Treatment of hydrocephalus following fetal repair of myelomeningocele: comparing endoscopic third ventriculostomy with choroid plexus cauterization to ventricular shunting.

OBJECTIVE: The aim of this study was to compare clinical and craniometric outcomes of patients treated for hydrocephalus following fetal myelomeningocele repair (fMMR) via a ventriculoperitoneal shunt (VPS) or endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC). METHODS: This was a retrospective cohort study of children who were treated for hydrocephalus following fMMR via VPS or ETV with or without CPC (ETV ± CPC) at Vanderbilt between 2012 and 2021. The primary outcomes were treatment failure and time to failure (TTF). Secondary outcomes included changes in hydrocephalus metrics (fronto-occipital horn ratio [FOHR] and head circumference measurements) and healthcare resource utilization (number of hospital admissions, clinic visits, and neuroimaging findings). RESULTS: Among 88 patients who underwent fMMR, 37 (42%) required permanent CSF diversion, of whom 19 received treatment at the authors' institution. Twelve patients underwent ETV ± CPC, and 7 underwent VPS placement at a median corrected age of 23 weeks versus 1 week (p = 0.002). The preoperative median head circumference percentiles and z-scores for patients in the ETV ± CPC cohort were similar to those of the VPS cohort (percentiles: 98.5 vs 94.0, p = 0.064; z-scores: 2.32 vs 1.60, p = 0.111). There was no difference in preoperative median FOHR measurements between the two cohorts (0.57 vs 0.59, p = 0.53). At 6 months postoperatively, the median head circumference percentile and z-score for the ETV ± CPC cohort remained similar between the two cohorts (percentiles: 98.0 vs 67.5, p = 0.315; z-scores: 2.12 vs 0.52, p = 0.307). There was no difference in the change in FOHR (-0.06 vs -0.09, p = 0.37) and change in head circumference percentile (-1.33 vs -28.6, p = 0.058) between the cohorts 6 months after the index CSF diversion procedure. One patient in the ETV ± CPC cohort experienced a seizure and a nonoperative subdural hemorrhage postoperatively; no other complications were observed. Six of the 7 patients in the VPS cohort required shunt revision with a median TTF of 9.8 months while 2 of the 12 ETV ± CPC patients required a repeat ETV at a median of 17.5 months (86% vs 17%, p = 0.013). The median number of hydrocephalus-related hospital readmissions was significantly lower in the ETV ± CPC cohort than in the VPS cohort (0 vs 1, p = 0.006). The ETV ± CPC cohort had fewer CT scans (0 vs 2, p = 0.004) and radiographs (0 vs 2, p < 0.001) than the VPS cohort. CONCLUSIONS: In a single-center cohort, hydrocephalic fMMR patients treated via ETV ± CPC remained shunt free, while a majority of patients receiving an upfront shunt required revision. This is the first study comparing ETV ± CPC with VPS in the fMMR hydrocephalus population. While larger, multicenter studies are needed, these results suggest that ETV/CPC may be a preferred means of CSF diversion following fMMR.

Lumbar Drain Use during Middle Fossa Approaches for Nonneoplastic Pathology of the Skull Base.

Introduction The middle fossa craniotomy (MFCs) is commonly utilized for spontaneous cerebrospinal fluid (CSF) leaks, encephaloceles, and superior semicircular canal dehiscence (SSCD). This study compares postoperative outcomes of MFCs with and without LD use. Methods A retrospective cohort study of adults over the age of 18 years presenting for the repair of nonneoplastic CSF leak, encephalocele, or SSCD via MFC from 2009 to 2021 was conducted. The main exposure of interest was the placement of an LD. The primary outcome was the presence of postoperative complications (acute/delayed neurologic deficit, meningitis, intracranial hemorrhage, and stroke). Secondary outcomes included operating room (OR) time, length of stay, recurrence, and need for reoperation. Results In total, 172 patients were included, 96 of whom received an LD and 76 who did not. Patients not receiving an LD were more likely to receive intraoperative mannitol ( n = 24, 31.6% vs. n = 16, 16.7%, p = 0.02). On univariate logistic regression, LD placement did not influence overall postoperative complications (OR: 0.38, 95% confidence interval [CI]: 0.05-2.02, p = 0.28), CSF leak recurrence (OR: 0.75, 95% CI: 0.25-2.29, p = 0.61), or need for reoperation (OR: 1.47, 95% CI: 0.48-4.96, p = 0.51). While OR time was shorter for patients not receiving LD (349 ± 71 vs. 372 ± 85 minutes), this difference was not statistically significant ( p = 0.07). Conclusion No difference in postoperative outcomes was observed in patients who had an intraoperative LD placed compared to those without LD. Operative times were increased in the LD cohort, but this difference was not statistically significant. Given the similar outcomes, we conclude that LD is not necessary to facilitate safe MCF for nonneoplastic skull base pathologies.

Symptom resolution following a repeat concussion within the same athlete.

INTRODUCTION: Repeat sport-related concussion (SRC) is anecdotally associated with prolonged recovery. Few studies have examined repeat concussion within the same athlete. We sought to explore differences in symptom burden and recovery outcomes in an individual athlete's initial and repeat SRC. METHODS: A retrospective within-subject cohort study of athletes aged 12-23 years diagnosed with two separate SRCs from 11/2017-10/2020 was conducted. Primary outcomes were initial symptom severity and time-to-symptom-resolution. Secondary outcomes included return-to-learn (RTL) and return-to-play (RTP) duration. RESULTS: Of 868 athletes seen, 47 athletes presented with repeat concussions. Median time between concussions was 244 days (IQR 136-395). Comparing initial to repeat concussion, no differences were observed in time-to-clinic (4.3 ± 7.3vs.3.7 ± 4.6 days, p = 0.56) or initial PCSS (26.2 ± 25.3 vs. 30.5 ± 24.1, p = 0.32). While a difference was observed in time-to-symptom resolution between initial/repeat concussion (21.2 ± 16.3 vs. 41.7 ± 86.0 days, p = 0.30), this did not reach statistical significance. No significant differences were observed in time-to-RTL (17.8 ± 60.6 vs. 6.0 ± 8.3 days, p = 0.26) and RTP (33.2 ± 44.1 vs. 29.4 ± 39.1 days, p = 0.75). Repeat concussion was not associated with symptom resolution on univariate (HR 1.64, 95% CI 0.96-2.78, p = 0.07) and multivariable (HR 0.85, 95% CI 0.49-1.46, p = 0.55) Cox regression. CONCLUSION: No significant differences in symptom duration and RTP/RTL were seen between initial/repeat concussion.

Sport-related concussion in 8- to 12-year-olds: an understudied population.

OBJECTIVE: Most studies regarding sport-related concussion (SRC) focus on high school and collegiate athletes; however, little has been published on children younger than 12 years of age. In a cohort of children aged 8-12 years with SRC, the authors sought to describe demographics, initial presentation, and recovery in this understudied population. METHODS: A retrospective cohort study of children aged 8-12 years who sustained an SRC between November 2017 and April 2022 and were treated at a regional sports concussion center was conducted. Demographic information, injury characteristics, traditional Sport Concussion Assessment Tool 5 (SCAT5) and Child/Parent SCAT5 scores, and outcomes, defined as days to return to learn (RTL), symptom resolution, and return to play (RTP), were reported. Outcomes in boys and girls were compared using effect size analyses given sample size constraints. RESULTS: Forty-seven athletes were included. The mean age was 11.0 ± 0.8 years, and the majority were male (34, 72.3%). A sizable proportion of patients visited an emergency department (19, 40.4%), and many received head imaging (16, 34.0%), mostly via CT (n = 13). The most common sport for boys was football (15, 44.1%), and the most common sports for girls were soccer (4, 30.8%) and cheerleading (4, 30.8%). These athletes reported a variety of symptoms on presentation. It took a mean of 8.8 ± 10.8 days to RTL, 27.3 ± 38.3 days to reach symptom resolution, and 35.4 ± 41.9 days to RTP. When comparing boys versus girls, there appeared to be moderate differences in symptom severity scores (Cohen's d = 0.44 for SCAT5, 0.13 for Child SCAT5, and 0.38 for Parent SCAT5) and minimal differences in recovery (Cohen's d = 0.11 for RTL, n = 35; 0.22 for symptom resolution, n = 22; and 0.12 for RTP, n = 21). CONCLUSIONS: In this cohort of concussed athletes aged 8-12 years, a little less than half of the athletes initially presented to the emergency department, and approximately one-third received acute head imaging. Across all athletes, the mean RTL was slightly more than a week and the mean symptom resolution and RTP were both approximately 1 month; however, much of the cohort is missing recovery outcome measures. This study demonstrated a strong positive correlation between Child SCAT5 and Parent SCAT5 symptom reporting. Future efforts are needed to evaluate differences in clinical presentation and outcomes following SRC between children and older populations.

Collegiate Athletes With Diabetes: Baseline Medical Comorbidities and Preseason Concussion Testing Performance.

CONTEXT: People with diabetes mellitus (DM) are at increased risk for adverse health events and complications throughout their lifetime. Whether DM significantly affects collegiate athletes' concussion baseline testing performance remains unclear. OBJECTIVES: To (1) describe the prevalence of DM and associated comorbidities and (2) compare concussion baseline testing performance between student-athletes with DM and student-athletes without DM (NoDM). DESIGN: Retrospective, cross-sectional study. SETTING: University. PATIENTS OR OTHER PARTICIPANTS: Using the Concussion, Assessment, Research and Education (CARE) Consortium research database, we matched athletes with self-reported DM (N = 229) by institution, sex, age, sport, position, testing year, and concussion history to athletes with NoDM (N = 229; total sample mean age = 19.6 ± 1.4 years, women = 42%). MAIN OUTCOME MEASURE(S): Descriptive statistics and χ2 tests of independence with subsequent odds ratios were calculated. Independent-samples t tests compared baseline symptoms, neurocognitive testing, and balance performance between athletes with DM and athletes with NoDM. Effect sizes were determined for significant group differences. RESULTS: At baseline, athletes with DM had higher rates of self-reported pre-existing balance disorders, sleep disorders, seizure disorders, motion sickness, learning disorders, vision and hearing problems, psychiatric disorders, depression, bipolar disorder, nonmigraine headaches, and meningitis than athletes with NoDM (P values < .05). We found balance differences between groups (P = .032, Cohen d = 0.17) such that, on average, athletes with DM had 1 additional error on the Balance Error Scoring System (DM = 13.4 ± 6.5; NoDM = 12.1 ± 5.9). No other comparisons yielded significant results. CONCLUSIONS: Although athletes with DM had high rates of self-reported balance disorders, sleep disorders, seizures, and meningitis, their baseline neurocognitive testing results were largely identical to those of athletes with NoDM. Our findings suggested that nonclinically meaningful differences were present in concussion baseline balance testing but no significant differences were noted in cognitive testing; however, the effect of DM on concussion recovery remains unknown.

Risk of Two Sport-Related Concussions in the Same Year: Is the Second Concussion Worse?

OBJECTIVES: 1) Evaluate the frequency of same-year, repeat concussions; (2) assess predictors of sustaining a repeat concussion; and (3) compare outcomes of athletes with repeat concussions with athletes with single concussion. DESIGN: A retrospective, case-control study. SETTING: Regional sports concussion center. PATIENTS: Adolescents sustaining a sport-related concussions (SRC) from November 2017 to October 2020. INDEPENDENT VARIABLES: Participants were dichotomized into 2 groups: (1) athletes with a single concussion; and (2) athletes with repeat concussions. MAIN OUTCOME MEASURES: Between group and within group analyses were completed to look for differences in demographics, personal and family history, concussion history, and recovery metrics between the 2 groups. RESULTS: Of 834 athletes with an SRC, 56 (6.7%) sustained a repeat concussion and 778 (93.3%) had a single concussion. Between group: Personal history of migraines (19.6% vs 9.5%, χ 2 = 5.795, P = 0.02), family history of migraines (37.5% vs 24.5%, χ 2 = 4.621, P = 0.03), and family history of psychiatric disorders (25% vs 13.1%, χ 2 = 6.224, P = 0.01) were significant predictors of sustaining a repeat concussion. Within group: Among those with a repeat concussion, initial symptom severity was greater (Z = -2.422; P = 0.02) during the repeat concussion and amnesia was more common (χ 2 = 4.775, P = 0.03) after the initial concussion. CONCLUSIONS: In a single-center study of 834 athletes, 6.7% suffered a same-year, repeat concussion. Risk factors included personal/family migraine history and family psychiatric history. For athletes with repeat concussions, initial symptom score was higher after the second concussion, yet amnesia was more common after the initial concussion.

Intersection of Race and Socioeconomic Status on Concussion Recovery among NCAA Student-Athletes: A CARE Consortium Study.

PURPOSE: The objectives of this study are to 1) describe collegiate student-athlete (SA) race and household income and 2) evaluate time to normal academic performance (i.e., return to learn (RTL)), initiation of the return to play (iRTP) protocol, RTP protocol duration, and time to unrestricted RTP (URTP) after sustaining sport-related concussion (SRC). METHODS: Data were collected between 2014 and 2020 by the Concussion Assessment, Research, and Education Consortium. Baseline data were used to characterize participant demographics ( N = 22,819) and post-SRC outcomes ( n = 5485 SRC) in time to RTL ( n = 1724) and RTP outcomes ( n = 2646) by race. Descriptive statistics and nonparametric tests examined differences across race by demographic and injury characteristics. Kaplan-Meier curves estimated median days to RTL, iRTP protocol, RTP protocol completion, and URTP by race and covariate measures. Multivariable Cox proportional hazards regression assessed the effect of race on risk of RTL and RTP recovery time points. RESULTS: SA largely identified as White (75%) followed by Black (14%), multiracial (7%), and Asian (3%). More than half (53%) of all SA reported a household income of >$120,000, whereas 41% of Black SA reported a household income <$60,000. Race was not associated with relative risk of RTL or iRTP but was associated with RTP protocol completion and URTP. Non-Black/non-White SA were 17% less likely (adjusted hazard ratio = 0.83; 95% confidence interval = 0.71, 0.97) to complete the RTP protocol, and Black SA were 17% more likely (adjusted hazard ratio = 1.17; 95% confidence interval = 1.05, 1.31) to reach the URTP time point compared with White SA. CONCLUSIONS: The present findings suggest collegiate SA enrolled in the Concussion Assessment, Research, and Education Consortium are primarily White and come from household incomes well above the US median. Race was not associated with RTL or iRTP but was associated with RTP protocol duration and total time to URTP. Clinicians should be conscientious of how their implicit or preconceived biases may influence SRC management among National Collegiate Athletic Association SA.

Systematic Review Examining the Reporting of Race and Ethnicity in Sport-Related Concussion Studies.

OBJECTIVE: Sport-related concussion (SRC) is an evolving public health concern among youth athletes. Despite emerging evidence that race/ethnicity are important factors in determining concussion outcomes, studies examining race/ethnicity are limited. We conducted a systematic review to: 1) determine the prevalence of SRC studies that report race/ethnicity of their participants, 2) describe how race/ethnicity are used within each study, and 3) assess predictive factors for reporting of race/ethnicity. DATA SOURCES: PubMed/Embase/PsycINFO/CINAHL databases. STUDY SELECTION: Study inclusion criteria were: 1) primary/peer-reviewed research 2) related to the diagnosis/treatment/recovery of SRC 3) involving school-aged athletes (ages 5-25) 4) with ≥ 25 participants. The search was performed 03/2021 and included only studies published after 03/2013. DATA EXTRACTION: For each article, we looked at whether race/ethnicity were reported, and if so, which races/ethnicities were mentioned. For each race/ethnicity mentioned, we extracted the corresponding sample size and how they were used as variables in the study. DATA SYNTHESIS: Of 4,583 studies screened, 854 articles met inclusion criteria. Of the included articles, 132 (15.5%) reported race of their sample and 65 (7.6%) reported ethnicity, whereas 721 (84.4%) reported neither. When examining the demographic characteristics of the 132 studies that reported race, 69.8% of athletes were reported to be White. Additionally, 79.5% of these studies solely used race as a demographic descriptor as opposed to as a main exposure or covariate of interest. Studies published more recently were more likely to report race. Further, specific study/journal topics and geographic location of the authors were more likely to report race. CONCLUSIONS: Reporting of race/ethnicity is limited in current SRC literature. Future studies should improve the reporting of race/ethnicity, diversify study samples by focusing on enrolling athletes from underrepresented groups, and consider the potential impact of race/ethnicity as social determinants of health on risk factors, recovery, and long-term sequelae after SRC.

Neurological Examination Frequency and Time-to-Delirium After Traumatic Brain Injury.

BACKGROUND: Frequent neurological examinations in patients with traumatic brain injury (TBI) disrupt sleep-wake cycles and potentially contribute to the development of delirium. OBJECTIVE: To evaluate the risk of delirium among patients with TBI with respect to their neuro-check frequencies. METHODS: A retrospective study of patients presenting with TBI at a single level I trauma center between January 2018 and December 2019. The primary exposure was the frequency of neurological examinations (neuro-checks) assigned at the time of admission. Patients admitted with hourly (Q1) neuro-check frequencies were compared with those who received examinations every 2 (Q2) or 4 (Q4) hours. The primary outcomes were delirium and time-to-delirium. The onset of delirium was defined as the first documented positive Confusion Assessment Method for the Intensive Care Unit score. RESULTS: Of 1552 patients with TBI, 458 (29.5%) patients experienced delirium during their hospital stay. The median time-to-delirium was 1.8 days (IQR: 1.1, 2.9). Kaplan-Meier analysis demonstrated that patients assigned Q1 neuro-checks had the greatest rate of delirium compared with the patients with Q2 and Q4 neuro-checks ( P < .001). Multivariable Cox regression modeling demonstrated that Q2 neuro-checks (hazard ratio: 0.439, 95% CI: 0.33-0.58) and Q4 neuro-checks (hazard ratio: 0.48, 95% CI: 0.34-0.68) were protective against the development of delirium compared with Q1. Other risk factors for developing delirium included pre-existing dementia, tobacco use, lower Glasgow Coma Scale score, higher injury severity score, and certain hemorrhage patterns. CONCLUSION: Patients with more frequent neuro-checks had a higher risk of developing delirium compared with those with less frequent neuro-checks.

Positive Head Computed Tomography Findings in the Setting of Sport Head Injuries: Can These Athletes Return-to-Play?

BACKGROUND: The literature on athletes with positive head computed tomography (HCT) findings in the setting of sport head injuries remains sparse. OBJECTIVE: To report the proportions of athletes with a positive HCT and compare acute injury characteristics and recovery between those with and without a positive HCT. METHODS: A retrospective, single-institution, cohort study was performed with all athletes aged 12 to 23 years seen at a regional concussion center from 11/2017 to 04/2022. The cohort was dichotomized into positive vs negative HCT (controls). Acute injury characteristics (ie, loss of consciousness and amnesia) and recovery, as measured by days to return-to-learn (RTL), symptom resolution, and return-to-play (RTP) were compared. χ 2 and Mann-Whitney U tests were performed. RESULTS: Of 2061 athletes, 226 (11.0%) received an HCT and 9 (4.0%) had positive findings. HCT findings included 4 (44.4%) subdural hematomas, 1 (11.1%) epidural hematoma, 2 (22.2%) facial fractures, 1 (11.1%) soft tissue contusion, and 1 (11.1%) cavernous malformation. All 9 (100.0%) athletes were treated nonoperatively and successfully returned-to-play at a median (IQR) of 73.0 (55.0-82.0) days. No differences in loss of consciousness or amnesia were seen between positive HCT group and controls. The Mann-Whitney U test showed differences in RTL (17.0 vs 4.0 days; U = 45.0, P = .016) and RTP (73.0 vs 27.0 days; U = 47.5, P = .007) but not in symptom resolution. Our subanalysis showed no differences across all recovery metrics between acute hemorrhages and controls. CONCLUSION: Among athletes seen at a regional concussion center who underwent an acute HCT, positive findings were seen in 4%. Although athletes with a positive HCT had longer RTL and RTP, symptom resolution was similar between those with a positive and negative HCT. All athletes with a positive HCT successfully returned to play. Despite a more conservative approach to athletes with a positive HCT, clinical outcomes are similar between those with and without a positive HCT.

Predicting early versus late recovery from sport-related concussion using decision tree analysis.

OBJECTIVE: Accurately predicting early (≤ 14 days) versus typical (15-27 days) or delayed (≥ 28 days) recovery from sport-related concussion (SRC) may allow for improved resource utilization and precision in planning and carrying out rehabilitation. In this study, the authors sought to develop an algorithm that enables accurate differentiation of recovery periods and duration after SRC. The authors hypothesized that data regarding initial symptom burden as quantified by a Post-Concussion Symptom Scale (PCSS) score, time to presentation, and number of prior concussions would be the most useful for analyzing predictive factors for concussion recovery duration. METHODS: A retrospective case-control study was conducted to assess the primary outcome of days to clinical recovery following SRC in pediatric patients. Data from patients 12-18 years old presenting within 28 days of injury to an SRC clinic between November 11, 2017, and October 10, 2020, were analyzed. Patients with positive evidence of injury on head imaging or incomplete records were excluded. The primary outcome was duration of clinical recovery, grouped as early (≤ 14 days), typical (15-27 days), or delayed (≥ 28 days). Recovery was defined as follows: 1) symptom resolution or return to baseline, or 2) initiation of graduated return to play. CHAID (chi-square automatic interaction detection) analysis was used to optimize a decision tree based on 16 input factors, including age, sex, initial PCSS score, time to clinic presentation, number of prior concussions, and presence of defined symptom clusters. The cohort was randomized into training (70%) and test (30%) samples for algorithm validation. RESULTS: A total of 493 patients met the inclusion criteria (mean age 15.7 ± 1.5 years, 68.2% male, 70.0% White). The median time to presentation was 5 days (IQR 2-10 days). Most patients (52.3%) recovered within 14 days of injury, 21.5% recovered within 15-27 days, and 26.2% had a recovery period of 28 days or longer. The variables most predictive of recovery were initial PCSS score (cutoffs ≤ 6, 7-28, or ≥ 29), time to presentation (≤ 7 vs > 7 days), or prior concussions (0 vs ≥ 1). The model accurately discriminated between early versus typical or delayed recovery duration groupings (area under the curve 0.80, Youden index 0.44), and correctly classified > 90% of patients who recovered early. CONCLUSIONS: This novel three-factor predictive tool enabled accurate discrimination of early versus typical or delayed SRC recovery to better allocate resources, counsel patients, and make timely referrals.

Investigation of Factors Contributing to Racial Differences in Sport-Related Concussion Outcomes.

OBJECTIVE: Following sport-related concussion (SRC), early studies have demonstrated racial differences in time to clinical recovery; however, these differences have not been fully explained. We sought to further explore these associations by considering possible mediating/moderating factors. METHODS: Data from patients aged 12-18 years diagnosed with SRC from November 2017 to October 2020 were analyzed. Those missing key data, lost to follow-up, or missing race were excluded. The exposure of interest was race, dichotomized as Black/White. The primary outcome was time to clinical recovery (days from injury until the patient was either deemed recovered by an SRC provider or symptom score returned to baseline or zero.) RESULTS: A total of 389 (82%) White and 87 (18%) Black athletes with SRC were included. Black athletes more frequently reported no SRC history (83% vs. 67%, P = 0.006) and lower symptom burden at presentation (median total Post-Concussion Symptom Scale 11 vs. 23, P < 0.001) than White athletes. Black athletes achieved earlier clinical recovery (hazard ratio [HR] = 1.35, 95% CI 1.03-1.77, P = 0.030), which remained significant (HR = 1.32, 95% CI 1.002-1.73, P = 0.048) after adjusting for confounders associated with recovery but not race. A third model adding the initial Post-Concussion Symptom Scale score nullified the association between race/recovery (HR = 1.12, 95% CI 0.85-1.48, P = 0.410). Adding prior concussion history further reduced the association between race/recovery (HR = 1.01, 95% CI 0.77-1.34, P = 0.925). CONCLUSIONS: Overall, Black athletes initially presented with fewer concussion symptoms than White athletes, despite no difference in time to clinic. Black athletes achieved earlier clinical recovery following SRC, a difference explained by differences in initial symptom burden and self-reported concussion history. These crucial differences may stem from cultural/psychologic/organic factors.

Comparison of supratentorial meningioma resection outcomes by dural reconstruction technique.

OBJECTIVE: Excision of intracranial meningiomas often requires resection or coagulation of the dura mater. The choice of dural closure technique is individualized and based on surgeon preference. The objective of this study was to determine outcomes following various dural closure techniques for supratentorial meningiomas. METHODS: A retrospective, single-center cohort study was performed for patients who underwent excision of supratentorial meningiomas from 2000 to 2019. Outcomes including operative time, postoperative in-hospital complications, readmission, causes of readmission including surgical site infection, pseudomeningocele, need for shunt surgery, and imaging appearance of pseudomeningocele on long-term follow-up imaging were compared. Univariate and multivariable analyses were conducted. RESULTS: A total of 353 patients who had complete clinical and operative data available for review were included. Of these patients, 227 (64.3%) had nonsutured dural graft reconstruction and 126 (35.7%) had sutured dural repair, including primary closure, artificial dura, or pericranial graft. There was significant variability in using nonsutured dural reconstruction compared with sutured dural repair technique among surgeons (p < 0.001). Tumors with sagittal sinus involvement were more likely to undergo nonsutured closure (n = 79, 34.8%) than dural repair (n = 26, 20.6%) (p = 0.003). There were no other differences in preoperative imaging findings or WHO grade. Frequency of surgical site infection and pseudomeningocele, need for shunt surgery, and recurrence were similar between those undergoing nonsutured and those undergoing sutured dural repair. The mean operative time for the study cohort was 234.9 (SD 106.6) minutes. The nonsutured dural reconstruction group had a significantly shorter mean operative time (223.9 [SD 99.7] minutes) than the sutured dural repair group (254.5 [SD 115.8] minutes) (p = 0.015). In a multivariable linear regression analysis, after controlling for tumor size and sinus involvement, nonsutured dural graft reconstruction was associated with a 36.8-minute reduction (95% CI -60.3 to -13.2 minutes; p = 0.002) in operative time. CONCLUSIONS: Dural reconstruction using a nonsutured graft and sutured dural repair exhibit similar postoperative outcomes for patients undergoing resection for supratentorial meningiomas. Although sutured grafts may sometimes be necessary, nonsutured graft reconstruction for most supratentorial meningioma resections may suffice. The decreased operative time associated with nonsutured grafts may ultimately result in cost savings. These findings should be taken into consideration when selecting a dural reconstruction technique for supratentorial meningioma.

Intrauterine closure of myelomeningocele defects with primary linear repair versus bipedicle fasciocutaneous flaps: a post-MOMS cohort study with long-term follow-up.

OBJECTIVE: The objective of this study was to determine the effects of in utero bipedicle flaps on maternal-fetal morbidity/mortality, the need for CSF diversion, and long-term functional outcomes. METHODS: Eighty-six patients who underwent fetal myelomeningocele repair from 2011 to 2021 at a single institution were reviewed. Primary outcomes included intrauterine fetal demise, postnatal death, postnatal myelomeningocele repair dehiscence, and CSF diversion by final follow-up. RESULTS: The cohorts were no different with regard to race, ethnicity, maternal age at fetal surgery, body mass index, gravidity, parity, gestational age at fetal surgery, estimated fetal weight at fetal surgery, or fetal lesion level. Of the 86 patients, 64 underwent primary linear repair and 22 underwent bipedicle flap repair. There were no significant differences in rates of intrauterine fetal demise, postnatal mortality, midline repair site dehiscence, or the need for CSF diversion by final follow-up. Operative times were longer (32.5 vs 18.7 minutes, p < 0.001) and gestational age at delivery was lower (232 vs 241 days, p = 0.01) in the bipedicle flap cohort, but long-term functional outcomes were not different. CONCLUSIONS: Analysis of the total cohort affirms the long-term benefits of fetal myelomeningocele repair. In utero bipedicle flaps are safe and can be used for high-tension lesions without increasing perioperative risks to the mother or fetus. In utero flaps preserve the long-term benefits seen with primary linear repair and may expand inclusion criteria for fetal repair, providing life-changing care for more patients.

Trends in utilization of standardized letters of recommendation in the 2021-2022 neurosurgery application process.

OBJECTIVE: Standardized letters of recommendation (SLORs) were introduced during the 2020-2021 neurosurgery residency application cycle, but suffered from poor interrater reliability and grade inflation. Changes were made to the SLOR template and utilization patterns in response to these shortcomings. The authors examined the second year of SLOR utilization. They hypothesized that grade inflation and interrater reliability would be improved from the first iteration. They also hypothesized that increased numbers of letters by single writers would correlate with broader rating distributions. METHODS: This cross-sectional study analyzed all SLORs submitted to a single neurosurgery residency program over the 2021-2022 cycle. Data from 7 competency domains and the overall rating were recorded and stratified by academic category of the letter writer. Interrater reliability was evaluated using Krippendorff's alpha. The frequency of letters written was evaluated using the Kruskal-Wallis H test. RESULTS: Ninety percent of SLORs rated applicants among the top 25%, but there was a significant decrease in the usage of the top 1% and top 2%-5% ratings. Interrater reliability was poor across all competencies. Writers who completed 1 SLOR rated applicants higher and had a narrower range than those who completed multiple SLORs. CONCLUSIONS: Changes in the format and subsequent utilization patterns of SLORs have slightly decreased grade inflation; however, interrater reliability remains poor. The most wide-ranging evaluators submitted the highest number of SLORs, suggesting that future evaluation and usage of SLORs should emphasize letter-writer characteristics and numbers of SLORs written. Overall, SLORs have been well and broadly accepted with subtle improvements in the second year of utilization.

Words matter: using natural language processing to predict neurosurgical residency match outcomes.

OBJECTIVE: Narrative letters of recommendation (NLORs) are considered by neurosurgical program directors to be among the most important parts of the residency application. However, the utility of these NLORs in predicting match outcomes compared to objective measures has not been determined. In this study, the authors compare the performance of machine learning models trained on applicant NLORs and demographic data to predict match outcomes and investigate whether narrative language is predictive of standardized letter of recommendation (SLOR) rankings. METHODS: This study analyzed 1498 NLORs from 391 applications submitted to a single neurosurgery residency program over the 2020-2021 cycle. Applicant demographics and match outcomes were extracted from Electronic Residency Application Service applications and training program websites. Logistic regression models using least absolute shrinkage and selection operator were trained to predict match outcomes using applicant NLOR text and demographics. Another model was trained on NLOR text to predict SLOR rankings. Model performance was estimated using area under the curve (AUC). RESULTS: Both the NLOR and demographics models were able to discriminate similarly between match outcomes (AUCs 0.75 and 0.80; p = 0.13). Words including "outstanding," "seamlessly," and "AOA" (Alpha Omega Alpha) were predictive of match success. This model was able to predict SLORs ranked in the top 5%. Words including "highest," "outstanding," and "best" were predictive of the top 5% SLORs. CONCLUSIONS: NLORs and demographic data similarly discriminate whether applicants will or will not match into a neurosurgical residency program. However, NLORs potentially provide further insight regarding applicant fit. Because words used in NLORs are predictive of both match outcomes and SLOR rankings, continuing to include narrative evaluations may be invaluable to the match process.

Attention-Deficit Hyperactivity Disorder and Learning Disabilities Modify Recovery and Sport Behavior Following Sport-Related Concussion.

Limited evidence exists concerning how a diagnosis of attention-deficit hyperactivity disorder and/or learning disabilities (ADHD/LD) modifies recovery and behavior following sport-related concussion (SRC). To understand how ADHD/LD modifies the post-SRC experience, we conducted a retrospective cohort study of concussed young athletes through phone interviews with patients and guardians. Outcomes included time until symptom resolution (SR) and return-to-learn (RTL), plus subjective changes in post-SRC activity and sports behavior. Multivariate Cox and logistic regression was performed, adjusting for biopsychosocial characteristics. The ADHD/LD diagnosis was independently associated with worse outcomes, including lower likelihood to achieve SR (hazard ratio [HR] = 0.62, 95% confidence interval [CI] = [0.41-0.94]; P = .02) and RTL (HR = 0.55, 95% CI = [0.36-0.83]; P < .01) at any time following injury, and increased odds of changing sport behavior after concussion (odds ratio [OR] = 3.26, 95% CI = [1.26-8.42], P = .02), often to a safer style of play (62.5% vs 39.6%; P = .02) or retiring from the sport (37.5% vs 18.5%; P = .02). These results provide further evidence of the unique needs for athletes with ADHD/LD following SRC.

Factors Associated With Additional Clinic Visits in the Treatment of Sports-Related Concussion.

OBJECTIVE: To evaluate the variables associated with additional concussion clinic visits before discharge to athletic trainer (AT). DESIGN: Retrospective cohort study. SETTING: Multidisciplinary Sports Concussion Center. PATIENTS: Patients ages 12 to 23 years presenting with a sport-related concussion between January 11, 2017, and January 10, 2020, and were discharged to an AT. METHODOLOGY: Our main outcome variable was being discharged to AT after the initial clinic visit versus those who attended additional clinic visits before AT discharge. We examined the influence of age, sex, initial visit symptom score, family and personal history of psychiatric disorders and migraines, history of prior concussions, and other variables on this outcome. RESULTS: Of 524 patients, 236 were discharged to AT after the initial clinic visit, while 288 patients required additional clinic visits. The additional visit group had higher initial visit symptom scores ( P = 0.002), head imaging performed more frequently ( P < 0.02), a family history of psychiatric disorders and/or migraines ( P < 0.001, P < 0.001), more often reported a prior concussion ( P = 0.02), and was younger ( P = 0.014) compared with the one visit group. In a multiple variable model, the family history of psychiatric disorders [odds ratio (OR), 3.12 (95% CI, 1.531-6.343), P = 0.002], prior concussions [OR, 1.39 (95% CI, 1.020-1.892), P = 0.037], greater initial symptom score [OR, 1.05 (95% CI, 1.031-1.058), P < 0.001], and younger age [OR, 0.87 (95% CI, 0.773-0.979), P = 0.021] were strongly associated with additional visits. CONCLUSIONS: Among athletes treated at a regional sports concussion center, family history of psychiatric disorders, increased symptom score at initial visit, prior concussions, and younger age were each uniquely associated with needing additional clinic visits at the time of initial assessment. Understanding these variables may guide treatment protocols for optimal care.

Pediatric spinal injury patterns and management in all-terrain vehicle and dirt bike crashes, 2010-2019.

OBJECTIVE: Pediatric spinal injuries in all-terrain vehicle (ATV) and dirt bike crashes are relatively uncommon but may be associated with significant morbidity. There are no recent studies examining these injuries, their management, and outcomes. Therefore, a retrospective study was performed to characterize pediatric spinal injuries related to ATV and dirt bike crashes over the last decade. METHODS: Data on all patients involved in ATV or dirt bike crashes evaluated at a regional level 1 pediatric trauma center over a 10-year period (2010-2019) were analyzed. Descriptive statistics were analyzed and chi-square, Fisher exact, and Mann-Whitney U-tests were performed comparing the demographics, injury characteristics, and clinical outcomes in patients with versus those without spinal injuries. RESULTS: Of 680 patients evaluated, 35 (5.1%) were diagnosed with spinal injuries. Over the study period, both spinal injuries and emergency department visits related to ATV or dirt bike crashes increased in frequency. All spinal injuries were initially diagnosed on CT scans, and 57.9% underwent spinal MRI. Injuries were most commonly thoracic (50%), followed by cervical (36.8%). The injuries of most patients were classified as American Spinal Injury Association (ASIA) grade E on presentation (86.8%), while 2 (5.3%) had complete spinal cord injuries (ASIA grade A) and 3 patients (8.6%) were ASIA grade B-D. Operative management was required for 13 patients (28.9%). Nonoperative management was used in 71.1% of injuries, including bracing in 33% of all injuries. Patients with spinal injuries were older than those without (13.4 ± 3.35 vs 11.5 ± 3.79 years, p = 0.003). Spinal injuries occurred via similar crash mechanisms (p = 0.48) and in similar locations (p = 0.29) to nonspinal injuries. Patients with spinal injuries more frequently required admission to the intensive care unit (ICU; 34.2% vs 14.6%, p = 0.011) and had longer hospital stays (mean 4.7 ± 5.5 vs 2.7 ± 4.0 days, p = 0.0025). CONCLUSIONS: Although infrequent among young ATV and dirt bike riders, spinal injuries are associated with longer hospital stays, increased ICU use, and required operative intervention in 29%. Increasing awareness among ATV and dirt bike riders about the severity of riding-related injuries may encourage safer riding behaviors.

Use of acute cognitive symptom cluster to predict return-to-learn duration following a sport-related concussion.

OBJECTIVE: Adolescents sustaining sport-related concussion often experience difficulties with the return-to-learn (RTL) process. Whereas the initial symptom burden has predicted prolonged RTL, no studies have established a relationship between acute cognitive symptoms and RTL duration. The authors sought to evaluate the relationship between initial cognitive symptoms and RTL duration. METHODS: A retrospective single-institution cohort study of adolescent athletes aged 12-23 years who were evaluated within 5 days of a diagnosed sport-related concussion between November 2017 and October 2020 was conducted. Athletes missing cognitive symptom ratings and RTL data were excluded. The primary exposure variable was the Cognitive Symptom Ratio (CSR), defined as total cognitive symptom cluster score divided by total Post-Concussion Symptom Scale (PCSS) score from the initial clinic visit. Primary and secondary outcomes were time to RTL and total length of care, respectively. Multivariable Cox proportional hazards modeling was used to assess the effect of CSR on RTL duration. RESULTS: Of 653 athletes evaluated within 5 days of injury, 346 patients were included in the final cohort. Athletes reported a median initial PCSS score of 21 (interquartile range [IQR] 6-37) and a median cognitive symptom score of 4 (IQR 0-9). Most patients endorsed some degree of difficulty concentrating (n = 212, 61.3%). The median CSR was 0.18 (IQR 0.00-0.27). On multivariable regression analysis, a higher CSR was associated with prolonged RTL duration (HR 0.30, 95% CI 0.13-0.69, p = 0.004). When initial PCSS score was added to the model, the previously significant association between CSR and RTL was no longer significant (HR 0.67, 95% CI 0.29-1.59, p = 0.367). When dichotomized based on frequency distribution, a higher proportion of patients with low CSR achieved RTL by 7 days postinjury (82.2% vs 69.9%, p = 0.007), a difference not seen at 14 days (92.2% vs 87.3%, p = 0.133). CONCLUSIONS: An acute ratio of cognitive symptoms may predict patients at increased risk for prolonged RTL and those with normal PCSS scores who may experience difficulties once resuming school activities.