Faculty Bibliography

OBJECTIVE:This study compared outcomes in patients with and without preoperative stress testing undergoing carotid revascularization including carotid endarterectomy (CEA), transfemoral carotid artery stenting (TF-CAS), and transcarotid revascularization (TCAR). METHODS:Patients in the Vascular Quality Initiative Vascular Implant Surveillance and Interventional Outcomes Network (VQI VISION) database who underwent elective carotid revascularization 2016-2020 were included. Patients were analyzed by group based upon whether they underwent cardiac stress testing within two years preceding revascularization without subsequent coronary intervention. Subset analysis was performed comparing outcomes between those with negative and positive results (evidence of ischemia or MI). Outcomes of interest were postoperative MI/neurologic events, 90-day re-admission rates, as well as long-term mortality. RESULTS:We analyzed 18,364 patients (78.8% CEA, 9.3% TF-CAS, 11.9% TCAR). Of these, 35.8% underwent preoperative stress testing (37.4% of CEA patients, 27.5% of TF-CAS patients, and 31.9% of TCAR patients). While comorbidities were significantly higher amongst patients undergoing CEA with preoperative stress test compared to those without stress testing, the overall prevalence of co-morbidities was higher amongst patients undergoing TF-CAS or TCAR irrespective of preoperative stress test status. Compared to patients with a negative stress test, patients with positive stress test undergoing any form of carotid revascularization had a significant increase in 90-day re-admission rates (CEA 19.6% vs 15.8%, p=0.003; CAS 33.3% vs. 18.6%, p<0.001; TCAR 25% vs. 17.5%, p=0.04). No group demonstrated a difference in the incidence of in-hospital postoperative neurologic events or CHF, but those undergoing CEA (but not CAS or TCAR) experienced a significant increase in-hospital post-operative MI (1.7% vs 0.6%, p<0.001). In 3-year follow-up, those with a positive compared to negative stress test were more likely to undergo CABG/PCI in the CEA (adjusted HR 1.87 [1.42-2.27], p<0.0001) and CAS groups (adjusted HR 3.89 [1.77-8.57], p<0.01), but not the TCAR cohort. Notably those undergoing CEA with a positive compared to negative stress test, but not CAS or TCAR, exhibited a 28% increase in mortality (adjusted HR 1.28 [1.03-1.58], p=0.03) at 3 years. Conversely, those patients with a negative stress test compared to no stress test undergoing CEA experienced a 14% reduction in mortality at 3 years (adjusted HR 0.86 [0.76-0.98], p=0.02); this mortality difference was not observed in similar stress test cohort undergoing TF-CAS or TCAR. CONCLUSIONS:Our study highlights that a positive stress test in appropriately selected, asymptomatic patients undergoing elective carotid revascularization can predict select perioperative and long-term cardiovascular outcomes. However, given the high follow-up mortality associated with those undergoing CEA for elective carotid revascularization, our findings call into question whether these patients should be preferentially offered optimal medical management and/or stenting.

Brain death/death by neurologic criteria (BD/DNC) is accepted as legal death throughout much of the world. The World Brain Death Project and a subsequent review of the literature through 2023 highlighted several medicolegal controversies related to BD/DNC in Canada, the United Kingdom, and the United States but did not discuss medicolegal controversies related to BD/DNC in low- and middle-income countries, such as India. Although the Transplantation of Human Organs Act of 1994 acknowledged BD/DNC as death in India, BD/DNC evaluations are not always completed when BD/DNC is suspected. This has been attributed to lack of awareness/acceptance by medical professionals, lack of public awareness/acceptance of BD/DNC, communication challenges, fear, time limitations, and the inclusion of BD/DNC in organ donation law (but not general law). There has been a gradual rise in the number of donations after BD/DNC (a correlate for the number of BD/DNC determinations) in southern and western states, but the number of donations after BD/DNC has decreased in the southwestern state of Kerala in the setting of recent medicolegal controversies. This article reviews the history of BD/DNC determination in India as a whole, then describes the recent medicolegal controversies related to BD/DNC in the state of Kerala. Finally, these controversies are contextualized relative to the aforementioned controversies in high-income countries. Three key international themes of medicolegal controversies related to BD/DNC are regulation, religion, and resource allocation. The global neurocritical care community must advocate for consistency and accuracy in BD/DNC determination and collaborate with legal and policy experts to develop means to mitigate these challenges through revisions to the law, standardization of practice and policies, education, and communication.

Definitive endoluminal reconstruction, widely known as flow diversion, revolutionized treatment of brain aneurysms. A range of targets, by location, size, etiology, and acuity, can be cured with an excellent risk/benefit profile. Requirement for effective antiplatelet state is balanced with superior treatment durability. Implant and delivery system technology continue to evolve. Some aneurysm types/locations remain undertreated. Maximizing efficacy while minimizing risks requires deep understanding of flow diversion principles, pathologic anatomy, endoluminal implants, delivery systems, and clinical management.

This article looks at the current state of aneurysm risk modeling, exploring the limitations of linear measurement. It reviews articles using Food and Drug Administration (FDA)-approved artificial intelligence-driven volumetric measurement tools both for evaluating potential aneurysm growth in patients being managed conservatively as well as in assessing morphologic change prerupture and postrupture. The challenges of defining the aneurysm boundary are explored, and a novel definition of aneurysm/parent artery interface is proposed.

Imaging follow-up is an established component of intracranial aneurysm management that allows ongoing assessment of rupture risk and timely intervention to maintain protection from bleeding. Yet the frequency, duration, and imaging modality for follow-up vary widely. This review outlines contemporary imaging techniques and practice for follow-up of treated and untreated aneurysms, highlighting existing knowledge gaps and technical limitations that limit standardization. Updated evidence on the expected evolution and long-term outcome of common treatment strategies is presented to guide accurate reporting of radiological outcome after treatment and considerations regarding follow-up regimen.

OBJECTIVE:This study was undertaken to investigate diagnostic delay in adolescent onset focal epilepsy, including reasons for longer delays and associated morbidities. METHODS:Secondary analysis was done using enrollment data from the Human Epilepsy Project, a multi-institutional cohort including 34 sites in the USA, Canada, Finland, Austria, and Australia (2012-2017). Participants were aged 11-64 years at enrollment and within 4 months of treatment initiation for newly diagnosed focal epilepsy. Participants with seizure onset at age ≤ 21 years were evaluated. Data included seizure diaries documenting onset, frequency, and characteristics of seizures, reasons for diagnostic delays, and prediagnosis morbidities, including injuries, suicidal ideation, and self-injurious behaviors. RESULTS: = 7.04, p = .008). SIGNIFICANCE/CONCLUSIONS:This study highlights significant delays in diagnosing adolescent onset focal epilepsy, especially in cases with nonmotor seizures. These delays, often due to lack of recognition by patients and health care providers, are linked to more frequent seizures, higher injury rates, and increased suicidal ideation and self-injury. Early recognition and diagnosis may mitigate adverse outcomes and improve quality of life for adolescents with epilepsy.

BACKGROUND:Metabolic dysfunction-associated steatotic liver disease (MASLD) increases risk of cardiovascular disease (CVD). Despite the high prevalence of MASLD among Hispanic populations, there is a scarcity of research on the associations between non-invasive markers of liver disease and incident CVD and all-cause mortality. In this study we investigated the association of liver related biomarkers with CVD events and all-cause mortality in a population based Hispanic/Latino cohort. METHODS:We included 15,216 participants from the Hispanic Community Health Study/Study of Latinos (HCHS/SOL) aged 18-74 years with no pre-existing CVD. The composite outcome combined incident CVD and all-cause mortality. Having "elevated ALT/AST" was defined as ALT > 40 IU/mL or AST > 37 IU/mL for males, and ALT or AST > 31 IU/mL for females. We estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) relating our composite outcome to elevated ALT/AST, FIB-4 and MASLD. Using interaction terms, we assessed whether the relationship between elevated ALT/AST and the composite outcome differed by MASLD status. RESULTS:The study population was 40 years old on average, 52.7% female and had 740 CVD or all-cause mortality events. Elevated FIB-4 had the strongest association with incident CVD or all-cause mortality (comparing FIB-4 > 2.67 versus ≤ 2.67, HR:3.47; CI:2.34-5.14). Elevated AST was found to be associated with incident CVD or all-cause mortality (HR:1.53; CI:1.14-2.05). MASLD was not associated with incident CVD or all-cause mortality (HR:1.14; CI: 0.94-1.40), but it was associated with incident CVD alone (HR:1.69; CI:1.19-2.39). The relationship between elevated ALT/AST and incident or all-cause mortality was modified by MASLD, such that the strongest association between elevated ALT/AST and incident CVD or all-cause mortality was in the absence of MASLD (HR:1.95; CI:1.20-3.18). CONCLUSIONS:Among Hispanic adults FIB-4 was strongly associated with CVD or all-cause mortality and among persons without MASLD, elevated ALT/AST were associated with CVD or all-cause mortality.

BACKGROUND:Small tectal gliomas (TGs) may be unrecognized at initial diagnosis of noncommunicating hydrocephalus, with the etiology typically attributed to idiopathic congenital aqueductal stenosis (CAS). There are 2 published cases of TGs found on follow-up imaging after treatment with endoscopic third ventriculostomy (ETV). The authors investigated for this phenomenon in a large cohort of patients with TG or CAS treated with ETV or CSF shunting. OBSERVATIONS/METHODS:The authors reviewed records at their institution from 1999 to 2024, identifying 10 patients initially diagnosed with presumed idiopathic CAS and later found to have underlying TG. Of these, 7 were younger than 1 year of age at hydrocephalus presentation. The median time from CAS to glioma diagnosis was 13 months. Reasons for repeat imaging that identified glioma included postoperative surveillance and recurrent hydrocephalus. Five (50%) lesions grew over follow-up, and 2 required chemotherapy. LESSONS/CONCLUSIONS:The authors describe the eventual emergence of TG as a probable cause of hydrocephalus in a cohort of patients initially diagnosed with CAS. As most of these cases were identified incidentally on interval imaging to evaluate adequate function of CSF diversion procedures, follow-up imaging to evaluate for tectal expansion should be considered in children, particularly infants, with a new diagnosis of idiopathic CAS. https://thejns.org/doi/10.3171/CASE24695.

PURPOSE/OBJECTIVE:To compare the performance of different measures of long-term psychiatric outcomes in patients with post-acute autoimmune encephalitis (AE) who may require comprehensive psychiatric evaluation. METHODS:The sensitivity of three self-reported measures of mood and anxiety symptoms (Patient Health Questionnaire [PHQ-9]; Profiles of Mood States-2 [POMS-2]; Generalized Anxiety Disorder 7-item [GAD7]) was compared with a structured clinician-administered tool (Mini Neuropsychiatric Inventory 7.0.2 [MINI 7.0.2]). New cutoff scores that optimized accuracy were then identified by Youden Index Method. RESULTS:Thirty-five patients with post-acute AE completed testing a median of 3 years after symptomatic onset (range = 1-22 years). The median PHQ9 score was 5 (range = 0-18), median POMS2 Total Mood Disturbance T-Score was 52 (range = 37-93), and median GAD7 score was 3 (range = 0-17). Twenty-five patients (71 %) met criteria for a psychiatric diagnosis on the MINI. When compared with the MINI, the sensitivity and specificity of the self-reported psychiatric symptom tools using standard cutoffs were 25 % and 80 % for the PHQ9, 50 % and 87 % for the POMS-2, 23 % and 91 % for the GAD7. Accuracy was improved when cutoffs of ≥5 for the PHQ9, ≥50 for the POMS2, and ≥ 3 for the GAD7 were used, at the cost of lower specificity. CONCLUSIONS:Patients with post-acute AE with psychiatric sequalae may be underrecognized if self-reported measures of psychiatric symptoms are used instead of clinician-administered structured interviews. If self-reported measures are used in AE, consideration should be given into using tools with higher validity in this patient population, such as the POMS-2.