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Agopyan-Miu AH, Merricks EM, Smith EH, McKhann GM, Sheth SA, Feldstein NA, Trevelyan AJ, Schevon CA. Cell-type specific and multiscale dynamics of human focal seizures in limbic structures. Brain 2023; 146:5209-5223. [PMID: 37536281 PMCID: PMC10689922 DOI: 10.1093/brain/awad262] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 06/30/2023] [Accepted: 07/19/2023] [Indexed: 08/05/2023] Open
Abstract
The relationship between clinically accessible epileptic biomarkers and neuronal activity underlying the transition to seizure is complex, potentially leading to imprecise delineation of epileptogenic brain areas. In particular, the pattern of interneuronal firing at seizure onset remains under debate, with some studies demonstrating increased firing and others suggesting reductions. Previous study of neocortical sites suggests that seizure recruitment occurs upon failure of inhibition, with intact feedforward inhibition in non-recruited territories. We investigated whether the same principle applies in limbic structures. We analysed simultaneous electrocorticography (ECoG) and neuronal recordings of 34 seizures in a cohort of 19 patients (10 male, 9 female) undergoing surgical evaluation for pharmacoresistant focal epilepsy. A clustering approach with five quantitative metrics computed from ECoG and multiunit data was used to distinguish three types of site-specific activity patterns during seizures, which at times co-existed within seizures. Overall, 156 single units were isolated, subclassified by cell-type and tracked through the seizure using our previously published methods to account for impacts of increased noise and single-unit waveshape changes caused by seizures. One cluster was closely associated with clinically defined seizure onset or spread. Entrainment of high-gamma activity to low-frequency ictal rhythms was the only metric that reliably identified this cluster at the level of individual seizures (P < 0.001). A second cluster demonstrated multi-unit characteristics resembling those in the first cluster, without concomitant high-gamma entrainment, suggesting feedforward effects from the seizure. The last cluster captured regions apparently unaffected by the ongoing seizure. Across all territories, the majority of both excitatory and inhibitory neurons reduced (69.2%) or ceased firing (21.8%). Transient increases in interneuronal firing rates were rare (13.5%) but showed evidence of intact feedforward inhibition, with maximal firing rate increases and waveshape deformations in territories not fully recruited but showing feedforward activity from the seizure, and a shift to burst-firing in seizure-recruited territories (P = 0.014). This study provides evidence for entrained high-gamma activity as an accurate biomarker of ictal recruitment in limbic structures. However, reduced neuronal firing suggested preserved inhibition in mesial temporal structures despite simultaneous indicators of seizure recruitment, in contrast to the inhibitory collapse scenario documented in neocortex. Further study is needed to determine if this activity is ubiquitous to hippocampal seizures or indicates a 'seizure-responsive' state in which the hippocampus is not the primary driver. If the latter, distinguishing such cases may help to refine the surgical treatment of mesial temporal lobe epilepsy.
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Affiliation(s)
- Alexander H Agopyan-Miu
- Department of Neurological Surgery, Columbia University Medical Center, NewYork, NY 10032, USA
| | - Edward M Merricks
- Department of Neurology, Columbia University Medical Center, NewYork, NY 10032, USA
| | - Elliot H Smith
- Department of Neurology, Columbia University Medical Center, NewYork, NY 10032, USA
- Department of Neurosurgery, University of Utah, Salt Lake City, UT 84132, USA
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, NewYork, NY 10032, USA
| | - Sameer A Sheth
- Department of Neurosurgery, Baylor College of Medicine, Houston TX 77030, USA
| | - Neil A Feldstein
- Department of Neurological Surgery, Columbia University Medical Center, NewYork, NY 10032, USA
| | - Andrew J Trevelyan
- Biosciences Institute, Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - Catherine A Schevon
- Department of Neurology, Columbia University Medical Center, NewYork, NY 10032, USA
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2
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Yang N, Feldstein NA, Gudis DA. Combined Endoscopic Endonasal and Transpalatal Repair of Congenital Anterior Cranial Fossa Agenesis. Oper Neurosurg (Hagerstown) 2023; 24:e402-e406. [PMID: 37071753 DOI: 10.1227/ons.0000000000000636] [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: 05/16/2022] [Accepted: 11/29/2022] [Indexed: 04/20/2023] Open
Abstract
BACKGROUND Congenital basal meningoceles and encephaloceles are rare pathologies that may present in isolation or with characteristic-associated clinical features. Rarely, children with congenital midline defects may present with massive encephaloceles secondary to anterior cranial fossa agenesis. Traditionally, transcranial approaches with frontal craniotomies were used to reduce the herniated contents and repair the skull base defect. However, high rates of morbidity and mortality associated with craniotomies have favored the development and adoption of less-invasive techniques. OBJECTIVE To present a novel technique for combined endoscopic endonasal and transpalatal repair of a giant basal meningocele through an extensive sphenoethmoidal skull base defect. METHODS A representative case of congenital anterior cranial fossa agenesis with a giant meningocele was selected. Clinical and radiological presentations were reviewed, and the intraoperative surgical technique was documented and recorded. RESULTS A surgical video highlighting each surgical step was included to complement the description of the technique. The surgical outcome from the selected case is also presented. CONCLUSION This report describes a combined endoscopic endonasal and transpalatal approach to repair an extensive anterior skull base defect with herniation of intracranial content. This technique capitalizes on the advantages of each approach to address this complex pathology.
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Affiliation(s)
- Nathan Yang
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, New York, USA
| | - Neil A Feldstein
- Department of Neurologic Surgery, Neurological Institute of New York-Columbia University Medical Center, New York, New York, USA
| | - David A Gudis
- Department of Otolaryngology-Head and Neck Surgery, New York Presbyterian Hospital-Columbia University Irving Medical Center, New York, New York, USA
- Department of Neurologic Surgery, Neurological Institute of New York-Columbia University Medical Center, New York, New York, USA
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Tobochnik S, Bateman LM, Akman CI, Anbarasan D, Bazil CW, Bell M, Choi H, Feldstein NA, Kent PF, McBrian D, McKhann GM, Mendiratta A, Pack AM, Sands TT, Sheth SA, Srinivasan S, Schevon CA. Tracking Multisite Seizure Propagation Using Ictal High-Gamma Activity. J Clin Neurophysiol 2022; 39:592-601. [PMID: 34812578 PMCID: PMC8611231 DOI: 10.1097/wnp.0000000000000833] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 12/28/2020] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Spatial patterns of long-range seizure propagation in epileptic networks have not been well characterized. Here, we use ictal high-gamma activity (HGA) as a proxy of intense neuronal population firing to map the spatial evolution of seizure recruitment. METHODS Ictal HGA (80-150 Hz) was analyzed in 13 patients with 72 seizures recorded by stereotactic depth electrodes, using previously validated methods. Distinct spatial clusters of channels with the ictal high-gamma signature were identified, and seizure hubs were defined as stereotypically recruited nonoverlapping clusters. Clusters correlated with asynchronous seizure terminations to provide supportive evidence for independent seizure activity at these sites. The spatial overlap between seizure hubs and interictal ripples was compared. RESULTS Ictal HGA was detected in 71% of seizures and 10% of implanted contacts, enabling tracking of contiguous and noncontiguous seizure recruitment. Multiple seizure hubs were identified in 54% of cases, including 43% of patients thought preoperatively to have unifocal epilepsy. Noncontiguous recruitment was associated with asynchronous seizure termination (odds ratio = 19.7; p = 0.029). Interictal ripples demonstrated greater spatial overlap with ictal HGA in cases with single seizure hubs compared with those with multiple hubs (100% vs. 66% per patient; p = 0.03). CONCLUSIONS Ictal HGA may serve as a useful adjunctive biomarker to distinguish contiguous seizure spread from propagation to remote seizure sites. High-gamma sites were found to cluster in stereotyped seizure hubs rather than being broadly distributed. Multiple hubs were common even in cases that were considered unifocal.
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Affiliation(s)
- Steven Tobochnik
- Brigham and Women’s Hospital, Department of Neurology, Boston, MA
| | - Lisa M. Bateman
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Cigdem I. Akman
- Columbia University Medical Center, Division of Child Neurology, New York, NY
| | | | - Carl W. Bazil
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Michelle Bell
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Hyunmi Choi
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Neil A. Feldstein
- Columbia University Medical Center, Department of Neurological Surgery, New York, NY
| | - Paul F. Kent
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Danielle McBrian
- Columbia University Medical Center, Division of Child Neurology, New York, NY
| | - Guy M. McKhann
- Columbia University Medical Center, Department of Neurological Surgery, New York, NY
| | - Anil Mendiratta
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Alison M. Pack
- Columbia University Medical Center, Department of Neurology, New York, NY
| | - Tristan T. Sands
- Columbia University Medical Center, Division of Child Neurology, New York, NY
| | - Sameer A. Sheth
- Baylor College of Medicine, Department of Neurosurgery, Houston, TX
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4
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Alexiades NG, Shao B, Ahn ES, Blount JP, Brockmeyer DL, Hankinson TC, Nesvick CL, Sandberg DI, Heuer GG, Saiman L, Feldstein NA, Anderson RCE. High prevalence of gram-negative and multiorganism surgical site infections after pediatric complex tethered spinal cord surgery: a multicenter study. J Neurosurg Pediatr 2022; 30:1-7. [PMID: 35901675 DOI: 10.3171/2022.6.peds2238] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Accepted: 06/16/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Complex tethered spinal cord (cTSC) release in children is often complicated by surgical site infection (SSI). Children undergoing this surgery share many similarities with patients undergoing correction for neuromuscular scoliosis, where high rates of gram-negative and polymicrobial infections have been reported. Similar organisms isolated from SSIs after cTSC release were recently demonstrated in a single-center pilot study. The purpose of this investigation was to determine if these findings are reproducible across a larger, multicenter study. METHODS A multicenter, retrospective chart review including 7 centers was conducted to identify all cases of SSI following cTSC release during a 10-year study period from 2007 to 2017. Demographic information along with specific microbial culture data and antibiotic sensitivities for each cultured organism were collected. RESULTS A total of 44 SSIs were identified from a total of 655 cases, with 78 individual organisms isolated. There was an overall SSI rate of 6.7%, with 43% polymicrobial and 66% containing at least one gram-negative organism. Half of SSIs included an organism that was resistant to cefazolin, whereas only 32% of SSIs were completely susceptible to cefazolin. CONCLUSIONS In this study, gram-negative and polymicrobial infections were responsible for the majority of SSIs following cTSC surgery, with approximately half resistant to cefazolin. Broader gram-negative antibiotic prophylaxis should be considered for this patient population.
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Affiliation(s)
| | - Belinda Shao
- 2Department of Neurosurgery, Brown University, Providence, Rhode Island
| | - Edward S Ahn
- 3Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Jeffrey P Blount
- 4Division of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Douglas L Brockmeyer
- 5Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Todd C Hankinson
- 6Department of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Cody L Nesvick
- 3Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - David I Sandberg
- 7Division of Pediatric Neurosurgery, McGovern Medical School/UT Health/Children's Memorial Hermann Hospital, Houston, Texas
| | - Gregory G Heuer
- 8Department of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - Lisa Saiman
- 9Department of Pediatric Infectious Disease, Columbia University Medical Center, New York, New York
| | - Neil A Feldstein
- 10Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
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5
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Yang N, Feldstein NA, Gudis DA. A Modified Endoscopic Draf III Approach in the Non-Pneumatized Frontal Bone for Dermoid Cysts. Laryngoscope 2022; 132:1530-1531. [PMID: 35262201 DOI: 10.1002/lary.30091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/19/2022] [Accepted: 02/15/2022] [Indexed: 11/08/2022]
Affiliation(s)
- Nathan Yang
- Department of Otolaryngology- Head and Neck Surgery, New York Presbyterian Hospital- Columbia University Irving Medical Center, New York, New York, USA
| | - Neil A Feldstein
- Department of Neurologic Surgery, Neurological Institute of New York- Columbia University Medical Center, New York, New York, USA
| | - David A Gudis
- Department of Otolaryngology- Head and Neck Surgery, New York Presbyterian Hospital- Columbia University Irving Medical Center, New York, New York, USA.,Department of Neurologic Surgery, Neurological Institute of New York- Columbia University Medical Center, New York, New York, USA
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6
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Norman-Haignere SV, Long LK, Devinsky O, Doyle W, Irobunda I, Merricks EM, Feldstein NA, McKhann GM, Schevon CA, Flinker A, Mesgarani N. Multiscale temporal integration organizes hierarchical computation in human auditory cortex. Nat Hum Behav 2022; 6:455-469. [PMID: 35145280 PMCID: PMC8957490 DOI: 10.1038/s41562-021-01261-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 10/30/2020] [Accepted: 11/18/2021] [Indexed: 01/11/2023]
Abstract
To derive meaning from sound, the brain must integrate information across many timescales. What computations underlie multiscale integration in human auditory cortex? Evidence suggests that auditory cortex analyses sound using both generic acoustic representations (for example, spectrotemporal modulation tuning) and category-specific computations, but the timescales over which these putatively distinct computations integrate remain unclear. To answer this question, we developed a general method to estimate sensory integration windows-the time window when stimuli alter the neural response-and applied our method to intracranial recordings from neurosurgical patients. We show that human auditory cortex integrates hierarchically across diverse timescales spanning from ~50 to 400 ms. Moreover, we find that neural populations with short and long integration windows exhibit distinct functional properties: short-integration electrodes (less than ~200 ms) show prominent spectrotemporal modulation selectivity, while long-integration electrodes (greater than ~200 ms) show prominent category selectivity. These findings reveal how multiscale integration organizes auditory computation in the human brain.
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Affiliation(s)
- Sam V Norman-Haignere
- Zuckerman Mind, Brain, Behavior Institute, Columbia University,HHMI Postdoctoral Fellow of the Life Sciences Research Foundation
| | - Laura K. Long
- Zuckerman Mind, Brain, Behavior Institute, Columbia University,Doctoral Program in Neurobiology and Behavior, Columbia University
| | - Orrin Devinsky
- Department of Neurology, NYU Langone Medical Center,Comprehensive Epilepsy Center, NYU Langone Medical Center
| | - Werner Doyle
- Comprehensive Epilepsy Center, NYU Langone Medical Center,Department of Neurosurgery, NYU Langone Medical Center
| | - Ifeoma Irobunda
- Department of Neurology, Columbia University Irving Medical Center
| | | | - Neil A. Feldstein
- Department of Neurological Surgery, Columbia University Irving Medical Center
| | - Guy M. McKhann
- Department of Neurological Surgery, Columbia University Irving Medical Center
| | | | - Adeen Flinker
- Department of Neurology, NYU Langone Medical Center,Comprehensive Epilepsy Center, NYU Langone Medical Center,Department of Biomedical Engineering, NYU Tandon School of Engineering
| | - Nima Mesgarani
- Zuckerman Mind, Brain, Behavior Institute, Columbia University,Doctoral Program in Neurobiology and Behavior, Columbia University,Department of Electrical Engineering, Columbia University
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7
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Troy C, Gill BJA, Miller ML, Hickman RA, Canoll P, Zacharoulis S, Feldstein NA, Bruce JN. Adenocarcinoma Arising in a Yolk Sac Tumor of the Pineal Gland. J Neuropathol Exp Neurol 2022; 81:291-295. [PMID: 35172008 DOI: 10.1093/jnen/nlac002] [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)
- Christopher Troy
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Brian J A Gill
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Michael L Miller
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Richard A Hickman
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York, USA
| | - Stergios Zacharoulis
- Department of Hematology-Oncology, Columbia University Irving Medical Center, New York, New York, USA
| | - Neil A Feldstein
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
| | - Jeffrey N Bruce
- Department of Neurosurgery, Columbia University Irving Medical Center, New York, New York, USA
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8
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Kim W, Shen MY, Provenzano FA, Lowenstein DB, McBrian DK, Mandel AM, Sands TT, Riviello JJ, McKhann GM, Feldstein NA, Akman CI. The role of stereo-electroencephalography to localize the epileptogenic zone in children with nonlesional brain magnetic resonance imaging. Epilepsy Res 2022; 179:106828. [PMID: 34920378 DOI: 10.1016/j.eplepsyres.2021.106828] [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] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Revised: 11/06/2021] [Accepted: 11/19/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This study aimed to assess the clinical outcome and outcome predictive factors in pediatric epilepsy patients evaluated with stereo-electroencephalography (SEEG). METHODS Thirty-eight patients who underwent SEEG implantation at the Pediatric Epilepsy Center in New York Presbyterian Hospital between June 2014 and December 2019 were enrolled for retrospective chart review. Postoperative seizure outcomes were evaluated in patients with at least 12-months follow up. Meta-analysis was conducted via electronic literature search of data reported from 2000 to 2020 to evaluate significant surgical outcome predictors for SEEG evaluation in the pediatric population. RESULTS In the current case series of 25 postsurgical patients with long-term follow up, 16 patients (64.0%) were seizure free. An additional 7 patients (28.0%) showed significant seizure improvement and 2 patients (8.0%) showed no change in seizure activity. Patients with nonlesional magnetic resonance imaging (MRI) achieved seizure freedom in 50% (5/10) of cases. By comparison, 73% (11/15) of patients with lesional MRI achieved seizure freedom. Out of 12 studies, 158 pediatric patients were identified for inclusion in a meta-analysis of the effectiveness of SEEG. Seizure freedom was reported 54.4% (n = 86/158) of patients at last follow up. Among patients with nonlesional MRI, 45% (n = 24) achieved seizure freedom compared with patients with lesional MRI findings (61.2%, n:= 60) (p = 0.02). The risk for seizure recurrence was 2.15 times higher [95% confidence interval [CI] 1.06-4.37, p = 0.033] in patients diagnosed with nonlesional focal epilepsy compared to those with lesional epilepsy [ 1.49 (95% CI 1.06-2.114, p = 0.021]. CONCLUSION Evaluation by SEEG implantation in pediatric epilepsy is effective in localizing the epileptogenic zone with favorable outcome. Presence of a non-lesional brain MRI was associated with lower chances of seizure freedom. Further research is warranted to improve the efficacy of SEEG in localizing the epileptogenic zone in pediatric patients with non-lesional brain MRI.
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Affiliation(s)
- Woojoong Kim
- Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, USA
| | - Min Y Shen
- Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, USA
| | - Frank A Provenzano
- Taub Institute for Research on Alzheimer's Disease and the Aging Brain, Columbia University Irving Medical Center, New York, USA
| | - Daniel B Lowenstein
- Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, USA
| | - Danielle K McBrian
- Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, USA
| | - Arthur M Mandel
- Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, USA
| | - Tristan T Sands
- Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, USA
| | - James J Riviello
- Department of Pediatrics, Section of Pediatric Neurology and Developmental Neuroscience, Baylor College of Medicine, Houston, TX, USA
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, Columbia-Presbyterian, New York, USA
| | - Neil A Feldstein
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Columbia University Medical Center, Columbia-Presbyterian, New York, USA
| | - Cigdem I Akman
- Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, USA.
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9
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Gill BJA, Higgins DM, Banu MA, Argenziano MG, Feldstein NA, Bruce JN. Right occipital transtentorial approach for a pineal malignant germ cell tumor. Neurosurg Focus Video 2021; 5:V3. [PMID: 36284916 PMCID: PMC9549986 DOI: 10.3171/2021.4.focvid2151] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/14/2021] [Indexed: 06/16/2023]
Abstract
Germ cell tumors account for up to 53% of the malignant lesions found in the pineal region and are typically managed with a combination of radiation therapy and chemotherapy. Malignant somatic transformation of intracranial germ cell tumors is exceedingly rare and has only been reported on two other occasions. Here the authors present the case of a pineal yolk sac tumor that failed optimum first-line treatment and underwent malignant somatic transformation to an enteric mucinous adenocarcinoma requiring surgical intervention. This video demonstrates the technical nuances of the occipital transtentorial approach and the safe microsurgical dissection of lesions within the pineal region. The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2151.
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Affiliation(s)
- Brian J A Gill
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Dominique M Higgins
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Matei A Banu
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Michael G Argenziano
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Neil A Feldstein
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
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10
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Fleiss N, Klein-Cloud R, Gill B, Feldstein NA, Fallon EM, Ruzal-Shapiro C, Collins A. Subdural extravasation of crystalloids and blood products through a scalp peripheral intravenous catheter into the subdural space of a neonate on veno-arterial extracorporeal membrane oxygenation. J Neonatal Perinatal Med 2021; 14:601-605. [PMID: 33523026 DOI: 10.3233/npm-200610] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/15/2022]
Abstract
We describe a rare and devastating complication of a malpositioned scalp peripheral intravenous catheter (PIV) that resulted in subdural extravasation of infused fluids and midline shift in a critically ill neonate who required extracorporeal membrane oxygenation (ECMO). Recognition of increased intracranial pressure was hindered by the hemodynamic changes of being on ECMO and only identified by routine surveillance ultrasonography. Awareness of this complication may lead providers to seek alternate sites for vascular access in such patients, and encourage closer monitoring for this complication when an alternate site is unavailable.
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Affiliation(s)
- N Fleiss
- Department of Pediatrics, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - R Klein-Cloud
- Department of Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - B Gill
- Department of Neurosurgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - N A Feldstein
- Department of Neurosurgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - E M Fallon
- Department of Surgery, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - C Ruzal-Shapiro
- Department of Radiology, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
| | - A Collins
- Department of Pediatrics, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, USA
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11
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Wei HJ, Upadhyayula PS, Pouliopoulos AN, Englander ZK, Zhang X, Jan CI, Guo J, Mela A, Zhang Z, Wang TJC, Bruce JN, Canoll PD, Feldstein NA, Zacharoulis S, Konofagou EE, Wu CC. Focused Ultrasound-Mediated Blood-Brain Barrier Opening Increases Delivery and Efficacy of Etoposide for Glioblastoma Treatment. Int J Radiat Oncol Biol Phys 2020; 110:539-550. [PMID: 33346092 DOI: 10.1016/j.ijrobp.2020.12.019] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 11/22/2020] [Accepted: 12/13/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Glioblastoma (GBM) is a devastating disease. With the current treatment of surgery followed by chemoradiation, outcomes remain poor, with median survival of only 15 months and a 5-year survival rate of 6.8%. A challenge in treating GBM is the heterogeneous integrity of the blood-brain barrier (BBB), which limits the bioavailability of systemic therapies to the brain. There is a growing interest in enhancing drug delivery by opening the BBB with the use of focused ultrasound (FUS). We hypothesize that an FUS-mediated BBB opening can enhance the delivery of etoposide for a therapeutic benefit in GBM. METHODS AND MATERIALS A murine glioma cell line (Pdgf+, Pten-/-, P53-/-) was orthotopically injected into B6(Cg)-Tyrc-2J/J mice to establish the syngeneic GBM model for this study. Animals were treated with FUS and microbubbles to open the BBB to enhance the delivery of systemic etoposide. Magnetic resonance (MR) imaging was used to evaluate the BBB opening and tumor progression. Liquid chromatography tandem mass spectrometry was used to measure etoposide concentrations in the intracranial tumors. RESULTS The murine glioma cell line is sensitive to etoposide in vitro. MR imaging and passive cavitation detection demonstrate the safe and successful BBB opening with FUS. The combined treatment of an FUS-mediated BBB opening and etoposide decreased tumor growth by 45% and prolonged median overall survival by 6 days: an approximately 30% increase. The FUS-mediated BBB opening increased the brain tumor-to-serum ratio of etoposide by 3.5-fold and increased the etoposide concentration in brain tumor tissue by 8-fold compared with treatment without ultrasound. CONCLUSIONS The current study demonstrates that BBB opening with FUS increases intratumoral delivery of etoposide in the brain, resulting in local control and overall survival benefits.
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Affiliation(s)
- Hong-Jian Wei
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York
| | - Pavan S Upadhyayula
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | | | - Zachary K Englander
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Xu Zhang
- Institute for Cancer Genetics, Columbia University Irving Medical Center, New York, New York; Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Chia-Ing Jan
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York; Division of Molecular Pathology, Department of Pathology, China Medical University and Hospital, Taichung, Taiwan; Department of Medicine, China Medical University, Taichung, Taiwan; Translational Cell Therapy Center, Department of Medical Research, China Medical University Hospital, Taichung, Taiwan
| | - Jia Guo
- Department of Psychiatry, Columbia University, New York, New York
| | - Angeliki Mela
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York
| | - Zhiguo Zhang
- Institute for Cancer Genetics, Columbia University Irving Medical Center, New York, New York; Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Tony J C Wang
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York; Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Peter D Canoll
- Department of Pathology and Cell Biology, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, New York, New York
| | - Neil A Feldstein
- Department of Neurological Surgery, Columbia University Irving Medical Center, New York, New York
| | - Stergios Zacharoulis
- Department of Pediatrics, Columbia University Irving Medical Center, New York, New York
| | - Elisa E Konofagou
- Department of Biomedical Engineering, Columbia University, New York, New York
| | - Cheng-Chia Wu
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, New York; Herbert Irving Comprehensive Cancer Center, New York, New York.
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12
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Higgins D, Upadhyayula PS, Humala N, Mahajan A, Mela A, Sudhakar T, Zacharoulis S, Feldstein NA, Canoll PD, Bruce JN. Ex Vivo Modeling of Malignant Pineal Tumors Using Viral Transformation of Transgenic Murine Pineal Gland Cultures. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_836] [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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13
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Shao B, Tariq AA, Goldstein HE, Alexiades NG, Mar KM, Feldstein NA, Anderson RCE, Giordano M. Multimodal Analgesia After Posterior Fossa Decompression With and Without Duraplasty for Children With Chiari Type I. Hosp Pediatr 2020; 10:447-451. [PMID: 32321740 DOI: 10.1542/hpeds.2019-0298] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Multimodal analgesia (MMA) may reduce opioid use after surgery for Chiari malformation type I. An MMA protocol was implemented after both posterior fossa decompression without dural opening (PFD) and posterior fossa decompression with duraplasty (PFDD). METHODS Scheduled nonsteroidal antiinflammatory drugs (ketorolac or ibuprofen) and diazepam were alternated with acetaminophen, and as-needed oxycodone or intravenous morphine. The primary outcome was total opioid requirement over postoperative days 0 to 2. RESULTS From 2012 to 2017, 49 PFD and 29 PFDD procedures were performed, and 46 of 78 patients used the protocol. Patients with PFD required less opioids than patients with PFDD. Among patients with PFDD, patients with MMA protocol usage had a lower mean opioid requirement than patients with no MMA protocol usage (0.53 ± 0.49 mgEq/kg versus 1.4 ± 1.0 mgEq/kg, P = .0142). In multivariable analysis, MMA protocol usage status independently predicted a mean decrease in opioid requirement of 0.146 mg equivalents/kg (P = .0497) after adjustment for procedure and surgeon. Statistically significant differences were not demonstrated in antiemetic requirements, discharge opioid prescriptions, total direct cost, and length of stay. CONCLUSIONS A protocol of scheduled nonsteroidal antiinflammatory drugs alternating with scheduled acetaminophen and diazepam was associated with opioid use reductions.
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Affiliation(s)
- Belinda Shao
- Departments of Neurological Surgery and.,Department of Neurosurgery, Brown University, Providence, Rhode Island
| | - Abdul A Tariq
- Value Institute, New York-Presbyterian Hospital, New York, New York; and
| | | | | | - Krista M Mar
- Department of Information Services and Technology, Jefferson Health, Philadelphia, Pennsylvania
| | | | | | - Mirna Giordano
- Pediatrics, Columbia University Irving Medical Center, Columbia University, New York, New York;
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14
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Shao B, Tariq AA, Goldstein HE, Alexiades NG, Mar KM, Feldstein NA, Anderson RCE, Giordano M. Opioid-Sparing Multimodal Analgesia After Selective Dorsal Rhizotomy. Hosp Pediatr 2019; 10:84-89. [PMID: 31862854 DOI: 10.1542/hpeds.2019-0016] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Multimodal analgesia (MMA) may reduce opioid use among children who are hospitalized, and may contribute toward enhanced recovery after selective dorsal rhizotomy (SDR) for patients with spasticity in pediatric cerebral palsy. In this retrospective cohort study, we assess an MMA protocol consisting of scheduled nonsteroidal antiinflammatory drug doses (ketorolac or ibuprofen), alternating with scheduled acetaminophen and diazepam doses, with as-needed opioids. It was hypothesized that protocol use would be associated with reductions in opioid requirements and other clinical improvements. METHODS Data were obtained for 52 patients undergoing SDR at an academic tertiary care pediatric hospital (2012-2017, with the protocol implemented in 2014). Using a retrospective cohort design, we compared outcomes between protocol and nonprotocol patients, employing both univariate t test and Wilcoxon rank test comparisons as well as multivariable regression methods. The primary outcome was total as-needed opioid requirements over postoperative days (PODs) 0 to 2, measured in oral morphine milligram equivalents per kilogram. Additional outcomes included antiemetic medication doses, discharge opioid prescriptions, total direct cost, and length of stay. RESULTS Twelve patients received the MMA protocol, and 40 patients did not. POD-0 MMA initiation was independently associated with a reduction of 0.14 morphine milligram equivalents per kilogram in mean opioid requirements over PODs 0 to 2 in the multiple regression analysis (95% confidence interval 0.01 to 0.28; P = .04). No statistically significant differences were demonstrated in doses of antiemetic medications, discharge opioid prescriptions, total direct cost, and length of stay. CONCLUSIONS This MMA protocol may help reduce opioid use after SDR. Improving protocol implementation in a prospective, multisite study will help elucidate further MMA effects on pain, costs, and recovery.
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Affiliation(s)
- Belinda Shao
- Departments of Neurologic Surgery and.,Department of Neurosurgery, Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Abdul A Tariq
- The Value Institute, NewYork-Presbyterian Hospital, New York, New York; and
| | | | | | - Krista M Mar
- Department of Data Science, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
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15
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Goldstein HE, Shao B, Madsen PJ, Hartnett SM, Blount JP, Brockmeyer DL, Campbell RM, Conklin M, Hankinson TC, Heuer GG, Jea AH, Kennedy BC, Tuite GF, Rodriguez L, Feldstein NA, Vitale MG, Anderson RCE. Increased complications without neurological benefit are associated with prophylactic spinal cord untethering prior to scoliosis surgery in children with myelomeningocele. Childs Nerv Syst 2019; 35:2187-2194. [PMID: 31267182 DOI: 10.1007/s00381-019-04276-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 05/06/2019] [Accepted: 06/25/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE Children with myelomeningocele (MMC) are at increased risk of developing neuromuscular scoliosis and spinal cord re-tethering (Childs Nerv Syst 12:748-754, 1996; Neurosurg Focus 16:2, 2004; Neurosurg Focus 29:1, 2010). Some centers perform prophylactic untethering on asymptomatic MMC patients prior to scoliosis surgery because of concern that additional traction on the cord may place the patient at greater risk of neurologic deterioration peri-operatively. However, prophylactic untethering may not be justified if it carries increased surgical risks. The purpose of this study was to determine if prophylactic untethering is necessary in asymptomatic children with MMC undergoing scoliosis surgery. METHODS A multidisciplinary, retrospective cohort study from seven children's hospitals was performed including asymptomatic children with MMC < 21 years old, managed with or without prophylactic untethering prior to scoliosis surgery. Patients were divided into three groups for analysis: (1) untethering at the time of scoliosis surgery (concomitant untethering), (2) untethering within 3 months of scoliosis surgery (prior untethering), and (3) no prophylactic untethering. Baseline data, intra-operative reports, and 90-day post-operative outcomes were analyzed to assess for differences in neurologic outcomes, surgical complications, and overall length of stay. RESULTS A total of 208 patients were included for analysis (mean age 9.4 years, 52% girls). No patient in any of the groups exhibited worsened motor or sensory function at 90 days post-operatively. However, comparing the prophylactic untethering groups with the group that was not untethered, there was an increased risk of surgical site infection (SSI) (31.3% concomitant, 28.6% prior untethering vs. 12.3% no untethering; p = 0.0104), return to the OR (43.8% concomitant, 23.8% prior untethering vs. 17.4% no untethering; p = 0.0047), need for blood transfusion (51.6% concomitant, 57.1% prior untethering vs. 33.8% no untethering; p = 0.04), and increased mean length of stay (LOS) (13.4 days concomitant, 10.6 days prior untethering vs. 6.8 days no untethering; p < 0.0001). In multivariable logistic regression analysis, prophylactic untethering was independently associated with increased adjusted relative risks of surgical site infection (aRR = 2.65, 95% CI 1.17-5.02), unplanned re-operation (aRR = 2.17, 95% CI 1.02-4.65), and any complication (aRR = 2.25, 95% CI 1.07-4.74). CONCLUSION In this study, asymptomatic children with myelomeningocele who underwent scoliosis surgery developed no neurologic injuries regardless of prophylactic untethering. However, those who underwent prophylactic untethering were more likely to experience SSIs, return to the OR, need a blood transfusion, and have increased LOS than children not undergoing untethering. Based on these data, prophylactic untethering in asymptomatic MMC patients prior to scoliosis surgery does not provide any neurological benefit and is associated with increased surgical risks.
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Affiliation(s)
- Hannah E Goldstein
- Department of Neurological Surgery, Columbia University Medical Center, Columbia-Presbyterian, New York, NY, USA.
| | - Belinda Shao
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY, USA
| | - Peter J Madsen
- Department of Neurosurgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Sara M Hartnett
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, The University of Alabama at Birmingham, Children's Hospital Birmingham, Birmingham, AL, USA
| | - Douglas L Brockmeyer
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah Medical Center, Salt Lake City, UT, USA
| | - Robert M Campbell
- Department of Orthopedic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michael Conklin
- Division of Pediatric Orthopedics, Department of Surgery, University of Alabama at Birmingham, Children's Hospital, Birmingham, AL, USA
| | - Todd C Hankinson
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
| | - Gregory G Heuer
- Department of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrew H Jea
- Department of Neurosurgery, Goodman Campbell Brain and Spine, Indianapolis, IN, USA
| | - Benjamin C Kennedy
- Department of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gerald F Tuite
- Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Luis Rodriguez
- Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Neil A Feldstein
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY, USA
| | - Michael G Vitale
- Division of Pediatric Orthopedic Surgery, Department of Orthopedic Surgery, Columbia University Medical Center, New York, NY, USA
| | - Richard C E Anderson
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY, USA
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16
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Wang A, Mandigo GK, Feldstein NA, Sisti MB, Connolly ES, Solomon RA, Lavine SD, Meyers PM. Curative treatment for low-grade arteriovenous malformations. J Neurointerv Surg 2019; 12:48-54. [DOI: 10.1136/neurintsurg-2019-015115] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/12/2019] [Accepted: 06/16/2019] [Indexed: 11/03/2022]
Abstract
BackgroundSpetzler-Martin (SM) grade I-II (low-grade) arteriovenous malformations (AVMs) are often considered safe for microsurgery or radiosurgery. The adjunctive use of preoperative embolization to reduce surgical risk in these AVMs remains controversial.ObjectiveTo assess the safety of combined treatment of grade I-II AVMs with preoperative embolization followed by surgical resection or radiosurgery, and determine the long-term functional outcomes.MethodsWith institutional review board approval, a retrospective analysis was carried out on patients with ruptured and unruptured SM I-II AVMs between 2002 and 2017. Details of the endovascular procedures, including number of arteries supplying the AVM, number of branches embolized, embolic agent(s) used, and complications were studied. Baseline clinical and imaging characteristics were compared. Functional status using the modified Rankin Scale (mRS) before and after endovascular and microsurgical treatments was compared.Results258 SM I-II AVMs (36% SM I, 64% SM II) were identified in patients with a mean age of 38 ± 17 years. 48% presented with hemorrhage, 21% with seizure, 16% with headache, 10% with no symptoms, and 5% with clinical deficits. 90 patients (68%) in the unruptured group and 74 patients (59%) in the ruptured group underwent presurgical embolization (p = 0.0013). The mean number of arteries supplying the AVM was 1.44 and 1.41 in the unruptured and ruptured groups, respectively (p = 0.75). The mean number of arteries embolized was 2.51 in the unruptured group and 1.82 in the ruptured group (p = 0.003). n-Butyl cyanoacrylate and Onyx were the two most commonly used embolic agents. Four complications were seen in four patients (4/164 patients embolized): two peri-/postprocedural hemorrhage, one dissection, and one infarct. All patients undergoing surgery had a complete cure on postoperative angiography. Patients were followed up for a mean of 55 months. Good long-term outcomes (mRS score ≤ 2) were seen in 92.5% of patients with unruptured AVMs and 88.0% of those with ruptured AVMs. Permanent neurological morbidity occurred in 1.2%.ConclusionsCurative treatment of SM I-II AVMs can be performed using endovascular embolization with microsurgical resection or radiosurgery in selected cases, with very low morbidity and high cure rates. Compared with other published series, these outcomes suggest that preoperative embolization is a safe and effective adjunct to definitive surgical treatment. Long-term follow-up showed that patients with low-grade AVMs undergoing surgical resection or radiosurgery have good functional outcomes.
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17
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Shao B, Banu MA, Carroll JJ, Meyers PM, Lavine SD, Feldstein NA, Anderson RCE. Cerebral Vasospasm after Open Fenestration of an Arachnoid Cyst in a 4-Year-Old Boy: Case Report and Review of the Literature. Pediatr Neurosurg 2019; 54:132-138. [PMID: 30650412 DOI: 10.1159/000495834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 05/28/2018] [Accepted: 11/23/2018] [Indexed: 11/19/2022]
Abstract
Cerebral vasospasm is associated with significant morbidity, and most commonly occurs following subarachnoid hemorrhage. Rarely, vasospasm can follow tumor resection and traumatic brain injury. We present the first reported case of a young child who developed diffuse vasospasm following open fenestration of an arachnoid cyst and was promptly treated, with full recovery of neurologic function. Although vasopasm after arachnoid cyst fenestration is rare, it can be included in the differential for a new focal neurologic deficit.
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Affiliation(s)
- Belinda Shao
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey, USA
| | - Matei A Banu
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Jason J Carroll
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Philip M Meyers
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Sean D Lavine
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA
| | - Neil A Feldstein
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA.,Morgan Stanley Children's Hospital of New York-Presbyterian, New York, New York, USA
| | - Richard C E Anderson
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, New York, USA, .,Morgan Stanley Children's Hospital of New York-Presbyterian, New York, New York, USA,
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18
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Alexiades NG, Ahn ES, Blount JP, Brockmeyer DL, Browd SR, Grant GA, Heuer GG, Hankinson TC, Iskandar BJ, Jea A, Krieger MD, Leonard JR, Limbrick DD, Maher CO, Proctor MR, Sandberg DI, Wellons JC, Shao B, Feldstein NA, Anderson RCE. Development of best practices to minimize wound complications after complex tethered spinal cord surgery: a modified Delphi study. J Neurosurg Pediatr 2018; 22:701-709. [PMID: 30215584 DOI: 10.3171/2018.6.peds18243] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 04/26/2018] [Accepted: 06/13/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEComplications after complex tethered spinal cord (cTSC) surgery include infections and cerebrospinal fluid (CSF) leaks. With little empirical evidence to guide management, there is variability in the interventions undertaken to limit complications. Expert-based best practices may improve the care of patients undergoing cTSC surgery. Here, authors conducted a study to identify consensus-driven best practices.METHODSThe Delphi method was employed to identify consensual best practices. A literature review regarding cTSC surgery together with a survey of current practices was distributed to 17 board-certified pediatric neurosurgeons. Thirty statements were then formulated and distributed to the group. Results of the second survey were discussed during an in-person meeting leading to further consensus, which was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree).RESULTSSeventeen consensus-driven best practices were identified, with all participants willing to incorporate them into their practice. There were four preoperative interventions: (1, 2) asymptomatic AND symptomatic patients should be referred to urology preoperatively, (3, 4) routine preoperative urine cultures are not necessary for asymptomatic AND symptomatic patients. There were nine intraoperative interventions: (5) patients should receive perioperative cefazolin or an equivalent alternative in the event of allergy, (6) chlorhexidine-based skin preparation is the preferred regimen, (7) saline irrigation should be used intermittently throughout the case, (8) antibiotic-containing irrigation should be used following dural closure, (9) a nonlocking running suture technique should be used for dural closure, (10) dural graft overlay should be used when unable to obtain primary dural closure, (11) an expansile dural graft should be incorporated in cases of lipomyelomeningocele in which primary dural closure does not permit free flow of CSF, (12) paraxial muscles should be closed as a layer separate from the fascia, (13) routine placement of postoperative drains is not necessary. There were three postoperative interventions: (14) postoperative antibiotics are an option and, if given, should be discontinued within 24 hours; (15) patients should remain flat for at least 24 hours postoperatively; (16) routine use of abdominal binders or other compressive devices postoperatively is not necessary. One intervention was prioritized for additional study: (17) further study of additional gram-negative perioperative coverage is needed.CONCLUSIONSA modified Delphi technique was used to develop consensus-driven best practices for decreasing wound complications after cTSC surgery. Further study is required to determine if implementation of these practices will lead to reduced complications. Discussion through the course of this study resulted in the initiation of a multicenter study of gram-negative surgical site infections in cTSC surgery.
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Affiliation(s)
- Nikita G Alexiades
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Edward S Ahn
- 2Department of Neurological Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jeffrey P Blount
- 3Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Douglas L Brockmeyer
- 4Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 5Department of Neurosurgery, University of Washington Seattle Children's Hospital, Seattle, Washington
| | - Gerald A Grant
- 6Department of Neurosurgery, Stanford University, Stanford, California
| | - Gregory G Heuer
- 7Department of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - Todd C Hankinson
- 8Department of Pediatric Neurosurgery, Children's Hospital Colorado, Anschutz Medical Campus, Aurora, Colorado
| | - Bermans J Iskandar
- 9Department of Neurosurgery, University of Wisconsin Hospitals and Clinics, Madison, Wisconsin
| | - Andrew Jea
- 10Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Mark D Krieger
- 11Department of Neurological Surgery, USC Keck School of Medicine/Children's Hospital of Los Angeles, California
| | - Jeffrey R Leonard
- 12Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - David D Limbrick
- 13Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Cormac O Maher
- 14Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Mark R Proctor
- 15Department of Neurosurgery, Children's Hospital Boston, Harvard Medical School, Boston, Massachusetts
| | - David I Sandberg
- 16Department of Neurosurgery, McGovern Medical School/University of Texas Health Science Center, Houston, Texas
| | - John C Wellons
- 17Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; and
| | - Belinda Shao
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York.,18Rutgers New Jersey Medical School, Newark, New Jersey
| | - Neil A Feldstein
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Richard C E Anderson
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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19
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Alter AS, Dhamija R, McDonough TL, Shen S, McBrian DK, Mandel AM, McKhann GM, Feldstein NA, Akman CI. Ictal onset patterns of subdural intracranial electroencephalogram in children: How helpful for predicting epilepsy surgery outcome? Epilepsy Res 2018; 149:44-52. [PMID: 30476812 DOI: 10.1016/j.eplepsyres.2018.10.008] [Citation(s) in RCA: 9] [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: 07/03/2018] [Revised: 09/26/2018] [Accepted: 10/21/2018] [Indexed: 11/28/2022]
Abstract
AIMS We aimed to classify ictal onset patterns (IOPs) in pediatric patients undergoing intracranial electroencephalography (IEEG) to guide surgery for refractory epilepsy. We aimed to determine if morphology of IOPs can predict surgical outcome. MATERIALS AND METHODS We performed a retrospective review of pediatric patients who underwent epilepsy surgery guided by subdural IEEG from 2007 to 2016. IEEG seizures were reviewed by a blinded epileptologist. Data was collected on outcomes. RESULTS Twenty-three patients with 784 seizures were included. Age at seizure onset was 0.2-11 (mean 4.3, standard deviation 3.2) years. Age at time of IEEG was 4-20 (mean 13.5, standard deviation 4.4) years. Five distinct IOPs were seen at seizure onset: A) Low voltage fast activity (LVFA) with spread to adjacent electrodes (n = 7 patients, 30%), B) Burst of LVFA followed by electrodecrement (n = 12 patients, 52%), C) Burst of rhythmic spike waves (RSW) followed by electrodecrement (n = 9 patients, 39%), D) RSW followed by LVFA (n = 7 patients, 30%), E) Rhythmic spikes alone (n = 10 patients, 43%). Twelve patients (52%) had the same IOP type with all seizures. When the area of the IOP was resected, 14 patients (61%) had Engel I outcomes. Patients who had LVFA seen within their predominant IOP type were more likely to have good surgical outcomes (odds ratio 7.50, 95% confidence interval 1.02-55.0, p = 0.05). Patients who had only one IOP type were more likely to have good outcomes than patients who had multiple IOP types (odds ratio 12.6, 95% confidence interval 1.19-134, p = 0.04). Patients who had LVFA in their predominant IOP type were older than patients who did not have LVFA (mean age 15.0 vs. 9.9 years, p = 0.02). CONCLUSIONS LVFA at ictal onset and all seizures having the same IOP morphology are associated with increased likelihood of surgical success in children, but LVFA is less common in children who are younger at the time of IEEG.
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Affiliation(s)
- Aliza S Alter
- Department of Neurology, Division of Child Neurology, New York-Presbyterian Hospital/ Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, New York, New York, USA.
| | - Ravi Dhamija
- Department of Neurology, Division of Child Neurology, New York-Presbyterian Hospital/ Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, New York, New York, USA.
| | - Tiffani L McDonough
- Department of Neurology, Division of Child Neurology, New York-Presbyterian Hospital/ Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, New York, New York, USA.
| | - Stephie Shen
- Department of Neurology, Division of Child Neurology, New York-Presbyterian Hospital/ Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, New York, New York, USA.
| | - Danielle K McBrian
- Department of Neurology, Division of Child Neurology, New York-Presbyterian Hospital/ Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, New York, New York, USA.
| | - Arthur M Mandel
- Department of Neurology, Division of Child Neurology, New York-Presbyterian Hospital/ Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, New York, New York, USA.
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, New York, USA.
| | - Neil A Feldstein
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, 710 West 168th Street, New York, New York, USA.
| | - Cigdem I Akman
- Department of Neurology, Division of Child Neurology, New York-Presbyterian Hospital/ Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, New York, New York, USA.
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20
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Goldstein HE, Youngerman BE, Shao B, Akman CI, Mandel AM, McBrian DK, Riviello JJ, Sheth SA, McKhann GM, Feldstein NA. Safety and efficacy of stereoelectroencephalography in pediatric focal epilepsy: a single-center experience. J Neurosurg Pediatr 2018; 22:444-452. [PMID: 30028270 DOI: 10.3171/2018.5.peds1856] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Patients with medically refractory localization-related epilepsy (LRE) may be candidates for surgical intervention if the seizure onset zone (SOZ) can be well localized. Stereoelectroencephalography (SEEG) offers an attractive alternative to subdural grid and strip electrode implantation for seizure lateralization and localization; yet there are few series reporting the safety and efficacy of SEEG in pediatric patients. METHODS The authors review their initial 3-year consecutive experience with SEEG in pediatric patients with LRE. SEEG coverage, SOZ localization, complications, and preliminary seizure outcomes following subsequent surgical treatments are assessed. RESULTS Twenty-five pediatric patients underwent 30 SEEG implantations, with a total of 342 electrodes placed. Ten had prior resections or ablations. Seven had no MRI abnormalities, and 8 had multiple lesions on MRI. Based on preimplantation hypotheses, 7 investigations were extratemporal (ET), 1 was only temporal-limbic (TL), and 22 were combined ET/TL investigations. Fourteen patients underwent bilateral investigations. On average, patients were monitored for 8 days postimplant (range 3-19 days). Nearly all patients were discharged home on the day following electrode explantation. There were no major complications. Minor complications included 1 electrode deflection into the subdural space, resulting in a minor asymptomatic extraaxial hemorrhage; and 1 in-house and 1 delayed electrode superficial scalp infection, both treated with local wound care and oral antibiotics. SEEG localized the hypothetical SOZ in 23 of 25 patients (92%). To date, 18 patients have undergone definitive surgical intervention. In 2 patients, SEEG localized the SOZ near eloquent cortex and subdural grids were used to further delineate the seizure focus relative to mapped motor function just prior to resection. At last follow-up (average 21 months), 8 of 15 patients with at least 6 months of follow-up (53%) were Engel class I, and an additional 6 patients (40%) were Engel class II or III. Only 1 patient was Engel class IV. CONCLUSIONS SEEG is a safe and effective technique for invasive SOZ localization in medically refractory LRE in the pediatric population. SEEG permits bilateral and multilobar investigations while avoiding large craniotomies. It is conducive to deep, 3D, and perilesional investigations, particularly in cases of prior resections. Patients who are not found to have focally localizable seizures are spared craniotomies.
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Affiliation(s)
- Hannah E Goldstein
- 1Department of Neurological Surgery, Columbia University Medical Center, Columbia-Presbyterian, New York
| | - Brett E Youngerman
- 1Department of Neurological Surgery, Columbia University Medical Center, Columbia-Presbyterian, New York
| | - Belinda Shao
- 2Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York
| | - Cigdem I Akman
- 3Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, New York; and
| | - Arthur M Mandel
- 3Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, New York; and
| | - Danielle K McBrian
- 3Department of Neurology, Child Neurology Division, Children's Hospital of New York, Columbia-Presbyterian, New York, New York; and
| | - James J Riviello
- 4Department of Neurology and Developmental Neuroscience, Texas Children's Hospital, Houston, Texas
| | - Sameer A Sheth
- 1Department of Neurological Surgery, Columbia University Medical Center, Columbia-Presbyterian, New York
| | - Guy M McKhann
- 1Department of Neurological Surgery, Columbia University Medical Center, Columbia-Presbyterian, New York
| | - Neil A Feldstein
- 2Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York
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Youngerman BE, Oh JY, Anbarasan D, Billakota S, Casadei CH, Corrigan EK, Banks GP, Pack AM, Choi H, Bazil CW, Srinivasan S, Bateman LM, Schevon CA, Feldstein NA, Sheth SA, McKhann GM. Laser ablation is effective for temporal lobe epilepsy with and without mesial temporal sclerosis if hippocampal seizure onsets are localized by stereoelectroencephalography. Epilepsia 2018; 59:595-606. [DOI: 10.1111/epi.14004] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Brett E. Youngerman
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
| | - Justin Y. Oh
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
| | - Deepti Anbarasan
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Santoshi Billakota
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Camilla H. Casadei
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Emily K. Corrigan
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
| | - Garret P. Banks
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
| | - Alison M. Pack
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Hyunmi Choi
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Carl W. Bazil
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Shraddha Srinivasan
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Lisa M. Bateman
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Catherine A. Schevon
- Department of Neurology; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Neil A. Feldstein
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Sameer A. Sheth
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
| | - Guy M. McKhann
- Department of Neurological Surgery; Columbia University Medical Center; New York NY USA
- Columbia Comprehensive Epilepsy Center; Columbia University Medical Center; New York NY USA
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22
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Youngerman BE, Oh J, Pathak Y, Banks GP, Sheth SA, Feldstein NA, McKhann GM. 350 Stereoelectroencephalography for Refractory Localization-related Epilepsy. Neurosurgery 2017. [DOI: 10.1093/neuros/nyx417.350] [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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23
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D'Amico RS, Praver M, Zanazzi GJ, Englander ZK, Sims JS, Samanamud JL, Ogden AT, McCormick PC, Feldstein NA, McKhann GM, Sisti MB, Canoll P, Bruce JN. Subependymomas Are Low-Grade Heterogeneous Glial Neoplasms Defined by Subventricular Zone Lineage Markers. World Neurosurg 2017; 107:451-463. [PMID: 28804038 DOI: 10.1016/j.wneu.2017.08.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [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: 03/01/2017] [Revised: 07/28/2017] [Accepted: 08/01/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Subependymomas are infrequent, low-grade gliomas associated with the ventricular system and the spinal cord. Little is known about the origin and natural history of these slow-growing lesions. METHODS We identified all patients with pathologically proven subependymomas presenting to our institution between 1998 and 2016. We retrospectively reviewed clinical, radiographic, histologic, and surgical outcomes data in all patients who underwent surgical resection. Immunohistochemical analyses for cell lineage markers were performed. RESULTS A total of 31 patients with pathologically proven subependymomas were identified. Of these, 7 asymptomatic lesions were discovered at autopsy and 24 symptomatic cases were treated surgically. There were 15 (48%) lateral ventricle tumors, 11 (35%) fourth ventricular tumors, and 5 (17%) spinal tumors. Symptomatic intracranial lesions most commonly presented with headaches and balance and gait abnormalities. Subependymomas had no distinguishing radiographic features that provided definitive preoperative diagnosis. At last follow-up, no patient treated surgically experienced recurrence. Immunohistochemical analyses demonstrated a diffusely GFAP-positive glial neoplasm with mixed populations of cells that were variably positive for Olig2, NHERF1, Sox2, and CD44. The Ki67 proliferation index was generally low (<1% in many of the tumors). CONCLUSIONS Subependymomas demonstrate mixed populations of cells expressing glial lineage markers as well as putative stem cell markers, suggesting these tumors may arise from multipotent glial progenitors that reside in the subventricular zone. Definitive diagnosis requires surgical sampling. Although the clinical course of subependymomas appears benign, the inability to radiographically diagnose these lesions, and the possibility of an alternative malignant lesion support a low threshold for early and safe maximal resection.
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Affiliation(s)
- Randy S D'Amico
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA.
| | - Moshe Praver
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - George J Zanazzi
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | - Zachary K Englander
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Jennifer S Sims
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Jorge L Samanamud
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Alfred T Ogden
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Paul C McCormick
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Neil A Feldstein
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Guy M McKhann
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Michael B Sisti
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York, USA
| | - Jeffrey N Bruce
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York, USA
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24
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Taskin BD, Tanji K, Feldstein NA, McSwiggan-Hardin M, Akman CI. Epilepsy surgery for epileptic encephalopathy as a sequela of herpes simplex encephalitis: case report. J Neurosurg Pediatr 2017; 20:56-63. [PMID: 28452654 DOI: 10.3171/2017.3.peds16632] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [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] [Indexed: 11/06/2022]
Abstract
Herpes simplex virus (HSV) encephalitis can manifest with different clinical presentations, including acute monophasic illness and biphasic chronic granulomatous HSV encephalitis. Chronic encephalitis is much less common, and very rare late relapses are associated with intractable epilepsy and progressive neurological deficits with or without evidence of HSV in the cerebrospinal fluid. The authors report on an 8-year-old girl with a history of treated HSV-1 encephalitis when she was 13 months of age and focal epilepsy when she was 2 years old. Although free of clinical seizures, when she was 5, she experienced behavioral and academic dysfunction, which was later attributed to electrographic focal seizures and worsening electroencephalography (EEG) findings with electrical status epilepticus during slow-wave sleep (ESES). Following a right temporal lobectomy, chronic granulomatous encephalitis was diagnosed. The patient's clinical course improved with the resolution of seizures and EEG abnormalities.
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Affiliation(s)
- Birce Dilge Taskin
- Department of Pediatric Neurology, Ankara Children's Hematology Oncology Training and Research Hospital, Ankara, Turkey; and
| | - Kurenai Tanji
- Department of Pathology and Cell Biology, Division of Neuropathology
| | | | | | - Cigdem I Akman
- Department of Neurology, Division of Child Neurology, Columbia University Medical Center, New York
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25
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Yang J, Bassuk AG, Merl-Pham J, Hsu CW, Colgan DF, Li X, Au KS, Zhang L, Smemo S, Justus S, Nagahama Y, Grossbach AJ, Howard MA, Kawasaki H, Feldstein NA, Dobyns WB, Northrup H, Hauck SM, Ueffing M, Mahajan VB, Tsang SH. Catenin delta-1 (CTNND1) phosphorylation controls the mesenchymal to epithelial transition in astrocytic tumors. Hum Mol Genet 2016; 25:4201-4210. [PMID: 27516388 DOI: 10.1093/hmg/ddw253] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2016] [Revised: 07/14/2016] [Accepted: 07/21/2016] [Indexed: 11/14/2022] Open
Abstract
Inactivating mutations of the TSC1/TSC2 complex (TSC1/2) cause tuberous sclerosis (TSC), a hereditary syndrome with neurological symptoms and benign hamartoma tumours in the brain. Since TSC effectors are largely unknown in the human brain, TSC patient cortical tubers were used to uncover hyperphosphorylation unique to TSC primary astrocytes, the cell type affected in the brain. We found abnormal hyperphosphorylation of catenin delta-1 S268, which was reversible by mTOR-specific inhibitors. In contrast, in three metastatic astrocytoma cell lines, S268 was under phosphorylated, suggesting S268 phosphorylation controls metastasis. TSC astrocytes appeared epithelial (i.e. tightly adherent, less motile, and epithelial (E)-cadherin positive), whereas wild-type astrocytes were mesenchymal (i.e. E-cadherin negative and highly motile). Despite their epithelial phenotype, TSC astrocytes outgrew contact inhibition, and monolayers sporadically generated tuberous foci, a phenotype blocked by the mTOR inhibitor, Torin1. Also, mTOR-regulated phosphokinase C epsilon (PKCe) activity induced phosphorylation of catenin delta-1 S268, which in turn mediated cell-cell adhesion in astrocytes. The mTOR-dependent, epithelial phenotype of TSC astrocytes suggests TSC1/2 and mTOR tune the phosphorylation level of catenin delta-1 by controlling PKCe activity, thereby regulating the mesenchymal-epithelial-transition (MET). Thus, some forms of TSC could be treated with PKCe inhibitors, while metastasis of astrocytomas might be blocked by PKCe stimulators.
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Affiliation(s)
- Jin Yang
- Barbara & Donald Jonas Stem Cell Laboratory, and Bernard & Shirlee Brown Glaucoma Laboratory, Departments of Ophthalmology, Pathology & Cell Biology, Institute of Human Nutrition, Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Tianjin Medical University Eye Hospital, Tianjin, People's Republic of China.,Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA
| | - Alexander G Bassuk
- Department of Pediatrics and Neurology, Departments of Neurosurgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa, IA, USA
| | - Juliane Merl-Pham
- Research Unit Protein Science, Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Munich, Germany
| | - Chun-Wei Hsu
- Barbara & Donald Jonas Stem Cell Laboratory, and Bernard & Shirlee Brown Glaucoma Laboratory, Departments of Ophthalmology, Pathology & Cell Biology, Institute of Human Nutrition, Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA
| | | | - Xiaorong Li
- Tianjin Medical University Eye Hospital, Tianjin, People's Republic of China
| | - Kit Sing Au
- Division of Medical Genetics, Department of Pediatrics, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Lijuan Zhang
- Barbara & Donald Jonas Stem Cell Laboratory, and Bernard & Shirlee Brown Glaucoma Laboratory, Departments of Ophthalmology, Pathology & Cell Biology, Institute of Human Nutrition, Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA.,Shanxi Eye Hospital, affiliated with Shanxi Medical University, Xinghualing, Taiyuan, Shanxi, China
| | - Scott Smemo
- Barbara & Donald Jonas Stem Cell Laboratory, and Bernard & Shirlee Brown Glaucoma Laboratory, Departments of Ophthalmology, Pathology & Cell Biology, Institute of Human Nutrition, Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA
| | - Sally Justus
- Barbara & Donald Jonas Stem Cell Laboratory, and Bernard & Shirlee Brown Glaucoma Laboratory, Departments of Ophthalmology, Pathology & Cell Biology, Institute of Human Nutrition, Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA.,Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA
| | - Yasunori Nagahama
- Department of Pediatrics and Neurology, Departments of Neurosurgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa, IA, USA
| | - Andrew J Grossbach
- Department of Pediatrics and Neurology, Departments of Neurosurgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa, IA, USA
| | - Matthew A Howard
- Department of Pediatrics and Neurology, Departments of Neurosurgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa, IA, USA
| | - Hiroto Kawasaki
- Department of Pediatrics and Neurology, Departments of Neurosurgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa, IA, USA
| | - Neil A Feldstein
- Departments of Neurosurgery, New York-Presbyterian Hospital, Columbia University Medical Center, New York, NY, USA
| | - William B Dobyns
- Division of Genetic Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington, Seattle, Washington, USA Departments of Pediatrics and Neurology, University of Washington, Seattle, Washington, WA, USA
| | - Hope Northrup
- Division of Medical Genetics, Department of Pediatrics, University of Texas Health Science Center at Houston, McGovern Medical School, Houston, TX, USA
| | - Stefanie M Hauck
- Research Unit Protein Science, Helmholtz Zentrum Munich, German Research Center for Environmental Health (GmbH), Munich, Germany
| | - Marius Ueffing
- Institute for Ophthalmic Research, Center of Ophthalmology, University Medical Center, University of Tübingen, Germany
| | - Vinit B Mahajan
- Department of Pediatrics and Neurology, Departments of Neurosurgery, Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa, IA, USA.,Omics Laboratory, University of Iowa, Iowa, IA, USA
| | - Stephen H Tsang
- Barbara & Donald Jonas Stem Cell Laboratory, and Bernard & Shirlee Brown Glaucoma Laboratory, Departments of Ophthalmology, Pathology & Cell Biology, Institute of Human Nutrition, Irving Comprehensive Cancer Center, College of Physicians and Surgeons, Columbia University, New York, NY, USA .,Edward S. Harkness Eye Institute, New York-Presbyterian Hospital, New York, NY, USA
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26
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Ladner TR, Greenberg JK, Guerrero N, Olsen MA, Shannon CN, Yarbrough CK, Piccirillo JF, Anderson RCE, Feldstein NA, Wellons JC, Smyth MD, Park TS, Limbrick DD. Chiari malformation Type I surgery in pediatric patients. Part 1: validation of an ICD-9-CM code search algorithm. J Neurosurg Pediatr 2016; 17:519-24. [PMID: 26799412 PMCID: PMC4853277 DOI: 10.3171/2015.10.peds15370] [Citation(s) in RCA: 12] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Administrative billing data may facilitate large-scale assessments of treatment outcomes for pediatric Chiari malformation Type I (CM-I). Validated International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) code algorithms for identifying CM-I surgery are critical prerequisites for such studies but are currently only available for adults. The objective of this study was to validate two ICD-9-CM code algorithms using hospital billing data to identify pediatric patients undergoing CM-I decompression surgery. METHODS The authors retrospectively analyzed the validity of two ICD-9-CM code algorithms for identifying pediatric CM-I decompression surgery performed at 3 academic medical centers between 2001 and 2013. Algorithm 1 included any discharge diagnosis code of 348.4 (CM-I), as well as a procedure code of 01.24 (cranial decompression) or 03.09 (spinal decompression or laminectomy). Algorithm 2 restricted this group to the subset of patients with a primary discharge diagnosis of 348.4. The positive predictive value (PPV) and sensitivity of each algorithm were calculated. RESULTS Among 625 first-time admissions identified by Algorithm 1, the overall PPV for CM-I decompression was 92%. Among the 581 admissions identified by Algorithm 2, the PPV was 97%. The PPV for Algorithm 1 was lower in one center (84%) compared with the other centers (93%-94%), whereas the PPV of Algorithm 2 remained high (96%-98%) across all subgroups. The sensitivity of Algorithms 1 (91%) and 2 (89%) was very good and remained so across subgroups (82%-97%). CONCLUSIONS An ICD-9-CM algorithm requiring a primary diagnosis of CM-I has excellent PPV and very good sensitivity for identifying CM-I decompression surgery in pediatric patients. These results establish a basis for utilizing administrative billing data to assess pediatric CM-I treatment outcomes.
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Affiliation(s)
- Travis R. Ladner
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob K. Greenberg
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Nicole Guerrero
- Department of Neurosurgery, Columbia University Medical Center, New York, New York
| | - Margaret A. Olsen
- Medicine, Washington University School of Medicine in St. Louis, Missouri,Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Chevis N. Shannon
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chester K. Yarbrough
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Jay F. Piccirillo
- Otolaryngology–Head and Neck Surgery, Washington University School of Medicine in St. Louis, Missouri
| | | | - Neil A. Feldstein
- Department of Neurosurgery, Columbia University Medical Center, New York, New York
| | - John C. Wellons
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D. Smyth
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Tae Sung Park
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - David D. Limbrick
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, Missouri
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27
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Goldstein HE, Kennedy BC, Santos J, Anderson RCE, Feldstein NA. Bilateral occipital endoscopic choroid plexus cauterization for persistent hydrocephalus following frontal endoscopic third ventriculostomy and choroid plexus cauterization--the "bowling ball" technique. Childs Nerv Syst 2016; 32:697-701. [PMID: 26458905 DOI: 10.1007/s00381-015-2925-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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: 04/22/2015] [Accepted: 09/28/2015] [Indexed: 10/22/2022]
Abstract
Endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) as a primary treatment for hydrocephalus is gaining popularity in North America, particularly among the infant population. Unfortunately, despite considerable experience with ETV/CPC at several centers, treatment failures still exist. Early reports have suggested that greater than 90 % cauterization of the choroid plexus is associated with improved clinical outcomes. However, individual patient anatomy and smaller overall ventricular size can limit the amount of choroid plexus cauterization that is technically possible through a single frontal burr hole. Furthermore, the degree of cauterization achieved by surgeons using this technique is difficult to quantify objectively. In this report, we describe the case of an infant who failed initial ETV/CPC but then had successful resolution of hydrocephalus after additional choroid plexus cauterization performed through bilateral occipital burr holes. The child remains shunt-free over a year after treatment, suggesting that this three-pronged CPC approach (the "bowling ball" technique) may be successful in some young children with persistent hydrocephalus after ETV/CPC from a single frontal burr hole.
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Affiliation(s)
- Hannah E Goldstein
- Department of Neurosurgery, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY, USA.
- The Neurological Institute, Columbia University Medical Center, 710 West 168th Street, 4th floor, New York, NY, 10032, USA.
| | - Benjamin C Kennedy
- Department of Neurosurgery, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY, USA
| | - Junia Santos
- Department of Neurosurgery, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY, USA
| | - Richard C E Anderson
- Department of Neurosurgery, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY, USA
| | - Neil A Feldstein
- Department of Neurosurgery, Morgan Stanley Children's Hospital of New York, Columbia University, New York, NY, USA
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28
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Kennedy BC, Kelly KM, Anderson RCE, Feldstein NA. Isolated thoracic syrinx in children with Chiari I malformation. Childs Nerv Syst 2016; 32:531-4. [PMID: 26758882 DOI: 10.1007/s00381-015-3009-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 11/08/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Syrinx has been reported in 25-85 % of children with Chiari malformation type I (CMI), and it is most commonly cervical in location. As a result, cervical MRI is routinely included in an evaluation for CMI. Isolated thoracic syrinx without involvement of the cervical cord in this population is uncommon but clinically important because its presence may influence the decision to operate, surgical techniques employed, or interpretation of follow-up imaging. The purpose of this study was to determine the incidence of isolated thoracic syrinx in a large group of children evaluated for CMI. METHODS We retrospectively reviewed all patients under 21 years of age who were evaluated for CMI at Columbia University/Morgan Stanley Children's Hospital of New York from 1998 to 2013. All patients underwent MRI of the entire spine as part of the CMI evaluation, regardless of whether surgery was planned. The proportion of patients exhibiting isolated thoracic syrinx was determined. Presenting signs, symptoms, and imaging findings were then studied in an attempt to identify any clinical features associated with isolated thoracic syrinx. RESULTS We identified 266 patients evaluated over the study period. One-hundred thirty-two patients (50 %) presented with a syrinx, and 12 patients (4.5 % of all patients evaluated and 9.1 % of all patients with a syrinx) had an isolated thoracic syrinx. Demographic variables, clinical presentation, and extent of tonsillar ectopia showed great heterogeneity in this group, and no factor was consistently associated with isolated thoracic syrinx. CONCLUSIONS Isolated thoracic syrinx is an uncommon but clinically significant finding in children with CMI. Our data demonstrate that the presence of a CMI-related thoracic syrinx cannot be reliably predicted clinically and is therefore likely to be missed in patients who do not undergo complete spinal cord imaging. MRI of the entire spinal cord should be considered for all children undergoing initial evaluation for CMI.
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Affiliation(s)
- Benjamin C Kennedy
- Department of Neurological Surgery, Columbia University, New York, NY, USA.
| | - Kathleen M Kelly
- Department of Otolaryngology Head and Neck Surgery at UT Southwestern, Dallas, TX, USA
| | - Richard C E Anderson
- Department of Neurological Surgery, Columbia University, New York, NY, USA.,Children's Hospital of New York, Columbia University, New York, NY, USA
| | - Neil A Feldstein
- Department of Neurological Surgery, Columbia University, New York, NY, USA.,Children's Hospital of New York, Columbia University, New York, NY, USA
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29
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Ellis JA, Mejia Munne JC, Feldstein NA, Meyers PM. Determination of sinus pericranii resectability by external compression during angiography: technical note. J Neurosurg Pediatr 2016; 17:129-133. [PMID: 26474103 DOI: 10.3171/2015.6.peds15183] [Citation(s) in RCA: 4] [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] [Indexed: 11/06/2022]
Abstract
Sinus pericranii is an uncommon congenital cranial venous malformation that may become symptomatic in the pediatric population. Both dominant and accessory sinus pericranii, as determined by the intracranial venous drainage pattern, have been described. The dominant variety drain a significant proportion of the intracranial venous outflow while the accessory variety have minimal or no role in this. Classic teachings hold that dominant sinus pericranii should never be treated while accessory sinus pericranii may be safely obliterated. This determination of dominance is solely based on a qualitative assessment of standard venous phase catheter cerebral angiography, leaving some doubt regarding the actual safety of obliteration. In this paper the authors describe a simple and unique method for determining whether intracranial venous outflow may be compromised by sinus pericranii treatment. This involves performing catheter angiography while the lesion is temporarily obliterated by external compression. Analysis of intracranial venous outflow in this setting allows visualization of angiographic changes that will occur once the sinus pericranii is permanently obliterated. Thus, the safety of surgical intervention can be more fully appraised using this technique.
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Affiliation(s)
- Jason A Ellis
- Department of Neurological Surgery, Columbia University Medical Center, New York
| | - Juan C Mejia Munne
- Department of Neurological Surgery, Columbia University Medical Center, New York
| | - Neil A Feldstein
- Department of Neurological Surgery, Columbia University Medical Center, New York
| | - Philip M Meyers
- Department of Neurological Surgery, Columbia University Medical Center, New York
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Ung TH, Kellner C, Neira JA, Wang SHJ, D'Amico R, Faust PL, Canoll P, Feldstein NA, Bruce JN. The use of fluorescein sodium in the biopsy and gross-total resection of a tectal plate glioma. J Neurosurg Pediatr 2015; 16:732-5. [PMID: 26407010 DOI: 10.3171/2015.5.peds15142] [Citation(s) in RCA: 9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Intravenous administration of fluorescein sodium fluoresces glioma burden tissue and can be visualized using the surgical microscope with a specialized filter. Intraoperative guidance afforded through the use of fluorescein may enhance the fidelity of tissue sampling, and increase the ability to accomplish complete resection of tectal lesions. In this report the authors present the case of a 19-year-old man with a tectal anaplastic pilocytic astrocytoma in which the use of fluorescein sodium and a Zeiss Pentero surgical microscope equipped with a yellow 560 filter enabled safe complete resection. In conjunction with neurosurgical navigation, added intraoperative guidance provided by fluorescein may be beneficial in the resection of brainstem gliomas.
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Affiliation(s)
| | | | | | - Shih-Hsiu J Wang
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | | | - Phyllis L Faust
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
| | - Peter Canoll
- Department of Pathology and Cell Biology, Columbia University Medical Center, New York, New York
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Kennedy BC, Anderson RCE, Feldstein NA. Response. J Neurosurg Pediatr 2015; 16:758-60. [PMID: 26958673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/03/2023]
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Kennedy BC, Nelp TB, Kelly KM, Phan MQ, Bruce SS, McDowell MM, Feldstein NA, Anderson RCE. Delayed resolution of syrinx after posterior fossa decompression without dural opening in children with Chiari malformation Type I. J Neurosurg Pediatr 2015; 16:599-606. [PMID: 26314201 DOI: 10.3171/2015.4.peds1572] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [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] [Indexed: 01/12/2023]
Abstract
OBJECT Chiari malformation Type I (CM-I) is associated with a syrinx in 25%-85% of patients. Although posterior fossa decompression (PFD) without dural opening is an accepted treatment option for children with symptomatic CM-I, many surgeons prefer to open the dura if a syrinx exists. The purpose of this study was to investigate the frequency and timing of syrinx resolution in children undergoing PFD without dural opening for CM-I. METHODS A retrospective review of 68 consecutive pediatric patients with CM-I and syringomyelia who underwent PFD without dural opening was conducted. Patient demographics, presenting symptoms and signs, radiographic findings, and intraoperative ultrasound and neuromonitoring findings were studied as well as the patients' clinical and radiographic follow-up. RESULTS During the mean radiographic follow-up period of 32 months, 70% of the syringes improved. Syrinx improvement occurred at a mean of 31 months postoperatively. All patients experienced symptom improvement within the 1st year, despite only 26% of patients showing radiographic improvement during that period. Patients presenting with sensory symptoms or motor weakness had a higher likelihood of having radiographic syrinx improvement postoperatively. CONCLUSIONS In children with CM-I and a syrinx undergoing PFD without dural opening, syrinx resolution occurs in approximately 70% of patients. Radiographic improvement of the syrinx is delayed, but this does not correlate temporally with symptom improvement. Sensory symptoms or motor weakness on presentation are associated with syrinx resolution after surgery.
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Affiliation(s)
| | | | | | | | | | - Michael M McDowell
- Department of Neurological Surgery, University of Pittsburgh, Pennsylvania
| | - Neil A Feldstein
- Department of Neurological Surgery and.,Children's Hospital of New York, Columbia University, New York, New York; and
| | - Richard C E Anderson
- Department of Neurological Surgery and.,Children's Hospital of New York, Columbia University, New York, New York; and
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Affiliation(s)
- Hannah E Goldstein
- Columbia University, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, NY
| | - Neil A Feldstein
- Columbia University, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, NY
| | - Richard C E Anderson
- Columbia University, Morgan Stanley Children's Hospital of NewYork-Presbyterian, New York, NY
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Kennedy BC, Kelly KM, Phan MQ, Bruce SS, McDowell MM, Anderson RCE, Feldstein NA. Outcomes after suboccipital decompression without dural opening in children with Chiari malformation Type I. J Neurosurg Pediatr 2015; 16:150-8. [PMID: 25932779 PMCID: PMC4593701 DOI: 10.3171/2014.12.peds14487] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [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] [Indexed: 11/06/2022]
Abstract
OBJECT Symptomatic pediatric Chiari malformation Type I (CM-I) is most often treated with posterior fossa decompression (PFD), but controversy exists over whether the dura needs to be opened during PFD. While dural opening as a part of PFD has been suggested to result in a higher rate of resolution of CM symptoms, it has also been shown to lead to more frequent complications. In this paper, the authors present the largest reported series of outcomes after PFD without dural opening surgery, as well as identify risk factors for recurrence. METHODS The authors performed a retrospective review of 156 consecutive pediatric patients in whom the senior authors performed PFD without dural opening from 2003 to 2013. Patient demographics, clinical symptoms and signs, radiographic findings, intraoperative ultrasound results, and neuromonitoring findings were reviewed. Univariate and multivariate regression analyses were performed to determine risk factors for recurrence of symptoms and the need for reoperation. RESULTS Over 90% of patients had a good clinical outcome, with improvement or resolution of their symptoms at last follow-up (mean 32 months). There were no major complications. The mean length of hospital stay was 2.0 days. In a multivariate regression model, partial C-2 laminectomy was an independent risk factor associated with reoperation (p = 0.037). Motor weakness on presentation was also associated with reoperation but only with trend-level significance (p = 0.075). No patient with < 8 mm of tonsillar herniation required reoperation. CONCLUSIONS The vast majority (> 90%) of children with symptomatic CM-I will have improvement or resolution of symptoms after a PFD without dural opening. A non-dural opening approach avoids major complications. While no patient with tonsillar herniation < 8 mm required reoperation, children with tonsillar herniation at or below C-2 have a higher risk for failure when this approach is used.
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Affiliation(s)
| | - Kathleen M. Kelly
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Michelle Q. Phan
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Samuel S. Bruce
- Department of Neurological Surgery, Columbia University, New York, New York
| | - Michael M. McDowell
- Department of Neurological Surgery, Pittsburgh University, Pittsburgh, Pennsylvania
| | - Richard C. E. Anderson
- Department of Neurological Surgery, Columbia University, New York, New York,Children’s Hospital of New York, Columbia University, New York, New York
| | - Neil A. Feldstein
- Department of Neurological Surgery, Columbia University, New York, New York,Children’s Hospital of New York, Columbia University, New York, New York
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Kennedy BC, Cloney MB, Anderson RCE, Feldstein NA. Superior parietal lobule approach for choroid plexus papillomas without preoperative embolization in very young children. J Neurosurg Pediatr 2015; 16:101-6. [PMID: 25860983 DOI: 10.3171/2014.11.peds14281] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [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] [Indexed: 11/06/2022]
Abstract
OBJECT Choroid plexus papillomas (CPPs) are rare neoplasms, often found in the atrium of the lateral ventricle of infants, and cause overproduction hydrocephalus. The extensive vascularity and medially located blood supply of these tumors, coupled with the young age of the patients, can make prevention of blood loss challenging. Preoperative embolization has been advocated to reduce blood loss and prevent the need for transfusion, but this mandates radiation exposure and the additional risks of vessel injury and stroke. For these reasons, the authors present their experience using the superior parietal lobule approach to CPPs of the atrium without adjunct therapy. METHODS A retrospective review was conducted of all children who presented to Columbia University/Morgan Stanley Children's Hospital of New York with a CPP in the atrium of the lateral ventricle and who underwent surgery using a superior parietal lobule approach without preoperative embolization. RESULTS Nine children were included, with a median age of 7 months. There were no perioperative complications or new neurological deficits. All patients had intraoperative blood loss of less than 100 ml, with a mean minimum hematocrit of 26.9% (range 19.6%-36.2%). No patients required a blood transfusion. The median follow-up was 39 months, during which time no patient demonstrated residual or recurrent tumor on MRI, nor did any have an increase in ventricular size or require CSF diversion. CONCLUSIONS The superior parietal lobule approach is safe and effective for very young children with CPPs in the atrium of the lateral ventricle. The results suggest that preoperative embolization is not essential to avoid transfusion or achieve overall good outcomes in these patients. This management strategy avoids radiation exposure and the additional risks associated with embolization.
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Affiliation(s)
| | | | - Richard C E Anderson
- Department of Neurological Surgery and.,Children's Hospital of New York, Columbia University, New York, New York
| | - Neil A Feldstein
- Department of Neurological Surgery and.,Children's Hospital of New York, Columbia University, New York, New York
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36
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Abstract
OBJECT Cystic lesions in the atrium (trigone) of the lateral ventricle may become symptomatic due to obstruction of physiological CSF circulation and/or from mass effect on adjacent structures. A minimally invasive approach that not only allows for straightforward access to multiple regions of the atrial cyst wall, but also enables direct inspection of the entire lateral ventricular system, has not been elaborated. In this paper the authors describe their experience with the endoscopic transoccipital horn approach for treating cystic lesions in the atrium of the lateral ventricle. METHODS A retrospective review was performed of all patients who underwent endoscopic surgical treatment for cysts in the atrium of the lateral ventricle between 1999 and 2014. RESULTS The cohort consisted of 13 consecutive patients who presented with symptomatic lateral ventricular entrapment due to the presence of an atrial cyst. There were 9 male and 4 female patients, with a median age of 5 years. Headache was the most common complaint at presentation. The transoccipital horn approach facilitated successful cyst reduction and fenestration in all cases. Temporal and occipital horn entrapment was reversed in all cases, with reestablishment of a physiological CSF flow pattern throughout the ventricles. Hydrocephalus was also reversed in all patients presenting with this neuroimaging finding at presentation. No cyst or ventricular entrapment was noted to recur during a mean follow-up period of 36 months. No patient in the study cohort required repeat surgery or permanent CSF diversion postoperatively. CONCLUSIONS The endoscopic transoccipital horn approach represents a safe and effective treatment strategy for patients with symptomatic atrial cysts of the lateral ventricle. Using this minimally invasive technique, all poles of the lateral ventricular system can be visualized and the unobstructed flow of CSF can be confirmed after cyst resection obviating the need for additional diversion.
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Affiliation(s)
- Jason A Ellis
- 1Department of Neurological Surgery, Columbia University Medical Center; and
| | - Paul C McCormick
- 1Department of Neurological Surgery, Columbia University Medical Center; and
| | - Neil A Feldstein
- 1Department of Neurological Surgery, Columbia University Medical Center; and
| | - Saadi Ghatan
- 2Department of Neurosurgery, Mount Sinai Roosevelt Hospital, New York, New York
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McGovern RA, Ratneswaren T, Smith EH, Russo JF, Jongeling AC, Bateman LM, Schevon CA, Feldstein NA, McKhann GM, Sheth S. Investigating the function of deep cortical and subcortical structures using stereotactic electroencephalography: lessons from the anterior cingulate cortex. J Vis Exp 2015. [PMID: 25938224 DOI: 10.3791/52773] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
Stereotactic Electroencephalography (SEEG) is a technique used to localize seizure foci in patients with medically intractable epilepsy. This procedure involves the chronic placement of multiple depth electrodes into regions of the brain typically inaccessible via subdural grid electrode placement. SEEG thus provides a unique opportunity to investigate brain function. In this paper we demonstrate how SEEG can be used to investigate the role of the dorsal anterior cingulate cortex (dACC) in cognitive control. We include a description of the SEEG procedure, demonstrating the surgical placement of the electrodes. We describe the components and process required to record local field potential (LFP) data from consenting subjects while they are engaged in a behavioral task. In the example provided, subjects play a cognitive interference task, and we demonstrate how signals are recorded and analyzed from electrodes in the dorsal anterior cingulate cortex, an area intimately involved in decision-making. We conclude with further suggestions of ways in which this method can be used for investigating human cognitive processes.
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Affiliation(s)
- Robert A McGovern
- Department of Neurosurgery, Columbia University Medical Center, New York Presbyterian Hospital; Columbia University Medical Center, New York Presbyterian Hospital;
| | | | - Elliot H Smith
- Department of Neurosurgery, Columbia University Medical Center, New York Presbyterian Hospital; Columbia University Medical Center, New York Presbyterian Hospital
| | - Jennifer F Russo
- Columbia University Medical Center, New York Presbyterian Hospital
| | - Amy C Jongeling
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital; Columbia University Medical Center, New York Presbyterian Hospital
| | - Lisa M Bateman
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital; Columbia University Medical Center, New York Presbyterian Hospital
| | - Catherine A Schevon
- Department of Neurology, Columbia University Medical Center, New York Presbyterian Hospital; Columbia University Medical Center, New York Presbyterian Hospital
| | - Neil A Feldstein
- Department of Neurosurgery, Columbia University Medical Center, New York Presbyterian Hospital; Columbia University Medical Center, New York Presbyterian Hospital
| | - Guy M McKhann
- Department of Neurosurgery, Columbia University Medical Center, New York Presbyterian Hospital; Columbia University Medical Center, New York Presbyterian Hospital
| | - Sameer Sheth
- Department of Neurosurgery, Columbia University Medical Center, New York Presbyterian Hospital; Columbia University Medical Center, New York Presbyterian Hospital
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Kennedy BC, McDowell MM, Yang PH, Wilson CM, Li S, Hankinson TC, Feldstein NA, Anderson RCE. Pial synangiosis for moyamoya syndrome in children with sickle cell anemia: a comprehensive review of reported cases. Neurosurg Focus 2014; 36:E12. [PMID: 24380478 DOI: 10.3171/2013.10.focus13405] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Pediatric patients with sickle cell anemia (SCA) carry a significant risk of developing moyamoya syndrome (MMS) and brain ischemia. The authors sought to review the safety and efficacy of pial synangiosis in the treatment of MMS in children with SCA by performing a comprehensive review of all previously reported cases in the literature. METHODS The authors retrospectively reviewed the clinical and radiographic records in 17 pediatric patients with SCA treated at the Morgan Stanley Children's Hospital of New York (MSCHONY) who developed radiological evidence of MMS and underwent pial synangiosis between 1996 and 2012. The authors then added any additional reported cases of pial synangiosis for this population in the literature for a combined analysis of clinical and radiographic outcomes. RESULTS The combined data consisted of 48 pial synangiosis procedures performed in 30 patients. Of these, 27 patients (90%) presented with seizure, stroke, or transient ischemic attack, whereas 3 (10%) were referred after transcranial Doppler screening. At the time of surgery, the median age was 12 years. Thirteen patients (43%) suffered an ischemic stroke while on chronic transfusion therapy. Long-term follow-up imaging (MR angiography or catheter angiography) at a mean of 25 months postoperatively was available in 39 (81%) treated hemispheres. In 34 (87%) of those hemispheres there were demonstrable collateral vessels on imaging. There were 4 neurological events in 1590 cumulative months of follow-up, or 1 event per 33 patient-years. In the patients in whom complete data were available (MSCHONY series, n = 17), the postoperative stroke rate was reduced more than 6-fold from the preoperative rate (p = 0.0003). CONCLUSIONS Pial synangiosis in patients with SCA, MMS, and brain ischemia appears to be a safe and effective treatment option. Transcranial Doppler and/or MRI screening in asymptomatic patients with SCA is recommended for the diagnosis of MMS.
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Affiliation(s)
- Benjamin C Kennedy
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York; and
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AndersoN RCE, Kennedy B, Yanes CL, Garvin J, Needle M, Canoll P, Feldstein NA, Bruce JN. Convection-enhanced delivery of topotecan into diffuse intrinsic brainstem tumors in children. J Neurosurg Pediatr 2013; 11:289-95. [PMID: 23240851 PMCID: PMC7227321 DOI: 10.3171/2012.10.peds12142] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [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] [Indexed: 11/06/2022]
Abstract
Convection-enhanced delivery (CED) for the treatment of malignant gliomas is a technique that can deliver chemotherapeutic agents directly into the tumor and the surrounding interstitium through sustained, low-grade positive-pressure infusion. This allows for high local concentrations of drug within the tumor while minimizing systemic levels that often lead to dose-limiting toxicity. Diffuse intrinsic pontine gliomas (DIPGs) are universally fatal childhood tumors for which there is currently no effective treatment. In this report the authors describe CED of the topoisomerase inhibitor topotecan for the treatment of DIPG in 2 children. As part of a pilot feasibility study, the authors treated 2 pediatric patients with DIPG. Stereotactic biopsy with frozen section confirmation of glial tumor was followed by placement of bilateral catheters for CED of topotecan during the same procedure. The first patient underwent CED 210 days after initial diagnosis, after radiation therapy and at the time of tumor recurrence, with a total dose of 0.403 mg in 6.04 ml over 100 hours. Her Karnofsky Performance Status (KPS) score was 60 before CED and 50 posttreatment. Serial MRI initially demonstrated a modest reduction in tumor size and edema, but the tumor progressed and the patient died 49 days after treatment. The second patient was treated 24 days after the initial diagnosis prior to radiation with a total dose of 0.284 mg in 5.30 ml over 100 hours. Her KPS score was 70 before CED and 50 posttreatment. Serial MRI similarly demonstrated an initial modest reduction in tumor size. The patient subsequently underwent fractionated radiation therapy, but the tumor progressed and she died 120 days after treatment. Topotecan delivered by prolonged CED into the brainstem in children with DIPG is technically feasible. In both patients, high infusion rates (> 0.12 ml/hr) and high infusion volumes (> 2.8 ml) resulted in new neurological deficits and reduction in the KPS score, but lower infusion rates (< 0.04 ml/hr) were well tolerated. While serial MRI showed moderate treatment effect, CED did not prolong survival in these 2 patients. More studies are needed to improve patient selection and determine the optimal flow rates for CED of chemotherapeutic agents into DIPG to maximize safety and efficacy. Clinical trial registration no.: NCT00324844.
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Affiliation(s)
- Richard C. E. AndersoN
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Benjamin Kennedy
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Candix L. Yanes
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
| | - James Garvin
- Departments of Oncology, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Michael Needle
- Departments of Oncology, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Peter Canoll
- Departments of Pathology and Cell Biology, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Neil A. Feldstein
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
| | - Jeffrey N. Bruce
- Departments of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York
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Appelboom G, Zoller SD, Piazza MA, Szpalski C, Bruce SS, McDowell MM, Vaughan KA, Zacharia BE, Hickman Z, D'Ambrosio A, Feldstein NA, Anderson RCE. Traumatic brain injury in pediatric patients: evidence for the effectiveness of decompressive surgery. Neurosurg Focus 2012; 31:E5. [PMID: 22044104 DOI: 10.3171/2011.8.focus11177] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Traumatic brain injury (TBI) is the current leading cause of death in children over 1 year of age. Adequate management and care of pediatric patients is critical to ensure the best functional outcome in this population. In their controversial trial, Cooper et al. concluded that decompressive craniectomy following TBI did not improve clinical outcome of the analyzed adult population. While the study did not target pediatric populations, the results do raise important and timely clinical questions regarding the effectiveness of decompressive surgery in pediatric patients. There is still a paucity of evidence regarding the effectiveness of this therapy in a pediatric population, and there is an especially noticeable knowledge gap surrounding age-stratified interventions in pediatric trauma. The purposes of this review are to first explore the anatomical variations between pediatric and adult populations in the setting of TBI. Second, the authors assess how these differences between adult and pediatric populations could translate into differences in the impact of decompressive surgery following TBI.
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Affiliation(s)
- Geoffrey Appelboom
- Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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Haque R, Wojtasiewicz T, Gerrah R, Gilmore L, Saiki Y, Chen JM, Richmond M, Feldstein NA, Anderson RCE. Management of intracranial hemorrhage in a child with a left ventricular assist device. Pediatr Transplant 2012; 16:E135-9. [PMID: 22332723 DOI: 10.1111/j.1399-3046.2012.01650.x] [Citation(s) in RCA: 5] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Pediatric patients bridged to heart transplant with LVADs require chronic anticoagulation and are at increased risk of hemorrhagic complications, including intracranial hemorrhage. In this population, intracranial hemorrhage is often fatal. We report a case of successful management of a five-yr-old-boy with DCM on an LVAD who developed a subdural hematoma. We initially chose medical management, weighing the patient's high risk of thromboembolism from anticoagulation reversal against the risk of his chronic subdural hematoma. When head CT showed expansion of the hemorrhage with increasing midline shift, we chose prompt surgical evacuation of the hematoma with partial reversal of anticoagulation, given the increased risk of acute deterioration. The patient ultimately received an orthotopic heart transplant and was discharged with no permanent neurological complications. This represents a case of a pediatric patient on an LVAD who survived a potentially fatal subdural hematoma and was successfully bridged to cardiac transplantation.
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Affiliation(s)
- Raqeeb Haque
- Department of Neurological Surgery, College of Physicians and Surgeons, Neurological Institute of New York, Columbia University, New York, NY 10032, USA
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Ellis JA, Anderson RCE, O'Hanlon J, Goodman RR, Feldstein NA, Ghatan S. Internal cranial expansion surgery for the treatment of refractory idiopathic intracranial hypertension. J Neurosurg Pediatr 2012; 10:14-20. [PMID: 22702327 DOI: 10.3171/2012.3.peds11228] [Citation(s) in RCA: 14] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Idiopathic intracranial hypertension (IIH) may be refractory to available medical and surgical therapies. Patients with this condition may suffer from intractable headaches, experience visual deterioration, or have other symptoms related to elevated intracranial pressure. Internal cranial expansion (ICE) is a novel surgical procedure that the authors have developed for the treatment of patients with this condition. Here, they describe ICE and present their initial experience in using this surgical procedure for the treatment of patients with refractory IIH. METHODS The authors conducted a retrospective review of 10 consecutive patients who underwent ICE for the treatment of IIH during a 5-year period. Preoperative and postoperative clinical parameters including patient symptoms, presence of papilledema, and available ICP or CSF opening pressures were compared. Procedural details and complications were noted. Intracranial volume increases were calculated using available pre- and postoperative CT scans. RESULTS Follow-up for the 10 patients in this series ranged from 1 to 39.6 months (mean 15.5 months). Technically successful ICE was performed in all patients within the cohort. Surgical complications included a single postoperative seizure in one patient and a sagittal sinus tear with no clinical sequelae in another patient. At the time of last follow-up, 7 (70%) of 10 patients were either symptomatically improved or asymptomatic. Six (67%) of 9 patients with preoperative headaches had reduction or resolution of this symptom, and all patients (4 of 4) with preoperative papilledema had a reduction in or complete resolution of this sign. Postoperative ICP or CSF opening pressures were normal in all patients (4 of 4) tested. Postoperative intracranial volume expansion ranged between 3.8% and 12%. CONCLUSIONS Internal cranial expansion is a safe and effective surgery for the treatment of patients with refractory IIH. This surgery expands the intracranial volume and thus promotes ICP normalization, which may lead to the reduction or complete resolution of the signs and symptoms of IIH. Internal cranial expansion may be used as part of a multidisciplinary management approach in the treatment of refractory IIH.
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Affiliation(s)
- Jason A Ellis
- Department of Neurological Surgery, Columbia University Medical Center, New York, New York 10022, USA
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Ellis JA, Orr L, II PCM, Anderson RCE, Feldstein NA, Meyers PM. Cognitive and functional status after vein of Galen aneurysmal malformation endovascular occlusion. World J Radiol 2012; 4:83-9. [PMID: 22468188 PMCID: PMC3314932 DOI: 10.4329/wjr.v4.i3.83] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2011] [Revised: 01/02/2012] [Accepted: 01/09/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the clinical outcomes of treating vein of Galen aneurysmal malformations (VGAM), we assessed our patient cohort using standardized cognitive and functional measures.
METHODS: A retrospective review of patients with VGAM treated by a single practitioner between 2003 and 2009 was performed for this study. In addition to routine clinical assessment, all patients were evaluated for cognitive and functional impairment using validated measures including the Neurobehavioral Rating Scale-Revised, the Bicêtre outcome score, and the Barthel index.
RESULTS: Five patients underwent combined transarterial and transvenous embolization of their VGAM during the study period. VGAMs were classified based on angioarchitecture as either choroidal (1/5) or mural (4/5) according to the classification scheme of Lasjaunias. In total, 13 embolization procedures were performed consisting of 1 to 3 treatment stages per patient. Complete or near complete occlusion was achieved in 4 patients, while subtotal occlusion was achieved in 1 patient. During follow-up (median 62.6 mo), all patients were either unchanged or cognitively and neurologically intact.
CONCLUSION: VGAM can be safely and effectively treated by staged transarterial and transvenous embolization. Using this strategy, excellent long-term cognitive and functional outcomes can be achieved.
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Anderson RCE, McDowell MM, Kellner CP, Appelboom G, Bruce SS, Kotchetkov IS, Haque R, Feldstein NA, Connolly ES, Solomon RA, Meyers PM, Lavine SD. Arteriovenous malformation-associated aneurysms in the pediatric population. J Neurosurg Pediatr 2012; 9:11-6. [PMID: 22208314 DOI: 10.3171/2011.10.peds11181] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Conventional cerebral angiography and treatment for ruptured arteriovenous malformations (AVMs) in children are often performed in a delayed fashion. In adults, current literature suggests that AVM-associated aneurysms may be more likely to hemorrhage than isolated AVMs, which often leads to earlier angiography and endovascular treatment of associated aneurysms. The nature of AVM-associated aneurysms in the pediatric population is virtually unknown. In this report, the authors investigate the relationship of associated aneurysms in a large group of children with AVMs. METHODS Seventy-seven pediatric patients (≤ 21 years old) with AVMs were treated at the Columbia University Medical Center between 1991 and 2010. Medical records and imaging studies were retrospectively reviewed, and associated aneurysms were classified as arterial, intranidal, or venous in location. Clinical presentation and outcome variables were compared between children with and without AVM-associated aneurysms. RESULTS A total of 30 AVM-associated aneurysms were found in 22 children (29% incidence). Eleven were arterial, 9 intranidal, and 10 were venous in location. There was no significant difference in the rate of hemorrhage (p = 0.91) between children with isolated AVMs (35 of 55 [64%]) and children with AVM-associated aneurysms (13 of 22 [59%]). However, of the 11 children with AVM-associated aneurysms in an arterial location, 10 presented with hemorrhage (91%). An association with hemorrhage was significant in univariate analysis (p = 0.045) but not in multivariate analysis (p = 0.37). CONCLUSIONS Associated aneurysms are present in nearly a third of children with AVMs, and when arterially located, are more likely to present with hemorrhage. These data suggest that early angiography with endovascular treatment of arterial-based aneurysms in children with AVMs may be indicated.
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Affiliation(s)
- Richard C E Anderson
- Columbia University, Department of Neurological Surgery, New York, New York, USA.
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Abstract
Os odontoideum is a common cause of atlantoaxial instability in the pediatric population. The authors present the cases of 2 patients whose initial clinical presentation and MR imaging findings were suggestive of an intramedullary neoplasm, but whose ultimate diagnosis was determined to be cervical spine instability and cord injury due to os odontoideum.
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Affiliation(s)
- Paul R Gigante
- Department of Pediatric Neurological Surgery, Columbia University College of Physicians & Surgeons, New York, New York 10032, USA.
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Ayer A, Campbell A, Appelboom G, Hwang BY, McDowell M, Piazza M, Feldstein NA, Anderson RCE. The sociopolitical history and physiological underpinnings of skull deformation. Neurosurg Focus 2010; 29:E1. [DOI: 10.3171/2010.9.focus10202] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this report, the evidence, mechanisms, and rationale for the practice of artificial cranial deformation (ACD) in ancient Peru and during Akhenaten's reign in the 18th dynasty in Egypt (1375–1358 BCE) are reviewed. The authors argue that insufficient attention has been given to the sociopolitical implications of the practice in both regions. While evidence from ancient Peru is widespread and complex, there are comparatively fewer examples of deformed crania from the period of Akhenaten's rule. Nevertheless, Akhenaten's own deformity, the skull of the so-called “Younger Lady” mummy, and Tutankhamen's skull all evince some degree of plagiocephaly, suggesting the need for further research using evidence from depictions of the royal family in reliefs and busts. Following the anthropological review, a neurosurgical focus is directed to instances of plagiocephaly in modern medicine, with special attention to the conditions' etiology, consequences, and treatment. Novel clinical studies on varying modes of treatment will also be studied, together forming a comprehensive review of ACD, both in the past and present.
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Affiliation(s)
- Amit Ayer
- 1Department of Neurological Surgery, Columbia University College of Physicians & Surgeons, New York, New York; and
| | | | - Geoffrey Appelboom
- 1Department of Neurological Surgery, Columbia University College of Physicians & Surgeons, New York, New York; and
| | - Brian Y. Hwang
- 1Department of Neurological Surgery, Columbia University College of Physicians & Surgeons, New York, New York; and
| | - Michael McDowell
- 1Department of Neurological Surgery, Columbia University College of Physicians & Surgeons, New York, New York; and
| | - Matthew Piazza
- 1Department of Neurological Surgery, Columbia University College of Physicians & Surgeons, New York, New York; and
| | - Neil A. Feldstein
- 1Department of Neurological Surgery, Columbia University College of Physicians & Surgeons, New York, New York; and
| | - Richard C. E. Anderson
- 1Department of Neurological Surgery, Columbia University College of Physicians & Surgeons, New York, New York; and
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Hankinson TC, Fontana EJ, Anderson RCE, Feldstein NA. Surgical treatment of single-suture craniosynostosis: an argument for quantitative methods to evaluate cosmetic outcomes. J Neurosurg Pediatr 2010; 6:193-7. [PMID: 20672943 DOI: 10.3171/2010.5.peds09313] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The traditional reasons for surgical intervention in children with single-suture craniosynostosis (SSC) are cosmetic improvement and the avoidance/treatment of intracranial hypertension, which has been thought to contribute to neurocognitive deficits. Despite considerable work on the topic, the exact prevalence of intracranial hypertension in the population of patients with SSC is unknown, although it appears to be present in only a minority. Additionally, recent neuropsychological and anatomical literature suggests that the subtle neurocognitive deficits identified in children with a history of SSC may not result from external compression. They may instead reflect an underlying developmental condition that includes disordered primary CNS development and early suture fusion. This implies that current surgical techniques are unlikely to prevent neurocognitive deficits in patients with SSC. As such, the most common indication for surgical treatment in SSC is cosmetic, and most patients benefit from considerable subjective cosmetic normalization following surgery. Pediatric craniofacial surgeons have not, however, agreed upon objective means to assess postoperative cranial morphological improvement. We should therefore endeavor to agree upon objective craniometric tools for the assessment of operative outcomes, allowing us to accurately compare the various surgical techniques that are currently available.
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Affiliation(s)
- Todd C Hankinson
- Division of Pediatric Neurosurgery, Children's Hospital of Alabama, University of Alabama, Birmingham, Alabama, USA.
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Hankinson TC, Mocco J, Kimball B, Anderson RCE, Feldstein NA. Internal cranial expansion procedure for the treatment of symptomatic intracranial hypertension. J Neurosurg 2009; 107:402-5. [PMID: 18459904 DOI: 10.3171/ped-07/11/402] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The authors describe the internal cranial expansion (ICE) procedure, a surgical technique that was used to treat two chronically shunt-treated children who presented with medically and surgically refractory intracranial hypertension despite the presence of functioning cerebrospinal fluid shunt systems. The ICE procedure was used as a means to increase intracranial volume without sacrificing calvarial rigidity. Intracranial volume was increased by 5% in one case and 10% in the other. Both patients have returned to their neurological and functional baselines, and they are free of symptoms related to intracranial hypertension.
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Affiliation(s)
- Todd C Hankinson
- Department of Neurosurgery, Columbia University, College of Physicians and Surgeons, New York, New York 10032, USA.
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Syed ON, Hankinson TC, Mack WJ, Feldstein NA, Anderson RCE. Radiolucent hair accessories causing depressed skull fracture following blunt cranial trauma. J Neurosurg Pediatr 2008; 2:424-6. [PMID: 19035690 DOI: 10.3171/ped.2008.2.12.424] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pediatric neurosurgeons frequently care for children with traumatic scalp and skull injury. Foreign objects are often observed on imaging and may influence the clinician's decision-making process. The authors report on 2 cases of poorly visualized hair beads that had become embedded into the skull during blunt trauma. In both cases, skull radiography and CT scanning demonstrated depressed, comminuted fractures with poorly demonstrated spherical radiolucencies in the overlying scalp. The nature of these objects was initially unclear, and they could have represented air that entered the scalp during trauma. In one case, scalp inspection demonstrated no evidence of the bead. In the other case, a second bead was observed at the site of scalp laceration. In both cases, the beads were surgically removed, the fractures were elevated, and the patients recovered uneventfully. Radiolucent fashion accessories, such as hair beads, may be difficult to appreciate on clinical examination and may masquerade as clinically insignificant air following cranial trauma. If they are not removed, these foreign bodies may pose the risk of an infection. Pediatric neurosurgeons should consider hair accessories in the differential diagnosis of foreign bodies that may produce skull fracture following blunt trauma.
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Affiliation(s)
- Omar N Syed
- Department of Neurological Surgery, New York Presbyterian Hospital, Columbia University College of Physicians and Surgeons, New York, New York 10032, USA.
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Abstract
Although there has been considerable experience with anterior approaches to ventral intradural, extramedullary, and pial-based spinal lesions, there is no information in the literature regarding the safety and feasibility of the resection of an intramedullary tumor via an anterior approach. The authors report on the gross-total resection of an intramedullary cervical pilocytic astrocytoma via a C-7 corpectomy and anterior myelotomy. The surgery proceeded without complication, and postoperatively the patient maintained the preoperative deficit of mild unilateral hand weakness but had no sensory deficits. Follow-up MR imaging at 6 months showed gross-total macroscopic resection. Selected intramedullary tumors can be safely removed via an anterior approach. This approach avoids the typical sensory dysfunction associated with posterior midline myelotomy.
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