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COVID-19 is commonly mild and self-limiting, but in a considerable portion of patients the disease is severe and fatal. Determining which patients are at high risk of severe illness or mortality is essential for appropriate clinical decision making. We propose a novel severity score specifically for COVID-19 to help predict disease severity and mortality. 4711 patients with confirmed SARS-CoV-2 infection were included. We derived a risk model using the first half of the cohort (n = 2355 patients) by logistic regression and bootstrapping methods. The discriminative power of the risk model was assessed by calculating the area under the receiver operating characteristic curves (AUC). The severity score was validated in a second half of 2356 patients. Mortality incidence was 26.4% in the derivation cohort and 22.4% in the validation cohort. A COVID-19 severity score ranging from 0 to 10, consisting of age, oxygen saturation, mean arterial pressure, blood urea nitrogen, C-Reactive protein, and the international normalized ratio was developed. A ROC curve analysis was performed in the derivation cohort achieved an AUC of 0.824 (95% CI 0.814–0.851) and an AUC of 0.798 (95% CI 0.789–0.818) in the validation cohort. Furthermore, based on the risk categorization the probability of mortality was 11.8%, 39% and 78% for patient with low (0–3), moderate (4–6) and high (7–10) COVID-19 severity score. This developed and validated novel COVID-19 severity score will aid physicians in predicting mortality during surge periods.

Background Aging and brain atrophy are risk factors for subdural hematoma (SDH). This preliminary analysis aims to quantify the effect of living with dementia on 1‐year mortality following hospital admission for SDH. Method Medical record data between Dec 2021 and Jan 2023 were reviewed retrospectively with a sampling rate of 1:2 (with dementia: without dementia) for participants with SDH managed conservatively. Propensity score matching (PSM) was used to estimate the average marginal effect of living with dementia on 1‐year mortality, accounting for covariates (age, sex, chronicity of SDH, average hematoma width, midline shift). We used a 1:1 nearest neighbour PSM without replacement with propensity scores estimated using logistic regression of dementia status on covariates. Risk Ratio (RR) with 95% confidence intervals (CI) is reported from logistic regression after PSM to evaluate the association between dementia (as the sole predictor due to a low event rate <10) and 1‐year mortality, with statistical significance considered at p < 0.05. Result A total of 54 adults with a mean age of 77±15 were included, 50% (27/60) being men, 39% (21/54) having dementia, and 7.4% (4/54) having chronic SDH. The 1‐year mortality rate was approximately twice in those living with dementia, 19% (4/21) vs. without 9.1% (3/33) (Cramer V = .14, df = 1, N = 54). After PSM, 12 non‐dementia cases were excluded, and all covariate differences were 0.3, indicating an acceptable balance for preliminary analysis. The effect of dementia on 1‐year mortality is as follows: RR = 1.33, 95% CI [0.28, 6.18], p = 0.713, N = 42. Conclusion 1‐year mortality appears 33% more likely in the dementia cohort, but the confidence interval is too wide to be conclusive. A sample size of 154 is needed for sufficient power (1‐β=0.80, α=0.05) and to include covariates with an absolute std. mean difference of > 0.1 after PSM. Additional information: Funded by the Canadian Institutes of Health Research Micheal Smith Foreign Study Supplement (Funding reference number: FSS ‐ 191081)

Acute neurological manifestation is a common complication of acute Coronavirus Disease 2019 (COVID-19) disease. This retrospective cohort study investigated the 3-year outcomes of patients with and without significant neurological manifestations during initial COVID-19 hospitalization. Patients hospitalized for Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection between 03/01/2020 and 4/16/2020 in the Montefiore Health System in the Bronx, an epicenter of the early pandemic, were included. Follow-up data was captured up to 01/23/2023 (3 years post-COVID-19). This cohort consisted of 414 patients with COVID-19 with significant neurological manifestations and 1,199 propensity-matched patients (for age and COVID-19 severity score) with COVID-19 without neurological manifestations. Neurological involvement during the acute phase included acute stroke, new or recrudescent seizures, anatomic brain lesions, presence of altered mentation with evidence for impaired cognition or arousal, and neuro-COVID-19 complex (headache, anosmia, ageusia, chemesthesis, vertigo, presyncope, paresthesias, cranial nerve abnormalities, ataxia, dysautonomia, and skeletal muscle injury with normal orientation and arousal signs). There were no significant group differences in female sex composition (44.93% versus 48.21%, p = 0.249), ICU and IMV status, white, not Hispanic (6.52% versus 7.84%, p = 0.380), and Hispanic (33.57% versus 38.20%, p = 0.093), except black non-Hispanic (42.51% versus 36.03%, p = 0.019). Primary outcomes were mortality, stroke, heart attack, major adverse cardiovascular events (MACE), reinfection, and hospital readmission post-discharge. Secondary outcomes were neuroimaging findings (hemorrhage, active and prior stroke, mass effect, microhemorrhages, white matter changes, microvascular disease (MVD), and volume loss). More patients in the neurological cohort were discharged to acute rehabilitation (10.39% versus 3.34%, p < 0.001) or skilled nursing facilities (35.75% versus 25.35%, p < 0.001) and fewer to home (50.24% versus 66.64%, p < 0.001) than matched controls. Incidence of readmission for any reason (65.70% versus 60.72%, p = 0.036), stroke (6.28% versus 2.34%, p < 0.001), and MACE (20.53% versus 16.51%, p = 0.032) was higher in the neurological cohort post-discharge. Per Kaplan-Meier univariate survival curve analysis, such patients in the neurological cohort were more likely to die post-discharge compared to controls (hazard ratio: 2.346, (95% confidence interval (CI) [1.586, 3.470]; p < 0.001)). Across both cohorts, the major causes of death post-discharge were heart disease (13.79% neurological, 15.38% control), sepsis (8.63%, 17.58%), influenza and pneumonia (13.79%, 9.89%), COVID-19 (10.34%, 7.69%), and acute respiratory distress syndrome (ARDS) (10.34%, 6.59%). Factors associated with mortality after leaving the hospital involved the neurological cohort (odds ratio (OR): 1.802 (95% CI [1.237, 2.608]; p = 0.002)), discharge disposition (OR: 1.508 (95% CI [1.276, 1.775]; p < 0.001)), congestive heart failure (OR: 2.281 (95% CI [1.429, 3.593]; p < 0.001)), higher COVID-19 severity score (OR: 1.177 (95% CI [1.062, 1.304]; p = 0.002)), and older age (OR: 1.027 (95% CI [1.010, 1.044]; p = 0.002)). There were no group differences in radiological findings, except that the neurological cohort showed significantly more age-adjusted brain volume loss (p = 0.045) than controls. The study's patient cohort was limited to patients infected with COVID-19 during the first wave of the pandemic, when hospitals were overburdened, vaccines were not yet available, and treatments were limited. Patient profiles might differ when interrogating subsequent waves. Patients with COVID-19 with neurological manifestations had worse long-term outcomes compared to matched controls. These findings raise awareness and the need for closer monitoring and timely interventions for patients with COVID-19 with neurological manifestations, as their disease course involving initial neurological manifestations is associated with enhanced morbidity and mortality.

Aging and brain atrophy are risk factors for subdural hematoma (SDH). This preliminary analysis aims to quantify the effect of living with dementia on 1-year mortality following hospital admission for SDH. Medical record data between Dec 2021 and Jan 2023 were reviewed retrospectively with a sampling rate of 1:2 (with dementia: without dementia) for participants with SDH managed conservatively. Propensity score matching (PSM) was used to estimate the average marginal effect of living with dementia on 1-year mortality, accounting for covariates (age, sex, chronicity of SDH, average hematoma width, midline shift). We used a 1:1 nearest neighbour PSM without replacement with propensity scores estimated using logistic regression of dementia status on covariates. Risk Ratio (RR) with 95% confidence intervals (CI) is reported from logistic regression after PSM to evaluate the association between dementia (as the sole predictor due to a low event rate <10) and 1-year mortality, with statistical significance considered at p < 0.05. A total of 54 adults with a mean age of 77±15 were included, 50% (27/60) being men, 39% (21/54) having dementia, and 7.4% (4/54) having chronic SDH. The 1-year mortality rate was approximately twice in those living with dementia, 19% (4/21) vs. without 9.1% (3/33) (Cramer V = .14, df = 1, N = 54). After PSM, 12 non-dementia cases were excluded, and all covariate differences were 0.3, indicating an acceptable balance for preliminary analysis. The effect of dementia on 1-year mortality is as follows: RR = 1.33, 95% CI [0.28, 6.18], p = 0.713, N = 42. 1-year mortality appears 33% more likely in the dementia cohort, but the confidence interval is too wide to be conclusive. A sample size of 154 is needed for sufficient power (1-β=0.80, α=0.05) and to include covariates with an absolute std. mean difference of > 0.1 after PSM. Additional information: Funded by the Canadian Institutes of Health Research Micheal Smith Foreign Study Supplement (Funding reference number: FSS - 191081).

Moyamoya disease (MMD) is a rare cerebrovascular disorder characterized by the progressive narrowing and occlusion of the intracranial internal carotid arteries, leading to the formation of abnormal collateral vessels. MMD primarily affects the cerebrovascular system, and evidence suggests it is associated with various neuropsychiatric outcomes. This manuscript aims to provide an overview of the current understanding of MMD, including its epidemiology, pathophysiology, clinical manifestations, and diagnosis. Furthermore, it explores the emerging research on the neuropsychiatric sequelae of MMD, such as cognitive impairment, psychiatric disorders, and quality of life. The manuscript concludes with the challenges in managing MMD-related neuropsychiatric outcomes and potential avenues for future research.

We aim to characterize the incidence, risk for mortality, and identify risk factors for mortality in patients presenting with hemorrhage and COVID-19. This retrospective cohort study included a cohort of patients admitted to one of three major hospitals of our healthcare network including, an academic medical center and comprehensive stroke center, which accepts transfers for complex cases from eight community hospitals, during March 1 to May 1, 2020. All patients that received imaging of the neuroaxis and had positive PCR testing for COVID-19 were identified and reviewed by an attending neuroradiologist. Demographics and comorbidities were recorded. Biomarkers were recorded from the day of the hemorrhagic event. Vital signs from the day of the hemorrhagic event mechanical ventilation orders at admission were recorded. Imaging findings were divided into 5 subtypes; acute subdural hematoma (SDH), subarachnoid hemorrhage (SAH), multi-compartmental hemorrhage (MCH), multi-focal intracerebral hemorrhage (MFH), and focal intracerebral hemorrhage (fICH). Outcomes were recorded as non-routine discharge and mortality. We found a total of 35 out of 5227 patients with COVID-19 that had hemorrhage of some kind. Mortality for the entire cohort was 45.7 % (n = 16). SDH patients had a mortality rate of 35.3 % (n = 6), SAH had a mortality of 50 % (n = 1), MCH patients had a mortality of 71.4 % (n = 5), MFH patients had a mortality of 50 % (n = 2), fICH patients had a mortality of 40 % (n = 2). Patients with severe pulmonary COVID requiring mechanical ventilation (OR 10.24 [.43−243.12] p = 0.015), with INR > 1.2 on the day of the hemorrhagic event (OR 14.36 [1.69−122.14] p = 0.015], and patients presenting with spontaneous vs. traumatic hemorrhage (OR 6.11 [.31−118.89] p = 0.023) had significantly higher risk for mortality. Hemorrhagic presentations with COVID-19 are a rare but serious way in which the illness can manifest. It is important for neurosurgeons to realize that patients can present with these findings without primary pulmonary symptoms, and that severe pulmonary symptoms, elevated INR, and spontaneous hemorrhagic presentations is associated with increased risk for mortality.

Idiopathic Intracranial Hypertension (IIH) is a neurological disorder characterized by elevated intracranial pressure without definitive etiology, primarily affecting young, obese women. This study aimed to compare the efficacy of bariatric surgery versus conventional community weight management in treating IIH. We conducted a retrospective cohort study in IIH patients undergoing bariatric procedures versus conventional weight loss interventions. Propensity score matching was employed to balance study groups. Outcomes were assessed at 3, 6, 12, and 24 months, including papilledema, headache, visual symptoms, and therapeutic interventions. Bariatric surgery demonstrated superior outcomes compared to community weight management. Papilledema incidence was consistently lower in the bariatric group (RR = 0.591 at 24 months, p  = 0.0001). Headache prevalence and visual symptoms were also reduced in the surgical group. Acetazolamide dose was lower in bariatric patients, starting at 12 and 24 months. Subgroup analysis of different bariatric procedures showed comparable efficacy. Body mass index reduction was significantly greater in the bariatric group throughout the follow-up period. This study provides evidence supporting the efficacy of bariatric surgery in managing IIH, with superior outcomes across multiple parameters compared to conventional weight management. The sustained improvements in papilledema, headache, and visual symptoms, coupled with for the reduction in pharmacological intervention dose, suggest that bariatric surgery may offer a more definitive solution for IIH patients with concurrent obesity. Further research is needed to develop evidence-based guidelines for patient selection and optimize post-operative care protocols.

Idiopathic intracranial hypertension (IIH) is characterized by elevated intracranial pressure without a clear cause, often linked to cerebral venous sinus constriction from embryological or acquired factors. Although less common, brain tumors like parasagittal meningiomas can compress the superior sagittal sinus, leading to IIH. Venous stenting has become a minimally invasive and effective intervention for managing IIH caused by superior sagittal sinus stenosis, particularly when residual meningiomas continue to exert pressure on the sinus.1–6 Video 1 presents a step-by-step technique for deploying dual Onyx cardiac stents to treat stenosis in the superior sagittal sinus, which is complemented by middle meningeal artery embolization. This helps to reduce the vascular supply to the remaining meningioma tissue. This combined approach not only provides immediate relief from IIH symptoms but also minimizes surgical risks, such as venous infarction and excessive blood loss. It serves as a valuable adjunct in cases where complete surgical tumor removal is challenging. Video 1 - Techinical video of a case of superior sagittal sinus stenosis from an invasive meningioma causing intracranial hypertension successfully treated with a coronary balloon mounted stent.­

Objectives Percutaneous vertebroplasty and kyphoplasty are common interventions for osteoporotic vertebral compression fractures. However, there is concern about an increased risk of adjacent-level fractures after treatment. This study aimed to compare the risk of adjacent-level fractures after vertebroplasty and kyphoplasty with the natural history after osteoporotic vertebral compression fractures. Materials and methods A network meta-analysis of randomized controlled trials (RCTs) was conducted to evaluate the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to the natural history after osteoporotic vertebral compression fractures. Frequentist network meta-analysis was conducted using the “netmeta” package, and heterogeneity was assessed using Q statistics. The pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using random effects. Results Twenty-three RCTs with a total of 2838 patients were included in the analysis. The network meta-analysis showed comparable risks of adjacent-level fractures between vertebroplasty, kyphoplasty, and natural history after osteoporotic vertebral compression fractures with a mean follow-up of 21.2 (range: 3–49.4 months). The pooled RR for adjacent-level fractures after kyphoplasty compared to natural history was 1.35 (95% CI, 0.78–2.34, p  = 0.23) and for vertebroplasty compared to natural history was 1.16 (95% CI, 0.62–2.14) p  = 0.51. The risk of bias assessment showed a low to moderate risk of bias among included RCTs. Conclusion There was no difference in the risk of adjacent-level fractures after vertebroplasty and kyphoplasty compared to natural history after osteoporotic vertebral compression fractures. The inclusion of a large patient number and network meta-analysis of RCTs serve evidence-based clinical practice. Clinical relevance statement The risk of adjacent-level fracture following percutaneous vertebroplasty or kyphoplasty is similar to that observed in the natural history after osteoporotic vertebral compression fractures. Key Points RCTs have examined the risk of adjacent-level fracture after intervention for osteoporotic vertebral compression fractures . There was no difference between vertebroplasty and kyphoplasty patients compared to the natural disease history for adjacent compression fractures . This is strong evidence that interventional treatments for these fractures do not increase the risk of adjacent fractures .