Faculty Bibliography

PURPOSE/OBJECTIVE:Pediatric low-grade gliomas (pLGGs) typically have excellent long-term outcomes; intratumoral hemorrhage is a rare, potentially dangerous complication. Hemorrhage risk in the context of molecular alterations and targeted therapies remains poorly characterized. We analyzed the incidence, timing, and independent risk factors for hemorrhage in a large contemporary pLGG cohort. METHODS:We conducted a retrospective cohort study of 236 children with pLGG treated at a single center (2011-2025). Clinical, radiographic, and molecular variables were abstracted. The primary endpoint was spontaneous tumoral hemorrhage. Time-to-event analyses utilized Kaplan-Meier methods and Cox proportional hazards modeling; penalized regression mitigated overfitting given the event rarity. RESULTS:Twelve patients (5.1%) experienced hemorrhage over 2,234 person-years (incidence: 0.54/100 person-years). Hemorrhage typically occurred years after initial tumor diagnosis (median 6.4 years). The presence of a KIAA1549::BRAF fusion in the tumor had the strongest association with hemorrhage, persisting across multivariable models (approximately sixfold increased risk), although estimates were limited by low event number. MAPK inhibitor exposure (specifically binimetinib and tovorafenib) was associated with hemorrhage in univariate analysis but partially confounded by fusion status. CSF diversion independently increased risk at brainstem, optic pathway, and hypothalamic locations. No hemorrhages occurred among patients with underlying genetic syndromes, including neurofibromatosis type 1 and tuberous sclerosis. CONCLUSION/CONCLUSIONS:Hemorrhage in pLGG is an infrequent late complication associated with tumor biology. KIAA1549::BRAF fusion may identify a higher-risk subgroup, with MAPK inhibitor exposure and CSF diversion further modifying risk. These findings support biology-informed surveillance and personalized management strategies for at-risk children.

Prediction of future events is essential for guiding effective actions in dynamic environments. Studies on the neural mechanisms for time-forward predictions have typically used stimuli with relatively simple statistical regularities. Here, we investigated time-forward predictions using stimuli containing statistical regularities similar to those found in natural auditory stimuli. Using intracranial EEG recordings in neurosurgical patients, we found that prediction signals were primarily carried by low-frequency activity across widespread cortical regions, including sensory, parietal, and frontal areas. Prediction-error (PE) signals were found in both low- and high-frequency activity, with high-frequency components localized mainly to sensory areas. Contrary to previous hypotheses, prediction and PE signals did not show a clear spatial or spectral segregation. Directed connectivity between brain regions decreased over the course of the stimulus sequence as predictability increased, except for pathways originating from the parietal cortex. These results reveal integrative and distributed predictive processing and highlight the dorsal auditory pathway in time-forward prediction.

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.

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.

Lance Adams Syndrome (LAS), or chronic post-hypoxic myoclonus (PHM), is a rare and disabling condition which occurs in the aftermath of a diffuse hypoxic brain injury, usually when patient regains consciousness. Due to its refractoriness to antiepileptics, deep brain stimulation (DBS) has been attempted over the past fifteen years. We describe three patients who underwent Globus Pallidus interna (GPi)-DBS at the NYU Langone Department of Neurosurgery. Despite varying stimulation parameters and contact combinations, none achieved substantial improvement of action and negative myoclonus or regained the ability to ambulate unassisted. We compared our results with previous reports. Our literature review identified ten cases of LAS treated with DBS since 2010. The target was GPi in 8/10 patients, the ventralis intermedius (VIM) nucleus in one, and the subtalamic nucleus (STN) in one. Varying degrees of improvement were reported, with some evidence suggesting that long pulse width and lower frequency might be more effective. However, most reports provided only partial Unified Myoclonus Rating Scale (UMRS) scores, with missing information on rest and reflex myoclonus as well as negative myoclonus. Due to the paucity of prior reports and the limited generalizability of existing evidence, the efficacy of DBS in LAS has yet to be demonstrated. Further case reports, both positive and negative, supported by neurophysiological measures, may help bridge this knowledge gap.

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.

OBJECTIVE:To evaluate the effectiveness and implementation of a multicomponent intervention to address the burden of drug use-related infectious diseases and overdose in rural settings. DESIGN/METHODS:Single-arm hybrid implementation-effectiveness design. SETTING/METHODS:Rural area comprising the Illinois counties of the Delta Regional Authority. PARTICIPANTS/METHODS:People who use opioids and/or stimulants nonmedically. INTERVENTION/METHODS:Expansion of community-based harm reduction services, capacity-building for opioid use disorder and hepatitis C treatment. MAIN OUTCOME MEASURES/METHODS:Harm reduction service expansion intervention Reach, Effectiveness (injection equipment sharing), Adoption and Cost (per participant and budget impact analysis). RESULTS:Three hundred six people who use drugs were enrolled. Of the 207 of who were not previously engaged in harm reduction services, 121 (59%) accepted referral and were retained in services at 6 months past study enrollment (intervention reach). In regards to intervention efficacy, among these individuals, 41 (35%) completed follow-up surveys; compared with their baseline self-report, there was a significant increase in obtaining sterile equipment from the harm reduction organization (43.9% vs. 68.3%, P = 0.03) and decrease in sharing injection equipment (46.3%-19.5%, P = .02). The harm reduction organization experienced an increase of approximately 100-550 program participants and an increase in service delivery area coverage from 1258 to 5509 square miles after intervention implementation (adoption). Cost per participant served by the harm reduction organization was $1486 per year, with annual budget impact to the program of $817 295. In regards to treatment capacity building, a total of 80 providers in the study area completed training in opioid use and/or hepatitis C management. CONCLUSION/CONCLUSIONS:The pragmatic evaluation of harm reduction service expansion supported by a suite of implementation strategies serves to inform the practical considerations and decision-making by community-based organizations seeking to increase services in rural areas heavily affected by substance use, overdose, and related infectious diseases.

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:Long-term effect of COVID-19 (Long COVID) may persist for months or years after SARS-CoV-2 infection, but longer-term cardiopulmonary manifestations have not been previously reported. OBJECTIVES/OBJECTIVE:The objective of the study was to characterize cardiopulmonary function after SARS-CoV-2 infection in a digital health substudy of the nationwide Researching COVID-19 to Enhance Recovery Adult Cohort Study. METHODS:Associations between wearable sensor device measures of cardiopulmonary fitness and survey-derived Long COVID symptoms were estimated over a 6-month window at least 6 months after infection using linear regression models adjusted for wear time, age, sex, race/ethnicity, and body mass index. RESULTS:Among 1,475 participants (72% female, 65% non-Hispanic White) a median of 21 months (IQR: 15-31 months) after infection, 498 (34%) had high symptom burden as characterized by the Researching COVID-19 to Enhance Recovery Long COVID Research Index (LCRI). High LCRI (vs low LCRI) was associated with significantly lower heart rate variability (-4.4 ms; 95% CI: -6.5 to -2.4; P < 0.001), higher resting heart rate (+1.5 beats/min [+0.7 to +2.4]; P < 0.001), fewer metabolic equivalent of task minutes (-96.3 [-128.8 to -63.8]; P < 0.001), lower step counts (-1,624 steps/day [-1,952 to -1,296]; P < 0.001), and lower activity levels (-7.9 minutes/day very or fairly active [-10.9 to -5.0]; P < 0.001). Hierarchal clustering analysis identified two subphenotypes with abnormal cardiovascular measures associated with low quality of life scores. CONCLUSIONS:Long COVID is associated with worse cardiovascular fitness. Additional studies are needed to determine if Long COVID is a novel risk factor for incident cardiovascular disease.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Direct electrocortical stimulation (DES) is the gold standard for mapping eloquent cortex, yet existing functional atlases are limited by sampling biases and density-based methods that obscure a region's true functional probability. Consequently, interpatient variability and the functional contributions of nontraditional language areas, such as the middle frontal gyrus, remain poorly characterized, particularly in epilepsy populations where functional reorganization is common. We therefore developed a probabilistic functional atlas of extraoperative DES and applied data-driven methods to characterize the functional organization of language, motor, and sensory cortex. METHODS:This was a retrospective observational study of patients undergoing intracranial monitoring for drug-resistant epilepsy (2008-2023). Electrical stimulation was delivered to intracranial electrodes during language tasks, and language, motor, and sensory findings were recorded. Positive and negative stimulation sites were analyzed in standard patient space and using the Human Connectome Project parcellation atlas. A multilevel statistical framework, including probability mapping, bootstrapped region-of-interest analyses, and kernel density estimation, defined structure-function relationships. Generalized linear mixed-effects models assessed the influence of clinical variables on language disruption. RESULTS:= 0.003) independently predicted a lower probability of language disruption in the temporal lobe. DISCUSSION/CONCLUSIONS:This extraoperative DES atlas provides a comprehensive benchmark for understanding functional cortical organization in epilepsy. We add evidence to the growing literature that language and motor systems are more distributed and variable than classically described. Substantial interpatient variability underscores the necessity of individualized mapping to guide safe neurosurgical planning. Limitations include the retrospective design and sampling bias inherent to electrode placement.