Diffusion and functional MRI in surgical neuromodulation.

Surgical neuromodulation has witnessed significant progress in recent decades. Notably, deep brain stimulation (DBS), delivered precisely within therapeutic targets, has revolutionized the treatment of medication-refractory movement disorders and is now expanding for refractory psychiatric disorders, refractory epilepsy, and post-stroke motor recovery. In parallel, the advent of incisionless treatment with focused ultrasound ablation (FUSA) can offer patients life-changing symptomatic relief. Recent research has underscored the potential to further optimize DBS and FUSA outcomes by conceptualizing the therapeutic targets as critical nodes embedded within specific brain networks instead of strictly anatomical structures. This paradigm shift was facilitated by integrating two imaging modalities used regularly in brain connectomics research: diffusion MRI (dMRI) and functional MRI (fMRI). These advanced imaging techniques have helped optimize the targeting and programming techniques of surgical neuromodulation, all while holding immense promise for investigations into treating other neurological and psychiatric conditions. This review aims to provide a fundamental background of advanced imaging for clinicians and scientists, exploring the synergy between current and future approaches to neuromodulation as they relate to dMRI and fMRI capabilities. Focused research in this area is required to optimize existing, functional neurosurgical treatments while serving to build an investigative infrastructure to unlock novel targets to alleviate the burden of other neurological and psychiatric disorders.

Excelencia en Neurocirugía: María Cristina García-Sancho, the First Latina Neurosurgeon in the World.

BACKGROUND: Neurosurgery is a specialty that has been dominated by males. Although there has been an increase in the number of women in the field, it is not yet close to being equal. Some noteworthy women who have carved the path for other women to follow in their footsteps include Drs. Sofía Ionescu and Diana Beck, the first and second female neurosurgeons worldwide, respectively. However, there are limited publications on Dr. María Cristina García-Sancho, the first Latina neurosurgeon. METHODS: The purpose of this review was to illuminate the neurosurgical community on the life of Dr. García-Sancho. A thorough literature was performed on medical and non-medical publications that were either authored by Dr. García-Sancho or mentioned her directly. RESULTS: Dr. García-Sancho earned her medical degree at the School of Medicine of the National Autonomous University of Mexico under the guidance of Dr. Clemente Robles, who founded Mexico's first neurosurgical department. Her training took her worldwide. CONCLUSIONS: Her expertise allowed her to pioneer a revolutionary advancement known as the one-step bilateral cordotomy. Her perseverance led her to becoming the head of the Department of Neurosurgery at the National Cancer Institute of Mexico and co-found the Mexican Society of Neurological Surgery, where she served on the board of directors. This review aims to advocate for an equitable environment in the field of neurosurgery with Dr. García-Sancho's story.

A Decade of Global Skull Base Researchers: Gender Data from over 2,700 Abstract Authors in the Journal of Neurological Surgery Part B: Skull Base.

Objective The North American Skull Base Society (NASBS) annual conference brings together skull base researchers from surgical and nonsurgical fields. Our objective was to quantify the contributions of the authors by gender, who presented their work at NASBS and were subsequently published in the Journal of Neurological Surgery Part B: Skull Base . Methods Oral and poster abstracts presented at the NASBS annual meeting from January 1, 2011 to December 31, 2020 were extracted from the Journal of Neurological Surgery Part B: Skull Base. The genderize.io Web application programming interface was utilized to determine authorship gender. A minority of first and last authors had departmental affiliations listed; a subgroup analysis was performed of these authors. Results Female gender was assigned to 498 (17.8%) of the 2,798 first authors and 269 (9.7%) of the 2,762 last authors. Female authorship has consistently increased over the last decade. Representation was higher in otolaryngology (23.3% of first authors, 12.1% of last authors; p = 0.018) than neurosurgery (13.5% of first authors, 4.3% of last authors; p = 0.004). Female researchers were not less likely than their male counterparts to receive prestigious oral presentations. Of the 52 total countries represented, 20 (38.5%) had at least one female first author. Representation varied dramatically between countries. Conclusion The NASBS' efforts have undoubtedly contributed to these impressive strides toward gender parity. More work is needed to ensure that the best and the brightest, regardless of background, continue to contribute to skull base surgery research.

A Decade of Global Skull Base Researchers: Authorship Trends from 3,295 Abstracts in the Journal of Neurological Surgery Part B: Skull Base.

Objective The North American Skull Base Society (NASBS) multidisciplinary annual conference hosts skull base researchers from across the globe. We hypothesized that the work presented at the NASBS annual conference would reveal diverse authorship teams in terms of specialty and geography. Methods In this retrospective review, abstracts presented at the NASBS annual meeting and subsequently published in the Journal of Neurological Surgery Part B: Skull Base between 01/01/2011 and 12/31/2020 were collected. Variables extracted included year, type of presentation, and author names and affiliations. Statistical analyses were performed with SPSS V23.0 with p -values less than 0.05 considered significant. Geographic heat maps were created to assess author distribution, and a network analysis was performed to display authorship collaboration between geographic regions. Results Of 3,312 published abstracts, 731 (22.1%) had an author with an affiliation outside of the United States. Fifty-seven distinct countries were represented. Three-hundred twenty-four abstracts (9.8%) had authorship teams representing at least 2 different countries. The top five US states by abstract representation were Pennsylvania, California, New York, Ohio, and Minnesota. A majority of authors reported neurosurgery affiliations (56.7% first authors, 53.2% last authors), closely followed by otolaryngology (39.1% first authors, 41.5% last authors). No solo authors and very few (3.3%) of the first authors reported a departmental affiliation outside of otolaryngology or neurosurgery. Conclusions Authors from many countries disseminate their work through poster and oral presentations at the NASBS annual meeting. Ten percent of abstracts were the product of international collaboration. Most authors were affiliated with a neurosurgery or otolaryngology department.

Outcomes following surgical intervention for acute hemorrhage in severe traumatic brain injury: a review of the National Trauma Data Bank.

OBJECTIVE: Severe traumatic brain injury (TBI) is a public health issue posing significant morbidity and mortality to afflicted patients. While the effect of time to surgery as the primary factor for survival has been extensively studied, long-term dispositional outcomes following intracranial hemorrhage evacuation have not been well described in the literature. Therefore, the aim of this study was to elicit potential prognostic factors in patients presenting with severe TBI that may have a significant impact on discharge disposition. METHODS: The authors searched the National Trauma Data Bank (NTDB) for patients included between 2010 and 2019, solely focusing on those with a Glasgow Coma Scale score ≤ 8, signifying severe TBI, and with associated intracranial hemorrhage treated via surgical intervention. Numerous characteristics were analyzed, including demographics (age, sex, race, ethnicity, payment status), discharge disposition, time to surgery, pupillary response, midline shift (> 5 mm), and postoperative inpatient complications and comorbidities. Disposition included routine discharge to home, discharge to home with home health services (HHSs), discharge to acute inpatient rehabilitation (AIR), discharge to a skilled nursing facility (SNF)/long-term acute care hospital (LTACH), and death. RESULTS: The authors analyzed data on 7308 patients, 69.6% of whom were White and 11.2% of whom were Black. More young Black and Hispanic patients had severe TBI events than their matched elders, whereas more elderly White patients had severe TBI events than their matched younger counterparts. The most common disposition across all ages was SNF/LTACH. Septuagenarians and octogenarians were 12.1 and 21 times more likely, respectively, to die following a severe TBI than their younger counterparts (p < 0.001). Patients aged 18-29 were 1.7 times more likely to be discharged with HHSs (p < 0.001). Minority race/ethnicity groups were less likely to be discharged to AIR. As age increased, a patient's intensive care unit stay increased by 15 days (p < 0.001) and total hospital length of stay increased by 25 days (p < 0.001). CONCLUSIONS: Neurosurgical evacuation of intracranial hemorrhage in severe TBI has variable long-term morbidity. Utilizing the largest collection of trauma data within the United States, the authors present quantitative evidence on discharge disposition. Understanding these tangible points can help neurosurgeons present potential outcomes to patients, promote preventative care, and generate tangible conversations with patients and their family members.

Fluorescein-guided resection for pediatric low-grade gliomas: institutional experience on two cases and a narrative literature review.

PURPOSE: Low-grade gliomas compose 30% of pediatric central nervous system tumors and outcomes of disease-free progression, and survival is directly correlated to the extent of resection. The use of sodium fluorescein (Na-Fl) is an intraoperative method in the localization of tumor cells in adult patients to optimize resection. Our purpose is to describe the use of Na-Fl in pediatric low-grade gliomas and its outcomes. METHODS: Patients under 18 years of age with low-grade gliomas at the author's institution underwent resection with the use of Na-Fl, with review of preoperative imaging findings, intraoperative results, and follow-up. Then, a comprehensive, narrative literature review of the use of Na-Fl in pediatric low-grade glioma was performed. RESULTS: Our single-institution use of Na-Fl in pediatric patients with suspected low-grade glioma demonstrated excellent results of intraoperative enhancement of tumor cells as well as gross total resection. The literature demonstrated 84% Na-Fl staining and 59.2% of gross total resection in pediatric low-grade gliomas with few small case studies, a range of reported findings, and few side effects. CONCLUSION: Na-Fl has a promising use in low-grade glioma resection in the pediatric patient population. Further research is warranted, such as randomized controlled studies, to assess Na-Fl as a potential tool in improving resection and long-term favorable outcomes.

Evolution of spinal cord injury treatment in military neurosurgery.

During the mid-1900s, military medicine made historical advancements in the diagnosis, stabilization, and treatment of spinal cord injuries (SCIs). In particular, World War II was an inflection point for clinical practice related to SCIs because of the vast number of devastating injuries to soldiers seen during World War I (WWI). The unprecedented rate of SCI along with growth in the field served as a catalyst for surgical and interdisciplinary advancements through the increased exposure to this challenging pathology. Initially, a tragic fate was assumed for soldiers with SCIs in WWI resulting in a very conservative approach strategy given a multitude of factors. However, soldiers with similar injuries 20 years later saw improved outcomes with more aggressive management interventions by specialists in spine trauma, who applied measures such as spinal traction, arthrodesis, and internal fixation, and with the significant developments in the complex rehabilitation of these patients. This article describes the historical shift in the management of SCIs through the two world wars. These historical lessons of SCI and the fundamental advances in their neurosurgical intervention have molded not only military but also modern civilian treatment of SCI.

Women neurosurgeons around the world: a systematic review.

OBJECTIVE: Gender disparities in neurosurgery have persisted even as the number of female medical students in many countries has risen. An understanding of the current gender distribution of neurosurgeons around the world and the possible factors contributing to country-specific gender disparities is an important step in improving gender equity in the field. METHODS: The authors performed a systematic review of studies pertaining to women in neurosurgery. Papers listed in PubMed in the English language were collected. A modified grounded theory approach was utilized to systematically identify and code factors noted to contribute to gender disparities in neurosurgery. Statistical analysis was performed with IBM SPSS Statistics for Windows. RESULTS: The authors identified 39 studies describing the density of women neurosurgeons in particular regions, 18 of which documented the proportion of practicing female neurosurgeons in a single or in multiple countries. The majority of these studies were published within the last 5 years. Eight factors contributing to gender disparity were identified, including conference representation, the proverbial glass ceiling, lifestyle, mentoring, discrimination, interest, salary, and physical burden. CONCLUSIONS: The topic of women in neurosurgery has received considerable global scholarly attention. The worldwide proportion of female neurosurgeons varies by region and country. Mentorship was the most frequently cited factor contributing to noted gender differences, with lifestyle, the glass ceiling, and discrimination also frequently mentioned. Future studies are necessary to assess the influence of country-specific sociopolitical factors that push and pull individuals of all backgrounds to enter this field.

Gender Representation at Conferences, Executive Boards, and Program Committees in Otolaryngology.

OBJECTIVE: Women represent approximately 28.0% of academic otolaryngologists. Previous studies have shown that women in academic medicine, including surgical subspecialties, have disparate career advancement opportunities and grant funding compared to male counterparts. Representation at major academic meetings is an important career advancement opportunity. In this study, we assess the representation of women at otolaryngology conferences. STUDY DESIGN: Cross-sectional analysis of otolaryngology conference programs. METHODS: All publicly available scientific programs from The American Academy of Otolaryngology-Head and Neck Surgery Foundation Annual Meeting (AAO-HNSF), the Triological Society Annual Combined Sections Meeting (TS), and the Triological Society Annual Meeting at Combined Otolaryngology Spring Meetings (TS-COSM) were obtained and analyzed. Name and gender were collected, along with the type of role: speaker, panelist, oral session moderator, and other leadership positions. Yearly trends were analyzed and compared between the conferences and in aggregate. RESULTS: AAO-HNSF had available scientific programs from 2012-2017, while TS and TS-COSM had programs available from 2003-2018. Across all conferences and years, 16.9% of recorded opportunities were occupied by women, with an upward trend from 2005 to 2018. Program committees had the highest proportion of women (21.4%) and presidential citation and guest of honor recipients had the lowest (9.1%). Of all panels, 87.5% did not have any women panelists in 2003, but by 2018 only 24.0% panels were male-only. There was marked repetition among women occupying roles, with only 423 unique women occupying a total of 1,733 filled spots. CONCLUSION: Measured representation of women in academic otolaryngology conferences has improved from 2003-2018. Despite this improvement, gender disparity still exists. LEVEL OF EVIDENCE: 5 Laryngoscope, 131:E373-E379, 2021.

Gender differences in NIH grant funding in neurological surgery.

Research productivity is a vital component to an academic neurosurgeon's career. We sought to evaluate gender differences in NIH funding among faculty in neurological surgery departments. NIH funding awarded to PIs of neurological surgery departments from 2014 to 2019 were obtained and analyzed for gender differences in funding trends, with attention to terminal degree and academic rank, as well as publication range in length of years and h-index. 79.4% of all NIH grants were awarded to male PIs, with the remaining 20.5% given to their female counterparts. Mean of the total NIH grants awarded to men was significantly higher at $1,796,684 (± Standard Error of Mean (SEM) $155,849, IQR: $1,759,250) compared to women at $1,151,968 (± SEM $137,914, IQR: $1,388,538) (P = 0.022). Mean NIH funding per grant for men was $365,760 (± SEM: $39,592, IQR: $189,692) and for women was $292,912 (± SEM: 28,239, IQR: $283,177). Differences in mean NIH funding per grant approached but did not reach statistical significance between men and women (P = 0.122). When stratified for academic rank, there was a significant difference in mean NIH funding per grant between men and women on the associate professor level (p < 0.005), with women exceeding men in funding at this academic level, with other academic ranks remaining non-significant. Overall, male neurosurgeons receive significantly more total NIH grant funding than their female counterparts, except at the level of associate professor where women were found to surpass men.

Evaluating the Readability of Online Patient Education Materials for Trigeminal Neuralgia.

BACKGROUND: Patients, including patients with chronic pain conditions, increasingly turn to the Internet for health information. To facilitate comprehension, this information ought to be written at or below the 8th grade reading level, which is the average American adult's reading level. This study measured the reading level of popular online sources for trigeminal neuralgia. METHODS: The top 10 search results for the search term "trigeminal neuralgia" were selected for inclusion. Flesch Reading Ease, Flesch-Kincaid Grade Level, Gunning Fog Index, Simple Measure of Gobbledygook, Coleman-Liau Index, Automated Readability Index, and Linsear Write Formula were used to assess readability. One-way analysis of variance was used to test for statistical differences in average readability scores among the different web pages. RESULTS: Across the web pages, the average readability scores were as follows: Flesch Reading Ease, 42.1 ± 7.7; Flesch-Kincaid Grade Level, 10.9 ± 0.9; Gunning Fog Index, 15 ± 1.5; Simple Measure of Gobbledygook, 10.9 ± 1.2; Coleman-Liau Index, 12.1 ± 1.3; Automated Readability Index, 11.9 ± 1.4; Linsear Write Formula, 12.4 ± 1.7. Results from one-way analysis of variance demonstrated no statistically significant difference in overall readability scores (F12,78 = 0.008; P > 0.05). CONCLUSIONS: The writing of popular online education materials for trigeminal neuralgia is likely too complex for the average American adult to comprehend. This material should be revised to be readable at or below the 8th grade reading level. A variety of easily readable online education materials for trigeminal neuralgia can assist patients in understanding their illness and potentially improve patient decision making and outcomes.

Fellowship, gender, and scholarly productivity: trends among academic neurosurgeons in the US.

OBJECTIVE: Current data on fellowship choice and completion by neurosurgical residents are limited, especially in relation to gender, scholarly productivity, and career progression. The objective of this study was to determine gender differences in the selection of fellowship training and subsequent scholarly productivity and career progression. METHODS: The authors conducted a quantitative analysis of the fellowship training information of practicing US academic neurosurgeons. Information was extracted from publicly available websites, the Scopus database, and the Centers for Medicare and Medicaid Services Open Payments website. RESULTS: Of 1641 total academic neurosurgeons, 1403 (85.5%) were fellowship trained. There were disproportionately more men (89.9%) compared to women (10.1%). A higher proportion of women completed fellowships than men (p = 0.004). Proportionally, significantly more women completed fellowships in pediatrics (p < 0.0001), neurooncology (p = 0.012), and critical care/trauma (p = 0.001), while significantly more men completed a spine fellowship (p = 0.012). Within those who were fellowship trained, the academic rank of professor was significantly more commonly held by men (p = 0.001), but assistant professor was held significantly more often by women (p = 0.017). The fellowships with the largest mean h-indices were functional/stereotactic, pediatrics, and critical care/trauma. Despite more women completing neurooncology and pediatric fellowships, men had significantly greater h-indices in these subspecialties compared to women. Women had more industry funding awards than men in pediatrics (p < 0.0001), while men had more in spine (p = 0.023). CONCLUSIONS: Women were found to have higher rates for fellowship completion compared with their male counterparts, yet had lower scholarly productivity in every subspecialty. Fellowship choice remains unequally distributed between genders, and scholarly productivity and career progression varies between fellowship choice.

Vulnerable Immigrant Populations in the New York Metropolitan Area and COVID-19: Lessons Learned in the Epicenter of the Crisis.

The epicenter of the COVID-19 crisis since March 17, 2020-the New York metropolitan area-is home to some of the largest Latino immigrant communities in the nation. These communities have long faced barriers to health care access, challenges due to immigration status, and financial and labor instability. The COVID-19 pandemic has aggravated these existing issues in a vulnerable, often forgotten, immigrant community. It has been challenging for this population to access public information regarding COVID-19 testing, treatment, and assistance programs because this information has seldom been disseminated in Spanish and even less frequently in Portuguese. While long-term solutions will require time and changes to policy, some short-term measures can mitigate the current situation. The authors share their experience from Newark, New Jersey, where partnerships of public and private community-based organizations (CBOs) have been successful in establishing trust between the health care system and a fearful Latino community. The Ironbound Initiative, a student group at Rutgers New Jersey Medical School in Newark, New Jersey, has partnered with Mantena Global Care, a Brazilian CBO in Newark, to facilitate dissemination of COVID-19-relevant information. Medical student volunteers, removed from their clinical duties, serve as virtual patient navigators, using social media to reach community members with the goals of improving awareness of precautions to take during the pandemic and of increasing access to needed medical care. These students have collaborated with colleagues in other disciplines to provide necessary legal guidance to community members fearful of seeking care because of their immigration status. The authors urge other academic institutions across the country to recruit multidisciplinary teams of medical, health professions, and law students invested in their local communities and to empower students to partner with CBOs, immigrant community leaders, faith-based organizations, hospitals, and local authorities to support these vulnerable communities during this crisis.

Obstruction of Ventriculoperitoneal Shunt After Myelography-Report of a Unique Case and Its Treatment.

BACKGROUND: Myelography, frequently supplanted by noninvasive, efficient magnetic resonance imaging, remains a useful technique when evaluating the spinal canal in nerve root avulsion, radiation therapy treatment planning, cerebrospinal fluid (CSF) loculation, and CSF leak. Myelography is achieved through a lumbar puncture and instillation of nonionic, water-soluble intrathecal iohexol (Omnipaque, GE Healthcare, Marlborough, Massachusetts, USA) contrast. The aim of the study was to highlight a possible complication of obstruction of a shunt valve due to an increased viscosity of the CSF after intrathecal Omnipaque contrast administration during myelography. CASE DESCRIPTION: The authors report a case of myelography that resulted in obstruction of a ventriculoperitoneal (VP) shunt. A 23-year-old female with significant medical history of neurofibromatosis type I, obstructive hydrocephalus, anterior cervical diskectomy and fusion, and VP shunt placement underwent diagnostic computed tomography after myelography with Omnipaque contrast to assess possible CSF loculation and cord impingement from her cervical instrumentation. The patient experienced somnolence after myelography from obstruction of the VP shunt, with marked ventriculomegaly demonstrated by computed tomography of the head. A shunt tap and shunt pumping regimen resulted in resolution of the obstruction and hydrocephalus, with return to neurologic baseline. CONCLUSIONS: This is a recent case of VP shunt obstruction after myelography, of which previous cases reported are decades old. A shunt pumping regimen may be a nonoperative, effective mean for similar mechanical obstructions of VP shunts for restoration of flow and patency of the shunt system in these patients. We encourage physicians to consider the possibility of shunt obstruction after diagnostic myelography. Caution and close observation should be considered in patients undergoing myelography with a programmable VP shunt.

Neurosurgery in the Brazilian Amazon: Is It Possible?

BACKGROUND: The need for neurosurgical care across the globe remains a public health issue. The creation of sustainable neurological surgery departments and training programs will be indispensable in alleviating the burden of neurological disease in low to middle income countries (LMICs). METHODS: We reviewed the history of the neurological surgery department and residency program of Santarém in the state of Pará, Brazil, from 1999 to the present. We have described the epidemiology unique to the region and provided evidence of a sustainable practice in a LMIC. The challenges, limitations, and resources were explored. RESULTS: We have provided a historical vignette of the evolution of neurological surgery in the Brazilian Amazon, including the creation of a sustainable neurological surgery practice and accredited residency program. In addition, we assessed the neurological surgery burden and epidemiology unique to the region, with an emphasis on the community and indigenous health in this remote area. We also explored the future directions of this example, which could affect the international neurological surgery community. CONCLUSION: A sustainable neurosurgery practice and training program is possible in a LMIC. Training neurosurgeons in developing regions of LMICs is a sustainable method to decrease the morbidity and mortality of neurological diseases and prevent the misdistribution of physicians in a country. We encourage adaptation of sustainable neurological surgery practices in similar regions across the world to increase access to necessary neurosurgical care.

Female Medical Student Retention in Neurosurgery: A Multifaceted Approach.

BACKGROUND: Since 2011, more women than men have graduated from medical school, yet there remains a paucity of female physicians in surgical specialties. After the 2018 Neurosurgery Match, only 17.5% of neurosurgery residents are women. Previous literature documented gender inequality, poor medical school exposure, and lack of female mentorship as reasons for this disparity. We sought to further explore factors that deter female medical students from pursuing neurosurgery. METHODS: A comprehensive survey was created and distributed to the 2017-2018 Rutgers New Jersey Medical School student body, requesting anonymous input from female medical students. RESULTS: Of 104 female respondents, 26.9% had considered neurosurgery as a career and felt dissuaded because of their gender. Of respondents, 88% did not have a senior female medical student pursuing neurosurgery or a female neurosurgical resident as a mentor. More than half of respondents disagreed that they would be dissuaded from a field if they did not have a female mentor. The 88.46% of women who felt that there was a glass ceiling in medicine were also more likely to feel that they would face inequality and adversity that would inhibit training in a male-dominated field. Women who described themselves as seeking challenging and competitive careers strongly felt that they would benefit from exposure to surgical subspecialties during their preclinical years. CONCLUSIONS: Female medical students remain resilient, ambitious, interested in competitive specialties, and eager to explore surgical subspecialties during preclinical years. A multifaceted approach is imperative to recruit and retain qualified women interested in neurosurgery.

Impact of venous thromboembolism during admission for meningioma surgery on hospital charges and postoperative complications.

Surgical resection of meningiomas has been associated with high rates of venous thromboembolic events (VTE) as compared with all other intracranial tumors. There is a paucity of data regarding the clinical complications and comorbidities associated with this cohort yet the underlying pathophysiological mechanism for this tumor-specific finding remains unclear. Our goal was to determine the various impacts of VTE on meningioma surgery in a large cohort of inpatient admissions. This retrospective analysis utilized discharge data from the National Inpatient Sample (NIS) from 2002 to 2010. Patient demographics, comorbidities, length of stay, hospital charges, and postoperative complications were compared between patients with and without VTE. Of 20,259 patients, 426 (2.1%) experienced a VTE. Compared to the non-VTE cohort, patients that experienced a VTE were older (62.7 ±â€¯13.7 vs. 57.2 ±â€¯14.7; p < 0.001), were more commonly male (38.0% vs 30.1%; p = 0.001), had longer hospitalizations (18.8 vs 6.6 days; p < 0.001), and incurred significantly greater hospital charges ($195,837 vs $74,434; p < 0.001). VTE patients experienced significantly higher rates of acute postoperative complications including shock, hemorrhage, wound dehiscence, infection, intracerebral hemorrhage, hemiparesis/hemiplegia, stroke, and death during admission. Odds ratio of aforementioned postsurgical complications remained significantly higher both before and after adjusting for age and sex (all p < 0.01). Occurrence of VTE in patients undergoing meningioma resection portends greater hospital charges, most likely attributed to longer lengths of admission. Increased postoperative complications and mortality in the VTE group warrants further investigation and wariness of the surgeon when treating surgical candidates of meningioma.

Return to the Emergency Room with or without Readmission After Endoscopic Transsphenoidal Surgery in Socioeconomically Disadvantaged Patients at an Urban Medical Center.

BACKGROUND: Although reducing 30-day hospital readmissions is now a priority in neurosurgical quality improvement, postoperative emergency room (ER) visits have remained poorly understood, in particular, in populations with limited access to outpatient care. After endoscopic transsphenoidal surgery, the unique pathologic entities treated can engender a variety of surgical and metabolic complications-often dangerous, delayed, and nonspecific in presentation. We sought to characterize the causes and timing of ER visits-with or without readmission-in a socioeconomically disadvantaged population. METHODS: We reviewed all the patients undergoing ETS by our skull base team from 2009 to 2017 to determine their socioeconomic profile and causes of ER visits. For external validation, we compared our results with national data from the American College of Surgeons National Surgical Quality Improvement Program. RESULTS: Of the 229 patients, 35 (15.3%) had visited the ER within 30 days of discharge. Of these 229 patients, 21 (9.2%) were readmitted, and 109 (47.6%) were insured by Medicaid. The most common reasons for the ER visits were headache (8 of 35 [22.9%]), hyponatremia (7 of 35 [20.0%]), and epistaxis (5 of 35 [14.3%]). The most common cause for readmission was symptomatic hyponatremia (6 of 21 [28.6%]). The other reasons for readmission included meningitis (2 of 21 [9.5%]), adrenal crisis (2 of 21 [9.5%]), and cerebrospinal fluid leakage (1 of 21 [4.8%]). The average time to readmission was 10.9 days. According to the National Surgical Quality Improvement Program database, the 30-day readmission rate was 5.5%, of which 22.2% were for hyponatremia. CONCLUSION: Delayed hyponatremia accounts for a large proportion of ER visits and unplanned readmissions. Close follow-up with diligent, multidisciplinary care might reduce the number of ER visits and readmission in this population.

Unruptured aneurysms in the elderly: perioperative outcomes and cost analysis of endovascular coiling and surgical clipping.

OBJECTIVE Observation and neurosurgical intervention for unruptured intracranial aneurysms (UIAs) in the elderly population is rapidly increasing. Cerebral aneurysm coiling (CACo) is favored over cerebral aneurysm clipping (CAC) in elderly patients, yet some elderly individuals still undergo CAC. The cost-effectiveness of treating UIAs requires further exploration. Understanding the effect of intervention on hospital charges and length of stay (LOS) as well as perioperative mortality and complications can further shed light on its economic impact. The purpose of this study was to analyze the cost and perioperative outcomes of UIAs in elderly patients (≥ 65 years of age) after CACo or CAC intervention. METHODS Retrospective cohorts of CACo and CAC admissions were extracted from National (Nationwide) Inpatient Sample data obtained between 2002 and 2013, forming parallel intervention groups to compare the following outcomes between elderly and nonelderly patients: average LOS and mean hospital admission costs, in-hospital mortality, and complications. Covariates included sex, race or ethnicity, and comorbidities. RESULTS Elderly patients undergoing CAC experienced an average LOS of 8.0 days, whereas elderly patients undergoing CACo stayed an average of 3.2 days. The mean hospital charges incurred during admission totaled $95,960 in the elderly patients who underwent CAC versus $87,960 in the ones who underwent CACo. Elderly patients in whom CAC was performed had a 2.2% rate of in-hospital mortality, with a 2.6 greater adjusted odds of in-hospital mortality than nonelderly patients treated with CAC. In contrast, elderly patients who underwent CACo had a 1.36 greater adjusted odds of in-hospital mortality than their nonelderly counterparts. Compared to nonelderly patients receiving both interventions, elderly individuals had a significantly higher prevalence of various comorbidities and incidence of complications. Elderly patients who received CAC experienced a 10.3% incidence rate of perioperative stroke, whereas their CACo counterparts experienced this complication at a rate of 3.5%. Elderly patients treated with CAC had greater odds of perioperative acute renal failure, whereas their CACo counterparts had greater odds of perioperative deep venous thrombosis and pulmonary embolism. CONCLUSIONS Intervention with CAC and CACo in the elderly is resource intensive and is associated with higher risk than in the nonelderly. Those deciding between intervention and conservative management should consider these risks and costs, especially the 2.2% postoperative mortality rate associated with CAC in the elderly population. Further comparative cost-effectiveness research is needed to weigh these costs and outcomes against those of conservative management.