Publications by authors named "Hussam Abou-Al-Shaar"

115 Publications

Applications of Endoscopic Endonasal Surgery in Early Childhood: A Case Series.

Pediatr Neurosurg 2021 Sep 10:1-10. Epub 2021 Sep 10.

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

Introduction: Endoscopic endonasal surgery (EES) has been slower to gain popularity in early childhood due to anatomical challenges. We sought to describe the safety and efficacy of EES in early childhood.

Methods: All patients younger than 7 years who underwent EES at a large Cranial Base Center from 2002 to 2019 were reviewed as a retrospective cohort study.

Results: Thirty-six patients underwent EES before the age of 7 years. Four patients had two-stage EES. Two patients required combined transcranial and endonasal approaches. The mean age at the time of initial surgery was 4 years (range: 1-6). Twenty patients were male, and 16 were female. Of 21 tumors intended for resection, 11 patients had gross total resections, and 10 had near total (>95% tumor removed) resections. Nine patients (43%) had recurrences, of which 6 were craniopharyngiomas (p = 0.01). There was no difference in recurrence rates based on the degree of resection (p = 0.67). Three cerebrospinal fluid (CSF) leaks occurred following primary EES (8%). Following an increase in nasoseptal flap usage (31-52%) and CSF diversion (15-39%) in 2008, there was only one CSF leak out of 23 patients (4 vs. 15%; p = 0.54). Postoperatively, 1 patient developed a permanent new cranial neuropathy, and 1 patient developed a permanent visual field cut. Six patients developed permanent postoperative panhypopituitarism, of which all were craniopharyngiomas (p < 0.001). The mean follow-up was 64 months.

Conclusions: Early childhood EES is both safe and technically feasible for a variety of pathologies.
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http://dx.doi.org/10.1159/000518681DOI Listing
September 2021

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

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

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

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

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

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

Highly Selective Partial Neurectomies for Spasticity: A Single-Center Experience.

Neurosurgery 2021 Aug 12. Epub 2021 Aug 12.

Department of Physical Medicine and Rehabilitation, University of Utah School of Medicine, Salt Lake City, Utah, USA.

Background: Sedating antispastic medications and focal therapies like botulinum toxin are the most common therapies for spasticity but are temporary and must be performed continuously for a principally static neurological insult. Alternatively, highly selective partial neurectomies (HSPNs) may reduce focal spasticity more permanently.

Objective: To quantify the change in spasticity after HSPN and assess patient satisfaction.

Methods: We retrospectively reviewed the records of patients with upper- and/or lower-extremity spasticity treated with HSPN from 2014 to 2018. Only cases with a modified Ashworth scale (MAS) score independently determined by a physical therapist were included. Pre- and postoperative MAS, complications, and patient satisfaction were evaluated.

Results: The 38 patients identified (24 male, 14 female; mean age 49 yr) underwent a total of 88 procedures for focal spasticity (73% upper extremity, 27% lower extremity). MAS scores were adjusted to a 6-point scale for evaluation. The mean preoperative and final postoperative follow-up adjusted MAS scores were 3.6 and 1.7, respectively (P < .001), which represents average MAS less than 1+. Positive, neutral, and worse results were described by 91%, 6%, and 3% of patients, respectively. Four patients requested revision surgery. No perioperative complications were encountered.

Conclusion: This is the first North American series to analyze HSPN for spasticity and the only series based on independent evaluation results. HSPN surgery demonstrated objective short- and long-term reduction in spasticity with minimal morbidity and excellent patient satisfaction.
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http://dx.doi.org/10.1093/neuros/nyab303DOI Listing
August 2021

Intraparenchymal hematoma and intraventricular catheter placement using robotic stereotactic assistance (ROSA): A single center preliminary experience.

J Clin Neurosci 2021 Sep 2;91:391-395. Epub 2021 Aug 2.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.

Background: Large supratentorial intraparenchymal hemorrhages are managed emergently with image-guided catheters that aim to minimize injury to surrounding parenchyma. Robotic assistance may offer advantages for stereotactic guidance and placement of such catheters. We describe our center's experience with minimally invasive ROSA-assisted intraventricular and intraparenchymal hemorrhage catheter placement and delineate its safety and outcomes.

Methods: A retrospective analysis was performed including all patients with intraparenchymal hematoma that underwent ROSA-assisted intraparenchymal and intraventricular catheter placement at the University of Pittsburgh Medical Center between 2017 and 2019. All patients received tissue plasminogen activator (tPA) through the intraparenchymal catheter. We performed a manual chart review of these patients. Pertinent clinical and radiological characteristics and patient outcomes were recorded and analyzed. Catheter trajectory was independently quantified and analyzed by two independent reviewers. Error between the planned trajectory and final position was calculated and analyzed.

Results: Four patients (2 males and 2 females, mean age of 64 years) with deep brain large volume intraparenchymal hemorrhages were treated with catheter evacuation with robotic assistance. For 2 of the 4 patients, thin-cut CT imaging allowed for the real trajectory of the catheter to be compared to the targeted trajectory to calculate error. The mean error of catheter placement was 3.48 mm. ROSA-assisted catheter placement achieved up to 95% reduction of intraparenchymal hematoma volume with a statistically significant decrease following catheter drainage (pre- 51.8 ± 19.1 cc vs. post- 13.0 ± 14.4; p < 0.01).

Conclusion: Robotic stereotactic assistance offers a safe and sufficiently accurate technique for intraparenchymal hematoma and intraventricular catheter placement.
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http://dx.doi.org/10.1016/j.jocn.2021.04.006DOI Listing
September 2021

Thoracic intramedullary neurosarcoidosis with thoracic disc herniation: Diagnostic importance of intramedullary contrast enhancement.

Surg Neurol Int 2021 6;12:331. Epub 2021 Jul 6.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.

Background: Thoracic intramedullary neurosarcoidosis is an uncommon but serious manifestation of spinal cord disease. Its concomitant occurrence with thoracic disc herniation can mislead the physician into attributing neurologic and radiographic findings in the spinal cord to disc pathology rather than inflammatory disorder. Here, we present such a rare case of concomitant thoracic disc and spinal neurosarcoidosis.

Case Description: A 37-year-old male presented with progressive right lower extremity weakness and numbness. Magnetic resonance imaging (MRI) of the thoracic spinal cord revealed a T6-T7 paracentral disc eccentric to the right with T2 signal change extending from T2 to T10 level. This prompted acquiring a contrasted MRI that also depicted intramedullary enhancement around the T6-T7 disc bulge. Computed tomography scan of the chest showed mediastinal lymphadenopathy concerning for sarcoidosis. Lymph node biopsy confirmed the diagnosis of sarcoidosis, and high-dose steroid treatment was initiated. The patient had significant symptomatic improvement with steroids with full neurological recovery and improvement of his symptoms.

Conclusion: While stenosis from thoracic disc disease could potentially suggest a mechanical etiology for the patient's symptoms, attention must be paid to the imaging findings as well as the degree and extent of cord signal change and intramedullary contrast enhancement. Appropriate and timely diagnosis is essential to avoid unnecessary invasive procedures.
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http://dx.doi.org/10.25259/SNI_535_2021DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8326063PMC
July 2021

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

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

Departments of1Neurological Surgery and.

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

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

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

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

Stereotactic Electroencephalography Implantation Through Nonautologous Cranioplasty: Proof of Concept.

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

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

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

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

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

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

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

Neuroophthalmological manifestations of congenital aqueductal stenosis.

J Neurosurg Pediatr 2021 Jun 25:1-6. Epub 2021 Jun 25.

Departments of2Neurological Surgery and.

Objective: Congenital aqueductal stenosis (CAS) is a common etiology of hydrocephalus that occurs in a subset of infants and may be linked to an increased incidence of ophthalmological abnormalities and delayed developmental milestones. Although hydrocephalus is common and widely studied, sparse literature exists on patients with isolated (no identifiable genetic link) CAS along with analysis of ophthalmological manifestations. In this study, the authors sought to describe the ophthalmological abnormalities and delayed developmental milestones of patients with isolated CAS.

Methods: Data of patients with CAS were prospectively entered and monitored in a surgical database maintained by the Department of Neurological Surgery at Children's Hospital of Pittsburgh from January 2005 to October 2016. Patients with a family history of congenital hydrocephalus, positive testing for genetic forms of aqueductal stenosis, other congenital abnormalities suggesting an underlying genetic syndrome, and stenosis/obstruction due to secondary causes were excluded from this study. Prenatal and perinatal history, CSF diversion history, and a variety of outcomes, including ophthalmological deficits and developmental milestones, were collected and analyzed.

Results: A total of 41 patients with isolated CAS were identified, with a mean follow-up duration of 6 years. Among that cohort, 26 patients (63.4%) developed neuroophthalmological complications, which were further stratified. Fourteen patients (34.1%) developed strabismus and 11 (26.8%) developed astigmatism, and 1 patient (2.4%) with papilledema was recorded. Among patients with ophthalmological abnormalities, 76.9% had delayed developmental milestones (p = 0.045).

Conclusions: Patients with CAS were found to have increased risk of ophthalmological abnormalities requiring correction, along with an increased risk of delayed developmental milestones. Importantly, there was a significant correlation between the development of ophthalmological abnormalities and delayed developmental milestones that was independent of CSF diversion history. Larger patient cohort studies are required to explore whether earlier development of hydrocephalus, as is the case in CAS, causes elevated rates of neurological and ophthalmological complications, and if earlier CSF diversion correlates with improved outcomes.
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http://dx.doi.org/10.3171/2021.2.PEDS20824DOI Listing
June 2021

Histopathological changes of neuronal tissue following the use of hydrogen peroxide in neurosurgical procedures.

Surg Neurol Int 2021 8;12:91. Epub 2021 Mar 8.

Division of Neurosurgery, Department of Surgery, College of Medicine, King Abduaziz University, Jeddah, Saudi Arabia.

Background: Hydrogen peroxide (HP) is routinely used in neurosurgical procedures to achieve surgical hemostasis. However, its safety profile is still debatable with various reports depicting range of adverse effects on neuronal tissue. The objective of this paper is to evaluate the safety and efficacy of HP as a hemostatic agent in normal neuronal tissue during neurosurgical procedures conducted on rats.

Methods: One hundred rats were divided into three groups. The first and third group underwent cortical irrigation with HP and the second group underwent spinal irrigation with HP. All groups were irrigated with different concentrations of HP (1%, 3%, or 6%) for 3 min and tissue biopsies were obtained immediately afterwards (Groups A and B) or 1 week after HP irrigation (Group C). Study specimens were examined histologically and compared to control tissue.

Results: All rats showed normal behavioral, functional, and motor neurological activity following the procedures. Histopathologically, dark neurons were observed in all HP exposed tissue. The cytoplasm revealed condensed and dark Nissl substance and the neurites and axons exhibited a corkscrew morphology. No ischemic changes or inflammatory infiltrates were detected. The majority of dark neurons were observed at the periphery of tissue fragments. These findings were present and consistent in both the short- and long-term groups.

Conclusion: HP irrigation showed no significant short- or long-term clinical and histopathological changes in comparison to normal saline when used on rats' neuronal tissue. This may confirm the safety of intraoperative HP usage as hemostatic agent during neurosurgical procedures.
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http://dx.doi.org/10.25259/SNI_26_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7982094PMC
March 2021

Spontaneous Cerebrospinal Fluid Rhinorrhea from a Prolactin-Secreting Pituitary Macroadenoma.

Cureus 2021 Feb 3;13(2):e13111. Epub 2021 Feb 3.

Neurosurgery, University of Utah, Salt Lake City, USA.

Cerebrospinal fluid (CSF) rhinorrhea is a rare complication of macroprolactinomas that, in the vast majority of cases, is subsequent to either medical or surgical intervention. Here, we present the successful management of a rare case of spontaneous, noniatrogenic CSF rhinorrhea in a patient with an untreated macroprolactinoma. A 27-year-old man with no significant medical history presented with six months of persistent CSF rhinorrhea, which was confirmed by testing for beta-2-transferrin. He had had decreased libido since adolescence and impaired growth of secondary sexual characteristics. Workup revealed an elevated prolactin level, and imaging demonstrated erosion of the anterior sellar floor and soft tissue within the sphenoid sinus, concerning for tumor. The patient underwent surgical repair of the CSF leak via a transnasal transsphenoidal approach, with resection and biopsy of tumor material within the sinus. No tumor was noted within the sella itself. The patient tolerated the procedure well and had subsequent normalization of his prolactin level with no further CSF egress. Spontaneous noniatrogenic CSF rhinorrhea, although rare, should be considered in the differential diagnosis of invasive pituitary macroadenomas, especially prolactinomas. The mechanism of CSF leak from a prolactinoma is not completely understood, but the CSF leak should be urgently repaired through a transnasal transsphenoidal approach. Concurrently, tumor resection should be performed and a postoperative lumbar puncture or lumbar drain should be considered to reinforce the skull base reconstruction.
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http://dx.doi.org/10.7759/cureus.13111DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935238PMC
February 2021

Interdisciplinary treatment of posterior fossa dural arteriovenous fistulas.

Acta Neurochir (Wien) 2021 09 8;163(9):2515-2524. Epub 2021 Mar 8.

Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, USA.

Background: Posterior fossa dural arteriovenous fistulas (dAVFs) are rare vascular lesions with variable risk of hemorrhage, mostly depending on the pattern of the venous drainage. While endovascular embolization is the mainstay treatment for most dAVFs, some posterior fossa lesions require a multidisciplinary approach including surgery. The goal of our study was to examine the outcome of an interdisciplinary treatment for posterior fossa dAVFs.

Methods: A retrospective review of patients treated for posterior fossa dAVFs was conducted.

Results: A total of 28 patients with a mean age of 57.8 years were included. Patients presented with a Cognard grade I in 2 (7%), II a in 5 (18 %), II b in 7 (25%), II a + b in 5 (18%), III in 3 (11%), and IV in 6 (21%) cases. Hemorrhage was the initial presentation in 2 (22%) patients with Cognard grade IV, in 3 with Cognard grade III (33%), in 1 (11%) with Cognard II a + b, and 3 (33%) with Cognard II b. A complete angiographic cure was achieved in 24 (86%) patients-after a single-session embolization in 16 (57%) patients, multiple embolization sessions in 2 (7%), a multimodal treatment with embolization and surgical disconnection in 3 (11%), and with an upfront surgery in 3 (11%). Complete long-term obliteration was demonstrated in 18/22 (82%) at the mean follow-up of 17 months. Fistulas were converted into asymptomatic Cognard I lesion in 4 (14%) patients.

Conclusion: Posterior fossa dAVFs represent a challenging vascular pathology; however, despite their complexity, an interdisciplinary treatment can achieve high rates of angiographic and symptomatic cure with low morbidity and mortality rates. Long-term surveillance is warranted as late recurrences may occur.
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http://dx.doi.org/10.1007/s00701-021-04795-2DOI Listing
September 2021

Spinal pigmented villonodular synovitis and tenosynovial giant cell tumor: A report of two cases and a comprehensive systematic review.

Clin Neurol Neurosurg 2021 Mar 12;202:106489. Epub 2021 Jan 12.

Department of Neurosurgery, Tulane Medical Center, New Orleans, LA, USA; Department of Neurosurgery, Ochsner Clinic Foundation, New Orleans, LA, USA. Electronic address:

Background And Objective: Pigmented villonodular synovitis (PVNS) is a lesion of uncertain etiology that involves the synovial membranes of joints or tendon sheaths, representing a diffuse and non-encapsulated form of the more common giant cell tumors of the synovium (GCTTS). PVNS was reclassified to denote a diffuse form of synovial giant cell tumor (TSGCT), while 'giant cell tumor of the tendon sheath (GCTTS)' was used for localized lesions. These pathologies rarely affect the axial skeleton. We provide an unprecedented and extensive systematic review of both lesions highlighting presentation, diagnostic considerations, treatment, prognosis, and outcomes, and we report a short case-series.

Method: We describe two-cases and conduct a systematic review in accordance with PRISMA guidelines.

Result: PVNS was identified in most of the cases reviewed (91.6 %), manifesting predominantly in the cervical spine (40 %). Patients commonly presented with neck pain (59 %), back pain (53 %), and lower back pain (81.2 %) for cervical, thoracic, and lumbar lesions, respectively. GTR occurred at rates of 94 %, 80 %, and 87.5 %. Recurrence was most common in the lumbar region (30.7 %). GCTTS cases (8%) manifested in the cervical and thoracic spine at the same frequency. We reported first case of GCTTS in the lumbosacral region. Both poses high rate of facet and epidural involvements.

Conclusion: Spinal PVNS and GCTTS are rare. These lesions manifest most commonly as PVNS within the cervical spine. Both types have a high rate of facet and epidural involvement, while PVNS has the highest rate of recurrence within the lumbar spine. The clinical and radiological features of these lesions make them difficult to differentiate from others with similar histogenesis, necessitating tissue diagnosis. Proper management via GTR resolves the lesion, with low rates of recurrence.
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http://dx.doi.org/10.1016/j.clineuro.2021.106489DOI Listing
March 2021

Highly Selective Partial Neurectomy for Lower-Extremity Spasticity: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2021 05;20(6):E442-E443

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, USA.

Spasticity is a common debilitating condition after central nervous system injury. The principal therapies-sedating antispasticity medications and focal therapies (eg, botulinum toxin)-may not provide sufficient reduction in tone, have intolerable side effects, and lose efficacy over time. Selective neurectomy is a surgical option for durable reduction in tone.1-6 Although commonly performed internationally, neurectomies are used less often within the USA. We present the surgical case of a 23-yr-old woman with cerebral palsy and severe spastic diplegia. Medications, injections, and tendon surgeries had failed to relieve her spastic lower extremities. She presented with crouch gait, adductor scissoring, and bilateral equinovarus. She had previously benefitted significantly from bilateral hamstring and obturator neurectomies, with improvement in mobility. She desired tibial neurectomies for her bilateral equinovarus, which impacted her gait substantially. To reduce unwanted plantarflexion and internal rotation tone, selective neurectomies of the motor nerves to the medial and lateral gastrocnemius, soleus, and posterior tibialis muscles were performed. The surgical video details a technique for longitudinally opening the epineurium, separating small nerves into their individual fascicles, and subdividing submillimeter fascicles by approximately 50% to 60% of the fascicle cross-sectional area. She reported significant improvement in gait, her modified Ashworth score dropped from 3 to 0, and her motor power remained unchanged, which is equivalent or better than most published results.2,7 Neurectomies are a highly effective procedure for focal extremity spasticity. Additional clinical series or trials would help establish the appropriate indications and durability and quantify the risks and benefits. The patient consented to treatment and publication.
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http://dx.doi.org/10.1093/ons/opab020DOI Listing
May 2021

The Use of Image-Guided Navigation Systems During Spine Surgeries in Saudi Arabia: A Cross-Sectional Study.

Int J Spine Surg 2020 Dec 29;14(6):1016-1022. Epub 2020 Dec 29.

Department of Orthopaedics, King Faisal Specialist Hospital & Research Centre Riyadh, Saudi Arabia.

Background: We used a cross-sectional study design (questionnaire) to investigate the use of image-guided navigation (IGN) in Saudi Arabia and explore possible differences in implementing IGN for daily practice.

Methods: An internet-based survey was sent to all spine surgeons who are practicing in Saudi Arabia (orthopedics or neurosurgery). The survey is composed of 12 items that collected demographic and academic data.

Results: Ninety-nine answered the questionnaire from 197; 80% were from Riyadh, the capital, and 50% were consultants (attending physicians). Orthopedic surgeons were almost 60% of responders compared to 40% neurosurgeons. The use of navigation in Saudi hospitals was high (76.8%). There was a significant difference between specialties in the preference of using navigation (23.2% for orthopedics versus 81.4% for neurosurgery, < .001) and routine use in surgical spine cases (88.4% for neurosurgery versus 50.0% orthopedics, < .001). The majority of responders from neurosurgery learned to use navigation during residency compared to orthopedics responders (51.2% versus 28.6%, = .001). More than 30% of orthopedics responders expressed they never learned navigation compared to only 4% of neurosurgery responders. The comfort level of > 75% with performing surgery using navigation was significantly different between specialties (25% for orthopedics versus 46.5% for neurosurgery, < .001).

Conclusion: Saudi spine surgeons are among the highest users of IGN systems. The strong healthcare infrastructure and the availability of these devices across the country are among the most important factors for its prevalence. Enhancing surgical exposure and education of postgraduate trainees to use these tools, especially within orthopedics, could increase use and comfort level rates.
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http://dx.doi.org/10.14444/7152DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7872406PMC
December 2020

A Case Report of Pediatric Geniculate Neuralgia Treated with Sectioning of the Nervus Intermedius and Microvascular Decompression of Cranial Nerves IX and X.

Pediatr Neurosurg 2020 14;55(6):439-443. Epub 2021 Jan 14.

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

Background: Classic geniculate neuralgia (GN) is a rare condition characterized by lancinating pain centered in the ear and not involving the throat. To the best of our knowledge, no case of pediatric GN has been reported in the English literature.

Case Presentation: We present the first reported case of successfully treated GN in a child via an endoscopic approach. The patient was a 9-year-old boy who presented with a 1-year history of lancinating right ear pain. Neuroleptics resulted in a short-lived improvement in symptoms, but with significant side effects. Extensive evaluation by multiple specialties did not reveal a cause for his pain. Imaging disclosed a tortuous loop of the right posterior inferior cerebellar artery abutting cranial nerves IX and X but no other abnormalities. The patient underwent an endoscopic microvascular decompression of cranial nerves IX and X, and sectioning of the nervus intermedius through a right retromastoid craniotomy. Postoperatively, the patient reported complete resolution of his symptoms that persisted at 3 months of follow-up. At the 5-year follow-up, the patient maintained pain relief and was developing normally.

Conclusion: GN can affect the pediatric population. In carefully selected patients with consistent clinical and radiographic presentation, sectioning of the nervus intermedius and microvascular decompression of the lower cranial nerves can be an effective treatment.
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http://dx.doi.org/10.1159/000509760DOI Listing
January 2021

Aneurysmal subarachnoid hemorrhage during pregnancy: a comprehensive and systematic review of the literature.

Neurosurg Rev 2021 Jan 7. Epub 2021 Jan 7.

Department of Neurological Surgery, Tulane University, New Orleans, LA, USA.

Aneurysmal subarachnoid hemorrhage (aSAH) is an emergent condition requiring rapid intervention and prolonged monitoring. There are few recommendations regarding the management of aSAH in pregnancy. We identified all available literature and compiled management decisions as well as reported outcomes through a systematic literature review without meta-analysis to provide recommendations for management of aSAH during pregnancy. We included a total of 23 articles containing 54 cases of pregnancy-related aSAH in our review. From these reports and other literature, we evaluated information on aSAH pathophysiology, diagnosis, and management with respect to pregnancy. Early transfer to an appropriate facility with neurocritical care, a high-risk obstetric service, and a neurosurgery team available is crucial for the management of aSAH in pregnancy. Intensive monitoring and a multidisciplinary approach remain fundamental to ensure maternal and fetal health.
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http://dx.doi.org/10.1007/s10143-020-01457-2DOI Listing
January 2021

Multistage surgical repair for split notochord syndrome with neuroenteric fistula: case report.

J Neurosurg Pediatr 2020 Dec 4:1-9. Epub 2020 Dec 4.

1Department of Neurosurgery, Tulane/Ochsner Medical Center, New Orleans, Louisiana.

Split notochord syndrome (SNS) is a rare congenital defect of the central nervous system and has been associated with several anomalies affecting multiple organ systems. One association has been communication with the gastrointestinal tract and the spine, previously identified as a neuroenteric fistula (NEF). Here, the authors describe the unique case of a female infant with SNS and NEF treated with a multistage surgical repair. The three-stage operative plan included a two-stage repair of the defect and temporary subgaleal shunting followed by delayed ventriculoperitoneal shunt placement. The infant recovered well postsurgery and over a 5-year follow-up. A case description, surgical techniques, and rationale are reported. Additionally, a systematic review of the literature utilizing the MEDLINE database was performed.Treatment of SNS with NEF using a multidisciplinary multistaged approach to repair the intestinal defect, close the neural elements, and divert cerebrospinal fluid to the peritoneum is shown to be a safe and viable option for future cases.
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http://dx.doi.org/10.3171/2020.7.PEDS20441DOI Listing
December 2020

Anterior cervical discectomy and fusion in the setting of kissing carotids: A technical report and literature review.

Clin Neurol Neurosurg 2021 01 18;200:106366. Epub 2020 Nov 18.

Department of Neurological Surgery, Ochsner Clinic Foundation, New Orleans, LA, United States. Electronic address:

Background: The "kissing carotids" (KCS) phenomenon refers to bilateral retropharyngeal displacement of the internal carotid arteries (ICA). This anomalous anatomy can impose a significant surgical challenge to spine surgeons.

Objective: In this report, we describe our approach for an anterior cervical discectomy and fusion in the setting of kissing carotids.

Methods: We discuss our case, surgical technique, rationale, and outcome. Additionally, we conducted a systematic review of the literature.

Case Description: An 82-year-old female presented to our service with progressive myelopathy. Cervical spinal imaging revealed a large disc herniation at C3-C4 and severe spinal canal stenosis. Vascular imaging showed anomalous ICAs bilaterally overlying the prevertebral fascia at the midline. The patient received aspirin preoperatively and underwent a multidisciplinary approach with neurosurgery and otolaryngology. A standard transcervical approach centered on the C5-C6 disc space, where the carotid arteries splayed most from midline, allowed for facilitated visualization and mobilization of the vessels. Prevertebral dissection was then performed rostrally to the C3-C4 disc space. The patient was put into burst suppression prior to retraction and underwent uncomplicated anterior discectomy and fusion.

Conclusions: KCS is a rare but critical presentation of extreme medial displacement of bilateral ICAs. Few cases have been reported in the spinal surgery literature. Knowledge of this rare variant is important to avoid iatrogenic injury and complications.
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http://dx.doi.org/10.1016/j.clineuro.2020.106366DOI Listing
January 2021

Cerebellar pleomorphic xanthoastrocytoma in the setting of neurofibromatosis type-I: Does it portend a different prognosis? A case report and systematic review.

Clin Neurol Neurosurg 2021 01 2;200:106346. Epub 2020 Nov 2.

Ochsner Health System, Department of Neurosurgery, Ochsner Neuroscience Institute, Ochsner Clinic Foundation, New Orleans, LA, USA.

Background: Pleomorphic xanthoastrocytoma (PXA) is a rare brain tumor occurring supra- and infra-tentorially in both young adults and children. PXA is a benign tumor with a favorable prognosis. It is not traditionally considered as a neurofibromatosis type 1 (NF-1)-associated lesion, and its prognosis remains largely unknown, on the contrary to non-NF-1 PXA tumors.

Objective: Herein, we present a rare case of cerebellar PXA in a patient with NF-1 and performed systematic review of NF-1-associated PXA.

Method: We present a case of NF-1-associated PXA arising in the cerebellar region. We also reviewed the literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines to identify published cases of cerebellar vs. non-cerebellar NF-1-associated PXA and NF1 vs. non-NF1 PXAs, highlighting their management paradigm, prognosis, and outcomes.

Result: Our systematic review yielded only four previously reported cases of NF-1-associated PXAs in the cerebellar region. Our review suggests that infratentorial PXAs have a higher recurrence and lower survival rates than non-cerebellar NF-1-associated PXAs and non-NF1 PXAs in general.

Conclusion: Early and precise diagnosis is important for these lesions with the aid of imaging features, histology, immunohistochemistry, and genetic markers. Surgical resection with goal of GTR remains the mainstay management strategy for PXA, with adjuvant therapy usually reserved for anaplastic or malignant lesions. The identification of BRAF-V600E mutation and role of BRAF inhibitors hold promise as a diagnostic tool and treatment modality, respectively, for PXAs, and their relationship to NF-1 is worth further exploration.
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http://dx.doi.org/10.1016/j.clineuro.2020.106346DOI Listing
January 2021

Surgical Management of Multifocal Trigeminal Schwannomas.

Oper Neurosurg (Hagerstown) 2020 Nov;19(6):659-666

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.

Background: Isolated trigeminal schwannomas occur in 0.07% to 0.3% of intracranial tumors and account for 0.8% to 8% of intracranial schwannomas and 1/3 of Meckel cave tumors. The presence of multisegmental schwannoma is rare, resulting in a limited understanding of its optimal management.

Objective: To describe potential surgical options to manage this rare entity.

Methods: A 2-institution retrospective review of all patients with pathologically confirmed trigeminal schwannoma managed with resection from January 2009 through January 2019 was conducted. A manual chart review was performed to verify patients' inclusion and collect data about age, sex, tumor size, tumor site, treatment modality, surgical approach, complications, and follow-up duration and status.

Results: A total of 4 patients (age range 12-50 yr) who underwent a variety of cranial and orbitocranial approaches for tumor resection were identified. Patients achieved good outcomes with improvement of visual outcomes. One case of infection and 1 case of partial tumor recurrence requiring reresection were identified.

Conclusion: Multisegmental trigeminal schwannoma is a rare and unique entity, often associated with trigeminal schwannomatosis. Interdisciplinary management has been shown to be the most effective method for improving patient outcomes with these complex and poorly understood diseases.
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http://dx.doi.org/10.1093/ons/opaa227DOI Listing
November 2020

Sources of residuals after endoscopic transsphenoidal surgery for large and giant pituitary adenomas.

Acta Neurochir (Wien) 2020 10 22;162(10):2341-2351. Epub 2020 Jul 22.

Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, NY, 11030, USA.

Background: Giant and large pituitary adenomas (PA) constitute a specific subset of PAs, with gross total resection (GTR) rates frequently not exceeding 50%. Both an anatomical inaccessibility and an inadequate tumor visualization are thought to play a role. This study analyzes risk factors for postoperative residuals after endoscopic transsphenoidal pituitary surgery for large and giant pituitary adenomas.

Methods: A retrospective analysis of patients with giant and large PA operated between 2015 and 2018 was performed.

Results: Forty patients (13 females, 27 males) were included in the analysis (30 large and 10 giant PAs). The mean MRI follow-up time was 5.9 ± 6.54 months. Overall, GTR was achieved in 29 patients (72.5%), subtotal resection in 9 (22.5%), and the inconclusive result was in 2 (5%). Unexpected residuals represented 7 (77.7%) of all 9 residual tumors. The most frequent intraoperative factor associated with unexpected residual tumors was improper identification of residual tumor due to obstruction of view in 2 (28.5%) cases and inability to distinguish normal tissue from tumor in the other two (28.5%). Sub-analysis based on tumor size revealed that with large PAs, GTR was achieved in 25 (83.3%), STR in 4 (13.3%), and inconclusive in 1 (3.3%) patient. In patients with giant PAs, GTR was achieved in 4 (40%), STR in 5 (50%), and inconclusive in 1 (10%). Analysis of preoperative factors showed a significant association of residual tumors with larger suprasellar AP distance (p = 0.041), retrosellar extension (p = 0.007), and higher Zurich Score (p = 0.029).

Conclusion: Large and giant PAs are challenging lesions with high subtotal resection rates. Suprasellar AP distance, retrosellar extension, and higher Zurich Score seem to be significant predictors of degree of resection in these tumors. Improving the intraoperative ability to distinguish tumor from a normal tissue might further decrease the number of unexpected residuals.
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http://dx.doi.org/10.1007/s00701-020-04497-1DOI Listing
October 2020

B-Cell Lymphoma 2 (Bcl-2) and Regulation of Apoptosis after Traumatic Brain Injury: A Clinical Perspective.

Medicina (Kaunas) 2020 Jun 18;56(6). Epub 2020 Jun 18.

Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA.

The injury burden after head trauma is exacerbated by secondary sequelae, which leads to further neuronal loss. B-cell lymphoma 2 (Bcl-2) is an anti-apoptotic protein and a key modulator of the programmed cell death (PCD) pathways. The current study evaluates the clinical evidence on Bcl-2 and neurological recovery in patients after traumatic brain injury (TBI). All studies in English were queried from the National Library of Medicine PubMed database using the following search terms: (B-cell lymphoma 2/Bcl-2/Bcl2) AND (brain injury/head injury/head trauma/traumatic brain injury) AND (human/patient/subject). There were 10 investigations conducted on Bcl-2 and apoptosis in TBI patients, of which 5 analyzed the pericontutional brain tissue obtained from surgical decompression, 4 studied Bcl-2 expression as a biomarker in the cerebrospinal fluid (CSF), and 1 was a prospective randomized trial. Immunohistochemistry (IHC) in 94 adults with severe TBI showed upregulation of Bcl-2 in the pericontusional tissue. Bcl-2 was detected in 36-75% of TBI patients, while it was generally absent in the non-TBI controls, with Bcl-2 expression increased 2.9- to 17-fold in TBI patients. Terminal deoxynucleotidyl transferase-mediated biotinylated dUTP nick-end labeling (TUNEL) positivity for cell death was detected in 33-73% of TBI patients. CSF analysis in 113 TBI subjects (90 adults, 23 pediatric patients) showed upregulation of Bcl-2 that peaked on post-injury day 3 and subsequently declined after day 5. Increased Bcl-2 in the peritraumatic tissue, rising CSF Bcl-2 levels, and the variant allele of are associated with improved mortality and better outcomes on the Glasgow Outcome Score (GOS). Bcl-2 is upregulated in the pericontusional brain and CSF in the acute period after TBI. Bcl-2 has a neuroprotective role as a pro-survival protein in experimental models, and increased expression in patients can contribute to improvement in clinical outcomes. Its utility as a biomarker and therapeutic target to block neuronal apoptosis after TBI warrants further evaluation.
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http://dx.doi.org/10.3390/medicina56060300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7353854PMC
June 2020

Familial Cerebral Cavernous Malformation Syndrome with Concomitant Fourth Ventricular Ependymoma: True Association or Mere Coincidence?

Cancer Genet 2020 06 3;244:36-39. Epub 2020 May 3.

Department of Neurological Surgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA. Electronic address:

Familial cerebral cavernous malformation syndromes are most commonly caused by mutations in one of three genes. The overlap of these genetic malformations with other acquired neoplastic lesions and congenital malformations is still under investigation. To the best of our knowledge, the concurrent occurrence of familial cavernous malformations and ependymoma has not been previously reported in the literature. Herein, we describe a patient with familial cerebral cavernous malformation syndrome and posterior fossa ependymoma. A 17-year-old asymptomatic male was referred to our outpatient neurosurgery clinic after genetic testing identified a familial KRIT1 (CCM1) mutation. The patient's sister had presented with a seizure disorder previously; multiple cavernous malformations were discovered, and a symptomatic large cavernous malformation required a craniotomy for resection. Two years later, she was diagnosed with follicular thyroid cancer due to HRAS (c.182A>G) mutation. The patient and his sister were found to have a novel germline KRIT1 disease-causing variant (c.1739deletion, p.ASN580Ilefs*2) and a variant of uncertain significance, potentially pathogenic (c.1988 A>G, p.Asn663Ser) in cis in CCM1 (KRIT1), of paternal inheritance. Due to the presence of genetic abnormalities, the patient underwent screening imaging of his neuraxis. Multiple cavernous malformations were identified, as was an incidental fourth ventricular mass. Resection of the fourth ventricular lesion was performed, and histopathological examination was consistent with ependymoma. We report a unique case of posterior fossa ependymoma in an individual with a familial cerebral cavernous malformation syndrome and a novel genetic abnormality in KRIT1. The association of these two findings may be valuable in determining a potential genetic association between the two pathologies and elucidating the pathogenesis of both cavernous malformations and ependymomas.
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http://dx.doi.org/10.1016/j.cancergen.2020.04.075DOI Listing
June 2020

Cranio-Orbital and Orbitocranial Approaches to Orbital and Intracranial Disease: Eye-Opening Approaches for Neurosurgeons.

Front Surg 2020 7;7. Epub 2020 Feb 7.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States.

Orbital approaches for targeting intracranial, orbital, and infratemporal disease have evolved over the years in an effort to discover safe, reliable, effective, and cosmetically satisfying surgical corridors. The surgical goals of these approaches balance important factors such as proximity of the lesion to the optic nerve, the degree of anticipated manipulation and required space for surgical maneuverability, and the type of disease. The authors provide a comprehensive review of the most commonly used periorbital approaches in the management of intra- and extracranial disease, with emphasis on the advantages and limitations of each approach.
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http://dx.doi.org/10.3389/fsurg.2020.00001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7025513PMC
February 2020

Internal Auditory Canal Variability: Anatomic Variation Affects Cisternal Facial Nerve Visualization.

Oper Neurosurg (Hagerstown) 2020 09;19(3):E251-E258

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.

Background: The internal auditory canal (IAC) is an important landmark during surgery for lesions of the cerebellopontine angle. There is significant variability in the position and orientation of the IAC radiographically, and the authors have noted differences in surgical exposure depending on the individual anatomy of the IAC.

Objective: To test the hypothesis that IAC position and orientation affects the surgical exposure of the IAC and facial nerve, especially when performing the translabyrinthine approach.

Methods: The authors retrospectively reviewed magnetic resonance imaging studies of 50 randomly selected patients with pathologically confirmed vestibular schwannomas. Measurements, including the anterior (APD) and posterior (PPD) petrous distances, the anterior (APA) and posterior (PPA) petro-auditory angles, and the internal auditory angle (IAA), were obtained to quantify the position and orientation of the IAC within the petrous temporal bone.

Results: The results quantitatively demonstrate tremendous variability of the position and orientation of the IAC in the petrous temporal bone. The measurement ranges were APD 10.2 to 26.1 mm, PPD 15.1 to 37.2 mm, APA 104 to 157°, PPA 30 to 96°, and IAA -5 to 40°.

Conclusion: IAC variability can have a substantial effect on the surgical exposure of the IAC and facial and vestibulocochlear nerves. Specifically, a horizontally oriented IAC with a small IAA may have significant impact on visualization of the facial nerve within its cisternal segment with the translabyrinthine approach. The retrosigmoid approach is less affected with IAC variability in position and angle.
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http://dx.doi.org/10.1093/ons/opz410DOI Listing
September 2020

Rescue Craniectomy with Subsequent Cranioplasty for Recurrent Symptomatic Subdural Hematoma in Elderly Patients.

World Neurosurg 2020 Apr 31;136:e294-e299. Epub 2019 Dec 31.

Department of Neurosurgery, Hofstra Northwell School of Medicine, Manhasset, New York, USA. Electronic address:

Objective: Recurrent subdural hematoma (SDH) is commonly encountered in clinical practice. Multiple surgical techniques have been reported for management of recurrent SDH with variable success and complication rates. We report an alternative technique to halt SDH reaccumulation in elderly patients with multiple recurrences despite multiple surgical evacuations via rescue craniectomy and subsequent cranioplasty.

Methods: We retrospectively identified all symptomatic recurrent SDHs in elderly patients (≥60 years old) who were surgically managed with rescue craniectomy with subsequent cranioplasty from November 2004 to January 2018. Patients' demographics and radiologic and surgical variables were recorded and analyzed.

Results: Of 287 patients who received surgical treatment for SDH, 19 patients (6.6%) underwent SDH evacuation with rescue craniectomy and subsequent cranioplasty were included in the study. The median age of the cohort was 73 years (interquartile range: 62-78 years), with 13 men and 6 women. Trauma was the cause of SDH in most cases. Five patients had acute SDH, 4 patients had subacute SDH, and 10 patients had chronic SDH. Fourteen patients had only 1 recurrence of SDH requiring surgical re-evacuation, and 5 had 2 recurrences. Median interval between craniectomy and cranioplasty was 64.5 days (interquartile range: 15-123.3 days). Four complications were encountered. After cranioplasty, 15 patients had no further hemorrhage or recurrence and 4 patients had stable subdural collection during an average follow-up of 38.2 ± 46.9 months.

Conclusions: Rescue craniectomy followed by cranioplasty is a safe and effective salvage technique for the management of symptomatic recurrent SDH in elderly patients.
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http://dx.doi.org/10.1016/j.wneu.2019.12.142DOI Listing
April 2020

Distal nerve transfer for thenar palsy: A cadaveric study.

Clin Anat 2020 Apr 6;33(3):414-418. Epub 2020 Jan 6.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.

Introduction: Severe proximal median nerve palsies often result in irreversible thenar atrophy and thumb abduction function loss. Tendon transfer involves substantial limitations and challenges; but, distal nerve transfer may provide an alternative treatment. Our goal was to validate the anatomical suitability of two distal ulnar nerve branches for thenar muscle reanimation.

Materials And Methods: We assessed nerve transfer to the recurrent branch of median nerve (RMN) in 16 embalmed cadaveric hands. The ulnar motor branch to the flexor digiti minimi brevis (FDMBn) and the ulnar motor branch to the third lumbrical (3rdLn) were assessed for transfer. Coaptation success was measured by the overlap of the nerve donor with the RMN and correspondence of nerve diameters.

Results: The mean transferable length and width of the RMN were 20.7 ± 4.5 and 1.0 ± 0.3 mm, respectively. We identified an average of three branches in the branching anatomy from the ulnar nerve to the hypothenar muscles. The maximal transferable lengths and widths of the FDMBn and the 3rdLn were 13.8 ± 4.4 and 0.5 ± 0.1 mm and 24.1 ± 6.4 and 0.4 ± 0.1 mm, respectively. The overlap with the RMN of the FDMBn and 3rdLn was 9.0 ± 3.6 (2.0-15.3) and 17.8 ± 6.0 (4.7-27.5) mm, respectively.

Conclusions: This anatomical study demonstrates the feasibility of distal nerve transfers between the ulnar and median nerves in the hand for reanimation of thenar muscles. Ulnar motor donors of the BrFDMBn and 3rdLn likely represent the least morbid donors with short distances for regeneration and a single coaptation repair.
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http://dx.doi.org/10.1002/ca.23540DOI Listing
April 2020

Anterior Petrosectomy for Resection of Brainstem Cavernous Malformation.

World Neurosurg 2020 03 29;135. Epub 2019 Nov 29.

Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.

Brainstem cavernous malformations are uncommon vascular lesions that require complex surgical approaches. The case described in this video involved a 23-year-old male who presented with repeated, symptomatic episodes of bleeding of pontomedullary cavernous malformation, which was resected. The anterior petrosectomy approach is detailed in Video 1, highlighting middle fossa triangles and their boundaries, as well as important safety techniques. Postoperative imaging depicted complete resection of the cavernoma. Six months after surgery, the patient reported complete resolution of his symptoms.
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http://dx.doi.org/10.1016/j.wneu.2019.11.138DOI Listing
March 2020

Resection of a Neuroenteric Cyst Using a Far Lateral Approach.

J Neurol Surg B Skull Base 2019 Dec 28;80(Suppl 4):S346-S347. Epub 2019 Oct 28.

Mayfield Clinic, Cincinnati, Ohio, United States.

This operative video highlights a rare case of a neuroenteric cyst at the ventral craniocervical junction. The case involved a 30-year-old man who initially presented 13 years earlier with acute onset of headache and visual changes. At that time, he was found to have a small, enhancing ventral intradural extramedullary mass at the rostral aspect of C1 thought to be a meningioma. The lesion was managed conservatively, and surveillance imaging tracked its slow progressive enlargement to a size of 1.4 cm ( Fig. 1A, B ). Although he remained asymptomatic, nonurgent elective resection was recommended because of his age and mass progression. The patient underwent a left far lateral approach to the craniocervical junction for resection of the mass. This involved dissection of the suboccipital musculature to expose the C1 transverse process in the suboccipital triangle and ultimately the vertebral artery. After a small craniectomy and C1 hemilaminectomy, the dura was opened and a cystic lesion encountered ( Fig. 2 ). The cystic contents were debulked and the capsule resected. Histopathologic examination revealed abundant goblet cells consistent with a neuroenteric cyst. Dural closure was bolstered with fascia lata and autologous fat graft. Postoperative magnetic resonance imaging (MRI) was consistent with gross total resection ( Fig. 1C, D ). The patient tolerated the procedure well with no new postoperative neurological deficits and was discharged home on postoperative day 2. On completing a 3-day decadron taper, he developed steroid-responsive symptoms consistent with aseptic meningitis, possibly related to cerebrospinal fluid contamination with the cyst contents during resection. The link to the video can be found at: https://youtu.be/SskETPe5PXQ .
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http://dx.doi.org/10.1055/s-0039-3399492DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6864110PMC
December 2019

Pathologic remodeling in human neuromas: insights from clinical specimens.

Acta Neurochir (Wien) 2019 12 14;161(12):2453-2466. Epub 2019 Oct 14.

Department of Pathology, University of Utah, Salt Lake City, UT, USA.

Background: Neuroma pathology is commonly described as lacking a clear internal structure, but we observed evidence that there are consistent architectural elements. Using human neuroma samples, we sought to identify molecular features that characterize neuroma pathophysiology.

Methods: Thirty specimens-12 neuromas-in-continuity (NICs), 11 stump neuromas, two brachial plexus avulsions, and five controls-were immunohistochemically analyzed with antibodies against various components of normal nerve substructures.

Results: There were no substantial histopathologic differences between stump neuromas and NICs, except that NICs had intact fascicle(s) in the specimen. These intact fascicles showed evidence of injury and fibrosis. On immunohistochemical analysis of the neuromas, laminin demonstrated a consistent double-lumen configuration. The outer lumen stained with GLUT1 antibodies, consistent with perineurium and microfascicle formation. Antibodies to NF200 revealed small clusters of small-diameter axons within the inner lumen, and the anti-S100 antibody showed a relatively regular pattern of non-myelinating Schwann cells. CD68+ cells were only seen in a limited temporal window after injury. T-cells were seen in neuroma specimens, with both a temporal evolution as well as persistence long after injury. Avulsion injury specimens had similar architecture to control nerves. Seven pediatric specimens were not qualitatively different from adult specimens. NICs demonstrated intact but abnormal fascicles that may account for the neurologically impoverished outcomes from untreated NICs.

Conclusions: We propose that there is consistent pathophysiologic remodeling after fascicle disruption. Particular features, such as predominance of small caliber axons and persistence of numerous T-cells long after injury, suggest a potential role in chronic pain associated with neuromas.
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http://dx.doi.org/10.1007/s00701-019-04052-7DOI Listing
December 2019
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