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Fayed I, Smit RD, Vinjamuri S, Kang K, Sathe A, Sharan A, Wu C. Robot-Assisted Minimally Invasive Asleep Single-Stage Deep Brain Stimulation Surgery: Operative Technique and Systematic Review. Oper Neurosurg (Hagerstown) 2024; 26:363-371. [PMID: 37888994 DOI: 10.1227/ons.0000000000000977] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/16/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Robotic assistance has garnered increased use in neurosurgery. Recently, this has expanded to include deep brain stimulation (DBS). Several studies have reported increased accuracy and improved efficiency with robotic assistance, but these are limited to individual robotic platforms with smaller sample sizes or are broader studies on robotics not specific to DBS. Our objectives are to report our technique for robot-assisted, minimally invasive, asleep, single-stage DBS surgery and to perform a meta-analysis comparing techniques from previous studies. METHODS We performed a single-center retrospective review of DBS procedures using a floor-mounted robot with a frameless transient fiducial array registration. We compiled accuracy data (radial entry error, radial target error, and 3-dimensional target error) and efficiency data (operative time, setup time, and total procedure time). We then performed a meta-analysis of previous studies and compared these metrics. RESULTS We analyzed 315 electrodes implanted in 160 patients. The mean radial target error was 0.9 ± 0.5 mm, mean target 3-dimensional error was 1.3 ± 0.7 mm, and mean radial entry error was 1.1 ± 0.8 mm. The mean procedure time (including pulse generator placement) was 182.4 ± 47.8 minutes, and the mean setup time was 132.9 ± 32.0 minutes. The overall complication rate was 8.8% (2.5% hemorrhagic/ischemic, 2.5% infectious, and 0.6% revision). Our meta-analysis showed increased accuracy with floor-mounted over skull-mounted robotic platforms and with fiducial-based registrations over optical registrations. CONCLUSION Our technique for robot-assisted, minimally invasive, asleep, single-stage DBS surgery is safe, accurate, and efficient. Our data, combined with a meta-analysis of previous studies, demonstrate that robotic assistance can provide similar or increased accuracy and improved efficiency compared with traditional frame-based techniques. Our analysis also suggests that floor-mounted robots and fiducial-based registration methods may be more accurate.
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Affiliation(s)
- Islam Fayed
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Rupert D Smit
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Shreya Vinjamuri
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - KiChang Kang
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Anish Sathe
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Ashwini Sharan
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Chengyuan Wu
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
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Cobourn KD, Chesney KM, Mueller K, Fayed I, Tsering D, Keating RF. Isolated subependymal giant cell astrocytoma (SEGA) in the absence of clinical tuberous sclerosis: two case reports and literature review. Childs Nerv Syst 2024; 40:73-78. [PMID: 37658938 DOI: 10.1007/s00381-023-06105-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/25/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE Subependymal giant cell astrocytoma (SEGA) is a WHO grade I pediatric glioma arising in 5-15% of patients with tuberous sclerosis (TSC). Rare cases of isolated SEGA without TSC have been described. The etiology, genetic mechanisms, natural history, and response to treatment of these lesions are currently unknown. We describe two such cases of isolated SEGA with follow-up. METHODS Retrospective review was performed at a single institution to describe the clinical course of pathology-confirmed SEGA in patients with germline testing negative for TSC mutations. RESULTS Two cases of isolated SEGA were identified. Genetic analysis of the tumor specimen was available for one, which revealed an 18 base pair deletion in TSC1. Both cases were managed with surgical resection, one with preoperative embolization. In spite of a gross total resection, one patient experienced recurrence after three years. Treatment with an mTOR inhibitor led to a significant interval reduction of the mass on follow-up MRI. The patient tolerated the medication well for 6 years and is now off of treatment for 2 years with a stable lesion. CONCLUSION Cases of SEGA outside of the context of TSC are exceedingly rare, with only 48 cases previously described. The genetic mechanisms and treatment response of these lesions are poorly understood. To date, these lesions appear to respond well to mTOR inhibitors and may behave similarly to SEGAs associated with TSC. However, given that experience is extremely limited, these cases should be followed long term to better understand their natural history and treatment response.
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Affiliation(s)
- Kelsey D Cobourn
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Kelsi M Chesney
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Kyle Mueller
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Islam Fayed
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Deki Tsering
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA.
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Fayed I, Syed M, Gingold E, Alizadeh M, Sharan A, Wu C. A Novel and Simple Method Using Computed Tomography Streak Artifact to Determine the Orientation of Directional Deep Brain Stimulation Leads. Neurosurgery 2023; 93:1036-1045. [PMID: 37227135 DOI: 10.1227/neu.0000000000002536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 03/27/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Directional leads have garnered widespread use in deep brain stimulation (DBS) because of the ability to steer current and maximize the therapeutic window. Accurate identification of lead orientation is critical to effective programming. Although directional markers are visible on 2-dimensional imaging, precise orientation may be difficult to interpret. Recent studies have suggested methods of determining lead orientation, but these involve advanced intraoperative imaging and/or complex computational algorithms. Our objective is to develop a precise and reliable method of determining orientation of directional leads using conventional imaging techniques and readily available software. METHODS We examined postoperative thin-cut computed tomography (CT) scans and x-rays of patients who underwent DBS with directional leads from 3 vendors. Using commercially available stereotactic software, we localized the leads and planned new trajectories precisely overlaying the leads visualized on CT. We used trajectory view to locate the directional marker in a plane orthogonal to the lead and inspected the streak artifact. We then validated this method with a phantom CT model by acquiring thin-cut CT images orthogonal to 3 different leads in various orientations confirmed under direct visualization. RESULTS The directional marker creates a unique streak artifact that reflects the orientation of the directional lead. There is a hyperdense symmetric streak artifact parallel to the axis of the directional marker and a symmetric hypodense dark band orthogonal to the marker. This is often sufficient to infer the direction of the marker. If not, it at least renders 2 opposite possibilities for the direction of the marker, which can then be easily reconciled by comparison with x-ray images. CONCLUSION We propose a method to determine orientation of directional DBS leads in a precise manner on conventional imaging and readily available software. This method is reliable across DBS vendors, and it can simplify this process and aid in effective programming.
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Affiliation(s)
- Islam Fayed
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Mashaal Syed
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Eric Gingold
- Department of Radiology, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Mahdi Alizadeh
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
- Department of Radiology, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Ashwini Sharan
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Chengyuan Wu
- Department of Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
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Vedaei F, Fayed I, Alizadeh M, Miller C, Zhang AB, Koa V, Khan S, Mohamed FB, Wu C. Effect of Enlarged Perivascular Spaces in Reliable Distinction of Prospective Targeting During Deep Brain Stimulation in Patients With Advanced Parkinson's Disease: A Study of Deterministic and Probabilistic Tractography. Neurosurgery 2023; 93:691-698. [PMID: 37010304 DOI: 10.1227/neu.0000000000002478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Precise electrode position is vital for effective deep brain stimulation in treating motor symptoms in Parkinson's disease (PD). Enlarged perivascular spaces (PVSs) are associated with pathophysiology of neurodegenerative diseases including PD and may affect the microstructure of surrounding brain tissue. OBJECTIVE To quantify the clinical implications of enlarged PVS on tractography-based stereotactic targeting in patients with advanced PD selected to undergo deep brain stimulation. METHODS Twenty patients with PD underwent MRI scanning. The PVS areas were visualized and segmented. Based on the size of the PVS areas, the patient group was split into 2 categories of large vs small PVSs. Probabilistic and deterministic tractography methods were applied to a diffusion-weighted data set. Fiber assignment was performed using motor cortex as an initiation seed and the globus pallidus interna and subthalamic nucleus, separately, as inclusion masks. Two exclusion masks used consisted of cerebral peduncles and the PVS mask. The center of gravity of the tract density map was measured and compared between the tracts generated with and without consideration of the PVS mask. RESULTS The average differences between the center of gravity of the tracts made by excluding PVS and without excluding PVS using deterministic and probabilistic tractography methods were less than 1 mm. Statistical analysis showed nonsignificant differences between deterministic and probabilistic methods and differences between patients with large and small PVSs ( P > .05). CONCLUSION This study demonstrated that the presence of enlarged PVS is unlikely to affect targeting of basal ganglia nuclei based on tractography.
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Affiliation(s)
- Faezeh Vedaei
- Department of Radiology, Jefferson Integrated Magnetic Resonance Imaging Center, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Islam Fayed
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Mahdi Alizadeh
- Department of Radiology, Jefferson Integrated Magnetic Resonance Imaging Center, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Christopher Miller
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Ashley B Zhang
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Victoria Koa
- College of Medicine, Drexel University, Philadelphia , Pennsylvania , USA
| | - Suharto Khan
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Feroze B Mohamed
- Department of Radiology, Jefferson Integrated Magnetic Resonance Imaging Center, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Chengyuan Wu
- Department of Radiology, Jefferson Integrated Magnetic Resonance Imaging Center, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
- Department of Neurological Surgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
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Ailes I, Syed M, Matias CM, Krisa L, Miao J, Sathe A, Fayed I, Alhussein A, Natale P, Mohamed FB, Talekar K, Alizadeh M. Case report: Utilizing diffusion-weighted MRI on a patient with chronic low back pain treated with spinal cord stimulation. Front Neuroimaging 2023; 2:1137848. [PMID: 37554655 PMCID: PMC10406238 DOI: 10.3389/fnimg.2023.1137848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 04/20/2023] [Indexed: 08/10/2023]
Abstract
Diffusion-weighted magnetic resonance imaging (dwMRI) has increasingly demonstrated greater utility in analyzing neuronal microstructure. In patients with chronic low back pain (cLBP), using dwMRI to observe neuronal microstructure can lead to non-invasive biomarkers which could provide clinicians with an objective quantitative prognostic tool. In this case report, we investigated dwMRI for the development of non-invasive biomarkers by conducting a region-based analysis of a 55-year-old male patient with failed back surgery syndrome (FBSS) treated with spinal cord stimulation (SCS). We hypothesized that dwMRI could safely generate quantitative data reflecting cerebral microstructural alterations driven by neuromodulation. Neuroimaging was performed at 6- and 12- months post-SCS implantation. The quantitative maps generated included diffusion tensor imaging (DTI) parameters; fractional anisotropy (FA), axial diffusivity (AD), radial diffusivity (RD), and mean diffusivity (MD) computed from whole brain tractography. To examine specific areas of the brain, 44 regions of interest (ROIs), collectively representing the pain NeuroMatrix, were extracted and registered to the patient's diffusion space. Average diffusion indices were calculated from the ROIs at both 6- and 12- months. Regions with >10% relative change in at least 3 of the 4 maps were reported. Using this selection criterion, 8 ROIs demonstrated over 10% relative changes. These ROIs were mainly located in the insular gyri. In addition to the quantitative data, a series of questionnaires were administered during the 6- and 12-month visits to assess pain intensity, functional disability, and quality of life. Overall improvements were observed in these components, with the Pain Catastrophizing Scale (PCS) displaying the greatest change. Lastly, we demonstrated the safety of dwMRI for a patient with SCS. In summary, the results from the case report prompt further investigation in applying dwMRI in a larger cohort to better correlate the influence of SCS with brain microstructural alterations, supporting the utility of dwMRI to generate non-invasive biomarkers for prognostication.
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Affiliation(s)
- Isaiah Ailes
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, United States
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Mashaal Syed
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, United States
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Caio M. Matias
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, United States
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Laura Krisa
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
- Department of Occupational Therapy, Thomas Jefferson University, Philadelphia, PA, United States
| | - Jingya Miao
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, United States
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA, United States
| | - Anish Sathe
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, United States
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Islam Fayed
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, United States
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Abdulaziz Alhussein
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, United States
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, United States
| | - Peter Natale
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Feroze B. Mohamed
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Kiran Talekar
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
| | - Mahdi Alizadeh
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, United States
- Jefferson Integrated Magnetic Resonance Imaging Center (JIMRIC), Department of Radiology, Thomas Jefferson University, Philadelphia, PA, United States
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Beall D, Fayed I. Abstract No. 121 ▪ FEATURED ABSTRACT Viable Disc Allograft Supplementation in Patients with Chronic Low Back Pain (VAST Trial): Interim 36-Month Results of an Open-Label Extension Study. J Vasc Interv Radiol 2023. [DOI: 10.1016/j.jvir.2022.12.171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
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Solanki C, Williams J, Andrews C, Fayed I, Wu C. Insula in epilepsy - "untying the gordian knot": A systematic review. Seizure 2023; 106:148-161. [PMID: 36878050 DOI: 10.1016/j.seizure.2023.02.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 02/23/2023] [Accepted: 02/25/2023] [Indexed: 03/02/2023] Open
Abstract
PURPOSE Despite significant advances in epileptology, there are still many uncertainties about the role of the insula in epilepsy. Until recently, most insular onset seizures were wrongly attributed to the temporal lobe. Further, there are no standardised approaches to the diagnosis and treatment of insular onset seizures. This systematic review gathers the available information about insular epilepsy and synthesizes current knowledge as a basis for future research. METHOD Adhering to the PRISMA guidelines, studies were meticulously extracted from the PubMed database. The empirical data pertaining to the semiology of insular seizures, insular networks in epilepsy, techniques of mapping the insula, and the surgical intricacies of non-lesional insular epilepsy were reviewed from published studies. The corpus of information available was then subjected to a process of concise summarization and astute synthesis. RESULTS Out of 235 studies identified for full-text review, 86 studies were included in the systematic review. The insula emerges as a brain region with a number of functional subdivisions. The semiology of insular seizures is diverse and depends on the involvement of particular subdivisions. The semiological heterogeneity of insular seizures is explained by the extensive connectivity of the insula and its subdivisions with all four lobes of the brain, deep grey matter structures, and remote brainstem areas. The mainstay of the diagnosis of seizure onset in the insula is stereoelectroencephalography (SEEG). The surgical resection of the insular epileptogenic zone (when possible) is the most effective treatment. Open surgery on the insula is challenging but magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) also holds promise. CONCLUSION The physiological and functional roles of the insula in epilepsy have remained obfuscated. The dearth of precisely defined diagnostic and therapeutic protocols acts as an impediment to scientific advancement. This review could potentially facilitate forthcoming research endeavours by establishing a foundational framework for uniform data collection protocols, thereby enhancing the feasibility of comparing findings across future studies and promoting progress in this domain.
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Affiliation(s)
- Chirag Solanki
- Consultant Neurosurgeon, Department of Neurosurgery, Sterling Hospital, Ahmedabad, Gujarat, India.
| | - Justin Williams
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, United States.
| | - Carrie Andrews
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, United States.
| | - Islam Fayed
- Stereotactic and Functional Neurosurgery, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, United States.
| | - Chengyuan Wu
- Associate Professor of Neurosurgery and Radiology, Vickie and Jack Farber Institute for Neuroscience, Thomas Jefferson University, Philadelphia, United States.
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Ksendzovsky A, Bachani M, Altshuler M, Walbridge S, Mortazavi A, Moyer M, Chen C, Fayed I, Steiner J, Edwards N, Inati SK, Jahanipour J, Maric D, Heiss JD, Kapur J, Zaghloul KA. Chronic neuronal activation leads to elevated lactate dehydrogenase A through the AMP-activated protein kinase/hypoxia-inducible factor-1α hypoxia pathway. Brain Commun 2022; 5:fcac298. [PMID: 36655171 PMCID: PMC9838803 DOI: 10.1093/braincomms/fcac298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Revised: 07/11/2022] [Accepted: 11/28/2022] [Indexed: 12/03/2022] Open
Abstract
Recent studies suggest that changes in neuronal metabolism are associated with epilepsy. High rates of ATP depletion, lactate dehydrogenase A and lactate production have all been found in epilepsy patients, animal and tissue culture models. As such, it can be hypothesized that chronic seizures lead to continuing elevations in neuronal energy demand which may lead to an adapted metabolic response and elevations of lactate dehydrogenase A. In this study, we examine elevations in the lactate dehydrogenase A protein as a long-term cellular adaptation to elevated metabolic demand from chronic neuronal activation. We investigate this cellular adaptation in human tissue samples and explore the mechanisms of lactate dehydrogenase A upregulation using cultured neurones treated with low Mg2+, a manipulation that leads to NMDA-mediated neuronal activation. We demonstrate that human epileptic tissue preferentially upregulates neuronal lactate dehydrogenase A, and that in neuronal cultures chronic and repeated elevations in neural activity lead to upregulation of neuronal lactate dehydrogenase A. Similar to states of hypoxia, this metabolic change occurs through the AMP-activated protein kinase/hypoxia-inducible factor-1α pathway. Our data therefore reveal a novel long-term bioenergetic adaptation that occurs in chronically activated neurones and provide a basis for understanding the interplay between metabolism and neural activity during epilepsy.
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Affiliation(s)
- Alexander Ksendzovsky
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA,Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institute of Health, Bethesda, MD 20892, USA,Department of Neurological Surgery, University of Virginia Health System, University of Virginia, Charlottesville, VA 22903, USA
| | | | | | | | - Armin Mortazavi
- Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institute of Health, Bethesda, MD 20892, USA
| | - Mitchell Moyer
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
| | - Chixiang Chen
- Department of Neurosurgery, School of Medicine, University of Maryland, Baltimore, MD 21201, USA
| | - Islam Fayed
- Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institute of Health, Bethesda, MD 20892, USA
| | - Joseph Steiner
- Department of Neurological Surgery, University of Virginia Health System, University of Virginia, Charlottesville, VA 22903, USA
| | - Nancy Edwards
- Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institute of Health, Bethesda, MD 20892, USA
| | - Sara K Inati
- Office of the Clinical Director, National Institute of Neurologic Disorders and Stroke, National Institute of Health, Bethesda, MD 20892, USA
| | - Jahandar Jahanipour
- Flow and Cytometry Core, National Institute of Neurologic Disorders and Stroke, National Institute of Health, Bethesda MD, 20892, USA
| | - Dragan Maric
- Flow and Cytometry Core, National Institute of Neurologic Disorders and Stroke, National Institute of Health, Bethesda MD, 20892, USA
| | - John D Heiss
- Surgical Neurology Branch, National Institute of Neurologic Disorders and Stroke, National Institute of Health, Bethesda, MD 20892, USA
| | - Jaideep Kapur
- Department of Neurology, University of Virginia Health System, University of Virginia, Charlottesville, VA 22903, USA,Neuroscience Department, University of Virginia Health System, University of Virginia, Charlottesville, VA 22903, USA
| | - Kareem A Zaghloul
- Correspondence to: Kareem A. Zaghloul Surgical Neurology Branch, NINDS National Institutes of Health Building 10, Room 3D20 10 Center Drive, Bethesda, MD 20892-1414, USA E-mail:
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Chesney K, Stylli J, Elsouri M, Phelps E, Fayed I, Anaizi A, Voyadzis JM, Sandhu FA. Minimally Invasive Surgical Decompression without Fusion for the Treatment of Lumbar Synovial Cysts: Feasibility and Long-Term Outcomes. World Neurosurg 2022; 167:e323-e332. [PMID: 35961590 DOI: 10.1016/j.wneu.2022.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 10/31/2022]
Abstract
BACKGROUND Lumbar synovial cysts (LSCs) can cause painful radiculopathy and sensory and/or motor deficits. Historically, first-line surgical treatment has been decompression with fusion. Recently, minimally invasive laminectomy without fusion has shown equal or superior results to traditional decompression and fusion methods. OBJECTIVE This study investigates the long-term efficacy of minimally invasive laminectomy without fusion in the treatment of LSC as it relates to the rate of subsequent fusion surgery. METHODS A retrospective review was performed over a 10-year period of patients undergoing minimally invasive laminectomy for symptomatic LSCs. The primary end point was the rate of revision surgery requiring fusion. RESULTS Eighty-five patients with symptomatic LSCs underwent minimally invasive laminectomy alone January 2010-August 2020 at our institution. The most common location was L4-5 (72%). Preoperative imaging identified spondylolisthesis (grade 1) in 43 patients (57%), none of which was unstable on available dynamic radiographs. Average procedure duration was 93 minutes, with 78% of patients discharged home on the same day of surgery. Over 46 months of mean follow-up, 17 patients (20%) required 19 revision operations. Of those operations, 16 were spinal fusions (17.6%). Median time to fusion surgery was 36 months. There were no identifiable risk factors on multivariate regression analysis that predicted the need for fusion. CONCLUSIONS Minimally invasive laminectomy is an effective first-line treatment for symptomatic LSCs and avoids the need for fusion in most treated patients. Of our patients, 18% required a fusion over 46 months, suggesting that further studies are required to guide patient selection.
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Affiliation(s)
- Kelsi Chesney
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jack Stylli
- Georgetown University School of Medicine, Washington, DC, USA
| | - Mohamad Elsouri
- Georgetown University School of Medicine, Washington, DC, USA
| | - Emily Phelps
- Georgetown University School of Medicine, Washington, DC, USA
| | - Islam Fayed
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Amjad Anaizi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.
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Zhao D, Fayed I, Coleman G, Onyiah A, Bharil S, Liu J, Anaizi AN, Voyadzis JM, Sandhu FA. 448 Revision Rate and Long-Term Outcome After Minimally Invasive Surgical Treatment of Lumbar Adjacent Segment Disease: A Retrospective Review of 176 Adjacent Level Reoperations. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Chesney K, Elsouri M, Stylli J, Phelps E, Fayed I, Voyadzis JM, Sandhu FA. 453 Long-Term Outcomes Following Minimally Invasive Laminectomy for the Treatment of Lumbar Synovial Cysts. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Fayed I, Tai A, Triano MJ, Weitz D, Sayah A, Voyadzis JM, Sandhu FA. Lateral versus prone robot-assisted percutaneous pedicle screw placement: a CT-based comparative assessment of accuracy. J Neurosurg Spine 2022; 37:1-9. [PMID: 35120316 DOI: 10.3171/2021.12.spine211176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 12/02/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Single-position lateral lumbar interbody fusion (SP-LLIF) has recently gained significant popularity due to increased operative efficiency, but it remains technically challenging. Robot-assisted percutaneous pedicle screw (RA-PPS) placement can facilitate screw placement in the lateral position. The authors have reported their initial experience with SP-LLIF with RA-PPS placement in the lateral position, and they have compared this accuracy with that of RA-PPS placement in the prone position. METHODS The authors reviewed prospectively collected data from their first 100 lateral-position RA-PPSs. The authors graded screw accuracy on CT and compared it to the accuracy of all prone-position RA-PPS procedures during the same time period. The authors analyzed the effect of several demographic and perioperative metrics, as a whole and specifically for lateral-position RA-PPS placement. RESULTS The authors placed 99 lateral-position RA-PPSs by using the ExcelsiusGPS robotic platform in the first 18 consecutive patients who underwent SP-LLIF with postoperative CT imaging; these patients were compared with 346 prone-position RA-PPSs that were placed in the first consecutive 64 patients during the same time period. All screws were placed at L1 to S1. Overall, the lateral group had 14 breaches (14.1%) and the prone group had 25 breaches (7.2%) (p = 0.032). The lateral group had 5 breaches (5.1%) greater than 2 mm (grade C or worse), and the prone group had 4 (1.2%) (p = 0.015). The operative level had an effect on the breach rate, with breach rates (grade C or worse) of 7.1% at L3 and 2.8% at L4. Most breaches were grade B (< 2 mm) and lateral, and no breach had clinical sequelae or required revision. Within the lateral group, multivariate regression analysis demonstrated that BMI and number of levels affected accuracy, but the side that was positioned up or down did not. CONCLUSIONS RA-PPSs can improve the feasibility of SP-LLIF. Spine surgeons should be cautious and selective with this technique owing to decreased accuracy in the lateral position, particularly in obese patients. Further studies should compare SP-LLIF techniques performed while the patient is in the prone and lateral positions.
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Affiliation(s)
- Islam Fayed
- 1Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Alexander Tai
- 1Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | | | - Daniel Weitz
- 2Georgetown University School of Medicine, Washington, DC; and
| | - Anousheh Sayah
- 3Department of Radiology, MedStar Georgetown University Hospital, Washington, DC
| | - Jean-Marc Voyadzis
- 1Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Faheem A Sandhu
- 1Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
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13
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Alexander H, Govindan RB, Anwar T, Chirumamilla VC, Fayed I, Keating RF, Gaillard WD, Oluigbo CO. Global and intertuberal epileptic networks in tuberous sclerosis based on stereoelectroencephalographic (sEEG) findings: a quantitative EEG analysis in pediatric subjects and surgical implications. Childs Nerv Syst 2022; 38:407-419. [PMID: 34455445 DOI: 10.1007/s00381-021-05342-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 08/23/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Recent evidence favors a network concept in tuberous sclerosis (TSC) with seizure generation and propagation related to changes in global and regional connectivity between multiple, anatomically distant tubers. Direct exploration of network dynamics in TSC has been made possible through intracranial sampling with stereoelectroencephalography (sEEG). The objective of this study is to define epileptic networks in TSC using quantitative analysis of sEEG recordings. We also discuss the impact of the definition of these epileptic networks on surgical decision-making. METHODS Intracranial sEEG recordings were obtained from four pediatric patients who presented with medically refractory epilepsy secondary to TSC and subjected to quantitative signal analysis methods. Cortical connectivity was quantified by calculating pairwise coherence between all contacts and constructing an association matrix. The global coherence, defined as the ratio of the largest eigenvalue to the sum of all the eigenvalues, was calculated for each frequency band (delta, theta, alpha, beta, gamma). Spatial distribution of the connectivity was identified by plotting the leading principal component (product of the largest eigenvalue and its corresponding eigenvector). RESULTS Four pediatric subjects with TSC underwent invasive intracranial monitoring with sEEG, comprising 31 depth electrodes and 250 contacts, for localization of the epileptogenic focus and guidance of subsequent surgical intervention. Quantitative connectivity analysis revealed a change in global coherence during the ictal period in the beta/low gamma (14-30 Hz) and high gamma (31-80 Hz) bands. Our results corroborate findings from existing literature, which implicate higher frequencies as a driver of synchrony and desynchrony. CONCLUSIONS Coordinated high-frequency activity in the beta/low gamma and high gamma bands among spatially distant sEEG define the ictal period in TSC. This time-dependent change in global coherence demonstrates evidence for intra-tuberal and inter-tuberal connectivity in TSC. This observation has surgical implications. It suggests that targeting multiple tubers has a higher chance of seizure control as there is a higher chance of disrupting the epileptic network. The use of laser interstitial thermal therapy (LITT) allowed us to target multiple disparately located tubers in a minimally invasive manner with good seizure control outcomes.
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Affiliation(s)
- H Alexander
- Division of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Georgetown University School of Medicine, 3900 Reservoir Rd NW, Washington, DC, 20007, USA
| | - R B Govindan
- Division of Fetal and Transitional Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - T Anwar
- Division of Neurology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - V C Chirumamilla
- Division of Fetal and Transitional Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - I Fayed
- Division of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC, 20007, USA
| | - R F Keating
- Division of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - W D Gaillard
- George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA.,Division of Neurology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - C O Oluigbo
- Division of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA. .,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA.
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14
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Mortazavi A, Fayed I, Bachani M, Dowdy T, Jahanipour J, Khan A, Owotade J, Walbridge S, Inati SK, Steiner J, Wu J, Gilbert M, Yang CZ, Larion M, Maric D, Ksendzovsky A, Zaghloul KA. IDH-mutated gliomas promote epileptogenesis through d-2-hydroxyglutarate-dependent mTOR hyperactivation. Neuro Oncol 2022; 24:1423-1435. [PMID: 34994387 PMCID: PMC9435503 DOI: 10.1093/neuonc/noac003] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Uncontrolled seizures in patients with gliomas have a significant impact on quality of life and morbidity, yet the mechanisms through which these tumors cause seizures remain unknown. Here, we hypothesize that the active metabolite d-2-hydroxyglutarate (d-2-HG) produced by the IDH-mutant enzyme leads to metabolic disruptions in surrounding cortical neurons that consequently promote seizures. METHODS We use a complementary study of in vitro neuron-glial cultures and electrographically sorted human cortical tissue from patients with IDH-mutant gliomas to test this hypothesis. We utilize micro-electrode arrays for in vitro electrophysiological studies in combination with pharmacological manipulations and biochemical studies to better elucidate the impact of d-2-HG on cortical metabolism and neuronal spiking activity. RESULTS We demonstrate that d-2-HG leads to increased neuronal spiking activity and promotes a distinct metabolic profile in surrounding neurons, evidenced by distinct metabolomic shifts and increased LDHA expression, as well as upregulation of mTOR signaling. The increases in neuronal activity are induced by mTOR activation and reversed with mTOR inhibition. CONCLUSION Together, our data suggest that metabolic disruptions in the surrounding cortex due to d-2-HG may be a driving event for epileptogenesis in patients with IDH-mutant gliomas.
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Affiliation(s)
- Armin Mortazavi
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland, USA
| | - Islam Fayed
- Department of Neurosurgery, Georgetown University, Washington, District of Columbia, USA
| | - Muzna Bachani
- NeuroTherapeutics Development Unit, NINDS, National Institutes of Health, Bethesda, Maryland, USA
| | - Tyrone Dowdy
- NeuroOncology Branch, NCI, National Institutes of Health, Bethesda, Maryland, USA
| | - Jahandar Jahanipour
- Flow and Cytometry Core, NINDS, National Institutes of Health, Bethesda, Maryland, USA
| | - Anas Khan
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland, USA
| | - Jemima Owotade
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland, USA
| | - Stuart Walbridge
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland, USA
| | - Sara K Inati
- Surgical Neurology Branch, NINDS, National Institutes of Health, Bethesda, Maryland, USA
| | - Joseph Steiner
- NeuroTherapeutics Development Unit, NINDS, National Institutes of Health, Bethesda, Maryland, USA
| | - Jing Wu
- NeuroOncology Branch, NCI, National Institutes of Health, Bethesda, Maryland, USA
| | - Mark Gilbert
- NeuroOncology Branch, NCI, National Institutes of Health, Bethesda, Maryland, USA
| | - Chun Zhang Yang
- NeuroOncology Branch, NCI, National Institutes of Health, Bethesda, Maryland, USA
| | - Mioara Larion
- NeuroOncology Branch, NCI, National Institutes of Health, Bethesda, Maryland, USA
| | - Dragan Maric
- Flow and Cytometry Core, NINDS, National Institutes of Health, Bethesda, Maryland, USA
| | | | - Kareem A Zaghloul
- Corresponding Author: Kareem A. Zaghloul, MD, PhD, Surgical Neurology Branch, NINDS, National Institutes of Health, Building 10, Room 3D20, 10 Center Drive Bethesda, MD 20892-1414, USA ()
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15
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Mortazavi A, Fayed I, Bachani M, Dowdy T, Jahanipour J, Khan A, Yang C, Maric D, Larion M, Ksendzovsky A, Zaghloul K. NCMP-07. IDH MUTANT GLIOMAS PROMOTE EPILEPTOGENESIS VIA D-2-HYDROXYGLUTARATE DEPENDENT MTOR HYPER-ACTIVATION. Neuro Oncol 2021. [DOI: 10.1093/neuonc/noab196.580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Uncontrolled seizures in patients with low grade gliomas have a significant impact on quality of life and morbidity, yet the mechanisms through which these tumors cause seizures remain unknown. Albeit there are multiple features that contribute to tumor related epileptogenesis, IDH mutations are determined to be an independent factor, although the pathogenesis remains poorly understood. Here, we hypothesize that the active metabolite D-2-hydroxyglutarate (D-2-HG) produced by the IDH-mutant enzyme leads to metabolic disruptions in surrounding cortical neurons that consequently promote seizures. We use a complementary study of in vitro cortical cultures and electrographically sorted human cortical tissue from patients (n=5) with IDH-mutant gliomas to test this hypothesis. We demonstrate that D-2-HG leads to increased neuronal spiking activity (p< 0.0001) and promotes a distinct metabolic profile in surrounding neurons and upregulation of mTOR signaling (p< 0.0001), which is consistent in human epileptic cortex compared to peritumoral nonepileptic cortex. Furthermore, increases in neuronal activity are induced by mTOR activation and reversed with mTOR inhibition. Together, our data suggest that metabolic disruptions and mTOR signaling upregulation in the surrounding cortex due to D-2-HG may be a driving event for epileptogenesis in patients with IDH-mutant low grade gliomas.
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Affiliation(s)
| | - Islam Fayed
- Georgetown Medstar University Hospital, Washington, DC, USA
| | | | - Tyrone Dowdy
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | | | | | | | | | | | | | - Kareem Zaghloul
- Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, Bethesda, MD, USA
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16
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Cobourn KD, Qadir I, Fayed I, Alexander H, Oluigbo CO. Does the Modified Arrhenius Model Reliably Predict Area of Tissue Ablation After Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Pediatric Lesional Epilepsy? Oper Neurosurg (Hagerstown) 2021; 21:265-269. [PMID: 34270761 DOI: 10.1093/ons/opab225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 05/02/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Commercial magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) systems utilize a generalized Arrhenius model to estimate the area of tissue damage based on the power and time of ablation. However, the reliability of these estimates in Vivo remains unclear. OBJECTIVE To determine the accuracy and precision of the thermal damage estimate (TDE) calculated by commercially available MRgLITT systems using the generalized Arrhenius model. METHODS A single-center retrospective review of pediatric patients undergoing MRgLITT for lesional epilepsy was performed. The area of each lesion was measured on both TDE and intraoperative postablation, postcontrast T1 magnetic resonance images using ImageJ. Lesions requiring multiple ablations were excluded. The strength of the correlation between TDE and postlesioning measurements was assessed via linear regression. RESULTS A total of 32 lesions were identified in 19 patients. After exclusion, 13 pairs were available for analysis. Linear regression demonstrated a strong correlation between estimated and actual ablation areas (R2 = .97, P < .00001). The TDE underestimated the area of ablation by an average of 3.92% overall (standard error (SE) = 4.57%), but this varied depending on the type of pathologic tissue involved. TDE accuracy and precision were highest in tubers (n = 3), with average underestimation of 2.33% (SE = 0.33%). TDE underestimated the lesioning of the single hypothalamic hamartoma in our series by 52%. In periventricular nodular heterotopias, TDE overestimated ablation areas by an average of 13% (n = 2). CONCLUSION TDE reliability is variably consistent across tissue types, particularly in smaller or periventricular lesions. Further investigation is needed to understand the accuracy of this emerging minimally invasive technique.
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Affiliation(s)
- Kelsey D Cobourn
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Imazul Qadir
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Howard University College of Medicine, Washington, District of Columbia, USA
| | - Islam Fayed
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Hepzibha Alexander
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Division of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
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17
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Triano M, Fayed I, Sandhu FA. Robot-assisted revision of sacroiliac joint fusion using a triangular titanium implant in an S2-alar-iliac trajectory: illustrative case. Journal of Neurosurgery: Case Lessons 2021; 2:CASE2169. [PMID: 35854956 PMCID: PMC9272365 DOI: 10.3171/case2169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 04/30/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sacroiliac joint (SIJ) dysfunction can lead to significant pain and disability, greatly impairing quality of life. Arthrodesis may take up to 1 year to occur, after which revision can be considered. There is a need for highly accurate and reproducible techniques for revision that allow for purchase through undisturbed bone to prevent prolonged pain and disability. Moreover, a minimally invasive technique for revision would be favorable for recovery, particularly in elderly patients. OBSERVATIONS An 84-year-old man with a prior history of lumbar fusion presented with severe buttock pain limiting ambulation and sitting because of the failure of arthrodesis after SIJ fusion 1 year earlier. He underwent revision using a triangular titanium implant (TTI) in an S2-alar-iliac (S2-AI) trajectory under robotic guidance, which is a novel technique not yet described in the literature. The patient’s pain largely resolved, he was able to ambulate independently, and his quality of life improved tremendously. There were no complications of surgery. LESSONS Placement of a TTI using an S2-AI trajectory is a safe and effective method for revision that can be considered for elderly patients. Robot-assisted navigation can be used to facilitate an accurate and reproducible approach using a minimally invasive approach.
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Affiliation(s)
- Matthew Triano
- Georgetown University School of Medicine, Washington, DC; and
| | - Islam Fayed
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
| | - Faheem A. Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC
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18
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Mortazavi A, Fayed I, Bachani M, Maric D, Dowdy T, Larion M, Ksendzovsky A, Zaghloul K. OTME-4. IDH mutated gliomas promote epileptogenesis via D-2-hydroxyglutarate dependent mTOR hyperactivation. Neurooncol Adv 2021. [PMCID: PMC8255454 DOI: 10.1093/noajnl/vdab070.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Epilepsy in the context of brain tumors provides a great burden in these patients, yet mechanisms underlying this process are poorly understood. It has been demonstrated that isocitrate dehydrogenase (IDH) mutations are an independent factor in epileptogenesis in patients with low grade gliomas. Here, using electrographically sorted human cortical tissue from patients with IDH mutated tumor related epilepsy and in vitro cortical cultures, we explore a metabolic paradigm and its impact on increased neuronal excitability. We hypothesize the IDH mutation promotes epileptogenesis through its neomorphic activity of D-2-hydroxyglutarate (D-2-HG) production in turn interrupts surrounding normal neuronal circuitry potentially through metabolic perturbations. We demonstrate D-2-HG increases neuronal spiking activity, promotes distinct metabolic profiles independent of neuronal spiking activity, as well as increases neuronal mTOR signaling, which is reflected in human peritumoral epileptic cortex. Increased mTOR signaling is sufficient to upregulate neuronal spiking activity and, reciprocally, inhibition of mTOR corrects neuronal activity as well as partially corrects metabolic reprogramming. Our results suggest D-2-HG can lead to mTOR activation within the peritumoral neurons, thereby suggesting an additional possible mechanism of epileptogenesis in patients with IDH mutated low grade gliomas. Ultimately, our results raise the possibility of mTOR inhibition may be a promising treatment of seizures in patients with these tumors.
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Affiliation(s)
| | - Islam Fayed
- Medstar Georgetown University Hospital, Washington, DC, USA
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19
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Fayed I, Conte AG, Keating G, Cobourn KD, Altshuler M, Makariou E, Spitz SM, Anaizi AN, Nair MN, Voyadzis JM, Sandhu FA. Comparison of Clinical and Radiographic Outcomes After Standalone Versus Cage and Plate Constructs for Anterior Cervical Discectomy and Fusion. Int J Spine Surg 2021; 15:403-412. [PMID: 33963034 DOI: 10.14444/8060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Anterior cervical discectomy and fusion (ACDF) has conventionally been performed using an allograft cage with a plate-and-screw construct. Recently, standalone cages have gained popularity due to theorized decreases in operative time and postoperative dysphagia. Few studies have compared these outcomes. Here, we directly compare the outcomes of plated versus standalone ACDF constructs. METHODS A single-center retrospective review of patients undergoing ACDF after June 2011 with at least 6 months of follow up was conducted. Clinical outcomes were analyzed and compared between standalone and plated constructs. Multivariate regression analysis of the primary outcome, need for revision surgery, as well as several secondary outcomes, procedure duration, estimated blood loss (EBL), length of hospital stay, disposition, and incidence of dysphagia, hoarseness, or surgical site infection, was completed. RESULTS A total of 321 patients underwent ACDF and met inclusion-exclusion criteria, with mean follow-up duration of 20 months. Forty-six (14.3%) patients received standalone constructs, while 275 (85.7%) received plated constructs. Fourteen (4.4%) total revisions were necessary, 4 in the standalone group and 10 in the plated group, yielding revision rates of 8.7% and 3.6%, respectively (P = .125). Mean EBL was 98 mL in the standalone group and 63 mL in the plated group (P = .001). Mean procedure duration was 147 minutes in the standalone group and 151 minutes in the plated group (P = .800). Mean hospital stay was 3.6 days in the standalone group and 2.5 days in the plated group (P = .270). There was no significant difference in incidence of dysphagia (P = .700) or hoarseness (P = .700). CONCLUSIONS Standalone ACDF demonstrates higher, but not statistically significant, revision rates than plate-and-screw constructs, without the hypothesized decreased incidence of dysphagia or hoarseness and without decreased procedure duration or EBL. Surgeons may consider limiting use of these constructs to cases of adjacent segment disease. Larger studies with longer follow up are necessary to make more definitive conclusions. LEVEL OF EVIDENCE 4. CLINICAL RELEVANCE This study will help spine surgeons decide between using standalone or cage-and-plate constructs for ACDF.
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Affiliation(s)
- Islam Fayed
- MedStar Georgetown University Hospital, Department of Neurosurgery, Washington, DC
| | - Anthony G Conte
- MedStar Georgetown University Hospital, Department of Neurosurgery, Washington, DC
| | | | - Kelsey D Cobourn
- MedStar Georgetown University Hospital, Department of Neurosurgery, Washington, DC
| | | | - Erini Makariou
- MedStar Georgetown University Hospital, Department of Radiology, Washington, DC
| | - Steven M Spitz
- MedStar Georgetown University Hospital, Department of Neurosurgery, Washington, DC
| | - Amjad N Anaizi
- MedStar Georgetown University Hospital, Department of Neurosurgery, Washington, DC
| | - M Nathan Nair
- MedStar Georgetown University Hospital, Department of Neurosurgery, Washington, DC
| | - Jean-Marc Voyadzis
- MedStar Georgetown University Hospital, Department of Neurosurgery, Washington, DC
| | - Faheem A Sandhu
- MedStar Georgetown University Hospital, Department of Neurosurgery, Washington, DC
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20
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Mortazavi A, Fayed I, Bachani M, Dowdy T, Steiner J, Maric D, Yang CZ, Larion M, Ksendzovsky A, Zaghloul K. DDRE-27. IDH MUTATED GLIOMAS PROMOTE EPILEPTOGENESIS VIA D-2-HYDROXYGLUTARATE DEPENDENT MTOR HYPERACTIVATION. Neurooncol Adv 2021. [PMCID: PMC7992218 DOI: 10.1093/noajnl/vdab024.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
INTRODUCTION
Epileptic seizures in patients with low-grade, isocitrate dehydrogenase (IDH) mutated gliomas reach 90%, a major source of morbidity for these patients. Albeit there are multiple features that contribute to tumor related epileptogenesis, IDH mutations are determined to be an independent factor, although the pathogenesis remains poorly understood. We demonstrate IDH-mutated tumors promote epileptogenesis through D-2-hydroxyglutarate (D-2-HG) dependent mTOR hyperactivation and metabolic reprogramming.
METHODS
Human epileptic and nonepileptic cortex were identified via subdural electrodes in patients with IDH-mutated gliomas (n=5). An in vitro rat cortical neuronal model on microelectrode arrays were utilized to investigate the role of D-2-HG on neuronal excitability. mTOR and lysine demethylase (KDM) modulators were applied to elucidate the epileptogenic mechanism. Tetrodotoxin was utilized to evaluate the contribution of neuronal activity to mTOR signaling and metabolism. mTOR signaling was evaluated through western blot analysis and multiplex immunofluorescence. Metabolic function were analyzed via Seahorse assays and metabolomic analysis.
RESULTS
D-2-HG increased normalized bursting rate in the neuronal cultures (p<0.0001). Inhibition of mTOR with rapamycin corrected bursting levels to control levels. Furthermore, D-2-HG induced mTOR hyperactivation, independent of bursting activity, which correlated with upregulation of mTOR signaling in human epileptic tissue. KDM inhibition resulted in mTOR hyperactivation and neuronal hyperexcitability, which we demonstrated with D-2-HG, succinate, and PFI-90, a small molecule KDM inhibitor. Epileptic cortex and D-2-HG-treated neurons, have distinct metabolisms independent of neuronal activity compared to peritumoral nonepileptic cortex and control, respectively.
CONCLUSION
We demonstrate IDH-mutated gliomas promote epileptogenesis through a D-2-HG dependent mTOR hyperactivation via KDM inhibition, a putative mechanism and potential therapeutic targets. Furthermore, we argue mTOR hyperactivation results in metabolic reprogramming, independent of neuronal firing, which may contribute to epileptogenesis, a heretofore unrecognized aspect of pathologic mTOR signaling in neurological diseases.
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Affiliation(s)
| | - Islam Fayed
- National Institute of Health, Bethesda, MD, USA
- Medstar Georgetown University Hospital, Washington, DC, USA
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21
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Mortazavi A, Fayed I, Ksendzovsky A, Bachani M, Walbridge S, Edwards NA, Steiner J, Inati SK, Heiss JD, Yang CZ, Zaghloul KA. IDH1 Mutated Tumors Promote Epileptogensis via A 2-Hydroxyglutarate Dependent mTOR Hyperactivation. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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22
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Fayed I, Toscano DT, Triano MJ, Makariou E, Lee C, Spitz SM, Anaizi AN, Nair MN, Sandhu FA, Voyadzis JM. Crossing the Cervicothoracic Junction During Posterior Cervical Decompression and Fusion: Is It Necessary? Neurosurgery 2020; 86:E544-E550. [PMID: 32315427 DOI: 10.1093/neuros/nyaa078] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 02/02/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Posterior cervical fusion (PCF) is performed to treat cervical myelopathy, radiculopathy, and/or deformity. Constructs ending at the cervicothoracic junction (CTJ) may lead to higher rates of adjacent segment disease, and much debate exists regarding crossing the CTJ due to paucity of data in the literature. OBJECTIVE To determine whether extension of PCF constructs across the CTJ decreases incidence of adjacent segment disease and need for revision surgery. METHODS A single-center retrospective case series of patients undergoing multilevel PCFs since 2011 with at least 6-mo follow-up was conducted. Outcomes were analyzed and compared based on caudal extent of instrumentation via multivariate regression. RESULTS A total of 149 patients underwent PCF, with a mean follow-up of 18.9 mo. A total of 15 (10.1%) revisions were performed, 7 (4.7%) of which were related to the construct. Five (8.3%) revisions were performed for constructs ending at C6, 1 (5.3%) at C7, 1 (2.6%) at T1, and none (0%) at T2 (P = .035). Mean procedure duration was 215 min at C6, 214 min at C7, 239 min at T1, and 343 min at T2 (P = .001). Mean estimated blood loss was 224 mL at C6, 178 mL at C7, 308 mL at T1, and 575 mL at T2 (P = .001). There was no difference in length of stay, disposition, surgical site infection, or radiographic parameters. CONCLUSION Extension of PCFs across the CTJ leads to lower early revision rates, but also to increased procedure duration and estimated blood loss. As such, decisions regarding caudal extent of instrumentation must weigh the risk of pseudarthrosis against that of longer procedures with higher blood loss.
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Affiliation(s)
- Islam Fayed
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Daniel T Toscano
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Matthew J Triano
- Georgetown University School of Medicine, Washington, District of Columbia
| | - Erini Makariou
- Department of Radiology, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Christabel Lee
- Department of Radiology, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Steven M Spitz
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Amjad N Anaizi
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - M Nathan Nair
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
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Majidi S, Bageac DV, Fayed I, Yim B, De Leacy R, Armonda RA. JET 7 XTRA Flex reperfusion catheter related complications during endovascular thrombectomy. J Neurointerv Surg 2020; 13:352-356. [PMID: 33229422 DOI: 10.1136/neurintsurg-2020-016826] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/04/2020] [Accepted: 11/05/2020] [Indexed: 11/04/2022]
Abstract
Endovascular thrombectomy has revolutionized the management of acute ischemic stroke from emergent large vessel occlusion. Continued technological advancement in the field, as evidenced by successive introduction of large bore aspiration catheters with enhanced trackability and large inner diameter, has played a major role in achieving fast and robust recanalization and improved clinical outcome. Here, we present three patients with intraprocedural device malfunction related to the JET 7 XTRA Flex reperfusion catheter.
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Affiliation(s)
- Shahram Majidi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Devin V Bageac
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Islam Fayed
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
| | - Benjamin Yim
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University Medical Center, Washington, District of Columbia, USA
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Fayed I, Tai A, Triano M, Sayah A, Makariou E, Voyadzis JM, Sandhu FA. Robot-Assisted Percutaneous Pedicle Screw Placement: Evaluation of Accuracy of the First 100 Screws and Comparison with Cohort of Fluoroscopy-guided Screws. World Neurosurg 2020; 143:e492-e502. [DOI: 10.1016/j.wneu.2020.07.203] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/26/2020] [Accepted: 07/28/2020] [Indexed: 11/26/2022]
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25
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Dowlati E, Zhou T, Sarpong K, Pivazyan G, Briscoe J, Fayed I, Mualem W, Black J, Kalhorn CG, Nair MN, Felbaum DR. In Reply to the Letter to the Editor Regarding "Case Volumes and Perioperative COVID-19 Incidence in Neurosurgical Patients During a Pandemic: Experiences at Two Tertiary Care Centers in Washington, DC". World Neurosurg 2020; 143:633. [PMID: 33167156 PMCID: PMC7608060 DOI: 10.1016/j.wneu.2020.08.159] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 08/22/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA.
| | - Tianzan Zhou
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Kwadwo Sarpong
- Georgetown University School of Medicine, Washington, DC, USA
| | - Gnel Pivazyan
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Jessica Briscoe
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Islam Fayed
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - William Mualem
- Georgetown University School of Medicine, Washington, DC, USA
| | - Jordan Black
- Georgetown University School of Medicine, Washington, DC, USA
| | - Christopher G Kalhorn
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Mani N Nair
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA; Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
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26
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Dowlati E, Zhou T, Sarpong K, Pivazyan G, Briscoe J, Fayed I, Mualem W, Black J, Kalhorn CG, Nair MN, Felbaum DR. Case Volumes and Perioperative Coronavirus Disease 2019 Incidence in Neurosurgical Patients During a Pandemic: Experiences at Two Tertiary Care Centers in Washington, DC. World Neurosurg 2020; 143:e550-e560. [PMID: 32777390 PMCID: PMC7834543 DOI: 10.1016/j.wneu.2020.08.015] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/02/2020] [Indexed: 12/21/2022]
Abstract
OBJECTIVE The true incidence of perioperative coronavirus disease 2019 (COVID-19) has not been well elucidated in neurosurgical studies. We reviewed the effects of the pandemic on the neurosurgical case volume to study the incidence of COVID-19 in patients undergoing these procedures during the perioperative period and compared the characteristics and outcomes of this group to those of patients without COVID-19. METHODS The neurosurgical and neurointerventional procedures at 2 tertiary care centers during the pandemic were reviewed. The case volume, type, and acuity were compared to those during the same period in 2019. The perioperative COVID-19 tests and results were evaluated to obtain the incidence. The baseline characteristics, including a modified Medically Necessary Time Sensitive (mMeNTS) score, and outcome measures were compared between those with and without COVID-19. RESULTS A total of 405 cases were reviewed, and a significant decrease was found in total spine, cervical spine, lumbar spine, and functional/pain cases. No significant differences were found in the number of cranial or neurointerventional cases. Of the 334 patients tested, 18 (5.4%) had tested positive for COVID-19. Five of these patients were diagnosed postoperatively. The mMeNTS score, complications, and case acuity were significantly different between the patients with and without COVID-19. CONCLUSION A small, but real, risk exists of perioperative COVID-19 in neurosurgical patients, and those patients have tended to have a greater complication rate. Use of the mMeNTS score might play a role in decision making for scheduling elective cases. Further studies are warranted to develop risk stratification and validate the incidence.
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Affiliation(s)
- Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA.
| | - Tianzan Zhou
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Kwadwo Sarpong
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Gnel Pivazyan
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Jessica Briscoe
- Department of General Surgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Islam Fayed
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - William Mualem
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Jordan Black
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Christopher G Kalhorn
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Mani N Nair
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA; Department of Neurosurgery, MedStar Washington Hospital Center, Washington, District of Columbia, USA
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Fayed I, Pivazyan G, Conte AG, Chang J, Mai JC. Intracranial hemorrhage in critically ill patients hospitalized for COVID-19. J Clin Neurosci 2020; 81:192-195. [PMID: 33222915 PMCID: PMC7434499 DOI: 10.1016/j.jocn.2020.08.026] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 08/05/2020] [Accepted: 08/16/2020] [Indexed: 01/02/2023]
Abstract
In this study, we report three cases of spontaneous intracranial hemorrhage in patients who were initially hospitalized at our tertiary care center in Washington, DC with symptoms of COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection was diagnosed in all three patients, who were critically ill, requiring intubation and ventilatory support. During their protracted hospitalizations, subsequent imaging disclosed intracranial hemorrhages, including intracerebral and subarachnoid hemorrhages, in the context of anticoagulation and coagulopathy. We believe this is related to the tropism of SARS-CoV-2 to the endothelial lining of the cerebral vasculature via their angiotensin-converting enzyme (ACE) II receptors. Given our findings, we advocate heightened vigilance for intracerebral hemorrhage events, and scanning when practicable, in COVID-19 patients which have prolonged ventilatory support and depressed neurologic examinations.
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Affiliation(s)
- Islam Fayed
- MedStar Georgetown University Hospital, Department of Neurosurgery, 3800 Reservoir Road NW, 7PHC, Washington, DC 20007, USA; MedStar Washington Hospital Center, Department of Neurosurgery, 110 Irving Street NW, Washington, DC 20010, USA
| | - Gnel Pivazyan
- MedStar Georgetown University Hospital, Department of Neurosurgery, 3800 Reservoir Road NW, 7PHC, Washington, DC 20007, USA; MedStar Washington Hospital Center, Department of Neurosurgery, 110 Irving Street NW, Washington, DC 20010, USA
| | - Anthony G Conte
- MedStar Georgetown University Hospital, Department of Neurosurgery, 3800 Reservoir Road NW, 7PHC, Washington, DC 20007, USA; MedStar Washington Hospital Center, Department of Neurosurgery, 110 Irving Street NW, Washington, DC 20010, USA
| | - Jason Chang
- MedStar Washington Hospital Center, Department of Critical Care Medicine, 110 Irving Street NW, Washington, DC 20010, USA
| | - Jeffrey C Mai
- MedStar Georgetown University Hospital, Department of Neurosurgery, 3800 Reservoir Road NW, 7PHC, Washington, DC 20007, USA; MedStar Washington Hospital Center, Department of Neurosurgery, 110 Irving Street NW, Washington, DC 20010, USA.
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28
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Mueller KB, Fayed I, Spitz S, Nair N, Voyadzis JM, Sandhu F. In Reply: Contralateral Minimally Invasive Laminectomy for Resection of a Synovial Cyst: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2020; 18:E260-E261. [PMID: 32147710 DOI: 10.1093/ons/opaa048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Kyle B Mueller
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Islam Fayed
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Steve Spitz
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Nathan Nair
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Jean-Marc Voyadzis
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
| | - Faheem Sandhu
- Department of Neurosurgery Georgetown University Medical Center Washington, District of Columbia
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29
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Saway BF, Fayed I, Dowlati E, Derakhshandeh R, Sandhu FA. Initial Report of an Intradural Extramedullary Metastasis of a Pancreatic Neuroendocrine Tumor to the Cervical Spine: A Case Report and Review of the Literature. World Neurosurg 2020; 139:355-360. [PMID: 32344144 DOI: 10.1016/j.wneu.2020.04.120] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Pancreatic neuroendocrine tumors (pNETs) are known to frequently metastasize to the liver and lymphatics; however, metastasis to the spine is exceedingly rare. We report the first case of an intradural, extramedullary pNET metastasis to the upper cervical spine. CASE DESCRIPTION A 75-year-old Hispanic male patient with history of stage IV pNET with metastasis to the liver and lymph nodes and new-onset lymphadenopathy seen on CT of the chest was found on positron emission tomography scan to have a lesion in the cervical spine. The patient was neurologically intact on physical examination, yet given the patient's medical history, magnetic resonance imaging of the cervical spine was performed, revealing a right-sided intradural, extramedullary mass at the C1-C2 level with associated mass effect on the spinal cord, likely representing a schwannoma. Due to the tumor size, mass effect, and the need for definitive tissue diagnosis, a partial C1-C2 laminectomy with intradural resection of the tumor was performed. The histology was consistent with the patient's known pNET. CONCLUSIONS As treatment for pNETs has evolved, there has been a surge in unique presentations of systemic well-differentiated pNETs being reported. It is vital that patients diagnosed with pNET be monitored for metastases, and when discovered, treated promptly.
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Affiliation(s)
- Brian F Saway
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA.
| | - Islam Fayed
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | | | - Faheem A Sandhu
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
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30
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Alexander H, Cobourn K, Fayed I, Oluigbo CO. Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for the Treatment of Nonlesional Insular Epilepsy in Pediatric Patients: Technical Considerations. Pediatr Neurosurg 2020; 55:155-162. [PMID: 32750699 DOI: 10.1159/000509006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 05/26/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION The insula presents anatomic challenges to surgical exploration and intervention. Open neurosurgical intervention is associated with high rates of complications despite improved seizure control. Minimally invasive techniques using novel energy delivery methods have gained popularity due to their relative safety and ability to overcome access-related barriers. The goal of this paper is to present an operative technical report and methodological considerations on the application of magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) for the treatment of nonlesional, medically refractory, insular epilepsy in pediatric patients. METHODS Visualase laser probe(s) were implanted using ROSA robotic stereotactic guidance into the insula using a parasagittal trajectory. After confirmation of placement using intraoperative MRI, thermal energy was delivered under real-time MR guidance. Laser wire pullback was performed when the initial dose of thermal energy was insufficient to ablate the target in its entirety. Thermal ablation within the intended target was confirmed using gadolinium-enhanced brain MRI. Following removal of laser wires, a final T1-weighted axial brain MRI was performed to confirm no evidence of hemorrhage. RESULTS Three patients underwent MRgLITT of nonlesional insular epilepsy over an 11-month period. The epileptogenic focus was localized to the insula using stereoelectroencephalography. The anterior and middle portions of the insula were accessed using a parasagittal trajectory. Laser ablation was performed for up to 3 min using an output of 10.5 W. No complications were encountered, and all patients were discharged within 24 h after the surgery. At the most recent follow-up, all patients had an Engel I outcome without any new neurologic deficits. CONCLUSION This small cohort shows that insular ablation can be achieved safely with promising seizure outcomes in the short term.
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Affiliation(s)
- Hepzibha Alexander
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Kelsey Cobourn
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Islam Fayed
- Division of Neurosurgery, Children's National Medical Center, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA,
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Sacino M, Huang SS, Alexander H, Fayed I, Keating RF, Oluigbo CO. An Initial Cost-Effectiveness Analysis of Magnetic Resonance-Guided Laser Interstitial Thermal Therapy in Pediatric Epilepsy Surgery. Pediatr Neurosurg 2020; 55:141-148. [PMID: 32829333 DOI: 10.1159/000509329] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 06/09/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a new technology that provides a clinically efficacious and minimally invasive alternative to conventional microsurgical resection. However, little data exist on how costs compare to traditional open surgery. The goal of this paper is to investigate the cost-effectiveness of MRgLITT in the treatment of pediatric epilepsy. METHODS We retrospectively analyzed the medical records of pediatric patients who underwent MRgLITT via the Visualase® thermal therapy system (Medtronic, Inc., Minneapolis, MN, USA) between December 2013 and September 2017. Direct costs associated with preoperative, operative, and follow-up care were extracted. Benefit was calculated in quality-adjusted life years (QALYs), and the cost-effectiveness was derived from the discounted total direct costs over QALY. Sensitivity analysis on 4 variables was utilized to assess the validity of our results. RESULTS Twelve consecutive pediatric patients with medically refractory epilepsy underwent MRgLITT procedures. At the last postoperative follow-up, 8 patients were seizure free (Engel I, 66.7%), 2 demonstrated significant improvement (Engel II, 16.7%), and 2 patients showed worthwhile improvement (Engel III, 16.7%). The average cumulative discounted QALY was 2.11 over the lifetime of a patient. Adjusting for inflation, MRgLITT procedures had a cost-effectiveness of USD 22,211 per QALY. Our sensitivity analysis of cost variables is robust and supports the procedure to be cost--effective. CONCLUSION Our data suggests that MRgLITT may be a cost-effective alternative to traditional surgical resection in pediatric epilepsy surgery.
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Affiliation(s)
- Matthew Sacino
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - Sean S Huang
- Department of Health Systems Administration, Georgetown University, Washington, District of Columbia, USA
| | - Hepzibha Alexander
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Islam Fayed
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA, .,Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA,
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Mueller K, Fayed I, Spitz S, Nair N, Voyadzis JM, Sandhu FA. Contralateral Minimally Invasive Laminectomy for Resection of a Synovial Cyst: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2019; 19:E63-E64. [DOI: 10.1093/ons/opz278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Accepted: 07/06/2019] [Indexed: 11/15/2022] Open
Abstract
Abstract
Synovial cysts of the lumbar spine result from degeneration of the facet capsule, and their prevalence may be as high as 10% in symptomatic patients. Although conservative management is possible, the majority of patients will require resection. Traditional procedures for resection use an ipsilateral approach requiring partial or complete resection of the ipsilateral facet complex, possibly leading to further destabilization. A contralateral technique using minimally invasive tubular retractors for synovial cyst resection avoids facet disruption, minimizes soft-tissue trauma, and limits disruption of the ligamentous and bony structures. Additionally, by approaching contralateral, the cyst/dura interface is better visualized especially at the depths of the lateral recess. Seeing the full extent of this interface from an ipsilateral approach is very difficult without decompressing the cyst, which, in turn, makes dissecting and separating the remaining cyst wall more difficult and increases the risk of durotomies.1,2
We report the case of a 53-yr-old female who presented with persistent left leg pain in an L5 distribution that was associated with some mild lower back pain. She was refractory to conservative management that included physical therapy along with a series of epidural steroid injections. She was noted to have some weakness with dorsiflexion on the left side and as absent a straight leg raise. Given the predominance of her leg over her back symptoms along with the patient's age, a minimally invasive contralateral approach for resection of the synovial cyst was offered as opposed to more traditional decompression and fusion. Institutional Review Board approval and patient consent for solitary case reports are not needed at our institution.
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Affiliation(s)
- Kyle Mueller
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Islam Fayed
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Steven Spitz
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Nathan Nair
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Jean-Marc Voyadzis
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia
| | - Faheem A Sandhu
- Department of Neurosurgery, Medstar Georgetown University Hospital, Washington, District of Columbia
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Alexander H, Govindan RB, Garrett CT, Anwar T, Fayed I, Keating RF, Gaillard W, Oluigbo C. Global and Intertuberal Epileptic Networks in Tuberous Sclerosis Based on Stereoelectroencephalographic (sEEG) Findings: A Quantitative EEG Analysis in Pediatric Subjects and Surgical Implications. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Fayed I, Cobourn KD, Pivazyan G, Pagan F, Lo S, Torres-Yaghi Y, Mandir AS, Kalhorn CG. Combination Targeting of Subthalamic Nucleus and Ventral Intermediate Thalamic Nucleus in Deep Brain Stimulation for Tremor-Dominant Parkinson's Disease: Experience and Outcomes. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Altshuler M, Ksendzovsky A, Bachani M, Walbridge S, Inati S, Fayed I, Heiss JD, Kapur J, Zaghloul KA. A Feedforward Mechanism for Epileptogenesis Regulated by Lactate Dehydrogenase A. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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36
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Alexander H, Fayed I, Oluigbo CO. Rigid Cranial Fixation for Robot-Assisted Stereoelectroencephalography in Toddlers: Technical Considerations. Oper Neurosurg (Hagerstown) 2019; 18:614-620. [DOI: 10.1093/ons/opz247] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 05/31/2019] [Indexed: 11/12/2022] Open
Abstract
Abstract
BACKGROUND
Stereoelectroencephalography (sEEG) using depth electrodes has become a mainstay of pediatric epilepsy surgery. This technique relies on rigid cranial fixation using skull pins, which forms the basis for accurate stereotactic navigation. The use of cranial fixation pins poses the threat of traumatic skull injuries in young children because of inadequate cranial bone thickness.
OBJECTIVE
To describe a rigid cranial fixation technique involving the integrated Gel Head Ring from the DORO QR3 multipurpose skull clamp set (Pro Med Instruments) with superimposed pin fixation in children below the age of 36 mo undergoing sEEG.
METHODS
Patients were placed in the supine position and the head was fixed using a DORO skull clamp with 3 pediatric cranial pins. The head was supported on the integrated Gel Head Ring, and a pin pressure of 20 pounds was applied. The DORO skull clamp set was then attached to the ROSA neurosurgical robot support telescopic arm for stereotactic navigation.
RESULTS
We present an illustrative series of 2 patients below the age of 3 yr with medically refractory epilepsy who underwent sEEG using our modified cranial fixation technique. Head position and reference registration were stable throughout the surgeries. Postoperative volumetric computed tomography scans of the head showed accurate placement of sEEG depth electrodes and did not reveal any fractures or epidural hematoma. No other complications related to cranial fixation were noted.
CONCLUSION
Concurrent use of rigid and nonrigid cranial fixation using the DORO skull clamp set provides safe and effective cranial fixation in infants and toddlers undergoing sEEG.
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Affiliation(s)
- Hepzibha Alexander
- Children's National Medical Center, Department of Neurosurgery, School of Medicine, Georgetown University, Washington, District of Columbia
| | - Islam Fayed
- Children's National Medical Center, Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia
| | - Chima O Oluigbo
- Children's National Medical Center, Department of Neurosurgery, School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia
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Stewart JJ, Fayed I, Henault S, Kalantar B, Voyadzis JM. Use of a Smartphone Application for Spine Surgery Improves Patient Adherence with Preoperative Instructions and Decreases Last-minute Surgery Cancellations. Cureus 2019; 11:e4192. [PMID: 31106092 PMCID: PMC6504025 DOI: 10.7759/cureus.4192] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background: Smartphone applications (apps) are being increasingly utilized in the health care arena to improve patient care and outcomes. Objective: To further demonstrate the ability of a smartphone app to improve patient compliance with preoperative instructions and to decrease the number of last-minute surgery cancellations. Methods: Patients undergoing spine surgery were prospectively accrued. Smartphone app users were compared to non-app users. Patient adherence with preoperative instructions as well as last-minute surgery cancellations were analyzed. Results: All 85 app users adhered to preoperative instructions according to the acknowledgements sent to the web portal, and there were no cancelled surgeries. Among the 89 non-app users, there were five cancelled surgeries (5.6%). Conclusions: We demonstrate the ability of a smartphone application to improve patient adherence with preoperative instructions and decrease last-minute surgery cancellations.
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Affiliation(s)
- Jeffrey J Stewart
- Miscellaneous, Georgetown University School of Medicine, Washington DC, USA
| | - Islam Fayed
- Neurosurgery, Medstar Georgetown University Hospital, Washington DC, USA
| | - Shawnda Henault
- Miscellaneous, Georgetown University School of Medicine, Washington DC, USA
| | - Babak Kalantar
- Orthopaedics, Medstar Georgetown University Hospital, Washington DC, USA
| | - Jean-Marc Voyadzis
- Neurosurgery, Medstar Georgetown University Hospital, Washington DC, USA
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Alexander H, Cobourn K, Fayed I, Depositario-Cabacar D, Keating RF, Gaillard WD, Oluigbo CO. Magnetic resonance-guided laser interstitial thermal therapy for the treatment of non-lesional insular epilepsy in pediatric patients: thermal dynamic and volumetric factors influencing seizure outcomes. Childs Nerv Syst 2019; 35:453-461. [PMID: 30627771 DOI: 10.1007/s00381-019-04051-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/03/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the safety and efficacy of stereoelectroencephalography (sEEG) directed magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) in medically refractory insular epilepsy in pediatric patients, define the relationship between ablation volumes and seizure control, and analyze the relationship between thermal energy and ablation volumes. METHODS A single-institution, retrospective review of pediatric patients with insular epilepsy who underwent sEEG directed MRgLITT over a 10-month period was performed. Perioperative, imaging, and outcome data were analyzed. Seizure outcomes were determined based on Engel score (Engel I versus Engel II-IV). Insula and ablation volumes were measured, and the proportion of insula volume ablated was calculated. Thermal energy was calculated in joules. RESULTS Four patients underwent sEEG directed MRgLITT of insular epileptogenic foci. The ablation volume was higher in patients with Engel I outcome (3.93 cm3) compared to Engel II-IV outcome (1.02 cm3). The proportion of ablation to insula volume was lowest in patients with Engel II-IV outcome (25.09%). The mean energy requirement to create a unit volume of ablation in the insula is 1205.86 J. A linear trend was noted between thermal ablation energy and ablation volume (R2 = 0.884). Over a mean follow-up period of 104 days, three patients were seizure-free (Engel I), and one patient saw significant improvement in seizure frequency (Engel III). CONCLUSIONS The proportion of insula ablated, as well as the volume of ablation, are related to seizure outcome with increasing ablation volumes corresponding to improved seizure control. Further analysis of insula laser ablation thermal dynamics and volumes is needed.
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Affiliation(s)
- Hepzibha Alexander
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Kelsey Cobourn
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Islam Fayed
- Division of Neurosurgery, Children's National Medical Center, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Dewi Depositario-Cabacar
- Division of Neurology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - William D Gaillard
- Division of Neurology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
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Cobourn KD, Fayed I, Sullivan S, Oluigbo C. 127 Thermal Dynamics, Volumetrics and Seizure Outcomes Following Magnetic Resonance-Guided Laser Interstitial Thermal Therapy in Pediatric Lesional Epilepsy. Neurosurgery 2018. [DOI: 10.1093/neuros/nyy303.127] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Cobourn K, Fayed I, Keating RF, Oluigbo CO. Early outcomes of stereoelectroencephalography followed by MR-guided laser interstitial thermal therapy: a paradigm for minimally invasive epilepsy surgery. Neurosurg Focus 2018; 45:E8. [DOI: 10.3171/2018.6.focus18209] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVEStereoelectroencephalography (sEEG) and MR-guided laser interstitial thermal therapy (MRgLITT) have both emerged as minimally invasive alternatives to open surgery for the localization and treatment of medically refractory lesional epilepsy. Although some data are available about the use of these procedures individually, reports are almost nonexistent on their use in conjunction. The authors’ aim was to report early outcomes regarding efficacy and safety of sEEG followed by MRgLITT for localization and ablation of seizure foci in the pediatric population with medically refractory lesional epilepsy.METHODSA single-center retrospective review of pediatric patients who underwent sEEG followed by MRgLITT procedures was performed. Demographic, intraoperative, and outcome data were compiled and analyzed.RESULTSFour pediatric patients with 9 total lesions underwent sEEG followed by MRgLITT procedures between January and September 2017. The mean age at surgery was 10.75 (range 2–21) years. Two patients had tuberous sclerosis and 2 had focal cortical dysplasia. Methods of stereotaxy consisted of BrainLab VarioGuide and ROSA robotic guidance, with successful localization of seizure foci in all cases. The sEEG procedure length averaged 153 (range 67–235) minutes, with a mean of 6 (range 4–8) electrodes and 56 (range 18–84) contacts per patient. The MRgLITT procedure length averaged 223 (range 179–252) minutes. The mean duration of monitoring was 6 (range 4–8) days, and the mean total hospital stay was 8 (range 5–11) days. Over a mean follow-up duration of 9.3 (range 5.1–16) months, 3 patients were seizure free (Engel class I, 75%), and 1 patient saw significant improvement in seizure frequency (Engel class II, 25%). There were no complications.CONCLUSIONSThese early data demonstrate that sEEG followed by MRgLITT can be used safely and effectively to localize and ablate epileptogenic foci in a minimally invasive paradigm for treatment of medically refractory lesional epilepsy in pediatric populations. Continued collection of data with extended follow-up is needed.
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Fayed I, Sacino MF, Gaillard WD, Keating RF, Oluigbo CO. MR-Guided Laser Interstitial Thermal Therapy for Medically Refractory Lesional Epilepsy in Pediatric Patients: Experience and Outcomes. Pediatr Neurosurg 2018; 53:322-329. [PMID: 30110689 DOI: 10.1159/000491823] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 07/04/2018] [Indexed: 11/19/2022]
Abstract
INTRODUCTION MR-guided laser interstitial thermal therapy (MRgLITT) has emerged as a safe and effective treatment option for the ablation of epileptic foci. Its minimally invasive nature makes it attractive due to decreased morbidity and hospital stay. OBJECTIVE To report the efficacy and safety of MRgLITT as a minimally invasive procedure for the ablation of epileptic foci in the pediatric population of medically refractory lesional epilepsy. METHODS A retrospective review of patients who underwent MRgLITT via Visualase laser ablation at a single pediatric center was performed. Demographic and outcome data were compiled and analyzed. RESULTS Twelve pediatric patients with a total 18 lesions underwent MRgLITT procedures between December 2013 and September 2017. Mean age at surgery was 11.1 years. Surgical substrates included 4 hypothalamic hamartomas, 3 periventricular heterotopias, 2 deep focal cortical dysplasias, 2 tuberous sclerosis, and 1 mesial temporal sclerosis. Methods of stereotaxis used included Leksell frame, BrainLab VarioGuide, ROSA robot guidance, and ClearPoint navigation. Mean procedure length was 250 min, and mean length of stay was 1.3 days. After treatment, 8 patients were seizure free (Engel I, 66.7%), 2 patients demonstrated significant improvement (Engel II, 16.7%), and 2 patients showed worthwhile improvement (Engel III, 16.7%). One patient developed a left superior quadrantanopsia postoperatively. Mean follow-up duration was 10 months. CONCLUSION This study contributes to the sparse literature in this field by demonstrating the high efficacy and low morbidity of MRgLITT as a minimally invasive method of ablation of epileptic foci in the pediatric population of medically refractory lesional epilepsy.
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Affiliation(s)
- Islam Fayed
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Matthew F Sacino
- Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Willilam D Gaillard
- Department of Neurology, Children's National Medical Center, Washington, District of Columbia, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
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Felbaum DR, Fayed I, Stewart JJ, Sandhu FA. Relief of Lumbar Symptoms After Cervical Decompression in Patients with Tandem Spinal Stenosis Presenting with Primarily Lumbar Pain. Cureus 2016; 8:e940. [PMID: 28123921 PMCID: PMC5262435 DOI: 10.7759/cureus.940] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Objective: Tandem cervical and lumbar spinal stenosis (TSS) is classically described as intermittent claudication, gait disturbance, and clinical findings of mixed myelopathy and polyradiculopathy. Rarely, patients can present with TSS manifesting in isolated lumbar pain. Several reports have demonstrated improved lumbar back pain and radiculopathy after decompressive cervical spine procedures. We present six patients with dramatic resolution of lumbar spine related symptoms after decompression of the cervical spinal cord despite presenting solely with lower back complaints. Methods: Clinical records of the senior author (F.A.S.) gathered from April 2006 to March 2013 were retrospectively reviewed identifying six patients presenting solely with lumbar symptoms and diagnosed with TSS based on history and physical examination. Results: Six patients with a mean age of 55 (range 39 to 60) presented with solely lower back symptoms and clinical findings suspicious for TSS. Mean follow-up time for all patients was 12 months (range three to 27 months, median 11.5 months). Three patients underwent a cervical procedure as the principal operation, while the remainder had the lumbar spine decompressed initially. All patients that underwent a cervical procedure initially experienced a dramatic decrease or complete resolution of their preoperative lower back pain and radiculopathy (mean preoperative VAS of 6.7 vs. 3.7 postoperative). The remainder of patients with persistent lumbar symptoms resolved after a subsequent cervical operation. Conclusion: Patients presenting with lumbar symptoms out of proportion to imaging require further investigation. We highlight the resolution of lumbar symptoms after a cervical procedure in a select group of patients presenting with lone lower back complaints. In patients presenting with symptoms disproportionate to lumbar imaging, treatment of cervical pathology may provide robust long-term relief of the initial lumbar-related presentation.
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Affiliation(s)
| | - Islam Fayed
- Neurosurgery, Medstar Georgetown University Hospital
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