A guide to selecting upper thoracic versus lower thoracic uppermost instrumented vertebra in adult spinal deformity correction.

PURPOSE: Operative treatment of adult spinal deformity (ASD) has been shown to improve patient health-related quality of life (HRQOL). Selection of the uppermost instrumented vertebra (UIV) in either the upper thoracic (UT) or lower thoracic (LT) spine is a pivotal decision with effects on operative and postoperative outcomes. This review overviews the multifaceted decision-making process for UIV selection in ASD correction. METHODS: PubMed was queried for articles using the keywords "uppermost instrumented vertebra", "upper thoracic", "lower thoracic", and "adult spinal deformity". RESULTS: Optimization of UIV selection may lead to superior deformity correction, better patient-reported outcomes, and lower risk of proximal junctional kyphosis (PJK) and failure (PJF). Patient alignment characteristics, including preoperative thoracic kyphosis, coronal deformity, and the magnitude of sagittal correction influence surgical decision-making when selecting a UIV, while comorbidities such as poor body mass index, osteoporosis, and neuromuscular pathology should also be taken in to account. Additionally, surgeon experience and resources available to the hospital may also play a role in this decision. Currently, it is incompletely understood whether postoperative HRQOLs, functional and radiographic outcomes, and complications after surgery differ between selection of the UIV in either the UT or LT spine. CONCLUSION: The correct selection of the UIV in surgical planning is a challenging task, which requires attention to preoperative alignment, patient comorbidities, clinical characteristics, available resources, and surgeon-specific factors such as experience.

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.

Associating T1-Weighted and T2-Weighted Magnetic Resonance Imaging Radiomic Signatures With Preoperative Symptom Severity in Patients With Cervical Spondylotic Myelopathy.

BACKGROUND: Preoperative symptom severity in cervical spondylotic myelopathy (CSM) can be variable. Radiomic signatures could provide an imaging biomarker for symptom severity in CSM. This study utilizes radiomic signatures of T1-weighted and T2-weighted magnetic resonance imaging images to correlate with preoperative symptom severity based on modified Japanese Orthopaedic Association (mJOA) scores for patients with CSM. METHODS: Sixty-two patients with CSM were identified. Preoperative T1-weighted and T2-weighted magnetic resonance imaging images for each patient were segmented from C2-C7. A total of 205 texture features were extracted from each volume of interest. After feature normalization, each second-order feature was further subdivided to yield a total of 400 features from each volume of interest for analysis. Supervised machine learning was used to build radiomic models. RESULTS: The patient cohort had a median mJOA preoperative score of 13; of which, 30 patients had a score of >13 (low severity) and 32 patients had a score of ≤13 (high severity). Radiomic analysis of T2-weighted imaging resulted in 4 radiomic signatures that correlated with preoperative mJOA with a sensitivity, specificity, and accuracy of 78%, 89%, and 83%, respectively (P < 0.004). The area under the curve value for the ROC curves were 0.69, 0.70, and 0.77 for models generated by independent T1 texture features, T1 and T2 texture features in combination, and independent T2 texture features, respectively. CONCLUSIONS: Radiomic models correlate with preoperative mJOA scores using T2 texture features in patients with CSM. This may serve as a surrogate, objective imaging biomarker to measure the preoperative functional status of patients.

Machine Learning in Spine Surgery: A Narrative Review.

Artificial intelligence and machine learning (ML) can offer revolutionary advances in their application to the field of spine surgery. Within the past 5 years, novel applications of ML have assisted in surgical decision-making, intraoperative imaging and navigation, and optimization of clinical outcomes. ML has the capacity to address many different clinical needs and improve diagnostic and surgical techniques. This review will discuss current applications of ML in the context of spine surgery by breaking down its implementation preoperatively, intraoperatively, and postoperatively. Ethical considerations to ML and challenges in ML implementation must be addressed to maximally benefit patients, spine surgeons, and the healthcare system. Areas for future research in augmented reality and mixed reality, along with limitations in generalizability and bias, will also be highlighted.

Infant Rudimentary Meningocele with Tethering of the Cervical Cord: A Case Report.

Rudimentary meningoceles of the spine with dural extension are very rare and warrant surgical excision to prevent infection and long-term neurological deficits in pediatric patients. We present the case of a 5-month-old infant with a tethered spinal cord secondary to a rudimentary meningocele. The patient presented shortly after birth with a midline cervical dimple that was evaluated for a suspected dermal sinus tract. Magnetic resonance imaging scan of the spine showed a sinus tract with intradural extension to C2-3 and external opening at the level of spinous process C5. En bloc surgical excision and spinal cord release were successfully performed. Histological analysis of the specimen confirmed the presence of two blunt sinus tracts and staining was consistent with a rudimentary meningocele. Intradural rudimentary meningoceles in infants can successfully be managed with surgical intervention. Surgery is indicated to prevent future motor complications from spinal cord tethering and neoplastic growth from the rudimentary meningocele.

Local control and survival after stereotactic radiosurgery for colorectal cancer brain metastases: an international multicenter analysis.

OBJECTIVE: The goal of this study was to characterize local tumor control (LC), overall survival (OS), and safety of stereotactic radiosurgery for colorectal brain metastasis (CRBM). METHODS: Ten international institutions participating in the International Radiosurgery Research Foundation provided data for this retrospective case series. This study included 187 patients with CRBM (281 tumors), with a median age of 62 years and 56.7% being male. Most patients (53.5%) had solitary tumors, although 10.7% had > 5 tumors. The median tumor volume was 2.7 cm3 (IQR 0.22-8.1 cm3), and the median margin dose was 20 Gy (IQR 18-22 Gy). RESULTS: The 3-year LC and OS rates were 72% and 20%, respectively. Symptomatic adverse radiation effects occurred in 1.6% of patients. In the multivariate analysis, age > 65 years and tumor volume > 4.0 cm3 were significant predictors of tumor progression (hazard ratio [HR] 2.6, 95% CI 1.4-4.9; p = 0.003 and HR 3.4, 95% CI 1.7-6.9; p < 0.001, respectively). Better performance status (Karnofsky Performance Scale score > 80) was associated with a reduced risk of tumor progression (HR 0.38, 95% CI 0.19-0.73; p = 0.004). Patient age > 62 years (HR 1.6, 95% CI 1.1-2.3; p = 0.03) and the presence of active extracranial disease (HR 1.7, 95% CI 1.1-2.4; p = 0.009) were significantly associated with worse OS. CONCLUSIONS: Stereotactic radiosurgery offers a high LC rate and a low rate of symptomatic adverse radiation effects for the majority of CRBMs. The OS and LC favored younger patients with high functional performance scores and inactive extracranial disease.

Power Drill Craniostomy for Bedside Intracranial Access in Traumatic Brain Injury Patients.

Invasive neuromonitoring is a bedrock procedure in neurosurgery and neurocritical care. Intracranial hypertension is a recognized emergency that can potentially lead to herniation, ischemia, and neurological decline. Over 50,000 external ventricular drains (EVDs) are performed in the United States annually for traumatic brain injuries (TBI), tumors, cerebrovascular hemorrhaging, and other causes. The technical challenge of a bedside ventriculostomy and/or parenchymal monitor placement may be increased by complex craniofacial trauma or brain swelling, which will decrease the tolerance of brain parenchyma to applied procedural force during a craniostomy. Herein, we report on the implementation and safety of a disposable power drill for bedside neurosurgical practices compared with the manual twist drill that is the current gold standard. Mechanical testing of the drill's stop extension (n = 8) was conducted through a calibrated tensile tester, simulating an axial plunging of 22.68 kilogram (kg) or 50 pounds of force (lbf) and measuring the strength-responsive displacement. The mean displacement following compression was 0.18 ± 0.11 mm (range of 0.03 mm to 0.34 mm). An overall cost analysis was calculated based on the annual institutional pricing, with an estimated $64.90 per unit increase in the cost of the disposable electric drill. Power drill craniostomies were utilized in a total of 34 adult patients, with a median Glasgow Coma Scale (GCS) score of six. Twenty-seven patients were male, with a mean age of 50.7 years old. The two most common injury mechanisms were falls and motor vehicle/motorcycle accidents. EVDs were placed in all subjects, and additional quad-lumen neuromonitoring was applied to 23 patients, with no incidents of plunging events or malfunctions. One patient developed an intracranial infection and another had intraparenchymal tract hemorrhaging. Two illustrative TBI cases with concomitant craniofacial trauma were provided. The disposable power drill was successfully implemented as an option for bedside ventriculostomies and had an acceptable safety profile.

Stereotactic Radiosurgery for Meningiomas in Children and Adolescents: An International Multi-Institutional Study.

BACKGROUND AND OBJECTIVES: Meningiomas in children are uncommon, with distinct characteristics that set them apart from their adult counterparts. The existing evidence for stereotactic radiosurgery (SRS) in this patient population is limited to only case series. The objective of this study was to evaluate the safety and efficacy of SRS in managing pediatric meningiomas. METHODS: Children and adolescents who had been treated for meningioma with single-fraction SRS were included in this retrospective, multicenter study. The assessment included local tumor control, any complications related to the tumor or SRS, and the emergence of new neurological deficits after SRS. RESULTS: The cohort included 57 patients (male-to-female ratio 1.6:1) with a mean age of 14.4 years who were managed with single-fraction SRS for 78 meningiomas. The median radiological and clinical follow-up periods were 69 months (range, 6-268) and 71 months (range, 6-268), respectively. At the last follow-up, tumor control (tumor stability and regression) was achieved in 69 (85.9%) tumors. Post-SRS, new neurological deficits occurred in 2 (3.5%) patients. Adverse radiation effects occurred in 5 (8.8%) patients. A de novo aneurysm was observed in a patient 69 months after SRS. CONCLUSION: SRS seems to be a safe and effective up-front or adjuvant treatment option for surgically inaccessible, recurrent, or residual pediatric meningiomas.

Anterior Thoracic Discectomy and Fusion for Symptomatic Ventral Bone Spur Associated Type I Cerebrospinal Fluid Leak: A Technical Report and Operative Video.

STUDY DESIGN: Technical Report. OBJECTIVE: Cerebrospinal fluid (CSF) leak secondary to anterior osteophytes at the cervico-thoracic junction is a rare cause of intracranial hypotension. In this article we describe a technique for anterior repair of spontaneous ventral cerebrospinal fluid leaks in the upper thoracic spine. METHODS: In this technical report and operative video, we describe a 23-year-old male who presented with positional headaches and bilateral subdural hematoma. Dynamic CT myelography demonstrated a high flow ventral cerebrospinal fluid leak associated with a ventral osteophyte at the level of the T1-T2 disc space. Targeted blood patch provided only temporary improvement in symptoms. An anterior approach was chosen to remove the offending spur and micro-surgically repair the dural defect. RESULTS: The patient had complete resolution of his preoperative symptoms after primary repair. CONCLUSIONS: In select cases, an anterior approach to the upper thoracic spine is effective to repair Type 1 cerebrospinal fluid leaks.

Local Control and Survival Outcomes After Stereotactic Radiosurgery for Brain Metastases From Gastrointestinal Primaries: An International Multicenter Analysis.

BACKGROUND: There are limited data regarding outcomes for patients with gastrointestinal (GI) primaries and brain metastases treated with stereotactic radiosurgery (SRS). OBJECTIVE: To examine clinical outcomes after SRS for patients with brain metastases from GI primaries and evaluate potential prognostic factors. METHODS: The International Radiosurgery Research Foundation centers were queried for patients with brain metastases from GI primaries managed with SRS. Primary outcomes were local control (LC) and overall survival (OS). Kaplan-Meier analysis was used for univariate analysis (UVA) of prognostic factors. Factors significant on UVA were evaluated with a Cox multivariate analysis proportional hazards model. Logistic regressions were used to examine correlations with RN. RESULTS: We identified 263 eligible patients with 543 brain metastases. Common primary sites were rectal (31.2%), colon (31.2%), and esophagus (25.5%) with a median age of 61.6 years (range: 37-91.4 years) and a median Karnofsky performance status (KPS) of 90% (range: 40%-100%). One-year and 2-year LC rates were 83.5% (95% CI: 78.9%-87.1%) and 73.0% (95% CI: 66.4%-78.5%), respectively. On UVA, age >65 years ( P = .001), dose <20 Gy ( P = .006) for single-fraction plans, KPS <90% ( P < .001), and planning target volume ≥2cc ( P = .007) were associated with inferior LC. All factors other than dose were significant on multivariate analysis ( P ≤ .002). One-year and 2-year OS rates were 68.0% (95% CI: 61.5%-73.6%) and 31.2% (95% CI: 24.6%-37.9%), respectively. Age > 65 years ( P = .006), KPS <90% ( P = .005), and extracranial metastases ( P = .05) were associated with inferior OS. CONCLUSION: SRS resulted in comparable LC with common primaries. Age and KPS were associated with both LC and OS with planning target volume and extracranial metastases correlating with LC and OS, respectively. These factors should be considered in GI cancer patient selection for SRS.

Hunt-Hess Score at 48 Hours Improves Prognostication in Grade 5 Aneurysmal Subarachnoid Hemorrhage.

BACKGROUND: Patients with Hunt-Hess (HH)5 aneurysmal subarachnoid hemorrhage (SAH) have high mortality rates. Despite an initial moribund exam, a subset of patients progress to favorable outcomes. OBJECTIVE: To evaluate the utility of delayed HH grading to improve prognostication. METHODS: We retrospectively reviewed patients undergoing treatment of ruptured aneurysms at two level 1 stroke centers from January 2012 through December 2020. We collected relevant clinical information and developed a multivariate cox regression model to identify independent predictors of mortality. To evaluate the utility of delayed examinations in predicting outcomes, we re-assessed the HH grade at 48 hours post admission and constructed a logistic regression model with potential confounders to predict mortality. RESULTS: From 2012 to 2020, 621 patients underwent treatment for aneurysmal SAH. We identified 63 HH5 patients (10%) with a mean age of 58 years. Among these patients, the median length of stay was 14 days, with 3 patients passing away within 48 hours. The overall mortality rate was 63% at 24 months. To predict mortality, our cox regression model found only age to be significant (P = 0.002). Delayed HH grading improved prognostication at 48 hours and remained significant on multivariate analysis as a predictor of mortality (P = 0.0001). We observed a significant difference in mortality between patients HH5 and patients HH4 or lower at 48 hours (P = 0.0003). CONCLUSIONS: Delayed reassessment of HH grade 48 hours postadmission is a predictor of mortality, suggesting reassessment at 48 hours in high grade SAH leads to better prognostication.

Single session versus multisession stereotactic radiosurgery for the management of intracranial meningiomas: a systematic review and meta-analysis.

PURPOSE: To compare the efficacy, outcomes, and complications of single session (SS-SRS) and multisession (MS-SRS) stereotactic radiosurgery in the treatment of intracranial meningiomas. METHODS: Relevant articles were retrieved from PubMed, Scopus, Web of Science, and Cochrane. A systematic review and meta-analysis of treatment protocols and outcomes were conducted. After the selection process, 20 articles describing 1483 cases were included. RESULTS: A total of 1303 patients who underwent SS-SRS and 180 patients who underwent MS-SRS for the management of their intracranial meningioma were reported in the included studies. SS-SRS and MS-SRS had comparable one-year (SS-SRS: 98% vs. MS-SRS: 100%, p > 0.99) and five-year (SS-SRS: 94% vs. MS-SRS: 93%, p = 0.71) tumor control rates. The groups also had comparable tumor volume reduction/tumor regression rates (SS-SRS: 44% vs. MS-SRS: 25%, p = 0.25), tumor volume stability rates (SS-SRS: 51% vs. MS-SRS: 75%, p = 0.12), and tumor progression rates (SS-SRS: 4% vs. MS-SRS: 4%, p = 0.89). SS-SRS and MS-SRS yielded similar complication rates (10.4% vs. 11.4%, p = 0.68) and comparable functional improvement rates (MS-SRS: 44% vs. SS-SRS: 36%, p = 0.57). However, MS-SRS was used for significantly larger tumor volumes (MS-SRS: 23.8 cm3 vs. SS-SRS: 6.1 cm3, p = 0.02). CONCLUSION: SS-SRS and MS-SRS resulted in comparable tumor control, tumor volumetric change, and functional outcomes despite significant biases in selecting patients for SS- or MS-SRS.

On-field assessment of concussion: clinical utility of the King-Devick test.

Sport-related concussion (SRC) is an important public health concern with up to 3.8 million SRCs occurring each year. As the incidence and rate of SRC increases, reliable and valid tools for diagnosis and management are needed. The King-Devick (K-D) test assesses a patient's visual function based on reading a series of numbers as well as counting both time to completion and errors. Its rapid administration time and simplicity make the K-D test a potentially useful SRC diagnostic tool, though limitations exist in baseline testing and what constitutes an abnormal score. Additionally, the K-D tests should never be used in isolation to diagnose a concussion, but rather as one test in conjunction with additional clinical measures, as part of an individualized approach to each patient. The current review examines the clinical utility of the K-D test.

Sport-Related Structural Brain Injury in High School Soccer: Epidural Hemorrhage After a "Header".

BACKGROUND: Sports-related structural brain injury (SRSBI) is a rare, but potentially catastrophic, injury. Limited data exist outlining its epidemiology, pathophysiology, and outcomes. We have presented a case of an epidural hematoma (EDH) that occurred during a high school soccer game. CASE DESCRIPTION: A 16-year-old boy had experienced a head-to-ball collision and head-to-head collision with another player. He denied loss of consciousness, endorsed retrograde amnesia, and complained of a minor headache. On the sidelines, he subsequently passed brief orientation and physical exertion tests. However, on returning to play, he experienced blurry vision, along with headache and nausea/vomiting. At the local hospital, he was found to have a 2.6-cm right frontal EDH. After transfer to our institution, increasing somnolence was noted, prompting emergent evacuation of the EDH. His postoperative course was unremarkable, and he was discharged on postoperative day 2. At the 2-week and 3-month follow-up visits, he did not express any complaints or residual deficits and was cleared for full sporting activity. CONCLUSIONS: The present case highlights one of the few SRSBIs that have occurred in soccer. Because of their rarity and severity, a concerted effort should be made to report these cases of SRSBIs regarding the mechanism, postcollision symptoms, and long-term outcomes.

Imaging findings after acute sport-related concussion in American football players: A systematic review.

Sport-related concussion (SRC) has emerged as a major public health problem. The results of brain imaging studies following SRC have raised questions about long-term neurologic health, but the clinical implications of these findings remain unknown. A systematic review of brain imaging findings after SRC was performed utilizing the following inclusion criteria: football players, brain imaging within 6 months of SRC, and sample size >5. Studies were assessed for: 1) methodology, 2) imaging outcomes, and 3) number of positive statistical comparisons. Imaging was classified as immediate (≤1 week post-injury) or subacute (>1 week to 6 months post-injury). Eleven studies met inclusion criteria. Eight of the 11 studies conducted a total of 809 comparisons of brain function, of which 149 (18%) were statistically significant. Nine of the 11 studies (82%) reported positive immediate findings, but were more likely to be subject to recall bias (86% vs. 0%) and to lack baseline advanced brain imaging (78% vs. 50%) than negative studies. Only 3 of 9 studies that reported subacute findings (33%) reported positive results, and these positive studies were also more likely to be subject to recall bias (100% vs. 40%) and to lack baseline advanced brain imaging (100% vs. 67%) than negative studies. The results of the study demonstrate the transitory nature of positive imaging findings and methodological limitations that complicate study interpretation. Further research is required to correlate imaging findings with clinical outcomes.

Long-Term Neuroimaging Findings in American Football Players: Systematic Review.

BACKGROUND: Lasting neuroimaging changes after participation in American football are an increasing public health concern. The clinical relevance of imaging findings remains unknown. METHODS: A systematic review was performed with the following inclusion criteria: football players, brain imaging ≥2 years from previous concussion or retirement, and sample size ≥5. Studies were assessed for 1) methodology (control selection, type I error, and recall bias), 2) imaging outcomes, and 3) number of significant statistical comparisons. RESULTS: Sixteen studies (all cross-sectional studies) met the inclusion criteria. Highest level of play included high school (n = 1), college (n = 3), and professional (n = 12). Thirteen of the 16 studies made a total 456 comparisons of brain activity, of which 171 were statistically significant (38%). Nine of 16 studies (56%) had appropriate controls, and 5 of 16 studies (31%) appropriately accounted for type I error. To obtain player concussion history, all studies (16/16) had recall bias or unclear methodology. Imaging outcome measures included structural magnetic resonance imaging (MRI) (29.2%), diffusion tensor imaging (25%), radioactive tracer uptake on positron emission tomography (16.7%), patterns of connectivity on functional MRI (fMRI) (12.5%), transcranial magnetic stimulation (8.3%), arterial spin labeling MRI (4.2%), and metabolic changes on 1H-magnetic resonance spectroscopy (4.2%). CONCLUSIONS: Long-term neuroimaging findings in American football players are heterogeneous in both methodology and findings. Understanding the clinical importance of statistically significant findings is complicated by methodological limitations and study design. Further research is required to correlate imaging findings with clinical outcomes.

The role of family and personal psychiatric history in postconcussion syndrome following sport-related concussion: a story of compounding risk.

OBJECTIVE Sport-related concussion (SRC) has become a major public health concern. Prolonged recovery after SRC, named postconcussion syndrome (PCS), has been associated with several biopsychosocial factors, yet the role of both family and personal psychiatric histories requires investigation. In a cohort of concussed high school athletes, the authors examined the role(s) of family and personal psychiatric histories in the risk of developing PCS. METHODS A retrospective cohort study of 154 high school athletes with complete documentation of postconcussion symptom resolution or persistence at 6 weeks was conducted. PCS was defined as 3 or more symptoms present 6 weeks after SRC. Three groups were defined: 1) positive family psychiatric history and personal psychiatric history (FPH/PPH), 2) positive FPH only, and 3) negative family and personal psychiatric histories (controls). Three bivariate regression analyses were conducted: FPH/PPH to controls, FPH only to controls, and FPH/PPH to FPH. Post hoc bivariate regression analyses examined specific FPH pathologies and PCS. RESULTS Athletes with FPH/PPH compared with controls had an increased risk of PCS (χ2 = 8.90, p = 0.018; OR 5.06, 95% CI 1.71-14.99). Athletes with FPH only compared with controls also had an increased risk of PCS (χ2 = 6.04, p = 0.03; OR 2.52, 95% CI 1.20-5.30). Comparing athletes with FPH/PPH to athletes with FPH only, no added PCS risk was noted (χ2 = 1.64, p = 0.247; OR 2.01, 95% CI 0.68-5.94). Among various FPH diagnoses, anxiety (χ2 = 7.48, p = 0.021; OR 2.99, 95% CI 1.36-6.49) and bipolar disorder (χ2 = 5.13, p = 0.036; OR 2.74, 95% CI 1.14-6.67) were significantly associated with the presence of PCS. CONCLUSIONS Concussed high school athletes with FPH/PPH were greater than 5 times more likely to develop PCS than controls. Athletes with only FPH were over 2.5 times more likely to develop PCS than controls. Those with an FPH of anxiety or bipolar disorder are specifically at increased risk of PCS. These results suggest that not only are athletes with FPH/PPH at risk for slower recovery after SRC, but those with an FPH only-especially anxiety or bipolar disorder-may also be at risk. Overall, this study supports taking a detailed FPH and PPH in the management of SRC.

Comparison between Widefield En Face Swept-Source OCT and Conventional Multimodal Imaging for the Detection of Reticular Pseudodrusen.

PURPOSE: The ability to detect reticular pseudodrusen (RPD)/subretinal drusenoid deposits (SDDs) using 12×12-mm widefield en face swept-source optical coherence tomography (SS-OCT) imaging was compared with conventional multimodal imaging (color, fundus autofluorescence (FAF), and infrared reflectance [IR] imaging) in eyes with nonexudative age-related macular degeneration (AMD). DESIGN: Cross-sectional study. PARTICIPANTS: Patients with nonexudative AMD were prospectively enrolled in an SS-OCT imaging study at the Bascom Palmer Eye Institute. METHODS: On the same day, all participants underwent color, FAF, and IR fundus imaging, as well as imaging with a prototype Zeiss 100 kHz SS-OCT instrument (Carl Zeiss Meditec Inc, Dublin, CA). Two masked graders assessed the presence, absence, or uncertainty of RPD/SDDs on conventional multimodal images and separately on 4 different SS-OCT en face images derived from the same volumetric dataset. The results from grading the conventional images and the SS-OCT en face images were compared. MAIN OUTCOME MEASURES: Agreement in the detection of RPD/SDDs using different imaging modalities. RESULTS: A total of 307 eyes (209 patients) were graded for the presence or absence of RPD/SDDs. The agreement between SS-OCT and multimodal imaging was 83%. The difference in RPD/SDD detection with either image modality was not statistically significant (P = 0.21). The sensitivity of SS-OCT in RPD/SDD detection was 83%, and when using conventional imaging, the sensitivity was 75%. When using SS-OCT imaging alone, 10% of RPD/SDD cases would be missed, and when using conventional imaging alone, 14% of RPD/SDD cases would be missed. The presence of RPD/SDD was confirmed retrospectively in 48 of 52 cases once the overall grading was unmasked and the graders reevaluated the conventional multimodal images and the widefield SS-OCT en face images. CONCLUSIONS: All 4 imaging modalities used together provided the best strategy for the detection of RPD/SDDs. However, when using widefield en face SS-OCT slab imaging alone, the detection of RPD/SDDs was at least as good as conventional imaging.

Choroidal Thickness and Choroidal Vessel Density in Nonexudative Age-Related Macular Degeneration Using Swept-Source Optical Coherence Tomography Imaging.

Purpose: To analyze the relationship between choroidal thickness and the distribution of choroidal blood vessels in eyes with nonexudative AMD. Methods: Eyes with a diagnosis of nonexudative AMD were imaged using a prototype 100-kHz swept-source (SS) optical coherence tomography (OCT) instrument (Carl Zeiss Meditec, Dublin, CA, USA) with a central wavelength of 1050 nm. We used an OCT cube scan pattern consisting of 512 × 512 A-scans over a 12 × 12 mm retinal area. The eyes were partitioned into two groups based on the presence or absence of reticular pseudodrusen (RPD). All scans were segmented using an automated algorithm. In addition, five eyes from each of the two groups were randomly chosen for manual segmentation. Binary choroidal vessels maps were generated from suitable OCT choroidal slabs, and the relationship between the density of large choroidal vessels and choroidal thickness was analyzed using an Early Treatment Diabetic Retinopathy Study-like target centered on the fovea. Results: Twenty-five eyes were enrolled in each group. The automated algorithm produced accurate choroidal thickness maps with an average difference between the manual and automated segmentations of 13.7 µm. There was a significant and stable correlation between choroidal thickness and choroidal vessel density across the two groups. Both average choroidal thickness and vessel density were significantly lower in eyes with RPD. Conclusions: Our fully automated choroidal segmentation algorithm was able to capture the different patterns of choroidal thickness over a wide area. Choroidal thickness has a clear relationship with the density of large choroid vessels in our sample, irrespective of the presence or absence of RPD.