Background Types of hemorrhagic stroke and other forms of bleeding within the cranial vault, account for a significant portion of neurological emergencies. External ventricular drain (EVD) placement is a common, life-saving intervention for patients presenting with acute hydrocephalus following intracranial hemorrhage. EVDs reduce intracranial pressure (ICP) by draining cerebrospinal fluid (CSF), minimizing the risk of secondary brain injury. Additionally, EVDs allow for continuous ICP monitoring, providing critical data to guide decisions. However, post-procedural complications may occur following EVD placement. While previous studies have examined EVD outcomes using traditional statistical methods, the impact of provider heterogeneity and resident learning curves on these outcomes remains poorly understood. Understanding the impact of these complications is crucial for improving surgical quality and outcomes. Methods To address these critical gaps and advance our understanding of EVD outcomes, we reviewed medical records of patients with subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH), or interventricular hemorrhage (IVH) who received EVDs for ICP at the Mount Sinai Health System in New York City from 2019 to 2022. We evaluated surgical complications and patient outcomes following EVD placement by neurosurgeons at different stages of their training. Random effect survival models were implemented to account for heterogeneity between providers. This novel methodological approach integrated provider heterogeneity and learning curves into EVD outcome analysis, extending beyond traditional statistical methods used in previous studies. Conclusions We found that in time-to-death Cox models, age was a significant predictor while for time-to-complication, device type and pre-operative modified Rankin score were significant predictors. A Cox frailty model did not show significant predictors, but our unique evaluation of restricted mean survival time with frailty showed that smoking was a significant predictor of survival. Furthermore, we also modeled learning curves amongst neurosurgeons performing EVDs to improve surgical proficiency. We found that employing the frailty modeling improved the learning curve fit.
Objectives: Since the onset of the COVID-19 pandemic many large institutions have turned towards virtual education. Neurosurgery in our institute, recognizing its benefits, readily embraced the virtual learning experience using Zoom Inc (San Jose, California) beginning on May 21, 2020. The result of this form of educational experience may not be apparent readily. Hence, nearing the end of one year of monthly Zoom meetings, an effort was undertaken to assess the feasibility and the barriers of effective virtual teaching learning activity in neurosurgery among the participants. Methods: The participants consisted of neurosurgeons and trainees from department of neurosurgery Tribhuvan University Teaching Hospital in Nepal, neurosurgeons based in Seattle, United States of America and neurosurgeons based in Sweden, who have been regularly attending the monthly virtual education organized by Dr. Wohns. At the end of one-year experience of monthly Zoom teaching and learning activities between the participants a questionnaire comprising objective questions related to their experience of virtual education in neurosurgery was distributed to the participants and answers were collected and analyzed. Results: A total of 18 persons out of 25 responded to the questionnaire. Majority of participants responded favorably to virtual education. A few responders faced disturbance in internet connectivity affecting the quality of video and sound during the presentations. None of the participants faced inconvenience due to time difference. Most responders preferred to continue virtual education even after the pandemic. Conclusions: Overall most participants responded favorably to virtual education which has helped them increase their participation and hence broaden their knowledge in the field. Most participants look forward to continuing this form of education even in future. Thus, this form of education may be incorporated at least in part in the future of neurosurgical training.
Background:Initially, novel severe acute respiratory syndrome coronavirus (SARS-CoV-2) was considered primarily a respiratory pathogen. However, with time it has behaved as a virus with the potential to cause multi-system involvement, including neurological manifestations which varies from acute to subacute onset of headache, seizures, a decrease of consciousness, and paralysis. Case description:Two cases of cerebral sinus venous thrombosis in COVID-19 patients were reported, following respiratory disorders, which was triggered by the SARS-CoV-2 infection. The first patient, presented with a decrease in level of consciousness and hemiparesis, was 23 years old female having no history of previous medical co-morbidities. The latter case, 21 years old woman showed less severe presentations of COVID-19 associated with headache, vomiting and papilledema. These two cases marvellously improved with no neurological deficit with aggressive course of anticoagulation. Conclusion:CVST should be suspected in COVID-19 patients presenting with headache, paralysis, aphasia or seizures. The high mortality rate of CVST in COVID-19 infection warrants a high index of suspicion from physicians, and early treatment with anticoagulation should be initiated.
Background: The COVID-19 pandemic raised major challenges to the management of patient flows and medical staff resource allocation. To prevent the collapse of medical facilities, elective diagnostic and surgical procedures were drastically reduced, canceled or rescheduled. Methods: We recorded all in-hospital treated patients and outpatient clinics visits of our neurosurgical department from March 2017 to February 2021. Changes of OR capacity, in-hospital neurosurgical treatments and outpatient clinics visits during the pandemic episode was compared on a monthly bases to the previous years. Results: A total of 3'214 data points from in-house treated patients and 11'400 outpatient clinics visits were collected. The ratio of elective (73.5% +/- 1.5) to emergency surgeries (26.5% +/- 1.5) remained unchanged from 2017 to 2021. Significantly less neurosurgical interventions were performed in April 2020 (42%), significantly more in July 2020 (+36%). Number of outpatient clinics visits remained in the expected monthly range (mean n = 211 +/- 67). Total OR capacity was reduced to 30% in April 2020 and 55% in January 2021. No significant delay of urgent surgical treatments was detected during restricted (<85%) OR capacity. On average, the delay of rescheduled consultations was 58 days (range 3 - 183 days), three (6.5%) were referred as emergencies. Conclusions: Dynamic monitoring and adjustment of resources is essential to maintain surgical care. The sharp restrictions of surgical activities resulted in significant fluctuations and 5% decrease of treated neurosurgical patients during the COVID-19 pandemic. However, urgent neurosurgical care was assured without significant time delay during periods of reduced OR capacity.
Background: As vaccinations against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continue worldwide, increased rates of venous thrombotic events, mainly as cerebral venous sinus thrombosis (CVST), have been reported following adenovirus vector-based SARS-CoV-2 vaccination. However, few reports have described the occurrence of venous thrombosis after messenger RNA (mRNA)-based vaccination. Here, we describe a case of CVST after a first dose of mRNA-based vaccination that was treated with emergent endo-vascular mechanical thrombectomy and systemic heparinization.Case Description.A 43-year-old, previously healthy man suffered severe headache and partial seizures affecting the left arm 4 days after receiving the first dose of an mRNA-based SARS-CoV-2 vaccination (FC3661; Pfizer/BioNTech). Computed tomography showed intraparenchymal hemorrhage. Seven days after vaccination, symptoms worsened and he was transferred to our tertiary hospital. Magnetic resonance venography revealed CVST with occlusion of the superior sagittal sinus (SSS) and right transverse sinus (TS). Since no findings suggested thrombosis with thrombocytopenia syndrome, the patient underwent systemic heparinization and emergent mechanical throm-bectomy with balloon transluminal angioplasty, a stent retriever and an aspiration catheter. Complete SSS and right TS recanalization were achieved and the patient was discharged without neurological deficits.Conclusion: Clinicians should be aware that apparently healthy individuals with no risk factors can develop CVST after receiving an mRNA-based vaccine and appropriate treatment including EMT need to be performed immediately. (228 words)
