Publications by authors named "Arka N Mallela"

15 Publications

  • Page 1 of 1

Robotic-assisted stereotactic drainage of cerebral abscess and placement of ventriculostomy.

Br J Neurosurg 2021 Aug 31:1-4. Epub 2021 Aug 31.

Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

Background: Robotic surgery has found increasing use in multiple subfields of neurosurgery. While the initial applications of stereotactic robotic surgery were for the placement of electrodes for extra-operative seizure monitoring, this technique has become increasingly relevant in other areas of neurosurgery. To the best of our knowledge, we report the first case of successful robotic surgery utilization to drain a cerebral abscess and place an external ventricular drain.

Case Report: The authors demonstrate a novel use for stereotactic robotic assistance to drain a cerebral abscess and place ventriculostomy in a 74-year-old female patient who presented with a left basal ganglia abscess and concomitant ventriculitis. Drainage of a deep-seated abscess and placement of ventriculostomy was successfully performed in this patient without intraoperative difficulties or complications. The total operative time, including registration was 64 minutes and the estimated blood loss was 25 mL. The patient recovered well and was discharged to inpatient rehabilitation on postoperative day 19.

Conclusions: The use of robotic surgery to drain cerebral abscesses and place ventriculostomies is technically feasible and may potentially decrease operative time and increase accuracy and safety.
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http://dx.doi.org/10.1080/02688697.2021.1969006DOI Listing
August 2021

Chronic encapsulated expanding hematomas after stereotactic radiosurgery for intracranial arteriovenous malformations.

J Neurosurg 2021 Jul 30:1-11. Epub 2021 Jul 30.

Departments of1Neurological Surgery and.

Objective: Cerebral arteriovenous malformations (AVMs) are rare cerebral vascular lesions that are associated with high morbidity and mortality from hemorrhage; however, stereotactic radiosurgery (SRS) is a well-validated treatment modality. Few reports have delineated a subgroup of patients who develop delayed chronic encapsulated expanding hematomas (CEEHs) despite angiographic evidence of AVM obliteration following radiosurgery. In this report, the authors performed a retrospective review of more than 1000 radiosurgically treated intracranial AVM cases to delineate the incidence and management of this rare entity.

Methods: Between 1988 and 2019, 1010 patients with intracranial AVM underwent Gamma Knife SRS at the University of Pittsburgh Medical Center. In addition to a review of a prospective institutional database, the authors performed a retrospective chart review of the departmental AVM database to specifically identify patients with CEEH. Pertinent clinical and radiological characteristics as well as patient outcomes were recorded and analyzed.

Results: Nine hundred fifty patients with intracranial AVM (94%) had sufficient clinical follow-up for analysis. Of these, 6 patients with CEEH underwent delayed resection (incidence rate of 0.0045 event per person-year). These patients included 4 males and 2 females with a mean age of 45.3 ± 13.8 years at the time of initial SRS. Four patients had smaller AVM volumes (4.9-10 cm3), and 3 of them were treated with a single SRS procedure. Two patients had larger-volume AVMs (55 and 56 cm3), and both underwent multimodal management that included staged SRS and embolization. Time to initial recognition of the CEEH after initial SRS ranged between 66 and 243 months. The time between CEEH recognition and resection ranged from 2 to 9 months. Resection was required because of progressive neurological symptoms that correlated with imaging evidence of gradual hematoma expansion. All 6 patients had angiographically confirmed obliteration of their AVM. Pathology revealed a mixed chronicity hematoma with areas of fibrosed blood vessels and rare areas of neovascularization with immature blood vessels but no evidence of a persistent AVM. All 6 patients reported persistent clinical improvement after hematoma resection.

Conclusions: CEEH after SRS for AVM is a rare complication with an incidence rate of 0.0045 event per person-year over the authors' 30-year experience. When clinical symptoms progress and imaging reveals progressive enlargement over time, complete resection of a CEEH results in significant clinical recovery. Knowledge of this rare entity facilitates timely detection and eventual surgical intervention to achieve optimal outcomes.
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http://dx.doi.org/10.3171/2021.1.JNS203476DOI Listing
July 2021

Stereotactic Electroencephalography Implantation Through Nonautologous Cranioplasty: Proof of Concept.

Oper Neurosurg (Hagerstown) 2021 Sep;21(4):258-264

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.

Background: Stereoelectroencephalography (SEEG) is an effective method to define the epileptogenic zone (EZ) in patients with medically intractable epilepsy. Typical placement requires passing and anchoring electrodes through native skull.

Objective: To describe the successful placement of SEEG electrodes in patients without native bone. To the best of our knowledge, the use of SEEG in patients with nonautologous cranioplasties has not been described.

Methods: We describe 3 cases in which SEEG was performed through nonautologous cranioplasty. The first is a 30-yr-old male with a titanium mesh cranioplasty following a left pterional craniotomy for aneurysm clipping. The second is a 51-yr-old female who previously underwent lesionectomy of a ganglioglioma with mesh cranioplasty and subsequent recurrence of her seizures. The third is a 31-yr-old male with a polyether ether ketone cranioplasty following decompressive hemicraniectomy for trauma.

Results: SEEG was performed successfully in all three cases without intraoperative difficulties or complications and with excellent electroencephalogram recording and optimal localization of the seizure focus. The EZ was successfully localized in all three patients. There were no limitations related to drilling or inserting the guiding bolt/electrode through the nonautologous cranioplasties.

Conclusion: SEEG through nonautologous cranioplasties was clinically feasible, safe, and effective in our series. The presence of nonautologous bone cranioplasty should not preclude such patients from undergoing SEEG explorations.
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http://dx.doi.org/10.1093/ons/opab260DOI Listing
September 2021

An additive score optimized by a genetic learning algorithm predicts readmission risk after glioblastoma resection.

J Clin Neurosci 2020 Oct 17;80:1-5. Epub 2020 Aug 17.

Department of Neurological Surgery, UT Southwestern Medical Center, Dallas, TX 75390, USA. Electronic address:

Thirty-day readmission following glioblastoma (GBM) resection is not only correlated with decreased overall survival but also increasingly tied to quality metrics and reimbursement. This study aimed to determine factors linked with 30-day readmission to develop a simple risk stratification score. From 2005 to 2016, 666 unique resections (467 patients) of primary/recurrent tissue-confirmed glioblastoma were retrospectively identified. We recorded patient demographics and medical history, tumor characteristics, post-operative complications and 30-day readmission. Univariate and multivariate logistic regression, optimized using a genetic learning algorithm, were used to determine factors associated with readmission. The multivariate model was converted to a simple additive score. The 30-day readmission rate was 20.3% in our cohort of 666 unique resections (60.7% first resection). Lower pre/post-operative KPS, recurrent resection, surgical-site infection, post-operative VTE, post-operative VPS, and discharge to a rehabilitation facility were significantly associated with an increased readmission risk (p < 0.05). MGMT methylation and chemoradiation were associated with decreased readmission risk (p < 0.05). Medical co-morbidities and past medical history, location of tumor in eloquent areas of the brain, and length of ICU/hospital stay did not predict readmission. The Glioblastoma Readmission Risk Score, developed from the multivariate model, accounts for increased BMI, decreased pre-operative KPS, current smoking, post-operative complications, MGMT methylation, and post-operative radiation. This risk score can be routinely used to stratify risk and assist in clinical decision making and outcome analyses.
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http://dx.doi.org/10.1016/j.jocn.2020.07.048DOI Listing
October 2020

Sylvian fissure development is linked to differential genetic expression in the pre-folded brain.

Sci Rep 2020 09 2;10(1):14489. Epub 2020 Sep 2.

Department of Neurological Surgery, University of Pittsburgh Medical Center, UPMC Presbyterian Hospital, 200 Lothrop Street, Suite B-400, Pittsburgh, PA, 15213, USA.

The mechanisms by which the human cerebral cortex folds into its final form remain poorly understood. With most of the current models and evidence addressing secondary folds, we sought to focus on the global geometry of the mature brain by studying its most distinctive feature, the Sylvian fissure. A digital human fetal brain atlas was developed using previously obtained MRI imaging of 81 healthy fetuses between gestational ages 21 and 38 weeks. To account for the development of the Sylvian fissure, we compared the growth of the frontotemporal opercula over the insular cortex and compared the transcriptome of the developing cortices for both regions. Spatiotemporal mapping of the lateral hemispheric surface showed the highest rate of organized growth in regions bordering the Sylvian fissure of the frontal, parietal and temporal lobes. Volumetric changes were first observed in the posterior aspect of the fissure moving anteriorly to the frontal lobe and laterally in the direction of the temporal pole. The insular region, delineated by the limiting insular gyri, expanded to a much lesser degree. The gene expression profile, before folding begins in the maturing brain, was significantly different in the developing opercular cortex compared to the insula. The Sylvian fissure forms by the relative overgrowth of the frontal and temporal lobes over the insula, corresponding to domains of highly expressed transcription factors involved in neuroepithelial cell differentiation.
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http://dx.doi.org/10.1038/s41598-020-71535-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7468287PMC
September 2020

Different Principles Govern Different Scales of Brain Folding.

Cereb Cortex 2020 07;30(9):4938-4948

Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.

The signature folds of the human brain are formed through a complex and developmentally regulated process. In vitro and in silico models of this process demonstrate a random pattern of sulci and gyri, unlike the highly ordered and conserved structure seen in the human cortex. Here, we account for the large-scale pattern of cortical folding by combining advanced fetal magnetic resonance imaging with nonlinear diffeomorphic registration and volumetric analysis. Our analysis demonstrates that in utero brain growth follows a logistic curve, in the absence of an external volume constraint. The Sylvian fissure forms from interlobar folding, where separate lobes overgrow and close an existing subarachnoid space. In contrast, other large sulci, which are the ones represented in existing models, fold through an invagination of a flat surface, a mechanistically different process. Cortical folding is driven by multiple spatially and temporally different mechanisms; therefore regionally distinct biological process may be responsible for the global geometry of the adult brain.
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http://dx.doi.org/10.1093/cercor/bhaa086DOI Listing
July 2020

Commentary: Endoscopic Interhemispheric Disconnection for Intractable Multifocal Epilepsy: Surgical Technique and Functional Neuroanatomy.

Oper Neurosurg (Hagerstown) 2020 02;18(2):E30-E31

Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania.

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http://dx.doi.org/10.1093/ons/opz211DOI Listing
February 2020

Liver disease is an independent predictor of poor 30-day outcomes following surgery for degenerative disease of the cervical spine.

Spine J 2019 03 24;19(3):448-460. Epub 2018 Jul 24.

Department of Neurosurgery, Hospital of the University of Pennsylvania, 3400 Spruce St, Philadelphia, PA, USA.

Background And Context: The impact of underlying liver disease on surgical outcomes has been recognized in a wide variety of surgical disciplines. However, less empiric data are available about the importance of liver disease in spinal surgery.

Purpose: To measure the independent impact of underlying liver disease on 30-day outcomes following surgery for the degenerative cervical spine.

Study Design: Retrospective comparative study.

Patient Sample: A cohort of 21,207 patients undergoing elective surgery for degenerative disease of the cervical spine from the American College of Surgeons National Surgical Quality Improvement Program.

Outcome Measures: Outcome measures included mortality, hospital length of stay, and postoperative complications within 30 days of surgery.

Methods: The NSQIP dataset was queried for patients undergoing surgery for degenerative disease of the cervical spine from 2006 to 2015. Assessment of underlying liver disease was based on aspartate aminotransferase-to-platelet ratio index and Model of End-Stage Liver Disease-Sodium scores, computed from preoperative laboratory data. The effect of liver disease on outcomes was assessed by bivariate and multivariate analyses, in comparison with 16 other preoperative and operative factors.

Results: Liver disease could be assessed in 21,207 patients based on preoperative laboratory values. Mild liver disease was identified in 2.2% of patients, and advanced liver disease was identified in 1.6% of patients. The 30-day mortality rates were 1.7% and 5.1% in mild and advanced liver diseases, respectively, compared with 0.6% in patients with healthy livers. The 30-day complication rates were 11.8% and 31.5% in these patients, respectively, compared with 8.8% in patients with healthy livers. In multivariate analysis, the presence of any liver disease (mild or advanced) was independently associated with an increased risk of mortality (OR=2.00, 95% CI=1.12-3.55, p=.019), morbidity (OR=1.35, 95% CI=1.07-1.70, p=.012), and length of hospital stay longer than 7 days (OR=1.73, 95% CI=1.40-2.13, p<.001), when compared with 18 other preoperative and operative factors. Liver disease was also independently associated with perioperative respiratory failure (OR=1.80, 95% CI=1.21-2.68, p=.004), bleeding requiring transfusion (OR=1.43, 95% CI=1.01-2.02, p=.044), wound disruption (OR=2.82, 95% CI=1.04-7.66, p=.042), and unplanned reoperation (OR=1.49, 95% CI=1.05-2.11, p=.025).

Conclusions: Liver disease independently predicts poor perioperative outcome following surgery for degenerative disease of the cervical spine. Based on these findings, careful consideration of a patient's underlying liver function before surgery may prove valuable in surgical decision-making, preoperative patient counseling, and postoperative patient care.
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http://dx.doi.org/10.1016/j.spinee.2018.07.010DOI Listing
March 2019

Complications Predicting Perioperative Mortality in Patients Undergoing Elective Craniotomy: A Population-Based Study.

World Neurosurg 2018 Oct 30;118:e195-e205. Epub 2018 Jun 30.

Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA.

Objective: The objective of this study was to assess the independent effect of complications on 30-day mortality in 32,695 patients undergoing elective craniotomy.

Methods: The American College of Surgeons National Surgical Quality Improvement Program was queried for patients undergoing elective craniotomy from 2006 to 2015. Multivariate logistic regression was used to examine the effect of complications on mortality independent of preoperative risk and other postoperative complications. This effect was further assessed in risk-stratified patient subgroups using the American College of Surgeons National Surgical Quality Improvement Program Surgical Risk Calculator.

Results: Of 13 complications analyzed, the 5 most strongly associated with mortality independent of preoperative risk factors were unplanned intubation (odds ratio [OR], 12.1; 95% confidence interval [CI], 9.5-15.4; P < 0.001), stroke (OR, 11.1; 95% CI, 8.3-14.9; P < 0.001), ventilator requirement >48 hours after surgery (OR, 9.9; 95% CI, 7.9-12.6; P < 0.001), and renal failure (OR, 8.5; 95% CI, 4.4-16.2; P < 0.001). These same complications were also the 5 most associated with mortality independent of other postoperative complications. They were also associated with mortality across all risk-stratified patient subgroups. On the contrary, venous thromboembolism (OR, 1.3; 95% CI, 0.98-1.7; P = 0.06), urinary tract infection (OR, 1.1; 95% CI, 0.76-1.6; P = 0.61), unplanned reoperation (OR, 1.1; 95% CI, 0.83-1.4; P = 0.55), and surgical site infection (OR, 0.35; 95% CI, 0.18-0.71; P = 0.004) showed no significant link with increased mortality independent of other complications.

Conclusions: Of 13 complications analyzed, myocardial infarction, unplanned intubation, prolonged ventilator requirement, stroke, and renal failure showed the strongest association with mortality independent of preoperative risk, independent of other complications, and across all risk-stratified subgroups. These findings help identify causes of perioperative mortality after elective craniotomy. Dedicating additional resources toward preventing and treating these complications postoperatively may help reduce rates of failure-to-rescue in the neurosurgical population.
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http://dx.doi.org/10.1016/j.wneu.2018.06.153DOI Listing
October 2018

The effect and evolution of patient selection on outcomes in endoscopic third ventriculostomy for hydrocephalus: A large-scale review of the literature.

J Neurol Sci 2018 02 20;385:185-191. Epub 2017 Dec 20.

Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania Silverstein 3rd Floor, 3400 Spruce Street, Philadelphia, PA 19104, USA.

Endoscopic third ventriculostomy (ETV) has become a popular technique for the treatment of hydrocephalus, but small sample size has limited the generalizability of prior studies. We performed a large-scale review of all available studies to help eliminate bias and determine how outcomes have changed and been influenced by patient selection over time. A systematic literature search was performed for studies of ETV that contained original, extractable patient data, and a meta-analytic model was generated for correlative and predictive analysis. A total of 130 studies were identified, which included 11,952 cases. Brain tumor or cyst was the most common hydrocephalus etiology, but high-risk etiologies, post-infectious or post-hemorrhagic hydrocephalus, accounted for 18.4%. Post-operative mortality was very low (0.2%) and morbidity was only slightly higher in developing than in industrialized countries. The rate of ETV failure was 34.7% and was higher in the first months and plateaued around 20months. As anticipated, ETV is less successful in high-risk etiologies of hydrocephalus and younger patients. Younger patient age and high-risk etiologies predicted failure. ETVs were performed more often in high-risk etiologies over time, but, surprisingly, there was no overall change in ETV success rate over time. This study should help to influence optimal patient selection and offer guidance in predicting outcomes.
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http://dx.doi.org/10.1016/j.jns.2017.12.025DOI Listing
February 2018

Topical Vancomycin Reduces Surgical-Site Infections After Craniotomy: A Prospective, Controlled Study.

Neurosurgery 2018 10;83(4):761-767

Department of Neurosurgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania.

Background: Surgical-site infections (SSIs) are an important cause of morbidity and mortality in neurosurgical patients. Topical antibiotics are one potential method to reduce the incidence of these infections.

Objective: To examine the efficacy of topical vancomycin applied within the wound during craniotomy in a large prospective cohort study at a major academic center.

Methods: Three hundred fifty-five patients were studied prospectively in this cohort study; 205 patients received 1 g of topical vancomycin powder in the subgaleal space while 150 matched control patients did not. Patients otherwise received identical care. The primary outcome variable was SSI rate factored by cohort. Secondary analysis examined cost savings from vancomycin usage estimated from hospital costs associated with SSI in craniotomy patients.

Results: The addition of topical vancomycin was associated with a significantly lower rate of SSI than standard of care alone (0.49% [1/205] vs 6% [9/150], P = .002). Based on the costs of revision surgery for infections, topical vancomycin usage was estimated to save $1367 446 per 1000 craniotomy patients. No adverse reactions occurred.

Conclusion: Topical vancomycin is a safe, effective, and cost-saving measure to prevent SSIs following craniotomy. These results have broad implications for standard of care in craniotomy.
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http://dx.doi.org/10.1093/neuros/nyx559DOI Listing
October 2018

Thirty-Day Readmission Rates Following Deep Brain Stimulation Surgery.

Neurosurgery 2017 Aug;81(2):259-267

Department of Neurosurgery, Perelman School of Medicine, University of Penn-sylvania, Philadelphia, Pennsylvania.

Background: Deep brain stimulation (DBS) has emerged as a safe and efficacious surgical intervention for several movement disorders; however, the 30-day all-cause readmission rate associated with this procedure has not previously been documented.

Object: To perform a retrospective cohort study to estimate the 30-day all-cause readmission rate associated with DBS.

Methods: We reviewed medical records of patients over the age of 18 who underwent DBS surgery at Pennsylvania Hospital of the University of Pennsylvania between 2009 and 2014. We identified patients who were readmitted to an inpatient medical facility within 30 days from their initial discharge.

Results: Over the study period, 23 (6.6%) of 347 DBS procedures resulted in a readmission to the hospital within 30 days. Causes of readmission were broadly categorized into surgery-related (3.7%): intracranial lead infection (0.6%), battery-site infection (0.6%), intracranial hematoma along the electrode tract (0.6%), battery-site hematoma (0.9%), and seizures (1.2%); and nonsurgery-related (2.9%): altered mental status (1.8%), nonsurgical-site infections (0.6%), malnutrition and poor wound healing (0.3%), and a pulse generator malfunction requiring reprogramming (0.3%). Readmissions could be predicted by the presence of medical comorbidities ( P < .001), but not by age, gender, or length of stay ( P s > .15).

Conclusion: All-cause 30-day readmission for DBS is 6.6%. This compares favorably to previously studied neurosurgical procedures. Readmissions frequently resulted from surgery-related complications, particularly infection, seizures, and hematomas, and were significantly associated with the presence of medical comorbidities ( P < .001).
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http://dx.doi.org/10.1093/neuros/nyx019DOI Listing
August 2017

Excellent neurologic recovery after prolonged coma in a cardiac arrest patient with multiple poor prognostic indicators.

Resuscitation 2017 04 9;113:e11-e12. Epub 2017 Feb 9.

Division of Neurocritical Care, Department of Neurology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, USA. Electronic address:

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http://dx.doi.org/10.1016/j.resuscitation.2017.01.022DOI Listing
April 2017

Altered Resting-State Functional Connectivity in the Hand Motor Network in Glioma Patients.

Brain Connect 2016 10 22;6(8):587-595. Epub 2016 Aug 22.

1 Functional MRI Laboratory, Department of Radiology, Memorial Sloan-Kettering Cancer Center , New York, New York.

To examine the functional connectivity of the primary and supplementary motor areas (SMA) in glioma patients using resting-state functional MRI (rfMRI). To correlate rfMRI data with tumor characteristics and clinical information to characterize functional reorganization of resting-state networks (RSN) and the limitations of this method. This study was IRB approved and in compliance with Health Insurance Portability and Accountability Act. Informed consent was waived in this retrospective study. We analyzed rfMRI in 24 glioma patients and 12 age- and sex-matched controls. We compared global activation, interhemispheric connectivity, and functional connectivity in the hand motor RSNs using hemispheric voxel counts, pairwise Pearson correlation, and pairwise total spectral coherence. We explored the relationship between tumor grade, volume, location, and the patient's clinical status to functional connectivity. Global network activation and interhemispheric connectivity were reduced in gliomas (p < 0.05). Functional connectivity between the bilateral motor cortices and the SMA was reduced in gliomas (p < 0.01). High-grade gliomas had lower functional connectivity than low-grade gliomas (p < 0.05). Tumor volume and distance to ipsilateral motor cortex demonstrated no association with functional connectivity loss. Functional connectivity loss is associated with motor deficits in low-grade gliomas, but not in high-grade gliomas. Global reduction in resting-state connectivity in areas distal to tumor suggests that radiological tumor boundaries underestimate areas affected by glioma. Association between motor deficits and rfMRI suggests that rfMRI may accurately reflect functional changes in low-grade gliomas. Lack of association between rfMRI and clinical motor deficits implies decreased sensitivity of rfMRI in high-grade gliomas, possibly due to neurovascular uncoupling.
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http://dx.doi.org/10.1089/brain.2016.0432DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6913111PMC
October 2016

Neuropathological Characteristics of Brachial Plexus Avulsion Injury With and Without Concomitant Spinal Cord Injury.

J Neuropathol Exp Neurol 2016 Jan;75(1):69-85

Neonatal brachial plexus avulsion injury (BPAI) commonly occurs as a consequence of birth trauma and can result in lifetime morbidity; however, little is known regarding the evolving neuropathological processes it induces. In particular, mechanical forces during BPAI can concomittantly damage the spinal cord and may contribute to outcome. Here, we describe the functional and neuropathological outcome following BPAI, with or without spinal cord injury, in a novel pediatric animal model. Twenty-eight-day-old piglets underwent unilateral C5–C7 BPAI with and without limited myelotomy. Following avulsion, all animals demonstrated right forelimb monoparesis. Injury extending into the spinal cord conferred greater motor deficit, including long tract signs. Consistent with clinical observations, avulsion with myelotomy resulted in more severe neuropathological changes with greater motor neuron death, progressive axonopathy, and persistent glial activation. These data demonstrate neuropathological features of BPAI associated with poor functional outcome. Interestingly, in contrast to adult small animal models of BPAI, a degree of motor neuron survival was observed, even following severe injury in this neonatal model. If this is also the case in human neonatal BPAI, repair may permit functional restoration. This model also provides a clinically relevant platform for exploring the complex postavulsion neuropathological responses that may inform therapeutic strategies.
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http://dx.doi.org/10.1093/jnen/nlv002DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6322589PMC
January 2016
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