Publications by authors named "Nikhil K Prasad"

23 Publications

  • Page 1 of 1

A Nation-wide Review of Elective Surgery and COVID-Surge Capacity.

J Surg Res 2021 Jun 19;267:211-216. Epub 2021 Jun 19.

Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland; Surgery Service, Veterans Affairs Medical Centre, Baltimore, Maryland. Electronic address:

Background: The COVID-19 pandemic has resulted in over 225,000 excess deaths in the United States. A moratorium on elective surgery was placed early in the pandemic to reduce risk to patients and staff and preserve critical care resources. This report evaluates the impact of the elective surgical moratorium on case volumes and intensive care unit (ICU) bed utilization.

Methods: This retrospective review used a national convenience sample to correlate trends in the weekly rates of surgical cases at 170 Veterans Affairs Hospitals around the United States from January 1 to September 30, 2020 to national trends in the COVID-19 pandemic. We reviewed data on weekly number of procedures performed and ICU bed usage, stratified by level of urgency (elective, urgent, emergency), and whether an ICU bed was required within 24 hours of surgery. National data on the proportion of COVID-19 positive test results and mortality rates were obtained from the Center for Disease Control website.

Results: 198,911 unique surgical procedures performed during the study period. The total number of cases performed from January 1 to March 16 was 86,004 compared with 15,699 from March 17 to May 17. The reduction in volume occurred before an increase in the percentage of COVID-19 positive test results and deaths nationally. There was a 91% reduction from baseline in the number of elective surgeries performed allowing 78% of surgical ICU beds to be available for COVID-19 positive patients.

Conclusion: The moratorium on elective surgical cases was timely and effective in creating bed capacity for critically ill COVID-19 patients. Further analyses will allow targeted resource allocation for future pandemic planning.
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http://dx.doi.org/10.1016/j.jss.2021.05.028DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213966PMC
June 2021

Veno-Arterial Extracorporeal Membrane Oxygenation for Pulmonary Embolism after Systemic Thrombolysis.

Semin Thorac Cardiovasc Surg 2021 May 8. Epub 2021 May 8.

Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, Baltimore, Maryland. Electronic address:

Massive pulmonary embolism (PE) is a life-threatening condition with a high mortality. Both systemic thrombolytics and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) have been used in the management of massive PE. However, the safety of VA- ECMO in the setting of recent thrombolytic administration is not clear. The purpose of this study is to analyze the outcomes of patients who received VA-ECMO in the setting of systemic thrombolytics (ST). A single institution retrospective study of PE patients treated with VA-ECMO between December 2015 and December 2020 was performed. Patients who received ST were compared with those who did not receive ST. Outcomes, including mortality, major bleeding, duration of mechanical ventilation, need for renal replacement therapy, and length of hospital stay, were compared. A total of 83 patients with PE required VA-ECMO support and 18 of these received systemic thrombolytics. There was no statistically significant difference in survival to discharge between the patients who received ST compared with those who did not (88.9% vs 84.6%; p = 0.94). Major bleeding events occurred more often in patients who received ST (61.1% vs 26.2%; p = 0.01). There was no significant difference in time on mechanical ventilation, need for renal replacement therapy, or length of stay between the groups. Reasonable survival can be achieved despite an increased frequency of major bleeding events in patients that receive ST prior to VA-ECMO for PE. ST administration should not be considered an absolute contraindication to VA-ECMO. Further multi-center studies are needed to corroborate these findings.
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http://dx.doi.org/10.1053/j.semtcvs.2021.04.004DOI Listing
May 2021

Increased complications in patients who test COVID-19 positive after elective surgery and implications for pre and postoperative screening.

Am J Surg 2021 Apr 14. Epub 2021 Apr 14.

Department of Surgery, University of Maryland School of Medicine, Baltimore, MD, USA; Surgery Service, Veterans Affairs Medical Center, Baltimore, MD, USA. Electronic address:

Background: The COVID-19 pandemic has necessitated the adoption of protocols to minimize risk of periprocedural complications associated with SARS-CoV-2 infection. This typically involves a preoperative symptom screen and nasal swab RT-PCR test for viral RNA. Asymptomatic patients with a negative COVID-19 test are cleared for surgery. However, little is known about the rate of postoperative COVID-19 positivity among elective surgical patients, risk factors for this group and rate of complications.

Methods: This prospective multicenter study included all patients undergoing elective surgery at 170 Veterans Health Administration (VA) hospitals across the United States. Patients were divided into groups based on first positive COVID-19 test within 30 days after surgery (COVID[-/+]), before surgery (COVID[+/-]) or negative throughout (COVID[-/-]). The cumulative incidence, risk factors for and complications of COVID[-/+], were estimated using univariate analysis, exact matching, and multivariable regression.

Results: Between March 1 and December 1, 2020 90,093 patients underwent elective surgery. Of these, 60,853 met inclusion criteria, of which 310 (0.5%) were in the COVID[-/+] group. Adjusted multivariable logistic regression identified female sex, end stage renal disease, chronic obstructive pulmonary disease, congestive heart failure, cancer, cirrhosis, and undergoing neurosurgical procedures as risk factors for being in the COVID[-/+] group. After matching on current procedural terminology code and month of procedure, multivariable Poisson regression estimated the complication rate ratio for the COVID[-/+] group vs. COVID[-/-] to be 8.4 (C.I. 4.9-14.4) for pulmonary complications, 3.0 (2.2, 4.1) for major complications, and 2.6 (1.9, 3.4) for any complication.

Discussion: Despite preoperative COVID-19 screening, there remains a risk of COVID infection within 30 days after elective surgery. This risk is increased for patients with a high comorbidity burden and those undergoing neurosurgical procedures. Higher intensity preoperative screening and closer postoperative monitoring is warranted in such patients because they have a significantly elevated risk of postoperative complications.
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http://dx.doi.org/10.1016/j.amjsurg.2021.04.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8045424PMC
April 2021

Ischemia-reperfusion Injury in the Transplanted Lung: A Literature Review.

Transplant Direct 2021 Feb 7;7(2):e652. Epub 2021 Jan 7.

Department of Surgery, University of Maryland Medical Center, Baltimore, MD.

Lung ischemia-reperfusion injury (LIRI) and primary graft dysfunction are leading causes of morbidity and mortality among lung transplant recipients. Although extensive research endeavors have been undertaken, few preventative and therapeutic treatments have emerged for clinical use. Novel strategies are still needed to improve outcomes after lung transplantation. In this review, we discuss the underlying mechanisms of transplanted LIRI, potential modifiable targets, current practices, and areas of ongoing investigation to reduce LIRI and primary graft dysfunction in lung transplant recipients.
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http://dx.doi.org/10.1097/TXD.0000000000001104DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793349PMC
February 2021

Transcarotid Approach for Ascending Aortic Endovascular Repair.

Ann Thorac Surg 2021 07 4;112(1):e17-e19. Epub 2021 Jan 4.

Department of Surgery, Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland.

This report describes a case of penetrating aortic ulcer in zone 0 of the ascending aorta with concern for free rupture that was treated with a transcarotid endovascular stent graft. The patient was noted to be a poor candidate for open repair given comorbidities, frailty, and age. She had chronic occlusion of the right external iliac artery and stenosis of the left external iliac artery. Endovascular ascending aortic stenting was deployed successfully through right common carotid access. The patient had an uncomplicated postoperative course without evidence of stroke. The transcarotid approach is an optimal alternative access for patients undergoing endovascular ascending aortic repair.
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http://dx.doi.org/10.1016/j.athoracsur.2020.10.063DOI Listing
July 2021

Periprocedural complications in patients with SARS-CoV-2 infection compared to those without infection: A nationwide propensity-matched analysis.

Am J Surg 2021 08 28;222(2):431-437. Epub 2020 Dec 28.

Geriatrics Research, Education, and Clinical Center, Veterans Affairs Medical Center, Baltimore, MD, USA; Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA.

Background: Reports on emergency surgery performed soon after a COVID-19 infection that are not controlled for premorbid risk-factors show increased 30-day mortality and pulmonary complications. This contributed to a virtual cessation of elective surgery during the pandemic surge. To inform evidence-based guidance on the decisions for surgery during the recovery phase of the pandemic, we compare 30-day outcomes in patients testing positive for COVID-19 before their operation, to contemporary propensity-matched COVID-19 negative patients undergoing the same procedures.

Methods: This prospective multicentre study included all patients undergoing surgery at 170 Veterans Health Administration (VA) hospitals across the United States. COVID-19 positive patients were propensity matched to COVID-19 negative patients on demographic and procedural factors. We compared 30-day outcomes between COVID-19 positive and negative patients, and the effect of time from testing positive to the date of procedure (≤10 days, 11-30 days and >30 days) on outcomes.

Results: Between March 1 and August 15, 2020, 449 COVID-19 positive and 51,238 negative patients met inclusion criteria. Propensity matching yielded 432 COVID-19 positive and 1256 negative patients among whom half underwent elective surgery. Infected patients had longer hospital stays (median seven days), higher rates of pneumonia (20.6%), ventilator requirement (7.6%), acute respiratory distress syndrome (ARDS, 17.1%), septic shock (13.7%), and ischemic stroke (5.8%), while mortality, reoperations and readmissions were not significantly different. Higher odds for ventilation and stroke persisted even when surgery was delayed 11-30 days, and for pneumonia, ARDS, and septic shock >30 days after a positive test.

Discussion: 30-day pulmonary, septic, and ischaemic complications are increased in COVID-19 positive, compared to propensity score matched negative patients. Odds for several complications persist despite a delay beyond ten days after testing positive. Individualized risk-stratification by pulmonary and atherosclerotic comorbidities should be considered when making decisions for delaying surgery in infected patients.
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http://dx.doi.org/10.1016/j.amjsurg.2020.12.024DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836786PMC
August 2021

Ex Vivo Lung Perfusion: Current Achievements and Future Directions.

Transplantation 2021 05;105(5):979-985

Department of Surgery, University of Maryland School of Medicine, Baltimore, MD.

There is a severe shortage in the availability of donor organs for lung transplantation. Novel strategies are needed to optimize usage of available organs to address the growing global needs. Ex vivo lung perfusion has emerged as a powerful tool for the assessment, rehabilitation, and optimization of donor lungs before transplantation. In this review, we discuss the history of ex vivo lung perfusion, current evidence on its use for standard and extended criteria donors, and consider the exciting future opportunities that this technology provides for lung transplantation.
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http://dx.doi.org/10.1097/TP.0000000000003483DOI Listing
May 2021

Understanding the Pathognomonic Tumefactive Appearance of Neurolymphomatosis: A Unifying Theory of Neurolymphoma.

World Neurosurg 2020 09 31;141:e490-e497. Epub 2020 May 31.

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

Background: The diagnosis of peripheral neurolymphomatosis (NL) is difficult and often delayed, because patients can have isolated, nonspecific nerve symptoms. Magnetic resonance imaging will usually show nonspecific findings of enlarged, contrast-enhancing nerves. We aimed to elucidate the mechanism behind an imaging finding we believe is pathognomonic of NL and likely of other hematologic diseases with peripheral nerve involvement.

Methods: We reviewed the imaging studies of a previously reported cohort of patients, in addition to those from more recent patients, all with tumefactive NL, in which enlarged nerve bundles were surrounded by tumor. We reviewed the demographic data, clinical data (e.g., primary or secondary disease, biopsy-proven diagnosis), and imaging findings (e.g., tumefactive appearance, primary involved nerve, location of epicenter of tumefactive appearance, vascular involvement).

Results: All cases showed a maximum tumefactive appearance at branch or junction points, with a gradual decrease of this appearance moving proximally and distally from the epicenter in a "crescendo-decrescendo" pattern. We have described this as a phasic mechanism with 3 phases: malignant cells fill the intraneural space; extrude at a weak spot of the nerve, which often occurs at a branch or junction point; and then expand and fill the subparaneurial space, creating the grossly tumefactive appearance with proximal and distal spread.

Conclusions: We have presented a novel, unifying theory explaining the pathognomonic tumefactive appearance of NL. Our theory offers the first rational explanation for the radiological appearance of NL with peripheral nerve involvement. We believe that with earlier recognition of NL on imaging studies, patients will be able to receive an earlier diagnosis and undergo earlier treatment.
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http://dx.doi.org/10.1016/j.wneu.2020.05.228DOI Listing
September 2020

Recurrent desmoid-type fibromatosis associated with underlying neuromuscular choristoma.

J Neurosurg 2018 Aug;131(1):175-183

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

Objective: Desmoid-type fibromatosis (DTF) presents a therapeutic dilemma. While lacking metastatic potential, it is a locally aggressive tumor with a strong propensity for occurrence near nerve(s) and recurrence following resection. In this study, the authors introduce the association of an occult neuromuscular choristoma (NMC) identified in patients with DTF.

Methods: After experiencing a case of DTF found to have an occult NMC, the authors performed a retrospective database review of all other cases of biopsy-proven DTF involving the extremities or limb girdles in patients with available MRI data. Two musculoskeletal radiologists with expertise in peripheral nerve imaging reviewed the MRI studies of the eligible cases for evidence of previously unrecognized NMC.

Results: The initial case of a patient with an occult sciatic NMC is described. The database review yielded 40 patients with DTF-18 (45%) in the upper limb and 22 (55%) in the lower limb. Two cases (5%) had MRI findings of NMC associated with the DTF, one in the proximal sciatic nerve and the other in the proximal tibial and sural nerves.

Conclusions: The coexistence of NMC may be under-recognized in a subset of patients with extremity DTF. This finding poses implications for DTF treatment and the likelihood of recurrence after resection or biopsy. Further study may reveal crucial links between the pathogenesis of NMC and DTF and offer novel therapeutic strategies.
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http://dx.doi.org/10.3171/2018.3.JNS152935DOI Listing
August 2018

The Right Way to Teach Left-Handed Residents: Strategies for Training by Right Handers.

J Surg Educ 2018 Mar - Apr;75(2):271-277. Epub 2017 Jul 27.

Department of Surgery, University Of Maryland Medical Center, Baltimore, Maryland. Electronic address:

Purpose: Left-handed (LH) residents remain underrepresented among surgical trainees, and there are few available data on how best to train them. The challenge is amplified when pairing a LH resident with a right-handed (RH) mentor. This report provides recommendations on how to improve the training of LH surgeons in a safe and effective manner.

Methods: A comprehensive literature review was performed using different databases and search engines to identify all articles relevant to the training of LH residents.

Results: A total of 40 articles highlighted the challenges for LH surgical residents and RH mentors. Our recommendations are based on the following 4 themes: identifying inherent differences in left vs. RH residents, providing guidance to RH mentors training LH residents, adapting the RH environment to the LH surgeon, and maximizing safety during training.

Conclusion: An organized approach needs to be taken in training the LH resident. Changes should be instituted at program-wide and national levels to ensure that the training experience of the sinistral surgical resident is optimized.
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http://dx.doi.org/10.1016/j.jsurg.2017.07.004DOI Listing
December 2018

Axillary Intraneural Ganglion Cysts.

J Surg Orthop Adv Summer 2017;26(2):69-74

Department of Neurosurgery, Justus Liebig University Giessen, Germany.

Aside from affecting the stability of the glenohumeral joint, tears in the joint capsule can give rise to extraneural (paralabral) and, very rarely, intraneural ganglion cysts. This report presents the first two cases of axillary intraneural ganglion cysts in the literature with magnetic resonance imaging. Both cases were incidentally noted to have coexisting lesions (lymphadenopathy from an undifferentiated malignancy and suprascapular nerve entrapment, respectively). This report reinforces the applicability of the articular theory for intraneural ganglion cysts at a novel site.
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February 2018

Can Intraneural Perineuriomas Occur Intradurally? An Anatomic Perspective.

Neurosurgery 2017 02;80(2):226-234

Department of Neurological Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Background: Intraneural perineuriomas are rare, benign lesions produced by the neoplastic proliferation of perineurial cells. They typically present in adolescents and affect nerves of the limbs. In our experience, we have not encountered a single case of classic intraneural perineurioma at an intradural location.

Objective: To determine whether intraneural perineuriomas could occur intradurally, given the prevalence of intradural nerve sheath tumors, and explain our findings with an anatomic perspective.

Methods: We retrospectively reviewed the high-resolution magnetic resonance images of 56 patients from an institutional registry of patients with intraneural perineurioma. All cases were analyzed for signs of proximal extension toward spinal nerves, roots, and spinal cord. A literature review was performed. The clinical, radiological, and histopathological features of potential intradural lesions were critically appraised against strict criteria for a diagnosis of classic intraneural perineurioma.

Results: Fifteen of 56 (27%) patients with intraneural perineurioma had a proximal localization in the lumbosacral or brachial plexus. Not a single case occurred proximal to the dorsal root ganglia (DRG). One case of trigeminal intraneural perineurioma occurred distal to the gasserian ganglion. A literature review did not reveal any convincing cases of classic intraneural perineuriomas occurring in an intraspinal intradural location and revealed only 1 possible case in an intracranial intradural location.

Conclusion: Based on our study, the occurrence of classic intraneural perineuriomas intradurally is exceedingly rare, if at all present. This may be related to the paucity of perineurial cells at the nerve root level and reciprocal interactions between neuroglial cells at the central-to-peripheral transition zones.
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http://dx.doi.org/10.1093/neuros/nyw028DOI Listing
February 2017

Foot and Ankle Kinematics and Dynamic Electromyography: Quantitative Analysis of Recovery From Peroneal Neuropathy in a Professional Football Player.

J Surg Orthop Adv Fall 2016;25(3):180-186

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.

The assessment of neuromuscular recovery after peripheral nerve surgery has typically been a subjective physical examination. The purpose of this report was to assess the value of gait analysis in documenting recovery quantitatively. A professional football player underwent gait analysis before and after surgery for a peroneal intraneural ganglion cyst causing a left-sided foot drop. Surface electromyography (SEMG) recording from surface electrodes and motion parameter acquisition from a computerized motion capture system consisting of 10 infrared cameras were performed simultaneously. A comparison between SEMG recordings before and after surgery showed a progression from disorganized activation in the left tibialis anterior and peroneus longus muscles to temporally appropriate activation for the phase of the gait cycle. Kinematic analysis of ankle motion planes showed resolution from a complete foot drop preoperatively to phase-appropriate dorsiflexion postoperatively. Gait analysis with dynamic SEMG and motion capture complements physical examination when assessing postoperative recovery in athletes.
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January 2017

A new pattern of lipomatosis of nerve: case report.

J Neurosurg 2017 Mar 6;126(3):933-937. Epub 2016 May 6.

Departments of 1 Neurologic Surgery and.

Lipomatosis of nerve (LN) is a rare disorder of peripheral nerves that produces proliferation of interfascicular adipose tissue. It may be associated with soft-tissue and bony overgrowth within the affected nerve territory. LN has been almost exclusively reported in appendicular peripheral nerves; the median nerve at the wrist and palm is among the most common locations. The authors present a new pattern of LN that shows circumferential proliferation of fat around the epineurium of the nerve. They believe that this case and the two other documented examples in the literature (also affecting cervical and thoracic spinal nerves) share the same new pattern of LN. Defining the full spectrum of adipose lesions of the nerve and establishing a cause-effect relationship with nerve-territory overgrowth disorders may offer options for future management through targeted nerve lesioning.
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http://dx.doi.org/10.3171/2016.2.JNS151051DOI Listing
March 2017

A radiological classification system for intraneural vascular anomalies: assessment of potential for resection with high-resolution MRI.

Acta Neurochir (Wien) 2016 Feb 23;158(2):329-34; discussion 334. Epub 2015 Dec 23.

Department of Neurosurgery, Mayo Clinic Rochester, Gonda 8-214, Rochester, MN, 55905, USA.

Background: Intraneural hemangiomas and vascular malformations are rare, with approximately 50 cases reported in the literature. They present a therapeutic challenge; surgical resection can result in damage to the nerve and lesion recurrence is common. We introduce a new framework to classify intraneural vascular anomalies in relation to the anatomic compartments of the nerve and assess amenability to surgical resection.

Methods: We retrospectively reviewed cases of intraneural hemangiomas and vascular malformations treated at our institution between 2003 and 2013 that had high-resolution 3-T magnetic resonance imaging (MRI). A review of the literature was also performed. Our cases and reports in the literature with available MRI data were sub-categorized according to their relationship to the paraneurium and epineurium of the nerve.

Results: Nine patients were identified with intraneural (subparaneurial or subepineurial) vascular lesions. Two patients had a predominantly subparaneurial involvement of the nerve, six patients had predominantly subepineurial involvement, and one patient exhibited extensive involvement in both compartments. Four patients were managed surgically and the rest conservatively. Targeted resection of two subparaneurial hemangiomas provided complete relief of symptoms and freedom from recurrence at 18 month and 24 months respectively. One patient with extensive subepineurial and extraneural vascular malformations did not appear to benefit from sub-total resection with interfascicular dissection. No surgical morbidity was noted in any of the cases.

Conclusions: We believe that the subparaneurial compartment-a potential space between the epineurium and paraneurium-provides a tissue plane within which benign vascular lesions can occur. Hemangiomas and vascular malformations are complex and can occupy different intraneural and extraneural compartments. The anatomic framework aids surgical decision-making and ensures that all components of the lesion are considered. We advocate a multimodal approach in the treatment of these rare lesions.
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http://dx.doi.org/10.1007/s00701-015-2663-6DOI Listing
February 2016

Subparaneurial ganglion cysts of the fibular and tibial nerves: A new variant of intraneural ganglion cysts.

Clin Anat 2016 May 18;29(4):530-7. Epub 2015 Dec 18.

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

Over the last decade, the mechanism of formation of intraneural ganglion cysts has been established through a meticulous review of clinical findings and correlation with patterns produced on magnetic resonance imaging (MRI). Pathognomonic imaging patterns distinguish these rare lesions from the more common extraneural variants in almost all cases. In this report, we present a new pattern of cyst occurrence in the subparaneurial compartment of the nerve and provide potential anatomic explanations for its pathogenesis. Using an anatomic framework of connective tissue compartments of the nerve, we reviewed 63 (56 fibular and seven tibial) intraneural ganglion cysts in the knee region evaluated at our institution and all reports with MRI in the world's literature for evidence of cyst occurrence in the subparaneurial compartment. We identified six cases (five in the common fibular nerve and one in the tibial nerve) at our institution that had MR evidence of cyst in the subparaneurial compartment with a new complex lobulated pattern. All cases had articular branch connections to the superior tibiofibular joint, which at operation were resected along with the joints. Follow-up revealed complete recovery in all instances and no clinical or radiological signs of recurrence. Three cases out of 80 in the literature exhibited the new complex lobulated MRI pattern. We present a new pattern of intraneural ganglion cyst occurrence in a potential space that surrounds peripheral nerves--the subparaneurial compartment. We believe that the unifying articular theory applies to the pathogenesis and management of these rare variants.
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http://dx.doi.org/10.1002/ca.22671DOI Listing
May 2016

Intraneural Hematoma: A Proposed Anatomic Classification with Potential Treatment Implications.

World Neurosurg 2015 Dec 4;84(6):1977-84. Epub 2015 Sep 4.

Department of Neurosurgery, Mount Sinai Beth Israel Medical Center, New York, New York, USA.

Intraneural hematoma is a rare entity with fewer than 20 cases reported in the literature. There is no consensus on surgical treatment due to its rarity. We present a novel classification for intraneural hematomas based on a review of the literature and illustrated by 4 cases that were treated in our 3 centers. This classification system localizes the hematoma to the different connective tissue layers that compose the nerve: the paraneurium, epineurium, and perineurium. We believe that this classification has consequences for surgical treatment and can form the foundation for future research into the natural history of these types of lesions.
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http://dx.doi.org/10.1016/j.wneu.2015.08.063DOI Listing
December 2015

The successful arthroscopic treatment of suprascapular intraneural ganglion cysts.

Neurosurg Focus 2015 Sep;39(3):E11

Departments of 1 Orthopedics.

OBJECT High-resolution magnetic resonance imaging (MRI) can distinguish between intraneural ganglion cysts and paralabral (extraneural) cysts at the glenohumeral joint. Suprascapular intraneural ganglion cysts share the same pathomechanism as their paralabral counterparts, emanating from a tear in the glenoid labrum. The authors present 2 cases to demonstrate that the identification and arthroscopic repair of labral tears form the cornerstone of treatment for intraneural ganglion cysts of the suprascapular nerve. METHODS Two patients with suprascapular intraneural ganglion cysts were identified: 1 was recognized and treated prospectively, and the other, previously reported as a paralabral cyst, was identified retrospectively through the reinter-pretation of high-resolution MR images. RESULTS Both patients achieved full functional recovery and had complete radiological involution of the intraneural ganglion cysts at the 3-month and 12-month follow-ups, respectively. CONCLUSIONS Previous reports of suprascapular intraneural ganglion cysts described treatment by an open approach to decompress the cysts and resect the articular nerve branch to the glenohumeral joint. The 2 cases in this report demonstrate that intraneural ganglion cysts, similar to paralabral cysts, can be treated with arthroscopic repair of the glenoid labrum without resection of the articular branch. This approach minimizes surgical morbidity and directly addresses the primary etiology of intraneural and extraneural ganglion cysts.
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http://dx.doi.org/10.3171/2015.6.FOCUS15201DOI Listing
September 2015

The subparaneurial compartment: A new concept in the clinicoanatomic classification of peripheral nerve lesions.

Clin Anat 2015 Oct 16;28(7):925-30. Epub 2015 Jul 16.

Departments of Neurological Surgery, Mayo Clinic, Rochester, Minnesota.

Based on our experience in treating peripheral non-neural sheath derived pathology, we have identified a novel pattern of lesion progression along the anatomic course of nerves. This report highlights the existence of a subparaneurial compartment around peripheral nerves. We first applied an anatomic framework to review MR images and intraoperative photographs of patients treated by the senior author in the last 10 years. After identifying a pattern that was consistent with subparaneurial lesion progression, we searched for other examples of cases that might exhibit this pattern. Four examples of subparaneurial pathology were identified, a hemangioma of the ulnar nerve, a ganglion cyst of the common fibular nerve, a lymphoma of the sciatic nerve and a lipoma of the ulnar nerve. All four patients were operated on and had intraoperative photographs; three had high resolution MR imaging. This report highlights the existence of pathology contained within a subparaneurial compartment, outside of the epineurium, that follows the course of the nerve and surrounds it circumferentially. The subparaneurial localization of peripheral nerve lesions has hitherto received little attention. Identification of this new pattern on preoperative MRI may have implications for surgical management.
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http://dx.doi.org/10.1002/ca.22589DOI Listing
October 2015

Concurrent Lateral Dorsal Cutaneous and Deep Peroneal Intraneural Ganglion Cysts in the Foot.

J Foot Ankle Surg 2016 Mar-Apr;55(2):401-5. Epub 2015 May 13.

Professor and Chair, Department of Neurosurgery, Mayo Clinic, Rochester, MN. Electronic address:

Intraneural ganglion cysts are non-neoplastic collections of mucinous material within the epineurium of peripheral nerves. We present a rare case of 2 intraneural ganglion cysts in separate nerves of the foot, originating from different joints within the same joint complex. Our findings add to the large body of evidence supporting the unifying articular (synovial) theory. We emphasize the importance of delineating the cyst morphology and origins using high-resolution magnetic resonance imaging before surgery and searching for and resecting the articular branch or branches during surgery.
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http://dx.doi.org/10.1053/j.jfas.2015.02.006DOI Listing
December 2016

An anatomic explanation for combined so-called adventitial/intraneural cysts.

Clin Anat 2015 Oct 10;28(7):829-32. Epub 2015 Apr 10.

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

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http://dx.doi.org/10.1002/ca.22538DOI Listing
October 2015

How to explain cystic adventitial disease coexisting in an adjacent artery and vein.

Clin Anat 2015 Oct 2;28(7):833-5. Epub 2015 Feb 2.

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

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http://dx.doi.org/10.1002/ca.22506DOI Listing
October 2015
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