A Right-Sided Approach to Anterior Communicating Artery Aneurysms: A Case Review and Technical Report.

Anterior communicating artery (ACoA) aneurysms are the most frequently encountered type of intracranial aneurysm. ACoA aneurysms may require treatment depending on clinical presentation, size, risk of rupture, and ruptured status. In patients where treatment is indicated, options entail endovascular securement or clipping. Under the clipping umbrella, surgical approaches traditionally entail a pterional craniotomy and its modifications such as the lateral supraorbital approach. Sidedness of this craniotomy has been a topic of debate. To discuss this we present a case and technical report with nuances of the approach wherein a 48-year-old female presented with the worst headache of her life. The patient was found to have a ruptured wide-necked 7.2 x 8.1 x 5.8 mm ACoA aneurysm more eccentric to the left and fed from the left A1 intertwined with a frontopolar branch, numerous perforators and the recurrent artery of Heubner. The patient underwent a successful clipping from a right-sided approach. As such, with appropriate skull base drilling, exposure, optimization of brain relaxation, and a generous opening of the Sylvian fissure bilateral internal carotid arteries, anterior cerebral arteries with both A1 and A2 segments, middle cerebral arteries, the ACoA, and the relevant anatomy can be appropriately visualized from a right-sided approach. Therefore, an approach is described to optimize exposure to allow for nearly all anterior communicating aneurysms to be clipped from a right-sided pterional approach.

Immunomodulatory Effect of Electromagnetic Field in the Treatment of Traumatic Brain Injury.

A review was performed utilizing PubMed and GoogleScholar to highlight the future directions of EMF research in the setting of brain pathology, specifically in ischemic and traumatic brain injury. Additionally, a critical review of the current state-of-the art of EMF use in treating brain pathology has been conducted. The authors have added to this large body of research their own experimental studies, including a description of the on-going studies. The field of EMF utilization in the diagnosis and treatment of brain injury is highly promising and warrant careful studies in clinically relevant experimental models followed by human trials in TBI.

Thoracic Pedicle Screw Placement Utilizing Hands-On Training Session on Three-Dimensional Models.

The utilization of three-dimensional (3D) models has been an important element of medical education. We demonstrate a three-dimensionally-printed (3DP) thoracic spine model for use in the teaching of freehand pedicle screw placement. Neurosurgical residents with varying years of experience practiced screw placement on these models. Residents were timed, and models were evaluated for medial and lateral breaches. Overall, this technical report describes the utility of 3D spine models in the training of thoracic pedicle screw placement. The tactile feedback from the 3D models was designed to represent both cortical and cancellous bones.

External Ventricular Drain (EVD) Placement Using a Hands-On Training Session on a Simple Three-Dimensional (3D) Model.

Neurosurgery is a demanding field with small margins of error within the operative field. Small errors can yield devastating consequences. Simulation has been proposed as a methodology for improving surgical skills within the neurosurgical realm. This study was conducted to investigate a novel realistic design for a clinical simulation based, low-cost alternative of external ventricular drain (EVD) placement, an essential basic neurosurgical procedure that is necessary for clinicians to master. A low-cost three-dimensional (3D) printed head using thermoplastic polylactic acid was designed with the tactile feedback of outer table, cancellous bone, and inner tables for drilling with replaceable frontal bones pieces for multi-use purposes. An agar gel filled with water was designed to simulate tactile passage through the cortex and into the ventricles. Neurosurgical and emergency resident physicians participated in a didactic session and then attempted placement of an EVD using the model to gauge the simulated model for accuracy and realism. Positioning, procedural time, and realism was evaluated. Improvements in procedural time and positioning were identified for both neurosurgical and emergency medicine (EM) residents. Catheter placement was within ideal position for all participants by the third attempt. All residents stated they felt more comfortable with placement with subsequent attempts. Neurosurgical residents subjectively noted similarities in tactile feedback during drilling compared to in-vivo. A low-cost realistic 3D printed model simulating basic neurosurgical procedures demonstrated improved procedural times and precision with neurosurgical and EM residents. Further, similarities between in-vivo tactile feedback and the low-cost simulation technology was noted. This low cost-model may be used as an adjunct for teaching to promote early procedural competency in neurosurgical techniques to promote learning without predisposition to patient morbidity.

The Awake Craniotomy: A Patient's Experience and A Literature Review.

We present a case report and a literature review of the awake craniotomy procedure for mass resection, with emphasis on the historical aspects, anatomical and surgical considerations, and, uniquely, a patient's experience undergoing this procedure. This procedure is a safe and effective method for lesion resection when working in and around eloquent brain. We have described our process of guiding a patient through an awake craniotomy procedure and detailed the patient's experience in this study. We also conducted a systematic literature review of studies involving awake craniotomy over three years, 2018-2021. Lastly, we compared the methodology used by our institution and the current mostly used methods within the neurosurgical community. Several studies were identified using PubMed and Google Scholar. Awake craniotomy is a safe and effective method of achieving a high rate of resection of lesions located in and around the eloquent cortex with a low degree of postoperative neurological deficit.

Changing Frequency of the Use of Intraoperative Equipment Among Neurosurgeons, Neurosurgery Residency Faculty, and Neurosurgery Residents.

Neurosurgical procedures have relied on the use of various intraoperative equipment since its advent. These include an operative microscope, ultrasound, and loupes with a headlight. The necessity of these pieces of equipment makes them vital in the training of residents as well. A national survey utilizing a Likert scale to determine how often loupes, microscopes, and ultrasound were used for various neurosurgeries was created. This was then compared to a single program's responses, and it identified that the practice parameters of residents closely modeled those behaviors portrayed by their attending mentors. It appears that the higher frequency of use by residents when compared to faculty and neurosurgeons nationwide highlights the importance of this equipment in training neurosurgical residents.  As such, they should be available to residents from the onset of training to promote the highest quality of learning. Faculty should encourage the use of this equipment by leading by example, and residents, in turn, should use all the available equipment as often as possible to maximize the quality of their training. Modulating the use of learning technologies can be accomplished if it is a nationally accepted practice, discussed in an academic setting with the residents, and modeled by the faculty.

Measuring the Electromagnetic Field of the Human Brain at a Distance Using a Shielded Electromagnetic Field Channel.

Introduction The electromagnetic field (EMF) of the human brain generated by the movement of ions in the brain can be measured in a novel manner. The measurement can be completed through the skull, in a non-contact, non-invasive, continuous manner using a lightweight helmet. This investigation was conducted to determine if brain activity from movement and thoughts of movement can be measured at a distance and if that measurement can be readily evaluated at a distance using shielding with a shielded helmet and a shielded EMF channel surrounding a sensor. Methods Non-clinical human subject volunteers donned a lightweight sensor helmet and performed a variety of specific tasks synchronized with an audible tone generated by a metronome. Constructs were created to determine if the human subjects' brain EMF can be recorded at a distance using sensors surrounded by shielding acting similar to a waveguide in an EMF channel connected to a shielded helmet. Results The EMF sensors appeared to record brain electromagnetic activity as it is funneled into a shielded channel acting as a waveguide at a considerable distance including distances as far as 63 cm away. Conclusion Specific brain EMFs from movement, thoughts of movement, and emotional thought can be continuously measured in a non-contact fashion at a distance using an EMF waveguide approach with an EMF channel and shielded helmet.

Evaluating the Intrinsic Electromagnetic Field Generated by Neurons From Repetitive Motor Activities in Humans With a Non-contact Non-invasive Electromagnetic Helmet.

Introduction The actions of neurons are dependent on electrochemical signal pathways mediated by neurotransmitters and create measurable electrical charges. These charges have been found to be measurable through neuroimaging technologies and now through a novel non-contact non-invasive sensor without supercooling. Identifying whether this technology can be appropriately interpreted with synchronized motor well-defined activities in vivo may allow for further clinical applications. Methods A non-contact, non-invasive helmet constructed and modified using shielding technology with proprietary magnetic field sensors was utilized to measure the brain's electromagnetic field (EMF). Human volunteers donned helmets and were asked to perform repetitive tapping exercises in order to identify waves consistent with tapping from the left and right hemispheres. A gyroscope was utilized to ensure that measured waves were not from micro-movement but were from neuronal firing. Multiple individuals were tested to evaluate the reproducibility of tapping and commonalities between individuals Results Right and left-sided tapping generated discernible wave changes from baseline measurements obtained by the helmet without a subject as well as differed from when the subject was at rest. Wave patterns varied from person to person but were overall similar in each subject individually. Shielding was necessary to identify signals but EMF was identified when shielding was transitioned from around the helmet to within the helmet design. Conclusion It is possible to measure in-vivo electromagnetic fields generated by the human brain generated by stereotyped tasks in a non-contact non-invasive manner. These waves were reliably obtained within each individual with some variability in morphology from subject to subject however were similar in each subject. Signals varied based on activity and stereotyped motor activities were identified. A helmet using shielding technology within the helmet itself was able to effectively identify EMF signals. Future analysis may focus on translating these waves into functional mapping for clinical applications.

Measuring Electromagnetic Field Activity Generated by Neurons In Vivo by Humans With Thoughts of Repetitive Motor Activities and Emotional Thoughts.

Background In this study, a novel method of electromagnetic field (EMF) measurements of the human brain has been performed to evaluate neuronal activity. This measurement in a non-contact, non-invasive, continuous manner through the human skull and scalp in the standard environment is completed through a lightweight inexpensive helmet. We sought to further delineate whether specific activities of complex thought can be identified using this non-invasive technique. Methodology Non-clinical human subject volunteers donned a lightweight helmet with attached sensors and performed activities of motor movement, specific motor imagery, and specific emotional imagery synchronized to an audible tone for consistency. The human subjects' brain EMF was recorded and analyzed. Results The novel method of continuously recording real-time human brain EMF was able to determine differing brain activity between individuals performing motor movement, motor imagery, and emotional imagery in a non-contact manner at different distances from the scalp. Conclusions It may be possible to measure specific human brain activity using EMF in a non-invasive fashion. Emotional imagery, motor imagery, and motor movement generate different EMFs that have different discernible forms compared to baseline activity.

Novel Method of Electromagnetic Field Measurements of the Human Brain.

Introduction Advancements in neuroimaging have changed the field of medicine. Computed tomography (CT) and magnetic resonance imaging (MRI) typically produce a static image of the brain, while continuous electroencephalogram (EEG) data is limited to the cortical surface. The brain's chemical reactions produce an electric circuit that generates a magnetic field. We seek to test the ability of a non-contact sensor to measure the human brain's electromagnetic field (EMF). Methods A lightweight, inexpensive construct was designed to hold EMF sensors to non-invasively measure the human brain's dynamic EMF. Measurements were conducted on non-clinical human volunteers. Background data without the human subjects was obtained, followed by introducing human subjects. Motionless human subject data was obtained, followed by a subject performing a task. Finally, a subject received auditory stimulation, and data was obtained. Results Our non-contact sensor was able to detect a difference between background activity without a human subject and the electromagnetic field of a human brain within the scalp and skull. Detectable differences in magnetic field potential were also obtained when the subject performed a task and received auditory stimulation. Conclusion It is possible to continuously measure living human brain dynamic electromagnetic fields throughout the entire brain in a non-contact, non-invasive, continuous manner through the human scalp and skull in the standard environment. The signals are unique to the individual human and can be differentiated from background activity.

P13BP, a Calpain-2-Mediated Breakdown Product of PTPN13, Is a Novel Blood Biomarker for Traumatic Brain Injury.

Biomarkers play an increasing role in medicinal biology. They are used for diagnosis, management, drug target identification, drug responses, and disease prognosis. We have discovered that calpain-1 and calpain-2 play opposite functions in neurodegeneration, with calpain-1 activation being neuroprotective, while prolonged calpain-2 activation is neurodegenerative. This notion has been validated in several mouse models of acute neuronal injury, in particular in mouse models of traumatic brain injury (TBI) and repeated concussions. We have identified a selective substrate of calpain-2, the tyrosine phosphatase, PTPN13, which is cleaved in brain after TBI. One of the fragments generated by calpain-2, referred to as P13BP, is also found in the blood after TBI both in mice and humans. In humans, P13BP blood levels are significantly correlated with the severity of TBI, as measured by Glasgow Coma Scale scores and loss of consciousness. The results indicate that P13BP represents a novel blood biomarker for TBI.

Medical Comorbidities Associated With Outcomes in Patients With Traumatic Epidural Hematomas.

Background Traumatic brain injury (TBI) is a frequently encountered neurosurgical pathology with significant morbidity and mortality. One such subtype is the epidural hematoma. Literature regarding the effects of comorbidities in TBI and epidural hematomas is limited. Methodology This was a single-center retrospective review of 50 consecutive patients admitted to a level two trauma center with epidural hematomas. Patients were identified using an internal trauma database. Patients were included if they were 18 years of age with a diagnosed epidural hematoma. Outcome variables of Glasgow coma scale (GCS), length of stay in the intensive care unit (ICU) and hospital, and requirement of a neurosurgical procedure were analyzed. Identification of the presence of diagnosed comorbidities was performed including common comorbidities such as obesity, diabetes, hypertension, hyperlipidemia, drug use, tobacco use, cancer, psychiatric disease, and renal disease. Correlations were evaluated using two-sided bivariate analysis (p < 0.05). Results A total of 50 patients were included for analysis. Significant correlations with a p-value less of than 0.05 were noted in initial GCS and cancer (r = -0.357, p = 0.011), requirements of an intracranial procedure with a history of gastrointestinal disease (r = 0.377, p = 0.007), and younger age (r = -0.306, p = 0.031). Increased ICU length of stay was related to a history of cancer (r = 0.494, p < 0.001), a history of respiratory disease (r = 0.427, p = 0.002), and a history of psychiatric disease (r = 0.297, p = 0.036). Increased hospital length of stay was related to psychiatric disorders (r = 0.285, p = 0.045). Discharge GCS was negatively associated with a history of hypertension (r = -0.374, p = 0.008), tobacco use (r = -0.417, p = 0.003), drug use (r = -0.294, p = 0.037), and history of cancer (r = -0.303, p = 0.032). Discussion and Conclusions In our 50 consecutive patient subset, selected comorbidities demonstrated significant relationships with outcome measures of GCS, need for a procedure, and lengths of stay in the hospital and ICU. Obtaining comorbidity information when available from families can better allow the clinician to optimize treatment and educate loved ones about the potential effects of these comorbidities on the overall health of the patient. Understanding these correlations may allow for a better understanding of the systemic effects of the pathophysiology of injury in epidural hematomas.

Using the Decrease in Trauma Admissions During the COVID-19 Pandemic to Evaluate Compliance With Stay-at-Home and Social Distancing Guidelines.

Introduction The coronavirus disease 2019 (COVID-19) virus was declared a pandemic on March 10, 2020 by the World Health Organization (WHO) and has massively burdened healthcare systems with cases exponentially rising throughout the United States and the rest of the world. Since implementing precautions to reduce the spread of this disease, emergency departments have seen a decrease in the number of traumas. By evaluating the differences in the number of trauma admissions in different subgroups of patients, we can assess where to target messaging to increase compliance with these precautions. In this study, we aim to analyze the effect of the COVID-19 pandemic on trauma admissions. Methodology This was a retrospective review of the trauma database at our institution, a level 2 trauma center in Southern California, to assess the impact of COVID-19 on the number of traumas. The inclusion criteria were patients activated as traumas, regardless of age. Patients were excluded from the study if they did not have complete information in the trauma database. Data were stratified by date into two groups: (a) COVID period (January to April 2020) and (b) pre-COVID period (January to April 2019). The primary endpoint of this study was to determine whether there was a significant change in the number of patients presenting as trauma during the COVID-19 pandemic. This difference was analyzed and divided into subgroups based on age and trauma type. Results In our review, an average of 279 patients per month presented as trauma from January to April in 2019, and an average of 222 patients per month presented as trauma from January to April 2020 (p = 0.049). We found a significant decrease in the number of patients presenting with the chief complaint of fall and vehicular accident, but a nonsignificant difference in patients presenting as assaults or pedestrian accidents. There was also a significant decrease in the number of traumas in the 18-39 and 65+ age groups and a nonsignificant decrease in the 40-64 age group. It was also noted that the number of trauma admissions in May 2020 increased to 253 compared to 269 in 2019. This increase was most notable in the 18-39 and 40-64 age groups. Discussion As seen in the data, the most notable year-over-year difference was seen in March and April. In California specifically, a stay-at-home order was set in place in March, which was in conjunction with the WHO's declaration of a pandemic. An interesting finding was the significant decrease in patients with traumas in the age groups of 18-39 and 65+ from 2019 to 2020. There was a smaller, nonsignificant decrease in patients aged 40-64. This would be a good group to target with future messaging to increase compliance with health advisories. There was also a notable increase in the number of traumas in May 2020, signaling an end to the cooperation of the majority of people, also indicating that further measures needed to be enacted in all groups. Conclusions COVID-19 has disrupted social structures worldwide. As the pandemic continued, even the observers of stay-at-home and social distancing measures, the 18-39 age group, became fatigued with the guidelines and ventured out into the warming weather and summer activities. This difference in trauma admission due to COVID-19 between subsequent years can highlight the behavioral changes in our patient population and can be further extrapolated to target additional messaging to help reduce the spread of COVID-19.

Osteopathic Manipulative Treatment to Optimize the Glymphatic Environment in Severe Traumatic Brain Injury Measured With Optic Nerve Sheath Diameter, Intracranial Pressure Monitoring, and Neurological Pupil Index.

Background Traumatic brain injury (TBI) has a complex pathophysiology that has historically been poorly understood. New evidence on the pathophysiology, molecular biology, and diagnostic studies involved in TBI have shed new light on optimizing rehabilitation and recovery. The goal of this study was to assess the effect of osteopathic manipulative treatment (OMT) on peripheral and central glial lymphatics in patients with severe TBI, brain edema, and elevated intracranial pressure (ICP) by measuring changes in several parameters regularly used in management. Methodology This was a retrospective study at a level II trauma center that occurred in 2018. The study enrolled patients with TBI, increased ICP, or brain edema who had an external ventricular drain placed. Patients previously underwent a 51-minute treatment with OMT with an established protocol. Patients received 51 minutes of OMT to the head, neck, and peripheral lymphatics. The ICP, cerebrospinal fluid (CSF) drainage, optic nerve sheath diameter (ONSD) measured by ultrasonography, and Neurological Pupil Index (NPi) measured by pupillometer were recorded before, during, and after receiving OMT. Results A total of 11 patients were included in the study, and 21 points of data were collected from the patients meeting inclusion criteria who received OMT. There was a mean decrease in the ONSD of 0.62 mm from 6.24 mm to 5.62 mm (P = 0.0001). The mean increase in NPi was 0.18 (P = 0.01). The mean decrease in ICP was 3.33 mmHg (P= 0.0001). There was a significant decrease in CSF output after treatment (P = 0.0001). Each measurement of ICP, ONSD, and NPi demonstrated a decrease in overall CSF volume and pressure after OMT compared to CSF output and ICP prior to OMT. Conclusions This study demonstrates that OMT may help optimize glial lymphatic clearance of CSF and improve brain edema, interstitial waste product removal, NPi, ICP, CSF volume, and ONSD. A holistic approach including OMT may be considered to enhance management in TBI patients. As TBI is a spectrum of disease, utilizing similar techniques may be considered for all forms of TBI including concussions and other diseases with brain edema. The results of this study can better inform future trials to specifically study the effectiveness of OMT in post-concussive treatment and in those with mild-to-moderate TBI.

Risk Factors Associated with 90-day Readmissions Following Odontoid Fractures: A Nationwide Readmissions Database Study.

STUDY DESIGN: Nationwide Readmissions Database Study. OBJECTIVE: The aim of this study was to investigate readmission rates and factors related to readmission after surgical and nonsurgical management of odontoid fractures. SUMMARY OF BACKGROUND DATA: Management of odontoid fractures, which are the most common isolated spine fracture in the elderly, continues to be debated. The choice between surgical or nonsurgical treatment has been reported to impact mortality and might influence readmission rates. Hospital readmissions represent a large financial burden upon our healthcare system. Factors surrounding hospital readmissions would benefit from a better understanding of their associated causes to lower health care costs. METHODS: A retrospective study was performed using the 2016 Healthcare Utilization Project (HCUP) Nationwide Readmission Database (NRD). Demographic information and factors associated with readmission were collected. Readmission rates, complications, length of hospital stay were collected. Patients treated operatively, nonoperatively, and patients who were readmitted or not readmitted were compared. Statistical analysis was performed using open source software SciPy (Python v1.3.0) for all analyses. RESULTS: We identified 2921 patients who presented with Type II dens fractures from January 1, 2016 to September 30, 2016, 555 of which underwent surgical intervention. The readmission rate in patients who underwent surgery was 16.4% (91/555) and 29.4% (696/2366) in the nonoperative group. Hospital costs for readmitted and nonreadmitted patients were $353,704 and $174,922, and $197,099 and $80,715 for nonoperatively managed patients, respectively. Medicaid and Medicare patients had the highest readmission rate in both groups. Charlson and Elixhauser comorbidity indices were significantly higher in patients who were readmitted (P < 0.0001). CONCLUSION: We report an overall 90-day readmission rate of 16.4% and 29.4%, in operative and nonoperative management of type II odontoid fractures, respectively. In the face of a rising incidence of this fracture in the elderly population, an understanding of the comorbidities and age-related demographics associated with 90-day readmissions following both surgical and nonsurgical treatment are critical.Level of Evidence: 3.

Inflammatory Markers in Severity of Intracerebral Hemorrhage II: A Follow Up Study.

Introduction Spontaneous intracerebral hemorrhage (ICH) results in significant morbidity and mortality. The pathogenesis of brain injury after ICH is thought to be due to mechanical damage followed by ischemic, cytotoxic, and inflammatory changes in the underlying and surrounding tissue. Various inflammatory and non-inflammatory biomarkers have been studied as predictors and potential therapeutic targets for intracerebral hemorrhage. Our prior study showed an association with low vascular endothelial growth factor (VEGF) levels and increased mortality. This current study looks to expand on our prior results and will look at the relationship between tumor necrosis factor alpha (TNFα), C-reactive protein (CRP), VEGF, Homocysteine (Hcy), and CRP to albumin ratio (CAR) in predicting outcomes and severity in spontaneous intracerebral hemorrhage. Methods We conducted a retrospective chart review of patients with spontaneous intracerebral hemorrhage with TNFα, CRP, VEGF, Hcy levels drawn on admission. Albumin and CRP levels on admission were used to calculate CAR. Ninety-nine patients were included in the study. Primary outcomes included death, early neurologic decline (END), and hemorrhage size. Secondary outcomes included late neurologic decline (LND), Glasgow Coma Scale (GCS) on admission, GCS on discharge, ICH score, change in hemorrhage size, need for surgical intervention, and length of ICU stay. Results A total of 99 patients were included in this study, with 42% requiring surgical intervention and an overall mortality of 16%. Basal ganglia hemorrhage was seen in 41% of patients. Hcy and CAR were significantly correlated with ICH size in basal ganglia patients (r-=0.36, p=0.03; r=0.43, p=0.03, respectively). CAR was significantly correlated with ICH score (r=0.33, p=0.007874). Admission VEGF levels less than 45 pg/ml had 8.4-fold increase in mortality (odds ratio [OR] 8.4545, p=0.0488). Patients with TNFα levels greater than 1.40 pg/ml had a 4.1-fold increase in mortality (OR 4.1, p=0.04) Conclusion Our study demonstrated that low levels (<45 pg/ml) of VEGF were associated with an 8.4-fold increase in mortality, supporting the neuroprotective effect of this protein. Elevated Hcy and CAR levels were associated with an increase in hemorrhage size in patients with basal ganglia hemorrhages. TNFα levels greater than 1.40 pg/ml were associated with a 4.1-fold increase in mortality, and this together with CAR being correlated with increased hemorrhage size and ICH score further demonstrate the inflammatory consequences after intracerebral hemorrhage. Future studies directed at lowering CRP, TNFα, and Hcy and/or increasing VEGF in intracerebral hemorrhage patients are needed and may be beneficial.

Timing of Chemoradiation in Newly Diagnosed Glioblastoma: Comparative Analysis Between County and Managed Care Health Care Models.

BACKGROUND: Glioblastoma multiforme (GBM) is a primary brain malignancy with significant morbidity and mortality. The current standard of treatment for GBM is surgery followed by radiotherapy and temozolomide. Despite an established treatment protocol, there exists heterogeneity in outcomes due to patients not receiving all treatments. We analyzed patients in different health care models to investigate this heterogeneity. METHODS: A retrospective analysis was performed at 2 hospitals in San Bernardino County, California, for patients with newly diagnosed GBM from 2004 to 2019. Patients younger than 18 years of age, with history of low-grade glioma, who had undergone prior treatment, and those lost to follow-up were excluded. RESULTS: A total of 57 patients were included in our study. Chemotherapy was started at 41 ± 30 and 77 ± 68 days in the health maintenance organization (HMO) and county model, respectively (P = 0.050); radiation therapy was started at 46 ± 34 and 85 ± 76 days in the HMO and county models, respectively (P = 0.036). In individuals who underwent both chemotherapy and radiation therapy (XRT), the difference in time to XRT was no longer significant (P = 0.060). Recurrence time was 309 ± 263 and 212 ± 180 days in the HMO and county groups, respectively (P = 0.379). The time to death was 412 ± 285 and 343 ± 304 days for HMO and county models, respectively (P = 0.334). CONCLUSIONS: Our study demonstrates a statistically significant difference in time to adjuvant therapies between patients within a county hospital and a managed health care organization. This information has the potential to inform future policies and care coordination for patients within the county model.

Retraction: Racial Disparity Amongst Stroke Patients During the Coronavirus Disease 2019 Pandemic.

[This retracts the article DOI: 10.7759/cureus.10369.].

Spinal Arteriovenous Malformation: Case Report and Review of the Literature.

Spinal arteriovenous malformations (AVMs) are a rare form of spinal blood vessel defect that results in vessel engorgement leading to clinical signs secondary to mass effect and ischemia. We present the patient's clinical course following suspicion of spinal AVM along with a review of current classification and imaging modalities.

Generalized Dystonia Treated With Deep Brain Stimulator: An Institutional Single Surgeon Experience.

Introduction Dystonia can cause severe disability when left untreated. Once a patient has exhausted medical management, surgical intervention may be the only treatment option. Although not curative, deep brain stimulation has been shown to be beneficial for patients affected by this condition. Our study sought to review patients undergoing deep brain stimulation for medically refractory dystonia to assess outcomes. Methods Our institution's operative database was reviewed retrospectively for all patients undergoing deep brain stimulator placement over the last six years. These medical records were reviewed for the severity of dystonia preoperatively and followed postoperatively for 24 months, focusing on the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). Patients with less than two-year postoperative follow-up were excluded from the study. The patients were further stratified by age into Group A, consisting of patients less than 40 years old, and Group B, patients greater than or equal to 40 years old. Other attributes such as age, sex, age of disease onset, disease duration at the time of surgery, genetic tests for dystonia-related genes, and any complication associated with surgery were also reviewed. Results Four hundred fifty-five operative cases for deep brain stimulator placement were reviewed, and 16 patients met inclusion criteria for the study. The mean age for our patient cohort was 43.75 years, with four males and 12 females. The average time from the age of disease onset to time of surgery was 9.7 years for Group A and 10.8 years for Group B; the overall average was 10.3 years. All patients had globus pallidus interna (GPi) as their surgical target. The first incidence of a statistically significant decrease in BFMDRS score was noted at three months postoperatively (p<0.001) when compared to preoperative values. Fourteen patients in our cohort underwent preoperative genetic testing for DYT gene mutations, out of which four were found to have a mutation. Conclusion Our review of outcomes for primary generalized dystonia at our institution found that deep brain stimulator targeting the GPi is safe and effective. We found an overall 88% response rate with younger patients (< 40-year-old) showing a better response at two years than older patients.