Outcomes of Mechanical Thrombectomy for Ischemic Stroke in Nonagenarians: A 10-Year Institutional Experience.

BACKGROUND: Nonagenarians have been underrepresented in stroke trials that established endovascular treatment as the standard for acute ischemic stroke (AIS). Evidence remains inconclusive regarding the efficacy of thrombectomy in this population. OBJECTIVES: To report our experience with thrombectomy in nonagenarians with stroke, and to identify predictors of mortality. We further investigated the effects of first-pass reperfusion and the addition of intravenous thrombolysis (IVT) on achieving better outcomes. MATERIALS AND METHODS: Data was collected for consecutively treated patients at three affiliated comprehensive stroke centers from 2010 to 2021. We included patients ≥90 years-old with AIS secondary to large vessel occlusion. Bivariate analyses were performed using the Mann-Whitney U test for continuous variables, and χ2 and Fisher's exact tests, respectively, for nominal and ordinal variables. RESULTS: Thirty-two nonagenarians underwent thrombectomy, of whom 25 (81%) had prestroke mRS ≤2. Thrombectomies were performed using stents (2, 6.7%), aspiration (8, 26.7%), or a combination of both (20, 66.7%). Successful recanalization was achieved in 97%. Procedural complications occurred in 2 (6.3%) and intracranial hemorrhage in 3 (9.4%). Sixteen patients (50%) were discharged home or to rehabilitation, 9 (28.2%) to nursing home or hospice, and 7 (21.9%) died during hospitalization. Only 2 (6%) patients had mRS ≤2 at discharge. No independent predictors of in-hospital mortality were identified, and neither first-pass reperfusion nor the addition of IVT correlated with improvement in clinical outcome. CONCLUSIONS: Although thrombectomy is safe for nonagenarian stroke and can achieve excellent recanalization, high mortality and poor functional status remain high given the advanced age and frailty of this population.

Epidemiological Review of Spinal Cord Injury due to Road Traffic Accidents in Latin America.

Spinal cord injury (SCI) is a disease that affects the normal function of the spinal cord. Road traffic accidents (RTAs) represent the main cause of SCI worldwide. SCI may generate physical disability and economic dependency, which is especially significant in low- and middle-income countries such as most of the Latin American countries. The main objective of this study was to present an epidemiological review of SCI secondary to RTAs. Stronger evidence on this condition in Latin America is important for future-specific data collection and prevention strategies. A literature review was carried out using specific search strategies in databases of indexed journals from the period 2000 to 2019. Data on SCI secondary to RTAs in the Latin American region were collected and analyzed. After initial screening and removal of duplicates, 16 articles met the inclusion criteria and were chosen for analysis. Data from 7 Latin American countries were retrievable. On average, RTAs were responsible for 40.81% of SCI. Data from different studies are heterogeneous. Car accidents and moto accidents were equally responsible for SCIs (50.61% vs. 49.06%). The thoracic segments were the most commonly affected (57.87%). Males in their 30s were the most affected category (76.6%). SCI due to RTAs may represent a severe but preventable condition that affects mostly men in their productive age, generating important social and economic issues. Data about this condition in Latin America are scarce, and could limit prevention and treatment strategies. Prospective data collection about this condition is recommended.

Leptomeningeal disease in glioblastoma: endgame or opportunity?

INTRODUCTION: Glioblastoma is an aggressive cancer with a notoriously poor prognosis. Recent advances in treatment have increased overall survival, though this may be accompanied by an increased incidence of leptomeningeal disease (LMD). LMD carries a particularly severe prognosis and remains a late stage manifestation of glioblastoma without satisfactory treatment. The objective of this review is to survey the literature on treatment of LMD in glioblastoma and to more fully characterize the current therapeutic strategies. METHODS: The authors performed a systematic review following PRISMA criteria on PubMed and OVID databases. Articles that included adult patients with LMD from glioblastoma were retrieved and reviewed. RESULTS: LMD in glioblastoma patients is increasing in incidence, with reports of up to 21%. The overall survival without treatment is alarmingly brief, with patients surviving between 1.6-3.8 months. All studies showed that treatment does improve overall survival significantly, increasing to 11.7 months in one study. However, no one adjuvant or surgical therapy has been shown to improve survival in LMD significantly over another. Direct treatment methods include chemotherapy (standard, anti-angiogenic, intrathecal, immunotherapy), and radiation. Hydrocephalus is a complication in LMD that can be treated with ventriculoperitoneal shunt placement, however treating hydrocephalus and delivering intrathecal chemotherapy is a challenge. CONCLUSION: Though evidence remains lacking and there is no consensus, treatments show a trend towards improving survival and should be considered on a case-by-case basis. Further studies are necessary in the pursuit of a standard of care.

Is It Possible to Save the Deep Brain Stimulation Hardware when Presenting with Wound Dehiscence or Hardware Infection?

INTRODUCTION: Deep brain stimulation (DBS) hardware complications have been traditionally managed by removal of the entire system. Explantation of the system results in prolonged interruption to the patient's care and potential challenges when considering reimplantation of the cranial leads. The purpose of this study was to understand whether complete explantation can be avoided for patients initially presenting with wound dehiscence and/or infection of hardware. METHODS: We performed a retrospective study that included 30 cases of wound dehiscence or infection involving the DBS system. Patients underwent reoperation without explantation of the DBS system, with partial explanation, or with complete explantation as initial management of the complication. RESULTS: A total of 17/30 cases were managed with hardware-sparing wound revisions. The majority presented with wound dehiscence (94%), with the scalp (n = 9) as the most common location. This was successful in 76.5% of patients (n = 13). Over 11/30 patients were managed with partial explantation. The complication was located at the generator (91%) or at the scalp (9%). Partial explantation was successful in 64% of patients (n = 7). In cases that underwent a lead-sparing approach, 33% of patients ultimately required removal of the intracranial lead, and 2/30 cases of hardware infection were managed initially with total explantation. DISCUSSION/CONCLUSION: Wound dehiscence can be successfully managed without complete removal of the DBS system in most cases. In cases of infection, removing the involved component(s) and sparing the intracranial leads may be considered. Wound revision without removal of the entire DBS system is safe and can improve quality of life by preventing or shortening the withdrawal of DBS treatment.

Biographies of international women leaders in neurosurgery.

We received so many biographies of women neurosurgery leaders for this issue that only a selection could be condensed here. In all of them, the essence of a leader shines through. Many are included as "first" of their country or color or other achievement. All of them are included as outstanding-in clinical, academic, and organized neurosurgery. Two defining features are tenacity and service. When faced with shocking discrimination, or numbing indifference, they ignored it or fought valiantly. When choosing their life's work, they chose service, often of the most neglected-those with pain, trauma, and disability. These women inspire and point the way to a time when the term "women leaders" as an exception is unnecessary.-Katharine J. Drummond, MD, on behalf of this month's topic editors.

Alcohol Availability, Cost, Age of First Drink, and Its Association with At-Risk Alcohol Use in Moshi, Tanzania.

BACKGROUND: The Kilimanjaro region has one of the highest levels of reported alcohol intake per capita in Tanzania. Age at first drink has been found to be associated with alcohol problems in adulthood, but there is less information on the age of first drink in the Kilimanjaro region and its associations with alcohol-related consequences later in life. Furthermore, local alcohol cost and availability may influence the prevalence of alcohol use and alcohol use disorders. METHODS: Data on the age of first drink, alcohol use disorder identification tool (AUDIT), number and type of alcohol consequences (DrInC), and perceived alcohol at low cost and high availability for children and adolescents were collected from an alcohol and health behavior survey of injury patients (N = 242) in Moshi, Tanzania. Generalized linear models were used to test age at first drink, perceived alcohol cost and availability, and their association with the AUDIT and DrInC scores, and current alcohol use, respectively. RESULTS: Consuming alcohol before age 18 was significantly associated with higher AUDIT and DrInC scores, with odds ratios of 1.22 (CI: 1.004, 1.47) and 1.72 (CI: 1.11, 2.63), respectively. Female gender is strongly associated with less alcohol use and alcohol consequences, represented by an odds ratio of 3.70 (CI: 1.72, 8.33) for an AUDIT score above 8 and an odds ratio of 3.84 (CI: 2.13, 6.67) with the DrInC score. Perceived high availability of alcohol for children is significantly related to higher alcohol use quantity, with the odds ratio of 1.6 (CI: 1.17, 2.20). CONCLUSIONS: The first use of alcohol before the age of 18 is associated with higher alcohol use and alcohol-related adverse consequences. In Tanzania, age at first drink is an important target for interventions aiming to prevent negative alcohol-related consequences later in life.

Magnetic resonance-guided laser interstitial thermal therapy for brain tumors in geriatric patients.

OBJECTIVE: There is a paucity of studies assessing the use of MR-guided laser interstitial thermal therapy (LITT), specifically in the elderly population. The aim of this study was to evaluate the safety of LITT for brain tumors in geriatric patients. METHODS: Geriatric patients (≥ 65 years of age) treated with LITT for intracranial tumors at a single institution between January 2011 and November 2019 were retrospectively identified. The authors grouped patients into two distinct age cohorts: 65-74 years (group 1) and 75 years or older (group 2). Baseline characteristics, operative parameters, postoperative course, and morbidity were recorded for each patient. RESULTS: Fifty-five geriatric patients underwent 64 distinct LITT procedures for brain tumors. The majority of lesions (40 [62.5%]) treated were recurrent brain metastases or radiation necrosis. The median modified frailty index was 0.1 (low frailty; range 0-0.4) for patients in group 1 and 0.2 (intermediate frailty; range 0-0.4) for patients in group 2 (p > 0.05). The median hospital length of stay (LOS) was 1 day (IQR 1-2 days); there was no significant difference in LOS between the age groups. The hospital stay was significantly longer in patients who presented with a neurological symptom and in those who experienced a postoperative complication. The majority of patients (43 [68.3%] of 63 cases) were fit for discharge to their preoperative accommodation following LITT. The rate of discharge to home was not significantly different between the age groups. Those discharged to rehabilitation facilities were more likely to have presented with a neurological symptom. Nine patients (14.1% of cases) were found to have acute neurological complications following LITT, with nearly all patients showing complete or partial recovery at follow-up. The 30-day postoperative mortality rate was 1.6% (1 case). The complication and 30-day postoperative mortality rates were not significantly different between the two age groups. CONCLUSIONS: LITT can be considered a minimally invasive and safe neurosurgical procedure for the treatment of intracranial tumors in geriatric patients. Careful preoperative preparation and postoperative care is essential as LITT is not without risk. Appropriate patient selection for cranial surgery is essential, because neurosurgeons are treating an increasing number of elderly patients, but advanced age alone should not exclude patients from LITT without considering frailty and comorbidities.

Functional outcomes in MRI-guided laser interstitial therapy for temporal lobe epilepsy: a systematic review and meta-analysis.

OBJECTIVE: The use of MRI-guided laser interstitial thermal therapy (MRgLITT) has emerged as a promising treatment option for patients with drug-resistant temporal lobe epilepsy (TLE). Although the minimally invasive approach holds promise as an effective treatment for achieving seizure freedom, a comprehensive review of its impact on functional outcomes is still warranted. To address this need, this review aims to summarize data pertaining to the functional and neurocognitive outcomes following MRgLITT for TLE. METHODS: Four primary electronic databases were screened following PRISMA guidelines by two independent reviewers. All functional data related to cognitive, behavioral, and emotional outcomes were gathered and analyzed as well as the neuropsychological tests issued to assess pre- and postoperative outcomes. The functional outcomes assessed were grouped into the 5 most common categories: verbal cognition, visual cognition, cognitive emotion, visual deficits, and other higher-order cognitive functioning. RESULTS: A total of 4184 studies were screened and ultimately 408 patients from 14 studies were included for analysis. Changes in functional areas were assessed by comparing pre- and postoperative scores across a comprehensive set of 31 different functional and cognitive assessments, and were tabulated as the percentage of patients whose status improved, declined, or was maintained, where possible. In verbal (n = 112) and visual (n = 42) cognition, the rates of patients experiencing a decline were 20.4% and 13.5%, respectively, and the rates of improvement were 24.9% and 16.7%, respectively. Other functional outcomes assessed, including cognitive emotion (n = 150), visual deficits (n = 325), and higher-order cognitive processes like attention/processing (n = 19), motor cognition (n = 18), and general executive function (n = 4), exhibited varying rates of decline, ranging from 10.5% to 25%. CONCLUSIONS: MRgLITT is an effective and minimally invasive surgical alternative treatment for TLE, but there is an observable impact on patient functioning and cognitive status. This review demonstrates the need for standardized methods that can accurately capture and quantify the associated risk of MRgLITT to optimize its effect on patient quality of life moving forward.

GPT-4 as a Source of Patient Information for Anterior Cervical Discectomy and Fusion: A Comparative Analysis Against Google Web Search.

STUDY DESIGN: Comparative study. OBJECTIVES: This study aims to compare Google and GPT-4 in terms of (1) question types, (2) response readability, (3) source quality, and (4) numerical response accuracy for the top 10 most frequently asked questions (FAQs) about anterior cervical discectomy and fusion (ACDF). METHODS: "Anterior cervical discectomy and fusion" was searched on Google and GPT-4 on December 18, 2023. Top 10 FAQs were classified according to the Rothwell system. Source quality was evaluated using JAMA benchmark criteria and readability was assessed using Flesch Reading Ease and Flesch-Kincaid grade level. Differences in JAMA scores, Flesch-Kincaid grade level, Flesch Reading Ease, and word count between platforms were analyzed using Student's t-tests. Statistical significance was set at the .05 level. RESULTS: Frequently asked questions from Google were varied, while GPT-4 focused on technical details and indications/management. GPT-4 showed a higher Flesch-Kincaid grade level (12.96 vs 9.28, P = .003), lower Flesch Reading Ease score (37.07 vs 54.85, P = .005), and higher JAMA scores for source quality (3.333 vs 1.800, P = .016). Numerically, 6 out of 10 responses varied between platforms, with GPT-4 providing broader recovery timelines for ACDF. CONCLUSIONS: This study demonstrates GPT-4's ability to elevate patient education by providing high-quality, diverse information tailored to those with advanced literacy levels. As AI technology evolves, refining these tools for accuracy and user-friendliness remains crucial, catering to patients' varying literacy levels and information needs in spine surgery.

Modern Internet Search Analytics: Is There a Difference in What Patients are Searching Regarding the Operative and Nonoperative Management of Scoliosis?

STUDY DESIGN: Observational Study. OBJECTIVES: This study aimed to investigate the most searched types of questions and online resources implicated in the operative and nonoperative management of scoliosis. METHODS: Six terms related to operative and nonoperative scoliosis treatment were searched on Google's People Also Ask section on October 12, 2023. The Rothwell classification was used to sort questions into fact, policy, or value categories, and associated websites were classified by type. Fischer's exact tests compared question type and websites encountered between operative and nonoperative questions. Statistical significance was set at the .05 level. RESULTS: The most common questions concerning operative and nonoperative management were fact (53.4%) and value (35.5%) questions, respectively. The most common subcategory pertaining to operative and nonoperative questions were specific activities/restrictions (21.7%) and evaluation of treatment (33.3%), respectively. Questions on indications/management (13.2% vs 31.2%, P < .001) and evaluation of treatment (10.1% vs 33.3%, P < .001) were associated with nonoperative scoliosis management. Medical practice websites were the most common website to which questions concerning operative (31.9%) and nonoperative (51.4%) management were directed to. Operative questions were more likely to be directed to academic websites (21.7% vs 10.0%, P = .037) and less likely to be directed to medical practice websites (31.9% vs 51.4%, P = .007) than nonoperative questions. CONCLUSIONS: During scoliosis consultations, spine surgeons should emphasize the postoperative recovery process and efficacy of conservative treatment modalities for the operative and nonoperative management of scoliosis, respectively. Future research should assess the impact of website encounters on patients' decision-making.

Brain abscesses following carotid blowout syndrome: a case report.

We report a case of intracranial abscesses development in a patient with head and neck cancer after emergent treatment of carotid blowout syndrome with coil embolization. Our patient is a 60-year-old male who presented with hemoptysis and hematemesis, which raised concerns for impending carotid blowout syndrome. Endovascular occlusion was successfully achieved, and the patient was discharged in stable condition. Ten days later, the patient reported headaches and right facial pain, and magnetic resonance imaging revealed multiple intracranial abscesses. Broad-spectrum intravenous antibiotics were administered, leading to a variable response with some abscesses decreasing in size and others increasing. Seven weeks from discharge, the patient had no neurological deficits, and all abscesses had decreased in size.

Enhanced recovery after surgery (ERAS) for craniotomies in the treatment of brain tumors: A systematic review.

INTRODUCTION: Postoperative complications after craniotomy for brain tumors include pain, nausea/vomiting, and infection. A standardized enhanced recovery after surgery (ERAS) protocol is not widely accepted for this common neurosurgical procedure. Few studies have explored its application. METHODS: A literature search of PubMed, Cochrane, and Google Scholar databases was performed between January 1992 and March 2023. Original studies that implemented an ERAS protocol for patients that underwent craniotomy for brain tumors were included. The following variables were evaluated: hospital length of stay (LOS), postoperative pain, postoperative nausea and vomiting (PONV) prophylaxis, non-opioid analgesia, and quality of life (QOL). RESULTS: Twelve studies with a total of 1309 patients met inclusion criteria, including ten randomized controlled trials, one nonrandomized controlled trial, and one quality control study. Most frequently assessed metrics included hospital LOS, PONV prophylaxis, and non-opioid analgesia. A significant reduction in postoperative LOS was observed in 7 studies with ERAS or ERAS components. ERAS was significantly associated with pain reduction on the visual analog scale and verbal numerical rating scale (n=8). Non-opioid analgesia in ERAS improved postoperative pain control (n=4) and decreased the duration of pain (n=1). Three of six studies found no difference in PONV in ERAS vs. control. No studies reported an increase in postoperative complications using ERAS vs. control. One study showed greater patient satisfaction at 30-day follow-up with improved QOL. CONCLUSION: Implementing ERAS protocol may enhance outcomes and quality of life in patients with moderate evidence for improved recovery in those undergoing craniotomy for brain tumors.

The Role of Intrathecal Pumps in Nonmalignant Pain.

Intrathecal pumps deliver analgesic medication directly into the central nervous system. In patients with chronic nonmalignant pain, intrathecal therapy using morphine or ziconotide has been shown to be an effective option when traditional noninvasive methods do not provide adequate relief. There has been increasing use of intrathecal drug administration in the management of patients with nonmalignant pain in recent years given the advances in technology and research on the topic. However, due to its invasive nature, intrathecal pumps remain the last option among patients with chronic pain.

Charles Jacques Bouchard (1837-1915) and the Charcot-Bouchard aneurysm.

Charles Jacques Bouchard was a distinguished French physician and scientist of the early 19th century. Despite his humble beginnings, Bouchard was able to achieve meteoric success within the scientific and medical fields, establishing himself as one of the most influential physician-scientists of his time. This was in part due to his superb commitment, as well as the prosperity engendered by the strong influence of his teachers, which can be seen as a testament to the importance of mentorship in medicine. Besides his myriad contributions, Bouchard is most well known for describing the Charcot-Bouchard aneurysm in 1866 alongside his mentor Jean-Martin Charcot, linking them for the first time to intracranial hemorrhage. Bouchard's thesis entitled "A Study of Some Points in the Pathology of Cerebral Hemorrhage" was regarded by some as the most original and important of all recent works on the subject of cerebral hemorrhage at the time of publication. Sadly, the great relationship Bouchard shared with his mentor Charcot would later deteriorate into perhaps one of the most well-known student-mentor quarrels in the history of medicine. Herein, the authors present a historical recollection of Bouchard's life, career, and contributions to medicine, as well as the famous controversy with Jean-Martin Charcot.

Frameless Robotic-Assisted Deep Brain Stimulation With the Mazor Renaissance System.

BACKGROUND: Robotic-assisted stereotactic systems for deep brain stimulation (DBS) have recently gained popularity because of their abilities to automate arduous human error-prone steps for lead implantation. Recent DBS literature focuses on frame-based robotic platforms, but little has been reported on frameless robotic approaches, specifically the Food and Drug Administration-approved Mazor Renaissance Guidance System (Mazor Robotics Ltd). OBJECTIVE: To present an initial case series for patients undergoing awake DBS with the Mazor Renaissance Guidance System and evaluate operative variables and stereotactic accuracy. METHODS: Retrospective data collection at a single institution was conducted for an initial 35 consecutive patients. Patient demographics and operative variables, including case times, microelectrode recording passes, and postoperative complications, were obtained by chart review. Implant accuracy was evaluated through measuring radial and vector (x, y) errors using the Mazor software. Pneumocephalus volumes were calculated using immediate postoperative T1-weighted MRI scans. RESULTS: Total operating room (245 ± 5.5 min) and procedural (179 ± 4.7) times were comparable with previous awake DBS literature. The radial error for center tract implants was 1.3 ± 0.1 mm, with smaller error in the first (1.1 ± 0.2) vs second (1.7 ± 0.3) implants of bilateral DBS (P = .048). Vector error analysis demonstrated larger shifts posteriorly for first implants and medially for second implants. Pneumocephalus volumes (12.4 ± 2.2 cm3) were not associated with increased microelectrode recording passes, radial error, or complications. CONCLUSION: Frameless robotic-assisted DBS is a safe and efficient new technology that has been easily adopted into the workflow at our institution.

Does active coaching reduce actual treatment duration for frameless Gamma Knife stereotactic radiosurgery?

Purpose/Objectives: Frameless Gamma Knife stereotactic radiosurgery (GKSRS) has become an effective supplement to frame-based, which is however sensitive to patient's involuntary motions and prone to prolonged treatment duration. Such delays during treatment inevitably result in patient discomfort and the inability to complete intended treatment. The purpose of this study is to investigate whether active coaching during frameless GKSRS can reduce actual treatment duration. Materials/Methods: Patients treated at a single institution with frameless GKSRS from 2017 to 2020 were retrospectively identified. Beginning in 2019, all patients treated with frameless GKSRS were actively coached to prevent treatment interruptions. Patient characteristics and treatment plans were compared between the cohorts of patients treated with and without active coaching. Linear regressions between the planned and actual treatment duration of treatment sessions were performed on either cohort. ANOVA and Wilcoxon tests were used for statistical analyses with a p-value less than 0.05 considered as significant. Results: Of the total 43 patients and 105 treatment sessions identified, 27 patients underwent 51 treatment sessions of frameless GKSRS with active coaching. There was no significant difference in patient characteristics and treatment plans between the two cohorts. Patients treated with active coaching underwent significantly fewer CBCTs during treatment. The median planned and actual treatment durations were 31.4 and 51.7 min for the non-coached cohort, and 38.6 and 49.8 min for the coached cohort. The results of linear regressions showed that the actual treatment duration was 1.29 and 1.56 times longer with and without active coaching, respectively, which indicated a significant reduction in the actual treatment duration with active coaching. Conclusion: Our results suggest that active coaching was associated with significant reductions of actual treatment duration. This simple intervention can be clinically implemented to prevent unnecessary treatment interruptions, improve patient comfort and ensure completion of treatment as prescribed during frameless GKSRS.

Intramedullary Spinal Cord Metastasis from Primary Lung Neuroendocrine Carcinoma: A Case Report and Operative Video.

BACKGROUND: Intramedullary spinal cord metastasis (ISCM) account for a minority of all spinal cord tumors. Rarely, symptoms from ISCM may be the initial presentation of an unknown primary carcinoma. Intramedullary metastasis from a second malignancy or from an unknown neuroendocrine malignancy is extremely rare and has never been reported in the literature. Because of the rarity of these tumors and the low volume of cases, well-defined treatment guidelines do not exist for the management of ISCM. Here we present a rare and one of the first reports of an intramedullary metastatic neuroendocrine tumor. CASE DESCRIPTION: A 66-year-old woman with a history of breast cancer presented with worsening bilateral lower extremity numbness for 2 months. Imaging revealed an intramedullary spinal cord tumor at the T4 level. The patient underwent microsurgical resection of the intramedullary spinal cord tumor. At operation, the tumor had an exophytic component. Subtotal resection was achieved. Pathology revealed a neuroendocrine metastasis, likely pulmonary in origin. She achieved partial resolution of neurologic symptoms at follow-up. CONCLUSIONS: Neuroendocrine ISCM are rare and lack well-defined treatment guidelines. Care should be individualized in these cases. Whenever feasible, surgical resection should be considered. Despite multidisciplinary care, the prognosis is dismal with limited life expectancy. Larger, multiinstitutional, or national database studies are needed that compare treatment modalities in the management of ISCM to identify the therapy with the best outcomes.

Legacies of Neurosurgery and its Implications on Global Neurosurgery Today.

Trephination, the practice of boring a hole in the skull, is one of the oldest surgical procedures performed by and on humans. Fossil records show evidence of trephined skulls on separate continents throughout ancient history. Even more remarkably, fossils show that ancient humans actually survived the procedure, some more than once. Ancient mythologies and texts provide context to the fossil record, indicating that trephination was performed some of the time for medical indications, including traumatic head injury and intractable neurologic conditions. In the modern day, traumatic brain injury accounts for a significant percentage of the overall global burden of disease and its incidence is disproportionately increasing in low- and middle-income countries. In critical situations, neurosurgical intervention may be indicated. The burr hole procedure, or trephination, was identified as an essential surgical procedure that all first-level hospitals should be able to perform; however, there exists a dramatic lack of access to neurosurgical specialists and care globally, especially among low- and middle-income countries. Task-shifting/sharing is one paradigm that may be used effectively to broaden access to this life-saving procedure but it is at the moment a contested practice.

Lateral Myelotomy for Resection of a Ruptured Intramedullary Cervico-Thoracic Cavernous Malformation.

BACKGROUND AND IMPORTANCE: Intramedullary spinal cord cavernous malformations represent 5% to 12% of spinal vascular disease. Most patients present with acute or progressive neurological symptoms, including motor weakness or sensory loss. Surgical resection is the only definitive management and is recommended for symptomatic lesions that are surgically accessible. CLINICAL PRESENTATION: A 35-yr-old woman presented with a sudden onset of pain and temperature sensation loss in the left lower extremity. Magnetic resonance imaging of the spine showed a hemorrhage located ventral and slightly lateral to the right of the midline of the spinal cord from C7 through T3. Ultimately, a right lateral myelotomy between the ventral and dorsal roots was performed, and the cavernous malformation was removed. Postoperative imaging confirmed gross total resection of the cavernous malformation. CONCLUSION: In this article, we report a highly unusual case of a multisegment, ruptured intramedullary cavernous malformation that was ultimately resected through a lateral myelotomy approach. This case demonstrates that a lateral approach to the spinal cord substance can be utilized for ruptured cavernous malformation, especially if there is hemorrhage at the surface of the spinal cord. This can be used as an entry into the anterolateral compartment of the spinal cord, which would otherwise be regarded as a highly morbid approach due to the sensory deficits induced. We believe this entry point to the spinal cord is feasible in highly select cases such as this.

A longitudinal surgical systems strengthening research program for medical students: the exploration of a model for global health education.

BACKGROUND: In response to the staggering global burden of conditions requiring emergency and essential surgery, the development of international surgical system strengthening (SSS) is fundamental to achieving universal, timely, quality, and affordable surgical care. Opportunity exists in identifying optimal collaborative processes that both promote global surgery research and SSS, and include medical students. This study explores an education model to engage students in academic global surgery and SSS via institutional support for longitudinal research. OBJECTIVES: We set out to design a program to align global health education and longitudinal health systems research by creating an education model to engage medical students in academic global surgery and SSS. PROGRAM DESIGN AND IMPLEMENTATION: In 2015, medical schools in the United States and Colombia initiated a collaborative partnership for academic global surgery research and SSS. This included development of two longitudinal academic tracks in global health medical education and academic global surgery, which we differentiated by level of institutional resourcing. Herein is a retrospective evaluation of the first two years of this program by using commonly recognized academic output metrics. MAIN ACHIEVEMENTS: In the first two years of the program, there were 76 total applicants to the two longitudinal tracks. Six of the 16 (37.5%) accepted students selected global surgery faculty as mentors (Acute Care Surgery faculty participating in SSS with Colombia). These global surgery students subsequently spent 24 total working weeks abroad over the two-year period participating in culminating research experiences in SSS. As a quantitative measure of the program's success, the students collectively produced a total of twenty scholarly pieces in the form of accepted posters, abstracts, podium presentations, and manuscripts in partnership with Colombian research mentors. POLICY IMPLICATIONS: The establishment of scholarly global health education and research tracks has afforded our medical students an active role in international SSS through participation in academic global surgery research. We propose that these complementary programs can serve as a model for disseminated education and training of the future global systems-aware surgeon workforce with bidirectional growth in south and north regions with traditionally under-resourced SSS training programs.