Publications by authors named "Yigal Shoshan"

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

[F]-FDHT PET/CT as a tool for imaging androgen receptor expression in high-grade glioma.

Neurooncol Adv 2021 Jan-Dec;3(1):vdab019. Epub 2021 Jan 29.

Leslie and Michael Gaffin Center for Neuro-Oncology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel.

Background: G lioblastoma (GBM) is associated with poor overall survival. Recently, we showed that androgen receptor (AR) protein is overexpressed in 56% of GBM specimens and AR antagonists induced dose-dependent death in several GBM cell lines and significantly reduced tumor growth and prolonged the lifespan of mice implanted with human GBM. 16β-18F-fluoro-5α-dihydrotestosterone ([F]-FDHT) is a positron emission tomography (PET) tracer used to detect AR expression in prostate and breast cancers. This study was aimed at exploring the ability of [F]-FDHT-PET to detect AR expression in high-grade gliomas.

Methods: Twelve patients with suspected high-grade glioma underwent a regular workup and additional dynamic and static [F]-FDHT-PET/CT. Visual and quantitative analyses of [ F]-FDHT kinetics in the tumor and normal brain were performed. Mean and maximum (max) standardized uptake values (SUVs) were determined in selected volumes of interest. The patients had surgery or biopsy after PET/CT. AR protein was analyzed in the tumor samples by western blot. Fold change in AR expression was calculated by densitometry analysis. Correlation between imaging and AR protein samples was determined.

Results: In six of the 12 patients, [ F]-FDHT uptake was significantly higher in the tumor than in the normal brain. These patients also had increased AR protein expression within the tumor. Pearson correlation coefficient analysis for the tumor-to-control normal brain uptake ratio in terms of SUV versus AR protein expression was positive and significant (R = 0.84; = .002).

Conclusion: [ F]-FDHT-PET/CT could identify increased AR expression in high-grade glioma.
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http://dx.doi.org/10.1093/noajnl/vdab019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954111PMC
January 2021

VHL-Related Neuroendocrine Neoplasms And Beyond: An Israeli Specialized Center Real-Life Report.

Endocr Pract 2020 Oct;26(10):1131-1142

From the Neuroendocrine Tumor Unit, Department of Endocrinology, ENETS Centre of Excellence.

Objective: Von Hippel-Lindau (VHL) syndrome is a rare and complex disease. In 1996, we described a 3 generation VHL 2A kindred with 11 mutation carriers. We aim to share our experience regarding the long-term follow-up of this family and the management of all our other VHL patients focusing on frequently encountered neuroendocrine neoplasms: pheochromocytoma/paraganglioma and pancreatic neuroendocrine neoplasms (PNEN).

Methods: All VHL patients in follow-up at our tertiary center from 1980 to 2019 were identified. Clinical, laboratory, imaging, and therapeutic characteristics were retrospectively analyzed.

Results: We identified 32 VHL patients in 16 different families, 7/16 were classified as VHL 2 subtype. In the previously described family, the 4 initially asymptomatic carriers developed a neuroendocrine tumor; 7 new children were born, 3 of them being mutation carriers; 2 patients died, 1 due to metastatic PNEN-related liver failure. Pheochromocytoma was frequent (22/32), bilateral (13/22;59%), often diagnosed in early childhood when active screening was timely performed, associated with paraganglioma in 5/22, rarely malignant (1/22), and recurred after surgery in some cases after more than 20 years. PNEN occurred in 8/32 patients (25%), and was metastatic in 3 patients. Surgery and palliative therapy allowed relatively satisfactory outcomes. Severe disabling morbidities due to central-nervous system and ophthalmologic hemangiomas, and other rare tumors as chondrosarcoma in 2 patients and polycythemia in 1 patient were observed.

Conclusion: A multidisciplinary approach and long-term follow-up is mandatory in VHL patients to manage the multiple debilitating morbidities and delay mortality in these complex patients.
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http://dx.doi.org/10.4158/EP-2020-0220DOI Listing
October 2020

Radiation-induced vascular malformations in the brain, mimicking tumor in MRI-based treatment response assessment maps (TRAMs).

Clin Transl Radiat Oncol 2019 Feb 14;15:1-6. Epub 2018 Nov 14.

Advanced Technology Center, Sheba Medical Center, Ramat-Gan 52621, Israel.

•Of 310 brain tumors patients recruited, histology of 99 lesions was available.•Of those, 5 were histologically confirmed as radiation-induced malformations.•TRAMs cannot differentiate active tumor from vascular malformation.
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http://dx.doi.org/10.1016/j.ctro.2018.11.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6282630PMC
February 2019

The clinical characteristics of posttraumatic epilepsy following moderate-to-severe traumatic brain injury in children.

Seizure 2018 May 20;58:29-34. Epub 2018 Mar 20.

The pediatric Neurosurgery Unit, Rambam Health Care Campus, Haifa, Israel. Electronic address:

Purpose: Children with traumatic brain injury (TBI) are at increased risk of posttraumatic epilepsy (PTE); the risk increases according to TBI severity. We examined the long-term incidence and risk factors for developing PTE in a cohort of children hospitalised at one medical centre with moderate or severe TBI.

Methods: Moderate brain injury was classified as Glasgow Coma Score on Arrival (GCSOA) of 9-13, and severe brain injury as GCSOA ≤8. We collected demographics and clinical data from medical records and interviewed patients and parents at 5-11 years following the TBI event.

Results: During a median follow-up period of 7.3 years, 9 (9%) of 95 children with moderate-to-severe TBI developed PTE; 4 developed intractable epilepsy. The odds for developing PTE was 2.9 in patients with severe compared to moderate TBI. CT findings showed fractures in 7/9 (78%) of patients with PTE, compared to 40/86 (47%) of those without PTE (p = 0.09). Of the patients with fractures, all those with PTE had additional features on CT (such as haemorrhage, contusion and mass effect), compared to 29/40 (73%) of those without PTE. One of nine (11%) PTE patients and 10 of 86 (12%) patients without PTE had immediate seizures. Two (22%) children with PTE had their first seizure more than 2 years after the TBI.

Conclusion: Among children with moderate or severe TBI, the presence of additional CT findings, other than skull fractures, seem to increase the risk of PTE. In our cohort, the occurrence of an early seizure did not confer an increased risk of PTE.
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http://dx.doi.org/10.1016/j.seizure.2018.03.018DOI Listing
May 2018

Prevalence, Characteristics, and Long-Term Prognosis of Epilepsy Associated with Pediatric Brain Tumors.

World Neurosurg 2018 Jan 17;109:e594-e600. Epub 2017 Oct 17.

The Pediatric Neurosurgery Unit, Rambam Health Care Campus, Haifa, Israel. Electronic address:

Objective: We investigated the prevalence, onset, characteristics, and long-term course of epilepsy disease in children who underwent surgical intervention for diagnosed brain tumors.

Methods: We reviewed the medical records of children with diagnosed brain tumors who underwent surgery during 2004-2014 at the Hadassah Medical Center. All patients with epilepsy were invited to a clinical visit that included a neurologic examination. The primary outcome measures were neurologic status according to the Glasgow outcome score (GOS) and postoperative seizure outcome according to the Engel system. We compared clinical characteristics according to the timing of epilepsy onset.

Results: The mean follow-up was 49 months. Of 128 patients included in the study, 44 (34%) had seizures; 23 (18%) developed epilepsy after surgery. Of the 30 patients with epilepsy who survived, 21 (70%) are in Engel class I and 13% Engel are in class II. Forty-five percent of the children are classified as GOS 5. Children who developed epilepsy after surgery were more likely to be in GOS 1-2 than were those who had seizures before surgery (P = 0.0173). Children with seizures were more likely to have cortical tumors and less likely to have tumors of the posterior fossa (P < 0.001). Children who underwent gross total resection were less likely to have epilepsy (P < 0.001).

Conclusions: We show a high incidence of epilepsy in the late course of pediatric brain tumor disease. In the long term, seizure outcome was excellent. However, postsurgical onset of epilepsy was associated with a less favorable neurologic outcome.
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http://dx.doi.org/10.1016/j.wneu.2017.10.038DOI Listing
January 2018

Computer-based radiological longitudinal evaluation of meningiomas following stereotactic radiosurgery.

Int J Comput Assist Radiol Surg 2018 Feb 14;13(2):215-228. Epub 2017 Oct 14.

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

Purpose: Stereotactic radiosurgery (SRS) is a common treatment for intracranial meningiomas. SRS is planned on a pre-therapy gadolinium-enhanced T1-weighted MRI scan (Gd-T1w MRI) in which the meningioma contours have been delineated. Post-SRS therapy serial Gd-T1w MRI scans are then acquired for longitudinal treatment evaluation. Accurate tumor volume change quantification is required for treatment efficacy evaluation and for treatment continuation.

Method: We present a new algorithm for the automatic segmentation and volumetric assessment of meningioma in post-therapy Gd-T1w MRI scans. The inputs are the pre- and post-therapy Gd-T1w MRI scans and the meningioma delineation in the pre-therapy scan. The output is the meningioma delineations and volumes in the post-therapy scan. The algorithm uses the pre-therapy scan and its meningioma delineation to initialize an extended Chan-Vese active contour method and as a strong patient-specific intensity and shape prior for the post-therapy scan meningioma segmentation. The algorithm is automatic, obviates the need for independent tumor localization and segmentation initialization, and incorporates the same tumor delineation criteria in both the pre- and post-therapy scans.

Results: Our experimental results on retrospective pre- and post-therapy scans with a total of 32 meningiomas with volume ranges 0.4-26.5 cm[Formula: see text] yield a Dice coefficient of [Formula: see text]% with respect to ground-truth delineations in post-therapy scans created by two clinicians. These results indicate a high correspondence to the ground-truth delineations.

Conclusion: Our algorithm yields more reliable and accurate tumor volume change measurements than other stand-alone segmentation methods. It may be a useful tool for quantitative meningioma prognosis evaluation after SRS.
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http://dx.doi.org/10.1007/s11548-017-1673-7DOI Listing
February 2018

Posttraumatic epilepsy: long-term follow-up of children with mild traumatic brain injury.

J Neurosurg Pediatr 2017 Jul 5;20(1):64-70. Epub 2017 May 5.

Pediatric Neurosurgery Unit.

OBJECTIVE Posttraumatic epilepsy (PTE) is a known complication of traumatic brain injury (TBI). The true incidence of PTE in children is still uncertain, because most research has been based primarily on adults. This study aimed to determine the true incidence of PTE in a pediatric population with mild TBI (MTBI) and to identify risk factors for the development of epileptic events. METHODS Data were collected from electronic medical records of children 0-17 years of age, who were admitted to a single medical center between 2007 and 2009 with a diagnosis of MTBI. This prospective research consisted of a telephone survey between 2015 and 2016 of children or their caregivers, querying for information about epileptic episodes and current seizure and neurological status. The primary outcome measure was the incidence of epilepsy following TBI, which was defined as ≥ 2 unprovoked seizure episodes. Posttraumatic seizure (PTS) was defined as a single, nonrecurrent convulsive episode that occurred > 24 hours following injury. Seizures within 24 hours of the injury were defined as immediate PTS. RESULTS Of 290 children eligible for this study, 191 of them or their caregivers were reached by telephone survey and were included in the analysis. Most injuries (80.6%) were due to falls. Six children had immediate PTS. All children underwent CT imaging; of them, 72.8% demonstrated fractures and 10.5% did not demonstrate acute findings. The mean follow-up was 7.4 years. Seven children (3.7%) experienced PTS; of them, 6 (85.7%) developed epilepsy and 3 (42.9%) developed intractable epilepsy. The overall incidence of epilepsy and intractable epilepsy in this cohort was 3.1% and 1.6%, respectively. None of the children who had immediate PTS developed epilepsy. Children who developed epilepsy spent an average of 2 extra days in the hospital at the time of the injury. The mean time between trauma and onset of seizures was 3.1 years. Immediate PTS was not correlated with PTE. CONCLUSIONS In this analysis of data from medical records and long-term follow-up, MTBI was found to confer increased risk for the development of PTE and intractable PTE, of 4.5 and 8 times higher, respectively. As has been established in adults, these findings confirm that MTBI increases the risk for PTE in the pediatric population.
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http://dx.doi.org/10.3171/2017.2.PEDS16585DOI Listing
July 2017

Clinical Significance of Long-Term Follow-Up of Children with Posttraumatic Skull Base Fracture.

World Neurosurg 2017 Jul 19;103:315-321. Epub 2017 Apr 19.

Neurosurgical Pediatric Unit, Hadassah Ein Kerem Medical Center, Jerusalem, Israel; Neurosurgery Department, Hadassah Ein Kerem Medical Center, Jerusalem, Israel. Electronic address:

Objective: To assess the incidence of cerebrospinal fluid (CSF) leak and meningitis, and the need for prophylactic antibiotics, antipneumococcal vaccination, and surgical interventions, in children with a skull base fracture.

Methods: We reviewed the records of children with a skull base fracture who were admitted to our tertiary care center between 2009 and 2014.

Results: A total of 196 children (153 males), age 1 month to 18 years (mean age, 6 ± 4 years), were hospitalized with skull base fracture. Causes of injury were falls (n = 143), motor vehicle accidents (n = 34), and other (n = 19). Fracture locations were the middle skull base in 112 patients, frontal base in 62, and occipital base in 13. Fifty-four children (28%) had a CSF leak. In 34 of these children (63%), spontaneous resolution occurred within 3 days. Three children underwent surgery on admission owing to a CSF leak from an open wound, 3 underwent CSF diversion by spinal drainage, and 4 (2%) required surgery to repair a dural tear after failure of continuous spinal drainage and acetazolamide treatment. Twenty-eight children (14%) received prophylactic antibiotic therapy, usually due to other injuries, and 11 received pneumococcal vaccination. Two children developed meningitis, and 3 children died. Long-term follow up in 124 children revealed 12 children with delayed hearing loss and 3 with delayed facial paralysis.

Conclusions: This is the largest pediatric series of skull base fractures reporting rates of morbidity and long-term outcomes published to date. The rate of meningitis following skull base fracture in children is low, supporting a policy of not administering prophylactic antibiotics or pneumococcal vaccine. Long-term follow up is important to identify delayed complications.
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http://dx.doi.org/10.1016/j.wneu.2017.04.068DOI Listing
July 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

Evaluation of the necessity of hospitalization in children with an isolated linear skull fracture (ISF).

Childs Nerv Syst 2016 Sep 21;32(9):1669-74. Epub 2016 Jul 21.

The Neurosurgical Pediatric Unit and the Neurosurgery Department, Hadassah Ein Kerem Medical Center, Jerusalem, Israel.

Objective: The prevalence of skull fractures after mild head trauma is 2 % in children of all ages and 11 % in children younger than 2 years. The current standard management for a child diagnosed with an isolated skull fracture (ISF), in our institute, is hospitalization for a 24-h observation period. Based on data from the literature, less than 1 % of all minor head injuries require neurosurgical intervention. The main objective of this study was to evaluate the risk of neurological deterioration of ISF cases, in order to assess the need for hospitalization.

Methods: We reviewed the medical charts of 222 children who were hospitalized from 2006 to 2012 with ISF and Glascow Coma Scale-15 at the time of arrival. We collected data regarding demographic characteristics, mechanism of injury, fracture location, clinical symptoms and signs, need for hospitalization, and need for repeated imaging. Data was collected at three time points: at presentation to the emergency room, during hospitalization, and 1 month after admission, when the patients' parents were asked about the course of the month following discharge.

Results: None of the 222 children included in the study needed neurosurgical intervention. All were asymptomatic 1 month after the injury. Two children underwent repeated head CT due to persistence or worsening of symptoms; these CT scans did not reveal any new findings and did not lead to any intervention whatsoever.

Conclusion: Children arriving at the emergency room with a minor head injury and isolated skull fracture on imaging studies may be considered for discharge after a short period of observation. Discharge should be considered in these cases provided the child has a reliable social environment and responsible caregivers who are able to return to the hospital if necessary. Hospital admission should be reserved for children with neurologic deficits, persistent symptoms, suspected child abuse, or when the parent is unreliable or is unable to return to the hospital if necessary. Reducing unnecessary hospitalizations can prevent emotional stress, in addition to saving costs for the child's family and the health care system.
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http://dx.doi.org/10.1007/s00381-016-3175-2DOI Listing
September 2016

Review of controversies in management of non-benign meningioma.

J Clin Neurosci 2016 Sep 20;31:37-46. Epub 2016 Jun 20.

The Department of Neurosurgery, Hadassah Medical Center, Ein-Kerem Campus, Jerusalem 91120, Israel.

Meningiomas are one of the most common brain tumors. World Health Organisation (WHO) Grade II and Grade III meningiomas are grouped together as non-benign meningioma (NBM). There are several controversies surrounding NBM management, including the significance of extent of resection and the efficacy of post-operative radiation and drug treatment. We reviewed the literature to develop recommendations for management of NBM. The questions we sought to answer were: Does gross total resection (GTR) improve patient outcome? Is radiation therapy (RT) warranted after complete or after incomplete resection of NBM? What drug therapies have been proven to improve outcome in patients with NBM? We found that GTR improves outcome in WHO Grade II meningioma, and should be attempted whenever considered safe. GTR correlates less closely to outcome in Grade III meningioma compared to subtotal resection (STR). Extreme measures to completely resect Grade III meningioma are not warranted. RT following GTR of Grade II meningioma does not improve patient outcome, and may be reserved for recurrence. RT improves outcome following STR of Grade II meningioma. RT improves outcome after resection of Grade III meningioma. No drug therapy has been shown to improve outcome in NBM. This review elucidates recommendations for some of the controversies involving NBM.
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http://dx.doi.org/10.1016/j.jocn.2016.03.014DOI Listing
September 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

Supraciliary keyhole craniotomy for anterior frontal lesions in children.

J Clin Neurosci 2016 Apr 4;26:37-41. Epub 2016 Jan 4.

Neurosurgery Department, Soroka Medical Center, Beer-Sheva, Israel.

Treatment for anterior frontal space occupying lesions such as epidural hematoma, vascular malformations or brain tumors, have typically involved invasive craniotomies. This method often requires large incisions with wide exposure and may be associated with high morbidity rates. The basis for the "keyhole" method is that a minimally invasive craniotomy is often sufficient for exposing large areas deep in tissue, and may limit exposure and decrease surgically related morbidity while enabling adequate removal and decompression. The supraciliary method includes a cut above the eyebrow and a small craniotomy to uncover the base of the frontal lobe and the orbital roof. We demonstrate our experience with this method. We identified children who were operated via the supraciliary approach between January 2009 and December 2013, and gathered their pre- and post-operative clinical and radiological statistics. Fourteen patients were identified. Pathologies included tumors, abscesses and epidural hematomas. Nine were operated due to epidural hematoma, two due to tumors, two due to brain abscesses, and one for anterior encephalocele. No significant peri-operative or post-operative complications were observed. Long-term follow-up shows that the surgical scars were nearly invisible. The supraciliary approach is a safe, effective and elegant technique for treating lesions in the anterior skull base. The method should be weighed alongside traditional methods on a case-by-case basis.
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http://dx.doi.org/10.1016/j.jocn.2015.10.024DOI Listing
April 2016

Delayed contrast extravasation MRI: a new paradigm in neuro-oncology.

Neuro Oncol 2015 Mar 30;17(3):457-65. Epub 2014 Nov 30.

Oncology Institute (L.Z., A.T.); Advanced Technology Center (D.G., D.L., D.D., S.S., Y.M.); Neurosurgery Department (Y.G., O.N., R.S., M.H., J.Z., Z.R.C.); Radiology Institute (C.H., G.T.); Pathology Institute (D.N.); Pediatric Hemato-Oncology Department, Sheba Medical Center, Ramat-Gan, Israel (M.Y.); Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel (L.Z., D.D., C.H., R.S., G.T., M.Y., Z.R.C., Y.M.); Neuro-Oncology Service (D.T.B., F.B.); Neurosurgery Department, Tel-Aviv Medical Center, Tel-Aviv, Israel (A.K., J.R.); Neuro-Oncology Service (E.F., M.W.); Neurosurgery Department, Hadassah Medical Center, Jerusalem, Israel (Y.S.); Oncology Institute, Davidoff Center, Rabin Medical Center, Petach Tikva, Israel (D.L.); Neuro-Oncology Service, Rambam Medical Center, Haifa, Israel (T.T.).

Background: Conventional magnetic resonance imaging (MRI) is unable to differentiate tumor/nontumor enhancing tissues. We have applied delayed-contrast MRI for calculating high resolution treatment response assessment maps (TRAMs) clearly differentiating tumor/nontumor tissues in brain tumor patients.

Methods: One hundred and fifty patients with primary/metastatic tumors were recruited and scanned by delayed-contrast MRI and perfusion MRI. Of those, 47 patients underwent resection during their participation in the study. Region of interest/threshold analysis was performed on the TRAMs and on relative cerebral blood volume maps, and correlation with histology was studied. Relative cerebral blood volume was also assessed by the study neuroradiologist.

Results: Histological validation confirmed that regions of contrast agent clearance in the TRAMs >1 h post contrast injection represent active tumor, while regions of contrast accumulation represent nontumor tissues with 100% sensitivity and 92% positive predictive value to active tumor. Significant correlation was found between tumor burden in the TRAMs and histology in a subgroup of lesions resected en bloc (r(2) = 0.90, P < .0001). Relative cerebral blood volume yielded sensitivity/positive predictive values of 51%/96% and there was no correlation with tumor burden. The feasibility of applying the TRAMs for differentiating progression from treatment effects, depicting tumor within hemorrhages, and detecting residual tumor postsurgery is demonstrated.

Conclusions: The TRAMs present a novel model-independent approach providing efficient separation between tumor/nontumor tissues by adding a short MRI scan >1 h post contrast injection. The methodology uses robust acquisition sequences, providing high resolution and easy to interpret maps with minimal sensitivity to susceptibility artifacts. The presented results provide histological validation of the TRAMs and demonstrate their potential contribution to the management of brain tumor patients.
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http://dx.doi.org/10.1093/neuonc/nou230DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4483101PMC
March 2015

Ventriculo-peritoneal shunt malfunction due to complete migration and subgaleal coiling of the proximal and distal catheters.

J Clin Neurosci 2015 Jan 28;22(1):224-6. Epub 2014 Oct 28.

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

Ventriculo-peritoneal (VP) shunt malfunction due to proximal and distal catheter migration has been rarely reported in the literature. Shunt migration has been proposed to occur as a result of a combination of various mechanisms, including the windlass effect, retained memory of the shunt tubing, inadequate shunt fixation, and increased intra-abdominal pressures. We describe a rare case of a 6-week-old child who presented in our department with VP shunt malfunction due to complete proximal migration and coiling of the peritoneal and ventricular VP shunt catheters within a subgaleal pocket at the left occipital area.
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http://dx.doi.org/10.1016/j.jocn.2014.08.005DOI Listing
January 2015

Intracranial pressure monitoring following decompressive hemicraniectomy for malignant cerebral infarction.

J Clin Neurosci 2015 Jan 12;22(1):79-82. Epub 2014 Sep 12.

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

Randomized controlled trials have demonstrated the efficacy of decompressive craniectomy in substantially decreasing mortality and improving functional outcome in middle cerebral artery infarction. The role of intracranial pressure (ICP) monitoring following decompressive craniectomy for stroke has not been well studied. We present a retrospective review of our experience with postoperative ICP monitoring in 12 stroke patients who underwent decompressive craniectomy. All elevations of ICP above a 20 mm Hg threshold were noted. ICP was recorded for 1417 hours during which 68 ICP elevations were seen. Nine out of 12 patients had events of raised ICP, including eight with more than three elevations. A total of 81 interventions were employed to treat elevated ICP; 71 were effective in reducing ICP below the 20 mm Hg threshold. The most frequent intervention was cerebrospinal fluid drainage via an external ventricular drain, which was effective in 85.4% of cases. Eleven out of 12 patients survived (92%) and attained a median modified Rankin Scale score of 4 (interquartile range 4-5) at a mean 15 month follow-up. In our experience, elevated ICP may commonly occur following decompressive craniectomy for stroke. Monitoring ICP influenced postoperative management and standard measures for reducing ICP were usually effective in the current series.
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http://dx.doi.org/10.1016/j.jocn.2014.07.006DOI Listing
January 2015

Spontaneous spinal epidural hematoma: the importance of preoperative neurological status and rapid intervention.

J Clin Neurosci 2015 Jan 22;22(1):123-8. Epub 2014 Aug 22.

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

We describe the presentation, management, and outcome of spontaneous spinal epidural hematoma (SSEH) in two tertiary academic centers. We retrospectively reviewed clinical and imaging files in patients diagnosed with SSEH from 2002-2011. Neurologic status was assessed using the American Spinal Injury Association (ASIA) Impairment Scale (AIS). A total of 17 patients (10 females; mean age 54 years, range 10-89) were included. Among patients presenting with AIS A, 5/8 showed no improvement and 3/8 reached AIS C. Among those presenting with AIS C, 5/6 reached AIS E and 1/6 reached AIS D. Of those presenting with AIS D, 3/3 reached AIS E. Mean time-to-surgery (TTS) was 28 hours (range 3-96). TTS surgery in two patients remaining at AIS A was ⩽ 12 hours; in 4/8 patients recovering to AIS E it was > 12 hours, including three patients operated on after > 24 hours. In patients remaining at AIS A, a mean of 4.4 levels were treated compared with means of 3.7 and 3.5 in those with AIS C and E, respectively, at late follow-up. In this series, preoperative neurological status had greater impact on late outcome than time from symptom onset to surgery in patients with SSEH.
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http://dx.doi.org/10.1016/j.jocn.2014.07.003DOI Listing
January 2015

Efficacy and safety of vertebral stenting for painful vertebral compression fractures in patients with metastatic disease.

Neurol Res 2014 Dec 16;36(12):1086-93. Epub 2014 Jun 16.

Background And Purpose: Painful vertebral compression fractures in cancer patients reduce quality of life and may limit survival. We assessed pain relief, vertebral height restoration, and kyphosis correction following vertebral augmentation using a novel expandable titanium stent implant in cancer patients with painful vertebral compression fractures.

Materials And Methods: Patients >18 years of age with metastatic disease who presented symptomatic compression fractures of vertebral bodies T5-L5, with or without a history of osteoporosis, were included in the study. Back pain at presentation, immediately after vertebral stenting, and at 1-, 3-, 6-, and 12-month follow-up was estimated using the visual analog scale (VAS). Vertebral height and local kyphotic angle (alpha angle) were measured on lateral standing X-ray before and 1-3 months after stenting.

Results: Forty-one cancer patients with painful vertebral compression fractures underwent vertebral stenting procedures at 55 levels. There was no perioperative mortality and no significant complication. Median preoperative VAS was 8.0 (range 8-10), falling to 2.0 immediately postop (range 1-6, P  =  0.000) and 0 at all subsequent follow-up (P ≤ 0.012). Mean preoperative vertical height loss was 25.8% (range 0-84.0%) versus a postoperative mean of 18.0% (range 0-66.0%, P  =  0.000). Median pre- and postoperative kyphotic angle improved from 8.3° (range 0.2°-54.0°) to 7.1° (range 0.2°-25.0°, P  =  0.000). Wilcoxon signed rank test or student's t-test was used for comparisons.

Conclusions: Vertebral augmentation using a novel vertebral stenting system provided immediate and enduring pain relief and improved vertebral height loss and kyphotic angle.
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http://dx.doi.org/10.1179/0161641214Z.000000000459DOI Listing
December 2014

Are they too old? Surgical treatment for metastatic epidural spinal cord compression in patients aged 65 years and older.

Neurol Res 2014 Jun 16;36(6):530-43. Epub 2014 Apr 16.

Objectives: We aimed to assess the efficacy of surgical decompression of metastatic epidural spinal cord compression (MESCC) in patients ≧65 years and review our multidisciplinary surgical decision-making process.

Methods: We identified all patients operated for MESCC from August 2008 to June 2012. Patients ≧65 years, with a single area of cord compression, back/radicular pain, neurological signs of cord compression, surgery within 48 hours after onset of MESCC-related paraplegia, and follow-up for ≧1 year or until death were included. Files were reviewed retrospectively. The requirement for informed consent was waived. Neurological status was assessed with the American Spinal Injury Association (ASIA) Impairment Scale (AIS). Duration of ambulation and survival were assessed with Kaplan-Meier and Cox regression analysis.

Results: Twenty-one patients met inclusion criteria (11 women/10 men; mean age 73 years, range 65-87). All presented with debilitating back/neck pain. Ten patients (48%) were not ambulatory before surgery and four suffered urinary incontinence/constipation (19%). Preoperative AIS was E in 5 patients (24%), D in 11 (62%), and C in 5 (24%). Motor symptoms had been present for a mean of 3·8 days (range 1-14). All patients regained ambulation. Overall, mean survival was 320 days (range 19-798) and mean ambulation was 302 days (range 18-747). On 31 March 2013, 7 patients (33%) were alive and ambulatory at a mean of 459 days (range 302-747); 14 patients had died (67%) at a mean of 251 days (range 19-798), with a mean ambulation of 223 days (range 18-730).

Discussion: With careful patient selection, surgery may achieve long duration of ambulation in patients ≧65 years with MESCC.
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http://dx.doi.org/10.1179/1743132814Y.0000000368DOI Listing
June 2014

Assessment of a noninvasive cerebral oxygenation monitor in patients with severe traumatic brain injury.

J Neurosurg 2014 Apr 31;120(4):901-7. Epub 2014 Jan 31.

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

Object: Development of a noninvasive monitor to assess cerebral oxygenation has long been a goal in neurocritical care. The authors evaluated the feasibility and utility of a noninvasive cerebral oxygenation monitor, the CerOx 3110, which uses near-infrared spectroscopy and ultrasound to measure regional cerebral tissue oxygenation in patients with severe traumatic brain injury (TBI), and compared measurements obtained using this device to those obtained using invasive cerebral monitoring.

Methods: Patients with severe TBI admitted to the intensive care unit at Hadassah-Hebrew University Hospital requiring intracranial pressure (ICP) monitoring and advanced neuromonitoring were included in this study. The authors assessed 18 patients with severe TBI using the CerOx monitor and invasive advanced cerebral monitors.

Results: The mean age of the patients was 45.3 ± 23.7 years and the median Glasgow Coma Scale score on admission was 5 (interquartile range 3-7). Eight patients underwent unilateral decompressive hemicraniectomy and 1 patient underwent craniotomy. Sixteen patients underwent insertion of a jugular bulb venous catheter, and 18 patients underwent insertion of a Licox brain tissue oxygen monitor. The authors found a strong correlation (r = 0.60, p < 0.001) between the jugular bulb venous saturation from the venous blood gas and the CerOx measure of regional cerebral tissue saturation on the side ipsilateral to the catheter. A multivariate analysis revealed that among the physiological parameters of mean arterial blood pressure, ICP, brain tissue oxygen tension, and CerOx measurements on the ipsilateral and contralateral sides, only ipsilateral CerOx measurements were significantly correlated to jugular bulb venous saturation (p < 0.001).

Conclusions: Measuring regional cerebral tissue oxygenation with the CerOx monitor in a noninvasive manner is feasible in patients with severe TBI in the neurointensive care unit. The correlation between the CerOx measurements and the jugular bulb venous measurements of oxygen saturation indicate that the CerOx may be able to provide an estimation of cerebral oxygenation status in a noninvasive manner.
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http://dx.doi.org/10.3171/2013.12.JNS131089DOI Listing
April 2014

Spinal meningioma becoming symptomatic in the third trimester of pregnancy.

J Clin Neurosci 2013 Dec 14;20(12):1797-9. Epub 2013 Aug 14.

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

We report a rare case of a spinal meningioma leading to symptoms of spinal cord compression starting in the third trimester of gestation in a 32-year-old woman. Neurological symptoms, which continued to progress after the patient had given birth, were assumed to be sequelae of pregnancy and delivery, leading to a 6 month delay in diagnosis and treatment. Fortunately a gross total resection was achieved at surgery and the patient recovered fully, without permanent consequences. Associated symptoms of spinal cord compression may be falsely attributed to pregnancy, both by the pregnant women and her treating physician. A high index of suspicion and thorough history and physical examination to identify red flags should be performed in patients with neurological symptoms.
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http://dx.doi.org/10.1016/j.jocn.2013.08.001DOI Listing
December 2013

Establishing the position of neurosurgery nurse coordinator as a catalyst for advancing quality of care in a tertiary hospital in Israel.

J Neurosci Nurs 2013 Oct;45(5):E3-E12

Questions or comments about this article may be directed to Inbal Savion, RN BSN Ma Med Sc, at She is a Nursing Administration Academic Consultant and Neurosurgery Nurse Coordinator, Hadassah Hebrew University Medical Center, Jerusalem, Israel. Nurit Porat, RN PhD, is a Coordinator of the Clinical Quality Assurance in Nursing, Nursing Administration, Hadassah Hebrew University Medical Center, Jerusalem, Israel. Yigal Shoshan, MD, is the Chairman, Department of Neurosurgery, Surgical Neuro-oncology, Stereotaxis and Radiosurgery, Department of Neurosurgery, Hadassah Hebrew University Medical Center, Jerusalem, Israel.

Background: The role of neurosurgery nurse coordinator is unique in Israel and was developed to provide a comprehensive response to the needs of patients undergoing cranial surgery to remove various types of tumors. The creation of the neurosurgery nurse coordinator role was based on patient and staff needs assessment and focused on two major areas: (1) the patient and his or her family-creating personal and empathic communication with the goal of offering emotional support, providing support to assist in relieving symptoms, coordinating between the patient and/or the patient's family and the physicians and consultants, and assisting with bureaucratic processes and with familiarization with the hospital's medical environment; and (2) establishing departmental processes related to improving patient care within a multidisciplinary team.

Objective: The aim of this study was to investigate the needs and level of satisfaction of patients and their families, hospitalized in the neurosurgery department for the surgical removal of cranial tumors.

Methods: Satisfaction survey is composed of 47 questions.

Sample: A convenience sample of 67 patients completed a satisfaction survey related to various aspects of their hospitalization.

Findings: The study results reflect patient needs for emotional support, information, and additional education. These findings emphasize the great importance of the position of nurse coordinator in the neurosurgery department.
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http://dx.doi.org/10.1097/JNN.0b013e31829dba48DOI Listing
October 2013

Acute pseudotumoral hemicerebellitis: diagnosis and neurosurgical considerations of a rare entity.

J Clin Neurosci 2014 Feb 16;21(2):337-9. Epub 2013 Aug 16.

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

Acute pseudotumoral hemicerebellitis is an exceptionally rare unilateral presentation of acute cerebellitis mimicking a tumor. It typically has a benign course without specific therapy; thus, recognizing this entity is important to avoid needless surgical intervention. MRI provides the key for diagnosis and usually reveals a diffusely swollen cerebellar hemisphere with no well-defined mass. Some patients will require neurosurgical assistance by means of ventriculostomy or posterior fossa decompression. We present a 17-year-old girl with pseudotumoral hemicerebellitis, review the available literature, and discuss the diagnosis and therapeutic dilemma from the neurosurgical perspective.
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http://dx.doi.org/10.1016/j.jocn.2013.04.006DOI Listing
February 2014

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

Superficial siderosis of the central nervous system due to chronic hemorrhage from a giant invasive prolactinoma.

J Clin Neurosci 2013 Jul 9;20(7):1032-4. Epub 2013 May 9.

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

Superficial siderosis of the central nervous system (CNS) is a rare disorder caused by deposition of hemosiderin in neuronal tissue in the subpial layer of the CNS due to slow subarachnoid or intraventricular hemorrhage. The most common neurologic manifestations include progressive gait ataxia, sensorineural hearing loss, and corticospinal tract signs. We present a case of superficial siderosis in a 43-year-old man who presented to the Emergency Department with sudden onset bilateral visual deterioration and a loss of consciousness. A hemorrhagic giant prolactinoma was diagnosed based on brain CT scan, T1-weighted MRI, and an endocrine blood examination. Susceptibility-weighted non-contrast MRI showed pathognomonic signs of superficial siderosis in the form of a hypointensity rim surrounding the brainstem, cerebellar fissures, and cranial nerves VII and VIII. This report demonstrates that superficial siderosis can be caused by pituitary apoplexy.
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http://dx.doi.org/10.1016/j.jocn.2012.07.022DOI Listing
July 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

Reduced risk trajectory planning in image-guided keyhole neurosurgery.

Med Phys 2012 May;39(5):2885-95

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

Purpose: The authors present and evaluate a new preoperative planning method and computer software designed to reduce the risk of candidate trajectories for straight rigid tool insertion in image-guided keyhole neurosurgery.

Methods: Trajectories are computed based on the surgeon-defined target and a candidate entry point area on the outer head surface on preoperative CT/MRI scans. A multiparameter risk card provides an estimate of the risk of each trajectory according to its proximity to critical brain structures. Candidate entry points in the outer head surface areas are then color-coded and displayed in 3D to facilitate selection of the most adequate point. The surgeon then defines and/or revised the insertion trajectory using an interactive 3D visualization of surrounding structures. A safety zone around the selected trajectory is also computed to visualize the expected worst-case deviation from the planned insertion trajectory based on tool placement errors in previous surgeries.

Results: A retrospective comparative study for ten selected targets on MRI head scans for eight patients showed a significant reduction in insertion trajectory risk. Using the authors' method, trajectories longer than 30 mm were an average of 2.6 mm further from blood vessels compared to the conventional manual method. Average planning times were 8.4 and 5.9 min for the conventional technique and the authors' method, respectively. Neurosurgeons reported improved understanding of possible risks and spatial relations for the trajectory and patient anatomy.

Conclusions: The suggested method may result in safer trajectories, shorter preoperative planning time, and improved understanding of risks and possible complications in keyhole neurosurgery.
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http://dx.doi.org/10.1118/1.4704643DOI Listing
May 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

Fiducial optimization for minimal target registration error in image-guided neurosurgery.

IEEE Trans Med Imaging 2012 Mar 6;31(3):725-37. Epub 2011 Dec 6.

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

This paper presents new methods for the optimal selection of anatomical landmarks and optimal placement of fiducial markers in image-guided neurosurgery. These methods allow the surgeon to optimally plan fiducial marker locations on routine diagnostic images before preoperative imaging and to intraoperatively select the set of fiducial markers and anatomical landmarks that minimize the expected target registration error (TRE). The optimization relies on a novel empirical simulation-based TRE estimation method built on actual fiducial localization error (FLE) data. Our methods take the guesswork out of the registration process and can reduce localization error without additional imaging and hardware. Our clinical experiments on five patients who underwent brain surgery with a navigation system show that optimizing one marker location and the anatomical landmarks configuration reduced the TRE. The average TRE values using the usual fiducials setup and using the suggested method were 4.7 mm and 3.2 mm, respectively. We observed a maximum improvement of 4 mm. Reducing the target registration error has the potential to support safer and more accurate minimally invasive neurosurgical procedures.
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http://dx.doi.org/10.1109/TMI.2011.2175939DOI Listing
March 2012