Endoscope-Assisted Evacuation of Acute-on-Chronic Subdural Hematomas: A Single-Center Series.

PURPOSE: Acute subdural hematomas are frequent, highly morbid, and affect all age groups. The most common mechanism of injury is a low-velocity fall, and the incidence of the disease is growing due to increasingly aggressive antithrombotic and anticoagulant therapies. In this study, we aimed to share our experience with the endoscopic-assisted evacuation of acute subdural hematoma, a less invasive procedure compared to standard craniotomy. METHODS: We retrospectively reviewed data of all consecutive patients aged 18 years and older who underwent endoscopic-assisted evacuation of acute-on-chronic subdural hematoma at our institution from 2015 to 2019. Preoperative, intraoperative, postoperative, and follow-up data were collected and reported. Statistical tests were done using Python statistical packages. RESULTS: Of the 35 patients that underwent this procedure, 32 were 18 years and older. The median age was 69.5 years and 37.5% were female. Twenty patients (62.5%) were on antiplatelet therapy, and six patients (18.75%) were on anticoagulants upon presentation. A fall was the most common cause of trauma (71.88%). The median operative time was 107 minutes. The median length of stay in days and Glasgow Coma Scale (GCS) at discharge were 8.5 and 15, respectively. There were no surgical site infections or in-hospital mortality in this series. At the latest follow-up, the median GCS and modified Rankin Scale were 15 and 1, respectively. CONCLUSION: Evacuation of acute-on-chronic subdural hematomas can be performed safely and efficiently via a smaller craniotomy and with the assistance of an endoscope. This may represent a less invasive alternative than standard craniotomy/craniectomy in selected patients.

Racial, ethnic, and gender diversity of applicants and matriculants to neurological surgery residency programs.

OBJECTIVE: The aim of this study was to identify trends in the demographic constitution of applicants and matriculants to neurological surgery based on race, ethnicity, and gender. METHODS: The authors conducted a cross-sectional study using compiled demographic data obtained from the Association of American Medical Colleges. Trends analyzed included proportional changes in race, ethnicity, and gender of applicants and matriculants to neurosurgical residency programs from academic years 2010-2011 to 2018-2019. RESULTS: A total of 5100 applicants and 2104 matriculants to neurosurgical residency programs were analyzed. No significant change in the percentage of overall women applicants (+0.3%, 95% CI -0.7% to 1.3%; p = 0.77) or in the percentage of women matriculants (+0.3%, 95% CI -2.2% to 2.9%; p = 0.71) was observed. For applicants, no change over time was observed in the percentages of American Indian or Alaska Native (AI/AN) men (0.0%, 95% CI -0.3% to 0.3%; p = 0.65); Asian men (-0.1%, 95% CI -1.2% to 1.1%; p = 0.97); Black or African American men (-0.2%, 95% CI -0.7% to 0.4%; p = 0.91); Hispanic, Latino, or of Spanish Origin men (+0.4%, 95% CI -0.8% to 1.7%; p = 0.26); White men (+0.5%, 95% CI -2.1% to 3.0%; p = 0.27); Asian women (+0.1,% 95% CI -0.9% to 1.1%; p = 0.73); Black or African American women (0.0%, 95% CI -0.6% to 0.5%; p = 0.30); Hispanic, Latino, or of Spanish Origin women (0.0%, 95% CI -0.4% to 0.4%; p = 0.71); and White women (+0.3%, 95% CI -1.1% to 1.7%; p = 0.34). For matriculants, no change over time was observed in the percentages of AI/AN men (0.0%, 95% CI -0.6% to 0.6%; p = 0.56); Asian men (0.0%, 95% CI -2.7% to 2.7%; p = 0.45); Black or African American men (-0.3%, 95% CI -1.4% to 0.8%; p = 0.52); Hispanic, Latino, or of Spanish Origin men (+0.6%, 95% CI -0.8 to 2.0%; p = 0.12); White men (-1.0%, 95% CI -5.3% to 3.3%; p = 0.92); Asian women (+0.1%, 95% CI -1.3% to 1.5%; p = 0.85); Black or African American women (0.0%, 95% CI -0.6% to 0.7%; p = 0.38); Hispanic, Latino, or of Spanish Origin women (-0.1%, 95% CI -0.7% to 0.5%; p = 0.46); and White women (+0.3%, 95% CI -2.4% to 3.0%; p = 0.70). CONCLUSIONS: Despite efforts to diversify the demographic constitution of incoming neurosurgical trainees, few significant advances have been made in recent years. This study suggests that improved strategies for recruitment and cultivating early interest in neurological surgery are required to further increase the diversification of future cohorts of neurosurgical trainees.

Ballistic lobar trajectory outcomes in civilian firearm penetrating brain injury.

OBJECTIVE: Penetrating brain injury (PBI) is the most lethal of all firearm injuries, with reported survival rates of less than 20%. The projectile trajectory (PT) has been shown to impact mortality, but the significant lobar tracks have not been defined. The aim of this retrospective case-control study was to test for associations between distinct ballistic trajectories, missile types, and patient outcomes. METHODS: A total of 243 patients who presented with a PBI to the Saint Louis University emergency department from 2008 through 2019 were identified from the hospital registry. Conventional CT scans combined with 3D CT reconstructions and medical records were reviewed for each patient to identify distinct PTs. RESULTS: A total of 65 ballistic lobar trajectories were identified. Multivariable regression models were used, and the results were compared with those in the literature. Penetrating and perforating types of PBI associated with bitemporal (t-statistic = -2.283, p = 0.023) or frontal-to-contralateral parietal (t-statistic = -2.311, p = 0.025) projectile paths were universally found to be fatal. In the group in which the Glasgow Coma Scale (GCS) score at presentation was lower than 8, a favorable penetrating missile trajectory was one that involved a single frontal lobe (adjusted OR 0.02 [95% CI 0.00-0.38], p = 0.022) or parietal lobe (adjusted OR 0.15 [95% CI 0.02-0.97], p = 0.048). Expanding or fragmenting types of projectiles carry higher mortality rates (OR 2.53 [95% CI 1.32-4.83], p < 0.001) than do nondeformable missiles. Patient age was not associated with worse outcomes when controlled by other significant predictive factors. CONCLUSIONS: Patients with penetrating or perforating types of PBI associated with bitemporal or frontal-to-contralateral parietal PTs should be considered as potential donor candidates. Trauma patients with penetrating missile trajectories involving a single frontal or parietal lobe should be considered for early neurosurgical intervention, especially in the circumstances of a low GCS score (< 8). Surgeons should not base their decision-making solely on advanced patient age to defer further treatment. Patients with PBIs caused by nondeformable types of projectiles can survive multiple simultaneous intracranial missile trajectories.

Symptomatic cerebral vasospasm in the setting of carmustine wafer placement for glioblastoma: A case presentation and review of literature.

BACKGROUND: Gliadel placement in glioblastoma resection, particularly with concurrent chemoradiation, has demonstrated an improvement in survival. There have been several reported adverse effects, some of which lend to significantly increased morbidity and mortality. With only two other cases described in literature, cerebral vasospasm secondary to carmustine-impregnated wafers is an extremely rare side effect. CASE DESCRIPTION: We report the case of a 51-year-old female who presented with the left lower limb paresis 8 days after high-grade glioma resection provoked by carmustine wafer placement. CONCLUSION: We urge surgeons to reconsider placement of carmustine wafers in nations where the surgical resection cavity includes exposed large cerebral vasculature. We also propose the early identification of this devastating complication in the postoperative period by maintaining a high clinical suspicion and prompt utilization of computed tomography and digital subtraction angiography in the management and treatment of these patients accordingly.

Minimally Invasive Evacuation of Severe Intraventricular Hemorrhage Using the BrainPath Endoport-Assisted Microsurgical System.

OBJECTIVE: We present the application of the BrainPath endoport-assisted microsurgical device (EAMD) as a treatment modality for patients with severe intraventricular hemorrhage (IVH) secondary to spontaneous supratentorial intracerebral hemorrhage (sICH). METHODS: Patients with severe secondary IVH (defined as Graeb score [GS] >6) who presented to Saint Louis University Hospital, St. Louis, Missouri, United States, from 2017 to 2019 were treated with the minimally invasive approach for IVH evacuation using the atraumatic BrainPath aspiration system. RESULTS: Three patients (2 men and 1 woman) with a mean age of 54 years were included in this study. The mean preoperative GS was 10.0 with a modified GS of 23.3. The mean postoperative GS was 4.0 (P = 0.001) with a modified GS of 10.67 (P = 0.001). There were no complications related to the surgery itself in any of the reported cases. CONCLUSIONS: BrainPath EAMD evacuation of severe IVH secondary to sICH appears to be a safe and effective treatment modality that significantly increases the extent of IVH clearance, which could also lead to improved long-term patient outcomes.

Significant Association of Aldosterone and Liver Fat Among HIV-Infected Individuals With Metabolic Dysregulation.

OBJECTIVE: Fatty liver disease is increased among individuals with HIV. We sought to explore how aldosterone, a key hormone linked to insulin resistance and inflammation, relates to liver fat in the large population of individuals with HIV and metabolic abnormalities. METHODS: Forty-six individuals with HIV and increased waist circumference and dysglycemia were assessed for liver fat using proton magnetic resonance spectroscopy. Serum aldosterone level was obtained following strictly controlled posture conditions and a standardized sodium diet and was related to liver fat. RESULTS: Among the entire group [median (interquartile range) liver fat: 5% (3%, 12%) and homeostatic model assessment of insulin resistance: 1.74 (1.21, 2.83)], serum aldosterone significantly correlated with liver fat (r = 0.31; P = 0.049). Liver fat level was significantly higher in those with aldosterone above vs below the median [8% (3%, 20%) vs 4% (2%, 10%); P = 0.02]. In the presence of metabolic syndrome, individuals with aldosterone levels above vs below the median had markedly elevated liver fat values [14% (9%, 23%) vs 5% (3%, 12%); P = 0.005] and increased presence of fatty liver disease (FLD; 92% vs 50%; P = 0.02). Controlling for metabolic syndrome, hepatitis C virus, and alcohol use, aldosterone was a significant and independent predictor of liver fat (ß estimate: 0.6038, P = 0.01; overall model r 2 = 0.41, P = 0.0005) and FLD (OR: 1.38, P = 0.02; overall model r 2 = 0.28, P = 0.002). CONCLUSION: These data highlight a robust association between aldosterone and liver fat among individuals with HIV and metabolic dysregulation. Increased aldosterone may be a risk factor for liver fat accumulation among the population with HIV.

Trans-Sulcal Endoport-Assisted Evacuation of Supratentorial Intracerebral Hemorrhage: Initial Single-Institution Experience Compared to Matched Medically Managed Patients and Effect on 30-Day Mortality.

BACKGROUND: The surgical management of supratentorial intracerebral hemorrhages (ICH) remains controversial due to large trials failing to show clear benefits. Several minimally invasive techniques have emerged as an alternative to a conventional craniotomy with promising results. OBJECTIVE: To report our experience with endoport-assisted surgery in the evacuation of supratentorial ICH and its effects on outcome compared to matched medical controls. METHODS: Retrospective data were gathered of patients who underwent endoport-assisted evacuation between January 2014 and October 2016 by a single surgeon. Patients who were managed medically during the same period were matched to the surgical cohort. Previously published cohorts investigating the same technique were analyzed against the present cohort. RESULTS: Sixteen patients were identified and matched to 16 patients treated medically. Location, hemorrhage volume, and initial Glasgow Coma Scale (GCS) score did not differ significantly between the 2 cohorts. The mean volume reduction in the surgical cohort was 92.05% ± 7.05%. The improvement in GCS in the surgical cohort was statistically significant (7-13, P = .006). Compared to the medical cohort, endoport-assisted surgery resulted in a statistically significant difference in in-hospital mortality (6.25% vs 75.0%, P < .001) and 30-d mortality (6.25% vs 81.25%, P < .001). Compared to previously published cohorts, the present cohort had lower median preoperative GCS (7 vs 10, P = .02), but postoperative GCS did not differ significantly (13 vs 14, P = .28). CONCLUSION: Endoport-assisted surgery is associated with high clot evacuation and decreases 30-d mortality compared to a similar medical group.