTING

Background. Pressure ulcer is a major burden in surgical patients, increasing the length of hospital stay and the healing process, possibly leading to infectious complications and higher health care costs. In current literature there is no consensus on which element is mainly responsible for the onset of these lesions neither the role of surgery has been clarified. Methods. We collected a case series of consecutive admitted patients to Cattinara Hospital Neurosurgery Department in Trieste from March 2019 to June 2019. All the patients were assessed for surgery related pressure ulcer (SRPU) risk using the Pressure Score Risk Assessment Scale modified by Scotts. Epidemiologic data of all patients were recorded and the incidence of surgical related pressure ulcer calculated. The sample consisted of 124 patients with an average hospitalization length of 12.45 days; 71.8% of the enrolled patients were elective surgery patients, 5.5% emergency surgery and 22.6% urgency surgery. Comorbidity data were collected for each patient and surgical related time procedures noted. Results. The calculated incidence rate of surgery related pressure ulcer in a single center perioperative neurosurgical setting was 4.8%; the average surgery duration time was 213 minutes (mean ± 81 standard deviation, SD) whilst four out of six of these patients were admitted to intensive care unit due to unstable clinical conditions (average ICU stay time: 2.83 days; mean ± 4.99 standard deviation, SD). Time to SRPU onset was 6.83 days (mean ± 3.66 standard deviation, SD). The main site of SRPU onset was sacrum (66% of patients with developed SRPU). Discussion. This study evaluates single-center incidence of SRPU in neurosurgical perioperative setting with specifically SRPU management trained healthcare providers; deeper and systematic understanding of SRPU epidemiology in other local hospital wards and multi-centered comparison are needed.