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Continuous somatosensory evoked potential monitoring during brain tumor resection

Report of four cases and review of the literature

Gerald A. Grant, Donald Farrell, and Daniel L. Silbergeld

✓ The neurosurgical management of intrinsic brain tumors and brain metastases mandates maximum resection with preservation of functional cortex. There have been previous reports on the use of cortical somatosensory evoked potentials (SSEPs) for localization of functional cortex prior to resection. The identification of rolandic cortex with the use of intraoperative SSEP monitoring enables the neurosurgeon to tailor the surgery to achieve a greater extent of resection while minimizing the risk of morbidity. The use of continuous SSEP monitoring during resection to provide an ongoing functional assessment of somatosensory cortex has not been reported. This powerful technique is illustrated using four case examples.

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Diffuse cerebral venous air embolism following subarachnoid hemorrhage

Case illustration

Mohan R. Sharma, David W. Newell, and Gerald A. Grant

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Endoscopic endonasal surgery for giant pediatric craniopharyngioma

Ahmed Mohyeldin, Peter Hwang, Gerald A. Grant, and Juan C. Fernandez-Miranda

Pediatric craniopharyngiomas that were once thought to be inoperable or considered only for salvage medical therapy are now being reconsidered for aggressive surgical resection via endoscopic endonasal approaches. Here we review the operative video case of an 11-year-old with a giant complex craniopharyngioma that was resected via an endoscopic endonasal approach. Due to the extent of tumor burden near the basilar apex, a transclival approach was necessary. To accomplish this, a wide sphenoidotomy, posterior ethmoidectomy, and resection of the middle turbinate were necessary to create enough working space for the resection. We also highlight several key innovations in pediatric endoscopic endonasal surgery management and underscore a multidisciplinary approach that allows for the safe and successful treatment of these lesions. Our multidisciplinary team involves an experienced fellowship-trained endoscopic skull base surgeon and otolaryngologist, as well as a pediatric neurosurgeon, pediatric endocrinologist, pediatric anesthesiologist, and pediatric intensivists who play important roles in the preoperative, intraoperative, and postoperative phases of care of the patient. Finally, we discuss critical surgical decision points including pituitary transposition, which has a lot of conceptual appeal when it is anatomically feasible but unfortunately, in our experience, has low functional preservation rates. Initially, we always aim to utilize pituitary transposition for tuberoinfundibular craniopharyngiomas, and once the relationship between the tumor and the stalk is determined, a decision on whether to preserve or sacrifice the stalk and pituitary gland is made. In this particular case, there was a salvageable stalk and the transposition was performed knowing that the chances for functional preservation were low.

The video can be found here:

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Vein of Galen malformations in the newborn: case series

Erik F. Hauck, Jeremy A. Yarden, Lily I. Hauck, Joseph M. Bibawy, Shervin Mirshahi, and Gerald A. Grant


Vein of Galen malformations (VoGMs) in newborns often represent life-threatening emergencies. Outcome is difficult to predict. The authors review 50 VoGM cases to correlate anatomical types with treatment and outcome.


Four distinct types of VoGMs are identified: mural simple (type I), mural complex (type II), choroidal (type III), and choroidal with deep venous drainage (type IV). Seven patients presented with mural simple VoGMs with a “single hole” fistula supplied by only one large feeder. These patients were treated electively at >6 months; development was normal. Fifteen patients presented with complex mural VoGMs. Multiple large feeders joined a single fistulous point within the wall of the varix. Patients typically presented with congestive heart failure (CHF) and required emergent transarterial intervention. Mortality was 7.7% with less than two-thirds developing normally. Twenty-five patients presented with choroidal VoGMs. Multiple large arterial feeders joined at multiple fistulous sites. Severe CHF in most patients required emergent transarterial and sometimes transvenous intervention. Mortality was 9.5%; two-thirds of the patients had a normal development. Three babies presented with choroidal VoGMs with deep intraventricular venous drainage. This phenomenon caused fatal “melting brain syndrome” in all three patients.


Recognition of the specific VoGM type determines treatment options and sets outcome expectations.

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Recurrent intracranial Masson's vegetant intravascular hemangioendothelioma

Case report and review of the literature

Anthony M. Avellino, Gerald A. Grant, A. Basil Harris, Sharon K. Wallace, and Cheng-Mei Shaw

✓ In the central nervous system, recurrence of intracranial Masson's vegetant intravascular hemangioendothelioma (MVIH) is rare. To the authors' knowledge, only three recurrent intracranial cases have been reported.

The authors report the case of a 75-year-old woman with a recurrent left-sided cerebellopontine angle and middle cranial fossa MVIH. When the patient was 62 years of age, she underwent preoperative embolization and subtotal resection of the intracranial lesion followed by postoperative radiotherapy. She was well and free from disease until 9 years postoperatively when she became symptomatic. At 71 years of age, the patient again underwent preoperative embolization and near-gross-total resection of the lesion. Follow-up imaging performed 15 months later revealed tumor recurrence, and she underwent stereotactic gamma knife radiosurgery. At a 2.75-year follow-up review, the patient's imaging studies revealed stable residual tumor.

This case report is unique in that it documents the clinical and pathological features, surgical and postoperative treatment, and long-term follow-up review of a patient with recurrent intracranial MVIH and suggests that this unusual vascular lesion is a slow-growing benign tumor rather than a reactive process. Because the pathological composition of the lesion may resemble an angiosarcoma, understanding this benign vascular neoplasm is crucial so that an erroneous diagnosis of malignancy is not made and unnecessary adjuvant therapy is not given.

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Adenosine-induced modulation of excitatory amino acid transport across isolated brain arterioles

Gerald A. Grant, Joseph R. Meno, Thien-Son Nguyen, Kathe A. Stanness, Damir Janigro, and H. Richard Winn

Object. Excitatory amino acid (EAA) uptake by neurons and glia acts synergistically with stereoselective transport across the blood—brain barrier (BBB) to maintain EAA homeostasis in the brain. The endogenous neuroprotectant adenosine counteracts many aspects of excitotoxicity by increasing cerebral blood flow and by producing pre- and postsynaptic actions on neurons. In the present study, the authors explored the effect of adenosine on EAA transport across the BBB.

Methods. The effects of adenosine on the permeability of the BBB and transport of aspartate and glutamate across the BBB were studied in a well-characterized isolated penetrating cerebral arteriole preparation suitable for simultaneous investigations of changes in diameter and permeability. At concentrations within the physiological to low pathophysiological range (10−7–10−6 M), the net vectorial transport of [3H]l-glutamate or [3H]l-aspartate from blood to brain was significantly attenuated, whereas there was no effect of adenosine on paracellular BBB permeability to [14C]sucrose or [3H]d-aspartate. With higher concentrations of adenosine (10−4 M and 10−3 M) the net vectorial transport of [3H]l-glutamate and [3H]l-aspartate returned toward baseline. At 10−3 M, the permeability to [14C]sucrose was significantly altered, indicating a breakdown in the BBB. The effect of adenosine (10−6 M) was blocked by theophylline, a blocker of the A1 and A2 receptors of adenosine.

Conclusions. Adenosine-mediated modulation of glutamate and aspartate transport across the BBB is a novel physiological finding.

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Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015

Kunal Varshneya, Adrian J. Rodrigues, Zachary A. Medress, Martin N. Stienen, Gerald A. Grant, John K. Ratliff, and Anand Veeravagu


Skull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.


The authors queried the MarketScan database (2007–2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.


The authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non–CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6–13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2–44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7–5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5–4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).


The authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

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Letter to the Editor. Simultaneous vagus nerve stimulation and responsive neurostimulation in pediatric epilepsy

Andreas Seas, Shiva A. Nischal, Shivanand P. Lad, and Gerald A. Grant

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A novel mesial temporal stereotactic coordinate system

Kai J. Miller, Casey H. Halpern, Mark F. Sedrak, John A. Duncan III, and Gerald A. Grant


Stereotactic laser ablation and neurostimulator placement represent an evolution in staged surgical intervention for epilepsy. As this practice evolves, optimal targeting will require standardized outcome measures that compare electrode lead or laser source with postprocedural changes in seizure frequency. The authors propose and present a novel stereotactic coordinate system based on mesial temporal anatomical landmarks to facilitate the planning and delineation of outcomes based on extent of ablation or region of stimulation within mesial temporal structures.


The body of the hippocampus contains a natural axis, approximated by the interface of cornu ammonis area 4 and the dentate gyrus. The uncal recess of the lateral ventricle acts as a landmark to characterize the anterior-posterior extent of this axis. Several volumetric rotations are quantified for alignment with the mesial temporal coordinate system. First, the brain volume is rotated to align with standard anterior commissure–posterior commissure (AC-PC) space. Then, it is rotated through the axial and sagittal angles that the hippocampal axis makes with the AC-PC line.


Using this coordinate system, customized MATLAB software was developed to allow for intuitive standardization of targeting and interpretation. The angle between the AC-PC line and the hippocampal axis was found to be approximately 20°–30° when viewed sagittally and approximately 5°–10° when viewed axially. Implanted electrodes can then be identified from CT in this space, and laser tip position and burn geometry can be calculated based on the intraoperative and postoperative MRI.


With the advent of stereotactic surgery for mesial temporal targets, a mesial temporal stereotactic system is introduced that may facilitate operative planning, improve surgical outcomes, and standardize outcome assessment.

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Dynamic contrast-enhanced magnetic resonance angiography of vascular malformations in pediatric patients

Case report

Srinivasan Mukundan, Herbert Fuchs, Michael J. Alexander, and Gerald A. Grant

✓The authors report the first clinical use of 3-tesla dynamic contrast-enhanced magnetic resonance (MR) angiography for the diagnosis of a vascular malformation in a pediatric patient. The supply and drainage of an arteriovenous malformation were accurately demonstrated on MR angiography, which was performed without sedating the patient. This lesion was confirmed on catheter angiography, and definitive treatment via embolization was undertaken in a single session. The patient's therapeutic response will be followed with surveillance dynamic MR imaging.