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.

Iliac Screw Fixation Revisited: Improved Clinical and Radiologic Outcomes Using a Modified Iliac Screw Fixation Technique

STUDY DESIGN

A retrospective study.

OBJECTIVE

To describe the modified iliac screw (mILS) technique and compare it to other spinopelvic fixation techniques in terms of wound healing complications, hardware prominence, and failure.

SUMMARY OF BACKGROUND DATA

The traditional entry point of an iliac screw often causes postoperative gluteal pain from the prominent screw head. The use of an offset connector also adds a point of weakness to the construct. By choosing a different screw entry point offset connectors can be avoided, and the screw head itself is less prominent, thereby reducing postoperative discomfort.

MATERIALS AND METHODS

A retrospective analysis was performed of adult patients undergoing lumbopelvic fixation (LPF) between January 2014 and June 2019. Patients were grouped into 1 of 3 groups based on the technique of pelvic fixation: S2 alar-iliac (S2AI) screw, traditional iliac screw (tILS), and mILS. The primary outcome parameter was the minimal distance from screw head to skin. Secondary outcome parameters were instrumentation loosening/failure, adjacent level fractures, pseudoarthrosis, and medial or lateral iliac screw perforation.

RESULTS

A total of 190 patients undergoing LPF were included in the following 3 groups: mILS group (n=113), tILS group (n=40), and S2AI group (n=37). The mean minimal distance from screw head to skin in the mILS group was 31.3 mm compared with 23.7 mm in the tILS group (P<0.00199). No statistically significant differences were found when comparing the 3 groups with respect to complications. The mILS group did not show any cases of prominent instrumentation and had the lowest rate of instrumentation failure.

CONCLUSIONS

The mILS technique is an acceptable alternative for LPF, offering the benefits of iliac screw fixation while avoiding offset connectors and screw prominence complications associated with tILS.

LEVEL OF EVIDENCE

Level III.

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.

Evidence on the impacts of business coaching

Purpose

Based upon a survey of 87 companies having used the services of business coaches, this paper considers the extent to which coaching is likely to be beneficial to a leader's business success as well as that of the respective company.

Design/methodology/approach

The research methodology is mixed methods and survey-based combining quantitative Likert scaling with open-ended questions.

Findings

At the 99 percent confidence level, surveyed respondents believe that, on average, the coaching process has provided results above the investment required and has led to progress for them and their organizations. Of the six targeted areas, five showed a very positive relationship between the coaching experience and the results from its clients.

Research limitations/implications

As the research is based on a convenience sample it has shortcomings relative to probability sampling. However, it is widely recognized that such samples can be attained more easily, more rapidly, and at less cost than probability-based samples. On the other hand, it is understood that inferences to broader populations of interest are limited.

Practical implications

The results confirm findings from past research such as that reported by the Institute of Coaching (2018), that managers should not undervalue potential contributions to individual and company attributes from coaching.

Originality/value

The motivation for this paper is to bring together both academic and practitioner experience to provide more evidence and understanding related to the coaching definition, its implementation, and effectiveness. While not conclusive in the absolute sense, the original data original collected and analyzed for this research is based on known client contacts in close time proximity to the coaching engagement and delivers added insight to current research.

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.

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.

Seizure Prophylaxis in Traumatic Brain Injury: A Comparative Study of Levetiracetam and Phenytoin Cerebrospinal Fluid Levels in Trauma Patients with Signs of Increased Intracranial Pressure Requiring Ventriculostomy

Background

One of the most common life-threatening injuries to trauma patients arriving in the emergency department (ED) is traumatic brain injury (TBI). Traditionally, intravenous medications have been given as seizure prophylaxis in patients demonstrating signs of increased intracranial pressure (ICP), as post-traumatic seizures in trauma patients are associated with higher morbidity and mortality. Medications traditionally given for this indication such as phenytoin have been established to reach therapeutic levels in the cerebrospinal fluid (CSF) quickly and are effective in preventing post-traumatic seizures but often have a large side-effect profile. A newer medication that is being used for seizure prophylaxis in patients with epilepsy is levetiracetam. Levetiracetam typically has a better side effect profile, but it has not been demonstrated that the drug reaches therapeutic levels in the CSF as quickly as phenytoin. Studies have shown levetiracetam and phenytoin to be equivocal in the prevention of post-TBI seizure prophylaxis.

Methods

This was a prospective, randomized, case-control study at a Level II trauma center of adult patients (age >/= 18 years) who suffered severe TBI (sTBI) requiring the placement of an external ventricular drain (EVD) from May 2017 to June 2018. Twelve patients were randomly placed into one of two groups for the administration of antiepileptic medication (either levetiracetam or phenytoin), allowing for the subsequent serial collection of CSF for the analysis of therapeutic levels of antiepileptic medications. Levetiracetam or phenytoin was administered at standardized fixed doses per our neurosurgical center standard protocol. CSF was collected before either drug was administered, 60 minutes after completion of administration and 360 minutes after completion of drug administration. Data analysis was performed to compare the time frame for which therapeutic levels of the medications were achieved in the CSF. The published steady-state and therapeutic CSF level of levetiracetam is 32 mcg/ml and phenytoin is 2 mcg/ml.

Results

A trend was observed in which the closer the fixed dosage approximated the weight-based dosing of phenytoin, the more their CSF phenytoin level increased (and approximated the therapeutic range) with an associated R-squared value of 0.6274. This trend was not found in patients receiving levetiracetam.

Conclusions

Levetiracetam does not reach levels needed for seizure prophylaxis in human CSF when loaded at standard dosing regimens in the acute setting. Phenytoin does reach levels needed for seizure prophylaxis in human CSF with standardized regimen dosing when dosages approximate weight-based dosing. If needed, in the acute setting phenytoin should have additional doses given prior to six hours after the loading dose to achieve therapeutic CSF levels. 

Impressions of Osteopathic Neurosurgeon on Preparedness for Practice: Survey Results from the American College of Osteopathic Surgeons

Introduction Neurosurgeons trained in the US are rigorously educated on the surgical management of neurosurgical conditions. These neurosurgeons have been trained through one of two avenues: the Accreditation Council for Graduate Medical Education (ACGME) or the American Osteopathic Association (AOA). With the formation of a single accreditation system from the AOA and ACGME accrediting bodies and significant changes introduced in the training of neurosurgeons from both bodies, we sought to identify common practice parameters and perceptions of preparedness of AOA-trained neurosurgeons. Methods  A survey was conducted through the neurosurgery section of the American College of Osteopathic Surgeons (ACOS), requesting responses from attending neurosurgeons who completed AOA neurosurgery residency. Responses were obtained through an anonymous, web-based system using single-select multiple-choice questions. Results  In total, 52 neurosurgeons participated in the survey. The majority of the 52 respondents practiced in non-academic settings in urban areas and were exposed to a wide variety of practice environments in terms of case volume and clinical responsibilities. Significantly, 96.15% of the respondents said they felt adequately prepared for neurosurgical practice after their AOA training.  Conclusion  Overall, this study highlights both the similarities and variances in practices of osteopathic neurosurgeons. The majority of the participants feel that their training has appropriately prepared them for practice and they are skilled surgeons capable of caring for the safety and well-being of numerous patients in a variety of settings. Most of them practice primarily in private-practice settings at urban centers. Overall, osteopathic neurosurgeons trained in AOA programs report that their training has equipped them well for careers in neurosurgery.

Spinal Cord Reperfusion Injury: Case Report, Review of the Literature, and Future Treatment Strategies

A rare complication of cervical spine decompression is acute paralysis following the procedure. This neurologic deficit is thought to be due to reperfusion injury of a chronically ischemic spinal cord and is referred to as "white cord syndrome" given the pathognomonic finding of hyperintensity on T2-weighted MRI. Three prior cases have been reported. We present a case of transient quadriplegia following posterior cervical decompression.

A 41-year-old male with cervical spondylotic myelopathy presented with bilateral progressive upper extremity weakness, hyperreflexia, and cervical spine MRI showing severe cord compression at C1 and partial hyperintense signal. Intraoperatively, after C1 bony decompression and without perceptible technical cause, the patient experienced a complete loss of both somatosensory evoked potentials (SSEPs) and motor evoked potentials (MEPs) with an eventual return to baseline prior to completing the operation.

The patient awoke from surgery with acute quadriplegia without perceptible technical cause (intraoperative compression or evident anatomic compromise). An immediate postoperative MRI revealed a more pronounced hyperintensity in the central cervical cord on T2-weighted sequences. Treatment with increased mean arterial pressure (MAP) therapy and dexamethasone resulted in the patient regaining some movement over a period of hours and full strength over a period of months.

The mechanism of acute weakness following cervical spine decompression in the absence of perceptible technical cause is not fully understood, but current theory suggests that a reperfusion injury is most likely the cause. It remains a diagnosis of exclusion. Familiarity with this potential postoperative complication can aid in appropriate postoperative therapy with early diagnosis and intervention leading to restored spinal cord function and excellent prognosis.

Primary Spinal Astrocytomas: A Literature Review

Primary spinal astrocytoma is a subtype of glioma, the most common spinal cord tumor found in the intradural intramedullary compartment. Spinal astrocytomas account for 6-8% of all spinal cord tumors and are primarily low grade (World Health Organization grade I (WHO I) or WHO II). They are seen in both the adult and pediatric population with the most common presenting symptoms being back pain, sensory dysfunction, or motor dysfunction. Magnetic Resonance Imaging (MRI) with and without gadolinium is the imaging of choice, which usually reveals a hypointense T1 weighted and hyperintense T2 weighted lesion with a heterogeneous pattern of contrast enhancement. Further imaging which may aid in surgical planning includes computerized tomography, diffusion tensor imaging, and tractography. Median survival in spinal cord astrocytomas ranges widely. The factors most significantly associated with poor prognosis and shorter median survival are older age at initial diagnosis, higher grade lesion based on histology, and extent of resection. The mainstay of treatment for primary spinal cord astrocytomas is surgical resection, with the goal of preservation of neurologic function, guided by intraoperative neuromonitoring. Adjunctive radiation has been shown beneficial and may increase overall survival. The role of adjunctive chemotherapy is employed, however, its benefit has not been clearly defined. Primary spinal cord astrocytomas are rare and challenging to treat. The gold standard treatment is surgical resection. Second-line treatments include radiation and chemotherapy, although, the optimal regimen for adjunctive therapy has not yet been clearly defined.

Tight Control of Systolic Blood Pressure in Spontaneous Intraparenchymal Brain Hemorrhage

Background Tight blood pressure control is critical in neurosurgical patients. Systolic blood pressure (SBP) must be low enough to avoid injury and minimize intraparenchymal hemorrhage (IPH) but high enough to maintain cerebral perfusion. American Heart Association (AHA) guidelines recommend SBP <140 in intracerebral hemorrhage. This paper sought to elucidate the effect of early control of SBP on IPH expansion. Methods 134 patients with spontaneous IPH between 2011 and 2015 were analyzed utilizing chart review. Initial versus follow-up bleed size, presentation and discharge condition, discharge disposition, and blood pressure control adequacy were analyzed using the generalized linear model. Results Altered mental status was the most common presenting complaint (78%). Presenting GCS failed to demonstrate a significant main effect. Age, initial IPH volume, presenting SBP, and one-hour SBP significantly affected IPH percent expansion (p=0.002, =0.002, <0.0005, and =0.026). Several two-way interactions affected IPH percent change implying synergistic effects of the predictor variables. Conclusion Patients aged 60-70 years had the largest percent IPH expansion followed by patients aged 20-30 years. Initial IPH volume of 65.23-78.26 ml showed the largest expansion. Initial IPH volume of 52.18-65.22 ml demonstrated the least percentage of IPH expansion. One-hour control of SBP to binned groups of 111-121 mmHg or 121-132 mmHg portends relative minima in bleed expansion corresponding with AHA recommendations for IPH patients. This study suggests that this degree of early and aggressive control of SBP is achievable, safe, and may minimize IPH expansion. Future studies are needed to elucidate the role of co-morbidities and to confirm these findings in broader populations.

The Use of Computed Tomography Perfusion on Admission to Predict Outcomes in Surgical and Nonsurgical Traumatic Brain Injury Patients

Introduction: The objective of this study was to investigate if data obtained from a computed tomography (CT) perfusion study on admission could correlate to outcomes for the patient, including the patient’s length of stay in the hospital and their initial and final Glasgow Coma Scale (GCS), as well as the modified Rankin Scale (mRS) on discharge. We present an initial subset of patients fulfilling the inclusion criteria: over the age of 18 with mild, moderate, or severe traumatic brain injury (TBI). Patients admitted with a diagnosis of TBI had CT perfusion studies performed within 48 hours of admission. GCS, length of stay, mRS, and discharge location were tracked, along with the patient’s course of hospitalization. Initial results and discussion on the utility of CT perfusion for predicting outcomes are presented.

Methods: Patients exhibiting mild, moderate, or severe TBI were assessed using CT perfusion within 48 hours of admission from January to July 2019 at the Arrowhead Regional Medical Center (ARMC). The neurosurgery census and patient records were assessed for progression of outcomes. Data obtained from the perfusion scans were correlated to patient outcomes to evaluate the utility of CT perfusion in predicting outcomes in surgical and nonsurgical TBI patients.

Results: Preliminary data were obtained on six patients exhibiting TBI, ranging from mild to severe. The mean GCS of our patient cohort on admission was eight, with the most common mechanism of injury found to be falls (50%) and motor vehicle accidents (50%). Cerebral blood volume (CBV) seemed to increase with Rankin value (Pearson's correlations coefficient = 0.43 but was statistically insignificant (P = 0.21)). Cerebral blood flow (CBF) was found to be correlated with CBV, and both increased with Rankin score (Pearson's correlation coefficient = 0.56) but were statistically insignificant (P = 0.27). These results suggest that with a larger sample size, CBV and CBF may be correlated to patient outcome.

Conclusion: Although more data is needed, preliminary results suggest that with larger patient populations, CT perfusion may provide information that can be correlated clinically to patient outcomes. This study shows that CBF and CBV may serve as useful indicators for prognostication of TBI patients.

Minimization of Intraparenchymal Hemorrhagic Stroke Size by Optimization of Serum Lipids

Introduction

Intraparenchymal hemorrhages (IPHs) are the most common type of hemorrhagic stroke. One of the main associated risk factors is total cholesterol (TC) above 200. A severely decreased level of TC potentially interferes with the stabilization of the cell membrane and can potentially lead to a larger hemorrhage. Previous population-based studies have confirmed an association between low TCs and a high incidence of hemorrhagic stroke. It has been established that a TC below 200 decreases the potential for cardiovascular disease. This study suggests that the balance that needs to be achieved between these two extremes presents a unique possibility for an optimal therapeutic range of total cholesterol levels.

Materials & methods

Inclusion criteria included all adult patients with International Classification of Diseases (ICD)-9/10 code for hemorrhagic stroke, from June 2007 to June 2017. A total of 300 patients met the criteria (N=300). For each patient, the following data were collected: NIH Stroke Scale, TC level, triglyceride level, low-density lipoprotein (LDL) and high-density lipoprotein (HDL), cholesterol reducing medications, size of hemorrhage on computed tomography (CT) of the head, location of hemorrhage, and patient disposition. Statistical analysis was done using the Generalized Linear Modeling with Wald Chi-square as the statistical determinant.

Results

Intracerebral hemorrhage size is dependent on the intracranial location with brain lobes having larger bleeds. Minimum hemorrhage size was noted in TC 188-196 and this effect was statistically significant independent of location. HDL has a significant independent effect on hemorrhage size with overall minimum bleed occurring in the range of 43-51 mg/dL HDL (98-106 mg/dL for men and 43-51 mg/dL for women). This sex effect within HDL on hemorrhage size is statistically significant. There was a differential effect of HDL dependent on patient race. Asian and black patients had least IPH volume with HDL 70-79 mg/dL, while Hispanic patients had a minimum at 43-51 mg/dL. White patients required a higher HDL, 80-88 mg/dL to minimize the IPH size. The triglyceride level had a statistically significant independent effect on the bleed size with the minimum hemorrhage size occurring in the range of 205-224 mg/dL. This effect was nuanced by patient race with statistically significant minimum IPH size occurring at 144-164 mg/dL for white patients, 124-143 mg/dL for Hispanic and black patients, and 84-103 mg/dL for Asian patients. Post-hospital patient disposition was not significantly affected by any of the above predictor variables.

Conclusion

This study found TC, HDL and triglycerides in specific ranges are associated with significantly decreased hemorrhage size across all genders and hemorrhage locations. The ranges with the strongest hemorrhage-limiting effect are as follows: TC 188-196 mg/dL, HDL 43-51 mg/dL (98-106 mg/dL for men and 43-51 mg/dL for women), triglycerides 205-224 mg/dL. Lipids both below and above these ranges yield larger bleeds. It also found larger brain areas will have more extensive hemorrhage than smaller brain areas. Future work in this arena should include collaboration with cardiology to determine ideal ranges for both cardio- and neuroprotection as well as a prospective study to validate the applicability of these findings in patient care.

Inflammatory Markers and Severity of Intracerebral Hemorrhage

Background and purpose

The pathogenesis of brain injury after intracerebral hemorrhage is thought to be due to mechanical damage followed by ischemic, cytotoxic, and inflammatory changes in the underlying and surrounding tissue.In recent years, there has been a greater research interest into the various inflammatory biomarkers and growth factors that are secreted during intracerebral hemorrhage. The biomarkers investigated in this study are tumor necrosis factor alpha (TNF alpha), C-reactive protein (CRP), homocysteine (Hcy), and vascular endothelial growth factor (VEGF). The aim of this study was to further investigate the effects of these biomarkers in predicting the acute severity outcome of intracerebral hemorrhage (ICH).

Methods

We conducted a retrospective chart review of patients with spontaneous ICH with TNF alpha, CRP, VEGF, and Hcy levels drawn on admission. Forty-two patients with spontaneous ICH with at least one of the above labs were included in the study. Primary outcomes included death, Glasgow Coma Scale (GCS) on admission, early neurologic decline (END), and hemorrhage size. Secondary outcomes included GCS on discharge, ICH score, functional outcome risk stratification scale of intracerebral hemorrhage (FUNC score), change in hemorrhage size, need for surgical intervention, and length of intensive care unit (ICU) stay.

Results

Forty-two patients with spontaneous intracerebral hemorrhage (ICH) were analyzed, 12 patients (28.5%) required surgical intervention, and four patients (9.5%) died. Only low VEGF serum values were found to predict mortality. TNF alpha, CRP, Hcy, and VEGF levels in our patients with ICH were not found to predict early neurologic decline and were not correlated with GCS on admission, initial hemorrhage size, change in hemorrhage size, need for surgical intervention, ICH score, FUNC score, midline shift, and length of ICU stay. CRP and Hcy were elevated in 58% and 31% of patients tested, respectively. GCS on admission and ICH score were significantly associated with mortality.

Conclusion

After careful statistical review of the data obtained from this patient population, only low VEGF values were found to be a significant predictor of mortality. However, elevated CRP and Hcy levels were associated with a non-significant trend in hemorrhage size and mortality suggesting that CRP and Hcy-lowering therapies may decrease hemorrhagic stroke risk and severity.

Novel Method of Non-contact Remote Measurement of Neuronal Electrical Activity

Measuring the electrical potential of a neuron cell currently requires direct contact with the cell surface. This method requires invasive probing and is limited by the deflection of electricity from baseline. From a clinical perspective, the electrical potential of the brain's surface can only be measured to a depth of one centimeter using an electroencephalogram (EEG), however, it cannot measure much deeper structures. In this trial, we attempt a novel method to remotely record the electromagnetic field (EMF) of action potential provoked from hippocampal neurons without contact.

A bipolar stimulating electrode was placed in contact with the CA1 region of viable hippocampal slice from donor mice. The specimen was bathed in artifical cerebrospinal fluid (aCSF) to simulate in vivo conditions. This setup was then placed into a magnetic shielded tube. Very low-frequency EMF sensors were used to obtain recordings. The impedance of the aCSF and hippocampal slice were measured after each stimulation individually and in combination.

An electromagnetic signal was detected in three out of four scenarios: (a) aCSF alone with electrical stimulus without a hippocampal slice, (b) Hippocampal slice in aCSF without electrical stimulus and, (c) Hippocampal slice in aCSF with an electric stimulus applied. Therefore, our trial suggests that EMFs from neuronal tissue can be recorded through non-invasive non-contact sensors.

A rare presentation of ruptured abdominal aortic aneurysm leading to aortoduodenal syndrome

Duodenal obstruction is a rare complication of abdominal aortic aneurysm. Obstruction developing acutely from ruptured abdominal aortic aneurysm (RAAA) is exceedingly rare. We present a case of gastroduodenal outlet obstruction developing as the primary presentation for RAAA and a discussion of the relevant literature pertaining to the gastrointestinal complications related to the presence of intact and RAAA. Relief of obstruction is focused on direct aortic replacement with further evaluation of the upper gastrointestinal tract if indicated based on intraoperative findings.