Publications by authors named "Vinayak Narayan"

46 Publications

Compliance With Preferred Reporting Items for Systematic Review and Meta-Analysis Individual Participant Data Statement for Meta-Analyses Published for Stroke Studies.

Stroke 2021 Jun 4:STROKEAHA120033288. Epub 2021 Jun 4.

Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School & University Hospital, New Brunswick, NJ (F.J., O.A., M.S.R., B.R., A.G., H.S., V.N., G.G., A.N.).

Background And Purpose: Individual-participant data meta-analyses (IPD-MA) are powerful evidence synthesis studies which are considered the gold-standard of MA. The quality of reporting in these studies is guided by the 2015 Preferred Reporting Items for Systematic Review and Meta-Analysis of Individual Participant Data (PRISMA-IPD) guidelines. The growing number of IPD-MA published for stroke studies calls for an assessment of the compliance of these studies with the PRISMA-IPD statement.

Methods: PubMed and EMBASE were searched for MA in stroke published between January 1, 2016, and March 30, 2020, in journals with impact factor >2. Literature reviews, scoping reviews, and aggregate MA were excluded. The final articles were scored using the 31-item PRISMA-IPD checklist. Results were depicted using descriptive statistics. Compliance with each item in PRISM-IPD guideline was recorded. The study was defined as compliant to IPD analyses if it satisfied all IPD specific items.

Results: From an initial set of 321 articles, 31 met the final eligibility for data extraction. Only 4 (13%) described the use of PRISMA-IPD guidelines in their methodology, while 8/31 (26%) used the old PRISMA guidelines and 19/31 (61%) followed none. Regardless of mention of using IPD specific guidelines, 42% (n=13) of studies were compliant with all 4 IPD specific domains. The poorest areas of compliance were bias assessment within (32%) and across (39%) studies, reporting protocol and registration (42%), and reporting of IPD integrity (48%). The median journal impact factor was similar between the compliant (median, 8.1 [interquartile range, 5.4-39.9]) and noncompliant (median, 6 [interquartile range, 4.5-16.2]) groups (=0.24). Similarly, the journal, country of correspondence, number of authors, number of studies included in MA, study sample size, and funding source were statistically similar between the groups.

Conclusions: For the published IPD-MA stroke studies, the compliance with PRISMA-IPD statement and compliance with 4 IPD specific items was suboptimal. The journal, author, and study-related factors were not associated with compliance. Additional scrutiny measures to ensure adherence to mandated guidelines might increase the compliance. Several avenues to improve compliance and ensure optimal adherence are discussed.
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http://dx.doi.org/10.1161/STROKEAHA.120.033288DOI Listing
June 2021

Does preoperative embolization improve outcomes of meningioma resection? A systematic review and meta-analysis.

Neurosurg Rev 2021 Mar 16. Epub 2021 Mar 16.

Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, Rutgers-New Jersey Medical School, New Brunswick, NJ, USA.

Current evidence regarding the benefit of preoperative embolization (POE) of meningiomas is inconclusive. This systematic review and meta-analysis aims to evaluate the safety profile of the procedure and to compare outcomes in embolized versus non-embolized meningiomas. PubMed was queried for studies after January 1990 reporting outcomes of POE. Pertinent variables were extracted and synthesized from eligible articles. Heterogeneity was assessed using I, and random-effects model was employed to calculate pooled 95% CI effect sizes. Publication bias was assessed using funnel plots and Harbord's and Begg's tests. Meta-analyses were used to assess estimated blood loss and operative duration (mean difference; MD), gross-total resection (odds ratio; OR), and postsurgical complications and postsurgical mortality (risk difference; RD). Thirty-four studies encompassing 1782 preoperatively embolized meningiomas were captured. The pooled immediate complication rate following embolization was 4.3% (34 studies, n = 1782). Although heterogeneity was moderate to high (I = 35-86%), meta-analyses showed no statistically significant differences in estimated blood loss (8 studies, n = 1050, MD = 13.9 cc, 95% CI = -101.3 to 129.1), operative duration (11 studies, n = 1887, MD = 2.4 min, 95% CI = -35.5 to 30.8), gross-total resection (6 studies, n = 1608, OR = 1.07, 95% CI = 0.8-1.5), postsurgical complications (12 studies, n = 2060, RD = 0.01, 95% CI = -0.04 to 0.07), and postsurgical mortality (12 studies, n = 2060, RD = 0.01, 95% CI = 0-0.01). Although POE is relatively safe, no clear benefit was observed in operative and postoperative outcomes. However, results must be interpreted with caution due to heterogeneity and selection bias between studies. Well-controlled future investigations are needed to define the patient population most likely to benefit from the procedure.
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http://dx.doi.org/10.1007/s10143-021-01519-zDOI Listing
March 2021

Resection of Foramen Magnum Meningioma through Modified Far Lateral Approach: Surgical Principles and Technical Nuances.

J Neurol Surg B Skull Base 2021 Feb 23;82(Suppl 1):S22-S24. Epub 2020 Nov 23.

Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey, United States.

 Safe maximal resection is the basic principle of cranial base surgery and the grade of resection is an important factor influencing the prognostic outcome. This operative video highlights the surgical principles and technical nuances in the microsurgical resection of foramen magnum meningioma (FMM).  The surgery was performed in a 45-year-old lady who presented with hoarseness of voice and spastic quadriparesis (grade 4/5). On imaging, FMM with mass effect on brainstem and spinal cord was identified. The tumor was gross totally resected through modified far lateral approach with minimal occipital condyle drilling. This video demonstrates the surgical techniques of tumor resection including early devascularization, operating in the arachnoid plane to dissect the neurovascular structures, piecemeal decompression, sharp dissection to separate tumor from lower cranial nerves (LCN), identifying the brainstem veins, and resecting the lesion from tumor-brainstem interface. Postoperatively, she had significant neurological improvement and the magnetic resonance imaging revealed excellent radiological outcome ( Figs. 1 and 2 ).  The surgery of FMM is challenging due to the deep surgical corridor, critical location, close proximity with various neurovascular structures, firm consistency, and high vascularity of the tumor. The modified far lateral approach by preserving the occipital condyle may prevent the postoperative incidence of craniovertebral junction instability. The key operative principles to achieve the best surgical outcome include careful dissection along the arachnoid plane, gentle handling of cranial nerves, veins, and perforator vessels, avoidance of traction on brainstem and spinal cord, intraoperative neurophysiological monitoring, proper hemostasis, and meticulous dural closure. The link to the video can be found at: https://youtu.be/1qvAeUmNIUw .
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http://dx.doi.org/10.1055/s-0040-1714405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7935725PMC
February 2021

Multi-modal endovascular management of traumatic pseudoaneurysm and arteriovenous fistula of the ascending cervical artery: A technical report and review of literature.

Clin Neurol Neurosurg 2021 Mar 2;202:106539. Epub 2021 Feb 2.

Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA. Electronic address:

Objective: The management of traumatic pseudoaneurysm (PA) with concomitant arteriovenous fistula (AVF) arising from the thyrocervical trunk is challenging and rarely reported. Here, the usefulness of a multi-modal endovascular strategy for management of traumatic PA and AVF arising from the thyrocervical trunk is presented. A literature review describing unique clinical features and management strategies of traumatic vascular lesions of the thyrocervical trunk is included.

Methods: A 58-year-old man presented with two PAs arising from the ascending cervical artery (AsCA) and a robust AVF between the AsCA and the left vertebral venous plexus which arose acutely after a stabbing incident. These lesions were managed with endovascular vessel sacrifice via coiling and controlled Onyx injection. Relevant literature was identified via a targeted search of the PubMed database.

Results: Post-management angiography demonstrated complete occlusion of the two traumatic PAs and successful disconnection of the concomitant AVF. Our literature review demonstrates a shift in preferred management approach from invasive surgery to endovascular treatment due to the lower risk and cosmetic preferability.

Conclusion: Timely treatment of enlarging PA is necessary for reducing associated morbidity and mortality. While surgical resection has been the mainstay therapy, endovascular management has gained popularity in recent years. The choice of endovascular technique is variable and should be individualized based on patient's clinical status, associated risk factors, and lesion morphology. We have shown that parent vessel sacrifice is safe and effective. Reconstruction with a combination of stents, coils, glue, or liquid embolics may be necessary when collateral flow is limited.
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http://dx.doi.org/10.1016/j.clineuro.2021.106539DOI Listing
March 2021

The mediums of dissemination of knowledge and illustration in neurosurgery: unraveling the evolution.

J Neurosurg 2020 Dec 4:1-7. Epub 2020 Dec 4.

1Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick, New Jersey; and.

The earliest evidence of man's attempts in communicating ideas and emotions can be seen on cave walls and ceilings from the prehistoric era. Ingenuity, as well as the development of tools, allowed clay tablets to become the preferred method of documentation, then papyrus and eventually the codex. As civilizations advanced to develop structured systems of writing, knowledge became a power available to only those who were literate. As the search to understand the intricacies of the human brain moved forward, so did the demand for teaching the next generation of physicians. The different methods of distributing information were forced to advance, lest the civilization falls behind. Here, the authors present a historical perspective on the evolution of the mediums of illustration and knowledge dissemination through the lens of neurosurgery. They highlight how the medium of choice transitioned from primitive clay pots to cutting-edge virtual reality technology, aiding in the propagation of medical literature from generation to generation across the centuries.
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http://dx.doi.org/10.3171/2020.7.JNS201053DOI Listing
December 2020

Big data, machine learning, and artificial intelligence: a field guide for neurosurgeons.

J Neurosurg 2020 Oct 2:1-11. Epub 2020 Oct 2.

1Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital; and.

Big data has transformed into a trend phrase in healthcare and neurosurgery, becoming a pervasive and inescapable phrase in everyday life. The upsurge in big data applications is a direct consequence of the drastic boom in information technology as well as the growing number of internet-connected devices called the Internet of Things in healthcare. Compared with business, marketing, and other sectors, healthcare applications are lagging due to a lack of technical knowledge among healthcare workers, technological limitations in acquiring and analyzing the data, and improper governance of healthcare big data. Despite these limitations, the medical literature is flooded with big data-related articles, and most of these are filled with abstruse terminologies such as machine learning, artificial intelligence, artificial neural network, and algorithm. Many of the recent articles are restricted to neurosurgical registries, creating a false impression that big data is synonymous with registries. Others advocate that the utilization of big data will be the panacea to all healthcare problems and research in the future. Without a proper understanding of these principles, it becomes easy to get lost without the ability to differentiate hype from reality. To that end, the authors give a brief narrative of big data analysis in neurosurgery and review its applications, limitations, and the challenges it presents for neurosurgeons and healthcare professionals naive to this field. Awareness of these basic concepts will allow neurosurgeons to understand the literature regarding big data, enabling them to make better decisions and deliver personalized care.
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http://dx.doi.org/10.3171/2020.5.JNS201288DOI Listing
October 2020

Arteriovenous malformation presenting as traumatic subdural hematoma: A case report.

Surg Neurol Int 2020 25;11:203. Epub 2020 Jul 25.

Department of Neurological Surgery, University of Alabama at Birmingham, Birmingham, Alabama.

Background: Brain arteriovenous malformations (AVMs) are congenital aberrant connections between afferent arteries and draining veins with no intervening capillary bed or neural parenchyma. Other than seizures, the most common initial presentation of AVM is hemorrhage, which is typically intraparenchymal, subarachnoid, or intraventricular, and very rarely subdural.

Case Description: This patient is a 66-year-old male with a history of atrial fibrillation, chronically anticoagulated with apixaban, who presented through emergency services after a fall. On presentation, computed tomography (CT) of the head showed a small, 6 mm right subdural hematoma, and the patient was neurologically intact. The hematoma was evacuated by burr hole craniotomy and placement of a subdural drain 12 days after the initial presentation due to worsening headaches and further hematoma expansion. Two weeks postevacuation, the patient was readmitted for seizures, and at this time, CT angiography showed no intracranial vascular lesion. Approximately 1 month later, the patient was readmitted for decreased responsiveness, and CT head at this time found right frontal intraparenchymal hemorrhage. On subsequent catheter angiography, the right frontal AVM was discovered. It was treated with preoperative embolization followed by surgical resection. Postoperatively, the patient followed commands and tracked with his eyes. There was spontaneous antigravity movement of the right upper extremity, but still no movement of the left upper or bilateral lower extremities.

Conclusion: This case emphasizes the importance of maintaining a high index of suspicion for underlying vascular lesions when evaluating intracranial bleeding, even in the setting of traumatic history, particularly in cases of hematoma expansion.
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http://dx.doi.org/10.25259/SNI_160_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7451141PMC
July 2020

Proteomic profiling of medulloblastoma reveals novel proteins differentially expressed within each molecular subgroup.

Clin Neurol Neurosurg 2020 09 17;196:106028. Epub 2020 Jun 17.

Department of Neuropathology, National Institute of Mental Health and Neurosciences [NIMHANS], Bangalore, India. Electronic address:

Objectives: The objective of the study was to identify novel medulloblastoma (MB) biomarkers through proteomic profiling, correlate it with the molecular subgroups of MB and assess the clinical significance.

Methods: Archived paraffin embedded tumor tissue blocks from 118 MB patients, operated at our institute were retrieved. Clinical information was documented from the hospital database. Tumours were stratified into molecular subgroups using the IHC markers- β Catenin, GAB-1, YAP-1 and p53. Six fresh MB tumour tissues and two control cerebellar tissues were subjected to proteomic profiling to study differential protein expression in molecular subgroups using high resolution mass spectrometry. Prominent signalling pathways activated in each subgroup were identified using the Panther pathway software.

Results: Non WNT/SHH group was the most common (61.1 %), followed by SHH and WNT. p53 immunopositivity did not correlate with prognosis in any subgroup. Proteomic profiling revealed several novel proteins differentially expressed between MB molecular subgroups. Signalling pathways exclusively enriched in each molecular subgroup were also identified. The top upregulated proteins were PMEL and FBN2 in the WNT subgroup, SYNGR2 in the SHH subgroup and GFAP, IMPG2 and MAGEA10 in the Non WNT/Non SHH group. We validated GFAP by immunohistochemistry on the archived samples (n = 118) and noted two types of staining pattern in MBs - reactive (stellate) astrocytes and tumour cell staining. GFAP immunopositivity in tumor cells of SHH subgroup correlated with a better prognosis.

Conclusions: Proteomic profile identified several novel proteins differentially regulated within the molecular subgroups that could serve as potential diagnostic /prognostic biomarkers. Notably, GFAP, which was derived from proteomics data, when validated by IHC, revealed a variable staining pattern in MB tumours. The prognostic significance of GFAP in SHH tumor patients further points at the heterogeneity of this subgroup. The study also throws light on the signaling pathways activated in MB and in turn its plausible role in the tumorigenesis.
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http://dx.doi.org/10.1016/j.clineuro.2020.106028DOI Listing
September 2020

Endovascular Management of Intracranial Vertebral Artery Dissection: Technical Nuances for the Preservation of Posterior Inferior Cerebellar Artery and Basilar Artery.

Oper Neurosurg (Hagerstown) 2020 09;19(3):241-248

Department of Radiology, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey.

Background: The treatment of intracranial vertebral artery dissection (VAD) can be challenging.

Objective: To evaluate the clinical presentation, endovascular treatment techniques, and prognostic outcome of patients diagnosed with intracranial VAD at our institution.

Methods: A retrospective analysis of 35 patients who were diagnosed with VAD at our institution over 17-yr period (2001-2017) is presented. A total of 27 patients with a total of 30 affected arteries underwent endovascular treatment, and their outcome was evaluated.

Results: Of the 35 total patients with VAD, 15 presented with headache, 12 with focal neurological deficits, 2 with neck pain, 2 with dizziness, 1 with syncope, and 3 after trauma. Of the 30 dissected arteries, 18 were treated with deconstruction and 12 were treated with stent reconstruction. Treatment method was determined by the dominance of the affected artery and location relative to the ipsilateral posterior inferior cerebellar artery (PICA) and the basilar artery. Deconstructive techniques were utilized in all cases of hypoplastic artery dissection and the majority of codominant artery dissections, whereas reconstruction was performed on the majority of dominant artery dissections. Rupture did not impact treatment technique. Four patients demonstrated post-treatment infarcts, and another 1 patient died because of intraparenchymal bleed. The remaining 22 patients demonstrated favorable clinical outcome. None of the patients developed recanalization or needed retreatment till the last follow-up.

Conclusion: This study suggests that endovascular treatment of intracranial VAD with deconstruction or stent reconstruction based on the patients anatomy, particularly vessel dominance and location with respect to PICA, is feasible and effective though the revascularization procedures still has its role in selected cases.
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http://dx.doi.org/10.1093/ons/opaa174DOI Listing
September 2020

Do Narrow Networks Affect the Delivery of Outpatient Care in Neurosurgery?: A Statewide Analysis of Marketplace Plans in New Jersey.

World Neurosurg 2020 09 17;141:e213-e222. Epub 2020 May 17.

Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA. Electronic address:

Background: The aftermath of the Affordable Care Act (ACA) witnessed the rise of narrow networks, which feature fewer providers in exchange for lower premiums. Debate still continues on whether narrow networks provide adequate access to health care, especially in specialty care services such as neurosurgery. The objective of this article was to analyze the 2019 Marketplace plans' impact on delivering outpatient neurosurgical care in New Jersey.

Methods: The 2019 Marketplace Public Use Files were queried for "silver" plans, identifying a total of 11 plans across 3 insurance companies. Online search engines were used to identify the number of in-network neurosurgeons within 20-25 miles of ZIP codes at the center of each county. The primary outcome was the number of neurosurgeon-deficient plans, defined as those having no in-network neurosurgeons within the assigned mile radius.

Results: Of all individuals who purchased an insurance plan, 73% (185,797/255,246) opted for a silver plan. Out of 111 active neurosurgeons in New Jersey, 25% (28/111) did not participate in any of the silver plans. Analysis showed 8 plans as neurosurgeon-deficient in Sussex and Warren. Meanwhile, most of the silver plans provided access to >5 neurosurgeons within 20-25 miles of most (17/21) county centers.

Conclusions: In more densely populated states such as New Jersey, the impact of narrow networks on neurosurgical coverage is less apparent. However, frustrations regarding access to care still exist because nearly 25% of neurosurgeons do not participate in the standard ACA insurance product. Furthermore, guidelines that define network adequacy in neurosurgery remain elusive, which calls for more robust parameters to monitor and ensure adequate access to health care.
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http://dx.doi.org/10.1016/j.wneu.2020.05.086DOI Listing
September 2020

Ethical and medicolegal aspects in the management of neurosurgical emergencies among Jehovah's Witnesses: Clinical implications and review.

Clin Neurol Neurosurg 2020 07 19;194:105798. Epub 2020 Mar 19.

Department of Neurosurgery, Rutgers- Robert Wood Johnson Medical School, New Brunswick, NJ, USA. Electronic address:

When an incapacitated Jehovah's Witness neurologically deteriorates and requires immediate craniectomy, institutional protocols may delay surgery if the patient's refusal of blood products is ambiguous. We are among the first to describe such an ethically contentious case in emergency neurosurgery, review the morbidity of operative delays, discuss medicolegal concerns raised, and provide a detailed guide to hemostasis in patients who refuse blood products. We discuss the case of a 46-year-old woman presented with nausea, vomiting, and right-sided weakness, progressing to stupor over several hours. When an initial Computed Tomography (CT) scan showed a large, left-sided intraparenchymal hematoma with significant midline shift, she was booked for an emergency hemicraniectomy. According to the family, she was a Jehovah's Witness and would have refused blood consent, but was without the proper documentation. Despite her worsening neurological status, an indeterminate blood consent delayed surgery for more than two hours. Her neurological exam did not improve postoperatively, and she later expired. The ethical, legal, and operative concerns that arise in the emergency neurosurgical treatment of Jehovah's Witness patients pose unique management challenges. Since operative delay is a preventable cause of mortality in patients requiring urgent craniectomy, and the likelihood of requiring a transfusion from hemorrhage is minimal, an ambiguous blood consent should not postpone a potentially life-saving treatment. For the beneficence and autonomy of Jehovah's Witness patients, institutional policies should respect the family's wishes in order to expedite surgical decompression. In addition to discussing the nuances of such ethical considerations, we also provide a detailed list of commonly used, topical and parenteral hemostatic agents from the neurosurgical operating room which, depending on whether they are blood-derived, either should or should not be used when treating a Jehovah's Witness.
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http://dx.doi.org/10.1016/j.clineuro.2020.105798DOI Listing
July 2020

Tribute to Milton D. Heifetz (1921-2015): The Man Behind the Heifetz Aneurysm Clip.

Neurosurgery 2020 10;87(5):E584-E589

Department of Neurosurgery, Rutgers Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey.

Milton Dave Heifetz (1921-2013) was a pioneer American neurosurgeon who spent the majority of his career at Cedars-Sinai Hospital in California. Heifetz greatly influenced the field of neurosurgery as an innovator, leader, and academic neurosurgeon. His redesign of the aneurysm clip addressed the long-standing issue of a fatiguing spring. Heifetz's innovation allowed the spring to maintain adequate closing force despite repetitive opening and closing. This clip was recognized as one of the most effective aneurysm clips for approximately 15 yr. While he was best known for this eponymous aneurysm clip, Heifetz also developed other various microsurgical instruments and tools for stereotactic approaches. Beyond neurosurgery, he was an influential figure and well-published author in fields such as medical ethics, philosophy, astronomy, and poetry. In 1975, he published The Right to Die: A Neurosurgeon Speaks of Death With Candor, a book which played a major role in our modern-day advanced directives. Throughout his life, Heifetz was an inspirational individual who consistently worked towards solutions to surgical and ethical problems. We present a historical vignette on his life, career, and contributions to neurosurgery.
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http://dx.doi.org/10.1093/neuros/nyaa035DOI Listing
October 2020

Incidental Brain Tumors in the Pediatric Population: A Systematic Review and Reappraisal of Literature.

World Neurosurg 2020 07 9;139:121-131. Epub 2020 Mar 9.

Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School University Hospital, New Brunswick, New Jersey, USA. Electronic address:

Objectives: Management of incidental asymptomatic brain tumors in children is controversial due to lack of clear evidence-based guidelines. We present this systematic review in an attempt to highlight an optimal treatment paradigm.

Methods: This systematic review was conducted in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. Databases were searched up to August 2019 using the keywords "incidental," "brain tumor," and "pediatric." Our main focus was on brain lesions suspected for neoplasm, diagnosed incidentally on neuroimaging in an otherwise asymptomatic patient <18 years old. Cystic, vascular, and inflammatory brain lesions were excluded.

Results: Fourteen studies comprising 308 patients were included. All cases were diagnosed using magnetic resonance imaging. The most common indications for imaging were headache (93; 30%) and trauma (72; 23%). Lesion distribution was supratentorial (179; 58%), infratentorial (121; 40%), and intraventricular (8; 3%). Of 308 cases, 243 (79%) were managed with neuroradiological surveillance and 57 (19%) by upfront surgical excision. Of those managed conservatively, 177 (73%) remained stable within a mean follow-up of 30 months, 54 (22%) progressed, and 12 (5%) spontaneously regressed. Meanwhile, upfront excision achieved complete remission in all 57 cases over a mean follow-up of 68.3 months.

Conclusion: A small body of evidence has emerged, highlighting the marked heterogeneity and contradictory results between the available studies, limiting our ability to draw solid conclusions. At this point, the decision between surgery and "watchful waiting" should be tailored on an individual patient basis depending on suspicion of malignancy, clinical or radiologic progression, and parental preference.
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http://dx.doi.org/10.1016/j.wneu.2020.02.178DOI Listing
July 2020

Resection of a posterior fossa arteriovenous malformation complicated by leaked Onyx: a case report and review of literature.

Acta Neurochir (Wien) 2020 04 30;162(4):923-928. Epub 2020 Jan 30.

Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick, NJ, USA.

Extravasation of Onyx is a rare complication during embolization of arteriovenous malformations (AVM). We present a case of embolization that was complicated by leakage of Onyx into the cerebellum which was later encountered during surgical excision of the AVM. Our goal is to report this rare event and to outline successful treatment of this complication. The patient's records were reviewed for medical history, laboratory and radiologic workup, and outpatient clinical follow-up. A 62-year-old female presented with Hunt Hess grade 2 and modified Fisher grade 2 subarachnoid hemorrhage (SAH) secondary to ruptured left posterior inferior cerebellar artery (PICA) aneurysm associated with a superior cerebellar vermian AVM. Following endovascular intervention, the aneurysm was completely embolized; however, only 75% of the AVM could be safely obliterated. Extravasation of Onyx from the ruptured aneurysm was noted on her initial angiogram. Elective suboccipital craniectomy was subsequently planned for resection of the residual AVM where the extravasated Onyx posed an operative nuisance during resection. Post-op angiogram confirmed complete resection of the AVM, as well as the bulk of the extravasated Onyx. Patient did well post-operatively, remaining neurologically intact throughout her hospital course. Although infrequently reported in the literature, Onyx extravasation is a potential complication that neurosurgeons should be ready to face. Adherence of Onyx to surrounding parenchyma could hinder optimal surgical resection of AVM and increase complications. Therefore, careful surgical dissection should be performed with special care to delicate neurovasculature. In this case, complete resection of the AVM and Onyx mass was safely achieved.
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http://dx.doi.org/10.1007/s00701-019-04199-3DOI Listing
April 2020

Efficacy and safety of middle meningeal artery embolization in the management of refractory or chronic subdural hematomas: a systematic review and meta-analysis.

Acta Neurochir (Wien) 2020 03 4;162(3):499-507. Epub 2020 Jan 4.

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA, USA.

Introduction: Refractory or chronic subdural hematomas (cSDH) constitute a challenging entity that neurosurgeons face frequently nowadays. Middle meningeal artery embolization (MMAE) has emerged in the recent years as a promising treatment option. However, solid evidence that can dictate management guidelines is still lacking.

Methods: We conducted a systematic review and meta-analysis (MA) in compliance with the PRISMA guidelines to evaluate the efficacy and safety of MMAE compared with conventional treatments for refractory or cSDH. Databases were searched up to March 2019. Using a random-effects model, meta-analyses of proportions and risk difference were conducted recurrence, need for surgical rescue, and complications.

Results: Eleven studies (177 patients) were included. Majority (116, 69%) were males with a weighted mean age of 71 + -19.5 years. Meta-analysis of proportions showed treatment failure to be 2.8%, need for surgical rescue 2.7%, and embolization-related complications 1.2%. Meta-analysis of risk-difference between embolized and non-embolized patients showed a 26% (p < 0.001, 95% CI 21%-31%, I = 0) lower risk of hematoma recurrence in MMAE. Similarly, in the embolized group, the need for surgical rescue was 20% less (p < 0.001, 95% CI = 12%-27%, I = 12.4), and complications were 3.6% less (p = 0.008, 95% CI 1%-6%, I = 0) compared to conventional groups.

Conclusions: Although MMAE appears to be a promising treatment for refractory or cSDH, drawing definitive conclusions remains limited by paucity of data and small sample sizes. Multicenter, randomized, prospective trials are needed to compare embolization to conventional treatments like watchful waiting, medical management, or surgical evacuation. More extensive research on MMAE could begin a new era in the minimally invasive management of cSDH.
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http://dx.doi.org/10.1007/s00701-019-04161-3DOI Listing
March 2020

Ozagrel for Postoperative Management of Aneurysmal Subarachnoid Hemorrhages.

Neurol India 2019 Sep-Oct;67(5):1286-1289

Department of Neurosurgery, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India.

Background: A number of pharmacological agents have been tried to circumvent the problem of delayed cerebral ischemia (DCI) with ozagrel sodium being one such agent aimed at the prevention of DCI. Ozagrel is an inhibitor of thromboxane synthetase. It has anti-platelet aggregation action and it dilates vessels. Ozagrel was not available outside Japan till recently. It is available now in India and we had the opportunity to use it among patients with aneurysmal subarachnoid hemorrhage (SAH).

Aims: To analyse the results of ozagrel administration for patients with aneurysmal SAH.

Settings And Design: Tertiary care neurosurgical center.

Materials And Methods: Retrospective analysis of the outcomes of patients who received ozagrel after microsurgical cllipping of aneurysm and comparison with a control grpup who received treatment as usual.

Statistical Analysis: The t-test (two-tailed), Chi-square test, and Mann-Whitney U-test asymptomatic significance (two-tailed), were used respectively for continuous, categorical, and ordinal variables. The significance was determined at P = 0.05 level.

Results: A total of 106 patients underwent surgical clipping of their ruptured intracranial aneurysms over a period of 22 months. Forty two (39.6%) patients received ozagrel, and 62 (60.4%) received the standard treatment. Ozagrel was started at a median of one [interquartile range (IQR) 0.75] day after the surgery, and was given for a median of five (IQR 5) days after the surgery. There was no difference in age, postictal days, World Federation Neurosurgical Society grade, Fisher grade, and the size of ruptured aneurysm in patients who received ozagrel compared to the patients who did not receive ozagrel. Of the 42 patients who received ozagrel, 30 patients (71.4%) had preoperative angiographic vasospasm which improved after the administration of ozagrel. Fifteen (35.5%) patients who received ozagrel developed delayed cerebral ischemia compared to only 11 (17.2%) patients who did not receive ozagrel. Thirty-six (85.7%) patients who received ozagrel had favorable outcome at discharge compared to 52 (81.3%) patients who did not receive ozagrel. No adverse event was observed with ozagrel therapy. At 3-month follow-up, 37 patients (88.1%) who received ozagrel had favorable outcomes against 53 patients (82.8%) who did not receive ozagrel.

Conclusion: Ozagrel may be a useful drug in the armamentarium to treat vasospasm after aneurysmal SAH. A future multicenter large cohort study may validate the findings of our study.
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http://dx.doi.org/10.4103/0028-3886.271236DOI Listing
April 2020

The Origins of Eponymous Aneurysm Clips: A Review.

World Neurosurg 2020 Feb 19;134:518-531. Epub 2019 Sep 19.

Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, New Jersey, USA. Electronic address:

Aneurysm clips are indispensable tools in the armamentarium of vascular neurosurgeons. The history of the development of aneurysm clips is witness to ingenuity and tenacity in treating a potentially devastating disease. Few know the stories of their innovators and the inspiration behind their designs. Hence, we present this historical vignette in an attempt to shed more light on the pioneers who shaped the evolution of aneurysm clips as we know them. A comprehensive literature search was performed using PubMed, Google Scholar, Google Books, and library historical archives, as well as personal communications with relatives, colleagues, and institutions of the surgeon-designers. We present the following aneurysm clip innovators and chronicle their biographies and contributions: Herbert Olivecrona (1891-1980), Frank Mayfield (1908-1991), Charles Drake (1920-1998), Joseph McFadden (1920-present), Thoralf Sundt Jr. (1930-1992), William M. Lougheed (1923-2004), William B. Scoville (1906-1984), Milton D. Heifetz (1921-2015), Gazi Yaşargil (1925-present), Kenichiro Sugita (1932-1994), and Robert Spetzler (1944-present). Although this compilation of eponymous clips is by no means complete, we hope that it provides an informative historical perspective and an inspiration for aspiring neurosurgeons. The history of aneurysm surgery, an entity once deemed inoperable, teaches us the importance of innovation in medicine.
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http://dx.doi.org/10.1016/j.wneu.2019.09.061DOI Listing
February 2020

Medulloblastoma: Distinctive Histo-Molecular Correlation with Clinical Profile, Radiologic Characteristics, and Surgical Outcome.

Pediatr Neurosurg 2019 3;54(5):329-340. Epub 2019 Sep 3.

Department of Neuropathology, National Institute of Mental Health and Neurosciences, Bangalore, India.

Objective: Medulloblastoma (MB) is a heterogenous tumor, and the prognosis is influenced by various clinical, histological, and molecular factors. The aim of the study is to determine the clinical profile and radiologic characteristics among the histo-molecular subgroups, the predictors of surgical outcome, and the pattern of relapse in pediatric and adult MB.

Method: An analysis of 118 patients of MB who underwent surgical treatment at National Institute of Mental Health and Neurosciences, India, over a 7-year period (2005-2011) is presented. The clinical profile, radiologic characteristics, surgical nuances, and survival patterns are discussed. The relevant statistical analysis was done using SPSS software, version 22.0.

Results: The mean age of the cohort was 12 years (12.3 ± 8.7). The primary manifestation was raised intracranial tension headache in 53 patients (44.9%), which was the predominant symptom in large cell/anaplastic (LCA)- and WNT-activated subgroups. The median preoperative Karnofsky performance score was 60 (60.6 ± 12.9). Vermian and hemispheric location of tumor was most commonly observed in non-WNT/non-SHH (groups 3 and 4; 91.7%) and SHH-activated (42.9%) subgroups, respectively. Ninety-two patients (78%) underwent preoperative ventriculoperitoneal shunts (VPS) for obstructive hydrocephalus (HCP) and 14 patients (11.8%) underwent VPS in the postoperative period. The median overall survival (OS) for the whole group was 82.1 ± 5.7 months and the median recurrence-free survival was 51.0 ± 4.8 months. While radiotherapy had a significant influence on OS, progression-free survival was influenced by radiotherapy as well as chemotherapy in both pediatric and adult cohort. Desmoplastic/nodular subtype and WNT-activated subgroup had the best prognosis; LCA and non-WNT/non-SHH had the worst prognosis.

Conclusions: Majority of the patients were pediatric in the study. Age, hemispheric location of tumor, extent of resection, and adjuvant treatment status were the important clinical prognostic factors for survival. Surgery for MB is formidable, and VPS can be considered in persistent symptomatic and progressive HCP. Our study on pediatric and adult MB validates the prognostic significance of various clinical, radiologic, and histo-molecular parameters of MB.
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http://dx.doi.org/10.1159/000501913DOI Listing
March 2020

Efficacy and safety of gamma knife radiosurgery for posterior cranial fossa meningioma: a systematic review.

Neurosurg Rev 2020 Aug 5;43(4):1089-1099. Epub 2019 Aug 5.

Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School & University Hospital, New Brunswick, NJ, USA.

The management of posterior cranial fossa meningioma [PCFM] is challenging and many neurosurgeons advise gamma knife radiosurgery [GKRS] as a modality for its upfront or adjuvant treatment. Due to the varying radiosurgical response based on lesion location, tumor biology, and radiation dosage, we performed a pioneer attempt in doing a systematic review analyzing the treatment efficacy and safety profile of GKRS for PCFM based on current literature. A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses [PRISMA] guidelines. A thorough literature search was conducted on PubMed, Web of science, and Cochrane data base; articles were selected systematically based on PRISMA protocol, reviewed completely, and relevant data was summarized and discussed. A total of 18 publications pertaining to GKRS for PCFM were included with a pooled sample size of 2131 patients. The median pre-GKRS tumor volume ranged from 2.28 to 10.5 cm [3]. Primary GKRS was administered in 61.1% of the pooled study cohorts, adjuvant treatment in 32.9%, and salvage therapy in 6.5% patients. Majority of the meningiomas were WHO grade 1 tumors (99.7%). The pooled mean marginal dose in the studies was 13.6 Gy (range 12-15.2 Gy) while the mean of maximum doses was 28.6 Gy (range 25-35 Gy). Most studies report an excellent radiosurgical outcome including the tumor control rate and the progression-free survival [PFS] of over 90%. The tumor control, PFS, and adverse radiation effect [ARE] rates in author's series were 92.3%, 91%, and 9.6%, respectively. The favorable radiosurgical outcome depends on multiple factors such as small tumor volume, absence of previous radiotherapy, tumor location, elderly patients, female gender, longer time from symptom onset, and decreasing maximal dose. GKRS as primary or adjuvant treatment modality needs to be considered as a promising management strategy for PCFM in selected patients in view of the growing evidence of high tumor control rate, improved neurological functions, and low incidence of ARE. The use of multiple isocenters, 3-D image planning, and limit GKRS treatment to tumors less than 3.5 cm help to avoid complications and achieve the best results. The treatment decisions in PCFM cases must be tailored and should consider the factors such as radiological profile, symptom severity, performance level, and patient preference for a good outcome.
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http://dx.doi.org/10.1007/s10143-019-01144-xDOI Listing
August 2020

Nocardia amikacinitolerans and cytomegalovirus: distinctive clinical and radiological characterization of the rare etiologies of brain abscesses: report of 2 cases.

Neurosurg Focus 2019 08;47(2):E18

Departments of1Neurosurgery and.

Central nervous system infections in immunosuppressed patients are rare but potentially lethal complications that require swift diagnoses and intervention. While the differential diagnosis for new lesions on neuroradiological imaging of immunosuppressed patients typically includes infections and neoplasms, image-based heuristics to differentiate the two has been shown to have variable reliability.The authors describe 2 rare CNS infections in immunocompromised patients with atypical physical and radiological presentations. In the first case, a 59-year-old man, who had recently undergone a renal transplantation, was found to have multifocal Nocardia amikacinitolerans abscesses masquerading as neoplasms on diffusion-weighted imaging (DWI); in the second case, a 33-year-old man with suspected recurrent Hodgkin's lymphoma was found to have a nonpyogenic abscess with cytomegalovirus (CMV) encephalitis.As per review of the literature, this appears to be the first case of brain abscess caused by N. amikacinitolerans, a recently isolated superbug. Despite confirmation through brain biopsy later on in case 1, the initial radiological appearance was atypical, showing subtle diffusion restriction on DWI. Similarly, the authors present a case of CMV encephalitis that presented as a ring-enhancing lesion, which is extremely rare. Both cases draw attention to the reliability of neuroimaging in differentiating an abscess from a neoplasm.
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http://dx.doi.org/10.3171/2019.5.FOCUS19284DOI Listing
August 2019

Management of Meningiomas Involving the Major Venous Sinuses: A Single-Institution Experience.

World Neurosurg 2019 Jul 13;127:e179-e185. Epub 2019 Mar 13.

Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School, New Brunswick, New Jersey, USA. Electronic address:

Background: In the management of meningiomas invading the major venous sinuses, balance between tumor control and complication prevention is desirable. The aim of this study was to describe an institutional experience in management of meningiomas involving major venous sinuses.

Methods: A retrospective study was carried out over 18 years, between 1999 and 2017, in patients with meningiomas involving major venous sinuses. Clinical features, operative strategy, histology, postoperative complications, adjuvant therapy, and long-term follow-up were studied.

Results: The study included 84 patients. Neurologic deficits were seen in 26 (31%) patients at presentation. The recurrence rates in Simpson grade I, II, and III excision were 7.6%, 25%, and 29.4% at a mean follow-up of 45.4 months (range, 1-192 months). No intervention of the involved sinus was done in 64 (76%) cases, venotomy was done in 3 (3.5%) cases, sinus resection without graft was done in 14 (16.6%) cases, and sinus reconstruction with patch was done in 3 (3.5%) cases. There were 53 (67.0%) patients with World Health Organization grade I histology and 25 (31.6%) patients with World Health Organization grade II histology. Fifteen recurrences were treated with Gamma Knife radiosurgery. In univariate analysis using Cox proportional hazards model, World Health Organization grade (P = 0.036, hazard ratio 2.90, 95% confidence interval = 1.07-7.87) and Simpson grade (P = 0.017, hazard ratio 2.90, 95% confidence interval = 1.18-5.29) were found to be significant factors to predict tumor recurrence.

Conclusions: Management of meningiomas involving major venous sinus with microsurgical techniques and adjuvant Gamma Knife radiosurgery achieves a good tumor control rate with an acceptable complication rate.
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http://dx.doi.org/10.1016/j.wneu.2019.03.043DOI Listing
July 2019

Far-lateral skull base approaches: Shades of grey.

Neurol India 2019 Jan-Feb;67(1):61-64

Department of Neurosurgery, Rutgers-Robert Wood Johnson Medical School and University Hospital, New Brunswick; Department of Neurosurgery, Rutgers-New Jersey Medical School and University Hospital, Newark, New Jersey, USA.

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http://dx.doi.org/10.4103/0028-3886.253596DOI Listing
February 2020

Timing of Carotid Endarterectomy for Symptomatic Carotid Stenosis: A Snapshot of Current Trends and Systematic Review of Literature on Changing Paradigm towards Early Surgery.

Neurosurgery 2019 08;85(2):E214-E225

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana.

Carotid revascularization has been recommended as the maximally beneficial treatment for stroke prevention in patients with recently symptomatic carotid stenosis (SCS). The appropriate timing for performing carotid endarterectomy (CEA) within the first 14 d after the occurrence of the index event remains controversial. We aim to provide a snapshot of the pertinent current literature related to the timing of CEA for patients with SCS. A systematic review of literature was conducted to study the timing of CEA for SCS. The guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) were followed. A total of 63 articles were identified as relevant to this topic. A summary of 15 articles favoring urgent CEA (within 48 h) for SCS within 48 h of index event and 9 articles not favoring urgent CEA is presented. A consensus is still to be achieved on the ideal timing of CEA for SCS within the 14-d window presently prescribed. The current literature suggests that patients who undergo urgent CEA (within 48 h) after nondisabling stroke as the index event have an increased periprocedural risk as compared to those who had transient ischemic attack (TIA) as the index event. Further prospective studies and clinical trials studying this question with separate groups classified as per the index event are required to shed more light on the subject. The current literature points to a changing paradigm towards early carotid surgery, specifically targeted within 48 h if the index event is TIA, and within 7 d if the index event is stroke.
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http://dx.doi.org/10.1093/neuros/nyy557DOI Listing
August 2019

Posterior Interhemispheric Precuneal Approach: Fundamental Principles and Case Illustration: 3-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2019 Aug;17(2):E58

Department of Neurosurgery, Louisiana State University Health Sciences Centre, Shreveport, Louisiana.

Peritrigonal lesions are deeply seated and are surrounded by critical neurovascular structures. Traditional transcortical approaches carry the risk of damage to important surrounding white matter tracts. In this regard, a posterior interhemispheric approach gives a more direct and less invasive route and therefore is a reasonable alternative to transcortical approaches. The 3-dimensional video includes illustrations and animations showing the anatomy of the white matter tracts around the trigone and explains the physiological basis of posterior interhemispheric precuneal approach to this complex region. This also includes a 3-dimensional operative video of the same approach in a 50-yr-old male patient with left periatrial lesion describing surgical techniques and nuances. An informed written consent has been obtained from the patient.
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http://dx.doi.org/10.1093/ons/opy358DOI Listing
August 2019

Incidence, Pathophysiology, and Prevention Strategies for Cerebral Venous Complications after Neurologic Surgery: A Systematic Review of the Literature.

World Neurosurg 2018 11 6;119:294-299. Epub 2018 Jul 6.

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA. Electronic address:

Background: Complications arising from cerebral venous occlusion/sacrifice during neurosurgical procedures have received comparatively less attention in the neurosurgical literature. Consequently, cerebral venous complications are not given due recognition, even though most practicing neurosurgeons would agree that they are not uncommon. We present a review of complications arising from venous sacrifice/occlusion during neurosurgery and discuss strategies described in the literature to prevent such occurrences.

Methods: We conducted a systematic review of the literature to provide a synopsis of the current evidence regarding cerebral venous injury after a neurosurgical procedure. The objectives of this review were to assess the incidence of venous injuries after a neurosurgical procedure with their clinical outcome and to evaluate current strategies and technical advances for their prevention. Complications related to dural venous sinuses were not considered in this review.

Results: Twenty-six relevant articles were identified and reviewed. Complications from cerebral venous occlusion/sacrifice are being increasingly recognized, and venous preservation strategies are being promoted in the neurosurgical literature. Based on our review of literature, the incidence of venous injury can range from 2.6% to 30%. We discuss the pathophysiology after venous injury and factors affecting outcome after cerebral venous injury. An overview of surgical techniques described to prevent or manage venous injury during neurosurgical procedures is presented.

Conclusions: The unpredictable response of the brain to venous injury causes catastrophic complications in a few patients. To avoid these complications, meticulous venous preservation should be a goal in all neurosurgical procedures. Increased recognition of cerebral venous complications over the last 2 decades has resulted in the increasing recognition among neurosurgeons that venous preservation is an essential tenet of neurosurgery.
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http://dx.doi.org/10.1016/j.wneu.2018.06.231DOI Listing
November 2018

Repeat Gamma Knife radiosurgery versus microvascular decompression following failure of GKRS in trigeminal neuralgia: a systematic review and meta-analysis.

J Neurosurg 2018 10 1:1-10. Epub 2018 Oct 1.

OBJECTIVE: Gamma Knife radiosurgery (GKRS) has emerged as a promising treatment modality for patients with classical trigeminal neuralgia (TN); however, considering that almost half of the patients experience post-GKRS failure or lesion recurrence, a repeat treatment is typically necessary. The existing literature does not offer clear evidence to establish which treatment modality, repeat GKRS or microvascular decompression (MVD), is superior. The present study aimed to compare the overall outcome of patients who have undergone either repeat GKRS or MVD after failure of their primary GKRS; the authors do so by conducting a systematic review and meta-analysis of the literature and analysis of data from their own institution. METHODS: The authors conducted a systematic review and meta-analysis of the PubMed, Cochrane Library, Web of Science, and CINAHL databases to identify studies describing patients who underwent either repeat GKRS or MVD after initial failed GKRS for TN. The primary outcomes were complete pain relief (CPR) and adequate pain relief (APR) at 1 year. The secondary outcomes were rate of postoperative facial numbness and the retreatment rate. The pooled data were analyzed with R software. Bias and heterogeneity were assessed using funnel plots and I2 tests, respectively. A retrospective analysis of a series of patients treated by the authors who underwent repeat GKRS or MVD after post-GKRS failure or relapse is presented. RESULTS: A total of 22 studies met the selection criteria and were included for final data retrieval and meta-analysis. The search did not identify any study that had directly compared outcomes between patients who had undergone repeat GKRS versus those who had undergone MVD. Therefore, the authors' final analysis included two groups: studies describing outcome after repeat GKRS (n = 17) and studies describing outcome after MVD (n = 5). The authors' institutional study was the only study with direct comparison of the two cohorts. The pooled estimates of primary outcomes were APR in 83% of patients who underwent repeat GKRS and 88% of those who underwent MVD (p = 0.49), and CPR in 46% of patients who underwent repeat GKRS and 72% of those who underwent MVD (p = 0.02). The pooled estimates of secondary outcomes were facial numbness in 32% of patients who underwent repeat GKRS and 22% of those who underwent MVD (p = 0.11); the retreatment rate was 19% in patients who underwent repeat GKRS and 13% in those who underwent MVD (p = 0.74). The authors' institutional study included 42 patients (repeat GKRS in 15 and MVD in 27), and the outcomes 1 year after retreatment were APR in 80% of those who underwent repeat GKRS and 81% in those who underwent MVD (p = 1.0); CPR was achieved in 47% of those who underwent repeat GKRS and 44% in those who underwent MVD (p = 1.0). There was no difference in the rate of postoperative facial numbness or retreatment. CONCLUSIONS: The current meta-analysis failed to identify any superiority of one treatment over the other with comparable outcomes in terms of APR, postoperative facial numbness, and retreatment rates. However, MVD was shown to provide a better chance of CPR compared with repeat GKRS.
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http://dx.doi.org/10.3171/2018.5.JNS18583DOI Listing
October 2018

Acute Supratentorial Ischemic Stroke with Ipsilateral Hemiparesis: Pathomechanism and Management Challenges.

World Neurosurg 2018 11 30;119:1-5. Epub 2018 Jul 30.

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA; Department of Radiology, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA. Electronic address:

Background: Supratentorial stroke manifesting as ipsilateral hemiparesis is rare. Multiple pathophysiologic mechanisms are possible for this unusual phenomenon and has been previously described. Its implication in therapeutic decision making in a patient with an acute emergent condition has never been discussed. We describe our experience with a patient with this unusual presentation.

Case Description: A 44-year-old woman presented with acute-onset right hemiparesis and left facial weakness. Evaluation with computed tomography angiography showed right M3 segment occlusion. Her National Institutes of Health Stroke Scale score on arrival was 9. Urgent magnetic resonance imaging was performed, which showed ongoing ischemia in the right frontotemporal cortex. She underwent endovascular thrombectomy, and complete revascularization was achieved. Postoperatively, the patient experience complete neurologic recovery. Further diffusion tractography imaging showed near-complete nondecussation of corticospinal fibers.

Conclusions: Discordance between clinical and initial computed tomography angiography findings in a patient with acute ischemic stroke poses a management challenge. Additional imaging to correlate clinical findings in equivocal cases may help in decision making but may significantly delay intervention, and therefore its utility during the short therapeutic window period needs careful consideration. Considering the risks and benefits, timely intervention should be balanced judiciously against appropriate intervention to achieve a positive patient outcome.
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http://dx.doi.org/10.1016/j.wneu.2018.07.172DOI Listing
November 2018

Novel Use of Pipeline Stent Device After Inadvertent Microcatheter Rupture During Arteriovenous Fistula Embolization.

World Neurosurg 2018 Nov 30;119:345-348. Epub 2018 Jul 30.

Department of Neurosurgery, LSU-HSC, Shreveport, Louisiana, USA.

Background: Onyx, a liquid embolic agent, is the mainstay of embolization treatment of arteriovenous malformation or arteriovenous fistula. Microcatheter retention in an embolic cast is a well-known complication. Rupture of catheter with spillage of onyx is a rare phenomenon but can lead to potential occlusion of the parent vessel.

Methods: We describe a case in which a patient with ruptured arteriovenous fistula experienced rupture of a microcatheter at the proximal part and spillage of onyx on embolization. A Pipeline embolization device (PED) was successfully deployed, and onyx was jailed between the catheter and vessel wall at the third segment of the vertebral artery (V3 segment). A balloon angioplasty helped to complete the opening of the stent.

Results: The procedure was uneventful, and the patient recovered well. Follow-up angiogram revealed patency of posterior circulation. The 6-month follow-up angiogram revealed a patent stent.

Conclusions: Microcatheter rupture and spillage of onyx during embolization of arteriovenous malformation/arteriovenous fistula is a potential complication, and management should be individualized. The unique close cell design of the PED was successfully used to avoid a potentially life-threatening occlusion of the vertebrobasilar system. To the best of our knowledge, we report for the first time this novel use of PED.
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http://dx.doi.org/10.1016/j.wneu.2018.07.171DOI Listing
November 2018

Safety profile of superior petrosal vein (the vein of Dandy) sacrifice in neurosurgical procedures: a systematic review.

Neurosurg Focus 2018 07;45(1):E3

OBJECTIVE Walter E. Dandy described for the first time the anatomical course of the superior petrosal vein (SPV) and its significance during surgery for trigeminal neuralgia. The patient's safety after sacrifice of this vein is a challenging question, with conflicting views in current literature. The aim of this systematic review was to analyze the current surgical considerations regarding Dandy's vein, as well as provide a concise review of the complications after its obliteration. METHODS A systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A thorough literature search was conducted on PubMed, Web of Science, and the Cochrane database; articles were selected systematically based on the PRISMA protocol and reviewed completely, and then relevant data were summarized and discussed. RESULTS A total of 35 publications pertaining to the SPV were included and reviewed. Although certain studies report almost negligible complications of SPV sectioning, there are reports demonstrating the deleterious effects of SPV obliteration when achieving adequate exposure in surgical pathologies like trigeminal neuralgia, vestibular schwannoma, and petroclival meningioma. The incidence of complications after SPV sacrifice (32/50 cases in the authors' series) is 2/32 (6.2%), and that reported in various case series varies from 0.01% to 31%. It includes hemorrhagic and nonhemorrhagic venous infarction of the cerebellum, sigmoid thrombosis, cerebellar hemorrhage, midbrain and pontine infarct, intracerebral hematoma, cerebellar and brainstem edema, acute hydrocephalus, peduncular hallucinosis, hearing loss, facial nerve palsy, coma, and even death. In many studies, the difference in incidence of complications between the SPV-sacrificed group and the SPV-preserved group was significant. CONCLUSIONS The preservation of Dandy's vein is a neurosurgical dilemma. Literature review and experiences from large series suggest that obliterating the vein of Dandy while approaching the superior cerebellopontine angle corridor may be associated with negligible complications. However, the counterview cannot be neglected in light of some series showing an up to 30% complication rate from SPV sacrifice. This review provides the insight that although the incidence of complications due to SPV obliteration is low, they can happen, and the sequelae might be worse than the natural history of the existing pathology. Therefore, SPV preservation should be attempted to optimize patient outcome.
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http://dx.doi.org/10.3171/2018.4.FOCUS18133DOI Listing
July 2018

Meningioma: The Tumor That Taught Us Neurosurgery.

World Neurosurg 2018 Oct 12;118:342-347. Epub 2018 Jun 12.

Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, Louisiana, USA. Electronic address:

The history of neurosurgery is ever fascinating. The journey has been tedious; nevertheless, in the landscape of success and failures we have become more efficient and polished. Skills were learned, innovations were made, and in the process we evolved. The immense contribution of meningioma surgery in this maturation process is attested by history itself. Countless stories that testify the momentous role of meningioma in the process of evolution and reformation of neurosurgical techniques exist in the literature. With every step and every attempt at conquering this tumor, we reformed to be better surgeons, more skilled and more precise. In this paper we have walked down the lane of neurosurgery and paid a due tribute to this "necessary evil."
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http://dx.doi.org/10.1016/j.wneu.2018.06.017DOI Listing
October 2018
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