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Stewart A, Hale AT, Saccomano BW, Barkley AS, Hopson BD, Arynchyna-Smith A, Johnston JM, Rocque BG, Blount JP, Rozzelle CJ. Neurosurgical Management of Myelomeningocele in Premature Infants: A Case Series. Res Sq 2024:rs.3.rs-4158288. [PMID: 38645257 PMCID: PMC11030521 DOI: 10.21203/rs.3.rs-4158288/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Introduction Myelomeningocele (MMC) is the most common neural tube defect, but rarely seen in premature infants. Most centers advocate for closure of MMC within 24 hours of birth. However, this is not always possible in severely premature infants. Given the rarity of this patient population, we aimed to share our institutional experience and outcomes of severely premature infants with MMC. Methods We performed a retrospective, observational review of premature infants (≤ 32 weeks gestational age) identified through our multidisciplinary spina bifida clinic (1995-2021) and surgical logs. Descriptive statistics were compiled about this sample including timing of MMC closure and incidence of adverse events such as sepsis, CSF diversion, meningitis, and death. Results Eight patients were identified (50% male) with MMC who were born ≤ 32 weeks gestational age. Mean gestational age of the population was 27.3 weeks (SD 3.5). Median time to MMC closure was 1.5 days (IQR = 1-80.8). Five patients were taken for surgery within the recommended 48 hours of birth; 2 patients underwent significantly delayed closure (107 and 139 days); and one patient's defect epithelized without surgical intervention. Six of eight patients required permanent cerebrospinal fluid (CSF) diversion (2 patients were treated with ventriculoperitoneal shunting (VPS), three were treated with endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) and 1 patient treated with ETV; mean of 3 years after birth, ranging from 1 day to 16 years). Two patients required more than one permanent CSF diversion procedure. Two patients developed sepsis (defined as meeting at least 2/4 SIRS criteria), and 2 patients had intraventricular hemorrhage (both grade III). No patients developed meningitis (defined as positive CSF cultures) prior to MMC closure. Median follow up duration was 9.7 years. During this time epoch, 3 patients died: Two before 2 years of age of causes unrelated to surgical intervention. One of the two patients with grade III IVH died within 24 hours of MMC closure. Conclusions In our institutional experience with premature infants with MMC, some patients underwent delayed MMC closure. The overall rate of meningitis, sepsis, and mortality for preterm children with MMC was similar to MMC patients born at term.
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Thrash GW, Hale AT, Feldman MJ, Saccomano BW, Barrett DJ, Malenkia PD, Das S, Tsemo GB, Blount JP, Rocque BG, Rozzelle CJ, Johnston JM, Jones JG. Pediatric non-galenic pial arteriovenous fistula's characteristics and outcomes: a systematic review. Childs Nerv Syst 2024:10.1007/s00381-024-06352-5. [PMID: 38506930 DOI: 10.1007/s00381-024-06352-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 03/01/2024] [Indexed: 03/22/2024]
Abstract
INTRODUCTION Pediatric non-galenic pial arteriovenous fistulas (pAVFs) are rare vascular malformations that are characterized by a pial arterial-venous connection without an intervening capillary bed. Outcomes and treatment strategies for pAVFs are highly individualized, owing to the rarity of the disease and lack of large-scale data guiding optimal treatment approaches. METHODS We performed a systematic review of pediatric patients (< 18 years at diagnosis) diagnosed with a pAVF by digital subtraction angiogram (DSA). The demographics, treatment modalities, and outcomes were documented for each patient and clinical outcome data was collected. Descriptive information stratified by outcome scores were classified as follows: 1 = excellent (no deficit and full premorbid activity), 2 = good (mild deficit and full premorbid activity), 3 = fair (moderate deficit and impaired activity), 4 = poor (severe deficit and dependent on others), 5 = death. RESULTS A total of 87 studies involving 231 patients were identified. Median age at diagnosis was 3 years (neonates to 18 years). There was slight male preponderance (55.4%), and 150 subjects (81.1%*) experienced excellent outcomes after treatment. Of the 189 patients treated using endovascular approaches, 80.3% experienced excellent outcomes and of the 15 patients surgically treated subjects 75% had an excellent outcome. The highest rate of excellent outcomes was achieved in patients treated with Onyx (95.2%) and other forms of EvOH (100%). High output heart failure and comorbid vascular lesions tended to result in worse outcomes, with only 54.2% and 68% of subjects experiencing an excellent outcome, respectively. *Outcomes were reported in only 185 patients. CONCLUSION pAVFs are rare lesions, necessitating aggregation of patient data to inform natural history and optimal treatment strategies. This review summarizes the current literature on pAVF in children, where children presenting with heart failure as a result of high flow through the lesion were less likely to experience an excellent outcome. Prospective, large-scale studies would further characterize pediatric pAVFs and enable quantitative analysis of outcomes to inform best treatment practices.
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Affiliation(s)
- Garrett W Thrash
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA.
| | - Michael J Feldman
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Benjamin W Saccomano
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - D Jonah Barrett
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Pedram D Malenkia
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Somnath Das
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - Georges Bouobda Tsemo
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Curtis J Rozzelle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James M Johnston
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jesse G Jones
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA
- Department of Diagnostic Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
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Hale AT, Boudreau H, Devulapalli R, Duy PQ, Atchley TJ, Dewan MC, Goolam M, Fieggen G, Spader HL, Smith AA, Blount JP, Johnston JM, Rocque BG, Rozzelle CJ, Chong Z, Strahle JM, Schiff SJ, Kahle KT. The genetic basis of hydrocephalus: genes, pathways, mechanisms, and global impact. Fluids Barriers CNS 2024; 21:24. [PMID: 38439105 PMCID: PMC10913327 DOI: 10.1186/s12987-024-00513-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/25/2024] [Indexed: 03/06/2024] Open
Abstract
Hydrocephalus (HC) is a heterogenous disease characterized by alterations in cerebrospinal fluid (CSF) dynamics that may cause increased intracranial pressure. HC is a component of a wide array of genetic syndromes as well as a secondary consequence of brain injury (intraventricular hemorrhage (IVH), infection, etc.) that can present across the age spectrum, highlighting the phenotypic heterogeneity of the disease. Surgical treatments include ventricular shunting and endoscopic third ventriculostomy with or without choroid plexus cauterization, both of which are prone to failure, and no effective pharmacologic treatments for HC have been developed. Thus, there is an urgent need to understand the genetic architecture and molecular pathogenesis of HC. Without this knowledge, the development of preventive, diagnostic, and therapeutic measures is impeded. However, the genetics of HC is extraordinarily complex, based on studies of varying size, scope, and rigor. This review serves to provide a comprehensive overview of genes, pathways, mechanisms, and global impact of genetics contributing to all etiologies of HC in humans.
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Affiliation(s)
- Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2ndAve, Birmingham, AL, 35294, UK.
| | - Hunter Boudreau
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2ndAve, Birmingham, AL, 35294, UK
| | - Rishi Devulapalli
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Phan Q Duy
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Travis J Atchley
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2ndAve, Birmingham, AL, 35294, UK
| | - Michael C Dewan
- Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Mubeen Goolam
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Graham Fieggen
- Neuroscience Institute, University of Cape Town, Cape Town, South Africa
- Division of Pediatric Neurosurgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - Heather L Spader
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Anastasia A Smith
- Division of Pediatric Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, UK
| | - James M Johnston
- Division of Pediatric Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Curtis J Rozzelle
- Division of Pediatric Neurosurgery, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Zechen Chong
- Heflin Center for Genomics, University of Alabama at Birmingham, Birmingham, AL, UK
| | - Jennifer M Strahle
- Division of Pediatric Neurosurgery, St. Louis Children's Hospital, Washington University in St. Louis, St. Louis, MO, USA
| | - Steven J Schiff
- Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, USA
| | - Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Pan S, Hale AT, Lemieux ME, Raval DK, Garton TP, Sadler B, Mahaney KB, Strahle JM. Iron homeostasis and post-hemorrhagic hydrocephalus: a review. Front Neurol 2024; 14:1287559. [PMID: 38283681 PMCID: PMC10811254 DOI: 10.3389/fneur.2023.1287559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 11/21/2023] [Indexed: 01/30/2024] Open
Abstract
Iron physiology is regulated by a complex interplay of extracellular transport systems, coordinated transcriptional responses, and iron efflux mechanisms. Dysregulation of iron metabolism can result in defects in myelination, neurotransmitter synthesis, and neuronal maturation. In neonates, germinal matrix-intraventricular hemorrhage (GMH-IVH) causes iron overload as a result of blood breakdown in the ventricles and brain parenchyma which can lead to post-hemorrhagic hydrocephalus (PHH). However, the precise mechanisms by which GMH-IVH results in PHH remain elusive. Understanding the molecular determinants of iron homeostasis in the developing brain may lead to improved therapies. This manuscript reviews the various roles iron has in brain development, characterizes our understanding of iron transport in the developing brain, and describes potential mechanisms by which iron overload may cause PHH and brain injury. We also review novel preclinical treatments for IVH that specifically target iron. Understanding iron handling within the brain and central nervous system may provide a basis for preventative, targeted treatments for iron-mediated pathogenesis of GMH-IVH and PHH.
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Affiliation(s)
- Shelei Pan
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Andrew T. Hale
- Department of Neurosurgery, University of Alabama at Birmingham School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Mackenzie E. Lemieux
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Dhvanii K. Raval
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Thomas P. Garton
- Department of Neurology, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Brooke Sadler
- Department of Pediatrics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Hematology and Oncology, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Kelly B. Mahaney
- Department of Neurosurgery, Stanford University School of Medicine, Stanford University, Palo Alto, CA, United States
| | - Jennifer M. Strahle
- Department of Neurosurgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Pediatrics, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
- Department of Orthopedic Surgery, Washington University School of Medicine, Washington University in St. Louis, St. Louis, MO, United States
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Zhang T, Hale AT, Guo S, York JD. Coordinated inositide lipid-phosphatase activities of synaptojanin modulates actin cytoskeleton organization. Adv Biol Regul 2024; 91:101012. [PMID: 38220563 DOI: 10.1016/j.jbior.2023.101012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 12/27/2023] [Indexed: 01/16/2024]
Abstract
Synaptojanin proteins are evolutionarily conserved regulators of vesicle transport and membrane homeostasis. Disruption of synaptojanin function has been implicated in a wide range of neurological disorders. Synaptojanins act as dual-functional lipid phosphatases capable of hydrolyzing a variety of phosphoinositides (PIPs) through autonomous SAC1-like PIP 4-phosphatase and PIP2 5-phosphatase domains. The rarity of an evolutionary configuration of tethering two distinct enzyme activities in a single protein prompted us to investigate their individual and combined roles in budding yeast. Both PIP and PIP2 phosphatase activities are encoded by multiple gene products and are independently essential for cell viability. In contrast, we observed that the synaptojanin proteins utilized both lipid-phosphatase activities to properly coordinate polarized distribution of actin during the cell cycle. Expression of each activity untethered (in trans) failed to properly reconstitute the basal actin regulatory activity; whereas tethering (in cis), even through synthetic linkers, was sufficient to complement these defects. Studies of chimeric proteins harboring PIP and PIP2 phosphatase domains from a variety of gene products indicate synaptojanin proteins have highly specialized activities and that the length of the linker between the lipid-phosphatase domains is critical for actin regulatory activity. Our data are consistent with synaptojanin possessing a strict requirement for both two-domain configuration for some but not all functions and provide mechanistic insights into a coordinated role of tethering distinct lipid-phosphatase activities.
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Affiliation(s)
- Tong Zhang
- Departments of Pharmacology and Cancer Biology, Howard Hughes Medical Institute, Duke University Medical Center, Durham, NC, 27710, USA
| | - Andrew T Hale
- Department of Biochemistry, Vanderbilt University, Nashville, TN, 37232, USA
| | - Shuling Guo
- Departments of Pharmacology and Cancer Biology, Howard Hughes Medical Institute, Duke University Medical Center, Durham, NC, 27710, USA
| | - John D York
- Departments of Pharmacology and Cancer Biology, Howard Hughes Medical Institute, Duke University Medical Center, Durham, NC, 27710, USA; Department of Biochemistry, Vanderbilt University, Nashville, TN, 37232, USA.
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Maleknia PD, Hale AT, Savage C, Blount JP, Rocque BG, Rozzelle CJ, Johnston JM, Jones JGA. Characteristics and outcomes of pediatric dural arteriovenous fistulas: a systematic review. Childs Nerv Syst 2024; 40:197-204. [PMID: 37864710 DOI: 10.1007/s00381-023-06156-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Accepted: 09/09/2023] [Indexed: 10/23/2023]
Abstract
BACKGROUND Dural arteriovenous fistulas (dAVF) are arteriovenous shunts in communication with the dural vasculature in the brain or spine. Apart from single-center series, risk factors and treatment outcomes for pediatric dAVFs are largely undescribed. METHODS We performed a systematic literature review of pediatric (< 18 years at diagnosis) intracranial and spinal dAVF according to PRISMA guidelines. We queried PubMed, CINAHL, SCOPUS, and Embase databases without time/date restriction. Search strings included a variety of MeSH keywords relating to dural AV fistulas in combination with MeSH keywords related to pediatric cases (see Appendix). Manuscripts describing patients diagnosed with dural sinus malformations or pial AVF were excluded. RESULTS We identified 61 studies describing 69 individual patients. Overall, dAVF were more common in males (55.1%) with a mean age of diagnosis (5.17 ± 4.42 years). Approximately 20.2% of patients presented with cardiovascular disease (CVD), and 31.9% were discovered incidentally on neuroimaging studies. Transverse-sigmoid junction was the most common location (17.3%). Ninety-three percent (64 patients) were treated, most commonly using endovascular embolization (68.1%) followed by surgery (8.7%) and radiosurgery (2.9%). Almost half (43.8%) of dAVFs were completely obliterated. Of the 64 procedures, there were 19 neurological complications (29.7%) of varying severity where 12.5% were considered transient (i.e., pseudomeningocele) and 17.2% permanent (i.e., mortality secondary to acute sinus thrombosis, etc.). CONCLUSION There is a paucity of information on pediatric dAVFs. This systematic review summarizes the published cases of dAVFs in the pediatric population. While the rate of missing data is high, there is publication bias, and precise details regarding complications are difficult to ascertain, this review serves as a descriptive summary of pediatric dAVFs.
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Affiliation(s)
- Pedram D Maleknia
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA.
| | - Cody Savage
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Curtis J Rozzelle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - James M Johnston
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jesse G A Jones
- Department of Neurosurgery, University of Alabama at Birmingham, FOT Suite 1060, 1720 2nd Ave S, Birmingham, AL, 35294, USA
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Diagnostic Radiology, University of Alabama at Birmingham, Birmingham, AL, USA
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7
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Zhao S, Mekbib KY, van der Ent MA, Allington G, Prendergast A, Chau JE, Smith H, Shohfi J, Ocken J, Duran D, Furey CG, Hao LT, Duy PQ, Reeves BC, Zhang J, Nelson-Williams C, Chen D, Li B, Nottoli T, Bai S, Rolle M, Zeng X, Dong W, Fu PY, Wang YC, Mane S, Piwowarczyk P, Fehnel KP, See AP, Iskandar BJ, Aagaard-Kienitz B, Moyer QJ, Dennis E, Kiziltug E, Kundishora AJ, DeSpenza T, Greenberg ABW, Kidanemariam SM, Hale AT, Johnston JM, Jackson EM, Storm PB, Lang SS, Butler WE, Carter BS, Chapman P, Stapleton CJ, Patel AB, Rodesch G, Smajda S, Berenstein A, Barak T, Erson-Omay EZ, Zhao H, Moreno-De-Luca A, Proctor MR, Smith ER, Orbach DB, Alper SL, Nicoli S, Boggon TJ, Lifton RP, Gunel M, King PD, Jin SC, Kahle KT. Mutation of key signaling regulators of cerebrovascular development in vein of Galen malformations. Nat Commun 2023; 14:7452. [PMID: 37978175 PMCID: PMC10656524 DOI: 10.1038/s41467-023-43062-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 10/30/2023] [Indexed: 11/19/2023] Open
Abstract
To elucidate the pathogenesis of vein of Galen malformations (VOGMs), the most common and most severe of congenital brain arteriovenous malformations, we performed an integrated analysis of 310 VOGM proband-family exomes and 336,326 human cerebrovasculature single-cell transcriptomes. We found the Ras suppressor p120 RasGAP (RASA1) harbored a genome-wide significant burden of loss-of-function de novo variants (2042.5-fold, p = 4.79 x 10-7). Rare, damaging transmitted variants were enriched in Ephrin receptor-B4 (EPHB4) (17.5-fold, p = 1.22 x 10-5), which cooperates with p120 RasGAP to regulate vascular development. Additional probands had damaging variants in ACVRL1, NOTCH1, ITGB1, and PTPN11. ACVRL1 variants were also identified in a multi-generational VOGM pedigree. Integrative genomic analysis defined developing endothelial cells as a likely spatio-temporal locus of VOGM pathophysiology. Mice expressing a VOGM-specific EPHB4 kinase-domain missense variant (Phe867Leu) exhibited disrupted developmental angiogenesis and impaired hierarchical development of arterial-capillary-venous networks, but only in the presence of a "second-hit" allele. These results illuminate human arterio-venous development and VOGM pathobiology and have implications for patients and their families.
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Affiliation(s)
- Shujuan Zhao
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kedous Y Mekbib
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Martijn A van der Ent
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Garrett Allington
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
| | - Andrew Prendergast
- Yale Zebrafish Research Core, Yale School of Medicine, New Haven, CT, USA
| | - Jocelyn E Chau
- Department of Molecular Biophysics and Biochemistry, Yale School of Medicine, New Haven, CT, USA
| | - Hannah Smith
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - John Shohfi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Jack Ocken
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Daniel Duran
- Department of Neurosurgery, University of Mississippi Medical Center, Jackson, MS, USA
| | - Charuta G Furey
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
- Ivy Brain Tumor Center, Department of Translational Neuroscience, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Le Thi Hao
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Phan Q Duy
- Department of Neurosurgery, University of Virginia School of Medicine, Charlottesville, VA, USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Junhui Zhang
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | | | - Di Chen
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Boyang Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Timothy Nottoli
- Yale Genome Editing Center, Department of Comparative Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Suxia Bai
- Yale Genome Editing Center, Department of Comparative Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Myron Rolle
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Xue Zeng
- Department of Molecular Biophysics and Biochemistry, Yale School of Medicine, New Haven, CT, USA
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Weilai Dong
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Po-Ying Fu
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Yung-Chun Wang
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA
| | - Shrikant Mane
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Paulina Piwowarczyk
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Katie Pricola Fehnel
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alfred Pokmeng See
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bermans J Iskandar
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Beverly Aagaard-Kienitz
- Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA
| | - Quentin J Moyer
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Evan Dennis
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Emre Kiziltug
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Adam J Kundishora
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Tyrone DeSpenza
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Ana B W Greenberg
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Andrew T Hale
- Department of Neurosurgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - James M Johnston
- Department of Neurosurgery, University of Alabama School of Medicine, Birmingham, AL, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Phillip B Storm
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Shih-Shan Lang
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - William E Butler
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Bob S Carter
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Paul Chapman
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Georges Rodesch
- Service de Neuroradiologie Diagnostique et Thérapeutique, Hôpital Foch, Suresnes, France
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
| | - Stanislas Smajda
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
| | - Alejandro Berenstein
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tanyeri Barak
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Hongyu Zhao
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| | - Andres Moreno-De-Luca
- Department of Radiology, Autism & Developmental Medicine Institute, Genomic Medicine Institute, Geisinger, Danville, PA, USA
| | - Mark R Proctor
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Darren B Orbach
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurointerventional Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Seth L Alper
- Division of Nephrology and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, and Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Stefania Nicoli
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
- Department of Pharmacology, Yale School of Medicine, New Haven, CT, USA
- Yale Cardiovascular Research Center, Department of Internal Medicine, Section of Cardiology, Yale School of Medicine, New Haven, CT, USA
| | - Titus J Boggon
- Department of Molecular Biophysics and Biochemistry, Yale School of Medicine, New Haven, CT, USA
- Department of Pharmacology, Yale School of Medicine, New Haven, CT, USA
| | - Richard P Lifton
- Laboratory of Human Genetics and Genomics, The Rockefeller University, New York, NY, USA
| | - Murat Gunel
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA
| | - Philip D King
- Department of Microbiology and Immunology, University of Michigan Medical School, Ann Arbor, MI, USA.
| | - Sheng Chih Jin
- Department of Genetics, Washington University School of Medicine, St. Louis, MO, USA.
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Department of Neurosurgery, Yale School of Medicine, New Haven, CT, USA.
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, US.
- Broad Institute of MIT and Harvard, Cambridge, MA, USA.
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8
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Hale AT, Estevez-Ordonez D, Badrani J, Sha W, Arynchyna-Smith A, Goyal M, Mohamed I, Kankirawatana P, Rozzelle CJ, Blount JP. Hemispherectomy Outcome Prediction Scale: a validity study. J Neurosurg Pediatr 2023; 32:488-496. [PMID: 37503923 DOI: 10.3171/2023.5.peds2391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2023] [Accepted: 05/10/2023] [Indexed: 07/29/2023]
Abstract
OBJECTIVE Hemispherectomy is highly effective for patients with medically refractory epilepsy (MRE) arising from a single hemisphere. Recently, the Hemispherectomy Outcome Prediction Scale (HOPS) was developed as a prediction tool for seizure freedom after hemispherectomy. The authors' goal was to perform a validation study to determine the generalizability of the HOPS score. METHODS The authors present an observational, retrospective, 20-year, single-institution, two-surgeon experience using the lateral peri-insular hemispherectomy approach to validate the HOPS score. Variables used to derive the HOPS score included seizure onset age, semiology, PET hypometabolism, seizure substrate, and history of prior epilepsy resection. Multivariable logistic regression, multiple imputation, and Bayesian analyses were used to determine validity. RESULTS The authors' cohort comprised 60 patients; 55% of patients were male and 78% were Caucasian. The median age at first hemispherectomy surgery was 72 months. At 1 year postoperatively, 80% of patients had Engel class I outcomes, analogous to most contemporary series. All patients who experienced seizure recurrence after hemispherectomy did so within the first 2 years postoperatively. Sixteen (27%) and 10 (17%) patients had contralateral MRI findings and hypometabolism on PET, respectively. Both a multivariable logistic regression model using HOPS score variables (model p = 0.2588) and a revised model that included contralateral MRI findings (model p = 0.4715) were not statistically significant in this cohort. Bayesian analysis also did not validate the HOPS score. CONCLUSIONS While seizure outcome prediction tools may be helpful for counseling patients about postoperative outcomes, rigorous validity and reliability testing are required. Prospective, standardized, and longitudinal evaluation of patients undergoing hemispherectomy are needed.
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Affiliation(s)
- Andrew T Hale
- 1Department of Neurosurgery, University of Alabama at Birmingham
| | | | - Jana Badrani
- 2Heersink School of Medicine, University of Alabama at Birmingham
| | - Wen Sha
- 3Department of Public Health, Heersink School of Medicine, University of Alabama at Birmingham
| | | | - Monisha Goyal
- 5Division of Pediatric Neurology, Children's of Alabama, Birmingham, Alabama
| | - Ismail Mohamed
- 5Division of Pediatric Neurology, Children's of Alabama, Birmingham, Alabama
| | | | - Curtis J Rozzelle
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 4Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham; and
| | - Jeffrey P Blount
- 1Department of Neurosurgery, University of Alabama at Birmingham
- 4Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham; and
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9
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Johnson GW, Greenberg JK, Hale AT, Ahluwalia R, Hill M, Belal A, Baygani S, Foraker RE, Carpenter CR, Yan Y, Ackerman LL, Noje C, Jackson E, Burns EC, Sayama CM, Selden NR, Vachhrajani S, Shannon CN, Kuppermann N, Limbrick DD. Toward rational use of repeat imaging in children with mild traumatic brain injuries and intracranial injuries. J Neurosurg Pediatr 2023; 32:26-34. [PMID: 37021760 DOI: 10.3171/2023.2.peds22393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 02/22/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE Limited evidence exists on the utility of repeat neuroimaging in children with mild traumatic brain injuries (mTBIs) and intracranial injuries (ICIs). Here, the authors identified factors associated with repeat neuroimaging and predictors of hemorrhage progression and/or neurosurgical intervention. METHODS The authors performed a multicenter, retrospective cohort study of children at four centers of the Pediatric TBI Research Consortium. All patients were ≤ 18 years and presented within 24 hours of injury with a Glasgow Coma Scale score of 13-15 and evidence of ICI on neuroimaging. The outcomes of interest were 1) whether patients underwent repeat neuroimaging during index admission, and 2) a composite outcome of progression of previously identified hemorrhage ≥ 25% and/or repeat imaging as an indication for subsequent neurosurgical intervention. The authors performed multivariable logistic regression and report odds ratios and 95% confidence intervals. RESULTS A total of 1324 patients met inclusion criteria; 41.3% of patients underwent repeat imaging. Repeat imaging was associated with clinical change in 4.8% of patients; the remainder of the imaging tests were for routine surveillance (90.9%) or of unclear prompting (4.4%). In 2.6% of patients, repeat imaging findings were reported as an indication for neurosurgical intervention. While many factors were associated with repeat neuroimaging, only epidural hematoma (OR 3.99, 95% CI 2.22-7.15), posttraumatic seizures (OR 2.95, 95% CI 1.22-7.41), and age ≥ 2 years (OR 2.25, 95% CI 1.16-4.36) were significant predictors of hemorrhage progression and/or neurosurgery. Of patients without any of these risk factors, none underwent neurosurgical intervention. CONCLUSIONS Repeat neuroimaging was commonly used but uncommonly associated with clinical deterioration. Although several factors were associated with repeat neuroimaging, only posttraumatic seizures, age ≥ 2 years, and epidural hematoma were significant predictors of hemorrhage progression and/or neurosurgery. These results provide the foundation for evidence-based repeat neuroimaging practices in children with mTBI and ICI.
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Affiliation(s)
| | | | - Andrew T Hale
- 2Department of Neurological Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Ranbir Ahluwalia
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madelyn Hill
- 4Department of Neurological Surgery, Dayton Children's Hospital, Dayton, Ohio
| | - Ahmed Belal
- 5Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Shawyon Baygani
- 5Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - Yan Yan
- 8Surgery, Washington University School of Medicine in St. Louis, Missouri
| | - Laurie L Ackerman
- 5Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | | | - Eric Jackson
- 10Neurological Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | | | - Christina M Sayama
- 12Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Nathan R Selden
- 12Neurological Surgery, Oregon Health & Science University, Portland, Oregon; and
| | - Shobhan Vachhrajani
- 4Department of Neurological Surgery, Dayton Children's Hospital, Dayton, Ohio
| | - Chevis N Shannon
- 2Department of Neurological Surgery, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama
| | - Nathan Kuppermann
- Departments of13Emergency Medicine and
- 14Pediatrics, University of California, Davis, School of Medicine, Sacramento, California
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10
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Hale AT, Savage C, Parr MS, Hedaya A, Saccomano B, Tsema GB, Hafeez M, Tanweer O, Kan P, Solomon L, Deloison B, Meila D, Blount JP, Johnston JM, Rocque BG, Rozzelle CJ, Bhatia K, Muthusami P, Krings T, Jones J. 807 Outcomes of Endovascular Embolization for Vein of Galen Malformations: An Individual Participant Data Meta-Analysis. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
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11
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Hale AT, He J, Jones J. 163 Integrative Genomics Analysis Implicates Decreased FGD6 Expression Underlying Risk of Intracranial Aneurysm Rupture. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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12
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Zhao S, Mekbib KY, van der Ent MA, Allington G, Prendergast A, Chau JE, Smith H, Shohfi J, Ocken J, Duran D, Furey CG, Le HT, Duy PQ, Reeves BC, Zhang J, Nelson-Williams C, Chen D, Li B, Nottoli T, Bai S, Rolle M, Zeng X, Dong W, Fu PY, Wang YC, Mane S, Piwowarczyk P, Fehnel KP, See AP, Iskandar BJ, Aagaard-Kienitz B, Kundishora AJ, DeSpenza T, Greenberg ABW, Kidanemariam SM, Hale AT, Johnston JM, Jackson EM, Storm PB, Lang SS, Butler WE, Carter BS, Chapman P, Stapleton CJ, Patel AB, Rodesch G, Smajda S, Berenstein A, Barak T, Erson-Omay EZ, Zhao H, Moreno-De-Luca A, Proctor MR, Smith ER, Orbach DB, Alper SL, Nicoli S, Boggon TJ, Lifton RP, Gunel M, King PD, Jin SC, Kahle KT. Genetic dysregulation of an endothelial Ras signaling network in vein of Galen malformations. bioRxiv 2023:2023.03.18.532837. [PMID: 36993588 PMCID: PMC10055230 DOI: 10.1101/2023.03.18.532837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
To elucidate the pathogenesis of vein of Galen malformations (VOGMs), the most common and severe congenital brain arteriovenous malformation, we performed an integrated analysis of 310 VOGM proband-family exomes and 336,326 human cerebrovasculature single-cell transcriptomes. We found the Ras suppressor p120 RasGAP ( RASA1 ) harbored a genome-wide significant burden of loss-of-function de novo variants (p=4.79×10 -7 ). Rare, damaging transmitted variants were enriched in Ephrin receptor-B4 ( EPHB4 ) (p=1.22×10 -5 ), which cooperates with p120 RasGAP to limit Ras activation. Other probands had pathogenic variants in ACVRL1 , NOTCH1 , ITGB1 , and PTPN11 . ACVRL1 variants were also identified in a multi-generational VOGM pedigree. Integrative genomics defined developing endothelial cells as a key spatio-temporal locus of VOGM pathophysiology. Mice expressing a VOGM-specific EPHB4 kinase-domain missense variant exhibited constitutive endothelial Ras/ERK/MAPK activation and impaired hierarchical development of angiogenesis-regulated arterial-capillary-venous networks, but only when carrying a "second-hit" allele. These results illuminate human arterio-venous development and VOGM pathobiology and have clinical implications.
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13
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Bersell KR, Yang T, Mosley JD, Glazer AM, Hale AT, Kryshtal DO, Kim K, Steimle JD, Brown JD, Salem JE, Campbell CC, Hong CC, Wells QS, Johnson AN, Short L, Blair MA, Behr ER, Petropoulou E, Jamshidi Y, Benson MD, Keyes MJ, Ngo D, Vasan RS, Yang Q, Gerszten RE, Shaffer C, Parikh S, Sheng Q, Kannankeril PJ, Moskowitz IP, York JD, Wang TJ, Knollmann BC, Roden DM. Transcriptional Dysregulation Underlies Both Monogenic Arrhythmia Syndrome and Common Modifiers of Cardiac Repolarization. Circulation 2023; 147:824-840. [PMID: 36524479 PMCID: PMC9992308 DOI: 10.1161/circulationaha.122.062193] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 11/03/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Brugada syndrome (BrS) is an inherited arrhythmia syndrome caused by loss-of-function variants in the cardiac sodium channel gene SCN5A (sodium voltage-gated channel alpha subunit 5) in ≈20% of subjects. We identified a family with 4 individuals diagnosed with BrS harboring the rare G145R missense variant in the cardiac transcription factor TBX5 (T-box transcription factor 5) and no SCN5A variant. METHODS We generated induced pluripotent stem cells (iPSCs) from 2 members of a family carrying TBX5-G145R and diagnosed with Brugada syndrome. After differentiation to iPSC-derived cardiomyocytes (iPSC-CMs), electrophysiologic characteristics were assessed by voltage- and current-clamp experiments (n=9 to 21 cells per group) and transcriptional differences by RNA sequencing (n=3 samples per group), and compared with iPSC-CMs in which G145R was corrected by CRISPR/Cas9 approaches. The role of platelet-derived growth factor (PDGF)/phosphoinositide 3-kinase (PI3K) pathway was elucidated by small molecule perturbation. The rate-corrected QT (QTc) interval association with serum PDGF was tested in the Framingham Heart Study cohort (n=1893 individuals). RESULTS TBX5-G145R reduced transcriptional activity and caused multiple electrophysiologic abnormalities, including decreased peak and enhanced "late" cardiac sodium current (INa), which were entirely corrected by editing G145R to wild-type. Transcriptional profiling and functional assays in genome-unedited and -edited iPSC-CMs showed direct SCN5A down-regulation caused decreased peak INa, and that reduced PDGF receptor (PDGFRA [platelet-derived growth factor receptor α]) expression and blunted signal transduction to PI3K was implicated in enhanced late INa. Tbx5 regulation of the PDGF axis increased arrhythmia risk due to disruption of PDGF signaling and was conserved in murine model systems. PDGF receptor blockade markedly prolonged normal iPSC-CM action potentials and plasma levels of PDGF in the Framingham Heart Study were inversely correlated with the QTc interval (P<0.001). CONCLUSIONS These results not only establish decreased SCN5A transcription by the TBX5 variant as a cause of BrS, but also reveal a new general transcriptional mechanism of arrhythmogenesis of enhanced late sodium current caused by reduced PDGF receptor-mediated PI3K signaling.
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Affiliation(s)
- Kevin R Bersell
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Tao Yang
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Jonathan D Mosley
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Andrew M Glazer
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Andrew T Hale
- Biochemistry (A.T.H., J.D.Y.), Vanderbilt University, Nashville, TN
| | - Dmytro O Kryshtal
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Kyungsoo Kim
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Jeffrey D Steimle
- Departments of Pediatrics, Pathology, and Human Genetics, University of Chicago, IL (J.D.S., I.P.M.)
| | - Jonathan D Brown
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Joe-Elie Salem
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
- Assistance Publique - Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Department of Pharmacology, CIC-1901, Sorbonne University, Paris, France (J-E.S.)
- Sorbonne Universités, UPMC Univ Paris 06, Faculty of Medicine, France (J-E.S.)
| | - Courtney C Campbell
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Charles C Hong
- Department of Medicine, University of Maryland School of Medicine, Baltimore (C.C.H.)
| | - Quinn S Wells
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
- Biomedical Informatics (Q.S.W., D.M.R.), Vanderbilt University, Nashville, TN
| | - Amanda N Johnson
- Molecular Physiology and Biophysics (A.N.J.), Vanderbilt University, Nashville, TN
| | - Laura Short
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Marcia A Blair
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | | | - Evmorfia Petropoulou
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London and St George's University Hospitals National Health Service Foundation Trust, London, UK (E.P., Y.J.)
| | - Yalda Jamshidi
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Institute, St George's, University of London and St George's University Hospitals National Health Service Foundation Trust, London, UK (E.P., Y.J.)
| | - Mark D Benson
- Cardiovascular Research Center (E.J.B., M.D.B., M.J.K., R.E.G.), Beth Israel Deaconess Hospital, Boston, MA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (M.D.B.)
| | - Michelle J Keyes
- Cardiovascular Research Center (E.J.B., M.D.B., M.J.K., R.E.G.), Beth Israel Deaconess Hospital, Boston, MA
| | - Debby Ngo
- Division of Pulmonary and Cardiovascular Medicine (D.N., R.E.G.), Beth Israel Deaconess Hospital, Boston, MA
| | | | - Qiong Yang
- Boston University School of Medicine, MA (R.S.V., Q.Y.)
| | - Robert E Gerszten
- Cardiovascular Research Center (E.J.B., M.D.B., M.J.K., R.E.G.), Beth Israel Deaconess Hospital, Boston, MA
- Division of Pulmonary and Cardiovascular Medicine (D.N., R.E.G.), Beth Israel Deaconess Hospital, Boston, MA
| | - Christian Shaffer
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Shan Parikh
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | | | | | - Ivan P Moskowitz
- Departments of Pediatrics, Pathology, and Human Genetics, University of Chicago, IL (J.D.S., I.P.M.)
| | - John D York
- Biochemistry (A.T.H., J.D.Y.), Vanderbilt University, Nashville, TN
| | - Thomas J Wang
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Bjorn C Knollmann
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
| | - Dan M Roden
- Departments of Pharmacology (K.R.B., A.M.G., D.O.K., K.K., J-E.S., C.C.C., Q.S.W., S.P., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
- Medicine (T.Y., J.D.M., J.D.B., J-E.S., Q.S.W., L.S., M.A.B., C.S., T.J.W., B.C.K., D.M.R.), Vanderbilt University, Nashville, TN
- Biomedical Informatics (Q.S.W., D.M.R.), Vanderbilt University, Nashville, TN
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14
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Keating O, Hale AT, Smith AA, Jimenez V, Ashraf AP, Rocque BG. Hyponatremia after craniotomy in children: a single-institution review. Childs Nerv Syst 2023; 39:617-623. [PMID: 36308540 DOI: 10.1007/s00381-022-05729-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 10/25/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Hyponatremia after craniotomy can be associated with increased morbidity. However, the incidence of and factors associated with post-craniotomy hyponatremia in children are not known. METHODS We performed a retrospective cohort study of patients aged 0-21 years who underwent craniotomy in 2017-2019 at a single center to determine the incidence of and to identify risk factors for hyponatremia after craniotomy. Indications for craniotomy included tumors (excluding craniopharyngioma), epilepsy, intracranial infection, trauma, craniofacial, suboccipital decompression for the treatment of Chiari malformation, and cerebrovascular disease. Hyponatremia was defined as a serum sodium level ≤ 135 mEq/L any time during the postoperative hospital stay. Statistical significance was defined a priori at p < 0.05. RESULTS Postoperative hyponatremia occurred in 61 (25%) of 240 children. On univariate analysis, hyponatremia was associated with younger age (8.5 vs 6.3 years, p = 0.01), use of preoperative anti-epileptic drugs (p = 0.02), need for blood transfusion (p = 0.02), government/private insurance (p = 0.04), and pre-existing hydrocephalus, defined as the requirement for permanent cerebrospinal fluid (CSF) diversion (p = 0.04). On multivariate analysis, only hydrocephalus (OR 2.95, 95% CI 1.03-8.40) remained statistically significant. Hyponatremia most occurred on the first postoperative day, with normonatremia achieved in a median of 14 (IQR 9.8-24.3) h. Hyponatremia was significantly associated with longer length of stay (median 8 vs 3 days, p < 0.01). CONCLUSION Hyponatremia was present in 25% of children after craniotomy. Preoperative hydrocephalus as an independent risk factor for hyponatremia after craniotomy.
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Affiliation(s)
- Olivia Keating
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA.
| | - Anastasia A Smith
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Victoria Jimenez
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Ambika P Ashraf
- Division of Pediatric Endocrinology, University of Alabama at Birmingham, Children's of Alabama, Birmingham, AL, USA
| | - Brandon G Rocque
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
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15
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Obaid S, Chen JS, Ibrahim GM, Bouthillier A, Dimentberg E, Surbeck W, Guadagno E, Brunette-Clément T, Shlobin NA, Shulkin A, Hale AT, Tomycz LD, Von Lehe M, Perry MS, Chassoux F, Bouilleret V, Taussig D, Fohlen M, Dorfmuller G, Hagiwara K, Isnard J, Oluigbo CO, Ikegaya N, Nguyen DK, Fallah A, Weil AG. Predictors of outcomes after surgery for medically intractable insular epilepsy: A systematic review and individual participant data meta-analysis. Epilepsia Open 2023; 8:12-31. [PMID: 36263454 PMCID: PMC9978079 DOI: 10.1002/epi4.12663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 09/28/2022] [Indexed: 11/11/2022] Open
Abstract
Insular epilepsy (IE) is an increasingly recognized cause of drug-resistant epilepsy amenable to surgery. However, concerns of suboptimal seizure control and permanent neurological morbidity hamper widespread adoption of surgery for IE. We performed a systematic review and individual participant data meta-analysis to determine the efficacy and safety profile of surgery for IE and identify predictors of outcomes. Of 2483 unique citations, 24 retrospective studies reporting on 312 participants were eligible for inclusion. The median follow-up duration was 2.58 years (range, 0-17 years), and 206 (66.7%) patients were seizure-free at last follow-up. Younger age at surgery (≤18 years; HR = 1.70, 95% CI = 1.09-2.66, P = .022) and invasive EEG monitoring (HR = 1.97, 95% CI = 1.04-3.74, P = .039) were significantly associated with shorter time to seizure recurrence. Performing MR-guided laser ablation or radiofrequency ablation instead of open resection (OR = 2.05, 95% CI = 1.08-3.89, P = .028) was independently associated with suboptimal or poor seizure outcome (Engel II-IV) at last follow-up. Postoperative neurological complications occurred in 42.5% of patients, most commonly motor deficits (29.9%). Permanent neurological complications occurred in 7.8% of surgeries, including 5% and 1.4% rate of permanent motor deficits and dysphasia, respectively. Resection of the frontal operculum was independently associated with greater odds of motor deficits (OR = 2.75, 95% CI = 1.46-5.15, P = .002). Dominant-hemisphere resections were independently associated with dysphasia (OR = 13.09, 95% CI = 2.22-77.14, P = .005) albeit none of the observed language deficits were permanent. Surgery for IE is associated with a good efficacy/safety profile. Most patients experience seizure freedom, and neurological deficits are predominantly transient. Pediatric patients and those requiring invasive monitoring or undergoing stereotactic ablation procedures experience lower rates of seizure freedom. Transgression of the frontal operculum should be avoided if it is not deemed part of the epileptogenic zone. Well-selected candidates undergoing dominant-hemisphere resection are more likely to exhibit transient language deficits; however, the risk of permanent deficit is very low.
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Affiliation(s)
- Sami Obaid
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Jia-Shu Chen
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - George M Ibrahim
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Alain Bouthillier
- Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Evan Dimentberg
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Faculty of Medicine, Université Laval, Quebec City, Quebec, Canada
| | - Werner Surbeck
- Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital of the University of Zurich, Zurich, Switzerland
| | - Elena Guadagno
- Harvey E. Beardmore Division of Pediatric Surgery, McGill University Health Centre, Montreal, Quebec, Canada
| | - Tristan Brunette-Clément
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Nathan A Shlobin
- Department of Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Aidan Shulkin
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Luke D Tomycz
- The Epilepsy Institute of New Jersey, Jersey City, New Jersey, USA
| | - Marec Von Lehe
- Department of Neurosurgery, Brandenburg Medical School, Neuruppin, Germany
| | - Michael Scott Perry
- Comprehensive Epilepsy Program, Jane and John Justin Neuroscience Center, Cook Children's Medical Center, Fort Worth, Texas, USA
| | - Francine Chassoux
- Service de Neurochirurgie, GHU Paris Psychiatrie et Neurosciences, Université Paris-Descartes Paris, Paris, France
| | - Viviane Bouilleret
- Université Paris Saclay-APHP, Unité de Neurophysiologie Clinique et d'Épileptologie(UNCE), Le Kremlin Bicêtre, France
| | - Delphine Taussig
- Université Paris Saclay-APHP, Unité de Neurophysiologie Clinique et d'Épileptologie(UNCE), Le Kremlin Bicêtre, France.,Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Martine Fohlen
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Georg Dorfmuller
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Koichi Hagiwara
- Epilepsy and Sleep Center, Fukuoka Sanno Hospital, Fukuoka, Japan
| | - Jean Isnard
- Department of Functional Neurology and Epileptology, Hospices Civils de Lyon, Hospital for Neurology and Neurosurgery, Lyon, France
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Naoki Ikegaya
- Departments of Neurosurgery, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Dang K Nguyen
- Division of Neurology, University of Montreal Hospital Center, Montreal, Quebec, Canada
| | - Aria Fallah
- Department of Neurosurgery and Pediatrics, David Geffen School of Medicine at University of California Los Angeles, Los Angeles, California, USA
| | - Alexander G Weil
- Division of Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Quebec, Montreal, Canada.,Division of Neurosurgery, University of Montreal Hospital Center, Montreal, Quebec, Canada.,Department of Neuroscience, University of Montreal, Montreal, Quebec, Canada
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16
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Hale AT, Barkley AS, Blount JP. Corpus Callosotomy Is a Safe and Effective Procedure for Medically Resistant Epilepsy. Adv Tech Stand Neurosurg 2023; 48:355-369. [PMID: 37770691 DOI: 10.1007/978-3-031-36785-4_13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2023]
Abstract
Corpus callosotomy (CC) is an effective surgical treatment for medically resistant generalized or multifocal epilepsy (MRE). The premise of CC extrapolates from the observation that the corpus callosum is the predominant commissural pathway that allows spread and synchroneity of epileptogenic activity between the hemispheres. Candidacy for CC is typically reserved for patients seeking palliative epilepsy treatment with the goal of reducing the frequency of drop attacks, although reduction of other seizure semiologies (absence, complex partial seizures, and tonic-clonic) has been observed. A reduction in morbidity affiliated with evolution of surgical techniques to perform CC has improved the safety profile of the procedure without necessarily sacrificing efficacy.
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Affiliation(s)
- Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Ariana S Barkley
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA.
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17
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Muacevic A, Adler JR, Laskay N, Hale AT, Fisher WS. Transpetrosal Approach to a Ruptured Distal Basilar Perforating Artery Aneurysm. Cureus 2023; 15:e34273. [PMID: 36860217 PMCID: PMC9969324 DOI: 10.7759/cureus.34273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/27/2023] [Indexed: 01/28/2023] Open
Abstract
Basilar perforating artery aneurysms are rare and underreported vascular anomalies in the cerebrovascular literature. Various open and endovascular treatment approaches can be employed to treat these aneurysms based on several patient- and aneurysm-specific factors. Some authors have even advocated for conservative, nonoperative management. Here, we report a case of a ruptured distal basilar perforating artery aneurysm secured by an open transpetrosal approach. A 67-year-old male presented to our institution with a Hunt-Hess grade 2, modified Fisher grade 3 subarachnoid hemorrhage (SAH). Initial cerebral digital subtraction angiography (DSA) did not identify an intracranial aneurysm or other vascular lesions. However, the patient had a re-rupture event several days after presentation. DSA at this time revealed a posteriorly projecting distal basilar perforating artery aneurysm. Initial attempts with endovascular coil embolization were unsuccessful. Thus, an open transpetrosal approach was taken to gain access to the middle and distal basilar trunk to secure the aneurysm. This case underscores the unpredictability of basilar perforating artery aneurysms and the challenges encountered when considering active treatment. We demonstrate an open surgical approach with an intraoperative video for definitive management after failed attempted endovascular treatment.
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Affiliation(s)
- Alexander Muacevic
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
| | - John R Adler
- Neurological Surgery, University of Alabama at Birmingham, Birmingham, USA
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18
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Parr MS, Salehani A, Ogilvie M, Ethan Tabibian B, Rahm S, Hale AT, Tsemo GB, Aluri A, Kim J, Mathru M, Jones JGA. The effect of procedural end-tidal CO2 on infarct expansion during anterior circulation thrombectomy. Interv Neuroradiol 2022:15910199221143175. [PMID: 36464668 DOI: 10.1177/15910199221143175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Carbon dioxide is a potent cerebral vasodilator that may influence outcomes after ischemic stroke. The objective of this study was to investigate the effect of intraprocedural mean end-tidal CO2 (ETCO2) levels on core infarct expansion and neurologic outcome following thrombectomy for anterior circulation ischemic stroke. METHODS A retrospective review was conducted of consecutive patients from March 2020 to June 2021 who underwent mechanical thrombectomy for acute anterior circulation ischemic stroke under general anesthesia and achieved successful recanalization (Thrombolysis in Cerebral Infarction [TICI] ≥ 2b). Only patients with CT perfusion, procedural ETCO2, and postoperative MRI data were included. Segmentation software was used for multi-parametric image analysis. Normocarbia defined as mean ETCO2 of 35 mmHg was used to dichotomize subjects. Univariate and multivariate statistics were applied. RESULTS Fifty-eight patients met criteria for analysis. Of these, 44 had TICI 3 recanalization, 9 had TICI 2c, and 5 had TICI 2b. Within this combined recanalization group, patients with mean ETCO2 > 35 had significantly higher rates of functional independence at 90 days. Although patients tended to salvage more penumbra and experience smaller final infarcts when ETCO2 exceeded 35 mmHg, this did not reach statistical significance. CONCLUSIONS Stroke patients who underwent successful thrombectomy with general anesthesia achieved higher rates of functional independence when procedural ETCO2 exceeded 35 mmHg. Further studies to confirm this effect and investigate optimal ETCO2 parameters should be considered.
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Affiliation(s)
- Matthew S Parr
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Arsalaan Salehani
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mark Ogilvie
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Radiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - B Ethan Tabibian
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sage Rahm
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew T Hale
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Georges Bouobda Tsemo
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Akshay Aluri
- Heersink School of Medicine, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jinsuh Kim
- Department of Radiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Mali Mathru
- Department of Anesthesiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jesse G A Jones
- Department of Neurosurgery, 9968University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Radiology, 9968University of Alabama at Birmingham, Birmingham, AL, USA
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19
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Hale AT, He J, Jones J. Integrative Genomics Analysis Implicates Decreased FGD6 Expression Underlying Risk of Intracranial Aneurysm Rupture. Neurosurgery Open 2022. [DOI: 10.1227/neuopn.0000000000000025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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20
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Hale AT, He J, Jones J. Multinational Genome-Wide Association Study and Functional Genomics Analysis Implicates Decreased SIRT3 Expression Underlying Intracranial Aneurysm Risk. Neurosurgery 2022; 91:625-632. [PMID: 35838494 DOI: 10.1227/neu.0000000000002082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 05/23/2022] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The genetic mechanisms regulating intracranial aneurysm (IA) formation and rupture are largely unknown. To identify germline-genetic risk factors for IA, we perform a multinational genome-wide association study (GWAS) of individuals from the United Kingdom, Finland, and Japan. OBJECTIVE To identify a shared, multinational genetic basis of IA. METHODS Using GWAS summary statistics from UK Biobank, FinnGen, and Biobank Japan, we perform a meta-analysis of IA, containing ruptured and unruptured IA cases. Logistic regression was used to identify IA-associated single-nucleotide polymorphisms. Effect size was calculated using the coefficient r , estimating the contribution of the single-nucleotide polymorphism to the genetic variance of the trait. Genome-wide significance was set at 5.0 × 10 -8 . Expression quantitative trait loci mapping and functional genomics approaches were used to infer mechanistic consequences of implicated variants. RESULTS Our cohort contained 155 154 individuals (3132 IA cases and 152 022 controls). We identified 4 genetic loci reaching genome-wide: rs73392700 ( SIRT3 , effect size = 0.28, P = 4.3 × 10 -12 ), rs58721068 ( EDNRA , effect size = -0.20, P = 4.8 × 10 -12 ), rs4977574 ( AL359922.1 , effect size = 0.18, P = 7.9 × 10 -12 ), and rs11105337 ( ATP2B1 , effect size = -0.15, P = 3.4 × 10 -8 ). Expression quantitative trait loci mapping suggests that rs73392700 has a large effect size on SIRT3 gene expression in arterial and muscle, but not neurological, tissues. Functional genomics analysis suggests that rs73392700 causes decreased SIRT3 gene expression. CONCLUSION We perform a multinational GWAS of IA and identify 4 genetic risk loci, including 2 novel IA risk loci ( SIRT3 and AL359922.1 ). Identification of high-risk genetic loci across ancestries will enable population-genetic screening approaches to identify patients with IA.
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Affiliation(s)
- Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jing He
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jesse Jones
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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21
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Stein JS, Estevez-Ordonez D, Laskay NMB, Atchley TJ, Saccomano BW, Hale AT, Patel OU, Burge K, Haynes W, Yadav I, Van Wagoner N, Markert JM. Assessing the Impact of Changes to USMLE Step 1 Grading on Evaluation of Neurosurgery Residency Applicants in the United States: A Program Director Survey. World Neurosurg 2022; 166:e511-e520. [PMID: 35843584 DOI: 10.1016/j.wneu.2022.07.045] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neurosurgery (NS) is among the most selective specialties in the United States. As the United States Medical Licensing Examination (USMLE) Step 1 transitions to a binary pass/fail score, residency programs face unclear challenges in screening and evaluating applicants. The aim of this study is to provide insights into the perceived impact of changes to the USMLE Step 1 grading in the applicant selection process. METHODS We created a survey using questions regarding NS program demographics, the perceived predictive abilities of Step 1 and Step 2 clinical knowledge (CK), and several factors that programs consider when assessing applicants. We queried program directors (PDs), program coordinators (PCs), and assistant PDs at 117 NS residency programs. Respondents were asked to rank these factors in order of importance for selection at their respective training program. We used descriptive statistics and a Wilcoxon matched-pairs signed-rank test to evaluate the effects of these changes using STATA 17. RESULTS A total of 35 (30%) residency programs responded with 26 (74%) completing the factor ranking questions. 86% (95% confidence interval, 71.5%-94.3%) disagreed that the changes will better prepare students clinically. USMLE Step 2 CK scores, class rank, and away rotations saw significant increases in priority in the absence of a graded Step 1, whereas letters of recommendation and surrogates for research productivity saw notable, but not significant, changes after adjusting for multiple testing. CONCLUSIONS Reporting binary Step 1 grades marks a significant shift in assessing applicants for NS residency by emphasizing Step 2 CK, class rank, and research productivity.
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Affiliation(s)
- John S Stein
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Nicholas M B Laskay
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Travis J Atchley
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Benjamin W Saccomano
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Om U Patel
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Kaitlin Burge
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Will Haynes
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Ishant Yadav
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Nicholas Van Wagoner
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - James M Markert
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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22
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Savage C, Hale AT, Parr MS, Hedaya A, Saccomano BW, Tsemo GB, Hafeez MU, Tanweer O, Kan P, Solomon LJ, Meila D, Dirks PB, Blount JP, Johnston JM, Rocque BG, Rozzelle CJ, Bhatia K, Muthusami P, Krings T, Jones J. Outcomes of endovascular embolization for Vein of Galen malformations: An individual participant data meta-analysis. Front Pediatr 2022; 10:976060. [PMID: 36245731 PMCID: PMC9561813 DOI: 10.3389/fped.2022.976060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022] Open
Abstract
Introduction Understanding outcomes after Vein of Galen malformation (VOGM) embolization has been limited by small sample size in reported series and predominantly single center studies. To address these limitations, we perform an individual-participant meta-analysis (IPMA) to identify risk factors associated with all-cause mortality and clinical outcome after VOGM endovascular embolization. Methods We performed a systematic review and IPMA of VOGM endovascular outcomes according to PRISMA guidelines. Individual patient characteristics including demographic, intra/post-operative adverse events, treatment efficacy (partial or complete occlusion), and clinical outcome were collected. Mixed-effects logistic regression with random effects modeling and Bonferroni correction was used (p ≤ 0.003 threshold for statistical significance). The primary and secondary outcomes were all-cause mortality and poor clinical outcome (moderate/severe developmental delay or permanent disabling injury), respectively. Data are expressed as (mean ± standard deviation (SD)) or (odds ratio (OR), 95% confidence interval (CI), I 2, p-value). Results Thirty-five studies totaling 307 participants quantifying outcomes after endovascular embolization for VOGM were included. Follow up time was 42 (±57) months. Our analysis contained 42% neonates (<1 month) at first embolization, 45% infants (1 month ≤2 years), and 13% children (>2 years). Complete occlusion was reported in 48% of participants. Overall all-cause mortality was 16%. Overall, good clinical outcome was achieved in 68% of participants. First embolization as a neonate [OR = 6.93; 95% CI (1.99-24.08); I 2 < 0.01; p < 0.001] and incomplete embolization [OR = 10.87; 95% CI (1.86-63.55); I 2 < 0.01; p < 0.001] were associated with mortality. First embolization as a neonate [OR = 3.24; 95% CI (1.47-7.15); I 2 < 0.01; p < 0.001], incomplete embolization [OR = 5.26; 95% CI (2.06-13.43); I 2 < 0.01; p < 0.001], and heart failure at presentation [OR = 3.10; 95% CI (1.03-9.33); I 2 < 0.01; p = 0.002] were associated with poor clinical outcomes. Sex, angioarchitecture of lesion, embolization approach (transvenous vs. transarterial), and single or multistage embolization were not associated with mortality or clinical outcome. Conclusions We identify incomplete VOGM embolization independently associated with mortality and poor clinical outcome. While this study provides the highest level of evidence for VOGM embolization to date, prospective multicenter studies are needed to understand the optimal treatment strategies, outcomes, and natural history after VOGM embolization.
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Affiliation(s)
- Cody Savage
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Andrew T. Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Matthew S. Parr
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Alexander Hedaya
- Department of Neurology, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Benjamin W. Saccomano
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Georges Bouobda Tsemo
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Muhammad U. Hafeez
- Department of Neurology, Baylor College of Medicine, Houston, TX, United States
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston TX, United States
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, TX, United States
| | - Laurent J. Solomon
- Department of Obstetrics and Fetal Medicine, Paris Descartes University, Assistance Publique-Hôpitaux de Paris, Hôpital Necker Enfants, Paris, France
| | - Dan Meila
- Department of Interventional Radiology, Helois Klinikum Krefeld, Johanna-Etienne Hospital Neuss, Neuss, Germany
| | - Peter B. Dirks
- Division of Pediatric Neurosurgery, The Hospital for Sick Children, Toronto, ON, Canada
| | - Jeffrey P. Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - James M. Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Brandon G. Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Curtis J. Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Kartik Bhatia
- Department of Medical Imaging, Sydney Children’s Hospital Network, Westmead, NSW, Australia
| | - Prakash Muthusami
- Division of Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Timo Krings
- Division of Interventional Radiology, University of Toronto and the Hospital for Sick Children, Toronto, ON, Canada
| | - Jesse Jones
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, United States
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23
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Hale AT, Chari A, Scott RC, Cross JH, Rozzelle CJ, Blount JP, Tisdall MM. Expedited epilepsy surgery prior to drug resistance in children: a frontier worth crossing? Brain 2022; 145:3755-3762. [PMID: 35883201 DOI: 10.1093/brain/awac275] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 06/18/2022] [Accepted: 07/08/2022] [Indexed: 11/14/2022] Open
Abstract
Epilepsy surgery is an established safe and effective treatment for selected candidates with drug-resistant epilepsy. In this opinion piece, we outline the clinical and experimental evidence for selectively considering epilepsy surgery prior to drug resistance. Our rationale for expedited surgery is based on the observations that, 1) a high proportion of patients with lesional epilepsies (e.g. focal cortical dysplasia, epilepsy associated tumours) will progress to drug-resistance, 2) surgical treatment of these lesions, especially in non-eloquent areas of brain, is safe, and 3) earlier surgery may be associated with better seizure outcomes. Potential benefits beyond seizure reduction or elimination include less exposure to anti-seizure medications (ASM), which may lead to improved developmental trajectories in children and optimize long-term neurocognitive outcomes and quality of life. Further, there exists emerging experimental evidence that brain network dysfunction exists at the onset of epilepsy, where continuing dysfunctional activity could exacerbate network perturbations. This in turn could lead to expanded seizure foci and contribution to the comorbidities associated with epilepsy. Taken together, we rationalize that epilepsy surgery, in carefully selected cases, may be considered prior to drug resistance. Lastly, we outline the path forward, including the challenges associated with developing the evidence base and implementing this paradigm into clinical care.
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Affiliation(s)
- Andrew T Hale
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK.,Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Rod C Scott
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Paediatric Neurology, Nemours Children's Hospital, Wilmington, DE, USA.,Department of Paediatric Neurology, Great Ormond Street Hospital, London, UK
| | - J Helen Cross
- Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.,Department of Paediatric Neurology, Great Ormond Street Hospital, London, UK
| | - Curtis J Rozzelle
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Martin M Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK.,Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
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24
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Chisolm PF, Warner JD, Hale AT, Estevez-Ordonez D, Murdaugh D, Rozzelle CJ, Blount JP. Quantifying and Reporting Outcomes in Pediatric Epilepsy Surgery: A Systematic Review. Epilepsia 2022; 63:2754-2781. [PMID: 35847999 DOI: 10.1111/epi.17369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/15/2022] [Accepted: 07/15/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Several instruments and outcomes measures have been reported in pediatric patients undergoing epilepsy surgery. The objective of this systematic review is to summarize, evaluate, and quantify outcome metrics for the surgical treatment of pediatric epilepsy that address seizure frequency, neuropsychological, and health-related quality of life (HRQL). METHODS We performed a systematic review according to PRISMA guidelines to identify publications between 2010 and June 2021 from PubMed, Embase, and the Cochrane Database of Systematic Reviews that report clinical outcomes in pediatric epilepsy surgery. RESULTS Eighty-one papers were included for review. Overall, rates of post-operative seizure frequency were the most common metric reported (n= 78 studies, 96%). Among the seizure frequency metrics, the Engel Epilepsy Surgery Outcome Scale (n= 48 studies, 59%) was most commonly reported. Neuropsychological outcomes, performed in 32 studies (40%) were assessed using 36 different named metrics. Health-Related Quality of Life (HRQL) outcomes were performed in 16 studies (20%) using 13 different metrics. Forty-six studies (57%) reported postoperative changes in anti-epileptic drug (AED) regimen and time-to-event analysis was performed in 15 (19%) studies. Only 13 outcomes metrics (1/5 seizure frequency, 6/13 HRQL, 6/36 neuropsychological) have been validated for use in pediatric patients with epilepsy and only 13 have been assessed through reliability studies (4/5 seizure frequency, 6/13 HRQL, and 3/36 neuropsychological). Of the 81 included studies, 17 (21%) used at least one validated metric. SIGNIFICANCE Outcome variable metrics in pediatric epilepsy surgery are highly variable. While nearly all studies report seizure frequency, there is considerable variation in reporting. HRQL and neuropsychological outcomes are less frequently and much more heterogeneously reported. Reliable and validated outcomes metrics should be used to increase standardization and accuracy of reporting outcomes in pediatric patients undergoing epilepsy surgery.
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Affiliation(s)
- Paul F Chisolm
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jeffrey D Warner
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Andrew T Hale
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Donna Murdaugh
- Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Curtis J Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
| | - Jeffrey P Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA.,Division of Pediatric Neurosurgery, Children's of Alabama, Birmingham, AL, USA
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Greenberg JK, Olsen MA, Johnson GW, Ahluwalia R, Hill M, Hale AT, Belal A, Baygani S, Foraker RE, Carpenter CR, Ackerman LL, Noje C, Jackson EM, Burns E, Sayama CM, Selden NR, Vachhrajani S, Shannon CN, Kuppermann N, Limbrick DD. Measures of Intracranial Injury Size Do Not Improve Clinical Decision Making for Children With Mild Traumatic Brain Injuries and Intracranial Injuries. Neurosurgery 2022; 90:691-699. [PMID: 35285454 PMCID: PMC9117421 DOI: 10.1227/neu.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND When evaluating children with mild traumatic brain injuries (mTBIs) and intracranial injuries (ICIs), neurosurgeons intuitively consider injury size. However, the extent to which such measures (eg, hematoma size) improve risk prediction compared with the kids intracranial injury decision support tool for traumatic brain injury (KIIDS-TBI) model, which only includes the presence/absence of imaging findings, remains unknown. OBJECTIVE To determine the extent to which measures of injury size improve risk prediction for children with mild traumatic brain injuries and ICIs. METHODS We included children ≤18 years who presented to 1 of the 5 centers within 24 hours of TBI, had Glasgow Coma Scale scores of 13 to 15, and had ICI on neuroimaging. The data set was split into training (n = 1126) and testing (n = 374) cohorts. We used generalized linear modeling (GLM) and recursive partitioning (RP) to predict the composite of neurosurgery, intubation >24 hours, or death because of TBI. Each model's sensitivity/specificity was compared with the validated KIIDS-TBI model across 3 decision-making risk cutoffs (<1%, <3%, and <5% predicted risk). RESULTS The GLM and RP models included similar imaging variables (eg, epidural hematoma size) while the GLM model incorporated additional clinical predictors (eg, Glasgow Coma Scale score). The GLM (76%-90%) and RP (79%-87%) models showed similar specificity across all risk cutoffs, but the GLM model had higher sensitivity (89%-96% for GLM; 89% for RP). By comparison, the KIIDS-TBI model had slightly higher sensitivity (93%-100%) but lower specificity (27%-82%). CONCLUSION Although measures of ICI size have clear intuitive value, the tradeoff between higher specificity and lower sensitivity does not support the addition of such information to the KIIDS-TBI model.
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Affiliation(s)
- Jacob K. Greenberg
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Margaret A. Olsen
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Gabrielle W. Johnson
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Ranbir Ahluwalia
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
| | - Madelyn Hill
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA;
| | - Andrew T. Hale
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
| | - Ahmed Belal
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA;
| | - Shawyon Baygani
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA;
| | - Randi E. Foraker
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Laurie L. Ackerman
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA;
| | - Corina Noje
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Critical Care Medicine, The Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA;
| | - Eric M. Jackson
- Neurological Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA;
| | - Erin Burns
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA;
| | - Christina M. Sayama
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA;
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA;
| | - Nathan R. Selden
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA;
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA;
| | - Shobhan Vachhrajani
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA;
- Department of Pediatrics, Wright State University, Dayton, Ohio, USA;
| | - Chevis N. Shannon
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA;
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis, School of Medicine, Sacramento, California, USA;
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, California, USA
| | - David D. Limbrick
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
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26
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Greenberg JK, Olsen M, Johnson G, Ahluwalia R, Hill M, Hale AT, Belal AMA, Baygani S, Foraker R, Carpenter C, Ackerman L, Noje C, Jackson E, Burns E, Sayama CM, Selden NR, Vachhrajani SH, Shannon C, Kuppermann N, Limbrick DD. 133 Quantitative Imaging Measurements Marginally Improve Risk Prediction for Children with Mild Traumatic Brain Injuries and Intracranial Injuries. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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27
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Hale AT, Akinnusotu O, He J, Sale R, Wang J, Bastarache L, Gamazon ER. 128 Genome-wide Association Study Reveals Genetic Risk Factors for Trigeminal Neuralgia. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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28
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Greenberg JK, Ahluwalia R, Hill M, Johnson G, Hale AT, Belal AMA, Baygani S, Olsen M, Foraker R, Carpenter C, Yan Y, Ackerman L, Noje C, Jackson E, Burns E, Sayama CM, Selden NR, Vachhrajani SH, Shannon C, Kuppermann N, Limbrick DD. 129 Development and External Validation of the KIIDS-TBI Tool for Managing Children with Mild Traumatic Brain Injury and Intracranial Injuries. Neurosurgery 2022. [DOI: 10.1227/neu.0000000000001880_129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Eisele BS, Wu AJ, Luka Z, Hale AT, York JD. Bisphosphate nucleotidase 2 (BPNT2), a molecular target of lithium, regulates chondroitin sulfation patterns in the cerebral cortex and hippocampus. Adv Biol Regul 2022; 83:100858. [PMID: 34920982 PMCID: PMC8858884 DOI: 10.1016/j.jbior.2021.100858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 12/06/2021] [Accepted: 12/07/2021] [Indexed: 01/03/2023]
Abstract
Bisphosphate nucleotidase 2 (BPNT2) is a member of a family of phosphatases that are directly inhibited by lithium, the first-line medication for bipolar disorder. BPNT2 is localized to the Golgi, where it metabolizes the by-products of glycosaminoglycan sulfation reactions. BPNT2-knockout mice exhibit impairments in total-body chondroitin-4-sulfation which lead to abnormal skeletal development (chondrodysplasia). These mice die in the perinatal period, which has previously prevented the investigation of BPNT2 in the adult nervous system. Previous work has demonstrated the importance of chondroitin sulfation in the brain, as chondroitin-4-sulfate is a major component of perineuronal nets (PNNs), a specialized neuronal extracellular matrix which mediates synaptic plasticity and regulates certain behaviors. We hypothesized that the loss of BPNT2 in the nervous system would decrease chondroitin-4-sulfation and PNNs in the brain, which would coincide with behavioral abnormalities. We used Cre-lox breeding to knockout Bpnt2 specifically in the nervous system using Bpnt2 floxed (fl/fl) animals and a Nestin-driven Cre recombinase. These mice are viable into adulthood, and do not display gross physical abnormalities. We identified decreases in total glycosaminoglycan sulfation across selected brain regions, and specifically show decreases in chondroitin-4-sulfation which correspond with increases in chondroitin-6-sulfation. Interestingly, these changes were not correlated with gross alterations in PNNs. We also subjected these mice to a selection of neurobehavioral assessments and did not identify significant behavioral abnormalities. In summary, this work demonstrates that BPNT2, a known target of lithium, is important for glycosaminoglycan sulfation in the brain, suggesting that lithium-mediated inhibition of BPNT2 in the nervous system warrants further investigation.
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Affiliation(s)
- BS Eisele
- Department of Pharmacology, Vanderbilt University, Nashville, TN, USA.,Department of Biochemistry, Vanderbilt University, Nashville, TN, USA
| | - AJ Wu
- Department of Biochemistry, Vanderbilt University, Nashville, TN, USA
| | - Z Luka
- Department of Biochemistry, Vanderbilt University, Nashville, TN, USA
| | - AT Hale
- Department of Biochemistry, Vanderbilt University, Nashville, TN, USA
| | - JD York
- Department of Biochemistry, Vanderbilt University, Nashville, TN, USA.,Correspondence to: John D. York.
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30
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Greenberg JK, Ahluwalia R, Hill M, Johnson G, Hale AT, Belal A, Baygani S, Olsen MA, Foraker RE, Carpenter CR, Yan Y, Ackerman L, Noje C, Jackson E, Burns E, Sayama CM, Selden NR, Vachhrajani S, Shannon CN, Kuppermann N, Limbrick DD. Development and external validation of the KIIDS-TBI tool for managing children with mild traumatic brain injury and intracranial injuries. Acad Emerg Med 2021; 28:1409-1420. [PMID: 34245632 DOI: 10.1111/acem.14333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/06/2021] [Accepted: 06/24/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND Clinical decision support (CDS) may improve the postneuroimaging management of children with mild traumatic brain injuries (mTBI) and intracranial injuries. While the CHIIDA score has been proposed for this purpose, a more sensitive risk model may have broader use. Consequently, this study's objectives were to: (1) develop a new risk model with improved sensitivity compared to the CHIIDA model and (2) externally validate the new model and CHIIDA model in a multicenter data set. METHODS We analyzed children ≤18 years old with mTBI and intracranial injuries included in the PECARN head injury data set (2004-2006). We used binary recursive partitioning to predict the composite outcome of neurosurgical intervention, intubation for > 24 h due to TBI, or death due to TBI. The new model was externally validated in a separate data set that included children treated at any one of six centers from 2006 to 2019. RESULTS Based on 839 patients from the PECARN data set, a new risk model, the KIIDS-TBI model, was developed that incorporated imaging (e.g., midline shift) and clinical (e.g., Glasgow Coma Scale score) findings. Based on the model-predicted probability of the composite outcome, three cutoffs were evaluated to classify patients as "high risk" for level of care decisions. In the external validation data set consisting of 1,630 patients, the most conservative cutoff (i.e., any predictor present) identified 119 of 119 children with the composite outcome (sensitivity = 100%), but had the lowest specificity (26.3%). The other two decision-making cutoffs had worse sensitivity (94.1%-96.6%) but improved specificity (67.4%-81.3%). The CHIIDA model lacked the most conservative cutoff and otherwise showed the same or slightly worse performance compared to the other two cutoffs. CONCLUSIONS The KIIDS-TBI model has high sensitivity and moderate specificity for risk stratifying children with mTBI and intracranial injuries. Use of this CDS tool may help improve the safe, resource-efficient management of this important patient population.
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Affiliation(s)
- Jacob K. Greenberg
- Department of Neurological Surgery Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Ranbir Ahluwalia
- Department of Neurological Surgery Vanderbilt University Medical Center Nashville TN USA
| | - Madelyn Hill
- Department of Neurological Surgery Dayton Children’s Hospital Dayton OH USA
| | - Gabbie Johnson
- Department of Neurological Surgery Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Andrew T. Hale
- Department of Neurological Surgery Vanderbilt University Medical Center Nashville TN USA
| | - Ahmed Belal
- Department of Neurological Surgery Indiana University School of Medicine Indianapolis IN USA
| | - Shawyon Baygani
- Department of Neurological Surgery Indiana University School of Medicine Indianapolis IN USA
| | - Margaret A. Olsen
- Department of Medicine Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Randi E. Foraker
- Department of Medicine Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Yan Yan
- Department of Surgery Washington University School of Medicine in St. Louis St. Louis MO USA
| | - Laurie Ackerman
- Department of Neurological Surgery Indiana University School of Medicine Indianapolis IN USA
| | - Corina Noje
- Department of Anesthesiology Johns Hopkins School of Medicine Baltimore MD USA
| | - Eric Jackson
- Department of Neurological Surgery Johns Hopkins School of Medicine Baltimore MD USA
| | - Erin Burns
- Department of Pediatrics Oregon Health and Science University Portland OR USA
| | - Christina M. Sayama
- Department of Neurological Surgery Oregon Health and Science University Portland OR USA
| | - Nathan R. Selden
- Department of Neurological Surgery Oregon Health and Science University Portland OR USA
| | | | - Chevis N. Shannon
- Department of Neurological Surgery Vanderbilt University Medical Center Nashville TN USA
- American Society for Reproductive Medicine University of California Davis Davis CA USA
| | - Nathan Kuppermann
- Department of Emergency Medicine University of California–Davis Davis CA USA
| | - David D. Limbrick
- Department of Neurological Surgery Washington University School of Medicine in St. Louis St. Louis MO USA
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31
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Eisele BS, Luka Z, Wu AJ, Yang F, Hale AT, York JD. Sulfation of glycosaminoglycans depends on the catalytic activity of lithium-inhibited phosphatase BPNT2 in vitro. J Biol Chem 2021; 297:101293. [PMID: 34634304 PMCID: PMC8551643 DOI: 10.1016/j.jbc.2021.101293] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 01/02/2023] Open
Abstract
Golgi-resident bisphosphate nucleotidase 2 (BPNT2) is a member of a family of magnesium-dependent, lithium-inhibited phosphatases that share a three-dimensional structural motif that directly coordinates metal binding to effect phosphate hydrolysis. BPNT2 catalyzes the breakdown of 3'-phosphoadenosine-5'-phosphate, a by-product of glycosaminoglycan (GAG) sulfation. KO of BPNT2 in mice leads to skeletal abnormalities because of impaired GAG sulfation, especially chondroitin-4-sulfation, which is critical for proper extracellular matrix development. Mutations in BPNT2 have also been found to underlie a chondrodysplastic disorder in humans. The precise mechanism by which the loss of BPNT2 impairs sulfation remains unclear. Here, we used mouse embryonic fibroblasts (MEFs) to test the hypothesis that the catalytic activity of BPNT2 is required for GAG sulfation in vitro. We show that a catalytic-dead Bpnt2 construct (D108A) does not rescue impairments in intracellular or secreted sulfated GAGs, including decreased chondroitin-4-sulfate, present in Bpnt2-KO MEFs. We also demonstrate that missense mutations in Bpnt2 adjacent to the catalytic site, which are known to cause chondrodysplasia in humans, recapitulate defects in overall GAG sulfation and chondroitin-4-sulfation in MEF cultures. We further show that treatment of MEFs with lithium (a common psychotropic medication) inhibits GAG sulfation and that this effect depends on the presence of BPNT2. Taken together, this work demonstrates that the catalytic activity of an enzyme potently inhibited by lithium can modulate GAG sulfation and therefore extracellular matrix composition, revealing new insights into lithium pharmacology.
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Affiliation(s)
- Brynna S Eisele
- Department of Biochemistry, Vanderbilt University, Nashville, Tennessee, USA; Department of Pharmacology, Vanderbilt University, Nashville, Tennessee, USA
| | - Zigmund Luka
- Department of Biochemistry, Vanderbilt University, Nashville, Tennessee, USA
| | - Alice J Wu
- Department of Biochemistry, Vanderbilt University, Nashville, Tennessee, USA
| | - Fei Yang
- Department of Biochemistry, Vanderbilt University, Nashville, Tennessee, USA
| | - Andrew T Hale
- Department of Biochemistry, Vanderbilt University, Nashville, Tennessee, USA
| | - John D York
- Department of Biochemistry, Vanderbilt University, Nashville, Tennessee, USA.
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Hale AT, Akinnusotu O, He J, Wang J, Hibshman N, Shannon CN, Naftel RP. Genome-Wide Association Study Identifies Genetic Risk Factors for Spastic Cerebral Palsy. Neurosurgery 2021; 89:435-442. [PMID: 34098570 PMCID: PMC8364821 DOI: 10.1093/neuros/nyab184] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/31/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Although many clinical risk factors of spastic cerebral palsy (CP) have been identified, the genetic basis of spastic CP is largely unknown. Here, using whole-genome genetic information linked to a deidentified electronic health record (BioVU) with replication in the UK Biobank and FinnGen, we perform the first genome-wide association study (GWAS) for spastic CP. OBJECTIVE To define the genetic basis of spastic CP. METHODS Whole-genome data were obtained using the multi-ethnic genotyping array (MEGA) genotyping array capturing single-nucleotide polymorphisms (SNPs), minor allele frequency (MAF) > 0.01, and imputation quality score (r2) > 0.3, imputed based on the 1000 genomes phase 3 reference panel. Threshold for genome-wide significance was defined after Bonferroni correction for the total number of SNPs tested (P < 5.0 × 10-8). Replication analysis (defined as P < .05) was performed in the UK Biobank and FinnGen. RESULTS We identify 1 SNP (rs78686911) reaching genome-wide significance with spastic CP. Expression quantitative trait loci (eQTL) analysis suggests that rs78686911 decreases expression of GRIK4, a gene that encodes a high-affinity kainate glutamatergic receptor of largely unknown function. Replication analysis in the UK Biobank and FinnGen reveals additional SNPs in the GRIK4 loci associated with CP. CONCLUSION To our knowledge, we perform the first GWAS of spastic CP. Our study indicates that genetic variation contributes to CP risk.
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Affiliation(s)
- Andrew T Hale
- Vanderbilt University School of Medicine, Medical Scientist Training Program, Nashville, Tennessee, USA
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
- Division of Genetic Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Oluwatoyin Akinnusotu
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
| | - Jing He
- Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Janey Wang
- Department of Bioinformatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Natalie Hibshman
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee, USA
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Hale AT, Bastarache L, Morales DM, Wellons JC, Limbrick DD, Gamazon ER. Multi-omic analysis elucidates the genetic basis of hydrocephalus. Cell Rep 2021; 35:109085. [PMID: 33951428 PMCID: PMC8124085 DOI: 10.1016/j.celrep.2021.109085] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2019] [Revised: 07/01/2019] [Accepted: 04/14/2021] [Indexed: 11/17/2022] Open
Abstract
We conducted PrediXcan analysis of hydrocephalus risk in ten neurological tissues and whole blood. Decreased expression of MAEL in the brain was significantly associated (Bonferroni-adjusted p < 0.05) with hydrocephalus. PrediXcan analysis of brain imaging and genomics data in the independent UK Biobank (N = 8,428) revealed that MAEL expression in the frontal cortex is associated with white matter and total brain volumes. Among the top differentially expressed genes in brain, we observed a significant enrichment for gene-level associations with these structural phenotypes, suggesting an effect on disease risk through regulation of brain structure and integrity. We found additional support for these genes through analysis of the choroid plexus transcriptome of a murine model of hydrocephalus. Finally, differential protein expression analysis in patient cerebrospinal fluid recapitulated disease-associated expression changes in neurological tissues, but not in whole blood. Our findings provide convergent evidence highlighting the importance of tissue-specific pathways and mechanisms in the pathophysiology of hydrocephalus. Hale et al. present an integrated omics approach to characterize the genetic basis of hydrocephalus. They reveal tissue-specific genetic associations and enrichment of genes associated with human brain structure phenotypes. Validation of hydrocephalus-associated genes in mouse choroid plexus and human cerebrospinal fluid supports polygenic contributions to hydrocephalus risk.
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Affiliation(s)
- Andrew T Hale
- Vanderbilt University School of Medicine, Medical Scientist Training Program, Nashville, TN 37232, USA; Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN 37232, USA.
| | - Lisa Bastarache
- Department of Bioinformatics, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Diego M Morales
- Division of Pediatric Neurosurgery, St. Louis Children's Hospital, St. Louis, MO 63110, USA
| | - John C Wellons
- Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN 37232, USA
| | - David D Limbrick
- Division of Pediatric Neurosurgery, St. Louis Children's Hospital, St. Louis, MO 63110, USA
| | - Eric R Gamazon
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, TN 37232, USA; Data Science Institute, Vanderbilt University, Nashville, TN 37232, USA; Clare Hall, University of Cambridge, Cambridge CB3 9AL, UK; MRC Epidemiology Unit, University of Cambridge, Cambridge CB3 9AL, UK.
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Hale AT, Riva-Cambrin J, Wellons JC, Jackson EM, Kestle JRW, Naftel RP, Hankinson TC, Shannon CN. Machine learning predicts risk of cerebrospinal fluid shunt failure in children: a study from the hydrocephalus clinical research network. Childs Nerv Syst 2021; 37:1485-1494. [PMID: 33515058 DOI: 10.1007/s00381-021-05061-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE While conventional statistical approaches have been used to identify risk factors for cerebrospinal fluid (CSF) shunt failure, these methods may not fully capture the complex contribution of clinical, radiologic, surgical, and shunt-specific variables influencing this outcome. Using prospectively collected data from the Hydrocephalus Clinical Research Network (HCRN) patient registry, we applied machine learning (ML) approaches to create a predictive model of CSF shunt failure. METHODS Pediatric patients (age < 19 years) undergoing first-time CSF shunt placement at six HCRN centers were included. CSF shunt failure was defined as a composite outcome including requirement for shunt revision, endoscopic third ventriculostomy, or shunt infection within 5 years of initial surgery. Performance of conventional statistical and 4 ML models were compared. RESULTS Our cohort consisted of 1036 children undergoing CSF shunt placement, of whom 344 (33.2%) experienced shunt failure. Thirty-eight clinical, radiologic, surgical, and shunt-design variables were included in the ML analyses. Of all ML algorithms tested, the artificial neural network (ANN) had the strongest performance with an area under the receiver operator curve (AUC) of 0.71. The ANN had a specificity of 90% and a sensitivity of 68%, meaning that the ANN can effectively rule-in patients most likely to experience CSF shunt failure (i.e., high specificity) and moderately effective as a tool to rule-out patients at high risk of CSF shunt failure (i.e., moderately sensitive). The ANN was independently validated in 155 patients (prospectively collected, retrospectively analyzed). CONCLUSION These data suggest that the ANN, or future iterations thereof, can provide an evidence-based tool to assist in prognostication and patient-counseling immediately after CSF shunt placement.
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Affiliation(s)
- Andrew T Hale
- Medical Scientist Training Program, Vanderbilt University School of Medicine, 2200 Pierce Ave., Light Hall 514, Nashville, TN, 37232, USA. .,Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
| | - John C Wellons
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.,Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins Children's Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John R W Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, UT, USA
| | - Robert P Naftel
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.,Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
| | - Todd C Hankinson
- Division of Pediatric Neurosurgery, Children's Hospital Colorado, Aurora, CO, USA
| | - Chevis N Shannon
- Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA.,Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN, USA
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Sadler B, Wilborn J, Antunes L, Kuensting T, Hale AT, Gannon SR, McCall K, Cruchaga C, Harms M, Voisin N, Reymond A, Cappuccio G, Brunetti-Pierri N, Tartaglia M, Niceta M, Leoni C, Zampino G, Ashley-Koch A, Urbizu A, Garrett ME, Soldano K, Macaya A, Conrad D, Strahle J, Dobbs MB, Turner TN, Shannon CN, Brockmeyer D, Limbrick DD, Gurnett CA, Haller G. Rare and de novo coding variants in chromodomain genes in Chiari I malformation. Am J Hum Genet 2021; 108:530-531. [PMID: 33667397 DOI: 10.1016/j.ajhg.2021.01.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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36
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Sadler B, Wilborn J, Antunes L, Kuensting T, Hale AT, Gannon SR, McCall K, Cruchaga C, Harms M, Voisin N, Reymond A, Cappuccio G, Brunetti-Pierri N, Tartaglia M, Niceta M, Leoni C, Zampino G, Ashley-Koch A, Urbizu A, Garrett ME, Soldano K, Macaya A, Conrad D, Strahle J, Dobbs MB, Turner TN, Shannon CN, Brockmeyer D, Limbrick DD, Gurnett CA, Haller G. Rare and de novo coding variants in chromodomain genes in Chiari I malformation. Am J Hum Genet 2021; 108:100-114. [PMID: 33352116 DOI: 10.1016/j.ajhg.2020.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 11/24/2020] [Indexed: 12/16/2022] Open
Abstract
Chiari I malformation (CM1), the displacement of the cerebellum through the foramen magnum into the spinal canal, is one of the most common pediatric neurological conditions. Individuals with CM1 can present with neurological symptoms, including severe headaches and sensory or motor deficits, often as a consequence of brainstem compression or syringomyelia (SM). We conducted whole-exome sequencing (WES) on 668 CM1 probands and 232 family members and performed gene-burden and de novo enrichment analyses. A significant enrichment of rare and de novo non-synonymous variants in chromodomain (CHD) genes was observed among individuals with CM1 (combined p = 2.4 × 10-10), including 3 de novo loss-of-function variants in CHD8 (LOF enrichment p = 1.9 × 10-10) and a significant burden of rare transmitted variants in CHD3 (p = 1.8 × 10-6). Overall, individuals with CM1 were found to have significantly increased head circumference (p = 2.6 × 10-9), with many harboring CHD rare variants having macrocephaly. Finally, haploinsufficiency for chd8 in zebrafish led to macrocephaly and posterior hindbrain displacement reminiscent of CM1. These results implicate chromodomain genes and excessive brain growth in CM1 pathogenesis.
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Hale AT, Wellons JC, Limbrick DD, Schiff SJ, Gamazon ER. Alterations in White Matter and Total Brain Volumes Underlie Genetic Risk of Hydrocephalus. Neurosurgery 2020. [DOI: 10.1093/neuros/nyaa447_588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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38
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Mistry AM, Mummareddy N, CreveCoeur TS, Lillard JC, Vaughn BN, Gallant JN, Hale AT, Griffin N, Wellons JC, Limbrick DD, Klimo P, Naftel RP. Association between supratentorial pediatric high-grade gliomas involved with the subventricular zone and decreased survival: a multi-institutional retrospective study. J Neurosurg Pediatr 2020; 26:288-294. [PMID: 32442975 DOI: 10.3171/2020.3.peds19593] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 03/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The subventricular zone (SVZ), housed in the lateral walls of the lateral ventricles, is the largest neurogenic niche in the brain. In adults, high-grade gliomas in contact or involved with the SVZ are associated with decreased survival. Whether this association holds true in the pediatric population remains unexplored. To address this gap in knowledge, the authors conducted this retrospective study in a pediatric population with high-grade gliomas treated at three comprehensive centers in the United States. METHODS The authors retrospectively identified 63 patients, age ≤ 21 years, with supratentorial WHO grade III-IV gliomas treated at three academic centers. Basic demographic and clinical data regarding presenting signs and symptoms and common treatment variables were obtained. Preoperative MRI studies were evaluated to assess SVZ contact by tumor and to quantify tumor volume. RESULTS Sixty-three patients, including 34 males (54%), had a median age of 12.3 years (IQR 6.50-16.2) and a median tumor volume of 39.4 ml (IQR 19.4-65.8). Tumors contacting the SVZ (SVZ+) were noted in 34 patients (54%) and overall were larger than those not in contact with the SVZ (SVZ-; 51.1 vs 27.3, p = 0.002). The SVZ+ tumors were also associated with decreased survival. However, age, tumor volume, tumor grade, and treatment with chemotherapy and/or radiation were not associated with survival in the 63 patients. In the univariable analysis, near-total resection, gross-total resection, and seizure presentation were associated with increased survival (HR = 0.23, 95% CI 0.06-0.88, p = 0.03; HR = 0.26, 95% CI 0.09-0.74, p = 0.01; and HR = 0.46, 95% CI 0.22-0.97, p = 0.04, respectively). In a multivariable stepwise Cox regression analysis, only SVZ+ tumors remained significantly associated with decreased survival (HR = 1.94, 95% CI 1.03-3.64, p = 0.04). CONCLUSIONS High-grade glioma contact with the SVZ neural stem cell niche was associated with a significant decrease in survival in the pediatric population, as it is in the adult population. This result suggests that tumor contact with the SVZ is a general negative prognosticator in high-grade glioma independent of age group and invites biological investigations to understand the SVZ's role in glioma pathobiology.
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Affiliation(s)
| | | | | | - Jock C Lillard
- 4Department of Neurological Surgery, University of Tennessee Health Science Center, Memphis
| | - Brandy N Vaughn
- 4Department of Neurological Surgery, University of Tennessee Health Science Center, Memphis
| | - Jean-Nicolas Gallant
- 5Medical Scientist Training Program, School of Medicine, Vanderbilt University, Nashville
| | - Andrew T Hale
- 5Medical Scientist Training Program, School of Medicine, Vanderbilt University, Nashville
| | - Natalie Griffin
- 3School of Medicine, Washington University, St. Louis, Missouri
| | - John C Wellons
- 1Department of Neurological Surgery, Vanderbilt University Medical Center.,6Vanderbilt Children's Hospital, Nashville, Tennessee; and
| | - David D Limbrick
- 7Department of Neurosurgery, Washington University, St. Louis, Missouri
| | - Paul Klimo
- 4Department of Neurological Surgery, University of Tennessee Health Science Center, Memphis
| | - Robert P Naftel
- 1Department of Neurological Surgery, Vanderbilt University Medical Center.,6Vanderbilt Children's Hospital, Nashville, Tennessee; and
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Chotai S, Chan EW, Ladner TR, Hale AT, Gannon SR, Shannon CN, Bonfield CM, Naftel RP, Wellons JC. Timing of syrinx reduction and stabilization after posterior fossa decompression for pediatric Chiari malformation type I. J Neurosurg Pediatr 2020; 26:193-199. [PMID: 32330878 DOI: 10.3171/2020.2.peds19366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 02/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to determine the timeline of syrinx regression and to identify factors mitigating syrinx resolution in pediatric patients with Chiari malformation type I (CM-I) undergoing posterior fossa decompression (PFD). METHODS The authors conducted a retrospective review of records from pediatric patients (< 18 years old) undergoing PFD for the treatment of CM-I/syringomyelia (SM) between 1998 and 2015. Patient demographic, clinical, radiological, and surgical variables were collected and analyzed. Radiological information was reviewed at 4 time points: 1) pre-PFD, 2) within 6 months post-PFD, 3) within 12 months post-PFD, and 4) at maximum available follow-up. Syrinx regression was defined as ≥ 50% decrease in the maximal anteroposterior syrinx diameter (MSD). The time to syrinx regression was determined using Kaplan-Meier analysis. Multivariate analysis was conducted using a Cox proportional hazards model to determine the association between preoperative, clinical, and surgery-related factors and syrinx regression. RESULTS The authors identified 85 patients with CM-I/SM who underwent PFD. Within 3 months post-PFD, the mean MSD regressed from 8.1 ± 3.4 mm (preoperatively) to 5.6 ± 2.9 mm within 3 months post-PFD. Seventy patients (82.4%) achieved ≥ 50% regression in MSD. The median time to ≥ 50% regression in MSD was 8 months (95% CI 4.2-11.8 months). Using a risk-adjusted multivariable Cox proportional hazards model, the patients who underwent tonsil coagulation (n = 20) had a higher likelihood of achieving ≥ 50% syrinx regression in a shorter time (HR 2.86, 95% CI 1.2-6.9; p = 0.02). Thirty-six (75%) of 45 patients had improvement in headache at 2.9 months (IQR 1.5-4.4 months). CONCLUSIONS The maximum reduction in syrinx size can be expected within 3 months after PFD for patients with CM-I and a syrinx; however, the syringes continue to regress over time. Tonsil coagulation was associated with early syrinx regression in this cohort. However, the role of surgical maneuvers such as tonsil coagulation and arachnoid veil identification and sectioning in the overall role of CM-I surgery remains unclear.
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Affiliation(s)
- Silky Chotai
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emily W Chan
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Travis R Ladner
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,3Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York; and
| | - Andrew T Hale
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Stephen R Gannon
- 2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Robert P Naftel
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,2Surgical Outcomes Center for Kids (SOCKs), Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee.,4Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University Medical Center, Nashville, Tennessee
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40
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Hale AT, Sen S, Haider AS, Perkins FF, Clarke DF, Lee MR, Tomycz LD. Open Resection versus Laser Interstitial Thermal Therapy for the Treatment of Pediatric Insular Epilepsy. Neurosurgery 2020; 85:E730-E736. [PMID: 30888028 DOI: 10.1093/neuros/nyz094] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/28/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Various studies suggest that the insular cortex may play an underappreciated role in pediatric frontotemporal/parietal epilepsy. Here, we report on the postsurgical outcomes in 26 pediatric patients with confirmed insular involvement by depth electrode monitoring. OBJECTIVE To describe one of the largest series of pediatric patients with medically refractory epilepsy undergoing laser interstitial thermal therapy (LITT) or surgical resection of at least some portion of the insular cortex. METHODS Pediatric patients in whom invasive insular sampling confirmed insular involvement and who subsequently underwent a second stage surgery (LITT or open resection) were included. Complications and Engel Class outcomes at least 1 yr postsurgery were compiled as well as pathology results in the open surgical cases. RESULTS The average age in our cohort was 10.3 yr, 58% were male, and the average length of follow-up was 2.43 ± 0.20 (SEM) yr. A total of 14 patients underwent LITT, whereas 12 patients underwent open resection. Complications in patients undergoing either LITT or open resection were mostly minimal and generally transient. Forty-three percent of patients who underwent LITT were Engel Class I, compared to 50% of patients who underwent open insular resection. CONCLUSION Both surgical resection and LITT are valid management options in the treatment of medically refractory insular/opercular epilepsy in children. Although LITT may be a less invasive alternative to craniotomy, further studies are needed to determine its noninferiority in terms of complication rates and seizure freedom, especially in cases of cortical dysplasia that may involve extensive regions of the brain.
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Affiliation(s)
- Andrew T Hale
- Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Sonali Sen
- Division of Child Neurology, Baylor College of Medicine, Houston, Texas
| | - Ali S Haider
- Department of Neurological Surgery, Texas A&M College of Medicine, Bryan, Texas
| | - Freedom F Perkins
- Department of Pediatric Neurology, Dell Children's Hospital, Austin, Texas
| | - Dave F Clarke
- Department of Pediatric Neurology, Texas Children's Hospital, Houston, Texas
| | - Mark R Lee
- Department of Neurological Surgery, Dell Children's Medical Center, Austin, Texas.,Department of Neurological Surgery, Rutgers New Jersey Medical School, Newark, New Jersey
| | - Luke D Tomycz
- Department of Neurosurgery, West Virginia University, Morgantown, West Virginia
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41
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Hale AT, Adelson PD, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bonfield CM, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Durham SR, Ellenbogen RG, Eskandari R, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Johnston JM, Keating RF, Leonard JR, Maher CO, Mangano FT, McComb JG, Meehan T, Menezes AH, O'Neill B, Olavarria G, Park TS, Ragheb J, Selden NR, Shah MN, Smyth MD, Stone SSD, Strahle JM, Wait SD, Wellons JC, Whitehead WE, Shannon CN, Limbrick DD. Factors associated with syrinx size in pediatric patients treated for Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2020; 25:1-11. [PMID: 32114543 DOI: 10.3171/2020.1.peds19493] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Factors associated with syrinx size in pediatric patients undergoing posterior fossa decompression (PFD) or PFD with duraplasty (PFDD) for Chiari malformation type I (CM-I) with syringomyelia (SM; CM-I+SM) are not well established. METHODS Using the Park-Reeves Syringomyelia Research Consortium registry, the authors analyzed variables associated with syrinx radiological outcomes in patients (< 20 years old at the time of surgery) with CM-I+SM undergoing PFD or PFDD. Syrinx resolution was defined as an anteroposterior (AP) diameter of ≤ 2 mm or ≤ 3 mm or a reduction in AP diameter of ≥ 50%. Syrinx regression or progression was defined using 1) change in syrinx AP diameter (≥ 1 mm), or 2) change in syrinx length (craniocaudal, ≥ 1 vertebral level). Syrinx stability was defined as a < 1-mm change in syrinx AP diameter and no change in syrinx length. RESULTS The authors identified 380 patients with CM-I+SM who underwent PFD or PFDD. Cox proportional hazards modeling revealed younger age at surgery and PFDD as being independently associated with syrinx resolution, defined as a ≤ 2-mm or ≤ 3-mm AP diameter or ≥ 50% reduction in AP diameter. Radiological syrinx resolution was associated with improvement in headache (p < 0.005) and neck pain (p < 0.011) after PFD or PFDD. Next, PFDD (p = 0.005), scoliosis (p = 0.007), and syrinx location across multiple spinal segments (p = 0.001) were associated with syrinx diameter regression, whereas increased preoperative frontal-occipital horn ratio (FOHR; p = 0.007) and syrinx location spanning multiple spinal segments (p = 0.04) were associated with syrinx length regression. Scoliosis (HR 0.38 [95% CI 0.16-0.91], p = 0.03) and smaller syrinx diameter (5.82 ± 3.38 vs 7.86 ± 3.05 mm; HR 0.60 [95% CI 0.34-1.03], p = 0.002) were associated with syrinx diameter stability, whereas shorter preoperative syrinx length (5.75 ± 4.01 vs 9.65 ± 4.31 levels; HR 0.21 [95% CI 0.12-0.38], p = 0.0001) and smaller pB-C2 distance (6.86 ± 1.27 vs 7.18 ± 1.38 mm; HR 1.44 [95% CI 1.02-2.05], p = 0.04) were associated with syrinx length stability. Finally, younger age at surgery (8.19 ± 5.02 vs 10.29 ± 4.25 years; HR 1.89 [95% CI 1.31-3.04], p = 0.01) was associated with syrinx diameter progression, whereas increased postoperative syrinx diameter (6.73 ± 3.64 vs 3.97 ± 3.07 mm; HR 3.10 [95% CI 1.67-5.76], p = 0.003), was associated with syrinx length progression. PFD versus PFDD was not associated with syrinx progression or reoperation rate. CONCLUSIONS These data suggest that PFDD and age are independently associated with radiological syrinx improvement, although forthcoming results from the PFDD versus PFD randomized controlled trial (NCT02669836, clinicaltrials.gov) will best answer this question.
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Affiliation(s)
- Andrew T Hale
- 1Vanderbilt University School of Medicine, Medical Scientist Training Program, Nashville, Tennessee
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - P David Adelson
- 3Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Gregory W Albert
- 4Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Philipp R Aldana
- 5Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- 6Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Richard C E Anderson
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York
| | - David F Bauer
- 8Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Bonfield
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - Douglas L Brockmeyer
- 10Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- 11Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, Georgia
| | - Daniel E Couture
- 12Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- 13Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Susan R Durham
- 14Department of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Richard G Ellenbogen
- 15Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- 16Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Timothy M George
- 17Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, Texas
| | - Gerald A Grant
- 18Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, California
| | - Patrick C Graupman
- 19Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- 20Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- 21Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Naina L Gross
- 22Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Daniel J Guillaume
- 23Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gregory G Heuer
- 24Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Iantosca
- 25Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Bermans J Iskandar
- 26Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Eric M Jackson
- 27Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James M Johnston
- 28Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Jeffrey R Leonard
- 30Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Cormac O Maher
- 31Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Francesco T Mangano
- 32Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - J Gordon McComb
- 33Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, California
| | - Thanda Meehan
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Arnold H Menezes
- 35Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Brent O'Neill
- 36Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Tae Sung Park
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Matthew D Smyth
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Scellig S D Stone
- 41Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer M Strahle
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Scott D Wait
- 42Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina; and
| | - John C Wellons
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- 43Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - David D Limbrick
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Hale AT, Gannon SR, Zhao S, Dewan MC, Bhatia R, Bezzerides M, Stanton AN, Naftel RP, Shannon CN, Pruthi S, Wellons JC. Graft dural closure is associated with a reduction in CSF leak and hydrocephalus in pediatric patients undergoing posterior fossa brain tumor resection. J Neurosurg Pediatr 2019; 25:1-7. [PMID: 31783365 DOI: 10.3171/2019.9.peds1939] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 09/16/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to evaluate clinical, radiological, and surgical factors associated with posterior fossa tumor resection (PFTR)-related outcomes, including postoperative complications related to dural augmentation (CSF leak and wound infection), persistent hydrocephalus ultimately requiring permanent CSF diversion after PFTR, and 90-day readmission rate. METHODS Pediatric patients (0-17 years old) undergoing PFTR between 2000 and 2016 at Monroe Carell Jr. Children's Hospital of Vanderbilt University were retrospectively reviewed. Descriptive statistics included the Wilcoxon signed-rank test to compare means that were nonnormally distributed and the chi-square test for categorical variables. Variables that were nominally associated (p < 0.05) with each outcome by univariate analysis were included as covariates in multivariate linear regression models. Statistical significance was set a priori at p < 0.05. RESULTS The cohort consisted of 186 patients with a median age at surgery of 6.62 years (range 3.37-11.78 years), 55% male, 83% Caucasian, and average length of follow-up of 3.87 ± 0.25 years. By multivariate logistic regression, the variables primary dural closure (PDC; odds ratio [OR] 8.33, 95% confidence interval [CI] 1.07-100, p = 0.04), pseudomeningocele (OR 7.43, 95% CI 2.23-23.76, p = 0.0007), and hydrocephalus ultimately requiring permanent CSF diversion within 90 days of PFTR (OR 9.25, 95% CI 2.74-31.2, p = 0.0003) were independently associated with CSF leak. PDC versus graft dural closure (GDC; 35% vs 7%, OR 5.88, 95% CI 2.94-50.0, p = 0.03) and hydrocephalus ultimately requiring permanent CSF diversion (OR 3.30, 95% CI 1.07-10.19, p = 0.0007) were associated with wound infection requiring surgical debridement. By multivariate logistic regression, GDC versus PDC (23% vs 37%, OR 0.13, 95% CI 0.02-0.87, p = 0.04) was associated with persistent hydrocephalus ultimately requiring permanent CSF diversion, whereas pre- or post-PFTR ventricular size, placement of peri- or intraoperative extraventricular drain (EVD), and radiation therapy were not. Furthermore, the addition of perioperative EVD placement and dural closure method to a previously validated predictive model of post-PFTR hydrocephalus improved its performance from area under the receiver operating characteristic curve of 0.69 to 0.74. Lastly, the authors found that autologous (vs synthetic) grafts may be protective against persistent hydrocephalus (p = 0.02), but not CSF leak, pseudomeningocele, or wound infection. CONCLUSIONS These results suggest that GDC, independent of potential confounding factors, may be protective against CSF leak, wound infection, and hydrocephalus in patients undergoing PFTR. Additional studies are warranted to further evaluate clinical and surgical factors impacting PFTR-associated complications.
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Affiliation(s)
- Andrew T Hale
- 1Medical Scientist Training Program, and
- 2Surgical Outcomes Center for Kids, and
| | - Stephen R Gannon
- 2Surgical Outcomes Center for Kids, and
- 4Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shilin Zhao
- 3Department of Biostatistics, Vanderbilt University School of Medicine
| | - Michael C Dewan
- 2Surgical Outcomes Center for Kids, and
- 4Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | | | | | - Robert P Naftel
- 2Surgical Outcomes Center for Kids, and
- 4Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, and
- 4Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sumit Pruthi
- 5Department of Radiology, Monroe Carell Jr. Children's Hospital of Vanderbilt University; and
| | - John C Wellons
- 2Surgical Outcomes Center for Kids, and
- 4Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Hale AT, Stonko DP, Brown A, Lim J, Voce DJ, Gannon SR, Le TM, Shannon CN. Machine-learning analysis outperforms conventional statistical models and CT classification systems in predicting 6-month outcomes in pediatric patients sustaining traumatic brain injury. Neurosurg Focus 2019; 45:E2. [PMID: 30453455 DOI: 10.3171/2018.8.focus17773] [Citation(s) in RCA: 60] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 08/15/2018] [Indexed: 01/30/2023]
Abstract
OBJECTIVEModern surgical planning and prognostication requires the most accurate outcomes data to practice evidence-based medicine. For clinicians treating children following traumatic brain injury (TBI) these data are severely lacking. The first aim of this study was to assess published CT classification systems in the authors' pediatric cohort. A pediatric-specific machine-learning algorithm called an artificial neural network (ANN) was then created that robustly outperformed traditional CT classification systems in predicting TBI outcomes in children.METHODSThe clinical records of children under the age of 18 who suffered a TBI and underwent head CT within 24 hours after TBI (n = 565) were retrospectively reviewed.RESULTS"Favorable" outcome (alive with Glasgow Outcome Scale [GOS] score ≥ 4 at 6 months postinjury, n = 533) and "unfavorable" outcome (death at 6 months or GOS score ≤ 3 at 6 months postinjury, n = 32) were used as the primary outcomes. The area under the receiver operating characteristic (ROC) curve (AUC) was used to delineate the strength of each CT grading system in predicting survival (Helsinki, 0.814; Rotterdam, 0.838; and Marshall, 0.781). The AUC for CT score in predicting GOS score ≤ 3, a measure of overall functionality, was similarly predictive (Helsinki, 0.717; Rotterdam, 0.748; and Marshall, 0.663). An ANN was then constructed that was able to predict 6-month outcomes with profound accuracy (AUC = 0.9462 ± 0.0422).CONCLUSIONSThis study showed that machine-learning can be leveraged to more accurately predict TBI outcomes in children.
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Affiliation(s)
- Andrew T Hale
- 1Surgical Outcomes Center for Kids, and.,2Vanderbilt University School of Medicine, Medical Scientist Training Program
| | | | | | - Jaims Lim
- 1Surgical Outcomes Center for Kids, and
| | - David J Voce
- 4Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Truc M Le
- 5Division of Pediatric Critical Care Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt
| | - Chevis N Shannon
- 1Surgical Outcomes Center for Kids, and.,4Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Hale AT, Stonko DP, Wang L, Strother MK, Chambless LB. Machine learning analyses can differentiate meningioma grade by features on magnetic resonance imaging. Neurosurg Focus 2019; 45:E4. [PMID: 30453458 DOI: 10.3171/2018.8.focus18191] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 08/15/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVEPrognostication and surgical planning for WHO grade I versus grade II meningioma requires thoughtful decision-making based on radiographic evidence, among other factors. Although conventional statistical models such as logistic regression are useful, machine learning (ML) algorithms are often more predictive, have higher discriminative ability, and can learn from new data. The authors used conventional statistical models and an array of ML algorithms to predict atypical meningioma based on radiologist-interpreted preoperative MRI findings. The goal of this study was to compare the performance of ML algorithms to standard statistical methods when predicting meningioma grade.METHODSThe cohort included patients aged 18-65 years with WHO grade I (n = 94) and II (n = 34) meningioma in whom preoperative MRI was obtained between 1998 and 2010. A board-certified neuroradiologist, blinded to histological grade, interpreted all MR images for tumor volume, degree of peritumoral edema, presence of necrosis, tumor location, presence of a draining vein, and patient sex. The authors trained and validated several binary classifiers: k-nearest neighbors models, support vector machines, naïve Bayes classifiers, and artificial neural networks as well as logistic regression models to predict tumor grade. The area under the curve-receiver operating characteristic curve was used for comparison across and within model classes. All analyses were performed in MATLAB using a MacBook Pro.RESULTSThe authors included 6 preoperative imaging and demographic variables: tumor volume, degree of peritumoral edema, presence of necrosis, tumor location, patient sex, and presence of a draining vein to construct the models. The artificial neural networks outperformed all other ML models across the true-positive versus false-positive (receiver operating characteristic) space (area under curve = 0.8895).CONCLUSIONSML algorithms are powerful computational tools that can predict meningioma grade with great accuracy.
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Affiliation(s)
- Andrew T Hale
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,3Vanderbilt University School of Medicine
| | | | - Li Wang
- 4Department of Biostatistics, Vanderbilt University; and
| | - Megan K Strother
- 5Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lola B Chambless
- 1Department of Neurosurgery, Vanderbilt University Medical Center.,3Vanderbilt University School of Medicine
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Dewan MC, Shults R, Hale AT, Sukul V, Englot DJ, Konrad P, Yu H, Neimat JS, Rodriguez W, Dawant BM, Pallavaram S, Naftel RP. Stereotactic EEG via multiple single-path omnidirectional trajectories within a single platform: institutional experience with a novel technique. J Neurosurg 2019; 129:1173-1181. [PMID: 29243976 DOI: 10.3171/2017.6.jns17881] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 06/13/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVEStereotactic electroencephalography (SEEG) is being used with increasing frequency to interrogate subcortical, cortical, and multifocal epileptic foci. The authors describe a novel technique for SEEG in patients with suspected epileptic foci refractory to medical management.METHODSIn the authors' technique, standard epilepsy evaluation and neuroimaging are used to create a hypothesis-driven SEEG plan, which informs the 3D printing of a novel single-path, multiple-trajectory, omnidirectional platform. Following skull-anchor platform fixation, electrodes are sequentially inserted according to the preoperative plan. The authors describe their surgical experience and technique based on a review of all cases, adult and pediatric, in which patients underwent invasive epilepsy monitoring via SEEG during an 18-month period at Vanderbilt University Medical Center. Platform and anatomical variables influencing localization error were evaluated using multivariate linear regression.RESULTSUsing this novel technology, 137 electrodes were inserted in 15 patients with focal epilepsy with favorable recording results and no clinical complications. The mean entry point localization error was 1.42 mm (SD 0.98 mm), and the mean target point localization error was 3.36 mm (SD 2.68 mm). Platform distance, electrode trajectory angle, and intracranial distance, but not skull thickness, were independently associated with localization error.CONCLUSIONSThe multiple-trajectory, single-path, omnidirectional platform offers satisfactory accuracy and favorable clinical results, while avoiding cumbersome frames and prohibitive up-front costs associated with other SEEG technologies.
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Affiliation(s)
- Michael C Dewan
- 1Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Robert Shults
- 2Department of Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee; and
| | - Andrew T Hale
- 1Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Vishad Sukul
- 1Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Dario J Englot
- 1Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Peter Konrad
- 1Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Hong Yu
- 1Department of Neurological Surgery, Vanderbilt University Medical Center
| | - Joseph S Neimat
- 3Department of Neurological Surgery, University of Louisville, Kentucky
| | - William Rodriguez
- 2Department of Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee; and
| | - Benoit M Dawant
- 2Department of Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee; and
| | - Srivatsan Pallavaram
- 2Department of Engineering and Computer Science, Vanderbilt University, Nashville, Tennessee; and
| | - Robert P Naftel
- 1Department of Neurological Surgery, Vanderbilt University Medical Center
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Sellyn GE, Hale AT, Tang AR, Waters A, Shannon CN, Bonfield CM. Pediatric thoracolumbar spine surgery and return to athletics: a systematic review. J Neurosurg Pediatr 2019; 24:1-11. [PMID: 31561230 DOI: 10.3171/2019.7.peds19290] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Accepted: 07/10/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Spinal conditions and injuries in the pediatric population can necessitate surgical treatment. For many pediatric patients, a return to athletic activity after spinal surgery is a significant postoperative focus. However, there is a lack of standardized guidelines to determine criteria for safe return to play (RTP). To understand clinical criteria for patients to safely RTP, the authors conducted a systematic review of outcomes and the period of time before physicians recommend an RTP for pediatric patients undergoing spinal surgery. METHODS English-language publications were searched systematically in the PubMed electronic database, and a review was conducted in accordance with the PRISMA guidelines. Additional relevant studies found via a supplementary literature search were also included. Studies assessing return to athletic activity in a pediatric population after spinal surgery were included. Studies without an RTP, postsurgical activity outcomes, or surgical intervention were excluded. RESULTS A PubMed search identified 295 articles, with 29 included for the systematic review. In addition, 4 studies were included from a supplementary literature search. The majority of these studies were retrospective case series and cohort studies, and the remaining studies included questionnaire-based studies, prospective cohorts, and case-control studies. The most common spinal conditions or injuries included spondylolysis, and this was followed by adolescent idiopathic scoliosis. Overall, the most frequent recommendation for RTP for noncontact and contact sports was 6 months after surgery (range 1-12 months), and for collision sports it was 12 months after surgery. However, some physicians recommended never returning to collision sports after spinal intervention. CONCLUSIONS Most pediatric patients are able to return to some level of sports after spinal surgery. However, no standardized criteria have been proposed, and RTP recommendations vary according to the treating surgeon. In addition, limited data are published on the variation in timelines for RTP with regard to classifications of sports (noncontact, contact, and collision). Further analysis of specific spinal conditions and injuries with postoperative athletic recovery is needed.
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Affiliation(s)
- Georgina E Sellyn
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Andrew T Hale
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University
- 2Vanderbilt University School of Medicine; and
| | - Alan R Tang
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University
- 2Vanderbilt University School of Medicine; and
| | - Alaina Waters
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University
| | - Chevis N Shannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Clarke BP, Logeman BL, Hale AT, Luka Z, York JD. A synthetic biological approach to reconstitution of inositide signaling pathways in bacteria. Adv Biol Regul 2019; 73:100637. [PMID: 31378699 DOI: 10.1016/j.jbior.2019.100637] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 07/01/2019] [Accepted: 07/04/2019] [Indexed: 11/19/2022]
Abstract
Inositide lipid (PIP) and soluble (IP) signaling pathways produce essential cellular codes conserved in eukaryotes. In many cases, deconvoluting metabolic and functional aspects of individual pathways are confounded by promiscuity and multiplicity of PIP and IP kinases and phosphatases. We report a molecular genetic approach that reconstitutes eukaryotic inositide lipid and soluble pathways in a prokaryotic cell which inherently lack inositide kinases and phosphatases in their genome. By expressing synthetic cassettes of eukaryotic genes, we have reconstructed the heterologous formation of a range of inositide lipids, including PI(3)P, PI(4,5)P2 and PIP3. In addition, we report the reconstruction of lipid-dependent production of inositol hexakisphosphate (IP6). Our synthetic system is scalable, reduces confounding metabolic issues, for example it is devoid of inositide phosphatases and orthologous kinases, and enables accurate characterization gene product enzymatic activity and substrate selectivity. This genetically engineered tool is designed to help interpret metabolic pathways and may facilitate in vivo testing of regulators and small molecule inhibitors. In summary, heterologous expression of inositide pathways in bacteria provide a malleable experimental platform for aiding signaling biologists and offers new insights into metabolism of these essential pathways.
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Affiliation(s)
- Bradley P Clarke
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Brandon L Logeman
- Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA
| | - Andrew T Hale
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Zigmund Luka
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - John D York
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, TN, USA; Department of Pharmacology and Cancer Biology, Duke University, Durham, NC, USA.
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Liles C, Dallas J, Hale AT, Gannon S, Vance EH, Bonfield CM, Shannon CN. The economic impact of open versus endoscope-assisted craniosynostosis surgery. J Neurosurg Pediatr 2019; 24:145-152. [PMID: 31151096 DOI: 10.3171/2019.4.peds18586] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 04/11/2019] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Open and endoscope-assisted repair are surgical options for sagittal craniosynostosis, with limited research evaluating each technique's immediate and long-term costs. This study investigates the cost-effectiveness of open and endoscope-assisted repair for single, sagittal suture craniosynostosis. METHODS The authors performed a retrospective cohort study of patients undergoing single, sagittal suture craniosynostosis repair (open in 17 cases, endoscope-assisted in 16) at less than 1 year of age at Monroe Carell Jr. Children's Hospital at Vanderbilt (MCJCHV) between August 2015 and August 2017. Follow-up data were collected/analyzed for 1 year after discharge. Surgical and follow-up costs were derived by merging MCJCHV financial data with each patient's electronic medical record (EMR) and were adjusted for inflation using the healthcare Producer Price Index. Proxy helmet costs were derived from third-party out-of-pocket helmet prices. To account for variable costs and probabilities, overall costs were calculated using TreeAge tree diagram software. RESULTS Open repair occurred in older patients (mean age 5.69 vs 2.96 months, p < 0.001) and required more operating room time (median 203 vs 145 minutes, p < 0.001), more ICU days (median 3 vs 1 day, p < 0.001), more hospital days (median 4 vs 1 day, p < 0.001), and more frequently required transfusion (88% vs 6% of cases). Compared to patients who underwent open surgery, patients who underwent endoscopically assisted surgery more often required postoperative orthotic helmets (100% vs 6%), had a similar number of follow-up clinic visits (median 3 vs 3 visits, p = 0.487) and CT scans (median 3 vs 2 scans), and fewer emergency department visits (median 1 vs 3 visits). The TreeAge diagram showed that, overall, open repair was 73% more expensive than endoscope-assisted repair ($31,314.10 vs $18,081.47). Sensitivity analysis identified surgical/hospital costs for open repair (mean $30,475, SEM $547) versus endoscope-assisted repair (mean $13,746, SEM $833) (p < 0.001) as the most important determinants of overall cost. Two-way sensitivity analysis comparing initial surgical/hospital costs confirmed that open repair remains significantly more expensive under even worst-case initial repair scenarios ($3254.81 minimum difference). No major surgical complications or surgical revisions occurred in either cohort. CONCLUSIONS The results of this study suggest that endoscope-assisted craniosynostosis repair is significantly more cost-effective than open repair, based on markedly lower costs and similar outcomes, and that the difference in initial surgical/hospital costs far outweighs the difference in subsequent costs associated with helmet therapy and outpatient management, although independent replication in a multicenter study is needed for confirmation due to practice and cost variation across institutions. Longer-term results will also be needed to examine whether cost differences are maintained.
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Affiliation(s)
- Campbell Liles
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Dallas
- 1Vanderbilt University School of Medicine.,2Surgical Outcomes Center for Kids (SOCKs) at Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
| | - Andrew T Hale
- 1Vanderbilt University School of Medicine.,2Surgical Outcomes Center for Kids (SOCKs) at Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
| | - Stephen Gannon
- 1Vanderbilt University School of Medicine.,2Surgical Outcomes Center for Kids (SOCKs) at Monroe Carell Jr. Children's Hospital at Vanderbilt University; and
| | - E Haley Vance
- 2Surgical Outcomes Center for Kids (SOCKs) at Monroe Carell Jr. Children's Hospital at Vanderbilt University; and.,3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 2Surgical Outcomes Center for Kids (SOCKs) at Monroe Carell Jr. Children's Hospital at Vanderbilt University; and.,3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids (SOCKs) at Monroe Carell Jr. Children's Hospital at Vanderbilt University; and.,3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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McNamara DE, Dovey CM, Hale AT, Quarato G, Grace CR, Guibao CD, Diep J, Nourse A, Cai CR, Wu H, Kalathur RC, Green DR, York JD, Carette JE, Moldoveanu T. Direct Activation of Human MLKL by a Select Repertoire of Inositol Phosphate Metabolites. Cell Chem Biol 2019; 26:863-877.e7. [PMID: 31031142 DOI: 10.1016/j.chembiol.2019.03.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 02/08/2019] [Accepted: 03/15/2019] [Indexed: 12/29/2022]
Abstract
Necroptosis is an inflammatory form of programmed cell death executed through plasma membrane rupture by the pseudokinase mixed lineage kinase domain-like (MLKL). We previously showed that MLKL activation requires metabolites of the inositol phosphate (IP) pathway. Here we reveal that I(1,3,4,6)P4, I(1,3,4,5,6)P5, and IP6 promote membrane permeabilization by MLKL through directly binding the N-terminal executioner domain (NED) and dissociating its auto-inhibitory region. We show that IP6 and inositol pentakisphosphate 2-kinase (IPPK) are required for necroptosis as IPPK deletion ablated IP6 production and inhibited necroptosis. The NED auto-inhibitory region is more extensive than originally described and single amino acid substitutions along this region induce spontaneous necroptosis by MLKL. Activating IPs bind three sites with affinity of 100-600 μM to destabilize contacts between the auto-inhibitory region and NED, thereby promoting MLKL activation. We therefore uncover MLKL's activating switch in NED triggered by a select repertoire of IP metabolites.
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Affiliation(s)
- Dan E McNamara
- Department of Structural Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Cole M Dovey
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Andrew T Hale
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Giovanni Quarato
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Christy R Grace
- Department of Structural Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Cristina D Guibao
- Department of Structural Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Jonathan Diep
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305, USA
| | - Amanda Nourse
- Molecular Interaction Analysis Shared Resource, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Casey R Cai
- Department of Structural Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Hong Wu
- Department of Structural Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Ravi C Kalathur
- Department of Structural Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - Douglas R Green
- Department of Immunology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA
| | - John D York
- Department of Biochemistry, Vanderbilt University School of Medicine, Nashville, TN 37232, USA
| | - Jan E Carette
- Department of Microbiology and Immunology, Stanford University School of Medicine, Stanford, CA 94305, USA.
| | - Tudor Moldoveanu
- Department of Structural Biology, St. Jude Children's Research Hospital, Memphis, TN 38105, USA; Department of Chemical Biology and Therapeutics, St. Jude Children's Research Hospital, Memphis, TN 38105, USA.
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Hale AT, Stanton AN, Zhao S, Haji F, Gannon SR, Arynchyna A, Wellons JC, Rocque BG, Naftel RP. Predictors of endoscopic third ventriculostomy ostomy status in patients who experience failure of endoscopic third ventriculostomy with choroid plexus cauterization. J Neurosurg Pediatr 2019; 24:41-46. [PMID: 31003223 DOI: 10.3171/2019.2.peds18743] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/12/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE At failure of endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC), the ETV ostomy may be found to be closed or open. Failure with a closed ostomy may indicate a population that could benefit from evolving techniques to keep the ostomy open and may be candidates for repeat ETV, whereas failure with an open ostomy may be due to persistently abnormal CSF dynamics. This study seeks to identify clinical and radiographic predictors of ostomy status at the time of ETV/CPC failure. METHODS The authors conducted a multicenter, retrospective cohort study on all pediatric patients with hydrocephalus who failed initial ETV/CPC treatment between January 2013 and October 2016. Failure was defined as the need for repeat ETV or ventriculoperitoneal (VP) shunt placement. Clinical and radiographic data were collected, and ETV ostomy status was determined endoscopically at the subsequent hydrocephalus procedure. Statistical analysis included the Mann-Whitney U-test, Wilcoxon rank-sum test, t-test, and Pearson chi-square test where appropriate, as well as multivariate logistic regression. RESULTS Of 72 ETV/CPC failures, 28 patients (39%) had open-ostomy failure and 44 (61%) had closed-ostomy failure. Patients with open-ostomy failure were older (median 5.1 weeks corrected age for gestation [interquartile range (IQR) 0.9-15.9 weeks]) than patients with closed-ostomy failure (median 0.2 weeks [IQR -1.3 to 4.5 weeks]), a significant difference by univariate and multivariate regression. Etiologies of hydrocephalus included intraventricular hemorrhage of prematurity (32%), myelomeningocele (29%), congenital communicating (11%), aqueductal stenosis (11%), cyst/tumor (4%), and other causes (12%). A wider baseline third ventricle was associated with open-ostomy failure (median 15.0 mm [IQR 10.3-18.5 mm]) compared to closed-ostomy failure (median 11.7 mm [IQR 8.9-16.5 mm], p = 0.048). Finally, at the time of failure, patients with closed-ostomy failure had enlargement of their ventricles (frontal and occipital horn ratio [FOHR], failure vs baseline, median 0.06 [IQR 0.00-0.11]), while patients with open-ostomy failure had no change in ventricle size (median 0.01 [IQR -0.04 to 0.05], p = 0.018). Previous CSF temporizing procedures, intraoperative bleeding, and time to failure were not associated with ostomy status at ETV/CPC failure. CONCLUSIONS Older corrected age for gestation, larger baseline third ventricle width, and no change in FOHR were associated with open-ostomy ETV/CPC failure. Future studies are warranted to further define and confirm features that may be predictive of ostomy status at the time of ETV/CPC failure.
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Affiliation(s)
- Andrew T Hale
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville.,2Medical Scientist Training Program, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Amanda N Stanton
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville.,3Virginia Commonwealth University School of Medicine, Richmond, Virginia
| | - Shilin Zhao
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Faizal Haji
- 4Divsion of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Alabama.,5Department of Neurosurgery, Queens University, Kingston, Ontario, Canada; and
| | - Stephen R Gannon
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville
| | - Anastasia Arynchyna
- 4Divsion of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - John C Wellons
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville.,6Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Brandon G Rocque
- 4Divsion of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Robert P Naftel
- 1Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville.,6Division of Pediatric Neurosurgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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