Supinator to posterior interosseous nerve transfer to restore hand opening in brachial plexus and spinal cord injury: a systematic review and individual patient-data meta-analysis.

OBJECTIVE: Cervical spinal cord injury (SCI) and lower trunk brachial plexus injury (BPI) commonly result in hand paralysis. Although restoring hand function is complex and challenging to achieve, regaining volitional hand control drastically enhances functionality for these patients. The authors aimed to systematically review the outcomes of hand-opening function after supinator to posterior interosseous nerve (PIN) transfer. METHODS: A systematic literature review was performed according to the PRISMA guidelines. RESULTS: A total of 16 studies with 88 patients and 119 supinator to PIN transfers were included (87 transfers for SCI and 32 for BPI). In most studies, the time interval from injury to surgery was 6-12 months. Finger extension and thumb extension (Medical Research Council grade ≥ 3/5) recovered in 86.5% (103/119) and 78.1% (93/119) of cases, respectively, over a median follow-up of 19 months. The rates of recovery were similar for the SCI and BPI populations (finger extension, 87.3% in SCI and 84.3% in BPI; thumb extension, 75.8% in SCI and 84.3% in BPI). Type of injury (OR 1.05, 95% CI 0.17-6.4, p = 0.95), time from injury to surgery (OR 1.01, 95% CI 0.8-1.29, p = 0.88), and age (OR 0.97, 95% CI 0.90-1.06, p = 0.60) were not associated with odds of a successful outcome. Duration of follow-up was significantly associated with successful finger extension (OR 1.15, 95% CI 1.01-1.30, p = 0.026). No donor-associated supinator weakness was reported postoperatively given that patients had an intact bicep muscle preoperatively contributing to supination. CONCLUSIONS: Supinator to PIN transfer is a safe and effective procedure that can achieve successful restoration of digital extension in the SCI and BPI population at similar rates. Duration of follow-up was associated with superior outcomes, which was expected.

The demographic, clinical, and management differences between traumatic dens fracture patients with and without simultaneous atlas fractures.

Introduction: Atlas fractures often accompany traumatic dens fractures, but existing literature on the management of simultaneous atlantoaxial fractures is limited. Methods: We examined all patients with traumatic dens fractures at our institution between 2008 and 2018. We used multivariable logistic regression and ordinal logistic regression to identify factors independently associated with presentation with a simultaneous atlas fracture, as well myelopathy severity, fracture nonunion, and selection for surgery. Results: Two hundred and eighty-two patients with traumatic dens fractures without subaxial fractures were identified, including 65 (22.8%) with simultaneous atlas fractures. The distribution of injury mechanisms differed between groups (χ2 P = 0.0360). On multivariable logistic regression, dens nonunion was positively associated with type II fractures (odds ratio [OR] = 2.00, P = 0.038) and negatively associated with having surgery (OR = 0.52, P = 0.049), but not with having a C1 fracture (P = 0.3673). Worse myelopathy severity on presentation was associated with having a severe injury severity score (OR = 102.3, P < 0.001) and older age (OR = 1.28, P = 0.002), but not with having an atlas fracture (P = 0.2446). Having a simultaneous atlas fracture was associated with older age (OR = 1.29, P = 0.024) and dens fracture angulation (OR = 2.62, P = 0.004). Among patients who underwent surgery, C1/C2 posterior fusion was the most common procedure, and having a simultaneous atlas fracture was associated with selection for occipitocervical fusion (OCF) (OR = 14.35, P = 0.010). Conclusions: Among patients with traumatic dens, patients who have simultaneous atlas fractures are a distinct subpopulation with respect to age, mechanism of injury, fracture morphology, and management. Traumatic dens fractures with simultaneous atlas fractures are independently associated with selection for OCF rather than posterior cervical fusion alone.

Predictors of salvage therapy for parasagittal meningiomas treated with primary surgery, radiosurgery, or surgery plus adjuvant radiotherapy.

OBJECTIVE: Parasagittal meningiomas (PM) are treated with primary microsurgery, radiosurgery (SRS), or surgery with adjuvant radiation. We investigated predictors of tumor progression requiring salvage surgery or radiation treatment. We sought to determine whether primary treatment modality, or radiologic, histologic, and clinical variables were associated with tumor progression requiring salvage treatment. METHODS: Retrospective study of 109 consecutive patients with PMs treated with primary surgery, radiation (RT), or surgery plus adjuvant RT (2000-2017) and minimum 5 years follow-up. Patient, radiologic, histologic, and treatment data were analyzed using standard statistical methods. RESULTS: Median follow up was 8.5 years. Primary treatment for PM was surgery in 76 patients, radiation in 16 patients, and surgery plus adjuvant radiation in 17 patients. Forty percent of parasagittal meningiomas in our cohort required some form of salvage treatment. On univariate analysis, brain invasion (OR: 6.93, p < 0.01), WHO grade 2/3 (OR: 4.54, p < 0.01), peritumoral edema (OR: 2.81, p = 0.01), sagittal sinus invasion (OR: 6.36, p < 0.01), sagittal sinus occlusion (OR: 4.86, p < 0.01), and non-spherical shape (OR: 3.89, p < 0.01) were significantly associated with receiving salvage treatment. On multivariate analysis, superior sagittal sinus invasion (OR: 8.22, p = 0.01) and WHO grade 2&3 (OR: 7.58, p < 0.01) were independently associated with receiving salvage treatment. There was no difference in time to salvage therapy (p = 0.11) or time to progression (p = 0.43) between patients receiving primary surgery alone, RT alone, or surgery plus adjuvant RT. Patients who had initial surgery were more likely to have peritumoral edema on preoperative imaging (p = 0.01). Median tumor volume was 19.0 cm3 in patients receiving primary surgery, 5.3 cm3 for RT, and 24.4 cm3 for surgery plus adjuvant RT (p < 0.01). CONCLUSION: Superior sagittal sinus invasion and WHO grade 2/3 are independently associated with PM progression requiring salvage therapy regardless of extent of resection or primary treatment modality. Parasagittal meningiomas have a high rate of recurrence with 80.0% of patients with WHO grade 2/3 tumors with sinus invasion requiring salvage treatment whereas only 13.6% of the WHO grade 1 tumors without sinus invasion required salvage treatment. This information is useful when counseling patients about disease management and setting expectations.

Repeat Surgery for Vestibular Schwannomas: An Institutional Case Series.

Introduction Vestibular schwannomas (VSs) are treated with microsurgery and/or radiosurgery. Repeat resection is rare, and few studies have reported postoperative outcomes. The objective of this study was to describe clinical characteristics and outcomes in patients undergoing repeat surgery for VS. Methods All adult (≥ 18 years) patients undergoing VS resection between 2003 and 2022 at our institution were retrospectively reviewed to identify patients who underwent repeat surgery of an ipsilateral VS following prior gross-total (GTR) or subtotal resection. Patient, radiographic, and clinical characteristics were reviewed. Primary outcomes were postoperative tumor volume, extent of resection, postoperative cranial nerve deficits, and time to further tumor progression. Results Of 102 patients undergoing VS resection, 6 (5.9%) had undergone repeat surgery. Median (range) follow-up was 20 (5-117) months. Three patients were female. Median age was 56 (36-60) years. Median pre- and postoperative tumor volumes were 8.2 (1.8-28.2) cm 3 and 0.4 (0-3.8) cm 3 . GTR was achieved in two patients. Four patients had higher House-Brackmann scores at last follow-up, but none had tumor progression. Conclusion In this small cohort of patients, repeat resection of recurrent or progressive VS can effectively reduce tumor volume with acceptable perioperative outcomes.

Using machine learning and big data for the prediction of venous thromboembolic events after spine surgery: A single-center retrospective analysis of multiple models on a cohort of 6869 patients.

Objective: Venous thromboembolic event (VTE) after spine surgery is a rare but potentially devastating complication. With the advent of machine learning, an opportunity exists for more accurate prediction of such events to aid in prevention and treatment. Methods: Seven models were screened using 108 database variables and 62 preoperative variables. These models included deep neural network (DNN), DNN with synthetic minority oversampling technique (SMOTE), logistic regression, ridge regression, lasso regression, simple linear regression, and gradient boosting classifier. Relevant metrics were compared between each model. The top four models were selected based on area under the receiver operator curve; these models included DNN with SMOTE, linear regression, lasso regression, and ridge regression. Separate random sampling of each model was performed 1000 additional independent times using a randomly generated training/testing distribution. Variable weights and magnitudes were analyzed after sampling. Results: Using all patient-related variables, DNN using SMOTE was the top-performing model in predicting postoperative VTE after spinal surgery (area under the curve [AUC] =0.904), followed by lasso regression (AUC = 0.894), ridge regression (AUC = 0.873), and linear regression (AUC = 0.864). When analyzing a subset of only preoperative variables, the top-performing models were lasso regression (AUC = 0.865) and DNN with SMOTE (AUC = 0.864), both of which outperform any currently published models. Main model contributions relied heavily on variables associated with history of thromboembolic events, length of surgical/anesthetic time, and use of postoperative chemoprophylaxis. Conclusions: The current study provides promise toward machine learning methods geared toward predicting postoperative complications after spine surgery. Further study is needed in order to best quantify and model real-world risk for such events.

Outcomes following surgical resection of trigeminal schwannomas: a systematic review and meta-analysis.

Although typically benign, trigeminal schwannomas (TS) may require surgical resection when large or symptomatic and can cause significant morbidity. This study aims to summarize the literature and synthesize outcomes following surgical resection of TS. A systematic review was performed according to PRISMA guidelines. Data extracted included patient and tumor characteristics, surgical approaches, and postoperative outcomes. Odds ratios (OR) with corresponding 95% confidence intervals (CI) were used for outcome analysis. The initial search yielded 1838 results, of which 26 studies with 974 patients undergoing surgical resection of TS were included. The mean age was 42.9 years and 58.0% were female. The mean tumor diameter was 4.7 cm, with Samii type A, B, C, and D tumors corresponding to 33.4%, 15.8%, 37.2%, and 13.6%, respectively. Over a mean symptom duration of 29 months, patients presented with trigeminal hypesthesia (58.7%), headache (32.8%), trigeminal motor weakness (22.8%), facial pain (21.3%), ataxia (19.4%), diplopia (18.7%), and visual impairment (12.0%). Surgical approaches included supratentorial (61.4%), infratentorial (15.0%), endoscopic (8.6%), combined/staged (5.3%), and anterior (5.7%) or posterior (4.0%) petrosectomy. Postoperative improvement of facial pain (83.9%) was significantly greater than trigeminal motor weakness (33.0%) or hypesthesia (29.4%). The extent of resection (EOR) was reported as gross total (GTR), near total, and subtotal in 77.7%, 7.7%, and 14.6% of cases, respectively. Over a mean follow-up time of 62.6 months, recurrence/progression was noted in 7.4% of patients at a mean time to recurrence of 44.9 months. Patients with GTR had statistically significantly lower odds of recurrence/progression (OR: 0.07; 95% CI: 0.04-0.15) compared to patients with non-GTR. This systematic review and meta-analysis report patient outcomes following surgical resection of TS. EOR was found to be an important predictor of the risk of recurrence. Facial pain was more likely to improve postoperatively than facial hypesthesia. This work reports baseline rates of post-operative complications across studies, establishing benchmarks for neurosurgeons innovating and working to improve surgical outcomes for TS patients.

Traumatic Dens Fracture Patients Comprise Distinct Subpopulations Distinguished by Differences in Age, Sex, Injury Mechanism and Severity, and Outcome.

BACKGROUND: Dens fractures are an increasingly common injury, yet their epidemiology and its implications remain underexamined. METHODS: We retrospectively analyzed all traumatic dens fracture patients managed at our institution over a 10-year period, examining demographic, clinical, and outcomes data. Patient subsets were compared across these parameters. RESULTS: Among 303 traumatic dens fracture patients, we observed a bimodal age distribution with a strong goodness of fit centered at age 22.3 ± 5.7 (R = 0.8781) and at 77.7 ± 13.9 (R = 0.9686). A population pyramid demonstrated a bimodal distribution among male patients, but not female patients, which was confirmed with a strong goodness of fit for male patient subpopulations age <35 (R = 0.9791) and age ≥35 (R = 0.8843), but a weaker fit for a second female subpopulation age <35. Both age groups were equally likely to undergo surgery. Patients younger than age 35 were more likely to be male (82.4% vs. 46.9%, odds ratio [OR] = 5.29 [1.54, 17.57], P = 0.0052), have motor vehicle collision as their mechanism of injury (64.7% vs. 14.1%, OR = 11.18 [3.77, 31.77], P < 0.0001), and to have a severe trauma injury severity score (17.6% vs. 2.9%, OR = 7.23 [1.88, 28.88], P = 0.0198). Nevertheless, patients age <35 were less likely to have fracture nonunion at follow (18.2% vs. 53.7%, OR = 0.19 [0.041, 0.76], P = 0.0288). CONCLUSIONS: The dens fracture patient population comprises 2 subpopulations, distinguished by differences in age, sex, injury mechanism and severity, and outcome, with male dens fracture patients demonstrating a bimodal age distribution. Young, male patients were more likely to have high-energy injury mechanisms leading to severe trauma, yet were less likely to have fracture nonunion at follow-up.

Outcomes following anterior odontoid screw versus posterior arthrodesis for odontoid fractures: a systematic review and meta-analysis.

OBJECTIVE: Odontoid fractures can be managed surgically when indicated. The most common approaches are anterior dens screw (ADS) fixation and posterior C1-C2 arthrodesis (PA). Each approach has theoretical advantages, but the optimal surgical approach remains controversial. The goal in this study was to systematically review the literature and synthesize outcomes including fusion rates, technical failures, reoperation, and 30-day mortality associated with ADS versus PA for odontoid fractures. METHODS: A systematic literature review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines by searching the PubMed, EMBASE, and Cochrane databases. A random-effects meta-analysis was performed and the I2 statistic was used to assess heterogeneity. RESULTS: In total, 22 studies comprising 963 patients (ADS 527, PA 436) were included. The average age of the patients ranged from 28 to 81.2 years across the included studies. The majority of the odontoid fractures were type II based on the Anderson-D'Alonzo classification. The ADS group was associated with statistically significantly lower odds to achieve bony fusion at last follow-up compared to the PA group (ADS 84.1%; PA 92.3%; OR 0.46; 95% CI 0.23-0.91; I2 42.6%). The ADS group was associated with statistically significantly higher odds of reoperation compared to the PA group (ADS 12.4%; PA 5.2%; OR 2.56; 95% CI 1.50-4.35; I2 0%). The rates of technical failure (ADS 2.3%; PA 1.1%; OR 1.11; 95% CI 0.52-2.37; I2 0%) and all-cause mortality (ADS 6%; PA 4.8%; OR 1.35; 95% CI 0.67-2.74; I2 0%) were similar between the two groups. In the subgroup analysis of patients > 60 years old, the ADS was associated with statistically significantly lower odds of fusion compared to the PA group (ADS 72.4%; PA 89.9%; OR 0.24; 95% CI 0.06-0.91; I2 58.7%). CONCLUSIONS: ADS fixation is associated with statistically significantly lower odds of fusion at last follow-up and higher odds of reoperation compared to PA. No differences were identified in the rates of technical failure and all-cause mortality. Patients receiving ADS fixation at > 60 years old had significantly higher and lower odds of reoperation and fusion, respectively, compared to the PA group. PA is preferred to ADS fixation for odontoid fractures, with a stronger effect size for patients > 60 years old.

Outpatient telemedicine in neurosurgery: 15,677 consecutive encounters in a comparative analysis of its effectiveness and impact on the surgical conversion rate.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has necessitated the use of telehealth visits (THVs). The effects on neurosurgical practice have not been well characterized, especially concerning new-patient THVs. Therefore, the authors of this study reviewed their institution's experience with outpatient clinic visits and THVs from before the COVID-19 pandemic to the present to focus on clinical metrics, rates of surgery, and the effects of implementing THVs in order to better understand their implications for clinical practice as more data emerge over time. METHODS: The authors reviewed 15,677 consecutive new outpatient in-person visits (IPVs), THVs, and neurosurgical procedures/cases proceeding from their institution between 2018 and 2022 for trends and associations related to THVs. RESULTS: Among spine patients, there was no difference in the proportion of encounters that led to surgery (surgical conversion rate) between THVs and IPVs (p = 0.49). Among cranial patients, THVs were negatively associated with conversion (OR 0.73, p = 0.03). On average, patients using THVs lived further from the hospital (p < 0.001); however, the patient catchment area appeared unchanged. The median distance to the hospital among THV patients was counterbalanced by a decreased distance for spine patients pursing IPVs (p < 0.001), with no significant change to case volume. There was no change in distance to the hospital among cranial patients. For both cranial and spine patients, surgical conversion was more likely among those who lived a great distance from the hospital if their initial encounter was an IPV (p = 0.007 and < 0.001, respectively). However, there was no relationship between distance from the hospital and surgical conversion among THV patients (p = 0.565). The availability of THVs did not significantly affect follow-up time (p = 0.837). For new patients at IPVs, there was no difference in time to the operating room between cranial and spine cases; for new patients at THVs, however, time to the operating room was significantly faster for cranial cases than for spine cases (p = 0.0018). CONCLUSIONS: Compared to IPVs, THVs lead to decreased surgical conversion for cranial patients but not spine patients. THVs do not appear to increase the catchment area. For patients who live far from the hospital, an IPV is associated with surgical conversion. Surgical conversion is faster following cranial THVs than after spine THVs. THVs did not increase the duration of follow-up.

Atlas fractures with and without simultaneous dens fractures differ with respect to clinical, demographic, and management characteristics.

Background: Patients with simultaneous fractures of the atlas and dens have traditionally been managed according to the dens fracture's morphology, but data supporting this practice are limited. Methods: We retrospectively examined all patients with traumatic atlas fractures at our institution between 2008 and 2016. We used multivariable regression and propensity score matching to compare the presentation, management, and outcomes of patients with isolated atlas fractures to patients with simultaneous atlas-dens fractures. Results: Ninety-nine patients were identified. Patients with isolated atlas fractures were younger (61 ± 22 vs. 77 ± 14, P = 0.0003), had lower median Charlson Comorbidity Index (3 vs. 5, P = 0.0005), had better presenting Nurick myelopathy scores (0 vs. 3, P < 0.0001), and had different mechanisms of injury (P = 0.0011). Multivariable regression showed that having a simultaneous atlas-dens fracture was independently associated with older age (odds ratio [OR] =1.59 [1.22, 2.07], P = 0.001), worse presenting myelopathy (OR = 3.10 [2.04, 4.16], P < 0.001), and selection for surgery (OR = 4.91 [1.10, 21.97], P = 0.037). Propensity score matching yielded balanced populations (Rubin's B = 23.3, Rubin's R = 1.96) and showed that the risk of atlas fracture nonunion was no different among isolated atlas fractures compared to simultaneous atlas-dens fractures (P = 0.304). Age was the only variable independently associated with atlas fracture nonunion (OR = 2.39 [1.15, 5.00], P = 0.020), having a simultaneous atlas-dens fracture was not significant (P = 0.2829). Conclusions: Among patients with atlas fractures, simultaneous fractures of the dens occur in older patients and confer an increased risk of myelopathy and requiring surgical stabilization. Controlling for confounders, the risk of atlas fracture nonunion is equivalent for isolated atlas fractures versus simultaneous atlas-dens fractures.

Outcomes following stereotactic radiosurgery for foramen magnum meningiomas: a single-center experience and systematic review of the literature.

OBJECTIVE: Foramen magnum meningiomas (FMMs) pose a unique challenge given their intimate anatomical relationship with the craniovertebral junction. While resection has been studied extensively, much less has been reported about the use of stereotactic radiosurgery (SRS) for FMMs. This study includes what is to the authors' knowledge the first systematic review in the literature that summarizes patient and treatment characteristics and synthesizes outcomes following SRS for FMMs. METHODS: A retrospective chart review was conducted at a single major academic institution, and a systematic review was performed according to PRISMA guidelines. The initial search on the PubMed and Scopus databases yielded 530 results. Key data extracted from both databases included Karnofsky Performance Status (KPS) score and neurological deficits at presentation, tumor location, treatment indication, target volume, single versus multiple fractions, marginal and maximum doses, isodose line, clinical and radiographic follow-up times, and primary (clinical stability and local control at last follow-up) and secondary (mortality, adverse radiation events, time to regression, progression-free survival) outcomes. RESULTS: The study patients included 9 patients from the authors' institution and 165 patients across 4 studies who received SRS for FMMs. The weighted median age at treatment was 60.2 years, and 73.9% of patients were female. Common presenting symptoms included headache (33.9%), dizziness/ataxia (29.7%), cranial nerve deficit(s) (27.9%), numbness (22.4%), weakness (15.2%), and hydrocephalus (4.2%). Lateral/ventrolateral (64.2%) was the most common tumor location. SRS was utilized as the primary therapy in 63.6% of patients and as salvage (21.8%) or adjuvant (14.5%) therapy for the rest of the patients. Most patients (91.5%) were treated with a single fraction. A tumor with a weighted median target volume of 2.9 cm3 was treated with a weighted median marginal dose, maximum dose, and isodose line of 12.9 Gy, 22.8 Gy, and 58%, respectively. Clinical stability and local control at last follow-up were achieved in 98.8% and 97.0% of patients, respectively. Only one possible adverse radiation event occurred, and no mortality directly related to the tumor or SRS was reported. CONCLUSIONS: In this retrospective analysis and systematic review, the authors demonstrate SRS to be an effective and safe treatment option for carefully selected patients with FMMs.

Embolic protection devices for carotid artery stenting: A network meta-analysis.

OBJECTIVES: Carotid artery stenting (CAS) is an alternative treatment option for patients at high risk for carotid endarterectomy (CEA) but has been correlated with increased risk for distal embolization and periprocedural stroke despite the use of adjunctive embolic protection devices (EPD). This study compared four types of EPDs and their intra and periprocedural related complications. METHODS: A systematic review of the literature was conducted in PubMed/Medline to identify studies that investigated the outcomes of CAS with adjuvant use of EPDs, including Proximal Balloon (PB), Distal Filter (DF), and Distal Balloon (DB) strategy. Continuous flow reversal performed via transcarotid approach by a commercially available device as an embolic protection strategy was intentionally excluded based on its distinct procedural characteristics and lack of availability outside of the United States. This network meta-analysis was performed according to the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS: Overall, 45 studies, consisting of 7600 participants satisfied the predetermined search criteria and were included in this network meta-analysis. Overall, 13 studies provided data regarding the number of patients with new ischemic lesions detected in the DW-MRI. DF (OR: 3.15; 95% CI: 1.54-6.44; p = 0.002) and DB (OR: 2.28; 95% CI: 1.58-3.29; p < 0.001) were associated with higher odds of new ischemic lesions compared to PB on DW-MRI imaging. No statistical difference was identified between DB versus DF groups (OR: 1.48; 95% CI: 0.73-2.59; p = 0.317). 36 and 27 studies reported on periprocedural stroke and transient ischemic attack (TIA) rates, respectively, showing similar odds of neurologic adverse events between all three groups. CONCLUSIONS: PB deployment during CAS is superior to DF and DB in preventing distal embolization phenomena. However, no statistically significant difference in TIA and stroke rate was found among any of the analyzed EPD groups. Further research is warranted to investigate the association of embolic phenomena on imaging after CAS with clinically significant neurologic deficits.

A Systematic Review of Outpatient Telemedicine Use in Neurosurgery Since the Start of Coronavirus Disease 2019.

OBJECTIVE: The coronavirus disease 2019 (COVID-19) pandemic has sparked interest in telemedicine, resulting in an increase in neurosurgical publications focused on it. We summarize this new literature to evaluate telemedicine applications to neurosurgery. METHODS: A systematic literature review was performed in accordance with the PRISMA guidelines by searching PubMed, Embase, and Scopus for journal articles published after January 1, 2020. All journal articles that included data after the start of COVID-19 and evaluated any aspect of telemedicine relevant to outpatient neurosurgical visits were included. The premise and key findings of each included study were extracted, as well as patient and provider satisfaction with and preference for telemedicine. RESULTS: Thirty-seven articles met the inclusion criteria. Four studies proposed and evaluated a remote neurologic examination. Two studies reported similar postvisit outcomes between remote and in-person visits. Twenty-four studies reported a combination of patient and provider opinions toward telemedicine. Of 9834 patients and 116 providers, 82.4% and 65.2% were satisfied overall with telemedicine, respectively. Of 3526 patients and 168 providers, 57.0% and 66.5% preferred telemedicine to in-person visits, respectively. CONCLUSIONS: Overall, most patients and providers have a high opinion of telemedicine for outpatient visits, and increasing evidence suggests that remote visits yield favorable clinical outcomes. The high rates of patient and provider satisfaction and preference may be considered for further adoption of remote neurosurgical visits beyond the COVID-19 era.

Outcomes Following Penetrating Brain Injuries in Military Settings: A Systematic Review and Meta-Analysis.

OBJECTIVE: While neurosurgeons are experienced in treating penetrating brain injuries (PBIs) in civilian settings, much less is known about management and outcomes of PBIs in military settings. METHODS: A systematic review was performed according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. Data extracted included surgical management, age, gender, location/type of injury, initial Glasgow Coma Scale (GCS) score, and outcomes. The primary outcomes were last reported Glasgow Outcome Score (GOS) and mortality. The secondary outcomes included central nervous system infections, seizures, and cerebrospinal fluid leak/fistula. Odds ratios (ORs) with corresponding 95% confidence intervals (CIs) were used for outcome analysis. RESULTS: Twelve studies with 1738 patients treated for PBIs in military settings were included. The weighted mean age was 27.8 years, 86.7% were male, and 64.3% underwent neurosurgical intervention. Most patients (64.3%) presented with a GCS score >8, while 31.0% presented in a coma (GCS score <8). Over a median last follow-up time of 9 months, 68.6% achieved a favorable (GOS = 4-5) outcome and 34.2% achieved a poor (GCS score = 1-3) outcome. The overall mortality was 18.0%. A meta-analysis was performed using 5 of 12 studies to evaluate the effect of the presenting GCS score on primary outcomes. Patients with an initial GCS score <8 had statistically significant lower odds of a favorable (GOS = 4-5) outcome (OR: 0.03; 95% CI: 0.00-0.19; P: 0.000) and higher odds of mortality (OR: 28.46; 95% CI: 8.62-94; P: 0.000) than patients with an initial GCS score >8. The pooled rates of central nervous system infection, seizures, and cerebrospinal fluid leak/fistula were 13.8%, 13.2%, and 5.4%, respectively. CONCLUSIONS: In this first systematic review and meta-analysis of outcomes following combat-related PBIs, a GCS score >8 at presentation was found to be an important predictor of a favorable GOS and decreased mortality.

High resolution 3D magnetic resonance imaging of Gruber's ligament: a pilot study.

INTRODUCTION: Gruber's ligament (GL), a surgical landmark, extends from the lateral upper clivus to the petrous apex (PA), forming the superior boundary of Dorello's canal (DC). It overlies the interdural segment of the abducens nerve (CN VI). High-resolution 3D skull base MRI (SB-MRI) demonstrates anatomic details visible to the surgeon, but not well seen on traditional cross-sectional imaging. The aim of this study was to demonstrate visualization of the GL and its relationship to CN VI utilizing contrast enhanced high-resolution SB-MRI. METHODS: Two neuroradiologists retrospectively reviewed in consensus the SB-MRIs of 27 skull base sides, among 14 patients. GL detection rate, confidence of detection, and GL length were recorded. When GL was successfully identified, the position of the interdural segment of CN VI within DC was recorded. RESULTS: GL was readily identified in 16 skull base sides (59%), identified with some difficulty in 2 skull base sides (7%), and failed to be identified in 9 skull base sides (33%). The mean GL length was 7.1 mm (4.5-9.3 mm). Among the 18 cases where GL was successfully identified, CN VI was readily identified in all cases (100%), coursing the lateral third of DC in 72% of sides, and middle third in the remaining 28% of sides. CONCLUSION: GL can be identified in approximately two-thirds of cases utilizing 3D high resolution SB-MRI. CN VI passes most commonly along the lateral third of DC. This is the first report demonstrating visualization of GL and its relation to CN VI, on imaging.

The role of neurosurgery in the management of tuberous sclerosis complex-associated epilepsy: a systematic review.

OBJECTIVE: Tuberous sclerosis complex (TSC) is an autosomal dominant, multisystem neurocutaneous disorder associated with cortical tubers, brain lesions seen in nearly all patients with TSC, which are frequently epileptogenic. Seizures are often the earliest clinical manifestation of TSC, leading to epilepsy in over 70% of patients. Medical management with antiepileptic drugs constitutes early therapy, but over 50% develop medically refractory epilepsy, necessitating surgical evaluation and treatment. The objective of this study was to summarize the literature and report seizure outcomes following surgical treatment for TSC-associated epilepsy. METHODS: A systematic literature review was performed in accordance with the PRISMA guidelines. The PubMed and Embase databases were searched for journal articles reporting seizure outcomes following epilepsy surgery in TSC patients. Included studies were placed into one of two groups based on the surgical technique used. Excellent and worthwhile seizure reductions were defined for each group as outcomes and extracted from each study. RESULTS: A total of 46 studies were included. Forty of these studies reported seizure outcomes following any combination of resection, disconnection, and ablation on a collective 1157 patients. Excellent and worthwhile seizure reductions were achieved in 59% (683/1157) and 85% (450/528) of patients, respectively. Six of these studies reported seizure outcomes following treatment with neuromodulation. Excellent and worthwhile seizure reductions were achieved in 34% (24/70) and 76% (53/70) of patients, respectively. CONCLUSIONS: Surgery effectively controls seizures in select patients with TSC-associated epilepsy, but outcomes vary. Further understanding of TSC-associated epilepsy, improving localization strategies, and emerging surgical techniques represent promising avenues for improving surgical outcomes.

Mass Deployment of Deep Neural Network: Real-Time Proof of Concept With Screening of Intracranial Hemorrhage Using an Open Data Set.

BACKGROUND: Intracranial hemorrhage (ICH) is considered an emergency that requires rapid medical or surgical management. Previous studies have used artificial intelligence to attempt to expedite the diagnosis of this pathology on neuroimaging. However, these studies have used local, institution-specific data for training of networks that limit deployment of across broader hospital networks or regions because of data biases. OBJECTIVE: To demonstrate the creation of a neural network based on an openly available imaging data tested on data from our institution demonstrating a high-efficacy, institution-agnostic network. METHODS: A data set was created from publicly available noncontrast computed tomography images of known ICH. These data were used to train a neural network using distinct windowing and augmentation. This network was then validated in 2 phases using cohort-based (phase 1) and longitudinal (phase 2) approaches. RESULTS: Our convolutional neural network was trained on 752 807 openly available slices, which included 112 762 slices containing intracranial hemorrhage. In phase 1, the final network performance for intracranial hemorrhage showed a receiver operating characteristic curve (AUC) of 0.99. At the inflection point, our model showed a sensitivity of 98% at a threshold specificity of 99%. In phase 2, we obtained an AUC of 0.98 after analysis of 726 scans with a negative predictive value of 99.70% (n = 726). CONCLUSION: We demonstrate an effective neural network trained on completely open data for screening ICH at an unrelated institution. This study demonstrates a proof of concept for screening networks for multiple sites while maintaining high efficacy.