World Federation Of Neurosurgical Societies Research Articles

Letter to the Editor Regarding “The Oculomotor Cistern and its Role in the Management of Pituitary Lesions: An Anatomical, Radiographic, and Clinical Scoping Review”

Our aim was to assess the 5-year h-index (h5)-index by nation. We aimed to assess the relationship between a nation’s h5-index and numbers of neurosurgeons, population, gross domestic product (GDP), and expenditure on both health and research.Using Web of Science we collected data on each nation’s h5-index and number of publications for the 5-year period 2016 to 2020. Neurosurgical data were collected from the global neurosurgical workforce map provided by the World Federation of Neurosurgical Societies. National economic data were collected from the World Bank Open Data provided. We analyzed how economic and neurosurgical factors correlated with h5-index and publication numbers.We report the top 28 countries ranked according to their h5-index. Regarding the h5-index the strongest positive relationship was found with GDP, proportion of GDP spent on health and total amount spent on health per capita. In regard to the total number of publications (2016 to 2020), the strongest positive relationship was found with GDP and total number of neurosurgeons.This is the first study to explore the h-index between nations on an international level. GDP and proportion of GDP spent on health expenditure are the strongest correlates of the h5-index. Although a higher number of neurosurgeons in a nation does result in more publications, this is not necessarily translated into higher quality research.

Early Stages of Global Neurosurgery

The year 2015 was pivotal for the growth of global neurosurgery. In January, the United Nations (UN) adopted the Sustainable Development Goals (SDGs), replacing the expiring Millennial Development Goals. The SDGs were more comprehensive, having 17 Goals with 169 associated targets; a significant number of these included the necessity for surgical care to achieve the targets. 1
 In early Spring 2015, publication of Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development - The Lancet Commission on Global Surgery created a paradigm shift in the understanding of surgical needs worldwide, particularly in access to safe, timely and affordable surgical care for billions of individuals and large gaps in global surgical health workforce.2 At around the same time, Disease Control Priorities 3rd Edition, Volume 1, Essential Surgery laid out the economic case for surgical care, particularly in low resource settings.3 In May, the 68th World Health Assembly unanimously approved WHA resolution 68.15 on strengthening emergency and essential surgical care as a component of universal health coverage.4 
 The adoption of SDGs and WHA 68.15 provided the political impetus toward making surgical care a global priority, DCP3 created the health economic basis for global surgical care, and the Lancet Commission developed the factual needs basis for greatly enlarging global surgical service delivery.
 The World Health Organization (WHO) is the health technical arm of the UN. The WHA is composed of the health ministers of all UN Member States (countries) and is the governing body of WHO, setting the global health agenda and steering WHO’s work. The WHO Emergency and Essential Surgical Care (EESC) Programme5 was given the mandate to implement WHA resolution 68.15; a task that could only be achieved through extensive worldwide partnerships, such as the World Federation of Neurosurgical Societies (WFNS), which has official working relations as a non-state actor with WHO.6
 September 9-12, 2015, the 15th Interim Meeting of the World Federation of Neurosurgical Societies (WFNS) met in Rome, Italy.7 For the first time, a neurosurgeon was Lead of WHO EESC, creating a unique opportunity for optimally augmenting this WHO/WFNS partnership going forward. The Foundation for International Education in Neurosurgery (FIENS) held a session during this meeting, further highlighting future prospects.

Global Neurosurgery Advocacy

The white paper published by the Lancet Commission put forward surgery as a global health priority. In that paper, their findings showed that 5 billion people in the world do not have access to 'safe, affordable surgical and anesthesia services when needed,' and this inequity is more evident in lower- and middle-income countries (LMICs). These deficits are even more profound in surgical subspecialties such as neurosurgery. The paper "Global Neurosurgery: The Unmet Needs," published in 2016, addresses the system-level thinking and programs required to address the needs of neurosurgical care in lower resource settings. Neurosurgeons need to have influence, presence, and leadership role in advocating for the surgical system strengthening worldwide as it is estimated that there are 5 million emergency and essential neurosurgery neurosurgical services currently unmet, especially in LMICs. Thus, in 2019, the World Federation of Neurosurgical Societies (WFNS) established the Global Neurosurgery Committee (GNC), an ad hoc committee dedicated to organizing and furthering global neurosurgical efforts. The Committee is co-chaired by Kee B. Park, MD, MPH from the United States, and Abdessamad El Ouahabi, MD from Morocco. The body of the GNC was the Committee of 22 neurosurgeons from 19 countries; the Secretariat Team primarily managed internal GNC operations with support from the later-added Junior Committee, both of which were international medical students and trainees. One of the objectives of this Committee is to promote advocacy efforts for neurosurgical care within universal healthcare coverage. This paper explores the fifth "ADVOCATE" objective, including its significance, the GNC's efforts, and progress toward executing its defining targets.

The Role of Medical Students in Global Neurosurgery Committee 1.0

In 2019, the World Federation of Neurosurgical Societies (WFNS) established an ad hoc Global Neurosurgery Committee (GNC) to coordinate its global efforts to promote equitable neurosurgical care. Medical students have been essential to the GNC since its first generation (“GNC 1.0”). We describe the integration of medical students in GNC 1.0 and provide suggestions on the incorporation of medical students into the second-generation GNC (“GNC 2.0”).

Advancing Relevant Research

The Global Neurosurgery Committee (GNC) of the World Federation of Neurosurgical Societies (WFNS) launched the Global Action Plan during the 2016 Bogota Declaration on Global Neurosurgery in Colombia in order to coordinate efforts and bring neurosurgeons around the world to address unmet neurosurgical care. The Global Action Plan contains five objectives: Amplify, Align, Advance, Assimilate and Advocate for neurosurgical care. In this paper, we present the goals and the work of the Advance team. The goal of the Advance objective was to “A. Map research output by region and themes, B. Establish one or more Global Neurosurgery research grant and/or award mechanisms, C. Advocate for Global Neurosurgery category/sections in major neurosurgery journals (3 or more by 2021), D. Establish funding mechanisms for training in future leaders in the public health practice of Global Neurosurgery (2 or more by 2021), E. Inclusion of Global Neurosurgery Sessions in major neurosurgery meetings (>75% by 2021), F. Establish a mentoring relationship between editorial board members from HIC and LMICs (>1 by 2021), and G. Establish a mentoring relationship between authors from HIC and LMICs (>1 by 2021).

Global Nursing Care for Neurosurgical Patients

To address the staggering inequalities in access to neurosurgical care worldwide is the foundation of the global neurosurgery movement. The Global Neurosurgery Committee (GNC), which is part of the World Federation of Neurosurgical Societies (WFNS), represents the highest organizational level of the global neurosurgery movement. The endeavors of the inaugural GNC 1.0 culminated with the accomplishment of the Global Action Plan which objectives are to amplify, align, advance, assimilate and advocate for core neurosurgical activities such as the implementation and strengthening of neurosurgical capacity building into existing health systems1.
 To operationalize and decentralize the Global Action Plan, the recently commissioned GNC 2.0 is divided into designated teams; importantly neurosurgical nursing is included for the first time in the history of the WFNS/GNC. We (Yee Yit Cheng, Malaysia and Camilla G. Aukrust, Norway) have been invited to lead the nursing team in the time 2021-2023. The overall main goal is to build relationships and to reinforce the neurosurgical nursing workforce, specifically focusing on low-and middle-income countries (LMIC). To reach the goal we have assembled a diverse and global team of professionals, and created a mini-strategic plan with specific and time bound objectives within the following areas; policy/advocacy, clinical training/education and research. The consolidated efforts of the team members will be instrumental to reach the targets of the strategic plan. In the following four paragraphs, we will briefly outline the main objectives of the GNC nursing teams’ strategic plan.

Working Out of the Silo of Global Neurosurgery

The field of global surgery has gained attention since the publication of the Lancet Commission landmark report in 2015. The authors estimated that 5 billion people worldwide do not have access to safe, affordable surgical and anesthesia services. The paper “Global Neurosurgery: The Unmet Need,” published in 2016, launched the modern global neurosurgery era by advocating for the system-level thinking and programs required to address limited neurosurgical care in low-resource settings.
 
 At present, many individuals, academic institutions, governmental agencies, and nongovernmental organizations (NGOs) are involved in the global neurosurgery movement. These include the Program in Global Surgery and Social Change at Harvard Medical School, Duke Global Neurology and Neurosurgery, Weill Cornell Tanzania Neurosurgery Project, CURE Children’s Hospital of Uganda, and the Virtue Foundation in Mongolia. Nonetheless, as global neurosurgery efforts continue to expand, it is essential to align global neurosurgery activity in order to prevent duplication of effort.
 
 In 2019, the World Federation of Neurosurgical Societies (WFNS) established the Global Neurosurgery Committee (GNC) to promote access to safe, affordable, and timely neurosurgical care worldwide. The GNC initially included five primary objectives – Amplify, Align, Advance, Assimilate, and Advocate – with the sixth objective, Communication, added in 2021. In this manuscript, we provide an update on the Align objective team.

Global Neurosurgery Committee 1.0: A Model for Virtual Collaboration in Global Surgery

The World Federation of Neurosurgical Societies (WFNS), the governing body for national and regional neurosurgical societies worldwide, established the ad hoc Global Neurosurgery Committee (GNC) in 2019. This international board of neurosurgeons collaborated virtually in pursuit of defined goals and targets related to neurosurgical equity. We summarize the work of the WFNS GNC, highlight the role of virtual collaboration in global surgery, and delineate best practices for virtual collaboration in global surgery.

Global Neurosurgery Assimilation into the Global Surgery Movement

In 2019, the World Federation of Neurosurgical Societies (WFNS) created the Global Neurosurgery Committee (GNC). The GNC’s Global Action Plan is comprised of 5 objectives: 1) amplifying access to neurosurgical care, 2) aligning global neurosurgical activity, 3) advancing relevant research, especially from low-and-middle-income country (LMIC) authors, 4) assimilating neurosurgical capacity building into surgical systems planning and 5) advocating for (neuro)surgical care within universal health coverage. The goal to assimilate global neurosurgery (GNS) into surgical system planning is further divided into 2 specific goals for 2021: 1) Increasing participation of neurosurgeons in >50% of efforts to strengthen national surgical systems, and 2) increasing the rate of participation by neurosurgeons in major global surgery conferences by >20%. In this paper, the importance of the assimilate objectives will be reviewed, current progress towards the first Assimilate objective will be highlighted, and next steps will be discussed.

Factors related to intracerebral haematoma in patients with aneurysmal subarachnoid haemorrhage in Vietnam: a multicentre prospective cohort study

ObjectivesTo investigate the impact of intracerebral haematoma (ICH) on the outcomes and the factors related to an ICH in patients with aneurysmal subarachnoid haemorrhage (aSAH) in a low- and middle-income...

Terson Syndrome in Patients with Aneurysmal Subarachnoid Hemorrhage: A 10-Year Single-Center Experience.

Terson syndrome (TS), an intraocular hemorrhage associated with aneurysmal subarachnoid hemorrhage (aSAH), occurs in up to 46% of all patients with subarachnoid hemorrhage. Despite its high incidence, TS is underrepresented in the literature, and patients with aSAH are sometimes not systematically evaluated for the presence of TS in clinical practice. This work aims to raise awareness of TS, reevaluate previous scientific findings, describe risk factors associated with the occurrence of TS, and present our local diagnostic and treatment concept. All patients with aSAH treated at our institution between October 2010 and May 2020 were included in this retrospective study. The frequency of ophthalmological screening by indirect funduscopy, as well as the results, was investigated. In addition, the collection and statistical analysis of epidemiological and clinical data was performed using χ2, Kruskal-Wallis, and analysis of variance testing; multivariate regression; and receiver operating characteristic analysis. The significance level was set at p < 0.05. A total of 617 patients were treated for aSAH in our institution. Of these, 367 patients (59.5%) were ophthalmologically examined for the presence of TS. The rate of TS in the examined patients was 21.3% (n = 78). Patients with TS had significantly higher Fisher and World Federation of Neurosurgical Societies (WFNS) scores (p < 0.0001). Regression analyses showed WFNS grade (p = 0.003) and the occurrence of seizures (p = 0.002) as independent predictors of TS, as did receiver operating characteristic analyses, which had a significant area under the curve of 0.66 for the combination of WFNS grade and seizures. For 12 (15.4%) patients, the TS had to be surgically treated by pars plana vitrectomy in a total of 14 eyes, which resulted in significant improvement of visual function in all patients: mean preoperative best-corrected visual acuity was 0.03 (± 0.08) versus 0.76 (± 0.21) postoperatively (p < 0.001). TS is a common complication in patients with aSAH, affecting approximately one in five patients. A higher WFNS grade and the occurrence of seizures are associated with TS; therefore, screening for TS should be performed in these patients.

Elevated levels of several chemokines in the cerebrospinal fluid of patients with subarachnoid hemorrhage are associated with worse clinical outcome.

Chemokines are small cytokines that exert chemotactic actions on immune cells and are involved in many inflammatory processes. The present study aims to provide insight in the role of this relatively unexplored family of proteins in the inflammatory pathophysiology of subarachnoid hemorrhage (SAH). Cerebrospinal fluid of 29 patients (17 female; mean age 57 years) was collected at days 1, 4 and 10 after SAH, centrifuged and frozen at -70°C. Analysis of 92 inflammation-related proteins was performed using Target 96 Inflammation ® assay (Olink Proteomics, Uppsala, Sweden) based on Proximity Extension Assay technology. The panel included 20 chemokines (CCL2 (or MCP-1), CCL3, CCL4, CCL7 (or MCP-3), CCL8 (or MCP-2), CCL11 (or Eotaxin), CCL13 (or MCP-4), CCL19, CCL20, CCL23, CCL25, CCL28, CXCL1, CXCL5, CXCL6, CXCL8 (or IL-8), CXCL9, CXCL10, CXCL11 and CX3CL1 (or Fractalkine)) that were analyzed for their temporal patterns of expression and compared in dichotomized clinical groups based on World Federation of Neurosurgical Societies (WFNS) admission score and amount of blood on admission CT based on Fisher scale; presence of delayed cerebral ischemia(DCI)/delayed ischemic neurological deficit (DIND); and clinical outcome based on Glasgow Outcome Scale. Protein expression levels were provided in output unit Normalized Protein Expression (NPX). ANOVA models were used for statistical analyses. Four temporal patterns of expression were observed (i.e., early, middle, late peak and no peak). Significantly higher day 10 mean NPX values were observed in patients with poor outcome (GOS 1-3) for chemokines CCL2, CCL4, CCL7, CCL11, CCL13, CCL19, CCL20, CXCL1, CXCL5, CXCL6 and CXCL8. In the WFNS 4-5 group, CCL11 showed significantly higher day 4 and day 10 mean NPX values and CCL25 significantly higher day 4 values. In patients with SAH Fisher 4, CCL11 showed significantly higher mean NPX values on days 1, 4 and 10. Finally, patients with DCI/DIND had significantly higher day 4 mean NPX values of CXCL5. Higher levels of multiple chemokines at the late stage of SAH seemed to correlate with worse clinical outcome. A few chemokines correlated with WFNS score, Fisher score and occurrence of DCI/DIND. Chemokines may be useful as biomarkers for describing the pathophysiology and prognosis of SAH. Further studies are needed to better understand their exact mechanism of action in the inflammatory cascade.

Abstract Number ‐ 85: Distal Anterior Choroidal Artery Fusiform Aneurysm Successfully Treated with Flow Diversion

Introduction Anterior choroidal artery (AChA) aneurysms account for 3–5% of intracranial aneurysms, and are often saccular, arising at or near the origin of the AChA, with distal lesions being exceedingly rare. Contrary to saccular aneurysms, fusiform aneurysms are associated with a higher risk of rebleeding and mortality due to their formidable anatomy requiring advanced techniques including bypass, stent‐assisted coiling, and, more recently, flow diversion. While flow diverters are becoming more popular, they are currently only approved forinternal carotid artery segment aneurysms. However, many institutions areexpanding their use to more distal and smaller caliber vessels. Herein we present a novel pathology of a dissecting distal AChA fusiform pseudoaneurysm with a small vessel caliber treated successfully with flow diversion. Methods Case presentation and surgical technique. Results We describe a 40‐year‐old woman with monoclonal gammopathy of unknown significance (MGUS), lichen sclerosis, and an unspecified connective tissue disease presenting with diffuse subarachnoid hemorrhage (SAH) (World Federation of Neurosurgical Societies 1; Hunt &amp; Hess scale 2; Modified Fisher Scale 3). A digital subtraction cerebral angiogram revealed a dissecting (5×3 mm) left AChA pseudoaneurysm, 4mm distal to the origin (Figure 1). Flow Redirection Endoluminal Device (FRED Jr, Microvention, CA) (2.5mm 8/13 working/total length) was deployed within the vessel proximal to the aneurysm, preceded by an infusion of 5mg of verapamil to facilitate stent placement (Figure 2). Post procedure, she remained neurologically intact and was discharged on dual antiplatelet therapy (aspirin/ticagrelor). Repeat cerebral angiogram at six months showed patent flow diversion device and no pseudoaneurysm remnant (Figure 3) with a nonfocal physical examination. Conclusions Flow diversion may be a successful, and safe, therapeutic intervention for challenging distal intracranial aneurysms with smaller caliber vessels.

Intraoperative arterial pressure and delayed cerebral ischemia in patients with aneurysmal subarachnoid hemorrhage after surgical clipping: A retrospective cohort study.

Delayed cerebral ischemia (DCI) is the major predictor of poor outcomes in patients with aSAH. Previous studies have attempted to assess the relationship between controlling blood pressure and DCI. However, the management of intraoperative blood pressure in reducing the occurrence of DCI still remains inconclusive. All patients with aSAH who received general anesthesia for surgical clipping between January 2015 and December 2020 were prospectively reviewed. Patients were divided in the DCI group or the non-DCI group depending on whether DCI occurred or not. Intraoperative arterial pressure was measured every minute and recorded in an electronic anesthesia recording system along with intraoperative medication and other vital signs. The initial neurological function score, aneurysm characteristics, surgical and anesthetic information, and outcomes were compared between the DCI and the non-DCI groups. Among 534 patients who were enrolled, a total of 164 (30.71%) patients experienced DCI. The baseline characteristics of patients were similar between the groups. The World Federation of Neurosurgical Societies (WFNS) Scale > 3, age ≥ 70 years, and the modified Fisher Scale > 2 were significantly higher in patients with DCI than those without. Though it was the second derivative of the regression analysis, 105 mmHg was adopted as the threshold for intraoperative hypotension and was not associated with DCI. The threshold of 105 mmHg was adopted as intraoperative hypotension even though it was the second derivative of the regression analysis and could not be proved to be associated with delayed cerebral ischemia adjusted by the baseline severity of aSAH and age.

Blood Pressure Affects the Early CT Perfusion Imaging in Patients with aSAH Reflecting Early Disturbed Autoregulation.

Early computed tomography perfusion (CTP) is frequently used to predict delayed cerebral ischemia following aneurysmatic subarachnoid hemorrhage (aSAH). However, the influence of blood pressure on CTP is currently controversial (HIMALAIA trial), which differs from our clinical observations. Therefore, we aimed to investigate the influence of blood pressure on early CTP imaging in patients with aSAH. We retrospectively analyzed the mean transit time (MTT) of early CTP imaging within 24h after bleeding prior to aneurysm occlusion with respect to blood pressure shortly before or after the examination in 134 patients. We correlated the cerebral blood flow with the cerebral perfusion pressure in the case of patients with intracranial pressure measurement. We performed a subgroup analysis of good-grade (World Federation of Neurosurgical Societies [WFNS] I-III), poor-grade (WFNS IV-V), and solely WFNS grade V aSAHpatients. Mean arterial pressure (MAP) significantly correlated inversely with the mean MTT in early CTP imaging (R = - 0.18, 95% confidence interval [CI] - 0.34 to - 0.01, p = 0.042). Lower mean blood pressure was significantly associated with a higher mean MTT. Subgroup analysis revealed an increasing inverse correlation when comparing WFNS I-III (R = - 0.08, 95% CI - 0.31 to 0.16, p = 0.53) patients with WFNS IV-V (R = - 0.2, 95% CI - 0.42 to 0.05, p = 0.12) patients, without reaching statistical significance. However, if only patients with WFNS V are considered, a significant and even stronger correlation between MAP and MTT (R = - 0.4, 95% CI - 0.65 to 0.07, p = 0.02) is observed. In patients with intracranial pressure monitoring, a stronger dependency of cerebral blood flow on cerebral perfusion pressure is observed for poor-grade patients compared with good-grade patients. The inverse correlation between MAP and MTT in early CTP imaging, increasing with the severity of aSAH, suggests an increasing disturbance of cerebral autoregulation with the severity of early brain injury. Our results emphasize the importance of maintaining physiological blood pressure values in the early phase of aSAH and preventing hypotension, especially in patients with poor-grade aSAH.

Neurosurgical Academic Impact Rankings by h5-Index: A Global Perspective

Our aim was to assess the 5-year h-index (h5)-index by nation. We aimed to assess the relationship between a nation's h5-index and numbers of neurosurgeons, population, gross domestic product (GDP), and expenditure on both health and research. Using Web of Science we collected data on each nation's h5-index and number of publications for the 5-year period 2016 to 2020. Neurosurgical data were collected from the global neurosurgical workforce map provided by the World Federation of Neurosurgical Societies. National economic data were collected from the World Bank Open Data provided. We analyzed how economic and neurosurgical factors correlated with h5-index and publication numbers. We report the top 28 countries ranked according to their h5-index. Regarding the h5-index the strongest positive relationship was found with GDP, proportion of GDP spent on health and total amount spent on health per capita. In regard to the total number of publications (2016 to 2020), the strongest positive relationship was found with GDP and total number of neurosurgeons. This is the first study to explore the h-index between nations on an international level. GDP and proportion of GDP spent on health expenditure are the strongest correlates of the h5-index. Although a higher number of neurosurgeons in a nation does result in more publications, this is not necessarily translated into higher quality research.

In Memoriam: Jules Hardy, 1932 to 2022.

Dr Jules Hardy, circa 1980. Courtesy of Mr VeraHardy-Marino. Consent to publish was obtained.During the past century, we have witnessed the amazing advances of our extraordinary specialty of neurological surgery. Much of this has been the result of several cherished leaders who gave us new horizons as our specialty progressed. Among the foremost of these great pioneers was Jules Hardy of Canada, who passed away at the age 90 years in October 2022 (Figure). He was born in Sorel, Quebec, in 1932. His high school education in Montreal was followed by intense study of classical humanities with the Jesuits, and he was fascinated by the ideas of Thielhard de Chardin, a famous Archeologist, Philosopher, and Theologian. In 1956, he received an MD cum laude at the University of Montreal, after which he became the Director of the Neurosurgery program there (1979-1988). His neurosurgical training began with Claude Bertrand at the Notre Dame Hospital, University of Montreal. He also studied and experimented in neurophysiology with Herbert Jasper at the Montreal Neurological Institute. Subsequently, a fellowship from the McLaughlin Foundation led him to Paris to study stereotactic neurosurgery and pituitary surgery with Gerard Guiot, who was a pupil of Norman Dott of Edinburgh. When Dr Hardy returned to Montreal, he introduced many important innovations, including the use of intraoperative radio fluoroscopy and most importantly the incorporation of the surgical microscope, which then began to be widely used in the modern use of trans-sphenoidal surgery for pituitary tumors. These advances resulted in his discovery and identification of pituitary microadenomas, which could be successfully removed without damage to the normal pituitary gland. This concept of the “selective adenomectomy” was the key operative strategy that results in the surgical cure of functional adenomas with preservation of pituitary function that remains with us today. This began the trans-sphenoidal era of microscope assisted removal of pituitary lesions, with markedly improved accuracy, operative results, and outcomes for his patients. His thorough and elegant methods were presented and widely applied beginning in the late 1960s and were rapidly used by neurosurgeons in North America, Europe, and later throughout the world. Dr Hardy shared freely of his wisdom and skill as attested by his numerous residents, fellows, and learners from all over the world, and he was a staunch member of the International Society of Pituitary Surgeons. His many honors (Table) are testament to the importance and scope of the intellect and expertise he developed to modernize not only pituitary surgery but also to enlighten many aspects of pituitary endocrinology. TABLE. - Dr Hardy's Lifetime Honors 1974—Received the order of merit for sciences and health from the government of Lebanon 1978—Queen Elizabeth II Silver Jubilee Medal 1979—Honorary doctorate from the University of Guadalajara in Mexico 1983—Professeur itinerant du Commonwealth britannique 1987—Officer of the Order of Canada 1987—Commandeur de l’Ordre de Rio Branco—Brazil 1989—Knight of the National Order of Quebec 1989—Recipient of the Prix Léo-Pariseau 1989—Recipient of the Prix Izaak-Walton-Killam 1997—Medal of Honor, World Federation of Neurosurgical Societies 2007—Schloffer Award, Vienna Modified from wikipedia.com, “Jules Hardy: Honors,” under CC BY-SA 3.0, courtesy of Dr Mohr. Dr Hardy had a brilliant career, developing new paradigms, new techniques, new concepts, and giant advances in understanding the complexity, diagnosis, and management of the “master gland” and its disorders. He did this with the support of his loving family, his colleagues, students, and his many patients. To know him and to learn from him was unforgettable. He was one of the great pioneers of neurosurgery and a truly iconic role model for others who strive for and achieve continuing progress in our endeavors.

Validation of the accuracy of the modified World Federation of Neurosurgical Societies subarachnoid hemorrhage grading scale for predicting the outcomes of patients with aneurysmal subarachnoid hemorrhage.

Evaluating the prognosis of patients with aneurysmal subarachnoid hemorrhage (aSAH) who may be at risk of poor outcomes using grading systems is one way to make a better decision on treatment for these patients. This study aimed to compare the accuracy of the modified World Federation of Neurosurgical Societies (WFNS), WFNS, and Hunt and Hess (H&H) Grading Scales in predicting the outcomes of patients with aSAH. From August 2019 to June 2021, we conducted a multicenter prospective cohort study on adult patients with aSAH in three central hospitals in Hanoi, Vietnam. The primary outcome was the 90-day poor outcome, measured by a score of 4 (moderately severe disability) to 6 (death) on the modified Rankin Scale (mRS). We calculated the areas under the receiver operator characteristic (ROC) curve (AUROCs) to determine how well the grading scales could predict patient prognosis upon admission. We also used ROC curve analysis to find the best cut-off value for each scale. We compared AUROCs using Z-statistics and compared 90-day mean mRS scores among intergrades using the pairwise multiple-comparison test. Finally, we used logistic regression to identify factors associated with the 90-day poor outcome. Of 415 patients, 32% had a 90-day poor outcome. The modified WFNS (AUROC: 0.839 [95% confidence interval, CI: 0.795-0.883]; cut-off value≥2.50; PAUROC<0.001), WFNS (AUROC: 0.837 [95% CI: 0.793-0.881]; cut-off value≥3.5; PAUROC<0.001), and H&H scales (AUROC: 0.836 [95% CI: 0.791-0.881]; cut-off value≥3.5; PAUROC<0.001) were all good at predicting patient prognosis on day 90th after ictus. However, there were no significant differences between the AUROCs of these scales. Only grades IV and V of the modified WFNS (3.75 [standard deviation, SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), WFNS (3.75 [SD: 2.46] vs 5.24 [SD: 1.68], p = 0.026, respectively), and H&H scales (2.96 [SD: 2.60] vs 4.97 [SD: 1.87], p<0.001, respectively) showed a significant difference in the 90-day mean mRS scores. In multivariable models, with the same set of confounding variables, the modified WFNS grade of III to V (adjusted odds ratio, AOR: 9.090; 95% CI: 3.494-23.648; P<0.001) was more strongly associated with the increased risk of the 90-day poor outcome compared to the WFNS grade of IV to V (AOR: 6.383; 95% CI: 2.661-15.310; P<0.001) or the H&H grade of IV to V (AOR: 6.146; 95% CI: 2.584-14.620; P<0.001). In this study, the modified WFNS, WFNS, and H&H scales all had good discriminatory abilities for the prognosis of patients with aSAH. Because of the better effect size in predicting poor outcomes, the modified WFNS scale seems preferable to the WFNS and H&H scales.

Predictors of Outcomes Six Months after Endovascular Coil Embolization of Poor-Grade Aneurysmal Subarachnoid Hemorrhage.

To identify factors associated with the outcome and prognosis of coil embolization for poor-grade aneurysmal subarachnoid hemorrhage (aSAH). We retrospectively reviewed 118 patients with World Federation of Neurosurgical Societies (WFNS) grade IV or V subarachnoid hemorrhage at our institute between January 2010 and December 2020. Outcomes were assessed using modified Rankin Scale (mRS) scores at discharge and at six months after aSAH onset. In addition, patient background, aneurysm characteristics, and treatment outcome were compared between patients showing favorable (mRS scores: 0-2) and unfavorable (mRS scores: 3-6) outcomes at six months. Factors for change of mRS during follow-up were explored, and cut off values were calculated for age using the receiver operating characteristic analysis. Endovascular treatment was performed in 51 of the 118 enrolled patients. Data were analyzed for 43 of these patients who underwent coil embolization of ruptured aneurysms and had complete datasets. The mean age was 61.7 years and 24 (55.8%) patients had WFNS grade V aSAH. Coil embolization-related complications were observed in three patients. There were no treatment-related deaths; however, eight patients (18.6%) died at three months. Multivariate analysis showed that the maximum diameter of the aneurysm (p=0.041) and the postoperative dual antiplatelet therapy (DAPT) (p=0.040) were associated with unfavorable and favorable outcomes, respectively. Older age (p=0.033) was independently associated with mRS score deterioration following discharge. Age 72 years and older was the cut off value for mRS deterioration. Aneurysm size and postoperative DAPT might be associated with outcomes at 6 months. Moreover, we identified older age as an independent factor that influences mRS deterioration following discharge; thus, especially in cases of elderly patients over 72 years of age, it is highly likely that long-term care to prevent disuse and regular follow-up on imaging will be necessary.

Postoperative red blood cell distribution width predicts functional outcome in aneurysmal subarachnoid hemorrhage after surgical clipping: A single-center retrospective study.

Red blood cell (RBC) parameters are associated with outcomes following aneurysmal subarachnoid hemorrhage (aSAH), but their predictive value remains uncertain. This study aimed to detect the association between RBC parameters and functional outcome in aSAH patients undergoing surgical clipping. This retrospective observational study included aSAH patients who underwent surgical clipping at Affiliated Hospital of North Sichuan Medical College between August 2016 and September 2019. The functional outcome following aSAH was assessed by modified Rankin Scale (mRS), and mRS 3-6 was defined as poor functional outcome. Out of 187 aSAH patients included (62% female, 51-66 years old), 73 patients had poor functional outcome. Multivariate logistic regression of admission parameters showed that World Federation of Neurosurgical Societies (WFNS) grade (odds ratio [95% CI]: 1.322 [1.023-1.707], p = 0.033) and white blood cell (WBC) (odds ratio [95% CI]: 1.136 [1.044-1.236], p = 0.003) were independently associated with poor functional outcome. In postoperative parameters, RBC distribution width (RDW) (odds ratio [95% CI]: 1.411 [1.095-1.818], p = 0.008), mean platelet volume (MPV, odds ratio [95% CI]: 1.253 [1.012-1.552], p = 0.039) and admission WFNS grade (odds ratio [95% CI]: 1.439 [1.119-1.850], p = 0.005) were independently associated with poor functional outcome. The predictive model including WFNS grade, admission WBC, and postoperative RDW and MPV had significantly higher predictive power compared to WFNS grade alone (0.787 [0.722-0.852] vs. 0.707 [0.630-0.784], p = 0.024). The combination of WFNS grade and WBC on admission showed the highest positive predictive value (75.5%) and postoperative RDW and MPV combined with admission WFNS grade and WBC showed the highest negative predictive value (83.7%). Postoperative RDW is independently associated with poor functional outcome in aSAH patients undergoing surgical clipping. A combined model containing postoperative RDW may help predict good outcome in patients with aSAH after timely aneurysm clipping.