Faculty Bibliography

INTRODUCTION/BACKGROUND:Subway-related trauma is an understudied category of urban injury. Prior work has focused on high-acuity train-contact events, with less attention to more common mechanisms and the roles of psychiatric illness and substance use. We analyzed a large contemporary cohort to define epidemiology, injury patterns, and outcome predictors across the full spectrum of subway trauma. METHODS:We performed a retrospective cohort study of adults presenting with subway-related injury to a Level I trauma center (2018-2024). Registry data and manual chart review captured demographics, mechanisms, comorbidities, intoxication, injury severity, and outcomes. Injuries were categorized using validated natural language processing. Multivariable logistic regression identified predictors of train-contact mechanism, major trauma (ISS ≥ 15), TBI, and assault. RESULTS:Among 809 patients, median age was 50 years and 81.2% were male. Falls were most common (57.2%), followed by train contact (16.8%) and assault (16.7%). Median ISS was 9, with 25.0% sustaining major trauma. TBI occurred in 40.5% and did not differ by mechanism. Train contact was the most severe mechanism and the only independent predictor of major trauma (aOR 5.08). Psychiatric diagnosis (aOR 1.59) and acute intoxication (aOR 1.69) independently predicted train contact, while intoxication predicted TBI (aOR 1.66). Psychiatric illness and substance use disorder were associated with longer hospitalization independent of injury severity. Assault exposure varied by race/ethnicity. CONCLUSION/CONCLUSIONS:Most subway injuries result from falls rather than intentional mechanisms. Train contact drives severity, while intoxication increases TBI risk. Psychiatric and substance use comorbidities prolong hospitalization, supporting routine behavioral health screening and targeted prevention strategies.

INTRODUCTION/BACKGROUND:Hemispherotomy is an effective treatment for children with drug-resistant epilepsy (DRE). While hemispherotomy techniques and indications have evolved, access remains predominantly constrained to high-resource settings. METHODS:We performed a retrospective analysis of children who underwent hemispherotomy from 2011 to 2023 by a hybrid team, including local Panamanian and US neurologists, neurosurgeons, and EEG technicians and analyzed surgical, epilepsy, and quality of life (QoL) parameters. Follow-up data were collected according to the International Consortium for Health Outcomes Measurement (ICHOM) guidelines for children with epilepsy. RESULTS:Twenty-three children underwent hemispherotomy. The median age at surgery was 10 years (range 2-20). The median follow-up time was 6 years (range 1-13). The etiology of DRE included malformations of cortical development in 14 children (60.8%), including 8 (34.8%) with schizencephaly, and secondary causes in 9 children (39.1%). Seizure frequency improved for all 23 children (100%): Engel I was achieved in 15 children (65.2%), Engel II (26.1%) in six children, and Engel III (8.7%) in two children. Patients with seizure freedom had significantly fewer preoperative seizures per day than patients with seizure recurrence. Complications occurred in six children (26.1%): 2 wound infections, 2 meningitis, 1 femoral vein thrombosis, and 1 wound hematoma with return to OR. There were no perioperative mortality and no postoperative hydrocephalus or CSF diversion. QoL-related outcomes were available for 16 children: 16/16 (100%) reported that the surgery was a worthwhile and repeatable choice, 14 (87.5%) reported improved cognitive function, the median QOLCE-16 score was 62.5 ± 21. CONCLUSION/CONCLUSIONS:Hemispherotomy for DRE in selected children is a safe and effective surgery in a public children's hospital in a low-resource setting. At last follow-up, the majority of children were seizure-free, and all children had decreased seizure frequency. Families reported improved cognitive function, improved QoL and high satisfaction with their decision to pursue this surgery.

BACKGROUND AND OBJECTIVES/OBJECTIVE:General purpose vision-language models (VLMs) demonstrate impressive capabilities, but their opaque training on uncurated internet data poses critical limitations for high-stakes decision making, such as in neurosurgery. We present CNS-Obsidian, a neurosurgical VLM trained on peer-reviewed neurosurgical literature, and demonstrate its clinical utility compared with GPT-4o in a real-world setting. METHODS:We compiled 23 984 articles from Neurosurgery Publications journals, yielding 78 853 figures and captions. Using GPT-4o and Claude Sonnet-3.5, we converted these image-text pairs into 263 064 training samples across 3 formats: instruction fine-tuning, multiple-choice questions, and differential diagnosis. We trained CNS-Obsidian, a fine-tune of the 34-billion parameter Large Language and Visual Assistant-Next model. In a blinded, randomized deployment trial at NYU Langone Health (August 30-November 30, 2024), neurosurgeons were assigned to use either CNS-Obsidian or a Health Insurance Portability and Accountability Act-compliant GPT-4o end point as a diagnostic copilot after patient consultations. Primary outcomes were diagnostic helpfulness and accuracy, assessed through user ratings and presence of the correct diagnosis within the VLM-provided differential, respectively. RESULTS:CNS-Obsidian matched GPT-4o on synthetic questions (76.13% vs 77.54%, P = .235), but only achieved 46.81% accuracy on human-generated questions vs GPT-4o's 65.70% (P < 10-15). In the randomized trial, 70 consultations were evaluated (32 CNS-Obsidian, 38 GPT-4o) from 959 total consults (7.3% utilization). CNS-Obsidian received positive ratings in 40.62% of cases vs 57.89% for GPT-4o (P = .230). Both models included correct diagnosis in approximately 60% of cases (59.38% vs 65.79%, P = .626). CONCLUSION/CONCLUSIONS:Domain-specific VLMs trained on curated scientific literature can approach frontier model performance in specialized medical domains despite being orders of magnitude smaller and less expensive to train. This establishes a transparent framework for scientific communities to build specialized artificial intelligence models. However, low clinical utilization suggests chatbot interfaces may not align with specialist workflows, indicating need for alternative artificial intelligence integration strategies.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Normal pressure hydrocephalus (NPH) is characterized by the classic triad of cognitive decline, gait instability, and urinary incontinence in the setting of ventriculomegaly with normal intracranial pressure. Cerebrospinal fluid diversion is the current standard treatment, yet it carries a risk of overdrainage, resulting in subdural hematoma or hygroma. Different valves have been developed to mitigate this risk, yet consensus remains unclear regarding optimal valve for NPH. METHODS:We performed a retrospective cohort study on all patients with NPH who underwent cerebrospinal fluid shunting or revision between January 2014 and September 2025 at our institution. Demographic, clinical, and radiological data were collected from the electronic health record. Kaplan-Meier survival analysis, univariate logistic regression, and multivariate modeling were used to identify predictors of subdural collections and the need for surgical treatment. RESULTS:Since our change in practice from the Integra NPH Low Flow Valve (Low Flow OSV) to other valves in 2022, we observed a rise in symptomatic subdural collections. Programmable valves were associated with a markedly increased 1-year risk of both subdural collection formation and need for surgical intervention compared with the Low Flow OSV. Overall, Certas and Strata valves demonstrated higher rates of subdural collections requiring surgery than the Low Flow OSV (14.6% vs 2.1%, P < .001; 10.5% vs 2.1%, P = .005, respectively). On multivariate analysis, both the Strata and Certas valves were independently associated with increased odds of developing any subdural collection and necessitating surgery. Vascular disease and dual antiplatelet therapy also increased risk. CONCLUSION/CONCLUSIONS:In this large single-center cohort study, programmable valves, specifically the Certas and Strata, were associated with an increased rate and severity of subdural collections compared with the Low Flow OSV. The use of low-flow designs may mitigate complications for the NPH population, and the use of lower programmable valve settings should be carefully considered.

In children undergoing craniotomy, the impact of postoperative pain on recovery is receiving growing recognition. While opioids are often the primary treatment, their administration requires a delicate balance between achieving sufficient analgesia and mitigating side effects like sedation, nausea, vomiting, and respiratory depression. We review the emerging adjunct treatment modality regional scalp block (RSB) infiltration for post-craniotomy pain. Postoperative pain after pediatric craniotomy can be challenging to manage and may contribute to unnecessary suffering as well as the development of long-term neurocognitive and psychological sequelae. Pain during the PICU stay is also a major risk factor for post-PICU syndrome, which involves persistent impairments in children's physical, cognitive, or mental health persisting beyond acute hospitalization. Despite increasing awareness and treatment strategies for post-craniotomy pain in adults, significant gaps remain in understanding its assessment and management in children. This review examines the current literature surrounding post-craniotomy pain management in children with a special emphasis on RSB, a treatment option increasingly used in adults and children. RSB has been shown in randomized trials to reduce postoperative pain and opioid use. However, while pediatric perioperative trials support its safety and feasibility, robust clinical evidence supporting RSB's efficacy for post-craniotomy pain in children remains limited, hindering wider translation into clinical standard. RSB infiltration is an emerging and promising technique for pediatric post-craniotomy pain management. Early evidence suggests it is both safe and effective, with potential to enhance postoperative recovery and to be integrated into clinical practice. Further research is critical to validate initial findings and better define the benefits across diverse pediatric populations.

PURPOSE/OBJECTIVE:To identify clinical variables associated with ventricular shunt infection and shunt failure in pediatric hydrocephalus. METHODS:Patients ≤ 18 years treated with ventricular shunts between 2013 and 2024 were identified from one institution's electronic medical record. Children with a confirmed diagnosis of hydrocephalus and ≥ 6 months of postoperative follow-up were included. Primary and revision shunt surgeries were included. Records were manually reviewed for clinical variables. Statistical analyses were performed using R (version 4.2.3). RESULTS:The dataset included 474 surgeries, 146 primary and 328 revisions, undergone by 226 patients. Infection necessitating removal of a previously placed shunt occurred following 3.59% (17/474) of cases. Discharge in ≤ 4 days had a 75% lower relative risk for infection compared to stays > 4 days (1.5% vs. 6% 100-day infection risk; p = 0.011). Patients who underwent revision surgeries for shunt infections were more likely to experience subsequent infections in the first 100 days postoperatively than those revised for other causes (2.42% vs. 21.05%; p < 0.0001). Patient characteristics associated with shunt failure during the 10-year study included younger age (median age: 2.23 years in those with failure vs. 6.62 years in those without; p < 0.0002) and lower weight (median weight: 11.8 kg vs. 20.3 kg; p < 0.0002) at the time of admission. Congenital hydrocephalus (OR = 1.86; p = 0.0045) and aqueductal stenosis (OR = 1.75; p = 0.025) were also associated with shunt failure. CONCLUSIONS:Length of stay > 4 days and previous shunt infection are associated with an increased risk of infection after shunt surgery. These findings are important to consider when counseling pediatric patients and during postoperative monitoring.

BACKGROUND:Sturge-Weber syndrome (SWS) is a congenital neurocutaneous disorder characterized by angiomas of the face, choroid, and leptomeninges. Seizures in these children often present within the first 2 years of life. SWS is typically unilateral, but bilateral SWS occurs in approximately 15% of cases. Bilateral SWS is associated with earlier seizure onset and poorer cognitive, developmental, and functional outcomes. More than half of children with SWS develop drug-resistant epilepsy requiring surgical intervention. Hemispherotomy has been established as a successful treatment for unilateral SWS, but resective surgery has traditionally not been considered a treatment option for patients with bilateral disease. OBSERVATIONS/METHODS:In this report, the authors present the cases of 4 children (7 months-2 years of age) with bilateral SWS and drug-resistant epilepsy with a unilateral electroencephalography predominance. After a multidisciplinary conference in each case, all children were successfully treated with unilateral hemispherotomy. These patients achieved prolonged periods of seizure freedom postoperatively, a better quality of life, and demonstrated improved developmental progress at long-term follow-up. LESSONS/CONCLUSIONS:This case series suggests that functional hemispherotomy may be a safe and effective therapeutic option for improving seizure burden in cases of bilateral drug-resistant SWS with asymmetric seizure burden. https://thejns.org/doi/10.3171/CASE25125.

INTRODUCTION/BACKGROUND:Traumatic brain injury (TBI) is the leading cause of pediatric disability. Most pediatric TBIs are mild but can result in long-term cognitive and functional impairments. Outpatient follow-up is essential to detect post-concussive symptoms and aid recovery. METHODS:All patients 3-18 years of age with positive TBI findings on CT or MRI from 2018-2024 were retrospectively reviewed. Follow-up was defined as an appointment with neurology, neuropsychology, neurosurgery, or physical medicine and rehabilitation within three months of discharge. Analyses were performed with appropriate Chi-squared, Fisher's exact, Mann-Whitney U, or t-tests. RESULTS:Fifty-seven patients (41 male, mean age 11.4 years) were identified, with mild TBIs (GCS 13-15) comprising 41/57 (71.9%). Four patients (7.0%) died from their injury. Of 53 surviving patients, 20 (37.7%) had follow-up appointments scheduled for them at discharge, seven (13.2%) were given a specific date and contact number, 17 (32.1%) received service referrals without a specific date, and eight (15.1%) received nonspecific directions or were directed only to follow-up with non-neuroscience services. Within three months, 32 (60.4%) patients followed up, though only 22/53 (41.5%) patients saw a non-surgical neuroscience discipline. Patients who followed up were more likely to have undergone neurosurgery (p = 0.007) or any surgical procedure at all (p = 0.007). They were also more likely to have a shorter hospital length of stay (p = 0.021). Discharge instruction type was significantly associated with follow-up (p = 0.0013); 62.5% of patients who followed up had an appointment scheduled for them or were given a specific date versus 33.4% of patients who did not follow-up. Conversely, 38.1% of patients without follow-up received nonspecific instructions or were told to follow-up with non-neuroscience specialties. This finding remained significant when excluding patients with severe TBI. Follow-up had no significant associations with demographics, injury severity, or insurance type. CONCLUSION/CONCLUSIONS:Patient-centered discharge instructions with detailed service referrals increase access to critical follow-up care. Children with TBIs should have follow-up care arranged regardless of injury severity. Larger multicenter studies are needed to validate these findings.

OBJECTIVE:Endoscopic third ventriculostomy (ETV) is a treatment option for obstructive hydrocephalus; reported success rates vary. We investigated immediate postoperative magnetic resonance imaging (MRI) to evaluate the role of imaging parameters associated with outcomes. METHODS:Retrospective chart review was performed patients undergoing initial ETV between 2005 -2019. Patients with pre- and postoperative MRI with follow-up >one year were included. The following were noted: changes in subarachnoid CSF, third ventricle diameter (TV), bowing of the TV floor, and postoperative flow void. Kaplan-Meier survival methods were used to assess ETV success, Univariable and multivariable Cox proportional-hazards models were fitted to assess factors contributing to ETV success. RESULTS:Fifty-eight subjects were included. Nineteen (32.8%) experienced failure within one year, individually, no single imaging parameter predicted success. However, all cases with failure had no identifiable flow void. Any postoperative radiological change was not consistently associated with decreased odds of failure. Obstructive hydrocephalus treated with ETV demonstrated significantly better ETV success than patients treated for non-obstructive hydrocephalus Inter-observer reliability was moderate for two of the radiological variables and substantial for one of the radiological variables. CONCLUSIONS:Individually none of the qualitative radiologic parameters measured in our study predicted ETV success. Absence of a flow void predicted ETV failure, but additional studies are needed to determine its true negative predictive value. Inability to clarify which specific parameter predicts success, reflects the limited role of immediate postoperative imaging in influencing clinical management.

UNLABELLED:DNA methylation is an essential molecular assay for central nervous system (CNS) tumor diagnostics. While some fusions define specific brain tumors, others occur across many different diagnoses. We performed a retrospective analysis of 219 primary CNS tumors with whole genome DNA methylation and RNA next-generation sequencing. DNA methylation profiling results were compared with RNAseq detected gene fusions. We detected 105 rare fusions involving 31 driver genes, including 23 fusions previously not implicated in brain tumors. In addition, we identified 6 multi-fusion tumors. Rare fusions and multi-fusion events can impact the diagnostic accuracy of DNA methylation by decreasing confidence in the result, such as BRAF, RAF, or FGFR1 fusions, or result in a complete mismatch, such as NTRK, EWSR1, FGFR, and ALK fusions. IMPLICATIONS/UNASSIGNED:DNA methylation signatures need to be interpreted in the context of pathology and discordant results warrant testing for novel and rare gene fusions.