Utilizing artificial intelligence and electroencephalography to assess expertise on a simulated neurosurgical task.

Virtual reality surgical simulators have facilitated surgical education by providing a safe training environment. Electroencephalography (EEG) has been employed to assess neuroelectric activity during surgical performance. Machine learning (ML) has been applied to analyze EEG data split into frequency bands. Although EEG is widely used in fields requiring expert performance, it has yet been used to classify surgical expertise. Thus, the goals of this study were to (a) develop an ML model to accurately differentiate skilled and less-skilled performance using EEG data recorded during a simulated surgery, (b) explore the relative importance of each EEG bandwidth to expertise, and (c) analyze differences in EEG band powers between skilled and less-skilled individuals. We hypothesized that EEG recordings during a virtual reality surgery task would accurately predict the expertise level of the participant. Twenty-one participants performed three simulated brain tumor resection procedures on the NeuroVR™ platform (CAE Healthcare, Montreal, Canada) while EEG data was recorded. Participants were divided into 2 groups. The skilled group was composed of five neurosurgeons and five senior neurosurgical residents (PGY4-6), and the less-skilled group was composed of six junior residents (PGY1-3) and five medical students. A total of 13 metrics from EEG frequency bands and ratios (e.g., alpha, theta/beta ratio) were generated. Seven ML model types were trained using EEG activity to differentiate between skilled and less-skilled groups. The artificial neural network achieved the highest testing accuracy of 100% (AUROC = 1.0). Model interpretation via Shapley analysis identified low alpha (8-10 Hz) as the most important metric for classifying expertise. Skilled surgeons displayed higher (p = 0.044) low-alpha than the less-skilled group. Furthermore, skilled surgeons displayed significantly lower TBR (p = 0.048) and significantly higher beta (13-30 Hz, p = 0.049), beta 1 (15-18 Hz, p = 0.014), and beta 2 (19-22 Hz, p = 0.015), thus establishing these metrics as important markers of expertise. ACGME CORE COMPETENCIES: Practice-Based Learning and Improvement.

Nondominant Hand Skills Spatial and Psychomotor Analysis During a Complex Virtual Reality Neurosurgical Task-A Case Series Study.

BACKGROUND: Virtual reality surgical simulators provide detailed psychomotor performance data, allowing qualitative and quantitative assessment of hand function. The nondominant hand plays an essential role in neurosurgery in exposing the operative area, assisting the dominant hand to optimize task execution, and hemostasis. Outlining expert-level nondominant hand skills may be critical to understand surgical expertise and aid learner training. OBJECTIVE: To (1) provide validity for the simulated bimanual subpial tumor resection task and (2) to use this simulation in qualitative and quantitative evaluation of nondominant hand skills for bipolar forceps utilization. METHODS: In this case series study, 45 right-handed participants performed a simulated subpial tumor resection using simulated bipolar forceps in the nondominant hand for assisting the surgery and hemostasis. A 10-item questionnaire was used to assess task validity. The nondominant hand skills across 4 expertise levels (neurosurgeons, senior trainees, junior trainees, and medical students) were analyzed by 2 visual models and performance metrics. RESULTS: Neurosurgeon median (range) overall satisfaction with the simulated scenario was 4.0/5.0 (2.0-5.0). The visual models demonstrated a decrease in high force application areas on pial surface with increased expertise level. Bipolar-pia mater interactions were more focused around the tumoral region for neurosurgeons and senior trainees. These groups spent more time using the bipolar while interacting with pia. All groups spent significantly higher time in the left upper pial quadrant than other quadrants. CONCLUSION: This work introduces new approaches for the evaluation of nondominant hand skills which may help surgical trainees by providing both qualitative and quantitative feedback.

Continuous monitoring of surgical bimanual expertise using deep neural networks in virtual reality simulation.

In procedural-based medicine, the technical ability can be a critical determinant of patient outcomes. Psychomotor performance occurs in real-time, hence a continuous assessment is necessary to provide action-oriented feedback and error avoidance guidance. We outline a deep learning application, the Intelligent Continuous Expertise Monitoring System (ICEMS), to assess surgical bimanual performance at 0.2-s intervals. A long-short term memory network was built using neurosurgeon and student performance in 156 virtually simulated tumor resection tasks. Algorithm predictive ability was tested separately on 144 procedures by scoring the performance of neurosurgical trainees who are at different training stages. The ICEMS successfully differentiated between neurosurgeons, senior trainees, junior trainees, and students. Trainee average performance score correlated with the year of training in neurosurgery. Furthermore, coaching and risk assessment for critical metrics were demonstrated. This work presents a comprehensive technical skill monitoring system with predictive validation throughout surgical residency training, with the ability to detect errors.

Assessment of learning curves on a simulated neurosurgical task using metrics selected by artificial intelligence.

OBJECTIVE: Understanding the variation of learning curves of experts and trainees for a given surgical procedure is important in implementing formative learning paradigms to accelerate mastery. The study objectives were to use artificial intelligence (AI)-derived metrics to determine the learning curves of participants in 4 groups with different expertise levels who performed a series of identical virtual reality (VR) subpial resection tasks and to identify learning curve differences among the 4 groups. METHODS: A total of 50 individuals participated, 14 neurosurgeons, 4 neurosurgical fellows and 10 senior residents (seniors), 10 junior residents (juniors), and 12 medical students. All participants performed 5 repetitions of a subpial tumor resection on the NeuroVR (CAE Healthcare) platform, and 6 a priori-derived metrics selected using the K-nearest neighbors machine learning algorithm were used to assess participant learning curves. Group learning curves were plotted over the 5 trials for each metric. A mixed, repeated-measures ANOVA was performed between the first and fifth trial. For significant interactions (p < 0.05), post hoc Tukey's HSD analysis was conducted to determine the location of the significance. RESULTS: Overall, 5 of the 6 metrics assessed had a significant interaction (p < 0.05). The 4 groups, neurosurgeons, seniors, juniors, and medical students, showed an improvement between the first and fifth trial on at least one of the 6 metrics evaluated. CONCLUSIONS: Learning curves generated using AI-derived metrics provided novel insights into technical skill acquisition, based on expertise level, during repeated VR-simulated subpial tumor resections, which will allow educators to develop more focused formative educational paradigms for neurosurgical trainees.

Effect of Artificial Intelligence Tutoring vs Expert Instruction on Learning Simulated Surgical Skills Among Medical Students: A Randomized Clinical Trial.

Importance: To better understand the emerging role of artificial intelligence (AI) in surgical training, efficacy of AI tutoring systems, such as the Virtual Operative Assistant (VOA), must be tested and compared with conventional approaches. Objective: To determine how VOA and remote expert instruction compare in learners' skill acquisition, affective, and cognitive outcomes during surgical simulation training. Design, Setting, and Participants: This instructor-blinded randomized clinical trial included medical students (undergraduate years 0-2) from 4 institutions in Canada during a single simulation training at McGill Neurosurgical Simulation and Artificial Intelligence Learning Centre, Montreal, Canada. Cross-sectional data were collected from January to April 2021. Analysis was conducted based on intention-to-treat. Data were analyzed from April to June 2021. Interventions: The interventions included 5 feedback sessions, 5 minutes each, during a single 75-minute training, including 5 practice sessions followed by 1 realistic virtual reality brain tumor resection. The 3 intervention arms included 2 treatment groups, AI audiovisual metric-based feedback (VOA group) and synchronous verbal scripted debriefing and instruction from a remote expert (instructor group), and a control group that received no feedback. Main Outcomes and Measures: The coprimary outcomes were change in procedural performance, quantified as Expertise Score by a validated assessment algorithm (Intelligent Continuous Expertise Monitoring System [ICEMS]; range, -1.00 to 1.00) for each practice resection, and learning and retention, measured from performance in realistic resections by ICEMS and blinded Objective Structured Assessment of Technical Skills (OSATS; range 1-7). Secondary outcomes included strength of emotions before, during, and after the intervention and cognitive load after intervention, measured in self-reports. Results: A total of 70 medical students (41 [59%] women and 29 [41%] men; mean [SD] age, 21.8 [2.3] years) from 4 institutions were randomized, including 23 students in the VOA group, 24 students in the instructor group, and 23 students in the control group. All participants were included in the final analysis. ICEMS assessed 350 practice resections, and ICEMS and OSATS evaluated 70 realistic resections. VOA significantly improved practice Expertise Scores by 0.66 (95% CI, 0.55 to 0.77) points compared with the instructor group and by 0.65 (95% CI, 0.54 to 0.77) points compared with the control group (P < .001). Realistic Expertise Scores were significantly higher for the VOA group compared with instructor (mean difference, 0.53 [95% CI, 0.40 to 0.67] points; P < .001) and control (mean difference. 0.49 [95% CI, 0.34 to 0.61] points; P < .001) groups. Mean global OSATS ratings were not statistically significant among the VOA (4.63 [95% CI, 4.06 to 5.20] points), instructor (4.40 [95% CI, 3.88-4.91] points), and control (3.86 [95% CI, 3.44 to 4.27] points) groups. However, on the OSATS subscores, VOA significantly enhanced the mean OSATS overall subscore compared with the control group (mean difference, 1.04 [95% CI, 0.13 to 1.96] points; P = .02), whereas expert instruction significantly improved OSATS subscores for instrument handling vs control (mean difference, 1.18 [95% CI, 0.22 to 2.14]; P = .01). No significant differences in cognitive load, positive activating, and negative emotions were found. Conclusions and Relevance: In this randomized clinical trial, VOA feedback demonstrated superior performance outcome and skill transfer, with equivalent OSATS ratings and cognitive and emotional responses compared with remote expert instruction, indicating advantages for its use in simulation training. Trial Registration: ClinicalTrials.gov Identifier: NCT04700384.

Pattern of neurosurgical practice at a university hospital in KSA during COVID-19 pandemic.

Objective: The coronavirus disease 2019 (COVID-19) pandemic affected both medical services as well as hospital admissions. Scholars have attempted to study the effect of the pandemic on the services of multiple specialities. In this study, we aim to examine the pandemic's impact on the neurosurgical service provided at the King Abdulaziz University Hospital in Jeddah over an eight-month period. Methods: In this retrospective, single-centre case series study, we included all the consecutive neurosurgical patients who underwent a surgical intervention in the 8-month period starting on 3rd March, 2020 and ending on 3rd November, 2020. The demographics, diagnosis, surgery type, priority category, and mortality data of the patients were collected. Results: A total of 147 patients underwent surgery during the study period. The mean age was 30.8 years. Forty-nine percent of the study population were men. Oncology (31.3%) and hydrocephalus (23.8%) recorded the highest number of cases. More than half of the cases were Priority 1 (immediate and within 24 h). The mortality rate was 4.1% among all the performed cases. Conclusion: By describing this local neurosurgical experience during the COVID-19 pandemic, we hope to bring out some of the difficulties we encountered and improve what we learned during the pandemic.

Cervical Spinal Cord Injury During Prone Position Ventilation in the COVID-19 Pandemic.

The prone positioning of patients experiencing acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has been proven effective in optimizing oxygenation and lung function. However, such patients may be at risk of developing complications due to the prolonged prone position in intensive critical care. A 45-year-old COVID-19 female, not known with cervical spine disease, presented with progressive severe COVID-19-related hypoxemia that required intensive care unit admission for pulmonary care. She was positioned prone and ventilated for several weeks. She developed a rapidly advanced decreased level of consciousness and flaccid quadriparesis. CT and MRI scans of the cervical spine revealed C4/C5 fracture-dislocation with spinal cord compression in asymptomatic ankylosing spondylitis and focal ossification of a posterior longitudinal ligament. In addition, the patient had severe ARDS-SARS-CoV-2 hemodynamic instability. Surgery was not performed due to her critical condition, and the patient died from multi-organ failure. Patients with underlying cervical spine disease or deformity can be subjected to hyperextension and develop fatigue (stress) spinal fracture, leading to spinal cord compression. To our knowledge, this is the first case of spontaneous cervical spine fracture dislocation in a COVID-19 patient after several weeks in prone position ventilation in ICU. Hence, our case report raises the awareness of the possibility of devastating spinal cord injuries in prone position ventilation during the COVID-19 pandemic and the need for early screening using plain X-rays of these patients for cervical spine disease.

Risk factors for surgical site infection following spinal surgery in Saudi Arabia: A retrospective case-control study.

ABSTRACT: Surgical site infections (SSIs) are common complications after spinal surgery that result in increased morbidity, mortality, and healthcare costs. It was estimated that SSIs after spinal surgery resulted in a 4-fold increase in health care costs. The reported SSI rate following spinal surgery remains highly variable between approximately 0.5% and 18%. In this study, we aimed to estimate the SSI rate and identify possible risk factors for SSI after spinal surgery in our Saudi patient population.We conducted a single-center, retrospective case-control study in Saudi Arabia that included patients who developed SSIs, while the controls were all consecutive patients who underwent spinal surgery between January 2014 and December 2016. We extracted data on patient characteristics, anthropometric measurements, preoperative laboratory investigations, preoperative infection prevention measures, intraoperative measures, comorbidities, and postoperative care.We included 201 consecutive patients in our study; their median age was 56.9 years, and 51.2% were men. Only 4% (n = 8) of these patients developed SSIs postoperatively. Postoperative SSIs were significantly associated with longer postoperative hospital stays, hypertension, higher American Society of Anesthesia (ASA) scores, longer procedure durations, and the use of a greater number of blood transfusion units.This study revealed a low SSI rate following spinal surgery. We identified a history of hypertension, prolonged hospitalization, longer operative time, blood transfusion, and higher ASA score as risk factors for SSI in spine surgery in our population. As our findings are from a single institute, we believe that a national research collaboration among multiple disciplines should be performed to provide better estimates of SSI risk factors in our patient population.

Perception of Neurosurgery Residents and Attendings on Online Webinars During COVID-19 Pandemic and Implications on Future Education.

BACKGROUND: Online education has provided an important tool to continue medical education during the COVID-19 pandemic. Our study aimed to evaluate trainee and attending perceptions of online webinars as an educational tool in neurosurgery. METHODS: We conducted a cross-sectional survey study. A web-based 19-question survey was distributed to the people who attended the webinar series that was carried out by the Saudi Association of Neurological Surgery from March 29, 2020 to May 31, 2020. Candidates were identified through their registration e-mails. The survey was distributed June 5-8, 2020. RESULTS: A total of 156 responses were received (survey response rate: 60%). The overall satisfaction rate among residents and attendings (board-certified neurosurgeons) was similar (>80%). However, only 56.4% of attendings reported they were comfortable with online webinars compared with 81.2% of residents (P value <0.0001). Seventy-five percent of residents found online lectures more useful than traditional in-person lectures compared with 52% of attendings (P value = 0.01). CONCLUSIONS: Online educational webinars provide an educational value that can be considered as an adjunct to traditional (in-person) education methods. Among trainees, the satisfaction of neurosurgery webinars was encouraging to consider as an education method. More objective research and progress are required to adopt and refine existing online didactic and neurosurgical teaching tools while creating more engaging future distant learning models.

The longitudinal impact of COVID-19 pandemic on neurosurgical practice.

OBJECTIVE: This observational cross-sectional multicenter study aimed to evaluate the longitudinal impact of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical practice. METHODS: We included 29 participating neurosurgeons in centers from all geographical regions in the Kingdom of Saudi Arabia. The study period, which was between March 5, 2020 and May 20, 2020, was divided into three equal periods to determine the longitudinal effect of COVID-19 measures on neurosurgical practice over time. RESULTS: During the 11-week study period, 474 neurosurgical interventions were performed. The median number of neurosurgical procedures per day was 5.5 (interquartile range [IQR]: 3.5-8). The number of cases declined from 72 in the first week and plateaued at the 30's range in subsequent weeks. The most and least number of performed procedures were oncology (129 [27.2 %]) and functional procedures (6 [1.3 %]), respectively. Emergency (Priority 1) cases were more frequent than non-urgent (Priority 4) cases (178 [37.6 %] vs. 74 [15.6 %], respectively). In our series, there were three positive COVID-19 cases. There was a significant among-period difference in the length of hospital stay, which dropped from a median stay of 7 days (IQR: 4-18) to 6 (IQR: 3-13) to 5 days (IQR: 2-8). There was no significant among-period difference with respect to institution type, complications, or mortality. CONCLUSION: Our study demonstrated that the COVID-19 pandemic decreased the number of procedures performed in neurosurgery practice. The load of emergency neurosurgery procedures did not change throughout the three periods, which reflects the need to designate ample resources to cover emergencies. Notably, with strict screening for COVID -19 infections, neurosurgical procedures could be safely performed during the early pandemic phase. We recommend to restart performing neurosurgical procedures once the pandemic gets stabilized to avoid possible post pandemic health-care system intolerable overload.

Neurosurgical Procedures and Safety During the COVID-19 Pandemic: A Case-Control Multicenter Study.

OBJECTIVE: Quantitative documentation of the effects of outbreaks, including the coronavirus disease 2019 (COVID-19) pandemic, is limited in neurosurgery. Our study aimed to evaluate the effects of the COVID-19 pandemic on neurosurgical practice and to determine whether surgical procedures are associated with increased morbidity and mortality. METHODS: A multicenter case-control study was conducted, involving patients who underwent neurosurgical intervention in the Kingdom of Saudi Arabia during 2 periods: pre-COVID-19 and during the COVID-19 pandemic. The surgical intervention data evaluated included diagnostic category, case priority, complications, length of hospital stay, and 30-day mortality. RESULTS: A total of 850 procedures were included, 36% during COVID-19. The median number of procedures per day was significantly lower during the COVID-19 period (5.5 cases) than during the pre-COVID-19 period (12 cases; P < 0.0001). Complications, length of hospital stay, and 30-day mortality did not differ during the pandemic. In a multivariate analysis comparing both periods, case priority levels 1 (immediate) (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.24-2.67), 1 (1-24 h) (OR, 1.63; 95% CI, 1.10-2.41), and 4 (OR, 0.28; 95% CI, 0.19-0.42) showed significant differences. CONCLUSIONS: During the early phase of the COVID-19 pandemic, the overall number of neurosurgical procedures declined, but the load of emergency procedures remained the same, thus highlighting the need to allocate sufficient resources for emergencies. More importantly, performing neurosurgical procedures during the pandemic in regions with limited effects of the outbreak on the health care system was safe. Our findings may aid in developing guidelines for acute and long-term care during pandemics in surgical subspecialties.

Dural Venous Sinus Thrombosis in Patients Presenting with Blunt Traumatic Brain Injuries and Skull Fractures: A Systematic Review and Meta-Analysis.

BACKGROUND: Dural venous sinus thrombosis (DVST) is an increasingly recognized complication of blunt traumatic brain injury (TBI) and skull fractures. However, data concerning epidemiology and clinical significance of DVST are unclear. Determining the disease burden in patients with TBI is an important first step to guide future studies assessing the natural course of traumatic DVST or the effects of its treatment. Therefore, we performed to our knowledge the first systematic review and meta-analysis evaluating the prevalence of DVST in patients with TBI and skull fractures. METHODS: MEDLINE and Embase databases were systematically searched for relevant studies published up to March 2018. All studies that assessed the prevalence of DVST among patients with TBI who underwent a vascular imaging study were included. The primary outcome was the presence or absence of DVST on imaging. A random-effects meta-analysis was used to pool studies. RESULTS: Our systematic review yielded 638 articles, and 13 articles met inclusion criteria. In patients with skull fractures adjacent to a venous sinus, the prevalence was 26.2% (95% confidence interval = 19.4%-34.4%). This elevated risk was similar between adult (pooled estimate 23.8%; 95% CI = 16.2%-33.5%) and pediatric (pooled estimate 31.3%; 95% CI = 19.1%-46.9%) populations. CONCLUSIONS: We found an unexpectedly high and consistent frequency of DVST among patients with skull fractures regardless of age group or severity of brain injury. These findings are important and highlight the need for further understanding the natural history of DVST and providing better guidelines on its management.

Significant incidental brain magnetic resonance imaging findings in migraine headache patients: Retrospective cross-sectional study.

BACKGROUND: Migraine is one of the most common complaints encountered in neurology clinics. Accurate diagnoses of migraine are usually informed by the patient's history, and neuroimaging is only performed in cases of atypical or severe, medically intractable headache to rule out underlying pathologies. Our study aimed to identify the spectrum of brain magnetic resonance imaging (MRI) findings characteristic of chronic headache. METHODS: This retrospective study of adult patients referred to the First Scan radiology clinic in Jeddah, Saudi Arabia, for brain MRI with a known diagnosis of migraine headache was performed between April 2016 to May 2017. RESULTS: We included 275 adults (115 men; median age, 38 years, IQR 30-52) with known diagnoses of chronic migraine. Incidental MRI findings were discovered in 157 (57 %) of the scans; 23 (8.3 %) of these were clinically significant, indicating the need for an intervention. Patients aged >40 years were more likely to have an abnormal scan. There were no significant differences related to sex or duration of headaches for more than one year. CONCLUSION: The performance of brain MRI warrants consideration in patients who do not respond as expected to migraine and headache treatment. We found clinically significant MRI findings in up to 8 % of such patients. Abnormal imaging findings were the most common among patients of >40 years of age.

Roadmap for Developing Complex Virtual Reality Simulation Scenarios: Subpial Neurosurgical Tumor Resection Model.

BACKGROUND: Advancement and evolution of current virtual reality (VR) surgical simulation technologies are integral to improve the available armamentarium of surgical skill education. This is especially important in high-risk surgical specialties. Such fields including neurosurgery are beginning to explore the utilization of virtual reality simulation in the assessment and training of psychomotor skills. An important issue facing the available VR simulation technologies is the lack of complexity of scenarios that fail to replicate the visual and haptic realities of complex neurosurgical procedures. Therefore there is a need to create more realistic and complex scenarios with the appropriate visual and haptic realities to maximize the potential of virtual reality technology. METHODS: We outline a roadmap for creating complex virtual reality neurosurgical simulation scenarios using a step-wise description of our team's subpial tumor resection project as a model. RESULTS: The creation of complex neurosurgical simulations involves integrating multiple modules into a scenario-building roadmap. The components of each module are described outlining the important stages in the process of complex VR simulation creation. CONCLUSIONS: Our roadmap of a stepwise approach for the creation of complex VR-simulated neurosurgical procedures may also serve as a guide to aid the development of other VR scenarios in a variety of surgical fields. The generation of new VR complex simulated neurosurgical procedures, by surgeons for surgeons, with the help of computer scientists and engineers may improve the assessment and training of residents and ultimately improve patient care.

A Comparison of Visual Rating Scales and Simulated Virtual Reality Metrics in Neurosurgical Training: A Generalizability Theory Study.

BACKGROUND: Adequate assessment and feedback remains a cornerstone of psychomotor skills acquisition, particularly within neurosurgery where the consequence of adverse operative events is significant. However, a critical appraisal of the reliability of visual rating scales in neurosurgery is lacking. Therefore, we sought to design a study to compare visual rating scales with simulated metrics in a neurosurgical virtual reality task. METHODS: Neurosurgical faculty rated anonymized participant video recordings of the removal of simulated brain tumors using a visual rating scale made up of seven composite elements. Scale reliability was evaluated using generalizability theory, and scale subcomponents were compared with simulated metrics using Pearson correlation analysis. RESULTS: Four staff neurosurgeons evaluated 16 medical student neurosurgery applicants. Overall scale reliability and internal consistency were 0.73 and 0.90, respectively. Reliability of 0.71 was achieved with two raters. Individual participants, raters, and scale items accounted for 27%, 11%, and 0.6% of the data variability. The hemostasis scale component related to the greatest number of simulated metrics, whereas respect for no-go zones and tissue was correlated with none. Metrics relating to instrument force and patient safety (brain volume removed and blood loss) were captured by the fewest number of rating scale components. CONCLUSIONS: To our knowledge, this is the first study comparing participant's ratings with simulated performance. Given rating scales capture less well instrument force, quantity of brain volume removed, and blood loss, we suggest adopting a hybrid educational approach using visual rating scales in an operative environment, supplemented by simulated sessions to uncover potentially problematic surgical technique.

Effect of Intrawound Vancomycin on Surgical Site Infections in Nonspinal Neurosurgical Procedures: A Systematic Review and Meta-Analysis.

BACKGROUND: Applying vancomycin into the surgical site has been well-described in spinal neurosurgery, with extensive institutional experience and systematic reviews describing its effectiveness in reducing surgical site infections (SSIs). Its use in nonspinal neurosurgical procedures is a logical extension of those findings; however, recent studies have described varying degrees of success. We have summarized the effect of local vancomycin application on SSIs in nonspinal neurosurgical procedures and describe the quality of the supporting evidence. METHODS: MEDLINE, Embase, and Google Scholar were searched through June 2018. Information on study design, demographic data, exposure, and outcomes was extracted. The estimates were combined using random-effects models. RESULTS: Our search retrieved 9 studies for quantitative analysis. They assessed vancomycin use in craniotomy, cranioplasty, deep brain stimulator-related procedures, and ventriculoperitoneal shunt surgery. Most of the studies had serious methodological shortcomings that introduced confounding. We found an overall beneficial effect on SSI incidence (odds ratio, 0.25; 95% confidence interval, 0.12-0.52), which was seen across all subspecialties, except for cranioplasty. The use of vancomycin did not result in the emergence of resistant infections or in a significant increase in the proportion of infections caused by gram-negative organisms. CONCLUSIONS: Vancomycin use in nonspinal neurosurgery is not supported by high-quality evidence, limiting the strength of the conclusions that can be drawn on the topic. Nonetheless, we found an overall favorable effect on SSIs (except in the context of cranioplasty), which should be reproduced in a randomized controlled fashion.

Is Virtual Reality Surgical Performance Influenced by Force Feedback Device Utilized?

OBJECTIVE: The study objectives were to assess if surgical performance and subjective assessment of a virtual reality simulator platform was influenced by changing force feedback devices. DESIGN: Participants used the NeuroVR (formerly NeuroTouch) simulator to perform 5 practice scenarios and a realistic scenario involving subpial resection of a virtual reality brain tumor with simulated bleeding. The influence of force feedback was assessed by utilizing the Omni and Entact haptic systems. Tier 1, tier 2, and tier 2 advanced metrics were used to compare results. Operator subjective assessment of the haptic systems tested utilized seven Likert criteria (score 1 to 5). SETTING: The study is carried out at the McGill Neurosurgical Simulation Research and Training Centre, Montreal Neurological Institute and Hospital, Montreal, Canada. PARTICIPANTS: Six expert operators in the utilization of the NeuroVR simulator platform. RESULTS: No significant differences in surgical performance were found between the two haptic devices. Participants significantly preferred the Entact system on all 7 Likert criteria of subjective assessment. CONCLUSIONS: Our results show no statistical differences in virtual reality surgical performance utilizing the two bimanual haptic devices tested. Subjective assessments demonstrated that participants preferred the Entact system. Our results suggest that to maximize realism of the training experience educators employing virtual reality simulators may find it useful to assess expert opinion before choosing a force feedback device.

Use of a radial artery 'slender' sheath for facilitating transfemoral arterial access for neuroendovascular embolization in a very young infant.

Pediatric neuroendovascular procedures are increasingly performed as several studies have shown the safety of these interventions. In the literature, an upper limit of 4 French catheter size is conventionally used for femoral access in neuroangiography of very young infants. However, this constraint in luminal size may not allow for more complex procedures. We present the previously unreported use of a radial 5 French slender catheter with ultrathin walls for femoral access for aneurysm embolization in a 3-month-old boy presenting with left M2 aneurysm rupture.