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Sauson Soldozy, Pedro Norat, Kaan Yağmurlu, Jennifer D. Sokolowski, Khadijeh A. Sharifi, Petr Tvrdik, Min S. Park, and M. Yashar S. Kalani

Arteriovenous malformation (AVM) presenting with epilepsy significantly impacts patient quality of life, and it should be considered very much a seizure disorder. Although hemorrhage prevention is the primary treatment aim of AVM surgery, seizure control should also be at the forefront of therapeutic management. Several hemodynamic and morphological characteristics of AVM have been identified to be associated with seizure presentation. This includes increased AVM flow, presence of long pial draining vein, venous outflow obstruction, and frontotemporal location, among other aspects. With the advent of high-throughput image processing and quantification methods, new radiographic attributes of AVM-related epilepsy have been identified. With respect to therapy, several treatment approaches are available, including conservative management or interventional modalities; this includes microsurgery, radiosurgery, and embolization or a combination thereof. Many studies, especially in the domain of microsurgery and radiosurgery, evaluate both techniques with respect to seizure outcomes. The advantage of microsurgery lies in superior AVM obliteration rates and swift seizure response. In addition, by incorporating electrophysiological monitoring during AVM resection, adjacent or even remote epileptogenic foci can be identified, leading to extended lesionectomy and improved seizure control. Radiosurgery, despite resulting in reduced AVM obliteration and prolonged time to seizure freedom, avoids the risks of surgery altogether and may provide seizure control through various antiepileptic mechanisms. Embolization continues to be used as an adjuvant for both microsurgery and radiosurgery. In this study, the authors review the latest imaging techniques in characterizing AVM-related epilepsy, in addition to reviewing each treatment modality.

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Sauson Soldozy, Michelle Yeghyayan, Kaan Yağmurlu, Pedro Norat, Davis G. Taylor, M. Yashar S. Kalani, John A. Jane Jr., and Hasan R. Syed

OBJECTIVE

The goal of this study was to systematically review the outcomes of endoscopic endonasal surgery (EES) for pediatric craniopharyngiomas so as to assess its safety and efficacy.

METHODS

A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2019. All studies assessing outcomes following EES for pediatric craniopharyngiomas were included.

RESULTS

Of the total 48 articles identified in the original literature search, 13 studies were ultimately selected. This includes comparative studies with other surgical approaches, retrospective cohort studies, and case series.

CONCLUSIONS

EES for pediatric craniopharyngiomas is a safe and efficacious alternative to other surgical approaches. Achieving gross-total resection with minimal complications is feasible with EES and is comparable, if not superior in some cases, to traditional means of resection. Ideally, a randomized controlled trial might be implemented in the future to further elucidate the effectiveness of EES for resection of craniopharyngiomas.

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Sauson Soldozy, Jacob Galindo, Harrison Snyder, Yusuf Ali, Pedro Norat, Kaan Yağmurlu, Jennifer D. Sokolowski, Khadijeh Sharifi, Petr Tvrdik, Min S. Park, and M. Yashar S. Kalani

Neuroimaging is an indispensable tool in the workup and management of patients with neurological disorders. Arterial spin labeling (ASL) is an imaging modality that permits the examination of blood flow and perfusion without the need for contrast injection. Noninvasive in nature, ASL provides a feasible alternative to existing vascular imaging techniques, including angiography and perfusion imaging. While promising, ASL has yet to be fully incorporated into the diagnosis and management of neurological disorders. This article presents a review of the most recent literature on ASL, with a special focus on its use in moyamoya disease, brain neoplasms, seizures, and migraines and a commentary on recent advances in ASL that make the imaging technique more attractive as a clinically useful tool.

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Kathryn N. Kearns, Jennifer D. Sokolowski, Kimberly Chadwell, Maureen Chandler, Therese Kiernan, Francesco Prada, M. Yashar S. Kalani, and Min S. Park

Contrast-enhanced ultrasound (CEUS) is a relatively new imaging modality in the realm of neurosurgical disease. CEUS permits the examination of blood flow through arteries, veins, and capillaries via intravascular contrast agents and allows vascular architectural mapping with extreme sensitivity and specificity. While it has established utility in other organ systems such as the liver and kidneys, CEUS has not been studied extensively in the brain. This report presents a review of the literature on the neurosurgical applications of CEUS and provides an outline of the imaging modality’s role in the diagnosis, evaluation, and treatment of neurosurgical disease.

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Sauson Soldozy, Pedro Norat, Mazin Elsarrag, Ajay Chatrath, John S. Costello, Jennifer D. Sokolowski, Petr Tvrdik, M. Yashar S. Kalani, and Min S. Park

The pathogenesis of intracranial aneurysms remains complex and multifactorial. While vascular, genetic, and epidemiological factors play a role, nascent aneurysm formation is believed to be induced by hemodynamic forces. Hemodynamic stresses and vascular insults lead to additional aneurysm and vessel remodeling. Advanced imaging techniques allow us to better define the roles of aneurysm and vessel morphology and hemodynamic parameters, such as wall shear stress, oscillatory shear index, and patterns of flow on aneurysm formation, growth, and rupture. While a complete understanding of the interplay between these hemodynamic variables remains elusive, the authors review the efforts that have been made over the past several decades in an attempt to elucidate the physical and biological interactions that govern aneurysm pathophysiology. Furthermore, the current clinical utility of hemodynamics in predicting aneurysm rupture is discussed.

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Mazin Elsarrag, Sauson Soldozy, Parantap Patel, Pedro Norat, Jennifer D. Sokolowski, Min S. Park, Petr Tvrdik, and M. Yashar S. Kalani

OBJECTIVE

Enhanced recovery after surgery (ERAS) is a multidimensional approach to improving the care of surgical patients using subspecialty- and procedure-specific evidence-based protocols. The literature provides evidence of the benefits of ERAS implementation, which include expedited functional recovery, decreased postoperative morbidity, reduced costs, and improved subjective patient experience. Although extensively examined in other surgical areas, ERAS principles have been applied to spine surgery only in recent years. The authors examine studies investigating the application of ERAS programs to patients undergoing spine surgery.

METHODS

The authors conducted a systematic review of the PubMed and MEDLINE databases up to November 20, 2018.

RESULTS

Twenty full-text articles were included in the qualitative analysis. The majority of studies were retrospective reviews of nonrandomized data sets or qualitative investigations lacking formal control groups; there was 1 protocol for a future randomized controlled trial. Most studies demonstrated reduced lengths of stay and no increase in rates of readmissions or complications after introduction of an ERAS pathway.

CONCLUSIONS

These introductory studies demonstrate the potential of ERAS protocols, when applied to spine procedures, to reduce lengths of stay, accelerate return of function, minimize postoperative pain, and save costs.

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Daniel M. S. Raper, Nasser Mohammed, M. Yashar S. Kalani, and Min S. Park

The preferred method for treating complex dural arteriovenous fistulae of the transverse and sigmoid sinuses is via endovascular, transarterial embolization using liquid embolysate. However, this treatment approach mandates access to distal dural feeding arteries that can be technically challenging by standard endovascular approaches. This video describes a left temporal craniotomy for direct stick microcatheterization of an endovascularly inaccessible distal posterior division of the middle meningeal artery for embolization of a complex left temporal dural arteriovenous fistula. The case was performed in the hybrid operative suite with biplane intraoperative angiography. Technical considerations, operative nuances, and outcomes are reviewed.

The video can be found here: https://youtu.be/Dnd4yHgaKcQ.

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Sauson Soldozy, John S. Costello, Pedro Norat, Jennifer D. Sokolowski, Kamron Soldozy, Min S. Park, Petr Tvrdik, and M. Yashar S. Kalani

While the majority of cerebral revascularization advancements were made in the last century, it is worth noting the humble beginnings of vascular surgery throughout history to appreciate its progression and application to neurovascular pathology in the modern era. Nearly 5000 years of basic human inquiry into the vasculature and its role in neurological disease has resulted in the complex neurosurgical procedures used today to save and improve lives. This paper explores the story of the extracranial-intracranial approach to cerebral revascularization.

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Francesco Prada, Massimiliano Del Bene, Giovanni Mauri, Massimo Lamperti, Davide Vailati, Carla Richetta, Marco Saini, Davide Santuari, M. Yashar S. Kalani, and Francesco DiMeco

The relevance of the cerebral venous system is often underestimated during neurosurgical procedures. Damage to this draining system can have catastrophic implications for the patient. Surgical decision-making and planning must consider each component of the venous compartment, from the medullary draining vein to the dural sinuses and extracranial veins. Intraoperative ultrasound (ioUS) permits the real-time study of venous compartments using different modalities, thus allowing complete characterization of their anatomical and functional features. The B-mode (brightness mode) offers a high-resolution anatomical representation of veins and their relationships with lesions. Doppler modalities (color, power, spectral) allow the study of blood flow and identification of vessels to distinguish their functional characteristics. Contrast-enhanced US allows one to perform real-time angiosonography showing both the functional and the anatomical aspects of vessels.

In this technical report, the authors demonstrate the different applications of multimodal ioUS in neurosurgery for identifying the anatomical and functional characteristics of the venous compartment. They discuss the general principles and technical nuances of ioUS and analyze their potential implications for the study of various venous districts during neurosurgical procedures.

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Nam Yoon, Aatman Shah, William T. Couldwell, M. Yashar S. Kalani, and Min S. Park

Skull base meningiomas are technically challenging tumors to treat because of their deep vascular supply that can preclude early devascularization during resection. Preoperative embolization of these arterial feeders is thought to decrease blood loss and facilitate resection; however, given the complex and varied anatomy of these skull base lesions, preoperative embolization is not without risk. It is essential for both endovascular and skull base neurosurgeons to understand these risks in light of the potential benefits. The authors review the vascular anatomy of skull base meningiomas, indications for preoperative devascularization, endovascular techniques, and published results regarding embolization of these lesions.