A free-standing children's hospital helps a post-partum woman needing VV-ECMO during COVID-19 Pandemic when ECMO resources were limited

Our case is a 21 y/o pregnant female, 26weeks gestation who presented to OB triage with COVID-19. She was admitted to OB/GYN unit in acute hypoxic respiratory failure and started on steroids and remdesivir. On hospital day 6, she underwent an emergent c-section for fetal distress due to increasing hypoxia and severe ARDS. As her arterial blood gas being ph 7.17/81/40/29.6/-0.4, lactate 6.8nmol/L with escalating vasoactive medication and ventilator settings;ECMO was decided. However, all adult ECMO resources were limited, even within other adult facilities in Central Florida. Through multidisciplinary discussions amongst OB/GYN, adult ICU, and our pediatric ECMO activation team, it was decided to transfer the patient to our free-standing pediatric hospital. The patient was successfully transferred and cannulated for VV-ECMO. Total ECMO run was 413 hours. On ECMO day #12 patient underwent a tracheostomy. On ECMO day # 17, patient developed headaches and seizure activity in which CT revealed a subdural hemorrhage. She was taken off ECMO and underwent an emergent decompressive craniectomy with hematoma evacuation by our pediatric neurosurgical team. Once stable enough, she was discharged post ECMO day #15 (PICU day #32) to rehabilitation center. Two weeks later she had her bone flap replaced, trach removed, and she walked out of our unit home. This case exudes two key points for discussion. The first point of understanding ECMO physiology allows a team to treat many different patient populations. Although this patient was unusual to our pediatric bedside providers being post-partum, our team knew we could help. The second key point is excellent multidisciplinary teamwork and that communication is essential. At Orlando Health Arnold Palmer Hospital, our ECMO activation team consists of surgeons, pediatric intensivists, CT surgeons, perfusionists, nursing, and administration. We meet virtually to discuss how to execute initiation and daily ECMO treatment plans. There were some on the virtual call that were hesitant in accepting care of this adult due to variety of reasons, saying no would have been the easier answer, but not the right thing to do. What we learned from this case may seem so obvious and simple but very difficult to execute;multidisciplinary teamwork, humility, and open communication gave this patient the ability to walk out of the hospital with her baby. Other pediatric ECMO teams can learn from this case is they too can help in extraordinary times such as during a pandemic when adult recourses are limited.

Subdural empyema in immunocompetent pediatric patients with recent SARS-CoV-2 positivity: case report.

Subdural empyema refers to the collection of purulent material in the subdural space and the most source of it is bacterial meningitis in infants while sinusitis and otitis media in older children. It has been very recently reported that coronaviruses (CoV) exhibit neurotropic properties and may also cause neurological diseases. CoV-related complications as hypercoagulability with thrombosis and associated inflammation, catastrophic cerebral venous sinus thrombose sand bacterial-fungal superinfections have been well documented in adult patients. Hereby, we describe 15-year-old and 12-year-old female children with subdural empyema after SARS-CoV2. The patients presented limitation of eye in the outward gaze, impaired speech, drowsiness, fever, vomiting and they also were tested positive for COVID-19. MRI indicated subdural empyema and surgical interventions were needed to relieve intracranial pressure and drain pus after receiving broad spectrum antibiotics treatments. The microbiological analysis of abscess material revealed Streptococcus constellatus which is extremely rare in an immunocompetent child and the patients received appropriate IV antibiotic therapy. Eventually, patients became neurologically intact. Pediatric patients with CoV infections should be closely monitored for neurological symptoms. Further research and more data on the correlation between CoV infections would provide better recognition and treatment options in an efficient manner in children.

Prevalence of adverse drug reactions associated with emergency department visits and risk factors for hospitalization

Objective: Adverse drug reactions increase morbidity and mortality, prolong hospital stay and increase healthcare costs. The primary objective of this study was to determine the prevalence of emergency department visits for adverse drug reactions and to describe their characteristics. The secondary objective was to determine the predictor variables of hospitalization for adverse drug reactions associated with emergency department visits. Method(s): Observational and retrospective study of adverse drug reactions registered in an emergency department, carried out from November 15th to December 15th, 2021. The demographic and clinical characteristics of the patients, the drugs involved and the adverse drug reactions were described. Logistic regression was performed to identify factors related to hospitalization for adverse drug reactions. Result(s): 10,799 patients visited the emergency department and 216 (2%) patients with adverse drug reactions were included. The mean age was 70 +/- 17.5 (18-98) years and 47.7% of the patients were male. A total of 54.6% of patients required hospitalization and 1.6% died from adverse drug reactions. The total number of drugs involved was 315 with 149 different drugs. The pharmacological group corresponding to the nervous system constituted the most representative group (n = 81). High-risk medications, such as antithrombotic agents (n = 53), were the subgroup of medications that caused the most emergency department visits and hospitalization. Acenocumarol (n = 20) was the main drug involved. Gastrointestinal (n = 62) disorders were the most common. Diarrhea (n = 16) was the most frequent adverse drug reaction, while gastrointestinal bleeding (n = 13) caused the highest number of hospitalizations. Charlson comorbidity index behaved as an independent risk factor for hospitalization (aOR 3.24, 95% CI: 1.47-7.13, p = 0.003, in Charlson comorbidity index 4-6;and aOR 20.07, 95% CI: 6.87-58.64, p = 0.000, in Charlson comorbidity index >= 10). Conclusion(s): The prevalence of emergency department visits for adverse drug reactions continues to be a non-negligible health problem. High-risk drugs such as antithrombotic agents were the main therapeutic subgroup involved. Charlson comorbidity index was an independent factor in hospitalization, while gastrointestinal bleeding was the adverse drug reaction with the highest number of hospital admissions.Copyright © 2022 Sociedad Espanola de Farmacia Hospitalaria (S.E.F.H)

Spontaneous Surgical Intracranial Haemorrhages Associated with SARS-Cov-2 Infection: Case Report.

Spontaneous surgical acute and chronic intracranial haemorrhage in patients with SARS-Cov-2 infection is a theoretical possibility. We report two cases of SARS-CoV-2 infection that was associated with spontaneous surgical acute and chronic intracranial haemorrhage. The two patients had successful surgical intervention. Surgical haemorrhages should be considered in patients with SARS-COV-2 infection especially if there is an associated altered sensorium.

Was Covid Era a Blessing in Disguise for the Patient?

Background and Aims: In the Covid era, Continuous blood glucose monitoring(CGM) was used more frequently and it proved to be quite a helpful and accurate tool for glycemic regulation. Method(s): 75 yrs old Saudi gentleman, had Type 2 diabetes >30yrs, Hypertension, Primary Hypothyroidism, dyslipidemia, mixed polyneuropathy, Iron deficiency anemia, and benign prostatic hypertrophy. In March,2020 his BP and blood glucose readings were high at home. He had a past history of subdural hematoma with hydrocephalus(staus post-shunting). He was on Glargine, oral hypoglycemic agents, anti-hypertensives, Levothyroxine, Atorvastatin, Aspirin, iron fumarate, calcium carbonate and cholecalciferol. Fully conscious, and co-operative, of average built and height.BP 170/70 mmHg, pulse 93/m, RR 18/ m,O2sat 100%, afebrile, BMI 24.96 kg/m2. Fundoscopy normal. He had dry feet and impaired monofilament and vibration testing. Result(s): Hb% 13.1g/dl(12.6 before),MCV 93.8fl,S.Ferritin 10.5ug/l(30-400),Vit.B12 270 pmol/l(145-637),HbA1c 8%(6.4 in Feb.2020).The renal, liver and thyroid functions-intact. Albumin creatinine ratio 12.23mg/g(0-30). Nerve conduction study-mixed polyneuropathy. He continued to follow-up physically even during the Covid crisis due to the elevated SMBG and BP values. Gliclazide & antihypertensive doses were optimized and Glargine was started.On patient's follow-up in August, 2020, time in range had improved to 80%(33% in June,2020),average glucose was 147 mg/dl(200 before), glucose variability was 27.8%(28.9), hypoglycemia (54-79mg/dl) was 1%(0). On last follow-up on 27.06.2022 his HbA1c had climbed up to 8.3%(7.3 in September, 2021). He was compliant to the diabetes regime, but had stopped using the Libre sensor. Conclusion(s): The case signifies the advantage of a meticulous CGM usage during the Covid pandemic, that resulted in a reasonable glycemic control.

Subdural empyema secondary to pansinusitis after coronavirus disease 2019 infection in an immunocompetent patient: illustrative case.

BACKGROUND: Superimposed intracranial infection is an uncommon but clinically significant complication in patients with active coronavirus disease 2019 (COVID-19), particularly in those with predisposing immunocompromising conditions. OBSERVATIONS: The authors describe a case of subdural empyema, secondary to extension from pansinusitis, in a 20-year-old otherwise healthy immunocompetent male who was recently diagnosed with COVID-19. Despite his critical condition at time of presentation, he made a full clinical recovery with aggressive multidisciplinary surgical management between neurosurgery and otolaryngology, despite negative cultures to guide directed antimicrobial therapy. Ultimately, use of molecular-based polymerase chain reaction testing diagnosed Aspergillus fumigatus as the offending pathogen after the patient had already recovered and was discharged from the hospital. LESSONS: This case demonstrates the potential for significant superimposed intracranial infection even in young, healthy individuals, infected by COVID-19 and suggests an aggressive surgical approach to achieve source control, particularly in the absence of positive cultures to guide antimicrobial therapies, may lead to rapid clinical improvement.

Spontaneous subdural effusion in a hospitalized Covid-19 patient: Case report.

Subdural effusions (SE) have already been associated with several viruses, but there are few associations with Covid-19 reported to date, and all of them had one thing in common: the presence of superimposed bacterial rhinosinusitis. Here we describe the case of a 76-year-old male patient that was transferred to our center due to severe SARS-CoV-2 infection and developed a SE during hospital stay. He presented sensory level impairment during hospitalization, but an initial Head CT scan showed no alterations. A new CT scan performed six days later evidentiated a bilateral SE. The patient had a cardiorespiratory arrest during the night of the same day, resulting in death. Covid-19 as a direct cause of subdural effusion (positive Covid-19 PCR in subdural fluid) has never before been reported in the literature, and, unfortunately, it was not possible to rule out or confirm this phenomenon in our case due to the rapid evolution of the clinical picture. However, our case clearly differs from the literature as the patient did not show any signs of sinus disease or intracranial hypotension, and the possible causes of the effusion boil down to spontaneity and the direct action of Covid-19 in the CNS and subdural space.

The monthly incidence of abusive head trauma, inflicted skeletal trauma, and unexplained skin lesion in children in six French university hospitals during the COVID-19 pandemic.

INTRODUCTION: The COVID-19 pandemic was a stressful period. Lockdowns may have added to parental difficulty leading to an increase in violence. This study aimed to compare the monthly incidence of high suspicion of child physical abuse before and during the COVID-19 pandemic. MATERIAL: We have retrospectively reviewed imaging examinations of children having a skeletal X-ray examination in six university hospitals with high suspicion of abusive head traumatism (AHT), inflicted skeletal trauma (IST) and unexplained skin lesions (USL) between March 2020 and June 2021 and compared with the similar period from 2018 to 2019. The monthly incidence of the different physical maltreatment was analyzed using a QuasiPoisson regression model. RESULTS: We included 178 children (n = 127 boys, 71.3 %), 110 during the pandemic period, median age 5 months. AHT was diagnosed in 91 children, 55 had inflicted skeletal trauma (IST) and 46 had unexplained skin lesions (USL). Among the 91 patients with AHT, 86 had a subdural hematoma (95.6 %) and 40 had bridging veins thrombosis (44 %). The ophthalmological examination performed on 89 children (97.9 %) revealed retinal hemorrhages in 57 children (89.8 %). The incidence of AHT doubled during the months of COVID-19 lockdowns (rate ratio = 2; 95 % CI [1.1; 3.6], p = 0.03). No difference in monthly incidence was observed for IST and USL groups. CONCLUSION: A significant increase in AHT was observed during the months with lockdowns and curfews during the COVID-19 pandemic. This highlights the need for developing a national strategy to prevent physical abuse in children in this context.

Intracranial hemorrhage and Covid-19: A retrospective analysis of 1675 hospitalized Covid-19 Brazilian patients.

Objective: The present study seeks to overcome the lack of data on Covid-19 associated intracranial hemorrhage (ICH) in Brazil. Methods: This is a retrospective, single-center case series of consecutive patients. It is a subanalysis of a larger study still in progress, which covers all neurological manifestations that occurred in patients admitted between March 1st, 2020 and June 1st, 2022, with active SARS-CoV-2 infection confirmed by polymerase chain reaction test. All patients with non-traumatic ICH were included. Results: A total of 1675 patients were evaluated: 917 (54.75 %) had one or more neurological symptoms and 19 had non-traumatic ICH, comprising an incidence of 1.13 %. All patients had one or more risk factors for ICH. The presence of neurological manifestations before the ICH and ICU admission showed a statistically significant relationship with the occurrence of ICH (X2 = 6.734, p = 0.0095; OR = 4.47; CI = 1.3-15.4; and FET = 9.13; p = <0.001; OR = 9.15; CI = 3.27-25.5 respectively). Conclusion: Our findings were largely congruent with the world literature. We believe that the assessment of risk factors can accurately predict the subgroup of patients at increased risk of ICH, but further studies are needed to confirm these hypotheses.

Randomized Evaluation of Surgery in Elderly with Traumatic Acute SubDural Hematoma (RESET-ASDH trial): study protocol for a pragmatic randomized controlled trial with multicenter parallel group design.

BACKGROUND: The rapidly increasing number of elderly (≥ 65 years old) with TBI is accompanied by substantial medical and economic consequences. An ASDH is the most common injury in elderly with TBI and the surgical versus conservative treatment of this patient group remains an important clinical dilemma. Current BTF guidelines are not based on high-quality evidence and compliance is low, allowing for large international treatment variation. The RESET-ASDH trial is an international multicenter RCT on the (cost-)effectiveness of early neurosurgical hematoma evacuation versus initial conservative treatment in elderly with a t-ASDH METHODS: In total, 300 patients will be recruited from 17 Belgian and Dutch trauma centers. Patients ≥ 65 years with at first presentation a GCS ≥ 9 and a t-ASDH > 10 mm or a t-ASDH < 10 mm and a midline shift > 5 mm, or a GCS < 9 with a traumatic ASDH < 10 mm and a midline shift < 5 mm without extracranial explanation for the comatose state, for whom clinical equipoise exists will be randomized to early surgical hematoma evacuation or initial conservative management with the possibility of delayed secondary surgery. When possible, patients or their legal representatives will be asked for consent before inclusion. When obtaining patient or proxy consent is impossible within the therapeutic time window, patients are enrolled using the deferred consent procedure. Medical-ethical approval was obtained in the Netherlands and Belgium. The choice of neurosurgical techniques will be left to the discretion of the neurosurgeon. Patients will be analyzed according to an intention-to-treat design. The primary endpoint will be functional outcome on the GOS-E after 1 year. Patient recruitment starts in 2022 with the exact timing depending on the current COVID-19 crisis and is expected to end in 2024. DISCUSSION: The study results will be implemented after publication and presented on international conferences. Depending on the trial results, the current Brain Trauma Foundation guidelines will either be substantiated by high-quality evidence or will have to be altered. TRIAL REGISTRATION: Nederlands Trial Register (NTR), Trial NL9012 . CLINICALTRIALS: gov, Trial NCT04648436 .

ALCOHOL WITHDRAWAL SYNDROME TREATMENT WITH PHENOBARBITAL VS BENZODIAZEPINE: SAFETY AND LENGTH OF STAY

SESSION TITLE: What's New in Critical Care? SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: Alcohol withdrawal syndrome (AWS) is a common etiology of intensive care unit (ICU) admission(Vigouroux et al 2021). Emergency Department (ED) related alcohol visits have increased in incidence dramatically since the beginning of the SARS-CoV2 pandemic. A median ICU length of stay (LOS) of 8 days for severe AWS has been previously reported. The increase in substance abuse observed during the pandemic may prolong future patients’ LOS. Pandemic staffing and bed shortages have made it even more evident the need to research efficient and safe treatment options of common hospital admission diagnosis such as AWS. Current national guidelines recommend benzodiazepines as first-line therapy for inpatient management of AWS (American Society of Addiction Medicine Clinical Practice Guidelines). However, historically phenobarbital (PB) and other barbiturates have been utilized with varying success. Recent evidence has demonstrated phenobarbital loading followed by symptom-triggered benzodiazepines may reduce LOS and ICU admission (Rosenson et al 2012). We retrospectively evaluated ED and ICU data to further guide our future research on PB in AWS, specifically;LOS, location of admission, and high risk side effects frequently associated with PB such as intubation. METHODS: Patients admitted for AWS and who received PB from 8/1/2021 to 02/01/2022 were identified. Subsequently, these subjects were then matched to themselves for historical AWS admissions without receipt of PB. Exclusion criteria included: admission with concomitant diagnosis with expected admission LOS longer than AWS treatment course;no separate admission for AWS. Pertinent patient demographics were collected including cumulative dosing of benzodiazepines, disposition from the ED, hospital LOS, ICU LOS, relative hypotension, and intubation. Data was analyzed using descriptive statistics and one-sided Student T-test. RESULTS: Total of 16 patients received PB during the six month identification period. Six were excluded due to lack of previous admission for AWS. Three were excluded for previous admissions with concomitant disease states requiring prolonged admissions. These included endoscopy, long-bone fracture, and subdural hematoma. Seven patients (14 unique admissions) met inclusion criteria. Patients were all male with a mean age of 58. Compared to non-PB admissions a trend in mean reduction of hospital LOS was 39.3 hours shorter in the PB cohort (p-value=0.068). Mean benzodiazepine reduction (lorazepam equivalents) was 26.3mg less in the PB cohort (p-value = 0.064). No intubations or hypotensive events were observed in either cohort. CONCLUSIONS: When PB was utilized there was reduction in total hospital LOS with no increase in intubations. Preliminary patient matched data of PB in AWS appears efficacious and safe. CLINICAL IMPLICATIONS: PB may decrease overall hospital LOS in AWS. DISCLOSURES: No relevant relationships by Yara Albair No relevant relationships by Nicholas Barreras No relevant relationships by Jessica Kim No relevant relationships by Marc McDowell No relevant relationships by Joshua Posner No relevant relationships by Mariana Silva

Retroclival hematomas in adult patients: A systematic review of a rare intracranial hematoma

Objective: Adulthood retroclival hematomas (RCHs) are a rare condition characterized by intracranial bleeding along the posterior aspect of the clivus. There are few reports in the literature that describe these hematomas. There is no agreement on how to treat these hematomas. Methods: An extensive literature review was performed, and the data was classified and analyzed on this topic from January 2000 to January 2022. A systematic review was carried out in accordance with the PRISMA and CARE Guidelines. Results were analyzed and potential clinical links were extracted. Results: Twenty-seven RCHs in adulthood were reported in twenty high-quality articles. 12/27 RCHs in adults were spontaneous. Epidural retroclival hematomas were present in 12/27 patients, while subdural hematomas were present in 13/27 patients. 15 of 22 adult RCHs observed were small in size. Epidural hematomas are typically associated with trauma (9/15 traumatic RCHs), whereas subdural hematomas are more frequently associated with spontaneous bleeding (8/12 spontaneous RCHs). There was one case of hydrocephalus, six cases of cranial nerve palsies (five of which were traumatic), and thirteen cases of intraspinal extension of the hematoma. Seven individuals exhibited craniovertebral instability (100 percent traumatic). Most hematomas were conservatively treated (77.8 percent). 21 hematomas had favorable clinical outcomes. Conclusions: There is a lack of agreement on management protocols for RCHs in adulthood. These hematomas occur almost equally in both the extradural and the subdural spaces, and they are typically small in size. When an RCH occurs in the epidural space, it is more likely to result in cranial nerve palsies and craniospinal instability. Associated craniovertebral anomalies must be thoroughly analyzed in trauma patients. Only patients with a significant mass effect on the brainstem are candidates for surgical hematoma evacuation. It is imperative that future studies on this rare entity adhere to strict publication guidelines.

Spontaneous spinal subdural hematoma in COVID-19 patient: Croatian national COVID hospital experience.

Background: Spontaneous spinal subdural hematoma (SSDH) is a rare condition and causes of acute spinal cord compression, with symptoms varying from mild to severe neurological deficit. SSDH could occur as a consequence of posttraumatic, iatrogenic, or spontaneous causes, including underlying arteriovenous malformations, tumors, or coagulation disorder. Due to its rarity, it is difficult to establish standardized treatment. We present a rare case of SSDH in COVID-19 patient and course of treatment in COVID hospital. Case Description: A 71-year-old female patient was admitted due to instability, weakness of the left leg, and intensive pain in the upper part of thoracic spine as well as mild respiratory symptoms of COVID-19. She was not on pronounced anticoagulant therapy and her coagulogram at admission was within normal range. MRI revealed acute subdural hematoma at the level C VII to Th III compressing the spinal cord. The patient underwent a decompressive Th I and Th II laminectomy and hematoma evacuation. Post-operative MRI revealed a satisfactory decompression and re-expansion of the spinal cord. COVID-19 symptoms remained mild. Conclusion: SSDH represents a neurological emergency, possibly leading to significant deficit and requires urgent recognition and treatment. One of the main difficulties when diagnosing is to consider such condition when there is no history of anticoagulant treatment or previous trauma. Since high incidence of coagulation abnormalities and thromboembolic events was described COVID-19 patients, when considering the pathology of the central nervous system, the bleeding within it due to COVID-19 should be taken into account, in both brain and spine.

Adolescent subdural empyema in setting of COVID-19 infection: illustrative case.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is an ongoing viral pandemic that has affected modern medical practice and can complicate known pathology. The novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) causes symptoms that may mimic a viral pneumonia, with potential for serious sequelae, including acute respiratory distress syndrome, coagulopathy, multiorgan dysfunction, systemic vascular abnormalities, and secondary infection. OBSERVATIONS: The authors describe a case of a 15-year-old boy who presented with a right subdural empyema and sinusitis while having active COVID-19 infection. The patient initially presented with left-sided weakness, frontal sinusitis, and subdural empyema. Emergent surgery was performed for evacuation of empyema and sinus debridement. Samples of purulent material within the subdural space were tested for SARS-CoV-2 by reverse transcriptase polymerase chain reaction. The patient had a successful recovery and regained the use of his right side after combined treatment. To our knowledge, this is the first reported case of a bacterial subdural empyema associated with frontal sinusitis in a coinfected patient with COVID-19 without evidence of COVID-19 intracranial infection. LESSONS: A subdural empyema, which is a surgical emergency, was likely a superinfection caused by COVID-19. This, along with the coagulopathy caused by the virus, introduced unique challenges to the treatment of a known pathology.

Inversed probability case-control analysis of operative burr hole evacuation versus subdural evacuating port system for chronic subdural hematomas: Clinical and economic outcomes.

INTRODUCTION: There are multiple treatments for a chronic subdural hematoma, a significant cause of neurosurgical morbidity that cost the healthcare system $5B in 2007, but few generalizable prospective studies. The purpose of this study was to examine outcomes of bedside Subdural Evacuation Port System (SEPS) placement as compared to operating room burr hole evacuation (BHE) to acquire data to support a randomized trial. METHODS: All procedures were performed in a single institution between 2011 and 2019. Patients were included if > 18 years of age, had chronic subdural hematoma, and were treated by SEPS or BHE. Patients with prior neurosurgical history, mass lesions or bilateral hematomas were excluded. Patients who met inclusion for SEPS (n = 55) or BHE (n = 105). Samples were propensity matched to account for variability. Non-inferiority tests compared outcomes. Cost data was obtained through billable charges. RESULTS: Patients with multiple comorbidities were more likely to undergo SEPS drainage. Noninferiority tests reported no statistically significant evidence to suggest SEPS drains were worse in reoperation-rate (18% vs 9%), post-operative seizure, or functional outcome. SEPS drain placement trended towards a faster time to procedure (3 h faster; p = 0.07) but the overall hospital stay was longer (4.23 vs 5.81, p = 0.01). SEPS drain placement costs are less than BHE, but these patients had 25% higher overall hospital costs (p = 0.01) due to comorbidities and increased hospital stay.

MIDDLE MENINGEAL ARTERY EMBOLIZATION AS A SAME-DAY DISCHARGE PROCEDURE

Introduction Middle meningeal artery embolization (MMAE) is a fundamental piece in the management of Chronic Subdural Hematoma (cSDH) that prevents recurrence and can serve as primary treatment for nonoperative candidates. MMAE offers time-effectiveness, since it may be performed in less than one hour under minimal sedation. As the COVID-19 pandemic makes inpatient beds scarce, MMAE could potentially become a same-day procedure which poses a potential economic benefit for both patients and health institutions alike. We reviewed MMAEs performed at our institution and measured the complication rates in an effort to determine if hospital admission after the procedure is necessary. Methods A retrospective analysis of patients who underwent MMAE for cSDH at the University of California, San Diego was performed. Data collected included post-procedural complications such as focal neurologic deficit, cognitive decline, and groin access-point hemorrhage identified within the first 4 hours, 24 hours, and delayed manner respectively. Success of treatment was defined as patient stability and return to baseline following the post-procedure assessment protocol performed routinely at our institution. We further characterized patients with the Charlson Comorbidity Index (CCI) to identify higher risk populations that would require increased observation. The CCI was also used to determine a cut-off point for same-day discharge eligibility. Results We analyzed data from 95 patients that had 143 subdural hematomas treated at our institution. Of the 95 patients, 93 patients (98%) had no complications following our institution's standardized assessments after MMAE or at discharge the following day. Average SDH size was 12.9mm. Twenty-one patients underwent surgical drainage after MMAE. Following MMAE, two patients presented complications;one patient, an 83-year-old female, developed transient headache and blurry vision one day after MMAE and was discharged uneventfully;this patient had a CCI of 4 points. The other patient was a 77-year-old male with metastatic prostate carcinoma and had an SDH volume expansion one day after the procedure which required operative intervention with burr-hole craniotomy and drainage;this patient had a CCI of 9 points (0% estimated 10-year survival). The remaining 93 patients suffered no complications after MMAE. Conclusion Time-effectiveness and low complication rates make MMAE an ideal same-day procedure for patients with cSDH and a low CCI score. The grand majority of patients had no complications following MMAE, suggesting a large patient population that may benefit from the same-day procedure aspect of intervention. Although some patients underwent planned surgical drainage, the embolization component of management was uneventful. Our analysis provides evidence that MMAE could develop into an ambulatory procedure in patients with cSDH and a low comorbidity profile;this could have economic benefits for both the patients requiring and the institutions offering the procedure. Further prospective studies are needed to strengthen these findings.

Decline in the Incidence of Chronic Subdural Hematoma During the Coronavirus Disease 2019 Pandemic: A Retrospective Single-Center Descriptive Study.

The coronavirus disease 2019 (COVID-19) pandemic has forced restrictions on social activities in some areas. There has also been a decrease in the number of trauma patients in the United States during the COVID-19 pandemic. Chronic subdural hematoma (CSDH) is a traumatic disorder that often develops following head injury. We therefore investigated the impact of the COVID-19 pandemic on CSDH. In this retrospective single-center descriptive study from April 2018 through September 2021, there were 5,282 head trauma patients and 196 patients with CSDH in the pre-pandemic group compared to 4,459 head trauma patients and 140 patients with CSDH in the intra-pandemic group. Significant decreases in the incidence rate (IR) of head trauma (951/100,000 vs. 795/100,000 person-years; IR ratio (IRR): 0.836, 95% confidence interval (CI): 0.803-0.870, p < 0.001) and also in the IR of CSDH (35.0/100,000 vs. 24.8/100,000 person-years, IRR: 0.708, 95% CI: 0.570-0.879, p = 0.002) were seen in the intra-pandemic group compared to the pre-pandemic group. In this study, the COVID-19 pandemic was associated with significant decreases in the IRs of head trauma and CSDH due to forced restrictions on social activities. Besides, the IR of mild cases of CSDH was significantly lower in the intra-pandemic group than in the pre-pandemic group (IRR: 0.68, 95% CI: 0.51-0.89, p = 0.006). Fewer people being out in communities should result in fewer chances for head trauma and CSDH. On the other hand, forced restrictions on social activities due to the COVID-19 pandemic should aggravate CSDH.

Adherence to the NICE traumatic brain injury management guidelines in a trauma centre during the covid pandemic

Objectives: The National Institute of Health and Care Excellence (NICE) has set standards for TBI patients' initial assessment and management. This study assessed respect for NICE TBI guidelines in patients referred to an English trauma centre during the Covid-19 pandemic. Design: A cross-sectional study. Subjects: TBI patients who presented to a District General Hospital between 1st December 2020 and 12th August 2021 and were referred to the tertiary neurosurgical centre. Methods: Data were collected from the electronic medical records of our subjects. Descriptive statistical analysis of the time between patients presenting to the emergency department, being reviewed by a trained member of staff, request for cranial CT imaging, and response to neurosurgical referral was done with SPSS version 27.0. Results: We collected data on 115 patients, and the TBI frequency peaked in the 60-99 age range. Most patients were men (55.9%, n = 65), and 77% had a frailty score of 5 or less, with 90% presenting with a GCS range of 13-15. At the referring hospital, twenty-eight percent (n = 32) of the patients were evaluated by a trained member of staff within 15 min of admission, and only 30% (n = 35) had cranial CT imaging within an hour of the assessment. Only half of the referrals (n = 58) were reviewed by Neurosurgeons within an hour. The most common lesion on cranial CT imaging was a subdural haemorrhage (34%, n = 40).

Making every operation count - using an instructional design model to maximise the learning experience in neurosurgery

Objectives: Recent reforms to postgraduate medical education, the 'Shape of Training (SoT)' and 'Excellence by Design: standard for postgraduate curricula' mandate a re-evaluation of the way in which surgical education is delivered, particularly in the teaching of surgical techniques. More so, as we continue to train with the restrictions imposed by the COVID pandemic, emphasis must be placed on maximising every training opportunity. Design: In this article, we demonstrate the utility of an instructional design method to enhance the teaching of neurosurgical procedures. Specifically, we utilise the instructional design method of teaching first described by Robert Gagne in the 1960s. Subjects: The framework we provide can be used to equip all neurosurgical trainees with the necessary capabilities to achieve the high-level outcomes expected from the new curriculum. Methods: We design a lesson plan using Gagne's nine events of instruction, in this case using burr hole evacuation of chronic subdural haematomas as an example. The ordered nature of Gagne's nine-step model allows a complete picture to be formed and structures teaching for a comparable learning experience. Conclusions: One particular strength of this teaching method is placing the learned skill in the wider context of patient care includes perioperative management. By empowering trainees to consider all aspects of the underlying reasoning for a procedure, well-rounded clinicians can be developed who are comfortable in the real-world application of procedural skills. The creative lesson plan optimises the learning process and ensures that the objectives are comprehensively fulfilled. The structured approach fortifies a good basis for understanding the operation and ensures that progression to independence is a safe approach.