Faculty Bibliography

INTRODUCTION AND PROBLEM STATEMENT/UNASSIGNED:Competency in brain death/death by neurologic criteria (BD/DNC) determination is an Accreditation Council for Graduate Medical Education (ACGME) milestone in neurology residency and neurocritical care fellowship; however, trainees have limited clinical exposure and receive inconsistent training across institutions. Simulation offers a standardized, safe environment to teach and assess BD/DNC, but multi-institutional implementation remains unstudied. The aim of this study was to evaluate the feasibility of implementing a consensus-based BD/DNC curriculum and to assess its impact on trainee confidence. LEARNING OBJECTIVES/UNASSIGNED:By the end of the curriculum, trainees will be confident in assessing BD/DNC prerequisites, performing a complete neurologic examination, safely conducting and interpreting apnea testing, and accurately declaring BD/DNC. METHODS AND CURRICULUM DESCRIPTION/UNASSIGNED:test. RESULTS/UNASSIGNED:Nineteen participants (9 female [47%]; predominantly PGY-4 trainees) were enrolled. Median [IQR] pre-post composite confidence scores improved significantly across all domains: "Setup and Family Counseling," 4 [3.5-4] to 4.5 [4-5]; "Prerequisites," 4 [4-5] to 4.5 [4-5]; "Neurologic Examination," 4 [4-4] to 4.5 [4-5]; and "Apnea Test and Declaration of BD/DNC," 3 [3-4] to 5 [4-5]. The effect sizes (Wilcoxon r) ranged from 0.79 to 0.88 across domains. There were no significant differences in the magnitude of improvement between high-fidelity and low-fidelity groups. After curriculum implementation, 13 of 19 participants (68%) self-assessed their ACGME BD/DNC milestone competency to be level 4 or 5. DISCUSSION AND LESSONS LEARNED/UNASSIGNED:This multi-institutional pilot demonstrated that a consensus-based BD/DNC simulation curriculum is feasible and improves trainee confidence despite limited previous clinical exposure. Key lessons include the feasibility of multicenter collaboration, standardizing core practices while accommodating local variability, and designing adaptable curricula that achieve similar outcomes across resource-diverse settings.

BACKGROUND:Final infarct volume (FIV) on 24-hour magnetic resonance imaging is a well-established imaging biomarker linked to functional recovery after ischemic stroke, yet its prognostic value in intracranial atherosclerosis-related large vessel occlusion remains poorly explored. The impact of adjunct intracranial stenting on both infarct size and progression also remains unclear in this population. This study aimed to examine the association between FIV and clinical outcome, evaluate the effect of adjunct stenting on FIV and infarct progression, and assess the relationship between infarct progression and functional independence. METHODS:We conducted a post hoc secondary analysis of the RESCUE-ICAS registry (Registry of Emergent Large Vessel Occlusion due to Intracranial Stenosis); only patients with anterior circulation large vessel occlusion with magnetic resonance imaging after thrombectomy were included. FIV was measured on diffusion-weighted magnetic resonance imaging performed 24 to 36 hours postthrombectomy. Infarct progression was defined as the difference between baseline computed tomography perfusion infarct volume (cerebral blood flow <30%) on presentation and 24- to 36-hour FIV. The primary outcome was 90-day functional independence (modified Rankin Scale score 0-2). Additional analyses evaluated the association between adjunct intracranial stenting and FIV, and the association between infarct progression and 90-day functional outcome. Associations were analyzed using multivariable logistic regression and inverse probability of treatment weighting. RESULTS:=0.008). CONCLUSIONS:Among intracranial atherosclerosis-related large vessel occlusion patients, 24- to 36-hour FIV is a strong predictor of functional outcome. Adjunct stenting is associated with smaller FIV. Lower infarct progression was also associated with favorable outcome. These findings highlight FIV as a reliable imaging biomarker and potential surrogate end point in future trials.

BACKGROUND/UNASSIGNED:Retained foreign bodies (RFB), or those left behind following spine surgery, are considered "Never Events (NE < 1/1000: they should never happen)," or "Near Never Events (NNE < 1/100; they should nearly never happen)", but are not just "Adverse Events (AE >/= 1/100)." The vast majority of NE/NNE are due to cotton sponges, cottonoids, or residual cotton strands (i.e., collectively called Textilomas or Gossypibomas). However, RFB additionally included; fractured needles, guidewires, fractured screws/implants/drains, and/or broken instruments (i.e., scalpels). Notably, the spine surgeon of record, as captain of the ship, is primarily liable for RFB and is central to ensuing medicolegal suits. However, secondarily liable are the adjunctive surgical/medical personnel, (i.e., physicians, Physician Assistants, Nurses, Nurse Practitioners, Physical Therapists, Occupational Therapists), and others who are independent or work full-time for hospitals. METHODS/UNASSIGNED:Patients with RFB may present with acute, subacute, or chronic/delayed pain and suffering. Additional complaints include; lost wages, sustained physical disability and/or injury attributed to these objects. Most RFB are diagnosed on plain X-rays, followed by MR and/or CT studies. RESULTS/UNASSIGNED:RBS's may include; retained drain fragments, broken needles, fractured guidewires, broken scalpel blades, fractured screws, and/or instruments. Retrieval procedures warrant a wide variety of different techniques, some of which fail. Notably, RFB's largely occur due to the performance of; emergent procedures, doing an unfamiliar operation, encountering anatomical variants, or operating on patients with elevated body mass indexes (BMI). Additionally these include; surgeons' failure to order and/or radiologists' failure to correctly read intraoperative X-rays/fluoroscopic images, and/or nurses' failures to correctly perform end of surgery counts. CONCLUSION/UNASSIGNED:RFBs, or foreign bodies left behind following spine surgery, are considered "Never Events (< 1/1000)" or "Near Never Events (< 1/100)," and are not just "Adverse Events (> 1/100)". When they do occur, the operating surgeon bears primary responsibility, but the nursing/adjunctive staff and hospital are also liable.

BACKGROUND:People with multiple sclerosis (PwMS) frequently experience invisible symptoms, including cognitive impairment, fatigue, depression, anxiety, and psychosocial factors such as stigma, which can substantially affect social role participation (SRP). These factors are often under-recognized in clinical care despite their functional impact. OBJECTIVE:To examine the unique contributions of invisible MS-related symptoms to SRP after accounting for demographic characteristics and objective cognitive performance. METHODS:A cross-sectional sample of 434 PwMS was recruited from a large outpatient neurology clinic specializing in MS care. The sample was predominantly female (75%), largely white (85%), and middle-aged (M = 51.0, SD = 11.7), with mild-to-moderate disability. Participants completed a computerized cognitive battery and validated patient-reported outcome measures assessing disease impact, mood, fatigue, stigma, and SRP. Hierarchical regression models evaluated the variance explained by demographics, cognitive performance, and patient-reported symptoms. RESULTS:Demographic variables were not significant predictors of SRP. Cognitive performance accounted for 13.3% of the variance. Adding patient-reported outcomes increased explained variance to 70.6%. Depression, disease impact, fatigue, and executive functioning remained significant predictors, whereas stigma did not. CONCLUSIONS:Patient-reported symptom burden showed strong associations with SRP and explained more variance than demographic factors and most cognitive measures, while executive functioning also contributed independently.

BACKGROUND AND PURPOSE/OBJECTIVE:Chronic subdural hematoma (cSDH) affects approximately 20 per 100,000 individuals annually, with surgical recurrence rates of 10-20%. Middle meningeal artery embolization (MMAE) has emerged as a promising minimally invasive treatment, but the optimal timing remains unclear. We evaluated the association between MMAE timing and radiological and functional outcomes in cSDH. METHODS:We conducted a retrospective multicenter international cohort study across 33 centres, including patients who underwent MMAE for cSDH between January 2018 and December 2024. Patients were stratified by timing from diagnosis: Q1 (≤1 day), Q2 (2 days), Q3 (3-6 days), and Q4 (>6 days). The primary composite endpoint required radiological success (hematoma thickness <5 mm at 1-3 months), absence of emergency surgical evacuation, and either functional improvement or good functional outcome (modified Rankin Scale 0-2). Propensity score matching compared Q1 and Q4. RESULTS:Of 1,781 patients screened, 908 met inclusion criteria. Mean age was 73.7 ± 12.2 years, and 70.9% were female. Early embolization (Q1) achieved the primary composite endpoint more frequently than delayed embolization (Q4), with concordant improvements in radiological and functional components and no difference in rescue surgery. Good functional outcome was achieved in 76.0% of Q1 patients versus 63.8% in Q4 (absolute difference, 12.2%; P=.003; number needed to treat approximately 8). Hospital length of stay was 21.0 days shorter in Q1 versus Q4 (P<.001), partly attributable to the timing definition. In 174 propensity score-matched pairs, early embolization was associated with higher odds of achieving the primary endpoint (odds ratio, 6.41; 95% confidence interval, 3.29-12.48; P<.001), with pronounced benefit among patients receiving antithrombotic therapy (odds ratio, 8.06; 95% confidence interval, 3.65-17.80). CONCLUSIONS:Early MMAE (≤1 day from diagnosis) was overall associated with better outcomes compared with delayed intervention, particularly among patients receiving antithrombotic therapy. Prospective confirmation is warranted.

BACKGROUND/UNASSIGNED:Predominantly Dorsal Thoracic Spinal Arachnoid Webs (DAW/SAW: 90%-100%), attributed to arachnoidal scarring obstructing cerebrospinal fluid (CSF) dynamics, typically cause dorsal cord compression. Their multiple etiologies include; trauma, idiopathic/post-surgical, inflammatory/infection, subarachnoid hemorrhage, and/or congenital defects. METHODS/UNASSIGNED:Patients with DAW/SAW are typically in their early/mid-fifties, and present with; back pain (i.e., 41.2%-88.9%), motor deficits (i.e. 59%-77.8%), sensory loss (i.e., numbness 65%-66.7%), and/or sphincter dysfunction (i.e., 33.3%). RESULTS/UNASSIGNED:MR and Myelo-CT studies for DAW/SAW classically demonstrate the positive scalpel sign (i.e., single or multilevel dorsally compressive "fluid" collections often containing multiple loculations/fenestrations usually accompanied by Syrinxes (i.e., 44 - 83%), and/or Spinal Arachnoid Cyst (SAC) formation. Conservative treatment is rarely effective. Alternatively, surgery consisting of laminectomy/decompression, resection/ lysis, marsupialization and/or fenestration of loculated collections including attendant SAC resections, and decompression/shunting of Syrinxes, results in postoperative improvement in up to 91% of patients. CONCLUSION/UNASSIGNED:Patients with DAW/SAW typically present with MR/Myelo-CT studies that demonstrate the dorsal thoracic positive scalpel sign in conjunction with Syrinxes, and/or SAC. Surgery typically includes laminectomy/ decompression, lysis/resection of arachnoidal adhesions with marsupialization/fenestration, and/or shunting, to achieve up to a 91% incidence of postoperative neurological improvement.

Obstructive sleep apnea (OSA) is a common but underdiagnosed and undertreated sleep disorder among people with epilepsy (PWE). In PWE, this sleep disorder is often managed as a comorbid condition rather than a contributor to epilepsy outcomes. For many years, OSA has been associated with higher seizure burden and interictal epileptiform discharges. Emerging evidence links OSA to late onset epilepsy (LOE) and increased risk markers for sudden unexpected death in epilepsy (SUDEP). This evidence also suggests that treating OSA with continuous positive airway pressure may improve seizure control. This critical review of the literature posits that OSA should be viewed as a modifiable risk factor for PWE. We apply the Bradford Hill criteria for causation as a framework to appraise the evidence connecting OSA with (1) seizure severity, (2) incident LOE, and (3) SUDEP risk. OSA supports eight of nine Bradford Hill criteria to varying degrees: strength, consistency, temporality, biological gradient, plausibility, coherence, analogy, and experiment, but not specificity. Key limitations include confounding, selection and adherence biases, and limited randomized evidence. However, the evidence supports integrating systematic OSA screening and evidence-based treatment into epilepsy care. Future research should prioritize randomized trials to assess the impact of OSA treatment on epilepsy incidence, severity, and SUDEP risk.

Vision-language models (VLMs) have demonstrated remarkable performance across a wide range of computer-vision tasks, sparking interest in their potential for digital health applications. Here, we apply VLMs to two fundamental challenges in data-driven stroke rehabilitation: automatic quantification of rehabilitation dose and impairment from videos. We formulate these problems as motion-identification tasks, which can be addressed using VLMs. We evaluate our proposed framework on 20 healthy controls and 51 stroke survivors. Our results show that current VLMs lack the fine-grained motion understanding required for precise quantification: dose estimates are comparable to a baseline that excludes visual information, and impairment scores cannot be reliably predicted. Nevertheless, several findings suggest future promise. With optimized prompting and post-processing, VLMs can classify high-level activities from a few frames, detect motion and grasp with moderate accuracy, and approximate dose counts within 30% of ground truth for mildly impaired and healthy participants, all without task-specific training or finetuning. These results highlight both the current limitations and emerging opportunities of VLMs for data-driven stroke rehabilitation and broader clinical video analysis.

BackgroundPeople with subjective cognitive decline (SCD) are at increased risk of Alzheimer's disease. Prior research has suggested that amygdala volume may be more sensitive than hippocampal volume in detecting differences between SCD and age-matched controls, as well as in predicting SCD conversion to mild cognitive impairment. However, the microstructure underlying this volumetric change remains unclear.ObjectiveThis study evaluated amygdala microstructural differences in SCD versus control participants as well as associations between amygdala microstructure and volume, age, memory performance, anxiety, and depression using diffusion imaging.MethodsDiffusion tensor imaging, diffusion kurtosis imaging, and neurite orientation dispersion and density imaging were fit to diffusion MRI images. Group differences and correlations between diffusion metrics, age, memory, anxiety, and depression were assessed in 123 SCD versus 194 age-matched controls over age 55.ResultsIn the left amygdala, SCD participants had significantly lower fractional anisotropy (FA), lower kurtosis fractional anisotropy (KFA), and higher free water fraction (FWF). KFA was lower in the right amygdala in SCD. There were no significant group differences in the amygdala volume. Bilateral KFA negatively correlated with FWF, a marker of neuroinflammation and neurodegeneration. Left FA negatively correlated with orientation dispersion index, a marker of neuritic branching. Right KFA correlated with age only in SCD, while left FA correlated with anxiety only in controls.ConclusionsKFA is sensitive to group differences between SCD and controls in bilateral amygdala. KFA may reflect neuroinflammation and increased sensitivity to aging in the amygdala in SCD.