Publications by authors named "Sergey Spektor"

53 Publications

Flow-diverter stents in the early management of acutely ruptured brain aneurysms: effective rebleeding protection with low thromboembolic complications.

J Neurosurg 2021 Apr 16:1-8. Epub 2021 Apr 16.

4Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel; and.

Objective: Flow-diverter stents (FDSs) are not generally used for the management of acutely ruptured aneurysms with associated subarachnoid hemorrhage (SAH). Herein, the authors present their experience with FDSs in this scenario, focusing on the antiplatelet regimen, perioperative management, and outcome.

Methods: The authors retrospectively reviewed their institutional database for the treatment and outcomes of all patients with acutely ruptured aneurysms and associated SAH from July 2010 to September 2018 who had received an FDS implant as stand-alone treatment within 4 days after diagnosis. The protocol with the use of flow diversion in these patients includes a low threshold for placement of external ventricular drains before stenting, followed by the administration of aspirin and clopidogrel with platelet testing before stent implantation. With this approach, the risk of hemorrhage and stent-related thrombus formation is limited. Demographic, clinical, technical, and imaging data were analyzed.

Results: Overall, 76 patients (61% females, mean age 42.8 ± 11.3 years) met the inclusion criteria. FDS implantation was performed a median of 2 days after diagnosis. On average, 1.05 devices were used per procedure. There was no procedural mortality directly attributed to the endovascular intervention. Procedural device-related clinical complications were recorded in a total of 6 cases (7.9%) and resulted in permanent neurological morbidity in 2 cases (2.6%). There was complete immediate aneurysm occlusion in 11 patients (14.5%), and persistent aneurysm filling was seen in 65 patients (85.5%). Despite this, no patient presented with rebleeding from the target aneurysm. There was an excellent clinical outcome in 62 patients (81.6%), who had a 90-day modified Rankin Scale score of 0-2. Among the 71 survivors, total or near-total occlusion was observed in 64/67 patients (95.5%) with a 3- to 6-month angiographic follow-up and in all cases evaluated at 12 months. Five patients (6.6%) died during follow-up for reasons unrelated to the procedure or new hemorrhage.

Conclusions: Flow diversion is an effective therapeutic strategy for the management of select acutely ruptured aneurysms. Despite low rates of immediate aneurysm occlusion after FDS implantation, the device exerts an important protective effect. The authors' experience confirmed no aneurysm rerupture, high rates of delayed complete occlusion, and complication rates that compare favorably with the rates obtained using other techniques.
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http://dx.doi.org/10.3171/2020.10.JNS201642DOI Listing
April 2021

Solid vs. cystic predominance in posterior fossa hemangioblastomas: implications for cerebrovascular risks and patient outcome.

Acta Neurochir (Wien) 2021 Apr 3. Epub 2021 Apr 3.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.

Background: Hemangioblastomas (HGBs) are highly vascular benign tumors, commonly located in the posterior fossa, and 80% of them are sporadic. Patients usually present with features of raised intracranial pressure and cerebellar symptoms. HGB can be classified as either mostly cystic or solids. Although the solid component is highly vascularized, aneurysm or hemorrhagic presentation is rarely described, having catastrophic results.

Methods: We identified 32 consecutive patients with posterior fossa HBG who underwent surgery from 2008 through 2020 at our medical center. Tumors were classified as predominantly cystic or solid according to radiological features. Resection was defined as gross total (GTR) or subtotal (STR).

Results: During the study period, 32 posterior fossa HGBs were resected. There were 26 cerebellar lesions and 4 medullar lesions, and in 2 patients, both structures were affected. Predominant cystic tumors were seen in 15 patients and solids in 17. Preoperative digital subtraction angiography (DSA) was performed in 8 patients with solid tumors, and 4 showed tumor-related aneurysms. Embolization of the tumors was performed in 6 patients, including the four tumor-related aneurysms. GTR was achieved in 29 tumors (91%), and subtotal resection in 3 (9%). Three patients had postoperative lower cranial nerve palsy. Functional status was stable in 5 patients (16%), improved in 24 (75%), and 3 patients (9%) deteriorated. One patient died 2 months after the surgery. Two tumors recurred and underwent a second surgery achieving GTR. The mean follow-up was 42.7 months (SD ± 51.0 months).

Conclusions: Predominant cystic HGB is usually easily treated as the surgery is straightforward. Those with a solid predominance present a more complex challenge sharing features similar to arteriovenous malformations. Given the important vascular association of solid predominance HGB with these added risk factors, the preoperative assessment should include DSA, as in arteriovenous malformations, and endovascular intervention should be considered before surgery.
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http://dx.doi.org/10.1007/s00701-021-04828-wDOI Listing
April 2021

Acquisition of Basic Microsurgical Skills Using Low-Cost, Readily Available Models: The Orange Model.

World Neurosurg 2021 Feb 18;146:189-196. Epub 2020 Nov 18.

Department of Neurosurgery, New York University Langone Health, New York, New York, USA.

Background: Attainment of basic microsurgical skills in neurosurgery presents a departmental challenge worldwide. Models for teaching are either not readily available or expensive and are incompatible with a resident's busy schedule, requiring lengthy and proper setup. We present a model and a set of measurable tasks, based on a fruit (orange) that is cheap, easy to set up instantly when desired, and useful for training of basic microsurgical skills.

Methods: Basic microsurgical skills were identified, necessitating hand-eye coordination working with the microscope. The goal was to dissect an orange segment while preserving adjacent segments. Assessment was based on the number of side tears and task completion duration. The task was repeated in a sequential manner (n = 10), for validation purposes, for 3 operators at different seniority levels.

Results: An improvement in the number of side tears (mean of 12.66 ± 9.01 in the first trial vs. 4 ± 4.35 in the 10th trial, P < 0.01), as well as duration of time required for task completion (mean initial duration of 28:16 ± 19:00 minutes to a duration of 16:33 ± 10:50 minutes in the last attempt, P < 0.01), was observed. Daily practice scores and time gradually improved, and the seniority level of operators was correlated with scoring between individuals.

Conclusions: The orange model is an easily accessible, cheap model that enables the acquisition of basic microneurosurgical skills. In this work, we validated and defined reproducible tasks that can be scored and tracked, correlated with operator's proficiency and experience. This model can be incorporated into a resident's workflow environment and provides a platform for attainment of elementary microsurgical skills for neurosurgical residents.
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http://dx.doi.org/10.1016/j.wneu.2020.11.060DOI Listing
February 2021

Spontaneous symptomatic orbital meningoencephalocele in an adult patient. Case report and review of the literature.

J Clin Neurosci 2020 Jul 11;77:224-226. Epub 2020 May 11.

Department of Neurosurgery. Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Symptomatic spontaneous meningoencephalocele (MEC) is a very rare entity in adults and there have been no reported cases of spontaneous MEC through the orbital roof in an adult. We report a 41-year-old woman who presented with a left eyelid swelling for several weeks without any history of trauma. Brain magnetic resonance imaging (MRI) showed a MEC through the orbital roof causing a significant blepharocele in this young patient. Supraorbital craniotomy was performed to repair the bone defect. The symptoms resolved immediately after surgery. Even though blepharocele is a rare manifestation of spontaneous orbital MEC it should be considered in the differential diagnosis for appropriate surgical management.
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http://dx.doi.org/10.1016/j.jocn.2020.05.020DOI Listing
July 2020

The oblique occipital sinus - implications in posterior fossa approaches.

J Clin Neurosci 2020 Jun 18;76:202-204. Epub 2020 Apr 18.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

The retrosigmoid craniotomy is the standard approach to resect pathologies in the cerebellopontine angle (CPA). Following the craniotomy, the dura mater is opened in the inferolateral direction and the basal cistern arachnoid is dissected in order to release pressure by the outflow of cerebrospinal fluid (CSF) from the foramen magnum, so that the CPA compartment can be approached with minimal retraction of the cerebellum. We report two patients, both with vestibular schwannoma, in whom preoperative magnetic resonance imaging (MRI) revealed unusual large oblique occipital sinus (OOS) draining laterally into the sigmoid sinus - jugular bulb junction. The sinuses were preserved intact while dura mater was opened for CSF release. Careful preoperative imaging is essential prior to posterior fossa lesions approaches in order to evaluate the persistency of an OOS, especially in a retrosigmoid approach. Inadvertent OOS damage might result in, not only significant bleeding during dural opening, but also air embolism or venous hypertension, if the contralateral sigmoid sinus is small or absent.
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http://dx.doi.org/10.1016/j.jocn.2020.04.055DOI Listing
June 2020

The infratranstentorial subtemporal approach (ITSTA): a valuable skull base approach to deep-seated non-skull base pathology.

Acta Neurochir (Wien) 2019 11 5;161(11):2335-2342. Epub 2019 Sep 5.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.

Background: Surgical access to space-occupying lesions such as tumors and vascular malformations located in the area of the tentorial notch, mediobasal temporal lobe, and para-midbrain is difficult. Lesions in this area are typically resected with supratentorial approaches demanding significant elevation of the temporal lobe or even partial lobectomy, or via a supracerebellar transtentorial approach. We introduce an alternative, the skull base infratranstentorial subtemporal approach (ITSTA), which provides excellent exposure of the incisural area while minimizing risk to the temporal lobe.

Methods: We included consecutive patients with pathology involving the area of the tentorial incisura, para-midbrain, and mediobasal temporal area who underwent surgery via ITSTA from 2012 to 2018. The approach includes partial mastoidectomy, temporal craniotomy, and tentorial section. Space obtained by mastoidectomy provides a sharp high-rising angle-of-attack, significantly diminishing the need for temporal lobe retraction. Surgeries were performed using microsurgical techniques, neuronavigation, and electrophysiological monitoring. Clinical presentation, tumor characteristics, extent of resection, complications, and outcome were retrospectively reviewed under a waiver of informed consent.

Results: Nine patients met inclusion criteria (five female, four male; mean age 44 years, range 7-72). They underwent surgery for removal of para-midbrain arteriovenous malformation (AVM, 3/9), medial tentorial meningioma (2/9), mediobasal epidermoid cyst (2/9), oculomotor schwannoma (1/9), or pleomorphic xanthoastrocytoma (PXA) of the fusiform gyrus (1/9). Three AVMs were removed completely; among six patients with tumors, gross total resection was achieved in three and subtotal resection in three. All surgeries were uneventful without complications. There were no new permanent neurological deficits. At late follow-up (mean 42.5 months), eight patients had a Glasgow Outcome Score (GOS) of 5. One 66-year-old female died 18 months after surgery for reasons not related to her disease or surgery.

Conclusions: The ITSTA is a valuable skull base approach for removal of non-skull base pathologies located in the difficult tentorial-incisural parabrainstem area.
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http://dx.doi.org/10.1007/s00701-019-04050-9DOI Listing
November 2019

CPA Epidermoid Cyst with Rare Anatomic Variant: Anterior Inferior Cerebellar Artery Embedded in the Subarcuate Fossa: Operative Video and Technical Nuances.

J Neurol Surg B Skull Base 2019 Jun 18;80(Suppl 3):S323-S324. Epub 2018 Oct 18.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Intracranial epidermoid cysts are considered benign tumors with a good general prognosis; however, their radical removal, including tumor capsule, is associated with significant morbidity, especially when the capsule is attached to neurovascular structures. We show an operative video describing main steps and surgical nuances in the resection of a large right cerebellopontine angle (CPA) epidermoid cyst in a 42-year-old male patient who presented with intractable trigeminal neuralgia. Craniectomy was performed to exposure the transverse-sigmoid sinus junction. A mold for a polymethylmethacrylate (PMMA) bone flap was built before opening the dura to avoid potentially neurotoxic effects on the cerebellum. The video illustrates the management of the rare anatomical variant of the anterior inferior cerebellar artery (AICA). Its loop was embedded in the dura, covering the subarcuate fossa where it gives off the subarcuate artery. Near total removal of the epidermoid cyst was achieved, leaving only a tiny capsule remnant adhering to the abducens nerve. Postoperatively the patient's trigeminal neuralgia was fully relieved and medications were discontinued. The patient's hearing was preserved per audiometry at the preoperative level (Gardner-Robertson II). Postoperative magnetic resonance imaging (MRI) revealed no signs of residual tumor. In this case, it was not possible to obtain optimal surgical exposure of the CPA without handling a rare anatomical anomaly of the AICA in the dura of the subarcuate fossa, which demanded coagulation and transection of the subarcuate artery and transposition of AICA with the dural cuff. This manipulation enabled optimal surgical removal of the epidermoid and didn't cause any neurological deficit. The link to the video can be found at: https://youtu.be/lLZqBHlu-uA .
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http://dx.doi.org/10.1055/s-0038-1675165DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6534694PMC
June 2019

Combination Treatment with Intravenous Tigecycline and Intraventricular and Intravenous Colistin in Postoperative Ventriculitis Caused by Multidrug-resistant Acinetobacter baumannii.

Cureus 2019 Jan 15;11(1):e3888. Epub 2019 Jan 15.

Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, ISR.

Nosocomial infections with multidrug-resistant (MDR) pathogens are a life-threatening complication in neurosurgery. An MDR Acinetobacter baumannii (A. baumannii) central nervous system (CNS) infection following neurosurgery has been previously reported and was treated with relative success using intraventricular and/or intravenous (IV) colistin, IV tigecycline, or IV colistin-rifampicin combination therapy. We present a case of MDR A. baumannii in a 13-year-old girl following parietal craniotomy for the resection of a right intraventricular meningioma. Several days after surgery, the patient presented with clinical, radiological, laboratorial, and microbiological evidence of carbapenem-resistant A. baumannii ventriculitis. She was treated with IV colistin and then with combined intraventricular-IV colistin, with partial failure. The combined treatment of IV tigecycline and associated intraventricular and intravenous colistin was started and significant improvement was seen clinically and radiologically, with negative cultures after one week. To the best of our knowledge, this is the first case of a successful combination of intraventricular and IV colistin combined with IV tigecycline after a partial treatment failure with intraventricular and IV colistin alone.
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http://dx.doi.org/10.7759/cureus.3888DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6424557PMC
January 2019

Stent and flow diverter assisted treatment of acutely ruptured brain aneurysms.

J Neurointerv Surg 2018 Sep 19;10(9):851-858. Epub 2018 May 19.

Department of Neurosurgery, Rabin Medical Center, Petah Tikva, Israel.

Objective: We present our experience with stent techniques in the management of acutely ruptured aneurysms, focusing on aneurysm occlusion rates, intraprocedural complications, and late outcomes.

Methods: We retrospectively reviewed the clinical records of patients treated by stent techniques during the early acute phase of aneurysmal rupture, from June 2011 to June 2016. Patients who underwent stenting for the management of unruptured aneurysms, or in a delayed fashion for a ruptured lesion, were excluded.

Results: 47 patients met inclusion criteria, including 46 with subarachnoid hemorrhage (SAH). There were 27 men and 20 women, mean age 38 years (range 23-73). They harbored 71 aneurysms, including 56 treated in the acute phase. Aneurysmal dome and neck width averaged 4.7 mm (range 1.7-12.1) and 3.2 mm (range 1.5-7.1), respectively. Single stent techniques were used in 39 patients and dual stent techniques in 17. External ventricular drains (EVDs) were placed before embolization in 35 patients (92%) and after in 3. Intraprocedure thromboembolic complications due to a hyporesponse to antiplatlets in 4 patients (8.5%) were successfully managed with intra-arterial antiplatelet agents. In 45 surviving patients (96%), there was complete aneurysm occlusion at the 9-12 month follow-up in 26/29 aneurysms treated by stent-assisted coiling (90%), in 2/3 aneurysms treated by flow diverter-assisted coiling (66%), and in 19/22 aneurysms treated by flow diverter alone (86%); 42/45 patients (93%) presented with a modified Rankin Scale score of 0-2.

Conclusion: Stenting techniques in ruptured aneurysms can be performed with good technical success; however, procedural thromboembolic complications related to the antiplatelet strategy merit investigation. EVD placement before stenting must be considered.
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http://dx.doi.org/10.1136/neurintsurg-2017-013742DOI Listing
September 2018

Vestibular Schwannoma Presenting with Bilateral Papilledema Without Hydrocephalus: Case Study.

Cureus 2017 Nov 20;9(11):e1862. Epub 2017 Nov 20.

Neurosurgery, Hadassah-Hebrew University Medical Center.

Bilateral papilledema secondary to obstructive or communicating hydrocephalus in patients with vestibular schwannomas is a known presentation; however, papilledema in the absence of hydrocephalus is rarely reported and its mechanism is poorly understood. We report a case of a 20-year-old woman presenting with visual deterioration and bilateral papilledema on fundoscopy. Magnetic resonance imaging (MRI) revealed a giant vestibular schwannoma with no sign of hydrocephalus. The only imaging evidence of increased pressure on preoperative imaging studies was seen on a T2-weighted MRI, where there was subtle dilatation of the arachnoid space of the optic sleeve. We presume that this patient developed papilledema by some mechanism not connected to hydrocephalus. In a young patient, papilledema may be a sign preceding hydrocephalus, or she may have had pseudotumor cerebri concomitant with her vestibular schwannoma. In either case, removal of the vestibular schwannoma solved the problem. She had complete visual recovery, irrespective of the mechanism.
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http://dx.doi.org/10.7759/cureus.1862DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5773271PMC
November 2017

Extensive bone erosion caused by pseudotumoral aneurysm growth.

J Clin Neurosci 2017 Feb 11;36:54-56. Epub 2016 Nov 11.

Department of Neurosurgery, Hadassah University Medical Center, Affiliated to the Hebrew University and Hadassah Medical School, Jerusalem, Israel.

Carotid ophthalmic aneurysms constitute 0.9-6.5% of the aneurysms of the ICA with up to 20% of the cases presenting with visual symptoms. We report a case of an adult woman, presented with chronic headaches and protracted visual alterations progressing to left eye amaurosis. Neuroradiological exams, revealed a giant partially thrombosed carotid ophthalmic aneurysm extending anteriorly, causing pseudotumoral spheno-orbital bone erosion. The patient underwent surgical clipping, evacuation of the thrombotic mass and decompression of the optic pathways with rapid recovery of the vision. This unusual case, contributes to the available body of evidence on aneurysms growth.
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http://dx.doi.org/10.1016/j.jocn.2016.10.028DOI Listing
February 2017

Idiopathic bilateral occlusion of the foramen of Monro: An unusual entity with varied clinical presentations.

J Clin Neurosci 2016 Dec 31;34:140-144. Epub 2016 Aug 31.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel.

We review our experience with four patients who presented to our Medical Center from 2005-2015 with adult idiopathic occlusion of the foramen of Monro (FM). All patients underwent CT scanning and MRI. Standard MRI was performed in each patient to rule out a secondary cause of obstruction (T1-weighted without- and with gadolinium, T2-weighted, fluid-attenuated inversion recovery [FLAIR] and diffusion-weighted imaging [DWI] protocols). When occlusion of the FM appeared to be idiopathic, further high-resolution MRI with multiplanar reconstructions for evaluation of stenosis or an occluding membrane at the level of the FM was performed (T1-weighted without- and with gadolinium, T2-weighted 3D turbo spin-echo). Occlusion of the FM was due to unilateral stenosis and septum pellucidum deviation in two patients, to an occluding membrane in one, and to bilateral stenosis in one patient. Urgent surgical intervention is mandatory when there are signs of increased intracranial pressure while asymptomatic patients may be managed conservatively. In this patient series, truly bilateral stenotic obstruction of the FM was best managed with ventriculoperitoneal shunt and patients with membranous obstruction or unilateral stenosis with septum deviation were treated endoscopically.
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http://dx.doi.org/10.1016/j.jocn.2016.05.015DOI Listing
December 2016

Iatrogenic postoperative cerebellar cyst.

J Clin Neurosci 2016 Dec 21;34:219-221. Epub 2016 Jul 21.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel.

Cerebellar cyst is a known but uncommon entity. It is congenital in most cases, or may develop after brain parenchyma injuries or interventions. To our knowledge, de novo cerebellar cyst after extra-axial tumor excision, has not been described in the literature. We present the first reported case of a de novo cerebellar cyst developing in a 70-year-old woman following retrosigmoid craniotomy for vestibular schwannoma excision, and discuss the possible causes. Following cyst fenestration, there was no clinical or radiological evidence of a residual cyst.
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http://dx.doi.org/10.1016/j.jocn.2016.05.019DOI Listing
December 2016

Author response: The essense of primum no nocere--striking a balance between benefit and harm.

Acta Neurochir (Wien) 2016 08 8;158(8):1603-4. Epub 2016 Jun 8.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

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http://dx.doi.org/10.1007/s00701-016-2848-7DOI Listing
August 2016

Response.

Neurosurg Focus 2016 Jan;40(1):E8

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January 2016

Ventriculoperitoneal shunt malfunction caused by proximal catheter fat obstruction.

J Clin Neurosci 2016 Aug 20;30:120-123. Epub 2016 Apr 20.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel.

Ventriculoperitoneal (VP) shunt placement is the mainstay of treatment for hydrocephalus, yet shunts remain vulnerable to a variety of complications. Although fat droplet migration into the subarachnoid space and cerebrospinal fluid pathways following craniotomy has been observed, a VP shunt obstruction with fat droplets has never been reported to our knowledge. We present the first reported case of VP shunt catheter obstruction by migratory fat droplets in a 55-year-old woman who underwent suboccipital craniotomy for removal of a metastatic tumor of the left medullocerebellar region, without fat harvesting. A VP shunt was inserted 1month later due to communicating hydrocephalus. The patient presented with gait disturbance, intermittent confusion, and pseudomeningocele 21days after shunt insertion. MRI revealed retrograde fat deposition in the ventricular system and VP shunt catheter, apparently following migration of fat droplets from the fatty soft tissue of the craniotomy site. Spinal tap revealed signs of aseptic meningitis. Steroid treatment for aseptic "lipoid" meningitis provided symptom relief. MRI 2months later revealed partial fat resorption and resolution of the pseudomeningocele. VP shunt malfunction caused by fat obstruction of the ventricular catheter should be acknowledged as a possible complication in VP shunts after craniotomy, even in the absence of fat harvesting.
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http://dx.doi.org/10.1016/j.jocn.2015.11.029DOI Listing
August 2016

Purely endoscopic removal of a parasagittal/falx meningioma.

Acta Neurochir (Wien) 2016 Mar 8;158(3):451-6. Epub 2016 Jan 8.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem, Israel, 91120.

Background: Endoscopic techniques are an integral part of the neurosurgical armamentarium with a growing list of indications. We describe the purely endoscopic removal of an atypical parasagittal meningioma in a patient who could not undergo standard craniotomy due to severe scalp atrophy following childhood irradiation for tinea capitis.

Methods: A 68-year-old man in good general health presented with a parasagittal meningioma that recurred following subtotal removal and adjuvant fractionated stereotactic radiosurgery (FSR). The scalp above the tumor location was very diseased and precluded a regular craniotomy for tumor removal. A 4-cm craniotomy was made in the midline forehead, where the skin was normal. A rigid endoscope was advanced under neuronavigation through the interhemispheric fissure, which provided good access with limited retraction, until the tumor was encountered at a depth of 7-8 cm. Two surgeons performed the surgery using a "four-hands technique". The tumor was removed and the insertion area was resected and coagulated.

Results: The surgery was uneventful, with no coagulation or transection of major veins. A subtotal resection was achieved, and the patient recovered with no neurological deficit.

Conclusions: Safe resection of parasagittal meningiomas with a purely endoscopic technique is feasible. This option needs further exploration as an alternative strategy in patients with severely atrophic scalp skin that greatly increases the risk of significant healing complications with calvarian craniotomy.
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http://dx.doi.org/10.1007/s00701-015-2689-9DOI Listing
March 2016

Modified pterional craniotomy without "MacCarty keyhole".

J Clin Neurosci 2016 Feb 9;24:135-7. Epub 2015 Oct 9.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel. Electronic address:

Pterional craniotomy is one of the most widely used approaches in neurosurgery. The MacCarty keyhole has remained the preferred means of beginning the craniotomy to achieve a low access point; however, the bone opening may result in a residual defect and an aesthetically unpleasant depression in the periorbital area. We present our modification of the traditional technique. Instead of drilling the keyhole in the frontoperiorbital area, the classical location, we perform a 5 × 15 mm strip craniectomy at the lowest accessible point in the infratemporal fossa, corresponding to the projection of the most lateral point of the sphenoid ridge. The anterior half of this opening exposes the basal frontal dura, while the posterior half brings the temporal dura into view. This modified technique was applied in 48 pterional craniotomies performed for removal of a variety of neoplasms during 2014-2015. There were no approach-related complications. Aesthetic outcomes and patient acceptance have been good; no patient developed skin depression in the periorbital area. In our experience, craniotomy for a pterional approach with the lowest possible access to the frontotemporal skull base may be performed by drilling a narrow oblong opening, without the use of any keyhole or burr hole, to create a smaller skull defect and achieve optimal aesthetic outcomes.
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http://dx.doi.org/10.1016/j.jocn.2015.07.010DOI Listing
February 2016

Physiological Correlates and Predictors of Functional Recovery After Chiasmal Decompression.

J Neuroophthalmol 2015 Dec;35(4):348-52

Department of Neurology (NR, ASB, TB-H, NL), The Agnes Ginges Center for Human Neurogenetics, Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Neurosurgery (SS), Hadassah Hebrew University Medical Center, Jerusalem, Israel; Department of Ophthalmology (AK), Sydney University, Sydney, Australia; and Translational Neuroradiology Unit (DR), National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland.

Background: The intrinsic abilities and limits of the nervous system to repair itself after damage may be assessed using a model of optic chiasmal compression, before and after a corrective surgical procedure.

Methods: Visual fields (VFs), multifocal visual evoked potentials (mfVEP), retinal nerve fiber layer (RNFL) thickness, and diffusion tensor imaging were used to evaluate a patient before and after removal of a meningioma compressing the chiasm. Normally sighted individuals served as controls. The advantage of each modality to document visual function and predict postoperative outcome (2-year follow-up) was evaluated.

Results: Postsurgery visual recovery was best explained by critical mass of normally conducting fibers and not associated with average conduction amplitudes. Recovered VF was observed in quadrants in which more than 50% of fibers were identified, characterized by intact mfVEP latencies, but severely reduced amplitudes. Recovery was evident despite additional reduction of RNFL thickness and abnormal optic tract diffusivity. The critical mass of normally conducting fibers was also the best prognostic indicator for functional outcome 2 years later.

Conclusions: Our results highlight the ability of the remaining normally conductive axons to predict visual recovery after decompression of the optic chiasm. The redundancy in anterior visual pathways may be explained, neuroanatomically, by overlapping receptive fields.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5078717PMC
http://dx.doi.org/10.1097/WNO.0000000000000266DOI Listing
December 2015

"Lazy" far-lateral approach to the anterior foramen magnum and lower clivus.

Neurosurg Focus 2015 Apr;38(4):E14

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

The far-lateral approach (FLA) has become a mainstay for skull base surgeries involving the anterior foramen magnum and lower clivus. The authors present a surgical technique using the FLA for the management of lesions of the anterior/ anterolateral foramen magnum and lower clivus. The authors consider this modification a "lazy" FLA. The vertebral artery (VA) is both a critical anatomical structure and a barrier that limits access to this region. The most important nuance of this FLA technique is the management of this critical vessel. When the lazy FLA is used, the VA is reflected laterally, encased in its periosteal sheath and wrapped in the dura, greatly minimizing the risk for vertebral injury while preserving a wide working space. To accomplish this step, drilling is performed lateral to the point where the VA pierces the dura. The dura is incised medial to the VA entry point by using a slightly curved longitudinal cut. Drilling of the condyle and the C-1 lateral mass is performed in a manner that preserves craniocervical stability. The lazy FLA is a true FLA that is based on manipulation of the VA and lateral bone removal to obtain excellent exposure ventral to the spinal cord and medulla, yet it is among the most conservative FLA techniques for management of the VA and provides a safer window for bone work and lesion management. Among 44 patients for whom this technique was used to resect 42 neoplasms and clip 2 posterior inferior cerebral artery aneurysms, there was no surgical mortality and no injury to the VA.
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http://dx.doi.org/10.3171/2015.2.FOCUS14784DOI Listing
April 2015

Comparison of outcomes following complex posterior fossa surgery performed in the sitting versus lateral position.

J Clin Neurosci 2015 Apr 6;22(4):705-12. Epub 2015 Mar 6.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel.

The sitting position during surgery is thought to provide important advantages, yet it remains controversial. We compared surgical and neurological outcomes for patients operated on in the sitting versus lateral position. Technically difficult procedures performed from the years 2001-2008 for complex lesions in the posterior fossa (vestibular schwannomas, other cerebellopontine angle tumors, foramen magnum meningiomas, brainstem cavernomas, pineal region tumors) were included. Outcomes in the two surgical positions were compared for all 243 patients (93 sitting, 38.3%; 150 lateral, 61.7%) and for 130/243 patients with vestibular schwannomas (50 sitting, 38.5%; 80 lateral, 61.5%). Sitting and lateral patient subgroups were clinically comparable. There were no surgical mortalities. The extent of removal and surgical and neurological outcomes were comparable. We found no advantage in surgical or neurological outcomes for use of the sitting or lateral surgical positions in technically difficult posterior fossa procedures. In vestibular schwannoma surgeries facial nerve preservation (House-Brackmann score 1-2) was related to extent of resection but not to surgical position. The choice of operative position should be based on lesion characteristics and the patient's preoperative medical status as well as the experience and preferences of the surgeons performing the procedure.
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http://dx.doi.org/10.1016/j.jocn.2014.12.005DOI Listing
April 2015

Optic nerve vascular compression in a patient with a tuberculum sellae meningioma.

Case Rep Ophthalmol Med 2015 1;2015:681632. Epub 2015 Feb 1.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, 91120 Jerusalem, Israel.

Background. Optic nerve vascular compression in patients with suprasellar tumor is a known entity but is rarely described in the literature. Case Description. We present a unique, well-documented case of optic nerve strangulation by the A1 segment of the anterior cerebral artery in a patient with a tuberculum sellae meningioma. The patient presented with pronounced progressive visual deterioration. Following surgery, there was immediate resolution of her visual deficit. Conclusion. Vascular strangulation of the optic nerve should be considered when facing progressive and/or severe visual field deterioration in patients with tumors proximal to the optic apparatus.
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http://dx.doi.org/10.1155/2015/681632DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4331469PMC
February 2015

Potential neurotoxic effects of polymethylmethacrylate during cranioplasty.

J Clin Neurosci 2015 Jan 29;22(1):139-43. Epub 2014 Jul 29.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem 91120, Israel. Electronic address:

Cranioplasty for the surgical correction of cranial defects is often performed using polymethyl methacrylate (PMMA), or bone cement. Immediately prior to PMMA application, a liquid monomer form (methylacrylate) and a benzoyl peroxide accelerator are mixed resulting in polymerization, an exothermic reaction during which monomer linking and subsequent formation of solid polymer occur. The potential side effects of residual methylacrylate monomer toxicity and thermal damage of neural tissue during PMMA hardening have been described in various in vitro, animal, and cadaveric studies; however, clinically documented in vivo neurotoxicity in humans attributed to either of the above two mechanisms during PMMA cranioplasty is lacking. We present a series of four patients operated for removal of cerebellopontine angle lesions and two operated for the excision of parieto-occipital tumors who sustained cranial neuropathies and encephalopathies with transient or permanent neurological deficits that could not be attributed to surgical manipulation. We hypothesize that these complications most likely occurred due to thermal damage and/or chemical toxicity from exposure to PMMA during cranioplasty. Our case series indicates that even small volumes of PMMA used for cranioplasty may cause severe side effects related to thermal damage or to exposure of neural tissue to methylacrylate monomer.
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http://dx.doi.org/10.1016/j.jocn.2014.06.006DOI Listing
January 2015

Parasellar meningiomas in pregnancy: surgical results and visual outcomes.

World Neurosurg 2014 Sep-Oct;82(3-4):e503-12. Epub 2013 Jul 10.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel. Electronic address:

Background: Rapid visual deterioration may occur as the result of the quick growth of parasellar meningiomas in the high-hormone/increased fluid retention milieu of pregnancy; however, surgery before delivery entails increased maternal-fetal risk. We present our experience in the management of parasellar meningiomas that compress the optic apparatus during pregnancy, with a focus on decisions regarding the timing of surgery.

Methods: Serial visual examinations and other clinical data for 11 women presenting from 2002 to 2012 with visual deterioration during pregnancy or delivery as the result of parasellar meningiomas involving the optic apparatus were reviewed. Indications for surgery during pregnancy included severely compromised vision, rapid visual deterioration, and early-to-midstage pregnancy with the potential for significant tumor growth and visual decrease before delivery. All patients underwent surgery with the use of skull base techniques via pterional craniotomy. An advanced extradural-intradural (i.e., Dolenc) approach, with modifications, was used in seven.

Results: All women achieved a Glasgow Outcome Score of 5 at discharge with no new neurologic deficits; all children are developing normally at a mean 4.5 years of age (range, 1-9.5 years). Surgery during pregnancy was recommended for six women: four operated at gestational weeks 20-23 had excellent postoperative visual recovery; two who delayed surgery until after delivery have permanent unilateral blindness. Among five others operated after delivery, four had good visual recovery and one has pronounced but correctable deficits. Three of five women diagnosed at gestational weeks 32-35 experienced spontaneous visual improvement after delivery, before surgery.

Conclusions: We recommend that surgery be offered to patients during pregnancy when a delay may result in severe permanent visual impairment.
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http://dx.doi.org/10.1016/j.wneu.2013.06.019DOI Listing
March 2015

Safety of drilling for clinoidectomy and optic canal unroofing in anterior skull base surgery.

Acta Neurochir (Wien) 2013 Jun 20;155(6):1017-24. Epub 2013 Apr 20.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, P.O. Box 12000, Jerusalem, 91120, Israel.

Background: Skull base drilling is a necessary and important element of skull base surgery; however, drilling around vulnerable neurovascular structures has certain risks. We aimed to assess the frequency of complications related to drilling the anterior skull base in the area of the optic nerve (ON) and internal carotid artery (ICA), in a large series of patients.

Methods: We included anterior skull base surgeries performed from 2000 to 2012 that demanded unroofing of the optic canal, with extra- or intradural clinoidectomy and/or drilling of the clinoidal process and lateral aspect of the tuberculum sella. Data was retrieved from a prospective database and supplementary retrospective file review. Our IRB waived the requirement for informed consent. The nature and location of pathology, clinical presentation, surgical techniques, surgical morbidity and mortality, pre- and postoperative vision, and neurological outcomes were reviewed.

Results: There were 205 surgeries, including 22 procedures with bilateral optic canal unroofing (227 optic canals unroofed). There was no mortality, drilling-related vascular damage, or brain trauma. Complications possibly related to drilling included CSF leak (6 patients, 2.9 %), new ipsilateral blindness (3 patients, 1.5 %), visual deterioration (3 patients, 1.5 %), and transient oculomotor palsy (5 patients, 2.4 %). In all patients with new neuropathies, the optic and oculomotor nerves were manipulated during tumor removal; thus, new deficits could have resulted from drilling, or tumor dissection, or both.

Conclusion: Drilling of the clinoid process and tuberculum sella, and optic canal unroofing are important surgical techniques, which may be performed relatively safely by a skilled neurosurgeon.
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http://dx.doi.org/10.1007/s00701-013-1704-2DOI Listing
June 2013

Solitary juvenile xanthogranuloma mimicking intracranial tumor in children.

J Clin Neurosci 2013 Jan 19;20(1):183-8. Epub 2012 Sep 19.

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, POB 12000, Jerusalem 91120, Israel.

Juvenile xanthogranuloma (JXG) is primarily a benign cutaneous disorder of non-Langerhans hystiocytic proliferation. Systemic involvement occurs in 4% of patients; isolated central nervous system (CNS) lesions are rare. We report solitary CNS-JXG lesions in two patients. A 3.5-year-old boy with a parietal-occipital lesion underwent total resection with no surgical morbidity and no recurrence at 16-month follow-up. A 3.5-year-old girl underwent subtotal resection of a tumor extending from the left Meckel's cave and invading the cavernous sinus and left orbit with extensive cranial nerve involvement. Tumor regrowth with leptomeningeal spread at 9-month and 12-month follow-up was managed with steroids and chemotherapy (vinblastine and later cladribine). We present our experience and review the literature pertaining to rare reports of solitary CNS-JXG.
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http://dx.doi.org/10.1016/j.jocn.2012.05.019DOI Listing
January 2013

Giant anterior clinoidal meningiomas: surgical technique and outcomes.

J Neurosurg 2012 Oct 17;117(4):654-65. Epub 2012 Aug 17.

Department of Neurosurgery, Hebrew University-Hadassah Medical Center, Jerusalem, Israel.

Object: Surgery for giant anterior clinoidal meningiomas that invade vital neurovascular structures surrounding the anterior clinoid process is challenging. The authors present their skull base technique for the treatment of giant anterior clinoidal meningiomas, defined here as globular tumors with a maximum diameter of 5 cm or larger, centered around the anterior clinoid process, which is usually hyperostotic.

Methods: Between 2000 and 2010, the authors performed 23 surgeries in 22 patients with giant anterior clinoidal meningiomas. They used a skull base approach with extradural unroofing of the optic canal, extradural clinoidectomy (Dolenc technique), transdural debulking of the tumor, early optic nerve decompression, and early identification and control of key neurovascular structures.

Results: The mean age at surgery was 53.8 years. The mean tumor diameter was 59.2 mm (range 50-85 mm) with cavernous sinus involvement in 59.1% (13 of 22 patients). The tumor involved the prechiasmatic segment of the optic nerve in all patients, invaded the optic canal in 77.3% (17 of 22 patients), and caused visual impairment in 86.4% (19 of 22 patients). Total resection (Simpson Grade I or II) was achieved in 30.4% of surgeries (7 of 23); subtotal and partial resections were each achieved in 34.8% of surgeries (8 of 23). The main factor precluding total removal was cavernous sinus involvement. There were no deaths. The mean Glasgow Outcome Scale score was 4.8 (median 5) at a mean of 56 months of follow-up. Vision improved in 66.7% (12 of 18 patients) with consecutive neuroophthalmological examinations, was stable in 22.2% (4 of 18), and deteriorated in 11.1% (2 of 18). New deficits in cranial nerve III or IV remained after 8.7% of surgeries (2 of 23).

Conclusions: This modified surgical protocol has provided both a good extent of resection and a good neurological and visual outcome in patients with giant anterior clinoidal meningiomas.
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http://dx.doi.org/10.3171/2012.7.JNS111675DOI Listing
October 2012

Single-center experience on endovascular reconstruction of traumatic internal carotid artery dissections.

J Trauma Acute Care Surg 2012 Jan;72(1):216-21

Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Background: Traumatic internal carotid artery dissection (CAD) has a potentially grave outcome. Anticoagulant therapy may be ineffective or contraindicated; surgery impractical. We present our experience with endovascular stenting in CAD patients.

Methods: From 2004 to 2011, 23 patients with angiographically proven traumatic CAD underwent endovascular stent-assisted arterial reconstruction based on clinical and radiographic criteria: contraindication or failure of anticoagulation, evidence of impending ischemic stroke, or need for urgent intracranial revascularization. Dissections were graded based on degree of stenosis and extent of injury.

Results: Seventeen patients (73.9%) presented with stroke or transient ischemic attack. Carotid revascularization was achieved with one (11 patients, 48%) or multiple stents (12 patients, 52%); distal protection was used rarely (three patients, 13%). No complications were directly attributed to stenting. Mean dissection-related stenosis improved from 72% ± 28.87% to 4% ± 8.29%. At a mean clinical follow-up of 28.7 months ± 31.9 months, 16 patients (69.6%) improved, six (26.1%) remained stable, and one (4.3%) had died secondary to multiple traumatic injuries. At long-term follow-up, no patient had a transient ischemic attack or stroke or presented evidence of de novo in-stent stenosis or stent thrombosis. There were no neurologic sequelae after partial or total discontinuation of antiplatelet therapy in seven patients undergoing trauma-related surgeries.

Conclusions: Selected cases of traumatic CAD can be safely managed by endovascular stent-assisted angioplasty. Procedural complications are infrequent; the need for postprocedure antiplatelet therapy is a concern. Early detection is essential to avoid stroke. Stenting restores the integrity of the vessel lumen immediately, efficiently prevents the occurrence or recurrence of ischemic events, and avoids the need of long-term anticoagulation.
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http://dx.doi.org/10.1097/TA.0b013e31823f630aDOI Listing
January 2012

Target and trajectory clinical application accuracy in neuronavigation.

Neurosurgery 2011 Mar;68(1 Suppl Operative):95-101; discussion 101-2

School of Engineering and Computer Science, The Hebrew University, Jerusalem, Israel.

Background: Catheter, needle, and electrode misplacement in navigated neurosurgery can result in ineffective treatment and severe complications.

Objective: To assess the Ommaya ventricular catheter localization accuracy both along the planned trajectory and at the target.

Methods: We measured the localization error along the ventricular catheter and on its tip for 15 consecutive patients who underwent insertion of the Ommaya catheter surgery with a commercial neuronavigation system. The preoperative computed tomography/magnetic resonance images and the planned trajectory were aligned with the postoperative computed tomography images showing the Ommaya catheter. The localization errors along the trajectory and at the target were then computed by comparing the preoperative planned trajectory with the actual postoperative catheter position. The measured localization errors were also compared with the error reported by the navigation system.

Results: The mean localization errors at the target and entry point locations were 5.9 ± 4.3 and 3.3 ± 1.9 mm, respectively. The mean shift and angle between planned and actual trajectories were 1.6 ± 1.9 mm and 3.9 ± 4.7°, respectively. The mean difference between the localization error at the target and entry point was 3.9 ± 3.7 mm. The mean difference between the target localization error and the reported navigation system error was 4.9 ± 4.8 mm.

Conclusion: The catheter localization errors have significant variations at the target and along the insertion trajectory. Trajectory errors may differ significantly from the errors at the target. Moreover, the single registration error number reported by the navigation system does not appropriately reflect the trajectory and target errors and thus should be used with caution to assess the procedure risk.
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http://dx.doi.org/10.1227/NEU.0b013e31820828d9DOI Listing
March 2011