Neurosurgical Societies Research Articles

Role of the Subarachnoid Hemorrhage Early Brain Edema Score in the Management of Decompressive Craniectomy for Poor-Grade Aneurysmal Subarachnoid Hemorrhage

The Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) is a radiographic marker for early brain injury after aneurysmal subarachnoid hemorrhage (aSAH). We evaluated the role of the SEBES in performing decompressive craniectomy (DC) for poor-grade aSAH. We retrospectively analyzed all cases of poor-grade (World Federation of Neurosurgical Societies [WFNS] grade IV and V) aSAH in adults who underwent microsurgery at our center between April 2017 and March 2021. Patient demographics, clinical presentation, imaging findings, and surgical data were obtained. The study endpoints of DC rate, complications, and functional outcomes (modified Rankin Scale score >3) were compared between the traditional surgery and SEBES-informed groups. A survival analysis was performed to estimate 180-day survival and hazard ratios for death. The study included 116 patients (mean age, 60.8±9.5years, DCs [n= 63, 54.3%]). In the univariate analysis, age, intracranial pressure, midline shift, pupil changes, SEBES grade III-IV, traditional group, and WFNS grade Ⅴ were associated with DC. DC (46.4% vs. 67.4%) and in-hospital mortality rates (9.6% vs. 25.6%) were significantly lower in the SEBES-informed group. At day 180 after admission, modified Rankin Scale scores did not significantly differ between the 2 groups, but 180-day survival was significantly higher in the SEBES-informed group (78.1% vs. 53.5%). In the multivariable analysis, age, pupil changes, being in the traditional group, and delayed cerebral ischemia were independently associated with 180-day postadmission mortality. The SEBES provides good imaging support for preoperative and intraoperative intracranial pressure management in poor-grade aSAH, allowing for improved DC-related decision-making and better 180-day survival.

U.S. Patient Preferences for Interventional and Pharmaceutical Hypertension Treatments: Initial Subgroup Analyses

The goal in treating patients with subarachnoid hemorrhage (SAH) is shifting to preventing early brain injury. Intracranial pressure must be controlled to manage such an injury. We retrospectively analyzed the impact of aggressive removal of cisternal subarachnoid clots with simultaneous aneurysm repair for all grades of SAH.Our study included 260 consecutive patients with SAH treated through aggressive subarachnoid clot removal with simultaneous aneurysm repair. Baseline patient characteristics, history, radiographic findings, and time of SAH onset to arrival in the operating room were retrospectively collected. Factors related to poor outcome (modified Rankin Scale score >2) were analyzed.Multivariate analysis revealed several characteristics were significantly associated with poor outcome: advanced age (adjusted odds ratio [aOR] 1.07, 95% confidence interval [CI] 1.04–01.10); time of SAH onset to operating room per 1-hour increments (aOR 1.03, 95% CI 1.01–01.05; postoperative hematoma volume (aOR 1.04, 95% CI 1.01–01.06); and poorer World Federation of Neurosurgical Societies grade (aOR 2.18, 95% CI 1.63–02.92). According to a receiver operating characteristic analysis, the cut-off time of SAH onset to operating room was 6.0 hours (area under the curve 0.61, P = 0.01, 95% CI 0.52–0.69, sensitivity = 0.79, specificity = 0.43) as the threshold between modified Rankin Scale scores of 0–2 and 3–6.Prognostic factors of SAH in patients undergoing emergent aneurysm repair with simultaneous removal of a cisternal subarachnoid clot are advanced age, poorer World Federation of Neurosurgical Societies grade, postoperative hematoma volume, and a longer time from SAH onset to operating room. The clinical outcome may improve with emergent reduction of intracranial pressure through removal of the subarachnoid clot as soon as possible.

Validity of B-Type Natriuretic Peptide, Growth Differentiation Factor 15, and High-Sensitivity Troponin I Levels in Ischemic Heart Failure

The goal in treating patients with subarachnoid hemorrhage (SAH) is shifting to preventing early brain injury. Intracranial pressure must be controlled to manage such an injury. We retrospectively analyzed the impact of aggressive removal of cisternal subarachnoid clots with simultaneous aneurysm repair for all grades of SAH.Our study included 260 consecutive patients with SAH treated through aggressive subarachnoid clot removal with simultaneous aneurysm repair. Baseline patient characteristics, history, radiographic findings, and time of SAH onset to arrival in the operating room were retrospectively collected. Factors related to poor outcome (modified Rankin Scale score >2) were analyzed.Multivariate analysis revealed several characteristics were significantly associated with poor outcome: advanced age (adjusted odds ratio [aOR] 1.07, 95% confidence interval [CI] 1.04–01.10); time of SAH onset to operating room per 1-hour increments (aOR 1.03, 95% CI 1.01–01.05; postoperative hematoma volume (aOR 1.04, 95% CI 1.01–01.06); and poorer World Federation of Neurosurgical Societies grade (aOR 2.18, 95% CI 1.63–02.92). According to a receiver operating characteristic analysis, the cut-off time of SAH onset to operating room was 6.0 hours (area under the curve 0.61, P = 0.01, 95% CI 0.52–0.69, sensitivity = 0.79, specificity = 0.43) as the threshold between modified Rankin Scale scores of 0–2 and 3–6.Prognostic factors of SAH in patients undergoing emergent aneurysm repair with simultaneous removal of a cisternal subarachnoid clot are advanced age, poorer World Federation of Neurosurgical Societies grade, postoperative hematoma volume, and a longer time from SAH onset to operating room. The clinical outcome may improve with emergent reduction of intracranial pressure through removal of the subarachnoid clot as soon as possible.

Glibenclamide in aneurysmal subarachnoid hemorrhage: a randomized controlled clinical trial.

Glibenclamide has been shown to improve outcomes in cerebral ischemia, traumatic brain injury, and subarachnoid hemorrhage (SAH). The authors sought to evaluate glibenclamide's impact on mortality and functional outcomes of patients with aneurysmal SAH (aSAH). Patients with radiologically confirmed aSAH, aged 18 to 70 years, who presented to the hospital within 96 hours of ictus were randomly allocated to receive 5 mg of oral glibenclamide for 21 days or placebo, in a modified intention-to-treat analysis. Outcomes were mortality and functional status at discharge and 6 months, evaluated using the modified Rankin Scale (mRS). A total of 78 patients were randomized and allocated to glibenclamide (n = 38) or placebo (n = 40). Baseline characteristics were similar between groups. The mean patient age was 53.1 years, and the majority of patients were female (75.6%). The median Hunt and Hess, World Federation of Neurosurgical Societies (WFNS), and modified Fisher scale (mFS) scores were 3 (IQR 2-4), 3 (IQR 3-4), and 3 (IQR 1-4), respectively. Glibenclamide did not improve the functional outcome (mRS) after 6 months (ordinal analysis, unadjusted common OR 0.66 [95% CI 0.29-1.48], adjusted common OR 1.25 [95% CI 0.46-3.37]). Similar results were found for analyses considering the dichotomized 6-month mRS score (favorable score 0-2), as well as for the secondary outcomes of discharge mRS score (either ordinal or dichotomized), mortality, and delayed cerebral ischemia. Hypoglycemia was more frequently observed in the glibenclamide group (5.3%). In this study, glibenclamide was not associated with better functional outcomes after aSAH. Mortality and delayed cerebral ischemia rates were also similar compared with placebo.

Silk Vista Baby flow diverter stent for ruptured intracranial aneurysms: a retrospective observational study.

Flow diversion changed the approach to complex intracranial aneurysms, leading to a widespread use and a rapid technological evolution. Indeed, indications continued to expand, including ruptured intracranial aneurysms in selected cases. Recently, new devices have been designed specifically to target smaller vessels. Therefore, we conducted a multicenter study to evaluate clinical outcome, complications, and occlusion rate of patients with ruptured aneurysms treated with new generation low profile Silk Vista Baby (SVB) flow diverter stent (FD). We performed a retrospective observational study on consecutive patients who underwent treatment with SVB for ruptured aneurysms at 12 Italian centers. Primary end point was favorable clinical outcome rate, defined as modified ranking score (mRS) of 0-2 at the 3months. Secondary outcomes were complication rate, aneurysm re-rupture, and complete aneurysm occlusion at last radiological follow-up. Twenty-five patients were included; at 3months' follow-up, 19 patients (79.1%) had favorable clinical outcome (mRS 0-2). Three patients (12.5%) died during follow-up. In-stent thrombosis occurred in two cases (8.3%), managed with glycoprotein IIb/IIIA and intra-stent angioplasty, without clinical consequences. In 18 (85.7%) patients, complete occlusion at 3months was demonstrated. No rebleeding occurred during follow-up. Presentation with unfavorable World Federation of Neurosurgical Societies grading system (WFNS) and posterior circulation location were both significantly correlated with unfavorable clinical outcome (p = 0.005 and p = 0.02). Our data suggests that low profile FD treatment of ruptured intracranial aneurysms located distally of the circle of Willis is feasible. New generation low profile FD may represent an alternative option in carefully selected cases.

Development and Internal Validation of the ARISE Prediction Models for Rebleeding After Aneurysmal Subarachnoid Hemorrhage.

Aneurysmal rerupture is one of the most important determents for outcome after aneurysmal subarachnoid hemorrhage and still occurs frequently because individual risk assessment is challenging given the heterogeneity in patient characteristics and aneurysm morphology. To develop and internally validate a practical prediction model to estimate the risk of aneurysmal rerupture before aneurysm closure. We designed a multinational cohort study of 2 prospective hospital registries and 3 retrospective observational studies to predict the risk of computed tomography confirmed rebleeding within 24 and 72 hours after ictus. We assessed predictors with Cox proportional hazard regression analysis. Rerupture occurred in 269 of 2075 patients. The cumulative incidence equaled 7% and 11% at 24 and 72 hours, respectively. Our base model included hypertension, World Federation of Neurosurgical Societies scale, Fisher grade, aneurysm size, and cerebrospinal fluid drainage before aneurysm closure and showed good discrimination with an optimism corrected c-statistic of 0.77. When we extend the base model with aneurysm irregularity, the optimism-corrected c-statistic increased to 0.79. Our prediction models reliably estimate the risk of aneurysm rerupture after aneurysmal subarachnoid hemorrhage using predictor variables available upon hospital admission. An online prognostic calculator is accessible at https://www.evidencio.com/models/show/2626 .

Changes in Short-Term Outcomes After Discharge in Patients with Aneurysmal Subarachnoid Hemorrhage: A Multicenter, Prospective, Observational Study

The objective of the study was to clarify the prevalence of and factors associated with changes in patients' outcomes between discharge and 3months after the onset of aneurysmal subarachnoid hemorrhage (aSAH). Additionally, the World Federation of Neurosurgical Societies (WFNS) and modified WFNS (mWFNS) scales were compared. The data of curatively treated patients with aSAH, collected prospectively in the mWFNS scale study between January 2010 and December 2012, were analyzed retrospectively. The improvement or decline in the modified Rankin Scale (mRS) scores between discharge and 3months after onset was determined. A multivariable logistic regression analysis was performed to identify factors, such as age and WFNS and mWFNS grades, associated with changes in the outcome. The mRS scores improved in 28.3% and declined in 2.5% of the patients. WFNS and mWFNS grades Ⅱ-V on admission were significantly associated with improved mRS scores at 3months after onset. Older age (age: 65-74years vs. age <65years, odds ratio: 6.59, 95% confidence interval: 1.28-34.01; age ≥75years vs. age <65years, odds ratio: 17.67, 95% confidence interval: 2.11-148.26) and WFNS grade III were significantly associated with a decline in mRS scores at 3months after onset. The optimal timing for postdischarge assessment of outcomes may be at 3months after onset, especially in older patients with aSAH. The mWFNS scale is presumed to more accurately assess the outcomes of patients with aSAH than the WFNS scale, as demonstrated in this study.

Predictive Factors of Functional Outcome in World Federation of Neurosurgical Societies Grade V Subarachnoid Hemorrhage

Patients with World Federation of Neurosurgical Societies (WFNS) grade V subarachnoid hemorrhage (SAH) frequently have poor outcomes. The current understanding of the predictors of functional outcome only in WFNS grade V SAH is limited. Patients with WFNS grade V SAH were retrospectively analyzed between April 2008 and August 2019. Surgical treatment is commonly delayed until clinical improvement is observed using a less aggressive approach. Clinical and radiologic data on admission were assessed, and disease-related characteristics were compared between patients with favorable outcomes (modified Rankin Scale score 0-3) and those with unfavorable outcomes (modified Rankin Scale score 4-6). A total of 144 patients were included, and 22 patients (15.3%) achieved favorable outcomes, whereas 122 patients (84.7%) had unfavorable outcomes. Surgical aneurysm repair was performed in all patients with favorable outcomes and in 21.3% of those with unfavorable outcomes. Multivariate analysis showed that Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and hypertension were significantly associatedwith unfavorable outcomes (odds ratio [OR], 9.54, P= 0.03; OR, 5.37, P= 0.04; OR, 11.80, P= 0.009; OR, 0.14, P= 0.02 and OR, 6.53, P= 0.04, respectively). The final outcome of patients with WFNS grade V SAH was still poor and highly predicted by Glasgow Coma Scale score of 3, high-grade Early Brain Edema Score, absence of bilaterally light reflex and neurologic improvement, and a history of hypertension. The efficacy of aggressive surgical treatment for these patients remains controversial, and the indications should be clearly defined in patients with desolate clinical status on admission.

P.146 Exploring the Canadian management of aSAH and delayed cerebral ischemia

Background: Delayed Cerebral Ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. A paucity of high-quality evidence is available to guide the management of DCI. As such, our objective was to evaluate practice patterns of Canadian physicians regarding the management of aSAH and DCI. Methods: The Canadian Neurosurgery Research Collaborative (CNRC) performed a cross-sectional survey of Canadian neurosurgeons, intensivists, and neurologists who manage aSAH. The survey was distributed to members of the Canadian Neurosurgical and Neurocritical Care Societies, respectively. Responses were analyzed using quantitative and qualitative methods. Results: The response rate was 129/340 (38%). Agreement among respondents included the need for intensive care unit admission, use of clinical and radiographic monitoring, and prophylaxis for prevention of DCI. Indications for starting hyperdynamic therapy varied. There was discrepancy in the proportion of patients felt to require intravenous milrinone, intra-arterial vasodilators, or physical angioplasty for treatment of DCI. Most respondents reported their facility does not utilize a standardized definition for DCI. Conclusions: DCI is an important clinical entity for which no consensus exists in management among Canadian practitioners. The CNRC calls for the development of national standards in the diagnosis and management of DCI.

Low serum albumin as a risk factor for delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage: eICU collaborative research database analysis.

Delayed cerebral ischemia (DCI) represents a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH) and is a significant predictor of morbidity and mortality. Recent studies have implicated inflammatory processes in the pathogenesis of DCI. aSAH patient data were retrospectively obtained from the eICU Collaborative Research Database (eICU CRD). Multivariable logistic regression models and receiver operating characteristic (ROC) curve analyses were employed to assess the association between low serum albumin (<3.4 g/dL) and clinical endpoints: DCI and in-hospital mortality. Among 276 aSAH patients included in the analysis, 35.5% (N.=98) presented with low serum albumin levels and demonstrated a higher incidence of DCI (18.4% vs. 8.4%, OR=2.45, 95% CI=1.17, 5.10; P=0.017) and in-hospital mortality (27.6% vs. 16.3%, OR=1.95, 95% CI=1.08, 3.54; P=0.027) compared to patients with normal admission albumin values. In a multivariable model controlling for age and World Federation of Neurosurgical Societies grade, low serum albumin remained significantly associated with DCI (OR=2.52, 95% CI=1.18, 5.36; P=0.017), but not with in-hospital mortality. A combined model for prediction of DCI, encompassing known risk factors in addition to low serum albumin, achieved an area under the curve of 0.65 (sensitivity = 0.55, specificity = 0.75). Serum albumin, a routine and inexpensive laboratory measurement, may potentially aid in the identification of patients with aSAH at risk for the development of DCI.

Incidence and Clinical Characteristics of Takotsubo Syndrome in Patients with Subarachnoid Hemorrhage.

Although takotsubo syndrome (TTS) has been reported in patients with subarachnoid hemorrhage (SAH), its incidence and relation to the severity of SAH are unknown.Of 319 consecutive patients with aneurysmal SAH, 245 patients who underwent both the ECG and echocardiography were analyzed.The incidence of TTS was 6.9% (22 patients (21 women), median age 68 years (range, 60-83) ). Regional wall motion abnormalities were present as apical (64%), mid-ventricular (9%), basal (4%) and focal (23%) forms. Heart failure was found in 10 patients (45%) but there was no cardiac death. Regarding SAH severity, 10 patients (45%) with TTS were in World Federation of Neurosurgical Societies classification grade V, as compared to 40 patients (18%) without TTS (P = 0.005). Seven patients (32%) with TTS died during hospitalization, as compared to 26 patients (12%) without TTS (P = 0.018). Four patients (18%) with TTS were estimated as independent at discharge, as compared to 100 patients (45%) without TTS (P = 0.013).The incidence of TTS in patients with SAH was estimated as 6.9% with significant predominance of women. The severity of SAH was significantly greater in patients with TTS than in those without TTS.

A novel risk score for predicting hospital acquired pneumonia in aneurysmal subarachnoid hemorrhage patients

BackgroundPneumonia is a common complication in aneurysmal subarachnoid hemorrhage (aSAH) patients and has been confirmed associated with unfavorable outcome of aSAH patients. This study is designed to explore risk factors and develop predictive model of hospital acquired pneumonia in aSAH patients. Methods351 aSAH patients received treatments in the neuro-intensive care unit (NICU) of West China hospital were included. Univariate and multivariate logistic regression were performed to explore risk factors of hospital acquired pneumonia. And predictive model for pneumonia was also constructed using logistic regression. Area under the receiver operating characteristics curve (AUC) were calculated to evaluate the accuracy of the constructed model and single markers. Results96 aSAH patients developed hospital acquired pneumonia with incidence of 27.4%. Logistic regression analysis showed World Federation of Neurosurgical Societies (WFNS) score (0R = 1.677, p = 0.006), neutrophil count (0R = 1.300, p = 0.042), red blood cell transfusion (0R = 3.035, p = 0.030) and tracheostomy (0R = 7.645, p < 0.001) were independent risk factors of pneumonia in aSAH patients. Consisted of these four factors, the constructed model was valuable in predicting pneumonia with AUC of 0.808. The AUC of neutrophil to lymphocyte ratio and lactate dehydrogenase for predicting pneumonia was 0.671 and 0.613, respectively. ConclusionsWFNS, high neutrophil at admission, need of RBC transfusion and tracheostomy were independent risk factors of hospital acquired pneumonia in aSAH patients. The novel predictive model we constructed is efficient in evaluating possibility of pneumonia in aSAH patients during hospitalizations.

Representation of Women as Neurological Surgery Society Award Recipients

BACKGROUND: Women comprise more than half of medical school matriculants, but only 8.4% of US neurosurgeons. Awards given by neurosurgical societies are instrumental in shaping and advancing careers of women within academic neurosurgery, which can serve to increase the pipeline of women in the field. OBJECTIVE: To quantify the gender diversity of awards given by neurosurgical societies over 54 years. METHODS: Awards given by the American Association of Neurological Surgeons, Congress of Neurological Surgeons, and American Association of Neurological Surgeons/Congress of Neurological Surgeons joint sections were classified as research, humanitarian/achievement, or lectureships and analyzed for gender. Composite gender data were obtained from the societies. Percentage differences were calculated using comparison of proportions testing. RESULTS: Ninety six distinct awards granted to 1281 individuals from 1965 to 2019 were analyzed, and 9.4% were awarded to women. Seven percent of neurosurgeon awardees were women (excluding Women in Neurosurgery Section [WINS] awards). 36.1% of awards given at least 5 times were never awarded to women. Female awardees increased from 2000-2009 to 2010-2019 (5.2% difference, P = .018). The Cerebrovascular (2.0%) and Spine (2.3%) sections awarded the fewest awards to women, whereas the WINS (73.3%) and Pediatric section (20.6%) awarded the most. Spine, WINS, Pain, Cerebrovascular, and Tumor sections awarded significantly fewer awards to women than respective society demographic proportions. One-hundred percent (39 of 39) of named awards (excluding 2 from WINS) were named after men. CONCLUSION: Women remain underrepresented in the field of neurosurgery and as award winners. Many subspecialty sections continue to give significantly fewer awards to women than their society demographic proportions.

Alcohol Abuse Associated With Increased Risk of Angiographic Vasospasm and Delayed Cerebral Ischemia in Patients With Aneurysmal Subarachnoid Hemorrhage Requiring Mechanical Ventilation.

ObjectiveAlthough alcohol abuse has been indicated to cause cerebral aneurysm development and rupture, there is limited data on the impact of alcohol abuse on outcomes after an aneurysmal subarachnoid hemorrhage (aSAH). This study aims to investigate whether alcohol abuse increases the risk of angiographic vasospasm and delayed cerebral ischemia (DCI) in critically ill patients with aSAH.MethodsWe conducted a secondary analysis based on a retrospective study in a French university hospital intensive care unit (ICU). Patients with aSAH requiring mechanical ventilation hospitalized between 2010 and 2015 were included. Patients were segregated according to alcohol abuse (yes or no). Multivariable logistic regression analysis was used to identify the independent risk factors associated with angiographic vasospasm and DCI.ResultsThe patient proportion of alcohol abuse was dramatically greater in males than that in females (p < 0.001). The Simplified Acute Physiology Score II (SAPSII) score on admission did not show a statistical difference. Neither did the World Federation of Neurosurgical Societies (WFNS) and Fisher scores. Patients with alcohol abuse were more likely to develop angiographic vasospasm (OR 3.65, 95% CI 1.17–11.39; p = 0.0260) and DCI (OR 3.53, 95% CI 1.13–10.97; p = 0.0294) as evidenced by multivariable logistic regression analysis.ConclusionsIn this study, patients with alcohol abuse are at higher odds of angiographic vasospasm and DCI, which are related to poor prognosis following aSAH. These findings are important for the prevention and clinical management of aSAH.

Prof. Dr. Willian Harkness 1955-2021

We are deeply saddened by the passing of Dr. William Harkness. A gifted surgeon, a caring clinician, a visionary leader and devoted family man, William left an indelible impression on pediatric neurosurgery and the many people whose lives he touched. Dr. William was educated at Eton School and qualified in medicine in 1979, at the University of Birmingham. His neurosurgical training commenced at the Radcliffe Infirmary, Oxford and later continued in Birmingham. Upon completion of his specialist training in 1991, he was appointed as a consultant neurosurgeon at the National Hospital for Neurology and Neurosurgery, Queen Square and Great Ormond Street Hospital for Sick Children (GOSH), but it was the latter institution that became his professional home as he focused his career on pediatric neurosurgery, establishing a legendary partnership with Dr. Richard Hayward. Dr. William spent a year in North America undergoing training at UCLA, Seattle, Miami and Montreal. He enthusiastically embraced the multidisciplinary team approach, enabling him to establish a world-leading children’s epilepsy surgery service together with Helen Cross at GOSH. While this is where he had his greatest scientific impact, he was a consummate pediatric neurosurgeon who thought deeply and wrote on a wide range of conditions. William was known to be an exceptionally skillful surgeon, with many neurosurgical trainees citing him as the one of the leading technical neurosurgeons they had worked with. He served as clinical lead for pediatric neurosciences at GOSH and led the development of a national plan for epilepsy surgery services in Great Britain. Throughout his career William was an ardent advocate for pediatric neurosurgery, representing the specialty in many forums including the Society of British Neurological Surgeons. Dr. Willian was a participant in the first ever European Society for Pediatric Neurosurgery (ESPN) educational course, where he struck up a legendary friendship with the late Jim Goodrich, he went on to become one of the most sought-after lecturers worldwide, including many Latin American Courses of Pediatric Neurosurgery (LACPN). In ISPN, there are few who have contributed more to the society. Dr. William served as scientific chair, communications chair, treasurer and ultimately president, (2016-2017). Combining his organizational and technical skills, he worked with Jim Johnson to develop InterSurgeon, a web-based platform promoting international collaboration through linking neurosurgeons and related organisations across the world. Supported by among others, the ISPN, UAB and the G4Alliance, InterSurgeon has grown beyond neurosurgery and will be a lasting tribute to William’s vision and drive. Dr. William was also an integral member of the Global Neurosurgery Committee of the World Federation of Neurosurgical Societies (WFNS). He worked tirelessly to propel the field, and always made sure he was available to provide advice and assistance. During his time with the committee, he expanded the knowledge base on global neurosurgery, worked to align the multitude of projects in the field, and improved collaboration amongst neurosurgeons around the world. He married Philippa Lubomirski in 1982. She survives him as do their four children, Fran, Ed, Gabi and Letitia, their grandchildren, Arlo, Joanie, Betsy, Peggy and Ari, and his sister, Nicola. Above all else, we remember William’s devotion to his family most vividly. His beloved wife Philippa, who accompanied him on most of his travels. And his four children, Fran, Ed, Gabi and Letitia, their grandchildren, Arlo, Joanie, Betsy, Peggy and Ari, and his sister, Nicola. We extend our sincere condolences to his family and close friends

The Big Data Awareness of Turkish Neurosurgeons: A National Survey

Objective: The term big data refers to high volumes of data that are difficult to store, process, and analyze through traditional database technologies. This paper aims to discover the big data knowledge and awareness of Turkish neurosurgeons. Methods: An online survey link was sent to all members of the Turkish Neurosurgical Society (n=1707 neurosurgeons) by e-mail. The survey, which was available during September and October 2021, was filled by 211 specialists (12.4%) neurosurgeons. Participants were scored based on the questions asked in “Big Data” and the scores were compared with baseline characteristics.There was no statistically significant correlation between baseline characteristics (age, gender, the residency/current institution, academic title, the presence of a Ph.D. degree, and professional specialist period) and survey score. The survey scores of the participants who used a big data platform, wrote code, thought that the use of big data was beneficial, and wanted to learn more about this subject were statistically significantly higher. Conclusions: Obtaining information about big data seems to be related only to personal interests. Necessary arrangements should be made in the training programs of neurosurgeons on this topic, which is gaining in popularity and provides useful information for daily clinical practice.

Proper Use of Multiple Imputation and Dealing with Missing Covariate Data

Missing data is a typical problem in clinical studies, where the value of variables of interest is not measured or collected for some patients. This article aimed to review imputation approaches for missing values and their application in neurosurgery. We reviewed current practices on detecting missingness patterns and applications of multiple imputation approaches under different scenarios. Statistical considerations and importance of sensitivity analysis were explained. Various imputation methods were applied to a retrospective cohort. For illustration purposes, a retrospective cohort of 609 patients harboring both ruptured and unruptured intracranial aneurysms and undergoing microsurgical clip reconstruction at Erasmus MC University Medical Center, Rotterdam, The Netherlands, between 2000 and 2019 was used. modified Rankin Scale score at 6 months was the clinical outcome, and potential predictors were age, sex, size of aneurysm, hypertension, smoking, World Federation of Neurosurgical Societies grade, and aneurysm location. Associations were investigated using different imputation approaches, and the results were compared and discussed. Missing values should be treated carefully. Advantages and disadvantages of multiple imputation methods along with imputation in small and big data should be considered depending on the research question and specifics of the study.

Cerebral Microdialysis-Based Interventions Targeting Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage

BackgroundDelayed cerebral ischemia (DCI), a complication of subarachnoid hemorrhage (SAH), is linked to cerebral vasospasm and associated with poor long-term outcome. We implemented a structured cerebral microdialysis (CMD) based protocol using the lactate/pyruvate ratio (LPR) as an indicator of the cerebral energy metabolic status in the neurocritical care decision making, using an LPR ≥ 30 as a cutoff suggesting an energy metabolic disturbance. We hypothesized that CMD monitoring could contribute to active, protocol-driven therapeutic interventions that may lead to the improved management of patients with SAH.MethodsBetween 2018 and 2020, 49 invasively monitored patients with SAH, median Glasgow Coma Scale 11 (range 3–15), and World Federation of Neurosurgical Societies scale 4 (range 1–5) on admission receiving CMD were included. We defined a major CMD event as an LPR ≥ 40 for ≥ 2 h and a minor CMD event as an LPR ≥ 30 for ≥ 2 h.ResultsWe analyzed 7,223 CMD samples over a median of 6 days (5–8). Eight patients had no CMD events. In 41 patients, 113 minor events were recorded, and in 23 patients 42 major events were recorded. Our local protocols were adhered to in 40 major (95%) and 98 minor events (87%), with an active intervention in 32 (76%) and 71 (63%), respectively. Normalization of energy metabolic status (defined as four consecutive samples with LPR < 30 for minor and LPR < 40 for major events) was seen after 69% of major and 59% of minor events. The incidence of DCI-related infarcts was 10% (five patients), with only two observed in a CMD-monitored brain region.ConclusionsActive interventions were initiated in a majority of LPR events based on CMD monitoring. A low DCI incidence was observed, which may be associated with the active interventions. The potential aid of CMD in the clinical decision-making targeting DCI needs confirmation in additional SAH studies.

Subarachnoid Hemorrhage, Delayed Cerebral Ischemia, and Milrinone Use in Canada.

Delayed cerebral ischemia (DCI) is a complication of aneurysmal subarachnoid hemorrhage (aSAH) and is associated with significant morbidity and mortality. There is little high-quality evidence available to guide the management of DCI. The Canadian Neurosurgery Research Collaborative (CNRC) is comprised of resident physicians who are positioned to capture national, multi-site data. The objective of this study was to evaluate practice patterns of Canadian physicians regarding the management of aSAH and DCI. We performed a cross-sectional survey of Canadian neurosurgeons, intensivists, and neurologists who manage aSAH. A 19-question electronic survey (Survey Monkey) was developed and validated by the CNRC following a DCI-related literature review (PubMed, Embase). The survey was distributed to members of the Canadian Neurosurgical Society and to Canadian members of the Neurocritical Care Society. Responses were analyzed using quantitative and qualitative methods. The response rate was 129/340 (38%). Agreement among respondents was limited to the need for intensive care unit admission, use of clinical and radiographic monitoring, and prophylaxis for the prevention of DCI. Several inconsistencies were identified. Indications for starting hyperdynamic therapy varied. There was discrepancy in the proportion of patients who felt to require IV milrinone, IA vasodilators, or physical angioplasty for treatment of DCI. Most respondents reported their facility does not utilize a standardized definition for DCI. DCI is an important clinical entity for which no homogeneity and standardization exists in management among Canadian practitioners. The CNRC calls for the development of national standards in the definition, identification, and treatment of DCI.

Surgical Clipping of Ruptured Intracranial Aneurysm: Experience of a Tertiary Centre in Western India

Abstract Background Surgical clipping has been a gold standard procedure for management of intracranial aneurysms. Outcome studies of surgical clipping at institutional level are important to identify modifiable factors and further improve the results. These are even more important in areas where resources are limited, and patient presents late due to ignorance and lack of education. This study is a review of our institutional experience in microsurgical clipping of ruptured intracranial aneurysms. Methods A retrospective study of patients who underwent surgical clipping for ruptured intracranial aneurysms from January 2014 to February 2020. The medical records of patients were reviewed for demographic data, clinical presentation, radiological investigations, surgery performed and neurological outcome. Outcome at discharge and outcome at follow-up were measured by modified Rankin scale (mRS). Results In this study of 289 patients, 194 patients (67.13%) had good outcome at discharge (mRS0–2), while 95 patients (32.87%) had poor outcome at discharge (mRS 3–6) and 50 patients (17.30%) expired during hospital stay. Out of 289 patients, 208 patients (71.97%) were admitted after more than 3 days of ictus. Significant factors affecting outcome were neurological status determined by Glasgow coma scale (GCS) score, World Federation of Neurosurgical Societies (WFNS) grade or Hunt and Hess Grade, time interval from onset of subarachnoid hemorrhage to admission, and time interval from admission to surgery. Conclusion The present study identifies factors for improving outcome in patients of ruptured aneurysm at institutional and community level. Time from ictus to admission and admission to surgery are important modifiable factors in our study.