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Gaurav Gupta and Allen Maniker

Malignant peripheral nerve sheath tumors (MPNSTs) are rare soft tissue sarcomas of ectomesenchymal origin. The World Health Organization coined the term MPNST to replace previous heterogeneous and often confusing terminology, such as “malignant schwannoma,” “malignant neurilemmoma,” “neurogenic sarcoma,” and “neurofibrosarcoma.” Malignant peripheral nerve sheath tumors arise from major or minor peripheral nerve branches or sheaths of peripheral nerve fibers, and are derived from Schwann cells or pluripotent cells of neural crest origin.

The Schwann cell is thought to be the major contributor to the formation of benign as well as malignant neoplasms of the nerve sheath. While this fact remains essentially true, the identity of cell of origin of the MPNST remains elusive, and has not yet been conclusively identified. It has been suggested that these tumors may have multiple cell line origins. In this review, the authors discuss the epidemiology, diagnosis, management, and treatment of MPNSTs.

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Gaurav Gupta and Charles J. Prestigiacomo


Writers of neurosurgical history have traditionally maintained that the initial use of cranial bone wax for hemostasis in humans was developed and promoted by Sir Victor Horsley, the father of British neurosurgery. A thorough literature review, however, suggests that the use of bone wax for cranial bone hemostasis had its roots more than 50 years before Dr. Horsley's description in 1892. In this study the authors review the sources addressing this issue and establish due credit to the surgeons using bone wax for cranial bone hemostasis before Horsley.


Primary and secondary general surgery and neurosurgery literature from 1850 to the present was comprehensively reviewed. The key words used in the literature searchers were “bone wax,” “sealing wax,” “cranial surgery,” “Victor Horsley,” “hemostasis,” and “bone hemostasis.”


Although Dr. Horsley's description in 1892 clearly delineates the necessary formula for creating a soft, malleable, nonbrittle wax that would easily promote hemostasis, the literature suggests that sealing wax was commonly used as early as 1850 for hemostasis in cranial bones. Even though there is documentation that Magendie (1783–1855) used wax to occlude venous sinuses in animals, detailed documentation of the constituents are not available. Evidence reveals that surgeons like Henri Ferdinand Dolbeau (1840–1877), professor of external pathology and the surgical clinic (1868–1872) at the Paris hospitals, used bone wax in 1864 for the extirpation of a frontal osteoma/exostoses of the frontal sinus.


The use of bone wax in cranial surgery was described by Henri Ferdinand Dolbeau, 50 years prior to Sir Victor Horsley's report in 1892. Nonetheless, it was Horsley who advocated and popularized its use in neurological surgery as an additional tool in the hemostatic and surgical armamentarium.

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Gaurav Gupta, Robert F. Heary and Jennifer Michaels

The importance of early surgery for tethered cord syndrome in the pediatric population is well established. Optimal treatment and prognosis of tethered cord in adults, on the other hand, is less clear. Some advocate a conservative approach in asymptomatic patients, while others recommend early detethering in all patients. For symptomatic patients, however, there is a consensus in favor of early surgery to prevent progression of neurological deficit. Many studies have reported cessation of neurological decline or reversal of recently acquired neurological deficits in patients with adult tethered cord syndrome. There are limited data in the literature about late surgery for the treatment of tethered spinal cords when the neurological deficits are longstanding. We report on a 37-year-old woman who demonstrated dramatic neurological improvement after surgical release of a tethered spinal cord more than 20 years after the onset of progressive neurological deficits.

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Michael S. Rallo, Omar Ashraf, Fareed Jumah, Gaurav Gupta and Anil Nanda


Engagement in research and scholarship is considered a hallmark of neurosurgical training. However, the participation of neurosurgical trainees in this experience has only recently been analyzed and described in the United States, with little, if any, data available regarding the research environment in neurosurgical training programs across the globe. Here, the authors set out to identify requirements for research involvement and to quantify publication rates in leading neurosurgical journals throughout various nations across the globe.


The first aim was to identify the research requirements set by relevant program-accrediting and/or board-certifying agencies via query of the literature and published guidelines. For the second part of the study, the authors attempted to determine each country’s neurosurgical research productivity by quantifying publications in the various large international neurosurgical journals—World Neurosurgery, Journal of Neurosurgery, and Neurosurgery—via a structured search of PubMed.


Data on neurosurgical training requirements addressing research were available for 54 (28.1%) of 192 countries. Specific research requirements were identified for 39 countries, partial requirements for 8, and no requirements for 7. Surprisingly, the authors observed a trend of increased average research productivity with the absence of designated research requirements, although this finding is not unprecedented in the literature.


A variety of countries of various sizes and neurosurgical workforce densities across the globe have instituted research requirements during training and/or prior to board certification in neurosurgery. These requirements range in intensity from 1 publication or presentation to the completion of a thesis or dissertation and occur at various time points throughout training. While these requirements do not correlate directly to national research productivity, they may provide a foundation for developing countries to establish a culture of excellence in research.

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James K. Liu, Lana D. Christiano, Gaurav Gupta and Peter W. Carmel

Giant craniopharyngiomas in the retrochiasmatic space are challenging tumors, given the location and surrounding vital structures. Surgical removal remains the first line of therapy and offers the best chance of cure. For tumors with extension into the retrochiasmatic space, the authors use the translamina terminalis corridor via the transbasal subfrontal approach. Although the lamina terminalis can be accessed via anterolateral approaches (pterional or orbitozygomatic), the surgical view of the optic chiasm is oblique and prevents adequate visualization of the ipsilateral wall of the third ventricle. The transbasal subfrontal approach, on the other hand, offers the major advantage of direct midline orientation and access to the third ventricle through the lamina terminalis. This provides the significant advantage of visualization of both walls of the third ventricle and hypothalamus as well as inferior midline access to the interpeduncular cistern to permit safe neurovascular dissection and total tumor removal. In this report, the authors describe the transbasal subfrontal translamina terminalis approach, with specific emphasis on technical surgical nuances in removing retrochiasmatic craniopharyngiomas. An illustrative video demonstrating the technique is also presented.

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Lana D. Christiano, Gaurav Gupta, Charles J. Prestigiacomo and Chirag D. Gandhi

Segal and McLaurin first described giant serpentine aneurysms, based on their distinct angiographic features, in 1977. These lesions are ≥ 25 mm, partially thrombosed aneurysms with a patent, serpiginous vascular channel that courses through the aneurysm. There is a separate inflow and outflow of the aneurysm, of which the outflow channel supplies brain parenchyma in the territory of the parent vessel. Given the large size, unique neck, and dependent distal vessels, these aneurysms pose a technical challenge in treatment. Initial management has included surgical obliteration, but as endovascular techniques have evolved, treatment options too have expanded. In this review the authors attempt to summarize the existing body of literature on this rare entity and describe some of their institutional management strategies.

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Bharath Raju, Fareed Jumah, Omar Ashraf, Vinayak Narayan, Gaurav Gupta, Hai Sun, Patrick Hilden and Anil Nanda

Big data has transformed into a trend phrase in healthcare and neurosurgery, becoming a pervasive and inescapable phrase in everyday life. The upsurge in big data applications is a direct consequence of the drastic boom in information technology as well as the growing number of internet-connected devices called the Internet of Things in healthcare. Compared with business, marketing, and other sectors, healthcare applications are lagging due to a lack of technical knowledge among healthcare workers, technological limitations in acquiring and analyzing the data, and improper governance of healthcare big data. Despite these limitations, the medical literature is flooded with big data–related articles, and most of these are filled with abstruse terminologies such as machine learning, artificial intelligence, artificial neural network, and algorithm. Many of the recent articles are restricted to neurosurgical registries, creating a false impression that big data is synonymous with registries. Others advocate that the utilization of big data will be the panacea to all healthcare problems and research in the future. Without a proper understanding of these principles, it becomes easy to get lost without the ability to differentiate hype from reality. To that end, the authors give a brief narrative of big data analysis in neurosurgery and review its applications, limitations, and the challenges it presents for neurosurgeons and healthcare professionals naive to this field. Awareness of these basic concepts will allow neurosurgeons to understand the literature regarding big data, enabling them to make better decisions and deliver personalized care.