Parenthood and neurosurgery in Europe, a white paper from the European association of neurosurgical societies' diversity in neurosurgery committee, part II - practice with children.

Introduction: In the first part of this White Paper, the European Association of Neurosurgical Societies (EANS) Diversity in Neurosurgery Committee (DC) addressed the obstacles faced by neurosurgeons when planning to have a family and practice during pregnancy, attempting to enumerate potential, easily implementable solutions for departments to be more family-friendly and retain as well as foster talent of parent-neurosurgeons, regardless of their gender identity and/or sexual orientation. Attrition avoidance amongst parent-neurosurgeons is at the heart of these papers. Research question: In this second part, we address the obstacles posed by practice with children and measures to mitigate attrition rates among parent-neurosurgeons. For the methodology employed to compose this White Paper, please refer to Supplementary Electronic Materials (SEM) 1. Materials and methods: For composing these white papers, the European Association of Neurosurgical Societies (EANS)'s Diversity Committee (DC) recruited neurosurgeon volunteers from all member countries, including parents, aspiring parents, and individuals without any desire to have a family to create a diverse and representative working group (WG). Results: In spite of the prevailing heterogeneity in policies across the continent, common difficulties can be identified for both mothers and fathers considering the utilization of parental leave. Discussion and conclusion: Reconciliation of family and a neurosurgical career is challenging, especially for single parents. However, institutional support in form of childcare facilities and/or providers, guaranteed lactation breaks and rooms, flexible schedule models including telemedicine, and clear communication of policies can improve working conditions for parent-neurosurgeons, avoid their attrition, and foster family-friendly work environments.

Parenthood and neurosurgery in Europe a white paper from the European Association of Neurosurgical Societies' Diversity in Neurosurgery Committee Part I - Family Planning and Practice during Pregnancy.

Introduction: Family and work have immensely changed and become intertwined over the past half century for both men and women. Additionally, alongside to traditional family structures prevalent, other forms of families such as single parents, LGBTQ + parents, and bonus families are becoming more common. Previous studies have shown that surgical trainees regularly leave residency when considering becoming a parent due to the negative stigma associated with pregnancy during training, dissatisfaction with parental leave options, inadequate lactation and childcare support, and desire for greater mentorship on work-life integration. Indeed, parenthood is one of the factors contributing to attrition in surgical specialities, neurosurgery not being an exception. Research question: The Diversity in Neurosurgery Committee (DC) of the European Association of Neurosurgical Societies (EANS) recognizes the challenges individuals face in parenthood with neurosurgery and wishes to address them in this white paper. Materials and methods: In the following sections, the authors will focus on the issues pertaining to family planning and neurosurgical practice during pregnancy in itemized fashion based on an exhaustive literature search and will make recommendations to address the matters raised. Results: Potential solutions would be to further improve the work-family time ration as well as improving working conditions in the hospital. Discussion and conclusion: While many obstacles have been quoted in the literature pertaining to parenthood in medicine, and in neurosurgery specifically, initiatives can and should be undertaken to ensure not only retention of colleagues, but also to increase productivity and job satisfaction of those seeking to combine neurosurgery and a family life, regardless of their sexual identity and orientation.

Sequencing of SARS-CoV-2 RNA Fragments in Wastewater Detects the Spread of New Variants during Major Events.

The sequencing of SARS-CoV-2 RNA in wastewater is an unbiased method to detect the spread of emerging variants and to track regional infection dynamics, which is especially useful in case of limited testing and clinical sequencing. To test how major international events influence the spread of new variants we have sequenced SARS-CoV-2 RNA in the wastewater samples of Davos, Landquart, Lostallo, and St. Moritz in the Swiss canton of Grisons in the time around the international sports competitions in Davos and St. Moritz in December 2021, and additionally in May 2022 and January 2023 in Davos and St. Moritz during the World Economic Forum (WEF) in Davos. The prevalence of the variants identified from the wastewater sequencing data showed that the Omicron variant BA.1 had spread in Davos and St. Moritz during the international sporting events hosted there in December 2021. This spread was associated with an increase in case numbers, while it was not observed in Landquart and Lostallo. Another instance of new variant spread occurred during the WEF in January 2023, when the Omicron variant BA.2.75 arrived in Davos but not in St. Moritz. We can therefore conclude that major international events promote the spread of new variants in the respective host region, which has important implications for the protective measures that should be taken.

Women in leadership positions in European neurosurgery - Have we broken the glass ceiling?

Introduction: The proportion of male neurosurgeons has historically been higher than of women, although at least equal numbers of women have been entering European medical schools. The Diversity Committee (DC) of the European Association of Neurosurgical Societies (EANS) was founded recently to address this phenomenon. Research question: In this cross-sectional study, we aimed to characterize the status quo of female leadership by assessing the proportion of women heading European neurosurgical departments. Material and methods: European neurosurgical departments were retrieved from the EANS repository. The gender of all department chairs was determined via departmental websites or by personal contact. The proportion of females was stratified by region and by type of hospital (university versus non-university). Results: A total of 41 (4.3%) female department chairs were identified in 961 neurosurgery departments in 41 European countries. Two thirds (68.3%) of European countries do not have a female neurosurgery chair. The highest proportion of female chairs was found in Northern Europe (11.1%), owing to four female chairs in a relatively small number of departments (n = 36). The proportions were considerably smaller in Western Europe (n = 17/312 (5.5%)), Southern Europe (n = 14/353 (4.0%)) and Central and Eastern Europe (n = 6/260 (2.3%)) (p = 0.06). The distribution of female chairs in university (n = 19 (46.3%)) versus non-university departments (n = 22 (53.7%)) was even. Discussion and Conclusion: There is a significant gender imbalance with 4% of all European neurosurgery departments headed by women. The DC intends to develop strategies to support equal chances and normalize the presence of female leaders in European neurosurgery.

Effectiveness of Lumbar Cerebrospinal Fluid Drain Among Patients With Aneurysmal Subarachnoid Hemorrhage: A Randomized Clinical Trial.

Importance: After aneurysmal subarachnoid hemorrhage, the use of lumbar drains has been suggested to decrease the incidence of delayed cerebral ischemia and improve long-term outcome. Objective: To determine the effectiveness of early lumbar cerebrospinal fluid drainage added to standard of care in patients after aneurysmal subarachnoid hemorrhage. Design, Setting, and Participants: The EARLYDRAIN trial was a pragmatic, multicenter, parallel-group, open-label randomized clinical trial with blinded end point evaluation conducted at 19 centers in Germany, Switzerland, and Canada. The first patient entered January 31, 2011, and the last on January 24, 2016, after 307 randomizations. Follow-up was completed July 2016. Query and retrieval of data on missing items in the case report forms was completed in September 2020. A total of 20 randomizations were invalid, the main reason being lack of informed consent. No participants meeting all inclusion and exclusion criteria were excluded from the intention-to-treat analysis. Exclusion of patients was only performed in per-protocol sensitivity analysis. A total of 287 adult patients with acute aneurysmal subarachnoid hemorrhage of all clinical grades were analyzable. Aneurysm treatment with clipping or coiling was performed within 48 hours. Intervention: A total of 144 patients were randomized to receive an additional lumbar drain after aneurysm treatment and 143 patients to standard of care only. Early lumbar drainage with 5 mL per hour was started within 72 hours of the subarachnoid hemorrhage. Main Outcomes and Measures: Primary outcome was the rate of unfavorable outcome, defined as modified Rankin Scale score of 3 to 6 (range, 0 to 6), obtained by masked assessors 6 months after hemorrhage. Results: Of 287 included patients, 197 (68.6%) were female, and the median (IQR) age was 55 (48-63) years. Lumbar drainage started at a median (IQR) of day 2 (1-2) after aneurysmal subarachnoid hemorrhage. At 6 months, 47 patients (32.6%) in the lumbar drain group and 64 patients (44.8%) in the standard of care group had an unfavorable neurological outcome (risk ratio, 0.73; 95% CI, 0.52 to 0.98; absolute risk difference, -0.12; 95% CI, -0.23 to -0.01; P = .04). Patients treated with a lumbar drain had fewer secondary infarctions at discharge (41 patients [28.5%] vs 57 patients [39.9%]; risk ratio, 0.71; 95% CI, 0.49 to 0.99; absolute risk difference, -0.11; 95% CI, -0.22 to 0; P = .04). Conclusion and Relevance: In this trial, prophylactic lumbar drainage after aneurysmal subarachnoid hemorrhage lessened the burden of secondary infarction and decreased the rate of unfavorable outcome at 6 months. These findings support the use of lumbar drains after aneurysmal subarachnoid hemorrhage. Trial Registration: ClinicalTrials.gov Identifier: NCT01258257.

Projection of healthcare demand in Germany and Switzerland urged by Omicron wave (January-March 2022).

In January 2022, after the implementation of broad vaccination programs, the Omicron wave was propagating across Europe. There was an urgent need to understand how population immunity affects the dynamics of the COVID-19 pandemic when the loss of vaccine protection was concurrent with the emergence of a new variant of concern. In particular, assessing the risk of saturation of the healthcare systems was crucial to manage the pandemic and allow a transition towards the endemic course of SARS-CoV-2 by implementing more refined mitigation strategies that shield the most vulnerable groups and protect the healthcare systems. We investigated the epidemic dynamics by means of compartmental models that describe the age-stratified social-mixing and consider vaccination status, type, and waning of the efficacy. In response to the acute situation, our model aimed at (i) providing insight into the plausible scenarios that were likely to occur in Switzerland and Germany in the midst of the Omicron wave, (ii) informing public health authorities, and (iii) helping take informed decisions to minimize negative consequences of the pandemic. Despite the unprecedented numbers of new positive cases, our results suggested that, in all plausible scenarios, the wave was unlikely to create an overwhelming healthcare demand; due to the lower hospitalization rate and the effectiveness of the vaccines in preventing a severe course of the disease. This prediction came true and the healthcare systems in Switzerland and Germany were not pushed to the limit, despite the unprecedentedly large number of infections. By retrospective comparison of the model predictions with the official reported data of the epidemic dynamic, we demonstrate the ability of the model to capture the main features of the epidemic dynamic and the corresponding healthcare demand. In a broader context, our framework can be applied also to endemic scenarios, offering quantitative support for refined public health interventions in response to recurring waves of COVID-19 or other infectious diseases.

Results from Canton Grisons of Switzerland suggest repetitive testing reduces SARS-CoV-2 incidence (February-March 2021).

In February 2021, in response to emergence of more transmissible SARS-CoV-2 virus variants, the Canton Grisons launched a unique RNA mass testing program targeting the labour force in local businesses. Employees were offered weekly tests free of charge and on a voluntary basis. If tested positive, they were required to self-isolate for ten days and their contacts were subjected to daily testing at work. Thereby, the quarantine of contact persons could be waved.Here, we evaluate the effects of the testing program on the tested cohorts. We examined 121,364 test results from 27,514 participants during February-March 2021. By distinguishing different cohorts of employees, we observe a noticeable decrease in the test positivity rate and a statistically significant reduction in the associated incidence rate over the considered period. The reduction in the latter ranges between 18 and 50%. The variability is partly explained by different exposures to exogenous infection sources (e.g., contacts with visiting tourists or cross-border commuters). Our analysis provides the first empirical evidence that applying repetitive mass testing to a real population over an extended period of time can prevent spread of COVID-19 pandemic. However, to overcome logistic, uptake, and adherence challenges it is important that the program is carefully designed and that disease incursion from the population outside of the program is considered and controlled.

Incidental findings of typical iNPH imaging signs in asymptomatic subjects with subclinical cognitive decline.

BACKGROUND: The etiology of idiopathic normal pressure hydrocephalus (iNPH) remains unclear. Little is known about the pre-symptomatic stage. This study aimed to investigate the association of neuropsychological data with iNPH-characteristic imaging changes compared to normal imaging and unspecific atrophy in a healthy population. METHODS: We extracted data from the community-dwelling Austrian Stroke Prevention Family Study (ASPS-Fam) database (2006-2010). All subjects underwent a baseline and identical follow-up examination after 3-5 years with MR imaging and an extensive neuropsychological test battery (Trail Making Test B, short physical performance balance, walking speed, memory, visuo-practical skills, composite scores of executive function and g-factor). We categorized the subjects into "iNPH"-associated, non-specific "atrophy," and "normal" based on the rating of different radiological cerebrospinal fluid (CSF) space parameters. We noted how the categories developed over time. We assessed the association of the image categories with the neuropsychological data, different demographic, and lifestyle parameters (age, sex, education, alcohol intake, arterial hypertension, hypercholesterolemia), and the extent of white matter hyperintensities. We investigated whether neuropsychological data associated with the image categories were independent from other parameters as confounders. RESULTS: One hundred and thirteen subjects, aged 50-70 years, were examined. The imaging category "iNPH" was only present at follow-up. A third of subjects with "atrophy" at baseline changed to the category "iNPH" at follow-up. More white matter hyperintensities (WMH) were present in later "iNPH" subjects. Subjects with "iNPH" performed worse than "normal" subjects on executive function (p = 0.0118), memory (p = 0.0109), and Trail Making Test B (TMT-B. p < 0.0001). Education, alcohol intake, diabetes, arterial hypertension, and hypercholesterolemia had no effect. Age, number of females, and the extent of white matter hyperintensities were higher in "iNPH" than in "normal" subjects but did not significantly confound the neuropsychological results. CONCLUSIONS: Apparent asymptomatic subjects with "iNPH" imaging characteristics presented with subclinical cognitive decline and showed worse executive function, memory, and TMT-B results than "normal" subjects. WMH seem to play a role in the etiology before ventriculomegaly. Clinical screening of individuals with incidental iNPH-characteristic imaging and conspicuous results sof these neurocognitive tests needs further validation.

Spinal meningioma surgery in the elderly: who can benefit from it?

BACKGROUND: With increasing life expectancy and increasing demands on quality of life more spinal meningiomas will limit quality of life in elderly in the coming decades. We investigated whether elderly can improve neurologically and gain self-dependence postoperatively. METHODS: Medical records of consecutive spinal meningioma patients from 2004-2015 were retrospectively analyzed. Age, gender, preoperative duration and quality of symptoms, pre- and postoperative McCormick score, Karnofsky Performance Status (KPS), American Society of Anesthesiologists Physical Status (ASA), modified Clinical Scoring System (mCSS) and tumor characteristics were included. Elderly were defined by ≥70 years. RESULTS: One hundred and twenty-nine patients were included, of whom 44 were 70 years or older. Younger patients were significantly better preoperatively in McCormick, KPS, ASA and mCSS within the first postoperative year. Both younger and elderly patients improved significantly postoperatively in McCormick, KPS and mCSS. Surgical complication rate was similar for younger and elderly patients (5.9 vs. 6.8%). Systemic complication rate was higher in elderly (0 vs. 6.8%). CONCLUSIONS: Surgery for spinal meningioma in elderly (KPS≥40 and ASA≤III) leads to a significant improvement of McCormick, KPS and mCSS postoperatively. This leads to a higher rate of self-dependency and thereby probably to an improvement of quality of life in elderly. However, special attention for systemic complications is necessary.

Longitudinal Assessment of Rotation Angles after Implantation of Directional Deep Brain Stimulation Leads.

PURPOSE: The risk/benefit-ratio of deep brain stimulation (DBS) depends on focusing the electrical field onto the target volume, excluding side-effect eliciting structures. Directional leads limiting radial current diffusion can target stimulation but add a spatial degree of freedom that requires control to align multimodal imaging datasets and for anatomical interpretation of stimulation. Unpredictable postoperative lead rotations have been reported. The extent and timing of rotation from the surgically intended alignment remain uncertain, as does the time point at which directional stimulation can be safely initiated without risking unexpected shifts in stimulation volume. We present a retrospective analysis of clinically indicated, repeated neuroimaging controls postimplantation in patients with directional DBS systems, which allow estimation of the amount and timing of postoperative lead rotation. METHODS: Data from 67 patients with directional leads and multiple cranial computer tomographies (CCT) and/or rotation fluoroscopies at different postoperative time points were included. Rotation angles were detected based on CCT artifacts (n = 56) or direct visualization of lead segments on rotation fluoroscopies (n = 52). Cross-validation of both methods was conducted in patients who received both imaging modalities (n = 51). RESULTS: Rotation angles deviated significantly (∼30°) from their intended 0° anterior/posterior orientation. Rotation was firmly established within the first postoperative day, with no additional torque in subsequent scans. The two methods highly correlated (right hemisphere: R2 = 0.94, left hemisphere: R2 = 0.91). CONCLUSION: Both methods for measuring rotation angles led to comparable results and can be used interchangeably. Directional stimulation settings can safely be initiated after the first postoperative day, without risking subsequent lead rotation-related anatomical shifts.

Central nervous system microbleeds in the acute phase are associated with structural integrity by DTI one year after mild traumatic brain injury: A longitudinal study.

INTRODUCTION: Several imaging modalities are under investigation to unravel the pathophysiological mystery of delayed performance deficits in patients after mild traumatic brain injury (mTBI). Although both imaging and neuropsychological studies have been conducted, only few data on longitudinal correlations of diffusion tensor imaging (DTI), susceptibility weighted imaging (SWI) and extensive neuropsychological testing exist. METHODS: MRI with T1- and T2-weighted, SWI and DTI sequences at baseline and 12 months of 30 mTBI patients were compared with 20 healthy controls. Multiparametric assessment included neuropsychological testing of cognitive performance and post-concussion syndrome (PCS) at baseline, 3 and 12 months post-injury. Data analysis encompassed assessment of cerebral microbleeds (Mb) in SWI, tract-based spatial statistics (TBSS) and voxel-based morphometry (VBM) of DTI (VBM-DTI). Imaging markers were correlated with neuropsychological testing to evaluate sensitivity to cognitive performance and post-concussive symptoms. RESULTS: Patients with Mb in SWI in the acute phase showed worse performance in several cognitive tests at baseline and in the follow-ups during the chronic phase and higher symptom severity in the post concussion symptom scale (PCSS) at twelve months post-injury. In the acute phase there was no statistical difference in structural integrity as measured with DTI between mTBI patients and healthy controls. At twelve months post-injury, loss of structural integrity in mTBI patients was found in nearly all DTI indices compared to healthy controls. CONCLUSIONS: Presence of Mb detected by SWI was associated with worse cognitive outcome and persistent PCS in mTBI patients, while DTI did not prove to predict neuropsychological outcome in the acute phase.

Overshunting-Associated Myelopathy (OSAM) in a Patient with Bilateral Jugular Vein Occlusion.

BACKGROUND: Overshunting-associated myelopathy (OSAM) is a very rare complication of ventricular shunt therapy, and only 11 previous cases have been reported in the literature. We report the successful surgical management of a case of OSAM in a patient with bilateral jugular vein occlusion and congenital hydrocephalus. CASE DESCRIPTION: A 45-year-old patient with shunt-dependent, congenital hydrocephalus presented to our department with an 8-year history of progressive tetraparesis and gait disturbance. The patient was wheelchair-dependent. A new magnetic resonance imaging scan of the head revealed slit ventricle syndrome and dural enhancement due to shunt overdrainage. Magnetic resonance imaging and a computed tomography-phlebography of the cervical spine revealed engorgement of the epidural venous plexus with secondary compression of the spinal cord and myelomalacia. Surgery was performed, during which we implanted a shunt valve. The patient recovered from surgery without any new deficits. The tetraparesis improved during the inpatient hospital stay. Computed tomography-phlebography was performed 5 days after surgery and showed that the epidural venous plexus anterior to the cervical spinal cord had returned to nearly normal size. On follow-up examination 3 months after surgery, the patient's strength had improved, and he was able to walk short distances with assistance and with ankle foot orthosis on the right side. CONCLUSIONS: OSAM has to be considered according to the Monro-Kellie doctrine and is affected by an engorgement of the epidural cervical venous plexus, which can produce cervical myelopathy. Because it can be treated simply by increasing the shunt resistance, surgeons should be aware of the rarely detected overdrainage complication.

Room Air Readings of Brain Tissue Oxygenation Probes.

OBJECTIVE: Brain tissue oxygenation (pbtO2) monitoring with microprobes is increasingly used as an important parameter in addition to intracranial pressure in acutely brain-injured patients. Data on accuracy and long-term drift after use are scarce. We investigated room air readings of used pbtO2 probes for their relationship with the duration of monitoring, geographic location of the center, and manufacturer type. METHODS: After finishing clinically indicated monitoring in patients, pbtO2 probes used in two centers in Berlin and Munich were explanted and cleaned to avoid blood contamination. Immediately afterward, room air readings of partial oxygen pressure (pairO2) from 44 Licox® and 10 Raumedic ® pbtO2 probes were recorded. Assumed height above sea level was 42 m for Berlin and 485 m for Munich; this resulted in assumed theoretical pairO2 readings of 157.8 mmHg in Berlin and 149.9 mmHg in Munich. RESULTS: Licox ® probes in Berlin showed a mean pairO2 of 160.5 (SD 14.4) mmHg and of 147.8 (11.9) mmHg in Munich. Raumedic ® probes in Berlin showed a mean pairO2 of 170.5 (12.2) mmHg and the single Raumedic ® probe used in Munich 155 mmHg. No significant drift was found over time for probes with up to 14 days of monitoring. Prolonged use of up to 20 days showed a clinically negligible drift of 1.2 mmHg per day of use for Licox® probes.Mean absolute deviation for pairO2 from expected values was 6.4% for Licox ® and 9.7% for Raumedic ® probes. CONCLUSION: Room air partial oxygen pressure pairO2 may be utilized to assess the proper function of a pbtO2 probe. It provides a tool for quality control which is easy to implement. Probe readings are stable in the clinically relevant range, even after prolonged use.

Three versus seven days to return-to-work after mild traumatic brain injury: a randomized parallel-group trial with neuropsychological assessment.

Although most patients with a mild traumatic brain injury (mTBI) recover within days to weeks, some experience persistent physical, cognitive and emotional symptoms, often described as post-concussion syndrome (PCS). The optimal recovery time including return-to-work (RTW) after mTBI is unclear. In this single-centre parallel-group trial, patients assigned three days (3D-group) or seven days (7D-group) sick leave were compared with a comprehensive neuropsychological test battery including the Post-Concussion Symptom Scale (PCSS) within one week, after three and 12 months post-injury. The influence of the effective time until RTW on post-concussional symptoms and cognitive performance was analysed. The 3D-group rated significantly higher mean scores in some PCSS symptoms, tended to fulfil diagnosis criteria of PCS more often and showed better cognitive performance in several neuropsychological test scores than the 7D-group at all three time-points of follow-up. Overall, patients returned to work 11.35 d post-injury, thus distinctly above both recommended sick leaves. There was a trend for longer sick leave in patients randomized into the 3D-group. Further analyses revealed that the group with an absolute RTW within one week showed lower symptom severity in fatigue at 3 and 12 months, less PCS and faster performance in fine motor speed at 12 months than the group with an absolute RTW after one week. Our data underline the heterogeneity of mTBI and show that acute and sub-acute symptoms are not prognostic factors for neuropsychological outcome at one year. Later, ability to work seems to be prognostic for long-term occurrence of PCS.

A basic model for training of microscopic and endoscopic transsphenoidal pituitary surgery: the Egghead.

BACKGROUND: Transsphenoidal endoscopic surgery has gained popularity in the last 2 decades and is becoming a standard technique for resection of pituitary adenomas. In contrast to their ENT colleagues, neurosurgical residents have practically no endoscopic experience when they reach the training stage for transsphenoidal procedures. We have developed an affordable method for repetitive training in endoscopic (and microscopic) work in a narrow channel, allowing training of the basic movements needed for resection of pituitary adenoma. METHODS: In collaboration with colleagues in the ENT Department, Cantonal Hospital St. Gall, and the Technical University of Zurich, a three-dimensional model of the nasal cavity was developed and patented. The Egghead model consists of a 3D synthetic reconstruction of the head nasal cavity and sphenoid sinus. A boiled egg represents the sella. For validation, 17 neurosurgical residents from the Department of Neurosurgery, University Hospital of Basel, and Department of Neurosurgery, Cantonal Hospital of St. Gall, St. Gall, Switzerland, and two experts performed a standardized procedure mimicking a transsphenoidal pituitary procedure by dissecting a corridor to the egg yolk and resecting it, respecting the surrounding egg white. This procedure was performed under both microscopic and video-endoscopic visualization. A score for the precision and speed of the surgical performance was developed and used. RESULTS: The model allows repetitive training of the resection of the egg yolk under sparing of the egg white after careful opening of the shell. The validation data showed a steeper learning curve using the endoscopic technique than performing the same task using the microscope. After three repetitions, the quality of resection was better with the endoscopic technique. CONCLUSIONS: Our model, the Egghead, is affordable, offers tactile feedback and allows infinite repetitions in basic training for pituitary surgery. It can be used for training of advanced neurosurgical residents, who thus far have very few possibilities of acquiring endoscopic experience.

Transfrontal sinus approach for an anterior cranial fossa, ethmoidal, dural arteriovenous fistula.

BACKGROUND: Ethmoidal dural arteriovenous fistulas (eDAVFs) are usually approached via a pterional or a frontal craniotomy. A more direct route to the fistula is possible through a purely transfrontal sinus approach. The aim of this report is to illustrate the interest of transsinus frontal approach for eDAVFs. CASE DESCRIPTION: The transfrontal sinus approach is described and illustrated in a case of an ethmoidal arteriovenous fistula. This approach is the most direct when treating an eDAVF surgically, allowing preserving neural structures with minimal to no brain manipulation. CONCLUSION: For eDAVFs, the purely transfrontal sinus approach is highly worth considering in cases of large frontal sinuses.

Standardizing data collection in severe trauma: call for linking up.

Standardization of data collection in severely injured trauma patients in order to find the best performance and practice has been an issue for more than 20 years. The incidence of trauma has decreased and outcomes have improved over the past decades. Trauma still remains an important public health problem, however, and is listed by the World Health Organization as a leading cause of death and disability. Ringdal and colleagues prove the feasibility on a basic level in their prospective, intercontinental study showing the results of the Utstein Trauma Template. In-depth analysis is currently only partially possible. The future of standardizing data collection in trauma looks bright. However, bridging and cross-linking is necessary to a great extent in the future.

Inhalation of nitric oxide prevents ischemic brain damage in experimental stroke by selective dilatation of collateral arterioles.

RATIONALE: Stroke is the third most common cause of death in industrialized countries. The main therapeutic target is the ischemic penumbra, potentially salvageable brain tissue that dies within the first few hours after blood flow cessation. Hence, strategies to keep the penumbra alive until reperfusion occurs are needed. OBJECTIVE: To study the effect of inhaled nitric oxide on cerebral vessels and cerebral perfusion under physiological conditions and in different models of cerebral ischemia. METHODS AND RESULTS: This experimental study demonstrates that inhaled nitric oxide (applied in 30% oxygen/70% air mixture) leads to the formation of nitric oxide carriers in blood that distribute throughout the body. This was ascertained by in vivo microscopy in adult mice. Although under normal conditions inhaled nitric oxide does not affect cerebral blood flow, after experimental cerebral ischemia induced by transient middle cerebral artery occlusion it selectively dilates arterioles in the ischemic penumbra, thereby increasing collateral blood flow and significantly reducing ischemic brain damage. This translates into significantly improved neurological outcome. These findings were validated in independent laboratories using two different mouse models of cerebral ischemia and in a clinically relevant large animal model of stroke. CONCLUSIONS: Inhaled nitric oxide thus may provide a completely novel strategy to improve penumbral blood flow and neuronal survival in stroke or other ischemic conditions.

Standardizing data collection in traumatic brain injury.

Collaboration among investigators, centers, countries, and disciplines is essential to advancing the care for traumatic brain injury (TBI). It is thus important that we "speak the same language." Great variability, however, exists in data collection and coding of variables in TBI studies, confounding comparisons between and analysis across different studies. Randomized controlled trials can never address the many uncertainties concerning treatment approaches in TBI. Pooling data from different clinical studies and high-quality observational studies combined with comparative effectiveness research may provide excellent alternatives in a cost-efficient way. Standardization of data collection and coding is essential to this end. Common data elements (CDEs) are presented for demographics and clinical variables applicable across the broad spectrum of TBI. Most recommendations represent a consensus derived from clinical practice. Some recommendations concern novel approaches, for example assessment of the intensity of therapy in severely injured patients. Up to three levels of detail for coding data elements were developed: basic, intermediate, and advanced, with the greatest level of detail attained in the advanced version. More detailed codings can be collapsed into the basic version. Templates were produced to summarize coding formats, explanation of choices, and recommendations for procedures. Endorsement of the recommendations has been obtained from many authoritative organizations. The development of CDEs for TBI should be viewed as a continuing process; as more experience is gained, refinement and amendments will be required. This proposed process of standardization will facilitate comparative effectiveness research and encourage high-quality meta-analysis of individual patient data.