Assessing the Suitability of Artificial Intelligence-Based Chatbots as Counseling Agents for Patients with Brain Tumor: A Comprehensive Survey Analysis.

OBJECTIVE: The internet, particularly social media, has become a popular resource for learning about health and investigating one's own health conditions. The development of artificial intelligence (AI) chatbots has been fueled by the increasing availability of digital health data and advances in natural language processing techniques. While these chatbots are more accessible than before, they sometimes fail to provide accurate information. METHODS: We used representative chatbots currently available (Chat Generative Pretrained Transformer-3.5, Bing Chat, and Google Bard) to answer questions commonly asked by brain tumor patients. The simulated situations with questions were made and selected by the brain tumor committee. These questions are commonly asked by brain tumor patients. The goal of the study was introduced to each chatbot, the situation was explained, and questions were asked. All responses were collected without modification. The answers were shown to the committee members, and they were asked to judge the responses while blinded to the type of chatbot. RESULTS: There was no significant difference in accuracy and communication ability among the 3 groups (P = 0.253, 0.090, respectively). For empathy, Bing Chat and Google Bard were superior to Chat Generative Pretrained Transformer (P = 0.004, 0.002, respectively). The purpose of this study was not to assess or verify the relative superiority of each chatbot. Instead, the aim was to identify the shortcomings and changes needed if AI chatbots are to be used for patient medical purposes. CONCLUSION: AI-based chatbots are a convenient way for patients and the general public to access medical information. Under such circumstances, medical professionals must ensure that the information provided to chatbot users is accurate and safe.

Preliminary Report of Fully Endoscopic Microvascular Decompression.

Objective: Microscopic microvascular decompression (MVD) has been considered to be a useful treatment modality for medically refractory hemifacial spasm (HFS) and trigeminal neuralgia (TN). But, the advent of the endoscopic era has presented new possibilities to MVD surgery. While the microscope remains a valuable tool, the endoscope offers several advantages with comparable clinical outcomes. Thus, fully endoscopic MVD (E-MVD) could be a reasonable alternative to microscopic MVD. This paper explores the safety and efficacy of the fully E-MVD technique. Methods: A single-center retrospective study was conducted in 25 patients diagnosed with HFS between September 2019 and July 2023. All surgeries were performed by a single neurosurgeon using the fully E-MVD technique without any assistance of a microscope. The study reviewed intraoperative brainstem auditory evoked potentials and disappearance of the lateral spread response. Outcomes were assessed based on the patients' clinical status immediately after surgery and at their last follow-up. Complications, including facial palsy, hearing loss, ataxia, dysphagia, palsy of other cranial nerves, and cerebrospinal fluid (CSF) leakage, were also examined. Results: The most common offending artery was the anterior inferior cerebellar artery (AICA) in 15 cases (60.0%), followed by the posterior inferior cerebellar artery (PICA) in 8 cases (32.0%), vertebral artery (VA) in 1 case (4.0%), tandem lesions involving the AICA and VA in 1 case (4.0%). Ten patients (40.0%) had pre-operative facial palsy on the ipsilateral side, and 8 patients (32.0%) experienced delayed facial palsy on the ipsilateral side, from which they fully recovered by the last follow-up. The median operation time was 105 minutes. All patients were symptom free immediately after surgery and at the last follow-up. One patient experienced a permanent complication, such as high-frequency hearing loss, from which he partially recovered over time. Conclusion: Fully E-MVD demonstrated similar clinical outcomes to microscopic MVD. It offered a similar complication rate, shorter operation time, and a panoramic view with a smaller craniectomy size. Although there is a learning curve associated with fully E-MVD, it presents a viable alternative in the endoscopic era.

Strategy of stretched Coils: Insights from a single center experience.

OBJECTIVE: A stretched coil, characterized by excessive elongation within the parent artery during a coil embolization procedure, poses a significant risk of forming a thrombus. This study reports on cases of stretched coils spanning 16 years and discusses effective assessment methods and treatment strategies. METHOD: Retrospective analysis of the institutional database comprising 14 cases where stretched coils were observed during coil embolization procedures was conducted, starting from January 2007. RESULTS: Among the 14 cases, four involved coil embolization for subarachnoid hemorrhage due to ruptured aneurysm, while the remaining cases were unruptured aneurysms. Starting in 2017, vaso-computed tomography (vaso-CT) was employed in nine cases to evaluate the proximal end of the stretched coils. Reimplantation was performed in 3 cases. Among them, two cases were relieved by pushing the coil delivery wire or microwire, while one case underwent balloon-assisted reimplantation. The stretched coils were removed in three cases by pulling. A rescue gooseneck microsnare technique was applied in one case. The stent was fixed in five cases. In two cases, no additional procedures were performed. Thrombosis is a potential complication that occurred in three cases of stretched coils. CONCLUSION: Many studies have addressed coil stretching and introduced various rescue methods, but relying solely on angiography for diagnosis or applying an inappropriate rescue technique can lead to ischemic stroke. This study emphasized the importance of vaso-CT as a tool for accurately identifying the proximal end of a stretched coil. Additionally, we aimed to facilitate the selection of an appropriate rescue technique.

Navigation guided small craniectomy and direct cannulation of pure isolated sigmoid sinus for treatment of dural arteriovenous fistula.

Dural arteriovenous fistula (DAVF) is a rare condition affecting approximately 1.5% of 1,000,000 individuals annually. It frequently occurs in the transsigmoid and cavernous sinuses. An isolated sigmoid sinus is extremely rare and is treated by performing transfemoral transvenous embolization along the opposite transverse sinus. A 69-year-old woman presented with asymptomatic Borden type III/Cognard type III DAVF involving an isolated sigmoid sinus. She underwent a staged operation in which a navigation system was used to expose the sigmoid sinus in the operating room before transferring the patient to the angio suite for transvenous embolization. Various modalities have been used to treat DAVF, including surgical disconnection, transarterial embolization, transvenous embolization, and stereotactic radiosurgery. However, treating DAVF cases where the affected sinus is isolated can be challenging because an easily accessible surgical route may not be available. In this case, direct sinus cannulation and transvenous embolization were the most effective treatments.

Optimization of a Protocol for Isolating Cell-free DNA From Cerebrospinal Fluid.

A standardized protocol for the isolation of cell-free DNA (cfDNA) from cerebrospinal fluid (CSF) is lacking. Therefore, we established a cfDNA isolation protocol optimized for clinical CSF specimens, integrating acceptable modifications and using artificial CSF generated from remnant CSF spiked with reference cell-free tumor DNA (ctDNA). We compared the isolation yields of in vitro diagnostic (IVD)-certified column-based (CB) and magnetic bead-based (MB) isolation. Furthermore, we modified both methods, including pre- and post-elution steps. To confirm ctDNA integrity and quantify the variant allele frequency after isolation, we performed droplet digital PCR (ddPCR) targeting IDH1 R132C in the reference ctDNA. MB isolation had a higher yield than CB isolation (P<0.0001), and post-isolation vacuum increased the final concentration in both methods, with little effect on cfDNA integrity. Our study provides a protocol to maximize CSF-ctDNA concentrations in IVD testing and future studies.

Deep Sedation in Traumatic Brain Injury Patients.

Traumatic brain injury (TBI) is one of the leading causes of mortality and disability in adults. In cases of severe TBI, preventing secondary brain injury by managing intracranial hypertension during the acute phase is a critical treatment challenge. Among surgical and medical interventions to control intracranial pressure (ICP), deep sedation can provide comfort to patients and directly control ICP by regulating cerebral metabolism. However, insufficient sedation does not achieve the intended treatment goals, and excessive sedation can lead to fatal sedative-related complications. Therefore, it is important to continuously monitor and titrate sedatives by measuring the appropriate depth of sedation. In this review, we discuss the effectiveness of deep sedation, techniques to monitor the depth of sedation, and the clinical use of recommended sedatives, barbiturates, and propofol in TBI.

The Korean Society for Neuro-Oncology (KSNO) Guideline for the Management of Brain Tumor Patients During the Crisis Period: A Consensus Recommendation Using the Delphi Method (Version 2023.1).

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, the need for appropriate treatment guidelines for patients with brain tumors was indispensable due to the lack and limitations of medical resources. Thus, the Korean Society for Neuro-Oncology (KSNO), a multidisciplinary academic society, has undertaken efforts to develop a guideline that is tailored to the domestic situation and that can be used in similar crisis situations in the future. METHODS: The KSNO Guideline Working Group was composed of 22 multidisciplinary experts on neuro-oncology in Korea. In order to reach consensus among the experts, the Delphi method was used to build up the final recommendations. RESULTS: All participating experts completed the series of surveys, and the results of final survey were used to draft the current consensus recommendations. Priority levels of surgery and radiotherapy during crises were proposed using appropriate time window-based criteria for management outcome. The highest priority for surgery is assigned to patients who are life-threatening or have a risk of significant impact on a patient's prognosis unless immediate intervention is given within 24-48 hours. As for the radiotherapy, patients who are at risk of compromising their overall survival or neurological status within 4-6 weeks are assigned to the highest priority. Curative-intent chemotherapy has the highest priority, followed by neoadjuvant/adjuvant and palliative chemotherapy during a crisis period. Telemedicine should be actively considered as a management tool for brain tumor patients during the mass infection crises such as the COVID-19 pandemic. CONCLUSION: It is crucial that adequate medical care for patients with brain tumors is maintained and provided, even during times of crisis. This guideline will serve as a valuable resource, assisting in the delivery of treatment to brain tumor patients in the event of any future crisis.

The Korean Society for Neuro-Oncology (KSNO) Guideline for the Management of Brain Tumor Patients During the Crisis Period: A Consensus Survey About Specific Clinical Scenarios (Version 2023.1).

BACKGROUND: During the coronavirus disease 2019 (COVID-19) pandemic, there was a shortage of medical resources and the need for proper treatment guidelines for brain tumor patients became more pressing. Thus, the Korean Society for Neuro-Oncology (KSNO), a multidisciplinary academic society, has undertaken efforts to develop a guideline that is tailored to the domestic situation and that can be used in similar crisis situations in the future. As part II of the guideline, this consensus survey is to suggest management options in specific clinical scenarios during the crisis period. METHODS: The KSNO Guideline Working Group consisted of 22 multidisciplinary experts on neuro-oncology in Korea. In order to confirm a consensus reached by the experts, opinions on 5 specific clinical scenarios about the management of brain tumor patients during the crisis period were devised and asked. To build-up the consensus process, Delphi method was employed. RESULTS: The summary of the final consensus from each scenario are as follows. For patients with newly diagnosed astrocytoma with isocitrate dehydrogenase (IDH)-mutant and oligodendroglioma with IDH-mutant/1p19q codeleted, observation was preferred for patients with low-risk, World Health Organization (WHO) grade 2, and Karnofsky Performance Scale (KPS) ≥60, while adjuvant radiotherapy alone was preferred for patients with high-risk, WHO grade 2, and KPS ≥60. For newly diagnosed patients with glioblastoma, the most preferred adjuvant treatment strategy after surgery was radiotherapy plus temozolomide except for patients aged ≥70 years with KPS of 60 and unmethylated MGMT promoters. In patients with symptomatic brain metastasis, the preferred treatment differed according to the number of brain metastasis and performance status. For patients with newly diagnosed atypical meningioma, adjuvant radiation was deferred in patients with older age, poor performance status, complete resection, or low mitotic count. CONCLUSION: It is imperative that proper medical care for brain tumor patients be sustained and provided, even during the crisis period. The findings of this consensus survey will be a useful reference in determining appropriate treatment options for brain tumor patients in the specific clinical scenarios covered by the survey during the future crisis.

Long-term outcomes of carotid artery stenting in patients with carotid artery stenosis: A single-center 14-year retrospective analysis.

OBJECTIVE: Carotid artery stenting (CAS) is currently widely used for the treatment of carotid artery stenosis. The objective of this study was to analyze the outcomes of CAS performed in a single institution. METHODS: We retrospectively analyzed 313 CAS cases from January 2007 to December 2020, including 206 (66%) symptomatic and 107 (34%) asymptomatic cases. Procedure-related morbidity and mortality were assessed. Rates of periprocedural (≤30 days after CAS) and postprocedural ipsilateral strokes (>30 days after CAS) were also assessed. Logistic regression analysis was used to identify risk factors for the periprocedural complication, in-stent restenosis (ISR), and ipsilateral stroke. RESULTS: The success rate of CAS was 98%. Among 313 cases, 1 patient died due to hyperperfusion-related intracerebral hemorrhage (ICH). The CAS-related mortality rate was 0.31%. The overall incidence of periprocedural complications is 5.1%. A risk factor for periprocedural complication was a symptomatic carotid artery stenosis (7.3% vs. 0.9%, p=0.016). Twenty cases of ISR occurred during 63.7±42.1 months of follow-up. The overall incidence of ISR was 10.2% (20/196). A risk factors for ISR were diabetes mellitus (17.6% vs. 5.7%, p=0.008) and patients who used Open-cell stents (19.6% vs. 6.9%, p=0.010). The overall incidence of ipsilateral stroke is 5.6%. A risk factors for ipsilateral stroke was ISR (95% CI, p=0.002). CONCLUSIONS: CAS is a safe and effective procedure for carotid artery stenosis. Although the incidence of complications is low, fatal complication such as hyperperfusion- related ICH can occur. To prevent hyperperfusion-related ICH, several methods such as strict blood pressure (BP) control, intentional less widening of stenotic segment should be used. To prevent ISR or stroke occurrence, special attention should be paid to patients who have ISR or ipsilateral stroke risk factors.

Multiple Cerebral Hemorrhages Caused by Paradoxical Reperfusion Injury After Cranioplasty.

Cranioplasty-related reperfusion injury has rarely been reported. Although there are several hypotheses, particularly regarding the mechanisms of the event, clear evidence is lacking. Here, we report the case of an 84-year-old man with traumatic intracranial hemorrhage and subdural hematoma who underwent decompressive craniectomy and hematoma evacuation in the right hemisphere. After 45 days, cranioplasty was performed using titanium. A preoperative perfusion study with 99m-Tc-HMPAO brain single-photon emission tomography revealed diffuse hypoperfusion in the left cerebral hemisphere with decreased vascular reserve. After cranioplasty, multiple cerebral hemorrhages were observed on immediate postoperative computed tomography. Cerebral hemorrhage eventually improved without surgery. Here, we report a case with findings revealed through perfusion studies before and after surgery.

Treatment of pituitary adenoma with spontaneous cerebrospinal rhinorrhea using nasoseptal flap, two case reports.

Background: Postoperative cerebrospinal fluid (CSF) leakages are well documented, but pituitary adenoma with spontaneous CSF rhinorrhea as the initial symptoms are extremely rare. The objective of this study is to report two rare cases of pituitary adenoma with spontaneous CSF rhinorrhea successfully operated by endoscopic transsphenoidal approach with vascularized nasoseptal flap (NSF). Case Description: A 70-year-old woman presented with a 6-month history of watery rhinorrhea and posterior nasal drip that worsened when her head leaning forward. Sella magnetic resonance image (MRI) demonstrated pituitary macroadenoma (3.4 × 2.7 cm) invading cavernous sinus, clivus, and sphenoid sinus. A 47-year-old woman presented with a 10-month history of watery rhinorrhea and posterior nasal drip. Sella MRI demonstrated pituitary macroadenoma (6.3 × 4.6 cm) invading cavernous sinus, clivus, sphenoid sinus, and middle fossa. Both patients underwent endoscopic endonasal transsphenoidal operation and skull base reconstruction with vascularized NSF. The postoperative clinical course was uneventful and CSF rhinorrhea disappeared completely. Conclusion: Pituitary adenoma should be suspected if there is a watery CSF rhinorrhea that occurs without a history of trauma or nasal disease. In addition, effective treatment can be performed using NSF, a technique for endoscopic skull base reconstruction.

Supraorbital Endoscopic Evacuation for Traumatic Intracerebral Hematomas in the Frontal Lobe.

OBJECTIVE: Traumatic intracranial hematomas have been rarely evacuated by endoscopic surgery. The frontal lobe is the usual location for the traumatic intracerebral hematoma (TICH). Endoscopic evacuation for the frontal TICHs via an eyebrow incision is to be presented as minimally invasive surgery. METHODS: Thirteen patients with frontal TICHs were managed with endoscopic hematoma evacuation via eyebrow incision. After making the incision in the lateral eyebrow, a small frontal craniotomy was made, and the hematoma was evacuated under direct visualization of a rigid endoscope. No catheter was placed. Orbital rim resection, hematoma evacuation rate, surgical complications, and outcome at discharge were analyzed. RESULTS: Men were 11 and the mean age was 54 years old (range, 27-86). Orbitotomy was performed in four patients, and no effect on the hematoma evacuation rate was observed. More than 80% of the hematoma volume was successfully removed in 10 cases. Hematoma configuration was not related to the hematoma evacuation rate. None of the patients underwent revision operation or decompressive craniectomy. CONCLUSION: Endoscopic evacuation of the TICHs with the supraorbital approach may be a good method to evacuate the hematoma located in the frontal base.

A Radiological Assessment of Chronic Subdural Hematomas.

Chronic subdural hematoma (CSDH), which generally occurs in elderly patients, is a frequently diagnosed condition in neurosurgical departments. Computed tomography (CT) and magnetic resonance imaging (MRI) are the most preferred diagnostic modalities for CSDH assessment. With early diagnosis and adequate management, CSDH may show favorable prognosis in majority of the patients; however, recurrence after surgery can occur in a significant number of patients. The recently increasing number of CSDH studies could reveal the prognostic factors affecting CSDH recurrence. Particularly, radiological characteristics regarding the internal architecture of CSDH are considered closely associated with recurrence in surgically treated CSDH patients. In this literature review, we evaluated the various diagnostic modalities of CSDH and its radiological characteristics on CT and MRI. Furthermore, we summarized the prognostic factors of recurrence for the hematoma type based on the radiological findings.

Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society: A Review of a Group That Writes and Inherits the Thoughts and Will of the Society.

The Neurotrauma Clinical Practice Guidelines Committee of the Korean Neurotraumatology Society (KNTS-NCPGC) is developing clinical guidelines for neurotrauma in line with the capabilities of the Korean Neurotraumatology Society, which is leading pioneering development in the field of neurosurgery. From the mid-1990s, the KNTS-NCPGC has been working to develop guidelines and disseminate evidence-based medicine, including the development of Korean guidelines for the management of severe head injuries and active participation in the Clinical Practice Guidelines Committee of the Korean Academy of Medical Sciences. The KNTS-NCPGC strives to write and inherit the will of the society through the development of clinical practice guidelines, which are one of the outcomes representing professionalism and public interest and can be expressed in terms of "trust" and "best." In this review, the history and achievements of KNTS-NCPGC, the status of the ongoing development of guidelines, and the perspectives of the committee are covered.

Clinical Characteristics and Current Managements for Patients with Chronic Subdural Hematoma : A Retrospective Multicenter Pilot Study in the Republic of Korea.

OBJECTIVE: Chronic subdural hematoma (CSDH) is a common disease in neurosurgical departments, but optimal perioperative management guidelines have not yet been established. We aimed to assess the current clinical management and outcomes for CSDH patients and identify prognostic factors for CSDH recurrence. METHODS: We enrolled a total of 293 consecutive patients with CSDH who underwent burr hole craniostomy at seven institutions in 2018. Clinical and surgery-related characteristics and surgical outcomes were analyzed. The cohort included 208 men and 85 women. RESULTS: The median patient age was 75 years. Antithrombotic agents were prescribed to 105 patients. History of head trauma was identified in 59% of patients. Two hundred twenty-seven of 293 patients (77.5%) had unilateral hematoma and 46.1% had a homogenous hematoma type. About 70% of patients underwent surgery under general anesthesia, and 74.7% underwent a single burr hole craniostomy surgery. Recurrence requiring surgery was observed in 17 of 293 patients (5.8%), with a median of 32 days to recurrence. The postoperative complication rate was 4.1%. In multivariate analysis, factors associated with CSDH recurrence were separated hematoma type (odds ratio, 3.906; p=0.017) and patient who underwent surgery under general anesthesia had less recurrence (odds ratio, 0.277; p=0.017). CONCLUSION: This is the first retrospective multicenter generalized cohort pilot study in the Republic of Korea as a first step towards the development of Korean clinical practice guidelines for CSDH. The type of hematoma and anesthesia was associated with CSDH recurrence. Although the detailed surgical method differs depending on the institution, the surgical treatment of CSDH was effective. Further studies may establish appropriate management guidelines to minimize CSDH recurrence.