Neurosurgical residency adaptations for the residency application cycle amid the COVID-19 pandemic: Acute on chronic sequelae

Background: The COVID-19 pandemic has transformed medical education, including the upcoming residency application cycle. External rotations have been restricted, but virtual opportunities for applicants have not yet been assessed. Objective(s): To describe how neurosurgical residency programs are adapting to the 2021 application cycle through augmented social media usage and establishment of virtual sub-I’s and open houses. Methods: One hundred fifteen separate programs were identified on ERAS. Twitter, Facebook, Instagram, residency websites, and the Visiting Student Application Service (VSAS) were reviewed for virtual open house and sub-I opportunities. Professional neurosurgery society websites were also reviewed. All data is updated as of February 14 th, 2021. Results: Eighty-eight (77%) programs had some social media presence. Fourty-three (30%) departmental accounts were created in 2020. Twenty-four (57%) of the residency program accounts were created in 2020. Programs offered 35 (18%) open house opportunities on Twitter, 19 (17%) on Facebook, and 23 (20%) on Instagram. Nineteen (17%) virtual sub-I opportunities were on Twitter, 9 (8%) on Facebook, and 10 (9%) on Instagram.Virtual opportunities were updated on 13 (12%) residency websites. The National Neurosurgery MedEd website had the most website listings of virtual opportunities with 34 (30%) programs listing open houses and 18 (16%) programs listing virtual sub-I’s. No program specific virtual opportunities were found on the AANS or CNS websites. VSAS identified only 4 (4%) virtual sub-internships. Conclusion: Many neurosurgical residency programs increased their virtual presence amid the COVID-19 pandemic. More programs could utilize these platforms to mitigate applicant restriction in upcoming neurosurgery residency application cycles

Chronic Granulomatous Herpes Encephalitis in a Child with Clinically Intractable Epilepsy

Most patients with herpes simplex virus Type I encephalitis experience an acute, monophasic illness. Chronic encephalitis is much less common, and few late relapses are associated with intractable seizure disorders. A 10-year-old boy was admitted to our institution for intractable epilepsy as part of an evaluation for epilepsy surgery. His history was significant for herpes meningitis at age 4 months. At that time, he presented to an outside hospital with fever for three days, with acyclovir treatment beginning on day 4 of his 40-day hospital course. He later developed infantile spasms and ultimately a mixed seizure disorder. Video electroencephalogram showed a Lennox-Gastaut-type pattern with frequent right frontotemporal spikes. Imaging studies showed an abnormality in the right frontal operculum. Based on these findings, he underwent a right frontal lobectomy. Neuropathology demonstrated chronic granulomatous inflammation with focal necrosis and mineralizations. Scattered lymphocytes, microglial nodules and nonnecrotizing granulomas were present with multinucleated giant cells. Immunohistochemistry for herpes simplex virus showed focal immunoreactivity. After undergoing acyclovir therapy, he returned to baseline with decreased seizure frequency. This rare form of herpes encephalitis has only been reported in children, but the initial presentation of meningitis and the approximate 10-year-time interval in this case are unusual

Expedited epilepsy surgery prior to drug resistance in children: a frontier worth crossing?

Epilepsy surgery is an established safe and effective treatment for selected candidates with drug-resistant epilepsy. In this opinion piece, we outline the clinical and experimental evidence for selectively considering epilepsy surgery prior to drug resistance. Our rationale for expedited surgery is based on the observations that, 1) a high proportion of patients with lesional epilepsies (e.g. focal cortical dysplasia, epilepsy associated tumours) will progress to drug-resistance, 2) surgical treatment of these lesions, especially in non-eloquent areas of brain, is safe, and 3) earlier surgery may be associated with better seizure outcomes. Potential benefits beyond seizure reduction or elimination include less exposure to anti-seizure medications (ASM), which may lead to improved developmental trajectories in children and optimize long-term neurocognitive outcomes and quality of life. Further, there exists emerging experimental evidence that brain network dysfunction exists at the onset of epilepsy, where continuing dysfunctional activity could exacerbate network perturbations. This in turn could lead to expanded seizure foci and contribution to the comorbidities associated with epilepsy. Taken together, we rationalize that epilepsy surgery, in carefully selected cases, may be considered prior to drug resistance. Lastly, we outline the path forward, including the challenges associated with developing the evidence base and implementing this paradigm into clinical care