Publications by authors named "Christopher S Graffeo"

146 Publications

Foundations of Advanced Neuroanatomy: Technical Guidelines for Specimen Preparation, Dissection, and 3D-Photodocumentation in a Surgical Anatomy Laboratory.

J Neurol Surg B Skull Base 2021 Jul 28;82(Suppl 3):e248-e258. Epub 2019 Nov 28.

Department of Neurosurgery, Albany Medical Center, Albany, New York, United States.

 This study was aimed to provide a key update to the seminal works of Prof. Albert L. Rhoton Jr., MD, with particular attention to previously unpublished insights from the oral tradition of his fellows, recent technological advances including endoscopy, and high-dynamic range (HDR) photodocumentation, and, local improvements in technique, we have developed to optimize efficient neuroanatomic study.  Two formaldehyde-fixed cadaveric heads were injected with colored latex to demonstrate step-by-step specimen preparation for microscopic or endoscopic dissection. One formaldehyde-fixed brain was utilized to demonstrate optimal three-dimensional (3D) photodocumentation techniques.  Key steps of specimen preparation include vessel cannulation and securing, serial tap water flushing, specimen drainage, vessel injection with optimized and color-augmented latex material, and storage in 70% ethanol. Optimizations for photodocumentation included the incorporation of dry black drop cloth and covering materials, an imaging-oriented approach to specimen positioning and illumination, and single-camera stereoscopic capture techniques, emphasizing the three-exposure-times-per-eye approach to generating images for HDR postprocessing. Recommended tools, materials, and technical nuances were emphasized throughout. Relative advantages and limitations of major 3D projection systems were comparatively assessed, with sensitivity to audience size and purpose specific recommendations.  We describe the first consolidated step-by-step approach to advanced neuroanatomy, including specimen preparation, dissection, and 3D photodocumentation, supplemented by previously unpublished insights from the Rhoton fellowship experience and lessons learned in our laboratories in the past years such that Prof. Rhoton's model can be realized, reproduced, and expanded upon in surgical neuroanatomy laboratories worldwide.
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http://dx.doi.org/10.1055/s-0039-3399590DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8289531PMC
July 2021

Histopathology and prognosis of germ cell tumors metastatic to brain: cohort study.

J Neurooncol 2021 Aug 16;154(1):121-130. Epub 2021 Jul 16.

Department of Neurologic Surgery, Mayo Clinic, 200 First St. SW, Rochester, MN, 55905, USA.

Introduction: Germ cell tumors (GCTs) are uncommon neoplasms predominantly arising in midline tissues. The prognostic significance of histopathology in predicting metastatic GCT behavior is poorly understood.

Methods: Multicenter international cohort study including 29 patients with GCTs metastatic to brain were retrospectively investigated (18 patients from Mayo Clinic and 11 patients from the intracranial germ cell tumor genome analysis consortium in Japan). Clinical characteristics were analyzed using the Chi-square test (two-tailed) for categorical variables and using the log-rank test for survival data.

Results: Median age at treatment was 31 years (range 14-58). Primary disease sites were testis (71%), mediastinum (18%), and female reproductive organs (11%). Median metastatic interval was 223 days (range, 6-6124). Median follow-up was 346 days (range, 1-5356), with 16 deaths (57%) occurring after the median overall survival of 455 days. Actuarial one-year survival was 51%; 12-of-16 deaths (75%) were attributed to intracranial disease. Appearance of the same GCT subtype at the metastatic site as the primary was high for non-seminomatous GCT (NSGCT, 64-100%), but low for seminoma/dysgerminoma and mature teratoma (MT, 14, 17%, respectively). Gain of a new component was seen in 4 (20%)-3 of which included embryonal carcinoma (EC) at the primary site (75%). Incidence of cases without seminoma/dysgerminoma increased significantly after metastasis (p = 0.02). Metastatic interval was shorter in cases with histological change (199 vs 454 days, p = 0.009). Overall survival was associated with MT primary histopathology (p = 0.02).

Conclusion: Histological differentiation at the primary GCT site influences metastatic prognosis. Aggressive behavior is associated with NSGCT, while EC frequently demonstrates multi-directional histological differentiation after brain metastasis, and such histological dynamism is associated with shorter metastatic interval. Most metastases occurred within one year of diagnosis, emphasizing the need for close surveillance in newly diagnosed extra-cranial GCT.
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http://dx.doi.org/10.1007/s11060-021-03810-xDOI Listing
August 2021

Largest neurosurgical social media group and its impact on communication and research.

Br J Neurosurg 2021 Jul 8:1-5. Epub 2021 Jul 8.

Department of Neurosurgery, University of Washington, Seattle, WA, USA.

Background: The use of social media to communicate and disseminate knowledge has increased exponentially, especially in the field of neurosurgery. 'Neurosurgery cocktail' (NC) was developed by a group of young neurosurgeons as a means of sharing didactic materials and clinical experiences via social media. It connects 35.000 neurosurgeons worldwide on multiple platforms, primarily Facebook and Twitter. Given the rising utilization of social media in neurosurgery, the popularity of NC has also increased since its inception. In this study, the authors surveyed the social media analytics of NC for both Facebook and Twitter. Besides, we reviewed the literature on the use of social media in neurosurgery.

Methods: Facebook and Twitter metrics were extracted through each respective platform's analytics tools from December 2020 (earliest available date for data analysis) through January 2021. A literature search was conducted using PubMed (MEDLINE) and Scopus databases.

Results: On Facebook, as of January 2021, the group had a total of 25.590 members (87.6% male), most commonly (29%) between 35 and 44 years of age with over 100 countries were represented. As of January 2021, they had amassed 6457 followers on Twitter. During the last 28 d between December 2020 and January 2021, the account published 65 tweets that garnered a total of 196,900 impressions. Twelve articles were identified in our literature review on the use of social media within the neurosurgical community.

Conclusions: NC is one of the most widely utilized neurosurgical social media resources available. Sharing knowledge has been broadened thanks to the recent social media evolution, and NC has become a leading player in disseminating neurosurgical knowledge.
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http://dx.doi.org/10.1080/02688697.2021.1947978DOI Listing
July 2021

Perioperative Tranexamic Acid for ACTH-Secreting Pituitary Adenomas: Implementation Protocol Results and Trial Prospectus.

World Neurosurg 2021 Sep 3;153:e359-e364. Epub 2021 Jul 3.

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Objective: Primary resection of adrenocorticotropic hormone (ACTH)-secreting pituitary adenoma has become a front-line standard-of-care treatment for Cushing disease. However, surgical intervention can be challenging because of elevated blood pressure, as well as direct cortisol impacts on endothelial cells, vascular permeability, and tissue friability-potentially resulting in increased intraoperative bleeding. Tranexamic acid (TXA) is a well-studied, widely used intravenous hemostatic; however, the potential benefit during resection of ACTH-secreting pituitary adenoma is unstudied. The purpose of this study was to define an institutional protocol for perioperative administration of TXA in patients undergoing endoscopic endonasal approach for resection of ACTH-secreting pituitary adenoma, and to study the implementation of our novel protocol in a prospective fashion.

Methods: Criteria for preoperative TXA were defined by age, medical history, and risk factors. Descriptive statistics were reported for all patients receiving perioperative TXA.

Results: Thirty patients met inclusion criteria and underwent perioperative administration of TXA, using a standardized dosing protocol of a 10 mg/kg bolus in 30 minutes prior to incision, followed by maintenance infusion of 2 mg/kg/hour for the duration of the procedure. No incidence of myocardial infarction or postoperative thromboembolic events were noted. Subjective assessments indicated satisfaction with the patient selection protocol, and meaningful reduction in the extent of intraoperative bleeding.

Conclusions: Perioperative TXA represents a potentially efficacious approach for control of intraoperative bleeding during endonasal resection of ACTH-secreting tumors. Careful preoperative patient selection is emphasized, given the potential for thromboembolic complications; however, initial experience with our institutional protocol suggests a favorable risk/benefit profile when this treatment is applied judiciously.
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http://dx.doi.org/10.1016/j.wneu.2021.06.111DOI Listing
September 2021

Paradoxical Temporal Enlargement: An Expansion of Superficial Temporal Fat Pad Following Interfacial Technique for Pterional Craniotomy.

J Craniofac Surg 2021 Jun 28. Epub 2021 Jun 28.

Mayo Clinic Alix School of Medicine, Mayo Clinic Division of Plastic Surgery, Department of Surgery, Mayo Clinic Department of Neurosurgery, Mayo Clinic Department of Otolaryngology, Mayo Clinic Department of Radiology, Mayo Clinic, Rochester, MN.

Objective: Contour irregularities in the temporal region have been reported previously after procedures involving temporal dissection. In this study, we report paradoxical temporal enlargement (PTE) following interfascial pterional craniotomy.

Methods: A retrospective review of patients who underwent a unilateral transcranial procedure with frontotemporal approach at our institution between September 2013 and December 2017 was performed. Patients with a previous craniotomy or bilateral craniotomy were excluded. Radiological imaging series including computed tomography and magnetic resonance imaging were utilized to calculate temporal soft tissue volumes both preoperatively and postoperatively by using advanced software technology. Relative soft tissue volume differences between the operative side and the contralateral side were calculated at different time-points including preoperative, 3-months follow-up (3M), 12-months (12M) follow-up, and the last follow-up (LFU, over 1-year).

Results: Forty-three patients were included. Mean age was 52.7 ± 4.5 years. Mean follow-up was 27.9 ± 15.8 months. Significant changes of temporal fat pad relative-volume difference were observed between the preoperative and the corresponding 3M (t [82] = -2.8865, P = 0.0050); 12M (t [77] = -4.4321, P < 0.0001), and LFU (t [74] = -4.9862, P < 0.0001) postoperative time points. No significant change of the temporalis muscle was observed between the preoperative and the corresponding 3M (P = 0.3629), 12M (P = 0.1553), or LFU (P = 0.0715). Soft tissue volume showed a significant increase on the operative side between the preoperative and the corresponding LFU (t [74] = -2.5866, P =  0.0117).

Conclusions: Paradoxical temporal enlargement with more than 10% volumetric change was observed in 24% of the patients at their LFU (>1-year). This change was not due to temporalis muscle changes. Paradoxical temporal enlargement was due to hypertrophy of the superficial temporal fat pad. Before surgical correction of postoperative temporal contour changes, it is important to obtain imaging and characterize the etiology of the deformity.
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http://dx.doi.org/10.1097/SCS.0000000000007730DOI Listing
June 2021

Intracranial Hypotensive Crisis From an Insidious Spinal Cerebrospinal Fluid-Venous Fistula: A Case Report.

Oper Neurosurg (Hagerstown) 2021 Aug;21(3):E283-E288

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background And Importance: Progressive episodic spells of altered levels of consciousness, often advancing to include paroxysmal autonomic instability, may be indicative of a diencephalic dysfunction underlying spontaneous intracranial hypotension (SIH). A rare, and often indolent, etiology may be spinal cerebrospinal fluid (CSF) leak-an elusive diagnosis, especially in cases of CSF-venous fistula (CVF) that are often missed on routine computed tomography (CT) myelography and magnetic resonance imaging (MRI).

Clinical Presentation: We report an unusual case of a 50-yr-old woman who presented with rapidly progressive cyclical, self-resolving episodes of altered mentation and decreased arousal later in the day. Scrutiny of serial brain MRIs led to a diagnosis of SIH, with severe downward diencephalic and brain stem displacement-resulting in cerebral aqueduct occlusion with obstructive hydrocephalus. Initial clinical improvement occurred with CSF diversion, but the patient quickly deteriorated-developing diencephalic spells, including extensor posturing and severely depressed levels of consciousness. Clinical improvement was seen with stopping CSF diversion and Trendelenburg-positioning. After intensive spinal imaging, dynamic CT myelography identified a left T10 nerve root diverticula and CSF-venous fistula. Surgical obliteration resulted in rapid, profound neurological improvement, and ultimately full neurological recovery by 1 yr.

Conclusion: In our patient, worsening episodes of confusion, postural headaches, and autonomic instability developed due to SIH, which induced profound downward displacement and compression of the diencephalon and brain stem, and accompanied by subsequent obstructive hydrocephalus. Diagnostic persistence identified the CVF, which had caused the complex multifold pathophysiology and clinical presentation. If suspicion remains high for CVF, persistent spinal imaging, particularly with dynamic myelography, may be crucial.
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http://dx.doi.org/10.1093/ons/opab154DOI Listing
August 2021

Differential Impact of Advanced Age on Clinical Outcomes After Vestibular Schwannoma Resection in the Very Elderly: Cohort Study.

Oper Neurosurg (Hagerstown) 2021 Aug;21(3):104-110

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.

Background: Vestibular schwannomas (VS) have a peak incidence in the sixth and seventh decades of life. Stereotactic radiosurgery is often the preferred treatment for VS among patients of advanced age. The fraction of elderly patients potentially requiring consideration for surgical treatment is anticipated to expand, mandating an update to management paradigms in this population.

Objective: To describe our experience with surgical management of VS in patients aged 75 yr and older.

Methods: Cohort study of all patients aged ≥75 yr with sporadic VS requiring surgical treatment at our institution between 1999 and 2020. Data included preoperative baseline characteristics and outcome data including extent of resection, facial nerve and hearing status, functional outcome, length of stay, and complications.

Results: A total of 24 patients were included, spanning an age range of 75 to 90 yr. Average tumor size was 2.76 ± 1.04 cm, and average baseline Modified 5-item Frailty Index (mFI-5) score was 1.08 ± 0.93. Extent of resection was gross total in 5 (20.8%), near total in 3 (12.5%), and sub-total resection in the remaining 16 (66.7%). One patient died in the postoperative period because of an acute sub-dural hematoma. Favorable facial nerve function (HB1-2) was preserved in 12 patients (75%) between 75 and 79 yr and 2 patients (28.6%) aged ≥ 80 yr. No cerebrospinal fluid leak or surgical site infection was observed; 3 patients developed hydrocephalus requiring ventriculo-peritoneal shunt placement. Nine patients required out-of-home disposition; all patients eventually returned to independent living.

Conclusion: Microsurgical resection of VS can be safely undertaken in patients greater than 75 y/o but may carry an increased risk of poor facial function.
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http://dx.doi.org/10.1093/ons/opab170DOI Listing
August 2021

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Surgical Anatomy of the Retrosigmoid Approach.

J Neurol Surg B Skull Base 2021 Jun 28;82(3):321-332. Epub 2019 Oct 28.

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States.

 Neurosurgical anatomy is traditionally taught via anatomic and operative atlases; however, these resources present the skull base using views that emphasize three-dimensional (3D) relationships rather than operative perspectives, and are frequently written above a typical resident's understanding. Our objective is to describe, step-by-step, a retrosigmoid approach dissection, in a way that is educationally valuable for trainees at numerous levels.  Six sides of three formalin-fixed latex-injected specimens were dissected under microscopic magnification. A retrosigmoid was performed by each of three neurosurgery residents, under supervision by the senior authors (C.L.W.D. and M.J.L.) and a graduated skull base fellow, neurosurgeon, and neuroanatomist (M.P.C.). Dissections were supplemented with representative case applications.  The retrosigmoid craniotomy (aka lateral suboccipital approach) affords excellent access to cranial nerve (CN) IV to XII, with corresponding applicability to numerous posterior fossa operations. Key steps include positioning and skin incision, scalp and muscle flaps, burr hole and parasigmoid trough, craniotomy flap elevation, initial durotomy and deep cistern access, completion durotomy, and final exposure.  The retrosigmoid craniotomy is a workhorse skull base exposure, particularly for lesions located predominantly in the cerebellopontine angle. Operatively oriented neuroanatomy dissections provide trainees with a critical foundation for learning this fundamental skull base technique. We outline a comprehensive approach for neurosurgery residents to develop their familiarity with the retrosigmoid craniotomy in the cadaver laboratory in a way that simultaneously informs rapid learning in the operating room, and an understanding of its potential for wide clinical application to skull base diseases.
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http://dx.doi.org/10.1055/s-0039-1700513DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8133810PMC
June 2021

The Role of Biological Effective Dose in Predicting Obliteration After Stereotactic Radiosurgery of Cerebral Arteriovenous Malformations.

Mayo Clin Proc 2021 05;96(5):1157-1164

Department of Neurological Surgery, Mayo Clinic, Rochester, MN; Department of Radiation Oncology, Mayo Clinic, Rochester, MN. Electronic address:

Objective: To determine whether biological effective dose (BED) was predictive of obliteration after stereotactic radiosurgery (SRS) for cerebral arteriovenous malformations (AVMs).

Patients And Methods: We studied patients undergoing single-session AVM SRS between January 1, 1990, and December 31, 2014, with at least 2 years of imaging follow-up. Excluded were patients with syndromic AVM, previous SRS or embolization, and patients treated with volume-staged SRS. Biological effective dose was calculated using a mono-exponential model described by Jones and Hopewell. The primary outcome was likelihood of total obliteration defined by digital subtraction angiography or magnetic resonance imaging (MRI). Variables were analyzed as continuous and dichotomous variables based on the maximum value of (sensitivity-[1-specificity]).

Results: This study included 352 patients (360 AVM, median follow-up, 5.9 years). The median margin dose prescribed was 18.75 Gy (interquartile range [IQR]: 18 to 20 Gy). Two hundred fifty-nine patients (71.9%) had obliteration shown by angiography (n=176) or MRI (n=83) at a median of 36 months after SRS (IQR: 26 to 44 months). Higher BED was associated with increased likelihood of obliteration in univariate Cox regression analyses, when treated as either a dichotomous (≥133 Gy; hazard ratio [HR],1.52; 95% confidence interval [CI], 1.19 to 1.95; P<.001) or continuous variable (HR, 1.00, 95% CI, 1.0002 to 1.005; P=.04). In multivariable analyses including dichotomized BED and location, BED remained associated with obliteration (P=.001).

Conclusion: Biological effective dose ≥133 Gy was predictive of AVM obliteration after single-session SRS within the prescribed margin dose range 15 to 25 Gy. Further study is warranted to determine whether BED optimization should be considered as well as treatment dose for AVM SRS planning.
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http://dx.doi.org/10.1016/j.mayocp.2020.09.041DOI Listing
May 2021

Long-term outcomes of grade I/II skull base chondrosarcoma: an insight into the role of surgery and upfront radiotherapy.

J Neurooncol 2021 Jun 27;153(2):273-281. Epub 2021 Apr 27.

Departments of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.

Purpose: To clarify the need for post-operative radiation treatment in skull base chondrosarcomas (SBCs).

Methods: A retrospective analysis of patients with grade I or II SBC. Patients were divided according to post-surgical treatment strategies: (A) planned upfront radiotherapy and (B) watchful waiting. Tumor control and survival were compared between the treatment groups. The median follow-up after resection was 105 months (range, 9-376).

Results: Thirty-two patients (Grade 1, n = 16; Grade 2, n = 16) were included. The most frequent location was petroclival (21, 64%). A gross total resection (GTR) was achieved in 11 patients (34%). Fourteen (44%) underwent upfront radiotherapy (group A) whereas 18 (56%) were followed with serial MRI alone (group B). The tumor control rate for the entire group was 77% and 69% at 10- and 15-year, respectively. Upfront radiotherapy (P = 0.25), extent of resection (P = 0.11) or tumor grade (P = 0.83) did not affect tumor control. The majority of Group B patients with recurrent tumors (5/7) obtained tumor control with repeat resection (n = 2), salvage radiotherapy (n = 2), or a combination of both (n = 1). The 10-year disease-specific survival was 95% with no difference between the group A and B (P = 0.50).

Conclusion: For patients with grade I/II SBC, a reasonable strategy is deferral of radiotherapy after maximum safe resection until tumor progression or recurrence. At that time, most patients can be successfully managed with salvage radiotherapy or surgery. Late recurrences may occur, and life-long follow-up is advisable.
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http://dx.doi.org/10.1007/s11060-021-03764-0DOI Listing
June 2021

The Third Eye Sees Double: Cohort Study of Clinical Presentation, Histology, Surgical Approaches, and Ophthalmic Outcomes in Pineal Region Germ Cell Tumors.

World Neurosurg 2021 06 17;150:e482-e490. Epub 2021 Mar 17.

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

Background: Intracranial germ cell tumors (GCTs) predominantly occur in the adolescent and young adult population and are most frequently located at the pineal gland. Tumor masses in the pineal region may cause ophthalmic symptoms due to compression to the midbrain, frequently presenting with Parinaud syndrome and hydrocephalus due to aqueductal compression.

Methods: We conducted a single-institution cohort study of primary, pineal region GCTs to characterize the clinical presentation, as well as associated ophthalmic and hydrocephalus outcomes.

Results: Fifty-six primary pineal GCTs were identified. Among the 40 isolated pineal region GCTs, 15 were germinomas while 25 were nongerminomatous GCTs. Among 43 cases of hydrocephalus, endoscopic third ventriculostomy was the primary treatment in 27 cases, which was successful in 23 but failed and required additional treatment for the rest. Pineal tumor mass was significantly larger in cases with hydrocephalus compared with those without, and the 20-mm diameter of the tumor was the crucial point for obstructive hydrocephalus. Ophthalmic symptoms were commonly observed at presentation, which included diplopia (74.3%), upward-gaze palsy (69.7%), and Argyll Robertson pupil (40%). These symptoms tended to remain, and the existence of these symptoms at presentation predicted the remaining symptoms in the follow-up.

Conclusions: Intracranial GCTs presenting with ophthalmic abnormalities appear to be at increased risk of residual posttreatment symptoms, while second-look surgery presents a significant risk factor for the development of new deficits. Hydrocephalus often accompanies pineal region GCTs, and in most cases both cerebrospinal fluid diversion and tissue diagnosis can be successfully achieved via endoscopic third ventriculostomy.
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http://dx.doi.org/10.1016/j.wneu.2021.03.030DOI Listing
June 2021

Far Lateral Approach for Malignant, Severely Calcified Cerebellopontine Angle Tumor.

J Neurol Surg B Skull Base 2021 Feb 17;82(Suppl 1):S29-S30. Epub 2020 Nov 17.

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States.

 The far-lateral approach is an effective skull base technique that provides access to the lower clivus and premedullary area. This approach is also useful for maximal visualization and resection of large posterior fossa tumors with extensive medial extension, especially when aggressive resection is ideal for a malignant tumor in a young patient, or it is technically challenging because of tumor calcification. We demonstrate a microsurgical operative video to describe technical pearls in this difficult situation.  A 45-year-old man with history of "hoarseness" for up to two decades was presented with imbalance and mild dysphagia over 3 years. Imaging demonstrated a 55-mm left cerebellopontine angle (CPA) tumor extending medially across the midline with severe calcification ( Figs. 1 and 2 ). His neurological examination revealed left facial numbness, complete left facial weakness, left deafness, complete left vocal paralysis, as well as severe left hemibody ataxia. The tumor was resected via a left suboccipital craniotomy with far lateral approach including drilling to the occipital condyle and C1 laminectomy. Initial manipulation of the inferior pole of the tumor resulted in asystole which was managed successfully with glycol pyrolate. Pathology demonstrated IDH-1 wild type, MGMT-methylated glioblastoma. The patient subsequently underwent adjuvant chemoradiation.  The far-lateral approach is an effective approach for maximal safe resection of a malignant brainstem, cerebellar, and CPA tumor. The link to the video can be found at: https://youtu.be/AIGebJPJEnw .
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http://dx.doi.org/10.1055/s-0040-1705164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935727PMC
February 2021

Acute Sialadenitis After Skull Base Surgery: Systematic Review and Summative Practice Recommendations.

World Neurosurg 2021 06 5;150:205-210.e1. Epub 2021 Mar 5.

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Background: Sialadenitis is a rare complication of skull base neurosurgery, in which the submandibular gland undergoes acute inflammation with edema after surgery. Although attributable to transient obstruction or manual compression, presentation may be rapidly life-threatening as a result of airway obstruction. Understanding risk factors is limited at present, and no practical management guidelines have been reported. Our objective was to survey the literature and to characterize the associated risk factors, treatment considerations, and overall trends in outcomes for patients experiencing post skull base neurosurgery sialadenitis.

Methods: A search of the Ovid EMBASE, SCOPUS, and PubMed databases from inception through August 2020 was performed via Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results: Systematic review identified 13 publications describing 18 cases of acute sialadenitis after skull base surgery. We describe the 19th reported case. Commonalities include the need for aggressive respiratory support as intubation or emergent tracheostomy is almost universally required. Risk factors are poorly understood but may include extreme flexion and/or rotation of the head and neck. Outcomes are favorable overall, although secondary complications have been described.

Conclusions: Sialadenitis is a rare but potentially life-threatening complication of skull base neurosurgery, owing to acute loss of airway and the potential for a diverse array of secondary complications.
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http://dx.doi.org/10.1016/j.wneu.2021.02.124DOI Listing
June 2021

Generation Why: Neurosurgery and the Millennial Moment.

World Neurosurg 2021 05 20;149:8-10. Epub 2021 Feb 20.

Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA. Electronic address:

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http://dx.doi.org/10.1016/j.wneu.2021.02.070DOI Listing
May 2021

Bibliometric Analysis of the 200 Most Cited Articles in WORLD NEUROSURGERY.

World Neurosurg 2021 05 3;149:226-231.e3. Epub 2021 Feb 3.

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: WORLD NEUROSURGERY (WN) is among the most influential peer-reviewed neurosurgery journals and has had an explicitly global focus historically. The goal of the current study was to perform quantitative bibliographic and social network analyses to identify key contributors and trends influencing article citation patterns.

Methods: WN articles were searched using Web of Science and the sampling frame January 1, 1990, to June 18, 2020. Articles were sorted in decreasing order of total citations; the 200 most cited articles were included. BibExcel was used to calculate the H-index of the authors of the top 200 most cited articles; VOSViewer was used to visualize networks by document, author, and keyword.

Results: Twenty-one individual authors published at least 2 first-author articles within the 200 most cited manuscripts, including Hakuba (4 articles), Jaaskelainen (4 articles), Cho (3 articles), and Rhoton (3 articles). Authors with the highest H-index were Hernesniemi (5), Rhoton (4), Jaaskelainen (4), Hakuba (4), and Ausman (4). Articles by Huang (2006), Wieser (1982), and Foo (1981) had the largest number of links to other articles (connections between nodes). Ausman articles demonstrated the highest number of collaborations with coauthors who had also published top 200 articles. The most prevalent topics among included articles were neuro-oncology in the 1990s, cerebrovascular in the early 2000s, and skull base in the 2010s.

Conclusions: Bibliographic analysis suggests that WN has published a wide range of novel and impactful research studies in neurosurgery, which collectively demonstrate strong collaborative trends in association with advancement of new tools and techniques in all aspects of neurosurgery.
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http://dx.doi.org/10.1016/j.wneu.2021.01.121DOI Listing
May 2021

Sternberg's Canal and Defect: Is the Lateral Craniopharyngeal Canal a Source of Spontaneous Cerebrospinal Fluid Leak? Anatomic and Radiological Analysis in Pediatric and Adult Populations.

Oper Neurosurg (Hagerstown) 2021 03;20(4):426-432

Department of Neurosurgery, Albany Medical Center, Albany, New York.

Background: The lateral craniopharyngeal or Sternberg's canal (SC) originates from superior orbital fissure (SOF) and traverses the sphenoid body into the nasopharynx. A remnant of the canal, Sternberg's defect (SD), has been debated as a source of cerebrospinal fluid (CSF) leak. The canal was described in 1888, and there is limited accurate visual illustration in the literature.

Objective: To provide a detailed anatomic and radiological illustration of the canal in pediatric and adult population including the mechanism undermining the incidence of the canal, and the possibility of the canal as a source of CSF leak.

Methods: A total of 195 high-resolution computed tomographies (CT) of patients (50 3-yr-old, 20 5-yr-old, and 125 adults) and 43 dry adult skulls (86 sides) were analyzed for a canal matching the description of the SC.

Results: A SC was identified in 86% of the 3-yr-old and 40% of 5-yr-old patients. The diameter and length were 2.12 mm and 12 mm, respectively. The incidence of the canal decreased with age as sinus pneumatization extended into the sphenoid sinus. Only 0.8% of the adult skull on CT had the canal. The canal was not present on the dry adult skulls examination, but SD was found in 4.65%.

Conclusion: SC exists with high incidence in the pediatric group. Sinus pneumatization obliterates the canal in the adult population, leaving a defect in 4.65% of cases, which given the location and related anatomic structures, is unlikely to be a source of CSF leak.
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http://dx.doi.org/10.1093/ons/opaa446DOI Listing
March 2021

Biological Effective Dose as a Predictor of Hypopituitarism After Single-Fraction Pituitary Adenoma Radiosurgery: Dosimetric Analysis and Cohort Study of Patients Treated Using Contemporary Techniques.

Neurosurgery 2021 03;88(4):E330-E335

Departments of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.

Background: Hypopituitarism is the most frequent complication after pituitary adenoma stereotactic radiosurgery (SRS) and is correlated with increasing radiation to the pituitary gland. Biological effective dose (BED) is a dosimetric parameter that incorporates a time component to adjust for mechanisms of deoxyribonucleic acid repair activated during treatment.

Objective: To assess mean gland BED as a predictor of post-SRS hypopituitarism, as compared to mean gland dose, in a contemporary cohort study of patients undergoing single-fraction SRS for pituitary adenoma.

Methods: Cohort study of 97 patients undergoing single-fraction SRS from 2007 to 2014. Eligible patients had no prior pituitary irradiation, normal pre-SRS endocrine function, and >24 mo of endocrine follow-up. Cox proportional hazards analysis was used to assess mean gland dose and BED as predictors of new post-SRS hypopituitarism.

Results: Median post-SRS follow-up was 48 mo (interquartile range [IQR], 34-68). A total of 27 patients (28%) developed new hypopituitarism at a median 22 mo (IQR, 12-36). Actuarial rates of new endocrinopathy were 17% at 2 yr (95% CI 10%-25%) and 31% at 5 yr (95% CI 20%-42%). On univariate analysis, sex (P = .02), gland volume (P = .03), mean gland dose (P < .0001), and BED significantly predicted new hypopituitarism (P < .0001). After adjusting for sex and gland volume, BED > 45 Gy2.47 and mean gland dose > 10 Gy were significantly associated increased risk of hypopituitarism (hazard ratio [HR] = 14.32, 95% CI = 4.26-89.0, P < .0001; HR = 11.91, 95% CI = 3.54-74.0, P < .0001).

Conclusion: BED predicted hypopituitarism more reliably than mean gland dose after pituitary adenoma SRS, but additional studies are needed to confirm these results.
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http://dx.doi.org/10.1093/neuros/nyaa555DOI Listing
March 2021

Subarachnoid hemorrhage rebleeding in the first 24 h is associated with external ventricular drain placement and higher grade on presentation: Cohort study.

J Clin Neurosci 2020 Nov 12;81:180-185. Epub 2020 Oct 12.

Department of Neurology, Mayo Clinic, Rochester, MN, United States.

Background: Rebleeding after aneurysmal subarachnoid hemorrhage (aSAH) confers a poor prognosis; however, risk factors and differential outcomes associated with early rebleeding in the first 24 h after symptom presentation are incompletely understood.

Methods: A retrospective cohort study of all aSAH presenting to our institution between 2001 and 2016 was performed. Early rebleeding events were defined as clinical neurologic decline with radiographically confirmed acute intracranial hemorrhage within 24 h after symptom presentation. Univariate and multivariate logistic regression analyses were used to assess clinical associations, with a specific focus on baseline Glasgow Coma Score (GCS), World Federation of Neurosurgical Societies (WFNS), and modified Fisher scores.

Results: Of 471 aSAH cases, 33 (7%) experienced early rebleeding. Multivariate regression identified extraventricular drain (EVD) placement (OR = 2.16, P = 0.04) and WFNS 3-5 (OR = 2.69, P = 0.02) as significant predictors of early rebleeding. Good functional outcomes were observed in 8 patients with early rebleeding (24%), all of whom underwent aneurysm treatment. Higher SAH grade prior to rebleeding (WFNS 3-5) was significantly associated with increased odds of an unfavorable functional outcome (OR = 8.09, P < 0.01). Anticoagulation, aneurysm size and location were not significantly associated with either early rebleeding incidence or functional outcome.

Conclusions: Early rebleeding in aSAH is associated with unfavorable functional outcomes. EVD placement and higher SAH grade on presentation appear to be significantly and independently associated with increased risk of rebleeding within first 24 h, as well as unfavorable long-term functional outcome; however, the clinical benefit of hyper-acute aneurysm treatment requires further investigation.
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http://dx.doi.org/10.1016/j.jocn.2020.09.064DOI Listing
November 2020

Beyond the ABCs: Hearing Loss and Quality of Life in Vestibular Schwannoma.

Mayo Clin Proc 2020 11;95(11):2420-2428

Department of Neurologic Surgery, Mayo Clinic, Rochester, MN; Department Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN. Electronic address:

Objective: To assess the impact of differential hearing loss on QOL in sporadic unilateral vestibular schwannoma.

Patients And Methods: Cross-sectional observational multicenter study including 422 patients with vestibular schwannoma and formal audiometry within 1 year of survey administration, analyzed using multivariable regression.

Results: Among 422 patients included, the median age was 57 (range, 18-81) years; 223 (53%) were women. Among 390 patients with complete audiometric data, American Academy of Otolaryngology-Head and Neck Surgery class was A in 134 (34%), B in 69 (18%), C in 26 (7%), and D in 161 (41%). A total of 335 of 390 (86%) reported subjective ipsilateral hearing loss (median severity, 6/10 [1 = normal, 10 = deaf]), 166 (43%) reported ipsilateral inability to use the telephone, 155 (37%) reported that hearing loss had affected personal relationships, and 213 (51%) reported difficulty with conversations. After adjusting for age and sex, the odds ratio (OR) for hearing loss adversely affecting relationships was 4.4 for class B hearing vs class A (95% CI, 2.1-9.4; P<.0001). The OR for difficulty with conversations was 2.7 for class B vs class A (95% CI, 1.4-5.3; P=.003). The OR for lost ipsilateral telephone use was 6.3 for class B vs class A (95% CI, 3.2-13.0; P<.0001). Differences between class B and class C were not significant. WRS outperformed PTA as a predictor of hearing-related QOL. The optimal threshold for predicting a significant adverse impact on QOL was WRS less than 72% to 76%.

Conclusion: Hearing loss adversely affects QOL after only modest audiometric disability. The WRS alone appears to be a much more reliable predictor of hearing-related QOL than PTA or American Academy of Otolaryngology-Head and Neck Surgery class.
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http://dx.doi.org/10.1016/j.mayocp.2020.03.033DOI Listing
November 2020

Carotid Artery Injury during Transsphenoidal Pituitary Surgery: Lessons from a 15-Year Modern Microsurgery Cohort.

J Neurol Surg B Skull Base 2020 Oct 24;81(5):594-602. Epub 2019 Jul 24.

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, United States.

 Internal carotid artery (ICA) injury is a rare but potentially catastrophic complication of transsphenoidal resection (TSR) of pituitary tumors, potentially resulting in a host of deficits due to the risk of hemorrhage, ischemia, or even death. The endoscopic endonasal approach (EEA) has gained considerable popularity in the modern era, with few busy neurosurgeons remaining committed to practicing transnasal pituitary microsurgery. Our objective was therefore to characterize the overall incidence of ICA injury in a large, longitudinal, single-surgeon microscopic TSR series conducted during the modern EEA era.  Retrospective case series.  Overall TSR volume by the senior author (F.B.M.) was 817 pituitary tumors during the study period, 2002 to 2017. Within that cohort, two instances of ICA injury were identified (0.2%), including one each with Cushing's disease and acromegaly, both of whom ultimately recovered without residual neurologic deficit. No pediatric injuries were identified.  Vascular injury is an exceedingly rare complication of transsphenoidal pituitary surgery. Adjuncts to prevent this complication include careful review of the coronal magnetic resonance imaging, identification of the midline, as needed use of the Doppler, and initial caudal opening of the sellar dura. Although potentially disastrous, good neurologic outcomes may be obtained, with immediate judicious packing followed by immediate digital subtraction angiography to assess vessel patency and secondary complications such as pseudoaneurysm.
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http://dx.doi.org/10.1055/s-0039-1692484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7591353PMC
October 2020

Surgery versus radiosurgery for facial nerve schwannoma: a systematic review and meta-analysis of facial nerve function, postoperative complications, and progression.

J Neurosurg 2020 Oct 30:1-12. Epub 2020 Oct 30.

Departments of1Neurosurgery.

Objective: Intracranial facial nerve schwannomas (FNS) requiring treatment are frequently recommended for surgery or stereotactic radiosurgery (SRS). The objective of this study was to compare facial nerve function outcomes between these two interventions for FNS via a systematic review and meta-analysis.

Methods: A search of the Ovid EMBASE, PubMed, SCOPUS, and Cochrane databases from inception to July 2019 was conducted following PRISMA guidelines. Articles were screened against prespecified criteria. Facial nerve outcomes were classified as improved, stabilized, or worsened by last follow-up. Incidence was pooled by random-effects meta-analysis of proportions.

Results: Thirty-three articles with a pooled cohort of 519 patients with FNS satisfied all criteria. Twenty-five articles described operative outcomes in 407 (78%) patients; 10 articles reported SRS outcomes in 112 (22%). In the surgical cohort, facial nerve function improved in 23% (95% CI 15%-32%), stabilized in 41% (95% CI 32%-50%), and worsened in 30% (95% CI 21%-40%). In the SRS cohort, facial nerve function was improved in 20% (95% CI 9%-34%), stable in 66% (95% CI 54%-78%), and worsened in 9% (95% CI 3%-16%). Compared with SRS, microsurgery was associated with a significantly lower incidence of stable facial nerve function (p < 0.01) and a significantly higher incidence of worsened facial nerve function (p < 0.01). Tumor progression and complication rates were comparable. Outcome certainty assessments were very low to moderate for all parameters.

Conclusions: Unfavorable facial nerve function outcomes are associated with surgical treatment of intracranial FNS, whereas stable facial nerve function outcomes are associated with SRS. Therefore, SRS should be recommended to patients with FNS who require treatment, and surgery should be reserved for patients with another indication, such as decompression of the brainstem. Further study is required to definitively optimize and validate management strategies for these rare skull base tumors.
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http://dx.doi.org/10.3171/2020.6.JNS201548DOI Listing
October 2020

Disseminated tuberculosis confounding a co-morbid primary CNS lymphoma.

IDCases 2020 22;22:e00965. Epub 2020 Sep 22.

Division of Infectious Diseases, Mayo Clinic, USA.

Primary central nervous system lymphoma is notoriously challenging to diagnose in immunocompetent patients as it is an uncommon diagnosis. We present a case of synchronous diagnosis with tuberculosis. A 60-year-old woman presented with cognitive difficulties, memory loss, social withdrawal, unintentional weight loss, and night sweats, the work-up of which ultimately identified multiple brain lesions and mediastinal adenopathy. Brain biopsy showed lymphohistiocytic infiltrate, while mediastinal node histopathology showed necrotizing granulomas, and cultures grew The patient was initiated on anti-tuberculosis therapy. However, follow-up brain MRI demonstrated disease progression, prompting repeat brain biopsy, which in turn confirmed the diagnosis of diffuse large B-cell lymphoma. Although unrelated synchronous diagnoses are rare, the potential for clinically significant confounding is considerable-particularly where disease markers may overlap, as is often the case with infectious, inflammatory, and neoplastic processes. The present case illustrates the importance of diligence in ruling out competing diagnosis, and timely action when an anticipated finding or response-to-treatment is not observed.
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http://dx.doi.org/10.1016/j.idcr.2020.e00965DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522090PMC
September 2020

A Puzzling Exam: Kernohan's Notch Reimaged.

J Clin Neurosci 2020 Sep 14. Epub 2020 Sep 14.

Department of Neurology, Mayo Clinic, Rochester, MN, USA. Electronic address:

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http://dx.doi.org/10.1016/j.jocn.2020.06.017DOI Listing
September 2020

An arrow that missed the mark: a pediatric case report of remarkable neurologic improvement following penetrating spinal cord injury.

Childs Nerv Syst 2021 05 5;37(5):1771-1778. Epub 2020 Aug 5.

Department of Neurological Surgery, Pediatric Neurosurgery, Mayo Clinic, Rochester, MN, 55905, USA.

Penetrating spinal cord injuries are rare in children but result in devastating impacts on long-term morbidity and mortality-with little known about the recovery capacity in this age group. We present the case of an eight-year-old child who sustained a penetrating injury through the right anterior thorax. Thoracic CT showed the arrow tip extending through the spinal canal at T6. Neurologic examination revealed no motor or sensory function below T6. The arrow was surgically removed without complications through an anterior-only approach. MRI on post-operative day (POD) 4 showed focal T2 hyperintensity at the T6 spinal cord. Patient was discharged on POD33 with an American Spinal Injury Association (ASIA)-D score and trace voluntary control over bowel and bladder function. Remarkably, four months later, he had near normal bowel and bladder function, with near-intact lower extremity strength and self-sustained ambulation. Follow-up imaging revealed hemicord formation at the level of injury. We review our case of penetrating spinal cord injury in a child and similar reports in the literature. Penetrating thoracic spinal cord trauma portends poor clinical outcomes, particularly when employing available adult prognostic spinal cord injury scoring metrics. Incomplete spinal cord injury, and often-associated spinal shock, can mimic a complete injury-as in our patient, which improved to near-complete motor and sensory restoration of function and resulted in the formation of a split hemicord. This case represents a unique penetrating spinal cord injury with remarkable neurologic recovery, which would advocate against definitive early prognostication in the pediatric population.
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http://dx.doi.org/10.1007/s00381-020-04842-wDOI Listing
May 2021
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