Through the Looking Glass: Comparing Resident and Attending Views on Competency and Autonomy.

BACKGROUND: Surgical residencies act as an apprenticeship to train new surgeons, ideally with increasing trainee autonomy and competency. Objective methods of measuring these two qualities are needed. METHODS: The objective of this pilot study is to use the Surgical Autonomy Program to compare resident and attending perception of competency, via Zones of Proximal Development (ZPDs), and autonomy, via Teach, Advise, Guide, Solo (TAGS) scale for a common pediatric neurosurgical procedure. The most common pediatric neurosurgical procedure, a ventriculoperitoneal shunt, was broken down into four ZPDs. After each procedure, the resident and the attending rated the competency of the resident by ZPD and their autonomy using TAGS. These ratings were then compared to see if the attending and the resident agreed on their levels of competency and autonomy. RESULTS: There were no significant differences in the rating of competency or autonomy between the residents and the attendings. Postgraduate year was significantly associated with differences in TAGS ratings with those having less experience showing a positive perception gap. Other covariates (age, gender) were not associated with differences in rating. The residents found that the ZPDs checklist was a useful tool for communicating with the attending and for getting appropriate autonomy in the operating room. CONCLUSIONS: Pediatric neurosurgical trainees and attendings had concordance on their perceptions of resident autonomy and competency, suggesting that this tool could be a useful way of objectively grading the progress of neurosurgical residents in surgery.

Pediatric neurosurgery through the lens of time-driven activity-based costing: a pilot study.

OBJECTIVE: Time-driven activity-based costing (TDABC) is a method used in cost accounting that has gained traction in health economics to identify value optimization initiatives. It measures time, assigns value to time increments spent on a patient, and integrates the cost of material and human resources utilized in each episode of care. In this study, the authors report the first use of TDABC to evaluate costs in a pediatric neurosurgical practice. METHODS: A clinical pathway was developed with a multifunction team. A time survey among each care team member, including surgeons, medical assistants (MAs), and patient service representatives (PSRs), was carried out prospectively over a 10-week period at a pediatric neurosurgery clinic. Consecutive patient encounters for Chiari malformation (CM), hydrocephalus, or tethered cord syndrome (TCS) were included. Encounters were categorized as new or established. Relative annual personnel costs, using the salary of a PSR as a reference (i.e., 1.0-unit cost), were calculated for all members using departmental financial data after adjustments. The relative capacity cost rates (minute-1) for each personnel, a representation of per capita cost per minute, were then derived, and the relative costs per visit were calculated. RESULTS: A total of 110 visits (24 new, 86 established) were captured, including 40% CM, 41% hydrocephalus, and 19% TCS encounters. Surgeons had the highest relative capacity cost rate (118.4 × 10-6), more than 10-fold higher than that of an MA or PSR (10.65 × 10-6 and 9.259 × 10-6, respectively). Surgeons also logged more time with patients compared with the rest of the care team in nearly all visits (p ≤ 0.002); consequently, the total visit costs were primarily driven by the surgeon cost (p < 0.0001). Overall, surgeon cost constituted the vast majority of the total visit cost (92%-93%), regardless of whether the visits were new or established. Visit costs did not differ by diagnosis. On average, new visits took longer than established visits (p < 0.001). This difference was largely driven by new CM visits (44.3 ± 13.7 minutes), which were significantly longer than established CM visits (29.8 ± 9.2 minutes; p = 0.001). CONCLUSIONS: TDABC may reveal opportunities to maximize value by highlighting instances of variability and high cost in each module of care delivery. Physician leaders in pediatric neurosurgery may be able to use this information to allocate costs and streamline value care pathways.

A systematic review of the power of standardization in pediatric neurosurgery.

In the current neurosurgical field, there is a constant emphasis on providing the best care with the most value. Such work requires the constant optimization of not only surgical but also perioperative services. Recent work has demonstrated the power of standardized techniques in limiting complication while promoting optimal outcomes. In this review article, protocols addressing operative and perioperative care for common pediatric neurosurgical procedures are discussed. These articles address how various institutions have optimized procedures through standardization. Our objective is to improve patient outcomes through the optimization of protocols.

Bilateral cerebellopontine angle lipomas in an infant with encephalocele: illustrative case.

BACKGROUND: Bilateral cerebellopontine angle (CPA) lipomas are extremely rare. Herein the authors present a case of bilateral CPA lipomas in an infant along with a literature review of bilateral CPA lipomas. OBSERVATIONS: A newborn girl was incidentally found to have bilateral CPA lipomas during the workup for an occipital encephalocele. The encephalocele was repaired primarily on day 2 after birth. The patient demonstrated no symptoms associated with the bilateral CPA lipomas. Eight cases of bilateral CPA lipomas were identified in the literature review and are summarized. Conservative management is the consensus strategy, given minimum growth of the tumor and the high risk of surgical intervention. LESSONS: This is the first reported case of bilateral CPA lipomas in an infant as well as the first with a coexisting intracranial malformation. Intracranial lipomas share an extremely low growth rate and typically do not cause severe symptoms. The management of asymptomatic or mildly symptomatic bilateral CPA lipomas is usually conservative.

Review of Pediatric Extraosseous Chordomas with a Unique, Illustrative Case.

INTRODUCTION: Chordoma is a rare, aggressive tumor that is believed to originate from notochord remnants. It can occur anywhere from the clivus to the sacrum and often recurs even after resection and radiotherapy. We present a unique case that initially suggested a different pathology based on imaging and presentation but was found to be a chordoma on gross and pathological analysis. CASE PRESENTATION: An 11-year-old girl presented outpatient for scoliosis evaluation and was found to have what appeared to be a right L4 peripheral nerve sheath tumor on MRI, causing dextroconvex scoliosis. She underwent a gross total resection via a retroperitoneal approach and was found to have what appeared to be an extraosseous, extradural, extra-spinal canal lumbar chordoma. Immunohistochemical features on surgical pathology were consistent with chordoma. The patient was referred to radiation oncology for adjuvant radiotherapy and pediatric hematology/oncology for recurrence monitoring. DISCUSSION: Our case is the first to present in such a manner, was shown to be external to the spinal canal, encasing the nerve root, and was the first such case in a pediatric patient. We reviewed the growing body of literature on spinal extraosseous chordomas and their characteristics within the pediatric patient population. We also reviewed chordoma pathogenesis theories as well as current and future treatment options.

Influence of the living Pareto chart and data transparency on patient outcomes in neurosurgery.

OBJECTIVE: Quality improvement (QI) tools are increasingly being used to calibrate healthcare quality. Achieving healthcare quality is essential, as there is a movement toward value-based healthcare delivery. Visual management, such as a living Pareto chart, is a strategy for improvement within the QI framework. The authors herein hypothesized that transparency of data through a living Pareto chart is a powerful way to improve patient outcomes and gain clinical efficiency. METHODS: The authors retrospectively reviewed patient outcomes and complications; cerebrospinal fluid (CSF) leaks; shunt, baclofen, and other surgical site infections; readmission rates; and same- or next-day appointments in a cohort of patients at the Riley Hospital for Children from November 1, 2016, to May 31, 2020. Similarly, they reviewed neurosurgical outcomes and complications at a second institution, the Oklahoma Children's Hospital, where a living Pareto chart was utilized from February 1, 2021, to March 31, 2022. The discrete frequency and rates per month of outcomes and complications were graphed on scatterplots, Pearson correlation coefficients were calculated to measure the strength of the relationship between event frequency and time, and best-fit lines illustrated the relationship between those points through the least-squares method. RESULTS: At both the Riley Hospital for Children and Oklahoma Children's Hospital, the use of a living Pareto chart to display data transparently was associated with decreasing infections, and it was associated with decreasing readmissions at Riley. On the other hand, it encouraged same- or next-day clinic appointments to be offered to patients and families. Interestingly, CSF leaks were not mitigated with data transparency alone. CONCLUSIONS: Transparency is a driver of change in patient, provider, and institutional behaviors. It is an essential element of QI and patient safety, as well as building a culture of trust. Readmissions, infections, and same- or next-day appointments were influenced by the living Pareto chart; however, CSF leaks remained recalcitrant to data transparency. Other QI strategies may be necessary to positively affect the occurrence of CSF leaks in neurosurgery.

Torcular pseudomass in a 14-month-old child: illustrative case.

BACKGROUND: "Torcular pseudomass," or redundant soft tissue in the torcular region, is not an infrequent incidental finding on advanced imaging of the brain in infants and young children. It was recently codified among pediatric neuroradiologists; however, its report in the pediatric neurosurgical community has not previously been elucidated. OBSERVATIONS: The authors present a case of a 14-month-old child who presented with fever and a first-time seizure. Computed tomography of the head suggested an epidural abscess; however, magnetic resonance imaging characteristics of the lesion were consistent with torcular pseudomass, a normal variant. At the 3-month follow-up, the child was continuing to do well and had not had another seizure. There have been no indications for surgical intervention or additional radiographic surveillance. LESSONS: The differential diagnosis for torcular pseudomass includes dural venous sinus thrombosis, dermoid cysts, occipital encephalocele, eosinophilic granuloma, and primary and metastatic tumors, such as neuroblastoma. The management of each of these disorders in the differential diagnosis may be much more invasive than continued observation in the case of torcular pseudomass. Therefore, it is important for pediatric neurosurgeons to become familiar with this developmental anomaly of the dura and occipital skull.

Contemporary outcomes of diffuse leptomeningeal glioneuronal tumor in pediatric patients: A case series and literature review.

BACKGROUND: Diffuse leptomeningeal glioneuronal tumor (DLGNT), also known as oligodendrogliomatosis, is a rare neuro-oncologic condition along the neuraxis that remains poorly understood in children. We sought to describe our institutional experience and quantitively summarize the clinical survival and prognostic features of DLGNT in the pediatric population across the contemporary literature. METHODS: We report four institutional cases of pediatric DLGNT diagnosed between 2000 and 2020 based on retrospective review of our records, and performed a comprehensive literature search for published cases from 2000 onwards to create an integrated cohort for analysis. Kaplan-Meier estimations, Fisher's exact test, and logistic regression were utilized to interrogate the data. RESULTS: Of our four cases, three females aged 2-, 3- and 13-years old at diagnosis survived 6-years, 3-years and 14-months respectively, and one male aged 5-years old at diagnosis was still alive 5 years later. Our overall integrated cohort consisted of 54 pediatric DLGNT patients, with 19 (35%) female and 35 (65%) male patients diagnosed at an average age of 6.4 years (range, 1.3-17 years) by means of surgical biopsy. Chemotherapy was used in 45 cases (83%), and mean follow-up time of 54 months (range, 3-204). Across the entire cohort, overall survival 1 month after diagnosis was 96% (95% CI 86-99%), and by 10 years was 69% (95% CI 49-82%). On multivariate analysis of complete data, chemotherapy treatment (HR=0.23, P = 0.04) was statistically predictive of longer overall survival. CONCLUSIONS: More than 2-out-of-3 pediatric DLGNT patients survive beyond one decade. Chemotherapy is statistically associated with longer survival in DLGNT pediatric patients and should form the core of any treatment regimen in this setting. Early detection by means of judicious imaging and surgical biopsy for tissue diagnosis can lead to earlier treatment and likely superior outcomes.

Machine learning to predict passenger mortality and hospital length of stay following motor vehicle collision.

OBJECTIVE: Motor vehicle collisions (MVCs) account for 1.35 million deaths and cost $518 billion US dollars each year worldwide, disproportionately affecting young patients and low-income nations. The ability to successfully anticipate clinical outcomes will help physicians form effective management strategies and counsel families with greater accuracy. The authors aimed to train several classifiers, including a neural network model, to accurately predict MVC outcomes. METHODS: A prospectively maintained database at a single institution's level I trauma center was queried to identify all patients involved in MVCs over a 20-year period, generating a final study sample of 16,287 patients from 1998 to 2017. Patients were categorized by in-hospital mortality (during admission) and length of stay (LOS), if admitted. All models included age (years), Glasgow Coma Scale (GCS) score, and Injury Severity Score (ISS). The in-hospital mortality and hospital LOS models further included time to admission. RESULTS: After comparing a variety of machine learning classifiers, a neural network most effectively predicted the target features. In isolated testing phases, the neural network models returned reliable, highly accurate predictions: the in-hospital mortality model performed with 92% sensitivity, 90% specificity, and a 0.98 area under the receiver operating characteristic curve (AUROC), and the LOS model performed with 2.23 days mean absolute error after optimization. CONCLUSIONS: The neural network models in this study predicted mortality and hospital LOS with high accuracy from the relatively few clinical variables available in real time. Multicenter prospective validation is ultimately required to assess the generalizability of these findings. These next steps are currently in preparation.

White Cord Syndrome after Thoracic Cord Decompression in a Pediatric Patient.

INTRODUCTION: White cord syndrome (WCS) is a rare phenomenon which causes acute neurologic deterioration after a chronically compressed spinal cord is surgically decompressed, resulting in a T2-hyperintense signal to appear in the cord. We present the first case of pediatric WCS in the thoracic spine and the first to show complete resolution of symptoms. CASE PRESENTATION: A 3-year-old girl presented with difficulty ambulating due to pain caused by T4-8 spinal cord compression from a mass of ganglioneuromatous tissue, consistent with her previously treated mediastinal neuroblastoma. She underwent laminoplasty and microsurgical debulking of the mass. She developed severe bilateral leg weakness on postoperative day 1. Magnetic resonance imaging (MRI) showed T2 hyperintensity in the spinal cord from T1 to T10 without enhancement, concerning for WCS. She was started on high-dose steroids and monitored. Her strength improved to 3/5 in both legs prior to discharge to inpatient rehabilitation. On the latest follow-up, 4 months after surgery, she did not demonstrate any neurologic deficits and was ambulating well. Follow-up MRIs have showed continued improvement in the T2 hyperintensity. DISCUSSION/CONCLUSION: Most cases in the literature occur in older adults with chronic cervical compression. Only 1 pediatric case, caused by a cervical arachnoid cyst, has been reported and only resulted in partial improvement. Our case is the first pediatric case of WCS to occur in the thoracic spine, the first pediatric case to demonstrate complete resolution, and the first case of any age to start to establish a length of time the compression is needed to be at risk for WCS.

Women in Neurosurgery Around the World: A Systematic Review and Discussion of Barriers, Training, Professional Development, and Solutions.

BACKGROUND: Women have been a minority in neurosurgery since the foundation of the specialty. Women who choose to pursue neurosurgery or advance in their career must overcome various obstacles. In this article, we discuss the proportion of women in neurosurgery globally and the obstacles they face, as well as the solutions being implemented. METHODS: A systematic review of studies concerning international women in neurosurgery was conducted. Article inclusion was assessed based on relevance to women of neurosurgery, geographic region, date, and classification (rates/data, barriers, or solutions). RESULTS: From the specified search, 127 articles were retrieved, and 27 met the inclusion criteria. Of the total, 25 countries were represented and discussed in the articles. Primary classification of articles resulted in 50 for data/rates, 22 for barriers, and 17 for possible solutions. DISCUSSION: Despite cultural differences among unique regions of the globe, women face similar challenges when pursuing neurosurgery, such as difficulty advancing their careers, balancing duties at work and at home, meeting social and cultural expectations, and finding support and mentorship. Encouragingly, measures are already being implemented worldwide to allow women to fulfill their multiple other roles through maternity leave policies, increasing their access to mentors, and enabling promotions throughout their careers. CONCLUSIONS: With the shortage of neurosurgeons in many regions of the world, the recruitment of female neurosurgeons plays a vital role in meeting those demands. Our cultures and professional societies should celebrate their inclusion and promotion and accommodate the complex role of women as neurosurgeons, mothers, partners, scientists, and leaders.

Management of Chiari I malformation in children: personal opinions.

PURPOSE: This manuscript describes our management philosophy of Chiari I malformation in children based on a single neurosurgeon's personal experience. METHODS: Based on 61 infants and children with Chiari I malformation treated from 2007 to 2017, typical symptoms, surgical indications, types of surgery, and evaluation of surgical decompression are reviewed. RESULTS: Sixty-one patients had 69 decompressions, with 90% having symptom improvement. Seven (11.5%) needed reoperation, 1 of which needed 2 reoperations for recurrence. The recurrence rates were 20% (5 of 25) after dural scoring and 5.6% (2 of 36) after duraplasty (p = 0.1116, Fisher's exact test). Six (16%) of 36 patients developed pseudomeningocele or CSF leak. CONCLUSIONS: We recommend surgical intervention for Chiari I malformation for clearly symptomatic patients and those with significant hydromyelia regardless of symptoms. A bony decompression with dural scoring is recommended for patients with typical occipital headaches with a lesser degree of tonsillar descent, while an expansile duraplasty is standard for those with high-grade tonsillar descent, medullary kink, or hydromyelia. Intraoperative ultrasound is often helpful to ensure the adequacy of the decompression. Most patients will have improvements in symptom and imaging after either type of decompressive surgery.

Predictors of Successful Discharge of Patients on Postoperative Day 1 After Craniotomy for Brain Tumor.

BACKGROUND: Shorter hospital stays have been associated with decreased complication rates, fewer hospital-acquired infections, and lower costs. We evaluated an optimized treatment paradigm for patients undergoing craniotomy allowing for postoperative day 1 (POD1) discharge if the criteria were met. We compared the complication and readmission rates between the POD1 patients and those with longer stays, and examined the patient and surgical variables for predictors of POD1 discharge. METHODS: We performed a retrospective review of craniotomies performed for tumor from 2011 to 2015. Craniotomies for tumors were included, and laser ablations and biopsies were excluded. RESULTS: A total 424 of patients were included, 132 (31%) of whom had been discharged on POD1. The mean length of stay was 6 days. The POD1 patients had had significantly better preoperative Karnofsky performance scale scores (P < 0.0001) and modified Rankin scale scores (P < 0.0001). Patient frailty, measured using the modified frailty index, was negatively predictive of POD1 discharge (P = 0.0183). Surgical factors predictive of early discharge were awake surgery (P < 0.0001) and supratentorial location (P < 0.0001). No POD1 patients experienced deep venous thrombosis (DVT), pulmonary embolus (PE), or urinary tract infections. However, of the patients with a length of stay >1 day, 4.4% and 2.7% developed DVT or PE (P = 0.0119) and urinary tract infections (P = 0.0202), respectively. Multivariate regression identified patient factors (male gender, low preoperative modified Rankin scale score), tumor factors (right-sided, supratentorial, smaller size), lower modified frailty index score, and operative factors (lack of a cerebrospinal fluid drain, awake surgery) as independent predictors of successful early discharge. CONCLUSIONS: Patients with good functional status can be safely discharged on POD1 after tumor craniotomy if the appropriate postoperative criteria have been met. Patients with early discharge had lower 30-day readmission and DVT/PE rates, likely owing to better baseline health status.

Just the Tip: Resection of a Narcotic Catheter-Tip Granuloma: 2-Dimensional Operative Video.

The catheter tip "granuloma" is a rare inflammatory mass that forms in about 3% of patients with an intradural catheter, most commonly from a morphine pump. It has also been seen with other narcotic pumps, narcotic-non-narcotic combinations, and baclofen pumps. Mass formation is associated with increased opioid dose and concentration. It typically presents with increasing pain requiring increasing doses of medication, with minimal improvement, although it may present with neurologic deficits or be asymptomatic. On MRI, it appears as a round, rim-enhancing lesion that is low intensity with a hypointense rim on both T1 and T2. In the absence of neurologic deficits, there are many treatment options, ranging from a temporary stopping of the pump to catheter replacement. When the lesion presents with neurologic deficits, surgical intervention, beyond catheter replacement or repositioning, is indicated. A laminectomy is performed, with intradural exploration and careful resection of the mass, which is likely adherent to the spinal cord. Postoperative worsening of symptoms is common due to the mass being densely adherent to the spinal cord, requiring spinal cord manipulation. This worsening is usually temporary, and many patients make excellent recoveries. We present a case of a hydromorphone pump inflammatory mass, which initially presented with increasing pain, then progressive neurologic deficits, requiring referral and mass resection. We achieved only a partial resection due to the lesion's adherent nature. This surgical video demonstrates our intradural technique for resection of this rare and technically difficult mass, with 6-mo patient follow-up. The patient has consented to this case report.

Central Neurocytoma: Rare Presentation in Fourth Ventricle and Review of Literature.

Central neurocytomas are rare tumors, typically found in the third ventricle. We present the unusual case of a fourth ventricular central neurocytoma in a 70-year-old female presenting with imbalance and headaches, with an enhancing fourth ventricular mass on imaging. We examine the details of her clinical presentation, imaging characteristics, histopathologic analysis, and postoperative course. We performed a critical literature review of fourth ventricular central neurocytoma, identifying 6 previously reported cases. In contrast to our patient, the majority of these cases were in young males. The 2 females with fourth ventricular neurocytoma developed it at a much later age (mean 63.5 years) than their male counterparts (mean 22.8 years; P = 0.005). Despite being a rare cause for a fourth ventricular lesion, given the appropriate clinical context and radiographic findings, this should remain part of the differential diagnosis.

Frontal Sinus Osteoma Presenting with Meningitis and Epilepsy.

BACKGROUND: Osteomas are benign lesions of bone, most frequently seen in the paranasal sinuses; however, they are typically asymptomatic and without complication. We report a rare case of large frontal sinus osteoma with intracranial extension, associated with meningitis and the development of seizures. CASE DESCRIPTION: The patient is a 38-year-old man with a prolonged history of headache and seizures, who was seen by multiple specialists previously, all of whom deferred treatment. After years of worsening seizure activity, he finally underwent surgical resection of the lesion at our institution in a joint operation with neurosurgery and otolaryngology. We examine his course, presentation, and management, and examine the literature for cases of complicated sinus osteomas. CONCLUSIONS: This represents the fourth reported case of frontal sinus osteoma associated with meningitis. We believe this case demonstrates the value of a robust differential and a multidisciplinary approach.

Treatment of posttraumatic lumbar interspinous ligament calcification with partial resection of spinous processes and calcified interspinous ligaments: case report.

The authors report on the first surgical treatment for traumatic interspinous ligament calcification, with significant radiographic and symptomatic improvements at long-term follow-up. Heterotopic ossification occurs following traumatic injury but does not typically affect the interspinous ligaments. While these ligaments can calcify with age, this is rarely seen in patients younger than 50 years of age. The authors present the unusual case of a 31-year-old man who suffered traumatic fractures of thoracic and lumbar spinous processes. He developed progressive low-back pain that failed to respond to conservative treatments. At presentation, he was neurologically intact. CT scanning demonstrated partial calcification of the interspinous ligaments at L2-3, L3-4, and L4-5 with significant hypertrophy of the spinous processes at those levels. He did not have significant disc pathology, and his symptoms were attributed to the limited range of motion caused by the enlarged spinous processes. Partial resection of the spinous processes and calcified interspinous ligaments was performed to remove the heterotopic bone. The patient was seen in follow-up at 5 months postoperatively for imaging, and he was interviewed at 1 and 2 years postoperatively. He is doing well with significant pain relief and an improved range of motion. His Oswestry Disability Index improved from 25 preoperatively to 18 at 2 years postoperatively.

Bridging the gap: creating a self-sustaining neurosurgical residency program in Haiti.

Given Haiti's longstanding socioeconomic burden and recent environmental and epidemiological catastrophes, the capacity for neurosurgery within Haiti has been limited, and outcomes for patients with neurosurgical conditions have remained poor. With few formally trained neurosurgeons (4) in a country of 10.5 million inhabitants, there is a significant need for the development of formal structured neurosurgical training. To mitigate the lack of neurosurgical care within Haiti, the authors established the first neurosurgical residency program within the country by creating an integrated model that uniquely fortifies existing Haitian neurosurgery with government sponsorship (Haitian Ministry of Health and National Medical School) and continual foreign support. By incorporating web-based learning modules, online assessments, teleconferences, and visiting professorships, the residency aims to train neurosurgeons over the course of 3-5 years to meet the healthcare needs of the nation. Although in its infancy, this model aims to facilitate neurosurgical capacity building by ultimately creating a self-sustaining residency program.

Patientem Fortuna Adiuvat: The Delayed Treatment of Surgical Acute Subdural Hematomas-A Case Series.

BACKGROUND: Current guidelines prescribe emergent decompression of acute subdural hematomas (aSDHs) with width 10 mm or larger or midline shift 5 mm or larger. A subset of patients who meet these criteria, including those with high Glasgow Coma Scale (GCS) scores and coagulopathy because of medication or multiple medical comorbidities, may be treated conservatively until the hematoma can be removed by burr hole drainage. We present a series of conservatively managed surgical patients with aSDH, examining their hospital course and outcomes. METHODS: Patients were included who met guidelines for surgery on admission but who had decompression delayed until it could be accomplished by burr hole drainage. Charts were reviewed for presentation, computed tomography scan findings, and outcomes. Patients were classified according to outcome and whether their eventual surgery was scheduled or emergent. RESULTS: Eighteen patients were included with a mean age of 70.2 years. Average GCS score at presentation was 14.6 ± 0.6. Most patients were using some form of blood-thinning medication at presentation (72.2%). Admission CT scan revealed aSDH with a mean width of 13.6 mm and midline shift of 6.6 mm. Average total length of stay was 28.4 ± 17.0 days, of which 14.2 ± 9.2 days were spent in the intensive care unit. Outcomes were generally acceptable, with an average Glasgow Outcome Scale score at discharge of 3.8 ± 1.4. There were only 2 deaths, neither of which was related to the initial trauma or a neurologic process. CONCLUSIONS: Delayed treatment of aSDH by burr hole drainage is an effective option in certain patients who are suboptimal craniotomy candidates. Acceptable outcomes may be achievable with this conservative approach, when applied in appropriate patients.