Publications by authors named "Ben A Strickland"

88 Publications

Commentary: Infra-Occipital Supra-Tentorial Approach for Resection of Low-Grade Tumor of the Left Lingual Gyrus: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 Jun 10. Epub 2021 Jun 10.

Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

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http://dx.doi.org/10.1093/ons/opab178DOI Listing
June 2021

Commentary: Application of Augmented Reality in Percutaneous Procedures-Rhizotomy of the Gasserian Ganglion.

Oper Neurosurg (Hagerstown) 2021 Jun 7. Epub 2021 Jun 7.

Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

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http://dx.doi.org/10.1093/ons/opab179DOI Listing
June 2021

Stereotactic Radiosurgery for Differentiated Thyroid Cancer Brain Metastases: An International, Multicenter Study.

Thyroid 2021 May 11. Epub 2021 May 11.

Department of Neurosurgery, University of Virginia, Charlottesville, Virginia, USA.

Brain metastases (BM) from differentiated thyroid cancer are rare. Stereotactic radiosurgery (SRS) is commonly used for the treatment of BMs; however, the experience with SRS for thyroid cancer BMs remains limited. The goal of this international, multi-centered study was to evaluate the efficacy and safety of SRS for thyroid cancer BMs. From 10 institutions participating in the International Radiosurgery Research Foundation, we pooled patients with established papillary or follicular thyroid cancer diagnosis who underwent SRS for histologically confirmed or radiologically suspected BMs. We investigated patient overall survival (OS), local tumor control, and adverse radiation events (AREs). We studied 42 (52% men) patients who underwent SRS for 122 papillary (83%) or follicular (17%) thyroid cancer BMs. The mean age at SRS was 59.86 ± 12.69 years. The mean latency from thyroid cancer diagnosis to SRS for BMs was 89.05 ± 105.49 months. The median number of BMs per patient was 2 (range: 1-10 BMs). The median SRS treatment volume was 0.79 cm (range: 0.003-38.18 cm), and the median SRS prescription dose was 20 Gy (range: 8-24 Gy). The median survival after SRS for BMs was 14 months (range: 3-58 months). The OS was significantly shorter in patients harboring ≥2 BMs, when compared with patients with one BM (Log-rank = 5.452,  = 0.02). Two or more BMs (odds ratio [OR] = 3.688; confidence interval [CI]: 1.143-11.904;  = 0.03) and lower Karnofsky performance score at the time of SRS (OR = 0.807; CI: 0.689-0.945;  = 0.008) were associated with shorter OS. During post-SRS imaging follow-up of 25.21 ± 30.49 months, local failure (progression and/or radiation necrosis) of BMs treated with SRS was documented in five (4%) BMs at 7.2 ± 7.3 months after the SRS. At the last imaging follow-up, the majority of patients with available imaging data had stable intracranial disease (33%) or achieved complete (26%) or partial (24%) response. There were no clinical AREs. Post-SRS peritumoral T2/fluid attenuated inversion recovery signal hyperintensity was noted in 7% BMs. The SRS allows durable local control of papillary and follicular thyroid cancer BMs in the vast majority of patients. Higher number of BMs and worse functional status at the time of SRS are associated with shorter OS in patients with thyroid cancer BMs. The SRS is safe and is associated with a low risk of AREs.
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http://dx.doi.org/10.1089/thy.2020.0947DOI Listing
May 2021

Silent corticotroph pituitary adenomas: clinical characteristics, long-term outcomes, and management of disease recurrence.

J Neurosurg 2021 May 7:1-8. Epub 2021 May 7.

Departments of1Neurological Surgery.

Objective: Silent corticotroph adenomas (SCAs) are a distinct subtype of nonfunctioning pituitary adenomas (NFAs) that demonstrate positive immunohistochemistry for adrenocorticotropic hormone (ACTH) without causing Cushing's disease. SCAs are hypothesized to exhibit more aggressive behavior than standard NFAs. The authors analyzed their institution's surgical experience with SCAs in an effort to characterize rates of invasion, postoperative clinical outcomes, and patterns of disease recurrence and progression. The secondary objectives were to define the best treatment strategies in the event of tumor recurrence and progression.

Methods: A retrospective analysis of patients treated at the authors' institution identified 100 patients with SCAs and 841 patients with NFAs of other subtypes who were treated surgically from 2000 to 2019. Patient demographics, tumor characteristics, surgical and neuroimaging data, rates of endocrinopathy, and neurological outcomes were recorded. Cohorts of patients with SCAs and patients with standard NFAs were compared with regard to these characteristics and outcomes.

Results: The SCA cohort presented with cranial neuropathy (13% vs 5.7%, p = 0.0051) and headache (53% vs 42.3%, p = 0.042) compared to the NFA cohort, despite similar rates of apoplexy. The SCA cohort included a higher proportion of women (SCA 60% vs NFA 45.8%, p = 0.0071) and younger age at presentation (SCA 50.5 ± 13.3 vs NFA 54.6 ± 14.9 years of age, p = 0.0082). Reoperations were comparable between the cohorts (SCA 16% vs NFA 15.7%, p = 0.98). Preoperative pituitary function was comparable between the cohorts with the exception of higher rates of preoperative panhypopituitarism in NFA patients (2% vs 6.1%, respectively; p = 0.0033). The mean tumor diameter in SCA patients was 24 ± 10.8 mm compared to 26 ± 11.3 mm in NFA patients (p = 0.05). Rates of cavernous sinus invasion were higher in the SCA group (56% vs 49.7%), although this result did not reach statistical significance. There were no significant differences in extent of resection, intraoperative CSF leak rates, endocrine or neurological outcomes, or postoperative complications. Ki-67 rates were significantly increased in the SCA cohort (2.88 ± 2.79) compared to the NFA cohort (1.94 ± 1.99) (p = 0.015). Although no differences in overall rates of progression or recurrence were noted, SCAs had a significantly lower progression-free survival (24.5 vs 51.1 months, p = 0.0011). Among the SCA cohort, progression was noted despite the use of adjuvant radiosurgery in 33% (n = 4/12) of treated tumors. Adequate tumor control was not achieved in half (n = 6) of the SCA progression cohort despite radiosurgery or multiple resections.

Conclusions: In this study, to the authors' knowledge the largest surgical series to assess outcomes in SCAs to date, the findings suggest that SCAs are more biologically aggressive tumors than standard NFAs. The progression-free survival duration of patients with SCAs is only about half that of patients with other NFAs. Therefore, close neuroimaging and clinical follow-up are warranted in patients with SCAs, and residual disease should be considered for early postoperative adjuvant radiosurgery, particularly in younger patients.
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http://dx.doi.org/10.3171/2020.10.JNS203236DOI Listing
May 2021

Use of Salvage Surgery or Stereotactic Radiosurgery for Multiply Recurrent Skull Base Chordomas: A Single-Institution Experience and Review of the Literature.

J Neurol Surg B Skull Base 2021 Apr 14;82(2):161-174. Epub 2020 Jan 14.

Department of Radiation Oncology, University of Southern California, Keck School of Medicine, Los Angeles, California, United States.

 Chordomas are locally destructive neoplasms characterized by appreciable recurrence rates after initial multimodality treatment. We examined the outcome of salvage treatment in recurrent/progressive skull base chordomas.  This is a retrospective review of recurrent/progressive skull base chordomas at a tertiary urban academic medical center. The outcomes evaluated were overall survival, progression-free survival (PFS), and incidence of new toxicity.  Eighteen consecutive patients who underwent ≥1 course of treatment (35.3% salvage surgery, 23.5% salvage radiation, and 41.2% both) were included. The median follow-up was 98.6 months (range 16-215 months). After initial treatment, the median PFS was 17.7 months (95% confidence interval [CI]: 4.9-22.6 months). Following initial therapy, age ≥ 40 had improved PFS on univariate analysis (  = 0.03). All patients had local recurrence, with 15 undergoing salvage surgical resections and 16 undergoing salvage radiation treatments (mostly stereotactic radiosurgery [SRS]). The median PFS was 59.2 months (95% CI: 4.0-99.3 months) after salvage surgery, 58.4 months (95% CI: 25.9-195 months) after salvage radiation, and 58.4 months (95% CI: 25.9.0-98.4 months) combined. Overall survival for the total cohort was 98.7% ± 1.7% at 2 years and 92.8% ± 5.5% at 5 years. Salvage treatments were well-tolerated with two patients (11%) reporting tinnitus and one patient each (6%) reporting headaches, visual field deficits, hearing loss, anosmia, dysphagia, or memory loss.  Refractory skull base chordomas present a challenging treatment dilemma. Repeat surgical resection or SRS seems to provide adequate salvage therapy that is well-tolerated when treated at a tertiary center offering multimodality care.
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http://dx.doi.org/10.1055/s-0039-3402019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7987397PMC
April 2021

Neuroprotective effect of minocycline against acute brain injury in clinical practice: A systematic review.

J Clin Neurosci 2021 Apr 27;86:50-57. Epub 2021 Jan 27.

Department of Neurosurgery, University of Southern California, Los Angeles, CA 90033, USA.

Acute brain injury is a leading cause of morbidity and mortality worldwide. The term is inclusive of traumatic brain injury, cerebral ischemia, subarachnoid hemorrhage, and intracerebral hemorrhage. Current pharmacologic treatments have had minimal effect on improving neurological outcomes leading to a significant interest in the development neuroprotective agents. Minocycline is a second-generation tetracycline with high blood brain barrier penetrance due to its lipophilic properties. It functions across multiple molecular pathways involved in secondary-injury cascades following acute brain injury. Animal model studies suggest that minocycline might lead to improved neurologic outcomes, but few such trials exist in humans. Clinical investigations have been limited to small randomized trials in ischemic stroke patients which have not demonstrated a clear advantage in neurologic outcomes, but also have not been sufficiently powered to draw definitive conclusions. The potential neuroprotective effect of minocycline in the setting of traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage have all been limited to pilot studies with phase II/III investigations pending. The authors aim to synthesize what is currently known about minocycline as a neuroprotective agent against acute brain injury in humans.
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http://dx.doi.org/10.1016/j.jocn.2021.01.005DOI Listing
April 2021

Investigating the blood-spinal cord barrier in preclinical models: a systematic review of in vivo imaging techniques.

Spinal Cord 2021 Jun 19;59(6):596-612. Epub 2021 Mar 19.

Department of Physiology and Neuroscience, The Zilkha Neurogenetic Institute, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA.

Study Design: This study is a systematic review.

Objectives: To evaluate current in vivo techniques used in the investigation of the blood-spinal cord barrier (BSCB).

Methods: Search of English language literature for animal studies that investigated the BSCB in vivo. Data extraction included animal model/type, protocol for BSCB evaluation, and study outcomes. Descriptive syntheses are provided.

Results: A total of 40 studies were included, which mainly investigated rodent models of experimental autoimmune encephalomyelitis (EAE) or spinal cord injury (SCI). The main techniques used were magnetic resonance imaging (MRI) and intravital microscopy (IVM). MRI served as a reliable tool to longitudinally track BSCB permeability changes with dynamic contrast enhancement (DCE) using gadolinium, or assess inflammatory infiltrations with targeted alternative contrast agents. IVM provided high-resolution visualization of cellular and molecular interactions across the microvasculature, commonly with either epi-fluorescence or two-photon microscopy. MRI and IVM techniques enabled the evaluation of therapeutic interventions and mechanisms that drive spinal cord dysfunction in EAE and SCI. A small number of studies demonstrated the feasibility of DCE-computed tomography, ultrasound, bioluminescent, and fluorescent optical imaging methods to evaluate the BSCB. Technique-specific limitations and multiple protocols for image acquisition and data analyses are described for all techniques.

Conclusion: There are few in vivo investigations of the BSCB. Additional studies are needed in less commonly studied spinal cord disorders, and to establish standardized protocols for data acquisition and analysis. Further development of techniques and multimodal approaches could overcome current imaging limitations to the spinal cord. These advancements might promote wider adoption of techniques, and can provide greater potential for clinical translation.
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http://dx.doi.org/10.1038/s41393-021-00623-7DOI Listing
June 2021

Demographic-Dependent Risk of Developing Severe Novel Psychiatric Disorders after Concussion.

J Neurotrauma 2021 Apr 26. Epub 2021 Apr 26.

Department of Neurosurgery, and Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Current guidelines for patients experiencing a concussion or mild traumatic brain injury (mTBI) often focus on conservative care and observation. However, mTBI may increase the risk of severe novel psychiatric disorders (NPDs) within 180 days, and long-term management of mTBI should include psychiatric evaluation in patient populations. Retrospective cohort analysis was conducted using 8 years of the Nationwide Readmission Database. All individuals who were admitted for concussion and were readmitted within 180 days were queried. This cohort was then subdivided based on age, sex, and whether they experienced loss of consciousness (LOC) to control for demographic-dependent confounding. A binary decision tree provided recommendations for patients who may be at risk of developing severe NPDs. Analysis included 12,080 patients who experienced concussion. Males and females with LOC had higher rates of depression in all age quartiles within 180 days ( < 0.05). Young females with LOC had increased rates of suicidal ideation ( < 0.01), and those >25 years of age had increased rates of anxiety ( < 0.005). Adult males with LOC had increased rates of suicidal ideation ( < 0.002) and males >75 years of age had increased rates of anxiety at readmission ( < 0.05). Males without LOC had increased rates of depression ( < 0.005), with men in the second quartile also at higher risk of developing anxiety ( < 0.05). Females without LOC showed the fewest number of NPDs at readmission. Concussion may be associated with increased rates of NPDs in the first 6 months following discharge. We use these data to develop recommendations for psychiatric screening of patients with mTBI.
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http://dx.doi.org/10.1089/neu.2020.7467DOI Listing
April 2021

Prevalence Rate of Coexisting Rathke Cleft Cysts and Pineal Cysts: A Multicenter Cross-Sectional Study.

World Neurosurg 2021 May 7;149:e455-e459. Epub 2021 Feb 7.

Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: Rathke cleft cysts (RCCs) are benign sellar lesions originating from remnants of primitive ectoderm. They have not been previously linked to other cystic lesions, such as pineal cysts (PCs). Our objective was to perform a multicenter cross-sectional neuroimaging study to examine prevalence rates of coexisting RCC and PC.

Methods: We retrospectively queried prospectively maintained, institutional review board-approved, databases from the authors' centers. All patients undergoing transsphenoidal surgery for RCC between the years of 2011 and 2020 were included for analysis. Preoperative magnetic resonance imaging was reviewed to identify the coexistence of a PC. Patient demographics and neuroimaging characteristics were recorded. A control cohort comprised of 100 age- and sex-matched patients with nonfunctional pituitary adenoma (NFPA) who also underwent surgical intervention was utilized.

Results: Eighty-four patients with RCC were identified for analysis. A coexistent PC was identified in 40.5% (n = 34) of patients with RCC compared with 14.3% (n = 12) in the NFPA cohort (P < 0.001). There was no significant difference in PC size between patients with RCC and PA (8 vs. 8.8 mm, respectively; P = 0.77). Although the majority (85.7%; n = 72) of the RCC cohort were female patients, there was no sex predominance with respect to coexisting PC in either the RCC or PA cohort.

Conclusions: This is the first study to report an increased prevalence of coexisting PC and RCC, possibly because of an embryologic link or other propensity for intracranial cyst formation. Additional studies in more generalizable populations can further explore the relation between RCC and PC, or other cyst formation.
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http://dx.doi.org/10.1016/j.wneu.2021.02.004DOI Listing
May 2021

Neural network modeling for prediction of recurrence, progression, and hormonal non-remission in patients following resection of functional pituitary adenomas.

Pituitary 2021 Feb 2. Epub 2021 Feb 2.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Purpose: Functional pituitary adenomas (FPAs) cause severe neuro-endocrinopathies including Cushing's disease (CD) and acromegaly. While many are effectively cured following FPA resection, some encounter disease recurrence/progression or hormonal non-remission requiring adjuvant treatment. Identification of risk factors for suboptimal postoperative outcomes may guide initiation of adjuvant multimodal therapies.

Methods: Patients undergoing endonasal transsphenoidal resection for CD, acromegaly, and mammosomatotroph adenomas between 1992 and 2019 were identified. Good outcomes were defined as hormonal remission without imaging/biochemical evidence of disease recurrence/progression, while suboptimal outcomes were defined as hormonal non-remission or MRI evidence of recurrence/progression despite adjuvant treatment. Multivariate regression modeling and multilayered neural networks (NN) were implemented. The training sets randomly sampled 60% of all FPA patients, and validation/testing sets were 20% samples each.

Results: 348 patients with mean age of 41.7 years were identified. Eighty-one patients (23.3%) reported suboptimal outcomes. Variables predictive of suboptimal outcomes included: Requirement for additional surgery in patients who previously had surgery and continue to have functionally active tumor (p = 0.0069; OR = 1.51, 95%CI 1.12-2.04), Preoperative visual deficit not improved after surgery (p = 0.0033; OR = 1.12, 95%CI 1.04-1.20), Transient diabetes insipidus (p = 0.013; OR = 1.27, 95%CI 1.05-1.52), Higher MIB-1/Ki-67 labeling index (p = 0.038; OR = 1.08, 95%CI 1.01-1.15), and preoperative low cortisol axis (p = 0.040; OR = 2.72, 95%CI 1.06-7.01). The NN had overall accuracy of 87.1%, sensitivity of 89.5%, specificity of 76.9%, positive predictive value of 94.4%, and negative predictive value of 62.5%. NNs for all FPAs were more robust than for CD or acromegaly/mammosomatotroph alone.

Conclusion: We demonstrate capability of predicting suboptimal postoperative outcomes with high accuracy. NNs may aid in stratifying patients for risk of suboptimal outcomes, thereby guiding implementation of adjuvant treatment in high-risk patients.
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http://dx.doi.org/10.1007/s11102-021-01128-5DOI Listing
February 2021

Stereotactic Radiosurgery for Perioptic Meningiomas: An International, Multicenter Study.

Neurosurgery 2021 03;88(4):828-837

Department of Radiation Oncology, University of Colorado, Denver, Colorado.

Background: Stereotactic radiosurgery (SRS) is increasingly used for management of perioptic meningiomas.

Objective: To study the safety and effectiveness of SRS for perioptic meningiomas.

Methods: From 12 institutions participating in the International Radiosurgery Research Foundation (IRRF), we retrospectively assessed treatment parameters and outcomes following SRS for meningiomas located within 3 mm of the optic apparatus.

Results: A total of 438 patients (median age 51 yr) underwent SRS for histologically confirmed (29%) or radiologically suspected (71%) perioptic meningiomas. Median treatment volume was 8.01 cm3. Median prescription dose was 12 Gy, and median dose to the optic apparatus was 8.50 Gy. A total of 405 patients (93%) underwent single-fraction SRS and 33 patients (7%) underwent hypofractionated SRS. During median imaging follow-up of 55.6 mo (range: 3.15-239 mo), 33 (8%) patients experienced tumor progression. Actuarial 5-yr and 10-yr progression-free survival was 96% and 89%, respectively. Prescription dose of ≥12 Gy (HR: 0.310; 95% CI [0.141-0.679], P = .003) and single-fraction SRS (HR: 0.078; 95% CI [0.016-0.395], P = .002) were associated with improved tumor control. A total of 31 (10%) patients experienced visual decline, with actuarial 5-yr and 10-yr post-SRS visual decline rates of 9% and 21%, respectively. Maximum dose to the optic apparatus ≥10 Gy (HR = 2.370; 95% CI [1.086-5.172], P = .03) and tumor progression (HR = 4.340; 95% CI [2.070-9.097], P < .001) were independent predictors of post-SRS visual decline.

Conclusion: SRS provides durable tumor control and quite acceptable rates of vision preservation in perioptic meningiomas. Margin dose of ≥12 Gy is associated with improved tumor control, while a dose to the optic apparatus of ≥10 Gy and tumor progression are associated with post-SRS visual decline.
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http://dx.doi.org/10.1093/neuros/nyaa544DOI Listing
March 2021

Safety and Effectiveness of the Direct Endoscopic Endonasal Approach for Primary Sellar Pathology: A Contemporary Case Series of More Than 400 Patients.

World Neurosurg 2021 Apr 14;148:e536-e546. Epub 2021 Jan 14.

USC Pituitary Center, Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Background: The direct endoscopic endonasal approach (EEA) has become the primary technique used for resection of sellar pathology, meriting investigation into the risk factors for complications and predictors of postoperative outcomes after direct EEA.

Methods: We retrospectively analyzed the patient and tumor characteristics from 404 patients who had undergone direct EEA for sellar pathology at the USC Pituitary Center from September 2011 to December 2019.

Results: Of the 404 pathologic entities included, 349 (86%) were pituitary adenomas (PAs), 29 (7%) were Rathke cleft cysts, and 26 (6%) were other sellar lesions. The mean lesion diameter was 2.3 cm, with 34 microadenomas (10%) and 315 macroadenomas (90%). Cavernous sinus invasion was present in 39% of the PAs. No patient died. The surgical complications included internal carotid artery injury without neurological sequelae (0.2%), vision loss (0.7%), meningitis (0.7%), cerebrospinal fluid leak (4%), epistaxis (4%), sinusitis (1%), transient cranial nerve paresis (0.5%), and postoperative abscess (0.25%). New hypopituitarism developed in 3%. Gross total resection was achieved in 208 PA cases (58%). Clinical improvement of headaches and visual deficits were reported for 67% and 76% of cases, respectively. Hormonal remission was achieved in 82% of patients with functional PAs. The median hospital stay was 2 days, with 34 patients (8%) readmitted within 30 days and 10 (3%) undergoing early reoperation. Disease recurrence or progression developed in 10% and was less likely in the case of gross total resection and apoplexy.

Conclusion: In the present, large, consecutive, mostly single-surgeon series, the patients experienced clinical improvement in most preoperative symptoms and had low rates of perioperative morbidity. We have demonstrated that direct EEA can be efficiently, safely, and successfully performed by a neurosurgical team.
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http://dx.doi.org/10.1016/j.wneu.2021.01.018DOI Listing
April 2021

5-ALA Enhanced Fluorescence-Guided Microscopic to Endoscopic Resection of Deep Frontal Subcortical Glioblastoma Multiforme.

World Neurosurg 2021 Apr 13;148:65. Epub 2021 Jan 13.

Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

Glioblastoma multiforme remains the most common adult primary brain tumor with a life expectancy of 15-18 months following best treatment strategies. Current paradigms incorporate maximal safe resection, chemotherapy, and radiation. Multiple variables correlate with increased survival; perhaps most notably are stepwise survival advantages following 78% and 98% extent of resection thresholds. 5-Aminolevulinic acid has become a vital tool in the intraoperative identification and differentiation of high-grade glioma as it provides a fluorescent effect capable of distinguishing tumor from normal brain tissue when observed under blue light, which to date has been used primarily via a microscopic light source. However, this effect is attenuated with increasing distance between the blue light source and the tumor, as in the case of deep seated resection cavities. We aimed to overcome this obstacle by using a blue light endoscope as the primary visualization platform, thereby advancing the light source directly into the resection cavity. We present the case of a 69-year-old man with a deep left frontal subcortical lesion proven to be glioblastoma multiforme on prior biopsy. He consented to undergo an interhemispheric "M2E" (microscopic-to-endoscopic) approach with subcortical motor mapping. Tumor fluorescence under blue light visualization was not appreciated by the operating microscope but was easily observed with the blue light endoscope. Tumor resection proceeded under direct blue light endoscopy with intermittent subcortical motor mapping until a threshold of 4 mA was reached. The patient had transient right arm and leg weakness. Postoperative magnetic resonance imaging confirmed >98% resection (Video 1).
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http://dx.doi.org/10.1016/j.wneu.2020.12.168DOI Listing
April 2021

Exoscopic to Endoscopic Channel-Based Trans-Sulcal Resection of a Third Ventricular Cavernous Malformation: Technical Case Illustration.

World Neurosurg 2021 Apr 13;148:66. Epub 2021 Jan 13.

Department of Neurosurgery, University of Southern California, Los Angeles, California, USA.

Cavernous malformations are angiographically occult vascular hamartomas without intervening neural tissue that represent an estimated 10% of central nervous system vascular pathologies. Management is often dictated by lesion location, intranidal versus extranidal hemorrhage, presenting symptoms, acuity of onset, and surgical accessibility. Deep-seated cavernous malformations are often adjacent to eloquent structures, including functional white matter tracts that must be accounted for during surgical planning and respected during resection of the cavernoma. Exoscopic-guided channel-based approaches can help minimize retraction of brain tissue while providing a navigated, direct path to the target lesion. We report a case of an 18-year-old man who presented with seizures and was found to have a hemorrhagic third ventricular cavernous malformation resulting in hydrocephalus. A right frontal trans-sulcal approach using an exoscope and channel-based retractor was performed and directed along the long axis of the lesion to minimize displacement of surrounding eloquent structures and manipulation of the fornix. An uneventful gross total resection was achieved and confirmed using an angled endoscope to inspect the cavity walls, the "exoscopic to endoscopic or E2E approach" (Video 1). The patient developed transient short-term memory dysfunction in the immediate postoperative period, likely due to retraction of the fornix, which dramatically improved with speech therapy and rehabilitation. The patient provided informed consent for surgery and video recording.
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http://dx.doi.org/10.1016/j.wneu.2021.01.007DOI Listing
April 2021

Stereotactic radiosurgery for treatment of radiation-induced meningiomas: a multiinstitutional study.

J Neurosurg 2021 Jan 1:1-9. Epub 2021 Jan 1.

1Department of Neurological Surgery, University of Virginia Health System, Charlottesville, Virginia.

Objective: Radiation-induced meningiomas (RIMs) are associated with aggressive clinical behavior. Stereotactic radiosurgery (SRS) is sometimes considered for selected RIMs. The authors investigated the effectiveness and safety of SRS for the management of RIMs.

Methods: From 12 institutions participating in the International Radiosurgery Research Foundation, the authors pooled patients who had prior cranial irradiation and were subsequently clinically diagnosed with WHO grade I meningiomas that were managed with SRS.

Results: Fifty-two patients underwent 60 SRS procedures for histologically confirmed or radiologically suspected WHO grade I RIMs. The median ages at initial cranial radiation therapy and SRS for RIM were 5.5 years and 39 years, respectively. The most common reasons for cranial radiation therapy were leukemia (21%) and medulloblastoma (17%). There were 39 multiple RIMs (35%), the mean target volume was 8.61 ± 7.80 cm3, and the median prescription dose was 14 Gy. The median imaging follow-up duration was 48 months (range 4-195 months). RIM progressed in 9 patients (17%) at a median duration of 30 months (range 3-45 months) after SRS. Progression-free survival at 5 years post-SRS was 83%. Treatment volume ≥ 5 cm3 predicted progression (HR 8.226, 95% CI 1.028-65.857, p = 0.047). Seven patients (14%) developed new neurological symptoms or experienced SRS-related complications or T2 signal change from 1 to 72 months after SRS.

Conclusions: SRS is associated with durable local control of RIMs in the majority of patients and has an acceptable safety profile. SRS can be considered for patients and tumors that are deemed suboptimal, poor surgical candidates, and those whose tumor again progresses after removal.
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http://dx.doi.org/10.3171/2020.7.JNS202064DOI Listing
January 2021

Commentary: Middle Cerebral Artery Aneurysm Clipping With Immersive 360° Virtual Reality Model: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 03;20(4):E315-E316

Department of Neurosurgery, University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1093/ons/opaa428DOI Listing
March 2021

Management of acute subdural hematoma in incarcerated patients.

Clin Neurol Neurosurg 2021 02 15;201:106441. Epub 2020 Dec 15.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA.

Introduction: Incarcerated patients have been documented to have higher rates of mental illness, substance abuse disorders, trauma, and chronic illnesses compared to non-incarcerated populations. In this study, we evaluated the incidence of subdural hematoma (SDH) in incarcerated patients and compared the outcomes of these patients to those of non-incarcerated patients.

Methods: We conducted a retrospective cohort study of incarcerated patients admitted to a hospital with acute SDH using the Nationwide Readmissions Database between 2016-2017. Nearest-neighbor propensity score matching for demographics was implemented to identify non-incarcerated control patients admitted with SDH. Analysis used chi-squared testing, Mann-Whitney U testing, and generalized binomial regression modeling.

Results: A total of 962 incarcerated and non-incarcerated patients were identified at primary admission. No significant difference was found between the two cohorts with regards to rates of neurosurgical complications or readmissions. Incarcerated patients were found to receive a significantly lower number of procedures, including respiratory ventilation, intubation, central venous line placement, and imaging, during their primary admission (NPR = 2.7 ± 4.0) compared to non-incarcerated patients (NPR = 3.9 ± 4.9) (p = 0.00050), reduced length of stay (p = 0.0052), and reduced hospital costs (p = 0.00026) compared to non-incarcerated patients. Furthermore, female incarcerated patients with SDH had significantly worse outcomes compared to male patients with SDH, including higher rates of mortality (p = 0.0017) and 30-day readmission rates (p = 0.041).

Discussion: Our study suggests that incarcerated patients may receive significantly fewer diagnostic and supportive procedures while admitted for SDH and may be discharged sooner than non-incarcerated patients with SDH. In addition, outcomes following SDH within incarcerated patients may be significantly worse for females.
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http://dx.doi.org/10.1016/j.clineuro.2020.106441DOI Listing
February 2021

Commentary: Minimally Invasive Posterior Cervical Foraminotomy Using 3-Dimensional Total Navigation: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 01;20(2):E141-E142

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA.

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http://dx.doi.org/10.1093/ons/opaa395DOI Listing
January 2021

Comparative Assessment of Extracranial-to-Intracranial and Intracranial-to-Intracranial In Situ Bypass for Complex Intracranial Aneurysm Treatment Based on Rupture Status: A Case Series.

World Neurosurg 2021 Feb 17;146:e122-e138. Epub 2020 Oct 17.

Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. Electronic address:

Background: Comparative outcomes of extracranial-to-intracranial (EC-IC) and intracranial-to-intracranial (IC-IC) bypass for complex aneurysm treatment based on rupture status are not well described in the literature. In this study, we compare outcomes of EC-IC and IC-IC bypass for complex intracranial aneurysm treatment based on rupture status.

Methods: A prospective neurosurgical patient database was retrospectively reviewed. Sixty-three consecutive patients with aneurysm managed with revascularization were identified between July 2014 and December 2018.

Results: During the study period, 41 patients with aneurysm underwent EC-IC bypass (65%; 24 [58.5%] ruptured, 17 [41.5%] unruptured) and 22 patients with aneurysm underwent IC-IC bypass (34.9%; 13 [59.1%] ruptured, 9 [40.9%] unruptured). Graft spasm occurred in 4 patients (9.8%) in the EC-IC group (all ruptured aneurysms) and all anastomoses were patent on immediate postoperative imaging. Perioperative mortality occurred in 5 patients who underwent EC-IC bypass (12.2%; 3 ruptured, 2 unruptured) EC-IC and 2 patients who underwent IC-IC bypass (9.1%; both ruptured); (P = 0.709). Bypass-related complications occurred only in patients with ruptured aneurysm (2 [8.3%] in the EC-IC group and 0 [0%] in the IC-IC group; P = 0.285). For unruptured aneurysms, the overall complication rate was lower in IC-IC compared with the EC-IC group (P = 0.006). Modified Rankin Scale scores on discharge were significantly lower in IC-IC compared with EC-IC bypass for unruptured aneurysms (P = 0.008). There was a trend for shorter temporary occlusion and hospitalization times and overall better outcomes with IC-IC compared with EC-IC bypass.

Conclusions: Although often considered riskier than EC-IC bypass, IC-IC in situ bypass showd a favorable technical and safety profile for the treatment of complex, unruptured aneurysms.
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http://dx.doi.org/10.1016/j.wneu.2020.10.056DOI Listing
February 2021

Commentary: Microsurgical Treatment of Unruptured Anterior Communicating Artery Aneurysms: Approaches and Outcomes in a Large Contemporary Series and Review of the Literature.

Oper Neurosurg (Hagerstown) 2020 Aug 19. Epub 2020 Aug 19.

University of Southern California, Department of Neurosurgery, Los Angeles, California.

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http://dx.doi.org/10.1093/ons/opaa254DOI Listing
August 2020

An Expedited Transition to the Back Wall Suturing for Side-to-Side In Situ Microvascular Anastomosis: A Technique Update.

Oper Neurosurg (Hagerstown) 2020 Aug 6. Epub 2020 Aug 6.

Neurorestoration Center, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.

Background: The side-to-side in situ microvascular anastomosis is an important tool in the cerebrovascular neurosurgeon's armamentarium. The execution of the side-to-side anastomosis, however, can be limited by the inability to acquire sufficient visualization and approximation of the recipient and donor vessels.

Objective: To expedite the transition to the back wall suturing of the donor and recipient vessels during side-to-side in situ microvascular anastomosis.

Methods: Incorporation of the first suture throw from the outside to the inside of the vessel lumen with the initial stay suture at the proximal apex of the arteriotomy is described. The apical knot is tied between one limb of the resultant loop and the free end of the suture. The remainder of side-to-side anastomosis can then be completed in a standard fashion starting from the inside of the lumen.

Results: This modification allows for an expedited transition to the back wall suturing of the 2 arterial segments and avoids difficulties associated with taking the first bite from behind the knot at the proximal apex of the arteriotomy or the transfer of the needle between the approximated vessels. This updated technique is illustrated with a case example, illustration, and video.

Conclusion: This technical modification for the side-to-side anastomosis helps optimize microsurgical efficiency by limiting needle, suture, and vessel handling after the initial suture placement, which has classically been a challenge of this bypass.
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http://dx.doi.org/10.1093/ons/opaa231DOI Listing
August 2020

Commentary: Mini-Pterional Craniotomy and Extradural Clinoidectomy for Clinoid Meningioma: Optimization of Exposure Using Augmented Reality Template: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 Aug 6. Epub 2020 Aug 6.

University of Southern California, Department of Neurosurgery, Los Angeles, California.

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http://dx.doi.org/10.1093/ons/opaa260DOI Listing
August 2020

Earlier radiosurgery leads to better pain relief and less medication usage for trigeminal neuralgia patients: an international multicenter study.

J Neurosurg 2020 Jul 3:1-8. Epub 2020 Jul 3.

1Department of Neurosurgery, New York University Langone Medical Center, New York, New York.

Objective: Trigeminal neuralgia (TN) is a chronic pain condition that is difficult to control with conservative management. Furthermore, disabling medication-related side effects are common. This study examined how stereotactic radiosurgery (SRS) affects pain outcomes and medication dependence based on the latency period between diagnosis and radiosurgery.

Methods: The authors conducted a retrospective analysis of patients with type I TN at 12 Gamma Knife treatment centers. SRS was the primary surgical intervention in all patients. Patient demographics, disease characteristics, treatment plans, medication histories, and outcomes were reviewed.

Results: Overall, 404 patients were included. The mean patient age at SRS was 70 years, and 60% of the population was female. The most common indication for SRS was pain refractory to medications (81%). The median maximum radiation dose was 80 Gy (range 50-95 Gy), and the mean follow-up duration was 32 months. The mean number of medications between baseline (pre-SRS) and the last follow-up decreased from 1.98 to 0.90 (p < 0.0001), respectively, and this significant reduction was observed across all medication categories. Patients who received SRS within 4 years of their initial diagnosis achieved significantly faster pain relief than those who underwent treatment after 4 years (median 21 vs 30 days, p = 0.041). The 90-day pain relief rate for those who received SRS ≤ 4 years after their diagnosis was 83.8% compared with 73.7% in patients who received SRS > 4 years after their diagnosis. The maximum radiation dose was the strongest predictor of a durable pain response (OR 1.091, p = 0.003). Early intervention (OR 1.785, p = 0.007) and higher maximum radiation dose (OR 1.150, p < 0.0001) were also significant predictors of being pain free (a Barrow Neurological Institute pain intensity score of I-IIIA) at the last follow-up visit. New sensory symptoms of any kind were seen in 98 patients (24.3%) after SRS. Higher maximum radiation dose trended toward predicting new sensory deficits but was nonsignificant (p = 0.075).

Conclusions: TN patients managed with SRS within 4 years of diagnosis experienced a shorter interval to pain relief with low risk. SRS also yielded significant decreases in adjunct medication utilization. Radiosurgery should be considered earlier in the course of treatment for TN.
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http://dx.doi.org/10.3171/2020.4.JNS192780DOI Listing
July 2020

Ventral Thoracic Spinal Cord Herniation: Clinical Image and Video Illustration of Microsurgical Treatment.

World Neurosurg 2020 10 27;142:152-154. Epub 2020 Jun 27.

Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Idiopathic spinal cord herniation is a rare cause of progressive myelopathy that can result in severe disability. In the following report, an illustrative case and associated video in the surgical management of ventral thoracic spinal cord herniation is presented and discussed. Spinal cord herniation is most commonly observed in the thoracic spine and is characterized by ventral displacement of the spinal cord through a defect in the dura. Over time ventral herniation of the spinal cord can compromise its vascular perfusion, resulting in further ischemic injury. The etiology is unclear, but suspected to be either acquired or congenital. Multiple surgical techniques have been reported with the goal of detethering the cord and taking adjunctive measures in reducing the risk for re-herniation. Surgical management of thoracic spinal cord herniation carries great risks, although neurological outcomes are generally favorable with improvements reported in the majority of cases.
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http://dx.doi.org/10.1016/j.wneu.2020.06.164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7529978PMC
October 2020

Analysis of modifiable and nonmodifiable risk factors in patients undergoing pituitary surgery.

J Neurosurg 2020 Jun 12:1-8. Epub 2020 Jun 12.

Objective: Pituitary adenomas (PAs) are among the most common intracranial tumors. Understanding the clinical effects of various modifiable risk factors (MRFs) and nonmodifiable risk factors (NMRFs) is important in guiding proper treatment, yet there is limited evidence outlining the influence of MRFs and NMRFs on outcomes of PA resection. The aim of this study was to analyze MRFs and NMRFs in patients undergoing resection for PAs.

Methods: Using the 2016 and 2017 National Readmission Database, the authors identified a cohort of 9472 patients undergoing microscopic or endoscopic resection of a PA. Patients with nonoverlapping MRFs and NMRFs were analyzed for length of stay (LOS), hospital cost, readmission rates, and postoperative complications. From the original cohort, a subset of 373 frail patients (as defined by the Johns Hopkins Frailty Index) were identified and propensity matched to nonfrail patients. Statistical analysis included 1-way ANOVA, Tukey multiple comparisons of means, odds ratios, Wald testing, and unpaired Welch 2-sample t-tests to compare complications, outcomes, and costs between each cohort. Perioperative outcomes and hospital readmission rates were tracked, and predictive algorithms were developed to establish precise relationships between relevant risk factors and neurosurgical outcomes.

Results: Malnourished patients had significantly longer LOSs when compared to nonmalnourished patients (p < 0.001). There was a significant positive correlation between the number of MRFs and readmission at 90 days (p = 0.012) and 180 days (p = 0.020). Obese patients had higher rates of postoperative neurological injury at the 30-day follow-up (p = 0.048) compared to patients with normal BMI. Within this NMRF cohort, frail patients were found to have significantly increased hospital LOS (p < 0.001) and total inpatient costs compared to nonfrail patients (p < 0.001). Predictive analytics showed that frail patients had significantly higher readmission rates at both 90-day (p < 0.001) and 180-day follow-ups (p < 0.001). Lastly, rates of acute postsurgical infection were higher in frail patients compared to nonfrail patients (p < 0.001).

Conclusions: These findings suggest that both MRFs and NMRFs negatively affect the perioperative outcomes following PA resection. Notable risk factors including malnutrition, obesity, elevated lipid panels, and frailty make patients more prone to prolonged LOS, higher inpatient costs, and readmission. Further prospective research with longitudinal data is required to precisely pinpoint the effects of various risk factors on the outcomes of pituitary surgery.
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http://dx.doi.org/10.3171/2020.4.JNS20417DOI Listing
June 2020

Commentary: Expanded Endoscopic Endonasal Transtuberculum Approach for Tuberculum Sellae Meningioma: Operative Video With 360-Degree Fly-Through and Surgical Rehearsal in Virtual Reality: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 08;19(2):E181-E182

Department of Neurosurgery, The Keck School of Medicine of the University of Southern California, Los Angeles, California.

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http://dx.doi.org/10.1093/ons/opaa064DOI Listing
August 2020

Discrepancy in Neurologic Outcomes Following Aneurysmal Subarachnoid Hemorrhage as a Function of Socioeconomic Class.

World Neurosurg 2020 06 23;138:e787-e794. Epub 2020 Mar 23.

Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, USA.

Objective: To investigate potential health care discrepancies in patients with ruptured cerebral aneurysms undergoing microsurgical intervention.

Methods: We retrospectively reviewed patients with ruptured intracranial aneurysms treated at our tertiary referral university hospital (UH) and safety net county hospital (CH) from 2010 to 2015. We identified 73 UH patients and 58 CH patients.

Results: UH patients had shorter time duration between rupture and intervention (P < 0.001) and higher rates of intubation on admission (P = 0.01). Verapamil was more frequently used for clinical vasospasm in UH patients, at 0.13 (95% confidence interval [CI], 0.09-0.18) treatments per patient per day versus 0.077 (95% CI, 0.047-0.12) treatments per patient per day in CH patients, though there was no difference in delayed cerebral ischemia (P = 0.15). The majority of the CH cohort was uninsured (26.3%; UH 0%) or had Medicaid (59.7%; UH 35.2%) (P < 0.001). The UH had more dispositions to home or rehabilitation centers than the CH (82% vs. 67.3%; P = 0.04). After adjusting for disease severity, hospital stay, and insurance status, CH patients were 3.73 (95% CI, 1.25-12.14) times more likely to be discharged with a poor modified Rankin Scale score and 3.08 (95% CI, 1.04-9.61) times more likely to be discharged with a poor Glasgow Outcome Scale score compared with UH patients (P = 0.02 and P = 0.04, respectively).

Conclusions: Limited resource availability in a safety net hospital system could be a major driving force behind the health care discrepancy identified in our ruptured cerebral aneurysm population. Reallocation of resources to supplement advanced inpatient acute care technologies and, more importantly, post-acute care environments can narrow the outcomes gap.
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http://dx.doi.org/10.1016/j.wneu.2020.03.087DOI Listing
June 2020

Intentional Subtotal Resection of Vestibular Schwannoma: A Reexamination.

J Neurol Surg B Skull Base 2020 Apr 1;81(2):136-141. Epub 2019 Mar 1.

Department of Neurosurgery, Keck School of Medicine, University of Southern California, Los Angeles, California, United States.

 Treatment of vestibular schwannomas (VS) remains controversial. Historical surgical series prioritized gross total resections (GTR); however, near total resections (NTR) and intentional subtotal resections (STR) aiming at improving cranial nerve outcomes are becoming more popular.  The main purpose of this article is to assess the tumor control and facial nerve outcomes in VS patients treated with STR or NTR.  VS patients undergoing STR or NTR at our institution between 1984 and 2016 were retrospectively reviewed. Patient demographics, extent of tumor resection, facial nerve injury, tumor recurrence, and need for Gamma Knife radiosurgery were analyzed. Facial nerve outcomes were quantified using House-Brackmann (HB) scores. Tumor regrowth was defined by the San Francisco criteria.  Four-hundred fifty-seven VS resections were performed in a 32-year period. Sixty cases met inclusion criteria. The mean (range) follow-up duration was 30.9 (12-103) months. The STR cohort (  = 33) demonstrated regrowth in 12 patients (36.3%) at an average of 23.6 months. The NTR cohort (  = 27) did not experience tumor recurrence. Risk of tumor recurrence was positively correlated with preoperative tumor size (  = 0.002), size of residual tumor (  < 0.001), and STR (  < 0.001). Facial nerve outcomes of HB1-2 were observed in the majority of patients in both cohorts (74.1% NTR, 56% STR), though NTR was associated with a higher likelihood of facial nerve recovery (  = 0.003).  GTR remains the gold standard as long as facial nerve outcomes remain acceptable. NTR achieved superior tumor control and higher likelihood of facial nerve recovery compared with STR.
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http://dx.doi.org/10.1055/s-0039-1679898DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7082167PMC
April 2020