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Yue JK, Lee YM, Sun X, van Essen TA, Elguindy MM, Belton PJ, Pisică D, Mikolic A, Deng H, Kanter JH, McCrea MA, Bodien YG, Satris GG, Wong JC, Ambati VS, Grandhi R, Puccio AM, Mukherjee P, Valadka AB, Tarapore PE, Huang MC, DiGiorgio AM, Markowitz AJ, Yuh EL, Okonkwo DO, Steyerberg EW, Lingsma HF, Menon DK, Maas AIR, Jain S, Manley GT. Performance of the IMPACT and CRASH prognostic models for traumatic brain injury in a contemporary multicenter cohort: a TRACK-TBI study. J Neurosurg 2024:1-13. [PMID: 38489823 PMCID: PMC11010725 DOI: 10.3171/2023.11.jns231425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 11/16/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE The International Mission on Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) and Corticosteroid Randomization After Significant Head Injury (CRASH) prognostic models for mortality and outcome after traumatic brain injury (TBI) were developed using data from 1984 to 2004. This study examined IMPACT and CRASH model performances in a contemporary cohort of US patients. METHODS The prospective 18-center Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) study (enrollment years 2014-2018) enrolled subjects aged ≥ 17 years who presented to level I trauma centers and received head CT within 24 hours of TBI. Data were extracted from the subjects who met the model criteria (for IMPACT, Glasgow Coma Scale [GCS] score 3-12 with 6-month Glasgow Outcome Scale-Extended [GOSE] data [n = 441]; for CRASH, GCS score 3-14 with 2-week mortality data and 6-month GOSE data [n = 831]). Analyses were conducted in the overall cohort and stratified on the basis of TBI severity (severe/moderate/mild TBI defined as GCS score 3-8/9-12/13-14), age (17-64 years or ≥ 65 years), and the 5 top enrolling sites. Unfavorable outcome was defined as GOSE score 1-4. Original IMPACT and CRASH model coefficients were applied, and model performances were assessed by calibration (intercept [< 0 indicated overprediction; > 0 indicated underprediction] and slope) and discrimination (c-statistic). RESULTS Overall, the IMPACT models overpredicted mortality (intercept -0.79 [95% CI -1.05 to -0.53], slope 1.37 [1.05-1.69]) and acceptably predicted unfavorable outcome (intercept 0.07 [-0.14 to 0.29], slope 1.19 [0.96-1.42]), with good discrimination (c-statistics 0.84 and 0.83, respectively). The CRASH models overpredicted mortality (intercept -1.06 [-1.36 to -0.75], slope 0.96 [0.79-1.14]) and unfavorable outcome (intercept -0.60 [-0.78 to -0.41], slope 1.20 [1.03-1.37]), with good discrimination (c-statistics 0.92 and 0.88, respectively). IMPACT overpredicted mortality and acceptably predicted unfavorable outcome in the severe and moderate TBI subgroups, with good discrimination (c-statistic ≥ 0.81). CRASH overpredicted mortality in the severe and moderate TBI subgroups and acceptably predicted mortality in the mild TBI subgroup, with good discrimination (c-statistic ≥ 0.86); unfavorable outcome was overpredicted in the severe and mild TBI subgroups with adequate discrimination (c-statistic ≥ 0.78), whereas calibration was nonlinear in the moderate TBI subgroup. In subjects ≥ 65 years of age, the models performed variably (IMPACT-mortality, intercept 0.28, slope 0.68, and c-statistic 0.68; CRASH-unfavorable outcome, intercept -0.97, slope 1.32, and c-statistic 0.88; nonlinear calibration for IMPACT-unfavorable outcome and CRASH-mortality). Model performance differences were observed across the top enrolling sites for mortality and unfavorable outcome. CONCLUSIONS The IMPACT and CRASH models adequately discriminated mortality and unfavorable outcome. Observed overestimations of mortality and unfavorable outcome underscore the need to update prognostic models to incorporate contemporary changes in TBI management and case-mix. Investigations to elucidate the relationships between increased survival, outcome, treatment intensity, and site-specific practices will be relevant to improve models in specific TBI subpopulations (e.g., older adults), which may benefit from the inclusion of blood-based biomarkers, neuroimaging features, and treatment data.
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Affiliation(s)
- John K Yue
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Young M Lee
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Xiaoying Sun
- 3Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, California
| | - Thomas A van Essen
- 4University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center, Leiden, The Hague, The Netherlands
| | - Mahmoud M Elguindy
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Patrick J Belton
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Dana Pisică
- 5Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ana Mikolic
- 5Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
- 6Department of Psychology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Hansen Deng
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - John H Kanter
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Michael A McCrea
- 8Department of Neurological Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yelena G Bodien
- 9Department of Neurological Surgery, University of Utah Health Center, Salt Lake City, Utah
- 10Department of Neurology, Harvard Medical School, Boston, Massachusetts
| | - Gabriela G Satris
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Justin C Wong
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Vardhaan S Ambati
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Ramesh Grandhi
- 11Department of Rehabilitation Medicine, Spaulding Rehabilitation Hospital, Boston, Massachusetts
| | - Ava M Puccio
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Pratik Mukherjee
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- 12Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - Alex B Valadka
- 13Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Phiroz E Tarapore
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Michael C Huang
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Anthony M DiGiorgio
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- 14Institute of Health Policy Studies, University of California, San Francisco, California
| | - Amy J Markowitz
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
| | - Esther L Yuh
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
- 12Department of Radiology and Biomedical Imaging, University of California, San Francisco, California
| | - David O Okonkwo
- 7Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ewout W Steyerberg
- 15Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - Hester F Lingsma
- 5Department of Public Health, Erasmus Medical Center, Rotterdam, The Netherlands
| | - David K Menon
- 16Division of Anesthesia, Department of Medicine, University of Cambridge, United Kingdom; and
| | - Andrew I R Maas
- 17Department of Neurological Surgery, Antwerp University Hospital and University of Antwerp, Belgium
| | - Sonia Jain
- 3Biostatistics Research Center, Herbert Wertheim School of Public Health and Longevity Science, University of California, San Diego, California
| | - Geoffrey T Manley
- 1Department of Neurological Surgery, University of California, San Francisco, California
- 2Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, California
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Jones VM, Kanter JH, Russo GA, Simmons NE, Tafe LJ, Zanazzi GJ. A Pineal Parenchymal Tumor of Intermediate Differentiation in an Octogenarian Contains a Rare KBTBD4 Insertion. Int J Surg Pathol 2023:10668969231201411. [PMID: 37855103 DOI: 10.1177/10668969231201411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2023]
Abstract
Pineal parenchymal tumors are rare central nervous system tumors that pose diagnostic challenges for surgical pathologists. Due to their paucity, their clinicopathologic features are still being defined. We report an 86-year-old woman with a remote history of breast lobular carcinoma who presented with a 2-month neurologic history that included gait instability, blurry vision, and headaches. Magnetic resonance imaging revealed a lobular, heterogeneously enhancing pineal region mass compressing the aqueduct of Sylvius. A biopsy performed concomitant with endoscopic third ventriculostomy consisted of small sheets of cells with eosinophilic to clear cytoplasm, multipolar processes, and ovoid nuclei with stippled chromatin. Whole exome sequencing revealed a small in-frame insertion (duplication) in exon 4 of KBTBD4 (c.931_939dup, p.P311_R313dup/ p.R313_M314insPRR), which has very recently been reported in 2 pineal parenchymal tumors of intermediate differentiation (PPTID). Additionally, variants of uncertain significance in CEBPA (c.863G > C, p.R288P) and MYC (c.655T > C, p.S219P) were identified. Although PPTID is considered a disease of young adulthood, review of 2 institutional cohorts of patients with pineal region tumors revealed that 25% of individuals with PPTID were over 65 years of age. In conclusion, PPTID should be considered in the differential diagnosis of pineal region tumors in older adults.
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Affiliation(s)
- Victoria M Jones
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - John H Kanter
- Department of Neurosurgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Gregory A Russo
- Department of Radiation Oncology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Nathan E Simmons
- Department of Neurosurgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Laura J Tafe
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - George J Zanazzi
- Department of Pathology and Laboratory Medicine, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
- Dartmouth Cancer Center, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Yue JK, Krishnan N, Kanter JH, Deng H, Okonkwo DO, Puccio AM, Madhok DY, Belton PJ, Lindquist BE, Satris GG, Lee YM, Umbach G, Duhaime AC, Mukherjee P, Yuh EL, Valadka AB, DiGiorgio AM, Tarapore PE, Huang MC, Manley GT, Investigators TTRACKTBI. Neuroworsening in the Emergency Department Is a Predictor of Traumatic Brain Injury Intervention and Outcome: A TRACK-TBI Pilot Study. J Clin Med 2023; 12:2024. [PMID: 36902811 PMCID: PMC10004432 DOI: 10.3390/jcm12052024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2023] [Revised: 03/02/2023] [Accepted: 03/02/2023] [Indexed: 03/08/2023] Open
Abstract
INTRODUCTION Neuroworsening may be a sign of progressive brain injury and is a factor for treatment of traumatic brain injury (TBI) in intensive care settings. The implications of neuroworsening for clinical management and long-term sequelae of TBI in the emergency department (ED) require characterization. METHODS Adult TBI subjects from the prospective Transforming Research and Clinical Knowledge in Traumatic Brain Injury Pilot Study with ED admission and disposition Glasgow Coma Scale (GCS) scores were extracted. All patients received head computed tomography (CT) scan <24 h post-injury. Neuroworsening was defined as a decline in motor GCS at ED disposition (vs. ED admission). Clinical and CT characteristics, neurosurgical intervention, in-hospital mortality, and 3- and 6-month Glasgow Outcome Scale-Extended (GOS-E) scores were compared by neuroworsening status. Multivariable regressions were performed for neurosurgical intervention and unfavorable outcome (GOS-E ≤ 3). Multivariable odds ratios (mOR) with [95% confidence intervals] were reported. RESULTS In 481 subjects, 91.1% had ED admission GCS 13-15 and 3.3% had neuroworsening. All neuroworsening subjects were admitted to intensive care unit (vs. non-neuroworsening: 26.2%) and were CT-positive for structural injury (vs. 45.4%). Neuroworsening was associated with subdural (75.0%/22.2%), subarachnoid (81.3%/31.2%), and intraventricular hemorrhage (18.8%/2.2%), contusion (68.8%/20.4%), midline shift (50.0%/2.6%), cisternal compression (56.3%/5.6%), and cerebral edema (68.8%/12.3%; all p < 0.001). Neuroworsening subjects had higher likelihoods of cranial surgery (56.3%/3.5%), intracranial pressure (ICP) monitoring (62.5%/2.6%), in-hospital mortality (37.5%/0.6%), and unfavorable 3- and 6-month outcome (58.3%/4.9%; 53.8%/6.2%; all p < 0.001). On multivariable analysis, neuroworsening predicted surgery (mOR = 4.65 [1.02-21.19]), ICP monitoring (mOR = 15.48 [2.92-81.85], and unfavorable 3- and 6-month outcome (mOR = 5.36 [1.13-25.36]; mOR = 5.68 [1.18-27.35]). CONCLUSIONS Neuroworsening in the ED is an early indicator of TBI severity, and a predictor of neurosurgical intervention and unfavorable outcome. Clinicians must be vigilant in detecting neuroworsening, as affected patients are at increased risk for poor outcomes and may benefit from immediate therapeutic interventions.
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Affiliation(s)
- John K. Yue
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Nishanth Krishnan
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - John H. Kanter
- Section of Neurological Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH 03766, USA
| | - Hansen Deng
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - David O. Okonkwo
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Ava M. Puccio
- Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15261, USA
| | - Debbie Y. Madhok
- Department of Emergency Medicine, University of California San Francisco, San Francisco, CA 94110, USA
| | - Patrick J. Belton
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Britta E. Lindquist
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Neurology, University of California San Francisco, San Francisco, CA 94110, USA
| | - Gabriela G. Satris
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Young M. Lee
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Gray Umbach
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Ann-Christine Duhaime
- Department of Neurological Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA 02114, USA
| | - Pratik Mukherjee
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94110, USA
| | - Esther L. Yuh
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA 94110, USA
| | - Alex B. Valadka
- Department of Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Anthony M. DiGiorgio
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
- Institute for Health Policy Studies, University of California San Francisco, San Francisco, CA 94158, USA
| | - Phiroz E. Tarapore
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Michael C. Huang
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
| | - Geoffrey T. Manley
- Department of Neurological Surgery, University of California San Francisco, San Francisco, CA 94110, USA
- Brain and Spinal Injury Center, Zuckerberg San Francisco General Hospital, San Francisco, CA 94110, USA
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Tshimbombu TN, Fefe MN, Shin M, Kanter JH, Crockett SC, Richard BR, Muyembe Tamfum JJ. Demographic and Clinical Factors Affecting Pediatric Survival in South Kivu, the Democratic Republic of the Congo. Am J Trop Med Hyg 2023; 108:231-234. [PMID: 36410325 PMCID: PMC9833088 DOI: 10.4269/ajtmh.22-0455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/05/2022] [Indexed: 11/23/2022] Open
Abstract
Promoting children's health is challenging in underresourced regions, with worse outcomes in areas of sociopolitical instabilities. This encapsulates the difficulties faced by the Panzi General Referral Hospital (PGRH) in South Kivu, the Democratic Republic of the Congo. In this retrospective, cross-sectional study of 456 children ≤ 18 years who presented to the pediatric emergency department of PGRH between December 2018 and May 2019, we present demographic and clinical predictors that affect pediatric survival. We note that referrals from external clinics (odds ratio [OR], 0.37; 95% CI, 0.18-0.75), poor maternal education (OR, 0.21; 95% CI, 0.07-0.67), diagnoses of meningitis (OR, 0.37; 95% CI, 0.18-0.75) or malnutrition (OR, 0.21; 95% CI, 0.07-0.67) are risk factors hindering pediatric survival. Paternal unemployment or longer durations of hospital stay, on the other hand, are protective toward survival. These predictors confirm the importance of accessibility and availability of medical resources and knowledge as levers to establish an effective, robust network of pediatric care delivery capable of withstanding South Kivu's unresolved political tumult.
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Affiliation(s)
| | - Mapendo N Fefe
- Department of Medicine, University of Kaziba, South-Kivu
| | | | - John H Kanter
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Sarah C Crockett
- Department of Emergency Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Bahizire R Richard
- Department of Public Health, Higher Institute Medical Techniques, Nyangezi, Democratic Republic of the Congo
| | - Jean-Jacques Muyembe Tamfum
- National Institute of Biomedical Research and Department of Medical Microbiology and Virology, Faculty of Medicine, University of Kinshasa, Kinshasa, Democratic Republic of the Congo
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Song Y, Surgenor JV, Leeds ZT, Kanter JH, Martinez-Camblor P, Smith WJ, Boone MD, Abess AT, Evans LT, Kobylarz EJ. Variables associated with cortical motor mapping thresholds: A retrospective data review with a unique case of interlimb motor facilitation. Front Neurol 2023; 14:1150670. [PMID: 37114230 PMCID: PMC10128911 DOI: 10.3389/fneur.2023.1150670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 03/15/2023] [Indexed: 04/29/2023] Open
Abstract
Introduction Intraoperative neuromonitoring (IONM) is crucial to preserve eloquent neurological functions during brain tumor resections. We observed a rare interlimb cortical motor facilitation phenomenon in a patient with recurrent high-grade glioma undergoing craniotomy for tumor resection; the patient's upper arm motor evoked potentials (MEPs) increased in amplitude significantly (up to 44.52 times larger, p < 0.001) following stimulation of the ipsilateral posterior tibial nerve at 2.79 Hz. With the facilitation effect, the cortical MEP stimulation threshold was reduced by 6 mA to maintain appropriate continuous motor monitoring. It likely has the benefit of reducing the occurrence of stimulation-induced seizures and other adverse events associated with excessive stimulation. Methods We conducted a retrospective data review including 120 patients who underwent brain tumor resection with IONM at our center from 2018 to 2022. A broad range of variables collected pre-and intraoperatively were reviewed. The review aimed to determine: (1) whether we overlooked this facilitation phenomenon in the past, (2) whether this unique finding is related to any specific demographic information, clinical presentation, stimulation parameter (s) or anesthesia management, and (3) whether it is necessary to develop new techniques (such as facilitation methods) to reduce cortical stimulation intensity during intraoperative functional mapping. Results There is no evidence suggesting that clinical presentation, stimulation configuration, or intraoperative anesthesia management of the patient with the facilitation effect were significantly different from our general patient cohort. Even though we did not identify the same facilitation effect in any of these patients, we were able to determine that stimulation thresholds for motor mapping are significantly associated with the location of stimulation (p = 0.003) and the burst suppression ratio (BSR) (p < 0.001). Stimulation-induced seizures, although infrequent (4.05%), could occur unexpectedly even when the BSR was 70%. Discussion We postulated that functional reorganization and neuronal hyperexcitability induced by glioma progression and repeated surgeries were probable underlying mechanisms of the interlimb facilitation phenomenon. Our retrospective review also provided a practical guide to cortical motor mapping in brain tumor patients under general anesthesia. We also underscored the need for developing new techniques to reduce the stimulation intensity and, hence, seizure occurrence.
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Affiliation(s)
- Yinchen Song
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
- Geisel School of Medicine, Dartmouth College, Hanover, NH, United States
- *Correspondence: Yinchen Song,
| | - James V. Surgenor
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
- Haverford College, Haverford, PA, United States
| | - Zachary T. Leeds
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - John H. Kanter
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
- Department of Biomedical Data Science, Geisel School of Medicine, Dartmouth College, Hanover, NH, United States
| | - William J. Smith
- Geisel School of Medicine, Dartmouth College, Hanover, NH, United States
| | - M. Dustin Boone
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
- Geisel School of Medicine, Dartmouth College, Hanover, NH, United States
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Alexander T. Abess
- Geisel School of Medicine, Dartmouth College, Hanover, NH, United States
- Department of Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Linton T. Evans
- Geisel School of Medicine, Dartmouth College, Hanover, NH, United States
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
| | - Erik J. Kobylarz
- Department of Neurology, Dartmouth-Hitchcock Medical Center, Lebanon, NH, United States
- Geisel School of Medicine, Dartmouth College, Hanover, NH, United States
- Thayer School of Engineering, Dartmouth College, Hanover, NH, United States
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Tshimbombu TN, Kalubye AB, Hoffman C, Kanter JH, Rosseau G, Nteranya DS, Nyalundja AD, Kalala Okito JP. Review of Neurosurgery in the Democratic Republic of Congo: Historical Approach of a Local Context. World Neurosurg 2022; 167:81-88. [PMID: 35948213 DOI: 10.1016/j.wneu.2022.07.113] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 07/23/2022] [Accepted: 07/25/2022] [Indexed: 11/26/2022]
Abstract
Neurosurgical practice in the Democratic Republic of Congo (DRC) is challenged by limited resources and infrastructure. The DRC has 16 local residing neurosurgeons for 95 million inhabitants, a ratio of 1 neurosurgeon per 5.9 million Congolese citizens. This is attributable to decades of political unrest and a loosely regulated health care system. Understanding the role of neurosurgery in a historical context is necessary to appreciate and overcome current challenges in the delivery of neurosurgical care. We describe past and present political, social, and economic challenges surrounding the development of neurosurgical practice and training. Highlights of early innovators, current challenges, and a suggested framework to guide future advances in neurosurgical practice are provided. Interviews with Dr. Antoine Beltchika Kalubye, the oldest living neurosurgeon in the DRC, and Dr. Jean-Pierre Kalala Okito, current president of the Congolese Society of Neurosurgery, provide a detailed account of events. Firsthand narrative was supplemented via literature review and collaboration with registrars in the DRC to review current neurosurgery programs. Our discussions revealed that decades of political unrest and inconsistent management of health care resources are responsible for the current state of healthcare, including the dearth of local neurosurgeons. The neurosurgery workforce deficit in the DRC remains substantial. It is essential to understand local neurosurgical history, in its present state and breadth of challenges, to inform future development of neurosurgical care and to secure equitable partnerships between local stakeholders and the international community.
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Affiliation(s)
| | | | - Caitlin Hoffman
- Department of Neurological Surgery, New York-Presbyterian Hospital, Weill Cornell Medical College, New York, New York
| | - John H Kanter
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Gail Rosseau
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Daniel Safari Nteranya
- Surgery Department, Official University of Bukavu, University Clinics of Bukavu, Democratic Republic of Congo
| | - Arsene Daniel Nyalundja
- Center for Tropical Diseases and Global Health, Faculty of Medicine, Université Catholique de Bukavu, Democratic Republic of Congo
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Smith WJ, Kanter JH, Jaleel N, Aronson JP. Idiopathic Spinal Subarachnoid and Subdural Hemorrhage in a Patient With Eosinophilic Granulomatosis and Polyangiitis. Neurosurgery Open 2022. [DOI: 10.1227/neuopn.0000000000000014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Glaser AC, Kanter JH, Martinez-Camblor P, Taenzer A, Anderson MV, Buhl L, Shaefi S, Pannu A, Boone MD. The Effect of Antiseizure Medication Administration on Mortality and Early Posttraumatic Seizures in Critically Ill Older Adults with Traumatic Brain Injury. Neurocrit Care 2022; 37:538-546. [PMID: 35641806 DOI: 10.1007/s12028-022-01531-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 04/27/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a major cause of morbidity and mortality in the United States. Older adults represent an understudied and growing TBI population. Current Brain Trauma Foundation guidelines support prophylactic antiseizure medication (ASM) administration to reduce the risk of early posttraumatic seizures (within 7 days of injury) in patients with severe TBI. Whether ASM decreases mortality or early seizure risk in this population remains unclear. This study addresses the knowledge gap regarding the impact of ASM administration on the risk of seizure or mortality after TBI in patients more than 65 years of age. METHODS This retrospective cohort study used a publicly available data set from the Medical Information Mart for Intensive Care-III from the Massachusetts Institute of Technology. Our cohort included patients 65 years or older with a primary exposure of early ASM administration with TBI resulting in an intensive care unit (ICU) admission in a level I trauma center from 2001 to 2012. A double-robust inverse propensity scale weighted model on the basis of proportional hazard and logistic regression models was created to assess the association between ASM administration and risk of death within 7 days of admission to the ICU. Secondary outcomes included 30-day mortality and 1-year mortality, early posttraumatic seizures, ICU length of stay, and hospital length of stay. RESULTS Of 1145 patients 65 years or older with TBI admitted to an ICU, 783 (68.4%) received ASM within the first 24 h. Patients meeting inclusion criteria were predominantly white (83.8%) and were male (52.3%), with a median (interquartile range) age of 81 (74-86) years. TBI severity, classified by Glasgow Coma Score, was predominantly mild (71.2%), followed by moderate (16.8%) and severe (11.3%). Patients who received ASM were less likely to have died at 7 days (adjusted death hazard ratio [HR] = 0.48 [95% confidence interval {CI} 0.28-0.88], P = 0.005), at 30 days (adjusted HR 0.67 [95% CI 0.45-0.99], P = 0.045), and at 1 year (adjusted HR 0.72 [95% CI 0.54-0.97], P = 0.029). Groups were not different in regard to seizure (adjusted seizure odds ratio 1.18 [95% CI 0.61-2.26]) compared with those who did not receive ASM. CONCLUSIONS Early ASM administration was associated with reduced mortality at 7 days, 30 days, and 1 year but did not decrease the risk of early seizures among older adults who presented with TBI at an ICU. This benefit was observed in mild, moderate, and severe TBI assessed by Glasgow Coma Score on presentation among patients 65 years old and older and suggests broader recommendations for the use of ASM in older adults who present with TBI of any severity at an ICU.
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Affiliation(s)
- Adam C Glaser
- Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH, USA
| | - John H Kanter
- Section of Neurosurgery, Dartmouth Hitchcock Medical Center, 1 Medical Center Drive, Lebanon, NH, 03756, USA.
| | - Pablo Martinez-Camblor
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA.,Department of Biomedical Data Sciences, Geisel School of Medicine at Dartmouth, Dartmouth College, Hanover, NH, USA
| | - Andreas Taenzer
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA.,The Dartmouth Institute for Health Policy and Clinical Practice, Dartmouth College, Lebanon, NH, USA.,Department of Pediatrics, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA
| | - Matt V Anderson
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA
| | - Lauren Buhl
- Beth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Shahzad Shaefi
- Beth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Ameeka Pannu
- Beth Israel Deaconess Medical Center Department of Anesthesia, Critical Care, and Pain Medicine, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Myles D Boone
- Department of Anesthesiology, Dartmouth Hitchcock Medical Center, Dartmouth Health System, Lebanon, NH, USA.,Department of Neurology, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
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Tshimbombu TN, Song SH, Kanter JH. Shako Djunga, M.D., 1938 -1986: The first Congolese Neurosurgeon. World Neurosurg 2022; 160:68-70. [PMID: 35101612 DOI: 10.1016/j.wneu.2022.01.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 10/19/2022]
Abstract
Antoine Shako Hiango Omokanda Djunga was the pioneer of neurosurgery in the Democratic Republic of Congo (DRC), a country located in Central Africa. He was born in 1938 in Sankuru, a province of the DRC. He graduated from the Free University of Brussels medical school and later trained there in neurosurgery. Thereafter, he completed a fellowship at Bellevue Hospital in New York. As a neurosurgeon, he worked at the Kinshasa University Clinic (KUC) of Lovanium School of Medicine in the DRC, where he introduced neurosurgery and advocated for the construction of the first dedicated neurosurgical operating room. His leadership helped ensure sustainability in the field in the DRC. He died at the age of 48 leaving a void in neurosurgery and an unfulfilled mission of advocating for the construction of an independent neurosurgery hospital in the DRC.
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Affiliation(s)
| | - Seo Ho Song
- Dartmouth Geisel School of Medicine, 1 Rope Ferry Rd, Hanover, NH 03755
| | - John H Kanter
- Section of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH 03766
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Root BK, Kanter JH, Calnan DC, Reyes-Zaragosa M, Gill HS, Lanter PL. Emergency department observation of mild traumatic brain injury with minor radiographic findings: shorter stays, less expensive, and no increased risk compared to hospital admission. J Am Coll Emerg Physicians Open 2020; 1:609-617. [PMID: 33000079 PMCID: PMC7493558 DOI: 10.1002/emp2.12124] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Revised: 03/30/2020] [Accepted: 05/04/2020] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE The management of mild traumatic brain injury (mTBI) with minor radiographic findings traditionally involves hospital admission for monitoring, although this practice is expensive with unclear benefit. We implemented a protocol to manage these patients in our emergency department observation unit (EDOU), hypothesizing that this pathway was cost effective and not associated with any difference in clinical outcome. METHODS mTBI patients with minor radiographic findings were managed under the EDOU protocol over a 3-year period from May 1, 2015 to April 30, 2018 (inclusions: ≥19 years old, isolated acute head trauma, normal neurological exam [except transient alteration in consciousness], and a computed tomography [CT] scan of the head with at least 1 of the following: cerebral contusions <1 cm in maximum extent, convexity subarachnoid hemorrhage, or closed, non-displaced skull fractures). These patients were retrospectively analyzed; clinical outcomes and charges were compared to a control cohort of matched mTBI hospital admissions over the preceding 3 years. RESULTS Sixty patients were observed in the EDOU over the 3-year period, and 85 patients were identified for the control cohort. There were no differences in rate of radiographic progression, neurological exam change, or surgical intervention, and the overall incidence of hemorrhagic expansion was low in both groups. The EDOU group had a significantly faster time to interval CT scan (Mean Difference (MD) 3.92 hours, [95%CI 1.65, 6.19]), P = 0.001), shorter length of stay (MD 0.59 days [95% CI 0.29, 0.89], P = 0.001), and lower encounter charges (MD $3428.51 [95%CI 925.60, 5931.42], P = 0.008). There were no differences in 30-day re-admission, 30-day mortality, or delayed chronic subdural formation, although there was a high rate of loss to follow-up in both groups. CONCLUSIONS Compared to hospital admission, observing mTBI patients with minor radiographic findings in the EDOU was associated with significantly shorter time to interval scanning, shorter length of stay, and lower encounter charges, but no difference in observed clinical outcome. The overall risk of hemorrhagic progression in this subset of mTBI was very low. Using this approach can reduce unnecessary admissions while potentially yielding patient care and economic benefits. When designing a protocol, close attention should be given to clear inclusion criteria and a formal mechanism for patient follow-up.
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Affiliation(s)
- Brandon K Root
- Section of Neurosurgery Dartmouth-Hitchcock Medical Center Lebanon New Hampshire USA
| | - John H Kanter
- Section of Neurosurgery Dartmouth-Hitchcock Medical Center Lebanon New Hampshire USA
| | - Dan C Calnan
- Section of Neurosurgery Dartmouth-Hitchcock Medical Center Lebanon New Hampshire USA
| | | | - Harman S Gill
- Department of Emergency Medicine Dartmouth-Hitchcock Medical Center Lebanon New Hampshire USA
| | - Patricia L Lanter
- Department of Emergency Medicine Dartmouth-Hitchcock Medical Center Lebanon New Hampshire USA
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D'Agostino EN, Calnan DR, Makler VI, Khan I, Kanter JH, Bauer DF. Type I split cord malformation and tethered cord syndrome in an adult patient: A case report and literature review. Surg Neurol Int 2019; 10:90. [PMID: 31528428 PMCID: PMC6744800 DOI: 10.25259/sni-66-2019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 02/04/2019] [Indexed: 11/14/2022] Open
Abstract
Background: In a split cord malformation (SCM), the spinal cord is divided longitudinally into two distinct hemicords that later rejoin. This can result in a tethered cord syndrome (TCS). Rarely, TCS secondary to SCM presents in adulthood. Here, we present an adult female with Type I SCM resulting in TCS and a review of literature. Case Description: A 57-year-old female with a history of spina bifida occulta presented with a 2-year history of worsening back and left leg pain, difficulty with ambulation, and intermittent urinary incontinence; she had not responded to conservative therapy. Magnetic resonance imaging (MRI) revealed a tethered cord secondary to lumbar type I SCM. The patient underwent an L1–S1 laminectomy for resection of the bony septum with cord detethering. At 2-month follow-up, the patient had improvement in her motor symptoms and less pain. In literature, 25 cases of adult-onset surgically managed SCM with TCS were identified (between 1936 and 2018). Patients averaged 37 years of age at the time of diagnosis, and 56% were female. Conclusion: TCS can present secondary to SCM in adulthood and is characterized predominantly by back and leg pain.
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Affiliation(s)
- Erin N D'Agostino
- Department of Neurosurgery, Geisel School of Medicine, Dartmouth College, Hanover, United States
| | - Daniel R Calnan
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire, United States
| | - Vyacheslav I Makler
- Section of Neurology, 1 Medical Center Drive, Lebanon, New Hampshire, United States
| | - Imad Khan
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire, United States
| | - John H Kanter
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire, United States
| | - David F Bauer
- Dartmouth-Hitchcock Medical Center, Section of Neurosurgery, 1 Medical Center Drive, Lebanon, New Hampshire, United States
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