Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE:Traditional medical board examinations present clinical information in static vignettes with multiple-choices (MC), fundamentally different from how physicians gather and integrate data in practice. Recent advances in large language models (LLMs) offer promising approaches to creating more realistic clinical interactive conversations. However, these approaches are limited in neurosurgery, where patient communication capacity varies significantly and diagnosis heavily relies on objective data such as imaging and neurological examinations. We aimed to develop and evaluate a multi-artificial intelligence (AI) agent conversation framework for neurosurgical case assessment that enables realistic clinical interactions through simulated patients and structured access to objective clinical data. METHODS:We developed a framework to convert 608 Self-Assessment in Neurological Surgery first-order diagnosis questions into conversation sessions using 3 specialized AI agents: patient AI for subjective information, system AI for objective data, and clinical AI for diagnostic reasoning. We evaluated generative pretrained transformer 4o's (GPT-4o's) diagnostic accuracy across traditional vignettes, patient-only conversations, and patient + system AI interactions, with human benchmark testing from 10 neurosurgery residents. RESULTS:= .0030) using fewer interactions and reported high educational value of the interactive format. CONCLUSION/CONCLUSIONS:This multi-AI agent framework provides both a more challenging evaluation method for LLMs and an engaging educational tool for neurosurgical training. The significant performance drops in conversational formats suggest that traditional MC testing may overestimate LLMs' clinical reasoning capabilities, while the framework's interactive nature offers promising applications for enhancing medical education.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Implementation of telemedicine expanded options for outpatient neurology care. It remains uncertain which new neurology patients can be appropriately evaluated virtually. We compared subsequent health care utilization after virtual vs in-person new patient neurology visits across 3 academic medical centers. METHODS:We conducted a retrospective multicenter cohort study of adults with a new outpatient neurology visit from September 2020 through December 2021 using the Vizient Clinical Data Base and Clinical Practice Solutions Center databases. Virtual and in-person patients were matched 1:1 using propensity scores incorporating demographics, clinical characteristics, time period, and previous health care utilization. Outcomes were analyzed overall and stratified by neurologic chief complaint category and institution. We compared rates of subsequent neurologic clinic follow-up, emergency department (ED) visits, and hospitalizations after virtual and in-person encounters. Testing and all-cause ED visits/hospitalizations were also assessed. RESULTS:= 0.13, respectively). Analyses by chief complaint found that 90-day follow-up was higher after in-person visits for dementia, whereas 30- and 90-day follow-up was higher after virtual visits for Parkinson disease and multiple sclerosis, and 90-day follow-up was higher after virtual visits for headache. Testing was more frequent after in-person visits for certain chief complaints. DISCUSSION/CONCLUSIONS:In this propensity score-matched multicenter cohort, new neurology patients seen virtually had similar downstream utilization as those seen in-person, including comparable 90-day follow-up and similar neurologic and all-cause ED visits and hospitalizations. Although follow-up varied modestly by chief complaint and testing was more frequent after some in-person visits, no major differences emerged overall.

OBJECTIVES/OBJECTIVE:Anti-amyloid-beta immunotherapy requires frequent MRI screening for amyloid-related imaging abnormalities-hemorrhage subtype (ARIA-H), consisting of cerebral microbleeds (CMB) and/or superficial siderosis (SS), using gradient-recalled echo (GRE) or susceptibility-weighted imaging (SWI). Screening MRI sequences for ARIA-H may benefit from acceleration to maximize patient enrollment by increased throughput and reduced motion degradation. This study assessed the diagnostic performance of standard GRE and SWI to echo-planar imaging (EPI) accelerated substitutions for detecting CMB and SS. MATERIALS AND METHODS/METHODS:This retrospective single-center rater study included 50 patients, 25 with CMB and 25 patients without CMB (median age 77 y, IQR: 70 to 82 y; 30 of 50 female) who were imaged with FDG PET-3T MRI from April to July 2023. Standard GRE (90 s) and SWI (192 s) were compared with an EPI-accelerated GRE (aGRE; 13 s, 86% time reduction) and an EPI-accelerated SWI substitution (aSWI; 33 s, 83% time reduction). Three board-certified neuroradiologists independently reported CMB and SS (per ARIA-H monitoring guidelines), perceived image quality and motion for each sequence. There were 240 total assessments per rater (the 4 different sequences for the 50 patients plus 10 duplicated patients). Sensitivity, specificity, positive and negative predictive values, area under the curve (AUC), inter-rater and intrarater agreement were determined for each sequence and rater. RESULTS:The aggregate AUCs for the 4 individual sequences were excellent for detecting CMB (0.84 to 0.94) and SS (0.89 to 1.00) without statistical differences observed between standard and EPI-accelerated substitutions. Both aGRE and aSWI had high negative predictive values (96.5% to 100%). There were modest quantitative correlations between standard and accelerated sequences (0.606 and 0.391 for GRE and SWI, respectively), no differences in CMB count for aGRE (bias 0.01, P=0.895), but reduced CMB count with aSWI (bias -1.12, P=0.014). Inter-rater agreements were mildly reduced for both GRE versus aGRE (eg, 0.757 to 0.622 for CMB detection) and SWI versus aSWI (eg, 0.834 to 0.649 for SS detection). Perceived image quality for accelerated sequences was reduced, but with less motion observed with aSWI. CONCLUSIONS:The aGRE and aSWI sequences shorten scan times 86% and 83%, respectively, with similar diagnostic performance for ARIA-H screening, but reduced rater agreement and perceived image quality.

BACKGROUND AND OBJECTIVES/OBJECTIVE:The rapid rise of electric and mechanical bikes and scooters has transformed urban transportation, but their neurosurgical consequences remain underexplored. This study aimed to evaluate micromobility-related injuries over time, examining mechanisms of injury, patient risk factors, injury patterns, and associated clinical outcomes at a Level-1 trauma center over a 5-year period. METHODS:We performed a retrospective review of patients who sustained micromobility-related injuries and presented to the Bellevue Hospital Center between 2018 and 2023. The cohort included riders of electric or mechanical bikes and scooters, as well as pedestrians struck by these devices. Key clinical variables and outcomes were compared across device types, both before and after propensity score matching. Unlike national database studies, this hospital-based analysis provides detailed clinical and neurosurgical outcome data. RESULTS:A total of 914 patients presented with micromobility-related injuries, accounting for 6.9% of all trauma admissions. Annual case volume and electric device involvement increased over time. The most common mechanism was collision with a motor vehicle (49.9%). Most patients (68.7%) required admission; 30.2% required intensive care. The median length of hospital stay was 3 days [IQR 1-5]. Half underwent a surgical intervention or procedure, and the overall mortality was 1.2%. Helmet use was low (31.7%). Pedestrians experienced the most severe outcomes, particularly when struck by electric devices. Injuries clustered during evening hours, suggesting modifiable environmental and behavioral risk factors. CONCLUSION/CONCLUSIONS:Micromobility-related trauma imposes a substantial neurosurgical burden, with frequent traumatic brain injury, intensive care unit utilization, and operative intervention. Unlike previous database studies, this hospital-based analysis provides detailed neurosurgical outcome data and identifies prevention targets-including helmet use, intoxication, and urban infrastructure-to reduce morbidity and resource utilization.

Polyaminopathies are a recently described family of rare genetic neurodevelopmental disorders. Polyaminopathies disrupt the biosynthesis of the primary polyamines: putrescine, spermidine, and spermine. Snyder-Robinson syndrome results from hemizygous loss-of-function variants in the spermine synthase (SMS) gene, resulting in decreased or complete loss of spermine synthase enzyme activity. Bachmann-Bupp syndrome results from heterozygous gain-of-function variants in the ornithine decarboxylase 1 (ODC1) gene, resulting in increased ornithine decarboxylase enzyme activity. Faundes-Banka syndrome results from heterozygous loss-of-function variants in the eukaryotic translation initiation factor 5A (EIF5A) gene, impairing eIF5A protein function. DHPS (deoxyhypusine synthase) deficiency is an autosomal recessive disease and results from bi-allelic hypomorphic variants in the deoxyhypusine synthase (DHPS) gene, which results in reduced deoxyhypusine synthase enzyme activity. Finally, DOHH (deoxyhypusine hydroxylase) disorder is an autosomal recessive disorder caused by bi-allelic loss-of-function variants in the deoxyhypusine hydroxylase (DOHH) gene, which causes decreased deoxyhypusine hydroxylase enzyme activity. Snyder-Robinson syndrome was first described in 1969, while the other four syndromes have only been identified in the past 7 years. A comprehensive phenotypic and genotypic description of these five syndromes is needed. We review the clinical and genetic features of these five polyaminopathies to create an inclusive clinical resource. A systematic keyword search strategy was used to identify all published cases in PubMed, Web of Science, and Scopus databases. The five known syndromes associated with the polyamine pathway share many similar clinical phenotypes, and yet patients with each syndrome present with distinctive syndromic features. This review will serve as a valuable resource for clinicians diagnosing and caring for patients with these rare polyaminopathies.

The effectiveness of COVID-19 vaccination in children and adolescents with prior SARS-CoV-2 infection remains unclear, particularly for Omicron subvariants. We evaluate vaccine effectiveness against reinfection with Omicron BA.1/BA.2, BA.4/BA.5, XBB, and later subvariants among 5- to 17-year-olds using data from the RECOVER initiative, a national electronic health record database covering 37 U.S. children's hospitals and health institutions. We emulate target trials by age group and variant period, comparing previously infected participants between January 2022 and August 2023. During the BA.1/BA.2 period, vaccination reduces the risk of reinfection, with effectiveness rates of 62% in children and 65% in adolescents. During the BA.4/BA.5 period, protection effectiveness in children was 57%, whereas no statistically significant protection is observed in adolescents. During the XBB and later period, no significant protection is observed in either group. In summary, COVID-19 vaccination provides protection against reinfection during the early and mid-Omicron periods in previously infected pediatric populations, but effectiveness declines for later variants.

OBJECTIVE:To validate the carotid web (CW) risk stratification assessment described in previous works within a larger cohort of patients with symptomatic and incidentally found asymptomatic CWs. METHODS:A retrospective analysis of our institution's electronic medical records identified all patients with a diagnosis of CW from 2017 to 2024. We included symptomatic patients and those with asymptomatic CWs, that is, incidentally found webs without history of stroke or transient ischemic attack. Patient charts were reviewed for demographics, imaging, comorbidities, and a diagnosis of stroke after diagnosis of asymptomatic CW. All angles were measured as described in previous work on a sagittal reconstruction of neck CT angiography in which the common carotid artery (CCA), external carotid artery, and internal carotid artery (ICA) were well visualized, together with the CW itself. Principal component analysis and logistic regression were performed to evaluate the association between high-risk angles and stroke risk.  RESULTS: Twenty-six symptomatic and 26 asymptomatic patients were identified. Of note, the number of patients with hypertension, hyperlipidemia, and smoking history was 17 (65.0%), 16 (62.0%), and 8 (31.0%) for symptomatic patients and 18 (69.0%), 17 (65.0%), and 15 (58.0%) for asymptomatic patients. All angular measurements showed statistically significant associations with stroke status. The CCA-web-pouch angle showed the strongest association (p=2.07×10⁻⁴), followed by the CCA-pouch-tip angle (p=3.23×10⁻⁴), ICA-web-pouch angle (p=0.004), and ICA-pouch-tip angle (p=0.005). Each additional high-risk angle increased the odds of stroke by 9.47-fold (p<0.0001). The associated probability of stroke increased from 6.3% with no high-risk angles to 39.1% with one high-risk angle and further to 85.9% with two high-risk angles. The model demonstrated high sensitivity, correctly identifying 84.6% of positive cases, and high specificity, correctly identifying 88.5% of negative cases. The F1 score was 0.863, indicating good overall model performance.  CONCLUSION: Given this successful stratification of CWs into high- and low-risk groups, the utilization of geometric CW parameters may play a role in improving patient selection for intervention in the setting of incidentally diagnosed CW. .

Consumer wearable devices are commonly used by patients and consumers for several reasons with increasing application as new technologies are developed. Use of these devices is an emerging issue in Neurology because of increased adoption and the additional data reported to providers by patients. Understanding of possible functions, limitations, and effect on patients of non-US Food and Drug Administration (FDA)-cleared wearable technology to inform neurologic care is needed. A common theme in people with neurologic conditions regarding consumer wearables and associated tracking applications is that there is significant promise in these tools, but adherence (days per use/per week), continued engagement (attrition), and unintended consequences such as heightened anxiety remain important issues. Further understanding and validation of these devices is needed within the field of Neurology before full use and confidence can be achieved. Below, we provide examples of non-FDA-cleared wearable devices used in Neurology in the areas of epilepsy, headache, cardiac monitoring, and sleep.

BACKGROUND AND OBJECTIVES/OBJECTIVE:Severe hypoxemia after generalized convulsive seizures (GCSs) can trigger neural injury and is a potential biomarker for sudden unexpected death in epilepsy (SUDEP). Some degree of variability in interbreath interval is normal, but increased variability may suggest dysfunctional breathing control and may be associated with severe postictal hypoxemia. We evaluated the relationship between interictal breathing variability and severity and duration of hypoxemia after GCS. METHODS:nadir), and secondary outcome: occurrence of combined prolonged and pronounced hypoxemia. Univariable and multivariable models were created for primary outcomes, but only univariable analyses were performed for the secondary outcome. RESULTS:= 0.002) was the only variable significantly associated with hypoxemia severity after controlling for duration of postictal generalized EEG suppression, SD-2 of the awake interbreath interval, and body mass index. Univariable analyses for combined prolonged and pronounced hypoxemia showed SD-2 of the awake interbreath interval, temporal lobe epilepsy, ictal central apnea, and a shorter tonic phase duration were significantly associated. DISCUSSION/CONCLUSIONS:Measures of interictal respiratory variability are associated with severe and prolonged hypoxemia after GCS. Increased interictal respiratory variability suggests baseline respiratory dysregulation in some PWE and may be a surrogate for SUDEP risk.