Publications by authors named "Andrew W Grande"

38 Publications

Minimally-invasive tubular retraction ports for intracranial neurosurgery: History and future perspectives.

J Clin Neurosci 2021 Jul 6;89:97-102. Epub 2021 May 6.

University of Minnesota Medical School Department of Neurosurgery, United States.

Brain retraction is a necessary yet potentially damaging requirement of accessing lesions located in deep structures. The development of minimally-invasive tubular retractors (MITRs) provides the theoretical advantage of maximizing visualization of and access to deep-seated lesions, all while minimizing collateral tissue damage. These advantages make MITRs preferable to traditional bladed retractors in the majority of deep-seated lesions. Several commercially-available MITR systems currently exist and have been shown to aid in achieving excellent outcomes with acceptable safety profiles. Nevertheless, important drawbacks to currently-available MITR systems exist. Continued pursuit of an ideal MITR system that provides maximal visualization and access to deep-seated lesions while minimizing retraction-related tissue damage is therefore important. In this review, we discuss the historical development of MITRs, the advantages of MITRs compared to traditional bladed retractors, and opportunities to improve the development of prospective MITRs.
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http://dx.doi.org/10.1016/j.jocn.2021.04.035DOI Listing
July 2021

Microsurgical Management of the Middle Cerebral Artery Bifurcation Aneurysms: An Anatomic Feasibility Study.

ORL J Otorhinolaryngol Relat Spec 2021;83(3):187-195. Epub 2021 Mar 15.

Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.

Background: The proper head positioning decreases the surgical complications by enabling a better surgical maneuverability. Middle cerebral artery (MCA) bifurcation aneurysms have been classified by Dashti et al. [Surg Neurol. 2007 May;67(5):441-56] as the intertruncal, inferior, lateral, insular, and complex types based on dome projection. Our aim was to identify the optimum head positions and to explain the anatomic variables, which may affect the surgical strategy of MCA bifurcation aneurysms.

Methods: The lateral supraorbital approach bilaterally was performed in the 4 cadaveric heads. All steps of the dissection were recorded using digital camera.

Results: The distal Sylvian fissure (SF) dissection may be preferred for insular type and the proximal SF dissection may be preferred for all other types. Fifteen degrees head rotation was found as the most suitable position for the intertruncal, lateral type and subtype of complex aneurysms related with superior trunk. Thirty degrees head rotation was found the most suitable position for the inferior type, insular type, and subtype of complex aneurysms related with inferior trunk.

Conclusions: The head positioning in middle cerebral bifurcation aneurysms surgery is a critical step. It should be tailored according to the projection and its relationship with the parent vessels of the middle cerebral bifurcation.
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http://dx.doi.org/10.1159/000514177DOI Listing
May 2021

Neurosurgical management of aneurysms of the vertebrobasilar system: increasing indications for endovascular therapy with a continued role for open microneurosurgery.

Neurosurg Rev 2021 Jan 6. Epub 2021 Jan 6.

Department of Neurosurgery, University of Minnesota Medical School, 420 Delaware St SE., Minneapolis, MN, 55455, USA.

Aneurysms of the vertebrobasilar system remain among the most challenging subsets of aneurysms to treat with an open surgical approach. Since Charles Drake's pioneering work in the 1960s, several advances in microsurgical techniques have improved outcomes and feasibility in the open surgical management of these aneurysms. In parallel, the field of endovascular neurosurgery has provided several safe and effective treatment options. Multiple trials have suggested that endovascular therapy for aneurysms of the vertebrobasilar system is superior to open surgical management in most cases. In some instances, however, open surgical management likely represents a more effective and durable option relative to endovascular therapy. Therefore, continued training of future cerebrovascular specialists in open surgery of vertebrobasilar aneurysms remains crucial. With widespread utilization of endovascular techniques, however, proper exposure of trainees to such aneurysms is growing increasingly difficult. In this review, we discuss the recent advances in the endovascular management of vertebrobasilar aneurysms while also emphasizing the continued importance of open microneurosurgery in such cases.
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http://dx.doi.org/10.1007/s10143-020-01460-7DOI Listing
January 2021

The Rate of Symptomatic Ischemic Events after Passing Balloon Test Occlusion of the Major Intracranial Arteries: Meta-Analysis.

World Neurosurg 2021 02 30;146:e1182-e1190. Epub 2020 Nov 30.

Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA. Electronic address:

Background: Balloon test occlusion is a widely used method for predicting tolerance of vessel occlusion in the treatment of aneurysms, fistulae, and head and neck neoplasms. However, the false-negative rate is variably reported due in part to the diversity of perfusion monitoring methods.

Objective: To evaluate the rate of symptomatic ischemic events after a negative balloon test occlusion and determine whether perfusion monitoring methods contribute to differences in these rates.

Methods: PubMed was systematically searched for studies between 1990 and 2020 that reported rates of ischemic outcomes of parental vessel occlusion in patients who passed balloon test occlusion. A generalized linear mixed model meta-analysis was performed. Results were expressed as the rate of symptomatic ischemic events after parental vessel occlusion without vessel bypass in patients who passed balloon test occlusion.

Results: Thirty-two studies met the inclusion criteria. The overall pooled rate of ischemic events after passing balloon test occlusion was 3.7% (95% confidence interval [CI]: 1.7-7.8). This rate was 3.8% (95% CI: 1.1-12.8) when monitored with angiography, 2.2% (95% CI: 0.4-10.2) when monitored by a form of computed tomography, and 5.3% (95% CI: 1.2-20.4) when monitored by 2 or more methods of perfusion assessment. The complication rate of balloon test occlusion was 0.8% (95% CI: 0.2-2.7).

Conclusions: Balloon test occlusion results in a low rate of subsequent ischemic events, without conclusive evidence of variation between methods of perfusion assessment. The choice of method should focus on reduction of complication risk, experience of the interventional team, and avoidance of prolonged test occlusion times.
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http://dx.doi.org/10.1016/j.wneu.2020.11.134DOI Listing
February 2021

Zika virus-based immunotherapy enhances long-term survival of rodents with brain tumors through upregulation of memory T-cells.

PLoS One 2020 1;15(10):e0232858. Epub 2020 Oct 1.

Department of Neurosurgery, University of Minnesota, Minneapolis, MN, United States of America.

Zika virus (ZIKV) exhibits a tropism for brain tumor cells and has been used as an oncolytic virus to target brain tumors in mice with modest effects on extending median survival. Recent studies have highlighted the potential for combining virotherapy and immunotherapy to target cancer. We postulated that ZIKV could be used as an adjuvant to enhance the long-term survival of mice with malignant glioblastoma and generate memory T-cells capable of providing long-term immunity against cancer remission. To test this hypothesis mice bearing malignant intracranial GL261 tumors were subcutaneously vaccinated with irradiated GL261 cells previously infected with the ZIKV. Mice also received intracranial injections of live ZIKV, irradiation attenuated ZIKV, or irradiated GL261 cells previously infected with ZIKV. Long-term survivors were rechallenged with a second intracranial tumor to examine their immune response and look for the establishment of protective memory T-cells. Mice with subcutaneous vaccination plus intracranial irradiation attenuated ZIKV or intracranial irradiated GL261 cells previously infected with ZIKV exhibited the greatest extensions to overall survival. Flow cytometry analysis of immune cells within the brains of long-term surviving mice after tumor rechallenge revealed an increase in the number of T-cells, including CD4+ and tissue-resident effector/ effector memory CD4+ T-cells, in comparison to long-term survivors that were mock-rechallenged, and in comparison to naïve untreated mice challenged with intracranial gliomas. These results suggest that ZIKV can serve as an adjuvant to subcutaneous tumor vaccines that enhance long-term survival and generate protective tissue-resident memory CD4+ T-cells.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0232858PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529292PMC
November 2020

From the Historical Examples of Drs. Osler, Cushing, and Van Wagenen: Lessons on the Importance of Mentorship in Contemporary Neurosurgery.

World Neurosurg 2020 08 17;140:251-257. Epub 2020 May 17.

Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota, USA.

Although the historical relationships between William Osler, Harvey Williams Cushing, and William Perine Van Wagenen are well known in the neurosurgical world, the nature of the mentor-mentee relationships that existed between these historical giants is not widely appreciated. In this historical vignette, we describe and exemplify such relationships, while at the same time extract important and applicable principles from them. We reviewed relevant primary and secondary sources that documented the interactions between Cushing, Osler, and Van Wagenen. In founding the field of neurological surgery, the brilliant yet volatile Dr. Harvey Cushing received guidance from his mentor, Dr. William Osler. Through our review, it is undeniable that Dr. Osler's personal and professional guidance was vital to young Dr. Cushing's success as the founder of modern neurosurgery. Likewise, Cushing's tutelage of Van Wagenen enabled Van Wagenen to become a leader of a second generation of neurosurgeons, thereby perpetuating the existence of Cushing's high neurosurgical standards. These historical mentor-mentee relationships were built on 4 primary components: accurate recognition of talent, guidance, arrangement of opportunity, and sustenance of mentorship-actions that are commonly implicated in effective mentorship in contemporary studies. Proper mentorship remains indispensable for the success of neurosurgical trainees.
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http://dx.doi.org/10.1016/j.wneu.2020.05.100DOI Listing
August 2020

Efficacy of Cell-Based Therapies for Traumatic Brain Injuries.

Brain Sci 2019 Oct 10;9(10). Epub 2019 Oct 10.

Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN 55455, USA.

Traumatic brain injuries (TBIs) are a leading cause of death and disability. Additionally, growing evidence suggests a link between TBI-induced neuroinflammation and neurodegenerative disorders. Treatments for TBI patients are limited, largely focused on rehabilitation therapy, and ultimately, fail to provide long-term neuroprotective or neurorestorative benefits. Because of the prevalence of TBI and lack of viable treatments, new therapies are needed which can promote neurological recovery. Cell-based treatments are a promising avenue because of their potential to provide multiple therapeutic benefits. Cell-based therapies can promote neuroprotection via modulation of inflammation and promote neurorestoration via induction of angiogenesis and neurogenesis. Neural stem/progenitor cell transplantations have been investigated in preclinical TBI models for their ability to directly contribute to neuroregeneration, form neural-like cells, and improve recovery. Mesenchymal stem cells (MSCs) have been investigated in clinical trials through multiple different routes of administration. Intravenous administration of MSCs appears most promising, demonstrating a robust safety profile, correlation with neurological improvements, and reductions in systemic inflammation following TBI. While still preliminary, evidence suggests cell-based therapies may become a viable treatment for TBI based on their ability to promote neuroregeneration and reduce inflammation.
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http://dx.doi.org/10.3390/brainsci9100270DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826445PMC
October 2019

Interspecies Organogenesis for Human Transplantation.

Cell Transplant 2019 Sep-Oct;28(9-10):1091-1105. Epub 2019 Aug 19.

Department of Neurosurgery, University of Minnesota, Minneapolis, USA.

Blastocyst complementation combined with gene editing is an emerging approach in the field of regenerative medicine that could potentially solve the worldwide problem of organ shortages for transplantation. In theory, blastocyst complementation can generate fully functional human organs or tissues, grown within genetically engineered livestock animals. Targeted deletion of a specific gene(s) using gene editing to cause deficiencies in organ development can open a niche for human stem cells to occupy, thus generating human tissues. Within this review, we will focus on the pancreas, liver, heart, kidney, lung, and skeletal muscle, as well as cells of the immune and nervous systems. Within each of these organ systems, we identify and discuss (i) the common causes of organ failure; (ii) the current state of regenerative therapies; and (iii) the candidate genes to knockout and enable specific exogenous organ development via the use of blastocyst complementation. We also highlight some of the current barriers limiting the success of blastocyst complementation.
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http://dx.doi.org/10.1177/0963689719845351DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767879PMC
August 2020

Efficacy of stem cell-based therapies for stroke.

Brain Res 2019 11 2;1722:146362. Epub 2019 Aug 2.

Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN 55455, USA; Stem Cell Institute, University of Minnesota Medical School, Minneapolis, MN 55455, USA. Electronic address:

Stroke remains a prevalent disease with limited treatment options. Available treatments offer little in the way of enhancing neurogenesis and recovery. Because of the limitations of available treatments, new therapies for stroke are needed. Stem cell-based therapies for stroke offer promise because of their potential to provide neurorestorative benefits. Stem cell-based therapies aim to promote neurogenesis and replacement of lost neurons or protect surviving neurons in order to improve neurological recovery. The mechanism through which stem cell treatments mediate their therapeutic effect is largely dependent on the type of stem cell and route of administration. Neural stem cells have been shown in pre-clinical and clinical trials to promote functional recovery when used in intracerebral transplantations. The therapeutic effects of neural stem cells have been attributed to their formation of new neurons and promotion of neuroregeneration. Bone marrow stem cells (BMSC) and mesenchymal stem cells (MSC) have been shown to enhance neurogenesis in pre-clinical models in intracerebral transplantations, but lack clinical evidence to support this therapeutic approach in patients and appear to be less effective than neural stem cells. Intravenous and intra-arterial administration of BMSC and MSC have shown more promise, where their effects are largely mediated through neuroprotective mechanisms. The immune system has been implicated in exacerbating initial damage caused by stroke, and BMSC and MSC have demonstrated immunomodulatory properties capable of dampening post-stroke inflammation and potentially improving recovery. While still in development, stem cell therapies may yield new treatments for stroke which can improve neurological recovery.
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http://dx.doi.org/10.1016/j.brainres.2019.146362DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815222PMC
November 2019

Neural Repair in Stroke.

Cell Transplant 2019 Sep-Oct;28(9-10):1123-1126. Epub 2019 Jul 29.

Department of Neurosurgery, University of Minnesota, Minneapolis, MN, USA.

This article reviews the progress that has been made in the development of cell therapies for the repair of nervous system damage caused by strokes, since the first report on the use of cell transplants in animal models of ischemic brain injury in 1988. At that time neural progenitor cells derived from fetal brain tissue were used as sources of cells to replace specific subsets of neuronal cells that were lost in various regions of the brain following experimentally induced strokes. Since 1988, cells from other sources, such as embryonic stem cells and inducible pluripotent stem cells, have been investigated for their ability to replace neuronal cells and repair the damaged brain. Most recently, mesenchymal stem cells and cord blood stem cells have been studied for the ability to modulate the immune system and ameliorate the neuropathology and neurological deficits associated with experimental stroke. The preclinical investigation of different cell therapy approaches for treating stroke during the past three decades has now led to many ongoing clinical trials, with the clinical evaluation of stem cell therapies for stroke now involving global participants.
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http://dx.doi.org/10.1177/0963689719863784DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767877PMC
August 2020

Prospective Trial of Cerebrospinal Fluid Filtration After Aneurysmal Subarachnoid Hemorrhage via Lumbar Catheter (PILLAR).

Stroke 2019 09 26;50(9):2558-2561. Epub 2019 Jul 26.

Department of Neurology and Neuroscience, University of Virginia, Charlottesville (J.J.P.).

Background and Purpose- The PILLAR (Extracorporeal Filtration of Subarachnoid Hemorrhage via Spinal Catheter) study is a first-in-human trial of cerebrospinal fluid (CSF) filtration in aneurysmal subarachnoid hemorrhage. The study evaluates the safety and feasibility of a novel filtration system to rapidly remove blood and blood breakdown products from CSF after securement of a ruptured aneurysm. Methods- Patients with aneurysmal subarachnoid hemorrhage had a dual-lumen lumbar, intrathecal catheter placed after aneurysm securement and received up to 24 hours of CSF filtration (neurapheresis therapy). The catheter aspirated blood-contaminated CSF from the lumbar cistern and returned filtered CSF to the thoracic subarachnoid space. Neuro checks were performed q2 hours, and CSF samples were collected for cell counts, total protein, and gram stain. Computed tomography scans were acquired at baseline and post-filtration. Clinical follow-up occurred at 2 weeks and 30 days. Results- Thirteen patients had a catheter placed (mean time 24:13 hours after ictus). The system processed 632.0 mL (180.6-1447.6 mL) CSF in 15:07 hours (5:32-24:00 hours) of filtration. The mean initial CSF red blood cell count, 2.78×10 cells/µL, reduced to 1.17×10 cells/µL after filtration (52.9% reduction), and total protein reduced 71%. Independent analysis of baseline and postfiltration computed tomographies found notable cisternal blood decrease, with 46.5% mean Hijdra Score reduction. Three mild, anticipated adverse events were reported. Conclusions- The initial safety and feasibility of Neurapheresis therapy in aneurysmal subarachnoid hemorrhage demonstrated the potential to safely filter CSF and remove blood and blood byproducts. Future studies are warranted. Clinical Trial Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT0287263.
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http://dx.doi.org/10.1161/STROKEAHA.119.025399DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6710124PMC
September 2019

Immunomodulation with Human Umbilical Cord Blood Stem Cells Ameliorates Ischemic Brain Injury - A Brain Transcriptome Profiling Analysis.

Cell Transplant 2019 07 8;28(7):864-873. Epub 2019 May 8.

1 Department of Neurosurgery, University of Minnesota, Minneapolis, USA.

Our group previously demonstrated that administration of a CD34-negative fraction of human non- hematopoietic umbilical cord blood stem cells (UCBSC) 48 h after ischemic injury could reduce infarct volume by 50% as well as significantly ameliorate neurological deficits. In the present study, we explored possible mechanisms of action using next generation RNA sequencing to analyze the brain transcriptome profiles in rats with ischemic brain injury following UCBSC therapy. Two days after ischemic injury, rats were treated with UCBSC. Five days after administration, total brain mRNA was then extracted for RNAseq analysis using Illumina Hiseq 2000. We found 275 genes that were significantly differentially expressed after ischemic injury compared with control brains. Following UCBSC treatment, 220 of the 275 differentially expressed genes returned to normal levels. Detailed analysis of these altered transcripts revealed that the vast majority were associated with activation of the immune system following cerebral ischemia which were normalized following UCBSC therapy. Major alterations in gene expression profiles after ischemia include blood-brain-barrier breakdown, cytokine production, and immune cell infiltration. These results suggest that UCBSC protect the brain following ischemic injury by down regulating the aberrant activation of innate and adaptive immune responses.
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http://dx.doi.org/10.1177/0963689719836763DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6719500PMC
July 2019

Comprehensive anatomy of the foramen ovale critical to percutaneous stereotactic radiofrequency rhizotomy: cadaveric study of dry skulls.

J Neurosurg 2019 Apr 19;132(5):1414-1422. Epub 2019 Apr 19.

1Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota.

Objective: Percutaneous stereotactic radiofrequency rhizotomy (PSR) is often used to treat trigeminal neuralgia, a serious condition that results in lancinating, episodic facial pain. Thorough understanding of the microsurgical anatomy of the foramen ovale (FO) and its surrounding structures is required for efficient, effective, and safe use of this technique. This morphometric study compares anatomical and surgical orientations to identify the variations of the FO and assess cannulation difficulty.

Methods: Bilateral foramina from 174 adult human dry skulls (348 foramina) were analyzed using anatomical and surgical orientations in photographs from standardized projections. Measurements were obtained for shape, size, adjacent structures, and morphometric variability effect on cannulation. The risk of potential injury to surrounding structures was also assessed.

Results: The authors identified 6 distinctive shapes of the FO and 5 anomalous variants from the anatomical view, and 6 shapes from the surgical view. In measurements of surface area of this foramen obtained using the surgical view, loss (average 18.5% ± 5.7%) was significant compared with the anatomical view. Morphometrically, foramen size varied significantly and obstruction from a calcified pterygoalar ligament occurred in 7.8% of specimens. Importantly, 8% of foramina were difficult to cannulate, thus posing a 12% risk of inadvertent cannulation of the foramen lacerum.

Conclusions: Significant variability in the FO's shape and size probably affected its safe and effective cannulation. Preoperative imaging by 3D head CT may be helpful in predicting ease of cannulation and in guiding treatment decisions, such as a percutaneous approach over microvascular decompression or radiosurgery.
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http://dx.doi.org/10.3171/2019.1.JNS18899DOI Listing
April 2019

Development of a Novel Canine Model of Ischemic Stroke: Skull Base Approach with Transient Middle Cerebral Artery Occlusion.

World Neurosurg 2019 Jul 19;127:e251-e260. Epub 2019 Mar 19.

Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA; Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA; Stem Cell Institute, University of Minnesota, Minneapolis, Minnesota, USA. Electronic address:

Objective: Although canine stroke models have several intrinsic advantages, establishing consistent and reproducible territorial stroke in these models has been challenging because of the abundance of collateral circulation. We have described a skull-base surgical approach that yields reproducible stroke volumes.

Methods: Ten male beagles were studied. In all 10 dogs, a craniectomy was performed to expose the circle of Willis. Cerebral aneurysm clips were temporarily applied to the middle cerebral artery (MCA), anterior cerebral artery (ACA), posterior cerebral artery, and/or ophthalmic artery (OA) for 1 hour, followed by cauterization of the distal MCA pial collateral vessels. Indocyanine green angiography was performed to assess the local blood flow to the intended area of infarction. The dogs' neurologic examination was evaluated, and the stroke burden was quantified using magnetic resonance imaging.

Results: High mortality was observed after 1-hour clip occlusion of the posterior cerebral artery, MCA, ACA, and OA (n = 4). Without coagulation of the MCA collateral vessels, 1-hour occlusion of the MCA and/or ACA and OA yielded inconsistent stroke volumes (n = 2). In contrast, after coagulation of the distal MCA pial collateral vessels, 1-hour occlusion of the MCA, ACA, and OA yielded consistent territorial stroke volumes (n = 4; average stroke volume, 9.13 ± 0.90 cm; no surgical mortalities), with reproducible neurologic deficits.

Conclusion: Consistent stroke volumes can be achieved in male beagles using a skull base surgical approach with temporary occlusion of the MCA, ACA, and OA when combined with cauterization of the distal MCA pial collateral vessels.
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http://dx.doi.org/10.1016/j.wneu.2019.03.082DOI Listing
July 2019

Gadolinium to the rescue for mechanical thrombectomy in acute ischemic stroke.

Interv Neuroradiol 2019 Jun 19;25(3):301-304. Epub 2018 Dec 19.

2 Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.

Introduction: Mechanical thrombectomy in the setting of acute ischemic stroke (AIS) requires cerebral digital subtraction angiography (DSA), typically performed with iodinated contrast medium. We present a case of emergent cerebral DSA and mechanical thrombectomy using gadolinium-based contrast for cerebral DSA in a patient with a history of anaphylaxis to iodinated contrast agents (ICs).

Case Report: A 72-year-old man developed left ventricle assist device thrombus while on anticoagulation. During hospitalization he suffered right middle cerebral artery occlusion with a National Institutes of Health stroke scale score of 10. He had a history of anaphylaxis and the advanced directives revealed do not resuscitate/do not intubate status. We performed an emergent DSA as part of thrombectomy procedure using gadolinium-based contrast mixed in 1:1 proportion with normal saline. The images obtained were of adequate quality and the patient underwent successful thrombectomy with modified thrombolysis in cerebral infarction 2B recanalization.

Conclusion: Gadolinium-based contrast agents could be effective alternatives for cerebral DSA in patients undergoing mechanical thrombectomy for AIS who have a history of anaphylactic reaction to ICs.
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http://dx.doi.org/10.1177/1591019918815298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6547216PMC
June 2019

Safety and Feasibility of Balloon-Assisted Embolization with Onyx of Brain Arteriovenous Malformations Revisited: Personal Experience with the Scepter XC Balloon Microcatheter.

Interv Neurol 2018 Oct 13;7(6):439-444. Epub 2018 Jul 13.

Department of Radiology, University of Minnesota, Minneapolis, Minnesota, USA.

Background/objective: Compliant dual-lumen balloon microcatheters have been used to perform balloon-assisted embolization (BAE) of brain arteriovenous malformations (AVMs) with ethylene vinyl alcohol copolymer (Onyx). However, vessel rupture and microcatheter retention have been reported from BAE using these microcatheters. Using an extra-compliant balloon microcatheter (Scepter XC; Microvention, Tustin, CA, USA) could help avoid pial vessel rupture during BAE. We herein report our experience using this balloon microcatheter for BAE.

Methods: This retrospective study included patients who underwent BAE of brain AVMs at our institution between June 2012 and March 2017.

Results: The extra-compliant Scepter XC balloon microcatheter was used for BAE of brain AVMs in 23 patients aged 44.3 ± 16.7 years (range 0-65 years). A total of 40 intracranial vessels (39 pial arteries and 1 pial vein) were catheterized and embolized during 30 separate sessions. In all instances, the balloon microcatheter could be successfully advanced to the AVM nidus. A mean volume of 2.4 ± 1.7 mL (range 0.65-4.6 mL) of Onyx was injected per session. There were no instances of vessel rupture, microcatheter retention, or stroke.

Conclusion: Utilization of the extra-compliant balloon microcatheter results in safe and effective BAE, which adds to the growing experience with BAE for AVM treatment.
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http://dx.doi.org/10.1159/000490579DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6216782PMC
October 2018

Quantitative Anatomic Analysis of the Transcallosal-Transchoroidal Approach and the Transcallosal-Subchoroidal Approach to the Floor of the Third Ventricle: An Anatomic Study.

World Neurosurg 2018 Oct 11;118:219-229. Epub 2018 Aug 11.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA. Electronic address:

Objective: To compare transcallosal-transchoroidal and transcallosal-subchoroidal approaches to the ipsilateral and contralateral edges of the floor of the third ventricle using quantitative analyses.

Methods: Five formalin-fixed cadaveric human heads (10 sides) were examined under the operating microscope. Quantitative measurements (area of surgical freedom and angle of attack) were obtained using 3-T magnetic resonance imaging and a StealthStation image guidance system. The limits of the surgical approaches were shown by touching a probe to 6 designated points on the floor of the third ventricle.

Results: The transchoroidal approach provided greater surgical freedom than the subchoroidal approach to access ipsilateral and contralateral middle landmarks at the edges of the floor of the third ventricle in both longitudinal and horizontal planes (P ≤ 0.03). No significant difference between the 2 approaches was found in accessing the anterior and posterior landmarks of the third ventricle in each plane. The surgical freedom to the contralateral anterior, middle, and posterior landmarks was greater than to the ipsilateral landmarks in both the transchoroidal and subchoroidal approaches.

Conclusions: The transcallosal-transchoroidal approach, compared with the transcallosal-subchoroidal approach, may provide better exposure and require less retraction for removal of ipsilateral or contralateral lesions located in the midbrain or hypothalamus and situated near the floor of the third ventricle. The contralateral transcallosal approach with either the transchoroidal or subchoroidal approach may provide good surgical freedom for removal of lesions located near the floor of the third ventricle, such as lesions in the midbrain.
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http://dx.doi.org/10.1016/j.wneu.2018.05.126DOI Listing
October 2018

Novel Dual Lumen Catheter and Filtration Device for Removal of Subarachnoid hemorrhage: First Case Report.

Oper Neurosurg (Hagerstown) 2019 05;16(5):E148-E153

Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina.

Background And Importance: The amount of subarachnoid blood and the presence of toxic blood breakdown products in the cerebrospinal fluid (CSF) have long been associated with poor outcomes in aneurysmal subarachnoid hemorrhage. The Neurapheresis™ system (Minnetronix Inc, St. Paul, Minnesota) has been developed to filter CSF and remove blood products, and is being investigated for safety and feasibility in the ExtracorPoreal FILtration of subarachnoid hemorrhage via SpinaL CAtheteR (PILLAR) study. We report the first case using this novel device.

Clinical Presentation: A 65-yr-old female presented with a ruptured left posterior communicating artery aneurysm. Following placement of a ventriculostomy and coil embolization of her aneurysm, the patient underwent placement of a lumbar dual lumen catheter for CSF filtration as part of the PILLAR study. In this case, a total of 9 h of filtration during 31 h of catheter indwelling resulted in 309.47 mL of processed CSF without complication. Computed tomography images demonstrated an interval reduction of subarachnoid hemorrhage immediately after filtration. The patient was discharged home on postbleed day 11 and at 30 d showed good recovery.

Conclusion: Safety of the Neurapheresis procedure was confirmed in this first case, and we will continue to evaluate safety of the Neurapheresis system through the PILLAR trial.
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http://dx.doi.org/10.1093/ons/opy151DOI Listing
May 2019

Anterior temporal artery to posterior cerebral artery bypass for revascularization of the posterior circulation: An anatomical study.

J Clin Neurosci 2018 Jan 27;47:337-340. Epub 2017 Oct 27.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, United States. Electronic address:

We describe a novel intracranial-to-intracranial bypass technique between the anterior temporal artery and the posterior cerebral artery for revascularization of the posterior circulation. Four formalin-fixed human heads were examined to demonstrate the detailed anatomy of the middle cerebral artery and the posterior cerebral artery, and to illustrate the step-by-step bypass procedure. The anterior temporal artery, a branch of the middle cerebral artery, can be anastomosed to the P2 segment of the posterior cerebral artery as an alternative to extracranial bypass donor segments for treatment of complex aneurysms requiring revascularization. The anastomosis of the anterior temporal artery as a pedicled donor to the posterior cerebral artery provides a shorter graft, due to its close anatomical position to the posterior cerebral artery, for posterior circulation revascularization.
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http://dx.doi.org/10.1016/j.jocn.2017.10.047DOI Listing
January 2018

Contralateral anterior interhemispheric-transcallosal-transrostral approach to the subcallosal region: a novel surgical technique.

J Neurosurg 2018 08 3;129(2):508-514. Epub 2017 Nov 3.

3Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

OBJECTIVE The authors report a novel surgical route from a superior anatomical aspect-the contralateral anterior interhemispheric-transcallosal-transrostral approach-to a lesion located in the subcallosal region. The neurosurgical approach to the subcallosal region is challenging due to its deep location and close relationship with important vascular structures. Anterior and inferior routes to the subcallosal region have been described but risk damaging the branches of the anterior cerebral artery. METHODS Three formalin-fixed and silicone-injected adult cadaveric heads were studied to demonstrate the relationships between the transventricular surgical approach and the subcallosal region. The surgical, clinical, and radiological history of a 39-year-old man with a subcallosal cavernous malformation was retrospectively used to document the neurological examination and radiographic parameters of such a case. RESULTS The contralateral anterior interhemispheric-transcallosal-transrostral approach provides access to the subcallosal area that also includes the inferior portion of the pericallosal cistern, lamina terminalis cistern, the paraterminal and paraolfactory gyri, and the anterior surface of the optic chiasm. The approach avoids the neurocritical perforating branches of the anterior communicating artery. CONCLUSIONS The contralateral anterior interhemispheric-transcallosal-transrostral approach may be an alternative route to subcallosal area lesions, with less risk to the branches of the anterior cerebral artery, particularly the anterior communicating artery perforators.
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http://dx.doi.org/10.3171/2017.4.JNS16951DOI Listing
August 2018

Salvage of Herniated Flow Diverters Using Stent and Balloon Anchoring Techniques: A Technical Note.

Interv Neurol 2017 Mar 11;6(1-2):31-35. Epub 2016 Nov 11.

Department of Radiology, Minneapolis MN, USA.

Background: The pipeline embolization device (PED; Medtronic, MN, USA) can sometimes herniate into the aneurysmal sac in an unexpected manner during or shortly after its deployment due to device foreshortening. In this report, we describe 2 endovascular techniques, which can be used to reposition a herniated PED construct into a more favorable alignment.

Summary: In a 67-year-old patient who had an intraprocedural herniation of a PED device into a giant cavernous aneurysm, a stent anchor technique was used to reverse the herniation, reorient the PED construct, and achieve successful flow diversion. In a different patient with a giant superior hypophyseal aneurysm, a balloon anchor technique followed by deployment of an LVIS Jr (Microvention, Tustin, CA, USA) stent was used to reverse the herniation into the aneurysmal sac.

Key Messages: Stent anchor and balloon anchor techniques as described here can be used to reposition PED constructs, which have unexpectedly herniated into the aneurysm sac during attempted flow diversion for the treatment of giant aneurysms.
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http://dx.doi.org/10.1159/000452284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5465733PMC
March 2017

Fiber Connections of the Supplementary Motor Area Revisited: Methodology of Fiber Dissection, DTI, and Three Dimensional Documentation.

J Vis Exp 2017 05 23(123). Epub 2017 May 23.

Department of Neurosurgery, University of Minnesota.

The purpose of this study is to show the methodology for the examination of the white matter connections of the supplementary motor area (SMA) complex (pre-SMA and SMA proper) using a combination of fiber dissection techniques on cadaveric specimens and magnetic resonance (MR) tractography. The protocol will also describe the procedure for a white matter dissection of a human brain, diffusion tensor tractography imaging, and three-dimensional documentation. The fiber dissections on human brains and the 3D documentation were performed at the University of Minnesota, Microsurgery and Neuroanatomy Laboratory, Department of Neurosurgery. Five postmortem human brain specimens and two whole heads were prepared in accordance with Klingler's method. Brain hemispheres were dissected step by step from lateral to medial and medial to lateral under an operating microscope, and 3D images were captured at every stage. All dissection results were supported by diffusion tensor imaging. Investigations on the connections in line with Meynert's fiber tract classification, including association fibers (short, superior longitudinal fasciculus I and frontal aslant tracts), projection fibers (corticospinal, claustrocortical, cingulum, and frontostriatal tracts), and commissural fibers (callosal fibers) were also conducted.
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http://dx.doi.org/10.3791/55681DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5608134PMC
May 2017

Cortical Bone Trajectory Screw for Lumbar Fixation: A Quantitative Anatomic and Morphometric Evaluation.

World Neurosurg 2017 Jul 3;103:694-701. Epub 2017 May 3.

Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.

Background: Lumbar cortical bone trajectory (CBT) screw constructs provide an alternative method of pedicle screw fixation in minimally invasive spine surgery. In this study, we explored the CBT technique in further anatomic detail. The primary aims were to evaluate variations in anatomy relevant to CBT screw placement and to determine optimal screw location, trajectory, and length using measures obtained from computed tomography (CT) scans.

Methods: One hundred CT scans of the lumbar spine were reviewed, and 14 total measurements of entry points, trajectories, and lengths for placement of CBT screws were evaluated.

Results: Across all lumbar levels, the mean right pedicle-pars interarticularis junction length ranged from 7.58 ± 1.18 mm to 8.37 ± 1.42 mm, and the mean left pedicle-pars interarticularis junction length ranged from 7.95 ± 1.42 mm to 8.6 ± 1.74 mm. The pedicle-pars interarticularis junction from L1 to L5 was deemed too small for a 5-mm-diameter CBT screw in 35%, 24%, 17%, 17%, and 19%, respectively, on the right, and in 30%, 17%, 17%, 17%, and 20%, respectively, on the left. The average length of a screw placed along the cranial cortical bone of the pedicle ranged from 27 ± 2.5 mm to 30.5 ± 3.4 mm, and the angle of the screw with respect to the vertebral body endplate ranged from 44 ± 4.1° to 48 ± 6.2°.

Conclusions: Improved anatomic knowledge relevant to CBT screw placement for lumbar fixation offers the potential for improving outcomes and reducing complications. Moreover, detailed analysis of the anatomy of the pedicle-pars interarticularis junction via preoperative CT can aid in determining the ideal fixation method.
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http://dx.doi.org/10.1016/j.wneu.2017.03.137DOI Listing
July 2017

Feasibility of Telementoring for Microneurosurgical Procedures Using a Microscope: A Proof-of-Concept Study.

World Neurosurg 2017 Mar 2;99:680-686. Epub 2016 Dec 2.

Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.

Background: Our pilot study evaluated the effectiveness of our telementoring-telescripting model to facilitate seamless communication between surgeons while the operating surgeon is using a microscope.

Methods: As a first proof of concept, 4 students identified 20 anatomic landmarks on a dry human skull with or without telementoring guidance. To assess the ability to communicate operative information, a senior neurosurgery resident evaluated the student's ability and timing to complete a stepwise craniotomy on a cadaveric head, with and without telementoring guidance; a second portion included exposure of the anterior circulation. The mentor was able to annotate directly onto the operator's visual field, which was visible to the operator without looking away from the binocular view.

Results: The students showed that they were familiar with half (50% ± 10%) of the structures for identification and none was familiar with the steps to complete a craniotomy before using our system. With the guidance of a remote surgeon projected into the visual field of the microscope, the students were able to correctly identify 100% of the structures and complete a craniotomy. Our system also proved effective in guiding a more experienced neurosurgery resident through complex operative steps associated with exposure of the anterior circulation.

Conclusions: Our pilot study showed a platform feasible in providing effective operative direction to inexperienced operators while operating using a microscope. A remote mentor was able to view the visual field of the microscope, annotate on the visual stream, and have the annotated stream appear in the binocular view for the operating mentee.
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http://dx.doi.org/10.1016/j.wneu.2016.11.121DOI Listing
March 2017

Isolated Hypertrophic Neuropathy of the Oculomotor Nerve.

World Neurosurg 2017 Feb 19;98:880.e1-880.e4. Epub 2016 Nov 19.

Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA.

Background: Hypertrophic neuropathy is a rare entity commonly associated with peripheral nerve, characterized by onion bulb formations. Its cranial nerve involvement is very rare; only 7 cases have been found in the literature.

Case Description: A 32-year-old white man with a 5-year history of intermittent right retro-orbital headache and mild right ptosis presented to the Neurosurgery Clinic. A magnetic resonance imaging of his brain demonstrated an enhancing lesion associated with the right third nerve. He underwent biopsy of the lesion, and its pathology report confirmed the diagnosis of hypertrophic neuropathy. Within 4 months, his third nerve palsy had completely resolved and was functioning fully.

Conclusions: Here, we report a first case of isolated hypertrophic neuropathy involving the oculomotor nerve.
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http://dx.doi.org/10.1016/j.wneu.2016.11.048DOI Listing
February 2017

Microsurgical and Tractographic Anatomy of the Supplementary Motor Area Complex in Humans.

World Neurosurg 2016 Nov 28;95:99-107. Epub 2016 Jul 28.

Department of Neurosurgery, University of Minnesota, Minneapolis, Minnesota, USA. Electronic address:

Objective: To evaluate the microsurgical anatomy of the fiber tract connections of the supplementary motor area (SMA) and pre-SMA, and examine its potential functional role with reference to clinical trials in the literature.

Methods: Ten postmortem formalin-fixed human brains (20 sides) and 1 cadaveric head were prepared following Klingler's method. The fiber dissection was performed in a stepwise fashion, from lateral to medial and also from medial to lateral, under an operating microscope, with 3D images captured at each stage. Our findings were supported by in vivo magnetic resonance imaging tractography in 2 healthy subjects.

Results: The connections of the SMA complex, composed of the pre-SMA and the SMA proper, are composed of short "U" association fibers and the superior longitudinal fasciculus I, cingulum, claustrocortical fibers, callosal fibers, corticospinal tract, frontal aslant tract, and frontostriatal tract. The claustrocortical fibers may play an important role in the integration of motor, language, and limbic functions of the SMA complex. The frontostriatal tract connects the pre-SMA to the putamen and caudate nucleus, and also forms parts of both the internal capsule and the dorsal external capsule.

Conclusions: The SMA complex has numerous connections throughout the cerebrum. An understanding of these connections is important for presurgical planning for lesions in the frontal lobe and helps explain symptoms related to SMA injury.
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http://dx.doi.org/10.1016/j.wneu.2016.07.072DOI Listing
November 2016

Endovascular management of a vein of Galen aneurysmal malformation in an infant with challenging femoral arterial access.

J Neurosurg Pediatr 2016 Aug 8;18(2):231-4. Epub 2016 Apr 8.

Departments of 1 Radiology.

A 5-month-old infant was to be treated with elective transarterial embolization for a vein of Galen aneurysmal malformation (VGAM). A team of endovascular surgical neuroradiologists, pediatric interventional radiologists, and pediatric cardiologists attempted conventional femoral arterial access, which was unsuccessful given the small caliber of the femoral arteries and superimposed severe vasospasm. Thereafter, eventual arterial access was achieved by navigating from the venous to the arterial system across the patent foramen ovale following a right femoral venous access. Embolization was then successfully performed. At a later date, the child underwent successful transvenous balloon-assisted embolization and eventual arterial embolization with cure of the VGAM.
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http://dx.doi.org/10.3171/2016.2.PEDS15652DOI Listing
August 2016

The Lateral Mesencephalic Vein: Surgical Anatomy and Its Role in the Drainage of Tentorial Dural Arteriovenous Fistulae.

World Neurosurg 2016 Jan 1;85:163-8. Epub 2015 Sep 1.

Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Background: The lateral mesencephalic vein (LMV) represents an important connection between the infratentorial and supratentorial compartments. It joins the basal vein of Rosenthal and the petrosal system. In our experience with management of tentorial dural arteriovenous fistulas (DAVFs) we have often noted involvement of the lateral mesencephalic vein (LMV) in the venous drainage of these fistulas.

Methods: We reviewed the clinical and angiographic findings of 26 patients with tentorial DAVFs to study the incidence and pattern of drainage through the LMV. In addition, we reviewed the pertinent literature on the anatomy of the LMV.

Results: The LMV was involved in the venous drainage of 31% (8/26) of patients with tentorial DAVFs. The direction of venous drainage through the LMV is more commonly from the infratentorial to the supratentorial compartment. There were no specific clinical symptoms/signs associated with tentorial DAVFs involving the LMV compared with those without LMV involvement. When involved in DAVF drainage, the LMV could be invariably identified on noninvasive imaging studies. We present illustrative clinical/angiographic cases and provide a detailed review of the pertinent clinical anatomy of this important but often neglected intracranial vein.

Conclusions: The LMV is a constant venous anastomosis between the supratentorial and infratentorial compartments. Detailed knowledge of the most common variations of the LMV surgical and radiological anatomy has important clinical implications. The vein is an important anatomic landmark during surgery of midbrain lesions. It is often involved in the tentorial DAVF drainage, and it is critical in understanding some "unexpected" venous complications during surgery for posterior fossa lesions.
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http://dx.doi.org/10.1016/j.wneu.2015.08.060DOI Listing
January 2016
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