Neurosurgery & Trauma

This summer, amateur, elite male boxers are back to competing without headgear after nearly 3 decades of being required to wear it during competition. The headgear rule was put in place by the International Boxing Association (AIBA) before the 1984 Olympics, but now elite, male boxers are beginning to compete in much more professional style.

So what will this mean for concussion rates and concussion risk?

At first glance, it may seem to put boxers at greater risk; however, clinical evidence has shown that headgear does not necessarily reduce the incidence of concussion. The advantage of headgear is that it protects the face and decreases eye injuries, nose injuries, and facial lacerations. It does not stop the head from spinning, the primary cause of concussion in boxers.

There are four ways that boxers can get brain injury, but none of them can be prevented by wearing headgear. These mechanisms include:

• Rotational acceleration. This occurs when the head twists/spins – usually from a blow to the side of the jaw, cheek, or chin – and the brain follows, resulting in the stretching and tearing of axons. (This is why knockouts usually come from a severe blow to the chin.)

• Linear acceleration. This happens when the brain moves forward/backward – usually from a direct blow to the face – and strikes the skull, resulting in the stretching or tearing of neurons in the brain and brain stem.

• Injury to the carotid arteries. This occurs after a sudden flexion of the neck – usually from a direct blow to it – resulting in tears in one or both carotid arteries, causing a stroke.

• Impact deceleration. This is the rapid slowing of the brain inside the skull and is usually caused by hitting an immovable object like the ring floor, resulting in cerebral contusions.

In fact, there is a new, still unpublished AIBA study that suggests the removal of headgear would decrease head injuries, such as concussions. According to the study spearheaded by AIBA medical commission chairman Dr. Charles Butler, the rate of concussion was 0.38% in 7,352 rounds for boxers wearing headgear, compared with 0.17% in 7,545 rounds for those without headgear.

On the other hand, another recent study by the Cleveland Clinic found that headgear can help decrease linear acceleration and the potential for injury from it.

Clearly, there is still much debate on this issue. As amateur boxers start this new phase of competition, experts will be better able to observe changes in concussion rates, if any, and hopefully come to a definitive conclusion as to whether headgear use has any impact at all.

Dr. Jordan is the director of the brain injury program and the memory evaluation treatment service at Burke Rehabilitation Hospital in White Plains, N.Y. He currently serves as the chief medical officer of the New York State Athletic Commission, as a team physician for USA Boxing, and as a member of the NFL Players Association Mackey-White Traumatic Brain Injury Committee and the NFL Neuro-Cognitive Disability Committee.

This summer, amateur, elite male boxers are back to competing without headgear after nearly 3 decades of being required to wear it during competition. The headgear rule was put in place by the International Boxing Association (AIBA) before the 1984 Olympics, but now elite, male boxers are beginning to compete in much more professional style.

So what will this mean for concussion rates and concussion risk?

At first glance, it may seem to put boxers at greater risk; however, clinical evidence has shown that headgear does not necessarily reduce the incidence of concussion. The advantage of headgear is that it protects the face and decreases eye injuries, nose injuries, and facial lacerations. It does not stop the head from spinning, the primary cause of concussion in boxers.

There are four ways that boxers can get brain injury, but none of them can be prevented by wearing headgear. These mechanisms include:

• Rotational acceleration. This occurs when the head twists/spins – usually from a blow to the side of the jaw, cheek, or chin – and the brain follows, resulting in the stretching and tearing of axons. (This is why knockouts usually come from a severe blow to the chin.)

• Linear acceleration. This happens when the brain moves forward/backward – usually from a direct blow to the face – and strikes the skull, resulting in the stretching or tearing of neurons in the brain and brain stem.

• Injury to the carotid arteries. This occurs after a sudden flexion of the neck – usually from a direct blow to it – resulting in tears in one or both carotid arteries, causing a stroke.

• Impact deceleration. This is the rapid slowing of the brain inside the skull and is usually caused by hitting an immovable object like the ring floor, resulting in cerebral contusions.

In fact, there is a new, still unpublished AIBA study that suggests the removal of headgear would decrease head injuries, such as concussions. According to the study spearheaded by AIBA medical commission chairman Dr. Charles Butler, the rate of concussion was 0.38% in 7,352 rounds for boxers wearing headgear, compared with 0.17% in 7,545 rounds for those without headgear.

On the other hand, another recent study by the Cleveland Clinic found that headgear can help decrease linear acceleration and the potential for injury from it.

Clearly, there is still much debate on this issue. As amateur boxers start this new phase of competition, experts will be better able to observe changes in concussion rates, if any, and hopefully come to a definitive conclusion as to whether headgear use has any impact at all.

Dr. Jordan is the director of the brain injury program and the memory evaluation treatment service at Burke Rehabilitation Hospital in White Plains, N.Y. He currently serves as the chief medical officer of the New York State Athletic Commission, as a team physician for USA Boxing, and as a member of the NFL Players Association Mackey-White Traumatic Brain Injury Committee and the NFL Neuro-Cognitive Disability Committee.

This summer, amateur, elite male boxers are back to competing without headgear after nearly 3 decades of being required to wear it during competition. The headgear rule was put in place by the International Boxing Association (AIBA) before the 1984 Olympics, but now elite, male boxers are beginning to compete in much more professional style.

So what will this mean for concussion rates and concussion risk?

At first glance, it may seem to put boxers at greater risk; however, clinical evidence has shown that headgear does not necessarily reduce the incidence of concussion. The advantage of headgear is that it protects the face and decreases eye injuries, nose injuries, and facial lacerations. It does not stop the head from spinning, the primary cause of concussion in boxers.

There are four ways that boxers can get brain injury, but none of them can be prevented by wearing headgear. These mechanisms include:

• Rotational acceleration. This occurs when the head twists/spins – usually from a blow to the side of the jaw, cheek, or chin – and the brain follows, resulting in the stretching and tearing of axons. (This is why knockouts usually come from a severe blow to the chin.)

• Linear acceleration. This happens when the brain moves forward/backward – usually from a direct blow to the face – and strikes the skull, resulting in the stretching or tearing of neurons in the brain and brain stem.

• Injury to the carotid arteries. This occurs after a sudden flexion of the neck – usually from a direct blow to it – resulting in tears in one or both carotid arteries, causing a stroke.

• Impact deceleration. This is the rapid slowing of the brain inside the skull and is usually caused by hitting an immovable object like the ring floor, resulting in cerebral contusions.

In fact, there is a new, still unpublished AIBA study that suggests the removal of headgear would decrease head injuries, such as concussions. According to the study spearheaded by AIBA medical commission chairman Dr. Charles Butler, the rate of concussion was 0.38% in 7,352 rounds for boxers wearing headgear, compared with 0.17% in 7,545 rounds for those without headgear.

On the other hand, another recent study by the Cleveland Clinic found that headgear can help decrease linear acceleration and the potential for injury from it.

Clearly, there is still much debate on this issue. As amateur boxers start this new phase of competition, experts will be better able to observe changes in concussion rates, if any, and hopefully come to a definitive conclusion as to whether headgear use has any impact at all.

Dr. Jordan is the director of the brain injury program and the memory evaluation treatment service at Burke Rehabilitation Hospital in White Plains, N.Y. He currently serves as the chief medical officer of the New York State Athletic Commission, as a team physician for USA Boxing, and as a member of the NFL Players Association Mackey-White Traumatic Brain Injury Committee and the NFL Neuro-Cognitive Disability Committee.

LONDON – Decompressive surgery dramatically increased the survival chances of older adult patients who had massive brain swelling after a middle cerebral artery stroke, according to the results of a randomized clinical trial.

After 1 year of follow-up, 57% of patients aged 61 years or older were still alive if they had undergone hemicraniectomy, compared with 24% (P less than .001) of those who received standard intensive care alone in the DESTINY II trial. The increase in survival did not lead to an increase in severe disability, study investigator Dr. Werner Hacke of the University of Heidelberg, Germany, reported at the annual European Stroke Conference.

Sara Freeman/IMNG Medical Media

"Malignant infarction of the middle cerebral artery [MCA] is the deadliest type of ischemic brain infarction," Dr. Hacke noted. It is associated with rapid neurological deterioration caused by cerebral edema (Postgrad. Med. J. 2010;86:235-42) and is responsible for 70%-80% of in-hospital mortality if treated conservatively using mechanical ventilation and intracranial pressure reduction.

Evidence supporting decompressive surgery

Previous pooled research, including the DESTINY I study (Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery), showed that relieving the pressure on the brain by temporarily removing part of the skull within the first 48 hours of ischemic injury reduces the risk of death and poor clinical outcome by almost 50% in patients under the age of 60 years (Lancet Neurol. 2007;6:215-22). The DESTINY II data now show that older patients also can benefit from decompressive surgery, perhaps as much as their younger counterparts.

A total of 112 patients with malignant MCA infarction aged 61 years and older were recruited into the study and randomized to receive maximum conservative treatment alone or in addition to hemicraniectomy within 48 hours after symptom onset (Int. J. Stroke 2011;6:79-86). The mean age was 70 years, and 60%-67% had infarctions affecting the nondominant cerebral hemisphere. The mean National Institutes of Health Stroke Scale (NIHSS) score was 20-22 at admission.

The primary endpoint was the proportion of patients achieving a modified Rankin Scale (mRS) score of 0-4 versus 5-6 at 6 months. A score of 6 on this scale signifies death and a score of 5 represents severe disability, such as being bedridden and incontinent and requiring constant nursing care and attention.

Dr. Hacke noted that the trial’s data and safety monitoring board halted the trial at the 6-month assessment after reviewing data on 82 patients. The exact reasons were undisclosed, but part of the study’s protocol was to stop the trial once statistical significance was reached. At the time the trial has halted, a further 30 patients had already been randomized and were included in the intention-to-treat analysis (ITT).

DESTINY II results

Significantly more patients who underwent surgery had a mRS of 0-4 than did those who had standard intensive care treatment (40.5% vs. 18.6%, P = .039) using the DSMB data set. The percentages of surgically and conservatively treated patients with an mRS of 5 or 6 were 59.5% and 81.4%, respectively. Performing an ITT analysis did not change the findings.

The number needed to treat was just 4, Dr. Hacke reported.

At 12 months in the ITT population, he noted that 38% of surgically and 16% of conservatively managed patients with an mRS of 0-4 were alive, as were 62% versus 84% of those, respectively, who had a mRS of 5-6 (P =.009).

An ITT analysis of multiple secondary endpoints at 1 year – which included the NIHSS score, Barthel Activities of Daily Living Index, Short Form-36 physical and mental domains, Hamilton Rating Scale for Depression, and the EuroQoL-5D – was also significantly in favor of early hemicraniectomy. This was perhaps a statistical artifact, Dr. Hacke observed, as the significance disappeared when data were examined in only the patients who had survived to 1 year.

Retrospective consent to surgery

When survivors and their caregivers were asked if they would undergo the same procedure again, given the knowledge of the final outcome, the majority of both surgically treated (77%, n = 27) and conservatively managed survivors (73%, n = 15) said that they would.

This finding shows that most patients, including those with moderately severe disability (mRS of 4) would rather have the procedures than be dead.

Dr. Christine Roffe, professor of medicine at Keele University in Stoke-on-Trent, England, commented that a person’s point of view of disability often changes after having a stroke.

"We’ve always assumed that if you asked someone before they had a stroke, ‘Would you rather have a stroke or be dead?’ that people would say, ‘I’d rather be dead,’ " she said in an interview. It’s not unreasonable that most people would probably say they would rather be dead than be severely incapacitated for the rest of their lives, she added.

However, after having a stroke, people often report that they are able to continue to live their lives reasonably happily despite often being quite disabled and having lost their independence.

The DESTINY II data show that people who had surgery were quite happy despite any disability, and this was at a similar level to those who were treated conservatively but with higher survival rates, Dr. Roffe noted.

The ethical implications of this could be considerable, she suggested. It shows that people who have living wills or who decide that they do not want treatment in the event of a stroke could live just as happy a life after the event as before. It therefore begs the question of whether patients should be allowed to decide on this aspect of their care, she added.

The German Research Foundation and the German Ministry of Science and Education financially supported the study. Dr. Hacke had no disclosures. Dr. Roffe was not involved in the study and had no relevant conflicts of interest.

LONDON – Decompressive surgery dramatically increased the survival chances of older adult patients who had massive brain swelling after a middle cerebral artery stroke, according to the results of a randomized clinical trial.

After 1 year of follow-up, 57% of patients aged 61 years or older were still alive if they had undergone hemicraniectomy, compared with 24% (P less than .001) of those who received standard intensive care alone in the DESTINY II trial. The increase in survival did not lead to an increase in severe disability, study investigator Dr. Werner Hacke of the University of Heidelberg, Germany, reported at the annual European Stroke Conference.

Sara Freeman/IMNG Medical Media

"Malignant infarction of the middle cerebral artery [MCA] is the deadliest type of ischemic brain infarction," Dr. Hacke noted. It is associated with rapid neurological deterioration caused by cerebral edema (Postgrad. Med. J. 2010;86:235-42) and is responsible for 70%-80% of in-hospital mortality if treated conservatively using mechanical ventilation and intracranial pressure reduction.

Evidence supporting decompressive surgery

Previous pooled research, including the DESTINY I study (Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery), showed that relieving the pressure on the brain by temporarily removing part of the skull within the first 48 hours of ischemic injury reduces the risk of death and poor clinical outcome by almost 50% in patients under the age of 60 years (Lancet Neurol. 2007;6:215-22). The DESTINY II data now show that older patients also can benefit from decompressive surgery, perhaps as much as their younger counterparts.

A total of 112 patients with malignant MCA infarction aged 61 years and older were recruited into the study and randomized to receive maximum conservative treatment alone or in addition to hemicraniectomy within 48 hours after symptom onset (Int. J. Stroke 2011;6:79-86). The mean age was 70 years, and 60%-67% had infarctions affecting the nondominant cerebral hemisphere. The mean National Institutes of Health Stroke Scale (NIHSS) score was 20-22 at admission.

The primary endpoint was the proportion of patients achieving a modified Rankin Scale (mRS) score of 0-4 versus 5-6 at 6 months. A score of 6 on this scale signifies death and a score of 5 represents severe disability, such as being bedridden and incontinent and requiring constant nursing care and attention.

Dr. Hacke noted that the trial’s data and safety monitoring board halted the trial at the 6-month assessment after reviewing data on 82 patients. The exact reasons were undisclosed, but part of the study’s protocol was to stop the trial once statistical significance was reached. At the time the trial has halted, a further 30 patients had already been randomized and were included in the intention-to-treat analysis (ITT).

DESTINY II results

Significantly more patients who underwent surgery had a mRS of 0-4 than did those who had standard intensive care treatment (40.5% vs. 18.6%, P = .039) using the DSMB data set. The percentages of surgically and conservatively treated patients with an mRS of 5 or 6 were 59.5% and 81.4%, respectively. Performing an ITT analysis did not change the findings.

The number needed to treat was just 4, Dr. Hacke reported.

At 12 months in the ITT population, he noted that 38% of surgically and 16% of conservatively managed patients with an mRS of 0-4 were alive, as were 62% versus 84% of those, respectively, who had a mRS of 5-6 (P =.009).

An ITT analysis of multiple secondary endpoints at 1 year – which included the NIHSS score, Barthel Activities of Daily Living Index, Short Form-36 physical and mental domains, Hamilton Rating Scale for Depression, and the EuroQoL-5D – was also significantly in favor of early hemicraniectomy. This was perhaps a statistical artifact, Dr. Hacke observed, as the significance disappeared when data were examined in only the patients who had survived to 1 year.

Retrospective consent to surgery

When survivors and their caregivers were asked if they would undergo the same procedure again, given the knowledge of the final outcome, the majority of both surgically treated (77%, n = 27) and conservatively managed survivors (73%, n = 15) said that they would.

This finding shows that most patients, including those with moderately severe disability (mRS of 4) would rather have the procedures than be dead.

Dr. Christine Roffe, professor of medicine at Keele University in Stoke-on-Trent, England, commented that a person’s point of view of disability often changes after having a stroke.

"We’ve always assumed that if you asked someone before they had a stroke, ‘Would you rather have a stroke or be dead?’ that people would say, ‘I’d rather be dead,’ " she said in an interview. It’s not unreasonable that most people would probably say they would rather be dead than be severely incapacitated for the rest of their lives, she added.

However, after having a stroke, people often report that they are able to continue to live their lives reasonably happily despite often being quite disabled and having lost their independence.

The DESTINY II data show that people who had surgery were quite happy despite any disability, and this was at a similar level to those who were treated conservatively but with higher survival rates, Dr. Roffe noted.

The ethical implications of this could be considerable, she suggested. It shows that people who have living wills or who decide that they do not want treatment in the event of a stroke could live just as happy a life after the event as before. It therefore begs the question of whether patients should be allowed to decide on this aspect of their care, she added.

The German Research Foundation and the German Ministry of Science and Education financially supported the study. Dr. Hacke had no disclosures. Dr. Roffe was not involved in the study and had no relevant conflicts of interest.

LONDON – Decompressive surgery dramatically increased the survival chances of older adult patients who had massive brain swelling after a middle cerebral artery stroke, according to the results of a randomized clinical trial.

After 1 year of follow-up, 57% of patients aged 61 years or older were still alive if they had undergone hemicraniectomy, compared with 24% (P less than .001) of those who received standard intensive care alone in the DESTINY II trial. The increase in survival did not lead to an increase in severe disability, study investigator Dr. Werner Hacke of the University of Heidelberg, Germany, reported at the annual European Stroke Conference.

Sara Freeman/IMNG Medical Media

"Malignant infarction of the middle cerebral artery [MCA] is the deadliest type of ischemic brain infarction," Dr. Hacke noted. It is associated with rapid neurological deterioration caused by cerebral edema (Postgrad. Med. J. 2010;86:235-42) and is responsible for 70%-80% of in-hospital mortality if treated conservatively using mechanical ventilation and intracranial pressure reduction.

Evidence supporting decompressive surgery

Previous pooled research, including the DESTINY I study (Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery), showed that relieving the pressure on the brain by temporarily removing part of the skull within the first 48 hours of ischemic injury reduces the risk of death and poor clinical outcome by almost 50% in patients under the age of 60 years (Lancet Neurol. 2007;6:215-22). The DESTINY II data now show that older patients also can benefit from decompressive surgery, perhaps as much as their younger counterparts.

A total of 112 patients with malignant MCA infarction aged 61 years and older were recruited into the study and randomized to receive maximum conservative treatment alone or in addition to hemicraniectomy within 48 hours after symptom onset (Int. J. Stroke 2011;6:79-86). The mean age was 70 years, and 60%-67% had infarctions affecting the nondominant cerebral hemisphere. The mean National Institutes of Health Stroke Scale (NIHSS) score was 20-22 at admission.

The primary endpoint was the proportion of patients achieving a modified Rankin Scale (mRS) score of 0-4 versus 5-6 at 6 months. A score of 6 on this scale signifies death and a score of 5 represents severe disability, such as being bedridden and incontinent and requiring constant nursing care and attention.

Dr. Hacke noted that the trial’s data and safety monitoring board halted the trial at the 6-month assessment after reviewing data on 82 patients. The exact reasons were undisclosed, but part of the study’s protocol was to stop the trial once statistical significance was reached. At the time the trial has halted, a further 30 patients had already been randomized and were included in the intention-to-treat analysis (ITT).

DESTINY II results

Significantly more patients who underwent surgery had a mRS of 0-4 than did those who had standard intensive care treatment (40.5% vs. 18.6%, P = .039) using the DSMB data set. The percentages of surgically and conservatively treated patients with an mRS of 5 or 6 were 59.5% and 81.4%, respectively. Performing an ITT analysis did not change the findings.

The number needed to treat was just 4, Dr. Hacke reported.

At 12 months in the ITT population, he noted that 38% of surgically and 16% of conservatively managed patients with an mRS of 0-4 were alive, as were 62% versus 84% of those, respectively, who had a mRS of 5-6 (P =.009).

An ITT analysis of multiple secondary endpoints at 1 year – which included the NIHSS score, Barthel Activities of Daily Living Index, Short Form-36 physical and mental domains, Hamilton Rating Scale for Depression, and the EuroQoL-5D – was also significantly in favor of early hemicraniectomy. This was perhaps a statistical artifact, Dr. Hacke observed, as the significance disappeared when data were examined in only the patients who had survived to 1 year.

Retrospective consent to surgery

When survivors and their caregivers were asked if they would undergo the same procedure again, given the knowledge of the final outcome, the majority of both surgically treated (77%, n = 27) and conservatively managed survivors (73%, n = 15) said that they would.

This finding shows that most patients, including those with moderately severe disability (mRS of 4) would rather have the procedures than be dead.

Dr. Christine Roffe, professor of medicine at Keele University in Stoke-on-Trent, England, commented that a person’s point of view of disability often changes after having a stroke.

"We’ve always assumed that if you asked someone before they had a stroke, ‘Would you rather have a stroke or be dead?’ that people would say, ‘I’d rather be dead,’ " she said in an interview. It’s not unreasonable that most people would probably say they would rather be dead than be severely incapacitated for the rest of their lives, she added.

However, after having a stroke, people often report that they are able to continue to live their lives reasonably happily despite often being quite disabled and having lost their independence.

The DESTINY II data show that people who had surgery were quite happy despite any disability, and this was at a similar level to those who were treated conservatively but with higher survival rates, Dr. Roffe noted.

The ethical implications of this could be considerable, she suggested. It shows that people who have living wills or who decide that they do not want treatment in the event of a stroke could live just as happy a life after the event as before. It therefore begs the question of whether patients should be allowed to decide on this aspect of their care, she added.

The German Research Foundation and the German Ministry of Science and Education financially supported the study. Dr. Hacke had no disclosures. Dr. Roffe was not involved in the study and had no relevant conflicts of interest.

SYDNEY, AUSTRALIA – Many Parkinson’s disease centers performing deep brain stimulation surgery are not using formal, standardized screening for impulse control disorders in pre- or postsurgical patients, according to a large survey of Parkinson Study Group centers.

Deep brain stimulation surgery is known to increase impulsivity, and standard practice is to identify and treat impulse control disorders in patients before surgery, according to lead author Dr. Nawaz Hack, a junior fellow in movement disorders at the University of Florida, Gainesville, and his colleagues.

"Surgery will improve their motor symptoms, but it may make their impulsivity worse, especially if you don’t screen and appropriately identify it," Dr. Hack said. "But if you catch it early through a standardized screening, you can address it."

The researchers surveyed 48 Parkinson Study Group centers, 97% of which performed deep brain stimulation surgery and 67% of which said they served a population of over 500 patients a year.

The results showed that only 23% of sites employed a formal battery of tests for impulsive and compulsive behavior and that 7% did not report screening for impulse control disorders.

Speaking at a poster session at the international congress of Parkinson’s Disease and Movement Disorders, Dr. Hack said that the majority of sites were employing a more ad-hoc approach to screening for impulse control disorders, using questions that were not necessarily standardized.

The survey found that 80% of responding centers used a neuropsychologist to screen for potential behavioral issues but only 32% used a psychiatrist, suggesting that most are focused on identifying the problem but do not necessarily have the facilities to manage and treat it.

There was also a wide variety of approaches taken to manage impulse control issues in presurgical patients.

Seventy-nine percent of patients with an impulse control disorder were treated with medication reduction, although there were 10 different strategies employed across centers, the survey’s authors reported.

"This is what happens in the centers that understand Parkinson’s disease – these are centers that are knowledgeable – so if we’re deficient there, what’s happening?" Dr. Hack said.

The concern was that patients whose impulsivity becomes exacerbated by surgery were more likely to be lost to follow up because of the potential financial consequences of their behavioral disorder.

"If you’re impulsive before, and you’re not treated or screened, you will be seriously impulsive after, so they’ll leave the operating room, they’ll go home, and they’ll start doing behaviors that are literally destroying their family, their lives, and their finances," Dr. Hack said.

However, he said that identifying patients with impulse control disorders could be difficult because patients were sometimes reluctant to volunteer information on behaviors that might indicate the presence of impulsivity, such as hypersexuality or problem gambling.

Nearly three-quarters of centers (72%) reported observing impulse control disorders among deep brain stimulation surgery patients, and 68% reported it in postoperative patients.

Most centers (79%) did not feel that the choice of brain target, whether subthalamic nucleus or globus pallidus, was influential in behavioral disorders.

Dr. Hack did not declare any financial conflicts of interest with the research.

SYDNEY, AUSTRALIA – Many Parkinson’s disease centers performing deep brain stimulation surgery are not using formal, standardized screening for impulse control disorders in pre- or postsurgical patients, according to a large survey of Parkinson Study Group centers.

Deep brain stimulation surgery is known to increase impulsivity, and standard practice is to identify and treat impulse control disorders in patients before surgery, according to lead author Dr. Nawaz Hack, a junior fellow in movement disorders at the University of Florida, Gainesville, and his colleagues.

"Surgery will improve their motor symptoms, but it may make their impulsivity worse, especially if you don’t screen and appropriately identify it," Dr. Hack said. "But if you catch it early through a standardized screening, you can address it."

The researchers surveyed 48 Parkinson Study Group centers, 97% of which performed deep brain stimulation surgery and 67% of which said they served a population of over 500 patients a year.

The results showed that only 23% of sites employed a formal battery of tests for impulsive and compulsive behavior and that 7% did not report screening for impulse control disorders.

Speaking at a poster session at the international congress of Parkinson’s Disease and Movement Disorders, Dr. Hack said that the majority of sites were employing a more ad-hoc approach to screening for impulse control disorders, using questions that were not necessarily standardized.

The survey found that 80% of responding centers used a neuropsychologist to screen for potential behavioral issues but only 32% used a psychiatrist, suggesting that most are focused on identifying the problem but do not necessarily have the facilities to manage and treat it.

There was also a wide variety of approaches taken to manage impulse control issues in presurgical patients.

Seventy-nine percent of patients with an impulse control disorder were treated with medication reduction, although there were 10 different strategies employed across centers, the survey’s authors reported.

"This is what happens in the centers that understand Parkinson’s disease – these are centers that are knowledgeable – so if we’re deficient there, what’s happening?" Dr. Hack said.

The concern was that patients whose impulsivity becomes exacerbated by surgery were more likely to be lost to follow up because of the potential financial consequences of their behavioral disorder.

"If you’re impulsive before, and you’re not treated or screened, you will be seriously impulsive after, so they’ll leave the operating room, they’ll go home, and they’ll start doing behaviors that are literally destroying their family, their lives, and their finances," Dr. Hack said.

However, he said that identifying patients with impulse control disorders could be difficult because patients were sometimes reluctant to volunteer information on behaviors that might indicate the presence of impulsivity, such as hypersexuality or problem gambling.

Nearly three-quarters of centers (72%) reported observing impulse control disorders among deep brain stimulation surgery patients, and 68% reported it in postoperative patients.

Most centers (79%) did not feel that the choice of brain target, whether subthalamic nucleus or globus pallidus, was influential in behavioral disorders.

Dr. Hack did not declare any financial conflicts of interest with the research.

SYDNEY, AUSTRALIA – Many Parkinson’s disease centers performing deep brain stimulation surgery are not using formal, standardized screening for impulse control disorders in pre- or postsurgical patients, according to a large survey of Parkinson Study Group centers.

Deep brain stimulation surgery is known to increase impulsivity, and standard practice is to identify and treat impulse control disorders in patients before surgery, according to lead author Dr. Nawaz Hack, a junior fellow in movement disorders at the University of Florida, Gainesville, and his colleagues.

"Surgery will improve their motor symptoms, but it may make their impulsivity worse, especially if you don’t screen and appropriately identify it," Dr. Hack said. "But if you catch it early through a standardized screening, you can address it."

The researchers surveyed 48 Parkinson Study Group centers, 97% of which performed deep brain stimulation surgery and 67% of which said they served a population of over 500 patients a year.

The results showed that only 23% of sites employed a formal battery of tests for impulsive and compulsive behavior and that 7% did not report screening for impulse control disorders.

Speaking at a poster session at the international congress of Parkinson’s Disease and Movement Disorders, Dr. Hack said that the majority of sites were employing a more ad-hoc approach to screening for impulse control disorders, using questions that were not necessarily standardized.

The survey found that 80% of responding centers used a neuropsychologist to screen for potential behavioral issues but only 32% used a psychiatrist, suggesting that most are focused on identifying the problem but do not necessarily have the facilities to manage and treat it.

There was also a wide variety of approaches taken to manage impulse control issues in presurgical patients.

Seventy-nine percent of patients with an impulse control disorder were treated with medication reduction, although there were 10 different strategies employed across centers, the survey’s authors reported.

"This is what happens in the centers that understand Parkinson’s disease – these are centers that are knowledgeable – so if we’re deficient there, what’s happening?" Dr. Hack said.

The concern was that patients whose impulsivity becomes exacerbated by surgery were more likely to be lost to follow up because of the potential financial consequences of their behavioral disorder.

"If you’re impulsive before, and you’re not treated or screened, you will be seriously impulsive after, so they’ll leave the operating room, they’ll go home, and they’ll start doing behaviors that are literally destroying their family, their lives, and their finances," Dr. Hack said.

However, he said that identifying patients with impulse control disorders could be difficult because patients were sometimes reluctant to volunteer information on behaviors that might indicate the presence of impulsivity, such as hypersexuality or problem gambling.

Nearly three-quarters of centers (72%) reported observing impulse control disorders among deep brain stimulation surgery patients, and 68% reported it in postoperative patients.

Most centers (79%) did not feel that the choice of brain target, whether subthalamic nucleus or globus pallidus, was influential in behavioral disorders.

Dr. Hack did not declare any financial conflicts of interest with the research.

"When can I go back to play, doc?" is a question you’ll hear often when treating athletes with concussions. For many of them, the answer would be in 7-10 days, but for more moderate or severe cases, that could go up to a month or more. It all depends on the athlete and his or her concussion history. However, there are some general guidelines to follow to determine when an athlete is ready to get back on the field.

First of all, athletes should not be allowed to return to play in the current game or practice in which they were injured. From there, they should be medically managed and given adequate physical and cognitive rest until they are asymptomatic.

This means that all symptoms have resolved, the neurologic examination is normal and their cognitive function has returned to baseline, if this was established prior to injury. They also should not be on any medications for concussion, that is, they should not be popping acetaminophen for headaches.

Another way to determine if the athlete is ready to get back in the game is by using the graded return-to-play protocol.

Typically, athletes move up the stages one level a day, although that is not necessary. You can certainly accelerate the process depending on the sport and the athlete. Those who are in noncontact sports like swimming can probably go through the levels quicker than someone who plays soccer.

I would suggest documenting how the athlete is doing throughout the process so everyone has a record of the athlete’s progress. I don’t think you can ever overdocument, and it’s a good habit to get into.

Along with the protocol, there’s also a computerized neuropsychological testing tool that’s fairly short and really focuses on what functions are affected. People tend to rely on this tool but you have to keep in mind that this is only one tool and should not be used alone.

Tools cannot replace a thorough cognitive evaluation. Just as there are no tests that can diagnose a concussion, there’s no tool that’ll say the athlete is ok to return to play. Ultimately, it is up to you to make that call, but the evaluation tools should certainly be used to help.

Dr. Barry Jordan is the director of the brain injury program and the memory evaluation treatment service at Burke Rehabilitation Hospital in White Plains, N.Y. He currently serves as the chief medical officer of the New York State Athletic Commission, a team physician for U.S.A. Boxing, and as a member of the NFL Players Association Mackey-White Traumatic Brain Injury Committee and the NFL Neuro-Cognitive Disability Committee.

"When can I go back to play, doc?" is a question you’ll hear often when treating athletes with concussions. For many of them, the answer would be in 7-10 days, but for more moderate or severe cases, that could go up to a month or more. It all depends on the athlete and his or her concussion history. However, there are some general guidelines to follow to determine when an athlete is ready to get back on the field.

First of all, athletes should not be allowed to return to play in the current game or practice in which they were injured. From there, they should be medically managed and given adequate physical and cognitive rest until they are asymptomatic.

This means that all symptoms have resolved, the neurologic examination is normal and their cognitive function has returned to baseline, if this was established prior to injury. They also should not be on any medications for concussion, that is, they should not be popping acetaminophen for headaches.

Another way to determine if the athlete is ready to get back in the game is by using the graded return-to-play protocol.

Typically, athletes move up the stages one level a day, although that is not necessary. You can certainly accelerate the process depending on the sport and the athlete. Those who are in noncontact sports like swimming can probably go through the levels quicker than someone who plays soccer.

I would suggest documenting how the athlete is doing throughout the process so everyone has a record of the athlete’s progress. I don’t think you can ever overdocument, and it’s a good habit to get into.

Along with the protocol, there’s also a computerized neuropsychological testing tool that’s fairly short and really focuses on what functions are affected. People tend to rely on this tool but you have to keep in mind that this is only one tool and should not be used alone.

Tools cannot replace a thorough cognitive evaluation. Just as there are no tests that can diagnose a concussion, there’s no tool that’ll say the athlete is ok to return to play. Ultimately, it is up to you to make that call, but the evaluation tools should certainly be used to help.

Dr. Barry Jordan is the director of the brain injury program and the memory evaluation treatment service at Burke Rehabilitation Hospital in White Plains, N.Y. He currently serves as the chief medical officer of the New York State Athletic Commission, a team physician for U.S.A. Boxing, and as a member of the NFL Players Association Mackey-White Traumatic Brain Injury Committee and the NFL Neuro-Cognitive Disability Committee.

"When can I go back to play, doc?" is a question you’ll hear often when treating athletes with concussions. For many of them, the answer would be in 7-10 days, but for more moderate or severe cases, that could go up to a month or more. It all depends on the athlete and his or her concussion history. However, there are some general guidelines to follow to determine when an athlete is ready to get back on the field.

First of all, athletes should not be allowed to return to play in the current game or practice in which they were injured. From there, they should be medically managed and given adequate physical and cognitive rest until they are asymptomatic.

This means that all symptoms have resolved, the neurologic examination is normal and their cognitive function has returned to baseline, if this was established prior to injury. They also should not be on any medications for concussion, that is, they should not be popping acetaminophen for headaches.

Another way to determine if the athlete is ready to get back in the game is by using the graded return-to-play protocol.

Typically, athletes move up the stages one level a day, although that is not necessary. You can certainly accelerate the process depending on the sport and the athlete. Those who are in noncontact sports like swimming can probably go through the levels quicker than someone who plays soccer.

I would suggest documenting how the athlete is doing throughout the process so everyone has a record of the athlete’s progress. I don’t think you can ever overdocument, and it’s a good habit to get into.

Along with the protocol, there’s also a computerized neuropsychological testing tool that’s fairly short and really focuses on what functions are affected. People tend to rely on this tool but you have to keep in mind that this is only one tool and should not be used alone.

Tools cannot replace a thorough cognitive evaluation. Just as there are no tests that can diagnose a concussion, there’s no tool that’ll say the athlete is ok to return to play. Ultimately, it is up to you to make that call, but the evaluation tools should certainly be used to help.

Dr. Barry Jordan is the director of the brain injury program and the memory evaluation treatment service at Burke Rehabilitation Hospital in White Plains, N.Y. He currently serves as the chief medical officer of the New York State Athletic Commission, a team physician for U.S.A. Boxing, and as a member of the NFL Players Association Mackey-White Traumatic Brain Injury Committee and the NFL Neuro-Cognitive Disability Committee.

INDIANAPOLIS – The nation’s elite surgical educators are up in arms over reported widespread deficiencies in the skill set and judgment of recent graduates of 5-year general surgery residencies.

Many trainees arrive at surgical subspecialty fellowships unprepared in their basic skills, according to a detailed new survey of the nation’s subspecialty fellowship program directors. The underlying theme of the responses is that many fellows are pursuing fellowship positions to make up for inadequacies in their general surgery residency rather than to push their skills to the next level, according to Dr. Samer Mattar.

Courtesy Dr. Samer Mattar

About 80% of graduating general surgery residents now seek fellowships to obtain advanced training in bariatric, colorectal, thoracic, hepatobiliary, or other surgical specialty areas.

"Many new fellows must gain basic and fundamental skills at the beginning of their fellowship before they can commence to benefit from the advanced skills that they originally came to obtain. The current high demand for fellowship training and the lack of readiness upon completion of general surgery residencies should be a call to action for all stakeholders in surgical training," Dr. Mattar said in presenting the survey results at the annual meeting of the American Surgical Association.

Constructive changes are afoot, according to Dr. Mattar of Indiana University, Indianapolis. Plans are well underway to change the fourth year of medical school so that students interested in a career in surgery can begin preparing for it. And there are also efforts to custom tailor the final year of general surgery residency so residents can focus on their planned fellowship year. Toward that end, the Fellowship Council has moved the fellowship match date up to June so residents who know they are fellowship-bound can put their fifth year to the best use.

The survey was conducted by the Fellowship Council, an umbrella organization in charge of standardizing curricula, accrediting programs, and matching residents to fellowships. The group distributed the surveys to all 145 subspecialty fellowship program directors and drew a 63% response rate. That’s considered high for such a lengthy survey, said Dr. Mattar, and is an indication of the importance educators place on the subject.

The survey assessed five key educational domains: professionalism, independent practice, psychomotor skills, expertise in their chosen disease state, and scholarly focus.

"Incoming fellows exhibited high levels of professionalism, but there were deficiencies in autonomy and independence, psychomotor abilities, and – most profoundly – in academics and scholarship," Dr. Mattar said.

Among the key survey findings:

• Incoming fellows were unable to independently perform half an hour of a major procedure, according to 43% of program directors.

• Of incoming fellows, 30% couldn’t independently perform basic operations such as laparoscopic cholecystectomy.

• Of incoming fellows, 56% were able to laparoscopically suture and tie knots properly; 26% couldn’t recognize anatomic planes through the laparoscope.

• One-quarter was deemed unable to recognize early signs of complications.

In other findings, nearly 40% of program directors said new fellows display a lack of "patient ownership." "We promote patient ownership in our programs. We are somewhat disappointed and dismayed that the fellows feel that the patient is part of a service and not their own," Dr. Mattar commented. Half of the program directors indicated their incoming fellows demonstrated independence in the operating room and on call, although they reported the fellows showed marked improvement in these areas as the year went on.

A large majority of program directors felt their fellows were disinterested in research and in advancing the field, even though, as Dr. Mattar noted, "This is a mandate in our curriculum."

He reported having no financial conflicts.

[email protected]

INDIANAPOLIS – The nation’s elite surgical educators are up in arms over reported widespread deficiencies in the skill set and judgment of recent graduates of 5-year general surgery residencies.

Many trainees arrive at surgical subspecialty fellowships unprepared in their basic skills, according to a detailed new survey of the nation’s subspecialty fellowship program directors. The underlying theme of the responses is that many fellows are pursuing fellowship positions to make up for inadequacies in their general surgery residency rather than to push their skills to the next level, according to Dr. Samer Mattar.

Courtesy Dr. Samer Mattar

About 80% of graduating general surgery residents now seek fellowships to obtain advanced training in bariatric, colorectal, thoracic, hepatobiliary, or other surgical specialty areas.

"Many new fellows must gain basic and fundamental skills at the beginning of their fellowship before they can commence to benefit from the advanced skills that they originally came to obtain. The current high demand for fellowship training and the lack of readiness upon completion of general surgery residencies should be a call to action for all stakeholders in surgical training," Dr. Mattar said in presenting the survey results at the annual meeting of the American Surgical Association.

Constructive changes are afoot, according to Dr. Mattar of Indiana University, Indianapolis. Plans are well underway to change the fourth year of medical school so that students interested in a career in surgery can begin preparing for it. And there are also efforts to custom tailor the final year of general surgery residency so residents can focus on their planned fellowship year. Toward that end, the Fellowship Council has moved the fellowship match date up to June so residents who know they are fellowship-bound can put their fifth year to the best use.

The survey was conducted by the Fellowship Council, an umbrella organization in charge of standardizing curricula, accrediting programs, and matching residents to fellowships. The group distributed the surveys to all 145 subspecialty fellowship program directors and drew a 63% response rate. That’s considered high for such a lengthy survey, said Dr. Mattar, and is an indication of the importance educators place on the subject.

The survey assessed five key educational domains: professionalism, independent practice, psychomotor skills, expertise in their chosen disease state, and scholarly focus.

"Incoming fellows exhibited high levels of professionalism, but there were deficiencies in autonomy and independence, psychomotor abilities, and – most profoundly – in academics and scholarship," Dr. Mattar said.

Among the key survey findings:

• Incoming fellows were unable to independently perform half an hour of a major procedure, according to 43% of program directors.

• Of incoming fellows, 30% couldn’t independently perform basic operations such as laparoscopic cholecystectomy.

• Of incoming fellows, 56% were able to laparoscopically suture and tie knots properly; 26% couldn’t recognize anatomic planes through the laparoscope.

• One-quarter was deemed unable to recognize early signs of complications.

In other findings, nearly 40% of program directors said new fellows display a lack of "patient ownership." "We promote patient ownership in our programs. We are somewhat disappointed and dismayed that the fellows feel that the patient is part of a service and not their own," Dr. Mattar commented. Half of the program directors indicated their incoming fellows demonstrated independence in the operating room and on call, although they reported the fellows showed marked improvement in these areas as the year went on.

A large majority of program directors felt their fellows were disinterested in research and in advancing the field, even though, as Dr. Mattar noted, "This is a mandate in our curriculum."

He reported having no financial conflicts.

[email protected]

INDIANAPOLIS – The nation’s elite surgical educators are up in arms over reported widespread deficiencies in the skill set and judgment of recent graduates of 5-year general surgery residencies.

Many trainees arrive at surgical subspecialty fellowships unprepared in their basic skills, according to a detailed new survey of the nation’s subspecialty fellowship program directors. The underlying theme of the responses is that many fellows are pursuing fellowship positions to make up for inadequacies in their general surgery residency rather than to push their skills to the next level, according to Dr. Samer Mattar.

Courtesy Dr. Samer Mattar

About 80% of graduating general surgery residents now seek fellowships to obtain advanced training in bariatric, colorectal, thoracic, hepatobiliary, or other surgical specialty areas.

"Many new fellows must gain basic and fundamental skills at the beginning of their fellowship before they can commence to benefit from the advanced skills that they originally came to obtain. The current high demand for fellowship training and the lack of readiness upon completion of general surgery residencies should be a call to action for all stakeholders in surgical training," Dr. Mattar said in presenting the survey results at the annual meeting of the American Surgical Association.

Constructive changes are afoot, according to Dr. Mattar of Indiana University, Indianapolis. Plans are well underway to change the fourth year of medical school so that students interested in a career in surgery can begin preparing for it. And there are also efforts to custom tailor the final year of general surgery residency so residents can focus on their planned fellowship year. Toward that end, the Fellowship Council has moved the fellowship match date up to June so residents who know they are fellowship-bound can put their fifth year to the best use.

The survey was conducted by the Fellowship Council, an umbrella organization in charge of standardizing curricula, accrediting programs, and matching residents to fellowships. The group distributed the surveys to all 145 subspecialty fellowship program directors and drew a 63% response rate. That’s considered high for such a lengthy survey, said Dr. Mattar, and is an indication of the importance educators place on the subject.

The survey assessed five key educational domains: professionalism, independent practice, psychomotor skills, expertise in their chosen disease state, and scholarly focus.

"Incoming fellows exhibited high levels of professionalism, but there were deficiencies in autonomy and independence, psychomotor abilities, and – most profoundly – in academics and scholarship," Dr. Mattar said.

Among the key survey findings:

• Incoming fellows were unable to independently perform half an hour of a major procedure, according to 43% of program directors.

• Of incoming fellows, 30% couldn’t independently perform basic operations such as laparoscopic cholecystectomy.

• Of incoming fellows, 56% were able to laparoscopically suture and tie knots properly; 26% couldn’t recognize anatomic planes through the laparoscope.

• One-quarter was deemed unable to recognize early signs of complications.

In other findings, nearly 40% of program directors said new fellows display a lack of "patient ownership." "We promote patient ownership in our programs. We are somewhat disappointed and dismayed that the fellows feel that the patient is part of a service and not their own," Dr. Mattar commented. Half of the program directors indicated their incoming fellows demonstrated independence in the operating room and on call, although they reported the fellows showed marked improvement in these areas as the year went on.

A large majority of program directors felt their fellows were disinterested in research and in advancing the field, even though, as Dr. Mattar noted, "This is a mandate in our curriculum."

He reported having no financial conflicts.

[email protected]

BETHESDA, MD. – Surgery is curative in half of patients with refractory temporal lobe epilepsy, yet it is still highly underused – in part because of misperceptions about the risks and benefits, according to Dr. Edward F. Chang.

Dr. Chang, assistant professor of neurological surgery and physiology at the University of California, San Francisco, said that numerous studies have shown that 60%-70% of patients are free of seizures 1 year after surgery and that at least half have seizure freedom over the long term. Also, there are "well-documented quality of life improvements," he said at the meeting sponsored by the National Institute of Neurological Disorders and Stroke.

Sixty percent of people with epilepsy have focal seizures, and the temporal lobe form is the most common type of epilepsy that is characterized by focal seizures, according to NINDS. The Epilepsy Foundation estimates that there are at least 200,000 new cases of epilepsy (any type) in the United States each year.

Based on the totality of the evidence, in 2003 the American Academy of Neurology, the American Epilepsy Society, and the American Association of Neurological Surgeons jointly published a guideline statement (Neurology 2003;60:538-47), urging referral of refractory patients for surgery.

But physicians are still not heeding that guidance, said Dr. Chang. His own survey of clinicians (Neurology 2012;78:1200-6) showed that there had been no increase in surgery in a 5-year period after the joint recommendation. Dr. Chang characterized that as "very depressing in terms of how we are using evidence," especially since there has been an increasing burden of epilepsy. In some cases, patients have lived with epilepsy for 20-30 years before being referred for surgery, he said.

Surgery is safe and effective and the side effects are predictable, he noted, adding that the number needed to treat for one patient with refractory temporal lobe epilepsy to become free of disabling seizures is only two – a number that parallels the use of antibiotics for pneumonia.

"We are below the standard of care," Dr. Chang said. Clinicians and patients shy away from surgery because "of the idea that brain surgery is too dangerous," he said. And physicians don’t understand the data. Drug and device makers also are "spending millions of dollars a year telling patients there are other options," he said, but if "we address this basic utilization problem we’d see an immediate and substantial reduction ... in the burden of epilepsy worldwide."

There have been several advances in surgical technique in the last few years that might make neurologists and patients – who might be spooked by looking at photos and videos of temporal lobe surgery on the Internet – more comfortable. For instance, there are transcortical approaches, which use a small incision to go through the white matter to the hippocampus. With the subtemporal approach, "you don’t have to go through any lateral cortex at all," he noted.

"Even for relatively large lesions that are quite deep in the brain we can actually do these minimally invasive approaches by just going underneath the lateral temporal cortex and selectively removing the hippocampus," Dr. Chang said.

On the horizon, there are nonsurgical minimally invasive techniques under development that have the potential to yield outcomes similar to surgery, he added. NINDS is funding a pivotal trial of stereotactic radiosurgery. The device selectively delivers radiation to the hippocampus and mesial lobe and spares the lateral temporal areas en route. Overall, it is fairly safe, but some patients have severe swelling as long as a year after the procedure and most have no effect for at least a year.

Another approach under study is using MRI to guide laser thermoablation. "A lot of us are quite excited about this," Dr. Chang said. The MRI allows the clinician to accurately place the laser and study how much the tissue is heated, which can help researchers determine whether there is damage and if it might be irreversible.

Finally, there is MRI-guided focused ultrasound, which uses the same principles as radiosurgery to target structures deep in the brain, he said. The procedure is currently in phase III trials for essential tremor.

There is, however, "a lot of irrational exuberance with these technologies," he pointed out.

It is not clear how to validate them, especially since clinicians are currently struggling with how to validate different surgical approaches. A big issue for the surgery trials is that it is difficult to recruit patients. Many have said that they don’t want to participate because they don’t want to be randomized.

Researchers also are trying to better understand epileptogenesis and how to reduce procedural side effects, including how to predict effects on cognitive function. To get there, "we need to understand more about how human cognition works," Dr. Chang said. Brain-mapping studies are showing that most aspects of cognition are not centered in one specific, focused area.

"Just like we’re thinking now that seizures are part of a distributed network, we also need to understand comorbidities and morbidity from surgical approaches in the same kind of framework," he said.

Until surgery is better used and studied, it is unlikely that neurology can move forward to truly understand the safety and effectiveness of the minimally invasive approaches, Dr. Chang said.

Dr. Chang has received grants from the National Institutes of Health and the Esther A. and Joseph Klingenstein Fund.

[email protected]

On Twitter @aliciaault

BETHESDA, MD. – Surgery is curative in half of patients with refractory temporal lobe epilepsy, yet it is still highly underused – in part because of misperceptions about the risks and benefits, according to Dr. Edward F. Chang.

Dr. Chang, assistant professor of neurological surgery and physiology at the University of California, San Francisco, said that numerous studies have shown that 60%-70% of patients are free of seizures 1 year after surgery and that at least half have seizure freedom over the long term. Also, there are "well-documented quality of life improvements," he said at the meeting sponsored by the National Institute of Neurological Disorders and Stroke.

Sixty percent of people with epilepsy have focal seizures, and the temporal lobe form is the most common type of epilepsy that is characterized by focal seizures, according to NINDS. The Epilepsy Foundation estimates that there are at least 200,000 new cases of epilepsy (any type) in the United States each year.

Based on the totality of the evidence, in 2003 the American Academy of Neurology, the American Epilepsy Society, and the American Association of Neurological Surgeons jointly published a guideline statement (Neurology 2003;60:538-47), urging referral of refractory patients for surgery.

But physicians are still not heeding that guidance, said Dr. Chang. His own survey of clinicians (Neurology 2012;78:1200-6) showed that there had been no increase in surgery in a 5-year period after the joint recommendation. Dr. Chang characterized that as "very depressing in terms of how we are using evidence," especially since there has been an increasing burden of epilepsy. In some cases, patients have lived with epilepsy for 20-30 years before being referred for surgery, he said.

Surgery is safe and effective and the side effects are predictable, he noted, adding that the number needed to treat for one patient with refractory temporal lobe epilepsy to become free of disabling seizures is only two – a number that parallels the use of antibiotics for pneumonia.

"We are below the standard of care," Dr. Chang said. Clinicians and patients shy away from surgery because "of the idea that brain surgery is too dangerous," he said. And physicians don’t understand the data. Drug and device makers also are "spending millions of dollars a year telling patients there are other options," he said, but if "we address this basic utilization problem we’d see an immediate and substantial reduction ... in the burden of epilepsy worldwide."

There have been several advances in surgical technique in the last few years that might make neurologists and patients – who might be spooked by looking at photos and videos of temporal lobe surgery on the Internet – more comfortable. For instance, there are transcortical approaches, which use a small incision to go through the white matter to the hippocampus. With the subtemporal approach, "you don’t have to go through any lateral cortex at all," he noted.

"Even for relatively large lesions that are quite deep in the brain we can actually do these minimally invasive approaches by just going underneath the lateral temporal cortex and selectively removing the hippocampus," Dr. Chang said.

On the horizon, there are nonsurgical minimally invasive techniques under development that have the potential to yield outcomes similar to surgery, he added. NINDS is funding a pivotal trial of stereotactic radiosurgery. The device selectively delivers radiation to the hippocampus and mesial lobe and spares the lateral temporal areas en route. Overall, it is fairly safe, but some patients have severe swelling as long as a year after the procedure and most have no effect for at least a year.

Another approach under study is using MRI to guide laser thermoablation. "A lot of us are quite excited about this," Dr. Chang said. The MRI allows the clinician to accurately place the laser and study how much the tissue is heated, which can help researchers determine whether there is damage and if it might be irreversible.

Finally, there is MRI-guided focused ultrasound, which uses the same principles as radiosurgery to target structures deep in the brain, he said. The procedure is currently in phase III trials for essential tremor.

There is, however, "a lot of irrational exuberance with these technologies," he pointed out.

It is not clear how to validate them, especially since clinicians are currently struggling with how to validate different surgical approaches. A big issue for the surgery trials is that it is difficult to recruit patients. Many have said that they don’t want to participate because they don’t want to be randomized.

Researchers also are trying to better understand epileptogenesis and how to reduce procedural side effects, including how to predict effects on cognitive function. To get there, "we need to understand more about how human cognition works," Dr. Chang said. Brain-mapping studies are showing that most aspects of cognition are not centered in one specific, focused area.

"Just like we’re thinking now that seizures are part of a distributed network, we also need to understand comorbidities and morbidity from surgical approaches in the same kind of framework," he said.

Until surgery is better used and studied, it is unlikely that neurology can move forward to truly understand the safety and effectiveness of the minimally invasive approaches, Dr. Chang said.

Dr. Chang has received grants from the National Institutes of Health and the Esther A. and Joseph Klingenstein Fund.

[email protected]

On Twitter @aliciaault

BETHESDA, MD. – Surgery is curative in half of patients with refractory temporal lobe epilepsy, yet it is still highly underused – in part because of misperceptions about the risks and benefits, according to Dr. Edward F. Chang.

Dr. Chang, assistant professor of neurological surgery and physiology at the University of California, San Francisco, said that numerous studies have shown that 60%-70% of patients are free of seizures 1 year after surgery and that at least half have seizure freedom over the long term. Also, there are "well-documented quality of life improvements," he said at the meeting sponsored by the National Institute of Neurological Disorders and Stroke.

Sixty percent of people with epilepsy have focal seizures, and the temporal lobe form is the most common type of epilepsy that is characterized by focal seizures, according to NINDS. The Epilepsy Foundation estimates that there are at least 200,000 new cases of epilepsy (any type) in the United States each year.

Based on the totality of the evidence, in 2003 the American Academy of Neurology, the American Epilepsy Society, and the American Association of Neurological Surgeons jointly published a guideline statement (Neurology 2003;60:538-47), urging referral of refractory patients for surgery.

But physicians are still not heeding that guidance, said Dr. Chang. His own survey of clinicians (Neurology 2012;78:1200-6) showed that there had been no increase in surgery in a 5-year period after the joint recommendation. Dr. Chang characterized that as "very depressing in terms of how we are using evidence," especially since there has been an increasing burden of epilepsy. In some cases, patients have lived with epilepsy for 20-30 years before being referred for surgery, he said.

Surgery is safe and effective and the side effects are predictable, he noted, adding that the number needed to treat for one patient with refractory temporal lobe epilepsy to become free of disabling seizures is only two – a number that parallels the use of antibiotics for pneumonia.

"We are below the standard of care," Dr. Chang said. Clinicians and patients shy away from surgery because "of the idea that brain surgery is too dangerous," he said. And physicians don’t understand the data. Drug and device makers also are "spending millions of dollars a year telling patients there are other options," he said, but if "we address this basic utilization problem we’d see an immediate and substantial reduction ... in the burden of epilepsy worldwide."

There have been several advances in surgical technique in the last few years that might make neurologists and patients – who might be spooked by looking at photos and videos of temporal lobe surgery on the Internet – more comfortable. For instance, there are transcortical approaches, which use a small incision to go through the white matter to the hippocampus. With the subtemporal approach, "you don’t have to go through any lateral cortex at all," he noted.

"Even for relatively large lesions that are quite deep in the brain we can actually do these minimally invasive approaches by just going underneath the lateral temporal cortex and selectively removing the hippocampus," Dr. Chang said.

On the horizon, there are nonsurgical minimally invasive techniques under development that have the potential to yield outcomes similar to surgery, he added. NINDS is funding a pivotal trial of stereotactic radiosurgery. The device selectively delivers radiation to the hippocampus and mesial lobe and spares the lateral temporal areas en route. Overall, it is fairly safe, but some patients have severe swelling as long as a year after the procedure and most have no effect for at least a year.

Another approach under study is using MRI to guide laser thermoablation. "A lot of us are quite excited about this," Dr. Chang said. The MRI allows the clinician to accurately place the laser and study how much the tissue is heated, which can help researchers determine whether there is damage and if it might be irreversible.

Finally, there is MRI-guided focused ultrasound, which uses the same principles as radiosurgery to target structures deep in the brain, he said. The procedure is currently in phase III trials for essential tremor.

There is, however, "a lot of irrational exuberance with these technologies," he pointed out.

It is not clear how to validate them, especially since clinicians are currently struggling with how to validate different surgical approaches. A big issue for the surgery trials is that it is difficult to recruit patients. Many have said that they don’t want to participate because they don’t want to be randomized.

Researchers also are trying to better understand epileptogenesis and how to reduce procedural side effects, including how to predict effects on cognitive function. To get there, "we need to understand more about how human cognition works," Dr. Chang said. Brain-mapping studies are showing that most aspects of cognition are not centered in one specific, focused area.

"Just like we’re thinking now that seizures are part of a distributed network, we also need to understand comorbidities and morbidity from surgical approaches in the same kind of framework," he said.

Until surgery is better used and studied, it is unlikely that neurology can move forward to truly understand the safety and effectiveness of the minimally invasive approaches, Dr. Chang said.

Dr. Chang has received grants from the National Institutes of Health and the Esther A. and Joseph Klingenstein Fund.

[email protected]

On Twitter @aliciaault

SAN DIEGO – Tube-shaped linear lesions seen on advanced MRI in people admitted to the emergency department for head injuries may not be diffuse axonal injury but rather evidence of bleeding due to mild traumatic brain injury, judging from preliminary results of a novel study.

"Not everything that we’re calling diffuse axonal injury is diffuse axonal injury," Dr. Gunjan Y. Parikh said in an interview during a poster session at the annual meeting of the American Academy of Neurology. "There may be, in fact, evidence under our noses of vascular injury. This has implications, and those patients should be followed very closely. If we can pinpoint that they’re a vascular injury in the acute setting, there are a lot of therapies [we can use] that target the vasculature."

Doug Brunk/IMNG Medical Media

Between October 2010 and October 2012 Dr. Parikh, a neuroimaging fellow at the National Institute of Neurological Disorders and Stroke, and his associates prospectively evaluated 256 patients enrolled in the Traumatic Head Injury Neuroimaging Classification (THINC) study who were admitted to the emergency department at Suburban Hospital in Bethesda, Md., and Washington (D.C.) Hospital Center after mild head injuries.

Administered by the Center for Neuroscience and Regenerative Medicine at Uniformed Services University in Bethesda, the THINC study protocol includes taking an MRI in subjects within 48 hours of presenting with acute head injury, with or without a positive diagnosis of concussion, and at up to three follow-up visits at 4, 30, and 90 days. The protocol includes T2-weighted MRI, fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and three-dimensional tracking imaging (3-DTI).

The average age of the 256 patients was 50 years. Of these, 104 (41%) had imaging evidence of hemorrhage in the brain (67% reported loss of consciousness and 65% reported amnesia). These 104 patients underwent more detailed brain scans with advanced MRI within an average of 17 hours after the injury. This advanced imaging demonstrated that 20% of the 104 patients had microbleed lesions and 33% had tube-shaped linear lesions suggestive of vascular injury. Microbleeds were distributed throughout the brain, whereas linear lesions, which were found primarily in the anterior corona radiata, were more likely to be associated with injury to adjacent brain tissue.

"I was surprised that one-third of patients are having this linear type of lesion that we may think is vascular injury, and the majority of them – 91% – met the Glasgow Coma Scale criteria for mild TBI," Dr. Parikh commented. "These are patients who are usually sent home [after initial emergency department presentation]. I was also surprised to see so much evidence on other MRI sequences, proving that there is evidence of associated infarct or ischemia."

This type of analysis has not been done previously because "the logistical hurdles to imaging patients after any type of brain injury are so dramatic that it’s difficult to do this type of study," he said, emphasizing the preliminary nature of the work. "It was able to be done because of a unique collaboration between the National Institutes of Health (NIH) and the Department of Defense. If it weren’t for this collaboration, this would not have happened."

He noted that histopathological studies are "an important next step" to confirm the connection between the imaging markers and the pathology.

The study was supported by the NIH, the National Institute of Neurological Disorders and Stroke, and the Center for Neuroscience and Regenerative Medicine, a collaborative effort among the NIH, the Department of Defense, and Walter Reed National Military Medical Center, Bethesda. Dr. Parikh reported having no financial disclosures.

SAN DIEGO – Tube-shaped linear lesions seen on advanced MRI in people admitted to the emergency department for head injuries may not be diffuse axonal injury but rather evidence of bleeding due to mild traumatic brain injury, judging from preliminary results of a novel study.

"Not everything that we’re calling diffuse axonal injury is diffuse axonal injury," Dr. Gunjan Y. Parikh said in an interview during a poster session at the annual meeting of the American Academy of Neurology. "There may be, in fact, evidence under our noses of vascular injury. This has implications, and those patients should be followed very closely. If we can pinpoint that they’re a vascular injury in the acute setting, there are a lot of therapies [we can use] that target the vasculature."

Doug Brunk/IMNG Medical Media

Between October 2010 and October 2012 Dr. Parikh, a neuroimaging fellow at the National Institute of Neurological Disorders and Stroke, and his associates prospectively evaluated 256 patients enrolled in the Traumatic Head Injury Neuroimaging Classification (THINC) study who were admitted to the emergency department at Suburban Hospital in Bethesda, Md., and Washington (D.C.) Hospital Center after mild head injuries.

Administered by the Center for Neuroscience and Regenerative Medicine at Uniformed Services University in Bethesda, the THINC study protocol includes taking an MRI in subjects within 48 hours of presenting with acute head injury, with or without a positive diagnosis of concussion, and at up to three follow-up visits at 4, 30, and 90 days. The protocol includes T2-weighted MRI, fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and three-dimensional tracking imaging (3-DTI).

The average age of the 256 patients was 50 years. Of these, 104 (41%) had imaging evidence of hemorrhage in the brain (67% reported loss of consciousness and 65% reported amnesia). These 104 patients underwent more detailed brain scans with advanced MRI within an average of 17 hours after the injury. This advanced imaging demonstrated that 20% of the 104 patients had microbleed lesions and 33% had tube-shaped linear lesions suggestive of vascular injury. Microbleeds were distributed throughout the brain, whereas linear lesions, which were found primarily in the anterior corona radiata, were more likely to be associated with injury to adjacent brain tissue.

"I was surprised that one-third of patients are having this linear type of lesion that we may think is vascular injury, and the majority of them – 91% – met the Glasgow Coma Scale criteria for mild TBI," Dr. Parikh commented. "These are patients who are usually sent home [after initial emergency department presentation]. I was also surprised to see so much evidence on other MRI sequences, proving that there is evidence of associated infarct or ischemia."

This type of analysis has not been done previously because "the logistical hurdles to imaging patients after any type of brain injury are so dramatic that it’s difficult to do this type of study," he said, emphasizing the preliminary nature of the work. "It was able to be done because of a unique collaboration between the National Institutes of Health (NIH) and the Department of Defense. If it weren’t for this collaboration, this would not have happened."

He noted that histopathological studies are "an important next step" to confirm the connection between the imaging markers and the pathology.

The study was supported by the NIH, the National Institute of Neurological Disorders and Stroke, and the Center for Neuroscience and Regenerative Medicine, a collaborative effort among the NIH, the Department of Defense, and Walter Reed National Military Medical Center, Bethesda. Dr. Parikh reported having no financial disclosures.

SAN DIEGO – Tube-shaped linear lesions seen on advanced MRI in people admitted to the emergency department for head injuries may not be diffuse axonal injury but rather evidence of bleeding due to mild traumatic brain injury, judging from preliminary results of a novel study.

"Not everything that we’re calling diffuse axonal injury is diffuse axonal injury," Dr. Gunjan Y. Parikh said in an interview during a poster session at the annual meeting of the American Academy of Neurology. "There may be, in fact, evidence under our noses of vascular injury. This has implications, and those patients should be followed very closely. If we can pinpoint that they’re a vascular injury in the acute setting, there are a lot of therapies [we can use] that target the vasculature."

Doug Brunk/IMNG Medical Media

Between October 2010 and October 2012 Dr. Parikh, a neuroimaging fellow at the National Institute of Neurological Disorders and Stroke, and his associates prospectively evaluated 256 patients enrolled in the Traumatic Head Injury Neuroimaging Classification (THINC) study who were admitted to the emergency department at Suburban Hospital in Bethesda, Md., and Washington (D.C.) Hospital Center after mild head injuries.

Administered by the Center for Neuroscience and Regenerative Medicine at Uniformed Services University in Bethesda, the THINC study protocol includes taking an MRI in subjects within 48 hours of presenting with acute head injury, with or without a positive diagnosis of concussion, and at up to three follow-up visits at 4, 30, and 90 days. The protocol includes T2-weighted MRI, fluid-attenuated inversion recovery (FLAIR), diffusion-weighted imaging (DWI), and three-dimensional tracking imaging (3-DTI).

The average age of the 256 patients was 50 years. Of these, 104 (41%) had imaging evidence of hemorrhage in the brain (67% reported loss of consciousness and 65% reported amnesia). These 104 patients underwent more detailed brain scans with advanced MRI within an average of 17 hours after the injury. This advanced imaging demonstrated that 20% of the 104 patients had microbleed lesions and 33% had tube-shaped linear lesions suggestive of vascular injury. Microbleeds were distributed throughout the brain, whereas linear lesions, which were found primarily in the anterior corona radiata, were more likely to be associated with injury to adjacent brain tissue.

"I was surprised that one-third of patients are having this linear type of lesion that we may think is vascular injury, and the majority of them – 91% – met the Glasgow Coma Scale criteria for mild TBI," Dr. Parikh commented. "These are patients who are usually sent home [after initial emergency department presentation]. I was also surprised to see so much evidence on other MRI sequences, proving that there is evidence of associated infarct or ischemia."

This type of analysis has not been done previously because "the logistical hurdles to imaging patients after any type of brain injury are so dramatic that it’s difficult to do this type of study," he said, emphasizing the preliminary nature of the work. "It was able to be done because of a unique collaboration between the National Institutes of Health (NIH) and the Department of Defense. If it weren’t for this collaboration, this would not have happened."

He noted that histopathological studies are "an important next step" to confirm the connection between the imaging markers and the pathology.

The study was supported by the NIH, the National Institute of Neurological Disorders and Stroke, and the Center for Neuroscience and Regenerative Medicine, a collaborative effort among the NIH, the Department of Defense, and Walter Reed National Military Medical Center, Bethesda. Dr. Parikh reported having no financial disclosures.