Co-administration of Ketamine in Pediatric Patients with Neurologic Conditions at Risk for Intracranial Hypertension.

BACKGROUND: Ketamine has traditionally been avoided as an induction agent for tracheal intubation in patients with neurologic conditions at risk for intracranial hypertension due to conflicting data in the literature. The objective of this study was to evaluate and compare the effects of ketamine versus other medications as the primary induction agent on peri-intubation neurologic, hemodynamic and respiratory associated events in pediatric patients with neurologic conditions at risk for intracranial hypertension. METHODS: This retrospective observational study enrolled patients < 18 years of age at risk for intracranial hypertension who were admitted to a quaternary children's hospital between 2015 and 2020. Associated events included neurologic, hemodynamic and respiratory outcomes comparing primary induction agents of ketamine versus non-ketamine for tracheal intubation. RESULTS: Of 143 children, 70 received ketamine as the primary induction agent prior to tracheal intubation. Subsequently after tracheal intubation, all the patients received adjunct analgesic and sedative medications (fentanyl, midazolam, and/or propofol) at doses that were inadequate to induce general anesthesia but would keep them comfortable for further diagnostic workup. There were no significant differences between associated neurologic events in the ketamine versus non-ketamine groups (p = 0.42). This included obtaining an emergent computed tomography scan (p = 0.28), an emergent trip to the operating room within 5 h of tracheal intubation (p = 0.6), and the need for hypertonic saline administration within 15 min of induction drug administration for tracheal intubation (p = 0.51). There were two patients who had clinical and imaging evidence of herniation, which was not more adversely affected by ketamine compared with other medications (p = 0.49). Of the 143 patients, 23 had pre-intubation and post-intubation intracranial pressure values recorded; 11 received ketamine, and 3 of these patients had intracranial hypertension that resolved or improved, whereas the remaining 8 children had intracranial pressure within the normal range that was not exacerbated by ketamine. There were no significant differences in overall associated hemodynamic or respiratory events during tracheal intubation and no 24-h mortality in either group. CONCLUSIONS: The administration of ketamine as the primary induction agent prior to tracheal intubation in combination with other agents after tracheal intubation in children at risk for intracranial hypertension was not associated with an increased risk of peri-intubation associated neurologic, hemodynamic or respiratory events compared with those who received other induction agents.

Patient sentiment regarding stroke: Analysis of 2,992 social media posts.

INTRODUCTION: Social media reflects personalized sentiment toward disease and increasingly impacts perceptions of treatment options. This study aims to assess patients experience with and perception of stroke through an analysis of social media posts. METHODS: A variety of terms ("stroke", "stroke survivor", "stroke rehab", "stroke recovery") were used to search for possible qualified posts on Twitter and Instagram. Twitter posts containing "#stroke" and "@stroke" were identified, yielding 2,506 Twitter posts relating to the patient's own experience. Four hundred sixty-eight public Instagram posts marked under "#stroke" and "@stroke," including direct references to the patient's own experience, were analyzed. First vs. recurrent stroke was identified when possible. The posts were coded for themes relating to patient experience with the disease. RESULTS: The most common Twitter theme was raising stroke awareness (23.4 %), while spreading positivity was the most common Instagram theme (66.7 %). Most Twitter posts (93.9 %) were from patients experiencing their first stroke, with only 6.1 % of the posts being about recurrent strokes. Women created the majority of Instagram (75.7 %) and Twitter (77.3 %) posts. Men were more likely to discuss mobility/functional outcomes (p = 0.001) and survival/death (p = 0.014), while women were more likely to recount symptoms (p = 0.014), depression (p = 0.002), fear (p<0.001), and mental health (p = 0.006). CONCLUSION: Stroke patients most often describe their quality of life and discuss raising awareness via social media. Men and women differ in the most commonly shared aspects of their stroke experience. Gauging social media sentiment may guide physicians toward better counseling and psychosocial management of stroke patients.

Neurosurgical management of patients with neurocutaneous melanosis: a systematic review.

OBJECTIVE: Neurocutaneous melanocytosis (NCM), also referred to as neurocutaneous melanosis, is a rare neurocutaneous disorder characterized by excess melanocytic proliferation in the skin, leptomeninges, and cranial parenchyma. NCM most often presents in pediatric patients within the first 2 years of life and is associated with high mortality due to proliferation of melanocytes in the brain. Prognosis is poor, as patients typically die within 3 years of symptom onset. Due to the rarity of NCM, there are no specific guidelines for management. The aims of this systematic review were to investigate approaches toward diagnosis and examine modern neurosurgical management of NCM. METHODS: A systematic review was performed using the PubMed database between April and December 2021 to identify relevant articles using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. Search criteria were created and checked independently among the authors. Inclusion criteria specified unique studies and case reports of NCM patients in which relevant neurosurgical management was considered and/or applied. Exclusion criteria included studies that did not report associated neurological diagnoses and neuroimaging findings, clinical reports without novel observations, and those unavailable in the English language. All articles that met the study inclusion criteria were included and analyzed. RESULTS: A total of 26 extracted articles met inclusion criteria and were used for quantitative analysis, yielding a cumulative of 74 patients with NCM. These included 21 case reports, 1 case series, 2 retrospective cohort studies, 1 prospective cohort study, and 1 review. The mean patient age was 16.66 years (range 0.25-67 years), and most were male (76%). Seizures were the most frequently reported symptom (55%, 41/74 cases). Neurological diagnoses associated with NCM included epilepsy (45%, 33/74 cases), hydrocephalus (24%, 18/74 cases), Dandy-Walker malformation (24%, 18/74 cases), and primary CNS melanocytic tumors (23%, 17/74 cases). The most common surgical technique was CSF shunting (43%, 24/56 operations), with tethered cord release (4%, 2/56 operations) being the least frequently performed. CONCLUSIONS: Current management of NCM includes CSF shunting to reduce intracranial pressure, surgery, chemotherapy, radiotherapy, immunotherapy, and palliative care. Neurosurgical intervention can aid in the diagnosis of NCM through tissue biopsy and resection of lesions with surgical decompression. Further evidence is required to establish the clinical outcomes of this rare entity and to describe the diverse spectrum of intracranial and intraspinal abnormalities present.

Patient and Caregiver Perception of Adenoidectomies: A Non-Real-World Social Media Analysis.

Objective: To survey the social media outlets Twitter and Instagram for public posts related to adenoidectomy surgery. This study aims to investigate the attitudes and perceptions of patients and caregivers on social media, through thematic content-analysis of social media posts regarding adenoidectomy. Study Design: Non-real world qualitative study. Setting: Twitter and Instagram social media platforms. Methods: Public posts uploaded between February, 2021 and February, 2023 using the hashtags "#adenoidectomy," and "#adenoidectomyrecovery" were searched. Posts were excluded if they were unrelated to adenoidectomy or were in a non-English language. Relevant posts were stratified demographically as patient or caregiver and pre- or postoperative, and categorized into relevant themes for analysis. Outcomes were measured as the total number of posts. Results: A total of 394 relevant posts were analyzed. A significance threshold of P < 0.05 was used. Patients posted significantly more posts regarding procedure pain (P = 0.002) and concern for appearance (P = 0.048) compared to caregivers. Caregivers posted significantly (P < 0.001) more posts regarding condition awareness and were significantly (P < 0.001) more likely to spread positivity in their posts compared to patients themselves. Posts made by female caregivers were more likely to reference fear, while those made by male caregivers were more likely to provide education (P = 0.002). Conclusion: Patients may worry about appearance and mental health while caregivers are more likely to spread information and positivity. Male and female caregivers may also use social media differently. A better understanding of patient and caregiver concerns may optimize physician interaction and involvement.

Cerebral Cavernous Malformations Patient Perception Analysis via Social Media.

BACKGROUND: The rise of social media has allowed for individuals and patients to connect with each other and influence patient behavior. This study aimed to improve our understanding of the patients' experience with cerebral cavernous malformations (CCM) via social media. METHODS: Instagram and Twitter were searched using terms of ("cavernoma," "cavernous malformations," "cavernous angioma," or "cav mal"). Public Instagram posts tagged with "#cavernoma" and "@cavernoma" identified 327 posts that directly included a patient's own experience. Twitter posts that included "#cavernoma" and "@cavernoma" were searched, yielding 75 after eliminating those that did not pertain to the patient's own experience. The posts and tweets were coded for relevant themes related to their experience with the disease. RESULTS: Overall, more patients are using Instagram (n = 327) over Twitter (n = 84) to share their personal experience with CCM with a trend for male patients to use Twitter more compared to females with a female predominance in Instagram. A total of 277 of 327 (84.7%) Instagram posts and 67 of 84 (89.3%) Twitter posts were made after the patient's surgery. The most common theme on Instagram was focused on the postoperative rehabilitation process and mobility support (52.0 and 24.5%, respectively). Other common themes present on Twitter and Instagram were recounting symptoms and complications and life satisfaction (26.0 and 24.2%, respectively). Cavernoma patients prior to surgery were more likely to discuss on Instagram their symptoms (p = 0.001), fear of bleeding (p < 0.001), and mental health (p = 0.014). Postoperatively, cavernoma patients were more likely to discuss disability than they were preoperatively (p = 0.001). CONCLUSION: Social media platforms offer a communication tool for patients with CCM patients to share their experience with other patients and the general public and portrays their personal experience with CCM. These platforms allow for physicians to better understand the patient experience following cavernoma surgery.

Management of Atypical Teratoid/Rhabdoid Tumors in the Pediatric Population: A Systematic Review and Meta-Analysis.

BACKGROUND: Atypical teratoid/rhabdoid tumors are rare and aggressive tumors that mainly affect children <3 years of age. Despite aggressive treatment, the overall survival rate for pediatric atypical teratoid/rhabdoid tumors remains poor. Due to their rarity, little is known regarding prognostic factors, and there is no official standard of treatment. METHODS: A comprehensive database search was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Search terms included "atypical teratoid rhabdoid tumor" and "atypical (teratoid OR rhabdoid) tumor." Variables of interest included, but were not limited to, age, sex, tumor location, treatment modality, extent of resection, and overall survival. RESULTS: The study included 294 articles and 936 patients. The median age of patients was 22 months. There was a significant difference in survival among patients receiving surgery compared with patients receiving nonoperative treatment (50.3 months vs. 28 months; P < 0.005). Extent of resection did not significantly improve survival (P = 0.832 for gross total resection, P = 0.650 for partial resection). Combination therapy with surgical resection, radiotherapy, and chemotherapy demonstrated the largest median overall survival (54.9 months) and significantly improved survival on multivariate analysis (hazard ratio, 0.48; 95% confidence interval, 0.23-0.97; P = 0.042). CONCLUSIONS: The results of this study indicate that while surgery is a crucial treatment modality for pediatric atypical teratoid/rhabdoid tumors, the effect of extent of resection is unclear. Multimodal therapy including surgery, radiotherapy, and chemotherapy is effective in improving overall survival. Future studies should focus on using larger datasets to efficiently account for confounding factors and biases.

Art and Neurosurgery: The Importance of Medical Illustration.

Art in neurosurgery has been a critical part of the discipline for centuries. Numerous cultures, such as ancient India, China, and Egypt, and more contemporary scientists, such as Leonardo da Vinci, Max Brödel, and Norman Dott, have significantly contributed to medical illustration. Today, advancements in three-dimensional technology have allowed for the creation of detailed neuroanatomy models for surgical planning and education. Medical illustrations are also used for research and outcome documentation as they help visualize anatomy and surgical procedures. Its use in education, surgical planning, and navigation remains integral to the advancement of neurosurgery. This review demonstrates the invaluable contribution of art in neurosurgery and how it has enabled continuous progress in the field.

Intraoperative Ionizing Radiation Exposure Awareness and Associated Morbidity in Neurosurgery: A Nationwide Survey.

BACKGROUND: Neurosurgeons often use radiation to visualize blood vessels and implants intraoperatively. However, high exposure to radiation increases one's cancer risk. This study aims to investigate intraoperative ionizing radiation exposure awareness and associated morbidity among neurosurgeons. METHODS: An anonymized 30-question survey about their intraoperative radiation exposure, protective measures, radiation knowledge, and any conditions that can arise from protracted radiation exposure was disseminated to 3344 American Association of Neurological Surgeons members. RESULTS: A total of 227 (6.8%) neurosurgeons completed the survey. Most neurosurgeons (61, 27%) performed 2-4 surgeries per week necessitating radiation (61, 27%), did not use a dosimeter (134, 59%), and wore a lead apron (89%) and a thyroid shield (75%). Only 7 (3%) of respondents could correctly identify the safety limit for occupational radiation. One hundred and thirty-four (59%) respondents correctly identified the relationship between distance and radiation dose reduction. Two hundred and thirteen (94%) neurosurgeons reported concern about occupational radiation exposure. No significant association was found between occupational radiation exposure and the rate of cataracts, combined cancer, and skin cancer. Multivariate logistic regression adjusting for age and cancer history found that the likelihood of developing leukemia (P = 0.02) and nonmalignant thyroid nodular disease (P = 0.01) is positively associated with increased total occupational radiation exposure. CONCLUSIONS: There is a need for improved radiation safety awareness among neurosurgeons, especially in the context of rising usage of minimally invasive surgery. This can allow for a greater understanding of radiation-associated risks among neurosurgeons and guide the implementation of safer practices.

Intrasaccular Flow Disruption: Examining Global Access and Research Trends.

The Woven EndoBridge (WEB) and other intrasaccular flow disruptors show promise in treating intracranial aneurysms. We performed a bibliometric analysis to provide novel insights into the trends and trajectory of these devices. We systematically assessed bibliometric data such as citations, journals, study designs, open access status, and multi-institutional involvement for the top-cited articles on WEB and other disruptors. The top 100 cited studies on the WEB had citations from 7 to 144 (mean ± standard deviation 35.6 ± 29.5), while only 33 studies were published for other intrasaccular flow disruptors (4.24 ± 8.45). Of the other devices, the Contour has the most publications (n = 21). Retrospective reviews were the most common study design for both WEB and other intrasaccular devices. France published the most studies in the top 100 WEB papers (n = 35), while Germany led for other flow disruptors (n = 10). In all studies analyzed, no senior authors from Africa are present. The top 100 WEB publications had a higher mean citation count (35.6 vs. 4.24, P<0.001), higher mean citations per year (5.24 vs. 1.03, P<0.01), and a higher proportion of multi-institutional collaborations (44.0% vs. 12.1%, P<0.01) than other intrasaccular flow disruptors. In conclusion, countries with the most publications on WEB are not necessarily the ones leading the way with newer intrasaccular devices, while study designs remain similar. There is a limited contribution to the literature outside of Europe and North America. Our findings identify notable collaborators and trends, providing a snapshot of the field and a roadmap for future research.

Readability of cerebrovascular diseases online educational material from major cerebrovascular organizations.

INTRODUCTION: The internet is an essential resource for patients and their loved ones to understand their medical conditions, and professional medical organizations have taken great strides to develop educational material targeting patients. The average American reads at a seventh to eighth grade reading level, hence it is important to understand the readability of this medical information to ensure patients comprehend what is being presented. METHODS: In January 2023, online patient education material was downloaded from major cerebrovascular healthcare organizations and assessed using eight assessments, including Bormuth Cloze Mean, Bormuth Grade Placement, Coleman-Liau (grade levels), Coleman-Liau (predictive cloze scores), Flesch Reading Ease (FRE), and Fry. RESULTS: A total of 32 files were extracted from six organizations and analyzed across 15 readability measures. None of the organizations met the federal government guidelines for grade-level readability. This held constant across all measured tests. Two organizations had above a postgraduate level. The FRE graphs do not identify any organizations with material below a ninth grade reading level, while the American Association of Neurological Surgeons (AANS) and the Society of Interventional Radiology (SIR) have a postgraduate readability level. The Fry graphs show similar results, with AANS/CNS Cerebrovascular Section, Society of NeuroInterventional Surgery (SNIS), SIR, and AANS having college-level readability. The lowest readability across all measures is only at an early seventh grade reading level. CONCLUSIONS: Current health literacy content for cerebrovascular patients is far above the recommended readability level. We provide straightforward suggestions for how major professional organizations should improve their informational material on cerebrovascular diseases to improve patient understanding.

Utilization and reimbursement of diagnostic cerebral angiograms: A Medicare trends analysis from 2013 to 2020.

INTRODUCTION: Increasing life expectancy has caused growing concern about maintaining viable neurointerventional practices due to altered Medicare payment structures. This study analyzes the financial trends of three common diagnostic tests for cerebrovascular disease: cerebral digital subtraction angiography (DSA), computed tomography angiography (CTA), and magnetic resonance angiography (MRA). METHODS: Medicare Part B National Summary Data files from 2013 to 2020 were queried by Current Procedural Terminology (CPT) codes for DSA (36221-36228), CTA (70496, 70498), and MRA (70544-70547, 70549). Inflation-adjusted charges and reimbursement were calculated using the U.S. City Average Consumer Price Index for Medical Services. Regression analysis was performed on charges, reimbursement, and volume. RESULTS: A total of 1,519,245 diagnostic procedures were conducted between 2013 and 2020 (782,370 angiograms, 246,603 CTAs, and 490,272 MRAs). A total of $41.005 million was reimbursed by Medicare in 2020 for these diagnostic procedures. The annual percent change in volume for all procedures was -2.90%. From 2013 to 2020, inflation-adjusted: Medicare total physician reimbursement decreased for cerebral angiograms (-4.12%, p = 0.007), CTAs (-2.77%, p = 0.458), and MRAs (-9.06%, p < 0.001). Procedural volume billed to Medicare decreased for cerebral angiograms (-4.63%, p = 0.007) and MRAs (-2.94%, p = 0.0.81) and increased for CTAs (+3.15%, p = 0.004). The greatest increase in Medicare reimbursement (+66.75%) came from CPT code 36224, "place catheter carotid artery", and the greatest decrease in Medicare reimbursement (-8.66%) came from CPT code 36226, "place catheter vertebral artery." CONCLUSIONS: This study provides an analysis of Medicare reimbursement trends for routine cerebrovascular angiogram techniques. The findings highlight a decline in Medicare reimbursements for neurointerventionalists.

Usefulness and Accuracy of Artificial Intelligence Chatbot Responses to Patient Questions for Neurosurgical Procedures.

BACKGROUND AND OBJECTIVES: The Internet has become a primary source of health information, leading patients to seek answers online before consulting health care providers. This study aims to evaluate the implementation of Chat Generative Pre-Trained Transformer (ChatGPT) in neurosurgery by assessing the accuracy and helpfulness of artificial intelligence (AI)-generated responses to common postsurgical questions. METHODS: A list of 60 commonly asked questions regarding neurosurgical procedures was developed. ChatGPT-3.0, ChatGPT-3.5, and ChatGPT-4.0 responses to these questions were recorded and graded by numerous practitioners for accuracy and helpfulness. The understandability and actionability of the answers were assessed using the Patient Education Materials Assessment Tool. Readability analysis was conducted using established scales. RESULTS: A total of 1080 responses were evaluated, equally divided among ChatGPT-3.0, 3.5, and 4.0, each contributing 360 responses. The mean helpfulness score across the 3 subsections was 3.511 ± 0.647 while the accuracy score was 4.165 ± 0.567. The Patient Education Materials Assessment Tool analysis revealed that the AI-generated responses had higher actionability scores than understandability. This indicates that the answers provided practical guidance and recommendations that patients could apply effectively. On the other hand, the mean Flesch Reading Ease score was 33.5, suggesting that the readability level of the responses was relatively complex. The Raygor Readability Estimate scores ranged within the graduate level, with an average score of the 15th grade. CONCLUSION: The artificial intelligence chatbot's responses, although factually accurate, were not rated highly beneficial, with only marginal differences in perceived helpfulness and accuracy between ChatGPT-3.0 and ChatGPT-3.5 versions. Despite this, the responses from ChatGPT-4.0 showed a notable improvement in understandability, indicating enhanced readability over earlier versions.

Evidence Against a Traumatic Brain Injury "July Effect": An Analysis of 3 160 452 Patients From the National Inpatient Sample.

BACKGROUND AND OBJECTIVES: The "July Effect" hypothesizes increased morbidity and mortality after the addition of inexperienced physicians at the beginning of an academic year. However, the impact of newer members on neurosurgical teams managing patients with traumatic brain injury (TBI) has yet to be examined. This study conducted a nationwide analysis to evaluate the existence of the "July Effect" in the setting of patients with TBI. METHODS: The Healthcare Cost and Utilization Project Central Distributor's National Inpatient Sample data set was queried for patients with TBI using International Classification of Diseases (ICD)-9 and ICD-10 codes. Discharges were included for diagnoses of traumatic epidural, subdural, or subarachnoid hemorrhages. Only patients treated at teaching hospitals were included to ensure resident involvement in care. Patients were grouped into July admission and non-July admission cohorts. A subgroup of patients with neurotrauma undergoing any form of cranial surgery was created. Perioperative variables were recorded. Rates of different complications were assayed. Groups were compared using χ2 tests (qualitative variables) and t-tests or Mann-Whitney U-tests (quantitative variables). Logistic regression was used for binary variables. Gamma log-linked regression was used for continuous variables. RESULTS: The National Inpatient Sample database yielded a weighted average of 3 160 452 patients, of which 312 863 (9.9%) underwent surgical management. Patients admitted to the hospital in July had a 5% decreased likelihood of death (P = .027), and a 5.83% decreased likelihood of developing a complication (P < .001) compared with other months of the year. July admittance to a hospital showed no significant impact on mean length of stay (P = .392) or routine discharge (P = .147). Among patients with TBI who received surgical intervention, July admittance did not significantly affect the likelihood of death (P = .053), developing a complication (P = .477), routine discharge (P = .986), or mean length of stay (P = .385). CONCLUSION: The findings suggested that there is no "July Effect" on patients with TBI treated at teaching hospitals in the United States.

Femoral versus radial access for middle meningeal artery embolization for chronic subdural hematomas: multicenter propensity score matched study.

BACKGROUND: With transradial access (TRA) being more progressively used in neuroendovascular procedures, we compared TRA with transfemoral access (TFA) in middle meningeal artery embolization (MMAE) for chronic subdural hematoma (cSDH). METHODS: Consecutive patients undergoing MMAE for cSDH at 14 North American centers (2018-23) were included. TRA and TFA groups were compared using propensity score matching (PSM) controlling for: age, sex, concurrent surgery, previous surgery, hematoma thickness and side, midline shift, and pretreatment antithrombotics. The primary outcome was access site and overall complications, and procedure duration; secondary endpoints were surgical rescue, radiographic improvement, and technical success and length of stay. RESULTS: 872 patients (median age 73 years, 72.9% men) underwent 1070 MMAE procedures (54% TFA vs 46% TRA). Access site hematoma occurred in three TFA cases (0.5%; none required operative intervention) versus 0% in TRA (P=0.23), and radial-to-femoral conversion occurred in 1% of TRA cases. TRA was more used in right sided cSDH (58.4% vs 44.8%; P<0.001). Particle embolics were significantly higher in TFA while Onyx was higher in TRA (P<0.001). Following PSM, 150 matched pairs were generated. Particles were more utilized in the TFA group (53% vs 29.7%) and Onyx was more utilized in the TRA group (56.1% vs 31.5%) (P=0.001). Procedural duration was longer in the TRA group (median 68.5 min (IQR 43.1-95) vs 59 (42-84); P=0.038), and radiographic success was higher in the TFA group (87.3% vs 77.4%; P=0.036). No differences were noted in surgical rescue (8.4% vs 10.1%, P=0.35) or technical failures (2.4% vs 2%; P=0.67) between TFA and TRA. Sensitivity analysis in the standalone MMAE retained all associations but differences in procedural duration. CONCLUSIONS: In this study, TRA offered comparable outcomes to TFA in MMAE for cSDH in terms of access related and overall complications, technical feasibility, and functional outcomes. Procedural duration was slightly longer in the TRA group, and radiographic success was higher in the TFA group, with no differences in surgical rescue rates.

Cross-Sectional Analysis of Neurosurgical Residency Websites During the Virtual Interview Cycle.

BACKGROUND: The loss of in-person interviews during the COVID-19 pandemic warrants an investigation into what information is provided to applicants through neurosurgery residency program websites (NRPWs). This study examines NRPWs across the United States and Canada to determine what details are provided to applicants through their respective websites. METHODS: Accreditation Council for Graduate Medical Education accredited neurologic surgery residency programs were identified through the American Association of Neurological Surgeons (AANS) website. NRPWs were searched for 48 criteria, including program overview, application requirements, and curriculum information. Small programs were defined as 1-2 residents per class, while large programs were classified as those with 3-4 residents per year. Content differences were analyzed between the top 20 and remaining programs per the Doximity Residency Navigator Rankings. RESULTS: The most prevalent information among 122 NRPWs was the neurosurgery residency overview (95%), names of faculty members (95%), and names of current residents (94%). Top-20 NRPWs were more likely to include post PGY-7 fellowships (90% vs. 61% P = 0.0108), operating room virtual reality experience (35% vs. 12% P = 0.0160), and faculty research (90% vs. 62% P = 0.0182) than the remainder of the programs. CONCLUSIONS: This study investigates NRPW content after the COVID-19 pandemic. We report broad variability in content provided by various neurosurgical training programs. Higher-ranked neurosurgery programs are more likely to include fellowship information, operating room virtual reality experience, and faculty research than lower-ranked programs.

Comparison of pipeline embolization device, flow re-direction endoluminal device and surpass flow diverters in the treatment of intracerebral aneurysms.

OBJECTIVES: The use of flow diversion for the treatment of intracranial aneurysms has gained broad acceptance. Three flow-diverting stents are approved by the Food and Drug Administration for use in the United States. We sought to compare the outcomes and safety profiles between the three devices at our institution. METHODS: A retrospective review of aneurysms treated with pipeline embolization device (PED), flow re-direction endoluminal device (FRED), and SURPASS was performed for aneurysms treated between 2018 and 2022 at our institution. RESULTS: The study cohort consisted of 142 patients. Precisely, 86 aneurysms were treated with a pipeline, 33 aneurysms were treated with FRED, and 23 aneurysms were treated with SURPASS. The 1-year complete occlusion rates were 59.4%, 60%, and 65%, respectively (0.91). Linear regression models found that only adjunctive coiling predicted aneurysm occlusion at 6 months (p = 0.02), but this effect was lost at 1 year and beyond. There was no significant difference in acute thrombotic or acute hemorrhagic complications between the three cohorts. There was a higher rate of delayed hemorrhagic complications in the SURPASS cohort (10%) compared to the PED (1.3%) and FRED (0%) cohorts (p = 0.04). There was also a higher rate of in-stent stenosis in the SURPASS cohort (20%) compared to the PED (5%) and FRED (3.1%) cohorts (p < 0.01). CONCLUSIONS: Treatment with PED, FRED, and SURPASS all resulted in similar complete occlusion rates at 6 months and 1 year. SURPASS was associated with higher in-stent stenosis as well as delayed hemorrhagic complications. Additional future studies evaluating the newest generation of flow-diverting stents with long-term follow-up will be necessary to make any definitive conclusions.

Incidence of mechanical thrombectomy among stroke patients brought directly to a comprehensive stroke center versus transfer from a primary stroke center in upstate New York.

BACKGROUND: Faster time to treatment for stroke is associated with improved outcomes. In cases of large vessel occlusion (LVO), standard of care treatment with thrombectomy can only be provided at a comprehensive stroke center (CSC). We examine the outcomes of patients who are directly brought to our center, a CSC, compared to those seen at a primary stroke center (PSC) and then transferred. METHODS: Patients with LVO presenting to our center from 1/1/2019 to 12/31/2019 were included. Cohorts of patients presenting first to a PSC and presenting first to a CSC were compared. Demographics and outcome metrics (Discharge Modified Rankin Scale (mRS) and National Institute of Health Stroke Severity Scale (NIHSS) scores) were obtained for all LVO patients. Imaging was also assessed. RESULTS: Of 864 stroke admissions, 346 had LVO (40%) with 183 (53%) transferring from a PSC and 163 (47%) presenting directly. Similar percentages of each cohort were taken for thrombectomy (25.1% transfer and 31.3% direct). However, as distance between PSC and CSC increased, likelihood of thrombectomy decreased. Transfer patients were more likely to be excluded from thrombectomy secondary to a large volume of complete stroke (p = 0.0001). Direct presenters had lower discharge mRS scores than transfer patients (p < 0.01), however, severity of stroke upon admission was similar in the two groups. CONCLUSION: Patients transferred from a PSC were more likely to have a worse outcome at time of discharge than those presenting directly to our center. Large volume of completed stroke was a frequent reason for exclusion from thrombectomy. Optimizing stroke protocols to CSC in cases of LVOs may result in better outcomes.

What matters most to cerebral aneurysms patients: A digital analysis of 1127 social media posts.

INTRODUCTION: Social media serves as a way for patients to post about their condition online, as well as for healthcare providers to disseminate information. Intrinsic bias exists exist when patients are given surveys by physicians or healthcare providers. We aim to investigate patient-centered social media posts regarding cerebral aneurysms on Instagram, Twitter, and TikTok. METHODS: Posts that included "brain aneurysm", "#brainaneurysm", "#brainaneurysmsurvivor", and "#aneurysmsurvivor" were queried on Instagram, Twitter, and TikTok. Any posts unrelated to the patient experience were excluded. Five hundred and fourteen Instagram posts, fourty tweets, and five hundred seventy three TikTok posts about the patient experience were identified. Posts were coded for the relevant themes related to their experience with the disease. RESULTS: Most posts made online were by women (892, 82.1%). Patients made the post most of the time (776, 67.5%), while other individuals posted less often (420, 36.5%). The most common themes on Instagram were survival (475, 87.3%), spreading positivity (385, 70.77%), and recovery/rehabilitation (329, 60.5%). TikTok users most often referred to survival (573, 97.1%), raising awareness (464. 78.6%), and spreading positivity (414, 70.2%). Patients were more likely to discuss pre-operative pain (p = 0.0382), postoperative pain (p < 0.0001), invisible illness (p = 0.0130), humor (p = 0.0028), recovery (p < 0.0001), angiograms (p < 0.0001), and resiliency (p < 0.0001) when compared to other individuals posting about a patients' experience. CONCLUSION: Patients often focus on different aspects of their care than do other individuals. This may be useful for physicians discussing treatment plans and prognoses with the patient and their families.

Intraoperative angiography via popliteal artery access for spinal neurovascular lesions: an institutional experience and systematic review.

BACKGROUND: Intraoperative DSA is used to confirm complete obliteration of neurovascular pathologies. For spinal neurovascular lesions, femoral access can be challenging given the need to flip the patient after sheath placement. Similarly, radial access can be complicated by arch navigation difficulties. Vascular access via the popliteal artery represents an appealing alternative option; however, data regarding its utility and efficacy in these cases are limited. METHODS: A retrospective series of four consecutive patients between July 2016 and August 2022 who underwent intraoperative spinal DSA via the popliteal artery was analyzed. Additionally, a systematic review was conducted to collect previously reported such cases. Collective patient demographics and operative details are presented to consolidate the available evidence supporting popliteal access. RESULTS: Four patients met the inclusion criteria from our institution. The systematic review yielded six previously published studies reporting 16 additional transpopliteal access cases. Of the 20 total cases (mean±SD age 60.8±17.2 years), 60% were men. Most treated lesions were dural arteriovenous fistulas (80%) located in the thoracic spine (55%) or cervical spine (25%). The left popliteal artery was most accessed and the highest visualized level was the craniocervical junction. All outcomes were either stable or improving after surgery, and no complications were observed. CONCLUSIONS: We report the safety and feasibility of transpopliteal access for intraoperative DSA in the prone position in four cases in addition to 16 previously reported cases in the literature. Our case series highlights popliteal artery access as an alternative to transfemoral or transradial access in this setting.

Surgical Outcomes of Awake Craniotomy for Treatment of Arteriovenous Malformations in Eloquent Cortex: A Systematic Review.

OBJECTIVE: Arteriovenous malformations (AVMs) located in eloquent brain regions are historically associated with a poor prognosis. Awake craniotomy (AC) with the adjunct of brain mapping has the potential of identifying non-eloquent gyri to maximize resection, thereby theoretically decreasing the risk of neurologic deficits. With limited evidence regarding the efficacy of AC in treatment of eloquent AVMs, this review aims to investigate its surgical outcomes. METHODS: A systematic search in the PubMed database was performed to identify all relevant studies up to February 2022. RESULTS: A total of 13 studies were extracted for quantitative analysis, yielding a total of 46 patients. The mean age was 34.1 years, and most patients were female (54.8%). Seizures were the most frequently reported presenting symptom (41%, 19 of 46 cases). Spetzler-Martin Grade III was the most prevalent (45.9%, 17 cases) with a mean nidus size of 32.6 mm. Seventy-four percent of AVMs were located on the left side, with the frontal lobe being the most common location (30%, 14 of 46 cases). The most common eloquent regions were language (47.8%, 22 of 46 cases), motor (17.4%, 8 of 46 cases), and language + motor cortices (13.1%, 6 of 46 cases). Complete resection of AVM was achieved in 41 patients (89%). Intraoperative complications occurred in 14 of 46 cases (30.4%) with transient postoperative neurologic deficits in 14 patients (30.4%). CONCLUSIONS: AC may enable precise microsurgical excision of eloquent AVMs with preservation of critical brain functions. Risk factors for poor outcomes include eloquent AVMs located in the language + motor regions and the occurrence of intraoperative complications such as seizures/hemorrhage.