Publications by authors named "Jamie J Van Gompel"

253 Publications

Predicting Extent of Microsurgical Resection of Sporadic Vestibular Schwannoma.

Otol Neurotol 2022 Aug 6. Epub 2022 Aug 6.

Department of Otolaryngology-Head and Neck Surgery.

Objective: Develop a predictive model for incomplete microsurgical resection of sporadic vestibular schwannoma (VS).

Study Design: Historical cohort.

Setting: Tertiary referral center.

Patients: Patients with sporadic VS.

Interventions: Microsurgery with preoperative intent of gross total resection.

Main Outcome Measures: Patient and tumor characteristics that influence extent of resection.

Results: Among 603 patients, 101 (17%) had intracanalicular tumors and 502 (83%) had tumors with cerebellopontine angle (CPA) extension. For patients with CPA tumors, 331 (66%) underwent gross total resection and 171 (34%) underwent near-total or subtotal resection (NTR-STR). Multivariable modeling identified older age at surgery, larger linear tumor size, and absence of a fundal fluid cap as predictive of NTR-STR (p < 0.001). From this model, one can estimate that a 20-year-old with a tumor that has less than 10 mm of CPA extension and a present fundal fluid cap has a predicted probability of NTR-STR of 0.01 (or 1%), whereas a 70-year-old with a tumor that has 30 mm or greater CPA extension and absence of a fundal fluid cap has a predicted probability of NTR-STR of 0.91 (or 91%). Among the 171 patients who underwent NTR-STR, 24 required secondary treatment at the time of last follow-up.

Conclusion: The primary predictors of incomplete microsurgical resection of VS include older age at surgery, larger linear tumor size, and absence of a fundal fluid cap. These factors can be used to estimate the likelihood of NTR-STR, aiding in preoperative discussions regarding future surveillance and potential need of secondary treatment, as well as shared clinical decision making.
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http://dx.doi.org/10.1097/MAO.0000000000003593DOI Listing
August 2022

Subclinical seizures on stereotactic EEG: characteristics and prognostic value.

Seizure 2022 Jul 29;101:96-102. Epub 2022 Jul 29.

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

Objective: Although stereotactic EEG (sEEG) has become a widely used intracranial EEG technique, the significance of subclinical seizures (SCS) recorded on sEEG is unclear and studies examining this finding on sEEG are limited. We investigated (1) the prevalence of SCS in patients undergoing sEEG and clinical factors associated with their presence, (2) how often the subclinical seizure onset zone (SOZ) colocalizes with clinical SOZ, (3) the association of SCS and surgical outcomes, and (4) the influence of resection of the subclinical SOZ on surgical outcome.

Methods: We reviewed all patients who underwent intracranial monitoring with sEEG at our institution from 2015 through 2020 (n=169). Patient and seizure characteristics were recorded, as was concordance of subclinical and clinical seizures and post-surgical outcomes.

Results: SCS were observed during sEEG monitoring in 84 of 169 patients (50%). There was no difference in the prevalence of SCS based on imaging abnormalities, temporal vs extratemporal SOZ, number of electrodes, or pathology. SCS were more common in females than males (62% vs 40%, p=0.0054). SCS had complete concordance with clinical SOZ in 40% of patients, partial concordance in 29%, overlapping in 19%, and discordant in 12%. Eighty-three patients had surgery, 44 of whom had SCS. There was no difference in excellent outcome (ILAE 12 or 2) based on the presence of SCS or SCS concordance with clinical SOZ; however, there were improved outcomes in patients with complete resection of the subclinical SOZ compared with patients with incomplete resection (p =0.013).

Significance: These findings demonstrate that SCS are common during sEEG and colocalize with the clinical SOZ in most patients. Discordance with clinical SOZ does not necessarily predict poor surgical outcome; rather, complete surgical treatment of the subclinical SOZ correlates with excellent outcome. For unclear reasons, subclinical seizures occurred more commonly in females than males.
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http://dx.doi.org/10.1016/j.seizure.2022.07.015DOI Listing
July 2022

Introduction. Best practices in telemedicine for optimizing patient care.

Neurosurg Focus 2022 Jun;52(6):E1

7Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.

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http://dx.doi.org/10.3171/2022.3.FOCUS22149DOI Listing
June 2022

Long-term outcomes in patients with adult-onset craniopharyngioma.

Endocrine 2022 Jul 23. Epub 2022 Jul 23.

Division of Endocrinology, Diabetes, Metabolism and Nutrition, Mayo Clinic, Rochester, MN, USA.

Purpose: Craniopharyngiomas are nonmalignant sellar and parasellar tumors exhibiting a bimodal age distribution. While the outcomes following treatment in patients with childhood-onset craniopharyngiomas are well characterized, similar information in adult-onset craniopharyngiomas is limited. We aimed to describe the long-term outcomes (weight and metabolic parameters, mortality) in patients with adult-onset craniopharyngioma following treatment.

Methods: Patients with adult-onset craniopharyngioma with initial treatment (1993-2017) and >6 months of follow-up at our institution were retrospectively identified. Body mass index (BMI) categories included obese (BMI ≥ 30 kg/m), overweight (BMI 25-29.9 kg/m), and normal weight (BMI < 25 kg/m).

Results: For the 91 patients with adult-onset craniopharyngioma (44% women, mean diagnosis age 48.2 ± 18 years) over a mean follow-up of 100.3 ± 69.5 months, weight at last follow-up was significantly higher than before surgery (mean difference 9.5 ± 14.8 kg, P < 0.001) with a higher percentage increase in weight seen in those with lower preoperative BMI (normal weight (20.7 ± 18%) vs. overweight (13.3 ± 18.0%) vs. obese (6.4 ± 15%), P = 0.012). At last follow-up, the prevalence of obesity (62 vs. 40.5%, P = 0.0042) and impaired glucose metabolism (17.4% vs. 34%, P = 0.017) increased significantly. All-cause mortality was 12%, with the average age of death 71.9 ± 19.7 years (average U.S. life expectancy 77.7 years, CDC 2020).

Conclusion: Patients with adult-onset craniopharyngioma following treatment may experience weight gain, increased prevalence of obesity, impaired glucose metabolism, and early mortality. Lower preoperative BMI is associated with a greater percentage increase in postoperative weight.
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http://dx.doi.org/10.1007/s12020-022-03134-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9308022PMC
July 2022

Esthesioneuroblastoma (Olfactory Neuroblastoma): Overview and Extent of Surgical Approach and Skull Base Resection.

J Neurol Surg Rep 2022 Jul 10;83(3):e80-e82. Epub 2022 Jul 10.

Department of Otolaryngology - Head & Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States.

Esthesioneuroblastoma is a rare malignancy originating from the olfactory epithelium. Treatment consists of surgical resection with strong consideration for adjuvant treatment in advanced Kadish stage and high Hyams grade. In the modern era, overall outcomes for esthesioneuroblastoma are favorable compared with many other sinonasal malignancies with 5-year overall survival estimated to be 80%. When selecting the optimal surgical approach, the surgeon must consider the approach that will allow for a negative margin resection and adequate reconstruction. In appropriately selected patients, endoscopic outcomes appear at least equivalent to open approaches and unilateral endoscopic approach may be used in select olfactory preservation cases.
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http://dx.doi.org/10.1055/s-0042-1753519DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9272014PMC
July 2022

Insula and the Immune System: More than mere Co-existence?

Neurosci Bull 2022 Jun 28. Epub 2022 Jun 28.

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

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http://dx.doi.org/10.1007/s12264-022-00911-zDOI Listing
June 2022

Outcomes and Principles of Patient Selection for Laser Interstitial Thermal Therapy for Metastatic Brain Tumor Management: A Multisite Institutional Case Series.

World Neurosurg 2022 Jun 26. Epub 2022 Jun 26.

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

Background: Laser interstitial thermal therapy (LITT) is an emerging treatment modality for both primary brain tumors and metastases. We report initial outcomes after LITT for metastatic brain tumors across 3 sites at our institution and discuss potential strategies for optimal patient selection and outcomes.

Methods: International Classification of Diseases, Ninth Revision and Tenth Revision codes were used to identify patients with malignant brain tumors treated via LITT across all 3 Mayo Clinic sites with at least 6 months follow-up. Local control was based on radiologic and clinical evidence. Overall survival was measured from time of receiving LITT until death or end of the study period.

Results: Twenty-three patients were treated for progression of a single (n = 21) or multiple (n = 2) previously radiated metastatic lesions and/or radiation necrosis. Median age was 56 years (interquartile range, 47-66.5 years). LITT achieved local control of the lesion in most patients with metastatic tumors or radiation necrosis (n = 18; 81.8%) for the duration of follow-up. One patient did not have local control data available. Thirteen (56.5%) patients remained alive at the end of the study period. No other patients died of their treated disease during the study period; 5 of 10 deaths were attributable to central nervous system progression outside the treated lesion. Although median survival for this cohort has not yet been reached, the current median survival is 16 months (interquartile range, 12-48.5 months) after LITT for metastatic/radiation necrosis lesions.

Conclusions: LITT was associated with sustained local control in 81.8% of patients treated for radiographic progression of metastatic central nervous system disease.
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http://dx.doi.org/10.1016/j.wneu.2022.06.095DOI Listing
June 2022

Distributed brain co-processor for tracking spikes, seizures and behaviour during electrical brain stimulation.

Brain Commun 2022 6;4(3):fcac115. Epub 2022 May 6.

Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, USA.

Early implantable epilepsy therapy devices provided open-loop electrical stimulation without brain sensing, computing, or an interface for synchronized behavioural inputs from patients. Recent epilepsy stimulation devices provide brain sensing but have not yet developed analytics for accurately tracking and quantifying behaviour and seizures. Here we describe a distributed brain co-processor providing an intuitive bi-directional interface between patient, implanted neural stimulation and sensing device, and local and distributed computing resources. Automated analysis of continuous streaming electrophysiology is synchronized with patient reports using a handheld device and integrated with distributed cloud computing resources for quantifying seizures, interictal epileptiform spikes and patient symptoms during therapeutic electrical brain stimulation. The classification algorithms for interictal epileptiform spikes and seizures were developed and parameterized using long-term ambulatory data from nine humans and eight canines with epilepsy, and then implemented prospectively in out-of-sample testing in two pet canines and four humans with drug-resistant epilepsy living in their natural environments. Accurate seizure diaries are needed as the primary clinical outcome measure of epilepsy therapy and to guide brain-stimulation optimization. The brain co-processor system described here enables tracking interictal epileptiform spikes, seizures and correlation with patient behavioural reports. In the future, correlation of spikes and seizures with behaviour will allow more detailed investigation of the clinical impact of spikes and seizures on patients.
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http://dx.doi.org/10.1093/braincomms/fcac115DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9217965PMC
May 2022

Pituitary Adenoma Incidence, Management Trends, and Long-term Outcomes: A 30-Year Population-Based Analysis.

Mayo Clin Proc 2022 Jun 23. Epub 2022 Jun 23.

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

Objective: To perform a population-based study of pituitary adenoma epidemiology, including longitudinal trends in disease incidence, treatment patterns, and outcomes.

Patients And Methods: In this study of incident pituitary adenomas in Olmsted County, Minnesota, from January 1, 1989, through December 31, 2019, we identified 785 patients who underwent primary screening, 435 of whom were confirmed as harboring incident pituitary adenomas and were included. Primary outcomes of interest included demographic characteristics, presenting features, and disease outcomes (tumor control, biochemical control, and complications).

Results: Among our 435 study patients, 438 unique pituitary adenomas were diagnosed at a median patient age of 39 years (interquartile range [IQR], 27 to 58 years). Adenomas were incidentally identified in 164 of the 438 tumors (37%). Common symptomatic presentations included hyperprolactinemia (188 of 438 [43%]) and visual field deficit (47 of 438 [11%]). Laboratory tests confirmed pituitary hormone hypersecretion in 238 of the 435 patients (55%), which was symptomatic in 222. The median tumor diameter was 8 mm (IQR, 5 to 17 mm). Primary management strategies were observation (156 of 438 tumors [36%]), medication (162 of 438 tumors [37%]), and transsphenoidal resection (120 of 438 tumors [27%]). Tumor and biochemical control were achieved in 398 (95%) and 216 (91%) secreting tumors, respectively. New posttreatment pituitary or visual deficits were noted in 43 (11%) and 8 (2%); apoplexy occurred in 28 (6%). Median clinical follow-up was 98 months (IQR, 47 to 189 months). Standardized incidence rates were 3.77 to 16.87 per 100,000 population, demonstrating linear expansion over time (R=0.67). The mean overall standardized incidence rate was 10.1 per 100,000 population; final point prevalence was 175.1 per 100,000 population.

Conclusion: Pituitary adenoma is a highly incident disease, with prolactin-secreting and incidental lesions representing the majority of tumors. Incidence rates and asymptomatic detection appear to be increasing over time. Presenting symptoms and treatment pathways are variable; however, most patients achieve favorable outcomes with observation or a single treatment modality.
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http://dx.doi.org/10.1016/j.mayocp.2022.03.017DOI Listing
June 2022

Centromedian Nucleus of the Thalamus Deep Brain Stimulation for Genetic Generalized Epilepsy: A Case Report and Review of Literature.

Front Hum Neurosci 2022 20;16:858413. Epub 2022 May 20.

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

There is a paucity of treatment options for cognitively normal individuals with drug resistant genetic generalized epilepsy (GGE). Centromedian nucleus of the thalamus (CM) deep brain stimulation (DBS) may be a viable treatment for GGE. Here, we present the case of a 27-year-old cognitively normal woman with drug resistant GGE, with childhood onset. Seizure semiology are absence seizures and generalized onset tonic clonic (GTC) seizures. At baseline she had 4-8 GTC seizures per month and weekly absence seizures despite three antiseizure medications and vagus nerve stimulation. A multidisciplinary committee recommended off-label use of CM DBS in this patient. Over 12-months of CM DBS she had two GTC seizure days, which were in the setting of medication withdrawal and illness, and no GTC seizures in the last 6 months. There was no significant change in the burden of absence seizures. Presently, just two studies clearly document CM DBS in cognitively normal individuals with GGE or idiopathic generalized epilepsy (IGE) [in contrast to studies of cognitively impaired individuals with developmental and epileptic encephalopathies (DEE)]. Our results suggest that CM DBS can be an effective treatment for cognitively normal individuals with GGE and underscore the need for prospective studies of CM DBS.
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http://dx.doi.org/10.3389/fnhum.2022.858413DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9164300PMC
May 2022

Three-hundred and sixty degrees of surgical approaches to the maxillary sinus.

World J Otorhinolaryngol Head Neck Surg 2022 Mar 22;8(1):42-53. Epub 2022 Mar 22.

Division of Rhinology and Skull Base Surgery, Department of Otolaryngology-Head & Neck Surgery Mayo Clinic Rochester Minnesota USA.

Objectives: To demonstrate three-hundred and sixty degrees of maxillary sinus (MS) surgical approaches using cadaveric dissections, highlighting the step-by-step anatomy of each procedure.

Methods: Two latex-injected cadaveric specimens were utilized to perform surgical dissections to demonstrate different approaches to the MS. The procedures were documented with macroscopic images and endoscopic pictures.

Results: Dissections were performed to approach the MS medially (endoscopic maxillary antrostomy and ethmoidectomy), anteriorly (Caldwell-Luc), superiorly (transconjunctival/transorbital approach), inferiorly (transpalatal approach), and posterolaterally (preauricular hemicoronal approach).

Conclusion: A number of approaches have been described to address pathology in the MS. Surgeons should be familiar with indications, limitations, and surgical anatomy from different perspectives to approach the MS. This paper illustrates anatomic approaches to the MS with detailed step-by-step cadaveric dissections and case examples.
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http://dx.doi.org/10.1002/wjo2.12DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9126161PMC
March 2022

Ultra-early therapeutic anticoagulation after craniotomy - A single institution experience.

J Clin Neurosci 2022 Jun 6;100:46-51. Epub 2022 Apr 6.

Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA; Department of Otorhinolaryngology, Mayo Clinic, Rochester, MN, USA. Electronic address:

There is a paucity of information regarding the optimal timing of initiation or re-initiation of therapeutic anticoagulation after intracranial surgery. Anticoagulation that is started too soon after surgery may increase the risk of catastrophic intracranial bleeding. However, there are scenarios that necessitate the use of anticoagulation in the immediate post-operative period despite the increased risk of hemorrhage. Therefore, we sought to report our experience with ultra-early therapeutic anticoagulation after craniotomy. Retrospective chart review of patients from a single institution between 1/1/2010 and 10/1/2021 who were treated with therapeutic anticoagulation for venous thromboembolism on or before 7-days after a craniotomy or craniectomy. The primary endpoint was intracranial hemorrhage resulting in death or return to the operating room for hematoma evacuation. Secondary endpoints included extra-cranial hemorrhage, length of hospital stay, and 90-day readmission rate. Eighteen patients were included for analysis. The median time that therapeutic anticoagulation was started was post-operative day 5 (range 1-7 days). One patient (5.6%) met the primary endpoint as they experienced an intracranial hemorrhage 5 days after starting anticoagulation, which required surgical evacuation. No patients experienced an extra-cranial hemorrhage. The median length of hospitalization was 13 days (range 4-89 days). No patients were readmitted within 90 days. The 90-day survival rate was 100%. Ultra-early anticoagulation after craniotomy resulted in a 5.6% risk of intracranial hemorrhage. Thus, ultra-early anticoagulation can be performed safely but it does carry a substantial risk of intracranial bleeding that may require emergent hematoma evacuation or result in permeant neurologic deficits or death.
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http://dx.doi.org/10.1016/j.jocn.2022.03.042DOI Listing
June 2022

Long-term oncologic outcomes in esthesioneuroblastoma: An institutional experience of 143 patients.

Int Forum Allergy Rhinol 2022 Apr 6. Epub 2022 Apr 6.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, Minnesota, USA.

Objective: Esthesioneuroblastoma (ENB) is a rare malignant neoplasm arising from the olfactory epithelium of the cribriform plate. The goal of this study was to update our oncologic outcomes for this disease and explore prognostic factors associated with survival.

Materials And Methods: We performed a retrospective analysis of patients with ENB treated at a single tertiary care institution from January 1, 1960, to January 1, 2020. Univariate and multivariate analysis was performed. Overall survival (OS), progression-free survival (PFS), and distant metastasis-free survival (DMFS) were reported.

Results: Among 143 included patients, the 5-year OS was 82.3% and the 5-year PFS was 51.6%; 5-year OS and PFS have improved in the modern era (2005-present). Delayed regional nodal metastasis was the most common site of recurrence in 22% of patients (median, 57 months). On univariate analysis, modified Kadish staging (mKadish) had a negative effect on OS, PFS, and DMFS (p < 0.05). Higher Hyams grade had a negative effect on PFS and DMFS (p < 0.05). Positive margin status had a negative effect on PFS (p < 0.05). Orbital invasion demonstrated worsening OS (hazard ratio, 3.1; p < 0.05). On multivariable analysis, high Hyams grade (3 or 4), high mKadish stage (C+D), and increasing age were independent negative prognostic factors for OS (p < 0.05). High Hyams grade (3+4), high mKadish stage (C+D), age, and positive margin status were independent negative prognostic factors for PFS (p < 0.05). High Hyams grade (3+4) was an independent negative prognostic factor for DMFS (p < 0.05).

Conclusions: Patients with low Hyams grade and mKadish stage have favorable 5-year OS, PFS, and DMFS.
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http://dx.doi.org/10.1002/alr.23007DOI Listing
April 2022

Physician Identification Badges: A Multispecialty Quality Improvement Study to Address Professional Misidentification and Bias.

Mayo Clin Proc 2022 04;97(4):658-667

Department of Medicine, Mayo Clinic, Scottsdale, AZ. Electronic address:

Objective: To evaluate whether providing resident physicians with "DOCTOR" role identification badges would impact perceptions of bias in the workforce and alter misidentification rates.

Participants And Methods: Between October 2019 and December 2019, we surveyed 341 resident physicians in the anesthesiology, dermatology, internal medicine, neurologic surgery, otorhinolaryngology, and urology departments at Mayo Clinic in Rochester, Minnesota, before and after an 8-week intervention of providing "DOCTOR" role identification badges. Differences between paired preintervention and postintervention survey answers were measured, with a focus on the frequency of experiencing perceived bias and role misidentification (significance level, α=.01). Free-text comments were also compared.

Results: Of the 159 residents who returned both the before and after surveys (survey response rate, 46.6% [159 of 341]), 128 (80.5%) wore the "DOCTOR" badge. After the intervention, residents who wore the badges were statistically significantly less likely to report role misidentification at least once a week from patients, nonphysician team members, and other physicians (50.8% [65] preintervention vs 10.2% [13] postintervention; 35.9% [46] vs 8.6% [11]; 18.0% [23] vs 3.9% [5], respectively; all P<.001). The 66 female residents reported statistically significantly fewer episodes of gender bias (65.2% [43] vs 31.8% [21]; P<.001). The 13 residents who identified as underrepresented in medicine reported statistically significantly less misidentification from patients (84.6% [11] vs 23.1% [3]; P=.008); although not a statistically significant difference, the 13 residents identifying as underrepresented in medicine also reported less misidentification with nonphysician team members (46.2% [6] vs 15.4% [2]; P=.13).

Conclusion: Residents reported decreased role misidentification after use of a role identification badge, most prominently improved among women. Decreasing workplace bias is essential in efforts to improve both diversity and inclusion efforts in training programs.
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http://dx.doi.org/10.1016/j.mayocp.2022.01.007DOI Listing
April 2022

Safety and efficacy of responsive neurostimulation in the pediatric population: Evidence from institutional review and patient-level meta-analysis.

Epilepsy Behav 2022 04 14;129:108646. Epub 2022 Mar 14.

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

Background: Responsive neurostimulation (RNS) is a novel technology for drug-resistant epilepsy rising from bilateral hemispheres or eloquent cortex. Although recently approved for adults, its safety and efficacy for pediatric patients is under investigation.

Methods: A comprehensive literature search (Pubmed/Medline, Scopus, Cochrane) was conducted for studies on RNS for pediatric epilepsy (<18 y/o) and supplemented by our institutional series (4 cases). Reduction in seizure frequency at last follow-up compared to preoperative baseline comprised the primary endpoint.

Results: A total of 8 studies (49 patients) were analyzed. Median age at implant was 15 years (interquartile range [IQR] 12-17) and 63% were males. A lesional MRI was noted in 64% (14/22). Prior invasive EEG recording was performed in the majority of patients (90%) and the most common modality was stereoelectroencephalography (57%). The most common implant location (total of 94 RNS leads) was the frontal lobe (27%), followed by mesial temporal structures (23%) and thalamus (17%). At a median follow-up of 22 months, median seizure frequency reduction was 75% (IQR: 50-88%) and 80% were responders (>50% seizure reduction). Responses ranged from 50% for temporal lobe epilepsy to 81-93% for frontal, parietal, and multilobar epilepsy. Four infections were observed (8%) and there were no hematomas or postoperative neurological deficits.

Conclusion: Current evidence, albeit limited by potential publication bias, supports the promising safety and efficacy profile of RNS for medically refractory pediatric epilepsy. Randomized controlled trial data are needed to further establish the role of this intervention in preoperative discussions with patients and their families.
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http://dx.doi.org/10.1016/j.yebeh.2022.108646DOI Listing
April 2022

MRI enhancement patterns in 28 cases of clival chordomas.

J Clin Neurosci 2022 May 9;99:117-122. Epub 2022 Mar 9.

Mayo Clinic, Department of Radiology. Rochester, MN, USA.

Clival chordomas are classically thought of as locally aggressive tumors of the skull base and differentiate themselves from their benign counterparts by demonstrating moderate to marked contrast enhancement, reported as 95-100% in prior studies. The purpose of this review was to evaluate the imaging characteristics of lesions from a single institution classified as clival chordomas with an emphasis of highlighting lesions that do not follow the prevalent current description for chordoma. We searched our institutional databases for all patients with pathologically proven clival chordomas from 1997 to 2017 who had pre-operative imaging available. The images were evaluated for degree of contrast enhancement, MRI signal characteristics, osseous involvement, location, aggressiveness of appearance, and presence of calcifications. 28 cases were identified that had preoperative imaging available for review. Over half of the patients demonstrated either no/minimal (11/28, 39%) or mild enhancement (7/28, 25%). The remaining cases demonstrated moderate (4/28, 14%) and marked enhancement (6/28, 21%). The 4 lesions measuring less than 20 mm all had mild to minimal/no enhancement and lacked aggressive features on CT. Our experience finds that over half (64%) of clival chordomas will demonstrate mild or no enhancement at all. These findings suggest that the lack of MRI contrast enhancement should not be synonymous with a benign clival mass.
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http://dx.doi.org/10.1016/j.jocn.2022.02.037DOI Listing
May 2022

Beware: Sialadenitis as a Rare Post Neurosurgical Complication: A Single-Institution Clinical Case Series.

World Neurosurg 2022 Jun 5;162:e218-e224. Epub 2022 Mar 5.

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

Objective: Acute postoperative sialadenitis is a potentially life-threatening complication of cranial neurosurgery characterized by swelling of the face and neck due to obstruction of salivary ducts by either mechanical obstruction or, potentially, pharmacologic stasis or gland obstruction. Given the paucity of literature surrounding this rare phenomenon, we sought to report our experience with acute sialadenitis after cranial neurosurgery.

Methods: Retrospective review of patients with acute sialadenitis after neurosurgical craniotomy or craniectomy from a single institution from January 1, 2011, through December 31, 2021.

Results: Seven patients (median age: 27 years; 6 female) identified meeting our inclusion criteria out of 10,014 patients who underwent craniotomy and/or craniectomy procedures during last 11 years (∼0.006%), 5 of these cases were considered skull base procedures. Five (71%) patients required emergent airway management either via intubation or tracheostomy and 5 (71%) were treated with steroids. Additional supportive care included sialagogues, warm compress, massage, analgesics, and intravenous hydration for all 7 patients. Three patients (43%) developed concomitant transient focal neurologic deficits attributable to the sialadenitis. No mortalities occurred as a result of this complication.

Conclusions: Acute post-neurosurgical sialadenitis spans a range of severity, with some patients requiring emergent airway management and prolonged ventilator support whereas other patients only require conservative supportive care. Early recognition of acute sialadenitis after cranial neurosurgery can prevent fatal outcomes and provide complete recovery from this condition. Therefore, all neurosurgeons, anesthesiologists, and intensivists should be aware of this rare, but potentially life-threatening, complication.
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http://dx.doi.org/10.1016/j.wneu.2022.02.131DOI Listing
June 2022

Intraoperative Use of Electrical Stapedius Reflex Testing for Cochlear Nerve Monitoring During Simultaneous Translabyrinthine Resection of Vestibular Schwannoma and Cochlear Implantation.

Otol Neurotol 2022 04;43(4):506-511

Department of Otorhinolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota.

Objective: To report the novel use of intraoperative electrically evoked stapedial reflex (eSR) for cochlear nerve monitoring during simultaneous translabyrinthine resection of vestibular schwannoma (VS) and cochlear implantation.

Study Design: Clinical capsule report with video demonstration.

Setting: Tertiary academic referral center.

Patient: A 58-year-old female presented with a small right intracanalicular VS with associated asymmetrical right moderate to severe sensorineural hearing loss, poor word recognition, tinnitus, and disequilibrium. Based on patient symptomatology and goals, simultaneous CI with translabyrinthine resection of the VS was performed.

Intervention: Cochlear implantation before the tumor was resected facilitated intraoperative eSRs by delivering repeated single-electrode stimulations through the cochlear implant (CI) electrode during tumor resection. A pulse duration of 50-us and a current amplitude of 200-CL or 648-us was used to elicit eSRs visible through the facial recess. Intraoperative eSR was monitored in conjunction with electrically evoked compound action potentials via neural response telemetry and electrical auditory brainstem response.

Results: Despite the transient evoked compound action potentials amplitude and electrical auditory brainstem response latency changes, the visually observed eSR was preserved and remained robust throughout tumor dissection, indicating an intact cochlear nerve. Four weeks postoperatively, the patient exhibited open-set speech capacity (14% CNC and 36% AzBio in quiet).

Conclusion: The current study demonstrates the feasibility of using intraoperative eSR via a CI electrode to monitor cochlear nerve integrity during VS resection, which may indicate successful CI outcomes. These preliminary findings require further substantiation in a larger study.
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http://dx.doi.org/10.1097/MAO.0000000000003505DOI Listing
April 2022

Surgical approaches to refractory central lobule epilepsy: a systematic review on the role of resection, ablation, and stimulation in the contemporary era.

J Neurosurg 2022 Jan 14:1-12. Epub 2022 Jan 14.

1Department of Neurologic Surgery, Mayo Clinic, Rochester; and.

Objective: Epilepsy originating from the central lobule (i.e., the primary sensorimotor cortex) is a challenging entity to treat given its involvement of eloquent cortex. The objective of this study was to review available evidence on treatment options for central lobule epilepsy.

Methods: A comprehensive literature search (PubMed/Medline, EMBASE, and Scopus) was conducted for studies (1990 to date) investigating postoperative outcomes for central lobule epilepsy. The primary and secondary endpoints were seizure freedom at last follow-up and postoperative neurological deficit, respectively. The following procedures were included: open resection, multiple subpial transections (MSTs), laser and radiofrequency ablation, deep brain stimulation (DBS), responsive neurostimulation (RNS), and continuous subthreshold cortical stimulation (CSCS).

Results: A total of 52 studies and 504 patients were analyzed. Most evidence was based on open resection, yielding a total of 400 patients (24 studies), of whom 62% achieved seizure freedom at a mean follow-up of 48 months. A new or worsened motor deficit occurred in 44% (permanent in 19%). Forty-six patients underwent MSTs, of whom 16% achieved seizure freedom and 30% had a neurological deficit (permanent in 12%). There were 6 laser ablation cases (cavernomas in 50%) with seizure freedom in 4 patients and 1 patient with temporary motor deficit. There were 5 radiofrequency ablation cases, with 1 patient achieving seizure freedom, 2 patients each with Engel class III and IV outcomes, and 2 patients with motor deficit. The mean seizure frequency reduction at the last follow-up was 79% for RNS (28 patients), 90% for CSCS (15 patients), and 73% for DBS (4 patients). There were no cases of temporary or permanent neurological deficit in the CSCS or DBS group.

Conclusions: This review highlights the safety and efficacy profile of resection, ablation, and stimulation for refractory central lobe epilepsy. Resection of localized regions of epilepsy onset zones results in good rates of seizure freedom (62%); however, nearly 20% of patients had permanent motor deficits. The authors hope that this review will be useful to providers and patients when tailoring decision-making for this intricate pathology.
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http://dx.doi.org/10.3171/2021.10.JNS211875DOI Listing
January 2022

Electrical brain stimulation and continuous behavioral state tracking in ambulatory humans.

J Neural Eng 2022 02 8;19(1). Epub 2022 Feb 8.

Bioelectronics Neurophysiology and Engineering Laboratory, Department of Neurology, Mayo Clinic, Rochester, MN, United States of America.

Electrical deep brain stimulation (DBS) is an established treatment for patients with drug-resistant epilepsy. Sleep disorders are common in people with epilepsy, and DBS may actually further disturb normal sleep patterns and sleep quality. Novel implantable devices capable of DBS and streaming of continuous intracranial electroencephalography (iEEG) signals enable detailed assessments of therapy efficacy and tracking of sleep related comorbidities. Here, we investigate the feasibility of automated sleep classification using continuous iEEG data recorded from Papez's circuit in four patients with drug resistant mesial temporal lobe epilepsy using an investigational implantable sensing and stimulation device with electrodes implanted in bilateral hippocampus (HPC) and anterior nucleus of thalamus (ANT).The iEEG recorded from HPC is used to classify sleep during concurrent DBS targeting ANT. Simultaneous polysomnography (PSG) and sensing from HPC were used to train, validate and test an automated classifier for a range of ANT DBS frequencies: no stimulation, 2 Hz, 7 Hz, and high frequency (>100 Hz).We show that it is possible to build a patient specific automated sleep staging classifier using power in band features extracted from one HPC iEEG sensing channel. The patient specific classifiers performed well under all thalamic DBS frequencies with an average F1-score 0.894, and provided viable classification into awake and major sleep categories, rapid eye movement (REM) and non-REM. We retrospectively analyzed classification performance with gold-standard PSG annotations, and then prospectively deployed the classifier on chronic continuous iEEG data spanning multiple months to characterize sleep patterns in ambulatory patients living in their home environment.The ability to continuously track behavioral state and fully characterize sleep should prove useful for optimizing DBS for epilepsy and associated sleep, cognitive and mood comorbidities.
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http://dx.doi.org/10.1088/1741-2552/ac4bfdDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9070680PMC
February 2022

Thalamic deep brain stimulation modulates cycles of seizure risk in epilepsy.

Sci Rep 2021 12 20;11(1):24250. Epub 2021 Dec 20.

Department of Neurology, Bioelectronics Neurophysiology and Engineering Laboratory, Mayo Clinic, Rochester, MN, 55905, USA.

Chronic brain recordings suggest that seizure risk is not uniform, but rather varies systematically relative to daily (circadian) and multiday (multidien) cycles. Here, one human and seven dogs with naturally occurring epilepsy had continuous intracranial EEG (median 298 days) using novel implantable sensing and stimulation devices. Two pet dogs and the human subject received concurrent thalamic deep brain stimulation (DBS) over multiple months. All subjects had circadian and multiday cycles in the rate of interictal epileptiform spikes (IES). There was seizure phase locking to circadian and multiday IES cycles in five and seven out of eight subjects, respectively. Thalamic DBS modified circadian (all 3 subjects) and multiday (analysis limited to the human participant) IES cycles. DBS modified seizure clustering and circadian phase locking in the human subject. Multiscale cycles in brain excitability and seizure risk are features of human and canine epilepsy and are modifiable by thalamic DBS.
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http://dx.doi.org/10.1038/s41598-021-03555-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8688461PMC
December 2021

Hearing Preservation Microsurgery in Vestibular Schwannomas: Worth Attempting in "Larger" Tumors?

Laryngoscope 2022 08 2;132(8):1657-1664. Epub 2021 Dec 2.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, U.S.A.

Objectives/hypothesis: To review hearing preservation after microsurgical resection of sporadic vestibular schwannomas according to tumor size.

Study Design: Retrospective cohort.

Methods: Baseline, intraoperative, and postoperative patient and tumor characteristics were retrospectively collected for a cohort who underwent hearing preservation microsurgery. Serviceable hearing was defined by a pure tone average ≤50 dB and word recognition score ≥50%.

Results: A total of 243 patients had serviceable hearing preoperatively. Fifty (21%) tumors were confined to the internal auditory canal, and the median tumor size was 16.2 mm (interquartile range [IQR] 11.3-23.2) for tumors with cerebellopontine angle extension. Serviceable hearing was maintained in 64% of patients with tumors confined to the internal auditory canal, 28% with cerebellopontine angle extension <15 mm, and 9% with cerebellopontine angle extension ≥15 mm. On multivariable analysis, the odds ratios of acquiring nonserviceable hearing postoperatively for tumors extending <15 mm and ≥15 mm into the cerebellopontine angle were 5.75 (95% confidence interval [CI] 2.13-15.53; P < .001) and 22.11 (95% CI 7.04-69.42; P < .001), respectively, compared with intracanalicular tumors.

Conclusions: The strongest predictor of hearing preservation with microsurgery after multivariable adjustment is tumor size. Approximately 10% of patients with tumors ≥15 mm of cerebellopontine angle extension will retain serviceable hearing after microsurgery. Furthermore, hearing preservation techniques offer cochlear nerve preservation and cochlear patency allowing for possible future cochlear implantation. An attempt at hearing preservation, including avoiding surgical approaches that necessarily sacrifice hearing, is worthwhile even in larger tumors if serviceable hearing is present preoperatively.

Level Of Evidence: 4 Laryngoscope, 132:1657-1664, 2022.
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http://dx.doi.org/10.1002/lary.29968DOI Listing
August 2022

Outcomes of cingulate epilepsy surgery: insights from an institutional and patient-level systematic review and meta-analysis.

J Neurosurg 2021 Nov 19:1-10. Epub 2021 Nov 19.

1Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota.

Objective: Due to their deep and medial location, range of seizure semiologies, and poor localization on ictal electroencephalography (EEG), cingulate gyrus seizures can be difficult to diagnose and treat. The aim of this study was to review the available evidence on postoperative outcomes after cingulate epilepsy surgery.

Methods: A comprehensive literature search of the PubMed/MEDLINE, Ovid Embase, Ovid Scopus, and Cochrane Library databases was conducted to identify studies that investigated postoperative outcomes of patients with cingulate epilepsy. Seizure freedom at the last follow-up (at least 12 months) was the primary endpoint. The literature search was supplemented by the authors' institutional series (4 patients).

Results: Twenty-one studies were identified, yielding a total of 105 patients (68 with lesional epilepsy [65%]). Median age at surgery was 23 years, and 56% of patients were male. Median epilepsy duration was 7.5 years. Invasive EEG recording was performed on 69% of patients (53% of patients with lesional epilepsy and 97% of those with nonlesional epilepsy, p < 0.001). The most commonly resected region was the anterior cingulate (55%), followed by the posterior (17%) and middle (14%) cingulate. Lesionectomy alone was performed in 9% of patients. Additional extracingulate treatment was performed in 54% of patients (53% of patients with lesional epilepsy vs 57% of those with nonlesional epilepsy, p = 0.87). The most common pathology was cortical dysplasia (54%), followed by low-grade neoplasm (29%) and gliosis (8%). Seizure freedom was noted in 72% of patients (median follow-up 24 months). A neurological deficit was noted in 27% of patients (24% had temporary deficit), with the most common deficit being motor weakness (13%) followed by supplementary motor area syndrome (9.5%). Univariate survival analysis revealed significantly greater probability of seizure freedom in patients with lesional epilepsy (p = 0.015, log-rank test).

Conclusions: Surgical treatment of drug-resistant focal epilepsy originating from the cingulate gyrus is safe, leads to low rates of permanent adverse effects, and leads to high rates of long-term seizure freedom in carefully selected patients. These data may serve as a benchmark for surgical counseling of patients with cingulate epilepsy.
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http://dx.doi.org/10.3171/2021.8.JNS211558DOI Listing
November 2021

Lipochoristoma of the Cerebellopontine Angle.

Otol Neurotol 2022 03;43(3):e394-e396

Department of Otolaryngology - Head and Neck Surgery.

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http://dx.doi.org/10.1097/MAO.0000000000003412DOI Listing
March 2022

Predicting pituitary adenoma consistency with preoperative magnetic resonance elastography.

J Neurosurg 2021 Oct 29:1-8. Epub 2021 Oct 29.

2Radiology.

Objective: Pituitary adenoma is one of the most common primary intracranial neoplasms. Most of these tumors are soft, but up to 17% may have a firmer consistency. Therefore, knowing the tumor consistency in the preoperative setting could be helpful. Multiple imaging methods have been proposed to predict tumor consistency, but the results are controversial. This study aimed to evaluate the efficacy of MR elastography (MRE) in predicting tumor consistency and its potential use in a series of patients with pituitary adenomas.

Methods: Thirty-eight patients with pituitary adenomas (≥ 2.5 cm) were prospectively evaluated with MRI and MRE before surgery. Absolute MRE stiffness values and relative MRE stiffness ratios, as well as the relative ratio of T1 signal, T2 signal, and diffusion-weighted imaging apparent diffusion coefficient (ADC) values were determined prospectively by calculating the ratio of those values in the tumor to adjacent left temporal white matter. Tumors were classified into three groups according to surgical consistency (soft, intermediate, and firm). Statistical analysis was used to identify the predictive value of the different radiological parameters in determining pituitary adenoma consistency.

Results: The authors included 32 (84.21%) nonfunctional and 6 (15.79%) functional adenomas. The mean maximum tumor diameter was 3.7 cm, and the mean preoperative tumor volume was 16.4 cm3. Cavernous sinus invasion was present in 20 patients (52.63%). A gross-total resection was possible in 9 (23.68%) patients. The entire cohort's mean absolute tumor stiffness value was 1.8 kPa (range 1.1-3.7 kPa), whereas the mean tumor stiffness ratio was 0.66 (range 0.37-1.6). Intraoperative tumor consistency was significantly correlated with absolute and relative tumor stiffness (p = 0.0087 and 0.007, respectively). Tumor consistency alone was not a significant factor for predicting gross-total resection. Patients with intermediate and firm tumors had more complications compared to patients with soft tumors (50.00% vs 12.50%, p = 0.02) and also had longer operative times (p = 0.0002).

Conclusions: Whereas other MRI sequences have proven to be unreliable in determining tumor consistency, MRE has been shown to be a reliable tool for predicting adenoma consistency. Preoperative knowledge of tumor consistency could be potentially useful for surgical planning, counseling about potential surgical risks, and estimating the length of operative time.
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http://dx.doi.org/10.3171/2021.6.JNS204425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9050965PMC
October 2021

Long-term surgical outcomes of intracranial epidermoid tumors: impact of extent of resection on recurrence and functional outcomes in 63 patients.

J Neurosurg 2021 Oct 15:1-9. Epub 2021 Oct 15.

Departments of1Neurologic Surgery and.

Objective: The authors' objective was to reevaluate the role of microsurgery for epidermoid tumors by examining the associations between extent of resection (EOR), tumor control, and clinical outcomes.

Methods: This was a retrospective study of patients with microsurgically treated intracranial epidermoid tumors. The recurrence-free and intervention-free rates were calculated using the Kaplan-Meier method. EOR was graded as gross-total resection (GTR) (total resection without residual on MRI), near-total resection (NTR) (a cyst lining was left in place), subtotal resection (STR) (> 90% resection), and partial resection (PR) (any other suboptimal resection) and used to stratify outcomes.

Results: Sixty-three patients with mean clinical and radiological follow-up periods of 87.3 and 81.8 months, respectively, were included. Sixteen patients underwent second resections, and 5 underwent third resections. The rates of GTR/NTR, STR, and PR were 43%, 35%, and 22%, respectively, for the initial resections; 44%, 13%, and 44% for the second resections; and 40%, 0%, and 60% for the third resections (p < 0.001). The 5- and 10-year cumulative recurrence-free rates after initial resection were 64% and 32%, respectively. When stratified according to EOR, the 10-year recurrence-free rate after GTR/NTR was marginally better than that after STR (61% vs 35%, p = 0.130) and significantly better than that after PR (61% vs 0%, p < 0.001). The recurrence-free rates after initial microsurgery were marginally better than those after second surgery (p = 0.102) and third surgery (p = 0.065). The 5- and 10-year cumulative intervention-free rates after initial resection were 91% and 58%, respectively. When stratified according to EOR, the 10-year intervention-free rate after GTR/NTR was significantly better than that after STR (100% vs 51%, p = 0.022) and PR (100% vs 27%, p < 0.001). The 5-year intervention-free rate after initial surgery was marginally better than that after second surgery (52%, p = 0.088) and significantly better than that after third surgery (0%, p = 0.004). After initial, second, and third resections, permanent neurological complications were observed in 6 (10%), 1 (6%), and 1 (20%) patients, respectively. At the last follow-up visit, 82%, 23%, and 7% of patients were free from radiological recurrence after GTR/NTR, STR, and PR as the initial surgical procedure, respectively.

Conclusions: GTR/NTR seems to contribute to better disease control without significantly impairing functional status. Initial resection offers the best chance to achieve better EOR, leading to better disease control.
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http://dx.doi.org/10.3171/2021.5.JNS21650DOI Listing
October 2021
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