Exploring the impact of primary care utilization and health information exchange upon treatment patterns and clinical outcomes of glioblastoma patients.

PURPOSE: There is limited literature describing care coordination for patients with glioblastoma (GBM). We aimed to investigate the impact of primary care and electronic health information exchange (HIE) between neurosurgeons, oncologists, and primary care providers (PCP) on GBM treatment patterns, postoperative outcomes, and survival. METHODS: We identified adult GBM patients undergoing primary resection at our institution (2007-2020). HIE was defined as shared electronic medical information between PCPs, oncologists, and neurosurgeons. Multivariate logistic regression analyses were used to determine the effect of PCPs and HIE upon initiation and completion of adjuvant therapy. Kaplan-Meier and multivariate Cox regression models were used to evaluate overall survival (OS). RESULTS: Among 374 patients (mean age ± SD: 57.7 ± 13.5, 39.0% female), 81.0% had a PCP and 62.4% had electronic HIE. In multivariate analyses, having a PCP was associated with initiation (OR: 7.9, P < 0.001) and completion (OR: 4.4, P < 0.001) of 6 weeks of concomitant chemoradiation, as well as initiation (OR: 4.0, P < 0.001) and completion (OR: 3.0, P = 0.007) of 6 cycles of maintenance temozolomide thereafter. Having a PCP (median OS [95%CI]: 14.6[13.1-16.1] vs. 10.8[8.2-13.3] months, P = 0.005) and HIE (15.40[12.82-17.98] vs. 13.80[12.51-15.09] months, P = 0.029) were associated with improved OS relative to counterparts in Kaplan-Meier analysis and in multivariate Cox regression analysis (hazard ratio [HR] = 0.7, [95% CI] 0.5-1.0, P = 0.048). In multivariate analyses, chemoradiation (HR = 0.34, [95% CI] 0.2-0.7, P = 0.002) and maintenance temozolomide (HR = 0.5, 95%CI 0.3-0.8, P = 0.002) were associated with improved OS relative to counterparts. CONCLUSION: Effective care coordination between neurosurgeons, oncologists, and PCPs may offer a modifiable avenue to improve GBM outcomes.

Individualized homeopathic medicines in preventing the progression from pre-diabetes to diabetes: A double-blind, randomized, placebo-controlled, parallel-arm trial.

CONTEXT: Pre-diabetes is a significant public health problem worldwide. India has a very high rate of progression from pre-diabetes to diabetes, 75-78 per thousand persons per year. OBJECTIVE: To study the efficacy of individualized homeopathic medicinal products (HMPs) against placebos in preventing the progression from pre-diabetes to diabetes. DESIGN: Six-month, double-blind, randomized (1:1), two parallel arms, placebo-controlled trial. SETTING: Outpatient departments of D. N. De Homoeopathic Medical College and Hospital, Kolkata, West Bengal, India. PATIENTS: Sixty participants with pre-diabetes. INTERVENTIONS: Verum: HMPs plus yoga therapy (YT; n = 30); control: identical-looking placebos plus YT (n = 30). MAIN OUTCOME MEASURES: The primary efficacy endpoint was the proportion of participants progressing from pre-diabetes to diabetes, measured after three and six months. Secondary outcomes comprised of fasting blood glucose (FBS), oral glucose tolerance test (OGTT), glycated hemoglobin percentage (HbA1c%), lipid profile, liver enzymes (alanine transaminase, aspartate transaminase), urea and creatinine, and Measure Yourself Medical Outcome Profile version 2 (MYMOP-2); all measured after 3 and 6 months. RESULTS: The proportion of participants converted from pre-diabetics to diabetics (n/N; n = diabetics, N = prediabetics) was significantly less in the verum group than control: HbA1C% (month 3: verum - 2/30 versus control - 11/30, p = 0.003; month 6: 3/30 vs. 2/30, p = 0.008), OGTT (month 3: 0/30 vs. 8/30, p = 0.015; month 6: 0/30 vs. 1/30, p = 0.008), but not according to FBS (month 3: 1/30 vs. 1/30, p = 0.779; month 6: 1/30 vs. 3/30, p = 0.469). Several secondary outcomes also revealed significant improvements in the verum group than in placebo: HbA1C% (p < 0.001), OGTT (p = 0.001), serum ALT (p = 0.031), creatinine (p = 0.012), and MYMOP-2 profile scores (p < 0.001). Sulphur, Bryonia alba, and Thuja occidentalis were the most frequently indicated medicines. Thus, HMPs outperformed placebos by successfully preventing the progression of pre-diabetes to diabetes. TRIAL REGISTRATION: Clinical Trials Registry - India CTRI/2022/04/042,026; UTN: U1111-1277-0021.

The Socioeconomic Distressed Communities Index Predicts 90-day Mortality among Intracranial Tumor Patients.

BACKGROUND: Socioeconomic status (SES) is a major determinant of quality of life and outcomes. However, SES remains difficult to measure comprehensively. Distress communities index (DCI), a composite of seven socioeconomic factors, has been increasingly recognized for its correlation with poor outcomes. OBJECTIVE: To determine the predictive value of DCI on outcomes following intracranial tumor surgery. METHODS: A single institution, retrospective review was conducted to identify adult intracranial tumor patients undergoing resection (2016-2021). Patient ZIP codes were matched to DCI and stratified by DCI quartiles (low:0-24.9, low-intermediate:25-49.9, intermediate-high:50-74.9, high:75-100). Univariate followed by multivariate regressions assessed the effects of DCI on postoperative outcomes. Receiver operating curves (ROC) were generated for significant outcomes. RESULTS: A total of 2,389 patients were included: 1,015 patients (42.5%) resided in low distress communities, 689 (28.8%) in low-intermediate distress communities, 445 (18.6%) in intermediate-high distress communities, and 240 (10.0%) in high distress communities. On multivariate analysis, risk of fracture (adjusted odds ratio [aOR]=1.60, 95% confidence interval [CI] 1.26-2.05, p<0.001) and 90-day mortality (aOR=1.58, 95%CI 1.21-2.06, p<0.001) increased with increasing DCI quartile. Good predictive accuracy was observed for both models, with ROC of 0.746 (95%CI 0.720-0.766) for fracture and 0.743 (95%CI 0.714-0.772) for 90-day mortality. CONCLUSION: Intracranial tumor patients from distressed communities are at increased risk for adverse events and death in the postoperative period. DCI may be a useful, holistic measure of SES that can help risk stratifying patients and should be considered when building healthcare pathways.

The hospital frailty risk score independently predicts postoperative outcomes in meningioma patients.

OBJECTIVE: The Hospital Frailty Risk Score (HFRS) is a recently developed tool that uses ICD-10 codes to measure patient frailty. However, the effectiveness of HFRS has not yet been assessed in meningioma patients specifically. The present study aimed to evaluate the effectiveness of HFRS in predicting surgical outcomes for patients with meningiomas. METHODS: This retrospective study utilized data from patients undergoing meningioma resection at a single institution (2017-2019). Data were obtained through a combination of automated data retrieval and manual chart review. Bivariate logistic regression was used to assess the prognostic ability of several frailty indices for predicting postoperative outcomes. Further, discrimination for each model was assessed using the area under the receiver operating characteristic curve (AUROC). Generalized linear models with gamma error distributions and a log-link function were used to model hospital length of stay (LOS), total charges, complications, and disposition. RESULTS: A total of 464 meningioma patients (mean age 58.20 years, 72.8 % female, 66.4 % white) were included. HFRS had a significantly greater AUROC when compared to ASA (p = 0.0074) for postoperative complications, and HFRS significantly outperformed ASA (p = 0.0021) and mFI-5 (p = 0.018) when predicting nonroutine discharge. On multivariate analysis, increasing HFRS scores were significantly and independently associated with greater LOS (p < 0.0001), higher hospital charges (p < 0.0001), higher odds of postoperative complications (OR = 1.05, p = 0.019), and nonroutine discharge (OR = 1.12, p < 0.0001). The HFRS was non-inferior compared to the mFI-5, CCI, ASA and mFI-11 in terms of model discrimination. CONCLUSION: HFRS effectively predicts postoperative outcomes for meningiomas and outperforms other indices in predicting complications and nonroutine discharge. This novel index may be used to improve clinical decision-making and reduce adverse postoperative outcomes among meningioma patients.

Operative Corridors in Endoscopic Skull Base Tumor Surgery.

Advances in technology, instrumentation, and reconstruction have paved the way for extended endoscopic approaches to skull base tumors. In the sagittal plane, the endonasal approach may safely access pathologies from the frontal sinus to the craniocervical junction in the sagittal plane, the petrous apex in the coronal plane, and extend posteriorly to the clivus and posterior cranial fossa. This review article describes these modular extended endoscopic approaches, along with crucial anatomic considerations, illustrative cases, and practical operative pearls.

Exploring disparities in surgical recommendations for patients with primary intramedullary spinal cord tumors: an analysis of the Surveillance, Epidemiology, and End Results database from 2000 to 2019.

OBJECTIVE: Factors that may drive recommendations for operative intervention for patients with intramedullary spinal cord tumors (ISCTs) have yet to be extensively studied. The authors investigated racial and socioeconomic disparities in the management of patients with primary spinal cord ependymomas and nonependymal gliomas, with the aim of determining the associations between socioeconomic patient characteristics, survival, and recommendations for the resection of primary ISCTs. METHODS: The Surveillance, Epidemiology, and End Results registry was queried to identify all patients > 18 years of age with ISCTs diagnosed between 2000 and 2019. Univariable and multivariable logistic regression analyses were used to calculate odds ratios for variables associated with receiving a surgical recommendation. Log-rank tests and multivariable Cox proportional hazards models were used to investigate overall survival (OS) and disease-specific survival (DSS). RESULTS: The authors identified 2325 patients (mean age 49 [SD 16] years; 48.8% female; 67.4% non-Hispanic White, 7.8% non-Hispanic Black, 16.2% Hispanic, 6.5% Asian/Pacific Islander, 0.6% Native American; 56.7% married; 64.4% with household income < $75,000; 73.8% with spinal ependymoma; and 26.2% with nonependymal spinal glioma). Eighty-seven percent of patients received a surgical recommendation. In multivariable models, marriage was associated with higher odds of receiving a surgical recommendation for ependymomas (OR 1.80, p = 0.005). In multivariable models for nonependymal spinal gliomas, older age (OR 0.98, p = 0.001) and increased number of tumors (OR 0.62, p = 0.015) were associated with decreased odds of receiving surgical recommendations. Among ependymomas, marriage (HR 0.59, p = 0.001), younger age (HR 0.93, p < 0.001), female sex (HR 0.43, p = 0.006), and decreased number of tumors (HR 0.56, p < 0.001) were associated with improved OS. Among nonependymal spinal gliomas, median household income ≥ $75,000 (HR 0.69, p = 0.020) and younger age (HR 0.98, p < 0.001) were associated with improved DSS, while Black race (HR 4.65, p = 0.027) and older age (HR 1.05, p < 0.001) were associated with worse OS. CONCLUSIONS: In patients with spinal ependymomas and nonependymal spinal gliomas, recommendations for surgery appear to be unaffected by patient sex, race, or income. Survival disparities appear to exist among unmarried, male, Black, and lower-income cohorts. Continued initiatives to identify drivers of disparities while improving health equity in this patient population are needed.

Preoperative patient-reported physical health-related quality of life predicts short-term postoperative outcomes in brain tumor patients.

BACKGROUND: Patient-reported outcome measures (PROMs) are increasingly used to assess patients' perioperative health. The PROM Information System 29 (PROMIS-29) is a well-validated global health assessment instrument for patient physical health, though its utility in cranial neurosurgery is unclear. OBJECTIVE: To investigate the utility of preoperative PROMIS-29 physical health (PH) summary scores in predicting postoperative outcomes in brain tumor patients. METHODS: Adult brain tumor patients undergoing resection at a single institution (January 2018-December 2021) were identified and prospectively received PROMIS-29 surveys during pre-operative visits. PH summary scores were constructed and optimum prediction thresholds for length of stay (LOS), discharge disposition (DD), and 30-day readmission were approximated by finding the Youden index of the associated receiver operating characteristic curves. Bivariate analyses were used to study the distribution of low (z-score≤-1) versus high (z-score>-1) PH scores according to baseline characteristics. Logistic regression models quantified the association between preoperative PH summary scores and post-operative outcomes. RESULTS: A total of 157 brain tumor patients were identified (mean age 55.4±15.4 years; 58.0% female; mean PH score 45.5+10.5). Outcomes included prolonged LOS (24.8%), non-routine discharge disposition (37.6%), and 30-day readmission (19.1%). On bivariate analysis, patients with low PH scores were significantly more likely to be diagnosed with a high-grade tumor (69.6% vs 38.85%, p=0.010) and less likely to have elective surgery (34.8% vs 70.9%, p=0.002). Low PH score was associated with prolonged LOS (26.1% vs 22%, p<0.001), nonroutine discharge (73.9% vs 31.3%, p<0.001) and 30-day readmission (43.5% vs 14.9%, p=0.003). In multivariate analysis, low PH scores predicted greater LOS (odds ratio [OR]=6.09, p=0.003), nonroutine discharge (OR=4.25, p=0.020), and 30-day readmission (OR=3.93, p=0.020). CONCLUSION: The PROMIS-29 PH summary score predicts short-term postoperative outcomes in brain tumor patients and may be incorporated into prospective clinical workflows.

The Hospital Frailty Risk Score Independently Predicts Postoperative Outcomes in Glioblastoma Patients.

OBJECTIVE: The Hospital Frailty Risk Score (HFRS) is a tool for quantifying patient frailty using International Classification of Diseases, Tenth Revision codes. This study aimed to determine the utility of the HFRS in predicting surgical outcomes after resection of glioblastoma (GBM) and compare its prognostic ability with other validated indices such as American Society of Anesthesiologists score and Charlson Comorbidity Index. METHODS: A retrospective analysis was conducted using a GBM patient database (2017-2019) at a single institution. HFRS was calculated using International Classification of Diseases, Tenth Revision codes. Bivariate logistic regression was used to model prognostic ability of each frailty index, and model discrimination was assessed using area under the receiver operating characteristic curve. Multivariate linear and logistic regression models were used to assess for significant associations between HFRS and continuous and binary postoperative outcomes, respectively. RESULTS: The study included 263 patients with GBM. The HFRS had a significantly greater area under the receiver operating characteristic curve compared with American Society of Anesthesiologists score (P = 0.016) and Charlson Comorbidity Index (P = 0.037) for predicting 30-day readmission. On multivariate analysis, the HFRS was significantly and independently associated with hospital length of stay (P = 0.0038), nonroutine discharge (P = 0.018), and 30-day readmission (P = 0.0051). CONCLUSIONS: The HFRS has utility in predicting postoperative outcomes for patients with GBM and more effectively predicts 30-day readmission than other frailty indices. The HFRS may be used as a tool for optimizing clinical decision making to reduce adverse postoperative outcomes in patients with GBM.

The neurosurgery research & education foundation-young neurosurgeons committee webinar series: Providing education and inspiration during the COVID-19 pandemic.

OBJECTIVE: During the COVID-19 pandemic, the American Association of Neurological Surgeons (AANS) Young Neurosurgeons Committee (YNC) and Neurosurgery Research & Education Foundation (NREF) launched the YNC-NREF Webinar Series to provide young and aspiring neurosurgeons with timely information, education, and inspiration in the absence of in-person programming. DESIGN: Five 90-minute Zoom webinars were evaluated, each including 1-2 keynote speakers, a panel discussion, and an audience question-and-answer section. Topics included overviews of neurosurgery, the match, subspecialties, and inspirational career stories. Optional pre- and post-webinar surveys with 11-point Likert-type scores were distributed to attendees. We compared groups using chi-squared and Kruskal-Willis tests, and perceptions pre- and post-webinar using Mann-Whitney tests. SETTING: The webinars were live using Zoom, and the recordings were published on NREF's YouTube channel. PARTICIPANTS: The webinar series targeted young neurosurgeons. The first five episodes had a particular focus on medical students and undergraduates. RESULTS: A total of 673 unique participants attended the webinar series; 257 (38%) and 78 (11%) attendees completed the pre- and post-webinar survey, respectively. Respondents had high baseline interest in neurosurgery and were motivated to learn about the match and training in the US, understand neurosurgeons' day-to-day lives, and ask questions. There were significant differences in perceptions between USMSs, IMSs, and undergraduate students. The webinar improved attendees' knowledge about neurosurgical specialties, the match, and US neurosurgery training. CONCLUSIONS: The YNC and NREF effectively engaged a large, diverse audience through an online webinar series, building a foundation for future virtual programming by organized neurosurgery. ACGME competencies.

Initial institutional experience using a robotic arm-enabled 4K 3D exoscope in neurosurgical operations.

The extracorporeal telescope (exoscope) presents a novel digital camera system as a versatile alternative to traditional optical microscopy for microsurgery and minimally invasive neurosurgical operations. Recent innovations in exoscope technology offer 4K-definition multiscreen outputs, pneumatic robot arms, 3-dimensional depth perception, and greater illumination, focus, and magnification powers for enhanced intraoperative visualization. The authors present their initial institutional experience using a robotic arm-enabled 4K 3D exoscope in a variety of cranial and spinal neurosurgical operations, namely Chiari decompression, microvascular decompression for trigeminal neuralgia, anterior cervical discectomy, and lumbar decompressions. The video can be found here: https://stream.cadmore.media/r10.3171/2023.10.FOCVID23150.

Craniotomy versus craniectomy for traumatic acute subdural hematoma-coarsened exact matched analysis of outcomes.

BACKGROUND AND OBJECTIVES: Acute subdural hematoma (aSDH) after traumatic brain injury frequently requires emergent craniotomy (CO) or decompressive craniectomy (DC). We sought to determine the variables associated with either surgical approach and to compare outcomes between matched patients. METHODS: A multi-center retrospective review was used to identify traumatic aSDH patients who underwent CO or DC. Patient variables independently associated with surgical approach were used for coarsened exact matching.Multivariate logistic regression and multivariate Cox proportional-hazards regression wereconducted on matched patients to determine independent predictors of mortality. RESULTS: Seventy-six patients underwent CO and sixty-two underwent DC for aSDH evacuation. DC patients were21.4 years younger (P < 0.001), more likely to be male (80.6 % vs 60.5 %,P = 0.011), and present with GCS ≤ 8 (64.5 % vs 36.8 %,P = 0.001). Age (P < 0.001), epidural hematoma (P = 0.01), skull fracture (P = 0.001), and cisternal effacement (P = 0.02) were independently associated with surgical approach. After coarsened exact matching, DC (P = 0.008), older age (P = 0.007), male sex (P = 0.04), and intraventricular hemorrhage (P = 0.02), were independently associated with inpatient mortality. Multivariate Cox proportional-hazards regression demonstrated that DC was independently associated with mortality at 90-days (P = 0.001) and 1-year post-operation (P = 0.003). CONCLUSION: aSDH patients who receive surgical evacuation via DC as opposed to CO are younger, more likely to be male, and have worse clinical exam. After controlling for patient differences via coarsened exact matching, DC is independently associated with mortality.

Impact of Antithrombotic Medications and Reversal Strategies on the Surgical Management and Outcomes of Traumatic Acute Subdural Hematoma.

OBJECTIVE: Careful hematologic management is required in surgical patients with traumatic acute subdural hematoma (aSDH) taking antithrombotic medications. We sought to compare outcomes between patients with aSDH taking antithrombotic medications at admission who received antithrombotic reversal with patients with aSDH not taking antithrombotics. METHODS: Retrospective review identified patients with traumatic aSDH requiring surgical evacuation. The cohort was divided based on antithrombotic use and whether pharmacologic reversal agents or platelet transfusions were administered. A 3-way comparison of outcomes was performed between patients taking anticoagulants who received pharmacologic reversal, patients taking antiplatelets who received platelet transfusion, and patients not taking antithrombotics. Multivariable regressions, adjusted for injury severity, further investigated associations with outcomes. RESULTS: Of 138 patients who met inclusion criteria, 13.0% (n = 18) reported taking anticoagulants, 16.7% (n = 23) reported taking antiplatelets, and 3.6% (n = 5) reported taking both. Patients taking antiplatelets who received platelet transfusion had longer intraoperative times (P = 0.040) and higher rates of palliative care consultations (P = 0.046) compared with patients taking anticoagulants who received pharmacologic reversal and patients not taking antithrombotics. Across groups, no significant differences were found in frequency of in-hospital intracranial hemorrhage and venous thromboembolism, length of hospital stay, rate of inpatient mortality, or follow-up health status. In multivariable analysis, intraoperative time remained longest for the antiplatelets with platelet transfusion group. Other outcomes were not associated with patient group. CONCLUSIONS: Among surgical patients with traumatic aSDH, those taking antiplatelet medications who receive platelet transfusions experience longer intraoperative procedure times and higher rates of palliative care consultation. Comparable outcomes were observed between patients receiving antithrombotic reversal and patients not taking antithrombotics.

Decreasing Reimbursement of Pituitary Tumor Surgery: An Analysis of Medicare Data From 2010 to 2020.

BACKGROUND AND OBJECTIVES: Despite the extensive amount of research aimed at comparing patient outcomes between microscopic transsphenoidal surgery (MTSS) and endoscopic transsphenoidal surgery (ETSS) approaches, there has been relatively little recent investigation into the nationwide utilization and reimbursement trends of both techniques. This study aimed to identify trends in pituitary tumor surgery utilization, charges to Medicare, and reimbursement dependent on (1) MTSS/ETSS surgery type, (2) provider type (ie, neurosurgeon vs ear, nose, and throat), and (3) cosurgery status. METHODS: This study used publicly available data from the Medicare Physician/Supplier Procedure Summary for the years 2010-2020. Linear regression was used to quantify temporal trends for submitted service counts, submitted charges, reimbursements, and reimbursement-to-charge across the 2010-2020 period. RESULTS: Regarding service count trends from 2010 to 2020, our results demonstrate a significant increase in ETSS utilization ( = 1.55, CI = 0.99-2.12, P < .001), a significant decrease in MTSS utilization ( = -0.86, CI = -1.21 to -0.51, P < .001), a significant increase in services submitted by otolaryngologists ( = 0.59, CI = 0.24-0.93, P = .0040), and a significant increase in cosurgeries ( = 1.03, CI = 0.24-0.93, P = .0051). Importantly, our results also demonstrated a significant decrease in reimbursements for ETSS procedures ( = -12.74, CI = -22.38 to -3.09, P = .015) and for pituitary tumor surgeries submitted by neurosurgeons specifically ( = -41.56, CI = -51.67 to -31.63, P < .0001). CONCLUSION: Our results demonstrated a significant increase in ETSS utilization and a significant decrease in MTSS utilization. We also noted a significant decrease in reimbursements for ETSS procedures and among procedures submitted by neurosurgeons specifically. We hope that our study highlights nationwide utilization and reimbursement patterns that may be useful for guiding future reimbursement-oriented policy development.

A Prospective, Multicenter, Observational Study of Surgical vs Nonsurgical Management for Pituitary Apoplexy.

CONTEXT: Pituitary apoplexy (PA) has been traditionally considered a neurosurgical emergency, yet retrospective single-institution studies suggest similar outcomes among patients managed medically. OBJECTIVE: We established a multicenter, international prospective registry to compare presentation and outcomes in PA patients treated with surgery or medical management alone. METHODS: A centralized database captured demographics, comorbidities, clinical presentation, visual findings, hormonal status, and imaging features at admission. Treatment was determined independently by each site. Key outcomes included visual, oculomotor, and hormonal recovery, complications, and hospital length of stay. Outcomes were also compared based on time from symptom onset to surgery, and from admission or transfer to the treating center. Statistical testing compared treatment groups based on 2-sided hypotheses and P less than .05. RESULTS: A total of 100 consecutive PA patients from 12 hospitals were enrolled, and 97 (67 surgical and 30 medical) were evaluable. Demographics, clinical features, presenting symptoms, hormonal deficits, and imaging findings were similar between groups. Severe temporal visual field deficit was more common in surgical patients. At 3 and 6 months, hormonal, visual, and oculomotor outcomes were similar. Stratifying based on severity of visual fields demonstrated no difference in any outcome at 3 months. Timing of surgery did not affect outcomes. CONCLUSION: We found that medical and surgical management of PA yield similar 3-month outcomes. Although patients undergoing surgery had more severe visual field deficits, we could not clearly demonstrate that surgery led to better outcomes. Even without surgery, apoplectic tumor volumes regress substantially within 2 to 3 months, indicating that surgery is not always needed to reduce mass effect.

Risk of Subdural Hematoma Expansion in Patients With End-Stage Renal Disease: Continuous Venovenous Hemodialysis Versus Intermittent Hemodialysis.

BACKGROUND AND OBJECTIVES: Subdural hematoma (SDH) patients with end-stage renal disease (ESRD) require renal replacement therapy in addition to neurological management. We sought to determine whether continuous venovenous hemodialysis (CVVHD) or intermittent hemodialysis (iHD) is associated with higher rates of SDH re-expansion as well as morbidity and mortality. METHODS: Hemodialysis-dependent patients with ESRD who were discovered to have an SDH were retrospectively identified from 2016 to 2022. Rates of SDH expansion during CVVHD vs iHD were compared. Hemodialysis mode was included in a multivariate logistic regression model to test for independent association with SDH expansion and mortality. RESULTS: A total of 123 hemodialysis-dependent patients with ESRD were discovered to have a concomitant SDH during the period of study. Patients who received CVVHD were on average 10.2 years younger ( P < .001), more likely to have traumatic SDH (47.7% vs 19.0%, P < .001), and more likely to have cirrhosis (25.0% vs 10.1%, P = .029). SDH expansion affecting neurological function occurred more frequently during iHD compared with CVVHD (29.7% vs 12.0%, P = .013). Multivariate logistic regression analysis found that CVVHD was independently associated with decreased risk of SDH affecting neurological function (odds ratio 0.25, 95% CI 0.08-0.65). Among patients who experienced in-hospital mortality or were discharged to hospice, 5% suffered a neurologically devastating SDH expansion while on CVVHD compared with 35% on iHD. CONCLUSION: CVVHD was independently associated with decreased risk of neurologically significant SDH expansion. Therefore, receiving renal replacement therapy through a course of CVVHD may increase SDH stability in patients with ESRD.

Awake Versus Asleep Craniotomy for Patients With Eloquent Glioma: A Systematic Review and Meta-Analysis.

BACKGROUND AND OBJECTIVES: Awake vs asleep craniotomy for patients with eloquent glioma is debatable. This systematic review and meta-analysis sought to compare awake vs asleep craniotomy for the resection of gliomas in the eloquent regions. METHODS: MEDLINE and PubMed were searched from inception to December 13, 2022. Primary outcomes were the extent of resection (EOR), overall survival (month), progression-free survival (month), and rates of neurological deficit, Karnofsky performance score, and seizure freedom at the 3-month follow-up. Secondary outcomes were duration of operation (minute) and length of hospital stay (LOS) (day). RESULTS: Fifteen studies yielded 2032 patients, from which 800 (39.4%) and 1232 (60.6%) underwent awake and asleep craniotomy, respectively. The meta-analysis concluded that the awake group had greater EOR (mean difference [MD] = MD = 8.52 [4.28, 12.76], P < .00001), overall survival (MD = 2.86 months [1.35, 4.37], P = .0002), progression-free survival (MD = 5.69 months [0.75, 10.64], P = .02), 3-month postoperative Karnofsky performance score (MD = 13.59 [11.08, 16.09], P < .00001), and 3-month postoperative seizure freedom (odds ratio = 8.72 [3.39, 22.39], P < .00001). Furthermore, the awake group had lower 3-month postoperative neurological deficit (odds ratio = 0.47 [0.28, 0.78], P = .004) and shorter LOS (MD = -2.99 days [-5.09, -0.88], P = .005). In addition, the duration of operation was similar between the groups (MD = 37.88 minutes [-34.09, 109.86], P = .30). CONCLUSION: Awake craniotomy for gliomas in the eloquent regions benefits EOR, survival, postoperative neurofunctional outcomes, and LOS. When feasible, the authors recommend awake craniotomy for surgical resection of gliomas in the eloquent regions.

Exoscope Use in Spine Surgery: A Systematic Review of Applications, Benefits, and Limitations.

BACKGROUND: Exoscopes were recently developed as an alternative to the operative microscope (OM) and endoscope for intraoperative visualization during neurosurgery. Prior reviews studying mixed cranial and spinal surgical cohorts reported advantages with exoscope use, including improved ergonomics and teaching. In recent years, there has been an increase in exoscope research, with no updated systematic review focused exclusively on the benefits and limitations of exoscope use in spine surgery. Thus, we sought to systematically synthesize the literature related to exoscope-assisted spine surgery. METHODS: A literature search was conducted using the PubMed, Embase, Scopus, Cochrane, and Web of Science databases to identify relevant studies reported between 2010 and September 2023. Data, such as the exoscope model used, procedure types performed, and user observations, were then collected. RESULTS: A total of 31 studies met our inclusion criteria, including 481 patients with spine pathologies who underwent a surgical procedure using 1 of 9 exoscope models. The lumbar region was the most frequently operated area (n = 234; 48.6%), and discectomies comprised the most overall procedures (n = 273; 56.8%). All patients benefited clinically. The reported advantages of exoscopes compared with OMs or endoscopes were improved focal distance, surgeon posture, trainee education, compactness, and assistant participation. Other aspects such as stereopsis, illumination, and cost had various observations. CONCLUSIONS: Exoscopes have advantages compared with OMs or endoscopes during spine surgery. The user learning curve is minimal, and no negative patient outcomes have been reported. However, some aspects of exoscope use necessitate longer term prospective research before exoscopes can be considered a standard tool in the armamentarium of intraoperative visualization strategies.

Management and Molecular Characterization of Intraventricular Glioblastoma: A Single-Institution Case Series.

While the central nervous system (CNS) tumor classification has increasingly incorporated molecular parameters, there is a paucity of literature reporting molecular alterations found in intraventricular glioblastoma (IVGBM), which are rare. We present a case series of nine IVGBMs, including molecular alterations found in standardized next-generation sequencing (NGS). We queried the clinical charts, operative notes, pathology reports, and radiographic images of nine patients with histologically confirmed IVGBM treated at our institution (1995-2021). Routine NGS was performed on resected tumor tissue of two patients. In this retrospective case series of nine patients (22% female, median (range) age: 64.3 (36-85) years), the most common tumor locations were the atrium of the right lateral ventricle (33%) and the septum pellucidum (33%). Five patients had preoperative hydrocephalus, which was managed with intraoperative external ventricular drains in three patients and ventriculoperitoneal shunts in one patient. Hydrocephalus was managed with subtotal resection of a fourth ventricular IVGBM in one patient. The most common surgical approach was transcortical intraventricular (56%). Gross total resection was achieved in two patients, subtotal resection was achieved in six patients, and one patient received a biopsy only. Immunohistochemistry for IDH1 R132H mutant protein was performed in four cases and was negative in all four. Genetic alterations common in glioblastoma, IDH-wildtype, were seen in two cases with available NGS data, including EGFR gene amplification, TERT promoter mutation, PTEN mutation, trisomy of chromosome 7, and monosomy of chromosome 10. Following surgical resection, four patients received adjuvant chemoradiation. Median survival among our cohort was 4.7 months (IQR: 0.9-5.8 months). Management of IVGBM is particularly challenging due to their anatomical location, presentation with obstructive hydrocephalus, and fast growth, necessitating prompt intervention. Additional studies are needed to better understand the genetic landscape of IVGBM compared to parenchymal glioblastoma and may further elucidate the unique pathophysiology of these rare tumors.