Publications by authors named "Joshua Burks"

70 Publications

Treatment-Associated Stroke in Patients Undergoing Endovascular Therapy in the ARUBA Trial.

Stroke 2021 Oct 8:STROKEAHA120033743. Epub 2021 Oct 8.

Department of Neurosurgery, University of Miami, FL.

Background And Purpose: Since the publication of ARUBA trial (A Randomized Trial of Unruptured Brain Arteriovenous Malformations), outcomes in treated and untreated patients with unruptured arteriovenous malformation have been thoroughly compared. However, no prior analysis of ARUBA patients has sought to identify risk factors for perioperative stroke. Improved understanding of risks within the ARUBA cohort will help clinicians apply the study's findings in a broader context.

Methods: The National Institute of Neurological Disorders and Stroke database was queried for all data relating to ARUBA patients, including demographics, interventions undertaken, and timing of stroke. Retrospective cohort analysis was performed with the primary outcome of perioperative stroke in patients who underwent endovascular intervention, and stroke risk was modeled with multivariate analysis.

Results: A total of 64 ARUBA patients were included in the analysis. One hundred and fifty-ninth interventions were performed, and 26 (16%) procedures resulted in stroke within 48 hours of treatment. Posterior cerebral artery supply (adjusted odds ratio, 4.42 [95% CI, 1.23-15.9], =0.02) and Spetzler-Martin grades 2 and 3 arteriovenous malformation (adjusted odds ratio, 7.76 [95% CI, 1.20-50.3], =0.03; 9.64 [95% CI, 1.36-68.4], =0.04, respectively) were associated with increased perioperative stroke risk in patients who underwent endovascular intervention. Patients treated in the United States or Germany had a significantly lower stroke risk than patients treated in other countries (adjusted odds ratio, 0.18 [95% CI, 0.04-0.82], =0.02).

Conclusions: Knowing patient and lesion characteristics that increase risk during endovascular treatment can better guide clinicians managing unruptured brain arteriovenous malformation. Our analysis suggests risk of perioperative stroke is dependent on Spetzler-Martin grade and posterior-circulation arterial supply. Differences in regional treatment paradigms may also affect stroke risk.
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http://dx.doi.org/10.1161/STROKEAHA.120.033743DOI Listing
October 2021

Manual reduction of a radial artery loop under direct fluoroscopic visualization.

BMJ Case Rep 2021 Sep 28;14(9):1-4. Epub 2021 Sep 28.

Neurological Surgery, University of Miami, Miami, Florida, USA.

Transradial access (TRA) has become increasingly utilized in neurointerventions because it reduces access site complications. However, radial artery anomalies can be difficult to navigate, often necessitating conversion to femoral access. We describe the case of a female patient in her early 70s who underwent preoperative embolization of a carotid body tumor via right TRA. Her radial angiogram demonstrated the presence of a radial artery loop which was successfully navigated with a triaxial system but would not spontaneously reduce, even after the guide catheter was advanced into the subclavian artery. However, manual manipulation of the catheters in the antecubital fossa under direct fluoroscopic visualization reduced the loop, allowing the procedure to continue transradially. Although most radial loops can be traversed and reduced using standard techniques, this case demonstrates that manual reduction can be successful when other measures fail. We recommend attempting this method prior to converting the access site.
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http://dx.doi.org/10.1136/bcr-2021-017665DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8479982PMC
September 2021

Fusiform Dilatation of the Internal Carotid Artery in Childhood-Onset Craniopharyngioma- A Systematic Review.

World Neurosurg 2021 Sep 20. Epub 2021 Sep 20.

Department of Neurological Surgery, University of Miami - Miller School of Medicine, c/o Ingrid Menendez, 1095 NW 14 Terrace D4-6, Miami, FL 33136.

Objective: Patients with fusiform dilation of the internal carotid artery (FDCA) following pediatric craniopharyngioma resection typically have a benign clinical course. We sought to review the neurosurgical literature for FDCA outcomes after resection of these tumors.

Methods: Using PubMed, Web of Science, and Cochrane databases we identified surgical series or case reports reporting incidences of FDCA following craniopharyngioma resection. Inclusion criteria included FDCA outcomes reported specifically after craniopharyngioma resection, with at least 6 months of follow-up data.

Results: Our literature search yielded 12 full-text articles. This resulted in a total of 799 patients (376, 52.3% males). The weighted mean follow-up was 74.8 (9-140) months. The majority of tumors were found to be suprasellar (62.1%), with traditional microsurgery being more commonly employed than endoscopic endonasal surgery (80.9% versus 19.1%). Gross total resection was achieved in 42.6% of cases. A total of 55 aneurysms were reported, most commonly occurring at the terminal internal carotid artery (ICA) (66.7%) . Aneurysmal progression on follow-up occurred in 10 (18.5%) cases, with no reports of rupture. A total of 10 (18.2%) of aneurysms were treated with clipping, endovascular, or bypass techniques.

Conclusions: FDCA is a rare complication following pediatric craniopharyngioma resection. The exact cause is unclear, and factors related to tumor invasiveness, size, location, and differences in surgical approach all may contribute to FDCA development. The majority of patients who go on to develop FDCA follow an innocuous course on follow-up, with no reports of rupture in the present literature. For this reason, patients rarely require surgical or endovascular intervention for these lesions, and conservative management is favored.
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http://dx.doi.org/10.1016/j.wneu.2021.09.058DOI Listing
September 2021

Transient ipsilateral mydriasis following carotid artery stenting.

Br J Neurosurg 2021 Sep 23:1-4. Epub 2021 Sep 23.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.

Background And Importance: One of the most feared and devastating complications of carotid revascularization procedures is hyperperfusion hemorrhage. The acute onset of an ipsilateral mydriatic pupil following carotid endarterectomy (CEA) or carotid artery stenting (CAS) should prompt immediate neurosurgical evaluation to rule out hyperperfusion injury.

Clinical Presentation: We describe a case of benign, transient ipsilateral mydriasis following CAS. After undergoing right common and internal carotid artery (ICA) angioplasty and stenting with distal embolic protection, the patient developed anisocoria with a right-sided 5 mm minimally reactive pupil. Imaging demonstrated no acute pathology, and the mydriasis resolved spontaneously within 48 hours. We hypothesise that the pathophysiologic mechanism is secondary to transient ischemia of parasympathetic structures within the petrous/cavernous ICA from arterial ostium occlusion that occurred during device placement. Alternatively, sympathetic stimulation during angioplasty is also plausible.

Conclusions: Although an ipsilateral mydriatic pupil following carotid revascularization necessitates evaluation, it may represent a self-limiting process especially in the absence of other focal neurologic deficits.
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http://dx.doi.org/10.1080/02688697.2021.1981241DOI Listing
September 2021

Dose Adjustment Associated Complications of Bone Morphogenetic Protein: A Longitudinal Assessment.

World Neurosurg 2021 Sep 13. Epub 2021 Sep 13.

Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, Florida, USA. Electronic address:

Objective: Bone morphogenetic protein (BMP) is a growth factor that aids in osteoinduction and promotes bone fusion. There is a lack of literature regarding recombinant human BMP-2 (rhBMP-2) dosage in different spine surgeries. This study aims to investigate the trends in rhBMP-2 dosage and the associated complications in spinal arthrodesis.

Methods: A retrospective study was conducted investigating spinal arthrodesis using rhBMP-2. Variables including age, procedure type, rhBMP-2 size, complications, and postoperative imaging were collected. Cases were grouped into the following surgical procedures: anterior lumbar interbody fusion/extreme lateral interbody fusion (ALIF/XLIF), posterior lumbar interbody fusion/transforaminal lumbar interbody fusion (PLIF/TLIF), posterolateral fusion (PLF), anterior cervical discectomy and fusion (ACDF), and posterior cervical fusion (PCF).

Results: A total of 1209 patients who received rhBMP-2 from 2006 to 2020 were studied. Of these, 230 were categorized as ALIF/XLIF, 336 as PLIF/TLIF, 243 as PLF, 203 as ACDF, and 197 as PCF. PCF (P < 0.001), PLIF/TLIF (P < 0.001), and PLF (P < 0.001) demonstrated a significant decrease in the rhBMP-2 dose used per level, with major transitions seen in 2018, 2011, and 2013, respectively. In our sample, 129 complications following spinal arthrodesis were noted. A significant relation between rhBMP-2 size and complication rates (χ= 73.73, P = 0.0029) was noted. rhBMP-2 dosage per level was a predictor of complication following spinal arthrodesis (odds ratio = 1.302 [1.05-1.55], P < 0.001).

Conclusions: BMP is an effective compound in fusing adjacent spine segments. However, it carries some regional complications. We demonstrate a decreasing trend in the dose/vertebral level. A decrease rhBMP-2 dose per level correlated with a decrease in complication rates.
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http://dx.doi.org/10.1016/j.wneu.2021.08.142DOI Listing
September 2021

Supralesional Ablation Volumes Are Feasible in the Posterior Fossa and May Provide Enhanced Symptomatic Relief.

Oper Neurosurg (Hagerstown) 2021 Sep 15. Epub 2021 Sep 15.

University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA.

Background: Laser interstitial thermal therapy (LITT) for posterior fossa lesions remains rare as the small size of the infratentorial compartment, proximity to the brainstem, and thickness/angulation of the occipital bone creates barriers to procedural success. Furthermore, evaluation of the effect of ablation volume on outcomes is limited.

Objective: To analyze our institutional experience with LITT in the posterior fossa stratifying perioperative and long-term outcomes by ablation volumes.

Methods: Seventeen patients with posterior fossa lesions treated with LITT from 2013 to 2020 were identified. Local progression-free survival (PFS), overall survival, steroid dependence, and edema reduction were evaluated with Kaplan-Meier analysis grouped by ablation volume. Preoperative, postoperative, and last known Karnofsky Performance Status (KPS) were compared using a matched paired t test.

Results: No differences in pathology, preoperative KPS, or preoperative lesion volume were found between patients with total (100%-200% increase in pre-LITT lesion volume) versus radical (>200% increase in pre-LITT lesion volume) ablations. Patients who underwent radical ablation had a higher postoperative KPS (93 vs 82, P = .02) and higher KPS (94 vs 87, P = .04) and greater reduction in perilesional edema at last follow-up (P = .01). Median follow-up was 80.8 wk.

Conclusion: Despite obvious anatomical challenges, our results demonstrate that radical ablations are both feasible and safe in the posterior fossa. Furthermore, radical ablations may lead to greater decreases in perilesional edema and improved functional status both immediately after surgery and at last follow-up. Thus, LITT should be considered for patients with otherwise unresectable or radioresistant posterior fossa lesions.
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http://dx.doi.org/10.1093/ons/opab332DOI Listing
September 2021

Incidence and Clinical Outcomes of Hypothyroidism in Patients Undergoing Spinal Fusion.

Cureus 2021 Aug 11;13(8):e17099. Epub 2021 Aug 11.

Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA.

Background Hypothyroidism has been independently associated with the development of several comorbidities and is known to increase complication rates in non-spinal surgeries. However, there are limited data regarding the effects of hypothyroidism in major spine surgery. Therefore, we present the largest retrospective analysis evaluating outcomes in hypothyroid patients undergoing spinal fusion. Methods A retrospective review of the National Inpatient Sample (NIS) from 2004-2014 was performed. Patients with an International Classification of Diseases, 9th revision, Clinical Modification (ICD-9-CM) procedure code indicating spinal fusion (81.04-81.08, 81.34-81.38, 81.0x, 81.3x) were included. Patients with an ICD-9-CM diagnosis code indicating hypothyroidism (244.x) were compared to those without. Cervical and lumbar fusions were evaluated independently. Significant covariates in univariable logistic regression were utilized to construct multivariable models to analyze the effect of hypothyroidism on perioperative morbidity and mortality. Results A total of 4,149,125 patients were identified, of which 9.4% were hypothyroid. Although, hypothyroid patients had a higher risk of hematologic complications (lumbar - odds ratio [OR] 1.176, p < 0.0001; cervical - OR 1.162, p < 0.0001), they exhibited decreased in-hospital mortality (lumbar - OR .643, p < 0.0001; cervical - OR .606, p < 0.0001). Hypothyroid lumbar fusion patients also demonstrated decreased rates of perioperative myocardial infarction (MI) (OR .851, p < 0.0001). All these results were independent of patient gender. Conclusions Hypothyroid patients undergoing spinal fusion demonstrated lower rates of inpatient mortality and, in lumbar fusions, also had lower rates of acute MI when compared to their euthyroid counterparts. This suggests that hypothyroidism may offer protection against all-cause mortality and may be cardioprotective in the postoperative period for lumbar spinal fusions independent of patient gender.
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http://dx.doi.org/10.7759/cureus.17099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8432424PMC
August 2021

Effect of Hispanic Status in Mechanical Thrombectomy Outcomes After Ischemic Stroke: Insights From STAR.

Stroke 2021 Sep 14:STROKEAHA120033326. Epub 2021 Sep 14.

Department of Neurosurgery, Bon Secours Health System, Greenville, SC (S.W.).

Background And Purpose: Epidemiological studies have shown racial and ethnic minorities to have higher stroke risk and worse outcomes than non-Hispanic Whites. In this cohort study, we analyzed the STAR (Stroke Thrombectomy and Aneurysm Registry) database, a multi-institutional database of patients who underwent mechanical thrombectomy for acute large vessel occlusion stroke to determine the relationship between mechanical thrombectomy outcomes and race.

Methods: Patients who underwent mechanical thrombectomy between January 2017 and May 2020 were analyzed. Data included baseline characteristics, vascular risk factors, complications, and long-term outcomes. Functional outcomes were assessed with respect to Hispanic status delineated as non-Hispanic White (NHW), non-Hispanic Black (NHB), or Hispanic patients. Multivariate analysis was performed to identify variables associated with unfavorable outcome or modified Rankin Scale ≥3 at 90 days.

Results: Records of 2115 patients from the registry were analyzed. Median age of Hispanic patients undergoing mechanical thrombectomy was 60 years (72-84), compared with 63 years (54-74) for NHB, and 71 years (60-80) for NHW patients (<0.001). Hispanic patients had a higher incidence of diabetes (41%; <0.001) and hypertension (82%; <0.001) compared with NHW and NHB patients. Median procedure time was shorter in Hispanics (36 minutes) compared to NHB (39 minutes) and NHW (44 minutes) patients (<0.001). In multivariate analysis, Hispanic patients were less likely to have favorable outcome (odds ratio, 0.502 [95% CI, 0.263-0.959]), controlling for other significant predictors (age, admission National Institutes Health Stroke Scale, onset to groin time, number of attempts, procedure time).

Conclusions: Hispanic patients are less likely to have favorable outcome at 90 days following mechanical thrombectomy compared to NHW or NHB patients. Further prospective studies are required to validate our findings.
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http://dx.doi.org/10.1161/STROKEAHA.120.033326DOI Listing
September 2021

Medical Adjuvants in the Treatment of Surgically Refractory Arteriovenous Malformations of the Head and Face: Case Report and Review of Literature.

Cerebrovasc Dis 2021 1;50(5):493-499. Epub 2021 Jul 1.

Department of Neurological Surgery,University of Miami Miller School of Medicine, Miami, Florida, USA.

Background: Arteriovenous malformations (AVMs) of the brain and face present unique challenges for clinicians. Cerebral AVMs may induce hemorrhage or form aneurysms, while facial AVMs can cause significant disfigurement and pain. Moreover, facial AVMs often draw blood supply from arteries providing critical blood flow to other important structures of the head which may make them impossible to treat curatively. Medical adjuvants may be an important consideration in the management of these patients.

Summary: We conducted a systematic review of the literature to identify other instances of molecular target of rapamycin (mTOR) inhibitors used as medical adjuvants for the treatment of cranial and facial AVMs. We also present 2 cases from our own institution where patients were treated with partial embolization, followed by adjuvant therapy with rapamycin. After screening a total of 75 articles, 7 were identified which described use of rapamycin in the treatment of inoperable cranial or facial AVM. In total, 21 cases were reviewed. The median treatment duration was 12 months (3-24.5 months), and the highest recorded dose was 3.5 mg/m2. 76.2% of patients demonstrated at least a partial response to rapamycin therapy. In 2 patients treated at our institution, symptomatic and radiographic improvement were noted 6 months after initiation of therapy. Key Messages: Early results have been encouraging in a small number of patients with inoperable AVM of the head and face treated with mTOR inhibitors. Further study of medical adjuvants such as rapamycin may be worthwhile.
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http://dx.doi.org/10.1159/000515168DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8440490PMC
July 2021

Perioperative Complications in Endoscopic Endonasal versus Transcranial Resections of Adult Craniopharyngiomas.

World Neurosurg 2021 Aug 18;152:e729-e737. Epub 2021 Jun 18.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA; Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, Florida, USA. Electronic address:

Background: Adult craniopharyngiomas are low-grade tumors of the pituitary infundibulum that can be locally aggressive and frequently present with profound visual deficits and endocrinopathies. Surgical resection remains the preferred initial treatment for these lesions, and recently endoscopic endonasal approaches (EEAs) have become increasingly used. However, minimal data exist comparing these techniques with traditional transcranial (TC) methods. The purpose of this study was to evaluate perioperative differences in EEA and TC approaches for adult craniopharyngiomas over the past several decades.

Methods: Craniopharyngioma surgeries in the Nationwide Inpatient Sample from 1998 to 2014 were identified. Complication rates, mortality rates, and annual treatment trends were stratified by procedure. Annual caseload was assessed with linear regression, and multivariate logistic regression models were created to determine predictors of inpatient mortality and perioperative complications.

Results: From 1998-2014, a significant increase in EEAs for craniopharyngiomas (+4.36/year, r = 0.80, P < 0.0001) was observed. In contrast, no increase in TC surgeries for these lesions was seen. In multivariate analysis, EEAs were more likely to experience postoperative cerebrospinal fluid leak (odds ratio = 2.61, P < 0.0001). However, EEAs were protective against all other perioperative complications including diabetes insipidus, panhypopituitarism, visual impairment, and even mortality (odds ratio = 0.41, P = 0.0007).

Conclusions: Over the past several decades, utilization of EEAs to resect adult craniopharyngiomas has increased. EEAs appear to be associated with lower rates of perioperative mortality and complications. However, long-term, prospective studies controlling for tumor size, location, and preoperative symptomatology are needed to determine when one approach should be used preferentially over the other.
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http://dx.doi.org/10.1016/j.wneu.2021.06.066DOI Listing
August 2021

Vertebral multiple myeloma with pathological fracture: the most common etiology for emergency spine surgery in patients with no cancer diagnosis on admission.

Neurosurg Focus 2021 05;50(5):E2

Objective: Vertebral compression fractures are common in multiple myeloma (MM). Modern treatment paradigms place emphasis on treatment with radiation, with surgery reserved for cases involving frank instability or severe neural compression. However, experience at the authors' institution has led them to suspect a more prominent role for surgical intervention in some settings. The authors undertook the present study to better understand the incidence of MM in undiagnosed patients who require urgent surgery for pathological vertebral fracture.

Methods: The authors reviewed a prospectively collected database of all patients who underwent surgery with the senior author at their main hospital between June 1, 1998, and June 30, 2020. Patients admitted from the emergency room or after transfer from another hospital who then underwent surgery for pathological fracture during the same admission were included in the final analysis. Patients scheduled for elective surgery and those with previous cancer diagnoses were excluded.

Results: Forty-three patients were identified as having undergone urgent surgical decompression and/or stabilization for pathological fracture. Histopathology confirmed diagnosis of MM in 22 (51%) patients, lung metastasis in 5 (12%) patients, and breast metastasis in 4 (9%) patients. Twelve (28%) patients were diagnosed with other types of metastatic carcinoma or undifferentiated disease. Sixteen of 29 (55%) men and 6 of 14 (42%) women were diagnosed with MM (p = 0.02). Seventeen of 34 (50%) patients who underwent surgery for neurological deficit, 5 of 6 (83%) patients who underwent surgery for spinal instability, and 0 (0%) patients who underwent surgery for pain with impending spinal cord injury were diagnosed with MM (p = 0.12).

Conclusions: A majority of patients presenting to the authors' hospital with no history of malignancy who required urgent surgery for pathological compression fracture were found to have MM or plasmacytoma. This disease process may affect a significant portion of patients requiring decompressive or stabilizing surgery for compression fracture in academic medical centers.
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http://dx.doi.org/10.3171/2021.2.FOCUS201038DOI Listing
May 2021

The Focused Neurosurgical Examination During Telehealth Visits: Guidelines During the COVID-19 Pandemic and Beyond.

Cureus 2021 Feb 23;13(2):e13503. Epub 2021 Feb 23.

Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA.

Objective:  To provide guidelines to healthcare workers for performing a focused neurological examination via telemedicine during the coronavirus disease-2019 (COVID-2019) pandemic.

Methods:  We reviewed our department's outpatient clinic visits after the implementation of a telemedicine protocol in response to the COVID-19 crisis. Crossover rates from telehealth to in-person visits were evaluated and guidelines for performing a telemedicine neurological exam were created based on the consensus of 16 neurosurgical attending providers over a four-month period.

Results:  From March 23, 2020 to July 20, 2020, some 2157 telehealth visits were performed in our department. Some 26 were converted to in-person visits by the provider request with the most cited reason for conversion being the need for a more detailed patient evaluation. Based on these experiences, we created a graphical tutorial to address the key components of the neurological exam with adaptations specific to the telehealth visit.

Conclusions:  In response to the global coronavirus pandemic, telemedicine has become an integral part of neurosurgeons' daily practice. Telemedicine failures remain low but primarily occur due to a need for more comprehensive evaluations. We provide guidelines for the neurosurgical exam during telehealth visits in an effort to assuage some of these issues.
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http://dx.doi.org/10.7759/cureus.13503DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7992292PMC
February 2021

In Reply to the Letter to the Editor Regarding "Safety Analysis of Bilateral Laser Interstitial Thermal Therapy for Treatment of Butterfly Glioma".

World Neurosurg 2021 03;147:238

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

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http://dx.doi.org/10.1016/j.wneu.2020.12.011DOI Listing
March 2021

In Reply to the Letter to the Editor Regarding "Early Changes to Neurosurgery Resident Training During the COVID-19 Pandemic at a Large United States Academic Medical Center".

World Neurosurg 2021 02;146:423

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

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http://dx.doi.org/10.1016/j.wneu.2020.11.095DOI Listing
February 2021

Upper extremity transvenous access for neuroendovascular procedures: an international multicenter case series.

J Neurointerv Surg 2021 Apr 16;13(4):357-362. Epub 2021 Feb 16.

Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

Background: Radial artery access for transarterial procedures has gained recent traction in neurointerventional due to decreased patient morbidity, technical feasibility, and improved patient satisfaction. Upper extremity transvenous access (UETV) has recently emerged as an alternative strategy for the neurointerventionalist, but data are limited. Our objective was to quantify the use of UETV access in neurointerventions and to measure failure and complication rates.

Methods: An international multicenter retrospective review of medical records for patients undergoing UETV neurointerventions or diagnostic procedures was performed. We also present our institutional protocol for obtaining UETV and review the existing literature.

Results: One hundred and thirteen patients underwent a total of 147 attempted UETV procedures at 13 centers. The most common site of entry was the right basilic vein. There were 21 repeat puncture events into the same vein following the primary diagnostic procedure for secondary interventional procedures without difficulty. There were two minor complications (1.4%) and five failures (ie, conversion to femoral vein access) (3.4%).

Conclusions: UETV is safe and technically feasible for diagnostic and neurointerventional procedures. Further studies are needed to determine the benefit over alternative venous access sites and the effect on patient satisfaction.
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http://dx.doi.org/10.1136/neurintsurg-2020-017102DOI Listing
April 2021

Neuro-oncology practice guidelines from a high-volume surgeon at the COVID-19 epicenter.

J Clin Neurosci 2021 Mar 16;85:1-5. Epub 2020 Dec 16.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.

Background: During the coronavirus 19 (COVID-19) pandemic, physicians have begun adapting their daily practices to prevent transmissions. In this study we aimed to provide surgical neuro-oncologists with practice guidelines during the COVID-19 pandemic based on objective data from a high-volume brain tumor surgeon at the current COVID-19 epicenter.

Methods: All outpatient visits and surgeries performed by the senior author during the COVID-19 pandemic were compared between the initial quarantine (3/23/20-5/4/20), the plateau period following quarantine (5/5/20-6/27/20), and the second peak (6/28/20-7/20/20). In-person and telemedicine visits were evaluated for crossovers. Surgeries were subdivided based on lesion type and evaluated across the same time period.

Results: From 3/23/20-7/20/20, 469 clinic visits and 196 surgeries were identified. After quarantine was lifted, face-to-face visits increased (P < 0.01) yet no change in telehealth visits occurred. Of 327 telehealth visits, only 5.8% converted to in-person during the 4-month period with the most cited reason being patient preference (68.4%). Of the 196 surgeries performed during the pandemic, 29.1% occurred during quarantine, 49.0% during the plateau, and 21.9% occurred in the second peak. No COVID negative patients developed symptoms at follow-up. 55.6% were performed on malignant tumors and 31.6% were benign with no difference in case volumes throughout the pandemic.

Conclusions: Despite exceptional challenges, we have maintained a high-volume surgical neuro-oncology practice at the epicenter of the COVID-19 pandemic. We provide the protocols implemented at our institution in order to maximize neuro-oncology care while mitigating risk of COVID-19 exposure to both patients and providers.
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http://dx.doi.org/10.1016/j.jocn.2020.12.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7834482PMC
March 2021

Navigating radial artery loops in neurointerventions.

J Neurointerv Surg 2020 Dec 21. Epub 2020 Dec 21.

Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA.

Background: Although studies continue to demonstrate lower complications in neurointerventions using transradial access (TRA) compared with transfemoral approaches, anatomic radial variants can be difficult to navigate and remain one of the frequent causes of access site conversion.

Objective: To evaluate predictors of TRA failure in neuroendovascular patients with radial loops and suggest a protocol for managing these anomalies.

Methods: A prospective collection of patients undergoing TRA at participating institutions from July 2018 to September 2020 was reviewed. Patients with a radial loop were identified. Patient demographics and procedural characteristics were evaluated to determine predictors of both TRA failure and successful reduction of the radial loop.

Results: We identified 32 transradial neurointerventions in which patients had radial loops. Twenty-two (68.8%) were identified by diagnostic angiography, and the majority were performed for evaluation or treatment of an aneurysm (56.3%). TRA failure occurred in 13 (40.6%) of the cohort and happened more frequently in patients over 60 years of age (p=0.01) and those with recurrent radial artery diameters ≤2 mm (p=0.02). Of the 19 patients who had successful TRA, 12 (63.2%) procedures were performed through the recurrent radial artery.

Conclusion: Although radial loops are associated with high transradial failure rates, our results suggest that the presence of a loop is not an absolute contraindication to TRA. Therefore, we recommend attempting loop navigation using our protocol. Patient age, vascular tortuosity, and recurrent radial artery size should help dictate when to convert to an alternative access site.
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http://dx.doi.org/10.1136/neurintsurg-2020-016856DOI Listing
December 2020

Early Changes to Neurosurgery Resident Training During the COVID-19 Pandemic at a Large U.S. Academic Medical Center.

World Neurosurg 2020 12 28;144:e926-e933. Epub 2020 Sep 28.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

Background: The coronavirus disease 2019 pandemic has led to sweeping changes in residency programs across the world, including cancellation of elective cases. The effects of safety measures on neurosurgical training remain unclear. To understand how neurosurgical residents have been affected, we analyzed the operative experience in the months leading up to and during the pandemic.

Methods: The resident and institutional case totals were tallied for a single residency program in Miami-Dade County from January 1, 2019 to June 30, 2020. A matched cohort analysis was performed before and during the pandemic to assess the effects on resident surgical training.

Results: The case totals for all levels of training were lower when restrictions were placed on elective surgeries. An average of 11 cases was logged in April 2020, a decrease from 26 cases in April 2019 (95% confidence interval, 8.7-22; P < 0.01). An average of 20 cases was logged in May 2020, a decrease from 25 cases in May 2019 (95% confidence interval, 1.2-8.8; P = 0.01). In April and May 2020, 299 (66%) and 148 (50%) fewer cases had been performed at our institution compared with April and May 2109.

Conclusions: Operative experience was reduced for residents during the months when the performance of elective cases was restricted. Our data suggest experience in some areas of neurosurgery were more affected than were others, and residents at different levels of training were also affected differently. However, the extent of the coronavirus disease 2019 pandemic on neurosurgical training is unlikely to be understood in the short term.
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http://dx.doi.org/10.1016/j.wneu.2020.09.125DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7521299PMC
December 2020

Implementation of a radial long sheath protocol for radial artery spasm reduces access site conversions in neurointerventions.

J Neurointerv Surg 2021 Jun 25;13(6):547-551. Epub 2020 Aug 25.

Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA.

Background: Many neurointerventionalists have transitioned to transradial access (TRA) as the preferred approach for neurointerventions as studies continue to demonstrate fewer access site complications than transfemoral access. However, radial artery spasm (RAS) remains one of the most commonly cited reasons for access site conversions. We discuss the benefits, techniques, and indications for using the long radial sheath in RAS and present our experience after implementing a protocol for routine use.

Methods: A retrospective review of all patients undergoing neurointerventions via TRA at our institution from July 2018 to April 2020 was performed. In November 2019, we implemented a long radial sheath protocol to address RAS. Patient demographics, RAS rates, radial artery diameter, and access site conversions were compared before and after the introduction of the protocol.

Results: 747 diagnostic cerebral angiograms and neurointerventional procedures in which TRA was attempted as the primary access site were identified; 247 were performed after the introduction of the long radial sheath protocol. No significant differences in age, gender, procedure type, sheath sizes, and radial artery diameter were seen between the two cohorts. Radial anomalies and small radial diameters were more frequently seen in patients with RAS. Patients with clinically significant RAS more often required access site conversion (p<0.0001), and in our multivariable model use of the long sheath was the only covariate protective against radial failure (OR 0.061, 95% CI 0.007 to 0.517; p=0.0103).

Conclusion: In our experience, we have found that the use of long radial sheaths significantly reduces the need for access site conversions in patients with RAS during cerebral angiography and neurointerventions.
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http://dx.doi.org/10.1136/neurintsurg-2020-016564DOI Listing
June 2021

Bilateral Transradial Access for Complex Posterior Circulation Interventions.

World Neurosurg 2020 07 16;139:101-105. Epub 2020 Apr 16.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, USA.

Background: Transradial access (TRA) has recently gained traction as the preferred approach in a variety of neurointerventions after studies have demonstrated equivalent outcomes with fewer complications than transfemoral access (TFA). However, multiple access sites are occasionally necessary when simultaneous selective catheterization of 2 vessels is required. We present the first cases detailing bilateral TRA for complex posterior circulation interventions.

Case Descriptions: All neuroendovascular cases in which bilateral TRA was obtained at the University of Miami/Jackson Health System were reviewed. Two patients, each with complex left vertebral artery aneurysms, were identified. In each case, bilateral TRA was chosen because 1) left vertebral artery catheterization via right TRA can be technically challenging; 2) simultaneous catheterization of both vertebral arteries was felt to be necessary; 3) prior angiograms had demonstrated that the subclavian arteries would provide the most direct, anatomically feasible access route; and 4) the primary surgeon preferred to avoid TFA. Right TRA and left distal transradial access via the anatomic snuffbox were obtained in both cases to allow both arms to sit on the operator side of the table. Neither patient experienced any perioperative complications.

Conclusions: Bilateral TRA can be an effective method for catheterizing both vertebral arteries during complex posterior circulation interventions and obviates the need for TFA when multiple arterial access sites are required. Furthermore, distal transradial access allows the left hand to remain more anatomically neutral while being positioned on the right side of the table so that both access sites remain ergonomically favorable for the interventionalist.
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http://dx.doi.org/10.1016/j.wneu.2020.03.221DOI Listing
July 2020

Radical Laser Interstitial Thermal Therapy Ablation Volumes Increase Progression-Free Survival in Biopsy-Proven Radiation Necrosis.

World Neurosurg 2020 Apr 27;136:e646-e659. Epub 2020 Jan 27.

University of Miami Miller School of Medicine, Department of Neurological Surgery, Miami, Florida, USA; Sylvester Comprehensive Cancer Center, University of Miami Health System, Miami, Florida, USA.

Background: Treatment for surgically inaccessible medically refractory cerebral radiation necrosis (RN) has remained limited. Recently, laser interstitial thermal therapy (LITT) has gained traction as an effective means of treating these lesions but limited data are available regarding the effect of ablation size on patient outcome. Therefore, this study analyzed various outcome measures as a function of ablation volume/diameter for a series of 20 patients with surgically inaccessible biopsy-proven RN.

Methods: Twenty patients with biopsy-proven RN treated with LITT from 2013 to 2018 at our institution were retrospectively reviewed. Local progression-free survival (PFS), overall survival, and steroid dependence were analyzed with Kaplan-Meier and Cox regression analysis for ablation volume/diameter. Comparison of preoperative and postoperative Karnofsky Performance Status was conducted with a matched paired t test.

Results: Patients with subtotal ablation (<100% increase in pre-LITT lesion volume or <0 mm increase in pre-LITT lesion diameter) had higher risk of local disease progression (hazard ratio, 12.4; P = 0.004) compared with patients with total ablations. Patients who received radical ablations (>200% increase in pre-LITT lesion volume or >2 mm increase in pre-LITT lesion diameter) showed the most favorable PFS (P < 0.0458 and P < 0.0378, respectively). There was no difference in post-LITT Karnofsky Performance Status and time to steroid freedom between ablation groups. Overall survival increased with radical diametric ablation (P = 0.0401).

Conclusions: Although LITT has proved to be an effective salvage therapy for patients with RN, detailed volumetric studies have not been explored. Our results suggest that radical ablations have the potential to increase PFS.
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http://dx.doi.org/10.1016/j.wneu.2020.01.116DOI Listing
April 2020

Parcellation-based tractographic modeling of the ventral attention network.

J Neurol Sci 2020 Jan 24;408:116548. Epub 2019 Oct 24.

Center for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, Australia. Electronic address:

Introduction: The ventral attention network (VAN) is an important mediator of stimulus-driven attention. Multiple cortical areas, such as the middle and inferior frontal gyri, anterior insula, inferior parietal lobule, and temporo-parietal junction have been linked in this processing. However, knowledge of network connectivity has been devoid of structural specificity.

Methods: Using relevant task-based fMRI studies, an activation likelihood estimation (ALE) of the VAN was generated Regions of interest corresponding to the HCP cortical parcellation scheme were co-registered onto this ALE in MNI coordinate space and visually assessed for inclusion in the network. DSI-based fiber tractography was performed to determine the structural connections between cortical areas comprising the VAN.

Results: Fourteen regions within the right cerebral hemisphere were found to overlap the ALE of the VAN: 6a, 6r, 7AM, 7PM, 8C, AVI, FOP4, MIP, p9-46v, PCV, PFm, PGi, TPOJ1, and TPOJ2. Regions demonstrated consistent U-shaped interconnections between adjacent parcellations, and the SLF was found to connect frontal and parietal areas of the network.

Conclusions: We present a tractographic model of the VAN. This model comprises parcellations within the frontal and parietal cortices that are linked via the SLF. Future studies may refine this model with the ultimate goal of clinical application.
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http://dx.doi.org/10.1016/j.jns.2019.116548DOI Listing
January 2020

Parcellation-based tractographic modeling of the dorsal attention network.

Brain Behav 2019 10 19;9(10):e01365. Epub 2019 Sep 19.

Center for Minimally Invasive Neurosurgery, Prince of Wales Private Hospital, Sydney, NSW, Australia.

Introduction: The dorsal attention network (DAN) is an important mediator of goal-directed attentional processing. Multiple cortical areas, such as the frontal eye fields, intraparietal sulcus, superior parietal lobule, and visual cortex, have been linked in this processing. However, knowledge of network connectivity has been devoid of structural specificity.

Methods: Using attention-related task-based fMRI studies, an anatomic likelihood estimation (ALE) of the DAN was generated. Regions of interest corresponding to the cortical parcellation scheme previously published under the Human Connectome Project were co-registered onto the ALE in MNI coordinate space and visually assessed for inclusion in the network. DSI-based fiber tractography was performed to determine the structural connections between relevant cortical areas comprising the network.

Results: Twelve cortical regions were found to be part of the DAN: 6a, 7AM, 7PC, AIP, FEF, LIPd, LIPv, MST, MT, PH, V4t, VIP. All regions demonstrated consistent u-shaped interconnections between adjacent parcellations. The superior longitudinal fasciculus connects the frontal, parietal, and occipital areas of the network.

Conclusions: We present a tractographic model of the DAN. This model comprises parcellations within the frontal, parietal, and occipital cortices principally linked through the superior longitudinal fasciculus. Future studies may refine this model with the ultimate goal of clinical application.
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http://dx.doi.org/10.1002/brb3.1365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6790316PMC
October 2019

Neuro-Behcet Disease Mimicking Lymphoma of the Brain and Coexisting with A Dural Arteriovenous Fistula: A Case Report.

World Neurosurg 2020 Jan 13;133:205-211. Epub 2019 Sep 13.

Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA.

Background: Diverse clinical manifestations have characterized reports of central nervous system involvement in Behcet disease. There is a limited number of published case reports of neuro-Behcet disease mimicking brain tumor.

Case Description: We present a rare case of neuro-Behcet disease exhibiting mixed systemic and neurological symptoms mimicking malignant lymphoma. Delayed presentation of oral aphthae and rapid improvement of symptoms with steroid treatment led to a diagnosis of neuro-Behcet disease without brain biopsy. The patient also underwent surgery for the resection of an arterio-venous fistula.

Conclusions: We recommend management of neuro-Behcet disease based on perceived natural history risks, with the understanding that no data exist on this within patients population. A multidisciplinary team approach is always recommended because neuro-Behcet disease is an uncommon condition, especially in neurosurgical practice.
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http://dx.doi.org/10.1016/j.wneu.2019.09.035DOI Listing
January 2020

Short-term safety of tranexamic acid use in posterior cervical decompression and fusion surgery.

J Clin Neurosci 2019 Aug 30;66:41-44. Epub 2019 May 30.

Department of Orthopaedic Surgery, University of Miami Miller School of Medicine, Miami, FL, USA.

Posterior cervical decompression and fusion (PCDF) can result in substantial blood loss, leading to blood transfusions and associated complications, such as infections, hypotension and organ damage. The antifibrinolytic tranexamic acid (TXA), an inhibitor of the activation of plasminogen, has been shown to be beneficial in multiple surgical procedures without any apparent increase in postoperative complications. However, there are only few studies reporting TXA utilization in cervical spine surgery and there is currently no literature detailing the short-term safety of its use in this setting. The purpose of our study is to determine the safety profile of TXA in posterior cervical decompression and fusion. From January 2015 to April 2018, 47 patients were identified to have undergone PCDF, 19 with the utilization of a TXA protocol at our institution. The incidence of adverse events was evaluated in the perioperative period and at 1 month follow-up. Of 39 patients, Nineteen (49%) received TXA as per our instructional protocol and 20 (51%) did not. Post-operative blood was significantly reduced (453 ml vs 701 ml; p = 0.03) in the group that received TXA. There was also a significant reduction in duration of surgery associated with TXA use (269 min vs 328 min; p = 0.05). There were no complications on the first 30 days after surgical intervention on the TXA group. TXA use during PCDF is a safe, effective method to reduce postoperative blood loss. Considering the limited number of patients in this study, these results should be validated on a larger group of patients.
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http://dx.doi.org/10.1016/j.jocn.2019.05.029DOI Listing
August 2019

Imaging characteristics of chronic spinal cord injury identified during screening for a cell transplantation clinical trial.

Neurosurg Focus 2019 03;46(3):E8

Departments of1Neurological Surgery.

OBJECTIVEIn cell transplantation trials for spinal cord injury (SCI), quantifiable imaging criteria that serve as inclusion criteria are important in trial design. The authors' institutional experience has demonstrated an overall high rate of screen failures. The authors examined the causes for trial exclusion in a phase I, open-lab clinical trial examining the role of autologous Schwann cell intramedullary transplantation. Specifically, they reviewed the imaging characteristics in people with chronic SCI that excluded applicants from the trial, as this was a common cause of screening failures in their study.METHODSThe authors reviewed MRI records from 152 people with chronic (> 1 year) SCI who volunteered for intralesional Schwann cell transplantation but were deemed ineligible by prospectively defined criteria. Rostral-caudal injury lesion length was measured along the long axis of the spinal cord in the sagittal plane on T2-weighted MRI. Other lesion characteristics, specifically those pertaining to lesion cavity structure resulting in trial exclusion, were recorded.RESULTSImaging records from 152 potential participants with chronic SCI were reviewed, 42 with thoracic-level SCI and 110 with cervical-level SCI. Twenty-three individuals (55%) with thoracic SCI and 70 (64%) with cervical SCI were not enrolled in the trial based on imaging characteristics. For potential participants with thoracic injuries who did not meet the screening criteria for enrollment, the average rostral-caudal sagittal lesion length was 50 mm (SD 41 mm). In applicants with cervical injuries who did not meet the screening criteria for enrollment, the average sagittal lesion length was 34 mm (SD 21 mm).CONCLUSIONSWhile screening people with SCI for participation in a cell transplantation clinical trial, lesion length or volume can exclude potential subjects who appear appropriate candidates based on neurological eligibility criteria. In planning future cell-based therapy trials, the limitations incurred by lesion size should be considered early due to the screening burden and impact on candidate selection.
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http://dx.doi.org/10.3171/2018.12.FOCUS18593DOI Listing
March 2019

A Connectomic Atlas of the Human Cerebrum-Chapter 5: The Insula and Opercular Cortex.

Oper Neurosurg (Hagerstown) 2018 12;15(suppl_1):S175-S244

Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

In this supplement, we build on work previously published under the Human Connectome Project. Specifically, we show a comprehensive anatomic atlas of the human cerebrum demonstrating all 180 distinct regions comprising the cerebral cortex. The location, functional connectivity, and structural connectivity of these regions are outlined, and where possible a discussion is included of the functional significance of these areas. In part 5, we specifically address regions relevant to the insula and opercular cortex.
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http://dx.doi.org/10.1093/ons/opy259DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6924540PMC
December 2018

A Connectomic Atlas of the Human Cerebrum-Chapter 12: Tractographic Description of the Middle Longitudinal Fasciculus.

Oper Neurosurg (Hagerstown) 2018 12;15(suppl_1):S429-S435

Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

The middle longitudinal fasciculus (MdLF) is a small and somewhat controversial white matter tract of the human cerebrum, confined to the posterior superior temporal region from which it courses posteriorly to connect at the occipital-parietal interface. The tract appears to be involved in language processing as well as auditory organization and localization, while sub-serving other higher level cognitive functions that have yet to be fully elucidated. Little is known about the specific, interparcellation connections that integrate to form the MdLF. Utilizing diffusion spectrum magnetic resonance imaging tractography coupled with the human cortex parcellation data presented earlier in this supplement, we aim to describe the macro-connectome of the MdLF in relation to the linked parcellations present within the human cortex. The purpose of this study is to present this information in an indexed, illustrated, and tractographically aided series of figures and tables for anatomic and clinical reference.
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http://dx.doi.org/10.1093/ons/opy266DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887674PMC
December 2018

A Connectomic Atlas of the Human Cerebrum-Chapter 6: The Temporal Lobe.

Oper Neurosurg (Hagerstown) 2018 12;15(suppl_1):S245-S294

Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

In this supplement, we build on work previously published under the Human Connectome Project. Specifically, we show a comprehensive anatomic atlas of the human cerebrum demonstrating all 180 distinct regions comprising the cerebral cortex. The location, functional connectivity, and structural connectivity of these regions are outlined, and where possible a discussion is included of the functional significance of these areas. In part 6, we specifically address regions relevant to the temporal lobe.
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http://dx.doi.org/10.1093/ons/opy260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887748PMC
December 2018

A Connectomic Atlas of the Human Cerebrum-Chapter 3: The Motor, Premotor, and Sensory Cortices.

Oper Neurosurg (Hagerstown) 2018 12;15(suppl_1):S75-S121

Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma.

In this supplement, we build on work previously published under the Human Connectome Project. Specifically, we show a comprehensive anatomic atlas of the human cerebrum demonstrating all 180 distinct regions comprising the cerebral cortex. The location, functional connectivity, and structural connectivity of these regions are outlined, and where possible a discussion is included of the functional significance of these areas. In part 3, we specifically address regions relevant to the sensorimotor cortices.
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http://dx.doi.org/10.1093/ons/opy256DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6887944PMC
December 2018
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