Faculty Bibliography

BACKGROUND:Visual disability is a growing problem for many middle-aged and older adults. Conventional mobility aids, such as white canes and guide dogs, have notable limitations that have led to increasing interest in electronic travel aids (ETAs). Despite remarkable progress, current ETAs lack empirical evidence and realistic testing environments and often focus on the substitution or augmentation of a single sense. OBJECTIVE:This study aims to (1) establish a novel virtual reality (VR) environment to test the efficacy of ETAs in complex urban environments for a simulated visual impairment (VI) and (2) evaluate the impact of haptic and audio feedback, individually and combined, on navigation performance, movement behavior, and perception. Through this study, we aim to address gaps to advance the pragmatic development of assistive technologies (ATs) for persons with VI. METHODS:The VR platform was designed to resemble a subway station environment with the most common challenges faced by persons with VI during navigation. This environment was used to test our multisensory, AT-integrated VR platform among 72 healthy participants performing an obstacle avoidance task while experiencing symptoms of VI. Each participant performed the task 4 times: once with haptic feedback, once with audio feedback, once with both feedback types, and once without any feedback. Data analysis encompassed metrics such as completion time, head and body orientation, and trajectory length and smoothness. To evaluate the effectiveness and interaction of the 2 feedback modalities, we conducted a 2-way repeated measures ANOVA on continuous metrics and a Scheirer-Ray-Hare test on discrete ones. We also conducted a descriptive statistical analysis of participants' answers to a questionnaire, assessing their experience and preference for feedback modalities. RESULTS:Results from our study showed that haptic feedback significantly reduced collisions (P=.05) and the variability of the pitch angle of the head (P=.02). Audio feedback improved trajectory smoothness (P=.006) and mitigated the increase in the trajectory length from haptic feedback alone (P=.04). Participants reported a high level of engagement during the experiment (52/72, 72%) and found it interesting (42/72, 58%). However, when it came to feedback preferences, less than half of the participants (29/72, 40%) favored combined feedback modalities. This indicates that a majority preferred dedicated single modalities over combined ones. CONCLUSIONS:AT is crucial for individuals with VI; however, it often lacks user-centered design principles. Research should prioritize consumer-oriented methodologies, testing devices in a staged manner with progression toward more realistic, ecologically valid settings to ensure safety. Our multisensory, AT-integrated VR system takes a holistic approach, offering a first step toward enhancing users' spatial awareness, promoting safer mobility, and holds potential for applications in medical treatment, training, and rehabilitation. Technological advancements can further refine such devices, significantly improving independence and quality of life for those with VI.

OBJECTIVES/OBJECTIVE:Posterior circulation stroke (PCS) presents diagnostic challenges due to its diverse clinical presentations. Timely detection is crucial, yet a highly sensitive, non-invasive screening tool for PCS is lacking. This study explores gait assessment as a readily accessible diagnostic tool for ruling out PCS in acutely vertiginous patients. MATERIALS AND METHODS/METHODS:In this retrospective case-control study, we examined medical records of 311 acutely vertiginous patients from the Get with the Guidelines Database at an academic hospital in New York City. Of these, 40 were diagnosed with PCS and 271 did not have PCS based on imaging and clinical criteria. We used multivariable logistic regression models and ROC curves to evaluate the association between objective gait abnormality (OGA) and PCS. RESULTS:Objective gait abnormality (OGA) was observed in 38/40 (95 %) posterior circulation stroke (PCS) cases and 57/271 (21 %) controls (adjusted odds ratio 144, 95 %CI 24.4-855, p < 0.0001). In a predictive model, objective gait abnormality (OGA) exhibited excellent discrimination between cases and controls (AUC 0.9599, sensitivity 95.0 %, specificity 75.6 %, positive predictive value 36.5 %, negative predictive value 99.0 %). CONCLUSIONS:Gait assessment emerges as a highly-sensitive screening tool for ruling out posterior circulation stroke (PCS) in acutely vertiginous patients, enabling more efficient triage and patient management. Further prospective research is warranted to validate these findings in larger and more diverse patient populations.

OBJECTIVE:Hippocampal sclerosis (HS), the most common pathology associated with temporal lobe epilepsy (TLE), is not always visible on magnetic resonance imaging (MRI), causing surgical delays and reduced postsurgical seizure-freedom. We developed an open-source software to characterize and localize HS to aid the presurgical evaluation of children and adults with suspected TLE. METHODS:We included a multicenter cohort of 365 participants (154 HS; 90 disease controls; 121 healthy controls). HippUnfold was used to extract morphological surface-based features and volumes of the hippocampus from T1-weighted MRI scans. We characterized pathological hippocampi in patients by comparing them to normative growth charts and analyzing within-subject feature asymmetries. Feature asymmetry scores were used to train a logistic regression classifier to detect and lateralize HS. The classifier was validated on an independent multicenter cohort of 275 patients with HS and 161 healthy and disease controls. RESULTS:HS was characterized by decreased volume, thickness, and gyrification alongside increased mean and intrinsic curvature. The classifier detected 90.1% of unilateral HS patients and lateralized lesions in 97.4%. In patients with MRI-negative histopathologically-confirmed HS, the classifier detected 79.2% (19/24) and lateralized 91.7% (22/24). The model achieved similar performances on the independent cohort, demonstrating its ability to generalize to new data. Individual patient reports contextualize a patient's hippocampal features in relation to normative growth trajectories, visualise feature asymmetries, and report classifier predictions. INTERPRETATION/CONCLUSIONS:Automated and Interpretable Detection of Hippocampal Sclerosis (AID-HS) is an open-source pipeline for detecting and lateralizing HS and outputting clinically-relevant reports. ANN NEUROL 2024.

BACKGROUND:Health and healthcare disparities for surgical patients with blindness and low vision (pBLV) stem from inaccessible healthcare systems that lack universal design principles or, at a minimum, reasonable accommodations (RA). OBJECTIVES/OBJECTIVE:We aimed to identify barriers to developing and implementing RAs in the surgical setting and provide a review of best practices for providing RAs. METHODS:We conducted a search of PubMed for evidence of reasonable accommodations, or lack thereof, in the surgical setting. Articles related to gaps and barriers to providing RAs for pBLV or best practices for supporting RAs were reviewed for the study. RESULTS:Barriers to the implementation of reasonable accommodations, and, accordingly, best practices for achieving equity for pBLV, relate to policies and systems, staff knowledge and attitudes, and materials and technology. CONCLUSIONS:These inequities for pBLV require comprehensive frameworks that offer, maintain, and support education about disability disparities and RAs in the surgical field. Providing RAs for surgical pBLV, and all patients with disabilities is an important and impactful step towards creating a more equitable and anti-ableist health system.

BACKGROUND:Subdural hematoma is a rare manifestation of hereditary hemorrhagic telangiectasia (HHT), also known as Osler-Weber-Rendu disease. Here, the authors present a patient with HHT and a large chronic subdural hematoma, for whom nonsurgical management was pursued. OBSERVATIONS/METHODS:A 49-year-old right-handed male with a history of hypertension and familial HHT presented with complaints of mild confusion and left hemiparesis over several days. Noncontrast head computed tomography images demonstrated a large chronic right hemisphere subdural hematoma compressing the right cerebral hemisphere and causing a 1.3-cm midline shift. Due to concerns about surgical complications arising from hemorrhages of cryptic telangiectasias, the patient was treated conservatively with middle meningeal artery embolization and adjuvant tranexamic acid. There was clinical and radiological resolution several months later. LESSONS/CONCLUSIONS:This case highlights the rarity of a subdural hematoma as a manifestation of HHT and the nonsurgical treatment strategy as a mechanism to avoid hemorrhagic complications of surgical evacuation. https://thejns.org/doi/10.3171/CASE24483.

Although the role of the medial temporal lobe (MTL) and the hippocampus in episodic memory is well established, there is emerging evidence that these regions play a broader role in cognition, specifically in temporal processing. However, despite strong evidence that the hippocampus plays a critical role in sequential processing, the involvement of the MTL in timing per se is poorly understood. In the present study, we investigated whether patients with MTL damage exhibit differential performance on a temporal distance memory task. Critically, we manipulated context shifts, or boundaries, which have been shown to interfere with associative binding, leading to increases in subjective temporal distance. We predicted that patients with MTL damage would show impaired binding across boundaries and thus fail to show temporal expansion. Consistent with this hypothesis, unilateral patients failed to show a temporal expansion effect, and bilateral patients actually exhibited the reverse effect, suggesting a critical role for the MTL in binding temporal information across boundaries. Furthermore, patients were impaired overall on both the temporal distance memory task and recognition memory, but not on an independent, short-timescale temporal perception task. Interestingly, temporal distance performance could be independently predicted by performance on recognition memory and the short temporal perception task. Together, these data suggest that distinct mnemonic and temporal processes may influence long interval temporal memory and that damage to the MTL may impair the ability to integrate episodic and temporal information in memory.

OBJECTIVES/OBJECTIVE:The aim of this study was to determine whether MRI radiomic features of key cerebral structures differ between women and men, and whether detection of such differences depends on the image resolution. MATERIALS AND METHODS/METHODS:Ultrahigh resolution (UHR) 3D MP2RAGE (magnetization-prepared 2 rapid acquisition gradient echo) T1-weighted MR images (voxel size, 0.7 × 0.7 × 0.7 mm3) of the brain of 30 subjects (18 women and 12 men; mean age, 39.0 ± 14.8 years) without abnormal findings on MRI were retrospectively included. MRI was performed on a whole-body 7 T MR system. A convolutional neural network was used to segment the following structures: frontal cortex, frontal white matter, thalamus, putamen, globus pallidus, caudate nucleus, and corpus callosum. Eighty-seven radiomic features were extracted respectively: gray-level histogram (n = 18), co-occurrence matrix (n = 24), run-length matrix (n = 16), size-zone matrix (n = 16), and dependence matrix (n = 13). Feature extraction was performed at UHR and, additionally, also after resampling to 1.4 × 1.4 × 1.4 mm3 voxel size (standard clinical resolution). Principal components (PCs) of radiomic features were calculated, and independent samples t tests with Cohen d as effect size measure were used to assess differences in PCs between women and men for the different cerebral structures. RESULTS:At UHR, at least a single PC differed significantly between women and men in 6/7 cerebral structures: frontal cortex (d = -0.79, P = 0.042 and d = -1.01, P = 0.010), frontal white matter (d = -0.81, P = 0.039), thalamus (d = 1.43, P < 0.001), globus pallidus (d = 0.92, P = 0.020), caudate nucleus (d = -0.83, P = 0.039), and corpus callosum (d = -0.97, P = 0.039). At standard clinical resolution, only a single PC extracted from the corpus callosum differed between sexes (d = 1.05, P = 0.009). CONCLUSIONS:Nonnegligible differences in radiomic features of several key structures of the brain exist between women and men, and need to be accounted for. Very high spatial resolution may be required to uncover and further investigate the sexual dimorphism of brain structures on MRI.

With the growth of the older adult population, the number of older adults waitlisted for and undergoing kidney and liver transplantation has increased. Transplantation is an important and definitive treatment for this population. We present a contemporary review of the unique preoperative, intraoperative, and postoperative issues that patients older than 65 y face when they undergo kidney or liver transplantation. We focus on geriatric syndromes that are common in older patients listed for kidney or liver transplantation including frailty, sarcopenia, and cognitive dysfunction; discuss important considerations for older transplant recipients, which may impact preoperative risk stratification; and describe unique challenges in intraoperative and postoperative management for older patients. Intraoperative challenges in the older adult include using evidence-based best anesthetic practices, maintaining adequate perfusion pressure, and using minimally invasive surgical techniques. Postoperative concerns include controlling acute postoperative pain; preventing cardiovascular complications and delirium; optimizing immunosuppression; preventing perioperative kidney injury; and avoiding nephrotoxicity and rehabilitation. Future studies are needed throughout the perioperative period to identify interventions that will improve patients' preoperative physiologic status, prevent postoperative medical complications, and improve medical and patient-centered outcomes in this vulnerable patient population.

IMPORTANCE/UNASSIGNED:People with disabilities experience pervasive health disparities driven by adverse social determinants of health, such as unemployment. Section 14(c) of the 1938 Fair Labor Standards Act has been a controversial policy that allows people with disabilities to be paid below the prevailing minimum wage, but its impact on employment remains unknown despite ongoing national debates about its repeal. OBJECTIVE/UNASSIGNED:To estimate whether state-level repeal of Section 14(c) was associated with employment-related outcomes for people with cognitive disability. DESIGN, SETTING, AND PARTICIPANTS/UNASSIGNED:This quasi-experimental, synthetic difference-in-differences study used individual-level data from the 2010-2019 American Community Surveys. Outcomes before and after subminimum wage law repeal in 2 states (New Hampshire and Maryland) that repealed Section 14(c) were compared with a synthetic group of control states that did not implement repeal. Individuals aged 18 to 45 years who reported having a cognitive disability were included. Data were analyzed from May 2023 to May 2024. EXPOSURE/UNASSIGNED:Repeal of Section 14(c) in New Hampshire (2015) and Maryland (2016). MAIN OUTCOMES AND MEASURES/UNASSIGNED:Primary outcomes were labor force participation and employment rates. Secondary outcomes were annual wages, annual hours worked, hourly wages, and proportion earning above state minimum wage among employed individuals. RESULTS/UNASSIGNED:The sample included 450 838 individuals. Of these, 253 157 (55.7%) were male, and the mean (SD) age was 31.3 (8.4) years. In state-specific analyses, New Hampshire's labor force participation and employment had a statistically significant increase by 5.2 percentage points (β = 0.05; 95% CI, 0-0.10; P = .04) and 7 percentage points (β = 0.07; 95% CI, 0.01-0.13; P = .03), respectively, following Section 14(c) repeal. Labor force participation and employment both increased in Maryland, although estimates were not statistically significant. Pooling both states, Section 14(c) repeal was associated with a statistically significant 4.7-percentage point (β = 0.05; 95% CI, 0.01-0.08; P = .01) increase in labor force participation and a nonsignificant 4.3-percentage point (β = 0.04; 95% CI, 0-0.09; P = .07) increase in employment. CONCLUSIONS AND RELEVANCE/UNASSIGNED:In this study, repeal of Section 14(c), a policy allowing subminimum wages for people with disabilities, led to increases in labor force participation, though with heterogeneity at the state level. These findings suggest the importance of state-level factors in shaping program effects, especially as national-level Section 14(c) repeal is being debated.

INTRODUCTION/BACKGROUND:Anti-amyloid antibody therapies such as lecanemab are increasingly being used to treat Alzheimer's disease (AD). These therapies are associated with a high rate of amyloid-related imaging abnormalities (ARIA). METHODS:We review the case history of a patient who developed ARIA associated with lecanemab treatment. RESULTS:In addition to microhemorrhages and cerebral edema that are recognized features of ARIA, the patient developed several ischemic strokes. The patient also experienced frequent electrographic seizures without overt clinical seizures. The patient demonstrated clinical and radiographic improvement after steroid treatment. DISCUSSION/CONCLUSIONS:Our case suggests that ischemic strokes may be a feature of ARIA and highlights the importance of having a high clinical suspicion for seizures in ARIA. As anti-amyloid therapies are likely going to be increasingly used to treat AD, it is important to appreciate the spectrum of clinical and radiographic findings that can result as side effects from this class of therapies. HIGHLIGHTS/CONCLUSIONS:We report a patient who developed severe amyloid-related imaging abnormalities (ARIA) after treatment with lecanemab. Our report suggests that ischemic strokes may be a novel imaging feature of ARIA. Our report highlights the need for high clinical suspicion for seizures in ARIA.