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Ali R, Connolly ID, Tang OY, Mirza FN, Johnston B, Abdulrazeq HF, Lim RK, Galamaga PF, Libby TJ, Sodha NR, Groff MW, Gokaslan ZL, Telfeian AE, Shin JH, Asaad WF, Zou J, Doberstein CE. Author Correction: Bridging the literacy gap for surgical consents: an AI-human expert collaborative approach. NPJ Digit Med 2024; 7:93. [PMID: 38609435 PMCID: PMC11015017 DOI: 10.1038/s41746-024-01099-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024] Open
Affiliation(s)
- Rohaid Ali
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA.
- Norman Prince Neurosciences Institute, Providence, RI, USA.
| | - Ian D Connolly
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Oliver Y Tang
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Fatima N Mirza
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Benjamin Johnston
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Hael F Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Norman Prince Neurosciences Institute, Providence, RI, USA
| | - Rachel K Lim
- Department of Surgery & Division of Cardiothoracic Surgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Tiffany J Libby
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Neel R Sodha
- Department of Surgery & Division of Cardiothoracic Surgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael W Groff
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Norman Prince Neurosciences Institute, Providence, RI, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Norman Prince Neurosciences Institute, Providence, RI, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Wael F Asaad
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - James Zou
- Departments of Electrical Engineering, Biomedical Data Science, and Computer Science, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Curtis E Doberstein
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Norman Prince Neurosciences Institute, Providence, RI, USA
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Abdulrazeq HF, Ali R, Najib H, Doberstein C, Oyelese A, Gokaslan Z, Malik AN, Asaad WF, Greenblatt S. Al-Zahrawi (936-1013 AD): On the Surgical Treatment of Neurological Disorders by the Father of Operative Surgery. World Neurosurg 2024; 184:236-240.e1. [PMID: 38331026 DOI: 10.1016/j.wneu.2024.01.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Revised: 01/29/2024] [Accepted: 01/30/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Medical knowledge during the medieval ages flourished under the influence of great scholars of the Islamic Golden age such as Ibn Sina (Latinized as Avicenna), Abu Bakr al-Razi (Rhazes), and Abu al-Qasim Khalaf ibn al-Abbas al-Zahrawi, known as Albucasis. Much has been written on al-Zahrawi's innovation in various disciplines of medicine and surgery. In this article, we focus for on the contributions of al-Zahrawi toward the treatment of neurological disorders in the surgical chapters of his medical encyclopedia, Kitab al-Tasrif (The Method of Medicine). METHODS Excerpts from a modern copy of volume 30 of al-Zahrawi's Kitab al-Tasrif were reviewed and translated by the primary author from Arabic to English, to further provide specific details regarding his neurosurgical knowledge. In addition, a literature search was performed using PubMed and Google Scholar to review prior reports on al-Zahrawi's neurosurgical instructions. RESULTS In addition to what is described in the literature of al-Zahrawi's teachings in cranial and spine surgery, we provide insight into his diagnosis and management of cranial and spinal trauma, the devices he used, and prognostication of various traumatic injuries. CONCLUSIONS Al-Zahrawi was a renowned physician during the Islamic Golden age who made significant contributions to the diagnosis and treatment of neurological conditions, particularly cranial and spinal cord injuries. He developed innovative surgical techniques for trephination and spinal traction, which are still used in modern neurosurgery. His insights make him worthy of recognition as an important figure in the history of neurological surgery.
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Affiliation(s)
- Hael F Abdulrazeq
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA.
| | - Rohaid Ali
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Hebah Najib
- Department of Internal Medicine, Touro College of Osteopathic Medicine, Middletown, New York, USA
| | - Curt Doberstein
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adetokunbo Oyelese
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Ziya Gokaslan
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Athar N Malik
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Wael F Asaad
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Samuel Greenblatt
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA
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Ali R, Connolly ID, Tang OY, Mirza FN, Johnston B, Abdulrazeq HF, Lim RK, Galamaga PF, Libby TJ, Sodha NR, Groff MW, Gokaslan ZL, Telfeian AE, Shin JH, Asaad WF, Zou J, Doberstein CE. Bridging the literacy gap for surgical consents: an AI-human expert collaborative approach. NPJ Digit Med 2024; 7:63. [PMID: 38459205 PMCID: PMC10923794 DOI: 10.1038/s41746-024-01039-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 02/14/2024] [Indexed: 03/10/2024] Open
Abstract
Despite the importance of informed consent in healthcare, the readability and specificity of consent forms often impede patients' comprehension. This study investigates the use of GPT-4 to simplify surgical consent forms and introduces an AI-human expert collaborative approach to validate content appropriateness. Consent forms from multiple institutions were assessed for readability and simplified using GPT-4, with pre- and post-simplification readability metrics compared using nonparametric tests. Independent reviews by medical authors and a malpractice defense attorney were conducted. Finally, GPT-4's potential for generating de novo procedure-specific consent forms was assessed, with forms evaluated using a validated 8-item rubric and expert subspecialty surgeon review. Analysis of 15 academic medical centers' consent forms revealed significant reductions in average reading time, word rarity, and passive sentence frequency (all P < 0.05) following GPT-4-faciliated simplification. Readability improved from an average college freshman to an 8th-grade level (P = 0.004), matching the average American's reading level. Medical and legal sufficiency consistency was confirmed. GPT-4 generated procedure-specific consent forms for five varied surgical procedures at an average 6th-grade reading level. These forms received perfect scores on a standardized consent form rubric and withstood scrutiny upon expert subspeciality surgeon review. This study demonstrates the first AI-human expert collaboration to enhance surgical consent forms, significantly improving readability without sacrificing clinical detail. Our framework could be extended to other patient communication materials, emphasizing clear communication and mitigating disparities related to health literacy barriers.
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Affiliation(s)
- Rohaid Ali
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA.
- Norman Prince Neurosciences Institute, Providence, RI, USA.
| | - Ian D Connolly
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Oliver Y Tang
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Fatima N Mirza
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Benjamin Johnston
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Hael F Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Norman Prince Neurosciences Institute, Providence, RI, USA
| | - Rachel K Lim
- Department of Surgery & Division of Cardiothoracic Surgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | | | - Tiffany J Libby
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Neel R Sodha
- Department of Surgery & Division of Cardiothoracic Surgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Michael W Groff
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Norman Prince Neurosciences Institute, Providence, RI, USA
| | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Norman Prince Neurosciences Institute, Providence, RI, USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston, MA, USA
| | - Wael F Asaad
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - James Zou
- Departments of Electrical Engineering, Biomedical Data Science, and Computer Science, Stanford University, Stanford, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Curtis E Doberstein
- Department of Neurosurgery, Rhode Island Hospital and The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Norman Prince Neurosciences Institute, Providence, RI, USA
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Pagnier GJ, Asaad WF, Frank MJ. Double dissociation of dopamine and subthalamic nucleus stimulation on effortful cost/benefit decision making. Curr Biol 2024; 34:655-660.e3. [PMID: 38183986 PMCID: PMC10872531 DOI: 10.1016/j.cub.2023.12.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 11/10/2023] [Accepted: 12/13/2023] [Indexed: 01/08/2024]
Abstract
Deep brain stimulation (DBS) and dopaminergic therapy (DA) are common interventions for Parkinson's disease (PD). Both treatments typically improve patient outcomes, and both can have adverse side effects on decision making (e.g., impulsivity).1,2 Nevertheless, they are thought to act via different mechanisms within basal ganglia circuits.3 Here, we developed and formally evaluated their dissociable predictions within a single cost/benefit effort-based decision-making task. In the same patients, we manipulated DA medication status and subthalamic nucleus (STN) DBS status within and across sessions. Using a series of descriptive and computational modeling analyses of participant choices and their dynamics, we confirm a double dissociation: DA medication asymmetrically altered participants' sensitivities to benefits vs. effort costs of alternative choices (boosting the sensitivity to benefits while simultaneously lowering sensitivity to costs); whereas STN DBS lowered the decision threshold of such choices. To our knowledge, this is the first study to show, using a common modeling framework, a dissociation of DA and DBS within the same participants. As such, this work offers a comprehensive account for how different mechanisms impact decision making, and how impulsive behavior (present in DA-treated patients with PD and DBS patients) may emerge from separate physiological mechanisms.
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Affiliation(s)
- Guillaume J Pagnier
- Department of Neuroscience, Brown University, Box GL-N, 185 Meeting Street, Providence, RI 02912, USA; Carney Institute for Brain Science, Brown University, 164 Angell Street, 4(th) Floor, Providence, RI 02906, USA.
| | - Wael F Asaad
- Department of Neuroscience, Brown University, Box GL-N, 185 Meeting Street, Providence, RI 02912, USA; Norman Prince Neurosciences Institute, APC 633, Department of Neurosurgery, Rhode Island Hospital, 593 Eddy Street, Providence, RI 02903; Carney Institute for Brain Science, Brown University, 164 Angell Street, 4(th) Floor, Providence, RI 02906, USA
| | - Michael J Frank
- Department of Neuroscience, Brown University, Box GL-N, 185 Meeting Street, Providence, RI 02912, USA; Department of Cognitive, Linguistic and Psychological Sciences, Metcalf Research Building, 190 Thayer St, Providence, RI 02912, USA; Carney Institute for Brain Science, Brown University, 164 Angell Street, 4(th) Floor, Providence, RI 02906, USA
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Ali R, Tang OY, Connolly ID, Abdulrazeq HF, Mirza FN, Lim RK, Johnston BR, Groff MW, Williamson T, Svokos K, Libby TJ, Shin JH, Gokaslan ZL, Doberstein CE, Zou J, Asaad WF. Demographic Representation in 3 Leading Artificial Intelligence Text-to-Image Generators. JAMA Surg 2024; 159:87-95. [PMID: 37966807 PMCID: PMC10782243 DOI: 10.1001/jamasurg.2023.5695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Accepted: 08/25/2023] [Indexed: 11/16/2023]
Abstract
Importance The progression of artificial intelligence (AI) text-to-image generators raises concerns of perpetuating societal biases, including profession-based stereotypes. Objective To gauge the demographic accuracy of surgeon representation by 3 prominent AI text-to-image models compared to real-world attending surgeons and trainees. Design, Setting, and Participants The study used a cross-sectional design, assessing the latest release of 3 leading publicly available AI text-to-image generators. Seven independent reviewers categorized AI-produced images. A total of 2400 images were analyzed, generated across 8 surgical specialties within each model. An additional 1200 images were evaluated based on geographic prompts for 3 countries. The study was conducted in May 2023. The 3 AI text-to-image generators were chosen due to their popularity at the time of this study. The measure of demographic characteristics was provided by the Association of American Medical Colleges subspecialty report, which references the American Medical Association master file for physician demographic characteristics across 50 states. Given changing demographic characteristics in trainees compared to attending surgeons, the decision was made to look into both groups separately. Race (non-White, defined as any race other than non-Hispanic White, and White) and gender (female and male) were assessed to evaluate known societal biases. Exposures Images were generated using a prompt template, "a photo of the face of a [blank]", with the blank replaced by a surgical specialty. Geographic-based prompting was evaluated by specifying the most populous countries on 3 continents (the US, Nigeria, and China). Main Outcomes and Measures The study compared representation of female and non-White surgeons in each model with real demographic data using χ2, Fisher exact, and proportion tests. Results There was a significantly higher mean representation of female (35.8% vs 14.7%; P < .001) and non-White (37.4% vs 22.8%; P < .001) surgeons among trainees than attending surgeons. DALL-E 2 reflected attending surgeons' true demographic data for female surgeons (15.9% vs 14.7%; P = .39) and non-White surgeons (22.6% vs 22.8%; P = .92) but underestimated trainees' representation for both female (15.9% vs 35.8%; P < .001) and non-White (22.6% vs 37.4%; P < .001) surgeons. In contrast, Midjourney and Stable Diffusion had significantly lower representation of images of female (0% and 1.8%, respectively; P < .001) and non-White (0.5% and 0.6%, respectively; P < .001) surgeons than DALL-E 2 or true demographic data. Geographic-based prompting increased non-White surgeon representation but did not alter female representation for all models in prompts specifying Nigeria and China. Conclusion and Relevance In this study, 2 leading publicly available text-to-image generators amplified societal biases, depicting over 98% surgeons as White and male. While 1 of the models depicted comparable demographic characteristics to real attending surgeons, all 3 models underestimated trainee representation. The study suggests the need for guardrails and robust feedback systems to minimize AI text-to-image generators magnifying stereotypes in professions such as surgery.
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Affiliation(s)
- Rohaid Ali
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Oliver Y. Tang
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ian D. Connolly
- Department of Neurosurgery, Massachusetts General Hospital, Boston
| | - Hael F. Abdulrazeq
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Fatima N. Mirza
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Rachel K. Lim
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Michael W. Groff
- Department of Neurosurgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Konstantina Svokos
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Tiffany J. Libby
- Department of Dermatology, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - John H. Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston
| | - Ziya L. Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Curtis E. Doberstein
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - James Zou
- Department of Biomedical Data Science and, by courtesy, Computer Science and Electrical Engineering, Stanford University, Stanford, California
| | - Wael F. Asaad
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
- Department of Neuroscience, Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence
- Department of Neuroscience, Brown University, Providence, Rhode Island
- Department of Neuroscience, Carney Institute for Brain Science, Brown University, Providence, Rhode Island
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Abdulrazeq H, Kimata AR, Blum A, Malik AN, Asaad WF. Exploring the Role of the Pulvinar Nucleus of the Thalamus in Occipital Lobe Epilepsy: A Case Report. Cureus 2024; 16:e52534. [PMID: 38371112 PMCID: PMC10874469 DOI: 10.7759/cureus.52534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2024] [Indexed: 02/20/2024] Open
Abstract
Understanding the role of the pulvinar nucleus may be critical for guiding circuit-targeted neurosurgical intervention in some patients. In this report, a 33-year-old female presented with focal onset occipital epilepsy with secondary generalization and with a previously radiated arteriovenous malformation within the right primary visual cortex. Phase II monitoring demonstrated the pulvinar nucleus was not involved in subclinical seizures restricted to the primary visual cortex, but it did become involved in clinical events with more extensive seizure spread into higher visual cortical regions. She underwent responsive neurostimulation (RNS) with implantation of leads within the primary visual cortex. This case demonstrates the late propagation of epileptic activity from the visual cortex to the pulvinar nucleus and illustrates the pulvinar nucleus' connections with higher-order visual areas.
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Affiliation(s)
- Hael Abdulrazeq
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Anna R Kimata
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Andrew Blum
- Department of Neurology, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Athar N Malik
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
- Department of Neuroscience, The Warren Alpert Medical School of Brown University, Providence, USA
| | - Wael F Asaad
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence, USA
- Department of Neuroscience, The Warren Alpert Medical School of Brown University, Providence, USA
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Ali R, Tang OY, Connolly ID, Zadnik Sullivan PL, Shin JH, Fridley JS, Asaad WF, Cielo D, Oyelese AA, Doberstein CE, Gokaslan ZL, Telfeian AE. Performance of ChatGPT and GPT-4 on Neurosurgery Written Board Examinations. Neurosurgery 2023; 93:1353-1365. [PMID: 37581444 DOI: 10.1227/neu.0000000000002632] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 05/19/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Interest surrounding generative large language models (LLMs) has rapidly grown. Although ChatGPT (GPT-3.5), a general LLM, has shown near-passing performance on medical student board examinations, the performance of ChatGPT or its successor GPT-4 on specialized examinations and the factors affecting accuracy remain unclear. This study aims to assess the performance of ChatGPT and GPT-4 on a 500-question mock neurosurgical written board examination. METHODS The Self-Assessment Neurosurgery Examinations (SANS) American Board of Neurological Surgery Self-Assessment Examination 1 was used to evaluate ChatGPT and GPT-4. Questions were in single best answer, multiple-choice format. χ 2 , Fisher exact, and univariable logistic regression tests were used to assess performance differences in relation to question characteristics. RESULTS ChatGPT (GPT-3.5) and GPT-4 achieved scores of 73.4% (95% CI: 69.3%-77.2%) and 83.4% (95% CI: 79.8%-86.5%), respectively, relative to the user average of 72.8% (95% CI: 68.6%-76.6%). Both LLMs exceeded last year's passing threshold of 69%. Although scores between ChatGPT and question bank users were equivalent ( P = .963), GPT-4 outperformed both (both P < .001). GPT-4 answered every question answered correctly by ChatGPT and 37.6% (50/133) of remaining incorrect questions correctly. Among 12 question categories, GPT-4 significantly outperformed users in each but performed comparably with ChatGPT in 3 (functional, other general, and spine) and outperformed both users and ChatGPT for tumor questions. Increased word count (odds ratio = 0.89 of answering a question correctly per +10 words) and higher-order problem-solving (odds ratio = 0.40, P = .009) were associated with lower accuracy for ChatGPT, but not for GPT-4 (both P > .005). Multimodal input was not available at the time of this study; hence, on questions with image content, ChatGPT and GPT-4 answered 49.5% and 56.8% of questions correctly based on contextual context clues alone. CONCLUSION LLMs achieved passing scores on a mock 500-question neurosurgical written board examination, with GPT-4 significantly outperforming ChatGPT.
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Affiliation(s)
- Rohaid Ali
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Oliver Y Tang
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Ian D Connolly
- Department of Neurosurgery, Massachusetts General Hospital, Boston , Massachusetts , USA
| | - Patricia L Zadnik Sullivan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - John H Shin
- Department of Neuroscience, Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
| | - Jared S Fridley
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Wael F Asaad
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Department of Neuroscience, Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
- Department of Neuroscience, Brown University, Providence , Rhode Island , USA
- Department of Neuroscience, Carney Institute for Brain Science, Brown University, Providence , Rhode Island , USA
| | - Deus Cielo
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Curtis E Doberstein
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Albert E Telfeian
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
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Abdulrazeq HF, Kimata AR, Shao B, Svokos K, Ayub N, Nie D, Asaad WF. Laser amygdalohippocampotomy reduces contralateral hippocampal sub-clinical activity in bitemporal epilepsy: A case illustration of responsive neurostimulator ambulatory recordings. Epilepsy Behav Rep 2023; 25:100636. [PMID: 38162813 PMCID: PMC10755529 DOI: 10.1016/j.ebr.2023.100636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 11/29/2023] [Accepted: 11/30/2023] [Indexed: 01/03/2024] Open
Abstract
Responsive neurostimulation (RNS) is a valuable tool in the diagnosis and treatment of medication refractory epilepsy (MRE) and provides clinicians with better insights into patients' seizure patterns. In this case illustration, we present a patient with bilateral hippocampal RNS for presumed bilateral mesial temporal lobe epilepsy. The patient subsequently underwent a right sided LITT amygdalohippocampotomy based upon chronic RNS data revealing predominance of seizures from that side. Analyzing electrocorticography (ECOG) from the RNS system, we identified the frequency of high amplitude discharges recorded from the left hippocampal lead pre- and post- right LITT amygdalohippocampotomy. A reduction in contralateral interictal epileptiform activity was observed through RNS recordings over a two-year period, suggesting the potential dependency of the contralateral activity on the primary epileptogenic zone. These findings suggest that early targeted surgical resection or laser ablation by leveraging RNS data can potentially impede the progression of dependent epileptiform activity and may aid in preserving neurocognitive networks. RNS recordings are essential in shaping further management decisions for our patient with a presumed bitemporal epilepsy.
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Affiliation(s)
- Hael F. Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Anna R. Kimata
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
- Department of Neuroscience, Brown University, Providence, RI, United States
| | - Belinda Shao
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Konstantina Svokos
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
- Norman Prince Neurosciences Institute, Rhode Island Hospital & Hasbro Children’s Hospital, Providence, RI, United States
- Department of Neuroscience, Brown University, Providence, RI, United States
| | - Neishay Ayub
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
- Norman Prince Neurosciences Institute, Rhode Island Hospital & Hasbro Children’s Hospital, Providence, RI, United States
- Department of Neurology, Rhode Island Hospital, Providence, RI, United States
| | - Duyu Nie
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
- Norman Prince Neurosciences Institute, Rhode Island Hospital & Hasbro Children’s Hospital, Providence, RI, United States
- Department of Neurology, Rhode Island Hospital, Providence, RI, United States
| | - Wael F. Asaad
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
- The Warren Alpert Medical School of Brown University, Providence, RI, United States
- Norman Prince Neurosciences Institute, Rhode Island Hospital & Hasbro Children’s Hospital, Providence, RI, United States
- Department of Neuroscience, Brown University, Providence, RI, United States
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Ali R, Tang OY, Connolly ID, Fridley JS, Shin JH, Zadnik Sullivan PL, Cielo D, Oyelese AA, Doberstein CE, Telfeian AE, Gokaslan ZL, Asaad WF. Performance of ChatGPT, GPT-4, and Google Bard on a Neurosurgery Oral Boards Preparation Question Bank. Neurosurgery 2023; 93:1090-1098. [PMID: 37306460 DOI: 10.1227/neu.0000000000002551] [Citation(s) in RCA: 36] [Impact Index Per Article: 36.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 04/09/2023] [Indexed: 06/13/2023] Open
Abstract
BACKGROUND AND OBJECTIVES General large language models (LLMs), such as ChatGPT (GPT-3.5), have demonstrated the capability to pass multiple-choice medical board examinations. However, comparative accuracy of different LLMs and LLM performance on assessments of predominantly higher-order management questions is poorly understood. We aimed to assess the performance of 3 LLMs (GPT-3.5, GPT-4, and Google Bard) on a question bank designed specifically for neurosurgery oral boards examination preparation. METHODS The 149-question Self-Assessment Neurosurgery Examination Indications Examination was used to query LLM accuracy. Questions were inputted in a single best answer, multiple-choice format. χ 2 , Fisher exact, and univariable logistic regression tests assessed differences in performance by question characteristics. RESULTS On a question bank with predominantly higher-order questions (85.2%), ChatGPT (GPT-3.5) and GPT-4 answered 62.4% (95% CI: 54.1%-70.1%) and 82.6% (95% CI: 75.2%-88.1%) of questions correctly, respectively. By contrast, Bard scored 44.2% (66/149, 95% CI: 36.2%-52.6%). GPT-3.5 and GPT-4 demonstrated significantly higher scores than Bard (both P < .01), and GPT-4 outperformed GPT-3.5 ( P = .023). Among 6 subspecialties, GPT-4 had significantly higher accuracy in the Spine category relative to GPT-3.5 and in 4 categories relative to Bard (all P < .01). Incorporation of higher-order problem solving was associated with lower question accuracy for GPT-3.5 (odds ratio [OR] = 0.80, P = .042) and Bard (OR = 0.76, P = .014), but not GPT-4 (OR = 0.86, P = .085). GPT-4's performance on imaging-related questions surpassed GPT-3.5's (68.6% vs 47.1%, P = .044) and was comparable with Bard's (68.6% vs 66.7%, P = 1.000). However, GPT-4 demonstrated significantly lower rates of "hallucination" on imaging-related questions than both GPT-3.5 (2.3% vs 57.1%, P < .001) and Bard (2.3% vs 27.3%, P = .002). Lack of question text description for questions predicted significantly higher odds of hallucination for GPT-3.5 (OR = 1.45, P = .012) and Bard (OR = 2.09, P < .001). CONCLUSION On a question bank of predominantly higher-order management case scenarios for neurosurgery oral boards preparation, GPT-4 achieved a score of 82.6%, outperforming ChatGPT and Google Bard.
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Affiliation(s)
- Rohaid Ali
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Oliver Y Tang
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Ian D Connolly
- Department of Neurosurgery, Massachusetts General Hospital, Boston , Massachusetts , USA
| | - Jared S Fridley
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston , Massachusetts , USA
| | - Patricia L Zadnik Sullivan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Deus Cielo
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Curtis E Doberstein
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Albert E Telfeian
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Wael F Asaad
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
- Department of Neuroscience, Brown University, Providence , Rhode Island , USA
- Carney Institute for Brain Science, Brown University, Providence , Rhode Island , USA
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10
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Fields MC, Eka O, Schreckinger C, Dugan P, Asaad WF, Blum AS, Bullinger K, Willie JT, Burdette DE, Anderson C, Quraishi IH, Gerrard J, Singh A, Lee K, Yoo JY, Ghatan S, Panov F, Marcuse LV. A multicenter retrospective study of patients treated in the thalamus with responsive neurostimulation. Front Neurol 2023; 14:1202631. [PMID: 37745648 PMCID: PMC10516547 DOI: 10.3389/fneur.2023.1202631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Accepted: 06/19/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction For drug resistant epilepsy patients who are either not candidates for resective surgery or have already failed resective surgery, neuromodulation is a promising option. Neuromodulatory approaches include responsive neurostimulation (RNS), deep brain stimulation (DBS), and vagal nerve stimulation (VNS). Thalamocortical circuits are involved in both generalized and focal onset seizures. This paper explores the use of RNS in the centromedian nucleus of the thalamus (CMN) and in the anterior thalamic nucleus (ANT) of patients with drug resistant epilepsy. Methods This is a retrospective multicenter study from seven different epilepsy centers in the United States. Patients that had unilateral or bilateral thalamic RNS leads implanted in the CMN or ANT for at least 6 months were included. Primary objectives were to describe the implant location and determine changes in the frequency of disabling seizures at 6 months, 1 year, 2 years, and > 2 years. Secondary objectives included documenting seizure free periods, anti-seizure medication regimen changes, stimulation side effects, and serious adverse events. In addition, the global clinical impression scale was completed. Results Twelve patients had at least one lead placed in the CMN, and 13 had at least one lead placed in the ANT. The median baseline seizure frequency was 15 per month. Overall, the median seizure reduction was 33% at 6 months, 55% at 1 year, 65% at 2 years, and 74% at >2 years. Seizure free intervals of at least 3 months occurred in nine patients. Most patients (60%, 15/25) did not have a change in anti-seizure medications post RNS placement. Two serious adverse events were recorded, one related to RNS implantation. Lastly, overall functioning seemed to improve with 88% showing improvement on the global clinical impression scale. Discussion Meaningful seizure reduction was observed in patients who suffer from drug resistant epilepsy with unilateral or bilateral RNS in either the ANT or CMN of the thalamus. Most patients remained on their pre-operative anti-seizure medication regimen. The device was well tolerated with few side effects. There were rare serious adverse events. Most patients showed an improvement in global clinical impression scores.
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Affiliation(s)
- Madeline C Fields
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Onome Eka
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Patricia Dugan
- Department of Neurology, Langone Medical Center, New York University, New York, NY, United States
| | - Wael F Asaad
- Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Andrew S Blum
- Department of Neurology, Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - Katie Bullinger
- Department of Neurology, School of Medicine, Emory University, Atlanta, GA, United States
| | - Jon T Willie
- Department of Neurosurgery, School of Medicine, Washington University in St Louis, St. Louis, MO, United States
| | - David E Burdette
- Department of Neurosciences, Corewell Health, Grand Rapids, MI, United States
| | - Christopher Anderson
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Imran H Quraishi
- Department of Neurology, School of Medicine, Yale University, New Haven, CT, United States
| | - Jason Gerrard
- Department of Neurosurgery, School of Medicine, Yale University, New Haven, CT, United States
| | - Anuradha Singh
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Kyusang Lee
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Ji Yeoun Yoo
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Saadi Ghatan
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Fedor Panov
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Lara V Marcuse
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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11
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Zheng B, Abdulrazeq H, Shao B, Liu DD, Leary O, Lauro PM, Bartolini L, Blum AS, Asaad WF. Seizure and anatomical outcomes of repeat laser amygdalohippocampotomy for temporal lobe epilepsy: A single-institution case series. Epilepsy Behav 2023; 146:109365. [PMID: 37523797 DOI: 10.1016/j.yebeh.2023.109365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 07/12/2023] [Accepted: 07/20/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVE In patients with treatment-refractory temporal lobe epilepsy (TLE), a single stereotactic laser interstitial thermotherapy (LITT) procedure is sometimes insufficient to ablate epileptogenic tissue, particularly the medial structures often implicated in TLE. In patients with seizure recurrence after initial ablation, the extent to which a second ablation may achieve improved seizure outcomes is uncertain. The objective of this study was to investigate the feasibility and potential efficacy of repeat LITT amygdalohippocampotomy as a worthwhile strategy for intractable temporal lobe epilepsy by quantifying changes to targeted mesial temporal lobe structures and seizure outcomes. METHODS Patients who underwent two LITT procedures for drug-resistant mesial TLE at our institution were included in the study. Lesion volumes for both procedures were calculated by comparing post-ablation intraoperative sequences to preoperative anatomy. Clinical outcomes after the initial procedure and repeat procedure were classified according to Engel scores. RESULTS Five consecutive patients were included in this retrospective case series: 3 with right- and 2 with left-sided TLE. The median interval between LITT procedures was 294 days (range: 227-1918). After the first LITT, 3 patients experienced class III outcomes, 1 experienced a class IV, and 1 experienced a class IB outcome. All patients achieved increased seizure freedom after a second procedure, with class I outcomes (3 IA, 2 IB). CONCLUSIONS Repeat LITT may be sufficient to achieve satisfactory seizure outcomes in some individuals who might otherwise be considered for more aggressive resection or palliative neuromodulation. A larger study to establish the potential value of repeat LITT amygdalohippocampotomy vs. other re-operation strategies for persistent, intractable temporal lobe epilepsy is worth pursuing.
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Affiliation(s)
- Bryan Zheng
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Hael Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA.
| | - Belinda Shao
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - David D Liu
- Department of Neurosurgery, Brigham and Womens Hospital, Boston, MA, USA
| | - Owen Leary
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Peter M Lauro
- The Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Neuroscience, Brown University, Providence, RI, USA
| | - Luca Bartolini
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA; Deparment of Neurology, Rhode Island Hospital, Providence, RI, USA; Deparment of Pediatrics, Hasbro Children's Hospital, Providence, RI, USA
| | - Andrew S Blum
- Deparment of Neurology, Rhode Island Hospital, Providence, RI, USA
| | - Wael F Asaad
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA; Department of Neuroscience, Brown University, Providence, RI, USA; The Carney Institute for Brain Science, Brown University, Providence, RI, USA; The Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, USA
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12
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Alarie ME, Provenza NR, Herron JA, Asaad WF. Automated artifact injection into sensing-capable brain modulation devices for neural-behavioral synchronization and the influence of device state. Brain Stimul 2023; 16:1358-1360. [PMID: 37690601 DOI: 10.1016/j.brs.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/06/2023] [Indexed: 09/12/2023] Open
Affiliation(s)
- Michaela E Alarie
- Center for Biomedical Engineering, Brown University, Providence, RI, United States; Carney Institute for Brain Science, Brown University, Providence, RI, United States.
| | - Nicole R Provenza
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Jeffrey A Herron
- Department of Neurological Surgery, University of Washington, Seattle, WA, United States
| | - Wael F Asaad
- Carney Institute for Brain Science, Brown University, Providence, RI, United States; Departments of Neurosurgery & Neuroscience, Brown University, Providence, RI, United States; Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, United States
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13
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Tang OY, Ali R, Connolly ID, Fridley JS, Zadnik Sullivan PL, Cielo D, Oyelese AA, Doberstein CE, Telfeian AE, Gokaslan ZL, Shin JH, Asaad WF. Letter: The Urgency of Neurosurgical Leadership in the Era of Artificial Intelligence. Neurosurgery 2023; 93:e69-e70. [PMID: 37319400 DOI: 10.1227/neu.0000000000002576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 05/03/2023] [Indexed: 06/17/2023] Open
Affiliation(s)
- Oliver Y Tang
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
| | - Rohaid Ali
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
| | - Ian D Connolly
- Department of Neurosurgery, Massachusetts General Hospital, Boston , Massachusetts , USA
| | - Jared S Fridley
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
| | - Patricia L Zadnik Sullivan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
| | - Deus Cielo
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
| | - Adetokunbo A Oyelese
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
| | - Curtis E Doberstein
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
| | - Albert E Telfeian
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
| | - John H Shin
- Department of Neurosurgery, Massachusetts General Hospital, Boston , Massachusetts , USA
| | - Wael F Asaad
- Department of Neurosurgery, The Warren Alpert Medical School of Brown University, Providence , Rhode Island , USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence , Rhode Island , USA
- Department of Neuroscience, Brown University, Providence , Rhode Island , USA
- Carney Institute for Brain Science, Brown University, Providence , Rhode Island , USA
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14
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Lauro PM, Lee S, Amaya DE, Liu DD, Akbar U, Asaad WF. Concurrent decoding of distinct neurophysiological fingerprints of tremor and bradykinesia in Parkinson's disease. eLife 2023; 12:e84135. [PMID: 37249217 PMCID: PMC10264071 DOI: 10.7554/elife.84135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 05/26/2023] [Indexed: 05/31/2023] Open
Abstract
Parkinson's disease (PD) is characterized by distinct motor phenomena that are expressed asynchronously. Understanding the neurophysiological correlates of these motor states could facilitate monitoring of disease progression and allow improved assessments of therapeutic efficacy, as well as enable optimal closed-loop neuromodulation. We examined neural activity in the basal ganglia and cortex of 31 subjects with PD during a quantitative motor task to decode tremor and bradykinesia - two cardinal motor signs of PD - and relatively asymptomatic periods of behavior. Support vector regression analysis of microelectrode and electrocorticography recordings revealed that tremor and bradykinesia had nearly opposite neural signatures, while effective motor control displayed unique, differentiating features. The neurophysiological signatures of these motor states depended on the signal type and location. Cortical decoding generally outperformed subcortical decoding. Within the subthalamic nucleus (STN), tremor and bradykinesia were better decoded from distinct subregions. These results demonstrate how to leverage neurophysiology to more precisely treat PD.
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Affiliation(s)
- Peter M Lauro
- Department of Neuroscience, Brown UniversityProvidenceUnited States
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown UniversityProvidenceUnited States
- The Warren Alpert Medical School, Brown UniversityProvidenceUnited States
| | - Shane Lee
- Department of Neuroscience, Brown UniversityProvidenceUnited States
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown UniversityProvidenceUnited States
- Norman Prince Neurosciences Institute, Rhode Island HospitalProvidenceUnited States
- Department of Neurosurgery, Rhode Island HospitalProvidenceUnited States
| | - Daniel E Amaya
- Department of Neuroscience, Brown UniversityProvidenceUnited States
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown UniversityProvidenceUnited States
| | - David D Liu
- Department of Neurosurgery, Brigham and Women’s HospitalBostonUnited States
| | - Umer Akbar
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown UniversityProvidenceUnited States
- The Warren Alpert Medical School, Brown UniversityProvidenceUnited States
- Norman Prince Neurosciences Institute, Rhode Island HospitalProvidenceUnited States
- Department of Neurology, Rhode Island HospitalProvidenceUnited States
| | - Wael F Asaad
- Department of Neuroscience, Brown UniversityProvidenceUnited States
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown UniversityProvidenceUnited States
- The Warren Alpert Medical School, Brown UniversityProvidenceUnited States
- Norman Prince Neurosciences Institute, Rhode Island HospitalProvidenceUnited States
- Department of Neurosurgery, Rhode Island HospitalProvidenceUnited States
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15
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McLaughlin NCR, Magnotti JF, Banks GP, Nanda P, Hoexter MQ, Lopes AC, Batistuzzo MC, Asaad WF, Stewart C, Paulo D, Noren G, Greenberg BD, Malloy P, Salloway S, Correia S, Pathak Y, Sheehan J, Marsland R, Gorgulho A, De Salles A, Miguel EC, Rasmussen SA, Sheth SA. Gamma knife capsulotomy for intractable OCD: Neuroimage analysis of lesion size, location, and clinical response. Transl Psychiatry 2023; 13:134. [PMID: 37185805 PMCID: PMC10130137 DOI: 10.1038/s41398-023-02425-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 02/27/2023] [Accepted: 03/31/2023] [Indexed: 05/17/2023] Open
Abstract
Obsessive-compulsive disorder (OCD) affects 2-3% of the population. One-third of patients are poorly responsive to conventional therapies, and for a subgroup, gamma knife capsulotomy (GKC) is an option. We examined lesion characteristics in patients previously treated with GKC through well-established programs in Providence, RI (Butler Hospital/Rhode Island Hospital/Alpert Medical School of Brown University) and São Paulo, Brazil (University of São Paolo). Lesions were traced on T1 images from 26 patients who had received GKC targeting the ventral half of the anterior limb of the internal capsule (ALIC), and the masks were transformed into MNI space. Voxel-wise lesion-symptom mapping was performed to assess the influence of lesion location on Y-BOCS ratings. General linear models were built to compare the relationship between lesion size/location along different axes of the ALIC and above or below-average change in Y-BOCS ratings. Sixty-nine percent of this sample were full responders (≥35% improvement in OCD). Lesion occurrence anywhere within the targeted region was associated with clinical improvement, but modeling results demonstrated that lesions occurring posteriorly (closer to the anterior commissure) and dorsally (closer to the mid-ALIC) were associated with the greatest Y-BOCS reduction. No association was found between Y-BOCS reduction and overall lesion volume. GKC remains an effective treatment for refractory OCD. Our data suggest that continuing to target the bottom half of the ALIC in the coronal plane is likely to provide the dorsal-ventral height required to achieve optimal outcomes, as it will cover the white matter pathways relevant to change. Further analysis of individual variability will be essential for improving targeting and clinical outcomes, and potentially further reducing the lesion size necessary for beneficial outcomes.
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Affiliation(s)
- N C R McLaughlin
- Butler Hospital, Providence, RI, USA.
- Alpert Medical School of Brown University, Providence, RI, USA.
| | - J F Magnotti
- Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - G P Banks
- Columbia University Medical Center, New York, NY, USA
| | - P Nanda
- Columbia University Medical Center, New York, NY, USA
| | - M Q Hoexter
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - A C Lopes
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - M C Batistuzzo
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
- Department of Methods and Techniques in Psychology, Pontifical Catholic University, São Paulo, SP, Brazil
| | - W F Asaad
- Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | - C Stewart
- Boston University School of Public Health, Boston, MA, USA
| | - D Paulo
- Columbia University Medical Center, New York, NY, USA
| | - G Noren
- Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | - B D Greenberg
- Butler Hospital, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
- Providence Veterans Affairs Medical Center, Providence, RI, USA
| | - P Malloy
- Butler Hospital, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
| | - S Salloway
- Butler Hospital, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
| | - S Correia
- Alpert Medical School of Brown University, Providence, RI, USA
| | - Y Pathak
- Columbia University Medical Center, New York, NY, USA
| | - J Sheehan
- University of Virginia, Charlottesville, VA, USA
| | | | - A Gorgulho
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - A De Salles
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - E C Miguel
- Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP, Brazil
| | - S A Rasmussen
- Butler Hospital, Providence, RI, USA
- Alpert Medical School of Brown University, Providence, RI, USA
- Rhode Island Hospital, Providence, RI, USA
| | - S A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, USA
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16
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Kimata AR, Zheng B, Watanabe T, Asaad WF. The temporal cost of deploying attention limits accurate target identification in rapid serial visual presentation. Sci Rep 2023; 13:3590. [PMID: 36869218 PMCID: PMC9984373 DOI: 10.1038/s41598-023-30748-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/28/2023] [Indexed: 03/05/2023] Open
Abstract
Lag-1 sparing is a common exception to the attentional blink, where a target presented directly after T1 can be identified and reported accurately. Prior work has proposed potential mechanisms for lag 1 sparing, including the boost and bounce model and the attentional gating model. Here, we apply a rapid serial visual presentation task to investigate the temporal limitations of lag 1 sparing by testing three distinct hypotheses. We found that endogenous engagement of attention to T2 requires between 50 and 100 ms. Critically, faster presentation rates yielded lower T2 performance, whereas decreased image duration did not impair T2 detection and report. These observations were reinforced by subsequent experiments controlling for short-term learning and capacity-dependent visual processing effects. Thus, lag-1 sparing was limited by the intrinsic dynamics of attentional boost engagement rather than by earlier perceptual bottlenecks such as insufficient exposure to images in the stimulus stream or visual processing capacity limitations. Taken together, these findings support the boost and bounce theory over earlier models that focus only on attentional gating or visual short-term memory storage, informing our understanding of how the human visual system deploys attention under challenging temporal constraints.
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Affiliation(s)
- Anna R Kimata
- Department of Neuroscience, The Carney Institute, Brown University, Providence, RI, USA.
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.
- Department of Neurosurgery, Brown University Alpert Medical School and Rhode Island Hospital, 593 Eddy Street, Providence, RI, 02903, USA.
| | - Bryan Zheng
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Neurosurgery, Brown University Alpert Medical School and Rhode Island Hospital, 593 Eddy Street, Providence, RI, 02903, USA
| | - Takeo Watanabe
- Department of Neuroscience, The Carney Institute, Brown University, Providence, RI, USA
- Department of Cognitive, Linguistic, and Psychological Sciences, Brown University, Providence, RI, USA
| | - Wael F Asaad
- Department of Neuroscience, The Carney Institute, Brown University, Providence, RI, USA
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
- Department of Neurosurgery, Brown University Alpert Medical School and Rhode Island Hospital, 593 Eddy Street, Providence, RI, 02903, USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, USA
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17
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Zheng B, Liu DD, Theyel BB, Abdulrazeq H, Kimata AR, Lauro PM, Asaad WF. Thalamic neuromodulation in epilepsy: A primer for emerging circuit-based therapies. Expert Rev Neurother 2023; 23:123-140. [PMID: 36731858 DOI: 10.1080/14737175.2023.2176752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Epilepsy is a common, often debilitating disease of hyperexcitable neural networks. While medically intractable cases may benefit from surgery, there may be no single, well-localized focus for resection or ablation. In such cases, approaching the disease from a network-based perspective may be beneficial. AREAS COVERED Herein, the authors provide a narrative review of normal thalamic anatomy and physiology and propose general strategies for preventing and/or aborting seizures by modulating this structure. Additionally, they make specific recommendations for targeting the thalamus within different contexts, motivated by a more detailed discussion of its distinct nuclei and their respective connectivity. By describing important principles governing thalamic function and its involvement in seizure networks, the authors aim to provide a primer for those now entering this fast-growing field of thalamic neuromodulation for epilepsy. EXPERT OPINION The thalamus is critically involved with the function of many cortical and subcortical areas, suggesting it may serve as a compelling node for preventing or aborting seizures, and so it has increasingly been targeted for the surgical treatment of epilepsy. As various thalamic neuromodulation strategies for seizure control are developed, there is a need to ground such interventions in a mechanistic, circuit-based framework.
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Affiliation(s)
- Bryan Zheng
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - David D Liu
- The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Brian B Theyel
- Department of Psychiatry, Rhode Island Hospital, Providence, RI, USA.,Department of Neuroscience, Brown University, Providence, RI, USA
| | - Hael Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Anna R Kimata
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA
| | - Peter M Lauro
- The Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Neuroscience, Brown University, Providence, RI, USA
| | - Wael F Asaad
- Department of Neurosurgery, Rhode Island Hospital, Providence, RI, USA.,Department of Neuroscience, Brown University, Providence, RI, USA.,The Carney Institute for Brain Science, Brown University, Providence, RI, USA.,The Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, USA
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18
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Tang OY, Shao B, Kimata AR, Sastry RA, Wu J, Asaad WF. The Impact of Frailty on Traumatic Brain Injury Outcomes: An Analysis of 691 821 Nationwide Cases. Neurosurgery 2022; 91:808-820. [PMID: 36069524 DOI: 10.1227/neu.0000000000002116] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 06/12/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Frailty, a decline in physiological reserve, prognosticates poorer outcomes for several neurosurgical conditions. However, the impact of frailty on traumatic brain injury outcomes is not well characterized. OBJECTIVE To analyze the association between frailty and traumatic intracranial hemorrhage (tICH) outcomes in a nationwide cohort. METHODS We identified all adult admissions for tICH in the National Trauma Data Bank from 2007 to 2017. Frailty was quantified using the validated modified 5-item Frailty Index (mFI-5) metric (range = 0-5), with mFI-5 ≥2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition, complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression assessed the association between mFI-5 and outcomes, adjusting for patient demographics, hospital characteristics, injury severity, and neurosurgical intervention. RESULTS A total of 691 821 tICH admissions were analyzed. The average age was 57.6 years. 18.0% of patients were frail (mFI-5 ≥ 2). Between 2007 and 2017, the prevalence of frailty grew from 7.9% to 21.7%. Frailty was associated with increased odds of mortality (odds ratio [OR] = 1.36, P < .001) and decreased odds of favorable discharge disposition (OR = 0.72, P < .001). Frail patients exhibited an elevated rate of complications (OR = 1.06, P < .001), including unplanned return to the ICU (OR = 1.55, P < .001) and operating room (OR = 1.17, P = .003). Finally, frail patients experienced increased ventilator days (+12%, P < .001), ICU LOS (+11%, P < .001), and total LOS (+13%, P < .001). All associations with death and disposition remained significant after stratification for age, trauma severity, and neurosurgical intervention. CONCLUSION For patients with tICH, frailty predicted higher mortality and morbidity, independent of age or injury severity.
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Affiliation(s)
- Oliver Y Tang
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Belinda Shao
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Anna R Kimata
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Neuroscience, Brown University, Providence, Rhode Island, USA
| | - Rahul A Sastry
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Joshua Wu
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Wael F Asaad
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA.,Department of Neuroscience, Brown University, Providence, Rhode Island, USA.,Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island, USA.,Carney Institute for Brain Science, Brown University, Providence, Rhode Island, USA
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19
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Shao B, Zheng B, Liu DD, Anderson MN, Svokos K, Bartolini L, Asaad WF. Seizure freedom after laser amygdalohippocampotomy guided by bilateral responsive neurostimulation in pediatric epilepsy: illustrative case. Journal of Neurosurgery: Case Lessons 2022; 4:CASE22235. [PMID: 36051773 PMCID: PMC9426349 DOI: 10.3171/case22235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/05/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND
For patients with difficult-to-lateralize temporal lobe epilepsy, the use of chronic recordings as a diagnostic tool to inform subsequent surgical therapy is an emerging paradigm that has been reported in adults but not in children.
OBSERVATIONS
The authors reported the case of a 15-year-old girl with pharmacoresistant temporal lobe epilepsy who was found to have bitemporal epilepsy during a stereoelectroencephalography (sEEG) admission. She underwent placement of a responsive neurostimulator system with bilateral hippocampal depth electrodes. However, over many months, her responsive neurostimulation (RNS) recordings revealed that her typical, chronic seizures were right-sided only. This finding led to a subsequent right-sided laser amygdalohippocampotomy, resulting in seizure freedom.
LESSONS
In this case, RNS chronic recording provided real-world data that enabled more precise seizure localization than inpatient sEEG data, informing surgical decision-making that led to seizure freedom. The use of RNS chronic recordings as a diagnostic adjunct to seizure localization procedures and laser ablation therapies in children is an area with potential for future study.
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Affiliation(s)
| | | | | | | | - Konstantina Svokos
- Departments of Neurosurgery,
- Norman Prince Neurosciences Institute, Rhode Island Hospital & Hasbro Children’s Hospital, Providence, Rhode Island
| | - Luca Bartolini
- Departments of Neurosurgery,
- Neurology, Brown University Alpert Medical School, Providence, Rhode Island
| | - Wael F. Asaad
- Departments of Neurosurgery,
- Department of Neuroscience, Brown University, Providence, Rhode Island
- Norman Prince Neurosciences Institute, Rhode Island Hospital & Hasbro Children’s Hospital, Providence, Rhode Island
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20
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Zheng B, Hsieh B, Rex N, Lauro PM, Collins SA, Blum AS, Roth JL, Ayub N, Asaad WF. A hierarchical anatomical framework and workflow for organizing stereotactic encephalography in epilepsy. Hum Brain Mapp 2022; 43:4852-4863. [PMID: 35851977 PMCID: PMC9582372 DOI: 10.1002/hbm.26017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 06/20/2022] [Accepted: 06/24/2022] [Indexed: 11/17/2022] Open
Abstract
Stereotactic electroencephalography (SEEG) is an increasingly utilized method for invasive monitoring in patients with medically intractable epilepsy. Yet, the lack of standardization for labeling electrodes hinders communication among clinicians. A rational clustering of contacts based on anatomy rather than arbitrary physical leads may help clinical neurophysiologists interpret seizure networks. We identified SEEG electrodes on post‐implant CTs and registered them to preoperative MRIs segmented according to an anatomical atlas. Individual contacts were automatically assigned to anatomical areas independent of lead. These contacts were then organized using a hierarchical anatomical schema for display and interpretation. Bipolar‐referenced signal cross‐correlations were used to compare the similarity of grouped signals within a conventional montage versus this anatomical montage. As a result, we developed a hierarchical organization for SEEG contacts using well‐accepted, free software that is based solely on their post‐implant anatomical location. When applied to three example SEEG cases for epilepsy, clusters of contacts that were anatomically related collapsed into standardized groups. Qualitatively, seizure events organized using this framework were better visually clustered compared to conventional schemes. Quantitatively, signals grouped by anatomical region were more similar to each other than electrode‐based groups as measured by Pearson correlation. Further, we uploaded visualizations of SEEG reconstructions into the electronic medical record, rendering them durably useful given the interpretable electrode labels. In conclusion, we demonstrate a standardized, anatomically grounded approach to the organization of SEEG neuroimaging and electrophysiology data that may enable improved communication among and across surgical epilepsy teams and promote a clearer view of individual seizure networks.
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Affiliation(s)
- Bryan Zheng
- Department of Neurosurgery Warren Alpert Medical School, Brown University Providence Rhode Island USA
| | - Ben Hsieh
- Department of Diagnostic Imaging Warren Alpert Medical School, Brown University Providence Rhode Island USA
| | - Nathaniel Rex
- Department of Diagnostic Imaging Warren Alpert Medical School, Brown University Providence Rhode Island USA
| | - Peter M. Lauro
- Department of Neurosurgery Warren Alpert Medical School, Brown University Providence Rhode Island USA
| | - Scott A. Collins
- Department of Diagnostic Imaging Warren Alpert Medical School, Brown University Providence Rhode Island USA
| | - Andrew S. Blum
- Department of Neurology Warren Alpert Medical School, Brown University Providence Rhode Island USA
| | - Julie L. Roth
- Department of Neurology Warren Alpert Medical School, Brown University Providence Rhode Island USA
| | - Neishay Ayub
- Department of Neurology Warren Alpert Medical School, Brown University Providence Rhode Island USA
| | - Wael F. Asaad
- Department of Neurosurgery Warren Alpert Medical School, Brown University Providence Rhode Island USA
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21
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Phillips RK, Aghagoli G, Blum AS, Asaad WF. Bilateral thalamic responsive neurostimulation for multifocal, bilateral frontotemporal epilepsy: illustrative case. Journal of Neurosurgery: Case Lessons 2022; 3:CASE21672. [PMID: 36273865 PMCID: PMC9379679 DOI: 10.3171/case21672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 01/24/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND
Patients with refractory, bilateral, multifocal epilepsy have few treatment options that typically include a combination of antiseizure medications (ASMs) and vagus nerve stimulation (VNS). A man in his 40s presented with epilepsy refractory to a combination of five ASMs plus VNS; he was still experiencing 7–10 seizures per week. His seizure network involved multiple foci in both frontal and temporal lobes. Bilateral depth electrodes were implanted into the centromedian/parafascicular (CM/PF) complex of the thalamus and connected to the responsive neurostimulation (RNS) system for closed-loop stimulation and neurophysiological monitoring.
OBSERVATIONS
The patient reported clear improvement in his seizures since the procedure, with a markedly reduced number of seizures and decreased seizure intensity. He also reported stretches of seizure freedom not typical of his preoperative baseline, and his remaining seizures were milder, more often with preserved awareness. Generalized seizures with loss of consciousness have decreased to about one per month. RNS data confirmed a right-sided predominance of the bilateral seizure onsets.
LESSONS
In this patient with multifocal, bilateral frontotemporal epilepsy, RNS of the CM/PF thalamic complex combined with VNS was found to be beneficial. The RNS device was able to detect seizures propagating through the thalamus, and stimulation produced a decrease in seizure burden and intensity.
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Affiliation(s)
| | | | - Andrew S. Blum
- Neurology, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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22
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Barrios-Anderson A, McLaughlin NCR, Patrick MT, Marsland R, Noren G, Asaad WF, Greenberg BD, Rasmussen S. The Patient Lived-Experience of Ventral Capsulotomy for Obsessive-Compulsive Disorder: An Interpretive Phenomenological Analysis of Neuroablative Psychiatric Neurosurgery. Front Integr Neurosci 2022; 16:802617. [PMID: 35273481 PMCID: PMC8902594 DOI: 10.3389/fnint.2022.802617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 01/13/2022] [Indexed: 11/13/2022] Open
Abstract
Ventral Capsulotomy (VC) is a surgical intervention for treatment-resistant Obsessive-Compulsive Disorder (OCD). Despite clinical studies, little is known about patient perception and lived experience after neurosurgery for severe OCD. To examine the lived experiences of patients who have undergone VC for severe, treatment-resistant OCD through qualitative analysis. We conducted semi-structured interviews with six participants treated with VC for OCD. Interviews were analyzed using Interpretive Phenomenological Analysis. The following themes emerged: (1) After years of conventional treatments, patients felt neurosurgery was their “last hope” and described themselves as “desperate,” (2) While some described the surgery as a “supernatural experience,” patients also demonstrated understanding of the scientific procedure, its risks and potential benefits, (3) The surgical experience itself was positive or neutral, which was linked to trust in the clinical team, (4) Post-surgery, participants described months of heightened fear as they awaited lesion formation and functional improvement. (5) Patients consistently contextualized outcome in the context of their own life goals. Patients undergoing VC have positive views of this neurosurgical intervention, but psychiatric neurosurgical teams should anticipate patient discomfort with the time needed to achieve behavioral improvement following surgery and emphasize the importance of post-operative psychiatric care.
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Affiliation(s)
- Adriel Barrios-Anderson
- Warren Alpert Medical School of Brown University, Providence, RI, United States
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, United States
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
- *Correspondence: Adriel Barrios-Anderson,
| | - Nicole C. R. McLaughlin
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States
| | - Morgan T. Patrick
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
| | - Richard Marsland
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
| | - Georg Noren
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, United States
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
| | - Wael F. Asaad
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, United States
- Department of Neuroscience, Brown University, Providence, RI, United States
- Carney Institute for Brain Science, Brown University, Providence, RI, United States
| | - Benjamin D. Greenberg
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States
- Center for Neurorestoration and Neurotechnology (CfNN), Providence VA Medical Center, Providence, RI, United States
| | - Steven Rasmussen
- Psychiatric Neurosurgery Program, Butler Hospital, Providence, RI, United States
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, RI, United States
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23
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McLaughlin NCR, Lauro PM, Patrick MT, Pucci FG, Barrios-Anderson A, Greenberg BD, Rasmussen SA, Asaad WF. Magnetic Resonance Imaging-Guided Laser Thermal Ventral Capsulotomy for Intractable Obsessive-Compulsive Disorder. Neurosurgery 2021. [DOI: 10.1093/neuros/nyab050_s132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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24
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Targum SD, Fosdick L, Drake KE, Rosenberg PB, Burke AD, Wolk DA, Foote KD, Asaad WF, Sabbagh M, Smith GS, Lozano AM, Lyketsos CG. Effect of Age on Clinical Trial Outcome in Participants with Probable Alzheimer's Disease. J Alzheimers Dis 2021; 82:1243-1257. [PMID: 34151817 PMCID: PMC8461716 DOI: 10.3233/jad-210530] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Background: Age may affect treatment outcome in trials of mild probable Alzheimer’s disease (AD). Objective: We examined age as a moderator of outcome in an exploratory study of deep brain stimulation targeting the fornix (DBS-f) region in participants with AD. Methods: Forty-two participants were implanted with DBS electrodes and randomized to double-blind DBS-f stimulation (“on”) or sham DBS-f (“off”) for 12 months. Results: The intervention was safe and well tolerated. However, the selected clinical measures did not differentiate between the “on” and “off” groups in the intent to treat (ITT) population. There was a significant age by time interaction with the Alzheimer’s Disease Assessment Scale; ADAS-cog-13 (p = 0.028). Six of the 12 enrolled participants < 65 years old (50%) markedly declined on the ADAS-cog-13 versus only 6.7%of the 30 participants≥65 years old regardless of treatment assignment (p = 0.005). While not significant, post-hoc analyses favored DBS-f “off” versus “on” over 12 months in the < 65 age group but favored DBS-f “on” versus “off” in the≥65 age group on all clinical metrics. On the integrated Alzheimer’s Disease rating scale (iADRS), the effect size contrasting DBS-f “on” versus “off” changed from +0.2 (favoring “off”) in the < 65 group to –0.52 (favoring “on”) in the≥65 age group. Conclusion: The findings highlight issues with subject selection in clinical trials for AD. Faster disease progression in younger AD participants with different AD sub-types may influence the results. Biomarker confirmation and genotyping to differentiate AD subtypes is important for future clinical trials.
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Affiliation(s)
| | - Lisa Fosdick
- Functional Neuromodulation Ltd., Minneapolis MN, USA
| | | | - Paul B Rosenberg
- Memory and Alzheimer's Treatment Center & Alzheimer's Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Anna D Burke
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - David A Wolk
- Penn Memory Center, Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly D Foote
- Departments of and Neurosurgery and Neurology, University of Florida, Fixel Institute for Neurological Diseases, Gainesville, FL, USA
| | - Wael F Asaad
- Department of Neurosurgery, Rhode Island Hospital and the Alpert Medical School of Brown University, Providence, RI, USA
| | - Marwan Sabbagh
- Cleveland Clinic Lou Ruvo Center for Brain Health, Cleveland, OH, USA
| | - Gwenn S Smith
- Memory and Alzheimer's Treatment Center & Alzheimer's Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Andres M Lozano
- Department of Surgery (Neurosurgery), University of Toronto, Toronto, ON, Canada
| | - Constantine G Lyketsos
- Memory and Alzheimer's Treatment Center & Alzheimer's Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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25
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Liu DD, Lauro PM, Phillips RK, Leary OP, Zheng B, Roth JL, Blum AS, Segar DJ, Asaad WF. Two-trajectory laser amygdalohippocampotomy: Anatomic modeling and initial seizure outcomes. Epilepsia 2021; 62:2344-2356. [PMID: 34338302 DOI: 10.1111/epi.17019] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Laser interstitial thermal therapy (LITT) for mesial temporal lobe epilepsy (mTLE) is typically performed with one trajectory to target the medial temporal lobe (MTL). MTL structures such as piriform and entorhinal cortex are epileptogenic, but due to their relative geometry, they are difficult to target with one trajectory while simultaneously maintaining adequate ablation of the amygdala and hippocampus. We hypothesized that a two-trajectory approach could improve ablation of all relevant MTL structures. First, we created large-scale computer simulations to compare idealized one- vs two-trajectory approaches. A two-trajectory approach was then validated in an initial cohort of patients. METHODS We used magnetic resonance imaging (MRI) from the Human Connectome Project (HCP) to create subject-specific target structures consisting of hippocampus, amygdala, and piriform/entorhinal/perirhinal cortex. An algorithm searched for safe potential trajectories along the hippocampal axis (catheter one) and along the amygdala-piriform axis (catheter two) and compared this to a single trajectory optimized over all structures. The proportion of each structure ablated at various burn radii was evaluated. A cohort of 11 consecutive patients with mTLE received two-trajectory LITT; demographic, operative, and outcome data were collected. RESULTS The two-trajectory approach was superior to the one-trajectory approach at nearly all burn radii for all hippocampal subfields and amygdala nuclei (p < .05). Two-laser trajectories achieved full ablation of MTL cortical structures at physiologically realistic burn radii, whereas one-laser trajectories could not. Five patients with at least 1 year of follow-up (mean = 21.8 months) experienced Engel class I outcomes; 6 patients with less than 1 year of follow-up (mean = 6.6 months) are on track for Engel class I outcomes. SIGNIFICANCE Our anatomic analyses and initial clinical results suggest that LITT amygdalohippocampotomy performed via two-laser trajectories may promote excellent seizure outcomes. Future studies are required to validate the long-term clinical efficacy and safety of this approach.
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Affiliation(s)
- David D Liu
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Peter M Lauro
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA.,Department of Neuroscience, Brown University, Providence, RI, USA
| | - Ronald K Phillips
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Owen P Leary
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Bryan Zheng
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Julie L Roth
- Department of Neurology, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - Andrew S Blum
- Department of Neurology, The Warren Alpert Medical School, Brown University, Providence, RI, USA
| | - David J Segar
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wael F Asaad
- Department of Neurosurgery, The Warren Alpert Medical School, Brown University, Providence, RI, USA.,Department of Neuroscience, Brown University, Providence, RI, USA.,Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, USA
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26
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McLaughlin NCR, Lauro PM, Patrick MT, Pucci FG, Barrios-Anderson A, Greenberg BD, Rasmussen SA, Asaad WF. Magnetic Resonance Imaging-Guided Laser Thermal Ventral Capsulotomy for Intractable Obsessive-Compulsive Disorder. Neurosurgery 2021; 88:1128-1135. [PMID: 33693795 PMCID: PMC8223246 DOI: 10.1093/neuros/nyab050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 12/20/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Obsessive-compulsive disorder (OCD) is a disabling condition characterized by intrusive thoughts and repetitive behaviors. A subset of individuals have severe, treatment-resistant illness and are nonresponsive to medication or behavioral therapies. Without response to conventional therapeutic options, surgical intervention becomes an appropriate consideration. OBJECTIVE To report clinical outcomes and the safety profile of bilateral ventral anterior capsulotomy for OCD using magnetic resonance (MR)-guided laser interstitial thermal therapy (LITT) in 10 patients followed for 6 to 24 mo. METHODS A total of 10 patients underwent LITT for severe OCD; 1 patient withdrew prior to follow-up. LITT is a minimally invasive ablative technique performed with precise targeting and use of thermography under MR guidance. Lesions of the ventral anterior limb of the internal capsule by other techniques have been shown to be efficacious in prior studies. RESULTS A total of 7 of the 9 patients were considered full responders (77.8%; Yale-Brown Obsessive-Compulsive Scale change ≥35%). Adverse effects included transient apathy/amotivation postsurgery (2 patients). One patient had a small tract hemorrhage where the laser fiber traversed the cerebral cortex as well as persistent insomnia postsurgery. One individual died after a drug overdose 7 mo postsurgery, which was judged unrelated to the surgery. CONCLUSION LITT ventral capsulotomy was generally well tolerated, with promising evidence of effectiveness in the largest such series to date. Results were comparable to those after gamma knife ventral capsulotomy, as well as ventral anterior limb deep brain stimulation.
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Affiliation(s)
- Nicole C R McLaughlin
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, Rhode Island, USA
- Butler Hospital, Providence, Rhode Island, USA
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Peter M Lauro
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, Rhode Island, USA
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Neuroscience, Brown University, Providence, Rhode Island, USA
| | | | - Francesco G Pucci
- Department of Neurosurgery, Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Adriel Barrios-Anderson
- Butler Hospital, Providence, Rhode Island, USA
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Benjamin D Greenberg
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, Rhode Island, USA
- Butler Hospital, Providence, Rhode Island, USA
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Veterans Affairs, Providence, Rhode Island, USA
| | - Steven A Rasmussen
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, Rhode Island, USA
- Butler Hospital, Providence, Rhode Island, USA
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Wael F Asaad
- Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, Rhode Island, USA
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Neuroscience, Brown University, Providence, Rhode Island, USA
- Department of Neurosurgery, Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island, USA
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27
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Shao B, Tang OY, Leary OP, Abdulrazeq H, Sastry RA, Brown S, Wilson IB, Asaad WF, Gokaslan ZL. Demand for Essential Nonambulatory Neurosurgical Care Decreased While Acuity of Care Increased During the Coronavirus Disease 2019 (COVID-19) Surge. World Neurosurg 2021; 151:e523-e532. [PMID: 33905912 PMCID: PMC8589108 DOI: 10.1016/j.wneu.2021.04.080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 04/16/2021] [Accepted: 04/17/2021] [Indexed: 02/07/2023]
Abstract
Background In times of health resource reallocation, capacities must remain able to meet a continued demand for essential, nonambulatory neurosurgical acute care. This study sought to characterize the demand for and provision of neurosurgical acute care during the coronavirus disease 2019 (COVID-19) pandemic. Methods This single-center cross-sectional observational analysis compared nonambulatory neurosurgical consult encounters during the peri-surge period (March 9 to May 31, 2020) with those during an analogous period in 2019. Outcomes included consult volume, distribution of problem types, disease severity, and rate of acute operative intervention. Results A total of 1494 neurosurgical consults were analyzed. Amidst the pandemic surge, 583 consults were seen, which was 6.4 standard deviations below the mean among analogous 2016–2019 periods (mean 873; standard deviation 45, P = 0.001). Between 2019 and 2020, the proportion of degenerative spine consults decreased in favor of spinal trauma (25.6% vs. 34% and 51.9% vs. 41.4%, P = 0.088). Among aneurysmal subarachnoid hemorrhage cases, poor-grade (Hunt and Hess grades 4–5) presentations were more common (30% vs. 14.8%, P = 0.086). A greater proportion of pandemic era consults resulted in acute operative management, with an unchanged absolute frequency of acutely operative consults (123/583 [21.1%] vs. 120/911 [13.2%], P < 0.001). Conclusions Neurosurgical consult volume during the pandemic surge hit a 5-year institutional low. Amidst vast reallocation of health care resources, demand for high-acuity nonambulatory neurosurgical care continued and proportionally increased for greater-acuity pathologies. In our continued current pandemic as well as any future situations of mass health resource reallocation, neurosurgical acute care capacities must be preserved.
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Affiliation(s)
- Belinda Shao
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA.
| | - Oliver Y Tang
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Owen P Leary
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Hael Abdulrazeq
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Rahul A Sastry
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Sarah Brown
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Ira B Wilson
- Department of Health Services, Policy, and Practice, Brown University School of Public Health, Providence, Rhode Island, USA
| | - Wael F Asaad
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
| | - Ziya L Gokaslan
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence, Rhode Island, USA
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Reznik ME, Kalagara R, Moody S, Drake J, Margolis SA, Cizginer S, Mahta A, Rao SS, Stretz C, Wendell LC, Thompson BB, Asaad WF, Furie KL, Jones RN, Daiello LA. Common biomarkers of physiologic stress and associations with delirium in patients with intracerebral hemorrhage. J Crit Care 2021; 64:62-67. [PMID: 33794468 DOI: 10.1016/j.jcrc.2021.03.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Revised: 03/04/2021] [Accepted: 03/17/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE To examine associations between physiologic stress and delirium in the setting of a direct neurologic injury. MATERIALS AND METHODS We obtained initial neutrophil-to-lymphocyte ratio (NLR), glucose, and troponin in consecutive non-comatose patients with non-traumatic intracerebral hemorrhage (ICH) over 1 year, then used multivariable regression models to determine associations between each biomarker and incident delirium. Delirium diagnoses were established using DSM-5-based methods, with exploratory analyses further categorizing delirium as first occurring <24 h ("early-onset") or > 24 h after presentation ("later-onset"). RESULTS Of 284 patients, delirium occurred in 55% (early-onset: 39% [n = 111]; later-onset: 16% [n = 46]). Patients with delirium had higher NLR (mean 9.0 ± 10.4 vs. 6.4 ± 5.5; p = 0.01), glucose (mean 146.5 ± 59.6 vs. 129.9 ± 41.4 mg/dL; p = 0.008), and a higher frequency of elevated troponin (>0.05 ng/mL; 21% vs. 10%, p = 0.02). In adjusted models, elevated NLR (highest quartile: OR 3.4 [95% CI 1.5-7.8]), glucose (>180 mg/dL: OR 3.1 [95% CI 1.1-8.2]), and troponin (OR 3.0 [95% CI 1.2-7.2]) were each associated with delirium, but only initial NLR was specifically associated with later-onset delirium and with delirium in non-mechanically ventilated patients. CONCLUSIONS Stress-related biomarkers corresponding to multiple organ systems are associated with ICH-related delirium. Early NLR elevation may also predict delayed-onset delirium, potentially implicating systemic inflammation as a contributory delirium mechanism.
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Affiliation(s)
- Michael E Reznik
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, USA.
| | - Roshini Kalagara
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA
| | - Scott Moody
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA
| | - Jonathan Drake
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA
| | - Seth A Margolis
- Department of Psychiatry, Brown University, Alpert Medical School, Providence, RI, USA
| | - Sevdenur Cizginer
- Department of Medicine, Brown University, Alpert Medical School, Providence, RI, USA
| | - Ali Mahta
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, USA
| | - Shyam S Rao
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, USA
| | - Christoph Stretz
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, USA
| | - Linda C Wendell
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, USA; Section of Medical Education, Brown University, Alpert Medical School, Providence, RI, USA
| | - Bradford B Thompson
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA; Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, USA
| | - Wael F Asaad
- Department of Neurosurgery, Brown University, Alpert Medical School, Providence, RI, USA
| | - Karen L Furie
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA
| | - Richard N Jones
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA; Department of Psychiatry, Brown University, Alpert Medical School, Providence, RI, USA
| | - Lori A Daiello
- Department of Neurology, Brown University, Alpert Medical School, Providence, RI, USA
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Walek KW, Leary OP, Sastry R, Asaad WF, Walsh JM, Mermel L. Decreasing External Ventricular Drain Infection Rates in the Neurocritical Care Unit: 12-Year Longitudinal Experience at a Single Institution. World Neurosurg 2021; 150:e89-e101. [PMID: 33647492 DOI: 10.1016/j.wneu.2021.02.087] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 02/17/2021] [Accepted: 02/18/2021] [Indexed: 11/19/2022]
Abstract
OBJECTIVE External ventricular drain (EVD) placement is a common neurosurgical procedure, and EVD-related infection is a significant complication. We examined the effect of infection control protocol changes on EVD-related infection incidence. METHODS Changes in EVD placement protocol and incidence density of infections after implementation of protocol changes in the neurocritical care unit were tracked from 2007 to 2019. EVD infections were defined using a modified U.S. Centers for Disease Control and Prevention National Healthcare Safety Network surveillance definition of meningitis/ventriculitis for patients with EVDs in situ for at least 2 days confirmed by positive culture. Contribution of protocol changes to EVD infection risk was assessed via multivariate regression. RESULTS Fifteen major changes in EVD protocol were associated with a reduction in infections from 6.7 to 2.0 per 1000 EVD days (95% confidence interval [CI], 4.1-5.3; P < 0.001). Gram-positive bacterial infection incidence decreased from 4.8 to 1.7 per 1000 EVD days (95% CI, 2.3-3.9; P = 0.00882) and gram-negative infection incidence decreased from 1.9 to 0.5 per 1000 EVD days (95% CI, 0.6-2.3; P = 0.0303). Of all protocol changes since 2007, the largest reduction in incidence was 3.9 infections per 1000 days (95% CI, 0.50-7.30; P = 0.011), associated with combined standardization of reduced EVD sampling frequency, cutaneous antisepsis with alcoholic chlorhexidine before EVD placement, and use of a subcutaneous tunneling technique during EVD insertion. CONCLUSIONS The most significant reduction in EVD infections may be achieved through the combination of reducing EVD sampling frequency and standardizing alcoholic chlorhexidine cutaneous antisepsis and subcutaneous tunneling of the EVD catheter.
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Affiliation(s)
- Konrad W Walek
- Department of Neurosurgery, Warren Alpert Medical School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Owen P Leary
- Department of Neurosurgery, Warren Alpert Medical School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Rahul Sastry
- Department of Neurosurgery, Warren Alpert Medical School of Medicine of Brown University, Providence, Rhode Island, USA
| | - Wael F Asaad
- Department of Neurosurgery, Warren Alpert Medical School of Medicine of Brown University, Providence, Rhode Island, USA; Department of Neuroscience, Brown University, Providence, Rhode Island, USA; Norman Prince Neuroscience Institute, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Joan M Walsh
- Division of Critical Care, Department of Nursing, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Leonard Mermel
- Department of Medicine, Warren Alpert Medical School of Medicine of Brown University, Providence, Rhode Island, USA; Department of Epidemiology and Infection Control, Rhode Island Hospital, Providence, Rhode Island, USA; Division of Infectious Diseases, Rhode Island Hospital, Providence, Rhode Island, USA.
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Wu E, Marthi S, Asaad WF. Predictors of Mortality in Traumatic Intracranial Hemorrhage: A National Trauma Data Bank Study. Front Neurol 2020; 11:587587. [PMID: 33281725 PMCID: PMC7705094 DOI: 10.3389/fneur.2020.587587] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Accepted: 10/26/2020] [Indexed: 11/13/2022] Open
Abstract
Background/Objective: Traumatic intracranial hemorrhage (tICH) accounts for significant trauma morbidity and mortality. Several studies have developed prognostic models for tICH outcomes, but previous models face limitations, including poor generalizability and limited accuracy. The objective was to develop a prognostic model and determine predictors of mortality using the largest trauma database in the U.S., applying rigorous analytical methodology with true hold-out-set model validation. Methods: We identified 248,536 patients in the National Trauma Data Bank (NTDB) from 2012 to 2016 with a diagnosis code associated with tICH. For each admission, we collected demographic information, systolic blood pressure, blood alcohol level (BAL), Glasgow Coma Score (GCS), Injury Severity Score (ISS), presence of epidural/subdural/subarachnoid/intraparenchymal hemorrhage, comorbidities, complications, trauma center level, and trauma center region. Our final study population was 212,666 patients following exclusion of records with missing data. The dependent variable was patient death. Linear support vector machine (SVM) classification was carried out with recursive feature selection. Model performance was assessed using holdout 10-fold cross-validation. Results: Cross-validation demonstrated a mean accuracy of 0.792 (95% CI 0.783–0.799). Accuracy, precision, recall, and AUC were 0.827, 0.309, 0.750, and 0.791, respectively. In the final model, high ISS, advanced age, subdural hemorrhage, and subarachnoid hemorrhage were associated with increased mortality, while high GCS verbal and motor subscores, current smoker, BAL beyond the legal limit, and level 1 trauma center were associated with decreased mortality. Conclusions: A linear SVM model was developed for tICH, with nine features selected as predictors of mortality. These findings are applicable to multiple hemorrhage subtypes and may benefit the triage of high risk patients upon admission. While many studies have attempted to create models to predict mortality in TBI, we sought to confirm those predictors using modern modeling approaches, machine learning, and true hold-out test sets, using the largest available TBI database in the U.S. We find that while the predictors we identify are consistent with prior reports, overall prediction accuracy is somewhat lower than prior reports when assessed more rigorously.
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Affiliation(s)
- Esther Wu
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Siddharth Marthi
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, United States
| | - Wael F Asaad
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, RI, United States.,Carney Institute for Brain Science, Brown University, Providence, RI, United States.,Department of Neuroscience, Brown University, Providence, RI, United States.,Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, United States.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
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31
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Reznik ME, Moody S, Murray K, Costa S, Grory BM, Madsen TE, Mahta A, Wendell LC, Thompson BB, Rao SS, Stretz C, Sheth KN, Hwang DY, Zahuranec DB, Schrag M, Daiello LA, Asaad WF, Jones RN, Furie KL. The impact of delirium on withdrawal of life-sustaining treatment after intracerebral hemorrhage. Neurology 2020; 95:e2727-e2735. [PMID: 32913011 PMCID: PMC7734724 DOI: 10.1212/wnl.0000000000010738] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 06/12/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To determine the impact of delirium on withdrawal of life-sustaining treatment (WLST) after intracerebral hemorrhage (ICH) in the context of established predictors of poor outcome, using data from an institutional ICH registry. METHODS We performed a single-center cohort study on consecutive patients with ICH admitted over 12 months. ICH features were prospectively adjudicated, and WLST and corresponding hospital day were recorded retrospectively. Patients were categorized using DSM-5 criteria as never delirious, ever delirious (either on admission or later during hospitalization), or persistently comatose. We determined the impact of delirium on WLST using Cox regression models adjusted for demographics and ICH predictors (including Glasgow Coma Scale score), then used logistic regression with receiver operating characteristic curve analysis to compare the accuracy of ICH score-based models with and without delirium category in predicting WLST. RESULTS Of 311 patients (mean age 70.6 ± 15.6, median ICH score 1 [interquartile range 1-2]), 50% had delirium. WLST occurred in 26%, and median time to WLST was 1 day (0-6). WLST was more frequent in patients who developed delirium (adjusted hazard ratio 8.9 [95% confidence interval (CI) 2.1-37.6]), with high rates of WLST in both early (occurring ≤24 hours from admission) and later delirium groups. An ICH score-based model was strongly predictive of WLST (area under the curve [AUC] 0.902 [95% CI 0.863-0.941]), and the addition of delirium category further improved the model's accuracy (AUC 0.936 [95% CI 0.909-0.962], p = 0.004). CONCLUSION Delirium is associated with WLST after ICH regardless of when it occurs. Further study on the impact of delirium on clinician and surrogate decision-making is warranted.
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Affiliation(s)
- Michael E Reznik
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN.
| | - Scott Moody
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Kayleigh Murray
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Samantha Costa
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Brian Mac Grory
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Tracy E Madsen
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Ali Mahta
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Linda C Wendell
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Bradford B Thompson
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Shyam S Rao
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Christoph Stretz
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Kevin N Sheth
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - David Y Hwang
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Darin B Zahuranec
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Matthew Schrag
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Lori A Daiello
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Wael F Asaad
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Richard N Jones
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
| | - Karen L Furie
- From the Department of Neurology (M.E.R., S.M., K.M., S.C., B.M.G., A.M., L.C.W., B.B.T., S.S.R., C.S., L.A.D., R.N.J., K.L.F.), Department of Neurosurgery (M.E.R., A.M., L.C.W., B.B.T., S.S.R., W.F.A.), Department of Emergency Medicine (T.E.M.), Section of Medical Education (L.C.W.), and Department of Psychiatry and Human Behavior (R.N.J.), Alpert Medical School, Brown University, Providence, RI; Department of Neurology (K.N.S., D.Y.H.), Yale School of Medicine, New Haven, CT; Department of Neurology and Stroke Program (D.B.Z.), Michigan Medicine, Ann Arbor; and Department of Neurology (M.S.), Vanderbilt University School of Medicine, Nashville, TN
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Sanderson JB, Yu JH, Liu DD, Amaya D, Lauro PM, D'Abreu A, Akbar U, Lee S, Asaad WF. Multi-Dimensional, Short-Timescale Quantification of Parkinson's Disease and Essential Tremor Motor Dysfunction. Front Neurol 2020; 11:886. [PMID: 33071924 PMCID: PMC7530842 DOI: 10.3389/fneur.2020.00886] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/10/2020] [Indexed: 12/18/2022] Open
Abstract
Introduction: Parkinson's disease (PD) is a progressive movement disorder characterized by heterogenous motor dysfunction with fluctuations in severity. Objective, short-timescale characterization of this dysfunction is necessary as therapies become increasingly adaptive. Objectives: This study aims to characterize a novel, naturalistic, and goal-directed tablet-based task and complementary analysis protocol designed to characterize the motor features of PD. Methods: A total of 26 patients with PD and without deep brain stimulation (DBS), 20 control subjects, and eight patients with PD and with DBS completed the task. Eight metrics, each designed to capture an aspect of motor dysfunction in PD, were calculated from 1-second, non-overlapping epochs of the raw positional and pressure data captured during task completion. These metrics were used to generate a classifier using a support vector machine (SVM) model to produce a unifying, scalar “motor error score” (MES). The data generated from these patients with PD were compared to same-day standard clinical assessments. Additionally, these data were compared to analogous data generated from a separate group of 12 patients with essential tremor (ET) to assess the task's specificity for different movement disorders. Finally, an SVM model was generated for each of the eight patients with PD and with DBS to differentiate between their motor dysfunction in the “DBS On” and “DBS Off” stimulation states. Results: The eight metrics calculated from the raw positional and force data captured during task completion were non-redundant. MES generated by the SVM analysis protocol showed a strong correlation with MDS-UPDRS-III scores assigned by movement disorder specialists. Analysis of the relative contributions of each of the eight metrics showed a significant difference between the motor dysfunction of PD and ET. Much of this difference was attributable to the homogenous, tremor-dominant phenotype of ET motor dysfunction. Finally, in individual patients with PD with DBS, task performance and subsequent SVM classification effectively differentiated between the “DBS On” and “DBS Off” stimulation states. Conclusion: This tablet-based task and analysis protocol correlated strongly with expert clinical assessments of PD motor dysfunction. Additionally, the task showed specificity for PD when compared to ET, another common movement disorder. This specificity was driven by the relative heterogeneity of motor dysfunction of PD compared to ET. Finally, the task was able to distinguish between the “DBS On” and “DBS Off” states within single patients with PD. This task provides temporally-precise and specific information about motor dysfunction in at least two movement disorders that could feasibly correlate to neural activity.
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Affiliation(s)
- John B Sanderson
- The Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - James H Yu
- The Warren Alpert Medical School, Brown University, Providence, RI, United States
| | - David D Liu
- The Warren Alpert Medical School, Brown University, Providence, RI, United States.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States
| | - Daniel Amaya
- Department of Neuroscience, Brown University, Providence, RI, United States.,Carney Institute for Brain Science, Brown University, Providence, RI, United States.,Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, United States
| | - Peter M Lauro
- The Warren Alpert Medical School, Brown University, Providence, RI, United States.,Department of Neuroscience, Brown University, Providence, RI, United States.,Carney Institute for Brain Science, Brown University, Providence, RI, United States.,Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, United States
| | - Anelyssa D'Abreu
- The Warren Alpert Medical School, Brown University, Providence, RI, United States.,Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, United States.,Department of Neurology, Rhode Island Hospital, Providence, RI, United States
| | - Umer Akbar
- The Warren Alpert Medical School, Brown University, Providence, RI, United States.,Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, United States.,Department of Neurology, Rhode Island Hospital, Providence, RI, United States
| | - Shane Lee
- Department of Neuroscience, Brown University, Providence, RI, United States.,Carney Institute for Brain Science, Brown University, Providence, RI, United States.,Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, United States
| | - Wael F Asaad
- The Warren Alpert Medical School, Brown University, Providence, RI, United States.,Department of Neurosurgery, Rhode Island Hospital, Providence, RI, United States.,Department of Neuroscience, Brown University, Providence, RI, United States.,Carney Institute for Brain Science, Brown University, Providence, RI, United States.,Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, RI, United States
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Ahn M, Lee S, Lauro PM, Schaeffer EL, Akbar U, Asaad WF. Rapid motor fluctuations reveal short-timescale neurophysiological biomarkers of Parkinson's disease. J Neural Eng 2020; 17:046042. [PMID: 32756018 PMCID: PMC8140652 DOI: 10.1088/1741-2552/abaca3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Objective. Identifying neural activity biomarkers of brain disease is essential to provide objective estimates of disease burden, obtain reliable feedback regarding therapeutic efficacy, and potentially to serve as a source of control for closed-loop neuromodulation. In Parkinson’s disease (PD), microelectrode recordings (MER) are routinely performed in the basal ganglia to guide electrode implantation for deep brain stimulation (DBS). While pathologically-excessive oscillatory activity has been observed and linked to PD motor dysfunction broadly, the extent to which these signals provide quantitative information about disease expression and fluctuations, particularly at short timescales, is unknown. Furthermore, the degree to which informative signal features are similar or different across patients has not been rigorously investigated. We sought to determine the extent to which motor error in PD across patients can be decoded on a rapid timescale using spectral features of neural activity. Approach. Here, we recorded neural activity from the subthalamic nucleus (STN) of subjects with PD undergoing awake DBS surgery while they performed an objective, continuous behavioral assessment that synthesized heterogenous PD motor manifestations to generate a scalar measure of motor dysfunction at short timescales. We then leveraged natural motor performance variations as a ‘ground truth’ to identify corresponding neurophysiological biomarkers. Main results. Support vector machines using multi-spectral decoding of neural signals from the STN succeeded in tracking the degree of motor impairment at short timescales (as short as one second). Spectral power across a wide range of frequencies, beyond the classic ‘β’ oscillations, contributed to this decoding, and multi-spectral models consistently outperformed those generated using more isolated frequency bands. While generalized decoding models derived across subjects were able to estimate motor impairment, patient-specific models typically performed better. Significance. These results demonstrate that quantitative information about short-timescale PD motor dysfunction is available in STN neural activity, distributed across various patient-specific spectral components, such that an individualized approach will be critical to fully harness this information for optimal disease tracking and closed-loop neuromodulation.
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Affiliation(s)
- Minkyu Ahn
- Department of Neuroscience, Brown University, Providence, RI 02912, United States of America. Robert J. and Nancy D. Carney Institute for Brain Science, Brown University, Providence, RI 02912, United States of America
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Powers AY, Pinto MB, Tang OY, Chen JS, Doberstein C, Asaad WF. Predicting mortality in traumatic intracranial hemorrhage. J Neurosurg 2020; 132:552-559. [PMID: 30797192 DOI: 10.3171/2018.11.jns182199] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Accepted: 11/08/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic intracranial hemorrhage (tICH) is a significant source of morbidity and mortality in trauma patients. While prognostic models for tICH outcomes may assist in alerting clinicians to high-risk patients, previously developed models face limitations, including low accuracy, poor generalizability, and the use of more prognostic variables than is practical. This study aimed to construct a simpler and more accurate method of risk stratification for all tICH patients. METHODS The authors retrospectively identified a consecutive series of 4110 patients admitted to their institution's level 1 trauma center between 2003 and 2013. For each admission, they collected the patient's sex, age, systolic blood pressure, blood alcohol concentration, antiplatelet/anticoagulant use, Glasgow Coma Scale (GCS) score, Injury Severity Score, presence of epidural hemorrhage, presence of subdural hemorrhage, presence of subarachnoid hemorrhage, and presence of intraparenchymal hemorrhage. The final study population comprised 3564 patients following exclusion of records with missing data. The dependent variable under study was patient death. A k-fold cross-validation was carried out with the best models selected via the Akaike Information Criterion. These models risk stratified the study partitions into grade I (< 1% predicted mortality), grade II (1%-10% predicted mortality), grade III (10%-40% predicted mortality), or grade IV (> 40% predicted mortality) tICH. Predicted mortalities were compared with actual mortalities within grades to assess calibration. Concordance was also evaluated. A final model was constructed using the entire data set. Subgroup analysis was conducted for each hemorrhage type. RESULTS Cross-validation demonstrated good calibration (p < 0.001 for all grades) with a mean concordance of 0.881 (95% CI 0.865-0.898). In the authors' final model, older age, lower blood alcohol concentration, antiplatelet/anticoagulant use, lower GCS score, and higher Injury Severity Score were all associated with greater mortality. Subgroup analysis showed successful stratification for subarachnoid, intraparenchymal, grade II-IV subdural, and grade I epidural hemorrhages. CONCLUSIONS The authors developed a risk stratification model for tICH of any GCS score with concordance comparable to prior models and excellent calibration. These findings are applicable to multiple hemorrhage subtypes and can assist in identifying low-risk patients for more efficient resource allocation, facilitate family conversations regarding goals of care, and stratify patients for research purposes. Future work will include testing of more variables, validation of this model across institutions, as well as creation of a simplified model whose outputs can be calculated mentally.
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Affiliation(s)
- Andrew Y Powers
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University
| | - Mauricio B Pinto
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University
| | - Oliver Y Tang
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University
| | - Jia-Shu Chen
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University
| | - Cody Doberstein
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University
| | - Wael F Asaad
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University.,2Carney Institute for Brain Science, Brown University.,3Department of Neuroscience, Brown University; and.,4Norman Prince Neurosciences Institute and.,5Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island
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Reznik ME, Kalagara R, Moody S, Drake J, Margolis S, Mahta A, Rao S, Stretz C, Wendell LC, Thompson BB, Asaad WF, Furie KL, Daiello LA, Jones RN. Abstract TMP92: Serum Markers of Physiologic Stress and Associations With Delirium in Patients With Intracerebral Hemorrhage. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tmp92] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Delirium occurs frequently in patients with intracerebral hemorrhage (ICH), though its pathogenesis may be multifactorial. Given the potential role of systemic stressors in delirium, we aimed to explore differences in commonly measured markers of physiologic stress between delirious and non-delirious ICH patients.
Methods:
We performed a single-center cohort study using data from consecutive non-comatose ICH patients over 12 months. ICH and patient characteristics were prospectively collected, and the presence of delirium at any point during hospitalization was diagnosed based on DSM-5 criteria. We retrospectively abstracted admission laboratory values and selected three common markers of physiologic stress for comparison: neutrophil-lymphocyte ratio (NLR), troponin, and glucose. Using multivariable models adjusted for demographics, relevant comorbidities, and ICH severity, we determined associations between delirium and the following: NLR, using linear regression; elevated troponin (>0.05 ng/mL), using binary logistic regression; and elevated glucose (categorized as 130-180 or >180 mg/dL), using ordered logistic regression.
Results:
Of 284 ICH patients in our cohort, 55% (n=157) had delirium. Patients with delirium were not significantly older than non-delirious patients (mean age 71.7±16.2 vs. 68.3±15.1, p=0.07), but had larger ICH volumes (mean 23.3±24.6 vs. 7.0±10.6 cc, p<0.001) and were more likely to have intraventricular hemorrhage (55% vs. 22%, p<0.001). Delirious patients also had higher admission NLR (mean 9.0±10.4 vs. 6.4±5.5, p=0.01) and glucose (mean 146.5±59.6 vs. 129.9±41.4 mg/dL, p=0.008), and were more likely to have elevated troponin (21% vs. 10%, p=0.02). In adjusted models, patients with delirium had higher admission NLR than patients who were never delirious (adjusted mean difference 2.6, 95% CI 0.3-4.9), and were more likely to have elevated admission troponin (OR 2.8, 95% CI 1.2-6.4) and glucose (OR 2.0, 95% CI 1.1-3.6).
Conclusions:
Delirium after ICH is independently associated with elevated serum markers of physiologic stress, suggesting that systemic factors may be implicated in delirium pathogenesis.
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Affiliation(s)
| | | | | | | | | | - Ali Mahta
- Brown Univ, Alpert Med Sch, Providence, RI
| | - Shyam Rao
- Brown Univ, Alpert Med Sch, Providence, RI
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Asaad WF, Lauro PM, Lee S. The Design of Clinical Studies for Neuromodulation. Stereotact Funct Neurosurg 2020. [DOI: 10.1007/978-3-030-34906-6_37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Carnevale JA, Segar DJ, Powers AY, Shah M, Doberstein C, Drapcho B, Morrison JF, Williams JR, Collins S, Monteiro K, Asaad WF. Blossoming contusions: identifying factors contributing to the expansion of traumatic intracerebral hemorrhage. J Neurosurg 2019; 129:1305-1316. [PMID: 29303442 DOI: 10.3171/2017.7.jns17988] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2017] [Accepted: 07/06/2017] [Indexed: 11/06/2022]
Abstract
Here, the authors examined the factors involved in the volumetric progression of traumatic brain contusions. The variables significant in this progression are identified, and the expansion rate of a brain bleed can now effectively be predicted given the presenting characteristics of the patient.
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Affiliation(s)
- Joseph A Carnevale
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - David J Segar
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,2Department of Neurosurgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Andrew Y Powers
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Meghal Shah
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Benjamin Drapcho
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - John F Morrison
- 3Department of Neurosurgery, University at Buffalo, New York
| | - John R Williams
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,5Department of Neurological Surgery, University of Washington, Seattle, Washington; and
| | | | - Kristina Monteiro
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Wael F Asaad
- 1Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island.,7Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island
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Reznik ME, Drake J, Margolis SA, Moody S, Murray K, Costa S, Mac Grory BC, Yaghi S, Mahta A, Wendell LC, Thompson BB, Rao SS, Daiello LA, Asaad WF, Jones RN, Furie KL. Abstract WP413: Deconstructing Post-Stroke Delirium in a Prospective Cohort of Patients With Intracerebral Hemorrhage. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp413] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | | | | | - Scott Moody
- Alpert Med Sch at Brown Univ, Providence, RI
| | | | | | | | - Shadi Yaghi
- Alpert Med Sch at Brown Univ, Providence, RI
| | - Ali Mahta
- Alpert Med Sch at Brown Univ, Providence, RI
| | | | | | - Shyam S Rao
- Alpert Med Sch at Brown Univ, Providence, RI
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Reznik ME, Mac Grory BC, Moody S, Murray K, Costa S, Yaghi S, Burton TM, Cutting S, Mahta A, Wendell LC, Thompson BB, Rao SS, Asaad WF, Jones RN, Furie KL. Abstract WP443: The Impact of Delirium and Impaired Consciousness on Withdrawal of Life-Sustaining Treatment After Spontaneous Intracerebral Hemorrhage. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wp443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Established predictors for outcome after intracerebral hemorrhage (ICH) may be subject to self-fulfilling prophecy, as studies examining their effects on mortality have generally not considered changes in code status leading to withdrawal of life-sustaining treatment (WLST). We aimed to identify factors specifically associated with WLST, and hypothesized that impaired consciousness and delirium would be especially implicated.
Methods:
We analyzed data from consecutive patients admitted with ICH from February-June 2018. ICH score and other clinical predictors were prospectively adjudicated, and most patients had delirium assessments performed by an expert clinician; for those who did not, we established the presence of probable delirium via chart review. Using logistic regression models that adjusted for ICH severity, we determined the association of impaired consciousness on admission (Glasgow Coma Scale [GCS] <13) with early WLST (defined as <24 hours from admission), and the presence of delirium on subsequent assessments with WLST after 24 hours.
Results:
Of 106 patients in our cohort (mean age 68.7 [SD 17.8], median ICH score 1.5 [IQR 1-2]), WLST occurred in 29% (22/40 with admission GCS <13, 9/66 with GCS 13-15). After adjusting for ICH severity, admission GCS <13 was more strongly associated with early WLST (OR 26.8, 95% CI 2.8-255.8) than other components of the ICH score (OR 9.9, 95% CI 1.5-67.0 for age >80; OR 8.4, 95% CI 1.7-40.7 for size >30cc; intraventricular hemorrhage and infratentorial location were not significant). Of 92 patients who survived >24 hours without early WLST, 52% had delirium. We found that delirious patients were significantly more likely than patients without delirium to have subsequent WLST (33% vs. 2%, p<0.001; OR 18.8, 95% CI 2.1-165.5 after adjusting for ICH severity). Finally, we found that a composite predictor—initial GCS <13 or subsequent delirium—was strongly associated with WLST at any time during hospitalization (OR 19.0, 95% CI 2.3-158.0 after adjusting for ICH severity).
Conclusion:
Impaired consciousness and delirium likely play a significant role in WLST after ICH. However, whether this phenomenon is due to effects on clinician or surrogate decision-making remains unclear.
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Affiliation(s)
| | | | - Scott Moody
- Alpert Med Sch at Brown Univ, Providence, RI
| | | | | | - Shadi Yaghi
- Alpert Med Sch at Brown Univ, Providence, RI
| | | | | | - Ali Mahta
- Alpert Med Sch at Brown Univ, Providence, RI
| | | | | | - Shyam S Rao
- Alpert Med Sch at Brown Univ, Providence, RI
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Powers AY, Pinto MB, Tang OY, Chen JS, Candidate S, Doberstein CA, Asaad WF. Risk Stratification in Traumatic Space-Occupying Intracranial Hemorrhage. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Doberstein CA, Powers AY, Pinto MB, Tang OY, Chen JS, Asaad WF. Assessing the Efficacy of Platelet Transfusion for Patients with Traumatic Intracranial Hemorrhage. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.07.400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Schaeffer EL, Liu DY, Guerin J, Ahn M, Lee S, Asaad WF. A low-cost solution for quantification of movement during DBS surgery. J Neurosci Methods 2018; 303:136-145. [PMID: 29605668 DOI: 10.1016/j.jneumeth.2018.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 03/23/2018] [Accepted: 03/24/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND During the deep brain stimulation (DBS) electrode implantation operation with microelectrode recordings (MER) in awake patients, somatotopic testing and test stimulation are performed to improve electrode placement and provide the most beneficial symptom reduction possible, while minimizing side effects. As this procedure is commonly used to alleviate abnormal movements associated with Parkinson's disease (PD) and Essential Tremor (ET), intraoperative assessment of a patient's movements is critical to optimizing surgical benefit. However, despite its importance, movement assessment is typically subjective and qualitative. NEW METHOD Here, we present a detailed description of a low-cost, open-source system as a solution. RESULTS The described system measures movements intraoperatively and in synchrony with neurophysiological recordings for both online visualization and offline analysis. COMPARISON WITH EXISTING METHOD(S) Few movement quantification systems are designed to interface with intraoperative neurophysiological recordings; the widespread application of such systems may be limited by their cost and proprietary, closed-source nature. The system presented provides a low-cost, open-source alternative. CONCLUSIONS The system outlined in this work may improve the DBS procedure by adding valuable objectivity in movement quantification.
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Affiliation(s)
- Erin L Schaeffer
- Department of Neuroscience, Brown University, Providence, RI, 02903, United States
| | - Daniel Y Liu
- Department of Neuroscience, Brown University, Providence, RI, 02903, United States
| | - Julie Guerin
- Department of Neuroscience, Brown University, Providence, RI, 02903, United States
| | - Minkyu Ahn
- School of Computer Science and Electrical Engineering, Handong Global University, Pohang, 37554, South Korea
| | - Shane Lee
- Department of Neuroscience, Brown University, Providence, RI, 02903, United States; Brown Institute for Brain Science (BIBS), Brown University, Providence, RI, 02903, United States
| | - Wael F Asaad
- Department of Neuroscience, Brown University, Providence, RI, 02903, United States; Brown Institute for Brain Science (BIBS), Brown University, Providence, RI, 02903, United States; Department of Neurosurgery, The Warren Alpert Medical School, Providence, RI, 02903, United States; Department of Neuosurgry, Rhode Island Hospital, Providence, RI, 02903, United States; Norman Prince Neurosciences Institute, Lifespan, Providence, RI, 02903, United States.
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Bayer AD, Blum AS, Asaad WF, Roth J, Toms SA, Deck GM. Fighting Fire with Fire: Surgical Options for Patients with Drug-Resistant Epilepsy. R I Med J (2013) 2018; 101:37-40. [PMID: 29490324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
While antiepileptic drugs (AEDs) provide adequate seizure control for most patients with epilepsy, ~30% continue to have seizures despite treatment with two or more AEDs.1 In addition to direct harm from seizures, poor epilepsy control correlates with higher mortality, morbidity, 2, 3 and cost to the healthcare system.4 In the subset of patients with persistent seizures despite medical management, surgical intervention and neuromodulation may be more effective. Primary care physicians and general neurologists should be aware of non-AED treatment options that are standard of care for drug- resistant epilepsy (DRE).
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Affiliation(s)
- Alina D Bayer
- Neurology resident at Rhode Island Hospital, Providence, RI
| | - Andrew S Blum
- Professor and Vice Chair of Neurology at the Warren Alpert Medical School of Brown University; Medical Director of the Brown - Rhode Island Hospital Comprehensive Epilepsy Program
| | - Wael F Asaad
- Assistant Professor of Neurosurgery at the Warren Alpert Medical School of Brown University; Director of the Functional Neurosurgery and Epilepsy Program at Rhode Island Hospital
| | - Julie Roth
- Assistant Professor of Neurology at the Warren Alpert Medical School of Brown University; Attending neurologist, specializing in epilepsy, as part of the Comprehensive Epilepsy Program at Rhode Island Hospital
| | - Steven A Toms
- Professor of Neurosurgery and Radiation Oncology at the Warren Alpert Medical School of Brown University; Vice Chair of the Department of Neurosurgery; Director of the Brain Tumor and Stereotactic Radiosurgery Program at Rhode Island Hospital
| | - Gina M Deck
- Assistant Professor of Neurology at the Warren Alpert Medical School of Brown University; Attending neurologist, specializing in epilepsy, as part of the Comprehensive Epilepsy Program at Rhode Island Hospital
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Lauro PM, Lee S, Ahn M, Barborica A, Asaad WF. DBStar: An Open-Source Tool Kit for Imaging Analysis with Patient-Customized Deep Brain Stimulation Platforms. Stereotact Funct Neurosurg 2018; 96:13-21. [PMID: 29414819 DOI: 10.1159/000486645] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 01/08/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND/OBJECTIVES To create an open-source method for reconstructing microelectrode recording (MER) and deep brain stimulation (DBS) electrode coordinates along multiple parallel trajectories with patient-specific DBS implantation platforms to facilitate DBS research. METHODS We combined the surgical geometry (extracted from WayPoint Planner), pre-/intra-/postoperative computed tomography (CT) and/or magnetic resonance (MR) images, and integrated them into the Analysis of Functional NeuroImages (AFNI) neuroimaging analysis environment using functions written in Python. Electrode coordinates were calculated from image-based electrode surfaces and recording trajectory depth values. Coordinates were translated into appropriate trajectories, and were tested for proximity to patient-specific or atlas-based anatomical structures. Final DBS electrode coordinates for 3 patient populations (ventral intermediate nucleus [VIM], subthalamic nucleus [STN], and globus pallidus pars interna [GPi]) were calculated. For STN cases, MER site coordinates were then analyzed to see whether they were inside or outside the STN. RESULTS Final DBS electrode coordinates were described for VIM, STN, and GPi patient populations. 115/169 (68%) STN MER sites were within 1 mm of the STN in AFNI's Talairach and Tournoux (TT) atlas. CONCLUSIONS DBStar is a robust tool kit for understanding the anatomical location and context of electrode locations, and can easily be used for imaging, behavioral, or electrophysiological analyses.
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Affiliation(s)
- Peter M Lauro
- The Warren Alpert Medical School, Brown University, Providence, Rhode Island, USA.,Department of Neuroscience, Brown University, Providence, Rhode Island, USA
| | - Shane Lee
- Department of Neuroscience, Brown University, Providence, Rhode Island, USA.,Brown Institute for Brain Science (BIBS), Brown University, Providence, Rhode Island, USA
| | - Minkyu Ahn
- School of Computer Science and Electrical Engineering, Handong Global University, Pohang, Republic of Korea
| | - Andrei Barborica
- FHC Inc., Bowdoin, Maine, USA.,Physics Department, Bucharest University, Bucharest, Romania
| | - Wael F Asaad
- Department of Neuroscience, Brown University, Providence, Rhode Island, USA.,Brown Institute for Brain Science (BIBS), Brown University, Providence, Rhode Island, USA.,Department of Neurosurgery, The Warren Alpert Medical School, Providence, Rhode Island, USA.,Department of Neurosurgery, Rhode Island Hospital, Providence, Rhode Island, USA.,Norman Prince Neurosciences Institute, Lifespan, Providence, Rhode Island, USA
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Leoutsakos JMS, Yan H, Anderson WS, Asaad WF, Baltuch G, Burke A, Chakravarty MM, Drake KE, Foote KD, Fosdick L, Giacobbe P, Mari Z, McAndrews MP, Munro CA, Oh ES, Okun MS, Pendergrass JC, Ponce FA, Rosenberg PB, Sabbagh MN, Salloway S, Tang-Wai DF, Targum SD, Wolk D, Lozano AM, Smith GS, Lyketsos CG. Deep Brain Stimulation Targeting the Fornix for Mild Alzheimer Dementia (the ADvance Trial): A Two Year Follow-up Including Results of Delayed Activation. J Alzheimers Dis 2018; 64:597-606. [PMID: 29914028 PMCID: PMC6518401 DOI: 10.3233/jad-180121] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Given recent challenges in developing new treatments for Alzheimer dementia (AD), it is vital to explore alternate treatment targets, such as neuromodulation for circuit dysfunction. We previously reported an exploratory Phase IIb double-blind trial of deep brain stimulation targeting the fornix (DBS-f) in mild AD (the ADvance trial). We reported safety but no clinical benefits of DBS-f versus the delayed-on (sham) treatment in 42 participants after one year. However, secondary post hoc analyses of the one-year data suggested a possible DBS-f benefit for participants≥65 years. OBJECTIVE To examine the long-term safety and clinical effects of sustained and delayed-on DBS-f treatment of mild AD after two years. METHODS 42 participants underwent implantation of DBS-f electrodes, with half randomized to active DBS-f stimulation (early on) for two years and half to delayed-on (sham) stimulation after 1 year to provide 1 year of active DBS-f stimulation (delayed on). We evaluated safety and clinical outcomes over the two years of the trial. RESULTS DBS-f had a favorable safety profile with similar rates of adverse events across both trial phases (years 1 and 2) and between treatment arms. There were no differences between treatment arms on any primary clinical outcomes. However, post-hoc age group analyses suggested a possible benefit among older (>65) participants. CONCLUSION DBS-f was safe. Additional study of mechanisms of action and methods for titrating stimulation parameters will be needed to determine if DBS has potential as an AD treatment. Future efficacy studies should focus on patients over age 65.
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Affiliation(s)
- Jeannie-Marie S. Leoutsakos
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Haijuan Yan
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William S. Anderson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Wael F. Asaad
- Department of Neurosurgery, Rhode Island Hospital and the Alpert Medical School of Brown University, Providence, RI, USA
| | - Gordon Baltuch
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna Burke
- Banner Alzheimer’s Institute, Phoenix, AZ, USA | [m] Department of Neurology, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - M. Mallar Chakravarty
- Cerebral Imaging Centre, Douglas Mental Health University Institute, Montreal, QC, Canada; Departments of Psychiatry and Biomedical Engineering, McGill University, Montreal, QC, Canada
| | | | - Kelly D. Foote
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Lisa Fosdick
- Functional Neuromodulation Ltd, Minneapolis, MN, USA
| | - Peter Giacobbe
- Departments of Medicine (Neurology), Surgery (Neurosurgery) Psychology and Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Zoltan Mari
- Nevada Movement Disorders Program, Cleveland Clinic Lou Ruvo Center for Brain Health, Department of Neurology, University of Nevada, Las Vegas, NV, USA
| | - Mary Pat McAndrews
- Departments of Medicine (Neurology), Surgery (Neurosurgery) Psychology and Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Cynthia A. Munro
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Esther S. Oh
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michael S. Okun
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | | | - Francisco A. Ponce
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Paul B. Rosenberg
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Marwan N. Sabbagh
- Alzheimer’s Disease and Memory Disorders Division, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Stephen Salloway
- Department of Neurology, Butler Hospital and the Alpert Medical School of Brown University, Providence, RI, USA
| | - David F. Tang-Wai
- Departments of Medicine (Neurology), Surgery (Neurosurgery) Psychology and Psychiatry, University of Toronto, Toronto, ON, Canada
- University Health Network Memory Clinic, University of Toronto, Division of Neurology, Toronto, ON, Canada
| | | | - David Wolk
- Penn Memory Center, Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Andres M. Lozano
- Departments of Medicine (Neurology), Surgery (Neurosurgery) Psychology and Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Gwenn S. Smith
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Constantine G. Lyketsos
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Carnevale JA, Ahmedli N, Morrison JF, Asaad WF, Klinge P, Telfeian A. T-Connector Modification for Reducing Recurrent Distal Shunt Failure: Report of 2 Cases. Oper Neurosurg (Hagerstown) 2017; 13:E33-E36. [PMID: 29186599 DOI: 10.1093/ons/opx050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 02/17/2017] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND IMPORTANCE Cerebrospinal fluid shunt placement is used to treat the various causes of hydrocephalus by redirecting the cerebrospinal fluid to the body, most commonly from the ventricle to the peritoneum. Distal catheter displacement from the peritoneal cavity can occur as a complication, necessitating reoperation. CLINICAL PRESENTATION We report 2 such cases in obese patients involving retropulsion of the distal tubing. To address this complication, we implanted a T-connector to the distal catheter construct. CONCLUSION This study supports the use of a T-connector catheter construct to decrease and prevent the possibility of distal peritoneal catheter retropulsion in cases of elevated intra-abdominal pressure, both prophylactically and in revisions.
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Affiliation(s)
- Joseph A Carnevale
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nigar Ahmedli
- Department of Otolaryngology, Albert Einstein College of Medicine, Bronx, New York
| | - John F Morrison
- Department of Neurosurgery, University at Buffalo, Buffalo, New York
| | - Wael F Asaad
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Petra Klinge
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Albert Telfeian
- Department of Neurosurgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island
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47
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Akbar U, Asaad WF. A Comprehensive Approach to Deep Brain Stimulation for Movement Disorders. R I Med J (2013) 2017; 100:30-33. [PMID: 28564666] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Deep brain stimulation (DBS) is a well-established form of neuromodulation, used primarily for movement disorders such as Parkinson's disease (PD) and Essential Tremor (ET). The selection of patients who will benefit most from DBS depends on a team of clinicians from various disciplines, including neurology, neurosurgery, psychiatry, neuropsychology and rehabilitation specialists. The actual surgical procedure can take many forms. We apply a combination of multidisciplinary, team-based evaluations and intra-operative neurophysiology, test stimulation and imaging to optimize DBS therapy for individual patients. [Full article available at http://rimed.org/rimedicaljournal-2017-06.asp].
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Affiliation(s)
- Umer Akbar
- Assistant Professor of Neurology, Brown University Alpert Medical School and Movement Disorders Program, Department of Neurology, Rhode Island Hospital and Butler Hospital; member of the Norman Prince Neurosciences Institute of Lifespan
| | - Wael F Asaad
- Assistant Professor of Neurosurgery (& Neuroscience), Brown University Alpert Medical School and Director of Functional Neurosurgery, Rhode Island Hospital; member of the Norman Prince Neurosciences Institute of Lifespan
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Lee JJ, Segar DJ, Morrison JF, Mangham WM, Lee S, Asaad WF. Subdural hematoma as a major determinant of short-term outcomes in traumatic brain injury. J Neurosurg 2017; 128:236-249. [PMID: 28186445 DOI: 10.3171/2016.5.jns16255] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Early radiographic findings in patients with traumatic brain injury (TBI) have been studied in hopes of better predicting injury severity and outcome. However, prior attempts have generally not considered the various types of intracranial hemorrhage in isolation and have typically not excluded patients with potentially confounding extracranial injuries. Therefore, the authors examined the associations of various radiographic findings with short-term outcome to assess the potential utility of these findings in future prognostic models. METHODS The authors retrospectively identified 1716 patients who had experienced TBI without major extracranial injuries, and categorized them into the following TBI subtypes: subdural hematoma (SDH), traumatic subarachnoid hemorrhage, intraparenchymal hemorrhage (which included intraventricular hemorrhage), and epidural hematoma. They specifically considered isolated forms of hemorrhage, in which only 1 subtype was present. RESULTS In general, the presence of an isolated SDH was more likely to result in worse outcomes than the presence of other isolated forms of traumatic intracranial hemorrhage. Discharge to home was less likely and perihospital mortality rates were generally higher in patients with SDH. These findings were not simply related to age and were not fully captured by the admission Glasgow Coma Scale (GCS) score. The presence of SDH had a much higher sensitivity for poor outcome than the presence of other TBI subtypes, and was more sensitive for these poor outcomes than having a low GCS score (3-8). CONCLUSIONS In these ways, SDH was the most important finding associated with poor outcome, and the authors show that consideration of SDH, specifically, can augment age and GCS score in classification and prognostic models for TBI.
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Affiliation(s)
| | | | - John F Morrison
- 1Warren Alpert Medical School of Brown University.,2Department of Neurosurgery, Rhode Island Hospital
| | | | - Shane Lee
- 3Brown Institute for Brain Science.,4Department of Neuroscience, Brown University; and
| | - Wael F Asaad
- 1Warren Alpert Medical School of Brown University.,2Department of Neurosurgery, Rhode Island Hospital.,3Brown Institute for Brain Science.,4Department of Neuroscience, Brown University; and.,5Norman Prince Neurosciences Institute, Rhode Island Hospital, Providence, Rhode Island
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49
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Golebiowski D, van der Bom IMJ, Kwon CS, Miller AD, Petrosky K, Bradbury AM, Maitland S, Kühn AL, Bishop N, Curran E, Silva N, GuhaSarkar D, Westmoreland SV, Martin DR, Gounis MJ, Asaad WF, Sena-Esteves M. Direct Intracranial Injection of AAVrh8 Encoding Monkey β-N-Acetylhexosaminidase Causes Neurotoxicity in the Primate Brain. Hum Gene Ther 2017; 28:510-522. [PMID: 28132521 DOI: 10.1089/hum.2016.109] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
GM2 gangliosidoses, including Tay-Sachs disease and Sandhoff disease, are lysosomal storage disorders caused by deficiencies in β-N-acetylhexosaminidase (Hex). Patients are afflicted primarily with progressive central nervous system (CNS) dysfunction. Studies in mice, cats, and sheep have indicated safety and widespread distribution of Hex in the CNS after intracranial vector infusion of AAVrh8 vectors encoding species-specific Hex α- or β-subunits at a 1:1 ratio. Here, a safety study was conducted in cynomolgus macaques (cm), modeling previous animal studies, with bilateral infusion in the thalamus as well as in left lateral ventricle of AAVrh8 vectors encoding cm Hex α- and β-subunits. Three doses (3.2 × 1012 vg [n = 3]; 3.2 × 1011 vg [n = 2]; or 1.1 × 1011 vg [n = 2]) were tested, with controls infused with vehicle (n = 1) or transgene empty AAVrh8 vector at the highest dose (n = 2). Most monkeys receiving AAVrh8-cmHexα/β developed dyskinesias, ataxia, and loss of dexterity, with higher dose animals eventually becoming apathetic. Time to onset of symptoms was dose dependent, with the highest-dose cohort producing symptoms within a month of infusion. One monkey in the lowest-dose cohort was behaviorally asymptomatic but had magnetic resonance imaging abnormalities in the thalami. Histopathology was similar in all monkeys injected with AAVrh8-cmHexα/β, showing severe white and gray matter necrosis along the injection track, reactive vasculature, and the presence of neurons with granular eosinophilic material. Lesions were minimal to absent in both control cohorts. Despite cellular loss, a dramatic increase in Hex activity was measured in the thalamus, and none of the animals presented with antibody titers against Hex. The high overexpression of Hex protein is likely to blame for this negative outcome, and this study demonstrates the variations in safety profiles of AAVrh8-Hexα/β intracranial injection among different species, despite encoding for self-proteins.
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Affiliation(s)
- Diane Golebiowski
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Horae Gene Therapy Center, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Imramsjah M J van der Bom
- 3 Department of Radiology, University of Massachusetts Medical School , Worcester, Massachusetts.,4 New England Center for Stroke Research, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Churl-Su Kwon
- 5 Department of Neurosurgery, Massachusetts General Hospital , Boston, Massachusetts
| | - Andrew D Miller
- 6 New England Primate Research Center, Harvard Medical School , Southborough, Massachusetts
| | - Keiko Petrosky
- 6 New England Primate Research Center, Harvard Medical School , Southborough, Massachusetts
| | - Allison M Bradbury
- 7 Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University , Alabama.,8 Department of Anatomy, Physiology, and Pharmacology, College of Veterinary Medicine, Auburn University , Alabama
| | - Stacy Maitland
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Horae Gene Therapy Center, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Anna Luisa Kühn
- 3 Department of Radiology, University of Massachusetts Medical School , Worcester, Massachusetts.,4 New England Center for Stroke Research, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Nina Bishop
- 9 Department of Animal Medicine, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Elizabeth Curran
- 6 New England Primate Research Center, Harvard Medical School , Southborough, Massachusetts
| | - Nilsa Silva
- 6 New England Primate Research Center, Harvard Medical School , Southborough, Massachusetts
| | - Dwijit GuhaSarkar
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Horae Gene Therapy Center, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Susan V Westmoreland
- 6 New England Primate Research Center, Harvard Medical School , Southborough, Massachusetts
| | - Douglas R Martin
- 7 Scott-Ritchey Research Center, College of Veterinary Medicine, Auburn University , Alabama.,8 Department of Anatomy, Physiology, and Pharmacology, College of Veterinary Medicine, Auburn University , Alabama
| | - Matthew J Gounis
- 3 Department of Radiology, University of Massachusetts Medical School , Worcester, Massachusetts.,4 New England Center for Stroke Research, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Wael F Asaad
- 10 Department of Neurosurgery, Alpert Medical School, Brown University , Providence, Rhode Island.,11 Brown Institute for Brain Science, Brown University , Providence, Rhode Island.,12 Rhode Island Hospital , Providence, Rhode Island
| | - Miguel Sena-Esteves
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Horae Gene Therapy Center, University of Massachusetts Medical School , Worcester, Massachusetts
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50
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Lozano AM, Fosdick L, Chakravarty MM, Leoutsakos JM, Munro C, Oh E, Drake KE, Lyman CH, Rosenberg PB, Anderson WS, Tang-Wai DF, Pendergrass JC, Salloway S, Asaad WF, Ponce FA, Burke A, Sabbagh M, Wolk DA, Baltuch G, Okun MS, Foote KD, McAndrews MP, Giacobbe P, Targum SD, Lyketsos CG, Smith GS. A Phase II Study of Fornix Deep Brain Stimulation in Mild Alzheimer's Disease. J Alzheimers Dis 2016; 54:777-87. [PMID: 27567810 PMCID: PMC5026133 DOI: 10.3233/jad-160017] [Citation(s) in RCA: 199] [Impact Index Per Article: 24.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Deep brain stimulation (DBS) is used to modulate the activity of dysfunctional brain circuits. The safety and efficacy of DBS in dementia is unknown. OBJECTIVE To assess DBS of memory circuits as a treatment for patients with mild Alzheimer's disease (AD). METHODS We evaluated active "on" versus sham "off" bilateral DBS directed at the fornix-a major fiber bundle in the brain's memory circuit-in a randomized, double-blind trial (ClinicalTrials.gov NCT01608061) in 42 patients with mild AD. We measured cognitive function and cerebral glucose metabolism up to 12 months post-implantation. RESULTS Surgery and electrical stimulation were safe and well tolerated. There were no significant differences in the primary cognitive outcomes (ADAS-Cog 13, CDR-SB) in the "on" versus "off" stimulation group at 12 months for the whole cohort. Patients receiving stimulation showed increased metabolism at 6 months but this was not significant at 12 months. On post-hoc analysis, there was a significant interaction between age and treatment outcome: in contrast to patients <65 years old (n = 12) whose results trended toward being worse with DBS ON versus OFF, in patients≥65 (n = 30) DBS-f ON treatment was associated with a trend toward both benefit on clinical outcomes and a greater increase in cerebral glucose metabolism. CONCLUSION DBS for AD was safe and associated with increased cerebral glucose metabolism. There were no differences in cognitive outcomes for participants as a whole, but participants aged≥65 years may have derived benefit while there was possible worsening in patients below age 65 years with stimulation.
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Affiliation(s)
- Andres M. Lozano
- Departments of Medicine (Neurology), Surgery (Neurosurgery) Psychology and Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Lisa Fosdick
- Functional Neuromodulation Ltd, Minneapolis, MN, USA
| | - M. Mallar Chakravarty
- Cerebral Imaging Centre, Douglas Mental Health University Institute, Montreal, QC, Canada; Departments of Psychiatry and Biomedical Engineering, McGill University, Montreal, QC, Canada
| | - Jeannie-Marie Leoutsakos
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Cynthia Munro
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Esther Oh
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Medicine, Division of Geriatric Medicine and Gerontology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | - Christopher H. Lyman
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Paul B. Rosenberg
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - William S. Anderson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - David F. Tang-Wai
- Departments of Medicine (Neurology), Surgery (Neurosurgery) Psychology and Psychiatry, University of Toronto, Toronto, ON, Canada
- University Health Network Memory Clinic, University of Toronto, Division of Neurology, Toronto, ON, Canada
| | | | - Stephen Salloway
- Department of Neurology, Butler Hospital and the Alpert Medical School of Brown University, Providence, RI, USA
| | - Wael F. Asaad
- Department of Neurosurgery, Rhode Island Hospital and the Alpert Medical School of Brown University, Providence, RI, USA
| | - Francisco A. Ponce
- Division of Neurological Surgery, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
| | - Anna Burke
- Banner Alzheimer’s Institute, Phoenix, AZ, USA
| | - Marwan Sabbagh
- Department of Neurology, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - David A. Wolk
- Penn Memory Center, Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Gordon Baltuch
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Michael S. Okun
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Kelly D. Foote
- Departments of Neurology and Neurosurgery, University of Florida Center for Movement Disorders and Neurorestoration, Gainesville, FL, USA
| | - Mary Pat McAndrews
- Departments of Medicine (Neurology), Surgery (Neurosurgery) Psychology and Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Peter Giacobbe
- Departments of Medicine (Neurology), Surgery (Neurosurgery) Psychology and Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | - Constantine G. Lyketsos
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gwenn S. Smith
- Memory and Alzheimer’s Treatment Center & Alzheimer’s Disease Research Center, Division of Geriatric Psychiatry and Neuropsychiatry, Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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