Evaluation of nonaccidental trauma in infants presenting with skull fractures: a retrospective review.

OBJECTIVE: Nonaccidental trauma (NAT) is one of the leading causes of serious injury and death among young children in the United States, with a high proportion of head injury. Numerous studies have demonstrated the safety of discharge of infants with isolated skull fractures (ISFs); however, these same studies have noted that those infants with suspected abuse should not be immediately discharged. The authors aimed to create a standardized protocol for evaluation of infants presenting with skull fractures to our regional level I pediatric trauma center to best identify children at risk. METHODS: A protocol for evaluation of NAT was developed by our pediatric trauma committee, which consists of evaluation by neurosurgery, pediatric surgery, and ophthalmology, as well as the pediatric child protection team. Social work evaluations and a skeletal survey were also utilized. Patients presenting over a 2-year period, inclusive of all infants younger than 12 months at the time of presentation, were assessed. Factors at presentation, protocol compliance, and the results of the workup were evaluated to determine how to optimize identification of children at risk. RESULTS: A total of 45 infants with a mean age at presentation of 5.05 months (SD 3.14 months) were included. The most common stated mechanism of injury was a fall (75.6%), followed by an unknown mechanism (22.2%). The most common presenting symptoms were swelling over the fracture site (25 patients, 55.6%), followed by vomiting (5 patients, 11.1%). For the entire population of patients with skull fractures, there was suspicion of NAT in 24 patients (53.3% of the cohort). Among the 30 patients with ISFs, there was suspicion of NAT in 13 patients (43.3% of the subgroup). CONCLUSIONS: Infants presenting with skull fractures with intracranial findings and ISFs had a substantial rate of concern for the possibility of nonaccidental skull fracture. Although prior studies have demonstrated the relative safety of discharging infants with ISFs, it is critical to establish an appropriate standardized protocol to evaluate for infants at risk of abusive head trauma.

Impact of multidisciplinary engagement in a quality improvement blood conservation protocol for craniosynostosis.

OBJECTIVE: Patients undergoing open cranial vault remodeling for craniosynostosis frequently experience substantial blood loss requiring blood transfusion. Multiple reports in the literature have evaluated the impact of individual blood conservation techniques on blood transfusion rates during craniosynostosis surgery. The authors engaged a multidisciplinary team and assessed the impact of input from multiple stakeholders on the evolution of a comprehensive quality improvement protocol aimed at reducing or eliminating blood transfusion in patients undergoing open surgery for craniosynostosis. METHODS: Over a 4-year period from 2012 to 2016, 39 nonsyndromic patients were operated on by a single craniofacial plastic surgeon. Initially, no clear blood conservation protocol existed, and specific interventions were individually driven. In 2014, a new pediatric neurosurgeon joined the craniofacial team, and additional stakeholders in anesthesiology, transfusion medicine, critical care, and hematology were brought together to evaluate opportunities for developing a comprehensive blood conservation protocol. The initial version of the protocol involved the standardized administration of intraoperative aminocaproic acid (ACA) and the use of a cell saver. In the second version of the protocol, the team implemented the preoperative use of erythropoietin (EPO). In addition, intraoperative and postoperative resuscitation and transfusion guidelines were more clearly defined. The primary outcomes of estimated blood loss (EBL), transfusion rate, and intraoperative transfusion volume were analyzed. The secondary impact of multidisciplinary stakeholder input was inferred by trends in the data obtained with the implementation of the partial and full protocols. RESULTS: Implementing the full quality improvement protocol resulted in a 66% transfusion-free rate at the time of discharge compared to 0% without any conservation protocol and 27% with the intermediate protocol. The administration of EPO significantly increased starting hemoglobin/hematocrit (11.1 g/dl/31.8% to 14.7 g/dl/45.6%, p < 0.05). The group of patients receiving ACA had lower intraoperative EBL than those not receiving ACA, and trends in the final-protocol cohort, which had received both preoperative EPO and intraoperative ACA, demonstrated decreasing transfusion volumes, though the decrease did not reach statistical significance. CONCLUSIONS: Patients undergoing open calvarial vault remodeling procedures benefit from the input of a multidisciplinary stakeholder group in blood conservation protocols. Further research into comprehensive protocols for blood conservation may benefit from input from the full surgical team (plastic surgery, neurosurgery, anesthesiology) as well as additional pediatric subspecialty stakeholders including transfusion medicine, critical care, and hematology.

Optimal Timing of Whole-Brain Radiation Therapy Following Craniotomy for Cerebral Malignancies.

BACKGROUND: For patients with cerebral metastases that are limited in number, surgical resection followed by whole-brain radiation therapy is the standard of care. In addition, for high-grade gliomas, maximal surgical resection followed by local radiotherapy is considered the optimal treatment. Radiation is known to impair wound healing, including healing of surgical incisions. Radiotherapy shortly after surgical resection would be expected to minimize the opportunity for tumor regrowth or progression. Owing to these competing interests, the purpose of this study was to shed light on the optimal timing of radiotherapy after surgical resection of brain metastasis or high-grade gliomas. METHODS: A review of the literature was conducted on the following topics: radiation and wound healing, corticosteroid use and wound healing, radiotherapy for tumor control for cerebral metastases and high-grade gliomas, and whole-brain radiation therapy or focal radiotherapy after craniotomy with focus on the timing of radiotherapy after surgery. RESULTS: In animal models, wound integrity and healing was less impaired by radiotherapy administered 1 week after surgery. In humans, this timing would be expected to be significantly longer, on the order of several weeks. CONCLUSIONS: Given the limited literature, insufficient conclusions can be drawn. However, animal data suggest a period of at least 1 week (but it is likely several weeks in humans) is necessary for reconstitution of wound strength before initiation of radiation therapy. A randomized prospective study is recommended to understand better the effect of the timing of radiation therapy following surgical intervention for brain metastasis or high-grade gliomas.

A gender-based comparison of academic rank and scholarly productivity in academic neurological surgery.

The number of women pursuing training opportunities in neurological surgery has increased, although they are still underrepresented at senior positions relative to junior academic ranks. Research productivity is an important component of the academic advancement process. We sought to use the h-index, a bibliometric previously analyzed among neurological surgeons, to evaluate whether there are gender differences in academic rank and research productivity among academic neurological surgeons. The h-index was calculated for 1052 academic neurological surgeons from 84 institutions, and organized by gender and academic rank. Overall men had statistically higher research productivity (mean 13.3) than their female colleagues (mean 9.5), as measured by the h-index, in the overall sample (p<0.0007). When separating by academic rank, there were no statistical differences (p>0.05) in h-index at the assistant professor (mean 7.2 male, 6.3 female), associate professor (11.2 male, 10.8 female), and professor (20.0 male, 18.0 female) levels based on gender. There was insufficient data to determine significance at the chairperson rank, as there was only one female chairperson. Although overall gender differences in scholarly productivity were detected, these differences did not reach statistical significance upon controlling for academic rank. Women were grossly underrepresented at the level of chairpersons in this sample of 1052 academic neurological surgeons, likely a result of the low proportion of females in this specialty. Future studies may be needed to investigate gender-specific research trends for neurosurgical residents, a cohort that in recent years has seen increased representation by women.

Improving medical student recruitment into neurological surgery: a single institution's experience.

OBJECTIVE: Neurological surgery is historically among one of the most competitive residency matches, but data suggest a downward trend in neurosurgical residency applicants in the United States. In 2002, our department, in conjunction with our institution, began an initiative to increase exposure to and interest in neurological surgery, targeting both undergraduate and medical students. This study outlines and assesses the factors used by our institution to successfully prepare and recruit medical students for residency in the field of neurological surgery. METHODS: This initiative has been divided into four phases to date. In phase one, a 2-week neurosurgical experience was incorporated into the existing Neurology/Psychiatry third-year clerkship, and a chapter to the Student Interest Group in Neurology was created. In phase two, the neurological surgery department increased efforts recruiting undergraduate students and preclinical medical students for research projects through a summer research program. During phase three, new neurosurgical course electives were added for third- and fourth-year medical students, as well as allowing earlier completion of a fourth-year acting internship. In phase four, a neurosurgical interest group was created. RESULTS: Since the implementation of all four phases, the number of medical students matching successfully to neurological surgery at our institution has increased drastically. CONCLUSIONS: An earlier, organized involvement of the neurosurgical department in medical student education can result in an improved understanding of the role of neurosurgeons among other practitioners as well as a greater number of well-qualified residency applicants into neurological surgery.

A comparative analysis of neurosurgical online education materials to assess patient comprehension.

Americans have increasingly utilized the internet as a first-line resource for a variety of information, including healthcare-oriented materials. Therefore, these online resources should be written at a level the average American can understand. Patient education resources specifically written for and available to the public were downloaded from the American Association of Neurological Surgeons website and assessed for their level of readability using the Flesch Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook Grading, Coleman-Liau Index, and Gunning-Fog Index. A total of 71 subsections from different neurosurgical specialties were reviewed, including Cerebrovascular, Spine and Peripheral Nerves, Neurotrauma and Critical Care, Pain, Pediatric, Stereotactic and Functional, and Tumor material. All neurosurgical subspecialty education material provided on the American Association of Neurological Surgeons website was uniformly written at a level that was too high, as assessed by all modalities. In order to reach a larger patient population, patient education materials on the American Association of Neurological Surgeons website should be revised with the goal of simplifying readability.

Lipomyelomeningocele: pathology, treatment, and outcomes.

Lipomyelomeningocele represents a rare but complex neurological disorder that may present with neurological deterioration secondary to an inherent tethered spinal cord. Radiological testing is beneficial in determining the morphology of the malformation. Specialized testing such as urodynamic studies and neurophysiological testing may be beneficial in assessing for neurological dysfunction secondary to the lipomyelomeningocele. Early surgical intervention may be beneficial in preventing further neurological decline.

Complete regression of papillary tumor of the pineal region after radiation therapy: case report and review of the literature.

Papillary tumor of the pineal region (PTPR) is a rare neuroepithelial tumor that arises in the pineal region. The optimal treatment for PTPR remains controversial, as no definitive treatment strategy exists for this lesion. It is not clear whether aggressive surgical removal is superior to biopsy followed by radiotherapy. The majority of cases in the literature have undergone attempted gross total resection with a supracerebellar-infratentorial or a transcallosal-transventricular approach. In this report, we describe a case of PTPR in a 23 year-old male that presented as a third ventricular mass causing obstructive hydrocephalus. An endoscopic third ventriculostomy was performed followed by an endoscopic biopsy. Postoperative radiotherapy resulted in complete regression of the tumor with no evidence of tumor recurrence at 25 months. This case highlights a minimally invasive strategy for a rare neoplasm that resulted in a favorable response to radiation therapy, thereby avoiding the risks of aggressive surgical removal. We also review the radiographic and histopathologic features of PTPR and discuss various options of treatment reported in the literature.