Reducing implicit bias in the neurosurgery application and interview process: a single-institution experience.

OBJECTIVE: The neurosurgical match is a challenging process for applicants and programs alike. Programs must narrow a wide field of applicants to interview and then determine how to rank them after limited interaction. To streamline this, programs commonly screen applicants using United States Medical Licensing Examination (USMLE) Step scores. However, this approach removes nuance from a consequential decision and exacerbates existing biases. The primary objective of this study was to demonstrate the feasibility of effecting minor modifications to the residency application process, as the authors have done at their institution, specifically by reducing the prominence of USMLE board scores and Alpha Omega Alpha (AΩA) status, both of which have been identified as bearing racial biases. METHODS: At the authors' institution, residents and attendings holistically reviewed applications with intentional redundancy so that every file was reviewed by two individuals. Reviewers were blinded to applicants' photographs and test scores. On interview day, the applicant was evaluated for their strength in three domains: knowledge, commitment to neurosurgery, and integrity. For rank discussions, applicants were reviewed in the order of their domain scores, and USMLE scores were unblinded. A regression analysis of the authors' rank list was made by regressing the rank list by AΩA status, Step 1 score, Step 2 score, subinternship, and total interview score. RESULTS: No variables had a significant effect on the rank list except total interview score, for which a single-point increase corresponded to a 15-position increase in rank list when holding all other variables constant (p < 0.05). CONCLUSIONS: The goal of this holistic review and domain-based interview process is to mitigate bias by shifting the focus to selected core qualities in lieu of traditional metrics. Since implementation, the authors' final rank lists have closely reflected the total interview score but were not significantly affected by board scores or AΩA status. This system allows for the removal of known sources of bias early in the process, with the aim of reducing potential downstream effects and ultimately promoting a final list that is more reflective of stated values.

Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for the Treatment of Nonlesional Insular Epilepsy in Pediatric Patients: Technical Considerations.

INTRODUCTION: The insula presents anatomic challenges to surgical exploration and intervention. Open neurosurgical intervention is associated with high rates of complications despite improved seizure control. Minimally invasive techniques using novel energy delivery methods have gained popularity due to their relative safety and ability to overcome access-related barriers. The goal of this paper is to present an operative technical report and methodological considerations on the application of magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) for the treatment of nonlesional, medically refractory, insular epilepsy in pediatric patients. METHODS: Visualase laser probe(s) were implanted using ROSA robotic stereotactic guidance into the insula using a parasagittal trajectory. After confirmation of placement using intraoperative MRI, thermal energy was delivered under real-time MR guidance. Laser wire pullback was performed when the initial dose of thermal energy was insufficient to ablate the target in its entirety. Thermal ablation within the intended target was confirmed using gadolinium-enhanced brain MRI. Following removal of laser wires, a final T1-weighted axial brain MRI was performed to confirm no evidence of hemorrhage. RESULTS: Three patients underwent MRgLITT of nonlesional insular epilepsy over an 11-month period. The epileptogenic focus was localized to the insula using stereoelectroencephalography. The anterior and middle portions of the insula were accessed using a parasagittal trajectory. Laser ablation was performed for up to 3 min using an output of 10.5 W. No complications were encountered, and all patients were discharged within 24 h after the surgery. At the most recent follow-up, all patients had an Engel I outcome without any new neurologic deficits. CONCLUSION: This small cohort shows that insular ablation can be achieved safely with promising seizure outcomes in the short term.

Early outcomes of stereoelectroencephalography followed by MR-guided laser interstitial thermal therapy: a paradigm for minimally invasive epilepsy surgery.

OBJECTIVE Stereoelectroencephalography (sEEG) and MR-guided laser interstitial thermal therapy (MRgLITT) have both emerged as minimally invasive alternatives to open surgery for the localization and treatment of medically refractory lesional epilepsy. Although some data are available about the use of these procedures individually, reports are almost nonexistent on their use in conjunction. The authors' aim was to report early outcomes regarding efficacy and safety of sEEG followed by MRgLITT for localization and ablation of seizure foci in the pediatric population with medically refractory lesional epilepsy. METHODS A single-center retrospective review of pediatric patients who underwent sEEG followed by MRgLITT procedures was performed. Demographic, intraoperative, and outcome data were compiled and analyzed. RESULTS Four pediatric patients with 9 total lesions underwent sEEG followed by MRgLITT procedures between January and September 2017. The mean age at surgery was 10.75 (range 2-21) years. Two patients had tuberous sclerosis and 2 had focal cortical dysplasia. Methods of stereotaxy consisted of BrainLab VarioGuide and ROSA robotic guidance, with successful localization of seizure foci in all cases. The sEEG procedure length averaged 153 (range 67-235) minutes, with a mean of 6 (range 4-8) electrodes and 56 (range 18-84) contacts per patient. The MRgLITT procedure length averaged 223 (range 179-252) minutes. The mean duration of monitoring was 6 (range 4-8) days, and the mean total hospital stay was 8 (range 5-11) days. Over a mean follow-up duration of 9.3 (range 5.1-16) months, 3 patients were seizure free (Engel class I, 75%), and 1 patient saw significant improvement in seizure frequency (Engel class II, 25%). There were no complications. CONCLUSIONS These early data demonstrate that sEEG followed by MRgLITT can be used safely and effectively to localize and ablate epileptogenic foci in a minimally invasive paradigm for treatment of medically refractory lesional epilepsy in pediatric populations. Continued collection of data with extended follow-up is needed.