Publications by authors named "Michael T Lawton"

699 Publications

Microsurgical anatomy of the cerebellar interpeduncular entry zones.

World Neurosurg 2022 Aug 7. Epub 2022 Aug 7.

Department of Neurology and Neurosurgery, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; Laboratory of Microneurosurgery Anatomy, Universidade Federal de Sao Paulo, Sao Paulo, Brazil; Department of Neurosurgery, Hospital Beneficência Portuguesa de São Paulo, São Paulo, Brazil. Electronic address:

Objective: The CIPR, particularly the MCP and IPS are significant surgical relevance areas due to the high prevalence of vascular and tumoral pathologies, such as cavernomas, arteriovenous malformations, and gliomas. We defined the safer access areas of the middle cerebellar peduncle(MCP) and the interpeduncular sulcus(IPS), according to the surface anatomy, involved vessels, and fiber tracts of the cerebellar interpeduncular region(CIPR).

Methods: Fifteen formalin-fixed and silicone-injected cadaveric heads and 23 human brainstems with attached cerebellums prepared with the Klingler technique were bilaterally dissected to study the vascular and intrinsic anatomy.

Results: Surface anatomy: The mean length of the IPS was 12.73mm(SD,2.15mm), and the average measured angle formed by the IPS and the lateral mesencephalic sulcus(LMS) was 144.53°. The mean distance from the uppermost point of the IPS to CN IV was 2.63mm(SD,2.84mm). Vascular anatomy: The perforating branches of the superior cerebellar peduncle(SCP), IPS, and MCP originated predominantly from the caudal trunk of the superior cerebellar artery(SCA). The inferior third of the SCP and IPS was the third most pierced by perforating arteries, and for the MCP, was its superior third. Crossing vessels: The branches of the pontotrigeminal vein(PTV) and the caudal trunk of the SCA crossed the IPS mostly. The superior third of the IPS was the most crossed by arteries and veins.

Conclusion: The middle thirds of the IPS and MCP as entry zone might be safer than their superior and inferior thirds due to fewer perforating branches, arterial trunks, and veins crossing the sulcus as fewer eloquent tracts.
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http://dx.doi.org/10.1016/j.wneu.2022.07.142DOI Listing
August 2022

Seven bypasses simulation set: description and validity assessment of novel models for microneurosurgical training.

J Neurosurg 2022 Aug 5:1-8. Epub 2022 Aug 5.

1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Objective: Microsurgical training remains indispensable to master cerebrovascular bypass procedures, but simulation models for training that accurately replicate microanastomosis in narrow, deep-operating corridors are lacking. Seven simulation bypass scenarios were developed that included head models in various surgical positions with premade approaches, simulating the restrictions of the surgical corridors and hand positions for microvascular bypass training. This study describes these models and assesses their validity.

Methods: Simulation models were created using 3D printing of the skull with a designed craniotomy. Brain and external soft tissues were cast using a silicone molding technique from the clay-sculptured prototypes. The 7 simulation scenarios included: 1) temporal craniotomy for a superficial temporal artery (STA)-middle cerebral artery (MCA) bypass using the M4 branch of the MCA; 2) pterional craniotomy and transsylvian approach for STA-M2 bypass; 3) bifrontal craniotomy and interhemispheric approach for side-to-side bypass using the A3 branches of the anterior cerebral artery; 4) far lateral craniotomy and transcerebellomedullary approach for a posterior inferior cerebellar artery (PICA)-PICA bypass or 5) PICA reanastomosis; 6) orbitozygomatic craniotomy and transsylvian-subtemporal approach for a posterior cerebral artery bypass; and 7) extended retrosigmoid craniotomy and transcerebellopontine approach for an occipital artery-anterior inferior cerebellar artery bypass. Experienced neurosurgeons evaluated each model by practicing the aforementioned bypasses on the models. Face and content validities were assessed using the bypass participant survey.

Results: A workflow for model production was developed, and these models were used during microsurgical courses at 2 neurosurgical institutions. Each model is accompanied by a corresponding prototypical case and surgical video, creating a simulation scenario. Seven experienced cerebrovascular neurosurgeons practiced microvascular anastomoses on each of the models and completed surveys. They reported that actual anastomosis within a specific approach was well replicated by the models, and difficulty was comparable to that for real surgery, which confirms the face validity of the models. All experts stated that practice using these models may improve bypass technique, instrument handling, and surgical technique when applied to patients, confirming the content validity of the models.

Conclusions: The 7 bypasses simulation set includes novel models that effectively simulate surgical scenarios of a bypass within distinct deep anatomical corridors, as well as hand and operator positions. These models use artificial materials, are reusable, and can be implemented for personal training and during microsurgical courses.
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http://dx.doi.org/10.3171/2022.5.JNS22465DOI Listing
August 2022

Real-time intraoperative surgical telepathology using confocal laser endomicroscopy.

Neurosurg Focus 2022 Jun;52(6):E9

1The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.

Objective: Communication between neurosurgeons and pathologists is mandatory for intraoperative decision-making and optimization of resection, especially for invasive masses. Handheld confocal laser endomicroscopy (CLE) technology provides in vivo intraoperative visualization of tissue histoarchitecture at cellular resolution. The authors evaluated the feasibility of using an innovative surgical telepathology software platform (TSP) to establish real-time, on-the-fly remote communication between the neurosurgeon using CLE and the pathologist.

Methods: CLE and a TSP were integrated into the surgical workflow for 11 patients with brain masses (6 patients with gliomas, 3 with other primary tumors, 1 with metastasis, and 1 with reactive brain tissue). Neurosurgeons used CLE to generate video-flow images of the operative field that were displayed on monitors in the operating room. The pathologist simultaneously viewed video-flow CLE imaging using a digital tablet and communicated with the surgeon while physically located outside the operating room (1 pathologist was in another state, 4 were at home, and 6 were elsewhere in the hospital). Interpretations of the still CLE images and video-flow CLE imaging were compared with the findings on the corresponding frozen and permanent H&E histology sections.

Results: Overall, 24 optical biopsies were acquired with mean ± SD 2 ± 1 optical biopsies per case. The mean duration of CLE system use was 1 ± 0.3 minutes/case and 0.25 ± 0.23 seconds/optical biopsy. The first image with identifiable histopathological features was acquired within 6 ± 0.1 seconds. Frozen sections were processed within 23 ± 2.8 minutes, which was significantly longer than CLE usage (p < 0.001). Video-flow CLE was used to correctly interpret tissue histoarchitecture in 96% of optical biopsies, which was substantially higher than the accuracy of using still CLE images (63%) (p = 0.005).

Conclusions: When CLE is employed in tandem with a TSP, neurosurgeons and pathologists can view and interpret CLE images remotely and in real time without the need to biopsy tissue. A TSP allowed neurosurgeons to receive real-time feedback on the optically interrogated tissue microstructure, thereby improving cross-functional communication and intraoperative decision-making and resulting in significant workflow advantages over the use of frozen section analysis.
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http://dx.doi.org/10.3171/2022.3.FOCUS2250DOI Listing
June 2022

Machine learning for predicting hemorrhage in pediatric patients with brain arteriovenous malformation.

J Neurosurg Pediatr 2022 08 3;30(2):203-209. Epub 2022 Jun 3.

1Department of Neurological Surgery, University of California, San Francisco.

Objective: Ruptured brain arteriovenous malformations (bAVMs) in a child are associated with substantial morbidity and mortality. Prior studies investigating predictors of hemorrhagic presentation of a bAVM during childhood are limited. Machine learning (ML), which has high predictive accuracy when applied to large data sets, can be a useful adjunct for predicting hemorrhagic presentation. The goal of this study was to use ML in conjunction with a traditional regression approach to identify predictors of hemorrhagic presentation in pediatric patients based on a retrospective cohort study design.

Methods: Using data obtained from 186 pediatric patients over a 19-year study period, the authors implemented three ML algorithms (random forest models, gradient boosted decision trees, and AdaBoost) to identify features that were most important for predicting hemorrhagic presentation. Additionally, logistic regression analysis was used to ascertain significant predictors of hemorrhagic presentation as a comparison.

Results: All three ML models were consistent in identifying bAVM size and patient age at presentation as the two most important factors for predicting hemorrhagic presentation. Age at presentation was not identified as a significant predictor of hemorrhagic presentation in multivariable logistic regression. Gradient boosted decision trees/AdaBoost and random forest models identified bAVM location and a concurrent arterial aneurysm as the third most important factors, respectively. Finally, logistic regression identified a left-sided bAVM, small bAVM size, and the presence of a concurrent arterial aneurysm as significant risk factors for hemorrhagic presentation.

Conclusions: By using an ML approach, the authors found predictors of hemorrhagic presentation that were not identified using a conventional regression approach.
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http://dx.doi.org/10.3171/2022.4.PEDS21470DOI Listing
August 2022

Emerging pathogenic mechanisms in human brain arteriovenous malformations: a contemporary review in the multiomics era.

Neurosurg Focus 2022 Jul;53(1):E2

1Department of Neurological Surgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix; and.

A variety of pathogenic mechanisms have been described in the formation, maturation, and rupture of brain arteriovenous malformations (bAVMs). While the understanding of bAVMs has largely been formulated based on animal models of rare hereditary diseases in which AVMs form, a new era of "omics" has permitted large-scale examinations of contributory genetic variations in human sporadic bAVMs. New findings regarding the pathogenesis of bAVMs implicate changes to endothelial and mural cells that result in increased angiogenesis, proinflammatory recruitment, and breakdown of vascular barrier properties that may result in hemorrhage; a greater diversity of cell populations that compose the bAVM microenvironment may also be implicated and complicate traditional models. Genomic sequencing of human bAVMs has uncovered inherited, de novo, and somatic activating mutations, such as KRAS, which contribute to the pathogenesis of bAVMs. New droplet-based, single-cell sequencing technologies have generated atlases of cell-specific molecular derangements. Herein, the authors review emerging genomic and transcriptomic findings underlying pathologic cell transformations in bAVMs derived from human tissues. The application of multiple sequencing modalities to bAVM tissues is a natural next step for researchers, although the potential therapeutic benefits or clinical applications remain unknown.
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http://dx.doi.org/10.3171/2022.4.FOCUS2291DOI Listing
July 2022

Back to basal: contemporary cerebrovascular cohort study of the supratentorial-infraoccipital approach.

J Neurosurg 2022 Jul 8:1-11. Epub 2022 Jul 8.

1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.

Objective: The objective of this paper was to assess applications of the supratentorial-infraoccipital (STIO) approach for cerebrovascular neurosurgery.

Methods: The authors conducted a cohort study of all consecutive cases in which the STIO approach was used during the study period, December 1995 to January 2021, as well as a systematic review of the literature.

Results: Twenty-five cerebrovascular cases were identified in which the STIO approach was used. Diagnoses included arteriovenous malformation (n = 15), cerebral cavernous malformation (n = 5), arteriovenous fistula (n = 4), and aneurysm (n = 1). The arteriovenous malformations consisted of Spetzler-Martin grade II (n = 3), grade III (n = 8), and grade IV (n = 4) lesions. Lesion locations included the occipital lobe (n = 15), followed by the tentorial dural (n = 4), temporal-occipital (n = 3), temporal (n = 1), thalamic (n = 1), and quadrigeminal cistern (n = 1) regions. Many patients (75%) experienced transient visual deficits attributable to retraction of the occipital lobe, all of which resolved. As of last follow-up (n = 12), modified Rankin Scale scores had improved for 6 patients and were unchanged for 6 patients compared with the preoperative baseline.

Conclusions: The STIO approach is a safe and effective skull base approach that provides a specialized access corridor for appropriately selected cerebrovascular lesions.
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http://dx.doi.org/10.3171/2022.5.JNS22506DOI Listing
July 2022

Intraoperative confocal laser endomicroscopy: prospective in vivo feasibility study of a clinical-grade system for brain tumors.

J Neurosurg 2022 Jul 8:1-11. Epub 2022 Jul 8.

1The Loyal and Edith Davis Neurosurgical Research Laboratory, Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix.

Objective: The authors evaluated the feasibility of using the first clinical-grade confocal laser endomicroscopy (CLE) system using fluorescein sodium for intraoperative in vivo imaging of brain tumors.

Methods: A CLE system cleared by the FDA was used in 30 prospectively enrolled patients with 31 brain tumors (13 gliomas, 5 meningiomas, 6 other primary tumors, 3 metastases, and 4 reactive brain tissue). A neuropathologist classified CLE images as interpretable or noninterpretable. Images were compared with corresponding frozen and permanent histology sections, with image correlation to biopsy location using neuronavigation. The specificities and sensitivities of CLE images and frozen sections were calculated using permanent histological sections as the standard for comparison. A recently developed surgical telepathology software platform was used in 11 cases to provide real-time intraoperative consultation with a neuropathologist.

Results: Overall, 10,713 CLE images from 335 regions of interest were acquired. The mean duration of the use of the CLE system was 7 minutes (range 3-18 minutes). Interpretable CLE images were obtained in all cases. The first interpretable image was acquired within a mean of 6 (SD 10) images and within the first 5 (SD 13) seconds of imaging; 4896 images (46%) were interpretable. Interpretable image acquisition was positively correlated with study progression, number of cases per surgeon, cumulative length of CLE time, and CLE time per case (p ≤ 0.01). The diagnostic accuracy, sensitivity, and specificity of CLE compared with frozen sections were 94%, 94%, and 100%, respectively, and the diagnostic accuracy, sensitivity, and specificity of CLE compared with permanent histological sections were 92%, 90%, and 94%, respectively. No difference was observed between lesion types for the time to first interpretable image (p = 0.35). Deeply located lesions were associated with a higher percentage of interpretable images than superficial lesions (p = 0.02). The study met the primary end points, confirming the safety and feasibility and acquisition of noninvasive digital biopsies in all cases. The study met the secondary end points for the duration of CLE use necessary to obtain interpretable images. A neuropathologist could interpret the CLE images in 29 (97%) of 30 cases.

Conclusions: The clinical-grade CLE system allows in vivo, intraoperative, high-resolution cellular visualization of tissue microstructure and identification of lesional tissue patterns in real time, without the need for tissue preparation.
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http://dx.doi.org/10.3171/2022.5.JNS2282DOI Listing
July 2022

Cost Comparison of Microsurgery vs Endovascular Treatment for Ruptured Intracranial Aneurysms: A Propensity-Adjusted Analysis.

Neurosurgery 2022 09 23;91(3):470-476. Epub 2022 Jun 23.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

Background: In specialized neurosurgical centers, open microsurgery is routinely performed for aneurysmal subarachnoid hemorrhage (aSAH).

Objective: To compare the cost of endovascular vs microsurgical treatment for aSAH at a single quaternary center.

Methods: All patients undergoing aSAH treatment from July 1, 2014, to July 31, 2019, were retrospectively reviewed. Patients were grouped based on primary treatment (microsurgery vs endovascular treatment). The primary outcome was the difference in total cost (including hospital, discharge facility, and all follow-up) using a propensity-adjusted analysis.

Results: Of 384 patients treated for an aSAH, 234 (61%) were microsurgically treated and 150 (39%) were endovascularly treated. The mean cost of index hospitalization for these patients was marginally higher ($9504) for endovascularly treated patients ($103 980) than for microsurgically treated patients ($94 476) ( P = .047). For the subset of patients with follow-up data available, the mean total cost was $45 040 higher for endovascularly treated patients ($159 406, n = 59) than that for microsurgically treated patients ($114 366, n = 105) ( P < .001). After propensity scoring (adjusted for age, sex, comorbidities, Glasgow Coma Scale score, Hunt and Hess grade, Fisher grade, aneurysms, and type/size/location), linear regression analysis of patients with follow-up data available revealed that microsurgery was independently associated with healthcare costs that were $37 244 less than endovascular treatment costs ( P < .001). An itemized cost analysis suggested that this discrepancy was due to differences in the rates of aneurysm retreatment and long-term surveillance.

Conclusion: Microsurgical treatment for aSAH is associated with lower total healthcare costs than endovascular therapy. Aneurysm surveillance after endovascular treatments, retreatment, and device costs warrants attention in future studies.
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http://dx.doi.org/10.1227/neu.0000000000002061DOI Listing
September 2022

Lumbar drainage after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis.

World Neurosurg 2022 Jul 19. Epub 2022 Jul 19.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona. Electronic address:

Objective: This study reviews the use of lumbar drains (LDs) after aneurysmal subarachnoid hemorrhage (aSAH) and compares the outcomes to those associated with external ventricular drainage (EVD) and controls.

Methods: A comprehensive search of the literature was performed. English-language studies with a sample size of more than 10 patients were included. One-arm and 2-arm meta-analyses were designed to compare external drainage groups. Random-effects models, heterogeneity measures, and risk of bias were calculated.

Results: Seventeen studies were included in the meta-analysis. The 2-arm meta-analysis comparing LD to no drainage after aSAH found a significant improvement in postoperative modified Rankin Scale (mRS) score (0-2) within 1 month of hospital discharge in the LD group (p=0.003), a lower mortality rate (p=0.03), fewer cases of clinical vasospasm (p=0.007), and a lower incidence of ischemic stroke or delayed ischemic neurological deficits (p=0.003). When LD was compared to EVD, a significant improvement in postoperative mRS score (0-2) within 1 month of discharge was found in the LD group (p<0.001). In the LD group, rebleeding occurred in 15 (3.4%) cases and meningitis in 50 (4.7%) cases.

Conclusions: Compared with patients without cerebrospinal fluid drainage, patients with LD after aSAH had lower mortality rates, lower risk of clinical vasospasm, and lower risk of ischemic stroke, and they were more likely to have an mRS score of 0-2 within 1 month of discharge. Compared with patients with EVD, patients with LD were more likely to have an mRS score of 0-2 within 1 month of discharge.
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http://dx.doi.org/10.1016/j.wneu.2022.07.061DOI Listing
July 2022

Resection of a Recurrent, Irradiated Hemangiopericytoma With A3-A3 Anterior Cerebral Artery Bypass: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 06 14;22(6):e280. Epub 2022 Apr 14.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1227/ons.0000000000000189DOI Listing
June 2022

Left Callosomarginal to Right Pericallosal In Situ Bypass, Partial Trapping, and Thrombectomy of a Giant Anterior Communicating Artery Aneurysm.

Oper Neurosurg (Hagerstown) 2022 May 9. Epub 2022 May 9.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1227/ons.0000000000000273DOI Listing
May 2022

Coccidioidal meningitis with multiple aneurysms presenting with pseudo-subarachnoid hemorrhage: illustrative case.

J Neurosurg Case Lessons 2021 Oct 11;2(15):CASE21424. Epub 2021 Oct 11.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Background: Coccidioidomycosis is a primarily self-limiting fungal disease endemic to the western United States and South America. However, severe disseminated infection can occur. The authors report a severe case of coccidioidal meningitis that appeared to be a subarachnoid hemorrhage (SAH) on initial inspection.

Observations: A man in his early 40s was diagnosed with coccidioidal pneumonia after presenting with pulmonary symptoms. After meningeal spread characterized by declining mental status and hydrocephalus, coccidioidal meningitis was diagnosed. The uniquely difficult aspect of this case was the deceptive appearance of SAH due to the presence of multiple aneurysms and blood draining from the patient's external ventricular drain.

Lessons: Coccidioidal infection likely led to the formation of multiple intracranial aneurysms in this patient. Although few reports exist of coccidioidal meningitis progressing to aneurysm formation, patients should be closely monitored for this complication because outcomes are poor. The presence of basal cistern hyperdensities from a coccidioidal infection mimicking SAH makes interpreting imaging difficult. Surgical management of SAH can be considered safe and viable, especially when the index of suspicion is high, such as in the presence of multiple aneurysms. Even if it is unclear whether aneurysmal rupture has occurred, prompt treatment is advisable.
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http://dx.doi.org/10.3171/CASE21424DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9265202PMC
October 2021

Carotid Endarterectomy Requiring Intra-Arterial Shunting-A Technical Overview: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 Aug 20;23(2):e123-e124. Epub 2022 Apr 20.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1227/ons.0000000000000235DOI Listing
August 2022

Sphenoparietal Sinus Dural Arteriovenous Fistulas: A Series of 10 Patients.

Oper Neurosurg (Hagerstown) 2022 Aug 26;23(2):139-147. Epub 2022 May 26.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

Background: Dural arteriovenous fistulas (DAVFs) of the sphenoparietal sinus or sphenoid wing region are uncommon lesions with unique and interesting angioarchitecture. Understanding appropriate anatomy and recognizing patterns provide important treatment implications.

Objective: To describe a single surgeon's experience with open surgical treatment of sphenoparietal sinus DAVFs, the surgical indications for this uncommon lesion, and the microsurgical techniques related to its treatment and to review the literature on its surgical treatment.

Methods: Consecutive cases of sphenoparietal sinus DAVF treatment conducted by a single surgeon over 24 years (1997-2020) were retrospectively reviewed. Published reports of similar cases were reviewed.

Results: Of 202 surgically treated DAVFs, 10 lesions in 10 patients were sphenoparietal sinus DAVFs. Four patients presented with intracranial hemorrhage, 3 with headache, and 2 with pulsatile tinnitus; 1 patient was incidentally identified as having a DAVF during treatment for a ruptured aneurysm. Most patients (7 of 10) had undergone endovascular embolization previously. Nine patients had Borden type III DAVFs and one had a Borden type II fistula. Surgery in all 10 patients resulted in angiographically confirmed fistula obliteration. Clinical outcomes at the last follow-up, measured by a modified Rankin Scale (mRS) score, were excellent in 6 patients (mRS ≤ 2) and poor in 1 patient (mRS ≥ 3); late outcomes were not available for 3 patients.

Conclusion: Sphenoparietal sinus DAVFs are an uncommon anatomic subtype. Careful attention to angiographic detail leads to identification of the site of venous interruption and results in a high rate of surgical cure with excellent clinical outcomes.
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http://dx.doi.org/10.1227/ons.0000000000000269DOI Listing
August 2022

Unique Presentation and Novel Surgical Approach to a Transcribriform Penetrating Head Injury Caused by a Nail Gun.

Cureus 2022 Jun 1;14(6):e25581. Epub 2022 Jun 1.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, USA.

A penetrating head injury caused by a nail gun is an infrequent clinically diverse condition that varies in severity by the neurovascular structures involved. The authors present the case of a patient whose frontal lobe was pierced by a nail that entered via a transnasal transcribriform trajectory without causing vascular injury or intracranial hemorrhage; the man was unaware of the nail's presence and presented with headache five days after the incident. The nail was extracted using a bifrontal craniotomy for direct visualization and for defect repair of the skull base combined with endoscopic endonasal extraction of the nail.
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http://dx.doi.org/10.7759/cureus.25581DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9249433PMC
June 2022

Fourth-generation bypass and flow reversal to treat a symptomatic giant dolichoectatic basilar trunk aneurysm.

Acta Neurochir (Wien) 2022 Jul 1. Epub 2022 Jul 1.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, 350 W Thomas Rd, Phoenix, AZ, 85013, USA.

Background: Giant dolichoectatic basilar trunk aneurysms have an unfavorable natural history and are associated with high morbidity, but their neurosurgical treatment is complex and challenging.

Methods: Flow reversal reconstruction with fourth-generation bypass and proximal vertebral artery clip occlusion is performed via orbitozygomatic craniotomy with the Kawase approach under rapid ventricular pacing.

Conclusion: Fourth-generation bypass is an innovative, technically challenging, and clinically effective tool in the treatment armamentarium for giant dolichoectatic basilar trunk aneurysms.
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http://dx.doi.org/10.1007/s00701-022-05292-wDOI Listing
July 2022

Microsurgical treatment of ruptured aneurysms beyond 72 hours after rupture: implications for advanced management.

Acta Neurochir (Wien) 2022 Jun 23. Epub 2022 Jun 23.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.

Background: Aneurysmal subarachnoid hemorrhage (aSAH) patients admitted to primary stroke centers are often transferred to neurosurgical and endovascular services at tertiary centers. The effect on microsurgical outcomes of the resultant delay in treatment is unknown. We evaluated microsurgical aSAH treatment > 72 h after the ictus.

Methods: All aSAH patients treated at a single tertiary center between August 1, 2007, and July 31, 2019, were retrospectively reviewed. The additional inclusion criterion was the availability of treatment data relative to time of bleed. Patients were grouped based on bleed-to-treatment time as having acute treatment (on or before postbleed day [PBD] 3) or delayed treatment (on or after PBD 4). Propensity adjustments were used to correct for statistically significant confounding covariables.

Results: Among 956 aSAH patients, 92 (10%) received delayed surgical treatment (delayed group), and 864 (90%) received acute endovascular or surgical treatment (acute group). Reruptures occurred in 3% (26/864) of the acute group and 1% (1/92) of the delayed group (p = 0.51). After propensity adjustments, the odds of residual aneurysm (OR = 0.09; 95% CI = 0.04-0.17; p < 0.001) or retreatment (OR = 0.14; 95% CI = 0.06-0.29; p < 0.001) was significantly lower among the delayed group. The OR was 0.50 for rerupture, after propensity adjustments, in the delayed setting (p = 0.03). Mean Glasgow Coma Scale scores at admission in the acute and delayed groups were 11.5 and 13.2, respectively (p < 0.001).

Conclusions: Delayed microsurgical management of aSAH, if required for definitive treatment, appeared to be noninferior with respect to retreatment, residual, and rerupture events in our cohort after adjusting for initial disease severity and significant confounding variables.
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http://dx.doi.org/10.1007/s00701-022-05283-xDOI Listing
June 2022

Suboccipital Craniotomy and Transventricular Resection of a Trigonal Medullary Cavernous Malformation: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 07 20;23(1):e66. Epub 2022 Apr 20.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1227/ons.0000000000000214DOI Listing
July 2022

Torcular Craniotomy for Simultaneous Resection of a Tentorial Cerebellar Arteriovenous Malformation and Clipping of a Superior Cerebellar Artery Aneurysm: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2022 07 9;23(1):e65. Epub 2022 May 9.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.

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http://dx.doi.org/10.1227/ons.0000000000000213DOI Listing
July 2022

Neurosurgery Subspecialty Practice During a Pandemic: A Multicenter Analysis of Operative Practice in 7 U.S. Neurosurgery Departments During Coronavirus Disease 2019.

World Neurosurg 2022 Jun 18. Epub 2022 Jun 18.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA. Electronic address:

Objective: Changes to neurosurgical practices during the coronavirus disease 2019 (COVID-19) pandemic have not been thoroughly analyzed. We report the effects of operative restrictions imposed under variable local COVID-19 infection rates and health care policies using a retrospective multicenter cohort study and highlight shifts in operative volumes and subspecialty practice.

Methods: Seven academic neurosurgery departments' neurosurgical case logs were collected; procedures in April 2020 (COVID-19 surge) and April 2019 (historical control) were analyzed overall and by 6 subspecialties. Patient acuity, surgical scheduling policies, and local surge levels were assessed.

Results: Operative volume during the COVID-19 surge decreased 58.5% from the previous year (602 vs. 1449, P = 0.001). COVID-19 infection rates within departments' counties correlated with decreased operative volume (r = 0.695, P = 0.04) and increased patient categorical acuity (P = 0.001). Spine procedure volume decreased by 63.9% (220 vs. 609, P = 0.002), for a significantly smaller proportion of overall practice during the COVID-19 surge (36.5%) versus the control period (42.0%) (P = 0.02). Vascular volume decreased by 39.5% (72 vs. 119, P = 0.01) but increased as a percentage of caseload (8.2% in 2019 vs. 12.0% in 2020, P = 0.04). Neuro-oncology procedure volume decreased by 45.5% (174 vs. 318, P = 0.04) but maintained a consistent proportion of all neurosurgeries (28.9% in 2020 vs. 21.9% in 2019, P = 0.09). Functional neurosurgery volume, which declined by 81.4% (41 vs. 220, P = 0.008), represented only 6.8% of cases during the pandemic versus 15.2% in 2019 (P = 0.02).

Conclusions: Operative restrictions during the COVID-19 surge led to distinct shifts in neurosurgical practice, and local infective burden played a significant role in operative volume and patient acuity.
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http://dx.doi.org/10.1016/j.wneu.2022.06.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9212868PMC
June 2022

Endovascular and Medical Management of Cerebral Venous Thrombosis: A Systematic Review and Network Meta-Analysis.

World Neurosurg 2022 Jun 7. Epub 2022 Jun 7.

Carle Illinois College of Medicine, University of Illinois Urbana Champaign, Champaign, Illinois; Department of Neurosurgery, Carle Foundation Hospital, Urbana, Illinois. Electronic address:

Objective: Management of cerebral venous thrombosis (CVT) involves minimizing expansion of the thrombus and promoting the recanalization of the venous sinus. While current guidelines include indications of endovascular management and anticoagulation with heparin and warfarin, the use of direct-acting oral anticoagulants (DOACs) has increased. In this study, we aim to conduct a network meta-analysis comparing these 3 therapeutic options: standard anticoagulation, DOACs, and endovascular treatments (EVTs).

Methods: Seventeen of 2265 studies identified from 4 publication databases met inclusion criteria for this network meta-analysis. Outcomes analyzed included modified Rankin Scale score, complications, mortality, and 6-month recanalization rates using a frequentist network meta-analysis approach. For each outcome, the preferential order of each intervention was ranked hierarchically based on P-score calculations used for frequentist network meta-analyses.

Results: Modified Rankin Scale outcomes were not significantly different based on the type of treatment modality (i.e., standard anticoagulation, DOACs, or EVT). Evaluation of complications demonstrated that patients treated with EVT were significantly more likely to experience a worse outcome than individuals treated with standard anticoagulation (odds ratio [OR] = 1.83, P = 0.04). Other comparisons did not demonstrate a significant difference in adverse events. For all-cause mortality outcomes, EVT demonstrated significantly greater odds of mortality than standard anticoagulation (OR = 1.89, P = 0.02). Mortality between DOACs and standard anticoagulation was not significantly different. When comparing 6-month recanalization rates, DOACs and EVT were significantly more effective than standard anticoagulation (OR = 1.93, OR = 2.2, P < 0.05). EVT followed by DOACs was preferred over standard anticoagulation for 6-month recanalization rates.

Conclusions: This network meta-analysis evaluates the outcomes in CVT treatment, comparing standard anticoagulation, DOACs, and EVT, with evidence that DOACs have similar outcomes to standard anticoagulation in the treatment of CVT. EVT resulted in an increased risk of overall mortality but improved 6-month recanalization rates.
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http://dx.doi.org/10.1016/j.wneu.2022.05.142DOI Listing
June 2022

Development and Validation of a Novel Methodological Pipeline to Integrate Neuroimaging and Photogrammetry for Immersive 3D Cadaveric Neurosurgical Simulation.

Front Surg 2022 16;9:878378. Epub 2022 May 16.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona.

Background: Visualizing and comprehending 3-dimensional (3D) neuroanatomy is challenging. Cadaver dissection is limited by low availability, high cost, and the need for specialized facilities. New technologies, including 3D rendering of neuroimaging, 3D pictures, and 3D videos, are filling this gap and facilitating learning, but they also have limitations. This proof-of-concept study explored the feasibility of combining the spatial accuracy of 3D reconstructed neuroimaging data with realistic texture and fine anatomical details from 3D photogrammetry to create high-fidelity cadaveric neurosurgical simulations.

Methods: Four fixed and injected cadaver heads underwent neuroimaging. To create 3D virtual models, surfaces were rendered using magnetic resonance imaging (MRI) and computed tomography (CT) scans, and segmented anatomical structures were created. A stepwise pterional craniotomy procedure was performed with synchronous neuronavigation and photogrammetry data collection. All points acquired in 3D navigational space were imported and registered in a 3D virtual model space. A novel machine learning-assisted monocular-depth estimation tool was used to create 3D reconstructions of 2-dimensional (2D) photographs. Depth maps were converted into 3D mesh geometry, which was merged with the 3D virtual model's brain surface anatomy to test its accuracy. Quantitative measurements were used to validate the spatial accuracy of 3D reconstructions of different techniques.

Results: Successful multilayered 3D virtual models were created using volumetric neuroimaging data. The monocular-depth estimation technique created qualitatively accurate 3D representations of photographs. When 2 models were merged, 63% of surface maps were perfectly matched (mean [SD] deviation 0.7 ± 1.9 mm; range -7 to 7 mm). Maximal distortions were observed at the epicenter and toward the edges of the imaged surfaces. Virtual 3D models provided accurate virtual measurements (margin of error <1.5 mm) as validated by cross-measurements performed in a real-world setting.

Conclusion: The novel technique of co-registering neuroimaging and photogrammetry-based 3D models can (1) substantially supplement anatomical knowledge by adding detail and texture to 3D virtual models, (2) meaningfully improve the spatial accuracy of 3D photogrammetry, (3) allow for accurate quantitative measurements without the need for actual dissection, (4) digitalize the complete surface anatomy of a cadaver, and (5) be used in realistic surgical simulations to improve neurosurgical education.
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http://dx.doi.org/10.3389/fsurg.2022.878378DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9149243PMC
May 2022

A taxonomy for brainstem cavernous malformations: subtypes of medullary lesions.

J Neurosurg 2022 May 20:1-19. Epub 2022 May 20.

Objective: Medullary cavernous malformations are the least common of the brainstem cavernous malformations (BSCMs), accounting for only 14% of lesions in the authors' surgical experience. In this article, a novel taxonomy for these lesions is proposed based on clinical presentation and anatomical location.

Methods: The taxonomy system was applied to a large 2-surgeon experience over a 30-year period (1990-2019). Of 601 patients who underwent microsurgical resection of BSCMs, 551 were identified who had the clinical and radiological information needed for inclusion. These 551 patients were classified by lesion location: midbrain (151 [27%]), pons (323 [59%]), and medulla (77 [14%]). Medullary lesions were subtyped on the basis of their predominant surface presentation. Neurological outcomes were assessed according to the modified Rankin Scale (mRS), with an mRS score ≤ 2 defined as favorable.

Results: Five distinct subtypes were defined for the 77 medullary BSCMs: pyramidal (3 [3.9%]), olivary (35 [46%]), cuneate (24 [31%]), gracile (5 [6.5%]), and trigonal (10 [13%]). Pyramidal lesions are located in the anterior medulla and were associated with hemiparesis and hypoglossal nerve palsy. Olivary lesions are found in the anterolateral medulla and were associated with ataxia. Cuneate lesions are located in the posterolateral medulla and were associated with ipsilateral upper-extremity sensory deficits. Gracile lesions are located outside the fourth ventricle in the posteroinferior medulla and were associated with ipsilateral lower-extremity sensory deficits. Trigonal lesions in the ventricular floor were associated with nausea, vomiting, and diplopia. A single surgical approach was preferred (> 90% of cases) for each medullary subtype: the far lateral approach for pyramidal and olivary lesions, the suboccipital-telovelar approach for cuneate lesions, the suboccipital-transcisterna magna approach for gracile lesions, and the suboccipital-transventricular approach for trigonal lesions. Of these 77 patients for whom follow-up data were available (n = 73), 63 (86%) had favorable outcomes and 67 (92%) had unchanged or improved functional status.

Conclusions: This study confirms that the constellation of neurological signs and symptoms associated with a hemorrhagic medullary BSCM subtype is useful for defining the BSCM clinically according to a neurologically recognizable syndrome at the bedside. The proposed taxonomical classifications may be used to guide the selection of surgical approaches, which may enhance the consistency of clinical communications and help improve patient outcomes.
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http://dx.doi.org/10.3171/2022.3.JNS22626DOI Listing
May 2022

Unsuccessful bypass and trapping of a giant dolichoectatic thrombotic basilar trunk aneurysm. What went wrong?

Br J Neurosurg 2022 May 17:1-4. Epub 2022 May 17.

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.

Aneurysms of the basilar trunk represent an exceptional challenge to the neurosurgeon, due to high mortality and surgical morbidity. We present a 69-year-old man with a giant dolichoectatic thrombotic basilar trunk aneurysm (BTA), who underwent right orbitozygomatic craniotomy, posterior cerebral artery (PCA) to right middle cerebral artery (MCA) bypass and trapping of the BTA. Unfortunately, patient died after surgery due to multiple foci of intraparenchymal haemorrhage and thrombosis of a short segment proximal to aneurysm trapped and his body was donated to the hospital, giving us the unique opportunity to compare intraoperative details with anatomical dissection findings, according to our previously published cadaveric neurosurgical research. The great and unique opportunity of this reported case, to learn by watching and watching again what has been done during surgery, to observe small vessels and brainstem perforators and to look at stiches of the bypass, SVG and the position of the clips, permits to refine the theoretical and practical skills for the treatment of complex aneurysms such as that one reported.
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http://dx.doi.org/10.1080/02688697.2022.2077306DOI Listing
May 2022

Complex cranial surgery and the future of open cerebrovascular training.

J Neurosurg 2022 Apr 29:1-8. Epub 2022 Apr 29.

1Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona; and.

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http://dx.doi.org/10.3171/2022.3.JNS212939DOI Listing
April 2022

Giant cerebral cavernous malformations: redefinition based on surgical outcomes and systematic review of the literature.

J Neurosurg 2022 Apr 29:1-9. Epub 2022 Apr 29.

Objective: Giant cerebral cavernous malformations (GCCMs) are rare vascular malformations. Unlike for tumors and aneurysms, there is no clear definition of a "giant" cavernous malformation (CM). As a result of variable definitions, working descriptions and outcome data of patients with GCCM are unclear. A new definition of GCCM related to surgical outcomes is needed.

Methods: An institutional database was searched for all patients who underwent resection of CMs > 1 cm in diameter. Patient information, surgical technique, and clinical and radiographic outcomes were assessed. A systematic review was performed to augment an earlier published review.

Results: In the authors' institutional cohort of 183 patients with a large CM, 179 with preoperative and postoperative modified Rankin Scale (mRS) scores were analyzed. A maximum CM diameter of ≥ 3 cm was associated with greater risk of severe postoperative decline (≥ 2-point increase in mRS score). After adjustment for age and deep versus superficial location, size ≥ 3 cm was strongly predictive of severe postoperative decline (OR 4.5, 95% CI 1.2-16.9). A model with CM size and deep versus superficial location was developed to predict severe postoperative decline (area under the receiver operating characteristic curve 0.79). Thirteen more patients with GCCMs have been reported in the literature since the most recent systematic review, including some patients who were treated earlier and not discussed in the previous review.

Conclusions: The authors propose that cerebral CMs with a diameter ≥ 3 cm be defined as GCCMs on the basis of the inflection point for functional and neurological outcomes. This definition is in line with the definitions for other giant lesions. It is less exclusive than earlier definitions but captures the rarity of these lesions (approximately 1% incidence) and variation in outcomes. GCCMs remain operable with potentially favorable outcomes. The term "giant" is not meant to deter or contraindicate surgery.
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http://dx.doi.org/10.3171/2022.2.JNS22166DOI Listing
April 2022

Clinical Trials of Microsurgery for Cerebral Aneurysms: Past and Future.

World Neurosurg 2022 May;161:354-366

Department of Neurosurgery, Barrow Neurological Institute, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA. Electronic address:

Background: New findings and research regarding the microsurgical treatment of intracerebral aneurysms (IAs) continue to advance even in the era of endovascular therapies. Research in the past 2 decades has continued to revolve around the question of whether open surgery or endovascular treatment is preferable. The answer remains both complex and in flux.

Objective: This review focuses on microsurgery, reflects on the research decisions of previous landmark studies, and proposes future study designs that may further our understanding of IAs and how best to treat them.

Results: The future of IA research may include a combination of pragmatic trials, artificial intelligence integrated tools, and mining of large data sets, in addition to the publication of high-quality single-center studies.

Conclusions: The future will likely emphasize testing innovative techniques, looking at granular patient data, and considering every patient encounter as a potential source of knowledge, creating a system in which data are updated daily because each patient interaction contributes to answering important research questions.
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http://dx.doi.org/10.1016/j.wneu.2021.11.087DOI Listing
May 2022

Optic Tract as an Upper Limit in Amygdalectomy: Microsurgical Study.

Oper Neurosurg (Hagerstown) 2022 07 29;23(1):e42-e48. Epub 2022 Apr 29.

Department of Neurosurgery, Christian Doppler Klinic, Paracelsus Medical University, Salzburg, Austria.

Background: In surgeries involving resection of the amygdala, despite clear relations established with the medial, lateral, anterior, posterior, and inferior segments, the upper limit remains controversial. The optic tract (OT) has been anatomically considered as a good landmark immediately inferior to the striatopallidal region. This anatomic structure has barely been explored by microsurgical study, generating uncertainty about the exact relationship with the surrounding structures.

Objective: To describe the OT in its entire length through microsurgical study, showing its superior, inferior, medial, and lateral relationships and highlighting its value as a landmark in superior amygdala resection.

Methods: Microsurgical anatomic dissection of the OT, from its origin in the chiasm to the lateral geniculate nucleus was performed in 8 alcohol-fixed human hemispheres, showing its different segments and relations. Photographs were taken from different angles to facilitate surgical orientation.

Results: We performed a dissection of the OT, showing its position relative to caudate and hippocampal formations. We exposed the structures related to the OT superiorly (striatopallidal region and superior caudate fasciculus), inferiorly (head of the hippocampus, amygdala, anterior choroidal artery, perforating artery branch of the anterior choroidal artery, terminal stria, and basal vein), medially (internal capsule and midbrain), and laterally (temporal stem [uncinate and inferior fronto-occipital fascicle], anterior perforated substance, and superior caudate fasciculus).

Conclusion: To date, there is a paucity of articles describing the anatomy of the OT from a neurosurgery perspective. In this study, we describe the microsurgical anatomic path of the OT, as a reliable upper limit landmark for amygdala resection.
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http://dx.doi.org/10.1227/ons.0000000000000208DOI Listing
July 2022

Intracranial Venous Alteration in Patients With Aneurysmal Subarachnoid Hemorrhage: Protocol for the Prospective and Observational SAH Multicenter Study (SMS).

Front Surg 2022 5;9:847429. Epub 2022 Apr 5.

Department of Neurological Surgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.

Background: Arterial vasospasm has been ascribed as the responsible etiology of delayed cerebral infarction in patients with aneurysmal subarachnoid hemorrhage (aSAH), but other neurovascular structures may be involved. We present the protocol for a multicenter, prospective, observational study focused on analyzing morphological changes in cerebral veins of patients with aSAH.

Methods And Analysis: In a retrospective arm, we will collect head arterial and venous CT angiograms (CTA) of 50 patients with aSAH and 50 matching healthy controls at days 0-2 and 7-10, comparing morphological venous changes. A multicenter prospective observational study will follow. Patients aged ≥18 years of any gender with aSAH will be enrolled at 9 participating centers based on the predetermined eligibility criteria. A sample size of 52 aSAH patients is expected, and 52 healthy controls matched per age, gender, and comorbidities will be identified. For each patient, sequential CTA will be conducted upon admission (day 0-2), at 7-10 days, and at 14-21 days after aSAH, evaluating volumes and morphology of the cerebral deep veins and main cortical veins. One specialized image collecting center will analyze all anonymized CTA scans, performing volumetric calculation of targeted veins. Morphological venous changes over time will be evaluated using the Dice coefficient and the Jaccard index and scored using the Boeckh-Behrens system. Morphological venous changes will be correlated to clinical outcomes and compared between patients with aSAH and healthy-controls, and among groups based on surgical/endovascular treatments for aSAH.

Ethics And Dissemination: This protocol has been approved by the ethics committee and institutional review board of Ethikkommission, SALK, Salzburg, Austria, and will be approved at all participating sites. The study will comply with the Declaration of Helsinki. Written informed consent will be obtained from all enrolled patients or their legal tutors. We will present our findings at academic conferences and peer-reviewed journals.

Approved Protocol Version And Registration: Version 2, 09 June 2021.
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http://dx.doi.org/10.3389/fsurg.2022.847429DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9018107PMC
April 2022
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