Prevalence of Acute Alcohol Use in Traumatic Brain Injury Patients During the COVID-19 Pandemic: A Retrospective Analysis From Queens, New York.

Background This study investigates the impact of New York's relaxed alcohol consumption policies during the coronavirus disease (COVID-19) pandemic on alcohol-related traumatic brain injuries (TBIs) among patients admitted to a Level 1 trauma center in Queens. Given the limited research available, this study critically explores the link between public health policies and trauma care. It aims to address a significant gap in the literature and highlight the implications of alcohol regulations during global health emergencies. Methodology A retrospective analysis was conducted among trauma patients from 2019 to 2021. The study period was divided into the following three periods: pre-lockdown (March 7, 2019, to July 31, 2019), lockdown (March 7, 2020, to July 31, 2020), and post-lockdown (March 7, 2021, to July 31, 2021). Data on demographics, injury severity, comorbidities, and outcomes were collected. The study focused on assessing the correlation between New York's alcohol policies and alcohol-related TBI admissions during these periods. Results A total of 1,074 admissions were analyzed. The study found no significant changes in alcohol-positive patients over the full calendar years of 2019, 2020, and 2021 (42.65%, 38.91%, and 31.16% respectively; p = 0.08711). Specifically, during the lockdown period, rates of alcohol-positive TBI patients remained unchanged, despite the relaxed alcohol policies. There was a decrease in alcohol-related TBI admissions in 2021 compared to 2020 during the lockdown period. Conclusions Our study concludes that New York's specific alcohol policies during the COVID-19 pandemic were not correlated with an increase in alcohol-related TBI admissions. Despite the relaxation of alcohol consumption laws, there was no increase in alcohol positivity among TBI patients. The findings suggest a complex relationship between public policies, alcohol use, and trauma during pandemic conditions, indicating that factors other than policy relaxation might influence alcohol-related trauma incidences.

Vein of Galen Malformations.

Significant efforts have been made over the last few decades to improve the diagnosis and management of patients with vein of Galen malformations (VOGMs). The mainstays of treatment remain focused on primary endovascular management by staged transarterial embolizations with adjunctive use of transvenous embolization, medical therapy, and neurosurgical intervention for symptom control in select patients. Innovation in endovascular technology and techniques as well as promising new genomic research elucidating potential therapeutic targets hold significant promise for the future of VOGM treatment.

Safety and effectiveness assessment of the surpass evolve (SEASE): a post-market international multicenter study.

BACKGROUND: Flow diverters are the first-line treatment for specific intracranial aneurysms (iA). Surpass Evolve (SE) is a new-generation 64-wire flow diverter with a high braid angle. Current literature on the SE is limited. We aimed to report the first international real-world experience evaluating the safety and effectiveness of the SE. METHODS: The Safety and Effectiveness Assessment of the Surpass Evolve (SEASE) was a multicenter retrospective international post-marketing cohort study including consecutive patients treated with SE for iAs between 2020 and 2022. Demographic, clinical, and angiographic data were collected. Primary effectiveness was independent core lab adjudicated complete occlusion rates (Raymond-Roy Class 1) at last follow-up. Primary safety were major ischemic/hemorrhagic events and mortality. RESULTS: In total, 305 patients with 332 aneurysms underwent SE implantation. The patients had a median age of 59 [50-67] years, and 256 (83.9%) were female. The baseline modified Rankin scale score was 0-2 in 291 patients (96.7%). Most aneurysms were unruptured (285, 93.4%) and saccular (309, 93.1%). Previous treatment was present in 76 (22.9%) patients. The median aneurysm size was 5.1 [3.4-9.0] mm, and the median neck width was 3.6 [2.7-5.1] mm. Most aneurysms were in the internal carotid artery C6 ophthalmic segment (126, 38.0%), followed by the communicating segment (58, 17.5%). At median 10.2 [6.4-12.9] months follow-up, 233 (73.0%) aneurysms achieved complete occlusion. After adjusting for confounders, complete occlusion remained consistent. Major stroke and procedure-related mortality were reported in 6 (2%) and 2 (0.7%) cases, respectively. CONCLUSION: These results demonstrate that SE has a consistently high effectiveness and favorable safety for the treatment of iAs.

Clinical and Operative Risk Factors Associated With Prolonged Length of Stay After Endoscopic Pituitary Adenoma Resection.

BACKGROUND AND OBJECTIVES: Pituitary adenomas (PAs) are the most common intrasellar tumor. Clinically relevant adenomas have a prevalence of 1 per 1000 in the general population. Transsphenoidal surgery (TSS) is the most common surgical treatment and is the first-line management for most PAs. Most patients fare well postoperatively, but a subset of patients experience a prolonged length of stay (PLOS). In this article, we aim to identify demographic and clinical factors associated with PLOS after TSS for PA. METHODS: Patients with sellar pathologies surgically treated at a single tertiary center from March 1, 2009, to May 31, 2020, were retrospectively reviewed. All patients older than 18 years receiving nonemergent endoscopic TSS for pituitary adenoma were included. Clinical and demographic characteristics were analyzed using χ 2 -tests and student t -tests. For those factors with a P -value less than .01, multivariate logistic regression and negative binomial regression models were constructed to estimate the adjusted odds of PLOS across predictive factors. RESULTS: A total of 301 patients were included in the study. This cohort had an average age of 54.65 ± 15.06 years and an average body mass index of 29.47 ± 6.69. The median length of stay was 54.9 hours [25th-75th percentiles: 43.5-72.9]. Postoperative cerebrospinal fluid leak ( P < .01), postoperative diabetes insipidus (DI) ( P < .01), increased surgery duration ( P = .01), and elevated maximal tumor dimension ( P = .01) were predictive of PLOS in logistic regression. Increased surgery duration, previous pituitary radiation, intraoperative complications, and postoperative DI (all P < .01) were associated with increased rate of PLOS in negative binomial regression. CONCLUSION: Patients undergoing endoscopic TSS for PA resection demonstrate prolonged lengths of stay if they have higher tumor burden, have lengthier surgeries with intraoperative complications, or develop postoperative complications such as cerebrospinal fluid leak or DI. Careful monitoring of these factors will allow for better resource optimization, reducing costs to both the hospital and the patient.

Endovascular treatment of acute ischemic stroke patients with tandem lesions: antegrade versus retrograde approach.

OBJECTIVE: The optimal technique for treating tandem lesions (TLs) with endovascular therapy is debatable. The authors evaluated the functional, safety, and procedural outcomes of different approaches in a multicenter study. METHODS: Anterior circulation TL patients treated from January 2015 to December 2020 were divided on the basis of antegrade versus retrograde approach and included. The evaluated outcomes were favorable modified Rankin Scale (mRS) score (mRS score 0-2) at 3 months, ordinal shift in mRS score, successful recanalization, excellent recanalization, first-pass effect (FPE), time from groin puncture to successful recanalization, symptomatic intracranial hemorrhage (sICH), and 90-day mortality. RESULTS: Among 691 patients treated at 16 centers, 286 patients (174 antegrade and 112 retrograde approach patients) with acute stenting were included in the final analysis. There were no significant differences in mRS score 0-2 at 90 days (52.2% vs 50.0%, adjusted odds ratio [aOR] 0.83, 95% CI 0.42-1.56, p = 0.54), favorable shift in 90-day mRS score (aOR 1.03, 95% CI 0.66-1.29, p = 0.11), sICH (4.0% vs 4.5%, aOR 0.64, 95% CI 0.24-1.51, p = 0.45), successful recanalization (89.4% vs 93%, aOR 0.49, 95% CI 0.19-1.28, p = 0.19), excellent recanalization (51.4% vs 58.9%, aOR 0.59, 95% CI 0.40-1.07, p = 0.09), FPE (58.3% vs 69.7%, aOR 0.62, 95% CI 0.44-1.15, p = 0.21), and mortality at 90 days (16.6% vs 14.0%, aOR 0.94, 95% CI 0.35-2.44, p = 0.81) between the groups. The median (interquartile range) groin puncture to recanalization time was significantly longer in the antegrade group (59 [43-90] minutes vs 49 [35-73] minutes, p = 0.036). CONCLUSIONS: The retrograde approach was associated with faster recanalization times with a similar functional and safety profile when compared with the antegrade approach in patients with acute ischemic stroke with TL.

Use of a mini balloon microcatheter to facilitate penetration of fine vascular networks and curative embolization in vein of Galen malformations.

Background Patients with vein of Galen malformations (VOGMs) can develop fine angiogenic networks with fistulous connections to the precursor of the vein of Galen. In these cases, transarterial embolization (TAE) with liquid embolic agents (LEAs) is challenging due to reflux in the pedicle leading to the network, causing poor penetration. Transvenous approaches carry a risk of hemorrhage from pathologic vasculature. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA) improve distal pedicle access, preventing reflux.Objective Here, we report on the use of the Scepter Mini for TAE of angiogenic VOGM.Methods A single-institution retrospective chart review identified all VOGMs treated with Scepter Mini microcatheters. Clinical data, angioarchitecture, and technical parameters were reviewed.Results 17 Scepter Mini catheters were used in 12 embolization procedures of 7 patients with VOGM at a median age of 2.1 years. Patients presented with hydrocephalus (100%) and gross motor and speech delays (57.1%). Networks developed extra-axially into the subependymal zone fed by posterior choroidal, posterior cerebral, and thalamoperforator arteries. Posterior choroidal branches (n=7/17, 41.2%) were most frequently catheterized to achieve distal access to the network. Embolization with Onyx-18 and significant network penetration occurred in 17/17 uses. Near tip entrapment with LEA cast displacement occurred in 1/17 uses. Another patient experienced postprocedural intraventricular hemorrhage requiring a third ventriculostomy without permanent neurologic deficit.Conclusion The Scepter Mini provided excellent distal access with penetration to the fistula and extra-axial network reduction with few complications. The Scepter Mini provides a means for successful treatment of technically challenging angiogenic VOGM.

Preoperative cerebral angiography nearly doubles the rate of diffusion-weighted imaging lesion detection following minimally invasive surgery for intracerebral hemorrhage.

BACKGROUND: Diffusion-weighted imaging (DWI) lesions have been linked to poor outcomes after intracerebral hemorrhage (ICH). We aimed to assess the impact of cerebral digital subtraction angiography (DSA) on the presence of DWI lesions in patients who underwent minimally invasive surgery (MIS) for ICH. METHODS: Retrospective chart review was performed on ICH patients treated with MIS in a single health system from 2015 to 2021. One hundred and seventy consecutive patients who underwent postoperative MRIs were reviewed. Univariate analyses were conducted to determine associations. Variables with p<0.05 were included in multivariate analyses. RESULTS: DWI lesions were present in 88 (52%) patients who underwent MIS for ICH. Of the 83 patients who underwent preoperative DSA, 56 (67%) patients demonstrated DWI lesions. In this DSA cohort, older age, severe leukoaraiosis, larger preoperative hematoma volume, and increased presenting National Institutes of Health Stroke Score (NIHSS) were independently associated with DWI lesion identification (p<0.05). In contrast, of 87 patients who did not undergo DSA, 32 (37%) patients demonstrated DWI lesions on MRI. In the non-DSA cohort, presenting systolic blood pressure, intraventricular hemorrhage, and NIHSS were independently associated with DWI lesions (p<0.05). Higher DWI lesion burden was independently associated with poor modified Rankin Scale (mRS) at 6 months on a univariate (p=0.02) and multivariate level (p=0.02). CONCLUSIONS: In this cohort of ICH patients who underwent minimally invasive evacuation, preprocedural angiography was associated with the presence of DWI lesions on post-ICH evacuation MRI. Furthermore, the burden of DWI lesions portends a worse prognosis after ICH.

Predictors of Prolonged Length of Stay After Pituitary Adenoma Resection: A Large Cohort Analysis Using the National Inpatient Sample (2016-2019).

OBJECTIVE: In this nationwide retrospective study, the authors aimed to identify demographic, clinical, and baseline health risk factors predictive of a prolonged length of stay (PLOS) for patients with pituitary adenomas (PAs). METHODS: The National Inpatient Sample dataset from 2016 to 2019 was utilized to identify all included hospitalizations for PA resection as identified by the appropriate diagnosis-related group code. Comorbidities were classified based on the Charlson Comorbidity Index mapping of ICD-10 codes, and PLOS was identified as any stay longer than 3 days. Univariable and multivariable logistic regression models, accounting for the sample design, were built to determine factors associated with PLOS and emergent surgery. RESULTS: Overall, 30 945 patients were included in this study with 10 535 patients having PLOS. Female patients experienced an increased odds of PLOS (odds ratio [OR]: 1.29; P < .001). Black patients (OR: 1.49; P < .001) and Hispanic patients (OR: 1.30; P = .003) had 1.49 times and 1.30 times the odds of PLOS compared to White patients, respectively. Compared to patients insured by Medicare, patients insured by Medicaid had an increased odds of PLOS (OR: 1.36; P = .007) as well as emergent surgery (OR: 5.40; P < .001). When stratified by emergent surgeries, Black patients (OR: 1.89; P < .001), Hispanic patients, (OR: 2.14; P < .001), and patients on Medicaid insurance (OR: 1.71; P < .001) were at an increased risk of emergent procedures. However, female sex (OR: 0.65; P < .001), upper third quartile (OR: 0.73; P = .017), and fourth quartile (OR: 0.69; P = .014) of patients categorized by zip code income were at decreased odds of an emergent procedure. CONCLUSIONS: Black and Hispanic patients, patients with Medicaid insurance, and patients of low socioeconomic status patients are at significantly higher risk of emergent PA resection and PLOS. Efforts to prevent emergent surgeries and shorten hospitalization after pituitary surgery may need to primarily focus on patient groups with select sociodemographic characteristics.

Dysphagia after ischemic and hemorrhagic stroke: A propensity-matched 20-year analysis of the national inpatient sample.

OBJECTIVE: Dysphagia is a common symptom of acute ischemic stroke (AIS) and intracerebral hemorrhage (ICH), but little is known surrounding national trends of this post-stroke condition. Hence, this study aimed to identify the risk factors for dysphagia following AIS and ICH and evaluate in-hospital outcomes in these patients. METHODS: The 2000-2019 Nationwide Inpatient Sample was queried for patients admitted with AIS (ICD9 433, 43401, 43411, 43491, ICD-10 I63) and ICH (ICD9 431, 432.9, ICD-10 I61, I62.9). Univariate analysis with t-tests or chi-square performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences >0.1 were used in multivariable regression to generate adjusted odds ratios (AOR)/ß-coefficients for the presence of dysphagia on outcomes. RESULTS: Of 10,415,286 patients with AIS, 956,662 (9.2%) had in-hospital dysphagia. Total of 2,000,868 patients with ICH were identified; 203,511 (10.2%) had in-hospital dysphagia. Patients with dysphagia after AIS were less likely to experience in-hospital mortality (OR 0.61;95%CI: 0.60-0.63) or be discharged home (AOR 0.51;95%CI: 0.51-0.52), had increased length of stay (Beta-coefficient = 0.43 days; 95%CI: 0.36-0.50), and had increased hospital charges ($14411.96;95%CI: 13565.68-15257.44) (all p < 0.001). Patients with dysphagia after ICH were less likely to experience in-hospital mortality (AOR 0.39;95%CI: 0.37-0.4), less likely to be discharged home (AOR 0.59,95%CI:0.57-0.61), have longer hospital stay (Beta-coefficient = 1.99 days;95%CI: 1.78-2.21), and increased hospital charges ($28251.93; 95%CI: $25594.57-30909.28)(all p < 0.001). CONCLUSION: This is the first study to report on national trends in patients with dysphagia after AIS and ICH. These patients had longer hospital LOS, worse functional outcomes at discharge, and higher hospital costs.

Transcranioplasty Ultrasonography Through a Sonolucent Prosthesis: A Review of Feasibility, Safety, and Benefits.

Data on the effectiveness of transcranioplasty ultrasonography through sonolucent cranioplasty (SC) are new and heterogeneous. We performed the first systematic literature review on SC. Ovid Embase, Ovid Medline, and Web of Science Core Collection were systematically searched and published full text articles detailing new use of SC for the purpose of neuroimaging were critically appraised and extracted. Of 16 eligible studies, 6 reported preclinical research and 12 reported clinical experiences encompassing 189 total patients with SC. The cohort age ranged from teens to 80s and was 60% (113/189) female. Sonolucent materials in clinical use are clear PMMA (polymethylmethacrylate), opaque PMMA, polyetheretherketone, and polyolefin. Overall indications included hydrocephalus (20%, 37/189), tumor (15%, 29/189), posterior fossa decompression (14%, 26/189), traumatic brain injury (11%, 20/189), bypass (27%, 52/189), intracerebral hemorrhage (4%, 7/189), ischemic stroke (3%, 5/189), aneurysm and subarachnoid hemorrhage (3%, 5/189), subdural hematoma (2%, 4/189), and vasculitis and other bone revisions (2%, 4/189). Complications described in the entire cohort included revision or delayed scalp healing (3%, 6/189), wound infection (3%, 5/189), epidural hematoma (2%, 3/189), cerebrospinal fluid leaks (1%, 2/189), new seizure (1%, 2/189), and oncologic relapse with subsequent prosthesis removal (<1%, 1/189). Most studies utilized linear or phased array ultrasound transducers at 3-12 MHz. Sources of artifact on sonographic imaging included prosthesis curvature, pneumocephalus, plating system, and dural sealant. Reported findings were mainly qualitative. We, therefore, suggest that future studies should collect quantitative measurement data during transcranioplasty ultrasonography to validate imaging techniques.

Placement of an intrasaccular flow diverter in an intracranial sidewall aneurysm using the Bendit articulating microcatheter.

Intrasaccular flow diversion is a new endovascular option for managing unruptured intracranial aneurysms.1-6 However, catheter ejection can occur during placement of an intrasaccular flow diverter, especially in tortuous vasculature that creates unfavorable angles between the aneurysm neck and the parent vessel.5 The Bendit steerable microcatheter (Bendit Technologies, Petah Tikva, Israel) can dynamically change its tip angle and may mitigate these placement concerns.7-9 Here, we report the placement of an intrasaccular flow diverter for the treatment of an unruptured internal carotid artery sidewall aneurysm at an unfavorable neck angle using the Bendit microcatheter (video 1). The Bendit was navigated around the 180° turn of the carotid siphon and held a stable position during device delivery. The device was sequentially deployed as the Bendit was progressively straightened and was successfully placed within the aneurysm. No neurological complications were experienced and the patient was asymptomatic on follow-up 3 months later.neurintsurg;jnis-2023-020529v1/V1F1V1Video 1Placement of an intrasaccular flow diverter in an intracranial sidewall aneurysm using the Bendit articulating microcatheter.

Transvenous balloon-assisted approach to anterior fossa dural arteriovenous fistula using retrograde pressure cooker technique.

Endovascular embolization is the first-line therapy for dural arteriovenous fistulas (dAVFs). Transarterial embolization (TAE) may be limited by poor anatomical access. Transvenous embolization avoids this, but carries a risk of hemorrhage, venous redirection, and neurologic deterioration. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA, USA) provide flow arrest and prevent reflux during TAE with liquid embolic agents (LEAs), but use in the distensible veins may be challenging. In this video, we use a Scepter Mini in a transvenous approach to a Cognard type IV anterior ethmoidal dAVF as a safe alternative to surgery, transvenous pressure cooker, and trans-ophthalmic TAE (video 1). The Scepter Mini was navigated transvenously to the anterior superior sagittal sinus. LEA was injected with excellent penetration to the venous pouch and further penetration into the network of tortuous feeders. No neurologic complications were experienced, and follow-up angiogram 9 months later demonstrated cure of the dAVF. Video 2 describes procedural considerations in transvenous approaches, steps of the procedure, and includes references1-10 which are relevant to this topic.neurintsurg;jnis-2023-020530v1/V1F1V1Video 1 neurintsurg;jnis-2023-020530v1/V2F2V2Video 2 .

Trends and In-Hospital Outcomes in Patients with Vocal Fold Paralysis after Ischemic and Intracerebral Hemorrhagic Stroke: A Propensity Matched 20-Year Analysis of the Nationwide Inpatient Sample.

OBJECTIVE: Laryngeal manifestations of stroke have been sparsely described in the literature, specifically vocal fold paralysis (VFP). This study aimed to identify the prevalence, characteristics, and in-hospital outcomes of patients presenting with VFP after acute ischemic stroke (AIS) and intracranial hemorrhage (ICH). METHODS: A query of the 2000-2019 Nationwide Inpatient Sample was performed for patients admitted with AIS (International Classification of Diseases, Ninth Revision 433, 43,401, 43,411, 43,491, International Classification of Diseases, Tenth Revision I63) and ICH (International Classification of Diseases, Ninth Revision 431, 432.9, International Classification of Diseases, Tenth Revision I61, I62.9). Demographics, comorbidities, and outcomes were identified. Univariate analysis with t-tests or χ2 performed as appropriate. A 1:1 nearest neighbor propensity score matched cohort was generated. Variables with standardized mean differences > 0.1 used in multivariable regression to generate adjusted odds ratios (AOR)/ß-coefficients for VFP on outcomes. Significance was set at an alpha level of < 0.001. All analysis were performed in R version 4.1.3. RESULTS: A total of 10,415,286 patients with AIS were included; 11,328 (0.1%) had VFP. Of 2,000,868 patients with ICH 2132 (0.1%) had in-hospital VFP. Multivariable analysis revealed that patients with VFP after AIS were less likely to be discharged home (AOR 0.32; 95% confidence interval {CI}: 0.18-0.57; P < 0.001) and elevated total hospital charges (ß coefficient = 59,684.6; 95% CI = 18,365.12-101,004.07; P = 0.005). Patients with VFP after ICH were less likely to experience in-hospital mortality (AOR 0.53; 95% CI: 0.34-0.79; P = 0.002) with longer hospital stays (1.99 days; 95% CI: 1.78-2.21; P < 0.001) and elevated total hospital charges (ß coefficient = 53,905.35; 95% CI = 16,352.84-91,457.85; P = 0.005).. CONCLUSIONS: VFP in patients with ischemic stroke and ICH; although an infrequent complication is associated with functional impairment, longer hospital stay, and higher charges.

Ondine's curse: clinical presentation with diaphragmatic pacing and spontaneous respiratory recovery. Illustrative case.

BACKGROUND: The complexity of posterior fossa surgery can often lead to rare complications due to the anatomy involved. Vestibular schwannoma resection is a common pathology in the posterior fossa, often requiring surgical intervention. Given the proximity of this space to the brainstem, cranial nerve VII/VIII complex, and posterior inferior cerebellar artery (PICA), neurovascular complications are not infrequent. A rare vascular complication from this surgical approach is a lateral medullary infarction from injury to the lateral medullary segment of the proximal PICA, leading to central hypoventilation syndrome (CHS). OBSERVATIONS: This report presents a unique case of a 51-year-old man who underwent a retrosigmoid craniectomy for resection of a vestibular schwannoma. Following surgery, the patient was unable to be weaned off the ventilator and was noted to become apneic while he slept, a clinical picture consistent with Ondine's curse. LESSONS: This report discusses the anatomical considerations of this surgical corridor leading to this complication and the management of a patient with acquired Ondine's curse and reviews the scarce literature on this uncommon cause of acquired CHS.

External Ventricular Drain Training in Medical Students Improves Procedural Accuracy and Attitudes Toward Virtual Reality.

OBJECTIVE: Neurosurgery residents face a learning curve at the beginning of residency. Virtual reality (VR) training may alleviate challenges through an accessible, reusable, anatomical model. METHODS: Medical students performed external ventricular drain placements in VR to characterize the learning curve from novice to proficient. Distance from catheter to foramen of Monro and location with respect to ventricle were recorded. Changes in attitudes toward VR were assessed. Neurosurgery residents performed external ventricular drain placements to validate proficiency benchmarks. Resident and student impressions of the VR model were compared. RESULTS: Twenty-one students with no neurosurgical experience and 8 neurosurgery residents participated. Student performance improved significantly from trial 1 to 3 (15 mm [12.1-20.70] vs. 9.7 [5.8-15.3], P = 0.02). Student attitudes regarding VR utility improved significantly posttrial. The distance to foramen of Monro was significantly shorter for residents than for students in trial 1 (9.05 [8.25-10.73] vs. 15 [12.1-20.70], P = 0.007) and trial 2 (7.45 [6.43-8.3] vs. 19.5 [10.9-27.6], P = 0.002). By trial 3 there was no significant difference (10.1 [8.63-10.95 vs. 9.7 [5.8-15.3], P = 0.62). Residents and students provided similarly positive feedback for VR in resident curricula, patient consent, preoperative practice and planning. Residents provided more neutral-to-negative feedback regarding skill development, model fidelity, instrument movement, and haptic feedback. CONCLUSIONS: Students showed significant improvement in procedural efficacy which may simulate resident experiential learning. Improvements in fidelity are needed before VR can become a preferred training technique in neurosurgery.

Utilization of Palliative Care Services Among Patients With Malignant Brain Tumors: An Analysis of the National Inpatient Sample (2016-2019).

BACKGROUND: Recent advances in treatment of malignant brain tumors have improved outcomes. However, patients continue to experience significant disability. Palliative care helps patients with advanced illnesses improve their quality of life. There is a paucity of clinical studies examining palliative care usage among patients with malignant brain tumors. OBJECTIVE: To assess if there were any patterns in palliative care utilization among patients hospitalized with malignant brain tumors. METHODS: A retrospective cohort representing hospitalizations for malignant brain tumors was created from The National Inpatient Sample (2016-2019). Palliative care utilization was identified by ICD-10 code. Univariable and multivariable logistic regression models, accounting for the sample design, were built to evaluate the demographic variables associated with palliative care consultation in all patients and fatal hospitalizations. RESULTS: 375 010 patients admitted with a malignant brain tumor were included in this study. Over the whole cohort, 15.0% of patients used palliative care. In fatal hospitalizations, Black and Hispanic patients had 28% lower odds of receiving a palliative care consultation compared with White patients (odds ratio for both = 0.72; P = .02). For fatal hospitalizations, patients insured privately were 34% more likely to use palliative care services compared with patients insured with Medicare (odds ratio = 1.34, P = .006). CONCLUSION: Palliative care is underutilized among all patients with malignant brain tumors. Within this population, disparities in utilization are exacerbated by sociodemographic factors. Prospective studies investigating utilization disparities across race and insurance status are necessary to improve access to palliative care services for this population.

Orbital Foraminal Morphometrics in Nonsyndromic Unilateral Coronal Craniosynostosis.

ABSTRACT: Nonsyndromic unilateral coronal craniosynostosis (UCS) is a rare congenital disorder that results from premature fusion of either coronal suture. The result is growth restriction across the suture, between the ipsilateral frontal and parietal bones, leading to bony dysmorphogenesis affecting the calvarium, orbit, and skull base. Prior studies have reported associations between UCS and visual abnormalities. The present study utilizes a novel geometric morphometric analysis to compare dimensions of orbital foramina on synostotic versus nonsynostotic sides in patients with UCS. Computed tomography head scans of pediatric UCS patients were converted into 3-dimensional mesh models. Anatomical borders of left and right orbital structures were plotted by a single trained team member. Dimensions between synostotic and nonsynostotic sides were measured and compared. Medical records were examined to determine prevalence of visual abnormalities in this patient cohort. Visual abnormalities were reported in 22 of the 27 UCS patients (77.8%). Astigmatism (66.7%), anisometropic amblyopia (44.4%), and motor nerve palsies (33.3%) represented the 3 most prevalent ophthalmologic abnormalities. Orbits on synostotic sides were 11.3% narrower ( P < 0.001) with 21.2% less volume ( P = 0.028) than orbits on nonsynostotic sides. However, average widths, circumferences, and areas were similar between synostotic and nonsynostotic sides upon comparison of supraorbital foramina, infraorbital foramina, optic foramina, and foramina ovalia. Therefore, previously proposed compression or distortion of vital neurovascular structures within bony orbital foramina does not seem to be a likely etiology of visual abnormalities in UCS patients. Future studies will examine the role of ocular and/or neuro-ophthalmologic pathology in this disease process.

ARID1A mutation associated with recurrence and shorter progression-free survival in atypical meningiomas.

PURPOSE: The oncologic outcomes for atypical meningiomas can be poor. Generally, patients that have had a prior recurrence have a substantially elevated risk of a future recurrence. Additionally, certain tumor genomic profiles have been shown as markers of poor prognosis. We sought to characterize the genomic differences between primary and recurrent tumors as well as assess if those differences had implications on recurrence. METHODS: We identified primary and recurrent gross totally resected WHO grade II meningiomas with > 30 days of post-surgical follow-up at our institution. For genes with a prevalence of > 5% in the cohort, we compared the mutational prevalence in primary and recurrent tumors. For a gene of interest, we assessed the time to radiographic recurrence using adjusted cox-regression. RESULTS: We identified 88 meningiomas (77 primary, 16 recurrent) with a median follow-up of 5.33 years. Mutations in ARID1A found in association with recurrent tumors (7/16 recurrent tumors vs 5/72 primary tumors, p < 0.001). In the whole cohort, mutations in ARID1A were not associated with alterations in time to recurrence after adjusting for recurrence status (p = 0.713). When restricted to primary tumors, ARID1A is associated with a 625% increase in the hazard of recurrence (HR = 7.26 [1.42-37.0]; p = 0.017). CONCLUSION: We demonstrate mutations in ARID1A, a chromatin remodeling gene, in a higher prevalence in recurrent tumors. We further demonstrate that when mutations in ARID1A are present in primary atypical meningiomas, these tumors tend to have worse prognosis. Further prospective study may validate ARID1A as a prognostic marker.

NF2 mutations are associated with resistance to radiation therapy for grade 2 and grade 3 recurrent meningiomas.

PURPOSE: High grade meningiomas have a prognosis characterized by elevated recurrence rates and radiation resistance. Recent work has highlighted the importance of genomics in meningioma prognostication. This study aimed to assess the relationship between the most common meningioma genomic alteration (NF2) and response to postoperative radiation therapy (RT). METHODS: From an institutional tissue bank, grade 2 and 3 recurrent meningiomas with both > 30 days of post-surgical follow-up and linked targeted next-generation sequencing were identified. Time to radiographic recurrence was determined with retrospective review. The adjusted hazard of recurrence was estimated using Cox-regression for patients treated with postoperative RT stratified by NF2 mutational status. RESULTS: Of 53 atypical and anaplastic meningiomas (29 NF2 wild-type, 24 NF2 mutant), 19 patients underwent postoperative RT. When stratified by NF2 wild-type, postoperative RT in NF2 wild-type patients was associated with a 78% reduction in the risk of recurrence (HR 0.216; 95%CI 0.068-0.682; p = 0.009). When stratified by NF2 mutation, there was a non-significant increase in the risk of recurrence for NF2 mutant patients who received postoperative RT compared to those who did not (HR 2.43; 95%CI 0.88-6.73, p = 0.087). CONCLUSION: This study demonstrated a protective effect of postoperative RT in NF2 wild-type patients with recurrent high grade meningiomas. Further, postoperative RT may be associated with no improvement and perhaps an accelerated time to recurrence in NF2 mutant tumors. These differences in recurrence rates provide evidence that NF2 may be a valuable prognostic marker in treatment decisions regarding postoperative RT. Further prospective studies are needed to validate this relationship.