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Pate J. Duddleston, Julian L. Gendreau, Kristen A. Little, Amber Andrews, and Willard D. Thompson Jr.

Extraction of a bullet fragment seated in deep brain parenchyma utilizing a neuroendoscope has not been previously reported in the literature. The authors report the case of a 4-year-old patient who presented after a pellet gun injury with a projectile located 6 cm intracranially and lodged within the posterior thalamus and near the posterior limb of the internal capsule. Initial operative repair included repair of a CSF leak with duraplasty, minimal brain debridement, and elevation of a depressed skull fracture. Subsequent CT at 2 months postoperatively revealed migration of the deep intracranial pellet. This finding correlated with intermittent worsening neurological symptoms and signs. A rigid 3-mm neuroendoscope with CT stereotactic navigation was then used to remove the pellet fragment from the thalamus. The patient returned home with alleviation of clinical symptoms and an uneventful postoperative recovery. This case demonstrates that navigation-guided neuroendoscopy can be successfully used to remove projectile fragments from deep brain structures, especially when the migration is along the initial path of the bullet. This technique represents another low-risk curative option in the management of retained bullet fragments in gunshot wound injuries to the head.

Restricted access

Nolan J. Brown, Elliot H. Choi, Julian L. Gendreau, Vera Ong, Alexander Himstead, Brian V. Lien, Shane Shahrestani, Seth C. Ransom, Katelynn Tran, Ali R. Tafreshi, Ronald Sahyouni, Alvin Chan, and Michael Y. Oh


Tranexamic acid (TXA) is an antifibrinolytic agent associated with reduced blood loss and mortality in a wide range of procedures, including spine surgery, traumatic brain injury, and craniosynostosis. Despite this wide use, the safety and efficacy of TXA in spine surgery has been considered controversial due to a relative scarcity of literature and lack of statistical power in reported studies. However, if TXA can be shown to reduce blood loss in laminectomy with fusion and posterior instrumentation, more surgeons may include it in their armamentarium. The authors aimed to conduct an up-to-date systematic review and meta-analysis of the efficacy of TXA in reducing blood loss in laminectomy and fusion with posterior instrumentation.


A systematic review and meta-analysis, abiding by PRISMA guidelines, was performed by searching the databases of PubMed, Web of Science, and Cochrane. These platforms were queried for all studies reporting the use of TXA in laminectomy and fusion with posterior instrumentation. Variables retrieved included patient demographics, surgical indications, involved spinal levels, type of laminectomy performed, TXA administration dose, TXA route of administration, operative duration, blood loss, blood transfusion rate, postoperative hemoglobin level, and perioperative complications. Heterogeneity across studies was evaluated using a chi-square test, Cochran’s Q test, and I2 test performed with R statistical programming software.


A total of 7 articles were included in the qualitative study, while 6 articles featuring 411 patients underwent statistical analysis. The most common route of administration for TXA was intravenous with 15 mg/kg administered preoperatively. After the beginning of surgery, TXA administration patterns were varied among studies. Blood transfusions were increased in non-TXA cohorts compared to TXA cohorts. Patients administered TXA demonstrated a significant reduction in blood loss (mean difference −218.44 mL; 95% CI −379.34 to −57.53; p = 0.018). TXA administration was not associated with statistically significant reductions in operative durations. There were no adverse events reported in either the TXA or non-TXA patient cohorts.


TXA can significantly reduce perioperative blood loss in cervical, thoracic, and lumbar laminectomy and fusion procedures, while demonstrating a minimal complication profile.

Free access

Shane Shahrestani, Nolan J. Brown, Ben A. Strickland, Joshua Bakhsheshian, Seyed Mohammadreza Ghodsi, Tasha Nasrollahi, Michela Borrelli, Julian Gendreau, Jacob J. Ruzevick, and Gabriel Zada


Frailty embodies a state of increased medical vulnerability that is most often secondary to age-associated decline. Recent literature has highlighted the role of frailty and its association with significantly higher rates of morbidity and mortality in patients with CNS neoplasms. There is a paucity of research regarding the effects of frailty as it relates to neurocutaneous disorders, namely, neurofibromatosis type 1 (NF1). In this study, the authors evaluated the role of frailty in patients with NF1 and compared its predictive usefulness against the Elixhauser Comorbidity Index (ECI).


Publicly available 2016–2017 data from the Nationwide Readmissions Database was used to identify patients with a diagnosis of NF1 who underwent neurosurgical resection of an intracranial tumor. Patient frailty was queried using the Johns Hopkins Adjusted Clinical Groups frailty-defining indicator. ECI scores were collected in patients for quantitative measurement of comorbidities. Propensity score matching was performed for age, sex, ECI, insurance type, and median income by zip code, which yielded 60 frail and 60 nonfrail patients. Receiver operating characteristic (ROC) curves were created for complications, including mortality, nonroutine discharge, financial costs, length of stay (LOS), and readmissions while using comorbidity indices as predictor values. The area under the curve (AUC) of each ROC served as a proxy for model performance.


After propensity matching of the groups, frail patients had an increased mean ± SD hospital cost ($85,441.67 ± $59,201.09) compared with nonfrail patients ($49,321.77 ± $50,705.80) (p = 0.010). Similar trends were also found in LOS between frail (23.1 ± 14.2 days) and nonfrail (10.7 ± 10.5 days) patients (p = 0.0020). For each complication of interest, ROC curves revealed that frailty scores, ECI scores, and a combination of frailty+ECI were similarly accurate predictors of variables (p > 0.05). Frailty+ECI (AUC 0.929) outperformed using only ECI for the variable of increased LOS (AUC 0.833) (p = 0.013). When considering 1-year readmission, frailty (AUC 0.642) was outperformed by both models using ECI (AUC 0.725, p = 0.039) and frailty+ECI (AUC 0.734, p = 0.038).


These findings suggest that frailty and ECI are useful in predicting key complications, including mortality, nonroutine discharge, readmission, LOS, and higher costs in NF1 patients undergoing intracranial tumor resection. Consideration of a patient’s frailty status is pertinent to guide appropriate inpatient management as well as resource allocation and discharge planning.

Open access

Matthew A. Liu, Julian L. Gendreau, Joshua J. Loya, Nolan J. Brown, Amber Keith, Ronald Sahyouni, Mickey E. Abraham, David Gonda, and Michael L. Levy


Chordomas are rare malignant neoplasms that develop from the primitive notochord with < 5% of the tumors occurring in pediatric patients younger than the age of 20. Of these pediatric chordomas, those affecting the craniocervical junction (C1–C2) are even more rare; therefore, parameters for surgical management of these pediatric tumors are not well characterized.


In this case, a 3-year-old male was found to have a clival chordoma on imaging with extension to the craniocervical junction resulting in spinal cord compression. Endoscopic-assisted transoral transclival approach for clival tumor resection was performed first. As a second stage, the patient underwent a left-sided far lateral craniotomy and cervical laminectomy for resection of the skull base chordoma and instrumented fusion of the occiput to C3. He made excellent improvements in strength and dexterity during rehab and was discharged after 3 weeks.


In pediatric patients with chordoma with extension to the craniocervical junction and spinal cord compression, decompression with additional occipito-cervical fusion appears to offer a good clinical outcome. Fusion performed as a separate surgery before or at the same time as the initial tumor resection surgery may lead to better outcomes.