An Algorithm for Treatment of Symptomatic Chronic Subdural Hematomas

INTRODUCTION

Although chronic subdural hematoma (CSDH) is a common neurosurgical disease, there is a lack of algorithms for the treatment of asymptomatic and symptomatic CSDH. The purpose of this article is to describe an algorithm developed using our institutional experience for the treatment of symptomatic CSDH that aims to decrease symptoms and/or hematoma size or to completely resolve both. Our algorithm for treatment of symptomatic CSDH includes subdural drain (SDD) placement via twist-drill craniostomy (TDC) as the first-line treatment, followed by supplemental tissue plasminogen activator (tPA) as second-line treatment, with possible middle meningeal artery embolization (MMAE), followed by craniotomy as the last therapeutic option. This study investigated the efficacy of our institution's algorithm in treating symptomatic CSDH.

METHODS

A retrospective study was conducted from 2019 to 2023 identifying patients with CSDH treated with TDC. Electronic medical records were used to gather patient demographics, clinical presentation, radiographic findings, treatment modalities, and clinical outcomes.

RESULTS

There were a total of 109 patients with 128 SDD placements. All 109 patients underwent TDC; among them, 37 patients received tPA instillation with three patients requiring craniotomy. Factors including age, gender, race, mechanism of injury, blood thinner usage, Glasgow Coma Scale (GCS), neurologic exam, thickness of CSDH, and midline shift were comparable for all patients regardless of treatment received. The mean number of neomembranes was higher in patients who eventually required craniotomy (4.5) compared to those treated with TDC only (1.8) and TDC+tPA (2.1) (p=0.0035). There was a greater mean hematoma drainage in patients who received tPA instillation without craniotomy (586.7 mL) than those treated with TDC only (293.0 mL) (p<0.0001). Clinical improvement was found in 52/72 patients (72.2%) treated with TDC only, 23/34 patients (67.6%) treated with TDC+tPA only, and 0/3 patients (0.0%) treated with TDC+tPA+craniotomy. Radiographic improvement in mean thickness of CSDH and midline shift, respectively, was found in patients treated with TDC only (p<0.0001; p<0.0001) and TDC+tPA (p<0.0001; p<0.0001) but not in TDC+tPA+craniotomy (p=0.1494; p=0.0762). There were also fewer neomembranes after TDC+tPA treatment only (2.1 vs. 0.5, p<0.0001). Seven patients were readmitted that did not follow the algorithm and only patients treated following the algorithm showed clinical and radiographic improvement.

CONCLUSIONS

Using our institutional algorithm, our study demonstrates successful clinical outcomes in treating symptomatic CSDH and recurrent CSDH with minimally invasive therapeutic interventions including SDD via TDC and tPA, thereby minimizing the utilization of more invasive interventions including craniotomy.

Handheld Osteotome Laminectomy in Cadavers and a Case Study

Laminectomy is a commonly performed surgery to decompress the spinal canal to relieve spinal canal stenosis secondary to a variety of etiologies such as degenerative spinal changes, fractures, tumors, vascular lesions, and infections. Advances in technologies have allowed for more precise osteotomies and offer more protection to nearby structures; however, these technologies may not always be available at some facilities. To the best of the authors' knowledge, we describe an innovative technique to perform laminectomy using a handheld osteotome, which is widely available and at low cost. Our experience with cadavers and a case study shows that the technique appears to be safe and effective and may have the potential to reduce the procedure length of a laminectomy.

Modulation of Inflammatory Response by Electromagnetic Field Stimulation in Traumatic Brain Injury in Yucatan Swine

Traumatic brain injury is a leading cause of disability and death worldwide and represents a high economic burden for families and national health systems. After mechanical impact to the head, the first stage of the damage comprising edema, physical damage, and cell loss gives rise to a second phase characterized by glial activation, increased oxidative stress and excitotoxicity, mitochondrial damage, and exacerbated neuroinflammatory state, among other molecular calamities. Inflammation strongly influences the molecular events involved in the pathogenesis of TBI. Therefore, several components of the inflammatory cascade have been targeted in experimental therapies. Application of Electromagnetic Field (EMF) stimulation has been found to be effective in some inflammatory conditions. However, its effect in the neuronal recovery after TBI is not known. In this pilot study, Yucatan miniswine were subjected to TBI using controlled cortical impact approach. EMF stimulation via a helmet was applied immediately or two days after mechanical impact. Three weeks later, inflammatory markers were assessed in the brain tissues of injured and contralateral non-injured areas of control and EMF-treated animals by histomorphometry, immunohistochemistry, RT-qPCR, Western blot, and ELISA. Our results revealed that EMF stimulation induced beneficial effect with the preservation of neuronal tissue morphology as well as the reduction of inflammatory markers at the transcriptional and translational levels. Immediate EMF application showed better resolution of inflammation. Although further studies are warranted, our findings contribute to the notion that EMF stimulation could be an effective therapeutic approach in TBI patients.

Extraventricular Drain Care Bundle Decreases Cerebrospinal Fluid Infection Rates Associated With Extraventricular Drain-Related Procedures and Systemic Infection

BACKGROUND

Infection associated with extraventricular drain (EVD)-related procedures is well known.

OBJECTIVE

To investigate the impact of our institution's EVD care bundle on the infection rates associated with EVD-related procedures.

METHODS

A retrospective study was conducted from June 2022 to June 2023 to compare the infection rate six months before and six months after the implantation of the EVD care bundle.

RESULTS

A total of 58 patients were included in the study (n=33 patients in 2022 and n=25 patients in 2023). The infection rate was 21.2% (7/33) prior to the implementation of the EVD care bundle and 0.0% (0/25) afterward. The seven patients with cerebrospinal fluid (CSF) infection did not have a higher total number of EVD-related procedures compared to the other 26 patients without CSF infection (8.0 vs. 9.4, p=0.7364); however, the mean number of EVD replacements was higher in patients with CSF infection (1.4 vs. 3.4, p=0.0028). The total number of EVD-related procedures was not different between 2022 and 2023 (8.3 vs. 5.2, respectively, p=0.1892); however, the mean number of EVD replacements was lower in 2023 (1.8 vs. 1.0, p=0.0257). In 2022, 22/33 patients had systemic infection, among which 7/22 also had CSF infection. In 2023, 13/25 patients had a systemic infection, among which 0/13 had CSF infection.

CONCLUSIONS

The EVD care bundle consisting of standardizations, checklists, and monitoring reduces the CSF infection rates associated with EVD-related procedures and systemic infection.

Patient Satisfaction in Neurosurgery Clinic

BACKGROUND

National commercial surveys are used to assess patient satisfaction. However, the information obtained does not always correspond to the clinical situation and therefore may be inadequate to help improve a specific patient experience when through no fault of its design, results in low response rates and inadequate specifics.

OBJECTIVE

The objective is to investigate patient satisfaction using real-time in-person patient experience survey responses at the end of a neurosurgical clinic visit and review the results from these survey responses and those from national commercial survey responses provided by the hospital for the ability to affect change.

METHODS

This is a prospective study from October 2023 to December 2023 during which a paper copy of 10 questionnaires derived from a national commercial outpatient clinical survey was given to every unique patient who was neurologically capable of filling it out at the end of his or her neurosurgery clinic visit. The electronic medical record was used to collect patient demographics and details of the clinic visit. National commercial survey responses from July 2022 to November 2023 provided by the hospital were reviewed.

RESULTS

A total of 149 patients were seen in the neurosurgery clinic from October 2023 to December 2023, 121 patients were given the in-person patient satisfaction survey, and the response rate was 100%. The mean age was 46.5 years with females constituted 45.5% of the patient sample. The visit type included 46 (38.0%) new patients, 53 (43.8%) returning patients, and 22 (18.2%) post-op patients, of which 45.5% presented with cranial pathologies. Comparing the patient satisfaction level between those seen by one provider and those seen by two providers, such as resident, or mid-level with attending, patients seen by two providers were less satisfied with "feeling respected by the providers" (4.92 vs. 4.64, p=0.0088), "feeling listened to by the providers" (4.84 vs. 4.50, p=0.0180), and "feeling appreciated that the providers discussed illness prevention" (4.72 vs. 4.29, p=0.0232). Due to a lack of necessary information from our national commercial outpatient clinic survey responses provided by the hospital, a direct comparison between the in-person survey and our national commercial outpatient clinic survey was not made.

CONCLUSIONS

Patient satisfaction surveys when not given in real-time in-person run the risk of low response rate and lack of specifics to help guide providers in quality improvement. Our data supports the use of real-time in-person patient satisfaction surveys that not only increase response rate but also provide useful information to help improve patient experience.

A Right-Sided Approach to Anterior Communicating Artery Aneurysms: A Case Review and Technical Report

Anterior communicating artery (ACoA) aneurysms are the most frequently encountered type of intracranial aneurysm. ACoA aneurysms may require treatment depending on clinical presentation, size, risk of rupture, and ruptured status. In patients where treatment is indicated, options entail endovascular securement or clipping. Under the clipping umbrella, surgical approaches traditionally entail a pterional craniotomy and its modifications such as the lateral supraorbital approach. Sidedness of this craniotomy has been a topic of debate. To discuss this we present a case and technical report with nuances of the approach wherein a 48-year-old female presented with the worst headache of her life. The patient was found to have a ruptured wide-necked 7.2 x 8.1 x 5.8 mm ACoA aneurysm more eccentric to the left and fed from the left A1 intertwined with a frontopolar branch, numerous perforators and the recurrent artery of Heubner. The patient underwent a successful clipping from a right-sided approach. As such, with appropriate skull base drilling, exposure, optimization of brain relaxation, and a generous opening of the Sylvian fissure bilateral internal carotid arteries, anterior cerebral arteries with both A1 and A2 segments, middle cerebral arteries, the ACoA, and the relevant anatomy can be appropriately visualized from a right-sided approach. Therefore, an approach is described to optimize exposure to allow for nearly all anterior communicating aneurysms to be clipped from a right-sided pterional approach.

The Use of Induction Sensors and Helmet-Based Shielding Technology to Identify Differences in Electromagnetic Fields in Patients With Cranial Neurological Disease Versus Healthy Controls

Background and objective Electromagnetic fields (EMFs) stemming from neural circuits have been evaluated in healthy human subjects by using non-invasive induction sensor technologies with adjunctive shielding constrained to a helmet constructed of Mu-metal and copper mesh. These EMF measurements have been analyzed and discerned to alter physiological states of movement, thoughts of movement, emotional thoughts, and planned activities. However, these technologies have not yet been investigated as a diagnostic tool in patients with cranial neurological pathology to evaluate differences in patterns in the pathologic state compared to healthy controls. In light of this, we conducted this study to address this scarcity of data. Methods An observational study was conducted in which patients at a single center with cranial neurological disease of all causes were eligible to enroll; they had real-time non-invasive continuous EMF measurements obtained using induction sensors and a shielded helmet. These measurements were obtained in the resting state and then compared to previously obtained measurements in healthy volunteers. Post-processing analysis was conducted to evaluate the derivatives of these EMFs to identify changes in patterns. Results Fourteen patients with traumatic injury, stroke, and neoplasm with ages ranging from 14 to 81 years underwent successful analysis and post-processing of their cortically generated EMF waves. Patterns of EMF waves were compared to previously obtained data from four healthy controls. It was identified that there was less variation in the EMF measurements in patients with neurological disease compared to healthy controls. This was identified based on differences in derivatives of the EMF waves and decreased numbers of peaks and valleys in the EMF waves. Conclusions Novel induction sensors with an engineered, layered Mu-metal and copper mesh helmet for shielding with Mu-metal EMF channels appear to be efficient in measuring neural circuit-driven EMF non-invasively, in real-time, and continuously and can discern differences in EMF patterns between healthy volunteers and patients with neural circuit pathology. The decreased variability in EMF measurements in patients with neural pathology and greater decreases in slope within low-frequency measurements may be correlated with disrupted neural signaling from dysfunctional neurons and abnormalities in spatial and temporal summation. Some EMF changes in ill individuals correspond to changes in the experimentally induced lesions in the animal model. Further studies are warranted to devise models of disease and healthy states to improve these technologies as a diagnostic modality.

A Swine Model of Neural Circuit Electromagnetic Fields: Effects of Immediate Electromagnetic Field Stimulation on Cortical Injury

Background Neurologic diseases have profound disability, mortality, and socioeconomic effects worldwide. Treatment of these disorders varies but is largely limited to unique factors associated with neural physiology. Early studies have evaluated alterations in electromagnetic fields (EMF) due to neural disorders with subsequent modulation of EMF as a potential treatment modality. Swine models have begun to be evaluated as translational models in this effect. Methods EMF measurements of a Yucatan miniswine were recorded using proprietary non-contact, non-invasive induction sensors with a dual layer Mu-metal and interlaced copper mesh helmet. The swine then underwent controlled cortical impact (CCI) to simulate traumatic brain injury (TBI). Twenty minutes post-injury after surgical wound closure, the swine underwent targeted EMF signal modulation using a signal generator to stimulate the swine's injured cortical circuit using a sinusoidal wave individualized at 2.5 Hz with a 500mV positive offset at 1V. After 10 days of stimulation, settings were modified to another individualized frequency of 5.5 Hz, 500mV positive offset and 1V for stimulation. Behavioral patterns in swine were evaluated, and EMF measurements were recorded daily prior to, during, and after stimulation. Artificial intelligence (AI) models evaluated patterns in EMF signals. Histology of the stimulated swine cortex was evaluated using hematoxylin and eosin staining and pentachrome staining and compared to a control swine without stimulation and a swine that had received stimulation two days post-injury in a delayed fashion. Serial serum specimens and tissue at the time of euthanasia were obtained for assessment of neuron-specific enolase (NSE) concentration. Results Pre-operative and post-stimulation measurements demonstrated differences in patterns and activity early on. There was an identified peak at 1.6Hz, not frequently seen pre-operatively. There were convergent frequencies in both data sets at 10.5 Hz and 3.9 Hz. Plateaus and decreased variability of changes in slope were identified early in the post-injury phase. AI modeling identified early similarities in pre-operative and post-stimulation measurements through the patterns of peaks with similarities on postoperative day 10 and similarities in the valleys on postoperative day 17. Histologic specimens identified increased degrees of apoptosis and cellular death in the non-stimulated control compared to the stimulated swine. Similarly, the immediately stimulated swine had less apoptosis and increased histologic viability at the site of injury compared to the two-day delayed stimulation swine. There were increased levels of NSE noted in the stimulated swine at the site of injury compared to non-injured sites and the control swine. Conclusions Cortical function was appropriately measured through induction sensors and shielding in the form of a helmet and electromagnetic field channels. Early stimulation resulted in the early and durable recovery of neuronal circuit-driven electromagnetic field patterns. Histology identified increased viability of neurons with fewer apoptotic neurons and glial cells in stimulated swine with early stimulation identifying the best effect compared to a non-stimulated subject. This recovery identifies change and recovery at the circuit, cellular, and subcellular levels that potentiate the need for further study of EMF modulation as a treatment modality in neurological disorders.

A Swine Model of Traumatic Brain Injury: Effects of Neuronally Generated Electromagnetic Fields and Electromagnetic Field Stimulation on Traumatic Brain Injury-Related Changes

Background and objective Traumatic brain injury (TBI) has been associated with aberrations in neural circuitry attributable to the pathology resulting in electromagnetic field (EMF) changes. These changes have been evaluated in a variety of settings including through novel induction sensors with an ultra-portable shielded helmet and EMF channels with differences identified by comparing pre-injury and post-injury states. Modulation of the EMF has undergone cursory evaluation in neurologic conditions but has not yet been fully evaluated for clinical effects in treatment. Target EMF stimulation using EMF-related changes preoperatively to postoperatively has not yet been attempted and has not been completed using induction sensor technology. Our objectives in this study were twofold: we wanted to test the hypothesis that targeted stimulation using an EMF signal generator and stimulator to abnormal thresholds identified by real-time measurement of EMFs may enable early resolution of EMF changes and treatment of the TBI as modeled through controlled cortical impact (CCI); we also aimed to assess the feasibility of attempting this using real-time measurements with an EMF shielded helmet with EMF channels and non-contact, non-invasive induction sensors with attached EMF transmitters in real-time. Methods A singular Yucatan miniswine was obtained and baseline EMF recordings were obtained. A CCI of TBI and postoperative assessment of cortical EMF in a non-invasive, non-contact fashion were completed. Alterations in EMF were evaluated and EMF stimulation using those abnormal frequencies was completed using multiple treatments involving three minutes of EMF stimulation at abnormal frequencies. Stimulation thresholds of 2.5 Hz, 3.5 Hz, and 5.5 Hz with 1 V signal intensity were evaluated using sinusoidal waves. Additionally, stimulation thresholds using differing offsets to the sine wave at -500 mV, 0 mV, and 500 mv were assessed. Daily EMF and post-stimulation EMF measurements were recorded. EMF patterns were then assessed using an artificial intelligence (AI) model. Results AI modeling appropriately identified differences in EMF signal in pre-injury, post-injury, and post-stimulation states. EMF stimulation using a positive offset of 500 mV appeared to have maximal beneficial effects in return to baseline. Similarly targeted stimulation using thresholds of 2.5 Hz and 5.5 Hz with a positive 500 mV offset at 1 V allowed for recovery of EMF patterns post-injury towards patterns seen in baseline EMF measurements on stimulation day seven (postoperative day 17). Conclusion Stimulation of neural circuits with targeted EMF in a sinusoidal pattern with targeted thresholds after measurement with induction sensors with shielding isolated to a Mu-metal and copper mesh helmet and EMF channels is efficacious in promoting neuronal circuit recovery to preoperative baselines in the TBI miniswine model. Similarly, our findings confirm the appropriateness of this translational model in the evaluation of brain neuronal circuit EMF and that preoperative and post-trauma differences can be appropriately assessed with this technology.

A Swine Model of Changes in the Neuronal Electromagnetic Field After Traumatic Brain Injury: A Pilot Study

Background Traumatic brain injury (TBI) is a global cause of disability and mortality. Treatment depends on mitigation of secondary injury resulting in axonal injury, necrosis, brain dysfunction, and disruption of electrical and chemical signaling in neural circuits. To better understand TBI, translational models are required to study physiology, diagnostics, and treatments in homologous species, such as swine. Electromagnetic fields (EMFs) from altered neural circuits can be measured and historically have been reliant on expensive shielding and supercooling in magnetoencephalography. Using proprietary induction sensors, it has been found that a non-invasive, non-contact approach with an engineered Mu-metal and copper mesh-shielded helmet effectively measures EMFs. This has not yet been investigated in swine models. We wished to evaluate the efficacy of this technology to assess TBI-dependent EMF changes in swine to describe the efficacy of these sensors and this model using a gravity-dependent controlled cortical impact (CCI). Methods A Yucatan miniswine was evaluated using non-contact, non-invasive proprietary induction sensors with an engineered dual-layer Mu-metal and interlaced copper mesh helmet with sensors within EMF channels connected to a helmet. Swine EMF recordings were obtained prior to induced gravity-dependent CCI followed by post-TBI measurements. Behavioral changes and changes in EMF measurements were assessed. EMF measurements were evaluated with an artificial intelligence (AI) model. Results Differences between room "noise" EMF measurements and pre-TBI swine electromagnetic field measurements were identified. Morphological characteristics between pre-injury and post-injury measurements were noted. AI modeling differentiated pre-injury and post-injury patterns in the swine EMF. Frequently identified frequencies seen post-injury were peaks at 2.5 Hz and 6.5 Hz and a valley at 11 Hz. The AI model identified less changes in the slope and thus decreased variation of EMF measurements post-TBI between 4.5 Hz and 7 Hz. Conclusions For the first time, it was identified that cortical function in a swine can be appropriately measured using novel induction sensors and shielding isolated to a helmet and EMF channels. The swine model can be appropriately differentiated from the external noise signal with identifiably different pre-injury and post-injury EMFs. Patterns can be recognized within the post-injury EMF due to altered neural circuits that can be measured using these sensors continuously, non-invasively, and in real time.

Comparison of Osteopathic (DO) and Allopathic (MD) Candidates Matching Into Selected Surgical Subspecialties

Context Medical students and graduates apply for post-graduate year-one positions every year through the Single Accreditation System (SAS) National Residency Match Program (NRMP). New opportunities have arisen for osteopathic graduates through the transition to a single match. There is a paucity of information evaluating the effects of this single match on osteopathic (DO) and allopathic (MD) candidates in relation to match rates in competitive surgical sub-specialties such as neurosurgery, thoracic surgery, vascular surgery, otolaryngology (ENT), plastic surgery, orthopedic surgery, and general surgery. Objectives This paper utilizes published data to accomplish three tasks. Firstly, it investigates the effects of the SAS on DO and MD match rates in surgical subspecialties of neurosurgery, thoracic surgery, vascular surgery, ENT, plastic surgery, orthopedic surgery, and general surgery. Secondly, it investigates whether program director credentials and impressions correlate with the match rates of DO or MD candidates in each of these specialties. Finally, it discusses solutions for addressing ways to improve match outcomes for all candidates. Methods Previously published NRMP, National Matching Services, and Accreditation Council for Graduate Medical Education websites were queried for the number of DO and MD senior applicants for each position, match success rates, program director impressions, and program director credentials for the years 2018-2023. Match success rates were defined as a ratio of the number of candidates that applied to the number who successfully matched. Data were analyzed using descriptive statistics, chi-squared testing, student t-tests, and linear regression where appropriate. A p-value of less than 0.05 was considered significant. Results From 2020-2023, an increasing proportion of DO residents applied for the selected surgical subspecialties, increasing from 599 applicants in 2020 to 743 candidates in 2023. Overall match rates for DOs remain significantly lower than MD match rates for each of these specialties as well as overall (p-values all <0.05) with summative match rates of 52.89% for DOs compared to 73.61% for MDs in 2023 for the selected surgical subspecialties. From 2020 to 2023 match rates were 30.88% for DOs compared to 74.82% for MDs in neurosurgery, 16.67% versus 46.45% (DO vs MD) in thoracic surgery, 4.17% vs 68.84% (DO vs MD) in plastic surgery, 57.62% vs 73.18% (DO vs MD) in general surgery, 23.21% vs 74.18% (DO vs MD) in vascular surgery, 53.10% vs 72.57% (DO vs MD) for ENT, and 56.92% vs 72.51% (DO vs MD) for orthopedics. There was a statistically significant correlation between the proportion of DO program directors with the rate of DOs matching in the associated specialty (p=0.012). Conclusion There were significantly lower rates for DO candidates compared to MD candidates matching into selected surgical subspecialties of neurosurgery, thoracic surgery, vascular surgery, ENT, plastic surgery, orthopedic surgery, and general surgery. This may be addressed through increasing advocacy at local and national levels, improving mentorship, increasing DO medical student exposure to surgical subspecialties, and ensuring increasing selected surgical subspecialty involvement in teaching these diverse DO applicants in order to strengthen medicine and continue to address predicted growing physician shortages.

Neurosurgical Outcomes in Severe Traumatic Brain Injuries Between Service Lines: Review of a Single Institution Database

Severe traumatic injury (sTBI) continues to be a common source of morbidity and mortality. While there have been several advances in understanding the pathophysiology of this injury, the clinical outcome has remained grim. These trauma patients often require multidisciplinary care and are admitted to a surgical service line, depending on hospital policy. A retrospective chart review spanning 2019-2022 was completed using the electronic health record of the neurosurgery service. We identified 140 patients with a Glasgow Coma Scale (GCS) of eight or less, ages 18-99, who were admitted to a level-one trauma center in Southern California. Seventy patients were admitted under the neurosurgery service, while the other half were admitted to the surgical intensive care unit (SICU) service after initial assessment in the emergency department by both services to evaluate for multisystem injury. Between both groups, the injury severity scores that evaluated patients' overall injuries were not significantly different. The results demonstrate a significant difference in GCS change, modified Rankin Scale (mRS) change, and Glasgow Outcome Scale (GOS) change between the two groups. Furthermore, the mortality rate differed between neurosurgical care and other service care by 27% and 51%, respectively, despite similar Injury Severity Scores (ISS) (p=0.0026). Therefore, this data demonstrates that a well-trained neurosurgeon with critical care experience can safely manage a severe traumatic brain injury patient with an isolated head injury as a primary service while in the intensive care unit. Since injury severity scores did not differ between these two service lines, we further theorize that this is likely due to a deep understanding of the nuances of neurosurgical pathophysiology and Brain Trauma Foundation (BTF) guidelines.

Evaluation of Osteopathic Principles in Cadaveric Specimens Using Radiological Assessment

BACKGROUND

Osteopathic manipulative treatment (OMT) of the spine requires the physician to first be able to diagnose with palpation of the spinous processes, transverse processes, and facets, test for movement of the anatomy, and evaluate changes in tissue texture at each level. Physicians should then apply these changes to Fryette's Principles to effectively understand the corresponding somatic dysfunction and provide treatment. Continuing education in osteopathic principles and practices is important throughout an osteopathic physician's training.

AIM

Diagnosis and treatment require an understanding of the complex neuroanatomy and physiology of patients. We sought to evaluate the diagnostic capabilities of osteopathic physicians. This was done by evaluating the accuracy of diagnosis of somatic dysfunction on a cadaver specimen and verifying via fluoroscopy and blunt dissection.

MATERIALS & METHODS

Fresh refrigerated cadavers were palpated for lesions in the thoracic spine by residents and attendings, and diagnoses of somatic dysfunction were made. Anterior-posterior X-rays were taken with a C-arm. These levels were then exposed by blunt dissection, and somatic dysfunctions were visualized and recorded. Comparative analyses were conducted to evaluate the accuracy of diagnosis.  Results: The accuracy of diagnoses was correct in those who had OMT skills reassessed throughout training and continuing medical education. Osteopathic physicians who routinely kept up with their training were better able to make diagnoses of somatic dysfunction.

CONCLUSION

Continuing osteopathic medical education with an emphasis on the maintenance of palpatory skills is important. Those physicians with the greatest accuracy of somatic dysfunction diagnosis were physicians who routinely underwent reassessment and continuing medical education of osteopathic skills.

Utilization of Portable Brain Magnetic Resonance Imaging in an Acute Care Setting

Background Magnetic resonance imaging (MRI) is an important noninvasive diagnostic tool used in multiple facets of medicine, especially in the assessment of the neurological system with increasing usage over the past decades. Advancement in technology has led to the creation of portable MRI (pMRI) that was cleared for use recently. Methodology A prospectively collected retrospective study was conducted at a single institution to include patients aged >18 years, admitted to the hospital, and requiring MRI for any brain pathology. pMRI was completed using portable MRI. Traditional MRI was completed with a standard 1.5T MRI, and when possible, the results of the two studies were compared. Results We obtained pMRI on 20 patients, with a total of 22 scans completed. Notably, on the pMRI, we were able to identify midline structures to determine midline shifts, identify the size of ventricles, and see large pathologies, including ischemic and hemorrhagic strokes, edema, and tumors. Patients with implants or electrodes in and around the calvarium sometimes pose challenges to image acquisition. Conclusions Portable brain MRI is a practical and useful technology that can provide immediate information about the head, especially in an acute care setting. Portable brain MRI has a lower resolution and quality of imaging compared to that of transitional MRI, and therefore, it is not a replacement for traditional MRI.

Infrastructural Limitations in Establishing Neurosurgical Specialty Services in Liberia

Introduction

Liberia recently employed the first neurosurgeon in the country’s history. In a country with a population of 4.7 million people and staggering rates of cranial and spine trauma, as well as hydrocephalus and neural tube defects, neurosurgery is considered a luxury. Our study documents the experience of a team of neurosurgeons, critical care nurses, scrub technicians, nurses, and biomedical engineers who carried out a series of neurosurgical clinics and complex brain and spine surgeries in Liberia. Specifically, we aim to highlight some of the larger obstacles, beyond staff and equipment, facing the development of a neurosurgical or any other specialty practice in Liberia. 

Methods

Our institutions, in collaboration with the Korle-Bu Neuroscience Foundation, spent 10 days in Liberia, based in Tappita, and performed 18 surgeries in addition to seeing several hundred clinic patients. This is a retrospective review of the cases performed along with outcomes to investigate obstacles in providing neurosurgical services in the country.

Results

Before arriving in Liberia, we evaluated, planned, and supplied staff and materials for treating complex neurosurgical patients. Sixteen patients underwent 18 surgeries at a hospital in Tappita, Liberia, in November 2018. Their ages ranged from 1 month to 72 years (average 20 years). Five patients (28%) were female. Ten patients (56%) were under the age of 18. Surgeries included ventriculoperitoneal shunting (VP-shunt), lumbar myelomeningocele repair, encephalocele repair, laminectomy, and a craniotomy for tumor resection. Ten patients (55%) underwent VP-shunting. Two patients (11%) had a craniotomy for tumor resection. Three patients (17%) had laminectomy for lumbar stenosis. Two patients (11%) had repair of lumbar myelomeningocele.

Conclusion

After an aggressive and in-depth approach to planning, conducting, and supplying complex neurosurgical procedures in Liberia, the greatest limiting factor to successful outcomes lie in real-time is access to health care, which is largely limited by overall infrastructure. Our study documents the experience of a team of neurosurgeons, critical care nurses, scrub technicians, nurses, and biomedical engineers who carried out a series of neurosurgical clinics and complex brain and spine surgeries in Liberia. Specifically, we aim to highlight some of the larger obstacles, beyond staff and equipment, facing the development of a neurosurgical or any other specialty procedural practice in the country of Liberia. Most notably, we focus on infrastructure factors, including power, roads, water, education, and overall health care. 

Evaluating the Reliability of Neurological Pupillary Index as a Prognostic Measurement of Neurological Function in Critical Care Patients

Background

Neurological pupil index (NPi) is a novel method of assessing pupillary size and reactivity using pupillometry to reduce human subjectivity. This paper aims to evaluate the use of NPi as a potential prognostic tool in a broad population of neurocritical care patients by observing the correlation between NPi, modified Rankin Scale (mRS), and Glasgow Coma Scale (GCS).

Methods

Our data was collected from 194 patients in the neurosurgical intensive care unit (ICU) at Arrowhead Regional Medical Center (ARMC), as determined by the power calculation. We utilized the Kolmogorov-Smirnova and Shapiro-Wilk normality tests with Lilliefors significance correction. Pearson product-moment correlation was performed between average final NPi and final GCS. Multi-variate linear regression and analysis of variance (ANOVA) were used to evaluate the association and predictive capabilities of NPi on GCS and discharge mRS. Finally, we evaluated whether age, ethnicity, sex, length of stay (LOS), or discharge location were significantly associated with NPi. 

Results

We observed a significant correlation between final GCS and NPi (r=0.609, p<0.001). Our regression analysis revealed that NPi significantly predicted GCS and mRS scores; however, no associations were found between age, ethnicity, sex, LOS, or discharge location. Limitations of our study include a single institutional study with a lack of disease subtyping and the inability to quantify the predictive ability of NPi.

Conclusion

The analysis revealed a strong correlation between final GCS and average final NPi. NPi was also able to significantly predict GCS and mRS scores. The correlation between NPi and established methods to determine neurological function, such as mRS and GCS, suggests that NPi can be a good prognostication tool for neurological diseases.

Thoracic Pedicle Screw Placement Utilizing Hands-On Training Session on Three-Dimensional Models

The utilization of three-dimensional (3D) models has been an important element of medical education. We demonstrate a three-dimensionally-printed (3DP) thoracic spine model for use in the teaching of freehand pedicle screw placement. Neurosurgical residents with varying years of experience practiced screw placement on these models. Residents were timed, and models were evaluated for medial and lateral breaches. Overall, this technical report describes the utility of 3D spine models in the training of thoracic pedicle screw placement. The tactile feedback from the 3D models was designed to represent both cortical and cancellous bones.

Radiographic Predictors of Shunt Dependency in Intracranial Hemorrhage With Intraventricular Extension

Background

Intracranial hemorrhage (ICH) may be complicated by intraventricular hemorrhage (IVH) and hydrocephalus, which can require the placement of a ventriculoperitoneal shunt (VPS). ICH and IVH risk scores using radiographic and clinical characteristics have been developed but utilization for assessment of future need for VPS placement is limited.

Methods

This is a single-institution retrospective review for patients with primary ICH with IVH from 2018-2020. Initial CTs and charts were analyzed to determine ICH, IVH, LeRoux and Graeb scores, Evans’ index, ICH and IVH volumes, and comorbidities. Outcomes including Glasgow coma scale (GCS), National Institute of Health Stroke Scale (NIHSS), length of stay, and shunt placement were evaluated with bivariate correlations, t-tests, chi-squared tests, and receiver operating characteristic (ROC) curves (p=0.05).

Results

A total of 130 patients were included of which 102 underwent full treatment beyond hospital day one. VPS placement was significantly associated with longer length of stay (p<0.001), discharge NIHSS (p=0.001), arrival Evans’ index (p<0.001), IVH (p=0.033), LeRoux (p=0.049), but not comorbidities, ICH score, or admission GCS. When treated beyond hospital day one, Evans’ index (p<0.001), IVH volume (p=0.029), Graeb (p=0.0029), IVH (p=0.004), Slice (p=0.015), and Leroux scores (p=0.006) were associated with shunt placement of which an Evans’ index of 0.31 or greater had highest sensitivity and specificity (area under the ROC curve (AUC) 0.81, sensitivity 81%, specificity 0.76).

Conclusions

The higher the Evans’ index, Graeb, IVH, Slice, and LeRoux scores on admission, the higher the risk of shunt dependency in patients undergoing full treatment beyond hospital day one. Admission imaging scores significantly predict the development of shunt dependence and may be considered in treatment.

External Ventricular Drain (EVD) Placement Using a Hands-On Training Session on a Simple Three-Dimensional (3D) Model

Neurosurgery is a demanding field with small margins of error within the operative field. Small errors can yield devastating consequences. Simulation has been proposed as a methodology for improving surgical skills within the neurosurgical realm. This study was conducted to investigate a novel realistic design for a clinical simulation based, low-cost alternative of external ventricular drain (EVD) placement, an essential basic neurosurgical procedure that is necessary for clinicians to master. A low-cost three-dimensional (3D) printed head using thermoplastic polylactic acid was designed with the tactile feedback of outer table, cancellous bone, and inner tables for drilling with replaceable frontal bones pieces for multi-use purposes. An agar gel filled with water was designed to simulate tactile passage through the cortex and into the ventricles. Neurosurgical and emergency resident physicians participated in a didactic session and then attempted placement of an EVD using the model to gauge the simulated model for accuracy and realism. Positioning, procedural time, and realism was evaluated. Improvements in procedural time and positioning were identified for both neurosurgical and emergency medicine (EM) residents. Catheter placement was within ideal position for all participants by the third attempt. All residents stated they felt more comfortable with placement with subsequent attempts. Neurosurgical residents subjectively noted similarities in tactile feedback during drilling compared to in-vivo. A low-cost realistic 3D printed model simulating basic neurosurgical procedures demonstrated improved procedural times and precision with neurosurgical and EM residents. Further, similarities between in-vivo tactile feedback and the low-cost simulation technology was noted. This low cost-model may be used as an adjunct for teaching to promote early procedural competency in neurosurgical techniques to promote learning without predisposition to patient morbidity.

Changing Frequency of the Use of Intraoperative Equipment Among Neurosurgeons, Neurosurgery Residency Faculty, and Neurosurgery Residents

Neurosurgical procedures have relied on the use of various intraoperative equipment since its advent. These include an operative microscope, ultrasound, and loupes with a headlight. The necessity of these pieces of equipment makes them vital in the training of residents as well. A national survey utilizing a Likert scale to determine how often loupes, microscopes, and ultrasound were used for various neurosurgeries was created. This was then compared to a single program’s responses, and it identified that the practice parameters of residents closely modeled those behaviors portrayed by their attending mentors. It appears that the higher frequency of use by residents when compared to faculty and neurosurgeons nationwide highlights the importance of this equipment in training neurosurgical residents. 

As such, they should be available to residents from the onset of training to promote the highest quality of learning. Faculty should encourage the use of this equipment by leading by example, and residents, in turn, should use all the available equipment as often as possible to maximize the quality of their training. Modulating the use of learning technologies can be accomplished if it is a nationally accepted practice, discussed in an academic setting with the residents, and modeled by the faculty.

Measuring the Electromagnetic Field of Human Subjects Using Induction Sensors and a Shielded Helmet Without the Need for a Shielded Room

Introduction

Neurologic activity is mediated by electrochemical signaling pathways that generate an electric charge. These electrical signals generate electromagnetic fields (EMF) that have been found to be measurable through magnetoencephalography and induction sensors. These technologies typically rely on expensive shielding via shielded rooms to remove influence from the external environment. We aimed to investigate the effects of a lightweight shielded helmet constructed of Mu-metal and interlaced copper mesh and Mu-metal EMF “channels” on shielding externally mediated EMF when measuring cortically generated EMF during human activity.

Methods

Non-contact, non-invasive, proprietary induction sensors were utilized with a combination of a dual-layer Mu-metal and interlaced copper mesh helmet with sensors placed within EMF channels connected to the helmet. Five human volunteers participated in motor activities, verbalization activities, and visual object naming to evaluate the effectiveness of shielding solely via the helmet and EMF channel construct on generated EMF without placement of individuals within a shielded room. Background data without a subject were obtained.

Results

Differences in fast Fourier transformed data were noted in the background compared to rest and various activities throughout all trials. There were differences in rest phases and activity phases in each individual identifying active measurement of differences in cortically generated EMF during each activity.

Conclusion

It appears that eliminating a Mu-metal shielded room is possible when shielding is isolated to the helmet and EMF channels with induction sensors. The external EMF was appropriately excluded with differences in background data in all trials. During the activity, differences were noted between rest phases and activity phases in all activities noting the discernibility of these induction sensors in measuring cortically generated EMF. Measured activity through motor tapping with changes between 4 and 6 Hz appeared to correlate with previously documented changes during motor activity using these sensors in conjunction with shielded rooms.

A Review of Glymphatics and the Impact of Osteopathic Manipulative Treatment in Alzheimer's Disease, Concussions, and Beyond

Glymph is a fluid that circulates in the brain interstitium and, under pathological conditions, unusually accumulates and enhances the buildup of other noxious molecules. The study of this process of circulation, accumulation, and clearance is called glymphatics. We review the physiology of glymphatics and then dive into recent innovative research surrounding this neurological field of study and how it has applied to mainstream pathological processes, including Alzheimer's disease and spectrums of traumatic brain injury that range from a concussion to chronic traumatic encephalopathy (CTE). Furthermore, we explore the implications of glymphatics and a new and developing frontier of healthcare in space travel; with the advent of a Space Force and the introduction of space travel to consumer markets, this is an exciting time to develop novel techniques in enhancing its safety and optimizing human physiology for best outcomes. Therefore, we also propose that osteopathic manipulative treatment (OMT) plays an intuitive role in the treatment of abnormal glymphatics, as adjunctive therapy in Alzheimer's and CTE, and as a future staple before, during, and after space travel for the benefit of both enhancing healthcare in chronic conditions and advancing the capabilities of the human race in its shining new endeavor.

Measuring Electromagnetic Field Activity Generated by Neurons In Vivo by Humans With Thoughts of Repetitive Motor Activities and Emotional Thoughts

Background

In this study, a novel method of electromagnetic field (EMF) measurements of the human brain has been performed to evaluate neuronal activity. This measurement in a non-contact, non-invasive, continuous manner through the human skull and scalp in the standard environment is completed through a lightweight inexpensive helmet. We sought to further delineate whether specific activities of complex thought can be identified using this non-invasive technique.

Methodology

Non-clinical human subject volunteers donned a lightweight helmet with attached sensors and performed activities of motor movement, specific motor imagery, and specific emotional imagery synchronized to an audible tone for consistency. The human subjects’ brain EMF was recorded and analyzed.

Results

The novel method of continuously recording real-time human brain EMF was able to determine differing brain activity between individuals performing motor movement, motor imagery, and emotional imagery in a non-contact manner at different distances from the scalp.

Conclusions

It may be possible to measure specific human brain activity using EMF in a non-invasive fashion. Emotional imagery, motor imagery, and motor movement generate different EMFs that have different discernible forms compared to baseline activity.

Evaluating the Intrinsic Electromagnetic Field Generated by Neurons From Repetitive Motor Activities in Humans With a Non-contact Non-invasive Electromagnetic Helmet

Introduction

The actions of neurons are dependent on electrochemical signal pathways mediated by neurotransmitters and create measurable electrical charges. These charges have been found to be measurable through neuroimaging technologies and now through a novel non-contact non-invasive sensor without supercooling. Identifying whether this technology can be appropriately interpreted with synchronized motor well-defined activities in vivo may allow for further clinical applications.

Methods

A non-contact, non-invasive helmet constructed and modified using shielding technology with proprietary magnetic field sensors was utilized to measure the brain’s electromagnetic field (EMF). Human volunteers donned helmets and were asked to perform repetitive tapping exercises in order to identify waves consistent with tapping from the left and right hemispheres. A gyroscope was utilized to ensure that measured waves were not from micro-movement but were from neuronal firing. Multiple individuals were tested to evaluate the reproducibility of tapping and commonalities between individuals

Results

Right and left-sided tapping generated discernible wave changes from baseline measurements obtained by the helmet without a subject as well as differed from when the subject was at rest. Wave patterns varied from person to person but were overall similar in each subject individually. Shielding was necessary to identify signals but EMF was identified when shielding was transitioned from around the helmet to within the helmet design.

Conclusion

It is possible to measure in-vivo electromagnetic fields generated by the human brain generated by stereotyped tasks in a non-contact non-invasive manner. These waves were reliably obtained within each individual with some variability in morphology from subject to subject however were similar in each subject. Signals varied based on activity and stereotyped motor activities were identified. A helmet using shielding technology within the helmet itself was able to effectively identify EMF signals. Future analysis may focus on translating these waves into functional mapping for clinical applications.

Prevalence of Central Line-Associated Bloodstream Infections (CLABSI) in Intensive Care and Medical-Surgical Units

BACKGROUND

 Central line-associated bloodstream infections (CLABSIs) remain an important preventable healthcare-associated infection with a 2020 rate of 0.87 (per 1,000 central line days) in the United States intensive care units (ICU).

METHODS

 This was a retrospective cohort study of all adult patients in our institution. The total number of central venous catheter (CVC) insertions and line days were determined using daily unit logs maintained by unit managers. Central line insertion practice (CLIP) compliance was calculated as the total number of CLIP forms submitted divided by the total number of newly-inserted CVCs with and without associated CLIP forms as determined by unit logs.

RESULTS

A total of 1,125 CVCs were reviewed (448 - ICU and 677 - medical-surgical units). Of the 13 CLABSI, one patient had internal jugular (IJ), one patient had subclavian (SC), four patients had femoral, three patients had peripherally inserted central catheter (PICC) and four patients had hemodialysis catheters. Patients with CLABSI had CVC inserted for a range of five to 92 days with the average number of line days being 29 days.

CONCLUSION

 Based on the analysis of our CLABSI patient population, we recommend our institution implement the following criteria to decrease the prevalence of CLABSI: All patients receiving a CVC must adhere to CLIP documentation in all units, any femoral or HD CVC placed without a CLIP form should have the line changed within 48 hours, those patients with a femoral CVC or hemodialysis catheter in place for four days or greater with an abnormal WBC (<4.0 or >11 mg/dL) or abnormal temperature (<97.0F or >100.4F) should be considered for catheter exchange, and those patients with an IJ, SC, or PICC CVC in place for seven days or greater with an abnormal WBC or abnormal temperature should have the catheter changed.

P13BP, a Calpain-2-Mediated Breakdown Product of PTPN13, Is a Novel Blood Biomarker for Traumatic Brain Injury

Biomarkers play an increasing role in medicinal biology. They are used for diagnosis, management, drug target identification, drug responses, and disease prognosis. We have discovered that calpain-1 and calpain-2 play opposite functions in neurodegeneration, with calpain-1 activation being neuroprotective, while prolonged calpain-2 activation is neurodegenerative. This notion has been validated in several mouse models of acute neuronal injury, in particular in mouse models of traumatic brain injury (TBI) and repeated concussions. We have identified a selective substrate of calpain-2, the tyrosine phosphatase, PTPN13, which is cleaved in brain after TBI. One of the fragments generated by calpain-2, referred to as P13BP, is also found in the blood after TBI both in mice and humans. In humans, P13BP blood levels are significantly correlated with the severity of TBI, as measured by Glasgow Coma Scale scores and loss of consciousness. The results indicate that P13BP represents a novel blood biomarker for TBI.

Efficacy of Incentive Spirometer in Increasing Maximum Inspiratory Volume in an Out-Patient Setting

Background

Incentive spirometry (IS) is the mainstay of care in postoperative patients that has been heavily studied in the inpatient setting. Studies have shown that the utilization of IS improves lung volumes and reduces the rate of pneumonia in post-surgical patients. However, the literature is ambiguous on its benefit as many studies also demonstrate no significant benefit, especially in comparison to early ambulation. Our study sought to determine whether a consistent IS regimen can improve lung function in an outpatient setting.

Methods

This prospective cohort study included patients in a physical medicine and rehabilitation clinic setting during the COVID pandemic. Patients with severe respiratory disease, baseline cough, those unable to perform deep breathing, fever greater than 100.4 F due to non-pulmonary on initial evaluation, or inability to fill out the forms and complete the study were excluded. Each participant was given the IS along with hands-on instruction on how to use the device and accurately record measurements. Patients were asked to lie down and inhale and exhale through the tube ten times. They were asked to mark the highest volume during their 10 breaths. Patients were instructed to complete this exercise three times a day for 30 days. Patients were also asked to perform light exercises or walking for 20 minutes per day three times a week and postural drainage. Patients were instructed to call their primary care physician if a 20% or more decrease from their baseline was noted or if they experienced any new coughs, fever, or shortness of breath during the 30 days of exercise.

Results

A total of 48 patients enrolled in the study with a (median) age of 58.0 years (SD 10.2 years), 21 females and 27 males. Baseline maximal inspiration for study participants was 1885.4 mL prior to exercise, with a subsequent increase in lung capacity observed for all participants enrolled in the study. At the end of the study period, week four, the average maximal inspiratory volume was 2235.4 mL. Paired t-test showed a significant difference between baseline (1885.4) and maximum (2235.4) volumes (t=-4.59, p<0.0001). Analysis of variance (ANOVA) showed no significant difference among Week 1-4 averages (F=1.08, p=0.36). None of the participants reported any symptoms (fever, coughing, shortness of breath) or COVID-19 infection during the 30-days period. None of the participants reported contacting primary care physicians. 

Conclusion

When prescribed daily breathing exercises with an incentive spirometer, study participants experienced a 16% increase in maximal inspiratory volume over a span of 30 days and did not need to contact their primary care physician during the study period.

The Impact of the COVID-19 Pandemic on Resident Physicians Well-Being in the Surgical and Primary Care Specialties in the United States and Canada

Purpose: The COVID-19 pandemic disrupted the professional, social, and spiritual activities of resident physicians around the world, impacting wellness and personal relationships. Moreover, social distancing caused significant limitations or shutdown of places of worship, including churches, synagogues, mosques, etc. Our goal was to survey resident physicians in primary care and surgical subspecialties in the United States (U.S.) and Canada and to examine the effect of the COVID-19 pandemic on their well-being.

Methods: An international cross-sectional study was performed in November 2020, using an anonymous survey of programs in the U.S. and Canada, containing 20 questions to assess the impact of the pandemic on resident participation in social and spiritual activities and the effects on their wellness, and personal relationships. The emails with survey links attached were sent to individual program coordinators from accredited residency training programs in the United States and Canada. This consisted of programs accredited by the American Osteopathic Association (AOA), The Royal College of Physicians and Surgeons of Canada (RCPSC), and the Accreditation Council of Graduate Medical Education (ACGME). The survey was evenly divided among surgical programs (General Surgery, Neurological Surgery, Orthopedic Surgery, Urological Surgery, and Integrated Surgical Residency Programs such as Plastic Surgery, Cardiothoracic Surgery, Pediatric Surgery, and Vascular Surgery) as well as primary care programs (Internal Medicine and Family Medicine).

Results: A total of 196 residents, 60 primary care residents, and 136 surgery residents participated in the study. Ninety-six participants (49%) were female, and 98 of the participants (50%) were male, with the remainder two residents identifying as “Other.” Of the primary care residents, the majority (39, 65%) were female. Conversely, the majority (77, 57%) of surgery residents were male.

Conclusion: The COVID-19 pandemic has affected the social lives, relationships, and spiritual well-being of both surgical and primary care resident physicians. However, primary care residents reported significantly greater engagement in personal relationships and were more likely to express feelings of mental and physical exhaustion, prohibiting social attendance.

Predictive Value of Credit Score on Surgery Resident and Fellow Academic and Professional Performance

Introduction

Surgical specialties consistently remain among the most competitive residency and fellowship programs with some of the highest rates of unmatched applicants. Attrition in surgical specialties is as high as 30% and particularly problematic given the extended duration of training and limited number of positions. Applicants are traditionally evaluated using a streamlined set of objective metrics, such as board scores, class rank, leadership, letters of recommendation, research productivity, and volunteerism. Consumer credit scores have been shown to be predictors of personality and work performance, however, the literature has yet to explore consumer credit histories in the context of surgical resident and fellow performance. This study aims to determine whether consumer credit scores of surgery residents and fellows are predictive of academic and professional performance.

Methods

This is a multi-institutional observational survey study across all American Council of Graduate Medical Education and Royal College of Physicians and Surgeons accredited surgical residency and fellowship programs in the United States and Canada. Ninety-nine surgical residents and fellows with educational status of post-graduate year two or higher participated in this study. Dichotomous (yes or no) survey items were formulated to assess performance indicators in the domains of notable achievements and awards, research output, written examination performance, professionalism, and surgical/technical skills. Three-digit Fair Isaac Corporation (FICO) credit scores, a widely accepted consumer reporting score, were collected to avoid calculation variability between algorithms. 

Results

Surgical residents and fellows reported credit scores between 611( fair) and 853 (exceptional) with a median (interquartile range) of 774 (715-833). The majority of participants 51.5%(51) reported very good credit scores. Those with higher credit scores (very good/exceptional) were 377% more likely to have one or more positive performance indicators OR (95% CI) = 3.77 (1.43-9.97). Similarly, residents with lower credit scores (fair/good) were only 40% more likely to have one or more negative performance indicators. The credit score has a moderate ability to distinguish between the presence and absence of positive performance indicators (area under the curve {AUC} = 0.70, p = 0.001). The use of 753 as a credit score cutoff is 78.9% sensitive and 52.4% specific for discerning surgery residents and fellows with one or more positive performance indicators. The credit score did not significantly discern those with negative performance indicators.

Conclusions

While credit score was significantly functional in discerning those with and without positive performance indicators, sensitivity and specificity rates leave much to be desired. Although our data may have indicated that higher credit scores may be associated with increased residency academic performance on examinations and research productivity we are not recommending any implementation of using credit scores as a metric for selecting individual surgical candidates for a position in residency or fellowship due to extensive socioeconomic variables and historical context of credit scores, which must be taken into consideration. Additional studies are needed to assess this utility on a larger scale.

Medical Comorbidities Associated With Outcomes in Patients With Traumatic Epidural Hematomas

Background

Traumatic brain injury (TBI) is a frequently encountered neurosurgical pathology with significant morbidity and mortality. One such subtype is the epidural hematoma. Literature regarding the effects of comorbidities in TBI and epidural hematomas is limited.

Methodology

This was a single-center retrospective review of 50 consecutive patients admitted to a level two trauma center with epidural hematomas. Patients were identified using an internal trauma database. Patients were included if they were 18 years of age with a diagnosed epidural hematoma. Outcome variables of Glasgow coma scale (GCS), length of stay in the intensive care unit (ICU) and hospital, and requirement of a neurosurgical procedure were analyzed. Identification of the presence of diagnosed comorbidities was performed including common comorbidities such as obesity, diabetes, hypertension, hyperlipidemia, drug use, tobacco use, cancer, psychiatric disease, and renal disease. Correlations were evaluated using two-sided bivariate analysis (p < 0.05).

Results

A total of 50 patients were included for analysis. Significant correlations with a p-value less of than 0.05 were noted in initial GCS and cancer (r = -0.357, p = 0.011), requirements of an intracranial procedure with a history of gastrointestinal disease (r = 0.377, p = 0.007), and younger age (r = -0.306, p = 0.031). Increased ICU length of stay was related to a history of cancer (r = 0.494, p < 0.001), a history of respiratory disease (r = 0.427, p = 0.002), and a history of psychiatric disease (r = 0.297, p = 0.036). Increased hospital length of stay was related to psychiatric disorders (r = 0.285, p = 0.045). Discharge GCS was negatively associated with a history of hypertension (r = -0.374, p = 0.008), tobacco use (r = -0.417, p = 0.003), drug use (r = -0.294, p = 0.037), and history of cancer (r = -0.303, p = 0.032).

Discussion and Conclusions

In our 50 consecutive patient subset, selected comorbidities demonstrated significant relationships with outcome measures of GCS, need for a procedure, and lengths of stay in the hospital and ICU. Obtaining comorbidity information when available from families can better allow the clinician to optimize treatment and educate loved ones about the potential effects of these comorbidities on the overall health of the patient. Understanding these correlations may allow for a better understanding of the systemic effects of the pathophysiology of injury in epidural hematomas.

Using the Decrease in Trauma Admissions During the COVID-19 Pandemic to Evaluate Compliance With Stay-at-Home and Social Distancing Guidelines

Introduction

The coronavirus disease 2019 (COVID-19) virus was declared a pandemic on March 10, 2020 by the World Health Organization (WHO) and has massively burdened healthcare systems with cases exponentially rising throughout the United States and the rest of the world. Since implementing precautions to reduce the spread of this disease, emergency departments have seen a decrease in the number of traumas. By evaluating the differences in the number of trauma admissions in different subgroups of patients, we can assess where to target messaging to increase compliance with these precautions. In this study, we aim to analyze the effect of the COVID-19 pandemic on trauma admissions.

Methodology

This was a retrospective review of the trauma database at our institution, a level 2 trauma center in Southern California, to assess the impact of COVID-19 on the number of traumas. The inclusion criteria were patients activated as traumas, regardless of age. Patients were excluded from the study if they did not have complete information in the trauma database. Data were stratified by date into two groups: (a) COVID period (January to April 2020) and (b) pre-COVID period (January to April 2019). The primary endpoint of this study was to determine whether there was a significant change in the number of patients presenting as trauma during the COVID-19 pandemic. This difference was analyzed and divided into subgroups based on age and trauma type.

Results

In our review, an average of 279 patients per month presented as trauma from January to April in 2019, and an average of 222 patients per month presented as trauma from January to April 2020 (p = 0.049). We found a significant decrease in the number of patients presenting with the chief complaint of fall and vehicular accident, but a nonsignificant difference in patients presenting as assaults or pedestrian accidents. There was also a significant decrease in the number of traumas in the 18-39 and 65+ age groups and a nonsignificant decrease in the 40-64 age group. It was also noted that the number of trauma admissions in May 2020 increased to 253 compared to 269 in 2019. This increase was most notable in the 18-39 and 40-64 age groups.

Discussion

As seen in the data, the most notable year-over-year difference was seen in March and April. In California specifically, a stay-at-home order was set in place in March, which was in conjunction with the WHO’s declaration of a pandemic. An interesting finding was the significant decrease in patients with traumas in the age groups of 18-39 and 65+ from 2019 to 2020. There was a smaller, nonsignificant decrease in patients aged 40-64. This would be a good group to target with future messaging to increase compliance with health advisories. There was also a notable increase in the number of traumas in May 2020, signaling an end to the cooperation of the majority of people, also indicating that further measures needed to be enacted in all groups.

Conclusions

COVID-19 has disrupted social structures worldwide. As the pandemic continued, even the observers of stay-at-home and social distancing measures, the 18-39 age group, became fatigued with the guidelines and ventured out into the warming weather and summer activities. This difference in trauma admission due to COVID-19 between subsequent years can highlight the behavioral changes in our patient population and can be further extrapolated to target additional messaging to help reduce the spread of COVID-19.

Osteopathic Manipulative Treatment to Optimize the Glymphatic Environment in Severe Traumatic Brain Injury Measured With Optic Nerve Sheath Diameter, Intracranial Pressure Monitoring, and Neurological Pupil Index

Background

Traumatic brain injury (TBI) has a complex pathophysiology that has historically been poorly understood. New evidence on the pathophysiology, molecular biology, and diagnostic studies involved in TBI have shed new light on optimizing rehabilitation and recovery. The goal of this study was to assess the effect of osteopathic manipulative treatment (OMT) on peripheral and central glial lymphatics in patients with severe TBI, brain edema, and elevated intracranial pressure (ICP) by measuring changes in several parameters regularly used in management.

Methodology

This was a retrospective study at a level II trauma center that occurred in 2018. The study enrolled patients with TBI, increased ICP, or brain edema who had an external ventricular drain placed. Patients previously underwent a 51-minute treatment with OMT with an established protocol. Patients received 51 minutes of OMT to the head, neck, and peripheral lymphatics. The ICP, cerebrospinal fluid (CSF) drainage, optic nerve sheath diameter (ONSD) measured by ultrasonography, and Neurological Pupil Index (NPi) measured by pupillometer were recorded before, during, and after receiving OMT.

Results

A total of 11 patients were included in the study, and 21 points of data were collected from the patients meeting inclusion criteria who received OMT. There was a mean decrease in the ONSD of 0.62 mm from 6.24 mm to 5.62 mm (P = 0.0001). The mean increase in NPi was 0.18 (P = 0.01). The mean decrease in ICP was 3.33 mmHg (P= 0.0001). There was a significant decrease in CSF output after treatment (P = 0.0001). Each measurement of ICP, ONSD, and NPi demonstrated a decrease in overall CSF volume and pressure after OMT compared to CSF output and ICP prior to OMT.

Conclusions

This study demonstrates that OMT may help optimize glial lymphatic clearance of CSF and improve brain edema, interstitial waste product removal, NPi, ICP, CSF volume, and ONSD. A holistic approach including OMT may be considered to enhance management in TBI patients. As TBI is a spectrum of disease, utilizing similar techniques may be considered for all forms of TBI including concussions and other diseases with brain edema. The results of this study can better inform future trials to specifically study the effectiveness of OMT in post-concussive treatment and in those with mild-to-moderate TBI.

Inflammatory Markers in Severity of Intracerebral Hemorrhage II: A Follow Up Study

Introduction

Spontaneous intracerebral hemorrhage (ICH) results in significant morbidity and mortality. The pathogenesis of brain injury after ICH is thought to be due to mechanical damage followed by ischemic, cytotoxic, and inflammatory changes in the underlying and surrounding tissue. Various inflammatory and non-inflammatory biomarkers have been studied as predictors and potential therapeutic targets for intracerebral hemorrhage. Our prior study showed an association with low vascular endothelial growth factor (VEGF) levels and increased mortality. This current study looks to expand on our prior results and will look at the relationship between tumor necrosis factor alpha (TNFα), C-reactive protein (CRP), VEGF, Homocysteine (Hcy), and CRP to albumin ratio (CAR) in predicting outcomes and severity in spontaneous intracerebral hemorrhage.

Methods

We conducted a retrospective chart review of patients with spontaneous intracerebral hemorrhage with TNFα, CRP, VEGF, Hcy levels drawn on admission. Albumin and CRP levels on admission were used to calculate CAR. Ninety-nine patients were included in the study. Primary outcomes included death, early neurologic decline (END), and hemorrhage size. Secondary outcomes included late neurologic decline (LND), Glasgow Coma Scale (GCS) on admission, GCS on discharge, ICH score, change in hemorrhage size, need for surgical intervention, and length of ICU stay.

Results

A total of 99 patients were included in this study, with 42% requiring surgical intervention and an overall mortality of 16%. Basal ganglia hemorrhage was seen in 41% of patients. Hcy and CAR were significantly correlated with ICH size in basal ganglia patients (r-=0.36, p=0.03; r=0.43, p=0.03, respectively). CAR was significantly correlated with ICH score (r=0.33, p=0.007874). Admission VEGF levels less than 45 pg/ml had 8.4-fold increase in mortality (odds ratio [OR] 8.4545, p=0.0488). Patients with TNFα levels greater than 1.40 pg/ml had a 4.1-fold increase in mortality (OR 4.1, p=0.04)

Conclusion

Our study demonstrated that low levels (<45 pg/ml) of VEGF were associated with an 8.4-fold increase in mortality, supporting the neuroprotective effect of this protein. Elevated Hcy and CAR levels were associated with an increase in hemorrhage size in patients with basal ganglia hemorrhages. TNFα levels greater than 1.40 pg/ml were associated with a 4.1-fold increase in mortality, and this together with CAR being correlated with increased hemorrhage size and ICH score further demonstrate the inflammatory consequences after intracerebral hemorrhage. Future studies directed at lowering CRP, TNFα, and Hcy and/or increasing VEGF in intracerebral hemorrhage patients are needed and may be beneficial.

A Reassessment of Weaning Parameters in Patients With Spontaneous Intracerebral Hemorrhage

Background and purpose

Patients with spontaneous intracerebral haemorrhage have significant morbidity and mortality. One aspect of their care is the need for mechanical ventilation. Extubating a patient safely and efficiently is important in advancing their care; however, traditional extubation criteria using the rapid shallow breathing index and negative inspiratory force do not predict success in these patients as well as they do in other intubated patients. This study aimed to evaluate these criteria in patients with spontaneous intracerebral haemorrhage to improve the extubation success rate.

Methods

We conducted a retrospective chart review of patients with spontaneous intracerebral haemorrhage (sICH) who underwent spontaneous breathing trials from 2018 to 2020. Twenty-nine patients met the inclusion criteria, and of these 29, 20 had a trial of extubation. Rapid shallow breathing index (RSBI), negative inspiratory force (NIF), and cuff leak were recorded to analyze breathing parameters at the time of extubation. Patients who required reintubation were noted.

Results

All trials of extubation required a cuff leak. Using RSBI, patients with values <105 or <85, as the only other extubation criteria, were associated with a 70.6% and 71.4% success rate, respectively. With RSBI <105 and NIF <-25 cm water, the success rate was 88.9%. Any patient with a cuff leak that had a NIF <-30 had a success rate of 100%, regardless of RSBI.

Conclusion

The RSBI was not a reliable isolated measure to predict 100% extubation success. Using a NIF <-30 predicts a 100% extubation success rate if a cuff leak is present. This demonstrates that the NIF may be a more useful metric in sICH patients, as it accounts for patient participation and innate ability to draw a breath spontaneously. Future studies are warranted to evaluate further and optimize the extubation criteria in these patients.

Use of Endovascular Simulator in Training of Neurosurgery Residents - A Review and Single Institution Experience

Simulators for surgical procedures and interventions have undergone significant technological advancement in the past decade and are becoming more commonplace in medical training. Neurosurgery residents across multiple training levels underwent performance evaluation using a neuro-interventional simulator, employing a variety of metrics for assessment. We identified seven core metrics used in the evaluation of neurosurgery residents performing simulated mechanical thrombectomies. Additionally, a systematic PubMed search for studies related to Neurointerventional Radiology training via simulation was performed. The purpose of this study is to examine the validity and benefits of training with these simulation devices and compare our institution's experience. Additionally, an exploration of their applicability to neurosurgery resident training is discussed.

Pentobarbital Coma With Therapeutic Hypothermia for Treatment of Refractory Intracranial Hypertension in Traumatic Brain Injury Patients: A Single Institution Experience

Introduction Traumatic brain injury (TBI) results in primary and secondary brain injuries. Secondary brain injury can lead to cerebral edema resulting in increased intracranial pressure (ICP) secondary to the rigid encasement of the skull. Increased ICP leads to decreased cerebral perfusion pressure which leads to cerebral ischemia. Refractory intracranial hypertension (RICH) occurs when ICP remains elevated despite first-tier therapies such as head elevation, straightening of the neck, analgesia, sedation, paralytics, cerebrospinal fluid (CSF) drainage, mannitol and/or hypertonic saline administration. If unresponsive to these measures, second-tier therapies such as hypothermia, barbiturate infusion, and/or surgery are employed. Methods This was a retrospective review of patients admitted at Arrowhead Regional Medical Center from 2008 to 2019 for severe TBI who developed RICH requiring placement into a pentobarbital-induced coma with therapeutic hypothermia. Primary endpoints included mortality, good recovery which was designated at Glasgow outcome scale (GOS) of 4 or 5, and improvement in ICP (goal is <20 mmHg). Secondary endpoints included complications, length of intensive care unit (ICU) stay, length of hospital stay, length of pentobarbital coma, length of hypothermia, need for vasopressors, and decompressive surgery versus no decompressive surgery. Results Our study included 18 patients placed in pentobarbital coma with hypothermia for RICH. The overall mortality rate in our study was 50%; with 60% mortality in pentobarbital/hypothermia only group, and 46% mortality in surgery plus pentobarbital/hypothermia group. Maximum ICP prior to pentobarbital/hypothermia was significantly lower in patients who had a prior decompressive craniectomy than in patients who were placed into pentobarbital/hypothermia protocol first (28.3 vs 35.4, p<0.0238). ICP was significantly reduced at 4 hours, 8 hours, 12 hours, 24 hours, and 48 hours after pentobarbital and hypothermia treatment. Initial ICP and maximum ICP prior to pentobarbital/hypothermia was significantly correlated with mortality (p=0.022 and p=0.026). Patients with an ICP>25 mmHg prior to pentobarbital/hypothermia initiation had an increased risk of mortality (p=0.0455). There was no statistically significant difference in mean ICP after 24 hours after pentobarbital/hypothermia protocol in survivors vs non-survivors. Increased time to reach 33°C was associated with increased mortality (r=0.47, p=0.047); with a 10.5-fold increase in mortality for >7 hours (OR 10.5, p=0.039). Conclusion Prolonged cooling time >7 hours was associated with a 10.5-fold increase in mortality and ICP>25 mmHg prior to initiation of pentobarbital and hypothermia is suggestive of a poor response to treatment. We recommend patients with severe TBI who develop RICH should first undergo a 12 x 15 cm decompressive hemicraniectomy because they have better survival and are more likely to have ICP <25 mmHg as the highest elevation of ICP if the ICP were to become and stay elevated again. Pentobarbital and hypothermia should be initiated if the ICP becomes elevated and sustained above 20 mmHg with a prior decompressive hemicraniectomy and refractory to other medical therapies. However, our data suggests that patients are unlikely to survive if there ICP does not decrease to less than 15mmHg at 8 and 12 hours after pentobarbital/hypothermia and remain less than 20 mmHg within first 48 hours.

Racial Disparity Amongst Stroke Patients During the Coronavirus Disease 2019 Pandemic

Introduction The global coronavirus disease 2019 (COVID-19) pandemic has had deleterious effects on our healthcare system. Lockdown measures have decreased the number of patients presenting to the hospital for non-respiratory illnesses, such as strokes. Moreover, there appears to be a racial disparity among those afflicted with the virus. We sought to assess whether this disparity also existed for patients presenting with strokes. Methods The Get with the Guidelines National Stroke Database was reviewed to assess patients presenting with a final diagnosis of ischemic stroke, transient ischemic attack (TIA), subarachnoid hemorrhage (SAH), or spontaneous/nontraumatic intraparenchymal hemorrhage (IPH). The period of February - May 2020 was chosen given the surge of patients affected with the virus and national shutdowns. Data from this same time during 2019 was used as the control population. Our hospital numbers and four additional regions were assessed (California hospitals, Pacific State hospitals, Western Region hospitals, and all hospitals in the United States). Patients were categorized by race (White, Black/African American, Asian, Native American, Hispanic) in each cohort. The primary endpoint of this study is to compare whether there was a significant difference in the proportion of patients in each reported racial category presenting with stroke during the COVID-19 pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Results A downward trend in total number of patients was noted in all five regional cohorts assessed. A statistically significant increase in the number of Black and Hispanic patients presenting with strokes was noted in California, Pacific hospitals, Western hospitals, and all hospitals in the United States during various months studied comparing 2020 to 2019. A statistically significant increase in the Hispanic population was noted in February and March in all California hospitals (p=0.005 and 0.02, respectively) and Pacific Coast hospitals (p=0.005 and 0.039, respectively). The Western region and all national hospitals noted a significant increase in strokes in the Hispanic population in April (p=0.039 and 0.023, respectively). A statistically significant increase of strokes in the Black population was noted in April in Pacific hospitals, Western region hospitals, and all national hospitals (p=0.039, 0.03, and 0.03, respectively). Conclusion The COVID-19 pandemic has adversely affected certain racial groups more than others. A similar increase is noted in patients presenting with strokes in these specific racial populations. Moreover, lack of testing for the SARS-CoV-2 virus may be missing a possible link between racial disparity for patients infected with the virus and patients presenting with stroke. The authors advocate for widespread testing for all patients to further assess this correlation.

Effects of the COVID-19 Pandemic on Stroke Patients

Introduction

The severe acute respiratory syndrome coronavirus 2 (SARS2-CoV-2) induced pandemic (COVID-19 pandemic) has affected healthcare in all aspects, including stroke care. We sought to investigate this effect with analysis of our hospital’s stroke treatment protocols as well as stroke volume on state, regional, and national levels.

Methods

This was a retrospective review of prospectively collected data from our stroke registry to assess the impact of the SARS2-CoV-2 induced pandemic on the volume of stroke patients presenting to our facility. Demographics collected included age, sex, race, National Institute of Health Stroke Scale (NIHSS) on admission, discharge modified Rankin Score (mRS), type of stroke (ischemic, hemorrhagic, or transient ischemic attack), time of symptom onset, and time to initial imaging. Data were also stratified by date and comparison was made between the intra-COVID-period (March and April 2020), pre-COVID period (March and April 2019), and peri-COVID period (January and February 2020). To determine stroke trends on a national level, we utilized the Get with the Guidelines (GWTG) stroke database to compare stroke volumes in the pre-COVID, peri-COVID, and intra-COVID periods between our hospital, all California hospitals, and the West and Pacific regions.

Results

There was a significant increase in last known well time (LKWT) to arrival to the emergency department (ED) (LKWT to door) as well as time from arrival to the ED to obtaining a computed tomography (CT) of the head (door to CT) in March 2020 compared to 2019 (p=0.0220 and p=0.0475, respectively). There were significantly fewer transient ischemic attacks (TIAs) in California hospitals as well as in March and April 2020 in comparison to January and February 2020 (p=0.0417). Similarly, there were significantly fewer TIAs in March and April 2019 compared to March and April 2020 (p=0.0360). The decrease in TIAs was also seen at our hospital in both time frame comparisons as well as in West Regional Hospitals in March and April 2020 compared to March and April 2019 (p=0.0111, p=0.0215, and p=0.0414, respectively).

Conclusion

Stroke care has been disrupted by the COVID-19 pandemic worldwide. We identified a delay in LKWT to door as well as time from door to CT in March 2020 compared to March 2019 at our institution. There was a statistically significant decrease in final diagnosis of TIA at our hospital, all California hospitals, and all West Regional hospitals during the March-April 2020 window, suggesting that some patients with minor stroke symptoms may not be presenting to the hospital in the midst of the pandemic. Strategies to minimize delays in care and maximize functional recovery must continue to evolve as new challenges are met during the COVID-19 pandemic.

Optimal Partial Pressure of Oxygen Affects Outcomes in Patients With Severe Traumatic Brain Injury

Introduction Severe traumatic brain injury (TBI) is a leading cause of death and disability. Not all neuronal damage occurs at the time of primary injury, but rather TBI initiates a cascade of events that leads to secondary brain injury. Oxygenation is one crucial factor in maintaining brain tissue homeostasis post-injury. We performed a retrospective review of patients admitted to a single trauma center after TBI. Statistical analysis was performed to ascertain if the measured partial pressure of oxygen (PaO₂) affected overall outcome at the time of discharge from the hospital. Materials and Methods Statistical analysis was performed retrospectively on patients admitted with a Glasgow Coma Scale (GCS) < 8 and a diagnosis of TBI. GCS and Glasgow Outcome Scale (GOS) were calculated from physical examination findings at the time of hospital discharge or death. Patient data were separated into two groups: those with consistently higher average PaO₂ scores (≥ 150 mmHg; n = 7) and those with lower average PaO₂ scores (< 150 mmHg; n = 8). The minimum requirement to be categorized in the consistently higher group was to have an average hospital day 1 through 5 PaO₂ value of ≥ 150 mmHg. Results Patients with consistent hospital Day 1 through 5 PaO₂ scores of ≥ 150 mmHg had statistically significant higher GCS scores at the end of intensive care unit (ICU)-level care or hospital discharge (mean = 12, p = 0.01), compared to those in group 2 with lower PaO₂ levels (mean = 7.9). There was no statistically significant difference in GOS when comparing the two groups (p = 0.055); however, the data did show a trend toward significance. Discussion and Conclusion In our study we analyzed patients diagnosed with TBI and stratified them into groups based on PaO₂ ≥ or < 150 mmHg. We demonstrate overall outcome improvement based on GCS with a trend toward improved GOS. The GCS showed statistical significance in patients with PaO₂ consistently ≥ 150 mmHg versus those in group 2 over the first five days of hospitalization.

Comparison of Ventricular and Lumbar Cerebrospinal Fluid Composition

Objective Cerebrospinal fluid (CSF) analysis is a common diagnostic tool used to evaluate diseases of the central nervous system (CNS). We sought to determine whether there is a difference between the composition of CSF sampled from an external ventricular drain (EVD) and lumbar drain (LD) and whether this made a difference in guiding therapeutic decisions. Patients and Methods This study was a retrospective analysis from a single neurosurgery service between the dates of January 2011 and April 2019. A total of 12,134 patients were screened. Inclusion criteria were ages 18-80 and the presence of both an EVD and LD. Exclusion criteria were not having both routes of CSF sampling and the inability to determine which samples originated from which compartment. Results Six patients underwent simultaneous spinal and ventricular routine CSF sampling <24 hours apart and were analyzed for their compositions. There were 42 samples, but only 20 paired EVD-LD samples that could be analyzed. When comparing the EVD and LD sample compositions, there were statistically significant differences in white blood cells (WBCs; p = 0.040), total protein (p = 0.042), and glucose (p = 0.043). Red blood cells (RBCs; p = 0.104) and polymorphonuclear leukocytes (PMN; p = 0.544) were not statistically significant. We found a statistically significant correlation between cranial and spinal CSF WBC (r = 0.944, p < 0.001), protein (r = 0.679, p = 0.001), and glucose (r = 0.805, p < 0.001). We also found that there was a significant correlation between CSF and serum glucose (r = 0.502, p = 0.040). There was no statistically significant correlation between RBCs (r = 0.276, p = 0.252). Conclusion Our results demonstrate a correlation between the cranial and spinal CSF samples, except for RBCs, with statistically significant differences in WBC, glucose, and protein values between the two sites. This confirms that sampling CSF via lumbar puncture, which carries less risk than a ventriculostomy and provides accurate data to help establish a diagnosis for intracranial pathologies.

Increased Brain Tissue Oxygen Monitoring Threshold to Improve Hospital Course in Traumatic Brain Injury Patients

Introduction

This article is a retrospective analysis of the neurosurgical census at our institution to determine an optimal threshold for brain tissue oxygenation (PbtO2). The use of brain tissue oxygen monitoring has been in place for approximately three decades but data suggesting optimal thresholds to improve outcomes have been lacking. Though there are multiple modalities to monitor cerebral oxygenation, the monitoring of brain tissue oxygen tension has been deemed the gold standard. Still, it is not clear exactly how reductions in PbtO2 should be treated or what appropriate thresholds to treat might be. The aim of our study was to determine if our threshold of 28 mmHg for a good functional outcome could be correlated to the Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS).

Methods

A retrospective analysis of the Arrowhead Regional Medical Center (ARMC) Neurosurgery Census was performed. Patients from 2017-2019 who had placement of Licox® cerebral oxygen monitoring sensors (Integra® Lifesciences, Plainsboro Township, New Jersey) were included in the analysis. Fifteen patients were consecutively identified, all of which presented with traumatic brain injury (TBI). Data on age, gender, days in the intensive care unit (ICU), days before discharge or end of medical care, admission GCS, hospital length of stay, GOS, maximum and minimum PbtO2 values for five days following insertion, minimum and maximum intracranial pressures (ICPs), and brain temperature were included for analysis. Patient data were separated into two groups; those with consistently higher PbtO2 scores (≥ 28 mmHg; n = 7) and those with inconsistent/lower PbtO2 scores (< 28 mmHg; n = 8). Standard student t-tests were used to find potential statistical differences between the groups (α = 0.05).

Results

There were seven patients in the consistently high PbtO2 category (≥ 28 mmHg) and eight patients in the inconsistent/low PbtO2 category (<28 mmHg). The average maximum and minimum PbtO2 for the group displaying worse outcomes (as defined by GCS/GOS) was 23.0 mmHg and 14 mmHg, respectively. Those with consistent Day 2 PbtO2 scores of ≥ 28 mmHg had significantly higher GCS scores at discharge/end of medical care (p < 0.05). Average GCS for the patient group with >28 mmHg PbtO2 averaged over Days 2-5 group was 11.4 (n=7). Average GCS for the <28 group was 7.0 (n=8). The GCS for the >28 group was 63% higher than found in the <28 group (p = 0.03). GOS scores were significantly higher in those with consistently higher PbtO2 (≥ 28) than those with lower PbtO2 scores (< 28). The averages were 3.5 in the higher PbtO2 group as compared to 2 in the lower PbtO2 group.

Conclusion

Along with ICP monitors and monitoring in the assessment of CPP, brain tissue oxygenation allows yet another metric by which to optimize treatment in TBI patients. At our institution, a PbtO2 level of ≥ 28 mmHg is targeted in order to facilitate a good functional outcome in TBI patients. Keeping patients at this level improves GCS and GOS at discharge/end of medical treatment.

Intracatheter Tissue Plasminogen Activator for Chronic Subdural Hematomas after Failed Bedside Twist Drill Craniostomy: A Retrospective Review

Introduction

Chronic subdural hematomas (cSDH) are common in neurosurgery with various symptoms and significant morbidity and mortality. Treatment varies with procedures including twist-drill (TD) craniostomy, craniotomy, burr hole craniostomy, and craniectomy. Newer treatments including middle meningeal artery embolization are also being explored as no treatment has been determined to be optimal. Due to the lack of consensus treatment, tissue plasminogen activator (tPA) has begun to be investigated to promote drainage and has shown promise in some early studies in reducing recurrence rates. We retrospectively reviewed patients who underwent TD craniostomy and received intracatheter tPA to evaluate the safety and efficacy of this practice.

Methods 

A single-center retrospective review from December 2018 through August 2018 occurred for patients with cSDH 18 years of age or older who underwent a bedside TD craniostomy. Inclusion criteria included all patients who underwent treatment with TD craniostomy for drainage of cSDH during the time period in which tPA protocol was adopted as a possible therapeutic measure at our center. Exclusion criteria included all patients less than age 18 or incarcerated. Patients were stratified into two groups those that received tPA per our center's neurosurgical protocol and those that received drainage alone. Data collected included demographics, hospital/intensive care unit (ICU) length of stay, operative intervention, cSDH thickness throughout stay, length of drainage, and Glasgow Coma Scale (GCS) on arrival and discharge with analysis performed using t-tests.

Results

In all, 20 patients met inclusion: six received tPA at 48 hours per the institutional neurosurgical protocol and 14 did not. The average thickness of cSDH on arrival was significantly larger in the tPA group (26.5 mm vs 14.46 mm, p = 0.0029). Arrival and discharge GCS, average daily drainage, length of stay parameters, and percent change in thickness did not differ between tPA and no tPA groups. The average daily drainage was significantly less prior to the administration of tPA in the tPA group than in the cohort of not receiving tPA (30.71 mL vs 68.99 mL; p = 0.011). Average drainage in patients who received tPA after administration was significantly higher compared to pre-tPA values (131.39 mL vs 30.71 mL; p = 0.046). No patients were readmitted for re-accumulation or required an operating room procedure. There were no adverse outcomes identified through the instillation of tPA.

Conclusion

Intracatheter tPA increased drainage rates in the assessment of pre- and post-tPA values when administered at 48 hours after subdural drain (SDD) placement. Patients who received benefits from tPA tended to have larger subdural hematomas and less drainage prior to the instillation of tPA than patients that benefited from drainage alone. Larger prospective studies should investigate early treatment with tPA to identify if tPA is efficacious for all patients after TD craniostomy and to optimize patient selection with regard to thrombolytic therapy.

A Review of Lumbar Radiculopathy, Diagnosis, and Treatment

We review the epidemiology, etiology, symptomatology, clinical presentation, anatomy, pathophysiology, workup, diagnosis, non-surgical and surgical management, postoperative care, outcomes, long-term management, and morbidity of lumbar radiculopathy. We review when outpatient conservative management is appropriate and "red flag" warning symptoms that would necessitate an emergency evaluation. Diagnostic modalities, including magnetic resonance imaging (MRI), computerized tomography (CT), contrast myelogram, electromyogram (EMG), and nerve conduction velocity (NCV), are involved in the diagnosis and decision-making are discussed. Treatment of lumbar radiculopathy requires a multimodal and multispecialty team. We review indications for the involvement of other professionals, including physical therapy (PT), occupational therapy (OT), physical and rehabilitation medicine (PMR), and pain management.

Risks, Benefits, and the Optimal Time to Resume Deep Vein Thrombosis Prophylaxis in Patients with Intracranial Hemorrhage

Introduction It is common to start all patients on chemical prophylaxis for deep vein thrombosis (DVT) in order to decrease the risk of venous thromboembolism (VTE) and the associated adverse effects, including the potential for fatal pulmonary embolism (PE). There is no consensus in the literature on the optimal time to resume chemical DVT prophylaxis in patients who present with intracranial hemorrhage requiring neurosurgical intervention. The practice is variable and practitioner dependent. There can be difficulty in balancing the increased risk of further intracranial hemorrhage versus the benefit of starting DVT prophylaxis to prevent VTE. Method A retrospective review of patients that had diagnosis of intracranial hemorrhage (ICH) defined as epidural hematoma (EDH), subdural hematoma (SDH), or intra-parenchymal hematoma (IPH), was performed using the neurosurgical census at our institution. The review consisted of adult patients greater than 18 years old with a diagnosis of intracranial hemorrhage. Type of intracranial hemorrhage, method of neurosurgical intervention (whether surgical, bedside procedure, or both), day post-procedure prophylaxis was resumed, and the type of chemical prophylaxis used (subcutaneous heparin (SQH) versus enoxaparin) were recorded. The patient's sex, Glasgow Coma Scale on presentation and discharge, length of hospital stay, and length of intensive care unit (ICU) stay were also recorded. Patients with previously diagnosed bleeding dyscrasia, previously diagnosed DVT or PE, patients without post-procedure cranial imaging (CT or MRI), and patients without post-procedure duplex ultrasound for DVT screening were excluded. Patients were monitored with head CT for possible expansion of ICH after resumption of therapy. Furthermore, we investigated whether the patient developed an adverse effect such as venous thromboembolism including deep vein thrombosis and/or pulmonary embolism during the post-procedure period when they were not on chemical prophylaxis. Results A total of 94 patients were analyzed in our study. Nine (9.6%) had an EDH, seventeen (18.1%) had an IPH, and sixty-eight (72.3%) had a SDH. The three most common procedures were craniectomy (28.7%), craniotomy (34%), and subdural drain placement (28.7%). The most common agent for chemical DVT prophylaxis was SQH in 78% of patients. There was no statistically significant association between type of chemical DVT prophylaxis used with respect to either ICU length of stay or hospital length of stay. Change in GCS (the difference of GCS on presentation versus on discharge) was found to have statistically significant relationship with the use of chemical DVT prophylaxis. Furthermore, patients were found to have no statistically significant association with re-bleed or new hemorrhage upon starting chemical DVT prophylaxis, regardless of the type of ICH. Conclusion The rates of DVT diagnosis did not seem to be significantly affected by the specific type of chemical prophylaxis that was used. ICU and hospital length of stay were not adversely affected by starting prophylaxis for VTE in patients with ICH. On the contrary, an improvement in GCS (on presentation versus discharge) was associated with starting chemical DVT prophylaxis in ICH patients within 24 hours post-procedure.

Safety and Efficacy of Transcatheter Administration of Tissue Plasminogen Activating Factor as Adjuvant Therapy for Intraventricular Hemorrhage

Objective

Stroke is the fifth leading cause of death in the United States and the leading cause of disability. Hemorrhagic stroke has higher risks of mortality and neurologic deficit. Higher still, acute intraventricular hemorrhage (IVH) has mortality between 50% and 80% while complicating subarachnoid hemorrhage in 15% of cases and intracerebral hemorrhage in 40% of cases. We sought to demonstrate that early adjuvant intraventricular recombinant tissue plasminogen activating factor (rt-PA) improved outcomes.

Methods

Retrospective chart review was performed on patients aged 18-95 years with external ventricular drain (EVD) and intraventricular rt-PA for clot evacuation in IVH between 2005 and 2015. In total, 22 patients met the inclusion criteria. Generalized linear modeling was performed with factorial analysis using the Glasgow Coma Score (GCS) on arrival, GCS at EVD placement, EVD day of onset of rt-PA administration, GCS at onset of rt-PA administration, total duration of EVD, necessity of ventriculoperitoneal (VP) shunt, occurrence of ventriculitis, day of ventriculitis, GCS after rt-PA, length of stay (LOS) in the intensive care unit (ICU), and hospital disposition.

Results

Presenting GCS affected LOS significantly. Ventriculitis only significantly affected ICU LOS. GCS after rt-PA only significantly affected discharge GCS. EVD day of rt-PA protocol commencement demonstrated significant effects on EVD duration and cerebrospinal fluid (CSF) diversion requirement. Age affected ICU and hospital LOS.

Conclusion

These findings argue for larger prospective trials of EVD day two rt-PA protocol inception in acute IVH. Reported ventriculitis rates with EVDs are 8.8%, while we demonstrated a rate of 18% without significant effects except in ICU LOS. Transcatheter intraventricular rt-PA is safe and effective as an adjuvant in acute spontaneous intraventricular hemorrhage with the greatest benefit of rt-PA protocol at EVD day two.