A. John Popp

A national fundamentals curriculum for neurosurgery PGY1 residents: The 2010 society of neurological surgeons boot camp courses

BACKGROUND: In July 2009, the Accreditation Council for Graduate Medical Education (ACGME) incorporated postgraduate year 1 (PGY1 intern) level training into all U.S. neurosurgery residency programs. OBJECTIVE: To provide a fundamentals curriculum for all incoming neurosurgery PGY1 residents in ACGME-accredited programs, including skills, knowledge, and attitudes that promote quality, patient safety, and professionalism. METHODS: The Society of Neurological Surgeons organized 6 regional “boot camp” courses for incoming neurosurgery PGY1 residents in July 2010 that consisted of 9 lectures on clinical and nonclinical competencies plus 10 procedural and 6 surgical skills stations. Resident and faculty participants were surveyed to assess knowledge and course effectiveness. RESULTS: A total of 186 of 197 U.S. neurosurgical PGY1 residents (94%) and 75 neurosurgical faculty from 36 of 99 programs (36%) participated in the inaugural boot camp courses. All residents and 83% of faculty participants completed course surveys. All resident and faculty respondents thought that the boot camp courses fulfilled their purpose and objectives and imparted skills and knowledge that would improve patient care. PGY1 residents knowledge of information taught in the courses improved significantly in postcourse testing (P < .0001). Residents and faculty particularly valued simulated and other hands-on skills training. CONCLUSION: Regional organization facilitated an unprecedented degree of participation in a national fundamental skills program for entering neurosurgery residents. One hundred percent of resident and faculty respondents positively reviewed the courses. The boot camp courses may provide a model for enhanced learning, professionalism, and safety at the inception of training in other procedural specialties.

Intramedullary spinal cord cavernous malformations

Although originally the subject of rare case reports, intramedullary spinal cord cavernous malformations (CMs) have recently surfaced in an increasing number of case series and natural history reports in the literature. The authors reviewed 27 publications with 352 patients to consolidate modern epidemiological, natural history, and clinical and surgical data to facilitate decision making when managing these challenging vascular malformations. The mean age at presentation was 42 years without a sex predilection. Thirty-eight percent of the cases were cervical, 57% thoracic, 4% lumbar, and 1% unspecified location. Nine percent of the patients had a family history of CNS CMs. Twenty-seven percent of the patients had an associated cranial CM. On presentation 63% of the patients had motor deficits, 65% had sensory deficits, 27% had pain, and 11% had bowel or bladder dysfunction. Presentation was acute in 30%, recurrent in 16%, and progressive in 54% of cases. An overall annual hemorrhage rate was calculated as 2.5% for 92 patients followed up for a total of 2571 patient-years. Across 24 reviewed surgical series, a 91% complete resection rate was found. Transient morbidity was seen in 36% of cases. Sixty-one percent of patients improved, 27% were unchanged, and 12% were worse at the long-term follow-up. Using this information, the authors review surgical nuances in treating these lesions and propose a management algorithm.

Patterns in neurosurgical adverse events and proposed strategies for reduction

Neurosurgery is a high-risk specialty currently undertaking the pursuit of systematic approaches to reducing risk and to measuring and improving outcomes. The authors performed a review of patterns and frequencies of adverse events in neurosurgery as background for future efforts directed at the improvement of quality and safety in neurosurgery. They found 6 categories of contributory factors in neurosurgical adverse events, categorizing the events as influenced by issues in surgical technique, perioperative medical management, use of and adherence to protocols, preoperative optimization, technology, and communication. There was a wide distribution of reported occurrence rates for many of the adverse events, in part due to the absence of definitive literature in this area and to the lack of standardized reporting systems. On the basis of their analysis, the authors identified 5 priority recommendations for improving outcomes for neurosurgical patients at a population level: 1) development and implementation of a national registry for outcome data and monitoring; 2) full integration of the WHO Surgical Safety Checklist into the operating room workflow, which improves fundamental aspects of surgical care such as adherence to antibiotic protocols and communication within surgical teams; and 3-5) activity by neurosurgical societies to drive increased standardization for the safety of specialized equipment used by neurosurgeons (3), more widespread regionalization and/or subspecialization (4), and establishment of data-driven guidelines and protocols (5). The fraction of adverse events that might be avoided if proposed strategies to improve practice and decrease variability are fully adopted remains to be determined. The authors hope that this consolidation of what is currently known and practiced in neurosurgery, the application of relevant advances in other fields, and attention to proposed strategies will serve as a basis for informed and concerted efforts to improve outcomes and patient safety in neurosurgery.

Cerebral capillary telangiectasias: a meta-analysis and review of the literature

As a result of their presumed benign natural history, cerebral capillary telangiectasias (CCTs) are infrequently addressed in the neurosurgical literature. We performed a comprehensive review of CCTs via the PubMed database to synthesize overall epidemiological, radiographic, natural history, and treatment results. Across ten series with 203 patients, mean age was 47, and 45xa0% were male [95xa0% confidence interval (CI), 0.30–0.65]. Notably, 78xa0% of CCTs were in the pons (95xa0% CI, 0.58–1.0). Six percent of CCTs were symptomatic. Across five radiographic series, all lesions enhanced after gadolinium, and all were hypointense on gradient echo sequences. Thirty-three percent were hypointense on T1-weighted pre-contrast imaging (95xa0% CI, 0.2–0.51), 49xa0% were hyperintense on T2-weighted imaging (95xa0% CI, 0.31–0.72), and 74xa0% were hypointense on diffusion-weighted imaging (95xa0% CI, 0.5–1.0). Notably, 37xa0% were associated with a prominent draining vein (95xa0% CI, 0.21–0.6), and 11xa0% with a developmental venous anomaly (95xa0% CI, 0.04–0.25). Across four observational studies with 47 patients, there was no observed change in lesion morphology or hemorrhage in 65.7 patient-years of follow-up. Although the vast majority of CCTs are managed conservatively, we found ten cases of patients treated with surgical excision. We confirm that CCTs are a benevolent entity with a predilection for the pons. They have distinctive radiographic features including their lack of mass effect, consistent enhancement on T1-weighted sequences and hypointensity on gradient echo sequences, and common isointensity on pre-contrast T1-weighted and T2-weighted images. Management for these lesions has been nonoperative in almost all cases.

Stereotactic radiosurgery for cerebral dural arteriovenous fistulas

OBJECTnGiven the feasibility of curative surgical and endovascular therapy for cerebral dural arteriovenous fistulas (DAVFs), there is a relative paucity of radiosurgical series for these lesions as compared with their arteriovenous malformation counterparts.nnnMETHODSnThe authors reviewed records of 56 patients with 70 cerebral DAVFs treated at their institution over the past 6 years. Ten DAVFs (14%) in 9 patients were treated with stereotactic radiosurgery (SRS), with follow-up obtained for 8 patients with 9 DAVFs. They combined their results with those obtained from a comprehensive review of the literature, focusing on obliteration rates, post-SRS hemorrhage rates, and other complications.nnnRESULTSnIn the authors group of 9 DAVFs, angiographic obliteration was seen in 8 cases (89%), and no post-SRS hemorrhage or complications were observed after a mean follow-up of 2.9 years. Combining the results in these cases with data obtained from their review of the literature, they found 558 DAVFs treated with SRS across 14 series. The overall obliteration rate was 71%; transient worsening occurred in 9.1% of patients, permanent worsening in 2.4% (including 1 death, 0.2% of cases), and post-SRS hemorrhage occurred in 1.6% of cases (4.8% of those with cortical venous drainage [CVD]). The obliteration rate for cavernous DAVFs was 84%, whereas the rates for transversesigmoid and for tentorial DAVFs were 58% and 59%, respectively (adjusted p values, p(cav,TS) = 1.98 × 10(-4), p(cav,tent) = 0.032). Obliteration rates were greater for DAVFs without CVD (80%, compared with 60% for those with CVD, p = 7.59 × 10(-4)). Both transient worsening and permanent worsening were less common in patients without CVD than in those with CVD (3.4% vs 7.3% for transient worsening and 0.9% vs 2.4% for permanent worsening).nnnCONCLUSIONSnStereotactic radiosurgery with or without adjunctive embolization is an effective therapy for DAVFs that are not amenable to surgical or endovascular monotherapy. It is best suited for lesions without CVD and for cavernous DAVFs.

Factors associated with external ventricular drain placement accuracy: data from an electronic health record repository.

BackgroundWe evaluated external ventricular drain placement for factors associated with placement accuracy. Data were acquired using an electronic health record data requisition tool.MethodMedical records of all patients who underwent ventriculostomy from 2003 to 2010 were identified and evaluated. Patient demographics, diagnosis, type of guidance and number of catheter passes were searched for and recorded. Post-procedural hemorrhage and/or infection were identified. A grading scale was used to classify accuracy of catheter placements. A multiple logistic regression model was developed to assess features associated with accurate catheter placement.ResultsOne hundred nine patients who underwent 111 ventriculostomies from 2003 to 2010 were identified. Patient diagnoses were classified into vascular (63xa0%), tumor (21xa0%), trauma (14xa0%), and cyst (2xa0%). Procedures were performed freehand in 90 (81xa0%), with the Ghajar guide in 17 (15xa0%), and with image guidance in 4 (4xa0%) patients. Eighty-eight (79xa0%) catheters were placed in the correct location. Trauma patients were more likely to have catheters misplaced (pu2009=u20090.007) whereas patients in other diagnostic categories were not significantly associated with misplaced catheters. Post-procedural hemorrhage was noted in 2 (1.8xa0%) patients on post-procedural imaging studies. Five (4.5xa0%) definite and 6 (5.4xa0%) suspected infections were identified.ConclusionsExternal ventricular drain placement can be performed accurately in most patients. Patients with trauma are more likely to have catheters misplaced. Further development is required to identify and evaluate procedure outcomes using an electronic health record repository.

Smart Stylet: The Development and Use of a Bedside External Ventricular Drain Image-Guidance System

Background: Placement accuracy of ventriculostomy catheters is reported in a wide and variable range. Development of an efficient image-guidance system may improve physician performance and patient safety. Objective: We evaluate the prototype of Smart Stylet, a new electromagnetic image-guidance system for use during bedside ventriculostomy. Methods: Accuracy of the Smart Stylet system was assessed. System operators were evaluated for their ability to successfully target the ipsilateral frontal horn in a phantom model. Results: Target registration error across 15 intracranial targets ranged from 1.3 to 4.6 mm (mean 3.1 mm). Using Smart Stylet guidance, a test operator successfully passed a ventriculostomy catheter to a shifted ipsilateral frontal horn 20/20 (100%) times from the frontal approach in a skull phantom. Without Smart Stylet guidance, the operator was successful 4/10 (40%) times from the right frontal approach and 6/10 (60%) times from the left frontal approach. In a separate experiment, resident operators were successful 2/4 (50%) times when targeting the shifted ipsilateral frontal horn with Smart Stylet guidance and 0/4 (0%) times without image guidance using a skull phantom. Conclusions: Smart Stylet may improve the ability to successfully target the ventricles during frontal ventriculostomy.

Mind-Brain Identity Theory and the Musical Experience

he producers include such individuals as composers and perormers for whom the main product either is creation of a new usical idea by the composer or re-creation of another’s novel dea by the performer—a subclassification that becomes impreise when the performance of music, itself, has a substantial reative component such as jazz. Furthermore, the expressive rges of composers have led to elaborate attempts to convey usical structure and content beyond the staves of the score as xemplified by the early twentieth century Russian composer nd pianist, Alexander Scriabin, who had color-hearing synestheia. Scriabin composed the symphonic work, Prometheus, the oeme of Fire, to be accompanied by a light show with projection f the colors that he “saw” in relation to various tones of the rchestral score.