Publications by authors named "Eric Feldstein"

14 Publications

  • Page 1 of 1

Intraventricular Choroid Plexus Cavernoma Resection Using Tubular Retractor System and Exoscope Visualization: A Technical Case Report.

Oper Neurosurg (Hagerstown) 2022 Jan 14. Epub 2022 Jan 14.

Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, USA.

Background And Importance: Cavernous malformations (CMs) account for approximately 5% to 10% of all CNS vascular malformations, and intraventricular CMs (IVCMs) are a rare subtype, accounting for 2.5% to 10.8% of all intracranial CMs. IVCMs can expand rapidly, leading to compression of adjacent structures, intraventricular hemorrhage, and obstructive hydrocephalus. Diagnosis is challenging because it can mimic a variety of other lesions.

Clinical Presentation: A 71-year-old man presented after a fall because of imbalance. MRI of the head showed a homogenously enhancing 2-cm mass in the posterior aspect of the right lateral ventricle, with blood layering in the right occipital horn and adjacent parietal edema and leptomeningeal enhancement, as well as a pituitary lesion.

Discussion: The patient underwent a right parietal craniotomy for resection of the mass. The ventricle was accessed through a transsulcal approach through the intraparietal sulcus using a tubular retractor system. The mass was arising from the choroid plexus and dissected free in a piecemeal fashion. Postoperative imaging confirmed gross total resection, and the patient had an uneventful recovery.

Conclusion: Here, we present the first case of a choroid plexus IVCM removed using a tubular retractor system. We demonstrate that this is a safe and effective approach for this rare lesion given the minimal traction on brain parenchyma and enhanced visualization of a deep-seated cavernoma in the lateral ventricle.
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http://dx.doi.org/10.1227/ONS.0000000000000075DOI Listing
January 2022

Obstructive sleep apnea confers lower mortality risk in acute ischemic stroke patients treated with endovascular thrombectomy: National Inpatient Sample analysis 2010-2018.

J Neurointerv Surg 2021 Dec 20. Epub 2021 Dec 20.

Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA

BackgroundObstructive sleep apnea (OSA) portends increased morbidity and mortality following acute ischemic stroke (AIS). Evaluation of OSA in the setting of AIS treated with endovascular mechanical thrombectomy (MT) has not yet been evaluated in the literature.

Methods: The National Inpatient Sample from 2010 to 2018 was utilized to identify adult AIS patients treated with MT. Those with and without OSA were compared for clinical characteristics, complications, and discharge disposition. Multivariable logistic regression analysis and propensity score adjustment (PA) were employed to evaluate independent associations between OSA and clinical outcome.

Results: Among 101 093 AIS patients treated with MT, 6412 (6%) had OSA. Those without OSA were older (68.5 vs 65.6 years old, p<0.001), female (50.5% vs 33.5%, p<0.001), and non-caucasian (29.7% vs 23.7%, p<0.001). The OSA group had significantly higher rates of obesity (41.4% vs 10.5%, p<0.001), atrial fibrillation (47.1% vs 42.2%, p=0.001), hypertension (87.4% vs 78.5%, p<0.001), and diabetes mellitus (41.2% vs 26.9%, p<0.001). OSA patients treated with MT demonstrated lower rates of intracranial hemorrhage (19.1% vs 21.8%, p=0.017), treatment of hydrocephalus (0.3% vs 1.1%, p=0.009), and in-hospital mortality (9.7% vs 13.5%, p<0.001). OSA was independently associated with lower rate of in-hospital mortality (aOR 0.76, 95% CI 0.69 to 0.83; p<0.001), intracranial hemorrhage (aOR 0.88, 95% CI 0.83 to 0.95; p<0.001), and hydrocephalus (aOR 0.51, 95% CI 0.37 to 0.71; p<0.001). Results were confirmed by PA.

Conclusions: Our findings suggest that MT is a viable and safe treatment option for AIS patients with OSA.
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http://dx.doi.org/10.1136/neurintsurg-2021-018161DOI Listing
December 2021

Non-Operative Management of a Pediatric Patient With Bilateral Subdural Hematomas in the Setting of Ruptured Arachnoid Cyst.

Cureus 2021 Dec 2;13(12):e20099. Epub 2021 Dec 2.

Neurological Surgery, Westchester Medical Center, Valhalla, USA.

Pediatric subdural hematomas (SDH) are associated with arachnoid cysts (AC), particularly in the middle cranial fossa (MCF). Operative management of these hemorrhages is a mainstay of treatment. Conservative management may be an option if there is minimal mass effect and the patient is mildly symptomatic. A 14-year-old male presented with right frontal headaches that worsened with activity. He was found to have a large right MCF AC. Scheduled routine outpatient follow-up CT of the head demonstrated bilateral SDH. There was no history of significant head trauma. He was admitted for close observation and his inpatient scans remained stable. Outpatient follow-up imaging over the course of three and a half years demonstrated resolution of SDH and decreased AC size. He denied headaches and continued doing well in school. ACs are a risk factor for the development of SDH in young male patients after minor trauma. Development of intracranial hypotension secondary to AC rupture may have contributed to the development of bilateral SDH in our patient. We demonstrate here that close clinical follow up with serial imaging may be considered a management strategy in these patients.
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http://dx.doi.org/10.7759/cureus.20099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8637768PMC
December 2021

Does alar ligament injury predict conservative treatment failure of atlantoaxial rotatory subluxation in adults: Case report and review of the literature.

Spinal Cord Ser Cases 2021 Dec 3;7(1):103. Epub 2021 Dec 3.

Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, 10595, USA.

Introduction: The alar ligament is an important structure in restraining the rotational movement at the atlantoaxial joint. While bony fractures generally heal, rupture of ligaments may heal poorly in adults and often requires surgical stabilization. Atlantoaxial rotatory subluxation (AARS) is a rare injury in adults, and the prognostic importance of the presence of alar ligament injury with regard to the success of nonoperative management is unknown.

Case Presentation: A 28-year-old woman presented after a traumatic Type I AARS without evidence of osseous injury, but MRI demonstrated evidence of unilateral alar ligament disruption. Initial conservative management with closed reduction and maintenance in a rigid cervical collar proved unsuccessful, with worsening pain and failure to maintain reduction. She subsequently underwent open reduction and surgical fixation of C1-C2, resulting in resolution of her pain and maintenance of alignment.

Discussion: Alar ligament rupture may be a negative prognostic indicator in the success of nonoperative management of type I atlantoaxial rotatory subluxation. Additional study is warranted to better assess whether the status of the alar ligament should be considered an important factor in the management algorithm of type I AARS.
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http://dx.doi.org/10.1038/s41394-021-00464-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8642488PMC
December 2021

Relation between brain natriuretic peptide and delayed cerebral ischemia in patients with aneurysmalsubarachnoid hemorrhage.

Clin Neurol Neurosurg 2021 Dec 14;211:107031. Epub 2021 Nov 14.

Department of Neurosurgery and Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA. Electronic address:

Background: Brain natriuretic peptide (BNP), often used to evaluate degree of heart failure, has been implicated in fluid dysregulation and inflammation in critically-ill patients. Twenty to 30% of patients with aneurysmal subarachnoid hemorrhage (aSAH) will develop some degree of neurogenic stress cardiomyopathy (NSC) and in turn elevation of BNP levels. We sought to explore the association between BNP levels and development of delayed cerebral ischemia (DCI) in patients with aSAH.

Methods: We retrospectively evaluated the records of 149 patients admitted to the Neurological Intensive Care Unit between 2006 and 2015 and enrolled in an existing prospectively maintained aSAH database. Demographic data, treatment and outcomes, and BNP levels at admission and throughout the hospital admission were noted.

Results: Of the 149 patients included in the analysis, 79 developed DCI during their hospital course. We found a statistically significant association between DCI and the highest recorded BNP (OR 1.001, 95% CI-1.001-1.002, p = 0.002). The ROC curve analysis for DCI based on BNP showed that the highest BNP level during hospital admission (AUC 0.78) was the strongest predictor of DCI compared to the change in BNP over time (AUC 0.776) or the admission BNP (AUC 0.632).

Conclusion: Our study shows that DCI is associated not only with higher baseline BNP values (admission BNP), but also with the highest BNP level attained during the hospital course and the rapidity of change or increase in BNP over time. Prospective studies are needed to evaluate whether routine measurement of BNP may help identify SAH patients at high risk of DCI.
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http://dx.doi.org/10.1016/j.clineuro.2021.107031DOI Listing
December 2021

Spontaneous Regression of Cerebral Arteriovenous Malformation Following Onyx Embolization.

Cureus 2021 Nov 13;13(11):e19533. Epub 2021 Nov 13.

Neurosurgery, Westchester Medical Center, Valhalla, USA.

Little is known about the natural history of arteriovenous malformations (AVM) and less is known about their potential for spontaneous regression. The advent of endovascular treatment for embolization or pre-surgical embolization of cerebral arteriovenous malformations (cAVM) has seen several reports of spontaneous regression of partial embolization of cAVMs surface in the literature. A 66-year-old patient had an initial diagnostic cerebral angiogram revealing a left frontoparietal region Spetzler-Martin (SM) grading 4 cAVM. The patient underwent three stages of embolization over eight months leading to a 90% reduction in nidal volume, before being lost to follow up for six years. A six-vessel diagnostic cerebral angiogram was performed at that time to assess for any interval changes and surprisingly, the previously visualized left frontoparietal AVM had regressed. There was evidence of prior onyx embolization with no residual filling or recurrence. Spontaneous regression after partial embolization may be under-reported or the natural history is simply unable to temporally unfold because the typical treatment course results in surgery following partial embolization. Given the potential to forgo the risks of an open procedure, we believe this topic deserves further attention.
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http://dx.doi.org/10.7759/cureus.19533DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8592311PMC
November 2021

Treatment of an Elusive Symptomatic Sinus Pericranii: Case Report and Review of the Literature.

J Neurol Surg A Cent Eur Neurosurg 2021 Nov 15. Epub 2021 Nov 15.

Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, New York, United States.

Sinus pericranii (SP) are abnormal vascular connections between extracranial scalp venous channels and intracranial dural sinuses. This vascular abnormality rarely results in significant sequelae, but in select cases, it can be symptomatic. We describe the case of a 7-year-old girl with an SP who experienced intermittent visual, motor, and sensory symptoms not previously described in the literature. Her symptoms resolved after surgical treatment of the SP. We propose a mechanism for her symptoms and the rationale for the role of neurosurgical intervention along with a review of the literature.
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http://dx.doi.org/10.1055/s-0041-1735862DOI Listing
November 2021

Impact of pre-ictal antiplatelet therapy use in aneurysmal subarachnoid hemorrhage.

Clin Neurol Neurosurg 2021 Dec 10;211:107022. Epub 2021 Nov 10.

Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, United States.

Objective: There is limited evidence on the use of antiplatelet therapy (APT) to reduce the risk and morbidity of cerebral aneurysmal rupture. This analysis retrospectively assessed APT use in patients presenting to our institution with aneurysmal subarachnoid hemorrhage (aSAH).

Methods: We evaluated the records of 186 patients over 7 years of retrospective data from our tertiary care center and an existing database of patients with aSAH. A total of 18 cases with patients on APT and 168 patients not on APT (controls) were identified. Primary outcomes measured were clinical grade (Hunt and Hess score), radiographic grade (Fisher score), and presence of delayed cerebral ischemia (DCI). Secondary outcomes were modified Rankin score at discharge and at 3 months. DCI from cerebral vasospasm was defined as the occurrence of focal neurological impairment or a decrease in at least 2 points on the Glasgow Coma Scale. Logistic regression models were generated.

Results: We found that APT use did not appear to lead to statistically significant differences in initial presentation, including Hunt-Hess score and Fisher grade (2.91 vs 3.06, p = 0.66, and 3.23 vs 3.22, p = 0.96 respectively). In addition, APT use was not associated with increased rates of delayed cerebral ischemia (DCI) (OR 0.27 p = 0.12). Our analysis showed that increased Hunt Hess score and the presence of DCI are both associated with increased mRS at 90 days (OR 2.32 p < 0.001; OR 2.91 p = 0.002).

Conclusion: The patients in this retrospective observational study did not demonstrate worse outcomes from their aSAH despite APT therapy. Larger prospective studies should be performed to see if this relationship holds and if decreased rates of DCI can be observed.
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http://dx.doi.org/10.1016/j.clineuro.2021.107022DOI Listing
December 2021

Correction of Sagittal Balance With Resection of Kissing Spines.

Cureus 2021 Aug 4;13(8):e16874. Epub 2021 Aug 4.

Neurosurgery, Westchester Medical Center, Valhalla, USA.

Kissing spines syndrome, also known as Baastrup's disease, is a common yet underdiagnosed disorder involving close approximation of adjacent spinous processes. These painful pseudoarticulations may be secondary to the compensatory mechanisms that result from sagittal imbalance. Conventional operative correction of sagittal balance includes a wide range of procedures from facetectomies to vertebral column resection. Resection of kissing spines for the operative management of sagittal imbalance is a treatment modality not extensively discussed in the literature but may offer improved patient outcomes with shorter operative times, lower risk, and reduced length of stay. A 67-year old male with a history of degenerative disk disease and scoliosis presented with neurogenic claudication and severe back pain that worsened with walking and improved with sitting. X-ray imaging of the lumbar spine revealed straightening of the normal lumbar lordotic curvature with mild rotoscoliosis. There was also evidence of retrolisthesis of L2 on L3 that worsened with flexion. The patient had Baastrup's disease at the L3-4 and L4, 5 levels that contributed to his reduced range of motion on extension imaging. Operative treatments including long-segment fusion with interbody cages to correct sagittal balance were considered with a discussion of possible debilitating and high-risk post-surgical outcomes. Instead, the patient underwent a simple decompression surgery involving laminectomies and resection of kissing spines to correct his sagittal imbalance. Postoperative follow-up imaging demonstrated significant improvement in sagittal balance, and the patient expressed relief of back and leg pain. Although underdiagnosed, consideration of kissing spines syndrome in the surgical correction of sagittal imbalance may offer an improvement over conventional operations. Our case presents a unique surgical perspective on the treatment of spinal stenosis with kissing spines with particular regard to correcting the sagittal imbalance, avoiding debilitating procedures, and providing better immediate postoperative outcomes.
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http://dx.doi.org/10.7759/cureus.16874DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8415043PMC
August 2021

TOP2B Enzymatic Activity on Promoters and Introns Modulates Multiple Oncogenes in Human Gliomas.

Clin Cancer Res 2021 10 25;27(20):5669-5680. Epub 2021 Aug 25.

Department of Neurosurgery, Feinberg School of Medicine, Northwestern University and Northwestern Medicine Malnati Brain Tumor Institute of the Robert H. Lurie Comprehensive Cancer Center, Feinberg School of Medicine, Northwestern University, Chicago, Illinois.

Purpose: The epigenetic mechanisms involved in transcriptional regulation leading to malignant phenotype in gliomas remains poorly understood. Topoisomerase IIB (TOP2B), an enzyme that decoils and releases torsional forces in DNA, is overexpressed in a subset of gliomas. Therefore, we investigated its role in epigenetic regulation in these tumors.

Experimental Design: To investigate the role of TOP2B in epigenetic regulation in gliomas, we performed paired chromatin immunoprecipitation sequencing for TOP2B and RNA-sequencing analysis of glioma cell lines with and without TOP2B inhibition and in human glioma specimens. These experiments were complemented with assay for transposase-accessible chromatin using sequencing, gene silencing, and mouse xenograft experiments to investigate the function of TOP2B and its role in glioma phenotypes.

Results: We discovered that TOP2B modulates transcription of multiple oncogenes in human gliomas. TOP2B regulated transcription only at sites where it was enzymatically active, but not at all native binding sites. In particular, TOP2B activity localized in enhancers, promoters, and introns of PDGFRA and MYC, facilitating their expression. TOP2B levels and genomic localization was associated with and expression across glioma specimens, which was not seen in nontumoral human brain tissue. , TOP2B knockdown of human glioma intracranial implants prolonged survival and downregulated .

Conclusions: Our results indicate that TOP2B activity exerts a pleiotropic role in transcriptional regulation of oncogenes in a subset of gliomas promoting a proliferative phenotype.
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http://dx.doi.org/10.1158/1078-0432.CCR-21-0312DOI Listing
October 2021

Intrasellar hemorrhagic chordoma masquerading as pituitary apoplexy: case report and review of the literature.

Br J Neurosurg 2021 Jun 21:1-4. Epub 2021 Jun 21.

Department of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, USA.

Background And Importance: Chordomas are centrally located, expansile soft tissue neoplasms that arise from the remnants of the embryological notochord. Hemorrhagic presentation is exceedingly rare and can resemble pituitary apoplexy. Moreover, a purely intrasellar location of a chordoma is extremely uncommon. We report a case of a hemorrhagic intrasellar chordoma in an adult male, which presented similarly to pituitary apoplexy and was resolved with surgical resection.

Clinical Presentation: A 69-year-old male presented with a 4 week history of acute onset headache and concurrent diplopia, with significantly reduced testosterone and slightly reduced cortisol. His left eye demonstrated a sixth cranial nerve palsy. Magnetic resonance imaging of the brain showed a large hemorrhagic mass in the pituitary region with significant compression of the left cavernous sinus and superior displacement of the pituitary gland. The patient underwent an endoscopic endonasal transsphenoidal approach for the resection of the lesion. Near total resection was achieved. Final pathology revealed chordoma with evidence of intratumoral hemorrhage, further confirmed by immunopositive stain for brachyury. Post-operatively, the patient had improved diplopia and was discharged home on low dose hydrocortisone. At 3-month follow-up, his diplopia was resolved and new MRI showed stable small residual disease.

Conclusions: Apoplectic chordomas are uncommon given chordoma's characteristic lack of intralesional vascularity and represent a diagnostic challenge in the sellar region. Our unique case demonstrates that despite our initial impression of pituitary apoplexy, this was ultimately a case of apoplectic chordoma that responded well to endoscopic endonasal surgery.
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http://dx.doi.org/10.1080/02688697.2021.1941761DOI Listing
June 2021

Spinal Epidural Abscess Patients Have Higher Modified Frailty Indexes Than Back Pain Patients on Emergency Room Presentation: A Single-Center Retrospective Case-Control Study.

World Neurosurg 2021 08 12;152:e610-e616. Epub 2021 Jun 12.

Department of Neurosurgery, School of Medicine, University of New Mexico, Albuquerque, New Mexico, USA.

Objective: Spinal epidural abscess (SEA) patients have increased medical comorbidities and risk factors for infection compared with those without SEA. However, the association between frailty and SEA patients has not been documented.

Methods: A total of 46 SEA patients were randomly paired and matched by age and sex with a control group of patients with back pain who had presented to our emergency department from 2012 to 2017. Statistical analysis identified the risk factors associated with SEA and frailty using the modified frailty index (mFI), and the patients were stratified into robust, prefrail, and frail groups. We examined the value of the mFI as a prognostic predictor and evaluated the classic risk factors (CRFs).

Results: The SEA patients had higher mFIs and CRFs (P = 0.023 and P < 0.001, respectively) and a longer length of stay (22.89 days vs. 1.72 days; P < 0.001). Of the mFI variables, only diabetes had a significant association with SEA (odds ratio [OR], 3.60; P = 0.012). Among the stratified mFI subgroups, a frail ranking (mFI >2) was the strongest risk factor for SEA (OR, 5.18; P = 0.003). A robust ranking (mFI, 0-1) was a weak negative predictor for SEA (OR, 0.41; P = 0.058). The robust patients were also more likely to be discharged to home (OR, 7.58; P = 0.002). Of the CRF variables, only intravenous drug use had a statistically significant association with SEA (OR, 10.72; P = 0.015).

Conclusions: Patients with SEA were more frail compared with the control back pain patients. Frailty was determined to be an independent risk factor for SEA, outside of the CRFs. The use of the mFI could be potentially useful in predicting the diagnosis, prognosticating, and guiding SEA treatment.
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http://dx.doi.org/10.1016/j.wneu.2021.06.035DOI Listing
August 2021

Porencephalic cyst after endoscopic third ventriculostomy and Ommaya reservoir placement: case report and review of the literature.

Childs Nerv Syst 2021 09 13;37(9):2917-2921. Epub 2021 Jan 13.

Department of Neurosurgery, Westchester Medical Center, New York Medical College, 100 Woods Rd, Suite 1325-1333, Valhalla, NY, 10595, USA.

Background: A 13-year-old female patient was diagnosed with a tectal glioma (TG), a subgroup of astrocytoma that can result in obstructive hydrocephalus secondary to aqueductal stenosis. Endoscopic third ventriculostomy (ETV) is used to treat this type of hydrocephalus with a good success rate. Our institution performs ETV and Ommaya reservoir (OR) placement in these cases. The OR allows measurement of intracranial pressure (ICP) and cerebrospinal fluid (CSF) access and a method for performing ventricular dye studies to evaluate third ventricular stoma (TVS) patency. In this case, a porencephalic cyst (PC) developed around the OR's ventricular catheter (OVC) two and a half months after surgery.

Conclusion: The PC is thought to have developed in association with TVS stoma closure and resolved after ETV revision.
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http://dx.doi.org/10.1007/s00381-021-05042-wDOI Listing
September 2021

Ribosomal protein S11 influences glioma response to TOP2 poisons.

Oncogene 2020 07 11;39(27):5068-5081. Epub 2020 Jun 11.

Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University , Chicago, IL, United States.

Topoisomerase II poisons are one of the most common class of chemotherapeutics used in cancer. We and others had shown that a subset of glioblastomas, the most malignant of all primary brain tumors in adults, is responsive to TOP2 poisons. To identify genes that confer susceptibility to this drug in gliomas, we performed a genome-scale CRISPR knockout screen with etoposide. Genes involved in protein synthesis and DNA damage were implicated in etoposide susceptibility. To define potential biomarkers for TOP2 poisons, CRISPR hits were overlapped with genes whose expression correlates with susceptibility to this drug across glioma cell lines, revealing ribosomal protein subunit RPS11, 16, and 18 as putative biomarkers for response to TOP2 poisons. Loss of RPS11 led to resistance to etoposide and doxorubicin and impaired the induction of proapoptotic gene APAF1 following treatment. The expression of these ribosomal subunits was also associated with susceptibility to TOP2 poisons across cell lines from gliomas and multiple other cancers.
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http://dx.doi.org/10.1038/s41388-020-1342-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646677PMC
July 2020
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