The impact of post-operative enteral nutrition on duodenal injury outcomes: A post hoc analysis of an EAST multicenter trial.

BACKGROUND: Leak following surgical repair of traumatic duodenal injuries results in prolonged hospitalization and oftentimes nil per os(NPO) treatment. Parenteral nutrition(PN) has known morbidity; however, duodenal leak(DL) patients often have complex injuries and hospital courses resulting in barriers to enteral nutrition(EN). We hypothesized EN alone would be associated with 1)shorter duration until leak closure and 2)less infectious complications and shorter hospital length of stay(HLOS) compared to PN. METHODS: This was a post-hoc analysis of a retrospective, multicenter study from 35 Level-1 trauma centers, including patients >14 years-old who underwent surgery for duodenal injuries(1/2010-12/2020) and endured post-operative DL. The study compared nutrition strategies: EN vs PN vs EN + PN using Chi-Square and Kruskal-Wallis tests; if significance was found pairwise comparison or Dunn's test were performed. RESULTS: There were 113 patients with DL: 43 EN, 22 PN, and 48 EN + PN. Patients were young(median age 28 years-old) males(83.2%) with penetrating injuries(81.4%). There was no difference in injury severity or critical illness among the groups, however there were more pancreatic injuries among PN groups. EN patients had less days NPO compared to both PN groups(12 days[IQR23] vs 40[54] vs 33[32],p = <0.001). Time until leak closure was less in EN patients when comparing the three groups(7 days[IQR14.5] vs 15[20.5] vs 25.5[55.8],p = 0.008). EN patients had less intra-abdominal abscesses, bacteremia, and days with drains than the PN groups(all p < 0.05). HLOS was shorter among EN patients vs both PN groups(27 days[24] vs 44[62] vs 45[31],p = 0.001). When controlling for predictors of leak, regression analysis demonstrated EN was associated with shorter HLOS(ß -24.9, 95%CI -39.0 to -10.7,p < 0.001). CONCLUSION: EN was associated with a shorter duration until leak closure, less infectious complications, and shorter length of stay. Contrary to some conventional thought, PN was not associated with decreased time until leak closure. We therefore suggest EN should be the preferred choice of nutrition in patients with duodenal leaks whenever feasible. LEVEL OF EVIDENCE: IV.

Gender Differences in Medicare Practice and Payments to Neurosurgeons.

Importance: Despite efforts to promote diversity within the neurosurgical workforce, individuals from underrepresented groups face significant challenges. Objective: To compare practice metrics and earning potential between female and male neurosurgeons and investigate factors associated with gender disparity in Medicare reimbursement. Design, Setting, and Participants: This retrospective cross-sectional study used publicly accessible Medicare data on reimbursements to female and male neurosurgeons for procedural and evaluation and management services delivered in both inpatient and outpatient settings between January 1, 2013, and December 31, 2020. Data were analyzed from December 9, 2021, to December 5, 2022. Main Outcomes and Measures: The primary outcome was the mean annual payments received and charges submitted by female and male neurosurgeons for services rendered between 2013 and 2020. Secondary outcomes included the total number and types of services rendered each year and the number of beneficiaries treated. Univariate and multivariable analyses quantified differences in payment, practice volume, and composition. Results: A total of 6052 neurosurgeons (5540 men [91.54%]; 512 women [8.46%]) served the Medicare fee-for-service patient population. Female neurosurgeons billed for lesser Medicare charges (mean [SE], $395 851.62 [$19 449.39] vs $766 006.80 [$11 751.66]; P < .001) and were reimbursed substantially less (mean [SE], $69 520.89 [$2701.30] vs $124 324.64 [$1467.93]; P < .001). Multivariable regression controlling for practice volume metrics revealed a persistent reimbursement gap (-$24 885.29 [95% CI, -$27 964.72 to -$21 805.85]; P < .001). Females were reimbursed $24.61 less per service than males even after matching services by code (P = .02). Conclusions and Relevance: This study found significant gender-based variation in practice patterns and reimbursement among neurosurgeons serving the Medicare fee-for-service population. Female surgeons were reimbursed less than male surgeons when both performed the same primary procedure. Lower mean reimbursement per service may represent divergence in billing and coding practices among females and males that could be the focus of future research or educational initiatives.

Tension Pneumocranium Following Transsphenoidal Surgeries-A Case Report and Systematic Review of Literature with Analysis of Predisposing Factors and Treatment Regimens: Is Early Skull Base Repair Better than Conservative Treatment?

BACKGROUND: Conclusive evidence describing the outcomes following different treatment strategies for tension pneumocranium (TP) is lacking. Impact of predisposing conditions like multiple transnasal transsphenoidal (TNTS) procedures, intraoperative cerebrospinal fluid leak, obstructive sleep apnea, continuous positive airway pressure, violent coughing, nose blowing, positive pressure ventilation on TP outcomes is also unknown. METHODS: PubMed, Embase, Cochrane, and Google Scholar were searched for articles using Preferred Reporting Items for Systematic Review and Meta-Analysis guidelines. Multivariate logistic regression analysis was done using STATA/ BE ver 17.0. RESULTS: Thirty-five studies with 49 cases of endoscopic TNTS surgeries were included. Tension pneumocephalus was seen in 77.5% (n = 38), tension pneumosella in 7 (14.28%), and tension pneumoventricle in 4 (8.16%). Nonfunctional pituitary adenomas (40.81%) were most common lesions associated with TP. The need of mechanical ventilation was significantly higher in patients who received conservative management (odds ratio, 1.34; confidence interval, 0.65-2.74) (P < 0.01). However, incidence of meningitis or mortality were not influenced by factors like age, gender, pathological diagnosis, initial conservative management or early skull base repair, use of adjuvant radiation, intraoperative cerebrospinal fluid leak, multiple TNTS explorations, or presence of precipitating factors. CONCLUSIONS: Nonfunctional pituitary adenomas were the most common lesions associated with TP. Multiple TNTS procedures did not increase incidence of meningitis or mortality. Conservative management increased the need for mechanical ventilation but did not worsen the mortality outcomes.

The deep roots of military service in neurological surgery: an academic genealogical analysis of the founding generation.

Throughout human history, advancements in medicine have evolved out of periods of war. The carnage of battlefield injuries provided wartime surgeons an unprecedented opportunity to study anatomy, develop novel techniques, and improve systems of care. As a specialty that was established and evolved during the first half of the 20th century, neurological surgery was heavily influenced by the experiences of its founders during the World Wars I and II. Utilizing the published Neurosurgery Tree, the authors conducted an academic genealogical analysis to systematically define the influence of wartime service on neurosurgery's earliest generations. Through review of the literature and military records, the authors determined that at least 60% of American neurosurgical founders and early leaders served during World Wars I and/or II. Inspired by the call to serve their nation as forces for good, these individuals were heralded as expert clinicians, innovative systems thinkers, and prolific researchers. Importantly, the service of these early leaders helped highlight the viability of neurosurgery as a distinct specialty and provided a framework for early neurosurgical education and expansion. The equipment, techniques, and guidelines that were developed during these wars, such as management of craniocerebral trauma, peripheral nerve repair, and hemostasis, set the foundation for modern neurosurgical practice.

Aortic arch anomalies, embryology and their relevance in neuro-interventional surgery and stroke: A review.

BACKGROUND: Congenital aortic arch anomalies are commonly encountered during neurointerventional procedures. While some anomalies are identified at an early age, many are incidentally discovered later in adulthood during endovascular evaluations or interventions. Proper understanding of the normal arch anatomy and its variants is pivotal to safely navigate normal aortic arch branches and to negotiate the catheter through anomalies during neurointerventional procedures. This is particularly relevant in the increasingly "transradial first" culture of neurointerventional surgery. Moreover, some of these anomalies have a peculiar predilection for complications including aneurysm formation, dissection, and rupture during the procedure. Therefore, an understanding of these anomalies, their underlying embryological basis and associations, and pattern of circulation will help endovascular neurosurgeons and interventional radiologists navigate with confidence and consider relevant pathologic associations that may inform risk of cerebrovascular disease. METHODS: Here, we present a brief review of the basic embryology of the common anomalies of the aortic arch along with their neurological significances and discuss, through illustrative cases, the association of aortic arch anomalies with cerebral vascular pathology. CONCLUSIONS: Understanding the aortic arch anomalies and its embryological basis is essential to safely navigate the cerebral vascular system during neurointerventional surgeries.

Experimental animal models for moyamoya disease and treatment: a pathogenesis-oriented scoping review.

OBJECTIVE: Moyamoya disease (MMD) is an intracranial steno-occlusive pathology characterized by progressive narrowing of proximal large vessels, including the terminal internal carotid arteries (ICAs), middle cerebral arteries, or anterior cerebral arteries. Named for the "puff of smoke" appearance of the anomalous vascularization visualized on cerebral angiography, MMD lacks a well-defined etiology, although significant insights have been made, including the identification of a susceptibility gene, RNF213, in humans with the disease. A limitation to advancing the understanding and treatment of MMD has been the lack of experimental animal models that authentically reflect the clinical pathogenesis. In an effort to analyze characteristics of currently available models and identify strategies for future model generation, the authors performed a scoping review of experimental animal models that have been used to study MMD. METHODS: A systematic search of PubMed, Web of Science, and Scopus was performed to identify articles describing animal models used to study MMD. Additional articles were identified via citation searching. Study selection and data extraction were performed by two independent reviewers based on defined inclusion and exclusion criteria. RESULTS: A total of 44 articles were included for full-text review. The methods used to generate these animal models were broadly classified as surgical (n = 25, 56.8%), immunological (n = 7, 15.9%), genetic (n = 6, 13.6%), or a combination (n = 6, 13.6%). Surgical models typically involved permanent ligation of one or both of the common carotid arteries or ICAs to produce chronic cerebral hypoperfusion. Genetic models utilized known MMD or cerebrovascular disease-related genes, such as RNF213 or ACTA2, to induce heritable cerebral vasculopathy. Finally, immunological models attempted to induce vasculitis-type pathology by recapitulating the inflammatory milieu thought to underlie MMD. CONCLUSIONS: Models generated for MMD have involved three general approaches: surgical, immunological, and genetic. Although each reflects a key aspect of MMD pathogenesis, the failure of any individual model to recapitulate the development, progression, and consequences of the disease underscores the importance of future work in developing a multietiology model.

Inactivation of Hedgehog signal transduction in adult astrocytes results in region-specific blood-brain barrier defects.

In this study, we use molecular genetic approaches to clarify the role of the Hedgehog (Hh) pathway in regulating the blood-brain/spinal cord barrier (BBB) in the adult mouse central nervous system (CNS). Our work confirms and extends prior studies to demonstrate that astrocytes are the predominant cell type in the adult CNS that transduce Hh signaling, revealed by the expression of Gli1, a target gene of the canonical pathway that is activated in cells receiving Hh, and other key pathway transduction components. Gli1+ (Hh-responsive) astrocytes are distributed in specific regions of the CNS parenchyma, including layers 4/5/6 of the neocortex, hypothalamus, thalamus, and spinal cord, among others. Notably, although BBB properties in endothelial cells are normally regulated by both paracellular and transcellular mechanisms, conditional inactivation of Hh signaling in astrocytes results in transient, region-specific BBB defects that affect transcytosis but not paracellular diffusion. These findings stand in contrast to prior studies that implicated astrocytes as a source of Sonic hedgehog that limited extravasation via both mechanisms [J. I. Alvarez et al., Science 334, 1727-1731 (2011)]. Furthermore, using three distinct Cre driver lines as well as pharmacological approaches to inactivate Hh-pathway transduction globally in CNS astrocytes, we find that these specific BBB defects are only detected in the rostral hypothalamus and spinal cord but not the cortex or other regions where Gli1+ astrocytes are found. Together, our data show that Gli1+ Hh-responsive astrocytes have regionally distinct molecular and functional properties and that the pathway is required to maintain BBB properties in specific regions of the adult mammalian CNS.

Multi-modal endovascular management of traumatic pseudoaneurysm and arteriovenous fistula of the ascending cervical artery: A technical report and review of literature.

OBJECTIVE: The management of traumatic pseudoaneurysm (PA) with concomitant arteriovenous fistula (AVF) arising from the thyrocervical trunk is challenging and rarely reported. Here, the usefulness of a multi-modal endovascular strategy for management of traumatic PA and AVF arising from the thyrocervical trunk is presented. A literature review describing unique clinical features and management strategies of traumatic vascular lesions of the thyrocervical trunk is included. METHODS: A 58-year-old man presented with two PAs arising from the ascending cervical artery (AsCA) and a robust AVF between the AsCA and the left vertebral venous plexus which arose acutely after a stabbing incident. These lesions were managed with endovascular vessel sacrifice via coiling and controlled Onyx injection. Relevant literature was identified via a targeted search of the PubMed database. RESULTS: Post-management angiography demonstrated complete occlusion of the two traumatic PAs and successful disconnection of the concomitant AVF. Our literature review demonstrates a shift in preferred management approach from invasive surgery to endovascular treatment due to the lower risk and cosmetic preferability. CONCLUSION: Timely treatment of enlarging PA is necessary for reducing associated morbidity and mortality. While surgical resection has been the mainstay therapy, endovascular management has gained popularity in recent years. The choice of endovascular technique is variable and should be individualized based on patient's clinical status, associated risk factors, and lesion morphology. We have shown that parent vessel sacrifice is safe and effective. Reconstruction with a combination of stents, coils, glue, or liquid embolics may be necessary when collateral flow is limited.

Incidental Brain Tumors in the Pediatric Population: A Systematic Review and Reappraisal of Literature.

OBJECTIVES: Management of incidental asymptomatic brain tumors in children is controversial due to lack of clear evidence-based guidelines. We present this systematic review in an attempt to highlight an optimal treatment paradigm. METHODS: This systematic review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Databases were searched up to August 2019 using the keywords "incidental," "brain tumor," and "pediatric." Our main focus was on brain lesions suspected for neoplasm, diagnosed incidentally on neuroimaging in an otherwise asymptomatic patient <18 years old. Cystic, vascular, and inflammatory brain lesions were excluded. RESULTS: Fourteen studies comprising 308 patients were included. All cases were diagnosed using magnetic resonance imaging. The most common indications for imaging were headache (93; 30%) and trauma (72; 23%). Lesion distribution was supratentorial (179; 58%), infratentorial (121; 40%), and intraventricular (8; 3%). Of 308 cases, 243 (79%) were managed with neuroradiological surveillance and 57 (19%) by upfront surgical excision. Of those managed conservatively, 177 (73%) remained stable within a mean follow-up of 30 months, 54 (22%) progressed, and 12 (5%) spontaneously regressed. Meanwhile, upfront excision achieved complete remission in all 57 cases over a mean follow-up of 68.3 months. CONCLUSION: A small body of evidence has emerged, highlighting the marked heterogeneity and contradictory results between the available studies, limiting our ability to draw solid conclusions. At this point, the decision between surgery and "watchful waiting" should be tailored on an individual patient basis depending on suspicion of malignancy, clinical or radiologic progression, and parental preference.

Neurosurgical and Scalp Reconstructive Challenges During Craniotomy in the Setting of Cutis Verticis Gyrata.

BACKGROUND: Cutis verticis gyrata (CVG) is a rare condition of the scalp in which thickening of the dermis induces rigid folds and furrows resembling the cerebral cortex. Two forms of primary CVG exist: essential, in which CVG is the only presenting problem, and nonessential, in which the scalp condition occurs along with neuropsychiatric ailments. CVG can also occur secondary to a variety of causes including inflammatory, neoplastic, and metabolic conditions or drug use. A review of the available literature, including description of the epidemiology, pathophysiology, histology, and typical management of CVG, is provided. However, we identified no literature describing the complications of CVG in the setting of a craniotomy. CASE REPORT: The patient presented here is a 54-year-old man with CVG who presented with occlusion of the M2/M2 branches of the middle cerebral artery, resulting in malignant cerebral edema, requiring emergent management via decompressive craniectomy. Because of the thickening of the scalp, skin incision was complicated by bleeding and difficulty in achieving hemostasis using Raney clips. Plastic surgery was consulted intraoperatively for assistance with complex closure of the wound in a multilayered fashion. Despite this, the patient's postoperative course was complicated by cerebrospinal fluid leakage due to difficulty in approximating the incision during closure. Subsequent cranioplasty was performed jointly between neurosurgery and plastic surgery. CONCLUSIONS: Despite its rarity, CVG is an important issue for neurosurgeons to understand as it can present complications in performing craniotomy, most notably during the scalp exposure and closure. CVG may also complicate the postoperative course if adequate approximation of the tissues cannot be achieved, resulting in wound infection and/or cerebrospinal fluid leak. The presented patient benefited from a combined neurosurgical and plastic surgical approach that was implemented intraoperatively and continued through the postoperative stages and the subsequent cranioplasty.