Publications by authors named "Karim ReFaey"

39 Publications

The benefits of inferolateral transtubercular route on intradural surgical exposure using the endoscopic endonasal transclival approach.

Acta Neurochir (Wien) 2021 Apr 13. Epub 2021 Apr 13.

Department of Neurosurgery, Microsurgical Neuroanatomy Laboratory, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey.

Background: Surgical access to the ventral pontomedullary junction (PMJ) can be achieved through various corridors depending on the location and extension of the lesion. The jugular tubercle (JT), a surgically challenging obstacle to access the PMJ, typically needs to be addressed in transcranial exposures. We describe the endoscopic endonasal transclival approach (EETCA) and its inferolateral transtubercular extension to assess the intradural surgical field gained through JT removal. We also complement the dissections with an illustrative case.

Methods: EETCA was surgically simulated, and the anatomical landmarks were assessed in eight cadaveric heads. Microsurgical dissections were additionally performed along the endoscopic surgical path. Lastly, we present an intraoperative video of the trans-JT approach in a patient with lower clival chordoma.

Results: The EETCA allowed adequate extracranial visualization and removal of the JT. The surgical bony window-obtained along the clivus and centered at the JT via the EETCA-measured 11 × 9 × 7 mm. Removal of the JT provided an improved intradural field within the lower third of the cerebellopontine cistern to expose an area bordered by the cranial nerves VII/VIII and flocculus superior and anterior margin of the lateral recess of the fourth ventricle and cranial nerves IX-XI inferiorly, centered on the foramen of Luschka.

Conclusions: Removal of the JT via EETCA improves exposure along the lower third of the cerebellopontine and upper cerebellomedullary cisterns. The inferolateral transtubercular extension of the EETCA provides access to the lateral recess of the fourth ventricle, in combination with the ventral midline pontomedullary region.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00701-021-04835-xDOI Listing
April 2021

Reduced Pain and Opioid Use in the Early Postoperative Period in Patients Undergoing a Frontotemporal Craniotomy under Regional vs General Anesthesia.

World Neurosurg 2021 Mar 5. Epub 2021 Mar 5.

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA.

Introduction: This study compares the postsurgical course of frontotemporal craniotomies conducted "awake" under regional anesthesia (RA) versus "asleep" under general anesthesia (GA) to investigate postoperative recovery, pain, opioid use, and anesthesia-related side effects.

Methods: We retrospectively reviewed craniotomies for supratentorial, intra-axial tumors with frontotemporal exposure. Chronic opioid use and emergent cases were excluded. Primary outcomes included pain scores on a 0-10 numerical rating scale, opioid use as oral morphine milligram equivalence, first time to opioid use, nausea, and sedation on the Richmond Agitation and Sedation Scale (RASS). Secondary outcomes included postoperative seizures, Karnofsky Performance Scale (KPS) status, and hospital length of stay (LOS).

Results: A total of 91 patients met inclusion criteria: 56 underwent a craniotomy under RA versus 35 under GA. Demographics and operative characteristics were similar between cohorts. A significant reduction in both postoperative pain and opioid use was observed among RA versus GA (first postoperative pain score 2 vs. 5, P < 0.01; postoperative day [POD] 0 median pain score 2.5 vs. 4, P < 0.01; POD 0 mean opioid in mg 14.49 vs. 24.43, P < 0.01). The time until patients requested opioids for pain after surgery was prolonged for RA versus GA [mean 7.23 vs. 3.42 hours, P < 0.01). Somnolence (RASS < 0) on POD 0 was significantly reduced among RA versus GA, with 23% versus 43%. Both cohorts had equivocal postsurgical outcomes such as seizures, KPS, and hospital LOS.

Conclusions: Frontotemporal craniotomy under RA during awake craniotomies provides better pain control, a reduction in opioid use, and less somnolence in the early postoperative period.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2021.02.009DOI Listing
March 2021

Impact of Anesthetic Variation in Endovascular Treatment of Acute Ischemic Stroke.

Cureus 2020 Nov 4;12(11):e11328. Epub 2020 Nov 4.

Neurological Surgery, Carolina Neurosurgery and Spine Associates, Charlotte, USA.

Background Given recent technological advancements leading to better outcomes in endovascular therapy for acute ischemic stroke (AIS), updated guidelines recommend thrombectomy as the standard of care in acute large vessel occlusions. However, use of general anesthesia versus conscious sedation continues to be discussed. Two previous randomized trials have shown no significant difference between the use of conscious sedation compared with general anesthesia. Methods The authors performed a retrospective analysis of all consecutive patients with acute ischemia who underwent intra-arterial thrombectomy between September 2014 and May 2020 at a Level 1 stroke center. Patient characteristics along with clinical and operative data were extracted. Frequency distributions of selected characteristics were obtained and statistical significance of any differences according to the mode of anesthesia was assessed. Results A total of 480 patients were included in this study, 257 underwent general anesthesia and 223 underwent conscious sedation. Length of stay (LOS) in the ICU nor length of hospital stay was significantly different between groups. Change in National Institutes of Health Stroke Scale (NIHSS) score from admission to discharge, procedure times, and discharge disposition were not found to be significantly associated with either group although there was a trend towards longer door to puncture time with general anesthesia. Discharge disposition was found to be significantly associated with admission NIHSS (p=0.04). There was a trend towards longer hospital stay in patients with worse admission NIHSS (p=0.09). Success of thrombectomy was not significantly different between both anesthesia groups (p=0.37). Conclusions This large, single-center retrospective cohort study echoes the results of two previous randomized controlled trials in demonstrating non-inferiority of general anesthesia versus conscious sedation in cases of intra-arterial thrombectomy for AIS. These results contrast those of previously published retrospective studies.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7759/cureus.11328DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7719469PMC
November 2020

Concussion in soccer: a comprehensive review of the literature.

Concussion 2020 Jul 1;5(3):CNC76. Epub 2020 Jul 1.

Department of Neurosurgery, University of Alabama at Birmingham, 1813 6th Ave S #516, Birmingham, AL 35233, USA.

Sports-related concussion has been examined extensively in collision sports such as football and hockey. However, historically, lower-risk contact sports such as soccer have only more recently garnered increased attention. Here, we review articles examining the epidemiology, injury mechanisms, sex differences, as well as the neurochemical, neurostructural and neurocognitive changes associated with soccer-related concussion. From 436 titles and abstracts, 121 full texts were reviewed with a total of 64 articles identified for inclusion. Concussion rates are higher during competitions and in female athletes with purposeful heading rarely resulting in concussion. Given a lack of high-level studies examining sports-related concussion in soccer, clinicians and scientists must focus research efforts on large-scale data gathering and development of improved technologies to better detect and understand concussion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2217/cnc-2020-0004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7506470PMC
July 2020

A microfluidic cell-migration assay for the prediction of progression-free survival and recurrence time of patients with glioblastoma.

Nat Biomed Eng 2021 01 28;5(1):26-40. Epub 2020 Sep 28.

Department of Chemical and Biomolecular Engineering, Johns Hopkins University, Baltimore, MD, USA.

Clinical scores, molecular markers and cellular phenotypes have been used to predict the clinical outcomes of patients with glioblastoma. However, their clinical use has been hampered by confounders such as patient co-morbidities, by the tumoral heterogeneity of molecular and cellular markers, and by the complexity and cost of high-throughput single-cell analysis. Here, we show that a microfluidic assay for the quantification of cell migration and proliferation can categorize patients with glioblastoma according to progression-free survival. We quantified with a composite score the ability of primary glioblastoma cells to proliferate (via the protein biomarker Ki-67) and to squeeze through microfluidic channels, mimicking aspects of the tight perivascular conduits and white-matter tracts in brain parenchyma. The assay retrospectively categorized 28 patients according to progression-free survival (short-term or long-term) with an accuracy of 86%, predicted time to recurrence and correctly categorized five additional patients on the basis of survival prospectively. RNA sequencing of the highly motile cells revealed differentially expressed genes that correlated with poor prognosis. Our findings suggest that cell-migration and proliferation levels can predict patient-specific clinical outcomes.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41551-020-00621-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7855796PMC
January 2021

Neurosurgical Interactive Teaching Series: Multidisciplinary Educational Approach.

World Neurosurg 2020 Dec 18;144:e766-e773. Epub 2020 Sep 18.

Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA. Electronic address:

Objective: The goal of this manuscript is to investigate the effects of a multidisciplinary multinational web-based teaching conference on trainee education, research, and patient care.

Methods: We present the structure, case selection, and presentation of our educational lectures. We retrospectively reviewed our database to gather data on the number of presentations, type of presentation, and the pathology diagnosis from November 11, 2016 until February 28, 2020. To investigate attendee satisfaction, we analyzed our yearly continuing medical education evaluation survey results to report the impact that this series may have had on our attendees. We assigned a numeric value to the answers, and the mean overall scores were compared through an analysis of variance. Further analysis on specific questions was performed with a Fisher exact test.

Results: We have hosted 150 lectures, in which we have presented 208 neurosurgical cases corresponding to 133 general session, 59 pituitary, and 16 spine cases, as well as 28 distinct lectures by guest speakers from institutions across the globe. We received 61 responses to our yearly continuing medical education evaluations over the course of 3 years. On these evaluations, we have maintained an excellent overall rating from 2017-2019 (two-sided P > 0.05) and received significantly less suggestions to improve the series comparing 2017 with 2019 (two-sided, P= 0.04).

Conclusions: As the world of medicine is constantly changing, we are in need of developing new tools to enhance our ability to relay knowledge through accredited and validated methods onto physicians in training, such as the implementation of structured, multidisciplinary, case-based lectures as presented in this manuscript.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2020.09.074DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7500337PMC
December 2020

Inflammatory Mediators in Glioma Microenvironment Play a Dual Role in Gliomagenesis and Mesenchymal Stem Cell Homing: Implication for Cellular Therapy.

Mayo Clin Proc Innov Qual Outcomes 2020 Aug 5;4(4):443-459. Epub 2020 Aug 5.

Department of Neurosurgery, Mayo Clinic, Jacksonville, FL.

Glioblastoma is the most aggressive malignant primary brain tumor, with a dismal prognosis and a devastating overall survival. Despite aggressive surgical resection and adjuvant treatment, average survival remains approximately 14.6 months. The brain tumor microenvironment is heterogeneous, comprising multiple populations of tumor, stromal, and immune cells. Tumor cells evade the immune system by suppressing several immune functions to enable survival. Gliomas release immunosuppressive and tumor-supportive soluble factors into the microenvironment, leading to accelerated cancer proliferation, invasion, and immune escape. Mesenchymal stem cells (MSCs) isolated from bone marrow, adipose tissue, or umbilical cord are a promising tool for cell-based therapies. One crucial mechanism mediating the therapeutic outcomes often seen in MSC application is their tropism to sites of injury. Furthermore, MSCs interact with host immune cells to regulate the inflammatory response, and data points to the possibility of using MSCs to achieve immunomodulation in solid tumors. Interleukin 1β, interleukin 6, tumor necrosis factor α, transforming growth factor β, and stromal cell-derived factor 1 are notably up-regulated in glioblastoma and dually promote immune and MSC trafficking. Mesenchymal stem cells have widely been regarded as hypoimmunogenic, enabling this cell-based administration across major histocompatibility barriers. In this review, we will highlight (1) the bidirectional communication of glioma cells and tumor-associated immune cells, (2) the inflammatory mediators enabling leukocytes and transplantable MSC migration, and (3) review preclinical and human clinical trials using MSCs as delivery vehicles. Mesenchymal stem cells possess innate abilities to migrate great distances, cross the blood-brain barrier, and communicate with surrounding cells, all of which make them desirable "Trojan horses" for brain cancer therapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.mayocpiqo.2020.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7411162PMC
August 2020

Potential differences between monolingual and bilingual patients in approach and outcome after awake brain surgery.

J Neurooncol 2020 Jul 10;148(3):587-598. Epub 2020 Jun 10.

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA.

Introduction: 20.8% of the United States population and 67% of the European population speak two or more languages. Intraoperative different languages, mapping, and localization are crucial. This investigation aims to address three questions between BL and ML patients: (1) Are there differences in complications (i.e. seizures) and DECS techniques during intra-operative brain mapping? (2) Is EOR different? and (3) Are there differences in the recovery pattern post-surgery?

Methods: Data from 56 patients that underwent left-sided awake craniotomy for tumors infiltrating possible dominant hemisphere language areas from September 2016 to June 2019 were identified and analyzed in this study; 14 BL and 42 ML control patients. Patient demographics, education level, and the age of language acquisition were documented and evaluated. fMRI was performed on all participants.

Results: 0 (0%) BL and 3 (7%) ML experienced intraoperative seizures (P = 0.73). BL patients received a higher direct DECS current in comparison to the ML patients (average = 4.7, 3.8, respectively, P = 0.03). The extent of resection was higher in ML patients in comparison to the BL patients (80.9 vs. 64.8, respectively, P = 0.04). The post-operative KPS scores were higher in BL patients in comparison to ML patients (84.3, 77.4, respectively, P = 0.03). BL showed lower drop in post-operative KPS in comparison to ML patients (- 4.3, - 8.7, respectively, P = 0.03).

Conclusion: We show that BL patients have a lower incidence of intra-operative seizures, lower EOR, higher post-operative KPS and tolerate higher DECS current, in comparison to ML patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11060-020-03554-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7968692PMC
July 2020

The reliability of Deep Brain Stimulation YouTube videos.

J Clin Neurosci 2020 Apr 21;74:202-204. Epub 2020 Feb 21.

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA. Electronic address:

Background: Deep Brain Stimulation (DBS) was approved by the FDA in the 1990s and is used to treat a variety of movement disorders. Patients are increasingly turning to the internet for information regarding their ailments. In this study, we aim to evaluate the accuracy and reliability of information presented in DBS-related YouTube videos.

Methods: Using the "Relevance-Based Ranking" strategy for analysis we assessed the first 3 pages of YouTube for each of the following keywords: "Deep Brain Stimulation", "DBS", "DBS for Parkinson's disease", "DBS for essential tremor", and "DBS for movement disorders". Four independent healthcare personnel evaluated the videos' education quality and informational material using the validated DISCERN tool.

Results: Our study found that only 24% of the 42 published videos analyzed scored above a 3 on the DISCERN scoring scale (considered a "good" video). The search term "Deep Brain Stimulation" had the highest percentage of good videos (DISCERN > 3) (32%). We also found that the duration of videos was longer for the "good" videos (Good = 25.6 min vs Unhelpful = 3.0 min, P = 0.01).

Conclusion: YouTube is one of the largest video platforms; the uploaded videos lack reliability and institutional oversight by the experts. We believe that medical institutions should explore this way of communicating to patients by publishing evidence-based and informative videos on diseases and their management. As it is imperative that the medical field advance to combat medical misinformation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2020.02.015DOI Listing
April 2020

Investigation and Feasibility of Combined 3D Printed Thermoplastic Filament and Polymeric Foam to Simulate the Cortiocancellous Interface of Human Vertebrae.

Sci Rep 2020 02 19;10(1):2912. Epub 2020 Feb 19.

Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, FL, USA.

Disorders of the spine are among the most common indications for neurosurgical and orthopedic surgical interventions. Spinal fixation in the form of pedicle screw placement is a common form of instrumentation method in the lower cervical, thoracic, and lumbar spine. A vital principle to understand for the safe and accurate placement of pedicle screws is the palpable difference between the cortical and cancellous bone, both of which have different material properties and compositions. Probing and palpation of the hard cortical bone, also known as the "ventral lamina", covering the neural elements of the spinal canal during screw placement provides manual feedback to the surgeon, indicating an impending breach if continued directional force is applied. Generally, this practice is learned at the expense of patients in live operating room scenarios. Currently, there is a paucity of human vertebra simulation designs that have been validated based on the in vivo ultrastructure and physical properties of human cortical and cancellous bone. In this study, we examined the feasibility of combining three-dimensionally printed thermoplastic polymers with polymeric foam to replicate both the vertebral corticocancellous interface and surface anatomy for procedural education.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41598-020-59993-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7031368PMC
February 2020

Detection of after-discharges during intraoperative functional brain mapping in awake brain tumor surgery using a novel high-density circular grid.

Clin Neurophysiol 2020 04 30;131(4):828-835. Epub 2020 Jan 30.

Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA. Electronic address:

Objective: To evaluate intraoperative use of a novel high-density circular grid in detecting after-discharges (AD) on electrocorticography (ECoG) during functional brain mapping (FBM).

Methods: FBM during glioma surgery (10/2016 to 5/2019) recorded ADs using a 22-channel circular grid compared to conventional strip electrodes. ADs were analyzed for detection, duration, amplitude, morphology, histology, direction, and clinical signs.

Results: Thirty-two patients (mean age 54.2 years; r = 30-75) with glioma (WHO grade II-IV; 20 grade IV) had surgery. ADs during FBM were more likely in patients with wild-type as opposed to IDH-1 mutants (p < 0.0001) using more contacts compared with linear strip electrodes (p = 0.0001). More sensors tended to be involved in ADs detected by the circular grid vs strips (6.61 vs 3.43; p = 0.16) at lower stimulus intensity (3.14 mA vs 4.13 mA; p = 0.09). No difference in the number of cortical stimulations before resection was present (38.9 mA vs 47.9 mA; p = 0.26). ADs longer than 10 seconds were 32.5 seconds (circular grid) vs 58.4 (strips) (p = 0.12).

Conclusions: High-density circular grids detect ADs in 360 degrees during FBM for glioma resection. Provocation of ADs was more likely in patients with wild-type than IDH-1 mutation.

Significance: Circular grids offer high-resolution ECoG during intraoperative FBM for detection of ADs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clinph.2019.12.416DOI Listing
April 2020

Ex vivo virtual and 3D printing methods for evaluating an anatomy-based spinal instrumentation technique for the 12th thoracic vertebra.

Clin Anat 2020 Apr 25;33(3):458-467. Epub 2020 Jan 25.

Department of Neurosurgery, Mayo Clinic Health Systems, Eau Claire, Wisconsin.

Introduction: Three-dimensional printing and virtual simulation both provide useful methods of patient-specific anatomical modeling for assessing and validating surgical techniques. A combination of these two methods for evaluating the feasibility of spinal instrumentation techniques based on anatomical landmarks has not previously been investigated.

Materials And Methods: Nineteen anonymized CT scans of the thoracic spine in adult patients were acquired. Maximum pedicle width and height were recorded, and statistical analysis demonstrated normal distributions. The images were converted into standard tessellation language (STL) files, and the T12 vertebrae were anatomically segmented. The intersection of two diagonal lines drawn from the lateral and medial borders of the T12 transverse process (TP) to the lateral border of the pars and inferolateral portion of the TP was identified on both sides of each segmented vertebra. A virtual screw was created and insertion into the pedicle on each side was simulated using the proposed landmarks. The vertebral STL files were then 3D-printed, and 38 pedicles were instrumented according to the individual posterior landmarks used in the virtual investigation.

Results: There were no pedicle breaches using the proposed anatomical landmarks for insertion of T12 pedicle screws in the virtual simulation component. The technique was further validated by additive manufacturing of individual T12 vertebrae and demonstrated no breaches or model failures during live instrumentation using the proposed landmarks.

Conclusions: Ex vivo modeling through virtual simulation and 3D printing provides a powerful and cost-effective means of replicating vital anatomical structures for investigation of complex surgical techniques.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ca.23562DOI Listing
April 2020

Iatrogenic Lumbar Arachnoid Cyst Fenestration for Tethered Cord: 2-Dimensional Operative Video.

World Neurosurg 2020 Mar 12;135:130. Epub 2019 Dec 12.

Department of Neurological Surgery, Mayo Clinic Florida, Jacksonville, FL.

Iatrogenic lumbar arachnoid cysts are a rare occurrence after intradural surgery. To our knowledge, there is only 1 other previous case reported in the literature contributing to a symptomatic tethered cord. We present a surgical video (Video 1) demonstrating the history, preoperative workup, and operative technique for exploration and fenestration of a symptomatic iatrogenic lumbar arachnoid cyst with a tethered cord. The patient is a 57-year-old female with a history of a closed neural tube defect with a lipoma that was resected over 20 years before her evaluation. She was lost to follow-up and did not retain any previous medical documentation. She complained of a 2-month history of progressive bilateral lower extremity weakness, leg pain, and worsening of chronic urinary incontinence. Imaging demonstrated a cystic lesion compressing her conus and cauda equina at the L3-4 level. The risks, benefits, and alternatives were discussed, and the patient elected to proceed with surgery. Intraoperative findings demonstrated a complex multiloculated arachnoid cyst with tethering of the conus. The cysts were dissected from the conus and fenestrated, allowing spontaneous flow of cerebrospinal fluid and conus pulsations. Biopsy of the cyst wall confirmed the diagnosis of arachnoid cyst without neoplastic tissue. Due to the presence of multiple loculations, primary pial closure could not be performed. Thus, a circumferential detethering of the conus was performed to ensure complete decompression of the neural elements. Postoperatively, the patient demonstrated improvement in her bilateral lower extremity pain and weakness. Magnetic resonance imaging was scheduled during routine follow-up at 3 months.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.12.025DOI Listing
March 2020

Video-Assisted Bilateral Thoracoscopic Sympathotomy for Palmar Hyperhidrosis.

World Neurosurg 2019 Dec 13;132:333. Epub 2019 Sep 13.

Department of Neurological Surgery, Mayo Clinic, Jacksonville, Florida, USA. Electronic address:

In this video, we demonstrate a case of a 21-year-old right-handed man who presented with palmar hyperhidrosis. His symptoms started at the age of 4 years and progressively worsened throughout his life. Multiple medical treatments were used without significant benefit. His symptoms worsened to the limit that it affected his work and lifestyle. The patient was taken to the operating room in a supine position with both arms abducted 90°. The right and left chest were prepped and draped in a sterile fashion. The skin incision was done on the left side first, the left lung was isolated, and two 5-mm thoracoports were placed in the sixth and third intercostal spaces, respectively. Carbon dioxide insufflation was used to a pressure of 6 mm Hg for exposure. The chest was visualized, and the sympathetic chain was identified. Ribs were counted and then cautery at a low setting was used. The sympathetic chain was transected at the level of the head of the second rib. Accessory nerves of Kuntz were identified and resected. Carbon dioxide was then evacuated from the left chest using a bronchial tube exchanger and Valsalva maneuver. The lung was completely reinflated and skin was closed in a normal fashion. The same procedure was repeated on the right side. A chest radiograph was obtained intraoperatively, and no pneumothorax was observed. At the end of the procedure, both upper extremity temperature probes showed a significant increase from baseline. Informed patient consent was obtained.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.09.036DOI Listing
December 2019

The Eye of Horus: The Connection Between Art, Medicine, and Mythology in Ancient Egypt.

Cureus 2019 May 23;11(5):e4731. Epub 2019 May 23.

Neurosurgery, Mayo Clinic, Jacksonville, USA.

Ancient Egyptian civilization is one of the oldest cultures in human history. Ancient Egyptians are well-known for pioneering the fields of art, medicine, and the documentation of discoveries as mythological tales. The Egyptians mastered the integration of anatomy and mythology into artistic symbols and figures. The mythology of Isis, Osiris, and Horus is arguably one of the most recognized mythologies in ancient Egypt. The Eye of Horus was used as a sign of prosperity and protection, derived from the myth of Isis and Osiris. This symbol has an astonishing connection between neuroanatomical structure and function. Artistically, the Eye is comprised of six different parts. From the mythological standpoint, each part of the Eye is considered to be an individual symbol. Additionally, parts of the Eye represent terms in the series 1/2, 1/4, 1/8, 1/16, and 1/32; when this image is superimposed upon a sagittal image of the human brain, it appears that each part corresponds to the anatomic location of a particular human sensorium. In this manuscript, we highlight the possible scientific speculation of the ingenuity of ancient Egyptians' remarkable insight into human anatomy and physiology.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7759/cureus.4731DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6649877PMC
May 2019

Mysterious Civilizations: Is There a Connection between Medicine and Architecture in Ancient Egypt and Peru?

Cureus 2019 Apr 30;11(4):e4576. Epub 2019 Apr 30.

Neurosurgery, Mayo Clinic, Jacksonville, USA.

The ancient Egyptian and Peruvian Civilizations are two of the earliest cultures in human history. Through medical and architectural similarities, we wish to show a possible connection between these two cultures. A literature search was conducted by searching the database of Medline, National Geographic magazine, history books, and Google Scholar using the search terms: neurosurgery, pyramids, pyramidal architectures, ancient Egypt, ancient Peru, the connection between ancient Egypt and Peru. Both the ancient Egyptian and Peruvian Civilizations are well-known for their pioneering work in medicine and architecture; their accomplishments in these areas have been well-documented in the walls of uncovered tombs and discovered papyrus. Both these cultures also firmly believed in an afterlife and built pyramids to serve as tombs and homes for royalty in the afterlife. The sloping sides of the pyramids were inclined to signify the emergence of the physical body from Earth towards the Sun. Both civilizations independently pioneered the art of neurosurgery with different techniques and approaches. In this paper, we discuss the potential links between both civilizations. We recognize and appreciate the brilliance of these ancient cultures in mastering the medicinal and architectural sciences.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.7759/cureus.4576DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6605966PMC
April 2019

A 360° electronic device for recording high-resolution intraoperative electrocorticography of the brain during awake craniotomy.

J Neurosurg 2019 Jul 5:1-8. Epub 2019 Jul 5.

Departments of1Neurosurgery and.

Objective: Epilepsy is common among patients with supratentorial brain tumors; approximately 40%-70% of patients with glioma develop brain tumor-related epilepsy (BTRE). Intraoperative localization of the epileptogenic zone during surgical tumor resection (real-time data) may improve intervention techniques in patients with lesional epilepsy, including BTRE. Accurate localization of the epileptogenic signals requires electrodes with high-density spatial organization that must be placed on the cortical surface during surgery. The authors investigated a 360° high-density ring-shaped cortical electrode assembly device, called the "circular grid," that allows for simultaneous tumor resection and real-time electrophysiology data recording from the brain surface.

Methods: The authors collected data from 99 patients who underwent awake craniotomy from January 2008 to December 2018 (29 patients with the circular grid and 70 patients with strip electrodes), of whom 50 patients were matched-pair analyzed (25 patients with the circular grid and 25 patients with strip electrodes). Multiple variables were then retrospectively assessed to determine if utilization of this device provides more accurate real-time data and improves patient outcomes.

Results: Matched-pair analysis showed higher extent of resection (p = 0.03) and a shorter transient motor recovery period during the hospitalization course (by approximately 6.6 days, p ≤ 0.05) in the circular grid patients. Postoperative versus preoperative Karnofsky Performance Scale (KPS) score difference/drop was greater for the strip electrode patients (p = 0.007). No significant difference in postoperative seizures between the 2 groups was present (p = 0.80).

Conclusions: The circular grid is a safe, feasible tool that grants direct access to the cortical surgical surface for tissue resection while simultaneously monitoring electrical activity. Application of the circular grid to different brain pathologies may improve intraoperative epileptogenic detection accuracy and functional outcomes, while decreasing postoperative complications.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.4.JNS19261DOI Listing
July 2019

Development of a Novel 3D Printed Phantom for Teaching Neurosurgical Trainees the Freehand Technique of C2 Laminar Screw Placement.

World Neurosurg 2019 Sep 14;129:e812-e820. Epub 2019 Jun 14.

Department of Neurosurgery, Mayo Clinic, Jacksonville, Florida, USA.

Background: 3D printed models have grown in popularity for resident training. Currently there is a paucity of simulators specifically designed for advanced cervical instrumentation. Our institution created a unique simulator for the instruction of freehand placement of C2 laminar screws using a specific 3-dimensional printing technique to replicate the corticocancellous interface. This study was designed to determine the efficacy of the simulator for teaching neurosurgical residents the freehand technique of C2 laminar screw placement.

Methods: Ten participants with different experience levels participated in the study. The participants were separated into 2 groups based on experience level. Primary outcome assessments were breach rates, screw-screw interaction, and the ability to successfully place 2 screws in 1 model. Participants were graded based on a performance scoring system, and the outcomes of the 2 groups were compared.

Results: All participants in the novice group showed improved technical ability on repeated use of the simulator and were able to successfully place bilateral screws by the fourth attempt. Statistical analysis indicated an association between operative experience level and successful bilateral screw placement, implying that the simulator accurately represented an in vivo intraoperative scenario.

Conclusions: By utilizing our novel 3D printing production method, we have created a unique simulator for the freehand placement of C2 laminar screws. To our knowledge, this is the first report of a study investigating the use of a 3-dimensional printed simulator specifically designed to teach the freehand placement of C2 laminar screws to neurosurgical trainees.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.06.038DOI Listing
September 2019

Periodic focal epileptiform discharges.

Clin Neurophysiol 2019 08 31;130(8):1320-1328. Epub 2019 May 31.

Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA.

Objective: To report intraoperative periodic focal epileptiform discharges (PFEDs) during awake craniotomy using high-density electrocorticography (HD-ECoG).

Methods: We retrospectively analyzed 81 patients undergoing awake craniotomy between 9/29/2016 and 7/5/2018. Intraoperative HD-ECoG was performed with direct electrocortical stimulation (DECS) for functional brain mapping. Real-time interpretation was performed and compared to scalp EEG when performed. Perioperative seizures, surgical complications, and characteristics of PFEDs were assessed.

Results: 69/81 patients (mean age 48.5 years) underwent awake surgery; 55 operated for brain tumor, 11 for epilepsy and 3 for cavernomas. A focal abnormality on brain MRI was present in 63/69 (91.3%) patients. 43/69 (62.3%) patients had seizures preoperatively, 4/69 (5.7%) had seizures during DECS. PFEDs were identified in 11 patients (15.9%); 2 on depth recording and 9 during intraoperative HD-ECoG. 32 patients (46.3%) had preoperative EEG. HD-ECoG detected more epileptiform discharges (EDs) than standard EEG (32/43; 74.4% vs 9/32; 28.1%) (p = <0.001). Of 9/43 patients with PFEDs on HD-ECoG, 7 patients also had scalp EEG but only one case had EDs (p = 0.02), and 0/32 had periodic EDs.

Conclusions: Intraoperative PFEDs are novel, highly focal EDs approximating a single gyrus. In patients with brain tumors, PFEDs did not demonstrate a relationship to pre-operative seizures though has similarities to other common waveforms in patients with epilepsy.

Significance: PFEDs expand our understanding of the interictal-ictal continuum and highlight improved temporo-spatial information obtained from increasing sensor density during intracranial EEG recording.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.clinph.2019.04.718DOI Listing
August 2019

Potential influence of IDH1 mutation and MGMT gene promoter methylation on glioma-related preoperative seizures and postoperative seizure control.

Seizure 2019 Jul 20;69:283-289. Epub 2019 May 20.

Department of Pathology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, United States. Electronic address:

Purpose: To examine the occurrence of glioma-related preoperative seizures (GPS) and post-operative seizure control (PSC) with respect to patients characteristics including five commonly tested tumor molecular markers (TMMs).

Methods: A single-center retrospective cohort study of patients with glioma evaluated at the Mayo Clinic, Florida between 2016 and 2018.

Results: 68 adult patients (mean age = 51-years, 45-males) were included. 46 patients had GPS. 57 patients underwent intra-operative electrocorticography during awake craniotomy-assisted glioma resection. All patients underwent glioma resection (53, gross-total resection) with histologies of pilocytic astrocytoma (n = 2), diffuse astrocytoma (n = 4), oligodendroglioma (n = 14), anaplastic astrocytoma (n = 16), anaplastic oligodendroglioma (n = 1), and glioblastoma (n = 31). 31 (67%) patients had PSC (median follow-up = 14.5 months; IQR = 7-16.5 months). IDH1 mutation (IDH1) was present in 32, ARTX retention in 53, MGMT gene promotor methylation in 15, 1p/19q co-deletion in 15, and over-expression of p53 in 19 patients. Patients with IDH1 were more likely to have GPS (p = 0.037) and PSC (p = 0.035) compared to patients with IDH1 wild-type. Patients with MGMT gene promoter methylation were also likely to have PSC (p = 0.032). GPS or PSC did not differ by age, sex, extent of surgery, glioma grade, location, and histopathological subtype, p53 expression, ARTX retention, or 1p/19q co-deletion status.

Conclusions: GPS and PSC may be associated with IDH1 mutation and MGMT gene promoter methylation status but not other glioma characteristics including tumor grade, location, or histopathology. Prospective studies with larger sample size are needed to clarify the exact mechanisms of GPS and PSC by the various TMMs to identify new treatment targets.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.seizure.2019.05.018DOI Listing
July 2019

Medial Temporal Encephalocele and Medically Intractable Epilepsy: A Tailored Inferior Temporal Lobectomy and Case Report.

Oper Neurosurg (Hagerstown) 2020 01;18(1):E19-E22

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

Background And Importance: Temporal lobe encephaloceles are increasingly recognized as a potential cause of medically refractory epilepsy and surgical treatment has proven effective. Resection of the encephalocele and associated cortex is often sufficient to provide seizure control. However, it is difficult to determine the extent of adjacent temporal lobe that should be resected. We present a case report and our technique of a tailored inferior temporal pole resection.

Clinical Presentation: A 32-yr-old man with an 11-yr history of medically refractory epilepsy. Prolonged electroencephalography (EEG) revealed frequent left and rare right frontotemporal sharp waves. Numerous seizures were captured with EEG, all of which originated from the left temporal region. Statistical parametric mapping (SPM) subtraction ictal-interictal SPECT coregistered with magnetic resonance imaging (MRI) (SISCOM) demonstrated ictal hyperperfusion in the anterior left temporal lobe. MRI showed 2 encephaloceles in the left anterior temporal lobe with the accompanying bony defects in the floor of the middle cranial fossa apparent on the computed tomography scan. The patient underwent left temporal craniotomy with intraoperative electrocorticography, resection of the encephaloceles, and a tailored inferior temporal lobectomy (IFTL) and repair of the middle fossa defects. At 7 mo follow up he reported seizure-freedom since surgery.

Conclusion: Resection of temporal encephalocele and adjacent cortex is safe and effective procedure for select patients with medically refractory epilepsy. This video demonstrates our technique which provides a more standardized approach to the resection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ons/opz098DOI Listing
January 2020

A curious case of DBS radiofrequency programmer interference.

NPJ Parkinsons Dis 2019 1;5. Epub 2019 Feb 1.

1Department of Neurological Surgery, Mayo Clinic, Jacksonville, FL USA.

Deep brain stimulation (DBS) systems frequently rely on radiofrequency (RF) transmission for patient programming. The potential exists for other devices to interfere with communication between the internal pulse generator (IPG) and the programming device. In this paper, we are reporting a case of programming interference between the IPG and the WaveID device.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1038/s41531-019-0075-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6358610PMC
February 2019

The Reliability of YouTube Videos Describing Stereotactic Radiosurgery: A Call for Action.

World Neurosurg 2019 05 28;125:e398-e402. Epub 2019 Jan 28.

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA; Department of Radiation Oncology, Mayo Clinic, Jacksonville, Florida, USA.

Background: Gamma Knife radiosurgery was introduced in the 1960s and is currently used worldwide. The internet has become a foremost source of information used by patients and their families. In this study, we aim to evaluate the accuracy and reliability of the Gamma Knife radiosurgery-related YouTube videos.

Methods: We searched YouTube and the first 3 pages sorted according to "Relevance-Based Ranking" were included for analysis. Four independent health care workers from different disciplines evaluated the videos using the validated DISCERN tool.

Results: Our search resulted in 65,774 videos, and 14 videos met inclusion criteria. Our study found that 50% (7 of 14) of the videos were uploaded by university-affiliated hospitals; 14% of videos scored 3. The search term "Radiosurgery for intraaxial brain lesions" had the highest percentage of moderate videos (DISCERN = 3) (50%).

Conclusions: Patients and caregivers turn to online sources to gather information about the disease. However, the available YouTube published videos are published without proper academic monitoring, as in such a free platform, published videos tend to catch a general audience for different purposes, which leads to diminishing quality control. Academic medical institutions should consider a proper monitoring process for videos to improve the accuracy of the published information for the patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2019.01.086DOI Listing
May 2019

Prognostic factors and survival in low grade gliomas of the spinal cord: A population-based analysis from 2006 to 2012.

J Clin Neurosci 2019 Mar 6;61:14-21. Epub 2018 Dec 6.

Department of Neurosurgery, Mayo Clinic, Jacksonville, FL, USA. Electronic address:

Purpose: Primary spinal cord tumors are rare, and evidence-based management of these patients remains a source of controversy. This study used a large cohort of low-grade spinal cord astrocytomas to determine the effectiveness of prognostic factors and survival.

Methods: The Surveillance, Epidemiology, and End Results (SEER) cancer registry was used to identify patients with WHO grade I-II primary spinal cord astrocytomas from 1973 to 2012; however, patients before 2006 were excluded due to ambiguity diagnosis. Univariate and multivariate Cox proportional hazard models were created to compare survival across covariates and summarized using the Kaplan-Meier method.

Results: A total of 561 patients with low-grade glioma (astrocytoma) were identified. Among these, 15.5% of patients received a gross total resection (GTR), 26.1% subtotal resection (STR), and 46.2% unidentified extent of resection. 59.4% did not receive any radiation therapy at any point of the treatment course, while 40.6% underwent radiation therapy. In our cohort, only patients with GTR demonstrated statistically improved survival (HR: 0.22, P < 0.001). Patients with STR had nearly identical survival compared to patients with no surgery (HR: 0.98), and radiotherapy was associated with increased odds of mortality (HR: 1.47, P < 0.001). Multivariate analysis demonstrated a significant survival benefit among patients with younger age, GTR and absence of radiotherapy. Histologic grade did not statistically impact survival.

Conclusion: Our study suggests that GTR results in improved survival among patients with low-grade gliomas within the spinal cord. Future, considerable data research efforts will aim to better define the role of radiotherapy and tumor grading in this patient population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2018.11.025DOI Listing
March 2019

The reliability of YouTube videos in patients education for Glioblastoma Treatment.

J Clin Neurosci 2018 Sep 31;55:1-4. Epub 2018 Jul 31.

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, FL, USA. Electronic address:

Background: Glioblastomas (GBMs) are one of the most devastating primary tumors in humans and often results in minimal survival rates. Over the past 2 decades, patients have accessed the internet to obtain information related to their diagnoses. In this study, we aimed to evaluate the accuracy and the reliability of GBM-related YouTube videos.

Methods: In June of 2017, a search was conducted on YouTube using 6 keywords. Videos were sorted using "Relevance-Based Ranking" option, and the first 3 pages for each search were selected for further analysis. Three independent reviewers evaluated the videos using the validated DISCERN Tool.

Results: After sorting 23,100 videos, 9 videos were identified and included for analysis. Of the 9 videos analyzed, 88% (8/9) were from hospitals affiliated with prestigious universities across the country. Of the nine videos included in the analysis, two (22%) scored above a 3. There was an average 55% overlap in the videos analyzed by key term and the keyword search of "Malignant Glioma Treatment" had the highest percentage of videos above a score of 3 (66%).

Conclusion: Many patients with GBM and their families access information on YouTube to familiarize themselves with the epidemiology, survival, and treatment options for this form of tumor. However, the information that is currently available online is not monitored or vetted using an official filtering process prior to its release. Medical institutions must work to produce more peer-reviewed content in order to improve the availability of credible health information on internet platforms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2018.07.001DOI Listing
September 2018

Comparative Cost Analysis of Endoscopic versus Microscopic Endonasal Transsphenoidal Surgery for Pituitary Adenomas.

J Neurol Surg B Skull Base 2018 Apr 8;79(2):131-138. Epub 2017 Aug 8.

Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, United States.

 This study presents a comparative analysis of cost efficacy between the microscopic and endoscopic transsphenoidal approaches, evaluating neurological outcome, extent of resection (EOR), and inpatient hospital costs.  This study was a retrospective chart review.  This study was conducted at a tertiary care center.  The study group consisted of 68 patients with transsphenoidal surgeries between January 2007 and January 2014.  Two-sample -tests and Pearson's chi-square test evaluated inpatient costs, quality-adjusted life years (QALYs), volumetric EOR, and neurological outcomes.  Total inpatient costs per patient was $22,853 in the microscopic group and less ($19,736) in the endoscopic group (  = 0.049). Operating room costs were $5,974 in the microscopic group and lower in the endoscopic group ($5,045;  = 0.038). Operative time was 203.6 minutes in the microscopic group and 166.3 minutes in the endoscopic group (  = 0.032). The QALY score, length of hospital stay, and postoperative outcomes were found to be similar between the two cohorts. Multivariate linear regression modeling suggested that length of stay (  < 0.001) and operative time (  = 0.008) were important factors that influenced total inpatient costs following transsphenoidal surgery.  This study shows that transsphenoidal surgery is more cost effective with the endoscopic approach than with the microscopic approach and depends on efficiency in the operating room as well as reduction in the length of hospitalization.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0037-1604484DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5978862PMC
April 2018

High-frequency oscillations in awake patients undergoing brain tumor-related epilepsy surgery.

Neurology 2018 03 28;90(13):e1119-e1125. Epub 2018 Feb 28.

From the Departments of Neurology (A.M.F., W.O.T.), Neurological Surgery (D.M., K.R., A.Q.-H.), Hematology/Oncology (S.S.R.), and Anesthesiology (P.S.B.), Mayo Clinic, Jacksonville, FL; and Departments of Neurology (G.A.W., B.H.B.) and Physiology and Biomedical Engineering (G.A.W., B.H.B.), Mayo Clinic, Rochester, MN.

Objective: To examine the relationship between high-frequency oscillations (HFOs) and the presence of preoperative seizures, World Health Organization tumor grade, and isocitrate dehydrogenase 1 (IDH1) mutational status in gliomas.

Methods: We retrospectively studied intraoperative electrocorticography recorded in 16 patients with brain tumor (12 presenting with seizures) who underwent awake craniotomy and surgical resection between September 2016 and June 2017. The number and distribution of HFOs were determined and quantified visually and with an automated HFO detector.

Results: Five patients had low-grade (1 with grade I and 4 with grade II) and 11 had high-grade (6 with grade III and 5 with grade IV) brain tumors. An IDH1 mutation was found in 6 patients. Patients with a history of preoperative seizures were more likely to have HFOs than those without preoperative seizures (9 of 12 vs 0 of 4, = 0.02). The rate of HFOs was higher in patients with IDH1 mutant (mean 7.2 per minute) than IDH wild-type (mean 2.3 per minute) genotype ( = 0.03).

Conclusions: HFOs are common in brain tumor-related epilepsy, and HFO rate may be a useful measure of epileptogenicity in gliomas. Our findings further support the notion that IDH1 mutant genotype is more epileptogenic than IDH1 wild-type genotype gliomas.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1212/WNL.0000000000005216DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5880636PMC
March 2018

Three-Hand Endoscopic Endonasal Transsphenoidal Surgery: Experience With an Anatomy-Preserving Mononostril Approach Technique.

Oper Neurosurg (Hagerstown) 2018 02;14(2):158-165

Department of Neurological Surgery and Oncology Outcomes Lab, Johns Hopkins University, Baltimore, Maryland.

Background: Variations on the endoscopic transsphenoidal approach present unique surgical techniques that have unique effects on surgical outcomes, extent of resection (EOR), and anatomical complications.

Objective: To analyze the learning curve and perioperative outcomes of the 3-hand endoscopic endonasal mononostril transsphenoidal technique.

Methods: Prospective case series and retrospective data analysis of patients who were treated with the 3-hand transsphenoidal technique between January 2007 and May 2015 by a single neurosurgeon. Patient characteristics, preoperative presentation, tumor characteristics, operative times, learning curve, and postoperative outcomes were analyzed. Volumetric EOR was evaluated, and a logistic regression analysis was used to assess predictors of EOR.

Results: Two hundred seventy-five patients underwent an endoscopic transsphenoidal surgery using the 3-hand technique. One hundred eighteen patients in the early group had surgery between 2007 and 2010, while 157 patients in the late group had surgery between 2011 and 2015. Operative time was significantly shorter in the late group (161.6 min) compared to the early group (211.3 min, P = .001). Both cohorts had similar EOR (early group 84.6% vs late group 85.5%, P = .846) and postoperative outcomes. The learning curve showed that it took 54 cases to achieve operative proficiency with the 3-handed technique. Multivariate modeling suggested that prior resections and preoperative tumor size are important predictors for EOR.

Conclusion: We describe a 3-hand, mononostril endoscopic transsphenoidal technique performed by a single neurosurgeon that has minimal anatomic distortion and postoperative complications. During the learning curve of this technique, operative time can significantly decrease, while EOR, postoperative outcomes, and complications are not jeopardized.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ons/opx110DOI Listing
February 2018

Intraoperative Seizures in Awake Craniotomy for Perirolandic Glioma Resections That Undergo Cortical Mapping.

J Neurol Surg A Cent Eur Neurosurg 2018 May 18;79(3):239-246. Epub 2018 Jan 18.

Department of Neurosurgery, Johns Hopkins University, Baltimore, Maryland, United States.

Background:  Perirolandic motor area gliomas present invasive eloquent region tumors within the precentral gyrus that are difficult to resect without causing neurologic deficits.

Study Aims:  This study evaluates the role of awake craniotomy and motor mapping on neurologic outcome and extent of resection (EOR) of tumor in the perirolandic motor region. It also analyzes preoperative risk factors for intraoperative seizures.

Methods:  We evaluated 57 patients who underwent an awake craniotomy for a perirolandic motor area eloquent region glioma. Patients who had positive mapping (PM) or intraoperative identification of motor regions in the cortex using direct cortical stimulation were compared with patients with no positive motor mapping following direct cortical stimulation and negative mapping (NM). Preoperative risks, intraoperative seizures, perioperative outcomes, tumor characteristics, and EOR were also compared. A logistic regression model was used to evaluate the predictors for intraoperative seizures in this patient cohort.

Results:  Overall, 33 patients were in the PM cohort; 24 were in the NM cohort. Our study showed an 8.8% incidence of intraoperative seizures during cortical and subcortical mapping for awake craniotomies in the perirolandic motor area, none of which aborted the case. PM patients had significantly more intraoperative and postoperative seizures (15.5% and 30.3%, respectively) compared with the NM patients (0% and 8.3%, respectively;  = 0.046 and 0.044). New transient postoperative motor deficits were found more often in the PM group (51.5%) versus the NM group (12.5%;  = 0.002). A univariate logistic regression showed that PM (odds ratio [OR]: 1.16; 95% confidence interval [CI], 1.01-1.34;  = 0.035) and preoperative tumor volume (OR: 0.998; 95% CI, 0.996-0.999;  = 0.049) were significant predictors for intraoperative seizures in patients with perirolandic gliomas.

Conclusion:  Awake craniotomies in the perirolandic motor region can be safely performed with a similar incidence of intraoperative seizures as reported for the language cortex. PM in this region may increase the likelihood of perioperative seizures or motor deficits compared with NM. Craniotomies that minimize cortical exposure for perirolandic gliomas that may not localize motor regions can still allow for extensive tumor resection with a good postoperative outcome.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1055/s-0037-1617759DOI Listing
May 2018

Microsphere Embolization of Hypervascular Posterior Fossa Tumors.

World Neurosurg 2018 Jan 3;109:182-187. Epub 2017 Oct 3.

Department of Neurologic Surgery, Mayo Clinic, Jacksonville, Florida, USA. Electronic address:

Background: Preoperative embolization of highly vascular tumors of the posterior fossa can decrease morbidity and operative blood loss. No clear consensus exists for the embolization agent of choice for optimal devascularization of these tumors. The purpose of this study was to assess effectiveness of microsphere embolization in reducing tumor hypervascularity before surgical resection.

Methods: We retrospectively reviewed medical records of patients with hypervascular posterior fossa tumors who were treated at a single institution from 2009 to 2016.

Results: Four of 9 patients with hypervascular posterior fossa tumors underwent embolization with 300-500 μm microspheres before surgical resection. Patients selected for embolization had large tumors with large feeding vessels evident on brain magnetic resonance imaging. Surgical resection was performed within 24 hours of embolization in all 4 patients. Mean (SD) patient age was 42.5 years (18.4), and mean (SD) tumor size was 4.3 cm (1.4) in greatest dimension. All patients presented with symptoms related to mass effect. Gross total tumor resection was achieved in all patients. There were no intraoperative complications related to the embolization or craniotomy; mean (SD) blood loss was 350 mL (208).

Conclusions: Preoperative embolization with microspheres can effectively reduce vascularity of the hypervascular posterior fossa tumor bed. This technique helped achieve complete resection, particularly for patients with recurrence after previous resection.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.wneu.2017.09.147DOI Listing
January 2018