Serge Makarenko

Multimodal neuromonitoring for traumatic brain injury: A shift towards individualized therapy.

Multimodal neuromonitoring in the management of traumatic brain injury (TBI) enables clinicians to make individualized management decisions to prevent secondary ischemic brain injury. Traditionally, neuromonitoring in TBI patients has consisted of a combination of clinical examination, neuroimaging and intracranial pressure monitoring. Unfortunately, each of these modalities has its limitations and although pragmatic, this simplistic approach has failed to demonstrate improved outcomes, likely owing to an inability to consider the underlying heterogeneity of various injury patterns. As neurocritical care has evolved, so has our understanding of underlying disease pathophysiology and patient specific considerations. Recent additions to the multimodal neuromonitoring platform include measures of cerebrovascular autoregulation, brain tissue oxygenation, microdialysis and continuous electroencephalography. The implementation of neurocritical care teams to manage patients with advanced brain injury has led to improved outcomes. Herein, we present a narrative review of the recent advances in multimodal neuromonitoring and highlight the utility of dedicated neurocritical care.

Role of Facial Nerve Motor-Evoked Potential Ratio in Predicting Facial Nerve Function in Vestibular Schwannoma Surgery Both Immediate and at 1 Year.

Objective: To determine whether transcranial electrical stimulation-induced facial motor-evoked potential (FMEP) monitoring of the facial nerve (FN) during vestibular schwannoma (VS) tumor resection can predict both immediate and 1 year postoperative FN functional outcome. Design: Prospective consecutive non-comparative observational case series. Setting: Tertiary referral center. Main Outcome Measures: Facial function, immediate post operation and at 1 year using House–Brackmann (HB) grading scale. Methods: The study included 367 consecutive patients (men 178; women 189; age 13–81 years) monitored during primary sporadic VS microsurgery between November 2002 and April 2015. Neurofibromatosis type II, revision surgery, previous radiotherapy treatment, preoperative facial nerve weakness, and non-VS cases were excluded retrospectively during analysis of data. Data of facial function were missing from eight patients at 1 year and were excluded. The correlation between the final-to-baseline FMEP ratio and immediate and 1 year facial nerve function was examined. Results: Using logistic regression model, the cut-off points of FMEP ratio were 0.62 (PPV 0.96) and 0.59 (PPV 0.98) which predicted satisfactory FN function (HB grades 1 or 2) immediately postoperative and at 1 year after surgery, respectively. Conclusion: Transcranial electrical stimulation FMEP is a valuable tool for monitoring facial nerve function during resection of vestibular schwannoma. Maintaining a FMEP event-to-baseline ratio of 60% or greater is predictive of satisfactory long-term FN function.

Demographics, Interests, and Quality of Life of Canadian Neurosurgery Residents

BACKGROUND Neurosurgical residents face a unique combination of challenges, including long duty hours, technically challenging cases, and uncertain employment prospects. We sought to assess the demographics, interests, career goals, self-rated happiness, and overall well-being of Canadian neurosurgery residents. METHODS A cross-sectional survey was developed and sent through the Canadian Neurosurgery Research Collaborative to every resident enrolled in a Canadian neurosurgery program as of April 1, 2016. RESULTS We analyzed 76 completed surveys of 146 eligible residents (52% response rate). The median age was 29 years, with 76% of respondents being males. The most popular subspecialties of interest for fellowship were spine, oncology, and open vascular neurosurgery. The most frequent self-reported number of worked hours per week was the 80- to 89-hour range. The majority of respondents reported a high level of happiness as well as stress. Sense of accomplishment and fatigue were reported as average to high and overall quality of life was low for 19%, average for 49%, and high for 32%. Satisfaction with work-life balance was average for 44% of respondents and was the only tested domain in which significant dissatisfaction was identified (18%). Overall, respondents were highly satisfied with their choice of specialty, choice of program, surgical exposure, and work environment; however, intimidation was reported in 36% of respondents and depression by 17%. CONCLUSIONS Despite a challenging residency and high workload, the majority of Canadian neurosurgery residents are happy and satisfied with their choice of specialty and program. However, work-life balance, employability, resident intimidation, and depression were identified as areas of active concern.

Operative Landscape at Canadian Neurosurgery Residency Programs

Background Currently, the literature lacks reliable data regarding operative case volumes at Canadian neurosurgery residency programs. Our objective was to provide a snapshot of the operative landscape in Canadian neurosurgical training using the trainee-led Canadian Neurosurgery Research Collaborative. METHODS Anonymized administrative operative data were gathered from each neurosurgery residency program from January 1, 2014, to December 31, 2014. Procedures were broadly classified into cranial, spine, peripheral nerve, and miscellaneous procedures. A number of prespecified subspecialty procedures were recorded. We defined the resident case index as the ratio of the total number of operations to the total number of neurosurgery residents in that program. Resident number included both Canadian medical and international medical graduates, and included residents on the neurosurgery service, off-service, or on leave for research or other personal reasons. RESULTS Overall, there was an average of 1845 operative cases per neurosurgery residency program. The mean numbers of cranial, spine, peripheral nerve, and miscellaneous procedures were 725, 466, 48, and 193, respectively. The nationwide mean resident case indices for cranial, spine, peripheral nerve, and total procedures were 90, 58, 5, and 196, respectively. There was some variation in the resident case indices for specific subspecialty procedures, with some training programs not performing carotid endarterectomy or endoscopic transsphenoidal procedures. CONCLUSIONS This study presents the breadth of neurosurgical training within Canadian neurosurgery residency programs. These results may help inform the implementation of neurosurgery training as the Royal College of Physicians and Surgeons residency training transitions to a competence-by-design curriculum.

Natural History, Multimodal Management, and Quality of Life Outcomes of Trigeminal Schwannomas

Abstract Background Trigeminal schwannomas are the second most common among intracranial schwannomas. These can arise from anywhere between the root and the distal extracranial branches of the trigeminal nerve. Clinical presentation depends on location and size, including but not limited to facial hypesthesia or pain, headaches, dizziness, ataxia, and diplopia. Literature is strikingly scant discussing the natural history of these lesions, while the treatment goals are heavily dependent on tumor presentation. Management decisions must be individualized to each tumor and each patient, while attempting to maximize the quality of life. We present the natural history of these lesions as well as their management by surgical resection or radiation therapy, and report long‐term quality of life outcomes. Methods Between 2001 and 2015, 24 patients (66.7% female) with trigeminal schwannomas were diagnosed and managed at Vancouver General Hospital. We analyzed the clinical presentation, surgical results, resection rates, patient quality of life, and complications. To complete the evaluation, we prospectively collected 36‐Item Short Form Health Survey (SF‐36) quality of life assessments for comparison. Results We identified 12 patients treated with a craniotomy and surgical resection, 4 were treated with radiation therapy, while 8 patients were followed by observation. Mean age of study cohort was 49.2 years (range, 23‐79 years), and most patients presented with facial hypesthesia (54.2%) and headaches (37.5%), while 37.5% were incidental findings. There were no major differences in patient demographics between the three groups. Patients offered surgery had larger lesions (mean diameter, 3.4 ± 1.1 cm) when compared with those that were irradiated or observed, and were more likely to have extracranial extension. Overall patient quality of life improved following treatment (&Dgr;SF‐36 + 12.9) at 3.9 years. Conclusions The treatment goals of trigeminal schwannomas focus on improvement in neurologic symptoms, relief of mass effect, and preservation of cranial nerve function. We demonstrate that smaller lesions found incidentally with minimal symptoms can be followed safely with serial imaging, with 1 of 9 (11.1%) progressing to require treatment over the course of 7.1 years. Management of trigeminal schwannomas should be individualized with an involvement of a multidisciplinary skull base team.

Non-surgical transient cerebellar mutism—case report and systematic review

IntroductionTransient cerebellar mutism has been well recognized in literature as a complication of posterior fossa tumor resection. It is marked by profound impairment of fluency, articulation, and modulation of speech, irritability and autistic features and typically resolves within days to months. Underlying pathophysiology is debated, but currently unknown.MethodsWe present a case of a child with similar clinical findings after cerebellitis, demonstration of diffuse cerebellar signal changes, swelling, and protruding tonsils at the level of foramen magnum.DiscussionTo support the hypothesis that this clinical syndrome may occur in a non-surgical context, we present a review of literature of non-surgical transient cerebellar mutism.