Michael C. Schubert

BACKGROUND: Chronic subdural hematoma is a complex but commonly treated neurosurgical condition, particularly affecting the elderly. Traditional treatment involves open surgeries, but middle meningeal artery embolization (MMAE) has emerged as an effective, minimally invasive adjunctive. The objective of this study is to assess the safety and efficacy of MMAE in combination with surgery using real-world data. METHODS: This retrospective cohort study analyzed data from the TriNetX Research Network. Outcomes of mortality, reoperation, and hospital readmission were studied using Cox proportional hazard models controlling for age, sex, indications of severity, type of surgical intervention, antiplatelet/anticoagulant use, comorbidities, and hospitalization events. Patients were followed for up to 6 years. RESULTS: This study included 38 049 patients with chronic subdural hematoma, of which 486 received surgery with MMAE and 5362 received surgery monotherapy. At 90 days after surgery, mortality was 5.2% in the MMAE group and 7.7% in the surgery monotherapy group ( P =0.0467). After 6 years, mortality was 11.2% in the MMAE group and 19.0% in the surgery monotherapy group ( P P =0.173). Patients with MMAE had significantly lower rates of rehospitalization at 1 year (2.1% versus 4.4%; P =0.0195), even after adjustment (hazard ratio, 0.414 [95% CI, 0.203–0.845]; P =0.015). CONCLUSIONS: Among patients with chronic subdural hematoma who received surgery, patients receiving adjunctive MMAE experienced lower mortality rates out to 6 years of follow-up, but the difference was not significant after full adjustment. Beginning 1 year after surgery, patients receiving combination therapy had significantly lower long-term rehospitalization compared with patients receiving surgery monotherapy. Future prospective studies will help identify strengths and weaknesses of this highly promising treatment modality.

Objectives: The objective of this study was to evaluate the effectiveness and adverse effect profile of prophylactic levetiracetam in preventing epilepsy after traumatic brain injury (TBI). Methods: This retrospective cohort study used the TriNetX Research Network, encompassing >150 million patients. Adults (≥18 years) with a first TBI and Glasgow Coma Scale (GCS) score recorded were included. Patients with pre‐existing epilepsy, seizures on the day of injury, or prior levetiracetam exposure were excluded. The cohort (n = 51,263) was stratified into mild (GCS 13–15; n = 33,625) and severe (GCS 3–8; n = 10,805) TBI. The risk of early (p = 0.04) but not in mild TBI (HR = 0.85, 95% CI = 0.45–1.61, p = 0.61). Levetiracetam did not reduce late epilepsy in either mild (HR = 1.00, 95% CI = 0.79–1.15, p = 0.997) or severe (HR = 0.90, 95% CI = 0.68–1.19, p = 0.45) TBI. Older age, cerebral edema, and subdural hemorrhage were consistent risk factors. Adverse outcomes included impaired memory and awareness, metabolic disorders, and psychiatric symptoms. Interpretation: Levetiracetam prophylaxis reduced early epilepsy only in severe TBI and conferred no long‐term protection. Given its adverse effect burden, routine prophylaxis should be limited to severe TBI or high‐risk patients. These findings support re‐evaluation of current seizure prophylaxis guidelines, which are based on older antiseizure medications and predate large‐scale real‐world data. ANN NEUROL 2026

Parkinson's disease (PD) presents with both motor and non-motor symptoms. Postural and gait aspects, as well as the risk of falls, are important causes of morbidity and mortality in PD. The neural correlates of PD are alterations in the substantia nigra of the midbrain and, among other sites mentioned, the pontine peduncle nucleus stands out. Noninvasive neuromodulation, such as galvanic vestibular stimulation (GVS), can be used in the neural centers involved in motor control alterations in PD. Projections from the vestibular system are involved in motor control and can stimulate the basal nuclei and the pontine peduncle nucleus, as well as strengthen neural networks. To analyze the effects of GVS associated with physical-functional exercise on the motor control of PD patients. A randomized, placebo-controlled clinical trial. Participants with PD, diagnosed through the Hoehn & Yahr scale (HY) 2 or 3, will be allocated to groups. Pre- and postintervention and follow-up assessments will follow a structured protocol of physical-functional instruments, as recommended in the European Guidelines for managing people with PD. The intervention for both groups will follow the American Neurofunctional Physical Therapy Guideline for managing people with PD. It is expected that, in the experimental group, the exercises will be associated with active GVS. Finally, a descriptive and statistical analysis must be conducted to verify the effects of GVS. The study of new devices focusing on motor control in PD is a novel approach and warrants further investigation in the context of vestibular function.

Objective: Vestibular symptoms impose a high burden of disability. Understanding real‐world diagnostic and treatment pathways can identify care gaps and guide interventions. We aimed to characterize symptom profiles, diagnostic trends, provider involvement, and treatment patterns in vestibular disorders. We also examined whether these real‐world pathways align with expected clinical features in vestibular diagnoses. Methods: Data from the Vestibular Disorders Association (VeDA) patient registry from March 21, 2023, to January 29, 2024 was analyzed, focusing on vestibular diagnoses, symptom patterns, care pathways, treatments, and diagnostic predictors. Results: Of 172 respondents (75.6% female), 66.3% reported multiple vestibular diagnoses (mean 1.8) and 18.9% reported inability to work. The most prevalent diagnoses were vestibular migraine (VM, 50.6%), benign paroxysmal positional vertigo (BPPV, 36.0%), Meniere's disease (26.9%), persistent postural‐perceptual dizziness (PPPD, 20.9%), and vestibular neuritis (VN, 21.6%). VM overlapped with BPPV (44.8%), PPPD (31.0%), and Meniere's disease (27.6%). Patients consulted an average of ~15 providers, underscoring the combined effects of participation bias, diagnostic overlap, and fragmented care pathways characteristic of vestibular conditions. Symptoms, triggers, functional impact, provider involvement, and treatments were broadly similar across diagnoses. Logistic regressions revealed that VM was associated with frequent headaches, spontaneous vertigo, and frequent nausea/vomiting (ORs 24.70, 21.07, 5.58; p = 0.003, 0.02, 0.036), Meniere's with dietary improvement (OR 38.00; p = 0.016), PPPD with VM overlap and visual‐induced vertigo (ORs 6.83, 0.02; p = 0.03, 0.02), and VN with the lowest frequency of autonomic symptoms (OR 0.00006; p = 0.005). Interpretation: The findings reveal a complex clinical landscape of vestibular disorders marked by multiple diagnoses and barriers to effective care. Overlapping symptom profiles across disorders further complicate diagnostic accuracy. Although regression analysis confirmed diagnosis‐specific features, neither provider involvement nor treatments aligned consistently with diagnoses, highlighting fragmented care pathways. These findings call for clearer diagnostic pathways, enhanced provider training, and coordinated multidisciplinary care to improve diagnostic accuracy and treatment for vestibular disorders.

Objective: Refractory status epilepticus (RSE) is a medical emergency defined as “status epilepticus persisting despite administration of at least 2 appropriately selected and dosed parenteral medications including a benzodiazepine.” Control of RSE is critical to avoid irreversible neuronal damage, with midazolam and propofol as the most commonly used agents. This study evaluates the effectiveness of midazolam versus propofol in preventing mortality and complications of RSE. Methods: Patients from the TriNetX Research Network who received either midazolam or propofol monotherapy on the day of RSE onset were included. Outcomes were assessed at 30 days and maximal follow‐up (≤20 years) using Cox proportional hazard models. Propensity score matching (1:1) controlled for demographics and 93 comorbidities from the Charlson Comorbidity Index. Results: Among 117 736 patients with RSE, 5310 received midazolam and 2136 received propofol. Midazolam was associated with significantly decreased hazards of mortality at 30 days (HR = 0.509 [95% CI: 0.397, 0.653]) but not at maximal follow‐up (HR = 0.922 [0.797, 1.067]). Midazolam was also associated with significantly reduced hazards of lactic acidosis (HR = 0.537 [0.427, 0.674]), rhabdomyolysis (HR = 0.295 [0.150, 0.578]), hypertriglyceridemia (HR = 0.316 [0.135, 0.740]), tracheostomy (HR = 0.633 [0.438, 0.916]), PEG placement (HR = 0.519 [0.371, 0.725]), and mechanical ventilation (HR = 0.313 [0.265, 0.370]). Among patients with a traumatic brain injury in the week prior to RSE, midazolam was associated with a significantly lower hazard of 30‐day mortality (HR = 0.381 [0.136, 0.993]), while the hazards were not significantly changed in patients with CNS infections (HR = 1.150 [0.351, 3.768]) or cerebrovascular disease (HR = 0.656 [0.421, 1.025]) in the week prior to RSE onset. Significance: Midazolam monotherapy for RSE was associated with decreased mortality and adverse effects compared to propofol monotherapy in the short term, but relatively equivalent in the long term. Prospective comparative trials are needed to ascertain superiority of either intervention in reducing morbidity and mortality in patients with RSE.