Seizure and anatomical outcomes of repeat laser amygdalohippocampotomy for temporal lobe epilepsy: A single-institution case series.

OBJECTIVE: In patients with treatment-refractory temporal lobe epilepsy (TLE), a single stereotactic laser interstitial thermotherapy (LITT) procedure is sometimes insufficient to ablate epileptogenic tissue, particularly the medial structures often implicated in TLE. In patients with seizure recurrence after initial ablation, the extent to which a second ablation may achieve improved seizure outcomes is uncertain. The objective of this study was to investigate the feasibility and potential efficacy of repeat LITT amygdalohippocampotomy as a worthwhile strategy for intractable temporal lobe epilepsy by quantifying changes to targeted mesial temporal lobe structures and seizure outcomes. METHODS: Patients who underwent two LITT procedures for drug-resistant mesial TLE at our institution were included in the study. Lesion volumes for both procedures were calculated by comparing post-ablation intraoperative sequences to preoperative anatomy. Clinical outcomes after the initial procedure and repeat procedure were classified according to Engel scores. RESULTS: Five consecutive patients were included in this retrospective case series: 3 with right- and 2 with left-sided TLE. The median interval between LITT procedures was 294 days (range: 227-1918). After the first LITT, 3 patients experienced class III outcomes, 1 experienced a class IV, and 1 experienced a class IB outcome. All patients achieved increased seizure freedom after a second procedure, with class I outcomes (3 IA, 2 IB). CONCLUSIONS: Repeat LITT may be sufficient to achieve satisfactory seizure outcomes in some individuals who might otherwise be considered for more aggressive resection or palliative neuromodulation. A larger study to establish the potential value of repeat LITT amygdalohippocampotomy vs. other re-operation strategies for persistent, intractable temporal lobe epilepsy is worth pursuing.

Pediatric all-terrain vehicle (ATV) related head injury rates and patterns: A 10-year nationwide analysis.

INTRODUCTION: The use of all-terrain vehicles (ATVs) carries significant risk of permanent injury and death, disproportionately affecting children. These injuries commonly affect the head and are especially severe among children as they are often unhelmeted and more likely than adults to experience rollover injuries. Many studies examining patients with ATV-related injuries are single-center cohort studies, with few focusing specifically on head injuries. In the present study, we aimed to characterize the annual incidence of ATV-related head injuries between 2012 and 2021, classify and compare head injury types, and identify descriptive characteristics of ATV-related head injury victims. METHODS: Using the US Consumer Product Safety Commission's National Electronic Injury Surveillance System (NEISS) database, we queried all head injuries associated with operating or riding an ATV in children under 18 years-old from over 100 emergency departments (EDs). Patient information regarding age, race, sex, location of incident, diagnoses, and sequelae were analyzed. We also collected the estimated number of ATV-related head injuries from all US EDs using the NEISS algorithm provided by the database. RESULTS: Using the NEISS algorithm we identified 67,957 (95% CI: 43,608 - 92,305) total pediatric ATV-related head injuries between 2012 and 2021. The annual incidence of ATV-related head injury was similar throughout this study period except for a 20% increase during the COVID-19 pandemic period of 2019-2021 (2019: 6382 injuries, 2020: 6757 injuries, 2021: 7600 injuries). A subset of 1890 cases from approximately 100 EDs were then analyzed. Unspecified closed head injuries were the prevailing type of injury (38%, 900/1890), followed by concussions (27%, 510/1890). More severe injuries included intracranial hemorrhages in 91 children (3.8%, 91/1890). Injuries of all types were predominantly seen in 14-17 year-old's (780/1890, 41%) and in males (64.1%, 1211/1890). In addition, ATV-associated injuries were significantly more common in those coded as white (58.0%, 1096/1890) than any other racial group. ATV-associated accidents among children younger than 9 more commonly occurred at the home compared to accidents involving children older than 9 (57% vs. 32%, p < 0.0001). CONCLUSION: ATV-related head injuries cause a significant annual burden among children, with growing incidence in recent years. Further research may wish to explore potential benefits of helmet use and supervision of younger children in possible prevention of these accidents and their associated economic and non-economic costs.

The epidemiology of crib-related head injuries: A ten-year nationwide analysis.

INTRODUCTION: Falls from cribs resulting in head injury are understudied and poorly characterized. The purpose of this study was to advance current understanding of the prevalence, descriptive characteristics of injury victims, and the types of crib fall-related head injuries (CFHI) using queried patient cases from the National Electronic Injury Surveillance System (NEISS) database. METHODS: Using the US Consumer Product Safety Commission's System NEISS database, we queried all CFHIs among children from over 100 emergency departments (EDs). Patient information regarding age, race, sex, location of the incident, diagnoses, ED disposition, and sequelae were analyzed. The number of CFHI from all US EDs during each year was also collected from the database. RESULTS: There were an estimated 54,799 (95% CI: 30,228-79,369) total visits to EDs for CFHIs between 2012 and 2021, with a decrease in incidence of approximately 20% during the onset of the COVID-19 pandemic (2019: 5616 cases, 2020: 4459 cases). The annual incidence of injuries showed no significant trend over the 10-year study period. An available subset of 1782 cases of head injuries from approximately 100 EDs was analyzed, and 1442 cases were included in final analysis. Injuries were sorted into three primary categories: unspecified closed head injury (e.g., closed head injury, blunt head trauma, or traumatic brain injury), concussion, or open head injury and skull fracture. Unspecified closed head injuries were the most common of all head injuries (95.4%, 1376/1442). Open head injuries (14/1442, 0.97%) and concussions 3.6% (52/1442, 3.6%) were rare. Most injuries involved children under the age of 1 (42.6%) compared to children who were 1, 2, 3, or 4-years old. About a fourth of patients had other diagnoses in addition to their primary injury including scalp/forehead hematomas, emesis, and contusions. Female patients were more likely to present with other diagnoses in addition to their primary head injury (Difference: 12.3%, 95% CI: 9.87%-15.4%, p < .0001). CONCLUSION: Despite minimum rail height requirements set by the Consumer Safety Product Commission (CPSC), head injuries associated with crib falls are prevalent in the United States. However, most injuries were minor with a vast majority of patients being released following examination and treatment.

Reappraisal of intradural findings in Chiari malformation type I.

OBJECTIVE: Management of Chiari malformation type I (CM-I) requires the functional restoration of an obstructed cisterna magna. In posterior fossa decompression with duraplasty (PFDD), various intradural pathologies are suggested to alter CSF flow at the craniocervical junction and require surgical correction. However, reports of the spectrum of intraoperative intradural findings and their nuances are scarce, especially those characterizing rarer findings pertaining to the vascular structures and vascular compression. METHODS: The authors conducted a retrospective cohort analysis of adults and children who underwent first-time PFDD for CM-I (2011-2021), with and without syringomyelia. The surgical reports and intraoperative videos were reviewed, and the frequency and nature of the intradural observations in regard to the tonsils, arachnoid, and vasculature were analyzed along with the clinical findings and surgical outcomes. RESULTS: All 180 patients (age range 1-72 years; median [interquartile range] 24 (14-38) years; 37% of patients were children < 21 years of age) exhibited multiple intradural findings, with a median of 7 distinct concurrent observations in each patient. Novel findings not previously reported included posterior inferior communicating artery (PICA) branches compressing the neural elements at the cervicomedullary junction (26.7%). Other common findings included arachnoid adhesions (92.8%), thickening (90.6%), webs at the obex (52.2%), tonsillar gliosis (57.2%), tonsillar hypertrophy (18.3%), adhesions obstructing the foramen of Magendie (FoM) (62.2%), PICA obstruction of the FoM (17.2%), and dural scarring (87.8%). Tonsillar gliosis and intertonsillar adhesions obstructing the FoM were more common in children than adults. Tonsillar gliosis and arachnoid webs were more common among syringomyelia patients. After multivariable adjustment, none of the observed findings were independently associated with syringomyelia, preoperative symptoms, or postoperative improvement. The vast majority of patients improved postoperatively. The complication rate was low: 1.2% of patients required revision PFDD at > 3 years postoperatively, 3.6% experienced other operative complications, and 0% had CSF leaks. CONCLUSIONS: The diversity of intradural findings and observations revealed in this study suggests that obstructive and compressive structural anomalies may be more common than previously reported among CM-I patients, both those patients with and those without syringomyelia and especially those with obstructive and compressive PICA branches. Although the authors cannot conclude that all these findings are necessarily pathological, further study may determine how they contribute to CM-I pathology and symptomatology in the setting of a compromised cisterna magna.

Toward more accurate documentation in neurosurgical care.

OBJECTIVE: Accurate clinical documentation is foundational to any quality improvement endeavor as it is ultimately the medical record that is measured in assessing change. Literature on high-yield interventions to improve the accuracy and completeness of clinical documentation by neurosurgical providers is limited. Therefore, the authors sought to share a single-institution experience of a two-part intervention to enhance clinical documentation by a neurosurgery inpatient service. METHODS: At an urban, level I trauma, academic teaching hospital, a two-part intervention was implemented to enhance the accuracy of clinical documentation of neurosurgery inpatients by residents and advanced practice providers (APPs). Residents and APPs were instructed on the most common neurosurgical complications or comorbidities (CCs) and major complications or comorbidities (MCCs), as defined by Medicare. Additionally, a "system-based" progress note template was changed to a "problem-based" progress note template. Prepost analysis was performed to compare the CC/MCC capture rates for the 12 months prior to the intervention with those for the 3 months after the intervention. RESULTS: The CC/MCC capture rate for the neurosurgery service line rose from 62% in the 12 months preintervention to 74% in the 3 months after intervention, representing a significant change (p = 0.00002). CONCLUSIONS: Existing clinical documentation habits by neurosurgical residents and APPs may fail to capture the extent of neurosurgical inpatients with CC/MCCs. An intervention that focuses on the most common CC/MCCs and utilizes a problem-based progress note template may lead to more accurate appraisals of neurosurgical patient acuity.

High Prevalence of Gram-Negative Rod and Multi-Organism Surgical Site Infections after Pediatric Complex Tethered Spinal Cord Surgery: Preliminary Report from a Single-Center Study.

BACKGROUND: Surgical site infections (SSIs) are one of the most common complications following pediatric complex tethered spinal cord release. This patient population is similar in some ways to the neuromuscular scoliosis population, in which higher-than-expected rates of gram-negative SSIs have been identified. METHODS: We conducted a single-center retrospective chart review of all patients who underwent complex tethered spinal cord release over a 10-year period between 2007 and 2017. RESULTS: A total of 69 patients were identified, with 10 documented SSIs (14%). 50% of the SSIs were polymicrobial or included at least 1 gram-negative organism. Among the organisms isolated, 3 were fully or -partially resistant to cefazolin, the most common antibiotic prophylaxis in this population. CONCLUSION: Among children undergoing complex tethered spinal cord release, gram-negative and polymicrobial infections are a significant cause of SSIs. Although further multicenter data are needed, these findings suggest that standard antibiotic prophylaxis with cefazolin may not be sufficient.

Increased complications without neurological benefit are associated with prophylactic spinal cord untethering prior to scoliosis surgery in children with myelomeningocele.

PURPOSE: Children with myelomeningocele (MMC) are at increased risk of developing neuromuscular scoliosis and spinal cord re-tethering (Childs Nerv Syst 12:748-754, 1996; Neurosurg Focus 16:2, 2004; Neurosurg Focus 29:1, 2010). Some centers perform prophylactic untethering on asymptomatic MMC patients prior to scoliosis surgery because of concern that additional traction on the cord may place the patient at greater risk of neurologic deterioration peri-operatively. However, prophylactic untethering may not be justified if it carries increased surgical risks. The purpose of this study was to determine if prophylactic untethering is necessary in asymptomatic children with MMC undergoing scoliosis surgery. METHODS: A multidisciplinary, retrospective cohort study from seven children's hospitals was performed including asymptomatic children with MMC < 21 years old, managed with or without prophylactic untethering prior to scoliosis surgery. Patients were divided into three groups for analysis: (1) untethering at the time of scoliosis surgery (concomitant untethering), (2) untethering within 3 months of scoliosis surgery (prior untethering), and (3) no prophylactic untethering. Baseline data, intra-operative reports, and 90-day post-operative outcomes were analyzed to assess for differences in neurologic outcomes, surgical complications, and overall length of stay. RESULTS: A total of 208 patients were included for analysis (mean age 9.4 years, 52% girls). No patient in any of the groups exhibited worsened motor or sensory function at 90 days post-operatively. However, comparing the prophylactic untethering groups with the group that was not untethered, there was an increased risk of surgical site infection (SSI) (31.3% concomitant, 28.6% prior untethering vs. 12.3% no untethering; p = 0.0104), return to the OR (43.8% concomitant, 23.8% prior untethering vs. 17.4% no untethering; p = 0.0047), need for blood transfusion (51.6% concomitant, 57.1% prior untethering vs. 33.8% no untethering; p = 0.04), and increased mean length of stay (LOS) (13.4 days concomitant, 10.6 days prior untethering vs. 6.8 days no untethering; p < 0.0001). In multivariable logistic regression analysis, prophylactic untethering was independently associated with increased adjusted relative risks of surgical site infection (aRR = 2.65, 95% CI 1.17-5.02), unplanned re-operation (aRR = 2.17, 95% CI 1.02-4.65), and any complication (aRR = 2.25, 95% CI 1.07-4.74). CONCLUSION: In this study, asymptomatic children with myelomeningocele who underwent scoliosis surgery developed no neurologic injuries regardless of prophylactic untethering. However, those who underwent prophylactic untethering were more likely to experience SSIs, return to the OR, need a blood transfusion, and have increased LOS than children not undergoing untethering. Based on these data, prophylactic untethering in asymptomatic MMC patients prior to scoliosis surgery does not provide any neurological benefit and is associated with increased surgical risks.

Cerebral Vasospasm after Open Fenestration of an Arachnoid Cyst in a 4-Year-Old Boy: Case Report and Review of the Literature.

Cerebral vasospasm is associated with significant morbidity, and most commonly occurs following subarachnoid hemorrhage. Rarely, vasospasm can follow tumor resection and traumatic brain injury. We present the first reported case of a young child who developed diffuse vasospasm following open fenestration of an arachnoid cyst and was promptly treated, with full recovery of neurologic function. Although vasopasm after arachnoid cyst fenestration is rare, it can be included in the differential for a new focal neurologic deficit.

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.

Common Peroneal Nerve and Tarsal Tunnel Release Surgery in an Adolescent Male with Hunter Syndrome: Illustrative Case.

BACKGROUND: Children with Hunter syndrome have a high prevalence of nerve compression syndromes given the buildup of glycosaminoglycans in the tendon sheaths and soft tissue structures. These are often comorbid with orthopedic conditions given joint and tendon contractures due to the same pathology. While carpal tunnel syndrome and surgical treatment has been well-reported in this population, the literature on lower extremity nerve compression syndromes and their treatment in Hunter syndrome is sparse. OBSERVATIONS: We report the case of a 13-year-old male with a history of Hunter syndrome who presented with toe-walking and tenderness over the peroneal and tarsal tunnel areas. He underwent bilateral common peroneal nerve and tarsal tunnel releases, with findings of severe nerve compression and hypertrophied soft tissue structures demonstrating fibromuscular scarring on pathology. Post-operatively, the patient's family reported subjective improvement in lower extremity mobility and plantar flexion. LESSONS: In this case, peroneal and tarsal nerve compression were diagnosed clinically and treated effectively with surgical release and postoperative ankle casting. Given the wide differential of common comorbid orthopedic conditions in Hunter syndrome and the lack of validated electrodiagnostic normative values in this population, the history and physical examination and consideration of nerve compression syndromes are tantamount for successful workup and treatment of gait abnormalities in the child with Hunter syndrome.

Laser amygdalohippocampotomy reduces contralateral hippocampal sub-clinical activity in bitemporal epilepsy: A case illustration of responsive neurostimulator ambulatory recordings.

Responsive neurostimulation (RNS) is a valuable tool in the diagnosis and treatment of medication refractory epilepsy (MRE) and provides clinicians with better insights into patients' seizure patterns. In this case illustration, we present a patient with bilateral hippocampal RNS for presumed bilateral mesial temporal lobe epilepsy. The patient subsequently underwent a right sided LITT amygdalohippocampotomy based upon chronic RNS data revealing predominance of seizures from that side. Analyzing electrocorticography (ECOG) from the RNS system, we identified the frequency of high amplitude discharges recorded from the left hippocampal lead pre- and post- right LITT amygdalohippocampotomy. A reduction in contralateral interictal epileptiform activity was observed through RNS recordings over a two-year period, suggesting the potential dependency of the contralateral activity on the primary epileptogenic zone. These findings suggest that early targeted surgical resection or laser ablation by leveraging RNS data can potentially impede the progression of dependent epileptiform activity and may aid in preserving neurocognitive networks. RNS recordings are essential in shaping further management decisions for our patient with a presumed bitemporal epilepsy.

BRAF-mutated suprasellar glioblastoma mimicking craniopharyngioma: illustrative case.

BACKGROUND: Suprasellar masses commonly include craniopharyngiomas and pituitary adenomas. Suprasellar glioblastoma is exceedingly rare with only a few prior case reports in the literature. Suprasellar glioblastoma can mimic craniopharyngioma or other more common suprasellar etiologies preoperatively. OBSERVATIONS: A 65-year-old male with no significant history presented to the emergency department with a subacute decline in mental status. Work-up revealed a large suprasellar mass with extension to the right inferior medial frontal lobe and right lateral ventricle, associated with significant vasogenic edema. The patient underwent an interhemispheric transcallosal approach subtotal resection of the interventricular portion of the mass. Pathological analysis revealed glioblastoma, MGMT partially methylated, with a BRAF V600E mutation. LESSONS: Malignant glioblastomas can mimic benign suprasellar masses and should remain on the differential for a diverse set of brain masses with a broad range of radiological and clinical features. For complex cases accessible from the ventricle where the pituitary complex cannot be confidently preserved via a transsphenoidal approach, an interhemispheric approach is also a practical initial surgical option. In addition to providing diagnostic value, molecular profiling may also reveal therapeutically significant gene alterations such as BRAF mutations.

A child with unilateral abducens nerve palsy and neurovascular compression in Chiari malformation type 1 resolved with posterior fossa decompression: illustrative case.

BACKGROUND: Unilateral cranial nerve (CN) VI, or abducens nerve, palsy is rare in children and has not been reported in association with Chiari malformation type 1 (CM1) in the absence of other classic CM1 symptoms. OBSERVATIONS: A 3-year-old male presented with acute incomitant esotropia consistent with a unilateral, left CN VI palsy and no additional neurological symptoms. Imaging demonstrated CM1 without hydrocephalus or papilledema, as well as an anterior inferior cerebellar artery (AICA) vessel loop in the immediate vicinity of the left abducens nerve. Given the high risk of a skull base approach for direct microvascular decompression of the abducens nerve and the absence of other classic Chiari symptoms, the patient was initially observed. However, as his palsy progressed, he underwent posterior fossa decompression with duraplasty (PFDD), with the aim of restoring global cerebrospinal fluid dynamics and decreasing possible AICA compression of the left abducens nerve. Postoperatively, his symptoms completely resolved. LESSONS: In this first reported case of CM1 presenting as a unilateral abducens palsy in a young child, possibly caused by neurovascular compression, the patient's symptoms resolved after indirect surgical decompression via PFDD.

Profile of Patients Receiving Computed Tomography Scans for Mild Traumatic Brain Injury in a Tertiary Care Hospital in Ethiopia.

BACKGROUND: Traumatic brain injury (TBI) is a leading contributor to emergency department (ED) mortalities in Ethiopia. Mild TBI patients comprise half of all TBI patients presenting for care in Ethiopia and have a high potential for recovery. As such, context-specific care-improving strategies may be highly impactful for this group of patients. OBJECTIVE: This study examines the presentation and disposition of mTBI patients who received a computed tomography scan of the head upon arrival at the largest teaching hospital in Ethiopia. METHODS: A retrospective cohort study was conducted from 2018 to2021 including patients >13 years old with a head injury and a Glasgow Coma Score of 13-15 who obtained a computed tomography scan of the head. Variables were collected from medical charts and single and multivariable analyses assessed outcomes of clinically important TBI (ciTBI) requiring a neurosurgical procedure or admission. RESULTS: A total of 193 patients were included. They were predominantly young men with no comorbidities, injured in road traffic accidents or by assault, had stable vital signs and were treated in lower-acuity ED areas. A minority demonstrated focal deficits, and 29.5% of patients had ciTBI. Most patients were discharged from the ED, but 13% were taken for operative neurosurgical procedures and 10.4% were admitted to the neurosurgery ward for observation. ED stays ranged from 8 hours to 10 days, as patients waited for CT availability, neurosurgical decision, or transportation. Female sex was independently protective of ciTBI. Self-referral status was independently protective against operative intervention. Female sex and self-referral status were independently protective of a disposition of admission and/or going to the operating room. CONCLUSIONS: This study characterizes the mTBI subgroup of head injury patients in Ethiopia's busiest ED: predominantly healthy young men with low-acuity presentations and only a fraction with abnormal neurological examinations. Nonetheless, about one-third had ciTBI and a minority were taken for neurosurgical procedures or admission, with female sex and self-referral identified as protective factors. Meanwhile, many patients stayed in the ED for days due to social or other nonmedical reasons. As TBI care in Ethiopia continues to improve, optimizing care for the mTBI subgroup is tantamount given their high recovery potential. This care will benefit from efficiently identifying those who need intervention or hospital level of care, and discharging those who do not.

Validation of the Canadian CT Head Rule and the New Orleans Criteria for Mild Traumatic Brain Injury in Ethiopia.

BACKGROUND: Traumatic brain injury (TBI) is a major public health problem worldwide. Although computed tomography (CT) scans are often used for TBI workup, clinicians in low-income countries are limited by fewer radiographic resources. The Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) are widely used screening tools to rule out clinically important brain injury without CT imaging. Although these tools are well validated in studies from upper- and middle-income countries, it is important to study these tools in low-income countries. This study sought to validate the CCHR and NOC in a tertiary teaching hospital population in Addis Ababa, Ethiopia. METHODS: This single-center retrospective cohort study included patients older than 13 years presenting from December 2018 to July 2021 with a head injury and a Glasgow Coma Scale score of 13-15. Retrospective chart review collected demographic, clinical, radiographic, and hospital course variables. Proportion tables were constructed to determine the sensitivity and specificity of these tools. RESULTS: A total of 193 patients were included. Both tools showed 100% sensitivity for identifying patients requiring neurosurgical intervention and abnormal CT scans. The specificity for the CCHR was 41.5% and 26.5% for the NOC. Male gender, falling accidents, and headaches had the strongest association with abnormal CT findings. CONCLUSIONS: The NOC and the CCHR are highly sensitive screening tools that can help rule out clinically important brain injury in mild TBI patients without a head CT in an urban Ethiopian population. Their implementation in this low-resource setting may help spare a significant number of CT scans.

Postnatal Myelomeningocele Repair in the United States: Rates and Disparities Before and After the Management of Myelomeningocele Study Trial.

BACKGROUND AND OBJECTIVES: Evolving technologies have influenced the practice of myelomeningocele repair (MMCr), including mandatory folic acid fortification, advances in prenatal diagnosis, and the 2011 Management of Myelomeningocele Study (MOMS) trial demonstrating benefits of fetal over postnatal MMCr in select individuals. Postnatal MMCr continues to be performed, especially for those with limitations in prenatal diagnosis, health care access, anatomy, or personal preference. A comprehensive, updated national perspective on the trajectory of postnatal MMCr volumes and patient disparities is absent. We characterize national trends in postnatal MMCr rates before and after the MOMS trial publication (2000-2010 vs 2011-2019) and examine whether historical disparities persist. METHODS: This retrospective, cross-sectional analysis queried Nationwide Inpatient Sample data for postnatal MMCr admissions. Annual and race/ethnicity-specific rates were calculated using national birth registry data. Time series analysis assessed for trends relative to the year 2011. Patient, admission, and outcome characteristics were compared between pre-MOMS and post-MOMS cohorts. RESULTS: Between 2000 and 2019, 12 426 postnatal MMCr operations were estimated nationwide. After 2011, there was a gradual, incremental decline in the annual rate of postnatal MMCr. Post-MOMS admissions were increasingly associated with Medicaid insurance and the lowest income quartiles, as well as increased risk indices, length of stay, and hospital charges. By 2019, race/ethnicity-adjusted rates seemed to converge. The mortality rate remained low in both eras, and there was a lower rate of same-admission shunting post-MOMS. CONCLUSION: National rates of postnatal MMCr gradually declined in the post-MOMS era. Medicaid and low-income patients comprise an increasing majority of MMCr patients post-MOMS, whereas historical race/ethnicity-specific disparities are improving. Now more than ever, we must address disparities in the care of MMC patients before and after birth.

Patterns in Decompression and Fusion Procedures for Patients With Lumbar Stenosis After Major Clinical Trial Results, 2016 to 2019.

Importance: Use of lumbar fusion has increased substantially over the last 2 decades. For patients with lumbar stenosis and degenerative spondylolisthesis, 2 landmark prospective randomized clinical trials (RCTs) published in the New England Journal of Medicine in 2016 did not find clear evidence in favor of decompression with fusion over decompression alone in this population. Objective: To assess the national use of decompression with fusion vs decompression alone for the surgical treatment of lumbar stenosis and degenerative spondylolisthesis from 2016 to 2019. Design, Setting, and Participants: This retrospective cohort study included 121 745 hospitalized adult patients (aged ≥18 years) undergoing 1-level decompression alone or decompression with fusion for the management of lumbar stenosis and degenerative spondylolisthesis from January 1, 2016, to December 31, 2019. All data were obtained from the National Inpatient Sample (NIS). Analyses were conducted, reviewed, or updated on June 9, 2023. Main Outcome and Measure: The primary outcome of this study was the use of decompression with fusion vs decompression alone. For the secondary outcome, multivariable logistic regression analysis was used to evaluate factors associated with the decision to perform decompression with fusion vs decompression alone. Results: Among 121 745 eligible hospitalized patients (mean age, 65.2 years [95% CI, 65.0-65.4 years]; 96 645 of 117 640 [82.2%] non-Hispanic White) with lumbar stenosis and degenerative spondylolisthesis, 21 230 (17.4%) underwent decompression alone, and 100 515 (82.6%) underwent decompression with fusion. The proportion of patients undergoing decompression alone decreased from 2016 (7625 of 23 405 [32.6%]) to 2019 (3560 of 37 215 [9.6%]), whereas the proportion of patients undergoing decompression with fusion increased over the same period (from 15 780 of 23 405 [67.4%] in 2016 to 33 655 of 37 215 [90.4%] in 2019). In univariable analysis, patients undergoing decompression alone differed significantly from those undergoing decompression with fusion with regard to age (mean, 68.6 years [95% CI, 68.2-68.9 years] vs 64.5 years [95% CI, 64.3-64.7 years]; P < .001), insurance status (eg, Medicare: 13 725 of 21 205 [64.7%] vs 53 320 of 100 420 [53.1%]; P < .001), All Patient Refined Diagnosis Related Group risk of death (eg, minor risk: 16 900 [79.6%] vs 83 730 [83.3%]; P < .001), and hospital region of the country (eg, South: 7030 [33.1%] vs 38 905 [38.7%]; Midwest: 4470 [21.1%] vs 23 360 [23.2%]; P < .001 for both comparisons). In multivariable logistic regression analysis, older age (adjusted odds ratio [AOR], 0.96 per year; 95% CI, 0.95-0.96 per year), year after 2016 (AOR, 1.76 per year; 95% CI, 1.69-1.85 per year), self-pay insurance status (AOR, 0.59; 95% CI, 0.36-0.95), medium hospital size (AOR, 0.77; 95% CI, 0.67-0.89), large hospital size (AOR, 0.76; 95% CI, 0.67-0.86), and highest median income quartile by patient residence zip code (AOR, 0.79; 95% CI, 0.70-0.89) were associated with lower odds of undergoing decompression with fusion. Conversely, hospital region in the Midwest (AOR, 1.34; 95% CI, 1.14-1.57) or South (AOR, 1.32; 95% CI, 1.14-1.54) was associated with higher odds of undergoing decompression with fusion. Decompression with fusion vs decompression alone was associated with longer length of stay (mean, 2.96 days [95% CI, 2.92-3.01 days] vs 2.55 days [95% CI, 2.49-2.62 days]; P < .001), higher total admission costs (mean, $30 288 [95% CI, $29 386-$31 189] vs $16 190 [95% CI, $15 189-$17 191]; P < .001), and higher total admission charges (mean, $121 892 [95% CI, $119 566-$124 219] vs $82 197 [95% CI, $79 745-$84 648]; P < .001). Conclusions and Relevance: In this cohort study, despite 2 prospective RCTs that demonstrated the noninferiority of decompression alone compared with decompression with fusion, use of decompression with fusion relative to decompression alone increased from 2016 to 2019. A variety of patient- and hospital-level factors were associated with surgical procedure choice. These results suggest the findings of 2 major RCTs have not yet produced changes in surgical practice patterns and deserve renewed focus.

An Instructive Case of Cerebral Mucormycosis.

BACKGROUND: Mucormycosis can lead to fatal rhinocerebral infection. CASE: A 53-year-old male with diabetes presented with altered mental status. He had been recently discharged from an admission for COVID-19 pneumonia treated with remdesivir and methylprednisolone. Imaging demonstrated a large left frontal mass with midline shift suspicious for a primary brain neoplasm. His neurologic exam rapidly declined and the patient was taken to the operating room for decompressive hemicraniectomy. Post-operatively, the patient remained comatose and failed to improve. Autopsy revealed a cerebral mucormycosis infection. DISCUSSION: Despite concern for a primary brain neoplasm the patient was diagnosed postmortem with a mucormycosis infection. Other features supporting this diagnosis included nasal sinusitis on initial scans, his fulminant clinical decline, rapidly progressive imaging findings, and persistent hyperglycemia throughout his clinical course. CONCLUSION: In an era of high steroid usage to treat COVID-19, mucormycosis infection must be considered in high-risk patients demonstrating disproportionate clinical decline.

The Impact of Frailty on Traumatic Brain Injury Outcomes: An Analysis of 691 821 Nationwide Cases.

BACKGROUND: Frailty, a decline in physiological reserve, prognosticates poorer outcomes for several neurosurgical conditions. However, the impact of frailty on traumatic brain injury outcomes is not well characterized. OBJECTIVE: To analyze the association between frailty and traumatic intracranial hemorrhage (tICH) outcomes in a nationwide cohort. METHODS: We identified all adult admissions for tICH in the National Trauma Data Bank from 2007 to 2017. Frailty was quantified using the validated modified 5-item Frailty Index (mFI-5) metric (range = 0-5), with mFI-5 ≥2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition, complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression assessed the association between mFI-5 and outcomes, adjusting for patient demographics, hospital characteristics, injury severity, and neurosurgical intervention. RESULTS: A total of 691 821 tICH admissions were analyzed. The average age was 57.6 years. 18.0% of patients were frail (mFI-5 ≥ 2). Between 2007 and 2017, the prevalence of frailty grew from 7.9% to 21.7%. Frailty was associated with increased odds of mortality (odds ratio [OR] = 1.36, P < .001) and decreased odds of favorable discharge disposition (OR = 0.72, P < .001). Frail patients exhibited an elevated rate of complications (OR = 1.06, P < .001), including unplanned return to the ICU (OR = 1.55, P < .001) and operating room (OR = 1.17, P = .003). Finally, frail patients experienced increased ventilator days (+12%, P < .001), ICU LOS (+11%, P < .001), and total LOS (+13%, P < .001). All associations with death and disposition remained significant after stratification for age, trauma severity, and neurosurgical intervention. CONCLUSION: For patients with tICH, frailty predicted higher mortality and morbidity, independent of age or injury severity.

Seizure freedom after laser amygdalohippocampotomy guided by bilateral responsive neurostimulation in pediatric epilepsy: illustrative case.

BACKGROUND: For patients with difficult-to-lateralize temporal lobe epilepsy, the use of chronic recordings as a diagnostic tool to inform subsequent surgical therapy is an emerging paradigm that has been reported in adults but not in children. OBSERVATIONS: The authors reported the case of a 15-year-old girl with pharmacoresistant temporal lobe epilepsy who was found to have bitemporal epilepsy during a stereoelectroencephalography (sEEG) admission. She underwent placement of a responsive neurostimulator system with bilateral hippocampal depth electrodes. However, over many months, her responsive neurostimulation (RNS) recordings revealed that her typical, chronic seizures were right-sided only. This finding led to a subsequent right-sided laser amygdalohippocampotomy, resulting in seizure freedom. LESSONS: In this case, RNS chronic recording provided real-world data that enabled more precise seizure localization than inpatient sEEG data, informing surgical decision-making that led to seizure freedom. The use of RNS chronic recordings as a diagnostic adjunct to seizure localization procedures and laser ablation therapies in children is an area with potential for future study.