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.
To analyze the association between frailty and traumatic intracranial hemorrhage (tICH) outcomes in a nationwide cohort.
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.
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.
For patients with tICH, frailty predicted higher mortality and morbidity, independent of age or injury severity.
Frailty is associated with adverse outcomes in traumatically injured geriatric patients but has not been well-studied in geriatric Traumatic Brain Injury (TBI). To assess relationships between ...frailty and outcomes after TBI The records of all patients aged 70 or older admitted from home to the neurosurgical service of a single institution for non-operative TBI between January 2020 and July 2021 were retrospectively reviewed. The primary outcome was adverse discharge disposition (either in-hospital expiration or discharge to skilled nursing facility (SNF), hospice, or home with hospice). Secondary outcomes included major inpatient complication, 30-day readmission, and length of stay. 100 patients were included, 90% of whom presented with Glasgow Coma Score (GCS) 14-15. The mean length of stay was 3.78 days. 7% had an in-hospital complication, and 44% had an unfavorable discharge destination. 49% of patients attended follow-up within 3 months. The rate of readmission within 30 days was 13%. Patients were characterized as low frailty (FRAIL score 0-1, n = 35, 35%) or high frailty (FRAIL score 2-5, n = 65, 65%). In multivariate analysis controlling for age and other factors, frailty category (aOR 2.63, 95CI 1.02, 7.14, p = 0.005) was significantly associated with unfavorable discharge. Frailty was not associated with increased readmission rate, LOS, or rate of complications on uncontrolled univariate analyses. Frailty is associated with increased odds of unfavorable discharge disposition for geriatric patients admitted with TBI.
•RNS and ECoG data guided management in a presumed bitemporal epilepsy case.•Subsequent LITT of a primary seizure focus led to Engle 1A outcome for the patient.•Post-LITT, contralateral interictal ...activity was reduced gradually over two years.•This suggests dependence of the contralateral side on the ablated zone.
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.
In Chiari Malformation Type I (CM1), low-lying tonsils obstruct the cisterna magna at the foramen magnum, thereby compromising the essential juncture between the cranial and spinal compartments. The ...anatomical obstruction of the cisterna magna inhibits bi-directional CSF flow as well as CSF pulse pressure equilibration between the intracranial compartment and the intraspinal compartment in response to instances of increased intracranial pressure. Less understood, however, are the roles of the spinal cord suspension structures at the craniocervical junction which lend viscoelastic support to the spinal cord and tonsils, as well as maintain the anatomical integrity of the cisterna magna and the dura. These include extradural ligaments including the myodural bridges (MDBs), as well as intradural dentate ligaments and the arachnoid framework. We propose that when these elements are disrupted by the cisterna magna obstruction, tonsillar pathology, and altered CSF dynamics, there may arise a secondary pathophysiology of compromised and dysfunctional cranio-spinal suspension in CM1. We present intraoperative images and videos captured during surgical exposure of the craniocervical junction in CM1 to illustrate this proposal.
•Intramedullary spinal cord metastasis is rising in incidence with cancer survivorship.•We present a case of IMSCM that was the first sign of underlying lung adenocarcinoma.•We review 138 published ...cases treated with chemotherapy, radiotherapy, and surgery.•Microsurgical treatment of IMSCM can palliate symptoms and preserve ambulation.
Intramedullary spinal cord metastasis (IMSCM) is a rare entity which lacks well-defined treatment guidelines, yet sees rising incidence. We report a case of a 67-year-old man who presented with severe neck pain and numbness in his right fourth and fifth digits, and was found to have a C5-7 IMSCM of previously unknown lung adenocarcinoma. He underwent gross total resection of the IMSCM, afatinib, and radiation treatment. He had full reversal of his pain and sensory deficit, and remained ambulatory without any focal neurological deficit. Additionally, we conducted a literature review of original case series of IMSCM published between 1983 and 2016, representing 138 unique cases, and discuss various treatments with a focus on surgical resection and general treatment of stage IV lung adenocarcinoma. 18.75% of cases of IMSCM were an initial presentation of underlying malignancy. Rapidly progressive pain and weakness was the most common presentation, often compromising ambulatory status. Median survival ranged from 3.8 to 11.6 months after treatment in patients who were deceased at time of publication. Treatments included corticosteroids, chemotherapy, various radiotherapies, and surgical resection. Surgical resection was found to greatly improve symptoms and preserve ambulatory status, and was associated with increased survival time up to double that of non-surgical treatments. Most authors recommended surgical resection only in symptomatic patients with reversible deficits, to palliate symptoms and preserve ambulation. IMSCM can herald an underlying malignancy, and surgical resection can preserve ambulatory status and palliate symptoms as well increase survival time in a subset of patients.
INTRODUCTION:
Cognitive and affective dysfunction in Chiari Malformation Type I (CM1) patients are well-documented, but often rely on extensive neuropsychological tests.
METHODS:
Symptomatic CM1 ...patients considering surgical decompression were assessed by a board-certified neuropsychologist using the 105-point CNRS (N = 87) and the 10-task CCAS (N = 23), as well as a full neuropsychological battery (N = 24: Wechsler Full Scale IQ, Digit Span, Coding; WRAML Finger Windows; DKEFS Trail Making; verbal list learning; Grooved Pegboard). Descriptive and correlative measures were computed.
RESULTS:
The study included 66 adults and 21 children. A neuropsychological battery revealed impairment in 29% of patients on 1 test, 12.8% on 2 tests, and 20.8% on 3 or more tests. The CCAS indicated 26% with "possible CCAS" (1 task), 27% with "probable CCAS" (2 tasks), and 18% with "definite CCAS" (3 or more tasks). The median CNRS composite score was 31.0 (IQR: 18.5, 49.0), with positive and negative symptom sub-scores of 18.0 (10.0, 26.5) and 14.0 (7.5, 23.5), respectively. Moderate correlation with the neuropsychological battery was found between impairment detected by CCAS (Spearman rank coefficient ρ = 0.67, p = 0.002) and CNRS (ρ = 0.56, p = 0.003).
CONCLUSIONS:
A high prevalence of cognitive and affective impairments in pre-operative CM1 patients was observed by all three testing batteries. In this first report of CNRS and CCAS usage in CM1 patients, increased CNRS and CCAS impairment correlated with impairment on standard neuropsychological testing. These tools show promise for future studies CM1, providing a more concise alternative to traditional testing for cognitive and affective dysfunction.
Women constitute a minority (9.2%) of academic neurosurgeons. We previously found that women in academic medicine are disadvantaged in funding and career advancement opportunities. We hypothesized ...that women are also underrepresented at neurosurgical society conferences.
Programs from the 2014–2018 meetings of the Congress of Neurological Surgeons (CNS), American Association of Neurological Surgery (AANS), and North American Skull Base Society (NASBS) were analyzed. Demographic data, including name, gender, and geographic region of practice, were collected for speaker, moderator, or leadership positions. χ2 statistical analysis was performed for difference in gender representation across all opportunity spots.
In the period 2014–2018, there was no female presidents or honored guest at any academic meetings analyzed; 53.8% of executive committees comprised all men. Women often constituted a minority (<15%) of speakers and moderators at CNS, AANS, and NASBS meetings: speakers (% female, range), 8.6 (5.5–11.7), 13.6 (10.1–19.7), and 10.5 (5.6–16.6); moderators (% female, range), 7.8 (0–14.3), 23.0 (81.3–91.3), and 13.0 (8.6–18.7). Conference panels frequently comprised all men (58% CNS, 20.7% AANS, 61% NASBS). χ2 analysis found a disparity in male and female participation across all opportunity spots (P = 0.002). Additionally, female participants are often repeated, decreasing total number of unique women participating. There was no significant increase in female participation across the study period.
In 2014–2018, underrepresentation of women in national neurosurgical conferences either matched or exceeded the baseline gender disparity seen in academic neurosurgery. We discussed potential causes of and strategies to address these findings.
INTRODUCTION:
Earlier research has demonstrated that patient frailty, a decline in physiologic reserve, is associated with higher morbidity and mortality for several neurosurgical conditions. ...However, the impact of frailty on traumatic brain injury (TBI) outcomes is poorly characterized.
METHODS:
We identified all adult admissions for traumatic intracranial hemorrhage (tICH) in the National Trauma Data Bank from 2007-2017. Frailty was quantified via the validated mFI-5 metric (0-5), with mFI-5 =2 denoting frailty. Analyzed outcomes included in-hospital mortality, favorable discharge disposition (discharge home or to short-term care), complications, ventilator days, and intensive care unit (ICU) and total length of stay (LOS). Multivariable regression was used to assess the association between mFI-5 and outcomes, adjusting for patient demographics (age, sex, insurance, transfer status), hospital characteristics (teaching status, trauma center level, bed size), injury severity on admission (penetrating injury, Glasgow Coma Scale GCS, Injury Severity Score, hypotension, number of tICH subtypes), and neurosurgical procedures.
RESULTS:
691,821 tICH admissions were analyzed. 63.2% were male and average age was 57.6 years (standard deviation=21.2). 43.5% were above 65 years of age. 18.0% of patients were classified as frail (mFI-5 = 2), and the percentage of frail patients grew from 7.9% in 2007 to 21.9% in 2017. Frailty was associated with increased odds of mortality (odds ratio OR = 1.36, P < 0.001) and decreased odds of favorable discharge disposition (OR = 0.72, P < 0.001). Frail patients also exhibited an elevated rate of complications (OR = 1.06, P < 0.001), including unplanned return to the ICU (OR = 1.55, P < 0.001) and operating room (OR = 1.17, P = 0.003). Finally, ventilator days (+12%, P < 0.001), ICU LOS (+11%, P < 0.001), and total LOS (+13%, P < 0.001) were significantly higher in frail patients. All associations with death and disposition remained significant following stratification for age, polytrauma, ICU stay, and GCS on admission.
CONCLUSION:
For tICH patients, frailty was associated with elevated mortality, unfavorable discharge disposition, complications, ventilator days, and LOS, regardless of age or injury severity. Further research into integrated care pathways for this high-risk population is warranted.
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