A rare case of herpes simplex virus encephalitis from viral reactivation following surgically treated traumatic brain injury.

OBJECTIVE: Herpes simplex virus encephalitis (HSVE) is associated with significant morbidity and mortality. Here, we present the occurrence of HSVE in a 36-year-old immunocompetent patient following craniotomy for a traumatic acute subdural hematoma (ASDH). METHODS: Imaging after four days of progressive headache following a fall with head-strike demonstrated a 1 cm thick left holohemispheric ASDH with significant cerebral compression, edema, and 8 mm of left-to-right midline shift, and an emergent craniotomy and ASDH evacuation were performed, with additional treatment needed for reaccumulation. Postoperatively, the patient developed a worsening leukocytosis, became febrile, and was hypotensive requiring vasopressor support. RESULTS: Despite empiric antibiotics, the patient remained persistently febrile with significant leukocytosis. Repeat head CT showed a new left insular hypodensity and a subsequent viral encephalitis panel was positive for HSV-1. The patient was then started on intravenous acyclovir, with progressive neurological exam improvement. Of note, the patient was noted to have a positive serum HSV-1 IgG antibody titer, indicative of prior infection. CONCLUSIONS: Given the known systemic immunosuppression in brain injury and the high prevalence of HSV seropositivity, clinicians should consider the possibility of HSVE from HSV reactivation in TBI patients with persistent fever, leukocytosis, and/or neurological deficits without an obvious etiology.

Prevalence of Acute Alcohol Use in Traumatic Brain Injury Patients During the COVID-19 Pandemic: A Retrospective Analysis From Queens, New York.

Background This study investigates the impact of New York's relaxed alcohol consumption policies during the coronavirus disease (COVID-19) pandemic on alcohol-related traumatic brain injuries (TBIs) among patients admitted to a Level 1 trauma center in Queens. Given the limited research available, this study critically explores the link between public health policies and trauma care. It aims to address a significant gap in the literature and highlight the implications of alcohol regulations during global health emergencies. Methodology A retrospective analysis was conducted among trauma patients from 2019 to 2021. The study period was divided into the following three periods: pre-lockdown (March 7, 2019, to July 31, 2019), lockdown (March 7, 2020, to July 31, 2020), and post-lockdown (March 7, 2021, to July 31, 2021). Data on demographics, injury severity, comorbidities, and outcomes were collected. The study focused on assessing the correlation between New York's alcohol policies and alcohol-related TBI admissions during these periods. Results A total of 1,074 admissions were analyzed. The study found no significant changes in alcohol-positive patients over the full calendar years of 2019, 2020, and 2021 (42.65%, 38.91%, and 31.16% respectively; p = 0.08711). Specifically, during the lockdown period, rates of alcohol-positive TBI patients remained unchanged, despite the relaxed alcohol policies. There was a decrease in alcohol-related TBI admissions in 2021 compared to 2020 during the lockdown period. Conclusions Our study concludes that New York's specific alcohol policies during the COVID-19 pandemic were not correlated with an increase in alcohol-related TBI admissions. Despite the relaxation of alcohol consumption laws, there was no increase in alcohol positivity among TBI patients. The findings suggest a complex relationship between public policies, alcohol use, and trauma during pandemic conditions, indicating that factors other than policy relaxation might influence alcohol-related trauma incidences.

Ultra-Early (<5 Hours) Decompression for Thoracolumbar Spinal Cord Injury: A Case Series.

Early surgical decompression within 24 hours for traumatic spinal cord injury (SCI) is associated with improved neurological recovery. However, the ideal timing of decompression is still up for debate. The objective of this study was to utilize our retrospective single-institution series of ultra-early (<5 hours) decompression to determine if ultra-early decompression led to improved neurological outcomes and was a feasible target over previously defined early decompression targets. Retrospective data on patients with SCI who underwent ultra-early (<5 hours) decompression at a level one metropolitan trauma center were extracted and collected from 2015-2018. American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade improvement was the primary outcome, with ASIA Motor score improvement and complication rate as secondary outcomes. Four individuals met the criteria for inclusion in this case series. All four suffered thoracolumbar SCI. All patients improved neurologically by AIS grade, and there were no complications directly related to ultra-early surgery. Given the small sample size, there was no statistically significant difference in outcomes compared to a control group who underwent early (5-24 hour) decompression in the same period. Ultra-early decompression is a feasible and safe target for thoracolumbar SCI and may lead to improved neurological outcomes without increased risk of complications. This case series can help create the foundation for future, larger studies that may definitively show the benefit of ultra-early decompression.

Exploiting Natural Language Processing to Unveil Topics and Trends of Traumatic Brain Injury Research.

Traumatic brain injury (TBI) has evolved from a topic of relative obscurity to one of widespread scientific and lay interest. The scope and focus of TBI research have shifted, and research trends have changed in response to public and scientific interest. This study has two primary goals: first, to identify the predominant themes in TBI research; and second, to delineate "hot" and "cold" areas of interest by evaluating the current popularity or decline of these topics. Hot topics may be dwarfed in absolute numbers by other, larger TBI research areas but are rapidly gaining interest. Likewise, cold topics may present opportunities for researchers to revisit unanswered questions. We utilized BERTopic, an advanced natural language processing (NLP)-based technique, to analyze TBI research articles published since 1990. This approach facilitated the identification of key topics by extracting sets of distinctive keywords representative of each article's core themes. Using these topics' probabilities, we trained linear regression models to detect trends over time, recognizing topics that were gaining (hot) or losing (cold) relevance. Additionally, we conducted a specific analysis focusing on the trends observed in TBI research in the current decade (the 2020s). Our topic modeling analysis categorized 42,422 articles into 27 distinct topics. The 10 most frequently occurring topics were: "Rehabilitation," "Molecular Mechanisms of TBI," "Concussion," "Repetitive Head Impacts," "Surgical Interventions," "Biomarkers," "Intracranial Pressure," "Posttraumatic Neurodegeneration," "Chronic Traumatic Encephalopathy," and "Blast Induced TBI," while our trend analysis indicated that the hottest topics of the current decade were "Genomics," "Sex Hormones," and "Diffusion Tensor Imaging," while the cooling topics were "Posttraumatic Sleep," "Sensory Functions," and "Hyperosmolar Therapies." This study highlights the dynamic nature of TBI research and underscores the shifting emphasis within the field. The findings from our analysis can aid in the identification of emerging topics of interest and areas where there is little new research reported. By utilizing NLP to effectively synthesize and analyze an extensive collection of TBI-related scholarly literature, we demonstrate the potential of machine learning techniques in understanding and guiding future research prospects. This approach sets the stage for similar analyses in other medical disciplines, offering profound insights and opportunities for further exploration.

From Text to Insight: A Natural Language Processing-Based Analysis of Topics and Trends in Neurosurgery.

BACKGROUND AND OBJECTIVES: Neurosurgical research is a rapidly evolving field, with new research topics emerging continually. To provide a clearer understanding of the evolving research landscape, our study aimed to identify and analyze the prevalent research topics and trends in Neurosurgery. METHODS: We used BERTopic, an advanced natural language processing-based topic modeling approach, to analyze papers published in the journal Neurosurgery . Using this method, topics were identified based on unique sets of keywords that encapsulated the core themes of each article. Linear regression models were then trained on the topic probabilities to identify trends over time, allowing us to identify "hot" (growing in prominence) and "cold" (decreasing in prominence) topics. We also performed a focused analysis of the trends in the current decade. RESULTS: Our analysis led to the categorization of 12 438 documents into 49 distinct topics. The topics covered a wide range of themes, with the most commonly identified topics being "Spinal Neurosurgery" and "Treatment of Cerebral Ischemia." The hottest topics of the current decade were "Peripheral Nerve Surgery," "Unruptured Aneurysms," and "Endovascular Treatments" while the cold topics were "Chiari Malformations," "Thromboembolism Prophylaxis," and "Infections." CONCLUSION: Our study underscores the dynamic nature of neurosurgical research and the evolving focus of the field. The insights derived from the analysis can guide future research directions, inform policy decisions, and identify emerging areas of interest. The use of natural language processing in synthesizing and analyzing large volumes of academic literature demonstrates the potential of advanced analytical techniques in understanding the research landscape, paving the way for similar analyses across other medical disciplines.

Does lower extremity fracture fixation technique influence neurologic outcomes in patients with traumatic brain injury? The EAST Brain vs. Bone multicenter trial.

OBJECTIVE: This study aimed to determine whether lower extremity fracture fixation technique and timing (≤24 vs. >24 hours) impact neurologic outcomes in TBI patients. METHODS: A prospective observational study was conducted across 30 trauma centers. Inclusion criteria were age 18 years and older, head Abbreviated Injury Scale (AIS) score of >2, and a diaphyseal femur or tibia fracture requiring external fixation (Ex-Fix), intramedullary nailing (IMN), or open reduction and internal fixation (ORIF). The analysis was conducted using analysis of variamce, Kruskal-Wallis, and multivariable regression models. Neurologic outcomes were measured by discharge Ranchos Los Amigos Revised Scale (RLAS-R). RESULTS: Of the 520 patients enrolled, 358 underwent Ex-Fix, IMN, or ORIF as definitive management. Head AIS was similar among cohorts. The Ex-Fix group experienced more severe lower extremity injuries (AIS score, 4-5) compared with the IMN group (16% vs. 3%, p = 0.01) but not the ORIF group (16% vs. 6%, p = 0.1). Time to operative intervention varied between the cohorts with the longest time to intervention for the IMN group (median hours: Ex-Fix, 15 [8-24] vs. ORIF, 26 [12-85] vs. IMN, 31 [12-70]; p < 0.001). The discharge RLAS-R score distribution was similar across the groups. After adjusting for confounders, neither method nor timing of lower extremity fixation influenced the discharge RLAS-R. Instead, increasing age and head AIS score were associated with a lower discharge RLAS-R score (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002-1.03 and OR, 2.37; 95% CI, 1.75-3.22), and a higher Glasgow Coma Scale motor score on admission (OR, 0.84; 95% CI, 0.73-0.97) was associated with higher RLAS-R score at discharge. CONCLUSION: Neurologic outcomes in TBI are impacted by severity of the head injury and not the fracture fixation technique or timing. Therefore, the strategy of definitive fixation of lower extremity fractures should be dictated by patient physiology and the anatomy of the injured extremity and not by the concern for worsening neurologic outcomes in TBI patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level III.

Intracranial extramedullary hematopoiesis in a patient with beta-thalassemia presenting with head trauma.

Background: Beta-thalassemia is an inherited hemoglobinopathy, whereby reduced or absent expression of beta-globin genes causes impaired erythropoiesis. Extramedullary hematopoiesis (EMH) occurs in 1% of all patients with beta-thalassemia major receiving regular transfusions and is exceedingly rare intracranially. Case Description: We report a case of a male in his 20s with beta thalassemia who presented with head trauma found to have intracranial EMH mimicking multiple extra-axial hematomas. Making the correct diagnosis was critical in avoiding prolonged neuromonitoring and unnecessary interventions. Conclusion: Intracranial extramedullary hematopoietic pseudotumor is an exceedingly rare entity and seldom appears in a neurosurgeon's differential diagnosis. This case illustrates how this condition can easily mimic an acute intracranial hemorrhage in a patient with beta-thalassemia who presents with head trauma. We review the topic to further inform clinicians who may encounter this condition in their practice.

International Survey of Antiseizure Medication Use in Patients with Complicated Mild Traumatic Brain Injury: A New York Neurotrauma Consortium Study.

BACKGROUND: Seizures and epilepsy after traumatic brain injury (TBI) negatively affect quality of life and longevity. Antiseizure medication (ASM) prophylaxis after severe TBI is associated with improved outcomes; these medications are rarely used in mild TBI. However, a paucity of research is available to inform ASM use in complicated mild TBI (cmTBI) and no empirically based clinical care guidelines for ASM use in cmTBI exist. We aim to identify seizure prevention and management strategies used by clinicians experienced in treating patients with cmTBI to characterize standard care and inform a systematic approach to clinical decision making regarding ASM prophylaxis. METHODS: We recruited a multidisciplinary international cohort through professional organizational listservs and social media platforms. Our questionnaire assessed factors influencing ASM prophylaxis after cmTBI at the individual, institutional, and health system-wide levels. RESULTS: Ninety-two providers with experience managing cmTBI completed the survey. We found a striking diversity of ASM use in cmTBI, with 30% of respondents reporting no/infrequent use and 42% reporting frequent use; these tendencies did not differ by provider or institutional characteristics. Certain conditions universally increased or decreased the likelihood of ASM use and represent consensus. Based on survey results, ASMs are commonly used in patients with cmTBI who experience acute secondary seizure or select positive neuroimaging findings; we advise caution in elderly patients and those with concomitant neuropsychiatric illness. CONCLUSIONS: This study is the first to characterize factors influencing clinical decision making in ASM prophylaxis after cmTBI based on multidisciplinary multicenter provider practices. Prospective controlled studies are necessary to inform standardized guideline development.

Brainstem Hemorrhage Following Lumbar Drain for Post-traumatic Hydrocephalus.

Post-traumatic hydrocephalus is common after traumatic brain injury (TBI), particularly following decompressive craniectomy. Cerebrospinal fluid (CSF) removal by lumbar drain (LD) aids in the workup of post-traumatic hydrocephalus and serves as a bridge to definitive CSF diversion. Hemorrhagic complications following LD are rare but can include intracranial hemorrhage. We present a case of fatal brainstem hemorrhage following LD in a patient three months after craniectomy. A 32-year-old male presented with severe TBI and an acute subdural hematoma. He underwent emergent decompressive craniectomy and hematoma evacuation. The next day, he required ventriculostomy for elevated intracranial pressure (ICP), which was able to be successfully removed. Three months after the injury, the patient's neurological exam declined, and computed tomography (CT) findings were consistent with communicating hydrocephalus. An LD was placed with 15 mL of CSF and drained every two hours. Five days after LD placement, the CSF became blood-tinged, and a repeat head CT demonstrated an acute brainstem hemorrhage. The patient ultimately expired. Given the prevalence of post-traumatic hydrocephalus and the frequent use of CSF diversion in the management of this condition, it is important for neurosurgeons to remain cognizant of the potential risk for catastrophic brainstem hemorrhage following LD in decompressive craniectomy patients.

Racial and Socioeconomic Disparities in Neurotrauma: Research Priorities in the New York Metropolitan Area Through a Global Neurosurgery Paradigm.

The New York Neurotrauma Consortium (NYNC) is a nascent multidisciplinary research and advocacy organization based in the New York Metropolitan Area (NYMA). It aims to advance health equity and optimize outcomes for traumatic brain and spine injury patients. Given the extensive racial, ethnic, and socioeconomic diversity of the NYMA, global health frameworks aimed at eliminating disparities in neurotrauma may provide a relevant and useful model for the informing research agendas of consortia like the NYNC. In this review, we present a comparative analysis of key health disparities in traumatic brain injury (TBI) that persists in the NYMA as well as in low- and middle-income countries (LMICs). Examples include (a) inequitable access to quality care due to fragmentation of healthcare systems, (b) barriers to effective prehospital care for TBI, and (c) socioeconomic challenges faced by patients and their families during the subacute and chronic postinjury phases of TBI care. This review presents strategies to address each area of health disparity based on previous studies conducted in both LMIC and high-income country settings. Increased awareness of healthcare disparities, education of healthcare professionals, effective policy advocacy for systemic changes, and fostering racial diversity of the trauma care workforce can guide the development of trauma care systems in the NYMA that are free of racial and related healthcare disparities.

The Effect of Direct Oral Anti-Coagulants on Delayed Traumatic Intracranial Hemorrhage After Mild Traumatic Brain Injury: A Systematic Review.

BACKGROUND: The use of anticoagulant medications leads to a higher risk of developing traumatic intracranial hemorrhage (tICH) after a mild traumatic brain injury (mTBI). The management of anticoagulated patients can be difficult to determine when the initial head computed tomography is negative for tICH. There has been limited research on the risk of delayed tICH in patients taking direct oral anticoagulant (DOAC) medications. OBJECTIVE: Our aim was to determine the risk of delayed tICH for patients anticoagulated with DOACs after mTBI. METHODS: We conducted a systematic review using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and searched several medical databases to examine the risk of delayed tICH in patients on DOACs. RESULTS: There were 1252 nonduplicate studies that were identified through an initial database search, 15 of which met our inclusion and exclusion criteria and were included in our analysis after full-text review. A total of 1375 subjects were combined among the 15 studies, with 20 instances of delayed tICH after mTBI. Nineteen of the 20 patients with a delayed tICH were discharged without any neurosurgical intervention, and 1 patient on apixaban died due to a delayed tICH. CONCLUSIONS: This systematic review confirms that delayed tICH after mTBI in patients on DOACs is uncommon. However, large, multicenter, prospective studies are needed to confirm the true incidence of clinically significant delayed tICH after DOAC use. Due to the limited data, we recommend using shared decision-making for patients who are candidates for discharge.

Antiepileptics for Post-Traumatic Seizure Prophylaxis after Traumatic Brain Injury.

Traumatic brain injury (TBI) is an important public health concern plagued by high rates of mortality and significant long-term disability in many survivors. Post-traumatic seizures (PTS) are not uncommon following TBI, both in the early (within 7 days post-injury) and late (after 7 days post-injury) period. Due to the potential of PTS to exacerbate secondary injury following TBI and the possibility of developing post-traumatic epilepsy (PTE), the medical community has explored preventative treatment strategies. Prophylactic antiepileptic drug (AED) administration has been proposed as a measure to reduce the incidence of PTS and the ultimate development of PTE in TBI patients. In this topical review, we discuss the pathophysiologic mechanisms of early and late PTS and the development of PTE following TBI, the pharmacodynamic and pharmacokinetic properties of AEDs commonly used to prevent post-traumatic seizures, and summarize the available clinical evidence for employing AEDs for seizure prophylaxis after TBI.

Making Milestones: Development and Implementation of a Formal Socioeconomic Curriculum in a Neurosurgical Residency Training Program.

BACKGROUND: Improved training in the socioeconomic aspects of medicine is a priority of the Accreditation Council for Graduate Medical Education and the American Board of Neurological Surgeons. There is evidence that young neurosurgeons feel ill equipped in these areas and that additional education would improve patient care. OBJECTIVE: To present our experience with the introduction of a succinct but formal socioeconomic training course to the residency curriculum at our institution. METHODS: A monthly series of twelve 1-hour interactive modules was designed to address the pertinent Accreditation Council for Graduate Medical Education-American Board of Neurological Surgeons outcomes-based educational milestones. Slide-based lectures provided a comprehensive overview of social, legal, and business issues, and a monthly forum for open discussion allowed residents to draw on their applied experience. Residents took a 20-question pre- and postcourse knowledge assessment, as well as feedback surveys at 6 and 12 months. RESULTS: Residents were able to participate in the lectures, with an overall attendance rate of 91%. Residents felt that the course goals and objectives were well defined and communicated (4.88/5) and rated highly the content, quality, and relevance of the lectures (4.94/5). Performance on the knowledge assessment improved from 58% to 66%. CONCLUSION: Our experience demonstrates the feasibility of including a formal socioeconomic course in neurosurgical residency training with positive resident feedback and achievement of outcomes-based milestones. Extension to a 2-year curriculum cycle may allow the course to cover more material without compromising other residency training goals. Online modules should also be explored to allow for wider and more flexible participation. ABBREVIATIONS: ABNS, American Board of Neurological SurgeonsACGME, Accreditation Council for Graduate Medical Education.

Variability in outcome after elective cerebral aneurysm repair in high-volume academic medical centers.

BACKGROUND AND PURPOSE: Unruptured intracranial aneurysm repair is the most commonly performed procedure for the prevention of hemorrhagic stroke. Despite efforts to regionalize care in high-volume centers, overall results have improved little. This study aims to determine the effectiveness in improving outcomes of previous efforts to regionalize unruptured intracranial aneurysm repair to high-volume centers and to recommend future steps toward that goal. METHODS: Using data obtained via the New York Statewide Planning and Research Cooperative System, this study included all patients admitted to any of the 10 highest volume centers in New York state between 2005 and 2010 with a principal diagnosis of unruptured intracranial aneurysm who were treated either by microsurgical or endovascular repair. Mixed-effects logistic regression was used to determine the degree to which hospital-level and patient-level variables contributed to observed variation in good outcome, defined as discharge to home, between hospitals. RESULTS: Of 3499 patients treated during the study period, 2692 (76.9%) were treated at the 10 highest volume centers, with 2198 (81.6%) experiencing a good outcome. Good outcomes varied widely between centers, with 44.6% to 91.1% of clipped patients and 75.4% to 92.1% of coiled patients discharged home. Mixed-effects logistic regression revealed that procedural volume accounts for 85.8% of the between-hospital variation in outcome. CONCLUSIONS: There is notable interhospital heterogeneity in outcomes among even the largest volume unruptured intracranial aneurysm referral centers. Although further regionalization may be needed, mandatory participation in prospective, adjudicated registries will be necessary to reliably identify factors associated with superior outcomes.

Transnasal endoscopic approach to the pediatric craniovertebral junction and rostral cervical spine: case series and literature review.

The endoscopic transnasal approach to the rostral pediatric spine and craniovertebral junction is a relatively new technique that provides an alternative to the traditional transoral approach to the anterior pediatric spine. In this case series, the authors provide 2 additional examples of patients undergoing endoscopic transnasal odontoidectomies for ventral decompression of the spinal cord. Both patients would have required transection of the palate to undergo an effective transoral operation, which can be a cause of significant morbidity. In one case, transnasal decompression was initially incomplete, and decompression was successfully achieved via a second endoscopic transnasal operation. Both cases resulted in significant neurological recovery and stable long-term spinal alignment. The transnasal approach benefits from entering into the posterior pharynx at an angle that often reduces the length of postoperative intubation and may speed a patient's return to oral intake. Higher reoperation rates are a concern for many endoscopic approaches, but there are insufficient data to conclude if this is the case for this procedure. Further experience with this technique will provide a better understanding of the indications for which it is most effective. Transcervical and transoral endoscopic approaches have also been reported and provide additional options for pediatric anterior cervical spine surgery.