Publications by authors named "Jonathan Pace"

36 Publications

Early Experience With Virtual and Synchronized Augmented Reality Platform for Preoperative Planning and Intraoperative Navigation: A Case Series.

Oper Neurosurg (Hagerstown) 2021 Sep;21(4):189-196

Department of Neurosurgery, George Washington University Hospital, Washington, District of Columbia, USA.

Background: Virtual reality (VR) allows for presurgical planning. Intraoperatively, augmented reality (AR) enables integration of segmented anatomic information with neuronavigation into the microsurgical scene to provide guidance without workflow disruption. Combining VR and AR solutions may help guide microsurgical technique to improve safety, efficiency, and ergonomics.

Objective: To describe a VR/AR platform that provides VR planning and intraoperative guidance via microscope ocular injection of a comprehensive AR overlay of patient-specific 360°/3D anatomic model aligned and synchronized with neuronavigation.

Methods: Custom 360° models from preoperative imaging of 49 patients were utilized for preoperative planning using a VR-based surgical rehearsal platform. Each model was imported to SyncAR, the platform's intraoperative counterpart, which was coregistered with Medtronic StealthStation S8 and Zeiss or Leica microscope. The model was injected into the microscope oculars and referenced throughout by adjusting overlay opacity. For anatomic shifts or misalignment, the overlay was reregistered via manual realignment with known landmarks.

Results: No SyncAR-related complications occurred. SyncAR contributed positively to the 3D understanding of patient-specific anatomy and ability to operate. Preoperative planning and intraoperative AR with 360° models allowed for more precise craniotomy planning and execution. SyncAR was useful for guiding dissection, identifying critical structures including hidden anatomy, understanding regional anatomy, and facilitating resection. Manual realignment was performed in 48/49 surgeries. Gross total resection was achieved in 34/40 surgeries. All aneurysm clipping and microvascular decompression procedures were completed without complications.

Conclusion: SyncAR combined with VR planning has potential to enhance surgical performance by providing critical information in a user-friendly, continuously available, heads-up display format.
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http://dx.doi.org/10.1093/ons/opab188DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8453400PMC
September 2021

Correction to: Imaging Guidance for Therapeutic Delivery: the Dawn of Neuroenergetics.

Neurotherapeutics 2020 Oct;17(4):2090

Neurological Institute, University Hospitals Cleveland Medical, Center, Case Western Reserve University, Cleveland, OH, USA.

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http://dx.doi.org/10.1007/s13311-020-00863-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7851288PMC
October 2020

Imaging Guidance for Therapeutic Delivery: The Dawn of Neuroenergetics.

Neurotherapeutics 2020 04;17(2):522-538

Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.

Modern neurocritical care relies on ancillary diagnostic testing in the form of multimodal monitoring to address acute changes in the neurological homeostasis. Much of our armamentarium rests upon physiological and biochemical surrogates of organ or regional level metabolic activity, of which a great deal is invested at the metabolic-hemodynamic-hydrodynamic interface to rectify the traditional intermediaries of glucose consumption. Despite best efforts to detect cellular neuroenergetics, current modalities cannot appreciate the intricate coupling between astrocytes and neurons. Invasive monitoring is not without surgical complication, and noninvasive strategies do not provide an adequate spatial or temporal resolution. Without knowledge of the brain's versatile behavior in specific metabolic states (glycolytic vs oxidative), clinical practice would lag behind laboratory empiricism. Noninvasive metabolic imaging represents a new hope in delineating cellular, nigh molecular level energy exchange to guide targeted management in a diverse array of neuropathology.
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http://dx.doi.org/10.1007/s13311-020-00843-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7283376PMC
April 2020

Cerebral vessel anatomy as a predictor of first-pass effect in mechanical thrombectomy for emergent large-vessel occlusion.

J Neurosurg 2020 Jan 24:1-9. Epub 2020 Jan 24.

2Department of Neurological Surgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

Objective: Mechanical thrombectomy is effective in acute ischemic stroke secondary to emergent large-vessel occlusion, but optimal efficacy is contingent on fast and complete recanalization. First-pass recanalization does not occur in the majority of patients. The authors undertook this study to determine if anatomical parameters of the intracranial vessels impact the likelihood of first-pass complete recanalization.

Methods: The authors retrospectively evaluated data obtained in 230 patients who underwent mechanical thrombectomy for acute ischemic stroke secondary to large-vessel occlusion at their institution from 2016 to 2018. Eighty-six patients were identified as having pure M1 occlusions, and 76 were included in the final analysis. The authors recorded and measured clinical and anatomical parameters and evaluated their relationships to the first-pass effect.

Results: The first-pass effect was achieved in 46% of the patients. When a single device was employed, aspiration thrombectomy was more effective than stent retriever thrombectomy. A larger M1 diameter (p = 0.001), decreased vessel diameter tapering between the petrous segment of the internal carotid artery (ICA) and M1 (p < 0.001), and distal collateral grading (p = 0.044) were associated with first-pass recanalization. LASSO (least absolute shrinkage and selection operator) was used to generate a predictive model for recanalization using anatomical variables.

Conclusions: The authors demonstrated that a larger M1 vessel diameter, low rate of vessel diameter tapering along the course of the intracranial ICA, and distal collateral status are associated with first-pass recanalization for patients with M1 occlusions.
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http://dx.doi.org/10.3171/2019.11.JNS192673DOI Listing
January 2020

Commentary: Development and Evaluation of a Preoperative Trigeminal Neuralgia Scoring System to Predict Long-Term Outcome Following Microvascular Decompression.

Neurosurgery 2020 07;87(1):E12-E13

Department of Neurological Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio.

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http://dx.doi.org/10.1093/neuros/nyz446DOI Listing
July 2020

Morbidity and Mortality After Burr Hole Craniostomy Versus Craniotomy for Chronic Subdural Hematoma Evacuation: A Single-Center Experience.

World Neurosurg 2020 Feb 9;134:e196-e203. Epub 2019 Oct 9.

Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurosurgery, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA. Electronic address:

Background: Chronic subdural hematomas (cSDHs) are common neurosurgical pathological entities and typically occur after trauma in elderly patients. The 2 most commonly used strategies for treatment have included burr hole drainage and craniotomy with decompression. However, the choice of these procedures has remained controversial and has been primarily determined by surgeon preference. We designed a matched-cohort analysis to compare these 2 procedures and identify the risk factors associated with the postoperative outcomes. Thus, we compared the rates of reoperation and mortality for patients who had undergone craniotomy versus burr hole evacuation for cSDH.

Methods: A retrospective review examining the data from 299 consecutive patients with cSHDs from 2002 to 2015 was performed. We compared the following endpoints between the 2 procedures: 30-day mortality, discharge to a skilled nursing facility, and the need for reoperation. We also compared the potential risk factors in the patients with different primary outcomes.

Results: Patients undergoing craniotomy had a decreased need for reoperation compared with patients treated with burr hole evacuation (7.5% vs. 15.7%; P = 0.044). Older age was associated with both increased disposition to a nursing facility and increased 30-day mortality in both groups. Increased 30-day mortality was associated with aspirin usage in patients who had undergone craniotomy and with warfarin (Coumadin) in patients who had undergone burr hole evacuation.

Conclusions: Our study identified an increased need for reoperation for patients treated with burr hole evacuation compared with those undergoing craniotomy. Older age and low Glasgow coma scale scores were associated with worse outcomes in both groups. Certain methods of anticoagulation were also associated with worse outcomes, which varied between the 2 groups. We recommend that surgeons individualize the choice of procedure according to the specific patient characteristics with consideration of these findings.
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http://dx.doi.org/10.1016/j.wneu.2019.10.023DOI Listing
February 2020

Force and Aspiration on Catheters Utilized in the ADAPT Technique in Acute Ischemic Stroke: A Bench Top Analysis.

J Neuroradiol 2019 Apr 11. Epub 2019 Apr 11.

University Hospitals Cleveland Medical Center, The Neurological Institute, Department of Neurosurgery, 11100 Euclid Ave, Cleveland, 44106 OH USA; Case Western Reserve University School of Medicine, 2109 Adelbert Rd, Cleveland, 44106 OH USA.

Introduction: Given the high morbidity and mortality of stroke, there remains a demand for techniques that provide rapid and safe intervention while improving time to recanalization. The direct aspiration first-pass technique (ADAPT) uses force and aspiration for clot removal without the aid of separators or retrievers. In this study, we compare the force and aspiration qualities of commercially available catheters.

Methods: Four different catheters with varying inner diameters were set up in a bench top model to test catheter tip pressure and flow rate. Catheter tip pressure was measured by attaching the catheter to a vacuum pressure gauge and an aspiration pump. The flow rate was calculated by measuring the volume of room temperature water aspirated through each catheter over a given time.

Results: The Microvention Sofia catheter generated the greatest tip force (21.32 g), and the Stryker AXS Catalyst 6 catheter generated the smallest tip force (15.88 g). The Penumbra ACE 068 catheter and Medtronic ARC catheter measured 20.87 g and 16.78 g respectively. The ACE 068 had highest rate of aspiration at 289 mL/min, and the Catalyst 6 catheter had the lowest rate at 214. The Microvention Sofia catheter had the second highest rate while the ARC had the third highest rate, measuring 285 ml/min and 256 mL/min, respectively.

Conclusions: When using the ADAPT technique, knowledge of the tip force and catheter flow rate of newer catheters with larger distal inner diameters may guide selection of aspiration catheters. While this study demonstrates differences in tip force and flow rate of different commercially available catheters, clinical translation will require further testing and evaluation.
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http://dx.doi.org/10.1016/j.neurad.2019.03.013DOI Listing
April 2019

Retrosigmoid Transtentorial Approach: Technical Nuances and Quantification of Benefit From Tentorial Incision.

World Neurosurg 2018 11 6;119:176-182. Epub 2018 Aug 6.

Department of Neurosurgery, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.

Objective: The transtentorial extension of the retrosigmoid approach allows for improved visualization of the brainstem and petroclival region. This approach is an important tool in the skull base surgeon's armamentarium for pathologies involving the petroclival region. It has been shown that the addition of tentorial transection improves the exposed surface area of the brainstem. However, no data have been reported regarding the depth of the additional anterior and medial exposure. The goal of the present study was to describe the additional depth of exposure gained by performing tentorial transection. This information allows surgeons to preoperatively estimate the amount of operative exposure gained by this technique.

Methods: Five preserved cadaveric heads were dissected using frameless image guidance. A standard retrosigmoid craniotomy was performed, followed by tentorial transection. The boundaries of the surgical exposure and depth of the surgical field were compared before and after tentorial transection.

Results: After transection, we found a 20.1-mm increase in anterior exposure (P < 0.01) and a 13-mm increase in medial exposure (P < 0.01). No significant difference was found in the extent of the superior (P = 0.32) or lateral (P = 0.07) exposure. The surgical working distance increased significantly from 68.8 to 90.3 mm (P < 0.01).

Conclusions: When performing retrosigmoid craniotomy, the addition of tentorial transection allows for a significant increase in anterior and medial exposure with no significant increase in superior or lateral exposure.
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http://dx.doi.org/10.1016/j.wneu.2018.07.259DOI Listing
November 2018

Resection of a Thoracic Hemangioblastoma in a Patient With Von Hippel-Lindau: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2019 Mar;16(3):395

Department of Neurological Surgery, Neurological Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

This 3-dimensional operative video illustrates resection of a thoracic hemangioblastoma in a 30-year-old female with a history of Von Hippel-Lindau disease. The patient presented with right lower extremity numbness and flank pain. Magnetic resonance imaging (MRI) demonstrated an enhancing intradural intramedullary lesion at T 7 consistent with a hemangioblastoma. The patient underwent a thoracic laminectomy with a midline dural opening for tumor resection. This case demonstrates the principles of intradural intramedullary spinal cord tumor resection. In this particular case, internal debulking was untenable owing to the vascular nature of hemangioblastomas. The operative video demonstrates en bloc tumor removal. Postoperative MRI demonstrated gross total resection. The postoperative course was uneventful. The natural history of this disease, treatment options, and potential complications are discussed.
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http://dx.doi.org/10.1093/ons/opy178DOI Listing
March 2019

The Emerging Role of Inhaled Heroin in the Opioid Epidemic: A Review.

JAMA Neurol 2018 11;75(11):1423-1434

Neurocritical Care and Stroke Division, Department of Neurology, The Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio.

Importance: Opioid addiction affects approximately 2.4 million Americans. Nearly 1 million individuals, including a growing subset of 21 000 minors, abuse heroin. Its annual cost within the United States amounts to $51 billion. Inhaled heroin use represents a global phenomenon and is approaching epidemic levels east of the Mississippi River as well as among urban youth. Chasing the dragon (CTD) by heating heroin and inhaling its fumes is particularly concerning, because this method of heroin usage has greater availability, greater ease of administration, and impressive intensity of subjective experience (high) compared with sniffing or snorting, although it also has a safer infectious profile compared with heroin injection. This is relevant owing to peculiar and often catastrophic brain complications. Following the American Medical Association Opioid Task Force mandate, we contribute a description of the pharmacology, pathophysiology, clinical spectrum, neuroimaging, and neuropathology of CTD leukoencephalopathy, as distinct from other heroin abuse modalities.

Observations: The unique spectrum of CTD-associated health outcomes includes an aggressive toxic leukoencephalopathy with pathognomonic neuropathologic features, along with sporadic instances of movement disorders and hydrocephalus. Clinical CTD severity is predominantly moderate at admission, frequently unmodified at discharge, and largely improved in the long term. Mild cases survive with minor sequelae, while moderate to severe presentations might deteriorate and progress to death. Other methods of heroin use may complicate with stroke, seizure, obstructive hydrocephalus, and (uncharacteristically) leukoencephalopathy.

Conclusions And Relevance: The distinct pharmacology of CTD correlates with its specific clinical and radiological features and prompts grave concern for potential morbidity and long-term disability costs. Proposed diagnostic criteria and standardized reporting would ameliorate the limitations of CTD literature and facilitate patient selection for a coenzyme Q10 therapeutic trial.
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http://dx.doi.org/10.1001/jamaneurol.2018.1693DOI Listing
November 2018

Resection of 2 Intradural Extramedullary Cervical Spine Tumors in a Patient With Neurofibromatosis Type 2: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2019 Feb;16(2):274

Department of Neurological Surgery, Neurological Institute, Case Western Reserve University, University Hospitals Cleveland Medical Center, Cleveland, Ohio.

This 3-dimensional operative video illustrates resection of 2 cervical spine schwannomas in a 19-yr-old female with neurofibromatosis type 2. The patient presented with lower extremity hyperreflexity and hypertonicity. Magnetic resonance imaging (MRI) demonstrated 2 contrast-enhancing intradural extramedullary cervical spine lesions causing spinal cord compression at C4 and C5. The patient underwent a posterior cervical laminoplasty with a midline dural opening for tumor resection. Curvilinear spine cord compression is demonstrated in the operative video. After meticulous dissection, the tumors were resected without complication. The dural closure was performed in watertight fashion followed by laminoplasty using osteoplastic titanium miniplates and screws. Postoperative MRI demonstrated gross total resection with excellent decompression of the spinal cord. The postoperative course was uneventful. The natural history of this disease, treatment options, and potential complications are discussed.
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http://dx.doi.org/10.1093/ons/opy149DOI Listing
February 2019

Bedside optical coherence tomography for Terson's syndrome screening in acute subarachnoid hemorrhage: a pilot study.

J Neurosurg 2018 02;130(2):517-524

2Department of Ophthalmology, University Hospitals, Case Western Reserve University, Cleveland, Ohio.

Objective: Approximately 10% of patients with subarachnoid hemorrhage (SAH) become permanently, legally blind. The average cost of lifetime support and unpaid taxes for each blind person amounts to approximately $900,000. This study evaluates the feasibility and potential role of bedside optical coherence tomography (OCT) in Terson’s syndrome (TS) in patients with acute SAH (aSAH) and its potential role in blindness prevention.

Methods: The authors conducted an open-label pilot study, in which 31 patients with an angiographic diagnosis of aSAH were first screened for TS with dilated funduscopy and then with OCT in the acute phase and at 6-week followup visits. Outpatient mood assessments (Patient Health Questionnaire–depression module, Hamilton Depression Scale), and quality of life general (NIH Patient-Reported Outcomes Measurement Information System) and visual scales (25-item National Eye Institute Visual Functioning Questionnaire) were measured at 1 and 6 weeks after discharge. Exclusion criteria included current or previous history of severe cataracts, severe diabetic retinopathy, severe macular degeneration, or glaucoma.

Results: OCT identified 7 patients with TS, i.e., a 22.6% incidence in our aSAH sample: 7 in the acute phase, including a large retinal detachment that was initially missed by funduscopy and diagnosed by OCT in follow-up clinic. Dilated retinal funduscopy significantly failed to detect TS in 4 (57.1%) of these 7 cases. Intraventricular hemorrhage was significantly more common in TS cases (85.7% vs 25%). None of the participants experienced any complications from OCT examinations. Neither decreased quality of life visual scale scores nor a depressed mood correlated with objective OCT pathological findings at the 6-week follow-up after discharge. There were no significant mood differences between TS cases and controls.

Conclusions: OCT is the gold standard in retinal disease diagnosis. This pilot study shows that bedside OCT examination is feasible in aSAH. In this series, OCT was a safe procedure that enhanced TS detection by decreasing false-negative/inconclusive funduscopic examinations. It allows early diagnosis of macular holes and severe retinal detachments, which require acute surgical therapy to prevent legal blindness. In addition, OCT aids in ruling out potential false-positive visual deficits in individuals with a depressed mood at follow-up.
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http://dx.doi.org/10.3171/2017.7.JNS171302DOI Listing
February 2018

Acute Ischemic Pediatric Stroke Management: An Extended Window for Mechanical Thrombectomy?

Front Neurol 2017 29;8:634. Epub 2017 Nov 29.

Department of Neurology, Neurological Institute, University Hospitals, Cleveland, OH, United States.

Ischemic stroke is a rare condition to afflict the pediatric population. Congenital cardiomyopathy represents one of several possible etiologies in children. We report a 9-year-old boy who developed right middle cerebral artery stroke secondary to primary restrictive cardiomyopathy. In the absence of pediatric guidelines, the child met adult criteria for mechanical thrombectomy given the small core infarct and large penumbra. The literature suggests children may benefit from mechanical thrombectomy in carefully selected cases. Our patient exemplifies specific circumstances in which acute stroke therapy with thrombolysis and thrombectomy may be safe.
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http://dx.doi.org/10.3389/fneur.2017.00634DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5712569PMC
November 2017

Prolonged Intracisternal Papaverine Toxicity: Index Case Description and Proposed Mechanism of Action.

World Neurosurg 2018 Jan 7;109:251-257. Epub 2017 Oct 7.

Department of Neurology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA. Electronic address:

Background: Intracisternal papaverine (iPPV) is a vasodilator used for prophylaxis of intraoperative vasospasm during aneurysmal clipping. Postoperative side effects of iPPV include transient cranial nerve palsies, most commonly mydriasis owing to oculomotor nerve involvement, with rapid resolution.

Methods: We critically reviewed current literature on the adverse effects of iPPV in aneurysmal surgery with a focus on oculomotor nerve involvement. We also present the index case of prolonged bilateral mydriasis secondary to iPPV irrigation toxicity and its putative underlying mechanism.

Results: Papaverine toxicity occurs in the setting of its antimuscarinic action and blood-cerebrospinal fluid and blood-brain barrier compromise owing to acute subarachnoid hemorrhage and direct effect of papaverine. Our patient also experienced severe vasospasm and a minor stroke, both contributing to further blood-brain barrier disruption, and relatively acidic pH of the subarachnoid hemorrhage milieu.

Conclusions: We propose that these factors perpetuate phase dynamics of papaverine crystals and facilitate a sustained slow release of papaverine within the cisternal system. Were it indicated, 0.3% iPPV would reasonably diminish the risk for neurotoxicity.
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http://dx.doi.org/10.1016/j.wneu.2017.09.196DOI Listing
January 2018

Verapamil-induced breakdown of the blood-brain barrier presenting as a transient right middle cerebral artery syndrome.

Interv Neuroradiol 2017 Dec 28;23(6):601-604. Epub 2017 Sep 28.

24575 University Hospitals Cleveland Medical Center , Neurological Institute, Department of Neurological Surgery, Cleveland, OH, USA.

A middle-aged patient presented for elective embolization of an incidentally found right internal carotid aneurysm. An angiogram was performed, during which the left internal carotid artery was visualized to evaluate a second, small aneurysm. During the embolization of the right internal carotid artery aneurysm, a catheter-induced vasospasm was identified that prompted treatment with intra-arterial verapamil. The procedure was uncomplicated; a postoperative rotational flat-panel computed tomography scan was performed on the angiography table that demonstrated right hemisphere contrast staining. The patient developed a right middle cerebral artery (MCA) syndrome after extubation with repeat cerebral angiography negative for occlusion and magnetic resonance imaging negative for stroke. The patient was observed for 48 hours, during which time the patient had slowly improved. At a six-week follow up visit, the patient had fully recovered. We present an interesting case of a verapamil-induced breakdown of the blood-brain barrier and self-limited right MCA syndrome.
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http://dx.doi.org/10.1177/1591019917729822DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5814080PMC
December 2017

Rare Neurosurgical Complications of Epidural Injections: An 8-Yr Single-Institution Experience.

Oper Neurosurg (Hagerstown) 2017 04;13(2):271-279

Department of Neurosurgery, University Hospitals Case Medical Center, Cleveland, Ohio.

Background: Neurosurgical complications from epidural injections have rarely been reported.

Objective: To define the spectrum of complications from these procedures in order to identify risk factors and strategies for prevention.

Methods: A prospectively maintained database of 14 247 neurosurgical admissions over 8 yr was screened to identify patients who had suffered procedural complications associated with 1182 cervical and 4617 lumbar interlaminar epidural injection procedures performed at a single institution. Patients who developed new neurological symptoms or deficits were included. A retrospective analysis of demographic and procedural features was performed.

Results: Thirteen patients experienced complications requiring neurosurgical treatment, accounting for an overall procedural complication rate of 0.22% (0.51% and 0.15% for cervical and lumbar injections, respectively), and representing 0.09% of all neurosurgical admissions over 8 yr. There were 3 categories: hemorrhage (n = 7), infection (n = 3), and inadvertent dural penetration (n = 3). There was significant association with anticoagulation use among patients with hemorrhagic vs nonhemorrhagic complications ( P < .01, Fisher's exact test). Six patients who developed epidural hematoma had been managed in accordance with current guidelines, either after prolonged cessation of anticoagulation (n = 3) or taking only aspirin (n = 3); all were decompressed promptly with good long-term outcome. All infections were associated with lumbar injection. Dural penetration resulted in diffuse pneumocephalus (n = 1), intramedullary air at the site of injection (n = 1), and acutely symptomatic colloid cyst (n = 1).

Conclusion: A majority of neurosurgical complications from epidural injections are hemorrhagic and associated with anticoagulation, although infection and inadvertent dural penetration also occur. Prompt treatment of compressive lesions is associated with good outcome.
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http://dx.doi.org/10.1093/ons/opw014DOI Listing
April 2017

Procedural Requirements and Certification Paradigms for Stroke Care Delivery: Perspective of Neurointerventional Professional Societies.

Stroke 2017 10 15;48(10):2901-2904. Epub 2017 Sep 15.

From the University Hospitals Cleveland Medical Center, OH (N.C.B., Y.C.H., A.J.F., J.P.); Barrow Neurological Institute, Phoenix, AZ (P.N.); Penn State Hershey Neurosurgery, PA (K.C.); Massachusetts General Hospital, Boston (J.A.H.); Forsyth Medical Center, Winston-Salem, NC (D.H.); Department of Neurology, University of Pittsburgh, PA (T.J.); Mount Sinai Hospital, New York, NY (J.D.M.); University at Buffalo Neurosurgery, NY (A.S.); University of Illinois College of Medicine, Chicago (S.A.-H.); Washington University School of Medicine, St. Louis, MO (G.Z.); Lillian S. Wells Department of Neurosurgery at the University of Florida, Gainesville (B.H.); and Columbia University Medical Center, New York, NY (S.L.).

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http://dx.doi.org/10.1161/STROKEAHA.117.016773DOI Listing
October 2017

C5 Palsy After Cervical Spine Surgery: A Multicenter Retrospective Review of 59 Cases.

Global Spine J 2017 Apr 1;7(1 Suppl):64S-70S. Epub 2017 Apr 1.

Boston Medical Center, Scituate, MA, USA.

Study Design: A multicenter, retrospective review of C5 palsy after cervical spine surgery.

Objective: Postoperative C5 palsy is a known complication of cervical decompressive spinal surgery. The goal of this study was to review the incidence, patient characteristics, and outcome of C5 palsy in patients undergoing cervical spine surgery.

Methods: We conducted a multicenter, retrospective review of 13 946 patients across 21 centers who received cervical spine surgery (levels C2 to C7) between January 1, 2005, and December 31, 2011, inclusive. values were calculated using 2-sample test for continuous variables and χ tests or Fisher exact tests for categorical variables.

Results: Of the 13 946 cases reviewed, 59 patients experienced a postoperative C5 palsy. The incidence rate across the 21 sites ranged from 0% to 2.5%. At most recent follow-up, 32 patients reported complete resolution of symptoms (54.2%), 15 had symptoms resolve with residual effects (25.4%), 10 patients did not recover (17.0%), and 2 were lost to follow-up (3.4%).

Conclusion: C5 palsy occurred in all surgical approaches and across a variety of diagnoses. The majority of patients had full recovery or recovery with residual effects. This study represents the largest series of North American patients reviewed to date.
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http://dx.doi.org/10.1177/2192568216688189DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400195PMC
April 2017

A Multicenter Study of the Presentation, Treatment, and Outcomes of Cervical Dural Tears.

Global Spine J 2017 Apr 1;7(1 Suppl):58S-63S. Epub 2017 Apr 1.

Johns Hopkins Hospital, Baltimore, MD, USA.

Study Design: Retrospective multicenter case series study.

Objective: Because cervical dural tears are rare, most surgeons have limited experience with this complication. A multicenter study was performed to better understand the presentation, treatment, and outcomes following cervical dural tears.

Methods: Multiple surgeons from 23 institutions retrospectively identified 21 rare complications that occurred between 2005 and 2011, including unintentional cervical dural tears. Demographic data and surgical history were obtained. Clinical outcomes following surgery were assessed, and any reoperations were recorded. Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA), Nurick classification (NuC), and Short-Form 36 (SF36) scores were recorded at baseline and final follow-up at certain centers. All data were collected, collated, and analyzed by a private research organization.

Results: There were 109 cases of cervical dural tears among 18 463 surgeries performed. In 101 cases (93%) there was no clinical sequelae following successful dural tear repair. There were statistical improvements ( < .05) in mJOA and NuC scores, but not NDI or SF36 scores. No specific baseline or operative factors were found to be associated with the occurrence of dural tears. In most cases, no further postoperative treatments of the dural tear were required, while there were 13 patients (12%) that required subsequent treatment of cerebrospinal fluid drainage. Analysis of those requiring further treatments did not identify an optimum treatment strategy for cervical dural tears.

Conclusions: In this multicenter study, we report our findings on the largest reported series (n = 109) of cervical dural tears. In a vast majority of cases, no subsequent interventions were required and no clinical sequelae were observed.
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http://dx.doi.org/10.1177/2192568216688186DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400193PMC
April 2017

Incidence and Outcomes of Acute Implant Extrusion Following Anterior Cervical Spine Surgery.

Global Spine J 2017 Apr 1;7(1 Suppl):40S-45S. Epub 2017 Apr 1.

Cleveland Clinic Foundation, Cleveland, OH, USA.

Study Design: Multi-institutional retrospective case series of 8887 patients who underwent anterior cervical spine surgery.

Objective: Anterior decompression from discectomy or corpectomy is not without risk. Surgical morbidity ranges from 9% to 20% and is likely underreported. Little is known of the incidence and effects of rare complications on functional outcomes following anterior spinal surgery. In this retrospective review, we examined implant extrusions (IEs) following anterior cervical fusion.

Methods: A retrospective multicenter case series study involving 21 high-volume surgical centers from the AOSpine North America Clinical Research Network. Medical records for 17 625 patients who received cervical spine surgery (levels from C2 to C7) between January 1, 2005, and December 31, 2011, were reviewed to identify occurrence of 21 predefined treatment complications.

Results: Following anterior cervical fusion, the incidence of IE ranged from 0.0% to 0.8% across 21 institutions with 11 cases reported. All surgeries involved multiple levels, and 7/11 (64%) involved either multilevel corpectomies or hybrid constructs with at least one adjacent discectomy to a corpectomy. In 7/11 (64%) patients, constructs ended with reconstruction or stabilization at C7. Nine patients required surgery for repair and stabilization following IE. Average length of hospital stay after IE was 5.2 days. Only 2 (18%) had residual deficits after reoperation.

Conclusions: IE is a very rare complication after anterior cervical spine surgery often requiring revision. Constructs requiring multilevel reconstruction, especially at the cervicothoracic junction, have a higher risk for failure, and surgeons should proceed with caution in using an anterior-only approach in these demanding cases. Surgeons can expect most patients to regain function after reoperation.
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http://dx.doi.org/10.1177/2192568216686752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400179PMC
April 2017

Epidemiology and Outcomes of Vertebral Artery Injury in 16 582 Cervical Spine Surgery Patients: An AOSpine North America Multicenter Study.

Global Spine J 2017 Apr 1;7(1 Suppl):21S-27S. Epub 2017 Apr 1.

Columbia University, New York, NY, USA.

Study Design: A multicenter retrospective case series was compiled involving 21 medical institutions. Inclusion criteria included patients who underwent cervical spine surgery between 2005 and 2011 and who sustained a vertebral artery injury (VAI).

Objective: To report the frequency, risk factors, outcomes, and management goals of VAI in patients who have undergone cervical spine surgery.

Methods: Patients were evaluated on the basis of condition-specific functional status using the Neck Disability Index (NDI), modified Japanese Orthopaedic Association (mJOA) score, the Nurick scale, and the 36-Item Short-Form Health Survey (SF-36).

Results: VAIs were identified in a total of 14 of 16 582 patients screened (8.4 per 10 000). The mean age of patients with VAI was 59 years (±10) with a female predominance (78.6%). Patient diagnoses included myelopathy, radiculopathy, cervical instability, and metastatic disease. VAI was associated with substantial blood loss (770 mL), although only 3 cases required transfusion. Of the 14 cases, 7 occurred with an anterior-only approach, 3 cases with posterior-only approach, and 4 during circumferential approach. Fifty percent of cases of VAI with available preoperative imaging revealed anomalous vessel anatomy during postoperative review. Average length of hospital stay was 10 days (±8). Notably, 13 of the 14 (92.86%) cases resolved without residual deficits. Compared to preoperative baseline NDI, Nurick, mJOA, and SF-36 scores for these patients, there were no observed changes after surgery ( = .20-.94).

Conclusions: Vertebral artery injuries are potentially catastrophic complications that can be sustained from anterior or posterior cervical spine approaches. The data from this study suggest that with proper steps to ensure hemostasis, patients recover function at a high rate and do not exhibit residual deficits.
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http://dx.doi.org/10.1177/2192568216686753DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400180PMC
April 2017

Thoracic Duct Injury Following Cervical Spine Surgery: A Multicenter Retrospective Review.

Global Spine J 2017 Apr 1;7(1 Suppl):115S-119S. Epub 2017 Apr 1.

Cleveland Clinic, Cleveland, OH, USA.

Study Design: Multicenter retrospective case series.

Objective: To determine the rate of thoracic duct injury during cervical spine operations.

Methods: A retrospective case series study was conducted among 21 high-volume surgical centers to identify instances of thoracic duct injury during anterior cervical spine surgery. Staff at each center abstracted data for each identified case into case report forms. All case report forms were collected by the AOSpine North America Clinical Research Network Methodological Core for data processing, cleaning, and analysis.

Results: Of a total of 9591 patients reviewed that underwent cervical spine surgery, 2 (0.02%) incurred iatrogenic injury to the thoracic duct. Both patients underwent a left-sided anterior cervical discectomy and fusion. The interruption of the thoracic duct was addressed intraoperatively in one patient with no residual postoperative effects. The second individual developed a chylous fluid collection approximately 2 months after the operation that required drainage via needle aspiration.

Conclusions: Damage to the thoracic duct during cervical spine surgery is a relatively rare occurrence. Rapid identification of the disruption of this lymphatic vessel is critical to minimize deleterious effects of this complication.
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http://dx.doi.org/10.1177/2192568216688194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400197PMC
April 2017

Rare Complications of Cervical Spine Surgery: Pseudomeningocoele.

Global Spine J 2017 Apr 1;7(1 Suppl):109S-114S. Epub 2017 Apr 1.

University of Virginia, Charlottesville, VA, USA.

Study Design: This study was a retrospective, multicenter cohort study.

Objectives: Rare complications of cervical spine surgery are inherently difficult to investigate. Pseudomeningocoele (PMC), an abnormal collection of cerebrospinal fluid that communicates with the subarachnoid space, is one such complication. In order to evaluate and better understand the incidence, presentation, treatment, and outcome of PMC following cervical spine surgery, we conducted a multicenter study to pool our collective experience.

Methods: This study was a retrospective, multicenter cohort study of patients who underwent cervical spine surgery at any level(s) from C2 to C7, inclusive; were over 18 years of age; and experienced a postoperative PMC.

Results: Thirteen patients (0.08%) developed a postoperative PMC, 6 (46.2%) of whom were female. They had an average age of 48.2 years and stayed in hospital a mean of 11.2 days. Three patients were current smokers, 3 previous smokers, 5 had never smoked, and 2 had unknown smoking status. The majority, 10 (76.9%), were associated with posterior surgery, whereas 3 (23.1%) occurred after an anterior procedure. Myelopathy was the most common indication for operations that were complicated by PMC (46%). Seven patients (53%) required a surgical procedure to address the PMC, whereas the remaining 6 were treated conservatively. All PMCs ultimately resolved or were successfully treated with no residual effects.

Conclusions: PMC is a rare complication of cervical surgery with an incidence of less than 0.1%. They prolong hospital stay. PMCs occurred more frequently in association with posterior approaches. Approximately half of PMCs required surgery and all ultimately resolved without residual neurologic or other long-term effects.
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http://dx.doi.org/10.1177/2192568216687769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400191PMC
April 2017

Primary spinal intradural extramedullary lymphoma: A novel management strategy.

J Clin Neurosci 2017 Jan 10;35:122-126. Epub 2016 Nov 10.

Department of Neurological Surgery, University Hospitals, 11100 Euclid Ave, Cleveland, OH 44122, USA. Electronic address:

Primary spinal intradural extramedullary lymphoma remains a very rare entity in spinal oncology. In this case report, we present the first treatment of a PSIEL diagnosed by cytopathologic analysis alone followed by urgent radio- and chemotherapy in the literature. At 18-month follow-up, our patient was ambulatory with near total imaging resolution of the lesion. In conclusion, surgical excision or biopsy may not be necessary when suspicion for PSIEL exists, and may delay prompt medical and radiation treatment due to necessity for wound healing. Further research into the management of extramedullary lymphoma treatment strategies is warranted.
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http://dx.doi.org/10.1016/j.jocn.2016.10.033DOI Listing
January 2017

Computational Modeling and Neuroimaging Techniques for Targeting during Deep Brain Stimulation.

Front Neuroanat 2016 30;10:71. Epub 2016 Jun 30.

Department of Neurosurgery, University Hospitals Case Medical Center, Case Western Reserve University Cleveland, OH, USA.

Accurate surgical localization of the varied targets for deep brain stimulation (DBS) is a process undergoing constant evolution, with increasingly sophisticated techniques to allow for highly precise targeting. However, despite the fastidious placement of electrodes into specific structures within the brain, there is increasing evidence to suggest that the clinical effects of DBS are likely due to the activation of widespread neuronal networks directly and indirectly influenced by the stimulation of a given target. Selective activation of these complex and inter-connected pathways may further improve the outcomes of currently treated diseases by targeting specific fiber tracts responsible for a particular symptom in a patient-specific manner. Moreover, the delivery of such focused stimulation may aid in the discovery of new targets for electrical stimulation to treat additional neurological, psychiatric, and even cognitive disorders. As such, advancements in surgical targeting, computational modeling, engineering designs, and neuroimaging techniques play a critical role in this process. This article reviews the progress of these applications, discussing the importance of target localization for DBS, and the role of computational modeling and novel neuroimaging in improving our understanding of the pathophysiology of diseases, and thus paving the way for improved selective target localization using DBS.
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http://dx.doi.org/10.3389/fnana.2016.00071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4927621PMC
July 2016

A revolution in preventing fatal craniovertebral junction injuries: lessons learned from the Head and Neck Support device in professional auto racing.

J Neurosurg Spine 2016 Dec 12;25(6):756-761. Epub 2016 Jul 12.

Department of Neurosurgery, Case Western Reserve University, MetroHealth Medical Center; and.

Fatal craniovertebral junction (CVJ) injuries were the most common cause of death in high-speed motor sports prior to 2001. Following the death of a mutual friend and race car driver, Patrick Jacquemart (1946-1981), biomechanical engineer Dr. Robert Hubbard, along with race car driver and brother-in-law Jim Downing, developed the concept for the Head and Neck Support (HANS) device to prevent flexion-distraction injuries during high-velocity impact. Biomechanical testing showed that neck shear and loading forces experienced during collisions were 3 times the required amount for a catastrophic injury. Crash sled testing with and without the HANS device elucidated reductions in neck tension, neck compression, head acceleration, and chest acceleration experienced by dummies during high-energy crashes. Simultaneously, motor sports accidents such as Dale Earnhardt Sr.'s fatal crash in 2001 galvanized public opinion in favor of serious safety reform. Analysis of Earnhardt's accident demonstrated that his car's velocity parallel to the barrier was more than 150 miles per hour (mph), with deceleration upon impact of roughly 43 mph in a total of 0.08 seconds. After careful review, several major racing series such as the National Association for Stock Car Auto Racing (NASCAR) and Championship Auto Racing Team (CART) made major changes to ensure the safety of drivers at the turn of the 21st century. Since the rule requiring the HANS device in professional auto racing series was put in place, there has not been a single reported case of a fatal CVJ injury.
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http://dx.doi.org/10.3171/2015.10.SPINE15337DOI Listing
December 2016

Effect of the sonic hedgehog receptor smoothened on the survival and function of dopaminergic neurons.

Exp Neurol 2016 09 15;283(Pt A):235-45. Epub 2016 Jun 15.

Department of Neurological Surgery, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, USA. Electronic address:

Objective: To determine the influence of the sonic hedgehog (shh) pathway and its receptor smoothened (smo), on the survival and functionality of dopaminergic (DA) neurons.

Background: During early development, shh induces the differentiation of DA neurons. However, it is unknown whether shh signaling is required in the maturation or maintenance of DA neurons during later development and adulthood due to the lethality of traditional shh knockout models.

Methods: We utilized the cre-loxP system to achieve late developmental stage and cell type-specific deletion of the shh receptor, smo, in DA neurons by crossing DATcre (dopamine transporter) mice with Smo(loxP/loxP) mice. We assessed for differences between knockout (ko) and wildtype (wt) mice using combined histochemistry, gene expression analysis, and behavioral evaluation. Number and size of DA neurons in ventral midbrain and the DA neural terminal density in striatum were measured using unbiased stereological quantification. The survival of DA neurons under neurotoxin challenge was examined in the unilateral 6-hydroxydopamine (6-OHDA) Parkinson's disease animal model and the more subtle function under challenge of the dopaminergic system was examined by methamphetamine single- and repeated challenge in wt and ko mice.

Results: Tyrosine hydroxylase (TH) positive neuronal counts and neuronal size in substantia nigra (SN) and ventral tegmental area (VTA) showed no difference between wt and DAT-Smo ko mice in young (5months) or aged (22months) mice. There was also no difference in the striatal DA projections between wt and ko mice in both age groups. In unilateral striatal 6-OHDA lesions modeling Parkinson's disease, using stereotaxic injection of 6-OHDA intrastriatally led to loss of dopaminergic neurons in SN and diminished TH positive projections in striatum. However, there was no differences in survival of DA neurons between wt and ko mice. DAT-Smo ko mice demonstrated hyperactivity compared to wt mice at 5months, but showed no difference in activity at 22months. When injected with a one-time bolus of methamphetamine (METH), despite the higher basal locomotion activity, DAT-Smo ko mice showed a diminished response to a single METH challenge. In METH sensitization testing, ko mice showed decreased sensitization compared to wt mice without evidence of a delayed shift in dynamics of sensitization. Gene expression analysis showed decreased gene expression of smo, Gli 1 (known target gene of smo) and BDNF (brain-derived neurotrophic factor) in the SN. Gene expression was not altered in striatum for the genes examined in this study including dopamine receptor genes, neurotropic genes such as Glial cell line-derived neurotrophic factor (GDNF), and bone morphogenetic protein 7 (BMP7).

Conclusion: Our study showed the smo receptor function is not required for the maturation and survival of DA neurons during late development, aging or under stress challenge. However, smo function has an influence on behavior in young adult mice and in responses of mice to a drug that modulates DA neurochemistry through regulation of gene expression in DA neurons. Since young adult DAT-smo ko mice show hyperactivity and altered response to a psychostimulant drug (METH), this may indicate the involvement of the shh pathway in the development of functional changes that manifest as alterations in DA pathway dynamics.
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http://dx.doi.org/10.1016/j.expneurol.2016.06.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5479305PMC
September 2016

Use of a surgical rehearsal platform and improvement in aneurysm clipping measures: results of a prospective, randomized trial.

J Neurosurg 2017 Mar 13;126(3):838-844. Epub 2016 May 13.

Departments of 2 Neurological Surgery and.

OBJECTIVE The field of neurosurgery is constantly undergoing improvements and advances, both in technique and technology. Cerebrovascular neurosurgery is no exception, with endovascular treatments changing the treatment paradigm. Clipping of aneurysms is still necessary, however, and advances are still being made to improve patient outcomes within the microsurgical treatment of aneurysms. Surgical rehearsal platforms are surgical simulators that offer the opportunity to rehearse a procedure prior to entering the operative suite. This study is designed to determine whether use of a surgical rehearsal platform in aneurysm surgery is helpful in decreasing aneurysm dissection time and clip manipulation of the aneurysm. METHODS The authors conducted a blinded, prospective, randomized study comparing key effort and time variables in aneurysm clip ligation surgery with and without preoperative use of the SuRgical Planner (SRP) surgical rehearsal platform. Initially, 40 patients were randomly assigned to either of two groups: one in which surgery was performed after use of the SRP (SRP group) and one in which surgery was performed without use of the SRP (control group). All operations were videotaped. After exclusion of 6 patients from the SRP group and 9 from the control group, a total of 25 surgical cases were analyzed by a reviewer blinded to group assignment. The videos were analyzed for total microsurgical time, number of clips used, and number of clip placement attempts. Means and standard deviations (SDs) were calculated and compared between groups. RESULTS The mean (± SD) amount of operative time per clip used was 920 ± 770 seconds in the SRP group and 1294 ± 678 seconds in the control group (p = 0.05). In addition, the mean values for the number of clip attempts, total operative time, ratio of clip attempts to clips used, and time per clip attempt were all lower in the SRP group, although the between-group differences were not statistically significant. CONCLUSIONS Preoperative rehearsal with SRP increased efficiency and safety in aneurysm microsurgery as demonstrated by the statistically significant improvement in time per clip used. Although the rest of the outcomes did not demonstrate statistically significant between-group differences, the fact that the SRP group showed improvement in mean values for all measures studied suggests that preoperative rehearsal may increase the efficiency and safety of aneurysm microsurgery. Future studies aimed at improving patient outcome and safety during surgical clipping of aneurysms will be needed to keep pace with the quickly advancing endovascular field.
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http://dx.doi.org/10.3171/2016.1.JNS152576DOI Listing
March 2017

Author Response.

Neurology 2015 Dec;85(23):2083

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December 2015

Hippocampal Neurophysiologic Changes after Mild Traumatic Brain Injury and Potential Neuromodulation Treatment Approaches.

Front Syst Neurosci 2016 9;10. Epub 2016 Feb 9.

Department of Neurosurgery, University Hospitals Case Medical Center, Case Western Reserve University Cleveland, OH, USA.

Traumatic brain injury (TBI) is the leading cause of death and disability in individuals below age 45, and five million Americans live with chronic disability as a result. Mild TBI (mTBI), defined as TBI in the absence of major imaging or histopathological defects, is responsible for a majority of cases. Despite the lack of overt morphological defects, victims of mTBI frequently suffer lasting cognitive deficits, memory difficulties, and behavioral disturbances. There is increasing evidence that cognitive and memory dysfunction is related to subtle physiological changes that occur in the hippocampus, and these impact both the phenotype of deficits observed and subsequent recovery. Therapeutic modulation of physiological activity by means of medications commonly used for other indications or brain stimulation may represent novel treatment approaches. This review summarizes the present body of knowledge regarding neurophysiologic changes that occur in the hippocampus after mTBI, as well as potential targets for therapeutic modulation of neurologic activity.
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http://dx.doi.org/10.3389/fnsys.2016.00008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4746250PMC
February 2016
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