Gassie, Kelly

AbstractConjoined nerve roots are an infrequent and uncommon finding, rarely noted preoperatively. The conjoined root anomaly has potential for significant neurological injury during surgery. Preoperative recognition may avert disastrous nerve root injury but requires a high degree of clinical suspicion. We present the case of a 44-year-old patient with left L5/S1 radiculopathy caused by a herniated disc. During surgery we identified a triple conjoined nerve root anatomy. This anatomical variant, to our knowledge, has not been reported in literature. We describe the anatomical findings and surgical implications.

Basilar invagination is a challenging dilemma that neurosurgeons may face. Herein, we present a case of a 65-year-old female with a history of rheumatoid arthritis and status post a previous C4–7 ACDF who presented to our clinic with progressive weakness in her bilateral upper and lower extremities. Imaging revealed basilar invagination. She underwent an endoscopic endonasal odontoidectomy followed by an occiput–C6 fusion. We present the endonasal portion of the procedure and have highlighted the technical nuances of this approach. Our goal is to provide better insight into this surgical strategy when dealing with basilar invagination. The video can be found here: https://youtu.be/aeMbvI_zYQA

Background: Pediatric patients with sickle cell disease (SCD) and moyamoya syndrome (MMS) are at high risk for recurrent cerebrovascular accidents (CVA) despite best conservative management with chronic blood transfusions (CBT). The role of surgical revascularization in this patient population is not clearly defined. We aim to compare the risk of stroke occurrence in patients undergoing conservative treatment to those additionally undergoing surgical revascularization with conservative treatment. Methods: The authors performed a retrospective cohort study of pediatric SCD-MMS patients seen in Jacksonville and Delaware between 2006 and 2018. Patient characteristics and outcomes, including stroke occurrence, were compared between those who underwent conservative treatment and those who underwent surgical revascularization. Results: A total 17 patients diagnosed with SCD-MMS were on CBT, of which 12 (70.6%) were female. The average age at CBT initiation was 7.27 years. Prior to its initiation, 10 patients (83%) in the surgical and 6 (75%) in the conservative group experienced strokes. Twelve patients underwent surgical revascularization on 18 hemispheres (17 indirect, 1 direct) for severe vasculopathy or CVA - this included 2 patients who experienced a stroke while receiving CBT. The degree of vasculopathy was worse in the surgical group. The mean follow-up for conservative and surgical groups were 11.8 and 4.4 years, respectively. Three patients experienced strokes in the conservative group, while no strokes or major complications were observed in the surgical group. Conclusion: Surgical revascularization appears safe and may effectively reduce stroke rates in pediatric patients with SCD-MMS. Larger studies are needed to confirm these findings.

Abstract BACKGROUND: It is well known that for patients with solitary metastatic disease in the brain, aggressive surgical treatment can prolong survival. However, there is a paucity of literature focusing on simultaneous resection of multiple metastatic brain tumors. METHODS: We analyzed 13 patients and 26 tumors between 2005–2019 who had simultaneous resection of at least 2 metastatic brain tumors via either one or two craniotomies. We independently analyzed those patients with simultaneous resection of metastatic disease in both the supra- and infratentorial compartments. RESULTS: Overall, 26 tumors were resected in a simultaneous fashion. There were 7 females (53.8%) and 6 males (46.2%) total. 5/13 (38.5%) patients had previously known brain metastases in which all 5 had previous adjuvant radiation. All 13 patients had 2 metastatic lesions resected during one operation. Gross total resection rate reached 88.5% with a median post-operative stay of 3 days. Complications presented in only 3 out of 13 cases (grade 2 and 3 according to CTCAE). Primary sites of metastatic disease were lung, breast, skin and renal. 12/13 (92.3%) had two distinct craniotomies and 23/26 (88.5%) tumors had gross total resection of both lesions. There were 11 frontal (42.3%), 7 parietal (26.9%), 2 temporal (7.7%), 1 occipital (3.8%) and 5 cerebellar (19.2%) tumors. There were three patients with both supra- and intratentorial tumors with simultaneous resection. All three patients had two craniotomies and two separate incisions. 1 of the 3 had pre-operative SRS. Overall, average local progression since surgery to at least one resected tumor bed was 88.3 days. CONCLUSIONS: Our results suggest that patients with multiple metastatic brain lesions have comparable outcomes and similar rates of surgical risk to those with solitary brain lesions. In patients with simultaneous supra- and infratentorial brain metastatic disease and indications for decompression, safe resection is feasible.

Background and Study Aims/Objective Metastatic brain tumors are the most common type of adult brain tumors. Treatment involves surgery and/or radiation therapy. Surgery is typically reserved for patients with good neurologic function, solitary and accessible lesions, symptomatic lesions, and/or those with good systemic control of their primary cancer. Deep-seated lesions, however, are typically treated with palliative options including radiation and medical therapies. We summarize our personal experience with minimally invasive surgical approaches for these deep-seated metastatic brain tumors using tubular retractors with exoscopic visualization. Material and Methods Patients with deep-seated metastatic brain tumors who were operated on from January 2016 to December 2017 by the senior author were collected prospectively. “Deep seated” was defined as any subcortical location below the deepest adjacent sulcus in close proximity to the basal ganglia and/or thalamus. “Minimally invasive” was defined as the use of tubular retractors with exoscopic visualization. Results A total of 15 consecutive patients with an average ± standard deviation age of 63 ± 12 years underwent surgical resection of a deep-seated metastasis. The tumor was located in the centrum semiovale in seven (47%) (3 corticospinal tract, 2 superior longitudinal fasciculus, 1 visual tract, 1 inferior frontal occipital fasciculus), basal ganglia in three (20%), thalamus in two (13%), and cerebellum in three (20%). Median percentage resection was 100% (interquartile range:100–100%), and, following surgery, seven (47%), seven (47%), and one (7%) had an improved, stable, and worse Karnofsky Performance Score, respectively. No patients had notable local complications including stroke, infection, hemorrhage, and/or seizure. All patients underwent postoperative stereotactic radiosurgery. Conclusion This minimally invasive approach can be used to achieve extensive resection with minimal morbidity for arguably the highest risk metastatic brain tumors.