Faculty Bibliography

BACKGROUND:Management of modifiable risk factors is key in the prevention of recurrent stroke. We investigated trends in vascular risk factors (hyperglycemia, hyperlipidemia, hypertension, and smoking) control among US adults with stroke. METHODS:, low-density lipoprotein, and blood pressure and prevalence of meeting each recommended target were calculated for each epoch (1999 through 2002, 2003 through 2006, 2007 through 2010, 2011 through 2014, 2015 through 2020, and 2021 through 2023). RESULTS:-trend=0.002). The prevalence of meeting smoking and blood pressure guidelines was stable. Fewer than 10% of individuals met guidelines for all 4 risk factors over the study. CONCLUSIONS:In this nationally representative sample of US adults with stroke, <10% met guideline recommendations for all risk factors with an overall stable trend. These results suggest that efforts aimed at glycemia, blood pressure, and lipid control and smoking cessation could be improved to reduce the burden of recurrent stroke.

Alzheimer disease neuropathologic change (ADNC) is considered to be the most common cause of cognitive decline and dementia worldwide. ADNC level is determined using the density of neuritic plaques in combination with the topographical distribution of β-amyloid (Aβ) plaques and hyperphosphorylated tau (p-tau)-positive neurofibrillary tangles (NFTs). While cognitive decline correlates with the level of ADNC, there remains a great deal of variation in cognitive outcomes between individuals that is unaccounted for by current neuropathologic evaluation metrics. We leveraged quantitative computer-assisted positive pixel assessments to establish the neocortical p-tau burden in the middle frontal and superior temporal gyri of 61 individuals with Braak NFT stage V who had a wide range of cognitive outcomes and trajectories. Frontal and temporal neocortical p-tau burden varied between 0.2% and 53.7%. Both frontal and temporal p-tau burden directly affected cognitive outcome and correlated with function of multiple cognitive domains, including measures of language/semantic memory and attention/working memory. In multivariable analysis, only p-tau burden and microinfarcts significantly impacted cognitive decline, while Aβ, limbic-predominant age-related TDP-43 encephalopathy, Lewy body pathology, and other measures of cerebrovascular disease did not. Additionally, individuals with low mean neocortical p-tau burden (≤ 13%) had significantly better longitudinal cognitive trajectories over the final 15 years of life compared to those with high burden (≥ 23.5%). These results suggest that while all individuals with Braak stage V have some degree of neurofibrillary degeneration in the neocortex, the significant variation in cognitive decline observed between these individuals can be partially understood as a reflection of the variation in quantitatively assessed neocortical p-tau burden, which had a greater impact on progression to dementia than common comorbid neuropathologies associated with dementia risk. This argues for the incorporation of the density of ADNC-related pathology, in addition to its regional location, as an adjunct to future staging systems for Alzheimer disease.

Deep venous drainage (DVD) is considered a negative prognostic factor in AVM surgery, yet its effect on postoperative functional decline remains incompletely defined. This study evaluates whether DVD predicts worsened functional status after surgical resection of Spetzler-Martin Grade II-III AVMs. This retrospective multicenter study analyzed 129 patients with Spetzler-Martin Grade II-III AVMs across nine centers in North America and Europe who underwent primary surgical resection. We excluded cases with prior endovascular or stereotactic interventions. The primary outcome measured was poor functional status, defined as modified Rankin Scale (mRS) score 3-6 at last follow up. Among 129 patients with Spetzler-Martin Grade II-III AVMs, 38 (29.5%) exhibited deep venous drainage (DVD). Poor functional outcome (mRS ≥ 3) at last follow-up occurred in 14 patients (10.9%). This occurred in 6 of 38 patients with DVD (15.8%) compared with 8 of 91 without DVD (8.8%; Fisher's exact p = 0.244). On univariate Firth-penalized logistic regression, DVD was not significantly associated with poor outcome (OR 1.96, 95% CI 0.65-5.89; p = 0.228). In the primary reduced Firth model adjusting for age and pre-existing functional disability, DVD was independently associated with poor outcome (OR 6.87, 95% CI 1.07-44.20; p = 0.042). Increasing age (OR 1.08 per year, 95% CI 1.02-1.13; p = 0.004) and pre-existing functional disability (OR 6.53, 95% CI 1.63-26.22; p = 0.008) were also independently associated with poor outcome. DVD is associated with functional decline following surgical resection of Spetzler-Martin Grade II-III AVMs after adjustment for age and pre-existing functional disability.

BACKGROUND/UNASSIGNED:Attention impairment is common in post-traumatic brain injury. We synthesized evidence on pharmacological treatments for adults with attention deficits in the acute-to-chronic phases. METHODS/UNASSIGNED:We searched Ovid MEDLINE and Cochrane Library (1946-December 2024). Two reviewers screened studies, extracted data, and assessed study quality. Risk of bias was assessed using the Cochrane Risk of Bias tool and the PEDro scale for RCTs. Levels of evidence (LoE) were determined by the Sackett framework. RESULTS/UNASSIGNED:Twenty-nine studies met inclusion criteria across five drug classes and 14 medications. Results of LoE 1 were mixed: Methylphenidate improved classroom attention/processing speed, and exhibited neutral outcome; amantadine showed no improvement (LoE 1, 4, 5). MLC901 (a multi-herb antioxidant) improved complex attention (LoE 1). Donepezil improved sustained (LoE 1) and divided attention (LoE 4). Physostigmine/lecithin (LoE 1) and antidepressants (LoE 1, 3, 5) had mixed effects; growth hormone (LoE 4), and L-carnitine (LoE 1) showed no effect. Anticonvulsants impaired cognition (LoE 1). CONCLUSION/UNASSIGNED:Methylphenidate showed the strongest evidence at lower doses. Donepezil and MLC901 showed potential benefits. Phenytoin and carbamazepine showed adverse effects on cognition. Standardized attention outcome measures and other high-quality alternative clinical trials with larger study samples are recommended to overcome the current limitations.

INTRODUCTION/BACKGROUND:Although word-finding difficulties (WFD) are prevalent in multiple sclerosis (MS), they remain poorly understood. This cross-sectional study aimed to identify several important practical and theoretical challenges, including key knowledge gaps related to understanding and measuring aspects of language deficit in MS (i.e., WFD). Further investigations of possible correlates of deficits with other symptoms of MS (i.e., such as depression, fatigue and cognitive impairment) were also carried out as part of this study to find out if WFD is a standalone symptom or is a part of a broader and complex symptom of MS. METHODS:In this cohort study, all data from 586 consecutive Persons with MS (PwMS) (137 males and 449 females), with a mean age of 47.1 (SD±10.34) and a median EDSS score of 2.0, were included. A standardized naming task was used as part of a computerized cognitive assessment battery (CAB, NeuroTrax™) with computer-based administration and off-site scoring that has been validated for use in PwMS to determine the associations between cognitive impairment (CI), fatigue, and depression in WFD. RESULTS:A significant correlation (r = 0.327) was noted in this study between cognitive impairment and WFD (p < 0.001). PwMS with CI had a higher rate of WFD (i.e., 43.2%) as compared to individuals with WFD despite not having CI (i.e., 13.9%). Disability (EDSS), disease duration, depression and fatigue, were not correlated with WFD. CONCLUSION/CONCLUSIONS:WFD are most likely part of a larger underlying problem (i.e., CI), but there is a small group of persons with MS and WFD who have isolated WFD. Findings of this study have implications for activities of daily living (ADLs) and therapy for rehabilitation professionals working with PwMS.

OBJECTIVE:This study was undertaken to evaluate whether seizure freedom in pregnancy predicts seizure freedom in the postpartum period in women with epilepsy (WWE). Prior studies have shown that seizure freedom prior to conception strongly predicts seizure freedom during pregnancy. The postpartum period is considered especially vulnerable to recurrent seizures given rapid hormonal changes, shifting antiseizure medication pharmacokinetics, and disrupted sleep. There is a lack of sufficient data on whether seizure freedom during pregnancy predicts postpartum outcomes. METHODS:Pregnant WWE (aged 14-45 years) were enrolled at <20 weeks gestation in the prospective Maternal Outcomes and Neurodevelopmental Effects of Antiepileptic Drugs study. Participants completed electronic daily seizure and medication diaries with study visits each trimester, and at 6-12 weeks and 6 and 9 months postpartum. Participants also reported retrospective seizure frequency for the 9 months preconception. We used logistic regression to assess whether seizure freedom during pregnancy predicted seizure freedom postpartum, with additional analyses by seizure types. In participants with seizures during pregnancy, we evaluated median percent change in seizure frequency. RESULTS:This analysis included 331 pregnant WWE. Overall, 60.7% were seizure-free during pregnancy and 61.0% postpartum. Seizure freedom during pregnancy strongly predicted seizure freedom postpartum (odds ratio [OR] = 6.78, 95% confidence interval [CI] = 4.15-11.1, p < .0001), with a predictive value of 78% (95% CI = 72%-84%). Retrospectively reported preconception seizure freedom was also independently associated with postpartum seizure freedom (OR = 5.84, 95% CI = 3.57-9.58, p < .0001). Long-term seizure freedom during pregnancy and preconception was associated with 85% postpartum seizure freedom, whereas long-term presence of seizures was associated with only 36% postpartum seizure freedom. There were no significant differences by seizure type. Among participants with seizures during pregnancy, median postpartum seizure frequency declined by 77% (interquartile range = seizure-free to 31% reduced). SIGNIFICANCE/CONCLUSIONS:Our data demonstrated that seizure freedom during pregnancy was a robust predictor of seizure freedom during the postpartum period. These data can be used to counsel patients about seizure risk in the postpartum period.

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.

Persons with disorders of consciousness (DoC) occupy an ethically charged space in modern medicine and biomedical research. Their decisional capacity is characteristically absent or limited or unpredictably fluctuates, requiring clinicians and investigators to rely on surrogates. Although there is general guidance for informed consent (IC) for research studies, there is no specific guidance for research involving persons with DoC. There are inconsistencies in IC forms for these studies related to explanation of a DoC, evaluation of capacity, description of risks/benefits, and sharing investigational results. This is problematic for persons with DoC, their surrogates, researchers, and institutional review boards (IRBs)/research ethics boards (REBs). To address these issues, the Curing Coma Campaign (CCC) Ethics Workgroup developed the Common Consent Elements for Research Involving Persons with Disorders of Consciousness (CCE-DoC). This practical framework aims to clarify and standardize consent processes in this complex and ethically sensitive research area. Through this structured, adaptable approach, CCE-DoC may have the potential to enhance participant protections, strengthen trust, help families and decision-makers understand studies, reduce duplicative efforts across research groups, and guide investigators and IRBs/REBs in navigating the complex ethical terrain of consent in DoC research. In so doing, CCE-DoC seeks to extend respect for autonomy and trust and promote responsible research urgently needed to advance paradigms of diagnosis, prognosis, and treatment for individuals with disorders of consciousness. The framework offers example language to encourage standardization, while allowing teams flexibility to customize to local needs.

PURPOSE/UNASSIGNED:Optical character recognition (OCR), a process that converts printed or handwritten text into machine-readable form, is widely used in assistive technology for people with blindness and low vision. Yet most evaluations rely on static datasets that do not reflect the challenges of mobile use. This study evaluated how OCR performance changes under static and walking conditions relevant to real-world navigation. METHODS/UNASSIGNED:Static tests varied distance from 1-7 metres and viewing angle from 0°-75°. Dynamic tests examined the impact of motion by varying walking speed from 0.8 m/s to 1.8 m/s and compared head-mounted, shoulder-mounted, and handheld positions. We evaluated a smartphone and smart glasses, including the phone's main and ultra-wide cameras, across four OCR engines: Google Vision, PaddleOCR 3.0, EasyOCR, and Tesseract. Dynamic tests used PaddleOCR 3.0. Accuracy was computed at the character level using the Levenshtein ratio against manually defined ground truth. RESULTS/UNASSIGNED:Recognition accuracy declined with increased walking speed and wider viewing angles. Google Vision achieved the highest overall accuracy, with PaddleOCR close behind as the strongest open-source alternative. Across devices, the phone's main camera achieved the highest accuracy, and a shoulder-mounted placement yielded the highest average among body positions; however, differences among shoulder, head, and hand were not statistically significant. CONCLUSION/UNASSIGNED:OCR performance depends on the recognition engine, camera hardware, field of view, device placement, and user motion. OCR systems for navigation should be evaluated under dynamic, mobility-relevant conditions rather than static images alone and designed to balance coverage, recognition accuracy, and practical deployment.