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Outcomes after hemispherectomy in adult patients with intractable epilepsy: institutional experience and systematic review of the literature

Courtney M. Schusse, Kris Smith and Cornelia Drees

OBJECTIVE

Hemispherectomy is a surgical technique that is established as a standard treatment in appropriately selected patients with drug-resistant epilepsy. It has proven to be successful in pediatric patients with unilateral hemispheric lesions but is underutilized in adults. This study retrospectively evaluated the clinical outcomes after hemispherectomy in adult patients with refractory epilepsy.

METHODS

This study examined 6 cases of hemispherectomy in adult patients at Barrow Neurological Institute. In addition, all case series of hemispherectomy in adult patients were identified through a literature review using MEDLINE and PubMed. Case series of patients older than 18 years were included; reports of patients without clear follow-up duration or method of validated seizure outcome quantification were excluded. Seizure outcome was based on the Engel classification.

RESULTS

A total of 90 cases of adult hemispherectomy were identified, including 6 newly added by Barrow Neurological Institute. Sixty-five patients underwent functional hemispherectomy; 25 patients had anatomical hemispherectomy. Length of follow-up ranged from 9 to 456 months. Seizure freedom was achieved in 80% of patients. The overall morbidity rate was low, with 9 patients (10%) having new or additional postoperative speech or language dysfunction, and 19 patients (21%) reporting some worsening of hemiparesis. No patients lost ambulatory or significant functional ability, and 2 patients had objective ambulatory improvement. Among the 41 patients who underwent additional formal neuropsychological testing postoperatively, overall stability or improvement was seen.

CONCLUSIONS

Hemispherectomy is a valuable surgical tool for properly selected adult patients with pre-existing hemiparesis and intractable epilepsy. In published cases, as well as in this series, the procedure has overall been well tolerated without significant morbidity, and the majority of patients have been rendered free of seizures.

In Journal of Neurosurgery Volume 128: Issue 3 (Mar 2018): Pages 657-959

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Adjacent-segment disease following two-level axial lumbar interbody fusion

Alex P. Michael, Matthew W. Weber, Kristin R. Delfino and Venkatanarayanan Ganapathy

OBJECTIVE

While long-term studies have evaluated adjacent-segment disease (ASD) following posterior lumbar spine arthrodesis, no such studies have assessed the incidence and prevalence of ASD following axial lumbar interbody fusion (AxiaLIF). The aim of this study was to estimate the incidence of ASD following AxiaLIF.

METHODS

The authors retrospectively reviewed the medical records of 149 patients who underwent two-level index AxiaLIF and had at least 2 years of radiographic and clinical follow-up. ASD and pre- and postoperative lumbar lordosis were evaluated in each patient. ASD was defined as both radiographic and clinically significant disease at a level adjacent to a previous fusion requiring surgical intervention. The mean duration of follow-up was 6.01 years.

RESULTS

Twenty (13.4%) of the 149 patients developed ASD during the data collection period. Kaplan-Meier analysis predicted a disease-free ASD survival rate of 95.3% (95% CI 90.4%–97.7%) at 2 years and 89.1% (95% CI 82.8%–93.2%) at 5 years for two-level fusion. A laminectomy adjacent to a fusion site was associated with 5.1 times the relative risk of developing ASD. Furthermore, the ASD group had significantly greater loss of lordosis than the no-ASD group (p = 0.033).

CONCLUSIONS

Following two-level AxiaLIF, the rate of symptomatic ASD warranting either decompression or arthrodesis was found to be 4.7% at 2 years and 10.9% at 5 years. Adjacent-segment decompression and postoperative loss of lumbar lordosis predicted future development of ASD. To the authors’ knowledge, this is the largest reported cohort of patients to undergo two-level AxiaLIF in the United States.

In Journal of Neurosurgery: Spine Publish Before Print

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Arachnoid web of the spine: a systematic literature review

Peyton L. Nisson, Ibrahim Hussain, Roger Härtl, Samuel Kim and Ali A. Baaj

OBJECTIVE

An arachnoid web of the spine (AWS) is a rare and oftentimes challenging lesion to diagnose, given its subtle radiographic findings. However, when left untreated, this lesion can have devastating effects on a patient’s neurological function. To date, only limited case reports and series have been published on this topic. In this study, the authors sought to better describe this lesion, performing a systematic literature review and including 2 cases from their institution’s experience.

METHODS

A systematic literature search was performed in September 2018 that queried Ovid MEDLINE (1946–2018), PubMed (1946–2018), Wiley Cochrane Library: Central Register of Controlled Trials (1898–2018), and Thompson Reuters Web of Science: Citation Index (1900–2018), per PRISMA guidelines. Inclusion criteria specified all studies and case reports of patients with an AWS in which any relevant surgery types were considered and applied. Studies on arachnoid cysts and nonhuman populations, and those that did not report patient treatments or outcomes were excluded from the focus review.

RESULTS

A total of 19 records and 2 patients treated by the senior authors were included in the systematic review, providing a total of 43 patients with AWS. The mean age was 52 years (range 28–77 years), and the majority of patients were male (72%, 31/43). A syrinx was present in 67% (29/43) of the cases. All AWSs were located in the thoracic spine, and all but 2 (95%) were located dorsally (1 ventrally and 1 circumferentially). Weakness was the most frequently reported symptom (67%, 29/43), followed by numbness and/or sensory loss (65%, 28/43). Symptoms predominated in the lower extremities (81%, 35/43). It was found that nearly half (47%, 20/43) of patients had been experiencing symptoms for 1 year or longer before surgical intervention was performed, and 35% (15/43) of reports stated that symptoms were progressive in nature. The most commonly used surgical technique was a laminectomy with intradural excision of the arachnoid web (86%, 36/42). Following surgery, 91% (39/43) of patients had reported improvement in their neurological symptoms. The mean follow-up was 9.2 months (range 0–51 months).

CONCLUSIONS

AWS of the spine can be a debilitating disease of the spine with no more than an indentation of the spinal cord found on advanced imaging studies. The authors found this lesion to be reported in twice as many males than females, to be associated with a syrinx more than two-thirds of the time, and to only have been reported in the thoracic spine; over 90% of patients experienced improvement in their neurological function following surgery.

In Journal of Neurosurgery: Spine Publish Before Print

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Comprehensive anatomy of the foramen ovale critical to percutaneous stereotactic radiofrequency rhizotomy: cadaveric study of dry skulls

Adel Elnashar, Smruti K. Patel, Almaz Kurbanov, Kseniya Zvereva, Jeffrey T. Keller and Andrew W. Grande

OBJECTIVE

Percutaneous stereotactic radiofrequency rhizotomy (PSR) is often used to treat trigeminal neuralgia, a serious condition that results in lancinating, episodic facial pain. Thorough understanding of the microsurgical anatomy of the foramen ovale (FO) and its surrounding structures is required for efficient, effective, and safe use of this technique. This morphometric study compares anatomical and surgical orientations to identify the variations of the FO and assess cannulation difficulty.

METHODS

Bilateral foramina from 174 adult human dry skulls (348 foramina) were analyzed using anatomical and surgical orientations in photographs from standardized projections. Measurements were obtained for shape, size, adjacent structures, and morphometric variability effect on cannulation. The risk of potential injury to surrounding structures was also assessed.

RESULTS

The authors identified 6 distinctive shapes of the FO and 5 anomalous variants from the anatomical view, and 6 shapes from the surgical view. In measurements of surface area of this foramen obtained using the surgical view, loss (average 18.5% ± 5.7%) was significant compared with the anatomical view. Morphometrically, foramen size varied significantly and obstruction from a calcified pterygoalar ligament occurred in 7.8% of specimens. Importantly, 8% of foramina were difficult to cannulate, thus posing a 12% risk of inadvertent cannulation of the foramen lacerum.

CONCLUSIONS

Significant variability in the FO’s shape and size probably affected its safe and effective cannulation. Preoperative imaging by 3D head CT may be helpful in predicting ease of cannulation and in guiding treatment decisions, such as a percutaneous approach over microvascular decompression or radiosurgery.

In Journal of Neurosurgery Publish Before Print

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Editorial. Patient outcomes following treatment for craniopharyngioma

Nalin Gupta

In Journal of Neurosurgery Publish Before Print

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Effect of glycolysis inhibition by miR-448 on glioma radiosensitivity

Fengming Lan, Qing Qin, Huiming Yu and Xiao Yue

OBJECTIVE

Although glucose metabolism reengineering is a typical feature of various tumors, including glioma, key regulators of glycolytic reprogramming are still poorly understood. The authors sought to investigate whether glycolysis inhibition by microRNA (miR)–448 increases radiosensitivity in glioma cells.

METHODS

The authors used glioma tissue samples from glioma patients, cells from glioblastoma (GBM) cell lines and normal human astrocyte cells, and subcutaneous tumor–bearing U87 cells in mice to examine the effects of signaling regulation by miR-448 in the response of glioma tissues and cells to radiation treatment. Techniques used for investigation included bioinformatics analyses, biochemical assays, luciferase reporter assays, and establishment of subcutaneous tumors in a mouse model. Glucose consumption, LDH activity, and cellular ATP were measured to determine the ability of glioma cells to perform glycolysis. Expression of HIF-1α was measured as a potential target gene of miR-448 in glycolysis.

RESULTS

miR-448 was detected and determined to be significantly downregulated in both glioma tissues from glioma patients and GBM cell lines. Furthermore, miR-448 acted as a tumor-inhibiting factor and suppressed glycolysis in glioma by negatively regulating the activity of HIF-1α signaling and then interfering with its downstream regulators relative to glycolysis, HK1, HK2, and LDHA. Interestingly, overexpression of miR-448 increased the x-radiation sensitivity of glioma cells. Finally, in in vivo experiments, subcutaneous tumor–bearing U87 cells in a mouse model verified that high expression of miR-448 also enhanced glioma radiosensitivity via inhibiting glycolytic factors.

CONCLUSIONS

miR-448 can promote radiosensitivity by inhibiting HIF-1α signaling and then negatively controlling the glycolysis process in glioma. A newly identified miR-448–HIF-1α axis acts as a potentially valuable therapeutic target that may be useful in overcoming radioresistance in glioma treatment.

In Journal of Neurosurgery Publish Before Print

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Full tractography for detecting the position of cranial nerves in preoperative planning for skull base surgery: technical note

Timothee Jacquesson, Fang-Chang Yeh, Sandip Panesar, Jessica Barrios, Arnaud Attyé, Carole Frindel, Francois Cotton, Paul Gardner, Emmanuel Jouanneau and Juan C. Fernandez-Miranda

OBJECTIVE

Diffusion imaging tractography has allowed the in vivo description of brain white matter. One of its applications is preoperative planning for brain tumor resection. Due to a limited spatial and angular resolution, it is difficult for fiber tracking to delineate fiber crossing areas and small-scale structures, in particular brainstem tracts and cranial nerves. New methods are being developed but these involve extensive multistep tractography pipelines including the patient-specific design of multiple regions of interest (ROIs). The authors propose a new practical full tractography method that could be implemented in routine presurgical planning for skull base surgery.

METHODS

A Philips MRI machine provided diffusion-weighted and anatomical sequences for 2 healthy volunteers and 2 skull base tumor patients. Tractography of the full brainstem, the cerebellum, and cranial nerves was performed using the software DSI Studio, generalized-q-sampling reconstruction, orientation distribution function (ODF) of fibers, and a quantitative anisotropy–based generalized deterministic algorithm. No ROI or extensive manual filtering of spurious fibers was used. Tractography rendering was displayed in a tridimensional space with directional color code. This approach was also tested on diffusion data from the Human Connectome Project (HCP) database.

RESULTS

The brainstem, the cerebellum, and the cisternal segments of most cranial nerves were depicted in all participants. In cases of skull base tumors, the tridimensional rendering permitted the visualization of the whole anatomical environment and cranial nerve displacement, thus helping the surgical strategy.

CONCLUSIONS

As opposed to classical ROI-based methods, this novel full tractography approach could enable routine enhanced surgical planning or brain imaging for skull base tumors.

In Journal of Neurosurgery Publish Before Print

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Intraoperative monitoring of olfactory function: a feasibility study

Shahan Momjian, Rémi Tyrand, Basile N. Landis and Colette Boëx

OBJECTIVE

Intraoperative neuromonitoring of the chemical senses (smell and taste) has never been performed. The objective of this study was to determine if olfactory-evoked potentials could be obtained intraoperatively under general anesthesia.

METHODS

A standard olfactometer was used in the surgical theater with hydrogen sulfide (4 ppm, 200 msec). Olfactory-evoked potentials were recorded in 8 patients who underwent neurosurgery for resection of cerebral lesions. These patients underwent routine target-controlled propofol and sufentanil general anesthesia. Frontal, temporal, and parietal scalp subdermal electrodes were recorded ipsilaterally and contralaterally at the site of the surgery. Evoked potentials were computed if at least 70 epochs (0.5–100 Hz) satisfying the artifact rejection criterion (threshold 45 μV) could be extracted from signals of electrodes.

RESULTS

Contributive recordings were obtained for 5 of 8 patients (3 patients had fewer than 70 epochs with an amplitude < 45 μV). Olfactory-evoked potentials showed N1 responses (mean 442.8 ± 40.0 msec), most readily observed in the patient who underwent midline anterior fossa neurosurgery. No component of later latencies could be recorded consistently.

CONCLUSIONS

The study confirms that olfactory-evoked potentials can be measured in response to olfactory stimuli under general anesthesia. This demonstrates the feasibility of recording olfactory function intraoperatively and opens the potential for neuromonitoring of olfactory function during neurosurgery.

In Journal of Neurosurgery Publish Before Print

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Lumbar laminotomy for the intrathecal administration of nusinersen for spinal muscular atrophy: technical note and outcomes

Diana Ko, Daniel Blatt, Chafic Karam, Kunal Gupta and Ahmed M. Raslan

Nusinersen (Spinraza) is a US Food and Drug Administration–approved intrathecal medication for the treatment of spinal muscular atrophy (SMA). Adult patients with SMA often undergo thoracolumbar fusion to treat neurogenic scoliosis, preventing thecal access. The authors report a laminotomy technique and the ease of intrathecal access in three SMA patients with prior thoracolumbar fusions.

Patients were positioned in the lateral decubitus position or prone. Lumbar laminotomy was performed below the conus, between the lateral longitudinal rods, to preserve mechanical stability. Fluoroscopy provided real-time identification of instruments. Hardware was contoured with a carbide drill bit to develop the surgical window. Fiducial screws were placed along the perimeter for demarcation. Sublaminar wire removal caused dural defects that were repaired with a layer of dural substitute onlay and sealant. All patients successfully received nusinersen thecal injections via lumbar puncture by an interventional radiologist. Fluoroscopy time ranged from 6 to 36 seconds. No postoperative pseudomeningoceles, cerebrospinal fluid leaks, or wound complications occurred.

For patients with SMA and posterior fusion from prior scoliosis treatment, lumbar laminotomy is an effective method for creating thecal access for the administration of nusinersen.

In Journal of Neurosurgery: Spine Publish Before Print

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Natural history of neuromodulation devices and therapies: a patient-centered survival analysis

Zoe E. Teton, Daniel Blatt, Amr AlBakry, James Obayashi, Gulsah Ozturk, Vural Hamzaoglu, Philippe Magown, Nathan R. Selden, Kim J. Burchiel and Ahmed M. Raslan

OBJECTIVE

Despite rapid development and expansion of neuromodulation technologies, knowledge about device and/or therapy durability remains limited. The aim of this study was to evaluate the long-term rate of hardware and therapeutic failure of implanted devices for several neuromodulation therapies.

METHODS

The authors performed a retrospective analysis of patients’ device and therapy survival data (Kaplan-Meier survival analysis) for deep brain stimulation (DBS), vagus nerve stimulation (VNS), and spinal cord stimulation (SCS) at a single institution (years 1994–2015).

RESULTS

During the study period, 450 patients underwent DBS, 383 VNS, and 128 SCS. For DBS, the 5- and 10-year initial device survival was 87% and 73%, respectively, and therapy survival was 96% and 91%, respectively. For VNS, the 5- and 10-year initial device survival was 90% and 70%, respectively, and therapy survival was 99% and 97%, respectively. For SCS, the 5- and 10-year initial device survival was 50% and 34%, respectively, and therapy survival was 74% and 56%, respectively. The average initial device survival for DBS, VNS, and SCS was 14 years, 14 years, and 8 years while mean therapy survival was 18 years, 18 years, and 12.5 years, respectively.

CONCLUSIONS

The authors report, for the first time, comparative device and therapy survival rates out to 15 years for large cohorts of DBS, VNS, and SCS patients. Their results demonstrate higher device and therapy survival rates for DBS and VNS than for SCS. Hardware failures were more common among SCS patients, which may have played a role in the discontinuation of therapy. Higher therapy survival than device survival across all modalities indicates continued therapeutic benefit beyond initial device failures, which is important to emphasize when counseling patients.

In Journal of Neurosurgery Publish Before Print