Search

OBJECTIVE Idiopathic normal pressure hydrocephalus (iNPH) is an underdiagnosed, progressive, and disabling condition. Early treatment is associated with better outcomes and improved quality of life. In this paper, the authors aimed to identify features associated with patients with iNPH using natural language processing (NLP) to characterize this cohort, with the intention to later target the development of artificial intelligence–driven tools for early detection. METHODS The electronic health records of patients with shunt-responsive iNPH were retrospectively reviewed using an NLP algorithm. Participants were selected from a prospectively maintained single-center database of patients undergoing CSF diversion for probable iNPH (March 2008–July 2020). Analysis was conducted on preoperative health records including clinic letters, referrals, and radiology reports accessed through CogStack. Clinical features were extracted from these records as SNOMED CT (Systematized Nomenclature of Medicine Clinical Terms) concepts using a named entity recognition machine learning model. In the first phase, a base model was generated using unsupervised training on 1 million electronic health records and supervised training with 500 double-annotated documents. The model was fine-tuned to improve accuracy using 300 records from patients with iNPH double annotated by two blinded assessors. Thematic analysis of the concepts identified by the machine learning algorithm was performed, and the frequency and timing of terms were analyzed to describe this patient group. RESULTS In total, 293 eligible patients responsive to CSF diversion were identified. The median age at CSF diversion was 75 years, with a male predominance (69% male). The algorithm performed with a high degree of precision and recall (F1 score 0.92). Thematic analysis revealed the most frequently documented symptoms related to mobility, cognitive impairment, and falls or balance. The most frequent comorbidities were related to cardiovascular and hematological problems. CONCLUSIONS This model demonstrates accurate, automated recognition of iNPH features from medical records. Opportunities for translation include detecting patients with undiagnosed iNPH from primary care records, with the aim to ultimately improve outcomes for these patients through artificial intelligence–driven early detection of iNPH and prompt treatment.

OBJECTIVE: Invasive brain-computer interfaces (BCIs) require neurosurgical implantation, which confers a range of risks. Despite this, no studies have assessed the acceptability of invasive BCIs amongst the neurosurgical team. This study aims to establish baseline knowledge of BCIs within the neurosurgical team and identify attitudes towards different applications of invasive BCI. METHOD: A two-stage cross-sectional international survey of the neurosurgical team (neurosurgeons, anaesthetists, and operating room nurses) was conducted. Results from the first, qualitative, survey were used to guide the second stage quantitative survey, which assessed acceptability of invasive BCI applications. 5-part Likert Scales were used to collect quantitative data. Surveys were distributed internationally via social media and collaborators. RESULTS: 108 qualitative responses were collected. Themes included the promise of BCIs positively impacting disease targets, concerns regarding stability, and an overall positive emotional reaction to BCI technology. The quantitative survey generated 538 responses from 32 countries. Baseline knowledge of BCI technology was poor, with 9% claiming to have a 'good' or 'expert' knowledge of BCIs. Acceptability of invasive BCI for rehabilitative purposes was >80%. Invasive BCI for augmentation in healthy populations divided opinion. CONCLUSION: The neurosurgical team's view of the acceptability of BCI was divided across a range of indications. Some applications (for example stroke rehabilitation) were viewed as more appropriate than other applications (such as augmentation for military use). This range in views highlights the need for stakeholder consultation on acceptable use cases along with regulation and guidance to govern initial BCI implantations if patients are to realise the potential benefits.

Background and objectivesIn recent decades, the rise of endovascular management of aneurysms has led to a significant decline in operative training for surgical aneurysm clipping. Simulation has the potential to bridge this gap and benchtop synthetic simulators aim to combine the best of both anatomical realism and haptic feedback. The aim of this study was to validate a synthetic benchtop simulator for aneurysm clipping (AneurysmBox, UpSurgeOn).MethodsExpert and novice surgeons from multiple neurosurgical centres were asked to clip a terminal internal carotid artery aneurysm using the AneurysmBox. Face and content validity were evaluated using Likert scales by asking experts to complete a post-task questionnaire. Construct validity was evaluated by comparing expert and novice performance using the modified Objective Structured Assessment of Technical Skills (mOSATS), developing a curriculum-derived assessment of Specific Technical Skills (STS), and measuring the forces exerted using a force-sensitive glove.ResultsTen experts and eighteen novices completed the task. Most experts agreed that the brain looked realistic (8/10), but far fewer agreed that the brain felt realistic (2/10). Half the expert participants (5/10) agreed that the aneurysm clip application task was realistic. When compared to novices, experts had a significantly higher median mOSATS (27 vs. 14.5; p p p p = 0.77). Suggested improvements for the model included reduced stiffness and the addition of cerebrospinal fluid (CSF) and arachnoid mater.ConclusionAt present, the AneurysmBox has equivocal face and content validity, and future versions may benefit from materials that allow for improved haptic feedback. Nonetheless, it has good construct validity, suggesting it is a promising adjunct to training.

The vital physiological role of the pituitary gland, alongside its proximal critical neurovascular structures means pituitary adenomas cause significant morbidity or mortality. Whilst enormous advancements have been made in the surgical care of pituitary adenomas, treatment failure and recurrence remain challenges. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (e.g. endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, the future armamentarium of pituitary surgeons, including advanced optical devices, smart instruments and surgical robotics, will augment the surgeon's abilities. Intraoperative support to team members will benefit from a surgical data science approach, utilising machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, early detection of individuals at risk of complications and prediction of treatment failure through neural networks of multimodal datasets will support earlier intervention, safer hospital discharge, guide follow-up and adjuvant treatment decisions. Whilst advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of technological translation, ensuring systematic assessment of risk and benefit. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future.

Purpose Microsurgical Aneurysm Clipping Surgery (MACS) carries a high risk for intraoperative aneurysm rupture. Automated recognition of instances when the aneurysm is exposed in the surgical video would be a valuable reference point for neuronavigation, indicating phase transitioning and more importantly designating moments of high risk for rupture. This article introduces the MACS dataset containing 16 surgical videos with frame-level expert annotations and proposes a learning methodology for surgical scene understanding identifying video frames with the aneurysm present in the operating microscope’s field-of-view. Methods Despite the dataset imbalance (80% no presence, 20% presence) and developed without explicit annotations, we demonstrate the applicability of Transformer-based deep learning architectures (MACSSwin-T, vidMACSSwin-T) to detect the aneurysm and classify MACS frames accordingly. We evaluate the proposed models in multiple-fold cross-validation experiments with independent sets and in an unseen set of 15 images against 10 human experts (neurosurgeons). Results Average (across folds) accuracy of 80.8% (range 78.5–82.4%) and 87.1% (range 85.1–91.3%) is obtained for the image- and video-level approach, respectively, demonstrating that the models effectively learn the classification task. Qualitative evaluation of the models’ class activation maps shows these to be localized on the aneurysm’s actual location. Depending on the decision threshold, MACSWin-T achieves 66.7–86.7% accuracy in the unseen images, compared to 82% of human raters, with moderate to strong correlation. Conclusions Proposed architectures show robust performance and with an adjusted threshold promoting detection of the underrepresented (aneurysm presence) class, comparable to human expert accuracy. Our work represents the first step towards landmark detection in MACS with the aim to inform surgical teams to attend to high-risk moments, taking precautionary measures to avoid rupturing.

Purpose: Workflow recognition can aid surgeons before an operation when used as a training tool, during an operation by increasing operating room efficiency, and after an operation in the completion of operation notes. Although several methods have been applied to this task, they have been tested on few surgical datasets. Therefore, their generalisability is not well tested, particularly for surgical approaches utilising smaller working spaces which are susceptible to occlusion and necessitate frequent withdrawal of the endoscope. This leads to rapidly changing predictions, which reduces the clinical confidence of the methods, and hence limits their suitability for clinical translation. Methods: Firstly, the optimal neural network is found using established methods, using endoscopic pituitary surgery as an exemplar. Then, prediction volatility is formally defined as a new evaluation metric as a proxy for uncertainty, and two temporal smoothing functions are created. The first (modal, $$M_n$$ M n ) mode-averages over the previous n predictions, and the second (threshold, $$T_n$$ T n ) ensures a class is only changed after being continuously predicted for n predictions. Both functions are independently applied to the predictions of the optimal network. Results: The methods are evaluated on a 50-video dataset using fivefold cross-validation, and the optimised evaluation metric is weighted-$$F_1$$ F 1 score. The optimal model is ResNet-50+LSTM achieving 0.84 in 3-phase classification and 0.74 in 7-step classification. Applying threshold smoothing further improves these results, achieving 0.86 in 3-phase classification, and 0.75 in 7-step classification, while also drastically reducing the prediction volatility. Conclusion: The results confirm the established methods generalise to endoscopic pituitary surgery, and show simple temporal smoothing not only reduces prediction volatility, but actively improves performance.

ObjectiveEvaluate the effect of risk communication tools on the understanding of statistical risk of complications occurring in patients undergoing a surgical or interventional procedure.Summary Background DataInformed consent is an essential process in clinical decision-making, through which healthcare providers educate patients about the benefits, risks and alternatives of a procedure. Numerical risk information is by nature probabilistic and difficult to communicate. Aids which support statistical risk communication and studies assessing their effectiveness are needed.MethodsA systematic search was performed across Medline, Embase, PsycINFO, Scopus and Web of Science until July 2021 with a repeated search in September 2022. Studies examining risk communication tools (e.g. informative leaflets, audio-video) in adults (age>16) patients undergoing a surgical or interventional procedure were included. Studies only assessing understanding of non-statistical aspects of the procedure were excluded. Both randomised control trials (RCTs) and observational studies were included. Cochrane risk-of-bias and the Newcastle-Ottawa Scale were used to assess the quality of studies. Due to heterogeneity of the studies, a narrative synthesis was performed (PROSPERO ID: CRD42022285789).ResultsA total of 4348 articles were identified and following abstract and full-text screening a total of 11 articles were included. 8 studies were RCTs and 3 were cross-sectional. The total number of adult patients was 1030. The most common risk communication tool used was additional written information (n=7). Of the 8 RCTs, 5 showed statistically significant improvements in the intervention group in outcomes relating to recall of statistical risk. Quality assessment of RCTs found some concerns with all studies.ConclusionsRisk communication tools appear to improve recall of statistical risk. Additional prospective trials are warranted which can compare various aids and determine the most effective method of improving patient understanding.

IntroductionCushing’s disease presents major diagnostic and management challenges. Although numerous preoperative and intraoperative imaging modalities have been deployed, it is unclear whether these investigations have improved surgical outcomes. Our objective was to investigate whether advances in imaging improved outcomes for Cushing’s disease.MethodsSearches of PubMed and EMBASE were conducted. Studies reporting on imaging modalities and clinical outcomes after surgical management of Cushing’s disease were included. Multilevel multivariable meta-regressions identified predictors of outcomes, adjusting for confounders and heterogeneity prior to investigating the effects of imaging.Results166 non-controlled single-arm studies were included, comprising 13181 patients over 44 years.The overall remission rate was 77.0% [CI: 74.9%-79.0%]. Cavernous sinus invasion (OR: 0.21 [CI: 0.07-0.66]; p=0.010), radiologically undetectable lesions (OR: 0.50 [CI: 0.37–0.69]; pThe overall recurrence rate was 14.5% [CI: 12.1%-17.1%]. Lesion ≥10mm was associated with greater recurrence (OR: 1.83 [CI: 1.13–2.96]; p=0.015), as was greater duration of follow-up (OR: 1.53 (CI: 1.17–2.01); p=0.002). No imaging modality was associated with significant differences in recurrence.Despite significant improvements in detection rates over four decades, there were no significant changes in the reported remission or recurrence rates.ConclusionA lack of controlled comparative studies makes it difficult to draw definitive conclusions. Within this limitation, the results suggest that despite improvements in radiological detection rates of Cushing’s disease over the last four decades, there were no changes in clinical outcomes. Advances in imaging alone may be insufficient to improve surgical outcomes.Systematic Review Registrationhttps://www.crd.york.ac.uk/PROSPERO/, identifier CRD42020187751.

ObjectiveEndoscopic endonasal transsphenoidal surgery is an established technique for the resection of sellar and suprasellar lesions. The approach is technically challenging and has a steep learning curve. Simulation is a growing training tool, allowing the acquisition of technical skills pre-clinically and potentially resulting in a shorter clinical learning curve. We sought validation of the UpSurgeOn Transsphenoidal (TNS) Box for the endoscopic endonasal transsphenoidal approach to the pituitary fossa.MethodsNovice, intermediate and expert neurosurgeons were recruited from multiple centres. Participants were asked to perform a sphenoidotomy using the TNS model. Face and content validity were evaluated using a post-task questionnaire. Construct validity was assessed through post-hoc blinded scoring of operative videos using a Modified Objective Structured Assessment of Technical Skills (mOSAT) and a Task-Specific Technical Skill scoring system.ResultsFifteen participants were recruited of which n = 10 (66.6%) were novices and n = 5 (33.3%) were intermediate and expert neurosurgeons. Three intermediate and experts (60%) agreed that the model was realistic. All intermediate and experts (n = 5) strongly agreed or agreed that the TNS model was useful for teaching the endonasal transsphenoidal approach to the pituitary fossa. The consensus-derived mOSAT score was 16/30 (IQR 14–16.75) for novices and 29/30 (IQR 27–29) for intermediate and experts (p U). The median Task-Specific Technical Skill score was 10/20 (IQR 8.25–13) for novices and 18/20 (IQR 17.75–19) for intermediate and experts (p ConclusionThe TNS Box simulation model has demonstrated face, content, and construct validity as a simulator for the endoscopic endonasal transsphenoidal approach. With the steep learning curve associated with endoscopic approaches, this simulation model has the potential as a valuable training tool in neurosurgery with further improvements including advancing simulation materials, dynamic models (e.g., with blood flow) and synergy with complementary technologies (e.g., artificial intelligence and augmented reality).

This paper describes the Bárány Society Classification OverSight Committee (COSC) position on Cervical Dizziness, sometimes referred to as Cervical Vertigo. This involved an initial review by a group of experts across a broad range of fields, and then subsequent review by the Bárány Society COSC. Based upon the so far published literature, the Bárány Society COSC takes the view that the evidence supporting a mechanistic link between an illusory sensation of self-motion (i.e. vertigo – spinning or otherwise) and neck pathology and/or symptoms of neck pain - either by affecting the cervical vertebrae, soft tissue structures or cervical nerve roots - is lacking. When a combined head and neck movement triggers an illusory sensation of spinning, there is either an underlying common vestibular condition such as migraine or BPPV or less commonly a central vestibular condition including, when acute in onset, dangerous conditions (e.g. a dissection of the vertebral artery with posterior circulation stroke and, exceedingly rarely, a vertebral artery compression syndrome). The Committee notes, that migraine, including vestibular migraine, is by far, the commonest cause for the combination of neck pain and vestibular symptoms. The committee also notes that since head movement aggravates symptoms in almost any vestibular condition, the common finding of increased neck muscle tension in vestibular patients, may be linked as both cause and effect, to reduced head movements. Additionally, there are theoretical mechanisms, which have not been explored, whereby cervical pain may promote vaso-vagal, cardio-inhibitory reflexes and hence by presyncopal mechanisms, elicit transient disorientation and/or imbalance. The committee accepts that further research is required to answer the question as to whether those rare cases in which neck muscle spasm is associated with a vague sense of spatial disorientation and/or imbalance, is indeed linked to impaired neck proprioception. Future studies should ideally be placebo controlled and double-blinded where possible, with strict inclusion and exclusion criteria that aim for high specificity at the cost of sensitivity. To facilitate further studies in “cervical dizziness/vertigo”, we provide a narrative view of the important confounds investigators should consider when designing controlled mechanistic and therapeutic studies. Hence, currently, the Bárány COSC refrains from proposing any preliminary diagnostic criteria for clinical use outside a research study. This position may change as new research evidence is provided.

Objective An operative workflow systematically compartmentalizes operations into hierarchal components of phases, steps, instrument, technique errors, and event errors. Operative workflow provides a foundation for education, training, and understanding of surgical variation. In this Part 2, we present a codified operative workflow for the translabyrinthine approach to vestibular schwannoma resection. Methods A mixed-method consensus process of literature review, small-group Delphi's consensus, followed by a national Delphi's consensus was performed in collaboration with British Skull Base Society (BSBS). Each Delphi's round was repeated until data saturation and over 90% consensus was reached. Results Seventeen consultant skull base surgeons (nine neurosurgeons and eight ENT [ear, nose, and throat]) with median of 13.9 years of experience (interquartile range: 18.1 years) of independent practice participated. There was a 100% response rate across both the Delphi rounds. The translabyrinthine approach had the following five phases and 57 unique steps: Phase 1, approach and exposure; Phase 2, mastoidectomy; Phase 3, internal auditory canal and dural opening; Phase 4, tumor debulking and excision; and Phase 5, closure. Conclusion We present Part 2 of a national, multicenter, consensus-derived, codified operative workflow for the translabyrinthine approach to vestibular schwannomas. The five phases contain the operative, steps, instruments, technique errors, and event errors. The codified translabyrinthine approach presented in this manuscript can serve as foundational research for future work, such as the application of artificial intelligence to vestibular schwannoma resection and comparative surgical research.

A scoping review of the literature was conducted to identify intraoperative AI applications for robotic surgery under development and categorise them by 1) purpose of the applications, 2) level of autonomy, 3) stage of development, and 4) type of measured outcome.In robotic surgery, artificial intelligence (AI) based applications have the potential to disrupt a field so far based on a master-slave paradigm. However, there is no available overview about this technology's current stage of development and level of autonomy.MEDLINE and EMBASE were searched between January 1st 2010 and May 21st 2022. Abstract screening, full text review and data extraction were performed independently by two reviewers. Level of autonomy was defined according to the Yang et al classification and stage of development according to the IDEAL framework.129 studies were included in the review. 97 studies (75%) described applications providing Robot Assistance (autonomy level 1), 30 studies (23%) application enabling Task Autonomy (autonomy level 2), and two studies (2%) application achieving Conditional autonomy (autonomy level 3). All studies were at IDEAL stage 0 and no clinical investigations on humans were found. 116 (90%) conducted in silico or ex-vivo experiments on inorganic material, 9 (7%) ex-vivo experiments on organic material, and 4 (3%) performed in vivo experiments in porcine models.Clinical evaluation of intraoperative AI applications for robotic surgery is still in its infancy and most applications have a low level of autonomy. With increasing levels of autonomy, the evaluation focus seems to shift from AI-specific metrics to process outcomes, although common standards are needed to allow comparison between systems.

Funder: Wellcome Trust, PurposeSurgical workflow analysis seeks to systematically break down operations into hierarchal components. It facilitates education, training, and understanding of surgical variations. There are known educational demands and variations in surgical practice in endoscopic transsphenoidal approaches to pituitary adenomas. Through an iterative consensus process, we generated a surgical workflow reflective of contemporary surgical practice.MethodsA mixed-methods consensus process composed of a literature review and iterative Delphi surveys was carried out within the Pituitary Society. Each round of the survey was repeated until data saturation and > 90% consensus was reached.ResultsThere was a 100% response rate and no attrition across both Delphi rounds. Eighteen international expert panel members participated. An extensive workflow of 4 phases (nasal, sphenoid, sellar and closure) and 40 steps, with associated technical errors and adverse events, were agreed upon by 100% of panel members across rounds. Both core and case-specific or surgeon-specific variations in operative steps were captured.ConclusionsThrough an international expert panel consensus, a workflow for the performance of endoscopic transsphenoidal pituitary adenoma resection has been generated. This workflow captures a wide range of contemporary operative practice. The agreed "core" steps will serve as a foundation for education, training, assessment and technological development (e.g. models and simulators). The "optional" steps highlight areas of heterogeneity of practice that will benefit from further research (e.g. methods of skull base repair). Further adjustments could be made to increase applicability around the world.

The coronavirus disease 2019 pandemic may have affected the quality of clinical consultations. The objective was to use 10 proposed quality indicator questions to assess outpatient consultation quality; to assess whether the recent shift to telemedicine during the pandemic has affected consultation quality; and to determine whether consultation quality is associated with satisfaction and consultation outcome. A cross-sectional study was used to survey clinicians and patients after outpatient consultations (1 February to 31 March 2021). The consultation quality score (CQS) was the sum of ‘yes’ responses to the survey questions. In total, 78% (538/690) of consultations conducted were assessed by a patient, clinician, or both. Patient survey response rate was 60% (415/690) and clinician 42% (291/690). Face-to-face consultations had a greater CQS than telephone (patients and clinicians < 0.001). A greater CQS was associated with higher overall satisfaction (clinicians log-odds: 0.77 ± 0.52, p = 0.004; patients log-odds: 1.35 ± 0.57, p < 0.001) and with definitive consultation outcomes (clinician log-odds: 0.44 ± 0.36, p = 0.03). In conclusion, consultation quality is assessable; the shift to telemedicine has negatively impacted consultation quality; and high-quality consultations are associated with greater satisfaction and definitive consultation outcome decisions.

Objective An operative workflow systematically compartmentalizes operations into hierarchal components of phases, steps, instrument, technique errors, and event errors. Operative workflow provides a foundation for education, training, and understanding of surgical variation. In this Part 1, we present a codified operative workflow for the retrosigmoid approach to vestibular schwannoma resection. Methods A mixed-method consensus process of literature review, small-group Delphi's consensus, followed by a national Delphi's consensus, was performed in collaboration with British Skull Base Society (BSBS). Each Delphi's round was repeated until data saturation and over 90% consensus was reached. Results Eighteen consultant skull base surgeons (10 neurosurgeons and 8 ENT [ear, nose, and throat]) with median 17.9 years of experience (interquartile range: 17.5 years) of independent practice participated. There was a 100% response rate across both Delphi's rounds. The operative workflow for the retrosigmoid approach contained three phases and 40 unique steps as follows: phase 1, approach and exposure; phase 2, tumor debulking and excision; phase 3, closure. For the retrosigmoid approach, technique, and event error for each operative step was also described. Conclusion We present Part 1 of a national, multicenter, consensus-derived, codified operative workflow for the retrosigmoid approach to vestibular schwannomas that encompasses phases, steps, instruments, technique errors, and event errors. The codified retrosigmoid approach presented in this manuscript can serve as foundational research for future work, such as operative workflow analysis or neurosurgical simulation and education.

Background:Non-functioning pituitary macroadenomas (NFPMs) may present with hypopituitarism. Pituitary surgery and radiotherapy pose an additional risk to pituitary function.ObjectivesTo assess the incidence of hypopituitarism at presentation, the impact of treatment, and the likelihood of endocrine recovery during follow-up.MethodsAll patients treated surgically with and without radiotherapy for NFPMs between 1987 and 2018 who had longer than 6 months follow-up were identified. Demographics, presentation, investigation, treatment, and outcomes were collected.ResultsIn total, 383 patients were identified. The median age was 57 years with a median follow-up of 8 years. Preoperatively, 235 patients (235/377; 62%) had evidence of at least one pituitary deficiency. Anterior panhypopituitarism was more common in men (p =0.001), older patients (p =0.005), and in those with adenomas extending beyond the sella turcica (p =0.05). Patients treated with surgery and radiotherapy had a higher incidence of all individual pituitary hormone deficiency and anterior panhypopituitarism as well as significantly lower GH, ACTH, and TSH deficiencies free survival probability than those treated with surgery alone. Recovery of central hypogonadism, hypothyroidism, and anterior panhypopituitarism was also less likely to be reported in those treated with surgery and radiotherapy.ConclusionNFPMs are associated with significant degree of hypopituitarism at time of diagnosis and post therapy. The combination of surgery and radiotherapy is associated with higher risk of pituitary dysfunction. Recovery of pituitary hormone deficit may occur after surgical treatment. Patients should have regular ongoing endocrine evaluation post-treatment to assess changes in pituitary function and the need for long-term replacement therapy.

Background/Objective Technical skill acquisition is an essential component of neurosurgical training. Educational theory suggests that optimal learning and improvement in performance depends on the provision of objective feedback. Therefore, the aim of this study was to develop a vision-based framework based on a novel representation of surgical tool motion and interactions capable of automated and objective assessment of microsurgical skill. Methods Videos were obtained from 1 expert, 6 intermediate, and 12 novice surgeons performing arachnoid dissection in a validated clinical model using a standard operating microscope. A mask region convolutional neural network framework was used to segment the tools present within the operative field in a recorded video frame. Tool motion analysis was achieved using novel triangulation metrics. Performance of the framework in classifying skill levels was evaluated using the area under the curve and accuracy. Objective measures of classifying the surgeons' skill level were also compared using the Mann–Whitney U test, and a value of P Results The area under the curve was 0.977 and the accuracy was 84.21%. A number of differences were found, which included experts having a lower median dissector velocity (P = 0.0004; 190.38 ms–1 vs. 116.38 ms–1), and a smaller inter-tool tip distance (median 46.78 vs. 75.92; P = 0.0002) compared with novices. Conclusions Automated and objective analysis of microsurgery is feasible using a mask region convolutional neural network, and a novel tool motion and interaction representation. This may support technical skills training and assessment in neurosurgery.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has affected people of all ages, races, and socioeconomic groups, and placed extraordinary stress on health care workers (HCWs). We measured the prevalence of burnout and assessed wellbeing and quality of life (QoL) in HCWs at a single UK neuroscience center after the first pandemic surge. METHODS: A 38-item electronic questionnaire was disseminated through local team email lists between May 22 and June 7, 2020, to HCWs in a university neurosciences center. Burnout was measured using the single-item Emotional Exhaustion and Depersonalization scales, and wellbeing and QoL assessed using the Linear Analogue Self-Assessment Scale and the EuroQol-5 Dimension instrument. RESULTS: The response rate was 57.4% (n=234); 58.2% of respondents were nurses, 69.4% were women and 40.1% were aged 25 to 34 years. Overall, 21.4% of respondents reported burnout assessed by the Emotional Exhaustion scale; burnout was higher for nurses (23.5%) and allied health care professionals (22.5%) compared with doctors (16.4%). HCWs from ethnic minority groups reported a higher rate of burnout (24.5%) compared with white HCWs (15.0%). There were no differences in reported wellbeing or QoL between professional groups, or HCW age, sex, or race. Nurses (36.8%) and staff from ethnic minority groups (34.6%) were more fearful for their health than others. CONCLUSIONS: Our findings highlight the prevalence of HCW burnout after the first surge of the pandemic, with an increased risk of burnout among nurses and staff from ethnic minority groups. Both nursing and staff from ethnic minority groups were also more fearful for their health. With ongoing pandemic surges, the impact on HCW wellbeing should be continuously assessed to ensure that local strategies to support staff wellbeing are diverse and inclusive.

Background Artificial intelligence (AI) has the potential to disrupt how we diagnose and treat patients. Previous work by our group has demonstrated that the majority of patients and their relatives feel comfortable with the application of AI to augment surgical care. The aim of this study was to similarly evaluate the attitudes of surgeons and the wider surgical team toward the role of AI in neurosurgery. Methods In a 2-stage cross sectional survey, an initial open-question qualitative survey was created to determine the perspective of the surgical team on AI in neurosurgery including surgeons, anesthetists, nurses, and operating room practitioners. Thematic analysis was performed to develop a second-stage quantitative survey that was distributed via social media. We assessed the extent to which they agreed and were comfortable with real-world AI implementation using a 5-point Likert scale. Results In the first-stage survey, 33 participants responded. Six main themes were identified: imaging interpretation and preoperative diagnosis, coordination of the surgical team, operative planning, real-time alert of hazards and complications, autonomous surgery, and postoperative management and follow-up. In the second stage, 100 participants responded. Responders somewhat agreed or strongly agreed about AI being used for imaging interpretation (62%), operative planning (82%), coordination of the surgical team (70%), real-time alert of hazards and complications (85%), and autonomous surgery (66%). The role of AI within postoperative management and follow-up was less agreeable (49%). Conclusions This survey highlights that the majority of surgeons and the wider surgical team both agree and are comfortable with the application of AI within neurosurgery.

The postoperative recurrence of cystic lesions of the sella is frequent and may require further surgery for re-drainage.To tackle this problem, we propose to insert a small cross-shaped drain coursing from the cyst lumen to the suprasellar cistern. At this early stage of innovation, the technique is primarily intended for patients who present with a recurrence.The cruciform drain is fashioned from the tip of a ventricular catheter and is inserted under endoscopic vision. We retrospectively reviewed the pre- and postoperative records of patients in whom this technique was implemented.A cruciform drain was placed in five patients since the introduction of the technique into our practice in 2018. The use of the cruciform drain did not impact upon the expected surgical workflow nor was it associated with adverse intraoperative events, but three patients did develop a postoperative CSF leak that was successfully treated in all cases. None of the patients showed re-collection of their cysts on early radiological follow-up.The cruciform drain is intended to prevent the renewed build-up of cystic fluid by allowing it to flow through and around the drain into the subarachnoid space. We have modified our repair protocol in response to the observed high CSF leak rate, as a basis for further development of the technique. Studies involving long-term follow-up will also be required to assess its efficacy in reducing cyst recurrence.

Clinically non-functioning pituitary adenomas (NFPAs) represent the second most common subtype of pituitary tumours, representing 15-43% of all pituitary adenomas. NFPAs are usually benign tumours with no clinical evidence of hormonal hypersecretion. In most of the cases the tumours are arising from the gonadotroph linage, but silent corticotroph, somatotroph, thyrotroph and rarely lactotroph cell characteristics can be discovered with immunostaining. As a result of lack of hormonal hyper-secretion, the diagnosis of NFPAs is made most often when the patient presents with mass effects due to a macroadenoma. NFPAs are most common tumour types in surgical series, and their primary treatment is indeed surgery. However, complete resection is achieved only in about 66% of the cases, and 20% of gross total resected tumours recur after 10 years. Over the past few decades, remarkable progress has been achieved regarding medical treatment options for pituitary tumours. However, NFPAs remain the only subtype with no widely accepted pharmacological treatment. Dopamine receptor type 2 (DRD2) and somatostatin receptor (SST) expression have been demonstrated in NFPAs, prompting the investigation of dopamine agonists and somatostatin analogues as potential treatment strategies. The DRD2 agonist cabergoline is already used as first-line treatment of prolactinomas to induce tumour shrinkage and reduce prolactin secretion. Here we aim to investigate the efficacy of cabergoline on human NFPA tissue. We assessed DRD2 expression levels via immunohistochemistry and qPCR in a large cohort of NFPAs (n=40) and in few prolactinomas (n=10). D2DR has two different isoforms, long (D2RL) and short (D2RS), which are differently expressed and can induce different effects on cell viability. In cabergoline-sensitive prolactinomas D2RS is the predominant isoform. NFPAs shown 10-fold and 5-fold decrease expression of D2RS and D2RL compared to prolactinomas, respectively. Additionally, in NFPAs we observed a significant decrease of cAMP production after cabergoline treatment (45% ±7; p We have also seen in NFPAs downregulation of Ga i2 protein expression levels, highlighting the general decrease of expression levels in the dopamine pathway (50% less, p Our data suggest that the difference in cabergoline responses between NFPAs and prolactinomas may be due to their distinct expression of D2DR isoforms, which differ by 29 amino acids in the third cytoplasmic loop, essential for G-protein binding. It has been shown that D2RL, but not D2RS, requires Gai2. The difference in D2R isoform expression could translate to distinct G-protein activation, ultimately leading to the contrasting viability results after cabergoline treatment. Taken together, these data will help inform future treatment strategies for patients with NFPAs. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m.

While there have been great strides in endoscopic and endoscope-assisted neurosurgical approaches, particularly in the treatment of deep-sited brain and skull base tumours, the greatest technical barrier to their adoption has been the availability of suitable surgical instruments. This systematic review seeks to identify specialised instruments for these approaches and evaluate their safety, efficacy and usability. Conducted in accordance with the PRISMA guidelines, Medline, Embase, CENTRAL, SCOPUS and Web of Science were searched. Original research studies that reported the use of specialised mechanical instruments that manipulate tissue in human patients, cadavers or surgical models were included. The results identified 50 specialised instruments over 62 studies. Objective measures of safety were reported in 32 out of 62 studies, and 20 reported objective measures of efficacy. Instruments were broadly safe and effective with one instrument malfunction noted. Measures of usability were reported in 15 studies, with seven reporting on ergonomics and eight on the instruments learning curve. Instruments with reports on usability were generally considered to be ergonomic, though learning curve was often considered a disadvantage. Comparisons to standard instruments were made in eight studies and were generally favourable. While there are many specialised instruments for endoscopic and endoscope-assisted neurosurgery available, the evidence for their safety, efficacy and usability is limited with non-standardised reporting and few comparative studies to standard instruments. Future innovation should be tailored to unmet clinical needs, and evaluation guided by structured development processes.

Burnout is prevalent among neurosurgeons and can negatively impact both technical and nontechnical skills and subsequent patient care. Mindfulness training has previously been shown to ameliorate the effects of burnout and improve performance in health care workers and high-stress occupations, but no such evaluation has been formally conducted for neurosurgeons. We aimed to determine the effectiveness and feasibility of a virtual mindfulness-based intervention (MBI) in neurosurgeons.A prospective trial of an MBI was implemented and hosted from our tertiary academic unit, running virtually from October to December 2020. Practicing neurosurgeons of all grades were recruited from 9 neurosurgical centers. Participants underwent 8 weeks of 90-minute MBI classes and suggested daily practice. Psychometric measures related to burnout, stress, wellbeing, and mindfulness competencies were assessed at baseline and on course completion.Twenty-one neurosurgeons participated in the study (attendings = 2, residents = 18, interns = 1, mean age = 30.3 [standard deviation 3.9] years). Significant improvements after intervention were present in perceived stress (Z = -2.54, P = 0.04) and emotional exhaustion (Z = -2.41, P = 0.04). Mindfulness training was associated with improved mindfulness skills (Z = -2.58, P = 0.006), self-compassion (t = -4.4, P = 0.002), resilience (Z = -3.18, P = 0.004), and choice response times (Z = -2.13, P = 0.03). All neurosurgeons who completed the postintervention assessment stated they would recommend the course and agreed that it was relevant to their surgical practice.Preliminary evidence from this trial cautiously supports the effectiveness and feasibility of a virtual MBI for dealing with stress, burnout, and improving dexterity among young neurosurgeons. Further research is warranted to validate these findings.

Background Postoperative pediatric cerebellar mutism syndrome (pCMS) is a common but severe complication that may arise following the resection of posterior fossa tumors in children. Two previous studies have aimed to preoperatively predict pCMS, with varying results. In this work, we examine the generalization of these models and determine if pCMS can be predicted more accurately using an artificial neural network (ANN). Methods An overview of reviews was performed to identify risk factors for pCMS, and a retrospective dataset was collected as per these defined risk factors from children undergoing resection of primary posterior fossa tumors. The ANN was trained on this dataset and its performance was evaluated in comparison to logistic regression and other predictive indices via analysis of receiver operator characteristic curves. The area under the curve (AUC) and accuracy were calculated and compared using a Wilcoxon signed-rank test, with P Results Two hundred and four children were included, of whom 80 developed pCMS. The performance of the ANN (AUC 0.949; accuracy 90.9%) exceeded that of logistic regression (P Conclusion Using an ANN, we show improved prediction of pCMS in comparison to previous models and conventional methods.

Context The role of robot-assisted surgery continues to expand at a time when trainers and proctors have travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic. Objective To provide guidance on setting up and running an optimised telementoring service that can be integrated into current validated curricula. We define a standardised approach to training candidates in skill acquisition via telepresence technologies. We aim to describe an approach based on the current evidence and available technologies, and define the key elements within optimised telepresence services, by seeking consensus from an expert committee comprising key opinion leaders in training. Evidence acquisition This project was carried out in phases: a systematic review of the current literature, a teleconference meeting, and then an initial survey were conducted based on the current evidence and expert opinion, and sent to the committee. Twenty-four experts in training, including clinicians, academics, and industry, contributed to the Delphi process. An accelerated Delphi process underwent three rounds and was completed within 72 h. Additions to the second- and third-round surveys were formulated based on the answers and comments from the previous rounds. Consensus opinion was defined as ≥80% agreement. Evidence synthesis There was 100% consensus regarding an urgent need for international agreement on guidance for optimised telepresence. Consensus was reached in multiple areas, including (1) infrastructure and functionality; (2) definitions and terminology; (3) protocols for training, communication, and safety issues; and (4) accountability including ethical and legal issues. The resulting formulated guidance showed good internal consistency among experts, with a Cronbach alpha of 0.90. Conclusions Using the Delphi methodology, we achieved international consensus among experts for development and content validation of optimised telepresence services for robotic surgery training. This guidance lays the foundation for launching telepresence services in robotic surgery. This guidance will require further validation. Patient summary Owing to travel restrictions during the coronavirus disease 2019 (COVID-19) pandemic, development of remote training and support via telemedicine is becoming increasingly important. We report a key opinion leader consensus view on a standardised approach to telepresence., Take Home Message There is currently a lack of high-level evidence on utilising telepresence technologies to train in robot-assisted surgery. We report Delphi process consensus views, formulated by US and European training and industry experts, on safe launching of telepresence for robotic surgery.

The insertion of bolt external ventricular drains (EVD) on the intensive care unit (ICU) has enabled rapid cranial cerebrospinal fluid (CSF) diversion. However, bolt EVDs tend to be perceived as a more challenging technique, particularly when dealing with small ventricles or when there is midline shift distorting the ventricular morphology. Furthermore, if neuronavigation guidance is felt to be necessary, this usually assumes a transfer to an operating theatre. In this technical note, we describe the use of electromagnetic neuronavigation for bolt EVD insertion on the ICU and assess the protocol’s feasibility and accuracy. Case series of neuronavigation-assisted bolt EVD insertion in ICU setting, using Medtronic Flat Emitter for StealthStation EM. Neuronavigation-guided bolt EVDs were placed at the bedside in n = 5 patients on ICU. Their widest frontal ventricular horn diameter in the coronal plane ranged from 11 to 20 mm. No procedural complications were encountered. Post-procedural CT confirmed the optimal placement of the EVDs. Electromagnetic neuronavigation is feasible at the ICU bedside and can assist the insertion of bolt EVDs in this setting. The preference for a bolt EVD to be inserted in ICU—as is standard practice at this unit—should not prohibit patients from benefitting from image guidance if required.

Introduction Substantial healthcare resources have been diverted to manage the effects of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic, and nonemergency neurosurgery has been effectively closed. As we begin to emerge from the crisis, we will need to manage the backlog of nonemergency neurosurgical patients whose treatment has been delayed and remain responsive to further possible surges of SARS-CoV-2 infections. Methods In the present study, we aimed to identify the core themes and challenges that will limit resumption of a normal neurosurgical service after the SARS-CoV-2 pandemic and to provide pragmatic advice and solutions that could be of utility to clinicians seeking to resume nonemergency neurosurgical care. We reviewed the relevant international policies, a wide range of journalistic and media sources, and expert opinion documents to address the stated aims. Results We have presented and discussed a range of factors that could become potential barriers to resuming full elective neurosurgical provision and important steps that must be completed to achieve pre–SARS-CoV-2 surgical capacity. We also explored how these challenges can be overcome and outlined the key requirements for a successful neurosurgical exit strategy from the pandemic. Conclusion The performance of nonemergency neurosurgery can start once minimum criteria have been fulfilled: 1) a structured prioritization of surgical cases; 2) virus infection incidence decreased sufficiently to release previously diverted healthcare resources; 3) adequate safety criteria met for patients and staff, including sufficient personal protective equipment and robust testing availability; and 4) maintenance of systems for rapid communication at organizational and individual levels.

Funder: University of Cambridge, Background: The Idea, Development, Exploration, Assessment and Long-term study (IDEAL) framework was created to provide a structured way for assessing and evaluating novel surgical techniques and devices. Objectives: The aim of this paper was to investigate the utilization of the IDEAL framework within neurosurgery, and to identify factors influencing implementation. Methods: A bibliometric analysis of the 7 key IDEAL papers on Scopus, PubMed, Embase, Web of Science, and Google Scholar databases (2009–2019) was performed. A second journal-specific search then identified additional papers citing the IDEAL framework. Publications identified were screened by two independent reviewers to select neurosurgery-specific articles. Results: The citation search identified 1336 articles. The journal search identified another 16 articles. Following deduplication and review, 51 relevant articles remained; 14 primary papers (27%) and 37 secondary papers (73%). Of the primary papers, 5 (36%) papers applied the IDEAL framework to their research correctly; two were aligned to the pre-IDEAL stage, one to the Idea and Development stages, and two to the Exploration stage. Of the secondary papers, 21 (57%) explicitly discussed the IDEAL framework. Eighteen (86%) of these were supportive of implementing the framework, while one was not, and two were neutral. Conclusion: The adoption of the IDEAL framework in neurosurgery has been slow, particularly for early-stage neurosurgical techniques and inventions. However, the largely positive reviews in secondary literature suggest potential for increased use that may be achieved with education and publicity.

Compared with endovascular techniques, clipping of ruptured cerebral aneurysms has been shown to associate with increased morbidity in several studies. Despite this, clipping remains the preferred option for many aneurysms. The objective of this study is to describe the reported adverse events of open repair of ruptured cerebral aneurysms and their impact on patient outcome. The PubMed, Embase and Cochrane databases were searched between June 1999 and June 2019 to identify original studies of at least 100 patients undergoing surgical repair of ruptured cerebral aneurysms and in which adverse event rates were reported. Thirty-six studies reporting adverse events in a total of 12,410 operations for repair of ruptured cerebral aneurysms were included. Surgical adverse events were common with 36 event types reported including intraoperative rupture (median rate of 16.6%), arterial injury (median rate of 3.8%) and brain swelling (median rate 5.6%). Only 6 surgical events were statistically shown to associate with poor outcomes by any author and for intraoperative rupture (the most frequently analysed), there was an even split between authors finding a statistical association with poor outcome and those finding no association. Even with modern surgical techniques, the technical demands of surgical aneurysm repair continue to lead to a high rate of intraoperative adverse events. Despite this, it is not known which of these intraoperative events are the most important contributors to the poor outcomes often seen in these patients. More research directed towards identifying the events that most drive operative morbidity has the potential to improve outcomes for these patients. Electronic supplementary material The online version of this article (10.1007/s10143-020-01312-4) contains supplementary material, which is available to authorized users.